Pharmacy Benefit Guide Together with CCHP PO Box 1997 - MS 6280 | Milwaukee, WI 53201-1997 Toll-free: 1-844-201-4677 | togetherCCHP.org
Pharmacy Program Overview The pharmacy program of Together with Children’s Community Health Plan (CCHP) offers a variety of high-quality, effective generic and brand-name prescription drugs. This guide provides information that applies to most members. For information specific to your plan, please read your Schedule of Benefits.
When you need a prescription drug, you and your doctor can choose from six different levels, or “tiers”. Each tier has a different copayment or coinsurance. This gives you and your doctor the freedom to choose the drug that is right for you. At the same time, this will help you budget your health care dollars and may save you money.
This guide provides an overview of your pharmacy benefit with Together with CCHP. It tells you the process for getting certain drugs covered, your options for filling prescriptions, important phone numbers, and more. For a complete listing of benefits, exclusions, and limitations, please refer to the Schedule of Benefits for your plan. In the event there are discrepancies with the information in this guide, the terms and conditions of the coverage documents will govern.
Contact Numbers
• Current Together with CCHP Members: o Customer Service: 1-844-201-4672 o Pharmacy Services (for practitioners and pharmacies): 1-844-201-4677 o Hearing-impaired members: 1-844-531-4856
• Prospective Together with CCHP Members: o Prospective members should direct their questions to Together with CCHP Sales Team at 1-844-708-3837. Online information is available at togetherCCHP.org/formulary.
Read your contract carefully to determine which health care services are covered.
This Pharmacy Benefit Guide is current as of December 01, 2017.
For the latest information on the Together with CCHP drug formulary and other pharmacy benefits, go to: togetherCCHP.org/formulary. You may also call our Customer Service at the number listed above or on the back of your member ID card.
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Internal Reference: TOG Member Guide – Pharmacy Benefit Guide (2017.1201) Together with CCHP PO Box 1997 - MS 6280 | Milwaukee, WI 53201-1997 Toll-free: 1-844-201-4677 | togetherCCHP.org
Understanding Coverage and Cost Sharing Our formulary is the list of Food and Drug Administration (FDA)-approved drugs that we cover. Our Health Plan’s Pharmacy and Therapeutics (P&T) Committee researches and evaluates drugs it may cover. Committee members include doctors and pharmacists who meet regularly during the year to review and update the formulary. Committee members base their decision on the drug’s safety, effectiveness, and cost.
Together with CCHP prescription drugs are organized into six formulary tiers:
• Tier 1 includes a majority of generic medications. Generic drugs offer the same level of safety and quality as their brand- name equivalents. They have the same number of active ingredients as brand name medications. Together with CCHP requires you to use a generic version of the drug if one is available. This means that if you get a brand-name drug when a generic is available, you must pay the brand copayment and the retail cost difference between the brand- name and generic forms of the drug.
• Tier 2 is for preferred-brand medications. Together with CCHP classifies these drugs as “preferred” because of their value and effectiveness.
• Tier 3 is for non-preferred brand medications.
• Tier 4 is for specialty medications, for which you will have the highest level of cost sharing. Specialty medications usually treat complex and rare conditions. These drugs are created because of advancements in drug development. These drugs can be high-cost medications and biologicals regardless of how they are administered (injectable, oral, transdermal, or inhalant). Specialty drugs require close management by a physician. Physicians need to monitor these drugs because of potential side effects and the need for frequent dosage adjustments.
• Tier 5 is for select generic medications. Select generic medications are offered at no additional cost share to you, once your deductible is met. Many of these medications can help you avoid getting sick and improve your overall health.
• Tier 6 is for zero cost-share preventive drugs. In accordance with the Patient Protection and Affordable Care Act of 2010 (PPACA), many select preventive medications are covered at no cost to you.
About Generic Drugs Generic drugs have the same active ingredients as brand-name drugs, but cost much less. Not all drugs have a generic equivalent. Generally, new drugs receive patent protection. Once the patent expires, other pharmaceutical companies can produce the same drug in a generic formulation. Companies that make generic drugs do not have to invest large amounts of money in research, since the company making the brand-name equivalent has already done this. Also, generic companies do not need to advertise their drugs. As a result, generic drug makers can pass these savings on to you.
Generic drugs have the same active ingredients as brand-name drugs, but their inactive ingredients can vary. This is why the generic drug might look different from the brand-name drug. Inactive ingredients can be dyes used to color the drug or powders used to shape the tablets. Inactive ingredients do not affect how the generic drug works.
The FDA regulates generic drug manufacturers just as it regulates the makers of brand-name drugs. The generic drug must pass strict FDA measurements to ensure that it delivers the same amount of the active ingredient in the same time frame as its brand-name counterpart. The manufacturer of the generic drug must prove that it produces its product under the same strict guidelines as the brand name drug.
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Internal Reference: TOG Member Guide – Pharmacy Benefit Guide (2017.1201) Together with CCHP PO Box 1997 - MS 6280 | Milwaukee, WI 53201-1997 Toll-free: 1-844-201-4677 | togetherCCHP.org
Formulary Overview The most commonly prescribed Together with CCHP drugs are listed in the formulary section of this guide. Please note there are other drugs that Together with CCHP covers in addition to the ones listed in this guide. For the latest information on the complete Together with CCHP formulary and other pharmacy benefits, visit our website at togetherCCHP.org/formulary. (Select “Together with CCHP” to access the searchable drug list.)
You may also call our Customer Service at the number listed on your member ID card or on the first page of this guide. If you are a current Together with CCHP member, refer to your Schedule of Benefits for your applicable coinsurance or copayment amounts. If you did not receive a Schedule of Benefits, contact our Customer Service at the number on your member ID card. Your member ID card should also list your applicable coinsurance or copayment amounts.
For Prospective Members If you are thinking about joining CCHP and would like information about applicable coinsurance or copayment amounts, go to the Summary of Benefits and Coverage (SBC) on the Together with CCHP website at togetherCCHP.org or call the sales team at the number listed on the first page of this guide.
Getting Your Prescriptions Filled
I. Retail Together with CCHP’s network of retail pharmacies includes hundreds of locations, independent pharmacies, as well as multi- store chains throughout the region. You can take your drug to any pharmacy in the network. You must use 75 percent of your drug before you can get a refill. Go to togetherCCHP.org/pharmacy for specific pharmacy names, locations, and telephone numbers. You may also call our Customer Service at the number is listed on your member ID card and on the first page of this guide.
II. Mail Order If you take maintenance drugs for a chronic condition, you can get them through a mail-order pharmacy. Maintenance drugs are drugs that are taken on a regular, long-term basis. This may include drugs to treat high blood pressure, diabetes, asthma, high cholesterol, and more.
With convenient mail-order service, you: • Receive a 90-day supply of most drugs, plus refills, as prescribed by your doctor. • Usually pay a lower out-of-pocket cost for a 90- day supply at a mail-order pharmacy than you would pay at a retail pharmacy. • Get these drugs delivered right to your door.
Most mail-order prescriptions are written for a 90-day supply. If your doctor writes for a 30-day supply with two refills, the mail order facility may combine the prescription to make a 90-day supply. If you do not want a 90-day supply, you should write, “Do Not want a 90-day Supply” on the mail-order form. For a new medication, the first time you get a prescription or a new drug, Together with CCHP recommends that you try a 30-day supply of the drug from a retail pharmacy. That way your practitioner has a chance to make sure that it is the right dose for you and that it does not cause any side effects.
Once you’re confident that the drug is appropriate, ask your practitioner to write a prescription for a 90- day supply of each maintenance drug that you need (plus refills if appropriate). Then order the supply through the mail-order pharmacy. To avoid running out of your mail-order prescription, reorder your drug while you still have drugs to use for about two weeks, allowing a few weeks for processing and delivery. To request refills, you may order online or over the telephone. You can ask for a mail- order form by calling our Customer Service, or by requesting the form through togetherCCHP.org.
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Internal Reference: TOG Member Guide – Pharmacy Benefit Guide (2017.1201) Together with CCHP PO Box 1997 - MS 6280 | Milwaukee, WI 53201-1997 Toll-free: 1-844-201-4677 | togetherCCHP.org
III. Specialty Provider Most specialty drugs must be obtained through our designated specialty provider. When you are prescribed a specialty drug and use a specialty provider, you get mail-order delivery and better access to drugs, because many retail pharmacies do not have these types of drugs. Specialty drugs that require special handling, provider coordination, or patient education that cannot be provided by a retail pharmacy must be obtained through our designated specialty provider. A specialty provider offers cost-saving health care, and drug management and compliance programs.
IV. Drug supplies not covered If you'll be away from home for a long period of time, you may want to use our mail-order service to get a 90-day supply before you leave. • No authorizations will be provided for drugs reported by the member, provider, or pharmacy to be lost, misplaced, stolen, destroyed, or damaged. • Drugs received at no charge to the member (workers’ compensation, drugs purchased with a manufacturer’s coupon) will not be covered. • Prescriptions that are written more than a year ago will not be covered. Your practitioner will need to write a new prescription.
V. Medications not covered The following medications are benefit exclusions and will not be covered under the pharmacy benefit:
• Antimalarial agents when used for prevention • Anti-obesity medications, including, but not limited to appetite suppressants and lipase inhibitors • Blood or blood plasma products* • Compounded products containing excluded ingredients (examples are compounded hormone replacement therapies and compounded narcotic analgesics) • Drugs labeled for investigational use • Fertility agents • Legend vitamins (other than prenatal, fluoride, and certain therapeutic vitamins) Most over-the-counter medications** • Needles/Syringes (other than insulin)* • Nutrition and dietary supplements* • Therapeutic devices/appliances* • Urine strips. (Because our doctors feel blood glucose strips are more accurate than urine test strips in measuring blood glucose, urine strips are not a covered benefit.)
This is not a complete list and there may be other medications that are not covered. For more information, please contact Customer Service at the phone number on the back of your member ID card or on the first page of this guide.
*Please note that, under certain circumstances, your medical benefits may cover the items marked with an asterisk (*). For information on these items, you can contact our Customer Service at the number listed on the back of your member ID card. If you have not yet received an ID card, call the Customer Service number listed on the first page of this guide. **Additional OTC medications may be covered in accordance with the Pat ient Protection and Affordable Care Act. The Preventive Services Guide is available on our website contains information regarding this coverage.
VI. Filling your prescription when traveling When you travel outside of your network area, many pharmacies across the country will accept your Together with CCHP member ID card. To find a participating pharmacy, call our Customer Service. The number is on your member ID card, on the first page of this guide or online at togetherCCHP.org/formulary.
To fill a prescription at a participating out-of-area pharmacy, show them your Together with CCHP member ID card. Some pharmacies may ask you to pay the full price of the drug. If that happens and your claim is approved, you will be refunded the amount that you paid for the drug, less your copayment. You can request a “Pharmacy Program Direct Reimbursement Claim Form” by calling our Customer Service or requesting the form on our member portal, CCHP Connect.
Drug Exceptions Time Frames and Enrollee Responsibilities
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Internal Reference: TOG Member Guide – Pharmacy Benefit Guide (2017.1201) Together with CCHP PO Box 1997 - MS 6280 | Milwaukee, WI 53201-1997 Toll-free: 1-844-201-4677 | togetherCCHP.org
If the drug you take is not on the list of covered drugs for your benefit plan (also called a “formulary”), you can ask us to cover it. This is called a “non-formulary exception.” A request for a non-formulary exception will only be approved if there is documented evidence that the formulary alternatives are not effective in treating your condition; the formulary alternatives would cause adverse side effects; or a contraindication exists such that you cannot safely try the formulary drug.
As a first step, you can contact Customer Service for a list of similar drugs that are covered by your plan or you can go to togetherCCHP.org/formulary for this information. When you have the list, show it to your doctor and see whether he or she is able to prescribe one of the drugs on this list.
If you need to request a non-formulary exception, contact Customer Service or access the exception request form in the CCHP Connect member portal. When you make this request, we may contact your prescriber or physician for information to support your request. After CCHP receives your request, we will make our decision within 72 hours. You can request a faster (expedited) decision if you or your doctor believe that waiting up to 72 hours for a decision could seriously harm your health. If your request to expedite is granted, we must give you a decision no later than 24 hours from when we received your request.
If we deny your request for a non-formulary exception, you may first request an internal review of that decision by contacting Customer Service. If the denial of the non-formulary exception request is upheld through an internal review, you may then request an external review by an Independent Review Organization (IRO). You can also request an external review by contacting Customer Service at 1-844-201-4672.
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Internal Reference: TOG Member Guide – Pharmacy Benefit Guide (2017.1201) Together with CCHP PO Box 1997 - MS 6280 | Milwaukee, WI 53201-1997 Toll-free: 1-844-201-4677 | togetherCCHP.org
Non-Discrimination Statement and Information Children’s Community Health Plan (CCHP) complies with all applicable civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age, disability, or other legally protected status, in its administration of the plan, including enrollment and benefit determinations.
Children’s Community Health Plan provides appropriate auxiliary aids and services, including qualified interpreters for individuals with disabilities and who have language services needs and information in alternate formats, free of charge and in a timely manner, when such aids and services are necessary to ensure an equal opportunity to participate to individuals with disabilities.
Any person who believes someone has been subjected to discrimination on the basis of race, color, national origin; sex, age or disability may file a grievance in person, by mail, fax or email. The grievance must be filed with 60 days of the person filing the grievance becomes aware of the alleged discriminatory action. It is against the law for Children’s Community Health Plan to retaliate against anyone who files a grievance, or who participates in the investigation of a grievance. Members can request Children’s Community Health Plan’s grievance procedure by contacting the Section 1557 Coordinator:
Director, Corporate Compliance Mail Station C760 P.O. Box 1997 Milwaukee, WI 53201-1997 Telephone: (414) 266-2215 TDD-TTY (for the hearing impaired): (414) 266-2465 Fax: (414) 266-6409 [email protected]
Members must submit their complaints in writing with their name, address, the problem or action alleged to be discriminatory and the remedy or relief sought. Members can also file a complaint of discrimination electronically through the Office for Civil Rights Complaint Portal, which is available at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail at:
U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington, D.C. 20201
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
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Internal Reference: TOG Member Guide – Pharmacy Benefit Guide (2017.1201) Together with CCHP PO Box 1997 - MS 6280 | Milwaukee, WI 53201-1997 Toll-free: 1-844-201-4677 | togetherCCHP.org
Language Access
ENGLISH: If you or someone you’re helping has questions about Together with CCHP, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-844-201-4672. TTY users, call 1-844-531-4856.
SPANISH: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Together with CCHP tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-844-201-4672.
HMONG: Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Together with CCHP, koj muaj cai kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 1-844-201-4672.
CHINESE: 如果您，或是您正在協助的對象，有關於[插入SBM項目的名稱Together with CCHP面的問題，您有權利免費以您的母語得到幫 助和訊息。洽詢一位翻譯員，請撥電話 [在此插入數字1-844-201-4672.
GERMAN: Falls Sie oder jemand, dem Sie helfen, Fragen zum Together with CCHP haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1- 844-201-4672 an.
والمعلومات المساعدة على الحصول في الحق فلديك ،) Together with CCHP ( بخصوص أسئلة تساعده شخص لدى أو لديك كان إن :ARABIC 4672-201-844-1 ( ب اتصل مترجم مع للتحدث .تكلفة اية دون من بلغتك الضرورية
FRENCH: Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Together with CCHP vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-844-201-4672.
TAGALOG: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Together with CCHP, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-844-201-4672.
ALBAINIAN: Nëse ju, ose dikush që po ndihmoni, ka pyetje për Together with CCHP, keni të drejtë të merrni ndihmë dhe informacion falas në gjuhën tuaj. Për të folur me një përkthyes, telefononi numrin 1-844-201-4672.
HINDI: यदि आपके ,या आप 饍वारा सहायता ककए जा रहे ककसी व्य啍तत के Together with CCHP के बारे मᴂ प्रश्न हℂ ,तो आपके पास अपनी भाषा मᴂ मुफ्त मᴂ सहायता और सूचना प्राप्त करने का अधिकार है। ककसी िुुुभाषषए से बात करने के लिए 1-844-201-4672.पर कॉिु करᴂ।
POLISH: Jeśli Ty lub osoba, której pomagasz ,macie pytania odnośnie Together with CCHP, masz prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku .Aby porozmawiać z tłumaczem, zadzwoń pod numer 1-844-201-4672.
VIETNAMESE: Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Together with CCHP, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-844-201-4672.
PENNSYLVANIA DUTCH: Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut Together with CCHP, hoscht du es Recht fer Hilf un Information in deinre eegne Schprooch griege, un die Hilf koschtet nix. Wann du mit me Interpreter schwetze witt, kannscht du 1-844-201-4672 uffrufe.
LAOTIAN: ້າທ່ ານ, ຫ ້ ້ຄົ ນທ ່້ທ່ ານກໍ າລັ ງຊ່ ວຍເຫ ້ ້ອ, ມ ໍຄາຖາມກ່ ຽວກັ ບ Together with CCHP, ທ່ ານມ ິສດທ ່້ຈະໄດ ຮັ ບການຊ່ ວຍເຫ ້ ້ອ
ແລະໍຂ ມູ ນຂ່ າວສານທ ່້ເປັ ນພາສາຂອງທ່ ານໍບ່ ມ ຄ່ າໃຊ ຈ່ າຍ. ການໂອ ລົ ມກັ ບນາຍພາສາ, ໃຫ ໂທຫາ 1-844-201-4672.
KOREAN: 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이Together with CCHP에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는1-844-201-4672 로 전화하십시오.
RUSSIAN: Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Together with CCHP, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 1-844-201-4672.
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Internal Reference: TOG Member Guide – Pharmacy Benefit Guide (2017.1201)
Table of Contents
ANTI - INFECTIVES ...... 3 ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ...... 17 AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ...... 24 CARDIOVASCULAR, HYPERTENSION & LIPIDS ...... 41 DERMATOLOGICALS/TOPICAL THERAPY ...... 51 DIAGNOSTICS & MISCELLANEOUS AGENTS ...... 58 EAR, NOSE & THROAT MEDICATIONS...... 61 ENDOCRINE/DIABETES ...... 62 GASTROENTEROLOGY ...... 71 IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ...... 78 MUSCULOSKELETAL & RHEUMATOLOGY ...... 85 OBSTETRICS & GYNECOLOGY ...... 87 OPHTHALMOLOGY ...... 95 RESPIRATORY, ALLERGY, COUGH & COLD ...... 101 UROLOGICALS ...... 107 VITAMINS, HEMATINICS & ELECTROLYTES ...... 109 Index ...... 120
1
List of Abbreviations
ACA: Affordable Care Act.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service.
OTC: Over the Counter. An OTC drug is a non-prescription drug.
PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug.
QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.
ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
2
Drug Name Drug Tier Requirements / Limits ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET INTRAVENOUS SUSPENSION 3 AMBISOME INTRAVENOUS SUSPENSION 3 FOR RECONSTITUTION amphotericin b injection recon soln 1 CANCIDAS INTRAVENOUS RECON SOLN 3 caspofungin intravenous recon soln 50 mg 3 CASPOFUNGIN INTRAVENOUS RECON 3 SOLN 70 MG clotrimazole mucous membrane troche 1 CRESEMBA INTRAVENOUS RECON SOLN 4 QL CRESEMBA ORAL CAPSULE 4 QL ERAXIS(WATER DILUENT) INTRAVENOUS 3 RECON SOLN fluconazole in nacl (iso-osm) intravenous 1 piggyback 200 mg/100 ml, 400 mg/200 ml fluconazole oral suspension for reconstitution 1 fluconazole oral tablet 1 QL flucytosine oral capsule 4 griseofulvin microsize oral suspension 1 griseofulvin microsize oral tablet 1 griseofulvin ultramicrosize oral tablet 1 itraconazole oral capsule 1 PA; QL ketoconazole oral tablet 1 MYCAMINE INTRAVENOUS RECON SOLN 3 NOXAFIL ORAL SUSPENSION 4 PA NOXAFIL ORAL TABLET,DELAYED 4 PA; QL RELEASE (DR/EC) nystatin oral powder 150 million unit, 500 million 1 unit nystatin oral suspension 1 nystatin oral tablet 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 3
Drug Name Drug Tier Requirements / Limits ONMEL ORAL TABLET 3 PA; QL ORAVIG BUCCAL MUCO-ADHESIVE 3 PA; QL BUCCAL TABLET SPORANOX ORAL SOLUTION 3 PA terbinafine hcl oral tablet 1 QL voriconazole intravenous solution 1 voriconazole oral suspension for reconstitution 4 QL voriconazole oral tablet 4 QL ANTIVIRALS abacavir oral solution 1 QL abacavir oral tablet 1 QL abacavir-lamivudine oral tablet 1 QL abacavir-lamivudine-zidovudine oral tablet 1 QL acyclovir oral capsule 1 acyclovir oral suspension 200 mg/5 ml 1 acyclovir oral tablet 1 acyclovir sodium intravenous solution 1 adefovir oral tablet 4 PA amantadine hcl oral capsule 1 amantadine hcl oral solution 1 amantadine hcl oral tablet 1 APTIVUS ORAL CAPSULE 4 QL APTIVUS ORAL SOLUTION 4 QL ATRIPLA ORAL TABLET 4 QL BARACLUDE ORAL SOLUTION 4 PA cidofovir intravenous solution 1 COMPLERA ORAL TABLET 4 QL CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 2 QL DAKLINZA ORAL TABLET 4 PA; LA; QL DESCOVY ORAL TABLET 4 QL didanosine oral capsule,delayed release(dr/ec) 1 QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 4
Drug Name Drug Tier Requirements / Limits EDURANT ORAL TABLET 4 QL EMTRIVA ORAL CAPSULE 2 QL EMTRIVA ORAL SOLUTION 2 QL entecavir oral tablet 4 PA EPCLUSA ORAL TABLET 4 PA; LA; QL EPIVIR HBV ORAL SOLUTION 2 PA EVOTAZ ORAL TABLET 4 QL famciclovir oral tablet 1 QL fosamprenavir oral tablet 1 QL foscarnet intravenous solution 1 FUZEON SUBCUTANEOUS RECON SOLN 4 QL ganciclovir sodium intravenous recon soln 1 GENVOYA ORAL TABLET 4 QL HARVONI ORAL TABLET 4 PA; LA; QL INTELENCE ORAL TABLET 4 QL INVIRASE ORAL CAPSULE 4 QL INVIRASE ORAL TABLET 4 QL ISENTRESS HD ORAL TABLET 4 QL ISENTRESS ORAL POWDER IN PACKET 4 QL ISENTRESS ORAL TABLET 4 QL ISENTRESS ORAL TABLET,CHEWABLE 4 QL KALETRA ORAL TABLET 4 QL lamivudine oral solution 1 QL lamivudine oral tablet 100 mg 1 lamivudine oral tablet 150 mg, 300 mg 1 QL lamivudine-zidovudine oral tablet 1 QL LEXIVA ORAL SUSPENSION 4 QL LEXIVA ORAL TABLET 4 QL lopinavir-ritonavir oral solution 1 QL MAVYRET ORAL TABLET 4 PA; LA; QL nevirapine oral suspension 1 QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 5
Drug Name Drug Tier Requirements / Limits nevirapine oral tablet 1 QL nevirapine oral tablet extended release 24 hr 1 QL NORVIR ORAL CAPSULE 2 QL NORVIR ORAL SOLUTION 2 QL NORVIR ORAL TABLET 2 QL ODEFSEY ORAL TABLET 4 QL OLYSIO ORAL CAPSULE 4 PA; LA; QL oseltamivir oral capsule 1 QL PREZCOBIX ORAL TABLET 4 QL PREZISTA ORAL SUSPENSION 4 QL PREZISTA ORAL TABLET 150 MG, 600 MG, 4 QL 75 MG, 800 MG RELENZA DISKHALER INHALATION 3 QL BLISTER WITH DEVICE RESCRIPTOR ORAL TABLET 2 QL RESCRIPTOR ORAL TABLET, DISPERSIBLE 2 QL RETROVIR INTRAVENOUS SOLUTION 4 QL REYATAZ ORAL CAPSULE 150 MG, 200 MG, 4 QL 300 MG REYATAZ ORAL POWDER IN PACKET 4 QL rimantadine oral tablet 1 SELZENTRY ORAL SOLUTION 4 PA; QL SELZENTRY ORAL TABLET 4 PA; QL SOVALDI ORAL TABLET 4 PA; LA; QL stavudine oral capsule 1 QL stavudine oral recon soln 1 QL STRIBILD ORAL TABLET 4 QL SUSTIVA ORAL CAPSULE 4 QL SUSTIVA ORAL TABLET 4 QL SYNAGIS INTRAMUSCULAR SOLUTION 4 PA; LA; QL TAMIFLU ORAL SUSPENSION FOR 3 QL RECONSTITUTION TECHNIVIE ORAL TABLET 4 PA; LA; QL You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 6
Drug Name Drug Tier Requirements / Limits TIVICAY ORAL TABLET 4 QL TRIUMEQ ORAL TABLET 4 QL TRUVADA ORAL TABLET 4 QL TYBOST ORAL TABLET 2 valacyclovir oral tablet 1 QL valganciclovir oral recon soln 4 valganciclovir oral tablet 3 VEMLIDY ORAL TABLET 4 PA; QL VIDEX 2 GRAM PEDIATRIC ORAL RECON 2 QL SOLN VIEKIRA PAK ORAL TABLETS,DOSE PACK 4 PA; LA; QL VIEKIRA XR ORAL TABLET, IR - ER, 4 PA; LA; QL BIPHASIC 24HR VIRACEPT ORAL TABLET 4 QL VIRAMUNE XR ORAL TABLET EXTENDED 4 QL RELEASE 24 HR 100 MG VIREAD ORAL POWDER 4 QL VIREAD ORAL TABLET 4 QL VOSEVI ORAL TABLET 4 PA; LA; QL ZEPATIER ORAL TABLET 4 PA; LA; QL zidovudine oral capsule 1 QL zidovudine oral syrup 1 QL zidovudine oral tablet 1 QL CEPHALOSPORINS CEDAX ORAL CAPSULE 3 cefaclor oral capsule 1 cefaclor oral suspension for reconstitution 125 1 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr 1 cefadroxil oral capsule 1 cefadroxil oral suspension for reconstitution 250 1 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 7
