ConnectiCare Medicare Advantage plans ConnectiCare Choice Plan 1 (HMO) ConnectiCare Choice Plan 2 (HMO) ConnectiCare Choice Plan 3 (HMO) ConnectiCare Flex Plan 1 (HMO-POS) ConnectiCare Flex Plan 2 (HMO-POS) ConnectiCare Flex Plan 3 (HMO-POS) ConnectiCare Passage Plan 1 (HMO) 2020 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. 00020081, Version 21 This formulary was updated on 11/01/2020. For more recent information or other questions, please contact ConnectiCare Member Services at 1-800-224-2273, or for TTY users, 711, from 8 a.m. to 8 p.m. ET, seven days a week or visit connecticare.com/medicare. H3528_128286_C
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ConnectiCare Medicare Advantage plans ConnectiCare Choice Plan 1 (HMO) ConnectiCare Choice Plan 2 (HMO) ConnectiCare Choice Plan 3 (HMO) ConnectiCare Flex Plan 1 (HMO-POS) ConnectiCare Flex Plan 2 (HMO-POS) ConnectiCare Flex Plan 3 (HMO-POS) ConnectiCare Passage Plan 1 (HMO)
2020 Formulary (List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. 00020081, Version 21
This formulary was updated on 11/01/2020. For more recent information or other questions, please contact ConnectiCare Member Services at 1-800-224-2273, or for TTY users, 711, from 8 a.m. to 8 p.m. ET, seven days a week or visit connecticare.com/medicare.
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 ConnectiCare. When it refers to “plan” or “our plan,” it means ConnectiCare Medicare Advantage plans. Our Medicare Advantage plans include ConnectiCare Choice Plan 1 (HMO), ConnectiCare Choice Plan 2 (HMO), ConnectiCare Choice Plan 3 (HMO), ConnectiCare Flex Plan 1 (HMO-POS), ConnectiCare Flex Plan 2 (HMO-POS), ConnectiCare Flex Plan 3 (HMO-POS) and ConnectiCare Passage Plan 1 (HMO).
This document includes a list of the drugs (formulary) for our plan, which is current as of 11/01/2020. 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, 2021, and from time to time during the year.
ConnectiCare, Inc. is an HMO/HMO-POS plan with a Medicare contract. Enrollment in ConnectiCare depends on contract renewal.
ii
What is the ConnectiCare formulary?
A formulary is a list of covered drugs selected by our plan 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. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan 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? Most changes in drug coverage happen on January 1, but our plan may add or remove drugs on the drug list during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.
Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:
• New generic drugs. We may immediately remove a brand-name drug on our drug listif we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new genericdrug, we may decide to keep the brand-name drug on our drug list, but immediately moveit to a different cost-sharing tier or add new restrictions. If you are currently taking thatbrand-name drug, we may not tell you in advance before we make that change, but wewill later provide you with information about the specific change(s) we have made.
• If we make such a change, you or your prescriber can ask us to make an exceptionand continue to cover the brand-name drug for you. The notice we provide you willalso include information on how to request an exception, and you can also findinformation in the section on page vi entitled “How do I request an exception to theConnectiCare formulary?”
• Drugs removed from the market. If the Food and Drug Administration (FDA) deems adrug on our formulary to be unsafe or the drug’s manufacturer removes the drug from themarket, we will immediately remove the drug from our formulary and provide notice tomembers who take the drug.
• Other changes. We may make other changes that affect members currently taking adrug. For instance, we may add a generic drug that is not new to market to replace abrand-name drug currently on the formulary or add new restrictions to the brand-namedrug or move it to a different cost-sharing tier. Or, we may make changes based onnew clinical guidelines. If we remove drugs from our formulary, add prior authorization,quantity limits and/or step therapy restrictions on a drug or move a drug to a highercost-sharing tier, we must notify affected members of the change at least 30 days beforethe change becomes effective, or at the time the member requests a refill of the drug, atwhich time the member will receive a 30-day supply of the drug.
• If we make these other changes, you or your prescriber can ask us to make anexception and continue to cover the brand-name drug for you. The notice we provideyou will also include information on how to request an exception, and you can also findinformation on page vi entitled “How do I request an exception to the ConnectiCareformulary?”
iii
Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described on page iii. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year.
The enclosed formulary is current as of 11/01/2020. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages.
Note: In the event of a mid-year, non-maintenance formulary change, the change is added to a comprehensive list of changes that have been made since the formulary was printed. The list of changes is included with the formulary booklet that is mailed to new members with their welcome kit. Existing members can view the updated formulary by visiting us on the web at www.connecticare.com/medicare. The formulary that is posted on our website is updated monthly.
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. 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, “Cardiovascular Hypertensive/ Lipids.” If you know what your drug is used for, look for the category name in the list that begins on page 1. 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 87. 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? Our plan 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: Our plan requires you or your physician to get prior authorizationfor certain drugs. This means that you will need to get approval from our plan beforeyou fill your prescriptions. If you don’t get approval, our plan may not cover the drug.
• Quantity Limits: For certain drugs, our plan limits the amount of the drug that we willcover. For example, our plan provides 30 tablets per prescription for JANUVIA®. This maybe in addition to a standard one-month or three-month supply.
• Step Therapy: In some cases, our plan requires you to first try certain drugs to treatyour medical condition before we will cover another drug for that condition. For example,if Drug A and Drug B both treat your medical condition, our plan may not cover Drug Bunless you try Drug A first. If Drug A does not work for you, our plan will then coverDrug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online 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 our plan 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 ConnectiCare formulary?”, on page vi for information about how to request an exception.
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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. The Member Services phone number is listed on the front and back cover pages.
If you learn that our plan does not cover your drug, you have two options:
• You can ask Member Services for a list of similar drugs that are covered by our plan. Whenyou receive the list, show it to your doctor and ask him or her to prescribe a similar drugthat is covered by our plan.
You can ask us to make an exception and cover your drug. See below for information about how to request an exception.
How do I request an exception to the ConnectiCare formulary? You can ask our plan 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 willbe covered at a pre-determined cost-sharing level, and you would not be able to ask us toprovide 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 onthe 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, forcertain drugs, our plan limits the amount of the drug that we will cover. If your drug has aquantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, our plan 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 or utilization restriction exception. When you request a formulary 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.
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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. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility and 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 31-day emergency supply of that drug while you pursue a formulary exception.
If you are a current member in our plan and you experience a change in the level of care, such as an admission or discharge from the long-term care facility, we will provide you with a one-time temporary supply of your medications, as needed, to assist with your transition to the new level of care.
For more information
For more detailed information about your ConnectiCare prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about our plan, 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 1-800-MEDICARE (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.
The formulary that begins on page 1 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 87.
The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., SYNTHROID) and generic drugs are listed in lower-case italics (e.g., levothyroxine).
The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug.
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.
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.
LA Limited Availability. This prescription drug may be available only at certain pharmacies. For more information call Member Services.
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 the prescription. 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.
LDS Limited day supply. For certain drugs, the plan limits the days’ supply we will cover to one month.
viii
Please refer to the tables below for information about how the plan’s cost-sharing relates to the different tier levels listed in this formulary for a one-month supply of a drug. If you are eligible for “Extra Help” or “Low Income Subsidy” (LIS), some of the information in these tables about the cost of Part D prescription drugs may not apply to you. We will send you a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS rider), which tells you about your drug coverage. If you don’t have this insert, please call Member Services at the number on the front or back cover pages and ask for the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS rider).
Part D Prescription Drug Coverage for ConnectiCare Choice Plan 1 (HMO) or ConnectiCare Flex Plan 1 (HMO-POS)
Deductible $300 (excludes Tier 1 and Tier 2)
Tier Tier Name Initial Coverage Stage
Coverage Gap Stage
Catastrophic Coverage Stage
Tier 1 Preferred Generic Drugs
Preferred Cost-Sharing: $2 copay
Standard Cost-Sharing: $9 copay
The greater of 5% of the total cost of the drug, or $3.60 copay
The greater of 5% of the total cost of the drug, or $3.60 copay
Tier 3 Preferred Brand Drugs
Preferred Cost-Sharing: $42 copay
Standard Cost-Sharing: $47 copay
25% of the total cost of the drug
The greater of 5% of the total cost of the drug, or $8.95 copay
Tier 4 Non-Preferred Drugs
Preferred Cost-Sharing: $95 copay
Standard Cost-Sharing: $100 copay
25% of the total cost of the drug
The greater of 5% of the total cost of the drug, or
$3.60 copay for generic drugs;
$8.95 copay for all other drugs
Tier 5 Specialty Drugs Preferred Cost-Sharing:
27% of the total cost of the drug
Standard Cost-Sharing:
27% of the total cost of the drug
25% of the total cost of the drug
The greater of 5% of the total cost of the drug, or
$3.60 copay for generic drugs;
$8.95 copay for all other drugs
Please Note: Employer Group Health Plan (EGHP) please refer to your Summary of Benefits or contact Member Services for benefit details and cost sharing amounts.
ix
Please refer to the tables below for information about how the plan’s cost-sharing relates to the different tier levels listed in this formulary for a one-month supply of a drug. If you are eligible for “Extra Help” or “Low Income Subsidy” (LIS), some of the information in these tables about the cost of Part D prescription drugs may not apply to you. We will send you a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS rider), which tells you about your drug coverage. If you don’t have this insert, please call Member Services at the number on the front or back cover pages and ask for the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS rider).
Part D Prescription Drug Coverage for ConnectiCare Choice Plan 3 (HMO)
Deductible $435 (excludes Tier 1 and Tier 2)
Tier Tier Name Initial Coverage Stage
Coverage Gap Stage
Catastrophic Coverage Stage
Tier 1 Preferred Generic Drugs
Preferred Cost-Sharing: $2 copay
Standard Cost-Sharing: $9 copay
25% of the total cost of the drug
The greater of 5% of the total cost of the drug, or $3.60 copay
The greater of 5% of the total cost of the drug, or $3.60 copay
Tier 3 Preferred Brand Drugs
Preferred Cost-Sharing: $42 copay
Standard Cost-Sharing: $47 copay
25% of the total cost of the drug
The greater of 5% of the total cost of the drug, or $8.95 copay
Tier 4 Non-Preferred Drugs
Preferred Cost-Sharing: $95 copay
Standard Cost-Sharing: $100 copay
25% of the total cost of the drug
The greater of 5% of the total cost of
the drug, or
$3.60 copay for generic drugs;
$8.95 copay for all other drugs
Tier 5 Specialty Drugs Preferred Cost-Sharing:
25% of the total cost of the drug
Standard Cost-Sharing:
25% of the total cost of the drug
25% of the total cost of the drug
The greater of 5% of the total cost of
the drug, or
$3.60 copay for generic drugs;
$8.95 copay for all other drugs
Please Note: Employer Group Health Plan (EGHP) please refer to your Summary of Benefits or contact Member Services for benefit details and cost sharing amounts.
x
Please refer to the tables below for information about how the plan’s cost-sharing relates to the different tier levels listed in this formulary for a one-month supply of a drug. If you are eligible for “Extra Help” or “Low Income Subsidy” (LIS), some of the information in these tables about the cost of Part D prescription drugs may not apply to you. We will send you a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS rider), which tells you about your drug coverage. If you don’t have this insert, please call Member Services at the number on the front or back cover pages and ask for the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS rider).
