BlueCross BlueShield of Western New York 2018 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 00018104, Version Number 11
This formulary was updated on 5/22/2018. For more recent information or other questions, please contact BlueCross BlueShield of Western New York at 1-877-461-9218 or, for TTY users, 711, October 1 – February 14 8 a.m. to 8 p.m., 7 days a week and February 15 – September 30 8 a.m. to 8 p.m. Monday – Friday, or visit www.bcbswny.com/pharmacy.
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Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us”, or “our,” it means BlueCross BlueShield of Western New York. When it refers to “plan” or “our plan,” BlueCross BlueShield Retiree Pharmacy PDP. This document includes a list of the drugs (formulary) for our plan which is current as of 5/22/2018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year.
What is the BlueCross BlueShield of Western New York Formulary? A formulary is a list of covered drugs selected by BlueCross BlueShield of Western New York in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. BlueCross BlueShield of Western New York will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a BlueCross BlueShield of Western New York network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 5/22/2018. To get updated information about the drugs covered by BlueCross BlueShield of Western New York please contact us. Our contact information appears on the front and back cover pages. In the event that our plan has made an error in the printed formulary during the year, we will notify you directly by mail. We will send you a written notification explaining the error and a new formulary page reflecting the correct text and benefit. II EG189
How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 2. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Antihypertensive Therapy.” If you know what your drug is used for, look for the category name in the list that begins on page number 2. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page index page number 146. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs? BlueCross BlueShield of Western New York covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
•
Prior Authorization: BlueCross BlueShield of Western New York requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from BlueCross BlueShield of Western New York before you fill your prescriptions. If you don’t get approval, \BlueCross BlueShield of Western New York may not cover the drug.
•
Quantity Limits: For certain drugs, BlueCross BlueShield of Western New York limits the amount of the drug that BlueCross BlueShield of Western New York will cover. For example, BlueCross BlueShield of Western New York provides 30 tablets per prescription for atorvastatin. This may be in addition to a standard one-month or three-month supply.
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•
Step Therapy: In some cases, BlueCross BlueShield of Western New York requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, BlueCross BlueShield of Western New York may not cover Drug B unless you try Drug A first. If Drug A does not work for you, BlueCross BlueShield of Western New York will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 2. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask BlueCross BlueShield of Western New York to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the BlueCross BlueShield of Western New York formulary?” on IV for information about how to request an exception.
What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. \BlueCross BlueShield of Western New York pays for certain OTC drugs. The cost to BlueCross BlueShield of Western New York will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap).
What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that BlueCross BlueShield of Western New York does not cover your drug, you have two options: •
You can ask Member Services for a list of similar drugs that are covered by BlueCross BlueShield of Western New York. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by BlueCross BlueShield of Western New York.
•
You can ask BlueCross BlueShield of Western New York to make an exception and cover your drug. See below for information about how to request an exception.
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How do I request an exception to the BlueCross BlueShield of Western New York Formulary? You can ask BlueCross BlueShield of Western New York to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. •
You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
•
You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.
•
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, BlueCross BlueShield of Western New York limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, BlueCross BlueShield of Western New York will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30- day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. V EG189
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 93-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. If you submit a prescription for a transition eligible drug and it is rejected at Point of Sale, a message will be relayed to the pharmacists to call for additional instructions if you underwent a recent level of care change. After confirming that you had a level of care change, the pharmacist will be instructed to enter a series of override codes to allow you to receive a one-time transition supply of your prescription. At that time, all transition supply procedures will apply including member notifications for transition supply fills.
For more information For more detailed information about your BlueCross BlueShield of Western New York prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about BlueCross BlueShield of Western New York please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.
BlueCross BlueShield of Western New York Formulary The formulary that begins on the next page provides coverage information about the drugs covered by BlueCross BlueShield of Western New York. If you have trouble finding your drug in the list, turn to the Index that begins on page 146. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., WELCHOL) and generic drugs are listed in lower-case italics (e.g., simvasatin). The information in the Requirements/Limits column tells you if BlueCross BlueShield of Western New York has any special requirements for coverage of your drug.
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Below is a list of abbreviations that may appear on the following pages in the Requirements/Limits column that tells you if there are any special requirements for coverage of your drug. List of Abbreviations B/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. EXCL: We offer additional coverage of some prescription drugs not normally covered under a Medicare prescription drug plan (enhanced drug coverage). The amount you pay when you fill a prescription for these excluded drugs will not count towards any True out-of-pocket (TROOP) cost calculation. In addition, if you are receiving “Extra Help” from Medicare to pay for your prescriptions, the “Extra Help” program will not pay for these drugs. Please see your evidence of coverage (EOC) for further details. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. MO: Mail-Order Drug. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
1
Drug Name
Drug Tier
Requirements /Limits
ANTI - INFECTIVES ANTIFUNGAL AGENTS
Drug Name
Drug Tier
fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml
2
2
Requirements /Limits MO
ABELCET
5
B/D PA; EXCL; MO
AMBISOME
5
B/D PA; EXCL; MO
amphotericin b
4
B/D PA; EXCL; MO
fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml
ANCOBON
5
MO
flucytosine
5
MO
CANCIDAS
5
B/D PA; EXCL; MO
griseofulvin microsize
2
MO
caspofungin intravenous recon soln 50 mg
5
B/D PA; EXCL
griseofulvin ultramicrosize
2
MO
CASPOFUNGIN INTRAVENOUS RECON SOLN 70 MG
5
B/D PA; EXCL
GRIS-PEG (ULTRAMICROSIZ E)
4
MO
itraconazole
2
MO
clotrimazole mucous membrane
2
ketoconazole oral
2
MO
4
MO
CRESEMBA INTRAVENOUS
5
LAMISIL ORAL TABLET MYCAMINE
5
MO
CRESEMBA ORAL
5
MO
NOXAFIL ORAL
5
MO
DIFLUCAN
4
MO
2
MO
ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG
5
MO
nystatin oral suspension nystatin oral tablet
2
MO
ONMEL
5
MO; QL (30 per 30 days)
ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 50 MG
4
ORAVIG
3
MO
SPORANOX ORAL CAPSULE
4
MO
SPORANOX ORAL SOLUTION
3
MO
fluconazole
2
terbinafine hcl oral
2
MO
fluconazole in dextrose(iso-o)
2
VFEND
5
MO
VFEND IV
4
MO
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2
Drug Name
Drug Tier
voriconazole intravenous voriconazole oral
Requirements /Limits
Drug Name
Drug Tier
2
MO
BIKTARVY
5
MO
cidofovir
5
5
MO
B/D PA; EXCL; MO
CIMDUO
5
MO
ANTIVIRALS
Requirements /Limits
abacavir
2
MO
COMBIVIR
5
MO
abacavir-lamivudine
5
MO
COMPLERA
5
MO
abacavirlamivudinezidovudine
5
MO
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
3
MO
acyclovir oral capsule
2
MO
CYTOVENE
4
B/D PA; EXCL; MO
acyclovir oral suspension 200 mg/5 ml
2
MO
DAKLINZA
5
PA; MO; QL (28 per 28 days)
acyclovir oral tablet
2
MO
DESCOVY
5
MO
acyclovir sodium intravenous recon soln 500 mg
2
B/D PA; EXCL
2
MO
acyclovir sodium intravenous solution
4
B/D PA; EXCL; MO
didanosine oral capsule,delayed release(dr/ec) 200 mg, 250 mg, 400 mg EDURANT
5
MO
adefovir
5
MO
5
MO
amantadine hcl
2
MO
efavirenz oral capsule 200 mg
APTIVUS ORAL CAPSULE
5
MO
efavirenz oral capsule 50 mg
2
MO
APTIVUS ORAL SOLUTION
5
efavirenz oral tablet
5
MO
EMTRIVA
3
MO
atazanavir oral capsule 150 mg, 200 mg
2
entecavir
5
MO
EPCLUSA
5
atazanavir oral capsule 300 mg
5
PA; MO; QL (28 per 28 days)
EPIVIR
4
MO
ATRIPLA
5
MO
3
MO
BARACLUDE ORAL SOLUTION
3
MO
EPIVIR HBV ORAL SOLUTION
MO
5
MO
EPIVIR HBV ORAL TABLET
4
BARACLUDE ORAL TABLET
EPZICOM
5
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 3
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
KALETRA ORAL SOLUTION
5
MO
KALETRA ORAL TABLET 100-25 MG
3
MO
EVOTAZ
5
MO
famciclovir
2
MO
FLUMADINE ORAL TABLET
4
MO
fosamprenavir
5
MO
MO
2
B/D PA; EXCL
KALETRA ORAL TABLET 200-50 MG
5
foscarnet FUZEON SUBCUTANEOUS RECON SOLN
5
MO
lamivudine
2
MO
lamivudinezidovudine
2
MO
ganciclovir sodium
2
B/D PA; EXCL; MO
LEXIVA ORAL SUSPENSION
3
MO
GENVOYA
5
MO
MO
5
PA; MO; QL (28 per 28 days)
LEXIVA ORAL TABLET
5
HARVONI
lopinavir-ritonavir
2
MO
MAVYRET
5
PA; MO; QL (84 per 28 days)
moderiba
2
MO
moderiba dose pack oral tablets,dose pack 200 mg (28)400 mg (28), 400400 mg (28)-mg (28)
2
MO
moderiba dose pack oral tablets,dose pack 400 mg (7)400 mg (7)
2
moderiba dose pack oral tablets,dose pack 600 mg (7)600 mg (7)
5
moderiba dose pack oral tablets,dose pack 600-400 mg (28)-mg (28), 600600 mg (28)-mg (28)
5
HEPSERA
5
MO
INTELENCE ORAL TABLET 100 MG, 200 MG
5
MO
INTELENCE ORAL TABLET 25 MG
3
MO
INVIRASE
5
MO
ISENTRESS HD
5
MO
ISENTRESS ORAL POWDER IN PACKET
5
MO
ISENTRESS ORAL TABLET
5
MO
ISENTRESS ORAL TABLET,CHEWAB LE 100 MG
5
MO
ISENTRESS ORAL TABLET,CHEWAB LE 25 MG
3
MO
JULUCA
5
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 4
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
nevirapine oral tablet
2
MO
RETROVIR ORAL SYRUP
4
MO
nevirapine oral tablet extended release 24 hr
2
MO
REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG
5
MO
NORVIR ORAL CAPSULE
3
5
MO
NORVIR ORAL SOLUTION
3
REYATAZ ORAL POWDER IN PACKET
2
MO
NORVIR ORAL TABLET
3
ribasphere oral capsule
2
MO
ODEFSEY
5
MO
ribasphere oral tablet 200 mg, 400 mg
OLYSIO
5
PA; MO; QL (28 per 28 days)
ribasphere oral tablet 600 mg
5
MO
oseltamivir
2
MO
2
MO
PREVYMIS INTRAVENOUS
5
ribasphere ribapak oral tablets,dose pack 200 mg (28)400 mg (28)
PREVYMIS ORAL
5
MO
2
PREZCOBIX
5
MO
PREZISTA ORAL SUSPENSION
5
MO
ribasphere ribapak oral tablets,dose pack 200 mg (7)400 mg (7)
3
MO
PREZISTA ORAL TABLET 600 MG, 800 MG
5
MO
ribasphere ribapak oral tablets,dose pack 400 mg (7)400 mg (7), 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7)
5
PREZISTA ORAL TABLET 150 MG, 75 MG
5
MO
REBETOL ORAL SOLUTION
3
MO
RELENZA DISKHALER
3
MO
RESCRIPTOR
3
MO
ribasphere ribapak oral tablets,dose pack 400-400 mg (28)-mg (28), 600400 mg (28)-mg (28), 600-600 mg (28)-mg (28)
RETROVIR INTRAVENOUS
3
MO
ribavirin oral capsule
2
MO
RETROVIR ORAL CAPSULE
4
MO
ribavirin oral tablet 200 mg
2
MO
MO MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 5
Drug Name
Drug Tier
rimantadine
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
2
MO
valacyclovir oral tablet 1 gram
2
MO; QL (120 per 30 days)
ritonavir
2
MO
SELZENTRY
3
MO
valacyclovir oral tablet 500 mg
2
MO; QL (60 per 30 days)
SOVALDI
5
PA; MO; QL (28 per 28 days)
VALCYTE
5
MO
valganciclovir
5
MO
stavudine oral capsule
2
MO
VALTREX ORAL TABLET 1 GRAM
4
MO; QL (120 per 30 days)
STRIBILD
5
MO
4
SUSTIVA ORAL CAPSULE 200 MG
5
MO
VALTREX ORAL TABLET 500 MG
MO; QL (60 per 30 days)
VEMLIDY
5
MO
SUSTIVA ORAL CAPSULE 50 MG
3
MO
VIDEX 2 GRAM PEDIATRIC
3
MO
SUSTIVA ORAL TABLET
5
MO
VIDEX 4 GRAM PEDIATRIC
3
MO
SYMFI
5
MO
VIDEX EC
4
MO
SYMFI LO
5
MO
VIEKIRA PAK
5
SYNAGIS
5
MO; LA
PA; MO; QL (112 per 28 days)
TAMIFLU
3
MO
VIEKIRA XR
5
TECHNIVIE
5
PA; MO; QL (56 per 28 days)
PA; MO; QL (84 per 28 days) MO
5
MO
VIRACEPT ORAL TABLET
5
tenofovir disoproxil fumarate
VIRAMUNE
4
MO
TIVICAY ORAL TABLET 10 MG
3
MO
VIRAMUNE XR
4
MO
TIVICAY ORAL TABLET 25 MG, 50 MG
5
MO
VIREAD
5
MO
VOSEVI
5
TRIUMEQ
5
MO
PA; MO; QL (28 per 28 days)
TRIZIVIR
5
MO
ZEPATIER
5
TROGARZO
5
MO
PA; MO; QL (28 per 28 days)
TRUVADA
5
MO
ZERIT
4
MO
TYBOST
4
MO
ZIAGEN ORAL SOLUTION
3
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 6
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
cefazolin injection recon soln 1 gram, 500 mg
2
2
Requirements /Limits
ZIAGEN ORAL TABLET
4
MO
zidovudine
2
MO
ZOVIRAX ORAL CAPSULE
4
MO
ZOVIRAX ORAL SUSPENSION
4
MO
cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g
4
MO
cefazolin intravenous
2
ZOVIRAX ORAL TABLET 800 MG
cefdinir
2
MO
cefepime
2
MO
cefepime in dextrose,iso-osm intravenous piggyback 1 gram/50 ml
2
cefepime in dextrose,iso-osm intravenous piggyback 2 gram/100 ml
2
MO
cefixime
2
MO
CEPHALOSPORINS
MO
AVYCAZ
5
MO
cefaclor oral capsule
2
MO
cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml
2
MO
cefaclor oral suspension for reconstitution 375 mg/5 ml
2
cefaclor oral tablet extended release 12 hr
2
MO
cefotaxime injection recon soln 1 gram, 2 gram, 500 mg
2
cefadroxil oral capsule
2
MO
cefotaxime injection recon soln 10 gram
2
cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml
2
MO
cefotetan
2
cefoxitin in dextrose, iso-osm
2 2
cefadroxil oral tablet
2
MO
cefoxitin intravenous recon soln 1 gram, 2 gram
cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml
2
MO
cefoxitin intravenous recon soln 10 gram
2
cefpodoxime
2
MO
cefprozil
2
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 7
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
MO
SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 100 MG/5 ML, 200 MG/5 ML
4
SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML
4
SUPRAX ORAL TABLET,CHEWAB LE
4
TAZICEF INJECTION RECON SOLN 1 GRAM
4
4
MO
MO
ceftazidime injection recon soln 1 gram, 2 gram
2
ceftazidime injection recon soln 6 gram
2
CEFTIN ORAL SUSPENSION FOR RECONSTITUTIO N
4
MO
ceftriaxone in dextrose,iso-os
2
MO
ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg
2
MO
ceftriaxone injection recon soln 10 gram
2
ceftriaxone intravenous
2
MO
TAZICEF INJECTION RECON SOLN 2 GRAM, 6 GRAM
cefuroxime axetil oral tablet
2
MO
TEFLARO
5
ZERBAXA
5
cefuroxime sodium injection recon soln 750 mg
2
MO
cefuroxime sodium intravenous recon soln 1.5 gram
2
MO
cefuroxime sodium intravenous recon soln 7.5 gram
2
cephalexin
2
MAXIPIME INJECTION SUPRAX ORAL CAPSULE
Requirements /Limits MO
MO
ERYTHROMYCINS / OTHER MACROLIDES azithromycin
2
MO
clarithromycin
2
MO
DIFICID
5
MO
e.e.s. 400 oral tablet
2
MO
E.E.S. GRANULES
4
MO
MO
ERYPED 200
4
MO
4
MO
ERYPED 400
4
MO MO
MO
ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg
2
4
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 8
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml
2
MO
atovaquone
5
MO
atovaquoneproguanil
2
MO
AZACTAM
4
MO
aztreonam
2
MO
baciim
2
bacitracin intramuscular
2
BENZNIDAZOLE
3
BETHKIS
5
B/D PA; EXCL; MO; QL (224 per 28 days)
BILTRICIDE
3
MO
CAPASTAT
4
CAYSTON
5
chloramphenicol sod succinate
2
ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG
3
MO
erythrocin (as stearate) oral tablet 250 mg
2
MO
ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG
3
MO
erythromycin ethylsuccinate oral suspension for reconstitution
2
erythromycin ethylsuccinate oral tablet
2
MO
erythromycin oral capsule,delayed release(dr/ec)
2
MO
erythromycin oral tablet
2
MO
PCE
4
MO
ZITHROMAX
4
MO
ZITHROMAX TRIPAK
4
MO
chloroquine phosphate
2
MO
ZITHROMAX ZPAK
4
MO
CLEOCIN HCL
4
MO
CLEOCIN IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK 300 MG/50 ML, 600 MG/50 ML
4
MO
CLEOCIN IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK 900 MG/50 ML
4
MO
MISCELLANEOUS ANTIINFECTIVES ALBENZA
3
MO
ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N
3
MO
ALINIA ORAL TABLET
5
MO
MO
MO; LA; QL (84 per 28 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 9
Drug Name
Drug Tier
CLEOCIN INJECTION
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
4
MO
2
CLEOCIN PEDIATRIC
4
MO
clindamycin hcl
2
MO
gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/50 ml, 80 mg/100 ml, 90 mg/100 ml
clindamycin in 5 % dextrose
2
MO
gentamicin injection
2
MO MO
2
MO
gentamicin sulfate (ped) (pf)
2
clindamycin palmitate hcl
MO
2
MO
clindamycin phosphate injection
2
MO
gentamicin sulfate (pf) intravenous solution 100 mg/10 ml
2
clindamycin pediatric
2
clindamycin phosphate intravenous
2
GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML
COARTEM
3
MO
hydroxychloroquine
2
MO
colistin (colistimethate na)
2
MO
imipenem-cilastatin
2
MO
CUBICIN
5
MO
IMPAVIDO
5
MO
DALVANCE
4
MO
INVANZ INJECTION
4
MO
dapsone oral
2
MO
5
MO
INVANZ INTRAVENOUS
4
daptomycin DARAPRIM
5
PA; MO
isoniazid injection
2
DORIPENEM INTRAVENOUS RECON SOLN 500 MG
4
isoniazid oral
2
MO
ivermectin
2
MO
KITABIS PAK
5
MO
EMVERM
5
MO
LINCOCIN
4
MO
ethambutol
2
MO
lincomycin
2
FLAGYL
4
MO
linezolid intravenous
5
gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/50 ml
2
MO
linezolid oral
5
linezolid-0.9% sodium chloride
5
MALARONE
4
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 10
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
pyrazinamide
2
MO
QUALAQUIN
4
MO
quinine sulfate
2
MO
rifabutin
2
MO
RIFADIN ORAL CAPSULE 150 MG
4
MO
RIFAMATE
4
MO
rifampin
2
MO
MALARONE PEDIATRIC
4
MO
mefloquine
2
MO
MEPRON
5
MO
meropenem
2
MO
MERREM INTRAVENOUS RECON SOLN 500 MG
4
MO
metro i.v.
2
MO
RIFATER
4
MO
metronidazole in nacl (iso-os)
2
MO
SIRTURO
5
MO; LA
2
MO
SIVEXTRO INTRAVENOUS
5
metronidazole oral MYAMBUTOL ORAL TABLET 400 MG
4
MO
SIVEXTRO ORAL
5
MO
STREPTOMYCIN
3
MO
MYCOBUTIN
4
MO
STROMECTOL
4
MO
NEBUPENT
3
B/D PA; EXCL; MO; QL (1 per 28 days)
SYNERCID
5
TIGECYCLINE
5
TINDAMAX ORAL TABLET 500 MG
4
MO
neomycin
2
MO
tinidazole
2
MO
ORBACTIV
5
MO
TOBI
5
paromomycin
4
MO
PASER
3
MO
B/D PA; EXCL; MO; QL (280 per 28 days)
PENTAM
4
MO
5
PLAQUENIL
4
MO
QL (224 per 28 days)
polymyxin b sulfate
2
MO
TOBI PODHALER INHALATION CAPSULE
praziquantel
2
MO
5
MO; QL (224 per 28 days)
PRIFTIN
3
MO
PRIMAQUINE
3
MO
TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE
PRIMAXIN IV INTRAVENOUS RECON SOLN 500 MG
4
MO
tobramycin in 0.225 % nacl
5
B/D PA; EXCL; MO; QL (280 per 28 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 11
Drug Name
Drug Tier
tobramycin sulfate injection recon soln
2
tobramycin sulfate injection solution
2
TRECATOR
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
ampicillin sodium injection
2
MO
ampicillin sodium intravenous
2
3
MO
2
TYGACIL
5
MO
ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram
VABOMERE
5 5
MO; QL (9 per 30 days)
ampicillin-sulbactam injection recon soln 15 gram
2
XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG
5
MO; QL (60 per 30 days)
2
ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML
5
ampicillin-sulbactam intravenous recon soln 1.5 gram ampicillin-sulbactam intravenous recon soln 3 gram
2
MO
3
MO
ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML
5
MO
AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N 125-31.25 MG/5 ML
ZYVOX ORAL
5
MO
BICILLIN C-R
3
MO
BICILLIN L-A
3
MO
dicloxacillin
2
MO
nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml
2
nafcillin in dextrose iso-osm intravenous piggyback 2 gram/100 ml
2
MO
nafcillin injection recon soln 1 gram, 2 gram
2
MO
nafcillin injection recon soln 10 gram
5
MO
nafcillin intravenous
2
MO
PENICILLINS amoxicillin oral capsule
2
MO
amoxicillin oral suspension for reconstitution
2
MO
amoxicillin oral tablet
2
MO
amoxicillin oral tablet,chewable 125 mg, 250 mg
2
MO
amoxicillin-pot clavulanate
2
MO
ampicillin oral capsule
2
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 12
Drug Name
Drug Tier
Requirements /Limits
oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml
2
oxacillin in dextrose(iso-osm) intravenous piggyback 2 gram/50 ml
5
oxacillin injection recon soln 1 gram
2
oxacillin injection recon soln 10 gram
5
oxacillin injection recon soln 2 gram
2
PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 1 MILLION UNIT/50 ML, 2 MILLION UNIT/50 ML
3
PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 3 MILLION UNIT/50 ML
3
MO
penicillin g potassium
2
MO
penicillin g procaine intramuscular syringe 1.2 million unit/2 ml
2
MO
penicillin g procaine intramuscular syringe 600,000 unit/ml
2
MO
MO
Drug Name
Drug Tier
Requirements /Limits
penicillin g sodium
2
MO
penicillin v potassium
2
MO
pfizerpen-g
2
piperacillintazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram
2
UNASYN INJECTION RECON SOLN 15 GRAM
4
UNASYN INJECTION RECON SOLN 3 GRAM
4
ZOSYN IN DEXTROSE (ISOOSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML
4
ZOSYN IN DEXTROSE (ISOOSM) INTRAVENOUS PIGGYBACK 3.375 GRAM/50 ML
4
MO
ZOSYN INTRAVENOUS RECON SOLN 40.5 GRAM
4
MO
AVELOX
4
MO
AVELOX IN NACL (ISO-OSMOTIC)
4
MO
BAXDELA INTRAVENOUS
5
MO
MO
QUINOLONES
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 13
Drug Name
Drug Tier
Requirements /Limits
Drug Name
MO
moxifloxacin oral
2
MOXIFLOXACINSOD.ACE,SULWATER
4
ofloxacin oral tablet 300 mg
2
ofloxacin oral tablet 400 mg
2
BAXDELA ORAL
5
CIPRO IN D5W INTRAVENOUS PIGGYBACK 400 MG/200 ML
4
CIPRO ORAL SUSPENSION,MIC ROCAPSULE RECON
4
CIPRO ORAL TABLET 250 MG, 500 MG
4
ciprofloxacin
2
ciprofloxacin (mixture)
2
MO
ciprofloxacin hcl oral
2
MO
ciprofloxacin in 5 % dextrose
2
MO
ciprofloxacin lactate intravenous solution 400 mg/40 ml
2
LEVAQUIN ORAL TABLET 500 MG, 750 MG
4
levofloxacin in d5w intravenous piggyback 250 mg/50 ml
2
levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml
2
levofloxacin intravenous
2
levofloxacin oral
2
moxifloxacin in nacl (iso-osm)
2
MO
MO
Drug Tier
Requirements /Limits MO
MO
SULFA'S / RELATED AGENTS BACTRIM
4
MO
BACTRIM DS
4
MO
sulfadiazine
4
MO
sulfamethoxazoletrimethoprim
2
MO
sulfatrim
2
MO
TETRACYCLINES coremino
2
demeclocycline
4
MO
DORYX MPC
4
ST; MO
DORYX ORAL TABLET,DELAYE D RELEASE (DR/EC) 200 MG, 50 MG
4
ST; MO
doxy-100
2
MO
doxycycline hyclate oral capsule
2
MO
doxycycline hyclate oral tablet 100 mg, 150 mg, 20 mg, 75 mg
2
MO
MO
doxycycline hyclate oral tablet 50 mg
2
MO
doxycycline hyclate oral tablet,delayed release (dr/ec)
4
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 14
Drug Name
Drug Tier
Requirements /Limits
Drug Name
MO
TARGADOX
4
ST; MO
tetracycline
2
MO
VIBRAMYCIN ORAL CAPSULE 100 MG
4
ST; MO
VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTIO N
4
MO
VIBRAMYCIN ORAL SYRUP
3
MO
XIMINO
4
ST; MO
doxycycline monohydrate oral capsule
2
doxycycline monohydrate oral suspension for reconstitution
2
doxycycline monohydrate oral tablet
2
MO
MINOCIN INTRAVENOUS
4
MO
MINOCIN ORAL CAPSULE 100 MG, 50 MG
4
ST; MO
minocycline oral capsule
2
minocycline oral tablet
2
MO
minocycline oral tablet extended release 24 hr 115 mg, 65 mg
5
MO
minocycline oral tablet extended release 24 hr 135 mg, 45 mg, 90 mg
4
mondoxyne nl
2
MO
morgidox
2
MO
okebo oral capsule 75 mg
2
MO
ORACEA
4
ST; MO
SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG
5
ST; MO
MO
Drug Tier
Requirements /Limits
URINARY TRACT AGENTS MO
MO
FURADANTIN
4
HIPREX
4
MO
MACROBID
4
MO
MACRODANTIN
4
MO
methenamine hippurate
2
MO
methenamine mandelate
2
MO
MONUROL
4
MO
nitrofurantoin
2
MO
nitrofurantoin macrocrystal
2
MO
nitrofurantoin monohyd/m-cryst
2
MO
trimethoprim
2
MO
VANCOCIN
5
MO
VANCOMYCIN IN 0.9 % SODIUM CHL INTRAVENOUS PIGGYBACK
3
VANCOMYCIN
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 15
Drug Name
Drug Tier
VANCOMYCIN INJECTION
3
vancomycin intravenous
2
vancomycin oral capsule
5
VIBATIV INTRAVENOUS RECON SOLN 750 MG
5
Requirements /Limits
MO MO
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline
5
dexrazoxane hcl intravenous recon soln 250 mg
5
dexrazoxane hcl intravenous recon soln 500 mg
5
ELITEK
MO
Drug Name
Drug Tier
Requirements /Limits
levoleucovorin intravenous recon soln 50 mg
5
levoleucovorin intravenous solution
5
mesna
2
MO
MESNEX INTRAVENOUS
4
MO
MESNEX ORAL
5
MO
VISTOGARD
5
MO
XGEVA
5
B/D PA; EXCL; MO
ZINECARD (AS HCL) INTRAVENOUS RECON SOLN 250 MG
5
MO
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS MO
ABRAXANE
5
B/D PA; EXCL; MO
2
5
MO
adriamycin intravenous solution
B/D PA; EXCL
FUSILEV
5
MO
2
KEPIVANCE
5
MO
adrucil intravenous solution 2.5 gram/50 ml
B/D PA; EXCL
leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg
2
MO
adrucil intravenous solution 5 gram/100 ml, 500 mg/10 ml
2
B/D PA; EXCL; MO
leucovorin calcium injection recon soln 500 mg
2
AFINITOR DISPERZ
5
PA; MO
5
leucovorin calcium oral
2
AFINITOR ORAL TABLET 10 MG
PA; MO; QL (60 per 30 days)
LEVOLEUCOVORI N INTRAVENOUS RECON SOLN 175 MG
5
AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG
5
PA; MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 16
Drug Name
Drug Tier
ALECENSA
5
Requirements /Limits
Drug Name
PA; MO; QL (240 per 30 days)
AZASAN
4
B/D PA; EXCL; MO
azathioprine
2
B/D PA; EXCL; MO
azathioprine sodium
2
B/D PA; EXCL
BAVENCIO
5
B/D PA; EXCL; MO; LA
BELEODAQ
5
B/D PA; EXCL; MO
BENDEKA
5
B/D PA; EXCL; MO
BESPONSA
5
B/D PA; EXCL; MO
bexarotene
5
MO
bicalutamide
2
MO
BICNU
5
B/D PA; EXCL; MO
bleomycin
2
B/D PA; EXCL; MO
5
B/D PA; EXCL; MO
ALIMTA
5
B/D PA; EXCL; MO
ALIQOPA
5
B/D PA; EXCL; MO; LA
ALKERAN INTRAVENOUS
5
ALKERAN ORAL
3
B/D PA; EXCL; MO
ALUNBRIG ORAL TABLET 180 MG
5
PA; MO; QL (30 per 30 days)
ALUNBRIG ORAL TABLET 30 MG
5
ALUNBRIG ORAL TABLET 90 MG
5
B/D PA; EXCL
PA; MO; QL (180 per 30 days) PA; MO; QL (60 per 30 days) PA; MO; QL (30 per 30 days)
Drug Tier
Requirements /Limits
ALUNBRIG ORAL TABLETS,DOSE PACK
5
anastrozole
2
MO
BLINCYTO INTRAVENOUS KIT
ARIMIDEX
4
MO
BORTEZOMIB
5
AROMASIN
4
MO
B/D PA; EXCL; MO
ARRANON
5
B/D PA; EXCL
BOSULIF ORAL TABLET 100 MG
5
PA; MO
ARZERRA
5
B/D PA; EXCL; MO
BOSULIF ORAL TABLET 400 MG, 500 MG
5
PA; MO; QL (30 per 30 days)
ASTAGRAF XL
4
B/D PA; EXCL; MO
busulfan
5
B/D PA; EXCL
AVASTIN
5
B/D PA; EXCL; MO
BUSULFEX
5
B/D PA; EXCL
azacitidine
5
B/D PA; EXCL; MO
CABOMETYX
5
PA; MO; LA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 17
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
CALQUENCE
5
PA; MO; LA; QL (60 per 30 days)
COTELLIC
5
PA; MO; LA; QL (63 per 28 days)
CAMPTOSAR INTRAVENOUS SOLUTION 100 MG/5 ML
4
B/D PA; EXCL; MO
cyclophosphamide intravenous
2
B/D PA; EXCL; MO
3
B/D PA; EXCL; MO
capecitabine
1
MO; EXCL
CYCLOPHOSPHA MIDE ORAL CAPSULE
CAPRELSA ORAL TABLET 100 MG
5
PA; MO; LA; QL (90 per 30 days)
cyclosporine intravenous
2
B/D PA; EXCL
5
PA; MO; LA; QL (30 per 30 days)
cyclosporine modified
2
CAPRELSA ORAL TABLET 300 MG
B/D PA; EXCL; MO
cyclosporine oral capsule
2
B/D PA; EXCL; MO
carboplatin intravenous solution
2
B/D PA; EXCL; MO
CYRAMZA
5
B/D PA; EXCL; MO
CASODEX
4
MO
cytarabine
2
CELLCEPT INTRAVENOUS
3
B/D PA; EXCL; MO
B/D PA; EXCL; MO
4
B/D PA; EXCL; MO
B/D PA; EXCL; MO
CELLCEPT ORAL SUSPENSION FOR RECONSTITUTIO N
5
B/D PA; EXCL; MO
cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml)
2
CELLCEPT ORAL CAPSULE
2
B/D PA; EXCL
CELLCEPT ORAL TABLET
5
cytarabine (pf) injection solution 20 mg/ml dacarbazine
2
cisplatin
2
B/D PA; EXCL; MO
B/D PA; EXCL; MO
DACOGEN
5
B/D PA; EXCL; MO
B/D PA; EXCL; MO
dactinomycin
2
B/D PA; EXCL
B/D PA; EXCL
DARZALEX
5
B/D PA; EXCL; MO; LA
2
B/D PA; EXCL
cladribine clofarabine
5 5
B/D PA; EXCL; MO
CLOLAR
5
B/D PA; EXCL
COMETRIQ
5
PA; MO
daunorubicin intravenous solution
COSMEGEN
5
B/D PA; EXCL; MO
decitabine
5
B/D PA; EXCL; MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 18
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
B/D PA; EXCL
ELLENCE INTRAVENOUS SOLUTION 200 MG/100 ML
4
B/D PA; EXCL; MO
EMCYT
3
MO
EMPLICITI
5
B/D PA; EXCL; MO
ENVARSUS XR
4
B/D PA; EXCL; MO
epirubicin intravenous solution
2
B/D PA; EXCL; MO
ERBITUX
5
B/D PA; EXCL; MO
ERIVEDGE
5
PA; MO; QL (30 per 30 days)
ERLEADA
5
PA; MO
ERWINAZE
5
B/D PA; EXCL; MO
ETOPOPHOS
4
B/D PA; EXCL; MO
etoposide intravenous
2
B/D PA; EXCL; MO
etoposide oral
1
MO; EXCL
exemestane
2
MO
FARESTON
5
MO
FARYDAK ORAL CAPSULE 10 MG
5
PA; MO; QL (12 per 21 days)
5
PA; MO; QL (6 per 21 days)
docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 20 mg/2 ml (10 mg/ml)
5
docetaxel intravenous solution 160 mg/8 ml (20 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)
5
DOCETAXEL INTRAVENOUS SOLUTION 20 MG/ML
5
DOXIL
5
B/D PA; EXCL; MO
doxorubicin intravenous recon soln 10 mg
2
B/D PA; EXCL
doxorubicin intravenous recon soln 50 mg
2
doxorubicin intravenous solution
2
doxorubicin, pegliposomal
5
B/D PA; EXCL; MO
DROXIA
3
MO
ELIGARD
4
PA; MO
ELIGARD (3 MONTH)
4
PA; MO
ELIGARD (4 MONTH)
4
PA; MO
FARYDAK ORAL CAPSULE 15 MG, 20 MG
ELIGARD (6 MONTH)
4
PA; MO
FASLODEX
5
B/D PA; EXCL; MO
FEMARA
4
MO
B/D PA; EXCL; MO
B/D PA; EXCL
B/D PA; EXCL; MO B/D PA; EXCL; MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 19
Drug Name
Drug Tier
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG
5
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG
3
floxuridine
2
Requirements /Limits
Drug Name
B/D PA; EXCL; MO
gemcitabine intravenous solution 2 gram/52.6 ml (38 mg/ml)
2
B/D PA; EXCL
GEMZAR INTRAVENOUS RECON SOLN 1 GRAM
4
B/D PA; EXCL; MO
gengraf oral capsule 100 mg, 25 mg
2
B/D PA; EXCL; MO
gengraf oral solution
2
B/D PA; EXCL; MO
GILOTRIF ORAL TABLET 20 MG
5
PA; MO; QL (60 per 30 days)
GILOTRIF ORAL TABLET 30 MG
5
PA; MO; QL (40 per 30 days)
GILOTRIF ORAL TABLET 40 MG
5
PA; MO; QL (30 per 30 days)
GLEEVEC ORAL TABLET 100 MG
5
PA; MO
GLEEVEC ORAL TABLET 400 MG
5
PA; MO; QL (60 per 30 days)
GLEOSTINE
3
MO
HALAVEN
5
B/D PA; EXCL; MO
HERCEPTIN
5
B/D PA; EXCL; MO
HEXALEN
5
MO
HYCAMTIN INTRAVENOUS
5
B/D PA; EXCL; MO
HYCAMTIN ORAL
3
MO; EXCL
HYDREA
4
MO
hydroxyurea
2
MO
B/D PA; EXCL; MO
B/D PA; EXCL
fludarabine intravenous recon soln
2
B/D PA; EXCL; MO
fludarabine intravenous solution
2
B/D PA; EXCL
fluorouracil intravenous
2
B/D PA; EXCL; MO
flutamide
2
MO
FOLOTYN
5
B/D PA; EXCL; MO
GAZYVA
5
B/D PA; EXCL; MO
gemcitabine intravenous recon soln 1 gram, 200 mg
2
B/D PA; EXCL; MO
gemcitabine intravenous recon soln 2 gram
2
B/D PA; EXCL
gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml)
2
B/D PA; EXCL; MO
Drug Tier
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 20
Drug Name
Drug Tier
IBRANCE
Requirements /Limits
Drug Name
5
PA; MO; QL (21 per 28 days)
IMBRUVICA ORAL TABLET 140 MG
5
PA; MO; QL (120 per 30 days)
ICLUSIG ORAL TABLET 15 MG
5
PA; QL (90 per 30 days)
5
ICLUSIG ORAL TABLET 45 MG
5
PA; MO; QL (30 per 30 days)
IMBRUVICA ORAL TABLET 280 MG
PA; MO; QL (60 per 30 days)
5
IDAMYCIN PFS
4
IMBRUVICA ORAL TABLET 420 MG
PA; MO; QL (40 per 30 days)
IMBRUVICA ORAL TABLET 560 MG
5
PA; MO; QL (30 per 30 days)
IMFINZI
5
B/D PA; EXCL; MO; LA
IMURAN
4
B/D PA; EXCL; MO
INLYTA ORAL TABLET 1 MG
5
PA; MO
INLYTA ORAL TABLET 5 MG
5
PA; MO; QL (120 per 30 days)
B/D PA; EXCL; MO
idarubicin
2
B/D PA; EXCL
IDHIFA ORAL TABLET 100 MG
5
PA; MO; LA; QL (30 per 30 days)
IDHIFA ORAL TABLET 50 MG
5
PA; MO; LA; QL (60 per 30 days)
Requirements /Limits
IFEX INTRAVENOUS RECON SOLN 1 GRAM
4
ifosfamide intravenous recon soln
2
B/D PA; EXCL; MO
IRESSA
5
PA; MO; QL (30 per 30 days)
ifosfamide intravenous solution
2
B/D PA; EXCL
2
B/D PA; EXCL; MO
imatinib oral tablet 100 mg
5
PA; MO
irinotecan intravenous solution 100 mg/5 ml
5
imatinib oral tablet 400 mg
5
irinotecan intravenous solution 40 mg/2 ml
B/D PA; EXCL; MO
irinotecan intravenous solution 500 mg/25 ml
5
B/D PA; EXCL
ISTODAX
5
B/D PA; EXCL; MO
IXEMPRA
5
B/D PA; EXCL; MO
IMBRUVICA ORAL CAPSULE 140 MG
5
IMBRUVICA ORAL CAPSULE 70 MG
5
B/D PA; EXCL; MO
Drug Tier
PA; MO; QL (60 per 30 days) PA; MO; QL (120 per 30 days) PA; MO; QL (240 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 21
Drug Name
Drug Tier
JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG
5
JAKAFI ORAL TABLET 25 MG
5
JEVTANA
5
Requirements /Limits
Drug Name
Drug Tier
PA; MO
LYNPARZA
5
PA; MO
LYSODREN
3
MO
MARQIBO
3
B/D PA; EXCL; MO
MATULANE
5
MO
MEGACE ES
5
PA; MO
megestrol oral suspension 400 mg/10 ml (10 ml)
2
PA
megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml
2
PA; MO
megestrol oral tablet
2
PA; MO
MEKINIST ORAL TABLET 0.5 MG
5
PA; MO; QL (120 per 30 days)
MEKINIST ORAL TABLET 2 MG
5
PA; MO; QL (30 per 30 days)
melphalan
2
B/D PA; EXCL; MO
melphalan hcl
5
B/D PA; EXCL
mercaptopurine
2
MO
methotrexate sodium
2
B/D PA; EXCL; MO
methotrexate sodium (pf) injection recon soln
2
B/D PA; EXCL
methotrexate sodium (pf) injection solution
2
B/D PA; EXCL; MO
mitomycin intravenous recon soln 20 mg, 5 mg
2
B/D PA; EXCL; MO
PA; MO; QL (60 per 30 days) B/D PA; EXCL; MO
KADCYLA
5
PA; MO
KEYTRUDA INTRAVENOUS SOLUTION
5
PA; MO
KISQALI
5
PA; MO
KISQALI FEMARA CO-PACK
5
PA; MO
KYPROLIS
5
B/D PA; EXCL; MO
LARTRUVO
5
B/D PA; EXCL; MO; LA
LENVIMA
5
PA; MO
letrozole
2
MO
LEUKERAN
3
MO
leuprolide subcutaneous kit
2
MO
LONSURF
5
PA; MO
LUPRON DEPOT
5
PA; MO
LUPRON DEPOT (3 MONTH)
5
PA; MO
LUPRON DEPOT (4 MONTH)
5
PA; MO
LUPRON DEPOT (6 MONTH)
5
PA; MO
LUPRON DEPOTPED
5
PA; MO
LUPRON DEPOTPED (3 MONTH)
5
PA; MO
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 22
Drug Name
Drug Tier
Requirements /Limits
Drug Name
B/D PA; EXCL; MO
mitomycin intravenous recon soln 40 mg
5
mitoxantrone
2
B/D PA; EXCL; MO
MUSTARGEN
4
B/D PA; EXCL; MO
Drug Tier
Requirements /Limits
NINLARO ORAL CAPSULE 4 MG
5
PA; MO; QL (3 per 28 days)
NIPENT
5
B/D PA; EXCL; MO
NULOJIX
5
B/D PA; EXCL; MO
octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml
5
MO
octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml
2
MO
octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml)
2
MO
octreotide acetate injection syringe 500 mcg/ml (1 ml)
5
MO
ODOMZO
5
PA; MO; LA; QL (30 per 30 days)
mycophenolate mofetil hcl
2
B/D PA; EXCL
mycophenolate mofetil oral capsule
2
B/D PA; EXCL; MO
mycophenolate mofetil oral suspension for reconstitution
5
mycophenolate mofetil oral tablet
2
B/D PA; EXCL; MO
mycophenolate sodium
2
B/D PA; EXCL; MO
MYFORTIC
4
B/D PA; EXCL; MO
MYLERAN
3
MO; EXCL
MYLOTARG
5
B/D PA; EXCL; MO; LA
ONCASPAR
5
B/D PA; EXCL; MO
B/D PA; EXCL; MO
NEORAL
4
B/D PA; EXCL; MO
ONIVYDE
5
B/D PA; EXCL; MO
NERLYNX
5
MO; LA
OPDIVO
5
PA; MO
NEXAVAR
5
PA; MO; LA; QL (120 per 30 days)
oxaliplatin intravenous recon soln 100 mg
2
B/D PA; EXCL; MO
NILANDRON
5
MO
2
nilutamide
5
MO
oxaliplatin intravenous recon soln 50 mg
B/D PA; EXCL
NINLARO ORAL CAPSULE 2.3 MG
5
PA; MO; QL (6 per 28 days)
oxaliplatin intravenous solution
2
B/D PA; EXCL; MO
NINLARO ORAL CAPSULE 3 MG
5
PA; MO; QL (4 per 28 days)
paclitaxel
2
B/D PA; EXCL; MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 23
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
PERJETA
5
B/D PA; EXCL; MO
SANDIMMUNE INTRAVENOUS
4
B/D PA; EXCL; MO
POMALYST
5
MO; LA
4
PORTRAZZA
5
B/D PA; EXCL; MO
SANDIMMUNE ORAL CAPSULE
B/D PA; EXCL; MO
SANDIMMUNE ORAL SOLUTION
3
B/D PA; EXCL; MO
SANDOSTATIN INJECTION SOLUTION 100 MCG/ML
5
MO
SANDOSTATIN INJECTION SOLUTION 50 MCG/ML, 500 MCG/ML
4
MO
SANDOSTATIN LAR DEPOT INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON
5
MO
SIGNIFOR
5
MO
SIGNIFOR LAR
5
MO
SIMULECT INTRAVENOUS RECON SOLN 10 MG
3
B/D PA; EXCL
SIMULECT INTRAVENOUS RECON SOLN 20 MG
3
B/D PA; EXCL; MO
sirolimus oral tablet 0.5 mg, 1 mg
2
B/D PA; EXCL; MO
sirolimus oral tablet 2 mg
5
B/D PA; EXCL; MO
SOLTAMOX
3
MO
SOMATULINE DEPOT
5
MO
PROGRAF INTRAVENOUS
3
B/D PA; EXCL; MO
PROGRAF ORAL CAPSULE 0.5 MG, 1 MG
4
B/D PA; EXCL; MO
PROGRAF ORAL CAPSULE 5 MG
5
B/D PA; EXCL; MO
PURIXAN
5
MO
RAPAMUNE ORAL SOLUTION
5
B/D PA; EXCL; MO
RAPAMUNE ORAL TABLET 0.5 MG
4
B/D PA; EXCL; MO
RAPAMUNE ORAL TABLET 1 MG, 2 MG
5
B/D PA; EXCL; MO
REVLIMID
5
PA; MO; LA
RITUXAN
5
PA; MO
RITUXAN HYCELA
5
PA; MO
ROMIDEPSIN
5
B/D PA; EXCL
RUBRACA ORAL TABLET 200 MG
5
PA; MO; LA; QL (180 per 30 days)
RUBRACA ORAL TABLET 250 MG
5
PA; MO; LA; QL (150 per 30 days)
RUBRACA ORAL TABLET 300 MG
5
RYDAPT
5
PA; MO; LA; QL (120 per 30 days) PA; MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 24
Drug Name
Drug Tier
Requirements /Limits
Drug Name
SPRYCEL ORAL TABLET 100 MG, 20 MG, 50 MG, 80 MG
5
PA; MO
SPRYCEL ORAL TABLET 140 MG
5
PA; MO; QL (30 per 30 days)
SPRYCEL ORAL TABLET 70 MG
5
PA; MO; QL (60 per 30 days)
STIVARGA
5
PA; MO; QL (84 per 28 days)
SUTENT ORAL CAPSULE 12.5 MG
5
PA; MO
SUTENT ORAL CAPSULE 25 MG, 37.5 MG
5
PA; MO; QL (60 per 30 days)
SUTENT ORAL CAPSULE 50 MG
5
PA; MO; QL (30 per 30 days)
SYLVANT
5
B/D PA; EXCL; MO
SYNRIBO
5
B/D PA; EXCL; MO
TABLOID
3
MO
tacrolimus oral
2
B/D PA; EXCL; MO
TAFINLAR ORAL CAPSULE 50 MG
5
TAFINLAR ORAL CAPSULE 75 MG
5
TAGRISSO ORAL TABLET 40 MG
5
PA; MO; QL (180 per 30 days) PA; MO; QL (120 per 30 days) PA; MO; LA; QL (60 per 30 days)
Drug Tier
Requirements /Limits
TAGRISSO ORAL TABLET 80 MG
5
PA; MO; LA; QL (30 per 30 days)
tamoxifen
2
MO
TARCEVA ORAL TABLET 100 MG, 25 MG
5
PA; MO
TARCEVA ORAL TABLET 150 MG
5
PA; MO; QL (30 per 30 days)
TARGRETIN
5
MO
TASIGNA ORAL CAPSULE 150 MG, 50 MG
5
PA; MO
TASIGNA ORAL CAPSULE 200 MG
5
PA; MO; QL (112 per 28 days)
TAXOTERE INTRAVENOUS SOLUTION 80 MG/4 ML (20 MG/ML)
5
B/D PA; EXCL; MO
TECENTRIQ
5
B/D PA; EXCL; MO; LA
TEMODAR INTRAVENOUS
5
B/D PA; EXCL; MO
TEMODAR ORAL
3
MO; EXCL
temozolomide
1
MO; EXCL
THALOMID
5
PA; MO
thiotepa
5
B/D PA; EXCL; MO
toposar
2
B/D PA; EXCL; MO
topotecan intravenous recon soln
5
B/D PA; EXCL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 25
Drug Name
Drug Tier
Requirements /Limits
Drug Name
topotecan intravenous solution
5
B/D PA; EXCL; MO
TORISEL
5
B/D PA; EXCL; MO B/D PA; EXCL; MO
Drug Tier
Requirements /Limits
VERZENIO ORAL TABLET 100 MG
5
PA; MO; LA; QL (120 per 30 days)
VERZENIO ORAL TABLET 150 MG
5
PA; MO; LA; QL (80 per 30 days)