Drug Name Drug Tier Requirements / Limits CEFAZOLIN IN 0.9% SOD CHLORIDE 3 INTRAVENOUS PIGGYBACK cefazolin in dextrose (iso-os) intravenous 1 piggyback 1 gram/50 ml, 2 gram/50 ml CEFAZOLIN IN DEXTROSE 5 % 3 INTRAVENOUS PIGGYBACK 2 GRAM/50 ML cefazolin injection recon soln 1 cefazolin intravenous recon soln 1 cefdinir oral capsule 1 cefdinir oral suspension for reconstitution 1 cefditoren pivoxil oral tablet 1 CEFEPIME IN DEXTROSE 5 % 3 INTRAVENOUS PIGGYBACK cefepime in dextrose,iso-osm intravenous 3 piggyback cefepime injection recon soln 3 cefixime oral suspension for reconstitution 1 cefotaxime injection recon soln 1 cefotetan injection recon soln 1 cefotetan intravenous recon soln 1 cefoxitin in dextrose, iso-osm intravenous 1 piggyback cefoxitin intravenous recon soln 1 cefpodoxime oral suspension for reconstitution 1 cefpodoxime oral tablet 1 cefprozil oral suspension for reconstitution 1 cefprozil oral tablet 1 CEFTAZIDIME IN D5W INTRAVENOUS 3 PIGGYBACK ceftazidime injection recon soln 1 CEFTIN ORAL SUSPENSION FOR 3 RECONSTITUTION ceftriaxone in dextrose,iso-os intravenous 1 piggyback
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 8
Drug Name Drug Tier Requirements / Limits ceftriaxone injection recon soln 1 gram, 10 gram, 1 2 gram, 250 mg, 500 mg ceftriaxone intravenous recon soln 1 cefuroxime axetil oral tablet 1 cefuroxime sodium injection recon soln 750 mg 1 cefuroxime sodium intravenous recon soln 1 cephalexin oral capsule 250 mg, 500 mg 5 cephalexin oral capsule 750 mg 1 cephalexin oral suspension for reconstitution 125 1 QL mg/5 ml cephalexin oral suspension for reconstitution 250 1 mg/5 ml cephalexin oral tablet 1 MAXIPIME INTRAVENOUS RECON SOLN 3 SPECTRACEF ORAL TABLET 400 MG 3 SUPRAX ORAL CAPSULE 3 SUPRAX ORAL SUSPENSION FOR 3 RECONSTITUTION 100 MG/5 ML, 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 3 TEFLARO INTRAVENOUS RECON SOLN 3 ZINACEF IN STERILE WATER 3 INTRAVENOUS PIGGYBACK ERYTHROMYCINS & OTHER MACROLIDES azithromycin intravenous recon soln 1 azithromycin oral packet 1 azithromycin oral suspension for reconstitution 1 azithromycin oral tablet 1 clarithromycin oral suspension for reconstitution 1 clarithromycin oral tablet 1 clarithromycin oral tablet extended release 24 hr 1 DIFICID ORAL TABLET 4 ST; QL e.e.s. 400 oral tablet 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 9
Drug Name Drug Tier Requirements / Limits ERYPED 200 ORAL SUSPENSION FOR 3 RECONSTITUTION ERYPED 400 ORAL SUSPENSION FOR 3 RECONSTITUTION ery-tab oral tablet,delayed release (dr/ec) 250 mg, 1 333 mg erythrocin (as stearate) oral tablet 250 mg 1 ERYTHROCIN INTRAVENOUS RECON SOLN 3 500 MG erythromycin ethylsuccinate oral suspension for 3 reconstitution erythromycin ethylsuccinate oral tablet 1 erythromycin oral capsule,delayed release(dr/ec) 1 erythromycin oral tablet 1 MISCELLANEOUS ANTIINFECTIVES ALBENZA ORAL TABLET 2 ALINIA ORAL SUSPENSION FOR 2 RECONSTITUTION ALINIA ORAL TABLET 2 amikacin injection solution 1,000 mg/4 ml, 500 1 mg/2 ml atovaquone oral suspension 1 atovaquone-proguanil oral tablet 1 PA AZACTAM IN DEXTROSE (ISO-OSM) 3 INTRAVENOUS PIGGYBACK aztreonam injection recon soln 1 baciim intramuscular recon soln 1 bacitracin intramuscular recon soln 1 BETHKIS INHALATION SOLUTION FOR 4 QL NEBULIZATION BILTRICIDE ORAL TABLET 2 CAPASTAT INJECTION RECON SOLN 3 CAYSTON INHALATION SOLUTION FOR 4 QL NEBULIZATION
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 10
Drug Name Drug Tier Requirements / Limits chloramphenicol sod succinate intravenous recon 1 soln chloroquine phosphate oral tablet 1 PA clindamycin hcl oral capsule 1 CLINDAMYCIN IN 0.9 % SOD CHLOR 3 INTRAVENOUS PIGGYBACK clindamycin in 5 % dextrose intravenous 1 piggyback clindamycin palmitate hcl oral recon soln 1 clindamycin pediatric oral recon soln 1 clindamycin phosphate injection solution 1 clindamycin phosphate intravenous solution 1 COARTEM ORAL TABLET 2 colistin (colistimethate na) injection recon soln 1 CUBICIN INTRAVENOUS RECON SOLN 3 CYCLOSERINE ORAL CAPSULE 3 dapsone oral tablet 1 daptomycin intravenous recon soln 1 DARAPRIM ORAL TABLET 3 PA DORIBAX INTRAVENOUS RECON SOLN 3 DORIPENEM INTRAVENOUS RECON SOLN 3 ethambutol oral tablet 1 gentamicin in nacl (iso-osm) intravenous 1 piggyback 100 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml GENTAMICIN IN NACL (ISO-OSM) 3 INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML gentamicin injection solution 1 gentamicin sulfate (ped) (pf) injection solution 1 gentamicin sulfate (pf) intravenous solution 100 1 mg/10 ml GENTAMICIN SULFATE (PF) INTRAVENOUS 1 SOLUTION 60 MG/6 ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 11
Drug Name Drug Tier Requirements / Limits hydroxychloroquine oral tablet 1 imipenem-cilastatin intravenous recon soln 1 INVANZ INJECTION RECON SOLN 3 INVANZ INTRAVENOUS RECON SOLN 3 isoniazid injection solution 1 isoniazid oral solution 1 isoniazid oral tablet 1 ivermectin oral tablet 1 LINCOCIN INJECTION SOLUTION 3 lincomycin injection solution 1 linezolid intravenous parenteral solution 1 linezolid oral suspension for reconstitution 4 QL linezolid oral tablet 4 QL linezolid-0.9% sodium chloride intravenous 1 parenteral solution mefloquine oral tablet 1 PA meropenem intravenous recon soln 1 metro i.v. intravenous piggyback 1 metronidazole in nacl (iso-os) intravenous 1 piggyback metronidazole oral capsule 1 metronidazole oral tablet 1 NEBUPENT INHALATION RECON SOLN 2 neomycin oral tablet 1 paromomycin oral capsule 1 PASER ORAL GRANULES DR FOR SUSP IN 2 PACKET PENTAM INJECTION RECON SOLN 3 polymyxin b sulfate injection recon soln 1 PRIFTIN ORAL TABLET 3 PRIMAQUINE ORAL TABLET 3 PA pyrazinamide oral tablet 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 12
Drug Name Drug Tier Requirements / Limits quinine sulfate oral capsule 1 PA rifabutin oral capsule 1 RIFAMATE ORAL CAPSULE 3 rifampin intravenous recon soln 1 rifampin oral capsule 1 RIFATER ORAL TABLET 3 SIRTURO ORAL TABLET 4 PA SIVEXTRO INTRAVENOUS RECON SOLN 4 QL SIVEXTRO ORAL TABLET 4 QL STREPTOMYCIN INTRAMUSCULAR RECON 3 SOLN STROMECTOL ORAL TABLET 2 SYNERCID INTRAVENOUS RECON SOLN 3 TIGECYCLINE INTRAVENOUS RECON SOLN 3 tinidazole oral tablet 1 TOBI PODHALER INHALATION CAPSULE 4 QL TOBI PODHALER INHALATION CAPSULE, 4 QL W/INHALATION DEVICE tobramycin in 0.225 % nacl inhalation solution for 4 QL nebulization tobramycin in 0.9 % nacl intravenous piggyback 1 60 mg/50 ml tobramycin sulfate injection recon soln 1 tobramycin sulfate injection solution 1 TRECATOR ORAL TABLET 3 TYGACIL INTRAVENOUS RECON SOLN 3 XIFAXAN ORAL TABLET 200 MG 3 QL XIFAXAN ORAL TABLET 550 MG 4 PA; QL ZYVOX INTRAVENOUS PARENTERAL 3 SOLUTION 200 MG/100 ML PENICILLINS amoxicillin oral capsule 5 amoxicillin oral suspension for reconstitution 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 13
Drug Name Drug Tier Requirements / Limits amoxicillin oral tablet 1 amoxicillin oral tablet,chewable 125 mg, 250 mg 1 amoxicillin-pot clavulanate oral suspension for 1 reconstitution amoxicillin-pot clavulanate oral tablet 1 amoxicillin-pot clavulanate oral tablet extended 1 release 12 hr amoxicillin-pot clavulanate oral tablet,chewable 1 ampicillin oral capsule 5 ampicillin sodium injection recon soln 1 ampicillin sodium intravenous recon soln 1 ampicillin-sulbactam injection recon soln 1 ampicillin-sulbactam intravenous recon soln 1.5 1 gram AUGMENTIN ORAL SUSPENSION FOR 3 RECONSTITUTION 125-31.25 MG/5 ML BICILLIN C-R INTRAMUSCULAR SYRINGE 3 BICILLIN L-A INTRAMUSCULAR SYRINGE 3 dicloxacillin oral capsule 1 nafcillin in dextrose iso-osm intravenous 1 piggyback nafcillin injection recon soln 1 gram, 10 gram 1 nafcillin injection recon soln 2 gram 1 QL nafcillin intravenous recon soln 1 oxacillin in dextrose(iso-osm) intravenous 1 piggyback oxacillin injection recon soln 1 oxacillin intravenous recon soln 2 gram 1 PENICILLIN G POT IN DEXTROSE 3 INTRAVENOUS PIGGYBACK penicillin g potassium injection recon soln 1 penicillin g procaine intramuscular syringe 1 penicillin g sodium injection recon soln 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 14
Drug Name Drug Tier Requirements / Limits penicillin v potassium oral recon soln 1 penicillin v potassium oral tablet 250 mg 5 penicillin v potassium oral tablet 500 mg 1 pfizerpen-g injection recon soln 1 piperacillin-tazobactam intravenous recon soln 1 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram QUINOLONES AVELOX IN NACL (ISO-OSMOTIC) 3 INTRAVENOUS PIGGYBACK CIPRO ORAL SUSPENSION,MICROCAPSULE 3 RECON ciprofloxacin (mixture) oral tablet, er multiphase 1 QL 24 hr ciprofloxacin hcl oral tablet 100 mg, 750 mg 1 ciprofloxacin hcl oral tablet 250 mg, 500 mg 5 ciprofloxacin in 5 % dextrose intravenous 1 piggyback ciprofloxacin lactate intravenous solution 1 ciprofloxacin oral suspension,microcapsule recon 1 FACTIVE ORAL TABLET 3 QL levofloxacin in d5w intravenous piggyback 1 levofloxacin intravenous solution 1 levofloxacin oral solution 1 levofloxacin oral tablet 1 moxifloxacin oral tablet 1 MOXIFLOXACIN-SOD.ACE,SUL-WATER 3 INTRAVENOUS PIGGYBACK ofloxacin oral tablet 300 mg, 400 mg 1 SULFA'S & RELATED AGENTS sulfadiazine oral tablet 1 sulfamethoxazole-trimethoprim intravenous 1 solution sulfamethoxazole-trimethoprim oral suspension 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 15
Drug Name Drug Tier Requirements / Limits sulfamethoxazole-trimethoprim oral tablet 1 sulfatrim oral suspension 1 TETRACYCLINES demeclocycline oral tablet 1 doxy-100 intravenous recon soln 1 doxycycline hyclate oral capsule 1 doxycycline hyclate oral tablet 100 mg, 20 mg 1 doxycycline monohydrate oral capsule 100 mg, 50 1 mg doxycycline monohydrate oral suspension for 1 reconstitution doxycycline monohydrate oral tablet 1 MINOCIN INTRAVENOUS RECON SOLN 3 minocycline oral capsule 1 morgidox oral capsule 100 mg 1 tetracycline oral capsule 1 URINARY TRACT AGENTS methenamine hippurate oral tablet 1 methenamine mandelate oral tablet 1 nitrofurantoin macrocrystal oral capsule 1 nitrofurantoin monohyd/m-cryst oral capsule 1 trimethoprim oral tablet 1 VANCOMYCIN VANCOMYCIN IN 0.9% SODIUM CL 3 INTRAVENOUS PIGGYBACK VANCOMYCIN IN 0.9% SODIUM CL 3 INTRAVENOUS SOLUTION 1 GRAM/250 ML, 1.25 GRAM/250 ML, 1.5 GRAM/250 ML, 1.5 GRAM/500 ML, 1.75 GRAM/250 ML, 1.75 GRAM/500 ML, 2 GRAM/500 ML, 750 MG/150 ML, 750 MG/250 ML VANCOMYCIN IN DEXTROSE 5 % 2 INTRAVENOUS PIGGYBACK 500 MG/100 ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 16
Drug Name Drug Tier Requirements / Limits VANCOMYCIN IN DEXTROSE 5 % 3 INTRAVENOUS PIGGYBACK 750 MG/150 ML vancomycin intravenous recon soln 1 vancomycin oral capsule 4 VIBATIV INTRAVENOUS RECON SOLN 750 3 MG ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline intravenous recon soln 4 dexrazoxane hcl intravenous recon soln 4 LA ELITEK INTRAVENOUS RECON SOLN 4 LA KEPIVANCE INTRAVENOUS RECON SOLN 4 leucovorin calcium oral tablet 1 mesna intravenous solution 4 LA MESNEX ORAL TABLET 4 XGEVA SUBCUTANEOUS SOLUTION 4 PA; QL ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ABRAXANE INTRAVENOUS SUSPENSION 4 LA FOR RECONSTITUTION adriamycin intravenous solution 4 LA adrucil intravenous solution 4 LA AFINITOR DISPERZ ORAL TABLET FOR 4 PA; QL SUSPENSION AFINITOR ORAL TABLET 4 PA; QL ALECENSA ORAL CAPSULE 4 PA; LA; QL ALIMTA INTRAVENOUS RECON SOLN 4 LA ALUNBRIG ORAL TABLET 4 PA; LA; QL anastrozole oral tablet 1 ARRANON INTRAVENOUS SOLUTION 4 LA AVASTIN INTRAVENOUS SOLUTION 4 LA azathioprine oral tablet 1 azathioprine sodium injection recon soln 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 17
Drug Name Drug Tier Requirements / Limits bexarotene oral capsule 4 PA bicalutamide oral tablet 1 BICNU INTRAVENOUS RECON SOLN 4 LA bleo 15k injection recon soln 4 bleomycin injection recon soln 4 LA BOSULIF ORAL TABLET 4 PA; QL busulfan intravenous solution 4 LA BUSULFEX INTRAVENOUS SOLUTION 4 LA CABOMETYX ORAL TABLET 4 PA; LA; QL capecitabine oral tablet 4 PA CAPRELSA ORAL TABLET 4 PA; QL carboplatin intravenous solution 4 LA CELLCEPT INTRAVENOUS INTRAVENOUS 4 RECON SOLN CELLCEPT ORAL SUSPENSION FOR 4 RECONSTITUTION cisplatin intravenous solution 4 LA cladribine intravenous solution 4 LA COMETRIQ ORAL CAPSULE 4 PA; QL COTELLIC ORAL TABLET 4 PA; LA; QL cyclophosphamide intravenous recon soln 4 LA CYCLOPHOSPHAMIDE ORAL CAPSULE 4 cyclosporine intravenous solution 4 cyclosporine modified oral capsule 1 cyclosporine modified oral solution 1 cyclosporine oral capsule 1 cytarabine (pf) injection solution 4 LA cytarabine injection solution 4 LA dacarbazine intravenous recon soln 4 LA daunorubicin intravenous recon soln 4 LA daunorubicin intravenous solution 4 LA doxorubicin intravenous recon soln 4 LA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 18
Drug Name Drug Tier Requirements / Limits doxorubicin intravenous solution 4 LA doxorubicin, peg-liposomal intravenous 1 LA suspension ELIGARD (3 MONTH) SUBCUTANEOUS 4 PA; QL SYRINGE ELIGARD (4 MONTH) SUBCUTANEOUS 4 PA; QL SYRINGE ELIGARD (6 MONTH) SUBCUTANEOUS 4 PA; QL SYRINGE ELIGARD SUBCUTANEOUS SYRINGE 4 PA; QL EMCYT ORAL CAPSULE 4 PA epirubicin intravenous recon soln 200 mg 4 LA epirubicin intravenous solution 4 LA ERBITUX INTRAVENOUS SOLUTION 4 LA ERIVEDGE ORAL CAPSULE 4 PA; LA; QL ETOPOPHOS INTRAVENOUS RECON SOLN 4 LA etoposide intravenous solution 4 PA; LA etoposide oral capsule 4 PA exemestane oral tablet 1 FARESTON ORAL TABLET 4 FARYDAK ORAL CAPSULE 4 PA; LA; QL FASLODEX INTRAMUSCULAR SYRINGE 4 LA FIRMAGON KIT W DILUENT SYRINGE 4 PA; LA; QL SUBCUTANEOUS RECON SOLN floxuridine injection recon soln 4 LA fludarabine intravenous recon soln 4 LA fludarabine intravenous solution 4 LA fluorouracil intravenous solution 4 LA flutamide oral capsule 1 gemcitabine intravenous recon soln 4 LA gemcitabine intravenous solution 4 LA gengraf oral capsule 1 gengraf oral solution 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 19
Drug Name Drug Tier Requirements / Limits GILOTRIF ORAL TABLET 4 PA; LA; QL GLEEVEC ORAL TABLET 4 PA; QL GLEOSTINE ORAL CAPSULE 4 PA HEXALEN ORAL CAPSULE 3 HYCAMTIN ORAL CAPSULE 4 PA hydroxyurea oral capsule 1 IBRANCE ORAL CAPSULE 4 PA; LA; QL ICLUSIG ORAL TABLET 4 PA; QL idarubicin intravenous solution 4 LA; QL IDHIFA ORAL TABLET 4 PA; LA ifosfamide intravenous recon soln 4 LA ifosfamide intravenous solution 4 LA ifosfamide-mesna intravenous kit 4 LA IMBRUVICA ORAL CAPSULE 4 PA; QL INLYTA ORAL TABLET 4 PA; LA; QL IODOPEN INTRAVENOUS SOLUTION 3 IRESSA ORAL TABLET 4 PA; LA; QL irinotecan intravenous solution 4 LA IXEMPRA INTRAVENOUS RECON SOLN 4 LA JAKAFI ORAL TABLET 4 PA; LA; QL KISQALI FEMARA CO-PACK ORAL TABLET 4 PA; LA; QL KISQALI ORAL TABLET 4 PA; LA; QL LENVIMA ORAL CAPSULE 4 PA; LA; QL letrozole oral tablet 1 QL LEUKERAN ORAL TABLET 2 leuprolide subcutaneous kit 4 PA; LA lipodox intravenous suspension 4 LA LONSURF ORAL TABLET 4 PA; LA LUPRON DEPOT (3 MONTH) 4 PA; LA; QL INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT (4 MONTH) 4 PA; LA; QL INTRAMUSCULAR SYRINGE KIT
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 20
Drug Name Drug Tier Requirements / Limits LUPRON DEPOT (6 MONTH) 4 PA; LA; QL INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT INTRAMUSCULAR 4 PA; LA; QL SYRINGE KIT LUPRON DEPOT-PED (3 MONTH) 4 PA; LA; QL INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT-PED INTRAMUSCULAR KIT 4 PA; LA; QL LYNPARZA ORAL CAPSULE 4 PA; QL LYNPARZA ORAL TABLET 4 PA; LA; QL LYSODREN ORAL TABLET 4 PA; LA MATULANE ORAL CAPSULE 3 megestrol oral suspension 400 mg/10 ml (40 1 mg/ml) megestrol oral tablet 1 MEKINIST ORAL TABLET 4 PA; LA; QL melphalan oral tablet 1 mercaptopurine oral tablet 1 methotrexate sodium (pf) injection recon soln 4 methotrexate sodium (pf) injection solution 4 methotrexate sodium injection solution 4 methotrexate sodium oral tablet 1 mitomycin intravenous recon soln 4 LA mitoxantrone intravenous concentrate 4 LA MUSTARGEN INJECTION RECON SOLN 4 LA mycophenolate mofetil hcl intravenous recon soln 4 mycophenolate mofetil oral capsule 1 mycophenolate mofetil oral suspension for 4 reconstitution mycophenolate mofetil oral tablet 1 mycophenolate sodium oral tablet,delayed release 1 (dr/ec) MYLERAN ORAL TABLET 2 LA NERLYNX ORAL TABLET 4 PA; LA; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 21
Drug Name Drug Tier Requirements / Limits NEXAVAR ORAL TABLET 4 PA; LA; QL nilutamide oral tablet 4 PA; LA NINLARO ORAL CAPSULE 4 PA; LA; QL NULOJIX INTRAVENOUS RECON SOLN 4 PA; LA octreotide acetate injection solution 4 LA octreotide acetate injection syringe 4 LA ODOMZO ORAL CAPSULE 4 PA; LA; QL ONCASPAR INJECTION SOLUTION 4 LA oxaliplatin intravenous recon soln 4 LA oxaliplatin intravenous solution 4 LA paclitaxel intravenous concentrate 4 LA PHOTOFRIN INTRAVENOUS RECON SOLN 4 LA PROGRAF INTRAVENOUS SOLUTION 4 RAPAMUNE ORAL SOLUTION 4 PA RITUXAN HYCELA SUBCUTANEOUS 4 PA SOLUTION RITUXAN INTRAVENOUS CONCENTRATE 4 PA; LA RUBRACA ORAL TABLET 4 PA; QL RYDAPT ORAL CAPSULE 4 PA; LA; QL SANDOSTATIN LAR DEPOT 4 PA; LA; QL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON SIGNIFOR LAR INTRAMUSCULAR 4 PA; LA; QL SUSPENSION FOR RECONSTITUTION SIGNIFOR SUBCUTANEOUS SOLUTION 4 PA; LA; QL SIMULECT INTRAVENOUS RECON SOLN 4 LA sirolimus oral tablet 1 SOMATULINE DEPOT SUBCUTANEOUS 4 PA; LA; QL SYRINGE SPRYCEL ORAL TABLET 4 PA; QL STIVARGA ORAL TABLET 4 PA; LA; QL SUPPRELIN LA IMPLANT KIT 4 PA; LA; QL SUTENT ORAL CAPSULE 4 PA; LA; QL You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 22
Drug Name Drug Tier Requirements / Limits SYLVANT INTRAVENOUS RECON SOLN 4 PA; LA TABLOID ORAL TABLET 2 PA tacrolimus oral capsule 1 TAFINLAR ORAL CAPSULE 4 PA; LA; QL TAGRISSO ORAL TABLET 4 PA; LA; QL tamoxifen oral tablet 1 TARCEVA ORAL TABLET 100 MG, 150 MG 4 PA; LA; QL TARCEVA ORAL TABLET 25 MG 4 PA; LA TARGRETIN TOPICAL GEL 4 PA TASIGNA ORAL CAPSULE 4 PA; QL TEMODAR INTRAVENOUS RECON SOLN 4 temozolomide oral capsule 4 PA; LA THALOMID ORAL CAPSULE 4 PA; LA; QL toposar intravenous solution 4 LA topotecan intravenous recon soln 4 LA topotecan intravenous solution 4 LA TORISEL INTRAVENOUS RECON SOLN 4 LA TRELSTAR INTRAMUSCULAR SUSPENSION 4 PA; QL FOR RECONSTITUTION 11.25 MG, 3.75 MG TRELSTAR INTRAMUSCULAR SUSPENSION 4 PA; LA; QL FOR RECONSTITUTION 22.5 MG TRELSTAR INTRAMUSCULAR SYRINGE 4 PA; LA; QL tretinoin (chemotherapy) oral capsule 4 TRISENOX INTRAVENOUS SOLUTION 4 LA TYKERB ORAL TABLET 4 PA; LA; QL VANTAS IMPLANT KIT 4 PA; LA; QL VENCLEXTA ORAL TABLET 100 MG 4 PA; QL vinblastine intravenous solution 4 LA vincasar pfs intravenous solution 4 LA vincristine intravenous solution 4 LA vinorelbine intravenous solution 4 LA VOTRIENT ORAL TABLET 4 PA; LA; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 23
Drug Name Drug Tier Requirements / Limits XALKORI ORAL CAPSULE 4 PA; LA; QL XERMELO ORAL TABLET 4 PA; QL XTANDI ORAL CAPSULE 4 PA; LA; QL ZANOSAR INTRAVENOUS RECON SOLN 4 LA ZEJULA ORAL CAPSULE 4 PA; QL ZELBORAF ORAL TABLET 4 PA; LA; QL ZOLADEX SUBCUTANEOUS IMPLANT 4 PA; LA; QL ZOLINZA ORAL CAPSULE 4 PA; LA; QL ZORTRESS ORAL TABLET 4 ZYDELIG ORAL TABLET 4 PA; QL ZYKADIA ORAL CAPSULE 4 PA; LA; QL ZYTIGA ORAL TABLET 4 PA; LA; QL AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 3 PA; QL BANZEL ORAL SUSPENSION 3 PA BANZEL ORAL TABLET 3 PA BRIVIACT INTRAVENOUS SOLUTION 3 PA; QL BRIVIACT ORAL SOLUTION 3 PA; QL BRIVIACT ORAL TABLET 3 PA; QL carbamazepine oral capsule, er multiphase 12 hr 1 carbamazepine oral suspension 100 mg/5 ml 1 carbamazepine oral tablet 1 carbamazepine oral tablet extended release 12 hr 1 carbamazepine oral tablet,chewable 1 CELONTIN ORAL CAPSULE 300 MG 2 clonazepam oral tablet 1 clonazepam oral tablet,disintegrating 1 ST diazepam rectal kit 1 DILANTIN ORAL CAPSULE 30 MG 2 divalproex oral capsule, delayed rel sprinkle 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 24
Drug Name Drug Tier Requirements / Limits divalproex oral tablet extended release 24 hr 1 divalproex oral tablet,delayed release (dr/ec) 1 epitol oral tablet 1 ethosuximide oral capsule 1 ethosuximide oral solution 1 felbamate oral suspension 1 felbamate oral tablet 1 fosphenytoin injection solution 1 FYCOMPA ORAL SUSPENSION 3 PA; QL FYCOMPA ORAL TABLET 3 PA; QL gabapentin oral capsule 1 gabapentin oral solution 250 mg/5 ml 1 gabapentin oral tablet 600 mg, 800 mg 1 GRALISE 30-DAY STARTER PACK ORAL 3 PA; QL TABLET EXTENDED RELEASE 24 HR GRALISE ORAL TABLET EXTENDED 3 PA; QL RELEASE 24 HR lamotrigine oral tablet 1 lamotrigine oral tablet, chewable dispersible 1 QL levetiracetam in nacl (iso-os) intravenous 1 piggyback levetiracetam intravenous solution 1 levetiracetam oral solution 1 levetiracetam oral tablet 1 levetiracetam oral tablet extended release 24 hr 1 QL LYRICA ORAL CAPSULE 3 PA; QL LYRICA ORAL SOLUTION 3 PA; QL ONFI ORAL SUSPENSION 3 PA; QL ONFI ORAL TABLET 10 MG, 20 MG 3 PA; QL oxcarbazepine oral suspension 1 oxcarbazepine oral tablet 1 PEGANONE ORAL TABLET 3
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 25
Drug Name Drug Tier Requirements / Limits phenobarbital oral elixir 1 phenobarbital oral tablet 1 phenytoin oral suspension 125 mg/5 ml 1 phenytoin oral tablet,chewable 1 phenytoin sodium extended oral capsule 1 phenytoin sodium intravenous solution 1 phenytoin sodium intravenous syringe 1 primidone oral tablet 1 QL roweepra oral tablet 1 SABRIL ORAL TABLET 4 PA; LA; QL tiagabine oral tablet 1 topiramate oral capsule, sprinkle 1 QL topiramate oral tablet 1 valproate sodium intravenous solution 1 valproic acid (as sodium salt) oral solution 250 1 mg/5 ml valproic acid oral capsule 1 vigabatrin oral powder in packet 4 PA; LA; QL VIMPAT INTRAVENOUS SOLUTION 3 PA VIMPAT ORAL SOLUTION 3 PA VIMPAT ORAL TABLET 3 PA zonisamide oral capsule 1 ANTIPARKINSONISM AGENTS APOKYN SUBCUTANEOUS CARTRIDGE 4 PA; QL benztropine injection solution 1 benztropine oral tablet 1 bromocriptine oral capsule 1 bromocriptine oral tablet 1 carbidopa oral tablet 1 ST carbidopa-levodopa oral tablet 1 carbidopa-levodopa oral tablet extended release 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 26
Drug Name Drug Tier Requirements / Limits carbidopa-levodopa oral tablet,disintegrating 1 carbidopa-levodopa-entacapone oral tablet 1 DUOPA J-TUBE INTESTINAL PUMP 4 PA; LA SUSPENSION entacapone oral tablet 1 pramipexole oral tablet 1 rasagiline oral tablet 1 ropinirole oral tablet 1 ropinirole oral tablet extended release 24 hr 1 ST selegiline hcl oral capsule 1 selegiline hcl oral tablet 1 tolcapone oral tablet 1 ST trihexyphenidyl oral elixir 1 trihexyphenidyl oral tablet 1 MIGRAINE & CLUSTER HEADACHE THERAPY almotriptan malate oral tablet 3 ST; QL dihydroergotamine injection solution 3 dihydroergotamine nasal spray,non-aerosol 3 QL eletriptan hbr oral tablet 3 ST; QL ERGOMAR SUBLINGUAL TABLET 3 PA; QL frovatriptan oral tablet 3 ST; QL isometh-dichloral-acetaminophn oral capsule 1 naratriptan oral tablet 3 QL nodolor oral capsule 1 rizatriptan oral tablet 10 mg 1 QL rizatriptan oral tablet 5 mg 3 QL rizatriptan oral tablet,disintegrating 10 mg 1 QL rizatriptan oral tablet,disintegrating 5 mg 3 QL sumatriptan nasal spray,non-aerosol 3 QL sumatriptan succinate oral tablet 1 QL sumatriptan succinate subcutaneous cartridge 2 QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 27
Drug Name Drug Tier Requirements / Limits sumatriptan succinate subcutaneous pen injector 4 2 PA; QL mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 2 QL mg/0.5 ml sumatriptan succinate subcutaneous solution 2 QL zolmitriptan oral tablet 3 QL zolmitriptan oral tablet,disintegrating 3 QL ZOMIG NASAL SPRAY,NON-AEROSOL 3 QL MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA ORAL TABLET EXTENDED 4 PA; LA; QL RELEASE 12 HR AUSTEDO ORAL TABLET 4 PA; QL donepezil oral tablet 10 mg, 5 mg 1 PA donepezil oral tablet,disintegrating 1 PA galantamine oral capsule,ext rel. pellets 24 hr 1 PA galantamine oral solution 1 PA galantamine oral tablet 1 PA HORIZANT ORAL TABLET EXTENDED 3 PA; QL RELEASE KEVEYIS ORAL TABLET 4 PA; QL memantine oral solution 1 PA memantine oral tablet 1 PA MEMANTINE ORAL TABLETS,DOSE PACK 2 PA NAMENDA TITRATION PAK ORAL 2 PA TABLETS,DOSE PACK NUEDEXTA ORAL CAPSULE 4 PA; QL rivastigmine tartrate oral capsule 1 PA rivastigmine transdermal patch 24 hour 1 PA tetrabenazine oral tablet 4 PA; LA; QL TYSABRI INTRAVENOUS SOLUTION 4 PA; LA; QL MUSCLE RELAXANTS & ANTISPASMODIC THERAPY baclofen oral tablet 1 carisoprodol oral tablet 350 mg 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 28
Drug Name Drug Tier Requirements / Limits carisoprodol-aspirin oral tablet 3 chlorzoxazone oral tablet 500 mg 1 cyclobenzaprine oral tablet 10 mg, 5 mg 1 dantrolene oral capsule 1 meprobamate oral tablet 1 metaxall oral tablet 3 PA; QL metaxalone oral tablet 800 mg 3 PA; QL methocarbamol injection solution 1 methocarbamol oral tablet 1 orphenadrine citrate injection solution 1 orphenadrine citrate oral tablet extended release 1 pyridostigmine bromide oral tablet 1 pyridostigmine bromide oral tablet extended 4 PA release regonol injection solution 1 ROBAXIN INJECTION SOLUTION 3 tizanidine oral tablet 1 NARCOTIC ANALGESICS ABSTRAL SUBLINGUAL TABLET 4 PA; QL acetaminophen-codeine oral solution 120-12 mg/5 1 PA < 18 years of age; QL ml acetaminophen-codeine oral tablet 1 PA < 18 years of age; QL ascomp with codeine oral capsule 1 PA < 18 years of age; QL astramorph-pf injection solution 1 mg/ml 1 PA < 18 years of age BUPRENEX INJECTION SOLUTION 3 PA < 18 years of age buprenorphine hcl injection solution 1 PA < 18 years of age buprenorphine hcl injection syringe 1 PA < 18 years of age buprenorphine hcl sublingual tablet 1 PA; QL BUPRENORPHINE TRANSDERMAL PATCH 3 PA; QL WEEKLY butalbital compound w/codeine oral capsule 1 PA < 18 years of age; QL butalbital-acetaminop-caf-cod oral capsule 1 PA < 18 years of age; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 29
Drug Name Drug Tier Requirements / Limits butalbital-acetaminophen oral tablet 50-325 mg 1 butalbital-acetaminophen-caff oral capsule 50- 1 325-40 mg butalbital-acetaminophen-caff oral tablet 50-325- 1 40 mg butalbital-aspirin-caffeine oral capsule 1 butalbital-aspirin-caffeine oral tablet 1 BUTRANS TRANSDERMAL PATCH WEEKLY 3 PA; QL capacet oral capsule 1 codeine sulfate oral tablet 1 PA < 18 years of age; QL DEMEROL (PF) INJECTION SOLUTION 100 3 PA < 18 years of age MG/2 ML, 25 MG/0.5 ML, 75 MG/1.5 ML demerol (pf) injection solution 100 mg/ml 3 PA < 18 years of age DEMEROL (PF) INJECTION SYRINGE 3 PAPA < 18 years of age DEMEROL INJECTION SOLUTION 3 PA < 18 years of age diskets oral tablet,soluble 1 PA < 18 years of age; QL duramorph (pf) injection solution 1 PA < 18 years of age EMBEDA ORAL CAPSULE,ORAL 3 PA; QL ONLY,EXT.REL PELL endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 1 PA < 18 years of age; QL mg, 7.5-325 mg fentanyl citrate (pf) intravenous syringe 100 mcg/2 1 PA < 18 years of age ml (50 mcg/ml) fentanyl citrate buccal lozenge on a handle 4 PA; QL fentanyl transdermal patch 72 hour 100 mcg/hr, 1 PA < 18 years of age; QL 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA BUCCAL TABLET, 4 PA; QL EFFERVESCENT hydrocodone-acetaminophen oral solution 7.5-325 1 PA < 18 years of age; QL mg/15 ml hydrocodone-acetaminophen oral tablet 10-325 1 PA < 18 years of age; QL mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, 5- 1 PA < 18 years of age; QL 200 mg, 7.5-200 mg hydromorphone (pf) injection solution 1 PA < 18 years of age You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 30