Part D Prescription Drug Coverage for ConnectiCare Flex Plan 2 (HMO-POS) or ConnectiCare Flex Plan 3 (HMO-POS)
Deductible $300 (excludes Tier 1 and Tier 2)
Tier Tier Name Initial Coverage Stage
Coverage Gap Stage
Catastrophic Coverage Stage
Tier 1 Preferred Generic Drugs
Preferred Cost-Sharing: $2 copay
Standard Cost-Sharing: $9 copay
25% of the total cost of the drug
The greater of 5% of the total cost of the drug, or $3.60 copay
The greater of 5% of the total cost of the drug, or $3.60 copay
Tier 3 Preferred Brand Drugs
Preferred Cost-Sharing: $42 copay
Standard Cost-Sharing: $47 copay
25% of the total cost of the drug
The greater of 5% of the total cost of the drug, or $8.95 copay
Tier 4 Non-Preferred Drugs
Preferred Cost-Sharing: $95 copay
Standard Cost-Sharing: $100 copay
25% of the total cost of the drug
The greater of 5% of the total cost of the drug, or
$3.60 copay for generic drugs;
$8.95 copay for all other drugs
Tier 5 Specialty Drugs Preferred Cost-Sharing:
27% of the total cost of the drug
Standard Cost-Sharing:
27% of the total cost of the drug
25% of the total cost of the drug
The greater of 5% of the total cost of the drug, or
$3.60 copay for generic drugs;
$8.95 copay for all other drugs
Please Note: Employer Group Health Plan (EGHP) please refer to your Summary of Benefits or contact Member Services for benefit details and cost sharing amounts.
xi
Please refer to the tables below for information about how the plan’s cost-sharing relates to the different tier levels listed in this formulary for a one-month supply of a drug. If you are eligible for “Extra Help” or “Low Income Subsidy” (LIS), some of the information in these tables about the cost of Part D prescription drugs may not apply to you. We will send you a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS rider), which tells you about your drug coverage. If you don’t have this insert, please call Member Services at the number on the front or back cover pages and ask for the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS rider).
Part D Prescription Drug Coverage for ConnectiCare Passage Plan 1 (HMO)
Deductible $275 (excludes Tier 1 and Tier 2)
Tier Tier Name Initial Coverage Stage
Coverage Gap Stage
Catastrophic Coverage Stage
Tier 1 Preferred Generic Drugs
Preferred Cost-Sharing: $2 copay
Standard Cost-Sharing: $9 copay
25% of the total cost of the drug
The greater of 5% of the total cost of the drug, or $3.60 copay
The greater of 5% of the total cost of the drug, or $3.60 copay
Tier 3 Preferred Brand Drugs
Preferred Cost-Sharing: $42 copay
Standard Cost-Sharing: $47 copay
25% of the total cost of the drug
The greater of 5% of the total cost of the drug, or $8.95 copay
Tier 4 Non-Preferred Drugs
Preferred Cost-Sharing: $95 copay
Standard Cost-Sharing: $100 copay
25% of the total cost of the drug
The greater of 5% of the total cost of the drug, or
$3.60 copay for generic drugs;
$8.95 copay for all other drugs
Tier 5 Specialty Drugs Preferred Cost-Sharing:
28% of the total cost of the drug
Standard Cost-Sharing:
28% of the total cost of the drug
25% of the total cost of the drug
The greater of 5% of the total cost of the drug, or
$3.60 copay for generic drugs;
$8.95 copay for all other drugs
Please Note: Employer Group Health Plan (EGHP) please refer to your Summary of Benefits or contact Member Services for benefit details and cost sharing amounts.
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Language & Non-Discrimination Notice ConnectiCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ConnectiCare does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
ConnectiCare:
• Provides free aids and services to people with disabilities to communicate effectivelywith us, including qualified interpreters and information in alternate formats.
• Provides free language services to people whose primary language is not English, including translateddocuments and oral interpretation.
If you need these services, contact The Committee for Civil Rights.
If you believe that ConnectiCare has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: The Committee for Civil Rights, ConnectiCare, Inc., 175 Scott Swamp Road, Farmington, CT 06032, Phone: 1-800-224-2273, and TTY: 711. You can file a grievance in person or by mail. If you need help filing a grievance, The Committee for Civil Rights is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
ConnectiCare is an HMO/HMO–POS plan with a Medicare contract. Enrollment in ConnectiCare depends on contract renewal. For more information, contact the plan. ConnectiCare Insurance Company, Inc. is an HMO D-SNP plan with a Medicare contract and a contract with the Connecticut Medicaid Program. Enrollment inConnectiCare depends on contract renewal. For more information, contact the plan.
Continued
Y0026_128830_C CCIMEDADV_NONDIS 0819
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klor-con m15 oral tablet,er particles/crystals 2 MO
klor-con m20 oral tablet,er particles/crystals 2 MO
klor-con oral packet 2 MO
k-tab oral tablet extended release 8 meq 2 MO
lactated ringers intravenous parenteral solution 2 MO
magnesium sulfate injection solution 2 B/D PA; MO
magnesium sulfate injection syringe 2 B/D PA
NORMOSOL-R INTRAVENOUS
PARENTERAL SOLUTION
4 B/D PA; MO
You can find information on what the symbols and abbreviations on this table mean by going to page viii.
84
Drug Name Drug Tier Requirements/Limits
potassium chlorid-d5-0.45%nacl intravenous
parenteral solution 10 meq/l, 30 meq/l, 40 meq/l
2 B/D PA
potassium chlorid-d5-0.45%nacl intravenous
parenteral solution 20 meq/l
2 B/D PA; MO
potassium chloride in 0.9%nacl intravenous
parenteral solution 20 meq/l, 40 meq/l
2 B/D PA
potassium chloride in 5 % dex intravenous
parenteral solution 20 meq/l, 30 meq/l, 40 meq/l
2 B/D PA
potassium chloride in lr-d5 intravenous parenteral
solution 20 meq/l
2 B/D PA; MO
potassium chloride in lr-d5 intravenous parenteral
solution 40 meq/l
2 B/D PA
potassium chloride in water intravenous
piggyback 10 meq/100 ml
2 MO
potassium chloride in water intravenous
piggyback 10 meq/50 ml, 20 meq/100 ml, 20
meq/50 ml, 30 meq/100 ml, 40 meq/100 ml
2
potassium chloride intravenous solution 2 MO
potassium chloride oral capsule, extended release 2 MO
potassium chloride oral liquid 2 MO
potassium chloride oral packet 2 MO
potassium chloride oral tablet extended release 2 MO
potassium chloride oral tablet,er particles/crystals 2 MO
potassium chloride-0.45 % nacl intravenous
parenteral solution
2
potassium chloride-d5-0.2%nacl intravenous
parenteral solution 20 meq/l
2 B/D PA; MO
potassium chloride-d5-0.2%nacl intravenous
parenteral solution 30 meq/l, 40 meq/l
2 B/D PA
potassium chloride-d5-0.3%nacl intravenous
parenteral solution 20 meq/l
2 B/D PA
potassium chloride-d5-0.9%nacl intravenous
parenteral solution
2 B/D PA
ringer's intravenous parenteral solution 2 B/D PA
sodium chloride 0.45 % intravenous parenteral
solution
2 MO
sodium chloride 3 % intravenous parenteral
solution
2 MO
You can find information on what the symbols and abbreviations on this table mean by going to page viii.
85
Drug Name Drug Tier Requirements/Limits
sodium chloride 5 % intravenous parenteral
solution
2 MO
sodium chloride intravenous parenteral solution 2 MO
MISCELLANEOUS NUTRITION PRODUCTS
AMINOSYN II 10 % INTRAVENOUS
PARENTERAL SOLUTION
4 B/D PA
AMINOSYN II 15 % INTRAVENOUS
PARENTERAL SOLUTION
4 B/D PA
AMINOSYN-PF 7 % SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
4 B/D PA
CLINIMIX 5%/D15W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
4 B/D PA
CLINIMIX 4.25%/D10W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
4 B/D PA
CLINIMIX 5%-D20W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
4 B/D PA
CLINIMIX E 4.25%/D10W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
4 B/D PA
CLINIMIX E 4.25%/D5W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
4 B/D PA
CLINIMIX E 5%/D15W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
4 B/D PA
CLINIMIX E 5%/D20W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
4 B/D PA
DOJOLVI ORAL LIQUID 5 PA; MO; LA
electrolyte-48 in d5w intravenous parenteral
solution
2 B/D PA
HEPATAMINE 8% INTRAVENOUS
PARENTERAL SOLUTION
4 B/D PA
intralipid intravenous emulsion 20 % 4 B/D PA
INTRALIPID INTRAVENOUS EMULSION 30
%
4 B/D PA
IONOSOL-MB IN D5W INTRAVENOUS
PARENTERAL SOLUTION
4
ISOLYTE S PH 7.4 INTRAVENOUS
PARENTERAL SOLUTION
4
ISOLYTE-P IN 5 % DEXTROSE
INTRAVENOUS PARENTERAL SOLUTION
4
ISOLYTE-S INTRAVENOUS PARENTERAL
SOLUTION
4
You can find information on what the symbols and abbreviations on this table mean by going to page viii.
86
Drug Name Drug Tier Requirements/Limits
NEPHRAMINE 5.4 % INTRAVENOUS
PARENTERAL SOLUTION
4 B/D PA
NORMOSOL-M IN 5 % DEXTROSE
INTRAVENOUS PARENTERAL SOLUTION
4 B/D PA
NORMOSOL-R PH 7.4 INTRAVENOUS
PARENTERAL SOLUTION
4 B/D PA
PLASMA-LYTE 148 INTRAVENOUS
PARENTERAL SOLUTION
4 B/D PA
PLASMA-LYTE A INTRAVENOUS
PARENTERAL SOLUTION
4 B/D PA
plenamine intravenous parenteral solution 2 B/D PA
premasol 10 % intravenous parenteral solution 4 B/D PA; MO
PROCALAMINE 3% INTRAVENOUS
PARENTERAL SOLUTION
4 B/D PA
PROSOL 20 % INTRAVENOUS PARENTERAL
SOLUTION
4 B/D PA; MO
travasol 10 % intravenous parenteral solution 4 B/D PA; MO
TROPHAMINE 10 % INTRAVENOUS
PARENTERAL SOLUTION
4 B/D PA; MO
VITAMINS / HEMATINICS
fluoride (sodium) oral tablet 2 MO
fluoride (sodium) oral tablet,chewable 1 mg (2.2
mg sod. fluoride)
2 MO
prenatal vitamin oral tablet 2 MO
You can find information on what the symbols and abbreviations on this table mean by going to page viii.
