2018 Formulary Drug List
For Federal Employees Health Benefits Program Employees
GlobalHealth, Inc. 701 NE 10th Street, Suite 300 Oklahoma City, OK 73104-5403 MFEHBDF18 Lists Updated 12/2017 www.GlobalHealth.com/fehb HELPFUL NUMBERS Plan Issuer: Medication Prior Authorizations: GlobalHealth, Inc. [email protected] PO Box 2393 918.878.7361 Oklahoma City, OK 73101-2393 Mail Claims to: GlobalHealth Customer Care, Language Magellan Rx Management, LLC Assistance, and Disease Management: PO Box 85042 [email protected] Richmond, VA 23261-5042 405.280.2989 (local) 1.877.280.2989 (toll-free) Mail Order Pharmacy: 711 (TTY) Magellan Rx Management, LLC Monday – Friday, 9 a.m. – 5 p.m. Central 1.800.424.1789 (toll-free) www.GlobalHealth.com/fehb 711 (TTY) P.O. Box 620968 Behavioral Health and Substance Use: Orlando, FL 32862 [email protected] 405.280.2989 (local) 24/7 Nurse Help Line: 1.877.280.2989 (toll-free) Information Line 711 (TTY) 1.877.280.2993 (toll-free) Monday – Friday, 9 a.m. – 5 p.m. Central www.GlobalHealth.com/fehb GlobalHealth Compliance Officer: 1.877.280.5852 (toll-free) Pharmacy Benefits Manager: 405.280.5852 Magellan Rx Management, LLC [email protected] Customer Service 1.800.424.1789 (toll-free) GlobalHealth Privacy Officer: 711 (TTY) 405.280.5524 [email protected]
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IMPORTANT INFORMATION This formulary applies to Members who enrolled through the Federal Employees Health Benefits Program.
Member Materials Your Member materials are three booklets. Each one has a different purpose. These documents are important legal documents. Keep them in a safe place. Booklet Purpose FEHB Brochure Tells you about your benefits. o What benefits are covered and how much you will pay. o How they are covered (including limitations and exclusions). o How to use them. Physicians and Health Lists our Network of doctors, Facilities, and pharmacies. Providers Directory Tells you if a Facility is preferred or not. (“Provider Directory”) Formulary Drug List Lists drugs we cover. for Federal Employee Tells you what Tier a drug is in. Health Benefits Tells you if there are any rules to getting a drug. Program Employees (“Drug Formulary” or “Formulary”)
Member materials are available on our website. Contact Customer Care for printed copies at no charge. But, be aware that the most current Drug Formulary and Provider Directory lists are on the website.
When this document says “we”, “us”, or “our”, it means GlobalHealth, Inc.
For specific questions about your coverage, please call the phone number printed on your Member ID card.
Preferred Drugs Preferred drugs are listed in this Drug Formulary. Drugs on the list are selected based on quality (effectiveness and safety) as well as cost-effectiveness. Doctors and pharmacists have worked together to develop the Formulary, which includes generics and brand name drugs that are approved by the U. S. Food and Drug Administration (“FDA”).
For the Member: Generic drugs contain the same active ingredients in the same amounts as brand name products. However, they may be a different color, shape, or size.
For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you.
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THIS DOCUMENT LIST IS EFFECTIVE AS OF THE DATE ON THE COVER. THIS LIST IS SUBJECT TO CHANGE. You may find the most current list, including any Utilization Management requirements, on our website. Contact Customer Care for printed copies.
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TIER DESCRIPTION
0 Health Care Reform
1 Generics
2 Preferred Brands
3 Non-Preferred Brands
4 Preferred Specialty
5 Specialty
TYPE DESCRIPTION
There is a limit on the amount of this drug that is covered per QL Quantity Limit prescription, or within a specific time frame.
Your provider is required to get prior authorization before you fill PA Prior Authorization your prescription, which ensures appropriate use of the selected drug. Without prior approval, we may not cover this drug.
In some cases, you may be required to first try certain drugs to treat ST Step Therapy your medical condition before you move up a “step” to other drug options.
GL Gender Limit This prescription drug is restricted for a single gender. .
This prescription drug may only be covered if you meet the AL Age Limit minimum or maximum age limit.
C Custom This drug has unique restrictions.
Specialty drugs are high-cost drugs used to treat complex or rare S Specialty Drug conditions. Some examples of the diseases include; multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia.
This medication is not on our drug list. Click on the THERAPEUTIC MED Medical Drug CLASS or sub class to find covered alternative medications. If you have questions, please contact member services.
PAGE 1 LAST UPDATED 11/2017 The Affordable Care Act (ACA) requires certain preventive generic HCR Health Care Reform Products products to be covered at zero dollar copay. This does not include plans that are grandfathered.
PS Preferred Specialty Preferred Specialty.
HCG High Cost Generic High Cost Generic.
Generic drugs available at the lowest cost. Please note the specific strengths and dosage forms; other strengths and/or dosage forms LCG Low Cost Generic of these products would be subject to the standard generic Cost- share.
PAGE 2 LAST UPDATED 11/2017 LIST OF COVERED PRESCRIPTION MEDICATIONS PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ADRENERGIC AGENTS
ALPHA AND BETA ADRENERGIC AGONIST(RESPR)
QL 2 / fill ADRENACLICK 3 PA
ADRENALIN 3
ADYPHREN 3 QL 2 / fill
ADYPHREN AMP 3 QL 2 / fill
ADYPHREN AMP II 3 QL 2 / fill
ADYPHREN II 3 QL 2 / fill
QL 2 / fill AUVI-Q 3 PA
ephedrine hcl 3 ephedrine sulfate powder 3
epinephrine (0.15 mg auto-injct, 0.3 mg auto-inject) 1 QL 2 / fill
epinephrine (base powder, powder) 3 epinephrine (0.1 mg/ml syringe, 1 mg/ml ampul, 1 mg/ml vial) 1 epinephrine bitartrate 3 epinephrine hcl 3
EPINEPHRINESNAP-V 3 QL 2 / fill
QL 2 / fill EPIPEN 3 PA
QL 2 / fill EPIPEN 2-PAK 3 PA
QL 4 / fill EPIPEN JR 2-PAK 3 PA
PAGE 3 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EPISNAP 3 QL 2 / fill
EPY 3 QL 2 / fill
QL 40/ day HYCOFENIX 3 AL At least 18 yrs old pseudoephedrine hcl 3 racepinephrine hcl 3
QL 20 / day REZIRA 3 AL At least 18 yrs old
NON-SELECT.BETA-ADRENERGIC AGONT(RESPIR) isoproterenol hcl powder 3 ISUPREL 3 SELECT.BETA-2-ADRENERGIC AGONIST(RESPIR)
ADVAIR DISKUS 2 QL 2 / day
ADVAIR HFA 2 QL 0.4 / day albuterol sulfate powder 3 albuterol sulfate (sul 0.63 mg/3 ml sol, sul 1.25 mg/3 ml sol, sulf 2 mg/5 ml syrup, sulfate er 4 mg tab, sulfate er 8 mg tab) 1 albuterol sulfate (2.5 mg/0.5 ml sol, sul 2.5 mg/3 ml soln, sulfate 2 mg tab, sulfate 4 mg tab, 5 mg/ml solution) 1 LCG
ANORO ELLIPTA 2 QL 2 / day
QL 1 / day ARCAPTA NEOHALER 3 ST
QL 0.357 / day BEVESPI AEROSPHERE 3 ST
BREO ELLIPTA 2 QL 2 / day
BROVANA 3 QL 4 / day
PAGE 4 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
COMBIVENT RESPIMAT 2 QL 0.267 / day
QL 0.04 / day fluticasone-salmeterol 1 AL At least 12 yrs old
FORADIL 3 QL 3 / day formoterol fumarate (micro pwdr, powder) 3 ipratropium-albuterol 1 levalbuterol concentrate 3 HCG levalbuterol hcl (100% powder, powder) 3 levalbuterol hcl (0.31 mg/3 ml sol, 0.63 mg/3 ml sol, 1.25 mg/3 ml sol) 3 HCG metaproterenol sulfate powder 3 metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syr, 20 mg tablet) 1
PERFOROMIST 3 QL 120 / 30 days
PROAIR HFA 2 QL .8 / day
QL 0.07 / day PROAIR RESPICLICK 2 AL At least 12 yrs old
SEREVENT DISKUS 2 QL 2 / day
QL .144 / day STRIVERDI RESPIMAT 2 ST
SYMBICORT 2 QL 0.4 / day terbutaline sulfate powder 3 terbutaline sulfate (2.5 mg tab, 5 mg tab) 1 LCG terbutaline sulf 1 mg/ml vial 1
QL 2 / day UTIBRON NEOHALER 3 ST AL At least 18 yrs old
PAGE 5 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VENTOLIN HFA 2 QL 1.5 / day
VOSPIRE ER 3 XOPENEX 3 XOPENEX CONCENTRATE 3 ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)
NON-SEL.ALPHA-1-ADRENERGIC BLOCKING AGTS
CARDURA 3
QL 1 / day CARDURA XL 3 ST doxazosin mesylate powder 3 doxazosin mesylate (1 mg tab, 2 mg tab, 4 mg tab, 8 mg tab) 1 MINIPRESS 3 prazosin hcl (1 mg capsule, 2 mg capsule, 5 mg capsule) 1 prazosin hcl powder 3 terazosin hcl 1 NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS
CAFERGOT 3 D.H.E.45 3 DIBENZYLINE 3 dihydroergotamine mesylate (1 mg/ml am, 1 mg/ml vl) 1 dihydroergotamine powder 3
QL 8 / 30 days dihydroergotamine 4 mg/ml spry 3 HCG ergoloid mesylates powder 3 ergoloid mesylates 1 mg tab 1 ERGOMAR 3 ergotamine tartrate 3
PAGE 6 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ergotamine-caffeine 1 methysergide maleate 3 MIGERGOT 3
MIGRANAL 3 QL 8 / 30 days phenoxybenzamine hcl 10 mg cap 1 phenoxybenzamine hcl powder 3 phentolamine mesylate powder 3 phentolamine 5 mg vial 1 phentolamine-alprostadil 1 SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT
QL 1 / day alfuzosin hcl er 1 GL Male carvedilol 1 carvedilol er (er 10 mg capsule, er 20 mg capsule, er 40 mg 2 / day capsule) 1 QL carvedilol er 80 mg capsule 1 QL 1 / day
COREG 3
COREG CR (CR 10 MG CAPSULE, CR 20 MG CAPSULE, CR 40 MG QL 2 / day 3 CAPSULE) ST
QL 1 / day COREG CR 80 MG CAPSULE 3 ST
QL 1 / day dutasteride-tamsulosin 1 GL Male
FLOMAX 3 QL 2 / day
QL 1 / day JALYN 3 GL Male labetalol hcl powder 3
PAGE 7 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) 1
QL 1 / day RAPAFLO 2 GL Male tamsulosin hcl 1 QL 2 / day
QL 1 / day UROXATRAL 3 GL Male
ANALGESICS AND ANTIPYRETICS
ANALGESICS AND ANTIPYRETICS, MISC.
QL 10 / day acetamin-caff-dihydrocod 320.5 1 AL At least 18 yrs old acetamin-caff-dihydrocod 325 1 QL 10 / day acetaminophen 3 acetaminophen-codeine (acetamin-codein 300-30 mg/12.5, QL 139 / day 1 acetaminop-codeine 120-12 mg/5) AL At least 18 yrs old
QL 22 / day acetaminophen-cod #2 tablet 1 AL At least 18 yrs old
QL 12 / day acetaminophen-cod #3 tablet 1 AL At least 12 yrs old
QL 6 / day acetaminophen-cod #4 tablet 1 AL At least 12 yrs old
ALLZITAL 3 QL 6 / day
BUPAP 3 QL 6 / day butalb-acetaminoph-caff-codein 1 QL 6 / day butalb-caff-acetaminoph-codein 1 QL 6 / day butalbital-acetaminophen 3 QL 6 / day
PAGE 8 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS butalbital-acetaminophen-caffe (butalb-acetamin-caff 50-300- 40, butalb-acetamin-caff 50-325-40, butalbit-acetaminophen- 1 QL 6 / day caff cp)
CAPACET 1 QL 6 / day
QL 125 / day CAPITAL W-CODEINE 3 AL At least 18 yrs old
QL 12 / day ENDOCET 1 AL At least 18 yrs old
ESGIC CAPSULE 1 QL 6 / day
ESGIC 50-325-40 MG TABLET 3 QL 6 / day
FIORICET 3 QL 6 / day
FIORICET WITH CODEINE 3 QL 6 / day gabapentin (100 mg capsule, 300 mg capsule, 400 mg capsule) 1 QL 9 / day gabapentin powder 3 gabapentin (250 mg/5 ml soln, 300 mg/6 ml soln) 1 QL 72 / day gabapentin 600 mg tablet 1 QL 6 / day gabapentin 800 mg tablet 1 QL 5 / day
GRALISE 30-DAY STARTER PACK 3 ST
QL 1 / day GRALISE ER 300 MG TABLET 3 ST
QL 3 / day GRALISE ER 600 MG TABLET 3 ST
HORIZANT ER 300 MG TABLET 3 QL 4 / day
HORIZANT ER 600 MG TABLET 3 QL 2 / day
QL 140 / day HYCET 3 AL At least 2 yrs old
PAGE 9 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 100 / day hydrocodone-acetamin 2.5-167/5 1 AL At least 2 yrs old hydrocodone-acetaminophen (hydrocodone-acetamin 2.5- QL 140 / day 108/5, hydrocodone-acetamin 5-217/10, hydrocodone- 1 acetamn 7.5-325/15) AL At least 2 yrs old
QL 20 / day hydrocodone-acetamin 2.5-325 1 AL At least 18 yrs old
QL 8 / day hydrocodone-acetamin 7.5-325 1 AL At least 18 yrs old
QL 13 / day hydrocodone-acetaminophen (5-300 mg, 7.5-300, 10-300 mg) 1 AL At least 18 yrs old
QL 12 / day hydrocodone-acetaminophen (5-325 mg, 10-325 mg) 1 AL At least 18 yrs old isomethept-caff-acetaminophen 1 isomethept-dichloralp-acetamin 1
QL 12 / day LORCET 1 AL At least 18 yrs old
QL 12 / day LORCET HD 1 AL At least 18 yrs old
QL 6 / day LORCET PLUS 1 AL At least 18 yrs old
QL 90 / day LORTAB 10 MG-300 MG/15 ML ELXR 3 AL At least 2 yrs old
LORTAB (5-325 MG TABLET, 7.5-325 MG TABLET, 10-325 MG QL 8 / day 1 TABLET) AL At least 18 yrs old
MARGESIC 1 QL 6 / day
MARTEN-TAB 1 QL 6 / day
PAGE 10 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NEURONTIN (100 MG CAPSULE, 300 MG CAPSULE, 400 MG 9 / day CAPSULE) 3 QL
NEURONTIN 250 MG/5 ML SOLN 3 QL 72 / day
NEURONTIN 600 MG TABLET 3 QL 6 / day
NEURONTIN 800 MG TABLET 3 QL 5 / day
NODOLOR 1
QL 12 / day NORCO 3 AL At least 18 yrs old
QL 62 / day oxycodone-acetaminophn 5-325/5 1 AL At least 18 yrs old
QL 4 / day oxycodon-acetaminophen 7.5-300 1 AL At least 18 yrs old oxycodone-acetaminophen (oxycodon-acetaminophen 2.5-325, QL 12 / day oxycodon-acetaminophen 7.5-325, oxycodone-acetaminophen 1 5-325, oxycodone-acetaminophen 10-325) AL At least 18 yrs old
QL 3 / day oxycodone-acetaminophen 10-300 1 AL At least 18 yrs old
QL 7 / day oxycodone-acetaminophen 5-300 1 AL At least 18 yrs old
QL 12 / day PERCOCET 3 AL At least 18 yrs old
QL 3 / day PRIMLEV 10-300 MG TABLET 3 AL At least 18 yrs old
QL 7 / day PRIMLEV 5-300 MG TABLET 3 AL At least 18 yrs old
QL 4 / day PRIMLEV 7.5-300 MG TABLET 3 AL At least 18 yrs old
PAGE 11 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PRODRIN 3
TENCON 1 QL 6 / day
QL 8 / day tramadol hcl-acetaminophen 1 AL At least 18 yrs old
QL 10 / day TREZIX 3 AL At least 18 yrs old
QL 12 / day TYLENOL-CODEINE NO.3 3 AL At least 12 yrs old
QL 6 / day TYLENOL-CODEINE NO.4 3 AL At least 12 yrs old
QL 8 / day ULTRACET 3 AL At least 18 yrs old
VANATOL LQ 3
QL 20 / day VERDROCET 1 AL At least 18 yrs old
QL 8 / day VICODIN 1 AL At least 18 yrs old
QL 13 / day VICODIN ES 1 AL At least 18 yrs old
QL 13 / day VICODIN HP 1 AL At least 18 yrs old
QL 12 / day XARTEMIS XR 3 AL At least 18 yrs old
QL 13 / day XODOL 10-300 3 AL At least 18 yrs old
QL 13 / day XODOL 5-300 3 AL At least 18 yrs old
PAGE 12 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 13 / day XODOL 7.5-300 3 AL At least 18 yrs old
QL 90 / day ZAMICET 3 AL At least 2 yrs old
ZEBUTAL 1 QL 6 / day
OPIATE AGONISTS
QL 4 / day ACTIQ 3 PA AL At least 18 yrs old alfentanil 500 mcg/ml ampul 1 alfentanil 500 mcg/ml ampule 3
QL 3 / day ARYMO ER 3 PA
QL 6 / day asa-butalb-caffeine-codeine 1 AL At least 18 yrs old
QL 6 / day ASCOMP WITH CODEINE 1 AL At least 18 yrs old
ASTRAMORPH-PF (1 MG/ML AMPUL, 10 MG/10 ML VIAL) 1 QL 50 / day
ASTRAMORPH-PF (1 MG/2 ML AMPULE, 5 MG/10 ML VIAL) 1 QL 100 / day belladonna-opium 16.2-30 supp 1 QL 2 / day belladonna-opium 16.2-60 supp 1 QL 1 / day
QL 6 / day butalbital compound-codeine 1 AL At least 18 yrs old carisoprodol compound-codeine 1 QL 21 / day carisoprodol-aspirin-codeine 1 QL 21 / day
PAGE 13 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS codeine phosphate 3
QL 6 / day codeine sulfate 1 AL At least 18 yrs old
QL 1 / day CONZIP (100 MG CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE) 3 PA AL At least 18 yrs old
DEMEROL (25 MG/0.5 ML AMPUL, 50 MG/ML AMPUL, 50 MG/ML QL 10 / day CARPUJECT, 50 MG/ML VIAL, 75 MG/1.5 ML AMPUL, 100 MG/2 3 ML AMPUL) AL At least 18 yrs old
QL 20 / day DEMEROL 25 MG/ML CARPUJECT 3 AL At least 18 yrs old
QL 7 / day DEMEROL 75 MG/ML SYRINGE 3 AL At least 18 yrs old
QL 5 / day DEMEROL 100 MG TABLET 3 AL At least 18 yrs old
QL 10 / day DEMEROL 50 MG TABLET 3 AL At least 18 yrs old
DEMEROL (100 MG/ML AMPUL, 100 MG/ML CARPUJECT, 100 QL 5 / day 3 MG/ML VIAL) AL At least 18 yrs old dihydrocodeine bitartrate 3
QL 6 / day DILAUDID 2 MG/ML AMPUL 3 AL At least 18 yrs old
QL 3 / day DILAUDID 4 MG/ML AMPUL 3 AL At least 18 yrs old
QL 13 / day DILAUDID 5 MG/5 ML ORAL LIQUID 3 AL At least 18 yrs old
DILAUDID (0.5 MG/0.5 ML SYRINGE, 1 MG/ML SYRINGE, 2 At least 18 yrs old MG/ML SYRINGE, 4 MG/ML SYRINGE) 3 AL
PAGE 14 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 6 / day DILAUDID (2 MG TABLET, 4 MG TABLET, 8 MG TABLET) 3 AL At least 18 yrs old
QL 1 / day DILAUDID-HP 3 AL At least 18 yrs old
QL 3 / day DOLOPHINE HCL 3 PA
QL 0.5 / day DURAGESIC 3 PA
DURAMORPH 10 MG/10 ML AMPUL 1 QL 5 / day
DURAMORPH 5 MG/10 ML AMPUL 1 QL 10 / day
QL 2 / day EMBEDA 2 PA
QL 2 / day EXALGO 3 PA
QL 0.5 / day fentanyl 1 PA fentanyl base 3 fentanyl citrate (0.05 mg/ml ampul, 100 mcg/2 ml ampul, 100 mcg/2 ml vial, 1,000 mcg/20 ml ampul, 1,000 mcg/20 ml vial) 1
QL 4 / day fentanyl citrate (cit 1,200 mcg, cit 1,600 mcg, citrate 200 mcg, PA 3 citrate 400 mcg, citrate 600 mcg, citrate 800 mcg) AL At least 18 yrs old HCG fentanyl citrate powder 3 fentanyl citrate (250 mcg/5 ml vial, 2,500 mcg/50 ml vial) 1 fentanyl-bup-ns 4 mcg/ml-0.1% 1 QL 96 / day fentanyl-bupivacaine-0.9% nacl (2 mcg-0.1%, 2 mcg-0.125%) 1 QL 192 / day
PAGE 15 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fentanyl 2mcg-bupiv 0.0625%-ns 1 QL 192 / day fentanyl 2 mcg-ropiv 0.15%-ns 1 QL 192 / day
QL 6 / day FIORINAL WITH CODEINE #3 3 AL At least 18 yrs old
QL 20 / day hydrocod-cpm-pseudoephedrine 1 AL At least 18 yrs old hydrocodone bitartrate (crys, powder) 3
QL 5 / day hydrocodone-ibuprofen (7.5-200, 10-200) 1 AL At least 16 yrs old
QL 6 / day hydrocodone-ibuprofen 5-200 mg 1 AL At least 16 yrs old
QL 2 / day hydromorphone er 3 PA HCG hydromorphone hcl 1 mg/ml amp 1 QL 13 / day
QL 1 / day hydromorphone hcl 10 mg/ml amp 1 AL At least 18 yrs old
QL 13 / day hydromorphone hcl (1 mg/ml solution, 5 mg/5 ml soln) 1 AL At least 18 yrs old hydromorphone hcl powder 3 hydromorphone 3 mg suppos 1 QL 4 / day
QL 50 / day hydromorphone 0.5 mg/0.5 ml 1 AL At least 18 yrs old
QL 6 / day hydromorphone 2 mg/ml carpujct 1 AL At least 18 yrs old
QL 3 / day hydromorphone 4 mg/ml carpujct 1 AL At least 18 yrs old
PAGE 16 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 13 / day hydromorphone hcl (1 mg/ml carpujct, 1 mg/ml syringe) 1 AL At least 18 yrs old
QL 6 / day hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mg tablet) 1 AL At least 18 yrs old hydromorphone hcl (10 mg/ml vial, hcl 10 mg/ml vl, 50 mg/5 1 / day ml vial, 500 mg/50 ml via) 1 QL hydromorphone hcl (2 mg/ml vial, hcl 2 mg/ml amp) 1 QL 6 / day
QL 5 / day IBUDONE 10-200 MG TABLET 3 AL At least 16 yrs old
QL 6 / day IBUDONE 5-200 MG TABLET 1 AL At least 16 yrs old
INFUMORPH 200 MG/20 ML AMPUL 3 QL 5 / day
INFUMORPH 500 MG/20 ML AMPUL 3 QL 2 / day levorphanol tartrate powder 3 AL At least 18 yrs old
QL 4 / day levorphanol 2 mg tablet 1 AL At least 18 yrs old
QL 50 / day meperidine 10 mg/ml cartrdge 1 AL At least 18 yrs old meperidine hcl powder 3 AL At least 18 yrs old
QL 50 / day meperidine 50 mg/5 ml solution 1 AL At least 18 yrs old
QL 5 / day meperidine 100 mg tablet 1 AL At least 18 yrs old
QL 10 / day meperidine 50 mg tablet 1 AL At least 18 yrs old
QL 5 / day meperidine 100 mg/ml vial 1 AL At least 18 yrs old
PAGE 17 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 20 / day meperidine 25 mg/ml vial 1 AL At least 18 yrs old
QL 10 / day meperidine 50 mg/ml vial 1 AL At least 18 yrs old methadone hcl powder 3
QL 8 / day methadone 10 mg/5 ml solution 1 PA
QL 18 / day methadone 5 mg/5 ml solution 1 PA
QL 2 / day methadone hcl (10 mg/ml oral conc, hcl 10 mg tablet) 1 PA
QL 3 / day methadone hcl 5 mg tablet 1 PA methadone hcl (10 mg/ml vial, 200 mg/20 ml vl) 1 QL 2 / day
QL 2 / day METHADONE INTENSOL 1 PA
QL 2 / day METHADOSE 10 MG/ML ORAL CONC 3 PA morphine sulfate powder 3 PA morphine sulf 10 mg/5 ml soln 1 QL 25 / day morphine sulf 20 mg/5 ml soln 1 QL 13 / day morphine sulf 10 mg suppos 1 QL 5 / day morphine sulf 30 mg suppos 1 QL 2 / day morphine sulf 5 mg suppos 1 QL 10 / day morphine sulfate (20 mg suppos, 100 mg/5 ml soln) 1 QL 3 / day
PAGE 18 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 5 / day morphine 10 mg/ml syringe 1 PA
QL 25 / day morphine 2 mg/ml syringe 1 PA
QL 13 / day morphine 4 mg/ml syringe 1 PA
QL 10 / day morphine 5 mg/ml syringe 1 PA
QL 3 / day morphine sulfate ir 15 mg tab 1 AL At least 18 yrs old
QL 2 / day morphine sulfate ir 30 mg tab 1 AL At least 18 yrs old
QL 100 / day morphine 0.5 mg/ml vial 1 PA
QL 50 / day morphine 1 mg/ml vial p-f 1 PA
QL 6 / day morphine 8 mg/ml vial 1 PA
QL 3 / day morphine sulfate (10 mg/0.7 ml auto-inj, 15 mg/ml vial) 1 PA morphine sulfate er (er 10 mg cap, er 20 mg cap, er 50 mg cap, QL 2 / day 1 er 100 mg cap) PA morphine sulfate er (er 30 mg cap, er 45 mg cap, er 60 mg cap, QL 1 / day 1 er 75 mg cap, er 80 mg cap, er 90 mg cap, er 120 mg cap) PA morphine sulfate er (er 15 mg tablet, er 30 mg tablet, er 60 mg QL 3 / day 1 tablet, er 100 mg tablet, er 200 mg tablet) PA
PAGE 19 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 3 / day MS CONTIN 3 PA
QL 6 / day NUCYNTA (50 MG TABLET, 75 MG TABLET) 3 AL At least 18 yrs old
QL 7 / day NUCYNTA 100 MG TABLET 3 AL At least 18 yrs old
QL 17 / day OPANA 1 MG/ML INJ AMPULE 3 AL At least 18 yrs old
QL 12 / day OPANA (5 MG TABLET, 10 MG TABLET) 3 AL At least 18 yrs old
QL 2 / day OPANA ER 3 PA AL At least 18 yrs old
QL 8 / day OXAYDO 3 AL At least 18 yrs old
OXECTA 3 QL 8 / day oxycodone hcl (5 mg capsule, 5 mg tablet, 15 mg tablet, 20 mg QL 8 / day 1 tablet, 30 mg tablet) AL At least 18 yrs old oxycodone hcl 100 mg/5 ml soln 1 QL 2 / day oxycodone hcl 5 mg/5 ml soln 1 QL 33 / day oxycodon 10 mg/0.5 ml oral syr 1 QL 4 / day oxycodone hcl 10 mg tablet 1 QL 8 / day
QL 3 / day oxycodone hcl er 1 PA
QL 7 / day oxycodone hcl-aspirin 1 AL At least 18 yrs old
PAGE 20 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 4 / day oxycodone hcl-ibuprofen 1 AL At least 18 yrs old oxycodone hydrochloride 3
QL 3 / day OXYCONTIN 3 PA
QL 12 / day oxymorphone hcl 3 AL At least 18 yrs old HCG
QL 2 / day PA oxymorphone hcl er 3 AL At least 18 yrs old HCG
QL 30 / day promethazine vc-codeine 1 AL At least 6 yrs old
QL 30 / day promethazine-phenyleph-codeine 1 AL At least 6 yrs old
QL 5 / day REPREXAIN 10-200 MG TABLET 1 AL At least 16 yrs old
QL 5 / day REPREXAIN 2.5-200 MG TABLET 3 AL At least 16 yrs old
QL 6 / day REPREXAIN 5-200 MG TABLET 3 AL At least 16 yrs old
QL 8 / day ROXICODONE 3 AL At least 18 yrs old sufentanil citrate powder 3 tramadol hcl powder 3 AL At least 18 yrs old
QL 8 / day tramadol hcl 50 mg tablet 1 AL At least 18 yrs old
PAGE 21 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day tramadol hcl er (er 100 mg capsule, er 150 mg capsule, er 200 mg capsule, er 300 mg capsule) 1 PA AL At least 18 yrs old
QL 1 / day tramadol hcl er (er 100 mg tablet, er 200 mg tablet, er 300 mg PA tablet, hcl er 100 mg tablet, hcl er 200 mg tablet, hcl er 300 mg 3 tablet) AL At least 18 yrs old HCG
QL 20 / day TUZISTRA XR 3 AL At least 18 yrs old
QL 8 / day ULTRAM 3 AL At least 18 yrs old
QL 1 / day ULTRAM ER 3 PA AL At least 18 yrs old
QL 5 / day VICOPROFEN 3 AL At least 16 yrs old
XYLON 10 1
QL 20 / day ZUTRIPRO 3 AL At least 18 yrs old
OPIATE PARTIAL AGONISTS
QL 2 / day BELBUCA 3 PA AL At least 18 yrs old
QL 3 / day BUNAVAIL (2.1-0.3 MG FILM, 6.3-1 MG FILM) 3 PA
QL 2 / day BUNAVAIL 4.2-0.7 MG FILM 3 PA
PAGE 22 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BUPRENEX 3 QL 17 / day
QL 0.144 / day buprenorphine 3 PA buprenorphine hcl powder 3
QL 3 / day buprenorphine hcl (2 mg tablet, 8 mg tablet) 1 PA buprenorphine hcl (0.3 mg/ml syring, 0.3 mg/ml vial) 1 QL 17 / day
QL 3 / day buprenorphine-naloxone 3 PA HCG butorphanol tartrate powder 3 AL At least 18 yrs old
QL 0.3 / day butorphanol 10 mg/ml spray 1 AL At least 18 yrs old
QL 7 / day butorphanol 1 mg/ml vial 1 AL At least 18 yrs old
QL 4 / day butorphanol 2 mg/ml vial 1 AL At least 18 yrs old
QL 0.144 / day BUTRANS 3 PA nalbuphine hcl powder 3 nalbuphine hcl (10 mg/ml ampul, 100 mg/10 ml vial) 1 QL 5 / day nalbuphine hcl (20 mg/ml ampul, 200 mg/10 ml vial) 1 QL 3 / day
QL 12 / day pentazocine-naloxone hcl 1 AL At least 12 yrs old
QL 3 / day SUBOXONE (2 MG-0.5 MG FILM, 8 MG-2 MG FILM) 2 PA
PAGE 23 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 2 / day SUBOXONE (4 MG-1 MG FILM, 12 MG-3 MG FILM) 2 PA
TALWIN (30 MG/ML AMPUL, 30 MG/ML VIAL) 3 QL 5 / day
QL 3 / day ZUBSOLV 3 PA
ANOREXIGENIC AGENTS
AMPHETAMINE DERIVATIVES
QL 2 / day ADIPEX-P (37.5 MG CAPSULE, 37.5 MG TABLET) 3 PA AL At least 17 yrs old
QL 3 / day BONTRIL PDM 3 PA AL At least 17 yrs old diethylpropion hcl powder 3
QL 3 / day diethylpropion 25 mg tablet 1 PA AL At least 16 yrs old
QL 1 / day diethylpropion hcl er 1 PA
QL 3 / day LOMAIRA 1 PA AL At least 17 yrs old
QL 1 / day phendimetrazine er 105 mg cap 1 PA
QL 3 / day phendimetrazine 35 mg tablet 1 PA
PAGE 24 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day phentermine hcl (15 mg capsule, 30 mg capsule) 1 PA phentermine hcl powder 3
QL 2 / day phentermine hcl (37.5 mg capsule, 37.5 mg tablet) 1 PA AL At least 17 yrs old
QL 1 / day QSYMIA 3 PA AL At least 18 yrs old
SUPRENZA ODT 3 PA
ANOREXIGENIC AGENTS, MISCELLANEOUS
QL 4 / day CONTRAVE 3 PA AL At least 18 yrs old
SELECTIVE SEROTONIN RECEPTOR AGONISTS
QL 2 / day BELVIQ 3 PA AL At least 18 yrs old
QL 1 / day BELVIQ XR 3 PA AL At least 18 yrs old
ANOREXIGENICS;RESPIRATORY,CNS STIMULANTS
AMPHETAMINES
QL 2 / day ADDERALL 3 ST
QL 2 / day ADDERALL XR 3 ST
PAGE 25 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day ADZENYS XR-ODT 3 ST AL At least 6 yrs old
QL 3 / day benzphetamine hcl 25 mg tablet 1 PA AL At least 12 yrs old
QL 3 / day benzphetamine hcl 50 mg tablet 1 PA
QL 5 / day DESOXYN 3 ST
QL 5 / day DEXEDRINE SPANSULE 10 MG 3 ST
QL 4 / day DEXEDRINE SPANSULE 15 MG 3 ST
QL 2 / day DEXEDRINE SPANSULE 5 MG 3 ST
DEXEDRINE 10 MG TABLET 1 QL 6 / day
DEXEDRINE 5 MG TABLET 1 QL 2 / day
QL 60 / day dextroamphetamine 5 mg/5 ml 3 HCG
QL 6 / day dextroamphetamine 10 mg tab 3 HCG
QL 2 / day dextroamphetamine 5 mg tab 3 HCG
QL 5 / day d-amphetamine er 10 mg capsule 3 HCG
PAGE 26 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 4 / day d-amphetamine er 15 mg capsule 3 HCG
QL 2 / day d-amphetamine er 5 mg capsule 3 HCG dextroamphetamine-amphet er 1 QL 2 / day dextroamphetamine-amphetamine 1 QL 2 / day
QL 8 / day DYANAVEL XR 3 ST AL At least 6 yrs old
QL 6 / day EVEKEO 3 ST methamphetamine hcl 1 QL 5 / day
QL 60 / day PROCENTRA 3 ST
QL 3 / day REGIMEX 3 PA AL At least 12 yrs old
VYVANSE (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE, 70 MG 2 QL 1 / day CAPSULE) VYVANSE (10 MG TABLET, 20 MG TABLET, 30 MG TABLET, 40 1 / day MG TABLET, 50 MG TABLET, 60 MG TABLET) 2 QL
QL 2 / day ZENZEDI (15 MG TABLET, 30 MG TABLET) 3 ST
QL 3 / day ZENZEDI (2.5 MG TABLET, 20 MG TABLET) 3 ST
ZENZEDI 10 MG TABLET 1 QL 6 / day
PAGE 27 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZENZEDI 5 MG TABLET 1 QL 2 / day
QL 8 / day ZENZEDI 7.5 MG TABLET 3 ST
ANOREXIGENIC AGENTS AND STIMULANTS, MISC meclofenoxate hcl 3 RESPIRATORY AND CNS STIMULANTS
QL 1 / day APTENSIO XR 3 ST caffeine 3 caffeine and sodium benzoate 1 caffeine citrate (citrate powder, citrated powder) 3 caffeine cit 60 mg/3 ml oral 1
CONCERTA (ER 18 MG TABLET, ER 27 MG TABLET, ER 36 MG QL 2 / day 3 TABLET) ST
QL 1 / day CONCERTA ER 54 MG TABLET 3 ST
QL 1 / day DAYTRANA 3 ST dexmethylphenidate 10 mg tab 1 QL 2 / day dexmethylphenidate hcl (2.5 mg tab, 5 mg tab) 1 QL 3 / day
QL 2 / day dexmethylphenidate er 20 mg cp 3 HCG dexmethylphenidate hcl er (er 5 mg cap, er 10 mg cp, er 15 mg QL 1 / day 3 cp, er 25 mg cp, er 30 mg cp, er 35 mg cp, er 40 mg cp) HCG
QL 2 / day FOCALIN 3 ST
PAGE 28 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, QL 1 / day 25 MG CAPSULE, 30 MG CAPSULE, 35 MG CAPSULE, 40 MG 3 CAPSULE) ST
QL 2 / day FOCALIN XR 20 MG CAPSULE 3 ST
QL 1 / day METADATE CD 3 ST
QL 3 / day METADATE ER 1 LCG
QL 30 / day METHYLIN 10 MG/5 ML SOLUTION 3 ST
QL 60 / day METHYLIN 5 MG/5 ML SOLUTION 3 ST
QL 3 / day METHYLIN (2.5 MG TAB, 5 MG TABLET, 10 MG TABLET) 3 ST
QL 1 / day methylphenidate er (er 20 mg cap, er 40 mg cap) 3 HCG
QL 2 / day methylphenidate er 30 mg cap 3 HCG methylphenidate er (er 18 mg tab, er 27 mg tab, er 36 mg tab) 1 QL 2 / day methylphenidate er 54 mg tab 1 QL 1 / day methylphenidate er 10 mg tab 1 QL 5 / day methylphenidate er 20 mg tab 1 QL 3 / day methylphenidate hcl powder 3 methylphenidate 10 mg/5 ml sol 1 QL 30 / day methylphenidate 5 mg/5 ml soln 1 QL 60 / day
PAGE 29 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS methylphenidate 2.5 mg chew tb 1 methylphenidate hcl (5 mg chew tab, 10 mg chew tab, 20 mg 3 / day tablet) 1 QL
QL 5 / day methylphenidate 10 mg tablet 1 LCG
QL 3 / day methylphenidate 5 mg tablet 1 LCG
QL 1 / day methylphenidate hcl cd 3 HCG methylphenidate hcl er (er 10 mg cap, er 50 mg cap, er 60 mg 1 / day cap) 1 QL
QL 1 / day methylphenidate la (20 mg cap, 40 mg cap) 3 HCG
QL 2 / day methylphenidate la 30 mg cap 3 HCG methylphenidate la 60 mg cap 1 QL 1 / day
QL 1 / day QUILLICHEW ER (ER 20 MG CHEW TAB, ER 40 MG CHEW TAB) 3 ST AL At least 6 yrs old
QL 2 / day QUILLICHEW ER 30 MG CHEW TAB 3 ST AL At least 6 yrs old
QL 12 / day QUILLIVANT XR 3 ST
QL 3 / day RITALIN (5 MG TABLET, 20 MG TABLET) 3 ST
QL 5 / day RITALIN 10 MG TABLET 3 ST
PAGE 30 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RITALIN LA (10 MG CAPSULE, 20 MG CAPSULE, 40 MG CAPSULE, QL 1 / day 3 60 MG CAPSULE) ST
QL 2 / day RITALIN LA 30 MG CAPSULE 3 ST
WAKEFULNESS-PROMOTING AGENTS
QL 1 / day armodafinil 3 PA HCG
QL 1 / day modafinil 1 PA
QL 1 / day NUVIGIL 3 PA
QL 1 / day PROVIGIL 3 PA
ANTI-INFECTIVE AGENTS
ANTHELMINTICS albendazole 3
QL 4 / day ALBENZA 3 PA
BILTRICIDE 3 PA
EMVERM 3 PA ivermectin powder 3 ivermectin 3 mg tablet 1 PA levamisole hcl 3 mebendazole 3 niclosamide 3
PAGE 31 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS praziquantel 3 pyrantel pamoate 3
STROMECTOL 3 PA thiabendazole 3 ANTI-INFECTIVES (SYSTEMIC), MISC. diethylcarbamazine citrate 3 furazolidone 3 URINARY ANTI-INFECTIVES
AZUPHEN MB 1 FURADANTIN 3 HIPREX 3 HYOPHEN 1 INDIOMIN MB 1 MACROBID 3 MACRODANTIN 3 me-naphos-mb-hyo 1 1 methenamine 3 methenamine hippurate 1 methenamine mandelate powd 3 methenamine mandelate (md 1 gm tablet, md 500 mg tablet) 1 MONUROL 3 nitrofurantoin (25 mg/5 ml susp, mcr 25 mg cap, mcr 50 mg cap, mcr 100 mg cap) 1 nitrofurantoin powder 3 nitrofurantoin mono-macro 1 PHOSPHASAL 1 PRIMSOL 3
PAGE 32 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROSED-DS 3 trimethoprim powder 3 trimethoprim 100 mg tablet 1 trimethoprim micronized 3 UR N-C 1 URELLE 1 URETRON D-S 1
URIBEL 1 QL 4 / day
URIMAR-T 1 URIN D.S. 1 URO-458 1 URO-BLUE 1 URO-L 1 UROGESIC-BLUE 3 UROPHEN MB 1 UROQID-ACID NO.2 3 URYL 1 USTELL 1 UTA 1 UTIRA-C 1 ANTI-INFECTIVES (EENT)
ANTIBACTERIALS (EENT)
AK-POLY-BAC 1 QL 0.434 / day
AZASITE 3 QL 0.36/day bacitracin 500 unit/gm ophth 1 QL 0.434 / day bacitracin-polymyxin 1 QL 0.434 / day
PAGE 33 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BACTROBAN NASAL 2
BESIVANCE 3 QL 0.767 / day
BLEPH-10 3 QL 5 / fill
BLEPHAMIDE 3 QL 5 / fill
BLEPHAMIDE S.O.P. 3 QL 4 / fill
CETRAXAL 3 QL 0.567 / day
CILOXAN (EYE DROPS, OINTMENT) 3 QL 0.767 / day
CIPRO HC 3 QL 0.434 / day
CIPRODEX 2 QL 0.257 / day ciprofloxacin 0.2% otic soln 1 QL 0.567 / day ciprofloxacin 0.3% eye drop 1 QL 0.767 / day
COLY-MYCIN S 3 QL 10 / fill
CORTISPORIN-TC 3 QL 10 / fill doxycycline hyclate 20 mg tab 1 erythromycin 0.5% eye ointment 1 QL 0.54 / day
FLOXIN 3 QL 10 / 30 days gatifloxacin 1 QL 0.36/day gatifloxacin sesquihydrate 3
GENTAK 1 QL 0.54 / day gentamicin sulfate (0.3% drops, 3 mg/ml drops) 1 QL 2.143 / day gentamicin 0.3% eye ointment 1 QL 0.54 / day
ILOTYCIN 1 QL 0.54 / day levofloxacin 0.5% eye drops 1 QL 0.767 / day
PAGE 34 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MAXITROL EYE DROPS 3 QL 5 / fill
MAXITROL EYE OINTMENT 3 QL 4 / fill
MOXEZA 2 QL 0.434 / day moxifloxacin 0.5% eye drops 1 QL 0.434 / day mupirocin powder 3
NEO-POLYCIN 1 QL 0.124 / day
NEO-POLYCIN HC 1 QL 4 / fill neomycin-bacitracin-poly-hc 1 QL 4 / fill neomycin-bacitracin-polymyxin 1 QL 0.124 / day neomyc-polym-dexameth eye drop 1 QL 5 / fill neomyc-polym-dexamet eye ointm 1 QL 4 / fill neomycin-polymyxin-gramicidin 1 QL 1.47 / day neomycin-poly-hc eye drops 1 QL 10/ fill neomycin-polymyxin-hc ear susp 1 QL 10 / fill neomycin-polymyxin-hydrocort 1 QL 10 / fill
NEOSPORIN 3 QL 1.47 / day
OCUFLOX 3 QL 1.47 / day ofloxacin 0.3% ear drops 1 QL 10 / 30 days ofloxacin 0.3% eye drops 1 QL 1.47 / day
OTIPRIO 3 OTOVEL 3
POLYCIN 1 QL 0.434 / day polymyxin b sul-trimethoprim 1 QL 1.47 / day
PAGE 35 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
POLYTRIM 3 QL 1.47 / day
PRED-G 1% EYE DROPS 3 QL 5 / fill
PRED-G S.O.P. EYE OINTMENT 3 QL 4 / fill sulfacetamide 10% eye drops 1 QL 5 / fill sulfacetamide 10% eye ointment 1 QL 4 / fill sulfacetamide-prednisolone 1 QL 5 / fill
TOBRADEX EYE DROPS 3 QL 5 / fill
TOBRADEX EYE OINTMENT 3 QL 4 / fill
TOBRADEX ST 3 QL 5 / fill tobramycin 0.3% eye drops 1 QL 2.143 / day tobramycin-dexamethasone 1 QL 5 / fill
TOBREX 0.3% EYE DROPS 3 QL 2.143 / day
TOBREX 0.3% EYE OINTMENT 3 QL 0.54 / day
VIGAMOX 2 QL 0.434 / day
ZYLET 3 QL 5 / fill
ZYMAXID 3 QL 0.36/day
ANTIFUNGALS (EENT)
NATACYN 3 QL 0.767 / day
ANTIVIRALS (EENT) idoxuridine 3 trifluridine 1% eye drops 1 trifluridine powder 3 VIROPTIC 3
ZIRGAN 3 QL 0.167 / day
PAGE 36 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EENT ANTI-INFECTIVES, MISCELLANEOUS
ACETASOL HC 1 acetic acid 2% ear solution 1 acetic acid-aluminum 1 BETADINE 3 boric acid (granules, powder) 3 chlorhexidine 0.12% rinse 1 hydrocortisone-acetic acid 1 PAROEX 1 PERIDEX 3 PERIOGARD 1 povidone iodine 5% eye drop 1 ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)
ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)
ALTABAX 3 bacitracin (5 million units pwd, powder) 3 bacitracin micronized 3 bacitracin zinc 3 BACTROBAN (CREAM, OINTMENT) 3 CENTANY 3 CENTANY AT 3 CLEOCIN 2% VAGINAL CREAM 3 CLEOCIN 100 MG VAGINAL OVULE 2
CLEOCIN T 1% GEL 3 QL 75 / 30 days
CLEOCIN T (LOION, PLEDGES, SOLUION) 3 CLINDACIN ETZ KIT 3 CLINDACIN ETZ 1% PLEDGET 1
PAGE 37 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CLINDACIN P 1 CLINDACIN PAC 3
CLINDAGEL 3 QL 75 / 30 days clindamax 1
QL 1.5 / day clindamycin phos-benzoyl perox 3 HCG
QL 2 / day clindamycin phos-tretinoin 3 HCG clindamycin phosphate 1% foam 1 QL 1.667 / day clindamycin ph 1% gel 1 QL 75 / 30 days clindamycin phosphate (ph 1% solution, phos 1% pledget, phosp 1% lotion, 2% vaginal cream) 1 clindamycin-benzoyl peroxide (clinda-benzoyl 1-5% pump, QL 1.667 / day 3 clindamycin-benzoyl 1-5%) HCG
CLINDESSE 3
CORTISPORIN CREAM 3 QL 0.25 / day
CORTISPORIN OINTMENT 3 QL 0.5 / day
ERY 1
ERYGEL 3 QL 1 / day erythromycin 2% gel 1 QL 1 / day erythromycin (pledgets, solution) 1
QL 1.60 / day erythromycin-benzoyl peroxide 3 HCG
EVOCLIN 3 QL 1.667 / day gentamicin sulfate (cream, ointment) 1 METROCREAM 3
PAGE 38 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS METROGEL (GEL, PUMP) 3 METROGEL-VAGINAL 3 METROLOTION 3 metronidazole (0.75% cream, 0.75% lotion, topical 0.75% gl, topical 1% gel) 3 HCG metronidazole (top 1% gel pump, vaginal 0.75% gl) 1 mupirocin (cream, ointment) 1 NEO-SYNALAR 0.5%-0.025% CREAM 3
NEUAC GEL 1 QL 1.5 / day
NORITATE 3 NUVESSA 3
ONEXTON 1.2%-3.75% GEL 3 QL 1.667 / day
ONEXTON GEL PUMP 3 QL 1.967 / day
ROSADAN (CREAM, GEL) 1 ROSADAN (CREAM KIT, GEL KIT) 3 VANDAZOLE 1 ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) acyclovir 5% ointment 3 HCG
QL 0.167 / day DENAVIR 3 PA AL At least 12 yrs old docosanol 3
QL 0.167 / day XERESE 3 PA AL At least 6 yrs old
QL 0.167 / day ZOVIRAX 5% CREAM 2 PA AL At least 12 yrs old
PAGE 39 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 30 / fill ZOVIRAX 5% OINTMENT 3 PA AL At least 12 yrs old
LOCAL ANTI-INFECTIVES, MISCELLANEOUS arida 3 AVAR CLEANSER 1 AVAR 9.5-5% CLEANSING PADS 3 AVAR LS (10-2% CLEANSING PADS, CLEANSER) 3 AVAR LS 10%-2% FOAM 3 AVAR-E 1 AVAR-E GREEN 1 AVAR-E LS 3 AVC 3 benzalkonium chloride 3 BP 10-1 1 carbamide peroxide 3 chlorhexidine gluc 20% soln 3 CLARIFOAM EF 3 CLEANSING WASH 1 curity amd gauze 0.2% sponge 3 DERMAZENE 1 FEM PH 3 guaiacol 1 hydrocortisone-iodoquinol 1 hydrocortisone-iodoquinol-aloe 1 iodine 3 IODOFLEX 3
PAGE 40 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS IODOSORB 3 kerlix amd 3 kerlix amd bandage 3
KLARON 3 QL 4 / day
LUGOL'S STRONG IODINE SOLUTION 1 mafenide acetate 3 nitrofurazone 3
OVACE 3 QL 12 / day
OVACE PLUS 10% WASH 3 QL 15.767 / day
OVACE PLUS 10% CREAM 3 QL 2 / day
OVACE PLUS 9.8% FOAM 3 QL 3.334 / day
OVACE PLUS 9.8% LOTION 3 QL 4 / day
OVACE PLUS 10% SHAMPOO 3 QL 8 / day
OVACE PLUS WASH 3 QL 12 / day phenol (crystals, liquid) 3 phenol liquified 1 PLEXION (9.8-4.8% CLEANSER, 9.8-4.8% CLNSING CLOTH, 9.8- 4.8% CREAM, 9.8-4.8% LOTION) 3 povidone iodine powder 3 RELAGARD 3 ROSANIL 1
QL 12 / day SEB-PREV 3 HCG selenium sulfide (2.25% shampoo, 2.5% lotion) 1 selenium sulfide powder 3 SELRX 3
PAGE 41 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SILVADENE 3 silver nitrate crystals 3 silver nitrate (0.5% soln, 10% ointment, 25% solution, 50% solution) 1 silver protein 3 silver sulfadiazine 1% cream 1 silver sulfadiazine powder 3 silver sulphadiazine 3 sodium sulfacetamide (sod sulfacetam clnsng gel, sodium QL 12 / day 3 sulfacetamide wash) HCG sod sulfacetamide 10% shampoo 1 QL 8 / day sodium sulfacetamide-sulfur (sod sulfacet-sulfur 10-5% clsr, sodium sulf-sulfur cleanser) 1 sodium sulfacetamide-sulfur (sod sulface-sulf 9.8-4.8% clsr, sod sulface-sulfur 9-4.5% wash, sod sulfacet-sulfur 10-2% clsr, sod sulfacet-sulfur 10-4% pad, sod sulfacet-sulfur 10-5% lotn, sod sulfacetamide-sulfur foam, sod sulfacetamide-sulfur lotn, sod 1 sulfacetamide-sulfur susp, sodium sulfacet-sulfur wash, sulfacetamide-sulfur 8-4% susp, sulfacetamide-sulfur 10-2% crm, sulfacetamide-sulfur 10-5% crm)
SSD 1 SSS 10-5 (10-5 CREAM, 10-5 FOAM) 1 sulfacetamide sodium (sod top susp, sodium lotn) 1 QL 4 / day sulfacetamide sodium-sulfur 1
SULFACLEANSE 8-4 3 HCG
SULFAMYLON (8.5% CREAM, POWDER PACKET) 3 SUMADAN 9%-4.5% WASH 3 SUMAXIN (CLEANSING PADS, WASH) 3 SUMAXIN TS 3 TERSI FOAM 3
PAGE 42 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THERMAZENE 1 triclosan 3
ULESFIA 3 ST
VYTONE 3 ZENCIA 1 SCABICIDES AND PEDICULICIDES benzyl benzoate 3 crotamiton 3 ELIMITE 3
EURAX (CREAM, LOTION) 3 ST lindane (lotion, shampoo) 1 malathion 3 HCG
NATROBA 3 ST
OVIDE 3 ST permethrin 5% cream 1 permethrin technical liquid 3
SKLICE 3 ST spinosad 3 HCG
ANTI-INFLAMMATORY AGENTS (EENT)
CORTICOSTEROIDS (EENT)
ALREX 3 QL 0.5 / day
BECONASE AQ 3 QL 1.667 / day budesonide 32 mcg nasal spray 1 QL 0.574 / day budesonide micronized 3 CORTANE-B 3
PAGE 43 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DERMOTIC 3 dexamethasone 0.1% eye drop 1 QL 10 / fill
DUREZOL 3
FLAREX 3 QL 10 / fill flunisolide 0.025% spray 1 QL .834 / day fluocinolone acetonide oil 3 HCG fluorometholone 1 QL 10 / fill fluticasone prop 50 mcg spray 1 QL 0.6 / day
FML 3 QL 10 / fill
FML FORTE 3 QL 10 / fill
FML S.O.P. 3 QL 4 / fill
LOTEMAX 0.5% OPHTHALMIC GEL 3 QL 10 / fill
LOTEMAX 0.5% EYE DROPS 3 QL 21 / fill
LOTEMAX 0.5% EYE OINTMENT 3 QL 4 / fill
MAXIDEX 3 QL 10 / fill mometasone furoate powder 3 mometasone furoate 50 mcg spry 1 QL 0.567 / day
NASONEX 3 QL 0.567 / day
OMNARIS 3 QL 0.434 / day
OMNIPRED 3 QL 21 / fill
PRED FORTE 3 QL 21 / fill
PRED MILD 3 QL 21 / fill prednisolone acetate 1 QL 21 / fill
PAGE 44 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS prednisolone sod 1% eye drop 1
QNASL 3 QL 0.3 / day
QNASL CHILDREN 3
RHINOCORT AQUA 3 QL 0.574 / day triamcinolone 55 mcg nasal spr 1 QL 0.55 / day
TRIESENCE 3 QL 1 / day
VERAMYST 3 QL 0.357 / day
VEXOL 3 QL 10 / fill
ZETONNA 3 QL 0.22 / day
EENT ANTI-INFLAMMATORY AGENTS, MISC.