Drug Name Drug Tier Requirements / Limits hydromorphone in 0.9 % nacl intravenous pt 1 PA < 18 years of age controlled analgesia syring 15 mg/30 ml (0.5 mg/ml) hydromorphone injection solution 1 PA < 18 years of age HYDROMORPHONE INJECTION SYRINGE 3 PA < 18 years of age 0.5 MG/0.5 ML hydromorphone injection syringe 1 mg/ml, 2 1 PA < 18 years of age mg/ml, 4 mg/ml hydromorphone oral tablet 1 PA < 18 years of age; QL hydromorphone oral tablet extended release 24 hr 1 PA; QL hydromorphone rectal suppository 1 PA < 18 years of age ibuprofen-oxycodone oral tablet 1 PA < 18 years of age; QL LAZANDA NASAL SPRAY,NON-AEROSOL 4 PA; QL 100 MCG/SPRAY, 400 MCG/SPRAY levorphanol tartrate oral tablet 1 PA < 18 years of age; QL lorcet (hydrocodone) oral tablet 1 PA < 18 years of age; QL lorcet hd oral tablet 1 PA < 18 years of age; QL lorcet plus oral tablet 7.5-325 mg 1 PA < 18 years of age; QL marten-tab oral tablet 1 meperidine (pf) injection solution 100 mg/ml, 25 1 PA < 18 years of age mg/ml, 50 mg/ml meperidine injection cartridge 1 PA < 18 years of age meperidine oral solution 1 PA < 18 years of age; QL meperidine oral tablet 1 PA < 18 years of age; QL methadone injection solution 1 PA < 18 years of age methadone oral concentrate 1 PA < 18 years of age; QL methadone oral solution 1 PA < 18 years of age; QL methadone oral tablet 1 PA < 18 years of age; QL methadone oral tablet,soluble 1 PA < 18 years of age; QL methadose oral concentrate 1 PA < 18 years of age; QL methadose oral tablet,soluble 1 PA < 18 years of age; QL morphine (pf) injection solution 0.5 mg/ml, 1 1 PA < 18 years of age mg/ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 31
Drug Name Drug Tier Requirements / Limits morphine (pf) intravenous patient 1 PA < 18 years of age control.analgesia soln morphine concentrate oral solution 1 PA < 18 years of age; QL morphine injection solution 15 mg/ml, 8 mg/ml 1 PA < 18 years of age morphine injection syringe 10 mg/ml, 2 mg/ml, 4 1 PA < 18 years of age mg/ml, 5 mg/ml, 8 mg/ml MORPHINE INTRAMUSCULAR PEN 3 PA < 18 years of age INJECTOR morphine intravenous cartridge 10 mg/ml, 2 1 PA < 18 years of age mg/ml, 4 mg/ml MORPHINE INTRAVENOUS CARTRIDGE 8 3 PA < 18 years of age MG/ML morphine intravenous pt controlled analgesia 1 PA < 18 years of age syring morphine intravenous solution 10 mg/ml, 100 1 PA < 18 years of age mg/4 ml, 25 mg/ml, 250 mg/10 ml, 50 mg/ml morphine intravenous syringe 2 mg/ml, 4 mg/ml 1 PA < 18 years of age morphine oral solution 1 PA < 18 years of age; QL morphine oral tablet 1 PA < 18 years of age; QL morphine oral tablet extended release 1 PA < 18 years of age; QL morphine rectal suppository 1 PA < 18 years of age oxycodone oral capsule 1 PA < 18 years of age; QL oxycodone oral concentrate 1 PA < 18 years of age; QL oxycodone oral solution 1 PA < 18 years of age; QL oxycodone oral tablet 1 PA < 18 years of age; QL OXYCODONE ORAL TABLET,ORAL 3 PA; QL ONLY,EXT.REL.12 HR oxycodone-acetaminophen oral solution 1 PA < 18 years of age; QL oxycodone-acetaminophen oral tablet 10-325 mg, 1 PA < 18 years of age; QL 2.5-325 mg, 5-325 mg, 7.5-325 mg oxycodone-aspirin oral tablet 1 PA < 18 years of age; QL OXYCONTIN ORAL TABLET,ORAL 3 PA; QL ONLY,EXT.REL.12 HR oxymorphone oral tablet 1 PA < 18 years of age; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 32
Drug Name Drug Tier Requirements / Limits oxymorphone oral tablet extended release 12 hr 1 PA < 18 years of age; QL PROBUPHINE SUBDERMAL IMPLANT 4 PA; QL SUBSYS SUBLINGUAL SPRAY,NON- 4 PA; QL AEROSOL tencon oral tablet 50-325 mg 1 verdrocet oral tablet 1 PA < 18 years of age; QL XTAMPZA ER ORAL 2 PA < 18 years of age; QL CAPSULE,SPRINKLE,ER 12HR TMPRR NON-NARCOTIC ANALGESICS aspir-81 oral tablet,delayed release (dr/ec) 6 ACA; OTC aspirin low dose oral tablet,delayed release 6 ACA; OTC (dr/ec) aspirin oral tablet 6 ACA; OTC aspirin oral tablet,chewable 6 ACA; OTC aspirin oral tablet,delayed release (dr/ec) 325 mg, 6 ACA; OTC 81 mg aspir-low oral tablet,delayed release (dr/ec) 6 ACA; OTC aspir-trin oral tablet,delayed release (dr/ec) 6 ACA; OTC bayer aspirin oral tablet 6 ACA; OTC BUNAVAIL BUCCAL FILM 3 PA; QL buprenorphine-naloxone sublingual tablet 3 PA; QL butorphanol tartrate injection solution 1 PA < 18 years of age butorphanol tartrate nasal spray,non-aerosol 1 PA < 18 years of age; QL CALDOLOR INTRAVENOUS RECON SOLN 3 800 MG/8 ML (100 MG/ML) celecoxib oral capsule 2 ST; QL children's aspirin oral tablet,chewable 6 ACA; OTC choline,magnesium salicylate oral liquid 1 diclofenac potassium oral tablet 1 diclofenac sodium oral tablet extended release 24 1 hr diclofenac sodium oral tablet,delayed release 1 (dr/ec)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 33
Drug Name Drug Tier Requirements / Limits diclofenac sodium topical gel 1 % 1 QL diclofenac-misoprostol oral tablet,ir,delayed 1 rel,biphasic diflunisal oral tablet 1 e.c. prin oral tablet,delayed release (dr/ec) 6 ACA; OTC ecotrin low strength oral tablet,delayed release 6 ACA; OTC (dr/ec) ecotrin oral tablet,delayed release (dr/ec) 6 ACA; OTC etodolac oral capsule 1 etodolac oral tablet 1 etodolac oral tablet extended release 24 hr 1 EUFLEXXA INTRA-ARTICULAR SYRINGE 4 PA; LA; QL EVZIO INJECTION AUTO-INJECTOR 4 PA; QL fenoprofen oral tablet 3 PA flurbiprofen oral tablet 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 indomethacin oral capsule 1 indomethacin oral capsule, extended release 1 ketoprofen oral capsule 1 ketorolac injection cartridge 1 QL ketorolac injection solution 1 QL ketorolac injection syringe 1 QL ketorolac intramuscular solution 1 QL ketorolac intramuscular syringe 1 QL ketorolac oral tablet 1 QL lite coat aspirin oral tablet 6 ACA; OTC meclofenamate oral capsule 50 mg 3 PA mefenamic acid oral capsule 3 PA meloxicam oral suspension 3 meloxicam oral tablet 1 nabumetone oral tablet 1 nalbuphine injection solution 1 PA < 18 years of age
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 34
Drug Name Drug Tier Requirements / Limits naloxone injection solution 1 QL naloxone injection syringe 1 naltrexone oral tablet 1 naproxen oral suspension 1 naproxen oral tablet 1 naproxen oral tablet,delayed release (dr/ec) 1 naproxen sodium oral tablet 275 mg, 550 mg 1 NARCAN NASAL SPRAY,NON-AEROSOL 4 2 QL MG/ACTUATION oxaprozin oral tablet 1 pentazocine-naloxone oral tablet 1 PA < 18 years of age; QL piroxicam oral capsule 3 salsalate oral tablet 1 SUBOXONE SUBLINGUAL FILM 2 PA; QL sulindac oral tablet 1 TALWIN INJECTION SOLUTION 3 PA < 18 years of age tolmetin oral tablet 200 mg 3 PA tramadol oral tablet 1 PA < 18 years of age; QL tramadol oral tablet extended release 24 hr 1 PA < 18 years of age; QL tramadol oral tablet, er multiphase 24 hr 1 PA < 18 years of age; QL tramadol-acetaminophen oral tablet 1 PA < 18 years of age; QL VIVITROL INTRAMUSCULAR 4 PA; LA; QL SUSPENSION,EXTENDED REL RECON ZUBSOLV SUBLINGUAL TABLET 2 PA; QL PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA INTRAMUSCULAR 4 ST < 12 years of age; QL SUSPENSION,EXTENDED REL RECON ABILIFY MAINTENA INTRAMUSCULAR 4 ST < 12 years of age; QL SUSPENSION,EXTENDED REL SYRING ADDERALL XR ORAL CAPSULE,EXTENDED 1 PA < 4 and ≥ 18 years of age; QL RELEASE 24HR ADDYI ORAL TABLET 4 PA; QL alprazolam intensol oral concentrate 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 35
Drug Name Drug Tier Requirements / Limits alprazolam oral tablet 1 alprazolam oral tablet extended release 24 hr 1 alprazolam oral tablet,disintegrating 1 ST amitriptyline oral tablet 1 amitriptyline-chlordiazepoxide oral tablet 1 amoxapine oral tablet 1 aripiprazole oral solution 1 PA; QL aripiprazole oral tablet 1 PA < 12 years of age; QL aripiprazole oral tablet,disintegrating 1 PA; QL ARISTADA INTRAMUSCULAR 4 ST < 12 years of age; QL SUSPENSION,EXTENDED REL SYRING armodafinil oral tablet 3 PA; QL atomoxetine oral capsule 1 QL bupropion hcl oral tablet 1 bupropion hcl oral tablet extended release 12 hr 1 100 mg, 200 mg bupropion hcl oral tablet extended release 12 hr 5 150 mg bupropion hcl oral tablet extended release 24 hr 1 buspirone oral tablet 1 chlordiazepoxide hcl oral capsule 1 chlorpromazine injection solution 1 PA < 12 years of age chlorpromazine oral tablet 1 PA < 12 years of age citalopram oral solution 1 citalopram oral tablet 1 QL clomipramine oral capsule 1 ST clonidine hcl oral tablet extended release 12 hr 1 ST; QL clorazepate dipotassium oral tablet 1 clozapine oral tablet 1 PA < 12 years of age clozapine oral tablet,disintegrating 100 mg, 12.5 1 PA < 12 years of age; ST; QL mg, 25 mg CLOZAPINE ORAL 3 PA < 12 years of age; ST; QL TABLET,DISINTEGRATING 150 MG, 200 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 36
Drug Name Drug Tier Requirements / Limits CONCERTA ORAL TABLET EXTENDED 1 PA < 4 and ≥ 18 years of age; QL RELEASE 24HR desipramine oral tablet 1 DESVENLAFAXINE FUMARATE ORAL 3 ST; QL TABLET EXTENDED RELEASE 24HR DESVENLAFAXINE ORAL TABLET 3 ST; QL EXTENDED RELEASE 24 HR desvenlafaxine succinate oral tablet extended 1 ST; QL release 24 hr (generic Pristiq) dexmethylphenidate oral capsule,er biphasic 50- 3 PA < 4 and ≥ 18 years of age; QL 50 dexmethylphenidate oral tablet 1 QL dextroamphetamine oral capsule, extended release 3 PA < 4 and ≥ 18 years of age; QL dextroamphetamine oral tablet 1 PA < 4 and ≥ 18 years of age; QL dextroamphetamine-amphetamine oral tablet 1 QL diazepam injection solution 1 diazepam injection syringe 1 diazepam intensol oral concentrate 1 diazepam oral solution 5 mg/5 ml (1 mg/ml) 1 diazepam oral tablet 1 doxepin oral capsule 1 doxepin oral concentrate 1 duloxetine oral capsule,delayed release(dr/ec) 20 1 QL mg, 30 mg, 60 mg EMSAM TRANSDERMAL PATCH 24 HOUR 3 PA; QL ergoloid oral tablet 1 escitalopram oxalate oral solution 1 QL escitalopram oxalate oral tablet 1 QL estazolam oral tablet 1 eszopiclone oral tablet 1 QL FANAPT ORAL TABLET 3 PA; QL FANAPT ORAL TABLETS,DOSE PACK 3 PA; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 37
Drug Name Drug Tier Requirements / Limits FETZIMA ORAL CAPSULE,EXT REL 24HR 3 PA; QL DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED 3 PA; QL RELEASE 24 HR flumazenil intravenous solution 1 fluoxetine oral capsule 1 fluoxetine oral solution 1 fluoxetine oral tablet 10 mg, 20 mg 1 fluphenazine decanoate injection solution 1 PA < 12 years of age fluphenazine hcl injection solution 1 PA < 12 years of age fluphenazine hcl oral concentrate 1 PA < 12 years of age fluphenazine hcl oral elixir 1 PA < 12 years of age fluphenazine hcl oral tablet 1 PA < 12 years of age flurazepam oral capsule 1 fluvoxamine oral tablet 1 GEODON INTRAMUSCULAR RECON SOLN 3 PA < 12 years of age guanfacine oral tablet extended release 24 hr 1 QL guanidine oral tablet 1 haloperidol decanoate intramuscular solution 1 PA < 12 years of age haloperidol lactate injection solution 1 PA < 12 years of age haloperidol lactate oral concentrate 1 PA < 12 years of age haloperidol oral tablet 1 PA < 12 years of age HETLIOZ ORAL CAPSULE 4 PA; LA; QL imipramine hcl oral tablet 1 imipramine pamoate oral capsule 1 INVEGA SUSTENNA INTRAMUSCULAR 4 ST < 12 years of age; QL SYRINGE INVEGA TRINZA INTRAMUSCULAR 4 ST < 12 years of age; QL SYRINGE KHEDEZLA ORAL TABLET EXTENDED 3 ST; QL RELEASE 24HR LATUDA ORAL TABLET 3 PA < 12 years of age; ST; QL lithium carbonate oral capsule 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 38
Drug Name Drug Tier Requirements / Limits lithium carbonate oral tablet 1 lithium carbonate oral tablet extended release 1 lithium citrate oral solution 8 meq/5 ml 1 lorazepam intensol oral concentrate 1 lorazepam oral concentrate 1 lorazepam oral tablet 1 loxapine succinate oral capsule 1 PA < 12 years of age maprotiline oral tablet 1 MARPLAN ORAL TABLET 3 metadate er oral tablet extended release 1 PA < 4 and ≥ 18 years of age; QL methamphetamine oral tablet 1 PA < 4 and ≥ 18 years of age; QL methylphenidate hcl oral capsule, er biphasic 30- 1 PA < 4 and ≥ 18 years of age; QL 70 methylphenidate hcl oral capsule,er biphasic 50- 1 PA < 4 and ≥ 18 years of age; QL 50 methylphenidate hcl oral solution 3 PA < 4 and ≥ 18 years of age; QL methylphenidate hcl oral tablet 1 QL methylphenidate hcl oral tablet extended release 3 PA < 4 and ≥ 18 years of age; QL 10 mg methylphenidate hcl oral tablet extended release 1 PA < 4 and ≥ 18 years of age; QL 20 mg methylphenidate hcl oral tablet,chewable 1 PA < 4 and ≥ 18 years of age; QL midazolam oral syrup 2 mg/ml 1 mirtazapine oral tablet 1 mirtazapine oral tablet,disintegrating 1 modafinil oral tablet 3 PA; QL nefazodone oral tablet 1 nortriptyline oral capsule 1 nortriptyline oral solution 1 NUPLAZID ORAL TABLET 4 PA; LA; QL olanzapine intramuscular recon soln 1 PA < 12 years of age olanzapine oral tablet 1 PA < 12 years of age; QL olanzapine oral tablet,disintegrating 1 PA < 12 years of age; QL You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 39
Drug Name Drug Tier Requirements / Limits olanzapine-fluoxetine oral capsule 1 PA; QL oxazepam oral capsule 1 paliperidone oral tablet extended release 24hr 1 PA; QL paroxetine hcl oral tablet 1 perphenazine oral tablet 1 PA < 12 years of age perphenazine-amitriptyline oral tablet 1 phenelzine oral tablet 1 pimozide oral tablet 1 PA < 12 years of age protriptyline oral tablet 1 quazepam oral tablet 1 quetiapine oral tablet 1 PA < 12 years of age; QL quetiapine oral tablet extended release 24 hr 1 PA < 12 years of age; QL RISPERDAL CONSTA INTRAMUSCULAR 4 ST < 12 years of age; QL SYRINGE risperidone oral solution 1 PA < 12 years of age risperidone oral tablet 1 PA < 12 years of age; QL risperidone oral tablet,disintegrating 1 PA < 12 years of age; QL ROZEREM ORAL TABLET 3 PA; QL SAPHRIS (BLACK CHERRY) SUBLINGUAL 3 PA < 12 years of age; ST; QL TABLET sertraline oral concentrate 1 sertraline oral tablet 1 temazepam oral capsule 15 mg, 30 mg 1 thioridazine oral tablet 1 PA < 12 years of age thiothixene oral capsule 1 PA < 12 years of age tranylcypromine oral tablet 1 trazodone oral tablet 100 mg, 150 mg, 50 mg 1 triazolam oral tablet 1 trifluoperazine oral tablet 1 PA < 12 years of age trimipramine oral capsule 1 TRINTELLIX ORAL TABLET 3 PA < 12 years of age; QL venlafaxine oral capsule,extended release 24hr 1 QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 40
Drug Name Drug Tier Requirements / Limits venlafaxine oral tablet 1 VIIBRYD ORAL TABLET 3 PA; QL VIIBRYD ORAL TABLETS,DOSE PACK 10 3 PA; QL MG (7)- 20 MG (23) VRAYLAR ORAL CAPSULE 4 PA < 12 years of age; QL VRAYLAR ORAL CAPSULE,DOSE PACK 4 PA < 12 years of age; QL VYVANSE ORAL CAPSULE 3 PA; QL VYVANSE ORAL TABLET,CHEWABLE 3 PA; QL XYREM ORAL SOLUTION 4 PA; LA; QL zaleplon oral capsule 1 ziprasidone hcl oral capsule 1 PA < 12 years of age; QL zolpidem oral tablet 1 QL ZYPREXA RELPREVV INTRAMUSCULAR 4 ST < 12 years of age; QL SUSPENSION FOR RECONSTITUTION CARDIOVASCULAR, HYPERTENSION & LIPIDS ANTIARRHYTHMIC AGENTS amiodarone oral tablet 1 disopyramide phosphate oral capsule 1 dofetilide oral capsule 1 flecainide oral tablet 1 mexiletine oral capsule 1 MULTAQ ORAL TABLET 2 pacerone oral tablet 100 mg, 200 mg, 400 mg 1 propafenone oral capsule,extended release 12 hr 1 propafenone oral tablet 1 quinidine gluconate injection solution 1 quinidine gluconate oral tablet extended release 1 quinidine sulfate oral tablet 1 sotalol af oral tablet 1 SOTALOL INTRAVENOUS SOLUTION 3 sotalol oral tablet 1 ANTIHYPERTENSIVE THERAPY You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 41
Drug Name Drug Tier Requirements / Limits acebutolol oral capsule 1 afeditab cr oral tablet extended release 1 amiloride oral tablet 1 amiloride-hydrochlorothiazide oral tablet 1 amlodipine oral tablet 1 amlodipine-benazepril oral capsule 1 atenolol oral tablet 5 atenolol-chlorthalidone oral tablet 5 benazepril oral tablet 5 benazepril-hydrochlorothiazide oral tablet 3 betaxolol oral tablet 1 bisoprolol fumarate oral tablet 1 bisoprolol-hydrochlorothiazide oral tablet 5 bumetanide injection solution 1 bumetanide oral tablet 0.5 mg, 1 mg 5 bumetanide oral tablet 2 mg 1 BYSTOLIC ORAL TABLET 3 PA BYVALSON ORAL TABLET 3 PA candesartan oral tablet 1 candesartan-hydrochlorothiazid oral tablet 1 captopril oral tablet 3 captopril-hydrochlorothiazide oral tablet 3 cartia xt oral capsule,extended release 24hr 1 carvedilol oral tablet 5 chlorothiazide oral tablet 1 chlorothiazide sodium intravenous recon soln 1 chlorthalidone oral tablet 25 mg, 50 mg 1 clonidine hcl oral tablet 1 clonidine transdermal patch weekly 1 DEMSER ORAL CAPSULE 4 PA diltiazem hcl oral capsule,ext.rel 24h degradable 1 240 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 42
Drug Name Drug Tier Requirements / Limits diltiazem hcl oral capsule,extended release 12 hr 1 diltiazem hcl oral capsule,extended release 24 hr 1 240 mg, 420 mg diltiazem hcl oral capsule,extended release 24hr 1 diltiazem hcl oral tablet 1 diltiazem hcl oral tablet extended release 24 hr 1 180 mg, 240 mg, 300 mg, 360 mg dilt-xr oral capsule,ext.rel 24h degradable 1 DIURIL ORAL SUSPENSION 3 doxazosin oral tablet 1 DYRENIUM ORAL CAPSULE 3 ST EDARBI ORAL TABLET 3 PA EDARBYCLOR ORAL TABLET 3 PA enalapril maleate oral tablet 1 enalaprilat intravenous solution 1 enalapril-hydrochlorothiazide oral tablet 1 eplerenone oral tablet 1 epoprostenol (glycine) intravenous recon soln 4 PA; LA eprosartan oral tablet 1 esmolol intravenous solution 1 ethacrynic acid oral tablet 3 ST felodipine oral tablet extended release 24 hr 1 FLOLAN INTRAVENOUS RECON SOLN 4 PA; LA; QL fosinopril oral tablet 1 fosinopril-hydrochlorothiazide oral tablet 1 furosemide injection solution 1 furosemide injection syringe 1 furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 1 mg/ml) furosemide oral tablet 5 guanfacine oral tablet 1 hydralazine injection solution 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 43
Drug Name Drug Tier Requirements / Limits hydralazine oral tablet 1 hydrochlorothiazide oral capsule 5 hydrochlorothiazide oral tablet 12.5 mg 1 hydrochlorothiazide oral tablet 25 mg, 50 mg 5 indapamide oral tablet 1 irbesartan oral tablet 1 irbesartan-hydrochlorothiazide oral tablet 1 isradipine oral capsule 1 labetalol intravenous solution 1 labetalol intravenous syringe 20 mg/4 ml (5 1 mg/ml) labetalol oral tablet 1 LEVATOL ORAL TABLET 3 ST lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 5 lisinopril oral tablet 30 mg, 40 mg 1 lisinopril-hydrochlorothiazide oral tablet 5 losartan oral tablet 1 losartan-hydrochlorothiazide oral tablet 1 methyclothiazide oral tablet 1 methyldopa oral tablet 1 methyldopa-hydrochlorothiazide oral tablet 1 methyldopate intravenous solution 1 metolazone oral tablet 1 metoprolol succinate oral tablet extended release 1 24 hr metoprolol ta-hydrochlorothiaz oral tablet 1 metoprolol tartrate intravenous solution 1 metoprolol tartrate intravenous syringe 1 metoprolol tartrate oral tablet 100 mg, 25 mg, 50 5 mg minoxidil oral tablet 1 moexipril oral tablet 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 44
Drug Name Drug Tier Requirements / Limits moexipril-hydrochlorothiazide oral tablet 1 nadolol oral tablet 1 nadolol-bendroflumethiazide oral tablet 1 nicardipine intravenous solution 1 nicardipine oral capsule 1 nifedipine oral capsule 1 nifedipine oral tablet extended release 1 nifedipine oral tablet extended release 24hr 1 nimodipine oral capsule 1 nisoldipine oral tablet extended release 24 hr 1 ST olmesartan oral tablet 1 PA ORENITRAM ORAL TABLET EXTENDED 4 PA; LA RELEASE papaverine injection solution 1 perindopril erbumine oral tablet 1 phenoxybenzamine oral capsule 4 PA phentolamine injection recon soln 1 pindolol oral tablet 1 prazosin oral capsule 1 propranolol intravenous solution 1 propranolol oral capsule,extended release 24 hr 1 propranolol oral solution 1 propranolol oral tablet 10 mg, 20 mg, 40 mg, 80 5 mg propranolol oral tablet 60 mg 1 propranolol-hydrochlorothiazid oral tablet 1 quinapril oral tablet 1 quinapril-hydrochlorothiazide oral tablet 1 ramipril oral capsule 1 REMODULIN INJECTION SOLUTION 4 PA; LA spironolactone oral tablet 100 mg, 50 mg 1 spironolactone oral tablet 25 mg 5
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 45
Drug Name Drug Tier Requirements / Limits spironolacton-hydrochlorothiaz oral tablet 1 taztia xt oral capsule,extended release 24 hr 1 TEKTURNA HCT ORAL TABLET 2 ST TEKTURNA ORAL TABLET 2 ST telmisartan oral tablet 1 telmisartan-amlodipine oral tablet 1 telmisartan-hydrochlorothiazid oral tablet 1 terazosin oral capsule 1 timolol maleate oral tablet 1 torsemide oral tablet 1 trandolapril oral tablet 1 trandolapril-verapamil oral tablet, ir - er, biphasic 1 24hr triamterene-hydrochlorothiazid oral capsule 37.5- 5 25 mg triamterene-hydrochlorothiazid oral capsule 50-25 1 mg triamterene-hydrochlorothiazid oral tablet 5 UPTRAVI ORAL TABLET 4 PA; LA; QL UPTRAVI ORAL TABLETS,DOSE PACK 4 PA; LA; QL valsartan oral tablet 1 valsartan-hydrochlorothiazide oral tablet 1 veletri intravenous recon soln 4 PA; LA verapamil intravenous solution 1 verapamil intravenous syringe 1 verapamil oral capsule,ext rel. pellets 24 hr 120 1 mg, 180 mg, 240 mg verapamil oral tablet 1 verapamil oral tablet extended release 1 CARDIAC GLYCOSIDES digitek oral tablet 1 digox oral tablet 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 46
Drug Name Drug Tier Requirements / Limits digoxin injection solution 1 digoxin injection syringe 1 digoxin oral solution 50 mcg/ml 1 digoxin oral tablet 1 COAGULATION THERAPY aminocaproic acid intravenous solution 1 aspirin-dipyridamole oral capsule, er multiphase 1 12 hr bivalirudin intravenous recon soln 1 BRILINTA ORAL TABLET 2 QL cilostazol oral tablet 1 clopidogrel oral tablet 1 dipyridamole oral tablet 1 ELIQUIS ORAL TABLET 2 QL enoxaparin subcutaneous solution 4 QL enoxaparin subcutaneous syringe 4 QL fondaparinux subcutaneous syringe 4 QL FRAGMIN SUBCUTANEOUS SOLUTION 4 QL FRAGMIN SUBCUTANEOUS SYRINGE 4 QL hep flush-10 (pf) intravenous solution 1 HEPARIN (PORCINE) IN 0.9% NACL 3 INTRAVENOUS PARENTERAL SOLUTION 1,000 UNIT/1000 ML (1 UNIT/ML), 2,000 UNIT/500 ML (4 UNIT/ML), 4000 UNIT/1000 ML (4 UNIT/ML), 6,000 UNIT/1000 ML (6 UNIT/ML) heparin (porcine) in 5 % dex intravenous 1 parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous 1 parenteral solution heparin (porcine) injection cartridge 1 heparin (porcine) injection solution 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 47
Drug Name Drug Tier Requirements / Limits heparin (porcine) injection syringe 5,000 unit/ml 1 heparin flush(porcine)-0.9nacl intravenous kit 1 heparin lock flush (porcine) intravenous solution 1 100 unit/ml heparin lock flush intravenous solution 1 heparin lock flush intravenous syringe 1 heparin lockflush(porcine)(pf) intravenous syringe 1 HEPARIN(PORCINE) IN 0.45% NACL 3 INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML heparin(porcine) in 0.45% nacl intravenous 1 parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml heparin, porcine (pf) injection solution 1 heparin, porcine (pf) injection syringe 1 heparin, porcine (pf) intravenous solution 100 1 unit/ml (1 ml) heparin, porcine (pf) intravenous syringe 1 jantoven oral tablet 1 MEPHYTON ORAL TABLET 3 NPLATE SUBCUTANEOUS RECON SOLN 4 PA; LA pentoxifylline oral tablet extended release 1 PRADAXA ORAL CAPSULE 3 QL prasugrel oral tablet 1 QL PROMACTA ORAL TABLET 4 PA; LA; QL protamine intravenous solution 1 ticlopidine oral tablet 1 tranexamic acid intravenous solution 1 vitamin k injection solution 1 vitamin k1 injection solution 1 warfarin oral tablet 1 XARELTO ORAL TABLET 2 QL XARELTO ORAL TABLETS,DOSE PACK 2 QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 48
Drug Name Drug Tier Requirements / Limits ZONTIVITY ORAL TABLET 3 PA; QL LIPID/CHOLESTEROL LOWERING AGENTS atorvastatin oral tablet 1 cholestyramine (with sugar) oral powder 3 cholestyramine (with sugar) oral powder in packet 3 cholestyramine light oral powder 3 cholestyramine light oral powder in packet 3 colestipol oral granules 3 colestipol oral packet 3 colestipol oral tablet 3 ezetimibe oral tablet 1 fenofibrate micronized oral capsule 134 mg, 43 1 mg, 67 mg fenofibrate micronized oral capsule 200 mg 3 fenofibrate nanocrystallized oral tablet 1 fenofibrate oral tablet 160 mg, 54 mg 1 fenofibric acid (choline) oral capsule,delayed 3 release(dr/ec) fenofibric acid oral tablet 3 fluvastatin oral capsule 3 gemfibrozil oral tablet 1 JUXTAPID ORAL CAPSULE 4 PA; QL KYNAMRO SUBCUTANEOUS SYRINGE 4 PA; LA; QL LIVALO ORAL TABLET 3 PA lovastatin oral tablet 1 niacin oral tablet extended release 24 hr 3 omega-3 acid ethyl esters oral capsule 2 PRALUENT PEN SUBCUTANEOUS PEN 4 PA; LA; QL INJECTOR pravastatin oral tablet 1 prevalite oral powder 3 prevalite oral powder in packet 3
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 49
Drug Name Drug Tier Requirements / Limits REPATHA PUSHTRONEX SUBCUTANEOUS 4 PA; QL WEARABLE INJECTOR REPATHA SURECLICK SUBCUTANEOUS 4 PA; QL PEN INJECTOR REPATHA SYRINGE SUBCUTANEOUS 4 PA; QL SYRINGE rosuvastatin oral tablet 1 ST simvastatin oral tablet 1 triklo oral capsule 2 VASCEPA ORAL CAPSULE 2 WELCHOL ORAL POWDER IN PACKET 2 WELCHOL ORAL TABLET 2 MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR ORAL TABLET 3 PA; QL ENTRESTO ORAL TABLET 2 PA; QL RANEXA ORAL TABLET EXTENDED 2 RELEASE 12 HR NITRATES isosorbide dinitrate oral tablet 1 isosorbide dinitrate oral tablet extended release 1 isosorbide mononitrate oral tablet 1 isosorbide mononitrate oral tablet extended 1 release 24 hr nitro-bid transdermal ointment 1 NITRO-DUR TRANSDERMAL PATCH 24 3 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin in 5 % dextrose intravenous solution 1 nitroglycerin intravenous solution 1 nitroglycerin oral capsule, extended release 1 nitroglycerin sublingual tablet 1 nitroglycerin transdermal patch 24 hour 1 nitroglycerin translingual aerosol,spray 1 nitroglycerin translingual spray,non-aerosol 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 50