VERZENIO ORAL TABLET 200 MG
5
PA; MO; LA; QL (60 per 30 days)
TREANDA INTRAVENOUS RECON SOLN
5
TRELSTAR
5
B/D PA; EXCL; MO
tretinoin (chemotherapy)
5
MO
VERZENIO ORAL TABLET 50 MG
5
PA; MO; LA; QL (240 per 30 days)
TREXALL
4
B/D PA; EXCL; MO
VIDAZA
5
B/D PA; EXCL; MO
TRISENOX INTRAVENOUS SOLUTION 2 MG/ML
5
B/D PA; EXCL; MO
vinblastine intravenous solution
2
B/D PA; EXCL; MO
2
TYKERB
5
vincasar pfs intravenous solution 1 mg/ml
B/D PA; EXCL
vincasar pfs intravenous solution 2 mg/2 ml
2
B/D PA; EXCL; MO
vincristine
2
B/D PA; EXCL; MO
vinorelbine
2
B/D PA; EXCL; MO
VOTRIENT
5
PA; MO; QL (120 per 30 days)
VYXEOS
5
B/D PA; EXCL; MO
XALKORI ORAL CAPSULE 200 MG
5
PA; MO
XALKORI ORAL CAPSULE 250 MG
5
PA; MO; QL (60 per 30 days)
PA; MO; LA; QL (180 per 30 days)
UNITUXIN
5
B/D PA; EXCL; MO
VALSTAR
5
B/D PA; EXCL; MO
VANTAS
4
B/D PA; EXCL; MO
VECTIBIX
5
B/D PA; EXCL; MO
VELCADE
5
B/D PA; EXCL; MO
VENCLEXTA ORAL TABLET 10 MG, 50 MG
3
PA; MO; LA
VENCLEXTA ORAL TABLET 100 MG
5
PA; MO; LA
XATMEP 5 B/D PA; PA; MO; LA; EXCL; MO QL (42 per 180 days) XELODA 3 MO; EXCL You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 26 VENCLEXTA STARTING PACK
5
Drug Name
Drug Tier
Requirements /Limits
Drug Name
XERMELO
5
PA; MO; LA; QL (90 per 30 days)
AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
XTANDI
5
PA; MO; QL (120 per 30 days)
YERVOY YONDELIS ZALTRAP ZANOSAR ZEJULA
ZELBORAF
5 5 5 4 5
5
B/D PA; EXCL; MO B/D PA; EXCL; MO B/D PA; EXCL; MO B/D PA; EXCL; MO PA; MO; LA; QL (90 per 30 days) PA; MO; QL (240 per 30 days)
ZOLADEX
4
B/D PA; EXCL; MO
ZOLINZA
5
MO
ZORTRESS
5
B/D PA; EXCL; MO
ZYDELIG
ZYKADIA
5
5
ZYTIGA ORAL TABLET 250 MG
5
ZYTIGA ORAL TABLET 500 MG
5
PA; MO; QL (90 per 30 days) PA; MO; QL (150 per 30 days) PA; MO; QL (120 per 30 days) PA; MO; QL (60 per 30 days)
Drug Tier
Requirements /Limits
ANTICONVULSANTS APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG
4
MO
APTIOM ORAL TABLET 600 MG
5
MO
BANZEL ORAL SUSPENSION
3
MO
BANZEL ORAL TABLET 200 MG
3
MO
BANZEL ORAL TABLET 400 MG
5
MO
BRIVIACT INTRAVENOUS
4
BRIVIACT ORAL
5
MO
carbamazepine oral capsule, er multiphase 12 hr
2
MO
carbamazepine oral suspension 100 mg/5 ml
2
MO
carbamazepine oral tablet
1
MO
carbamazepine oral tablet extended release 12 hr
2
MO
carbamazepine oral tablet,chewable
1
MO
CARBATROL
4
MO
CELONTIN ORAL CAPSULE 300 MG
3
MO
CEREBYX INJECTION SOLUTION 500 MG PE/10 ML
4
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 27
Drug Name
Drug Tier
clonazepam
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
2
PA; MO
fosphenytoin
2
MO
DEPACON
4
MO
5
MO
DEPAKENE
4
MO
FYCOMPA ORAL SUSPENSION
DEPAKOTE
4
MO
FYCOMPA ORAL TABLET
3
MO
DEPAKOTE ER
4
MO
4
MO
gabapentin oral capsule 100 mg
1
DEPAKOTE SPRINKLES
MO; QL (1080 per 30 days)
4
MO
gabapentin oral capsule 300 mg
1
DIASTAT
MO; QL (360 per 30 days)
DIASTAT ACUDIAL
4
MO
gabapentin oral capsule 400 mg
1
MO; QL (270 per 30 days)
diazepam rectal
2
MO
2
DILANTIN 30 MG
3
MO
gabapentin oral solution 250 mg/5 ml
MO; QL (2160 per 30 days)
DILANTIN EXTENDED 100 MG
4
MO
gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml)
2
QL (2160 per 30 days)
DILANTIN INFATABS 50 MG
4
MO
gabapentin oral tablet 600 mg
1
MO; QL (180 per 30 days)
DILANTIN-125 125 MG/5 ML
4
MO
gabapentin oral tablet 800 mg
1
MO; QL (135 per 30 days)
divalproex oral capsule, delayed rel sprinkle
2
MO
GABITRIL ORAL TABLET 12 MG, 16 MG
3
MO
divalproex oral tablet extended release 24 hr
2
MO
GABITRIL ORAL TABLET 2 MG, 4 MG
4
MO
divalproex oral tablet,delayed release (dr/ec)
1
MO
GRALISE 30-DAY STARTER PACK
3
PA; MO; QL (78 per 180 days)
epitol
2
MO
4
MO
ethosuximide
2
MO
PA; MO; QL (30 per 30 days)
felbamate oral suspension
5
MO
GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 300 MG
3
EQUETRO
felbamate oral tablet
2
MO
FELBATOL
5
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 28
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
PA; MO; QL (90 per 30 days)
lamotrigine oral tablet extended release 24hr
4
MO
lamotrigine oral tablet, chewable dispersible
2
MO
lamotrigine oral tablet,disintegrating
4
MO
lamotrigine oral tablets,dose pack
2
MO
2
GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 600 MG
3
KEPPRA ORAL
4
MO
KEPPRA XR
4
MO
KLONOPIN
4
PA; MO
LAMICTAL ODT
4
MO
LAMICTAL ORAL TABLET
4
MO
LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG
4
MO
levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml
2
MO
LAMICTAL STARTER (BLUE) KIT
4
MO
levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml
MO
4
MO
levetiracetam intravenous
2
LAMICTAL STARTER (GREEN) KIT
levetiracetam oral solution 100 mg/ml
2
MO
LAMICTAL STARTER (ORANGE) KIT
4
MO
levetiracetam oral solution 500 mg/5 ml (5 ml)
2
LAMICTAL XR
4
MO
MO
4
MO
levetiracetam oral tablet
2
LAMICTAL XR STARTER (BLUE)
MO
4
MO
levetiracetam oral tablet extended release 24 hr
2
LAMICTAL XR STARTER (GREEN)
4
MO
PA; MO; QL (120 per 30 days)
lamotrigine oral tablet
1
MO
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG
4
LAMICTAL XR STARTER (ORANGE)
2 MO lamotrigine oral tablet disintegrating, dose pk You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 29
Drug Name
Drug Tier
Requirements /Limits
Drug Name
PA; MO; QL (60 per 30 days)
NEURONTIN ORAL CAPSULE 100 MG
4
PA; MO; QL (1080 per 30 days)
NEURONTIN ORAL CAPSULE 300 MG
4
PA; MO; QL (360 per 30 days)
NEURONTIN ORAL CAPSULE 400 MG
4
PA; MO; QL (270 per 30 days)
NEURONTIN ORAL SOLUTION
4
PA; MO; QL (2160 per 30 days)
NEURONTIN ORAL TABLET 600 MG
4
PA; MO; QL (180 per 30 days)
NEURONTIN ORAL TABLET 800 MG
4
PA; MO; QL (135 per 30 days)
ONFI ORAL SUSPENSION
3
PA; MO
ONFI ORAL TABLET 10 MG, 20 MG
3
PA; MO
oxcarbazepine
2
MO
OXTELLAR XR
4
MO
PEGANONE
3
MO
phenobarbital
2
PA; MO
phenobarbital sodium injection solution 130 mg/ml
2
MO
phenobarbital sodium injection solution 65 mg/ml
2
PHENYTEK
4
phenytoin oral suspension 100 mg/4 ml
2
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 330 MG
4
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 82.5 MG
4
LYRICA ORAL CAPSULE 100 MG
3
PA; MO; QL (180 per 30 days)
LYRICA ORAL CAPSULE 150 MG
3
PA; MO; QL (120 per 30 days)
LYRICA ORAL CAPSULE 200 MG
3
PA; MO; QL (90 per 30 days)
LYRICA ORAL CAPSULE 225 MG
3
PA; MO; QL (81 per 30 days)
LYRICA ORAL CAPSULE 25 MG
3
LYRICA ORAL CAPSULE 300 MG
3
LYRICA ORAL CAPSULE 50 MG
3
LYRICA ORAL CAPSULE 75 MG
3
LYRICA ORAL SOLUTION
3
MYSOLINE
5
PA; MO; QL (240 per 30 days)
PA; MO; QL (720 per 30 days) PA; MO; QL (60 per 30 days) PA; MO; QL (360 per 30 days) PA; MO; QL (240 per 30 days) PA; MO; QL (900 per 30 days) MO
Drug Tier
Requirements /Limits
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 30
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
TROKENDI XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 100 MG, 25 MG, 50 MG
4
PA; MO
TROKENDI XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 200 MG
5
PA; MO
valproate sodium
2
MO
phenytoin oral suspension 125 mg/5 ml
2
MO
phenytoin oral tablet,chewable
2
MO
phenytoin sodium extended
2
MO
phenytoin sodium intravenous solution
2
MO
phenytoin sodium intravenous syringe
2
primidone
2
MO
valproic acid
2
MO
QUDEXY XR
4
PA; MO
2
MO
roweepra
2
MO
valproic acid (as sodium salt) oral solution 250 mg/5 ml
roweepra xr
2 5
MO; LA
SPRITAM
4
MO
TEGRETOL ORAL SUSPENSION
4
MO
valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml)
2
SABRIL
TEGRETOL ORAL TABLET
4
MO
vigabatrin
5 3
TEGRETOL XR
4
MO
VIMPAT INTRAVENOUS
tiagabine
2
MO
VIMPAT ORAL SOLUTION
3
MO
TOPAMAX
4
PA; MO
3
MO
topiramate oral capsule, sprinkle
2
PA; MO
VIMPAT ORAL TABLET ZARONTIN
4
MO
TOPIRAMATE ORAL CAPSULE,SPRINK LE,ER 24HR
4
PA; MO
ZONEGRAN ORAL CAPSULE 100 MG, 25 MG
4
PA; MO
topiramate oral tablet
1
PA; MO
zonisamide
2
PA; MO
TRILEPTAL
4
MO
MO; LA
ANTIPARKINSONISM AGENTS APOKYN
5
MO; LA
AZILECT
4
MO
benztropine injection
2
MO
2 PA; MO benztropine oral You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 31
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
bromocriptine
4
MO
STALEVO 125
4
MO
carbidopa
2
MO
STALEVO 150
4
MO
carbidopa-levodopa
2
MO
STALEVO 200
4
MO
carbidopa-levodopaentacapone
4
MO
STALEVO 50
4
MO
STALEVO 75
4
MO
COGENTIN
4
MO
MO
4
MO
TASMAR ORAL TABLET 100 MG
5
COMTAN DUOPA
4
B/D PA; EXCL; MO
tolcapone
5
MO
ZELAPAR
4
MO
ELDEPRYL
4
entacapone
2
MO
MIGRAINE / CLUSTER HEADACHE THERAPY
GOCOVRI ORAL CAPSULE,EXTEN DED RELEASE 24HR 137 MG
5
PA; MO; QL (60 per 30 days)
almotriptan malate oral tablet 12.5 mg
2
MO; QL (24 per 28 days)
almotriptan malate oral tablet 6.25 mg
2
MO; QL (18 per 28 days)
GOCOVRI ORAL CAPSULE,EXTEN DED RELEASE 24HR 68.5 MG
5
PA; MO; QL (30 per 30 days)
AMERGE
4
MO; QL (18 per 28 days)
4
LODOSYN
4
MO
AXERT ORAL TABLET 12.5 MG
MO; QL (24 per 28 days)
MIRAPEX
4
MO
CAFERGOT
4
MO
MIRAPEX ER
4
MO
dihydroergotamine injection
2
MO
NEUPRO
3
MO
4
MO
dihydroergotamine nasal
2
PARLODEL
MO; QL (8 per 28 days)
pramipexole
2
MO
eletriptan
2
rasagiline
2
MO
MO; QL (18 per 28 days)
REQUIP
4
MO
ergotamine-caffeine
2
MO
REQUIP XL
4
MO
FROVA
4
ropinirole
2
MO
MO; QL (27 per 28 days)
RYTARY
4
MO
frovatriptan
2
MO; QL (27 per 28 days)
selegiline hcl
2
MO
4
SINEMET
4
MO
MO; QL (18 per 28 days)
SINEMET CR
4
MO
IMITREX NASAL SPRAY,NONAEROSOL 20 MG/ACTUATION
STALEVO 100
4
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 32
Drug Name
Drug Tier
Requirements /Limits
Drug Name sumatriptan nasal spray,non-aerosol 5 mg/actuation
2
MO; QL (36 per 28 days)
sumatriptan succinate oral
2
MO; QL (18 per 28 days)
sumatriptan succinate subcutaneous cartridge
2
MO; QL (8 per 28 days)
sumatriptan succinate subcutaneous pen injector
2
MO; QL (8 per 28 days)
sumatriptan succinate subcutaneous solution
2
MO; QL (8 per 28 days)
sumatriptannaproxen
2
MO; QL (18 per 28 days)
SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML
4
MO; QL (9 per 28 days)
TREXIMET ORAL TABLET 10-60 MG
4
MO; QL (9 per 28 days)
TREXIMET ORAL TABLET 85-500 MG
4
MO; QL (18 per 28 days)
ZEMBRACE SYMTOUCH
5
MO; QL (8 per 28 days)
zolmitriptan
2
MO; QL (18 per 28 days)
ZOMIG
4
MO; QL (18 per 28 days)
ZOMIG ZMT
4
MO; QL (18 per 28 days)
IMITREX NASAL SPRAY,NONAEROSOL 5 MG/ACTUATION
4
MO; QL (36 per 28 days)
IMITREX ORAL
4
MO; QL (18 per 28 days)
IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 6 MG/0.5 ML
4
MO; QL (8 per 28 days)
IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 4 MG/0.5 ML
4
IMITREX SUBCUTANEOUS
4
MO; QL (8 per 28 days)
MAXALT ORAL TABLET 10 MG
4
MO; QL (36 per 28 days)
MAXALT ORAL TABLET 5 MG
4
QL (36 per 28 days)
MAXALT-MLT
4
MO; QL (36 per 28 days)
migergot
2
MO
MIGRANAL
4
MO; QL (8 per 28 days)
naratriptan
2
MO; QL (18 per 28 days)
ONZETRA XSAIL
4
MO; QL (32 per 28 days)
RELPAX
4
MO; QL (18 per 28 days)
MO; QL (8 per 28 days)
rizatriptan
2
MO; QL (36 per 28 days)
sumatriptan nasal spray,non-aerosol 20 mg/actuation
2
MO; QL (18 per 28 days)
Drug Tier
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 33
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
glatopa subcutaneous syringe 20 mg/ml
5
PA; MO; QL (30 per 30 days)
glatopa subcutaneous syringe 40 mg/ml
5
PA; MO; QL (12 per 28 days)
HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG
4
PA; MO; QL (30 per 30 days)
HORIZANT ORAL TABLET EXTENDED RELEASE 600 MG
4
PA; MO; QL (60 per 30 days)
INGREZZA ORAL CAPSULE 40 MG
5
PA; MO; QL (12 per 28 days)
PA; MO; LA; QL (60 per 30 days)
INGREZZA ORAL CAPSULE 80 MG
5
PA; MO; LA; QL (30 per 30 days)
MO
KEVEYIS
5
PA; MO
LEMTRADA
5
PA; MO
2
PA; MO
MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA
5
PA; MO; LA
ARICEPT
4
MO
AUBAGIO
5
PA; MO
AUSTEDO ORAL TABLET 12 MG, 9 MG
5
PA; MO; LA; QL (120 per 30 days)
AUSTEDO ORAL TABLET 6 MG
5
PA; MO; LA; QL (60 per 30 days)
COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML
5
COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML
5
donepezil oral tablet 10 mg, 5 mg
1
donepezil oral tablet 23 mg
4
MO
donepezil oral tablet,disintegrating
1
MO
memantine oral capsule,sprinkle,er 24hr
2
PA; MO
EXELON TRANSDERMAL
4
MO
memantine oral solution
PA; MO
5
PA; MO
memantine oral tablet
2
EXONDYS 51 galantamine
2
MO
4
PA; MO
GILENYA
5
PA; MO
glatiramer subcutaneous syringe 20 mg/ml
5
PA; MO; QL (30 per 30 days)
MEMANTINE ORAL TABLETS,DOSE PACK NAMENDA ORAL TABLET
4
PA; MO
glatiramer subcutaneous syringe 40 mg/ml
5
NAMENDA TITRATION PAK
4
PA; MO
NAMENDA XR
3
PA; MO
PA; MO; QL (30 per 30 days)
PA; MO; QL (12 per 28 days)
NAMZARIC 3 PA; MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 34
Drug Name
Drug Tier
NUEDEXTA
Requirements /Limits
Drug Name
3
MO
5
OCREVUS
5
PA; MO
B/D PA; EXCL; MO
RADICAVA
5
MO
RAZADYNE ER
4
MO
GABLOFEN INTRATHECAL SOLUTION 40,000 MCG/20ML (2,000 MCG/ML)
RAZADYNE ORAL TABLET
4
MO
3
B/D PA; EXCL; MO
rivastigmine
2
MO
rivastigmine tartrate
2
MO
LIORESAL INTRATHECAL SOLUTION 2,000 MCG/ML, 500 MCG/ML
TECFIDERA
5
PA; MO; LA
3
tetrabenazine oral tablet 12.5 mg
5
PA; MO; QL (240 per 30 days)
LIORESAL INTRATHECAL SOLUTION 50 MCG/ML
B/D PA; EXCL
tetrabenazine oral tablet 25 mg
5
PA; MO; QL (120 per 30 days)
MESTINON ORAL
5
MO
MESTINON TIMESPAN
5
MO
TYSABRI
5
PA; MO; LA
2
MO
XENAZINE ORAL TABLET 12.5 MG
5
PA; MO; LA; QL (240 per 30 days)
neostigmine methylsulfate intravenous solution 0.5 mg/ml
XENAZINE ORAL TABLET 25 MG
5
PA; MO; LA; QL (120 per 30 days)
neostigmine methylsulfate intravenous solution 1 mg/ml
2
pyridostigmine bromide
2
regonol
2
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
Drug Tier
Requirements /Limits
MO
anectine
2
baclofen
2
MO
revonto
2
cyclobenzaprine oral tablet
4
PA; MO
tizanidine
2
MO
ZANAFLEX
4
MO
DANTRIUM ORAL CAPSULE 25 MG, 50 MG
4
MO
dantrolene
2
MO
FEXMID
4
PA; MO
NARCOTIC ANALGESICS ABSTRAL
5
PA; MO; QL (120 per 30 days)
acetaminophen-caffdihydrocod oral capsule
2
MO; QL (300 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 35
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
acetaminophencodeine oral solution 120 mg-12 mg /5 ml (5 ml), 300 mg-30 mg /12.5 ml
2
QL (4500 per 30 days)
BUTRANS
3
PA; MO; QL (4 per 28 days)
codeine sulfate oral tablet
2
MO; QL (180 per 30 days)
acetaminophencodeine oral solution 120-12 mg/5 ml
2
DILAUDID ORAL LIQUID
4
MO; QL (2400 per 30 days)
4
acetaminophencodeine oral tablet 300-15 mg, 300-30 mg
2
DILAUDID ORAL TABLET
MO; QL (180 per 30 days)
DOLOPHINE ORAL TABLET 10 MG
4
PA; MO; QL (120 per 30 days)
acetaminophencodeine oral tablet 300-60 mg
2
MO; QL (180 per 30 days)
DOLOPHINE ORAL TABLET 5 MG
4
PA; MO; QL (240 per 30 days)
ACTIQ
5
PA; MO; QL (120 per 30 days)
5
PA; MO; QL (10 per 30 days)
ARYMO ER
4
PA; MO; QL (120 per 30 days)
DURAGESIC TRANSDERMAL PATCH 72 HOUR 100 MCG/HR, 75 MCG/HR DURAGESIC TRANSDERMAL PATCH 72 HOUR 12 MCG/HR, 25 MCG/HR, 50 MCG/HR
4
PA; MO; QL (10 per 30 days)
duramorph (pf) injection solution 0.5 mg/ml
2
MO; QL (4000 per 30 days)
duramorph (pf) injection solution 1 mg/ml
2
QL (2000 per 30 days)
EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL 100-4 MG, 60-2.4 MG, 80-3.2 MG
5
PA; MO; QL (90 per 30 days)
MO; QL (4500 per 30 days) MO; QL (360 per 30 days)
BELBUCA
4
PA; MO; QL (60 per 30 days)
BUPRENEX
4
MO; QL (266 per 30 days)
buprenorphine hcl injection solution
2
MO; QL (266 per 30 days)
buprenorphine hcl injection syringe
2
QL (266 per 30 days)
buprenorphine hcl sublingual
2
MO
BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR
4
PA; MO; QL (4 per 28 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 36
Drug Name
Drug Tier
Requirements /Limits
Drug Name
PA; MO; QL (90 per 30 days)
FENTANYL TRANSDERMAL PATCH 72 HOUR 87.5 MCG/HOUR
5
PA; MO; QL (10 per 30 days)
FENTORA
5
PA; MO; QL (120 per 30 days)
HYCET
4
QL (5550 per 30 days)
hydrocodoneacetaminophen oral solution 7.5-325 mg/15 ml
2
MO; QL (5550 per 30 days)
hydrocodoneacetaminophen oral tablet 10-300 mg, 5300 mg, 7.5-300 mg
2
MO; QL (390 per 30 days)
hydrocodoneacetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
2
MO; QL (360 per 30 days)
hydrocodoneibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg
2
MO; QL (50 per 30 days)
hydromorphone (pf)
2
MO; QL (240 per 30 days)
hydromorphone injection solution 1 mg/ml
2
QL (300 per 30 days)
hydromorphone injection solution 2 mg/ml
2
MO; QL (150 per 30 days)
hydromorphone injection solution 4 mg/ml
2
MO; QL (75 per 30 days)
hydromorphone injection syringe 1 mg/ml
2
QL (300 per 30 days)
EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL 20-0.8 MG, 30-1.2 MG, 50-2 MG
4
endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5325 mg
2
EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 12 MG, 8 MG
4
EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 16 MG, 32 MG
5
fentanyl citrate
5
PA; MO; QL (120 per 30 days)
fentanyl citrate (pf) injection
2
MO; QL (400 per 30 days)
fentanyl citrate (pf) intravenous syringe 100 mcg/2 ml (50 mcg/ml)
2
QL (400 per 30 days)
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
2
FENTANYL TRANSDERMAL PATCH 72 HOUR 37.5 MCG/HOUR, 62.5 MCG/HOUR
4
MO; QL (360 per 30 days)
PA; MO; QL (60 per 30 days)
PA; MO; QL (60 per 30 days)
PA; MO; QL (10 per 30 days)
PA; MO; QL (10 per 30 days)
Drug Tier
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 37
Drug Name
Drug Tier
Requirements /Limits
Drug Name
hydromorphone injection syringe 2 mg/ml
2
QL (1200 per 30 days)
4
PA; MO; QL (90 per 30 days)
hydromorphone injection syringe 4 mg/ml
2
MO; QL (75 per 30 days)
KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 10 MG, 100 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG
hydromorphone oral liquid
2
MO; QL (2400 per 30 days)
5
hydromorphone oral tablet
2
MO; QL (180 per 30 days)
KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 200 MG
PA; MO; QL (90 per 30 days)
hydromorphone oral tablet extended release 24 hr 12 mg, 8 mg
2
PA; MO; QL (60 per 30 days)
LAZANDA NASAL SPRAY,NONAEROSOL 100 MCG/SPRAY
5
PA; MO; QL (45 per 30 days)
hydromorphone oral tablet extended release 24 hr 16 mg, 32 mg
5
PA; MO; QL (60 per 30 days)
LAZANDA NASAL SPRAY,NONAEROSOL 300 MCG/SPRAY
5
PA; QL (23 per 30 days)
HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 80 MG
5
PA; MO; QL (60 per 30 days)
LAZANDA NASAL SPRAY,NONAEROSOL 400 MCG/SPRAY
5
PA; MO; QL (30 per 30 days)
levorphanol tartrate
2
MO; QL (120 per 30 days)
HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 20 MG, 30 MG, 40 MG, 60 MG
4
lorcet (hydrocodone)
2
MO; QL (360 per 30 days)
lorcet hd
2
MO; QL (360 per 30 days)
2
IBUDONE ORAL TABLET 10-200 MG
4
lorcet plus oral tablet 7.5-325 mg
MO; QL (360 per 30 days)
methadone injection solution
2
QL (150 per 30 days)
ibuprofen-oxycodone
2
methadone intensol
2
PA; MO; QL (90 per 30 days)
methadone oral concentrate
2
PA; MO; QL (90 per 30 days)
PA; MO; QL (60 per 30 days)
MO; QL (50 per 30 days) MO; QL (28 per 30 days)
Drug Tier
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 38
Drug Name methadone oral solution 10 mg/5 ml
Drug Tier 2
Requirements /Limits
Drug Name
PA; MO; QL (600 per 30 days)
morphine injection syringe 5 mg/ml
2
QL (400 per 30 days)
morphine injection syringe 8 mg/ml
2
QL (250 per 30 days)
morphine intravenous cartridge 10 mg/ml
2
QL (200 per 30 days)
morphine intravenous cartridge 2 mg/ml
2
QL (1000 per 30 days)
morphine intravenous cartridge 4 mg/ml
2
QL (500 per 30 days)
morphine intravenous solution 10 mg/ml
2
MO; QL (200 per 30 days)
MORPHINE INTRAVENOUS SYRINGE 10 MG/ML
4
QL (200 per 30 days)
morphine intravenous syringe 2 mg/ml
2
QL (1000 per 30 days)
morphine intravenous syringe 4 mg/ml
2
QL (500 per 30 days)
MORPHINE INTRAVENOUS SYRINGE 8 MG/ML
4
QL (250 per 30 days)
morphine oral capsule, er multiphase 24 hr
2
PA; MO; QL (60 per 30 days)
PA; MO; QL (1200 per 30 days)
Drug Tier
Requirements /Limits
methadone oral solution 5 mg/5 ml
2
methadone oral tablet 10 mg
2
methadone oral tablet 5 mg
2
methadose oral concentrate
2
morphine (pf) injection solution 0.5 mg/ml
2
morphine (pf) injection solution 1 mg/ml
2
MO; QL (2000 per 30 days)
morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml
2
B/D PA; EXCL; MO; QL (400 per 30 days)
morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml
2
morphine concentrate oral solution
2
morphine injection syringe 10 mg/ml
2
MO; QL (200 per 30 days)
2
MO; QL (1000 per 30 days)
morphine oral capsule,extend.relea se pellets
2
morphine injection syringe 2 mg/ml
PA; MO; QL (90 per 30 days)
morphine injection syringe 4 mg/ml
2
MO; QL (500 per 30 days)
morphine oral solution
2
MO; QL (900 per 30 days)
PA; MO; QL (120 per 30 days) PA; MO; QL (240 per 30 days) PA; MO; QL (90 per 30 days) QL (4000 per 30 days)
B/D PA; EXCL; QL (2000 per 30 days) MO; QL (900 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 39
Drug Name
Drug Tier
Requirements /Limits
Drug Name
morphine oral tablet
2
MO; QL (180 per 30 days)
4
morphine oral tablet extended release 100 mg
2
PA; MO; QL (60 per 30 days)
OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 20 MG, 40 MG
PA; MO; QL (90 per 30 days)
morphine oral tablet extended release 15 mg, 200 mg, 30 mg, 60 mg
2
PA; MO; QL (120 per 30 days)
4
PA; QL (90 per 30 days)
MS CONTIN ORAL TABLET EXTENDED RELEASE 100 MG, 200 MG, 60 MG
5
PA; MO; QL (120 per 30 days)
OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 15 MG, 30 MG, 60 MG
5
PA; MO; QL (60 per 30 days)
MS CONTIN ORAL TABLET EXTENDED RELEASE 15 MG, 30 MG
4
OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG
2
MO; QL (360 per 30 days)
NORCO
4
MO; QL (360 per 30 days)
oxycodoneacetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
OPANA ORAL TABLET 10 MG
4
MO; QL (360 per 30 days)
oxycodone-aspirin
2
MO; QL (360 per 30 days)
OPANA ORAL TABLET 5 MG
4
MO; QL (180 per 30 days)
3
OXAYDO
5
MO; QL (360 per 30 days)
PA; MO; QL (90 per 30 days)
oxycodone oral capsule
2
MO; QL (360 per 30 days)
OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG
oxycodone oral concentrate
2
MO; QL (180 per 30 days)
5
oxycodone oral solution
2
MO; QL (1200 per 30 days)
PA; MO; QL (60 per 30 days)
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg
2
MO; QL (180 per 30 days)
OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet 10 mg
2
MO; QL (360 per 30 days)
oxycodone oral tablet 5 mg
2
MO; QL (360 per 30 days)
oxymorphone oral tablet 5 mg
2
MO; QL (180 per 30 days)
PA; MO; QL (120 per 30 days)
Drug Tier
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 40
Drug Name
Drug Tier
Requirements /Limits
Drug Name ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR
oxymorphone oral tablet extended release 12 hr
2
PA; MO; QL (90 per 30 days)
panlor(acetam-caffdihydrocod)
2
QL (300 per 30 days)
PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5325 MG, 7.5-325 MG
4
PRIMLEV
4
ROXICODONE ORAL TABLET 15 MG, 30 MG
4
ROXICODONE ORAL TABLET 5 MG
4
SUBSYS
5
MO; QL (360 per 30 days)
MO; QL (390 per 30 days) MO; QL (180 per 30 days) QL (360 per 30 days) PA; MO; QL (120 per 30 days)
TREZIX ORAL CAPSULE 320.530-16 MG
4
MO; QL (300 per 30 days)
TYLENOLCODEINE #3
4
MO; QL (360 per 30 days)
TYLENOLCODEINE #4
4
MO; QL (180 per 30 days)
vicodin
2
MO; QL (390 per 30 days)
vicodin es
2
MO; QL (390 per 30 days)
Drug Tier 4
Requirements /Limits PA; MO; QL (90 per 30 days)
NON-NARCOTIC ANALGESICS adult aspirin regimen
1
EXCL
adult low dose aspirin
1
MO; EXCL
ARTHROTEC 50
4
ST; MO
ARTHROTEC 75
4
ST; MO
aspir-81
1
EXCL
aspirin childrens
1
EXCL
aspirin low dose
1
MO; EXCL
aspirin oral tablet
1
MO; EXCL
aspirin oral tablet,chewable
1
MO; EXCL
aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg
1
MO; EXCL
aspir-low
1
MO; EXCL
aspir-trin
1
MO; EXCL
bayer aspirin
1
MO; EXCL
bufferin
1
MO; EXCL
BUNAVAIL BUCCAL FILM 2.1-0.3 MG
4
MO; QL (30 per 30 days)
4
MO; QL (60 per 30 days)
2
MO; QL (360 per 30 days)
vicodin hp
2
MO; QL (390 per 30 days)
BUNAVAIL BUCCAL FILM 4.2-0.7 MG, 6.3-1 MG
XTAMPZA ER
4
PA; MO; QL (90 per 30 days)
buprenorphinenaloxone sublingual tablet 2-0.5 mg
xylon 10
2
QL (50 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 41
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
EC-NAPROSYN ORAL TABLET,DELAYE D RELEASE (DR/EC) 375 MG
4
ST; MO
ecotrin
1
MO; EXCL
ecotrin low strength
1
MO; EXCL
enteric coated aspirin
1
EXCL
buprenorphinenaloxone sublingual tablet 8-2 mg
2
MO; QL (90 per 30 days)
butorphanol tartrate injection solution 1 mg/ml
2
MO; QL (857 per 30 days)
butorphanol tartrate injection solution 2 mg/ml
2
butorphanol tartrate nasal
2
MO; QL (10 per 28 days)
etodolac
2
MO
CAMBIA
4
ST; MO; QL (9 per 30 days)
EVZIO INJECTION AUTO-INJECTOR 2 MG/0.4 ML
4
MO; QL (0.8 per 30 days)
CELEBREX
4
MO
FELDENE
4
ST; MO
celecoxib
2
MO
4
ST; MO
children's aspirin
1
MO; EXCL
clonidine (pf) epidural solution 5,000 mcg/10 ml
2
FENOPROFEN ORAL CAPSULE 400 MG fenoprofen oral tablet
2
MO
CONZIP
4
PA; MO; QL (30 per 30 days)
FLECTOR
4
PA; MO; QL (60 per 30 days)
DAYPRO
4
ST; MO
flurbiprofen
2
MO
diclofenac potassium
2
MO
ibu
1
MO
diclofenac sodium oral
2
MO
ibuprofen oral suspension
2
MO
diclofenac sodium topical drops
2
MO; QL (300 per 28 days)
1
MO
diclofenac sodium topical gel 1 %
2
MO; QL (1000 per 28 days)
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
2
MO
diclofenacmisoprostol
2
ketoprofen oral capsule
2
MO
diflunisal
2
MO
ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg
DUEXIS
4
ST; MO
lite coat aspirin
1
EXCL
e.c. prin
1
EXCL
LODINE ORAL TABLET
4
ST
MO; QL (428 per 30 days)
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 42
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
NUCYNTA ER
4
PA; MO; QL (60 per 30 days)
NUCYNTA ORAL TABLET 100 MG
4
MO; QL (181 per 30 days)
NUCYNTA ORAL TABLET 50 MG
4
MO; QL (362 per 30 days)
NUCYNTA ORAL TABLET 75 MG
4
MO; QL (242 per 30 days)
oxaprozin
2
MO
PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP
5
ST; MO; QL (224 per 28 days)
MO
meclofenamate
2
MO
mefenamic acid
2
MO
meloxicam oral suspension
2
MO
meloxicam oral tablet 15 mg
1
MO
meloxicam oral tablet 7.5 mg
1
MO; QL (30 per 30 days)
MOBIC ORAL TABLET 15 MG
4
ST; MO
MOBIC ORAL TABLET 7.5 MG
4
ST; MO; QL (30 per 30 days)
nabumetone
2
MO
nalbuphine injection solution 10 mg/ml
2
MO; QL (200 per 30 days)
piroxicam
2
profeno
2
nalbuphine injection solution 20 mg/ml
2
MO; QL (100 per 30 days)
salsalate
1
MO
naloxone
2
MO
SPRIX
4
ST
naltrexone
2
MO
3
MO; QL (60 per 30 days)
NAPRELAN CR
4
ST; MO
SUBOXONE SUBLINGUAL FILM 12-3 MG
naproxen oral suspension
2
MO
3
MO; QL (360 per 30 days)
naproxen oral tablet
1
MO
SUBOXONE SUBLINGUAL FILM 2-0.5 MG
naproxen oral tablet,delayed release (dr/ec)
2
MO
SUBOXONE SUBLINGUAL FILM 4-1 MG, 8-2 MG
3
MO; QL (90 per 30 days)
naproxen sodium oral tablet 275 mg, 550 mg
2
MO
sulindac
1
MO
TIVORBEX
4
naproxen sodium oral tablet, er multiphase 24 hr
2
ST; MO; QL (90 per 30 days)
tolmetin
2
MO
NARCAN NASAL SPRAY,NONAEROSOL 4 MG/ACTUATION
3
MO
MO; QL (2 per 28 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 43
Drug Name
Drug Tier
Requirements /Limits
Drug Name ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.90.71 MG, 5.7-1.4 MG
3
MO; QL (30 per 30 days)
ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG
3
MO; QL (60 per 30 days)
TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 17-83
4
PA; MO; QL (30 per 30 days)
TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 25-75 100 MG, 200 MG
4
PA; MO; QL (30 per 30 days)
tramadol oral tablet
2
MO; QL (240 per 30 days)
tramadol oral tablet extended release 24 hr
2
PA; MO; QL (30 per 30 days)
tramadol oral tablet, er multiphase 24 hr
2
PA; MO; QL (30 per 30 days)
tramadolacetaminophen
2
MO; QL (240 per 30 days)
tri-buffered aspirin
1
MO; EXCL
ULTRACET
4
MO; QL (240 per 30 days)
ULTRAM
4
MO; QL (240 per 30 days)
VIMOVO
4
ST; MO
VIVITROL
5
MO
VIVLODEX ORAL CAPSULE 10 MG
4
ST; MO
VIVLODEX ORAL CAPSULE 5 MG
4
VOLTAREN TOPICAL
3
MO; QL (1000 per 28 days)
ZIPSOR
4
ST; MO
ZORVOLEX
4
ST; MO
ST; MO; QL (30 per 30 days)
Drug Tier
Requirements /Limits
PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA
5
MO
ABILIFY ORAL TABLET 10 MG
5
MO; QL (90 per 30 days)
ABILIFY ORAL TABLET 15 MG, 20 MG
5
MO; QL (60 per 30 days)
ABILIFY ORAL TABLET 2 MG
5
MO; QL (450 per 30 days)
ABILIFY ORAL TABLET 30 MG
5
MO; QL (30 per 30 days)
ABILIFY ORAL TABLET 5 MG
5
MO; QL (180 per 30 days)
ADASUVE
3
ADDERALL ORAL TABLET 20 MG, 5 MG, 7.5 MG
4
MO
ADDERALL XR
4
MO
ADZENYS ER
4
ADZENYS XRODT
4
MO
AMBIEN
4
ST; MO; QL (30 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 44
Drug Name
Drug Tier
AMBIEN CR
Requirements /Limits
Drug Name
4
ST; MO; QL (30 per 30 days)
aripiprazole oral tablet,disintegrating 15 mg
5
MO; QL (60 per 30 days)
amitriptyline
2
PA; MO
ARISTADA
5
MO
amoxapine
2
MO
armodafinil
4
PA; MO
ANAFRANIL
4
PA; MO
ATIVAN ORAL
4
PA; MO
APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG
4
MO; QL (90 per 30 days)
atomoxetine
2
MO
BELSOMRA
4
ST; MO; QL (30 per 30 days)
APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 348 MG
4
BRISDELLE
4
MO; QL (30 per 30 days)
bupropion hcl oral tablet
1
MO
4
bupropion hcl oral tablet extended release 12 hr 100 mg
2
APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 522 MG
MO; QL (120 per 30 days)
bupropion hcl oral tablet extended release 12 hr 150 mg
2
MO; QL (90 per 30 days)
APTENSIO XR
4
MO
5
MO
bupropion hcl oral tablet extended release 12 hr 200 mg
2
aripiprazole oral solution
MO; QL (60 per 30 days)
aripiprazole oral tablet 10 mg
2
MO; QL (90 per 30 days)
2
MO; QL (90 per 30 days)
aripiprazole oral tablet 15 mg
2
MO; QL (60 per 30 days)
bupropion hcl oral tablet extended release 24 hr 150 mg
2
aripiprazole oral tablet 2 mg
2
MO; QL (450 per 30 days)
bupropion hcl oral tablet extended release 24 hr 300 mg
MO; QL (60 per 30 days)
aripiprazole oral tablet 20 mg
5
MO; QL (60 per 30 days)
buspirone
2
MO
4
aripiprazole oral tablet 30 mg
5
CELEXA ORAL TABLET 10 MG
MO; QL (120 per 30 days)
4
aripiprazole oral tablet 5 mg
2
CELEXA ORAL TABLET 20 MG
MO; QL (60 per 30 days)
CELEXA ORAL TABLET 40 MG
4
MO; QL (30 per 30 days)
MO; QL (60 per 30 days)
MO; QL (30 per 30 days)
MO; QL (30 per 30 days) MO; QL (180 per 30 days)
Drug Tier
Requirements /Limits
5 MO; QL (90 aripiprazole oral 2 MO chlorpromazine per 30 days) tablet,disintegrating 10 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 45
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 60 MG
4
MO; QL (60 per 30 days)
DAYTRANA
4
MO
desipramine
2
MO
DESOXYN
4
PA; MO
DESVENLAFAXIN E ORAL TABLET EXTENDED RELEASE 24 HR 100 MG
4
MO; QL (120 per 30 days)
4
MO; QL (240 per 30 days)
citalopram oral solution
2
MO
citalopram oral tablet 10 mg
1
MO; QL (120 per 30 days)
citalopram oral tablet 20 mg
1
MO; QL (60 per 30 days)
citalopram oral tablet 40 mg
1
MO; QL (30 per 30 days)
clomipramine
4
PA; MO
clonidine hcl oral tablet extended release 12 hr
2
MO
clorazepate dipotassium
2
PA; MO
clozapine oral tablet
2
MO
clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg
2
DESVENLAFAXIN E ORAL TABLET EXTENDED RELEASE 24 HR 50 MG
2
CLOZAPINE ORAL TABLET,DISINTE GRATING 150 MG, 200 MG
4
desvenlafaxine succinate oral tablet extended release 24 hr 100 mg
MO; QL (120 per 30 days)
2
MO; QL (480 per 30 days)
CLOZARIL
4
desvenlafaxine succinate oral tablet extended release 24 hr 25 mg
CONCERTA
4
MO
4
MO; QL (180 per 30 days)
desvenlafaxine succinate oral tablet extended release 24 hr 50 mg
2
CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 20 MG
MO; QL (240 per 30 days)
DEXEDRINE SPANSULE
4
MO
CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 30 MG
4
dexmethylphenidate
2
MO
dextroamphetamine
2
MO
dextroamphetamineamphetamine
2
MO
diazepam injection solution
2
PA
MO; QL (120 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 46
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
diazepam injection syringe
2
PA; MO
ergoloid
4
MO MO
2
PA; MO
escitalopram oxalate oral solution
2
diazepam intensol diazepam oral concentrate
2
PA; MO
escitalopram oxalate oral tablet 10 mg
1
MO; QL (60 per 30 days)
diazepam oral solution 5 mg/5 ml (1 mg/ml)
2
PA; MO
escitalopram oxalate oral tablet 20 mg
1
MO; QL (30 per 30 days)
1
diazepam oral tablet
2
PA; MO
escitalopram oxalate oral tablet 5 mg
MO; QL (120 per 30 days)
doxepin oral
4
PA; MO
eszopiclone
4
duloxetine oral capsule,delayed release(dr/ec) 20 mg
2
MO; QL (180 per 30 days)
ST; MO; QL (30 per 30 days)
4
duloxetine oral capsule,delayed release(dr/ec) 30 mg
2
FANAPT ORAL TABLET 1 MG
MO; QL (720 per 30 days)
5
MO; QL (90 per 30 days)
duloxetine oral capsule,delayed release(dr/ec) 40 mg
2
FANAPT ORAL TABLET 10 MG, 8 MG FANAPT ORAL TABLET 12 MG
5
MO; QL (60 per 30 days)
duloxetine oral capsule,delayed release(dr/ec) 60 mg
2
MO; QL (60 per 30 days)
FANAPT ORAL TABLET 2 MG
4
MO; QL (360 per 30 days)
4
MO
FANAPT ORAL TABLET 4 MG
4
DYANAVEL XR
MO; QL (180 per 30 days)
EFFEXOR XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 150 MG
4
MO; QL (60 per 30 days)
FANAPT ORAL TABLET 6 MG
5
MO; QL (120 per 30 days)
FANAPT ORAL TABLETS,DOSE PACK
4
MO; QL (8 per 28 days)
EFFEXOR XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 37.5 MG
4
FAZACLO ORAL TABLET,DISINTE GRATING 100 MG
5
4
EFFEXOR XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 75 MG
4
MO; QL (90 per 30 days)
FAZACLO ORAL TABLET,DISINTE GRATING 12.5 MG, 150 MG, 200 MG, 25 MG
EMSAM
5
MO
MO; QL (120 per 30 days) MO; QL (90 per 30 days)
MO; QL (180 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 47
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
fluvoxamine oral capsule,extended release 24hr 100 mg
4
MO; QL (90 per 30 days)
fluvoxamine oral capsule,extended release 24hr 150 mg
4
MO; QL (60 per 30 days)
fluvoxamine oral tablet 100 mg
2
MO; QL (90 per 30 days)
fluvoxamine oral tablet 25 mg
2
MO; QL (360 per 30 days)
fluvoxamine oral tablet 50 mg
2
MO; QL (180 per 30 days)
FOCALIN
4
MO
FOCALIN XR
4
MO
FORFIVO XL
4
MO; QL (30 per 30 days)
GEODON INTRAMUSCULA R
4
MO
GEODON ORAL CAPSULE 20 MG
5
MO; QL (240 per 30 days)
GEODON ORAL CAPSULE 40 MG
5
MO; QL (120 per 30 days)
GEODON ORAL CAPSULE 60 MG
5
MO; QL (80 per 30 days)
GEODON ORAL CAPSULE 80 MG
5
MO; QL (60 per 30 days)
guanidine
2
MO
HALDOL
4
MO
HALDOL DECANOATE
4
MO
haloperidol
1
MO
FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK
3
MO; QL (28 per 28 days)
FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 120 MG
3
MO; QL (30 per 30 days)
FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 20 MG
3
FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 40 MG
3
FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 80 MG
3
flumazenil
2
MO
fluoxetine oral capsule 10 mg
1
MO; QL (240 per 30 days)
fluoxetine oral capsule 20 mg
1
MO
fluoxetine oral capsule 40 mg
1
MO; QL (60 per 30 days)
fluoxetine oral capsule,delayed release(dr/ec)
2
MO; QL (4 per 28 days)
fluoxetine oral solution
2
fluoxetine oral tablet 10 mg
2
fluoxetine oral tablet 20 mg, 60 mg
2
MO
haloperidol decanoate
2
MO
fluphenazine decanoate
2
MO
haloperidol lactate injection
2
MO
fluphenazine hcl
2
MO
MO; QL (180 per 30 days)
MO; QL (90 per 30 days)
MO; QL (45 per 30 days)
MO MO; QL (240 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 48
Drug Name
Drug Tier
Requirements /Limits
haloperidol lactate intramuscular
2
haloperidol lactate oral
2
MO
HETLIOZ
5
PA; MO; QL (30 per 30 days)
Drug Name
Drug Tier
Requirements /Limits
INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 39 MG/0.25 ML
4
MO
INVEGA TRINZA
5
MO
KAPVAY
4
MO
4
MO; QL (120 per 30 days)
imipramine hcl
4
PA; MO
imipramine pamoate
4
PA; MO
INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG
5
MO; QL (240 per 30 days)
KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG
4
MO; QL (240 per 30 days)
INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG
5
MO; QL (120 per 30 days)
KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG LATUDA ORAL TABLET 120 MG
5
MO; QL (30 per 30 days)
INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG
5
LATUDA ORAL TABLET 20 MG
3
MO; QL (240 per 30 days)
LATUDA ORAL TABLET 40 MG
3
MO; QL (120 per 30 days)
5
LATUDA ORAL TABLET 60 MG, 80 MG
3
INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG
MO; QL (60 per 30 days)
LEXAPRO ORAL TABLET 10 MG
4
MO; QL (60 per 30 days)
INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 78 MG/0.5 ML
5
LEXAPRO ORAL TABLET 20 MG
4
MO; QL (30 per 30 days)
LEXAPRO ORAL TABLET 5 MG
4
MO; QL (120 per 30 days)
lithium carbonate
1
MO
lithium citrate oral solution 8 meq/5 ml
2
MO
LITHOBID
4
MO
lorazepam injection solution
2
PA; MO
MO; QL (60 per 30 days)
MO; QL (41 per 30 days)
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 49
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
modafinil
2
PA; MO
MYDAYIS
4
MO
NARDIL
4
MO
nefazodone
2
MO
NORPRAMIN ORAL TABLET 10 MG, 25 MG
4
MO
nortriptyline
2
MO
NUPLAZID
5
MO
NUVIGIL
4
PA; MO
olanzapine intramuscular
2
MO
lorazepam injection syringe
2
PA
lorazepam intensol
2
PA; MO
lorazepam oral
2
PA; MO
loxapine succinate
2
MO
LUNESTA
4
ST; MO; QL (30 per 30 days)
maprotiline
2
MO
MARPLAN
3
MO
metadate er
2
MO
methamphetamine
2
PA; MO
METHYLIN ORAL SOLUTION
4
MO
olanzapine oral tablet 10 mg
2
MO; QL (60 per 30 days)
methylphenidate hcl oral capsule, er biphasic 30-70
2
MO
olanzapine oral tablet 15 mg, 20 mg
2
MO; QL (30 per 30 days)
2
methylphenidate hcl oral capsule,er biphasic 50-50
2
olanzapine oral tablet 2.5 mg
MO; QL (240 per 30 days)
olanzapine oral tablet 5 mg
2
MO; QL (120 per 30 days)
methylphenidate hcl oral solution
2
MO
olanzapine oral tablet 7.5 mg
2
MO; QL (81 per 30 days)
methylphenidate hcl oral tablet
2
MO
2
MO; QL (60 per 30 days)
methylphenidate hcl oral tablet extended release
2
MO
olanzapine oral tablet,disintegrating 10 mg
2
MO; QL (30 per 30 days)
methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg
2
MO
olanzapine oral tablet,disintegrating 15 mg, 20 mg olanzapine oral tablet,disintegrating 5 mg
2
MO; QL (120 per 30 days)
methylphenidate hcl oral tablet,chewable
2
MO
olanzapinefluoxetine
2
MO
mirtazapine oral tablet
1
MO
ORAP ORAL TABLET 1 MG
4
MO
mirtazapine oral tablet,disintegrating
2
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 50
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
paliperidone oral tablet extended release 24hr 1.5 mg
2
MO; QL (240 per 30 days)
PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 12.5 MG
4
MO; QL (180 per 30 days)
paliperidone oral tablet extended release 24hr 3 mg
2
MO; QL (120 per 30 days)
PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 25 MG
4
MO; QL (90 per 30 days)
paliperidone oral tablet extended release 24hr 6 mg
2
MO; QL (60 per 30 days)
paliperidone oral tablet extended release 24hr 9 mg
5
MO; QL (41 per 30 days)
4
MO; QL (60 per 30 days)
MO
PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 37.5 MG
PAMELOR
4
MO
PARNATE
4
paroxetine hcl oral tablet 10 mg
1
MO; QL (180 per 30 days)
PAXIL ORAL SUSPENSION
4
MO
paroxetine hcl oral tablet 20 mg
1
MO; QL (90 per 30 days)
PAXIL ORAL TABLET 10 MG
4
MO; QL (180 per 30 days)
paroxetine hcl oral tablet 30 mg
1
MO; QL (60 per 30 days)
PAXIL ORAL TABLET 20 MG
4
MO; QL (90 per 30 days)
paroxetine hcl oral tablet 40 mg
1
MO; QL (45 per 30 days)
PAXIL ORAL TABLET 30 MG
4
MO; QL (60 per 30 days)