RESTASIS 2 PA
RESTASIS MULTIDOSE 2 PA
QL 2 / day XIIDRA 3 PA AL At least 17 yrs old
EENT NONSTEROIDAL ANTI-INFLAM. AGENTS
ACULAR 3 QL 15 / 30 days
ACULAR LS 3 QL 5 / fill
ACUVAIL 2 QL 1 / day bromfenac sodium 0.09% eye drp 1 QL 8 / rx
BROMSITE 3 QL 15/ 180 days diclofenac 0.1% eye drops 1 QL 5 / fill flurbiprofen sodium 1 QL 3/ fill
ILEVRO 3 QL 4 / fill
PAGE 45 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ketorolac 0.4% ophth solution 1 QL 5 / fill ketorolac 0.5% ophth solution 1 QL 15 / 30 days
NEVANAC 3 QL 3/ fill
OCUFEN 3 QL 3/ fill
PROLENSA 3 QL 3/ fill
ANTI-INFLAMMATORY AGENTS (RESPIRATORY)
LEUKOTRIENE MODIFIERS
ACCOLATE 3 QL 2 / day montelukast sodium powder 3 montelukast sodium (4 mg granules, 4 mg tab chew, 5 mg tab 1 / day chew, 10 mg tablet) 1 QL SINGULAIR (4 MG GRANULES, 4 MG TABLET CHEW, 5 MG 1 / day TABLET CHEW, 10 MG TABLET) 3 QL zafirlukast 1 QL 2 / day
QL 4 / day zileuton er 3 ST
QL 4 / day ZYFLO 3 ST
QL 4 / day ZYFLO CR 3 ST
MAST-CELL STABILIZERS
ALOCRIL 3 QL 5 / fill cromolyn 20 mg/2 ml neb soln 1 cromolyn 4% eye drops 1 QL 10 / fill cromolyn 100 mg/5 ml oral conc 1 cromolyn sodium powder 3
PAGE 46 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GASTROCROM 3 tranilast 3 ANTIANEMIA DRUGS
IRON PREPARATIONS
ACTIVE FE 3 GL Female
ATABEX EC 3 GL Female
CADEAU DHA 3 DIALYVITE 800 WITH IRON 3 DOTHELLE DHA 3
ELITE-OB 400 3 GL Female
ESCAVITE LQ 3 FEROCON 1 FEROTRINSIC 1 FERREX 150 FORTE 3 ferric sulfate 3 FERROCITE PLUS 1 ferrous fumarate 3 ferrous gluconate 3 ferrous sulfate 3 FOCALGIN 90 DHA 3
FOCALGIN CA 3 GL Female
FOCALGIN DSS 3 GL Female
FOLIVANE-PLUS 3 FORTAVIT 3 FUSION PLUS 3 FUSION SPRINKLES 3
PAGE 47 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HEMATINIC PLUS 1 HEMATINIC WITH FOLIC ACID 1 HEMATRON-AF 3 HEMAX 1 HEMOCYTE PLUS 3 HEMOCYTE-F 1 ICAR-C PLUS 3
INFED 5 S levomefolate dha 3 GL Female
MACNATAL CN DHA 3 GL Female
MAXARON FORTE 3 MULTICHEW 3 MULTIGEN FOLIC 3 MULTIGEN PLUS 3 multivitamin-iron-fluoride 1 MYKIDZ IRON FL 3
MYNATAL CAPSULE 3 GL Female
MYNATAL ADVANCE 3 GL Female
MYNATAL PLUS 3 GL Female
MYNATAL-Z 3 GL Female
NEWGEN 3 NUTRICAP 3
O-CAL FA 3 GL Female
OBSTETRIX EC 3 GL Female
OBSTETRIX ONE 1 GL Female
PAGE 48 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
OBTREX DHA 3 GL Female
PNV 29-1 3 GL Female
PNV-DHA + DOCUSATE 3 GL Female
PNV-OMEGA 3 GL Female
POLY-VI-FLOR WITH IRON (0.25 MG, 0.5 MG) 3 POLYSACCHARIDE IRON FORTE 1
PRENA1 PEARL 3 GL Female
PRENA1 TRUE 3 GL Female
PRENATABS RX 3 GL Female prenatal low iron 3 GL Female prenatal plus multivitamin tab 3
PREPLUS 3 GL Female
PRETAB 3 GL Female
PROFERRIN-FORTE 3 PROTECT IRON 3 PROVIDA DHA 3
PROVIDA OB 3 GL Female
R-NATAL OB 3 GL Female
RULAVITE DHA 3 TEXAVITE LQ 3 THRIVITE 19 3 THRIVITE RX 3 TL FOLATE 3
TRI-TABS DHA 3 GL Female
TRICARE PRENATAL 3 GL Female
PAGE 49 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRIFERIC 272 MG POWDER PACKET 5 S
TRINATE 3 GL Female
TRIVEEN-ONE 3 GL Female
VINATE DHA 3 GL Female
VINATE DHA RF 3 GL Female
VINATE GT 3 GL Female
VINATE II 3 GL Female
VINATE ONE 3 GL Female
VINATE ULTRA 3 GL Female
VIRT-ADVANCE 3 GL Female
VIRT-C DHA 3
VIRT-NATE 3 GL Female
VIRT-NATE DHA 3 GL Female
VIRT-PN 3 GL Female
VIRT-PN DHA 3 GL Female
VIRT-PN PLUS 3 GL Female
VITAFOL GUMMIES 3 GL Female
VITATRUE 3 GL Female
VIVA DHA 3 GL Female
VOL-TAB RX 3 GL Female
VP-CH-PNV 3 GL Female
VP-HEME OB 3 GL Female
VP-HEME ONE 3 GL Female
PAGE 50 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VP-PNV-DHA 3
VYNATAL-FA 1 GL Female
ANTIARRHYTHMIC AGENTS
ANTIARRHYTHMICS, MISCELLANEOUS
DIGITEK 1 DIGOX 1 digoxin (0.05 mg/ml solution, 0.125 mg tablet, 0.25 mg tablet, 125 mcg tablet, 250 mcg tablet) 1 digoxin (0.25 mg/ml syringe, 500 mcg/2 ml ampule) 1 LANOXIN 500 MCG/2 ML AMPULE 2 LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, 187.5 MCG TABLET, 250 MCG TABLET) 2
LANOXIN PEDIATRIC 2 magnesium sulfate crystals 3 magnesium sulfate (syringe, vial) 1 CLASS IA ANTIARRHYTHMICS disopyramide phosphate 1 NORPACE 3 NORPACE CR 100 MG CAPSULE 2 NORPACE CR 150 MG CAPSULE 3 procainamide hcl powder 3 procainamide 500 mg/ml vial 1 quinidine gluc er 324 mg tab 1 quinidine gluc 80 mg/ml vial 1 quinidine sulfate (crystals, powder) 3 quinidine sulfate (sulf er 300 mg tab, sulfate 200 mg tab, sulfate 300 mg tab) 1
PAGE 51 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CLASS IB ANTIARRHYTHMICS
DILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 MG CAPSULE) 2 DILANTIN-125 2 lidocaine hcl (1% syringe, 2% vial) 1 MED Medical Drug lidocaine hcl (2% 100 mg/5 ml, 2% 40 mg/2 ml, 2% 40 mg/2 ml vl, 30 mg/3 ml syr, 100 mg/10 ml syr) 1 mexiletine hcl (150 mg capsule, 200 mg capsule, 250 mg capsule) 1 mexiletine hcl powder 3 PHENYTEK 2 phenytoin (50 mg infatab, 50 mg tablet chew, 100 mg/4 ml susp, 125 mg/5 ml susp) 1 phenytoin powder 3 phenytoin sodium powder 3 phenytoin sodium extended 1 XYLOCAINE 2% VIAL 3 XYLOCAINE-MPF (AMPUL, VIAL) 3 CLASS IC ANTIARRHYTHMICS flecainide acetate 1 propafenone hcl 1 propafenone hcl er 3 HCG
RYTHMOL 3 RYTHMOL SR 3 CLASS II ANTIARRHYTHMICS acebutolol hcl (200 mg capsule, 400 mg capsule) 1 acebutolol hcl powder 3 atenolol powder 3 atenolol (25 mg tablet, 50 mg tablet) 1 LCG
PAGE 52 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS atenolol 100 mg tablet 1 atenolol-chlorthalidone 1 BETAPACE 3 BETAPACE AF 3 betaxolol hcl (10 mg tablet, 20 mg tablet) 1 bisoprolol fumarate 1 bisoprolol-hydrochlorothiazide 1 LCG
CORGARD 3 CORZIDE 3
DUTOPROL 3 QL 2 / day
HEMANGEOL 5 S
INDERAL LA 3
INDERAL XL 3 ST
INNOPRAN XL 3 ST
LOPRESSOR (50 MG TABLET, 100 MG TABLET) 3 LOPRESSOR HCT 3 metoprolol succinate 1 metoprolol tartrate powder 3 metoprolol tartrate (25 mg tab, 50 mg tab) 1 LCG metoprolol tartrate (37.5 mg tb, 75 mg tab) 1 metoprolol tartrate 100 mg tab 1 metoprolol-hydrochlorothiazide 1 nadolol powder 3 nadolol (20 mg tablet, 40 mg tablet, 80 mg tablet) 1 nadolol-bendroflumethiazide 1 pindolol 1
PAGE 53 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS propranolol hcl powder 3 propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 ml soln, 40 mg tablet, 40 mg/5 ml soln, 60 mg tablet, 80 mg tablet) 1 propranolol hcl er 1 propranolol-hydrochlorothiazid 1 SECTRAL 3 SORINE 1 sotalol 1 sotalol af 1 SOTYLIZE 3 TENORETIC 100 3 TENORETIC 50 3 TENORMIN 3 timolol maleate powder 3 timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1 TOPROL XL 3 ZEBETA 3 ZIAC 3 CLASS III ANTIARRHYTHMICS amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet) 1 CORDARONE 2 dofetilide 5 S
MULTAQ 3 PA
PACERONE 1
TIKOSYN 5 S
CLASS IV ANTIARRHYTHMICS adenosine powder 3
PAGE 54 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CALAN 3 QL 3 / day
CALAN SR 3 QL 1 / day
CARDIZEM 3 QL 4 / day
CARDIZEM CD (180 MG CAPSULE, 240 MG CAPSULE, 300 MG CAPSULE, 360 MG CAPSULE) 3
CARDIZEM CD 120 MG CAPSULE 3 QL 1 / day
CARDIZEM LA (300 MG TABLET, 360 MG TABLET, 420 MG 1 / day TABLET) 3 QL
CARDIZEM LA 120 MG TABLET 3 QL 4 / day
CARDIZEM LA 180 MG TABLET 3 QL 3 / day
CARDIZEM LA 240 MG TABLET 3 QL 2 / day
CARTIA XT 1 QL 1 / day
DILT XR 120 MG CAPSULE 1 QL 1 / day
DILT-XR (180 MG CAPSULE, 240 MG CAPSULE) 1 diltiazem 12hr er 1 diltiazem 24hr cd (24hr 180 mg cap, 24hr 240 mg cap, 24hr 300 mg cap, 24hr 360 mg cap) 1 diltiazem 24hr cd 120 mg cap 1 QL 1 / day diltiazem 24hr er (24hr er 240 mg cap, 24hr er 300 mg cap, 24hr er 360 mg cap, 24hr er 420 mg cap) 1 diltiazem 24hr er (24hr er 120 mg cap, 24hr er 180 mg cap, 1 / day 24hr er 300 mg tab, 24hr er 360 mg tab, 24hr er 420 mg tab) 1 QL diltiazem 24hr er 180 mg tab 1 QL 3 / day diltiazem 24hr er 240 mg tab 1 QL 2 / day diltiazem er (er 120 mg capsule, er 180 mg capsule) 1 QL 1 / day diltiazem er 240 mg capsule 1 diltiazem hcl powder 3
PAGE 55 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS diltiazem 90 mg tablet 1 diltiazem hcl (30 mg tablet, 60 mg tablet, 120 mg tablet) 1 QL 4 / day
MATZIM LA (300 MG TABLET, 360 MG TABLET, 420 MG TABLET) 1 QL 1 / day
MATZIM LA 180 MG TABLET 1 QL 3 / day
MATZIM LA 240 MG TABLET 1 QL 2 / day
TAZTIA XT (120 MG CAPSULE, 180 MG CAPSULE) 1 QL 1 / day
TAZTIA XT (240 MG CAPSULE, 300 MG CAPSULE, 360 MG CAPSULE) 1
TIAZAC (ER 120 MG CAPSULE, ER 180 MG CAPSULE) 3 QL 1 / day
TIAZAC (ER 240 MG CAPSULE, ER 300 MG CAPSULE, ER 360 MG CAPSULE, ER 420 MG CAPSULE) 3 verapamil er (er 120 mg capsule, er 120 mg tablet, er 180 mg 1 / day capsule, er 180 mg tablet, er 240 mg capsule, er 240 mg tablet) 1 QL verapamil er pm 1 QL 1 / day verapamil 360 mg cap pellet 1 QL 1 / day verapamil hcl powder 3 verapamil 40 mg tablet 1 verapamil hcl (80 mg tablet, 120 mg tablet) 1 QL 3 / day verapamil sr 1 QL 1 / day
VERELAN 3 QL 1 / day
VERELAN PM 3 QL 1 / day
ANTIBACTERIALS
AMINOGLYCOSIDES amikacin 3 amikacin sulfate powder 3 amikacin sulfate (1 gram/4 ml vial, 500 mg/2 ml vial, 1,000 mg/4 ml vl) 1
PAGE 56 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PA BETHKIS 4 S PS gentamicin sulfate powder 3 gentamicin sulfate (20 mg/2 ml vial, ped 20 mg/2 ml vial, 40 mg/ml vial, 80 mg/2 ml vial, 800 mg/20 ml vial) 1 kanamycin sulfate 3
PA KITABIS PAK 5 S neomycin sulfate powder 3 neomycin 500 mg tablet 1 paromomycin 250 mg capsule 1 paromomycin sulfate powder 3 streptomycin sulfate powder 3 streptomycin sulf 1 gm vial 1
PA TOBI 5 S
PA TOBI PODHALER 5 S
PA tobramycin (300 mg/5 ml ampule, pak 300 mg/5 ml) 5 S tobramycin powder 3 tobramycin sulfate powder 3 tobramycin sulfate (1.2 gm vial, 1.2 gram/30 ml vial, 10 mg/ml vial, 40 mg/ml vial, 80 mg/2 ml vial, 1,200 mg/30 ml vial) 1 CHLORAMPHENICOL chloramphenicol 3 chloramphenicol palmitate 3
PAGE 57 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MACROLIDES clarithromycin powder 3 E.E.S. 200 3 E.E.S. 400 3 ERY-TAB 3 ERYPED 200 2 ERYPED 400 3 ERYTHROCIN STEARATE 3 erythromycin (dr 250 mg cap, ec 250 mg cap) 1 erythromycin (250 mg, 500 mg) 3 HCG erythromycin 200 mg/5 ml gran 1 erythromycin es 400 mg tab 3 HCG
PCE 3 QUINOLONES
AVELOX 3 QL 21 / fill
AVELOX ABC PACK 3 QL 5 / day
CIPRO 10% SUSPENSION 3 QL 10 / day
CIPRO 5% SUSPENSION 3 QL 7 / day
CIPRO (250 MG TABLET, 500 MG TABLET) 3 QL 2 / day
CIPRO XR 1,000 MG TABLET 3 QL 14 / 1 rx
CIPRO XR 500 MG TABLET 3 QL 28 / fill ciprofloxacin 250 mg/5 ml susp 1 QL 7 / day ciprofloxacin 500 mg/5 ml susp 1 QL 10 / day ciprofloxacin er 1,000 mg tab 1 QL 14 / 1 rx ciprofloxacin er 500 mg tablet 1 QL 28 / fill
PAGE 58 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ciprofloxacin hcl (crystals, powder) 3 ciprofloxacin hcl (100 mg tab, 250 mg tab, 750 mg tab) 1 QL 2 / day
QL 2 / day ciprofloxacin hcl 500 mg tab 1 LCG
QL 7 / day FACTIVE 3 PA
LEVAQUIN 3 QL 30 / fill levofloxacin powder 3 levofloxacin (25 mg/ml solution, 250 mg/10 ml soln, 500 mg/20 ml soln) 1 levofloxacin (250 mg tablet, 500 mg tablet, 750 mg tablet) 1 QL 30 / fill levofloxacin hemihydrate 3 moxifloxacin hcl powder 3 moxifloxacin hcl 400 mg tablet 1 QL 21 / fill nalidixic acid 3 ofloxacin (300 mg tablet, 400 mg tablet) 1 QL 56 / fill
SULFONAMIDES (SYSTEMIC)
AZULFIDINE (500 MG TABLET, ENTAB 500 MG) 3 BACTRIM 3 BACTRIM DS 3 sulfacetamide 3 sulfacetamide sod monohydrate 3 sulfacetamide sodium powder 3 sulfadiazine powder 3 sulfadiazine 500 mg tablet 1 sulfadiazine sodium 3
PAGE 59 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sulfamethoxazole 3 sulfamethoxazole-tmp ds tablet 1 LCG sulfamethoxazole-trimethoprim (ss tablet, susp) 1 sulfanilamide 3 sulfapyridine 3 sulfasalazine powder 3 sulfasalazine 500 mg tablet 1 sulfasalazine dr 1 sulfathiazole 3 SULFATRIM 1 sulfisoxazole 3 TETRACYCLINES
ACTICLATE 3 ST
ADOXA 3 ST
AVIDOXY 1 demeclocycline hcl 1
QL 7/ rx DORYX DR 200 MG TABLET 3 ST
DORYX DR 50 MG TABLET 3 ST
DORYX MPC 3 ST doxycycline hyclate (50 mg cap, 100 mg cap, 100 mg tab) 1 doxycycline hyclate powder 3 doxycycline hyclate (75 mg tab, 150 mg tab) 3 ST
QL 7/ rx doxycycline hyc dr 200 mg tab 3 HCG doxycycline hyclate (dr 50 mg tab, dr 75 mg tab, dr 100 mg tab, dr 150 mg tab) 3 HCG
PAGE 60 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS doxycycline ir-dr 1 QL 1 / day doxycycline mono 150 mg cap 1 QL 30 / fill doxycycline monohydrate powder 3 doxycycline monohydrate (25 mg/5 ml susp, mono 50 mg cap, mono 50 mg tablet, mono 75 mg capsule, mono 75 mg tablet, 1 mono 100 mg cap, mono 100 mg tablet, mono 150 mg tablet)
MINOCIN (50 MG CAP, 75 MG CAP, 100 MG CAP) 3 minocycline hcl (50 mg capsule, hcl 50 mg tablet, 75 mg capsule, hcl 75 mg tablet, 100 mg capsule, hcl 100 mg tablet) 1 minocycline hcl powder 3
QL 3 / day minocycline er 45 mg tablet 3 HCG
QL 1 / day minocycline hcl er (er 90 mg tablet, er 135 mg tablet) 3 HCG
MONDOXYNE NL 1 MONODOX 3 MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 1 OKEBO 1
QL 1 / day ORACEA 3 ST oxytetracycline hcl 3
PYLERA 2 QL 120 / 365 days
QL 1 / day SOLODYN 3 ST
TARGADOX 3 ST tetracycline hcl (250 mg capsule, 500 mg capsule) 3 HCG tetracycline hcl powder 3
PAGE 61 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VIBRAMYCIN (25 MG/5 ML SUSP, 50 MG/5 ML SYRUP, 100 MG CAPSULE) 3 ST ANTIBACTERIALS, MISCELLANEOUS
BACITRACINS
BACIIM 1 bacitracin (unit vial, units vial) 1 GLYCOPEPTIDES
VANCOCIN HCL 3 vancomycin hcl (125 mg capsule, 250 mg capsule) 3 HCG vancomycin hcl powder 3 vancomycin 125 mg/2.5 ml oral 1 LINCOMYCINS
CLEOCIN HCL 3 QL 4 / day
CLEOCIN PALMITATE 3 QL 70/ day
CLEOCIN PHOS 150 MG/ML VIAL 3 MED Medical Drug
CLEOCIN PHOSPHATE (9 G/60 ML VIAL, 300 MG/2 ML VIAL, 600 MG/4 ML VIAL, 900 MG/6 ML VIAL) 3 clindamycin hcl (75 mg capsule, 150 mg capsule, 300 mg 4 / day capsule) 1 QL clindamycin hcl powder 3 clindamycin palmitate hcl 1 QL 70/ day clindamycin pediatric 1 QL 70/ day clindamycin phosphate (phos crystals, phosphate powder) 3 clindamycin phosphate (9 g/60 ml vial, 300 mg/2 ml vl, 600 mg/4 ml vl, 900 mg/6 ml vl) 1
LINCOCIN 3 lincomycin hcl powder 3
PAGE 62 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS lincomycin hcl (3 gm/10 ml vial, 600 mg/2 ml vl) 1 QL 10 / day
OXAZOLIDINONES linezolid 100 mg/5 ml susp 1 QL 900 / rx linezolid 600 mg tablet 1 QL 2 / day
QL 6 / 30 days SIVEXTRO 200 MG TABLET 3 PA
QL 900 / rx ZYVOX 100 MG/5 ML SUSPENSION 3 PA
QL 2 / day ZYVOX 600 MG TABLET 3 PA
POLYMYXINS colistimethate 1 colistimethate sodium 3 colistin sulfate 3 COLY-MYCIN M PARENTERAL 3 polymyxin b sulfate (50 million unit, 100 million unit, sulfate powder) 3 polymyxin b sulfate vial 1 RIFAMYCINS
MYCOBUTIN 3
PRIFTIN 3 QL 1.25 / day rifabutin 1 RIFADIN (150 MG CAPSULE, 300 MG CAPSULE) 3 RIFAMATE 3 rifampin (150 mg capsule, 300 mg capsule) 1 rifampin powder 3
PAGE 63 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RIFATER 3 rifaximin 3
XIFAXAN 3 PA
ANTICHOLINERGIC AGENTS
ANTIMUSCARINICS/ANTISPASMODICS
ANASPAZ 3 ATROPEN 3 atropine sulfate powder 3 atropine sulfate (0.05 mg/ml syringe, 0.1 mg/ml abboject, 0.1 mg/ml syringe, 0.4 mg/ml vial, 1 mg/ml vial, 8 mg/20 ml vial) 1
ATROVENT HFA 3 QL 1.29 / day
B-DONNA 1 belladonna 3 belladonna leaf powder 3 belladonna-phenobarbital 1 BENTYL 10 MG/ML AMPUL 3 BENTYL (10 MG CAPSULE, 20 MG TABLET) 3 CANTIL 3 chlordiazepoxide-clidinium 1 clidinium bromide 3 CUVPOSA 3 dicyclomine hcl (10 mg capsule, 10 mg/5 ml soln, 20 mg tablet) 1 LCG dicyclomine hcl powder 3 dicyclomine 20 mg/2 ml vial 1 diphenoxylate-atropine (diphenoxylat-atrop 2.5-0.025/5, diphenoxylate-atrop 2.5-0.025) 1
DONNATAL (ELIXIR, TABLET) 3
PAGE 64 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DUODOTE 3 ED-SPAZ 1 glycopyrrolate powder 3 glycopyrrolate (1 mg tablet, 2 mg tablet) 1
QL 30 / day hydrocodone-homatropine mbr (soln, syrup) 1 AL At least 2 yrs old
QL 6 / day hydrocodone-homatropine 5-1.5 1 AL At least 6 yrs old
QL 30 / day HYDROMET 1 AL At least 2 yrs old hyoscyamine sulfate (0.125 mg odt, 0.125 mg tab sl, 0.125 mg/5 ml elix, 0.125 mg/ml drop, sulf 0.125 mg tab) 1 hyoscyamine sulfate powder 3 hyoscyamine sulfate er 1 hyoscyamine sulfate sr 1 HYOSYNE (0.125 MG/ML DROP, 125 MCG/5 ML ELIXIR) 1
INCRUSE ELLIPTA 2 QL 1 / day ipratropium bromide powder 3 ipratropium br 0.02% soln 1 QL 12.5 / day
LEVBID 3 LEVSIN 0.5 MG/ML AMPUL 3 LEVSIN 0.125 MG TABLET 3 LEVSIN-SL 3 LIBRAX 3 LOMOTIL 3 methscopolamine bromide powd 3 methscopolamine bromide (2.5 mg tb, 5 mg tab) 1
PAGE 65 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NULEV 1 OSCIMIN (0.125 MG ODT, 0.125 MG TABLET) 1 OSCIMIN SL 1 OSCIMIN SR 1 PHENOHYTRO 1 propantheline bromide powder 3 propantheline 15 mg tablet 1 ROBINUL 1 MG TABLET 3 ROBINUL (0.2 MG/ML VIAL, 0.4 MG/2 ML VIAL, 1 MG/5 ML VIAL, 4 MG/20 ML VIAL) 3
ROBINUL FORTE 3 scopolamine hbr powder 3 scopolamine 0.4 mg/ml vial 1 scopolamine methyl nitrate 3
QL 2 / day SEEBRI NEOHALER 3 PA AL At least 18 yrs old
SPIRIVA 2 QL 1 / day
SPIRIVA RESPIMAT 2 QL 1 / day
STIOLTO RESPIMAT 2 QL 0.134 / day
SYMAX 1 SYMAX DUOTAB 3 SYMAX-SL 1 SYMAX-SR 1
QL 6 / day TUSSIGON 1 AL At least 6 yrs old
PAGE 66 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIPARKINSONIAN AGENTS benztropine mesylate (0.5 mg tab, 1 mg tablet, 2 mg tablet) 1 benztropine mesylate (2 mg/2 ml ampule, 2 mg/2 ml vial) 1 COGENTIN 3 trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elx, 5 mg tablet) 1 ANTICOAGULANTS
ANTICOAGULANTS, MISCELLANEOUS
ACD-A 3 citrate phosphate dextrose 3 sodium citrate 4% soln 1 sodium citrate (lock flush, syringe) 1 COUMARIN DERIVATIVES
COUMADIN 2 dicumarol 3 JANTOVEN (1 MG TABLET, 2.5 MG TABLET, 3 MG TABLET, 4 MG TABLET, 5 MG TABLET) 1 LCG JANTOVEN (2 MG TABLET, 6 MG TABLET, 7.5 MG TABLET, 10 MG TABLET) 1 warfarin sodium powder 3 warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) 1 LCG warfarin sodium (6 mg tablet, 7.5 mg tablet, 10 mg tablet) 1 DIRECT FACTOR XA INHIBITORS
ARIXTRA (2.5 MG/0.5 ML SYRINGE, 5 MG/0.4 ML SYRINGE) 5 S
ARIXTRA (7.5 MG/0.6 ML SYRINGE, 10 MG/0.8 ML SYRINGE) 5 S
QL 2 / day ELIQUIS 3 PA
PAGE 67 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fondaparinux 5 mg/0.4 ml syr 5 S fondaparinux sodium (2.5 mg/0.5 ml syr, 7.5 mg/0.6 ml syr, 10 mg/0.8 ml syr) 5 S
QL 1 / day SAVAYSA 3 PA
XARELTO STARTER PACK 2
XARELTO (10 MG TABLET, 20 MG TABLET) 2 QL 1 / day
XARELTO 15 MG TABLET 2 QL 2 / day
DIRECT THROMBIN INHIBITORS
IPRIVASK 5 S
PRADAXA 2 QL 2 / day
HEPARINS enoxaparin sodium (30 mg/0.3 ml syr, 40 mg/0.4 ml syr, 60 mg/0.6 ml syr, 80 mg/0.8 ml syr, 100 mg/ml syringe, 120 5 S mg/0.8 ml syr, 150 mg/ml syringe, 300 mg/3 ml vial) FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR, 7,500 UNITS/0.3 ML SYR, 10,000 UNITS/ML SYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML, 5 S 95,000 UNITS/3.8 ML VL) heparin sodium (sod 190 units/mg powd, sodium powder) 3 heparin sodium (40,000 units/4 ml vial, 50,000 units/10 ml vl, 50,000 units/5 ml vial) 1 heparin sodium (5,000 unit/ 0.5 ml, 5,000 unit/0.5 ml, 5,000 unit/ml syr, 20,000 unit/ml vl) 1 LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 ML SYRINGE, 60 MG/0.6 ML SYRINGE, 80 MG/0.8 ML SYRINGE, 100 MG/ML SYRINGE, 120 MG/0.8 ML SYRINGE, 150 MG/ML SYRINGE, 300 5 S MG/3 ML VIAL)
PAGE 68 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
APTIOM 3 BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET) 3
QL 20 / day BRIVIACT 10 MG/ML ORAL SOLN 3 PA
QL 4 / day BRIVIACT (10 MG TABLET, 50 MG TABLET) 3 PA
QL 2 / day BRIVIACT 100 MG TABLET 3 PA
QL 8 / day BRIVIACT 25 MG TABLET 3 PA
QL 3 / day BRIVIACT 75 MG TABLET 3 PA carbamazepine powder 3 carbamazepine (100 mg tab chew, 100 mg/5 ml susp, 200 mg tablet) 1 carbamazepine er (er 100 mg cap, er 200 mg cap, er 300 mg cap) 1 carbamazepine er (er 100 mg tablet, er 200 mg tablet, er 400 mg tablet) 3 HCG
CARBATROL 2 DEPAKENE (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 3 DEPAKOTE 3 DEPAKOTE ER 2 DEPAKOTE SPRINKLE 2 divalproex sodium (dr 125 mg cap sprnk, sod dr 125 mg tab, sod dr 250 mg tab, sod dr 500 mg tab) 1
PAGE 69 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS divalproex sodium er 1 EPITOL 1 EQUETRO 3 felbamate (400 mg tablet, 600 mg tablet, 600 mg/5 ml susp) 1 FELBATOL (400 MG TABLET, 600 MG TABLET, 600 MG/5 ML SUSP) 3 PA
FYCOMPA 0.5 MG/ML ORAL SUSP 3 QL 6 / day
FYCOMPA (2 MG TABLET, 2 MG-4 MG TABLET KIT, 4 MG TABLET, 1 / day 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) 3 QL
GABITRIL (12 MG TABLET, 16 MG TABLET) 2 GABITRIL (2 MG TABLET, 4 MG TABLET) 3 KEPPRA (100 MG/ML ORAL SOLN, 250 MG TABLET, 500 MG TABLET, 750 MG TABLET, 1,000 MG TABLET) 3
KEPPRA XR 3 LAMICTAL (5 MG DISPER TABLET, 25 MG DISPER TABLET, 25 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET) 3
LAMICTAL (BLUE) 3 LAMICTAL (GREEN) 3 LAMICTAL (ORANGE) 3 LAMICTAL ODT 3 LAMICTAL ODT (BLUE) 3 LAMICTAL ODT (GREEN) 3 LAMICTAL ODT (ORANGE) 3 LAMICTAL XR 3 LAMICTAL XR (BLUE) 3 LAMICTAL XR (GREEN) 3 LAMICTAL XR (ORANGE) 3 lamotrigine powder 3
PAGE 70 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS lamotrigine (5 mg disper tablet, 25 mg disper tab, 25 mg tablet, 25 mg tb start kit, 100 mg tablet, 150 mg tablet, 200 mg tablet) 1 lamotrigine (blue) 1 lamotrigine (green) 1 lamotrigine (orange) 1 lamotrigine er 3 HCG lamotrigine odt 1 lamotrigine odt (blue) 1 lamotrigine odt (green) 1 lamotrigine odt (orange) 1 levetiracetam powder 3 levetiracetam 500 mg/5 ml soln 1 QL 946 / 30 days levetiracetam (100 mg/ml soln, 250 mg tablet, 500 mg tablet, 750 mg tablet, 1,000 mg tablet) 1 levetiracetam er 1
QL 2 / day LYRICA (225 MG CAPSULE, 300 MG CAPSULE) 3 PA
LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, QL 3 / day 3 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE) PA
QL 30 / day LYRICA 20 MG/ML ORAL SOLUTION 3 PA magnesium chl 200 mg/ml vial 1 oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5 ml susp, 600 mg tablet) 1
OXTELLAR XR 3
QL 3 / day POTIGA (200 MG TABLET, 300 MG TABLET, 400 MG TABLET) 3 PA
QL 9 / day POTIGA 50 MG TABLET 3 PA
PAGE 71 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS pregabalin 3 QUDEXY XR 3 ROWEEPRA 1
QL 6 / day SABRIL (500 MG POWDER PACKET, 500 MG TABLET) 5 PA S sodium valproate 3
QL 3 / day SPRITAM 3 AL At least 4 yrs old
TEGRETOL (100 MG/5 ML SUSP, 200 MG TABLET) 3 TEGRETOL XR 2 tiagabine hcl 1 TOPAMAX (15 MG SPRINKLE CAP, 25 MG SPRINKLE CAP, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET, 200 MG TABLET) 2 topiramate 15 mg sprinkle cap 1 LCG topiramate powder 3 topiramate (25 mg sprinkle cap, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) 1 topiramate er 3 HCG
TRILEPTAL (150 MG TABLET, 300 MG TABLET, 300 MG/5 ML SUSP, 600 MG TABLET) 3
TROKENDI XR 3 valproic acid liquid 3 valproic acid (250 mg capsule, 250 mg/5 ml soln, 500 mg/10 ml sol) 1
QL 6 / day vigabatrin 5 PA S
VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET, STARTER KIT) 3
PAGE 72 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZONEGRAN 2 zonisamide (25 mg capsule, 100 mg capsule) 1 zonisamide 50 mg capsule 1 LCG zonisamide powder 3 BARBITURATES (ANTICONVULSANTS)
BREVITAL SODIUM 3 MYSOLINE 3 phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elix, 20 mg/5 ml soln, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 1 64.8 mg tablet, 97.2 mg tablet, 100 mg tablet) phenobarbital sodium 1 primidone powder 3 primidone (50 mg tablet, 250 mg tablet) 1 BENZODIAZEPINES (ANTICONVULSANTS)
ATIVAN (0.5 MG TABLET, 1 MG TABLET) 3 QL 3 / day
ATIVAN 2 MG TABLET 3 QL 5 / day
ATIVAN (2 MG/ML VIAL, 4 MG/ML VIAL, 20 MG/10 ML VIAL, 40 MG/10 ML VIAL) 3 clonazepam powder 3 clonazepam (2 mg odt, 2 mg tablet) 1 QL 10 / day clonazepam (0.125 mg dis tab, 0.125 mg odt, 0.25 mg odt, 0.5 mg dis tablet, 0.5 mg odt, 0.5 mg tablet, 1 mg dis tablet, 1 mg 1 QL 3 / day odt, 1 mg tablet) clorazepate 15 mg tablet 1 QL 6 / day clorazepate 3.75 mg tablet 1 QL 24 / day clorazepate 7.5 mg tablet 1 QL 12 / day
DIASTAT 3 QL 0.07 / day
DIASTAT ACUDIAL 3 QL 0.07 / day
PAGE 73 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS diazepam (2.5 mg rectal gel sys, 10 mg rectal gel syst, 20 mg 0.07 / day rectal gel syst) 1 QL diazepam powder 3 diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml oral soln, 5 mg/5 ml solution, 5 mg/ml oral conc, 5 mg/ml vial, 10 mg tablet, 10 mg/2 ml carpuject, 10 mg/2 ml isecure, 10 mg/2 ml syringe, 50 1 mg/10 ml vial)
KLONOPIN (0.5 MG TABLET, 1 MG TABLET) 3 QL 3 / day
KLONOPIN 2 MG TABLET 3 QL 10 / day lorazepam (2 mg tablet, 2 mg/ml oral concent) 1 QL 5 / day lorazepam powder 3 lorazepam (0.5 mg tablet, 1 mg tablet) 1 QL 3 / day lorazepam (2 mg/ml carpuject, 2 mg/ml syringe, 2 mg/ml vial, 4 mg/ml carpuject, 4 mg/ml vial, 20 mg/10 ml vial, 40 mg/10 ml 1 vial)
LORAZEPAM INTENSOL 1 QL 5 / day
PA ONFI (2.5 MG/ML SUSPENSION, 10 MG TABLET, 20 MG TABLET) 5 S
TRANXENE T-TAB 3.75 MG 3 QL 24 / day
TRANXENE T-TAB 7.5 MG 3 QL 12 / day
VALIUM 3 HYDANTOINS
CEREBYX 3 PEGANONE 3 SUCCINIMIDES
CELONTIN 3 ethosuximide (250 mg capsule, 250 mg/5 ml soln) 1 ethosuximide powder 3
PAGE 74 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 2 ANTIDEPRESSANTS
ANTIDEPRESSANTS, MISCELLANEOUS
APLENZIN 3 QL 1 / day benactyzine hcl 3
QL 2 / day BUPROBAN 0 HCR bupropion hcl powder 3 bupropion hcl 100 mg tablet 1 QL 5 / day bupropion hcl 75 mg tablet 1 QL 6 / day bupropion hcl sr 100 mg tablet 1 QL 4 / day
QL 2 / day bupropion hcl sr 150 mg tablet 1 HCR bupropion hcl sr 200 mg tablet 1 QL 2 / day bupropion hcl xl 150 mg tablet 1 QL 3 / day bupropion hcl xl 300 mg tablet 1 QL 1 / day
FORFIVO XL 3 QL 1 / day mirtazapine 7.5 mg tablet 1 QL 2 / day mirtazapine (15 mg odt, 15 mg tablet, 30 mg odt, 30 mg tablet, 1 / day 45 mg odt, 45 mg tablet) 1 QL mirtazapine anhydrous 3 REMERON (15 MG SOLTAB, 15 MG TABLET, 30 MG SOLTAB, 30 1 / day MG TABLET, 45 MG SOLTAB, 45 MG TABLET) 3 QL
WELLBUTRIN 100 MG TABLET 3 QL 5 / day
WELLBUTRIN 75 MG TABLET 3 QL 6 / day
WELLBUTRIN SR (150 MG TABLET, 200 MG TABLET) 3 QL 2 / day
PAGE 75 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
WELLBUTRIN SR 100 MG TABLET 3 QL 4 / day
WELLBUTRIN XL 150 MG TABLET 3 QL 3 / day
WELLBUTRIN XL 300 MG TABLET 3 QL 1 / day
ZYBAN 3 QL 2 / day
MONOAMINE OXIDASE INHIBITORS
AZILECT 3 ELDEPRYL 3
EMSAM 3 QL 1 / day
MARPLAN 3 QL 6 / day
NARDIL 3 QL 6 / day
PARNATE 3 QL 6 / day phenelzine sulfate powder 3 phenelzine sulfate 15 mg tab 1 QL 6 / day rasagiline mesylate powder 3 rasagiline mesylate (0.5 mg tab, 1 mg tab) 1 selegiline hcl (5 mg capsule, 5 mg tablet) 1 selegiline hcl powder 3 tranylcypromine sulfate 1 QL 6 / day
ZELAPAR 3 SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR
CYMBALTA (20 MG CAPSULE, 30 MG CAPSULE) 3 QL 1 / day
CYMBALTA 60 MG CAPSULE 3 QL 2 / day
QL 1 / day desvenlafaxine er (er 50 mg tab, er 50 mg tablet) 3 HCG
QL 1 / day desvenlafaxine er 100 mg tab 3 HCG
PAGE 76 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day desvenlafaxine fumarate er 3 HCG
QL 1 / day desvenlafaxine succinate er 3 HCG duloxetine hcl (dr 20 mg cap, dr 30 mg cap) 1 QL 1 / day duloxetine hcl (dr 40 mg cap, dr 60 mg cap) 1 QL 2 / day duloxetine hcl powder 3
EFFEXOR XR (37.5 MG CAPSULE, 150 MG CAPSULE) 3 QL 1 / day
EFFEXOR XR 75 MG CAPSULE 3 QL 3 / day
FETZIMA (20-40 MG TITRATION PAK, ER 20 MG CAPSULE, ER 40 QL 1 / day 3 MG CAPSULE, ER 80 MG CAPSULE, ER 120 MG CAPSULE) ST
IRENKA 3 QL 2 / day
KHEDEZLA 3 QL 1 / day
PRISTIQ 3 QL 1 / day
SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 QL 2 / day 3 MG TABLET, TITRATION PACK) ST venlafaxine hcl (37.5 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet) 1 venlafaxine hcl 25 mg tablet 1 LCG venlafaxine hcl er 75 mg cap 1 QL 3 / day venlafaxine hcl er (er 37.5 mg cap, er 37.5 mg tab, er 75 mg tab, 1 / day er 150 mg cap, er 150 mg tab, er 225 mg tab) 1 QL SELECTIVE-SEROTONIN REUPTAKE INHIBITORS
BRISDELLE 3 QL 1 / day
CELEXA 3 QL 1 / day
PAGE 77 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS citalopram hbr 10 mg/5 ml soln 1 QL 20 / day
QL 1 / day citalopram hbr (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 LCG escitalopram oxalate 5 mg/5 ml 1 QL 20 / day escitalopram 20 mg tablet 1 QL 1 / day escitalopram oxalate (5 mg tablet, 10 mg tablet) 1 QL 1.5 / day fluoxetine dr 1 QL 0.142 / day
QL 1 / day fluoxetine hcl 10 mg capsule 1 LCG
QL 4 / day fluoxetine hcl 20 mg capsule 1 LCG fluoxetine hcl 40 mg capsule 1 QL 2 / day fluoxetine hcl powder 3 fluoxetine 20 mg/5 ml solution 1 QL 20 / day
QL 1.5 / day fluoxetine hcl 10 mg tablet 1 LCG fluoxetine hcl 20 mg tablet 1 QL 4 / day fluoxetine hcl 60 mg tablet 1 QL 1.5 / day fluvoxamine maleate (25 mg tab, 50 mg tab) 1 QL 1 / day fluvoxamine maleate 100 mg tab 1 QL 3 / day
QL 2 / day fluvoxamine maleate er 3 HCG
LEXAPRO 5 MG/5 ML SOLUTION 3 QL 20 / day
LEXAPRO (5 MG TABLET, 10 MG TABLET) 3 QL 1.5 / day
PAGE 78 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LEXAPRO 20 MG TABLET 3 QL 1 / day
QL 1 / day olanzapine-fluoxetine hcl 3 AL At least 10 yrs old HCG paroxetine cr (cr 25 mg tablet, cr 37.5 mg tablet) 1 QL 2 / day paroxetine cr 12.5 mg tablet 1 QL 1 / day paroxetine er (er 25 mg tablet, er 37.5 mg tablet) 1 QL 2 / day paroxetine er 12.5 mg tablet 1 QL 1 / day
QL 1.5 / day paroxetine hcl 10 mg tablet 1 LCG
QL 1 / day paroxetine hcl 20 mg tablet 1 LCG paroxetine hcl 30 mg tablet 1 QL 2 / day paroxetine hcl 40 mg tablet 1 QL 1 / day paroxetine mesylate 1 QL 1 / day
PAXIL 10 MG/5 ML SUSPENSION 3 QL 42 / day
PAXIL (20 MG TABLET, 40 MG TABLET) 3 QL 1 / day
PAXIL 10 MG TABLET 3 QL 1.5 / day
PAXIL 30 MG TABLET 3 QL 2 / day
PAXIL CR (CR 25 MG TABLET, CR 37.5 MG TABLET) 3 QL 2 / day
PAXIL CR 12.5 MG TABLET 3 QL 1 / day
PEXEVA 3 QL 1 / day
PROZAC 10 MG PULVULE 3
PROZAC 20 MG PULVULE 3 QL 4 / day
PAGE 79 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PROZAC 40 MG PULVULE 3 QL 2 / day
PROZAC WEEKLY 3 QL 0.15 / day
SARAFEM 10 MG TABLET 3 QL 1.5 / day
SARAFEM 20 MG TABLET 3 QL 4 / day sertraline 20 mg/ml oral conc 1 QL 10 / day sertraline hcl powder 3
QL 1.5 / day sertraline hcl (25 mg tablet, 50 mg tablet) 1 LCG
QL 2 / day sertraline hcl 100 mg tablet 1 LCG
QL 1 / day SYMBYAX 3 AL At least 10 yrs old
ZOLOFT 20 MG/ML ORAL CONC 3 QL 10 / day
ZOLOFT (25 MG TABLET, 50 MG TABLET) 3 QL 1.5 / day
ZOLOFT 100 MG TABLET 3 QL 2 / day
SEROTONIN MODULATORS
QL 1 / day BRINTELLIX 3 ST nefazodone hcl 100 mg tablet 1 QL 6 / day nefazodone hcl 150 mg tablet 1 QL 4 / day nefazodone hcl 200 mg tablet 1 QL 3 / day nefazodone hcl 250 mg tablet 1 QL 2.5 / day nefazodone hcl 50 mg tablet 1 QL 12 / day trazodone hcl powder 3
PAGE 80 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 4 / day trazodone 100 mg tablet 1 LCG
QL 2 / day trazodone 150 mg tablet 1 LCG trazodone 300 mg tablet 1 QL 1 / day
QL 3 / day trazodone 50 mg tablet 1 LCG
QL 1 / day TRINTELLIX (5 MG TABLET, 10 MG TABLET, 20 MG TABLET) 3 ST
VIIBRYD 10-20 MG STARTER PACK 3
VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL 1 / day
TRICYCLICS, OTHER NOREPI-RU INHIBITORS amitriptyline hcl powder 3 amitriptyline hcl (10 mg tab, 25 mg tab, 50 mg tab, 75 mg tab, 100 mg tab, 150 mg tab) 1 LCG amoxapine 1 ANAFRANIL 3 chlordiazepoxide-amitriptyline 1 clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mg capsule) 3 HCG clomipramine hcl powder 3 desipramine hcl powder 3 desipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet) 3 HCG doxepin hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 100 mg capsule) 1 LCG doxepin hcl (10 mg/ml oral conc, 75 mg capsule, 150 mg capsule) 1
PAGE 81 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS doxepin hcl powder 3 imipramine hcl powder 3 imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) 1 LCG imipramine pamoate 3 HCG maprotiline hcl 1 NORPRAMIN 3 nortriptyline hcl (10 mg/5 ml sol, hcl 10 mg cap, hcl 25 mg cap, hcl 50 mg cap, hcl 75 mg cap) 1 nortriptyline hcl powder 3 PAMELOR 3 perphenazine-amitriptyline 1 protriptyline hcl 1
SILENOR 3 QL 1 / day
SURMONTIL 3 TOFRANIL 3 TOFRANIL-PM 3 trimipramine maleate 1 ANTIDIABETIC AGENTS
ALPHA-GLUCOSIDASE INHIBITORS acarbose 100 mg tablet 1 QL 3 / day acarbose 25 mg tablet 1 QL 12 / day acarbose 50 mg tablet 1 QL 6 / day
GLYSET 3 QL 3 / day miglitol 1 QL 3 / day
PRECOSE 100 MG TABLET 3 QL 3 / day
PRECOSE 25 MG TABLET 3 QL 12 / day
PAGE 82 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PRECOSE 50 MG TABLET 3 QL 6 / day
AMYLINOMIMETICS
SYMLINPEN 120 2 QL 0.4 / day
SYMLINPEN 60 2 QL 0.2 / day
ANTIDIABETIC AGENTS, MISCELLANEOUS
PA KORLYM 5 S
WELCHOL 3.75G PACKET 2 QL 1 / day
WELCHOL 625 MG TABLET 2 QL 6 / day
BIGUANIDES
ACTOPLUS MET 3 QL 3 / day
QL 3 / day ACTOPLUS MET XR 15-1,000 MG TB 2 ST
QL 1 / day ACTOPLUS MET XR 30-1,000 MG TB 2 ST
QL 2 / day AVANDAMET 2 PA glipizide-metformin (2.5-500 mg, 5-500 mg) 1 QL 4 / day glipizide-metformin 2.5-250 mg 1 QL 8 / day
GLUCOPHAGE 1,000 MG TABLET 3 QL 2.5 / day
GLUCOPHAGE 500 MG TABLET 3 QL 5 / day
GLUCOPHAGE 850 MG TABLET 3 QL 3 / day
GLUCOPHAGE XR 500 MG TAB 3 QL 5 / day
GLUCOPHAGE XR 750 MG TAB 3 QL 3 / day
PAGE 83 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GLUCOVANCE 3 QL 4 / day
QL 8 / day glyburid-metformin 1.25-250 mg 1 LCG glyburide-metformin hcl (2.5-500 mg, 5-500 mg) 1 QL 4 / day
QL 2 / day INVOKAMET 2 ST
QL 2 / day INVOKAMET XR 2 ST
QL 2 / day JANUMET 2 ST
QL 2 / day JANUMET XR (50-1,000 MG TABLET, 50-500 MG TABLET) 2 ST
QL 1 / day JANUMET XR 100-1,000 MG TABLET 2 ST
QL 2 / day JENTADUETO 2 ST
QL 1 / day JENTADUETO XR 2 ST metformin hcl powder 3
QL 2.5 / day metformin hcl 1,000 mg tablet 1 LCG
QL 5 / day metformin hcl 500 mg tablet 1 LCG
QL 3 / day metformin hcl 850 mg tablet 1 LCG
QL 5 / day metformin hcl er 500 mg tablet 1 C Only Glucophage ER generic covered LCG
PAGE 84 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 3 / day metformin hcl er 750 mg tablet 1 C Only Glucophage ER generic covered metformin hydrochloride 3
QL 3 / day pioglitazone-metformin 3 HCG
PRANDIMET 3 QL 5 / day repaglinide-metformin hcl 1 QL 5 / day
RIOMET 3 QL 25 / day
QL 2 / day SYNJARDY 2 ST
SYNJARDY XR (5-1,000 MG TABLET, 10-1,000 MG TABLET, 12.5- QL 2 / day 2 1,000 MG TAB) ST
QL 1 / day SYNJARDY XR 25-1,000 MG TABLET 2 ST
DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS
QL 1 / day GLYXAMBI 3 PA
QL 1 / day JANUVIA 2 ST
QL 1 / day TRADJENTA 2 ST
INCRETIN MIMETICS
QL 0.15 / day BYDUREON 2 ST
QL .15 / day BYDUREON PEN 2 ST
PAGE 85 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 0.8 / day BYETTA 10 MCG DOSE PEN INJ 2 ST
QL 0.04 / day BYETTA 5 MCG DOSE PEN INJ 2 ST
QL 0.5 / day SAXENDA 3 PA AL At least 18 yrs old
QL 0.6 / day SOLIQUA 100-33 2 PA
QL 0.08 / day TRULICITY 2 ST
QL 0.3 / day VICTOZA 2-PAK 2 ST
QL 0.3 / day VICTOZA 3-PAK 2 ST
INSULINS
AFREZZA 3 PA
HUMALOG (100 UNITS/ML CARTRIDGE, 100 UNITS/ML VIAL) 2 HUMALOG KWIKPEN U-100 2 HUMALOG KWIKPEN U-200 2 HUMALOG MIX 50-50 2 HUMALOG MIX 50-50 KWIKPEN 2 HUMALOG MIX 75-25 2 HUMALOG MIX 75-25 KWIKPEN 2 HUMULIN R U-500 2 HUMULIN R U-500 KWIKPEN 2
PAGE 86 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LANTUS 2 LANTUS SOLOSTAR 2 TOUJEO SOLOSTAR 2 MEGLITINIDES nateglinide 1 QL 3 / day
PRANDIN (0.5 MG TABLET, 1 MG TABLET) 3 QL 4 / day
PRANDIN 2 MG TABLET 3 QL 8 / day repaglinide (0.5 mg tablet, 1 mg tablet) 1 QL 4 / day repaglinide 2 mg tablet 1 QL 8 / day
STARLIX 3 QL 3 / day
SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB
QL 1 / day INVOKANA 2 ST
QL 1 / day JARDIANCE 2 ST
SULFONYLUREAS
AMARYL 3 chlorpropamide 100 mg tablet 1 chlorpropamide 250 mg tablet 1 QL 3 / day
DIABETA 3
DUETACT 3 QL 1 / day glimepiride 1 LCG glipizide powder 3 glipizide (5 mg tablet, 10 mg tablet) 1 LCG glipizide er 1 LCG
PAGE 87 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS glipizide xl 1 LCG
GLUCOTROL 3 GLUCOTROL XL 3 glyburide powder 3 glyburide (1.25 mg tablet, 2.5 mg tablet, 5 mg tablet) 1 LCG glyburide micronized 1 LCG
GLYNASE 3 pioglitazone-glimepiride 1 QL 1 / day tolazamide 250 mg tablet 1 QL 4 / day tolazamide 500 mg tablet 1 QL 2 / day tolbutamide 1 QL 6 / day
THIAZOLIDINEDIONES
ACTOS 3 QL 1 / day
QL 3 / day AVANDIA 2 MG TABLET 2 PA
QL 2 / day AVANDIA 4 MG TABLET 2 PA
QL 1 / day AVANDIA 8 MG TABLET 2 PA pioglitazone hcl 1 QL 1 / day
ANTIEMETICS
5-HT3 RECEPTOR ANTAGONISTS
QL 0.15 / day AKYNZEO 5 PA S
PAGE 88 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANZEMET (50 MG TABLET, 100 MG TABLET) 3 QL 0.15 / day granisetron hcl 1 mg tablet 1 QL 6 / 30 days ondansetron hcl (4 mg/2 ml isecure, hcl 4 mg/2 ml amp, hcl 4 mg/2 ml syr, hcl 4 mg/2 ml vial) 5 S ondansetron hcl powder 3 ondansetron 4 mg/5 ml solution 1 QL 20 / day
QL 24 / 30 days ondansetron hcl (4 mg tablet, 8 mg tablet) 1 Max allowable- 3/day C with max of 24 / 30 days ondansetron hcl 24 mg tablet 1 QL 3 days
QL 24 / 30 days ondansetron odt 1 Max allowable- 3/day C with max of 24 / 30 days
QL 0.144 / day SANCUSO 5 S
ZOFRAN 4 MG/5 ML ORAL SOLN 3 QL 20 / day
QL 24 / 30 days ZOFRAN (4 MG TABLET, 8 MG TABLET) 3 Max allowable- 3/day C with max of 24 / 30 days
QL 24 / 30 days ZOFRAN ODT 3 Max allowable- 3/day C with max of 24 / 30 days
ZUPLENZ 3 QL 24 / 30 days
ANTIEMETICS, MISCELLANEOUS aprepitant 125-80-80 mg pack 1 QL 3/ fill aprepitant (40 mg capsule, 125 mg capsule) 1 QL 0.08 / day
PAGE 89 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS aprepitant 80 mg capsule 1 QL 0.15 / day
QL 0.67 / day CESAMET 5 PA S
QL 4 / day DICLEGIS 3 PA diphenidol hcl 3
QL 5 / day dronabinol 3 HCG
EMEND TRIPACK 3 QL 3/ fill
EMEND (40 MG CAPSULE, 125 MG CAPSULE) 3 QL 0.08 / day
EMEND 80 MG CAPSULE 3 QL 0.15 / day
QL 5 / day MARINOL 3 PA scopolamine 1
QL 13 / day SYNDROS 3 PA AL At least 18 yrs old
TRANSDERM-SCOP 2
QL 0.15 / day VARUBI 90 MG TABLET 5 PA S
ANTIHISTAMINES (GI DRUGS)
ANTIVERT 3 COMPAZINE 25 MG SUPPOSITORY 1 COMPAZINE (5 MG TABLET, 10 MG TABLET) 3
PAGE 90 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS COMPRO 1 dimenhydrinate 50 mg/ml vial 1 meclizine hcl powder 3 meclizine hcl (12.5 mg tablet, 25 mg tablet) 1 prochlorperazine 1 prochlorperazine edisylate pow 3 prochlorperazine edisylate (5 mg/ml vial, 10 mg/2 ml vl) 1 prochlorperazine mal powder 3 prochlorperazine maleate (5 mg tablet, 10 mg tab) 1 TIGAN 300 MG CAPSULE 3 TIGAN 100 MG/ML VIAL 3 trimethobenzamide 300 mg cap 1 trimethobenzamide hcl powder 3 ANTIFUNGAL (SYSTEMIC)
ALLYLAMINES
LAMISIL (125 MG GRANULES PACKET, 187.5 MG GRANULES PACK, 250 MG TABLET) 3 terbinafine hcl powder 3 terbinafine hcl 250 mg tablet 1 ANTIFUNGALS, MISCELLANEOUS
GRIFULVIN V 3 GRIS-PEG 3 griseofulvin powder 3 griseofulvin (125 mg/5 ml susp, micro 500 mg tab) 3 HCG griseofulvin micronized 3 griseofulvin ultramicrosize 1 LUGOL'S SOLUTION 1
PAGE 91 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS potassium iodide (crystals, granules) 3 sodium caprylate 3 SSKI 3 strong iodine 1 triacetin 1 AZOLES
CRESEMBA 186 MG CAPSULE 3 PA
DIFLUCAN (10 MG/ML SUSPENSION, 40 MG/ML SUSPENSION, 50 MG TABLET, 100 MG TABLET, 200 MG TABLET) 3
QL 0.4 / day DIFLUCAN 150 MG TABLET 3 GL Female fluconazole powder 3 fluconazole (10 mg/ml susp, 40 mg/ml susp, 50 mg tablet, 100 mg tablet, 200 mg tablet) 1
QL 0.4 / day fluconazole 150 mg tablet 1 LCG itraconazole 100 mg capsule 1 itraconazole powder 3 itraconazole micronized 3 ketoconazole powder 3 ketoconazole 200 mg tablet 1 ketoconazole micronized 3 NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET) 3
ONMEL 3 PA
SPORANOX (10 MG/ML SOLUTION, 100 MG CAPSULE) 3
VFEND 40 MG/ML SUSPENSION 3 QL 20 / day
VFEND (50 MG TABLET, 200 MG TABLET) 3 QL 4 / day