Drug Name Drug Tier Requirements / Limits nitro-time oral capsule, extended release 1 DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin oral capsule 4 ST calcipotriene scalp solution 3 calcipotriene topical cream 3 calcipotriene topical ointment 3 calcitrene topical ointment 3 calcitriol topical ointment 3 QL COSENTYX (2 SYRINGES) SUBCUTANEOUS 4 PA; LA; QL SYRINGE COSENTYX PEN (2 PENS) SUBCUTANEOUS 4 PA; LA; QL PEN INJECTOR COSENTYX PEN SUBCUTANEOUS PEN 4 PA; LA; QL INJECTOR COSENTYX SUBCUTANEOUS SYRINGE 4 PA; LA; QL drithocreme hp topical cream 1 hydrocortisone-pramoxine topical cream 1 seb-prev topical cleanser 1 selenium sulfide topical lotion 1 selenium sulfide topical shampoo 2.25 % 1 SILIQ SUBCUTANEOUS SYRINGE 4 PA; LA; QL STELARA INTRAVENOUS SOLUTION 4 PA; LA; QL STELARA SUBCUTANEOUS SOLUTION 4 PA; LA; QL STELARA SUBCUTANEOUS SYRINGE 4 PA; LA; QL sulfacetamide sodium topical cleanser 1 TACLONEX TOPICAL SUSPENSION 3 PA TALTZ AUTOINJECTOR (2 PACK) 4 PA; LA; QL SUBCUTANEOUS AUTO-INJECTOR TALTZ AUTOINJECTOR (3 PACK) 4 PA; LA; QL SUBCUTANEOUS AUTO-INJECTOR TALTZ AUTOINJECTOR SUBCUTANEOUS 4 PA; LA; QL AUTO-INJECTOR
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 51
Drug Name Drug Tier Requirements / Limits TALTZ SYRINGE (2 PACK) SUBCUTANEOUS 4 PA; LA; QL SYRINGE TALTZ SYRINGE (3 PACK) SUBCUTANEOUS 4 PA; LA; QL SYRINGE TALTZ SYRINGE SUBCUTANEOUS 4 PA; LA; QL SYRINGE TREMFYA SUBCUTANEOUS SYRINGE 4 PA; LA; QL BURN THERAPY silver sulfadiazine topical cream 1 ssd topical cream 1 KERATOLYTICS salicylic acid topical cream 1 salicylic acid topical cream,extended release 1 salicylic acid topical film forming liquid w/appl 1 salicylic acid topical liquid 26 % 1 salicylic acid topical lotion 1 salicylic acid topical shampoo 1 MISCELLANEOUS DERMATOLOGICALS ammonium lactate topical cream 1 avo cream topical emulsion 1 doxepin topical cream 3 DUPIXENT SUBCUTANEOUS SYRINGE 4 PA; QL ELIDEL TOPICAL CREAM 3 PA EUCRISA TOPICAL OINTMENT 3 PA; QL fluorouracil topical cream 5 % 1 fluorouracil topical solution 1 methoxsalen oral capsule,liqd-filled,rapid rel 4 PA PANRETIN TOPICAL GEL 4 PA podofilox topical solution 1 prudoxin topical cream 3 prutect topical emulsion 1 QUTENZA TOPICAL KIT 4 PA; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 52
Drug Name Drug Tier Requirements / Limits REGRANEX TOPICAL GEL 3 QL silver nitrate applicators topical stick 1 silver nitrate topical ointment 1 silver nitrate topical solution 1 tacrolimus topical ointment 3 urea topical cream 40 %, 50 % 1 urea topical lotion 40 % 1 ure-k topical cream 1 UVADEX INJECTION SOLUTION 3 VALCHLOR TOPICAL GEL 4 PA; LA THERAPY FOR ACNE adapalene topical cream 1 PA > 35 years of age adapalene topical gel 0.1 % 1 PA > 35 years of age adapalene-benzoyl peroxide topical gel with pump 3 PA amnesteem oral capsule 3 AVAR LS TOPICAL PADS, MEDICATED 3 PA AVAR TOPICAL PADS, MEDICATED 3 PA avita topical cream 1 claravis oral capsule 3 clindacin p topical swab 1 clindamycin phosphate topical gel 1 clindamycin phosphate topical lotion 1 clindamycin phosphate topical solution 1 clindamycin phosphate topical swab 1 clindamycin-benzoyl peroxide topical gel 1-5 % 1 PA clindamycin-tretinoin topical gel 3 PA ery pads topical swab 1 erythromycin with ethanol topical gel 3 erythromycin with ethanol topical solution 1 erythromycin with ethanol topical swab 1 FINACEA TOPICAL FOAM 3 PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 53
Drug Name Drug Tier Requirements / Limits FINACEA TOPICAL GEL 3 PA metronidazole topical cream 1 metronidazole topical gel 1 metronidazole topical gel with pump 1 metronidazole topical lotion 1 MIRVASO TOPICAL GEL 3 PA MIRVASO TOPICAL GEL WITH PUMP 3 PA RHOFADE TOPICAL CREAM 3 PA sulfacetamide sodium-sulfur topical cleanser 10-5 1 % (w/w) sulfacetamide sod-sulfur-urea topical cleanser 1 sulfact na-sul-avobnz-otn-ocsa topical combo 1 pack,cleanser and cream tazarotene topical cream 0.1% 1 PA TAZORAC TOPICAL CREAM 3 PA TAZORAC TOPICAL GEL 3 PA tretinoin topical cream 1 tretinoin topical gel 0.01 %, 0.025 % 1 zenatane oral capsule 3 TOPICAL ANESTHETICS ethyl chloride topical aerosol,spray 1 glydo mucous membrane jelly in applicator 1 lidocaine (pf) injection solution 1 lidocaine hcl injection solution 1 lidocaine hcl injection syringe 10 mg/ml (1 %) 1 lidocaine hcl laryngotracheal solution 1 lidocaine hcl mucous membrane jelly 1 lidocaine hcl mucous membrane jelly in applicator 1 lidocaine hcl mucous membrane solution 4 % (40 1 QL mg/ml) lidocaine hcl topical cream 3 % 1 lidocaine hcl topical lotion 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 54
Drug Name Drug Tier Requirements / Limits lidocaine hcl-hydrocortison ac topical cream 1 lidocaine topical adhesive patch,medicated 3 ST; QL lidocaine topical ointment 3 lidocaine viscous mucous membrane solution 1 lidocaine-epinephrine injection solution 1 lidocaine-prilocaine topical cream 1 lidocaine-prilocaine topical kit 1 lido-k topical lotion 1 lidopin topical cream 3 % 1 lta pre-attached laryngotracheal solution 1 SYNERA TOPICAL PATCH, MEDICATED 3 PA SELF-HEATING XYLOCAINE-MPF INJECTION SOLUTION 15 3 MG/ML (1.5 %) TOPICAL ANTIBACTERIALS ALTABAX TOPICAL OINTMENT 3 CORTISPORIN TOPICAL CREAM 3 CORTISPORIN TOPICAL OINTMENT 3 gentamicin topical cream 1 gentamicin topical ointment 1 mupirocin calcium topical cream 1 mupirocin topical ointment 1 SILVRSTAT TOPICAL GEL 3 sulfacetamide sodium (acne) topical suspension 1 SULFAMYLON TOPICAL CREAM 3 TOPICAL ANTIFUNGALS ciclodan topical cream 1 ciclodan topical solution 1 ciclopirox topical cream 1 ciclopirox topical solution 1 clotrimazole-betamethasone topical cream 1 clotrimazole-betamethasone topical lotion 3 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 55
Drug Name Drug Tier Requirements / Limits econazole topical cream 3 EXELDERM TOPICAL CREAM 3 EXELDERM TOPICAL SOLUTION 3 ketoconazole topical cream 1 ketoconazole topical shampoo 1 LUZU TOPICAL CREAM 3 PA MENTAX TOPICAL CREAM 3 PA NAFTIN TOPICAL GEL 1 % 3 PA nyamyc topical powder 1 nyata topical powder 1 nystatin topical cream 1 nystatin topical ointment 1 nystatin topical powder 1 nystatin-triamcinolone topical cream 3 nystatin-triamcinolone topical ointment 3 nystop topical powder 1 oxiconazole topical cream 3 PA TOPICAL ANTIVIRALS acyclovir topical ointment 3 TOPICAL CORTICOSTEROIDS ala-cort topical cream 2.5 % 1 alclometasone topical cream 1 alclometasone topical ointment 1 amcinonide topical cream 3 ST amcinonide topical lotion 3 ST amcinonide topical ointment 3 ST betamethasone dipropionate topical cream 1 betamethasone dipropionate topical lotion 1 betamethasone dipropionate topical ointment 1 betamethasone valerate topical cream 1 betamethasone valerate topical lotion 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 56
Drug Name Drug Tier Requirements / Limits betamethasone valerate topical ointment 1 betamethasone, augmented topical cream 1 betamethasone, augmented topical gel 3 betamethasone, augmented topical lotion 3 betamethasone, augmented topical ointment 3 clobetasol scalp solution 1 clobetasol topical cream 3 clobetasol topical gel 1 clobetasol topical ointment 3 CLODERM TOPICAL CREAM 3 PA cormax scalp solution 1 desonide topical cream 3 desonide topical ointment 3 desoximetasone topical cream 3 ST desoximetasone topical gel 3 ST desoximetasone topical ointment 3 ST diflorasone topical cream 3 ST diflorasone topical ointment 3 ST fluocinolone and shower cap scalp oil 1 fluocinolone topical cream 1 fluocinolone topical oil 1 fluocinolone topical ointment 1 fluocinolone topical solution 1 fluocinonide topical cream 0.05 % 1 fluocinonide topical gel 1 fluocinonide topical ointment 3 fluocinonide topical solution 1 fluocinonide-e topical cream 1 fluocinonide-emollient topical cream 1 fluticasone topical cream 1 fluticasone topical ointment 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 57
Drug Name Drug Tier Requirements / Limits halobetasol propionate topical cream 1 halobetasol propionate topical ointment 3 hydrocortisone butyrate topical ointment 1 hydrocortisone butyrate topical solution 1 hydrocortisone topical cream 2.5 % 1 hydrocortisone topical lotion 2.5 % 1 hydrocortisone topical ointment 2.5 % 1 hydrocortisone valerate topical cream 1 hydrocortisone valerate topical ointment 3 mometasone topical cream 1 mometasone topical ointment 1 mometasone topical solution 1 prednicarbate topical cream 1 prednicarbate topical ointment 1 triamcinolone acetonide topical cream 1 triamcinolone acetonide topical lotion 1 triamcinolone acetonide topical ointment 0.025 %, 1 0.1 %, 0.5 % triderm topical cream 1 TOPICAL ENZYMES SANTYL TOPICAL OINTMENT 3 PA TOPICAL SCABICIDES / PEDICULICIDES EURAX TOPICAL CREAM 3 EURAX TOPICAL LOTION 3 lindane topical shampoo 3 malathion topical lotion 3 permethrin topical cream 3 SKLICE TOPICAL LOTION 3 PA spinosad topical suspension 1 ULESFIA TOPICAL LOTION 3 DIAGNOSTICS & MISCELLANEOUS AGENTS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 58
Drug Name Drug Tier Requirements / Limits IRRIGATING SOLUTIONS lactated ringers irrigation solution 1 neomycin-polymyxin b gu irrigation solution 1 ringer's irrigation solution 1 tis-u-sol pentalyte irrigation solution 1 MISCELLANEOUS AGENTS acamprosate oral tablet,delayed release (dr/ec) 1 acetic acid irrigation solution 1 ADAGEN INTRAMUSCULAR SOLUTION 4 PA alendronate oral tablet 40 mg 1 anagrelide oral capsule 1 ARALAST NP INTRAVENOUS RECON SOLN 4 PA; LA BUPHENYL ORAL POWDER 4 PA; LA CARBAGLU ORAL TABLET, DISPERSIBLE 4 PA; LA cevimeline oral capsule 1 CHEMET ORAL CAPSULE 3 PA disulfiram oral tablet 1 etidronate disodium oral tablet 1 EXJADE ORAL TABLET, DISPERSIBLE 4 PA; LA FERRIPROX ORAL SOLUTION 4 PA FERRIPROX ORAL TABLET 4 PA GLASSIA INTRAVENOUS SOLUTION 4 PA; LA INCRELEX SUBCUTANEOUS SOLUTION 4 PA; LA JADENU ORAL TABLET 4 PA JADENU SPRINKLE ORAL GRANULES IN 4 PA PACKET levocarnitine (with sugar) oral solution 1 levocarnitine oral tablet 1 midodrine oral tablet 1 NITYR ORAL TABLET 4 PA NORTHERA ORAL CAPSULE 4 PA; LA; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 59
Drug Name Drug Tier Requirements / Limits ORFADIN ORAL CAPSULE 4 PA ORFADIN ORAL SUSPENSION 4 PA pilocarpine hcl oral tablet 5 mg 1 PROLASTIN-C INTRAVENOUS RECON SOLN 4 PA RAVICTI ORAL LIQUID 4 PA; LA; QL riluzole oral tablet 4 PA; QL risedronate oral tablet 30 mg 3 ST sodium chloride 0.9 % injection solution 1 sodium chloride 0.9 % injection syringe 1 sodium chloride 0.9 % intravenous parenteral 1 solution sodium chloride 0.9 % intravenous piggyback 1 sodium chloride irrigation solution 1 sodium ferric gluconat-sucrose intravenous 1 solution sodium phenylbutyrate oral powder 4 PA; LA sodium phenylbutyrate oral tablet 4 PA; LA SOLIRIS INTRAVENOUS SOLUTION 4 PA; LA SYPRINE ORAL CAPSULE 4 PA THIOLA ORAL TABLET 3 water for irrigation, sterile irrigation solution 1 XURIDEN ORAL GRANULES IN PACKET 4 PA; QL ZEMAIRA INTRAVENOUS RECON SOLN 4 PA; LA zoledronic acid-mannitol-water intravenous 4 LA; QL piggyback SMOKING DETERRENTS bupropion hcl (smoking deter) oral tablet extended 6 ACA; QL release 12 hr CHANTIX CONTINUING MONTH BOX ORAL 6 ST; ACA; QL TABLET CHANTIX ORAL TABLET 6 ST; ACA; QL CHANTIX STARTING MONTH BOX ORAL 6 ST; ACA; QL TABLETS,DOSE PACK
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 60
Drug Name Drug Tier Requirements / Limits nicorelief buccal gum 6 ACA; OTC; QL nicorette buccal gum 4 mg 6 ACA; OTC; QL nicotine (polacrilex) buccal gum 6 ACA; OTC; QL nicotine (polacrilex) buccal lozenge 6 ACA; OTC; QL nicotine (polacrilex) buccal mini lozenge 6 ACA; OTC; QL nicotine transdermal patch 24 hour 14 mg/24 hr, 6 ACA; OTC; QL 21 mg/24 hr, 7 mg/24 hr nicotine transdermal patch, td daily, sequential 6 ACA; OTC; QL NICOTROL INHALATION CARTRIDGE 6 ST; ACA; QL NICOTROL NS NASAL SPRAY,NON- 6 ST; ACA; QL AEROSOL nts step 1 transdermal patch 24 hour 6 ACA; OTC; QL quit 2 buccal gum 6 ACA; OTC; QL quit 4 buccal gum 6 ACA; OTC; QL stop smoking aid buccal lozenge 6 ACA; OTC; QL EAR, NOSE & THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal aerosol,spray 1 azelastine nasal spray,non-aerosol 1 chlorhexidine gluconate mucous membrane 1 mouthwash denta 5000 plus dental cream 1 dentagel dental gel 1 GELCLAIR MUCOUS MEMBRANE GEL IN 3 PACKET ipratropium bromide nasal spray,non-aerosol 1 olopatadine nasal spray,non-aerosol 1 ST oralone dental paste 1 ORAMAGICRX MUCOUS MEMBRANE 3 MOUTHWASH paroex oral rinse mucous membrane mouthwash 1 periogard mucous membrane mouthwash 1 pilocarpine hcl oral tablet 7.5 mg 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 61
Drug Name Drug Tier Requirements / Limits sf 5000 plus dental cream 1 sf dental gel 1 triamcinolone acetonide dental paste 1 MISCELLANEOUS OTIC PREPARATIONS acetic acid otic (ear) solution 1 ciprofloxacin hcl otic (ear) dropperette 1 floxin otic (ear) drops 1 fluocinolone acetonide oil otic (ear) drops 1 hydrocortisone-acetic acid otic (ear) drops 1 ofloxacin otic (ear) drops 1 OTIC STEROID / ANTIBIOTIC CIPRO HC OTIC (EAR) DROPS,SUSPENSION 2 CIPRODEX OTIC (EAR) DROPS,SUSPENSION 2 COLY-MYCIN S OTIC (EAR) 3 DROPS,SUSPENSION neomycin-polymyxin-hc otic (ear) 1 drops,suspension neomycin-polymyxin-hc otic (ear) solution 1 ENDOCRINE/DIABETES ADRENAL HORMONES ACTHAR H.P. INJECTION GEL 4 PA; LA; QL betamethasone acet,sod phos injection suspension 1 cortisone oral tablet 1 deltasone oral tablet 20 mg 1 DEPO-MEDROL INJECTION SUSPENSION 20 3 MG/ML dexamethasone intensol oral drops 1 dexamethasone oral elixir 1 dexamethasone oral solution 1 dexamethasone oral tablet 1 dexamethasone sodium phosphate injection 1 solution
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 62
Drug Name Drug Tier Requirements / Limits dexamethasone sodium phosphate injection 1 syringe EMFLAZA ORAL SUSPENSION 4 PA EMFLAZA ORAL TABLET 4 PA fludrocortisone oral tablet 1 hydrocortisone oral tablet 1 KENALOG INJECTION SUSPENSION 3 methylprednisolone acetate injection suspension 1 methylprednisolone oral tablet 1 methylprednisolone oral tablets,dose pack 1 millipred dp oral tablets,dose pack 1 prednisolone oral solution 15 mg/5 ml 1 prednisolone sodium phosphate oral solution 15 1 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisone intensol oral concentrate 1 prednisone oral solution 1 prednisone oral tablet 1 prednisone oral tablets,dose pack 1 triamcinolone acetonide injection suspension 1 TRIESENCE (PF) INTRAOCULAR 3 SUSPENSION ANTITHYROID AGENTS methimazole oral tablet 10 mg, 5 mg 1 propylthiouracil oral tablet 1 SSKI ORAL SOLUTION 3 BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES ONETOUCH ULTRA TEST STRIP 2 OTC; QL ONETOUCH VERIO STRIP 2 OTC; QL DIABETES, SUPPLIES, & DURABLE MEDICAL EQUIPMENT AEROCHAMBER MINI SPACER 3 QL AEROCHAMBER PLUS FLOW-VU SPACER 3 QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 63
Drug Name Drug Tier Requirements / Limits AEROCHAMBER PLUS Z STAT SM MSK 3 QL SPACER EASIVENT HOLDING CHAMBER SPACER 3 QL GLUCAGEN DIAGNOSTIC KIT INJECTION 2 QL RECON SOLN GLUCAGON HCL INJECTION RECON SOLN 2 QL INSPIRACHAMBER WITH MASK-LARGE 3 QL SPACER INSULIN SYRINGE-NEEDLE U-100 SYRINGE 2 0.5 ML 29 GAUGE X 1/2" LITEAIRE MDI CHAMBER SPACER 3 QL GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT INJECTION RECON 2 QL SOLN GLUCAGON EMERGENCY KIT (HUMAN) 2 QL INJECTION KIT PROGLYCEM ORAL SUSPENSION 3 INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL EQU LANCETS 33 GAUGE 2 OTC; QL LANCING DEVICE 2 OTC ONETOUCH ULTRA2 KIT 2 OTC ONETOUCH ULTRAMINI KIT 2 OTC ONETOUCH VERIO FLEX 2 OTC ONETOUCH VERIO IQ METER 2 OTC ONETOUCH VERIO SYSTEM 2 OTC PEN NEEDLE NEEDLE 31 GAUGE X 1/4" 2 OTC INSULIN THERAPY AFREZZA INHALATION CARTRIDGE WITH 3 PA INHALER APIDRA SOLOSTAR SUBCUTANEOUS 3 ST; QL INSULIN PEN APIDRA SUBCUTANEOUS SOLUTION 3 ST; QL BASAGLAR KWIKPEN SUBCUTANEOUS 3 QL INSULIN PEN
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 64
Drug Name Drug Tier Requirements / Limits HUMALOG JUNIOR KWIKPEN 2 QL SUBCUTANEOUS INSULIN PEN, HALF-UNIT HUMALOG KWIKPEN SUBCUTANEOUS 2 QL INSULIN PEN HUMALOG MIX 50-50 KWIKPEN 2 QL SUBCUTANEOUS INSULIN PEN HUMALOG MIX 50-50 SUBCUTANEOUS 2 QL SUSPENSION HUMALOG MIX 75-25 KWIKPEN 2 QL SUBCUTANEOUS INSULIN PEN HUMALOG MIX 75-25 SUBCUTANEOUS 2 QL SUSPENSION HUMALOG SUBCUTANEOUS CARTRIDGE 2 QL HUMALOG SUBCUTANEOUS SOLUTION 2 QL HUMULIN 70/30 KWIKPEN SUBCUTANEOUS 2 QL INSULIN PEN HUMULIN 70/30 SUBCUTANEOUS 2 QL SUSPENSION HUMULIN N KWIKPEN SUBCUTANEOUS 2 QL INSULIN PEN HUMULIN N SUBCUTANEOUS SUSPENSION 2 QL HUMULIN R U-100 INJECTION SOLUTION 2 QL HUMULIN R U-500 (CONC) KWIKPEN 2 QL SUBCUTANEOUS INSULIN PEN HUMULIN R U-500 (CONCENTRATED) 2 QL SUBCUTANEOUS SOLUTION LANTUS SOLOSTAR SUBCUTANEOUS 2 QL INSULIN PEN LANTUS SUBCUTANEOUS SOLUTION 2 QL LEVEMIR FLEXTOUCH SUBCUTANEOUS 2 QL INSULIN PEN LEVEMIR SUBCUTANEOUS SOLUTION 2 QL NOVOLOG FLEXPEN SUBCUTANEOUS 2 QL INSULIN PEN NOVOLOG MIX 70-30 FLEXPEN 2 QL SUBCUTANEOUS INSULIN PEN
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Drug Name Drug Tier Requirements / Limits NOVOLOG MIX 70-30 SUBCUTANEOUS 2 QL SOLUTION NOVOLOG PENFILL SUBCUTANEOUS 2 QL CARTRIDGE NOVOLOG SUBCUTANEOUS SOLUTION 2 QL TOUJEO SOLOSTAR SUBCUTANEOUS 2 QL INSULIN PEN TRESIBA FLEXTOUCH U-100 2 QL SUBCUTANEOUS INSULIN PEN TRESIBA FLEXTOUCH U-200 2 QL SUBCUTANEOUS INSULIN PEN XULTOPHY 100/3.6 SUBCUTANEOUS 2 QL INSULIN PEN MISCELLANEOUS HORMONES ALDURAZYME INTRAVENOUS SOLUTION 4 PA; LA ANADROL-50 ORAL TABLET 3 PA ANDRODERM TRANSDERMAL PATCH 24 3 PA HOUR ANDROGEL TRANSDERMAL GEL IN 2 PA METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN 2 PA PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) AVEED INTRAMUSCULAR SOLUTION 3 PA cabergoline oral tablet 1 calcitonin (salmon) nasal spray,non-aerosol 1 calcitriol intravenous solution 1 mcg/ml 1 calcitriol oral capsule 1 calcitriol oral solution 1 CERDELGA ORAL CAPSULE 4 PA; LA; QL CEREZYME INTRAVENOUS RECON SOLN 4 PA; LA 400 UNIT CHORIONIC GONADOTROPIN, HUMAN 4 PA INTRAMUSCULAR RECON SOLN
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Drug Name Drug Tier Requirements / Limits danazol oral capsule 1 PA desmopressin nasal solution 1 desmopressin nasal spray,non-aerosol 1 desmopressin oral tablet 1 doxercalciferol intravenous solution 1 doxercalciferol oral capsule 1 ELAPRASE INTRAVENOUS SOLUTION 4 PA; LA ELELYSO INTRAVENOUS RECON SOLN 4 PA FABRAZYME INTRAVENOUS RECON SOLN 4 PA; LA FORTESTA TRANSDERMAL GEL IN 3 PA METERED-DOSE PUMP HECTOROL INTRAVENOUS SOLUTION 3 KANUMA INTRAVENOUS SOLUTION 4 PA; LA KORLYM ORAL TABLET 4 PA; QL KUVAN ORAL POWDER IN PACKET 500 MG 4 PA; LA KUVAN ORAL TABLET,SOLUBLE 4 PA; LA LUMIZYME INTRAVENOUS RECON SOLN 4 PA; LA METHITEST ORAL TABLET 4 PA methyltestosterone oral capsule 4 PA MYALEPT SUBCUTANEOUS RECON SOLN 4 PA; LA; QL NAGLAZYME INTRAVENOUS SOLUTION 4 PA; LA NATPARA SUBCUTANEOUS CARTRIDGE 4 PA; LA; QL oxandrolone oral tablet 1 PA pamidronate intravenous recon soln 4 LA pamidronate intravenous solution 4 LA PARICALCITOL HEMODIALYSIS PORT 3 INJECTION SOLUTION paricalcitol intravenous solution 1 paricalcitol oral capsule 1 SAMSCA ORAL TABLET 4 PA; LA; QL SENSIPAR ORAL TABLET 2
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Drug Name Drug Tier Requirements / Limits SOMAVERT SUBCUTANEOUS RECON SOLN 4 PA; LA; QL 15 MG, 20 MG, 25 MG, 30 MG STIMATE NASAL SPRAY,NON-AEROSOL 4 STRENSIQ SUBCUTANEOUS SOLUTION 4 PA STRIANT BUCCAL MUCOADHESIVE 3 PA SYSTEM ER 12 HR SYNAREL NASAL SPRAY,NON-AEROSOL 4 PA; QL TESTIM TRANSDERMAL GEL 3 PA testosterone cypionate intramuscular oil 1 PA testosterone enanthate intramuscular oil 1 PA TESTOSTERONE TRANSDERMAL GEL IN 3 PA METERED-DOSE PUMP 10 MG/0.5 GRAM /ACTUATION testosterone transdermal gel in metered-dose 2 PA pump 12.5 mg/ 1.25 gram (1 %) testosterone transdermal gel in packet 2 PA testosterone transdermal solution in metered pump 1 PA w/app VIMIZIM INTRAVENOUS SOLUTION 4 PA; LA VPRIV INTRAVENOUS RECON SOLN 4 PA; LA ZAVESCA ORAL CAPSULE 4 PA; LA zoledronic acid intravenous recon soln 4 LA zoledronic acid intravenous solution 4 LA ZOLEDRONIC AC-MANNITOL-0.9NACL 4 ST; LA INTRAVENOUS PIGGYBACK ZOMETA INTRAVENOUS PIGGYBACK 4 LA NON-INSULIN HYPOGLYCEMIC AGENTS acarbose oral tablet 1 QL ADLYXIN SUBCUTANEOUS PEN INJECTOR 3 ST; QL BYDUREON SUBCUTANEOUS PEN 3 ST; QL INJECTOR BYDUREON SUBCUTANEOUS 3 ST; QL SUSPENSION,EXTENDED REL RECON BYETTA SUBCUTANEOUS PEN INJECTOR 3 ST; QL
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Drug Name Drug Tier Requirements / Limits chlorpropamide oral tablet 1 QL CYCLOSET ORAL TABLET 3 FARXIGA ORAL TABLET 3 PA; QL glimepiride oral tablet 1 QL glipizide oral tablet 1 QL glipizide oral tablet extended release 24hr 1 QL glipizide-metformin oral tablet 1 QL glyburide micronized oral tablet 1 QL glyburide oral tablet 1 QL glyburide-metformin oral tablet 1 QL GLYXAMBI ORAL TABLET 2 QL INVOKAMET ORAL TABLET 2 QL INVOKAMET XR ORAL TABLET, IR - ER, 2 QL BIPHASIC 24HR INVOKANA ORAL TABLET 2 QL JANUMET ORAL TABLET 2 QL JANUMET XR ORAL TABLET, ER 2 QL MULTIPHASE 24 HR JANUVIA ORAL TABLET 2 QL JARDIANCE ORAL TABLET 2 QL JENTADUETO ORAL TABLET 2 QL JENTADUETO XR ORAL TABLET, IR - ER, 2 QL BIPHASIC 24HR metformin oral tablet 1 QL metformin oral tablet extended release 24 hr 1 QL (generic Glucophage XR) miglitol oral tablet 1 QL nateglinide oral tablet 1 QL pioglitazone oral tablet 1 QL pioglitazone-metformin oral tablet 15-500 mg 1 QL pioglitazone-metformin oral tablet 15-850 mg 1 QL repaglinide oral tablet 1 QL repaglinide-metformin oral tablet 1 QL You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 69
Drug Name Drug Tier Requirements / Limits SYMLINPEN 120 SUBCUTANEOUS PEN 2 ST; QL INJECTOR SYMLINPEN 60 SUBCUTANEOUS PEN 2 ST; QL INJECTOR SYNJARDY ORAL TABLET 2 QL SYNJARDY XR ORAL TABLET, IR - ER, 2 QL BIPHASIC 24HR TANZEUM SUBCUTANEOUS PEN INJECTOR 3 ST; QL tolazamide oral tablet 1 QL tolbutamide oral tablet 1 QL TRADJENTA ORAL TABLET 2 QL TRULICITY SUBCUTANEOUS PEN 2 INJECTOR VICTOZA 2-PAK SUBCUTANEOUS PEN 2 INJECTOR VICTOZA 3-PAK SUBCUTANEOUS PEN 2 INJECTOR THYROID HORMONES ARMOUR THYROID ORAL TABLET 3 LEVOTHYROXINE INTRAVENOUS RECON 3 SOLN 100 MCG levothyroxine intravenous recon soln 200 mcg, 1 500 mcg levothyroxine oral tablet 100 mcg, 112 mcg, 125 5 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg levothyroxine oral tablet 300 mcg 1 levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 5 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine intravenous solution 1 liothyronine oral tablet 1 nature-throid oral tablet 1 np thyroid oral tablet 1 thyroid (pork) oral tablet 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 70
Drug Name Drug Tier Requirements / Limits THYROLAR-1 ORAL TABLET 3 THYROLAR-1/2 ORAL TABLET 3 THYROLAR-1/4 ORAL TABLET 3 THYROLAR-2 ORAL TABLET 3 THYROLAR-3 ORAL TABLET 3 unithroid oral tablet 1 westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 1 mg, 97.5 mg WP THYROID ORAL TABLET 3 GASTROENTEROLOGY ANTIDIARRHEALS & ANTISPASMODICS anaspaz oral tablet,disintegrating 1 atropine injection solution 1 atropine injection syringe 0.05 mg/ml, 0.1 mg/ml 1 belladonna alkaloids-opium rectal suppository 1 PA < 18 years of age belladonna-opium rectal suppository 1 PA < 18 years of age chlordiazepoxide-clidinium oral capsule 1 CUVPOSA ORAL SOLUTION 4 PA dicyclomine intramuscular solution 1 dicyclomine oral capsule 1 dicyclomine oral solution 1 dicyclomine oral tablet 1 diphenoxylate-atropine oral liquid 1 diphenoxylate-atropine oral tablet 1 ed-spaz oral tablet,disintegrating 1 glycopyrrolate injection solution 1 glycopyrrolate oral tablet 1 mg, 2 mg 1 hyoscyamine sulfate oral drops 1 hyoscyamine sulfate oral elixir 1 hyoscyamine sulfate oral tablet 1 hyoscyamine sulfate oral tablet extended release 1 12 hr You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 71
Drug Name Drug Tier Requirements / Limits hyoscyamine sulfate oral tablet,disintegrating 1 hyoscyamine sulfate sublingual tablet 1 hyosyne oral drops 1 hyosyne oral elixir 1 LEVSIN INJECTION SOLUTION 3 loperamide oral capsule 1 methscopolamine oral tablet 1 MYTESI ORAL TABLET,DELAYED RELEASE 4 PA; QL (DR/EC) oscimin oral tablet 1 oscimin oral tablet,disintegrating 1 oscimin sl sublingual tablet 1 oscimin sr oral tablet extended release 12 hr 1 paregoric oral liquid 1 propantheline oral tablet 1 MISCELLANEOUS GASTROINTESTINAL AGENTS AKYNZEO ORAL CAPSULE 3 QL alophen oral tablet,delayed release (dr/ec) 6 ACA; OTC alosetron oral tablet 4 PA ALOXI INTRAVENOUS SOLUTION 3 ST; QL AMITIZA ORAL CAPSULE 3 QL anucort-hc rectal suppository 1 ANZEMET ORAL TABLET 3 ST; QL aprepitant oral capsule 1 QL aprepitant oral capsule,dose pack 1 QL APRISO ORAL CAPSULE,EXTENDED 2 RELEASE 24HR ASACOL HD ORAL TABLET,DELAYED 2 RELEASE (DR/EC) AURYXIA ORAL TABLET 2 balsalazide oral capsule 1 bisacodyl oral tablet,delayed release (dr/ec) 6 ACA; OTC
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Drug Name Drug Tier Requirements / Limits bisa-lax oral tablet,delayed release (dr/ec) 6 ACA; OTC budesonide oral capsule,delayed,extend.release 1 calcium acetate oral capsule 1 calcium acetate oral tablet 667 mg 1 CANASA RECTAL SUPPOSITORY 3 CESAMET ORAL CAPSULE 3 ST CIMZIA SUBCUTANEOUS SYRINGE KIT 4 PA; LA; QL citrate of magnesia oral solution 6 ACA; OTC citroma oral solution 6 ACA; OTC clearlax oral powder 6 ACA; OTC colocort rectal enema 1 compro rectal suppository 1 constulose oral solution 1 CREON ORAL CAPSULE,DELAYED 2 RELEASE(DR/EC) cromolyn oral concentrate 1 CYSTADANE ORAL POWDER 4 PA DELZICOL ORAL CAPSULE (WITH DEL REL 2 TABLETS) dimenhydrinate injection solution 1 DIPENTUM ORAL CAPSULE 3 ST dronabinol oral capsule 3 droperidol injection solution 1 ducodyl oral tablet,delayed release (dr/ec) 6 ACA; OTC eliphos oral tablet 1 EMEND (FOSAPREPITANT) INTRAVENOUS 3 QL RECON SOLN EMEND ORAL SUSPENSION FOR 2 QL RECONSTITUTION ENTYVIO INTRAVENOUS RECON SOLN 4 PA; LA; QL enulose oral solution 1 fleet laxative oral tablet,delayed release (dr/ec) 6 ACA; OTC FOSRENOL ORAL POWDER IN PACKET 3 ST You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 73
Drug Name Drug Tier Requirements / Limits GATTEX 30-VIAL SUBCUTANEOUS KIT 4 PA; LA; QL gavilax oral powder 6 ACA; OTC gavilyte-c oral recon soln 6 ACA gavilyte-g oral recon soln 6 ACA gavilyte-n oral recon soln 6 ACA generlac oral solution 1 gentle laxative oral tablet,delayed release (dr/ec) 6 ACA; OTC gentlelax oral powder 6 ACA; OTC glycolax oral powder 6 ACA; OTC granisetron (pf) intravenous solution 1 ST granisetron hcl intravenous solution 1 ST granisetron hcl oral tablet 3 ST; QL healthylax oral powder in packet 6 ACA; OTC hemmorex-hc rectal suppository 25 mg 1 hydrocortisone acetate rectal suppository 25 mg 1 hydrocortisone rectal enema 1 hydrocortisone topical cream with perineal 1 applicator hydrocortisone-pramoxine rectal cream 1 kionex (with sorbitol) oral suspension 1 kionex oral powder 1 lactulose oral solution 10 gram/15 ml 1 lanthanum oral tablet,chewable 1 ST laxaclear oral powder 6 ACA; OTC laxative (bisacodyl) oral tablet 6 ACA; OTC laxative (bisacodyl) oral tablet,delayed release 6 ACA; OTC (dr/ec) laxative feminine oral tablet 6 ACA; OTC laxative peg 3350 oral powder 6 ACA; OTC LIALDA ORAL TABLET,DELAYED RELEASE 3 ST (DR/EC) lidocaine hcl-hydrocortison ac rectal cream 3-0.5 1 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 74