87
Index
A abacavir .................................. 1
abacavir-lamivudine ............... 1
abacavir-lamivudine-
zidovudine .......................... 1
ABELCET .............................. 1
ABILIFY MAINTENA ........ 32
abiraterone ............................ 13
ABRAXANE ........................ 13
acamprosate .......................... 51
acarbose ................................ 55
acebutolol ............................. 39
acetaminophen-codeine ........ 28
acetazolamide ....................... 76
acetazolamide sodium .......... 76
acetic acid ............................. 54
acetylcysteine ....................... 78
acitretin ................................. 46
ACTHAR ............................. 54
ACTHIB (PF) ....................... 66
ACTIMMUNE ..................... 64
acyclovir ....................... 1, 2, 49
acyclovir sodium .................... 2
ADACEL(TDAP
ADOLESN/ADULT)(PF) 66
adapalene .............................. 48
adefovir................................... 2
ADEMPAS ........................... 78
adriamycin ............................ 13
adrucil ................................... 13
ADVAIR HFA ..................... 78
AFINITOR ........................... 14
AFINITOR DISPERZ .... 13, 14
ak-poly-bac ........................... 74
ala-cort .................................. 50
albendazole ............................. 7
ALBENZA ............................. 7
albuterol sulfate .................... 78
alclometasone ....................... 50
alcohol pads .......................... 55
ALDURAZYME .................. 59
ALECENSA ......................... 14
alendronate ........................... 68
alfuzosin ............................... 82
ALIMTA .............................. 14
ALIQOPA ............................ 14
aliskiren ................................ 39
allopurinol ............................ 68
allopurinol sodium................ 68
alosetron ............................... 61
ALPHAGAN P ..................... 77
alprazolam ............................ 32
altavera (28) .......................... 71
ALUNBRIG ......................... 14
alyacen 1/35 (28) .................. 71
alyacen 7/7/7 (28) ................. 71
alyq ....................................... 78
amantadine hcl ........................ 2
AMBISOME .......................... 1
ambrisentan .......................... 78
amcinonide ........................... 50
amethia ................................. 71
amethia lo ............................. 71
amethyst (28) ........................ 71
amikacin ................................. 7
amiloride ............................... 39
amiloride-hydrochlorothiazide
.......................................... 39
AMINOSYN II 10 % ........... 83
AMINOSYN II 15 % ........... 83
AMINOSYN-PF 7 %
SULFITE FREE ............... 84
amiodarone ........................... 38
AMITIZA ............................. 61
amitriptyline ......................... 32
amlodipine ............................ 39
amlodipine-atorvastatin ........ 44
amlodipine-benazepril .......... 39
amlodipine-olmesartan ......... 39
amlodipine-valsartan ............ 39
amlodipine-valsartan-
hydrochlorothiazide .......... 39
ammonium lactate ................ 47
amnesteem ............................ 48
amoxapine ............................ 32
amoxicil-clarithromy-lansopraz
.......................................... 64
amoxicillin ............................ 10
amoxicillin-pot clavulanate .. 10
amphotericin b ........................ 1
ampicillin .............................. 10
ampicillin sodium ................. 10
ampicillin-sulbactam ...... 10, 11
ANADROL-50 ..................... 59
anagrelide ............................. 51
anastrozole ............................ 14
ANORO ELLIPTA............... 78
APOKYN ............................. 25
apraclonidine ........................ 77
aprepitant .............................. 61
apri ........................................ 71
APTIOM ............................... 22
APTIVUS ............................... 2
APTIVUS (WITH VITAMIN
E) ........................................ 2
ARALAST NP ...................... 51
aranelle (28) .......................... 71
ARCALYST ......................... 64
ARIKAYCE ........................... 7
aripiprazole ........................... 32
ARISTADA .......................... 33
ARISTADA INITIO ............. 32
armodafinil ........................... 33
ARNUITY ELLIPTA ........... 78
ashlyna .................................. 71
ASMANEX HFA ................. 78
ASMANEX TWISTHALER 79
aspirin-dipyridamole ............. 43
ASTAGRAF XL ................... 14
atazanavir ................................ 2
atenolol ................................. 39
atenolol-chlorthalidone ......... 39
atomoxetine .......................... 33
atorvastatin ........................... 44
atovaquone .............................. 7
atovaquone-proguanil ............. 7
ATRIPLA ............................... 2
atropine ................................. 61
ATROVENT HFA ................ 79
AUBAGIO ............................ 26
aubra ..................................... 71
aubra eq ................................ 71
AURYXIA ............................ 51
AVASTIN ............................. 14
aviane .................................... 71
AVONEX ............................. 64
AYVAKIT ............................ 14
azacitidine ............................. 14
AZASAN .............................. 14
AZASITE ............................. 74
azathioprine .......................... 14
azathioprine sodium .............. 14
azelastine ........................ 54, 75
azithromycin ........................... 7
aztreonam ............................... 7
azurette (28) .......................... 71
You can find information on what the symbols and abbreviations on this table mean by going to page viii.
88
B bacitracin .......................... 7, 74
bacitracin-polymyxin b ........ 74
baclofen ................................ 28
balsalazide ............................ 61
BALVERSA ......................... 14
balziva (28) ........................... 71
BANZEL .............................. 22
BARACLUDE ....................... 2
BASAGLAR KWIKPEN U-
100 INSULIN ................... 56
BAVENCIO ......................... 14
BCG VACCINE, LIVE (PF) 66
BELEODAQ ........................ 14
benazepril ............................. 39
benazepril-hydrochlorothiazide
.......................................... 39
BENDEKA ........................... 14
BENLYSTA ......................... 69
benztropine ........................... 25
BESIVANCE ....................... 74
BESPONSA ......................... 14
betamethasone dipropionate . 50
betamethasone valerate ........ 50
betamethasone, augmented... 50
BETASERON ...................... 65
betaxolol ......................... 39, 75
bethanechol chloride ............ 82
BETIMOL ............................ 75
BEVESPI AEROSPHERE ... 79
bexarotene ............................ 14
BEXSERO ............................ 66
bicalutamide ......................... 14
BICILLIN C-R ..................... 11
BICILLIN L-A ..................... 11
BIKTARVY ........................... 2
bisoprolol fumarate .............. 39
bisoprolol-hydrochlorothiazide
.......................................... 39
bleomycin ............................. 14
BLEPHAMIDE S.O.P. ......... 75
blisovi 24 fe .......................... 72
blisovi fe 1.5/30 (28) ............ 72
blisovi fe 1/20 (28) ............... 72
BOOSTRIX TDAP .............. 66
bosentan ................................ 79
BOSULIF ............................. 14
BRAFTOVI .......................... 14
BREO ELLIPTA .................. 79
briellyn ................................. 72
BRILINTA ........................... 43
brimonidine .......................... 77
BRIVIACT ........................... 23
bromocriptine ....................... 25
BRUKINSA.......................... 14
budesonide ...................... 61, 79
bumetanide ........................... 39
buprenorphine hcl ................. 28
buprenorphine-naloxone ....... 30
bupropion hcl ........................ 33
bupropion hcl (smoking deter)
.......................................... 53
buspirone .............................. 33
butalbital-acetaminop-caf-cod
.......................................... 28
butalbital-acetaminophen ..... 28
butalbital-acetaminophen-caff
.......................................... 28
butalbital-aspirin-caffeine .... 28
butorphanol ..................... 30, 31
BYDUREON ........................ 56
BYDUREON BCISE ........... 56
BYETTA .............................. 56
BYSTOLIC .......................... 39
C cabergoline ........................... 59
CABOMETYX ..................... 14
calcipotriene ......................... 46
calcipotriene-betamethasone 46
calcitonin (salmon) ............... 59
calcitriol .......................... 47, 59
calcium acetate(phosphat bind)
.......................................... 82
CALQUENCE ...................... 14
camila ................................... 70
camrese ................................. 72
camrese lo ............................. 72
candesartan ........................... 39
candesartan-
hydrochlorothiazide .......... 39
CAPASTAT ........................... 8
CAPLYTA............................ 33
CAPRELSA.......................... 14
captopril ................................ 39
captopril-hydrochlorothiazide
.......................................... 39
carbamazepine ...................... 23
carbidopa .............................. 25
carbidopa-levodopa .............. 25
carbidopa-levodopa-
entacapone ........................ 25
carboplatin ............................ 15
carmustine ............................. 15
carteolol ................................ 75
cartia xt ................................. 39
carvedilol .............................. 39
carvedilol phosphate ............. 39
caspofungin ............................. 1
CAYSTON ............................. 8
caziant (28) ........................... 72
cefaclor ................................... 5
cefadroxil ................................ 5
cefazolin ................................. 5
cefazolin in dextrose (iso-osm)
............................................ 5
cefdinir .................................... 5
cefepime ................................. 6
cefepime in dextrose (iso-osm)
............................................ 6
CEFEPIME IN DEXTROSE 5
% ......................................... 6
cefixime .................................. 6
cefotetan ................................. 6
CEFOTETAN IN DEXTROSE
(ISO-OSM) ......................... 6
cefoxitin .................................. 6
cefoxitin in dextrose (iso-osm)
............................................ 6
cefpodoxime ........................... 6
cefprozil .................................. 6
ceftazidime ............................. 6
CEFTAZIDIME IN D5W ....... 6
ceftriaxone .............................. 6
CEFTRIAXONE .................... 6
ceftriaxone in dextrose (iso-
osm) .................................... 6
cefuroxime axetil .................... 6
cefuroxime sodium ............. 6, 7
celecoxib ............................... 31
CELONTIN .......................... 23
cephalexin ............................... 7
CEREZYME ......................... 59
cetirizine ............................... 77
cevimeline ............................. 51
CHANTIX ............................ 53
CHANTIX CONTINUING
MONTH BOX .................. 53
CHANTIX STARTING
MONTH BOX .................. 53
chateal (28) ........................... 72
CHEMET .............................. 51
chloramphenicol sod succinate
............................................ 8
You can find information on what the symbols and abbreviations on this table mean by going to page viii.