PAGE 92 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS voriconazole powder 3
QL 20 / day voriconazole 40 mg/ml susp 3 HCG
QL 4 / day voriconazole (50 mg tablet, 200 mg tablet) 3 HCG
POLYENES amphotericin b powder 3 amphotericin b 50 mg vial 1 nystatin (100,000 unit/ml susp, 500,000 unit oral tab, 500,000 unit/5 ml sus, 50,000,000 units pwd, 150,000,000 units pwd, 1 500,000,000 units pwd) PYRIMIDINES
ANCOBON 3 flucytosine (250 mg capsule, 500 mg capsule) 1 flucytosine powder 3 ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)
ALLYLAMINES (SKIN AND MUCOUS MEMBRANE) naftifine hcl 1 NAFTIN (1% GEL, 2% CREAM, 2% GEL) 3 ANTIFULGALS (SKIN, MUCOUS MEMBRANE),MISC
ALA-QUIN 3 clioquinol 3 EXODERM 1 iodochlorohydroxyquinoline 3 sodium thiosulfate crystals 3 TRIPLE DYE 3 undecylenic acid 3
PAGE 93 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS zinc undecylenate 3 AZOLES (SKIN AND MUCOUS MEMBRANE) clotrimazole (crystalline, powder) 3 clotrimazole (1% cream, 1% solution, 10 mg troche) 1 clotrimazole-betamethasone (crm, lot) 1 econazole nitrate 1% cream 3 HCG econazole nitrate powder 3 ECOZA 3 ERTACZO 3 EXELDERM (CREAM, SOLUTION) 3 EXTINA 3 GYNAZOLE 1 3
QL 0.54 / day JUBLIA 3 PA AL At least 18 yrs old ketoconazole (cream, foam, shampoo) 1 LOTRISONE 3
QL 2 / day LUZU 3 PA miconazole 3 miconazole 3 3 GL Female miconazole nitrate 3 NIZORAL 3 ORAVIG 3 oxiconazole nitrate 3 HCG
OXISTAT (CREAM, LOTION) 3
QL 1.5 / day TERAZOL 3 3 GL Female
PAGE 94 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TERAZOL 7 3 QL 1.5 / day
QL 1.5 / day terconazole (0.4% cream, 0.8% cream, 80 mg suppository) 1 GL Female
VUSION 3 XOLEGEL 3
QL 1.5 / day zazole 1 GL Female
BENZYLAMINES (SKIN AND MUCOUS MEMBRANE)
MENTAX 3 HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)
CICLODAN 0.77% CREAM KIT 3 CICLODAN 0.77% CREAM 1
CICLODAN 8% SOLUTION 1 QL 0.22 / day ciclopirox (0.77% cream, 0.77% gel, 0.77% topical susp, 1% shampoo) 1 ciclopirox 8% solution 1 QL 0.22 / day ciclopirox olamine 3 CNL 8 3 LOPROX (0.77% TOPICAL SUSP, 1% SHAMPOO) 3
PENLAC 3 QL 0.22 / day
OXABOROLES
QL 0.67 / day KERYDIN 3 PA AL At least 18 yrs old
POLYENES (SKIN AND MUCOUS MEMBRANE)
NYAMYC 1
PAGE 95 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NYATA 100,000 UNIT/GM POWDER 1 nystatin (unit/gm cream, unit/gm powd, units/gm oint) 1 nystatin (1 billion unit powder, 2 billion unit powder, 5 billion unit powder, 10 billion unit powd, 15 billion unit powd, 50 million unit pwd, 100 million units pwd, 150 million unit pwd, 3 500 million unit pwd) nystatin-triamcinolone (cream, ointm) 3 HCG
NYSTOP 1 PEDIADERM AF 3 ANTIGLAUCOMA AGENTS
ALPHA-ADRENERGIC AGONISTS (EENT)
ALPHAGAN P 0.1% DROPS 2 QL 0.4 / day
ALPHAGAN P 0.15% EYE DROPS 3 QL 0.4 / day brimonidine tartrate (tartrate 0.15% drp, 0.2% eye drop) 1 QL 0.4 / day brimonidine tartrate powder 3
COMBIGAN 2 QL 0.334 / day
SIMBRINZA 3 QL 0.4 / day
BETA-ADRENERGIC BLOCKING AGENTS (EENT)
BETAGAN 3 QL 0.4 / day betaxolol hcl 0.5% eye drop 1 QL 0.54 / day
BETIMOL 0.25% EYE DROPS 3 QL 0.286 / day
BETIMOL 0.5% EYE DROPS 3 QL 0.334 / day
BETOPTIC S 3 QL 0.54 / day carteolol hcl 1 QL 0.334 / day
COSOPT 3 QL 0.334 / day
COSOPT PF 3 QL 2 / day
PAGE 96 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dorzolamide-timolol 1 QL 0.334 / day
ISTALOL 3 QL 0.286 / day levobunolol hcl 1 QL 0.4 / day metipranolol 1 QL 0.334 / day timolol 0.5% eye drops 1 QL 0.334 / day timolol maleate (0.25% eye drops, 0.25% gel-solution, 0.25% 0.286 / day gfs gel-solution, 0.5% gel-solution, 0.5% gfs gel-solution) 1 QL
TIMOPTIC 0.25% EYE DROPS 3 QL 0.286 / day
TIMOPTIC 0.5% EYE DROPS 3 QL 0.334 / day
TIMOPTIC OCUDOSE 3 QL 2 / day
TIMOPTIC-XE 3 QL 0.286 / day
CARBONIC ANHYDRASE INHIBITORS (EENT) acetazolamide er 500 mg cap 3 HCG acetazolamide powder 3 acetazolamide (125 mg tablet, 250 mg tablet) 1 acetazolamide sodium 1
AZOPT 2 QL 0.334 / day
DIAMOX SEQUELS 3 dorzolamide hcl 1 QL 0.4 / day methazolamide powder 3 methazolamide (25 mg tablet, 50 mg tablet) 1 NEPTAZANE 3
TRUSOPT 3 QL 0.4 / day
MIOTICS acetylcholine chloride 3
PAGE 97 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS carbachol 3
ISOPTO CARPINE 3 QL 0.54 / day
MIOCHOL-E 3 MIOSTAT 3 PHOSPHOLINE IODIDE 3 pilocarpine hcl (1% drops, 2% drops, 4% drops) 1 QL 0.54 / day pilocarpine hcl powder 3 pilocarpine nitrate 3 OSMOTIC AGENTS mannitol powder 3 PROSTAGLANDIN ANALOGS bimatoprost 0.03% eye drops 1 QL 0.13 / day bimatoprost 0.03% eyelash soln 1 latanoprost 0.005% eye drops 1 QL 0.13 / day latanoprost oil 3 LATISSE 3
LUMIGAN 2 QL 0.13 / day
TRAVATAN Z 2 QL 0.167 / day travoprost 1 QL 0.167 / day
XALATAN 3 QL 0.13 / day
ANTIHEMORRHAGIC AGENTS
ANTIHEPARIN AGENTS protamine sulfate powder 3 HEMOSTATICS
AMICAR (0.25 GRAM/ML ORAL SOLN, 500 MG TABLET, 1,000 MG TABLET) 3
PAGE 98 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS aminocaproic acid (6-aminocaproic powder, aminocaproic powder) 3
ASTRINGYN 3 AVITENE (FLOUR, SHEET 35MMX35MM, SHEET 70MMX35MM, SHEET 70MMX70MM) 3 DDAVP (0.1 MG TABLET, 0.2 MG TABLET, 10 MCG/0.1 ML SOLUTION) 3
DDAVP (4 MCG/ML AMPUL, 4 MCG/ML VIAL) 3 desmopressin acetate powder 3 desmopressin acetate (0.01% solution, 0.01% spray, 0.1 mg/ml sol, acetate 0.1 mg tb, acetate 0.2 mg tb) 1 desmopressin acetate (ac 4 mcg/ml ampul, ac 4 mcg/ml vial, 40 mcg/10 ml vial) 1
ENDO-AVITENE 3 EVARREST 3 EVICEL FIBRIN 2X5 ML SEALANT 3 GELFOAM POWDER 3
QL 6/ day plus 90/ 90 day LYSTEDA 3 limit GL Female
MONSEL'S 3 OXYCEL 3
RECOTHROM (5,000 UNIT VIAL, 20,000 UNIT VIAL) 5 S
STIMATE 5 S
SYRINGE AVITENE 3 TACHOSIL 3 THROMBIN-JMI (5,000 EPIST, 5,000 SYR, 5,000 VIAL, 20,000 PUMP, 20,000 SYR, 20,000 VIAL) 3 TISSEEL VHSD (2 ML KIT, FROZEN 2 ML SYR, 4 ML KIT, FROZEN 4 ML SYR, 10 ML KIT, FROZEN 10 ML SYR) 3
PAGE 99 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS tranexamic acid powder 3
QL 6 / day tranexamic acid 650 mg tablet 1 GL Female
ULTRAFOAM 3 ANTIHISTAMINE DRUGS
FIRST GENERATION ANTIHISTAMINES
ARBINOXA (4 MG TABLET, 4 MG/5 ML LIQUID) 1 AL At least 2 yrs old brompheniramine maleate 3 carbinoxamine maleate (4 mg/5 ml liquid, maleate 4 mg tab) 1 AL At least 2 yrs old chlorpheniramine maleate 3 clemastine fumarate powder 3 AL At least 2 yrs old clemastine fum 2.68 mg tab 1 AL At least 2 yrs old cyproheptadine hcl powder 3 AL At least 2 yrs old cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet, 4 mg/10 ml At least 2 yrs old syrp) 1 AL dimenhydrinate 100% powder 3 diphenhydramine hcl (12.5 mg/5 ml, 25 mg/10 ml) 1 diphenhydramine hcl powder 3 diphenhydramine hcl (50 mg/ml syrng, 50 mg/ml vial) 1 doxylamine succinate 3
KARBINAL ER 3 AL At least 2 yrs old
RYVENT 3 ST triprolidine hcl 3 OTHER ANTIHISTAMINES ketotifen fumarate 3
PAGE 100 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SECOND GENERATION ANTIHISTAMINES cetirizine hcl 1 QL 10 / day
CLARINEX 0.5 MG/ML (2.5 MG/5) 3 QL 10 / day
CLARINEX 5 MG TABLET 3 QL 1 / day
CLARINEX-D 12 HOUR 3 QL 2 / day desloratadine (2.5 mg odt, 5 mg odt, 5 mg tablet) 1 QL 1 / day fexofenadine hcl powder 3 fexofenadine hcl 180 mg tablet 1 QL 1 / day fexofenadine hcl 30 mg tablet 1 fexofenadine hcl 60 mg tablet 1 QL 2 / day levocetirizine dihydrochl pwdr 3 levocetirizine 2.5 mg/5 ml sol 1 QL 30 / day levocetirizine 5 mg tablet 1 QL 1 / day loratadine 3 loratadine micronized 3
SEMPREX-D 3 QL 4 / day
XYZAL 2.5 MG/5 ML SOLUTION 3 QL 30 / day
XYZAL 5 MG TABLET 3 QL 1 / day
ANTIHISTAMINES (RESPIRATORY TRACT AGNTS)
FIRST GENERATION ANTIHIST.(RESPIR TRACT)
BROMFED DM 1 AL At least 2 yrs old brompheniramine-pseudoephed-dm 1 AL At least 2 yrs old
CENTERGY 1 CENTERGY DM 1
PAGE 101 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 10 / day hydrocodone-chlorpheniramne er 1 AL At least 6 yrs old
PHENERGAN (25 MG/ML AMPUL, 25 MG/ML VIAL, 50 MG/ML At least 2 yrs old AMPUL, 50 MG/ML VIAL) 3 AL promethazine hcl powder 3 AL At least 2 yrs old
AL At least 2 yrs old promethazine 25 mg tablet 1 LCG promethazine hcl (6.25 mg/5 ml soln, 6.25 mg/5 ml syrp, 12.5 At least 2 yrs old mg tablet, 50 mg tablet) 1 AL promethazine hcl (25 mg/ml ampul, 25 mg/ml syringe, 25 At least 2 yrs old mg/ml vial, 50 mg/ml ampul, 50 mg/ml vial) 1 AL promethazine vc 1 promethazine-codeine 1
AL At least 2 yrs old promethazine-dm 1 LCG promethazine-phenylephrine 1 RESPA A.R. 3
QL 6 / day TUSSICAPS 3 AL At least 6 yrs old
QL 10 / day TUSSIONEX 3 AL At least 6 yrs old
QL 4 / day VITUZ 3 AL At least 6 yrs old
SECOND GENERATION ANTIHIST(RESPIR TRACT)
DYMISTA 2 QL 0.8 / day
PAGE 102 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIHYPOGLYCEMIC AGENTS
ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS diazoxide 3 PROGLYCEM 3 GLYCOGENOLYTIC AGENTS
GLUCAGEN 2 GLUCAGON EMERGENCY KIT 2 glucagon hcl 1 ANTILIPEMIC AGENTS
ANTILIPEMIC AGENTS, MISCELLANEOUS
QL 1 / day JUXTAPID (20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE) 5 PA S
QL 2 / day JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE) 5 PA S
QL 0.15 / day KYNAMRO 5 PA S
LOVAZA 3 QL 4 / day niacin 3 niacin er (er 750 mg tablet, er 1,000 mg tablet) 1 QL 2 / day niacin er 500 mg tablet 1 QL 3 / day
NIACOR 3 QL 12 / day
NIASPAN (ER 750 MG TABLET, ER 1,000 MG TABLET) 3 QL 2 / day
NIASPAN ER 500 MG TABLET 3 QL 3 / day
PAGE 103 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS nicotinic acid 3
QL 4 / day omega-3 acid ethyl esters 3 HCG
QL 4 / day TRIKLO 3 HCG
QL 4 / day VASCEPA 3 ST
VIT 3 3 BILE ACID SEQUESTRANTS cholestyramine powder 1 QL 24 / day cholestyramine packet 1 QL 4 / day
QL 24 / day cholestyramine light powder 3 HCG
QL 4 / day cholestyramine light packet 3 HCG cholestyramine resin 3 COLESTID (FLAVORED GRANULES, GRANULES, GRANULES 6 / day PACKET) 3 QL
COLESTID 1 GM TABLET 3 QL 4 / day colestipol hcl (granules, granules packet) 1 QL 6 / day colestipol hcl (hcl 1 gm tablet, micronized 1 gm tab) 1 QL 4 / day
QL 24 / day PREVALITE POWDER 3 HCG
QL 4 / day PREVALITE PACKET 3 HCG
QUESTRAN POWDER 3 QL 24 / day
PAGE 104 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QUESTRAN PACKET 3 QL 4 / day
QUESTRAN LIGHT 3 QL 24 / day
CHOLESTEROL ABSORPTION INHIBITORS ezetimibe 1 QL 1 / day ezetimibe-simvastatin 1 QL 1 / day
VYTORIN 3 QL 1 / day
ZETIA 3 QL 1 / day
FIBRIC ACID DERIVATIVES
ANTARA 30 MG CAPSULE 3 QL 2 / day
ANTARA 90 MG CAPSULE 3 QL 1 / day fenofibrate (40 mg tablet, 50 mg capsule) 1 QL 2 / day fenofibrate (67 mg capsule, 130 mg capsule, 134 mg capsule, 1 / day 145 mg tablet, 150 mg capsule, 160 mg tablet, 200 mg capsule) 1 QL fenofibrate (43 mg capsule, 48 mg tablet, 54 mg tablet) 1 QL 2 / day fenofibrate 120 mg tablet 1 QL 1 / day fenofibric acid (105 mg tablet, dr 135 mg cap) 1 QL 1 / day fenofibric acid (35 mg tablet, dr 45 mg cap) 1 QL 2 / day
FENOGLIDE 120 MG TABLET 3 QL 1 / day
FENOGLIDE 40 MG TABLET 3 QL 2 / day
FIBRICOR 105 MG TABLET 3 QL 1 / day
FIBRICOR 35 MG TABLET 3 QL 2 / day gemfibrozil powder 3 gemfibrozil 600 mg tablet 1 QL 2 / day
LIPOFEN 150 MG CAPSULE 3 QL 1 / day
PAGE 105 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LIPOFEN 50 MG CAPSULE 3 QL 2 / day
LOFIBRA (67 MG CAPSULE, 134 MG CAPSULE, 160 MG TABLET, 1 / day 200 MG CAPSULE) 3 QL
LOFIBRA 54 MG TABLET 3 QL 2 / day
LOPID 3 QL 2 / day
TRICOR 145 MG TABLET 3 QL 1 / day
TRICOR 48 MG TABLET 3 QL 2 / day
TRIGLIDE 3 QL 1 / day
TRILIPIX DR 135 MG CAPSULE 3 QL 1 / day
TRILIPIX DR 45 MG CAPSULE 3 QL 2 / day
HMG-COA REDUCTASE INHIBITORS
ADVICOR (500 MG TABLET, 750 MG TABLET, 1,000 MG TABLET) 3 QL 2 / day
ADVICOR 1,000 MG-40 MG TABLET 3 QL 1 / day
ALTOPREV 3 QL 1 / day
QL 1 / day amlodipine-atorvastatin 3 HCG atorvastatin calcium 1 QL 1 / day
CADUET 3 QL 1 / day
CRESTOR 3 QL 1 / day fluvastatin er 1 QL 1 / day fluvastatin sodium 20 mg cap 1 QL 1 / day fluvastatin sodium 40 mg cap 1 QL 2 / day
LESCOL 20 MG CAPSULE 3 QL 1 / day
LESCOL 40 MG CAPSULE 3 QL 2 / day
PAGE 106 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LESCOL XL 3
LIPITOR (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL 1 / day
LIPITOR 80 MG TABLET 3
LIVALO 3 QL 1 / day lovastatin (10 mg tablet, 20 mg tablet) 1 QL 1 / day lovastatin 40 mg tablet 1 QL 2 / day
PRAVACHOL 3 QL 1 / day
QL 1 / day pravastatin sodium (10 mg tab, 20 mg tab, 40 mg tab) 1 LCG pravastatin sodium 80 mg tab 1 rosuvastatin calcium 1 QL 1 / day
SIMCOR (500-20 MG TABLET, 750-20 MG TABLET, 1,000-20 MG 2 / day TABLET) 3 QL
SIMCOR (500-40 MG TABLET, 1,000-40 MG TABLET) 3 QL 1 / day simvastatin powder 3
QL 1.5 / day simvastatin (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 LCG
QL 1 / day simvastatin 5 mg tablet 1 LCG
QL 1 / day simvastatin 80 mg tablet 1 PA
ZOCOR (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL 1.5 / day
ZOCOR 5 MG TABLET 3 QL 1 / day
QL 1 / day ZOCOR 80 MG TABLET 3 PA
PAGE 107 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PCSK9 INHIBITORS
QL 0.08 / day PA PRALUENT PEN 4 S PS
QL 0.08 / day PA PRALUENT SYRINGE 4 S PS
QL 0.13 / day PA REPATHA PUSHTRONEX 4 S PS
QL 0.08 / day PA REPATHA SURECLICK 4 S PS
QL 0.08 / day PA REPATHA SYRINGE 4 S PS
ANTIMIGRAINE AGENTS
SELECTIVE SEROTONIN AGONISTS
QL 0.4 / day almotriptan malate 3 HCG
ALSUMA 3 QL 0.167 / day
AMERGE 3 QL 0.3 / day
PAGE 108 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AXERT 3 QL 0.4 / day
QL 0.4 / day eletriptan hbr 3 HCG
FROVA 3 QL 0.6 / day
QL 0.6 / day frovatriptan succinate 3 HCG
IMITREX (4 MG/0.5 ML CARTRIDGES, 4 MG/0.5 ML PEN INJECT, 6 MG/0.5 ML CARTRIDGES, 6 MG/0.5 ML PEN INJECT, 6 MG/0.5 3 QL 0.167 / day ML VIAL)
IMITREX (5 MG NASAL SPRAY, 20 MG NASAL SPRAY) 3 QL 6 / 30 days
IMITREX (25 MG TABLET, 50 MG TABLET, 100 MG TABLET) 3 QL 0.3 / day
MAXALT 3 QL 0.6 / day
MAXALT MLT 3 QL 0.6 / day naratriptan 1 QL 0.6 / day naratriptan hcl 1 QL 0.6 / day
ONZETRA XSAIL 3 ST
RELPAX 3 QL 0.4 / day rizatriptan (5 mg odt, 5 mg tablet, 10 mg odt, 10 mg tablet) 1 QL 0.6 / day sumatriptan powder 3
QL 6 / 30 days sumatriptan (5 mg nasal spray, 20 mg nasal spray) 3 HCG sumatriptan succinate (4 mg/0.5 ml cart, 4 mg/0.5 ml inject, 6 QL 0.167 / day 3 mg/0.5 ml inject, 6 mg/0.5 ml refill, 6 mg/0.5 ml vial) HCG sumatriptan succinate powder 3 sumatriptan 6 mg/0.5 ml syrng 1 QL 0.167 / day
PAGE 109 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg 0.3 / day tablet) 1 QL
SUMAVEL DOSEPRO 3 QL 0.134 / day
QL 0.3 / day TREXIMET 3 ST
QL 0.134 / day ZEMBRACE SYMTOUCH 3 ST zolmitriptan powder 3 QL 0.2 / day zolmitriptan (2.5 mg tablet, 5 mg tablet) 1 QL 0.2 / day
QL 0.2 / day zolmitriptan odt 3 HCG
ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 2 QL 0.2 / day
ZOMIG (2.5 MG TABLET, 5 MG TABLET) 3 QL 0.2 / day
ZOMIG ZMT 3 QL 0.2 / day
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, MISCELLANEOUS clofazimine 3 dapsone powder 3 dapsone (25 mg tablet, 100 mg tablet) 1 ANTITUBERCULOSIS AGENTS aminosalicylic acid 3 BIAXIN (250 MG TABLET, 250 MG/5 ML SUSPENSION, 500 MG TABLET) 3
CAPASTAT SULFATE 3 clarithromycin (125 mg/5 ml sus, 250 mg tablet, 250 mg/5 ml sus, 500 mg tablet) 1 clarithromycin er 1
PAGE 110 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cycloserine 250 mg capsule 1 cycloserine powder 3 ethambutol hcl 1 isoniazid powder 3 isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet) 1 isoniazid 100 mg/ml vial 1 MYAMBUTOL 3 PASER 3 pyrazinamide powder 3 pyrazinamide 500 mg tablet 1
SIRTURO 3 PA sodium 4-aminosalicylate 3 TRECATOR 3 ANTIPARKINSONIAN AGENTS (CNS)
ADAMANTANES (CNS) amantadine (50 mg/5 ml solution, 100 mg capsule, 100 mg tablet, 100 mg/10 ml soln) 1 amantadine hcl 3 CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. carbidopa-levodopa-entacapone 1 COMTAN 3 entacapone 1 STALEVO 100 3 STALEVO 125 3 STALEVO 150 3 STALEVO 200 3 STALEVO 50 3
PAGE 111 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS STALEVO 75 3 TASMAR 3 tolcapone 1 DOPAMINE PRECURSORS carbidopa-levodopa (carbidopa-levo 10-100 mg odt, carbidopa- levo 25-100 mg odt, carbidopa-levo 25-250 mg odt, carbidopa- levodopa 10-100 tab, carbidopa-levodopa 25-100 tab, 1 carbidopa-levodopa 25-250 tab) carbidopa-levodopa er 1
QL 1 / day DUOPA 5 PA S levodopa 3 RYTARY 3 SINEMET 10-100 3 SINEMET 25-100 3 SINEMET 25-250 3 SINEMET CR 3 MONOAMINE OXIDASE B INHIBITORS
QL 1 / day XADAGO 3 PA AL At least 18 yrs old
ANTIPROTOZOALS
AMEBICIDES
FLAGYL (250 MG TABLET, 375 CAPSULE, 500 MG TABLET) 3 FLAGYL ER 3 iodoquinol 3 metronidazole powder 3
PAGE 112 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS metronidazole (250 mg tablet, 375 mg capsule, 500 mg tablet) 1 metronidazole benzoate 3 ANTIMALARIALS atovaquone-proguanil hcl 1 PA chloroquine phosphate powder 3 chloroquine phosphate (250 mg tablet, 500 mg tablet) 1 COARTEM 3 hydroxychloroquine sulf pwd 3 hydroxychloroquine 200 mg tab 1
MALARONE 3 PA mefloquine hcl 1 PLAQUENIL 3 primaquine 1 pyrimethamine 3
QL 42 / 365 days QUALAQUIN 3 PA quinacrine hcl 3 quinine hcl 3
QL 42 / 365 days quinine sulfate 324 mg capsule 1 PA quinine sulfate powder 3 ANTIPROTOZOALS, MISCELLANEOUS
ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) 3 PA antimony trichloride 3 atovaquone 1 PA
IMPAVIDO 5 S
PAGE 113 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MEPRON 3 NEBUPENT 3 PENTAM 300 3 TINDAMAX 3 tinidazole powder 3 tinidazole (250 mg tablet, 500 mg tablet) 1 ANTIPSYCHOTIC AGENTS
ANTIPSYCHOTICS, MISCELLANEOUS
ADASUVE 3 AL At least 18 yrs old loxapine 1 AL At least 18 yrs old molindone hcl 1 ORAP 3 pimozide 1 ATYPICAL ANTIPSYCHOTICS
QL 1 / day ABILIFY 3 AL At least 6 yrs old
QL 0.04 / day ABILIFY MAINTENA (ER 300 MG SYR, ER 300 MG VL, ER 400 MG SYR, ER 400 MG VL) 3 PA AL At least 18 yrs old
QL 30 / day aripiprazole 1 mg/ml solution 1 AL At least 6 yrs old aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 15 mg QL 1 / day 1 tablet, 20 mg tablet, 30 mg tablet) AL At least 6 yrs old
QL 1 / day aripiprazole odt 1 AL At least 6 yrs old
QL 0.15 / day ARISTADA ER 1064 MG/3.9 ML SYR 3 PA AL At least 18 yrs old
PAGE 114 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 0.07 / day ARISTADA ER 441 MG/1.6 ML SYRN 3 PA AL At least 18 yrs old
QL 0.08 / day ARISTADA ER 662 MG/2.4 ML SYRN 3 PA AL At least 18 yrs old
QL 0.12 / day ARISTADA ER 882 MG/3.2 ML SYRN 3 PA AL At least 18 yrs old
QL 9 / day clozapine 100 mg tablet 1 AL At least 18 yrs old
QL 4 / day clozapine 200 mg tablet 1 AL At least 18 yrs old
QL 18 / day clozapine 25 mg tablet 1 AL At least 18 yrs old
QL 3 / day clozapine 50 mg tablet 1 AL At least 18 yrs old
QL 3 / day clozapine odt (odt 12.5 mg tablet, odt 25 mg tablet) 1 AL At least 18 yrs old clozapine odt (odt 150 mg tablet, odt 200 mg tablet) 1 AL At least 18 yrs old
QL 9 / day clozapine odt 100 mg tablet 1 AL At least 18 yrs old
QL 9 / day CLOZARIL 100 MG TABLET 3 AL At least 18 yrs old
QL 18 / day CLOZARIL 25 MG TABLET 3 AL At least 18 yrs old
PAGE 115 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 8 / rx FANAPT TITRATION PACK 3 AL At least 18 yrs old
QL 2 / day FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) 3 ST AL At least 18 yrs old
FAZACLO (12.5 MG ODT, 25 MG ODT, 150 MG ODT, 200 MG QL 3 / day 3 ODT) AL At least 18 yrs old
QL 9 / day FAZACLO 100 MG ODT 3 AL At least 18 yrs old
QL 2 / day GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MG CAPSULE) 3 ST AL At least 18 yrs old
GEODON 20 MG/ML VIAL 3 ST
ST INVEGA 3 AL At least 12 yrs old
QL 0.0333 / day INVEGA SUSTENNA 117 MG/0.75 ML 3 PA AL At least 18 yrs old
QL 0.04 / day INVEGA SUSTENNA 156 MG/ML SYRG 3 PA AL At least 18 yrs old
QL 0.057 / day INVEGA SUSTENNA 234 MG/1.5 ML 3 PA AL At least 18 yrs old
QL 0.0111 / day INVEGA SUSTENNA 39 MG/0.25 ML 3 PA AL At least 18 yrs old
PAGE 116 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 0.02 / day INVEGA SUSTENNA 78 MG/0.5 ML 3 PA AL At least 18 yrs old
QL 0.0333 / day INVEGA TRINZA 273 MG/0.875 ML 3 PA AL At least 18 yrs old
QL 0.057 / day INVEGA TRINZA 410 MG/1.315 ML 3 PA AL At least 18 yrs old
QL 0.067 / day INVEGA TRINZA 546 MG/1.75 ML 3 PA AL At least 18 yrs old
QL 0.1 / day INVEGA TRINZA 819 MG/2.625 ML 3 PA AL At least 18 yrs old
QL 1 / day LATUDA 3 AL At least 13 yrs old
QL 2 / day NUPLAZID 5 PA S olanzapine (2.5 mg tablet, 5 mg tablet) 1 QL 6 / day olanzapine 10 mg tablet 1 QL 3 / day olanzapine 15 mg tablet 1 QL 2 / day olanzapine 20 mg tablet 1 QL 1 / day olanzapine 7.5 mg tablet 1 QL 4 / day olanzapine 10 mg vial 1
PAGE 117 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 3 / day olanzapine odt 10 mg tablet 3 HCG
QL 2 / day olanzapine odt 15 mg tablet 3 HCG
QL 1 / day olanzapine odt 20 mg tablet 3 HCG
QL 6 / day olanzapine odt 5 mg tablet 3 HCG
AL At least 12 yrs old paliperidone er 3 HCG
QL 6 / day quetiapine fumarate (25 mg tab, 50 mg tab) 1 AL At least 10 yrs old
QL 3 / day quetiapine fumarate 100 mg tab 1 AL At least 10 yrs old
QL 1.5 / day quetiapine fumarate 200 mg tab 1 AL At least 10 yrs old
QL 1 / day quetiapine fumarate 300 mg tab 1 AL At least 10 yrs old
QL 2 / day quetiapine fumarate 400 mg tab 1 AL At least 10 yrs old
QL 5 / day quetiapine er 150 mg tablet 3 AL At least 10 yrs old HCG
QL 4 / day quetiapine er 200 mg tablet 3 AL At least 10 yrs old HCG
PAGE 118 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 6 / day quetiapine er 50 mg tablet 3 AL At least 10 yrs old HCG
QL 2 / day quetiapine fumarate er (er 300 mg tablet, er 400 mg tablet) 3 AL At least 10 yrs old HCG
QL 1 / day REXULTI 3 PA AL At least 18 yrs old
QL 16/day RISPERDAL 1 MG/ML SOLUTION 3 AL At least 5 yrs old
RISPERDAL (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET, 2 QL 8 / day 3 MG TABLET) AL At least 5 yrs old
QL 5 / day RISPERDAL 3 MG TABLET 3 AL At least 5 yrs old
QL 4 / day RISPERDAL 4 MG TABLET 3 AL At least 5 yrs old
QL 0.1 / day RISPERDAL CONSTA 3 PA AL At least 18 yrs old
QL 8 / day RISPERDAL M-TAB (0.5 MG ODT, 1 MG ODT, 2 MG ODT) 3 AL At least 5 yrs old
QL 5 / day RISPERDAL M-TAB 3 MG ODT 3 AL At least 5 yrs old
QL 4 / day RISPERDAL M-TAB 4 MG ODT 3 AL At least 5 yrs old
QL 16/day risperidone 1 mg/ml solution 1 AL At least 5 yrs old
PAGE 119 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg QL 8 / day 1 tablet) AL At least 5 yrs old
QL 5 / day risperidone 3 mg tablet 1 AL At least 5 yrs old
QL 4 / day risperidone 4 mg tablet 1 AL At least 5 yrs old
QL 5 / day risperidone 3 mg odt 3 AL At least 5 yrs old HCG
QL 4 / day risperidone 4 mg odt 3 AL At least 5 yrs old HCG
QL 8 / day risperidone odt (0.25 mg odt, 0.5 mg odt, 1 mg odt, 2 mg odt) 3 AL At least 5 yrs old HCG
QL 2 / day SAPHRIS 3 ST AL At least 10 yrs old
QL 6 / day SEROQUEL (25 MG TABLET, 50 MG TABLET) 3 AL At least 10 yrs old
QL 3 / day SEROQUEL 100 MG TABLET 3 AL At least 10 yrs old
QL 1.5 / day SEROQUEL 200 MG TABLET 3 AL At least 10 yrs old
QL 1 / day SEROQUEL 300 MG TABLET 3 AL At least 10 yrs old
QL 2 / day SEROQUEL 400 MG TABLET 3 AL At least 10 yrs old
PAGE 120 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SEROQUEL XR SAMPLE KIT 2 AL At least 10 yrs old
QL 2 / day SEROQUEL XR (300 MG TABLET, 400 MG TABLET) 2 AL At least 10 yrs old
QL 5 / day SEROQUEL XR 150 MG TABLET 2 AL At least 10 yrs old
QL 4 / day SEROQUEL XR 200 MG TABLET 2 AL At least 10 yrs old
QL 6 / day SEROQUEL XR 50 MG TABLET 2 AL At least 10 yrs old
QL 20 / day VERSACLOZ 3 AL At least 18 yrs old
QL 1 / day VRAYLAR (1.5 MG CAPSULE, 1.5 MG-3 MG PACK, 3 MG CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE) 3 PA AL At least 18 yrs old
QL 2 / day ziprasidone hcl 1 AL At least 18 yrs old
QL 6 / day ZYPREXA (2.5 MG TABLET, 5 MG TABLET) 3 AL At least 13 yrs old
QL 3 / day ZYPREXA 10 MG TABLET 3 AL At least 13 yrs old
QL 2 / day ZYPREXA 15 MG TABLET 3 AL At least 13 yrs old
QL 1 / day ZYPREXA 20 MG TABLET 3 AL At least 13 yrs old
QL 4 / day ZYPREXA 7.5 MG TABLET 3 AL At least 13 yrs old
PAGE 121 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZYPREXA 10 MG VIAL 3 AL At least 13 yrs old
QL 0.08 / day ZYPREXA RELPREVV 3 PA AL At least 18 yrs old
QL 3 / day ZYPREXA ZYDIS 10 MG TABLET 3 AL At least 13 yrs old
QL 2 / day ZYPREXA ZYDIS 15 MG TABLET 3 AL At least 13 yrs old
QL 1 / day ZYPREXA ZYDIS 20 MG TABLET 3 AL At least 13 yrs old
QL 6 / day ZYPREXA ZYDIS 5 MG TABLET 3 AL At least 13 yrs old
BUTYROPHENONES
HALDOL 3 HALDOL DECANOATE 100 3 HALDOL DECANOATE 50 3 haloperidol 5 mg/ml ampul 1 haloperidol powder 3 haloperidol (0.5 mg tablet, 2 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet) 1 haloperidol 1 mg tablet 1 LCG haloperidol decan 50 mg/ml amp 1 haloperidol decanoate powder 3 haloperidol decanoate (50 mg/ml vial, 100 mg/ml vial) 1 haloperidol decanoate 100 1 haloperidol lac 2 mg/ml conc 1 haloperidol lactate (5 mg/ml vial, 50 mg/10 ml vl) 1
PAGE 122 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PHENOTHIAZINES acepromazine maleate 3 chlorpromazine 25 mg/ml amp 1 chlorpromazine hcl powder 3 chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) 3 HCG fluphenazine decanoate (liquid, oil) 3 fluphenazine dec 125 mg/5 ml 1 fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5 ml elix, 5 mg tablet, 5 mg/ml conc, 10 mg tablet) 1 fluphenazine 2.5 mg/ml vial 1 perphenazine powder 3 AL At least 18 yrs old perphenazine (2 mg tablet, 4 mg tablet, 8 mg tablet, 16 mg At least 18 yrs old tablet) 1 AL promazine hcl 3 thioridazine hcl 1 thioridazine hydrochloride 3 trifluoperazine hcl 1 THIOXANTHENES thiothixene 1 ANTIRETROVIRALS
HIV ENTRY AND FUSION INHIBITORS
QL 2 / day FUZEON 5 S
SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET, 75 MG S 4 TABLET, 150 MG TABLET, 300 MG TABLET) PS
PAGE 123 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HIV INTEGRASE INHIBITORS
GENVOYA 5 S
S ISENTRESS 100 MG POWDER PACKET 4 PS
ISENTRESS (25 MG TABLET CHEW, 100 MG TABLET CHEW, 400 S 4 MG TABLET) PS
S ISENTRESS HD 4 PS
STRIBILD 5 S
TIVICAY 5 S
TRIUMEQ 5 S
HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.
S ATRIPLA 4 PS
S COMPLERA 4 PS
S EDURANT 4 PS
S INTELENCE 4 PS nevirapine (50 mg/5 ml susp, 200 mg tablet) 5 S nevirapine er 5 S
ODEFSEY 5 S
RESCRIPTOR (100 MG TABLET, 200 MG TABLET) 5 S
SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600 MG TABLET) 5 S
PAGE 124 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET) 5 S
VIRAMUNE XR 5 S
HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS abacavir (20 mg/ml solution, 300 mg tablet) 5 S abacavir-lamivudine 5 S abacavir-lamivudine-zidovudine 5 S
COMBIVIR 5 S
QL 1 / day DESCOVY 5 S didanosine 5 S
S EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 4 PS
EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MG TABLET) 5 S
EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET) 5 S
EPZICOM 5 S lamivudine 10 mg/ml oral soln 5 S lamivudine (100 mg tablet, 150 mg tablet, 300 mg tablet) 5 S lamivudine hbv 5 S lamivudine-zidovudine 5 S
RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE) 5 S stavudine (1 mg/ml solution, 15 mg capsule, 20 mg capsule, 30 mg capsule, 40 mg capsule) 5 S
TRIZIVIR 5 S
S TRUVADA 4 PS
PAGE 125 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
S VIDEX 4 PS
VIDEX EC 5 S
VIREAD POWDER 5 S
VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 S 4 MG TABLET) PS
ZERIT (1 MG/ML SOLUTION, 15 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE) 5 S
ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET) 5 S zidovudine (50 mg/5 ml syrup, 100 mg capsule, 300 mg tablet) 5 S
HIV PROTEASE INHIBITORS
S APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 4 PS
S CRIXIVAN 4 PS
EVOTAZ 5 S fosamprenavir calcium 5 S
S INVIRASE (200 MG CAPSULE, 500 MG TABLET) 4 PS
KALETRA (80 MG-20 MG/ML SOLN, 100-25 MG TABLET, 200-50 MG TABLET) 5 S
LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) 5 S
S lopinavir-ritonavir 4 PS
NORVIR (80 MG/ML SOLUTION, 100 MG SOFTGEL CAP, 100 MG TABLET) 5 S
PAGE 126 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PREZCOBIX 5 S
PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG S 4 TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET) PS
REYATAZ (150 MG CAPSULE, 200 MG CAPSULE, 300 MG S 4 CAPSULE) PS
S REYATAZ 50 MG POWDER PACKET 4 PS
QL 2 / day TECHNIVIE 5 PA S
QL 4 / day VIEKIRA PAK 5 PA S
QL 3 / day VIEKIRA XR 5 PA S
S VIRACEPT 4 PS
ANTITHROMBOTIC AGENTS
PLATELET-AGGREGATION INHIBITORS acetyl salicylic acid 3
AGGRENOX 3 QL 2 / day aspirin 3
QL 10 / day aspirin-caffeine-dihydrocodein 1 AL At least 18 yrs old
QL 2 / day aspirin-dipyridamole er 3 HCG
PAGE 127 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BRILINTA 2 QL 2 / day butalbital-asa-caffeine cap 1 QL 6 / day cilostazol 1 QL 2 / day clopidogrel 1 QL 1 / day clopidogrel bisulfate 3 dipyridamole powder 3 dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1 QL 4 / day
DURLAZA 3 QL 1 / day
EFFIENT 3 QL 1 / day
FIORINAL 3 QL 6 / day
LEVACET 3 PA
PERSANTINE 3 QL 4 / day
PLAVIX 3 QL 1 / day
PLETAL 3 QL 2 / day prasugrel hcl 1 QL 1 / day
QL 10 / day SYNALGOS-DC 3 AL At least 12 yrs old ticlopidine hcl 1 QL 2 / day
QL 1 / day ZONTIVITY 3 PA
PLATELET-REDUCING AGENTS
AGRYLIN 3 QL 4 / day anagrelide hcl 1 QL 4 / day
PAGE 128 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THROMBOLYTIC AGENTS
CATHFLO ACTIVASE 5 S
ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES
ANTITOXINS AND IMMUNE GLOBULINS antivenin latrodectus mactans 1 antivenin micrurus fulvius 1 CROFAB 3
PA CUVITRU 5 S
PA GAMMAGARD LIQUID 5 S
PA GAMMAKED 5 S
PA GAMUNEX-C 5 S
PA HIZENTRA 5 S
HYPERHEP B S-D (NEONATAL SYRIN., SYRINGE, VIAL) 5 S
HYPERRAB S-D 5 S
HYPERTET S-D 5 S
PA HYQVIA 5 S
PA HYQVIA IG COMPONENT 5 S
IMOGAM RABIES-HT 5 S
PAGE 129 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NABI-HB 5 S
VARIZIG (125 UNIT VIAL, 125 UNIT/1.2 ML VIAL) 5 S
TOXOIDS
ADACEL TDAP (SYRINGE, VIAL) 0 HCR
BOOSTRIX TDAP (SYRINGE, VIAL) 0 HCR
DAPTACEL DTAP 0 HCR diphtheria-tetanus toxoids-ped 1 INFANRIX DTAP (SYRINGE, VIAL) 2 PEDIARIX 2
TENIVAC (SYRINGE, VIAL) 0 HCR tetanus diphtheria toxoids 0 HCR
VACCINES
ACTHIB VACCINE WITH DILUENT 2
AFLURIA 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 0 HCR
AFLURIA QUAD 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 0 HCR bcg vaccine (tice strain) 3 BEXSERO 2 BIOTHRAX 2
CERVARIX 0 HCR
ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML VIAL) 0 HCR
ENGERIX-B PEDIATRIC-ADOLESCENT (10 MCG/0.5 ML PED VL, PEDI 10 MCG/0.5 SYRN) 0 HCR
EZ FLU 16-17 (FLUZON QUAD PED) 0 HCR
EZ FLU 2016-2017 (AFLURIA) 0 HCR
EZ FLU 2016-2017 (FLUVIRIN) 0 HCR
PAGE 130 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FLUAD 2016-2017 0 HCR
FLUARIX QUAD 2016-2017 0 HCR
FLUBLOK 2016-2017 0 HCR
FLUCELVAX QUAD 2016-2017 0 HCR
FLULAVAL QUAD 2016-2017 (2016-2017 SYR, 2016-2017 VIAL) 0 HCR
FLUVIRIN 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 0 HCR
FLUZONE HIGH-DOSE 2016-2017 0 HCR
FLUZONE INTRADERM QUAD 2016-17 0 HCR
FLUZONE QUAD 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 0 HCR
FLUZONE QUAD PEDI 2016-2017 0 HCR
GARDASIL (SYRINGE, VIAL) 0 HCR
GARDASIL 9 (9 SYRINGE, 9 VIAL) 0 HCR
HAVRIX (720 UNIT/0.5 ML SYRINGE, 720 UNITS/0.5 ML VIAL, 1,440 UNITS/ML SYRINGE, 1,440 UNITS/ML VIAL) 0 HCR
HIBERIX VACCINE WITH DILUENT 2 IMOVAX RABIES VACCINE 2 IPOL VIAL 2 IXIARO 2 KINRIX (TIP-LOK SYRINGE, VIAL) 2
M-M-R II VACCINE 0 HCR
MENACTRA 0 HCR
MENHIBRIX 2
MENOMUNE-A-C-Y-W-135 0 HCR
MENVEO A-C-Y-W-135-DIP 0 HCR
PAGE 131 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MENVEO MENA COMPONENT 2 MENVEO MENCYW-135 COMPONENT 2 PEDVAXHIB 2 PENTACEL 2 PENTACEL ACTHIB COMPONENT 3 PENTACEL DTAP-IPV COMPONENT 2
PNEUMOVAX 23 (23 SYRINGE, 23 VIAL) 0 HCR
PREVNAR 13 0 HCR
PROQUAD 2 QUADRACEL DTAP-IPV 2 RABAVERT 2 RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML VL, 10 MCG/ML SYR, 10 MCG/ML VIAL, 40 MCG/ML VIAL) 0 HCR
ROTARIX 2 ROTATEQ 2 STAMARIL 2
THERACYS 5 S
TRUMENBA 3
TWINRIX (SYRINGE, VIAL) 0 HCR
TYPHIM VI (25 MCG/0.5 ML AL, 25 MCG/0.5 ML SYRNG) 2 VAQTA (25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 ML VIAL, 50 UNITS/ML SYRINGE, 50 UNITS/ML VIAL) 0 HCR
VARIVAX VACCINE 0 HCR
VAXCHORA ACTIVE COMPONENT 2 VAXCHORA VACCINE 2 VIVOTIF 2 VIVOTIF BERNA 2
PAGE 132 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS YF-VAX 2
ZOSTAVAX 0 HCR
ANTIULCER AGENTS AND ACID SUPPRESSANTS
HISTAMINE H2-ANTAGONISTS cimetidine powder 3 cimetidine (200 mg tablet, 300 mg tablet, 300 mg/5 ml soln, 400 mg tablet, 800 mg tablet) 1 famotidine powder 3 famotidine (20 mg tablet, 40 mg tablet, 40 mg/5 ml susp) 1 nizatidine (15 mg/ml solution, 300 mg capsule) 1 nizatidine 150 mg capsule 1 QL 2 / day
PEPCID (20 MG TABLET, 40 MG TABLET, 40 MG/5 ML ORAL SUSP) 3 ranitidine hcl powder 3 ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150 mg tablet, 150 mg/10 ml syrup, 300 mg capsule, 300 mg tablet) 1 ranitidine hcl (50 mg/2 ml vial, 150 mg/6 ml vl) 1 ZANTAC (150 MG TABLET, 300 MG TABLET) 3 ZANTAC (50 MG/2 ML VIAL, 150 MG/6 ML VIAL, 1,000 MG/40 ML VIAL) 3 PROSTAGLANDINS
ARTHROTEC 50 3 ARTHROTEC 75 3 CYTOTEC 3 diclofenac sodium-misoprostol 1 misoprostol (hpmc powder, powder) 3 misoprostol (100 mcg tablet, 200 mcg tablet) 1 misoprostol hpmc 3
PAGE 133 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROTECTANTS
CARAFATE 1 GM/10 ML SUSP 2 CARAFATE 1 GM TABLET 3 sucralfate powder 3 sucralfate 1 gm tablet 1 PROTON-PUMP INHIBITORS
QL 2 / day ACIPHEX 3 ST
ACIPHEX SPRINKLE 3 QL 1 / day
QL 1 / day DEXILANT 3 ST esomeprazole mag dr 20 mg cap 1 QL 1 / day
QL 1 / day esomeprazole mag dr 40 mg cap 3 HCG esomeprazole strontium 1 QL 1 / day
QL 112 / 365 days lansoprazol-amoxicil-clarithro 3 HCG lansoprazole dr 15 mg capsule 1 lansoprazole dr 30 mg capsule 1 QL 1 / day lansoprazole powder 3
NEXIUM (DR 20 MG CAPSULE, DR 40 MG CAPSULE) 3 QL 1 / day
NEXIUM (DR 2.5 MG PACKET, DR 5 MG PACKET, DR 10 MG 2 / day PACKET, DR 20 MG PACKET, DR 40 MG PACKET) 3 QL
OMECLAMOX-PAK 3 QL 80 / 365 days omeprazole (dr 10 mg capsule, dr 20 mg capsule, dr 40 mg 1 / day capsule) 1 QL
PAGE 134 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS omeprazole powder 3 omeprazole-bicarb 40-1,100 cap 3 HCG omeprazole-sodium bicarbonate (20-1,100 cap, 20-1,680 pkt, 40-1,680 pkt) 1
QL 1 / day pantoprazole sodium (dr 20 mg tab, dr 40 mg tab) 1 LCG
PREVACID (15 MG SOLUTAB, DR 15 MG CAPSULE, 30 MG QL 1 / day 3 SOLUTAB, DR 30 MG CAPSULE) ST
PREVPAC 3 QL 112 / 365 days
PRILOSEC (DR 10 MG CAPSULE, DR 20 MG CAPSULE, DR 40 MG QL 1 / day 3 CAPSULE) ST
PRILOSEC (DR 2.5 MG SUSPENSION, DR 10 MG SUSPENSION) 3 ST
PROTONIX 40 MG SUSPENSION 3 QL 1 / day
QL 1 / day PROTONIX (DR 20 MG TABLET, DR 40 MG TABLET) 3 ST rabeprazole sodium 1 QL 2 / day
ZEGERID (20 MG CAPSULE, 20 MG PACKET, 40 MG CAPSULE) 3 ST
QL 1 / day ZEGERID 40 MG PACKET 3 ST
ANTIVIRALS (SYSTEMIC)
ADAMANTANES
FLUMADINE 3 rimantadine hcl 1 ANTIVIRALS, MISCELLANEOUS
2-deoxy-d-glucose 3
PAGE 135 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS INTERFERONS
INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 18 PA MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS 5 VIL) S
PA PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/ML VIAL) 5 S
PA PEGASYS PROCLICK 5 S
PA PEGINTRON 4 S PS
PA PEGINTRON REDIPEN 4 S PS
PA SYLATRON 5 S
NEURAMINIDASE INHIBITORS oseltamivir phosphate (30 mg capsule, 45 mg capsule, 75 mg 20 / 365 days capsule) 1 QL oseltamivir 6 mg/ml suspension 1 QL 180 / 30 days
RELENZA 3 QL 40 / 365 days
TAMIFLU (30 MG CAPSULE, 45 MG CAPSULE, 75 MG CAPSULE) 3 QL 20 / 365 days
TAMIFLU 6 MG/ML SUSPENSION 3 QL 180 / 30 days
NUCLEOSIDES AND NUCLEOTIDES acyclovir powder 3 acyclovir (200 mg capsule, 200 mg/5 ml susp, 400 mg tablet, 800 mg tablet) 1
PAGE 136 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS adefovir dipivoxil 5 S
QL 20 / day BARACLUDE 0.05 MG/ML SOLUTION 5 PA S
QL 1 / day BARACLUDE (0.5 MG TABLET, 1 MG TABLET) 5 PA S cidofovir powder 3
QL 6 / day COPEGUS 5 PA S
QL 1 / day entecavir 5 S famciclovir 1 FAMVIR 3
QL 1 / day HEPSERA 5 PA S
QL 2 / day MODERIBA (200-400 MG DOSEPACK, 400-400 MG DOSEPACK, 600-400 MG DOSEPACK, 600-600 MG DOSEPACK) 5 PA S
QL 6 / day MODERIBA 200 MG TABLET 5 PA S
QL 6 / day REBETOL 200 MG CAPSULE 5 PA S
PAGE 137 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 30 / day REBETOL 40 MG/ML SOLUTION 5 PA S
QL 6 / day RIBASPHERE (200 MG CAPSULE, 200 MG TABLET) 5 PA S
QL 3 / day RIBASPHERE 400 MG TABLET 5 PA S
QL 2 / day RIBASPHERE 600 MG TABLET 5 PA S
QL 2 / day RIBASPHERE RIBAPAK 5 PA S
QL 2 / day RIBATAB 5 PA S
QL 6 / day ribavirin (200 mg capsule, 200 mg tablet) 5 PA S ribavirin 6 gm inhalation vial 1
QL 2 / fill SITAVIG 3 PA AL At least 18 yrs old
QL 1 / day TYZEKA 5 PA S
PAGE 138 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS valacyclovir 3 HCG valacyclovir hcl 3 VALCYTE 50 MG/ML SOLUTION 3
VALCYTE 450 MG TABLET 3 QL 4 / day valganciclovir hcl 50 mg/ml 1 valganciclovir 450 mg tablet 1 QL 4 / day
VALTREX 3
QL 1 / day PA VEMLIDY 5 AL At least 18 yrs old S vidarabine 3 vidarabine monohydrate 3 VIRAZOLE 3 ZOVIRAX (200 MG CAPSULE, 200 MG/5 ML SUSP, 400 MG TABLET, 800 MG TABLET) 3 ANXIOLYTICS, SEDATIVES AND HYPNOTICS
ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC
QL 1 / day AMBIEN 3 ST
QL 1 / day AMBIEN CR 3 ST
BELSOMRA 3 ST buspirone hcl powder 3 buspirone hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg tablet, 30 mg tablet) 1 chloral hydrate 3 PA
PAGE 139 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dichloralphenazone 3 droperidol powder 3 droperidol (2.5 mg/ml ampul, 2.5 mg/ml vial) 1
QL 1 / day EDLUAR 3 ST eszopiclone (1 mg tablet, 2 mg tablet) 1 QL 1 / day
QL 1 / day eszopiclone 3 mg tablet 1 AL Up to 65 yrs old
QL 1 / day HETLIOZ 5 PA S hydroxyzine hcl powder 3 AL At least 2 yrs old hydroxyzine hcl (10 mg/5 ml soln, 10 mg/5 ml syrup, hcl 10 mg At least 2 yrs old tablet, hcl 25 mg tablet, 50 mg/25 ml syrup, hcl 50 mg tablet) 1 AL hydroxyzine hcl (25 mg/ml vial, 50 mg/ml vial, 100 mg/2 ml At least 2 yrs old vial, 500 mg/10 ml vial) 1 AL hydroxyzine pam 100 mg cap 1 hydroxyzine pamoate (25 mg cap, 50 mg cap) 1 AL At least 2 yrs old hydroxyzine pamoate powder 3
QL 1 / day INTERMEZZO 3 ST
QL 1 / day LUNESTA (1 MG TABLET, 2 MG TABLET) 3 ST
QL 1 / day LUNESTA 3 MG TABLET 3 ST AL Up to 65 yrs old meprobamate 1
PAGE 140 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PHENADOZ 1 AL At least 2 yrs old
PHENERGAN (12.5 MG, 25 MG, 50 MG) 1 AL At least 2 yrs old promethazine hcl (12.5 mg suppos, 25 mg suppository, 50 mg At least 2 yrs old suppository) 1 AL
PROMETHEGAN 1 AL At least 2 yrs old
QL 1 / day ROZEREM 3 ST
QL 1 / day SONATA 3 ST tryptophan (l) 3
VISTARIL 3 AL At least 2 yrs old zaleplon 1 QL 1 / day zolpidem tartrate (tart 1.75 mg tab sl, tart 3.5 mg tablet sl, 1 / day tartrate 5 mg tablet, tartrate 10 mg tablet) 1 QL zolpidem tartrate er 1 QL 1 / day
ZOLPIMIST 3 QL 0.257 / day
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)
AMYTAL SODIUM 3 butalbital 3 BUTISOL SODIUM 3 NEMBUTAL SODIUM 3 pentobarbital sodium powder 3 pentobarbital 1,000 mg/20 ml 1 phenobarbital powder 3 SECONAL SODIUM 3
PAGE 141 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) alprazolam powder 3 alprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet) 1 QL 4 / day alprazolam 2 mg tablet 1 QL 5 / day alprazolam er (er 0.5 mg tablet, er 1 mg tablet) 1 QL 1 / day alprazolam er 2 mg tablet 1 QL 5 / day alprazolam er 3 mg tablet 1 QL 3 / day