Drug Name Drug Tier Requirements / Limits LINZESS ORAL CAPSULE 2 QL magnesium citrate oral solution 6 ACA; OTC meclizine oral tablet 12.5 mg, 25 mg 1 mesalamine rectal enema 1 mesalamine with cleansing wipe rectal enema kit 1 metoclopramide hcl injection solution 1 metoclopramide hcl injection syringe 1 metoclopramide hcl oral solution 1 metoclopramide hcl oral tablet 1 milk of magnesia concentrated oral suspension 6 ACA; OTC milk of magnesia oral suspension 6 ACA; OTC miralax oral powder in packet 6 ACA; OTC MOVANTIK ORAL TABLET 2 QL MOVIPREP ORAL POWDER IN PACKET 2 OCALIVA ORAL TABLET 4 PA; LA; QL ondansetron hcl (pf) injection solution 1 ondansetron hcl (pf) injection syringe 1 ondansetron hcl intravenous solution 1 ondansetron hcl oral solution 1 ondansetron hcl oral tablet 1 QL ondansetron oral tablet,disintegrating 1 QL oral saline laxative oral liquid 6 ACA; OTC OSMOPREP ORAL TABLET 3 peg 3350-electrolytes oral recon soln 6 ACA peg3350 oral powder 6 ACA; OTC peg-electrolyte soln oral recon soln 6 ACA peg-prep oral kit 6 ACA PENTASA ORAL CAPSULE, EXTENDED 3 RELEASE phosphate laxative oral liquid 6 ACA; OTC polyethylene glycol 3350 oral powder 6 ACA powderlax oral powder 6 ACA; OTC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 75
Drug Name Drug Tier Requirements / Limits pramcort rectal cream 1 PREPOPIK ORAL POWDER IN PACKET 3 prochlorperazine edisylate injection solution 1 prochlorperazine maleate oral tablet 1 prochlorperazine rectal suppository 1 procto-med hc topical cream with perineal 1 applicator proctosol hc topical cream with perineal 1 applicator proctozone-hc topical cream with perineal 1 applicator purelax oral powder 6 ACA; OTC purelax oral powder in packet 6 ACA; OTC RECTIV RECTAL OINTMENT 3 PA RELISTOR ORAL TABLET 4 PA; QL RELISTOR SUBCUTANEOUS SOLUTION 4 PA; QL RELISTOR SUBCUTANEOUS SYRINGE 4 PA; QL REMICADE INTRAVENOUS RECON SOLN 4 PA; LA RENAGEL ORAL TABLET 2 SANCUSO TRANSDERMAL PATCH WEEKLY 3 ST; QL scopolamine base transdermal patch 3 day 1 sevelamer carbonate oral powder in packet 1 sevelamer carbonate oral tablet 1 smoothlax oral powder 6 ACA; OTC smoothlax oral powder in packet 6 ACA; OTC sodium polystyrene sulfonate oral powder 1 sodium polystyrene sulfonate oral suspension 1 sodium polystyrene sulfonate rectal enema 30 1 gram/120 ml SODIUM POLYSTYRENE SULFONATE 3 RECTAL ENEMA 50 GRAM/200 ML sps (with sorbitol) oral suspension 1 sps (with sorbitol) rectal enema 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 76
Drug Name Drug Tier Requirements / Limits SUCRAID ORAL SOLUTION 4 PA; LA sulfasalazine oral tablet 1 sulfasalazine oral tablet,delayed release (dr/ec) 1 SUPREP BOWEL PREP KIT ORAL RECON 2 SOLN TIGAN INTRAMUSCULAR SOLUTION 3 trilyte with flavor packets oral recon soln 6 ACA trimethobenzamide oral capsule 1 UCERIS ORAL TABLET,DELAYED AND 3 PA EXT.RELEASE UCERIS RECTAL FOAM 3 PA ursodiol oral capsule 1 ursodiol oral tablet 1 VELPHORO ORAL TABLET,CHEWABLE 3 ST VELTASSA ORAL POWDER IN PACKET 4 PA; LA; QL VIBERZI ORAL TABLET 4 PA; QL woman's laxative oral tablet,delayed release 6 ACA; OTC (dr/ec) women's laxative (bisacodyl) oral tablet 6 ACA; OTC ZENPEP ORAL CAPSULE,DELAYED 3 ST RELEASE(DR/EC) ULCER THERAPY amoxicil-clarithromy-lansopraz oral combo pack 1 CARAFATE ORAL SUSPENSION 3 cimetidine hcl oral solution 1 cimetidine oral tablet 1 DEXILANT ORAL CAPSULE,BIPHASE 3 PA; QL DELAYED RELEAS esomeprazole sodium intravenous recon soln 1 QL famotidine (pf) intravenous solution 1 famotidine (pf)-nacl (iso-os) intravenous 1 piggyback famotidine intravenous solution 1
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Drug Name Drug Tier Requirements / Limits famotidine oral suspension 1 famotidine oral tablet 20 mg, 40 mg 1 lansoprazole oral capsule,delayed release(dr/ec) 1 QL misoprostol oral tablet 1 NEXIUM IV INTRAVENOUS RECON SOLN 40 3 QL MG NEXIUM ORAL CAPSULE,DELAYED 1 ST; QL RELEASE(DR/EC) NEXIUM PACKET ORAL GRANULES DR 3 ST; QL FOR SUSP IN PACKET nizatidine oral capsule 1 nizatidine oral solution 1 omeprazole oral capsule,delayed release(dr/ec) 1 omeprazole-sodium bicarbonate oral capsule 1 PA; QL omeprazole-sodium bicarbonate oral packet 1 PA; QL pantoprazole intravenous recon soln 1 QL pantoprazole oral tablet,delayed release (dr/ec) 1 rabeprazole oral tablet,delayed release (dr/ec) 1 QL ranitidine hcl injection solution 1 ranitidine hcl oral capsule 3 ranitidine hcl oral syrup 1 ranitidine hcl oral tablet 150 mg 5 ranitidine hcl oral tablet 300 mg 1 sucralfate oral tablet 1 IMMUNOLOGY, VACCINES & BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ARANESP (IN POLYSORBATE) INJECTION 4 PA; LA SOLUTION ARANESP (IN POLYSORBATE) INJECTION 4 PA; LA SYRINGE EPOGEN INJECTION SOLUTION 10,000 4 PA; LA UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 78
Drug Name Drug Tier Requirements / Limits GRANIX SUBCUTANEOUS SYRINGE 4 PA; LA LEUKINE INJECTION RECON SOLN 4 LA MOZOBIL SUBCUTANEOUS SOLUTION 4 PA; LA; QL NEULASTA SUBCUTANEOUS SYRINGE 4 PA; LA NEULASTA SUBCUTANEOUS SYRINGE, W/ 4 PA; LA WEARABLE INJECTOR NEUPOGEN INJECTION SOLUTION 4 PA; LA NEUPOGEN INJECTION SYRINGE 4 PA; LA PROCRIT INJECTION SOLUTION 4 PA; LA ZARXIO INJECTION SYRINGE 4 PA; LA GROWTH HORMONES NORDITROPIN FLEXPRO SUBCUTANEOUS 4 PA PEN INJECTOR SEROSTIM SUBCUTANEOUS RECON SOLN 4 4 PA MG, 5 MG, 6 MG ZORBTIVE SUBCUTANEOUS RECON SOLN 4 PA INTERFERONS AUBAGIO ORAL TABLET 4 PA; LA; QL AVONEX (WITH ALBUMIN) 4 QL INTRAMUSCULAR KIT AVONEX INTRAMUSCULAR PEN INJECTOR 4 QL KIT AVONEX INTRAMUSCULAR SYRINGE KIT 4 QL BETASERON SUBCUTANEOUS KIT 4 ST; QL COPAXONE SUBCUTANEOUS SYRINGE 4 QL GILENYA ORAL CAPSULE 4 PA; LA; QL LEMTRADA INTRAVENOUS SOLUTION 4 PA; LA moderiba oral tablet 4 LA; QL OCREVUS INTRAVENOUS SOLUTION 4 PA; LA PEGASYS PROCLICK SUBCUTANEOUS PEN 4 PA; QL INJECTOR PEGASYS SUBCUTANEOUS SOLUTION 4 PA; LA; QL PEGASYS SUBCUTANEOUS SYRINGE 4 PA; LA; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 79
Drug Name Drug Tier Requirements / Limits PEGINTRON SUBCUTANEOUS KIT 50 4 PA; LA; QL MCG/0.5 ML PLEGRIDY SUBCUTANEOUS PEN INJECTOR 4 QL PLEGRIDY SUBCUTANEOUS SYRINGE 4 QL POMALYST ORAL CAPSULE 4 PA; LA; QL REBIF (WITH ALBUMIN) SUBCUTANEOUS 4 ST; QL SYRINGE REBIF REBIDOSE SUBCUTANEOUS PEN 4 ST; QL INJECTOR REBIF TITRATION PACK SUBCUTANEOUS 4 ST; QL SYRINGE REVLIMID ORAL CAPSULE 4 PA; LA; QL ribasphere oral capsule 4 LA; QL ribasphere oral tablet 4 LA; QL ribavirin oral capsule 4 LA; QL ribavirin oral tablet 200 mg 4 LA; QL SYLATRON SUBCUTANEOUS KIT 4 LA TECFIDERA ORAL CAPSULE,DELAYED 4 PA; LA; QL RELEASE(DR/EC) ZINBRYTA SUBCUTANEOUS SYRINGE 4 PA; QL INTERLEUKINS ACTIMMUNE SUBCUTANEOUS SOLUTION 4 PA; LA ALFERON N INJECTION SOLUTION 4 PA; LA ARCALYST SUBCUTANEOUS RECON SOLN 4 PA; LA; QL ILARIS (PF) SUBCUTANEOUS RECON SOLN 4 PA; LA; QL ILARIS (PF) SUBCUTANEOUS SOLUTION 4 PA; LA; QL imiquimod topical cream in packet 1 INTRON A INJECTION RECON SOLN 4 LA INTRON A INJECTION SOLUTION 4 LA KINERET SUBCUTANEOUS SYRINGE 4 PA; QL PROLEUKIN INTRAVENOUS RECON SOLN 4 LA VACCINES & MISCELLANEOUS IMMUNOLOGICALS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 80
Drug Name Drug Tier Requirements / Limits ACTHIB (PF) INTRAMUSCULAR RECON 6 ACA SOLN ADACEL(TDAP ADOLESN/ADULT)(PF) 6 ACA INTRAMUSCULAR SUSPENSION ADACEL(TDAP ADOLESN/ADULT)(PF) 6 ACA INTRAMUSCULAR SYRINGE AFLURIA 2017-2018 (PF) INTRAMUSCULAR 6 ACA SYRINGE AFLURIA 2017-2018 INTRAMUSCULAR 6 ACA SUSPENSION AFLURIA QUAD 2017-2018 (PF) 6 ACA INTRAMUSCULAR SYRINGE AFLURIA QUAD 2017-2018 6 ACA INTRAMUSCULAR SUSPENSION ATGAM INTRAVENOUS SOLUTION 4 LA BCG VACCINE, LIVE (PF) PERCUTANEOUS 6 ACA; LA SUSPENSION FOR RECONSTITUTION BIOTHRAX INTRAMUSCULAR SUSPENSION 6 ACA BIVIGAM INTRAVENOUS SOLUTION 4 PA; LA BOOSTRIX TDAP INTRAMUSCULAR 6 ACA SUSPENSION BOOSTRIX TDAP INTRAMUSCULAR 6 ACA SYRINGE BOTOX INJECTION RECON SOLN 4 PA; LA; QL CARIMUNE NF NANOFILTERED 4 PA; LA INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM DAPTACEL (DTAP PEDIATRIC) (PF) 6 ACA INTRAMUSCULAR SUSPENSION DYSPORT INTRAMUSCULAR RECON SOLN 4 PA; LA; QL ENGERIX-B (PF) INTRAMUSCULAR 6 ACA SUSPENSION ENGERIX-B (PF) INTRAMUSCULAR 6 ACA SYRINGE ENGERIX-B PEDIATRIC (PF) 6 ACA INTRAMUSCULAR SYRINGE
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 81
Drug Name Drug Tier Requirements / Limits FLEBOGAMMA DIF INTRAVENOUS 4 PA; LA SOLUTION FLUAD 2017-2018 (65 YR UP)(PF) 6 ACA INTRAMUSCULAR SYRINGE FLUARIX QUAD 2017-2018 (PF) 6 ACA INTRAMUSCULAR SYRINGE FLUBLOK 2017-2018 (PF) INTRAMUSCULAR 6 ACA SOLUTION FLUBLOK QUAD 2017-2018 (PF) 6 ACA INTRAMUSCULAR SYRINGE FLUCELVAX QUAD 2017-2018 (PF) 6 ACA INTRAMUSCULAR SYRINGE FLUCELVAX QUAD 2017-2018 6 ACA INTRAMUSCULAR SUSPENSION FLULAVAL QUAD 2017-2018 (PF) 6 ACA INTRAMUSCULAR SYRINGE FLULAVAL QUAD 2017-2018 6 ACA INTRAMUSCULAR SUSPENSION FLUVIRIN 2017-2018 (PF) INTRAMUSCULAR 6 ACA SYRINGE FLUVIRIN 2017-2018 INTRAMUSCULAR 6 ACA SUSPENSION FLUZONE HIGH-DOSE 2017-18 (PF) 6 ACA INTRAMUSCULAR SYRINGE FLUZONE INTRADERM QUAD 2017-18 6 ACA INTRADERMAL SYRINGE FLUZONE QUAD 2017-2018 (PF) 6 ACA INTRAMUSCULAR SUSPENSION FLUZONE QUAD 2017-2018 (PF) 6 ACA INTRAMUSCULAR SYRINGE FLUZONE QUAD 2017-2018 6 ACA INTRAMUSCULAR SUSPENSION FLUZONE QUAD PEDI 2017-18 (PF) 6 ACA INTRAMUSCULAR SYRINGE GAMASTAN S/D INTRAMUSCULAR 4 PA; LA SOLUTION
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Drug Name Drug Tier Requirements / Limits GAMMAGARD LIQUID INJECTION 4 PA; LA SOLUTION GAMMAGARD S-D (IGA < 1 MCG/ML) 4 PA; LA INTRAVENOUS RECON SOLN GAMMAKED INJECTION SOLUTION 4 PA; LA GAMMAPLEX (WITH SORBITOL) 4 PA; LA INTRAVENOUS SOLUTION GAMMAPLEX INTRAVENOUS SOLUTION 4 PA; LA GAMUNEX-C INJECTION SOLUTION 4 PA; LA GARDASIL 9 (PF) INTRAMUSCULAR 6 ACA SUSPENSION GARDASIL 9 (PF) INTRAMUSCULAR 6 ACA SYRINGE GRASTEK SUBLINGUAL TABLET 4 PA; QL HAVRIX (PF) INTRAMUSCULAR 6 ACA SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE 6 ACA HIBERIX (PF) INTRAMUSCULAR RECON 6 ACA SOLN HIZENTRA SUBCUTANEOUS SOLUTION 4 PA; LA HYQVIA SUBCUTANEOUS SOLUTION 4 PA; LA INFANRIX (DTAP) (PF) INTRAMUSCULAR 6 ACA SUSPENSION INFANRIX (DTAP) (PF) INTRAMUSCULAR 6 ACA SYRINGE IPOL INJECTION SUSPENSION 6 ACA IXIARO (PF) INTRAMUSCULAR SYRINGE 6 ACA KINRIX (PF) INTRAMUSCULAR 6 ACA SUSPENSION KINRIX (PF) INTRAMUSCULAR SYRINGE 6 ACA MENACTRA (PF) INTRAMUSCULAR 6 ACA SOLUTION MENHIBRIX (PF) INTRAMUSCULAR RECON 6 ACA SOLN
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Drug Name Drug Tier Requirements / Limits MENOMUNE - A/C/Y/W-135 (PF) 6 ACA SUBCUTANEOUS RECON SOLN MENOMUNE - A/C/Y/W-135 6 ACA SUBCUTANEOUS RECON SOLN M-M-R II (PF) SUBCUTANEOUS RECON 6 ACA SOLN MYOBLOC INTRAMUSCULAR SOLUTION 4 PA; LA; QL OCTAGAM INTRAVENOUS SOLUTION 4 PA; LA ORALAIR SUBLINGUAL TABLET 300 INDX 4 PA; QL REACTIVITY PEDIARIX (PF) INTRAMUSCULAR SYRINGE 6 ACA PEDVAX HIB (PF) INTRAMUSCULAR 6 ACA SOLUTION PENTACEL (PF) INTRAMUSCULAR KIT 6 ACA PENTACEL ACTHIB COMPONENT (PF) 6 ACA INTRAMUSCULAR RECON SOLN PNEUMOVAX 23 INJECTION SOLUTION 6 ACA PNEUMOVAX 23 INJECTION SYRINGE 6 ACA PREVNAR 13 (PF) INTRAMUSCULAR 6 SYRINGE PRIVIGEN INTRAVENOUS SOLUTION 4 PA; LA; QL PROQUAD (PF) SUBCUTANEOUS 6 ACA SUSPENSION FOR RECONSTITUTION QUADRACEL (PF) INTRAMUSCULAR 6 ACA SUSPENSION RAGWITEK SUBLINGUAL TABLET 4 PA; QL RECOMBIVAX HB (PF) INTRAMUSCULAR 6 ACA SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULAR 6 ACA SYRINGE ROTARIX ORAL SUSPENSION FOR 6 ACA RECONSTITUTION ROTATEQ VACCINE ORAL SOLUTION 6 TENIVAC (PF) INTRAMUSCULAR 6 ACA SUSPENSION
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Drug Name Drug Tier Requirements / Limits TENIVAC (PF) INTRAMUSCULAR SYRINGE 6 ACA TETANUS,DIPHTHERIA TOX PED(PF) 6 ACA INTRAMUSCULAR SUSPENSION TETANUS-DIPHTHERIA TOXOIDS-TD 6 ACA INTRAMUSCULAR SUSPENSION THYMOGLOBULIN INTRAVENOUS RECON 4 LA SOLN TWINRIX (PF) INTRAMUSCULAR SYRINGE 6 ACA TYPHIM VI INTRAMUSCULAR SOLUTION 6 ACA TYPHIM VI INTRAMUSCULAR SYRINGE 6 ACA VAQTA (PF) INTRAMUSCULAR 6 ACA SUSPENSION VAQTA (PF) INTRAMUSCULAR SYRINGE 6 ACA VARIVAX (PF) SUBCUTANEOUS 6 ACA SUSPENSION FOR RECONSTITUTION VARIZIG INTRAMUSCULAR RECON SOLN 6 ACA XEOMIN INTRAMUSCULAR RECON SOLN 4 PA; LA; QL YF-VAX (PF) SUBCUTANEOUS SUSPENSION 6 ACA FOR RECONSTITUTION ZOSTAVAX (PF) SUBCUTANEOUS 6 ACA SUSPENSION FOR RECONSTITUTION MUSCULOSKELETAL & RHEUMATOLOGY GOUT THERAPY allopurinol oral tablet 1 allopurinol sodium intravenous recon soln 1 aloprim intravenous recon soln 1 COLCRYS ORAL TABLET 2 DUZALLO ORAL TABLET 3 PA; QL KRYSTEXXA INTRAVENOUS SOLUTION 4 PA; LA; QL probenecid oral tablet 1 probenecid-colchicine oral tablet 1 ULORIC ORAL TABLET 40 MG 2 ST; QL ULORIC ORAL TABLET 80 MG 2 ST
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Drug Name Drug Tier Requirements / Limits ZURAMPIC ORAL TABLET 3 PA; QL OSTEOPOROSIS THERAPY alendronate oral solution 1 QL alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg 1 FORTEO SUBCUTANEOUS PEN INJECTOR 4 PA; LA; QL ibandronate intravenous solution 3 ST; QL ibandronate intravenous syringe 3 ST; QL ibandronate oral tablet 1 QL PROLIA SUBCUTANEOUS SYRINGE 4 LA; QL raloxifene oral tablet 1 risedronate oral tablet 150 mg, 35 mg 3 ST; QL risedronate oral tablet 5 mg 3 ST risedronate oral tablet,delayed release (dr/ec) 3 ST; QL TYMLOS SUBCUTANEOUS PEN INJECTOR 4 PA; LA; QL OTHER RHEUMATOLOGICALS ACTEMRA INTRAVENOUS SOLUTION 4 PA; LA; QL ACTEMRA SUBCUTANEOUS SYRINGE 4 PA; LA; QL BENLYSTA INTRAVENOUS RECON SOLN 4 PA; LA BENLYSTA SUBCUTANEOUS AUTO- 4 PA; LA; QL INJECTOR BENLYSTA SUBCUTANEOUS SYRINGE 4 PA; LA; QL DEPEN TITRATABS ORAL TABLET 4 PA ENBREL SUBCUTANEOUS RECON SOLN 4 PA; QL ENBREL SUBCUTANEOUS SYRINGE 4 PA; QL ENBREL SURECLICK SUBCUTANEOUS PEN 4 PA; QL INJECTOR HUMIRA PEDIATRIC CROHN'S START 4 PA; LA; QL SUBCUTANEOUS SYRINGE KIT HUMIRA PEN CROHN'S-UC-HS START 4 PA; QL SUBCUTANEOUS PEN INJECTOR KIT HUMIRA PEN SUBCUTANEOUS PEN 4 PA; QL INJECTOR KIT HUMIRA SUBCUTANEOUS SYRINGE KIT 4 PA; QL You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 86
Drug Name Drug Tier Requirements / Limits KEVZARA SUBCUTANEOUS SYRINGE 4 PA; LA; QL leflunomide oral tablet 1 ORENCIA (WITH MALTOSE) INTRAVENOUS 4 PA RECON SOLN ORENCIA CLICKJECT SUBCUTANEOUS 4 PA; QL AUTO-INJECTOR ORENCIA SUBCUTANEOUS SYRINGE 4 PA; QL OTEZLA ORAL TABLET 4 PA; LA; QL OTEZLA STARTER ORAL TABLETS,DOSE 4 PA; LA; QL PACK 10 MG (4)-20 MG (4)-30 MG (47) OTREXUP (PF) SUBCUTANEOUS AUTO- 4 PA; QL INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML RASUVO (PF) SUBCUTANEOUS AUTO- 4 PA; QL INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML RIDAURA ORAL CAPSULE 4 SAVELLA ORAL TABLET 3 PA; QL SAVELLA ORAL TABLETS,DOSE PACK 3 PA; QL SIMPONI ARIA INTRAVENOUS SOLUTION 4 PA; LA SIMPONI SUBCUTANEOUS PEN INJECTOR 4 PA; QL SIMPONI SUBCUTANEOUS SYRINGE 4 PA; QL XELJANZ ORAL TABLET 4 PA; QL XELJANZ XR ORAL TABLET EXTENDED 4 PA; QL RELEASE 24 HR OBSTETRICS & GYNECOLOGY DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES CAYA CONTOURED VAGINAL DIAPHRAGM 6 ACA FC2 FEMALE CONDOM 6 ACA; OTC FEMCAP VAGINAL DEVICE 22 MM 6 ACA WIDE-SEAL DIAPHRAGM 6 ACA
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Drug Name Drug Tier Requirements / Limits ESTROGENS & PROGESTINS amabelz oral tablet 1 camila oral tablet 6 ACA COMBIPATCH TRANSDERMAL PATCH 3 QL SEMIWEEKLY covaryx h.s. oral tablet 1 covaryx oral tablet 1 CRINONE VAGINAL GEL 4 % 3 deblitane oral tablet 6 ACA DEPO-ESTRADIOL INTRAMUSCULAR OIL 3 DUAVEE ORAL TABLET 2 eemt hs oral tablet 1 eemt oral tablet 1 errin oral tablet 6 ACA ESTRACE VAGINAL CREAM 3 estradiol oral tablet 1 estradiol transdermal patch semiweekly 1 QL estradiol transdermal patch weekly 1 QL estradiol vaginal tablet 1 estradiol valerate intramuscular oil 20 mg/ml, 40 1 mg/ml estradiol-norethindrone acet oral tablet 1 ESTROGEL TRANSDERMAL GEL IN 3 QL METERED-DOSE PUMP estrogens-methyltestosterone oral tablet 1 estropipate oral tablet 1 FEMRING VAGINAL RING 3 QL fyavolv oral tablet 1 heather oral tablet 6 ACA jencycla oral tablet 6 ACA jevantique lo oral tablet 1 jinteli oral tablet 1
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Drug Name Drug Tier Requirements / Limits jolivette oral tablet 6 ACA lopreeza oral tablet 1 lyza oral tablet 6 ACA MAKENA INTRAMUSCULAR OIL 4 PA; LA medroxyprogesterone intramuscular suspension 6 ACA; QL medroxyprogesterone intramuscular syringe 6 ACA; QL medroxyprogesterone oral tablet 1 MENEST ORAL TABLET 0.3 MG, 0.625 MG, 3 1.25 MG MENOSTAR TRANSDERMAL PATCH 3 QL WEEKLY mimvey lo oral tablet 1 mimvey oral tablet 1 nora-be oral tablet 6 ACA norethindrone (contraceptive) oral tablet 6 ACA norethindrone acetate oral tablet 1 norethindrone ac-eth estradiol oral tablet 0.5-2.5 1 mg-mcg, 1-5 mg-mcg norlyda oral tablet 6 ACA norlyroc oral tablet 6 ACA PREMARIN INJECTION RECON SOLN 3 PREMARIN ORAL TABLET 2 PREMARIN VAGINAL CREAM 2 PREMPHASE ORAL TABLET 2 PREMPRO ORAL TABLET 2 progesterone micronized oral capsule 1 sharobel oral tablet 6 ACA yuvafem vaginal tablet 1 MISCELLANEOUS OB/GYN clindamycin phosphate vaginal cream 1 CONCEPTROL VAGINAL GEL 6 ACA; OTC fem ph vaginal gel 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 89
Drug Name Drug Tier Requirements / Limits GYNAZOLE-1 VAGINAL CREAM 3 gynol ii vaginal gel 6 ACA; OTC isoxsuprine oral tablet 1 LUPANETA PACK (1 MONTH) KIT. SYRINGE 4 PA; QL AND TABLET LUPANETA PACK (3 MONTH) KIT. SYRINGE 4 PA; QL AND TABLET metronidazole vaginal gel 1 NUVARING VAGINAL RING 6 ACA; QL OSPHENA ORAL TABLET 3 PA; QL terconazole vaginal cream 1 terconazole vaginal suppository 1 TODAY CONTRACEPTIVE SPONGE 6 ACA; OTC VAGINAL CONTRACEPTIVE SPONGE tranexamic acid oral tablet 1 PA; QL vaginal contraceptive foam vaginal foam 6 ACA; OTC vandazole vaginal gel 1 xulane transdermal patch weekly 6 ACA ORAL CONTRACEPTIVES & RELATED AGENTS altavera (28) oral tablet 6 ACA alyacen 1/35 (28) oral tablet 6 ACA alyacen 7/7/7 (28) oral tablet 6 ACA amethia lo oral tablets,dose pack,3 month 6 ACA; QL amethia oral tablets,dose pack,3 month 6 ACA; QL amethyst oral tablet 6 ACA apri oral tablet 6 ACA aranelle (28) oral tablet 6 ACA ashlyna oral tablets,dose pack,3 month 6 ACA; QL aubra oral tablet 6 ACA aviane oral tablet 6 ACA azurette (28) oral tablet 6 ACA balziva (28) oral tablet 6 ACA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 90
Drug Name Drug Tier Requirements / Limits bekyree (28) oral tablet 6 ACA blisovi 24 fe oral tablet 6 ACA blisovi fe 1.5/30 (28) oral tablet 6 ACA blisovi fe 1/20 (28) oral tablet 6 ACA briellyn oral tablet 6 ACA camrese lo oral tablets,dose pack,3 month 6 ACA; QL camrese oral tablets,dose pack,3 month 6 ACA; QL caziant (28) oral tablet 6 ACA chateal oral tablet 6 ACA cryselle (28) oral tablet 6 ACA cyclafem 1/35 (28) oral tablet 6 ACA cyclafem 7/7/7 (28) oral tablet 6 ACA cyred oral tablet 6 ACA dasetta 1/35 (28) oral tablet 6 ACA dasetta 7/7/7 (28) oral tablet 6 ACA daysee oral tablets,dose pack,3 month 6 ACA; QL delyla (28) oral tablet 6 ACA desog-e.estradiol/e.estradiol oral tablet 6 ACA desogestrel-ethinyl estradiol oral tablet 6 ACA drospirenone-e.estradiol-lm.fa oral tablet 6 ACA drospirenone-ethinyl estradiol oral tablet 6 ACA econtra ez oral tablet 6 ACA; OTC elinest oral tablet 6 ACA ELLA ORAL TABLET 6 ACA emoquette oral tablet 6 ACA enpresse oral tablet 6 ACA enskyce oral tablet 6 ACA estarylla oral tablet 6 ACA ethynodiol diac-eth estradiol oral tablet 6 ACA falmina (28) oral tablet 6 ACA fayosim oral tablets,dose pack,3 month 6 ACA; QL
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Drug Name Drug Tier Requirements / Limits femynor oral tablet 6 ACA gianvi (28) oral tablet 6 ACA gildagia oral tablet 6 ACA introvale oral tablets,dose pack,3 month 6 ACA; QL isibloom oral tablet 6 ACA jolessa oral tablets,dose pack,3 month 6 ACA; QL juleber oral tablet 6 ACA junel 1.5/30 (21) oral tablet 6 ACA junel 1/20 (21) oral tablet 6 ACA junel fe 1.5/30 (28) oral tablet 6 ACA junel fe 1/20 (28) oral tablet 6 ACA junel fe 24 oral tablet 6 ACA kaitlib fe oral tablet,chewable 6 ACA kariva (28) oral tablet 6 ACA kelnor 1/35 (28) oral tablet 6 ACA kimidess (28) oral tablet 6 ACA kurvelo oral tablet 6 ACA l norgest/e.estradiol-e.estrad oral tablets,dose 6 ACA; QL pack,3 month larin 1.5/30 (21) oral tablet 6 ACA larin 1/20 (21) oral tablet 6 ACA larin 24 fe oral tablet 6 ACA larin fe 1.5/30 (28) oral tablet 6 ACA larin fe 1/20 (28) oral tablet 6 ACA larissia oral tablet 6 ACA layolis fe oral tablet,chewable 6 ACA leena 28 oral tablet 6 ACA lessina oral tablet 6 ACA levonest (28) oral tablet 6 ACA levonorgestrel-ethinyl estrad oral tablet 6 ACA levonorgestrel-ethinyl estrad oral tablets,dose 6 ACA pack,3 month
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Drug Name Drug Tier Requirements / Limits levonorg-eth estrad triphasic oral tablet 6 ACA levora-28 oral tablet 6 ACA lillow oral tablet 6 ACA LO LOESTRIN FE ORAL TABLET 3 lomedia 24 fe oral tablet 6 ACA loryna (28) oral tablet 6 ACA low-ogestrel (28) oral tablet 6 ACA lutera (28) oral tablet 6 ACA marlissa oral tablet 6 ACA melodetta 24 fe oral tablet,chewable 6 ACA mibelas 24 fe oral tablet,chewable 6 ACA microgestin 1.5/30 (21) oral tablet 6 ACA microgestin 1/20 (21) oral tablet 6 ACA microgestin fe 1.5/30 (28) oral tablet 6 ACA microgestin fe 1/20 (28) oral tablet 6 ACA MINASTRIN 24 FE ORAL 3 TABLET,CHEWABLE mono-linyah oral tablet 6 ACA mononessa (28) oral tablet 6 ACA my way oral tablet 6 ACA; OTC myzilra oral tablet 6 ACA NATAZIA ORAL TABLET 2 necon 0.5/35 (28) oral tablet 6 ACA necon 1/50 (28) oral tablet 6 ACA necon 7/7/7 (28) oral tablet 6 ACA next choice one dose oral tablet 6 ACA; OTC nikki (28) oral tablet 6 ACA noreth-ethinyl estradiol-iron oral tablet,chewable 6 ACA norethindrone ac-eth estradiol oral tablet 1-20 6 ACA mg-mcg norethindrone-e.estradiol-iron oral tablet 6 ACA
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Drug Name Drug Tier Requirements / Limits norethindrone-e.estradiol-iron oral 6 ACA tablet,chewable norgestimate-ethinyl estradiol oral tablet 6 ACA nortrel 0.5/35 (28) oral tablet 6 ACA nortrel 1/35 (21) oral tablet 6 ACA nortrel 1/35 (28) oral tablet 6 ACA nortrel 7/7/7 (28) oral tablet 6 ACA ocella oral tablet 6 ACA ogestrel (28) oral tablet 6 ACA opcicon one-step oral tablet 6 ACA; OTC option-2 oral tablet 6 ACA; OTC orsythia oral tablet 6 ACA philith oral tablet 6 ACA pimtrea (28) oral tablet 6 ACA pirmella oral tablet 6 ACA portia oral tablet 6 ACA previfem oral tablet 6 ACA quasense oral tablets,dose pack,3 month 6 ACA; QL rajani oral tablet 6 ACA reclipsen (28) oral tablet 6 ACA rivelsa oral tablets,dose pack,3 month 6 ACA; QL SAFYRAL ORAL TABLET 2 setlakin oral tablets,dose pack,3 month 6 ACA; QL sprintec (28) oral tablet 6 ACA sronyx oral tablet 6 ACA syeda oral tablet 6 ACA tarina fe 1/20 (28) oral tablet 6 ACA tilia fe oral tablet 6 ACA tri femynor oral tablet 6 ACA tri-estarylla oral tablet 6 ACA tri-legest fe oral tablet 6 ACA tri-linyah oral tablet 6 ACA You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 94
Drug Name Drug Tier Requirements / Limits tri-lo-estarylla oral tablet 6 ACA tri-lo-marzia oral tablet 6 ACA tri-lo-sprintec oral tablet 6 ACA trinessa (28) oral tablet 6 ACA trinessa lo oral tablet 6 ACA tri-previfem (28) oral tablet 6 ACA tri-sprintec (28) oral tablet 6 ACA trivora (28) oral tablet 6 ACA velivet triphasic regimen (28) oral tablet 6 ACA vestura (28) oral tablet 6 ACA vienva oral tablet 6 ACA viorele (28) oral tablet 6 ACA vyfemla (28) oral tablet 6 ACA wera (28) oral tablet 6 ACA wymzya fe oral tablet,chewable 6 ACA zarah oral tablet 6 ACA zenchent (28) oral tablet 6 ACA zovia 1/35e (28) oral tablet 6 ACA zovia 1/50e (28) oral tablet 6 ACA OXYTOCICS methergine oral tablet 1 OPHTHALMOLOGY ANTIBIOTICS AZASITE OPHTHALMIC (EYE) DROPS 3 bacitracin ophthalmic (eye) ointment 1 bacitracin-polymyxin b ophthalmic (eye) ointment 1 BESIVANCE OPHTHALMIC (EYE) 3 DROPS,SUSPENSION BETADINE OPHTHALMIC PREP 3 OPHTHALMIC (EYE) SOLUTION CILOXAN OPHTHALMIC (EYE) OINTMENT 3 ciprofloxacin hcl ophthalmic (eye) drops 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 95
Drug Name Drug Tier Requirements / Limits erythromycin ophthalmic (eye) ointment 1 gatifloxacin ophthalmic (eye) drops 1 gentak ophthalmic (eye) ointment 1 gentamicin ophthalmic (eye) drops 1 gentamicin ophthalmic (eye) ointment 1 levofloxacin ophthalmic (eye) drops 1 MOXEZA OPHTHALMIC (EYE) DROPS, 3 VISCOUS moxifloxacin ophthalmic (eye) drops 1 NATACYN OPHTHALMIC (EYE) 3 DROPS,SUSPENSION neomycin-bacitracin-polymyxin ophthalmic (eye) 1 ointment neomycin-polymyxin-gramicidin ophthalmic (eye) 1 drops neo-polycin ophthalmic (eye) ointment 1 ofloxacin ophthalmic (eye) drops 1 polycin ophthalmic (eye) ointment 1 polymyxin b sulf-trimethoprim ophthalmic (eye) 1 drops tobramycin ophthalmic (eye) drops 1 TOBREX OPHTHALMIC (EYE) OINTMENT 3 ANTIVIRALS trifluridine ophthalmic (eye) drops 1 ZIRGAN OPHTHALMIC (EYE) GEL 2 BETA-BLOCKERS betaxolol ophthalmic (eye) drops 1 BETOPTIC S OPHTHALMIC (EYE) 3 DROPS,SUSPENSION carteolol ophthalmic (eye) drops 1 levobunolol ophthalmic (eye) drops 0.5 % 1 metipranolol ophthalmic (eye) drops 1 timolol maleate ophthalmic (eye) drops 1
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Drug Name Drug Tier Requirements / Limits timolol maleate ophthalmic (eye) gel forming 3 solution CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE OPHTHALMIC (EYE) 3 DROPS CYCLOPLEGIC MYDRIATICS atropine ophthalmic (eye) drops 1 atropine ophthalmic (eye) ointment 1 cyclopentolate ophthalmic (eye) drops 1 homatropaire ophthalmic (eye) drops 1 homatropine hbr ophthalmic (eye) drops 1 tropicamide ophthalmic (eye) drops 1 DIRECT ACTING MIOTICS pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 1 4 % MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL OPHTHALMIC (EYE) DROPS 3 ALOMIDE OPHTHALMIC (EYE) DROPS 3 altacaine ophthalmic (eye) drops 1 altafluor ophthalmic (eye) drops 1 azelastine ophthalmic (eye) drops 1 BEPREVE OPHTHALMIC (EYE) DROPS 3 cromolyn ophthalmic (eye) drops 1 CYSTARAN OPHTHALMIC (EYE) DROPS 4 PA; QL EMADINE OPHTHALMIC (EYE) DROPS 3 epinastine ophthalmic (eye) drops 1 EYLEA INTRAVITREAL SOLUTION 4 PA; LA flucaine ophthalmic (eye) drops 1 fluorescein-proparacaine ophthalmic (eye) drops 1 flurox ophthalmic (eye) drops 1 JETREA (PF) INTRAVITREAL SOLUTION 4 PA; QL 0.125 MG/0.1 ML (1.25 MG/ML)
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Drug Name Drug Tier Requirements / Limits LACRISERT OPHTHALMIC (EYE) INSERT 3 PA LASTACAFT OPHTHALMIC (EYE) DROPS 3 LUCENTIS INTRAVITREAL SOLUTION 4 PA; LA LUCENTIS INTRAVITREAL SYRINGE 4 PA; LA MACUGEN INTRAVITREAL SYRINGE 4 PA; LA olopatadine ophthalmic (eye) drops 1 ST PAZEO OPHTHALMIC (EYE) DROPS 3 proparacaine ophthalmic (eye) drops 1 RESTASIS MULTIDOSE OPHTHALMIC (EYE) 2 QL DROPS RESTASIS OPHTHALMIC (EYE) 2 QL DROPPERETTE tetcaine ophthalmic (eye) drops 1 tetracaine hcl (pf) ophthalmic (eye) drops 1 tetracaine hcl ophthalmic (eye) drops 1 TETRAVISC OPHTHALMIC (EYE) 3 DROPPERETTE,VISCOUS TETRAVISC OPHTHALMIC (EYE) DROPS, 3 VISCOUS VITRASE INJECTION SOLUTION 3 XIIDRA OPHTHALMIC (EYE) DROPPERETTE 2 QL NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL (PF) OPHTHALMIC (EYE) 3 QL DROPPERETTE bromfenac ophthalmic (eye) drops 1 diclofenac sodium ophthalmic (eye) drops 1 flurbiprofen sodium ophthalmic (eye) drops 1 ILEVRO OPHTHALMIC (EYE) 3 DROPS,SUSPENSION ketorolac ophthalmic (eye) drops 1 NEVANAC OPHTHALMIC (EYE) 3 DROPS,SUSPENSION PROLENSA OPHTHALMIC (EYE) DROPS 3