89
chlorhexidine gluconate ....... 54
chloroquine phosphate............ 8
chlorothiazide ....................... 39
chlorothiazide sodium .......... 40
chlorpromazine ..................... 33
chlorthalidone ....................... 40
CHOLBAM .......................... 61
cholestyramine (with sugar) . 44
cholestyramine light ....... 44, 45
CHORIONIC
GONADOTROPIN,
HUMAN ........................... 59
ciclopirox .............................. 49
cidofovir ................................. 2
cilostazol............................... 43
CILOXAN ............................ 74
CIMDUO ................................ 2
cimetidine ............................. 64
cimetidine hcl ....................... 64
cinacalcet .............................. 59
CINRYZE............................. 79
CIPRODEX .......................... 54
ciprofloxacin......................... 11
ciprofloxacin hcl ............. 11, 74
ciprofloxacin in 5 % dextrose
.......................................... 11
ciprofloxacin-dexamethasone
.......................................... 54
cisplatin ................................ 15
citalopram ............................. 33
cladribine .............................. 15
claravis ................................. 48
clarithromycin ........................ 7
clemastine ............................. 77
CLEOCIN............................. 71
clindamycin hcl ...................... 8
clindamycin palmitate hcl ...... 8
clindamycin pediatric ............. 8
clindamycin phosphate .... 8, 48,
71
CLINDAMYCIN
PHOSPHATE ................... 48
clindamycin-benzoyl peroxide
.......................................... 48
CLINIMIX 5%/D15W
SULFITE FREE ............... 84
CLINIMIX 4.25%/D10W
SULFITE FREE ............... 84
CLINIMIX 4.25%/D5W
SULFITE FREE ............... 51
CLINIMIX 5%-D20W
SULFITE FREE ............... 84
CLINIMIX E 2.75%/D5W
SULFITE FREE ............... 51
CLINIMIX E 4.25%/D10W
SULFITE FREE ............... 84
CLINIMIX E 4.25%/D5W
SULFITE FREE ............... 84
CLINIMIX E 5%/D15W
SULFITE FREE ............... 84
CLINIMIX E 5%/D20W
SULFITE FREE ............... 84
clobazam ............................... 23
clofarabine ............................ 15
clomipramine ........................ 33
clonazepam ........................... 23
clonidine ............................... 40
clonidine hcl ................... 33, 40
clopidogrel ............................ 43
clorazepate dipotassium ....... 33
clotrimazole ...................... 1, 49
clotrimazole-betamethasone . 49
clozapine ............................... 33
CLOZAPINE ........................ 33
COARTEM ............................ 8
codeine sulfate ...................... 28
COLCRYS............................ 68
colesevelam .......................... 45
colestipol .............................. 45
colistin (colistimethate na) ..... 8
COMBIGAN ........................ 76
COMBIPATCH .................... 70
COMBIVENT RESPIMAT . 79
COMETRIQ ......................... 15
COMPLERA .......................... 2
compro .................................. 61
constulose ............................. 61
COPIKTRA .......................... 15
CORLANOR .................. 45, 46
cortisone ............................... 54
COSENTYX ......................... 47
COSENTYX (2 SYRINGES)
.......................................... 47
COSENTYX PEN ................ 47
COSENTYX PEN (2 PENS) 47
COTELLIC ........................... 15
CRINONE ............................ 70
CRIXIVAN ............................ 2
cromolyn ................... 61, 75, 79
cryselle (28) .......................... 72
cyclafem 1/35 (28)................ 72
cyclafem 7/7/7 (28) ............... 72
cyclobenzaprine .................... 28
cyclophosphamide ................ 15
CYCLOSET ......................... 56
cyclosporine .......................... 15
cyclosporine modified .......... 15
cyproheptadine ..................... 77
CYRAMZA .......................... 15
CYSTADANE ...................... 62
CYSTAGON ........................ 82
CYSTARAN ......................... 75
cytarabine ............................. 15
cytarabine (pf) ...................... 15
D d10 %-0.45 % sodium chloride
.......................................... 51
d2.5 %-0.45 % sodium
chloride ............................. 51
d5 % and 0.9 % sodium
chloride ............................. 52
d5 %-0.45 % sodium chloride
.......................................... 52
dacarbazine ........................... 15
dalfampridine ........................ 26
DALIRESP ........................... 79
danazol .................................. 59
dantrolene ............................. 28
dapsone ................................... 8
DAPTACEL (DTAP
PEDIATRIC) (PF) ............ 66
daptomycin ............................. 8
DARAPRIM ........................... 8
DARZALEX ......................... 15
dasetta 1/35 (28) ................... 72
dasetta 7/7/7 (28) .................. 72
daunorubicin ......................... 15
DAURISMO ......................... 15
daysee ................................... 72
decitabine .............................. 15
deferasirox ............................ 52
DELSTRIGO .......................... 2
demeclocycline ..................... 12
DEMSER .............................. 40
DENAVIR ............................ 49
denta 5000 plus ..................... 54
dentagel ................................. 54
DEPO-PROVERA ................ 70
DEPO-SUBQ PROVERA 104
.......................................... 70
DESCOVY ............................. 2
desipramine ........................... 33
You can find information on what the symbols and abbreviations on this table mean by going to page viii.
90
desloratadine......................... 77
desmopressin ........................ 59
desog-e.estradiol/e.estradiol . 72
desoximetasone .................... 50
desvenlafaxine succinate ...... 33
dexamethasone ..................... 54
dexamethasone intensol........ 54
dexamethasone sodium phos
(pf) .................................... 55
dexamethasone sodium
phosphate .................... 55, 77
DEXILANT .......................... 64
dexmethylphenidate ............. 33
dexrazoxane hcl .................... 13
dextroamphetamine ........ 33, 34
dextroamphetamine-
amphetamine .................... 34
dextrose 10 % and 0.2 % nacl
.......................................... 52
dextrose 10 % in water (d10w)
.......................................... 52
dextrose 20 % in water (d20w)
.......................................... 52
dextrose 25 % in water (d25w)
.......................................... 52
dextrose 30 % in water (d30w)
.......................................... 52
dextrose 40 % in water (d40w)
.......................................... 52
dextrose 5 % in water (d5w) 52
dextrose 5 %-lactated ringers52
dextrose 5%-0.2 % sod
chloride ............................. 52
dextrose 5%-0.3 %
sod.chloride ...................... 52
dextrose 50 % in water (d50w)
.......................................... 52
dextrose 70 % in water (d70w)
.......................................... 52
diazepam......................... 23, 34
diazepam intensol ................. 34
diazoxide .............................. 56
diclofenac potassium ............ 31
diclofenac sodium .... 31, 47, 76
diclofenac-misoprostol ......... 31
dicloxacillin .......................... 11
dicyclomine .......................... 61
didanosine............................... 2
diflorasone ............................ 50
diflunisal ............................... 31
digitek ................................... 46
digox ..................................... 46
digoxin .................................. 46
dihydroergotamine................ 26
DILANTIN 30 MG .............. 23
diltiazem hcl ......................... 40
dilt-xr .................................... 40
DIPENTUM ......................... 62
diphenhydramine hcl ............ 78
disulfiram.............................. 52
divalproex ............................. 23
dofetilide ............................... 38
DOJOLVI ............................. 84
donepezil .............................. 26
dorzolamide .......................... 76
dorzolamide-timolol ............. 76
DOVATO ............................... 2
doxazosin .............................. 40
doxepin ................................. 34
doxorubicin ........................... 15
doxorubicin, peg-liposomal .. 15
doxy-100 ............................... 12
doxycycline hyclate .............. 12
doxycycline monohydrate .... 12
DRIZALMA SPRINKLE ..... 34
dronabinol ............................. 62
drospirenone-e.estradiol-lm.fa
.......................................... 72
drospirenone-ethinyl estradiol
.......................................... 72
DROXIA .............................. 15
DULERA .............................. 79
duloxetine ............................. 34
DUPIXENT PEN ................. 47
DUPIXENT SYRINGE ........ 47
DUREZOL ........................... 77
dutasteride ............................ 82
dutasteride-tamsulosin .......... 82
E e.e.s. 400 ................................. 7
ec-naproxen .......................... 31
econazole .............................. 49
EDURANT ............................. 2
efavirenz ................................. 2
EGRIFTA SV ....................... 65
ELAPRASE .......................... 59
electrolyte-48 in d5w ............ 84
ELELYSO ............................ 59
ELIGARD ............................ 15
ELIGARD (3 MONTH) ....... 15
ELIGARD (4 MONTH) ....... 15
ELIGARD (6 MONTH) ....... 15
elinest .................................... 72
ELIQUIS ............................... 43
ELIQUIS DVT-PE TREAT
30D START ...................... 43
ELITEK ................................ 13
ELLA .................................... 72
ELMIRON ............................ 82
EMCYT ................................ 16
EMEND ................................ 62
emoquette ............................. 72
EMPLICITI .......................... 16
EMSAM ............................... 34
emtricitabine ........................... 2
EMTRIVA .............................. 2
enalapril maleate ................... 40
enalapril-hydrochlorothiazide
.......................................... 40
ENBREL ............................... 69
ENBREL MINI .................... 69
ENBREL SURECLICK ....... 69
ENDARI ............................... 52
endocet .................................. 28
ENGERIX-B (PF) ................ 66
ENGERIX-B PEDIATRIC
(PF) ................................... 66
enoxaparin ............................ 43
enpresse ................................ 72
enskyce ................................. 72
entacapone ............................ 25
entecavir ................................. 2
ENTRESTO .......................... 46
enulose .................................. 62
ENVARSUS XR .................. 16
EPCLUSA .............................. 2
EPIDIOLEX ......................... 23
epinastine .............................. 75
epinephrine ........................... 78
EPINEPHRINE .................... 78
EPIPEN ................................. 78
EPIPEN 2-PAK .................... 78
EPIPEN JR ........................... 78
EPIPEN JR 2-PAK ............... 78
epirubicin .............................. 16
epitol ..................................... 23
EPIVIR HBV .......................... 2
eplerenone ............................. 40
eprosartan ............................. 40
ergoloid ................................. 34
ERIVEDGE .......................... 16
ERLEADA ........................... 16
erlotinib ................................. 16
You can find information on what the symbols and abbreviations on this table mean by going to page viii.
