2017 Prescription Drug Formulary High Performance Plus
PLEASE READ: This document contains information about the drugs we cover in your plan. This formulary was updated 12/2017.
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Ordeór Number: Z8188-MCA R 11/16 Dept of Ins. Filing Number: Z8188-MCA R9/16
QUESTIONS ABOUT YOUR BENEFITS OR OTHER INQUIRIES ABOUT YOUR HEALTH INSURANCE SHOULD BE DIRECTED TO MEDICAL MUTUAL’S CUSTOMER CARE DEPARTMENT AT 1-800-382-5729.
Nondiscrimination Notice
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Medical Mutual does not exclude people or treat them differently because of race, color, national origin, age, disability or sex in its operation of health programs and activities. Q Medical Mutual provides free aids and services to people with disabilities to communicate effectively with
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Civil Rights Coordinator Medical Mutual of Ohio
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You can also le a civil rights complaint with the U.S. Department of Health and Human Services, Of ce for Civil Rights. U.S. Department of Health and Human Services Q Electronically through the Of ce for Civil Rights Complaint Portal available at: 200 Independence Avenue, SW Room 509F ocrportal.hhs.gov/ocr/portal/lobby.jsf
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High Performance Plus Formulary
What is the High Performance Plus When you visit your doctor or health provider, formulary? ask him or her to review this formulary at The High Performance Plus formulary is a list of MedMutual.com/2017drugs so he or she can medications covered by your plan. It includes a see what medications are covered by your plan. variety of clinically effective medications that may cost you less than other options used to What if my doctor prescribes a medication treat the same condition. The formulary that is not on the High Performance Plus includes five tiers: formulary? 1. Generic (lowest out-of-pocket cost) Talk with your doctor or health provider to see if 2. Preferred brand the formulary includes a medication to treat 3. Non-preferred brand your condition. In most cases, your provider will 4. Specialty (highest out-of-pocket cost) find one that meets your needs. 5. Preventive ($0 out-of-pocket cost) In the rare instance that none of the covered Refer to your Certificate or Benefit Book for medications is appropriate for you and a non- information about your cost share, including formulary medication is required, your provider copays, coinsurance and/or deductibles. Not all can contact Express Scripts at (800) 753-2851 tiers apply to all plans. and ask for a formulary coverage review. Your provider will receive a form to fill out and fax If you are a member of a plan that includes a back to Express Scripts. Express Scripts will preferred pharmacy network (e.g., CLE-Care), send you and your doctor a letter confirming if those preferred pharmacies may offer lower coverage is approved (usually within three cost sharing to help you save money. Check business days of receiving the necessary your benefit materials for more details. information). If an exception is made based on medical necessity, you will only pay your plan’s If a medication is not listed on this formulary, it applicable cost share (e.g., non-preferred will generally not be covered under the plan, brand, specialty). If your provider does not and you will pay the full cost. request a coverage review and you fill a prescription for a non-formulary medication, you How do I use the High Performance Plus will pay the full cost. formulary? Covered medications are organized two ways in How can I find a covered alternative if my the High Performance Plus formulary: medication is not on the formulary? 1. By condition If you cannot find your current medication on 2. By name the High Performance Plus formulary, you can find covered alternatives in two ways: If you know what your medication is used to 1. Visit MedMutual.com/member and log in to treat, you can look it up by condition in the front My Health Plan. of the document. If you don’t know what • Click Benefits & Coverage, then condition it is used to treat, you can look for it in Prescription Drug Benefits. the alphabetical Index at the back of the • Click the Sign on to Express Scripts document. button. Once you are redirected to the Express Scripts website, click Manage
Prescriptions, then Save with My Rx Does the High Performance Plus formulary Choices. include contraceptives? • Type the name of your medication in the Yes. Certain prescription contraceptives are Search bar to see covered alternatives. included on the High Performance Plus formulary at a $0 cost share. Prior 2. Call the Rx Member Services number on authorization, step therapy and quantity limit your Medical Mutual ID card. A Member programs may apply. If your provider feels none Services Representative can offer covered of the covered contraceptives on the High clinically appropriate alternatives. Performance Plus formulary is right for you, he or she may contact our pharmacy benefit Does the High Performance Plus formulary manager to request a formulary coverage include generics? review. If an exception is made to cover a non- Yes. The High Performance Plus formulary formulary contraceptive based on medical includes a large variety of generic medications necessity, Medical Mutual will cover that to help you pay less out of pocket. Generics are contraceptive. You will pay your plan’s shown in lower-case italic letters. applicable cost share.
Generic medications are approved by the U.S. Do I have to use mail order for my Food and Drug Administration (FDA) as having maintenance medications? the same active ingredient as their brand-name If you are a member of a CLE-Care plan, you counterparts. In addition, the FDA requires must fill mail-order medications through the generics to be just as safe and strong as their MetroHealth Central Fill Pharmacy. Visit brand-name counterparts so you get the same metrohealth.org/pharmacy for more information medical benefit. and to download a form.
Does the High Performance Plus formulary If you are NOT a member of a CLE-Care plan, include brand medications? you may be required to use mail order for your Yes. The High Performance Plus formulary maintenance medications (those you take for includes a selection of brand medications in three months or more), depending on your plan. most categories. Brand medications are shown Please check your Certificate or Benefit Book in ALL CAPITAL LETTERS. for details.
Does the High Performance Plus formulary Even if you are not required to do so, you may include specialty medications? save money on your maintenance medications Yes. Specialty medications are used to treat if you order them through the mail. certain complex medical conditions and may require special handling, instruction, or To get started using mail order, ask your monitoring. Many specialty medications are provider to write a prescription for up to a 90- included on the High Performance Plus day supply of your medication, plus up to three formulary. You must fill prescriptions for these refills, if applicable. Then: medications through one of Medical Mutual’s 1. Complete the home delivery form you contracted specialty pharmacies, Accredo or received in the mail from Express Scripts, Gentry. In addition, you can only get a 30-day and return it with your payment in the supply for most specialty medications. envelope provided. If you need another form, visit MedMutual.com and click If you are a member of a plan that includes a Member Forms at the bottom of the page. preferred pharmacy network (e.g., CLE-Care), Download and print the Prescription Drug you may be required to use specific preferred Mail Order Form. pharmacies for specialty drugs. Check your 2. Ask your provider to call Express Scripts at benefit materials for more details about ordering (888) 327-9791 for instructions on how to specialty medications. fax the prescription or use the e-prescribing system. Your provider must have your member ID number (which is on your When ordering through the Express Scripts member Medical Mutual ID card). Home Delivery PharmacyTM, your medication 3. Call the Rx Member Services number on should be delivered in about eight days (10-14 your Medical Mutual ID card. A Member days if it’s a new prescription). Please have a Services Representative can help you one-month supply of your medicine on hand transfer your prescriptions to mail order. when you place your order. You can check your order status by visiting the Express Scripts website through My Health Plan, or by calling the Rx Member Services number on your Medical Mutual ID card.
List of Abbreviations ACA: Affordable Care Act
OTC: Over the Counter
PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain medications. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, your plan may not cover the medication.
QL: Quantity Limit. For certain drugs, the plan limits the amount of the medication it will cover.
ST: Step Therapy. In some cases, the plan requires you to first try certain medications to treat your medical condition before we will cover another medication for that condition. For example, if Medication A and Medication B both treat your medical condition, the plan may not cover Medication B unless you try Medication A first. If Medication A does not work for you, the plan will then cover Medication B.
LA: Limited Availability
*: Drugs identified with an asterisk may not be covered for excluded uses; prior authorization may be required.
Note: You, your doctor or your pharmacist can call Express Scripts at (800) 753-2851 to begin the review process for medications that require PA, QL and ST. After contacting Express Scripts, your doctor will receive a form to fill out and fax back to Express Scripts. Express Scripts will send you and your doctor a letter confirming if coverage has been approved (usually within three business days of receiving the necessary information).
Table of Contents
ANTI - INFECTIVES ...... 3 ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ...... 18 AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ...... 29 CARDIOVASCULAR, HYPERTENSION & LIPIDS ...... 49 DERMATOLOGICALS/TOPICAL THERAPY ...... 64 DIAGNOSTICS & MISCELLANEOUS AGENTS ...... 75 EAR, NOSE & THROAT MEDICATIONS ...... 78 ENDOCRINE/DIABETES ...... 80 GASTROENTEROLOGY ...... 89 IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ...... 99 MUSCULOSKELETAL & RHEUMATOLOGY ...... 108 OBSTETRICS & GYNECOLOGY ...... 111 OPHTHALMOLOGY ...... 120 RESPIRATORY, ALLERGY, COUGH & COLD ...... 125 UROLOGICALS ...... 132 VITAMINS, HEMATINICS & ELECTROLYTES ...... 135 Index ...... 146
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ANTI - INFECTIVES fluconazole oral 1 tablet 100 mg, 200 ANTIFUNGAL AGENTS mg, 50 mg amphotericin b 1 fluconazole oral 1 QL injection recon soln tablet 150 mg 50 mg flucytosine oral 1 CANCIDAS 2 capsule 250 mg, 500 INTRAVENOUS mg RECON SOLN 50 MG, 70 MG griseofulvin 1 microsize oral caspofungin 1 suspension 125 mg/5 intravenous recon ml soln 50 mg griseofulvin 1 clotrimazole mucous 1 microsize oral tablet membrane troche 10 500 mg mg griseofulvin 1 CRESEMBA 2 ultramicrosize oral INTRAVENOUS tablet 125 mg, 250 RECON SOLN 372 mg MG itraconazole oral 1 QL CRESEMBA ORAL 2 capsule 100 mg CAPSULE 186 MG ketoconazole oral 1 fluconazole in 1 tablet 200 mg dextrose(iso-o) intravenous MYCAMINE 2 piggyback 200 INTRAVENOUS mg/100 ml, 400 RECON SOLN 100 mg/200 ml MG, 50 MG fluconazole in nacl 1 NOXAFIL 2 (iso-osm) INTRAVENOUS intravenous SOLUTION 300 piggyback 200 MG/16.7 ML mg/100 ml, 400 NOXAFIL ORAL 2 mg/200 ml SUSPENSION 200 fluconazole oral 1 MG/5 ML (40 suspension for MG/ML) reconstitution 10 mg/ml, 40 mg/ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 3
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NOXAFIL ORAL 2 acyclovir oral 1 TABLET,DELAYE suspension 200 mg/5 D RELEASE ml (DR/EC) 100 MG acyclovir oral tablet 1 nystatin oral powder 1 400 mg, 800 mg 150 million unit, 500 acyclovir sodium 1 million unit intravenous solution nystatin oral 1 50 mg/ml suspension 100,000 adefovir oral tablet 1 unit/ml 10 mg nystatin oral tablet 1 amantadine hcl oral 1 500,000 unit capsule 100 mg SPORANOX ORAL 2 amantadine hcl oral 1 SOLUTION 10 solution 50 mg/5 ml MG/ML amantadine hcl oral 1 voriconazole 1 tablet 100 mg intravenous solution 200 mg APTIVUS ORAL 4 LA CAPSULE 250 MG voriconazole oral 1 suspension for APTIVUS ORAL 4 LA reconstitution 200 SOLUTION 100 mg/5 ml (40 mg/ml) MG/ML voriconazole oral 1 ATRIPLA ORAL 4 LA tablet 200 mg, 50 mg TABLET 600-200- 300 MG ANTIVIRALS BARACLUDE 2 abacavir oral 4 LA ORAL SOLUTION solution 20 mg/ml 0.05 MG/ML abacavir oral tablet 4 LA cidofovir 1 300 mg intravenous solution abacavir-lamivudine 4 LA 75 mg/ml oral tablet 600-300 COMPLERA ORAL 4 LA mg TABLET 200-25- abacavir- 4 LA 300 MG lamivudine- CRIXIVAN ORAL 4 LA zidovudine oral CAPSULE 200 MG, tablet 300-150-300 400 MG mg acyclovir oral 1 capsule 200 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 4
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DAKLINZA ORAL 4 PA; LA; QL ganciclovir sodium 1 TABLET 30 MG, 60 intravenous recon MG, 90 MG soln 500 mg DESCOVY ORAL 4 LA GENVOYA ORAL 4 LA TABLET 200-25 TABLET 150-150- MG 200-10 MG didanosine oral 4 LA HARVONI ORAL 4 PA; LA; QL capsule,delayed TABLET 90-400 release(dr/ec) 125 MG mg, 200 mg, 250 mg, INTELENCE ORAL 4 LA 400 mg TABLET 100 MG, EDURANT ORAL 4 LA 200 MG, 25 MG TABLET 25 MG INVIRASE ORAL 4 LA EMTRIVA ORAL 4 LA CAPSULE 200 MG CAPSULE 200 MG INVIRASE ORAL 4 LA EMTRIVA ORAL 4 LA TABLET 500 MG SOLUTION 10 ISENTRESS HD 4 LA MG/ML ORAL TABLET entecavir oral tablet 1 600 MG 0.5 mg, 1 mg ISENTRESS ORAL 4 LA EPCLUSA ORAL 4 PA; LA; QL POWDER IN TABLET 400-100 PACKET 100 MG MG ISENTRESS ORAL 4 LA EPIVIR HBV 2 TABLET 400 MG ORAL SOLUTION ISENTRESS ORAL 4 LA 25 MG/5 ML (5 TABLET,CHEWAB MG/ML) LE 100 MG, 25 MG famciclovir oral 1 QL KALETRA ORAL 4 LA tablet 125 mg, 250 TABLET 100-25 mg, 500 mg MG, 200-50 MG fosamprenavir oral 4 LA lamivudine oral 4 LA tablet 700 mg solution 10 mg/ml foscarnet 1 lamivudine oral 1 intravenous solution tablet 100 mg 24 mg/ml lamivudine oral 4 LA FUZEON 4 LA tablet 150 mg, 300 SUBCUTANEOUS mg RECON SOLN 90 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 5
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lamivudine- 4 LA PREZISTA ORAL 4 LA zidovudine oral SUSPENSION 100 tablet 150-300 mg MG/ML LEXIVA ORAL 4 LA PREZISTA ORAL 4 LA SUSPENSION 50 TABLET 150 MG, MG/ML 600 MG, 75 MG, 800 MG LEXIVA ORAL 4 LA TABLET 700 MG RAPIVAB 2 INTRAVENOUS lopinavir-ritonavir 4 LA SOLUTION 200 oral solution 400- MG/20 ML (10 100 mg/5 ml MG/ML) MAVYRET ORAL 4 PA; LA; QL RELENZA 2 QL TABLET 100-40 DISKHALER MG INHALATION nevirapine oral 4 LA BLISTER WITH suspension 50 mg/5 DEVICE 5 ml MG/ACTUATION nevirapine oral 4 LA RESCRIPTOR 4 LA tablet 200 mg ORAL TABLET nevirapine oral 4 LA 200 MG tablet extended RESCRIPTOR 4 LA release 24 hr 100 ORAL TABLET, mg, 400 mg DISPERSIBLE 100 NORVIR ORAL 4 LA MG CAPSULE 100 MG RETROVIR 4 LA NORVIR ORAL 4 LA INTRAVENOUS SOLUTION 80 SOLUTION 10 MG/ML MG/ML NORVIR ORAL 4 LA REYATAZ ORAL 4 LA TABLET 100 MG CAPSULE 150 MG, 200 MG, 300 MG ODEFSEY ORAL 4 LA TABLET 200-25-25 REYATAZ ORAL 4 LA MG POWDER IN PACKET 50 MG OLYSIO ORAL 4 PA; LA; QL CAPSULE 150 MG ribavirin inhalation 1 recon soln 6 gram oseltamivir oral 1 QL capsule 30 mg, 45 rimantadine oral 1 mg, 75 mg tablet 100 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 6
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SELZENTRY 4 LA TRUVADA ORAL 4 LA ORAL SOLUTION TABLET 100-150 20 MG/ML MG, 133-200 MG, 167-250 MG, 200- SELZENTRY 4 LA 300 MG ORAL TABLET 150 MG, 25 MG, TYBOST ORAL 4 LA 300 MG, 75 MG TABLET 150 MG stavudine oral 4 LA valacyclovir oral 1 QL capsule 15 mg, 20 tablet 1 gram, 500 mg, 30 mg, 40 mg mg stavudine oral recon 4 LA valganciclovir oral 1 soln 1 mg/ml recon soln 50 mg/ml STRIBILD ORAL 4 LA valganciclovir oral 1 TABLET 150-150- tablet 450 mg 200-300 MG VEMLIDY ORAL 2 SUSTIVA ORAL 4 LA TABLET 25 MG CAPSULE 200 MG, VIDEX 2 GRAM 4 LA 50 MG PEDIATRIC ORAL SUSTIVA ORAL 4 LA RECON SOLN 10 TABLET 600 MG MG/ML (FINAL) SYNAGIS 4 PA; LA; QL VIEKIRA PAK 4 PA; LA; QL INTRAMUSCULA ORAL R SOLUTION 100 TABLETS,DOSE MG/ML, 50 MG/0.5 PACK 12.5 MG-75 ML MG -50 MG/250 MG TAMIFLU ORAL 2 QL SUSPENSION FOR VIEKIRA XR 4 PA; LA; QL RECONSTITUTIO ORAL TABLET, IR N 6 MG/ML - ER, BIPHASIC 24HR 8.33 MG-50 TECHNIVIE ORAL 4 PA; LA; QL MG- 33.33 MG-200 TABLET 12.5-75-50 MG MG VIRACEPT ORAL 4 LA TIVICAY ORAL 4 LA TABLET 250 MG, TABLET 10 MG, 25 625 MG MG, 50 MG VIREAD ORAL 4 LA TRIUMEQ ORAL 4 LA POWDER 40 TABLET 600-50- MG/SCOOP (40 300 MG MG/GRAM)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 7
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VIREAD ORAL 4 LA cefazolin in dextrose 1 TABLET 150 MG, (iso-os) intravenous 200 MG, 250 MG, piggyback 1 gram/50 300 MG ml, 2 gram/50 ml ZEPATIER ORAL 4 PA; LA; QL cefazolin injection 1 TABLET 50-100 recon soln 1 gram, MG 10 gram, 100 gram, 20 gram, 300 g, 500 zidovudine oral 4 LA mg capsule 100 mg cefazolin 1 zidovudine oral 4 LA intravenous recon syrup 10 mg/ml soln 1 gram zidovudine oral 4 LA cefdinir oral capsule 1 tablet 300 mg 300 mg CEPHALOSPORINS cefdinir oral 1 AVYCAZ 2 suspension for INTRAVENOUS reconstitution 125 RECON SOLN 2.5 mg/5 ml, 250 mg/5 GRAM ml cefaclor oral capsule 1 cefditoren pivoxil 1 250 mg, 500 mg oral tablet 200 mg, 400 mg cefaclor oral 1 suspension for cefepime in 1 reconstitution 125 dextrose,iso-osm mg/5 ml, 250 mg/5 intravenous ml, 375 mg/5 ml piggyback 1 gram/50 ml, 2 gram/100 ml cefaclor oral tablet 1 extended release 12 cefepime injection 1 hr 500 mg recon soln 1 gram, 2 gram cefadroxil oral 1 capsule 500 mg cefixime oral 1 suspension for cefadroxil oral 1 reconstitution 100 suspension for mg/5 ml, 200 mg/5 reconstitution 250 ml mg/5 ml, 500 mg/5 ml cefotaxime injection 1 recon soln 1 gram, cefadroxil oral tablet 1 10 gram, 2 gram, 1 gram 500 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 8
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits cefotetan injection 1 ceftriaxone 1 recon soln 1 gram, 2 intravenous recon gram soln 1 gram, 2 gram cefotetan 1 cefuroxime axetil 1 intravenous recon oral tablet 250 mg, soln 10 gram 500 mg cefoxitin in dextrose, 1 cefuroxime sodium 1 iso-osm intravenous injection recon soln piggyback 1 gram/50 750 mg ml, 2 gram/50 ml cefuroxime sodium 1 cefoxitin intravenous 1 intravenous recon recon soln 1 gram, soln 1.5 gram, 7.5 10 gram, 2 gram gram cefpodoxime oral 1 cephalexin oral 1 suspension for capsule 250 mg, 500 reconstitution 100 mg, 750 mg mg/5 ml, 50 mg/5 ml cephalexin oral 1 cefpodoxime oral 1 suspension for tablet 100 mg, 200 reconstitution 125 mg mg/5 ml, 250 mg/5 ml cefprozil oral 1 suspension for cephalexin oral 1 reconstitution 125 tablet 250 mg, 500 mg/5 ml, 250 mg/5 mg ml ZERBAXA 2 cefprozil oral tablet 1 INTRAVENOUS 250 mg, 500 mg RECON SOLN 1.5 GRAM ceftazidime injection 1 recon soln 1 gram, 2 ERYTHROMYCINS & OTHER
gram, 6 gram MACROLIDES ceftriaxone in 1 azithromycin 1 dextrose,iso-os intravenous recon intravenous soln 500 mg piggyback 1 gram/50 ml, 2 gram/50 ml azithromycin oral 1 packet 1 gram ceftriaxone injection 1 recon soln 1 gram, azithromycin oral 1 10 gram, 2 gram, suspension for 250 mg, 500 mg reconstitution 100 mg/5 ml, 200 mg/5 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 9
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits azithromycin oral 1 ERY-TAB ORAL 2 tablet 250 mg, 500 TABLET,DELAYE mg, 600 mg D RELEASE (DR/EC) 500 MG clarithromycin oral 1 suspension for erythrocin (as 1 reconstitution 125 stearate) oral tablet mg/5 ml, 250 mg/5 250 mg ml erythromycin 1 clarithromycin oral 1 ethylsuccinate oral tablet 250 mg, 500 suspension for mg reconstitution 200 mg/5 ml clarithromycin oral 1 tablet extended erythromycin 1 release 24 hr 500 mg ethylsuccinate oral tablet 400 mg DIFICID ORAL 3 TABLET 200 MG erythromycin oral 1 capsule,delayed e.e.s. 400 oral tablet 1 release(dr/ec) 250 400 mg mg E.E.S. GRANULES 2 erythromycin oral 1 ORAL tablet 250 mg, 500 SUSPENSION FOR mg RECONSTITUTIO N 200 MG/5 ML MISCELLANEOUS
ERYPED 200 2 ANTIINFECTIVES ORAL ALBENZA ORAL 2 QL SUSPENSION FOR TABLET 200 MG RECONSTITUTIO N 200 MG/5 ML ALINIA ORAL 2 QL SUSPENSION FOR ERYPED 400 2 RECONSTITUTIO ORAL N 100 MG/5 ML SUSPENSION FOR RECONSTITUTIO ALINIA ORAL 2 QL N 400 MG/5 ML TABLET 500 MG ery-tab oral 1 amikacin injection 1 tablet,delayed solution 1,000 mg/4 release (dr/ec) 250 ml, 500 mg/2 ml mg, 333 mg atovaquone oral 1 suspension 750 mg/5 ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 10
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits atovaquone- 1 clindamycin 1 proguanil oral tablet palmitate hcl oral 250-100 mg, 62.5-25 recon soln 75 mg/5 mg ml aztreonam injection 1 clindamycin 1 recon soln 1 gram, 2 pediatric oral recon gram soln 75 mg/5 ml baciim 1 clindamycin 1 intramuscular recon phosphate injection soln 50,000 unit solution 150 mg/ml bacitracin 1 clindamycin 1 intramuscular recon phosphate soln 50,000 unit intravenous solution 300 mg/2 ml, 600 BILTRICIDE 2 mg/4 ml, 900 mg/6 ORAL TABLET ml 600 MG COARTEM ORAL 2 QL CAYSTON 4 LA; QL TABLET 20-120 INHALATION MG SOLUTION FOR NEBULIZATION colistin 1 75 MG/ML (colistimethate na) injection recon soln chloramphenicol sod 1 150 mg succinate intravenous recon CUBICIN RF 2 soln 1 gram INTRAVENOUS RECON SOLN 500 chloroquine 1 MG phosphate oral tablet 250 mg, 500 CYCLOSERINE 3 mg ORAL CAPSULE 250 MG cleocin intravenous 1 solution 300 mg/2 ml DALVANCE 2 INTRAVENOUS clindamycin hcl oral 1 SOLUTION 500 capsule 150 mg, 300 MG mg, 75 mg dapsone oral tablet 1 clindamycin in 5 % 1 100 mg, 25 mg dextrose intravenous piggyback 300 daptomycin 1 mg/50 ml, 600 mg/50 intravenous recon ml, 900 mg/50 ml soln 500 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 11
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DARAPRIM ORAL 4 LA INVANZ 2 TABLET 25 MG INTRAVENOUS RECON SOLN 1 EMVERM ORAL 2 QL GRAM TABLET,CHEWAB LE 100 MG isoniazid injection 1 solution 100 mg/ml ethambutol oral 1 tablet 100 mg, 400 isoniazid oral 1 mg solution 50 mg/5 ml gentamicin in nacl 1 isoniazid oral tablet 1 (iso-osm) 100 mg, 300 mg intravenous ivermectin oral 1 QL piggyback 100 tablet 3 mg mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 KITABIS PAK 4 LA; QL mg/100 ml, 80 mg/50 INHALATION ml, 90 mg/100 ml SOLUTION FOR NEBULIZATION gentamicin injection 1 300 MG/5 ML solution 20 mg/2 ml, 40 mg/ml lincomycin injection 1 solution 300 mg/ml gentamicin sulfate 1 (ped) (pf) injection linezolid intravenous 1 solution 20 mg/2 ml parenteral solution 600 mg/300 ml gentamicin sulfate 1 (pf) intravenous linezolid oral 1 solution 100 mg/10 suspension for ml reconstitution 100 mg/5 ml hydroxychloroquine 1 oral tablet 200 mg linezolid oral tablet 1 600 mg imipenem-cilastatin 1 intravenous recon linezolid-0.9% 1 soln 250 mg, 500 mg sodium chloride intravenous IMPAVIDO ORAL 2 QL parenteral solution CAPSULE 50 MG 600 mg/300 ml INVANZ 2 mefloquine oral 1 QL INJECTION tablet 250 mg RECON SOLN 1 GRAM meropenem 1 intravenous recon soln 1 gram, 500 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 12
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MEROPENEM- 2 PRIFTIN ORAL 2 0.9% SODIUM TABLET 150 MG CHLORIDE PRIMAQUINE 3 QL INTRAVENOUS ORAL TABLET PIGGYBACK 1 26.3 MG GRAM/50 ML, 500 MG/50 ML pyrazinamide oral 1 tablet 500 mg metro i.v. 1 intravenous quinine sulfate oral 1 piggyback 500 capsule 324 mg mg/100 ml rifabutin oral 1 metronidazole in 1 capsule 150 mg nacl (iso-os) RIFAMATE ORAL 3 intravenous CAPSULE 300-150 piggyback 500 MG mg/100 ml rifampin intravenous 1 metronidazole oral 1 recon soln 600 mg capsule 375 mg rifampin oral 1 metronidazole oral 1 capsule 150 mg, 300 tablet 250 mg, 500 mg mg RIFATER ORAL 3 NEBUPENT 2 QL TABLET 50-120- INHALATION 300 MG RECON SOLN 300 MG SIRTURO ORAL 2 LA TABLET 100 MG neomycin oral tablet 1 500 mg SIVEXTRO 2 INTRAVENOUS ORBACTIV 2 RECON SOLN 200 INTRAVENOUS MG RECON SOLN 400 MG SIVEXTRO ORAL 3 TABLET 200 MG paromomycin oral 1 capsule 250 mg tinidazole oral tablet 1 250 mg PASER ORAL 3 GRANULES DR tinidazole oral tablet 1 QL FOR SUSP IN 500 mg PACKET 4 GRAM polymyxin b sulfate 1 injection recon soln 500,000 unit
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 13
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits tobramycin in 0.225 4 LA; QL amoxicillin oral 1 % nacl inhalation tablet 500 mg, 875 solution for mg nebulization 300 amoxicillin oral 1 mg/5 ml tablet,chewable 125 tobramycin in 0.9 % 1 mg, 250 mg nacl intravenous amoxicillin-pot 1 piggyback 60 mg/50 clavulanate oral ml suspension for tobramycin sulfate 1 reconstitution 200- injection recon soln 28.5 mg/5 ml, 250- 1.2 gram 62.5 mg/5 ml, 400- 57 mg/5 ml, 600- tobramycin sulfate 1 42.9 mg/5 ml injection solution 10 mg/ml, 40 mg/ml amoxicillin-pot 1 clavulanate oral TRECATOR ORAL 3 tablet 250-125 mg, TABLET 250 MG 500-125 mg, 875- TYGACIL 2 125 mg INTRAVENOUS amoxicillin-pot 1 RECON SOLN 50 clavulanate oral MG tablet extended XIFAXAN ORAL 2 QL release 12 hr 1,000- TABLET 200 MG, 62.5 mg 550 MG amoxicillin-pot 1 ZYVOX 2 clavulanate oral INTRAVENOUS tablet,chewable 200- PARENTERAL 28.5 mg, 400-57 mg SOLUTION 200 ampicillin oral 1 MG/100 ML capsule 250 mg, 500 PENICILLINS mg amoxicillin oral 1 ampicillin sodium 1 capsule 250 mg, 500 injection recon soln mg 1 gram, 10 gram, 125 mg, 2 gram, 250 amoxicillin oral 1 mg, 500 mg suspension for reconstitution 125 ampicillin sodium 1 mg/5 ml, 200 mg/5 intravenous recon ml, 250 mg/5 ml, 400 soln 1 gram, 2 gram mg/5 ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 14
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ampicillin-sulbactam 1 penicillin g 1 injection recon soln potassium injection 1.5 gram, 15 gram, 3 recon soln 20 gram million unit, 5 million unit ampicillin-sulbactam 1 intravenous recon penicillin g procaine 1 soln 1.5 gram intramuscular syringe 1.2 million AUGMENTIN 2 unit/2 ml, 600,000 ORAL unit/ml SUSPENSION FOR RECONSTITUTIO penicillin g sodium 1 N 125-31.25 MG/5 injection recon soln ML 5 million unit dicloxacillin oral 1 penicillin v 1 capsule 250 mg, 500 potassium oral recon mg soln 125 mg/5 ml, 250 mg/5 ml nafcillin in dextrose 1 iso-osm intravenous penicillin v 1 piggyback 1 gram/50 potassium oral tablet ml, 2 gram/100 ml 250 mg, 500 mg nafcillin injection 1 pfizerpen-g injection 1 recon soln 1 gram, recon soln 20 10 gram, 2 gram million unit, 5 million unit nafcillin intravenous 1 recon soln 1 gram, 2 piperacillin- 1 gram tazobactam intravenous recon oxacillin in 1 soln 2.25 gram, dextrose(iso-osm) 3.375 gram, 4.5 intravenous gram, 40.5 gram piggyback 1 gram/50 ml, 2 gram/50 ml QUINOLONES oxacillin injection 1 AVELOX IN NACL 2 recon soln 1 gram, (ISO-OSMOTIC) 10 gram, 2 gram INTRAVENOUS oxacillin intravenous 1 PIGGYBACK 400 recon soln 2 gram MG/250 ML ciprofloxacin 1 (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 15
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ciprofloxacin hcl 1 moxifloxacin oral 1 oral tablet 100 mg, tablet 400 mg 250 mg, 500 mg, 750 MOXIFLOXACIN- 2 mg SOD.ACE,SUL- ciprofloxacin in 5 % 1 WATER dextrose intravenous INTRAVENOUS piggyback 200 PIGGYBACK 400 mg/100 ml, 400 MG/250 ML mg/200 ml ofloxacin oral tablet 1 ciprofloxacin lactate 1 300 mg, 400 mg intravenous solution SULFA'S & RELATED AGENTS 200 mg/20 ml, 400 mg/40 ml sulfadiazine oral 1 tablet 500 mg ciprofloxacin oral 1 suspension,microcap sulfamethoxazole- 1 sule recon 250 mg/5 trimethoprim ml, 500 mg/5 ml intravenous solution 400-80 mg/5 ml FACTIVE ORAL 3 TABLET 320 MG sulfamethoxazole- 1 trimethoprim oral levofloxacin in d5w 1 suspension 200-40 intravenous mg/5 ml piggyback 250 mg/50 ml, 500 sulfamethoxazole- 1 mg/100 ml, 750 trimethoprim oral mg/150 ml tablet 400-80 mg, 800-160 mg levofloxacin 1 intravenous solution sulfatrim oral 1 25 mg/ml suspension 200-40 mg/5 ml levofloxacin oral 1 solution 250 mg/10 TETRACYCLINES ml avidoxy oral tablet 1 levofloxacin oral 1 100 mg tablet 250 mg, 500 demeclocycline oral 1 mg, 750 mg tablet 150 mg, 300 moxifloxacin in nacl 1 mg (iso-osm) doxy-100 1 intravenous intravenous recon piggyback 400 soln 100 mg mg/250 ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 16
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits doxycycline hyclate 1 tetracycline oral 1 oral capsule 100 mg, capsule 250 mg, 500 50 mg mg doxycycline hyclate 1 URINARY TRACT AGENTS oral tablet 100 mg, methenamine 1 150 mg, 20 mg, 75 hippurate oral tablet mg 1 gram doxycycline hyclate 1 methenamine 1 oral tablet,delayed mandelate oral release (dr/ec) 100 tablet 0.5 g, 1 gram mg, 150 mg, 200 mg, 50 mg, 75 mg MONUROL ORAL 3 PACKET 3 GRAM doxycycline 1 monohydrate oral nitrofurantoin 1 capsule 100 mg, 150 macrocrystal oral mg, 50 mg, 75 mg capsule 100 mg, 25 mg, 50 mg doxycycline 1 monohydrate oral nitrofurantoin 1 suspension for monohyd/m-cryst reconstitution 25 oral capsule 100 mg mg/5 ml nitrofurantoin oral 1 doxycycline 1 suspension 25 mg/5 monohydrate oral ml tablet 100 mg, 150 trimethoprim oral 1 mg, 50 mg, 75 mg tablet 100 mg minocycline oral 1 VANCOMYCIN capsule 100 mg, 50 mg, 75 mg VANCOMYCIN IN 2 0.9% SODIUM CL minocycline oral 1 INTRAVENOUS tablet 100 mg, 50 PIGGYBACK 1 mg, 75 mg GRAM/200 ML, minocycline oral 1 500 MG/100 ML, tablet extended 750 MG/150 ML release 24 hr 135 mg, 45 mg, 90 mg mondoxyne nl oral 1 capsule 100 mg, 50 mg, 75 mg morgidox oral 1 capsule 100 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 17
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VANCOMYCIN IN 2 ELITEK 2 0.9% SODIUM CL INTRAVENOUS INTRAVENOUS RECON SOLN 1.5 SOLUTION 1 MG, 7.5 MG GRAM/250 ML, KEPIVANCE 4 LA 1.25 GRAM/250 INTRAVENOUS ML, 1.5 GRAM/250 RECON SOLN 6.25 ML, 1.5 GRAM/500 MG ML, 1.75 GRAM/250 ML, leucovorin calcium 1 1.75 GRAM/500 injection recon soln ML, 2 GRAM/500 100 mg, 200 mg, 350 ML, 750 MG/150 mg, 50 mg, 500 mg ML, 750 MG/250 leucovorin calcium 1 ML oral tablet 10 mg, 15 VANCOMYCIN IN 2 mg, 25 mg, 5 mg DEXTROSE 5 % LEVOLEUCOVORI 2 INTRAVENOUS N INTRAVENOUS PIGGYBACK 1 RECON SOLN 175 GRAM/200 ML, MG 500 MG/100 ML levoleucovorin 1 vancomycin 1 intravenous recon intravenous recon soln 50 mg soln 1,000 mg, 10 gram, 5 gram, 500 levoleucovorin 1 mg, 750 mg intravenous solution 10 mg/ml vancomycin oral 1 capsule 125 mg, 250 mesna intravenous 1 mg solution 100 mg/ml ANTINEOPLASTIC & MESNEX ORAL 2 TABLET 400 MG IMMUNOSUPPRESSANT VISTOGARD 4 PA; LA DRUGS ORAL GRANULES ADJUNCTIVE AGENTS IN PACKET 10 GRAM amifostine 1 crystalline XGEVA 4 LA intravenous recon SUBCUTANEOUS soln 500 mg SOLUTION 120 MG/1.7 ML (70 dexrazoxane hcl 1 MG/ML) intravenous recon soln 250 mg, 500 mg ANTINEOPLASTIC &
IMMUNOSUPPRESSANT DRUGS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 18
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ABRAXANE 4 LA ARZERRA 4 LA INTRAVENOUS INTRAVENOUS SUSPENSION FOR SOLUTION 1,000 RECONSTITUTIO MG/50 ML, 100 N 100 MG MG/5 ML ADCETRIS 4 LA AVASTIN 4 LA INTRAVENOUS INTRAVENOUS RECON SOLN 50 SOLUTION 25 MG MG/ML adriamycin 1 azacitidine injection 4 PA; LA intravenous solution recon soln 100 mg 10 mg/5 ml, 2 mg/ml, AZASAN ORAL 4 LA 20 mg/10 ml, 50 TABLET 100 MG, mg/25 ml 75 MG adrucil intravenous 1 azathioprine oral 4 LA solution 2.5 gram/50 tablet 50 mg ml, 5 gram/100 ml, 500 mg/10 ml azathioprine sodium 4 LA injection recon soln AFINITOR 4 PA; LA 100 mg DISPERZ ORAL TABLET FOR BAVENCIO 4 LA SUSPENSION 2 INTRAVENOUS MG, 3 MG, 5 MG SOLUTION 20 MG/ML AFINITOR ORAL 4 PA; LA TABLET 10 MG, BENDEKA 4 LA 2.5 MG, 5 MG, 7.5 INTRAVENOUS MG SOLUTION 25 MG/ML ALECENSA ORAL 4 PA; LA; QL CAPSULE 150 MG BESPONSA 4 LA INTRAVENOUS ALIMTA 2 RECON SOLN 0.9 INTRAVENOUS MG (0.25 MG/ML RECON SOLN 100 INITIAL) MG, 500 MG bexarotene oral 4 PA; LA anastrozole oral 1 capsule 75 mg tablet 1 mg bicalutamide oral 1 ARRANON 4 LA tablet 50 mg INTRAVENOUS SOLUTION 250 BICNU 2 MG/50 ML INTRAVENOUS RECON SOLN 100 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 19