paroxetine hcl oral tablet extended release 24 hr 12.5 mg
2
MO; QL (180 per 30 days)
PAXIL ORAL TABLET 40 MG
4
MO; QL (45 per 30 days)
perphenazine
2
MO
2
PEXEVA ORAL TABLET 10 MG
4
paroxetine hcl oral tablet extended release 24 hr 25 mg
MO; QL (180 per 30 days)
PEXEVA ORAL TABLET 20 MG
4
MO; QL (90 per 30 days)
paroxetine hcl oral tablet extended release 24 hr 37.5 mg
2
PEXEVA ORAL TABLET 30 MG
4
MO; QL (60 per 30 days)
4
paroxetine mesylate(menop.sym )
2
PEXEVA ORAL TABLET 40 MG
MO; QL (45 per 30 days)
phenelzine
2
MO
pimozide
2
MO
MO; QL (90 per 30 days) MO; QL (60 per 30 days)
MO; QL (30 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 51
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG
4
MO; QL (120 per 30 days)
quetiapine oral tablet extended release 24 hr 200 mg
2
MO; QL (120 per 30 days)
quetiapine oral tablet extended release 24 hr 300 mg
2
MO; QL (81 per 30 days)
PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG
4
quetiapine oral tablet extended release 24 hr 400 mg
2
MO; QL (60 per 30 days)
PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG
4
quetiapine oral tablet extended release 24 hr 50 mg
2
MO; QL (480 per 30 days)
QUILLICHEW ER
4
MO
procentra
2
MO
QUILLIVANT XR
4
MO
protriptyline
2
MO
REMERON
4
MO
PROVIGIL
5
REMERON SOLTAB
4
MO
PA; MO
PROZAC ORAL CAPSULE 10 MG
4
MO; QL (240 per 30 days)
REXULTI ORAL TABLET 0.25 MG
5
MO; QL (480 per 30 days)
PROZAC ORAL CAPSULE 20 MG
4
MO
REXULTI ORAL TABLET 0.5 MG
5
MO; QL (240 per 30 days)
PROZAC ORAL CAPSULE 40 MG
4
MO; QL (60 per 30 days)
REXULTI ORAL TABLET 1 MG
5
MO; QL (120 per 30 days)
quetiapine oral tablet 100 mg
2
MO; QL (240 per 30 days)
REXULTI ORAL TABLET 2 MG
5
MO; QL (60 per 30 days)
quetiapine oral tablet 200 mg
2
MO; QL (120 per 30 days)
REXULTI ORAL TABLET 3 MG
5
MO; QL (40 per 30 days)
quetiapine oral tablet 25 mg
2
MO; QL (902 per 30 days)
REXULTI ORAL TABLET 4 MG
5
MO; QL (30 per 30 days)
quetiapine oral tablet 300 mg
2
MO; QL (81 per 30 days)
3
MO
quetiapine oral tablet 400 mg
2
MO; QL (60 per 30 days)
quetiapine oral tablet 50 mg
2
MO; QL (480 per 30 days)
RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 12.5 MG/2 ML, 25 MG/2 ML
MO; QL (480 per 30 days)
MO; QL (240 per 30 days)
2 MO; QL (160 quetiapine oral per 30 days) tablet extended release 24 hr 150 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 52
Drug Name
Drug Tier
Requirements /Limits
Drug Name
MO
RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 37.5 MG/2 ML, 50 MG/2 ML
5
RISPERDAL ORAL SOLUTION
4
MO; QL (480 per 30 days)
RISPERDAL ORAL TABLET 0.25 MG
4
MO; QL (1920 per 30 days)
RISPERDAL ORAL TABLET 0.5 MG
4
MO; QL (960 per 30 days)
RISPERDAL ORAL TABLET 1 MG
4
MO; QL (480 per 30 days)
RISPERDAL ORAL TABLET 2 MG
4
MO; QL (240 per 30 days)
RISPERDAL ORAL TABLET 3 MG
4
MO; QL (161 per 30 days)
RISPERDAL ORAL TABLET 4 MG
4
MO; QL (120 per 30 days)
risperidone oral solution
2
MO; QL (480 per 30 days)
risperidone oral tablet 0.25 mg
1
MO; QL (1920 per 30 days)
risperidone oral tablet 0.5 mg
1
MO; QL (960 per 30 days)
risperidone oral tablet 1 mg
1
MO; QL (480 per 30 days)
risperidone oral tablet 2 mg
1
MO; QL (240 per 30 days)
risperidone oral tablet 3 mg
1
MO; QL (161 per 30 days)
risperidone oral tablet 4 mg
1
MO; QL (120 per 30 days)
risperidone oral tablet,disintegrating 0.25 mg
2
MO; QL (1920 per 30 days)
Drug Tier
Requirements /Limits
risperidone oral tablet,disintegrating 0.5 mg
2
MO; QL (960 per 30 days)
risperidone oral tablet,disintegrating 1 mg
2
MO; QL (480 per 30 days)
risperidone oral tablet,disintegrating 2 mg
2
MO; QL (240 per 30 days)
risperidone oral tablet,disintegrating 3 mg
2
MO; QL (161 per 30 days)
risperidone oral tablet,disintegrating 4 mg
2
MO; QL (120 per 30 days)
RITALIN
4
MO
RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 10 MG, 20 MG, 30 MG, 40 MG
4
MO
ROZEREM
3
MO; QL (30 per 30 days)
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG
3
MO; QL (60 per 30 days)
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG
3
MO; QL (240 per 30 days)
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG
3
MO; QL (120 per 30 days)
SARAFEM ORAL TABLET 10 MG, 20 MG
4
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 53
Drug Name
Drug Tier
Requirements /Limits
Drug Name
SEROQUEL ORAL TABLET 100 MG
4
MO; QL (240 per 30 days)
sertraline oral tablet 100 mg
1
MO; QL (60 per 30 days)
SEROQUEL ORAL TABLET 200 MG
4
MO; QL (120 per 30 days)
sertraline oral tablet 25 mg
1
MO; QL (240 per 30 days)
SEROQUEL ORAL TABLET 25 MG
4
MO; QL (902 per 30 days)
sertraline oral tablet 50 mg
1
MO; QL (120 per 30 days)
SEROQUEL ORAL TABLET 300 MG
4
MO; QL (81 per 30 days)
SILENOR
4
MO; QL (30 per 30 days)
SEROQUEL ORAL TABLET 400 MG
4
MO; QL (60 per 30 days)
SONATA ORAL CAPSULE 10 MG
4
SEROQUEL ORAL TABLET 50 MG
4
MO; QL (480 per 30 days)
ST; MO; QL (60 per 30 days)
4
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG
4
SONATA ORAL CAPSULE 5 MG
ST; MO; QL (30 per 30 days)
STRATTERA
4
MO
SURMONTIL
4
PA; MO
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG
4
SYMBYAX
4
MO
thioridazine
4
MO
thiothixene
1
MO
TOFRANIL
4
PA; MO
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG
4
TRANXENE TTAB ORAL TABLET 7.5 MG
4
PA; MO
tranylcypromine
4
MO
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG
4
trazodone
1
MO
trifluoperazine
2
MO
trimipramine
4
PA; MO
3
MO; QL (60 per 30 days)
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG
4
TRINTELLIX ORAL TABLET 10 MG TRINTELLIX ORAL TABLET 20 MG
3
MO; QL (30 per 30 days)
sertraline oral concentrate
2
TRINTELLIX ORAL TABLET 5 MG
3
MO; QL (120 per 30 days)
MO; QL (160 per 30 days)
MO; QL (120 per 30 days)
MO; QL (81 per 30 days)
MO; QL (60 per 30 days)
MO; QL (480 per 30 days)
MO
Drug Tier
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 54
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
VIIBRYD ORAL TABLET 10 MG
3
MO; QL (120 per 30 days)
VIIBRYD ORAL TABLET 20 MG
3
MO; QL (60 per 30 days)
MO; QL (180 per 30 days)
VIIBRYD ORAL TABLET 40 MG
3
MO; QL (30 per 30 days)
3
MO; QL (30 per 180 days)
VALIUM
4
PA; MO
venlafaxine oral capsule,extended release 24hr 150 mg
2
MO; QL (60 per 30 days)
venlafaxine oral capsule,extended release 24hr 37.5 mg
2
venlafaxine oral capsule,extended release 24hr 75 mg
2
MO; QL (90 per 30 days)
VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)20 MG (23)
venlafaxine oral tablet 100 mg, 75 mg
2
MO; QL (90 per 30 days)
VRAYLAR ORAL CAPSULE 1.5 MG
5
MO; QL (120 per 30 days)
venlafaxine oral tablet 25 mg
2
MO; QL (270 per 30 days)
VRAYLAR ORAL CAPSULE 3 MG
5
MO; QL (60 per 30 days)
venlafaxine oral tablet 37.5 mg
2
MO; QL (180 per 30 days)
VRAYLAR ORAL CAPSULE 4.5 MG
5
MO; QL (40 per 30 days)
venlafaxine oral tablet 50 mg
2
MO; QL (150 per 30 days)
VRAYLAR ORAL CAPSULE 6 MG
5
MO; QL (30 per 30 days)
VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 150 MG
4
MO; QL (60 per 30 days)
VRAYLAR ORAL CAPSULE,DOSE PACK
4
MO; QL (7 per 30 days)
VYVANSE
4
MO
VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 225 MG
4
MO; QL (30 per 30 days)
WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG
4
MO; QL (120 per 30 days)
VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 37.5 MG
4
MO; QL (180 per 30 days)
WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 12 HR 150 MG
4
MO; QL (90 per 30 days)
VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 75 MG
4
MO; QL (90 per 30 days)
WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 12 HR 200 MG
4
MO; QL (60 per 30 days)
VERSACLOZ
5
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 55
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
MO; QL (90 per 30 days)
zolpidem oral tablet
2
ST; MO; QL (30 per 30 days)
zolpidem oral tablet,ext release multiphase
4
ST; MO; QL (30 per 30 days)
ZYPREXA INTRAMUSCULA R
4
MO
ZYPREXA ORAL TABLET 10 MG
4
MO; QL (60 per 30 days)
ZYPREXA ORAL TABLET 15 MG, 20 MG
5
MO; QL (30 per 30 days)
WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 150 MG
4
WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 300 MG
4
XYREM
5
PA; MO; LA
zaleplon oral capsule 10 mg
4
ST; MO; QL (60 per 30 days)
zaleplon oral capsule 5 mg
4
ST; MO; QL (30 per 30 days)
ZYPREXA ORAL TABLET 2.5 MG
4
MO; QL (240 per 30 days)
zenzedi oral tablet 10 mg, 5 mg
2
MO
ZYPREXA ORAL TABLET 5 MG
4
MO; QL (120 per 30 days)
ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG
4
MO
ZYPREXA ORAL TABLET 7.5 MG
4
MO; QL (81 per 30 days)
3
MO
ziprasidone hcl oral capsule 20 mg
2
MO; QL (240 per 30 days)
ziprasidone hcl oral capsule 40 mg
2
MO; QL (120 per 30 days)
ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 210 MG
ziprasidone hcl oral capsule 60 mg
2
MO; QL (80 per 30 days)
5
MO
ziprasidone hcl oral capsule 80 mg
2
MO; QL (60 per 30 days)
ZOLOFT ORAL TABLET 100 MG
4
MO; QL (60 per 30 days)
ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 300 MG, 405 MG
ZOLOFT ORAL TABLET 25 MG
4
MO; QL (240 per 30 days)
4
MO; QL (60 per 30 days)
ZOLOFT ORAL TABLET 50 MG
4
MO; QL (120 per 30 days)
ZYPREXA ZYDIS ORAL TABLET,DISINTE GRATING 10 MG
MO; QL (60 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 56
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
ZYPREXA ZYDIS ORAL TABLET,DISINTE GRATING 15 MG, 20 MG
5
MO; QL (30 per 30 days)
NEXTERONE INTRAVENOUS SOLUTION 150 MG/100 ML (1.5 MG/ML)
4
B/D PA; EXCL
ZYPREXA ZYDIS ORAL TABLET,DISINTE GRATING 5 MG
4
MO; QL (120 per 30 days)
NEXTERONE INTRAVENOUS SOLUTION 360 MG/200 ML (1.8 MG/ML)
4
B/D PA; EXCL; MO
pacerone oral tablet 100 mg, 200 mg, 400 mg
2
MO
procainamide injection solution 100 mg/ml
2
MO
procainamide injection solution 500 mg/ml
2
propafenone
2
MO
quinidine gluconate
2
MO
2
MO
CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS adenosine
2
amiodarone intravenous solution
2
B/D PA; EXCL; MO
amiodarone intravenous syringe
2
B/D PA; EXCL
amiodarone oral
2
MO
BETAPACE AF
4
MO
dofetilide
2
MO
flecainide
2
MO
quinidine sulfate oral tablet
ibutilide fumarate
2
MO
RYTHMOL SR
4
MO
lidocaine (pf) in d7.5w
2
MO
2
MO
lidocaine (pf) intravenous solution
2
MO
sorine oral tablet 120 mg, 160 mg, 80 mg
2
lidocaine (pf) intravenous syringe
2
sorine oral tablet 240 mg sotalol af
2
MO
lidocaine in 5 % dextrose (pf) intravenous parenteral solution 4 mg/ml (0.4 %), 8 mg/ml (0.8 %)
2
sotalol oral
2
MO
SOTYLIZE
3
MO
TIKOSYN
4
MO
mexiletine
2
MO
MULTAQ
4
MO
ANTIHYPERTENSIVE THERAPY ACCUPRIL
4
MO
ACCURETIC
4
MO
acebutolol
2
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 57
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
bisoprololhydrochlorothiazide
1
MO
bumetanide injection
2
MO
bumetanide oral
1
MO
BYSTOLIC
3
MO
BYVALSON
3
MO
CALAN
4
MO
CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 240 MG
4
MO
ADALAT CC
4
MO
afeditab cr
2
MO
ALDACTAZIDE
4
MO
ALDACTONE
4
MO
ALTACE
4
MO
amiloride
2
MO
amiloridehydrochlorothiazide
1
MO
amlodipine
1
MO
amlodipinebenazepril
2
MO
amlodipineolmesartan
2
MO
candesartan
2
MO MO
2
MO
candesartanhydrochlorothiazid
2
amlodipinevalsartan
captopril
2
MO
amlodipinevalsartan-hcthiazid
2
MO
captoprilhydrochlorothiazide
2
MO
ATACAND
4
MO
4
MO
atenolol
1
MO
CARDENE IV IN SODIUM CHLORIDE
4
ATACAND HCT atenololchlorthalidone
1
MO
4
MO
AVALIDE
4
MO
AVAPRO
4
MO
AZOR
4
MO
CARDIZEM CD ORAL CAPSULE,EXTEN DED RELEASE 24HR 120 MG, 180 MG, 240 MG, 360 MG
benazepril
1
MO
CARDIZEM LA
4
MO
benazeprilhydrochlorothiazide
2
MO
4
MO
BENICAR
4
MO
CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG
BENICAR HCT
4
MO
4
betaxolol oral
2
MO
CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG
ST; MO; QL (30 per 30 days)
BIDIL
3
MO
4
bisoprolol fumarate
2
MO
CARDURA ORAL TABLET 8 MG
ST; MO; QL (60 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 58
Drug Name CARDURA XL
Drug Tier 4
Requirements /Limits
Drug Name
ST; MO; QL (30 per 30 days)
DIBENZYLINE
5
diltiazem hcl intravenous
2
diltiazem hcl oral capsule,ext.rel 24h degradable
2
MO
diltiazem hcl oral capsule,extended release 12 hr
2
MO
diltiazem hcl oral capsule,extended release 24 hr
2
MO
diltiazem hcl oral capsule,extended release 24hr
2
MO
diltiazem hcl oral tablet
1
MO
diltiazem hcl oral tablet extended release 24 hr
2
MO
dilt-xr
2
MO
DIOVAN
4
MO
DIOVAN HCT
4
MO
DIURIL
4
MO
DIURIL IV
5
CAROSPIR
4
MO
cartia xt
2
MO
carvedilol
1
MO
carvedilol phosphate
2
MO
CATAPRES
4
MO
CATAPRES-TTS-1
4
MO; QL (4 per 28 days)
CATAPRES-TTS-2
4
MO; QL (4 per 28 days)
Drug Tier
Requirements /Limits MO
CATAPRES-TTS-3
4
MO; QL (4 per 28 days)
chlorothiazide
1
MO
chlorothiazide sodium
2
MO
chlorthalidone oral tablet 25 mg, 50 mg
1
MO
clonidine
4
MO; QL (4 per 28 days)
clonidine (pf) epidural solution 1,000 mcg/10 ml (100 mcg/ml)
2
clonidine hcl oral tablet
1
MO
doxazosin oral tablet 1 mg, 2 mg, 4 mg
1
MO; QL (30 per 30 days)
COREG
4
MO
doxazosin oral tablet 8 mg
1
MO; QL (60 per 30 days)
COREG CR
3
MO
DUTOPROL
4
MO
CORGARD
4
MO
DYAZIDE
4
MO
CORZIDE
4
MO
DYRENIUM
4
MO
COZAAR
4
MO
EDARBI
3
MO
DEMADEX ORAL TABLET 10 MG, 20 MG
4
MO
EDARBYCLOR
3
MO
EDECRIN
5
MO
DEMSER
5
enalapril maleate
1
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 59
Drug Name
Drug Tier
enalaprilat intravenous solution
2
enalaprilhydrochlorothiazide
1
eplerenone
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
irbesartanhydrochlorothiazide
2
MO
MO
isradipine
2
MO
2
MO
2
MO
labetalol intravenous solution
epoprostenol (glycine)
2
B/D PA; EXCL; MO
2
eprosartan
2
MO
labetalol intravenous syringe 20 mg/4 ml (5 mg/ml)
esmolol intravenous solution
2
labetalol oral
2
MO
ethacrynate sodium
5
LASIX
4
MO
ethacrynic acid
5
MO
lisinopril
1
MO
EXFORGE
4
MO
lisinoprilhydrochlorothiazide
1
MO
EXFORGE HCT
4
MO
LOPRESSOR HCT
4
felodipine
2
MO
MO
1
MO
fosinoprilhydrochlorothiazide
2
MO
LOPRESSOR ORAL TABLET 100 MG
4
fosinopril
losartan
1
MO
furosemide injection
2
MO
1
MO
furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)
2
MO
losartanhydrochlorothiazide LOTENSIN ORAL TABLET 20 MG, 40 MG
4
MO
furosemide oral tablet
1
MO
4
MO
hydralazine
2
MO
LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 510 MG, 5-20 MG
hydrochlorothiazide
1
MO
mannitol 20 %
2
HYZAAR
4
MO
MO
1
MO
mannitol 25 % intravenous solution
2
indapamide INDERAL LA
4
MO
matzim la
2
MO
INNOPRAN XL
4
MO
MAXZIDE
4
MO
INSPRA
4
MO
MAXZIDE-25MG
4
MO
irbesartan
1
MO
methyclothiazide
2
MO
methyldopa
2
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 60
Drug Name
Drug Tier
metolazone
Requirements /Limits
Drug Name
Drug Tier
2
MO
olmesartan
2
MO
metoprolol succinate
1
MO
2
MO
metoprolol tahydrochlorothiaz
2
MO
olmesartanamlodipin-hcthiazid
2
MO
metoprolol tartrate intravenous solution
2
olmesartanhydrochlorothiazide
4
PA; MO
metoprolol tartrate intravenous syringe
2
metoprolol tartrate oral
1
MO
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG
PA; MO
4
MO
MICARDIS HCT
4
MO
MICROZIDE
4
MO
MINIPRESS
4
MO
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG
5
MICARDIS
minoxidil oral
2
MO
osmitrol 15 %
2
moexipril
1
MO
osmitrol 20 %
2
moexiprilhydrochlorothiazide
2
MO
perindopril erbumine
1
MO
nadolol
2
MO
phenoxybenzamine
5
MO
nadololbendroflumethiazide
2
MO
phentolamine injection recon soln
2
nicardipine intravenous solution
2
MO
pindolol
2
MO
prazosin
2
MO
nicardipine oral
2
MO
4
MO
nifedipine oral tablet extended release
2
MO
PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG
nifedipine oral tablet extended release 24hr
2
MO
PROCARDIA XL
4
MO
propranolol intravenous
2
nimodipine
2
MO
2
MO
nisoldipine
2
MO
NORVASC
4
MO
propranolol oral capsule,extended release 24 hr
NYMALIZE ORAL SOLUTION 30 MG/10 ML
5
propranolol oral solution
2
MO
propranolol oral tablet
1
MO
MO
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 61
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
propranololhydrochlorothiazid
2
MO
terazosin oral capsule 10 mg
1
MO; QL (60 per 30 days)
QBRELIS
4
MO
TIAZAC
4
MO
quinapril
1
MO
timolol maleate oral
2
MO
quinaprilhydrochlorothiazide
2
MO
TOPROL XL
4
MO
torsemide oral
1
MO
ramipril
1
MO
trandolapril
1
MO
REMODULIN
5
PA; MO; LA
2
MO
spironolactone
1
MO
trandolaprilverapamil
spironolactonhydrochlorothiaz
1
MO
triamterenehydrochlorothiazid
1
MO
SULAR ORAL TABLET EXTENDED RELEASE 24 HR 17 MG, 34 MG, 8.5 MG
4
MO
TRIBENZOR
4
MO
TWYNSTA
4
MO
UPTRAVI
5
PA; MO; LA
valsartan
1
MO
TARKA ORAL TABLET, IR - ER, BIPHASIC 24HR 2180 MG, 2-240 MG, 4-240 MG
4
valsartanhydrochlorothiazide
1
MO
VASERETIC
4
MO
VASOTEC
4
MO
taztia xt
2
MO
veletri
2
B/D PA; EXCL; MO
TEKTURNA
3
MO
2
MO
TEKTURNA HCT
3
MO
verapamil intravenous solution
telmisartan
2
MO
2
telmisartanamlodipine
2
MO
verapamil intravenous syringe verapamil oral
1
MO
telmisartanhydrochlorothiazid
2
VERELAN
4
MO
VERELAN PM
4
MO
TENORETIC 100
4
MO
ZESTORETIC
4
MO
TENORETIC 50
4
MO
ZESTRIL
4
MO
TENORMIN
4
MO
4
MO
terazosin oral capsule 1 mg, 2 mg, 5 mg
1
MO; QL (30 per 30 days)
ZIAC ORAL TABLET 2.5-6.25 MG
MO
MO
CARDIAC GLYCOSIDES
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 62
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
CEPROTIN (GREEN BAR)
3
MO
cilostazol
2
MO
clopidogrel
1
MO
digitek
2
MO
digox
2
MO
digoxin oral solution 50 mcg/ml
2
MO
digoxin oral tablet
2
MO
COUMADIN ORAL
4
MO
LANOXIN ORAL TABLET 125 MCG, 250 MCG
4
MO
CYKLOKAPRON
4
MO
dipyridamole intravenous
2
PA
LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG
3
dipyridamole oral
2
MO
EFFIENT
3
MO
COAGULATION THERAPY
ELIQUIS
3
MO
AGGRENOX
4
MO
enoxaparin
2
MO
AMICAR
3
MO
5
MO
aminocaproic acid intravenous
2
MO
ARGATROBAN
5
MO
fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml
ARGATROBAN IN 0.9 % SOD CHLOR INTRAVENOUS SOLUTION
5
fondaparinux subcutaneous syringe 2.5 mg/0.5 ml
2
MO
ARIXTRA SUBCUTANEOUS SYRINGE 10 MG/0.8 ML, 5 MG/0.4 ML, 7.5 MG/0.6 ML
5
FRAGMIN SUBCUTANEOUS SOLUTION
5
MO
5
MO
ARIXTRA SUBCUTANEOUS SYRINGE 2.5 MG/0.5 ML
4
MO
aspirin-dipyridamole
2
MO
BEVYXXA
4
BRILINTA
3
MO
FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTIXA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 7,500 ANTI-XA UNIT/0.3 ML
CEPROTIN (BLUE BAR)
3
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 63
Drug Name
Drug Tier
Requirements /Limits
Drug Name
MO
heparin, porcine (pf) injection
2
MO
jantoven
1
MO
LOVENOX
4
MO
MEPHYTON
3
MO; EXCL
NPLATE
5
MO
pentoxifylline
2
MO
PHYTONADIONE (VITAMIN K1) INJECTION
3
MO; EXCL
PLAVIX
4
MO
PRADAXA
4
MO
prasugrel
2
MO
PROMACTA
5
PA; MO; LA
protamine
2
SAVAYSA
4
MO
tranexamic acid intravenous
2
MO
vitamin k
1
MO; EXCL
vitamin k1 injection
1
MO; EXCL
warfarin
1
MO
XARELTO
3
MO
YOSPRALA
4
MO
ZONTIVITY
3
MO
FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTIXA UNIT/0.2 ML
4
heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml)
2
heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)
2
heparin (porcine) in nacl (pf)
2
heparin (porcine) injection cartridge
2
MO
heparin (porcine) injection solution
2
MO
heparin (porcine) injection syringe 5,000 unit/ml
2
MO
HEPARIN(PORCIN E) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML
3
heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml
2
MO
Drug Tier
Requirements /Limits
LIPID/CHOLESTEROL LOWERING AGENTS
MO
ALTOPREV
4
MO; QL (30 per 30 days)
amlodipineatorvastatin
2
MO; QL (30 per 30 days)
ANTARA ORAL CAPSULE 30 MG, 90 MG
4
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 64
Drug Name
Drug Tier
atorvastatin
Requirements /Limits
Drug Name
1
MO; QL (30 per 30 days)
fluvastatin oral capsule 20 mg
2
MO; QL (30 per 30 days)
CADUET ORAL TABLET 10-10 MG, 10-20 MG, 1040 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG
4
MO; QL (30 per 30 days)
fluvastatin oral capsule 40 mg
2
MO; QL (60 per 30 days)
fluvastatin oral tablet extended release 24 hr
2
MO; QL (30 per 30 days)
cholestyramine (with sugar)
2
gemfibrozil
1
MO
JUXTAPID
5
PA; MO; LA
cholestyramine light
2
MO
KYNAMRO
5
PA; MO; LA
COLESTID ORAL PACKET
4
MO
LESCOL XL
4
MO; QL (30 per 30 days)
COLESTID ORAL TABLET
4
MO
LIPITOR
4
MO; QL (30 per 30 days)
colestipol
2
MO
LIPOFEN
4
MO
CRESTOR
4
MO; QL (30 per 30 days)
LIVALO
3
MO; QL (30 per 30 days)
ezetimibe
2
MO
LOPID
4
MO
ezetimibesimvastatin
2
MO; QL (30 per 30 days)
lovastatin oral tablet 10 mg
1
MO; QL (30 per 30 days)
fenofibrate micronized
2
MO
lovastatin oral tablet 20 mg, 40 mg
1
MO; QL (60 per 30 days)
fenofibrate nanocrystallized
2
MO
LOVAZA
4
ST; MO
2
MO
FENOFIBRATE ORAL CAPSULE
4
MO
niacin oral tablet extended release 24 hr
fenofibrate oral tablet
2
MO
NIACOR
4
MO
4
MO
fenofibric acid
2
MO
fenofibric acid (choline)
2
MO
NIASPAN EXTENDEDRELEASE
4
ST; MO
FENOGLIDE
4
MO
omega-3 acid ethyl esters
FIBRICOR
4
MO
5
PA; MO; QL (2 per 28 days)
FLOLIPID
4
MO; QL (150 per 30 days)
PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML
MO
Drug Tier
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 65
Drug Name
Drug Tier
Requirements /Limits
Drug Name
PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 75 MG/ML
5
PA; MO; QL (4 per 28 days)
VYTORIN 10-40
4
MO; QL (30 per 30 days)
VYTORIN 10-80
4
MO; QL (30 per 30 days)
PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG
4
WELCHOL
3
MO
ZETIA
4
MO
pravastatin
1
MO; QL (30 per 30 days)
ZOCOR
4
MO; QL (30 per 30 days)
prevalite
2
MO
QUESTRAN LIGHT ORAL POWDER
4
MO
MISCELLANEOUS CARDIOVASCULAR AGENTS
QUESTRAN ORAL POWDER IN PACKET
4
MO
REPATHA
5
PA; MO; QL (3 per 28 days)
REPATHA PUSHTRONEX
5
PA; MO; QL (3.5 per 28 days)
REPATHA SURECLICK
5
PA; MO; QL (3 per 28 days)
rosuvastatin
1
MO; QL (30 per 30 days)
simvastatin
1
MO; QL (30 per 30 days)
TRICOR
4
MO
TRIGLIDE ORAL TABLET 160 MG
4
MO
triklo
2
MO
TRILIPIX
4
MO
VASCEPA
3
MO
VYTORIN 10-10
4
MO; QL (30 per 30 days)
VYTORIN 10-20
4
MO; QL (30 per 30 days)
MO; QL (30 per 30 days)
Drug Tier
Requirements /Limits
cardioplegic soln
2
CORLANOR
3
PA; MO
dobutamine
2
B/D PA; EXCL
dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml)
2
B/D PA; EXCL; MO
dobutamine in d5w intravenous parenteral solution 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml)
2
B/D PA; EXCL
dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 400 mg/250 ml (1,600 mcg/ml), 400 mg/500 ml (800 mcg/ml), 800 mg/500 ml (1,600 mcg/ml)
2
B/D PA; EXCL
dopamine in 5 % dextrose intravenous solution 800 mg/250 ml (3,200 mcg/ml)
2
B/D PA; EXCL; MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 66
Drug Name
Drug Tier
Requirements /Limits
Drug Name nitroglycerin in 5 % dextrose intravenous solution 100 mg/250 ml (400 mcg/ml), 200 mg/500 ml (400 mcg/ml), 50 mg/250 ml (200 mcg/ml), 50 mg/500 ml (100 mcg/ml)
2
B/D PA; EXCL
nitroglycerin in 5 % dextrose intravenous solution 25 mg/250 ml (100 mcg/ml)
2
B/D PA; EXCL; MO
nitroglycerin intravenous
2
B/D PA; EXCL
nitroglycerin oral
2
MO
nitroglycerin sublingual
2
MO
nitroglycerin transdermal patch 24 hour
2
MO
nitroglycerin translingual spray,non-aerosol
2
MO
NITROSTAT
4
MO
dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 800 mg/10 ml (80 mg/ml), 800 mg/5 ml (160 mg/ml)
2
B/D PA; EXCL
dopamine intravenous solution 400 mg/10 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml)
2
B/D PA; EXCL; MO
ENTRESTO
3
MO; QL (60 per 30 days)
milrinone
2
B/D PA; EXCL; MO
milrinone in 5 % dextrose
2
B/D PA; EXCL; MO
norepinephrine bitartrate
2
RANEXA
3
sodium nitroprusside
2
VECAMYL
5
MO
NITRATES
Drug Tier
Requirements /Limits
GONITRO
4
MO
ISORDIL
4
MO
ISORDIL TITRADOSE ORAL TABLET 5 MG
4
MO
2
MO
acitretin oral capsule 10 mg
2
MO
isosorbide dinitrate oral
MO
1
MO
acitretin oral capsule 17.5 mg, 25 mg
5
isosorbide mononitrate MINITRAN
4
MO
calcipotriene scalp
2
MO
nitro-bid
2
MO
4
MO
NITRO-DUR
4
MO
calcipotriene topical cream
DERMATOLOGICALS/TOPICA L THERAPY ANTIPSORIATIC / ANTISEBORRHEIC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 67
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
calcipotriene topical ointment
2
MO
MISCELLANEOUS DERMATOLOGICALS
calcipotrienebetamethasone
2
MO
ALDARA
4
ST; MO
ammonium lactate
2
MO
calcitrene
2
MO
CARAC
5
MO
calcitriol topical
4
MO
MO
5
PA; MO
CONDYLOX TOPICAL GEL
3
COSENTYX COSENTYX (2 SYRINGES)
5
PA; MO
diclofenac sodium topical gel 3 %
5
COSENTYX PEN
5
PA; MO
PA; MO; QL (100 per 28 days)
COSENTYX PEN (2 PENS)
5
PA; MO
doxepin topical
2
MO
DUPIXENT
5
PA; MO
DOVONEX TOPICAL
4
MO
EFUDEX TOPICAL CREAM
4
ST; MO
ENSTILAR
5
MO
ELIDEL
4
selenium sulfide topical lotion
2
MO
PA; MO; QL (100 per 30 days)
SILIQ
5
PA; MO
EUCRISA
4
SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG
5
MO
PA; MO; QL (120 per 30 days)
5
ST; MO
SORILUX
4
MO
FLUOROURACIL TOPICAL CREAM 0.5 %
STELARA
5
PA; MO
fluorouracil topical cream 5 %
2
MO
TACLONEX
4
MO
2
MO
TALTZ AUTOINJECTOR
5
PA; MO
fluorouracil topical solution imiquimod
2
MO
TALTZ SYRINGE
5
PA; MO
methoxsalen
5
MO
TREMFYA
5
PA; MO
5
MO
VECTICAL
4
MO
OXSORALEN ULTRA PANRETIN
5
MO
BURN THERAPY SILVADENE
4
MO
PICATO
5
MO
silver sulfadiazine
2
MO
podofilox
2
MO
ssd
2
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 68
Drug Name
Drug Tier
PROTOPIC
4
Requirements /Limits
Drug Name
Drug Tier
PA; MO; QL (100 per 30 days)
AKTIPAK
4
MO
amnesteem
2
MO
ATRALIN
4
PA; MO
avita topical cream
2
PA; MO
AVITA TOPICAL GEL
4
PA; MO
AZELEX
4
MO
BENZACLIN PUMP
4
MO
prudoxin
2
MO
REGRANEX
5
MO
SOLARAZE
5
PA; QL (100 per 28 days)
tacrolimus topical
2
PA; MO; QL (100 per 30 days)
Requirements /Limits
TOLAK
4
MO
BENZAMYCIN
4
MO
UVADEX
4
B/D PA; EXCL
claravis
4
MO
CLEOCIN T
4
MO
2
MO
VALCHLOR
5
MO
VEREGEN
4
MO
clindacin etz topical swab
ZONALON
4
MO
clindacin p
2
MO
ZYCLARA
5
ST; MO
CLINDAGEL
4
MO
clindamycin phosphate topical
2
MO
clindamycin-benzoyl peroxide
2
MO
clindamycintretinoin
2
PA; MO
dapsone topical
2
MO
DIFFERIN TOPICAL CREAM
4
PA; MO
DIFFERIN TOPICAL GEL 0.1 %
4
PA; MO
4
PA; MO
THERAPY FOR ACNE ABSORICA ORAL CAPSULE 10 MG, 20 MG, 30 MG, 35 MG, 40 MG
4
MO
ABSORICA ORAL CAPSULE 25 MG
4
ACANYA TOPICAL GEL WITH PUMP
4
MO
ACZONE TOPICAL GEL
4
MO
adapalene topical cream
4
PA; MO
adapalene topical gel
4
PA; MO
DIFFERIN TOPICAL GEL WITH PUMP
4
PA; MO
adapalene topical gel with pump
4
PA; MO
DIFFERIN TOPICAL LOTION DUAC
4
MO
adapalene-benzoyl peroxide
2
EPIDUO FORTE
4
PA; MO
PA; MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 69
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
RETIN-A MICRO TOPICAL GEL WITH PUMP 0.06 %, 0.08 %
4
PA; MO
RHOFADE
4
PA; MO
rosadan topical cream
2
MO
rosadan topical gel
2
MO
SOOLANTRA
4
ST; MO
tazarotene
2
PA; MO
TAZORAC TOPICAL CREAM 0.05 %
3
PA; MO
4
PA; MO
EPIDUO TOPICAL GEL WITH PUMP
4
PA; MO
ery pads
2
MO
erygel
2
MO
erythromycin with ethanol
2
MO
erythromycinbenzoyl peroxide
2
MO
EVOCLIN
4
MO
FABIOR
4
MO
FINACEA
4
ST; MO
isotretinoin
2
METROCREAM
4
ST; MO
METROGEL TOPICAL GEL 1 %
4
ST; MO
TAZORAC TOPICAL CREAM 0.1 %
METROLOTION
4
ST; MO
TAZORAC TOPICAL GEL
3
PA; MO
metronidazole topical
2
MO
tretinoin microspheres
4
PA; MO
MIRVASO TOPICAL GEL WITH PUMP
4
PA; MO
tretinoin topical
2
PA; MO
zenatane
4
MO
myorisan oral capsule 10 mg, 20 mg, 40 mg
2
ZIANA
4
PA; MO
myorisan oral capsule 30 mg
2
bupivacaine
2
MO
2
MO
neuac
2
MO
NORITATE
5
ST; MO
bupivacaine (pf) injection solution 0.25 % (2.5 mg/ml), 0.5 % (5 mg/ml)
ONEXTON TOPICAL GEL WITH PUMP
4
MO
bupivacaine (pf) injection solution 0.75 % (7.5 mg/ml)
2
RETIN-A
4
PA; MO
2
RETIN-A MICRO
4
PA; MO
bupivacaineepinephrine (pf)
MO
TOPICAL ANESTHETICS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 70
Drug Name
Drug Tier
Requirements /Limits
bupivacaineepinephrine injection solution 0.25 %-1:200,000
2
bupivacaineepinephrine injection solution 0.5 %-1:200,000
2
carbocaine (pf) injection solution 15 mg/ml (1.5 %)
2
chloroprocaine (pf)
2
glydo
2
MO; QL (60 per 30 days)
lidocaine (pf) injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %)
2
MO
lidocaine (pf) injection solution 15 mg/ml (1.5 %)
2
lidocaine hcl injection solution
2
MO
lidocaine hcl laryngotracheal
2
MO
lidocaine hcl mucous membrane jelly
2
MO; QL (60 per 30 days)
lidocaine hcl mucous membrane jelly in applicator
2
MO; QL (60 per 30 days)
lidocaine hcl mucous membrane solution 4 % (40 mg/ml)
2
MO
lidocaine topical adhesive patch,medicated
2
PA; MO
MO
Drug Name
Drug Tier
Requirements /Limits
lidocaine topical ointment
4
MO; QL (36 per 30 days)
lidocaine viscous
2
MO
lidocaineepinephrine injection solution 0.5 %-1:200,000, 1.5 %1:200,000, 2 %1:200,000
2
lidocaineepinephrine injection solution 1 %-1:100,000, 2 %1:100,000
2
MO
lidocaine-prilocaine topical cream
2
MO; QL (30 per 30 days)
LIDODERM
4
PA; MO
marcaine (pf) injection solution 0.75 % (7.5 mg/ml)
2
PLIAGLIS
4
polocaine injection solution 1 % (10 mg/ml)
2
polocaine-mpf
2
sensorcaine injection solution 0.5 % (5 mg/ml)
2
sensorcaine-mpf injection solution 0.5 % (5 mg/ml)
2
XYLOCAINE INJECTION SOLUTION 20 MG/ML (2 %)
4
MO
MO
TOPICAL ANTIBACTERIALS BACTROBAN TOPICAL CREAM
4
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 71
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
CORTISPORIN TOPICAL
4
MO
naftifine
2
MO MO
2
MO
NAFTIN TOPICAL CREAM 2 %
4
gentamicin topical KLARON
4
MO
3
MO
mafenide acetate
2
MO
NAFTIN TOPICAL GEL
mupirocin
2
MO
4
MO
mupirocin calcium
2
MO
NIZORAL TOPICAL SHAMPOO
NEO-SYNALAR
4
MO
nyamyc
2
MO
sulfacetamide sodium (acne)
2
MO
nystatin topical
2
MO MO
3
MO
nystatintriamcinolone
2
SULFAMYLON
nystop
2
MO
TOPICAL ANTIFUNGALS ciclodan
2
MO
oxiconazole
2
MO
ciclopirox
2
MO
OXISTAT
4
MO
clotrimazole topical
2
MO
TOPICAL ANTIVIRALS
clotrimazolebetamethasone
2
MO
acyclovir topical
4
econazole
2
MO
PA; MO; QL (30 per 30 days)
ERTACZO
4
MO
DENAVIR
3
MO
EXELDERM
4
MO
XERESE
4
MO
EXTINA
4
MO
ZOVIRAX TOPICAL CREAM
5
PA; MO; QL (5 per 30 days)
JUBLIA
4
MO
4
MO
ketoconazole topical
2
MO
ZOVIRAX TOPICAL OINTMENT
5
KERYDIN
PA; MO; QL (30 per 30 days)
LOPROX (AS OLAMINE) TOPICAL CREAM
4
LOPROX TOPICAL SHAMPOO
4
MO
LOTRISONE TOPICAL CREAM
4
MO
LUZU
4
MO
MENTAX
4
MO
TOPICAL CORTICOSTEROIDS ala-cort topical cream
2
MO
ALA-SCALP
4
ST; MO
alclometasone
2
MO
amcinonide topical cream
4
MO
amcinonide topical lotion
4
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 72
Drug Name
Drug Tier
Requirements /Limits
amcinonide topical ointment
4
apexicon e
2
MO
betamethasone dipropionate
2
MO
betamethasone valerate
2
MO
betamethasone, augmented
2
CAPEX
3
MO
clobetasol scalp
2
MO; QL (100 per 28 days)
MO
clobetasol topical cream
2
MO; QL (120 per 28 days)
clobetasol topical foam
2
clobetasol topical gel
2
clobetasol topical lotion
2
MO; QL (118 per 28 days)
clobetasol topical ointment
2
MO; QL (120 per 28 days)
clobetasol topical shampoo
2
MO; QL (236 per 28 days)
clobetasol topical spray,non-aerosol
2
MO; QL (125 per 28 days)
clobetasol-emollient topical cream
2
MO; QL (120 per 28 days)
clobetasol-emollient topical foam
2
MO; QL (100 per 28 days)
CLOBEX TOPICAL LOTION
4
CLOBEX TOPICAL SHAMPOO
4
MO; QL (100 per 28 days) MO; QL (120 per 28 days)
ST; MO; QL (118 per 28 days) ST; MO; QL (236 per 28 days)
Drug Name
Drug Tier
Requirements /Limits
CLOBEX TOPICAL SPRAY,NONAEROSOL
4
ST; MO; QL (125 per 28 days)
clodan
4
MO; QL (236 per 28 days)
CLODERM
4
ST; MO
CORDRAN TAPE LARGE ROLL
4
ST; MO
CUTIVATE TOPICAL LOTION
4
ST; MO
DESONATE
4
ST; MO
desonide topical cream
4
MO
desonide topical lotion
4
MO
desonide topical ointment
2
MO
DESOWEN
4
ST; MO
desoximetasone
4
MO
diflorasone
4
MO
DIPROLENE TOPICAL OINTMENT
4
ST; MO
ELOCON TOPICAL CREAM
4
ST; MO
ELOCON TOPICAL OINTMENT
4
ST; MO
fluocinolone
2
MO
fluocinolone and shower cap
2
MO
fluocinonide
2
MO; QL (120 per 30 days)
fluocinonide-e
2
MO; QL (120 per 30 days)
fluocinonideemollient
2
QL (120 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 73
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
LOCOID LIPOCREAM
4
ST; MO
LOCOID TOPICAL LOTION
3
MO
LOCOID TOPICAL SOLUTION
4
ST; MO
mometasone topical
2
MO
nolix topical cream
2
nolix topical lotion
2
MO
OLUX
4
ST; MO; QL (100 per 28 days)
PANDEL
4
ST; MO
prednicarbate
2
MO
PSORCON
4
ST
SERNIVO
5
ST; MO
SYNALAR TOPICAL CREAM
4
ST; MO
MO
TOPICORT
4
ST; MO
triamcinolone acetonide topical aerosol
2
MO
flurandrenolide
2
MO
fluticasone topical cream
2
MO
fluticasone topical lotion
4
fluticasone topical ointment
2
halobetasol propionate
2
HALOG
4
ST; MO
hydrocortisone butyrate topical cream
4
MO
hydrocortisone butyrate topical lotion
2
hydrocortisone butyrate topical ointment
2
hydrocortisone butyrate topical solution
2
hydrocortisone butyr-emollient
4
MO
hydrocortisone topical cream 1 %, 2.5 %
2
MO
triamcinolone acetonide topical cream
2
MO
hydrocortisone topical lotion 2.5 %
2
MO
triamcinolone acetonide topical lotion
2
MO
hydrocortisone topical ointment 1 %, 2.5 %
2
MO
2
MO
hydrocortisone valerate
2
MO
triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 % trianex
2
MO
hydrocortisone-min oil-wht pet
2
MO
triderm topical cream 0.1 %
2
MO
KENALOG TOPICAL
4
ST; MO
triderm topical cream 0.5 %
2
MO MO MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 74
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
TRIDESILON
4
ST; MO
LOMAIRA
3
MO; EXCL
ULTRAVATE TOPICAL CREAM
4
ST; MO
phendimetrazine tartrate
1
MO; EXCL
ULTRAVATE TOPICAL LOTION
5
ST; MO
phentermine
1
MO; EXCL
QSYMIA
3
MO; EXCL
ULTRAVATE TOPICAL OINTMENT
4
REGIMEX
3
MO; EXCL
SAXENDA
3
MO; EXCL
VANOS
5
2
MO
ST; MO
ST; MO; QL (120 per 30 days)
TOPICAL ENZYMES SANTYL
ANTIDOTES acetylcysteine intravenous
IRRIGATING SOLUTIONS 3
MO
TOPICAL SCABICIDES / PEDICULICIDES
lactated ringers irrigation
2
MO
neomycin-polymyxin b gu
2
MO
ELIMITE
4
EURAX
4
MO
PHYSIOLYTE
4
lindane topical shampoo
2
MO
PHYSIOSOL IRRIGATION
4
malathion
2
MO
ringer's irrigation
2
NATROBA
3
MO
MISCELLANEOUS AGENTS
OVIDE
4
MO
acamprosate
4
MO
permethrin topical cream
2
MO
acetic acid irrigation
2
MO
4
SKLICE
3
MO
ACTONEL ORAL TABLET 30 MG
ST; MO; QL (30 per 30 days)
ADAGEN
5
MO
AGRYLIN
4
MO
DIAGNOSTICS / MISCELLANEOUS AGENTS ANOREXIANTS
MO
ADIPEX-P
3
MO; EXCL
alendronate oral tablet 40 mg
1
MO; QL (30 per 30 days)
BELVIQ
3
MO; EXCL
anagrelide
2
MO
BELVIQ XR
3
MO; EXCL
ANTABUSE
4
MO
benzphetamine
1
MO; EXCL
ARALAST NP
5
MO; LA
CONTRAVE
3
MO; EXCL
AURYXIA
5
MO
diethylpropion
1
MO; EXCL
BUPHENYL
5
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 75
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
bupivacainedextrose-water(pf)
2
dex4 glucose oral tablet,chewable
1
MO; EXCL
caffeine citrate intravenous
2
dex4 glucose pouch pack
1
EXCL
caffeine citrate oral
2
MO
1
EXCL
CARBAGLU
5
MO; LA
dex4 glucose quick dissolve
CARNITOR
4
MO
dextrose 10 % and 0.2 % nacl
2
cevimeline
2
MO
3
PA; MO
dextrose 10 % in water (d10w)
2
CHEMET CLINIMIX 4.25%/D5W SULFIT FREE
3
B/D PA; EXCL
dextrose 20 % in water (d20w)
2
4
B/D PA; EXCL
dextrose 25 % in water (d25w)
2
CLINIMIX E 2.75%/D10W SUL FREE
dextrose 30 % in water (d30w)
2
CLINIMIX E 2.75%/D5W SULF FREE
4
dextrose 40 % in water (d40w)
2
d10 %-0.45 % sodium chloride
2
dextrose 5 % in water (d5w)
2
MO
d2.5 %-0.45 % sodium chloride
2
dextrose 5 %lactated ringers
2
MO
d5 % and 0.9 % sodium chloride
2
MO
dextrose 5%-0.2 % sod chloride
2
d5 %-0.45 % sodium chloride
2
MO
dextrose 5%-0.3 % sod.chloride
2
deferoxamine
2
B/D PA; EXCL; MO
2
dex4 glucose bits
1
EXCL
dextrose 50 % in water (d50w) intravenous parenteral solution
dex4 glucose oral gel
1
MO; EXCL
2
DEX4 GLUCOSE ORAL GEL IN PACKET
1
MO; EXCL
dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w)
2
MO
DEX4 GLUCOSE ORAL LIQUID
1
DEXTROSE ORAL LIQUID
1
EXCL
B/D PA; EXCL
MO; EXCL
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 76
Drug Name
Drug Tier
dextrose with sodium chloride
2
disulfiram
2
ENDARI
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
levocarnitine oral tablet
2
MO
MO
LITHOSTAT
4
MO
5
PA; MO
2
etidronate disodium
2
MO
lmd 10 % in 0.9 % sodium chlor
EVOXAC
4
MO
lmd 10 % in 5 % dextrose
2
EXJADE
5
PA; MO; LA
midodrine
2
MO
FERRIPROX ORAL SOLUTION
5
PA
NORTHERA
5
PA; MO
FERRIPROX ORAL TABLET
5
PA; MO
NUTRESTORE
4
MO
5
LA
FERRLECIT
3
MO; EXCL
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG
FOSRENOL
4
MO
MO
5
MO; LA
ORFADIN ORAL CAPSULE 20 MG
5
GLASSIA gluco burst
1
EXCL
5
MO; LA
GLUCO SHOT
1
EXCL
ORFADIN ORAL SUSPENSION
glucose bits
1
EXCL
pilocarpine hcl oral
2
MO
glucose gel
1
EXCL
5
LA
glucose oral tablet,chewable 4 gram
1
MO; EXCL
PROLASTIN-C INTRAVENOUS RECON SOLN
5
MO; LA
GLUTOSE 15
1
MO; EXCL
PROLASTIN-C INTRAVENOUS SOLUTION
GLUTOSE 45
1
MO; EXCL
RAVICTI
5
MO
INCRELEX
5
MO; LA
RECLAST
4
PA; MO
JADENU
5
PA; MO
RENAGEL
4
MO
JADENU SPRINKLE
5
PA; MO
RENVELA
5
MO
RILUTEK
5
MO
kionex
2
MO
riluzole
2
MO
kionex (with sorbitol)
2
MO
risedronate oral tablet 30 mg
2
MO; QL (30 per 30 days)
lanthanum
2
MO
MO
2
MO
SALAGEN (PILOCARPINE)
4
levocarnitine (with sugar)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 77
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
TRUEPLUS GLUCOSE ORAL TABLET,CHEWAB LE
1
MO; EXCL
VELPHORO
5
MO
sevelamer carbonate oral powder in packet
5
MO
sevelamer carbonate oral tablet
2
MO
sodium benzoate-sod phenylacet
5
VELTASSA
3
MO
2
MO
sodium chloride 0.9 % intravenous
2
MO
water for irrigation, sterile XIAFLEX
5
MO
sodium chloride irrigation
2
MO
XURIDEN
5
MO
sodium ferric gluconat-sucrose
1
MO; EXCL
ZEMAIRA
5
MO; LA
2
PA; MO
sodium phenylbutyrate
5
zoledronic acidmannitol-water
sodium polystyrene (sorb free)
2
MO
bupropion hcl (smoking deter)
2
MO
sodium polystyrene sulfonate oral
2
MO
CHANTIX
3
MO
3
MO
sodium polystyrene sulfonate rectal enema 30 gram/120 ml
2
CHANTIX CONTINUING MONTH BOX
3
MO
SOLIRIS
5
B/D PA; EXCL; MO
CHANTIX STARTING MONTH BOX NICODERM CQ
1
MO; EXCL
sps (with sorbitol) oral
2
MO
nicorelief
1
MO; EXCL
sps (with sorbitol) rectal
2
NICORETTE
1
MO; EXCL
1
MO; EXCL
SYPRINE
5
PA; MO
nicotine (polacrilex) buccal gum
THIOLA
5
MO
1
MO; EXCL
trientine
5
PA; MO
TRUEPLUS GLUCOSE ORAL GEL IN PACKET
1
EXCL
NICOTINE (POLACRILEX) BUCCAL LOZENGE
1
EXCL
TRUEPLUS GLUCOSE ORAL LIQUID
1
NICOTINE (POLACRILEX) BUCCAL MINI LOZENGE
MO
SMOKING DETERRENTS
EXCL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 78
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
MO; EXCL
oralone
2
MO
paroex oral rinse
2
MO
PATANASE
4
MO; QL (30.5 per 30 days)
periogard
2
MO
4
MO
nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr
1
nicotine transdermal patch, td daily, sequential
1
NICOTROL
4
MO
PREVIDENT 5000 BOOSTER PLUS
NICOTROL NS
4
MO
sf
2
MO
quit 2 buccal gum
1
EXCL
sf 5000 plus
2
MO
QUIT 2 BUCCAL LOZENGE
1
EXCL
triamcinolone acetonide dental
2
MO
quit 4 buccal gum
1
EXCL
QUIT 4 BUCCAL LOZENGE
1
EXCL
MISCELLANEOUS OTIC PREPARATIONS
stop smoking aid
1
EXCL
ZYBAN
4
MO
MO; EXCL
EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS ASTEPRO NASAL SPRAY,NONAEROSOL
4
azelastine nasal
2
BACTROBAN NASAL
3
chlorhexidine gluconate mucous membrane
2
denta 5000 plus
MO; QL (60 per 30 days) MO; QL (60 per 30 days)
acetic acid otic (ear)
2
MO
ciprofloxacin hcl otic (ear)
2
MO
floxin otic (ear) drops
2
fluocinolone acetonide oil
2
MO
hydrocortisoneacetic acid
2
MO
ofloxacin otic (ear)
2
MO
OTIC STEROID / ANTIBIOTIC CIPRO HC
4
MO
CIPRODEX
3
MO
MO
COLY-MYCIN S
4
MO
2
MO
2
MO
neomycinpolymyxin-hc otic (ear)
dentagel
2
MO
OTOVEL
3
MO
ipratropium bromide nasal
2
MO; QL (30 per 30 days)
ENDOCRINE/DIABETES
olopatadine nasal
2
MO; QL (30.5 per 30 days)
ACTHAR H.P.