91
errin ...................................... 70
ERWINAZE ......................... 16
ery pads ................................ 48
ERYTHROCIN ...................... 7
erythrocin (as stearate) ........... 7
erythromycin .................... 7, 74
erythromycin ethylsuccinate .. 7
erythromycin with ethanol ... 48
erythromycin-benzoyl peroxide
.......................................... 48
ESBRIET .............................. 79
escitalopram oxalate ............. 34
esomeprazole sodium ........... 64
estarylla ................................ 72
estradiol ................................ 70
estradiol valerate .................. 70
eszopiclone ........................... 34
ethambutol .............................. 8
ethosuximide ........................ 23
etodolac ................................ 31
etoposide............................... 16
everolimus (antineoplastic) .. 16
everolimus
(immunosuppressive) ....... 16
EVOTAZ ................................ 2
exemestane ........................... 16
EXTAVIA ............................ 65
ezetimibe .............................. 45
ezetimibe-simvastatin ........... 45
F FABRAZYME ..................... 59
falmina (28) .......................... 72
famciclovir ............................. 3
famotidine............................. 64
famotidine (pf)...................... 64
famotidine (pf)-nacl (iso-osm)
.......................................... 64
FANAPT .............................. 34
FARXIGA ............................ 56
FARYDAK........................... 16
FASLODEX ......................... 16
febuxostat ............................. 68
felbamate .............................. 23
felodipine .............................. 40
fenofibrate ............................ 45
fenofibrate micronized ......... 45
fenofibrate nanocrystallized . 45
fenofibric acid ...................... 45
fenofibric acid (choline) ....... 45
fenoprofen ............................ 31
fentanyl ................................. 29
fentanyl citrate ................ 28, 29
FERRIPROX ........................ 52
FERRIPROX (2 TIMES A
DAY) ................................ 52
FETZIMA ............................. 34
FIASP FLEXTOUCH U-100
INSULIN .......................... 56
FIASP PENFILL U-100
INSULIN .......................... 56
FIASP U-100 INSULIN ....... 56
finasteride ............................. 82
FINTEPLA ........................... 23
FIRAZYR ............................. 79
flavoxate ............................... 81
flecainide .............................. 38
FLOVENT DISKUS ............ 79
FLOVENT HFA ................... 79
fluconazole ............................. 1
fluconazole in nacl (iso-osm) . 1
flucytosine .............................. 1
fludarabine ............................ 16
fludrocortisone...................... 55
flunisolide ............................. 79
fluocinolone .......................... 50
fluocinolone acetonide oil .... 54
fluocinolone and shower cap 50
fluoride (sodium) .................. 85
fluorometholone ................... 77
fluorouracil ..................... 16, 47
fluoxetine .............................. 34
fluphenazine decanoate ........ 34
fluphenazine hcl ................... 34
flurbiprofen ........................... 31
flurbiprofen sodium .............. 76
flutamide ............................... 16
fluticasone propionate .... 50, 80
fluticasone propion-salmeterol
.......................................... 80
fluvoxamine .......................... 34
fomepizole ............................ 66
fondaparinux ......................... 43
FORTEO .............................. 68
fosamprenavir ......................... 3
fosinopril .............................. 40
fosinopril-hydrochlorothiazide
.......................................... 40
fosphenytoin ......................... 23
FRAGMIN...................... 43, 44
fulvestrant ............................. 16
furosemide ............................ 40
FUZEON ................................ 3
FYCOMPA ........................... 23
G gabapentin ............................. 23
GALAFOLD ......................... 59
galantamine ........................... 26
GAMMAGARD LIQUID .... 66
GAMMAGARD S-D (IGA < 1
MCG/ML) ......................... 66
GAMUNEX-C ...................... 66
ganciclovir sodium ................. 3
GARDASIL 9 (PF) ............... 66
gatifloxacin ........................... 74
GATTEX 30-VIAL .............. 62
GATTEX ONE-VIAL .......... 62
GAUZE PAD ........................ 56
gavilyte-c .............................. 62
gavilyte-g .............................. 62
gavilyte-n .............................. 62
GAZYVA ............................. 16
GELNIQUE .......................... 81
gemcitabine ........................... 16
gemfibrozil ........................... 45
generlac ................................. 62
gengraf .................................. 16
gentak ................................... 75
gentamicin .................. 8, 49, 75
gentamicin in nacl (iso-osm) .. 8
GENTAMICIN IN NACL
(ISO-OSM) ......................... 8
GENVOYA ............................ 3
GEODON ............................. 35
gianvi (28) ............................ 72
GILENYA ............................ 26
GILOTRIF ............................ 16
glatiramer .............................. 27
glatopa .................................. 27
GLEOSTINE ........................ 16
glimepiride ............................ 56
glipizide ................................ 56
glipizide-metformin .............. 56
GLUCAGEN HYPOKIT ...... 56
GLUCAGON (HCL)
EMERGENCY KIT .......... 56
GLUCAGON EMERGENCY
KIT (HUMAN) ................. 56
glyburide ............................... 56
glyburide micronized ............ 56
glyburide-metformin ............. 56
glycopyrrolate ....................... 61
granisetron (pf) ..................... 62
granisetron hcl ...................... 62
You can find information on what the symbols and abbreviations on this table mean by going to page viii.
92
GRANIX .............................. 65
griseofulvin microsize ............ 1
griseofulvin ultramicrosize ..... 1
guanfacine ............................ 35
guanidine .............................. 35
GVOKE HYPOPEN 1-PACK
.......................................... 56
GVOKE HYPOPEN 2-PACK
.......................................... 56
GVOKE PFS 1-PACK
SYRINGE......................... 57
GVOKE PFS 2-PACK
SYRINGE......................... 57
H haloperidol ............................ 35
haloperidol decanoate ........... 35
haloperidol lactate ................ 35
HARVONI ............................. 3
HAVRIX (PF) ...................... 66
heather .................................. 70
heparin (porcine) .................. 44
heparin (porcine) in 5 % dex 44
heparin (porcine) in nacl (pf) 44
heparin(porcine) in 0.45% nacl
.......................................... 44
HEPARIN(PORCINE) IN
0.45% NACL .................... 44
heparin, porcine (pf) ............. 44
HEPATAMINE 8%.............. 84
HERCEPTIN ........................ 16
HETLIOZ ............................. 35
HIBERIX (PF)...................... 66
HUMIRA .............................. 69
HUMIRA PEN ..................... 69
HUMIRA PEN CROHNS-UC-
HS START ....................... 69
HUMIRA PEN PSOR-
UVEITS-ADOL HS ......... 69
HUMIRA(CF) ...................... 69
HUMIRA(CF) PEDI
CROHNS STARTER ....... 69
HUMIRA(CF) PEN.............. 69
HUMIRA(CF) PEN
CROHNS-UC-HS ............ 69
HUMIRA(CF) PEN PSOR-
UV-ADOL HS.................. 69
hydralazine ........................... 40
hydrochlorothiazide .............. 40
hydrocodone-acetaminophen 29
hydrocodone-ibuprofen ........ 29
hydrocortisone .... 50, 51, 55, 62
hydrocortisone butyrate ........ 50
hydrocortisone butyr-emollient
.......................................... 50
hydrocortisone valerate ........ 51
hydrocortisone-acetic acid .... 54
hydromorphone .................... 29
hydromorphone (pf) ............. 29
hydroxychloroquine................ 8
hydroxyprogesterone caproate
.......................................... 70
hydroxyurea .......................... 17
hydroxyzine hcl .................... 78
I ibandronate ........................... 68
IBRANCE ............................ 17
ibu ......................................... 31
ibuprofen .............................. 31
ibuprofen-oxycodone............ 29
icatibant ................................ 80
ICLUSIG .............................. 17
idarubicin .............................. 17
IDHIFA ................................ 17
ifosfamide ............................. 17
ILEVRO ............................... 76
imatinib ................................. 17
IMBRUVICA ....................... 17
IMFINZI ............................... 17
imipenem-cilastatin ................ 8
imipramine hcl ...................... 35
imipramine pamoate ............. 35
imiquimod ............................ 47
IMOVAX RABIES VACCINE
(PF) ................................... 67
INCRELEX .......................... 52
indapamide ........................... 40
indomethacin ........................ 31
INFANRIX (DTAP) (PF) ..... 67
INGREZZA .......................... 27
INGREZZA INITIATION
PACK ............................... 27
INLYTA ............................... 17
INQOVI ................................ 17
INREBIC .............................. 17
INSULIN PEN NEEDLE ..... 57
INSULIN SYRINGE (DISP)
U-100 ................................ 57
INTELENCE .......................... 3
intralipid ............................... 84
INTRALIPID........................ 84
INTRON A ........................... 65
introvale ................................ 72
INVEGA SUSTENNA ......... 35
INVIRASE ............................. 3
IONOSOL-MB IN D5W ...... 84
IPOL ..................................... 67
ipratropium bromide ....... 54, 80
ipratropium-albuterol ............ 80
irbesartan .............................. 40
irbesartan-hydrochlorothiazide
.......................................... 40
IRESSA ................................ 17
irinotecan .............................. 17
ISENTRESS ........................... 3
ISENTRESS HD .................... 3
ISOLYTE S PH 7.4 .............. 84
ISOLYTE-P IN 5 %
DEXTROSE ..................... 84
ISOLYTE-S .......................... 84
isoniazid .................................. 8
isosorbide dinitrate ............... 46
isosorbide mononitrate ......... 46
isradipine .............................. 41
ISTODAX ............................. 17
itraconazole ............................. 1
ivermectin ............................... 8
IXIARO (PF) ........................ 67
J JAKAFI ................................ 17
jantoven ................................ 44
JANUMET ........................... 57
JANUMET XR ..................... 57
JANUVIA ............................. 57
JARDIANCE ........................ 57
jencycla ................................. 70
jinteli ..................................... 71
jolessa ................................... 72
JULUCA ................................. 3
junel 1.5/30 (21) ................... 72
junel 1/20 (21) ...................... 72
junel fe 1.5/30 (28) ............... 72
junel fe 1/20 (28) .................. 72
junel fe 24 ............................. 72
JUXTAPID ........................... 45
JYNARQUE ......................... 60
K KADCYLA ........................... 17
KADIAN .............................. 29
KALETRA ............................. 3
KALYDECO ........................ 80
kariva (28) ............................ 72
kelnor 1/35 (28) .................... 72
KENALOG ........................... 55
You can find information on what the symbols and abbreviations on this table mean by going to page viii.