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits bleo 15k injection 1 CLOLAR 2 recon soln 15 unit INTRAVENOUS SOLUTION 20 bleomycin injection 1 MG/20 ML recon soln 15 unit, 30 unit COTELLIC ORAL 4 PA; LA; QL TABLET 20 MG BLINCYTO 4 LA INTRAVENOUS cyclophosphamide 1 KIT 35 MCG intravenous recon soln 1 gram, 2 gram, BOSULIF ORAL 4 PA; LA; QL 500 mg TABLET 100 MG, 500 MG CYCLOPHOSPHA 2 MIDE ORAL busulfan intravenous 1 CAPSULE 25 MG, solution 60 mg/10 ml 50 MG BUSULFEX 2 cyclosporine 4 LA INTRAVENOUS intravenous solution SOLUTION 60 250 mg/5 ml MG/10 ML cyclosporine 4 LA capecitabine oral 4 PA; LA modified oral tablet 150 mg, 500 capsule 100 mg, 25 mg mg, 50 mg CAPRELSA ORAL 4 PA; LA; QL cyclosporine 4 LA TABLET 100 MG, modified oral 300 MG solution 100 mg/ml carboplatin 1 cyclosporine oral 4 LA intravenous solution capsule 100 mg, 25 10 mg/ml mg CELLCEPT 4 LA CYRAMZA 4 LA INTRAVENOUS INTRAVENOUS INTRAVENOUS SOLUTION 10 RECON SOLN 500 MG/ML MG cytarabine (pf) 1 cisplatin intravenous 1 injection solution solution 1 mg/ml 100 mg/5 ml (20 cladribine 1 mg/ml), 2 gram/20 intravenous solution ml (100 mg/ml), 20 10 mg/10 ml mg/ml clofarabine 1 cytarabine injection 1 intravenous solution solution 20 mg/ml 20 mg/20 ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 20
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits dacarbazine 1 doxorubicin, peg- 1 intravenous recon liposomal soln 100 mg, 200 mg intravenous suspension 2 mg/ml DARZALEX 4 LA INTRAVENOUS DROXIA ORAL 2 SOLUTION 20 CAPSULE 200 MG, MG/ML 300 MG, 400 MG daunorubicin 1 ELIGARD (3 4 PA; LA intravenous recon MONTH) soln 20 mg SUBCUTANEOUS SYRINGE 22.5 MG daunorubicin 1 intravenous solution ELIGARD (4 4 PA; LA 5 mg/ml MONTH) SUBCUTANEOUS decitabine 4 PA; LA SYRINGE 30 MG intravenous recon soln 50 mg ELIGARD (6 4 PA; LA MONTH) docetaxel 1 SUBCUTANEOUS intravenous solution SYRINGE 45 MG 160 mg/16 ml (10 mg/ml), 160 mg/8 ml ELIGARD 4 PA; LA (20 mg/ml), 20 mg/2 SUBCUTANEOUS ml (10 mg/ml), 20 SYRINGE 7.5 MG mg/ml (1 ml), 80 (1 MONTH) mg/4 ml (20 mg/ml), EMCYT ORAL 2 80 mg/8 ml (10 CAPSULE 140 MG mg/ml) epirubicin 1 DOCETAXEL 2 intravenous recon INTRAVENOUS soln 200 mg SOLUTION 20 MG/ML epirubicin 1 intravenous solution doxorubicin 1 200 mg/100 ml, 50 intravenous recon mg/25 ml soln 10 mg, 50 mg ERBITUX 4 LA doxorubicin 1 INTRAVENOUS intravenous solution SOLUTION 100 10 mg/5 ml, 2 mg/ml, MG/50 ML, 200 20 mg/10 ml, 50 MG/100 ML mg/25 ml ERIVEDGE ORAL 4 PA; LA; QL CAPSULE 150 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 21
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ETOPOPHOS 2 GAZYVA 4 LA INTRAVENOUS INTRAVENOUS RECON SOLN 100 SOLUTION 1,000 MG MG/40 ML etoposide 1 gemcitabine 1 intravenous solution intravenous recon 20 mg/ml soln 1 gram, 2 gram, 200 mg etoposide oral 1 capsule 50 mg gemcitabine 1 intravenous solution exemestane oral 1 1 gram/26.3 ml (38 tablet 25 mg mg/ml), 2 gram/52.6 FARESTON ORAL 2 ml (38 mg/ml), 200 TABLET 60 MG mg/5.26 ml (38 FASLODEX 2 mg/ml) INTRAMUSCULA gengraf oral capsule 4 LA R SYRINGE 250 100 mg, 25 mg, 50 MG/5 ML mg floxuridine injection 1 gengraf oral solution 4 LA recon soln 0.5 gram 100 mg/ml fludarabine 1 GILOTRIF ORAL 4 PA; LA; QL intravenous recon TABLET 20 MG, 30 soln 50 mg MG, 40 MG fludarabine 1 GLEOSTINE ORAL 2 intravenous solution CAPSULE 10 MG, 50 mg/2 ml 100 MG, 40 MG, 5 fluorouracil 1 MG intravenous solution HALAVEN 4 LA 1 gram/20 ml, 2.5 INTRAVENOUS gram/50 ml, 5 SOLUTION 1 MG/2 gram/100 ml, 500 ML (0.5 MG/ML) mg/10 ml HERCEPTIN 4 LA flutamide oral 1 INTRAVENOUS capsule 125 mg RECON SOLN 150 FOLOTYN 4 LA MG, 440 MG INTRAVENOUS HEXALEN ORAL 2 SOLUTION 20 CAPSULE 50 MG MG/ML (1 ML), 40 HYCAMTIN ORAL 4 LA MG/2 ML (20 CAPSULE 0.25 MG/ML) MG, 1 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 22
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits hydroxyurea oral 1 irinotecan 1 capsule 500 mg intravenous solution 100 mg/5 ml, 40 IBRANCE ORAL 4 PA; LA; QL mg/2 ml, 500 mg/25 CAPSULE 100 MG, ml 125 MG, 75 MG ISTODAX 4 LA ICLUSIG ORAL 4 PA; LA; QL INTRAVENOUS TABLET 15 MG, 45 RECON SOLN 10 MG MG/2 ML idarubicin 1 IXEMPRA 4 LA intravenous solution INTRAVENOUS 1 mg/ml RECON SOLN 15 IDHIFA ORAL 4 PA; LA MG, 45 MG TABLET 100 MG, JAKAFI ORAL 4 PA; LA; QL 50 MG TABLET 10 MG, 15 ifosfamide 1 MG, 20 MG, 25 intravenous recon MG, 5 MG soln 1 gram, 3 gram KADCYLA 4 LA ifosfamide 1 INTRAVENOUS intravenous solution RECON SOLN 100 1 gram/20 ml, 3 MG, 160 MG gram/60 ml KEYTRUDA 4 LA ifosfamide-mesna 1 INTRAVENOUS intravenous kit 1-1 SOLUTION 25 gram, 3,000-1,000 MG/ML mg KYPROLIS 4 LA imatinib oral tablet 4 PA; LA; QL INTRAVENOUS 100 mg, 400 mg RECON SOLN 30 IMBRUVICA 4 PA; LA; QL MG, 60 MG ORAL CAPSULE LARTRUVO 4 LA 140 MG INTRAVENOUS INLYTA ORAL 4 PA; LA; QL SOLUTION 10 TABLET 1 MG, 5 MG/ML MG IRESSA ORAL 4 PA; LA; QL TABLET 250 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 23
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LENVIMA ORAL 4 PA; LA LUPRON DEPOT- 4 PA; LA CAPSULE 10 PED MG/DAY (10 MG X INTRAMUSCULA 1/DAY), 14 R KIT 11.25 MG, 15 MG/DAY(10 MG X MG, 7.5 MG (PED) 1-4 MG X 1), 18 LYNPARZA ORAL 4 PA; LA MG/DAY (10 MG X CAPSULE 50 MG 1-4 MG X2), 20 MG/DAY (10 MG X LYNPARZA ORAL 4 PA; LA 2), 24 MG/DAY(10 TABLET 100 MG, MG X 2-4 MG X 1), 150 MG 8 MG/DAY (4 MG LYSODREN ORAL 2 X 2) TABLET 500 MG letrozole oral tablet 1 MARQIBO 4 LA 2.5 mg INTRAVENOUS LEUKERAN ORAL 2 KIT 5 MG/31 TABLET 2 MG ML(0.16 MG/ML) FINAL leuprolide 4 PA; LA subcutaneous kit 1 MATULANE 4 LA mg/0.2 ml ORAL CAPSULE 50 MG lipodox intravenous 1 suspension 2 mg/ml megestrol oral 1 suspension 400 LONSURF ORAL 4 PA; LA mg/10 ml (40 TABLET 15-6.14 mg/ml), 625 mg/5 ml MG, 20-8.19 MG megestrol oral tablet 1 LUPRON DEPOT 4 PA; LA 20 mg, 40 mg (3 MONTH) INTRAMUSCULA MEKINIST ORAL 4 PA; LA; QL R SYRINGE KIT TABLET 0.5 MG, 2 11.25 MG MG LUPRON DEPOT 4 PA; LA melphalan hcl 1 INTRAMUSCULA intravenous recon R SYRINGE KIT soln 50 mg 3.75 MG melphalan oral 1 LUPRON DEPOT- 4 PA; LA tablet 2 mg PED (3 MONTH) mercaptopurine oral 1 INTRAMUSCULA tablet 50 mg R SYRINGE KIT 11.25 MG, 30 MG methotrexate sodium 1 (pf) injection recon soln 1 gram
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 24
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits methotrexate sodium 1 MYLERAN ORAL 2 (pf) injection TABLET 2 MG solution 25 mg/ml NERLYNX ORAL 4 PA; LA methotrexate sodium 1 TABLET 40 MG injection solution 25 NEXAVAR ORAL 4 PA; LA; QL mg/ml TABLET 200 MG methotrexate sodium 1 nilutamide oral 1 oral tablet 2.5 mg tablet 150 mg mitomycin 1 NINLARO ORAL 4 PA; LA; QL intravenous recon CAPSULE 2.3 MG, soln 20 mg, 40 mg, 5 3 MG, 4 MG mg NULOJIX 4 PA; LA mitoxantrone 4 LA INTRAVENOUS intravenous RECON SOLN 250 concentrate 2 mg/ml MG MUSTARGEN 2 octreotide acetate 4 LA INJECTION injection solution RECON SOLN 10 1,000 mcg/ml, 100 MG mcg/ml, 200 mcg/ml, mycophenolate 4 LA 50 mcg/ml, 500 mofetil hcl mcg/ml intravenous recon octreotide acetate 4 LA soln 500 mg injection syringe 100 mycophenolate 4 LA mcg/ml (1 ml), 50 mofetil oral capsule mcg/ml (1 ml), 500 250 mg mcg/ml (1 ml) mycophenolate 4 LA ONCASPAR 2 mofetil oral INJECTION suspension for SOLUTION 750 reconstitution 200 UNIT/ML mg/ml ONIVYDE 4 LA mycophenolate 4 LA INTRAVENOUS mofetil oral tablet DISPERSION 4.3 500 mg MG/ML mycophenolate 4 LA OPDIVO 4 LA sodium oral INTRAVENOUS tablet,delayed SOLUTION 100 release (dr/ec) 180 MG/10 ML, 40 mg, 360 mg MG/4 ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 25
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits oxaliplatin 1 RUBRACA ORAL 4 PA; LA; QL intravenous recon TABLET 200 MG, soln 100 mg, 50 mg 250 MG, 300 MG oxaliplatin 1 RYDAPT ORAL 4 PA; LA intravenous solution CAPSULE 25 MG 100 mg/20 ml, 50 SANDIMMUNE 4 LA mg/10 ml (5 mg/ml) ORAL SOLUTION paclitaxel 1 100 MG/ML intravenous SANDOSTATIN 4 LA concentrate 6 mg/ml LAR DEPOT PERJETA 4 LA INTRAMUSCULA INTRAVENOUS R SOLUTION 420 SUSPENSION,EXT MG/14 ML (30 ENDED REL MG/ML) RECON 10 MG, 20 MG, 30 MG PHOTOFRIN 2 INTRAVENOUS SIGNIFOR 4 LA RECON SOLN 75 SUBCUTANEOUS MG SOLUTION 0.3 MG/ML (1 ML), 0.6 PROGRAF 4 LA MG/ML (1 ML), 0.9 INTRAVENOUS MG/ML (1 ML) SOLUTION 5 MG/ML SIMULECT 4 LA INTRAVENOUS PURIXAN ORAL 4 LA RECON SOLN 10 SUSPENSION 20 MG, 20 MG MG/ML sirolimus oral tablet 4 LA RAPAMUNE 4 LA 0.5 mg, 1 mg, 2 mg ORAL SOLUTION 1 MG/ML SOLTAMOX 3 ORAL SOLUTION RITUXAN 4 PA; LA 10 MG/5 ML HYCELA SUBCUTANEOUS SOMATULINE 4 LA SOLUTION 1400 DEPOT MG/11.7 ML (120 SUBCUTANEOUS MG/ML), 1600 SYRINGE 120 MG/13.4 ML (120 MG/0.5 ML, 60 MG/ML) MG/0.2 ML, 90 MG/0.3 ML RITUXAN 4 PA; LA INTRAVENOUS CONCENTRATE 10 MG/ML You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 26
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SPRYCEL ORAL 4 PA; LA; QL TECENTRIQ 4 PA; LA TABLET 100 MG, INTRAVENOUS 140 MG, 20 MG, 50 SOLUTION 1,200 MG, 70 MG, 80 MG MG/20 ML (60 MG/ML) STIVARGA ORAL 4 PA; LA; QL TABLET 40 MG TEMODAR 4 PA; LA INTRAVENOUS SUTENT ORAL 4 PA; LA; QL RECON SOLN 100 CAPSULE 12.5 MG MG, 25 MG, 37.5 MG, 50 MG temozolomide oral 4 PA; LA capsule 100 mg, 140 SYLVANT 4 LA mg, 180 mg, 20 mg, INTRAVENOUS 250 mg, 5 mg RECON SOLN 100 MG, 400 MG TENIPOSIDE 2 INTRAVENOUS TABLOID ORAL 2 SOLUTION 50 TABLET 40 MG MG/5 ML tacrolimus oral 4 LA THALOMID ORAL 4 PA; LA capsule 0.5 mg, 1 CAPSULE 100 MG, mg, 5 mg 150 MG, 200 MG, TAFINLAR ORAL 4 PA; LA; QL 50 MG CAPSULE 50 MG, thiotepa injection 1 75 MG recon soln 15 mg TAGRISSO ORAL 4 PA; LA; QL toposar intravenous 1 TABLET 40 MG, 80 solution 20 mg/ml MG topotecan 4 LA tamoxifen oral tablet 1 intravenous recon 10 mg, 20 mg soln 4 mg TARCEVA ORAL 4 PA; LA; QL topotecan 4 LA TABLET 100 MG, intravenous solution 150 MG, 25 MG 4 mg/4 ml (1 mg/ml) TARGRETIN 4 PA; LA TORISEL 4 LA TOPICAL GEL 1 % INTRAVENOUS TASIGNA ORAL 4 PA; LA; QL RECON SOLN 30 CAPSULE 150 MG, MG/3 ML (10 200 MG MG/ML) (FIRST) TREANDA 4 LA INTRAVENOUS RECON SOLN 100 MG, 25 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 27
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits tretinoin 1 PA vincristine 1 (chemotherapy) oral intravenous solution capsule 10 mg 1 mg/ml, 2 mg/2 ml TREXALL ORAL 2 vinorelbine 1 TABLET 10 MG, 15 intravenous solution MG, 5 MG, 7.5 MG 10 mg/ml, 50 mg/5 ml TRISENOX 2 INTRAVENOUS VOTRIENT ORAL 4 PA; LA; QL SOLUTION 10 TABLET 200 MG MG/10 ML VYXEOS 4 LA TYKERB ORAL 4 PA; LA; QL INTRAVENOUS TABLET 250 MG RECON SOLN 44- 100 MG UNITUXIN 4 LA INTRAVENOUS XALKORI ORAL 4 PA; LA; QL SOLUTION 3.5 CAPSULE 200 MG, MG/ML 250 MG VANTAS 4 LA XERMELO ORAL 4 PA; LA; QL IMPLANT KIT 50 TABLET 250 MG MG (50 MCG/DAY) YERVOY 4 LA VECTIBIX 4 LA INTRAVENOUS INTRAVENOUS SOLUTION 200 SOLUTION 100 MG/40 ML (5 MG/5 ML (20 MG/ML), 50 MG/10 MG/ML), 400 ML (5 MG/ML) MG/20 ML (20 YONDELIS 4 LA MG/ML) INTRAVENOUS VELCADE 4 LA RECON SOLN 1 INJECTION MG RECON SOLN 3.5 ZANOSAR 2 MG INTRAVENOUS VENCLEXTA 4 PA; LA RECON SOLN 1 ORAL TABLET GRAM 100 MG ZEJULA ORAL 4 PA; LA; QL vinblastine 1 CAPSULE 100 MG intravenous solution ZELBORAF ORAL 4 PA; LA; QL 1 mg/ml TABLET 240 MG vincasar pfs 1 ZEVALIN (Y-90) 2 intravenous solution INTRAVENOUS 1 mg/ml, 2 mg/2 ml KIT 3.2 MG/2 ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 28
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ZOLADEX 4 LA carbamazepine oral 1 SUBCUTANEOUS tablet 200 mg IMPLANT 10.8 carbamazepine oral 1 MG, 3.6 MG tablet extended ZOLINZA ORAL 4 PA; LA release 12 hr 100 CAPSULE 100 MG mg, 200 mg, 400 mg ZORTRESS ORAL 4 LA carbamazepine oral 1 TABLET 0.25 MG, tablet,chewable 100 0.5 MG, 0.75 MG mg ZYDELIG ORAL 4 PA; LA; QL CELONTIN ORAL 2 TABLET 100 MG, CAPSULE 300 MG 150 MG clonazepam oral 1 ZYKADIA ORAL 4 PA; LA; QL tablet 0.5 mg, 1 mg, CAPSULE 150 MG 2 mg ZYTIGA ORAL 4 PA; LA; QL clonazepam oral 1 TABLET 250 MG, tablet,disintegrating 500 MG 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg AUTONOMIC & CNS DRUGS, diazepam rectal kit 1 NEUROLOGY & PSYCH 12.5-15-17.5-20 mg, ANTICONVULSANTS 2.5 mg, 5-7.5-10 mg APTIOM ORAL 3 DILANTIN ORAL 2 TABLET 200 MG, CAPSULE 30 MG 400 MG, 600 MG, divalproex oral 1 800 MG capsule, delayed rel BANZEL ORAL 2 sprinkle 125 mg SUSPENSION 40 divalproex oral 1 MG/ML tablet extended BANZEL ORAL 2 release 24 hr 250 TABLET 200 MG, mg, 500 mg 400 MG divalproex oral 1 carbamazepine oral 1 tablet,delayed capsule, er release (dr/ec) 125 multiphase 12 hr mg, 250 mg, 500 mg 100 mg, 200 mg, 300 epitol oral tablet 200 1 mg mg carbamazepine oral 1 ethosuximide oral 1 suspension 100 mg/5 capsule 250 mg ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 29
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ethosuximide oral 1 lamotrigine oral 1 solution 250 mg/5 ml tablet extended release 24hr 100 mg, felbamate oral 1 200 mg, 25 mg, 250 suspension 600 mg/5 mg, 300 mg, 50 mg ml lamotrigine oral 1 felbamate oral tablet 1 tablet, chewable 400 mg, 600 mg dispersible 25 mg, 5 fosphenytoin 1 mg injection solution lamotrigine oral 1 100 mg pe/2 ml, 500 tablet,disintegrating mg pe/10 ml 100 mg, 200 mg, 25 FYCOMPA ORAL 3 mg, 50 mg TABLET 10 MG, 12 lamotrigine oral 1 MG, 2 MG, 4 MG, 6 tablets,dose pack 25 MG, 8 MG mg (35), 25 mg (42) gabapentin oral 1 -100 mg (7), 25 mg capsule 100 mg, 300 (84) -100 mg (14) mg, 400 mg levetiracetam in nacl 1 gabapentin oral 1 (iso-os) intravenous solution 250 mg/5 ml piggyback 1,000 gabapentin oral 1 mg/100 ml, 1,500 tablet 600 mg, 800 mg/100 ml, 500 mg mg/100 ml GABITRIL ORAL 2 levetiracetam 1 TABLET 12 MG, 16 intravenous solution MG 500 mg/5 ml lamotrigine oral 1 levetiracetam oral 1 tablet 100 mg, 150 solution 100 mg/ml, mg, 200 mg, 25 mg 500 mg/5 ml (5 ml) lamotrigine oral 1 levetiracetam oral 1 tablet disintegrating, tablet 1,000 mg, 250 dose pk 25 mg (21) - mg, 500 mg, 750 mg 50 mg (7), 25 levetiracetam oral 1 mg(14)-50 mg (14)- tablet extended 100 mg (7), 50 mg release 24 hr 500 (42) -100 mg (14) mg, 750 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 30
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LYRICA ORAL 2 ST phenytoin sodium 1 CAPSULE 100 MG, extended oral 150 MG, 200 MG, capsule 100 mg, 200 225 MG, 25 MG, mg, 300 mg 300 MG, 50 MG, 75 phenytoin sodium 1 MG intravenous solution LYRICA ORAL 2 ST 50 mg/ml SOLUTION 20 phenytoin sodium 1 MG/ML intravenous syringe ONFI ORAL 2 50 mg/ml SUSPENSION 2.5 primidone oral 1 MG/ML tablet 250 mg, 50 mg ONFI ORAL 2 roweepra oral tablet 1 TABLET 10 MG, 20 1,000 mg, 500 mg, MG 750 mg oxcarbazepine oral 1 SABRIL ORAL 4 LA suspension 300 mg/5 POWDER IN ml (60 mg/ml) PACKET 500 MG oxcarbazepine oral 1 SABRIL ORAL 4 LA tablet 150 mg, 300 TABLET 500 MG mg, 600 mg tiagabine oral tablet 1 PEGANONE ORAL 2 2 mg, 4 mg TABLET 250 MG topiramate oral 1 phenobarbital oral 1 capsule, sprinkle 15 elixir 20 mg/5 ml (4 mg, 25 mg mg/ml) topiramate oral 1 phenobarbital oral 1 tablet 100 mg, 200 tablet 100 mg, 15 mg, 25 mg, 50 mg mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 valproate sodium 1 mg, 97.2 mg intravenous solution 500 mg/5 ml (100 phenytoin oral 1 mg/ml) suspension 125 mg/5 ml valproic acid (as 1 sodium salt) oral phenytoin oral 1 solution 250 mg/5 ml tablet,chewable 50 mg valproic acid oral 1 capsule 250 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 31
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits vigabatrin oral 4 LA carbidopa-levodopa 1 powder in packet oral tablet 10-100 500 mg mg, 25-100 mg, 25- 250 mg VIMPAT 2 INTRAVENOUS carbidopa-levodopa 1 SOLUTION 200 oral tablet extended MG/20 ML release 25-100 mg, 50-200 mg VIMPAT ORAL 2 SOLUTION 10 carbidopa-levodopa 1 MG/ML oral tablet,disintegrating VIMPAT ORAL 2 10-100 mg, 25-100 TABLET 100 MG, mg, 25-250 mg 150 MG, 200 MG, 50 MG carbidopa-levodopa- 1 entacapone oral zonisamide oral 1 tablet 12.5-50-200 capsule 100 mg, 25 mg, 18.75-75-200 mg, 50 mg mg, 25-100-200 mg, ANTIPARKINSONISM AGENTS 31.25-125-200 mg, 37.5-150-200 mg, APOKYN 4 PA; LA; QL 50-200-200 mg SUBCUTANEOUS CARTRIDGE 10 entacapone oral 1 MG/ML tablet 200 mg AZILECT ORAL 3 pramipexole oral 1 TABLET 0.5 MG, 1 tablet 0.125 mg, 0.25 MG mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg benztropine injection 1 solution 2 mg/2 ml pramipexole oral 1 tablet extended benztropine oral 1 release 24 hr 0.375 tablet 0.5 mg, 1 mg, mg, 0.75 mg, 1.5 mg, 2 mg 2.25 mg, 3 mg, 3.75 bromocriptine oral 1 mg, 4.5 mg capsule 5 mg rasagiline oral tablet 1 bromocriptine oral 1 0.5 mg, 1 mg tablet 2.5 mg ropinirole oral tablet 1 carbidopa oral 1 0.25 mg, 0.5 mg, 1 tablet 25 mg mg, 2 mg, 3 mg, 4 mg, 5 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 32
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ropinirole oral tablet 1 isometh-dichloral- 1 extended release 24 acetaminophn oral hr 12 mg, 2 mg, 4 capsule 65-100-325 mg, 6 mg, 8 mg mg selegiline hcl oral 1 isomethepten-caf- 1 capsule 5 mg acetaminophen oral tablet 65-20-325 mg selegiline hcl oral 1 tablet 5 mg migergot rectal 1 suppository 2-100 tolcapone oral tablet 1 mg 100 mg naratriptan oral 1 QL trihexyphenidyl oral 1 tablet 1 mg, 2.5 mg elixir 0.4 mg/ml nodolor oral capsule 1 trihexyphenidyl oral 1 65-100-325 mg tablet 2 mg, 5 mg rizatriptan oral 1 QL MIGRAINE & CLUSTER tablet 10 mg, 5 mg HEADACHE THERAPY rizatriptan oral 1 QL almotriptan malate 1 QL tablet,disintegrating oral tablet 12.5 mg, 10 mg, 5 mg 6.25 mg sumatriptan nasal 1 QL dihydroergotamine 1 spray,non-aerosol injection solution 1 20 mg/actuation, 5 mg/ml mg/actuation dihydroergotamine 1 QL sumatriptan 1 QL nasal spray,non- succinate oral tablet aerosol 0.5 mg/pump 100 mg, 25 mg, 50 act. (4 mg/ml) mg eletriptan hbr oral 1 QL sumatriptan 1 QL tablet 20 mg, 40 mg succinate ERGOMAR 3 subcutaneous SUBLINGUAL cartridge 4 mg/0.5 TABLET 2 MG ml, 6 mg/0.5 ml ergotamine-caffeine 1 sumatriptan 1 QL oral tablet 1-100 mg succinate subcutaneous pen frovatriptan oral 1 QL injector 4 mg/0.5 ml, tablet 2.5 mg 6 mg/0.5 ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 33
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits sumatriptan 1 QL NUEDEXTA ORAL 2 PA succinate CAPSULE 20-10 subcutaneous MG solution 6 mg/0.5 ml RADICAVA 4 PA; LA zolmitriptan oral 1 QL INTRAVENOUS tablet 2.5 mg, 5 mg PIGGYBACK 30 MG/100 ML zolmitriptan oral 1 QL tablet,disintegrating rivastigmine tartrate 1 2.5 mg, 5 mg oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg ZOMIG NASAL 2 ST; QL SPRAY,NON- rivastigmine 1 AEROSOL 2.5 MG, transdermal patch 5 MG 24 hour 13.3 mg/24 hour, 4.6 mg/24 hr, MISCELLANEOUS 9.5 mg/24 hr NEUROLOGICAL THERAPY tetrabenazine oral 4 PA; LA; QL AMPYRA ORAL 4 PA; LA tablet 12.5 mg, 25 TABLET mg EXTENDED RELEASE 12 HR TYSABRI 4 PA; LA 10 MG INTRAVENOUS SOLUTION 300 donepezil oral tablet 1 MG/15 ML 10 mg, 23 mg, 5 mg MUSCLE RELAXANTS & donepezil oral 1
tablet,disintegrating ANTISPASMODIC THERAPY 10 mg, 5 mg baclofen oral tablet 1 10 mg, 20 mg galantamine oral 1 capsule,ext rel. carisoprodol oral 1 pellets 24 hr 16 mg, tablet 250 mg, 350 24 mg, 8 mg mg galantamine oral 1 chlorzoxazone oral 1 solution 4 mg/ml tablet 250 mg, 500 mg galantamine oral 1 tablet 12 mg, 4 mg, 8 cyclobenzaprine oral 1 mg tablet 10 mg, 5 mg, 7.5 mg memantine oral 1 solution 2 mg/ml dantrolene oral 1 capsule 100 mg, 25 memantine oral 1 mg, 50 mg tablet 10 mg, 5 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 34
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits meprobamate oral 1 NARCOTIC ANALGESICS tablet 200 mg, 400 acetaminophen-caff- 1 mg dihydrocod oral MESTINON ORAL 2 capsule 320.5-30-16 SYRUP 60 MG/5 mg ML acetaminophen- 1 metaxall oral tablet 1 codeine oral solution 800 mg 120-12 mg/5 ml metaxalone oral 1 acetaminophen- 1 tablet 400 mg, 800 codeine oral tablet mg 300-15 mg, 300-30 methocarbamol 1 mg, 300-60 mg injection solution ascomp with codeine 1 100 mg/ml oral capsule 30-50- methocarbamol oral 1 325-40 mg tablet 500 mg, 750 astramorph-pf 1 mg injection solution 1 orphenadrine citrate 1 mg/ml injection solution 30 buprenorphine hcl 1 mg/ml injection solution 0.3 orphenadrine citrate 1 mg/ml oral tablet extended buprenorphine hcl 1 release 100 mg injection syringe 0.3 pyridostigmine 1 mg/ml bromide oral tablet buprenorphine hcl 1 60 mg sublingual tablet 2 pyridostigmine 1 mg, 8 mg bromide oral tablet butalbital compound 1 extended release 180 w/codeine oral mg capsule 30-50-325- regonol injection 1 40 mg solution 5 mg/ml butalbital- 1 revonto intravenous 1 acetaminop-caf-cod recon soln 20 mg oral capsule 50-300- 40-30 mg, 50-325- tizanidine oral 1 40-30 mg capsule 2 mg, 4 mg, 6 mg butalbital- 1 acetaminophen oral tizanidine oral tablet 1 tablet 50-300 mg, 2 mg, 4 mg 50-325 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 35
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits butalbital- 1 fentanyl citrate 1 ST; QL acetaminophen-caff buccal lozenge on a oral capsule 50-300- handle 1,200 mcg, 40 mg, 50-325-40 1,600 mcg, 200 mcg, mg 400 mcg, 600 mcg, 800 mcg butalbital- 1 acetaminophen-caff fentanyl citrate- 1 oral tablet 50-325- 0.9%nacl (pf) 40 mg intravenous solution 5 mcg/ml butalbital-aspirin- 1 caffeine oral capsule fentanyl transdermal 1 50-325-40 mg patch 72 hour 100 mcg/hr, 12 mcg/hr, butalbital-aspirin- 1 25 mcg/hr, 50 caffeine oral tablet mcg/hr, 75 mcg/hr 50-325-40 mg hydrocodone- 1 capacet oral capsule 1 acetaminophen oral 50-325-40 mg solution 7.5-325 codeine sulfate oral 1 mg/15 ml tablet 15 mg, 30 mg, hydrocodone- 1 60 mg acetaminophen oral diskets oral 1 tablet 10-300 mg, tablet,soluble 40 mg 10-325 mg, 2.5-325 duramorph (pf) 1 mg, 5-300 mg, 5-325 injection solution 0.5 mg, 7.5-300 mg, 7.5- mg/ml, 1 mg/ml 325 mg EMBEDA ORAL 3 ST; QL hydrocodone- 1 CAPSULE,ORAL ibuprofen oral tablet ONLY,EXT.REL 10-200 mg, 5-200 PELL 100-4 MG, mg, 7.5-200 mg 20-0.8 MG, 30-1.2 hydromorphone (pf) 1 MG, 50-2 MG, 60- injection solution 10 2.4 MG, 80-3.2 MG mg/ml endocet oral tablet 1 hydromorphone in 1 10-325 mg, 2.5-325 0.9 % nacl mg, 5-325 mg, 7.5- intravenous pt 325 mg controlled analgesia fentanyl citrate (pf) 1 syring 15 mg/30 ml intravenous syringe (0.5 mg/ml) 100 mcg/2 ml (50 mcg/ml)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 36
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits hydromorphone 1 marten-tab oral 1 injection solution 1 tablet 50-325 mg mg/ml, 2 mg/ml, 4 meperidine oral 1 mg/ml solution 50 mg/5 ml hydromorphone 1 meperidine oral 1 injection syringe 1 tablet 100 mg, 50 mg mg/ml, 2 mg/ml, 4 mg/ml methadone injection 1 solution 10 mg/ml hydromorphone oral 1 liquid 1 mg/ml methadone oral 1 concentrate 10 hydromorphone oral 1 mg/ml tablet 2 mg, 4 mg, 8 mg methadone oral 1 solution 10 mg/5 ml, hydromorphone oral 1 QL 5 mg/5 ml tablet extended release 24 hr 12 mg, methadone oral 1 16 mg, 32 mg, 8 mg tablet 10 mg, 5 mg hydromorphone 1 methadone oral 1 rectal suppository 3 tablet,soluble 40 mg mg methadose oral 1 HYSINGLA ER 3 ST; QL concentrate 10 ORAL mg/ml TABLET,ORAL methadose oral 1 ONLY,EXT.REL.24 tablet,soluble 40 mg HR 100 MG, 120 MG, 20 MG, 30 morphine (pf) in 0.9 1 MG, 40 MG, 60 % nacl intravenous MG, 80 MG syringe 0.5 mg/ml, 2 mg/2 ml (1 mg/ml) ibuprofen-oxycodone 1 oral tablet 400-5 mg morphine (pf) 1 injection solution 0.5 levorphanol tartrate 1 mg/ml, 1 mg/ml oral tablet 2 mg morphine (pf) 1 lorcet (hydrocodone) 1 intravenous patient oral tablet 5-325 mg control.analgesia lorcet hd oral tablet 1 soln 150 mg/30 ml, 10-325 mg 30 mg/30 ml lorcet plus oral 1 morphine 1 tablet 7.5-325 mg concentrate oral solution 100 mg/5 ml (20 mg/ml) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 37
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits morphine injection 1 morphine oral tablet 1 QL solution 15 mg/ml, 8 extended release 100 mg/ml mg, 15 mg, 200 mg, 30 mg, 60 mg morphine injection 1 syringe 10 mg/ml, 2 morphine rectal 1 mg/ml, 4 mg/ml, 5 suppository 10 mg, mg/ml, 8 mg/ml 20 mg, 30 mg, 5 mg morphine 1 oxycodone oral 1 intravenous capsule 5 mg cartridge 10 mg/ml, oxycodone oral 1 2 mg/ml, 4 mg/ml concentrate 20 morphine 1 mg/ml intravenous pt oxycodone oral 1 controlled analgesia solution 5 mg/5 ml syring 30 mg/30 ml (1 mg/ml) oxycodone oral 1 tablet 10 mg, 15 mg, morphine 1 20 mg, 30 mg, 5 mg intravenous solution 10 mg/ml, 100 mg/4 oxycodone- 1 ml, 25 mg/ml, 250 acetaminophen oral mg/10 ml, 50 mg/ml solution 5-325 mg/5 ml morphine 1 intravenous syringe oxycodone- 1 2 mg/ml, 4 mg/ml acetaminophen oral tablet 10-325 mg, morphine oral 1 QL 2.5-325 mg, 5-325 capsule, er mg, 7.5-325 mg multiphase 24 hr 120 mg, 30 mg, 45 oxycodone-aspirin 1 mg, 60 mg, 75 mg, oral tablet 4.8355- 90 mg 325 mg morphine oral 1 QL OXYCONTIN 3 ST; QL capsule,extend.relea ORAL se pellets 10 mg, 100 TABLET,ORAL mg, 20 mg, 30 mg, ONLY,EXT.REL.12 50 mg, 60 mg, 80 mg HR 10 MG, 15 MG, 20 MG, 30 MG, 40 morphine oral 1 MG, 60 MG, 80 MG solution 10 mg/5 ml, 20 mg/5 ml (4 oxymorphone oral 1 mg/ml) tablet 10 mg, 5 mg morphine oral tablet 1 15 mg, 30 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 38
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits oxymorphone oral 1 QL aspir-low oral 5 ACA; OTC tablet extended tablet,delayed release 12 hr 10 mg, release (dr/ec) 81 15 mg, 20 mg, 30 mg mg, 40 mg, 5 mg, 7.5 aspir-trin oral 5 ACA; OTC mg tablet,delayed tencon oral tablet 1 release (dr/ec) 325 50-325 mg mg verdrocet oral tablet 1 bayer aspirin oral 5 ACA; OTC 2.5-325 mg tablet 325 mg vicodin es oral tablet 1 BAYER 5 ACA; OTC 7.5-300 mg CHEWABLE ASPIRIN ORAL vicodin hp oral 1 TABLET,CHEWAB tablet 10-300 mg LE 81 MG vicodin oral tablet 5- 1 buprenorphine- 1 QL 300 mg naloxone sublingual xylon 10 oral tablet 1 tablet 2-0.5 mg, 8-2 10-200 mg mg zebutal oral capsule 1 butorphanol tartrate 1 50-325-40 mg injection solution 1 mg/ml, 2 mg/ml NON-NARCOTIC ANALGESICS butorphanol tartrate 1 QL aspir-81 oral 5 ACA; OTC nasal spray,non- tablet,delayed aerosol 10 mg/ml release (dr/ec) 81 mg celecoxib oral 1 capsule 100 mg, 200 aspirin low dose 5 ACA; OTC mg, 400 mg, 50 mg oral tablet,delayed release (dr/ec) 81 children's aspirin 5 ACA; OTC mg oral tablet,chewable 81 mg aspirin oral tablet 5 ACA; OTC 325 mg choline,magnesium 1 salicylate oral liquid aspirin oral 5 ACA; OTC 500 mg/5 ml tablet,chewable 81 mg diclofenac potassium 1 oral tablet 50 mg aspirin oral 5 ACA; OTC tablet,delayed diclofenac sodium 1 release (dr/ec) 325 oral tablet extended mg, 81 mg release 24 hr 100 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 39
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits diclofenac sodium 1 flurbiprofen oral 1 oral tablet,delayed tablet 100 mg, 50 mg release (dr/ec) 25 ibuprofen oral 1 mg, 50 mg, 75 mg suspension 100 mg/5 diclofenac sodium 1 QL ml topical drops 1.5 % ibuprofen oral tablet 1 diclofenac sodium 1 ST; QL 400 mg, 600 mg, 800 topical gel 1 % mg diclofenac- 1 indomethacin oral 1 misoprostol oral capsule 25 mg, 50 tablet,ir,delayed mg rel,biphasic 50-200 indomethacin oral 1 mg-mcg, 75-200 mg- capsule, extended mcg release 75 mg diflunisal oral tablet 1 ketoprofen oral 1 500 mg capsule 50 mg, 75 e.c. prin oral 5 ACA; OTC mg tablet,delayed ketoprofen oral 1 release (dr/ec) 325 capsule,ext rel. mg pellets 24 hr 200 mg ecotrin low strength 5 ACA; OTC ketorolac injection 1 oral tablet,delayed cartridge 15 mg/ml, release (dr/ec) 81 30 mg/ml mg ketorolac injection 1 ecotrin oral 5 ACA; OTC solution 15 mg/ml, tablet,delayed 30 mg/ml, 30 mg/ml release (dr/ec) 325 (1 ml) mg ketorolac injection 1 etodolac oral 1 syringe 15 mg/ml, 30 capsule 200 mg, 300 mg/ml mg ketorolac 1 etodolac oral tablet 1 intramuscular 400 mg, 500 mg solution 60 mg/2 ml etodolac oral tablet 1 ketorolac 1 extended release 24 intramuscular hr 400 mg, 500 mg, syringe 60 mg/2 ml 600 mg ketorolac oral tablet 1 QL fenoprofen oral 1 10 mg tablet 600 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 40
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lite coat aspirin oral 5 ACA; OTC naproxen sodium 1 tablet 325 mg oral tablet 275 mg, 550 mg meclofenamate oral 1 capsule 100 mg, 50 naproxen sodium 1 mg oral tablet, er multiphase 24 hr mefenamic acid oral 1 375 mg, 500 mg capsule 250 mg NARCAN NASAL 2 QL meloxicam oral 1 SPRAY,NON- suspension 7.5 mg/5 AEROSOL 4 ml MG/ACTUATION meloxicam oral 1 NUCYNTA ER 3 ST; QL tablet 15 mg ORAL TABLET meloxicam oral 1 QL EXTENDED tablet 7.5 mg RELEASE 12 HR nabumetone oral 1 100 MG, 150 MG, tablet 500 mg, 750 200 MG, 250 MG, mg 50 MG nalbuphine injection 1 NUCYNTA ORAL 3 QL solution 10 mg/ml, TABLET 100 MG, 20 mg/ml 50 MG, 75 MG naloxone injection 1 oxaprozin oral tablet 1 solution 0.4 mg/ml 600 mg naloxone injection 1 piroxicam oral 1 syringe 0.4 mg/ml, 1 capsule 10 mg, 20 mg/ml mg naltrexone oral 1 salsalate oral tablet 1 tablet 50 mg 500 mg, 750 mg naproxen oral 1 SUBOXONE 2 QL suspension 125 mg/5 SUBLINGUAL ml FILM 12-3 MG, 2- 0.5 MG, 4-1 MG, 8- naproxen oral tablet 1 2 MG 250 mg, 375 mg, 500 mg sulindac oral tablet 1 150 mg, 200 mg naproxen oral 1 tablet,delayed tolmetin oral capsule 1 release (dr/ec) 375 400 mg mg, 500 mg tolmetin oral tablet 1 200 mg, 600 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 41
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits tramadol oral tablet 1 QL alprazolam intensol 1 50 mg oral concentrate 1 mg/ml tramadol oral tablet 1 QL extended release 24 alprazolam oral 1 hr 100 mg, 200 mg, tablet 0.25 mg, 0.5 300 mg mg, 1 mg, 2 mg tramadol oral tablet, 1 alprazolam oral 1 er multiphase 24 hr tablet extended 100 mg, 200 mg, 300 release 24 hr 0.5 mg, mg 1 mg, 2 mg, 3 mg tramadol- 1 QL alprazolam oral 1 acetaminophen oral tablet,disintegrating tablet 37.5-325 mg 0.25 mg, 0.5 mg, 1 mg, 2 mg ZUBSOLV 2 QL SUBLINGUAL amitriptyline oral 1 TABLET 0.7-0.18 tablet 10 mg, 100 MG, 1.4-0.36 MG, mg, 150 mg, 25 mg, 11.4-2.9 MG, 2.9- 50 mg, 75 mg 0.71 MG, 5.7-1.4 amitriptyline- 1 MG, 8.6-2.1 MG chlordiazepoxide PSYCHOTHERAPEUTIC DRUGS oral tablet 12.5-5 mg, 25-10 mg ABILIFY 2 MAINTENA amoxapine oral 1 INTRAMUSCULA tablet 100 mg, 150 R mg, 25 mg, 50 mg SUSPENSION,EXT aripiprazole oral 1 ENDED REL solution 1 mg/ml RECON 300 MG, 400 MG aripiprazole oral 1 QL tablet 10 mg, 15 mg, ABILIFY 2 2 mg, 20 mg, 30 mg, MAINTENA 5 mg INTRAMUSCULA R aripiprazole oral 1 QL SUSPENSION,EXT tablet,disintegrating ENDED REL 10 mg, 15 mg SYRING 300 MG, 400 MG ADDYI ORAL 3 PA TABLET 100 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 42
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ARISTADA 2 chlorpromazine oral 1 INTRAMUSCULA tablet 10 mg, 100 R mg, 200 mg, 25 mg, SUSPENSION,EXT 50 mg ENDED REL citalopram oral 1 SYRING 1,064 solution 10 mg/5 ml MG/3.9 ML, 441 MG/1.6 ML, 662 citalopram oral 1 QL MG/2.4 ML, 882 tablet 10 mg, 20 mg, MG/3.2 ML 40 mg armodafinil oral 1 PA; QL clomipramine oral 1 tablet 150 mg, 200 capsule 25 mg, 50 mg, 250 mg, 50 mg mg, 75 mg atomoxetine oral 1 clonidine hcl oral 1 capsule 10 mg, 100 tablet extended mg, 18 mg, 25 mg, release 12 hr 0.1 mg 40 mg, 60 mg, 80 mg clorazepate 1 BELSOMRA ORAL 3 ST; QL dipotassium oral TABLET 10 MG, 15 tablet 15 mg, 3.75 MG, 20 MG, 5 MG mg, 7.5 mg bupropion hcl oral 1 clozapine oral tablet 1 tablet 100 mg, 75 mg 100 mg, 200 mg, 25 mg, 50 mg bupropion hcl oral 1 QL tablet extended clozapine oral 1 release 12 hr 100 tablet,disintegrating mg, 150 mg, 200 mg 100 mg, 12.5 mg, 25 mg bupropion hcl oral 1 QL tablet extended desipramine oral 1 release 24 hr 150 tablet 10 mg, 100 mg, 300 mg mg, 150 mg, 25 mg, 50 mg, 75 mg buspirone oral tablet 1 10 mg, 15 mg, 30 desvenlafaxine 1 QL mg, 5 mg, 7.5 mg succinate oral tablet extended release 24 chlordiazepoxide hcl 1 hr 100 mg, 25 mg, oral capsule 10 mg, 50 mg 25 mg, 5 mg chlorpromazine 1 injection solution 25 mg/ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 43