ALPRAZOLAM INTENSOL 3 QL 10 / day alprazolam odt (odt 0.25 mg tab, odt 0.5 mg tab, odt 1 mg tab) 1 QL 4 / day alprazolam odt 2 mg tab 1 QL 5 / day alprazolam xr (0.5 mg tablet, 1 mg tablet) 1 QL 1 / day alprazolam xr 2 mg tablet 1 QL 5 / day alprazolam xr 3 mg tablet 1 QL 3 / day chlordiazepoxide 10 mg capsule 1 QL 30 / day chlordiazepoxide 25 mg capsule 1 QL 12 / day chlordiazepoxide 5 mg capsule 1 QL 4 / day
DORAL 3 QL 1 / day estazolam 1 QL 1 / day flurazepam hcl 1 QL 1 / day
HALCION 3 QL 2 / day midazolam 3 midazolam hcl 2 mg/ml syrup 1
PAGE 142 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS midazolam hcl (hcl 1 mg/ml vial, 2 mg/2 ml syringe, hcl 2 mg/2 ml vial, 5 mg/ml isecure syr, 5 mg/ml syringe, hcl 5 mg/5 ml vial, hcl 5 mg/ml vial, hcl 10 mg/10 ml vial, hcl 10 mg/2 ml vial, 1 hcl 25 mg/5 ml vial, hcl 50 mg/10 ml vial) oxazepam 1 QL 4 / day quazepam 1 QL 1 / day
RESTORIL 3 QL 1 / day temazepam 1 QL 1 / day triazolam 0.125 mg tablet 1 QL 1 / day triazolam 0.25 mg tablet 1 QL 2 / day
XANAX (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET) 3 QL 4 / day
XANAX 2 MG TABLET 3 QL 5 / day
XANAX XR (0.5 MG TABLET, 1 MG TABLET) 3 QL 1 / day
XANAX XR 2 MG TABLET 3 QL 5 / day
XANAX XR 3 MG TABLET 3 QL 3 / day
AUTONOMIC DRUGS
AUTONOMIC DRUGS, MISCELLANEOUS
CHANTIX STARTING MONTH BOX 0 HCR
CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1 MG QL 2 / day 0 TABLET) HCR nicotine polacrilex 3
NICOTROL 3 QL 16/day
NICOTROL NS 3 QL 20 / day
PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)
ARICEPT (5 MG TABLET, 10 MG TABLET) 3 AL At least 40 yrs old
PAGE 143 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ST ARICEPT 23 MG TABLET 3 AL At least 40 yrs old bethanechol chloride powder 3 bethanechol chloride (5 mg tablet, 10 mg tablet, 25 mg tablet, 50 mg tablet) 1 cevimeline hcl 3 HCG donepezil hcl 1 AL At least 40 yrs old donepezil hcl odt 1 AL At least 40 yrs old
EVOXAC 3 EXELON (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG CAPSULE, 4.6 MG/24HR PATCH, 6 MG CAPSULE, 9.5 MG/24HR PATCH, 3 AL At least 40 yrs old 13.3 MG/24HR PATCH) galantamine er 3 HCG galantamine hbr 1 galantamine hydrobromide 1 guanidine hcl 1 MESTINON 60 MG/5 ML SYRUP 2 MESTINON (60 MG TABLET, 180 MG TIMESPAN) 3 NAMZARIC (7 MG-10 MG CAPSULE, 14 MG-10 MG CAPSULE, 21 MG-10 MG CAPSULE, 28 MG-10 MG CAPSULE, TITRATION PACK) 3 ST neostigmine methylsulfate powd 3 physostigmine salicylate 1 pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1 pyridostigmine bromide powder 3 pyridostigmine br 60 mg tablet 1 pyridostigmine bromide er 1 RAZADYNE 3 RAZADYNE ER 3
PAGE 144 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS REGONOL 3 rivastigmine (1.5 mg capsule, 3 mg capsule, 4.5 mg capsule, 4.6 mg/24hr patch, 6 mg capsule, 9.5 mg/24hr patch, 13.3 mg/24hr 1 AL At least 40 yrs old ptch)
SALAGEN 3 URECHOLINE 3 SYMPATHOMIMETIC (ADRENERGIC) AGENTS isometheptene mucate 3 BETA-3-ADRENERGIC AGONISTS
SELECTIVE BETA-3-ADRENERGIC AGONISTS
MYRBETRIQ 2 QL 1 / day
BETA-ADRENERGIC AGONISTS
SELECTIVE BETA-1-ADRENERGIC AGONISTS dopamine hcl powder 3 BETA-ADRENERGIC BLOCKING AGENTS(SYMPATH)
NON-SEL. BETA-ADRENERGIC BLOCKING AGENTS
BYSTOLIC (5 MG TABLET, 10 MG TABLET) 2 QL 3 / day
BYSTOLIC 2.5 MG TABLET 2 QL 1 / day
BYSTOLIC 20 MG TABLET 2 QL 2 / day
BYVALSON 2 QL 1 / day
PAGE 145 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BLOOD FORMATION, COAGULATION, THROMBOSIS
HEMATOPOIETIC AGENTS
ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/0.42 ML SYRING, 25 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 40 MCG/ML VIAL, 60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL, 100 MCG/0.5 ML PA SYRINGE, 100 MCG/ML VIAL, 150 MCG/0.3 ML SYRINGE, 150 4 S MCG/0.75 ML VIAL, 200 MCG/0.4 ML SYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL, 500 PS MCG/1 ML SYRINGE)
PA EPOGEN 5 S
PA GRANIX 5 S
PA LEUKINE 5 S
PA MIRCERA 5 S
PA MOZOBIL 5 S
PA NEULASTA (6 MG/0.6 ML SYRINGE, ONPRO 6 MG/0.6 ML KIT) 4 S PS
PA NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL, 480 MCG/0.8 ML SYR, 480 MCG/1.6 ML VIAL) 4 S PS
PA PROCRIT 4 S PS
PA PROMACTA 5 S
PAGE 146 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 90 / 30 days ZARXIO 5 PA S
HEMORRHEOLOGIC AGENTS pentoxifylline powder 3 pentoxifylline er 400 mg tab 1 BRONCHODILATORS
XANTHINE DERIVATIVES aminophylline (anhydrous pwd, powder) 3 dyphylline 3 ELIXOPHYLLIN 3 THEO-24 3 THEOCHRON 1 theophylline (80 mg/15 ml soln, er 400 mg tablet, er 600 mg tablet) 1 theophylline anhydrous powder 3 theophylline anhydrous (er 100 mg tablet, er 200 mg tablet, er 300 mg tab, er 450 mg tab) 1 CALCIUM-CHANNEL BLOCKING AGENTS
DIHYDROPYRIDINES felodipine er 1 QL 1 / day isradipine 1 QL 2 / day
QL 1 / day nisoldipine 3 HCG
SULAR 3 QL 1 / day
PAGE 147 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CALCIUM-CHANNEL BLOCKING AGENTS(HYPOTEN)
CALCIUM-CHANNEL BLOCK.AGT,MISC(HYPOTEN)
TARKA 3 QL 1 / day trandolapril-verapamil er 1 DIHYDROPYRIDINES (HYPOTENSIVE AGENTS)
ADALAT CC 30 MG TABLET 3 QL 1 / day
ADALAT CC 60 MG TABLET 3 QL 2 / day
ADALAT CC 90 MG TABLET 3
AFEDITAB CR 30 MG TABLET 1 QL 1 / day
AFEDITAB CR 60 MG TABLET 1 QL 2 / day amlodipine besilate 3 amlodipine besylate powder 3 amlodipine besylate (2.5 mg tab, 5 mg tab, 10 mg tab) 1 QL 1 / day amlodipine besylate-benazepril 1 QL 1 / day
QL 1 / day amlodipine-olmesartan 3 HCG amlodipine-valsartan (5-320 mg, 10-160 mg, 10-320 mg) 1 QL 1 / day amlodipine-valsartan 5-160 mg 1 QL 2 / day
QL 1 / day amlodipine-valsartan-hctz 3 HCG
AZOR 3 QL 1 / day
CARDENE SR 30 MG CAPSULE 3 QL 2 / day
EXFORGE 3 QL 1 / day
EXFORGE HCT 3 QL 1 / day
PAGE 148 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LOTREL 3 QL 1 / day nicardipine hcl (20 mg capsule, 30 mg capsule) 3 HCG
NIFEDICAL XL 1 QL 1 / day nifedipine (10 mg capsule, 20 mg capsule) 1 QL 4 / day nifedipine powder 3 nifedipine er (er 30 mg tablet, er 90 mg tablet) 1 QL 1 / day nifedipine er 60 mg tablet 1 QL 2 / day nimodipine 30 mg capsule 1 nimodipine powder 3
NORVASC 3 QL 1 / day
NYMALIZE 60 MG/20 ML SOLUTION 3 QL 120 / day
PROCARDIA 3 QL 4 / day
PROCARDIA XL 3 QL 1 / day
TEKAMLO 3 QL 1 / day
CARDIAC DRUGS
CARDIAC DRUGS, MISCELLANEOUS
QL 2 / day CORLANOR 2 ST
RANEXA 2 QL 2 / day
CARDIOVASCULAR DRUGS
BETA-ADRENERGIC BLOCKING AGENTS
LEVATOL 3 CALCIUM-CHANNEL BLOCKING AGENTS
QL 1 / day PRESTALIA 3 ST
PAGE 149 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS telmisartan-amlodipine 1 QL 1 / day
TWYNSTA 3 QL 1 / day
SCLEROSING AGENTS
SCLEROSOL 3 sodium tetradecyl sulfate (sul 27% soln, sulfate powd) 3 sterile talc 3 VASODILATING AGENTS betahistine 3 betahistine hcl 3 cyclandelate 3 nylidrin hcl 3 CENTRAL NERVOUS SYSTEM AGENTS
ANTIMANIC AGENTS lithium 1 lithium carbonate (150 mg cap, 300 mg cap, 300 mg tab, 600 mg cap) 1 lithium carbonate powder 3 lithium carbonate er 1 LITHOBID 3 CENTRAL NERVOUS SYSTEM AGENTS, MISC. acamprosate calcium 3 HCG
QL 1 / day PA ADDYI 3 GL Female AL 18 to 60 yrs old
QL 2 / day atomoxetine hcl 1 AL At least 6 yrs old
PAGE 150 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 4 / day PA AUSTEDO 5 AL At least 18 yrs old S carbidopa powder 3 carbidopa 25 mg tablet 1 flibanserin 3 flumazenil powder 3 guanfacine hcl 1 guanfacine hcl er 1 idebenone 3
QL 2 / day PA INGREZZA 40 MG CAPSULE 5 AL At least 18 yrs old S
INTUNIV 3 QL 1 / day
LODOSYN 3 memantine hcl powder 3 AL At least 40 yrs old
QL 360 / 30 days memantine hcl 2 mg/ml solution 1 AL At least 40 yrs old memantine 5-10 mg titration pk 1 AL At least 40 yrs old
QL 2 / day memantine hcl 10 mg tablet 1 AL At least 40 yrs old
QL 3 / day memantine hcl 5 mg tablet 1 AL At least 40 yrs old
NAMENDA (2 MG/ML SOLUTION, 5 MG TABLET, 5-10 MG At least 40 yrs old TITRATION PK, 10 MG TABLET) 3 AL
PAGE 151 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MG ST 3 CAPSULE, 28 MG CAPSULE, TITRATION PACK) AL At least 40 yrs old
NUEDEXTA 2 PA
RILUTEK 3 riluzole 1
QL 2 / day STRATTERA 3 AL At least 6 yrs old
TENEX 3
PA tetrabenazine 5 S
PA XENAZINE 5 S
QL 18 / day XYREM 5 PA S
OPIATE ANTAGONISTS
DEPADE 1 naloxone hcl powder 3 naloxone hcl (0.4 mg/ml carpuject, 0.4 mg/ml vial, 2 mg/2 ml syringe, 4 mg/10 ml vial) 1 naltrexone hcl powder 3 naltrexone 50 mg tablet 1 naltrexone hcl dihydrate 3
NARCAN 2 MG NASAL SPRAY 3 QL 5 / 30 days
NARCAN 4 MG NASAL SPRAY 3 QL 2 / 30 days
REVIA 3
PA VIVITROL 380 MG VIAL 5 S
PAGE 152 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CEPHALOSPORINS
FIRST GENERATION CEPHALOSPORINS cefadroxil (1 gm tablet, 250 mg/5 ml susp, 500 mg capsule, 500 mg/5 ml susp) 1 cefazolin sodium (10 gm vial, 20 gm bulk vial, sod 100 gm bulk bag, sod 300 gm bulk bag, 500 mg vial) 1 cephalexin (125 mg/5 ml susp, 250 mg capsule, 250 mg tablet, 250 mg/5 ml susp, 500 mg capsule, 500 mg tablet, 750 mg 1 capsule)
QL 4 / day DAXBIA 3 ST
KEFLEX 3 FOURTH GENERATION CEPHALOSPORINS cefepime hcl 1 MAXIPIME (1 VIAL, 2 VIAL) 3 SECOND GENERATION CEPHALOSPORINS cefaclor (125 mg/5 ml susp, 250 mg capsule, 250 mg/5 ml susp, 375 mg/5 ml suspen, 500 mg capsule) 1 cefaclor er 1 QL 20 / 30 days
CEFOTAN 3 cefotetan (1 gm vial, 2 gm vial) 1 cefprozil (125 mg/5 ml susp, 250 mg tablet, 250 mg/5 ml susp, 500 mg tablet) 1
CEFTIN (125 MG/5 ML ORAL SUSP, 250 MG/5 ML ORAL SUSP) 2 CEFTIN (250 MG TABLET, 500 MG TABLET) 3 cefuroxime 1 cefuroxime sod 750 mg vial 1 ZINACEF 750 MG VIAL 3
PAGE 153 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THIRD GENERATION CEPHALOSPORINS
CEDAX (180 MG/5 ML SUSPENSION, 400 MG CAPSULE) 3 cefdinir (125 mg/5 ml susp, 250 mg/5 ml susp, 300 mg capsule) 1 cefditoren pivoxil 1
QL 1200 / 90 days cefixime 3 HCG cefotaxime sodium 1 cefpodoxime proxetil (50 mg/5 ml susp, 100 mg tablet, 100 mg/5 ml susp, 200 mg tablet) 1 ceftazidime powder 3 ceftazidime (1 gm vial, 2 gm vial, 6 gm vial) 1 ceftazidime-sodium carbonate 3 ceftibuten (180 mg/5 ml susp, 400 mg capsule) 3 HCG ceftriaxone (2 gm vial, 10 gm vial, 100 gram bulk bag, 250 mg vial, 500 mg vial) 1 ceftriaxone 1 gm vial 1 MED Medical Drug ceftriaxone sodium 3 CLAFORAN (1 GM VIAL, 2 GM VIAL, 10 GM VIAL, 500 MG VIAL) 3 FORTAZ (1 GM VIAL, 2 GM VIAL, 6 GM VIAL, 500 MG VIAL) 3 SPECTRACEF 3 SUPRAX (100 MG TABLET CHEWABLE, 200 MG TABLET CHEWABLE, 400 MG CAPSULE, 500 MG/5 ML SUSPENSION) 3 SUPRAX (100 MG/5 ML SUSPENSION, 200 MG/5 ML 1200 / 90 days SUSPENSION) 3 QL
TAZICEF (1 VIAL, 2 VIAL, 6 VIAL) 1
PAGE 154 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CORTICOSTEROIDS (RESPIRATORY TRACT)
ORALLY INHALED PREPARATIONS (STEROIDS)
AEROSPAN 2 QL 0.334 / day
ARNUITY ELLIPTA 100 MCG INH 2 QL 2 / day
ARNUITY ELLIPTA 200 MCG INH 2 QL 1 / day budesonide (0.25 mg/2 ml susp, 0.5 mg/2 ml susp, 1 mg/2 ml inh susp) 1
FLOVENT 250 MCG DISKUS 2 QL 8 / day
FLOVENT DISKUS (50 MCG, 100 MCG) 2 QL 4 / day
FLOVENT HFA (HFA 110 MCG INHALER, HFA 220 MCG INHALER) 2 QL 0.8 / day
FLOVENT HFA 44 MCG INHALER 2 QL 0.767 / day
PULMICORT 3 QL 120 / 30 days
PULMICORT FLEXHALER 2 QL 0.07 / day
CYSTIC FIBROSIS (CFTR) MODULATORS
CYSTIC FIBROSIS (CFTR) CORRECTORS
QL 4 / day ORKAMBI 5 PA S
CYSTIC FIBROSIS (CFTR) POTENTIATORS
QL 2 / day KALYDECO (50 MG GRANULES PACKET, 75 MG GRANULES PACKET, 150 MG TABLET) 5 PA S
PAGE 155 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DEPIGMENTING AND PIGMENTING AGENTS
DEPIGMENTING AGENTS
ACLARO 3 ALPHAQUIN HP 1 BLANCHE 1 hydroquinone (cream, tl cream, tr cream) 1 hydroquinone (crystals, powder) 3 MELPAQUE HP 1 MELQUIN-3 3 mequinol 3 monobenzone 3 TRI-LUMA 3 PIGMENTING AGENTS
8-MOP 3 methoxsalen (10 mg capsule, 10 mg softgel) 1 methoxsalen (crystal, powder) 3 OXSORALEN 3 OXSORALEN-ULTRA 3
UVADEX 5 S
DIAGNOSTIC AGENTS
ADRENOCORTICAL INSUFFICIENCY adrenocorticotrophic hormone 3 corticotrophin 3 CORTROSYN 3 cosyntropin 0.25 mg vial 1
PA H.P. ACTHAR 5 S
PAGE 156 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ALLERGENIC EXTRACTS (DIAGNOSTIC) acacia 1:20 (w/v) vial 3 acremonium 3 alder 3 almond 3 alternaria 3 american beech 3 american cockroach extract 3 american elm 3 american sycamore 3 apple 3 arizona cypress 3 aspergillus fumigatus 3 aureobasidium 3 australian pine 3 avocado 3 bahia 3 bald cypress 3 banana 3 bayberry 3 beef 3 black walnut pollen 3 black willow 3 botrytis 3 box elder 3 brome 3 california pepper tree 3
PAGE 157 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS candida albicans 3 cantaloupe 3 carelessweed 3 casein 3 cattle epithelium 3 cedar elm 3 chicken meat 3 cladosporium cladosporioides 3 cladosporium sphaerospermum 3 cocklebur 3 cocoa bean 3 corn pollen 3 corn smut 3 crab 3 curvularia 3 d.farinae mite extract 3 d.pteronyssinus mite extract 3 dog epithelium extract 3 dog fennel 3 drechslera 3 eastern cottonwood 3 egg white 3 english plantain 3 epicoccum 3 fire ant 3 fusarium 3 german cockroach 3
PAGE 158 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS goldenrod 3 hackberry 3 honey bee venom protein 3 horse epithelium 3 johnson grass 3 kapok 3 kochia 3 lamb's quarters 3 melaleuca 3 mesquite 3 mixed aspergillus 3 mixed cockroach 3 mixed feathers 3 mixed ragweed extract 3 mixed vespid venom protein 3 mosquito 3 mountain cedar 3 mouse epithelium 3 mucor 3 mugwort 3 oat grain 3 olive tree 3 orange 3 peanut 3 pecan nut 3 pecan pollen 3 penicillium notatum 3
PAGE 159 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS phoma 3 pistachio nut 3 pork 3 privet 3 quack grass 3 queen palm 3 rabbit epithelium 3 red birch 3 red cedar 3 red maple 3 red mulberry 3 red oak 3 rhizopus 3 rice 3 rough marsh elder 3 rough pigweed 3 russian thistle 3 saccharomyces cerevisiae 3 sagebrush 3 sesame seed 3 shagbark hickory 3 sheep sorrel 3 sheep sorrel-yellow dock 3 short ragweed 3 shrimp 3 soybean 3 spiny pigweed 3
PAGE 160 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS standard bermuda grass pollen 3 standard mixed mite extract 3 standard rye grass pollen 3 standard sweet vernal grass 3 standardized cat hair 3 standardized june grass pollen 3 standardized meadow fescue 3 standardized orchard grass 3 standardized red top grass 3 std timothy grass 10,000/ml 3 std timothy grass 100,000/ml 3 QL 1 / day strawberry 3 sweet corn 3 sweetgum 3 tall ragweed 3 trichophyton 3 virginia live oak 3 wasp venom protein 3 western juniper 3 western ragweed 3 white ash 3 white birch 3 white faced hornet venom 3 white mulberry 3 white oak extract 3 white pine 3 whole egg 3
PAGE 161 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS yellow dock 3 yellow hornet venom protein 3 yellow jacket venom protein 3 CARDIAC FUNCTION
IC GREEN 3 indocyanine green 1 DRUG HYPERSENSITIVITY
PRE-PEN 3 FUNGI
CANDIN 3 SPHERUSOL 3 GALLBLADDER FUNCTION
KINEVAC 3 KIDNEY FUNCTION
INDIGO CARMINE 1 indigotindisulfonate sod-water 1 LYMPHATIC SYSTEM
LYMPHAZURIN 3 MYASTHENIA GRAVIS edrophonium chloride 3 ENLON 3 OCULAR DISORDERS
BIOGLO 1 FLUCAINE 1 FLUOR-I-STRIP AT 1 fluorescein powder 3
PAGE 162 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fluorescein-proparacaine 1 FUL-GLO 1 MG OPTH STRIPS 1 FUL-GLO EYE STRIPS 3 MEMBRANEBLUE 3 PANCREATIC FUNCTION secretin-mannitol 3 PITUITARY FUNCTION
METOPIRONE 3 ROENTGENOGRAPHY barium sulfate 3 CONRAY 3 CYSTOGRAFIN 3 CYSTOGRAFIN-DILUTE 3 E-Z DISK 3 E-Z-CAT 3 E-Z-HD 3 E-Z-PAQUE 3 E-Z-PASTE 3 ENTERO VU 3 GASTROGRAFIN 3 ISOVUE-200 41% VIAL 3 LIQUID E-Z PAQUE 3 LIQUID POLIBAR PLUS 3 MD-76 R (R 66-10 INFUSION BOTTLE, R 66-10 VIAL) 3 MD-GASTROVIEW 1 POLIBAR ACB 3 READI-CAT 2 3
PAGE 163 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SINOGRAFIN 3 SITZMARKS 3 TAGITOL 3 ULTRAVIST 3 VARIBAR HONEY 3 VARIBAR NECTAR 3 VARIBAR PUDDING 3 VARIBAR THIN HONEY 3 VARIBAR THIN LIQUID 3 VOLUMEN 3 THYROID FUNCTION protirelin 3 TUBERCULOSIS
APLISOL 3 TUBERSOL 3 DIURETICS
LOOP DIURETICS bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1 bumetanide (0.25 mg/ml vial, 1 mg/4 ml vial, 2.5 mg/10 ml vial) 1
DEMADEX 3 EDECRIN 3 ethacrynic acid 1 furosemide powder 3 furosemide (20 mg/2 ml vial, 40 mg/4 ml syringe, 40 mg/4 ml vial, 100 mg/10 ml syring, 100 mg/10 ml vial) 1 furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet, 40 mg/5 ml soln, 80 mg tablet) 1
PAGE 164 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LASIX 3 torsemide 1 OSMOTIC DIURETICS sorbitol-mannitol 1 POTASSIUM-SPARING DIURETICS amiloride hcl 1 amiloride-hydrochlorothiazide 1 DYAZIDE 3 DYRENIUM 3 MAXZIDE 3 MAXZIDE-25 MG 3 triamterene 3 triamterene-hydrochlorothiazid (37.5-25 mg cp, 37.5-25 mg tb, 50-25 mg cap, 75-50 mg tab) 1 THIAZIDE DIURETICS chlorothiazide 1 DIURIL 3 hydrochlorothiazide powder 3 hydrochlorothiazide (12.5 mg cp, 12.5 mg tb, 50 mg tab) 1 hydrochlorothiazide 25 mg tab 1 LCG methyclothiazide 1 MICROZIDE 3
QL 1 / day TEKTURNA HCT 3 ST trichlormethiazide 3 THIAZIDE-LIKE DIURETICS chlorthalidone 1
PAGE 165 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS indapamide 1 metolazone 1 VASOPRESSIN ANTAGONISTS
QL 1 / day SAMSCA 15 MG TABLET 5 PA S
QL 2 / day SAMSCA 30 MG TABLET 5 PA S
DIURETICS (HYPOTENSIVE AGENTS)
POTASSIUM-SPARING DIURETICS (HYPOTEN)
ALDACTAZIDE 3 ALDACTONE 3 eplerenone 3 HCG
INSPRA 3 spironolactone powder 3 spironolactone (25 mg tablet, 50 mg tablet, 100 mg tablet) 1 spironolactone-hctz 1 THIAZIDE DIURETICS(HYPOTENSIVE AGENTS)
ACCURETIC (10-12.5 MG TABLET, 20-12.5 MG TABLET) 3 QL 2 / day
ACCURETIC 20-25 MG TABLET 3 QL 1 / day
ATACAND HCT (32-12.5 MG TAB, 32-25 MG TABLET) 3 QL 1 / day
ATACAND HCT 16-12.5 MG TAB 3 QL 2 / day
AVALIDE 150-12.5 MG TABLET 3 QL 2 / day
AVALIDE 300-12.5 MG TABLET 3 QL 1 / day
PAGE 166 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS benazepril-hydrochlorothiazide 1 QL 1 / day
BENICAR HCT 3 QL 1 / day candesartan-hctz 16-12.5 mg tb 1 QL 2 / day candesartan-hydrochlorothiazid (32-12.5 mg tb, 32-25 mg tab) 1 QL 1 / day captopril-hydrochlorothiazide 1 QL 2 / day
DIOVAN HCT (320-12.5 MG TAB, 320-25 MG TABLET) 3 QL 1 / day
DIOVAN HCT (80-12.5 MG TABLET, 160-12.5 MG TAB, 160-25 2 / day MG TABLET) 3 QL enalapril-hctz 10-25 mg tablet 1 QL 2 / day enalapril-hctz 5-12.5 mg tab 1 fosinopril-hydrochlorothiazide 1 QL 2 / day
HYZAAR (100-12.5 TABLET, 100-25 TABLET) 3 QL 1 / day
HYZAAR 50-12.5 TABLET 3 QL 2 / day irbesartan-hctz 150-12.5 mg tb 1 QL 2 / day irbesartan-hctz 300-12.5 mg tb 1 QL 1 / day
QL 2 / day lisinopril-hctz 20-25 mg tab 1 LCG lisinopril-hydrochlorothiazide (10-12.5 mg tab, 20-12.5 mg 2 / day tab) 1 QL losartan-hctz 50-12.5 mg tab 1 QL 2 / day losartan-hydrochlorothiazide (100-12.5 mg tab, 100-25 mg 1 / day tab) 1 QL
LOTENSIN HCT 3 QL 1 / day methyldopa-hydrochlorothiazide 1
MICARDIS HCT (40-12.5 MG TABLET, 80-25 MG TABLET) 3 QL 1 / day
MICARDIS HCT 80-12.5 MG TABLET 3 QL 2 / day
PAGE 167 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS moexipril-hydrochlorothiazide 1 QL 2 / day
QL 1 / day olmesartan-amlodipine-hctz 3 HCG olmesartan-hydrochlorothiazide 1 QL 1 / day quinapril-hctz 20-25 mg tab 1 QL 1 / day quinapril-hydrochlorothiazide (10-12.5 mg tab, 20-12.5 mg 2 / day tab) 1 QL
QL 2 / day telmisartan-hctz 80-12.5 mg tb 3 HCG
QL 1 / day telmisartan-hydrochlorothiazid (40-12.5 mg tb, 80-25 mg tab) 3 HCG
TRIBENZOR 3 QL 1 / day valsartan-hydrochlorothiazide (320-12.5 mg tab, 320-25 mg 1 / day tab) 1 QL valsartan-hydrochlorothiazide (80-12.5 mg tab, 160-12.5 mg 2 / day tab, 160-25 mg tab) 1 QL
VASERETIC 3 QL 2 / day
ZESTORETIC 3 QL 2 / day
THIAZIDE-LIKE DIURETICS(HYPOTENSIVE AGT)
CLORPRES 3
QL 1 / day EDARBYCLOR 3 ST
DOPAMINE RECEPTOR AGONISTS
ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS bromocriptine mesylate (2.5 mg tablet, 5 mg capsule) 1 bromocriptine mesylate powder 3 cabergoline 1
PAGE 168 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 6 / day CYCLOSET 3 PA
PARLODEL (2.5 MG TABLET, 5 MG CAPSULE) 3 NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST
PA APOKYN 5 S apomorphine hcl 3 MIRAPEX 3
MIRAPEX ER 3 ST
NEUPRO 3 pramipexole dihydrochloride 1 pramipexole er 3 HCG
REQUIP 3
REQUIP XL 3 QL 1 / day ropinirole er 1 QL 1 / day ropinirole hcl 1 ELECTROLYTIC, CALORIC, AND WATER BALANCE
ACIDIFYING AGENTS ammonium chloride granules 3 K-PHOS NEUTRAL 3 K-PHOS NO.2 3 K-PHOS ORIGINAL 3 PHOSPHA 250 NEUTRAL 1 VIRT-PHOS 250 NEUTRAL 1
PAGE 169 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ALKALINIZING AGENTS
CYTRA-2 1 CYTRA-3 3 CYTRA-K (CRYSTALS PACKET, ORAL SOLUTION) 1 ORACIT 3 potass cit-sod cit-citric acid 1 potassium citrate er 1 potassium cit-citric acid soln 1 SHOHL'S MODIFIED 3 sodium bicarbonate powder 3 sodium citrate powder 3 sodium citrate dihydrate 3 sodium citrate-citric acid 1 TARON-CRYSTALS 1 TRICITRASOL 3 TRICITRATES 1 UROCIT-K 3 VIRTRATE-2 1 VIRTRATE-3 1 VIRTRATE-K 1 AMMONIA DETOXICANTS
BUPHENYL (500 MG TABLET, POWDER) 5 S
CARBAGLU 5 S
CONSTULOSE 1 ENULOSE 1 GENERLAC 1 KRISTALOSE 1
PAGE 170 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS lactulose 1 LITHOSTAT 3
QL 20 / day RAVICTI 5 PA S sodium phenylbutyrate powder 3 S sodium phenylbutyrate 500mg tb 5 S
CALORIC AGENTS
ACD 1 alanine 3 arginine (arginine 100% crystals, l-arginine powder) 3 arginine hcl 3 d-ribose 3 dextrose 3 l-alanine 3 l-citrulline 3 l-cysteine hydrochloride 3 l-leucine 3 leucine 3 lysine hcl 3 LYSIPLEX PLUS 1 phenylalanine 3 tyrosine powder 3 IRRIGATING SOLUTIONS
RESECTISOL 3
PAGE 171 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS REPLACEMENT PREPARATIONS calcium amino acid chelate 3 calcium carbonate 3 calcium chloride powder 3 calcium citrate 3 calcium glubionate 3 calcium gluconate monohydrate 3 calcium levulinate dihydrate 3 calcium phosphate 3 calcium saccharate 3 cardioplegia high potassium 3 cardioplegic 1 EFFER-K (10 TABLET EFF, 20 TABLET EFF) 3 EFFER-K 25 MEQ TABLET EFF 1
FOLBECAL 3 GL Female
FOLGARD OS 3 HYPER-SAL 3 K EFFERVESCENT 1 K-SOL 1 K-TAB ER 3 KLOR-CON 20 MEQ PACKET 1 KLOR-CON 25 MEQ PACKET 3 KLOR-CON 10 1 KLOR-CON 8 1 KLOR-CON M10 1 KLOR-CON M15 3 KLOR-CON M20 1
PAGE 172 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS KLOR-CON SPRINKLE 1 KLOR-CON-EF 1 magnesium amino acid chelate 3 magnesium glycinate 3 manganese chloride 3 manganese gluconate 3 molybdenum 3 MONOJECT 0.9% SODIUM CHLORIDE 1 MONOJECT PREFILL 0.9% FLUSH 1 MONOJECT PREFILL ADVANCED 1 NEBUSAL 3% VIAL 1 NEBUSAL 6% VIAL 3 normal saline flush 1 PLEGISOL 3 potassium bicarbonate 1 potassium chloride (granules, powder) 3 potassium chloride (er 8 meq capsule, er 8 meq tablet, 10% (20 meq/15 ml, 10% (40 meq/30 ml, er 10 meq capsule, er 10 meq tablet, 20 meq packet, 20% (40 meq/15 ml, er 20 meq tablet, 1 25 meq tab eff) potassium citrate 3 potassium citrate monohydrate 3 potassium phosphate powder 3
PRENAISSANCE NEXT 3 GL Female
PRISMASOL (B22GK 2/0, B22GK 4/0, BGK 0/2.5, BGK 2/0, BGK 2/3.5, BGK 4/0/1.2, BGK 4/2.5, BK 0/0/1.2) 3
PULMOSAL 1 selenomethionine 3 sodium acetate trihydrate (crys, powd) 3
PAGE 173 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sodium cacodylate 3 sodium chloride granules 3 sodium chloride (bacteriostatic saline vial, sodium chloride 0.9% vial) 1 sodium chloride (0.9% inhal vl, 0.9% syringe, 0.9% zr syr, 3% vial, 7% vial, 10% vial) 1 sodium l-aspartate monohydrate 3 SYREX 1 zinc chloride powder 3 zinc picolinate 3 zinc sulfate (heptahydrate powd, powder) 3 SALT AND SUGAR SUBSTITUTES saccharin 1 URICOSURIC AGENTS probenecid 1 QL 4 / day probenecid-colchicine 1 QL 2 / day
QL 1 / day ZURAMPIC 3 PA AL At least 18 yrs old
EMOLLIENTS, DEMULCENTS, AND PROTECTANTS
BASIC LOTIONS AND LINIMENTS ammonium lactate 12% lotion 1 ATOPICLAIR 3 calamine 3 lactic acid 10% lotion 1 PRUCLAIR 3
PAGE 174 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BASIC OILS AND OTHER SOLVENTS
AVO CREAM 3 BIAFINE 3 LUXAMEND 1 muri-lube mineral oil 3 PRUTECT 3 SONAFINE 3 SYNERDERM 3 BASIC OINTMENTS AND PROTECTANTS ammonium lactate 12% cream 1 DEXERYL 3 ELETONE CREAM 3 lactic acid 10% e cream 1 TETRIX 3 VASELINE WHITE PETROLEUM 3 XCLAIR 3 ESTROGENS AND ANTIESTROGENS
ESTROGEN AGONIST-ANTAGONISTS clomiphene citrate powder 3 clomiphene citrate 50 mg tab 1 GL Female
DUAVEE 2
EVISTA 3 QL 1 / day
OSPHENA 3 raloxifene hcl 0 HCR
SEROPHENE 1 GL Female
PAGE 175 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ESTROGENS
QL 1 / day ACTIVELLA 3 GL Female
QL 0.29 / day ALORA 3 GL Female
QL 1 / day AMABELZ 1 GL Female
QL 1 / day ANGELIQ 3 GL Female
QL 0.15 / day CLIMARA 3 GL Female
QL 0.15 / day CLIMARA PRO 2 GL Female
QL 0.29 / day COMBIPATCH 3 GL Female
COVARYX 1 GL Female
COVARYX H.S. 1 GL Female
DELESTROGEN 3 GL Female
DEPO-ESTRADIOL 3 GL Female diethylstilbestrol 3 DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 1 MG GEL Female PACKET) 2 GL
EEMT 1 GL Female
EEMT H.S. 1 GL Female
ELESTRIN 3 GL Female
QL 1 / day ENJUVIA 2 GL Female
PAGE 176 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ESTRACE 0.01% CREAM 2 GL Female
QL 1 / day ESTRACE (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET) 3 GL Female estradiol (0.025 mg patch, 0.0375 mg patch, 0.05 mg patch, QL 0.29 / day 1 0.075 mg patch, 0.1 mg patch) GL Female estradiol (tds 0.025 mg/day, 0.0375 mg/day patch, tds 0.0375 QL 0.15 / day mg/day, tds 0.05 mg/day, tds 0.06 mg/day, 0.075 mg/day 1 patch, tds 0.075 mg/day, tds 0.1 mg/day) GL Female
QL .15 / day estradiol 0.06 mg/day patch 1 GL Female estradiol powder 3
QL 1 / day estradiol (0.5 mg tablet, 1 mg tablet) 1 GL Female LCG estradiol 10 mcg vaginal insrt 1 GL Female
QL 1 / day estradiol 2 mg tablet 1 GL Female estradiol benzoate 3 estradiol cypionate 3 estradiol micronized 3 estradiol valerate powder 3 estradiol valerate (20 mg/ml vl, 40 mg/ml vl) 1 GL Female
QL 1 / day estradiol-norethindrone acetat 1 GL Female
QL 90 days ESTRING 2 GL Female estriol 3 GL Female
PAGE 177 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS estriol micronized 3 GL Female
QL 1.667 / day ESTROGEL 3 GL Female estrogen-methyltestosterone 1 GL Female estrone (crystal, powder) 3
QL 1 / day estropipate 1 GL Female LCG
QL 0.54 / day EVAMIST 3 GL Female
QL 1 / day FEMHRT 3 GL Female
QL 0.02 / day FEMRING 3 GL Female
FYAVOLV 1 GL Female
JEVANTIQUE LO 3 GL Female
QL 1 / day JINTELI 0 GL Female HCR
QL 1 / day LOPREEZA 1 GL Female
QL 1 / day MENEST (0.625 MG TABLET, 1.25 MG TABLET, 2.5 MG TABLET) 3 GL Female
QL 1 / day MENEST 0.3 MG TABLET 2 GL Female
QL 0.15 / day MENOSTAR 3 GL Female
PAGE 178 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day MIMVEY 1 GL Female
MIMVEY LO 1
QL 0.29 / day MINIVELLE 3 GL Female norethindron-ethinyl estradiol (norethin-eth 1 mg-5 mcg, norethind-eth 0.5-2.5) 0 HCR
QL 1 / day OGEN 3 GL Female
QL 1 / day PREFEST 3 GL Female
PREMARIN VAGINAL CREAM-APPL 2 GL Female
PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, QL 1 / day 2 0.9 MG TABLET, 1.25 MG TABLET) GL Female
PREMARIN 25 MG VIAL 2
QL 1 / day PREMPHASE 2 GL Female
QL 1 / day PREMPRO 2 GL Female
VAGIFEM 3 GL Female
QL 8 / 28 days VIVELLE-DOT 3 GL Female
YUVAFEM 1 GL Female
PAGE 179 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EYE, EAR, NOSE AND THROAT (EENT) PREPS.
ANTIALLERGIC AGENTS
ALOMIDE 3 QL 10 / fill
ASTEPRO 3 QL 2 / day azelastine hcl 0.05% drops 1 QL 0.267 / day azelastine hcl powder 3 azelastine hcl (0.1% (137 mcg) spry, 0.15% nasal spray) 1 QL 2 / day
BEPREVE 3 QL 0.286 / day
ELESTAT 3 QL 0.286 / day
EMADINE 3 QL 5 / fill epinastine hcl 1 QL 0.286 / day
QL 3 / 30 days LASTACAFT 3 ST olopatadine hcl (0.1% drops, 0.2% drop) 1 QL 0.286 / day
QL 31 / 30 days olopatadine 665 mcg nasal spry 3 HCG
PATADAY 3 QL 0.286 / day
PATANASE 3 QL 31 / 30 days
PATANOL 3 QL 0.286 / day
PAZEO 3 QL 0.286 / day
EENT DRUGS, MISCELLANEOUS acetylcysteine-water 1 QL 10 / 30 days apraclonidine hcl 1 QL 0.8 / day
ATROVENT 3 QL 2 / day
PAGE 180 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS balanced salt 1 BSS 1 BSS PLUS 3 CELLUGEL 3
PA CYSTARAN 5 S
GELFILM OPHTHALMIC 25X50MM 3
IOPIDINE (0.5% DROPS, 1% DROPS) 3 QL 0.8 / day ipratropium bromide (0.03% spray, 0.06% spray) 1 QL 2 / day
LACRISERT 3
QL 0.04 / day LUCENTIS (0.3 MG/0.05 ML VIAL, 0.5 MG/0.05 ML SYRING, 0.5 MG/0.05 ML VIAL) 5 PA S
OCUCOAT 1 LOCAL ANESTHETICS (EENT)
AKTEN 3 ALCAINE 3 ALTACAINE 1 ALTAFLUOR 1 BUCALSEP (SOLUTION, SPRAY) 3 cocaine hcl (hcl crystals, hcl powder, hydrochloride pwd) 3 cocaine 4% solution 1 cyclopentolate-lidoc-pe-tropic 1 dyclonine hcl 3 fluorescein-benoxinate 1 FLUROX 1 GLYDO 1
PAGE 181 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS lidocaine hcl (2% jelly, 4% solution) 1 lidocaine hcl viscous 1 proparacaine 0.5% eye drops 1 proparacaine hcl powder 3 TETCAINE 1 tetracaine hcl (eye drops, steri-unit sol) 1 TETRAVISC 1 TETRAVISC FORTE 1 XYLOCAINE 4% SOLUTION 3 MYDRIATICS atropine sulfate (drops, ointment) 1 atropine 0.01%-ns eye drops 1 CYCLOGYL 3 CYCLOMYDRIL 3 cyclopentolate hcl (0.5% eye drops, 1% eye drops, hcl 2% drops) 1 cyclopentolate hcl powder 3 cyclopentolate-tropicamide-pe 1 HOMATROPAIRE 1 homatropine hydrobromide 1 homatropine methylbromide 3 hydroxyamphetamine hbr 3 ISOPTO ATROPINE 3 MYDRIACYL 3 PAREMYD 3 tropicamide (0.5% drops, 1% drops) 1 tropicamide powder 3
PAGE 182 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VASOCONSTRICTORS
ADRENALIN CHLORIDE 3 PA naphazoline hcl 1 oxymetazoline hcl 3 phenylephrine hcl (2.5% drop, 10% drops) 1 tetrahydrozoline hcl 3 TYZINE (PEDIATRIC 0.05% DROP, 0.1% NOSE DROPS, 0.1% NOSE SPRAY) 3 FIRST GENERATION ANTIHISTAMINES
ETHYLENEDIAMINE DERIVATIVES pyrilamine maleate 3 tripelennamine hcl 3 PHENOTHIAZINE DERIVATIVES trimeprazine tartrate 3 GASTROINTESTINAL DRUGS
ANTACIDS AND ADSORBENTS aluminum hydroxide 3 magnesium oxide 3 ANTI-INFLAMMATORY AGENTS (GI DRUGS)
5-aminosalicylic acid 3
GL Female alosetron hcl 1 AL At least 18 yrs old
APRISO 2 balsalazide disodium 1 CANASA 2 COLAZAL 3
PAGE 183 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DIPENTUM 3
GIAZO 3 GL Male
LIALDA 2
PA LOTRONEX 3 GL Female AL At least 18 yrs old mesalamine (4 gm/60 ml enema, 4 gm/60 ml kit) 1 mesalamine powder 3 mesalamine dr 1.2 gm tablet 3 HCG
PENTASA 3 ROWASA 3 SFROWASA 3 ANTIDIARRHEA AGENTS acidophilus lactobacillus 3 attapulgite 3 bismuth subsalicylate 3
FULYZAQ 5 S loperamide 2 mg capsule 1 loperamide hcl powder 3 MOTOFEN 3
MYTESI 5 S opium tincture 1 QL 5 / day paregoric 1
PA XERMELO 5 AL At least 18 yrs old S
PAGE 184 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIFLATULENTS simethicone 3 CATHARTICS AND LAXATIVES
QL 2 / day AMITIZA 2 AL At least 18 yrs old bisacodyl 3 cascara sagrada 3 COLYTE WITH FLAVOR PACKETS 3 docusate sodium 3
GAVILYTE-C 0 HCR
GAVILYTE-G 0 HCR
GAVILYTE-N 0 HCR
GOLYTELY PACKET 0 HCR
GOLYTELY SOLUTION 3 karaya gum 3
MOVIPREP 0 HCR
NULYTELY WITH FLAVOR PACKS 3 OSMOPREP 3 peg 3350-electrolyte (3350 electrolyte soln, 3350-electrolyte solution) 0 HCR peg-3350 and electrolytes 0 HCR peg-3350 with flavor packs 0 HCR
PEG-PREP 1 polyethylene glycol 3350 0 HCR
PREPOPIK 3 QL 2 / fill sodium phosphate powder 3
PAGE 185 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sodium sulfate 3 sorbitol 70% solution 1
SUPREP 3 QL 354 / fill
TRILYTE WITH FLAVOR PACKETS 0 HCR
CHOLELITHOLYTIC AGENTS
ACTIGALL 3
CHENODAL 5 S
URSO 3 URSO FORTE 3 ursodiol powder 3 ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 1 DIGESTANTS
CREON 2 hydrochloric acid 3 pancreatin 3 pancreatin 8x 3 ZENPEP 2 GI DRUGS, MISCELLANEOUS
QL 7 / day CHOLBAM 250 MG CAPSULE 5 PA S
QL 4 / day CHOLBAM 50 MG CAPSULE 5 PA S
QL 0.08 / day CIMZIA (200 MG VIAL KIT, 200 MG/ML SYRINGE KIT) 5 PA S
PAGE 186 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 3/ fill CIMZIA 200 MG/ML STARTER KIT 5 PA S
ENTEREG 3
PA GATTEX 5 S glutamine 3
QL 0.22 / day PA HUMIRA (20 MG/0.4 ML SYRINGE, 40 MG/0.8 ML SYRINGE) 4 S PS
QL 0.15 / day PA HUMIRA 10 MG/0.2 ML SYRINGE 4 S PS
QL 0.22 / day PA HUMIRA PEDIATRIC CROHN'S 4 S PS
QL 0.22 / day PA HUMIRA PEN 4 S PS
QL 0.22 / day PA HUMIRA PEN CROHN-UC-HS STARTER 4 S PS
QL 0.22 / day PA HUMIRA PEN PSORIASIS-UVEITIS 4 S PS
PAGE 187 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS l-glutamine 3
QL 1 / day LINZESS 2 ST
NUTRESTORE 3
QL 1 / day OCALIVA 5 PA S
RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 ML SYRINGE, 12 MG/0.6 ML VIAL) 3 PA
RELISTOR 150 MG TABLET 3 PA
RESTORA SPRINKLES 3
QL 2 / day VIBERZI 2 PA
XENICAL 3 LIPOTROPIC AGENTS choline bitartrate 3 phosphatidylcholine 3 PROKINETIC AGENTS metoclopramide hcl powder 3 metoclopramide hcl (5 mg tablet, 5 mg/5 ml soln, 10 mg tablet, 10 mg/10 ml sol) 1 LCG metoclopramide 10 mg/2 ml syr 1 metoclopramide 10 mg/2 ml vial 1 LCG metoclopramide hcl odt 1 METOZOLV ODT 3 REGLAN 3
PAGE 188 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GENERAL ANESTHETICS
GENERAL ANESTHETICS, MISCELLANEOUS etomidate powder 3 KETALAR 3 ketamine hcl (100 mg/ml vial, 200 mg/20 ml vial, 500 mg/10 ml vial, 500 mg/5 ml vial, 1,000 mg/10 ml vial) 1 ketamine hydrochloride 3 INHALATION ANESTHETICS chloroform 3 COMPOUND 347 1 FORANE 3 isoflurane 1 sevoflurane 1 SOJOURN 1 SUPRANE 3 TERRELL 1 ULTANE 3 GENITOURINARY SMOOTH MUSCLE RELAXANTS
ANTIMUSCARINICS
QL 1 / day darifenacin er 3 HCG
DETROL 3 QL 2 / day
DETROL LA 3 QL 1 / day
DITROPAN XL (10 MG TABLET, 15 MG TABLET) 3 QL 2 / day
DITROPAN XL 5 MG TABLET 3 QL 1 / day
ENABLEX 3 QL 1 / day
PAGE 189 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS flavoxate hcl 1
QL 3.067 / day GELNIQUE 3% GEL 3 ST
QL 1 / day GELNIQUE (GEL PUMP, GEL SACHETS) 3 ST oxybutynin chloride powder 3 oxybutynin 5 mg/5 ml syrup 1 QL 20 / day oxybutynin 5 mg tablet 1 QL 4 / day oxybutynin chloride er (er 10 mg tablet, er 15 mg tablet) 1 QL 2 / day oxybutynin cl er 5 mg tablet 1 QL 1 / day
QL 0.357 / day OXYTROL 3 ST tolterodine tartrate 1 QL 2 / day
QL 1 / day tolterodine tartrate er 3 HCG
TOVIAZ 3 QL 1 / day
QL 2 / day trospium chloride 3 HCG
QL 1 / day trospium chloride er 3 HCG
VESICARE 2 QL 1 / day
HCV ANTIVIRALS
HCV POLYMERASE INHIBITORS
QL 1 / day PA EPCLUSA 4 S PS
PAGE 190 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day PA HARVONI 4 S PS
QL 1 / day PA SOVALDI 4 S PS
HCV PROTEASE INHIBITORS
QL 1 / day OLYSIO 5 PA S
QL 1 / day ZEPATIER 5 PA S
HCV REPLICATION COMPLEX INHIBITORS
QL 1 / day DAKLINZA 5 PA S
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
A-HYDROCORT 3 A-METHAPRED 1 aldosterone 3 ARISTOSPAN 3 beclomethasone dipropionate 3 betamethasone acetate micro 3
PAGE 191 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS betamethasone acetate-sod phos 1 betamethasone sodium phosphate 3 budesonide ec 3 HCG
CELESTONE 3 CORTEF 3 cortisone acetate powder 3 cortisone 25 mg tablet 1 DELTASONE 1 DEPO-MEDROL 3 desoxycorticosterone acetate 3 dexamethasone (0.5 mg tablet, 0.5 mg/5 ml elx, 0.5 mg/5 ml liq, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg 1 tablet, 6 mg tablet) dexamethasone acetate 3 dexamethasone acetate micro 3 DEXAMETHASONE INTENSOL 2 dexamethasone isonicotinate 3 dexamethasone micronized 3 dexamethasone sod ph powder 3 DEXPAK 3
PA EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/ML ORAL At least 5 yrs old SUSP, 30 MG TABLET, 36 MG TABLET) 5 AL S
ENTOCORT EC 3 EZ USE JOINT-TUNNEL-TRIGGER 3 FLO-PRED 3 fludrocortisone acetate powder 3 fludrocortisone 0.1 mg tablet 1
PAGE 192 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS flunisolide powder 3 fluticasone propionate powder 3 fluticasone propionate micro 3 hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) 1
QL 1 / day INTRAROSA 3 AL At least 18 yrs old
KENALOG-10 3 KENALOG-40 3 MEDROL (4 MG DOSEPAK, 4 MG TABLET, 8 MG TABLET, 16 MG TABLET, 32 MG TABLET) 3
MEDROL 2 MG TABLET 2 methylprednisolone powder 3 methylprednisolone (4 mg dosepk, 4 mg tablet, 8 mg tab, 16 mg tab, 32 mg tab) 1 methylprednisolone ac micro 3 methylprednisolone acetate 1 methylprednisolone sodium succ (40 mg vl, 125 mg) 1 MILLIPRED (5 MG TABLET, 10 MG/5 ML SOLUTION) 3 MILLIPRED DP 3 ORAPRED ODT 3 PEDIAPRED 3 prednisolone (anhydrous powder, powder) 3 prednisolone (15 mg/5 ml soln, 15 mg/5 ml syrup) 1 prednisolone acetate micronize 3 prednisolone micronized 3 prednisolone sodium phos odt 1 prednisolone sod ph powder 3 prednisolone sodium phosphate (5 mg/5 ml soln, 10 mg/5 ml soln, 20 mg/5 ml soln, sod ph 25 mg/5 ml) 1
PAGE 193 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS prednisone powder 3 prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab dose pack, 5 mg tablet, 5 mg/5 ml solution, 10 mg tab dose pack, 10 mg 1 tablet, 20 mg tablet, 50 mg tablet)
PREDNISONE INTENSOL 2 prednisone micronized 3 RAYOS 3 SOLU-CORTEF 3 SOLU-MEDROL (40 MG VIAL, 125 MG VIAL) 3 triamcinolone 3 triamcinolone acetonide powder 3 triamcinolone acetonide (40mg/ml vl, 50mg/5ml vl) 1 triamcinolone diacetate 3 triamcinolone diacetate micro 3 triamcinolone hexacetonide 3 UCERIS (2 MG RECTAL FOAM, 9 MG ER TABLET) 3 VERIPRED 20 3 ZODEX 6 DAY 1.5 MG TABLET 3 ANDROGENS
ANADROL-50 3 GL Male
QL 1 / day ANDRODERM 2 PA GL Male
QL 5 / day ANDROGEL (1.62% GEL PUMP, 1.62%(1.25G) GEL PCKT, 1.62%(2.5G) GEL PCKT) 2 PA GL Male
PA ANDROID 3 GL Male
PAGE 194 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS androstenedione 3
PA ANDROXY 3 GL Male danazol (50 mg capsule, 100 mg capsule, 200 mg capsule) 1 danazol powder 3 dehydroepiandrosterone 3
PA DELATESTRYL 3 GL Male
DEPO-TESTOSTERONE (100 MG/ML VL, 200 MG/ML) 3 GL Male dhea micronized 3 fluoxymesterone 3
PA METHITEST 3 GL Male methyltestosterone 10 mg cap 1 methyltestosterone powder 3 methyltestosterone micronized 3 nandrolone decanoate 3
QL 3 / day PA NATESTO 3 GL Male AL At least 18 yrs old
PA OXANDRIN 3 GL Male oxandrolone powder 3
PA oxandrolone (2.5 mg tablet, 10 mg tablet) 1 GL Male stanozolol 3
PAGE 195 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS stanozolol micronized 3
PA STRIANT 3 GL Male testosterone powder 3 GL Male testosterone cypionate powder 3 GL Male testosterone cypionate (testosteron 1,000 mg/10 ml, testosteron 2,000 mg/10 ml, testosterone 100 mg/ml, 1 GL Male testosterone 200 mg/ml) testosterone cypionate micro 3 GL Male testosterone enanthate powder 3 GL Male testosterone enanthate (testosteron 1,000 mg/5 ml, PA 1 testosterone 200 mg/ml) GL Male testosterone micronized 3 GL Male testosterone propionate 3 GL Male
PA TESTRED 3 GL Male
CONTRACEPTIVES
QL 1 / day ALTAVERA 0 GL Female HCR
GL Female ALYACEN 0 HCR
QL 91 days AMETHIA 0 GL Female HCR
QL 91 days AMETHIA LO 0 GL Female HCR
PAGE 196 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day AMETHYST 0 GL Female HCR
GL Female APRI 0 HCR
GL Female ARANELLE 0 HCR
GL Female ASHLYNA 0 HCR
QL 1 / day AUBRA 0 GL Female HCR
QL 1 / day AVIANE 0 GL Female HCR
GL Female AZURETTE 0 HCR
GL Female BALZIVA 0 HCR
GL Female BEKYREE 0 HCR
BEYAZ 3 GL Female
GL Female BLISOVI 24 FE 0 HCR
GL Female BLISOVI FE 0 HCR
PAGE 197 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BREVICON 3 GL Female
GL Female BRIELLYN 0 HCR
GL Female CAMILA 0 HCR
QL 91 days CAMRESE 0 GL Female HCR
QL 91 days CAMRESE LO 0 GL Female HCR
GL Female CAZIANT 0 HCR
QL 1 / day CHATEAL 0 GL Female HCR
GL Female CRYSELLE 0 HCR
GL Female CYCLAFEM 0 HCR
CYCLESSA 3 GL Female
GL Female CYRED 0 HCR
GL Female DASETTA 0 HCR
QL 91 days DAYSEE 0 GL Female HCR
PAGE 198 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female DEBLITANE 0 HCR
QL 1 / day DELYLA 0 GL Female HCR
DESOGEN 3 GL Female
GL Female desogestr-eth estrad eth estra 0 HCR
GL Female desogestrel-ethinyl estradiol 0 HCR
