USE THIS DOCUMENT TO LEARN ABOUT THE PRESCRIPTION DRUGS WE COVER IN ALL QUALIFIED HEALTH PLANS. Qualified Health Plans (QHP) are Affordable Care Act-compliant plans that cover essential health benefits and follow established limits on cost-sharing. This includes HAP Personal Alliance and small group QHPs purchased through the Health Insurance Marketplace or directly from HAP. For more information If you have questions about your health plan, please call a Customer Service specialist at one of the phone numbers listed below or log in at hap.org and send us a message. Personal Alliance QHPs HMO Plans: (800) 759-3436 PPO Plans: (800) 944-9399 Hours: April 1 through September 30 – Monday through Friday 8 a.m. to 8 p.m. October 1 through March 31 – Monday through Friday 8 a.m. to 8 p.m.; Saturday 8 a.m. to noon Small Group QHPs HMO Plans: (800) 422-4641 Hours: April 1 through September 30 – Monday through Friday 8 a.m. to 7 p.m. October 1 through March 31 – Monday through Friday 8 a.m. to 7 p.m.; Saturday 8 a.m. to noon PPO Plans: (888) 999-4347 Hours: April 1 through September 30 – Monday through Friday 8 a.m. to 5 p.m. October 1 through March 31 – Monday through Friday 8 a.m. to 5 p.m.; Saturday 8 a.m. to noon If you are deaf, hard of hearing or unable to speak, please call 711 for our TTY service. Please note: The list of drugs we cover is current as of January 2016. A drug's formulary status may change prior to being updated in this document. The listing of a drug does not imply coverage for all benefits. Some dosage forms or strengths of an existing formulary drug may not be covered. Please contact us for more details. 2016 Drug Formulary for Qualified Health Plans (HAP Personal Alliance ® and Small Group)
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USE THIS DOCUMENT TO LEARN ABOUT THE PRESCRIPTION DRUGS WE COVER IN ALL
QUALIFIED HEALTH PLANS.
Qualified Health Plans (QHP) are Affordable Care Act-compliant plans that cover essential health
benefits and follow established limits on cost-sharing. This includes HAP Personal Alliance and small
group QHPs purchased through the Health Insurance Marketplace or directly from HAP.
For more information
If you have questions about your health plan, please call a Customer Service specialist at one of the
phone numbers listed below or log in at hap.org and send us a message.
Personal Alliance QHPs
HMO Plans: (800) 759-3436
PPO Plans: (800) 944-9399
Hours: April 1 through September 30 – Monday through Friday 8 a.m. to 8 p.m. October 1 through March 31 – Monday through Friday 8 a.m. to 8 p.m.; Saturday 8 a.m. to noon
Small Group QHPs
HMO Plans: (800) 422-4641
Hours: April 1 through September 30 – Monday through Friday 8 a.m. to 7 p.m. October 1 through March 31 – Monday through Friday 8 a.m. to 7 p.m.; Saturday 8 a.m. to noon
PPO Plans: (888) 999-4347
Hours: April 1 through September 30 – Monday through Friday 8 a.m. to 5 p.m. October 1 through March 31 – Monday through Friday 8 a.m. to 5 p.m.; Saturday 8 a.m.
to noon
If you are deaf, hard of hearing or unable to speak, please call 711 for our TTY service.
Please note: The list of drugs we cover is current as of January 2016. A drug's formulary status
may change prior to being updated in this document. The listing of a drug does not imply
coverage for all benefits. Some dosage forms or strengths of an existing formulary drug may
not be covered. Please contact us for more details.
2016 Drug Formulary for Qualified Health Plans (HAP Personal Alliance
® and
Small Group)
What is the drug formulary?
A formulary is a list of covered prescription drugs. Prescription drugs are self-administered medications
that you can obtain from pharmacies and that you use in the outpatient setting. The list of covered
prescription drugs is selected with a team of health care providers. This represents the prescription
therapies believed to be a necessary part of a quality treatment program. We will cover the drug listed
in our formulary as long as it is medically necessary, the prescription is filled at an in-network pharmacy
and other rules of the health plan are followed.
Formulary list can change over time. We may add new drugs as they are approved by the FDA and
likewise we may remove drugs as new information about safety and effectiveness is available. We may
also change the tier which reflects your cost-share for the drug. We may update our rules for coverage
meaning that we may add or remove the need for prior approval, quantity limits or criteria for coverage
(see page XX for recent formulary changes).
This list only includes “medical drugs” that are required to be obtained from HAP contracted Specialty
Pharmacy. Medical drugs are those that are administered in the doctor’s office or other health care
facility. These are generally supplied by your doctor or other health care provider. Drugs provided for
home infusion therapy are also considered medical. Please refer to your Medical Cost Share Rider for
information about your cost-sharing for Medical drugs.
The Qualified Health Plan Formulary is available at hap.org/formulary.
How do I use the drug formulary?
The formulary has a list of covered generic and brand name drugs and is organized by categories. Each
category depends on the type of medical conditions that the drugs are used to treat. For example, drugs
used to treat a heart condition are listed under the category “Cardiovascular Agents.” If you know what a
drug is used for, look for the category name in the list. Then look under the category name for the drug.
If you are not sure what category to look under, you should look for your drug in the Index that is at the
end of formulary list. The Index provides an alphabetical list of all of the drugs included in this document.
To search for a specific drug within the formulary, select Ctrl-F and enter the name of the drug in the
search box.
What is a generic substitution?