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits dexmethylphenidate 1 diazepam oral tablet 1 oral capsule,er 10 mg, 2 mg, 5 mg biphasic 50-50 10 doxepin oral capsule 1 mg, 15 mg, 20 mg, 10 mg, 100 mg, 150 25 mg, 30 mg, 35 mg, 25 mg, 50 mg, mg, 40 mg, 5 mg 75 mg dexmethylphenidate 1 doxepin oral 1 oral tablet 10 mg, concentrate 10 2.5 mg, 5 mg mg/ml dextroamphetamine 1 duloxetine oral 1 QL oral capsule, capsule,delayed extended release 10 release(dr/ec) 20 mg, 15 mg, 5 mg mg, 30 mg, 40 mg, dextroamphetamine 1 60 mg oral solution 5 mg/5 EMSAM 3 ml TRANSDERMAL dextroamphetamine 1 PATCH 24 HOUR oral tablet 10 mg, 5 12 MG/24 HR, 6 mg MG/24 HR, 9 MG/24 HR dextroamphetamine- 1 amphetamine oral ergoloid oral tablet 1 capsule,extended 1 mg release 24hr 10 mg, escitalopram oxalate 1 15 mg, 20 mg, 25 oral solution 5 mg/5 mg, 30 mg, 5 mg ml dextroamphetamine- 1 escitalopram oxalate 1 QL amphetamine oral oral tablet 10 mg, 20 tablet 10 mg, 12.5 mg, 5 mg mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg estazolam oral tablet 1 1 mg, 2 mg diazepam injection 1 solution 5 mg/ml eszopiclone oral 1 QL tablet 1 mg, 2 mg, 3 diazepam injection 1 mg syringe 5 mg/ml FANAPT ORAL 3 QL diazepam intensol 1 TABLET 1 MG, 10 oral concentrate 5 MG, 12 MG, 2 MG, mg/ml 4 MG, 6 MG, 8 MG diazepam oral 1 solution 5 mg/5 ml (1 mg/ml)
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FANAPT ORAL 3 QL fluphenazine hcl oral 1 TABLETS,DOSE concentrate 5 mg/ml PACK 1MG(2)- fluphenazine hcl oral 1 2MG(2)- 4MG(2)- elixir 2.5 mg/5 ml 6MG(2) fluphenazine hcl oral 1 FETZIMA ORAL 3 ST; QL tablet 1 mg, 10 mg, CAPSULE,EXT 2.5 mg, 5 mg REL 24HR DOSE PACK 20 MG (2)- flurazepam oral 1 40 MG (26) capsule 15 mg, 30 mg FETZIMA ORAL 3 ST; QL CAPSULE,EXTEN fluvoxamine oral 1 QL DED RELEASE 24 capsule,extended HR 120 MG, 20 release 24hr 100 mg, MG, 40 MG, 80 MG 150 mg flumazenil 1 fluvoxamine oral 1 QL intravenous solution tablet 100 mg, 25 0.1 mg/ml mg, 50 mg fluoxetine oral 1 QL guanfacine oral 1 capsule 10 mg, 40 tablet extended mg release 24 hr 1 mg, 2 mg, 3 mg, 4 mg fluoxetine oral 1 capsule 20 mg guanidine oral tablet 1 125 mg fluoxetine oral 1 QL capsule,delayed haloperidol 1 release(dr/ec) 90 mg decanoate intramuscular fluoxetine oral 1 solution 100 mg/ml, solution 20 mg/5 ml 50 mg/ml (4 mg/ml) haloperidol lactate 1 fluoxetine oral tablet 1 QL injection solution 5 10 mg mg/ml fluoxetine oral tablet 1 haloperidol lactate 1 20 mg oral concentrate 2 fluphenazine 1 mg/ml decanoate injection haloperidol oral 1 solution 25 mg/ml tablet 0.5 mg, 1 mg, fluphenazine hcl 1 10 mg, 2 mg, 20 mg, injection solution 2.5 5 mg mg/ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 45
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits imipramine hcl oral 1 metadate er oral 1 tablet 10 mg, 25 mg, tablet extended 50 mg release 20 mg imipramine pamoate 1 methamphetamine 1 oral capsule 100 mg, oral tablet 5 mg 125 mg, 150 mg, 75 methylphenidate hcl 1 mg oral capsule, er LATUDA ORAL 3 QL biphasic 30-70 10 TABLET 120 MG, mg, 20 mg, 30 mg, 20 MG, 40 MG, 60 40 mg, 50 mg, 60 mg MG, 80 MG methylphenidate hcl 1 lithium carbonate 1 oral capsule,er oral capsule 150 mg, biphasic 50-50 20 300 mg, 600 mg mg, 30 mg, 40 mg, 60 mg lithium carbonate 1 oral tablet 300 mg methylphenidate hcl 1 oral solution 10 lithium carbonate 1 mg/5 ml, 5 mg/5 ml oral tablet extended release 300 mg, 450 methylphenidate hcl 1 mg oral tablet 10 mg, 20 mg, 5 mg lithium citrate oral 1 solution 8 meq/5 ml methylphenidate hcl 1 oral tablet extended lorazepam intensol 1 release 10 mg, 20 oral concentrate 2 mg mg/ml methylphenidate hcl 1 lorazepam oral 1 oral tablet extended concentrate 2 mg/ml release 24hr 18 mg, lorazepam oral 1 27 mg, 36 mg, 54 mg tablet 0.5 mg, 1 mg, methylphenidate hcl 1 2 mg oral tablet,chewable loxapine succinate 1 10 mg, 2.5 mg, 5 mg oral capsule 10 mg, midazolam oral 1 25 mg, 5 mg, 50 mg syrup 2 mg/ml maprotiline oral 1 mirtazapine oral 1 tablet 25 mg, 50 mg, tablet 15 mg, 30 mg, 75 mg 45 mg, 7.5 mg MARPLAN ORAL 3 mirtazapine oral 1 TABLET 10 MG tablet,disintegrating 15 mg, 30 mg, 45 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 46
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits modafinil oral tablet 1 PA; QL paroxetine hcl oral 1 QL 100 mg, 200 mg tablet extended release 24 hr 12.5 nefazodone oral 1 mg, 25 mg, 37.5 mg tablet 100 mg, 150 mg, 200 mg, 250 mg, paroxetine mesylate 1 QL 50 mg oral capsule 7.5 mg nortriptyline oral 1 perphenazine oral 1 capsule 10 mg, 25 tablet 16 mg, 2 mg, 4 mg, 50 mg, 75 mg mg, 8 mg nortriptyline oral 1 perphenazine- 1 solution 10 mg/5 ml amitriptyline oral tablet 2-10 mg, 2-25 olanzapine 1 mg, 4-10 mg, 4-25 intramuscular recon mg, 4-50 mg soln 10 mg phenelzine oral 1 olanzapine oral 1 QL tablet 15 mg tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, pimozide oral tablet 1 7.5 mg 1 mg, 2 mg olanzapine oral 1 QL procentra oral 1 tablet,disintegrating solution 5 mg/5 ml 10 mg, 15 mg, 20 protriptyline oral 1 mg, 5 mg tablet 10 mg, 5 mg olanzapine- 1 quazepam oral tablet 1 fluoxetine oral 15 mg capsule 12-25 mg, 12-50 mg, 3-25 mg, quetiapine oral 1 QL 6-25 mg, 6-50 mg tablet 100 mg, 200 mg, 25 mg, 300 mg, oxazepam oral 1 400 mg, 50 mg capsule 10 mg, 15 mg, 30 mg quetiapine oral 1 QL tablet extended paliperidone oral 1 QL release 24 hr 150 tablet extended mg, 200 mg, 300 mg, release 24hr 1.5 mg, 400 mg, 50 mg 3 mg, 6 mg, 9 mg REXULTI ORAL 3 QL paroxetine hcl oral 1 QL TABLET 0.25 MG, tablet 10 mg, 20 mg, 0.5 MG, 1 MG, 2 30 mg, 40 mg MG, 3 MG, 4 MG
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits RISPERDAL 2 thiothixene oral 1 CONSTA capsule 1 mg, 10 mg, INTRAMUSCULA 2 mg, 5 mg R SYRINGE 12.5 tranylcypromine 1 MG/2 ML, 25 MG/2 oral tablet 10 mg ML, 37.5 MG/2 ML, 50 MG/2 ML trazodone oral tablet 1 100 mg, 150 mg, 300 risperidone oral 1 mg, 50 mg solution 1 mg/ml triazolam oral tablet 1 risperidone oral 1 QL 0.125 mg, 0.25 mg tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 trifluoperazine oral 1 mg, 4 mg tablet 1 mg, 10 mg, 2 mg, 5 mg risperidone oral 1 QL tablet,disintegrating trimipramine oral 1 0.25 mg, 0.5 mg, 1 capsule 100 mg, 25 mg, 2 mg, 3 mg, 4 mg, 50 mg mg TRINTELLIX 3 ST; QL ROZEREM ORAL 2 ST; QL ORAL TABLET 10 TABLET 8 MG MG, 20 MG, 5 MG SAPHRIS (BLACK 3 QL venlafaxine oral 1 QL CHERRY) capsule,extended SUBLINGUAL release 24hr 150 mg, TABLET 10 MG, 37.5 mg, 75 mg 2.5 MG, 5 MG venlafaxine oral 1 QL seconal sodium oral 1 QL tablet 100 mg, 25 capsule 100 mg mg, 37.5 mg, 50 mg, 75 mg sertraline oral 1 concentrate 20 venlafaxine oral 1 QL mg/ml tablet extended release 24hr 150 mg, sertraline oral tablet 1 QL 225 mg, 37.5 mg, 75 100 mg, 25 mg, 50 mg mg VIIBRYD ORAL 3 ST; QL temazepam oral 1 TABLET 10 MG, 20 capsule 15 mg, 22.5 MG, 40 MG mg, 30 mg, 7.5 mg VIIBRYD ORAL 3 ST; QL thioridazine oral 1 TABLETS,DOSE tablet 10 mg, 100 PACK 10 MG (7)- mg, 25 mg, 50 mg 20 MG (23)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 48
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VYVANSE ORAL 2 ST dofetilide oral 1 CAPSULE 10 MG, capsule 125 mcg, 20 MG, 30 MG, 40 250 mcg, 500 mcg MG, 50 MG, 60 flecainide oral tablet 1 MG, 70 MG 100 mg, 150 mg, 50 VYVANSE ORAL 2 ST mg TABLET,CHEWAB mexiletine oral 1 LE 10 MG, 20 MG, capsule 150 mg, 200 30 MG, 40 MG, 50 mg, 250 mg MG, 60 MG MULTAQ ORAL 3 XYREM ORAL 4 PA; LA TABLET 400 MG SOLUTION 500 MG/ML pacerone oral tablet 1 100 mg, 200 mg, 400 zaleplon oral 1 QL mg capsule 10 mg, 5 mg procainamide 1 zenzedi oral tablet 1 injection solution 10 mg, 5 mg 100 mg/ml, 500 ziprasidone hcl oral 1 QL mg/ml capsule 20 mg, 40 propafenone oral 1 mg, 60 mg, 80 mg capsule,extended zolpidem oral tablet 1 QL release 12 hr 225 10 mg, 5 mg mg, 325 mg, 425 mg zolpidem oral 1 QL propafenone oral 1 tablet,ext release tablet 150 mg, 225 multiphase 12.5 mg, mg, 300 mg 6.25 mg quinidine gluconate 1 zolpidem sublingual 1 QL injection solution 80 tablet 1.75 mg, 3.5 mg/ml mg quinidine gluconate 1 CARDIOVASCULAR, oral tablet extended release 324 mg HYPERTENSION & LIPIDS quinidine sulfate 1
ANTIARRHYTHMIC AGENTS oral tablet 200 mg, amiodarone oral 1 300 mg tablet 100 mg, 200 sotalol af oral tablet 1 mg, 400 mg 120 mg, 160 mg, 80 disopyramide 1 mg phosphate oral capsule 100 mg, 150 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 49
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits sotalol oral tablet 1 amlodipine- 1 120 mg, 160 mg, 240 valsartan-hcthiazid mg, 80 mg oral tablet 10-160- 12.5 mg, 10-160-25 SOTYLIZE ORAL 2 mg, 10-320-25 mg, SOLUTION 5 5-160-12.5 mg, 5- MG/ML 160-25 mg
ANTIHYPERTENSIVE THERAPY atenolol oral tablet 1 acebutolol oral 1 100 mg, 25 mg, 50 capsule 200 mg, 400 mg mg atenolol- 1 afeditab cr oral 1 chlorthalidone oral tablet extended tablet 100-25 mg, release 30 mg, 60 50-25 mg mg benazepril oral 1 amiloride oral tablet 1 tablet 10 mg, 20 mg, 5 mg 40 mg, 5 mg amiloride- 1 benazepril- 1 hydrochlorothiazide hydrochlorothiazide oral tablet 5-50 mg oral tablet 10-12.5 mg, 20-12.5 mg, 20- amlodipine oral 1 25 mg, 5-6.25 mg tablet 10 mg, 2.5 mg, 5 mg betaxolol oral tablet 1 10 mg, 20 mg amlodipine- 1 benazepril oral bisoprolol fumarate 1 capsule 10-20 mg, oral tablet 10 mg, 5 10-40 mg, 2.5-10 mg mg, 5-10 mg, 5-20 bisoprolol- 1 mg, 5-40 mg hydrochlorothiazide amlodipine- 1 oral tablet 10-6.25 olmesartan oral mg, 2.5-6.25 mg, 5- tablet 10-20 mg, 10- 6.25 mg 40 mg, 5-20 mg, 5- bumetanide injection 1 40 mg solution 0.25 mg/ml amlodipine- 1 bumetanide oral 1 valsartan oral tablet tablet 0.5 mg, 1 mg, 10-160 mg, 10-320 2 mg mg, 5-160 mg, 5-320 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 50
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BYSTOLIC ORAL 3 ST clonidine 1 QL TABLET 10 MG, transdermal patch 2.5 MG, 20 MG, 5 weekly 0.1 mg/24 hr, MG 0.2 mg/24 hr, 0.3 mg/24 hr candesartan oral 1 tablet 16 mg, 32 mg, clorpres oral tablet 1 4 mg, 8 mg 0.1-15 mg, 0.2-15 mg candesartan- 1 hydrochlorothiazid DEMSER ORAL 2 oral tablet 16-12.5 CAPSULE 250 MG mg, 32-12.5 mg, 32- diltiazem hcl oral 1 25 mg capsule,ext.rel 24h captopril oral tablet 1 degradable 240 mg 100 mg, 12.5 mg, 25 diltiazem hcl oral 1 mg, 50 mg capsule,extended captopril- 1 release 12 hr 120 hydrochlorothiazide mg, 60 mg, 90 mg oral tablet 25-15 mg, diltiazem hcl oral 1 25-25 mg, 50-15 mg, capsule,extended 50-25 mg release 24 hr 240 cartia xt oral 1 mg, 420 mg capsule,extended diltiazem hcl oral 1 release 24hr 120 mg, capsule,extended 180 mg, 240 mg, 300 release 24hr 120 mg, mg 180 mg, 240 mg, 300 carvedilol oral tablet 1 mg, 360 mg 12.5 mg, 25 mg, diltiazem hcl oral 1 3.125 mg, 6.25 mg tablet 120 mg, 30 chlorothiazide oral 1 mg, 60 mg, 90 mg tablet 250 mg, 500 diltiazem hcl oral 1 mg tablet extended chlorothiazide 1 release 24 hr 180 sodium intravenous mg, 240 mg, 300 mg, recon soln 500 mg 360 mg chlorthalidone oral 1 dilt-xr oral 1 tablet 25 mg, 50 mg capsule,ext.rel 24h degradable 120 mg, clonidine hcl oral 1 180 mg, 240 mg tablet 0.1 mg, 0.2 mg, 0.3 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 51
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits doxazosin oral tablet 1 QL ethacrynate sodium 1 1 mg, 2 mg, 4 mg, 8 intravenous recon mg soln 50 mg DUTOPROL ORAL 2 ST ethacrynic acid oral 1 TABLET tablet 25 mg EXTENDED felodipine oral tablet 1 RELEASE 24 HR extended release 24 100-12.5 MG, 25- hr 10 mg, 2.5 mg, 5 12.5 MG, 50-12.5 mg MG fosinopril oral tablet 1 DYRENIUM ORAL 3 10 mg, 20 mg, 40 mg CAPSULE 100 MG, 50 MG fosinopril- 1 hydrochlorothiazide EDARBI ORAL 3 ST oral tablet 10-12.5 TABLET 40 MG, 80 mg, 20-12.5 mg MG furosemide injection 1 EDARBYCLOR 3 ST solution 10 mg/ml ORAL TABLET 40- 12.5 MG, 40-25 MG furosemide injection 1 syringe 10 mg/ml enalapril maleate 1 oral tablet 10 mg, furosemide oral 1 2.5 mg, 20 mg, 5 mg solution 10 mg/ml, 40 mg/5 ml (8 enalaprilat 1 mg/ml) intravenous solution 1.25 mg/ml furosemide oral 1 tablet 20 mg, 40 mg, enalapril- 1 80 mg hydrochlorothiazide oral tablet 10-25 mg, guanfacine oral 1 5-12.5 mg tablet 1 mg, 2 mg eplerenone oral 1 HEMANGEOL 4 LA tablet 25 mg, 50 mg ORAL SOLUTION 4.28 MG/ML epoprostenol 4 PA; LA (glycine) hydralazine injection 1 intravenous recon solution 20 mg/ml soln 0.5 mg, 1.5 mg hydralazine oral 1 eprosartan oral 1 tablet 10 mg, 100 tablet 600 mg mg, 25 mg, 50 mg esmolol intravenous 1 hydrochlorothiazide 1 solution 100 mg/10 oral capsule 12.5 mg ml (10 mg/ml) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 52
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits hydrochlorothiazide 1 losartan- 1 oral tablet 12.5 mg, hydrochlorothiazide 25 mg, 50 mg oral tablet 100-12.5 mg, 100-25 mg, 50- indapamide oral 1 12.5 mg tablet 1.25 mg, 2.5 mg matzim la oral tablet 1 extended release 24 irbesartan oral 1 hr 180 mg, 240 mg, tablet 150 mg, 300 300 mg, 360 mg, 420 mg, 75 mg mg irbesartan- 1 methyclothiazide 1 hydrochlorothiazide oral tablet 5 mg oral tablet 150-12.5 mg, 300-12.5 mg methyldopa oral 1 tablet 250 mg, 500 isradipine oral 1 mg capsule 2.5 mg, 5 mg methyldopa- 1 labetalol 1 hydrochlorothiazide intravenous solution oral tablet 250-15 5 mg/ml mg, 250-25 mg labetalol 1 methyldopate 1 intravenous syringe intravenous solution 20 mg/4 ml (5 250 mg/5 ml mg/ml) metolazone oral 1 labetalol oral tablet 1 tablet 10 mg, 2.5 mg, 100 mg, 200 mg, 300 5 mg mg metoprolol succinate 1 LEVATOL ORAL 3 ST oral tablet extended TABLET 20 MG release 24 hr 100 lisinopril oral tablet 1 mg, 200 mg, 25 mg, 10 mg, 2.5 mg, 20 50 mg mg, 30 mg, 40 mg, 5 metoprolol ta- 1 mg hydrochlorothiaz lisinopril- 1 oral tablet 100-25 hydrochlorothiazide mg, 100-50 mg, 50- oral tablet 10-12.5 25 mg mg, 20-12.5 mg, 20- metoprolol tartrate 1 25 mg intravenous solution losartan oral tablet 1 5 mg/5 ml 100 mg, 25 mg, 50 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 53
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits metoprolol tartrate 1 nisoldipine oral 1 intravenous syringe tablet extended 5 mg/5 ml release 24 hr 17 mg, 20 mg, 25.5 mg, 30 metoprolol tartrate 1 mg, 34 mg, 40 mg, oral tablet 100 mg, 8.5 mg 25 mg, 37.5 mg, 50 mg, 75 mg olmesartan oral 1 tablet 20 mg, 40 mg, minoxidil oral tablet 1 5 mg 10 mg, 2.5 mg olmesartan- 1 moexipril oral tablet 1 amlodipin-hcthiazid 15 mg, 7.5 mg oral tablet 20-5-12.5 moexipril- 1 mg, 40-10-12.5 mg, hydrochlorothiazide 40-10-25 mg, 40-5- oral tablet 15-12.5 12.5 mg, 40-5-25 mg mg, 15-25 mg, 7.5- olmesartan- 1 12.5 mg hydrochlorothiazide nadolol oral tablet 1 oral tablet 20-12.5 20 mg, 40 mg, 80 mg mg, 40-12.5 mg, 40- nadolol- 1 25 mg bendroflumethiazide ORENITRAM 4 PA; LA oral tablet 40-5 mg, ORAL TABLET 80-5 mg EXTENDED nicardipine 1 RELEASE 0.125 intravenous solution MG, 0.25 MG, 1 25 mg/10 ml MG, 2.5 MG, 5 MG nicardipine oral 1 papaverine injection 1 capsule 20 mg, 30 solution 30 mg/ml mg perindopril 1 nifedipine oral tablet 1 erbumine oral tablet extended release 2 mg, 4 mg, 8 mg 24hr 30 mg, 60 mg, phenoxybenzamine 1 90 mg oral capsule 10 mg nifedipine oral tablet 1 phentolamine 1 extended release 30 injection recon soln mg, 60 mg, 90 mg 5 mg nimodipine oral 1 pindolol oral tablet 1 capsule 30 mg 10 mg, 5 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 54
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits prazosin oral 1 spironolactone oral 1 capsule 1 mg, 2 mg, tablet 100 mg, 25 5 mg mg, 50 mg propranolol 1 spironolacton- 1 intravenous solution hydrochlorothiaz 1 mg/ml oral tablet 25-25 mg propranolol oral 1 taztia xt oral 1 capsule,extended capsule,extended release 24 hr 120 release 24 hr 120 mg, 160 mg, 60 mg, mg, 180 mg, 240 mg, 80 mg 300 mg, 360 mg propranolol oral 1 TEKTURNA HCT 3 solution 20 mg/5 ml ORAL TABLET (4 mg/ml), 40 mg/5 150-12.5 MG, 150- ml (8 mg/ml) 25 MG, 300-12.5 MG, 300-25 MG propranolol oral 1 tablet 10 mg, 20 mg, TEKTURNA ORAL 3 40 mg, 60 mg, 80 mg TABLET 150 MG, 300 MG propranolol- 1 hydrochlorothiazid telmisartan oral 1 oral tablet 40-25 mg, tablet 20 mg, 40 mg, 80-25 mg 80 mg quinapril oral tablet 1 telmisartan- 1 10 mg, 20 mg, 40 amlodipine oral mg, 5 mg tablet 40-10 mg, 40- 5 mg, 80-10 mg, 80- quinapril- 1 5 mg hydrochlorothiazide oral tablet 10-12.5 telmisartan- 1 mg, 20-12.5 mg, 20- hydrochlorothiazid 25 mg oral tablet 40-12.5 mg, 80-12.5 mg, 80- ramipril oral 1 25 mg capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg terazosin oral 1 QL capsule 1 mg, 10 mg, REMODULIN 4 PA; LA 2 mg, 5 mg INJECTION SOLUTION 1 timolol maleate oral 1 MG/ML, 10 tablet 10 mg, 20 mg, MG/ML, 2.5 5 mg MG/ML, 5 MG/ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 55
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits torsemide oral tablet 1 veletri intravenous 4 PA; LA 10 mg, 100 mg, 20 recon soln 0.5 mg, mg, 5 mg 1.5 mg trandolapril oral 1 verapamil 1 tablet 1 mg, 2 mg, 4 intravenous solution mg 2.5 mg/ml trandolapril- 1 verapamil 1 verapamil oral intravenous syringe tablet, ir - er, 2.5 mg/ml biphasic 24hr 1-240 verapamil oral 1 mg, 2-180 mg, 2-240 capsule, 24 hr er mg, 4-240 mg pellet ct 100 mg, 200 triamterene- 1 mg, 300 mg hydrochlorothiazid verapamil oral 1 oral capsule 37.5-25 capsule,ext rel. mg, 50-25 mg pellets 24 hr 120 mg, triamterene- 1 180 mg, 240 mg, 360 hydrochlorothiazid mg oral tablet 37.5-25 verapamil oral tablet 1 mg, 75-50 mg 120 mg, 40 mg, 80 UPTRAVI ORAL 4 PA; LA mg TABLET 1,000 verapamil oral tablet 1 MCG, 1,200 MCG, extended release 120 1,400 MCG, 1,600 mg, 180 mg, 240 mg MCG, 200 MCG, 400 MCG, 600 CARDIAC GLYCOSIDES MCG, 800 MCG digitek oral tablet 1 UPTRAVI ORAL 4 PA; LA 125 mcg, 250 mcg TABLETS,DOSE digox oral tablet 125 1 PACK 200 MCG mcg, 250 mcg (140)- 800 MCG (60) digoxin injection 1 solution 250 mcg/ml valsartan oral tablet 1 160 mg, 320 mg, 40 digoxin injection 1 mg, 80 mg syringe 250 mcg/ml valsartan- 1 digoxin oral solution 1 hydrochlorothiazide 50 mcg/ml oral tablet 160-12.5 digoxin oral tablet 1 mg, 160-25 mg, 320- 125 mcg, 250 mcg 12.5 mg, 320-25 mg, 80-12.5 mg COAGULATION THERAPY
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 56
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ADVATE 4 LA ALPHANATE 4 LA INTRAVENOUS INTRAVENOUS RECON SOLN RECON SOLN 1,000 (+/-) UNIT, 1,000 (400 VWF) 1,500 (+/-) UNIT, UNIT/10 ML, 1,500 2,000 (+/-) UNIT, (600 VWF) 250 (+/-) UNIT, UNIT/10 ML, 2,000 3,000 (+/-) UNIT, (800 VWF) 4,000 (+/-) UNIT, UNIT/10 ML, 250 500 (+/-) UNIT (100 VWF) UNIT/5 ML, 500 (200 VWF) ADYNOVATE 4 LA UNIT/5 ML INTRAVENOUS SOLUTION 1,000 ALPROLIX 4 LA (+/-) UNIT, 1,500 INTRAVENOUS (+/-) UNIT, 2,000 RECON SOLN (+/-) UNIT, 250 (+/- 1,000 UNIT, 2,000 ) UNIT, 3,000 (+/-) UNIT, 250 UNIT, UNIT, 500 (+/-) 3,000 UNIT, 4,000 UNIT, 750 (+/-) UNIT, 500 UNIT UNIT AMICAR ORAL 2 AFSTYLA 4 LA SOLUTION 250 INTRAVENOUS MG/ML (25 %) RECON SOLN AMICAR ORAL 2 1,000 (+/-) UNIT TABLET 1,000 MG, RANGE, 1,500 (+/-) 500 MG UNIT RANGE, 2,000 (+/-) UNIT aminocaproic acid 1 RANGE, 2,500 (+/-) intravenous solution UNIT RANGE, 250 250 mg/ml (+/-) UNIT RANGE, ARGATROBAN IN 2 3,000 (+/-) UNIT NACL (ISO-OS) RANGE, 500 (+/-) INTRAVENOUS UNIT RANGE SOLUTION 50 MG/50 ML (1 MG/ML) aspirin-dipyridamole 1 oral capsule, er multiphase 12 hr 25- 200 mg BEBULIN 4 LA INTRAVENOUS RECON SOLN 700 (+/-) UNIT You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 57
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BENEFIX 4 LA ELOCTATE 4 LA INTRAVENOUS INTRAVENOUS RECON SOLN RECON SOLN 1,000 UNIT, 2,000 1,000 UNIT, 1,500 UNIT, 250 UNIT, UNIT, 2,000 UNIT, 3,000 UNIT, 500 250 UNIT, 3,000 UNIT UNIT, 4,000 UNIT, 5,000 UNIT, 500 bivalirudin 1 UNIT, 6,000 UNIT, intravenous recon 750 UNIT soln 250 mg enoxaparin 4 LA BRILINTA ORAL 2 subcutaneous TABLET 60 MG, 90 solution 300 mg/3 ml MG enoxaparin 4 LA CEPROTIN (BLUE 4 LA subcutaneous BAR) syringe 100 mg/ml, INTRAVENOUS 120 mg/0.8 ml, 150 RECON SOLN 500 mg/ml, 30 mg/0.3 ml, UNIT 40 mg/0.4 ml, 60 CEPROTIN 4 LA mg/0.6 ml, 80 mg/0.8 (GREEN BAR) ml INTRAVENOUS FEIBA NF 4 LA RECON SOLN INTRAVENOUS 1,000 UNIT RECON SOLN cilostazol oral tablet 1 1,750-3,250 UNIT, 100 mg, 50 mg 400-650 UNIT, 651- clopidogrel oral 1 1,200 UNIT tablet 300 mg, 75 mg fondaparinux 4 LA COAGADEX 4 LA subcutaneous INTRAVENOUS syringe 10 mg/0.8 RECON SOLN 250 ml, 2.5 mg/0.5 ml, 5 (+/-) UNIT RANGE, mg/0.4 ml, 7.5 500 (+/-) UNIT mg/0.6 ml RANGE FRAGMIN 4 LA dipyridamole oral 1 SUBCUTANEOUS tablet 25 mg, 50 mg, SOLUTION 25,000 75 mg ANTI-XA UNIT/ML ELIQUIS ORAL 2 TABLET 2.5 MG, 5 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 58
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FRAGMIN 4 LA heparin (porcine) 1 SUBCUTANEOUS injection cartridge SYRINGE 10,000 5,000 unit/ml (1 ml) ANTI-XA heparin (porcine) 1 UNIT/ML, 12,500 injection solution ANTI-XA UNIT/0.5 1,000 unit/ml, ML, 15,000 ANTI- 10,000 unit/ml, XA UNIT/0.6 ML, 20,000 unit/ml, 18,000 ANTI-XA 5,000 unit/ml UNIT/0.72 ML, 2,500 ANTI-XA heparin (porcine) 1 UNIT/0.2 ML, 5,000 injection syringe ANTI-XA UNIT/0.2 5,000 unit/ml ML, 7,500 ANTI- heparin 1 XA UNIT/0.3 ML flush(porcine)- HELIXATE FS 4 LA 0.9nacl intravenous INTRAVENOUS kit 100 unit/ml RECON SOLN heparin lock flush 1 1,000 (+/-) UNIT, (porcine) 2,000 (+/-) UNIT, intravenous solution 250 (+/-) UNIT, 100 unit/ml 3,000 (+/-) UNIT, 500 (+/-) UNIT heparin lock flush 1 intravenous solution hep flush-10 (pf) 1 10 unit/ml intravenous solution 10 unit/ml heparin lock flush 1 intravenous syringe heparin (porcine) in 1 10 unit/ml 5 % dex intravenous parenteral solution heparin 1 20,000 unit/500 ml lockflush(porcine)(pf (40 unit/ml), 25,000 ) intravenous syringe unit/250 ml(100 10 unit/ml, 100 unit/ml), 25,000 unit/ml unit/500 ml (50 heparin(porcine) in 1 unit/ml) 0.45% nacl heparin (porcine) in 1 intravenous nacl (pf) intravenous parenteral solution parenteral solution 100 unit/100 ml (1 1,000 unit/500 ml, unit/ml), 25,000 2,000 unit/1,000 ml unit/250 ml, 25,000 unit/500 ml
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits heparin, porcine (pf) 1 KOVALTRY 4 LA injection solution INTRAVENOUS 1,000 unit/ml, 5,000 RECON SOLN unit/0.5 ml 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, heparin, porcine (pf) 1 250 (+/-) UNIT, injection syringe 3,000 (+/-) UNIT, 5,000 unit/0.5 ml 500 (+/-) UNIT heparin, porcine (pf) 1 MEPHYTON 2 intravenous solution ORAL TABLET 5 100 unit/ml (1 ml) MG heparin, porcine (pf) 1 MONOCLATE-P 4 LA intravenous syringe INTRAVENOUS 1 unit/ml, 10 unit/ml, RECON SOLN 100 unit/ml 1,000 (+/-) UNIT, HUMATE-P 4 LA 1,500 (+/-) UNIT INTRAVENOUS MONONINE 4 LA RECON SOLN INTRAVENOUS 1,000-2,400 UNIT, RECON SOLN 250-600 UNIT, 500- 1,000 (+/-) UNIT 1,200 UNIT NOVOEIGHT 4 LA IXINITY 4 LA INTRAVENOUS INTRAVENOUS RECON SOLN RECON SOLN 1,000 (+/-) UNIT, 1,000 UNIT, 1,500 1,500 (+/-) UNIT, UNIT, 2,000 UNIT, 2,000 (+/-) UNIT, 250 UNIT, 3,000 250 (+/-) UNIT, UNIT, 500 UNIT 3,000 (+/-) UNIT, jantoven oral tablet 1 500 (+/-) UNIT 1 mg, 10 mg, 2 mg, NOVOSEVEN RT 4 LA 2.5 mg, 3 mg, 4 mg, INTRAVENOUS 5 mg, 6 mg, 7.5 mg RECON SOLN 1 KOGENATE FS 4 LA MG (1,000 MCG), 2 INTRAVENOUS MG (2,000 MCG), 5 RECON SOLN MG (5,000 MCG), 8 1,000 (+/-) UNIT, MG (8,000 MCG) 2,000 (+/-) UNIT, NPLATE 4 PA; LA 250 (+/-) UNIT, SUBCUTANEOUS 3,000 (+/-) UNIT, RECON SOLN 250 500 (+/-) UNIT MCG, 500 MCG
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits OBIZUR 4 LA tranexamic acid 1 INTRAVENOUS intravenous solution RECON SOLN 500 1,000 mg/10 ml (100 (+/-) UNIT RANGE mg/ml) pentoxifylline oral 1 vitamin k injection 1 tablet extended solution 1 mg/0.5 ml release 400 mg vitamin k1 injection 1 PRADAXA ORAL 3 solution 10 mg/ml CAPSULE 110 MG, VONVENDI 4 LA 150 MG, 75 MG INTRAVENOUS prasugrel oral tablet 1 RECON SOLN 10 mg, 5 mg 1,300 (+/-) UNIT RANGE, 650 (+/-) PROFILNINE 4 LA UNIT RANGE INTRAVENOUS RECON SOLN warfarin oral tablet 1 1,000 (+/-) UNIT, 1 mg, 10 mg, 2 mg, 1,500 (+/-) UNIT, 2.5 mg, 3 mg, 4 mg, 500 (+/-) UNIT 5 mg, 6 mg, 7.5 mg PROMACTA 4 PA; LA XARELTO ORAL 2 ORAL TABLET TABLET 10 MG, 15 12.5 MG, 25 MG, 50 MG, 20 MG MG, 75 MG XARELTO ORAL 2 protamine 1 TABLETS,DOSE intravenous solution PACK 15 MG (42)- 10 mg/ml 20 MG (9) RECOMBINATE 4 LA XYNTHA 4 LA INTRAVENOUS INTRAVENOUS RECON SOLN SOLUTION 1,000 1,000 (+/-) UNIT, (+/-) UNIT, 2,000 1,500 (+/-) UNIT, (+/-) UNIT, 250 (+/- 2,000 (+/-) UNIT, ) UNIT, 500 (+/-) 250 (+/-) UNIT, 500 UNIT (+/-) UNIT XYNTHA 4 LA RIASTAP 4 LA SOLOFUSE INTRAVENOUS INTRAVENOUS RECON SOLN 1 SYRINGE 1,000 GRAM (900MG- (+/-) UNIT, 2,000 1,300MG) (+/-) UNIT, 250 (+/- ) UNIT, 3,000 (+/-) ticlopidine oral 1 UNIT, 500 (+/-) tablet 250 mg UNIT
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ZONTIVITY ORAL 3 ezetimibe- 1 QL TABLET 2.08 MG simvastatin oral tablet 10-10 mg, 10- LIPID/CHOLESTEROL LOWERING 20 mg, 10-40 mg, AGENTS 10-80 mg amlodipine- 1 QL fenofibrate 1 atorvastatin oral micronized oral tablet 10-10 mg, 10- capsule 130 mg, 134 20 mg, 10-40 mg, mg, 200 mg, 43 mg, 10-80 mg, 2.5-10 67 mg mg, 2.5-20 mg, 2.5- 40 mg, 5-10 mg, 5- fenofibrate 1 20 mg, 5-40 mg, 5- nanocrystallized 80 mg oral tablet 145 mg, 48 mg atorvastatin oral 1 QL tablet 10 mg, 20 mg, fenofibrate oral 1 40 mg, 80 mg tablet 120 mg, 160 mg, 40 mg, 54 mg cholestyramine (with 1 sugar) oral powder fenofibric acid 1 4 gram (choline) oral capsule,delayed cholestyramine (with 1 release(dr/ec) 135 sugar) oral powder mg, 45 mg in packet 4 gram fenofibric acid oral 1 cholestyramine light 1 tablet 105 mg, 35 mg oral powder 4 gram fluvastatin oral 1 QL cholestyramine light 1 capsule 20 mg, 40 oral powder in mg packet 4 gram fluvastatin oral 1 QL colestipol oral 1 tablet extended granules 5 gram release 24 hr 80 mg colestipol oral 1 gemfibrozil oral 1 packet 5 gram tablet 600 mg colestipol oral tablet 1 JUXTAPID ORAL 4 PA; LA 1 gram CAPSULE 10 MG, ezetimibe oral tablet 1 ST 20 MG, 30 MG, 40 10 mg MG, 5 MG, 60 MG LIVALO ORAL 3 ST; QL TABLET 1 MG, 2 MG, 4 MG
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lovastatin oral tablet 1 QL rosuvastatin oral 1 QL 10 mg, 20 mg, 40 mg tablet 10 mg, 20 mg, 40 mg, 5 mg niacin oral tablet 1 extended release 24 simvastatin oral 1 QL hr 1,000 mg, 500 tablet 10 mg, 20 mg, mg, 750 mg 40 mg, 5 mg, 80 mg omega-3 acid ethyl 1 triklo oral capsule 1 1 esters oral capsule 1 gram gram VASCEPA ORAL 2 PRALUENT PEN 4 PA; LA; QL CAPSULE 0.5 SUBCUTANEOUS GRAM, 1 GRAM PEN INJECTOR WELCHOL ORAL 3 150 MG/ML, 75 POWDER IN MG/ML PACKET 3.75 pravastatin oral 1 QL GRAM tablet 10 mg, 20 mg, WELCHOL ORAL 3 40 mg, 80 mg TABLET 625 MG prevalite oral 1 MISCELLANEOUS powder 4 gram CARDIOVASCULAR AGENTS prevalite oral 1 powder in packet 4 CORLANOR ORAL 2 PA gram TABLET 5 MG, 7.5 MG REPATHA 4 PA; LA; QL PUSHTRONEX ENTRESTO ORAL 2 PA; QL SUBCUTANEOUS TABLET 24-26 WEARABLE MG, 49-51 MG, 97- INJECTOR 420 103 MG MG/3.5 ML RANEXA ORAL 3 REPATHA 4 PA; LA; QL TABLET SURECLICK EXTENDED SUBCUTANEOUS RELEASE 12 HR PEN INJECTOR 1,000 MG, 500 MG 140 MG/ML NITRATES REPATHA 4 PA; LA; QL isosorbide dinitrate 1 SYRINGE oral tablet 10 mg, 20 SUBCUTANEOUS mg, 30 mg, 5 mg SYRINGE 140 MG/ML isosorbide dinitrate 1 oral tablet extended release 40 mg
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits isosorbide 1 nitroglycerin 1 mononitrate oral translingual tablet 10 mg, 20 mg spray,non-aerosol 400 mcg/spray isosorbide 1 mononitrate oral nitro-time oral 1 tablet extended capsule, extended release 24 hr 120 release 2.5 mg, 6.5 mg, 30 mg, 60 mg mg, 9 mg nitro-bid 1 DERMATOLOGICALS/TOPICA transdermal L THERAPY ointment 2 % ANTIPSORIATIC / nitroglycerin in 5 % 1 dextrose intravenous ANTISEBORRHEIC solution 100 mg/250 acitretin oral 1 ml (400 mcg/ml), capsule 10 mg, 17.5 200 mg/500 ml (400 mg, 25 mg mcg/ml), 25 mg/250 ml (100 mcg/ml), 50 calcipotriene scalp 1 mg/250 ml (200 solution 0.005 % mcg/ml), 50 mg/500 calcipotriene topical 1 ml (100 mcg/ml) cream 0.005 % nitroglycerin 1 calcipotriene topical 1 intravenous solution ointment 0.005 % 50 mg/10 ml (5 calcipotriene- 1 mg/ml) betamethasone nitroglycerin oral 1 topical ointment capsule, extended 0.005-0.064 % release 2.5 mg, 6.5 calcitrene topical 1 mg, 9 mg ointment 0.005 % nitroglycerin 1 calcitriol topical 1 sublingual tablet 0.3 ointment 3 mg, 0.4 mg, 0.6 mg mcg/gram nitroglycerin 1 COAL TAR 2 transdermal patch TOPICAL 24 hour 0.1 mg/hr, SOLUTION 20 % 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr COSENTYX (2 4 PA; LA SYRINGES) nitroglycerin 1 SUBCUTANEOUS translingual SYRINGE 150 aerosol,spray 400 MG/ML mcg/spray
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits COSENTYX PEN 4 PA; LA BURN THERAPY (2 PENS) silver sulfadiazine 1 SUBCUTANEOUS topical cream 1 % PEN INJECTOR 150 MG/ML ssd topical cream 1 1 % COSENTYX PEN 4 PA; LA SUBCUTANEOUS KERATOLYTICS PEN INJECTOR salicylic acid er- 1 150 MG/ML ceramides topical COSENTYX 4 PA; LA kit,cleanser and SUBCUTANEOUS cream er 6 % SYRINGE 150 salicylic acid topical 1 MG/ML cream 6 % drithocreme hp 1 salicylic acid topical 1 topical cream 1 % cream,extended hydrocortisone- 1 release 6 % pramoxine topical salicylic acid topical 1 cream 2.5-1 % film forming liquid seb-prev topical 1 w/appl 27.5 % cleanser 10 % salicylic acid topical 1 selenium sulfide 1 film-forming soln er topical lotion 2.5 % w/ appl 28.5 % selenium sulfide 1 salicylic acid topical 1 topical shampoo foam 6 % 2.25 % salicylic acid topical 1 STELARA 4 PA; LA gel 6 % SUBCUTANEOUS salicylic acid topical 1 SYRINGE 45 liquid 26 % MG/0.5 ML, 90 MG/ML salicylic acid topical 1 lotion 6 % sulfacetamide 1 sodium topical salicylic acid topical 1 cleanser 10 % lotion,extended release 6 % sulfacetamide 1 sodium topical salicylic acid topical 1 cleanser, gel 10 % shampoo 6 % sulfacetamide 1 salvax topical foam 1 sodium topical 6 % shampoo 10 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 65
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MISCELLANEOUS hpr plus topical 1
DERMATOLOGICALS foam ammonium lactate 1 hpr topical foam 1 topical cream 12 % luxamend topical 1 ammonium lactate 1 cream topical lotion 12 % mb hydrogel 1 avo cream topical 1 (cyclomethicone) emulsion topical kit,cream and gel bp-50% urea topical 1 emulsion 50 % mb hydrogel topical 1 kit,cream and gel celacyn topical gel 1 96.53-3-0.4 -0.066 with pump % cem-urea topical gel 1 methoxsalen oral 1 45 % capsule,liqd- diclofenac sodium 1 QL filled,rapid rel 10 topical gel 3 % mg doxepin topical 1 QL nivatopic plus 1 cream 5 % topical cream DUPIXENT 4 PA; LA; QL PANRETIN 3 SUBCUTANEOUS TOPICAL GEL 0.1 SYRINGE 300 % MG/2 ML PICATO TOPICAL 3 eletone topical 1 GEL 0.015 %, 0.05 cream % ELIDEL TOPICAL 3 ST; QL podofilox topical 1 CREAM 1 % solution 0.5 % emulsion sb topical 1 pruclair topical 1 emulsion cream fluorouracil topical 1 prudoxin topical 1 QL cream 5 % cream 5 % fluorouracil topical 1 prumyx topical 1 solution 2 %, 5 % cream hpr plus hydrogel 1 prutect topical 1 topical kit,cream emulsion and gel rea lo 39 topical 1 hpr plus topical 1 cream 39 % cream
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits rea lo 40 topical 1 VALCHLOR 4 LA lotion 40 % TOPICAL GEL 0.016 % REGRANEX 2 QL TOPICAL GEL 0.01 VEREGEN 3 % TOPICAL OINTMENT 15 % silver nitrate 1 applicators topical THERAPY FOR ACNE stick 75-25 % adapalene topical 1 silver nitrate topical 1 cream 0.1 % ointment 10 % adapalene topical 1 silver nitrate topical 1 gel 0.1 %, 0.3 % solution 0.5 %, 10 adapalene topical 1 %, 25 %, 50 % gel with pump 0.3 % sonafine topical 1 adapalene-benzoyl 1 emulsion peroxide topical gel sp antipruritic 1 with pump 0.1-2.5 % topical gel amnesteem oral 1 tacrolimus topical 1 ST; QL capsule 10 mg, 20 ointment 0.03 %, 0.1 mg, 40 mg % avar topical cleanser 1 umecta topical foam 1 10-5 % (w/w) 40 % avita topical cream 1 PA urea nail stick 1 0.025 % topical solution 50 AZELEX TOPICAL 3 ST % CREAM 20 % urea topical cream 1 benzepro topical 1 39 %, 40 %, 45 %, towelette 6 % 47 %, 50 % benzoyl peroxide 1 urea topical foam 35 1 topical cleanser 7 % % bp 10-1 topical 1 urea topical gel 45 1 cleanser 10-1 % % bpo topical gel 4 %, 1 urea topical lotion 1 8 % 40 %, 45 % bpo topical towelette 1 UVADEX 2 6 % INJECTION SOLUTION 20 MCG/ML