GL Female drospirenone-eth estra-levomef 0 HCR
GL Female drospirenone-ethinyl estradiol 0 HCR
GL Female ELINEST 0 HCR
QL 1 / day ELLA 0 GL Female HCR
GL Female EMOQUETTE 0 HCR
GL Female ENPRESSE 0 HCR
GL Female ENSKYCE 0 HCR
GL Female ERRIN 0 HCR
PAGE 199 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female ESTARYLLA 0 HCR
ESTROSTEP FE 3 GL Female
GL Female ethynodiol-ethinyl estradiol 0 HCR
QL 1 / day FALMINA 0 GL Female HCR
QL 91 days FAYOSIM 0 GL Female HCR
FEMCON FE 3 GL Female
GL Female FEMYNOR 0 HCR
GENERESS FE 3 GL Female
GL Female GIANVI 0 HCR
GL Female GILDAGIA 0 HCR
GL Female GILDESS 0 HCR
GL Female GILDESS 24 FE 0 HCR
GL Female GILDESS FE 0 HCR
GL Female HEATHER 0 HCR
PAGE 200 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 91 days INTROVALE 0 GL Female HCR
GL Female ISIBLOOM 0 HCR
GL Female JENCYCLA 0 HCR
QL 91 days JOLESSA 0 GL Female HCR
GL Female JOLIVETTE 0 HCR
GL Female JULEBER 0 HCR
GL Female JUNEL 0 HCR
GL Female JUNEL FE 0 HCR
GL Female JUNEL FE 24 0 HCR
GL Female KAITLIB FE 0 HCR
GL Female KARIVA 0 HCR
GL Female KELNOR 1-35 0 HCR
PAGE 201 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female KIMIDESS 0 HCR
QL 1 / day KURVELO 0 GL Female HCR
GL Female LARIN 0 HCR
GL Female LARIN 24 FE 0 HCR
GL Female LARIN FE 0 HCR
QL 1 / day LARISSIA 0 GL Female HCR
GL Female LAYOLIS FE 0 HCR
GL Female LEENA 0 HCR
QL 1 / day LESSINA 0 GL Female HCR
GL Female LEVONEST 0 HCR
GL Female levono-e estrad 0.15-0.03-0.01 0 HCR
QL 91 days levonorg-eth estrad eth estrad (levono-e estrad 0.10-0.02-0.01, Female levonorg 0.15mg-ee 20-25-30mcg) 0 GL HCR
PAGE 202 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 0.07 / day levonorgestrel 0 GL Female HCR
QL 91 days levonor-eth estrad 0.15-0.03 0 GL Female HCR
GL Female levonor-eth estrad triphasic 0 HCR
QL 1 / day levonorgestrel-eth estradiol (estra 0.09-0.02 mg, estrad 0.1- Female 0.02 mg) 0 GL HCR
QL 1 / day LEVORA-28 0 GL Female HCR
QL 1 / day LILLOW 0 GL Female HCR
GL Female LO LOESTRIN FE 0 HCR
LOESTRIN 3 GL Female
LOESTRIN FE 1-20 TABLET 3 GL Female
GL Female LOESTRIN FE 1.5-30 TABLET 0 HCR
GL Female LOMEDIA 24 FE 0 HCR
GL Female LORYNA 0 HCR
PAGE 203 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 91 days LOSEASONIQUE 3 GL Female
GL Female LOW-OGESTREL 0 HCR
QL 1 / day LUTERA 0 GL Female HCR
GL Female LYZA 0 HCR
QL 1 / day MARLISSA 0 GL Female HCR
GL Female MELODETTA 24 FE 0 HCR
GL Female MIBELAS 24 FE 0 HCR
GL Female MICROGESTIN 0 HCR
GL Female MICROGESTIN 24 FE 0 HCR
GL Female MICROGESTIN FE 0 HCR
MINASTRIN 24 FE 3 GL Female
MIRCETTE 3 GL Female
MODICON 3 GL Female
GL Female MONO-LINYAH 0 HCR
PAGE 204 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female MONONESSA 0 HCR
GL Female MYZILRA 0 HCR
NATAZIA 2 GL Female
NECON (0.5-35-28 TABLET, 1-35-28 TABLET, 1-50-28 TABLET, GL Female 0 10-11-28 TABLET) HCR
QL 1 / day NECON 7-7-7-28 TABLET 3 GL Female HCR
GL Female NIKKI 0 HCR
NOR-Q-D 3 GL Female
GL Female NORA-BE 0 HCR norethin-eth estra-ferrous fum (noret-estr-fe 0.4-0.035(21)-75, GL Female noreth-estrad-fe 1-0.02(21)-75, noreth-estrad-fe 1-0.02(24)- 0 75, norethin-estra-fe 0.8-0.025 mg) HCR
GL Female norethind-eth estrad 1-0.02 mg 0 HCR
GL Female norethindrone 0.35 mg tablet 0 HCR
GL Female norgestimate-ethinyl estradiol 0 HCR
GL Female NORINYL 1+50 0 HCR
NORINYL 1-35 3 GL Female
PAGE 205 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female NORLYDA 0 HCR
GL Female NORLYROC 0 HCR
GL Female NORTREL 0 HCR
GL Female NUVARING 0 HCR
GL Female OCELLA 0 HCR
QL 1 / day OGESTREL 0 GL Female HCR
QL 1 / day ORSYTHIA 0 GL Female HCR
ORTHO MICRONOR 3 GL Female
ORTHO TRI-CYCLEN 3 GL Female
ORTHO TRI-CYCLEN LO 3 GL Female
ORTHO-CEPT 3 GL Female
ORTHO-CYCLEN 3 GL Female
ORTHO-NOVUM 3 GL Female
OVCON-35 3 GL Female
GL Female PHILITH 0 HCR
PAGE 206 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female PIMTREA 0 HCR
GL Female PIRMELLA 0 HCR
QL 2 / 30 days PLAN B ONE-STEP 3 GL Female
QL 1 / day PORTIA 0 GL Female HCR
GL Female PREVIFEM 0 HCR
QUARTETTE 3 GL Female
QL 91 days QUASENSE 0 GL Female HCR
GL Female RAJANI 0 HCR
GL Female RECLIPSEN 0 HCR
QL 91 days RIVELSA 0 GL Female HCR
SAFYRAL 3 GL Female
QL 91 days SEASONIQUE 3 GL Female
QL 91 days SETLAKIN 0 GL Female HCR
PAGE 207 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female SHAROBEL 0 HCR
GL Female SPRINTEC 0 HCR
QL 1 / day SRONYX 0 GL Female HCR
GL Female SYEDA 0 HCR
GL Female TARINA FE 0 HCR
GL Female TAYTULLA 0 HCR
GL Female TILIA FE 0 HCR
GL Female TRI FEMYNOR 0 HCR
GL Female TRI-ESTARYLLA 0 HCR
GL Female TRI-LEGEST FE 0 HCR
GL Female TRI-LINYAH 0 HCR
GL Female TRI-LO-ESTARYLLA 0 HCR
GL Female TRI-LO-MARZIA 0 HCR
PAGE 208 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female TRI-LO-SPRINTEC 0 HCR
TRI-NORINYL 3 GL Female
GL Female TRI-PREVIFEM 0 HCR
GL Female TRI-SPRINTEC 0 HCR
GL Female TRINESSA 0 HCR
GL Female TRINESSA LO 0 HCR
GL Female TRIVORA-28 0 HCR
GL Female VELIVET 0 HCR
GL Female VESTURA 0 HCR
QL 1 / day VIENVA 0 GL Female HCR
GL Female VIORELE 0 HCR
GL Female VYFEMLA 0 HCR
GL Female WERA 0 HCR
PAGE 209 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GL Female WYMZYA FE 0 HCR
QL 0.12 / day XULANE 0 GL Female HCR
YASMIN 28 3 GL Female
YAZ 3 GL Female
GL Female ZARAH 0 HCR
GL Female ZENCHENT 0 HCR
GL Female ZENCHENT FE 0 HCR
GL Female ZEOSA 0 HCR
GL Female ZOVIA 1-35E 0 HCR
GL Female ZOVIA 1-50E 0 HCR
GONADOTROPINS
PA GL Female BRAVELLE 4 S PS chorionic gonadotropin (1 million unit, 2 million unit, 5 million unit, 10mm unit, 10,000 unit vl) 5 S chorionic gonadotropin powder 3
PAGE 210 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PA ELIGARD 5 S
FOLLISTIM AQ (75 UNIT VIAL, 300 UNIT CARTRIDG, 600 UNIT PA 5 CARTRIDG, 900 UNIT CARTRIDG) S
PA GONAL-F 4 S PS
PA GL Female GONAL-F RFF 4 S PS
PA GL Female GONAL-F RFF REDI-JECT 4 S PS
PA leuprolide acetate (1 mg/0.2 ml vial, 2wk 1 mg/0.2 ml kit) 5 S
PA leuprolide acetate (14 mg/2.8 ml kt, 14 mg/2.8 ml vl) 5 S
LUPANETA PACK 5 S
LUPRON DEPOT (DEPOT-4 MONTH KIT, DEPOT 7.5 MG KIT, PA DEPOT 11.25 MG 3MO KIT, DEPOT 22.5 MG 3MO KIT, DEPOT 45 5 MG 6MO KIT) S
PA LUPRON DEPOT 3.75 MG KIT 5 S
PA LUPRON DEPO 11.25MG (LUPANETA) 5 S
PA LUPRON DEPOT 3.75MG (LUPANETA) 5 S
PAGE 211 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG 3MO, 11.25 MG PA 5 KIT, 15 MG KIT, 30 MG 3MO KIT) S
PA GL Female MENOPUR 4 S PS
PA NOVAREL 10,000 UNITS VIAL 5 S
PA OVIDREL 4 S PS
PA PREGNYL 5 S
PA SYNAREL 5 S
LEPTINS
PA MYALEPT 5 S
PARATHYROID calcitonin-salmon 1 QL 0.13 / day
PA FORTEO 5 S
FORTICAL 3 QL 0.13 / day
MIACALCIN 200 UNIT NASAL SPRAY 3 QL 0.13 / day
MIACALCIN 400 UNIT/2 ML VIAL 5 S
PA NATPARA 5 S
PAGE 212 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1.60 / day PA TYMLOS 5 AL At least 18 yrs old S
PITUITARY
DDAVP 0.01% NASAL SPRAY 3 desmopressin 10 mcg/0.1 ml spr 1 GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4 MG, MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1 MG, PA MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK 1.6 MG, 5 MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MG S CARTRIDGE)
HUMATROPE (5 MG VIAL, 6 MG CARTRIDGE, 12 MG CARTRIDGE, PA 5 24 MG CARTRIDGE) S
PA NORDITROPIN FLEXPRO 4 S PS
PA NUTROPIN AQ 5 S
PA NUTROPIN AQ NUSPIN 5 S
OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML PA 5 CRTG) S
PA SAIZEN (5 MG VIAL, 8.8 MG CLICK.EASY CARTG, 8.8 MG VIAL) 5 S
PA SAIZEN-SAIZENPREP 5 S sermorelin acetate 3
PAGE 213 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day SEROSTIM 5 PA S vasopressin 1
PA ZOMACTON 5 S
QL 1 / day ZORBTIVE 5 PA S
PROGESTINS
AYGESTIN 3 GL Female
CRINONE 4% GEL 3 GL Female
CRINONE 8% GEL 3 GL Female
DEPO-PROVERA (150 MG/ML SYRINGE, 150 MG/ML VIAL) 3 GL Female
DEPO-PROVERA 400 MG/ML VIAL 3
QL 90 days DEPO-SUBQ PROVERA 104 0 GL Female HCR
GL Female ENDOMETRIN 4 S PS hydroxyprogesterone cap powder 3
PA hydroxyprogesterone 1.25 g/5ml 5 GL Female S
PA GL Female MAKENA (250 MG/ML VIAL, 1,250 MG/5 ML VIAL) 4 S PS
PAGE 214 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS medroxyprogesterone ac micro 3
QL 0.04 / day medroxyprogesterone 150 mg/ml 0 GL Female HCR
GL Female medroxyprogesterone acetate (2.5 mg tab, 5 mg tab, 10 mg tab) 1 LCG norethindrone powder 3 norethindrone ac (lupaneta) 1 GL Female norethindrone acetate powder 3 norethindrone 5 mg tablet 1 GL Female progesterone (100 mg capsule, 200 mg capsule) 1 GL Female progesterone powder 3 progesterone oil 50 mg/ml vl 1 GL Female progesterone in oil 1 GL Female progesterone micronized 3 GL Female
PROMETRIUM 3 GL Female
PROVERA 3 GL Female
HYPOTENSIVE AGENTS
CENTRAL ALPHA-AGONISTS
CATAPRES 3
CATAPRES-TTS 1 3 QL 0.15 / day
CATAPRES-TTS 2 3 QL 0.4 / day
CATAPRES-TTS 3 3 QL 0.4 / day
QL 0.29 / day clonidine (0.2 mg/day patch, 0.3 mg/day patch) 3 HCG
PAGE 215 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 0.15 / day clonidine 0.1 mg/day patch 3 HCG clonidine hcl powder 3 clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1 LCG
QL 4 / day clonidine hcl er 3 HCG guanabenz acetate 3
QL 4 / day KAPVAY 3 ST methyldopa 1 DIRECT VASODILATORS
BIDIL 3 QL 6 / day hydralazine hcl powder 3 hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1 hydralazine 20 mg/ml vial 1 minoxidil powder 3 minoxidil (2.5 mg tablet, 10 mg tablet) 1 HYPOTENSIVE AGENTS, MISCELLANEOUS guanethidine hemisulfate 3 mecamylamine hcl 3
PA VECAMYL 5 S
PERIPHERAL ADRENERGIC INHIBITORS rauwolfia serpentina 3 reserpine powder 3 reserpine (0.1 mg tablet, 0.25 mg tablet) 1
PAGE 216 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ION-REMOVING AGENTS
OTHER ION-REMOVING AGENTS
RADIOGARDASE 3 PHOSPHATE-REMOVING AGENTS
AURYXIA 3 calcium acetate (667 mg capsule, 667 mg gelcap, 667 mg tablet) 1
ELIPHOS 3 FOSRENOL (750 MG POWDER PACKET, 1,000 MG POWDER PACK) 3 FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET CHEW, 1,000 MG TABLET CHEW) 2 lanthanum carbonate 1 PHOSLYRA 3 RENAGEL 3 RENVELA (0.8 GM POWDER PACKET, 2.4 GM POWDER PACKET) 3 RENVELA 800 MG TABLET 2 sevelamer carbonate (0.8 gm powder packet, 2.4 gm powder packet, carbonate 800 mg tab) 3 HCG
VELPHORO 3 POTASSIUM-REMOVING AGENTS
KAYEXALATE 3 KIONEX (15 GM/60 ML SUSPENSION, POWDER) 1 sodium polystyrene sulfonate (sod polystyren sulf 15 g/60 ml, sodium polystyrene sulf powder, sps 15 gm/60 ml suspension, 1 sps 30 gm/120 ml enema, sps 50 gm/200 ml enema)
SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML ENEMA) 1
QL 1 / day VELTASSA 3 PA
PAGE 217 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MACROLIDES
ERYTHROMYCINS erythromycin powder 3 erythromycin estolate 3 erythromycin e.s. powder 3 KETOLIDES
KETEK 3 OTHER MACROLIDES azithromycin powder 3 azithromycin (1 gm pwd packet, 100 mg/5 ml susp, 200 mg/5 ml susp, 500 mg tablet, 600 mg tablet) 1 azithromycin 250 mg tablet 1 QL 6 / 5 days
DIFICID 3 PA
ZITHROMAX 100 MG/5 ML SUSP 3 QL 30 / fill
ZITHROMAX 200 MG/5 ML SUSP 3 QL 60 / fill
ZITHROMAX (1 GM POWDER PACKET, 250 MG Z-PAK TABLET) 3
ZITHROMAX 250 MG TABLET 3 QL 6 / 5 days
ZITHROMAX 500 MG TABLET 3 QL 5 / fill
ZITHROMAX 600 MG TABLET 3 QL 0.29 / day
ZITHROMAX TRI-PAK 3
ZMAX 2 QL 60 / fill
MISCELLANEOUS B-LACTAM ANTIBIOTICS
CARBAPENEMS
INVANZ 1 GM VIAL 3
PAGE 218 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MONOBACTAMS
AZACTAM 3 aztreonam 1
PA CAYSTON 5 S
MISCELLANEOUS THERAPEUTIC AGENTS
5-ALPHA-REDUCTASE INHIBITORS
QL 1 / day AVODART 3 GL Male
QL 1 / day dutasteride 3 GL Male HCG finasteride powder 3
QL 1 / day finasteride 5 mg tablet 1 GL Male
QL 1 / day PROSCAR 3 GL Male
ALCOHOL DETERRENTS
ANTABUSE 3 disulfiram powder 3 disulfiram (250 mg tablet, 500 mg tablet) 1 ANTIDOTES amyl nitrite 1 BAL IN OIL 3 calcium disodium versenate 1 CHEMET 3
PAGE 219 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS deferoxamine mesylate 1 DESFERAL 3 DESFERAL MESYLATE 3 dmsa powder 3 edetate calcium disodium 3 leucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab, 25 mg tab) 1 leucovorin calcium (50 mg vial, 100 mg vial, 200 mg vial, 350 mg vial, 500 mg vl) 5 S
MEPHYTON 2 methylpyrazole 3 phytonadione 1 mg/0.5 ml syr 1 pralidoxime chloride 300 mg/ml 1 pralidoxime chloride powder 3 PROTOPAM CHLORIDE 3 succimer dmsa 3
VISTOGARD 5 S vitamin k1 1 ANTIGOUT AGENTS allopurinol powder 3
QL 3 / day allopurinol 100 mg tablet 1 LCG
QL 2 / day allopurinol 300 mg tablet 1 LCG
ANAPROX 3 ANAPROX DS 3 colchicine 0.6 mg capsule 1 QL 2 / day colchicine powder 3
PAGE 220 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS colchicine 0.6 mg tablet 1 QL 4 / day
COLCRYS 2 QL 4 / day
EC-NAPROSYN 3
INDOCIN 25 MG/5 ML SUSPENSION 3 QL 6 / day
INDOCIN 50 MG SUPPOSITORY 3 QL 4 / day indomethacin 25 mg capsule 1 LCG indomethacin 50 mg capsule 1 indomethacin er 1
QL 2 / day MITIGARE 3 ST
NAPRELAN (CR 375 MG TABLET, CR 500 MG TABLET) 3
NAPRELAN CR 750 MG TABLET 3 QL 1 / day
NAPROSYN (125 MG/5 ML SUSPEN, 250 MG TABLET, 500 MG TABLET) 3 naproxen (125 mg/5 ml suspen, 375 mg tablet, 500 mg kit, 500 mg tablet) 1 LCG naproxen (250 mg tablet, dr 375 mg tablet, dr 500 mg tablet, ec 375 mg tablet, ec 500 mg tablet) 1 naproxen sodium (275 mg tab, 550 mg tab) 1 naproxen sodium cr 3 HCG naproxen sodium ds 1 naproxen sod er 375 mg tablet 3 HCG
TIVORBEX 3
QL 1 / day ULORIC 2 ST
ZYLOPRIM 100 MG TABLET 3 QL 3 / day
ZYLOPRIM 300 MG TABLET 3 QL 2 / day
PAGE 221 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BONE RESORPTION INHIBITORS
ACTONEL (5 MG TABLET, 30 MG TABLET) 3 QL 1 / day
ACTONEL 150 MG TABLET 3 QL 0.04 / day
ACTONEL 35 MG TABLET 3 QL 0.15 / day alendronate sodium (5 mg tablet, 10 mg tab) 1 QL 1 / day alendronate sodium (sod 70 mg/75 ml, sodium 35 mg tab, .15 / day sodium 40 mg tab, sodium 70 mg tab) 1 QL
QL 0.15 / day ATELVIA 3 ST
BINOSTO 3 QL .15 / day
BONIVA 150 MG TABLET 3 QL 0.04 / day etidronate disodium 1
FOSAMAX 3 QL .15 / day
FOSAMAX PLUS D 3 QL 0.15 / day ibandronate sodium 150 mg tab 1 QL 0.04 / day
QL 0.04 / day risedronate sodium 150 mg tab 3 HCG risedronate sodium 30 mg tab 3 HCG
QL 0.15 / day risedronate sodium 35 mg tab 3 HCG
QL 1 / day risedronate sodium 5 mg tablet 3 HCG risedronate sodium dr 1 CARIOSTATIC AGENTS
CLINPRO 5000 1
PAGE 222 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DENTA 5000 PLUS 1 DENTAGEL 1
FLUOR-A-DAY 2.5 MG/ML DROPS 0 HCR
FLUOR-A-DAY (0.25 MG TAB CHEW, 0.5 MG TAB CHEW, 1 MG TABLET CHEW) 3
FLUORABON 3 fluoride 0 HCR
FLUORIDEX 1 FLUORIDEX DAILY DEFENSE 1 FLUORIDEX SENSITIVITY RELIEF 1 FLUORITAB (0.125 MG/DRP DROPS, 0.5 MG TABLET CHEW, 1 MG TABLET CHEW) 0 HCR
FLURA-DROPS 0 HCR
LUDENT FLUORIDE 0 HCR multivitamin with fluoride (0.25 mg/ml drop, 0.5 mg/ml drop) 1 multivitamin with fluoride (multivit-fluor 0.25 mg tab chw, multivit-fluor 0.5 mg tab chew, multivit-fluoride 1 mg tab chw) 3 POLY-VI-FLOR (0.25 MG DROPS, 0.25 MG TAB CHEW, 0.5 MG TAB CHEW, 1 MG TAB CHEW) 3 PREVIDENT (0.2% RINSE, 1.1% GEL, 5000 BOOSTER PLUS, DENTAL RINSE) 3
PREVIDENT 5000 3 PREVIDENT 5000 ENAMEL PROTECT 3 PREVIDENT 5000 PLUS 3 PREVIDENT 5000 SENSITIVE 3 SF 1 SF 5000 PLUS 1 sodium fluoride powder 3 neutral sodium fluoride 1
PAGE 223 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sodium fluoride (0.5 mg(1.1 mg), 0.5 mg/ml drop, 1 mg (2.2 mg)) 0 HCR
TRI-VI-FLOR 3 COMPLEMENT INHIBITORS
PA FIRAZYR 5 S
DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
QL 0.15 / day ACTEMRA 162 MG/0.9 ML SYRINGE 5 PA S
ARAVA 3 AZASAN 3 azathioprine powder 3 azathioprine 50 mg tablet 1 azathioprine sodium 1 CUPRIMINE 3 cyclosporine (25 mg capsule, 100 mg capsule, 100 mg/ml soln) 5 S cyclosporine modified 5 S
DEPEN 2
QL 0.15 / day PA ENBREL 50 MG/ML SURECLICK SYR 4 S PS
QL 0.29 / day ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/ML PA 4 SYRINGE) S PS
PAGE 224 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GENGRAF (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 100 MG/ML SOLUTION) 5 S gold sodium thiomalate 3 IMURAN 3
QL 0.1 / day PA KEVZARA 5 AL At least 18 yrs old S leflunomide 1 methotrexate (1 gm vial, 2.5 mg tablet, 50 mg/2 ml vial, 250 mg/10 ml vial) 1 methotrexate sodium 1 NEORAL (25 MG GELATIN CAPSULE, 100 MG GELATIN CAPSULE, 100 MG/ML SOLUTION) 5 S
QL 0.15 / day ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 ML SYRINGE, 125 MG/ML SYRINGE) 5 PA S
QL 0.15 / day ORENCIA CLICKJECT 5 PA S
QL 2 / day OTEZLA (28 DAY STARTER PACK, 30 MG TABLET, STARTER PACK) 5 PA S
QL 0.08 / day OTREXUP 3 PA penicillamine 3 penicillamine(d-) 3
QL .08 / day RASUVO (10 MG/0.2 ML, 12.5 MG/0.25 ML) 3 PA
PAGE 225 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RASUVO (7.5 MG/0.15 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 QL 0.08 / day MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 3 ML, 30 MG/0.6 ML) PA
RHEUMATREX 3 RIDAURA 2
SANDIMMUNE (25 MG CAPSULE, 100 MG CAPSULE) 5 S
S SANDIMMUNE 100 MG/ML SOLN 4 PS
QL 0.04 / day SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 ML SYRINGE, 100 MG/ML PEN INJECTOR, 100 MG/ML SYRINGE) 5 PA S
QL 0.08 / day STELARA (45 MG/0.5 ML SYRINGE, 45 MG/0.5 ML VIAL, 90 MG/ML SYRINGE) 5 PA S
TREXALL 2
QL 4 / day XATMEP 3 PA AL Up to 18 yrs old
QL 2 / day XELJANZ 5 PA S
QL 1 / day XELJANZ XR 5 PA S
GONADOTROPIN-RELEASING HORMONE ANTAGNTS
PA GL Female CETROTIDE 4 S PS
PAGE 226 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PA FIRMAGON 120 MG VIAL 5 S
GL Female ganirelix acetate 5 S
IMMUNOMODULATORY AGENTS
ACTIMMUNE 5 S
QL 1 / day PA AUBAGIO 4 S PS
QL 0.15 / day AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG, PREFILLED PA 4 SYR 30 MCG KT) S PS
QL 0.15 / day PA AVONEX PEN (PEN 30 MCG/0.5 ML, PEN 30 MCG/0.5 ML KIT) 4 S PS
QL 0.5 / day BETASERON (0.3 MG KIT, 0.3 MG VIAL) 5 PA S
QL 1 / day PA COPAXONE 4 S PS
QL 0.5 / day EXTAVIA (0.3 MG KIT, 0.3 MG VIAL) 5 PA S
PAGE 227 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day PA GILENYA 4 S PS
QL 1 / day GLATOPA 5 PA S
QL 0.04 / day PA PLEGRIDY 125 MCG/0.5 ML SYRING 4 S PS
QL 1 / lifetime PA PLEGRIDY SYRINGE STARTER PACK 4 S PS
QL 0.04 / day PA PLEGRIDY 125 MCG/0.5 ML PEN 4 S PS
QL 1 / lifetime PA PLEGRIDY PEN INJ STARTER PACK 4 S PS
QL 1 / day POMALYST 5 PA S
QL 0.22 / day REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML SYRINGE) 5 PA S
PAGE 228 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 4.2 / 365 days REBIF TITRATION PACK 5 PA S
QL 0.22 / day REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML) 5 PA S
QL 4.2 / 365 days REBIF REBIDOSE TITRATION PACK 5 PA S
QL 1 / day REVLIMID 5 PA S
QL 2 / day PA TECFIDERA 4 S PS
QL 2 / day THALOMID (150 MG CAPSULE, 200 MG CAPSULE) 5 PA S
QL 1 / day THALOMID (50 MG CAPSULE, 100 MG CAPSULE) 5 PA S
QL 1 / day ZINBRYTA 5 PA S
IMMUNOSUPPRESSIVE AGENTS
QL 15 / day ASTAGRAF XL 0.5 MG CAPSULE 5 PA S
PAGE 229 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 30 / day ASTAGRAF XL 1 MG CAPSULE 5 PA S
QL 6 / day ASTAGRAF XL 5 MG CAPSULE 5 PA S
CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500 MG TABLET) 5 S cyclophosphamide (25 mg capsule, 50 mg capsule) 1 PA cyclophosphamide powder 3 cyclophosphamide monohydrate 3 cyclosporine (a powder, powder) 3
QL 2.5 / day ELIDEL 2 ST AL At least 2 yrs old
QL 1 / day ENVARSUS XR 5 PA S mercaptopurine powder 3 mercaptopurine 50 mg tablet 1 mycophenolate 200 mg/ml susp 5 S mycophenolate mofetil (250 mg capsule, 500 mg tablet) 5 S mycophenolic acid 5 S
MYFORTIC 5 S
PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE) 5 S
PA PURIXAN 5 S
PAGE 230 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/ML ORAL SOLN, 2 MG TABLET) 5 S sirolimus powder 3 sirolimus (1 mg tablet, 2 mg tablet) 5 S sirolimus 0.5 mg tablet 5 S
QL 2 / day tacrolimus 0.5 mg capsule 5 S
QL 8 / day tacrolimus 1 mg capsule 5 S
QL 4 / day tacrolimus 5 mg capsule 5 S tacrolimus (monohydrate powder, powder) 3 tacrolimus micronized 3
PA ZORTRESS 5 S
OTHER MISCELLANEOUS THERAPEUTIC AGENTS
4-aminopyridine 3 acetyl-l-carnitine hcl 3 acetylcysteine powder 3 acetylcysteine (10% vial, 20% vial) 1 alcohol,dehydrated (ampule, vial) 1 aminobutyric acid 3
QL 2 / day PA AMPYRA 4 S PS
PA ARCALYST 5 S
PAGE 231 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS beta glucan (1-3) nq 3 betaine hydrochloride 3
PA BOTOX COSMETIC 5 S butylated hydroxytoluene(bht) 3 calcium folinate 3 CARDIOVID PLUS 3 CARNITOR (100 MG/ML ORAL SOLN, 330 MG TABLET) 3 CARNITOR SF 3
QL 2 / day CERDELGA 5 PA S chondroitin sulfate 3 chondroitin sulfate sodium 3 coenzyme q10 3 coumarin 3 cryoserv 3 curcumin 3
CYSTADANE 5 S
CYSTAGON 5 S cysteamine hcl 3 DEMSER 3 diaminopyridine 3 dibutyl squarate 3 edetate disodium 3 EPIFIX AMNIOTIC MEMBRANE 3 ginkgo biloba 3
PAGE 232 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS glucosamine hcl 3 glucosamine sulfate kcl 3 glucosamine sulfate sodium 3 GRAFIX CORE 5CM X 5CM MATRIX 3 GRAFIX PRIME 5CM X 5CM MATRIX 3
QL 1 / day GRASTEK 3 PA
QL 0.04 / day ILARIS 150 MG/ML VIAL 5 PA S indole-3-carbinol 3
QL 4 / day KEVEYIS 5 PA S
KUVAN (100 MG POWDER PACKET, 100 MG TABLET, 500 MG PA 5 POWDER PACKET) S l-carnitine 3 l-theanine 3 leucovorin calcium powder 3 levocarnitine (l-carnitine powder, levocarnitine powder) 3 lycopene 3 melatonin 3 NEXAVIR 3 nicotinamide adenine 3
ORALAIR (100-300 IR CHILD SAMPL, 300 IR ADULT SAMPLE KT, PA 5 300 IR STARTER PACK, 300 IR SUBLINGUAL TAB) S
ORALAIR 100 IR STARTER PACK 5 S
PAGE 233 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 MG PA 5 CAPSULE, 10 MG CAPSULE, 20 MG CAPSULE) S
POTABA 3 potassium perchlorate 3
PROCYSBI 5 S pyruvic acid 3
QL 1 / day RAGWITEK 3 PA resveratrol 3
QL 2 / day SENSIPAR (30 MG TABLET, 60 MG TABLET) 5 PA S
QL 4 / day SENSIPAR 90 MG TABLET 5 PA S
STRAVIX (STRAVI3CM 6CM, STRAVI4CM 7CM) 3 theanine 3 THIOLA 3 tiopronin 3 turmeric root 3
S TYBOST 4 PS ubidecarenone 3 ubiquinol 3 VP-ZEL 3
XURIDEN 5 S
PA ZAVESCA 5 S
PAGE 234 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROTECTIVE AGENTS
ELMIRON 3
MESNEX 400 MG TABLET 5 S pentosan polysulfate sodium 3 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
CYCLOOXYGENASE-2 (COX-2) INHIBITORS
CELEBREX (50 MG CAPSULE, 200 MG CAPSULE) 3 QL 2 / day
CELEBREX 100 MG CAPSULE 3 QL 3 / day
CELEBREX 400 MG CAPSULE 3 QL 1 / day celecoxib (50 mg capsule, 200 mg capsule) 1 QL 2 / day celecoxib 100 mg capsule 1 QL 3 / day celecoxib 400 mg capsule 1 QL 1 / day celecoxib powder 3 OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS
ANSAID 3 DAYPRO 3 diclofenac potassium 1 diclofenac 1.5% topical soln 3 HCG
QL 1000/ 30 days diclofenac sodium 1% gel 3 HCG diclofenac sodium powder 3 diclofenac sodium (dr 25 mg tab, dr 50 mg tab, dr 75 mg tab, ec 25 mg tab, ec 50 mg tab, ec 75 mg tab) 1 diclofenac sodium er 1 diclofenac sodium micronized 3 diflunisal 1
PAGE 235 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS etodolac (200 mg capsule, 300 mg capsule, 400 mg tablet, 500 mg tablet) 1 etodolac er 1 FELDENE 3 fenoprofen calcium (200 mg capsule, 400 mg capsule, 600 mg tablet) 1 fenoprofen calcium powder 3 FENORTHO 3
FLECTOR 3 QL 2 / day flurbiprofen powder 3 flurbiprofen (50 mg tablet, 100 mg tablet) 1 ibuprofen 100 mg/5 ml susp 1 ibuprofen powder 3 ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) 1 LCG indomethacin powder 3 ketoprofen er 200 mg capsule 3 HCG ketoprofen 50 mg capsule 1 LCG ketoprofen 75 mg capsule 1 ketoprofen powder 3 ketoprofen micronized 3 ketorolac tromethamine (15 mg/ml carpuject, 15 mg/ml isecure 40 / 23 days syr, 15 mg/ml vial) 1 QL ketorolac tromethamine (30 mg/ml carpuject, 60 mg/2 ml QL 20 / 30 days 1 carpuject, 60 mg/2 ml vial) LCG ketorolac tromethamine powder 3 ketorolac tromethamine (30 mg/ml isecure syr, 30 mg/ml 20 / 23 days syringe) 1 QL
QL 21 / fill ketorolac 10 mg tablet 1 LCG
PAGE 236 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 20 / 23 days ketorolac 30 mg/ml vial 1 LCG ketorolac tromethamine (60 mg/2 ml syringe, 300 mg/10 ml 20 / 30 days vial) 1 QL
KLOFENSAID II 3 HCG
LODINE 3 meclofenamate sodium (50 mg capsule, 100 mg capsule) 1 meclofenamate sodium powder 3
QL 5 / day mefenamic acid 250 mg capsule 3 HCG mefenamic acid powder 3 meloxicam 7.5 mg/5 ml susp 1 QL 10 / day meloxicam powder 3
QL 1 / day meloxicam (7.5 mg tablet, 15 mg tablet) 1 LCG
MOBIC 7.5 MG/5 ML SUSPENSION 3 QL 10 / day
MOBIC (7.5 MG TABLET, 15 MG TABLET) 3 QL 1 / day nabumetone powder 3 nabumetone (500 mg tablet, 750 mg tablet) 1 nabumetone micronized 3 NALFON 3 naproxen powder 3 naproxen sodium powder 3 oxaprozin 3 HCG
PENNSAID 2% PUMP 3 QL 3.8 / day phenylbutazone 3
PAGE 237 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS piroxicam (10 mg capsule, 20 mg capsule) 1 AL Up to 75 yrs old piroxicam powder 3
PONSTEL 3 QL 5 / day
PROFENO 1
SPRIX 3 QL 5 days sulindac powder 3 sulindac (150 mg tablet, 200 mg tablet) 1 tolmetin sodium (200 mg tab, 400 mg cap, 600 mg tab) 1 TOXICOLOGY SALIVA COLLECTION 3
QL 1 / day VIVLODEX 3 PA AL At least 18 yrs old
VOLTAREN 3 QL 1000/ 30 days
VOLTAREN-XR 3
ZIPSOR 3 QL 4 / day
SALICYLATES carisoprodol compound 1 carisoprodol-aspirin 1 choline mag trisalicylate 1 choline magnesium trisalicylat 3 DISALCID 3 salsalate powder 3 salsalate (500 mg tablet, 750 mg tablet) 1
PAGE 238 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PENICILLINS
AMINOPENICILLINS amoxicillin (125 mg tab chew, 250 mg tab chew, 250 mg/5 ml susp, 500 mg capsule, 500 mg tablet) 1 amoxicillin (125 mg/5 ml susp, 200 mg/5 ml susp, 250 mg capsule, 400 mg/5 ml susp, 875 mg tablet) 1 LCG amoxicillin er 1 amoxicillin trihydrate 3 amoxicillin-clavulanate pot 3 amoxicillin-clavulanate pot er 3 HCG amoxicillin-clavulanate potass (200-28.5 mg tab chew, 200- 28.5 mg/5 ml sus, 250-125 mg tablet, 250-62.5 mg/5 ml sus, 400-57 mg tab chew, 400-57 mg/5 ml susp, 500-125 mg tablet, 1 600-42.9 mg/5 ml sus, 875-125 mg tablet) ampicillin sodium (1 gm vial, 2 gm vial, 10 gm vial, 125 mg vial, 250 mg vial, 500 mg vial) 1 ampicillin trihydrate (125 mg/5 ml susp, 250 mg capsule, 250 mg/5 ml susp, 500 mg capsule) 1 ampicillin-sulbactam (3 gm vial, 15 gm vl) 1 ampicillin-sulbactam 1.5 gm vl 1 MED Medical Drug
AUGMENTIN 125-31.25 MG/5 ML 2 AUGMENTIN (250-62.5 MG/5 ML, 500-125 TABLET, 875-125 TABLET) 3
AUGMENTIN ES-600 3 AUGMENTIN XR 3 MOXATAG 3 UNASYN 3 EXTENDED-SPECTRUM PENICILLINS ticarcillin disod-clavulanate 3
PAGE 239 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NATURAL PENICILLINS
BICILLIN C-R 3 BICILLIN L-A 3 penicillin g potassium 1 penicillin g procaine 1 penicillin g sodium 1 penicillin v potassium (125 mg/5 ml soln, 250 mg tablet, 250 mg/5 ml soln, 500 mg tablet) 1 LCG
PFIZERPEN 3 PENICILLINASE-RESISTANT PENICILLINS dicloxacillin 250 mg capsule 1 dicloxacillin 500 mg capsule 1 LCG nafcillin sodium (1 gm vial, 2 gm vial, 10 gm bulk vial, 10 gm vial) 1 oxacillin sodium (1 gm vial, 2 gm vial, 10 gm vial) 1 RENIN-ANGIOTENSIN-ALDOSTER.INHIB(HYPOTN)
ANGIOTENSIN II RECEPTOR ANTAGON.(HYPOTN)
ATACAND 3 QL 1 / day
AVAPRO 3 QL 1 / day
BENICAR 3 QL 3 / day candesartan cilexetil 1 QL 1 / day
COZAAR (25 MG TABLET, 50 MG TABLET) 3 QL 2 / day
COZAAR 100 MG TABLET 3 QL 1 / day
DIOVAN (40 MG TABLET, 80 MG TABLET, 160 MG TABLET) 3 QL 2 / day
DIOVAN 320 MG TABLET 3 QL 1 / day
QL 1 / day EDARBI 3 ST
PAGE 240 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS eprosartan mesylate 1 QL 1 / day irbesartan 1 QL 1 / day
QL 2 / day losartan potassium (25 mg tab, 50 mg tab) 1 LCG
QL 1 / day losartan potassium 100 mg tab 1 LCG
MICARDIS 3 QL 1 / day olmesartan medoxomil 1 QL 3 / day telmisartan 1 QL 1 / day valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet) 1 QL 2 / day valsartan 320 mg tablet 1 QL 1 / day
ANGIOTENSIN-CONVERT.ENZYME INHIB(HYPOTN)
ACCUPRIL 3 QL 2 / day
ACEON 3 QL 1 / day
ALTACE 3 QL 2 / day benazepril hcl (10 mg tablet, 40 mg tablet) 1 QL 2 / day benazepril hcl 20 mg tablet 1 QL 4 / day benazepril hcl 5 mg tablet 1 QL 3 / day captopril powder 3 captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg 4 / day tablet) 1 QL enalapril maleate powder 3 enalapril maleate (2.5 mg tab, 5 mg tablet, 10 mg tab, 20 mg 2 / day tab) 1 QL
EPANED (1 MG/ML ORAL SOLUTION, 1 MG/ML SOLUTION) 3 QL 5 / day
PAGE 241 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fosinopril sodium 1 QL 2 / day lisinopril 100% powder 3
QL 1 / day lisinopril (2.5 mg tablet, 10 mg tablet, 20 mg tablet) 1 LCG lisinopril (5 mg tablet, 30 mg tablet) 1 QL 1 / day lisinopril 40 mg tablet 1 QL 2 / day
LOTENSIN 20 MG TABLET 3 QL 4 / day
LOTENSIN 40 MG TABLET 3 QL 2 / day
MAVIK 3 QL 2 / day moexipril hcl 1 QL 1 / day perindopril erbumine 1 QL 1 / day
PRINIVIL 3 QL 1 / day
QBRELIS 3 QL 40/ day quinapril hcl 1 QL 2 / day ramipril 1 QL 2 / day trandolapril 1 QL 2 / day
VASOTEC 3 QL 2 / day
ZESTRIL 3 QL 1 / day
RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB
ANGIOTENSIN II RECEPTOR ANTAGONISTS
QL 2 / day ENTRESTO 3 PA
PAGE 242 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANGIOTENSIN-CONVERTING ENZYME INHIBITORS benazepril hcl powder 3 RENIN INHIBITORS
QL 1 / day TEKTURNA 3 ST
RESPIRATORY TRACT AGENTS
ANTIFIBROTIC AGENTS
QL 9 / day ESBRIET (267 MG CAPSULE, 267 MG TABLET) 5 PA S
QL 3 / day ESBRIET 801 MG TABLET 5 PA S
QL 2 / day OFEV 5 PA S
ANTITUSSIVES benzonatate 1 AL At least 11 yrs old dextromethorphan hbr 3
QL 60 / day FLOWTUSS 3 AL At least 18 yrs old
TESSALON PERLE 3 AL At least 11 yrs old
ZONATUSS 3 AL At least 11 yrs old
EXPECTORANTS bromhexine hcl 3 guaifenesin 3
PAGE 243 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS terpin hydrate 3 MUCOLYTIC AGENTS
QL 5 / day PULMOZYME 5 PA S
PHOSPHODIESTERASE TYPE 4 INHIBITORS
QL 1 / day DALIRESP 3 PA
PULMONARY SURFACTANTS
CUROSURF 3 INFASURF 3 SURVANTA 3 VASODILATING AGENTS (RESPIRATORY TRACT)
QL 2 / day ADCIRCA 5 PA S
QL 3 / day ADEMPAS 5 PA S
QL 1 / day PA LETAIRIS 4 S PS
QL 1 / day OPSUMIT 5 PA S
QL 3 / day ORENITRAM ER 5 PA S
PAGE 244 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PA REMODULIN 5 S
QL 6 / day PA REVATIO 10 MG/ML ORAL SUSP 5 AL At least 18 yrs old S
QL 3 / day PA REVATIO 20 MG TABLET 5 AL At least 18 yrs old S
QL 3 / day sildenafil 5 PA S sildenafil citrate powder 3
QL 2 / day PA TRACLEER (62.5 MG TABLET, 125 MG TABLET) 4 S PS
QL 1 / day TYVASO 5 PA S
QL 1 / day TYVASO INSTITUTIONAL START KIT 5 PA S
QL 1 / day TYVASO REFILL KIT 5 PA S
QL 1 / day TYVASO STARTER KIT 5 PA S
PAGE 245 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PA UPTRAVI 200-800 TITRATION PACK 5 AL At least 18 yrs old S
QL 2 / day UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600 MCG PA TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCG 5 TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET) AL At least 18 yrs old S
SKELETAL MUSCLE RELAXANTS
CENTRALLY ACTING SKELETAL MUSCLE RELAXNT
AMRIX 3 carisoprodol powder 3 carisoprodol (250 mg tablet, 350 mg tablet) 1 chlorzoxazone 500 mg tablet 1 cyclobenzaprine hcl powder 3 cyclobenzaprine 10 mg tablet 1 LCG cyclobenzaprine hcl (5 mg tablet, 7.5 mg tablet) 1 FEXMID 3 LORZONE 3 METAXALL 1 metaxalone 3 HCG methocarbamol powder 3 methocarbamol (500 mg tablet, 750 mg tablet) 1 methocarbamol 1,000 mg/10 ml 1 PARAFON FORTE DSC 3 ROBAXIN 500 MG TABLET 3 ROBAXIN 1,000 MG/10 ML VIAL 3 ROBAXIN-750 3
PAGE 246 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SKELAXIN 3 SOMA 3 tizanidine hcl (2 mg capsule, 2 mg tablet, 4 mg capsule, 4 mg tablet, 6 mg capsule) 1 tizanidine hcl powder 3 ZANAFLEX (2 MG CAPSULE, 4 MG CAPSULE, 4 MG TABLET, 6 MG CAPSULE) 3 DIRECT-ACTING SKELETAL MUSCLE RELAXANTS
DANTRIUM (25 MG CAPSULE, 50 MG CAPSULE) 3 dantrolene sodium (25 mg cap, 50 mg cap, 100 mg cap) 1 dantrolene sodium powder 3 GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT baclofen powder 3 baclofen (10 mg tablet, 20 mg tablet) 1 NEUROMUSCULAR BLOCKING AGENTS pancuronium bromide powder 3 rocuronium bromide powder 3 succinylcholine chloride powd 3 vecuronium bromide powder 3 SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS orphenadrine citrate powder 3 orphenadrine er 100 mg tablet 1 orphenadrine citrate (30 mg/ml vial, 60 mg/2 ml ampule, 60 mg/2 ml vial) 1 SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)
ALA-CORT 1 ALA-SCALP 3
PAGE 247 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS alclometasone dipropionate (dipr oint, dipro crm) 1 amcinonide (cream, lotion, ointment) 1 ANA-LEX 2-2% CREAM 3 ANALPRAM HC (1% CREAM, 2.5%-1% CREAM, 2.5%-1% CRM SINGLE, 2.5%-1% LOTION) 3
ANUCORT-HC 1 ANUSOL-HC 2.5% CREAM 3 ANUSOL-HC 25 MG SUPPOSITORY 1 APEXICON E 3 betamethasone dipropionate (aug crm, aug gel, aug lot, aug oin, crm, lot, oint) 1 betamethasone dp powder 3 betamethasone valerate (va 0.1% cream, va 0.1% lotion, valer 0.1% ointm, valer 0.12% foam) 1 betamethasone valerate powder 3 calcipotriene-betamethasone dp 1 QL 3 / day
CAPEX SHAMPOO 3 clobetasol emollient (emollient crm, emollnt foam) 1 clobetasol emulsion 1 clobetasol propionate (cream, gel, ointment, prop foam, prop spray, shampoo, solution, topical lotn) 1 clobetasol propionate micro 3 CLOBEX (SHAMPOO, SPRAY, TOPICAL LOTION) 3 clocortolone pivalate 1 CLODAN 0.05% SHAMPOO 1 CLODERM 3 COLOCORT 1 CORMAX 1 CORTENEMA 3
PAGE 248 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CORTIFOAM 3 CUTIVATE (CREAM, LOTION) 3 DERMA-SMOOTHE-FS (BODY OIL, SCALP OIL) 3 DERMATOP (EMOLLIENT CREAM, OINTMENT) 3 DESONATE 3 desonide (cream, lotion, ointment) 3 HCG desonide micronized 3 DESOWEN (CREAM, LOTION) 3 desoximetasone (0.05% cream, 0.05% gel, 0.05% ointment, 0.25% cream, 0.25% ointment) 3 HCG desoximetasone powder 3 diflorasone diacetate (cream, ointment) 1 DIPROLENE (LOTION, OINTMENT) 3 DIPROLENE AF 3 ELOCON (CREAM, LOTION, OINTMENT) 3
ENSTILAR 3 QL 2 / day
EPIFOAM 3
QL 2.143 / day EUCRISA 2 ST AL At least 2 yrs old fluocinolone acetonide (0.01% body oil, 0.01% cream, 0.01% scalp oil, 0.025% cream, 0.025% ointment) 3 HCG fluocinolone acetonide powder 3 fluocinolone 0.01% solution 1 fluocinonide (0.05% cream, 0.05% gel, 0.05% ointment, 0.05% solution, 0.1% cream) 1 fluocinonide micronized 3 fluocinonide-e 1
PAGE 249 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fluticasone propionate (0.005% oint, 0.05% cream, 0.05% lotion) 1 halobetasol propionate (cream, ointmnt) 3 HCG
HALOG (CREAM, OINTMENT) 3 HEMMOREX-HC 1 hydrocortisone (1% absorbase, 1% cream, 1% ointment, 2.5% cream, 2.5% lotion, 2.5% ointment, 100 mg/60 ml) 1 hydrocortisone (micronized pwd, powder) 3 hydrocortisone acetate powder 3 hydrocortisone acetate (25 mg, 30 mg) 1 hydrocortisone butyrate (hydrocort buty lipid crm, hydrocort buty lipo cream, hydrocortisone buty cream, hydrocortisone 1 butyr oint, hydrocortisone butyr soln) hydrocortisone valerate (cream, ointmt) 1 hydrocortisone-pramoxine (1%-1% crm, 2.5%-1% cm, 2.5-1% crm) 1 hydrocortisone-pramoxine hcl 1 KENALOG 3 lidocaine-hc 3-0.5% cream 3 HCG lidocaine-hydrocortisone (lidocaine-hc 2.8-0.55% gel, lidocaine-hydrocort 3-2.5% gel) 1
LOCOID (CREAM, LOTION, OINTMENT, SOLUTION) 3 lokara 1 LUXIQ 3 MICORT-HC 3 mometasone furoate (cream, oint, soln) 1 NOVACORT GEL 3 OLUX 3 OLUX-E 3
PAGE 250 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ORALONE 1 PANDEL 3 PRAMCORT 1 PRAMOSONE (1% LOTION, 1%-1% CREAM, 1%-1% OINTMENT, 2.5%-1% CREAM, 2.5%-1% LOTION, 2.5%-1% 3 OINTMENT)
PRAMOSONE E 3 prednicarbate (cream, ointment) 1 PROCORT 3 PROCTO-MED HC 1 PROCTO-PAK 1 PROCTOCORT (1% CREAM, 30 MG SUPPOSITORY) 3 PROCTOFOAM-HC 2 PROCTOSOL-HC 1 PROCTOZONE-HC 1 PSORCON 3 RIMSO-50 3 SANADERMRX 1 SCALACORT 1 SERNIVO 3 SYNALAR (0.01% SOLUTION, 0.025% CREAM) 3 SYNALAR TS 3
TACLONEX (0.005%-0.064% SUSPENS, OINTMENT) 3 QL 3 / day
TEMOVATE (CREAM, OINTMENT) 3 TEMOVATE EMOLLIENT 3 TEXACORT 3 TOPICORT (0.05% CREAM, 0.05% GEL, 0.05% OINTMENT, 0.25% CREAM, 0.25% OINTMENT, 0.25% SPRAY) 3
PAGE 251 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS triamcinolone acetonide (0.025% cream, 0.025% lotion, 0.025% oint, 0.1% cream, 0.1% lotion, 0.1% ointment, 0.1% 1 paste, 0.147 mg/g spray, 0.5% cream, 0.5% ointment)
TRIANEX 1 TRIDERM 1 TRIDESILON 3 ULTRAVATE (CREAM, LOTION, OINTMENT) 3 VANOS 3
VANOXIDE-HC 3 QL 0.84 / day
VERDESO 3 ANTIPRURITICS AND LOCAL ANESTHETICS
ANACAINE 3 ANASTIA 3 CETACAINE 3 CIDALEAZE 1 dibucaine hcl 3 doxepin 5% cream 1 EMLA 3 ethyl chloride 1
QL 3 / day lidocaine 5% patch 3 HCG lidocaine 5% ointment 1 lidocaine hcl (cream, hcl lotion) 1 lidocaine-prilocaine 1 lidocaine-tetracaine 1
LIDODERM 3 QL 3 / day
LIDOPIN 3% CREAM 1 LIDOPIN 3.25% CREAM 3
PAGE 252 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LIDOPRIL 1
QL 1 / day LIDORX 2 PA
LIDOTRAL 3 LIDOVEX 3 LIDTOPIC MAX 3 LP LITE PAK 1 NUMBONEX 3 PAIN EASE 3 phenazopyridine hcl 100% powdr 3 phenazopyridine hcl (100 mg tab, 200 mg tab) 1 PLIAGLIS 3 PONTOCAINE 3 pramoxine hcl 3 PRE-ATTACHED LTA KIT 3 PRUDOXIN 3 PYRIDIUM 3 REGENECARE 3 SPRAY AND STRETCH 3 SYNERA 3 ZONALON 3 ASTRINGENTS
DRYSOL 3 CELL STIMULANTS AND PROLIFERANTS
ATRALIN 3 QL 1.5 / day
AVITA (CREAM, GEL) 1 REFISSA 3
PAGE 253 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RENOVA 3 RENOVA PUMP 3 RETIN-A (0.01% GEL, 0.025% CREAM, 0.025% GEL, 0.05% CREAM, 0.1% CREAM) 3
RETIN-A MICRO 3 QL 50 / 30 days
RETIN-A MICRO PUMP (PUMP 0.04% GEL, PUMP 0.08% GEL, 50 / 30 days PUMP 0.1% GEL) 3 QL retinoic acid 3 TRETIN-X (0.0375% CREAM, 0.075% CREAM) 3 tretinoin (0.01% gel, 0.025% cream, 0.025% gel, 0.05% cream, 0.05% gel, 0.1% cream) 1 tretinoin 0.05% emollient crm 1 tretinoin powder 3 tretinoin acid 3 tretinoin microsphere (gel 0.04% pump, gel 0.04% tube, gel QL 1.667 / day 3 0.1% pump, gel 0.1% tube) HCG
EMOLLIENTS, DEMULCENTS, AND PROTECTANTS
ALEVICYN ANTIPRURITIC SG 3 KERATOLYTIC AGENTS
ALUVEA 3 BENSAL HP 3
BENZEFOAM 3 QL 2 / day
BENZEFOAM ULTRA 3 QL 3.334 / day
BENZEPRO (6% FOAMING CLOTHS, 7% CREAMY WASH) 1 pr benzoyl peroxide 7% wash 1 BP-50% UREA 1 BPO (4% GEL, 8% GEL) 3
BPO 6% FOAMING CLOTHS 1 QL 2 / day
PAGE 254 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CEM-UREA 3 GORDO-UREA 40% OINTMENT 3 HYDRO 35 3 HYDRO 40 3 KERAFOAM 3 KERALAC 3 KERALYT 3 lactic acid liquid 3 LATRIX 1
NUOX 3 QL 1.47 / day
PACNEX 1 PACNEX HP 3 PACNEX LP 3 podophyllum resin 3 potassium hydroxide pellets 3 potassium hydroxide 5% soln 1 PR BENZOYL PEROXIDE 1 REA LO 40 (40 CM, 40 TION) 1 REMEVEN 1 RYNODERM 3 SALACYN (CREAM, LOTION) 1 SALEX 6% SHAMPOO 3 salicylic acid (6% cream, 6% foam, 6% gel, 6% lotion, 6% shampoo, 26% liquid, 27.5% liquid) 1 salicylic acid powder 3 salicylic acid er 1 SALKERA 3 SALVAX 3
PAGE 255 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS silver nitrate 10% solution 1 grafco silver nit applicator 1 silver nitrate applicator 3 sodium hydroxide (10% solution, flakes, granules, pellets) 3 sulfur (powder, sublimed powder) 3 ULTRASAL-ER 3 UMECTA (EMULSION, NAIL FILM PEN, NAIL FILM SUSP) 3 UMECTA 40% MOUSSE 1 UMECTA PD (PD EMULSION, PD SUSPENSION) 3 URAMAXIN (20% FOAM, 45% LOTION, 45% NAIL GEL, 45% UREA CREAM) 3
URAMAXIN GT 45% PRE-FILLED APP 3 URE-K 1 urea (35% foam, 39% cream, 40% cream, 40% gel, 40% lotion, 40% nail film susp, 45% cream, 45% lotion, 45% nail 1 gel, 47% cream, 50% cream) urea (50% nail stick, powder) 3 UREVAZ 3 UTOPIC 3 VIRASAL 3 KERATOPLASTIC AGENTS anthralin 3 coal tar (tar, tar solution) 3 coal tar topical solution 1 DRITHOCREME HP 3 ZITHRANOL 3 ZITHRANOL-RR 3
PAGE 256 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SKIN AND MUCOUS MEMBRANE AGENTS, MISC.