When an FDA approved generic drug is available, your prescription will be filled with the generic form of
the medication. Generic drugs contain the same active ingredients and are equivalent in strength and
dosage to the original brand name product. Generic drugs cost you and your health plan less money
than a brand name drug.
.
What are specialty drugs?
Specialty drugs are biologics or prescription drugs that require close monitoring for safety and efficacy.
For this reason we contract with Pharmacy Advantage, a specialty pharmacy, from whom you can obtain
specialty drugs. Specialty drugs require prior authorization and Pharmacy Advantage can help you and
your doctor submit a request. You or your doctor can contact Pharmacy Advantage at (800) 456-2112.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. The coverage
requirements are listed on the drug formulary. These requirements and limits may include:
Prior Authorization – Some medications on our formulary have criteria you must meet before we cover them. This means that you will need to get approval from us before you fill your prescriptions for these drugs.
Step Therapy – In some cases, we require 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.
Quantity Limits – Certain drugs have quantity limits. A quantity limit is the maximum quantity that can be dispensed on each fill of medication or the maximum number of fills allowed for treatment of certain conditions. Specialty/injectable drugs (except insulin) and select oral drugs (e.g. opioid analgesics) are limited to a maximum 30-day supply per fill. Some specialty drugs require a 15-day supply for the first fill.
Benefit limitations
Our drug formulary applies to drugs used in an outpatient setting. It does not include medication
administered in the doctor’s office or while in the hospital. These are known as medical drugs. Note that
some medical drugs are listed on this formulary because they are part of our Specialty Program. Please
refer to “what are specialty drug?” section for information about these medications
The following are general drug coverage exclusions that apply to all members:
• Over-the-counter (OTC) medications and their equivalents are not covered unless specified in the formulary or on the rider
• Drug products used for cosmetic purposes are not covered • Experimental drugs and/or any drug products used in an experimental manner are not covered • Replacement of lost or stolen medication is not covered
Since the selected drug packages and coverage vary for each Qualified Health Plan, check your
Summary of Benefits and Coverage (SBC) for your cost-sharing and exclusions.
What if my drug is not on the drug formulary?
When your drug is not listed on the formulary it is considered non-formulary. You or your doctor can ask
us to make an exception and cover your drug and one of HAP clinical specialists will evaluate if the
medication will be covered by your plan. However it is best to first discuss with your doctor or pharmacist
if one of the formulary alternatives will work for you.
Exception approvals for standard non-formulary medications will process at the highest non specialty
(Tier three) copayment. Exception approvals for non-formulary specialty drugs will process at the
highest Specialty (Tier four) copayment. Non-formulary specialty drugs when approved for use by the
health plan can be required to be dispensed by Pharmacy Advantage.
How do I request prior authorization or drug formulary exception?
You or your doctor can ask us to make an exception to our requirements or limits. You may also ask us
to cover a drug not included on our formulary or ask us to exempt you from a formulary requirement
through the exception process. Your doctor must submit a request to us indicating why formulary
requirements should not apply. Your doctor may use the forms available at hap.org/mrf to send us
information when requesting either prior authorization or exception to the formulary.
What is included in the drug formulary? The name of the covered drug is listed in the first column. Brand name drugs are capitalized (e.g., ADVAIR DISKUS) and generic drugs are listed in lower-case (e.g., gabapentin). When a generic drug is listed on the formulary, only the generic is covered.
The second column represents the drug’s cost-sharing level, or Tier. Every drug on the formulary is in
one of four cost-sharing Tiers.
The following table will translate how the four Tiers shown on the formulary are applicable to your health
plan’s prescription drug benefit. Refer to your Summary of Benefits and Coverage for your cost-
sharing information.
Description of Tier Copay
Preventive (HCR) – generic prescription preventive drugs that
are mandated by the Affordable Care Act. These are covered
at zero copay when Health Care Reform rules are met.
Tier 0
Generic – non-brand name drugs that have the lowest copay Tier 1
Preferred Brand – brand name formulary drugs that have
the lowest brand copay
Tier 2
Non-Preferred Brand – brand name formulary drugs that
are not in the Preferred Brand Tier
Tier 3
Specialty Drugs – biologics or drugs that require close
monitoring for safety and efficacy and as designated by us to
be a specialty drug
Tier 4
Medical Drugs - These are drugs that are infused or
administered in doctor’s office or facility and are covered
under the medical benefit of your plan.
Medical Coinsurance
The third column lists the Requirements/Limits that must be met for coverage of your drug. Please
refer to the abbreviations used in this column and their explanation.
The fourth column is the Comment section and may include specific information about strengths or
dosage forms that are covered.
The fifth column is the list of covered lower cost alternatives that you may be able to use.
Abbreviations for Requirements/Limits are as follows: PA (Prior Authorization) – You or your doctor is required to get prior authorization from us before you fill your prescription for this drug. Without prior approval, we may not cover this drug. QL (Quantity Limit) – We limit the amount of these drugs that are covered for each prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. ST (Step Therapy) – Before we will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you.
SP (Specialty Pharmacy) –This specialty drug can only be obtained from Pharmacy Advantage by calling them at (800) 456 2112.
1Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T3 QL (840ml/14 days)ZYVOX SUS 100MG/5M (linezolid)
T3 QL (28 tabs/14 days)ZYVOX TAB 600MG (linezolid)
CEPHALOSPORINS
T2CEDAX CAP 400MG (ceftibuten)
T1cefaclor cap 250mg
T1cefaclor cap 500mg
T1cefaclor er tab 500mg
T1cefadroxil cap 500mg
T1cefadroxil sus 250/5ml
T1cefadroxil sus 500/5ml
T1cefadroxil tab 1gm
T1cefdinir cap 300mg
T1cefdinir sus 125/5ml
T1cefdinir sus 250/5ml
T1cefditoren tab 200mg
T1cefditoren tab 400mg
2Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIBACTERIALS
CEPHALOSPORINS
T1cefixime sus 100/5ml
T1cefixime sus 200/5ml
T1cefpodo prox sus 100/5ml
T1cefpodo prox sus 50mg/5ml
T1cefpodoxime tab 100mg
T1cefpodoxime tab 200mg
T1cefprozil sus 125/5ml
T1cefprozil sus 250/5ml
T1cefprozil tab 250mg
T1cefprozil tab 500mg
T1cefuroxime tab 250mg
T1cefuroxime tab 500mg
T1cephalexin cap 250mg
T1cephalexin cap 500mg
T1cephalexin cap 750mg
T1cephalexin sus 125/5ml
T1cephalexin sus 250/5ml
T3SUPRAX SUS 100/5ML (cefixime)
T3SUPRAX SUS 200/5ML (cefixime)
T3SUPRAX SUS 500/5ML (cefixime)
T3SUPRAX TAB 400MG (cefixime)
MACROLIDES
T1 QLazithromycin pow 1gm pak
T1 QL (120 ml/fill)azithromycin sus 100/5ml
T1 QL (120 ml/fill)azithromycin sus 200/5ml
T1 QL (8/5 days)azithromycin tab 250mg
T1 QL (8/5 days)azithromycin tab 500mg
T1 QL (8/5 days)azithromycin tab 600mg
T1clarithromyc sus 125/5ml
T1clarithromyc sus 250/5ml
T1clarithromyc tab 250mg
3Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIBACTERIALS
MACROLIDES
T1clarithromyc tab 500mg
T1clarithromyc tab 500mg er
T3 QL (20/10 days)DIFICID TAB 200MG (fidaxomicin)
T1e.e.s. 400 tab 400mg (erythromycin)
T2E.E.S. GRAN SUS 200/5ML (erythromycin)
T2ERYPED SUS 200/5ML (erythromycin)
T2ERYPED SUS 400/5ML (erythromycin)
T1erythrom eth tab 400mg
T1erythromycin tab 250mg bs
T1erythromycin tab 500mg bs
T3 QL (20 tabs/10 days)KETEK TAB 300MG (telithromycin)
T3 QL (20 tabs/10 days)KETEK TAB 400MG (telithromycin)
4Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIBACTERIALS
PENICILLINS
T1amoxicillin sus 250/5ml
T1amoxicillin sus 250mg/5m
T1amoxicillin sus 400/5ml
T1amoxicillin tab 500mg
T1amoxicillin tab 875mg
T1amox-pot cla tab er
T1ampicillin cap 250mg
T1ampicillin cap 500mg
T1ampicillin sus 125/5ml
T1ampicillin sus 250/5ml
T1dicloxacill cap 250mg
T1dicloxacill cap 500mg
T1penicilln vk sol 125/5ml
T1penicilln vk sol 250/5ml
T1penicilln vk tab 250mg
T1penicilln vk tab 500mg
QUINOLONES
T1ciprofloxacn sus 250mg/5
T1ciprofloxacn sus 500mg/5
T1 QL (14 tabs/Rx)ciprofloxacn tab 1000mg
T1ciprofloxacn tab 100mg
T1ciprofloxacn tab 250mg
T1ciprofloxacn tab 500mg
T1 QL (14 tabs/Rx)ciprofloxacn tab 500mg er
T1ciprofloxacn tab 750mg
T3 QL (7 tabs/7 days)FACTIVE TAB 320MG (gemifloxacin)
T1levofloxacin inj 25mg/ml
T1levofloxacin sol 25mg/ml
T1levofloxacin tab 250mg
T1levofloxacin tab 500mg
T1levofloxacin tab 750mg
5Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIBACTERIALS
QUINOLONES
T1 QL (14 tabs/Rx)moxifloxacin tab 400mg
T3 QL (56 tabs/28 days)NOROXIN TAB 400MG (norfloxacin)
T1sulfatrim pd sus 200-40/5 (sulfamethoxazole-trimethoprim)
T1sulfazine tab 500mg (sulfasalazine)
T1sulfazine ec tab 500mg (sulfasalazine)
TETRACYCLINES
T1demeclocycl tab 150mg
T1demeclocycl tab 300mg
T1doxycyc mono cap 100mg
T1doxycycl hyc cap 100mg
T1 QL (90 caps/30 days)doxycycl hyc cap 50mg
T1 QL (90 caps/30 days)doxycycl hyc tab 100mg
T1minocycline cap 100mg
T1minocycline cap 50mg
T1minocycline cap 75mg
T1minocycline tab 100mg
T1minocycline tab 50mg
T1minocycline tab 75mg
T1tetracycline cap 250mg
6Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIBACTERIALS
TETRACYCLINES
T1tetracycline cap 500mg
ANTIFUNGAL (SYSTEMIC)ALLYLAMINES
T1terbinafine tab 250mg
ANTIFUNGALS, MISCELLANEOUS
T1griseofulvin sus 125/5ml
T1griseofulvin tab micr 500
T1griseofulvin tab ultr 125
T1griseofulvin tab ultr 250