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits claravis oral capsule 1 ery pads topical 1 10 mg, 20 mg, 30 swab 2 % mg, 40 mg erygel topical gel 2 1 cleansing wash 1 % topical cleanser 10- erythromycin with 1 4-10 % ethanol topical gel 2 clindacin p topical 1 % swab 1 % erythromycin with 1 clindamycin 1 ethanol topical phosphate topical solution 2 % foam 1 % erythromycin with 1 clindamycin 1 ethanol topical swab phosphate topical 2 % gel 1 % erythromycin- 1 clindamycin 1 benzoyl peroxide phosphate topical topical gel 3-5 % lotion 1 % metronidazole 1 clindamycin 1 topical cream 0.75 phosphate topical % solution 1 % metronidazole 1 clindamycin 1 topical gel 0.75 %, 1 phosphate topical % swab 1 % metronidazole 1 clindamycin-benzoyl 1 topical gel with peroxide topical gel pump 1 % 1-5 %, 1.2 %(1 % metronidazole 1 base) -5 % topical lotion 0.75 % clindamycin-benzoyl 1 MIRVASO 3 PA peroxide topical gel TOPICAL GEL 0.33 with pump 1-5 % % clindamycin- 1 neuac topical gel 1.2 1 tretinoin topical gel %(1 % base) -5 % 1.2-0.025 % rosadan topical 1 dapsone topical gel 1 cream 0.75 % 5 % rosadan topical gel 1 EPIDUO FORTE 3 ST 0.75 % TOPICAL GEL WITH PUMP 0.3- 2.5 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 68
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits rosula cleansing 1 sulfacleanse 8-4 1 cloths topical pads, topical suspension 8- medicated 10-5 % 4 % SOOLANTRA 3 ST sulfact na-sul- 1 TOPICAL CREAM avobnz-otn-ocsa 1 % topical combo pack,cleanser and sss 10-5 topical 1 cream 9 %-4.5 % - cream 10-5 % (w/w) spf 25 sss 10-5 topical 1 tazarotene topical 1 PA foam 10-5 % cream 0.1 % sulfacetamide 1 TAZORAC 2 PA sodium-sulfur TOPICAL CREAM topical cleanser 10-2 0.05 % %, 10-5 % (w/w), 9- 4 %, 9-4.5 %, 9.8- TAZORAC 2 PA 4.8 % TOPICAL GEL 0.05 %, 0.1 % sulfacetamide 1 sodium-sulfur tretinoin 1 PA topical cream 10-2 microspheres topical %, 10-5 % (w/w), gel 0.04 %, 0.1 % 9.8-4.8 % tretinoin 1 PA sulfacetamide 1 microspheres topical sodium-sulfur gel with pump 0.04 topical lotion 10-5 %, 0.1 % % (w/v), 10-5 % tretinoin topical 1 PA (w/w), 9.8-4.8 % cream 0.025 %, 0.05 sulfacetamide 1 %, 0.1 % sodium-sulfur tretinoin topical gel 1 PA topical pads, 0.01 %, 0.025 %, medicated 10-4 % 0.05 % sulfacetamide 1 zenatane oral 1 sodium-sulfur capsule 10 mg, 20 topical suspension mg, 30 mg, 40 mg 10-5 %, 8-4 % TOPICAL ANESTHETICS sulfacetamide sod- 1 sulfur-urea topical ethyl chloride 1 cleanser 10-5-10 % topical aerosol,spray 100 % sulfacetamide- 1 sulfur-cleansr23 topical kit 9-4.5 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 69
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits glydo mucous 1 QL lidocaine viscous 1 membrane jelly in mucous membrane applicator 2 % solution 2 % lidocaine (pf) 1 lidocaine- 1 injection solution 10 epinephrine mg/ml (1 %), 15 injection solution 0.5 mg/ml (1.5 %), 20 %-1:200,000, 1 %- mg/ml (2 %), 40 1:100,000, 1.5 %- mg/ml (4 %), 5 1:200,000, 2 %- mg/ml (0.5 %) 1:100,000, 2 %- 1:200,000 lidocaine hcl 1 injection solution 10 lidocaine-prilocaine 1 QL mg/ml (1 %), 20 topical cream 2.5- mg/ml (2 %), 5 2.5 % mg/ml (0.5 %) lidocaine-prilocaine 1 lidocaine hcl 1 topical kit 2.5-2.5 % injection syringe 10 lta pre-attached 1 mg/ml (1 %) laryngotracheal lidocaine hcl 1 solution 4 % laryngotracheal PLIAGLIS 3 solution 4 % TOPICAL CREAM lidocaine hcl mucous 1 QL 7-7 % membrane jelly 2 % TOPICAL ANTIBACTERIALS lidocaine hcl mucous 1 QL ALTABAX 3 membrane jelly in TOPICAL applicator 2 % OINTMENT 1 % lidocaine hcl mucous 1 CORTISPORIN 3 membrane solution 4 TOPICAL CREAM % (40 mg/ml) 3.5-10,000-0.5 lidocaine hcl- 1 MG/G-UNIT/G-% hydrocortison ac CORTISPORIN 3 topical cream 3-0.5 TOPICAL % OINTMENT 1 % lidocaine topical 1 PA gentamicin topical 1 adhesive cream 0.1 % patch,medicated 5 % gentamicin topical 1 lidocaine topical 1 QL ointment 0.1 % ointment 5 %
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits hydrocortisone- 1 ciclopirox topical 1 QL iodoquinol-aloe suspension 0.77 % topical cream in clotrimazole topical 1 QL packet 1.9-1 % cream 1 % iodoquinol-hc 1 clotrimazole topical 1 QL topical cream 1-1 % solution 1 % lugols topical 1 clotrimazole- 1 QL solution 5-10 % betamethasone mupirocin calcium 1 topical cream 1-0.05 topical cream 2 % % mupirocin topical 1 clotrimazole- 1 QL ointment 2 % betamethasone topical lotion 1-0.05 NEO-SYNALAR 3 % TOPICAL CREAM 0.5 % (0.35 % econazole topical 1 QL BASE)-0.025 % cream 1 % sulfacetamide 1 ERTACZO 3 QL sodium (acne) TOPICAL CREAM topical suspension 2 % 10 % EXELDERM 3 QL SULFAMYLON 2 TOPICAL CREAM TOPICAL CREAM 1 % 85 MG/G EXELDERM 3 QL SULFAMYLON 2 TOPICAL TOPICAL PACKET SOLUTION 1 % 50 GRAM JUBLIA TOPICAL 3 ST TOPICAL ANTIFUNGALS SOLUTION WITH APPLICATOR 10 % ciclodan topical 1 QL cream 0.77 % ketoconazole topical 1 QL cream 2 % ciclodan topical 1 PA solution 8 % ketoconazole topical 1 QL foam 2 % ciclopirox topical 1 QL cream 0.77 % ketoconazole topical 1 QL shampoo 2 % ciclopirox topical 1 QL gel 0.77 % LUZU TOPICAL 3 QL CREAM 1 % ciclopirox topical 1 QL shampoo 1 %
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MENTAX 3 QL DENAVIR 3 TOPICAL CREAM TOPICAL CREAM 1 % 1 % naftifine topical 1 QL ZOVIRAX 2 QL cream 1 %, 2 % TOPICAL CREAM 5 % nyamyc topical 1 powder 100,000 TOPICAL CORTICOSTEROIDS unit/gram ala-cort topical 1 nyata topical powder 1 cream 1 %, 2.5 % 100,000 unit/gram alclometasone 1 nystatin topical 1 QL topical cream 0.05 cream 100,000 % unit/gram alclometasone 1 nystatin topical 1 QL topical ointment ointment 100,000 0.05 % unit/gram amcinonide topical 1 nystatin topical 1 cream 0.1 % powder 100,000 amcinonide topical 1 unit/gram lotion 0.1 % nystatin- 1 QL amcinonide topical 1 triamcinolone ointment 0.1 % topical cream 100,000-0.1 unit/g- apexicon e topical 1 % cream 0.05 % nystatin- 1 QL betamethasone 1 triamcinolone dipropionate topical topical ointment cream 0.05 % 100,000-0.1 betamethasone 1 unit/gram-% dipropionate topical nystop topical 1 lotion 0.05 % powder 100,000 betamethasone 1 unit/gram dipropionate topical oxiconazole topical 1 QL ointment 0.05 % cream 1 % betamethasone 1 TRIACETIN 2 valerate topical LIQUID 100 % cream 0.1 % TOPICAL ANTIVIRALS betamethasone 1 valerate topical acyclovir topical 1 QL foam 0.12 % ointment 5 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 72
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits betamethasone 1 clobetasol-emollient 1 QL valerate topical topical foam 0.05 % lotion 0.1 % clodan topical 1 QL betamethasone 1 shampoo 0.05 % valerate topical CORDRAN TAPE 3 ST ointment 0.1 % LARGE ROLL betamethasone, 1 TOPICAL TAPE 4 augmented topical MCG/CM2 cream 0.05 % cormax scalp 1 QL betamethasone, 1 solution 0.05 % augmented topical desonide topical 1 gel 0.05 % cream 0.05 % betamethasone, 1 desonide topical 1 augmented topical lotion 0.05 % lotion 0.05 % desonide topical 1 betamethasone, 1 ointment 0.05 % augmented topical ointment 0.05 % desoximetasone 1 topical cream 0.05 clobetasol scalp 1 QL %, 0.25 % solution 0.05 % desoximetasone 1 clobetasol topical 1 QL topical gel 0.05 % cream 0.05 % desoximetasone 1 clobetasol topical 1 QL topical ointment foam 0.05 % 0.05 %, 0.25 % clobetasol topical 1 QL diflorasone topical 1 gel 0.05 % cream 0.05 % clobetasol topical 1 QL diflorasone topical 1 lotion 0.05 % ointment 0.05 % clobetasol topical 1 QL fluocinolone and 1 ointment 0.05 % shower cap scalp oil clobetasol topical 1 QL 0.01 % shampoo 0.05 % fluocinolone topical 1 clobetasol topical 1 QL cream 0.01 %, 0.025 spray,non-aerosol % 0.05 % fluocinolone topical 1 clobetasol-emollient 1 QL oil 0.01 % topical cream 0.05 fluocinolone topical 1 % ointment 0.025 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 73
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fluocinolone topical 1 HALOG TOPICAL 3 ST solution 0.01 % OINTMENT 0.1 % fluocinonide topical 1 QL hydrocortisone 1 cream 0.05 %, 0.1 % butyrate topical cream 0.1 % fluocinonide topical 1 QL gel 0.05 % hydrocortisone 1 butyrate topical fluocinonide topical 1 QL ointment 0.1 % ointment 0.05 % hydrocortisone 1 fluocinonide topical 1 QL butyrate topical solution 0.05 % solution 0.1 % fluocinonide-e 1 QL hydrocortisone 1 topical cream 0.05 butyr-emollient % topical cream 0.1 % fluocinonide- 1 QL hydrocortisone 1 emollient topical topical cream 1 %, cream 0.05 % 2.5 % flurandrenolide 1 hydrocortisone 1 topical cream 0.05 topical lotion 2.5 % % hydrocortisone 1 flurandrenolide 1 topical ointment 1 topical lotion 0.05 % %, 2.5 % flurandrenolide 1 hydrocortisone 1 topical ointment valerate topical 0.05 % cream 0.2 % fluticasone topical 1 hydrocortisone 1 cream 0.05 % valerate topical fluticasone topical 1 ointment 0.2 % lotion 0.05 % mometasone topical 1 fluticasone topical 1 cream 0.1 % ointment 0.005 % mometasone topical 1 halobetasol 1 ointment 0.1 % propionate topical mometasone topical 1 cream 0.05 % solution 0.1 % halobetasol 1 nolix topical lotion 1 propionate topical 0.05 % ointment 0.05 % prednicarbate 1 HALOG TOPICAL 3 ST topical cream 0.1 % CREAM 0.1 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 74
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits prednicarbate 1 malathion topical 1 topical ointment 0.1 lotion 0.5 % % permethrin topical 1 scalacort topical 1 cream 5 % lotion 2 % spinosad topical 1 triamcinolone 1 suspension 0.9 % acetonide topical ULESFIA 3 aerosol 0.147 TOPICAL LOTION mg/gram 5 % triamcinolone 1 DIAGNOSTICS & acetonide topical cream 0.025 %, 0.1 MISCELLANEOUS AGENTS %, 0.5 % ANOREXIANTS triamcinolone 1 CONTRAVE ORAL 3 PA acetonide topical TABLET lotion 0.025 %, 0.1 EXTENDED % RELEASE 8-90 MG triamcinolone 1
acetonide topical IRRIGATING SOLUTIONS ointment 0.025 %, lactated ringers 1 0.1 %, 0.5 % irrigation solution trianex topical 1 neomycin-polymyxin 1 ointment 0.05 % b gu irrigation triderm topical 1 solution 40 mg- cream 0.1 %, 0.5 % 200,000 unit/ml ringer's irrigation 1 TOPICAL ENZYMES solution SANTYL TOPICAL 2 tis-u-sol pentalyte 1 OINTMENT 250 irrigation solution UNIT/GRAM 800-40-20-8.75- TOPICAL SCABICIDES / 6.25 mg/100 ml
PEDICULICIDES MISCELLANEOUS AGENTS EURAX TOPICAL 3 acamprosate oral 1 CREAM 10 % tablet,delayed EURAX TOPICAL 3 release (dr/ec) 333 LOTION 10 % mg lindane topical 1 acetic acid irrigation 1 shampoo 1 % solution 0.25 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 75
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ADAGEN 4 LA FERRIPROX ORAL 4 LA INTRAMUSCULA TABLET 500 MG R SOLUTION 250 ic green injection 1 UNIT/ML recon soln 25 mg alendronate oral 1 QL INCRELEX 4 PA; LA tablet 40 mg SUBCUTANEOUS anagrelide oral 1 SOLUTION 10 capsule 0.5 mg, 1 mg MG/ML ARALAST NP 4 PA; LA indocyanine green 1 INTRAVENOUS injection recon soln RECON SOLN 25 mg 1,000 MG, 500 MG JADENU ORAL 4 LA BUPHENYL ORAL 2 TABLET 180 MG, TABLET 500 MG 360 MG, 90 MG caffeine citrate oral 1 JADENU 4 LA solution 60 mg/3 ml SPRINKLE ORAL (20 mg/ml) GRANULES IN PACKET 180 MG, CARBAGLU ORAL 4 LA 360 MG, 90 MG TABLET, DISPERSIBLE 200 levocarnitine (with 1 MG sugar) oral solution 100 mg/ml cevimeline oral 1 capsule 30 mg levocarnitine oral 1 tablet 330 mg CHEMET ORAL 2 CAPSULE 100 MG midodrine oral 1 tablet 10 mg, 2.5 mg, disulfiram oral 1 5 mg tablet 250 mg, 500 mg NITYR ORAL 4 PA; LA TABLET 10 MG, 2 etidronate disodium 1 MG, 5 MG oral tablet 200 mg, 400 mg ORFADIN ORAL 4 LA CAPSULE 10 MG, EXJADE ORAL 4 LA 2 MG, 20 MG, 5 TABLET, MG DISPERSIBLE 125 MG, 250 MG, 500 ORFADIN ORAL 4 LA MG SUSPENSION 4 MG/ML FERRIPROX ORAL 4 LA SOLUTION 100 pilocarpine hcl oral 1 MG/ML tablet 5 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 76
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PROLASTIN-C 4 PA; LA sodium 1 INTRAVENOUS phenylbutyrate oral RECON SOLN powder 0.94 1,000 MG gram/gram RAVICTI ORAL 4 PA; LA sodium 1 LIQUID 1.1 phenylbutyrate oral GRAM/ML tablet 500 mg riluzole oral tablet 1 SOLIRIS 4 LA 50 mg INTRAVENOUS SOLUTION 300 risedronate oral 1 QL MG/30 ML tablet 30 mg SYPRINE ORAL 3 PA sodium benzoate-sod 1 CAPSULE 250 MG phenylacet intravenous solution water for irrigation, 1 10-10 % sterile irrigation solution sodium chlor 0.9% 1 bacteriostat XURIDEN ORAL 4 PA; LA injection solution 0.9 GRANULES IN % PACKET 2 GRAM sodium chloride 0.9 1 ZEMAIRA 4 PA; LA % injection solution INTRAVENOUS 0.9 % RECON SOLN 1,000 MG sodium chloride 0.9 1 % injection syringe zoledronic acid- 4 LA 0.9 % mannitol-water intravenous sodium chloride 0.9 1 piggyback 5 mg/100 % intravenous ml parenteral solution 0.9 % SMOKING DETERRENTS sodium chloride 0.9 1 bupropion hcl 5 ACA % intravenous (smoking deter) oral piggyback 0.9 % tablet extended sodium chloride 1 release 12 hr 150 mg irrigation solution CHANTIX 5 ACA 0.9 % CONTINUING sodium ferric 1 MONTH BOX gluconat-sucrose ORAL TABLET 1 intravenous solution MG 62.5 mg/5 ml
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CHANTIX ORAL 5 ACA nicotine transdermal 5 ACA; OTC TABLET 0.5 MG, 1 patch 24 hour 14 MG mg/24 hr, 21 mg/24 hr, 7 mg/24 hr CHANTIX 5 ACA STARTING nicotine transdermal 5 ACA; OTC MONTH BOX patch, td daily, ORAL sequential 21-14-7 TABLETS,DOSE mg/24 hr PACK 0.5 MG (11)- NICOTROL 5 ACA 1 MG (42) INHALATION NICODERM CQ 5 ACA; OTC CARTRIDGE 10 TRANSDERMAL MG PATCH 24 HOUR NICOTROL NS 5 ACA 14 MG/24 HR, 21 NASAL MG/24 HR, 7 SPRAY,NON- MG/24 HR AEROSOL 10 nicorelief buccal 5 ACA; OTC MG/ML gum 2 mg, 4 mg nts step 1 5 ACA; OTC NICORETTE 5 ACA; OTC transdermal patch BUCCAL GUM 2 24 hour 21 mg/24 hr MG quit 2 buccal gum 2 5 ACA; OTC nicorette buccal gum 5 ACA; OTC mg 4 mg QUIT 2 BUCCAL 5 ACA; OTC NICORETTE 5 ACA; OTC LOZENGE 2 MG BUCCAL quit 4 buccal gum 4 5 ACA; OTC LOZENGE 2 MG, 4 mg MG QUIT 4 BUCCAL 5 ACA; OTC NICORETTE 5 ACA; OTC LOZENGE 4 MG BUCCAL MINI LOZENGE 2 MG, 4 stop smoking aid 5 ACA; OTC MG buccal lozenge 2 mg, 4 mg nicotine (polacrilex) 5 ACA; OTC buccal gum 2 mg, 4 EAR, NOSE & THROAT
mg MEDICATIONS nicotine (polacrilex) 5 ACA; OTC MISCELLANEOUS AGENTS buccal lozenge 2 mg, 4 mg azelastine nasal 1 QL aerosol,spray 137 nicotine (polacrilex) 5 ACA; OTC mcg (0.1 %) buccal mini lozenge 2 mg, 4 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 78
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits azelastine nasal 1 pilocarpine hcl oral 1 spray,non-aerosol tablet 7.5 mg 0.15 % (205.5 mcg) sf 5000 plus dental 1 BACTROBAN 2 cream 1.1 % NASAL NASAL sf dental gel 1.1 % 1 OINTMENT 2 % triamcinolone 1 chlorhexidine 1 acetonide dental gluconate mucous paste 0.1 % membrane mouthwash 0.12 % MISCELLANEOUS OTIC
DEBACTEROL 2 PREPARATIONS MUCOUS acetic acid otic (ear) 1 MEMBRANE solution 2 % SOLUTION 30-50 ciprofloxacin hcl 1 % otic (ear) DEBACTEROL 2 dropperette 0.2 % MUCOUS floxin otic (ear) 1 MEMBRANE drops 0.3 % SWAB 30-50 % fluocinolone 1 denta 5000 plus 1 acetonide oil otic dental cream 1.1 % (ear) drops 0.01 % dentagel dental gel 1 hydrocortisone- 1 1.1 % acetic acid otic (ear) ipratropium bromide 1 QL drops 1-2 % nasal spray,non- ofloxacin otic (ear) 1 aerosol 0.03 %, 42 drops 0.3 % mcg (0.06 %)
olopatadine nasal 1 QL OTIC STEROID / ANTIBIOTIC spray,non-aerosol CIPRO HC OTIC 3 0.6 % (EAR) oralone dental paste 1 DROPS,SUSPENSI 0.1 % ON 0.2-1 % paroex oral rinse 1 CIPRODEX OTIC 2 mucous membrane (EAR) mouthwash 0.12 % DROPS,SUSPENSI ON 0.3-0.1 % periogard mucous 1 membrane mouthwash 0.12 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 79
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits COLY-MYCIN S 3 dexamethasone oral 1 OTIC (EAR) tablet 0.5 mg, 0.75 DROPS,SUSPENSI mg, 1 mg, 1.5 mg, 2 ON 3.3-3-10-0.5 mg, 4 mg, 6 mg MG/ML dexamethasone 1 neomycin- 1 sodium phos (pf) polymyxin-hc otic injection solution 10 (ear) mg/ml drops,suspension dexamethasone 1 3.5-10,000-1 mg/ml- sodium phosphate unit/ml-% injection solution 10 neomycin- 1 mg/ml, 4 mg/ml polymyxin-hc otic dexamethasone 1 (ear) solution 3.5- sodium phosphate 10,000-1 mg/ml- injection syringe 4 unit/ml-% mg/ml ENDOCRINE/DIABETES fludrocortisone oral 1 ADRENAL HORMONES tablet 0.1 mg ACTHAR H.P. 4 PA; LA; QL hydrocortisone oral 1 INJECTION GEL tablet 10 mg, 20 mg, 80 UNIT/ML 5 mg betamethasone 1 methylprednisolone 1 acet,sod phos acetate injection injection suspension suspension 40 6 mg/ml mg/ml, 80 mg/ml cortisone oral tablet 1 methylprednisolone 1 25 mg oral tablet 16 mg, 32 mg, 4 mg, 8 mg cosyntropin injection 1 recon soln 0.25 mg methylprednisolone 1 oral tablets,dose deltasone oral tablet 1 pack 4 mg 20 mg millipred dp oral 1 dexamethasone 1 tablets,dose pack 5 intensol oral drops 1 mg (21 tabs), 5 mg mg/ml (48 tabs) dexamethasone oral 1 millipred oral tablet 1 elixir 0.5 mg/5 ml 5 mg dexamethasone oral 1 prednisolone oral 1 solution 0.5 mg/5 ml solution 15 mg/5 ml
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 80
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits prednisolone sodium 1 GLUCAGEN 2 phosphate oral DIAGNOSTIC KIT solution 10 mg/5 ml, INJECTION 15 mg/5 ml (3 RECON SOLN 1 mg/ml), 20 mg/5 ml MG/ML (4 mg/ml), 25 mg/5 INSULIN 2 ml (5 mg/ml), 5 mg SYRINGE- base/5 ml (6.7 mg/5 NEEDLE U-100 ml) SYRINGE 0.5 ML prednisolone sodium 1 29 GAUGE X 1/2" phosphate oral
tablet,disintegrating GLUCOSE ELEVATING AGENTS 10 mg, 15 mg, 30 mg GLUCAGEN 2 HYPOKIT prednisone intensol 1 INJECTION oral concentrate 5 RECON SOLN 1 mg/ml MG prednisone oral 1 GLUCAGON 2 solution 5 mg/5 ml EMERGENCY KIT prednisone oral 1 (HUMAN) tablet 1 mg, 10 mg, INJECTION KIT 1 2.5 mg, 20 mg, 5 mg, MG 50 mg PROGLYCEM 2 prednisone oral 1 ORAL tablets,dose pack 10 SUSPENSION 50 mg, 5 mg MG/ML triamcinolone 1 INSULIN THERAPY acetonide injection suspension 10 APIDRA 3 ST mg/ml, 40 mg/ml SOLOSTAR SUBCUTANEOUS veripred 20 oral 1 INSULIN PEN 100 solution 20 mg/5 ml UNIT/ML (4 mg/ml) APIDRA 3 ST ANTITHYROID AGENTS SUBCUTANEOUS methimazole oral 1 SOLUTION 100 tablet 10 mg, 5 mg UNIT/ML propylthiouracil oral 1 BASAGLAR 2 tablet 50 mg KWIKPEN SUBCUTANEOUS DIABETES, SUPPLIES, & DURABLE INSULIN PEN 100 MEDICAL EQUIPMENT UNIT/ML (3 ML)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 81
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits HUMALOG 2 HUMULIN 70/30 2 JUNIOR KWIKPEN KWIKPEN SUBCUTANEOUS SUBCUTANEOUS INSULIN PEN, INSULIN PEN 100 HALF-UNIT 100 UNIT/ML (70-30) UNIT/ML HUMULIN 70/30 2 HUMALOG 2 SUBCUTANEOUS KWIKPEN SUSPENSION 100 SUBCUTANEOUS UNIT/ML (70-30) INSULIN PEN 100 HUMULIN N 2 UNIT/ML, 200 KWIKPEN UNIT/ML (3 ML) SUBCUTANEOUS HUMALOG MIX 2 INSULIN PEN 100 50-50 KWIKPEN UNIT/ML (3 ML) SUBCUTANEOUS HUMULIN N 2 INSULIN PEN 100 SUBCUTANEOUS UNIT/ML (50-50) SUSPENSION 100 HUMALOG MIX 2 UNIT/ML 50-50 HUMULIN R U-100 2 SUBCUTANEOUS INJECTION SUSPENSION 100 SOLUTION 100 UNIT/ML (50-50) UNIT/ML HUMALOG MIX 2 HUMULIN R U-500 2 75-25 KWIKPEN (CONC) KWIKPEN SUBCUTANEOUS SUBCUTANEOUS INSULIN PEN 100 INSULIN PEN 500 UNIT/ML (75-25) UNIT/ML (3 ML) HUMALOG MIX 2 HUMULIN R U-500 2 75-25 (CONCENTRATED SUBCUTANEOUS ) SUSPENSION 100 SUBCUTANEOUS UNIT/ML (75-25) SOLUTION 500 HUMALOG 2 UNIT/ML SUBCUTANEOUS LANTUS 2 CARTRIDGE 100 SOLOSTAR UNIT/ML SUBCUTANEOUS HUMALOG 2 INSULIN PEN 100 SUBCUTANEOUS UNIT/ML (3 ML) SOLUTION 100 UNIT/ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 82
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LANTUS 2 RELION N 3 SUBCUTANEOUS SUBCUTANEOUS SOLUTION 100 SUSPENSION 100 UNIT/ML UNIT/ML LEVEMIR 2 RELION R 3 FLEXTOUCH INJECTION SUBCUTANEOUS SOLUTION 100 INSULIN PEN 100 UNIT/ML UNIT/ML (3 ML) MISCELLANEOUS HORMONES LEVEMIR 2 ALDURAZYME 4 LA SUBCUTANEOUS INTRAVENOUS SOLUTION 100 SOLUTION 2.9 UNIT/ML MG/5 ML NOVOLOG 3 ST ANADROL-50 3 PA FLEXPEN ORAL TABLET 50 SUBCUTANEOUS MG INSULIN PEN 100 UNIT/ML BRINEURA 4 PA; LA INTRAVENTRICU NOVOLOG MIX 3 ST LAR KIT 300 70-30 FLEXPEN MG/10 ML SUBCUTANEOUS (150MG/5ML X2) INSULIN PEN 100 UNIT/ML (70-30) cabergoline oral 1 QL tablet 0.5 mg NOVOLOG MIX 3 ST 70-30 calcitonin (salmon) 1 SUBCUTANEOUS nasal spray,non- SOLUTION 100 aerosol 200 UNIT/ML (70-30) unit/actuation NOVOLOG 3 ST calcitriol 1 PENFILL intravenous solution SUBCUTANEOUS 1 mcg/ml CARTRIDGE 100 calcitriol oral 1 UNIT/ML capsule 0.25 mcg, NOVOLOG 3 ST 0.5 mcg SUBCUTANEOUS calcitriol oral 1 SOLUTION 100 solution 1 mcg/ml UNIT/ML CERDELGA ORAL 4 PA; LA RELION 70/30 3 CAPSULE 84 MG SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 83
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits danazol oral capsule 1 PA KUVAN ORAL 4 LA 100 mg, 200 mg, 50 POWDER IN mg PACKET 500 MG desmopressin nasal 1 KUVAN ORAL 4 LA solution 0.1 mg/ml TABLET,SOLUBL (refrigerate) E 100 MG desmopressin nasal 1 LUMIZYME 4 LA spray,non-aerosol INTRAVENOUS 10 mcg/spray (0.1 RECON SOLN 50 ml) MG desmopressin oral 1 METHITEST 2 PA tablet 0.1 mg, 0.2 mg ORAL TABLET 10 MG doxercalciferol 1 intravenous solution methyltestosterone 1 PA 4 mcg/2 ml oral capsule 10 mg doxercalciferol oral 1 MYALEPT 4 PA; LA capsule 0.5 mcg, 1 SUBCUTANEOUS mcg, 2.5 mcg RECON SOLN 5 MG/ML (FINAL ELAPRASE 4 LA CONC.) INTRAVENOUS SOLUTION 6 MG/3 NAGLAZYME 4 LA ML INTRAVENOUS SOLUTION 5 MG/5 ELELYSO 4 PA; LA ML INTRAVENOUS RECON SOLN 200 NATPARA 4 PA; LA UNIT SUBCUTANEOUS CARTRIDGE 100 FABRAZYME 4 LA MCG/DOSE, 25 INTRAVENOUS MCG/DOSE, 50 RECON SOLN 35 MCG/DOSE, 75 MG, 5 MG MCG/DOSE HECTOROL 2 NOVAREL 4 PA; LA; QL INTRAVENOUS INTRAMUSCULA SOLUTION 2 R RECON SOLN MCG/ML (1 ML) 10,000 UNIT KANUMA 4 LA oxandrolone oral 1 PA INTRAVENOUS tablet 10 mg, 2.5 mg SOLUTION 2 MG/ML pamidronate 1 intravenous recon soln 30 mg, 90 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 84
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits pamidronate 1 testosterone 1 PA intravenous solution cypionate 30 mg/10 ml (3 intramuscular oil mg/ml), 60 mg/10 ml 100 mg/ml, 200 (6 mg/ml), 90 mg/10 mg/ml ml (9 mg/ml) testosterone 1 PA paricalcitol 1 enanthate intravenous solution intramuscular oil 2 mcg/ml, 5 mcg/ml 200 mg/ml paricalcitol oral 1 testosterone 1 PA capsule 1 mcg, 2 transdermal gel 50 mcg, 4 mcg mg/5 gram (1 %) SAMSCA ORAL 4 LA; QL testosterone 1 PA TABLET 15 MG, 30 transdermal gel in MG metered-dose pump 12.5 mg/ 1.25 gram SENSIPAR ORAL 2 (1 %) TABLET 30 MG, 60 MG, 90 MG testosterone 1 PA transdermal gel in SOMAVERT 4 LA packet 1 % (25 SUBCUTANEOUS mg/2.5gram), 1 % RECON SOLN 15 (50 mg/5 gram) MG, 20 MG, 25 MG, 30 MG testosterone 1 PA transdermal solution STIMATE NASAL 4 LA in metered pump SPRAY,NON- w/app 30 AEROSOL 150 mg/actuation (1.5 MCG/SPRAY (0.1 ml) ML) vasopressin in 0.9 1 STRENSIQ 4 PA; LA % nacl intravenous SUBCUTANEOUS solution 60 unit/100 SOLUTION 100 ml (0.6 unit/ml) MG/ML, 40 MG/ML VIMIZIM 4 LA INTRAVENOUS SYNAREL NASAL 3 SOLUTION 5 MG/5 SPRAY,NON- ML (1 MG/ML) AEROSOL 2 MG/ML VPRIV 4 PA; LA INTRAVENOUS TESTOPEL 4 PA; LA RECON SOLN 400 IMPLANT PELLET UNIT 75 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 85
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ZAVESCA ORAL 4 PA; LA BYETTA 2 QL CAPSULE 100 MG SUBCUTANEOUS PEN INJECTOR 10 zoledronic acid 4 LA MCG/DOSE(250 intravenous recon MCG/ML) 2.4 ML, soln 4 mg 5 MCG/DOSE (250 zoledronic acid 4 LA MCG/ML) 1.2 ML intravenous solution chlorpropamide oral 1 4 mg/5 ml tablet 100 mg, 250 ZOMETA 4 LA mg INTRAVENOUS CYCLOSET ORAL 3 PIGGYBACK 4 TABLET 0.8 MG MG/100 ML FARXIGA ORAL 2 ST; QL NON-INSULIN HYPOGLYCEMIC TABLET 10 MG, 5 AGENTS MG acarbose oral tablet 1 glimepiride oral 1 100 mg, 25 mg, 50 tablet 1 mg, 2 mg, 4 mg mg ACTOPLUS MET 2 QL glipizide oral tablet 1 XR ORAL 10 mg, 5 mg TABLET, ER MULTIPHASE 24 glipizide oral tablet 1 HR 15-1,000 MG, extended release 30-1,000 MG 24hr 10 mg, 2.5 mg, 5 mg ALOGLIPTIN 3 ST; QL ORAL TABLET glipizide-metformin 1 12.5 MG, 25 MG, oral tablet 2.5-250 6.25 MG mg, 2.5-500 mg, 5- 500 mg BYDUREON 2 QL SUBCUTANEOUS glyburide 1 PEN INJECTOR 2 micronized oral MG/0.65 ML tablet 1.5 mg, 3 mg, 6 mg BYDUREON 2 QL SUBCUTANEOUS glyburide oral tablet 1 SUSPENSION,EXT 1.25 mg, 2.5 mg, 5 ENDED REL mg RECON 2 MG glyburide-metformin 1 oral tablet 1.25-250 mg, 2.5-500 mg, 5- 500 mg
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits GLYXAMBI ORAL 2 ST; QL metformin oral 1 QL TABLET 10-5 MG, tablet extended 25-5 MG release 24 hr 500 mg, 750 mg INVOKAMET 3 ST; QL ORAL TABLET miglitol oral tablet 1 150-1,000 MG, 150- 100 mg, 25 mg, 50 500 MG, 50-1,000 mg MG, 50-500 MG nateglinide oral 1 INVOKANA ORAL 3 ST; QL tablet 120 mg, 60 mg TABLET 100 MG, NESINA ORAL 3 ST; QL 300 MG TABLET 12.5 MG, JANUMET ORAL 2 QL 25 MG, 6.25 MG TABLET 50-1,000 ONGLYZA ORAL 3 ST; QL MG, 50-500 MG TABLET 2.5 MG, 5 JANUMET XR 2 QL MG ORAL TABLET, pioglitazone oral 1 QL ER MULTIPHASE tablet 15 mg, 30 mg, 24 HR 100-1,000 45 mg MG, 50-1,000 MG, 50-500 MG pioglitazone- 1 QL glimepiride oral JANUVIA ORAL 2 QL tablet 30-2 mg, 30-4 TABLET 100 MG, mg 25 MG, 50 MG pioglitazone- 1 QL JARDIANCE 2 ST; QL metformin oral ORAL TABLET 10 tablet 15-500 mg, MG, 25 MG 15-850 mg JENTADUETO 2 QL repaglinide oral 1 ORAL TABLET tablet 0.5 mg, 1 mg, 2.5-1,000 MG, 2.5- 2 mg 500 MG, 2.5-850 MG repaglinide- 1 QL metformin oral JENTADUETO XR 2 QL tablet 1-500 mg, 2- ORAL TABLET, IR 500 mg - ER, BIPHASIC 24HR 2.5-1,000 SYMLINPEN 120 2 QL MG, 5-1,000 MG SUBCUTANEOUS PEN INJECTOR metformin oral 1 2,700 MCG/2.7 ML tablet 1,000 mg, 500 mg, 850 mg
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SYMLINPEN 60 2 QL VICTOZA 3-PAK 3 ST; QL SUBCUTANEOUS SUBCUTANEOUS PEN INJECTOR PEN INJECTOR 0.6 1,500 MCG/1.5 ML MG/0.1 ML (18 MG/3 ML) SYNJARDY ORAL 2 ST; QL TABLET 12.5-1,000 XIGDUO XR 2 ST; QL MG, 12.5-500 MG, ORAL TABLET, IR 5-1,000 MG, 5-500 - ER, BIPHASIC MG 24HR 10-1,000 MG, 10-500 MG, 5-1,000 SYNJARDY XR 2 ST; QL MG, 5-500 MG ORAL TABLET, IR - ER, BIPHASIC THYROID HORMONES 24HR 10-1,000 MG, ARMOUR 2 12.5-1,000 MG, 25- THYROID ORAL 1,000 MG, 5-1,000 TABLET 120 MG, MG 15 MG, 180 MG, TANZEUM 2 ST; QL 240 MG, 30 MG, SUBCUTANEOUS 300 MG, 60 MG, 90 PEN INJECTOR 30 MG MG/0.5 ML, 50 levothyroxine 1 MG/0.5 ML intravenous recon tolazamide oral 1 soln 200 mcg, 500 tablet 250 mg, 500 mcg mg levothyroxine oral 1 tolbutamide oral 1 tablet 100 mcg, 112 tablet 500 mg mcg, 125 mcg, 137 TRADJENTA 2 QL mcg, 150 mcg, 175 ORAL TABLET 5 mcg, 200 mcg, 25 MG mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg TRULICITY 3 QL SUBCUTANEOUS levoxyl oral tablet 1 PEN INJECTOR 100 mcg, 112 mcg, 0.75 MG/0.5 ML, 125 mcg, 137 mcg, 1.5 MG/0.5 ML 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 VICTOZA 2-PAK 3 ST; QL mcg, 75 mcg, 88 mcg SUBCUTANEOUS PEN INJECTOR 0.6 liothyronine 1 MG/0.1 ML (18 intravenous solution MG/3 ML) 10 mcg/ml
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits liothyronine oral 1 westhroid oral tablet 1 tablet 25 mcg, 5 130 mg, 195 mg, mcg, 50 mcg 32.5 mg, 65 mg, 97.5 mg nature-throid oral 1 tablet 113.75 mg, GASTROENTEROLOGY 130 mg, 146.25 mg, ANTIDIARRHEALS & 16.25 mg, 162.5 mg, 195 mg, 260 mg, ANTISPASMODICS 32.5 mg, 325 mg, anaspaz oral 1 48.75 mg, 65 mg, tablet,disintegrating 81.25 mg, 97.5 mg 0.125 mg np thyroid oral 1 atropine injection 1 tablet 120 mg, 15 solution 0.4 mg/ml, 1 mg, 30 mg, 60 mg, mg/ml 90 mg atropine injection 1 thyroid (pork) oral 1 syringe 0.05 mg/ml, tablet 30 mg, 60 mg, 0.1 mg/ml 90 mg belladonna 1 THYROLAR-1 2 alkaloids-opium ORAL TABLET rectal suppository 12.5-50 MCG 16.2-60 mg THYROLAR-1/2 2 belladonna-opium 1 ORAL TABLET rectal suppository 6.25-25 MCG 16.2-30 mg THYROLAR-1/4 2 chlordiazepoxide- 1 ORAL TABLET clidinium oral 3.1-12.5 MCG capsule 5-2.5 mg THYROLAR-2 2 dicyclomine 1 ORAL TABLET 25- intramuscular 100 MCG solution 10 mg/ml THYROLAR-3 2 dicyclomine oral 1 ORAL TABLET capsule 10 mg 37.5-150 MCG dicyclomine oral 1 unithroid oral tablet 1 solution 10 mg/5 ml 100 mcg, 112 mcg, 125 mcg, 137 mcg, dicyclomine oral 1 150 mcg, 175 mcg, tablet 20 mg 200 mcg, 25 mcg, diphenoxylate- 1 300 mcg, 50 mcg, 75 atropine oral liquid mcg, 88 mcg 2.5-0.025 mg/5 ml
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits diphenoxylate- 1 MOTOFEN ORAL 3 atropine oral tablet TABLET 1-0.025 2.5-0.025 mg MG ed-spaz oral 1 opium tincture oral 1 tablet,disintegrating tincture 10 mg/ml 0.125 mg (morphine) glycopyrrolate 1 oscimin oral tablet 1 injection solution 0.2 0.125 mg mg/ml oscimin oral 1 glycopyrrolate oral 1 tablet,disintegrating tablet 1 mg, 2 mg 0.125 mg hyoscyamine sulfate 1 oscimin sl sublingual 1 oral drops 0.125 tablet 0.125 mg mg/ml oscimin sr oral 1 hyoscyamine sulfate 1 tablet extended oral elixir 0.125 release 12 hr 0.375 mg/5 ml mg hyoscyamine sulfate 1 paregoric oral liquid 1 oral tablet 0.125 mg 2 mg/5 ml hyoscyamine sulfate 1 phenobarb-hyoscy- 1 oral tablet extended atropine-scop oral release 12 hr 0.375 tablet 16.2-0.1037 - mg 0.0194 mg hyoscyamine sulfate 1 phenohytro oral 1 oral tablet 16.2-0.1037 - tablet,disintegrating 0.0194 mg 0.125 mg symax fastabs oral 1 hyoscyamine sulfate 1 tablet,disintegrating sublingual tablet 0.125 mg 0.125 mg symax-sl sublingual 1 hyosyne oral drops 1 tablet 0.125 mg 0.125 mg/ml symax-sr oral tablet 1 hyosyne oral elixir 1 extended release 12 0.125 mg/5 ml hr 0.375 mg loperamide oral 1 MISCELLANEOUS
capsule 2 mg GASTROINTESTINAL AGENTS methscopolamine 1 AKYNZEO ORAL 2 QL oral tablet 2.5 mg, 5 CAPSULE 300-0.5 mg MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 90
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits alophen oral 5 ACA; OTC calcium acetate oral 1 tablet,delayed capsule 667 mg release (dr/ec) 5 mg calcium acetate oral 1 alosetron oral tablet 1 tablet 667 mg 0.5 mg, 1 mg CANASA RECTAL 2 ALOXI 2 QL SUPPOSITORY INTRAVENOUS 1,000 MG SOLUTION 0.25 CESAMET ORAL 3 QL MG/5 ML CAPSULE 1 MG AMITIZA ORAL 2 PA CHENODAL ORAL 4 LA CAPSULE 24 MCG, TABLET 250 MG 8 MCG CHOLBAM ORAL 4 PA; LA anucort-hc rectal 1 CAPSULE 250 MG suppository 25 mg CHOLBAM ORAL 4 PA; LA; QL ANZEMET ORAL 3 QL CAPSULE 50 MG TABLET 100 MG, 50 MG CIMZIA POWDER 4 PA; LA FOR RECONST aprepitant oral 1 QL SUBCUTANEOUS capsule 125 mg, 40 KIT 400 MG (200 mg, 80 mg MG X 2 VIALS) aprepitant oral 1 QL CIMZIA 4 PA; LA capsule,dose pack SUBCUTANEOUS 125 mg (1)- 80 mg SYRINGE KIT 400 (2) MG/2 ML (200 APRISO ORAL 2 MG/ML X 2) CAPSULE,EXTEN citrate of magnesia 5 ACA; OTC DED RELEASE oral solution 24HR 0.375 GRAM citroma oral solution 5 ACA; OTC balsalazide oral 1 capsule 750 mg clearlax oral powder 5 ACA; OTC 17 gram/dose bisacodyl oral 5 ACA; OTC tablet,delayed clearlax oral powder 5 ACA; OTC release (dr/ec) 5 mg in packet 17 gram bisa-lax oral 5 ACA; OTC colocort rectal 1 tablet,delayed enema 100 mg/60 ml release (dr/ec) 5 mg compro rectal 1 budesonide oral 1 suppository 25 mg capsule,delayed,exte nd.release 3 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 91
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits constulose oral 1 EMEND 2 QL solution 10 gram/15 (FOSAPREPITANT ml ) INTRAVENOUS RECON SOLN 150 CORTIFOAM 2 MG RECTAL FOAM 10 % (80 MG) EMEND ORAL 2 QL CAPSULE 125 MG, CREON ORAL 2 40 MG CAPSULE,DELAY ED EMEND ORAL 2 QL RELEASE(DR/EC) SUSPENSION FOR 12,000-38,000 - RECONSTITUTIO 60,000 UNIT, N 125 MG (25 MG/ 24,000-76,000 - ML FINAL CONC.) 120,000 UNIT, ENTYVIO 4 PA; LA 3,000-9,500- 15,000 INTRAVENOUS UNIT, 36,000- RECON SOLN 300 114,000- 180,000 MG UNIT, 6,000-19,000 -30,000 UNIT enulose oral solution 1 10 gram/15 ml cromolyn oral 1 concentrate 100 fleet laxative oral 5 ACA; OTC mg/5 ml tablet,delayed release (dr/ec) 5 mg CYSTADANE 4 LA ORAL POWDER 1 FOSRENOL ORAL 3 GRAM/1.7 ML POWDER IN PACKET 1,000 MG, dimenhydrinate 1 750 MG injection solution 50 mg/ml FOSRENOL ORAL 3 TABLET,CHEWAB DIPENTUM ORAL 3 ST LE 1,000 MG, 500 CAPSULE 250 MG MG, 750 MG dronabinol oral 1 gavilax oral powder 5 ACA; OTC capsule 10 mg, 2.5 17 gram/dose mg, 5 mg gavilyte-c oral recon 5 ACA droperidol injection 1 soln 240-22.72-6.72 solution 2.5 mg/ml -5.84 gram ducodyl oral 5 ACA; OTC gavilyte-g oral recon 5 ACA tablet,delayed soln 236-22.74-6.74 release (dr/ec) 5 mg -5.86 gram eliphos oral tablet 1 gavilyte-n oral recon 5 ACA 667 mg soln 420 gram You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 92