ADRENAL HORMONES 5
PA; MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 79
Drug Name
Drug Tier
a-hydrocort
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
2
MO
1
MO
betamethasone acet,sod phos
2
MO
methylprednisolone oral tablets,dose pack
CORTEF
4
MO
2
MO
cortisone
2
MO
decadron
2
methylprednisolone sodium succ injection recon soln 125 mg, 40 mg
deltasone oral tablet 20 mg
2
B/D PA; EXCL; MO
methylprednisolone sodium succ intravenous
2
MO
DEPO-MEDROL
4
MO
millipred dp
2
MO
dexamethasone intensol
2
MO
MILLIPRED ORAL SOLUTION
4
MO
dexamethasone oral elixir
2
MO
millipred oral tablet
4
B/D PA; EXCL; MO
dexamethasone oral solution
2
MO
ORAPRED ODT
4
B/D PA; EXCL; MO
dexamethasone oral tablet
1
MO
prednisolone oral solution 15 mg/5 ml
2
MO
dexamethasone sodium phos (pf)
2
MO
2
MO
dexamethasone sodium phosphate injection
2
MO
DEXPAK 13 DAY
4
MO
EMFLAZA
5
PA; MO; LA
fludrocortisone
2
MO
prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)
hydrocortisone oral
2
MO
2
KENALOG INJECTION
4
MO
prednisolone sodium phosphate oral tablet,disintegrating
B/D PA; EXCL; MO
MEDROL
4
B/D PA; EXCL; MO
prednisone intensol
2
B/D PA; EXCL; MO
MEDROL (PAK)
4
MO
prednisone oral solution
2
MO
methylprednisolone acetate
2
MO
prednisone oral tablet
1
B/D PA; EXCL; MO
methylprednisolone oral tablet
1
B/D PA; EXCL; MO
prednisone oral tablets,dose pack
1
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 80
Drug Name
Drug Tier
Requirements /Limits
Drug Name ACCU-CHEK COMPACT PLUS TEST
1
MO; EXCL
ACCU-CHEK GUIDE
1
MO; EXCL
1
MO; EXCL
MO
ACCU-CHEK SMARTVIEW TEST STRIP
1
MO; EXCL
MO
ACCUTREND GLUCOSE ACTOPLUS MET
4
MO; QL (90 per 30 days)
ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 15-1,000 MG
4
MO; QL (60 per 30 days)
ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 30-1,000 MG
4
MO; QL (30 per 30 days)
ACTOS
4
MO; QL (30 per 30 days)
ADLYXIN SUBCUTANEOUS PEN INJECTOR 10 MCG/0.2 ML- 20 MCG/0.2 ML
4
PA; MO; QL (6 per 180 days)
ADLYXIN SUBCUTANEOUS PEN INJECTOR 20 MCG/0.2 ML
4
PA; MO; QL (6 per 30 days)
ADMELOG SOLOSTAR U-100 INSULIN
4
ST; MO
ADMELOG U-100 INSULIN LISPRO
4
ST; MO
AFREZZA
4
MO
RAYOS
5
B/D PA; EXCL; MO
SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 ML, 250 MG/2 ML
4
MO
SOLU-MEDROL (PF)
4
SOLU-MEDROL INTRAVENOUS RECON SOLN 2 GRAM
4
TAPERDEX
4
triamcinolone acetonide injection suspension 10 mg/ml
2
triamcinolone acetonide injection suspension 40 mg/ml
2
veripred 20
2
MO
MO
ANTITHYROID AGENTS methimazole oral tablet 10 mg, 5 mg
2
propylthiouracil
2
MO
TAPAZOLE
4
MO
Drug Tier
MO
DIABETES THERAPY acarbose oral tablet 100 mg
2
MO; QL (90 per 30 days)
acarbose oral tablet 25 mg
2
MO; QL (360 per 30 days)
acarbose oral tablet 50 mg
2
MO; QL (180 per 30 days)
ACCU-CHEK AVIVA PLUS TEST STRP
1
MO; EXCL
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 81
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML
3
PA; MO; QL (1.2 per 30 days)
CHEK-STIX CONTROL
1
EXCL
CHEMSTRIP 10 MD
1
MO; EXCL
CHEMSTRIP 10/SG
1
MO; EXCL
CHEMSTRIP 2 GP
1
MO; EXCL
CHEMSTRIP 50B
1
EXCL
CHEMSTRIP 7
1
MO; EXCL
CHEMSTRIP 9
1
MO; EXCL
CHEMSTRIP K
1
MO; EXCL
CHEMSTRIP UGK
1
MO; EXCL
COMBISTIX REAGENT
1
EXCL
CYCLOSET
4
MO; QL (180 per 30 days)
DUETACT
4
MO; QL (30 per 30 days)
FARXIGA ORAL TABLET 10 MG
3
MO; QL (30 per 30 days)
FARXIGA ORAL TABLET 5 MG
3
MO; QL (60 per 30 days)
ALCOHOL PADS
3
MO
ALOGLIPTIN
4
ST; MO; QL (30 per 30 days)
ALOGLIPTINMETFORMIN
4
ST; MO; QL (60 per 30 days)
ALOGLIPTINPIOGLITAZONE
4
MO; QL (30 per 30 days)
AMARYL ORAL TABLET 1 MG
4
MO; QL (240 per 30 days)
AMARYL ORAL TABLET 2 MG
4
MO; QL (120 per 30 days)
AMARYL ORAL TABLET 4 MG
4
MO; QL (60 per 30 days)
APIDRA SOLOSTAR U-100 INSULIN
4
ST; MO
APIDRA U-100 INSULIN
4
AVANDIA ORAL TABLET 2 MG, 4 MG
4
BASAGLAR KWIKPEN U-100 INSULIN
4
MO
BYDUREON
3
PA; MO; QL (4 per 28 days)
BYDUREON BCISE
3
PA; MO; QL (4 per 28 days)
FIASP FLEXTOUCH U100 INSULIN
4
ST; MO
BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML
3
PA; MO; QL (2.4 per 30 days)
FIASP U-100 INSULIN
4
ST; MO
FORTAMET ORAL TABLET EXTENDED RELEASE 24HR 1,000 MG
5
MO; QL (75 per 30 days)
ST; MO MO; QL (60 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 82
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
FORTAMET ORAL TABLET EXTENDED RELEASE 24HR 500 MG
5
MO; QL (150 per 30 days)
glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg
2
MO; QL (120 per 30 days)
GLUCAGEN HYPOKIT
3
MO
FREESTYLE FREEDOM
3
EXCL
GLUCAGON EMERGENCY KIT (HUMAN)
3
MO
FREESTYLE FREEDOM LITE
3
MO; EXCL
GLUCOPHAGE ORAL TABLET 1,000 MG
4
MO; QL (75 per 30 days)
FREESTYLE INSULINX
3
MO; EXCL
FREESTYLE LITE METER
3
MO; EXCL
GLUCOPHAGE ORAL TABLET 500 MG
4
MO; QL (150 per 30 days)
GAUZE PADS 2 X 2
3
MO
GLUCOPHAGE ORAL TABLET 850 MG
4
MO; QL (90 per 30 days)
glimepiride oral tablet 1 mg
1
MO; QL (240 per 30 days)
glimepiride oral tablet 2 mg
1
MO; QL (120 per 30 days)
GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG
4
MO; QL (120 per 30 days)
glimepiride oral tablet 4 mg
1
MO; QL (60 per 30 days)
glipizide oral tablet 10 mg
1
MO; QL (120 per 30 days)
GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 750 MG
4
MO; QL (75 per 30 days)
glipizide oral tablet 5 mg
1
MO; QL (240 per 30 days)
glipizide oral tablet extended release 24hr 10 mg
1
MO; QL (60 per 30 days)
GLUCOTROL ORAL TABLET 10 MG
4
MO; QL (120 per 30 days)
glipizide oral tablet extended release 24hr 2.5 mg
1
MO; QL (240 per 30 days)
GLUCOTROL ORAL TABLET 5 MG
4
MO; QL (240 per 30 days)
glipizide oral tablet extended release 24hr 5 mg
1
MO; QL (120 per 30 days)
GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG
4
MO; QL (60 per 30 days)
glipizide-metformin oral tablet 2.5-250 mg
2
MO; QL (240 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 83
Drug Name
Drug Tier
Requirements /Limits
Drug Name
GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 2.5 MG
4
MO; QL (240 per 30 days)
HUMALOG MIX 75-25 KWIKPEN
3
MO
HUMALOG MIX 75-25(U100)INSULN
3
MO
GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 5 MG
4
HUMALOG U-100 INSULIN
3
MO
HUMULIN 70/30 U-100 INSULIN
3
MO
GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 1,000 MG
5
HUMULIN 70/30 U-100 KWIKPEN
3
MO
3
MO
GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 500 MG
5
HUMULIN N NPH INSULIN KWIKPEN HUMULIN N NPH U-100 INSULIN
3
MO
GLYSET ORAL TABLET 100 MG
4
MO; QL (90 per 30 days)
HUMULIN R REGULAR U-100 INSULN
3
MO
GLYSET ORAL TABLET 25 MG
4
MO; QL (360 per 30 days)
HUMULIN R U-500 (CONC) INSULIN
3
MO
GLYSET ORAL TABLET 50 MG
4
MO; QL (180 per 30 days)
HUMULIN R U-500 (CONC) KWIKPEN
3
MO
GLYXAMBI
3
MO; QL (30 per 30 days)
INSTA-GLUCOSE (WITH DEXTRIN)
1
MO; EXCL
HEMACOMBISTIX
1
EXCL
INSULIN PEN NEEDLE
3
MO
HUMALOG JUNIOR KWIKPEN U-100
3
MO
3
MO
HUMALOG KWIKPEN INSULIN
3
MO
INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML
3
MO; QL (60 per 30 days)
HUMALOG MIX 50-50 INSULN U100
3
MO
INVOKAMET ORAL TABLET 150-1,000 MG, 150500 MG, 50-1,000 MG
HUMALOG MIX 50-50 KWIKPEN
3
MO
INVOKAMET ORAL TABLET 50500 MG
3
MO; QL (120 per 30 days)
MO; QL (120 per 30 days)
MO; QL (60 per 30 days)
MO; QL (120 per 30 days)
Drug Tier
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 84
Drug Name
Drug Tier
Requirements /Limits
Drug Name
MO; QL (60 per 30 days)
KAZANO
4
ST; MO; QL (60 per 30 days)
KETO-DIASTIX
1
MO; EXCL
KETONE CARE
1
EXCL
KETONE URINE TEST
1
EXCL
KETOSTIX
1
MO; EXCL
KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG
3
MO; QL (60 per 30 days)
KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG
3
MO; QL (30 per 30 days)
LABSTIX REAGENT
1
MO; EXCL
LANTUS SOLOSTAR U-100 INSULIN
3
MO
LANTUS U-100 INSULIN
3
MO
LEVEMIR FLEXTOUCH U100 INSULN
3
MO
LEVEMIR U-100 INSULIN
3
MO
metformin oral tablet 1,000 mg
1
MO; QL (75 per 30 days)
metformin oral tablet 500 mg
1
MO; QL (150 per 30 days)
metformin oral tablet 850 mg
1
MO; QL (90 per 30 days)
INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, 150-500 MG, 50-1,000 MG
3
INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 50-500 MG
3
INVOKANA ORAL TABLET 100 MG
3
MO; QL (90 per 30 days)
INVOKANA ORAL TABLET 300 MG
3
MO; QL (30 per 30 days)
JANUMET
3
MO; QL (60 per 30 days)
JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-500 MG
3
MO; QL (30 per 30 days)
JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG
3
JANUVIA
3
MO; QL (120 per 30 days)
MO; QL (60 per 30 days)
MO; QL (30 per 30 days)
JARDIANCE
3
MO; QL (30 per 30 days)
JENTADUETO
4
ST; MO; QL (60 per 30 days)
JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG
4
JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG
4
ST; MO; QL (60 per 30 days) ST; MO; QL (30 per 30 days)
Drug Tier
Requirements /Limits
1 MO; QL (120 metformin oral per 30 days) tablet extended release 24 hr 500 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 85
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
metformin oral tablet extended release 24 hr 750 mg
1
MO; QL (75 per 30 days)
NEEDLES, INSULIN DISP.,SAFETY
3
MO
metformin oral tablet extended release (osm) 24 hr 1,000 mg
5
MO; QL (75 per 30 days)
NESINA
4
ST; MO; QL (30 per 30 days)
NOVOFINE 32
3
MO
metformin oral tablet extended release (osm) 24 hr 500 mg
2
MO; QL (150 per 30 days)
NOVOLIN 70/30 U100 INSULIN
4
ST; MO
4
ST; MO
metformin oral tablet,er gast.retention 24 hr 1,000 mg
5
NOVOLIN N NPH U-100 INSULIN NOVOLIN R REGULAR U-100 INSULN
4
ST; MO
metformin oral tablet,er gast.retention 24 hr 500 mg
5
MO; QL (120 per 30 days)
NOVOLOG FLEXPEN U-100 INSULIN
4
ST; MO
ST; MO
2
MO; QL (90 per 30 days)
NOVOLOG MIX 70-30 U-100 INSULN
4
miglitol oral tablet 100 mg miglitol oral tablet 25 mg
2
MO; QL (360 per 30 days)
4
ST; MO
miglitol oral tablet 50 mg
2
MO; QL (180 per 30 days)
NOVOLOG MIX 70-30FLEXPEN U100
4
ST; MO
MULTISTIX
1
EXCL
NOVOLOG PENFILL U-100 INSULIN
MULTISTIX 10 SG
1
MO; EXCL
4
ST; MO
MULTISTIX 5
1
EXCL
NOVOLOG U-100 INSULIN ASPART
MULTISTIX 7
1
EXCL
4
MO
MULTISTIX 8 SG
1
EXCL
OMNIPOD INSULIN MANAGEMENT
MULTISTIX 9
1
EXCL
MO; EXCL
1
EXCL
nateglinide oral tablet 120 mg
2
MO; QL (90 per 30 days)
ONETOUCH ULTRA BLUE TEST STRIP
1
MULTISTIX 9 SG
3
MO; EXCL
nateglinide oral tablet 60 mg
2
ONETOUCH ULTRA2 ONETOUCH ULTRAMINI
3
MO; EXCL
MO; QL (60 per 30 days)
MO; QL (180 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 86
Drug Name
Drug Tier
ONETOUCH VERIO
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
1
MO; EXCL
repaglinide oral tablet 2 mg
2
MO; QL (240 per 30 days)
ONETOUCH VERIO IQ METER
3
MO; EXCL
repaglinidemetformin
2
MO; QL (150 per 30 days)
ONETOUCH VERIO SYSTEM
3
MO; EXCL
RIOMET
3
MO; QL (765 per 30 days)
ONGLYZA
3
MO; QL (30 per 30 days)
SEGLUROMET
4
MO
SOLIQUA 100/33
3
MO
STARLIX ORAL TABLET 120 MG
4
MO; QL (90 per 30 days)
STARLIX ORAL TABLET 60 MG
4
MO; QL (180 per 30 days)
STEGLATRO
4
MO
OSENI
4
MO; QL (30 per 30 days)
OZEMPIC
3
PA; MO
pioglitazone
2
MO; QL (30 per 30 days)
pioglitazoneglimepiride
2
MO; QL (30 per 30 days)
STEGLUJAN
4
MO; QL (30 per 30 days)
pioglitazonemetformin
2
MO; QL (90 per 30 days)
SYMLINPEN 120
5
PRANDIN ORAL TABLET 1 MG
4
MO; QL (480 per 30 days)
PA; MO; QL (10.8 per 30 days)
SYMLINPEN 60
5
PRANDIN ORAL TABLET 2 MG
4
MO; QL (240 per 30 days)
PA; MO; QL (6 per 30 days)
3
PRECISION XTRA MONITOR
3
MO; EXCL
MO; QL (60 per 30 days)
PRECOSE ORAL TABLET 100 MG
4
MO; QL (90 per 30 days)
SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG
3
PRECOSE ORAL TABLET 25 MG
4
SYNJARDY ORAL TABLET 5-500 MG
MO; QL (120 per 30 days)
3
PRECOSE ORAL TABLET 50 MG
4
MO; QL (180 per 30 days)
MO; QL (60 per 30 days)
PROGLYCEM
3
MO
QTERN
4
MO; QL (30 per 30 days)
SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 51,000 MG SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG
3
MO; QL (30 per 30 days)
TANZEUM
4
PA; MO; QL (4 per 28 days)
MO; QL (360 per 30 days)
relion glucose
1
EXCL
repaglinide oral tablet 0.5 mg
2
MO; QL (960 per 30 days)
repaglinide oral tablet 1 mg
2
MO; QL (480 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 87
Drug Name
Drug Tier
Requirements /Limits
Drug Name
tolazamide oral tablet 250 mg
2
MO; QL (120 per 30 days)
3
MO; QL (60 per 30 days)
tolazamide oral tablet 500 mg
2
MO; QL (60 per 30 days)
tolbutamide
2
MO; QL (180 per 30 days)
XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-500 MG, 2.5-1,000 MG, 51,000 MG, 5-500 MG
TOUJEO MAX SOLOSTAR
3
MO
XULTOPHY 100/3.6
5
MO; QL (15 per 30 days)
TOUJEO SOLOSTAR U-300 INSULIN
3
MO
MISCELLANEOUS HORMONES
TRADJENTA
4
ST; MO; QL (30 per 30 days)
TRESIBA FLEXTOUCH U100
3
MO
TRESIBA FLEXTOUCH U200
3
MO
TRUEPLUS KETONE
1
MO; EXCL
TRULICITY
4
PA; MO; QL (2 per 28 days)
URISTIX 4
1
MO; EXCL
URISTIX REAGENT
1
MO; EXCL
VGO 20
3
MO
VGO 30
3
MO
VGO 40
3
MO
VICTOZA 2-PAK
3
PA; MO; QL (9 per 30 days)
VICTOZA 3-PAK
3
PA; MO; QL (9 per 30 days)
XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG
3
MO; QL (30 per 30 days)
Drug Tier
Requirements /Limits
ALDURAZYME
5
MO
ANADROL-50
5
PA; MO
ANDRODERM
3
PA; MO
ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)
3
PA; MO
ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM)
4
PA; MO
ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)
3
PA; MO
ANDROID
5
MO
AVEED
4
MO; LA
AXIRON
4
PA; MO
BRAVELLE
3
MO; EXCL
cabergoline
2
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 88
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
calcitonin (salmon)
2
MO
ELELYSO
5
MO
calcitriol intravenous solution 1 mcg/ml
2
MO
FABRAZYME
5
MO
FOLLISTIM AQ SUBCUTANEOUS
3
MO; EXCL
calcitriol oral capsule
1
MO
FORTESTA
4
PA; MO
calcitriol oral solution
2
MO
GANIRELIX
3
MO; EXCL
GONAL-F
3
MO; EXCL
CERDELGA
5
MO
GONAL-F RFF
3
MO; EXCL
CEREZYME INTRAVENOUS RECON SOLN 400 UNIT
5
MO
GONAL-F RFF REDI-JECT
3
MO; EXCL
4
MO
CETROTIDE SUBCUTANEOUS KIT 0.25 MG
3
HECTOROL INTRAVENOUS SOLUTION 4 MCG/2 ML HECTOROL ORAL
4
MO
CHORIONIC GONADOTROPIN, HUMAN
4
KANUMA
5
MO
KORLYM
5
MO
clomiphene citrate
2
PA; MO
KUVAN
5
MO
danazol
4
MO
LUMIZYME
5
MO
DDAVP
4
MO
MENOPUR
3
MO; EXCL
DEPOTESTOSTERONE
4
MO
METHITEST
4
MO
5
MO
desmopressin injection
2
MO
methyltestosterone oral capsule
4
MO
desmopressin nasal solution
2
MIACALCIN INJECTION miglustat
5
MO
desmopressin nasal spray with pump
2
MO
MYALEPT
5
PA; MO; LA
desmopressin nasal spray,non-aerosol
2
MO
NAGLAZYME
5
MO; LA
NATPARA
5
PA; MO; LA
desmopressin oral
2
MO
NOCTIVA
4
PA; MO
doxercalciferol intravenous
2
NOVAREL
4
PA; MO
OVIDREL
3
MO; EXCL
doxercalciferol oral
2
MO
5
PA; MO
ELAPRASE
5
MO
oxandrolone oral tablet 10 mg
MO; EXCL
PA; MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 89
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 10 MG/0.5 GRAM /ACTUATION
4
PA; MO
testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)
2
PA; MO
testosterone transdermal gel in packet
2
PA; MO
2
PA; MO
oxandrolone oral tablet 2.5 mg
2
PA; MO
pamidronate
2
MO
paricalcitol intravenous solution 2 mcg/ml
2
paricalcitol intravenous solution 5 mcg/ml
2
MO
paricalcitol oral
4
MO
PREGNYL
4
PA; MO
RAYALDEE
5
MO
ROCALTROL
4
MO
SAMSCA
5
PA; MO
SENSIPAR ORAL TABLET 30 MG
3
MO
testosterone transdermal solution in metered pump w/app
SENSIPAR ORAL TABLET 60 MG, 90 MG
5
MO
TESTRED
5
MO
VIMIZIM
5
MO
SOMAVERT
5
MO
4
PA; MO
STIMATE
3
MO
STRENSIQ
5
MO; LA
STRIANT
4
PA; MO
VOGELXO TRANSDERMAL GEL IN METERED-DOSE PUMP
SYNAREL
5
MO
4
PA; MO
TESTIM
4
PA; MO
VOGELXO TRANSDERMAL GEL IN PACKET
testosterone cypionate
2
MO
VPRIV
5
MO
ZAVESCA
5
MO; LA
testosterone enanthate
2
MO
ZEMPLAR INTRAVENOUS
4
MO
testosterone transdermal gel
2
PA; MO
ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG
4
MO
zoledronic acid intravenous solution
2
B/D PA; EXCL; MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 90
Drug Name
Drug Tier
ZOMETA
5
Requirements /Limits
Drug Name
B/D PA; EXCL; MO
BENTYL INTRAMUSCULA R
4
MO
CUVPOSA
4
MO
dicyclomine intramuscular
2
MO
dicyclomine oral capsule
2
MO
dicyclomine oral solution
2
MO
dicyclomine oral tablet
2
MO
diphenoxylateatropine
2
MO
glycopyrrolate injection
2
MO
glycopyrrolate oral tablet 1 mg, 2 mg
2
MO
LOMOTIL
4
MO
loperamide oral capsule
2
MO
methscopolamine
2
MO
MYTESI
4
MO
opium tincture
2
MO
paregoric
2
MO
ROBINUL FORTE
4
MO
ROBINUL ORAL
4
MO
THYROID HORMONES CYTOMEL
4
MO
LEVO-T
4
LEVOTHYROXINE INTRAVENOUS RECON SOLN 100 MCG
4
levothyroxine intravenous recon soln 200 mcg, 500 mcg
2
levothyroxine oral
1
MO
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg
1
MO
liothyronine
2
MO
SYNTHROID
4
MO
THYROLAR-1
4
MO
THYROLAR-1/2
4
MO
THYROLAR-1/4
4
MO
THYROLAR-2
4
MO
THYROLAR-3
4
MO
TIROSINT
4
MO
TRIOSTAT
4
MO
unithroid
1
MO
MO
MO
Drug Tier
Requirements /Limits
MISCELLANEOUS GASTROINTESTINAL AGENTS ACTIGALL
4
MO
GASTROENTEROLOGY
alophen
1
EXCL
ANTIDIARRHEALS / ANTISPASMODICS
alosetron
5
MO
ALOXI
5
MO
AMITIZA
3
MO
atropine injection syringe 0.05 mg/ml, 0.1 mg/ml
2
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 91
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
CLENPIQ
4
ST; MO
COLAZAL
5
MO
colocort
2
MO
COLYTE WITH FLAVOR PACKS ORAL RECON SOLN 240-22.726.72 -5.84 GRAM
4
ST; MO
compro
2
MO
constulose
2
MO
CORTIFOAM
3
MO
CREON ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 12,000-38,000 60,000 UNIT, 24,000-76,000 120,000 UNIT, 3,000-9,500- 15,000 UNIT, 6,000-19,000 -30,000 UNIT
3
MO
CREON ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 36,000-114,000180,000 UNIT
5
MO
cromolyn oral
2
MO
CYSTADANE
5
MO
DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS)
3
MO
2
MO
ANUSOL-HC TOPICAL
4
MO
ANZEMET ORAL
4
B/D PA; EXCL; MO
aprepitant
2
B/D PA; EXCL; MO
APRISO
4
MO
ASACOL HD
3
MO
AZULFIDINE
4
MO
AZULFIDINE ENTABS
4
MO
balsalazide
2
MO
bisacodyl oral
1
MO; EXCL
bisa-lax
1
EXCL
BONJESTA
4
MO
budesonide oral
5
MO
CANASA
4
MO
CESAMET
5
B/D PA; EXCL; MO
CHENODAL
5
PA; LA
CHOLBAM ORAL CAPSULE 250 MG
5
PA; MO
CHOLBAM ORAL CAPSULE 50 MG
5
PA; MO; QL (120 per 30 days)
CIMZIA
5
PA; MO
CIMZIA POWDER FOR RECONST
5
PA; MO
CIMZIA STARTER KIT
5
CINVANTI
4
citrate of magnesia
1
EXCL
dimenhydrinate injection solution
citroma
1
EXCL
DIPENTUM
5
MO
clearlax
1
EXCL
dronabinol oral capsule 10 mg
5
B/D PA; EXCL; MO
PA; MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 92
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
dronabinol oral capsule 2.5 mg, 5 mg
4
B/D PA; EXCL; MO
glycolax oral powder
1
EXCL
droperidol injection solution
2
MO
GOLYTELY
4
ST; MO
granisetron (pf)
2
MO
ducodyl
1
EXCL
2
MO
EMEND (FOSAPREPITANT )
3
MO
granisetron hcl intravenous granisetron hcl oral
2
B/D PA; EXCL; MO
EMEND ORAL CAPSULE
4
B/D PA; EXCL; MO
healthylax
1
EXCL
EMEND ORAL CAPSULE,DOSE PACK
4
B/D PA; EXCL; MO
hydrocortisone rectal
2
MO
2
EMEND ORAL SUSPENSION FOR RECONSTITUTIO N
3
hydrocortisone topical cream with perineal applicator 1 %
2
MO
ENTOCORT EC
5
MO
ENTYVIO
5
PA; MO
hydrocortisone topical cream with perineal applicator 2.5 %
enulose
2
MO
2
MO
fleet laxative
1
EXCL
hydrocortisonepramoxine rectal cream 1-1 %
GASTROCROM
4
MO
INFLECTRA
5
PA; MO
GATTEX 30-VIAL
5
MO
KRISTALOSE
4
MO
GATTEX ONEVIAL
5
MO
lactulose
2
MO
gavilax oral powder
1
MO; EXCL
laxaclear
1
EXCL
gavilyte-c
2
MO
laxative (bisacodyl) oral
1
EXCL
gavilyte-g
2
MO
laxative feminine
1
EXCL
gavilyte-n
2
MO
EXCL
2
MO
laxative peg 3350 oral powder
1
generlac gentle laxative oral
1
EXCL
LIALDA
3
MO
gentlelax
1
EXCL
LINZESS
3
MO
GIALAX
3
EXCL
LOTRONEX
5
MO
GIAZO
5
MO
magnesium citrate oral solution
1
MO; EXCL
B/D PA; EXCL; MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 93
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
B/D PA; EXCL; MO
miralax oral powder in packet
1
MO; EXCL
MOVANTIK
3
MO
MOVIPREP
4
MO
natura-lax
1
EXCL
NULYTELY WITH FLAVOR PACKS
4
ST; MO
OCALIVA
5
PA; MO; LA; QL (30 per 30 days)
ondansetron
2
B/D PA; EXCL; MO
ondansetron hcl (pf)
2
MO
ondansetron hcl intravenous
2
MO
MARINOL ORAL CAPSULE 10 MG, 5 MG
5
MARINOL ORAL CAPSULE 2.5 MG
4
B/D PA; EXCL; MO
meclizine oral tablet 12.5 mg, 25 mg
2
MO
mesalamine oral tablet,delayed release (dr/ec) 1.2 gram
2
MESALAMINE ORAL TABLET,DELAYE D RELEASE (DR/EC) 800 MG
4
mesalamine rectal
2
MO
mesalamine with cleansing wipe
2
MO
ondansetron hcl oral solution
2
B/D PA; EXCL; MO
metoclopramide hcl injection solution
2
MO
ondansetron hcl oral tablet 24 mg
2
B/D PA; EXCL
metoclopramide hcl injection syringe
2
ondansetron hcl oral tablet 4 mg, 8 mg
2
B/D PA; EXCL; MO
metoclopramide hcl oral solution
2
MO
oral saline laxative liquid
1
EXCL
metoclopramide hcl oral tablet
1
MO
OSMOPREP
4
MO
4
metoclopramide hcl oral tablet,disintegrating
2
MO
PALONOSETRON INTRAVENOUS SOLUTION 0.25 MG/2 ML
MICORT-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %
4
ST; MO
palonosetron intravenous solution 0.25 mg/5 ml
2
milk of magnesia
1
MO; EXCL
milk of magnesia concentrated
1
MO; EXCL
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 94
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
ST; MO
PERTZYE ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 4,000-14,37515,125 UNIT, 8,00028,750- 30,250 UNIT
4
ST; MO
phosphate laxative oral liquid
1
EXCL
polyethylene glycol 3350 oral powder
2
MO
polyethylene glycol 3350 oral powder in packet
1
MO; EXCL
powderlax
1
EXCL
PREPOPIK
4
ST; MO
prochlorperazine
2
MO
prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml)
2
MO
MO; EXCL
prochlorperazine maleate oral
1
MO
PANCREAZE ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 10,500-35,50061,500 UNIT, 16,800-56,80098,400 UNIT, 2,6006,200- 10,850 UNIT, 21,000-54,70083,900 UNIT, 4,20014,200- 24,600 UNIT
4
peg 3350electrolytes oral recon soln 23622.74-6.74 -5.86 gram
2
peg 3350electrolytes oral recon soln 24022.72-6.72 -5.84 gram
2
peg3350
1
peg-electrolyte
2
peg-prep
1
EXCL
procto-med hc
2
MO
PENTASA ORAL CAPSULE, EXTENDED RELEASE 250 MG
3
MO
procto-pak
2
MO
proctosol hc topical
2
MO
proctozone-hc
2
MO
PENTASA ORAL CAPSULE, EXTENDED RELEASE 500 MG
5
purelax
1
EXCL
RECTIV
3
MO
REGLAN ORAL
4
MO
PERTZYE ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 16,000-57,50060,500 UNIT
5
RELISTOR ORAL
5
MO
RELISTOR SUBCUTANEOUS SOLUTION
5
MO
MO
MO
ST; MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 95
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
MO
women's gentle laxative(bisac)
1
EXCL
women's laxative (bisacodyl)
1
EXCL
ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 10,000-32,000 42,000 UNIT
5
ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 10,000-34,000 55,000 UNIT, 15,000-51,000 82,000 UNIT, 20,000-63,00084,000 UNIT, 25,000-79,000105,000 UNIT, 25,000-85,000136,000 UNIT, 3,000-10,00016,000 UNIT, 5,00017,000 -27,000 UNIT, 5,00017,000- 24,000 UNIT
3
MO
ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 40,000-126,000168,000 UNIT
5
MO
RELISTOR SUBCUTANEOUS SYRINGE
5
REMICADE
5
PA; MO
RENFLEXIS
5
PA; MO
ROWASA RECTAL ENEMA KIT
4
MO
SANCUSO
5
MO
scopolamine base
2
MO
smoothlax
1
EXCL
SUCRAID
5
MO
sulfasalazine
2
MO
SUPREP BOWEL PREP KIT
3
MO
SYMPROIC
3
MO
SYNDROS
5
B/D PA; EXCL; MO
TRANSDERMSCOP
4
MO
trilyte with flavor packets
2
MO
TRULANCE
4
MO
UCERIS ORAL
5
MO
UCERIS RECTAL
4
MO
URSO 250
4
MO
URSO FORTE
4
MO
ursodiol
2
MO
VARUBI INTRAVENOUS
3
VARUBI ORAL
3
B/D PA; EXCL; MO
ZOFRAN ODT
4
B/D PA; EXCL; MO
VIBERZI
5
MO
ZOFRAN ORAL
4
VIOKACE
3
MO
B/D PA; EXCL; MO
woman's laxative
1
EXCL
ZUPLENZ
4
B/D PA; EXCL; MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 96
Drug Name
Drug Tier
Requirements /Limits
ULCER THERAPY acid reducer (omeprazole)
1
EXCL
ACIPHEX
4
MO
ACIPHEX SPRINKLE
4
MO; QL (30 per 30 days)
amoxicilclarithromylansopraz
2
MO; QL (112 per 30 days)
CARAFATE
4
MO
cimetidine
2
MO
cimetidine hcl oral
2
MO
CYTOTEC
4
MO
DEXILANT ORAL CAPSULE,BIPHAS E DELAYED RELEAS 30 MG
4
MO; QL (30 per 30 days)
DEXILANT ORAL CAPSULE,BIPHAS E DELAYED RELEAS 60 MG
4
esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg
2
esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg
2
esomeprazole sodium intravenous recon soln 20 mg
2
esomeprazole sodium intravenous recon soln 40 mg
2
MO
MO; QL (30 per 30 days)
MO
MO
Drug Name
Drug Tier
Requirements /Limits
ESOMEPRAZOLE STRONTIUM ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 49.3 MG
4
MO
famotidine (pf)
2
MO
famotidine (pf)-nacl (iso-os)
2
MO
famotidine intravenous solution
2
MO
famotidine oral suspension
2
MO
famotidine oral tablet 20 mg, 40 mg
1
MO
heartburn treatment 24 hour
1
EXCL
lansoprazole oral capsule,delayed release(dr/ec) 15 mg
2
MO; QL (30 per 30 days)
lansoprazole oral capsule,delayed release(dr/ec) 30 mg
2
MO
lansoprazole oral tablet,disintegrat, delay rel 15 mg
2
MO; QL (30 per 30 days)
lansoprazole oral tablet,disintegrat, delay rel 30 mg
2
MO
misoprostol
2
MO
NEXIUM 24HR
1
MO; EXCL
NEXIUM IV INTRAVENOUS RECON SOLN 40 MG
4
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 97
Drug Name
Drug Tier
Requirements /Limits
Drug Name
MO; QL (30 per 30 days)
omeprazole-sodium bicarbonate oral capsule 20-1.1 mggram
4
MO; QL (30 per 30 days)
omeprazole-sodium bicarbonate oral capsule 40-1.1 mggram
4
MO
omeprazole-sodium bicarbonate oral packet 20-1,680 mg
4
MO; QL (30 per 30 days)
omeprazole-sodium bicarbonate oral packet 40-1,680 mg
4
MO
pantoprazole intravenous
2
MO
pantoprazole oral tablet,delayed release (dr/ec) 20 mg
1
MO; QL (30 per 30 days)
pantoprazole oral tablet,delayed release (dr/ec) 40 mg
1
MO
PEPCID
4
MO
PREVACID 24HR
1
MO; EXCL
PREVACID ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 15 MG
4
MO; QL (30 per 30 days)
PREVACID ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 30 MG
4
MO
NEXIUM ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 20 MG
4
NEXIUM ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 40 MG
4
NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 10 MG, 2.5 MG, 20 MG, 5 MG
3
NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 40 MG
3
nizatidine
2
MO
OMECLAMOXPAK
4
MO; QL (80 per 28 days)
omeppi oral capsule 20-1.1 mg-gram
2
QL (30 per 30 days)
omeppi oral capsule 40-1.1 mg-gram
2
omeprazole magnesium
1
EXCL
omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg
1
MO; QL (30 per 30 days)
omeprazole oral capsule,delayed release(dr/ec) 40 mg
1
MO
omeprazole oral tablet,delayed release (dr/ec)
1
MO; EXCL
MO
MO; QL (30 per 30 days)
MO
Drug Tier
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 98
Drug Name
Drug Tier
PREVACID SOLUTAB ORAL TABLET,DISINTE GRAT, DELAY REL 15 MG
4
PREVACID SOLUTAB ORAL TABLET,DISINTE GRAT, DELAY REL 30 MG
4
PREVPAC
4
Requirements /Limits
Drug Name
MO; QL (30 per 30 days)
ranitidine hcl oral tablet 150 mg, 300 mg
1
MO
sucralfate oral tablet
2
MO
ZANTAC INJECTION SOLUTION 25 MG/ML
4
MO
ZANTAC ORAL TABLET 300 MG
4
MO
ZEGERID ORAL CAPSULE 20-1.1 MG-GRAM
4
MO; QL (30 per 30 days)
ZEGERID ORAL CAPSULE 40-1.1 MG-GRAM
4
MO
ZEGERID ORAL PACKET 20-1,680 MG
4
MO; QL (30 per 30 days)
ZEGERID ORAL PACKET 40-1,680 MG
4
MO
ZEGERID OTC
1
MO; EXCL
MO
MO; QL (112 per 30 days)
PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON
4
MO
PRILOSEC OTC
1
MO; EXCL
PROTONIX INTRAVENOUS
4
MO
PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET
4
MO
PROTONIX ORAL TABLET,DELAYE D RELEASE (DR/EC) 20 MG
4
MO; QL (30 per 30 days)
PROTONIX ORAL TABLET,DELAYE D RELEASE (DR/EC) 40 MG
4
PYLERA
3
MO
rabeprazole
2
MO
ranitidine hcl injection
2
MO
ranitidine hcl oral capsule
1
MO
ranitidine hcl oral syrup
2
MO
MO
Drug Tier
Requirements /Limits
IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE
5
B/D PA; EXCL; MO
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML, 60 MCG/ML
5
PA; MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 99
Drug Name
Drug Tier
Requirements /Limits
Drug Name
PA
EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG
5
PA; MO
EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML
4
PA; MO
EPOGEN INJECTION SOLUTION 20,000 UNIT/ML
5
PA; MO
EXTAVIA SUBCUTANEOUS KIT
5
PA; MO; QL (15 per 28 days)
EXTAVIA SUBCUTANEOUS RECON SOLN
5
PA; QL (15 per 28 days)
GENOTROPIN
5
PA; MO
GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML
4
PA; MO
GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML
5
PA; MO
GRANIX
5
PA; MO
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 150 MCG/0.75 ML
5
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML
4
PA; MO
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML, 40 MCG/0.4 ML
4
PA; MO
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML, 60 MCG/0.3 ML
5
ARCALYST
5
PA; MO
AVONEX (WITH ALBUMIN)
5
PA; MO; QL (4 per 28 days)
AVONEX INTRAMUSCULA R PEN INJECTOR KIT
5
PA; MO; QL (4 per 28 days)
AVONEX INTRAMUSCULA R SYRINGE KIT
5
PA; MO; QL (4 per 28 days)
BETASERON SUBCUTANEOUS KIT
5
PA; MO; QL (15 per 28 days)
PA; MO
Drug Tier
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 100
Drug Name
Drug Tier
Requirements /Limits
Drug Name
HUMATROPE
5
PA; MO
ILARIS (PF) SUBCUTANEOUS SOLUTION
5
PA; MO; LA
INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML)
3
INTRON A INJECTION RECON SOLN 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)
5
INTRON A INJECTION SOLUTION
3
B/D PA; EXCL; MO
LEUKINE INJECTION RECON SOLN
5
MO
MIRCERA INJECTION SYRINGE 100 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML
4
MOZOBIL
5
MO
NEULASTA
5
PA; MO
NEUPOGEN
5
PA; MO
NORDITROPIN FLEXPRO
5
PA; MO
NUTROPIN AQ NUSPIN
5
PA; MO
OMNITROPE
5
PA; MO
PEGASYS PROCLICK
5
MO; QL (2 per 28 days)
B/D PA; EXCL; MO
B/D PA; EXCL; MO
PA; MO
Drug Tier
Requirements /Limits
PEGASYS SUBCUTANEOUS SOLUTION
5
MO; QL (4 per 28 days)
PEGASYS SUBCUTANEOUS SYRINGE
5
MO; QL (2 per 28 days)
PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML
5
MO; QL (4 per 28 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML
5
PA; MO; QL (1 per 28 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG/0.5 ML- 94 MCG/0.5 ML
5
PA; MO; QL (1 per 180 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML
5
PA; MO; QL (1 per 28 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG/0.5 ML- 94 MCG/0.5 ML
5
PA; MO; QL (1 per 180 days)
PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML
3
PA; MO
PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML
5
PA; MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 101
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
ADACEL(TDAP ADOLESN/ADULT )(PF)
3
MO
AFLURIA 20172018
3
EXCL
AFLURIA 20172018 (PF)
3
MO; EXCL
AFLURIA QUAD 2017-2018
3
EXCL
AFLURIA QUAD 2017-2018 (PF)
3
EXCL
ATGAM
5
B/D PA; EXCL
PROLEUKIN
5
B/D PA; EXCL; MO
REBIF (WITH ALBUMIN)
5
PA; MO; QL (6 per 28 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML
5
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)
5
REBIF TITRATION PACK
5
PA; MO; QL (4.2 per 180 days)
BCG VACCINE, LIVE (PF)
3
MO
BEXSERO
3
MO
SAIZEN
5
PA; MO
BIVIGAM
5
PA; MO
SAIZEN CLICK.EASY
5
PA; MO
BOOSTRIX TDAP
3
MO
SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG
5
PA; MO
BOTOX
3
PA; MO
5
PA; MO
SYLATRON
5
MO
CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM
ZARXIO
5
PA; MO
MO
5
PA; MO
DAPTACEL (DTAP PEDIATRIC) (PF)
3
ZOMACTON SUBCUTANEOUS RECON SOLN 10 MG
DYSPORT
4
PA; MO
ENGERIX-B (PF)
3
ZOMACTON SUBCUTANEOUS RECON SOLN 5 MG
4
B/D PA; EXCL; MO
3
B/D PA; EXCL; MO
ZORBTIVE
5
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SYRINGE FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 %
5
PA; MO
PA; MO; QL (6 per 28 days)
PA; MO; QL (4.2 per 180 days)
PA; MO
PA; MO
VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF)
3
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 102
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
FLUAD 2017-2018 (65 YR UP)(PF)
3
MO; EXCL
FLUZONE QUAD PEDI 2017-18 (PF)
3
FLUARIX QUAD 2017-2018 (PF)
3
MO; EXCL
fomepizole
2
GAMASTAN S/D
3
MO
FLUBLOK 20172018 (PF)
3
MO; EXCL
GAMMAGARD LIQUID
5
PA; MO
FLUBLOK QUAD 2017-2018 (PF)
3
EXCL
5
PA; MO
FLUCELVAX QUAD 2017-2018
3
EXCL
GAMMAGARD SD (IGA < 1 MCG/ML)
PA; MO
3
MO; EXCL
FLULAVAL QUAD 2017-2018
3
EXCL
GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10 %)
5
FLUCELVAX QUAD 2017-2018 (PF)
GAMMAPLEX
5
PA; MO
FLULAVAL QUAD 2017-2018 (PF)
3
MO; EXCL
GAMMAPLEX (WITH SORBITOL)
5
PA; MO
FLUMIST QUAD 2017-2018
3
EXCL
5
PA; MO
FLUVIRIN 20172018
3
EXCL
GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %)
FLUVIRIN 20172018 (PF)
3
MO; EXCL
GARDASIL 9 (PF)
3
MO
FLUZONE HIGHDOSE 2017-18 (PF)
3
MO; EXCL
GRASTEK
3
PA; MO
3
MO
FLUZONE INTRADERM QUAD 2017-18
3
HAVRIX (PF) INTRAMUSCULA R SUSPENSION
3
MO
FLUZONE QUAD 2017-2018
3
EXCL
HAVRIX (PF) INTRAMUSCULA R SYRINGE 1,440 ELISA UNIT/ML
FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULA R SUSPENSION
3
EXCL
3
FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULA R SYRINGE
3
MO; EXCL
HAVRIX (PF) INTRAMUSCULA R SYRINGE 720 ELISA UNIT/0.5 ML HIBERIX (PF)
3
HIZENTRA
5
EXCL
EXCL
MO
B/D PA; EXCL; MO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 103
Drug Name
Drug Tier
Requirements /Limits
HYPERHEP B S/D INTRAMUSCULA R SOLUTION 220 UNIT/ML
3
HYPERHEP B S/D INTRAMUSCULA R SOLUTION 220 UNIT/ML (5 ML)
3
HYPERHEP B S/D INTRAMUSCULA R SYRINGE
3
HYPERHEP B S-D NEONATAL
3
HYPERRAB S/D (PF)
4
HYPERRHO S/D INTRAMUSCULA R SYRINGE 1,500 UNIT (300 MCG)
3
HYPERRHO S/D INTRAMUSCULA R SYRINGE 250 UNIT (50 MCG)
3
HYPERTET S/D (PF)
3
MO
HYQVIA
5
Drug Name
Drug Tier
Requirements /Limits
KINRIX (PF) INTRAMUSCULA R SYRINGE
3
MO
MENACTRA (PF) INTRAMUSCULA R SOLUTION
3
MO
MENVEO A-C-YW-135-DIP (PF)
3
MO
M-M-R II (PF)
3
MO
OCTAGAM
5
PA; MO
ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY
4
PA; MO
PEDIARIX (PF)
3
MO
PEDVAX HIB (PF)
3
MO
PENTACEL (PF)
3
MO
PNEUMOVAX 23
3
MO; EXCL
PREVNAR 13 (PF)
3
MO; EXCL
PRIVIGEN
5
PA; MO
PROQUAD (PF)
3
MO
QUADRACEL (PF)
3
B/D PA; EXCL; MO
RABAVERT (PF)
3
MO
RAGWITEK
3
MO
RECOMBIVAX HB (PF) INTRAMUSCULA R SUSPENSION
3
B/D PA; EXCL; MO
RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 10 MCG/ML
3
B/D PA; EXCL; MO
MO
MO
IMOGAM RABIESHT (PF)
3
MO
IMOVAX RABIES VACCINE (PF)
3
MO
INFANRIX (DTAP) (PF)
3
MO
IPOL
3
MO
IXIARO (PF)
3
MO
KINRIX (PF) INTRAMUSCULA R SUSPENSION
3
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 104
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
B/D PA; EXCL
XEOMIN INTRAMUSCULA R RECON SOLN 50 UNIT
4
PA; MO
YF-VAX (PF)
3
MO
ZINPLAVA
5
MO
ZOSTAVAX (PF)
3
MO
RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 5 MCG/0.5 ML
3
ROTARIX
3
ROTATEQ VACCINE
3
MO
SHINGRIX (PF)
3
MO
STAMARIL (PF)
3
TENIVAC (PF)
3
MO
GOUT THERAPY
TETANUS,DIPHTH ERIA TOX PED(PF)
3
MO
allopurinol
1
allopurinol sodium
2
aloprim
2
TETANUSDIPHTHERIA TOXOIDS-TD
3
COLCHICINE
4
ST; MO
COLCRYS
4
ST; MO
THYMOGLOBULI N
5
B/D PA; EXCL
DUZALLO
4
ST; MO
KRYSTEXXA
5
MO
TICE BCG
3
B/D PA; EXCL; MO
MITIGARE
3
MO
TRUMENBA
3
MO
probenecid
2
MO
TWINRIX (PF) INTRAMUSCULA R SYRINGE
3
MO
probenecidcolchicine
2
MO
ULORIC
3
ST; MO
TYPHIM VI INTRAMUSCULA R SOLUTION
3
ZURAMPIC
4
MO
ZYLOPRIM
4
MO
TYPHIM VI INTRAMUSCULA R SYRINGE
3
VAQTA (PF)
3
MO
VARIVAX (PF)
3
MO
VARIZIG INTRAMUSCULA R SOLUTION
3
MO
MO
MO
MUSCULOSKELETAL / RHEUMATOLOGY MO
OSTEOPOROSIS THERAPY ACTONEL ORAL TABLET 150 MG
4
ST; MO; QL (1 per 30 days)
ACTONEL ORAL TABLET 35 MG
4
ST; MO; QL (4 per 28 days)
ACTONEL ORAL TABLET 5 MG
4
ST; MO; QL (30 per 30 days)
alendronate oral solution
2
MO; QL (1286 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 105
Drug Name
Drug Tier
Requirements /Limits
Drug Name TYMLOS
alendronate oral tablet 10 mg, 5 mg
1
MO; QL (30 per 30 days)
alendronate oral tablet 35 mg, 70 mg
1
MO; QL (4 per 28 days)
ATELVIA
4
ST; MO; QL (4 per 28 days)
BINOSTO
4
ST; MO; QL (4 per 28 days)
BONIVA INTRAVENOUS
4
PA; MO
BONIVA ORAL
4
ST; MO; QL (1 per 30 days)
EVISTA
4
MO
FORTEO
5
PA; MO; QL (2.4 per 28 days)
FOSAMAX ORAL TABLET 70 MG
4
ST; MO; QL (4 per 28 days)
FOSAMAX PLUS D
4
ST; MO; QL (4 per 28 days)
ibandronate intravenous
2
PA; MO
ibandronate oral
2
MO; QL (1 per 30 days)
PROLIA
3
PA; MO
raloxifene
2
MO
risedronate oral tablet 150 mg
2
MO; QL (1 per 30 days)
risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack)
2
MO; QL (4 per 28 days)
risedronate oral tablet 5 mg
2
MO; QL (30 per 30 days)
risedronate oral tablet,delayed release (dr/ec)
2
MO; QL (4 per 28 days)
Drug Tier 5
Requirements /Limits PA; MO; QL (1.56 per 30 days)
OTHER RHEUMATOLOGICALS ACTEMRA
5
PA; MO
ARAVA
5
MO; QL (30 per 30 days)
BENLYSTA
5
MO
CUPRIMINE
5
MO
DEPEN TITRATABS
5
MO
ENBREL MINI
5
PA; MO; QL (8 per 28 days)
ENBREL SUBCUTANEOUS RECON SOLN
5
PA; MO; QL (16 per 28 days)
ENBREL SUBCUTANEOUS SYRINGE
5
PA; MO; QL (8 per 28 days)
ENBREL SURECLICK
5
PA; MO; QL (8 per 28 days)
HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML
5
PA; MO; QL (3 per 180 days)
HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML (6 PACK)
5
PA; MO; QL (6 per 180 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 106
Drug Name
Drug Tier
Requirements /Limits
Drug Name
PA
OTEZLA
5
PA; MO
OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)20 MG (4)-30 MG (47)
5
PA; MO
OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)20 MG (4)-30 MG(19)
5
PA
OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML
4
MO
RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML
3
MO
RIDAURA
5
MO
SAVELLA ORAL TABLET
3
MO; QL (60 per 30 days)
SAVELLA ORAL TABLETS,DOSE PACK
3
MO; QL (55 per 30 days)
SIMPONI
5
PA; MO
HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML
5
HUMIRA PEN CROHN'S-UC-HS START
5
HUMIRA PEN PSORIASISUVEITIS
5
PA; MO; QL (4 per 180 days)
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML
5
PA
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML
5
PA; MO; QL (4 per 28 days)
HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML
5
PA; MO; QL (2 per 28 days)
HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML
5
PA; MO; QL (4 per 28 days)
KEVZARA
5
PA; MO; QL (2.28 per 28 days)
KINERET
5
PA; MO
leflunomide
2
MO; QL (30 per 30 days)
ORENCIA
5
PA; MO
ORENCIA (WITH MALTOSE)
5
PA; MO
ORENCIA CLICKJECT
5
PA; MO
PA; MO; QL (6 per 180 days)
Drug Tier
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 107
Drug Name
Drug Tier
Requirements /Limits
Drug Name DIVIGEL TRANSDERMAL GEL IN PACKET 1 MG/GRAM (0.1 %)
4
PA; MO; QL (30 per 30 days)
OBSTETRICS / GYNECOLOGY
DUAVEE
3
MO
ESTROGENS / PROGESTINS
ELESTRIN
4
PA; MO; QL (52 per 30 days)
ENDOMETRIN
3
MO; EXCL
errin
2
MO
ESTRACE ORAL
4
PA; MO
SIMPONI ARIA
5
PA; MO
XELJANZ
5
PA; MO
XELJANZ XR
5
PA; MO
Drug Tier
Requirements /Limits
ACTIVELLA
4
PA; MO
ALORA
4
PA; MO; QL (8 per 28 days)
amabelz
2
PA; MO
ANGELIQ
4
PA; MO
AYGESTIN
4
MO
ESTRACE VAGINAL
3
MO
camila
2
MO
estradiol oral
4
PA; MO
CLIMARA
4
PA; MO; QL (4 per 28 days)
2
PA; MO; QL (8 per 28 days)
CLIMARA PRO
4
PA; MO
estradiol transdermal patch semiweekly
COMBIPATCH
4
PA; MO
2
CRINONE VAGINAL GEL 4 %
4
MO
estradiol transdermal patch weekly
PA; MO; QL (4 per 28 days)
estradiol vaginal
2
MO
CRINONE VAGINAL GEL 8 %
4
PA; MO
estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml
2
MO
deblitane
2
MO
2
PA; MO
DELESTROGEN
4
MO
estradiolnorethindrone acet
DEPO-ESTRADIOL
4
MO
ESTRING
3
MO
DEPO-PROVERA INTRAMUSCULA R SUSPENSION 150 MG/ML
4
MO
estropipate
2
PA; MO
EVAMIST
4
PA; MO; QL (16.2 per 30 days)
DEPO-PROVERA INTRAMUSCULA R SUSPENSION 400 MG/ML
3
FEMHRT LOW DOSE
4
PA; MO
FEMRING
4
MO
DEPO-SUBQ PROVERA 104
4
fyavolv
2
PA; MO
heather
2
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 108
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
hydroxyprogesterone caproate
5
MO
PREMARIN ORAL
3
MO MO
2
MO
PREMARIN VAGINAL
4
jencycla jinteli
2
PA; MO
PREMPHASE
4
PA; MO
jolivette
2
MO
PREMPRO
4
PA; MO
lyza
2
MO
progesterone
2
MO
MAKENA
5
MO
progesterone in oil
2
MO
MAKENA (PF)
5
MO
2
MO
medroxyprogesteron e
2
MO
progesterone micronized PROMETRIUM
4
MO
MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG
3
PROVERA
4
MO
sharobel
2
MO
MENOSTAR
4
VAGIFEM
4
MO
VIVELLE-DOT
4
PA; MO; QL (8 per 28 days)
yuvafem
2
MO
PA; MO
PA; MO; QL (4 per 28 days)
mimvey
2
PA; MO
mimvey lo
2
PA; MO
MINIVELLE
4
PA; MO; QL (8 per 28 days)
nora-be
2
MO
norethindrone (contraceptive)
2
MO
norethindrone acetate
2
MO
norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg
4
PA; MO
norlyda
2
norlyroc
2
ORTHO MICRONOR
4
MO
PREFEST
4
PA; MO
PREMARIN INJECTION
4
MO
MO
MISCELLANEOUS OB/GYN AVC
4
MO
CLEOCIN VAGINAL CREAM
4
MO
CLEOCIN VAGINAL SUPPOSITORY
3
MO
clindamycin phosphate vaginal
2
MO
CLINDESSE
4
MO
CONCEPTROL
1
MO; EXCL
GYNAZOLE-1
4
MO
gynol ii
1
MO; EXCL
LUPANETA PACK (1 MONTH)
5
MO
LUPANETA PACK (3 MONTH)
5
MO
LYSTEDA
4
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 109
Drug Name
Drug Tier
METROGEL VAGINAL
Requirements /Limits
Drug Name
Drug Tier
4
MO
aranelle (28)
2
MO
ashlyna
2
MO
metronidazole vaginal
2
MO
aubra
2
MO
miconazole-3 vaginal suppository
2
MO
aviane
2
MO
azurette (28)
2
MO
MIRENA
3
MO
balziva (28)
2
MO
NEXPLANON
3
MO
bekyree (28)
2
MO
NUVARING
4
MO
BEYAZ
4
MO
TERAZOL 7
4
blisovi 24 fe
2
MO
terconazole
2
MO
blisovi fe 1.5/30 (28)
2
MO
TODAY CONTRACEPTIVE SPONGE
1
MO; EXCL
blisovi fe 1/20 (28)
2
MO
BREVICON (28)
4
MO
tranexamic acid oral
4
MO
briellyn
2
MO
VAGINAL CONTRACEPTIVE FILM
1
MO; EXCL
camrese
2
MO
camrese lo
2
MO
caziant (28)
2
MO
vaginal contraceptive foam
1
EXCL
chateal
2
MO
vandazole
2
MO
cryselle (28)
2
MO
VCF CONTRACEPTIVE GEL
1
EXCL
cyclafem 1/35 (28)
2
MO
cyclafem 7/7/7 (28)
2
MO
cyred
2
MO
xulane
2
dasetta 1/35 (28)
2
MO
dasetta 7/7/7 (28)
2
MO
daysee
2
MO
delyla (28)
2
desoge.estradiol/e.estradio l
2
desogestrel-ethinyl estradiol
2
drospirenonee.estradiol-lm.fa
2
MO
ORAL CONTRACEPTIVES / RELATED AGENTS AFTERA
1
EXCL
altavera (28)
2
MO
alyacen 1/35 (28)
2
MO
alyacen 7/7/7 (28)
2
MO
amethia
2
MO
amethia lo
2
MO
amethyst
2
MO
apri
2
MO
Requirements /Limits
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 110
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
kurvelo
2
MO
l norgest/e.estradiole.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7), 0.15 mg-30 mcg (84)/10 mcg (7)
2
MO
l norgest/e.estradiole.estrad oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg
2
larin 1.5/30 (21)
2
MO
drospirenone-ethinyl estradiol
2
MO
econtra ez
1
EXCL
econtra one-step
1
EXCL
elinest
2
MO
ELLA
3
emoquette
2
MO
enpresse
2
MO
enskyce
2
MO
estarylla
2
MO
ethynodiol diac-eth estradiol
2
falmina (28)
2
MO
larin 1/20 (21)
2
MO
fayosim
2
MO
larin 24 fe
2
MO
femynor
2
MO
larin fe 1.5/30 (28)
2
MO
GENERESS FE
4
MO
larin fe 1/20 (28)
2
MO
gianvi (28)
2
MO
larissia
2
MO
gildagia
2
MO
layolis fe
2
MO
introvale
2
MO
leena 28
2
MO
isibloom
2
MO
lessina
2
MO
jolessa
2
MO
levonest (28)
2
MO
juleber
2
MO
2
MO
junel 1.5/30 (21)
2
MO
levonorgestrelethinyl estrad
junel 1/20 (21)
2
MO
2
MO
junel fe 1.5/30 (28)
2
MO
levonorg-eth estrad triphasic
junel fe 1/20 (28)
2
MO
levora-28
2
MO
junel fe 24
2
MO
lillow
2
MO
kaitlib fe
2
MO
LO LOESTRIN FE
4
MO
kariva (28)
2
MO
LOESTRIN 1.5/30 (21)
4
MO
kelnor 1/35 (28)
2
MO
MO
2
MO
LOESTRIN 1/20 (21)
4
kelnor 1-50 kimidess (28)
2
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 111
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
LOESTRIN FE 1.5/30 (28-DAY)
4
MO
norethindronee.estradiol-iron
2
MO
LOESTRIN FE 1/20 (28-DAY)
4
MO
norgestimate-ethinyl estradiol
2
MO
loryna (28)
2
MO
nortrel 0.5/35 (28)
2
MO
LOSEASONIQUE
4
MO
nortrel 1/35 (21)
2
MO
low-ogestrel (28)
2
MO
nortrel 1/35 (28)
2
MO
lutera (28)
2
MO
nortrel 7/7/7 (28)
2
MO
marlissa
2
MO
ocella
2
MO
melodetta 24 fe
2
MO
ogestrel (28)
2
MO
mibelas 24 fe
2
MO
opcicon one-step
1
EXCL
microgestin 1.5/30 (21)
2
MO
option-2
1
EXCL
orsythia
2
MO
microgestin 1/20 (21)
2
MO
ORTHO TRICYCLEN (28)
4
MO
microgestin fe 1.5/30 (28)
2
MO
ORTHO TRICYCLEN LO (28)
4
MO
microgestin fe 1/20 (28)
2
MO
ORTHO-CYCLEN (28)
4
MO
MINASTRIN 24 FE
4
MO
4
MO
mono-linyah
2
MO
ORTHO-NOVUM 1/35 (28)
mononessa (28)
2
MO
4
MO
my choice
1
EXCL
ORTHO-NOVUM 7/7/7 (28)
my way
1
EXCL
philith
2
MO
myzilra
2
MO
pimtrea (28)
2
MO
NATAZIA
4
MO
pirmella
2
MO
necon 0.5/35 (28)
2
MO
PLAN B ONE-STEP
3
EXCL
necon 7/7/7 (28)
2
MO
portia
2
MO
nikki (28)
2
MO
previfem
2
MO
noreth-ethinyl estradiol-iron
2
MO
QUARTETTE
4
MO
quasense
2
MO
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg
2
rajani
2
MO
reclipsen (28)
2
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 112
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
rivelsa
2
MO
wera (28)
2
MO
SAFYRAL
4
MO
wymzya fe
2
MO
SEASONIQUE
4
MO
YASMIN (28)
4
MO
setlakin
2
MO
YAZ (28)
4
MO
sprintec (28)
2
MO
zarah
2
MO
sronyx
2
MO
zenchent (28)
2
MO
syeda
2
MO
zovia 1/35e (28)
2
MO
TAKE ACTION
1
EXCL
zovia 1/50e (28)
2
MO
tarina fe 1/20 (28)
2
MO
OXYTOCICS
tilia fe
2
MO
methergine
2
tri femynor
2
MO
2
tri-estarylla
2
MO
methylergonovine injection
tri-legest fe
2
MO
oxytocin injection solution
2
tri-linyah
2
MO
tri-lo-estarylla
2
MO
tri-lo-marzia
2
MO
tri-lo-sprintec
2
MO
trinessa (28)
2
MO
trinessa lo
2
MO
TRI-NORINYL (28)
4
MO
tri-previfem (28)
2
tri-sprintec (28)
MO
OPHTHALMOLOGY ANTIBIOTICS AZASITE
3
MO
bacitracin ophthalmic (eye)
2
MO
2
MO
MO
bacitracinpolymyxin b ophthalmic (eye)
2
MO
BESIVANCE
3
MO
trivora (28)
2
MO
CILOXAN
4
MO
tri-vylibra
2
ciprofloxacin hcl ophthalmic (eye)
2
MO
tydemy
2
MO
MO
2
MO
erythromycin ophthalmic (eye)
1
velivet triphasic regimen (28)
gatifloxacin
2
MO
vestura (28)
2
MO
MO
2
MO
gentak ophthalmic (eye) ointment
1
vienva viorele (28)
2
MO
1
MO
vyfemla (28)
2
MO
vylibra
2
gentamicin ophthalmic (eye) drops
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 113
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
BETAGAN OPHTHALMIC (EYE) DROPS 0.5 %
4
MO
betaxolol ophthalmic (eye)
2
MO
BETIMOL
4
MO
BETOPTIC S
4
MO
carteolol
1
MO
MO
ISTALOL
4
MO
1
MO
levofloxacin ophthalmic (eye)
2
MO
MOXEZA
4
MO
moxifloxacin ophthalmic (eye)
2
MO
NATACYN
3
MO
neomycinbacitracinpolymyxin
2
MO
neomycinpolymyxingramicidin
2
neo-polycin
2
MO
levobunolol ophthalmic (eye) drops 0.5 %
OCUFLOX
4
MO
metipranolol
2
ofloxacin ophthalmic (eye)
2
MO
1
MO
polycin
2
MO
timolol maleate ophthalmic (eye) drops
polymyxin b sulftrimethoprim
1
MO
timolol maleate ophthalmic (eye) drops, once daily
2
MO
POLYTRIM
4
MO