AZOLES
T1fluconazole sus 10mg/ml
T1fluconazole sus 40mg/ml
T1fluconazole tab 100mg
T1fluconazole tab 150mg
T1fluconazole tab 200mg
T1fluconazole tab 50mg
T1itraconazole cap 100mg
T1ketoconazole tab 200mg
T3 QL (2 bottles/fill)NOXAFIL SUS 40MG/ML (posaconazole)
T3SPORANOX SOL 10MG/ML (itraconazole)
T1 PAvoriconazole tab 200mg
T1 PAvoriconazole tab 50mg
POLYENES
T1nystatin pow
T1nystatin pow 10bu
T1nystatin pow 150mu
T1nystatin pow 1bu
T1nystatin pow 2bu
T1nystatin pow 500mu
T1nystatin pow 50mu
T1nystatin pow 5bu
T1nystatin sus 100000
7Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T3 QL (24 tabs/fill)COARTEM TAB 20-120MG (artemether-lumefantrine)
8Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIPROTOZOALS
ANTIMALARIALS
T3 QL (90 tabs/30 days)DARAPRIM TAB 25MG (pyrimethamine)
T1hydroxychlor tab 200mg
T1 QL (5 tabs/30 days)mefloquine tab 250mg
T2primaquine tab 26.3mg
ANTIPROTOZOALS, MISCELLANEOUS
T3 QL (150ml/3 days)ALINIA SUS 100/5ML (nitazoxanide)
T3 QL (6 tabs/3 days)ALINIA TAB 500MG (nitazoxanide)
T4 QL (180 caps/30 days)CRIXIVAN CAP 200MG (indinavir)
T4 QL (180 caps/30 days)CRIXIVAN CAP 400MG (indinavir)
T4CRIXIVAN 100 MG CAPSULE (INDINAVIR)
T4 QL (60 caps/30 day)didanosine cap 125mg
T4 QL (60 caps/30 day)didanosine cap 200mg
T4 QL (60 caps/30 day)didanosine cap 250mg
T4 QL (60 caps/30 day)didanosine cap 400mg
9Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
10Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
11Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T4 PA, SPVIEKIRA PAK TAB (ombitasvir-paritaprevir-ritonavir)
INTERFERONS
T4 PAINFERGEN INJ 15MCG (interferon)
T4 PAINFERGEN INJ 9MCG (interferon)
T4 PA, SPPEGASYS 180 MCG/0.5 ML CONV.PK (PEGINTERFERON)
T4 PA, SPPEGINTRON KIT 120MCG (peginterferon)
T4 PA, SPPEGINTRON KIT 150MCG (peginterferon)
T4 PA, SPPEGINTRON KIT 50MCG (peginterferon)
T4 PA, SPPEGINTRON KIT 80MCG (peginterferon)
T4 PA, SPPEG-INTRON KIT 120 RP (peginterferon)
T4 PA, SPPEG-INTRON KIT 120MCG (peginterferon)
T4 PA, SPPEG-INTRON KIT 150 RP (peginterferon)
T4 PA, SPPEG-INTRON KIT 150MCG (peginterferon)
T4 PA, SPPEG-INTRON KIT 50MCG (peginterferon)
T4 PA, SPPEG-INTRON KIT 50MCG RP (peginterferon)
T4 PA, SPPEG-INTRON KIT 80MCG (peginterferon)
T4 PA, SPPEG-INTRON KIT 80MCG RP (peginterferon)
12Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIVIRALS (SYSTEMIC)
MONOCLONAL ANTIBODIES
MED PA, SP Medical coinsuranceSYNAGIS INJ 50MG (palivizumab)
NEURAMINIDASE INHIBITORS
T3 QL (20 inhalations/fill; 2 fills/365 days)
RELENZA AER DISKHALE (zanamivir)
T3 QL (20 inhalations/fill; 2 fills/365 days)
RELENZA MIS DISKHALE (zanamivir)
T3 QL (10 caps/fill; 2 fills/365 days)TAMIFLU CAP 30MG (oseltamivir)
T3 QL (10 caps/fill; 2 fills/365 days)TAMIFLU CAP 45MG (oseltamivir)
T3 QL (10 caps/fill; 2 fills/365 days)TAMIFLU CAP 75MG (oseltamivir)
T3 QL (120ml/fill; 2 fills/365 days)TAMIFLU SUS 6MG/ML (oseltamivir)
NUCLEOSIDES AND NUCLEOTIDES
T1acyclovir cap 200mg
T1acyclovir sus 200/5ml
T1acyclovir tab 400mg
T1acyclovir tab 800mg
T4 PA, SPadefov dipiv tab 10mg
T4 PA, SPBARACLUDE SOL .05MG/ML (entecavir)
T4 PA, SPentecavir tab 0.5mg
T4 PA, SPentecavir tab 1mg
T1famciclovir tab 125mg
T1famciclovir tab 250mg
T1famciclovir tab 500mg
T1ganciclovir cap 250 mg
T1 PA, SPmoderiba tab 200mg (ribavirin)
T1 PAribapak pak 1200/day (ribavirin)
T1 PAribapak pak 800/day (ribavirin)
T1 PA, SPribasphere cap 200mg (ribavirin)
T1 PA, SPribasphere tab 200mg (ribavirin)
T1 PA, SPribasphere tab 400mg (ribavirin)
T1 PA, SPribasphere tab 600mg (ribavirin)
T1 PA, SPribatab pak 1000/day (ribavirin)
T1 PA, SPribatab tab 1200/day (ribavirin)
13Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIVIRALS (SYSTEMIC)
NUCLEOSIDES AND NUCLEOTIDES
T1 PA, SPribatab tab 800/day (ribavirin)
T1 PA, SPribavirin cap 200mg
T1 PA, SPribavirin tab 200mg