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits generlac oral 1 hydrocortisone- 1 solution 10 gram/15 pramoxine rectal ml cream 1-1 %, 2.5-1 %, 2.5-1 % (4g) gentle laxative oral 5 ACA; OTC tablet,delayed INFLECTRA 4 PA; LA release (dr/ec) 5 mg INTRAVENOUS RECON SOLN 100 gentlelax oral 5 ACA; OTC MG powder 17 gram/dose kionex (with 1 sorbitol) oral glycolax oral 5 ACA; OTC suspension 15-19.3 powder 17 gram/60 ml gram/dose kionex oral powder 1 granisetron (pf) 1 intravenous solution lactulose oral 1 1 mg/ml (1 ml), 100 solution 10 gram/15 mcg/ml ml granisetron hcl 1 lanthanum oral 1 intravenous solution tablet,chewable 1 mg/ml, 1 mg/ml (1 1,000 mg, 500 mg, ml) 750 mg granisetron hcl oral 1 QL laxaclear oral 5 ACA; OTC tablet 1 mg powder 17 gram/dose healthylax oral 5 ACA; OTC powder in packet 17 laxative (bisacodyl) 5 ACA; OTC gram oral tablet 5 mg hemmorex-hc rectal 1 laxative (bisacodyl) 5 ACA; OTC suppository 25 mg, oral tablet,delayed 30 mg release (dr/ec) 5 mg hydrocortisone 1 laxative feminine 5 ACA; OTC acetate rectal oral tablet 5 mg suppository 25 mg, laxative peg 3350 5 ACA; OTC 30 mg oral powder 17 hydrocortisone 1 gram/dose rectal enema 100 lidocaine hcl- 1 mg/60 ml hydrocortison ac hydrocortisone 1 rectal cream 3-0.5 % topical cream with perineal applicator 1 %, 2.5 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 93
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lidocaine hcl- 1 metoclopramide hcl 1 hydrocortison ac oral tablet 10 mg, 5 rectal kit 3-0.5 %, 3- mg 1 % (7 gram) metoclopramide hcl 1 lidocaine- 1 oral hydrocortisone-aloe tablet,disintegrating rectal gel 2.8-0.55 % 10 mg, 5 mg lidocaine- 1 milk of magnesia 5 ACA; OTC hydrocortisone-aloe concentrated oral rectal kit 2-2 %, 3- suspension 2,400 2.5 % (7 gram) mg/10 ml LINZESS ORAL 2 milk of magnesia 5 ACA; OTC CAPSULE 145 oral suspension 400 MCG, 290 MCG, 72 mg/5 ml MCG miralax oral powder 5 ACA; OTC magnesium citrate 5 ACA; OTC in packet 17 gram oral solution MOVANTIK ORAL 2 PA meclizine oral tablet 1 TABLET 12.5 MG, 12.5 mg, 25 mg 25 MG mesalamine oral 1 MOVIPREP ORAL 5 ACA tablet,delayed POWDER IN release (dr/ec) 1.2 PACKET 100-7.5- gram 2.691 GRAM mesalamine rectal 1 natura-lax oral 5 ACA; OTC enema 4 gram/60 ml powder 17 gram/dose mesalamine with 1 cleansing wipe OCALIVA ORAL 4 PA; LA; QL rectal enema kit 4 TABLET 10 MG, 5 gram/60 ml MG metoclopramide hcl 1 ondansetron hcl (pf) 1 injection solution 5 injection solution 4 mg/ml mg/2 ml metoclopramide hcl 1 ondansetron hcl (pf) 1 injection syringe 5 injection syringe 4 mg/ml mg/2 ml metoclopramide hcl 1 ondansetron hcl 1 oral solution 5 mg/5 intravenous solution ml 2 mg/ml
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ondansetron hcl oral 1 QL polyethylene glycol 5 ACA solution 4 mg/5 ml 3350 oral powder 17 gram/dose ondansetron hcl oral 1 QL tablet 24 mg, 4 mg, 8 polyethylene glycol 5 ACA mg 3350 oral powder in packet 17 gram ondansetron oral 1 QL tablet,disintegrating powderlax oral 5 ACA; OTC 4 mg, 8 mg powder 17 gram/dose oral saline laxative 5 ACA; OTC oral liquid 7.2-2.7 pramcort rectal 1 gram/15 ml cream 1-1 % OSMOPREP ORAL 5 ACA PREPOPIK ORAL 5 ACA TABLET 1.5 POWDER IN GRAM PACKET 10 MG- 3.5 GRAM-12 PEDIA-LAX ORAL 5 ACA; OTC GRAM TABLET,CHEWAB LE 400 MG (170 prochlorperazine 1 MG) edisylate injection solution 10 mg/2 ml peg 3350- 5 ACA (5 mg/ml), 5 mg/ml electrolytes oral recon soln 236- prochlorperazine 1 22.74-6.74 -5.86 maleate oral tablet gram, 240-22.72- 10 mg, 5 mg 6.72 -5.84 gram prochlorperazine 1 peg3350 oral 5 ACA; OTC rectal suppository 25 powder 17 mg gram/dose procto-med hc 1 peg-electrolyte soln 5 ACA topical cream with oral recon soln 420 perineal applicator gram 2.5 % peg-prep oral kit 5- 1 procto-pak topical 1 210 mg-gram cream with perineal applicator 1 % PENTASA ORAL 2 CAPSULE, proctosol hc topical 1 EXTENDED cream with perineal RELEASE 250 MG, applicator 2.5 % 500 MG proctozone-hc 1 phosphate laxative 5 ACA; OTC topical cream with oral liquid 7.2-2.7 perineal applicator gram/15 ml 2.5 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 95
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits purelax oral powder 5 ACA; OTC sodium polystyrene 1 17 gram/dose sulfonate oral powder purelax oral powder 5 ACA; OTC in packet 17 gram sodium polystyrene 1 sulfonate oral RECTIV RECTAL 2 suspension 15 OINTMENT 0.4 % gram/60 ml (W/W) sodium polystyrene 1 RELISTOR 2 PA sulfonate rectal SUBCUTANEOUS enema 30 gram/120 SOLUTION 12 ml MG/0.6 ML sps (with sorbitol) 1 RELISTOR 2 PA oral suspension 15- SUBCUTANEOUS 20 gram/60 ml SYRINGE 12 MG/0.6 ML, 8 sps (with sorbitol) 1 MG/0.4 ML rectal enema 30-40 gram/120 ml REMICADE 4 PA; LA INTRAVENOUS SUCRAID ORAL 4 LA RECON SOLN 100 SOLUTION 8,500 MG UNIT/ML RENVELA ORAL 2 sulfasalazine oral 1 TABLET 800 MG tablet 500 mg scopolamine base 1 sulfasalazine oral 1 transdermal patch 3 tablet,delayed day 1 mg over 3 release (dr/ec) 500 days mg sevelamer carbonate 1 SUPREP BOWEL 5 ACA oral powder in PREP KIT ORAL packet 0.8 gram, 2.4 RECON SOLN gram 17.5-3.13-1.6 GRAM sevelamer carbonate 1 oral tablet 800 mg trilyte with flavor 5 ACA packets oral recon smoothlax oral 5 ACA; OTC soln 420 gram powder 17 gram/dose trimethobenzamide 1 oral capsule 300 mg smoothlax oral 5 ACA; OTC powder in packet 17 gram
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits UCERIS ORAL 2 ZENPEP ORAL 3 TABLET,DELAYE CAPSULE,DELAY D AND ED EXT.RELEASE 9 RELEASE(DR/EC) MG 10,000-34,000 - 55,000 UNIT, ursodiol oral 1 15,000-51,000 - capsule 300 mg 82,000 UNIT, ursodiol oral tablet 1 20,000-68,000 - 250 mg, 500 mg 109,000 UNIT, VARUBI ORAL 2 QL 25,000-85,000- TABLET 90 MG 136,000 UNIT, 3,000-10,000- VELPHORO ORAL 3 16,000 UNIT, TABLET,CHEWAB 40,000-136,000- LE 500 MG 218,000 UNIT, VELTASSA ORAL 2 5,000-17,000 - POWDER IN 27,000 UNIT PACKET 16.8 ULCER THERAPY GRAM, 25.2 GRAM, 8.4 GRAM amoxicil- 1 QL clarithromy- VIBERZI ORAL 2 lansopraz oral TABLET 100 MG, combo pack 500- 75 MG 500-30 mg VIOKACE ORAL 2 CARAFATE ORAL 2 TABLET 10,440- SUSPENSION 100 39,150- 39,150 MG/ML UNIT, 20,880- 78,300- 78,300 cimetidine hcl oral 1 UNIT solution 300 mg/5 ml woman's laxative 5 ACA; OTC cimetidine oral 1 oral tablet,delayed tablet 200 mg, 300 release (dr/ec) 5 mg mg, 400 mg, 800 mg women's gentle 5 ACA; OTC DEXILANT ORAL 3 ST; QL laxative(bisac) oral CAPSULE,BIPHAS tablet,delayed E DELAYED release (dr/ec) 5 mg RELEAS 30 MG women's laxative 5 ACA; OTC DEXILANT ORAL 3 ST (bisacodyl) oral CAPSULE,BIPHAS tablet 5 mg E DELAYED RELEAS 60 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 97
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits esomeprazole 1 ST; QL nizatidine oral 1 magnesium oral solution 150 mg/10 capsule,delayed ml release(dr/ec) 20 mg omeprazole oral 1 QL esomeprazole 1 ST capsule,delayed magnesium oral release(dr/ec) 10 mg capsule,delayed omeprazole oral 1 release(dr/ec) 40 mg capsule,delayed esomeprazole 1 release(dr/ec) 20 sodium intravenous mg, 40 mg recon soln 20 mg, 40 omeprazole-sodium 1 ST; QL mg bicarbonate oral famotidine (pf) 1 capsule 20-1.1 mg- intravenous solution gram 20 mg/2 ml omeprazole-sodium 1 ST famotidine (pf)-nacl 1 bicarbonate oral (iso-os) intravenous capsule 40-1.1 mg- piggyback 20 mg/50 gram ml omeprazole-sodium 1 ST; QL famotidine 1 bicarbonate oral intravenous solution packet 20-1,680 mg 10 mg/ml omeprazole-sodium 1 ST famotidine oral 1 bicarbonate oral suspension 40 mg/5 packet 40-1,680 mg ml (8 mg/ml) pantoprazole 1 famotidine oral 1 intravenous recon tablet 20 mg, 40 mg soln 40 mg lansoprazole oral 1 QL pantoprazole oral 1 QL capsule,delayed tablet,delayed release(dr/ec) 15 mg release (dr/ec) 20 mg lansoprazole oral 1 capsule,delayed pantoprazole oral 1 release(dr/ec) 30 mg tablet,delayed release (dr/ec) 40 misoprostol oral 1 mg tablet 100 mcg, 200 mcg rabeprazole oral 1 ST tablet,delayed nizatidine oral 1 release (dr/ec) 20 capsule 150 mg, 300 mg mg
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ranitidine hcl 1 ARANESP (IN 4 PA; LA injection solution 25 POLYSORBATE) mg/ml, 50 mg/2 ml INJECTION (25 mg/ml) SYRINGE 10 MCG/0.4 ML, 100 ranitidine hcl oral 1 MCG/0.5 ML, 150 capsule 150 mg, 300 MCG/0.3 ML, 200 mg MCG/0.4 ML, 25 ranitidine hcl oral 1 MCG/0.42 ML, 300 syrup 15 mg/ml MCG/0.6 ML, 40 ranitidine hcl oral 1 MCG/0.4 ML, 500 tablet 150 mg, 300 MCG/ML, 60 mg MCG/0.3 ML sucralfate oral tablet 1 GRANIX 4 PA; LA 1 gram SUBCUTANEOUS SYRINGE 300 IMMUNOLOGY, VACCINES & MCG/0.5 ML, 480
BIOTECHNOLOGY MCG/0.8 ML BIOTECHNOLOGY DRUGS LEUKINE 4 PA; LA INJECTION ARANESP (IN 4 PA; LA RECON SOLN 250 POLYSORBATE) MCG INJECTION SOLUTION 100 MOZOBIL 4 LA MCG/ML, 150 SUBCUTANEOUS MCG/0.75 ML, 200 SOLUTION 24 MCG/ML, 25 MG/1.2 ML (20 MCG/ML, 300 MG/ML) MCG/ML, 40 NEULASTA 4 PA; LA; QL MCG/ML, 60 SUBCUTANEOUS MCG/ML SYRINGE 6 MG/0.6ML NEULASTA 4 PA; LA; QL SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML NEUPOGEN 4 PA; LA INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 99
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NEUPOGEN 4 PA; LA AVONEX (WITH 4 PA; LA; QL INJECTION ALBUMIN) SYRINGE 300 INTRAMUSCULA MCG/0.5 ML, 480 R KIT 30 MCG MCG/0.8 ML AVONEX 4 PA; LA; QL PROCRIT 4 PA; LA INTRAMUSCULA INJECTION R PEN INJECTOR SOLUTION 10,000 KIT 30 MCG/0.5 UNIT/ML, 2,000 ML UNIT/ML, 20,000 AVONEX 4 PA; LA; QL UNIT/2 ML, 20,000 INTRAMUSCULA UNIT/ML, 3,000 R SYRINGE KIT 30 UNIT/ML, 4,000 MCG/0.5 ML UNIT/ML, 40,000 UNIT/ML EXTAVIA 4 PA; LA; QL SUBCUTANEOUS ZARXIO 4 PA; LA KIT 0.3 MG INJECTION SYRINGE 300 EXTAVIA 4 PA; LA; QL MCG/0.5 ML, 480 SUBCUTANEOUS MCG/0.8 ML RECON SOLN 0.3 MG GROWTH HORMONES GILENYA ORAL 4 PA; LA EGRIFTA 4 LA CAPSULE 0.5 MG SUBCUTANEOUS RECON SOLN 1 glatiramer 4 PA; LA; QL MG subcutaneous syringe 20 mg/ml, 40 OMNITROPE 4 PA; LA mg/ml SUBCUTANEOUS CARTRIDGE 10 glatopa 4 PA; LA; QL MG/1.5 ML (6.7 subcutaneous MG/ML), 5 MG/1.5 syringe 20 mg/ml ML (3.3 MG/ML) LEMTRADA 4 PA; LA OMNITROPE 4 PA; LA INTRAVENOUS SUBCUTANEOUS SOLUTION 12 RECON SOLN 5.8 MG/1.2 ML MG moderiba dose pack 4 LA INTERFERONS oral tablets,dose pack 200 mg (28)- AUBAGIO ORAL 4 PA; LA 400 mg (28), 400- TABLET 14 MG, 7 400 mg (28)-mg MG (28), 600-400 mg (28)-mg (28), 600- 600 mg (28)-mg (28) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 100
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits moderiba oral tablet 4 LA REBIF REBIDOSE 4 PA; LA; QL 200 mg SUBCUTANEOUS PEN INJECTOR 22 OCREVUS 4 PA; LA MCG/0.5 ML, 44 INTRAVENOUS MCG/0.5 ML, SOLUTION 30 8.8MCG/0.2ML-22 MG/ML MCG/0.5ML (6) PEGASYS 4 LA; QL REBIF TITRATION 4 PA; LA; QL PROCLICK PACK SUBCUTANEOUS SUBCUTANEOUS PEN INJECTOR SYRINGE 135 MCG/0.5 ML, 8.8MCG/0.2ML-22 180 MCG/0.5 ML MCG/0.5ML (6) PEGASYS 4 LA; QL REVLIMID ORAL 4 PA; LA SUBCUTANEOUS CAPSULE 10 MG, SOLUTION 180 15 MG, 2.5 MG, 20 MCG/ML MG, 25 MG, 5 MG PEGASYS 4 LA; QL ribasphere oral 4 LA SUBCUTANEOUS capsule 200 mg SYRINGE 180 MCG/0.5 ML ribasphere oral 4 LA tablet 200 mg, 400 PLEGRIDY 4 PA; LA; QL mg, 600 mg SUBCUTANEOUS PEN INJECTOR ribasphere ribapak 4 LA 125 MCG/0.5 ML, oral tablets,dose 63 MCG/0.5 ML- 94 pack 200 mg (28)- MCG/0.5 ML 400 mg (28), 200 mg (7)- 400 mg (7), 400 PLEGRIDY 4 PA; LA; QL mg (7)- 400 mg (7), SUBCUTANEOUS 400-400 mg (28)-mg SYRINGE 125 (28), 600 mg (7)- MCG/0.5 ML, 63 400 mg (7), 600 mg MCG/0.5 ML- 94 (7)- 600 mg (7), 600- MCG/0.5 ML 400 mg (28)-mg POMALYST ORAL 4 PA; LA (28), 600-600 mg CAPSULE 1 MG, 2 (28)-mg (28) MG, 3 MG, 4 MG ribavirin oral 4 LA REBIF (WITH 4 PA; LA; QL capsule 200 mg ALBUMIN) ribavirin oral tablet 4 LA SUBCUTANEOUS 200 mg SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 101
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SYLATRON 4 PA; LA INTRON A 4 LA SUBCUTANEOUS INJECTION KIT 200 MCG, 300 RECON SOLN 10 MCG, 600 MCG MILLION UNIT (1 ML), 18 MILLION TECFIDERA ORAL 4 PA; LA UNIT (1 ML), 50 CAPSULE,DELAY MILLION UNIT (1 ED ML) RELEASE(DR/EC) 120 MG, 120 MG INTRON A 4 LA (14)- 240 MG (46), INJECTION 240 MG SOLUTION 10 MILLION
INTERLEUKINS UNIT/ML, 6 ACTIMMUNE 4 LA MILLION SUBCUTANEOUS UNIT/ML SOLUTION 100 KINERET 4 PA; LA MCG/0.5 ML SUBCUTANEOUS ALFERON N 2 SYRINGE 100 INJECTION MG/0.67 ML SOLUTION 5 PROLEUKIN 4 LA MILLION INTRAVENOUS UNIT/ML RECON SOLN 22 ARCALYST 4 LA MILLION UNIT SUBCUTANEOUS VACCINES & MISCELLANEOUS RECON SOLN 220 MG IMMUNOLOGICALS ILARIS (PF) 4 PA; LA ADACEL(TDAP 5 ACA SUBCUTANEOUS ADOLESN/ADULT RECON SOLN 180 )(PF) MG/1.2 ML (150 INTRAMUSCULA MG/ML) R SUSPENSION 2 LF-(2.5-5-3-5 ILARIS (PF) 4 PA; LA MCG)-5LF/0.5 ML SUBCUTANEOUS SOLUTION 150 ADACEL(TDAP 5 ACA MG/ML ADOLESN/ADULT )(PF) imiquimod topical 1 INTRAMUSCULA cream in packet 5 % R SYRINGE 2 LF- (2.5-5-3-5 MCG)- 5LF/0.5 ML
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AFLURIA 2017- 5 ACA DAPTACEL (DTAP 5 ACA 2018 (PF) PEDIATRIC) (PF) INTRAMUSCULA INTRAMUSCULA R SYRINGE 45 R SUSPENSION MCG (15 MCG X 15-10-5 LF-MCG- 3)/0.5 ML LF/0.5ML AFLURIA 2017- 5 ACA ENGERIX-B (PF) 5 ACA 2018 INTRAMUSCULA INTRAMUSCULA R SUSPENSION 20 R SUSPENSION 45 MCG/ML MCG (15 MCG X ENGERIX-B (PF) 5 ACA 3)/0.5 ML INTRAMUSCULA AFLURIA QUAD 5 ACA R SYRINGE 20 2017-2018 (PF) MCG/ML INTRAMUSCULA ENGERIX-B 5 ACA R SYRINGE 60 PEDIATRIC (PF) MCG/0.5 ML INTRAMUSCULA AFLURIA QUAD 5 ACA R SYRINGE 10 2017-2018 MCG/0.5 ML INTRAMUSCULA FLUAD 2017-2018 5 ACA R SUSPENSION 60 (65 YR UP)(PF) MCG/0.5 ML INTRAMUSCULA BEXSERO 5 ACA R SYRINGE 45 INTRAMUSCULA MCG (15 MCG X R SYRINGE 50-50- 3)/0.5 ML 50-25 MCG/0.5 ML FLUARIX QUAD 5 ACA BOOSTRIX TDAP 5 ACA 2017-2018 (PF) INTRAMUSCULA INTRAMUSCULA R SUSPENSION R SYRINGE 60 2.5-8-5 LF-MCG- MCG (15 MCG X LF/0.5ML 4)/0.5 ML BOOSTRIX TDAP 5 ACA FLUBLOK 2017- 5 ACA INTRAMUSCULA 2018 (PF) R SYRINGE 2.5-8-5 INTRAMUSCULA LF-MCG-LF/0.5ML R SOLUTION 135 MCG (45 MCG X BOTOX 4 PA; LA 3)/0.5 ML INJECTION RECON SOLN 100 UNIT, 200 UNIT
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FLUBLOK QUAD 5 ACA FLUVIRIN 2017- 5 ACA 2017-2018 (PF) 2018 (PF) INTRAMUSCULA INTRAMUSCULA R SYRINGE 180 R SYRINGE 45 MCG (45 MCG X MCG (15 MCG X 4)/0.5 ML 3)/0.5 ML FLUCELVAX 5 ACA FLUVIRIN 2017- 5 ACA QUAD 2017-2018 2018 (PF) INTRAMUSCULA INTRAMUSCULA R SUSPENSION 45 R SYRINGE 60 MCG (15 MCG X MCG (15 MCG X 3)/0.5 ML 4)/0.5 ML FLUZONE HIGH- 5 ACA FLUCELVAX 5 ACA DOSE 2017-18 (PF) QUAD 2017-2018 INTRAMUSCULA INTRAMUSCULA R SYRINGE 180 R SUSPENSION 60 MCG/0.5 ML MCG (15 MCG X FLUZONE 5 ACA 4)/0.5 ML INTRADERM FLULAVAL QUAD 5 ACA QUAD 2017-18 2017-2018 (PF) INTRADERMAL INTRAMUSCULA SYRINGE 36 R SYRINGE 60 MCG/0.1 ML MCG (15 MCG X FLUZONE QUAD 5 ACA 4)/0.5 ML 2017-2018 (PF) FLULAVAL QUAD 5 ACA INTRAMUSCULA 2017-2018 R SUSPENSION 60 INTRAMUSCULA MCG (15 MCG X R SUSPENSION 60 4)/0.5 ML MCG (15 MCG X FLUZONE QUAD 5 ACA 4)/0.5 ML 2017-2018 (PF) FLUMIST QUAD 5 ACA INTRAMUSCULA 2017-2018 NASAL R SYRINGE 60 NASAL SPRAY MCG (15 MCG X SYRINGE 4)/0.5 ML 10EXP6.5-7.5 FF FLUZONE QUAD 5 ACA UNIT/0.2 ML 2017-2018 INTRAMUSCULA R SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FLUZONE QUAD 5 ACA GRASTEK 2 PA PEDI 2017-18 (PF) SUBLINGUAL INTRAMUSCULA TABLET 2,800 R SYRINGE 30 BAU MCG (7.5 MCG X HAVRIX (PF) 5 ACA 4)/0.25 ML INTRAMUSCULA GAMASTAN S/D 4 LA R SUSPENSION INTRAMUSCULA 1,440 ELISA R SOLUTION 15-18 UNIT/ML, 720 % RANGE ELISA UNIT/0.5 ML GAMMAGARD 4 PA; LA LIQUID HAVRIX (PF) 5 ACA INJECTION INTRAMUSCULA SOLUTION 10 % R SYRINGE 1,440 ELISA UNIT/ML, GAMMAGARD S- 4 PA; LA 720 ELISA D (IGA < 1 UNIT/0.5 ML MCG/ML) INTRAVENOUS HIBERIX (PF) 5 ACA RECON SOLN 10 INTRAMUSCULA GRAM, 5 GRAM R RECON SOLN 10 MCG/0.5 ML GAMUNEX-C 4 PA; LA INJECTION HIZENTRA 4 PA; LA SOLUTION 1 SUBCUTANEOUS GRAM/10 ML (10 SOLUTION 1 %), 10 GRAM/100 GRAM/5 ML (20 ML (10 %), 2.5 %), 10 GRAM/50 GRAM/25 ML (10 ML (20 %), 2 %), 20 GRAM/200 GRAM/10 ML (20 ML (10 %), 40 %), 4 GRAM/20 ML GRAM/400 ML (10 (20 %) %), 5 GRAM/50 ML HYPERHEP B S/D 2 (10 %) INTRAMUSCULA GARDASIL 9 (PF) 5 ACA R SOLUTION 220 INTRAMUSCULA UNIT/ML, 220 R SUSPENSION 0.5 UNIT/ML (5 ML) ML HYPERHEP B S/D 2 GARDASIL 9 (PF) 5 ACA INTRAMUSCULA INTRAMUSCULA R SYRINGE 220 R SYRINGE 0.5 ML UNIT/ML
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits HYPERHEP B S-D 2 INFANRIX (DTAP) 5 ACA NEONATAL (PF) INTRAMUSCULA INTRAMUSCULA R SYRINGE 110 R SYRINGE 25-58- UNIT/0.5 ML 10 LF-MCG- LF/0.5ML HYPERRAB S/D 2 (PF) IPOL INJECTION 5 ACA INTRAMUSCULA SUSPENSION 40-8- R SOLUTION 150 32 UNIT/0.5 ML UNIT/ML IXIARO (PF) 2 HYQVIA 4 PA; LA INTRAMUSCULA SUBCUTANEOUS R SYRINGE 6 SOLUTION 10 MCG/0.5 ML GRAM /100 ML (10 MENACTRA (PF) 5 ACA %), 2.5 GRAM /25 INTRAMUSCULA ML (10 %), 20 R SOLUTION 4 GRAM /200 ML (10 MCG/0.5 ML %), 30 GRAM /300 ML (10 %), 5 MENOMUNE - 5 ACA GRAM /50 ML (10 A/C/Y/W-135 (PF) %) SUBCUTANEOUS RECON SOLN 50 IMOGAM RABIES- 2 MCG HT (PF) INTRAMUSCULA MENOMUNE - 5 ACA R SOLUTION 150 A/C/Y/W-135 UNIT/ML SUBCUTANEOUS RECON SOLN 50 IMOVAX RABIES 2 MCG VACCINE (PF) INTRAMUSCULA M-M-R II (PF) 5 ACA R RECON SOLN SUBCUTANEOUS 2.5 UNIT RECON SOLN 1,000-12,500 INFANRIX (DTAP) 5 ACA TCID50/0.5 ML (PF) INTRAMUSCULA PEDVAX HIB (PF) 5 ACA R SUSPENSION INTRAMUSCULA 25-58-10 LF-MCG- R SOLUTION 7.5 LF/0.5ML MCG/0.5 ML PNEUMOVAX 23 5 ACA INJECTION SOLUTION 25 MCG/0.5 ML
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PNEUMOVAX 23 5 ACA RECOMBIVAX HB 5 ACA INJECTION (PF) SYRINGE 25 INTRAMUSCULA MCG/0.5 ML R SUSPENSION 10 MCG/ML, 40 PREVNAR 13 (PF) 5 ACA MCG/ML, 5 INTRAMUSCULA MCG/0.5 ML R SYRINGE 0.5 ML RECOMBIVAX HB 5 ACA PRIVIGEN 4 PA; LA (PF) INTRAVENOUS INTRAMUSCULA SOLUTION 10 % R SYRINGE 10 PROQUAD (PF) 5 ACA MCG/ML, 5 SUBCUTANEOUS MCG/0.5 ML SUSPENSION FOR ROTATEQ 5 ACA RECONSTITUTIO VACCINE ORAL N 10EXP3-4.3-3- SOLUTION 2 ML 3.99 TCID50/0.5 STAMARIL (PF) 2 PROVENGE 4 LA SUBCUTANEOUS INTRAVENOUS SUSPENSION FOR SUSPENSION 50 RECONSTITUTIO MILLION N 1,000 UNIT/0.5 CELL/250 ML ML QUADRACEL (PF) 5 ACA TETANUS,DIPHTH 5 ACA INTRAMUSCULA ERIA TOX R SUSPENSION 15 PED(PF) LF-48 MCG- 5 LF INTRAMUSCULA UNIT/0.5ML R SUSPENSION 5- RABAVERT (PF) 2 25 LF UNIT/0.5 ML INTRAMUSCULA TETANUS- 5 ACA R SUSPENSION DIPHTHERIA FOR TOXOIDS-TD RECONSTITUTIO INTRAMUSCULA N 2.5 UNIT R SUSPENSION 2- RAGWITEK 2 PA 2 LF UNIT/0.5 ML SUBLINGUAL TRUMENBA 5 ACA TABLET 12 AMB INTRAMUSCULA A 1 UNIT R SYRINGE 120 MCG/0.5 ML
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TWINRIX (PF) 5 ACA VIVOTIF ORAL 2 INTRAMUSCULA CAPSULE,DELAY R SYRINGE 720 ED ELISA UNIT -20 RELEASE(DR/EC) MCG/ML 2 BILLION UNIT TYPHIM VI 2 YF-VAX (PF) 2 INTRAMUSCULA SUBCUTANEOUS R SOLUTION 25 SUSPENSION FOR MCG/0.5 ML RECONSTITUTIO N 10 EXP4.74 TYPHIM VI 2 UNIT/0.5 ML INTRAMUSCULA R SYRINGE 25 ZOSTAVAX (PF) 5 ACA MCG/0.5 ML SUBCUTANEOUS SUSPENSION FOR VARIVAX (PF) 5 ACA RECONSTITUTIO SUBCUTANEOUS N 19,400 UNIT/0.65 SUSPENSION FOR ML RECONSTITUTIO N 1,350 UNIT/0.5 MUSCULOSKELETAL & ML RHEUMATOLOGY VARIZIG 2
INTRAMUSCULA GOUT THERAPY R RECON SOLN allopurinol oral 1 125 UNIT tablet 100 mg, 300 VARIZIG 2 mg INTRAMUSCULA allopurinol sodium 1 R SOLUTION 125 intravenous recon UNIT/1.2 ML soln 500 mg VAXCHORA 2 aloprim intravenous 1 VACCINE ORAL recon soln 500 mg SUSPENSION FOR COLCRYS ORAL 2 RECONSTITUTIO TABLET 0.6 MG N 4X10EXP8 TO 2X 10EXP9 CF KRYSTEXXA 4 LA UNIT INTRAVENOUS SOLUTION 8 VIVOTIF BERNA 2 MG/ML VACCINE ORAL CAPSULE,DELAY MITIGARE ORAL 2 ED CAPSULE 0.6 MG RELEASE(DR/EC) probenecid oral 1 2 BILLION UNIT tablet 500 mg
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits probenecid- 1 TYMLOS 4 LA; QL colchicine oral SUBCUTANEOUS tablet 500-0.5 mg PEN INJECTOR 80 MCG (3,120 ULORIC ORAL 2 MCG/1.56 ML) TABLET 40 MG, 80 MG OTHER RHEUMATOLOGICALS OSTEOPOROSIS THERAPY ACTEMRA 4 PA; LA INTRAVENOUS alendronate oral 1 QL SOLUTION 200 solution 70 mg/75 ml MG/10 ML (20 alendronate oral 1 QL MG/ML), 400 tablet 10 mg, 35 mg, MG/20 ML (20 5 mg, 70 mg MG/ML), 80 MG/4 FORTEO 4 LA; QL ML (20 MG/ML) SUBCUTANEOUS ACTEMRA 4 PA; LA PEN INJECTOR 20 SUBCUTANEOUS MCG/DOSE - 600 SYRINGE 162 MCG/2.4 ML MG/0.9 ML FOSAMAX PLUS 3 ST; QL BENLYSTA 4 PA; LA D ORAL TABLET INTRAVENOUS 70 MG- 2,800 RECON SOLN 120 UNIT, 70 MG- MG, 400 MG 5,600 UNIT BENLYSTA 4 PA; LA ibandronate 4 LA SUBCUTANEOUS intravenous solution AUTO-INJECTOR 3 mg/3 ml 200 MG/ML ibandronate 4 LA BENLYSTA 4 PA; LA intravenous syringe SUBCUTANEOUS 3 mg/3 ml SYRINGE 200 ibandronate oral 1 QL MG/ML tablet 150 mg DEPEN 2 PA raloxifene oral tablet 1 TITRATABS ORAL 60 mg TABLET 250 MG risedronate oral 1 QL ENBREL 4 PA; LA; QL tablet 150 mg, 35 SUBCUTANEOUS mg, 5 mg RECON SOLN 25 MG (1 ML) risedronate oral 1 QL tablet,delayed release (dr/ec) 35 mg
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ENBREL 4 PA; LA; QL OTEZLA ORAL 4 PA; LA SUBCUTANEOUS TABLET 30 MG SYRINGE 25 OTEZLA 4 PA; LA MG/0.5ML (0.51), STARTER ORAL 50 MG/ML (0.98 TABLETS,DOSE ML) PACK 10 MG (4)- ENBREL 4 PA; LA; QL 20 MG (4)-30 MG SURECLICK (47) SUBCUTANEOUS RIDAURA ORAL 2 PEN INJECTOR 50 CAPSULE 3 MG MG/ML (0.98 ML) SAVELLA ORAL 2 ST; QL HUMIRA 4 PA; LA; QL TABLET 100 MG, PEDIATRIC 12.5 MG, 25 MG, 50 CROHN'S START MG SUBCUTANEOUS SYRINGE KIT 40 SAVELLA ORAL 2 ST; QL MG/0.8 ML TABLETS,DOSE PACK 12.5 MG (5)- HUMIRA PEN 4 PA; LA; QL 25 MG(8)-50 CROHN'S-UC-HS MG(42) START SUBCUTANEOUS SIMPONI ARIA 4 PA; LA PEN INJECTOR INTRAVENOUS KIT 40 MG/0.8 ML SOLUTION 12.5 MG/ML HUMIRA PEN 4 PA; LA; QL SUBCUTANEOUS SIMPONI 4 PA; LA PEN INJECTOR SUBCUTANEOUS KIT 40 MG/0.8 ML PEN INJECTOR 100 MG/ML, 50 HUMIRA 4 PA; LA; QL MG/0.5 ML SUBCUTANEOUS SYRINGE KIT 10 SIMPONI 4 PA; LA MG/0.2 ML, 20 SUBCUTANEOUS MG/0.4 ML, 40 SYRINGE 100 MG/0.8 ML MG/ML, 50 MG/0.5 ML leflunomide oral 1 QL tablet 10 mg, 20 mg XELJANZ ORAL 4 PA; LA TABLET 5 MG ORENCIA 4 PA; LA SUBCUTANEOUS XELJANZ XR 4 PA; LA SYRINGE 125 ORAL TABLET MG/ML, 50 MG/0.4 EXTENDED ML, 87.5 MG/0.7 RELEASE 24 HR ML 11 MG
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits OBSTETRICS & covaryx oral tablet 1 1.25-2.5 mg GYNECOLOGY CRINONE 2 DIAPHRAGMS AND OTHER NON- VAGINAL GEL 4 ORAL CONTRACEPTIVES % CAYA 5 ACA deblitane oral tablet 5 ACA CONTOURED 0.35 mg VAGINAL DIAPHRAGM 60- DEPO-PROVERA 2 85 MM INTRAMUSCULA R SOLUTION 400 FC2 FEMALE 5 ACA; OTC MG/ML CONDOM DUAVEE ORAL 3 FEMCAP 5 ACA TABLET 0.45-20 VAGINAL DEVICE MG 22 MM eemt hs oral tablet 1 MIRENA 5 ACA; LA 0.625-1.25 mg INTRAUTERINE INTRAUTERINE eemt oral tablet 1 DEVICE 20 1.25-2.5 mg MCG/24 HR (5 errin oral tablet 0.35 5 ACA YEARS) mg PARAGARD T 5 ACA; LA ESTRACE 2 380A VAGINAL CREAM INTRAUTERINE 0.01 % (0.1 INTRAUTERINE MG/GRAM) DEVICE 380 SQUARE MM estradiol oral tablet 1 0.5 mg, 1 mg, 2 mg WIDE-SEAL 5 ACA DIAPHRAGM 60 estradiol 1 QL VAGINAL transdermal patch DIAPHRAGM 60 semiweekly 0.025 MM mg/24 hr, 0.0375 mg/24 hr, 0.05 ESTROGENS & PROGESTINS mg/24 hr, 0.075 amabelz oral tablet 1 mg/24 hr, 0.1 mg/24 0.5-0.1 mg, 1-0.5 mg hr camila oral tablet 5 ACA 0.35 mg covaryx h.s. oral 1 tablet 0.625-1.25 mg
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits estradiol 1 QL jinteli oral tablet 1-5 1 transdermal patch mg-mcg weekly 0.025 mg/24 jolivette oral tablet 5 ACA hr, 0.0375 mg/24 hr, 0.35 mg 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 lopreeza oral tablet 1 mg/24 hr, 0.1 mg/24 0.5-0.1 mg, 1-0.5 mg hr lyza oral tablet 0.35 5 ACA estradiol vaginal 1 mg tablet 10 mcg MAKENA 4 LA estradiol valerate 1 INTRAMUSCULA intramuscular oil 20 R OIL 250 MG/ML, mg/ml, 40 mg/ml 250 MG/ML (1 ML) estradiol- 1 medroxyprogesteron 5 ACA; QL norethindrone acet e intramuscular oral tablet 0.5-0.1 suspension 150 mg, 1-0.5 mg mg/ml estrogens- 1 medroxyprogesteron 5 ACA; QL methyltestosterone e intramuscular oral tablet 0.625- syringe 150 mg/ml 1.25 mg, 1.25-2.5 medroxyprogesteron 1 mg e oral tablet 10 mg, estropipate oral 1 2.5 mg, 5 mg tablet 0.75 mg, 1.5 MENEST ORAL 2 mg, 3 mg TABLET 0.3 MG, fyavolv oral tablet 1 0.625 MG, 1.25 MG 0.5-2.5 mg-mcg, 1-5 mimvey lo oral 1 mg-mcg tablet 0.5-0.1 mg heather oral tablet 5 ACA mimvey oral tablet 1 0.35 mg 1-0.5 mg hydroxyprogesterone 1 nora-be oral tablet 5 ACA caproate 0.35 mg intramuscular oil 250 mg/ml norethindrone 5 ACA (contraceptive) oral jencycla oral tablet 5 ACA tablet 0.35 mg 0.35 mg norethindrone 1 jevantique lo oral 1 acetate oral tablet 5 tablet 0.5-2.5 mg- mg mcg
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits norethindrone ac-eth 1 GYNAZOLE-1 3 estradiol oral tablet VAGINAL CREAM 0.5-2.5 mg-mcg, 1-5 2 % mg-mcg gynol ii vaginal gel 3 5 ACA; OTC norlyda oral tablet 5 ACA % 0.35 mg isoxsuprine oral 1 norlyroc oral tablet 5 ACA tablet 10 mg, 20 mg 0.35 mg LUPANETA PACK 4 PA; LA PREMARIN 3 (1 MONTH) KIT. INJECTION SYRINGE AND RECON SOLN 25 TABLET 3.75 MG - MG 5 MG (30) PREMARIN ORAL 3 LUPANETA PACK 4 PA; LA TABLET 0.3 MG, (3 MONTH) KIT. 0.45 MG, 0.625 MG, SYRINGE AND 0.9 MG, 1.25 MG TABLET 11.25 MG -5 MG (90) PREMARIN 3 VAGINAL CREAM metronidazole 1 0.625 MG/GRAM vaginal gel 0.75 % progesterone 4 LA miconazole-3 1 intramuscular oil 50 vaginal suppository mg/ml 200 mg progesterone 1 NEXPLANON 5 ACA; LA micronized oral SUBDERMAL capsule 100 mg, 200 IMPLANT 68 MG mg NUVARING 5 ACA sharobel oral tablet 5 ACA VAGINAL RING 0.35 mg 0.12-0.015 MG/24 HR yuvafem vaginal 1 tablet 10 mcg OSPHENA ORAL 3 PA TABLET 60 MG MISCELLANEOUS OB/GYN terconazole vaginal 1 clindamycin 1 cream 0.4 %, 0.8 % phosphate vaginal cream 2 % terconazole vaginal 1 suppository 80 mg CONCEPTROL 5 ACA; OTC VAGINAL GEL 4 % fem ph vaginal gel 1 0.9-0.025 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 113
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TODAY 5 ACA; OTC amethia oral 5 ACA CONTRACEPTIVE tablets,dose pack,3 SPONGE month 0.15 mg-30 VAGINAL mcg (84)/10 mcg (7) CONTRACEPTIVE amethyst oral tablet 5 ACA SPONGE 1,000 MG 90-20 mcg tranexamic acid oral 1 apri oral tablet 0.15- 5 ACA tablet 650 mg 0.03 mg vaginal 5 ACA; OTC aranelle (28) oral 5 ACA contraceptive foam tablet 0.5/1/0.5-35 vaginal foam 12.5 % mg-mcg vandazole vaginal 1 ashlyna oral 5 ACA gel 0.75 % tablets,dose pack,3 VCF 5 ACA; OTC month 0.15 mg-30 CONTRACEPTIVE mcg (84)/10 mcg (7) FILM VAGINAL aubra oral tablet 5 ACA FILM 28 % 0.1-20 mg-mcg VCF 5 ACA; OTC aviane oral tablet 5 ACA CONTRACEPTIVE 0.1-20 mg-mcg GEL VAGINAL GEL 4 % azurette (28) oral 5 ACA tablet 0.15-0.02 xulane transdermal 5 ACA mgx21 /0.01 mg x 5 patch weekly 150-35 mcg/24 hr balziva (28) oral 5 ACA tablet 0.4-35 mg- ORAL CONTRACEPTIVES & mcg RELATED AGENTS bekyree (28) oral 5 ACA altavera (28) oral 5 ACA tablet 0.15-0.02 tablet 0.15-0.03 mg mgx21 /0.01 mg x 5 alyacen 1/35 (28) 5 ACA blisovi 24 fe oral 5 ACA oral tablet 1-35 mg- tablet 1 mg-20 mcg mcg (24)/75 mg (4) alyacen 7/7/7 (28) 5 ACA blisovi fe 1.5/30 (28) 5 ACA oral tablet 0.5/0.75/1 oral tablet 1.5 mg-30 mg- 35 mcg mcg (21)/75 mg (7) amethia lo oral 5 ACA blisovi fe 1/20 (28) 5 ACA tablets,dose pack,3 oral tablet 1 mg-20 month 0.10 mg-20 mcg (21)/75 mg (7) mcg (84)/10 mcg (7) briellyn oral tablet 5 ACA 0.4-35 mg-mcg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 114
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits camrese lo oral 5 ACA desog- 5 ACA tablets,dose pack,3 e.estradiol/e.estradio month 0.10 mg-20 l oral tablet 0.15- mcg (84)/10 mcg (7) 0.02 mgx21 /0.01 mg x 5 camrese oral 5 ACA tablets,dose pack,3 desogestrel-ethinyl 5 ACA month 0.15 mg-30 estradiol oral tablet mcg (84)/10 mcg (7) 0.15-0.03 mg caziant (28) oral 5 ACA drospirenone- 5 ACA tablet 0.1/.125/.15- e.estradiol-lm.fa 25 mg-mcg oral tablet 3-0.02- 0.451 mg (24) (4) chateal oral tablet 5 ACA 0.15-0.03 mg drospirenone-ethinyl 5 ACA estradiol oral tablet cryselle (28) oral 5 ACA 3-0.02 mg, 3-0.03 tablet 0.3-30 mg- mg mcg econtra ez oral 5 ACA; OTC; cyclafem 1/35 (28) 5 ACA tablet 1.5 mg QL oral tablet 1-35 mg- mcg elinest oral tablet 5 ACA 0.3-30 mg-mcg cyclafem 7/7/7 (28) 5 ACA oral tablet 0.5/0.75/1 ELLA ORAL 5 ACA; QL mg- 35 mcg TABLET 30 MG cyred oral tablet 5 ACA emoquette oral 5 ACA 0.15-0.03 mg tablet 0.15-0.03 mg dasetta 1/35 (28) 5 ACA enpresse oral tablet 5 ACA oral tablet 1-35 mg- 50-30 (6)/75-40 mcg (5)/125-30(10) dasetta 7/7/7 (28) 5 ACA enskyce oral tablet 5 ACA oral tablet 0.5/0.75/1 0.15-0.03 mg mg- 35 mcg estarylla oral tablet 5 ACA daysee oral 5 ACA 0.25-35 mg-mcg tablets,dose pack,3 ethynodiol diac-eth 5 ACA month 0.15 mg-30 estradiol oral tablet mcg (84)/10 mcg (7) 1-35 mg-mcg, 1-50 delyla (28) oral 5 ACA mg-mcg tablet 0.1-20 mg- falmina (28) oral 5 ACA mcg tablet 0.1-20 mg- mcg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 115
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fayosim oral 5 ACA kaitlib fe oral 5 ACA tablets,dose pack,3 tablet,chewable month 0.15 mg-20 0.8mg-25mcg(24) mcg/ 0.15 mg-25 and 75 mg (4) mcg kariva (28) oral 5 ACA femynor oral tablet 5 ACA tablet 0.15-0.02 0.25-35 mg-mcg mgx21 /0.01 mg x 5 gianvi (28) oral 5 ACA kelnor 1/35 (28) oral 5 ACA tablet 3-0.02 mg tablet 1-35 mg-mcg gildagia oral tablet 5 ACA kimidess (28) oral 5 ACA 0.4-35 mg-mcg tablet 0.15-0.02 mgx21 /0.01 mg x 5 introvale oral 5 ACA tablets,dose pack,3 kurvelo oral tablet 5 ACA month 0.15 mg-30 0.15-0.03 mg mcg l norgest/e.estradiol- 5 ACA isibloom oral tablet 5 ACA e.estrad oral 0.15-0.03 mg tablets,dose pack,3 month 0.10 mg-20 jolessa oral 5 ACA mcg (84)/10 mcg (7), tablets,dose pack,3 0.15 mg-20 mcg/ month 0.15 mg-30 0.15 mg-25 mcg, mcg 0.15 mg-30 mcg juleber oral tablet 5 ACA (84)/10 mcg (7) 0.15-0.03 mg larin 1.5/30 (21) 5 ACA junel 1.5/30 (21) 5 ACA oral tablet 1.5-30 oral tablet 1.5-30 mg-mcg mg-mcg larin 1/20 (21) oral 5 ACA junel 1/20 (21) oral 5 ACA tablet 1-20 mg-mcg tablet 1-20 mg-mcg larin 24 fe oral 5 ACA junel fe 1.5/30 (28) 5 ACA tablet 1 mg-20 mcg oral tablet 1.5 mg-30 (24)/75 mg (4) mcg (21)/75 mg (7) larin fe 1.5/30 (28) 5 ACA junel fe 1/20 (28) 5 ACA oral tablet 1.5 mg-30 oral tablet 1 mg-20 mcg (21)/75 mg (7) mcg (21)/75 mg (7) larin fe 1/20 (28) 5 ACA junel fe 24 oral 5 ACA oral tablet 1 mg-20 tablet 1 mg-20 mcg mcg (21)/75 mg (7) (24)/75 mg (4) larissia oral tablet 5 ACA 0.1-20 mg-mcg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 116
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits layolis fe oral 5 ACA lutera (28) oral 5 ACA tablet,chewable tablet 0.1-20 mg- 0.8mg-25mcg(24) mcg and 75 mg (4) marlissa oral tablet 5 ACA leena 28 oral tablet 5 ACA 0.15-0.03 mg 0.5/1/0.5-35 mg-mcg melodetta 24 fe oral 5 ACA lessina oral tablet 5 ACA tablet,chewable 1 0.1-20 mg-mcg mg-20 mcg(24) /75 mg (4) levonest (28) oral 5 ACA tablet 50-30 (6)/75- mibelas 24 fe oral 5 ACA 40 (5)/125-30(10) tablet,chewable 1 mg-20 mcg(24) /75 levonorgestrel- 5 ACA mg (4) ethinyl estrad oral tablet 0.1-20 mg- microgestin 1.5/30 5 ACA mcg, 0.15-0.03 mg, (21) oral tablet 1.5- 90-20 mcg 30 mg-mcg levonorgestrel- 5 ACA microgestin 1/20 5 ACA ethinyl estrad oral (21) oral tablet 1-20 tablets,dose pack,3 mg-mcg month 0.15 mg-30 microgestin fe 1.5/30 5 ACA mcg (28) oral tablet 1.5 levonorg-eth estrad 5 ACA mg-30 mcg (21)/75 triphasic oral tablet mg (7) 50-30 (6)/75-40 microgestin fe 1/20 5 ACA (5)/125-30(10) (28) oral tablet 1 levora-28 oral tablet 5 ACA mg-20 mcg (21)/75 0.15-0.03 mg mg (7) lillow oral tablet 5 ACA mono-linyah oral 5 ACA 0.15-0.03 mg tablet 0.25-35 mg- mcg lomedia 24 fe oral 5 ACA tablet 1 mg-20 mcg mononessa (28) oral 5 ACA (24)/75 mg (4) tablet 0.25-35 mg- mcg loryna (28) oral 5 ACA tablet 3-0.02 mg my way oral tablet 5 ACA; OTC; 1.5 mg QL low-ogestrel (28) 5 ACA oral tablet 0.3-30 myzilra oral tablet 5 ACA mg-mcg 50-30 (6)/75-40 (5)/125-30(10)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 117