MO
1
MO
TOBREX OPHTHALMIC (EYE) DROPS
4
MO
timolol maleate ophthalmic (eye) gel forming solution
2
tobramycin
TIMOPTIC OCUDOSE (PF)
4
MO
TOBREX OPHTHALMIC (EYE) OINTMENT
3
MO
4
MO
VIGAMOX
4
MO
TIMOPTIC-XE OPHTHALMIC (EYE) GEL FORMING SOLUTION 0.25 %
ZYMAXID
4
MO
trifluridine
2
MO
VIROPTIC
4
MO
PHOSPHOLINE IODIDE
ZIRGAN
4
MO
CYCLOPLEGIC MYDRIATICS
ANTIVIRALS
BETA-BLOCKERS
CHOLINESTERASE INHIBITOR MIOTICS
atropine ophthalmic (eye) drops
3
2
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 114
Drug Name
Drug Tier
Requirements /Limits
DIRECT ACTING MIOTICS ISOPTO CARPINE
4
MO
pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %
2
MO
MISCELLANEOUS OPHTHALMOLOGICS
Drug Name
Drug Tier
Requirements /Limits
olopatadine ophthalmic (eye)
2
MO
PATADAY
4
MO
PATANOL
4
MO
PAZEO
3
MO
RESTASIS
3
MO; QL (60 per 30 days)
3
MO; QL (5.5 per 30 days)
4
MO; QL (60 per 30 days)
ALOCRIL
4
MO
ALOMIDE
4
MO
RESTASIS MULTIDOSE
azelastine ophthalmic (eye)
2
MO
XIIDRA
balanced salt
2
BEPREVE
4
MO
bss
2
MO
cromolyn ophthalmic (eye)
2
MO
CYSTARAN
5
ELESTAT
NON-STEROIDAL ANTIINFLAMMATORY AGENTS ACULAR
4
MO
ACULAR LS
4
MO
ACUVAIL (PF)
4
MO
MO
bromfenac
2
MO
4
MO
BROMSITE
3
MO
EMADINE
4
MO
2
MO
epinastine
2
MO
diclofenac sodium ophthalmic (eye)
EYLEA
5
MO
flurbiprofen sodium
2
MO
JETREA (PF) INTRAVITREAL SOLUTION 0.125 MG/0.1 ML (1.25 MG/ML)
5
MO
ILEVRO
3
MO
ketorolac ophthalmic (eye)
2
MO
NEVANAC
4
MO
LACRISERT
4
MO
PROLENSA
3
MO
LASTACAFT
4
MO
LUCENTIS INTRAVITREAL SOLUTION 0.3 MG/0.05 ML
5
MO
LUCENTIS INTRAVITREAL SYRINGE
5
MO
ORAL DRUGS FOR GLAUCOMA acetazolamide
2
MO
acetazolamide sodium
2
MO
methazolamide
2
MO
OTHER GLAUCOMA DRUGS AZOPT
4
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 115
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
bimatoprost ophthalmic (eye)
2
MO
TOBRADEX ST
4
MO MO
3
MO
tobramycindexamethasone
2
COMBIGAN COSOPT
4
MO
ZYLET
3
MO
COSOPT (PF)
4
MO
STEROIDS
dorzolamide
2
MO
ALREX
4
MO
dorzolamide-timolol
2
MO
2
MO
latanoprost
2
MO
dexamethasone sodium phosphate ophthalmic (eye)
LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %
3
MO
DUREZOL
4
MO
FLAREX
4
MO
fluorometholone
2
MO
miostat
2
FML FORTE
4
MO
RHOPRESSA
4
MO
FML LIQUIFILM
4
MO
SIMBRINZA
4
MO
FML S.O.P.
3
MO
TRAVATAN Z
3
MO
LOTEMAX
3
MO
TRUSOPT
4
MO
MAXIDEX
4
MO
VYZULTA
4
ST; MO
OMNIPRED
4
MO
XALATAN
4
ST; MO
OZURDEX
5
MO
ZIOPTAN (PF)
4
ST; MO
PRED FORTE
4
MO
PRED MILD
4
MO
prednisolone acetate
2
MO
prednisolone sodium phosphate ophthalmic (eye)
2
MO
STEROID-ANTIBIOTIC COMBINATIONS MAXITROL
4
MO
neomycinbacitracin-poly-hc
2
MO
neomycin-polymyxin b-dexameth
1
MO
neomycinpolymyxin-hc ophthalmic (eye)
2
MO
neo-polycin hc
2
MO
PRED-G
4
MO
PRED-G S.O.P.
4
MO
TOBRADEX
4
MO
STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE
4
MO
BLEPHAMIDE S.O.P.
4
MO
sulfacetamideprednisolone
2
MO
4
MO
SULFONAMIDES BLEPH-10
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 116
Drug Name sulfacetamide sodium ophthalmic (eye)
Drug Tier 2
Requirements /Limits
Drug Name
Drug Tier
MO
ALLEGRA ALLERGY
1
MO; EXCL
ALLEGRA-D 12 HOUR
1
MO; EXCL
ALLEGRA-D 24 HOUR
1
MO; EXCL
allerclear
1
EXCL
allerclear d-12hr
1
EXCL
allerclear d-24hr
1
MO; EXCL
aller-ease oral tablet
1
EXCL
aller-fex
1
EXCL
SYMPATHOMIMETICS MO
Requirements /Limits
ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %
3
ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.15 %
4
apraclonidine
2
MO
brimonidine
2
MO
allergy and congestion relief
1
EXCL
IOPIDINE
4
MO
allergy complete-d
1
EXCL
allergy d-12
1
EXCL
allergy relief (cetirizine)
1
EXCL
1
EXCL
EXCL
allergy relief (fexofenadine) allergy relief (loratadine) oral solution
1
EXCL
1
MO; EXCL
MO
RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS 24hour allergy
1
adrenalin injection
2
alavert
1
MO; EXCL
alavert d-12 allergysinus
1
MO; EXCL
all day allergy (cetirizine) oral capsule
1
EXCL
allergy relief (loratadine) oral tablet
1
EXCL
all day allergy (cetirizine) oral solution
1
EXCL
allergy relief (loratadine) oral tablet,disintegrating allergy relief d12
1
EXCL
allergy relief d-24
1
EXCL
all day allergy (cetirizine) oral tablet
1
EXCL
allergy relief,nasal decongest
1
MO; EXCL
all day allergy relief(cetir)
1
EXCL
allergy relief-d (cetirizine)
1
EXCL
all day allergy-d
1
MO; EXCL
allergy relief-d (loratadine)
1
EXCL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 117
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
allergy reliefd(fexofenadine)
1
EXCL
cheratussin ac
1
MO; EXCL EXCL
1
EXCL
child allergy relf(cetirizine) oral solution
1
allergy-congest relief-d (cet) allergy-congestion relief-d oral tablet extended release 24 hr
1
EXCL
1
EXCL
aller-tec
1
EXCL
CHILD ALLERGY RELF(CETIRIZINE ) ORAL TABLET,CHEWAB LE
aller-tec d
1
EXCL
children's allegra allergy
1
MO; EXCL
AUVI-Q INJECTION AUTOINJECTOR 0.15 MG/0.15 ML, 0.3 MG/0.3 ML
5
ST; MO; QL (4 per 30 days)
CHILDREN'S ALLERGY RELIEF(FEX)
1
EXCL
1
EXCL
benzonatate
1
MO; EXCL
children's allergy relief(lor)
BROMFED DM
3
MO; EXCL
children's allergy(cetirizine)
1
EXCL
BROMPHENIRAMI NE MALEATE (BULK)
3
EXCL
children's aller-tec
1
EXCL
1
EXCL
brompheniraminepseudoeph-dm oral syrup
1
children's cetirizine oral solution
1
MO; EXCL
CAPCOF
3
MO; EXCL
CHILDREN'S CETIRIZINE ORAL TABLET,CHEWAB LE
cetiri-d
1
EXCL
MO; EXCL
2
MO
CHILDREN'S CLARITIN
1
cetirizine oral solution 1 mg/ml
EXCL
1
EXCL
CHILDREN'S WAL-FEX
1
cetirizine oral solution 5 mg/5 ml
EXCL
1
MO; EXCL
children's wal-zyr oral solution
1
cetirizine oral tablet 10 mg
EXCL
1
MO; EXCL
cetirizine oral tablet,chewable
1
MO; EXCL
CHILDREN'S WAL-ZYR ORAL TABLET,CHEWAB LE
1
CETIRIZINE ORAL TABLET 5 MG
1
EXCL
cetirizinepseudoephedrine
1
CHILDREN'S ZYRTEC ALLERGY ORAL SOLUTION
MO; EXCL
MO; EXCL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 118
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
MO; EXCL
desloratadine
2
MO; QL (30 per 30 days)
DIPHENHYDRAMI NE (BULK)
3
MO; EXCL
diphenhydramine hcl injection solution 50 mg/ml
2
MO
diphenhydramine hcl injection syringe
2
MO
diphenhydramine hcl oral capsule 50 mg
1
MO; EXCL
diphenhydramine hcl oral elixir
2
PA
EPINEPHRINE INJECTION AUTOINJECTOR 0.15 MG/0.15 ML, 0.3 MG/0.3 ML
4
ST; MO; QL (4 per 30 days)
EPINEPHRINE INJECTION AUTOINJECTOR 0.15 MG/0.3 ML, 0.3 MG/0.3 ML
3
MO; QL (4 per 30 days)
EPIPEN
3
MO; QL (4 per 30 days)
EPIPEN 2-PAK
3
MO; QL (4 per 30 days)
EPIPEN JR
3
MO; QL (4 per 30 days)
EPIPEN JR 2-PAK
3
MO; QL (4 per 30 days)
FEXOFENADINE (BULK)
3
EXCL
FEXOFENADINE ORAL SUSPENSION
1
EXCL
fexofenadine oral tablet 180 mg, 60 mg
1
MO; EXCL
CHILDREN'S ZYRTEC ALLERGY ORAL TABLET,DISINTE GRATING
1
child's all day allergy(cetir)
1
EXCL
CHLORPHENIRA MINE MALEATE(BULK)
3
MO; EXCL
CLARINEX ORAL SYRUP
4
MO
CLARINEX ORAL TABLET
4
MO; QL (30 per 30 days)
CLARINEX-D 12 HOUR
4
MO; QL (60 per 30 days)
CLARITIN LIQUIGEL
1
MO; EXCL
CLARITIN ORAL SOLUTION
1
EXCL
CLARITIN ORAL TABLET
1
MO; EXCL
CLARITIN REDITABS
1
MO; EXCL
CLARITIN-D 12 HOUR
1
MO; EXCL
CLARITIN-D 24 HOUR
1
MO; EXCL
CLEMASTINE FUMARATE (BULK)
3
EXCL
CODEINEGUAIFENESIN
3
MO; EXCL
CODITUSSIN AC
3
MO; EXCL
CODITUSSIN DAC
3
EXCL
CYPROHEPTADIN E (BULK)
3
EXCL
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 119
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
fexofenadinepseudoephedrine
1
EXCL
levocetirizine oral tablet
2
MO; QL (30 per 30 days)
g tussin ac
1
EXCL
loradamed
1
MO; EXCL
guaiatussin ac
1
MO; EXCL
lorata-d
1
EXCL
guaifenesin ac
1
EXCL
3
EXCL
guaifenesin dac
1
MO; EXCL
LORATADINE (BULK)
HISTEX-AC
3
EXCL
lorata-dine d
1
EXCL
hydrocodonechlorpheniramine
1
MO; EXCL
loratadine oral capsule
1
EXCL
hydrocodone-cpmpseudoephed
1
MO; EXCL
loratadine oral solution
1
MO; EXCL
hydrocodonehomatropine oral syrup 5-1.5 mg/5 ml
1
MO; EXCL
loratadine oral tablet
1
MO; EXCL
1
EXCL
HYDROCODONEHOMATROPINE ORAL SYRUP 51.5 MG/5 ML (5 ML)
3
loratadine oral tablet,disintegrating LORATADINE, MICRONIZED (BULK)
3
EXCL
loratadine-d
1
MO; EXCL
hydrocodonehomatropine oral tablet
1
lortuss ex oral syrup
1
EXCL
MAR-COF CG
3
MO; EXCL
hydromet
1
MO; EXCL
m-clear wc
1
MO; EXCL
HYDROXYZINE HCL (BULK)
3
MO; EXCL
M-END PE
3
MO; EXCL
NINJACOF-XG
3
MO; EXCL
hydroxyzine hcl intramuscular solution 50 mg/ml
1
non-drowsy allergy
1
EXCL
OBREDON
3
MO; EXCL
hydroxyzine hcl oral tablet
2
PA; MO
PHENERGAN INJECTION
4
MO
HYDROXYZINE PAMOATE (BULK)
3
MO; EXCL
3
MO; EXCL
KARBINAL ER
3
MO; EXCL
POLY-TUSSIN AC ORAL LIQUID 410-10 MG/5 ML
LEVOCETIRIZINE (BULK)
3
MO; EXCL
PROMETHAZINE (BULK)
3
MO; EXCL
levocetirizine oral solution
2
MO
promethazine injection solution
4
MO
EXCL
MO; EXCL
MO; EXCL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 120
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
promethazine oral
4
PA; MO
virtussin ac
1
MO; EXCL
promethazine rectal suppository 12.5 mg, 25 mg
1
MO; EXCL
virtussin dac
1
EXCL
wal-fex allergy
1
EXCL
promethazine vccodeine
1
wal-fex d 12 hour
1
EXCL
wal-fex d 24 hour
1
EXCL
promethazinecodeine
1
wal-itin d
1
EXCL
wal-itin d 12 hour
1
EXCL
promethazine-dm
1
MO; EXCL
wal-itin oral solution
1
EXCL
promethazinephenyleph-codeine
1
MO; EXCL
wal-itin oral tablet
1
EXCL
PRO-RED AC (W/ DEXCHLORPHENI R)
3
MO; EXCL
wal-zyr (cetirizine)
1
EXCL
wal-zyr d
1
EXCL
4
MO
PYRILAMINE MALEATE (BULK)
3
EXCL
XYZAL ORAL SOLUTION
1
MO; EXCL
relcof c
1
EXCL
XYZAL ORAL TABLET
RESPA-AR
3
MO; EXCL
ZODRYL AC 25
3
EXCL
robafen ac
1
EXCL
ZODRYL AC 30
3
EXCL
rydex
1
EXCL
ZODRYL AC 35
3
EXCL
SEMPREX-D
4
MO
ZODRYL AC 40
3
EXCL
TESSALON PERLES
3
MO; EXCL
ZODRYL AC 50
3
EXCL
ZODRYL AC 60
3
EXCL
TRIPELENNAMIN E (BULK)
3
EXCL
ZODRYL AC 80
3
EXCL
TRIPROLIDINE HCL (BULK)
3
EXCL
ZODRYL DAC 25
3
EXCL
ZODRYL DAC 30
3
EXCL
tusnel c
1
EXCL
ZODRYL DAC 35
3
EXCL
TUSNEL PEDIATRIC ORAL LIQUID
3
EXCL
ZODRYL DAC 40
3
EXCL
ZODRYL DAC 50
3
EXCL
ZODRYL DAC 60
3
EXCL
TUSSICAPS
3
MO; EXCL
ZODRYL DAC 80
3
EXCL
tussigon
1
MO; EXCL
ZODRYL DEC 25
3
EXCL
TUSSIONEX PENNKINETIC ER
3
MO; EXCL
ZODRYL DEC 30
3
EXCL
TUZISTRA XR
3
MO; EXCL
ZODRYL DEC 35
3
EXCL
MO; EXCL MO; EXCL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 121
Drug Name
Drug Tier
Requirements /Limits
Drug Name albuterol sulfate oral tablet extended release 12 hr
4
MO
ALVESCO INHALATION HFA AEROSOL INHALER 160 MCG/ACTUATION
4
MO; QL (12.2 per 30 days)
ALVESCO INHALATION HFA AEROSOL INHALER 80 MCG/ACTUATION
4
MO; QL (6.1 per 30 days)
aminophylline intravenous
2
ANORO ELLIPTA
3
MO; QL (60 per 30 days)
ARCAPTA NEOHALER
3
MO; QL (30 per 30 days)
ARMONAIR RESPICLICK
4
MO; QL (60 per 30 days)
ARNUITY ELLIPTA
3
MO; QL (30 per 30 days)
ASMANEX HFA
3
MO; QL (13 per 30 days)
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)
3
MO; QL (1 per 30 days)
ZODRYL DEC 40
3
EXCL
ZODRYL DEC 50
3
EXCL
ZODRYL DEC 60
3
EXCL
ZODRYL DEC 80
3
EXCL
Z-TUSS AC
3
MO; EXCL
ZYRTEC ORAL CAPSULE
1
MO; EXCL
ZYRTEC ORAL TABLET
1
MO; EXCL
ZYRTEC ORAL TABLET,DISINTE GRATING
1
MO; EXCL
ZYRTEC-D
1
MO; EXCL
PULMONARY AGENTS ACCOLATE
4
MO
acetylcysteine
2
B/D PA; EXCL; MO
ADCIRCA
5
PA; MO; QL (60 per 30 days)
ADEMPAS
5
PA; MO; LA
ADVAIR DISKUS
3
MO; QL (60 per 30 days)
ADVAIR HFA
3
MO; QL (12 per 30 days)
AEROSPAN
3
MO; QL (17.8 per 30 days)
AIRDUO RESPICLICK
4
MO; QL (60 per 30 days)
albuterol sulfate inhalation solution for nebulization
2
B/D PA; EXCL; MO
albuterol sulfate oral syrup
2
MO
albuterol sulfate oral tablet
4
MO
Drug Tier
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 122
Drug Name
Drug Tier
Requirements /Limits
Drug Name
QL (4 per 28 days)
cromolyn inhalation
2
B/D PA; EXCL; MO
DALIRESP
4
PA; MO
DULERA
3
MO; QL (13 per 30 days)
DYMISTA
3
MO; QL (23 per 30 days)
ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML
4
MO
ESBRIET ORAL CAPSULE
5
PA; MO; QL (270 per 30 days)
ESBRIET ORAL TABLET 267 MG
5
PA; MO; QL (270 per 30 days)
ESBRIET ORAL TABLET 801 MG
5
PA; MO; QL (90 per 30 days)
FASENRA
5
PA; MO
FIRAZYR
5
PA; MO
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION , 50 MCG/ACTUATION
3
MO; QL (60 per 30 days)
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION
3
MO; QL (240 per 30 days)
FLOVENT HFA AEROSOL INHALER 110 MCG/ACTUATION
3
MO; QL (12 per 30 days)
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES)
3
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (120 DOSES)
3
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (14 DOSES)
3
ATROVENT HFA
3
MO; QL (25.8 per 30 days)
BECONASE AQ
4
MO; QL (50 per 30 days)
BERINERT INTRAVENOUS KIT
5
PA; MO
BEVESPI AEROSPHERE
3
MO; QL (10.7 per 30 days)
BREO ELLIPTA
3
MO; QL (60 per 30 days)
BROVANA
4
B/D PA; EXCL; MO
budesonide inhalation
2
B/D PA; EXCL; MO
CINRYZE
5
PA; MO
COMBIVENT RESPIMAT
3
MO; QL (8 per 30 days)
MO; QL (2 per 30 days)
QL (2 per 28 days)
Drug Tier
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 123
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
LONHALA MAGNAIR STARTER
5
MO; QL (60 per 30 days)
metaproterenol
2
MO
mometasone nasal
2
MO; QL (34 per 30 days)
montelukast
2
MO
NASONEX
4
MO; QL (34 per 30 days)
NUCALA
5
PA; MO; LA; QL (1 per 28 days)
OFEV
5
PA; MO; QL (60 per 30 days)
OMNARIS
4
MO; QL (12.5 per 30 days)
OPSUMIT
5
PA; MO; LA
ORKAMBI
5
PA; MO; QL (112 per 28 days)
PERFOROMIST
3
B/D PA; EXCL; MO
PROAIR HFA
3
MO; QL (17 per 30 days)
PROAIR RESPICLICK
3
MO; QL (2 per 30 days)
PROVENTIL HFA
4
MO; QL (13.4 per 30 days)
PULMICORT
4
B/D PA; EXCL; MO
PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION
3
MO; QL (2 per 30 days)
FLOVENT HFA AEROSOL INHALER 220 MCG/ACTUATION
3
MO; QL (24 per 30 days)
FLOVENT HFA AEROSOL INHALER 44 MCG/ACTUATION
3
MO; QL (10.6 per 30 days)
flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)
2
fluticasone nasal
2
MO; QL (16 per 30 days)
FLUTICASONESALMETEROL
4
MO; QL (60 per 30 days)
HAEGARDA
5
PA; MO; LA
INCRUSE ELLIPTA
4
ST; MO; QL (30 per 30 days)
MO; QL (50 per 30 days)
ipratropium bromide inhalation
2
B/D PA; EXCL; MO
ipratropiumalbuterol
2
B/D PA; EXCL; MO
KALBITOR
5
MO
KALYDECO ORAL GRANULES IN PACKET
5
PA; MO; QL (56 per 28 days)
KALYDECO ORAL TABLET
5
LETAIRIS
5
PA; MO; LA
levalbuterol hcl
2
B/D PA; EXCL; MO
PA; MO; QL (60 per 30 days)
LEVALBUTEROL TARTRATE
4
MO; QL (30 per 30 days)
LONHALA MAGNAIR REFILL
5
QL (60 per 30 days)
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 124
Drug Name
Drug Tier
Requirements /Limits
Drug Name
PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION
3
MO; QL (1 per 30 days)
sildenafil (pulmonary arterial hypertension) intravenous solution 10 mg/12.5 ml
5
PA
2
PULMOZYME
5
B/D PA; EXCL; MO
sildenafil (pulmonary arterial hypertension) oral tablet 20 mg
PA; MO; QL (90 per 30 days)
QNASL NASAL HFA AEROSOL INHALER 40 MCG/ACTUATION
3
MO; QL (4.9 per 30 days)
SINGULAIR
4
MO
SPIRIVA RESPIMAT
3
MO; QL (4 per 30 days)
QNASL NASAL HFA AEROSOL INHALER 80 MCG/ACTUATION
3
SPIRIVA WITH HANDIHALER
3
MO; QL (90 per 90 days)
STIOLTO RESPIMAT
3
MO; QL (4 per 30 days)
QVAR
3
MO; QL (17.4 per 30 days)
STRIVERDI RESPIMAT
3
MO; QL (4 per 30 days)
QVAR REDIHALER
3
MO
SYMBICORT
3
MO; QL (10.2 per 30 days)
REVATIO INTRAVENOUS
5
PA; MO
SYMDEKO
5
REVATIO ORAL SUSPENSION FOR RECONSTITUTIO N
5
PA; MO; QL (224 per 30 days)
PA; MO; QL (56 per 28 days)
terbutaline
2
MO
THEO-24
3
MO
REVATIO ORAL TABLET
5
PA; MO; QL (90 per 30 days)
2
RUCONEST
5
PA; MO
SEEBRI NEOHALER
4
ST; MO; QL (60 per 30 days)
theophylline in dextrose 5 % intravenous parenteral solution 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml
SEREVENT DISKUS
3
MO; QL (60 per 30 days)
theophylline oral elixir
2
theophylline oral solution
2
MO; QL (8.7 per 30 days)
Drug Tier
Requirements /Limits
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 125
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
XOPENEX INHALATION SOLUTION FOR NEBULIZATION 0.31 MG/3 ML
4
B/D PA; EXCL
XOPENEX INHALATION SOLUTION FOR NEBULIZATION 0.63 MG/3 ML, 1.25 MG/3 ML
4
B/D PA; EXCL; MO
zafirlukast
2
MO
theophylline oral tablet extended release 12 hr
2
MO
theophylline oral tablet extended release 24 hr
2
MO
TRACLEER
5
PA; MO; LA
TRELEGY ELLIPTA
3
MO; QL (60 per 30 days)
triamcinolone acetonide nasal
2
MO; QL (16.5 per 30 days)
TUDORZA PRESSAIR
3
MO; QL (1 per 30 days)
ZETONNA
4
MO; QL (6.1 per 30 days)
TYVASO
5
B/D PA; EXCL; MO
zileuton
5
MO
ZYFLO
5
MO
B/D PA; EXCL
ZYFLO CR
5
MO
TYVASO INSTITUTIONAL START KIT
5
TYVASO REFILL KIT
5
B/D PA; EXCL; MO
ANTICHOLINERGICS / ANTISPASMODICS
TYVASO STARTER KIT
5
B/D PA; EXCL; MO
darifenacin
2
MO
UTIBRON NEOHALER
4
MO; QL (60 per 30 days)
DETROL
4
MO
DETROL LA
4
MO
VENTAVIS
5
B/D PA; EXCL; MO
DITROPAN XL
4
MO
ENABLEX
4
MO
VENTOLIN HFA
3
MO; QL (36 per 30 days)
flavoxate
2
MO
XOLAIR
5
PA; MO; LA; QL (6 per 28 days)
GELNIQUE TRANSDERMAL GEL IN PACKET
4
MO; QL (30 per 30 days)
XOPENEX CONCENTRATE
4
B/D PA; EXCL; MO
MYRBETRIQ
3
MO
oxybutynin chloride
2
MO
XOPENEX HFA
4
OXYTROL
4
MO; QL (8 per 28 days)
tolterodine
2
MO
TOVIAZ
3
MO
UROLOGICALS
MO; QL (30 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 126
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
trospium
2
MO
glycine urologic
2
VESICARE
3
MO
glycine urologic solution
2
K-PHOS NO 2
3
MO
K-PHOS ORIGINAL
3
MO
LEVITRA
3
MO; EXCL
MUSE
3
MO; EXCL
PAPAVPHENTOLAMALPROST-WATER
3
EXCL
3
EXCL
BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin
2
MO
AVODART
4
MO
dutasteride
2
MO
dutasteridetamsulosin
2
MO
finasteride oral tablet 5 mg
2
MO
FLOMAX
4
ST; MO
JALYN
4
MO
PAPAVPHENTOLAMINE IN WATER
PROSCAR
4
MO
potassium citrate
2
MO
RAPAFLO
3
ST; MO
PROCYSBI
5
MO
tamsulosin
1
MO
3
MO
UROXATRAL
4
ST; MO
RENACIDIN IRRIGATION SOLUTION 6.6023.268 GRAM/100 ML sildenafil
1
MO; EXCL
STAXYN
3
MO; EXCL
STENDRA
3
MO; EXCL
UROCIT-K 10
4
MO
UROCIT-K 15
4
MO
UROCIT-K 5
4
MO
VIAGRA
3
MO; EXCL
CHOLINERGIC STIMULANTS bethanechol chloride
2
MO
URECHOLINE
4
MO
MISCELLANEOUS UROLOGICALS alprostadil
2
MO
CAVERJECT
3
MO; EXCL
CAVERJECT IMPULSE
3
MO; EXCL
CIALIS ORAL TABLET 10 MG, 20 MG
3
CIALIS ORAL TABLET 2.5 MG, 5 MG
3
PA; MO; QL (30 per 30 days)
CYSTAGON
3
MO; LA
EDEX
3
MO; EXCL
ELMIRON
3
MO
MO; EXCL
URINARY ANESTHETICS phenazopyridine oral tablet 100 mg, 200 mg
1
MO; EXCL
PYRIDIUM
3
MO; EXCL
VITAMINS, HEMATINICS / ELECTROLYTES
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 127
Drug Name
Drug Tier
Requirements /Limits
2
albuminar 25 %
2
albuminar 5 %
2
alburx (human) 25 %
2
alburx (human) 5 %
2
albutein 25 %
2
albutein 5 %
2
buminate 5 %
2
plasbumin 25 %
2
plasbumin 5 %
2
Drug Tier
Requirements /Limits
calcium acetate oral tablet 667 mg
2
MO
calcium carb and citrate-vitd3
1
EXCL
1
MO; EXCL
MO
calcium carbonatevitamin d3 oral capsule 600 mg(1,500mg) -400 unit
1
MO; EXCL
MO
calcium carbonatevitamin d3 oral tablet 250-125 mgunit, 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit calcium carbonatevitamin d3 oral tablet 500 mg(1,250mg) -125 unit, 500mg (1,250mg) -600 unit
1
EXCL
calcium carbonatevitamin d3 oral tablet,chewable
1
MO; EXCL
calcium chloride
2
calcium citrate + d
1
EXCL
calcium citratevitamin d2
1
EXCL
calcium citratevitamin d3 oral tablet 200 mg calcium -250 unit, 200-125 mg-unit, 250 mg calcium- 200 unit
1
EXCL
BLOOD DERIVATIVES albumin, human 25 %
Drug Name
MO
ELECTROLYTES calcium 500 + d (d3)
1
EXCL
calcium 500 + d oral tablet 500 mg(1,250mg) -200 unit
1
MO; EXCL
calcium 500 with d
1
MO; EXCL
calcium 600 + d(3) oral capsule
1
MO; EXCL
calcium 600 + d(3) oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit
1
MO; EXCL
calcium 600 with vitamin d3 oral capsule
1
EXCL
calcium 600 with vitamin d3 oral tablet,chewable
1
MO; EXCL
calcium acetate oral capsule
2
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 128
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
MO; EXCL
lactated ringers intravenous
2
MO
magnesium chloride injection
2
MO
MAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/100 ML
3
calcium citratevitamin d3 oral tablet 315-200 mgunit, 315-250 mgunit
1
calcium gluconate intravenous
2
MO
calcium with vitamin d
1
EXCL
citrus calcium oral tablet 200 mg calcium -250 unit
1
EXCL
magnesium sulfate in water intravenous parenteral solution
2
citrus calcium oral tablet 315-250 mgunit
1
MO; EXCL
2
effer-k oral tablet, effervescent 25 meq
1
MO
magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/50 ml (8 %)
eliphos
2
MO
2
MO
hi-cal plus vit d
1
EXCL
k-effervescent
1
MO
magnesium sulfate in water intravenous piggyback 4 gram/100 ml (4 %)
klor-con
1
MO
magnesium sulfate injection solution
2
MO
klor-con 10
1
MO
1
MO
magnesium sulfate injection syringe
2
klor-con 8 klor-con m10
1
MO
NORMOSOL-R
3
klor-con m15
1
MO
3
klor-con m20
1
MO
NORMOSOL-R IN 5 % DEXTROSE
klor-con sprinkle
2
MO
1
MO; EXCL
klor-con/ef
1
MO
oysco 500/d oral tablet
K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ
4
MO
oyster shell + d3
1
EXCL
oyster shell calciumvit d3
1
MO; EXCL
oystercal-d
1
EXCL
PHOSLYRA
4
MO
k-tab oral tablet extended release 8 meq
2
POTABA ORAL CAPSULE
3
MO; EXCL
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 129
Drug Name
Drug Tier
Requirements /Limits
potassium acetate intravenous solution 2 meq/ml
2
potassium bicarb and chloride
1
MO
potassium bicarbcitric acid
1
MO
potassium chloridd5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l
2
potassium chloridd5-0.45%nacl intravenous parenteral solution 20 meq/l
2
potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l
2
potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l
2
potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l
2
potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l
2
MO
MO
Drug Name
Drug Tier
Requirements /Limits
potassium chloride in water intravenous piggyback 10 meq/100 ml, 10 meq/50 ml
2
MO
potassium chloride in water intravenous piggyback 20 meq/100 ml, 20 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml
2
potassium chloride intravenous
2
MO
potassium chloride oral capsule, extended release
1
MO
potassium chloride oral liquid
2
MO
potassium chloride oral packet
1
MO
potassium chloride oral tablet extended release
1
MO
potassium chloride oral tablet,er particles/crystals
1
MO
potassium chloride0.45 % nacl
2
potassium chlorided5-0.2%nacl intravenous parenteral solution 20 meq/l
2
potassium chlorided5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l
2
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 130
Drug Name
Drug Tier
Requirements /Limits
potassium chlorided5-0.3%nacl intravenous parenteral solution 20 meq/l
2
potassium chlorided5-0.9%nacl intravenous parenteral solution 20 meq/l
2
potassium chlorided5-0.9%nacl intravenous parenteral solution 40 meq/l
2
potassium phosphate m-/d-basic
2
ringer's intravenous
2
sodium acetate
2
sodium bicarbonate intravenous solution
2
MO
sodium bicarbonate intravenous syringe 10 meq/10 ml (8.4 %), 7.5 % (0.9 meq/ml)
2
MO
sodium bicarbonate intravenous syringe 4.2 % (0.5 meq/ml), 8.4 % (1 meq/ml)
2
sodium chloride 0.45 % intravenous parenteral solution
2
sodium chloride 0.45 % intravenous piggyback
2
sodium chloride 3 %
2
sodium chloride 5 %
2
MO
Drug Name
Drug Tier
sodium chloride intravenous
2
sodium lactate intravenous
2
sodium phosphate
2
TPN ELECTROLYTES
4
Requirements /Limits MO
MO
MISCELLANEOUS NUTRITION PRODUCTS
MO
MO
MO
AMINOSYN 10 %
3
B/D PA; EXCL
AMINOSYN 7 % WITH ELECTROLYTES
3
B/D PA; EXCL
AMINOSYN 8.5 %
3
B/D PA; EXCL
AMINOSYN 8.5 %ELECTROLYTES
3
B/D PA; EXCL
AMINOSYN II 10 %
3
B/D PA; EXCL
AMINOSYN II 15 %
3
B/D PA; EXCL
AMINOSYN II 7 %
3
B/D PA; EXCL
AMINOSYN II 8.5 %
3
B/D PA; EXCL
AMINOSYN II 8.5 %ELECTROLYTES
3
B/D PA; EXCL
AMINOSYN M 3.5 %
3
B/D PA; EXCL
AMINOSYN-HBC 7%
3
B/D PA; EXCL
AMINOSYN-PF 10 %
3
B/D PA; EXCL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 131
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
AMINOSYN-PF 7 % (SULFITEFREE)
3
B/D PA; EXCL
CLINIMIX E 5%/D25W SULFIT FREE
4
B/D PA; EXCL
AMINOSYN-RF 5.2 %
3
B/D PA; EXCL
CLINISOL SF 15 %
4
B/D PA; EXCL; MO
CLINIMIX 5%/D15W SULFITE FREE
3
B/D PA; EXCL
cysteine (l-cysteine) intravenous solution
2
B/D PA; EXCL
electrolyte-48 in d5w
2
CLINIMIX 5%/D25W SULFITE-FREE
3
B/D PA; EXCL
FORTAVIT
3
EXCL
4
CLINIMIX 2.75%/D5W SULFIT FREE
3
FREAMINE HBC 6.9 %
B/D PA; EXCL
freamine iii 10 %
2
B/D PA; EXCL
CLINIMIX 4.25%/D10W SULF FREE
3
HEPATAMINE 8%
3
B/D PA; EXCL
2
CLINIMIX 4.25%D20W SULF-FREE
3
B/D PA; EXCL
hetastarch 6 % in 0.9 % nacl
3
B/D PA; EXCL
intralipid intravenous emulsion 20 %
2
CLINIMIX 4.25%D25W SULF-FREE
B/D PA; EXCL
CLINIMIX 5%D20W(SULFITEFREE)
3
B/D PA; EXCL
INTRALIPID INTRAVENOUS EMULSION 30 %
4
B/D PA; EXCL
CLINIMIX E 4.25%/D10W SUL FREE
4
B/D PA; EXCL
IONOSOL-B IN D5W
3 3
CLINIMIX E 4.25%/D25W SUL FREE
4
IONOSOL-MB IN D5W ISOLYTE S PH 7.4
3
CLINIMIX E 4.25%/D5W SULF FREE
4
ISOLYTE-P IN 5 % DEXTROSE
3
ISOLYTE-S
3
CLINIMIX E 5%/D15W SULFIT FREE
4
NEPHRAMINE 5.4 %
3 4
CLINIMIX E 5%/D20W SULFIT FREE
4
NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH 7.4
3
B/D PA; EXCL B/D PA; EXCL
B/D PA; EXCL B/D PA; EXCL B/D PA; EXCL B/D PA; EXCL
B/D PA; EXCL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 132
Drug Name
Drug Tier
Requirements /Limits
Drug Name
B/D PA; EXCL
b complex-vitamin cfolic acid
1
MO; EXCL
b-100 complex oral tablet extended release
1
EXCL
B-12 COMPLIANCE
3
MO; EXCL
BACMIN
3
MO; EXCL
balance b-100
1
EXCL
balance b-50
1
MO; EXCL
balanced b-100 complex oral tablet extended release 100 mg
1
MO; EXCL
balanced b-100 oral tablet 0.4 mg
1
EXCL
balanced b-50 oral tablet
1
EXCL
b-complex with vitamin c oral tablet
1
MO; EXCL
b-complex with vitamin c oral tablet 400-500 mcg-mg
1
EXCL
BIFERA RX
3
MO; EXCL
CARDIOTEK-RX (BIOPERINE)
3
MO; EXCL
centratex
1
MO; EXCL
cholecalciferol (vitamin d3) oral capsule 1,000 unit
1
MO; EXCL
cholecalciferol (vitamin d3) oral capsule 400 unit
1
EXCL
cholecalciferol (vitamin d3) oral drops 400 unit/ml
1
MO; EXCL
NUTRILIPID
4
PLASMA-LYTE 148
3
PLASMA-LYTE A
3
plasmanate
2
plenamine
2
B/D PA; EXCL
premasol 10 %
2
B/D PA; EXCL; MO
PREMASOL 6 %
3
B/D PA; EXCL
PROCALAMINE 3%
4
B/D PA; EXCL
PROSOL 20 %
4
B/D PA; EXCL; MO
travasol 10 %
4
B/D PA; EXCL; MO
TROPHAMINE 10 %
3
B/D PA; EXCL; MO
TROPHAMINE 6%
3
B/D PA; EXCL
VITAMINS / HEMATINICS ACTIVE FE
3
MO; EXCL
ANIMI-3 WITH VITAMIN D
3
MO; EXCL
AQUASOL A
3
MO; EXCL
ASCOR
3
EXCL
ascorbic acid (vitamin c) injection
1
MO; EXCL
b complex 1
1
MO; EXCL
b complex 100 injection
1
MO; EXCL
b complex 100 oral
1
EXCL
b complex-vitamin b12
1
MO; EXCL
Drug Tier
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 133
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
MO; EXCL
DIALYVITE 800 WITH IRON
3
MO; EXCL
DIALYVITE SUPREME D
3
MO; EXCL
DRISDOL ORAL CAPSULE
3
EXCL
DURACHOL
3
MO; EXCL
d-vi-sol
1
MO; EXCL
ENLYTE
3
MO; EXCL
1
MO; EXCL
cholecalciferol (vitamin d3) oral tablet 1,000 unit
1
cholecalciferol (vitamin d3) oral tablet 400 unit
1
cholecalciferol (vitamin d3) oral tablet,chewable 1,000 unit
1
ciferex
1
MO; EXCL
complex b-100 oral tablet extended release
1
MO; EXCL
ergocalciferol (vitamin d2) oral capsule
1
MO; EXCL
corvita
1
MO; EXCL
corvita 150
1
MO; EXCL
ergocalciferol (vitamin d2) oral tablet 400 unit
CORVITE
3
MO; EXCL
FERAHEME
3
MO; EXCL
CORVITE 150 ORAL TABLET 150 MG IRON- 1 MG
3
MO; EXCL
FERIVA 21-7 TABLET
3
MO; EXCL
FERIVA FA (SUMALATE)
3
MO; EXCL
CORVITE FE ORAL TABLET 150 MG IRON- 1 MG
3
ferocon
1
MO; EXCL
FERRALET 90 DUAL-IRON DELIVERY
3
MO; EXCL
CORVITE FREE
3
MO; EXCL
ferraplus 90
1
MO; EXCL
cyanocobalamin (vitamin b-12) injection
1
MO; EXCL
ferrex 150 forte
1
MO; EXCL
ferrex 150 forte plus
1
MO; EXCL
delta d3
1
MO; EXCL
ferrex 28
1
MO; EXCL
DERMACINRX PUREFOLIX
3
MO; EXCL
ferrocite plus
1
MO; EXCL
2
MO
dialyvite
1
MO; EXCL
fluoride (sodium) oral drops
DIALYVITE 3000
3
MO; EXCL
4
MO
DIALYVITE 5000
3
MO; EXCL
FLUORIDE (SODIUM) ORAL TABLET
dialyvite 800
1
MO; EXCL
EXCL
EXCL
MO; EXCL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 134
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
MO; EXCL
hematogen fa
1
MO; EXCL
hematogen forte
1
MO; EXCL
HEMATRON-AF
3
MO; EXCL
HEMAX
1
EXCL
hemetab
1
MO; EXCL
HEMOCYTE-F
3
MO; EXCL
HEMOCYTE-PLUS
3
MO; EXCL
hydroxocobalamin
1
MO; EXCL
ICAR-C PLUS
3
MO; EXCL
iferex 150 forte
1
MO; EXCL
infed
1
MO; EXCL
INFUVITE ADULT
3
MO; EXCL
fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)
1
fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)
2
folbee
1
MO; EXCL
folbee plus
1
MO; EXCL
folbic
1
MO; EXCL
FOLGARD RX
3
MO; EXCL
folic acid injection
1
MO; EXCL
folic acid oral tablet
1
MO; EXCL
INFUVITE PEDIATRIC
3
MO; EXCL
folic acid-vit b6-vit b12 oral tablet 2.225-0.5 mg
1
MO; EXCL
INJECTAFER
3
MO; EXCL
INTEGRA F
3
MO; EXCL
FOLIKA-D
3
EXCL
INTEGRA PLUS
3
MO; EXCL
folivane-f
1
MO; EXCL
IROSPAN 24/6
3
MO; EXCL
folivane-plus
1
MO; EXCL
kobee
1
EXCL
FOLIXAPURE
3
EXCL
2
MO
folplex 2.2
1
MO; EXCL
foltabs 800
1
MO; EXCL
FOLTRATE
3
MO; EXCL
ludent fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)
full spectrum bvitamin c
1
EXCL
m.v.i. adult
1
EXCL
FUSION PLUS
3
MO; EXCL
M.V.I. PEDIATRIC
3
EXCL
FUSION SPRINKLES
3
MO; EXCL
MACUVEX
3
MO; EXCL
MACUZIN
3
EXCL
hematinic plus vit/minerals
1
MO; EXCL
MAXFE (FOLATEDOCUSATE)
3
MO; EXCL
hematinic/folic acid
1
MO; EXCL
MEBOLIC
3
MO; EXCL
hematogen
1
MO; EXCL
METHAVER
3
EXCL
MO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 135
Drug Name
Drug Tier
multigen folic
Requirements /Limits
Drug Name
1
MO; EXCL
3
MO; EXCL
multigen plus
1
MO; EXCL
NICOMIDE (SELENIUMCHROMIUM)
multi-vit with fluoride-iron
2
MO
NIVA-FOL
3
MO; EXCL
multivitamin with fluoride
2
MO
NOXIFOL-D3
3
EXCL
NUFERA
3
MO; EXCL
multi-vitamin with fluoride oral drops 0.25 mg/ml
2
NUTRICAP
3
EXCL
OMNIVEX
3
EXCL
MULTI-VITAMIN WITH FLUORIDE ORAL DROPS 0.5 MG/ML
3
ortho d
1
MO; EXCL
ORTHO DF
3
EXCL
1
EXCL
multi-vitamin with fluoride oral tablet,chewable
1
oyster shell calciumvit d2 oral tablet 250 (625)-125 mg-unit PHYSICIANS EZ USE B-12
3
MO; EXCL
multivitamins with fluoride
2
MO
poly-iron 150 forte
1
MO; EXCL
multivit-fluor (vit e acetate)
2
MO
PRENATAL VITAMIN ORAL TABLET
4
MO
mvc-fluoride
2
MO
3
MO; EXCL
myferon 150 forte
1
MO; EXCL
PROFERRINFORTE
mynephrocaps
1
MO; EXCL
PROTECT IRON
3
EXCL
mynephron
1
EXCL
PURALOR CI
3
MO; EXCL
NASCOBAL
3
MO; EXCL
purevit dualfe plus
1
MO; EXCL
natural b-100 complex
1
EXCL
pyridoxine (vitamin b6) injection
1
MO; EXCL
nephplex rx
1
MO; EXCL
QUFLORA
3
MO; EXCL
NEPHROCAPS
3
MO; EXCL
QUFLORA FE
3
MO; EXCL
NEPHROCAPS QT
3
MO; EXCL
renal caps
1
MO; EXCL
NEPHRON FA
3
MO; EXCL
rena-vite
1
MO; EXCL
nephro-vite rx
1
MO; EXCL
rena-vite rx
1
MO; EXCL
NEURIN-SL
3
MO; EXCL
reno caps
1
MO; EXCL
NICOMIDE
3
MO; EXCL
REQ49+
3
MO; EXCL
REVESTA
3
EXCL
MO
MO; EXCL
MO; EXCL
Drug Tier
Requirements /Limits
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 136
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
3
EXCL
risacal-d
1
MO; EXCL
ROXIFOL-D
3
EXCL
se-tan plus
1
MO; EXCL
TRIFERIC HEMODIALYSIS POWDER IN PACKET
stress formula
1
EXCL
trigels-f forte
1
MO; EXCL
stress formula 600 c
1
EXCL
triphrocaps
1
MO; EXCL
stress formula with iron
1
MO; EXCL
tri-vit with fluoride and iron
2
MO
stress formula with iron(sulf)
1
EXCL
tri-vitamin with fluoride
2
MO
STROVITE FORTE
3
MO; EXCL
UDAMIN SP
3
MO; EXCL
STROVITE ONE
3
MO; EXCL
1
EXCL
super b complexvitamin c
1
EXCL
ultra b-100 complex oral tablet v-c forte
1
MO; EXCL
super b maxi complex
1
EXCL
3
MO; EXCL
super b-50 complex plus
1
EXCL
super quints
1
EXCL
VENOFER INTRAVENOUS SOLUTION 100 MG IRON/5 ML, 200 MG IRON/10 ML
super quints b-50
1
EXCL
3
EXCL
superplex-t
1
EXCL
SUPERVITE
3
EXCL
VENOFER INTRAVENOUS SOLUTION 50 MG IRON/2.5 ML
TANDEM PLUS
3
MO; EXCL
vic-forte
1
EXCL
taron forte
1
MO; EXCL
VIRT-CAPS
3
MO; EXCL
thiamine hcl (vitamin b1) injection
1
MO; EXCL
virt-gard
1
MO; EXCL
virt-vite
1
MO; EXCL
tl gard rx
1
MO; EXCL
VIRT-VITE PLUS
3
MO; EXCL
tl icon
1
MO; EXCL
vit 3
1
MO; EXCL
tl-hem 150 oral tablet extended release 24 hr
1
MO; EXCL
vit b complex-folic acid oral tablet
1
EXCL
VITAFOL
3
MO; EXCL
total b/c
1
EXCL
vitajoy daily d
1
EXCL
tricon
1
MO; EXCL
VITAL-D RX
3
MO; EXCL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 137
Drug Name
Drug Tier
Requirements /Limits
Drug Name
Drug Tier
Requirements /Limits
vitamin b complex oral tablet
1
EXCL
vitamins a,c,d and fluoride
2
vitamin d2
1
MO; EXCL
1
EXCL
vitamin d3 oral capsule 1,000 unit, 400 unit
1
MO; EXCL
vitamins b complex oral tablet VITA-RESPA
3
MO; EXCL
vol-care rx
1
MO; EXCL
vitamin d3 oral tablet 1,000 unit, 400 unit
1
vp-vite rx
1
MO; EXCL
XYZBAC
3
MO; EXCL
vitamin d3 oral tablet,chewable
1
zavara
1
EXCL
ZYVIT
3
EXCL
MO; EXCL
MO; EXCL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 138
Index 2 24hour allergy .................... 117 A abacavir .................................. 3 abacavir-lamivudine ............... 3 abacavir-lamivudinezidovudine .......................... 3 ABELCET .............................. 2 ABILIFY .............................. 44 ABILIFY MAINTENA ........ 44 ABRAXANE........................ 16 ABSORICA.......................... 69 ABSTRAL............................ 35 acamprosate .......................... 75 ACANYA ............................. 69 acarbose ................................ 81 ACCOLATE....................... 122 ACCU-CHEK AVIVA PLUS TEST STRP ...................... 81 ACCU-CHEK COMPACT PLUS TEST ..................... 81 ACCU-CHEK GUIDE ......... 81 ACCU-CHEK SMARTVIEW TEST STRIP .................... 81 ACCUPRIL .......................... 57 ACCURETIC ....................... 57 ACCUTREND GLUCOSE .. 81 acebutolol ............................. 57 acetaminophen-caffdihydrocod........................ 35 acetaminophen-codeine ........ 36 acetazolamide ..................... 115 acetazolamide sodium ........ 115 acetic acid ....................... 75, 79 acetylcysteine ............... 75, 122 acid reducer (omeprazole) .... 97 ACIPHEX ............................ 97 ACIPHEX SPRINKLE ........ 97 acitretin ................................. 67 ACTEMRA ........................ 106 ACTHAR H.P. ..................... 79 ACTHIB (PF) ..................... 102 ACTIGALL .......................... 91 ACTIMMUNE ..................... 99 ACTIQ.................................. 36 ACTIVE FE ....................... 133
ACTIVELLA...................... 108 ACTONEL ................... 75, 105 ACTOPLUS MET ................ 81 ACTOPLUS MET XR ......... 81 ACTOS ................................. 81 ACULAR............................ 115 ACULAR LS ...................... 115 ACUVAIL (PF) .................. 115 acyclovir ........................... 3, 72 acyclovir sodium .................... 3 ACZONE .............................. 69 ADACEL(TDAP ADOLESN/ADULT)(PF) ........................................ 102 ADAGEN ............................. 75 ADALAT CC ....................... 58 adapalene .............................. 69 adapalene-benzoyl peroxide . 69 ADASUVE ........................... 44 ADCIRCA .......................... 122 ADDERALL ........................ 44 ADDERALL XR .................. 44 adefovir................................... 3 ADEMPAS ......................... 122 adenosine .............................. 57 ADIPEX-P ............................ 75 ADLYXIN ............................ 81 ADMELOG SOLOSTAR U100 INSULIN ................... 81 ADMELOG U-100 INSULIN LISPRO ............................ 81 adrenalin ............................. 117 adriamycin ............................ 16 adrucil ................................... 16 adult aspirin regimen ............ 41 adult low dose aspirin ........... 41 ADVAIR DISKUS ............. 122 ADVAIR HFA ................... 122 ADZENYS ER ..................... 44 ADZENYS XR-ODT ........... 44 AEROSPAN ....................... 122 afeditab cr ............................. 58 AFINITOR ........................... 16 AFINITOR DISPERZ .......... 16 AFLURIA 2017-2018 ........ 102 AFLURIA 2017-2018 (PF) 102
AFLURIA QUAD 2017-2018 ........................................ 102 AFLURIA QUAD 2017-2018 (PF) ................................. 102 AFREZZA ............................ 81 AFTERA............................. 110 AGGRENOX ........................ 63 AGRYLIN ............................ 75 a-hydrocort ...........................80 AIRDUO RESPICLICK .....122 AKTIPAK............................. 69 ala-cort .................................. 72 ALA-SCALP ........................ 72 alavert .................................117 alavert d-12 allergy-sinus ... 117 ALBENZA ............................. 9 albumin, human 25 % ......... 128 albuminar 25 %................... 128 albuminar 5 %..................... 128 alburx (human) 25 % .......... 128 alburx (human) 5 % ............ 128 albutein 25 % ...................... 128 albutein 5 % ........................ 128 albuterol sulfate .................. 122 alclometasone ....................... 72 ALCOHOL PADS ................82 ALDACTAZIDE ..................58 ALDACTONE ...................... 58 ALDARA ............................. 68 ALDURAZYME ..................88 ALECENSA .........................17 alendronate ...........75, 105, 106 alfuzosin .............................127 ALIMTA...............................17 ALINIA .................................. 9 ALIQOPA............................. 17 ALKERAN ........................... 17 all day allergy (cetirizine) ...117 all day allergy relief(cetir) .. 117 all day allergy-d .................. 117 ALLEGRA ALLERGY ......117 ALLEGRA-D 12 HOUR ....117 ALLEGRA-D 24 HOUR ....117 allerclear ............................. 117 allerclear d-12hr.................. 117 allerclear d-24hr.................. 117
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 139
aller-ease............................. 117 aller-fex .............................. 117 allergy and congestion relief ........................................ 117 allergy complete-d .............. 117 allergy d-12 ........................ 117 allergy relief (cetirizine) ..... 117 allergy relief (fexofenadine) ........................................ 117 allergy relief (loratadine).... 117 allergy relief d12 ................ 117 allergy relief d-24 ............... 117 allergy relief,nasal decongest ........................................ 117 allergy relief-d (cetirizine) . 117 allergy relief-d (loratadine) 117 allergy relief-d(fexofenadine) ........................................ 118 allergy-congest relief-d (cet) ........................................ 118 allergy-congestion relief-d . 118 aller-tec ............................... 118 aller-tec d ............................ 118 allopurinol .......................... 105 allopurinol sodium.............. 105 almotriptan malate ................ 32 ALOCRIL .......................... 115 ALOGLIPTIN ...................... 82 ALOGLIPTIN-METFORMIN .......................................... 82 ALOGLIPTINPIOGLITAZONE ............. 82 ALOMIDE ......................... 115 alophen ................................. 91 aloprim ............................... 105 ALORA .............................. 108 alosetron ............................... 91 ALOXI ................................. 91 ALPHAGAN P................... 117 alprostadil ........................... 127 ALREX .............................. 116 ALTACE .............................. 58 altavera (28)........................ 110 ALTOPREV ......................... 64 ALUNBRIG ......................... 17 ALVESCO ......................... 122 alyacen 1/35 (28) ................ 110 alyacen 7/7/7 (28) ............... 110
amabelz ............................... 108 amantadine hcl ........................ 3 AMARYL............................. 82 AMBIEN .............................. 44 AMBIEN CR ........................ 45 AMBISOME .......................... 2 amcinonide ..................... 72, 73 AMERGE ............................. 32 amethia ............................... 110 amethia lo ........................... 110 amethyst.............................. 110 AMICAR .............................. 63 amifostine crystalline ........... 16 amikacin ................................. 9 amiloride ............................... 58 amiloride-hydrochlorothiazide .......................................... 58 aminocaproic acid................. 63 aminophylline ..................... 122 AMINOSYN 10 % ............. 131 AMINOSYN 7 % WITH ELECTROLYTES.......... 131 AMINOSYN 8.5 % ............ 131 AMINOSYN 8.5 %ELECTROLYTES.......... 131 AMINOSYN II 10 % ......... 131 AMINOSYN II 15 % ......... 131 AMINOSYN II 7 % ........... 131 AMINOSYN II 8.5 % ........ 131 AMINOSYN II 8.5 %ELECTROLYTES.......... 131 AMINOSYN M 3.5 %........ 131 AMINOSYN-HBC 7%....... 131 AMINOSYN-PF 10 % ....... 131 AMINOSYN-PF 7 % (SULFITE-FREE) .......... 132 AMINOSYN-RF 5.2 % ...... 132 amiodarone ........................... 57 AMITIZA ............................. 91 amitriptyline ......................... 45 amlodipine ............................ 58 amlodipine-atorvastatin ........ 64 amlodipine-benazepril .......... 58 amlodipine-olmesartan ......... 58 amlodipine-valsartan ............ 58 amlodipine-valsartan-hcthiazid .......................................... 58 ammonium lactate ................ 68
amnesteem ............................ 69 amoxapine............................. 45 amoxicil-clarithromy-lansopraz .......................................... 97 amoxicillin ............................ 12 amoxicillin-pot clavulanate .. 12 amphotericin b ........................ 2 ampicillin .............................. 12 ampicillin sodium ................. 12 ampicillin-sulbactam ............ 12 AMPYRA ............................. 34 ANADROL-50 ..................... 88 ANAFRANIL ....................... 45 anagrelide .............................75 anastrozole ............................ 17 ANCOBON ............................ 2 ANDRODERM ....................88 ANDROGEL ........................ 88 ANDROID ............................ 88 anectine .................................35 ANGELIQ ..........................108 ANIMI-3 WITH VITAMIN D ........................................ 133 ANORO ELLIPTA ............. 122 ANTABUSE .........................75 ANTARA ............................. 64 ANUSOL-HC .......................92 ANZEMET ........................... 92 apexicon e ............................. 73 APIDRA SOLOSTAR U-100 INSULIN .......................... 82 APIDRA U-100 INSULIN ...82 APLENZIN........................... 45 APOKYN .............................31 apraclonidine ...................... 117 aprepitant .............................. 92 apri ...................................... 110 APRISO ................................ 92 APTENSIO XR ....................45 APTIOM ...............................27 APTIVUS ...............................3 AQUASOL A .....................133 ARALAST NP......................75 aranelle (28) ........................ 110 ARANESP (IN POLYSORBATE) ....99, 100 ARAVA .............................. 106 ARCALYST .......................100
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 140
ARCAPTA NEOHALER... 122 ARGATROBAN .................. 63 ARGATROBAN IN 0.9 % SOD CHLOR ................... 63 ARICEPT ............................. 34 ARIMIDEX .......................... 17 aripiprazole ........................... 45 ARISTADA.......................... 45 ARIXTRA ............................ 63 armodafinil ........................... 45 ARMONAIR RESPICLICK ........................................ 122 ARNUITY ELLIPTA......... 122 AROMASIN......................... 17 ARRANON .......................... 17 ARTHROTEC 50 ................. 41 ARTHROTEC 75 ................. 41 ARYMO ER ......................... 36 ARZERRA ........................... 17 ASACOL HD ....................... 92 ASCOR .............................. 133 ascorbic acid (vitamin c) .... 133 ashlyna................................ 110 ASMANEX HFA ............... 122 ASMANEX TWISTHALER ................................ 122, 123 aspir-81 ................................. 41 aspirin ................................... 41 aspirin childrens ................... 41 aspirin low dose.................... 41 aspirin-dipyridamole ............ 63 aspir-low ............................... 41 aspir-trin ............................... 41 ASTAGRAF XL .................. 17 ASTEPRO ............................ 79 ATACAND .......................... 58 ATACAND HCT ................. 58 atazanavir ............................... 3 ATELVIA........................... 106 atenolol ................................. 58 atenolol-chlorthalidone......... 58 ATGAM ............................. 102 ATIVAN............................... 45 atomoxetine .......................... 45 atorvastatin ........................... 65 atovaquone ............................. 9 atovaquone-proguanil ............. 9 ATRALIN ............................ 69
ATRIPLA ............................... 3 atropine ......................... 91, 114 ATROVENT HFA ............. 123 AUBAGIO............................ 34 aubra ................................... 110 AUGMENTIN ...................... 12 AURYXIA............................ 75 AUSTEDO ........................... 34 AUVI-Q .............................. 118 AVALIDE ............................ 58 AVANDIA ........................... 82 AVAPRO.............................. 58 AVASTIN ............................ 17 AVC.................................... 109 AVEED ................................ 88 AVELOX.............................. 13 AVELOX IN NACL (ISOOSMOTIC) ....................... 13 aviane.................................. 110 avita ...................................... 69 AVITA.................................. 69 AVODART ........................ 127 AVONEX ........................... 100 AVONEX (WITH ALBUMIN) ........................................ 100 AVYCAZ ............................... 7 AXERT................................. 32 AXIRON .............................. 88 AYGESTIN ........................ 108 azacitidine ............................. 17 AZACTAM ............................ 9 AZASAN .............................. 17 AZASITE ........................... 113 azathioprine .......................... 17 azathioprine sodium ............. 17 azelastine ...................... 79, 115 AZELEX .............................. 69 AZILECT ............................. 31 azithromycin ........................... 8 AZOPT ............................... 115 AZOR ................................... 58 aztreonam ............................... 9 AZULFIDINE ...................... 92 AZULFIDINE EN-TABS .... 92 azurette (28) ........................ 110 B b complex 1 ........................ 133 b complex 100 .................... 133