T4 PA, SPTYZEKA TAB 600MG (telbivudine)
T1 QL (30 tabs/30 days)valacyclovir tab 1gm
T1 QL (30 tabs/30 days)valacyclovir tab 500mg
T3 PAVALCYTE TAB 450MG (valganciclovir)
T1 PAvalganciclov tab 450mg
URINARY ANTI-INFECTIVES
T1 QLhyophen tab (methenamine-hyosc-methylene)
T1methenam hip tab 1gm
T3 PA, QL (3 packs/fill)MONUROL PAK GRANULES (fosfomycin)
T1nitrofur mac cap 100mg
T1nitrofur mac cap 50mg
T1nitrofurantn cap 100mg
T1nitrofurantn sus 25mg/5ml
T1nitrofuranto cap 100mg
T1trimethoprim tab 100mg
ANTINEOPLASTIC AGENTS
T4 PA, SPAFINITOR TAB 10MG (everolimus)
T4 PA, SPAFINITOR TAB 2.5MG (everolimus)
T4 PA, SPAFINITOR TAB 5MG (everolimus)
T4 PA, SPAFINITOR TAB 7.5MG (everolimus)
T4ALKERAN TAB 2MG (melphalan)
T1anastrozole tab 1mg
T4 PAbexarotene cap 75mg
T1bicalutamide tab 50mg
T4 PA, SPBOSULIF TAB 100MG (bosutinib)
T4 PA, SPBOSULIF TAB 500MG (bosutinib)
T4 PA, SPcapecitabine tab 150mg
T4 PA, SPcapecitabine tab 500mg
14Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTINEOPLASTIC AGENTS
T4 PACAPRELSA TAB 100MG (vandetanib)
T4 PACAPRELSA TAB 300MG (vandetanib)
T4 PACOMETRIQ KIT 100MG (cabozantinib)
T4 PACOMETRIQ KIT 140MG (cabozantinib)
T4 PACOMETRIQ KIT 60MG (cabozantinib)
T1cyclophosph cap 25mg
T1cyclophosph tab 25mg
T1cyclophosph tab 50mg
T2DROXIA CAP 200MG (hydroxyurea)
T2DROXIA CAP 300MG (hydroxyurea)
T2DROXIA CAP 400MG (hydroxyurea)
T2EMCYT CAP 140MG (estramustine)
T4 PA, SPERIVEDGE CAP 150MG (vismodegib)
T1etoposide cap 50mg
T1exemestane tab 25mg
T2FARESTON TAB 60MG (toremifene)
T1floxuridine inj 0.5gm
T1flutamide cap 125mg
T4 PA, SPGILOTRIF TAB 20MG (afatinib)
T4 PA, SPGILOTRIF TAB 30MG (afatinib)
T4 PA, SPGILOTRIF TAB 40MG (afatinib)
T4 PA, SPGLEEVEC TAB 100MG (imatinib)
T4 PA, SPGLEEVEC TAB 400MG (imatinib)
T2GLEOSTINE CAP 100MG (lomustine)
T2GLEOSTINE CAP 10MG (lomustine)
T2GLEOSTINE CAP 40MG (lomustine)
T2HEXALEN CAP 50MG (altretamine)
T1hydroxyurea cap 500mg
T4 PAIBRANCE CAP 100MG (palbociclib)
T4 PAIBRANCE CAP 125MG (palbociclib)
T4 PAIBRANCE CAP 75MG (palbociclib)
T4 PAICLUSIG TAB 15MG (ponatinib)
T4 PAICLUSIG TAB 45MG (ponatinib)
15Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTINEOPLASTIC AGENTS
T4 PA, SPIMBRUVICA CAP 140MG (ibrutinib)
T4 PA, SPINLYTA TAB 1MG (axitinib)
T4 PA, SPINLYTA TAB 5MG (axitinib)
T4 PAINTRON A INJ 10MU (interferon)
T4INTRON A INJ 18MU (interferon)
T4 PAINTRON A INJ 18MU (interferon)
T4 PAINTRON A INJ 25MU (interferon)
T4INTRON A INJ 50MU (interferon)
T4 PA, SPIRESSA TAB 250MG (gefitinib)
T4 PA, SPJAKAFI TAB 10MG (ruxolitinib)
T4 PA, SPJAKAFI TAB 15MG (ruxolitinib)
T4 PA, SPJAKAFI TAB 20MG (ruxolitinib)
T4 PA, SPJAKAFI TAB 25MG (ruxolitinib)
T4 PA, SPJAKAFI TAB 5MG (ruxolitinib)
T1letrozole tab 2.5mg
T2LEUKERAN TAB 2MG (chlorambucil)
T2LYSODREN TAB 500MG (mitotane)
T2MATULANE CAP 50MG (procarbazine)
T1megestrol ac sus 400mg/10
T1megestrol ac sus 40mg/ml
T1megestrol ac sus 800mg/20
T1megestrol ac tab 20mg
T1megestrol ac tab 40mg
T4 PA, SPMEKINIST TAB 0.5MG (trametinib)
T4 PA, SPMEKINIST TAB 2MG (trametinib)
T1mercaptopur tab 50mg
T1methotrexate tab 2.5mg
T4 PAMYLERAN TAB 2MG (busulfan)
T4 PA, SPNEXAVAR TAB 200MG (sorafenib)
T4 PANILANDRON TAB 150MG (nilutamide)
T4 PA, SPPOMALYST CAP 1MG (pomalidomide)
T4 PA, SPPOMALYST CAP 2MG (pomalidomide)
T4 PA, SPPOMALYST CAP 3MG (pomalidomide)
16Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTINEOPLASTIC AGENTS
T4 PA, SPPOMALYST CAP 4MG (pomalidomide)
T4 PA, SPREVLIMID CAP 10MG (lenalidomide)
T4 PA, SPREVLIMID CAP 15MG (lenalidomide)
T4 PA, SPREVLIMID CAP 2.5MG (lenalidomide)
T4 PA, SPREVLIMID CAP 20MG (lenalidomide)
T4 PA, SPREVLIMID CAP 25MG (lenalidomide)
T4 PA, SPREVLIMID CAP 5MG (lenalidomide)
MED PA, SP Medical coinsuranceRITUXAN INJ 500MG (rituximab)
T4 PA, SPSPRYCEL TAB 100MG (dasatinib)
T4 PA, SPSPRYCEL TAB 140MG (dasatinib)