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits necon 0.5/35 (28) 5 ACA nortrel 0.5/35 (28) 5 ACA oral tablet 0.5-35 oral tablet 0.5-35 mg-mcg mg-mcg necon 1/50 (28) oral 5 ACA nortrel 1/35 (21) 5 ACA tablet 1-50 mg-mcg oral tablet 1-35 mg- mcg necon 7/7/7 (28) 5 ACA oral tablet 0.5/0.75/1 nortrel 1/35 (28) 5 ACA mg- 35 mcg oral tablet 1-35 mg- mcg next choice one dose 5 ACA; OTC; oral tablet 1.5 mg QL nortrel 7/7/7 (28) 5 ACA oral tablet 0.5/0.75/1 nikki (28) oral tablet 5 ACA mg- 35 mcg 3-0.02 mg ocella oral tablet 3- 5 ACA noreth-ethinyl 5 ACA 0.03 mg estradiol-iron oral tablet,chewable ogestrel (28) oral 5 ACA 0.4mg-35mcg(21) tablet 0.5-50 mg- and 75 mg (7), mcg 0.8mg-25mcg(24) opcicon one-step 5 ACA; OTC; and 75 mg (4) oral tablet 1.5 mg QL norethindrone ac-eth 5 ACA option-2 oral tablet 5 ACA; OTC; estradiol oral tablet 1.5 mg QL 1-20 mg-mcg orsythia oral tablet 5 ACA norethindrone- 5 ACA 0.1-20 mg-mcg e.estradiol-iron oral tablet 1 mg-20 mcg philith oral tablet 5 ACA (21)/75 mg (7), 1 0.4-35 mg-mcg mg-20 mcg (24)/75 pimtrea (28) oral 5 ACA mg (4) tablet 0.15-0.02 norethindrone- 5 ACA mgx21 /0.01 mg x 5 e.estradiol-iron oral pirmella oral tablet 5 ACA tablet,chewable 1 0.5/0.75/1 mg- 35 mg-20 mcg(24) /75 mcg, 1-35 mg-mcg mg (4) PLAN B ONE-STEP 2 OTC; QL norgestimate-ethinyl 5 ACA ORAL TABLET 1.5 estradiol oral tablet MG 0.18/0.215/0.25 mg- 25 mcg, portia oral tablet 5 ACA 0.18/0.215/0.25 mg- 0.15-0.03 mg 35 mcg (28), 0.25-35 previfem oral tablet 5 ACA mg-mcg 0.25-35 mg-mcg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 118
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits quasense oral 5 ACA tri-legest fe oral 5 ACA tablets,dose pack,3 tablet 1-20(5)/1- month 0.15 mg-30 30(7) /1mg-35mcg mcg (9) rajani oral tablet 3- 5 ACA tri-linyah oral tablet 5 ACA 0.02-0.451 mg (24) 0.18/0.215/0.25 mg- (4) 35 mcg (28) reclipsen (28) oral 5 ACA tri-lo-estarylla oral 5 ACA tablet 0.15-0.03 mg tablet 0.18/0.215/0.25 mg- rivelsa oral 5 ACA 25 mcg tablets,dose pack,3 month 0.15 mg-20 tri-lo-marzia oral 5 ACA mcg/ 0.15 mg-25 tablet mcg 0.18/0.215/0.25 mg- 25 mcg setlakin oral 5 ACA tablets,dose pack,3 tri-lo-sprintec oral 5 ACA month 0.15 mg-30 tablet mcg 0.18/0.215/0.25 mg- 25 mcg sprintec (28) oral 5 ACA tablet 0.25-35 mg- trinessa (28) oral 5 ACA mcg tablet 0.18/0.215/0.25 mg- sronyx oral tablet 5 ACA 35 mcg (28) 0.1-20 mg-mcg trinessa lo oral 5 ACA syeda oral tablet 3- 5 ACA tablet 0.03 mg 0.18/0.215/0.25 mg- tarina fe 1/20 (28) 5 ACA 25 mcg oral tablet 1 mg-20 tri-previfem (28) 5 ACA mcg (21)/75 mg (7) oral tablet tilia fe oral tablet 1- 5 ACA 0.18/0.215/0.25 mg- 20(5)/1-30(7) /1mg- 35 mcg (28) 35mcg (9) tri-sprintec (28) oral 5 ACA tri femynor oral 5 ACA tablet tablet 0.18/0.215/0.25 mg- 0.18/0.215/0.25 mg- 35 mcg (28) 35 mcg (28) trivora (28) oral 5 ACA tri-estarylla oral 5 ACA tablet 50-30 (6)/75- tablet 40 (5)/125-30(10) 0.18/0.215/0.25 mg- 35 mcg (28)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 119
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits velivet triphasic 5 ACA bacitracin 1 regimen (28) oral ophthalmic (eye) tablet 0.1/.125/.15- ointment 500 25 mg-mcg unit/gram vestura (28) oral 5 ACA bacitracin- 1 tablet 3-0.02 mg polymyxin b ophthalmic (eye) vienva oral tablet 5 ACA ointment 500-10,000 0.1-20 mg-mcg unit/gram viorele (28) oral 5 ACA BESIVANCE 3 tablet 0.15-0.02 OPHTHALMIC mgx21 /0.01 mg x 5 (EYE) vyfemla (28) oral 5 ACA DROPS,SUSPENSI tablet 0.4-35 mg- ON 0.6 % mcg ciprofloxacin hcl 1 wera (28) oral tablet 5 ACA ophthalmic (eye) 0.5-35 mg-mcg drops 0.3 % wymzya fe oral 5 ACA erythromycin 1 tablet,chewable ophthalmic (eye) 0.4mg-35mcg(21) ointment 5 mg/gram and 75 mg (7) (0.5 %) zarah oral tablet 3- 5 ACA gatifloxacin 1 0.03 mg ophthalmic (eye) zenchent (28) oral 5 ACA drops 0.5 % tablet 0.4-35 mg- gentak ophthalmic 1 mcg (eye) ointment 0.3 % zovia 1/35e (28) oral 5 ACA (3 mg/gram) tablet 1-35 mg-mcg gentamicin 1 zovia 1/50e (28) oral 5 ACA ophthalmic (eye) tablet 1-50 mg-mcg drops 0.3 % gentamicin 1 OXYTOCICS ophthalmic (eye) methergine oral 1 ointment 0.3 % (3 tablet 0.2 mg mg/gram) OPHTHALMOLOGY levofloxacin 1 ophthalmic (eye) ANTIBIOTICS drops 0.5 % AZASITE 3 OPHTHALMIC (EYE) DROPS 1 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 120
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MOXEZA 3 tobramycin 1 OPHTHALMIC ophthalmic (eye) (EYE) DROPS, drops 0.3 % VISCOUS 0.5 % ANTIVIRALS moxifloxacin 1 trifluridine 1 ophthalmic (eye) ophthalmic (eye) drops 0.5 % drops 1 % NATACYN 2 ZIRGAN 3 OPHTHALMIC OPHTHALMIC (EYE) (EYE) GEL 0.15 % DROPS,SUSPENSI ON 5 % BETA-BLOCKERS neomycin- 1 betaxolol ophthalmic 1 bacitracin- (eye) drops 0.5 % polymyxin carteolol ophthalmic 1 ophthalmic (eye) (eye) drops 1 % ointment 3.5-400- 10,000 mg-unit- levobunolol 1 unit/g ophthalmic (eye) drops 0.5 % neomycin- 1 polymyxin- metipranolol 1 gramicidin ophthalmic (eye) ophthalmic (eye) drops 0.3 % drops 1.75 mg- timolol maleate 1 10,000 unit- ophthalmic (eye) 0.025mg/ml drops 0.25 %, 0.5 % neo-polycin 1 timolol maleate 1 ophthalmic (eye) ophthalmic (eye) gel ointment 3.5-400- forming solution 10,000 mg-unit- 0.25 %, 0.5 % unit/g CHOLINESTERASE INHIBITOR ofloxacin ophthalmic 1 (eye) drops 0.3 % MIOTICS polycin ophthalmic 1 PHOSPHOLINE 2 (eye) ointment 500- IODIDE 10,000 unit/gram OPHTHALMIC (EYE) DROPS polymyxin b sulf- 1 0.125 % trimethoprim ophthalmic (eye) CYCLOPLEGIC MYDRIATICS drops 10,000 unit- 1 atropine ophthalmic 1 mg/ml (eye) drops 1 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 121
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits atropine ophthalmic 1 BEPREVE 3 (eye) ointment 1 % OPHTHALMIC (EYE) DROPS 1.5 cyclopentolate 1 % ophthalmic (eye) drops 0.5 %, 1 %, 2 cromolyn 1 % ophthalmic (eye) drops 4 % homatropaire 1 ophthalmic (eye) CYSTARAN 4 LA drops 5 % OPHTHALMIC (EYE) DROPS 0.44 homatropine hbr 1 % ophthalmic (eye) drops 5 % EMADINE 3 OPHTHALMIC tropicamide 1 (EYE) DROPS 0.05 ophthalmic (eye) % drops 0.5 %, 1 % epinastine 1 DIRECT ACTING MIOTICS ophthalmic (eye) pilocarpine hcl 1 drops 0.05 % ophthalmic (eye) EYLEA 4 LA drops 1 %, 2 %, 4 % INTRAVITREAL MISCELLANEOUS SOLUTION 2
OPHTHALMOLOGICS MG/0.05 ML ALOCRIL 3 flucaine ophthalmic 1 OPHTHALMIC (eye) drops 0.25-0.5 (EYE) DROPS 2 % % ALOMIDE 3 fluorescein- 1 OPHTHALMIC proparacaine (EYE) DROPS 0.1 ophthalmic (eye) % drops 0.25-0.5 % altacaine ophthalmic 1 flurox ophthalmic 1 (eye) drops 0.5 % (eye) drops 0.25-0.4 % altafluor ophthalmic 1 (eye) drops 0.25-0.4 JETREA (PF) 4 LA % INTRAVITREAL SOLUTION 0.125 azelastine 1 MG/0.1 ML (1.25 ophthalmic (eye) MG/ML) drops 0.05 %
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 122
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LASTACAFT 3 bromfenac 1 OPHTHALMIC ophthalmic (eye) (EYE) DROPS 0.25 drops 0.09 % % diclofenac sodium 1 LUCENTIS 4 LA ophthalmic (eye) INTRAVITREAL drops 0.1 % SOLUTION 0.3 flurbiprofen sodium 1 MG/0.05 ML, 0.5 ophthalmic (eye) MG/0.05 ML drops 0.03 % LUCENTIS 4 LA ILEVRO 3 INTRAVITREAL OPHTHALMIC SYRINGE 0.5 (EYE) MG/0.05 ML DROPS,SUSPENSI olopatadine 1 ON 0.3 % ophthalmic (eye) ketorolac 1 drops 0.1 %, 0.2 % ophthalmic (eye) proparacaine 1 drops 0.4 %, 0.5 % ophthalmic (eye) NEVANAC 3 drops 0.5 % OPHTHALMIC RESTASIS 2 PA; QL (EYE) MULTIDOSE DROPS,SUSPENSI OPHTHALMIC ON 0.1 % (EYE) DROPS 0.05
% ORAL DRUGS FOR GLAUCOMA acetazolamide oral 1 RESTASIS 2 PA; QL capsule, extended OPHTHALMIC release 500 mg (EYE) DROPPERETTE acetazolamide oral 1 0.05 % tablet 125 mg, 250 mg tetcaine ophthalmic 1 (eye) drops 0.5 % acetazolamide 1 sodium injection tetracaine hcl (pf) 1 recon soln 500 mg ophthalmic (eye) drops 0.5 % methazolamide oral 1 tablet 25 mg, 50 mg tetracaine hcl 1 ophthalmic (eye) OTHER GLAUCOMA DRUGS drops 0.5 % NON-STEROIDAL ANTI-
INFLAMMATORY AGENTS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 123
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AZOPT 3 neomycin- 1 OPHTHALMIC bacitracin-poly-hc (EYE) ophthalmic (eye) DROPS,SUSPENSI ointment 3.5-400- ON 1 % 10,000 mg-unit/g- 1% bimatoprost 1 ophthalmic (eye) neomycin-polymyxin 1 drops 0.03 % b-dexameth ophthalmic (eye) COMBIGAN 3 drops,suspension OPHTHALMIC 3.5mg/ml-10,000 (EYE) DROPS 0.2- unit/ml-0.1 % 0.5 % neomycin-polymyxin 1 dorzolamide 1 b-dexameth ophthalmic (eye) ophthalmic (eye) drops 2 % ointment 3.5 mg/g- dorzolamide-timolol 1 10,000 unit/g-0.1 % ophthalmic (eye) neomycin- 1 drops 22.3-6.8 polymyxin-hc mg/ml ophthalmic (eye) latanoprost 1 drops,suspension ophthalmic (eye) 3.5-10,000-10 mg- drops 0.005 % unit-mg/ml miostat intraocular 1 neo-polycin hc 1 solution 0.01 % ophthalmic (eye) SIMBRINZA 3 ointment 3.5-400- OPHTHALMIC 10,000 mg-unit/g- (EYE) 1% DROPS,SUSPENSI tobramycin- 1 ON 1-0.2 % dexamethasone TRAVATAN Z 3 ophthalmic (eye) OPHTHALMIC drops,suspension (EYE) DROPS 0.3-0.1 % 0.004 % STEROIDS ZIOPTAN (PF) 3 ST dexamethasone 1 OPHTHALMIC sodium phosphate (EYE) ophthalmic (eye) DROPPERETTE drops 0.1 % 0.0015 % STEROID-ANTIBIOTIC
COMBINATIONS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 124
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DUREZOL 3 sulfacetamide- 1 OPHTHALMIC prednisolone (EYE) DROPS 0.05 ophthalmic (eye) % drops 10 %-0.23 % (0.25 %) fluorometholone 1 ophthalmic (eye) SULFONAMIDES drops,suspension 0.1 sulfacetamide 1 % sodium ophthalmic LOTEMAX 3 (eye) drops 10 % OPHTHALMIC sulfacetamide 1 (EYE) DROPS,GEL sodium ophthalmic 0.5 % (eye) ointment 10 % LOTEMAX 3
OPHTHALMIC SYMPATHOMIMETICS (EYE) ALPHAGAN P 2 DROPS,SUSPENSI OPHTHALMIC ON 0.5 % (EYE) DROPS 0.1 LOTEMAX 3 % OPHTHALMIC apraclonidine 1 (EYE) OINTMENT ophthalmic (eye) 0.5 % drops 0.5 % OZURDEX 4 LA brimonidine 1 INTRAVITREAL ophthalmic (eye) IMPLANT 0.7 MG drops 0.15 %, 0.2 % PRED MILD 2 VASOCONSTRICTOR
OPHTHALMIC DECONGESTANTS (EYE) DROPS,SUSPENSI phenylephrine hcl 1 ON 0.12 % ophthalmic (eye) drops 10 %, 2.5 % prednisolone acetate 1 ophthalmic (eye) RESPIRATORY, ALLERGY,
drops,suspension 1 COUGH & COLD % ANTIHISTAMINE &
prednisolone sodium 1 ANTIALLERGENIC AGENTS phosphate ophthalmic (eye) adrenalin injection 1 drops 1 % solution 1 mg/ml, 1 mg/ml (1 ml) STEROID-SULFONAMIDE
COMBINATIONS carbinoxamine 1 maleate oral liquid 4 mg/5 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 125
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits carbinoxamine 1 EPIPEN 2-PAK 2 ST; QL maleate oral tablet 4 INJECTION AUTO- mg INJECTOR 0.3 MG/0.3 ML cetirizine oral 1 solution 1 mg/ml EPIPEN JR 2-PAK 2 ST; QL INJECTION AUTO- clemastine oral 1 INJECTOR 0.15 tablet 2.68 mg MG/0.3 ML cyproheptadine oral 1 hydroxyzine hcl 1 syrup 2 mg/5 ml intramuscular cyproheptadine oral 1 solution 25 mg/ml, tablet 4 mg 50 mg/ml desloratadine oral 1 QL hydroxyzine hcl oral 1 tablet 5 mg solution 10 mg/5 ml desloratadine oral 1 QL hydroxyzine hcl oral 1 tablet,disintegrating tablet 10 mg, 25 mg, 2.5 mg, 5 mg 50 mg diphenhydramine hcl 1 hydroxyzine 1 injection solution 50 pamoate oral mg/ml capsule 100 mg, 25 diphenhydramine hcl 1 mg, 50 mg injection syringe 50 levocetirizine oral 1 mg/ml solution 2.5 mg/5 ml diphenhydramine hcl 1 levocetirizine oral 1 QL oral capsule 50 mg tablet 5 mg diphenhydramine hcl 1 phenadoz rectal 1 oral elixir 12.5 mg/5 suppository 12.5 mg, ml 25 mg EPINEPHRINE 2 QL phenergan rectal 1 INJECTION AUTO- suppository 12.5 mg, INJECTOR 0.15 25 mg, 50 mg MG/0.3 ML, 0.3 promethazine 1 MG/0.3 ML injection solution 25 epinephrine 1 mg/ml, 50 mg/ml injection solution 1 promethazine oral 1 mg/ml, 1 mg/ml (1 syrup 6.25 mg/5 ml ml) promethazine oral 1 epinephrine 1 tablet 12.5 mg, 25 injection syringe 0.1 mg, 50 mg mg/ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 126
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits promethazine rectal 1 hydrocodone- 1 suppository 12.5 mg, chlorpheniramine 25 mg, 50 mg oral suspension,extended promethegan rectal 1 rel 12 hr 10-8 mg/5 suppository 12.5 mg, ml 25 mg, 50 mg hydrocodone-cpm- 1
COUGH & COLD THERAPY pseudoephed oral benzonatate oral 1 solution 5-4-60 mg/5 capsule 100 mg, 150 ml mg, 200 mg hydrocodone- 1 brompheniramine- 1 homatropine oral pseudoeph-dm oral syrup 5-1.5 mg/5 ml syrup 2-30-10 mg/5 hydrocodone- 1 ml homatropine oral centergy oral drops 1 tablet 5-1.5 mg 1-2 mg/ml hydromet oral syrup 1 cheratussin ac oral 1 5-1.5 mg/5 ml liquid 10-100 mg/5 lortuss ex oral syrup 1 ml 30-10-100 mg/5 ml codeine-guaifenesin 1 m-clear wc oral 1 oral liquid 10-100 liquid 6.3-100 mg/5 mg/5 ml ml g tussin ac oral 1 promethazine vc- 1 liquid 10-100 mg/5 codeine oral syrup ml 6.25-5-10 mg/5 ml guaiatussin ac oral 1 promethazine- 1 liquid 10-100 mg/5 codeine oral syrup ml 6.25-10 mg/5 ml guaifenesin ac oral 1 promethazine-dm 1 liquid 10-100 mg/5 oral syrup 6.25-15 ml mg/5 ml guaifenesin dac oral 1 promethazine- 1 syrup 30-10-100 phenyleph-codeine mg/5 ml oral syrup 6.25-5-10 mg/5 ml promethazine- 1 phenylephrine oral syrup 6.25-5 mg/5 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 127
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits relcof c oral liquid 1 albuterol sulfate 1 6.3-100 mg/5 ml inhalation solution for nebulization 0.63 rydex oral liquid 1 mg/3 ml, 1.25 mg/3 1.3-10-6.3 mg/5 ml ml, 2.5 mg /3 ml tusnel c oral syrup 1 (0.083 %), 2.5 30-10-100 mg/5 ml mg/0.5 ml, 5 mg/ml tussigon oral tablet 1 albuterol sulfate oral 1 5-1.5 mg syrup 2 mg/5 ml virtussin ac oral 1 albuterol sulfate oral 1 liquid 10-100 mg/5 tablet 2 mg, 4 mg ml albuterol sulfate oral 1 virtussin dac oral 1 tablet extended syrup 30-10-100 release 12 hr 4 mg, 8 mg/5 ml mg ZODRYL AC 40 2 ALVESCO 3 ST; QL ORAL INHALATION HFA SUSPENSION 1-4.5 AEROSOL MG/4.5 ML INHALER 160 ZODRYL DEC 30 2 MCG/ACTUATION ORAL , 80 SUSPENSION 15- MCG/ACTUATION 3.5-70 MG/3.5 ML ANORO ELLIPTA 2 QL INHALATION PULMONARY AGENTS BLISTER WITH acetylcysteine 1 DEVICE 62.5-25 solution 100 mg/ml MCG/ACTUATION (10 %), 200 mg/ml ARCAPTA 2 QL (20 %) NEOHALER ADCIRCA ORAL 4 PA; LA; QL INHALATION TABLET 20 MG CAPSULE, ADEMPAS ORAL 4 PA; LA W/INHALATION TABLET 0.5 MG, 1 DEVICE 75 MCG MG, 1.5 MG, 2 MG, 2.5 MG
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 128
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ARMONAIR 2 BREO ELLIPTA 3 QL RESPICLICK INHALATION INHALATION BLISTER WITH AEROSOL POWDR DEVICE 100-25 BREATH MCG/DOSE, 200-25 ACTIVATED 113 MCG/DOSE MCG/ACTUATION BROVANA 3 QL , 232 INHALATION MCG/ACTUATION SOLUTION FOR , 55 NEBULIZATION MCG/ACTUATION 15 MCG/2 ML ASMANEX HFA 3 QL budesonide 1 QL INHALATION HFA inhalation AEROSOL suspension for INHALER 100 nebulization 0.25 MCG/ACTUATION mg/2 ml, 0.5 mg/2 , 200 ml, 1 mg/2 ml MCG/ACTUATION budesonide nasal 1 QL ASMANEX 3 QL spray,non-aerosol TWISTHALER 32 mcg/actuation INHALATION AEROSOL POWDR CINRYZE 4 PA; LA BREATH INTRAVENOUS ACTIVATED 110 RECON SOLN 500 MCG (30 DOSES), UNIT (5 ML) 110 MCG (7 COMBIVENT 2 QL DOSES), 220 MCG RESPIMAT (120 DOSES), 220 INHALATION MCG (14 DOSES), MIST 20-100 220 MCG (30 MCG/ACTUATION DOSES), 220 MCG (60 DOSES) cromolyn inhalation 1 solution for ATROVENT HFA 2 QL nebulization 20 mg/2 INHALATION HFA ml AEROSOL INHALER 17 DALIRESP ORAL 3 PA MCG/ACTUATION TABLET 500 MCG BEVESPI 2 QL AEROSPHERE INHALATION HFA AEROSOL INHALER 9-4.8 MCG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 129
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DULERA 2 QL ipratropium bromide 1 INHALATION HFA inhalation solution AEROSOL 0.02 % INHALER 100-5 ipratropium- 1 QL MCG/ACTUATION albuterol inhalation , 200-5 solution for MCG/ACTUATION nebulization 0.5 mg- ESBRIET ORAL 4 PA; LA; QL 3 mg(2.5 mg base)/3 CAPSULE 267 MG ml ESBRIET ORAL 4 PA; LA KALBITOR 4 PA; LA TABLET 267 MG, SUBCUTANEOUS 801 MG SOLUTION 10 MG/ML (1 ML) FIRAZYR 4 PA; LA SUBCUTANEOUS KALYDECO ORAL 4 PA; LA; QL SYRINGE 30 MG/3 GRANULES IN ML PACKET 50 MG, 75 MG flunisolide nasal 1 QL spray,non-aerosol KALYDECO ORAL 4 PA; LA; QL 25 mcg (0.025 %) TABLET 150 MG fluticasone nasal 1 QL LETAIRIS ORAL 4 PA; LA spray,suspension 50 TABLET 10 MG, 5 mcg/actuation MG FLUTICASONE- 2 QL levalbuterol hcl 1 SALMETEROL inhalation solution INHALATION for nebulization 0.31 AEROSOL POWDR mg/3 ml, 0.63 mg/3 BREATH ml, 1.25 mg/0.5 ml, ACTIVATED 113- 1.25 mg/3 ml 14 metaproterenol oral 1 MCG/ACTUATION syrup 10 mg/5 ml , 232-14 MCG/ACTUATION metaproterenol oral 1 , 55-14 tablet 10 mg, 20 mg MCG/ACTUATION mometasone nasal 1 QL INCRUSE 2 QL spray,non-aerosol ELLIPTA 50 mcg/actuation INHALATION montelukast oral 1 BLISTER WITH granules in packet 4 DEVICE 62.5 mg MCG/ACTUATION montelukast oral 1 tablet 10 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 130
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits montelukast oral 1 PULMOZYME 4 LA tablet,chewable 4 INHALATION mg, 5 mg SOLUTION 1 MG/ML nebusal inhalation 1 solution for QVAR 2 QL nebulization 3 % INHALATION AEROSOL 40 NUCALA 4 PA; LA; QL MCG/ACTUATION SUBCUTANEOUS , 80 RECON SOLN 100 MCG/ACTUATION MG SEREVENT 3 QL OFEV ORAL 4 PA; LA; QL DISKUS CAPSULE 100 MG, INHALATION 150 MG BLISTER WITH OPSUMIT ORAL 4 PA; LA DEVICE 50 TABLET 10 MG MCG/DOSE ORKAMBI ORAL 4 PA; LA; QL sildenafil 4 PA; LA TABLET 100-125 (antihypertensive) MG, 200-125 MG intravenous solution PERFOROMIST 2 QL 10 mg/12.5 ml INHALATION sildenafil 4 PA; LA; QL SOLUTION FOR (antihypertensive) NEBULIZATION oral tablet 20 mg 20 MCG/2 ML sodium chloride 1 PROAIR HFA 2 QL inhalation solution INHALATION HFA for nebulization 0.9 AEROSOL %, 10 %, 3 %, 7 % INHALER 90 STRIVERDI 2 QL MCG/ACTUATION RESPIMAT PROAIR 2 QL INHALATION RESPICLICK MIST 2.5 INHALATION MCG/ACTUATION AEROSOL POWDR SYMBICORT 2 QL BREATH INHALATION HFA ACTIVATED 90 AEROSOL MCG/ACTUATION INHALER 160-4.5 pulmosal inhalation 1 MCG/ACTUATION solution for , 80-4.5 nebulization 7 % MCG/ACTUATION terbutaline oral 1 tablet 2.5 mg, 5 mg
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits terbutaline 1 TYVASO REFILL 4 PA; LA subcutaneous KIT INHALATION solution 1 mg/ml SOLUTION FOR NEBULIZATION theochron oral tablet 1 1.74 MG/2.9 ML extended release 12 (0.6 MG/ML) hr 100 mg, 200 mg, 300 mg TYVASO 4 PA; LA STARTER KIT theophylline oral 1 INHALATION elixir 80 mg/15 ml SOLUTION FOR theophylline oral 1 NEBULIZATION solution 80 mg/15 ml 1.74 MG/2.9 ML theophylline oral 1 VENTAVIS 4 PA; LA tablet extended INHALATION release 12 hr 100 SOLUTION FOR mg, 200 mg, 300 mg, NEBULIZATION 450 mg 10 MCG/ML, 20 theophylline oral 1 MCG/ML tablet extended XOLAIR 4 PA; LA; QL release 24 hr 400 SUBCUTANEOUS mg, 600 mg RECON SOLN 150 TRACLEER ORAL 4 PA; LA MG TABLET 125 MG, zafirlukast oral 1 62.5 MG tablet 10 mg, 20 mg TUDORZA 2 QL zileuton oral tablet, 1 PRESSAIR er multiphase 12 hr INHALATION 600 mg AEROSOL POWDR ZYFLO ORAL 3 ST BREATH TABLET 600 MG ACTIVATED 400 MCG/ACTUATION UROLOGICALS TYVASO 4 PA; LA ANTICHOLINERGICS &
INHALATION ANTISPASMODICS SOLUTION FOR NEBULIZATION darifenacin oral 1 1.74 MG/2.9 ML tablet extended (0.6 MG/ML) release 24 hr 15 mg, 7.5 mg flavoxate oral tablet 1 100 mg
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MYRBETRIQ 3 CIALIS ORAL 3 PA ORAL TABLET TABLET 2.5 MG, 5 EXTENDED MG RELEASE 24 HR dutasteride oral 1 25 MG, 50 MG capsule 0.5 mg oxybutynin chloride 1 dutasteride- 1 oral syrup 5 mg/5 ml tamsulosin oral oxybutynin chloride 1 capsule, er oral tablet 5 mg multiphase 24 hr 0.5-0.4 mg oxybutynin chloride 1 oral tablet extended finasteride oral 1 release 24hr 10 mg, tablet 5 mg 15 mg, 5 mg RAPAFLO ORAL 3 tolterodine oral 1 CAPSULE 4 MG, 8 capsule,extended MG release 24hr 2 mg, 4 tamsulosin oral 1 mg capsule,extended tolterodine oral 1 release 24hr 0.4 mg tablet 1 mg, 2 mg CHOLINERGIC STIMULANTS TOVIAZ ORAL 3 bethanechol chloride 1 TABLET oral tablet 10 mg, 25 EXTENDED mg, 5 mg, 50 mg RELEASE 24 HR 4 MG, 8 MG MISCELLANEOUS UROLOGICALS trospium oral 1 alprostadil injection 1 capsule,extended solution 500 mcg/ml release 24hr 60 mg azuphen mb oral 1 trospium oral tablet 1 capsule 120-0.12 mg 20 mg CYSTAGON ORAL 4 LA VESICARE ORAL 3 CAPSULE 150 MG, TABLET 10 MG, 5 50 MG MG cytra k crystals oral 1 BENIGN PROSTATIC packet 3,300-1,002
HYPERPLASIA (BPH) THERAPY mg alfuzosin oral tablet 1 cytra-2 oral solution 1 extended release 24 500-334 mg/5 ml hr 10 mg cytra-3 oral solution 1 550-500-334 mg/5 ml
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits cytra-k oral solution 1 RENACIDIN 2 1,100-334 mg/5 ml IRRIGATION SOLUTION 6.602- ELMIRON ORAL 2 3.268 GRAM/100 CAPSULE 100 MG ML hyolev mb oral 1 sodium citrate-citric 1 tablet 81-10.8-40.8 acid oral solution mg 500-334 mg/5 ml hyophen oral tablet 1 tricitrates oral 1 81.6-0.12-10.8 mg solution 550-500- K-PHOS NO 2 2 334 mg/5 ml ORAL TABLET ur n-c oral tablet 1 305-700 MG 81.6-10.8-40.8 mg K-PHOS 2 uramit mb oral 1 ORIGINAL ORAL capsule 118-10- TABLET,SOLUBL 40.8-36 mg E 500 MG uretron d-s oral 1 methen-sod phos- 1 tablet 81.6-10.8-40.8 meth blue-hyos oral mg tablet 81.6-40.8-0.12 mg urimar-t oral tablet 1 120-0.12-10.8 mg phosphasal oral 1 tablet 81.6-10.8-40.8 urin ds oral tablet 1 mg 81.6-10.8-40.8 mg pot,sodium citrate- 1 uro-458 oral tablet 1 citric acid oral 81-10.8-40.8 mg solution 550-500- urogesic-blue oral 1 334 mg/5 ml tablet 81.6-40.8-0.12 potassium citrate 1 mg oral tablet extended uro-mp oral capsule 1 release 10 meq 118-10-40.8-36 mg (1,080 mg), 15 meq, 5 meq (540 mg) urophen mb oral 1 tablet 81.6-0.12-10.8 potassium citrate- 1 mg citric acid oral packet 3,300-1,002 uryl oral tablet 81.6- 1 mg 40.8-0.12 mg potassium citrate- 1 ustell oral capsule 1 citric acid oral 120-0.12 mg solution 1,100-334 mg/5 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 134
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits utira-c oral tablet 1 calcium 600 with 5 ACA; OTC 81.6-10.8-40.8 mg vitamin d3 oral capsule 600 virtrate-2 oral 1 mg(1,500mg) -400 solution 500-334 unit, 600 mg/5 ml mg(1,500mg) -500 virtrate-3 oral 1 unit solution 550-500- calcium 600 with 5 ACA; OTC 334 mg/5 ml vitamin d3 oral virtrate-k oral 1 tablet,chewable 600 solution 1,100-334 mg(1,500mg) -400 mg/5 ml unit URINARY ANESTHETICS calcium carb and 5 ACA; OTC citrate-vitd3 oral phenazopyridine 1 tablet extended oral tablet 100 mg, release 600 mg 200 mg calcium- 500 unit VITAMINS, HEMATINICS & calcium carbonate- 5 ACA; OTC ELECTROLYTES vitamin d3 oral capsule 600 ELECTROLYTES mg(1,500mg) -400 calcium 500 + d oral 5 ACA; OTC unit tablet 500 calcium carbonate- 5 ACA; OTC mg(1,250mg) -200 vitamin d3 oral unit tablet 500 calcium 500 + d oral 5 ACA; OTC mg(1,250mg) -125 tablet,chewable 500 unit, 500 mg(1,250mg) -400 mg(1,250mg) -200 unit unit, 500 calcium 500 with d 5 ACA; OTC mg(1,250mg) -400 oral tablet 500 unit, 500mg mg(1,250mg) -400 (1,250mg) -600 unit, unit 600 mg(1,500mg) - 200 unit, 600 calcium 600 + d(3) 5 ACA; OTC mg(1,500mg) -400 oral capsule 600 mg unit, 600 calcium- 200 unit mg(1,500mg) -800 calcium 600 + d(3) 5 ACA; OTC unit oral tablet 600 calcium carbonate- 5 ACA; OTC mg(1,500mg) -200 vitamin d3 oral unit, 600 tablet,chewable 500- mg(1,500mg) -400 100 mg-unit unit You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 135
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits calcium citrate + d 5 ACA; OTC klor-con m10 oral 1 oral tablet 315-200 tablet,er mg-unit particles/crystals 10 meq calcium citrate- 5 ACA; OTC vitamin d2 oral klor-con m15 oral 1 tablet 1,500-200 mg- tablet,er unit particles/crystals 15 meq calcium citrate- 5 ACA; OTC vitamin d3 oral klor-con m20 oral 1 tablet 200 mg tablet,er calcium -250 unit, particles/crystals 20 200-125 mg-unit, meq 250 mg calcium- 200 klor-con oral packet 1 unit, 315-200 mg- 20 meq unit, 315-250 mg- unit klor-con sprinkle 1 oral capsule, calcium gluconate in 1 extended release 10 0.9% nacl meq, 8 meq intravenous solution 1 gram/100 ml klor-con/ef oral 1 tablet, effervescent citrus calcium oral 5 ACA; OTC 25 meq tablet 200 mg calcium -250 unit, k-phos-neutral oral 1 315-250 mg-unit tablet 250 mg effer-k oral tablet, 1 k-tab oral tablet 1 effervescent 25 meq extended release 8 meq hi-cal plus vit d oral 5 ACA; OTC tablet 500 lugols oral solution 1 mg(1,250mg) -200 5 % unit oysco 500/d oral 5 ACA; OTC k-effervescent oral 1 tablet 500 tablet, effervescent mg(1,250mg) -200 25 meq unit klor-con 10 oral 1 oyster shell + d3 5 ACA; OTC tablet extended oral tablet 250-125 release 10 meq mg-unit klor-con 8 oral 1 tablet extended release 8 meq
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits oyster shell calcium- 5 ACA; OTC potassium chloride 1 vit d3 oral tablet in lr-d5 intravenous 250-125 mg-unit, parenteral solution 500 mg(1,250mg) - 20 meq/l, 40 meq/l 200 unit, 500 potassium chloride 1 mg(1,250mg) -400 intravenous unit piggyback 10 oystercal-d oral 5 ACA; OTC meq/100 ml, 10 tablet 500 meq/50 ml, 20 mg(1,250mg) -400 meq/100 ml, 20 unit meq/50 ml, 30 meq/100 ml, 40 phospha 250 neutral 1 meq/100 ml oral tablet 250 mg potassium chloride 1 potassium acetate 1 intravenous solution intravenous solution 2 meq/ml 2 meq/ml potassium chloride 1 potassium bicarb 1 oral capsule, and chloride oral extended release 10 tablet, effervescent meq, 8 meq 25 meq potassium chloride 1 potassium bicarb- 1 oral liquid 20 citric acid oral meq/15 ml, 40 tablet, effervescent meq/15 ml 25 meq potassium chloride 1 potassium chlorid- 1 oral packet 20 meq d5-0.45%nacl intravenous potassium chloride 1 parenteral solution oral tablet extended 10 meq/l, 20 meq/l, release 10 meq, 20 30 meq/l, 40 meq/l meq, 8 meq potassium chloride 1 potassium chloride 1 in 0.9%nacl oral tablet,er intravenous particles/crystals 10 parenteral solution meq, 20 meq 20 meq/l, 40 meq/l potassium chloride- 1 potassium chloride 1 0.45 % nacl in 5 % dex intravenous intravenous parenteral solution parenteral solution 20 meq/l 20 meq/l, 30 meq/l, 40 meq/l
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits potassium chloride- 1 sodium phosphate 1 d5-0.2%nacl intravenous solution intravenous 3 mmol/ml parenteral solution strong iodine oral 1 10 meq/l, 20 meq/l, solution 5 % 30 meq/l, 40 meq/l virt-phos 250 neutral 1 potassium chloride- 1 oral tablet 250 mg d5-0.3%nacl intravenous VITAMINS & HEMATINICS parenteral solution b complex 100 1 20 meq/l injection solution potassium chloride- 1 100-2-100-2-2 d5-0.9%nacl mg/ml intravenous bal-care dha oral 1 parenteral solution combo pack,tablet 20 meq/l, 40 meq/l and cap,dr 27-1-430 potassium phosphate 1 mg m-/d-basic calcium pnv oral 1 intravenous solution capsule 28-1-250 mg 3 mmol/ml calcium-folic acid- 1 sodium chloride 0.45 1 vitamin d oral wafer % intravenous 500-50-300-1 mg- parenteral solution mg-unit-mg 0.45 % centratex oral 1 sodium chloride 0.45 1 capsule 106 mg % intravenous iron- 1 mg piggyback 0.45 % cholecalciferol 5 ACA; OTC sodium chloride 3 % 1 (vitamin d3) oral intravenous capsule 1,000 unit parenteral solution 3 % cholecalciferol 5 ACA; OTC (vitamin d3) oral sodium chloride 5 % 1 drops 400 unit/ml intravenous parenteral solution 5 cholecalciferol 5 ACA; OTC % (vitamin d3) oral tablet 1,000 unit, sodium chloride 1 400 unit intravenous parenteral solution cholecalciferol 5 ACA; OTC 2.5 meq/ml, 4 (vitamin d3) oral meq/ml tablet,chewable 1,000 unit
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 138
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits c-nate dha oral 1 ferraplus 90 oral 1 capsule 28 mg iron- tablet 90-1-12-120- 1 mg -200 mg 50 mg-mg-mcg-mg- mg complete natal dha 1 oral combo pack 29- ferrex 150 forte oral 1 1-250 mg capsule 150-25-1 mg-mcg-mg completenate oral 1 tablet,chewable 29 ferrex 150 forte plus 1 mg iron- 1 mg oral capsule 150-60- 25-1 mg-mg-mcg-mg corvita 150 oral 1 tablet 150-1.25-120- ferrex 28 oral tablet 1 10 mg 151-200-1-0.8 mg corvita oral tablet 1 ferrocite plus oral 1 1.25-2.5-7 mg tablet 106 mg iron- 1 mg cyanocobalamin 1 (vitamin b-12) fluor-a-day (with 5 ACA injection solution xylitol) oral 1,000 mcg/ml tablet,chewable 0.25 mg f (0.55 mg)- delta d3 oral tablet 5 ACA; OTC 236.79mg 400 unit fluor-a-day (with 1 dialyvite oral tablet 1 xylitol) oral 1-100-300-50 mg- tablet,chewable 1 mg-mcg-mg, 100-1 mg f (2.2 mg)-236.79 mg mg dothelle dha oral 1 fluoride (sodium) 5 ACA capsule 35-1-200 mg oral drops 0.5 mg d-vi-sol oral drops 5 ACA; OTC (1.1 mg 400 unit/ml sod.fluorid)/ml elite-ob oral tablet 1 fluoride (sodium) 5 ACA 50 mg iron- 1.25 mg oral tablet,chewable ergocalciferol 1 0.25 mg(0.55 mg (vitamin d2) oral sod. fluoride), 0.5 capsule 50,000 unit mg (1.1 mg sodium fluorid) ergocalciferol 5 ACA; OTC (vitamin d2) oral fluoride (sodium) 1 tablet 400 unit oral tablet,chewable 1 mg (2.2 mg sod. ferocon oral capsule 1 fluoride) 110-0.5 mg
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fluoritab oral 5 ACA folivane-ob oral 1 tablet,chewable 0.5 capsule 85-1 mg mg (1.1 mg sodium folivane-plus oral 1 fluorid) capsule 125 mg fluoritab oral 1 iron- 1 mg tablet,chewable 1 folplex 2.2 oral 1 mg (2.2 mg sod. tablet 2.2-25-0.5 mg fluoride) hematinic plus 1 focalgin 90 dha oral 1 vit/minerals oral combo pack 90 mg tablet 106 mg iron- 1 iron-1 mg -50 mg- mg 300 mg hematinic/folic acid 1 focalgin ca oral 1 oral tablet 324 mg combo pack 35 mg (106 mg iron)-1 mg iron-1 mg -50 mg- 300 mg hematogen fa oral 1 capsule 200-250- focalgin dss oral 1 0.01-1 mg tablet 90-1-12-50 mg-mg-mcg-mg hematogen forte oral 1 capsule 460-60- folbee oral tablet 1 0.01-1 mg 2.5-25-1 mg hematogen oral 1 folbee plus oral 1 capsule 200 (66)-10- tablet 5 mg, 5-1.5-25 250 mg-mg-mcg-mg mg hemenatal ob + dha 1 folbic oral tablet 1 oral combo pack 28 2.5-25-2 mg mg iron-6 mg iron-1 folic acid injection 1 mg solution 5 mg/ml hemenatal ob oral 1 folic acid oral tablet 1 tablet 28-6-1 mg 1 mg hemetab oral tablet 1 folic acid oral tablet 5 ACA; OTC 22-6-1-25 mg-mg- 400 mcg, 800 mcg mg-mcg folic acid-vit b6-vit 1 hydroxocobalamin 1 b12 oral tablet 2.2- intramuscular 25-0.5 mg solution 1,000 mcg/ml folivane-f oral 1 capsule 125-1-40-3 iferex 150 forte oral 1 mg capsule 150-25-1 mg-mcg-mg
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits infed injection 1 multivitamins with 1 solution 100 mg/2 ml fluoride oral (50 mg/ml) tablet,chewable 0.25 mg, 0.5 mg, 1 mg levomefolate dha 1 oral capsule 27 mg- multivit-fluor (vit e 1 400 mcg- 1.13 mg- acetate) oral drops 250 mg 0.25 mg/ml ludent fluoride oral 5 ACA mvc-fluoride oral 1 tablet,chewable 0.25 tablet,chewable 0.25 mg(0.55 mg sod. mg, 0.5 mg, 1 mg fluoride), 0.5 mg myferon 150 forte 1 (1.1 mg sodium oral capsule 150-25- fluorid) 1 mg-mcg-mg ludent fluoride oral 1 mynatal advance 1 tablet,chewable 1 oral tablet 90-1-50 mg (2.2 mg sod. mg fluoride) mynatal oral capsule 1 m.v.i. adult 1 65 mg iron- 1 mg intravenous solution 3,300 unit- 150 mynatal oral tablet 1 mcg/10 ml 90-1-50 mg multigen folic oral 1 mynatal plus oral 1 tablet 70-150-10-1-2 tablet 65 mg iron- 1 mg-mg-mcg-mg-mg mg multigen plus oral 1 mynatal-z oral tablet 1 tablet 151-60-10-1 65 mg iron- 1 mg mg-mg-mcg-mg mynate 90 plus oral 1 multi-vit with 1 tablet extended fluoride-iron oral release 90 mg iron-1 drops 0.25mg mg fluoride -10 mg mynephrocaps oral 1 iron/ml capsule 1 mg multi-vitamin with 1 mynephron oral 1 fluoride oral drops capsule 1 mg 0.25 mg/ml, 0.5 mg/ml nephplex rx oral 1 tablet 1-60-300-12.5 multi-vitamin with 1 mg-mg-mcg-mg fluoride oral tablet,chewable 0.25 nephro-vite rx oral 1 mg, 0.5 mg, 1 mg tablet 1-60-300 mg- mg-mcg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 141