93
ketoconazole ..................... 1, 49
ketoprofen............................. 31
ketorolac ............................... 76
KEVEYIS ............................. 27
KEYTRUDA ........................ 17
KINRIX (PF) ........................ 67
kionex (with sorbitol) ........... 52
KISQALI ........................ 17, 18
KISQALI FEMARA CO-
PACK ............................... 17
klor-con ................................ 82
klor-con 10 ........................... 82
klor-con 8 ............................. 82
klor-con m15 ........................ 82
klor-con m20 ........................ 82
KOMBIGLYZE XR ............. 57
KORLYM............................. 60
KOSELUGO ........................ 18
k-tab ...................................... 82
kurvelo (28) .......................... 73
KUVAN ............................... 60
KYPROLIS .......................... 18
L l norgest/e.estradiol-e.estrad . 73
labetalol ................................ 41
lactated ringers ..................... 82
lactulose ................................ 62
lamivudine .............................. 3
lamivudine-zidovudine ........... 3
lamotrigine ........................... 24
LANOXIN ............................ 46
lansoprazole .......................... 64
lanthanum ............................. 53
LANTUS SOLOSTAR U-100
INSULIN .......................... 57
LANTUS U-100 INSULIN .. 57
larissia................................... 73
LASTACAFT ....................... 75
latanoprost ............................ 76
LATUDA ............................. 35
layolis fe ............................... 73
leflunomide........................... 69
LENVIMA ........................... 18
lessina ................................... 73
letrozole ................................ 18
leucovorin calcium ............... 13
LEUKERAN ........................ 18
LEUKINE............................. 65
leuprolide .............................. 18
levalbuterol hcl ..................... 80
LEVEMIR FLEXTOUCH U-
100 INSULN .................... 57
LEVEMIR U-100 INSULIN 57
levetiracetam ........................ 24
levetiracetam in nacl (iso-osm)
.......................................... 24
levobunolol ........................... 75
levocarnitine ......................... 53
levocarnitine (with sugar) ..... 53
levocetirizine ........................ 78
levofloxacin .................... 12, 75
levofloxacin in d5w .............. 12
levoleucovorin calcium ........ 13
levonest (28) ......................... 73
levonorgestrel-ethinyl estrad 73
levonorg-eth estrad triphasic 73
levora-28 ............................... 73
levorphanol tartrate............... 29
levothyroxine ........................ 61
levoxyl .................................. 61
LEXIVA ................................. 3
lidocaine ............................... 47
lidocaine (pf) .................. 38, 47
lidocaine hcl ......................... 47
lidocaine viscous .................. 47
lidocaine-prilocaine .............. 47
lindane .................................. 51
linezolid .................................. 8
linezolid in dextrose 5% ......... 8
linezolid-0.9% sodium chloride
............................................ 9
LINZESS .............................. 62
liothyronine .......................... 61
lisinopril................................ 41
lisinopril-hydrochlorothiazide
.......................................... 41
lithium carbonate .................. 35
lithium citrate ....................... 35
LONSURF ............................ 18
loperamide ............................ 61
lopinavir-ritonavir .................. 3
lorazepam ............................. 35
lorazepam intensol ................ 35
LORBRENA ........................ 18
loryna (28) ............................ 73
losartan ................................. 41
losartan-hydrochlorothiazide 41
lovastatin .............................. 45
low-ogestrel (28) .................. 73
loxapine succinate ................ 35
LUCEMYRA........................ 31
LUMIGAN ........................... 76
LUPRON DEPOT ................ 18
LUPRON DEPOT (3
MONTH) .......................... 18
LUPRON DEPOT (4
MONTH) .......................... 18
LUPRON DEPOT (6
MONTH) .......................... 18
LUPRON DEPOT-PED ....... 18
LUPRON DEPOT-PED (3
MONTH) .......................... 18
lutera (28) ............................. 73
LYNPARZA ......................... 18
LYSODREN ......................... 18
lyza ....................................... 71
M magnesium sulfate ................ 82
malathion .............................. 51
maprotiline ............................ 35
marlissa (28) ......................... 73
MARPLAN ........................... 35
MATULANE ........................ 18
matzim la .............................. 41
MAVENCLAD (10 TABLET
PACK) .............................. 27
MAVENCLAD (4 TABLET
PACK) .............................. 27
MAVENCLAD (5 TABLET
PACK) .............................. 27
MAVENCLAD (6 TABLET
PACK) .............................. 27
MAVENCLAD (7 TABLET
PACK) .............................. 27
MAVENCLAD (8 TABLET
PACK) .............................. 27
MAVENCLAD (9 TABLET
PACK) .............................. 27
meclizine ............................... 62
meclofenamate ...................... 31
medroxyprogesterone ........... 71
mefenamic acid ..................... 31
mefloquine .............................. 9
megestrol .............................. 18
MEKINIST ........................... 18
MEKTOVI ............................ 18
meloxicam ............................ 31
melphalan hcl ........................ 18
memantine ............................ 27
MEMANTINE ...................... 27
MENACTRA (PF) ................ 67
You can find information on what the symbols and abbreviations on this table mean by going to page viii.
94
MENVEO A-C-Y-W-135-DIP
(PF) ................................... 67
mercaptopurine ..................... 18
meropenem ............................. 9
MEROPENEM-0.9%
SODIUM CHLORIDE ....... 9
mesalamine ........................... 62
mesalamine with cleansing
wipe .................................. 62
mesna .................................... 13
MESNEX ............................. 13
metaproterenol ...................... 80
metaxalone ........................... 28
metformin ............................. 57
methadone ............................ 29
methadone intensol ............... 29
methadose ............................. 29
methamphetamine ................ 35
methazolamide ..................... 76
methenamine hippurate ........ 13
methenamine mandelate ....... 13
methimazole ......................... 55
methotrexate sodium ............ 19
methotrexate sodium (pf) ..... 18
methoxsalen .......................... 48
methscopolamine .................. 61
methyldopa-
hydrochlorothiazide .......... 41
methylergonovine ................. 74
METHYLERGONOVINE ... 74
methylphenidate hcl ....... 35, 36
methylprednisolone .............. 55
methylprednisolone acetate .. 55
methylprednisolone sodium
succ ................................... 55
methyltestosterone ................ 60
metoclopramide hcl .............. 62
metolazone ........................... 41
metoprolol succinate ............ 41
metoprolol tartrate ................ 41
metoprolol tartrate-
hydrochlorothiazide .......... 41
metro i.v. ................................ 9
metronidazole ............. 9, 48, 71
metronidazole in nacl (iso-
osm) .................................... 9
metyrosine ............................ 41
mexiletine ............................. 38
MIACALCIN ....................... 60
miconazole-3 ........................ 71
microgestin 1.5/30 (21) ........ 73
microgestin 1/20 (21) ........... 73
microgestin fe 1.5/30 (28) .... 73
microgestin fe 1/20 (28) ....... 73
midodrine.............................. 53
migergot................................ 26
miglustat ............................... 60
millipred ............................... 55
minocycline .................... 12, 13
minoxidil .............................. 41
mirtazapine ........................... 36
misoprostol ........................... 64
mitomycin ............................. 19
mitoxantrone ......................... 19
M-M-R II (PF) ...................... 67
modafinil .............................. 36
moexipril .............................. 41
molindone ............................. 36
mometasone .................... 51, 80
mono-linyah.......................... 73
montelukast .......................... 80
morgidox .............................. 13
morphine ......................... 29, 30
MORPHINE ................... 29, 30
morphine (pf) ........................ 29
morphine concentrate ........... 29
MOVANTIK ........................ 62
MOVIPREP .......................... 62
moxifloxacin ................... 12, 75
MOXIFLOXACIN-
SOD.ACE,SUL-WATER . 12
moxifloxacin-sod.chloride(iso)
.......................................... 12
MOZOBIL ............................ 65
MULPLETA ......................... 44
MULTAQ ............................. 38
mupirocin.............................. 49
mupirocin calcium ................ 49
mycophenolate mofetil ......... 19
mycophenolate mofetil (hcl) 19
mycophenolate sodium ......... 19
MYLOTARG ....................... 19
MYRBETRIQ ...................... 81
N nabumetone .......................... 31
nadolol .................................. 41
nadolol-bendroflumethiazide 41
nafcillin ................................. 11
nafcillin in dextrose (iso-osm)
.......................................... 11
NAGLAZYME ..................... 60
nalbuphine ............................ 31
naloxone ............................... 31
naltrexone ............................. 32
naproxen ............................... 32
naratriptan ............................. 26
NARCAN ............................. 32
NATACYN ........................... 75
nateglinide ............................ 57
NATPARA ........................... 60
NAYZILAM ......................... 24
necon 0.5/35 (28) .................. 73
NEEDLES, INSULIN
DISP.,SAFETY ................ 57
nefazodone ............................ 36
neomycin ................................ 9
neomycin-bacitracin-poly-hc 77
neomycin-bacitracin-
polymyxin ......................... 75
neomycin-polymyxin b gu .... 51
neomycin-polymyxin b-
dexameth ........................... 77
neomycin-polymyxin-
gramicidin ......................... 75
neomycin-polymyxin-hc . 54, 77
neo-polycin ........................... 75
neo-polycin hc ...................... 77
NEPHRAMINE 5.4 % .......... 84
NERLYNX ........................... 19
NEUPRO .............................. 26
nevirapine ............................... 3
NEXAVAR ........................... 19
niacin .................................... 45
nicardipine ............................ 41
NICOTROL .......................... 53
NICOTROL NS .................... 53
nifedipine .............................. 41
nikki (28) .............................. 73
nilutamide ............................. 19
nimodipine ............................ 41
NINLARO ............................ 19
nitro-bid ................................ 46
nitrofurantoin macrocrystal .. 13
nitrofurantoin monohyd/m-
cryst .................................. 13
nitroglycerin ......................... 46
nizatidine .............................. 64
NORDITROPIN FLEXPRO 65
noreth-ethinyl estradiol-iron . 73
norethindrone (contraceptive)
.......................................... 71
norethindrone acetate ............ 71
You can find information on what the symbols and abbreviations on this table mean by going to page viii.