T4 PA, SPSPRYCEL TAB 20MG (dasatinib)
T4 PA, SPSPRYCEL TAB 50MG (dasatinib)
T4 PA, SPSPRYCEL TAB 70MG (dasatinib)
T4 PA, SPSPRYCEL TAB 80MG (dasatinib)
T4 PA, SPSTIVARGA TAB 40MG (regorafenib)
T4 PA, SPSUTENT CAP 12.5MG (sunitinib)
T4 PA, SPSUTENT CAP 25MG (sunitinib)
T4 PA, SPSUTENT CAP 37.5MG (sunitinib)
T4 PA, SPSUTENT CAP 50MG (sunitinib)
T4 PA, SPSYLATRON KIT 200MCG (peginterferon)
T4 PA, SPSYLATRON KIT 300MCG (peginterferon)
T4 PA, SPSYLATRON KIT 600MCG (peginterferon)
T4 PA, SPSYLATRON 296 MCG 4-PACK (PEGINTERFERON)
T4 PA, SPSYLATRON 444 MCG 4-PACK (PEGINTERFERON)
T4 PA, SPSYLATRON 888 MCG 4-PACK (PEGINTERFERON)
T2TABLOID TAB 40MG (thioguanine)
T4 PA, SPTAFINLAR CAP 50MG (dabrafenib)
T4 PA, SPTAFINLAR CAP 75MG (dabrafenib)
T0 HCR Rules for Coveragetamoxifen citrate tab 10 mg
T0 HCR Rules for Coveragetamoxifen citrate tab 20 mg
T4 PA, SPTARCEVA TAB 100MG (erlotinib)
T4 PA, SPTARCEVA TAB 150MG (erlotinib)
T4 PA, SPTARCEVA TAB 25MG (erlotinib)
17Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTINEOPLASTIC AGENTS
T4 PA, SPTARGRETIN CAP 75MG (bexarotene)
T4 PA, SPTASIGNA CAP 150MG (nilotinib)
T4 PA, SPTASIGNA CAP 200MG (nilotinib)
T4 PA, SPtemozolomide cap 100mg
T4 PA, SPtemozolomide cap 140mg
T4 PA, SPtemozolomide cap 180mg
T4 PA, SPtemozolomide cap 20mg
T4 PA, SPtemozolomide cap 250mg
T4 PA, SPtemozolomide cap 5mg
T1tretinoin cap 10mg
T4 PATREXALL TAB 10MG (methotrexate)
T4 PATREXALL TAB 15MG (methotrexate)
T4 PATREXALL TAB 5MG (methotrexate)
T4 PATREXALL TAB 7.5MG (methotrexate)
T4 PA, SPTYKERB TAB 250MG (lapatinib)
T4 PA, SPVOTRIENT TAB 200MG (pazopanib)
T4 PA, SPXALKORI CAP 200MG (crizotinib)
T4 PA, SPXALKORI CAP 250MG (crizotinib)
T4 PA, SPXTANDI CAP 40MG (enzalutamide)
T4 PA, SPZELBORAF TAB 240MG (vemurafenib)
T4 PA, SPZOLINZA CAP 100MG (vorinostat)
T4 PA, SPZYDELIG TAB 100MG (idelalisib)
T4 PA, SPZYDELIG TAB 150MG (idelalisib)
T4 PA, SPZYTIGA TAB 250MG (abiraterone)
AUTONOMIC DRUGSANTICHOLINERGIC AGENTS
ANTIMUSCARINICS/ANTISPASMODICS
T3 PA, QLANORO ELLIPT AER 62.5-25 (umeclidinium-vilanterol)
18Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
AUTONOMIC DRUGSANTICHOLINERGIC AGENTS
ANTIMUSCARINICS/ANTISPASMODICS
T1 QLchlord/clidi cap 5-2.5mg
T1 QLclidi/chlord cap 2.5-5mg
T1dicyclomine cap 10mg
T1dicyclomine sol 10mg/5ml
T1dicyclomine tab 20mg
T1glycopyrrol tab 1mg
T1glycopyrrol tab 2mg
T1 QLhyoscyamine sub 0.125mg
T1 QLhyoscyamine tab 0.125mg
T1ipratropium sol 0.02%inh
T1ipratropium spr 0.03%
T1ipratropium spr 0.06%
T1methscopolam tab 2.5mg
T1methscopolam tab 5mg
T1 QLnulev tab 0.125mg (hyoscyamine)
T1 QLoscimin sub 0.125mg (hyoscyamine)
T1 QLoscimin tab 0.125mg (hyoscyamine)
T2 QL (1 inhaler/30 days)SPIRIVA CAP HANDIHLR (tiotropium)
T0 QL HCR Rules for CoverageCHANTIX PAK 0.5& 1MG (varenicline)
T0 QL (1 fill/30 days; 6 fills/365 days)
HCR Rules for CoverageCHANTIX PAK 1MG (varenicline)
T0 QL (1 fill/30 days; 6 fills/365 days)
HCR Rules for CoverageCHANTIX TAB 0.5MG (varenicline)
T0 QL (1 fill/30 days; 6 fills/365 days)
HCR Rules for CoverageCHANTIX TAB 1MG (varenicline)
19Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
AUTONOMIC DRUGSAUTONOMIC DRUGS, MISCELLANEOUS
T0 HCR Rules for Coveragenicotine kit
T0 QL (14 Patches/14 days, 12 fills/365 days)
HCR Rules for Coveragenicotine patch 14 mg/24hr
T0 QL HCR Rules for Coveragenicotine patch 14 mg/24hr
T0 QL HCR Rules for Coveragenicotine patch 21 mg/24hr
T0 QL (14 Patches/14 days, 12 fills/365 days)
HCR Rules for Coveragenicotine patch 21 mg/24hr
T0 QL HCR Rules for Coveragenicotine patch 7 mg/24hr
T0 QL (14 Patches/14 days, 12 fills/365 days)
HCR Rules for Coveragenicotine patch 7 mg/24hr
T0 QL (360 units/30 days, 6 fills/365 days)
HCR Rules for Coveragenicotine polacrilex gum 2 mg
T0 QL HCR Rules for Coveragenicotine polacrilex gum 2 mg
T0 QL HCR Rules for Coveragenicotine polacrilex lozg 2 mg