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits newgen oral tablet 1 pr natal 400 oral 1 32-1,000 mg-mcg combo pack 29-1- 400 mg obstetrix dha oral 1 combo pack,tablet pr natal 430 ec oral 1 and cap,dr 29 mg combo pack,tablet iron-1 mg -50 mg and cap,dr 29-1-430 mg oyster shell calcium- 5 ACA; OTC vit d2 oral tablet 250 pr natal 430 oral 1 (625)-125 mg-unit combo pack 29 mg iron-1 mg -430 mg pnv 29-1 oral tablet 1 29 mg iron- 1 mg prena1 chew oral 1 tablet,chew,ir - pnv ob+dha oral 1 dr,biphase 1.4 mg combo pack 27-1- 50-250 mg prena1 pearl oral 1 capsule,ir - delay pnv-dha + docusate 1 rel,biphase 30-1.4- oral capsule 27- 200 mg 1.25-55-300 mg prena1 true oral 1 pnv-dha oral capsule 1 combo pack 30 mg 27 mg iron-1 mg - iron- 1.4 mg-300 mg 300 mg prenaissance oral 1 pnv-ferrous 1 capsule 29-1.25-55- fumarate-docu-fa 325 mg oral tablet 29 mg iron- 1 mg-25 mg prenaissance plus 1 oral capsule 28-1- pnv-omega oral 1 50-250 mg capsule 28-1-300 mg prenatabs fa oral 1 pnv-select oral tablet 1 tablet 29-1 mg 27-1 mg prenatabs rx oral 1 pnv-vp-u oral 1 tablet 29 mg iron- 1 capsule 106.5-1 mg mg poly-iron 150 forte 1 prenatal plus 1 oral capsule 150-25- (calcium carb) oral 1 mg-mcg-mg tablet 27 mg iron- 1 pr natal 400 ec oral 1 mg combo pack,tablet prenatal plus oral 1 and cap,dr 29-1-400 tablet 29 mg iron- 1 mg mg
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Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits prenatal vitamin 1 taron forte oral 1 plus low iron oral capsule 150-60-25-1 tablet 27 mg iron- 1 mg-mg-mcg-mg mg taron-c dha oral 1 prenatal-u oral 1 capsule 35-1-200 mg capsule 106.5-1 mg taron-prex prenatal- 1 preplus oral tablet 1 dha oral capsule 30 27 mg iron- 1 mg mg iron-1.2 mg-55 mg-265 mg pretab oral tablet 1 29-1 mg thrivite-19 oral 1 tablet 29 mg iron- 1 PROFERRIN- 2 mg-25 mg FORTE ORAL TABLET 12-1 MG tl gard rx oral tablet 1 2.2-25-1 mg purevit dualfe plus 1 oral capsule 162- tl g-fol os oral tablet 1 115.2-1 mg 500-1.1 mg relnate dha oral 1 tl icon oral capsule 1 capsule 28 mg iron- 110-0.5 mg 1 mg -200 mg tl-hem 150 oral 1 renal caps oral 1 tablet extended capsule 1 mg release 24 hr 150-1- 50 mg rena-vite rx oral 1 tablet 1-60-300 mg- tricon oral capsule 1 mg-mcg 110-0.5 mg reno caps oral 1 trigels-f forte oral 1 capsule 1 mg capsule 460-60- 0.01-1 mg risacal-d oral tablet 5 ACA; OTC 105-120 mg-unit trinatal gt oral tablet 1 90-1-50 mg se-natal 19 (with 1 docusate) oral tablet trinatal rx 1 oral 1 29 mg iron- 1 mg-25 tablet 60 mg iron-1 mg mg se-natal 19 oral 1 trinate oral tablet 28 1 tablet,chewable 29 mg iron- 1 mg mg iron- 1 mg triphrocaps oral 1 se-tan plus oral 1 capsule 1 mg capsule 162-115.2-1 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 143
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits tri-tabs dha oral 1 vinate care oral 1 combo pack 32 mg tablet,chewable 40 iron- 1,000 mcg- mg iron- 1 mg 230mg vinate ii oral tablet 1 triveen-duo dha oral 1 29 mg iron- 1 mg combo pack 29-1- vinate m oral tablet 1 400 mg 27-1 mg tri-vit with fluoride 1 vinate one oral 1 and iron oral drops tablet 60 mg iron-1 0.25-10 mg/ml mg tri-vitamin with 1 virt-advance oral 1 fluoride oral drops tablet 90-1-50 mg 0.25 mg fluor. (0.55 mg)/ml, 0.5 mg virt-c dha oral 1 fluoride (1.1 mg)/ml capsule 35-1-200 mg trust natal dha oral 1 virt-gard oral tablet 1 combo pack 29-1- 2.2-25-1 mg 250 mg virt-nate dha oral 1 ultimatecare one nf 1 capsule 28 mg iron- oral capsule 27-1- 1 mg -200 mg 50-500 mg virt-nate oral tablet 1 ultimatecare one 1 28 mg iron- 1 mg oral capsule 27-1- virt-pn dha oral 1 330 mg capsule 27 mg iron- v-c forte oral 1 1 mg -300 mg capsule 1 mg virt-pn oral tablet 1 vemavite-prx-2 oral 1 27-1 mg capsule 27-1.25-55- virt-pn plus oral 1 300 mg capsule 28-1-300 mg VENOFER 2 virt-select oral 1 INTRAVENOUS capsule 29-1.25-55- SOLUTION 100 325 mg MG IRON/5 ML, 200 MG IRON/10 virt-vite forte oral 1 ML, 50 MG tablet 2.5-25-2 mg IRON/2.5 ML virt-vite gt oral 1 vic-forte oral 1 tablet 90-1-50 mg capsule 1 mg virt-vite oral tablet 1 2.5-25-1 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 144
Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits vit 3 oral capsule 1 vp-ch plus oral 1 500 mg-500 mcg -1 capsule 29 mg iron- mg-12.5 mg 1 mg -50 mg-265 mg VITAFOL-OB 2 vp-ch-pnv oral 1 ORAL TABLET 65- capsule 30 mg iron- 1 MG 1 mg -50 mg-260 mg vitajoy daily d oral 5 ACA; OTC vp-ggr-b6 oral tablet 1 tablet,chewable 1.2 mg-40 mg- 124.1 1,000 unit mg-100 mg vitamin d3 oral 5 ACA; OTC vp-heme ob oral 1 capsule 1,000 unit, tablet 28-6-1 mg 400 unit vp-heme one oral 1 vitamin d3 oral 5 ACA; OTC capsule 22-6-1-200 tablet 1,000 unit, mg 400 unit vp-vite rx oral tablet 1 vitamin d3 oral 5 ACA; OTC 1-60-300 mg-mg- tablet,chewable mcg 1,000 unit, 400 unit zatean-ch oral 1 vitamins a,c,d and 1 capsule 27-1-50-250 fluoride oral drops mg 0.25 mg fluor. (0.55 zatean-pn dha oral 1 mg)/ml capsule 27 mg iron- vol-care rx oral 1 1 mg -300 mg tablet 1-60-300 mg- zatean-pn plus oral 1 mg-mcg capsule 28-1-300 mg vol-nate oral tablet 1 zingiber oral tablet 1 28 mg iron- 1 mg 1.2 mg-40 mg- 124.1 vol-plus oral tablet 1 mg-100 mg 27 mg iron- 1 mg vol-tab rx oral tablet 1 29 mg iron- 1 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 145
Index A AFLURIA QUAD 2017-2018 AMICAR ...... 57 abacavir ...... 4 ...... 103 amifostine crystalline ...... 18 abacavir-lamivudine ...... 4 AFLURIA QUAD 2017-2018 amikacin ...... 10 abacavir-lamivudine- (PF) ...... 103 amiloride ...... 50 zidovudine ...... 4 AFSTYLA ...... 57 amiloride-hydrochlorothiazide ABILIFY MAINTENA ...... 42 AKYNZEO ...... 90 ...... 50 ABRAXANE ...... 19 ala-cort ...... 72 aminocaproic acid ...... 57 acamprosate ...... 75 ALBENZA ...... 10 amiodarone ...... 49 acarbose ...... 86 albuterol sulfate ...... 128 AMITIZA ...... 91 acebutolol ...... 50 alclometasone ...... 72 amitriptyline ...... 42 acetaminophen-caff- ALDURAZYME ...... 83 amitriptyline-chlordiazepoxide dihydrocod ...... 35 ALECENSA ...... 19 ...... 42 acetaminophen-codeine ...... 35 alendronate ...... 76, 109 amlodipine ...... 50 acetazolamide ...... 123 ALFERON N ...... 102 amlodipine-atorvastatin ...... 62 acetazolamide sodium ...... 123 alfuzosin ...... 133 amlodipine-benazepril ...... 50 acetic acid ...... 75, 79 ALIMTA ...... 19 amlodipine-olmesartan ...... 50 acetylcysteine ...... 128 ALINIA ...... 10 amlodipine-valsartan ...... 50 acitretin ...... 64 allopurinol ...... 108 amlodipine-valsartan-hcthiazid ACTEMRA ...... 109 allopurinol sodium ...... 108 ...... 50 ACTHAR H.P...... 80 almotriptan malate ...... 33 ammonium lactate ...... 66 ACTIMMUNE ...... 102 ALOCRIL ...... 122 amnesteem ...... 67 ACTOPLUS MET XR ...... 86 ALOGLIPTIN ...... 86 amoxapine ...... 42 acyclovir ...... 4, 72 ALOMIDE...... 122 amoxicil-clarithromy-lansopraz acyclovir sodium ...... 4 alophen ...... 91 ...... 97 ADACEL(TDAP aloprim...... 108 amoxicillin ...... 14 ADOLESN/ADULT)(PF) alosetron ...... 91 amoxicillin-pot clavulanate .. 14 ...... 102 ALOXI...... 91 amphotericin b ...... 3 ADAGEN ...... 76 ALPHAGAN P ...... 125 ampicillin ...... 14 adapalene ...... 67 ALPHANATE ...... 57 ampicillin sodium ...... 14 adapalene-benzoyl peroxide . 67 alprazolam ...... 42 ampicillin-sulbactam ...... 15 ADCETRIS ...... 19 alprazolam intensol...... 42 AMPYRA ...... 34 ADCIRCA ...... 128 ALPROLIX ...... 57 ANADROL-50 ...... 83 ADDYI ...... 42 alprostadil ...... 133 anagrelide ...... 76 adefovir...... 4 ALTABAX ...... 70 anaspaz ...... 89 ADEMPAS ...... 128 altacaine ...... 122 anastrozole ...... 19 adrenalin ...... 125 altafluor ...... 122 ANORO ELLIPTA ...... 128 adriamycin ...... 19 altavera (28) ...... 114 anucort-hc ...... 91 adrucil ...... 19 ALVESCO...... 128 ANZEMET ...... 91 ADVATE ...... 57 alyacen 1/35 (28) ...... 114 apexicon e ...... 72 ADYNOVATE ...... 57 alyacen 7/7/7 (28) ...... 114 APIDRA ...... 81 afeditab cr ...... 50 amabelz ...... 111 APIDRA SOLOSTAR ...... 81 AFINITOR ...... 19 amantadine hcl ...... 4 APOKYN ...... 32 AFINITOR DISPERZ ...... 19 amcinonide ...... 72 apraclonidine ...... 125 AFLURIA 2017-2018 ...... 103 amethia ...... 114 aprepitant ...... 91 AFLURIA 2017-2018 (PF) 103 amethia lo ...... 114 apri ...... 114 amethyst...... 114 APRISO ...... 91
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 146
APTIOM...... 29 avita ...... 67 benzonatate ...... 127 APTIVUS ...... 4 avo cream ...... 66 benzoyl peroxide ...... 67 ARALAST NP ...... 76 AVONEX ...... 100 benztropine ...... 32 aranelle (28)...... 114 AVONEX (WITH ALBUMIN) BEPREVE ...... 122 ARANESP (IN ...... 100 BESIVANCE ...... 120 POLYSORBATE) ...... 99 AVYCAZ ...... 8 BESPONSA ...... 19 ARCALYST ...... 102 azacitidine ...... 19 betamethasone acet,sod phos 80 ARCAPTA NEOHALER ... 128 AZASAN ...... 19 betamethasone dipropionate . 72 ARGATROBAN IN NACL AZASITE ...... 120 betamethasone valerate ... 72, 73 (ISO-OS) ...... 57 azathioprine ...... 19 betamethasone, augmented ... 73 aripiprazole ...... 42 azathioprine sodium ...... 19 betaxolol ...... 50, 121 ARISTADA ...... 43 azelastine ...... 78, 79, 122 bethanechol chloride ...... 133 armodafinil ...... 43 AZELEX ...... 67 BEVESPI AEROSPHERE . 129 ARMONAIR RESPICLICK AZILECT ...... 32 bexarotene ...... 19 ...... 129 azithromycin ...... 9, 10 BEXSERO ...... 103 ARMOUR THYROID ...... 88 AZOPT ...... 124 bicalutamide ...... 19 ARRANON ...... 19 aztreonam ...... 11 BICNU ...... 19 ARZERRA ...... 19 azuphen mb...... 133 BILTRICIDE ...... 11 ascomp with codeine ...... 35 azurette (28) ...... 114 bimatoprost ...... 124 ashlyna ...... 114 B bisacodyl ...... 91 ASMANEX HFA ...... 129 b complex 100 ...... 138 bisa-lax ...... 91 ASMANEX TWISTHALER baciim ...... 11 bisoprolol fumarate ...... 50 ...... 129 bacitracin ...... 11, 120 bisoprolol-hydrochlorothiazide aspir-81 ...... 39 bacitracin-polymyxin b...... 120 ...... 50 aspirin ...... 39 baclofen ...... 34 bivalirudin ...... 58 aspirin low dose ...... 39 BACTROBAN NASAL ...... 79 bleo 15k ...... 20 aspirin-dipyridamole ...... 57 bal-care dha ...... 138 bleomycin ...... 20 aspir-low ...... 39 balsalazide ...... 91 BLINCYTO ...... 20 aspir-trin ...... 39 balziva (28) ...... 114 blisovi 24 fe ...... 114 astramorph-pf ...... 35 BANZEL ...... 29 blisovi fe 1.5/30 (28) ...... 114 atenolol ...... 50 BARACLUDE...... 4 blisovi fe 1/20 (28) ...... 114 atenolol-chlorthalidone...... 50 BASAGLAR KWIKPEN ..... 81 BOOSTRIX TDAP ...... 103 atomoxetine ...... 43 BAVENCIO ...... 19 BOSULIF ...... 20 atorvastatin ...... 62 bayer aspirin ...... 39 BOTOX ...... 103 atovaquone ...... 10 BAYER CHEWABLE bp 10-1 ...... 67 atovaquone-proguanil ...... 11 ASPIRIN ...... 39 bp-50% urea ...... 66 ATRIPLA ...... 4 BEBULIN ...... 57 bpo ...... 67 atropine ...... 89, 121, 122 bekyree (28) ...... 114 BREO ELLIPTA ...... 129 ATROVENT HFA ...... 129 belladonna alkaloids-opium . 89 briellyn ...... 114 AUBAGIO ...... 100 belladonna-opium ...... 89 BRILINTA ...... 58 aubra ...... 114 BELSOMRA ...... 43 brimonidine ...... 125 AUGMENTIN ...... 15 benazepril ...... 50 BRINEURA ...... 83 avar ...... 67 benazepril-hydrochlorothiazide bromfenac ...... 123 AVASTIN ...... 19 ...... 50 bromocriptine ...... 32 AVELOX IN NACL (ISO- BENDEKA ...... 19 brompheniramine-pseudoeph- OSMOTIC)...... 15 BENEFIX ...... 58 dm ...... 127 aviane ...... 114 BENLYSTA ...... 109 BROVANA ...... 129 avidoxy ...... 16 benzepro ...... 67 budesonide ...... 91, 129 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 147 bumetanide ...... 50 camila ...... 111 ceftriaxone ...... 9 BUPHENYL...... 76 camrese ...... 115 ceftriaxone in dextrose,iso-os . 9 buprenorphine hcl ...... 35 camrese lo ...... 115 cefuroxime axetil ...... 9 buprenorphine-naloxone...... 39 CANASA...... 91 cefuroxime sodium ...... 9 bupropion hcl...... 43 CANCIDAS...... 3 celacyn ...... 66 bupropion hcl (smoking deter) candesartan ...... 51 celecoxib ...... 39 ...... 77 candesartan-hydrochlorothiazid CELLCEPT INTRAVENOUS buspirone ...... 43 ...... 51 ...... 20 busulfan ...... 20 capacet ...... 36 CELONTIN ...... 29 BUSULFEX ...... 20 capecitabine ...... 20 cem-urea ...... 66 butalbital compound w/codeine CAPRELSA...... 20 centergy ...... 127 ...... 35 captopril ...... 51 centratex ...... 138 butalbital-acetaminop-caf-cod captopril-hydrochlorothiazide cephalexin ...... 9 ...... 35 ...... 51 CEPROTIN (BLUE BAR) ... 58 butalbital-acetaminophen ..... 35 CARAFATE ...... 97 CEPROTIN (GREEN BAR) 58 butalbital-acetaminophen-caff CARBAGLU ...... 76 CERDELGA ...... 83 ...... 36 carbamazepine ...... 29 CESAMET ...... 91 butalbital-aspirin-caffeine .... 36 carbidopa ...... 32 cetirizine ...... 126 butorphanol tartrate ...... 39 carbidopa-levodopa ...... 32 cevimeline ...... 76 BYDUREON ...... 86 carbidopa-levodopa- CHANTIX ...... 78 BYETTA ...... 86 entacapone ...... 32 CHANTIX CONTINUING BYSTOLIC ...... 51 carbinoxamine maleate ...... 125, MONTH BOX ...... 77 C 126 CHANTIX STARTING cabergoline ...... 83 carboplatin ...... 20 MONTH BOX ...... 78 caffeine citrate ...... 76 carisoprodol ...... 34 chateal ...... 115 calcipotriene ...... 64 carteolol ...... 121 CHEMET ...... 76 calcipotriene-betamethasone 64 cartia xt ...... 51 CHENODAL ...... 91 calcitonin (salmon) ...... 83 carvedilol ...... 51 cheratussin ac ...... 127 calcitrene ...... 64 caspofungin ...... 3 children's aspirin ...... 39 calcitriol ...... 64, 83 CAYA CONTOURED ...... 111 chloramphenicol sod succinate calcium 500 + d ...... 135 CAYSTON ...... 11 ...... 11 calcium 500 with d ...... 135 caziant (28) ...... 115 chlordiazepoxide hcl ...... 43 calcium 600 + d(3) ...... 135 cefaclor ...... 8 chlordiazepoxide-clidinium .. 89 calcium 600 with vitamin d3 cefadroxil ...... 8 chlorhexidine gluconate ...... 79 ...... 135 cefazolin ...... 8 chloroquine phosphate ...... 11 calcium acetate ...... 91 cefazolin in dextrose (iso-os) . 8 chlorothiazide ...... 51 calcium carb and citrate-vitd3 cefdinir...... 8 chlorothiazide sodium ...... 51 ...... 135 cefditoren pivoxil ...... 8 chlorpromazine ...... 43 calcium carbonate-vitamin d3 cefepime ...... 8 chlorpropamide ...... 86 ...... 135 cefepime in dextrose,iso-osm . 8 chlorthalidone ...... 51 calcium citrate + d ...... 136 cefixime ...... 8 chlorzoxazone ...... 34 calcium citrate-vitamin d2 .. 136 cefotaxime ...... 8 CHOLBAM ...... 91 calcium citrate-vitamin d3 .. 136 cefotetan ...... 9 cholecalciferol (vitamin d3) 138 calcium gluconate in 0.9% nacl cefoxitin ...... 9 cholestyramine (with sugar) . 62 ...... 136 cefoxitin in dextrose, iso-osm 9 cholestyramine light ...... 62 calcium pnv ...... 138 cefpodoxime ...... 9 choline,magnesium salicylate calcium-folic acid-vitamin d cefprozil ...... 9 ...... 39 ...... 138 ceftazidime ...... 9 CIALIS ...... 133 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 148 ciclodan ...... 71 clonidine hcl ...... 43, 51 CRIXIVAN ...... 4 ciclopirox ...... 71 clopidogrel ...... 58 cromolyn ...... 92, 122, 129 cidofovir ...... 4 clorazepate dipotassium ...... 43 cryselle (28) ...... 115 cilostazol...... 58 clorpres ...... 51 CUBICIN RF ...... 11 cimetidine ...... 97 clotrimazole ...... 3, 71 cyanocobalamin (vitamin b-12) cimetidine hcl ...... 97 clotrimazole-betamethasone . 71 ...... 139 CIMZIA ...... 91 clozapine ...... 43 cyclafem 1/35 (28) ...... 115 CIMZIA POWDER FOR c-nate dha ...... 139 cyclafem 7/7/7 (28) ...... 115 RECONST ...... 91 COAGADEX...... 58 cyclobenzaprine ...... 34 CINRYZE...... 129 COAL TAR ...... 64 cyclopentolate ...... 122 CIPRO HC...... 79 COARTEM ...... 11 cyclophosphamide ...... 20 CIPRODEX ...... 79 codeine sulfate ...... 36 CYCLOPHOSPHAMIDE .... 20 ciprofloxacin...... 16 codeine-guaifenesin ...... 127 CYCLOSERINE ...... 11 ciprofloxacin (mixture) ...... 15 COLCRYS...... 108 CYCLOSET ...... 86 ciprofloxacin hcl ..... 16, 79, 120 colestipol ...... 62 cyclosporine ...... 20 ciprofloxacin in 5 % dextrose colistin (colistimethate na) ... 11 cyclosporine modified ...... 20 ...... 16 colocort ...... 91 cyproheptadine ...... 126 ciprofloxacin lactate ...... 16 COLY-MYCIN S ...... 80 CYRAMZA ...... 20 cisplatin ...... 20 COMBIGAN ...... 124 cyred ...... 115 citalopram ...... 43 COMBIVENT RESPIMAT 129 CYSTADANE ...... 92 citrate of magnesia ...... 91 COMPLERA ...... 4 CYSTAGON ...... 133 citroma ...... 91 complete natal dha ...... 139 CYSTARAN ...... 122 citrus calcium ...... 136 completenate ...... 139 cytarabine ...... 20 cladribine ...... 20 compro ...... 91 cytarabine (pf) ...... 20 claravis ...... 68 CONCEPTROL ...... 113 cytra k crystals ...... 133 clarithromycin ...... 10 constulose ...... 92 cytra-2 ...... 133 cleansing wash...... 68 CONTRAVE ...... 75 cytra-3 ...... 133 clearlax ...... 91 CORDRAN TAPE LARGE cytra-k ...... 134 clemastine ...... 126 ROLL...... 73 D cleocin ...... 11 CORLANOR ...... 63 dacarbazine ...... 21 clindacin p ...... 68 cormax ...... 73 DAKLINZA ...... 5 clindamycin hcl ...... 11 CORTIFOAM ...... 92 DALIRESP ...... 129 clindamycin in 5 % dextrose 11 cortisone ...... 80 DALVANCE ...... 11 clindamycin palmitate hcl .... 11 CORTISPORIN ...... 70 danazol ...... 84 clindamycin pediatric ...... 11 corvita ...... 139 dantrolene ...... 34 clindamycin phosphate .. 11, 68, corvita 150 ...... 139 dapsone ...... 11, 68 113 COSENTYX ...... 65 DAPTACEL (DTAP clindamycin-benzoyl peroxide COSENTYX (2 SYRINGES) PEDIATRIC) (PF) ...... 103 ...... 68 ...... 64 daptomycin ...... 11 clindamycin-tretinoin ...... 68 COSENTYX PEN ...... 65 DARAPRIM ...... 12 clobetasol ...... 73 COSENTYX PEN (2 PENS) 65 darifenacin ...... 132 clobetasol-emollient ...... 73 cosyntropin ...... 80 DARZALEX ...... 21 clodan ...... 73 COTELLIC ...... 20 dasetta 1/35 (28) ...... 115 clofarabine ...... 20 covaryx ...... 111 dasetta 7/7/7 (28) ...... 115 CLOLAR ...... 20 covaryx h.s...... 111 daunorubicin ...... 21 clomipramine ...... 43 CREON ...... 92 daysee ...... 115 clonazepam ...... 29 CRESEMBA ...... 3 DEBACTEROL ...... 79 clonidine ...... 51 CRINONE ...... 111 deblitane ...... 111 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 149 decitabine ...... 21 digox ...... 56 d-vi-sol ...... 139 delta d3 ...... 139 digoxin ...... 56 DYRENIUM ...... 52 deltasone ...... 80 dihydroergotamine...... 33 E delyla (28) ...... 115 DILANTIN ...... 29 e.c. prin ...... 40 demeclocycline ...... 16 diltiazem ...... 51 e.e.s. 400 ...... 10 DEMSER ...... 51 dilt-xr ...... 51 E.E.S. GRANULES ...... 10 DENAVIR ...... 72 dimenhydrinate ...... 92 econazole ...... 71 denta 5000 plus...... 79 DIPENTUM ...... 92 econtra ez ...... 115 dentagel ...... 79 diphenhydramine hcl ...... 126 ecotrin ...... 40 DEPEN TITRATABS ...... 109 diphenoxylate-atropine ... 89, 90 ecotrin low strength ...... 40 DEPO-PROVERA ...... 111 dipyridamole ...... 58 EDARBI ...... 52 DESCOVY ...... 5 diskets ...... 36 EDARBYCLOR ...... 52 desipramine ...... 43 disopyramide phosphate ...... 49 ed-spaz ...... 90 desloratadine...... 126 disulfiram...... 76 EDURANT ...... 5 desmopressin ...... 84 divalproex ...... 29 eemt ...... 111 desog-e.estradiol/e.estradiol docetaxel ...... 21 eemt hs ...... 111 ...... 115 DOCETAXEL ...... 21 effer-k ...... 136 desogestrel-ethinyl estradiol dofetilide ...... 49 EGRIFTA ...... 100 ...... 115 donepezil ...... 34 ELAPRASE ...... 84 desonide ...... 73 dorzolamide ...... 124 ELELYSO ...... 84 desoximetasone ...... 73 dorzolamide-timolol ...... 124 eletone ...... 66 desvenlafaxine succinate ...... 43 dothelle dha ...... 139 eletriptan hbr ...... 33 dexamethasone ...... 80 doxazosin ...... 52 ELIDEL ...... 66 dexamethasone intensol...... 80 doxepin ...... 44, 66 ELIGARD ...... 21 dexamethasone sodium phos doxercalciferol ...... 84 ELIGARD (3 MONTH) ...... 21 (pf) ...... 80 doxorubicin ...... 21 ELIGARD (4 MONTH) ...... 21 dexamethasone sodium doxorubicin, peg-liposomal .. 21 ELIGARD (6 MONTH) ...... 21 phosphate ...... 80, 124 doxy-100 ...... 16 elinest ...... 115 DEXILANT ...... 97 doxycycline hyclate ...... 17 eliphos ...... 92 dexmethylphenidate ...... 44 doxycycline monohydrate .... 17 ELIQUIS ...... 58 dexrazoxane hcl ...... 18 drithocreme hp ...... 65 ELITEK ...... 18 dextroamphetamine ...... 44 dronabinol ...... 92 elite-ob ...... 139 dextroamphetamine- droperidol ...... 92 ELLA ...... 115 amphetamine ...... 44 drospirenone-e.estradiol-lm.fa ELMIRON ...... 134 dialyvite ...... 139 ...... 115 ELOCTATE ...... 58 diazepam...... 29, 44 drospirenone-ethinyl estradiol EMADINE ...... 122 diazepam intensol ...... 44 ...... 115 EMBEDA ...... 36 diclofenac potassium ...... 39 DROXIA ...... 21 EMCYT ...... 21 diclofenac sodium ... 39, 40, 66, DUAVEE...... 111 EMEND ...... 92 123 ducodyl ...... 92 EMEND (FOSAPREPITANT) diclofenac-misoprostol ...... 40 DULERA ...... 130 ...... 92 dicloxacillin ...... 15 duloxetine ...... 44 emoquette ...... 115 dicyclomine ...... 89 DUPIXENT ...... 66 EMSAM ...... 44 didanosine...... 5 duramorph (pf) ...... 36 EMTRIVA ...... 5 DIFICID ...... 10 DUREZOL ...... 125 emulsion sb ...... 66 diflorasone ...... 73 dutasteride ...... 133 EMVERM ...... 12 diflunisal ...... 40 dutasteride-tamsulosin ...... 133 enalapril maleate ...... 52 digitek ...... 56 DUTOPROL ...... 52 enalaprilat ...... 52 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 150 enalapril-hydrochlorothiazide erythromycin-benzoyl peroxide FASLODEX ...... 22 ...... 52 ...... 68 fayosim ...... 116 ENBREL ...... 109, 110 ESBRIET ...... 130 FC2 FEMALE CONDOM . 111 ENBREL SURECLICK ..... 110 escitalopram oxalate ...... 44 FEIBA NF ...... 58 endocet ...... 36 esmolol ...... 52 felbamate ...... 30 ENGERIX-B (PF) ...... 103 esomeprazole magnesium..... 98 felodipine ...... 52 ENGERIX-B PEDIATRIC esomeprazole sodium ...... 98 fem ph ...... 113 (PF) ...... 103 estarylla ...... 115 FEMCAP ...... 111 enoxaparin ...... 58 estazolam ...... 44 femynor ...... 116 enpresse ...... 115 ESTRACE ...... 111 fenofibrate ...... 62 enskyce ...... 115 estradiol ...... 111, 112 fenofibrate micronized ...... 62 entacapone ...... 32 estradiol valerate...... 112 fenofibrate nanocrystallized . 62 entecavir ...... 5 estradiol-norethindrone acet fenofibric acid ...... 62 ENTRESTO ...... 63 ...... 112 fenofibric acid (choline) ...... 62 ENTYVIO ...... 92 estrogens-methyltestosterone fenoprofen ...... 40 enulose ...... 92 ...... 112 fentanyl ...... 36 EPCLUSA ...... 5 estropipate ...... 112 fentanyl citrate ...... 36 EPIDUO FORTE...... 68 eszopiclone ...... 44 fentanyl citrate (pf) ...... 36 epinastine ...... 122 ethacrynate sodium ...... 52 fentanyl citrate-0.9%nacl (pf) epinephrine ...... 126 ethacrynic acid ...... 52 ...... 36 EPINEPHRINE ...... 126 ethambutol ...... 12 ferocon ...... 139 EPIPEN 2-PAK ...... 126 ethosuximide ...... 29, 30 ferraplus 90 ...... 139 EPIPEN JR 2-PAK ...... 126 ethyl chloride ...... 69 ferrex 150 forte ...... 139 epirubicin ...... 21 ethynodiol diac-eth estradiol ferrex 150 forte plus ...... 139 epitol ...... 29 ...... 115 ferrex 28 ...... 139 EPIVIR HBV...... 5 etidronate disodium ...... 76 FERRIPROX ...... 76 eplerenone ...... 52 etodolac ...... 40 ferrocite plus ...... 139 epoprostenol (glycine) ...... 52 ETOPOPHOS ...... 22 FETZIMA ...... 45 eprosartan ...... 52 etoposide ...... 22 finasteride ...... 133 ERBITUX...... 21 EURAX ...... 75 FIRAZYR ...... 130 ergocalciferol (vitamin d2) . 139 EXELDERM ...... 71 flavoxate ...... 132 ergoloid...... 44 exemestane ...... 22 flecainide ...... 49 ERGOMAR ...... 33 EXJADE ...... 76 fleet laxative ...... 92 ergotamine-caffeine ...... 33 EXTAVIA ...... 100 floxin ...... 79 ERIVEDGE ...... 21 EYLEA ...... 122 floxuridine ...... 22 errin ...... 111 ezetimibe ...... 62 FLUAD 2017-2018 (65 YR ERTACZO ...... 71 ezetimibe-simvastatin ...... 62 UP)(PF) ...... 103 ery pads ...... 68 F FLUARIX QUAD 2017-2018 erygel ...... 68 FABRAZYME ...... 84 (PF) ...... 103 ERYPED 200 ...... 10 FACTIVE ...... 16 FLUBLOK 2017-2018 (PF) ERYPED 400 ...... 10 falmina (28) ...... 115 ...... 103 ery-tab...... 10 famciclovir...... 5 FLUBLOK QUAD 2017-2018 ERY-TAB...... 10 famotidine ...... 98 (PF) ...... 104 erythrocin (as stearate) ...... 10 famotidine (pf) ...... 98 flucaine ...... 122 erythromycin ...... 10, 120 famotidine (pf)-nacl (iso-os) 98 FLUCELVAX QUAD 2017- erythromycin ethylsuccinate 10 FANAPT ...... 44, 45 2018 ...... 104 erythromycin with ethanol ... 68 FARESTON ...... 22 FLUCELVAX QUAD 2017- FARXIGA ...... 86 2018 (PF) ...... 104 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 151 fluconazole ...... 3 FLUZONE QUAD 2017-2018 gavilax ...... 92 fluconazole in dextrose(iso-o) 3 ...... 104 gavilyte-c ...... 92 fluconazole in nacl (iso-osm) . 3 FLUZONE QUAD 2017-2018 gavilyte-g ...... 92 flucytosine ...... 3 (PF) ...... 104 gavilyte-n ...... 92 fludarabine ...... 22 FLUZONE QUAD PEDI GAZYVA ...... 22 fludrocortisone ...... 80 2017-18 (PF)...... 105 gemcitabine ...... 22 FLULAVAL QUAD 2017- focalgin 90 dha ...... 140 gemfibrozil ...... 62 2018 ...... 104 focalgin ca ...... 140 generlac ...... 93 FLULAVAL QUAD 2017- focalgin dss ...... 140 gengraf ...... 22 2018 (PF) ...... 104 folbee ...... 140 gentak ...... 120 flumazenil ...... 45 folbee plus ...... 140 gentamicin ...... 12, 70, 120 FLUMIST QUAD 2017-2018 folbic ...... 140 gentamicin in nacl (iso-osm) 12 ...... 104 folic acid ...... 140 gentamicin sulfate (ped) (pf) 12 flunisolide ...... 130 folic acid-vit b6-vit b12 ...... 140 gentamicin sulfate (pf) ...... 12 fluocinolone ...... 73, 74 folivane-f ...... 140 gentle laxative ...... 93 fluocinolone acetonide oil .... 79 folivane-ob...... 140 gentlelax ...... 93 fluocinolone and shower cap 73 folivane-plus ...... 140 GENVOYA ...... 5 fluocinonide ...... 74 FOLOTYN ...... 22 gianvi (28) ...... 116 fluocinonide-e...... 74 folplex 2.2 ...... 140 gildagia ...... 116 fluocinonide-emollient ...... 74 fondaparinux ...... 58 GILENYA ...... 100 fluor-a-day (with xylitol) .... 139 FORTEO ...... 109 GILOTRIF ...... 22 fluorescein-proparacaine .... 122 FOSAMAX PLUS D ...... 109 glatiramer ...... 100 fluoride (sodium) ...... 139 fosamprenavir ...... 5 glatopa ...... 100 fluoritab ...... 140 foscarnet ...... 5 GLEOSTINE ...... 22 fluorometholone ...... 125 fosinopril ...... 52 glimepiride ...... 86 fluorouracil ...... 22, 66 fosinopril-hydrochlorothiazide glipizide ...... 86 fluoxetine ...... 45 ...... 52 glipizide-metformin ...... 86 fluphenazine decanoate ...... 45 fosphenytoin ...... 30 GLUCAGEN DIAGNOSTIC fluphenazine hcl ...... 45 FOSRENOL ...... 92 KIT ...... 81 flurandrenolide ...... 74 FRAGMIN...... 58, 59 GLUCAGEN HYPOKIT ...... 81 flurazepam ...... 45 frovatriptan ...... 33 GLUCAGON EMERGENCY flurbiprofen...... 40 furosemide ...... 52 KIT (HUMAN) ...... 81 flurbiprofen sodium ...... 123 FUZEON ...... 5 glyburide ...... 86 flurox ...... 122 fyavolv ...... 112 glyburide micronized ...... 86 flutamide...... 22 FYCOMPA ...... 30 glyburide-metformin ...... 86 fluticasone ...... 74, 130 G glycolax ...... 93 FLUTICASONE- g tussin ac ...... 127 glycopyrrolate ...... 90 SALMETEROL ...... 130 gabapentin ...... 30 glydo ...... 70 fluvastatin ...... 62 GABITRIL ...... 30 GLYXAMBI ...... 87 FLUVIRIN 2017-2018 ...... 104 galantamine ...... 34 granisetron (pf) ...... 93 FLUVIRIN 2017-2018 (PF) GAMASTAN S/D ...... 105 granisetron hcl ...... 93 ...... 104 GAMMAGARD LIQUID .. 105 GRANIX ...... 99 fluvoxamine ...... 45 GAMMAGARD S-D (IGA < 1 GRASTEK ...... 105 FLUZONE HIGH-DOSE MCG/ML) ...... 105 griseofulvin microsize ...... 3 2017-18 (PF) ...... 104 GAMUNEX-C...... 105 griseofulvin ultramicrosize ..... 3 FLUZONE INTRADERM ganciclovir sodium ...... 5 guaiatussin ac ...... 127 QUAD 2017-18 ...... 104 GARDASIL 9 (PF) ...... 105 guaifenesin ac ...... 127 gatifloxacin ...... 120 guaifenesin dac ...... 127 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 152 guanfacine ...... 45, 52 hpr plus ...... 66 hydrocortisone-pramoxine ... 65, guanidine ...... 45 hpr plus hydrogel ...... 66 93 GYNAZOLE-1 ...... 113 HUMALOG...... 82 hydromet ...... 127 gynol ii...... 113 HUMALOG JUNIOR hydromorphone ...... 37 H KWIKPEN...... 82 hydromorphone (pf) ...... 36 HALAVEN...... 22 HUMALOG KWIKPEN ...... 82 hydromorphone in 0.9 % nacl halobetasol propionate...... 74 HUMALOG MIX 50-50 ...... 82 ...... 36 HALOG ...... 74 HUMALOG MIX 50-50 hydroxocobalamin ...... 140 haloperidol ...... 45 KWIKPEN...... 82 hydroxychloroquine ...... 12 haloperidol decanoate ...... 45 HUMALOG MIX 75-25 ...... 82 hydroxyprogesterone caproate haloperidol lactate ...... 45 HUMALOG MIX 75-25 ...... 112 HARVONI ...... 5 KWIKPEN...... 82 hydroxyurea ...... 23 HAVRIX (PF) ...... 105 HUMATE-P ...... 60 hydroxyzine hcl ...... 126 healthylax ...... 93 HUMIRA ...... 110 hydroxyzine pamoate ...... 126 heather ...... 112 HUMIRA PEDIATRIC hyolev mb ...... 134 HECTOROL...... 84 CROHN'S START ...... 110 hyophen ...... 134 HELIXATE FS ...... 59 HUMIRA PEN ...... 110 hyoscyamine sulfate ...... 90 HEMANGEOL...... 52 HUMIRA PEN CROHN'S- hyosyne ...... 90 hematinic plus vit/minerals 140 UC-HS START ...... 110 HYPERHEP B S/D ...... 105 hematinic/folic acid ...... 140 HUMULIN 70/30 ...... 82 HYPERHEP B S-D hematogen ...... 140 HUMULIN 70/30 KWIKPEN NEONATAL ...... 106 hematogen fa ...... 140 ...... 82 HYPERRAB S/D (PF) ...... 106 hematogen forte ...... 140 HUMULIN N ...... 82 HYQVIA ...... 106 hemenatal ob ...... 140 HUMULIN N KWIKPEN .... 82 HYSINGLA ER ...... 37 hemenatal ob + dha ...... 140 HUMULIN R U-100 ...... 82 I hemetab ...... 140 HUMULIN R U-500 (CONC) ibandronate ...... 109 hemmorex-hc ...... 93 KWIKPEN...... 82 IBRANCE ...... 23 hep flush-10 (pf) ...... 59 HUMULIN R U-500 ibuprofen ...... 40 heparin (porcine) ...... 59 (CONCENTRATED) ...... 82 ibuprofen-oxycodone ...... 37 heparin (porcine) in 5 % dex 59 HYCAMTIN ...... 22 ic green ...... 76 heparin (porcine) in nacl (pf) 59 hydralazine ...... 52 ICLUSIG ...... 23 heparin flush(porcine)-0.9nacl hydrochlorothiazide ...... 52, 53 idarubicin ...... 23 ...... 59 hydrocodone-acetaminophen 36 IDHIFA ...... 23 heparin lock flush ...... 59 hydrocodone-chlorpheniramine iferex 150 forte ...... 140 heparin lock flush (porcine) . 59 ...... 127 ifosfamide ...... 23 heparin lockflush(porcine)(pf) hydrocodone-cpm- ifosfamide-mesna ...... 23 ...... 59 pseudoephed ...... 127 ILARIS (PF) ...... 102 heparin(porcine) in 0.45% nacl hydrocodone-homatropine .. 127 ILEVRO ...... 123 ...... 59 hydrocodone-ibuprofen ...... 36 imatinib ...... 23 heparin, porcine (pf) ...... 60 hydrocortisone ...... 74, 80, 93 IMBRUVICA ...... 23 HERCEPTIN ...... 22 hydrocortisone acetate ...... 93 imipenem-cilastatin ...... 12 HEXALEN ...... 22 hydrocortisone butyrate ...... 74 imipramine hcl ...... 46 HIBERIX (PF)...... 105 hydrocortisone butyr-emollient imipramine pamoate ...... 46 hi-cal plus vit d ...... 136 ...... 74 imiquimod ...... 102 HIZENTRA ...... 105 hydrocortisone valerate ...... 74 IMOGAM RABIES-HT (PF) homatropaire...... 122 hydrocortisone-acetic acid .... 79 ...... 106 homatropine hbr ...... 122 hydrocortisone-iodoquinol-aloe IMOVAX RABIES VACCINE hpr...... 66 ...... 71 (PF) ...... 106 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 153