95
norgestimate-ethinyl estradiol
.......................................... 73
NORMOSOL-M IN 5 %
DEXTROSE ..................... 84
NORMOSOL-R ................... 82
NORMOSOL-R PH 7.4 ....... 84
NORTHERA ........................ 53
nortrel 0.5/35 (28) ................ 73
nortrel 1/35 (21) ................... 73
nortrel 1/35 (28) ................... 73
nortrel 7/7/7 (28) .................. 73
nortriptyline .......................... 36
NORVIR................................. 3
NOVAREL ........................... 60
NOVOFINE ......................... 57
NOVOLIN 70/30 U-100
INSULIN .......................... 57
NOVOLIN 70-30 FLEXPEN
U-100 ................................ 57
NOVOLIN N FLEXPEN ..... 57
NOVOLIN N NPH U-100
INSULIN .......................... 57
NOVOLIN R FLEXPEN ..... 57
NOVOLIN R REGULAR U-
100 INSULN .................... 58
NOVOLOG FLEXPEN U-100
INSULIN .......................... 58
NOVOLOG MIX 70-30 U-100
INSULN ........................... 58
NOVOLOG MIX 70-
30FLEXPEN U-100 ......... 58
NOVOLOG PENFILL U-100
INSULIN .......................... 58
NOVOLOG U-100 INSULIN
ASPART........................... 58
NOVOTWIST ...................... 58
NOXAFIL .............................. 1
NUBEQA ............................. 19
NUCYNTA .......................... 32
NUCYNTA ER .................... 32
NUEDEXTA ........................ 27
NULOJIX ............................. 19
NUPLAZID .......................... 36
nyamyc ................................. 49
nystatin ............................. 1, 49
nystatin-triamcinolone .......... 49
nystop ................................... 49
O ocella .................................... 73
octreotide acetate .................. 19
ODEFSEY .............................. 4
ODOMZO ............................ 19
OFEV.................................... 80
ofloxacin ................... 12, 54, 75
olanzapine ............................. 36
olanzapine-fluoxetine ........... 36
olmesartan ............................ 41
olmesartan-amlodipine-
hydrochlorothiazide .......... 41
olmesartan-
hydrochlorothiazide .......... 41
olopatadine ..................... 54, 76
omega-3 acid ethyl esters ..... 45
omeprazole ........................... 64
ONCASPAR ......................... 19
ondansetron .......................... 63
ondansetron hcl..................... 63
ondansetron hcl (pf)........ 62, 63
ONGLYZA ........................... 58
OPDIVO ............................... 19
OPSUMIT ............................ 80
ORENCIA ............................ 70
ORENCIA CLICKJECT ...... 70
ORIAHNN............................ 71
ORILISSA ............................ 60
ORKAMBI ........................... 80
orsythia ................................. 73
oseltamivir .............................. 4
OTEZLA .............................. 70
OTEZLA STARTER ............ 70
oxacillin ................................ 11
oxacillin in dextrose(iso-osm)
.......................................... 11
oxaliplatin ............................. 19
oxandrolone .......................... 60
oxaprozin .............................. 32
oxazepam .............................. 36
oxcarbazepine ....................... 24
OXERVATE ........................ 76
oxybutynin chloride .............. 81
oxycodone ............................ 30
oxycodone-acetaminophen ... 30
oxycodone-aspirin ................ 30
oxymorphone ........................ 30
OZEMPIC ............................ 58
P pacerone................................ 38
paclitaxel .............................. 19
paliperidone .......................... 36
pamidronate .......................... 60
PANCREAZE ...................... 63
PANRETIN .......................... 48
pantoprazole ......................... 64
paricalcitol ............................ 60
PARICALCITOL ................. 60
paroex oral rinse ................... 54
paromomycin .......................... 9
paroxetine hcl ................. 36, 37
paroxetine
mesylate(menop.sym) ....... 37
PASER .................................... 9
PAXIL .................................. 37
PAZEO ................................. 76
PEDIARIX (PF) ................... 67
PEDVAX HIB (PF) .............. 67
peg 3350-electrolytes ............ 63
PEGANONE ......................... 24
PEGASYS ............................ 65
peg-electrolyte ...................... 63
PEMAZYRE ......................... 20
penicillamine ........................ 70
penicillin g potassium ........... 11
penicillin g procaine ............. 11
penicillin g sodium ............... 11
penicillin v potassium ........... 11
pentamidine ............................ 9
PENTASA ............................ 63
pentoxifylline ........................ 44
PERFOROMIST ................... 80
perindopril erbumine ............ 41
periogard ............................... 54
PERJETA ............................. 20
permethrin ............................. 51
perphenazine ......................... 37
perphenazine-amitriptyline ... 37
phenelzine ............................. 37
phenobarbital ........................ 24
phenoxybenzamine ............... 41
phenytoin .............................. 24
phenytoin sodium ................. 24
phenytoin sodium extended .. 24
philith .................................... 73
PHOSPHOLINE IODIDE .... 76
PIFELTRO ............................. 4
pilocarpine hcl ................ 53, 76
pimecrolimus ........................ 48
pimozide ............................... 37
pimtrea (28) .......................... 73
pindolol ................................. 41
pioglitazone .......................... 58
pioglitazone-glimepiride ....... 58
pioglitazone-metformin ........ 58
piperacillin-tazobactam ........ 11
You can find information on what the symbols and abbreviations on this table mean by going to page viii.
96
PIPERACILLIN-
TAZOBACTAM .............. 11
PIQRAY ............................... 20
pirmella................................. 73
piroxicam .............................. 32
PLASMA-LYTE 148 ........... 84
PLASMA-LYTE A .............. 85
PLEGRIDY .......................... 65
plenamine ............................. 85
podofilox .............................. 48
polycin .................................. 75
polyethylene glycol 3350 ..... 63
polymyxin b sulfate ................ 9
polymyxin b sulf-trimethoprim
.......................................... 75
POMALYST ........................ 20
portia 28................................ 74
PORTRAZZA ...................... 20
potassium chlorid-d5-
0.45%nacl ......................... 82
potassium chloride................ 83
potassium chloride in 0.9%nacl
.......................................... 82
potassium chloride in 5 % dex
.......................................... 83
potassium chloride in lr-d5 ... 83
potassium chloride in water.. 83
potassium chloride-0.45 % nacl
.......................................... 83
potassium chloride-d5-
0.2%nacl ........................... 83
potassium chloride-d5-
0.3%nacl ........................... 83
potassium chloride-d5-
0.9%nacl ........................... 83
potassium citrate ................... 82
POTELIGEO ........................ 20
PRADAXA........................... 44
PRALUENT PEN ................ 45
pramipexole .......................... 26
prasugrel ............................... 44
pravastatin ............................ 45
prazosin ................................ 42
prednicarbate ........................ 51
prednisolone ......................... 55
prednisolone acetate ............. 77
prednisolone sodium phosphate
.................................... 55, 77
prednisone ............................ 55
prednisone intensol ............... 55
pregabalin ............................. 24
PREGNYL............................ 60
PREMARIN ......................... 71
premasol 10 % ...................... 85
prenatal vitamin oral tablet ... 85
PRETOMANID ...................... 9
prevalite ................................ 45
previfem................................ 74
PREVYMIS ............................ 4
PREZCOBIX .......................... 4
PREZISTA ............................. 4
PRIFTIN ................................. 9
primaquine .............................. 9
primidone.............................. 24
probenecid ............................ 68
probenecid-colchicine .......... 68
procainamide ........................ 38
PROCALAMINE 3% ........... 85
prochlorperazine ................... 63
prochlorperazine edisylate .... 63
prochlorperazine maleate oral
.......................................... 63
PROCRIT ............................. 65
procto-pak ............................. 63
proctosol hc .......................... 63
proctozone-hc ....................... 63
progesterone micronized ...... 71
PROGLYCEM ..................... 58
PROGRAF............................ 20
PROLEUKIN ....................... 65
PROLIA................................ 68
PROMACTA ........................ 44
promethazine ........................ 78
propafenone .......................... 38
propranolol ........................... 42
propranolol-
hydrochlorothiazide .......... 42
propylthiouracil .................... 55
PROQUAD (PF)................... 67
PROSOL 20 % ..................... 85
protriptyline .......................... 37
PULMOZYME ..................... 80
PURIXAN ............................ 20
pyrazinamide .......................... 9
pyridostigmine bromide ....... 28
pyrimethamine ........................ 9
Q QINLOCK ............................ 20
QUADRACEL (PF) ............. 67
quetiapine ............................. 37
quinapril................................ 42
quinapril-hydrochlorothiazide
.......................................... 42
quinidine gluconate .............. 38
quinidine sulfate ................... 38
quinine sulfate ........................ 9
R RABAVERT (PF) ................ 67
RADICAVA ......................... 27
raloxifene .............................. 68
ramelteon .............................. 37
ramipril ................................. 42
ranitidine hcl ......................... 64
ranolazine ............................. 46
rasagiline ............................... 26
RAVICTI .............................. 53
REBIF (WITH ALBUMIN) . 65
REBIF REBIDOSE .............. 65
REBIF TITRATION PACK . 65
reclipsen (28) ........................ 74
RECOMBIVAX HB (PF) ..... 67
RECTIV ................................ 63
regonol .................................. 28
REGRANEX ........................ 48
RELENZA DISKHALER ...... 4
RELISTOR ........................... 63
REMICADE ......................... 63
repaglinide ............................ 58
repaglinide-metformin .......... 58
REPATHA ............................ 45
REPATHA PUSHTRONEX 45
REPATHA SURECLICK .... 45
RESTASIS ............................ 76
RESTASIS MULTIDOSE .... 76
RETACRIT ........................... 65
RETEVMO ........................... 20
RETROVIR ............................ 4
REVLIMID ........................... 20
REXULTI ............................. 37
REYATAZ ............................. 4
RHOPRESSA ....................... 76
ribavirin .................................. 4
rifabutin .................................. 9
rifampin .................................. 9
riluzole .................................. 53
rimantadine ............................. 4
ringer's .................................. 83
RINVOQ ............................... 70
risedronate ................ 53, 68, 69
RISPERDAL CONSTA ....... 37
risperidone ............................ 37
ritonavir .................................. 4
You can find information on what the symbols and abbreviations on this table mean by going to page viii.