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Drug Name Drug Tier Requirements / Limits ORAL DRUGS FOR GLAUCOMA acetazolamide oral capsule, extended release 1 acetazolamide oral tablet 1 acetazolamide sodium injection recon soln 1 methazolamide oral tablet 1 OTHER GLAUCOMA DRUGS AZOPT OPHTHALMIC (EYE) 3 ST DROPS,SUSPENSION bimatoprost ophthalmic (eye) drops 2 ST COMBIGAN OPHTHALMIC (EYE) DROPS 2 COSOPT (PF) OPHTHALMIC (EYE) 3 ST DROPPERETTE dorzolamide ophthalmic (eye) drops 1 dorzolamide-timolol ophthalmic (eye) drops 1 latanoprost ophthalmic (eye) drops 1 LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 2 % miostat intraocular solution 1 SIMBRINZA OPHTHALMIC (EYE) 2 DROPS,SUSPENSION TRAVATAN Z OPHTHALMIC (EYE) DROPS 3 ST ZIOPTAN (PF) OPHTHALMIC (EYE) 3 ST DROPPERETTE STEROID-ANTIBIOTIC COMBINATIONS neomycin-bacitracin-poly-hc ophthalmic (eye) 1 ointment neomycin-polymyxin b-dexameth ophthalmic (eye) 1 drops,suspension neomycin-polymyxin b-dexameth ophthalmic (eye) 1 ointment neomycin-polymyxin-hc ophthalmic (eye) 1 drops,suspension neo-polycin hc ophthalmic (eye) ointment 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 99
Drug Name Drug Tier Requirements / Limits PRED-G OPHTHALMIC (EYE) 3 DROPS,SUSPENSION PRED-G S.O.P. OPHTHALMIC (EYE) 3 OINTMENT TOBRADEX OPHTHALMIC (EYE) 3 OINTMENT TOBRADEX ST OPHTHALMIC (EYE) 3 DROPS,SUSPENSION tobramycin-dexamethasone ophthalmic (eye) 1 drops,suspension ZYLET OPHTHALMIC (EYE) 3 DROPS,SUSPENSION STEROIDS ALREX OPHTHALMIC (EYE) 3 DROPS,SUSPENSION dexamethasone sodium phosphate ophthalmic 1 (eye) drops DUREZOL OPHTHALMIC (EYE) DROPS 2 FLAREX OPHTHALMIC (EYE) 3 DROPS,SUSPENSION fluorometholone ophthalmic (eye) 1 drops,suspension FML FORTE OPHTHALMIC (EYE) 3 DROPS,SUSPENSION FML S.O.P. OPHTHALMIC (EYE) OINTMENT 3 ILUVIEN INTRAVITREAL IMPLANT 4 PA; LA; QL LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 3 LOTEMAX OPHTHALMIC (EYE) 3 DROPS,SUSPENSION LOTEMAX OPHTHALMIC (EYE) OINTMENT 3 MAXIDEX OPHTHALMIC (EYE) 3 DROPS,SUSPENSION PRED MILD OPHTHALMIC (EYE) 3 DROPS,SUSPENSION prednisolone acetate ophthalmic (eye) 1 drops,suspension
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Drug Name Drug Tier Requirements / Limits prednisolone sodium phosphate ophthalmic (eye) 1 drops STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE OPHTHALMIC (EYE) 3 DROPS,SUSPENSION BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) 3 OINTMENT sulfacetamide-prednisolone ophthalmic (eye) 1 drops SULFONAMIDES sulfacetamide sodium ophthalmic (eye) drops 1 sulfacetamide sodium ophthalmic (eye) ointment 1 SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC (EYE) DROPS 2 0.1 % apraclonidine ophthalmic (eye) drops 1 brimonidine ophthalmic (eye) drops 0.15 % 2 brimonidine ophthalmic (eye) drops 0.2 % 1 VASOCONSTRICTOR DECONGESTANTS phenylephrine hcl ophthalmic (eye) drops 1 RESPIRATORY, ALLERGY, COUGH & COLD ANTIHISTAMINE & ANTIALLERGENIC AGENTS adrenalin injection solution 1 carbinoxamine maleate oral liquid 1 carbinoxamine maleate oral tablet 1 cetirizine oral solution 1 mg/ml 1 clemastine oral tablet 2.68 mg 1 cyproheptadine oral syrup 1 cyproheptadine oral tablet 1 diphenhydramine hcl injection solution 50 mg/ml 1 diphenhydramine hcl injection syringe 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 101
Drug Name Drug Tier Requirements / Limits EPINEPHRINE INJECTION AUTO-INJECTOR 1 0.15 MG/0.3 ML, 0.3 MG/0.3 ML (generic EpiPen) epinephrine injection solution 1 epinephrine injection syringe 0.1 mg/ml 1 EPIPEN 2-PAK INJECTION AUTO-INJECTOR 2 EPIPEN JR 2-PAK INJECTION AUTO- 2 INJECTOR hydroxyzine hcl intramuscular solution 1 hydroxyzine hcl oral solution 10 mg/5 ml 1 hydroxyzine hcl oral tablet 1 hydroxyzine pamoate oral capsule 1 levocetirizine oral solution 1 levocetirizine oral tablet 1 phenadoz rectal suppository 1 phenergan rectal suppository 12.5 mg, 25 mg 1 phenergan rectal suppository 50 mg 3 promethazine injection solution 1 promethazine oral syrup 1 promethazine oral tablet 1 promethazine rectal suppository 12.5 mg, 25 mg 1 promethazine rectal suppository 50 mg 3 promethegan rectal suppository 12.5 mg, 25 mg 1 promethegan rectal suppository 50 mg 3 COUGH & COLD THERAPY benzonatate oral capsule 100 mg, 200 mg 1 brompheniramine-pseudoeph-dm oral syrup 1 centergy oral drops 1 cheratussin ac oral liquid 1 codeine-guaifenesin oral liquid 1 FLOWTUSS ORAL SOLUTION 3 g tussin ac oral liquid 1
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Drug Name Drug Tier Requirements / Limits guaiatussin ac oral liquid 1 guaifenesin ac oral liquid 1 guaifenesin dac oral syrup 1 hydrocodone-chlorpheniramine oral 1 suspension,extended rel 12 hr hydrocodone-homatropine oral syrup 5-1.5 mg/5 1 ml hydrocodone-homatropine oral tablet 1 hydromet oral syrup 1 lortuss ex oral syrup 1 m-clear wc oral liquid 1 promethazine vc-codeine oral syrup 1 promethazine-codeine oral syrup 1 promethazine-dm oral syrup 1 promethazine-phenyleph-codeine oral syrup 1 promethazine-phenylephrine oral syrup 1 relcof c oral liquid 1 rydex oral liquid 1 tusnel c oral syrup 1 tussigon oral tablet 1 virtussin ac oral liquid 1 virtussin dac oral syrup 1 PULMONARY AGENTS acetylcysteine solution 1 ADCIRCA ORAL TABLET 4 PA; QL ADEMPAS ORAL TABLET 4 PA; LA; QL ADRENALIN NASAL SOLUTION 3 ADVAIR DISKUS INHALATION BLISTER 2 WITH DEVICE ADVAIR HFA INHALATION HFA AEROSOL 2 INHALER albuterol sulfate inhalation solution for 1 nebulization You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 103
Drug Name Drug Tier Requirements / Limits albuterol sulfate oral syrup 1 albuterol sulfate oral tablet 1 albuterol sulfate oral tablet extended release 12 hr 1 ALVESCO INHALATION HFA AEROSOL 3 ST INHALER ANORO ELLIPTA INHALATION BLISTER 2 WITH DEVICE ARCAPTA NEOHALER INHALATION 3 ST CAPSULE, W/INHALATION DEVICE ARNUITY ELLIPTA INHALATION BLISTER 2 WITH DEVICE ASMANEX HFA INHALATION HFA 2 AEROSOL INHALER ASMANEX TWISTHALER INHALATION 2 AEROSOL POWDR BREATH ACTIVATED ATROVENT HFA INHALATION HFA 3 AEROSOL INHALER BERINERT INTRAVENOUS KIT 4 PA; LA BREO ELLIPTA INHALATION BLISTER 2 WITH DEVICE BROVANA INHALATION SOLUTION FOR 3 NEBULIZATION budesonide inhalation suspension for nebulization 1 budesonide nasal spray,non-aerosol 1 CINRYZE INTRAVENOUS RECON SOLN 4 PA; LA; QL COMBIVENT RESPIMAT INHALATION MIST 2 cromolyn inhalation solution for nebulization 1 DALIRESP ORAL TABLET 3 PA ESBRIET ORAL CAPSULE 4 PA; LA; QL ESBRIET ORAL TABLET 4 PA; LA; QL FIRAZYR SUBCUTANEOUS SYRINGE 4 PA; LA; QL FLOVENT DISKUS INHALATION BLISTER 2 WITH DEVICE FLOVENT HFA INHALATION HFA AEROSOL 2 INHALER You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 104
Drug Name Drug Tier Requirements / Limits flunisolide nasal spray,non-aerosol 25 mcg (0.025 1 %) fluticasone nasal spray,suspension 1 FLUTICASONE-SALMETEROL INHALATION 1 AEROSOL POWDR BREATH ACTIVATED HAEGARDA SUBCUTANEOUS RECON SOLN 4 PA; LA HYPER-SAL INHALATION SOLUTION FOR 2 NEBULIZATION 3.5 % INCRUSE ELLIPTA INHALATION BLISTER 2 WITH DEVICE ipratropium bromide inhalation solution 1 ipratropium-albuterol inhalation solution for 1 nebulization KALBITOR SUBCUTANEOUS SOLUTION 4 PA; LA KALYDECO ORAL GRANULES IN PACKET 4 PA; LA; QL KALYDECO ORAL TABLET 4 PA; LA; QL LETAIRIS ORAL TABLET 4 PA; LA; QL levalbuterol hcl inhalation solution for 1 nebulization LEVALBUTEROL TARTRATE INHALATION 3 PA; QL HFA AEROSOL INHALER metaproterenol oral syrup 1 metaproterenol oral tablet 1 montelukast oral granules in packet 1 QL montelukast oral tablet 1 QL montelukast oral tablet,chewable 1 QL nebusal inhalation solution for nebulization 3 % 1 NEBUSAL INHALATION SOLUTION FOR 2 NEBULIZATION 6 % NUCALA SUBCUTANEOUS RECON SOLN 4 PA; LA; QL OFEV ORAL CAPSULE 4 PA; LA; QL OPSUMIT ORAL TABLET 4 PA; LA; QL ORKAMBI ORAL TABLET 4 PA; LA; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 105
Drug Name Drug Tier Requirements / Limits PERFOROMIST INHALATION SOLUTION 3 FOR NEBULIZATION PROAIR HFA INHALATION HFA AEROSOL 3 PA; QL INHALER PROVENTIL HFA INHALATION HFA 3 PA; QL AEROSOL INHALER pulmosal inhalation solution for nebulization 1 PULMOZYME INHALATION SOLUTION 4 PA; LA; QL QVAR INHALATION AEROSOL 3 PA RUCONEST INTRAVENOUS RECON SOLN 4 PA; LA SEREVENT DISKUS INHALATION BLISTER 2 WITH DEVICE sildenafil (antihypertensive) oral tablet 4 PA; QL sodium chloride inhalation solution for 1 nebulization 10 %, 3 %, 7 % SPIRIVA RESPIMAT INHALATION MIST 2 SPIRIVA WITH HANDIHALER INHALATION 2 CAPSULE, W/INHALATION DEVICE STIOLTO RESPIMAT INHALATION MIST 2 STRIVERDI RESPIMAT INHALATION MIST 3 terbutaline oral tablet 1 terbutaline subcutaneous solution 1 theochron oral tablet extended release 12 hr 1 theophylline oral elixir 1 theophylline oral solution 1 theophylline oral tablet extended release 12 hr 1 theophylline oral tablet extended release 24 hr 1 TRACLEER ORAL TABLET 4 PA; LA; QL TUDORZA PRESSAIR INHALATION 3 PA AEROSOL POWDR BREATH ACTIVATED TYVASO INHALATION SOLUTION FOR 4 PA; LA NEBULIZATION TYVASO REFILL KIT INHALATION 4 PA; LA SOLUTION FOR NEBULIZATION
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 106
Drug Name Drug Tier Requirements / Limits TYVASO STARTER KIT INHALATION 4 PA; LA SOLUTION FOR NEBULIZATION VENTAVIS INHALATION SOLUTION FOR 4 PA; LA NEBULIZATION VENTOLIN HFA INHALATION HFA 2 QL AEROSOL INHALER XOLAIR SUBCUTANEOUS RECON SOLN 4 PA; LA; QL XOPENEX HFA INHALATION HFA AEROSOL 3 PA; QL INHALER zafirlukast oral tablet 1 zileuton oral tablet, er multiphase 12 hr 4 ST; QL ZYFLO CR ORAL TABLET, ER MULTIPHASE 4 ST; QL 12 HR UROLOGICALS ANTICHOLINERGICS & ANTISPASMODICS darifenacin oral tablet extended release 24 hr 3 ST flavoxate oral tablet 1 MYRBETRIQ ORAL TABLET EXTENDED 2 QL RELEASE 24 HR oxybutynin chloride oral syrup 1 oxybutynin chloride oral tablet 1 oxybutynin chloride oral tablet extended release 1 24hr tolterodine oral capsule,extended release 24hr 1 tolterodine oral tablet 1 TOVIAZ ORAL TABLET EXTENDED 2 RELEASE 24 HR trospium oral capsule,extended release 24hr 1 trospium oral tablet 1 VESICARE ORAL TABLET 2 BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY alfuzosin oral tablet extended release 24 hr 1 CIALIS ORAL TABLET 5 MG 3 PA; QL dutasteride oral capsule 3 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 107
Drug Name Drug Tier Requirements / Limits dutasteride-tamsulosin oral capsule, er multiphase 3 24 hr finasteride oral tablet 5 mg 1 RAPAFLO ORAL CAPSULE 3 ST tamsulosin oral capsule,extended release 24hr 1 CHOLINERGIC STIMULANTS bethanechol chloride oral tablet 1 MISCELLANEOUS UROLOGICALS CYSTAGON ORAL CAPSULE 4 cytra k crystals oral packet 1 cytra-2 oral solution 1 cytra-3 oral solution 1 cytra-k oral solution 1 ELMIRON ORAL CAPSULE 3 hyophen oral tablet 1 methen-sod phos-meth blue-hyos oral tablet 1 pot,sodium citrate-citric acid oral solution 1 potassium citrate oral tablet extended release 1 potassium citrate-citric acid oral packet 1 potassium citrate-citric acid oral solution 1 PROCYSBI ORAL CAPSULE, DELAYED REL 4 PA; LA; QL SPRINKLE sodium citrate-citric acid oral solution 1 tricitrates oral solution 1 uretron d-s oral tablet 81.6-10.8-40.8 mg 1 urin ds oral tablet 1 urogesic-blue oral tablet 1 urophen mb oral tablet 1 uryl oral tablet 1 virtrate-2 oral solution 1 virtrate-3 oral solution 1 virtrate-k oral solution 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 108
Drug Name Drug Tier Requirements / Limits URINARY ANESTHETICS phenazopyridine oral tablet 100 mg, 200 mg 1 VITAMINS, HEMATINICS & ELECTROLYTES ELECTROLYTES calcium 500 + d oral tablet 500 mg(1,250mg) -200 6 ACA; OTC unit calcium 500 + d oral tablet,chewable 6 ACA; OTC calcium 500 with d oral tablet 6 ACA; OTC calcium 600 + d(3) oral capsule 6 ACA; OTC calcium 600 + d(3) oral tablet 600 mg(1,500mg) - 6 ACA; OTC 200 unit, 600 mg(1,500mg) -400 unit calcium 600 with vitamin d3 oral capsule 6 ACA; OTC calcium 600 with vitamin d3 oral tablet,chewable 6 ACA; OTC calcium carb and citrate-vitd3 oral tablet extended 6 ACA; OTC release calcium carbonate-vitamin d3 oral capsule 600 6 ACA; OTC mg(1,500mg) -400 unit calcium carbonate-vitamin d3 oral tablet 500 6 ACA; OTC mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit, 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) - 800 unit calcium carbonate-vitamin d3 oral 6 ACA; OTC tablet,chewable 500-100 mg-unit calcium citrate + d oral tablet 6 ACA; OTC calcium citrate-vitamin d2 oral tablet 6 ACA; OTC calcium citrate-vitamin d3 oral tablet 6 ACA; OTC citrus calcium oral tablet 6 ACA; OTC effer-k oral tablet, effervescent 25 meq 1 GALZIN ORAL CAPSULE 3 PA GLYCOPHOS INTRAVENOUS SOLUTION 3 hi-cal plus vit d oral tablet 6 ACA; OTC k-effervescent oral tablet, effervescent 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 109
Drug Name Drug Tier Requirements / Limits klor-con 10 oral tablet extended release 1 klor-con 8 oral tablet extended release 1 klor-con m10 oral tablet,er particles/crystals 1 klor-con m15 oral tablet,er particles/crystals 1 klor-con m20 oral tablet,er particles/crystals 1 klor-con oral packet 1 klor-con sprinkle oral capsule, extended release 1 klor-con/ef oral tablet, effervescent 1 k-phos-neutral oral tablet 1 k-tab oral tablet extended release 8 meq 1 NORMOSOL-R INTRAVENOUS 3 PARENTERAL SOLUTION oysco 500/d oral tablet 6 ACA; OTC oyster shell + d3 oral tablet 6 ACA; OTC oyster shell calcium-vit d3 oral tablet 6 ACA; OTC oystercal-d oral tablet 6 ACA; OTC phospha 250 neutral oral tablet 1 potassium acetate intravenous solution 2 meq/ml 1 potassium bicarb and chloride oral tablet, 1 effervescent potassium bicarb-citric acid oral tablet, 1 effervescent potassium chlorid-d5-0.45%nacl intravenous 1 parenteral solution potassium chloride in 0.9%nacl intravenous 1 parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous 1 parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral 1 solution potassium chloride intravenous piggyback 1 potassium chloride intravenous solution 1 potassium chloride oral capsule, extended release 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 110
Drug Name Drug Tier Requirements / Limits potassium chloride oral liquid 1 potassium chloride oral packet 1 potassium chloride oral tablet extended release 1 potassium chloride oral tablet,er particles/crystals 1 potassium chloride-0.45 % nacl intravenous 1 parenteral solution potassium chloride-d5-0.2%nacl intravenous 1 parenteral solution potassium chloride-d5-0.3%nacl intravenous 1 parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous 1 parenteral solution potassium phosphate m-/d-basic intravenous 1 solution sodium chloride 0.45 % intravenous parenteral 1 solution sodium chloride 0.45 % intravenous piggyback 1 sodium chloride 3 % intravenous parenteral 1 solution sodium chloride 5 % intravenous parenteral 1 solution sodium chloride intravenous parenteral solution 1 SODIUM PHOSPHATE IN 0.9 % NACL 4 INTRAVENOUS SOLUTION 15 MMOL/250 ML, 7.5 MMOL/100 ML sodium phosphate intravenous solution 1 virt-phos 250 neutral oral tablet 1 MISCELLANEOUS VITAMINS, HEMATINICS, & ELECTROLYTES ISOLYTE-S INTRAVENOUS PARENTERAL 3 SOLUTION PLASMA-LYTE 148 INTRAVENOUS 3 PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS 3 PARENTERAL SOLUTION VITAMINS & HEMATINICS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 111
Drug Name Drug Tier Requirements / Limits b complex-vitamin b12 oral tablet 6 ACA; OTC b complex-vitamin c-folic acid oral tablet 6 ACA; OTC balanced b-100 complex oral tablet extended 6 ACA; OTC release 100 mg balanced b-100 oral tablet 0.4 mg 6 ACA; OTC balanced b-50 oral tablet 6 ACA; OTC bal-care dha oral combo pack,tablet and cap,dr 1 b-complex with vitamin c oral tablet 6 ACA; OTC calcium pnv oral capsule 1 calcium-folic acid-vitamin d oral wafer 1 cholecalciferol (vitamin d3) oral capsule 1,000 6 ACA; OTC unit cholecalciferol (vitamin d3) oral drops 400 unit/ml 6 ACA; OTC cholecalciferol (vitamin d3) oral tablet 1,000 unit, 6 ACA; OTC 400 unit cholecalciferol (vitamin d3) oral tablet,chewable 6 ACA; OTC 1,000 unit classic prenatal oral tablet 6 ACA; OTC c-nate dha oral capsule 1 complete natal dha oral combo pack 1 completenate oral tablet,chewable 1 complex b-100 oral tablet extended release 6 ACA; OTC corvita 150 oral tablet 1 cyanocobalamin (vitamin b-12) injection solution 1 DECARA ORAL CAPSULE 50,000 UNIT 3 OTC delta d3 oral tablet 6 ACA; OTC dialyvite 800 oral tablet 6 ACA; OTC dialyvite oral tablet 1 dothelle dha oral capsule 1 d-vi-sol oral drops 6 ACA; OTC elite-ob oral tablet 1 ergocalciferol (vitamin d2) oral capsule 1 ergocalciferol (vitamin d2) oral tablet 400 unit 6 ACA; OTC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 112
Drug Name Drug Tier Requirements / Limits ferocon oral capsule 1 ferraplus 90 oral tablet 1 ferrex 150 forte oral capsule 1 ferrex 150 forte plus oral capsule 1 ferrex 28 oral tablet 1 fluor-a-day (with xylitol) oral tablet,chewable 0.25 6 ACA mg f (0.55 mg)-236.79mg fluor-a-day (with xylitol) oral tablet,chewable 1 1 mg f (2.2 mg)-236.79 mg fluoride (sodium) oral drops 6 ACA fluoride (sodium) oral tablet,chewable 0.25 6 ACA mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid) fluoride (sodium) oral tablet,chewable 1 mg (2.2 1 mg sod. fluoride) fluoritab oral tablet,chewable 0.5 mg (1.1 mg 6 ACA sodium fluorid) fluoritab oral tablet,chewable 1 mg (2.2 mg sod. 1 fluoride) focalgin 90 dha oral combo pack 1 focalgin ca oral combo pack 1 focalgin dss oral tablet 1 folbee oral tablet 1 folbee plus oral tablet 5 mg 1 folbic oral tablet 1 folic acid injection solution 1 folic acid oral tablet 1 mg 1 folic acid oral tablet 400 mcg, 800 mcg 6 ACA; OTC folic acid-vit b6-vit b12 oral tablet 2.2-25-0.5 mg 1 folivane-f oral capsule 1 folivane-ob oral capsule 1 folivane-plus oral capsule 1 folplex 2.2 oral tablet 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 113
Drug Name Drug Tier Requirements / Limits foltabs 800 oral tablet 6 ACA; OTC full spectrum b-vitamin c oral tablet 6 ACA; OTC FUSION PLUS ORAL CAPSULE 3 hematinic/folic acid oral tablet 1 hematogen fa oral capsule 1 hematogen forte oral capsule 1 hematogen oral capsule 1 hemenatal ob + dha oral combo pack 1 hemenatal ob oral tablet 1 hemetab oral tablet 1 hydroxocobalamin intramuscular solution 1 iferex 150 forte oral capsule 1 infed injection solution 1 kobee oral tablet 6 ACA; OTC kpn oral tablet 6 ACA; OTC levomefolate dha oral capsule 1 ludent fluoride oral tablet,chewable 0.25 mg(0.55 6 ACA mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid) ludent fluoride oral tablet,chewable 1 mg (2.2 mg 1 sod. fluoride) multigen folic oral tablet 1 multigen plus oral tablet 1 multi-vit with fluoride-iron oral drops 1 multi-vitamin with fluoride oral drops 6 ACA multi-vitamin with fluoride oral tablet,chewable 6 ACA 0.25 mg, 0.5 mg multi-vitamin with fluoride oral tablet,chewable 1 1 mg multivitamins with fluoride oral tablet,chewable 6 ACA 0.25 mg, 0.5 mg multivitamins with fluoride oral tablet,chewable 1 1 mg multivit-fluor (vit e acetate) oral drops 6 ACA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 114
Drug Name Drug Tier Requirements / Limits mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg 6 ACA mvc-fluoride oral tablet,chewable 1 mg 1 myferon 150 forte oral capsule 1 mynatal advance oral tablet 1 mynatal oral capsule 1 mynatal oral tablet 1 mynatal plus oral tablet 1 mynatal-z oral tablet 1 mynate 90 plus oral tablet extended release 1 mynephrocaps oral capsule 1 mynephron oral capsule 1 natural b-100 complex oral tablet 6 ACA; OTC nephplex rx oral tablet 1 nephro-vite rx oral tablet 1 newgen oral tablet 1 NEXAVIR INJECTION SOLUTION 3 obstetrix dha oral combo pack,tablet and cap,dr 1 one daily prenatal oral combo pack 28-800-440 6 ACA; OTC mg-mcg-mg oyster shell calcium-vit d2 oral tablet 250 (625)- 6 ACA; OTC 125 mg-unit perry prenatal oral capsule 6 ACA; OTC pnv 29-1 oral tablet 1 pnv ob+dha oral combo pack 27-1-50-250 mg 1 pnv-dha + docusate oral capsule 1 pnv-dha oral capsule 1 pnv-ferrous fumarate-docu-fa oral tablet 1 pnv-omega oral capsule 1 pnv-select oral tablet 1 pnv-vp-u oral capsule 1 poly-iron 150 forte oral capsule 1 pr natal 400 ec oral combo pack,tablet and cap,dr 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 115
Drug Name Drug Tier Requirements / Limits pr natal 400 oral combo pack 1 pr natal 430 ec oral combo pack,tablet and cap,dr 1 pr natal 430 oral combo pack 1 prena1 chew oral tablet,chew,ir - dr,biphase 1 prenaissance oral capsule 1 prenaissance plus oral capsule 1 prenatabs fa oral tablet 1 prenatabs rx oral tablet 1 prenatal 19 oral tablet,chewable 1 OTC prenatal complete oral tablet 6 ACA; OTC prenatal formula oral tablet 28 mg iron- 800 mcg 6 ACA; OTC prenatal multi-dha (algal oil) oral capsule 6 ACA; OTC prenatal one daily oral tablet 6 ACA; OTC prenatal oral tablet 28 mg iron- 800 mcg 6 ACA; OTC prenatal plus (calcium carb) oral tablet 1 prenatal plus oral tablet 1 prenatal vitamin oral tablet , 27 mg iron- 0.8 mg 6 ACA; OTC prenatal vitamin plus low iron oral tablet 1 prenatal vitamin with minerals oral tablet 6 ACA; OTC prenatal vits96-iron fum-folic oral tablet 6 ACA; OTC prenatal-u oral capsule 1 preplus oral tablet 1 pretab oral tablet 1 purevit dualfe plus oral capsule 1 relnate dha oral capsule 1 renal caps oral capsule 1 rena-vite oral tablet 6 ACA; OTC rena-vite rx oral tablet 1 reno caps oral capsule 1 risacal-d oral tablet 6 ACA; OTC se-natal 19 (with docusate) oral tablet 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 116
Drug Name Drug Tier Requirements / Limits se-natal 19 oral tablet,chewable 1 se-tan plus oral capsule 1 stress formula oral tablet 6 ACA; OTC stress formula with iron oral tablet 6 ACA; OTC stress formula with iron(sulf) oral tablet 6 ACA; OTC super b complex-vitamin c oral tablet 6 ACA; OTC super b maxi complex oral tablet 6 ACA; OTC super b-50 complex plus oral tablet 6 ACA; OTC super quints b-50 oral tablet 6 ACA; OTC super quints oral tablet 6 ACA; OTC superplex-t oral tablet 6 ACA; OTC taron forte oral capsule 1 taron-c dha oral capsule 1 taron-prex prenatal-dha oral capsule 1 thrivite-19 oral tablet 1 tl gard rx oral tablet 1 tl icon oral capsule 1 tl-hem 150 oral tablet extended release 24 hr 1 total b/c oral tablet 6 ACA; OTC tricon oral capsule 1 trigels-f forte oral capsule 1 trinatal gt oral tablet 1 trinatal rx 1 oral tablet 1 trinate oral tablet 1 triphrocaps oral capsule 1 tri-tabs dha oral combo pack 1 triveen-duo dha oral combo pack 1 tri-vit with fluoride and iron oral drops 1 tri-vitamin with fluoride oral drops 6 ACA trust natal dha oral combo pack 1 ultimatecare one nf oral capsule 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 117
Drug Name Drug Tier Requirements / Limits ultimatecare one oral capsule 1 ultra b-100 complex oral tablet 6 ACA; OTC vemavite-prx-2 oral capsule 1 VENOFER INTRAVENOUS SOLUTION 3 vinate care oral tablet,chewable 1 vinate ii oral tablet 1 vinate m oral tablet 1 vinate one oral tablet 1 virt-advance oral tablet 1 virt-c dha oral capsule 1 virt-gard oral tablet 1 virt-nate dha oral capsule 1 virt-nate oral tablet 1 virt-pn dha oral capsule 1 virt-pn oral tablet 1 virt-pn plus oral capsule 1 virt-select oral capsule 1 virt-vite forte oral tablet 1 virt-vite gt oral tablet 1 virt-vite oral tablet 1 vit 3 oral capsule 1 vit b complex-folic acid oral tablet 6 ACA; OTC vitamin b complex oral tablet 6 ACA; OTC vitamin d3 oral capsule 1,000 unit, 400 unit 6 ACA; OTC vitamin d3 oral tablet 1,000 unit, 400 unit 6 ACA; OTC vitamin d3 oral tablet,chewable 6 ACA; OTC vitamins a,c,d and fluoride oral drops 6 ACA vol-care rx oral tablet 1 vol-nate oral tablet 1 vol-plus oral tablet 1 vol-tab rx oral tablet 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 118
Drug Name Drug Tier Requirements / Limits vp-ch plus oral capsule 1 vp-ch-pnv oral capsule 1 vp-ggr-b6 oral tablet 1 vp-heme ob oral tablet 1 vp-heme one oral capsule 1 vp-vite rx oral tablet 1 zatean-ch oral capsule 1 zatean-pn dha oral capsule 1 zatean-pn plus oral capsule 1 zingiber oral tablet 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 119
Index