IMPAVIDO ...... 12 JADENU SPRINKLE ...... 76 klor-con m20 ...... 136 INCRELEX ...... 76 JAKAFI ...... 23 klor-con sprinkle ...... 136 INCRUSE ELLIPTA...... 130 jantoven ...... 60 klor-con/ef ...... 136 indapamide ...... 53 JANUMET ...... 87 KOGENATE FS ...... 60 indocyanine green ...... 76 JANUMET XR ...... 87 KOVALTRY ...... 60 indomethacin ...... 40 JANUVIA ...... 87 K-PHOS NO 2 ...... 134 INFANRIX (DTAP) (PF)... 106 JARDIANCE ...... 87 K-PHOS ORIGINAL ...... 134 infed ...... 141 jencycla ...... 112 k-phos-neutral ...... 136 INFLECTRA ...... 93 JENTADUETO ...... 87 KRYSTEXXA ...... 108 INLYTA ...... 23 JENTADUETO XR ...... 87 k-tab ...... 136 INSULIN SYRINGE- JETREA (PF) ...... 122 kurvelo ...... 116 NEEDLE U-100 ...... 81 jevantique lo ...... 112 KUVAN ...... 84 INTELENCE ...... 5 jinteli ...... 112 KYPROLIS ...... 23 INTRON A ...... 102 jolessa ...... 116 L introvale ...... 116 jolivette ...... 112 l norgest/e.estradiol-e.estrad INVANZ...... 12 JUBLIA ...... 71 ...... 116 INVIRASE ...... 5 juleber ...... 116 labetalol ...... 53 INVOKAMET ...... 87 junel 1.5/30 (21) ...... 116 lactated ringers ...... 75 INVOKANA ...... 87 junel 1/20 (21) ...... 116 lactulose ...... 93 iodoquinol-hc ...... 71 junel fe 1.5/30 (28) ...... 116 lamivudine ...... 5 IPOL ...... 106 junel fe 1/20 (28) ...... 116 lamivudine-zidovudine ...... 6 ipratropium bromide ..... 79, 130 junel fe 24 ...... 116 lamotrigine ...... 30 ipratropium-albuterol ...... 130 JUXTAPID ...... 62 lansoprazole ...... 98 irbesartan ...... 53 K lanthanum ...... 93 irbesartan-hydrochlorothiazide KADCYLA ...... 23 LANTUS ...... 83 ...... 53 kaitlib fe ...... 116 LANTUS SOLOSTAR ...... 82 IRESSA ...... 23 KALBITOR ...... 130 larin 1.5/30 (21) ...... 116 irinotecan ...... 23 KALETRA ...... 5 larin 1/20 (21) ...... 116 ISENTRESS ...... 5 KALYDECO ...... 130 larin 24 fe ...... 116 ISENTRESS HD ...... 5 KANUMA ...... 84 larin fe 1.5/30 (28) ...... 116 isibloom ...... 116 kariva (28) ...... 116 larin fe 1/20 (28) ...... 116 isometh-dichloral- k-effervescent ...... 136 larissia ...... 116 acetaminophn ...... 33 kelnor 1/35 (28) ...... 116 LARTRUVO ...... 23 isomethepten-caf- KEPIVANCE ...... 18 LASTACAFT ...... 123 acetaminophen ...... 33 ketoconazole ...... 3, 71 latanoprost ...... 124 isoniazid ...... 12 ketoprofen ...... 40 LATUDA ...... 46 isosorbide dinitrate ...... 63 ketorolac ...... 40, 123 laxaclear ...... 93 isosorbide mononitrate ...... 64 KEYTRUDA ...... 23 laxative (bisacodyl) ...... 93 isoxsuprine ...... 113 kimidess (28) ...... 116 laxative feminine ...... 93 isradipine ...... 53 KINERET ...... 102 laxative peg 3350 ...... 93 ISTODAX ...... 23 kionex ...... 93 layolis fe ...... 117 itraconazole ...... 3 kionex (with sorbitol) ...... 93 leena 28 ...... 117 ivermectin ...... 12 KITABIS PAK ...... 12 leflunomide ...... 110 IXEMPRA ...... 23 klor-con ...... 136 LEMTRADA ...... 100 IXIARO (PF) ...... 106 klor-con 10 ...... 136 LENVIMA ...... 24 IXINITY ...... 60 klor-con 8 ...... 136 lessina ...... 117 J klor-con m10 ...... 136 LETAIRIS ...... 130 JADENU ...... 76 klor-con m15 ...... 136 letrozole ...... 24 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 154 leucovorin calcium ...... 18 lisinopril...... 53 M LEUKERAN ...... 24 lisinopril-hydrochlorothiazide m.v.i. adult ...... 141 LEUKINE...... 99 ...... 53 magnesium citrate ...... 94 leuprolide ...... 24 lite coat aspirin ...... 41 MAKENA ...... 112 levalbuterol hcl ...... 130 lithium carbonate ...... 46 malathion ...... 75 LEVATOL ...... 53 lithium citrate ...... 46 maprotiline ...... 46 LEVEMIR ...... 83 LIVALO ...... 62 marlissa ...... 117 LEVEMIR FLEXTOUCH ... 83 lomedia 24 fe ...... 117 MARPLAN ...... 46 levetiracetam ...... 30 LONSURF ...... 24 MARQIBO ...... 24 levetiracetam in nacl (iso-os) 30 loperamide ...... 90 marten-tab ...... 37 levobunolol ...... 121 lopinavir-ritonavir ...... 6 MATULANE ...... 24 levocarnitine ...... 76 lopreeza ...... 112 matzim la ...... 53 levocarnitine (with sugar)..... 76 lorazepam ...... 46 MAVYRET ...... 6 levocetirizine ...... 126 lorazepam intensol ...... 46 mb hydrogel ...... 66 levofloxacin ...... 16, 120 lorcet (hydrocodone) ...... 37 mb hydrogel (cyclomethicone) levofloxacin in d5w ...... 16 lorcet hd ...... 37 ...... 66 levoleucovorin ...... 18 lorcet plus ...... 37 m-clear wc ...... 127 LEVOLEUCOVORIN ...... 18 lortuss ex...... 127 meclizine ...... 94 levomefolate dha ...... 141 loryna (28) ...... 117 meclofenamate ...... 41 levonest (28) ...... 117 losartan ...... 53 medroxyprogesterone ...... 112 levonorgestrel-ethinyl estrad losartan-hydrochlorothiazide 53 mefenamic acid ...... 41 ...... 117 LOTEMAX ...... 125 mefloquine ...... 12 levonorg-eth estrad triphasic lovastatin ...... 63 megestrol ...... 24 ...... 117 low-ogestrel (28) ...... 117 MEKINIST ...... 24 levora-28...... 117 loxapine succinate ...... 46 melodetta 24 fe ...... 117 levorphanol tartrate ...... 37 lta pre-attached ...... 70 meloxicam ...... 41 levothyroxine ...... 88 LUCENTIS ...... 123 melphalan ...... 24 levoxyl ...... 88 ludent fluoride ...... 141 melphalan hcl ...... 24 LEXIVA ...... 6 lugols ...... 71, 136 memantine ...... 34 lidocaine ...... 70 LUMIZYME ...... 84 MENACTRA (PF) ...... 106 lidocaine (pf) ...... 70 LUPANETA PACK (1 MENEST ...... 112 lidocaine hcl ...... 70 MONTH) ...... 113 MENOMUNE - A/C/Y/W-135 lidocaine hcl-hydrocortison ac LUPANETA PACK (3 ...... 106 ...... 70, 93, 94 MONTH) ...... 113 MENOMUNE - A/C/Y/W-135 lidocaine viscous ...... 70 LUPRON DEPOT ...... 24 (PF) ...... 106 lidocaine-epinephrine ...... 70 LUPRON DEPOT (3 MENTAX ...... 72 lidocaine-hydrocortisone-aloe MONTH) ...... 24 meperidine ...... 37 ...... 94 LUPRON DEPOT-PED ...... 24 MEPHYTON ...... 60 lidocaine-prilocaine ...... 70 LUPRON DEPOT-PED (3 meprobamate ...... 35 lillow...... 117 MONTH) ...... 24 mercaptopurine ...... 24 lincomycin ...... 12 lutera (28) ...... 117 meropenem ...... 12 lindane ...... 75 luxamend ...... 66 MEROPENEM-0.9% linezolid ...... 12 LUZU ...... 71 SODIUM CHLORIDE ..... 13 linezolid-0.9% sodium chloride LYNPARZA ...... 24 mesalamine ...... 94 ...... 12 LYRICA ...... 31 mesalamine with cleansing LINZESS ...... 94 LYSODREN ...... 24 wipe ...... 94 liothyronine ...... 88, 89 lyza ...... 112 mesna ...... 18 lipodox ...... 24 MESNEX ...... 18 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 155
MESTINON ...... 35 microgestin fe 1/20 (28) ..... 117 moxifloxacin in nacl (iso-osm) metadate er ...... 46 midazolam ...... 46 ...... 16 metaproterenol ...... 130 midodrine...... 76 MOXIFLOXACIN- metaxall ...... 35 migergot...... 33 SOD.ACE,SUL-WATER . 16 metaxalone ...... 35 miglitol ...... 87 MOZOBIL ...... 99 metformin ...... 87 milk of magnesia ...... 94 MULTAQ ...... 49 methadone ...... 37 milk of magnesia concentrated multigen folic ...... 141 methadose ...... 37 ...... 94 multigen plus ...... 141 methamphetamine ...... 46 millipred ...... 80 multi-vit with fluoride-iron . 141 methazolamide ...... 123 millipred dp ...... 80 multi-vitamin with fluoride 141 methenamine hippurate ...... 17 mimvey ...... 112 multivitamins with fluoride 141 methenamine mandelate ...... 17 mimvey lo ...... 112 multivit-fluor (vit e acetate) 141 methen-sod phos-meth blue- minocycline ...... 17 mupirocin ...... 71 hyos ...... 134 minoxidil ...... 54 mupirocin calcium ...... 71 methergine ...... 120 miostat ...... 124 MUSTARGEN ...... 25 methimazole ...... 81 miralax ...... 94 mvc-fluoride ...... 141 METHITEST ...... 84 MIRENA ...... 111 my way ...... 117 methocarbamol ...... 35 mirtazapine ...... 46 MYALEPT ...... 84 methotrexate sodium ...... 25 MIRVASO...... 68 MYCAMINE ...... 3 methotrexate sodium (pf) 24, 25 misoprostol ...... 98 mycophenolate mofetil ...... 25 methoxsalen ...... 66 MITIGARE ...... 108 mycophenolate mofetil hcl ... 25 methscopolamine ...... 90 mitomycin ...... 25 mycophenolate sodium ...... 25 methyclothiazide ...... 53 mitoxantrone ...... 25 myferon 150 forte ...... 141 methyldopa ...... 53 M-M-R II (PF) ...... 106 MYLERAN ...... 25 methyldopa- modafinil ...... 47 mynatal ...... 141 hydrochlorothiazide ...... 53 moderiba ...... 101 mynatal advance ...... 141 methyldopate ...... 53 moderiba dose pack ...... 100 mynatal plus ...... 141 methylphenidate hcl ...... 46 moexipril ...... 54 mynatal-z ...... 141 methylprednisolone ...... 80 moexipril-hydrochlorothiazide mynate 90 plus ...... 141 methylprednisolone acetate .. 80 ...... 54 mynephrocaps ...... 141 methyltestosterone ...... 84 mometasone ...... 74, 130 mynephron ...... 141 metipranolol ...... 121 mondoxyne nl ...... 17 MYRBETRIQ ...... 133 metoclopramide hcl ...... 94 MONOCLATE-P ...... 60 myzilra ...... 117 metolazone ...... 53 mono-linyah...... 117 N metoprolol succinate ...... 53 mononessa (28)...... 117 nabumetone ...... 41 metoprolol ta-hydrochlorothiaz MONONINE ...... 60 nadolol ...... 54 ...... 53 montelukast ...... 130, 131 nadolol-bendroflumethiazide 54 metoprolol tartrate ...... 53, 54 MONUROL ...... 17 nafcillin ...... 15 metro i.v...... 13 morgidox ...... 17 nafcillin in dextrose iso-osm 15 metronidazole ...... 13, 68, 113 morphine ...... 38 naftifine ...... 72 metronidazole in nacl (iso-os) morphine (pf) ...... 37 NAGLAZYME ...... 84 ...... 13 morphine (pf) in 0.9 % nacl.. 37 nalbuphine ...... 41 mexiletine ...... 49 morphine concentrate ...... 37 naloxone ...... 41 mibelas 24 fe ...... 117 MOTOFEN ...... 90 naltrexone ...... 41 miconazole-3 ...... 113 MOVANTIK ...... 94 naproxen ...... 41 microgestin 1.5/30 (21) ...... 117 MOVIPREP ...... 94 naproxen sodium ...... 41 microgestin 1/20 (21) ...... 117 MOXEZA ...... 121 naratriptan ...... 33 microgestin fe 1.5/30 (28) .. 117 moxifloxacin ...... 16, 121 NARCAN ...... 41 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 156
NATACYN ...... 121 NICOTROL NS ...... 78 NOVOSEVEN RT ...... 60 nateglinide ...... 87 nifedipine ...... 54 NOXAFIL ...... 3, 4 NATPARA ...... 84 nikki (28) ...... 118 np thyroid ...... 89 natura-lax ...... 94 nilutamide ...... 25 NPLATE ...... 60 nature-throid ...... 89 nimodipine ...... 54 nts step 1 ...... 78 NEBUPENT ...... 13 NINLARO ...... 25 NUCALA ...... 131 nebusal ...... 131 nisoldipine ...... 54 NUCYNTA ...... 41 necon 0.5/35 (28)...... 118 nitro-bid ...... 64 NUCYNTA ER ...... 41 necon 1/50 (28)...... 118 nitrofurantoin ...... 17 NUEDEXTA ...... 34 necon 7/7/7 (28) ...... 118 nitrofurantoin macrocrystal .. 17 NULOJIX ...... 25 nefazodone ...... 47 nitrofurantoin monohyd/m- NUVARING ...... 113 neomycin ...... 13 cryst ...... 17 nyamyc ...... 72 neomycin-bacitracin-poly-hc nitroglycerin ...... 64 nyata ...... 72 ...... 124 nitroglycerin in 5 % dextrose 64 nystatin ...... 4, 72 neomycin-bacitracin- nitro-time ...... 64 nystatin-triamcinolone ...... 72 polymyxin...... 121 NITYR ...... 76 nystop ...... 72 neomycin-polymyxin b gu ... 75 nivatopic plus ...... 66 O neomycin-polymyxin b- nizatidine ...... 98 OBIZUR ...... 61 dexameth ...... 124 nodolor...... 33 obstetrix dha ...... 142 neomycin-polymyxin- nolix ...... 74 OCALIVA ...... 94 gramicidin...... 121 nora-be ...... 112 ocella ...... 118 neomycin-polymyxin-hc ..... 80, noreth-ethinyl estradiol-iron OCREVUS ...... 101 124 ...... 118 octreotide acetate ...... 25 neo-polycin ...... 121 norethindrone (contraceptive) ODEFSEY ...... 6 neo-polycin hc ...... 124 ...... 112 OFEV ...... 131 NEO-SYNALAR ...... 71 norethindrone acetate ...... 112 ofloxacin ...... 16, 79, 121 nephplex rx ...... 141 norethindrone ac-eth estradiol ogestrel (28) ...... 118 nephro-vite rx ...... 141 ...... 113, 118 olanzapine ...... 47 NERLYNX ...... 25 norethindrone-e.estradiol-iron olanzapine-fluoxetine ...... 47 NESINA ...... 87 ...... 118 olmesartan ...... 54 neuac...... 68 norgestimate-ethinyl estradiol olmesartan-amlodipin- NEULASTA ...... 99 ...... 118 hcthiazid ...... 54 NEUPOGEN ...... 99, 100 norlyda ...... 113 olmesartan- NEVANAC ...... 123 norlyroc ...... 113 hydrochlorothiazide ...... 54 nevirapine ...... 6 nortrel 0.5/35 (28)...... 118 olopatadine ...... 79, 123 newgen ...... 142 nortrel 1/35 (21)...... 118 OLYSIO ...... 6 NEXAVAR ...... 25 nortrel 1/35 (28)...... 118 omega-3 acid ethyl esters ..... 63 NEXPLANON ...... 113 nortrel 7/7/7 (28) ...... 118 omeprazole ...... 98 next choice one dose ...... 118 nortriptyline ...... 47 omeprazole-sodium niacin ...... 63 NORVIR ...... 6 bicarbonate ...... 98 nicardipine ...... 54 NOVAREL ...... 84 OMNITROPE ...... 100 NICODERM CQ ...... 78 NOVOEIGHT ...... 60 ONCASPAR ...... 25 nicorelief...... 78 NOVOLOG ...... 83 ondansetron ...... 95 nicorette ...... 78 NOVOLOG FLEXPEN ...... 83 ondansetron hcl ...... 94, 95 NICORETTE ...... 78 NOVOLOG MIX 70-30 ...... 83 ondansetron hcl (pf) ...... 94 nicotine ...... 78 NOVOLOG MIX 70-30 ONFI ...... 31 nicotine (polacrilex) ...... 78 FLEXPEN ...... 83 ONGLYZA ...... 87 NICOTROL ...... 78 NOVOLOG PENFILL ...... 83 ONIVYDE ...... 25 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 157 opcicon one-step ...... 118 PANRETIN ...... 66 philith ...... 118 OPDIVO ...... 25 pantoprazole ...... 98 phospha 250 neutral ...... 137 opium tincture ...... 90 papaverine ...... 54 phosphasal ...... 134 OPSUMIT ...... 131 PARAGARD T 380A ...... 111 phosphate laxative ...... 95 option-2 ...... 118 paregoric ...... 90 PHOSPHOLINE IODIDE .. 121 oral saline laxative ...... 95 paricalcitol ...... 85 PHOTOFRIN ...... 26 oralone ...... 79 paroex oral rinse ...... 79 PICATO ...... 66 ORBACTIV ...... 13 paromomycin ...... 13 pilocarpine hcl ...... 76, 79, 122 ORENCIA ...... 110 paroxetine hcl ...... 47 pimozide ...... 47 ORENITRAM ...... 54 paroxetine mesylate ...... 47 pimtrea (28) ...... 118 ORFADIN ...... 76 PASER...... 13 pindolol ...... 54 ORKAMBI ...... 131 PEDIA-LAX ...... 95 pioglitazone ...... 87 orphenadrine citrate ...... 35 PEDVAX HIB (PF) ...... 106 pioglitazone-glimepiride ...... 87 orsythia ...... 118 peg 3350-electrolytes ...... 95 pioglitazone-metformin ...... 87 oscimin ...... 90 peg3350 ...... 95 piperacillin-tazobactam ...... 15 oscimin sl...... 90 PEGANONE ...... 31 pirmella ...... 118 oscimin sr ...... 90 PEGASYS ...... 101 piroxicam ...... 41 oseltamivir ...... 6 PEGASYS PROCLICK ..... 101 PLAN B ONE-STEP ...... 118 OSMOPREP ...... 95 peg-electrolyte soln ...... 95 PLEGRIDY ...... 101 OSPHENA ...... 113 peg-prep ...... 95 PLIAGLIS ...... 70 OTEZLA ...... 110 penicillin g potassium ...... 15 PNEUMOVAX 23 ...... 106, 107 OTEZLA STARTER...... 110 penicillin g procaine ...... 15 pnv 29-1 ...... 142 oxacillin ...... 15 penicillin g sodium ...... 15 pnv ob+dha ...... 142 oxacillin in dextrose(iso-osm) penicillin v potassium ...... 15 pnv-dha ...... 142 ...... 15 PENTASA ...... 95 pnv-dha + docusate ...... 142 oxaliplatin ...... 26 pentoxifylline...... 61 pnv-ferrous fumarate-docu-fa oxandrolone ...... 84 PERFOROMIST ...... 131 ...... 142 oxaprozin ...... 41 perindopril erbumine ...... 54 pnv-omega ...... 142 oxazepam ...... 47 periogard ...... 79 pnv-select ...... 142 oxcarbazepine ...... 31 PERJETA ...... 26 pnv-vp-u ...... 142 oxiconazole...... 72 permethrin ...... 75 podofilox ...... 66 oxybutynin chloride...... 133 perphenazine ...... 47 polycin ...... 121 oxycodone ...... 38 perphenazine-amitriptyline ... 47 polyethylene glycol 3350 ..... 95 oxycodone-acetaminophen ... 38 pfizerpen-g...... 15 poly-iron 150 forte ...... 142 oxycodone-aspirin ...... 38 phenadoz ...... 126 polymyxin b sulfate ...... 13 OXYCONTIN ...... 38 phenazopyridine ...... 135 polymyxin b sulf-trimethoprim oxymorphone ...... 38, 39 phenelzine ...... 47 ...... 121 oysco 500/d ...... 136 phenergan ...... 126 POMALYST ...... 101 oyster shell + d3 ...... 136 phenobarb-hyoscy-atropine- portia ...... 118 oyster shell calcium-vit d2 . 142 scop ...... 90 pot,sodium citrate-citric acid oyster shell calcium-vit d3 . 137 phenobarbital ...... 31 ...... 134 oystercal-d ...... 137 phenohytro ...... 90 potassium acetate ...... 137 OZURDEX ...... 125 phenoxybenzamine ...... 54 potassium bicarb and chloride P phentolamine ...... 54 ...... 137 pacerone ...... 49 phenylephrine hcl ...... 125 potassium bicarb-citric acid 137 paclitaxel ...... 26 phenytoin ...... 31 potassium chlorid-d5- paliperidone ...... 47 phenytoin sodium ...... 31 0.45%nacl ...... 137 pamidronate ...... 84, 85 phenytoin sodium extended .. 31 potassium chloride ...... 137 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 158 potassium chloride in 0.9%nacl prenatal vitamin plus low iron propranolol ...... 55 ...... 137 ...... 143 propranolol-hydrochlorothiazid potassium chloride in 5 % dex prenatal-u ...... 143 ...... 55 ...... 137 preplus ...... 143 propylthiouracil ...... 81 potassium chloride in lr-d5 . 137 PREPOPIK ...... 95 PROQUAD (PF) ...... 107 potassium chloride-0.45 % nacl pretab ...... 143 protamine ...... 61 ...... 137 prevalite ...... 63 protriptyline ...... 47 potassium chloride-d5- previfem...... 118 PROVENGE ...... 107 0.2%nacl ...... 138 PREVNAR 13 (PF) ...... 107 pruclair ...... 66 potassium chloride-d5- PREZISTA ...... 6 prudoxin ...... 66 0.3%nacl ...... 138 PRIFTIN ...... 13 prumyx ...... 66 potassium chloride-d5- PRIMAQUINE ...... 13 prutect ...... 66 0.9%nacl ...... 138 primidone...... 31 pulmosal ...... 131 potassium citrate ...... 134 PRIVIGEN ...... 107 PULMOZYME ...... 131 potassium citrate-citric acid 134 PROAIR HFA ...... 131 purelax ...... 96 potassium phosphate m-/d- PROAIR RESPICLICK ..... 131 purevit dualfe plus ...... 143 basic ...... 138 probenecid ...... 108 PURIXAN ...... 26 powderlax ...... 95 probenecid-colchicine ...... 109 pyrazinamide ...... 13 pr natal 400 ...... 142 procainamide ...... 49 pyridostigmine bromide ...... 35 pr natal 400 ec ...... 142 procentra ...... 47 Q pr natal 430 ...... 142 prochlorperazine ...... 95 QUADRACEL (PF) ...... 107 pr natal 430 ec ...... 142 prochlorperazine edisylate .... 95 quasense ...... 119 PRADAXA...... 61 prochlorperazine maleate ..... 95 quazepam ...... 47 PRALUENT PEN ...... 63 PROCRIT ...... 100 quetiapine ...... 47 pramcort ...... 95 procto-med hc ...... 95 quinapril ...... 55 pramipexole ...... 32 procto-pak ...... 95 quinapril-hydrochlorothiazide prasugrel ...... 61 proctosol hc ...... 95 ...... 55 pravastatin ...... 63 proctozone-hc ...... 95 quinidine gluconate ...... 49 prazosin ...... 55 PROFERRIN-FORTE ...... 143 quinidine sulfate ...... 49 PRED MILD ...... 125 PROFILNINE ...... 61 quinine sulfate ...... 13 prednicarbate ...... 74, 75 progesterone ...... 113 quit 2 ...... 78 prednisolone ...... 80 progesterone micronized .... 113 QUIT 2 ...... 78 prednisolone acetate ...... 125 PROGLYCEM ...... 81 quit 4 ...... 78 prednisolone sodium phosphate PROGRAF...... 26 QUIT 4 ...... 78 ...... 81, 125 PROLASTIN-C ...... 77 QVAR ...... 131 prednisone ...... 81 PROLEUKIN ...... 102 R prednisone intensol ...... 81 PROMACTA ...... 61 RABAVERT (PF) ...... 107 PREMARIN ...... 113 promethazine ...... 126, 127 rabeprazole ...... 98 prena1 chew...... 142 promethazine vc-codeine .... 127 RADICAVA ...... 34 prena1 pearl ...... 142 promethazine-codeine ...... 127 RAGWITEK ...... 107 prena1 true ...... 142 promethazine-dm ...... 127 rajani ...... 119 prenaissance ...... 142 promethazine-phenyleph- raloxifene ...... 109 prenaissance plus ...... 142 codeine...... 127 ramipril ...... 55 prenatabs fa ...... 142 promethazine-phenylephrine RANEXA ...... 63 prenatabs rx ...... 142 ...... 127 ranitidine hcl ...... 99 prenatal plus ...... 142 promethegan ...... 127 RAPAFLO ...... 133 prenatal plus (calcium carb)142 propafenone ...... 49 RAPAMUNE ...... 26 proparacaine ...... 123 RAPIVAB ...... 6 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 159 rasagiline ...... 32 RIFAMATE...... 13 se-natal 19 (with docusate) . 143 RAVICTI ...... 77 rifampin ...... 13 SENSIPAR ...... 85 rea lo 39 ...... 66 RIFATER ...... 13 SEREVENT DISKUS ...... 131 rea lo 40 ...... 67 riluzole ...... 77 sertraline ...... 48 REBIF (WITH ALBUMIN) rimantadine ...... 6 se-tan plus ...... 143 ...... 101 ringer's ...... 75 setlakin ...... 119 REBIF REBIDOSE ...... 101 risacal-d ...... 143 sevelamer carbonate ...... 96 REBIF TITRATION PACK risedronate ...... 77, 109 sf 79 ...... 101 RISPERDAL CONSTA ...... 48 sf 5000 plus ...... 79 reclipsen (28) ...... 119 risperidone ...... 48 sharobel ...... 113 RECOMBINATE ...... 61 RITUXAN ...... 26 SIGNIFOR ...... 26 RECOMBIVAX HB (PF) .. 107 RITUXAN HYCELA ...... 26 sildenafil (antihypertensive) RECTIV ...... 96 rivastigmine ...... 34 ...... 131 regonol ...... 35 rivastigmine tartrate ...... 34 silver nitrate ...... 67 REGRANEX ...... 67 rivelsa ...... 119 silver nitrate applicators ...... 67 relcof c ...... 128 rizatriptan...... 33 silver sulfadiazine ...... 65 RELENZA DISKHALER ...... 6 ropinirole ...... 32, 33 SIMBRINZA ...... 124 RELION 70/30 ...... 83 rosadan...... 68 SIMPONI ...... 110 RELION N ...... 83 rosula cleansing cloths...... 69 SIMPONI ARIA ...... 110 RELION R...... 83 rosuvastatin ...... 63 SIMULECT ...... 26 RELISTOR ...... 96 ROTATEQ VACCINE...... 107 simvastatin ...... 63 relnate dha ...... 143 roweepra ...... 31 sirolimus ...... 26 REMICADE ...... 96 ROZEREM ...... 48 SIRTURO ...... 13 REMODULIN ...... 55 RUBRACA ...... 26 SIVEXTRO ...... 13 RENACIDIN ...... 134 RYDAPT ...... 26 smoothlax ...... 96 renal caps ...... 143 rydex ...... 128 sodium benzoate-sod rena-vite rx ...... 143 S phenylacet ...... 77 reno caps ...... 143 SABRIL ...... 31 sodium chlor 0.9% bacteriostat RENVELA ...... 96 salicylic acid ...... 65 ...... 77 repaglinide ...... 87 salicylic acid er-ceramides ... 65 sodium chloride .... 77, 131, 138 repaglinide-metformin ...... 87 salsalate ...... 41 sodium chloride 0.45 % ...... 138 REPATHA PUSHTRONEX 63 salvax ...... 65 sodium chloride 0.9 % ...... 77 REPATHA SURECLICK .... 63 SAMSCA...... 85 sodium chloride 3 % ...... 138 REPATHA SYRINGE ...... 63 SANDIMMUNE ...... 26 sodium chloride 5 % ...... 138 RESCRIPTOR ...... 6 SANDOSTATIN LAR sodium citrate-citric acid .... 134 RESTASIS ...... 123 DEPOT ...... 26 sodium ferric gluconat-sucrose RESTASIS MULTIDOSE . 123 SANTYL ...... 75 ...... 77 RETROVIR ...... 6 SAPHRIS (BLACK sodium phenylbutyrate ...... 77 REVLIMID ...... 101 CHERRY) ...... 48 sodium phosphate ...... 138 revonto ...... 35 SAVELLA ...... 110 sodium polystyrene sulfonate REXULTI ...... 47 scalacort ...... 75 ...... 96 REYATAZ ...... 6 scopolamine base ...... 96 SOLIRIS ...... 77 RIASTAP ...... 61 seb-prev ...... 65 SOLTAMOX ...... 26 ribasphere ...... 101 seconal sodium ...... 48 SOMATULINE DEPOT ...... 26 ribasphere ribapak ...... 101 selegiline hcl ...... 33 SOMAVERT ...... 85 ribavirin ...... 6, 101 selenium sulfide ...... 65 sonafine ...... 67 RIDAURA ...... 110 SELZENTRY ...... 7 SOOLANTRA ...... 69 rifabutin ...... 13 se-natal 19...... 143 sotalol ...... 50 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 160 sotalol af ...... 49 SUPREP BOWEL PREP KIT temozolomide ...... 27 SOTYLIZE ...... 50 ...... 96 tencon ...... 39 sp antipruritic...... 67 SUSTIVA ...... 7 TENIPOSIDE ...... 27 spinosad ...... 75 SUTENT ...... 27 terazosin ...... 55 spironolactone ...... 55 syeda ...... 119 terbutaline ...... 131, 132 spironolacton-hydrochlorothiaz SYLATRON ...... 102 terconazole ...... 113 ...... 55 SYLVANT ...... 27 TESTOPEL ...... 85 SPORANOX ...... 4 symax fastabs ...... 90 testosterone ...... 85 sprintec (28)...... 119 symax-sl...... 90 testosterone cypionate ...... 85 SPRYCEL ...... 27 symax-sr ...... 90 testosterone enanthate ...... 85 sps (with sorbitol) ...... 96 SYMBICORT ...... 131 TETANUS,DIPHTHERIA sronyx ...... 119 SYMLINPEN 120 ...... 87 TOX PED(PF) ...... 107 ssd ...... 65 SYMLINPEN 60 ...... 88 TETANUS-DIPHTHERIA sss 10-5 ...... 69 SYNAGIS ...... 7 TOXOIDS-TD ...... 107 STAMARIL (PF) ...... 107 SYNAREL...... 85 tetcaine ...... 123 stavudine...... 7 SYNJARDY ...... 88 tetrabenazine ...... 34 STELARA ...... 65 SYNJARDY XR...... 88 tetracaine hcl ...... 123 STIMATE...... 85 SYPRINE ...... 77 tetracaine hcl (pf) ...... 123 STIVARGA ...... 27 T tetracycline ...... 17 stop smoking aid...... 78 TABLOID ...... 27 THALOMID ...... 27 STRENSIQ ...... 85 tacrolimus ...... 27, 67 theochron ...... 132 STRIBILD ...... 7 TAFINLAR ...... 27 theophylline ...... 132 STRIVERDI RESPIMAT .. 131 TAGRISSO ...... 27 thioridazine ...... 48 strong iodine ...... 138 TAMIFLU ...... 7 thiotepa ...... 27 SUBOXONE ...... 41 tamoxifen ...... 27 thiothixene ...... 48 SUCRAID ...... 96 tamsulosin ...... 133 thrivite-19 ...... 143 sucralfate ...... 99 TANZEUM ...... 88 thyroid (pork) ...... 89 sulfacetamide sodium ... 65, 125 TARCEVA ...... 27 THYROLAR-1 ...... 89 sulfacetamide sodium (acne) 71 TARGRETIN ...... 27 THYROLAR-1/2 ...... 89 sulfacetamide sodium-sulfur 69 tarina fe 1/20 (28) ...... 119 THYROLAR-1/4 ...... 89 sulfacetamide sod-sulfur-urea taron forte ...... 143 THYROLAR-2 ...... 89 ...... 69 taron-c dha ...... 143 THYROLAR-3 ...... 89 sulfacetamide-prednisolone 125 taron-prex prenatal-dha ...... 143 tiagabine ...... 31 sulfacetamide-sulfur-cleansr23 TASIGNA ...... 27 ticlopidine ...... 61 ...... 69 tazarotene...... 69 tilia fe ...... 119 sulfacleanse 8-4 ...... 69 TAZORAC ...... 69 timolol maleate ...... 55, 121 sulfact na-sul-avobnz-otn-ocsa taztia xt ...... 55 tinidazole ...... 13 ...... 69 TECENTRIQ ...... 27 tis-u-sol pentalyte ...... 75 sulfadiazine...... 16 TECFIDERA ...... 102 TIVICAY ...... 7 sulfamethoxazole-trimethoprim TECHNIVIE ...... 7 tizanidine ...... 35 ...... 16 TEKTURNA ...... 55 tl gard rx ...... 143 SULFAMYLON...... 71 TEKTURNA HCT ...... 55 tl g-fol os ...... 143 sulfasalazine ...... 96 telmisartan ...... 55 tl icon ...... 143 sulfatrim ...... 16 telmisartan-amlodipine ...... 55 tl-hem 150 ...... 143 sulindac...... 41 telmisartan-hydrochlorothiazid tobramycin ...... 121 sumatriptan ...... 33 ...... 55 tobramycin in 0.225 % nacl .. 14 sumatriptan succinate ..... 33, 34 temazepam ...... 48 tobramycin in 0.9 % nacl ...... 14 TEMODAR ...... 27 tobramycin sulfate ...... 14 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 161 tobramycin-dexamethasone 124 tri-linyah ...... 119 ultimatecare one ...... 144 TODAY CONTRACEPTIVE tri-lo-estarylla ...... 119 ultimatecare one nf ...... 144 SPONGE ...... 114 tri-lo-marzia ...... 119 umecta ...... 67 tolazamide ...... 88 tri-lo-sprintec ...... 119 unithroid ...... 89 tolbutamide ...... 88 trilyte with flavor packets ..... 96 UNITUXIN ...... 28 tolcapone ...... 33 trimethobenzamide ...... 96 UPTRAVI ...... 56 tolmetin...... 41 trimethoprim ...... 17 ur n-c ...... 134 tolterodine...... 133 trimipramine ...... 48 uramit mb ...... 134 topiramate ...... 31 trinatal gt...... 143 urea ...... 67 toposar ...... 27 trinatal rx 1 ...... 143 urea nail stick ...... 67 topotecan ...... 27 trinate ...... 143 uretron d-s ...... 134 TORISEL ...... 27 trinessa (28) ...... 119 urimar-t ...... 134 torsemide ...... 56 trinessa lo ...... 119 urin ds ...... 134 TOVIAZ ...... 133 TRINTELLIX ...... 48 uro-458 ...... 134 TRACLEER ...... 132 triphrocaps ...... 143 urogesic-blue ...... 134 TRADJENTA ...... 88 tri-previfem (28) ...... 119 uro-mp ...... 134 tramadol ...... 42 TRISENOX ...... 28 urophen mb ...... 134 tramadol-acetaminophen ...... 42 tri-sprintec (28) ...... 119 ursodiol ...... 97 trandolapril ...... 56 tri-tabs dha ...... 144 uryl ...... 134 trandolapril-verapamil ...... 56 TRIUMEQ ...... 7 ustell ...... 134 tranexamic acid ...... 61, 114 triveen-duo dha ...... 144 utira-c ...... 135 tranylcypromine ...... 48 tri-vit with fluoride and iron UVADEX ...... 67 TRAVATAN Z ...... 124 ...... 144 V trazodone ...... 48 tri-vitamin with fluoride ..... 144 vaginal contraceptive foam . 114 TREANDA ...... 27 trivora (28) ...... 119 valacyclovir ...... 7 TRECATOR ...... 14 tropicamide ...... 122 VALCHLOR ...... 67 tretinoin ...... 69 trospium ...... 133 valganciclovir ...... 7 tretinoin (chemotherapy) ...... 28 TRULICITY ...... 88 valproate sodium ...... 31 tretinoin microspheres ...... 69 TRUMENBA...... 107 valproic acid ...... 31 TREXALL ...... 28 trust natal dha ...... 144 valproic acid (as sodium salt) tri femynor ...... 119 TRUVADA ...... 7 ...... 31 TRIACETIN ...... 72 TUDORZA PRESSAIR ..... 132 valsartan ...... 56 triamcinolone acetonide 75, 79, tusnel c ...... 128 valsartan-hydrochlorothiazide 81 tussigon ...... 128 ...... 56 triamterene-hydrochlorothiazid TWINRIX (PF)...... 108 vancomycin ...... 18 ...... 56 TYBOST ...... 7 VANCOMYCIN IN 0.9% trianex ...... 75 TYGACIL ...... 14 SODIUM CL ...... 17, 18 triazolam ...... 48 TYKERB ...... 28 VANCOMYCIN IN tricitrates ...... 134 TYMLOS...... 109 DEXTROSE 5 % ...... 18 tricon...... 143 TYPHIM VI ...... 108 vandazole ...... 114 triderm ...... 75 TYSABRI ...... 34 VANTAS ...... 28 tri-estarylla ...... 119 TYVASO ...... 132 VARIVAX (PF) ...... 108 trifluoperazine ...... 48 TYVASO REFILL KIT...... 132 VARIZIG ...... 108 trifluridine...... 121 TYVASO STARTER KIT . 132 VARUBI ...... 97 trigels-f forte ...... 143 U VASCEPA ...... 63 trihexyphenidyl...... 33 UCERIS ...... 97 vasopressin in 0.9 % nacl .... 85 triklo ...... 63 ULESFIA...... 75 VAXCHORA VACCINE ... 108 tri-legest fe...... 119 ULORIC ...... 109 v-c forte ...... 144 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 162
VCF CONTRACEPTIVE viorele (28) ...... 120 VYXEOS ...... 28 FILM ...... 114 VIRACEPT ...... 7 W VCF CONTRACEPTIVE GEL VIREAD ...... 7, 8 warfarin ...... 61 ...... 114 virt-advance ...... 144 water for irrigation, sterile .... 77 VECTIBIX ...... 28 virt-c dha...... 144 WELCHOL ...... 63 VELCADE ...... 28 virt-gard ...... 144 wera (28) ...... 120 veletri ...... 56 virt-nate ...... 144 westhroid ...... 89 velivet triphasic regimen (28) virt-nate dha ...... 144 WIDE-SEAL DIAPHRAGM ...... 120 virt-phos 250 neutral ...... 138 ...... 111 VELPHORO...... 97 virt-pn ...... 144 woman's laxative ...... 97 VELTASSA ...... 97 virt-pn dha ...... 144 women's gentle laxative(bisac) vemavite-prx-2 ...... 144 virt-pn plus ...... 144 ...... 97 VEMLIDY ...... 7 virtrate-2 ...... 135 women's laxative (bisacodyl)97 VENCLEXTA ...... 28 virtrate-3 ...... 135 wymzya fe ...... 120 venlafaxine ...... 48 virtrate-k ...... 135 X VENOFER ...... 144 virt-select ...... 144 XALKORI ...... 28 VENTAVIS ...... 132 virtussin ac ...... 128 XARELTO ...... 61 verapamil ...... 56 virtussin dac ...... 128 XELJANZ ...... 110 verdrocet ...... 39 virt-vite ...... 144 XELJANZ XR ...... 110 VEREGEN ...... 67 virt-vite forte...... 144 XERMELO ...... 28 veripred 20...... 81 virt-vite gt ...... 144 XGEVA ...... 18 VESICARE ...... 133 VISTOGARD ...... 18 XIFAXAN ...... 14 vestura (28) ...... 120 vit 3 ...... 145 XIGDUO XR ...... 88 VIBERZI ...... 97 VITAFOL-OB ...... 145 XOLAIR ...... 132 vic-forte ...... 144 vitajoy daily d ...... 145 xulane ...... 114 vicodin ...... 39 vitamin d3 ...... 145 XURIDEN ...... 77 vicodin es...... 39 vitamin k ...... 61 xylon 10 ...... 39 vicodin hp ...... 39 vitamin k1 ...... 61 XYNTHA ...... 61 VICTOZA 2-PAK ...... 88 vitamins a,c,d and fluoride . 145 XYNTHA SOLOFUSE ...... 61 VICTOZA 3-PAK ...... 88 VIVOTIF ...... 108 XYREM ...... 49 VIDEX 2 GRAM PEDIATRIC VIVOTIF BERNA VACCINE Y ...... 7 ...... 108 YERVOY ...... 28 VIEKIRA PAK ...... 7 vol-care rx...... 145 YF-VAX (PF) ...... 108 VIEKIRA XR ...... 7 vol-nate ...... 145 YONDELIS ...... 28 vienva ...... 120 vol-plus ...... 145 yuvafem ...... 113 vigabatrin ...... 32 vol-tab rx ...... 145 Z VIIBRYD ...... 48 VONVENDI ...... 61 zafirlukast ...... 132 VIMIZIM ...... 85 voriconazole ...... 4 zaleplon ...... 49 VIMPAT...... 32 VOTRIENT ...... 28 ZANOSAR ...... 28 vinate care ...... 144 vp-ch plus ...... 145 zarah ...... 120 vinate ii ...... 144 vp-ch-pnv...... 145 ZARXIO ...... 100 vinate m ...... 144 vp-ggr-b6 ...... 145 zatean-ch ...... 145 vinate one ...... 144 vp-heme ob ...... 145 zatean-pn dha ...... 145 vinblastine ...... 28 vp-heme one ...... 145 zatean-pn plus ...... 145 vincasar pfs ...... 28 VPRIV ...... 85 ZAVESCA ...... 86 vincristine ...... 28 vp-vite rx ...... 145 zebutal ...... 39 vinorelbine ...... 28 vyfemla (28) ...... 120 ZEJULA ...... 28 VIOKACE ...... 97 VYVANSE ...... 49 ZELBORAF ...... 28 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 163
ZEMAIRA ...... 77 ZIRGAN ...... 121 ZONTIVITY ...... 62 zenatane ...... 69 ZODRYL AC 40 ...... 128 ZORTRESS ...... 29 zenchent (28) ...... 120 ZODRYL DEC 30 ...... 128 ZOSTAVAX (PF) ...... 108 ZENPEP ...... 97 ZOLADEX ...... 29 zovia 1/35e (28) ...... 120 zenzedi ...... 49 zoledronic acid ...... 86 zovia 1/50e (28) ...... 120 ZEPATIER ...... 8 zoledronic acid-mannitol-water ZOVIRAX ...... 72 ZERBAXA ...... 9 ...... 77 ZUBSOLV ...... 42 ZEVALIN (Y-90) ...... 28 ZOLINZA ...... 29 ZYDELIG ...... 29 zidovudine ...... 8 zolmitriptan ...... 34 ZYFLO ...... 132 zileuton ...... 132 zolpidem ...... 49 ZYKADIA ...... 29 zingiber ...... 145 ZOMETA ...... 86 ZYTIGA ...... 29 ZIOPTAN (PF) ...... 124 ZOMIG ...... 34 ZYVOX ...... 14 ziprasidone hcl...... 49 zonisamide ...... 32
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Updated December 1, 2017. 164