b complex-vitamin b12 ....... 133 b complex-vitamin c-folic acid ........................................ 133 b-100 complex .................... 133 B-12 COMPLIANCE ......... 133 baciim ..................................... 9 bacitracin ........................ 9, 113 bacitracin-polymyxin b ....... 113 baclofen ................................35 BACMIN ............................ 133 BACTRIM ............................ 14 BACTRIM DS ...................... 14 BACTROBAN ..................... 71 BACTROBAN NASAL ....... 79 balance b-100...................... 133 balance b-50........................ 133 balanced b-100.................... 133 balanced b-100 complex ..... 133 balanced b-50...................... 133 balanced salt ....................... 115 balsalazide ............................92 balziva (28) ......................... 110 BANZEL .............................. 27 BARACLUDE ........................ 3 BASAGLAR KWIKPEN U100 INSULIN ...................82 BAVENCIO .........................17 BAXDELA .....................13, 14 bayer aspirin ......................... 41 BCG VACCINE, LIVE (PF) ........................................ 102 b-complex with vitamin c ... 133 BECONASE AQ ................123 bekyree (28) ........................ 110 BELBUCA ........................... 36 BELEODAQ.........................17 BELSOMRA ........................45 BELVIQ ............................... 75 BELVIQ XR .........................75 benazepril ............................. 58 benazepril-hydrochlorothiazide .......................................... 58 BENDEKA ........................... 17 BENICAR............................. 58 BENICAR HCT....................58 BENLYSTA .......................106 BENTYL .............................. 91 BENZACLIN PUMP............69
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 141
BENZAMYCIN ................... 69 BENZNIDAZOLE ................. 9 benzonatate ......................... 118 benzphetamine...................... 75 benztropine ........................... 31 BEPREVE .......................... 115 BERINERT ........................ 123 BESIVANCE ..................... 113 BESPONSA ......................... 17 BETAGAN ......................... 114 betamethasone acet,sod phos 80 betamethasone dipropionate . 73 betamethasone valerate ........ 73 betamethasone, augmented... 73 BETAPACE AF ................... 57 BETASERON .................... 100 betaxolol ....................... 58, 114 bethanechol chloride .......... 127 BETHKIS ............................... 9 BETIMOL .......................... 114 BETOPTIC S ..................... 114 BEVESPI AEROSPHERE . 123 BEVYXXA .......................... 63 bexarotene ............................ 17 BEXSERO.......................... 102 BEYAZ .............................. 110 bicalutamide ......................... 17 BICILLIN C-R ..................... 12 BICILLIN L-A ..................... 12 BICNU ................................. 17 BIDIL ................................... 58 BIFERA RX ....................... 133 BIKTARVY ........................... 3 BILTRICIDE.......................... 9 bimatoprost ......................... 116 BINOSTO .......................... 106 bisacodyl............................... 92 bisa-lax ................................. 92 bisoprolol fumarate .............. 58 bisoprolol-hydrochlorothiazide .......................................... 58 BIVIGAM .......................... 102 bleomycin ............................. 17 BLEPH-10 .......................... 116 BLEPHAMIDE .................. 116 BLEPHAMIDE S.O.P. ....... 116 BLINCYTO.......................... 17 blisovi 24 fe ........................ 110
blisovi fe 1.5/30 (28) .......... 110 blisovi fe 1/20 (28) ............. 110 BONIVA ............................ 106 BONJESTA .......................... 92 BOOSTRIX TDAP............. 102 BORTEZOMIB .................... 17 BOSULIF ............................. 17 BOTOX .............................. 102 BRAVELLE ......................... 88 BREO ELLIPTA ................ 123 BREVICON (28) ................ 110 briellyn................................ 110 BRILINTA ........................... 63 brimonidine ........................ 117 BRISDELLE ........................ 45 BRIVIACT ........................... 27 BROMFED DM ................. 118 bromfenac ........................... 115 bromocriptine ....................... 32 BROMPHENIRAMINE MALEATE (BULK) ...... 118 brompheniramine-pseudoephdm ................................... 118 BROMSITE ........................ 115 BROVANA ........................ 123 bss ....................................... 115 budesonide .................... 92, 123 bufferin ................................. 41 bumetanide ........................... 58 buminate 5 % ...................... 128 BUNAVAIL ......................... 41 BUPHENYL......................... 75 bupivacaine........................... 70 bupivacaine (pf) .................... 70 bupivacaine-dextrose-water(pf) .......................................... 76 bupivacaine-epinephrine ...... 71 bupivacaine-epinephrine (pf) 70 BUPRENEX ......................... 36 BUPRENORPHINE ............. 36 buprenorphine hcl ................. 36 buprenorphine-naloxone. 41, 42 bupropion hcl........................ 45 bupropion hcl (smoking deter) .......................................... 78 buspirone .............................. 45 busulfan ................................ 17 BUSULFEX ......................... 17
butorphanol tartrate .............. 42 BUTRANS ...........................36 BYDUREON ........................ 82 BYDUREON BCISE............ 82 BYETTA .............................. 82 BYSTOLIC...........................58 BYVALSON ........................58 C cabergoline ...........................88 CABOMETYX ..................... 17 CADUET .............................. 65 CAFERGOT .........................32 caffeine citrate ......................76 CALAN ................................ 58 CALAN SR ..........................58 calcipotriene ................... 67, 68 calcipotriene-betamethasone 68 calcitonin (salmon) ............... 89 calcitrene...............................68 calcitriol .......................... 68, 89 calcium 500 + d .................. 128 calcium 500 + d (d3)........... 128 calcium 500 with d ............. 128 calcium 600 + d(3).............. 128 calcium 600 with vitamin d3 ........................................ 128 calcium acetate ................... 128 calcium carb and citrate-vitd3 ........................................ 128 calcium carbonate-vitamin d3 ........................................ 128 calcium chloride ................. 128 calcium citrate + d .............. 128 calcium citrate-vitamin d2 .. 128 calcium citrate-vitamin d3 . 128, 129 calcium gluconate ............... 129 calcium with vitamin d ....... 129 CALQUENCE ...................... 18 CAMBIA .............................. 42 camila ................................. 108 CAMPTOSAR ...................... 18 camrese ............................... 110 camrese lo ........................... 110 CANASA .............................. 92 CANCIDAS ............................ 2 candesartan ........................... 58
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 142
candesartan-hydrochlorothiazid .......................................... 58 CAPASTAT ........................... 9 CAPCOF ............................ 118 capecitabine .......................... 18 CAPEX ................................. 73 CAPRELSA ......................... 18 captopril................................ 58 captopril-hydrochlorothiazide .......................................... 58 CARAC ................................ 68 CARAFATE ......................... 97 CARBAGLU ........................ 76 carbamazepine ...................... 27 CARBATROL...................... 27 carbidopa .............................. 32 carbidopa-levodopa .............. 32 carbidopa-levodopaentacapone ........................ 32 carbocaine (pf)...................... 71 carboplatin ............................ 18 CARDENE IV IN SODIUM CHLORIDE...................... 58 cardioplegic soln .................. 66 CARDIOTEK-RX (BIOPERINE) ................ 133 CARDIZEM ......................... 58 CARDIZEM CD .................. 58 CARDIZEM LA................... 58 CARDURA .......................... 58 CARDURA XL .................... 59 CARIMUNE NF NANOFILTERED ......... 102 CARNITOR ......................... 76 CAROSPIR .......................... 59 carteolol .............................. 114 cartia xt ................................. 59 carvedilol .............................. 59 carvedilol phosphate............. 59 CASODEX ........................... 18 caspofungin ............................ 2 CASPOFUNGIN .................... 2 CATAPRES ......................... 59 CATAPRES-TTS-1.............. 59 CATAPRES-TTS-2.............. 59 CATAPRES-TTS-3.............. 59 CAVERJECT ..................... 127 CAVERJECT IMPULSE ... 127
CAYSTON ............................. 9 caziant (28) ......................... 110 cefaclor ................................... 7 cefadroxil ................................ 7 cefazolin ................................. 7 cefazolin in dextrose (iso-os) . 7 cefdinir.................................... 7 cefepime ................................. 7 cefepime in dextrose,iso-osm . 7 cefixime .................................. 7 cefotaxime .............................. 7 cefotetan ................................. 7 cefoxitin .................................. 7 cefoxitin in dextrose, iso-osm 7 cefpodoxime ........................... 7 cefprozil .................................. 7 ceftazidime ............................. 8 CEFTIN .................................. 8 ceftriaxone .............................. 8 ceftriaxone in dextrose,iso-os . 8 cefuroxime axetil .................... 8 cefuroxime sodium ................. 8 CELEBREX ......................... 42 celecoxib............................... 42 CELEXA .............................. 45 CELLCEPT .......................... 18 CELLCEPT INTRAVENOUS .......................................... 18 CELONTIN .......................... 27 centratex ............................. 133 cephalexin............................... 8 CEPROTIN (BLUE BAR) ... 63 CEPROTIN (GREEN BAR) 63 CERDELGA......................... 89 CEREBYX ........................... 27 CEREZYME ........................ 89 CESAMET ........................... 92 cetiri-d ................................ 118 cetirizine ............................. 118 CETIRIZINE ...................... 118 cetirizine-pseudoephedrine . 118 CETROTIDE ........................ 89 cevimeline ............................ 76 CHANTIX ............................ 78 CHANTIX CONTINUING MONTH BOX .................. 78 CHANTIX STARTING MONTH BOX .................. 78
chateal .................................110 CHEK-STIX CONTROL .....82 CHEMET .............................. 76 CHEMSTRIP 10 MD ...........82 CHEMSTRIP 10/SG ............82 CHEMSTRIP 2 GP...............82 CHEMSTRIP 50B ................ 82 CHEMSTRIP 7 .....................82 CHEMSTRIP 9 .....................82 CHEMSTRIP K .................... 82 CHEMSTRIP UGK .............. 82 CHENODAL ........................ 92 cheratussin ac...................... 118 child allergy relf(cetirizine) 118 CHILD ALLERGY RELF(CETIRIZINE) ...... 118 children's allegra allergy ..... 118 CHILDREN'S ALLERGY RELIEF(FEX) ................ 118 children's allergy relief(lor) 118 children's allergy(cetirizine) ........................................ 118 children's aller-tec............... 118 children's aspirin ................... 42 children's cetirizine ............. 118 CHILDREN'S CETIRIZINE ........................................ 118 CHILDREN'S CLARITIN . 118 CHILDREN'S WAL-FEX .. 118 children's wal-zyr ............... 118 CHILDREN'S WAL-ZYR . 118 CHILDREN'S ZYRTEC ALLERGY ............. 118, 119 child's all day allergy(cetir) 119 chloramphenicol sod succinate ............................................ 9 chlorhexidine gluconate........ 79 chloroprocaine (pf) ............... 71 chloroquine phosphate ............ 9 chlorothiazide ....................... 59 chlorothiazide sodium .......... 59 CHLORPHENIRAMINE MALEATE(BULK) .......119 chlorpromazine ..................... 45 chlorthalidone ....................... 59 CHOLBAM ..........................92 cholecalciferol (vitamin d3) ................................ 133, 134
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 143
cholestyramine (with sugar) . 65 cholestyramine light ............. 65 CHORIONIC GONADOTROPIN, HUMAN ........................... 89 CIALIS ............................... 127 ciclodan ................................ 72 ciclopirox.............................. 72 cidofovir ................................. 3 ciferex ................................. 134 cilostazol............................... 63 CILOXAN .......................... 113 CIMDUO................................ 3 cimetidine ............................. 97 cimetidine hcl ....................... 97 CIMZIA................................ 92 CIMZIA POWDER FOR RECONST........................ 92 CIMZIA STARTER KIT ..... 92 CINRYZE .......................... 123 CINVANTI........................... 92 CIPRO .................................. 14 CIPRO HC ........................... 79 CIPRO IN D5W ................... 14 CIPRODEX .......................... 79 ciprofloxacin......................... 14 ciprofloxacin (mixture) ........ 14 ciprofloxacin hcl..... 14, 79, 113 ciprofloxacin in 5 % dextrose .......................................... 14 ciprofloxacin lactate ............. 14 cisplatin ................................ 18 citalopram ............................. 46 citrate of magnesia ............... 92 citroma .................................. 92 citrus calcium ..................... 129 cladribine .............................. 18 claravis ................................. 69 CLARINEX........................ 119 CLARINEX-D 12 HOUR .. 119 clarithromycin ........................ 8 CLARITIN ......................... 119 CLARITIN LIQUI-GEL .... 119 CLARITIN REDITABS..... 119 CLARITIN-D 12 HOUR.... 119 CLARITIN-D 24 HOUR.... 119 clearlax ................................. 92
CLEMASTINE FUMARATE (BULK) .......................... 119 CLENPIQ ............................. 92 CLEOCIN..................... 10, 109 CLEOCIN HCL...................... 9 CLEOCIN IN 5 % DEXTROSE ....................... 9 CLEOCIN PEDIATRIC ....... 10 CLEOCIN T ......................... 69 CLIMARA.......................... 108 CLIMARA PRO ................. 108 clindacin etz.......................... 69 clindacin p ............................ 69 CLINDAGEL ....................... 69 clindamycin hcl .................... 10 clindamycin in 5 % dextrose 10 clindamycin palmitate hcl .... 10 clindamycin pediatric ........... 10 clindamycin phosphate .. 10, 69, 109 clindamycin-benzoyl peroxide .......................................... 69 clindamycin-tretinoin ........... 69 CLINDESSE ...................... 109 CLINIMIX 5%/D15W SULFITE FREE ............. 132 CLINIMIX 5%/D25W SULFITE-FREE ............. 132 CLINIMIX 2.75%/D5W SULFIT FREE................ 132 CLINIMIX 4.25%/D10W SULF FREE ................... 132 CLINIMIX 4.25%/D5W SULFIT FREE.................. 76 CLINIMIX 4.25%-D20W SULF-FREE ................... 132 CLINIMIX 4.25%-D25W SULF-FREE ................... 132 CLINIMIX 5%D20W(SULFITE-FREE) 132 CLINIMIX E 2.75%/D10W SUL FREE........................ 76 CLINIMIX E 2.75%/D5W SULF FREE ..................... 76 CLINIMIX E 4.25%/D10W SUL FREE...................... 132 CLINIMIX E 4.25%/D25W SUL FREE...................... 132
CLINIMIX E 4.25%/D5W SULF FREE.................... 132 CLINIMIX E 5%/D15W SULFIT FREE ................132 CLINIMIX E 5%/D20W SULFIT FREE ................132 CLINIMIX E 5%/D25W SULFIT FREE ................132 CLINISOL SF 15 % ...........132 clobetasol .............................. 73 clobetasol-emollient ............. 73 CLOBEX .............................. 73 clodan ...................................73 CLODERM...........................73 clofarabine ............................18 CLOLAR .............................. 18 clomiphene citrate ................ 89 clomipramine ........................ 46 clonazepam ...........................28 clonidine ............................... 59 clonidine (pf) .................. 42, 59 clonidine hcl ................... 46, 59 clopidogrel ............................ 63 clorazepate dipotassium........ 46 clotrimazole ...................... 2, 72 clotrimazole-betamethasone . 72 clozapine ...............................46 CLOZAPINE ........................ 46 CLOZARIL .......................... 46 COARTEM...........................10 codeine sulfate ......................36 CODEINE-GUAIFENESIN ........................................ 119 CODITUSSIN AC .............. 119 CODITUSSIN DAC ........... 119 COGENTIN .......................... 32 COLAZAL ........................... 92 COLCHICINE .................... 105 COLCRYS .......................... 105 COLESTID ........................... 65 colestipol...............................65 colistin (colistimethate na) ... 10 colocort ................................. 92 COLY-MYCIN S ................. 79 COLYTE WITH FLAVOR PACKS ............................. 92 COMBIGAN ......................116 COMBIPATCH ..................108
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 144
COMBISTIX REAGENT .... 82 COMBIVENT RESPIMAT 123 COMBIVIR ............................ 3 COMETRIQ ......................... 18 COMPLERA .......................... 3 complex b-100 .................... 134 compro.................................. 92 COMTAN ............................ 32 CONCEPTROL.................. 109 CONCERTA ........................ 46 CONDYLOX ....................... 68 constulose ............................. 92 CONTRAVE ........................ 75 CONZIP ............................... 42 COPAXONE ........................ 34 CORDRAN TAPE LARGE ROLL ............................... 73 COREG ................................ 59 COREG CR .......................... 59 coremino ............................... 14 CORGARD .......................... 59 CORLANOR ........................ 66 CORTEF .............................. 80 CORTIFOAM ...................... 92 cortisone ............................... 80 CORTISPORIN.................... 72 corvita ................................. 134 corvita 150 .......................... 134 CORVITE .......................... 134 CORVITE 150 ................... 134 CORVITE FE ..................... 134 CORVITE FREE ................ 134 CORZIDE ............................ 59 COSENTYX......................... 68 COSENTYX (2 SYRINGES) .......................................... 68 COSENTYX PEN ................ 68 COSENTYX PEN (2 PENS) 68 COSMEGEN ........................ 18 COSOPT ............................ 116 COSOPT (PF) .................... 116 COTELLIC........................... 18 COUMADIN ........................ 63 COZAAR ............................. 59 CREON ................................ 92 CRESEMBA .......................... 2 CRESTOR ............................ 65 CRINONE .......................... 108
CRIXIVAN ............................ 3 cromolyn ............... 92, 115, 123 cryselle (28) ........................ 110 CUBICIN.............................. 10 CUPRIMINE ...................... 106 CUTIVATE .......................... 73 CUVPOSA ........................... 91 cyanocobalamin (vitamin b-12) ........................................ 134 cyclafem 1/35 (28).............. 110 cyclafem 7/7/7 (28) ............ 110 cyclobenzaprine .................... 35 cyclophosphamide ................ 18 CYCLOPHOSPHAMIDE .... 18 CYCLOSET ......................... 82 cyclosporine.......................... 18 cyclosporine modified .......... 18 CYKLOKAPRON ................ 63 CYMBALTA........................ 46 CYPROHEPTADINE (BULK) ........................................ 119 CYRAMZA .......................... 18 cyred ................................... 110 CYSTADANE ...................... 92 CYSTAGON ...................... 127 CYSTARAN ...................... 115 cysteine (l-cysteine) ............ 132 cytarabine ............................. 18 cytarabine (pf) ...................... 18 CYTOMEL........................... 91 CYTOTEC............................ 97 CYTOVENE .......................... 3 D d10 %-0.45 % sodium chloride .......................................... 76 d2.5 %-0.45 % sodium chloride ............................. 76 d5 % and 0.9 % sodium chloride ............................. 76 d5 %-0.45 % sodium chloride .......................................... 76 dacarbazine ........................... 18 DACOGEN .......................... 18 dactinomycin ........................ 18 DAKLINZA ........................... 3 DALIRESP ......................... 123 DALVANCE ........................ 10 danazol.................................. 89
DANTRIUM.........................35 dantrolene ............................. 35 dapsone ........................... 10, 69 DAPTACEL (DTAP PEDIATRIC) (PF) ..........102 daptomycin ........................... 10 DARAPRIM .........................10 darifenacin ..........................126 DARZALEX.........................18 dasetta 1/35 (28) ................. 110 dasetta 7/7/7 (28) ................110 daunorubicin ......................... 18 DAYPRO .............................. 42 daysee ................................. 110 DAYTRANA ........................ 46 DDAVP ................................ 89 deblitane .............................108 decadron ............................... 80 decitabine .............................. 18 deferoxamine ........................ 76 DELESTROGEN ............... 108 delta d3 ............................... 134 deltasone ............................... 80 delyla (28) ........................... 110 DELZICOL........................... 92 DEMADEX .......................... 59 demeclocycline ..................... 14 DEMSER .............................. 59 DENAVIR ............................ 72 denta 5000 plus ..................... 79 dentagel................................. 79 DEPACON ........................... 28 DEPAKENE .........................28 DEPAKOTE .........................28 DEPAKOTE ER ................... 28 DEPAKOTE SPRINKLES ...28 DEPEN TITRATABS ........106 DEPO-ESTRADIOL ..........108 DEPO-MEDROL ................. 80 DEPO-PROVERA .............. 108 DEPO-SUBQ PROVERA 104 ........................................ 108 DEPO-TESTOSTERONE .... 89 DERMACINRX PUREFOLIX ........................................ 134 DESCOVY .............................3 desipramine........................... 46 desloratadine ....................... 119
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 145
desmopressin ........................ 89 desog-e.estradiol/e.estradiol ........................................ 110 desogestrel-ethinyl estradiol ........................................ 110 DESONATE ......................... 73 desonide................................ 73 DESOWEN .......................... 73 desoximetasone .................... 73 DESOXYN ........................... 46 DESVENLAFAXINE .......... 46 desvenlafaxine succinate ...... 46 DETROL ............................ 126 DETROL LA ...................... 126 dex4 glucose ......................... 76 DEX4 GLUCOSE ................ 76 dex4 glucose bits .................. 76 dex4 glucose pouch pack...... 76 dex4 glucose quick dissolve . 76 dexamethasone ..................... 80 dexamethasone intensol........ 80 dexamethasone sodium phos (pf) .................................... 80 dexamethasone sodium phosphate.................. 80, 116 DEXEDRINE SPANSULE .. 46 DEXILANT.......................... 97 dexmethylphenidate ............. 46 DEXPAK 13 DAY ............... 80 dexrazoxane hcl .................... 16 dextroamphetamine .............. 46 dextroamphetamineamphetamine .................... 46 DEXTROSE ......................... 76 dextrose 10 % and 0.2 % nacl .......................................... 76 dextrose 10 % in water (d10w) .......................................... 76 dextrose 20 % in water (d20w) .......................................... 76 dextrose 25 % in water (d25w) .......................................... 76 dextrose 30 % in water (d30w) .......................................... 76 dextrose 40 % in water (d40w) .......................................... 76 dextrose 5 % in water (d5w) 76 dextrose 5 %-lactated ringers76
dextrose 5%-0.2 % sod chloride ............................. 76 dextrose 5%-0.3 % sod.chloride ...................... 76 dextrose 50 % in water (d50w) .......................................... 76 dextrose 70 % in water (d70w) .......................................... 76 dextrose with sodium chloride .......................................... 77 dialyvite .............................. 134 DIALYVITE 3000 ............. 134 DIALYVITE 5000 ............. 134 dialyvite 800 ....................... 134 DIALYVITE 800 WITH IRON ........................................ 134 DIALYVITE SUPREME D ........................................ 134 DIASTAT ............................. 28 DIASTAT ACUDIAL .......... 28 diazepam................... 28, 46, 47 diazepam intensol ................. 47 DIBENZYLINE ................... 59 diclofenac potassium ............ 42 diclofenac sodium... 42, 68, 115 diclofenac-misoprostol ......... 42 dicloxacillin .......................... 12 dicyclomine .......................... 91 didanosine............................... 3 diethylpropion ...................... 75 DIFFERIN ............................ 69 DIFICID ................................. 8 diflorasone ............................ 73 DIFLUCAN ............................ 2 diflunisal ............................... 42 digitek ................................... 63 digox ..................................... 63 digoxin .................................. 63 dihydroergotamine................ 32 DILANTIN 30 MG .............. 28 DILANTIN EXTENDED 100 MG.................................... 28 DILANTIN INFATABS 50 MG.................................... 28 DILANTIN-125 125 MG/5 ML .................................... 28 DILAUDID .......................... 36 diltiazem hcl ......................... 59
dilt-xr ....................................59 dimenhydrinate ..................... 92 DIOVAN .............................. 59 DIOVAN HCT ..................... 59 DIPENTUM ......................... 92 DIPHENHYDRAMINE (BULK)...........................119 diphenhydramine hcl .......... 119 diphenoxylate-atropine ......... 91 DIPROLENE ........................ 73 dipyridamole ......................... 63 disulfiram .............................. 77 DITROPAN XL.................. 126 DIURIL.................................59 DIURIL IV ........................... 59 divalproex ............................. 28 DIVIGEL ............................ 108 dobutamine ........................... 66 dobutamine in d5w ............... 66 docetaxel ............................... 19 DOCETAXEL ......................19 dofetilide ............................... 57 DOLOPHINE .......................36 donepezil...............................34 dopamine .............................. 67 dopamine in 5 % dextrose .... 66 DORIPENEM ....................... 10 DORYX ................................ 14 DORYX MPC ......................14 dorzolamide ........................ 116 dorzolamide-timolol ........... 116 DOVONEX .......................... 68 doxazosin ..............................59 doxepin ...........................47, 68 doxercalciferol ......................89 DOXIL .................................. 19 doxorubicin ...........................19 doxorubicin, peg-liposomal ..19 doxy-100 ............................... 14 doxycycline hyclate ..............14 doxycycline monohydrate ....15 DRISDOL ........................... 134 dronabinol .......................92, 93 droperidol .............................93 drospirenone-e.estradiol-lm.fa ........................................ 110 drospirenone-ethinyl estradiol ........................................ 111
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 146
DROXIA .............................. 19 DUAC .................................. 69 DUAVEE ........................... 108 ducodyl ................................. 93 DUETACT ........................... 82 DUEXIS ............................... 42 DULERA............................ 123 duloxetine ............................. 47 DUOPA ................................ 32 DUPIXENT .......................... 68 DURACHOL...................... 134 DURAGESIC ....................... 36 duramorph (pf) ..................... 36 DUREZOL ......................... 116 dutasteride .......................... 127 dutasteride-tamsulosin........ 127 DUTOPROL......................... 59 DUZALLO ......................... 105 d-vi-sol ............................... 134 DYANAVEL XR ................. 47 DYAZIDE ............................ 59 DYMISTA.......................... 123 DYRENIUM ........................ 59 DYSPORT.......................... 102 E e.c. prin ................................. 42 e.e.s. 400 ................................. 8 E.E.S. GRANULES ............... 8 EC-NAPROSYN .................. 42 econazole .............................. 72 econtra ez............................ 111 econtra one-step.................. 111 ecotrin ................................... 42 ecotrin low strength .............. 42 EDARBI ............................... 59 EDARBYCLOR ................... 59 EDECRIN ............................ 59 EDEX ................................. 127 EDURANT ............................. 3 efavirenz ................................. 3 effer-k ................................. 129 EFFEXOR XR ..................... 47 EFFIENT .............................. 63 EFUDEX .............................. 68 EGRIFTA ........................... 100 ELAPRASE.......................... 89 ELDEPRYL ......................... 32 electrolyte-48 in d5w.......... 132
ELELYSO ............................ 89 ELESTAT ........................... 115 ELESTRIN ......................... 108 eletriptan ............................... 32 ELIDEL ................................ 68 ELIGARD ............................ 19 ELIGARD (3 MONTH) ....... 19 ELIGARD (4 MONTH) ....... 19 ELIGARD (6 MONTH) ....... 19 ELIMITE .............................. 75 elinest.................................. 111 eliphos ................................ 129 ELIQUIS .............................. 63 ELITEK ................................ 16 ELIXOPHYLLIN ............... 123 ELLA .................................. 111 ELLENCE ............................ 19 ELMIRON .......................... 127 ELOCON .............................. 73 EMADINE.......................... 115 EMBEDA ....................... 36, 37 EMCYT ................................ 19 EMEND ................................ 93 EMEND (FOSAPREPITANT) .......................................... 93 EMFLAZA ........................... 80 emoquette ........................... 111 EMPLICITI .......................... 19 EMSAM ............................... 47 EMTRIVA .............................. 3 EMVERM ............................ 10 ENABLEX ......................... 126 enalapril maleate................... 59 enalaprilat ............................. 60 enalapril-hydrochlorothiazide .......................................... 60 ENBREL ............................ 106 ENBREL MINI .................. 106 ENBREL SURECLICK ..... 106 ENDARI ............................... 77 endocet.................................. 37 ENDOMETRIN.................. 108 ENGERIX-B (PF) .............. 102 ENGERIX-B PEDIATRIC (PF) ................................. 102 ENLYTE ............................ 134 enoxaparin ............................ 63 enpresse .............................. 111
enskyce ...............................111 ENSTILAR ........................... 68 entacapone ............................32 entecavir ................................. 3 enteric coated aspirin ............42 ENTOCORT EC ................... 93 ENTRESTO .......................... 67 ENTYVIO ............................ 93 enulose ..................................93 ENVARSUS XR ..................19 EPCLUSA .............................. 3 EPIDUO ............................... 70 EPIDUO FORTE ..................69 epinastine ............................115 EPINEPHRINE .................. 119 EPIPEN...............................119 EPIPEN 2-PAK .................. 119 EPIPEN JR ......................... 119 EPIPEN JR 2-PAK ............. 119 epirubicin .............................. 19 epitol .....................................28 EPIVIR ...................................3 EPIVIR HBV ..........................3 eplerenone............................. 60 EPOGEN ............................ 100 epoprostenol (glycine) .......... 60 eprosartan ............................. 60 EPZICOM...............................3 EQUETRO ........................... 28 ERAXIS(WATER DILUENT) ............................................ 2 ERBITUX ............................. 19 ergocalciferol (vitamin d2) . 134 ergoloid .................................47 ergotamine-caffeine .............. 32 ERIVEDGE .......................... 19 ERLEADA ........................... 19 errin.....................................108 ERTACZO ............................ 72 ERWINAZE ......................... 19 ery pads ................................. 70 erygel .................................... 70 ERYPED 200.......................... 8 ERYPED 400.......................... 8 ery-tab .....................................8 ERY-TAB ............................... 9 ERYTHROCIN ......................9 erythrocin (as stearate) ...........9
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 147
erythromycin .................. 9, 113 erythromycin ethylsuccinate .. 9 erythromycin with ethanol ... 70 erythromycin-benzoyl peroxide .......................................... 70 ESBRIET............................ 123 escitalopram oxalate ............. 47 esmolol ................................. 60 esomeprazole magnesium .... 97 esomeprazole sodium ........... 97 ESOMEPRAZOLE STRONTIUM .................. 97 estarylla .............................. 111 ESTRACE .......................... 108 estradiol .............................. 108 estradiol valerate ................ 108 estradiol-norethindrone acet ........................................ 108 ESTRING ........................... 108 estropipate .......................... 108 eszopiclone ........................... 47 ethacrynate sodium............... 60 ethacrynic acid...................... 60 ethambutol ............................ 10 ethosuximide ........................ 28 ethynodiol diac-eth estradiol ........................................ 111 etidronate disodium .............. 77 etodolac ................................ 42 ETOPOPHOS ....................... 19 etoposide............................... 19 EUCRISA ............................. 68 EURAX ................................ 75 EVAMIST .......................... 108 EVISTA.............................. 106 EVOCLIN ............................ 70 EVOTAZ ................................ 4 EVOXAC ............................. 77 EVZIO .................................. 42 EXALGO ER ....................... 37 EXELDERM ........................ 72 EXELON .............................. 34 exemestane ........................... 19 EXFORGE ........................... 60 EXFORGE HCT .................. 60 EXJADE ............................... 77 EXONDYS 51 ...................... 34 EXTAVIA .......................... 100
EXTINA ............................... 72 EYLEA ............................... 115 ezetimibe .............................. 65 ezetimibe-simvastatin ........... 65 F FABIOR ............................... 70 FABRAZYME ..................... 89 falmina (28) ........................ 111 famciclovir.............................. 4 famotidine............................. 97 famotidine (pf) ...................... 97 famotidine (pf)-nacl (iso-os) 97 FANAPT .............................. 47 FARESTON ......................... 19 FARXIGA ............................ 82 FARYDAK........................... 19 FASENRA .......................... 123 FASLODEX ......................... 19 fayosim ............................... 111 FAZACLO............................ 47 felbamate .............................. 28 FELBATOL.......................... 28 FELDENE ............................ 42 felodipine .............................. 60 FEMARA ............................. 19 FEMHRT LOW DOSE ...... 108 FEMRING .......................... 108 femynor .............................. 111 fenofibrate ............................ 65 FENOFIBRATE ................... 65 fenofibrate micronized ......... 65 fenofibrate nanocrystallized . 65 fenofibric acid....................... 65 fenofibric acid (choline) ....... 65 FENOGLIDE........................ 65 fenoprofen ............................ 42 FENOPROFEN .................... 42 fentanyl ................................. 37 FENTANYL ......................... 37 fentanyl citrate ...................... 37 fentanyl citrate (pf) ............... 37 FENTORA............................ 37 FERAHEME ...................... 134 FERIVA 21-7 TABLET ..... 134 FERIVA FA (SUMALATE) ........................................ 134 ferocon ................................ 134
FERRALET 90 DUAL-IRON DELIVERY .................... 134 ferraplus 90 ......................... 134 ferrex 150 forte ...................134 ferrex 150 forte plus ........... 134 ferrex 28.............................. 134 FERRIPROX ........................ 77 FERRLECIT .........................77 ferrocite plus ....................... 134 FETZIMA ............................. 48 FEXMID ............................... 35 fexofenadine ....................... 119 FEXOFENADINE .............. 119 FEXOFENADINE (BULK) ........................................ 119 fexofenadine-pseudoephedrine ........................................ 120 FIASP FLEXTOUCH U-100 INSULIN .......................... 82 FIASP U-100 INSULIN ....... 82 FIBRICOR ............................ 65 FINACEA ............................. 70 finasteride ...........................127 FIRAZYR ........................... 123 FIRMAGON KIT W DILUENT SYRINGE ......20 FLAGYL .............................. 10 FLAREX.............................116 flavoxate ............................. 126 FLEBOGAMMA DIF ........102 flecainide .............................. 57 FLECTOR ............................ 42 fleet laxative ......................... 93 FLOLIPID ............................ 65 FLOMAX ...........................127 FLOVENT DISKUS ..........123 FLOVENT HFA ......... 123, 124 floxin.....................................79 floxuridine ............................ 20 FLUAD 2017-2018 (65 YR UP)(PF)...........................103 FLUARIX QUAD 2017-2018 (PF) ................................. 103 FLUBLOK 2017-2018 (PF) ........................................ 103 FLUBLOK QUAD 2017-2018 (PF) ................................. 103
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 148
FLUCELVAX QUAD 20172018 ................................ 103 FLUCELVAX QUAD 20172018 (PF) ........................ 103 fluconazole ............................. 2 fluconazole in dextrose(iso-o) 2 fluconazole in nacl (iso-osm) . 2 flucytosine .............................. 2 fludarabine............................ 20 fludrocortisone ..................... 80 FLULAVAL QUAD 20172018 ................................ 103 FLULAVAL QUAD 20172018 (PF) ........................ 103 FLUMADINE ........................ 4 flumazenil ............................. 48 FLUMIST QUAD 2017-2018 ........................................ 103 flunisolide ........................... 124 fluocinolone.......................... 73 fluocinolone acetonide oil .... 79 fluocinolone and shower cap 73 fluocinonide.......................... 73 fluocinonide-e....................... 73 fluocinonide-emollient ......... 73 fluoride (sodium) ........ 134, 135 FLUORIDE (SODIUM)..... 134 fluoritab .............................. 135 fluorometholone ................. 116 fluorouracil ..................... 20, 68 FLUOROURACIL ............... 68 fluoxetine.............................. 48 fluphenazine decanoate ........ 48 fluphenazine hcl ................... 48 flurandrenolide ..................... 74 flurbiprofen........................... 42 flurbiprofen sodium ............ 115 flutamide............................... 20 fluticasone .................... 74, 124 FLUTICASONESALMETEROL ............. 124 fluvastatin ............................. 65 FLUVIRIN 2017-2018 ....... 103 FLUVIRIN 2017-2018 (PF) ........................................ 103 fluvoxamine .......................... 48 FLUZONE HIGH-DOSE 2017-18 (PF) .................. 103
FLUZONE INTRADERM QUAD 2017-18 .............. 103 FLUZONE QUAD 2017-2018 ........................................ 103 FLUZONE QUAD 2017-2018 (PF) ................................. 103 FLUZONE QUAD PEDI 2017-18 (PF) .................. 103 FML FORTE ...................... 116 FML LIQUIFILM .............. 116 FML S.O.P. ........................ 116 FOCALIN............................. 48 FOCALIN XR ...................... 48 folbee .................................. 135 folbee plus .......................... 135 folbic................................... 135 FOLGARD RX................... 135 folic acid ............................. 135 folic acid-vit b6-vit b12 ...... 135 FOLIKA-D ......................... 135 folivane-f ............................ 135 folivane-plus ....................... 135 FOLIXAPURE ................... 135 FOLLISTIM AQ .................. 89 FOLOTYN ........................... 20 folplex 2.2........................... 135 foltabs 800 .......................... 135 FOLTRATE........................ 135 fomepizole .......................... 103 fondaparinux ......................... 63 FORFIVO XL ...................... 48 FORTAMET .................. 82, 83 FORTAVIT ........................ 132 FORTEO ............................ 106 FORTESTA .......................... 89 FOSAMAX ........................ 106 FOSAMAX PLUS D .......... 106 fosamprenavir ......................... 4 foscarnet ................................. 4 fosinopril .............................. 60 fosinopril-hydrochlorothiazide .......................................... 60 fosphenytoin ......................... 28 FOSRENOL ......................... 77 FRAGMIN...................... 63, 64 FREAMINE HBC 6.9 % .... 132 freamine iii 10 % ................ 132 FREESTYLE FREEDOM.... 83
FREESTYLE FREEDOM LITE ................................. 83 FREESTYLE INSULINX ....83 FREESTYLE LITE METER 83 FROVA................................. 32 frovatriptan ...........................32 full spectrum b-vitamin c.... 135 FURADANTIN .................... 15 furosemide ............................ 60 FUSILEV .............................. 16 FUSION PLUS ...................135 FUSION SPRINKLES .......135 FUZEON ................................ 4 fyavolv ................................ 108 FYCOMPA ...........................28 G g tussin ac ........................... 120 gabapentin............................. 28 GABITRIL ........................... 28 GABLOFEN .........................35 galantamine........................... 34 GAMASTAN S/D .............. 103 GAMMAGARD LIQUID ..103 GAMMAGARD S-D (IGA < 1 MCG/ML)....................... 103 GAMMAKED .................... 103 GAMMAPLEX .................. 103 GAMMAPLEX (WITH SORBITOL) ................... 103 GAMUNEX-C .................... 103 ganciclovir sodium ................. 4 GANIRELIX ........................89 GARDASIL 9 (PF) ............. 103 GASTROCROM ..................93 gatifloxacin .........................113 GATTEX 30-VIAL ..............93 GATTEX ONE-VIAL ..........93 GAUZE PAD........................83 gavilax ..................................93 gavilyte-c .............................. 93 gavilyte-g .............................. 93 gavilyte-n .............................. 93 GAZYVA ............................. 20 GELNIQUE ........................ 126 gemcitabine........................... 20 gemfibrozil ...........................65 GEMZAR .............................20 GENERESS FE ..................111