A afeditab cr ...... 42 amethia ...... 90 abacavir ...... 4 AFINITOR ...... 17 amethia lo ...... 90 abacavir-lamivudine ...... 4 AFINITOR DISPERZ ...... 17 amethyst ...... 90 abacavir-lamivudine- AFLURIA 2017-2018 ...... 81 amifostine crystalline...... 17 zidovudine ...... 4 AFLURIA 2017-2018 (PF) .. 81 amikacin ...... 10 ABELCET ...... 3 AFLURIA QUAD 2017-2018 amiloride ...... 42 ABILIFY MAINTENA ...... 35 ...... 81 amiloride-hydrochlorothiazide ABRAXANE ...... 17 AFLURIA QUAD 2017-2018 ...... 42 ABSTRAL ...... 29 (PF) ...... 81 aminocaproic acid ...... 47 acamprosate ...... 59 AFREZZA ...... 64 amiodarone ...... 41 acarbose ...... 68 AKYNZEO ...... 72 AMITIZA ...... 72 acebutolol ...... 42 ala-cort ...... 56 amitriptyline ...... 36 acetaminophen-codeine ...... 29 ALBENZA ...... 10 amitriptyline-chlordiazepoxide acetazolamide ...... 99 albuterol sulfate ...... 103, 104 ...... 36 acetazolamide sodium ...... 99 alclometasone ...... 56 amlodipine ...... 42 acetic acid ...... 59, 62 ALDURAZYME ...... 66 amlodipine-benazepril ...... 42 acetylcysteine ...... 103 ALECENSA ...... 17 ammonium lactate ...... 52 acitretin ...... 51 alendronate ...... 59, 86 amnesteem ...... 53 ACTEMRA ...... 86 ALFERON N ...... 80 amoxapine...... 36 ACTHAR H.P...... 62 alfuzosin ...... 107 amoxicil-clarithromy-lansopraz ACTHIB (PF) ...... 81 ALIMTA ...... 17 ...... 77 ACTIMMUNE ...... 80 ALINIA ...... 10 amoxicillin ...... 13, 14 ACUVAIL (PF) ...... 98 allopurinol ...... 85 amoxicillin-pot clavulanate .. 14 acyclovir ...... 4, 56 allopurinol sodium ...... 85 amphotericin b ...... 3 acyclovir sodium ...... 4 almotriptan malate ...... 27 ampicillin ...... 14 ADACEL(TDAP ALOCRIL ...... 97 ampicillin sodium ...... 14 ADOLESN/ADULT)(PF) 81 ALOMIDE...... 97 ampicillin-sulbactam ...... 14 ADAGEN ...... 59 alophen ...... 72 AMPYRA ...... 28 adapalene ...... 53 aloprim...... 85 ANADROL-50 ...... 66 adapalene-benzoyl peroxide . 53 alosetron ...... 72 anagrelide ...... 59 ADCIRCA ...... 103 ALOXI...... 72 anaspaz ...... 71 ADDERALL XR ...... 35 ALPHAGAN P ...... 101 anastrozole ...... 17 ADDYI ...... 35 alprazolam ...... 36 ANDRODERM ...... 66 adefovir...... 4 alprazolam intensol...... 35 ANDROGEL ...... 66 ADEMPAS ...... 103 ALREX ...... 100 ANORO ELLIPTA ...... 104 ADLYXIN ...... 68 ALTABAX ...... 55 anucort-hc ...... 72 adrenalin ...... 101 altacaine ...... 97 ANZEMET ...... 72 ADRENALIN...... 103 altafluor ...... 97 APIDRA ...... 64 adriamycin ...... 17 altavera (28) ...... 90 APIDRA SOLOSTAR...... 64 adrucil ...... 17 ALUNBRIG ...... 17 APOKYN ...... 26 ADVAIR DISKUS ...... 103 ALVESCO...... 104 apraclonidine ...... 101 ADVAIR HFA ...... 103 alyacen 1/35 (28) ...... 90 aprepitant ...... 72 AEROCHAMBER MINI ..... 63 alyacen 7/7/7 (28) ...... 90 apri ...... 90 AEROCHAMBER PLUS amabelz ...... 88 APRISO ...... 72 FLOW-VU ...... 63 amantadine hcl ...... 4 APTIOM ...... 24 AEROCHAMBER PLUS Z AMBISOME ...... 3 APTIVUS ...... 4 STAT SM MSK ...... 64 amcinonide ...... 56 ARALAST NP...... 59 120 aranelle (28)...... 90 AVONEX (WITH ALBUMIN) BETASERON...... 79 ARANESP (IN ...... 79 betaxolol ...... 42, 96 POLYSORBATE) ...... 78 AZACTAM IN DEXTROSE bethanechol chloride ...... 108 ARCALYST ...... 80 (ISO-OSM) ...... 10 BETHKIS ...... 10 ARCAPTA NEOHALER ... 104 AZASITE ...... 95 BETOPTIC S ...... 96 aripiprazole ...... 36 azathioprine ...... 17 bexarotene...... 18 ARISTADA ...... 36 azathioprine sodium ...... 17 bicalutamide ...... 18 armodafinil ...... 36 azelastine ...... 61, 97 BICILLIN C-R ...... 14 ARMOUR THYROID ...... 70 azithromycin ...... 9 BICILLIN L-A ...... 14 ARNUITY ELLIPTA ...... 104 AZOPT ...... 99 BICNU ...... 18 ARRANON ...... 17 aztreonam ...... 10 BILTRICIDE ...... 10 ASACOL HD ...... 72 azurette (28) ...... 90 bimatoprost ...... 99 ascomp with codeine ...... 29 B BIOTHRAX ...... 81 ashlyna ...... 90 b complex-vitamin b12 ...... 112 bisacodyl ...... 72 ASMANEX HFA ...... 104 b complex-vitamin c-folic acid bisa-lax ...... 73 ASMANEX TWISTHALER ...... 112 bisoprolol fumarate ...... 42 ...... 104 baciim ...... 10 bisoprolol-hydrochlorothiazide aspir-81 ...... 33 bacitracin ...... 10, 95 ...... 42 aspirin ...... 33 bacitracin-polymyxin b...... 95 bivalirudin...... 47 aspirin low dose ...... 33 baclofen ...... 28 BIVIGAM...... 81 aspirin-dipyridamole ...... 47 balanced b-100 ...... 112 bleo 15k ...... 18 aspir-low ...... 33 balanced b-100 complex ..... 112 bleomycin ...... 18 aspir-trin ...... 33 balanced b-50 ...... 112 BLEPHAMIDE ...... 101 astramorph-pf ...... 29 bal-care dha ...... 112 BLEPHAMIDE S.O.P...... 101 atenolol ...... 42 balsalazide ...... 72 blisovi 24 fe ...... 91 atenolol-chlorthalidone...... 42 balziva (28) ...... 90 blisovi fe 1.5/30 (28) ...... 91 ATGAM ...... 81 BANZEL ...... 24 blisovi fe 1/20 (28) ...... 91 atomoxetine ...... 36 BARACLUDE...... 4 BOOSTRIX TDAP ...... 81 atorvastatin ...... 49 BASAGLAR KWIKPEN ..... 64 BOSULIF ...... 18 atovaquone ...... 10 bayer aspirin ...... 33 BOTOX ...... 81 atovaquone-proguanil ...... 10 BCG VACCINE, LIVE (PF) 81 BREO ELLIPTA ...... 104 ATRIPLA ...... 4 b-complex with vitamin c ... 112 briellyn ...... 91 atropine ...... 71, 97 bekyree (28) ...... 91 BRILINTA ...... 47 ATROVENT HFA ...... 104 belladonna alkaloids-opium . 71 brimonidine...... 101 AUBAGIO ...... 79 belladonna-opium ...... 71 BRIVIACT ...... 24 aubra ...... 90 benazepril ...... 42 bromfenac ...... 98 AUGMENTIN ...... 14 benazepril-hydrochlorothiazide bromocriptine ...... 26 AURYXIA ...... 72 ...... 42 brompheniramine-pseudoeph- AUSTEDO ...... 28 BENLYSTA ...... 86 dm ...... 102 AVAR...... 53 benzonatate ...... 102 BROVANA ...... 104 AVAR LS ...... 53 benztropine ...... 26 budesonide ...... 73, 104 AVASTIN ...... 17 BEPREVE ...... 97 bumetanide ...... 42 AVEED ...... 66 BERINERT ...... 104 BUNAVAIL ...... 33 AVELOX IN NACL (ISO- BESIVANCE...... 95 BUPHENYL ...... 59 OSMOTIC)...... 15 BETADINE OPHTHALMIC BUPRENEX ...... 29 aviane ...... 90 PREP ...... 95 BUPRENORPHINE ...... 29 avita ...... 53 betamethasone acet,sod phos 62 buprenorphine hcl ...... 29 avo cream ...... 52 betamethasone dipropionate . 56 buprenorphine-naloxone ...... 33 AVONEX ...... 79 betamethasone valerate... 56, 57 bupropion hcl ...... 36 betamethasone, augmented ... 57 121 bupropion hcl (smoking deter) candesartan-hydrochlorothiazid cefpodoxime ...... 8 ...... 60 ...... 42 cefprozil ...... 8 buspirone ...... 36 capacet ...... 30 ceftazidime ...... 8 busulfan ...... 18 CAPASTAT ...... 10 CEFTAZIDIME IN D5W...... 8 BUSULFEX ...... 18 capecitabine ...... 18 CEFTIN ...... 8 butalbital compound w/codeine CAPRELSA...... 18 ceftriaxone ...... 9 ...... 29 captopril ...... 42 ceftriaxone in dextrose,iso-os . 8 butalbital-acetaminop-caf-cod captopril-hydrochlorothiazide cefuroxime axetil ...... 9 ...... 29 ...... 42 cefuroxime sodium ...... 9 butalbital-acetaminophen ..... 30 CARAFATE ...... 77 celecoxib ...... 33 butalbital-acetaminophen-caff CARBAGLU ...... 59 CELLCEPT ...... 18 ...... 30 carbamazepine ...... 24 CELLCEPT INTRAVENOUS butalbital-aspirin-caffeine .... 30 carbidopa ...... 26 ...... 18 butorphanol tartrate ...... 33 carbidopa-levodopa ...... 26, 27 CELONTIN ...... 24 BUTRANS ...... 30 carbidopa-levodopa- centergy ...... 102 BYDUREON ...... 68 entacapone ...... 27 cephalexin ...... 9 BYETTA ...... 68 carbinoxamine maleate ...... 101 CERDELGA ...... 66 BYSTOLIC ...... 42 carboplatin ...... 18 CEREZYME...... 66 BYVALSON ...... 42 CARIMUNE NF CESAMET ...... 73 C NANOFILTERED...... 81 cetirizine ...... 101 cabergoline ...... 66 carisoprodol ...... 28 cevimeline...... 59 CABOMETYX...... 18 carisoprodol-aspirin ...... 29 CHANTIX ...... 60 calcipotriene ...... 51 carteolol ...... 96 CHANTIX CONTINUING calcitonin (salmon) ...... 66 cartia xt ...... 42 MONTH BOX ...... 60 calcitrene ...... 51 carvedilol ...... 42 CHANTIX STARTING calcitriol ...... 51, 66 caspofungin ...... 3 MONTH BOX ...... 60 calcium 500 + d ...... 109 CASPOFUNGIN ...... 3 chateal ...... 91 calcium 500 with d ...... 109 CAYA CONTOURED ...... 87 CHEMET ...... 59 calcium 600 + d(3) ...... 109 CAYSTON ...... 10 cheratussin ac...... 102 calcium 600 with vitamin d3 caziant (28) ...... 91 children's aspirin ...... 33 ...... 109 CEDAX ...... 7 chloramphenicol sod succinate calcium acetate ...... 73 cefaclor ...... 7 ...... 11 calcium carb and citrate-vitd3 cefadroxil ...... 7 chlordiazepoxide hcl ...... 36 ...... 109 cefazolin ...... 8 chlordiazepoxide-clidinium .. 71 calcium carbonate-vitamin d3 CEFAZOLIN IN 0.9% SOD chlorhexidine gluconate ...... 61 ...... 109 CHLORIDE ...... 8 chloroquine phosphate ...... 11 calcium citrate + d ...... 109 cefazolin in dextrose (iso-os) . 8 chlorothiazide ...... 42 calcium citrate-vitamin d2 .. 109 CEFAZOLIN IN DEXTROSE chlorothiazide sodium ...... 42 calcium citrate-vitamin d3 .. 109 5 % ...... 8 chlorpromazine ...... 36 calcium pnv ...... 112 cefdinir...... 8 chlorpropamide ...... 69 calcium-folic acid-vitamin d cefditoren pivoxil ...... 8 chlorthalidone ...... 42 ...... 112 cefepime ...... 8 chlorzoxazone ...... 29 CALDOLOR ...... 33 CEFEPIME IN DEXTROSE 5 cholecalciferol (vitamin d3)112 camila ...... 88 % ...... 8 cholestyramine (with sugar) . 49 camrese ...... 91 cefepime in dextrose,iso-osm . 8 cholestyramine light ...... 49 camrese lo ...... 91 cefixime ...... 8 choline,magnesium salicylate CANASA ...... 73 cefotaxime ...... 8 ...... 33 CANCIDAS ...... 3 cefotetan ...... 8 CHORIONIC candesartan ...... 42 cefoxitin ...... 8 GONADOTROPIN, cefoxitin in dextrose, iso-osm 8 HUMAN ...... 66 122
CIALIS ...... 107 clotrimazole ...... 3 cyclafem 1/35 (28) ...... 91 ciclodan ...... 55 clotrimazole-betamethasone . 55 cyclafem 7/7/7 (28)...... 91 ciclopirox ...... 55 clozapine ...... 36 cyclobenzaprine ...... 29 cidofovir ...... 4 CLOZAPINE ...... 36 cyclopentolate ...... 97 cilostazol...... 47 c-nate dha ...... 112 cyclophosphamide ...... 18 CILOXAN ...... 95 COARTEM ...... 11 CYCLOPHOSPHAMIDE .... 18 cimetidine ...... 77 codeine sulfate ...... 30 CYCLOSERINE...... 11 cimetidine hcl ...... 77 codeine-guaifenesin ...... 102 CYCLOSET ...... 69 CIMZIA ...... 73 COLCRYS...... 85 cyclosporine ...... 18 CINRYZE...... 104 colestipol ...... 49 cyclosporine modified ...... 18 CIPRO ...... 15 colistin (colistimethate na) ... 11 cyproheptadine ...... 101 CIPRO HC...... 62 colocort ...... 73 cyred ...... 91 CIPRODEX ...... 62 COLY-MYCIN S ...... 62 CYSTADANE ...... 73 ciprofloxacin...... 15 COMBIGAN ...... 99 CYSTAGON ...... 108 ciprofloxacin (mixture) ...... 15 COMBIPATCH ...... 88 CYSTARAN...... 97 ciprofloxacin hcl ...... 15, 62, 95 COMBIVENT RESPIMAT 104 cytarabine ...... 18 ciprofloxacin in 5 % dextrose COMETRIQ ...... 18 cytarabine (pf) ...... 18 ...... 15 COMPLERA ...... 4 cytra k crystals ...... 108 ciprofloxacin lactate ...... 15 complete natal dha ...... 112 cytra-2 ...... 108 cisplatin ...... 18 completenate ...... 112 cytra-3 ...... 108 citalopram ...... 36 complex b-100 ...... 112 cytra-k ...... 108 citrate of magnesia ...... 73 compro ...... 73 D citroma ...... 73 CONCEPTROL ...... 89 dacarbazine ...... 18 citrus calcium ...... 109 CONCERTA ...... 37 DAKLINZA ...... 4 cladribine ...... 18 constulose ...... 73 DALIRESP ...... 104 claravis ...... 53 COPAXONE ...... 79 danazol ...... 67 clarithromycin ...... 9 CORLANOR ...... 50 dantrolene ...... 29 classic prenatal ...... 112 cormax ...... 57 dapsone ...... 11 clearlax ...... 73 cortisone ...... 62 DAPTACEL (DTAP clemastine ...... 101 CORTISPORIN ...... 55 PEDIATRIC) (PF) ...... 81 clindacin p ...... 53 corvita 150 ...... 112 daptomycin ...... 11 clindamycin hcl ...... 11 COSENTYX ...... 51 DARAPRIM ...... 11 CLINDAMYCIN IN 0.9 % COSENTYX (2 SYRINGES) darifenacin ...... 107 SOD CHLOR ...... 11 ...... 51 dasetta 1/35 (28) ...... 91 clindamycin in 5 % dextrose 11 COSENTYX PEN ...... 51 dasetta 7/7/7 (28) ...... 91 clindamycin palmitate hcl .... 11 COSENTYX PEN (2 PENS) 51 daunorubicin ...... 18 clindamycin pediatric ...... 11 COSOPT (PF)...... 99 daysee ...... 91 clindamycin phosphate .. 11, 53, COTELLIC ...... 18 deblitane ...... 88 89 covaryx ...... 88 DECARA ...... 112 clindamycin-benzoyl peroxide covaryx h.s...... 88 delta d3 ...... 112 ...... 53 CREON ...... 73 deltasone ...... 62 clindamycin-tretinoin ...... 53 CRESEMBA ...... 3 delyla (28) ...... 91 clobetasol ...... 57 CRINONE ...... 88 DELZICOL...... 73 CLODERM ...... 57 CRIXIVAN ...... 4 demeclocycline ...... 16 clomipramine ...... 36 cromolyn ...... 73, 97, 104 DEMEROL ...... 30 clonazepam ...... 24 cryselle (28) ...... 91 demerol (pf) ...... 30 clonidine ...... 42 CUBICIN...... 11 DEMEROL (PF) ...... 30 clonidine hcl ...... 36, 42 CUVPOSA ...... 71 DEMSER ...... 42 clopidogrel ...... 47 cyanocobalamin (vitamin b-12) denta 5000 plus ...... 61 clorazepate dipotassium ...... 36 ...... 112 dentagel...... 61 123
DEPEN TITRATABS ...... 86 disopyramide phosphate ...... 41 ed-spaz ...... 71 DEPO-ESTRADIOL ...... 88 disulfiram...... 59 EDURANT ...... 5 DEPO-MEDROL ...... 62 DIURIL ...... 43 eemt ...... 88 DESCOVY ...... 4 divalproex ...... 24, 25 eemt hs ...... 88 desipramine ...... 37 dofetilide ...... 41 effer-k ...... 109 desmopressin ...... 67 donepezil ...... 28 ELAPRASE ...... 67 desog-e.estradiol/e.estradiol . 91 DORIBAX ...... 11 ELELYSO ...... 67 desogestrel-ethinyl estradiol . 91 DORIPENEM ...... 11 eletriptan hbr ...... 27 desonide ...... 57 dorzolamide ...... 99 ELIDEL ...... 52 desoximetasone ...... 57 dorzolamide-timolol ...... 99 ELIGARD...... 19 DESVENLAFAXINE ...... 37 dothelle dha ...... 112 ELIGARD (3 MONTH) ...... 19 DESVENLAFAXINE doxazosin ...... 43 ELIGARD (4 MONTH) ...... 19 FUMARATE ...... 37 doxepin ...... 37, 52 ELIGARD (6 MONTH) ...... 19 desvenlafaxine succinate ...... 37 doxercalciferol ...... 67 elinest ...... 91 dexamethasone ...... 62 doxorubicin ...... 18, 19 eliphos...... 73 dexamethasone intensol...... 62 doxorubicin, peg-liposomal .. 19 ELIQUIS...... 47 dexamethasone sodium doxy-100 ...... 16 ELITEK ...... 17 phosphate ...... 62, 63, 100 doxycycline hyclate ...... 16 elite-ob ...... 112 DEXILANT ...... 77 doxycycline monohydrate .... 16 ELLA ...... 91 dexmethylphenidate ...... 37 drithocreme hp ...... 51 ELMIRON ...... 108 dexrazoxane hcl ...... 17 dronabinol ...... 73 EMADINE ...... 97 dextroamphetamine ...... 37 droperidol ...... 73 EMBEDA ...... 30 dextroamphetamine- drospirenone-e.estradiol-lm.fa EMCYT ...... 19 amphetamine ...... 37 ...... 91 EMEND ...... 73 dialyvite ...... 112 drospirenone-ethinyl estradiol EMEND (FOSAPREPITANT) dialyvite 800 ...... 112 ...... 91 ...... 73 diazepam...... 24, 37 DUAVEE...... 88 EMFLAZA ...... 63 diazepam intensol ...... 37 ducodyl ...... 73 emoquette ...... 91 diclofenac potassium ...... 33 duloxetine ...... 37 EMSAM ...... 37 diclofenac sodium .... 33, 34, 98 DUOPA ...... 27 EMTRIVA ...... 5 diclofenac-misoprostol ...... 34 DUPIXENT ...... 52 enalapril maleate ...... 43 dicloxacillin ...... 14 duramorph (pf) ...... 30 enalaprilat ...... 43 dicyclomine ...... 71 DUREZOL ...... 100 enalapril-hydrochlorothiazide didanosine...... 4 dutasteride ...... 107 ...... 43 DIFICID ...... 9 dutasteride-tamsulosin ...... 108 ENBREL...... 86 diflorasone ...... 57 DUZALLO ...... 85 ENBREL SURECLICK ...... 86 diflunisal ...... 34 d-vi-sol...... 112 endocet ...... 30 digitek ...... 46 DYRENIUM ...... 43 ENGERIX-B (PF) ...... 81 digox ...... 46 DYSPORT ...... 81 ENGERIX-B PEDIATRIC digoxin ...... 47 E (PF) ...... 81 dihydroergotamine ...... 27 e.c. prin ...... 34 enoxaparin ...... 47 DILANTIN ...... 24 e.e.s. 400 ...... 9 enpresse ...... 91 diltiazem ...... 42, 43 EASIVENT HOLDING enskyce ...... 91 dilt-xr ...... 43 CHAMBER ...... 64 entacapone ...... 27 dimenhydrinate ...... 73 econazole ...... 56 entecavir ...... 5 DIPENTUM ...... 73 econtra ez ...... 91 ENTRESTO ...... 50 diphenhydramine hcl ...... 101 ecotrin ...... 34 ENTYVIO ...... 73 diphenoxylate-atropine ...... 71 ecotrin low strength ...... 34 enulose ...... 73 dipyridamole...... 47 EDARBI ...... 43 EPCLUSA ...... 5 diskets ...... 30 EDARBYCLOR ...... 43 epinastine ...... 97 124 epinephrine ...... 102 etoposide ...... 19 finasteride ...... 108 EPINEPHRINE ...... 102 EUCRISA ...... 52 FIRAZYR ...... 104 EPIPEN 2-PAK ...... 102 EUFLEXXA ...... 34 FIRMAGON KIT W EPIPEN JR 2-PAK ...... 102 EURAX ...... 58 DILUENT SYRINGE ...... 19 epirubicin ...... 19 EVOTAZ ...... 5 FLAREX...... 100 epitol ...... 25 EVZIO ...... 34 flavoxate ...... 107 EPIVIR HBV...... 5 EXELDERM ...... 56 FLEBOGAMMA DIF ...... 82 eplerenone ...... 43 exemestane ...... 19 flecainide ...... 41 EPOGEN ...... 78 EXJADE ...... 59 fleet laxative ...... 73 epoprostenol (glycine) ...... 43 EYLEA ...... 97 FLOLAN ...... 43 eprosartan ...... 43 ezetimibe ...... 49 FLOVENT DISKUS ...... 104 ERAXIS(WATER DILUENT) F FLOVENT HFA ...... 104 ...... 3 FABRAZYME ...... 67 FLOWTUSS ...... 102 ERBITUX...... 19 FACTIVE ...... 15 floxin...... 62 ergocalciferol (vitamin d2) . 112 falmina (28) ...... 91 floxuridine ...... 19 ergoloid...... 37 famciclovir...... 5 FLUAD 2017-2018 (65 YR ERGOMAR ...... 27 famotidine ...... 77, 78 UP)(PF)...... 82 ERIVEDGE ...... 19 famotidine (pf) ...... 77 FLUARIX QUAD 2017-2018 errin ...... 88 famotidine (pf)-nacl (iso-os) 77 (PF) ...... 82 ery pads ...... 53 FANAPT ...... 37 FLUBLOK 2017-2018 (PF) . 82 ERYPED 200 ...... 10 FARESTON ...... 19 FLUBLOK QUAD 2017-2018 ERYPED 400 ...... 10 FARXIGA ...... 69 (PF) ...... 82 ery-tab...... 10 FARYDAK ...... 19 flucaine ...... 97 ERYTHROCIN ...... 10 FASLODEX ...... 19 FLUCELVAX QUAD 2017- erythrocin (as stearate) ...... 10 fayosim ...... 91 2018 ...... 82 erythromycin ...... 10, 96 FC2 FEMALE CONDOM ... 87 FLUCELVAX QUAD 2017- erythromycin ethylsuccinate 10 felbamate ...... 25 2018 (PF) ...... 82 erythromycin with ethanol ... 53 felodipine ...... 43 fluconazole ...... 3 ESBRIET ...... 104 fem ph ...... 89 fluconazole in nacl (iso-osm) . 3 escitalopram oxalate ...... 37 FEMCAP ...... 87 flucytosine ...... 3 esmolol ...... 43 FEMRING ...... 88 fludarabine ...... 19 esomeprazole sodium ...... 77 femynor ...... 92 fludrocortisone ...... 63 estarylla ...... 91 fenofibrate ...... 49 FLULAVAL QUAD 2017- estazolam ...... 37 fenofibrate micronized ...... 49 2018 ...... 82 ESTRACE ...... 88 fenofibrate nanocrystallized . 49 FLULAVAL QUAD 2017- estradiol ...... 88 fenofibric acid...... 49 2018 (PF) ...... 82 estradiol valerate ...... 88 fenofibric acid (choline) ...... 49 flumazenil ...... 38 estradiol-norethindrone acet . 88 fenoprofen ...... 34 flunisolide ...... 105 ESTROGEL ...... 88 fentanyl ...... 30 fluocinolone ...... 57 estrogens-methyltestosterone88 fentanyl citrate ...... 30 fluocinolone acetonide oil .... 62 estropipate ...... 88 fentanyl citrate (pf) ...... 30 fluocinolone and shower cap 57 eszopiclone ...... 37 FENTORA...... 30 fluocinonide ...... 57 ethacrynic acid...... 43 ferocon ...... 113 fluocinonide-e ...... 57 ethambutol ...... 11 ferraplus 90 ...... 113 fluocinonide-emollient ...... 57 ethosuximide ...... 25 ferrex 150 forte ...... 113 fluor-a-day (with xylitol) .... 113 ethyl chloride ...... 54 ferrex 150 forte plus ...... 113 fluorescein-proparacaine ...... 97 ethynodiol diac-eth estradiol 91 ferrex 28 ...... 113 fluoride (sodium) ...... 113 etidronate disodium ...... 59 FERRIPROX ...... 59 fluoritab ...... 113 etodolac ...... 34 FETZIMA ...... 38 fluorometholone ...... 100 ETOPOPHOS ...... 19 FINACEA ...... 53, 54 fluorouracil ...... 19, 52 125 fluoxetine ...... 38 FRAGMIN...... 47 GILENYA ...... 79 fluphenazine decanoate ...... 38 frovatriptan ...... 27 GILOTRIF ...... 20 fluphenazine hcl ...... 38 full spectrum b-vitamin c ... 114 GLASSIA ...... 59 flurazepam ...... 38 furosemide ...... 43 GLEEVEC ...... 20 flurbiprofen...... 34 FUSION PLUS ...... 114 GLEOSTINE ...... 20 flurbiprofen sodium ...... 98 FUZEON ...... 5 glimepiride ...... 69 flurox ...... 97 fyavolv ...... 88 glipizide ...... 69 flutamide...... 19 FYCOMPA ...... 25 glipizide-metformin ...... 69 fluticasone ...... 57, 105 G GLUCAGEN DIAGNOSTIC FLUTICASONE- g tussin ac ...... 102 KIT ...... 64 SALMETEROL ...... 105 gabapentin ...... 25 GLUCAGEN HYPOKIT...... 64 fluvastatin ...... 49 galantamine ...... 28 GLUCAGON EMERGENCY FLUVIRIN 2017-2018 ...... 82 GALZIN ...... 109 KIT (HUMAN) ...... 64 FLUVIRIN 2017-2018 (PF) . 82 GAMASTAN S/D ...... 82 GLUCAGON HCL ...... 64 fluvoxamine ...... 38 GAMMAGARD LIQUID .... 83 glyburide ...... 69 FLUZONE HIGH-DOSE GAMMAGARD S-D (IGA < 1 glyburide micronized ...... 69 2017-18 (PF) ...... 82 MCG/ML) ...... 83 glyburide-metformin...... 69 FLUZONE INTRADERM GAMMAKED ...... 83 glycolax ...... 74 QUAD 2017-18 ...... 82 GAMMAPLEX ...... 83 GLYCOPHOS ...... 109 FLUZONE QUAD 2017-2018 GAMMAPLEX (WITH glycopyrrolate ...... 71 ...... 82 SORBITOL) ...... 83 glydo ...... 54 FLUZONE QUAD 2017-2018 GAMUNEX-C...... 83 GLYXAMBI...... 69 (PF) ...... 82 ganciclovir sodium ...... 5 GRALISE ...... 25 FLUZONE QUAD PEDI GARDASIL 9 (PF) ...... 83 GRALISE 30-DAY STARTER 2017-18 (PF) ...... 82 gatifloxacin ...... 96 PACK ...... 25 FML FORTE ...... 100 GATTEX 30-VIAL ...... 74 granisetron (pf) ...... 74 FML S.O.P...... 100 gavilax ...... 74 granisetron hcl ...... 74 focalgin 90 dha ...... 113 gavilyte-c ...... 74 GRANIX...... 79 focalgin ca ...... 113 gavilyte-g ...... 74 GRASTEK ...... 83 focalgin dss ...... 113 gavilyte-n ...... 74 griseofulvin microsize ...... 3 folbee ...... 113 GELCLAIR ...... 61 griseofulvin ultramicrosize ..... 3 folbee plus ...... 113 gemcitabine ...... 19 guaiatussin ac...... 103 folbic...... 113 gemfibrozil ...... 49 guaifenesin ac ...... 103 folic acid ...... 113 generlac ...... 74 guaifenesin dac ...... 103 folic acid-vit b6-vit b12 ...... 113 gengraf ...... 19 guanfacine...... 38, 43 folivane-f ...... 113 gentak ...... 96 guanidine ...... 38 folivane-ob ...... 113 gentamicin ...... 11, 55, 96 GYNAZOLE-1 ...... 90 folivane-plus ...... 113 gentamicin in nacl (iso-osm) 11 gynol ii ...... 90 folplex 2.2...... 113 GENTAMICIN IN NACL H foltabs 800 ...... 114 (ISO-OSM) ...... 11 HAEGARDA ...... 105 fondaparinux...... 47 gentamicin sulfate (ped) (pf) 11 halobetasol propionate ...... 58 FORTEO ...... 86 gentamicin sulfate (pf)...... 11 haloperidol ...... 38 FORTESTA ...... 67 GENTAMICIN SULFATE haloperidol decanoate ...... 38 fosamprenavir ...... 5 (PF) ...... 11 haloperidol lactate ...... 38 foscarnet ...... 5 gentle laxative...... 74 HARVONI ...... 5 fosinopril ...... 43 gentlelax ...... 74 HAVRIX (PF) ...... 83 fosinopril-hydrochlorothiazide GENVOYA ...... 5 healthylax ...... 74 ...... 43 GEODON ...... 38 heather ...... 88 fosphenytoin ...... 25 gianvi (28) ...... 92 HECTOROL ...... 67 FOSRENOL ...... 73 gildagia ...... 92 hematinic/folic acid ...... 114 126 hematogen ...... 114 HUMULIN 70/30 KWIKPEN ifosfamide-mesna ...... 20 hematogen fa ...... 114 ...... 65 ILARIS (PF) ...... 80 hematogen forte ...... 114 HUMULIN N ...... 65 ILEVRO ...... 98 hemenatal ob ...... 114 HUMULIN N KWIKPEN .... 65 ILUVIEN ...... 100 hemenatal ob + dha ...... 114 HUMULIN R U-100 ...... 65 IMBRUVICA ...... 20 hemetab ...... 114 HUMULIN R U-500 (CONC) imipenem-cilastatin ...... 12 hemmorex-hc ...... 74 KWIKPEN...... 65 imipramine hcl ...... 38 hep flush-10 (pf) ...... 47 HUMULIN R U-500 imipramine pamoate ...... 38 heparin (porcine) ...... 47, 48 (CONCENTRATED) ...... 65 imiquimod...... 80 HEPARIN (PORCINE) IN HYCAMTIN ...... 20 INCRELEX ...... 59 0.9% NACL ...... 47 hydralazine ...... 43, 44 INCRUSE ELLIPTA ...... 105 heparin (porcine) in 5 % dex 47 hydrochlorothiazide ...... 44 indapamide ...... 44 heparin (porcine) in nacl (pf) 47 hydrocodone-acetaminophen 30 indomethacin ...... 34 heparin flush(porcine)-0.9nacl hydrocodone-chlorpheniramine INFANRIX (DTAP) (PF) ..... 83 ...... 48 ...... 103 infed ...... 114 heparin lock flush ...... 48 hydrocodone-homatropine.. 103 INLYTA ...... 20 heparin lock flush (porcine) . 48 hydrocodone-ibuprofen ...... 30 INSPIRACHAMBER WITH heparin lockflush(porcine)(pf) hydrocortisone ...... 58, 63, 74 MASK-LARGE ...... 64 ...... 48 hydrocortisone acetate ...... 74 INSULIN SYRINGE- heparin(porcine) in 0.45% nacl hydrocortisone butyrate ...... 58 NEEDLE U-100 ...... 64 ...... 48 hydrocortisone valerate ...... 58 INTELENCE ...... 5 HEPARIN(PORCINE) IN hydrocortisone-acetic acid .... 62 INTRON A ...... 80 0.45% NACL ...... 48 hydrocortisone-pramoxine... 51, introvale ...... 92 heparin, porcine (pf) ...... 48 74 INVANZ ...... 12 HETLIOZ ...... 38 hydromet ...... 103 INVEGA SUSTENNA ...... 38 HEXALEN ...... 20 hydromorphone ...... 31 INVEGA TRINZA ...... 38 HIBERIX (PF)...... 83 HYDROMORPHONE ...... 31 INVIRASE ...... 5 hi-cal plus vit d ...... 109 hydromorphone (pf) ...... 30 INVOKAMET ...... 69 HIZENTRA ...... 83 hydromorphone in 0.9 % nacl INVOKAMET XR ...... 69 homatropaire...... 97 ...... 31 INVOKANA...... 69 homatropine hbr ...... 97 hydroxocobalamin ...... 114 IODOPEN...... 20 HORIZANT ...... 28 hydroxychloroquine...... 12 IPOL ...... 83 HUMALOG ...... 65 hydroxyurea ...... 20 ipratropium bromide ..... 61, 105 HUMALOG JUNIOR hydroxyzine hcl ...... 102 ipratropium-albuterol ...... 105 KWIKPEN ...... 65 hydroxyzine pamoate ...... 102 irbesartan ...... 44 HUMALOG KWIKPEN ...... 65 hyophen ...... 108 irbesartan-hydrochlorothiazide HUMALOG MIX 50-50 ...... 65 hyoscyamine sulfate ...... 71, 72 ...... 44 HUMALOG MIX 50-50 hyosyne ...... 72 IRESSA ...... 20 KWIKPEN ...... 65 HYPER-SAL ...... 105 irinotecan ...... 20 HUMALOG MIX 75-25 ...... 65 HYQVIA ...... 83 ISENTRESS ...... 5 HUMALOG MIX 75-25 I ISENTRESS HD ...... 5 KWIKPEN ...... 65 ibandronate ...... 86 isibloom ...... 92 HUMIRA ...... 86 IBRANCE ...... 20 ISOLYTE-S ...... 111 HUMIRA PEDIATRIC ibuprofen ...... 34 isometh-dichloral- CROHN'S START ...... 86 ibuprofen-oxycodone...... 31 acetaminophn ...... 27 HUMIRA PEN ...... 86 ICLUSIG ...... 20 isoniazid ...... 12 HUMIRA PEN CROHN'S- idarubicin ...... 20 isosorbide dinitrate ...... 50 UC-HS START ...... 86 IDHIFA ...... 20 isosorbide mononitrate ...... 50 HUMULIN 70/30 ...... 65 iferex 150 forte ...... 114 isoxsuprine ...... 90 ifosfamide ...... 20 isradipine ...... 44 127 itraconazole ...... 3 KISQALI ...... 20 leena 28 ...... 92 ivermectin ...... 12 KISQALI FEMARA CO- leflunomide ...... 87 IXEMPRA ...... 20 PACK ...... 20 LEMTRADA ...... 79 IXIARO (PF) ...... 83 klor-con ...... 110 LENVIMA ...... 20 J klor-con 10 ...... 110 lessina ...... 92 JADENU ...... 59 klor-con 8 ...... 110 LETAIRIS ...... 105 JADENU SPRINKLE ...... 59 klor-con m10 ...... 110 letrozole ...... 20 JAKAFI ...... 20 klor-con m15 ...... 110 leucovorin calcium ...... 17 jantoven ...... 48 klor-con m20 ...... 110 LEUKERAN...... 20 JANUMET ...... 69 klor-con sprinkle...... 110 LEUKINE ...... 79 JANUMET XR ...... 69 klor-con/ef ...... 110 leuprolide ...... 20 JANUVIA...... 69 kobee ...... 114 levalbuterol hcl ...... 105 JARDIANCE ...... 69 KORLYM ...... 67 LEVALBUTEROL jencycla...... 88 k-phos-neutral ...... 110 TARTRATE ...... 105 JENTADUETO ...... 69 kpn ...... 114 LEVATOL ...... 44 JENTADUETO XR...... 69 KRYSTEXXA ...... 85 LEVEMIR ...... 65 JETREA (PF) ...... 97 k-tab ...... 110 LEVEMIR FLEXTOUCH.... 65 jevantique lo ...... 88 kurvelo ...... 92 levetiracetam ...... 25 jinteli...... 88 KUVAN...... 67 levetiracetam in nacl (iso-os) 25 jolessa ...... 92 KYNAMRO ...... 49 levobunolol ...... 96 jolivette ...... 89 L levocarnitine ...... 59 juleber ...... 92 l norgest/e.estradiol-e.estrad . 92 levocarnitine (with sugar) ..... 59 junel 1.5/30 (21) ...... 92 labetalol ...... 44 levocetirizine ...... 102 junel 1/20 (21) ...... 92 LACRISERT ...... 98 levofloxacin ...... 15, 96 junel fe 1.5/30 (28) ...... 92 lactated ringers ...... 59 levofloxacin in d5w ...... 15 junel fe 1/20 (28) ...... 92 lactulose ...... 74 levomefolate dha ...... 114 junel fe 24 ...... 92 lamivudine ...... 5 levonest (28) ...... 92 JUXTAPID ...... 49 lamivudine-zidovudine ...... 5 levonorgestrel-ethinyl estrad 92 K lamotrigine...... 25 levonorg-eth estrad triphasic 93 kaitlib fe...... 92 LANCETS ...... 64 levora-28 ...... 93 KALBITOR ...... 105 LANCING DEVICE ...... 64 levorphanol tartrate ...... 31 KALETRA ...... 5 lansoprazole ...... 78 levothyroxine ...... 70 KALYDECO ...... 105 lanthanum ...... 74 LEVOTHYROXINE ...... 70 KANUMA ...... 67 LANTUS ...... 65 levoxyl ...... 70 kariva (28) ...... 92 LANTUS SOLOSTAR...... 65 LEVSIN ...... 72 k-effervescent ...... 109 larin 1.5/30 (21) ...... 92 LEXIVA ...... 5 kelnor 1/35 (28) ...... 92 larin 1/20 (21) ...... 92 LIALDA ...... 74 KENALOG...... 63 larin 24 fe...... 92 lidocaine ...... 55 KEPIVANCE ...... 17 larin fe 1.5/30 (28) ...... 92 lidocaine (pf) ...... 54 ketoconazole ...... 3, 56 larin fe 1/20 (28) ...... 92 lidocaine hcl...... 54 ketoprofen...... 34 larissia ...... 92 lidocaine hcl-hydrocortison ac ketorolac ...... 34, 98 LASTACAFT ...... 98 ...... 55, 74 KEVEYIS ...... 28 latanoprost ...... 99 lidocaine viscous ...... 55 KEVZARA ...... 87 LATUDA...... 38 lidocaine-epinephrine ...... 55 KHEDEZLA...... 38 laxaclear...... 74 lidocaine-prilocaine ...... 55 kimidess (28) ...... 92 laxative (bisacodyl) ...... 74 lido-k...... 55 KINERET ...... 80 laxative feminine ...... 74 lidopin ...... 55 KINRIX (PF) ...... 83 laxative peg 3350...... 74 lillow ...... 93 kionex ...... 74 layolis fe ...... 92 LINCOCIN ...... 12 kionex (with sorbitol) ...... 74 LAZANDA ...... 31 lincomycin ...... 12 128 lindane ...... 58 LUPRON DEPOT (6 mercaptopurine ...... 21 linezolid ...... 12 MONTH) ...... 21 meropenem ...... 12 linezolid-0.9% sodium chloride LUPRON DEPOT-PED ...... 21 mesalamine ...... 75 ...... 12 LUPRON DEPOT-PED (3 mesalamine with cleansing LINZESS ...... 75 MONTH) ...... 21 wipe ...... 75 liothyronine ...... 70 lutera (28) ...... 93 mesna ...... 17 lipodox ...... 20 LUZU ...... 56 MESNEX ...... 17 lisinopril ...... 44 LYNPARZA ...... 21 metadate er...... 39 lisinopril-hydrochlorothiazide LYRICA ...... 25 metaproterenol ...... 105 ...... 44 LYSODREN ...... 21 metaxall ...... 29 lite coat aspirin ...... 34 lyza ...... 89 metaxalone ...... 29 LITEAIRE MDI CHAMBER M metformin ...... 69 ...... 64 MACUGEN ...... 98 methadone...... 31 lithium carbonate ...... 38, 39 magnesium citrate...... 75 methadose ...... 31 lithium citrate ...... 39 MAKENA ...... 89 methamphetamine...... 39 LIVALO ...... 49 malathion ...... 58 methazolamide ...... 99 LO LOESTRIN FE...... 93 maprotiline...... 39 methenamine hippurate ...... 16 lomedia 24 fe ...... 93 marlissa ...... 93 methenamine mandelate ...... 16 LONSURF ...... 20 MARPLAN ...... 