97
RITUXAN ............................ 20
rivastigmine .......................... 27
rivastigmine tartrate.............. 27
rizatriptan ............................. 26
ROCKLATAN ..................... 76
ropinirole .............................. 26
rosuvastatin........................... 45
ROTARIX ............................ 67
ROTATEQ VACCINE ........ 67
roweepra ............................... 24
roweepra xr ........................... 24
ROZLYTREK ...................... 20
RUBRACA........................... 20
RUKOBIA .............................. 4
RYDAPT .............................. 20
S SAMSCA ............................. 60
SANCUSO ........................... 63
SANDIMMUNE .................. 20
SANTYL .............................. 48
SAPHRIS ............................. 37
scopolamine base.................. 63
SECUADO ........................... 37
selegiline hcl ......................... 26
selenium sulfide.................... 47
SELZENTRY ......................... 4
SEREVENT DISKUS .......... 80
sertraline ............................... 37
sevelamer carbonate ............. 53
sf 54
sf 5000 plus .......................... 54
SHINGRIX (PF) ................... 67
SIGNIFOR ........................... 20
sildenafil (pulmonary arterial
hypertension) .................... 80
silver sulfadiazine ................. 48
SIMULECT .......................... 20
simvastatin ............................ 45
sirolimus ............................... 20
SIRTURO ............................... 9
SKYRIZI .............................. 47
sodium chloride .............. 53, 83
sodium chloride 0.45 % ........ 83
sodium chloride 0.9 % .......... 53
sodium chloride 3 % ............. 83
sodium chloride 5 % ............. 83
sodium polystyrene (sorb free)
.......................................... 53
sodium polystyrene sulfonate
.......................................... 53
solifenacin ............................ 81
SOLTAMOX ........................ 20
SOLU-CORTEF ACT-O-
VIAL (PF) ........................ 55
SOMATULINE DEPOT ...... 20
SOMAVERT ........................ 60
sorine .................................... 39
sotalol ................................... 39
sotalol af ............................... 39
SPIRIVA RESPIMAT .......... 80
SPIRIVA WITH
HANDIHALER ................ 80
spironolactone ...................... 42
spironolactone-
hydrochlorothiazide .......... 42
sprintec (28) .......................... 74
SPRITAM ............................. 24
SPRYCEL ............................ 20
sps (with sorbitol) ................. 53
sronyx ................................... 74
ssd ......................................... 48
STAMARIL (PF) ................. 67
stavudine ................................. 4
STELARA ............................ 47
STIOLTO RESPIMAT......... 80
STIVARGA .......................... 20
STREPTOMYCIN ................. 9
STRIBILD .............................. 4
sucralfate .............................. 64
sulfacetamide sodium ........... 76
sulfacetamide sodium (acne) 49
sulfacetamide-prednisolone .. 76
sulfadiazine ........................... 12
sulfamethoxazole-trimethoprim
.......................................... 12
SULFAMYLON ................... 49
sulfasalazine ......................... 63
sulindac ................................. 32
sumatriptan ........................... 26
sumatriptan succinate ........... 26
SUPRAX ................................ 7
SUTENT ............................... 20
syeda ..................................... 74
SYLATRON ......................... 66
SYMBICORT ....................... 80
SYMDEKO .......................... 80
SYMFI .................................... 4
SYMFI LO ............................. 4
SYMLINPEN 120 ................ 58
SYMLINPEN 60 .................. 58
SYMPAZAN .................. 24, 25
SYMTUZA ............................. 4
SYNAGIS ............................... 4
SYNAREL ............................ 60
SYNERCID ............................ 9
SYNJARDY ......................... 58
SYNJARDY XR ................... 58
SYNRIBO ............................. 21
SYNTHROID ....................... 61
T TABLOID ............................. 21
TABRECTA ......................... 21
tacrolimus ....................... 21, 48
tadalafil ................................. 82
tadalafil (pulm. hypertension)
.......................................... 81
TAFINLAR .......................... 21
TAGRISSO ........................... 21
TALZENNA ......................... 21
tamoxifen .............................. 21
tamsulosin ............................. 82
TARGRETIN ....................... 21
TASIGNA ............................. 21
tazarotene .............................. 49
taztia xt ................................. 42
TAZVERIK .......................... 21
TDVAX ................................ 67
TECENTRIQ ........................ 21
TECFIDERA ........................ 27
TEFLARO .............................. 7
TEGSEDI ............................. 27
TEKTURNA HCT ................ 42
telmisartan ............................ 42
telmisartan-
hydrochlorothiazide .......... 42
temazepam ............................ 37
TEMIXYS .............................. 4
TENIVAC (PF) .................... 68
tenofovir disoproxil fumarate . 5
terazosin ................................ 42
terbinafine hcl ......................... 1
terbutaline ............................. 81
terconazole ............................ 71
testosterone ........................... 60
testosterone cypionate .......... 60
testosterone enanthate ........... 60
TETANUS,DIPHTHERIA
TOX PED(PF) .................. 68
tetrabenazine ......................... 27
tetracycline ........................... 13
THALOMID ......................... 21
theophylline .......................... 81
thioridazine ........................... 37
You can find information on what the symbols and abbreviations on this table mean by going to page viii.
98
thiotepa ................................. 21
thiothixene ............................ 37
tiadylt er................................ 42
tiagabine ............................... 25
TIBSOVO............................. 21
tigecycline .............................. 9
tilia fe.................................... 74
timolol maleate ............... 42, 75
tinidazole ................................ 9
TIVICAY ............................... 5
TIVICAY PD ......................... 5
tizanidine .............................. 28
TOBI PODHALER .............. 10
TOBRADEX ST .................. 77
tobramycin ............................ 75
tobramycin in 0.225 % nacl . 10
tobramycin sulfate ................ 10
tobramycin-dexamethasone .. 77
tolcapone .............................. 26
tolmetin................................. 32
TOLSURA ............................. 1
tolterodine............................. 81
tolvaptan ............................... 60
topiramate ............................. 25
TOPIRAMATE .................... 25
toposar .................................. 21
topotecan .............................. 21
toremifene............................. 21
torsemide .............................. 42
TOUJEO MAX U-300
SOLOSTAR ..................... 58
TOUJEO SOLOSTAR U-300
INSULIN .......................... 58
TRACLEER ......................... 81
tramadol ................................ 32
tramadol-acetaminophen ...... 32
trandolapril ........................... 42
trandolapril-verapamil .......... 42
tranexamic acid .................... 71
tranylcypromine ................... 37
travasol 10 % ........................ 85
travoprost .............................. 76
trazodone .............................. 37
TREANDA ........................... 21
TRECATOR ......................... 10
TRELEGY ELLIPTA .......... 81
TRELSTAR .......................... 21
treprostinil sodium................ 42
TRESIBA FLEXTOUCH U-
100 .................................... 59
TRESIBA FLEXTOUCH U-
200 .................................... 59
TRESIBA U-100 INSULIN . 59
tretinoin (antineoplastic)....... 21
tretinoin microspheres .......... 49
tretinoin topical..................... 49
triamcinolone acetonide 51, 54,
55
triamterene-
hydrochlorothiazide .......... 42
trianex ................................... 51
triderm .................................. 51
trientine ................................. 53
tri-estarylla............................ 74
trifluoperazine ...................... 37
trifluridine ............................. 75
trihexyphenidyl ..................... 26
TRIKAFTA .......................... 81
tri-legest fe ............................ 74
tri-linyah ............................... 74
trilyte with flavor packets ..... 63
trimethoprim ......................... 13
trimipramine ......................... 37
TRINTELLIX ....................... 37
tri-previfem (28) ................... 74
TRISENOX .......................... 21
tri-sprintec (28) ..................... 74
TRIUMEQ .............................. 5
trivora (28) ............................ 74
TROGARZO .......................... 5
TROPHAMINE 10 % .......... 85
trospium ................................ 82
TRUMENBA........................ 68
TRUVADA ............................ 5
TUKYSA .............................. 21
TURALIO ............................ 21
TWINRIX (PF)..................... 68
TYBOST ................................ 5
TYKERB .............................. 21
TYMLOS.............................. 69
TYPHIM VI ......................... 68
TYSABRI ............................. 27
U unithroid ............................... 61
UPTRAVI ............................. 42
ursodiol ................................. 63
V valacyclovir ............................ 5
VALCHLOR ........................ 48
valganciclovir ......................... 5
valproate sodium .................. 25
valproic acid ......................... 25
valproic acid (as sodium salt)
.......................................... 25
valsartan ................................ 42
valsartan-hydrochlorothiazide
.......................................... 42
VALTOCO ........................... 25
vancomycin ........................... 10
VANCOMYCIN ................... 10
VANCOMYCIN IN 0.9 %
SODIUM CHL ................. 10
VANCOMYCIN IN
DEXTROSE 5 % .............. 10
vandazole .............................. 71
VAQTA (PF) ........................ 68
VARIVAX (PF) .................... 68
VARIZIG .............................. 68
VARUBI ............................... 63
VECAMYL .......................... 46
VELCADE ........................... 21
velivet triphasic regimen (28)
.......................................... 74
VENCLEXTA ................ 21, 22
VENCLEXTA STARTING
PACK ............................... 22
venlafaxine ..................... 37, 38
VENTOLIN HFA ................. 81
verapamil ........................ 42, 43
VERSACLOZ ....................... 38
VERZENIO .......................... 22
VICTOZA 2-PAK ................ 59
VICTOZA 3-PAK ................ 59
vigabatrin .............................. 25
VIIBRYD ............................. 38
VIMPAT ............................... 25
vinblastine ............................. 22
vincasar pfs ........................... 22
vincristine ............................. 22
vinorelbine ............................ 22
viorele (28) ........................... 74
VIRACEPT ............................. 5
VIREAD ................................. 5
VITRAKVI ........................... 22
VIVITROL ........................... 32
VIZIMPRO ........................... 22
voriconazole ........................... 1
VOTRIENT .......................... 22
VPRIV .................................. 60
VRAYLAR ........................... 38
VUMERITY ......................... 27
VYNDAMAX ...................... 46
You can find information on what the symbols and abbreviations on this table mean by going to page viii.
99
VYNDAQEL ........................ 46
W warfarin ................................ 44
wera (28) .............................. 74
wixela inhub ......................... 81
wymzya fe ............................ 74
X XALKORI ............................ 22
XARELTO ........................... 44
XARELTO DVT-PE TREAT
30D START ..................... 44
XATMEP ............................. 22
XCOPRI ............................... 25
XCOPRI MAINTENANCE
PACK ............................... 25
XCOPRI TITRATION PACK
.......................................... 25
XELJANZ ............................ 70
XELJANZ XR ...................... 70
XERMELO........................... 22
XGEVA ................................ 13
XIFAXAN ............................ 10
XIGDUO XR ........................ 59
XOFLUZA ............................. 5
XOLAIR ............................... 81
XOSPATA............................ 22
XPOVIO ............................... 22
XTANDI ............................... 22
XYREM................................ 38
Y YERVOY ............................. 22
YF-VAX (PF) ....................... 68
YONDELIS .......................... 22
YONSA ................................ 22
Z zafirlukast ............................. 81
ZALTRAP ............................ 22
zarah ..................................... 74
ZARXIO ............................... 66
ZEJULA ............................... 22
ZELBORAF ......................... 22
ZENPEP ............................... 64
zidovudine .............................. 5
ziprasidone hcl ...................... 38
ziprasidone mesylate ............ 38
ZIRGAN ............................... 75
zoledronic acid ...................... 61
zoledronic acid-mannitol-water
.................................... 53, 61
ZOLINZA ............................. 22
zolmitriptan ........................... 26
zolpidem ............................... 38
zonisamide ............................ 25
ZORTRESS .......................... 22
ZOSTAVAX (PF) ................ 68
zovia 1/35e (28) .................... 74
ZYDELIG ............................. 22
ZYKADIA ............................ 22
ZYPREXA RELPREVV ...... 38
ZYTIGA ............................... 22
175 Scott Swamp Road Farmington, CT 06032
This formulary was updated on 11/01/2020. For more recent information or other questions, please contact ConnectiCare Member Services at 1-800-224-2273, or for TTY users, 711, from 8 a.m. to 8 p.m. ET, seven days a week or visit connecticare.com/medicare.