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 149
generlac ................................ 93 gengraf.................................. 20 GENOTROPIN .................. 100 GENOTROPIN MINIQUICK ........................................ 100 gentak ................................. 113 gentamicin .............. 10, 72, 113 gentamicin in nacl (iso-osm) 10 gentamicin sulfate (ped) (pf) 10 gentamicin sulfate (pf) ......... 10 GENTAMICIN SULFATE (PF) ................................... 10 gentle laxative ...................... 93 gentlelax ............................... 93 GENVOYA ............................ 4 GEODON ............................. 48 GIALAX............................... 93 gianvi (28) .......................... 111 GIAZO ................................. 93 gildagia ............................... 111 GILENYA ............................ 34 GILOTRIF............................ 20 GLASSIA ............................. 77 glatiramer ............................. 34 glatopa .................................. 34 GLEEVEC............................ 20 GLEOSTINE ........................ 20 glimepiride ........................... 83 glipizide ................................ 83 glipizide-metformin.............. 83 GLUCAGEN HYPOKIT ..... 83 GLUCAGON EMERGENCY KIT (HUMAN) ................ 83 gluco burst ............................ 77 GLUCO SHOT..................... 77 GLUCOPHAGE ................... 83 GLUCOPHAGE XR ............ 83 glucose.................................. 77 glucose bits ........................... 77 glucose gel ............................ 77 GLUCOTROL...................... 83 GLUCOTROL XL ......... 83, 84 GLUMETZA ........................ 84 GLUTOSE 15....................... 77 GLUTOSE 45....................... 77 glycine urologic .................. 127 glycine urologic solution .... 127 glycolax ................................ 93
glycopyrrolate ....................... 91 glydo ..................................... 71 GLYSET............................... 84 GLYXAMBI ........................ 84 GOCOVRI ............................ 32 GOLYTELY......................... 93 GONAL-F ............................ 89 GONAL-F RFF .................... 89 GONAL-F RFF REDI-JECT 89 GONITRO ............................ 67 GRALISE ....................... 28, 29 GRALISE 30-DAY STARTER PACK ............................... 28 granisetron (pf) ..................... 93 granisetron hcl ...................... 93 GRANIX ............................ 100 GRASTEK.......................... 103 griseofulvin microsize ............ 2 griseofulvin ultramicrosize ..... 2 GRIS-PEG (ULTRAMICROSIZE) ...... 2 guaiatussin ac ..................... 120 guaifenesin ac ..................... 120 guaifenesin dac ................... 120 guanidine .............................. 48 GYNAZOLE-1 ................... 109 gynol ii................................ 109 H HAEGARDA...................... 124 HALAVEN........................... 20 HALDOL.............................. 48 HALDOL DECANOATE .... 48 halobetasol propionate .......... 74 HALOG ................................ 74 haloperidol ............................ 48 haloperidol decanoate ........... 48 haloperidol lactate .......... 48, 49 HARVONI.............................. 4 HAVRIX (PF) .................... 103 healthylax ............................. 93 heartburn treatment 24 hour . 97 heather ................................ 108 HECTOROL......................... 89 HEMA-COMBISTIX ........... 84 hematinic plus vit/minerals 135 hematinic/folic acid ............ 135 hematogen .......................... 135 hematogen fa ...................... 135
hematogen forte .................. 135 HEMATRON-AF ............... 135 HEMAX ............................. 135 hemetab............................... 135 HEMOCYTE-F .................. 135 HEMOCYTE-PLUS ........... 135 heparin (porcine) .................. 64 heparin (porcine) in 5 % dex 64 heparin (porcine) in nacl (pf) 64 heparin(porcine) in 0.45% nacl .......................................... 64 HEPARIN(PORCINE) IN 0.45% NACL .................... 64 heparin, porcine (pf) .............64 HEPATAMINE 8% ............132 HEPSERA .............................. 4 HERCEPTIN ........................20 hetastarch 6 % in 0.9 % nacl ........................................ 132 HETLIOZ ............................. 49 HEXALEN ........................... 20 HIBERIX (PF) ....................103 hi-cal plus vit d ................... 129 HIPREX ................................ 15 HISTEX-AC .......................120 HIZENTRA ........................ 103 HORIZANT .......................... 34 HUMALOG JUNIOR KWIKPEN U-100 ............ 84 HUMALOG KWIKPEN INSULIN .......................... 84 HUMALOG MIX 50-50 INSULN U-100 ................84 HUMALOG MIX 50-50 KWIKPEN ........................ 84 HUMALOG MIX 75-25 KWIKPEN ........................ 84 HUMALOG MIX 75-25(U100)INSULN ....................84 HUMALOG U-100 INSULIN .......................................... 84 HUMATROPE ...................101 HUMIRA ............................ 107 HUMIRA PEDIATRIC CROHN'S START . 106, 107 HUMIRA PEN ................... 107 HUMIRA PEN CROHN'SUC-HS START .............. 107
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 150
HUMIRA PEN PSORIASISUVEITIS ........................ 107 HUMULIN 70/30 U-100 INSULIN .......................... 84 HUMULIN 70/30 U-100 KWIKPEN ....................... 84 HUMULIN N NPH INSULIN KWIKPEN ....................... 84 HUMULIN N NPH U-100 INSULIN .......................... 84 HUMULIN R REGULAR U100 INSULN .................... 84 HUMULIN R U-500 (CONC) INSULIN .......................... 84 HUMULIN R U-500 (CONC) KWIKPEN ....................... 84 HYCAMTIN ........................ 20 HYCET ................................ 37 hydralazine ........................... 60 HYDREA ............................. 20 hydrochlorothiazide.............. 60 hydrocodone-acetaminophen 37 hydrocodone-chlorpheniramine ........................................ 120 hydrocodone-cpmpseudoephed ................... 120 hydrocodone-homatropine . 120 HYDROCODONEHOMATROPINE ........... 120 hydrocodone-ibuprofen ........ 37 hydrocortisone .......... 74, 80, 93 hydrocortisone butyrate ........ 74 hydrocortisone butyr-emollient .......................................... 74 hydrocortisone valerate ........ 74 hydrocortisone-acetic acid.... 79 hydrocortisone-min oil-wht pet .......................................... 74 hydrocortisone-pramoxine ... 93 hydromet............................. 120 hydromorphone .............. 37, 38 hydromorphone (pf) ............. 37 hydroxocobalamin .............. 135 hydroxychloroquine ............. 10 hydroxyprogesterone caproate ........................................ 109 hydroxyurea.......................... 20 hydroxyzine hcl .................. 120
HYDROXYZINE HCL (BULK) .......................... 120 HYDROXYZINE PAMOATE (BULK) .......................... 120 HYPERHEP B S/D ............ 104 HYPERHEP B S-D NEONATAL .................. 104 HYPERRAB S/D (PF) ....... 104 HYPERRHO S/D ............... 104 HYPERTET S/D (PF) ........ 104 HYQVIA ............................ 104 HYSINGLA ER ................... 38 HYZAAR ............................. 60 I ibandronate ......................... 106 IBRANCE ............................ 21 ibu ......................................... 42 IBUDONE ............................ 38 ibuprofen .............................. 42 ibuprofen-oxycodone............ 38 ibutilide fumarate ................. 57 ICAR-C PLUS.................... 135 ICLUSIG .............................. 21 IDAMYCIN PFS .................. 21 idarubicin .............................. 21 IDHIFA ................................ 21 iferex 150 forte ................... 135 IFEX ..................................... 21 ifosfamide ............................. 21 ILARIS (PF) ....................... 101 ILEVRO ............................. 115 imatinib................................. 21 IMBRUVICA ....................... 21 IMFINZI ............................... 21 imipenem-cilastatin .............. 10 imipramine hcl ...................... 49 imipramine pamoate ............. 49 imiquimod ............................ 68 IMITREX ....................... 32, 33 IMITREX STATDOSE KIT REFILL ............................ 33 IMITREX STATDOSE PEN33 IMOGAM RABIES-HT (PF) ........................................ 104 IMOVAX RABIES VACCINE (PF) ................................. 104 IMPAVIDO .......................... 10 IMURAN .............................. 21
INCRELEX .......................... 77 INCRUSE ELLIPTA ..........124 indapamide ........................... 60 INDERAL LA ......................60 INFANRIX (DTAP) (PF) ... 104 infed .................................... 135 INFLECTRA ........................93 INFUVITE ADULT ...........135 INFUVITE PEDIATRIC ....135 INGREZZA .......................... 34 INJECTAFER.....................135 INLYTA ............................... 21 INNOPRAN XL ...................60 INSPRA ................................ 60 INSTA-GLUCOSE (WITH DEXTRIN) ....................... 84 INSULIN PEN NEEDLE .....84 INSULIN SYRINGE (DISP) U-100 ................................ 84 INTEGRA F .......................135 INTEGRA PLUS ................135 INTELENCE .......................... 4 intralipid ............................. 132 INTRALIPID ...................... 132 INTRON A .........................101 introvale ..............................111 INVANZ ...............................10 INVEGA ...............................49 INVEGA SUSTENNA .........49 INVEGA TRINZA ...............49 INVIRASE ............................. 4 INVOKAMET ......................84 INVOKAMET XR ...............85 INVOKANA.........................85 IONOSOL-B IN D5W ........132 IONOSOL-MB IN D5W ....132 IOPIDINE ...........................117 IPOL ...................................104 ipratropium bromide ..... 79, 124 ipratropium-albuterol .......... 124 irbesartan ..............................60 irbesartan-hydrochlorothiazide .......................................... 60 IRESSA ................................ 21 irinotecan .............................. 21 IROSPAN 24/6 ................... 135 ISENTRESS ...........................4 ISENTRESS HD ....................4
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 151
isibloom .............................. 111 ISOLYTE S PH 7.4 ............ 132 ISOLYTE-P IN 5 % DEXTROSE ................... 132 ISOLYTE-S........................ 132 isoniazid ............................... 10 ISOPTO CARPINE ............ 115 ISORDIL .............................. 67 ISORDIL TITRADOSE ....... 67 isosorbide dinitrate ............... 67 isosorbide mononitrate ......... 67 isotretinoin............................ 70 isradipine .............................. 60 ISTALOL ........................... 114 ISTODAX ............................ 21 itraconazole ............................ 2 ivermectin ............................. 10 IXEMPRA ............................ 21 IXIARO (PF) ...................... 104 J JADENU .............................. 77 JADENU SPRINKLE .......... 77 JAKAFI ................................ 22 JALYN ............................... 127 jantoven ................................ 64 JANUMET ........................... 85 JANUMET XR..................... 85 JANUVIA ............................ 85 JARDIANCE........................ 85 jencycla............................... 109 JENTADUETO .................... 85 JENTADUETO XR.............. 85 JETREA (PF) ..................... 115 JEVTANA ............................ 22 jinteli .................................. 109 jolessa ................................. 111 jolivette ............................... 109 JUBLIA ................................ 72 juleber ................................. 111 JULUCA ................................ 4 junel 1.5/30 (21) ................. 111 junel 1/20 (21) .................... 111 junel fe 1.5/30 (28) ............. 111 junel fe 1/20 (28) ................ 111 junel fe 24 ........................... 111 JUXTAPID ........................... 65 K KADCYLA .......................... 22
KADIAN .............................. 38 kaitlib fe .............................. 111 KALBITOR ........................ 124 KALETRA ............................. 4 KALYDECO ...................... 124 KANUMA ............................ 89 KAPVAY ............................. 49 KARBINAL ER ................. 120 kariva (28) .......................... 111 KAZANO ............................. 85 k-effervescent ..................... 129 kelnor 1/35 (28) .................. 111 kelnor 1-50 ......................... 111 KENALOG ..................... 74, 80 KEPIVANCE ....................... 16 KEPPRA............................... 29 KEPPRA XR ........................ 29 KERYDIN ............................ 72 ketoconazole ..................... 2, 72 KETO-DIASTIX .................. 85 KETONE CARE .................. 85 KETONE URINE TEST ...... 85 ketoprofen ............................. 42 ketorolac ............................. 115 KETOSTIX .......................... 85 KEVEYIS ............................. 34 KEVZARA ......................... 107 KEYTRUDA ........................ 22 KHEDEZLA......................... 49 kimidess (28) ...................... 111 KINERET ........................... 107 KINRIX (PF) ...................... 104 kionex ................................... 77 kionex (with sorbitol) ........... 77 KISQALI .............................. 22 KISQALI FEMARA COPACK ............................... 22 KITABIS PAK ..................... 10 KLARON ............................. 72 KLONOPIN.......................... 29 klor-con .............................. 129 klor-con 10 ......................... 129 klor-con 8 ........................... 129 klor-con m10 ...................... 129 klor-con m15 ...................... 129 klor-con m20 ...................... 129 klor-con sprinkle................. 129 klor-con/ef .......................... 129
kobee................................... 135 KOMBIGLYZE XR ............. 85 KORLYM .............................89 K-PHOS NO 2 .................... 127 K-PHOS ORIGINAL .........127 KRISTALOSE ...................... 93 KRYSTEXXA .................... 105 k-tab ....................................129 K-TAB ................................ 129 kurvelo ................................ 111 KUVAN ................................ 89 KYNAMRO .........................65 KYPROLIS........................... 22 L l norgest/e.estradiol-e.estrad ........................................ 111 labetalol ................................ 60 LABSTIX REAGENT..........85 LACRISERT ...................... 115 lactated ringers..............75, 129 lactulose ................................93 LAMICTAL ......................... 29 LAMICTAL ODT ................ 29 LAMICTAL STARTER (BLUE) KIT .....................29 LAMICTAL STARTER (GREEN) KIT .................. 29 LAMICTAL STARTER (ORANGE) KIT ...............29 LAMICTAL XR ................... 29 LAMICTAL XR STARTER (BLUE) ............................. 29 LAMICTAL XR STARTER (GREEN) ..........................29 LAMICTAL XR STARTER (ORANGE) .......................29 LAMISIL ................................ 2 lamivudine .............................. 4 lamivudine-zidovudine ........... 4 lamotrigine ............................ 29 LANOXIN ............................ 63 lansoprazole .......................... 97 lanthanum ............................. 77 LANTUS SOLOSTAR U-100 INSULIN .......................... 85 LANTUS U-100 INSULIN ..85 larin 1.5/30 (21) .................. 111 larin 1/20 (21) ..................... 111
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 152
larin 24 fe ........................... 111 larin fe 1.5/30 (28).............. 111 larin fe 1/20 (28)................. 111 larissia................................. 111 LARTRUVO ........................ 22 LASIX .................................. 60 LASTACAFT ..................... 115 latanoprost .......................... 116 LATUDA ............................. 49 laxaclear ............................... 93 laxative (bisacodyl) .............. 93 laxative feminine .................. 93 laxative peg 3350 ................. 93 layolis fe ............................. 111 LAZANDA........................... 38 leena 28 .............................. 111 leflunomide......................... 107 LEMTRADA........................ 34 LENVIMA ........................... 22 LESCOL XL ........................ 65 lessina ................................. 111 LETAIRIS .......................... 124 letrozole ................................ 22 leucovorin calcium ............... 16 LEUKERAN ........................ 22 LEUKINE........................... 101 leuprolide.............................. 22 levalbuterol hcl ................... 124 LEVALBUTEROL TARTRATE ................... 124 LEVAQUIN ......................... 14 LEVEMIR FLEXTOUCH U100 INSULN .................... 85 LEVEMIR U-100 INSULIN 85 levetiracetam ........................ 29 levetiracetam in nacl (iso-os) 29 LEVITRA ........................... 127 levobunolol ......................... 114 levocarnitine ......................... 77 levocarnitine (with sugar)..... 77 levocetirizine ...................... 120 LEVOCETIRIZINE (BULK) ........................................ 120 levofloxacin .................. 14, 114 levofloxacin in d5w .............. 14 levoleucovorin ...................... 16 LEVOLEUCOVORIN ......... 16 levonest (28) ....................... 111
levonorgestrel-ethinyl estrad ........................................ 111 levonorg-eth estrad triphasic ........................................ 111 levora-28 ............................. 111 levorphanol tartrate............... 38 LEVO-T................................ 91 levothyroxine ........................ 91 LEVOTHYROXINE ............ 91 levoxyl .................................. 91 LEXAPRO............................ 49 LEXIVA ................................. 4 LIALDA ............................... 93 lidocaine ............................... 71 lidocaine (pf) in d7.5w ........ 57 lidocaine (pf) .................. 57, 71 lidocaine hcl ......................... 71 lidocaine in 5 % dextrose (pf) .......................................... 57 lidocaine viscous .................. 71 lidocaine-epinephrine ........... 71 lidocaine-prilocaine .............. 71 LIDODERM ......................... 71 lillow................................... 111 LINCOCIN ........................... 10 lincomycin ............................ 10 lindane .................................. 75 linezolid ................................ 10 linezolid-0.9% sodium chloride .......................................... 10 LINZESS .............................. 93 LIORESAL........................... 35 liothyronine .......................... 91 LIPITOR............................... 65 LIPOFEN.............................. 65 lisinopril................................ 60 lisinopril-hydrochlorothiazide .......................................... 60 lite coat aspirin ..................... 42 lithium carbonate .................. 49 lithium citrate ....................... 49 LITHOBID ........................... 49 LITHOSTAT ........................ 77 LIVALO ............................... 65 lmd 10 % in 0.9 % sodium chlor .................................. 77 lmd 10 % in 5 % dextrose .... 77 LO LOESTRIN FE............. 111
LOCOID ...............................74 LOCOID LIPOCREAM .......74 LODINE ............................... 42 LODOSYN ........................... 32 LOESTRIN 1.5/30 (21) ...... 111 LOESTRIN 1/20 (21) ......... 111 LOESTRIN FE 1.5/30 (28DAY) ..............................112 LOESTRIN FE 1/20 (28-DAY) ........................................ 112 LOMAIRA ........................... 75 LOMOTIL ............................ 91 LONHALA MAGNAIR REFILL...........................124 LONHALA MAGNAIR STARTER ...................... 124 LONSURF ............................ 22 loperamide ............................ 91 LOPID .................................. 65 lopinavir-ritonavir...................4 LOPRESSOR .......................60 LOPRESSOR HCT .............. 60 LOPROX .............................. 72 LOPROX (AS OLAMINE) ..72 loradamed ........................... 120 lorata-d ................................ 120 loratadine ............................ 120 LORATADINE (BULK) ....120 lorata-dine d ........................120 LORATADINE, MICRONIZED (BULK) 120 loratadine-d ......................... 120 lorazepam ....................... 49, 50 lorazepam intensol ................ 50 lorcet (hydrocodone) ............38 lorcet hd ................................ 38 lorcet plus ............................. 38 lortuss ex ............................. 120 loryna (28) .......................... 112 losartan ................................. 60 losartan-hydrochlorothiazide 60 LOSEASONIQUE .............. 112 LOTEMAX......................... 116 LOTENSIN........................... 60 LOTREL ...............................60 LOTRISONE ........................ 72 LOTRONEX.........................93 lovastatin...............................65
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 153
LOVAZA ............................. 65 LOVENOX........................... 64 low-ogestrel (28) ................ 112 loxapine succinate ................ 50 LUCENTIS ........................ 115 ludent fluoride .................... 135 LUMIGAN ......................... 116 LUMIZYME ........................ 89 LUNESTA............................ 50 LUPANETA PACK (1 MONTH) ........................ 109 LUPANETA PACK (3 MONTH) ........................ 109 LUPRON DEPOT ................ 22 LUPRON DEPOT (3 MONTH) .......................... 22 LUPRON DEPOT (4 MONTH) .......................... 22 LUPRON DEPOT (6 MONTH) .......................... 22 LUPRON DEPOT-PED ....... 22 LUPRON DEPOT-PED (3 MONTH) .......................... 22 lutera (28) ........................... 112 LUZU ................................... 72 LYNPARZA......................... 22 LYRICA ............................... 30 LYRICA CR................... 29, 30 LYSODREN......................... 22 LYSTEDA.......................... 109 lyza ..................................... 109 M m.v.i. adult.......................... 135 M.V.I. PEDIATRIC ........... 135 MACROBID ........................ 15 MACRODANTIN ................ 15 MACUVEX........................ 135 MACUZIN ......................... 135 mafenide acetate ................... 72 magnesium chloride ........... 129 magnesium citrate ................ 93 magnesium sulfate .............. 129 MAGNESIUM SULFATE IN D5W ............................... 129 magnesium sulfate in water 129 MAKENA .......................... 109 MAKENA (PF) .................. 109 MALARONE ....................... 10
MALARONE PEDIATRIC . 11 malathion .............................. 75 mannitol 20 % ...................... 60 mannitol 25 % ...................... 60 maprotiline............................ 50 marcaine (pf) ........................ 71 MAR-COF CG ................... 120 MARINOL ........................... 94 marlissa ............................... 112 MARPLAN .......................... 50 MARQIBO ........................... 22 MATULANE........................ 22 matzim la .............................. 60 MAVYRET ............................ 4 MAXALT ............................. 33 MAXALT-MLT ................... 33 MAXFE (FOLATEDOCUSATE) ................. 135 MAXIDEX ......................... 116 MAXIPIME ............................ 8 MAXITROL ....................... 116 MAXZIDE............................ 60 MAXZIDE-25MG ................ 60 m-clear wc .......................... 120 MEBOLIC .......................... 135 meclizine .............................. 94 meclofenamate...................... 43 MEDROL ............................. 80 MEDROL (PAK) ................. 80 medroxyprogesterone ......... 109 mefenamic acid..................... 43 mefloquine ............................ 11 MEGACE ES ....................... 22 megestrol .............................. 22 MEKINIST ........................... 22 melodetta 24 fe ................... 112 meloxicam ............................ 43 melphalan ............................. 22 melphalan hcl ....................... 22 memantine ............................ 34 MEMANTINE...................... 34 MENACTRA (PF) ............. 104 M-END PE ......................... 120 MENEST ............................ 109 MENOPUR .......................... 89 MENOSTAR ...................... 109 MENTAX ............................. 72
MENVEO A-C-Y-W-135-DIP (PF) ................................. 104 MEPHYTON ........................ 64 MEPRON .............................11 mercaptopurine ..................... 22 meropenem ...........................11 MERREM .............................11 mesalamine ........................... 94 MESALAMINE ...................94 mesalamine with cleansing wipe .................................. 94 mesna .................................... 16 MESNEX .............................. 16 MESTINON ......................... 35 MESTINON TIMESPAN .... 35 metadate er............................ 50 metaproterenol .................... 124 metformin ....................... 85, 86 methadone....................... 38, 39 methadone intensol ............... 38 methadose ............................. 39 methamphetamine................. 50 METHAVER ...................... 135 methazolamide .................... 115 methenamine hippurate ........ 15 methenamine mandelate ....... 15 methergine .......................... 113 methimazole ......................... 81 METHITEST ........................ 89 methotrexate sodium ............ 22 methotrexate sodium (pf) ..... 22 methoxsalen .......................... 68 methscopolamine .................. 91 methyclothiazide................... 60 methyldopa ........................... 60 methylergonovine ............... 113 METHYLIN .........................50 methylphenidate hcl.............. 50 methylprednisolone .............. 80 methylprednisolone acetate .. 80 methylprednisolone sodium succ ................................... 80 methyltestosterone ................ 89 metipranolol ........................ 114 metoclopramide hcl .............. 94 metolazone ............................ 61 metoprolol succinate ............. 61
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 154
metoprolol ta-hydrochlorothiaz .......................................... 61 metoprolol tartrate ................ 61 metro i.v. .............................. 11 METROCREAM.................. 70 METROGEL ........................ 70 METROGEL VAGINAL ... 110 METROLOTION ................. 70 metronidazole ......... 11, 70, 110 metronidazole in nacl (iso-os) .......................................... 11 mexiletine ............................. 57 MIACALCIN ....................... 89 mibelas 24 fe ...................... 112 MICARDIS .......................... 61 MICARDIS HCT ................. 61 miconazole-3 ...................... 110 MICORT-HC ....................... 94 microgestin 1.5/30 (21) ...... 112 microgestin 1/20 (21) ......... 112 microgestin fe 1.5/30 (28) .. 112 microgestin fe 1/20 (28) ..... 112 MICROZIDE........................ 61 midodrine ............................. 77 migergot ............................... 33 miglitol ................................. 86 miglustat ............................... 89 MIGRANAL ........................ 33 milk of magnesia .................. 94 milk of magnesia concentrated .......................................... 94 millipred ............................... 80 MILLIPRED......................... 80 millipred dp .......................... 80 milrinone .............................. 67 milrinone in 5 % dextrose .... 67 mimvey ............................... 109 mimvey lo........................... 109 MINASTRIN 24 FE ........... 112 MINIPRESS ......................... 61 MINITRAN .......................... 67 MINIVELLE ...................... 109 MINOCIN ............................ 15 minocycline .......................... 15 minoxidil .............................. 61 miostat ................................ 116 miralax.................................. 94 MIRAPEX ............................ 32
MIRAPEX ER ...................... 32 MIRCERA .......................... 101 MIRENA ............................ 110 mirtazapine ........................... 50 MIRVASO............................ 70 misoprostol ........................... 97 MITIGARE ........................ 105 mitomycin....................... 22, 23 mitoxantrone......................... 23 M-M-R II (PF) .................... 104 MOBIC ................................. 43 modafinil .............................. 50 moderiba ................................. 4 moderiba dose pack ................ 4 moexipril .............................. 61 moexipril-hydrochlorothiazide .......................................... 61 mometasone .................. 74, 124 mondoxyne nl ....................... 15 mono-linyah........................ 112 mononessa (28)................... 112 montelukast ........................ 124 MONUROL .......................... 15 morgidox .............................. 15 morphine......................... 39, 40 MORPHINE ......................... 39 morphine (pf) ........................ 39 morphine concentrate ........... 39 MOVANTIK ........................ 94 MOVIPREP .......................... 94 MOXEZA ........................... 114 moxifloxacin ................. 14, 114 moxifloxacin in nacl (iso-osm) .......................................... 14 MOXIFLOXACINSOD.ACE,SUL-WATER . 14 MOZOBIL .......................... 101 MS CONTIN ........................ 40 MULTAQ ............................. 57 multigen folic ..................... 136 multigen plus ...................... 136 MULTISTIX ........................ 86 MULTISTIX 10 SG ............. 86 MULTISTIX 5 ..................... 86 MULTISTIX 7 ..................... 86 MULTISTIX 8 SG ............... 86 MULTISTIX 9 ..................... 86 MULTISTIX 9 SG ............... 86
multi-vit with fluoride-iron. 136 multivitamin with fluoride .. 136 multi-vitamin with fluoride 136 multi-vitamin with fluoride 136 MULTI-VITAMIN WITH FLUORIDE .................... 136 multivitamins with fluoride 136 multivit-fluor (vit e acetate) 136 mupirocin .............................. 72 mupirocin calcium ................ 72 MUSE ................................. 127 MUSTARGEN ..................... 23 mvc-fluoride ....................... 136 my choice............................112 my way ............................... 112 MYALEPT ........................... 89 MYAMBUTOL .................... 11 MYCAMINE .......................... 2 MYCOBUTIN ......................11 mycophenolate mofetil ......... 23 mycophenolate mofetil hcl ... 23 mycophenolate sodium ......... 23 MYDAYIS ...........................50 myferon 150 forte ............... 136 MYFORTIC .........................23 MYLERAN .......................... 23 MYLOTARG ....................... 23 mynephrocaps ..................... 136 mynephron .......................... 136 myorisan ............................... 70 MYRBETRIQ.....................126 MYSOLINE ......................... 30 MYTESI ............................... 91 myzilra ................................112 N nabumetone........................... 43 nadolol .................................. 61 nadolol-bendroflumethiazide 61 nafcillin ................................. 12 nafcillin in dextrose iso-osm 12 naftifine.................................72 NAFTIN ............................... 72 NAGLAZYME .....................89 nalbuphine ............................ 43 naloxone ............................... 43 naltrexone ............................. 43 NAMENDA .......................... 34
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 155
NAMENDA TITRATION PAK .................................. 34 NAMENDA XR ................... 34 NAMZARIC......................... 34 NAPRELAN CR .................. 43 naproxen ............................... 43 naproxen sodium .................. 43 naratriptan............................. 33 NARCAN ............................. 43 NARDIL ............................... 50 NASCOBAL ...................... 136 NASONEX ......................... 124 NATACYN ........................ 114 NATAZIA .......................... 112 nateglinide ............................ 86 NATPARA ........................... 89 NATROBA .......................... 75 natural b-100 complex........ 136 natura-lax.............................. 94 NEBUPENT ......................... 11 necon 0.5/35 (28)................ 112 necon 7/7/7 (28) ................. 112 NEEDLES, INSULIN DISP.,SAFETY ................ 86 nefazodone ........................... 50 neomycin .............................. 11 neomycin-bacitracin-poly-hc ........................................ 116 neomycin-bacitracinpolymyxin ...................... 114 neomycin-polymyxin b gu ... 75 neomycin-polymyxin bdexameth ........................ 116 neomycin-polymyxingramicidin....................... 114 neomycin-polymyxin-hc ..... 79, 116 neo-polycin ......................... 114 neo-polycin hc .................... 116 NEORAL.............................. 23 neostigmine methylsulfate.... 35 NEO-SYNALAR ................. 72 nephplex rx ......................... 136 NEPHRAMINE 5.4 % ....... 132 NEPHROCAPS .................. 136 NEPHROCAPS QT............ 136 NEPHRON FA ................... 136 nephro-vite rx ..................... 136
NERLYNX ........................... 23 NESINA ............................... 86 neuac..................................... 70 NEULASTA ....................... 101 NEUPOGEN ...................... 101 NEUPRO .............................. 32 NEURIN-SL ....................... 136 NEURONTIN....................... 30 NEVANAC ........................ 115 nevirapine ............................... 5 NEXAVAR .......................... 23 NEXIUM .............................. 98 NEXIUM 24HR ................... 97 NEXIUM IV ......................... 97 NEXIUM PACKET ............. 98 NEXPLANON.................... 110 NEXTERONE ...................... 57 niacin .................................... 65 NIACOR............................... 65 NIASPAN EXTENDEDRELEASE ........................ 65 nicardipine ............................ 61 NICODERM CQ .................. 78 NICOMIDE ........................ 136 NICOMIDE (SELENIUMCHROMIUM) ................ 136 nicorelief............................... 78 NICORETTE ........................ 78 nicotine ................................. 79 nicotine (polacrilex) ............. 78 NICOTINE (POLACRILEX) .......................................... 78 NICOTROL .......................... 79 NICOTROL NS.................... 79 nifedipine .............................. 61 nikki (28) ............................ 112 NILANDRON ...................... 23 nilutamide ............................. 23 nimodipine ............................ 61 NINJACOF-XG.................. 120 NINLARO ............................ 23 NIPENT ................................ 23 nisoldipine ............................ 61 nitro-bid ................................ 67 NITRO-DUR ........................ 67 nitrofurantoin ........................ 15 nitrofurantoin macrocrystal .. 15
nitrofurantoin monohyd/mcryst .................................. 15 nitroglycerin ......................... 67 nitroglycerin in 5 % dextrose67 NITROSTAT ........................ 67 NIVA-FOL ......................... 136 nizatidine .............................. 98 NIZORAL............................. 72 NOCTIVA ............................ 89 nolix ...................................... 74 non-drowsy allergy .............120 nora-be ................................ 109 NORCO ................................ 40 NORDITROPIN FLEXPRO ........................................ 101 norepinephrine bitartrate ...... 67 noreth-ethinyl estradiol-iron ........................................ 112 norethindrone (contraceptive) ........................................ 109 norethindrone acetate.......... 109 norethindrone ac-eth estradiol ................................ 109, 112 norethindrone-e.estradiol-iron ........................................ 112 norgestimate-ethinyl estradiol ........................................ 112 NORITATE .......................... 70 norlyda ................................ 109 norlyroc...............................109 NORMOSOL-M IN 5 % DEXTROSE ...................132 NORMOSOL-R .................. 129 NORMOSOL-R IN 5 % DEXTROSE ...................129 NORMOSOL-R PH 7.4......132 NORPRAMIN ......................50 NORTHERA ........................77 nortrel 0.5/35 (28) ............... 112 nortrel 1/35 (21) .................. 112 nortrel 1/35 (28) .................. 112 nortrel 7/7/7 (28).................112 nortriptyline ..........................50 NORVASC ........................... 61 NORVIR ................................. 5 NOVAREL ...........................89 NOVOFINE 32 ..................... 86
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 156
NOVOLIN 70/30 U-100 INSULIN .......................... 86 NOVOLIN N NPH U-100 INSULIN .......................... 86 NOVOLIN R REGULAR U100 INSULN .................... 86 NOVOLOG FLEXPEN U-100 INSULIN .......................... 86 NOVOLOG MIX 70-30 U-100 INSULN ........................... 86 NOVOLOG MIX 7030FLEXPEN U-100 ......... 86 NOVOLOG PENFILL U-100 INSULIN .......................... 86 NOVOLOG U-100 INSULIN ASPART .......................... 86 NOXAFIL .............................. 2 NOXIFOL-D3 .................... 136 NPLATE .............................. 64 NUCALA ........................... 124 NUCYNTA .......................... 43 NUCYNTA ER .................... 43 NUEDEXTA ........................ 35 NUFERA ............................ 136 NULOJIX ............................. 23 NULYTELY WITH FLAVOR PACKS ............................. 94 NUPLAZID .......................... 50 NUTRESTORE .................... 77 NUTRICAP ........................ 136 NUTRILIPID ..................... 133 NUTROPIN AQ NUSPIN . 101 NUVARING....................... 110 NUVIGIL ............................. 50 nyamyc ................................. 72 NYMALIZE ......................... 61 nystatin ............................. 2, 72 nystatin-triamcinolone .......... 72 nystop ................................... 72 O OBREDON ........................ 120 OCALIVA ............................ 94 ocella .................................. 112 OCREVUS ........................... 35 OCTAGAM ........................ 104 octreotide acetate .................. 23 OCUFLOX ......................... 114 ODEFSEY .............................. 5
ODOMZO ............................ 23 OFEV.................................. 124 ofloxacin ................. 14, 79, 114 ogestrel (28) ........................ 112 okebo .................................... 15 olanzapine............................. 50 olanzapine-fluoxetine ........... 50 olmesartan ............................ 61 olmesartan-amlodipinhcthiazid ........................... 61 olmesartanhydrochlorothiazide .......... 61 olopatadine ................... 79, 115 OLUX ................................... 74 OLYSIO ................................. 5 OMECLAMOX-PAK .......... 98 omega-3 acid ethyl esters ..... 65 omeppi .................................. 98 omeprazole ........................... 98 omeprazole magnesium ........ 98 omeprazole-sodium bicarbonate ....................... 98 OMNARIS.......................... 124 OMNIPOD INSULIN MANAGEMENT ............. 86 OMNIPRED ....................... 116 OMNITROPE..................... 101 OMNIVEX ......................... 136 ONCASPAR......................... 23 ondansetron .......................... 94 ondansetron hcl..................... 94 ondansetron hcl (pf).............. 94 ONETOUCH ULTRA BLUE TEST STRIP..................... 86 ONETOUCH ULTRA2........ 86 ONETOUCH ULTRAMINI. 86 ONETOUCH VERIO ........... 87 ONETOUCH VERIO IQ METER ............................ 87 ONETOUCH VERIO SYSTEM .......................... 87 ONEXTON........................... 70 ONFI ..................................... 30 ONGLYZA........................... 87 ONIVYDE ............................ 23 ONMEL .................................. 2 ONZETRA XSAIL............... 33 OPANA ................................ 40
opcicon one-step .................112 OPDIVO ............................... 23 opium tincture ....................... 91 OPSUMIT........................... 124 option-2...............................112 ORACEA .............................. 15 oral saline laxative ................ 94 ORALAIR .......................... 104 oralone .................................. 79 ORAP ...................................50 ORAPRED ODT ..................80 ORAVIG.................................2 ORBACTIV .......................... 11 ORENCIA .......................... 107 ORENCIA (WITH MALTOSE) ....................107 ORENCIA CLICKJECT ....107 ORENITRAM ...................... 61 ORFADIN ............................ 77 ORKAMBI ......................... 124 orsythia ............................... 112 ortho d .................................136 ORTHO DF ........................136 ORTHO MICRONOR ........109 ORTHO TRI-CYCLEN (28) ........................................ 112 ORTHO TRI-CYCLEN LO (28) ................................. 112 ORTHO-CYCLEN (28) ..... 112 ORTHO-NOVUM 1/35 (28) ........................................ 112 ORTHO-NOVUM 7/7/7 (28) ........................................ 112 oseltamivir .............................. 5 OSENI ..................................87 osmitrol 15 % ....................... 61 osmitrol 20 % ....................... 61 OSMOPREP ......................... 94 OTEZLA............................. 107 OTEZLA STARTER .......... 107 OTOVEL .............................. 79 OTREXUP (PF)..................107 OVIDE .................................. 75 OVIDREL............................. 89 oxacillin ................................ 13 oxacillin in dextrose(iso-osm) .......................................... 13 oxaliplatin .............................23
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 157
oxandrolone .................... 89, 90 oxaprozin .............................. 43 OXAYDO ............................ 40 oxcarbazepine ....................... 30 oxiconazole........................... 72 OXISTAT ............................. 72 OXSORALEN ULTRA ....... 68 OXTELLAR XR .................. 30 oxybutynin chloride............ 126 oxycodone ............................ 40 OXYCODONE .................... 40 oxycodone-acetaminophen ... 40 oxycodone-aspirin ................ 40 OXYCONTIN ...................... 40 oxymorphone.................. 40, 41 oxytocin .............................. 113 OXYTROL ......................... 126 oysco 500/d ........................ 129 oyster shell + d3 ................. 129 oyster shell calcium-vit d2 . 136 oyster shell calcium-vit d3 . 129 oystercal-d .......................... 129 OZEMPIC ............................ 87 OZURDEX ......................... 116 P pacerone ............................... 57 paclitaxel .............................. 23 paliperidone .......................... 51 palonosetron ......................... 94 PALONOSETRON .............. 94 PAMELOR ........................... 51 pamidronate .......................... 90 PANCREAZE ...................... 95 PANDEL .............................. 74 panlor(acetam-caffdihydrocod) ...................... 41 PANRETIN .......................... 68 pantoprazole ......................... 98 PAPAV-PHENTOLAMALPROST-WATER ...... 127 PAPAV-PHENTOLAMINE IN WATER .................... 127 paregoric ............................... 91 paricalcitol ............................ 90 PARLODEL ......................... 32 PARNATE ........................... 51 paroex oral rinse ................... 79 paromomycin........................ 11
paroxetine hcl ....................... 51 paroxetine mesylate(menop.sym)....... 51 PASER.................................. 11 PATADAY ......................... 115 PATANASE ......................... 79 PATANOL ......................... 115 PAXIL .................................. 51 PAXIL CR ............................ 51 PAZEO ............................... 115 PCE......................................... 9 PEDIARIX (PF) ................. 104 PEDVAX HIB (PF) ............ 104 peg 3350-electrolytes ........... 95 peg3350 ................................ 95 PEGANONE ........................ 30 PEGASYS .......................... 101 PEGASYS PROCLICK ..... 101 peg-electrolyte ...................... 95 PEGINTRON ..................... 101 peg-prep ................................ 95 PENICILLIN G POT IN DEXTROSE ..................... 13 penicillin g potassium........... 13 penicillin g procaine ............. 13 penicillin g sodium ............... 13 penicillin v potassium........... 13 PENNSAID .......................... 43 PENTACEL (PF) ............... 104 PENTAM.............................. 11 PENTASA ............................ 95 pentoxifylline........................ 64 PEPCID ................................ 98 PERCOCET.......................... 41 PERFOROMIST ................ 124 perindopril erbumine ............ 61 periogard ............................... 79 PERJETA ............................. 24 permethrin ............................ 75 perphenazine ......................... 51 PERTZYE ............................ 95 PEXEVA .............................. 51 pfizerpen-g............................ 13 phenazopyridine ................. 127 phendimetrazine tartrate ....... 75 phenelzine............................. 51 PHENERGAN .................... 120 phenobarbital ........................ 30