ABSORICA 3 PA
QL 2 / day acitretin (17.5 mg capsule, 25 mg capsule) 3 HCG
QL 4 / day acitretin 10 mg capsule 3 HCG
ACZONE (5% GEL, 7.5% GEL PUMP) 3 QL 3 / day
QL 1.5 / day adapalene (0.1% cream, 0.3% gel, 0.3% gel pump) 3 HCG adapalene 0.1% gel 1 QL 1.5 / day adapalene 0.1% lotion 1 QL 2 / day adapalene-benzoyl peroxide 3 QL 1.5 / day
QL 0.434 / day ALDARA 3 AL At least 12 yrs old
PA AMNESTEEM 3 HCG
ARTISS 3
AVAGE 3 QL 1.47 / day azelaic acid (flakes, powder) 3
AZELEX 3 QL 1.667 / day
QL 2 / day calcipotriene (cream, ointment) 3 HCG calcipotriene 0.005% solution 1 QL 2 / day
CALCITRENE 1 QL 2 / day calcitriol 3 mcg/g ointment 1 QL 3.334 / day
PAGE 257 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS camphor 3 capsaicin 3 capsaicin palmitate 3 capsicum oleoresin 3 CARAC 2
PA CLARAVIS 3 HCG collagenase 3 CONDYLOX (GEL, TOPICAL SOLN) 3
QL 0.357 / day COSENTYX (2 SYRINGES) 5 PA S
QL 0.357 / day COSENTYX PEN 5 PA S
QL 0.357 / day COSENTYX PEN (2 PENS) 5 PA S
QL 0.357 / day COSENTYX SYRINGE 5 PA S dapsone 5% gel 1 QL 3 / day
DEBACTEROL (SOLUTION, SWABSTICK) 3 diclofenac sodium 3% gel 1 QL 100 / 30 days
DIFFERIN (0.1% CREAM, 0.1% GEL, 0.3% GEL, 0.3% GEL 1.5 / day PUMP) 3 QL
DIFFERIN 0.1% LOTION 3 QL 1.967 / day
PAGE 258 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DOVONEX 3 QL 2 / day
QL 0.15 / day PA DUPIXENT 5 AL At least 18 yrs old S
EFUDEX 3
EPIDUO 0.1-2.5% GEL 3 QL 1.667 / day
EPIDUO 0.1-2.5% GEL PUMP 3 QL 1.5 / day
EPIDUO FORTE 3 QL 1.667 / day
QL 3.73 / day FABIOR 3 AL Up to 34 yrs old
QL 50 / 30 days FINACEA (FOAM, GEL) 3 PA finasteride 1 mg tablet 1 FLUOROPLEX 2 fluorouracil (0.5% cream, 2% topical soln, 5% cream, 5% topical soln) 1
FORMADON 1 formaldehyde 1 GRANULEX 3
QL 0.434 / day imiquimod 5% cream packet 1 AL At least 12 yrs old imiquimod powder 3 isotretinoin 3 LEVULAN 3 methyl 5-aminolevulinate hcl 3
MIRVASO (GEL, GEL PUMP) 2 QL 1 / day
PAGE 259 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MUCOTROL 3
PA MYORISAN 3 HCG
PANRETIN 3
PICATO 3 ST
PODOCON-25 3 podofilox 0.5% topical soln 1 PROPECIA 3
QL 2.5 / day PROTOPIC 0.03% OINTMENT 3 ST AL At least 2 yrs old
QL 2.5 / day PROTOPIC 0.1% OINTMENT 3 ST AL At least 16 yrs old
PYROGALLIC ACID 1 RECTIV 3
REGRANEX 3 QL 1 / day
RENOVO 3
QL 1.25 / day RHOFADE 3 PA
SANTYL 3 SINELEE 5%-0.05% PATCH 3
SOLARAZE 3 QL 100 / 30 days
SOOLANTRA 2 QL 1.5 / day
SORIATANE (17.5 MG CAPSULE, 25 MG CAPSULE) 3 QL 2 / day
SORIATANE 10 MG CAPSULE 3 QL 4 / day
PAGE 260 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SORILUX 3 QL 2 / day
QL 100 / 30 days tacrolimus (0.03% ointment, 0.1% ointment) 3 ST HCG
QL 0.15 / day TALTZ AUTOINJECTOR 5 PA S
QL 0.15 / day TALTZ AUTOINJECTOR (2 PACK) 5 PA S
QL 0.15 / day TALTZ AUTOINJECTOR (3 PACK) 5 PA S
QL 0.15 / day TALTZ SYRINGE 5 PA S
QL 0.15 / day TALTZ SYRINGE (2 PACK) 5 PA S
QL 0.15 / day TALTZ SYRINGE (3 PACK) 5 PA S
PA TARGRETIN 1% GEL 5 S
QL 1.47 / day tazarotene 0.1% cream 3 HCG tazarotene powder 3
PAGE 261 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TAZORAC (0.05% CREAM, 0.1% CREAM) 3 QL 2 / day
TAZORAC (0.05% GEL, 0.1% GEL) 3 QL 3.334 / day
QL 1.47 / day TOLAK 3 ST
TRI-CHLOR 3 trichloroacetic acid (25%, 75%) 1
QL 3 / day VALCHLOR 5 PA S
VANIQA 3
VECTICAL 3 QL 3.334 / day
VENELEX (OINTMENT, OINTMENT PACKET) 3 VEREGEN 3
PA ZENATANE 3 HCG
QL 56 / 60 days ZYCLARA (CREAM, CREAM PUMP) 3 AL At least 12 yrs old
QL 56 / 30 days ZYCLARA 2.5% CREAM PUMP 3 AL At least 12 yrs old
SUNSCREEN AGENTS zinc oxide 3
PAGE 262 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SOMATOSTATIN AGONISTS AND ANTAGONISTS
SOMATOSTATIN AGONISTS octreotide acetate (acet 0.05 mg/ml vl, acet 50 mcg/ml amp, acet 50 mcg/ml syr, acet 50 mcg/ml vial, acet 100 mcg/ml amp, acet 100 mcg/ml syr, acet 100 mcg/ml vl, acet 200 mcg/ml vl, PA 5 acet 500 mcg/ml amp, acet 500 mcg/ml syr, acet 500 mcg/ml S vl, 1,000 mcg/5 ml vial, 1,000 mcg/ml vial, 5,000 mcg/5 ml vial)
QL 30 / day SANDOSTATIN 0.05 MG/ML AMPUL 5 PA S
QL 15 / day SANDOSTATIN 0.1 MG/ML AMPUL 5 PA S
QL 3 / day SANDOSTATIN 0.5 MG/ML AMPUL 5 PA S
QL 8 / day SANDOSTATIN 0.2 MG/ML VIAL 5 PA S
QL 1.5 / day SANDOSTATIN 1 MG/ML VIAL 5 PA S
QL 0.04 / day SANDOSTATIN LAR DEPOT (10 MG KT, 10 MG VL, 30 MG KT, 30 MG VL) 5 PA S
QL 0.07 / day SANDOSTATIN LAR DEPOT (20 MG KT, 20 MG VL) 5 PA S
PAGE 263 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PA SIGNIFOR 5 S
QL 0.1 / day SIGNIFOR LAR (20 MG KIT, 20 MG VIAL) 5 PA S
QL 0.067 / day SIGNIFOR LAR (40 MG KIT, 40 MG VIAL) 5 PA S
QL 0.04 / day SIGNIFOR LAR (60 MG KIT, 60 MG VIAL) 5 PA S
SOMATOTROPIN AGONISTS AND ANTAGONISTS
SOMATOTROPIN AGONISTS
QL 2 / day EGRIFTA 5 PA S
PA INCRELEX 5 S
SOMATOTROPIN ANTAGONISTS
SOMAVERT 5 S
SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTS
ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH) yohimbine hcl powder 3
PAGE 264 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SYMPATHOMIMETIC (ADRENERGIC) AGENTS
ALPHA- AND BETA-ADRENERGIC AGONISTS bupivacaine hcl-epinephrine 1 lidocaine hcl-epinephrine 1 lidocaine-epinephrine 1 MARCAINE-EPINEPHRINE 3 norepinephrine bitartrate powd 3
QL 84 / 14 days NORTHERA 5 PA S phenylpropanolamine hcl 3 SENSORCAINE-EPINEPHRINE 1 SENSORC MPF 0.75%-EPI 1:200000 3 SENSORCAINE-MPF EPINEPHRINE (SENSORC MPF 0.25%-EPI, SENSORCN-MPF 0.5%-EPI) 1
XYLOCAINE DENTAL-EPINEPHRINE 1 XYLOCAINE WITH EPINEPHRINE (0.5%-EPI 1:200,000, 1%-EPI 1:100,000, 2%-EPI 1:100,000, 2%-EPI 1:200,000) 3
XYLOCAINE-MPF WITH EPINEPHRINE 3 ALPHA-ADRENERGIC AGONISTS midodrine hcl 1 phenylephrine hcl powder 3 phenylephrine 10 mg/ml vial 1 THYROID AND ANTITHYROID AGENTS
ANTITHYROID AGENTS carbimazole 3 methimazole powder 3
PAGE 265 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS methimazole (5 mg tablet, 10 mg tablet) 1 propylthiouracil powder 3 propylthiouracil 50 mg tablet 1 TAPAZOLE 3 THYROID AGENTS
ARMOUR THYROID 3 CYTOMEL 3 LEVO-T 1 levothyroxine sodium powder 3 levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 1 LCG mcg tablet, 175 mcg tablet) levothyroxine sodium (75 mcg tablet, 88 mcg tablet, 200 mcg tablet, 300 mcg tablet) 1
LEVOXYL (25 MCG TABLET, 50 MCG TABLET, 100 MCG TABLET) 1 LCG
LEVOXYL (75 MCG TABLET, 88 MCG TABLET, 112 MCG TABLET, 125 MCG TABLET, 137 MCG TABLET, 150 MCG TABLET, 175 1 MCG TABLET, 200 MCG TABLET) liothyronine sodium powder 3 liothyronine sodium (5 mcg tab, 25 mcg tab, 50 mcg tab) 1 NATURE-THROID 3 NP THYROID 1 pcca t3 sodium dilution 3 pcca t4 sodium dilution 3 SYNTHROID 2 thyroid (3x usp powder, 30 mg tablet, 60 mg tablet, 90 mg tablet, powder) 3
THYROLAR-1 3 THYROLAR-1/2 3
PAGE 266 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THYROLAR-1/4 3 THYROLAR-2 3 THYROLAR-3 3
TIROSINT 3 QL 1 / day
UNITHROID (25 MCG TABLET, 50 MCG TABLET, 100 MCG TABLET, 112 MCG TABLET) 1 LCG UNITHROID (75 MCG TABLET, 88 MCG TABLET, 125 MCG TABLET, 137 MCG TABLET, 150 MCG TABLET, 175 MCG TABLET, 1 200 MCG TABLET, 300 MCG TABLET)
WESTHROID 3 WP THYROID 3 Uncategorized
Unclassified
2-methoxyestradiol 3 4-aminobenzoic acid potassium 3 7-keto dhea 3 acacia powder 3 ace aerosol cloud enhancer 3 acetarsone 3 acetyl hexapeptide-8 3 acetyl-d-glucosamine 3 acticoat (2"x2", 4"x4", 5"x5") 3 acticoat (4"x48", 4"x8", 8"x16", 16"x16") 1 acticoat 7 3 acticoat flex 3 3 acticoat flex 7 3 acticoat surgical 1 ademetionine disulfate tosylat 3
PAGE 267 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS advance plus intermittent 3 aerochamber mini 2 aerochamber mv 2 aerochamber plus flow-vu 2 aerochamber with flowsignal 2 aerochamber z-stat plus 2 aeroeclipse ii 3 aerogear asthma action kit 3 aeroneb go 3 aeroneb go nebulizer 3 aerotrach plus 3 aerovent plus 3
QL 2 / day AFINITOR (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET) 5 PA S
QL 1 / day AFINITOR 2.5 MG TABLET 5 PA S
PA AFINITOR DISPERZ 5 S
AFLURIA 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 0 HCR
AFLURIA QUAD 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 0 HCR air filter 1
QL 8 / day PA ALECENSA 5 AL At least 18 yrs old S
PAGE 268 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS alginic acid 3 ALKERAN 2 MG TABLET 3 all flow 1000 3 all flow 3000 kit 3 all flow 3000 pft 3 all flow 4000 3 all flow 5000 3 all flow 6000 3 allantoin 3 allergist syringe 3 allergist tray 3 allevyn 1 allevyn adhesive 1 allevyn ag 1 allevyn ag adhesive 3 allevyn ag gentle 1 allevyn heel 1 allevyn life (5 1/16"x5 1/16", 6 1/16"x 6 1/16", 8 1/4"x8 1/4") 1 allevyn life dressing 4"x4" 3 ALLFEN CDX 3 almond oil 3 aloe vera 3 alpha lipoic acid 3 altera nebulizer 3 aluminum acetate 3 aluminum chloride 3 aluminum chlorohydrate 3
PAGE 269 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS aluminum sulfate 3
QL 6 / day PA ALUNBRIG 5 AL At least 18 yrs old S american ginseng root 3 ammonium lactate solution 3 ammonium sulfate 3 ammonium tetrathiomolybdate 3 AMVISC 3 AMVISC PLUS 3 anastrozole powder 3 anastrozole 1 mg tablet 1 anisindione 3 APLIGRAF 3 apogee hc intermittent 3 apogee ic intermittent cathetr 3 AQUORAL 3 argyle feeding tube-x-ray line 3 ARIMIDEX 3 arnica lg 3 AROMASIN 3 arsenic trioxide 3 ashwagandha extract 3 aspartic acid magnesium salt 3 assura 3 asthmapack children's 3 astragalus extract 3
PAGE 270 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ATRAPRO DERMAL SPRAY 3 ATRAPRO HYDROGEL 3 AURSTAT ANTI-ITCH HYDROGEL 3 AVAILNEX 3 AVENOVA 3 azacitidine 5 S
B-PLEX PLUS 1 baby conversion kit 3 baby conversion pack 1 3 baby conversion pack 2 3 baby nebulizer 3 BEAU RX 3
PA BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/ML SYRINGE) 5 S benzocaine 3 benzoic acid 3 benzoyl peroxide powder 3 benzyl alcohol 3 beta glucan 3
PA bexarotene 5 S bicalutamide 1 BIONECT (CREAM, GEL) 3 biostep 3 biostep ag 3 biotin 3 biotin-d 3
PAGE 271 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS bismuth citrate 3 bismuth subgallate 3 bitter melon extract 3
BLEO 15K 5 S bleomycin sulfate 5 S
QL 4 / day PA BOSULIF 100 MG TABLET 4 S PS
QL 1 / day PA BOSULIF 500 MG TABLET 4 S PS boswellia serrata extract 3 bovine serum albumin 3 breatherite 3 breathrite 3 bromelain 3 bromfenac sodium powder 3 buffered lidocaine 3 buflomedil hcl 3 bupivacaine hcl (0.25% ampul, 0.5% ampul, 0.75% ampul) 1 bupivacaine hcl powder 3 bupivacaine-dextrose 1 butalb-aspirin-caffe 50-325-40 1 QL 6 / day
BYDUREON BCISE 2 QL 0.15 / day
QL 4 / day CABOMETYX 20 MG TABLET 5 PA S
PAGE 272 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 2 / day CABOMETYX 40 MG TABLET 5 PA S
QL 1.5 / day CABOMETYX 60 MG TABLET 5 PA S calcipotriene powder 3 calcipotriene monohydrate 3 calcipotriol 3 calcitriol in almond oil 3 cantharidin (crystals, powder) 3 capecitabine 5 S
CAPHOSOL 3
QL 2 / day CAPRELSA 100 MG TABLET 5 PA S
QL 1 / day CAPRELSA 300 MG TABLET 5 PA S caprylic acid 3 CARBOCAINE (1% VIAL, 1.5% VIAL, 2% VIAL) 3
CARDENE SR 45 MG CAPSULE 3 QL 2 / day carrasyn hydrogel wound 3 CASODEX 3 catheter 1 CEDAX 90 MG/5 ML SUSPENSION 3 CERAMAX 1
PAGE 273 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CERVIDIL 3 GL Female cesium chloride 3 cetyl myristoleate (40% oil, 40% wax, powder) 3 cetylpyridinium chloride 3 chlorambucil 3 chloroacetic acid 3 chlorobutanol 3 chloroprocaine hcl 1 chloroxine 3 chloroxylenol 3 chlorzoxazone 250 mg tablet 1 cholesterol 3 chromium picolinate 3 chromium polynicotinate 3 chrysin 3 chymotrypsin 3 citric acid (granules, powder) 3 citrus bergamot 3 clemizole hcl 3 clever choice holding chamber 3 clever choice nebulizer 3 clever choice whisper aire ped 3 coaguchek xs 3 cobalt gluconate 3
QL 2 / day COMETRIQ 100 MG DAILY-DOSE PK 5 PA S
PAGE 274 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 4 / day COMETRIQ 140 MG DAILY-DOSE PK 5 PA S
QL 3 / day COMETRIQ 60 MG DAILY-DOSE PACK 5 PA S comp-air elite compressor syst 3 comp-air nebulizer compressor 3 compact space chamber 3 conception 1 copper peptide ghk-cu 3
QL 2.5 / day PA COTELLIC 5 AL At least 18 yrs old S
QL 1 / day COTEMPLA XR-ODT 3 ST creatine 3 creatine monohydrate 3 creatinine 3 curafil 3 curity 3 curity amd packing strips 3 curity iodoform 3 cyclodextrin-beta 3 cytarabine 5 S dapiprazole hcl 3
PAGE 275 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS demecarium bromide 3 deoxycholic acid 3 DERMAGRAFT 3 devil's claw 3 devilbiss traveler 3 dexchlorpheniramine maleate 1 dexpanthenol 3 dibucaine 3 dichloroacetic acid 3 diethanolamine 3 diethylen glycol m-ethyl ether 3 diindolylmethane 3 diiodo-l-thyronine 3 DILUENT FOR ELITEK 3 dimercaptopropanesulfonate sod (crystal, powder) 3 dimethyl sulfone 3 dimethyl sulfoxide 3 dimethylacetamide 3 dinitrochlorobenzene 3 diphenylcyclopropenone 3 DISCOVISC 3 dl-3-hydroxybutyric acid sod 3 dmae 3 dover advantage 3 dover advantage drainage 3 dover coated latex foley 3 dover latex foley catheter 3
PAGE 276 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dover premium 3 dover red rubber robibson cath 3 dover universal 3 DROXIA 3 DUOVISC 3 e-z spacer 3 e-z spacer pedspak 3 ear popper 1 easivent (holding chamber, mask-large, mask-medium, mask- small) 3 ebase controller 3 eclipse needle 3 eclipse syringe 3 egcg 3
EMCYT 5 S
EMULSION SB TOPICAL EMULSION 3
QL 0.15 / day PA ENBREL 50 MG/ML MINI CARTRIDGE 4 S PS
ENDOFORM (4" 5" TEMPLATE, FENESTRATED, FENESTRATED 4" 5", TEMPLATE) 3 enteral gravity bag set-enfit 3 ENTTY 3 EPICERAM 3 EPISIL 3 erapid nebulizer 3 erapid nebulizer handset 3
PAGE 277 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day ERIVEDGE 5 PA S
ERWINAZE 5 S ethoxy diglycol 3 ethyl acetate 1 ethyl oleate 3 etoposide 50 mg capsule 5 S exemestane 1
PA EXJADE 5 S
EXPAREL 3 FARESTON 2
PA FARYDAK 5 S female self catheter 1
FEMARA 3 PA femcap (26 cap, 30 cap) 3 femcap 22 mm cervical cap 0 HCR ferric ammonium citrate 3 ferric subsulfate 3
PA FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET) 5 S fexofenadine-pse er 1 QL 1 / day filter needle 19gx1-1/2" 3 filter needle 5 micron 3
PAGE 278 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS filter, valve set for ll & lc 3 flexichamber 3 flexichamber mask 3 floxuridine powder 3 floxuridine 500 mg vial 5 S
AL At least 65 yrs old FLUAD 2017-2018 0 HCR
FLUARIX QUAD 2017-2018 0 HCR
FLUBLOK 2017-2018 0 HCR
FLUBLOK QUAD 2017-2018 0 HCR
FLUCELVAX QUAD 2017-2018 (2017-2018 SYR, 2017-2018 VIAL) 0 HCR FLULAVAL QUAD 2017-2018 (2017-2018 SYR, 2017-2018 VIAL) 0 HCR fluorouracil powder 3 flutamide 1 flutter 3
FLUVIRIN 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 0 HCR
AL At least 65 yrs old FLUZONE HIGH-DOSE 2017-2018 0 HCR
FLUZONE INTRADERM QUAD 2017-18 0 HCR
FLUZONE QUAD 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 0 HCR
FLUZONE QUAD PEDI 2017-2018 0 HCR
FORMA-RAY 3 freedom derma-d 3 freedom precision airless 3
PAGE 279 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GALZIN 3 GASTROMARK 3 GELCLAIR 3 gelfilm 3 GELFOAM (DENTAL SPONGE SZ 4, 12-7MM SPONGE, SIZE 50 SPONGE, SIZE 100 SPONGE, SIZE 200 SPONGE) 3
GELFOAM COMPRESSED 3 GELFOAM JMI SPONGE KIT 3 GELX 3 GENADUR NAIL LACQUER 3
QL 1 / day GILOTRIF 5 PA S ginseng root 3
QL 8 / day PA GLEEVEC 100 MG TABLET 4 S PS
QL 2 / day PA GLEEVEC 400 MG TABLET 4 S PS
GLEOSTINE 3 gluconolactone 3 glutaraldehyde 1 glutathione 3 glutathione-l 3 glycine powder 3
PAGE 280 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS glycolic acid (70% solution, crystals) 3 glycopyrrolate 1.5 mg tablet 1 glycosaminoglycans 3 glycyrrhizic acid 3 gramicidin d 3 guarana seed extract 3 guardian link 3 3 guardian sensor 3 3 HEMABATE 3
PA HEXALEN 5 S
HICON (500 MCI/0.5 ML KIT, 1,000 MCI/ML KIT) 3 histamine phosphate 3 histidine hcl 3 home nebulizer plus sidestream 3 HPR 3 HPR PLUS (CREAM, EMOLLIENT FOAM) 3 HUMALOG JUNIOR KWIKPEN 2 hyaluronic acid 3 hyaluronic acid sodium salt 3 hyaluronidase 3
PA HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 5 S hydrazine sulfate 3 HYDREA 3 hydrofera blue 3 hydrofera blue ready 1
PAGE 281 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hydrogen peroxide 3 hydroxyethyl methacrylate 3 hydroxypropy-beta-cyclodextrin 3 hydroxytryptophan 3 hydroxyurea 500 mg capsule 1 hydroxyurea powder 3 HYGEL 3 HYLATOPIC 3 HYLATOPICPLUS (CREAM, EMOLLIENT FOAM, LOTION) 3 HYLENEX 3 hypodermic needle 3
PA HYQVIA HY COMPONENT 5 S
QL 1.25 / day IBRANCE 100 MG CAPSULE 5 PA S
QL 1 / day IBRANCE 125 MG CAPSULE 5 PA S
QL 1.667 / day IBRANCE 75 MG CAPSULE 5 PA S ichthammol 3
QL 2 / day ICLUSIG 15 MG TABLET 5 PA S
QL 1 / day ICLUSIG 45 MG TABLET 5 PA S
PAGE 282 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 4 / day IMBRUVICA 5 PA S
INDICLOR 3
QL 1 / day PA INGREZZA 80 MG CAPSULE 5 AL At least 18 yrs old S
QL 4 / day PA INLYTA 4 S PS innospire deluxe 3 innospire elegance 3 innospire essence compress neb 3 innospire mini 3 innospire replacement filter 3 inositol 3 inspirachamber 3 inspiration 3 inspiration elite 3 inspiration elite filter 1 insulin syringe (insulin syrin 0.5 ml 30gx1/2", insulin syrin 0.5 ml 30gx5/16", insulin syringe 1 ml 30gx1/2", insulin syringe 1 ml 30gx5/16", ulticare ins safety 1ml 29x1/2, ulticare safety 0.5 2 ml 29gx1/2) insulin syringe u-500 2 iodoform 3 iopanoic acid 3
PAGE 283 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS IPOL SINGLE DOSE SYRINGE 2
QL 1 / day IRESSA 5 PA S isoleucine 3 isopropamide iodide 3 isopropyl myristate 3 isoproterenol hcl (0.2 mg/ml vial, 1 mg/5 ml vial) 1
PA JADENU 5 S
PA JADENU SPRINKLE 5 S
QL 2 / day JAKAFI 5 PA S jetco-spray cannula 3 kangaroo 924 safety screw 3 kangaroo epump set 3 kangaroo gravity set 3 kendall 0.9% nacl with cap 1 kenguard (add-a-foley cath tray, foley catheter) 3
QL 3 / day PA KISQALI 200 MG DAILY DOSE 5 AL At least 18 yrs old S
QL 1.5 / day PA KISQALI 400 MG DAILY DOSE 5 AL At least 18 yrs old S
PAGE 284 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 1 / day PA KISQALI 600 MG DAILY DOSE 5 AL At least 18 yrs old S
QL 3 / day PA KISQALI FEMARA 200 MG CO-PACK 5 AL At least 18 yrs old S
QL 1.5 / day PA KISQALI FEMARA 400 MG CO-PACK 5 AL At least 18 yrs old S
QL 1 / day PA KISQALI FEMARA 600 MG CO-PACK 5 AL At least 18 yrs old S kojic acid 3 l-aspartic acid 3 l-glutamic acid 3 l-histidine 3 l-isoleucine 3 l-methionine 3 l-proline 3 l-serine 3 l-threonine 3 lc plus 3 lc sprint nebulizer 3 lc star 3
PAGE 285 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 3 / day LENVIMA 5 PA S letrozole powder 3 letrozole 2.5 mg tablet 1 LEUKERAN 3 leuprolide acetate powder 3 lidocaine powder 3 lidocaine hcl powder 3 lidocaine hcl (1% 20 mg/2 ml, 1% 20 mg/2 ml vl, 1% 300 mg/30 ml, 1% 50 mg/5 ml, 1% 50 mg/5 ml vl, 1% vial, 1.5% 1 ampul, 10 mg/ml syringe, 50 mg/5 ml syrng, 200 mg/10 ml syr) lidocaine hcl 0.5% vial 1 MED Medical Drug lipoic acid 3 liteaire 3 litetouch 3 lomustine 1
QL 2.15 / day LONSURF 15 MG-6.14 MG TABLET 5 PA S
QL 3 / day LONSURF 20 MG-8.19 MG TABLET 5 PA S
LOUTREX 3 LUMINAL SODIUM 3 lutein 3
PA LYNPARZA (50 MG CAPSULE, 100 MG TABLET, 150 MG TABLET) 5 S
PAGE 286 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LYSODREN 5 S maca root 3 magellan insulin safety syrng (syr 0.3 ml, syr 0.5 ml, syringe 1 ml) 2 magellan insulin syringe (syringe 0.3 ml, syringe 0.5 ml) 2 magellan tuberculin syringe 3 magic3 intermittent catheter 3 magnesium chloride crystals 3 magnesium malate 3 malic acid 3 MARCAINE (0.25% VIAL, 0.5% VIAL, 0.75% VIAL) 3 MARCAINE SPINAL AMPUL 3 mask set with y-piece 3
MATULANE 5 S
QL 3 / day PA MAVYRET 4 AL At least 18 yrs old S PS
MAXIFED CDX 3 MAXIPHEN CD 3 MAXIPHEN CDX 3 mechlorethamine hcl 3 MEGACE 3
MEGACE ES 3 GL Female megestrol acetate (acet 40 mg/ml susp, acet 400 mg/10 ml, 625 mg/5 ml susp) 1 megestrol acetate powder 3
PAGE 287 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS megestrol acetate (20 mg tablet, 40 mg tablet) 1
QL 4 / day MEKINIST 0.5 MG TABLET 5 PA S
QL 1 / day MEKINIST 2 MG TABLET 5 PA S melphalan 1 menadione 3 menthol 3 mepivacaine hcl 1 methacholine chloride 3
QL 2 / day methadone 5 mg/0.5 ml syringe 1 PA
METHERGINE 1 methionine 3 methotrexate powder 3 methylergonovine 0.2 mg tablet 1 methylergonovine maleate (0.2 mg/ml amp, 0.2 mg/ml vl) 1 methylparaben 3 micro elite (micro elite lith-poly battery, microelite compressor nebulize) 3 micro plus 3 microchamber 3 microcrystalline cellulose 3 MICROCYN 3 MICROCYN HYDROGEL 3 microspacer 3
PAGE 288 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MIFEPREX 3 milk thistle 3 mini plus nebulizer 3 mini-wright peak flow meter 3 minielite (compressor nebulizer, lithium ion battery) 3 minimed 630g guardian start kt 3 misterneb compressor 3 misterneb pediatric compressor 3 mitomycin (c powder, powder) 3 mitomycin c 3 mitotane 3 mono-flo 3 monoject 0.5 ml syrn 28gx1/2" 2 monoject 6cc safety syringe 3 monoject blood collection 3 monoject control syringe 3 monoject enfit syringe (1 ml syringe, 3 ml syringe, 6 ml syringe, 12 ml syringe, 35 ml syringe, 60 ml syringe) 1 monoject enfit syringe cap 1 monoject insulin syringe (insulin syr 0.3 ml, insulin syr 0.5 ml, 1 ml syrn 28gx1/2", insulin syr 1 ml, insulin syr u-100, syringe 1 2 ml) monoject luer lock tb syringe 3 monoject magellan (syringe, syringe 1 ml) 3 monoject megellan tb syringe 3 monoject pharmacy tray 3 monoject safety syringe 3 monoject smartip cannula (3 ml, 6 ml, 12 ml) 3
PAGE 289 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS monoject syringe (syringe 3 ml, 6 ml syrn 20gx11/2", 6 ml syrn 21gx1", 6 ml syrn 21gx11/2", 6 ml syrn 22gx11/2", syringe 6 3 ml, syringe 12 ml) mouthpiece 3 MUGARD 3
MUSTARGEN 5 S my mdi portable nebuliser 3
MYLERAN 5 S
NAROPIN (0.2% 20 MG/10 ML AMP, 0.2% 20 MG/10 ML VIAL, 0.2% 200 MG/100 ML BAG, 0.2% 40 MG/20 ML AMP, 0.2% 40 MG/20 ML VIAL, 0.2% 400 MG/200 ML BAG, 0.2% 400 MG/200 ML BTL, 0.5% 100 MG/20 ML AMP, 0.5% 100 MG/20 ML VIAL, 0.5% 150 MG/30 ML VIAL, 0.75% 150 MG/20 ML 3 AMP, 0.75% 150 MG/20 ML VL, 1% 100 MG/10 ML AMPULE, 1% 100 MG/10 ML VIAL, 1% 200 MG/20 ML AMPULE, 1% 200 MG/20 ML VIAL, 2 MG/ML INFUSION BTL, 5 MG/ML INFUSION BTL, 200 MG/100 ML INF BTL) needle 3 NEOSALUS (CREAM, FOAM, LOTION) 3 NEOSALUS CP 3 NESACAINE 3 NESACAINE-MPF 3 nettle leaf 3 NEUTRASAL 538 MG POWDER PACKET 3
QL 4 / day NEXAVAR 5 PA S
NILANDRON 5 S
PA nilutamide 5 S
QL 0.124 / day PA NINLARO 5 AL At least 18 yrs old S
PAGE 290 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NIVATOPIC PLUS 3
PA NOVAREL 5,000 UNIT VIAL 5 S
NUMOISYN (LIQUID, LOZENGE) 3 nutriport balloon 3 NUVAIL 3
NYMALIZE 30 MG/10 ML SOLUTION 3 QL 120 / day oasis ultra (tri-layer sheet, ultra 3 x 3.5 cm, ultra 3 x 7 cm) 3
QL 1 / day ODOMZO 5 PA S ombra compressor system 3 omega-3 dha 3
ONCASPAR 5 S optichamber 1 optichamber diamond 3
ORAFATE 5 S
ORAMAGICRX 3 ornithine 3 oxytocin powder 3 oxytocin 10 units/ml vial 1 papain 3 parachlorophenol 3 pari lc plus nebulizer 3 pari lc sprint sinus 3 pari sinus aerosol system 3 pediatric dinosaur nebulizer 3
PAGE 291 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS pediatric dog nebulizer 3 pediatric frog nebulizer 3 pen needle 2 pentylenetetrazole 3 pflex trainer 3 phaseal protector 3 phenindione 3 phenolsulfonic acid 3 phenylmercuric nitrate 3 phenyltoloxamine dihyd cit 3 phosphatidylserine 3 pillow mask for children 1 pine bark extract 3 PITOCIN 3 pocket chamber 3 podofilox powder 3 POLOCAINE (1% VIAL, 2% VIAL, 3% CARTRIDGE) 1 POLOCAINE-MPF 1 polyvinyl alcohol 3 portable nebulizer system 3 potassium bromide (crystals, powder) 3 potassium p-aminobenzoate 3 potassium permanganate (crys, gran) 3 potassium sorbate (crystals, powder) 3 povidone 3 povidone k-30 3 pregnenolone 3
PAGE 292 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS pregnenolone micronized 3
PREPIDIL 3 GL Female
PRESERA 3 prilocaine hcl 3 primeaire 3 procaine hcl 3 procarbazine hcl 3 prochamber 3 prodigy mini-mist 3 PROMISEB 3 proneb ultra ii 3 propyl gallate 3 propylene glycol 3
PROSTIN E2 VAGINAL SUPPOSITORY 3 GL Female
PROTHELIAL 5 S provent starter kit 3 PROVISC 3 PROVOCHOLINE 3 PRUMYX 3 pulmo-aide 3 pyridoxal-5-phosphate 3 quake 3 quaternium-15 3 quercetin dihydrate 3 RADIAPLEXRX 3 RADIGEL 3 rapport vacuum therapy 3
PAGE 293 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RECEDO 3 red yeast rice 3 replicare (4"x4", 6"x6", 8"x8") 1 replicare ultra 4"x4" dressing 3 replicare ultra 6"x6" dressing 1 replicare ultra sacrum 3 resorcinol (crystals, powder) 3 restore (1"x12" dressing, 2"x2" dressing, 4"x4" foam silver drsg, 6"x8" foam silver drsg) 3 restore calcium alginate 3 restore contact layer silver 3
RETIN-A MICRO PUMP 0.06% GEL 3 QL 50 / 30 days retinaldehyde 3 reusable nebulizer kit 1 riteflo 3 robinson clear vinyl catheter 3 ropivacaine hcl (20 mg/10 ml, autofuser pmp) 1 ropivacaine hcl powder 3 ropivacaine hcl (0.2% 40 mg/20 ml, 0.5% 150 mg/30 ml, 0.75% 150 mg/20 ml, 1% 100 mg/10 ml vl, 1% 200 mg/20 ml 1 vl) ropivacaine-ns 0.1% on-q pump 1 rubber mouthpiece 2
QL 2 / day PA RUBRACA (200 MG TABLET, 250 MG TABLET) 5 AL At least 18 yrs old S
QL 2 / day PA RUBRACA 300 MG TABLET 5 AL At least 18 yrs old S
PAGE 294 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 2 / day PA RYDAPT 5 AL At least 18 yrs old S safety syringe with shield 3 safety syringe-needle 3 safetyglide allergy syringe 3 SALIVAMAX 3 SALIVATERX 3 sami the seal 3 sami the seal mask 3 saw palmetto 3 SEBUDERM 3 SENSORCAINE 1 SENSORCAINE WITH DEXTROSE 1 SENSORCAINE-MPF (0.25% AMPUL, 0.25% VIAL, 0.5% AMPUL, 0.5% VIAL, 0.75% AMPUL, 0.75% VIAL) 1 sensura click ostomy pouch 3 sensura flex ostomy base plate 3 sensura flex ostomy pouch 3 sensura ostomy base plate 3 serotonin hcl 3 sidestream 3 sidestream mask 3 sidestream nebulizer 3 sidestream plus 3 silicone mask (mask-adult, mask-infant, mask-pediatric) 1 silverseal hydrogel 3
PAGE 295 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SILVRSTAT 3 sinustar (aerosol delivery syst, reusable nebulizer) 3 sodium benzoate 3 sodium butyrate 3 sodium deoxycholate 3 sodium dichloroacetate 3 sodium hyaluronate 3 sodium hyaluronic acid 3 sodium iodide 3 sodium metabisulfite (granules, powder) 3 sodium stearyl fumarate 3 sodium succinate 1 SOLTAMOX 3 sorbic acid 3 SP ANTIPRURITIC 3 spectragel 3 spirulina 3
QL 1 / day SPRYCEL (100 MG TABLET, 140 MG TABLET) 5 PA S
QL 2 / day SPRYCEL (70 MG TABLET, 80 MG TABLET) 5 PA S
QL 9 / day SPRYCEL 20 MG TABLET 5 PA S
QL 3 / day SPRYCEL 50 MG TABLET 5 PA S
PAGE 296 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QL 4 / day STIVARGA 5 PA S
PA AL Up to 18 yrs old STRENSIQ 4 S PS
SUCRAID 5 S sulfurated potash 3 sunrise compressor-nebulizer 1
QL 1 / day PA SUTENT (37.5 MG CAPSULE, 50 MG CAPSULE) 4 S PS
QL 7 / day PA SUTENT 12.5 MG CAPSULE 4 S PS
QL 3 / day PA SUTENT 25 MG CAPSULE 4 S PS
SWABFLUSH 1
PA SYNRIBO 5 S
PA SYPRINE 5 S
PAGE 297 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS bd luer-lok 5 ml syringe 3 syringe-needle 3 t.e.d. anti-embolism stocking (anti-embol, anti-embolism) 3 TABLOID 3
QL 6 / day TAFINLAR 50 MG CAPSULE 5 PA S
QL 4 / day TAFINLAR 75 MG CAPSULE 5 PA S
QL 1 / day PA TAGRISSO 4 AL At least 18 yrs old S PS tamoxifen citrate powder 3 tamoxifen citrate (10 mg tablet, 20 mg tablet) 0 HCR
QL 1 / day TARCEVA (100 MG TABLET, 150 MG TABLET) 5 PA S
QL 6 / day TARCEVA 25 MG TABLET 5 PA S
PA TARGRETIN 75 MG CAPSULE 5 S
QL 4 / day PA TASIGNA 4 S PS
PAGE 298 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MG CAPSULE, PA 5 140 MG CAPSULE, 180 MG CAPSULE, 250 MG CAPSULE) S
PA temozolomide 5 S tens 502 3 tens 504 3 terumo surguard2 (ndl 21gx1 1.5, ndl 22x1-1/2", ndl 23x1- 1/2", needle 18gx1", needle 18x1.5, needle 19gx1", needle 19x1.5, needle 20gx1", needle 20x1.5, needle 21gx1", needle 22gx1", needle 23gx1", needle 25gx1", needle 25x1.5, needle 25x5/8, needle 26x1/2, needle 27x1/2, needle 30x1/2, syr 20g- 3 10 ml, syr 20g-3 ml, syr 20g-5 ml, syr 21g 3 ml, syr 21g-10 ml, syr 21g-3 ml, syr 21g-5 ml, syr 22g 3 ml, syr 23g 3 ml, syr 25g 3 ml, syr 25g-1 ml, syr 26g-1 ml, syr 27g-1 ml) tetracaine 3 tetracaine hcl 1% ampul 1 tetracaine hcl powder 3 tetrahydro-l-biopterin di-hcl 3 tetrahydrobiopterin di-hcl 3 tetrahydrobiopterin hcl 3 theobromine 3 thioguanine 3 thiotepa powder 3 thiotepa 15 mg vial 5 S threonine 3 threshold imt 3 threshold pep 3 THROMBI-GEL 3 THROMBI-PAD 3 titanium dioxide 3
PAGE 299 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TL-CERMIDE 3 toomey syringe 1 touch-trol 3
PA TRACLEER 32 MG TABLET FOR SUSP 4 S PS
TREAGAN OTIC 3 trek s combo pack 3 trek s compact compressor 3 trek s portable pwr kit 3
QL 90 / 365 days tretinoin 10 mg capsule 5 S trichloroacetic acid (crystal, powder) 3 trilostane 3 trioxsalen 3 trolamine 3 TROPAZONE 3 truneb nebulizer 3 truzone peak flow meter 3 trypsin 3
QL 6 / day PA TYKERB 4 S PS ulticare 3 unistik 2 normal 2 vacustim black 3
PAGE 300 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS valine 3
VALSTAR 5 S vapro plus intermitt catheter 3 vascuderm hydrogel wound 3 VAXCHORA BUFFER COMPONENT 2
VENATAL COMPLETE DHA 3 GL Female
QL 4 / day VENCLEXTA 5 PA S
QL 1.5 / day VENCLEXTA STARTING PACK 5 PA S
VIASPAN BELZER-UW 3 vios aerosol delivery system 3 VISCOAT 3
VITASPIRE 3 GL Female
VITRASE 3 vixone nebulizer 3 vortex 3 vortex vhc frog mask 3 vortex vhc ladybug mask 3
QL 1 / day PA VOSEVI 4 AL At least 18 yrs old S PS
QL 4 / day VOTRIENT 5 PA S
PAGE 301 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS water (bacteriostatic vial, for injection ampul, for injection vial) 1 white willow bark 3 wide seal diaphragm 0 HCR wound matrix 3
QL 2 / day XALKORI 5 PA S xanthan gum 3
QL 4 / day XELODA 5 PA S xeroform 3 xeroform petrolatum dressing 3
QL 4 / day XTANDI 5 PA S
XYLOCAINE (0.5% VIAL, 1% VIAL) 3 XYLOCAINE-MPF (0.5% VIAL, 1% AMPUL, 1% VIAL, 1.5% AMPUL, 4% AMPUL) 3 xylometazoline hcl 3 yohimbine 5.4 mg tablet 1 ZANABIN 3 zeaxanthin 3
QL 3 / day PA ZEJULA 5 AL At least 18 yrs old S
QL 8 / day ZELBORAF 5 PA S
PAGE 302 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS zinc acetate (crystals, dihydrate powder) 3 zinc pyrithione 3 ZINGO 3 ZODEX 12 DAY 1.5 MG TABLET 3
QL 4 / day ZOLINZA 5 PA S
ZOTEX-C 3
QL 2 / day ZYDELIG 5 PA S
QL 8 / day PA ZYKADIA 5 AL At least 18 yrs old S
QL 4 / day PA ZYTIGA 250 MG TABLET 4 S PS
QL 2 / day PA ZYTIGA 500 MG TABLET 4 S PS
VASODILATING AGENTS
NITRATES AND NITRITES
DILATRATE-SR 3 QL 4 / day
QL 1.25 / day GONITRO 3 PA AL At least 18 yrs old
PAGE 303 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ISOCHRON 1 QL 4 / day
ISORDIL 3 QL 12 / day
ISORDIL TITRADOSE 3 QL 12 / day isosorbide 3 isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg tablet, 30 12 / day mg tablet) 1 QL isosorbide dn er 40 mg tablet 1 QL 4 / day isosorbide mononitrate 1 QL 2 / day isosorbide mononitrate er 1 QL 2 / day
MINITRAN 1 QL 1 / day
NITRO-BID 2 QL 4 / day
NITRO-DUR 3 QL 1 / day
NITRO-TIME 1 QL 4 / day nitroglycerin (er 2.5 mg cap, er 6.5 mg cap, er 9 mg capsule) 1 QL 4 / day
QL 0.3 / day nitroglycerin 400 mcg spray 3 HCG
QL 0.8 / day nitroglycerin lingual 0.4 mg 3 HCG nitroglycerin (0.3 mg tablet, 0.4 mg tablet, 0.6 mg tablet) 1 QL 6 / day nitroglycerin patch 1 QL 1 / day
NITROLINGUAL 3 QL 0.8 / day
NITROMIST 3 QL 0.3 / day
NITROSTAT 3 QL 6 / day sodium nitrite powder 3
PAGE 304 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PHOSPHODIESTERASE TYPE 5 INHIBITORS
QL 0.2 / day CIALIS (10 MG TABLET, 20 MG TABLET) 2 GL Male
QL 1 / day CIALIS (2.5 MG TABLET, 5 MG TABLET) 2 GL Male
QL 0.2 / day VIAGRA 2 GL Male AL At least 18 yrs old
VASODILATING AGENTS, MISCELLANEOUS alprostadil powder 3 alprostadil 500 mcg/ml vial 1 CAVERJECT 40 MCG/2 ML AMPUL 3 CAVERJECT (IMPULSE 10 MCG KIT, 20 MCG VIAL, IMPULSE 20 Male MCG KIT, 40 MCG VIAL) 3 GL
EDEX 3 GL Male isoxsuprine hcl powder 3 isoxsuprine hcl (10 mg tablet, 20 mg tablet) 1
MUSE 3 GL Male papaverine hcl powder 3 papaverine 60 mg/2 ml vial 1 papaverine-alprostadil 1 prostaglandin e1 3 PROSTIN VR PEDIATRIC 3 tolazoline hcl 3
PAGE 305 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VITAMINS
MULTIVITAMIN PREPARATIONS
ELDERCAPS 1
ELITE OB DHA 3 GL Female
ELITE-OB 3 GL Female
MATERNITY 1 GL Female
MAXINATE 3 GL Female multivitamins-a,b,d,e,k,zn (chewables tablet, pediatric drops, softgels) 1
MYNATAL ULTRACAPLET 3 GL Female
MYNATE 90 PLUS 3 GL Female
PNV-VP-U 3
PRENA1 CHEW 3 GL Female prenatal-u 3 GL Female
REQ49+ 3 SUPERVITE EC 3 THERAPEUTIC VITAMIN W-MINERALS 1
TRIVEEN-U 3 GL Female
TRUST NATAL DHA 3 GL Female
UDAMIN SP 3 V-C FORTE 1 VIC-FORTE 1
VINATE PN CARE 3 GL Female
VINATE-M 3 GL Female
PAGE 306 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VITAMIN A
AQUASOL A 3 beta carotene 3 vitamin a acetate 3 vitamin a palmitate (1.7 million unit/gm, 18,000 units/ml liq, plmitte liquid) 3 vitamins a,c,d and fluoride 1 VITAMIN B COMPLEX adenosylcobalamin 3 B-12 COMPLIANCE 3 B-12 KIT 1 b-complex 1 calcium pantothenate 3 CARDIOTEK-RX 3 cobamamide 3 cyanocobalamin 3 cyanocobalamin injection 1 FOLBEE 1 FOLBEE AR 3 FOLBEE PLUS CZ 1 FOLGARD RX 3 folic acid powder 3 folic acid 1 mg tablet 1 folic acid 5 mg/ml vial 1 folic acid-vit b6-vit b12 1 FOLPLEX 2.2 1 hydroxocobalamin powder 3 hydroxocobalamin 1,000 mcg/ml 1
PAGE 307 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS l-5 methyltetrahydrofolate cal 3 l-methylfolate calcium 3 levomefolate calcium 3 methylcobalamin 3 methyltetrahydrofolate calcium 3 methyltetrahydrofolic acid 3 NASCOBAL 3 NEPHRO-VITE RX 3 NEURIN-SL 3 niacinamide 3 panthenol 3 pyridoxine hcl (crystals, powder) 3 pyridoxine 100 mg/ml vial 1 RENA-VITE RX 1 riboflavin 3 riboflavin-5-phosphate sodium 3 SUPERVITE 3 thiamine hcl powder 3 thiamine 200 mg/2 ml vial 1 VIRT-CAPS 1 VIRT-GARD 1 VIRT-VITE 1 VIRT-VITE PLUS 1 VITA-RESPA 3 VP-VITE RX 1 ZOLATE 1
PAGE 308 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VITAMIN C ascorbic acid powder 3 ascorbic acid 500 mg/ml vial 1 sodium ascorbate 3 VITAMIN D calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution) 1 calcitriol (crystals, powder) 3 doxercalciferol (0.5 mcg cap, 1 mcg capsule, 2.5 mcg cap) 5 S
DRISDOL 3 ergocalciferol 3 HECTOROL (0.5 MCG CAPSULE, 1 MCG CAPSULE, 2.5 MCG CAPSULE) 5 S paricalcitol (1 mcg capsule, 2 mcg capsule, 4 mcg capsule) 5 S
RAYALDEE 5 S
ROCALTROL (0.25 MCG CAPSULE, 0.5 MCG CAPSULE, 1 MCG/ML ORAL SOLN) 3 vitamin d2 1 vitamin d3 (2,400 units/ml liq, 100,000 unit/gm pwd) 3
PA ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE) 5 S
VITAMIN E natural mixed tocopherols 3 tocopheryl acid succinate 3 vitamin e acetate (vit actat125 units/ml liq, vitamin actat50% powdr, vitamin actatliquid) 3
PAGE 309 LAST UPDATED 11/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VITAMIN K ACTIVITY phytonadione liquid 3 vitamin k 3 vitamin k2 3