T0 QL (360 units/30 days, 6 fills/365 days)
HCR Rules for Coveragenicotine polacrilex lozg 2 mg
T0 QL (360 units/30 days, 6 fills/365 days)
HCR Rules for Coveragenicotine polacrilex lozg 4 mg
T0 QL HCR Rules for Coveragenicotine polacrilex lozg 4 mg
T3 QL (14 Patches/14 days, 12 fills/365 days)
NICOTROL INH (nicotine)
T3NICOTROL NS SPR 10MG/ML (nicotine)
PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)
T1cevimeline cap 30mg
T1donepezil tab 10mg
T1donepezil tab 10mg odt
T1donepezil tab 5mg
T1donepezil tab 5mg odt
T1galantamine cap 16mg er
T1galantamine cap 24mg er
T1galantamine cap 8mg er
T1galantamine sol 4mg/ml
T1galantamine tab 12mg
T1galantamine tab 4mg
T1galantamine tab 8mg
20Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
21Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
22Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
23Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T0 HCR Rules for Coveragecarbonyl iron suspension 15 mg/1.25ml
T1fe c plus tab (iron-vitamin)
T0 HCR Rules for Coverageferrous aspartate tab 112 mg
T0 HCR Rules for Coverageferrous fumarate cap 86 mg
T0 HCR Rules for Coverageferrous fumarate tab 18 mg
T0 HCR Rules for Coverageferrous fumarate tab 29 mg
T0 HCR Rules for Coverageferrous fumarate tab 324 mg
T0 HCR Rules for Coverageferrous fumarate tab 325 mg
T0 HCR Rules for Coverageferrous fumarate tab 90 mg
T0 HCR Rules for Coverageferrous gluconate tab 225 mg
T0 HCR Rules for Coverageferrous gluconate tab 240 mg
T0 HCR Rules for Coverageferrous gluconate tab 27 mg
T0 HCR Rules for Coverageferrous gluconate tab 324 mg
T0 HCR Rules for Coverageferrous gluconate tab 325 mg
T0 HCR Rules for Coverageferrous sulfate elixir 220 mg/5ml
T0 HCR Rules for Coverageferrous sulfate soln 15 mg/ml
T0 HCR Rules for Coverageferrous sulfate syrup 300 mg/5ml
T0 HCR Rules for Coverageferrous sulfate tab 134 mg
T0 HCR Rules for Coverageferrous sulfate tab 140 mg
T0 HCR Rules for Coverageferrous sulfate tab 142 mg
T0 HCR Rules for Coverageferrous sulfate tab 143 mg
T0 HCR Rules for Coverageferrous sulfate tab 160 mg
T0 HCR Rules for Coverageferrous sulfate tab 200 mg
T0 HCR Rules for Coverageferrous sulfate tab 27 mg
T0 HCR Rules for Coverageferrous sulfate tab 28 mg
T0 HCR Rules for Coverageferrous sulfate tab 324 mg
T0 HCR Rules for Coverageferrous sulfate tab 325 mg
T0 HCR Rules for Coverageferrous sulfate tab 45 mg
T0 HCR Rules for Coverageferrous sulfate tab 47.5 mg
T0 HCR Rules for Coverageferrous sulfate tab 50 mg
24Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T0 HCR Rules for Coverageferrous sulfate tab 65 mg
T0 HCR Rules for Coverageferrous sulfate tab 90 mg
T0 HCR Rules for Coveragepolysaccharide iron complex cap 150 mg
T0 HCR Rules for Coveragepolysaccharide iron complex cap 200 mg
ANTIHEMORRHAGIC AGENTSHEMOSTATICS
MED PA, SP Medical coinsuranceADVATE INJ 1000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceADVATE INJ 1500UNIT (antihemophilic)
MED PA, SP Medical coinsuranceADVATE INJ 2000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceADVATE INJ 250UNIT (antihemophilic)
MED PA, SP Medical coinsuranceADVATE INJ 3000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceADVATE INJ 500UNIT (antihemophilic)
MED PA, SP Medical coinsuranceALPHANATE INJ VWF/HUM (antihemophilic)
MED PA, SP Medical coinsuranceALPHANATE 1,000-400 UNIT VIAL (ANTIHEMOPHILIC)
MED PA, SP Medical coinsuranceALPHANATE 1,500-600 UNIT VIAL (ANTIHEMOPHILIC)
MED PA, SP Medical coinsuranceALPHANATE 500-200 UNIT VIAL (ANTIHEMOPHILIC)
MED PA, SP Medical coinsuranceALPHANINE SD INJ 1000UNIT (coagulation)
MED PA, SP Medical coinsuranceALPHANINE SD INJ 1500UNIT (coagulation)
MED PA, SP Medical coinsuranceBEBULIN INJ 200-1200 (factor)
MED PA, SP Medical coinsuranceBEBULIN VH IMMU 200-1,200 UNIT (FACTOR)