phenobarbital sodium ........... 30 phenoxybenzamine ............... 61 phentermine .......................... 75 phentolamine ........................ 61 PHENYTEK .........................30 phenytoin ........................30, 31 phenytoin sodium ................. 31 phenytoin sodium extended .. 31 philith .................................. 112 PHOSLYRA .......................129 phosphate laxative ................95 PHOSPHOLINE IODIDE ..114 PHYSICIANS EZ USE B-12 ........................................ 136 PHYSIOLYTE .....................75 PHYSIOSOL IRRIGATION 75 PHYTONADIONE (VITAMIN K1) ................ 64 PICATO ................................ 68 pilocarpine hcl .............. 77, 115 pimozide ............................... 51 pimtrea (28) ........................ 112 pindolol ................................. 61 pioglitazone .......................... 87 pioglitazone-glimepiride....... 87 pioglitazone-metformin ........ 87 piperacillin-tazobactam ........ 13 pirmella ............................... 112 piroxicam .............................. 43 PLAN B ONE-STEP ..........112 PLAQUENIL ........................ 11 plasbumin 25 % .................. 128 plasbumin 5 % .................... 128 PLASMA-LYTE 148 ......... 133 PLASMA-LYTE A ............ 133 plasmanate .......................... 133 PLAVIX ............................... 64 PLEGRIDY ........................ 101 plenamine ........................... 133 PLIAGLIS ............................ 71 PNEUMOVAX 23..............104 podofilox...............................68 polocaine............................... 71 polocaine-mpf ....................... 71 polycin ................................ 114 polyethylene glycol 3350 ..... 95 poly-iron 150 forte .............. 136 polymyxin b sulfate .............. 11
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 158
polymyxin b sulf-trimethoprim ........................................ 114 POLYTRIM ....................... 114 POLY-TUSSIN AC ........... 120 POMALYST ........................ 24 portia................................... 112 PORTRAZZA ...................... 24 POTABA ............................ 129 potassium acetate................ 130 potassium bicarb and chloride ........................................ 130 potassium bicarb-citric acid 130 potassium chlorid-d50.45%nacl ....................... 130 potassium chloride.............. 130 potassium chloride in 0.9%nacl ........................................ 130 potassium chloride in 5 % dex ........................................ 130 potassium chloride in lr-d5. 130 potassium chloride in water 130 potassium chloride-0.45 % nacl ........................................ 130 potassium chloride-d50.2%nacl ......................... 130 potassium chloride-d50.3%nacl ......................... 131 potassium chloride-d50.9%nacl ......................... 131 potassium citrate................. 127 potassium phosphate m-/dbasic................................ 131 powderlax ............................. 95 PRADAXA .......................... 64 PRALUENT PEN .......... 65, 66 pramipexole .......................... 32 PRANDIN ............................ 87 prasugrel ............................... 64 PRAVACHOL ..................... 66 pravastatin ............................ 66 praziquantel .......................... 11 prazosin ................................ 61 PRECISION XTRA MONITOR ....................... 87 PRECOSE ............................ 87 PRED FORTE .................... 116 PRED MILD ...................... 116 PRED-G ............................. 116
PRED-G S.O.P. .................. 116 prednicarbate ........................ 74 prednisolone ......................... 80 prednisolone acetate ........... 116 prednisolone sodium phosphate .................................. 80, 116 prednisone ............................ 80 prednisone intensol ............... 80 PREFEST ........................... 109 PREGNYL............................ 90 PREMARIN ....................... 109 premasol 10 % .................... 133 PREMASOL 6 % ............... 133 PREMPHASE .................... 109 PREMPRO ......................... 109 PRENATAL VITAMIN ORAL TABLET ............. 136 PREPOPIK ........................... 95 PREVACID .......................... 98 PREVACID 24HR ............... 98 PREVACID SOLUTAB....... 99 prevalite ................................ 66 PREVIDENT 5000 BOOSTER PLUS ................................ 79 previfem.............................. 112 PREVNAR 13 (PF) ............ 104 PREVPAC ............................ 99 PREVYMIS ............................ 5 PREZCOBIX .......................... 5 PREZISTA ............................. 5 PRIFTIN ............................... 11 PRILOSEC ........................... 99 PRILOSEC OTC .................. 99 PRIMAQUINE ..................... 11 PRIMAXIN IV ..................... 11 primidone.............................. 31 PRIMLEV ............................ 41 PRINIVIL ............................. 61 PRISTIQ ............................... 52 PRIVIGEN ......................... 104 PROAIR HFA .................... 124 PROAIR RESPICLICK ..... 124 probenecid .......................... 105 probenecid-colchicine ........ 105 procainamide ........................ 57 PROCALAMINE 3% ......... 133 PROCARDIA XL................. 61 procentra ............................... 52
prochlorperazine ................... 95 prochlorperazine edisylate .... 95 prochlorperazine maleate oral .......................................... 95 PROCRIT ........................... 101 procto-med hc ....................... 95 procto-pak ............................. 95 proctosol hc .......................... 95 proctozone-hc ....................... 95 PROCYSBI.........................127 profeno .................................. 43 PROFERRIN-FORTE ........136 progesterone ....................... 109 progesterone in oil ..............109 progesterone micronized .... 109 PROGLYCEM .....................87 PROGRAF ............................ 24 PROLASTIN-C ....................77 PROLENSA .......................115 PROLEUKIN .....................102 PROLIA .............................. 106 PROMACTA ........................64 promethazine .............. 120, 121 PROMETHAZINE (BULK) ........................................ 120 promethazine vc-codeine .... 121 promethazine-codeine......... 121 promethazine-dm ................ 121 promethazine-phenylephcodeine ............................ 121 PROMETRIUM .................109 propafenone ..........................57 propranolol ........................... 61 propranolol-hydrochlorothiazid .......................................... 62 propylthiouracil .................... 81 PROQUAD (PF).................104 PRO-RED AC (W/ DEXCHLORPHENIR)...121 PROSCAR .......................... 127 PROSOL 20 % ................... 133 protamine .............................. 64 PROTECT IRON................136 PROTONIX .......................... 99 PROTOPIC ........................... 69 protriptyline ..........................52 PROVENTIL HFA .............124 PROVERA ......................... 109
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 159
PROVIGIL ........................... 52 PROZAC .............................. 52 prudoxin ............................... 69 PSORCON ........................... 74 PULMICORT ..................... 124 PULMICORT FLEXHALER ................................ 124, 125 PULMOZYME .................. 125 PURALOR CI .................... 136 purelax .................................. 95 purevit dualfe plus .............. 136 PURIXAN ............................ 24 PYLERA .............................. 99 pyrazinamide ........................ 11 PYRIDIUM ........................ 127 pyridostigmine bromide ....... 35 pyridoxine (vitamin b6)...... 136 PYRILAMINE MALEATE (BULK) .......................... 121 Q QBRELIS ............................. 62 QNASL .............................. 125 QSYMIA .............................. 75 QTERN ................................ 87 QUADRACEL (PF) ........... 104 QUALAQUIN ...................... 11 QUARTETTE .................... 112 quasense ............................. 112 QUDEXY XR ...................... 31 QUESTRAN......................... 66 QUESTRAN LIGHT............ 66 quetiapine ............................. 52 QUFLORA ......................... 136 QUFLORA FE ................... 136 QUILLICHEW ER ............... 52 QUILLIVANT XR ............... 52 quinapril ............................... 62 quinapril-hydrochlorothiazide .......................................... 62 quinidine gluconate .............. 57 quinidine sulfate ................... 57 quinine sulfate ...................... 11 quit 2..................................... 79 QUIT 2 ................................. 79 quit 4..................................... 79 QUIT 4 ................................. 79 QVAR ................................ 125 QVAR REDIHALER ......... 125
R RABAVERT (PF) .............. 104 rabeprazole ........................... 99 RADICAVA ......................... 35 RAGWITEK....................... 104 rajani ................................... 112 raloxifene ............................ 106 ramipril ................................. 62 RANEXA ............................. 67 ranitidine hcl ......................... 99 RAPAFLO .......................... 127 RAPAMUNE........................ 24 rasagiline .............................. 32 RASUVO (PF) ................... 107 RAVICTI .............................. 77 RAYALDEE ........................ 90 RAYOS ................................ 81 RAZADYNE ........................ 35 RAZADYNE ER .................. 35 REBETOL .............................. 5 REBIF (WITH ALBUMIN) ........................................ 102 REBIF REBIDOSE ............ 102 REBIF TITRATION PACK ........................................ 102 RECLAST ............................ 77 reclipsen (28) ...................... 112 RECOMBIVAX HB (PF) . 104, 105 RECTIV................................ 95 REGIMEX ............................ 75 REGLAN .............................. 95 regonol .................................. 35 REGRANEX ........................ 69 relcof c ................................ 121 RELENZA DISKHALER ...... 5 relion glucose ....................... 87 RELISTOR ..................... 95, 96 RELPAX .............................. 33 REMERON .......................... 52 REMERON SOLTAB .......... 52 REMICADE ......................... 96 REMODULIN ...................... 62 RENACIDIN ...................... 127 RENAGEL ........................... 77 renal caps ............................ 136 rena-vite .............................. 136 rena-vite rx ......................... 136
RENFLEXIS.........................96 reno caps ............................. 136 RENVELA ........................... 77 repaglinide ............................ 87 repaglinide-metformin .......... 87 REPATHA ............................ 66 REPATHA PUSHTRONEX 66 REPATHA SURECLICK ....66 REQ49+ ..............................136 REQUIP ................................ 32 REQUIP XL .........................32 RESCRIPTOR ........................ 5 RESPA-AR ......................... 121 RESTASIS .......................... 115 RESTASIS MULTIDOSE..115 RETIN-A .............................. 70 RETIN-A MICRO ................70 RETROVIR ............................ 5 REVATIO........................... 125 REVESTA .......................... 136 REVLIMID...........................24 revonto ..................................35 REXULTI ............................. 52 REYATAZ ............................. 5 RHOFADE ...........................70 RHOPRESSA .....................116 ribasphere ............................... 5 ribasphere ribapak .................. 5 ribavirin ..................................5 RIDAURA .......................... 107 rifabutin ................................ 11 RIFADIN .............................. 11 RIFAMATE .......................... 11 rifampin ................................ 11 RIFATER .............................11 RILUTEK ............................. 77 riluzole .................................. 77 rimantadine ............................. 6 ringer's .......................... 75, 131 RIOMET ............................... 87 risacal-d ..............................137 risedronate ....................77, 106 RISPERDAL ........................ 53 RISPERDAL CONSTA . 52, 53 risperidone ............................ 53 RITALIN .............................. 53 RITALIN LA ........................53 ritonavir .................................. 6
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 160
RITUXAN ............................ 24 RITUXAN HYCELA........... 24 rivastigmine .......................... 35 rivastigmine tartrate.............. 35 rivelsa ................................. 113 rizatriptan ............................. 33 robafen ac ........................... 121 ROBINUL ............................ 91 ROBINUL FORTE .............. 91 ROCALTROL ...................... 90 ROMIDEPSIN ..................... 24 ropinirole .............................. 32 rosadan ................................. 70 rosuvastatin........................... 66 ROTARIX .......................... 105 ROTATEQ VACCINE ...... 105 ROWASA ............................ 96 roweepra ............................... 31 roweepra xr........................... 31 ROXICODONE ................... 41 ROXIFOL-D ...................... 137 ROZEREM ........................... 53 RUBRACA .......................... 24 RUCONEST ....................... 125 RYDAPT .............................. 24 rydex ................................... 121 RYTARY ............................. 32 RYTHMOL SR .................... 57 S SABRIL................................ 31 SAFYRAL.......................... 113 SAIZEN.............................. 102 SAIZEN CLICK.EASY ..... 102 SALAGEN (PILOCARPINE) .......................................... 77 salsalate ................................ 43 SAMSCA ............................. 90 SANCUSO ........................... 96 SANDIMMUNE .................. 24 SANDOSTATIN .................. 24 SANDOSTATIN LAR DEPOT ............................. 24 SANTYL .............................. 75 SAPHRIS (BLACK CHERRY) ........................ 53 SARAFEM ........................... 53 SAVAYSA ........................... 64 SAVELLA.......................... 107
SAXENDA ........................... 75 scopolamine base .................. 96 SEASONIQUE ................... 113 SEEBRI NEOHALER........ 125 SEGLUROMET ................... 87 selegiline hcl ......................... 32 selenium sulfide .................... 68 SELZENTRY ......................... 6 SEMPREX-D ..................... 121 SENSIPAR ........................... 90 sensorcaine ........................... 71 sensorcaine-mpf.................... 71 SEREVENT DISKUS ........ 125 SERNIVO............................. 74 SEROQUEL ......................... 54 SEROQUEL XR................... 54 SEROSTIM ........................ 102 sertraline ............................... 54 se-tan plus ........................... 137 setlakin................................ 113 sevelamer carbonate ............. 78 sf 79 sf 5000 plus .......................... 79 sharobel .............................. 109 SHINGRIX (PF) ................. 105 SIGNIFOR............................ 24 SIGNIFOR LAR................... 24 sildenafil ............................. 127 sildenafil (pulmonary arterial hypertension) .................. 125 SILENOR ............................. 54 SILIQ .................................... 68 SILVADENE........................ 68 silver sulfadiazine ................. 68 SIMBRINZA ...................... 116 SIMPONI............................ 107 SIMPONI ARIA ................. 108 SIMULECT .......................... 24 simvastatin ............................ 66 SINEMET............................. 32 SINEMET CR ...................... 32 SINGULAIR ...................... 125 sirolimus ............................... 24 SIRTURO ............................. 11 SIVEXTRO .......................... 11 SKLICE ................................ 75 smoothlax ............................. 96 sodium acetate .................... 131
sodium benzoate-sod phenylacet .........................78 sodium bicarbonate ............. 131 sodium chloride ............ 78, 131 sodium chloride 0.45 % ...... 131 sodium chloride 0.9 % .......... 78 sodium chloride 3 % ........... 131 sodium chloride 5 % ........... 131 sodium ferric gluconat-sucrose .......................................... 78 sodium lactate intravenous . 131 sodium nitroprusside ............ 67 sodium phenylbutyrate ......... 78 sodium phosphate ............... 131 sodium polystyrene (sorb free) .......................................... 78 sodium polystyrene sulfonate .......................................... 78 SOLARAZE .........................69 SOLIQUA 100/33 ................87 SOLIRIS ............................... 78 SOLODYN ........................... 15 SOLTAMOX ........................24 SOLU-CORTEF (PF) ...........81 SOLU-MEDROL ................. 81 SOLU-MEDROL (PF) .........81 SOMATULINE DEPOT ......24 SOMAVERT ........................ 90 SONATA .............................. 54 SOOLANTRA ...................... 70 SORIATANE .......................68 SORILUX ............................. 68 sorine .................................... 57 sotalol ...................................57 sotalol af ............................... 57 SOTYLIZE ........................... 57 SOVALDI...............................6 SPIRIVA RESPIMAT ........125 SPIRIVA WITH HANDIHALER .............. 125 spironolactone....................... 62 spironolacton-hydrochlorothiaz .......................................... 62 SPORANOX...........................2 sprintec (28) ........................ 113 SPRITAM .............................31 SPRIX ................................... 43 SPRYCEL.............................25
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 161
sps (with sorbitol) ................. 78 sronyx ................................. 113 ssd ......................................... 68 STALEVO 100..................... 32 STALEVO 125..................... 32 STALEVO 150..................... 32 STALEVO 200..................... 32 STALEVO 50....................... 32 STALEVO 75....................... 32 STAMARIL (PF) ............... 105 STARLIX ............................. 87 stavudine................................. 6 STAXYN............................ 127 STEGLATRO....................... 87 STEGLUJAN ....................... 87 STELARA ............................ 68 STENDRA ......................... 127 STIMATE ............................ 90 STIOLTO RESPIMAT ...... 125 STIVARGA.......................... 25 stop smoking aid................... 79 STRATTERA ....................... 54 STRENSIQ ........................... 90 STREPTOMYCIN ............... 11 stress formula ..................... 137 stress formula 600 c............ 137 stress formula with iron ...... 137 stress formula with iron(sulf) ........................................ 137 STRIANT ............................. 90 STRIBILD .............................. 6 STRIVERDI RESPIMAT .. 125 STROMECTOL ................... 11 STROVITE FORTE ........... 137 STROVITE ONE ............... 137 SUBOXONE ........................ 43 SUBSYS ............................... 41 SUCRAID ............................ 96 sucralfate .............................. 99 SULAR ................................. 62 sulfacetamide sodium ......... 117 sulfacetamide sodium (acne) 72 sulfacetamide-prednisolone 116 sulfadiazine........................... 14 sulfamethoxazole-trimethoprim .......................................... 14 SULFAMYLON .................. 72 sulfasalazine ......................... 96
sulfatrim................................ 14 sulindac................................. 43 sumatriptan ........................... 33 sumatriptan succinate ........... 33 sumatriptan-naproxen ........... 33 SUMAVEL DOSEPRO ....... 33 super b complex-vitamin c . 137 super b maxi complex......... 137 super b-50 complex plus..... 137 super quints......................... 137 super quints b-50 ................ 137 superplex-t .......................... 137 SUPERVITE ...................... 137 SUPRAX ................................ 8 SUPREP BOWEL PREP KIT .......................................... 96 SURMONTIL....................... 54 SUSTIVA ............................... 6 SUTENT............................... 25 syeda ................................... 113 SYLATRON....................... 102 SYLVANT ........................... 25 SYMBICORT..................... 125 SYMBYAX .......................... 54 SYMDEKO ........................ 125 SYMFI .................................... 6 SYMFI LO ............................. 6 SYMLINPEN 120 ................ 87 SYMLINPEN 60 .................. 87 SYMPROIC ......................... 96 SYNAGIS............................... 6 SYNALAR ........................... 74 SYNAREL............................ 90 SYNDROS ........................... 96 SYNERCID .......................... 11 SYNJARDY ......................... 87 SYNJARDY XR................... 87 SYNRIBO ............................ 25 SYNTHROID ....................... 91 SYPRINE ............................. 78 T TABLOID ............................ 25 TACLONEX ........................ 68 tacrolimus ....................... 25, 69 TAFINLAR .......................... 25 TAGRISSO .......................... 25 TAKE ACTION ................. 113 TALTZ AUTOINJECTOR .. 68
TALTZ SYRINGE ............... 68 TAMIFLU .............................. 6 tamoxifen .............................. 25 tamsulosin ........................... 127 TANDEM PLUS ................ 137 TANZEUM...........................87 TAPAZOLE ......................... 81 TAPERDEX .........................81 TARCEVA ........................... 25 TARGADOX ........................ 15 TARGRETIN .......................25 tarina fe 1/20 (28) ............... 113 TARKA ................................ 62 taron forte ...........................137 TASIGNA............................. 25 TASMAR .............................32 TAXOTERE .........................25 tazarotene .............................. 70 TAZICEF ................................ 8 TAZORAC ........................... 70 taztia xt ................................. 62 TECENTRIQ ........................25 TECFIDERA ........................ 35 TECHNIVIE ...........................6 TEFLARO .............................. 8 TEGRETOL ......................... 31 TEGRETOL XR ................... 31 TEKTURNA.........................62 TEKTURNA HCT................ 62 telmisartan ............................ 62 telmisartan-amlodipine ......... 62 telmisartan-hydrochlorothiazid .......................................... 62 TEMODAR .......................... 25 temozolomide ....................... 25 TENIVAC (PF) .................. 105 tenofovir disoproxil fumarate . 6 TENORETIC 100 .................62 TENORETIC 50 ...................62 TENORMIN .........................62 TERAZOL 7 .......................110 terazosin ................................ 62 terbinafine hcl .........................2 terbutaline ...........................125 terconazole .......................... 110 TESSALON PERLES ........ 121 TESTIM ................................ 90 testosterone ........................... 90
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 162
TESTOSTERONE ............... 90 testosterone cypionate .......... 90 testosterone enanthate .......... 90 TESTRED ............................ 90 TETANUS,DIPHTHERIA TOX PED(PF) ................ 105 TETANUS-DIPHTHERIA TOXOIDS-TD................ 105 tetrabenazine......................... 35 tetracycline ........................... 15 THALOMID......................... 25 THEO-24 ............................ 125 theophylline ................ 125, 126 theophylline in dextrose 5 % ........................................ 125 thiamine hcl (vitamin b1) ... 137 THIOLA ............................... 78 thioridazine ........................... 54 thiotepa ................................. 25 thiothixene ............................ 54 THYMOGLOBULIN ......... 105 THYROLAR-1 ..................... 91 THYROLAR-1/2.................. 91 THYROLAR-1/4.................. 91 THYROLAR-2 ..................... 91 THYROLAR-3 ..................... 91 tiagabine ............................... 31 TIAZAC ............................... 62 TICE BCG .......................... 105 TIGECYCLINE ................... 11 TIKOSYN ............................ 57 tilia fe.................................. 113 timolol maleate ............. 62, 114 TIMOPTIC OCUDOSE (PF) ........................................ 114 TIMOPTIC-XE .................. 114 TINDAMAX ........................ 11 tinidazole .............................. 11 TIROSINT............................ 91 TIVICAY ............................... 6 TIVORBEX.......................... 43 tizanidine .............................. 35 tl gard rx ............................. 137 tl icon .................................. 137 tl-hem 150 .......................... 137 TOBI .................................... 11 TOBI PODHALER .............. 11 TOBRADEX ...................... 116
TOBRADEX ST................. 116 tobramycin .......................... 114 tobramycin in 0.225 % nacl .. 11 tobramycin sulfate ................ 12 tobramycin-dexamethasone 116 TOBREX ............................ 114 TODAY CONTRACEPTIVE SPONGE ........................ 110 TOFRANIL .......................... 54 TOLAK ................................ 69 tolazamide ............................ 88 tolbutamide ........................... 88 tolcapone .............................. 32 tolmetin................................. 43 tolterodine ........................... 126 TOPAMAX .......................... 31 TOPICORT .......................... 74 topiramate ............................. 31 TOPIRAMATE .................... 31 toposar .................................. 25 topotecan ........................ 25, 26 TOPROL XL ........................ 62 TORISEL.............................. 26 torsemide .............................. 62 total b/c ............................... 137 TOUJEO MAX SOLOSTAR .......................................... 88 TOUJEO SOLOSTAR U-300 INSULIN .......................... 88 TOVIAZ ............................. 126 TPN ELECTROLYTES ..... 131 TRACLEER ....................... 126 TRADJENTA ....................... 88 tramadol ................................ 44 TRAMADOL ....................... 44 tramadol-acetaminophen ...... 44 trandolapril ........................... 62 trandolapril-verapamil .......... 62 tranexamic acid............. 64, 110 TRANSDERM-SCOP .......... 96 TRANXENE T-TAB ............ 54 tranylcypromine.................... 54 travasol 10 % ...................... 133 TRAVATAN Z................... 116 trazodone .............................. 54 TREANDA ........................... 26 TRECATOR ......................... 12 TRELEGY ELLIPTA......... 126
TRELSTAR .......................... 26 TREMFYA ........................... 68 TRESIBA FLEXTOUCH U100 .................................... 88 TRESIBA FLEXTOUCH U200 .................................... 88 tretinoin (chemotherapy) ...... 26 tretinoin microspheres .......... 70 tretinoin topical ..................... 70 TREXALL ............................ 26 TREXIMET .......................... 33 TREZIX ................................ 41 tri femynor .......................... 113 triamcinolone acetonide. 74, 79, 81, 126 triamterene-hydrochlorothiazid .......................................... 62 trianex ...................................74 TRIBENZOR ........................ 62 tri-buffered aspirin ................44 tricon ...................................137 TRICOR ............................... 66 triderm .................................. 74 TRIDESILON.......................75 trientine .................................78 tri-estarylla .......................... 113 TRIFERIC .......................... 137 trifluoperazine....................... 54 trifluridine ........................... 114 trigels-f forte ....................... 137 TRIGLIDE ............................ 66 triklo ..................................... 66 tri-legest fe .......................... 113 TRILEPTAL .........................31 tri-linyah .............................113 TRILIPIX ............................. 66 tri-lo-estarylla ..................... 113 tri-lo-marzia ........................ 113 tri-lo-sprintec ...................... 113 trilyte with flavor packets ..... 96 trimethoprim ......................... 15 trimipramine ......................... 54 trinessa (28) ........................ 113 trinessa lo ............................113 TRI-NORINYL (28) ........... 113 TRINTELLIX .......................54 TRIOSTAT ........................... 91
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 163
TRIPELENNAMINE (BULK) ........................................ 121 triphrocaps .......................... 137 tri-previfem (28) ................. 113 TRIPROLIDINE HCL (BULK) .......................... 121 TRISENOX .......................... 26 tri-sprintec (28)................... 113 TRIUMEQ.............................. 6 tri-vit with fluoride and iron ........................................ 137 tri-vitamin with fluoride ..... 137 trivora (28).......................... 113 tri-vylibra............................ 113 TRIZIVIR ............................... 6 TROGARZO .......................... 6 TROKENDI XR ................... 31 TROPHAMINE 10 % ........ 133 TROPHAMINE 6% ........... 133 trospium.............................. 127 TRUEPLUS GLUCOSE ...... 78 TRUEPLUS KETONE......... 88 TRULANCE......................... 96 TRULICITY ......................... 88 TRUMENBA ..................... 105 TRUSOPT .......................... 116 TRUVADA ............................ 6 TUDORZA PRESSAIR ..... 126 tusnel c................................ 121 TUSNEL PEDIATRIC....... 121 TUSSICAPS ....................... 121 tussigon .............................. 121 TUSSIONEX PENNKINETIC ER ................................... 121 TUZISTRA XR .................. 121 TWINRIX (PF) .................. 105 TWYNSTA .......................... 62 TYBOST ................................ 6 tydemy ................................ 113 TYGACIL ............................ 12 TYKERB .............................. 26 TYLENOL-CODEINE #3 ... 41 TYLENOL-CODEINE #4 ... 41 TYMLOS ........................... 106 TYPHIM VI ....................... 105 TYSABRI ............................. 35 TYVASO............................ 126
TYVASO INSTITUTIONAL START KIT.................... 126 TYVASO REFILL KIT...... 126 TYVASO STARTER KIT . 126 U UCERIS ................................ 96 UDAMIN SP ...................... 137 ULORIC ............................. 105 ultra b-100 complex............ 137 ULTRACET ......................... 44 ULTRAM ............................. 44 ULTRAVATE ...................... 75 UNASYN ............................. 13 unithroid ............................... 91 UNITUXIN .......................... 26 UPTRAVI ............................. 62 URECHOLINE .................. 127 URISTIX 4 ........................... 88 URISTIX REAGENT........... 88 UROCIT-K 10 .................... 127 UROCIT-K 15 .................... 127 UROCIT-K 5 ...................... 127 UROXATRAL ................... 127 URSO 250 ............................ 96 URSO FORTE...................... 96 ursodiol ................................. 96 UTIBRON NEOHALER.... 126 UVADEX ............................. 69 V VABOMERE........................ 12 VAGIFEM .......................... 109 VAGINAL CONTRACEPTIVE FILM ........................................ 110 vaginal contraceptive foam 110 valacyclovir ............................ 6 VALCHLOR ........................ 69 VALCYTE ............................. 6 valganciclovir ......................... 6 VALIUM .............................. 55 valproate sodium .................. 31 valproic acid ......................... 31 valproic acid (as sodium salt) .......................................... 31 valsartan................................ 62 valsartan-hydrochlorothiazide .......................................... 62 VALSTAR............................ 26
VALTREX ............................. 6 VANCOCIN .........................15 vancomycin........................... 16 VANCOMYCIN...................16 VANCOMYCIN IN 0.9 % SODIUM CHL ................. 15 vandazole ............................ 110 VANOS ................................ 75 VANTAS ..............................26 VAQTA (PF) ......................105 VARIVAX (PF)..................105 VARIZIG ............................ 105 VARUBI ...............................96 VASCEPA ............................ 66 VASERETIC ........................62 VASOTEC ............................ 62 v-c forte .............................. 137 VCF CONTRACEPTIVE GEL ........................................ 110 VECAMYL .......................... 67 VECTIBIX ........................... 26 VECTICAL .......................... 68 VELCADE ........................... 26 veletri .................................... 62 velivet triphasic regimen (28) ........................................ 113 VELPHORO .........................78 VELTASSA .......................... 78 VEMLIDY .............................. 6 VENCLEXTA ...................... 26 VENCLEXTA STARTING PACK ...............................26 venlafaxine ...........................55 VENLAFAXINE .................. 55 VENOFER .......................... 137 VENTAVIS ........................ 126 VENTOLIN HFA ............... 126 verapamil .............................. 62 VEREGEN ........................... 69 VERELAN ........................... 62 VERELAN PM .....................62 veripred 20 ............................ 81 VERSACLOZ....................... 55 VERZENIO .......................... 26 VESICARE.........................127 vestura (28) ......................... 113 VFEND ................................... 2 VFEND IV.............................. 2
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 164
VGO 20 ................................ 88 VGO 30 ................................ 88 VGO 40 ................................ 88 VIAGRA ............................ 127 VIBATIV ............................. 16 VIBERZI .............................. 96 VIBRAMYCIN .................... 15 vic-forte .............................. 137 vicodin .................................. 41 vicodin es.............................. 41 vicodin hp ............................. 41 VICTOZA 2-PAK ................ 88 VICTOZA 3-PAK ................ 88 VIDAZA............................... 26 VIDEX 2 GRAM PEDIATRIC ............................................ 6 VIDEX 4 GRAM PEDIATRIC ............................................ 6 VIDEX EC ............................. 6 VIEKIRA PAK ...................... 6 VIEKIRA XR ......................... 6 vienva ................................. 113 vigabatrin.............................. 31 VIGAMOX ........................ 114 VIIBRYD ............................. 55 VIMIZIM ............................. 90 VIMOVO ............................. 44 VIMPAT .............................. 31 vinblastine ............................ 26 vincasar pfs........................... 26 vincristine ............................. 26 vinorelbine............................ 26 VIOKACE ............................ 96 viorele (28) ......................... 113 VIRACEPT ............................ 6 VIRAMUNE .......................... 6 VIRAMUNE XR .................... 6 VIREAD ................................. 6 VIROPTIC ......................... 114 VIRT-CAPS ....................... 137 virt-gard .............................. 137 virtussin ac.......................... 121 virtussin dac........................ 121 virt-vite ............................... 137 VIRT-VITE PLUS ............. 137 VISTOGARD ....................... 16 vit 3..................................... 137 vit b complex-folic acid...... 137
VITAFOL ........................... 137 vitajoy daily d ..................... 137 VITAL-D RX ..................... 137 vitamin b complex .............. 138 vitamin d2 ........................... 138 vitamin d3 ........................... 138 vitamin k ............................... 64 vitamin k1 ............................. 64 vitamins a,c,d and fluoride . 138 vitamins b complex ............ 138 VITA-RESPA..................... 138 VIVELLE-DOT.................. 109 VIVITROL ........................... 44 VIVLODEX ......................... 44 VOGELXO........................... 90 vol-care rx........................... 138 VOLTAREN ........................ 44 voriconazole ........................... 3 VOSEVI ................................. 6 VOTRIENT .......................... 26 VPRIV .................................. 90 vp-vite rx ............................ 138 VRAYLAR........................... 55 vyfemla (28) ....................... 113 vylibra................................. 113 VYTORIN 10-10.................. 66 VYTORIN 10-20.................. 66 VYTORIN 10-40.................. 66 VYTORIN 10-80.................. 66 VYVANSE ........................... 55 VYXEOS .............................. 26 VYZULTA ......................... 116 W wal-fex allergy .................... 121 wal-fex d 12 hour ............... 121 wal-fex d 24 hour ............... 121 wal-itin................................ 121 wal-itin d............................. 121 wal-itin d 12 hour ............... 121 wal-zyr (cetirizine) ............. 121 wal-zyr d ............................. 121 warfarin ................................ 64 water for irrigation, sterile .... 78 WELCHOL .......................... 66 WELLBUTRIN SR .............. 55 WELLBUTRIN XL .............. 56 wera (28)............................. 113 woman's laxative .................. 96
women's gentle laxative(bisac) .......................................... 96 women's laxative (bisacodyl)96 wymzya fe ..........................113 X XALATAN .........................116 XALKORI ............................26 XARELTO ........................... 64 XATMEP .............................. 26 XELJANZ........................... 108 XELJANZ XR ....................108 XELODA .............................. 26 XENAZINE .......................... 35 XEOMIN ............................ 105 XERESE ............................... 72 XERMELO ........................... 27 XGEVA ................................ 16 XIAFLEX .............................78 XIFAXAN ............................ 12 XIGDUO XR ........................88 XIIDRA .............................. 115 XIMINO ...............................15 XOLAIR ............................. 126 XOPENEX ......................... 126 XOPENEX CONCENTRATE ........................................ 126 XOPENEX HFA ................126 XTAMPZA ER.....................41 XTANDI ...............................27 xulane .................................110 XULTOPHY 100/3.6 ...........88 XURIDEN ............................ 78 XYLOCAINE .......................71 xylon 10 ................................ 41 XYREM ................................ 56 XYZAL...............................121 XYZBAC ............................ 138 Y YASMIN (28) ..................... 113 YAZ (28) ............................ 113 YERVOY ............................. 27 YF-VAX (PF) ..................... 105 YONDELIS .......................... 27 YOSPRALA .........................64 yuvafem ..............................109 Z zafirlukast ........................... 126 zaleplon.................................56
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 165
ZALTRAP ............................ 27 ZANAFLEX ......................... 35 ZANOSAR ........................... 27 ZANTAC.............................. 99 zarah ................................... 113 ZARONTIN ......................... 31 ZARXIO ............................. 102 zavara ................................. 138 ZAVESCA ........................... 90 ZEGERID ............................. 99 ZEGERID OTC .................... 99 ZEJULA ............................... 27 ZELAPAR ............................ 32 ZELBORAF ......................... 27 ZEMAIRA............................ 78 ZEMBRACE SYMTOUCH. 33 ZEMPLAR ........................... 90 zenatane ................................ 70 zenchent (28) ...................... 113 ZENPEP ............................... 96 zenzedi.................................. 56 ZENZEDI ............................. 56 ZEPATIER ............................. 6 ZERBAXA ............................. 8 ZERIT..................................... 6 ZESTORETIC ...................... 62 ZESTRIL .............................. 62 ZETIA .................................. 66 ZETONNA ......................... 126 ZIAC .................................... 62 ZIAGEN ............................. 6, 7 ZIANA ................................. 70 zidovudine .............................. 7 zileuton ............................... 126 ZINECARD (AS HCL) ........ 16 ZINPLAVA ........................ 105 ZIOPTAN (PF)................... 116 ziprasidone hcl...................... 56 ZIPSOR ................................ 44
ZIRGAN ............................. 114 ZITHROMAX ........................ 9 ZITHROMAX TRI-PAK ....... 9 ZITHROMAX Z-PAK ........... 9 ZOCOR ................................ 66 ZODRYL AC 25 ................ 121 ZODRYL AC 30 ................ 121 ZODRYL AC 35 ................ 121 ZODRYL AC 40 ................ 121 ZODRYL AC 50 ................ 121 ZODRYL AC 60 ................ 121 ZODRYL AC 80 ................ 121 ZODRYL DAC 25 ............. 121 ZODRYL DAC 30 ............. 121 ZODRYL DAC 35 ............. 121 ZODRYL DAC 40 ............. 121 ZODRYL DAC 50 ............. 121 ZODRYL DAC 60 ............. 121 ZODRYL DAC 80 ............. 121 ZODRYL DEC 25 .............. 121 ZODRYL DEC 30 .............. 121 ZODRYL DEC 35 .............. 121 ZODRYL DEC 40 .............. 122 ZODRYL DEC 50 .............. 122 ZODRYL DEC 60 .............. 122 ZODRYL DEC 80 .............. 122 ZOFRAN .............................. 96 ZOFRAN ODT ..................... 96 ZOHYDRO ER .................... 41 ZOLADEX ........................... 27 zoledronic acid ..................... 90 zoledronic acid-mannitol-water .......................................... 78 ZOLINZA ............................. 27 zolmitriptan .......................... 33 ZOLOFT............................... 56 zolpidem ............................... 56 ZOMACTON ..................... 102 ZOMETA ............................. 91
ZOMIG .................................33 ZOMIG ZMT........................33 ZONALON ........................... 69 ZONEGRAN ........................31 zonisamide ............................ 31 ZONTIVITY.........................64 ZORBTIVE ........................ 102 ZORTRESS .......................... 27 ZORVOLEX.........................44 ZOSTAVAX (PF) ..............105 ZOSYN ................................. 13 ZOSYN IN DEXTROSE (ISOOSM) ................................ 13 zovia 1/35e (28) .................. 113 zovia 1/50e (28) .................. 113 ZOVIRAX ........................ 7, 72 Z-TUSS AC ........................ 122 ZUBSOLV ............................ 44 ZUPLENZ ............................ 96 ZURAMPIC .......................105 ZYBAN ................................ 79 ZYCLARA ........................... 69 ZYDELIG ............................. 27 ZYFLO ............................... 126 ZYFLO CR .........................126 ZYKADIA ............................ 27 ZYLET ............................... 116 ZYLOPRIM ........................ 105 ZYMAXID ......................... 114 ZYPREXA ............................ 56 ZYPREXA RELPREVV ......56 ZYPREXA ZYDIS .........56, 57 ZYRTEC.............................122 ZYRTEC-D ........................ 122 ZYTIGA ............................... 27 ZYVIT ................................ 138 ZYVOX ................................ 12
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 166