PAGE 310 LAST UPDATED 11/2017 Index of Covered Drugs acetaminophen-codeine 8 2 acetarsone 267 2-deoxy-d-glucose 135 ACETASOL HC 37 2-methoxyestradiol 267 acetazolamide 97 acetazolamide sodium 97 4 acetic acid 37 4-aminobenzoic acid potassium 267 acetic acid-aluminum 37 4-aminopyridine 231 acetyl hexapeptide-8 267 acetyl salicylic acid 127 5 acetyl-d-glucosamine 267 5-aminosalicylic acid 183 acetyl-l-carnitine hcl 231 acetylcholine chloride 97 7 acetylcysteine 231 7-keto dhea 267 acetylcysteine-water 180 acidophilus lactobacillus 184 8 ACIPHEX 134 8-MOP 156 ACIPHEX SPRINKLE 134 acitretin 257 A ACLARO 156 A-HYDROCORT 191 acremonium 157 A-METHAPRED 191 ACTEMRA 224 abacavir 125 ACTHIB 130 abacavir-lamivudine 125 ACTICLATE 60 abacavir-lamivudine-zidovudine 125 acticoat 267 ABILIFY 114 acticoat 7 267 ABILIFY MAINTENA 114 acticoat flex 3 267 ABSORICA 257 acticoat flex 7 267 acacia 157,267 acticoat surgical 267 acamprosate calcium 150 ACTIGALL 186 acarbose 82 ACTIMMUNE 227 ACCOLATE 46 ACTIQ 13 ACCUPRIL 241 ACTIVE FE 47 ACCURETIC 166 ACTIVELLA 176 ACD 171 ACTONEL 222 ACD-A 67 ACTOPLUS MET 83 ace aerosol cloud enhancer 267 ACTOPLUS MET XR 83 acebutolol hcl 52 ACTOS 88 ACEON 241 ACULAR 45 acepromazine maleate 123 ACULAR LS 45 acetamin-caff-dihydrocodeine 8 ACUVAIL 45 acetaminophen 8 acyclovir 39,136 ACZONE 257 aerovent plus 268 ADACEL TDAP 130 AFEDITAB CR 148 ADALAT CC 148 AFINITOR 268 adapalene 257 AFINITOR DISPERZ 268 adapalene-benzoyl peroxide 257 AFLURIA 2016-2017 130 ADASUVE 114 AFLURIA 2017-2018 268 ADCIRCA 244 AFLURIA QUAD 2016-2017 130 ADDERALL 25 AFLURIA QUAD 2017-2018 268 ADDERALL XR 25 AFREZZA 86 ADDYI 150 AGGRENOX 127 adefovir dipivoxil 137 AGRYLIN 128 ademetionine disulfate tosylat 267 air filter 268 ADEMPAS 244 AK-POLY-BAC 33 adenosine 54 AKTEN 181 adenosylcobalamin 307 AKYNZEO 88 ADIPEX-P 24 ALA-CORT 247 ADOXA 60 ALA-QUIN 93 ADRENACLICK 3 ALA-SCALP 247 ADRENALIN 3 alanine 171 ADRENALIN CHLORIDE 183 albendazole 31 adrenocorticotrophic hormone 156 ALBENZA 31 ADVAIR DISKUS 4 albuterol sulfate 4 ADVAIR HFA 4 ALCAINE 181 advance plus intermittent 268 alclometasone dipropionate 248 ADVICOR 106 alcohol,dehydrated 231 ADYPHREN 3 ALDACTAZIDE 166 ADYPHREN AMP 3 ALDACTONE 166 ADYPHREN AMP II 3 ALDARA 257 ADYPHREN II 3 alder 157 ADZENYS XR-ODT 26 aldosterone 191 aerochamber mini 268 ALECENSA 268 aerochamber mv 268 alendronate sodium 222 aerochamber plus flow-vu 268 ALEVICYN ANTIPRURITIC SG 254 aerochamber with flowsignal 268 alfentanil hcl 13 aerochamber z-stat plus 268 alfuzosin hcl er 7 aeroeclipse ii 268 alginic acid 269 aerogear asthma action kit 268 ALINIA 113 aeroneb go 268 ALKERAN 269 aeroneb go nebulizer 268 all flow 1000 269 AEROSPAN 155 all flow 3000 kit 269 aerotrach plus 268 all flow 3000 pft 269 all flow 4000 269 alternaria 157 all flow 5000 269 ALTOPREV 106 all flow 6000 269 aluminum acetate 269 allantoin 269 aluminum chloride 269 allergist syringe 269 aluminum chlorohydrate 269 allergist tray 269 aluminum hydroxide 183 allevyn 269 aluminum sulfate 270 allevyn adhesive 269 ALUNBRIG 270 allevyn ag 269 ALUVEA 254 allevyn ag adhesive 269 ALYACEN 196 allevyn ag gentle 269 AMABELZ 176 allevyn heel 269 amantadine 111 allevyn life 269 amantadine hcl 111 ALLFEN CDX 269 AMARYL 87 allopurinol 220 AMBIEN 139 ALLZITAL 8 AMBIEN CR 139 almond 157 amcinonide 248 almond oil 269 AMERGE 108 almotriptan malate 108 american beech 157 ALOCRIL 46 american cockroach extract 157 aloe vera 269 american elm 157 ALOMIDE 180 american ginseng root 270 ALORA 176 american sycamore 157 alosetron hcl 183 AMETHIA 196 alpha lipoic acid 269 AMETHIA LO 196 ALPHAGAN P 96 AMETHYST 197 ALPHAQUIN HP 156 AMICAR 98 alprazolam 142 amikacin 56 alprazolam er 142 amikacin sulfate 56 ALPRAZOLAM INTENSOL 142 amiloride hcl 165 alprazolam odt 142 amiloride-hydrochlorothiazide 165 alprazolam xr 142 aminobutyric acid 231 alprostadil 305 aminocaproic acid 99 ALREX 43 aminophylline 147 ALSUMA 108 aminosalicylic acid 110 ALTABAX 37 amiodarone hcl 54 ALTACAINE 181 AMITIZA 185 ALTACE 241 amitriptyline hcl 81 ALTAFLUOR 181 amlodipine besilate 148 ALTAVERA 196 amlodipine besylate 148 altera nebulizer 269 amlodipine besylate-benazepril 148 amlodipine-atorvastatin 106 androstenedione 195 amlodipine-olmesartan 148 ANDROXY 195 amlodipine-valsartan 148 ANGELIQ 176 amlodipine-valsartan-hctz 148 anisindione 270 ammonium chloride 169 ANORO ELLIPTA 4 ammonium lactate 174,175,270 ANSAID 235 ammonium sulfate 270 ANTABUSE 219 ammonium tetrathiomolybdate 270 ANTARA 105 AMNESTEEM 257 anthralin 256 amoxapine 81 antimony trichloride 113 amoxicillin 239 antivenin latrodectus mactans 129 amoxicillin er 239 antivenin micrurus fulvius 129 amoxicillin trihydrate 239 ANTIVERT 90 amoxicillin-clavulanate pot 239 ANUCORT-HC 248 amoxicillin-clavulanate pot er 239 ANUSOL-HC 248 amoxicillin-clavulanate potass 239 ANZEMET 89 amphotericin b 93 APEXICON E 248 ampicillin sodium 239 APLENZIN 75 ampicillin trihydrate 239 APLIGRAF 270 ampicillin-sulbactam 239 APLISOL 164 AMPYRA 231 apogee hc intermittent 270 AMRIX 246 apogee ic intermittent cathetr 270 AMVISC 270 APOKYN 169 AMVISC PLUS 270 apomorphine hcl 169 amyl nitrite 219 apple 157 AMYTAL SODIUM 141 apraclonidine hcl 180 ANA-LEX 248 aprepitant 89,90 ANACAINE 252 APRI 197 ANADROL-50 194 APRISO 183 ANAFRANIL 81 APTENSIO XR 28 anagrelide hcl 128 APTIOM 69 ANALPRAM HC 248 APTIVUS 126 ANAPROX 220 AQUASOL A 307 ANAPROX DS 220 AQUORAL 270 ANASPAZ 64 ARANELLE 197 ANASTIA 252 ARANESP 146 anastrozole 270 ARAVA 224 ANCOBON 93 ARBINOXA 100 ANDRODERM 194 ARCALYST 231 ANDROGEL 194 ARCAPTA NEOHALER 4 ANDROID 194 arginine 171 arginine hcl 171 ATELVIA 222 argyle 270 atenolol 52,53 ARICEPT 143,144 atenolol-chlorthalidone 53 arida 40 ATIVAN 73 ARIMIDEX 270 atomoxetine hcl 150 aripiprazole 114 ATOPICLAIR 174 aripiprazole odt 114 atorvastatin calcium 106 ARISTADA 114,115 atovaquone 113 ARISTOSPAN 191 atovaquone-proguanil hcl 113 ARIXTRA 67 ATRALIN 253 arizona cypress 157 ATRAPRO DERMAL SPRAY 271 armodafinil 31 ATRAPRO HYDROGEL 271 ARMOUR THYROID 266 ATRIPLA 124 arnica lg 270 ATROPEN 64 ARNUITY ELLIPTA 155 atropine sulfate 64,182 AROMASIN 270 atropine sulfate-0.9% nacl 182 arsenic trioxide 270 ATROVENT 180 ARTHROTEC 50 133 ATROVENT HFA 64 ARTHROTEC 75 133 attapulgite 184 ARTISS 257 AUBAGIO 227 ARYMO ER 13 AUBRA 197 asa-butalb-caffeine-codeine 13 AUGMENTIN 239 ASCOMP WITH CODEINE 13 AUGMENTIN ES-600 239 ascorbic acid 309 AUGMENTIN XR 239 ASHLYNA 197 aureobasidium 157 ashwagandha extract 270 AURSTAT 271 aspartic acid magnesium salt 270 AURYXIA 217 aspergillus fumigatus 157 AUSTEDO 151 aspirin 127 australian pine 157 aspirin-caffeine-dihydrocodein 127 AUVI-Q 3 aspirin-dipyridamole er 127 AVAGE 257 assura 270 AVAILNEX 271 ASTAGRAF XL 229,230 AVALIDE 166 ASTEPRO 180 AVANDAMET 83 asthmapack children's 270 AVANDIA 88 astragalus extract 270 AVAPRO 240 ASTRAMORPH-PF 13 AVAR 40 ASTRINGYN 99 AVAR LS 40 ATABEX EC 47 AVAR-E 40 ATACAND 240 AVAR-E GREEN 40 ATACAND HCT 166 AVAR-E LS 40 AVC 40 baby conversion pack 2 271 AVELOX 58 baby nebulizer 271 AVELOX ABC PACK 58 BACIIM 62 AVENOVA 271 bacitracin 33,37,62 AVIANE 197 bacitracin micronized 37 AVIDOXY 60 bacitracin zinc 37 AVITA 253 bacitracin-polymyxin 33 AVITENE 99 baclofen 247 AVO CREAM 175 BACTRIM 59 avocado 157 BACTRIM DS 59 AVODART 219 BACTROBAN 37 AVONEX 227 BACTROBAN NASAL 34 AVONEX PEN 227 bahia 157 AXERT 109 BAL IN OIL 219 AYGESTIN 214 balanced salt 181 azacitidine 271 bald cypress 157 AZACTAM 219 balsalazide disodium 183 AZASAN 224 BALZIVA 197 AZASITE 33 banana 157 azathioprine 224 BANZEL 69 azathioprine sodium 224 BARACLUDE 137 azelaic acid 257 barium sulfate 163 azelastine hcl 180 bayberry 157 AZELEX 257 bcg vaccine (tice strain) 130 AZILECT 76 BEAU RX 271 azithromycin 218 beclomethasone dipropionate 191 AZOPT 97 BECONASE AQ 43 AZOR 148 beef 157 aztreonam 219 BEKYREE 197 AZULFIDINE 59 BELBUCA 22 AZUPHEN MB 32 belladonna 64 AZURETTE 197 belladonna leaf powder 64 belladonna-opium 13 B belladonna-phenobarbital 64 B-12 COMPLIANCE 307 BELSOMRA 139 B-12 KIT 307 BELVIQ 25 b-complex 307 BELVIQ XR 25 B-DONNA 64 benactyzine hcl 75 B-PLEX PLUS 271 benazepril hcl 241,243 baby conversion kit 271 benazepril-hydrochlorothiazide 167 baby conversion pack 1 271 BENICAR 240 BENICAR HCT 167 BEXSERO 130 BENLYSTA 271 BEYAZ 197 BENSAL HP 254 BIAFINE 175 BENTYL 64 BIAXIN 110 benzalkonium chloride 40 bicalutamide 271 BENZEFOAM 254 BICILLIN C-R 240 BENZEFOAM ULTRA 254 BICILLIN L-A 240 BENZEPRO 254 BIDIL 216 benzocaine 271 BILTRICIDE 31 benzoic acid 271 bimatoprost 98 benzonatate 243 BINOSTO 222 benzoyl peroxide 254,271 BIOGLO 162 benzphetamine hcl 26 BIONECT 271 benztropine mesylate 67 biostep 271 benzyl alcohol 271 biostep ag 271 benzyl benzoate 43 BIOTHRAX 130 BEPREVE 180 biotin 271 BESIVANCE 34 biotin-d 271 beta carotene 307 bisacodyl 185 beta glucan 271 bismuth citrate 272 beta glucan (1-3) nq 232 bismuth subgallate 272 BETADINE 37 bismuth subsalicylate 184 BETAGAN 96 bisoprolol fumarate 53 betahistine 150 bisoprolol-hydrochlorothiazide 53 betahistine hcl 150 bitter melon extract 272 betaine hydrochloride 232 black walnut pollen 157 betamethasone acetate micro 191 black willow 157 betamethasone acetate-sod phos 192 BLANCHE 156 betamethasone dipropionate 248 BLEO 15K 272 betamethasone sodium phosphate 192 bleomycin sulfate 272 betamethasone valerate 248 BLEPH-10 34 BETAPACE 53 BLEPHAMIDE 34 BETAPACE AF 53 BLEPHAMIDE S.O.P. 34 BETASERON 227 BLISOVI 24 FE 197 betaxolol hcl 53,96 BLISOVI FE 197 bethanechol chloride 144 BONIVA 222 BETHKIS 57 BONTRIL PDM 24 BETIMOL 96 BOOSTRIX TDAP 130 BETOPTIC S 96 boric acid 37 BEVESPI AEROSPHERE 4 BOSULIF 272 bexarotene 271 boswellia serrata extract 272 BOTOX COSMETIC 232 bupivacaine hcl 272 botrytis 157 bupivacaine hcl-epinephrine 265 bovine serum albumin 272 bupivacaine-dextrose 272 box elder 157 BUPRENEX 23 BP 10-1 40 buprenorphine 23 BP-50% UREA 254 buprenorphine hcl 23 BPO 254 buprenorphine-naloxone 23 BRAVELLE 210 BUPROBAN 75 breatherite 272 bupropion hcl 75 breathrite 272 bupropion hcl sr 75 BREO ELLIPTA 4 bupropion xl 75 BREVICON 198 buspirone hcl 139 BREVITAL SODIUM 73 butalb-acetaminoph-caff-codein 8 BRIELLYN 198 butalb-caff-acetaminoph-codein 8 BRILINTA 128 butalbital 141 brimonidine tartrate 96 butalbital compound-codeine 13 BRINTELLIX 80 butalbital-acetaminophen 8 BRISDELLE 77 butalbital-acetaminophen-caffe 9 BRIVIACT 69 butalbital-aspirin-caffeine 128,272 brome 157 BUTISOL SODIUM 141 bromelain 272 butorphanol tartrate 23 BROMFED DM 101 BUTRANS 23 bromfenac sodium 45,272 butylated hydroxytoluene(bht) 232 bromhexine hcl 243 BYDUREON 85 bromocriptine mesylate 168 BYDUREON BCISE 272 brompheniramine maleate 100 BYDUREON PEN 85 brompheniramine-pseudoephed-dm 101 BYETTA 86 BROMSITE 45 BYSTOLIC 145 BROVANA 4 BYVALSON 145 BSS 181 BSS PLUS 181 C BUCALSEP 181 cabergoline 168 budesonide 43,155 CABOMETYX 272,273 budesonide ec 192 CADEAU DHA 47 budesonide micronized 43 CADUET 106 buffered lidocaine 272 CAFERGOT 6 buflomedil hcl 272 caffeine 28 bumetanide 164 caffeine and sodium benzoate 28 BUNAVAIL 22 caffeine citrate 28 BUPAP 8 calamine 174 BUPHENYL 170 CALAN 55 CALAN SR 55 CAPRELSA 273 calcipotriene 257,273 caprylic acid 273 calcipotriene monohydrate 273 capsaicin 258 calcipotriene-betamethasone dp 248 capsaicin palmitate 258 calcipotriol 273 capsicum oleoresin 258 calcitonin-salmon 212 captopril 241 CALCITRENE 257 captopril-hydrochlorothiazide 167 calcitriol 257,309 CARAC 258 calcitriol in almond oil 273 CARAFATE 134 calcium acetate 217 carbachol 98 calcium amino acid chelate 172 CARBAGLU 170 calcium carbonate 172 carbamazepine 69 calcium chloride 172 carbamazepine er 69 calcium citrate 172 carbamide peroxide 40 calcium disodium versenate 219 CARBATROL 69 calcium folinate 232 carbidopa 151 calcium glubionate 172 carbidopa-levodopa 112 calcium gluconate monohydrate 172 carbidopa-levodopa er 112 calcium levulinate dihydrate 172 carbidopa-levodopa-entacapone 111 calcium pantothenate 307 carbimazole 265 calcium phosphate 172 carbinoxamine maleate 100 calcium saccharate 172 CARBOCAINE 273 california pepper tree 157 CARDENE SR 148,273 CAMILA 198 cardioplegia high potassium 172 camphor 258 cardioplegic 172 CAMRESE 198 CARDIOTEK-RX 307 CAMRESE LO 198 CARDIOVID PLUS 232 CANASA 183 CARDIZEM 55 candesartan cilexetil 240 CARDIZEM CD 55 candesartan-hydrochlorothiazid 167 CARDIZEM LA 55 candida albicans 158 CARDURA 6 CANDIN 162 CARDURA XL 6 cantaloupe 158 carelessweed 158 cantharidin 273 carisoprodol 246 CANTIL 64 carisoprodol compound 238 CAPACET 9 carisoprodol compound-codeine 13 CAPASTAT SULFATE 110 carisoprodol-aspirin 238 capecitabine 273 carisoprodol-aspirin-codeine 13 CAPEX SHAMPOO 248 CARNITOR 232 CAPHOSOL 273 CARNITOR SF 232 CAPITAL W-CODEINE 9 carrasyn hydrogel wound 273 carteolol hcl 96 celecoxib 235 CARTIA XT 55 CELESTONE 192 carvedilol 7 CELEXA 77 carvedilol er 7 CELLCEPT 230 cascara sagrada 185 CELLUGEL 181 casein 158 CELONTIN 74 CASODEX 273 CEM-UREA 255 CATAPRES 215 CENTANY 37 CATAPRES-TTS 1 215 CENTANY AT 37 CATAPRES-TTS 2 215 CENTERGY 101 CATAPRES-TTS 3 215 CENTERGY DM 101 catheter 273 cephalexin 153 CATHFLO ACTIVASE 129 CERAMAX 273 cattle epithelium 158 CERDELGA 232 CAVERJECT 305 CEREBYX 74 CAYSTON 219 CERVARIX 130 CAZIANT 198 CERVIDIL 274 cedar elm 158 CESAMET 90 CEDAX 154,273 cesium chloride 274 cefaclor 153 CETACAINE 252 cefaclor er 153 cetirizine hcl 101 cefadroxil 153 CETRAXAL 34 cefazolin sodium 153 CETROTIDE 226 cefdinir 154 cetyl myristoleate 274 cefditoren pivoxil 154 cetylpyridinium chloride 274 cefepime hcl 153 cevimeline hcl 144 cefixime 154 CHANTIX 143 CEFOTAN 153 CHATEAL 198 cefotaxime sodium 154 CHEMET 219 cefotetan 153 CHENODAL 186 cefpodoxime proxetil 154 chicken meat 158 cefprozil 153 chloral hydrate 139 ceftazidime 154 chlorambucil 274 ceftazidime-sodium carbonate 154 chloramphenicol 57 ceftibuten 154 chloramphenicol palmitate 57 CEFTIN 153 chlordiazepoxide hcl 142 ceftriaxone 154 chlordiazepoxide-amitriptyline 81 ceftriaxone sodium 154 chlordiazepoxide-clidinium 64 cefuroxime 153 chlorhexidine gluconate 37,40 cefuroxime sodium 153 chloroacetic acid 274 CELEBREX 235 chlorobutanol 274 chloroform 189 ciprofloxacin er 58 chloroprocaine hcl 274 ciprofloxacin hcl 34,59 chloroquine phosphate 113 citalopram hbr 78 chlorothiazide 165 citrate phosphate dextrose 67 chloroxine 274 citric acid 274 chloroxylenol 274 citrus bergamot 274 chlorpheniramine maleate 100 cladosporium cladosporioides 158 chlorpromazine hcl 123 cladosporium sphaerospermum 158 chlorpropamide 87 CLAFORAN 154 chlorthalidone 165 CLARAVIS 258 chlorzoxazone 246,274 CLARIFOAM EF 40 CHOLBAM 186 CLARINEX 101 cholesterol 274 CLARINEX-D 12 HOUR 101 cholestyramine 104 clarithromycin 58,110 cholestyramine light 104 clarithromycin er 110 cholestyramine resin 104 CLEANSING WASH 40 choline bitartrate 188 clemastine fumarate 100 choline mag trisalicylate 238 clemizole hcl 274 choline magnesium trisalicylat 238 CLEOCIN 37 chondroitin sulfate 232 CLEOCIN HCL 62 chondroitin sulfate sodium 232 CLEOCIN PALMITATE 62 chorionic gonadotropin 210 CLEOCIN PHOSPHATE 62 chromium picolinate 274 CLEOCIN T 37 chromium polynicotinate 274 clever choice holding chamber 274 chrysin 274 clever choice nebulizer 274 chymotrypsin 274 clever choice whisper aire ped 274 CIALIS 305 clidinium bromide 64 CICLODAN 95 CLIMARA 176 ciclopirox 95 CLIMARA PRO 176 ciclopirox olamine 95 CLINDACIN ETZ 37 CIDALEAZE 252 CLINDACIN P 38 cidofovir 137 CLINDACIN PAC 38 cilostazol 128 CLINDAGEL 38 CILOXAN 34 clindamax 38 cimetidine 133 clindamycin hcl 62 CIMZIA 186,187 clindamycin palmitate hcl 62 CIPRO 58 clindamycin pediatric 62 CIPRO HC 34 clindamycin phos-benzoyl perox 38 CIPRO XR 58 clindamycin phos-tretinoin 38 CIPRODEX 34 clindamycin phosphate 38,62 ciprofloxacin 58 clindamycin-benzoyl peroxide 38 CLINDESSE 38 colchicine 220,221 CLINPRO 5000 222 COLCRYS 221 clioquinol 93 COLESTID 104 clobetasol emollient 248 colestipol hcl 104 clobetasol emulsion 248 colistimethate 63 clobetasol propionate 248 colistimethate sodium 63 clobetasol propionate micro 248 colistin sulfate 63 CLOBEX 248 collagenase 258 clocortolone pivalate 248 COLOCORT 248 CLODAN 248 COLY-MYCIN M PARENTERAL 63 CLODERM 248 COLY-MYCIN S 34 clofazimine 110 COLYTE WITH FLAVOR PACKETS 185 clomiphene citrate 175 COMBIGAN 96 clomipramine hcl 81 COMBIPATCH 176 clonazepam 73 COMBIVENT RESPIMAT 5 clonidine 215,216 COMBIVIR 125 clonidine hcl 216 COMETRIQ 274,275 clonidine hcl er 216 comp-air elite compressor syst 275 clopidogrel 128 comp-air nebulizer compressor 275 clopidogrel bisulfate 128 compact space chamber 275 clorazepate dipotassium 73 COMPAZINE 90 CLORPRES 168 COMPLERA 124 clotrimazole 94 COMPOUND 347 189 clotrimazole-betamethasone 94 COMPRO 91 clozapine 115 COMTAN 111 clozapine odt 115 conception 275 CLOZARIL 115 CONCERTA 28 CNL 8 95 CONDYLOX 258 coaguchek xs 274 CONRAY 163 coal tar 256 CONSTULOSE 170 COARTEM 113 CONTRAVE 25 cobalt gluconate 274 CONZIP 14 cobamamide 307 COPAXONE 227 cocaine hcl 181 COPEGUS 137 cocklebur 158 copper peptide ghk-cu 275 cocoa bean 158 CORDARONE 54 codeine phosphate 14 COREG 7 codeine sulfate 14 COREG CR 7 coenzyme q10 232 CORGARD 53 COGENTIN 67 CORLANOR 149 COLAZAL 183 CORMAX 248 corn pollen 158 curafil 275 corn smut 158 curcumin 232 CORTANE-B 43 curity 275 CORTEF 192 curity amd 40,275 CORTENEMA 248 curity iodoform 275 corticotrophin 156 CUROSURF 244 CORTIFOAM 249 curvularia 158 cortisone acetate 192 CUTIVATE 249 CORTISPORIN 38 CUVITRU 129 CORTISPORIN-TC 34 CUVPOSA 64 CORTROSYN 156 cyanocobalamin 307 CORZIDE 53 cyanocobalamin injection 307 COSENTYX (2 SYRINGES) 258 CYCLAFEM 198 COSENTYX PEN 258 cyclandelate 150 COSENTYX PEN (2 PENS) 258 CYCLESSA 198 COSENTYX SYRINGE 258 cyclobenzaprine hcl 246 COSOPT 96 cyclodextrin-beta 275 COSOPT PF 96 CYCLOGYL 182 cosyntropin 156 CYCLOMYDRIL 182 COTELLIC 275 cyclopentolate hcl 182 COTEMPLA XR-ODT 275 cyclopentolate-lidoc-pe-tropic 181 COUMADIN 67 cyclopentolate-tropicamide-pe 182 coumarin 232 cyclophosphamide 230 COVARYX 176 cyclophosphamide monohydrate 230 COVARYX H.S. 176 cycloserine 111 COZAAR 240 CYCLOSET 169 crab 158 cyclosporine 224,230 creatine 275 cyclosporine modified 224 creatine monohydrate 275 CYMBALTA 76 creatinine 275 cyproheptadine hcl 100 CREON 186 CYRED 198 CRESEMBA 92 CYSTADANE 232 CRESTOR 106 CYSTAGON 232 CRINONE 214 CYSTARAN 181 CRIXIVAN 126 cysteamine hcl 232 CROFAB 129 CYSTOGRAFIN 163 cromolyn sodium 46 CYSTOGRAFIN-DILUTE 163 crotamiton 43 cytarabine 275 cryoserv 232 CYTOMEL 266 CRYSELLE 198 CYTOTEC 133 CUPRIMINE 224 CYTRA-2 170 CYTRA-3 170 DEPAKENE 69 CYTRA-K 170 DEPAKOTE 69 DEPAKOTE ER 69 D DEPAKOTE SPRINKLE 69 d-ribose 171 DEPEN 224 d.farinae mite extract 158 DEPO-ESTRADIOL 176 D.H.E.45 6 DEPO-MEDROL 192 d.pteronyssinus mite extract 158 DEPO-PROVERA 214 DAKLINZA 191 DEPO-SUBQ PROVERA 104 214 DALIRESP 244 DEPO-TESTOSTERONE 195 danazol 195 DERMA-SMOOTHE-FS 249 DANTRIUM 247 DERMAGRAFT 276 dantrolene sodium 247 DERMATOP 249 dapiprazole hcl 275 DERMAZENE 40 dapsone 110,258 DERMOTIC 44 DAPTACEL DTAP 130 DESCOVY 125 darifenacin er 189 DESFERAL 220 DASETTA 198 DESFERAL MESYLATE 220 DAXBIA 153 desipramine hcl 81 DAYPRO 235 desloratadine 101 DAYSEE 198 desmopressin acetate 99,213 DAYTRANA 28 DESOGEN 199 DDAVP 99,213 desogestr-eth estrad eth estra 199 DEBACTEROL 258 desogestrel-ethinyl estradiol 199 DEBLITANE 199 DESONATE 249 deferoxamine mesylate 220 desonide 249 dehydroepiandrosterone 195 desonide micronized 249 DELATESTRYL 195 DESOWEN 249 DELESTROGEN 176 desoximetasone 249 DELTASONE 192 desoxycorticosterone acetate 192 DELYLA 199 DESOXYN 26 DEMADEX 164 desvenlafaxine er 76 demecarium bromide 276 desvenlafaxine fumarate er 77 demeclocycline hcl 60 desvenlafaxine succinate er 77 DEMEROL 14 DETROL 189 DEMSER 232 DETROL LA 189 DENAVIR 39 devil's claw 276 DENTA 5000 PLUS 223 devilbiss traveler 276 DENTAGEL 223 dexamethasone 192 deoxycholic acid 276 dexamethasone acetate 192 DEPADE 152 dexamethasone acetate micro 192 DEXAMETHASONE INTENSOL 192 dicyclomine hcl 64 dexamethasone isonicotinate 192 didanosine 125 dexamethasone micronized 192 diethanolamine 276 dexamethasone sodium phosphate 44,192 diethylcarbamazine citrate 32 dexchlorpheniramine maleate 276 diethylen glycol m-ethyl ether 276 DEXEDRINE 26 diethylpropion hcl 24 DEXERYL 175 diethylpropion hcl er 24 DEXILANT 134 diethylstilbestrol 176 dexmethylphenidate hcl 28 DIFFERIN 258 dexmethylphenidate hcl er 28 DIFICID 218 DEXPAK 192 diflorasone diacetate 249 dexpanthenol 276 DIFLUCAN 92 dextroamphetamine sulfate 26 diflunisal 235 dextroamphetamine sulfate er 26,27 DIGITEK 51 dextroamphetamine-amphet er 27 DIGOX 51 dextroamphetamine-amphetamine 27 digoxin 51 dextromethorphan hbr 243 dihydrocodeine bitartrate 14 dextrose 171 dihydroergotamine mesylate 6 dhea micronized 195 diindolylmethane 276 DIABETA 87 diiodo-l-thyronine 276 DIALYVITE 800 WITH IRON 47 DILANTIN 52 diaminopyridine 232 DILANTIN-125 52 DIAMOX SEQUELS 97 DILATRATE-SR 303 DIASTAT 73 DILAUDID 14,15 DIASTAT ACUDIAL 73 DILAUDID-HP 15 diazepam 74 DILT-XR 55 diazoxide 103 diltiazem 12hr er 55 DIBENZYLINE 6 diltiazem 24hr cd 55 dibucaine 276 diltiazem 24hr er 55 dibucaine hcl 252 diltiazem er 55 dibutyl squarate 232 diltiazem hcl 55,56 dichloralphenazone 140 DILUENT FOR ELITEK 276 dichloroacetic acid 276 dimenhydrinate 91,100 DICLEGIS 90 dimercaptopropanesulfonate sod 276 diclofenac potassium 235 dimethyl sulfone 276 diclofenac sodium 45,235,258 dimethyl sulfoxide 276 diclofenac sodium er 235 dimethylacetamide 276 diclofenac sodium micronized 235 dinitrochlorobenzene 276 diclofenac sodium-misoprostol 133 DIOVAN 240 dicloxacillin sodium 240 DIOVAN HCT 167 dicumarol 67 DIPENTUM 184 diphenhydramine hcl 100 dover red rubber robibson cath 277 diphenidol hcl 90 dover universal 277 diphenoxylate-atropine 64 DOVONEX 259 diphenylcyclopropenone 276 doxazosin mesylate 6 diphtheria-tetanus toxoids-ped 130 doxepin hcl 81,82,252 DIPROLENE 249 doxercalciferol 309 DIPROLENE AF 249 doxycycline hyclate 34,60 dipyridamole 128 doxycycline ir-dr 61 DISALCID 238 doxycycline monohydrate 61 DISCOVISC 276 doxylamine succinate 100 disopyramide phosphate 51 drechslera 158 disulfiram 219 DRISDOL 309 DITROPAN XL 189 DRITHOCREME HP 256 DIURIL 165 dronabinol 90 divalproex sodium 69 droperidol 140 divalproex sodium er 70 drospirenone-eth estra-levomef 199 DIVIGEL 176 drospirenone-ethinyl estradiol 199 dl-3-hydroxybutyric acid sod 276 DROXIA 277 dmae 276 DRYSOL 253 dmsa 220 DUAVEE 175 docosanol 39 DUETACT 87 docusate sodium 185 duloxetine hcl 77 dofetilide 54 DUODOTE 65 dog epithelium extract 158 DUOPA 112 dog fennel 158 DUOVISC 277 DOLOPHINE HCL 15 DUPIXENT 259 donepezil hcl 144 DURAGESIC 15 donepezil hcl odt 144 DURAMORPH 15 DONNATAL 64 DUREZOL 44 dopamine hcl 145 DURLAZA 128 DORAL 142 dutasteride 219 DORYX 60 dutasteride-tamsulosin 7 DORYX MPC 60 DUTOPROL 53 dorzolamide hcl 97 DYANAVEL XR 27 dorzolamide-timolol 97 DYAZIDE 165 DOTHELLE DHA 47 dyclonine hcl 181 dover advantage 276 DYMISTA 102 dover advantage drainage 276 dyphylline 147 dover coated latex foley 276 DYRENIUM 165 dover latex foley catheter 276 dover premium 277 ELESTAT 180 E ELESTRIN 176 E-Z DISK 163 ELETONE 175 e-z spacer 277 eletriptan hbr 109 e-z spacer pedspak 277 ELIDEL 230 E-Z-CAT 163 ELIGARD 211 E-Z-HD 163 ELIMITE 43 E-Z-PAQUE 163 ELINEST 199 E-Z-PASTE 163 ELIPHOS 217 E.E.S. 200 58 ELIQUIS 67 E.E.S. 400 58 ELITE OB DHA 306 ear popper 277 ELITE-OB 306 easivent 277 ELITE-OB 400 47 eastern cottonwood 158 ELIXOPHYLLIN 147 ebase controller 277 ELLA 199 EC-NAPROSYN 221 ELMIRON 235 eclipse needle 277 ELOCON 249 eclipse syringe 277 EMADINE 180 econazole nitrate 94 EMBEDA 15 ECOZA 94 EMCYT 277 ED-SPAZ 65 EMEND 90 EDARBI 240 EMFLAZA 192 EDARBYCLOR 168 EMLA 252 EDECRIN 164 EMOQUETTE 199 edetate calcium disodium 220 EMSAM 76 edetate disodium 232 EMTRIVA 125 EDEX 305 EMULSION SB 277 EDLUAR 140 EMVERM 31 edrophonium chloride 162 ENABLEX 189 EDURANT 124 enalapril maleate 241 EEMT 176 enalapril-hydrochlorothiazide 167 EEMT H.S. 176 ENBREL 224,277 EFFER-K 172 ENDO-AVITENE 99 EFFEXOR XR 77 ENDOCET 9 EFFIENT 128 ENDOFORM 277 EFUDEX 259 ENDOMETRIN 214 egcg 277 ENGERIX-B ADULT 130 egg white 158 ENGERIX-B PEDIATRIC-ADOLESCENT 130 EGRIFTA 264 english plantain 158 ELDEPRYL 76 ENJUVIA 176 ELDERCAPS 306 ENLON 162 enoxaparin sodium 68 EPZICOM 125 ENPRESSE 199 EQUETRO 70 ENSKYCE 199 erapid nebulizer 277 ENSTILAR 249 erapid nebulizer handset 277 entacapone 111 ergocalciferol 309 entecavir 137 ergoloid mesylates 6 enteral gravity bag set-enfit 277 ERGOMAR 6 ENTEREG 187 ergotamine tartrate 6 ENTERO VU 163 ergotamine-caffeine 7 ENTOCORT EC 192 ERIVEDGE 278 ENTRESTO 242 ERRIN 199 ENTTY 277 ERTACZO 94 ENULOSE 170 ERWINAZE 278 ENVARSUS XR 230 ERY 38 EPANED 241 ERY-TAB 58 EPCLUSA 190 ERYGEL 38 ephedrine hcl 3 ERYPED 200 58 ephedrine sulfate 3 ERYPED 400 58 EPICERAM 277 ERYTHROCIN STEARATE 58 epicoccum 158 erythromycin 34,38,58,218 EPIDUO 259 erythromycin estolate 218 EPIDUO FORTE 259 erythromycin ethylsuccinate 58,218 EPIFIX AMNIOTIC MEMBRANE 232 erythromycin-benzoyl peroxide 38 EPIFOAM 249 ESBRIET 243 epinastine hcl 180 ESCAVITE LQ 47 epinephrine 3 escitalopram oxalate 78 epinephrine bitartrate 3 ESGIC 9 epinephrine hcl 3 esomeprazole magnesium 134 EPINEPHRINESNAP-V 3 esomeprazole strontium 134 EPIPEN 3 ESTARYLLA 200 EPIPEN 2-PAK 3 estazolam 142 EPIPEN JR 2-PAK 3 ESTRACE 177 EPISIL 277 estradiol 177 EPISNAP 4 estradiol benzoate 177 EPITOL 70 estradiol cypionate 177 EPIVIR 125 estradiol micronized 177 EPIVIR HBV 125 estradiol valerate 177 eplerenone 166 estradiol-norethindrone acetat 177 EPOGEN 146 ESTRING 177 eprosartan mesylate 241 estriol 177 EPY 4 estriol micronized 178 ESTROGEL 178 EZ FLU 2016-2017 (AFLURIA) 130 estrogen-methyltestosterone 178 EZ FLU 2016-2017 (FLUVIRIN) 130 estrone 178 EZ USE JOINT-TUNNEL-TRIGGER 192 estropipate 178 ezetimibe 105 ESTROSTEP FE 200 ezetimibe-simvastatin 105 eszopiclone 140 ethacrynic acid 164 F ethambutol hcl 111 FABIOR 259 ethosuximide 74 FACTIVE 59 ethoxy diglycol 278 FALMINA 200 ethyl acetate 278 famciclovir 137 ethyl chloride 252 famotidine 133 ethyl oleate 278 FAMVIR 137 ethynodiol-ethinyl estradiol 200 FANAPT 116 etidronate disodium 222 FARESTON 278 etodolac 236 FARYDAK 278 etodolac er 236 FAYOSIM 200 etomidate 189 FAZACLO 116 etoposide 278 felbamate 70 EUCRISA 249 FELBATOL 70 EURAX 43 FELDENE 236 EVAMIST 178 felodipine er 147 EVARREST 99 FEM PH 40 EVEKEO 27 female self catheter 278 EVICEL 99 FEMARA 278 EVISTA 175 femcap 278 EVOCLIN 38 FEMCON FE 200 EVOTAZ 126 FEMHRT 178 EVOXAC 144 FEMRING 178 EXALGO 15 FEMYNOR 200 EXELDERM 94 fenofibrate 105 EXELON 144 fenofibric acid 105 exemestane 278 FENOGLIDE 105 EXFORGE 148 fenoprofen calcium 236 EXFORGE HCT 148 FENORTHO 236 EXJADE 278 fentanyl 15 EXODERM 93 fentanyl base 15 EXPAREL 278 fentanyl citrate 15 EXTAVIA 227 fentanyl-bupivacaine-0.9% nacl 15,16 EXTINA 94 fentanyl-ropivacaine-0.9% nacl 16 EZ FLU 16-17 (FLUZON QUAD PED) 130 FEROCON 47 FEROTRINSIC 47 floxuridine 279 FERREX 150 FORTE 47 FLUAD 2016-2017 131 ferric ammonium citrate 278 FLUAD 2017-2018 279 ferric subsulfate 278 FLUARIX QUAD 2016-2017 131 ferric sulfate 47 FLUARIX QUAD 2017-2018 279 FERRIPROX 278 FLUBLOK 2016-2017 131 FERROCITE PLUS 47 FLUBLOK 2017-2018 279 ferrous fumarate 47 FLUBLOK QUAD 2017-2018 279 ferrous gluconate 47 FLUCAINE 162 ferrous sulfate 47 FLUCELVAX QUAD 2016-2017 131 FETZIMA 77 FLUCELVAX QUAD 2017-2018 279 FEXMID 246 fluconazole 92 fexofenadine hcl 101 flucytosine 93 fexofenadine-pse er 278 fludrocortisone acetate 192 FIBRICOR 105 FLULAVAL QUAD 2016-2017 131 filter needle 278 FLULAVAL QUAD 2017-2018 279 filter, valve set for ll & lc 279 FLUMADINE 135 FINACEA 259 flumazenil 151 finasteride 219,259 flunisolide 44,193 FIORICET 9 fluocinolone acetonide 249 FIORICET WITH CODEINE 9 fluocinolone acetonide oil 44 FIORINAL 128 fluocinonide 249 FIORINAL WITH CODEINE #3 16 fluocinonide micronized 249 FIRAZYR 224 fluocinonide-e 249 fire ant 158 FLUOR-A-DAY 223 FIRMAGON 227 FLUOR-I-STRIP AT 162 FLAGYL 112 FLUORABON 223 FLAGYL ER 112 fluorescein powder 162 FLAREX 44 fluorescein-benoxinate 181 flavoxate hcl 190 fluorescein-proparacaine 163 flecainide acetate 52 fluoride 223 FLECTOR 236 FLUORIDEX 223 flexichamber 279 FLUORIDEX DAILY DEFENSE 223 flexichamber mask 279 FLUORIDEX SENSITIVITY RELIEF 223 flibanserin 151 FLUORITAB 223 FLO-PRED 192 fluorometholone 44 FLOMAX 7 FLUOROPLEX 259 FLOVENT DISKUS 155 fluorouracil 259,279 FLOVENT HFA 155 fluoxetine dr 78 FLOWTUSS 243 fluoxetine hcl 78 FLOXIN 34 fluoxymesterone 195 fluphenazine decanoate 123 folic acid-vit b6-vit b12 307 fluphenazine hcl 123 FOLIVANE-PLUS 47 FLURA-DROPS 223 FOLLISTIM AQ 211 flurazepam hcl 142 FOLPLEX 2.2 307 flurbiprofen 236 fondaparinux sodium 68 flurbiprofen sodium 45 FORADIL 5 FLUROX 181 FORANE 189 flutamide 279 FORFIVO XL 75 fluticasone propionate 44,193,250 FORMA-RAY 279 fluticasone propionate micro 193 FORMADON 259 fluticasone-salmeterol 5 formaldehyde 259 flutter 279 formoterol fumarate 5 fluvastatin er 106 FORTAVIT 47 fluvastatin sodium 106 FORTAZ 154 FLUVIRIN 2016-2017 131 FORTEO 212 FLUVIRIN 2017-2018 279 FORTICAL 212 fluvoxamine maleate 78 FOSAMAX 222 fluvoxamine maleate er 78 FOSAMAX PLUS D 222 FLUZONE HIGH-DOSE 2016-2017 131 fosamprenavir calcium 126 FLUZONE HIGH-DOSE 2017-2018 279 fosinopril sodium 242 FLUZONE INTRADERM QUAD 2016-17 131 fosinopril-hydrochlorothiazide 167 FLUZONE INTRADERM QUAD 2017-18 279 FOSRENOL 217 FLUZONE QUAD 2016-2017 131 FRAGMIN 68 FLUZONE QUAD 2017-2018 279 freedom derma-d 279 FLUZONE QUAD PEDI 2016-2017 131 freedom precision airless 279 FLUZONE QUAD PEDI 2017-2018 279 FROVA 109 FML 44 frovatriptan succinate 109 FML FORTE 44 FUL-GLO 163 FML S.O.P. 44 FULYZAQ 184 FOCALGIN 90 DHA 47 FURADANTIN 32 FOCALGIN CA 47 furazolidone 32 FOCALGIN DSS 47 furosemide 164 FOCALIN 28 fusarium 158 FOCALIN XR 29 FUSION PLUS 47 FOLBECAL 172 FUSION SPRINKLES 47 FOLBEE 307 FUZEON 123 FOLBEE AR 307 FYAVOLV 178 FOLBEE PLUS CZ 307 FYCOMPA 70 FOLGARD OS 172 FOLGARD RX 307 G folic acid 307 gabapentin 9 GABITRIL 70 GILDAGIA 200 galantamine er 144 GILDESS 200 galantamine hbr 144 GILDESS 24 FE 200 galantamine hydrobromide 144 GILDESS FE 200 GALZIN 280 GILENYA 228 GAMMAGARD LIQUID 129 GILOTRIF 280 GAMMAKED 129 ginkgo biloba 232 GAMUNEX-C 129 ginseng root 280 ganirelix acetate 227 GLATOPA 228 GARDASIL 131 GLEEVEC 280 GARDASIL 9 131 GLEOSTINE 280 GASTROCROM 47 glimepiride 87 GASTROGRAFIN 163 glipizide 87 GASTROMARK 280 glipizide er 87 gatifloxacin 34 glipizide xl 88 gatifloxacin sesquihydrate 34 glipizide-metformin 83 GATTEX 187 GLUCAGEN 103 GAVILYTE-C 185 GLUCAGON EMERGENCY KIT 103 GAVILYTE-G 185 glucagon hcl 103 GAVILYTE-N 185 gluconolactone 280 GELCLAIR 280 GLUCOPHAGE 83 GELFILM 181 GLUCOPHAGE XR 83 gelfilm 280 glucosamine hcl 233 GELFOAM 99,280 glucosamine sulfate kcl 233 GELFOAM COMPRESSED 280 glucosamine sulfate sodium 233 GELFOAM JMI 280 GLUCOTROL 88 GELNIQUE 190 GLUCOTROL XL 88 GELX 280 GLUCOVANCE 84 gemfibrozil 105 glutamine 187 GENADUR 280 glutaraldehyde 280 GENERESS FE 200 glutathione 280 GENERLAC 170 glutathione-l 280 GENGRAF 225 glyburide 88 GENOTROPIN 213 glyburide micronized 88 GENTAK 34 glyburide-metformin hcl 84 gentamicin sulfate 34,38,57 glycine 280 GENVOYA 124 glycolic acid 281 GEODON 116 glycopyrrolate 65,281 german cockroach 158 glycosaminoglycans 281 GIANVI 200 glycyrrhizic acid 281 GIAZO 184 GLYDO 181 GLYNASE 88 HALDOL DECANOATE 100 122 GLYSET 82 HALDOL DECANOATE 50 122 GLYXAMBI 85 halobetasol propionate 250 gold sodium thiomalate 225 HALOG 250 goldenrod 159 haloperidol 122 GOLYTELY 185 haloperidol decanoate 122 GONAL-F 211 haloperidol decanoate 100 122 GONAL-F RFF 211 haloperidol lactate 122 GONAL-F RFF REDI-JECT 211 HARVONI 191 GONITRO 303 HAVRIX 131 GORDO-UREA 255 HEATHER 200 GRAFIX CORE 233 HECTOROL 309 GRAFIX PRIME 233 HEMABATE 281 GRALISE 9 HEMANGEOL 53 gramicidin d 281 HEMATINIC PLUS 48 granisetron hcl 89 HEMATINIC WITH FOLIC ACID 48 GRANIX 146 HEMATRON-AF 48 GRANULEX 259 HEMAX 48 GRASTEK 233 HEMMOREX-HC 250 GRIFULVIN V 91 HEMOCYTE PLUS 48 GRIS-PEG 91 HEMOCYTE-F 48 griseofulvin 91 heparin sodium 68 griseofulvin micronized 91 HEPSERA 137 griseofulvin ultramicrosize 91 HETLIOZ 140 guaiacol 40 HEXALEN 281 guaifenesin 243 HIBERIX 131 guanabenz acetate 216 HICON 281 guanethidine hemisulfate 216 HIPREX 32 guanfacine hcl 151 histamine phosphate 281 guanfacine hcl er 151 histidine hcl 281 guanidine hcl 144 HIZENTRA 129 guarana seed extract 281 HOMATROPAIRE 182 guardian link 3 281 homatropine hydrobromide 182 guardian sensor 3 281 homatropine methylbromide 182 GYNAZOLE 1 94 home nebulizer plus sidestream 281 honey bee venom protein 159 H HORIZANT 9 H.P. ACTHAR 156 horse epithelium 159 hackberry 159 HPR 281 HALCION 142 HPR PLUS 281 HALDOL 122 HUMALOG 86 HUMALOG JUNIOR KWIKPEN 281 hydrocortisone-pramoxine 250 HUMALOG KWIKPEN U-100 86 hydrocortisone-pramoxine hcl 250 HUMALOG KWIKPEN U-200 86 hydrofera blue 281 HUMALOG MIX 50-50 86 hydrofera blue ready 281 HUMALOG MIX 50-50 KWIKPEN 86 hydrogen peroxide 282 HUMALOG MIX 75-25 86 HYDROMET 65 HUMALOG MIX 75-25 KWIKPEN 86 hydromorphone er 16 HUMATROPE 213 hydromorphone hcl 16,17 HUMIRA 187 hydroquinone 156 HUMIRA PEDIATRIC CROHN'S 187 hydroxocobalamin 307 HUMIRA PEN 187 hydroxyamphetamine hbr 182 HUMIRA PEN CROHN-UC-HS STARTER 187 hydroxychloroquine sulfate 113 HUMIRA PEN PSORIASIS-UVEITIS 187 hydroxyethyl methacrylate 282 HUMULIN R U-500 86 hydroxyprogesterone caproate 214 HUMULIN R U-500 KWIKPEN 86 hydroxypropy-beta-cyclodextrin 282 hyaluronic acid 281 hydroxytryptophan 282 hyaluronic acid sodium salt 281 hydroxyurea 282 hyaluronidase 281 hydroxyzine hcl 140 HYCAMTIN 281 hydroxyzine pamoate 140 HYCET 9 HYGEL 282 HYCOFENIX 4 HYLATOPIC 282 hydralazine hcl 216 HYLATOPICPLUS 282 hydrazine sulfate 281 HYLENEX 282 HYDREA 281 HYOPHEN 32 HYDRO 35 255 hyoscyamine sulfate 65 HYDRO 40 255 hyoscyamine sulfate er 65 hydrochloric acid 186 hyoscyamine sulfate sr 65 hydrochlorothiazide 165 HYOSYNE 65 hydrocod-cpm-pseudoephedrine 16 HYPER-SAL 172 hydrocodone bitartrate 16 HYPERHEP B S-D 129 hydrocodone-acetaminophen 10 HYPERRAB S-D 129 hydrocodone-chlorpheniramne er 102 HYPERTET S-D 129 hydrocodone-homatropine mbr 65 hypodermic needle 282 hydrocodone-ibuprofen 16 HYQVIA 129 hydrocortisone 193,250 HYQVIA HY COMPONENT 282 hydrocortisone acetate 250 HYQVIA IG COMPONENT 129 hydrocortisone butyrate 250 HYZAAR 167 hydrocortisone valerate 250 hydrocortisone-acetic acid 37 I hydrocortisone-iodoquinol 40 ibandronate sodium 222 hydrocortisone-iodoquinol-aloe 40 IBRANCE 282 IBUDONE 17 innospire deluxe 283 ibuprofen 236 innospire elegance 283 IC GREEN 162 innospire essence 283 ICAR-C PLUS 48 innospire mini 283 ichthammol 282 innospire replacement filter 283 ICLUSIG 282 inositol 283 idebenone 151 inspirachamber 283 idoxuridine 36 inspiration 283 ILARIS 233 inspiration elite 283 ILEVRO 45 inspiration elite filter 283 ILOTYCIN 34 INSPRA 166 IMBRUVICA 283 insulin syringe 283 imipramine hcl 82 insulin syringe u-500 283 imipramine pamoate 82 INTELENCE 124 imiquimod 259 INTERMEZZO 140 IMITREX 109 INTRAROSA 193 IMOGAM RABIES-HT 129 INTRON A 136 IMOVAX RABIES VACCINE 131 INTROVALE 201 IMPAVIDO 113 INTUNIV 151 IMURAN 225 INVANZ 218 INCRELEX 264 INVEGA 116 INCRUSE ELLIPTA 65 INVEGA SUSTENNA 116,117 indapamide 166 INVEGA TRINZA 117 INDERAL LA 53 INVIRASE 126 INDERAL XL 53 INVOKAMET 84 INDICLOR 283 INVOKAMET XR 84 INDIGO CARMINE 162 INVOKANA 87 indigotindisulfonate sod-water 162 iodine 40 INDIOMIN MB 32 iodochlorohydroxyquinoline 93 INDOCIN 221 IODOFLEX 40 indocyanine green 162 iodoform 283 indole-3-carbinol 233 iodoquinol 112 indomethacin 221,236 IODOSORB 41 indomethacin er 221 iopanoic acid 283 INFANRIX DTAP 130 IOPIDINE 181 INFASURF 244 IPOL 131,284 INFED 48 ipratropium bromide 65,181 INFUMORPH 17 ipratropium-albuterol 5 INGREZZA 151,283 IPRIVASK 68 INLYTA 283 irbesartan 241 INNOPRAN XL 53 irbesartan-hydrochlorothiazide 167 IRENKA 77 JANUMET XR 84 IRESSA 284 JANUVIA 85 ISENTRESS 124 JARDIANCE 87 ISENTRESS HD 124 JENCYCLA 201 ISIBLOOM 201 JENTADUETO 84 ISOCHRON 304 JENTADUETO XR 84 isoflurane 189 jetco-spray cannula 284 isoleucine 284 JEVANTIQUE LO 178 isomethept-caff-acetaminophen 10 JINTELI 178 isomethept-dichloralp-acetamin 10 johnson grass 159 isometheptene mucate 145 JOLESSA 201 isoniazid 111 JOLIVETTE 201 isopropamide iodide 284 JUBLIA 94 isopropyl myristate 284 JULEBER 201 isoproterenol hcl 4,284 JUNEL 201 ISOPTO ATROPINE 182 JUNEL FE 201 ISOPTO CARPINE 98 JUNEL FE 24 201 ISORDIL 304 JUXTAPID 103 ISORDIL TITRADOSE 304 isosorbide 304 K isosorbide dinitrate 304 K EFFERVESCENT 172 isosorbide mononitrate 304 K-PHOS NEUTRAL 169 isosorbide mononitrate er 304 K-PHOS NO.2 169 isotretinoin 259 K-PHOS ORIGINAL 169 ISOVUE-200 163 K-SOL 172 isoxsuprine hcl 305 K-TAB ER 172 isradipine 147 KAITLIB FE 201 ISTALOL 97 KALETRA 126 ISUPREL 4 KALYDECO 155 itraconazole 92 kanamycin sulfate 57 itraconazole micronized 92 kangaroo 924 safety screw 284 ivermectin 31 kangaroo epump set 284 IXIARO 131 kangaroo gravity set 284 kapok 159 J KAPVAY 216 JADENU 284 karaya gum 185 JADENU SPRINKLE 284 KARBINAL ER 100 JAKAFI 284 KARIVA 201 JALYN 7 KAYEXALATE 217 JANTOVEN 67 KEFLEX 153 JANUMET 84 KELNOR 1-35 201 KENALOG 250 KLOR-CON M20 172 KENALOG-10 193 KLOR-CON SPRINKLE 173 KENALOG-40 193 KLOR-CON-EF 173 kendall 0.9% nacl with cap 284 kochia 159 kenguard 284 kojic acid 285 KEPPRA 70 KORLYM 83 KEPPRA XR 70 KRISTALOSE 170 KERAFOAM 255 KURVELO 202 KERALAC 255 KUVAN 233 KERALYT 255 KYNAMRO 103 kerlix amd 41 kerlix amd bandage 41 L KERYDIN 95 l-5 methyltetrahydrofolate cal 308 KETALAR 189 l-alanine 171 ketamine hcl 189 l-aspartic acid 285 ketamine hydrochloride 189 l-carnitine 233 KETEK 218 l-citrulline 171 ketoconazole 92,94 l-cysteine hydrochloride 171 ketoconazole micronized 92 l-glutamic acid 285 ketoprofen 236 l-glutamine 188 ketoprofen micronized 236 l-histidine 285 ketorolac tromethamine 46,236,237 l-isoleucine 285 ketotifen fumarate 100 l-leucine 171 KEVEYIS 233 l-methionine 285 KEVZARA 225 l-methylfolate calcium 308 KHEDEZLA 77 l-proline 285 KIMIDESS 202 l-serine 285 KINEVAC 162 l-theanine 233 KINRIX 131 l-threonine 285 KIONEX 217 labetalol hcl 7,8 KISQALI 284,285 LACRISERT 181 KISQALI FEMARA CO-PACK 285 lactic acid 174,175,255 KITABIS PAK 57 lactulose 171 KLARON 41 lamb's quarters 159 KLOFENSAID II 237 LAMICTAL 70 KLONOPIN 74 LAMICTAL (BLUE) 70 KLOR-CON 172 LAMICTAL (GREEN) 70 KLOR-CON 10 172 LAMICTAL (ORANGE) 70 KLOR-CON 8 172 LAMICTAL ODT 70 KLOR-CON M10 172 LAMICTAL ODT (BLUE) 70 KLOR-CON M15 172 LAMICTAL ODT (GREEN) 70 LAMICTAL ODT (ORANGE) 70 LENVIMA 286 LAMICTAL XR 70 LESCOL 106 LAMICTAL XR (BLUE) 70 LESCOL XL 107 LAMICTAL XR (GREEN) 70 LESSINA 202 LAMICTAL XR (ORANGE) 70 LETAIRIS 244 LAMISIL 91 letrozole 286 lamivudine 125 leucine 171 lamivudine hbv 125 leucovorin calcium 220,233 lamivudine-zidovudine 125 LEUKERAN 286 lamotrigine 70,71 LEUKINE 146 lamotrigine (blue) 71 leuprolide acetate 211,286 lamotrigine (green) 71 LEVACET 128 lamotrigine (orange) 71 levalbuterol concentrate 5 lamotrigine er 71 levalbuterol hcl 5 lamotrigine odt 71 levamisole hcl 31 lamotrigine odt (blue) 71 LEVAQUIN 59 lamotrigine odt (green) 71 LEVATOL 149 lamotrigine odt (orange) 71 LEVBID 65 LANOXIN 51 levetiracetam 71 LANOXIN PEDIATRIC 51 levetiracetam er 71 lansoprazol-amoxicil-clarithro 134 LEVO-T 266 lansoprazole 134 levobunolol hcl 97 lanthanum carbonate 217 levocarnitine 233 LANTUS 87 levocetirizine dihydrochloride 101 LANTUS SOLOSTAR 87 levodopa 112 LARIN 202 levofloxacin 34,59 LARIN 24 FE 202 levofloxacin hemihydrate 59 LARIN FE 202 levomefolate calcium 308 LARISSIA 202 levomefolate dha 48 LASIX 165 LEVONEST 202 LASTACAFT 180 levonorg-eth estrad eth estrad 202 latanoprost 98 levonorgestrel 203 LATISSE 98 levonorgestrel-eth estradiol 203 LATRIX 255 LEVORA-28 203 LATUDA 117 levorphanol tartrate 17 LAYOLIS FE 202 levothyroxine sodium 266 lc plus 285 LEVOXYL 266 lc sprint nebulizer 285 LEVSIN 65 lc star 285 LEVSIN-SL 65 LEENA 202 LEVULAN 259 leflunomide 225 LEXAPRO 78,79 LEXIVA 126 LOCOID 250 LIALDA 184 LODINE 237 LIBRAX 65 LODOSYN 151 lidocaine 252,286 LOESTRIN 203 lidocaine hcl 52,182,252,286 LOESTRIN FE 203 lidocaine hcl viscous 182 LOFIBRA 106 lidocaine hcl-epinephrine 265 lokara 250 lidocaine-epinephrine 265 LOMAIRA 24 lidocaine-hydrocortisone 250 LOMEDIA 24 FE 203 lidocaine-prilocaine 252 LOMOTIL 65 lidocaine-tetracaine 252 lomustine 286 LIDODERM 252 LONSURF 286 LIDOPIN 252 loperamide 184 LIDOPRIL 253 LOPID 106 LIDORX 253 lopinavir-ritonavir 126 LIDOTRAL 253 LOPREEZA 178 LIDOVEX 253 LOPRESSOR 53 LIDTOPIC MAX 253 LOPRESSOR HCT 53 LILLOW 203 LOPROX 95 LINCOCIN 62 loratadine 101 lincomycin hcl 62,63 loratadine micronized 101 lindane 43 lorazepam 74 linezolid 63 LORAZEPAM INTENSOL 74 LINZESS 188 LORCET 10 liothyronine sodium 266 LORCET HD 10 LIPITOR 107 LORCET PLUS 10 LIPOFEN 105,106 LORTAB 10 lipoic acid 286 LORYNA 203 LIQUID E-Z PAQUE 163 LORZONE 246 LIQUID POLIBAR PLUS 163 losartan potassium 241 lisinopril 242 losartan-hydrochlorothiazide 167 lisinopril-hydrochlorothiazide 167 LOSEASONIQUE 204 liteaire 286 LOTEMAX 44 litetouch 286 LOTENSIN 242 lithium 150 LOTENSIN HCT 167 lithium carbonate 150 LOTREL 149 lithium carbonate er 150 LOTRISONE 94 LITHOBID 150 LOTRONEX 184 LITHOSTAT 171 LOUTREX 286 LIVALO 107 lovastatin 107 LO LOESTRIN FE 203 LOVAZA 103 LOVENOX 68 magnesium chloride 71,287 LOW-OGESTREL 204 magnesium glycinate 173 loxapine 114 magnesium malate 287 LP LITE PAK 253 magnesium oxide 183 LUCENTIS 181 magnesium sulfate 51 LUDENT FLUORIDE 223 MAKENA 214 LUGOL'S 41,91 MALARONE 113 LUMIGAN 98 malathion 43 LUMINAL SODIUM 286 malic acid 287 LUNESTA 140 manganese chloride 173 LUPANETA PACK 211 manganese gluconate 173 LUPRON DEPOT 211 mannitol 98 LUPRON DEPOT (LUPANETA) 211 maprotiline hcl 82 LUPRON DEPOT-PED 212 MARCAINE 287 lutein 286 MARCAINE SPINAL 287 LUTERA 204 MARCAINE-EPINEPHRINE 265 LUXAMEND 175 MARGESIC 10 LUXIQ 250 MARINOL 90 LUZU 94 MARLISSA 204 lycopene 233 MARPLAN 76 LYMPHAZURIN 162 MARTEN-TAB 10 LYNPARZA 286 mask set with y-piece 287 LYRICA 71 MATERNITY 306 lysine hcl 171 MATULANE 287 LYSIPLEX PLUS 171 MATZIM LA 56 LYSODREN 287 MAVIK 242 LYSTEDA 99 MAVYRET 287 LYZA 204 MAXALT 109 MAXALT MLT 109 M MAXARON FORTE 48 M-M-R II VACCINE 131 MAXIDEX 44 maca root 287 MAXIFED CDX 287 MACNATAL CN DHA 48 MAXINATE 306 MACROBID 32 MAXIPHEN CD 287 MACRODANTIN 32 MAXIPHEN CDX 287 mafenide acetate 41 MAXIPIME 153 magellan insulin safety syrng 287 MAXITROL 35 magellan insulin syringe 287 MAXZIDE 165 magellan tuberculin syringe 287 MAXZIDE-25 MG 165 magic3 intermittent catheter 287 MD-76 R 163 magnesium amino acid chelate 173 MD-GASTROVIEW 163 me-naphos-mb-hyo 1 32 MEPRON 114 mebendazole 31 mequinol 156 mecamylamine hcl 216 mercaptopurine 230 mechlorethamine hcl 287 mesalamine 184 meclizine hcl 91 MESNEX 235 meclofenamate sodium 237 mesquite 159 meclofenoxate hcl 28 MESTINON 144 MEDROL 193 METADATE CD 29 medroxyprogesterone ac micro 215 