39 methen-sod phos-meth blue- loperamide ...... 72 marten-tab ...... 31 hyos...... 108 lopinavir-ritonavir ...... 5 MATULANE...... 21 methergine ...... 95 lopreeza ...... 89 MAVYRET ...... 5 methimazole ...... 63 lorazepam ...... 39 MAXIDEX ...... 100 METHITEST ...... 67 lorazepam intensol...... 39 MAXIPIME ...... 9 methocarbamol ...... 29 lorcet (hydrocodone) ...... 31 m-clear wc ...... 103 methotrexate sodium ...... 21 lorcet hd ...... 31 meclizine ...... 75 methotrexate sodium (pf) ..... 21 lorcet plus ...... 31 meclofenamate...... 34 methoxsalen ...... 52 lortuss ex ...... 103 medroxyprogesterone ...... 89 methscopolamine ...... 72 loryna (28) ...... 93 mefenamic acid...... 34 methyclothiazide...... 44 losartan ...... 44 mefloquine ...... 12 methyldopa ...... 44 losartan-hydrochlorothiazide 44 megestrol ...... 21 methyldopa- LOTEMAX ...... 100 MEKINIST ...... 21 hydrochlorothiazide ...... 44 lovastatin ...... 49 melodetta 24 fe ...... 93 methyldopate ...... 44 low-ogestrel (28) ...... 93 meloxicam ...... 34 methylphenidate hcl...... 39 loxapine succinate ...... 39 melphalan ...... 21 methylprednisolone ...... 63 lta pre-attached ...... 55 memantine ...... 28 methylprednisolone acetate .. 63 LUCENTIS...... 98 MEMANTINE...... 28 methyltestosterone ...... 67 ludent fluoride ...... 114 MENACTRA (PF) ...... 83 metipranolol ...... 96 LUMIGAN ...... 99 MENEST ...... 89 metoclopramide hcl ...... 75 LUMIZYME ...... 67 MENHIBRIX (PF) ...... 83 metolazone ...... 44 LUPANETA PACK (1 MENOMUNE - A/C/Y/W-135 metoprolol succinate ...... 44 MONTH) ...... 90 ...... 84 metoprolol ta-hydrochlorothiaz LUPANETA PACK (3 MENOMUNE - A/C/Y/W-135 ...... 44 MONTH) ...... 90 (PF) ...... 84 metoprolol tartrate ...... 44 LUPRON DEPOT ...... 21 MENOSTAR ...... 89 metro i.v...... 12 LUPRON DEPOT (3 MENTAX ...... 56 metronidazole ...... 12, 54, 90 MONTH) ...... 20 meperidine ...... 31 metronidazole in nacl (iso-os) LUPRON DEPOT (4 meperidine (pf) ...... 31 ...... 12 MONTH) ...... 20 MEPHYTON ...... 48 mexiletine ...... 41 meprobamate ...... 29 mibelas 24 fe...... 93 129 microgestin 1.5/30 (21) ...... 93 multi-vitamin with fluoride 114 nebusal ...... 105 microgestin 1/20 (21) ...... 93 multivitamins with fluoride 114 NEBUSAL ...... 105 microgestin fe 1.5/30 (28) .... 93 multivit-fluor (vit e acetate) 114 necon 0.5/35 (28) ...... 93 microgestin fe 1/20 (28) ...... 93 mupirocin...... 55 necon 1/50 (28) ...... 93 midazolam ...... 39 mupirocin calcium ...... 55 necon 7/7/7 (28) ...... 93 midodrine ...... 59 MUSTARGEN ...... 21 nefazodone ...... 39 miglitol ...... 69 mvc-fluoride ...... 115 neomycin ...... 12 milk of magnesia ...... 75 my way ...... 93 neomycin-bacitracin-poly-hc 99 milk of magnesia concentrated MYALEPT ...... 67 neomycin-bacitracin- ...... 75 MYCAMINE ...... 3 polymyxin ...... 96 millipred dp ...... 63 mycophenolate mofetil ...... 21 neomycin-polymyxin b gu .... 59 mimvey ...... 89 mycophenolate mofetil hcl ... 21 neomycin-polymyxin b- mimvey lo ...... 89 mycophenolate sodium ...... 21 dexameth...... 99 MINASTRIN 24 FE ...... 93 myferon 150 forte ...... 115 neomycin-polymyxin- MINOCIN ...... 16 MYLERAN ...... 21 gramicidin ...... 96 minocycline ...... 16 mynatal ...... 115 neomycin-polymyxin-hc. 62, 99 minoxidil ...... 44 mynatal advance ...... 115 neo-polycin ...... 96 miostat ...... 99 mynatal plus ...... 115 neo-polycin hc ...... 99 miralax ...... 75 mynatal-z ...... 115 nephplex rx ...... 115 mirtazapine ...... 39 mynate 90 plus...... 115 nephro-vite rx ...... 115 MIRVASO ...... 54 mynephrocaps ...... 115 NERLYNX ...... 21 misoprostol ...... 78 mynephron ...... 115 NEULASTA ...... 79 mitomycin...... 21 MYOBLOC ...... 84 NEUPOGEN...... 79 mitoxantrone...... 21 MYRBETRIQ ...... 107 NEVANAC...... 98 M-M-R II (PF) ...... 84 MYTESI ...... 72 nevirapine ...... 5, 6 modafinil ...... 39 myzilra ...... 93 newgen ...... 115 moderiba ...... 79 N NEXAVAR...... 22 moexipril ...... 44 nabumetone ...... 34 NEXAVIR ...... 115 moexipril-hydrochlorothiazide nadolol ...... 45 NEXIUM ...... 78 ...... 45 nadolol-bendroflumethiazide 45 NEXIUM IV ...... 78 mometasone ...... 58 nafcillin ...... 14 NEXIUM PACKET...... 78 mono-linyah ...... 93 nafcillin in dextrose iso-osm 14 next choice one dose ...... 93 mononessa (28) ...... 93 NAFTIN ...... 56 niacin ...... 49 montelukast ...... 105 NAGLAZYME ...... 67 nicardipine ...... 45 morgidox ...... 16 nalbuphine ...... 34 nicorelief ...... 61 morphine...... 32 naloxone ...... 35 nicorette ...... 61 MORPHINE ...... 32 naltrexone ...... 35 nicotine ...... 61 morphine (pf)...... 31, 32 NAMENDA TITRATION nicotine (polacrilex) ...... 61 morphine concentrate ...... 32 PAK ...... 28 NICOTROL ...... 61 MOVANTIK ...... 75 naproxen ...... 35 NICOTROL NS ...... 61 MOVIPREP ...... 75 naproxen sodium ...... 35 nifedipine ...... 45 MOXEZA ...... 96 naratriptan ...... 27 nikki (28) ...... 93 moxifloxacin...... 15, 96 NARCAN ...... 35 nilutamide ...... 22 MOXIFLOXACIN- NATACYN ...... 96 nimodipine ...... 45 SOD.ACE,SUL-WATER . 15 NATAZIA ...... 93 NINLARO ...... 22 MOZOBIL ...... 79 nateglinide ...... 69 nisoldipine ...... 45 MULTAQ ...... 41 NATPARA ...... 67 nitro-bid ...... 50 multigen folic ...... 114 natural b-100 complex ...... 115 NITRO-DUR ...... 50 multigen plus ...... 114 nature-throid ...... 70 nitrofurantoin macrocrystal .. 16 multi-vit with fluoride-iron 114 NEBUPENT ...... 12 130 nitrofurantoin monohyd/m- O ORENITRAM ...... 45 cryst ...... 16 obstetrix dha ...... 115 ORFADIN ...... 60 nitroglycerin ...... 50 OCALIVA ...... 75 ORKAMBI ...... 105 nitroglycerin in 5 % dextrose50 ocella ...... 94 orphenadrine citrate ...... 29 nitro-time ...... 51 OCREVUS ...... 79 orsythia ...... 94 NITYR ...... 59 OCTAGAM ...... 84 oscimin ...... 72 nizatidine ...... 78 octreotide acetate ...... 22 oscimin sl ...... 72 nodolor ...... 27 ODEFSEY ...... 6 oscimin sr...... 72 nora-be ...... 89 ODOMZO ...... 22 oseltamivir ...... 6 NORDITROPIN FLEXPRO 79 OFEV...... 105 OSMOPREP ...... 75 noreth-ethinyl estradiol-iron . 93 ofloxacin ...... 15, 62, 96 OSPHENA ...... 90 norethindrone (contraceptive) ogestrel (28) ...... 94 OTEZLA...... 87 ...... 89 olanzapine ...... 39 OTEZLA STARTER ...... 87 norethindrone acetate ...... 89 olanzapine-fluoxetine ...... 40 OTREXUP (PF)...... 87 norethindrone ac-eth estradiol olmesartan ...... 45 oxacillin ...... 14 ...... 89, 93 olopatadine ...... 61, 98 oxacillin in dextrose(iso-osm) norethindrone-e.estradiol-iron OLYSIO ...... 6 ...... 14 ...... 93, 94 omega-3 acid ethyl esters ..... 49 oxaliplatin ...... 22 norgestimate-ethinyl estradiol omeprazole ...... 78 oxandrolone ...... 67 ...... 94 omeprazole-sodium oxaprozin ...... 35 norlyda ...... 89 bicarbonate ...... 78 oxazepam ...... 40 norlyroc ...... 89 ONCASPAR ...... 22 oxcarbazepine ...... 25 NORMOSOL-R ...... 110 ondansetron ...... 75 oxiconazole ...... 56 NORTHERA ...... 59 ondansetron hcl...... 75 oxybutynin chloride ...... 107 nortrel 0.5/35 (28) ...... 94 ondansetron hcl (pf)...... 75 oxycodone...... 32 nortrel 1/35 (21) ...... 94 one daily prenatal ...... 115 OXYCODONE ...... 32 nortrel 1/35 (28) ...... 94 ONETOUCH ULTRA TEST oxycodone-acetaminophen ... 32 nortrel 7/7/7 (28) ...... 94 ...... 63 oxycodone-aspirin ...... 32 nortriptyline ...... 39 ONETOUCH ULTRA2 ...... 64 OXYCONTIN ...... 32 NORVIR...... 6 ONETOUCH ULTRAMINI. 64 oxymorphone ...... 32, 33 NOVOLOG ...... 66 ONETOUCH VERIO ...... 63 oysco 500/d ...... 110 NOVOLOG FLEXPEN...... 65 ONETOUCH VERIO FLEX 64 oyster shell + d3...... 110 NOVOLOG MIX 70-30 ...... 66 ONETOUCH VERIO IQ oyster shell calcium-vit d2.. 115 NOVOLOG MIX 70-30 METER ...... 64 oyster shell calcium-vit d3.. 110 FLEXPEN ...... 65 ONETOUCH VERIO oystercal-d ...... 110 NOVOLOG PENFILL ...... 66 SYSTEM ...... 64 P NOXAFIL ...... 3 ONFI ...... 25 pacerone ...... 41 np thyroid ...... 70 ONMEL ...... 4 paclitaxel...... 22 NPLATE...... 48 opcicon one-step ...... 94 paliperidone ...... 40 nts step 1 ...... 61 OPSUMIT ...... 105 pamidronate ...... 67 NUCALA ...... 105 option-2 ...... 94 PANRETIN ...... 52 NUEDEXTA ...... 28 oral saline laxative ...... 75 pantoprazole ...... 78 NULOJIX ...... 22 ORALAIR ...... 84 papaverine...... 45 NUPLAZID ...... 39 oralone ...... 61 paregoric ...... 72 NUVARING...... 90 ORAMAGICRX ...... 61 paricalcitol ...... 67 nyamyc ...... 56 ORAVIG ...... 4 PARICALCITOL ...... 67 nyata ...... 56 ORENCIA ...... 87 paroex oral rinse ...... 61 nystatin ...... 3, 56 ORENCIA (WITH paromomycin ...... 12 nystatin-triamcinolone ...... 56 MALTOSE) ...... 87 paroxetine hcl ...... 40 nystop ...... 56 ORENCIA CLICKJECT ...... 87 PASER ...... 12 131
PAZEO ...... 98 pimozide ...... 40 potassium chloride-d5- PEDIARIX (PF) ...... 84 pimtrea (28) ...... 94 0.9%nacl ...... 111 PEDVAX HIB (PF) ...... 84 pindolol ...... 45 potassium citrate ...... 108 peg 3350-electrolytes ...... 75 pioglitazone ...... 69 potassium citrate-citric acid 108 peg3350 ...... 75 pioglitazone-metformin ...... 69 potassium phosphate m-/d- PEGANONE ...... 25 piperacillin-tazobactam ...... 15 basic ...... 111 PEGASYS ...... 79 pirmella ...... 94 powderlax ...... 75 PEGASYS PROCLICK ...... 79 piroxicam ...... 35 pr natal 400 ...... 116 peg-electrolyte soln ...... 75 PLASMA-LYTE 148 ...... 111 pr natal 400 ec ...... 115 PEGINTRON ...... 80 PLASMA-LYTE A ...... 111 pr natal 430 ...... 116 peg-prep ...... 75 PLEGRIDY ...... 80 pr natal 430 ec ...... 116 PEN NEEDLE ...... 64 PNEUMOVAX 23 ...... 84 PRADAXA ...... 48 PENICILLIN G POT IN pnv 29-1 ...... 115 PRALUENT PEN ...... 49 DEXTROSE ...... 14 pnv ob+dha ...... 115 pramcort ...... 76 penicillin g potassium...... 14 pnv-dha ...... 115 pramipexole ...... 27 penicillin g procaine ...... 14 pnv-dha + docusate ...... 115 prasugrel ...... 48 penicillin g sodium ...... 14 pnv-ferrous fumarate-docu-fa pravastatin...... 49 penicillin v potassium...... 15 ...... 115 prazosin...... 45 PENTACEL (PF) ...... 84 pnv-omega ...... 115 PRED MILD ...... 100 PENTACEL ACTHIB pnv-select...... 115 PRED-G ...... 100 COMPONENT (PF) ...... 84 pnv-vp-u ...... 115 PRED-G S.O.P...... 100 PENTAM ...... 12 podofilox ...... 52 prednicarbate ...... 58 PENTASA ...... 75 polycin ...... 96 prednisolone ...... 63 pentazocine-naloxone ...... 35 polyethylene glycol 3350 ..... 75 prednisolone acetate ...... 100 pentoxifylline ...... 48 poly-iron 150 forte...... 115 prednisolone sodium phosphate PERFOROMIST ...... 106 polymyxin b sulfate ...... 12 ...... 63, 101 perindopril erbumine ...... 45 polymyxin b sulf-trimethoprim prednisone...... 63 periogard...... 61 ...... 96 prednisone intensol ...... 63 permethrin ...... 58 POMALYST ...... 80 PREMARIN ...... 89 perphenazine...... 40 portia ...... 94 PREMPHASE...... 89 perphenazine-amitriptyline... 40 pot,sodium citrate-citric acid PREMPRO ...... 89 perry prenatal...... 115 ...... 108 prena1 chew ...... 116 pfizerpen-g ...... 15 potassium acetate ...... 110 prenaissance ...... 116 phenadoz...... 102 potassium bicarb and chloride prenaissance plus ...... 116 phenazopyridine ...... 109 ...... 110 prenatabs fa ...... 116 phenelzine...... 40 potassium bicarb-citric acid 110 prenatabs rx ...... 116 phenergan ...... 102 potassium chlorid-d5- prenatal ...... 116 phenobarbital ...... 26 0.45%nacl ...... 110 prenatal 19 ...... 116 phenoxybenzamine ...... 45 potassium chloride ...... 110, 111 prenatal complete ...... 116 phentolamine ...... 45 potassium chloride in 0.9%nacl prenatal formula...... 116 phenylephrine hcl ...... 101 ...... 110 prenatal multi-dha (algal oil) phenytoin ...... 26 potassium chloride in 5 % dex ...... 116 phenytoin sodium ...... 26 ...... 110 prenatal one daily ...... 116 phenytoin sodium extended .. 26 potassium chloride in lr-d5 . 110 prenatal plus...... 116 philith ...... 94 potassium chloride-0.45 % nacl prenatal plus (calcium carb)116 phospha 250 neutral ...... 110 ...... 111 prenatal vitamin ...... 116 phosphate laxative ...... 75 potassium chloride-d5- prenatal vitamin plus low iron PHOSPHOLINE IODIDE .... 97 0.2%nacl ...... 111 ...... 116 PHOTOFRIN ...... 22 potassium chloride-d5- prenatal vitamin with minerals pilocarpine hcl ...... 60, 61, 97 0.3%nacl ...... 111 ...... 116 132 prenatal vits96-iron fum-folic propylthiouracil ...... 63 RELENZA DISKHALER ...... 6 ...... 116 PROQUAD (PF)...... 84 RELISTOR ...... 76 prenatal-u ...... 116 protamine ...... 48 relnate dha ...... 116 preplus ...... 116 protriptyline ...... 40 REMICADE ...... 76 PREPOPIK ...... 76 PROVENTIL HFA ...... 106 REMODULIN ...... 45 pretab ...... 116 prudoxin...... 52 RENAGEL ...... 76 prevalite ...... 49 prutect ...... 52 renal caps ...... 116 previfem ...... 94 pulmosal ...... 106 rena-vite ...... 116 PREVNAR 13 (PF) ...... 84 PULMOZYME ...... 106 rena-vite rx...... 116 PREZCOBIX ...... 6 purelax ...... 76 reno caps ...... 116 PREZISTA ...... 6 purevit dualfe plus ...... 116 repaglinide ...... 69 PRIFTIN ...... 12 pyrazinamide ...... 12 repaglinide-metformin ...... 69 PRIMAQUINE ...... 12 pyridostigmine bromide ...... 29 REPATHA PUSHTRONEX 50 primidone ...... 26 Q REPATHA SURECLICK .... 50 PRIVIGEN ...... 84 QUADRACEL (PF) ...... 84 REPATHA SYRINGE ...... 50 PROAIR HFA ...... 106 quasense...... 94 RESCRIPTOR ...... 6 probenecid ...... 85 quazepam ...... 40 RESTASIS ...... 98 probenecid-colchicine ...... 85 quetiapine ...... 40 RESTASIS MULTIDOSE.... 98 PROBUPHINE ...... 33 quinapril...... 45 RETROVIR ...... 6 prochlorperazine ...... 76 quinapril-hydrochlorothiazide REVLIMID...... 80 prochlorperazine edisylate.... 76 ...... 45 REYATAZ ...... 6 prochlorperazine maleate ..... 76 quinidine gluconate ...... 41 RHOFADE ...... 54 PROCRIT ...... 79 quinidine sulfate ...... 41 ribasphere ...... 80 procto-med hc ...... 76 quinine sulfate ...... 13 ribavirin ...... 80 proctosol hc ...... 76 quit 2 ...... 61 RIDAURA ...... 87 proctozone-hc ...... 76 quit 4 ...... 61 rifabutin ...... 13 PROCYSBI ...... 108 QUTENZA ...... 52 RIFAMATE ...... 13 progesterone micronized ...... 89 QVAR ...... 106 rifampin ...... 13 PROGLYCEM ...... 64 R RIFATER ...... 13 PROGRAF ...... 22 rabeprazole ...... 78 riluzole ...... 60 PROLASTIN-C ...... 60 RAGWITEK ...... 84 rimantadine ...... 6 PROLENSA ...... 98 rajani ...... 94 ringer's ...... 59 PROLEUKIN ...... 80 raloxifene ...... 86 risacal-d ...... 116 PROLIA ...... 86 ramipril ...... 45 risedronate ...... 60, 86 PROMACTA ...... 48 RANEXA ...... 50 RISPERDAL CONSTA ...... 40 promethazine ...... 102 ranitidine hcl ...... 78 risperidone ...... 40 promethazine vc-codeine.... 103 RAPAFLO ...... 108 RITUXAN ...... 22 promethazine-codeine ...... 103 RAPAMUNE...... 22 RITUXAN HYCELA ...... 22 promethazine-dm ...... 103 rasagiline ...... 27 rivastigmine ...... 28 promethazine-phenyleph- RASUVO (PF) ...... 87 rivastigmine tartrate ...... 28 codeine ...... 103 RAVICTI ...... 60 rivelsa ...... 94 promethazine-phenylephrine REBIF (WITH ALBUMIN) . 80 rizatriptan ...... 27 ...... 103 REBIF REBIDOSE ...... 80 ROBAXIN ...... 29 promethegan ...... 102 REBIF TITRATION PACK . 80 ropinirole ...... 27 propafenone ...... 41 reclipsen (28) ...... 94 rosuvastatin ...... 50 propantheline ...... 72 RECOMBIVAX HB (PF) .... 84 ROTARIX ...... 84 proparacaine ...... 98 RECTIV...... 76 ROTATEQ VACCINE ...... 84 propranolol ...... 45 regonol ...... 29 roweepra ...... 26 propranolol-hydrochlorothiazid REGRANEX ...... 53 ROZEREM ...... 40 ...... 45 relcof c ...... 103 RUBRACA ...... 22 133
RUCONEST ...... 106 SKLICE ...... 58 stress formula with iron(sulf) RYDAPT ...... 22 smoothlax ...... 76 ...... 117 rydex ...... 103 sodium chloride .... 60, 106, 111 STRIANT ...... 68 S sodium chloride 0.45 % ...... 111 STRIBILD ...... 6 SABRIL ...... 26 sodium chloride 0.9 % ...... 60 STRIVERDI RESPIMAT .. 106 SAFYRAL ...... 94 sodium chloride 3 % ...... 111 STROMECTOL ...... 13 salicylic acid ...... 52 sodium chloride 5 % ...... 111 SUBOXONE ...... 35 salsalate ...... 35 sodium citrate-citric acid .... 108 SUBSYS ...... 33 SAMSCA ...... 67 sodium ferric gluconat-sucrose SUCRAID...... 77 SANCUSO ...... 76 ...... 60 sucralfate...... 78 SANDOSTATIN LAR sodium phenylbutyrate ...... 60 sulfacetamide sodium ... 51, 101 DEPOT ...... 22 sodium phosphate ...... 111 sulfacetamide sodium (acne) 55 SANTYL ...... 58 SODIUM PHOSPHATE IN sulfacetamide sodium-sulfur 54 SAPHRIS (BLACK 0.9 % NACL ...... 111 sulfacetamide sod-sulfur-urea CHERRY) ...... 40 sodium polystyrene sulfonate ...... 54 SAVELLA ...... 87 ...... 76 sulfacetamide-prednisolone 101 scopolamine base...... 76 SODIUM POLYSTYRENE sulfact na-sul-avobnz-otn-ocsa seb-prev ...... 51 SULFONATE ...... 76 ...... 54 selegiline hcl ...... 27 SOLIRIS ...... 60 sulfadiazine ...... 15 selenium sulfide...... 51 SOMATULINE DEPOT ...... 22 sulfamethoxazole-trimethoprim SELZENTRY ...... 6 SOMAVERT ...... 68 ...... 15, 16 se-natal 19 ...... 117 sotalol ...... 41 SULFAMYLON ...... 55 se-natal 19 (with docusate) . 116 SOTALOL ...... 41 sulfasalazine ...... 77 SENSIPAR ...... 67 sotalol af ...... 41 sulfatrim ...... 16 SEREVENT DISKUS ...... 106 SOVALDI ...... 6 sulindac ...... 35 SEROSTIM ...... 79 SPECTRACEF ...... 9 sumatriptan ...... 27 sertraline ...... 40 spinosad ...... 58 sumatriptan succinate ..... 27, 28 se-tan plus ...... 117 SPIRIVA RESPIMAT ...... 106 super b complex-vitamin c . 117 setlakin ...... 94 SPIRIVA WITH super b maxi complex ...... 117 sevelamer carbonate ...... 76 HANDIHALER ...... 106 super b-50 complex plus ..... 117 sf 62 spironolactone ...... 45 super quints ...... 117 sf 5000 plus ...... 62 spironolacton-hydrochlorothiaz super quints b-50 ...... 117 sharobel ...... 89 ...... 46 superplex-t ...... 117 SIGNIFOR ...... 22 SPORANOX ...... 4 SUPPRELIN LA ...... 22 SIGNIFOR LAR ...... 22 sprintec (28) ...... 94 SUPRAX ...... 9 sildenafil (antihypertensive) SPRYCEL ...... 22 SUPREP BOWEL PREP KIT ...... 106 sps (with sorbitol) ...... 76 ...... 77 SILIQ ...... 51 sronyx ...... 94 SUSTIVA ...... 6 silver nitrate ...... 53 ssd ...... 52 SUTENT ...... 22 silver nitrate applicators ...... 53 SSKI ...... 63 syeda ...... 94 silver sulfadiazine ...... 52 stavudine ...... 6 SYLATRON ...... 80 SILVRSTAT ...... 55 STELARA ...... 51 SYLVANT ...... 23 SIMBRINZA ...... 99 STIMATE ...... 68 SYMLINPEN 120 ...... 70 SIMPONI ...... 87 STIOLTO RESPIMAT...... 106 SYMLINPEN 60 ...... 70 SIMPONI ARIA ...... 87 STIVARGA ...... 22 SYNAGIS ...... 6 SIMULECT ...... 22 stop smoking aid ...... 61 SYNAREL ...... 68 simvastatin ...... 50 STRENSIQ ...... 68 SYNERA ...... 55 sirolimus ...... 22 STREPTOMYCIN ...... 13 SYNERCID ...... 13 SIRTURO ...... 13 stress formula ...... 117 SYNJARDY ...... 70 SIVEXTRO ...... 13 stress formula with iron ...... 117 SYNJARDY XR ...... 70 134
SYPRINE ...... 60 TESTIM...... 68 TOBREX ...... 96 T testosterone ...... 68 TODAY CONTRACEPTIVE TABLOID ...... 23 TESTOSTERONE...... 68 SPONGE...... 90 TACLONEX ...... 51 testosterone cypionate ...... 68 tolazamide...... 70 tacrolimus ...... 23, 53 testosterone enanthate...... 68 tolbutamide ...... 70 TAFINLAR ...... 23 TETANUS,DIPHTHERIA tolcapone...... 27 TAGRISSO ...... 23 TOX PED(PF) ...... 85 tolmetin ...... 35 TALTZ AUTOINJECTOR .. 51 TETANUS-DIPHTHERIA tolterodine ...... 107 TALTZ AUTOINJECTOR (2 TOXOIDS-TD ...... 85 topiramate ...... 26 PACK) ...... 51 tetcaine...... 98 toposar ...... 23 TALTZ AUTOINJECTOR (3 tetrabenazine ...... 28 topotecan...... 23 PACK) ...... 51 tetracaine hcl...... 98 TORISEL ...... 23 TALTZ SYRINGE ...... 52 tetracaine hcl (pf)...... 98 torsemide ...... 46 TALTZ SYRINGE (2 PACK) tetracycline ...... 16 total b/c ...... 117 ...... 52 TETRAVISC ...... 98 TOUJEO SOLOSTAR ...... 66 TALTZ SYRINGE (3 PACK) THALOMID ...... 23 TOVIAZ ...... 107 ...... 52 theochron ...... 106 TRACLEER ...... 106 TALWIN ...... 35 theophylline ...... 106 TRADJENTA ...... 70 TAMIFLU ...... 6 THIOLA ...... 60 tramadol ...... 35 tamoxifen ...... 23 thioridazine ...... 40 tramadol-acetaminophen ...... 35 tamsulosin...... 108 thiothixene ...... 40 trandolapril ...... 46 TANZEUM ...... 70 thrivite-19 ...... 117 trandolapril-verapamil ...... 46 TARCEVA ...... 23 THYMOGLOBULIN ...... 85 tranexamic acid ...... 48, 90 TARGRETIN ...... 23 thyroid (pork) ...... 70 tranylcypromine ...... 40 tarina fe 1/20 (28) ...... 94 THYROLAR-1 ...... 71 TRAVATAN Z ...... 99 taron forte ...... 117 THYROLAR-1/2 ...... 71 trazodone ...... 40 taron-c dha ...... 117 THYROLAR-1/4 ...... 71 TRECATOR ...... 13 taron-prex prenatal-dha ...... 117 THYROLAR-2 ...... 71 TRELSTAR ...... 23 TASIGNA ...... 23 THYROLAR-3 ...... 71 TREMFYA ...... 52 tazarotene ...... 54 tiagabine ...... 26 TRESIBA FLEXTOUCH U- TAZORAC ...... 54 ticlopidine ...... 48 100 ...... 66 taztia xt ...... 46 TIGAN...... 77 TRESIBA FLEXTOUCH U- TECFIDERA ...... 80 TIGECYCLINE...... 13 200 ...... 66 TECHNIVIE...... 6 tilia fe ...... 94 tretinoin...... 54 TEFLARO ...... 9 timolol maleate ...... 46, 96, 97 tretinoin (chemotherapy) ...... 23 TEKTURNA ...... 46 tinidazole ...... 13 tri femynor ...... 94 TEKTURNA HCT ...... 46 tis-u-sol pentalyte ...... 59 triamcinolone acetonide . 58, 62, telmisartan ...... 46 TIVICAY...... 7 63 telmisartan-amlodipine ...... 46 tizanidine ...... 29 triamterene-hydrochlorothiazid telmisartan-hydrochlorothiazid tl gard rx ...... 117 ...... 46 ...... 46 tl icon ...... 117 triazolam ...... 40 temazepam ...... 40 tl-hem 150...... 117 tricitrates ...... 108 TEMODAR ...... 23 TOBI PODHALER ...... 13 tricon ...... 117 temozolomide ...... 23 TOBRADEX ...... 100 triderm ...... 58 tencon ...... 33 TOBRADEX ST...... 100 TRIESENCE (PF) ...... 63 TENIVAC (PF) ...... 84, 85 tobramycin ...... 96 tri-estarylla ...... 94 terazosin ...... 46 tobramycin in 0.225 % nacl .. 13 trifluoperazine...... 40 terbinafine hcl ...... 4 tobramycin in 0.9 % nacl ...... 13 trifluridine ...... 96 terbutaline ...... 106 tobramycin sulfate ...... 13 trigels-f forte ...... 117 terconazole ...... 90 tobramycin-dexamethasone 100 trihexyphenidyl ...... 27 135 triklo ...... 50 ultimatecare one nf ...... 117 VESICARE...... 107 tri-legest fe...... 94 ultra b-100 complex...... 118 vestura (28) ...... 95 tri-linyah ...... 94 unithroid ...... 71 VIBATIV ...... 17 tri-lo-estarylla ...... 95 UPTRAVI ...... 46 VIBERZI ...... 77 tri-lo-marzia ...... 95 urea ...... 53 VICTOZA 2-PAK ...... 70 tri-lo-sprintec ...... 95 ure-k...... 53 VICTOZA 3-PAK ...... 70 trilyte with flavor packets ..... 77 uretron d-s...... 108 VIDEX 2 GRAM PEDIATRIC trimethobenzamide ...... 77 urin ds ...... 108 ...... 7 trimethoprim ...... 16 urogesic-blue ...... 108 VIEKIRA PAK ...... 7 trimipramine ...... 40 urophen mb ...... 108 VIEKIRA XR ...... 7 trinatal gt ...... 117 ursodiol ...... 77 vienva ...... 95 trinatal rx 1 ...... 117 uryl...... 108 vigabatrin ...... 26 trinate ...... 117 UVADEX ...... 53 VIIBRYD ...... 41 trinessa (28) ...... 95 V VIMIZIM ...... 68 trinessa lo...... 95 vaginal contraceptive foam .. 90 VIMPAT ...... 26 TRINTELLIX...... 40 valacyclovir ...... 7 vinate care ...... 118 triphrocaps ...... 117 VALCHLOR ...... 53 vinate ii ...... 118 tri-previfem (28) ...... 95 valganciclovir ...... 7 vinate m ...... 118 TRISENOX ...... 23 valproate sodium ...... 26 vinate one...... 118 tri-sprintec (28) ...... 95 valproic acid ...... 26 vinblastine...... 23 tri-tabs dha ...... 117 valproic acid (as sodium salt) vincasar pfs ...... 23 TRIUMEQ ...... 7 ...... 26 vincristine ...... 23 triveen-duo dha ...... 117 valsartan...... 46 vinorelbine ...... 23 tri-vit with fluoride and iron valsartan-hydrochlorothiazide viorele (28) ...... 95 ...... 117 ...... 46 VIRACEPT...... 7 tri-vitamin with fluoride ..... 117 vancomycin ...... 17 VIRAMUNE XR ...... 7 trivora (28)...... 95 VANCOMYCIN IN 0.9% VIREAD ...... 7 tropicamide ...... 97 SODIUM CL ...... 16 virt-advance ...... 118 trospium ...... 107 VANCOMYCIN IN virt-c dha ...... 118 TRULICITY ...... 70 DEXTROSE 5 % ...... 16, 17 virt-gard ...... 118 trust natal dha ...... 117 vandazole ...... 90 virt-nate...... 118 TRUVADA ...... 7 VANTAS ...... 23 virt-nate dha ...... 118 TUDORZA PRESSAIR ..... 106 VAQTA (PF) ...... 85 virt-phos 250 neutral...... 111 tusnel c...... 103 VARIVAX (PF) ...... 85 virt-pn ...... 118 tussigon...... 103 VARIZIG...... 85 virt-pn dha ...... 118 TWINRIX (PF) ...... 85 VASCEPA ...... 50 virt-pn plus...... 118 TYBOST ...... 7 veletri ...... 46 virtrate-2 ...... 108 TYGACIL ...... 13 velivet triphasic regimen (28) virtrate-3 ...... 108 TYKERB ...... 23 ...... 95 virtrate-k ...... 108 TYMLOS ...... 86 VELPHORO ...... 77 virt-select ...... 118 TYPHIM VI ...... 85 VELTASSA...... 77 virtussin ac ...... 103 TYSABRI ...... 28 vemavite-prx-2 ...... 118 virtussin dac ...... 103 TYVASO ...... 106 VEMLIDY...... 7 virt-vite ...... 118 TYVASO REFILL KIT ..... 106 VENCLEXTA ...... 23 virt-vite forte ...... 118 TYVASO STARTER KIT . 107 venlafaxine ...... 40, 41 virt-vite gt ...... 118 U VENOFER...... 118 vit 3 ...... 118 UCERIS ...... 77 VENTAVIS ...... 107 vit b complex-folic acid ...... 118 ULESFIA ...... 58 VENTOLIN HFA ...... 107 vitamin b complex ...... 118 ULORIC ...... 85 verapamil ...... 46 vitamin d3 ...... 118 ultimatecare one ...... 118 verdrocet ...... 33 vitamin k ...... 48 136 vitamin k1 ...... 48 XELJANZ ...... 87 zidovudine ...... 7 vitamins a,c,d and fluoride . 118 XELJANZ XR ...... 87 zileuton ...... 107 VITRASE ...... 98 XEOMIN ...... 85 ZINACEF IN STERILE VIVITROL ...... 35 XERMELO ...... 24 WATER ...... 9 vol-care rx ...... 118 XGEVA ...... 17 ZINBRYTA ...... 80 vol-nate ...... 118 XIFAXAN ...... 13 zingiber ...... 119 vol-plus ...... 118 XIIDRA ...... 98 ZIOPTAN (PF) ...... 99 vol-tab rx ...... 118 XOLAIR ...... 107 ziprasidone hcl ...... 41 voriconazole ...... 4 XOPENEX HFA ...... 107 ZIRGAN ...... 96 VOSEVI ...... 7 XTAMPZA ER...... 33 ZOLADEX ...... 24 VOTRIENT ...... 23 XTANDI ...... 24 zoledronic acid...... 68 vp-ch plus ...... 119 xulane ...... 90 zoledronic acid-mannitol-water vp-ch-pnv ...... 119 XULTOPHY 100/3.6 ...... 66 ...... 60 vp-ggr-b6 ...... 119 XURIDEN ...... 60 ZOLEDRONIC AC- vp-heme ob ...... 119 XYLOCAINE-MPF ...... 55 MANNITOL-0.9NACL.... 68 vp-heme one ...... 119 XYREM...... 41 ZOLINZA ...... 24 VPRIV ...... 68 Y zolmitriptan...... 28 vp-vite rx ...... 119 YF-VAX (PF) ...... 85 zolpidem ...... 41 VRAYLAR...... 41 yuvafem ...... 89 ZOMETA ...... 68 vyfemla (28) ...... 95 Z ZOMIG ...... 28 VYVANSE ...... 41 zafirlukast ...... 107 zonisamide ...... 26 W zaleplon ...... 41 ZONTIVITY...... 49 warfarin ...... 48 ZANOSAR ...... 24 ZORBTIVE ...... 79 water for irrigation, sterile .... 60 zarah ...... 95 ZORTRESS ...... 24 WELCHOL ...... 50 ZARXIO ...... 79 ZOSTAVAX (PF) ...... 85 wera (28) ...... 95 zatean-ch ...... 119 zovia 1/35e (28) ...... 95 westhroid ...... 71 zatean-pn dha ...... 119 zovia 1/50e (28) ...... 95 WIDE-SEAL DIAPHRAGM zatean-pn plus ...... 119 ZUBSOLV ...... 35 ...... 87 ZAVESCA...... 68 ZURAMPIC ...... 86 woman's laxative ...... 77 ZEJULA ...... 24 ZYDELIG ...... 24 women's laxative (bisacodyl)77 ZELBORAF ...... 24 ZYFLO CR ...... 107 WP THYROID ...... 71 ZEMAIRA ...... 60 ZYKADIA ...... 24 wymzya fe ...... 95 zenatane ...... 54 ZYLET ...... 100 X zenchent (28) ...... 95 ZYPREXA RELPREVV ...... 41 XALKORI ...... 24 ZENPEP ...... 77 ZYTIGA ...... 24 XARELTO ...... 48 ZEPATIER ...... 7 ZYVOX ...... 13
137