METADATE ER 29 medroxyprogesterone acetate 215 metaproterenol sulfate 5 mefenamic acid 237 METAXALL 246 mefloquine hcl 113 metaxalone 246 MEGACE 287 metformin hcl 84 MEGACE ES 287 metformin hcl er 84,85 megestrol acetate 287,288 metformin hydrochloride 85 MEKINIST 288 methacholine chloride 288 melaleuca 159 methadone hcl 18,288 melatonin 233 METHADONE INTENSOL 18 MELODETTA 24 FE 204 METHADOSE 18 meloxicam 237 methamphetamine hcl 27 MELPAQUE HP 156 methazolamide 97 melphalan 288 methenamine 32 MELQUIN-3 156 methenamine hippurate 32 memantine hcl 151 methenamine mandelate 32 MEMBRANEBLUE 163 METHERGINE 288 MENACTRA 131 methimazole 265,266 menadione 288 methionine 288 MENEST 178 METHITEST 195 MENHIBRIX 131 methocarbamol 246 MENOMUNE-A-C-Y-W-135 131 methotrexate 225,288 MENOPUR 212 methotrexate sodium 225 MENOSTAR 178 methoxsalen 156 MENTAX 95 methscopolamine bromide 65 menthol 288 methyclothiazide 165 MENVEO A-C-Y-W-135-DIP 131 methyl 5-aminolevulinate hcl 259 MENVEO MENA COMPONENT 132 methylcobalamin 308 MENVEO MENCYW-135 COMPONENT 132 methyldopa 216 meperidine hcl 17,18 methyldopa-hydrochlorothiazide 167 MEPHYTON 220 methylergonovine maleate 288 mepivacaine hcl 288 METHYLIN 29 meprobamate 140 methylparaben 288 methylphenidate er 29 microchamber 288 methylphenidate hcl 29,30 microcrystalline cellulose 288 methylphenidate hcl cd 30 MICROCYN 288 methylphenidate hcl er 30 MICROCYN HYDROGEL 288 methylphenidate la 30 MICROGESTIN 204 methylprednisolone 193 MICROGESTIN 24 FE 204 methylprednisolone ac micro 193 MICROGESTIN FE 204 methylprednisolone acetate 193 microspacer 288 methylprednisolone sodium succ 193 MICROZIDE 165 methylpyrazole 220 midazolam 142 methyltestosterone 195 midazolam hcl 142,143 methyltestosterone micronized 195 midodrine hcl 265 methyltetrahydrofolate calcium 308 MIFEPREX 289 methyltetrahydrofolic acid 308 MIGERGOT 7 methysergide maleate 7 miglitol 82 metipranolol 97 MIGRANAL 7 metoclopramide hcl 188 milk thistle 289 metoclopramide hcl odt 188 MILLIPRED 193 metolazone 166 MILLIPRED DP 193 METOPIRONE 163 MIMVEY 179 metoprolol succinate 53 MIMVEY LO 179 metoprolol tartrate 53 MINASTRIN 24 FE 204 metoprolol-hydrochlorothiazide 53 mini plus nebulizer 289 METOZOLV ODT 188 mini-wright peak flow meter 289 METROCREAM 38 minielite 289 METROGEL 39 minimed 630g guardian start kt 289 METROGEL-VAGINAL 39 MINIPRESS 6 METROLOTION 39 MINITRAN 304 metronidazole 39,112,113 MINIVELLE 179 metronidazole benzoate 113 MINOCIN 61 mexiletine hcl 52 minocycline hcl 61 MIACALCIN 212 minocycline hcl er 61 MIBELAS 24 FE 204 minoxidil 216 MICARDIS 241 MIOCHOL-E 98 MICARDIS HCT 167 MIOSTAT 98 miconazole 94 MIRAPEX 169 miconazole 3 94 MIRAPEX ER 169 miconazole nitrate 94 MIRCERA 146 MICORT-HC 250 MIRCETTE 204 micro elite 288 mirtazapine 75 micro plus 288 mirtazapine anhydrous 75 MIRVASO 259 monoject safety syringe 289 misoprostol 133 monoject smartip cannula 289 misoprostol hpmc 133 monoject syringe 290 misterneb compressor 289 MONONESSA 205 misterneb pediatric compressor 289 MONSEL'S 99 MITIGARE 221 montelukast sodium 46 mitomycin 289 MONUROL 32 mitomycin c 289 MORGIDOX 61 mitotane 289 morphine sulfate 18,19 mixed aspergillus 159 morphine sulfate er 19 mixed cockroach 159 mosquito 159 mixed feathers 159 MOTOFEN 184 mixed ragweed extract 159 mountain cedar 159 mixed vespid venom protein 159 mouse epithelium 159 MOBIC 237 mouthpiece 290 modafinil 31 MOVIPREP 185 MODERIBA 137 MOXATAG 239 MODICON 204 MOXEZA 35 moexipril hcl 242 moxifloxacin 35 moexipril-hydrochlorothiazide 168 moxifloxacin hcl 59 molindone hcl 114 MOZOBIL 146 molybdenum 173 MS CONTIN 20 mometasone furoate 44,250 mucor 159 MONDOXYNE NL 61 MUCOTROL 260 mono-flo 289 MUGARD 290 MONO-LINYAH 204 mugwort 159 monobenzone 156 MULTAQ 54 MONODOX 61 MULTICHEW 48 monoject 289 MULTIGEN FOLIC 48 MONOJECT 0.9% SODIUM CHLORIDE 173 MULTIGEN PLUS 48 monoject blood collection 289 multivitamin with fluoride 223 monoject control syringe 289 multivitamin-iron-fluoride 48 monoject enfit syringe 289 multivitamins-a,b,d,e,k,zn 306 monoject enfit syringe cap 289 mupirocin 35,39 monoject insulin syringe 289 muri-lube mineral oil 175 monoject luer lock tb syringe 289 MUSE 305 monoject magellan 289 MUSTARGEN 290 monoject megellan tb syringe 289 my mdi portable nebuliser 290 monoject pharmacy tray 289 MYALEPT 212 MONOJECT PREFILL 173 MYAMBUTOL 111 MONOJECT PREFILL ADVANCED 173 MYCOBUTIN 63 mycophenolate mofetil 230 naproxen sodium cr 221 mycophenolic acid 230 naproxen sodium ds 221 MYDRIACYL 182 naproxen sodium er 221 MYFORTIC 230 naratriptan 109 MYKIDZ IRON FL 48 naratriptan hcl 109 MYLERAN 290 NARCAN 152 MYNATAL 48,306 NARDIL 76 MYNATAL ADVANCE 48 NAROPIN 290 MYNATAL PLUS 48 NASCOBAL 308 MYNATAL-Z 48 NASONEX 44 MYNATE 90 PLUS 306 NATACYN 36 MYORISAN 260 NATAZIA 205 MYRBETRIQ 145 nateglinide 87 MYSOLINE 73 NATESTO 195 MYTESI 184 NATPARA 212 MYZILRA 205 NATROBA 43 natural mixed tocopherols 309 N NATURE-THROID 266 NABI-HB 130 NEBUPENT 114 nabumetone 237 NEBUSAL 173 nabumetone micronized 237 NECON 205 nadolol 53 needle 290 nadolol-bendroflumethiazide 53 nefazodone hcl 80 nafcillin sodium 240 NEMBUTAL SODIUM 141 naftifine hcl 93 NEO-POLYCIN 35 NAFTIN 93 NEO-POLYCIN HC 35 nalbuphine hcl 23 NEO-SYNALAR 39 NALFON 237 neomycin sulfate 57 nalidixic acid 59 neomycin-bacitracin-poly-hc 35 naloxone hcl 152 neomycin-bacitracin-polymyxin 35 naltrexone hcl 152 neomycin-polymyxin-dexameth 35 naltrexone hcl dihydrate 152 neomycin-polymyxin-gramicidin 35 NAMENDA 151 neomycin-polymyxin-hc 35 NAMENDA XR 152 neomycin-polymyxin-hydrocort 35 NAMZARIC 144 NEORAL 225 nandrolone decanoate 195 NEOSALUS 290 naphazoline hcl 183 NEOSALUS CP 290 NAPRELAN 221 NEOSPORIN 35 NAPROSYN 221 neostigmine methylsulfate 144 naproxen 221,237 NEPHRO-VITE RX 308 naproxen sodium 221,237 NEPTAZANE 97 NESACAINE 290 nitrofurantoin 32 NESACAINE-MPF 290 nitrofurantoin mono-macro 32 nettle leaf 290 nitrofurazone 41 NEUAC 39 nitroglycerin 304 NEULASTA 146 nitroglycerin patch 304 NEUPOGEN 146 NITROLINGUAL 304 NEUPRO 169 NITROMIST 304 NEURIN-SL 308 NITROSTAT 304 NEURONTIN 11 NIVATOPIC PLUS 291 NEUTRASAL 290 nizatidine 133 NEVANAC 46 NIZORAL 94 nevirapine 124 NODOLOR 11 nevirapine er 124 NOR-Q-D 205 NEWGEN 48 NORA-BE 205 NEXAVAR 290 NORCO 11 NEXAVIR 233 NORDITROPIN FLEXPRO 213 NEXIUM 134 norepinephrine bitartrate 265 niacin 103 norethin-eth estra-ferrous fum 205 niacin er 103 norethindron-ethinyl estradiol 179,205 niacinamide 308 norethindrone 205,215 NIACOR 103 norethindrone ac (lupaneta) 215 NIASPAN 103 norethindrone acetate 215 nicardipine hcl 149 norgestimate-ethinyl estradiol 205 niclosamide 31 NORINYL 1+50 205 nicotinamide adenine 233 NORINYL 1-35 205 nicotine polacrilex 143 NORITATE 39 nicotinic acid 104 NORLYDA 206 NICOTROL 143 NORLYROC 206 NICOTROL NS 143 normal saline flush 173 NIFEDICAL XL 149 NORPACE 51 nifedipine 149 NORPACE CR 51 nifedipine er 149 NORPRAMIN 82 NIKKI 205 NORTHERA 265 NILANDRON 290 NORTREL 206 nilutamide 290 nortriptyline hcl 82 nimodipine 149 NORVASC 149 NINLARO 290 NORVIR 126 nisoldipine 147 NOVACORT 250 NITRO-BID 304 NOVAREL 212,291 NITRO-DUR 304 NOXAFIL 92 NITRO-TIME 304 NP THYROID 266 NUCYNTA 20 ofloxacin 35,59 NUEDEXTA 152 OGEN 179 NULEV 66 OGESTREL 206 NULYTELY WITH FLAVOR PACKS 185 OKEBO 61 NUMBONEX 253 olanzapine 117 NUMOISYN 291 olanzapine odt 118 NUOX 255 olanzapine-fluoxetine hcl 79 NUPLAZID 117 olive tree 159 NUTRESTORE 188 olmesartan medoxomil 241 NUTRICAP 48 olmesartan-amlodipine-hctz 168 nutriport balloon 291 olmesartan-hydrochlorothiazide 168 NUTROPIN AQ 213 olopatadine hcl 180 NUTROPIN AQ NUSPIN 213 OLUX 250 NUVAIL 291 OLUX-E 250 NUVARING 206 OLYSIO 191 NUVESSA 39 ombra compressor system 291 NUVIGIL 31 OMECLAMOX-PAK 134 NYAMYC 95 omega-3 acid ethyl esters 104 NYATA 96 omega-3 dha 291 nylidrin hcl 150 omeprazole 134,135 NYMALIZE 149,291 omeprazole-sodium bicarbonate 135 nystatin 93,96 OMNARIS 44 nystatin-triamcinolone 96 OMNIPRED 44 NYSTOP 96 OMNITROPE 213 ONCASPAR 291 O ondansetron hcl 89 O-CAL FA 48 ondansetron odt 89 oasis ultra 291 ONEXTON 39 oat grain 159 ONFI 74 OBSTETRIX EC 48 ONMEL 92 OBSTETRIX ONE 48 ONZETRA XSAIL 109 OBTREX DHA 49 OPANA 20 OCALIVA 188 OPANA ER 20 OCELLA 206 opium tincture 184 octreotide acetate 263 OPSUMIT 244 OCUCOAT 181 optichamber 291 OCUFEN 46 optichamber diamond 291 OCUFLOX 35 ORACEA 61 ODEFSEY 124 ORACIT 170 ODOMZO 291 ORAFATE 291 OFEV 243 ORALAIR 233 ORALONE 251 oxazepam 143 ORAMAGICRX 291 oxcarbazepine 71 orange 159 OXECTA 20 ORAP 114 oxiconazole nitrate 94 ORAPRED ODT 193 OXISTAT 94 ORAVIG 94 OXSORALEN 156 ORENCIA 225 OXSORALEN-ULTRA 156 ORENCIA CLICKJECT 225 OXTELLAR XR 71 ORENITRAM ER 244 oxybutynin chloride 190 ORFADIN 234 oxybutynin chloride er 190 ORKAMBI 155 OXYCEL 99 ornithine 291 oxycodone hcl 20 orphenadrine citrate 247 oxycodone hcl er 20 ORSYTHIA 206 oxycodone hcl-aspirin 20 ORTHO MICRONOR 206 oxycodone hcl-ibuprofen 21 ORTHO TRI-CYCLEN 206 oxycodone hydrochloride 21 ORTHO TRI-CYCLEN LO 206 oxycodone-acetaminophen 11 ORTHO-CEPT 206 OXYCONTIN 21 ORTHO-CYCLEN 206 oxymetazoline hcl 183 ORTHO-NOVUM 206 oxymorphone hcl 21 OSCIMIN 66 oxymorphone hcl er 21 OSCIMIN SL 66 oxytetracycline hcl 61 OSCIMIN SR 66 oxytocin 291 oseltamivir phosphate 136 OXYTROL 190 OSMOPREP 185 OSPHENA 175 P OTEZLA 225 PACERONE 54 OTIPRIO 35 PACNEX 255 OTOVEL 35 PACNEX HP 255 OTREXUP 225 PACNEX LP 255 OVACE 41 PAIN EASE 253 OVACE PLUS 41 paliperidone er 118 OVACE PLUS WASH 41 PAMELOR 82 OVCON-35 206 pancreatin 186 OVIDE 43 pancreatin 8x 186 OVIDREL 212 pancuronium bromide 247 oxacillin sodium 240 PANDEL 251 OXANDRIN 195 PANRETIN 260 oxandrolone 195 panthenol 308 oxaprozin 237 pantoprazole sodium 135 OXAYDO 20 papain 291 papaverine hcl 305 PEG-PREP 185 papaverine-alprostadil 305 PEGANONE 74 parachlorophenol 291 PEGASYS 136 PARAFON FORTE DSC 246 PEGASYS PROCLICK 136 paregoric 184 PEGINTRON 136 PAREMYD 182 PEGINTRON REDIPEN 136 pari lc plus nebulizer 291 pen needle 292 pari lc sprint sinus 291 penicillamine 225 pari sinus aerosol system 291 penicillamine(d-) 225 paricalcitol 309 penicillin g potassium 240 PARLODEL 169 penicillin g procaine 240 PARNATE 76 penicillin g sodium 240 PAROEX 37 penicillin v potassium 240 paromomycin sulfate 57 penicillium notatum 159 paroxetine cr 79 PENLAC 95 paroxetine er 79 PENNSAID 237 paroxetine hcl 79 PENTACEL 132 paroxetine mesylate 79 PENTACEL ACTHIB COMPONENT 132 PASER 111 PENTACEL DTAP-IPV COMPONENT 132 PATADAY 180 PENTAM 300 114 PATANASE 180 PENTASA 184 PATANOL 180 pentazocine-naloxone hcl 23 PAXIL 79 pentobarbital sodium 141 PAXIL CR 79 pentosan polysulfate sodium 235 PAZEO 180 pentoxifylline 147 pcca t3 sodium dilution 266 pentylenetetrazole 292 pcca t4 sodium dilution 266 PEPCID 133 PCE 58 PERCOCET 11 peanut 159 PERFOROMIST 5 pecan nut 159 PERIDEX 37 pecan pollen 159 perindopril erbumine 242 PEDIADERM AF 96 PERIOGARD 37 PEDIAPRED 193 permethrin 43 PEDIARIX 130 perphenazine 123 pediatric dinosaur nebulizer 291 perphenazine-amitriptyline 82 pediatric dog nebulizer 292 PERSANTINE 128 pediatric frog nebulizer 292 PEXEVA 79 PEDVAXHIB 132 PFIZERPEN 240 peg 3350-electrolyte 185 pflex trainer 292 peg-3350 and electrolytes 185 phaseal protector 292 peg-3350 with flavor packs 185 PHENADOZ 141 phenazopyridine hcl 253 pine bark extract 292 phendimetrazine tartrate 24 pioglitazone hcl 88 phenelzine sulfate 76 pioglitazone-glimepiride 88 PHENERGAN 102,141 pioglitazone-metformin 85 phenindione 292 PIRMELLA 207 phenobarbital 73,141 piroxicam 238 phenobarbital sodium 73 pistachio nut 160 PHENOHYTRO 66 PITOCIN 292 phenol 41 PLAN B ONE-STEP 207 phenolsulfonic acid 292 PLAQUENIL 113 phenoxybenzamine hcl 7 PLAVIX 128 phentermine hcl 25 PLEGISOL 173 phentolamine mesylate 7 PLEGRIDY 228 phentolamine-alprostadil 7 PLEGRIDY PEN 228 phenylalanine 171 PLETAL 128 phenylbutazone 237 PLEXION 41 phenylephrine hcl 183,265 PLIAGLIS 253 phenylmercuric nitrate 292 PNEUMOVAX 23 132 phenylpropanolamine hcl 265 PNV 29-1 49 phenyltoloxamine dihyd cit 292 PNV-DHA + DOCUSATE 49 PHENYTEK 52 PNV-OMEGA 49 phenytoin 52 PNV-VP-U 306 phenytoin sodium 52 pocket chamber 292 phenytoin sodium extended 52 PODOCON-25 260 PHILITH 206 podofilox 260,292 phoma 160 podophyllum resin 255 PHOSLYRA 217 POLIBAR ACB 163 PHOSPHA 250 NEUTRAL 169 POLOCAINE 292 PHOSPHASAL 32 POLOCAINE-MPF 292 phosphatidylcholine 188 POLY-VI-FLOR 223 phosphatidylserine 292 POLY-VI-FLOR WITH IRON 49 PHOSPHOLINE IODIDE 98 POLYCIN 35 physostigmine salicylate 144 polyethylene glycol 3350 185 phytonadione 220,310 polymyxin b sul-trimethoprim 35 PICATO 260 polymyxin b sulfate 63 pillow mask for children 292 POLYSACCHARIDE IRON FORTE 49 pilocarpine hcl 98,144 POLYTRIM 36 pilocarpine nitrate 98 polyvinyl alcohol 292 pimozide 114 POMALYST 228 PIMTREA 207 PONSTEL 238 pindolol 53 PONTOCAINE 253 pork 160 PRE-ATTACHED LTA KIT 253 portable nebulizer system 292 PRE-PEN 162 PORTIA 207 PRECOSE 82,83 POTABA 234 PRED FORTE 44 potass cit-sod cit-citric acid 170 PRED MILD 44 potassium bicarbonate 173 PRED-G 36 potassium bromide 292 prednicarbate 251 potassium chloride 173 prednisolone 193 potassium citrate 173 prednisolone acetate 44 potassium citrate er 170 prednisolone acetate micronize 193 potassium citrate monohydrate 173 prednisolone micronized 193 potassium citrate-citric acid 170 prednisolone sodium phos odt 193 potassium hydroxide 255 prednisolone sodium phosphate 45,193 potassium iodide 92 prednisone 194 potassium p-aminobenzoate 292 PREDNISONE INTENSOL 194 potassium perchlorate 234 prednisone micronized 194 potassium permanganate 292 PREFEST 179 potassium phosphate 173 pregabalin 72 potassium sorbate 292 pregnenolone 292 POTIGA 71 pregnenolone micronized 293 povidone 292 PREGNYL 212 povidone iodine 37,41 PREMARIN 179 povidone k-30 292 PREMPHASE 179 PR BENZOYL PEROXIDE 255 PREMPRO 179 PRADAXA 68 PRENA1 CHEW 306 pralidoxime chloride 220 PRENA1 PEARL 49 PRALUENT PEN 108 PRENA1 TRUE 49 PRALUENT SYRINGE 108 PRENAISSANCE NEXT 173 PRAMCORT 251 PRENATABS RX 49 pramipexole dihydrochloride 169 prenatal low iron 49 pramipexole er 169 prenatal plus 49 PRAMOSONE 251 prenatal-u 306 PRAMOSONE E 251 PREPIDIL 293 pramoxine hcl 253 PREPLUS 49 PRANDIMET 85 PREPOPIK 185 PRANDIN 87 PRESERA 293 prasugrel hcl 128 PRESTALIA 149 PRAVACHOL 107 PRETAB 49 pravastatin sodium 107 PREVACID 135 praziquantel 32 PREVALITE 104 prazosin hcl 6 PREVIDENT 223 PREVIDENT 5000 223 PROCTOSOL-HC 251 PREVIDENT 5000 ENAMEL PROTECT 223 PROCTOZONE-HC 251 PREVIDENT 5000 PLUS 223 PROCYSBI 234 PREVIDENT 5000 SENSITIVE 223 prodigy mini-mist 293 PREVIFEM 207 PRODRIN 12 PREVNAR 13 132 PROFENO 238 PREVPAC 135 PROFERRIN-FORTE 49 PREZCOBIX 127 progesterone 215 PREZISTA 127 progesterone in oil 215 PRIFTIN 63 progesterone micronized 215 prilocaine hcl 293 PROGLYCEM 103 PRILOSEC 135 PROGRAF 230 primaquine 113 PROLENSA 46 primeaire 293 PROMACTA 146 primidone 73 promazine hcl 123 PRIMLEV 11 promethazine hcl 102,141 PRIMSOL 32 promethazine vc 102 PRINIVIL 242 promethazine vc-codeine 21 PRISMASOL 173 promethazine-codeine 102 PRISTIQ 77 promethazine-dm 102 privet 160 promethazine-phenyleph-codeine 21 PROAIR HFA 5 promethazine-phenylephrine 102 PROAIR RESPICLICK 5 PROMETHEGAN 141 probenecid 174 PROMETRIUM 215 probenecid-colchicine 174 PROMISEB 293 procainamide hcl 51 proneb ultra ii 293 procaine hcl 293 propafenone hcl 52 procarbazine hcl 293 propafenone hcl er 52 PROCARDIA 149 propantheline bromide 66 PROCARDIA XL 149 proparacaine hcl 182 PROCENTRA 27 PROPECIA 260 prochamber 293 propranolol hcl 54 prochlorperazine 91 propranolol hcl er 54 prochlorperazine edisylate 91 propranolol-hydrochlorothiazid 54 prochlorperazine maleate 91 propyl gallate 293 PROCORT 251 propylene glycol 293 PROCRIT 146 propylthiouracil 266 PROCTO-MED HC 251 PROQUAD 132 PROCTO-PAK 251 PROSCAR 219 PROCTOCORT 251 PROSED-DS 33 PROCTOFOAM-HC 251 prostaglandin e1 305 PROSTIN E2 VAGINAL SUPPOSITORY 293 PYROGALLIC ACID 260 PROSTIN VR PEDIATRIC 305 pyruvic acid 234 protamine sulfate 98 PROTECT IRON 49 Q PROTHELIAL 293 QBRELIS 242 protirelin 164 QNASL 45 PROTONIX 135 QNASL CHILDREN 45 PROTOPAM CHLORIDE 220 QSYMIA 25 PROTOPIC 260 quack grass 160 protriptyline hcl 82 QUADRACEL DTAP-IPV 132 provent 293 quake 293 PROVERA 215 QUALAQUIN 113 PROVIDA DHA 49 QUARTETTE 207 PROVIDA OB 49 QUASENSE 207 PROVIGIL 31 quaternium-15 293 PROVISC 293 quazepam 143 PROVOCHOLINE 293 QUDEXY XR 72 PROZAC 79,80 queen palm 160 PROZAC WEEKLY 80 quercetin dihydrate 293 PRUCLAIR 174 QUESTRAN 104,105 PRUDOXIN 253 QUESTRAN LIGHT 105 PRUMYX 293 quetiapine fumarate 118 PRUTECT 175 quetiapine fumarate er 118,119 pseudoephedrine hcl 4 QUILLICHEW ER 30 PSORCON 251 QUILLIVANT XR 30 PULMICORT 155 quinacrine hcl 113 PULMICORT FLEXHALER 155 quinapril hcl 242 pulmo-aide 293 quinapril-hydrochlorothiazide 168 PULMOSAL 173 quinidine gluconate 51 PULMOZYME 244 quinidine sulfate 51 PURIXAN 230 quinine hcl 113 PYLERA 61 quinine sulfate 113 pyrantel pamoate 32 pyrazinamide 111 R PYRIDIUM 253 R-NATAL OB 49 pyridostigmine bromide 144 RABAVERT 132 pyridostigmine bromide er 144 rabbit epithelium 160 pyridoxal-5-phosphate 293 rabeprazole sodium 135 pyridoxine hcl 308 racepinephrine hcl 4 pyrilamine maleate 183 RADIAPLEXRX 293 pyrimethamine 113 RADIGEL 293 RADIOGARDASE 217 RELENZA 136 RAGWITEK 234 RELISTOR 188 RAJANI 207 RELPAX 109 raloxifene hcl 175 REMERON 75 ramipril 242 REMEVEN 255 RANEXA 149 REMODULIN 245 ranitidine hcl 133 RENA-VITE RX 308 RAPAFLO 8 RENAGEL 217 RAPAMUNE 231 RENOVA 254 rapport vacuum therapy 293 RENOVA PUMP 254 rasagiline mesylate 76 RENOVO 260 RASUVO 225,226 RENVELA 217 rauwolfia serpentina 216 repaglinide 87 RAVICTI 171 repaglinide-metformin hcl 85 RAYALDEE 309 REPATHA PUSHTRONEX 108 RAYOS 194 REPATHA SURECLICK 108 RAZADYNE 144 REPATHA SYRINGE 108 RAZADYNE ER 144 replicare 294 REA LO 40 255 replicare ultra 294 READI-CAT 2 163 replicare ultra sacrum 294 REBETOL 137,138 REPREXAIN 21 REBIF 228,229 REQ49+ 306 REBIF REBIDOSE 229 REQUIP 169 RECEDO 294 REQUIP XL 169 RECLIPSEN 207 RESCRIPTOR 124 RECOMBIVAX HB 132 RESECTISOL 171 RECOTHROM 99 reserpine 216 RECTIV 260 resorcinol 294 red birch 160 RESPA A.R. 102 red cedar 160 RESTASIS 45 red maple 160 RESTASIS MULTIDOSE 45 red mulberry 160 RESTORA SPRINKLES 188 red oak 160 restore 294 red yeast rice 294 restore calcium alginate 294 REFISSA 253 restore contact layer silver 294 REGENECARE 253 RESTORIL 143 REGIMEX 27 resveratrol 234 REGLAN 188 RETIN-A 254 REGONOL 145 RETIN-A MICRO 254 REGRANEX 260 RETIN-A MICRO PUMP 254,294 RELAGARD 41 retinaldehyde 294 retinoic acid 254 riteflo 294 RETROVIR 125 rivastigmine 145 reusable nebulizer kit 294 RIVELSA 207 REVATIO 245 rizatriptan 109 REVIA 152 ROBAXIN 246 REVLIMID 229 ROBAXIN-750 246 REXULTI 119 robinson clear vinyl catheter 294 REYATAZ 127 ROBINUL 66 REZIRA 4 ROBINUL FORTE 66 RHEUMATREX 226 ROCALTROL 309 RHINOCORT AQUA 45 rocuronium bromide 247 rhizopus 160 ropinirole er 169 RHOFADE 260 ropinirole hcl 169 RIBASPHERE 138 ropivacaine hcl 294 RIBASPHERE RIBAPAK 138 ropivacaine hcl-0.9% nacl 294 RIBATAB 138 ROSADAN 39 ribavirin 138 ROSANIL 41 riboflavin 308 rosuvastatin calcium 107 riboflavin-5-phosphate sodium 308 ROTARIX 132 rice 160 ROTATEQ 132 RIDAURA 226 rough marsh elder 160 rifabutin 63 rough pigweed 160 RIFADIN 63 ROWASA 184 RIFAMATE 63 ROWEEPRA 72 rifampin 63 ROXICODONE 21 RIFATER 64 ROZEREM 141 rifaximin 64 rubber mouthpiece 294 RILUTEK 152 RUBRACA 294 riluzole 152 RULAVITE DHA 49 rimantadine hcl 135 russian thistle 160 RIMSO-50 251 RYDAPT 295 RIOMET 85 RYNODERM 255 risedronate sodium 222 RYTARY 112 risedronate sodium dr 222 RYTHMOL 52 RISPERDAL 119 RYTHMOL SR 52 RISPERDAL CONSTA 119 RYVENT 100 RISPERDAL M-TAB 119 risperidone 119,120 S risperidone odt 120 SABRIL 72 RITALIN 30 saccharin 174 RITALIN LA 31 saccharomyces cerevisiae 160 safety syringe with shield 295 secretin-mannitol 163 safety syringe-needle 295 SECTRAL 54 safetyglide allergy syringe 295 SEEBRI NEOHALER 66 SAFYRAL 207 selegiline hcl 76 sagebrush 160 selenium sulfide 41 SAIZEN 213 selenomethionine 173 SAIZEN-SAIZENPREP 213 SELRX 41 SALACYN 255 SELZENTRY 123 SALAGEN 145 SEMPREX-D 101 SALEX 255 SENSIPAR 234 salicylic acid 255 SENSORCAINE 295 salicylic acid er 255 SENSORCAINE WITH DEXTROSE 295 SALIVAMAX 295 SENSORCAINE-EPINEPHRINE 265 SALIVATERX 295 SENSORCAINE-MPF 295 SALKERA 255 SENSORCAINE-MPF EPINEPHRINE 265 salsalate 238 sensura click ostomy pouch 295 SALVAX 255 sensura flex ostomy base plate 295 sami the seal 295 sensura flex ostomy pouch 295 sami the seal mask 295 sensura ostomy base plate 295 SAMSCA 166 SEREVENT DISKUS 5 SANADERMRX 251 sermorelin acetate 213 SANCUSO 89 SERNIVO 251 SANDIMMUNE 226 SEROPHENE 175 SANDOSTATIN 263 SEROQUEL 120 SANDOSTATIN LAR DEPOT 263 SEROQUEL XR 121 SANTYL 260 SEROSTIM 214 SAPHRIS 120 serotonin hcl 295 SARAFEM 80 sertraline hcl 80 SAVAYSA 68 sesame seed 160 SAVELLA 77 SETLAKIN 207 saw palmetto 295 sevelamer carbonate 217 SAXENDA 86 sevoflurane 189 SCALACORT 251 SF 223 SCLEROSOL 150 SF 5000 PLUS 223 scopolamine 90 SFROWASA 184 scopolamine hydrobromide 66 shagbark hickory 160 scopolamine methyl nitrate 66 SHAROBEL 208 SEASONIQUE 207 sheep sorrel 160 SEB-PREV 41 sheep sorrel-yellow dock 160 SEBUDERM 295 SHOHL'S MODIFIED 170 SECONAL SODIUM 141 short ragweed 160 shrimp 160 sodium ascorbate 309 sidestream 295 sodium benzoate 296 sidestream mask 295 sodium bicarbonate 170 sidestream nebulizer 295 sodium butyrate 296 sidestream plus 295 sodium cacodylate 174 SIGNIFOR 264 sodium caprylate 92 SIGNIFOR LAR 264 sodium chloride 174 sildenafil 245 sodium citrate 67,170 sildenafil citrate 245 sodium citrate dihydrate 170 SILENOR 82 sodium citrate-citric acid 170 silicone mask 295 sodium deoxycholate 296 SILVADENE 42 sodium dichloroacetate 296 silver nitrate 42,256 sodium fluoride 223,224 silver nitrate applicator 256 sodium hyaluronate 296 silver protein 42 sodium hyaluronic acid 296 silver sulfadiazine 42 sodium hydroxide 256 silver sulphadiazine 42 sodium iodide 296 silverseal hydrogel 295 sodium l-aspartate monohydrate 174 SILVRSTAT 296 sodium metabisulfite 296 SIMBRINZA 96 sodium nitrite 304 SIMCOR 107 sodium phenylbutyrate 171 simethicone 185 sodium phosphate 185 SIMPONI 226 sodium polystyrene sulfonate 217 simvastatin 107 sodium stearyl fumarate 296 SINELEE 260 sodium succinate 296 SINEMET 10-100 112 sodium sulfacetamide 42 SINEMET 25-100 112 sodium sulfacetamide-sulfur 42 SINEMET 25-250 112 sodium sulfate 186 SINEMET CR 112 sodium tetradecyl sulfate 150 SINGULAIR 46 sodium thiosulfate 93 SINOGRAFIN 164 sodium valproate 72 sinustar 296 SOJOURN 189 sirolimus 231 SOLARAZE 260 SIRTURO 111 SOLIQUA 100-33 86 SITAVIG 138 SOLODYN 61 SITZMARKS 164 SOLTAMOX 296 SIVEXTRO 63 SOLU-CORTEF 194 SKELAXIN 247 SOLU-MEDROL 194 SKLICE 43 SOMA 247 sodium 4-aminosalicylate 111 SOMAVERT 264 sodium acetate trihydrate 173 SONAFINE 175 SONATA 141 STAMARIL 132 SOOLANTRA 260 standard bermuda grass pollen 161 sorbic acid 296 standard mixed mite extract 161 sorbitol 186 standard rye grass pollen 161 sorbitol-mannitol 165 standard sweet vernal grass 161 SORIATANE 260 standardized cat hair 161 SORILUX 261 standardized june grass pollen 161 SORINE 54 standardized meadow fescue 161 sotalol 54 standardized orchard grass 161 sotalol af 54 standardized red top grass 161 SOTYLIZE 54 standardized timothy grass 161 SOVALDI 191 stanozolol 195 soybean 160 stanozolol micronized 196 SP ANTIPRURITIC 296 STARLIX 87 SPECTRACEF 154 stavudine 125 spectragel 296 STELARA 226 SPHERUSOL 162 sterile talc 150 spinosad 43 STIMATE 99 spiny pigweed 160 STIOLTO RESPIMAT 66 SPIRIVA 66 STIVARGA 297 SPIRIVA RESPIMAT 66 STRATTERA 152 spironolactone 166 STRAVIX 234 spironolactone-hctz 166 strawberry 161 spirulina 296 STRENSIQ 297 SPORANOX 92 streptomycin sulfate 57 SPRAY AND STRETCH 253 STRIANT 196 SPRINTEC 208 STRIBILD 124 SPRITAM 72 STRIVERDI RESPIMAT 5 SPRIX 238 STROMECTOL 32 SPRYCEL 296 strong iodine 92 SPS 217 SUBOXONE 23,24 SRONYX 208 succimer dmsa 220 SSD 42 succinylcholine chloride 247 SSKI 92 SUCRAID 297 SSS 10-5 42 sucralfate 134 STALEVO 100 111 sufentanil citrate 21 STALEVO 125 111 SULAR 147 STALEVO 150 111 sulfacetamide 59 STALEVO 200 111 sulfacetamide sod monohydrate 59 STALEVO 50 111 sulfacetamide sodium 36,42,59 STALEVO 75 112 sulfacetamide sodium-sulfur 42 sulfacetamide-prednisolone 36 SYMAX-SL 66 SULFACLEANSE 8-4 42 SYMAX-SR 66 sulfadiazine 59 SYMBICORT 5 sulfadiazine sodium 59 SYMBYAX 80 sulfamethoxazole 60 SYMLINPEN 120 83 sulfamethoxazole-trimethoprim 60 SYMLINPEN 60 83 SULFAMYLON 42 SYNALAR 251 sulfanilamide 60 SYNALAR TS 251 sulfapyridine 60 SYNALGOS-DC 128 sulfasalazine 60 SYNAREL 212 sulfasalazine dr 60 SYNDROS 90 sulfathiazole 60 SYNERA 253 SULFATRIM 60 SYNERDERM 175 sulfisoxazole 60 SYNJARDY 85 sulfur 256 SYNJARDY XR 85 sulfurated potash 297 SYNRIBO 297 sulindac 238 SYNTHROID 266 SUMADAN 42 SYPRINE 297 sumatriptan 109 SYREX 174 sumatriptan succinate 109,110 syringe 298 SUMAVEL DOSEPRO 110 SYRINGE AVITENE 99 SUMAXIN 42 syringe-needle 298 SUMAXIN TS 42 sunrise compressor-nebulizer 297 T SUPERVITE 308 t.e.d. anti-embolism stocking 298 SUPERVITE EC 306 TABLOID 298 SUPRANE 189 TACHOSIL 99 SUPRAX 154 TACLONEX 251 SUPRENZA ODT 25 tacrolimus 231,261 SUPREP 186 tacrolimus micronized 231 SURMONTIL 82 TAFINLAR 298 SURVANTA 244 TAGITOL 164 SUSTIVA 124 TAGRISSO 298 SUTENT 297 tall ragweed 161 SWABFLUSH 297 TALTZ AUTOINJECTOR 261 sweet corn 161 TALTZ AUTOINJECTOR (2 PACK) 261 sweetgum 161 TALTZ AUTOINJECTOR (3 PACK) 261 SYEDA 208 TALTZ SYRINGE 261 SYLATRON 136 TALTZ SYRINGE (2 PACK) 261 SYMAX 66 TALTZ SYRINGE (3 PACK) 261 SYMAX DUOTAB 66 TALWIN 24 TAMIFLU 136 TERAZOL 7 95 tamoxifen citrate 298 terazosin hcl 6 tamsulosin hcl 8 terbinafine hcl 91 TAPAZOLE 266 terbutaline sulfate 5 TARCEVA 298 terconazole 95 TARGADOX 61 terpin hydrate 244 TARGRETIN 261,298 TERRELL 189 TARINA FE 208 TERSI FOAM 42 TARKA 148 terumo surguard2 299 TARON-CRYSTALS 170 TESSALON PERLE 243 TASIGNA 298 testosterone 196 TASMAR 112 testosterone cypionate 196 TAYTULLA 208 testosterone cypionate micro 196 tazarotene 261 testosterone enanthate 196 TAZICEF 154 testosterone micronized 196 TAZORAC 262 testosterone propionate 196 TAZTIA XT 56 TESTRED 196 TECFIDERA 229 tetanus diphtheria toxoids 130 TECHNIVIE 127 TETCAINE 182 TEGRETOL 72 tetrabenazine 152 TEGRETOL XR 72 tetracaine 299 TEKAMLO 149 tetracaine hcl 182,299 TEKTURNA 243 tetracycline hcl 61 TEKTURNA HCT 165 tetrahydro-l-biopterin di-hcl 299 telmisartan 241 tetrahydrobiopterin di-hcl 299 telmisartan-amlodipine 150 tetrahydrobiopterin hcl 299 telmisartan-hydrochlorothiazid 168 tetrahydrozoline hcl 183 temazepam 143 TETRAVISC 182 TEMODAR 299 TETRAVISC FORTE 182 TEMOVATE 251 TETRIX 175 TEMOVATE EMOLLIENT 251 TEXACORT 251 temozolomide 299 TEXAVITE LQ 49 TENCON 12 THALOMID 229 TENEX 152 theanine 234 TENIVAC 130 THEO-24 147 TENORETIC 100 54 theobromine 299 TENORETIC 50 54 THEOCHRON 147 TENORMIN 54 theophylline 147 tens 502 299 theophylline anhydrous 147 tens 504 299 THERACYS 132 TERAZOL 3 94 THERAPEUTIC VITAMIN W-MINERALS 306 THERMAZENE 43 TIVORBEX 221 thiabendazole 32 tizanidine hcl 247 thiamine hcl 308 TL FOLATE 49 thioguanine 299 TL-CERMIDE 300 THIOLA 234 TOBI 57 thioridazine hcl 123 TOBI PODHALER 57 thioridazine hydrochloride 123 TOBRADEX 36 thiotepa 299 TOBRADEX ST 36 thiothixene 123 tobramycin 36,57 threonine 299 tobramycin sulfate 57 threshold imt 299 tobramycin-dexamethasone 36 threshold pep 299 TOBREX 36 THRIVITE 19 49 tocopheryl acid succinate 309 THRIVITE RX 49 TOFRANIL 82 THROMBI-GEL 299 TOFRANIL-PM 82 THROMBI-PAD 299 TOLAK 262 THROMBIN-JMI 99 tolazamide 88 thyroid 266 tolazoline hcl 305 THYROLAR-1 266 tolbutamide 88 THYROLAR-1/2 266 tolcapone 112 THYROLAR-1/4 267 tolmetin sodium 238 THYROLAR-2 267 tolterodine tartrate 190 THYROLAR-3 267 tolterodine tartrate er 190 tiagabine hcl 72 toomey syringe 300 TIAZAC 56 TOPAMAX 72 ticarcillin disod-clavulanate 239 TOPICORT 251 ticlopidine hcl 128 topiramate 72 TIGAN 91 topiramate er 72 TIKOSYN 54 TOPROL XL 54 TILIA FE 208 torsemide 165 timolol maleate 54,97 touch-trol 300 TIMOPTIC 97 TOUJEO SOLOSTAR 87 TIMOPTIC OCUDOSE 97 TOVIAZ 190 TIMOPTIC-XE 97 TOXICOLOGY SALIVA COLLECTION 238 TINDAMAX 114 TRACLEER 245,300 tinidazole 114 TRADJENTA 85 tiopronin 234 tramadol hcl 21 TIROSINT 267 tramadol hcl er 22 TISSEEL VHSD 99 tramadol hcl-acetaminophen 12 titanium dioxide 299 trandolapril 242 TIVICAY 124 trandolapril-verapamil er 148 tranexamic acid 100 triamterene-hydrochlorothiazid 165 tranilast 47 TRIANEX 252 TRANSDERM-SCOP 90 triazolam 143 TRANXENE T-TAB 74 TRIBENZOR 168 tranylcypromine sulfate 76 TRICARE PRENATAL 49 TRAVATAN Z 98 trichlormethiazide 165 travoprost 98 trichloroacetic acid 262,300 trazodone hcl 80,81 trichophyton 161 TREAGAN OTIC 300 TRICITRASOL 170 TRECATOR 111 TRICITRATES 170 trek s combo pack 300 triclosan 43 trek s compact compressor 300 TRICOR 106 trek s portable pwr kit 300 TRIDERM 252 TRETIN-X 254 TRIDESILON 252 tretinoin 254,300 TRIESENCE 45 tretinoin acid 254 TRIFERIC 50 tretinoin microsphere 254 trifluoperazine hcl 123 TREXALL 226 trifluridine 36 TREXIMET 110 TRIGLIDE 106 TREZIX 12 trihexyphenidyl hcl 67 TRI FEMYNOR 208 TRIKLO 104 TRI-CHLOR 262 TRILEPTAL 72 TRI-ESTARYLLA 208 TRILIPIX 106 TRI-LEGEST FE 208 trilostane 300 TRI-LINYAH 208 TRILYTE WITH FLAVOR PACKETS 186 TRI-LO-ESTARYLLA 208 trimeprazine tartrate 183 TRI-LO-MARZIA 208 trimethobenzamide hcl 91 TRI-LO-SPRINTEC 209 trimethoprim 33 TRI-LUMA 156 trimethoprim micronized 33 TRI-NORINYL 209 trimipramine maleate 82 TRI-PREVIFEM 209 TRINATE 50 TRI-SPRINTEC 209 TRINESSA 209 TRI-TABS DHA 49 TRINESSA LO 209 TRI-VI-FLOR 224 TRINTELLIX 81 triacetin 92 trioxsalen 300 triamcinolone 194 tripelennamine hcl 183 triamcinolone acetonide 45,194,252 TRIPLE DYE 93 triamcinolone diacetate 194 triprolidine hcl 100 triamcinolone diacetate micro 194 TRIUMEQ 124 triamcinolone hexacetonide 194 TRIVEEN-ONE 50 triamterene 165 TRIVEEN-U 306 TRIVORA-28 209 ubiquinol 234 TRIZIVIR 125 UCERIS 194 TROKENDI XR 72 UDAMIN SP 306 trolamine 300 ULESFIA 43 TROPAZONE 300 ULORIC 221 tropicamide 182 ULTANE 189 trospium chloride 190 ulticare 300 trospium chloride er 190 ULTRACET 12 TRULICITY 86 ULTRAFOAM 100 TRUMENBA 132 ULTRAM 22 truneb nebulizer 300 ULTRAM ER 22 TRUSOPT 97 ULTRASAL-ER 256 TRUST NATAL DHA 306 ULTRAVATE 252 TRUVADA 125 ULTRAVIST 164 truzone peak flow meter 300 UMECTA 256 trypsin 300 UMECTA PD 256 tryptophan (l) 141 UNASYN 239 TUBERSOL 164 undecylenic acid 93 turmeric root 234 unistik 2 normal 300 TUSSICAPS 102 UNITHROID 267 TUSSIGON 66 UPTRAVI 246 TUSSIONEX 102 UR N-C 33 TUZISTRA XR 22 URAMAXIN 256 TWINRIX 132 URAMAXIN GT 256 TWYNSTA 150 URE-K 256 TYBOST 234 urea 256 TYKERB 300 URECHOLINE 145 TYLENOL-CODEINE NO.3 12 URELLE 33 TYLENOL-CODEINE NO.4 12 URETRON D-S 33 TYMLOS 213 UREVAZ 256 TYPHIM VI 132 URIBEL 33 tyrosine 171 URIMAR-T 33 TYVASO 245 URIN D.S. 33 TYVASO INSTITUTIONAL START KIT 245 URO-458 33 TYVASO REFILL KIT 245 URO-BLUE 33 TYVASO STARTER KIT 245 URO-L 33 TYZEKA 138 UROCIT-K 170 TYZINE 183 UROGESIC-BLUE 33 UROPHEN MB 33 U UROQID-ACID NO.2 33 ubidecarenone 234 UROXATRAL 8 URSO 186 VARIVAX VACCINE 132 URSO FORTE 186 VARIZIG 130 ursodiol 186 VARUBI 90 URYL 33 VASCEPA 104 USTELL 33 vascuderm hydrogel wound 301 UTA 33 VASELINE WHITE PETROLEUM 175 UTIBRON NEOHALER 5 VASERETIC 168 UTIRA-C 33 vasopressin 214 UTOPIC 256 VASOTEC 242 UVADEX 156 VAXCHORA ACTIVE COMPONENT 132 VAXCHORA BUFFER COMPONENT 301 V VAXCHORA VACCINE 132 V-C FORTE 306 VECAMYL 216 vacustim black 300 VECTICAL 262 VAGIFEM 179 vecuronium bromide 247 valacyclovir 139 VELIVET 209 valacyclovir hcl 139 VELPHORO 217 VALCHLOR 262 VELTASSA 217 VALCYTE 139 VEMLIDY 139 valganciclovir hcl 139 VENATAL COMPLETE DHA 301 valine 301 VENCLEXTA 301 VALIUM 74 VENCLEXTA STARTING PACK 301 valproic acid 72 VENELEX 262 valsartan 241 venlafaxine hcl 77 valsartan-hydrochlorothiazide 168 venlafaxine hcl er 77 VALSTAR 301 VENTOLIN HFA 6 VALTREX 139 VERAMYST 45 VANATOL LQ 12 verapamil er 56 VANCOCIN HCL 62 verapamil er pm 56 vancomycin hcl 62 verapamil hcl 56 VANDAZOLE 39 verapamil sr 56 VANIQA 262 VERDESO 252 VANOS 252 VERDROCET 12 VANOXIDE-HC 252 VEREGEN 262 vapro plus intermitt catheter 301 VERELAN 56 VAQTA 132 VERELAN PM 56 VARIBAR HONEY 164 VERIPRED 20 194 VARIBAR NECTAR 164 VERSACLOZ 121 VARIBAR PUDDING 164 VESICARE 190 VARIBAR THIN HONEY 164 VESTURA 209 VARIBAR THIN LIQUID 164 VEXOL 45 VFEND 92 VIRT-ADVANCE 50 VIAGRA 305 VIRT-C DHA 50 VIASPAN BELZER-UW 301 VIRT-CAPS 308 VIBERZI 188 VIRT-GARD 308 VIBRAMYCIN 62 VIRT-NATE 50 VIC-FORTE 306 VIRT-NATE DHA 50 VICODIN 12 VIRT-PHOS 250 NEUTRAL 169 VICODIN ES 12 VIRT-PN 50 VICODIN HP 12 VIRT-PN DHA 50 VICOPROFEN 22 VIRT-PN PLUS 50 VICTOZA 2-PAK 86 VIRT-VITE 308 VICTOZA 3-PAK 86 VIRT-VITE PLUS 308 vidarabine 139 VIRTRATE-2 170 vidarabine monohydrate 139 VIRTRATE-3 170 VIDEX 126 VIRTRATE-K 170 VIDEX EC 126 VISCOAT 301 VIEKIRA PAK 127 VISTARIL 141 VIEKIRA XR 127 VISTOGARD 220 VIENVA 209 VIT 3 104 vigabatrin 72 VITA-RESPA 308 VIGAMOX 36 VITAFOL GUMMIES 50 VIIBRYD 81 vitamin a acetate 307 VIMPAT 72 vitamin a palmitate 307 VINATE DHA 50 vitamin d2 309 VINATE DHA RF 50 vitamin d3 309 VINATE GT 50 vitamin e acetate 309 VINATE II 50 vitamin k 310 VINATE ONE 50 vitamin k1 220 VINATE PN CARE 306 vitamin k2 310 VINATE ULTRA 50 vitamins a,c,d and fluoride 307 VINATE-M 306 VITASPIRE 301 VIORELE 209 VITATRUE 50 vios aerosol delivery system 301 VITRASE 301 VIRACEPT 127 VITUZ 102 VIRAMUNE 125 VIVA DHA 50 VIRAMUNE XR 125 VIVELLE-DOT 179 VIRASAL 256 VIVITROL 152 VIRAZOLE 139 VIVLODEX 238 VIREAD 126 VIVOTIF 132 virginia live oak 161 VIVOTIF BERNA 132 VIROPTIC 36 vixone nebulizer 301 VOL-TAB RX 50 white oak extract 161 VOLTAREN 238 white pine 161 VOLTAREN-XR 238 white willow bark 302 VOLUMEN 164 whole egg 161 voriconazole 93 wide seal diaphragm 302 vortex 301 wound matrix 302 vortex vhc frog mask 301 WP THYROID 267 vortex vhc ladybug mask 301 WYMZYA FE 210 VOSEVI 301 VOSPIRE ER 6 X VOTRIENT 301 XADAGO 112 VP-CH-PNV 50 XALATAN 98 VP-HEME OB 50 XALKORI 302 VP-HEME ONE 50 XANAX 143 VP-PNV-DHA 51 XANAX XR 143 VP-VITE RX 308 xanthan gum 302 VP-ZEL 234 XARELTO 68 VRAYLAR 121 XARTEMIS XR 12 VUSION 95 XATMEP 226 VYFEMLA 209 XCLAIR 175 VYNATAL-FA 51 XELJANZ 226 VYTONE 43 XELJANZ XR 226 VYTORIN 105 XELODA 302 VYVANSE 27 XENAZINE 152 XENICAL 188 W XERESE 39 warfarin sodium 67 XERMELO 184 wasp venom protein 161 xeroform 302 water 302 xeroform petrolatum dressing 302 WELCHOL 83 XIFAXAN 64 WELLBUTRIN 75 XIIDRA 45 WELLBUTRIN SR 75,76 XODOL 10-300 12 WELLBUTRIN XL 76 XODOL 5-300 12 WERA 209 XODOL 7.5-300 13 western juniper 161 XOLEGEL 95 western ragweed 161 XOPENEX 6 WESTHROID 267 XOPENEX CONCENTRATE 6 white ash 161 XTANDI 302 white birch 161 XULANE 210 white faced hornet venom 161 XURIDEN 234 white mulberry 161 XYLOCAINE 52,182,302 XYLOCAINE DENTAL-EPINEPHRINE 265 ZENCHENT 210 XYLOCAINE WITH EPINEPHRINE 265 ZENCHENT FE 210 XYLOCAINE-MPF 52,302 ZENCIA 43 XYLOCAINE-MPF WITH EPINEPHRINE 265 ZENPEP 186 xylometazoline hcl 302 ZENZEDI 27,28 XYLON 10 22 ZEOSA 210 XYREM 152 ZEPATIER 191 XYZAL 101 ZERIT 126 ZESTORETIC 168 Y ZESTRIL 242 YASMIN 28 210 ZETIA 105 YAZ 210 ZETONNA 45 yellow dock 162 ZIAC 54 yellow hornet venom protein 162 ZIAGEN 126 yellow jacket venom protein 162 zidovudine 126 YF-VAX 133 zileuton er 46 yohimbine hcl 264,302 ZINACEF 153 YUVAFEM 179 ZINBRYTA 229 zinc acetate 303 Z zinc chloride 174 zafirlukast 46 zinc oxide 262 zaleplon 141 zinc picolinate 174 ZAMICET 13 zinc pyrithione 303 ZANABIN 302 zinc sulfate 174 ZANAFLEX 247 zinc undecylenate 94 ZANTAC 133 ZINGO 303 ZARAH 210 ziprasidone hcl 121 ZARONTIN 75 ZIPSOR 238 ZARXIO 147 ZIRGAN 36 ZAVESCA 234 ZITHRANOL 256 zazole 95 ZITHRANOL-RR 256 zeaxanthin 302 ZITHROMAX 218 ZEBETA 54 ZITHROMAX TRI-PAK 218 ZEBUTAL 13 ZMAX 218 ZEGERID 135 ZOCOR 107 ZEJULA 302 ZODEX 194,303 ZELAPAR 76 ZOFRAN 89 ZELBORAF 302 ZOFRAN ODT 89 ZEMBRACE SYMTOUCH 110 ZOLATE 308 ZEMPLAR 309 ZOLINZA 303 ZENATANE 262 zolmitriptan 110 zolmitriptan odt 110 ZOLOFT 80 zolpidem tartrate 141 zolpidem tartrate er 141 ZOLPIMIST 141 ZOMACTON 214 ZOMIG 110 ZOMIG ZMT 110 ZONALON 253 ZONATUSS 243 ZONEGRAN 73 zonisamide 73 ZONTIVITY 128 ZORBTIVE 214 ZORTRESS 231 ZOSTAVAX 133 ZOTEX-C 303 ZOVIA 1-35E 210 ZOVIA 1-50E 210 ZOVIRAX 39,40,139 ZUBSOLV 24 ZUPLENZ 89 ZURAMPIC 174 ZUTRIPRO 22 ZYBAN 76 ZYCLARA 262 ZYDELIG 303 ZYFLO 46 ZYFLO CR 46 ZYKADIA 303 ZYLET 36 ZYLOPRIM 221 ZYMAXID 36 ZYPREXA 121,122 ZYPREXA RELPREVV 122 ZYPREXA ZYDIS 122 ZYTIGA 303 ZYVOX 63 NOTICE ABOUT NON-DISCRIMINATION
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If you believe that GlobalHealth has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: ATTN: Director of Compliance and Legal Services, 701 NE 10th St, Ste. 300, Oklahoma City, OK 73104-5403, Fax: (405) 280-5894, or E-mail: [email protected]. You can file a grievance in person or by mail, fax, or e-mail. If you need help filing a grievance, the Compliance Attorney is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Language Translation Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-280-2989 (TTY: 711). Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-280-2989 (TTY: 711). Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-877-280- 2989 (TTY: 711). Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-877-280-2989 OR (TTY: 711)번으로 전화해 주십시오. German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche
Language Translation Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-280-2989 (TTY: 711). 117) .اتصل .إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان :ملحوظة Arabic 4692-082-778-1 (ھاتف الصم والبكم برقم Burmese သတိျပဳရန္ - အကယ္၍ သင္သည္ ျမန္မာစကား ကို ေျပာပါက၊ ဘာသာစကား အကူအညီ၊ အခမဲ့၊ သင့္အတြက္ စီစဥ္ေဆာင္ရြက္ေပးပါမည္။ ဖုန္းနံပါတ္ 1-877-280-2989 (TTY: 711) သုိ႔ ေခၚဆိုပါ။ Hmong LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-877-280-2989 (TTY: 711). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-280-2989 (TTY: 711). French ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-877-280-2989 (ATS: 711). Laotian ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍ ລິ ການຊ່ວຍເຫ ອດ້ານພາສາ, ໂດຍບໍ່ ເສັ ຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ ທ່ານ. ໂທຣ 1-877-280-2989 (TTY: 711). Thai เรียน: ถา้ คณุ พดู ภาษาไทยคณุ สามารถใชบ้ รกิ ารชว่ ยเหลอื ทางภาษาไดฟ้ ร ี โทร 1-877-280-2989 (TTY: 711). -280-877-1 کریں کال ۔ ہیں دستیاب میں مفت خدمات کی مدد کی زبان کو آپ تو ہیں، بولتے اردو آپ اگر :خبردار Urdu 2989 (TTY: 711). Cherokee Hagsesda: iyuhno hyiwoniha [tsalagi gawonihisdi]. Call 1-877-280-2989 (TTY: 711). اگر بھ زبان فارسی گفتگو می کنید، تسھیالت زبانی بصورت رایگان برای شما :توجھ Persian .با تماس بگیرید .فراھم می باشد (TTY: 711) 1-877-280-2989
GlobalHealth, Inc. PO Box 2393 Oklahoma City, OK 73101-2393 www.GlobalHealth.com/fehb Effective: 2018 Lists Updated 12/2017
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