MED PA, SP Medical coinsuranceBENEFIX INJ 1000UNIT (coagulation)
MED PA, SP Medical coinsuranceBENEFIX INJ 2000UNIT (coagulation)
MED PA, SP Medical coinsuranceBENEFIX INJ 250UNIT (coagulation)
MED PA, SP Medical coinsuranceBENEFIX INJ 500UNIT (coagulation)
MED PA, SP Medical coinsuranceCORIFACT KIT (factor)
MED PA, SP Medical coinsuranceELOCTATE INJ 1000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceELOCTATE INJ 1500UNIT (antihemophilic)
MED PA, SP Medical coinsuranceELOCTATE INJ 2000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceELOCTATE INJ 250UNIT (antihemophilic)
MED PA, SP Medical coinsuranceELOCTATE INJ 3000UNIT (antihemophilic)
25Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
MED PA, SP Medical coinsuranceELOCTATE INJ 500UNIT (antihemophilic)
MED PA, SP Medical coinsuranceELOCTATE INJ 750UNIT (antihemophilic)
MED PA, SP Medical coinsuranceFEIBA VH IMMU 1,750-3,250 UNIT (ANTIINHIBITOR)
MED PA, SP Medical coinsuranceHELIXATE FS INJ 1000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceHELIXATE FS INJ 2000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceHELIXATE FS INJ 250UNIT (antihemophilic)
MED PA, SP Medical coinsuranceHELIXATE FS INJ 500UNIT (antihemophilic)
MED PA, SP Medical coinsuranceHEMOFIL M INJ 1700UNIT (antihemophilic)
MED PA, SP Medical coinsuranceHEMOFIL M INJ 220-400 (antihemophilic)
MED PA, SP Medical coinsuranceHEMOFIL M INJ 401-800 (antihemophilic)
MED PA, SP Medical coinsuranceHEMOFIL M SOL 501-2000 (antihemophilic)
MED PA, SP Medical coinsuranceHEMOFIL M SOL 801-1500 (antihemophilic)
MED PA, SP Medical coinsuranceHUMATE-P SOL 2400UNIT (antihemophilic)
MED PA, SP Medical coinsuranceHUMATE-P SOL 250-600 (antihemophilic)
MED PA, SP Medical coinsuranceHUMATE-P SOL 500-1200 (antihemophilic)
MED PA, SP Medical coinsuranceKCENTRA KIT 1000UNIT (prothrombin)
MED PA, SP Medical coinsuranceKCENTRA KIT 500UNIT (prothrombin)
MED PA, SP Medical coinsurancekoate-dvi inj 1000unit (antihemophilic)
MED PA, SP Medical coinsurancekoate-dvi inj 250unit (antihemophilic)
MED PA, SP Medical coinsuranceKOATE-DVI INJ 500UNIT (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 1000/BS (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 1000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 2000/BS (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 2000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 250/BS (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 250UNIT (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 3000/BS (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 3000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 500/BS (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 500UNIT (antihemophilic)
MED PA, SP Medical coinsuranceMONOCLATE-P INJ 250UNIT (antihemophilic)
26Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
MED PA, SP Medical coinsuranceMONOCLATE-P INJ 500UNIT (antihemophilic)
MED PA, SP Medical coinsuranceMONONINE INJ 500UNIT (coagulation)
MED PA, SP Medical coinsuranceNOVOSEVEN INJ 2400MCG (coagulation)
MED PA, SP Medical coinsuranceNOVOSEVEN 1,200 MCG VIAL (COAGULATION)
MED PA, SP Medical coinsuranceNOVOSEVEN 4,800 MCG VIAL (COAGULATION)
MED PA, SP Medical coinsuranceNOVOSEVEN RT INJ 1MG (coagulation)
MED PA, SP Medical coinsuranceNOVOSEVEN RT INJ 2MG (coagulation)
MED PA, SP Medical coinsuranceNOVOSEVEN RT INJ 5MG (coagulation)
MED PA, SP Medical coinsuranceNOVOSEVEN RT INJ 8MG (coagulation)
MED PA, SP Medical coinsurancePROFILNINE SD 500 UNITS VIAL (FACTOR)
MED PA, SP Medical coinsuranceRECOMBINATE INJ 220-400 (antihemophilic)
MED PA, SP Medical coinsuranceRECOMBINATE INJ 401-800 (antihemophilic)
MED PA, SP Medical coinsuranceRECOMBINATE INJ 801-1240 (antihemophilic)
MED PA, SP Medical coinsuranceRIASTAP SOL 1GM (fibrinogen)
MED PA, SP Medical coinsuranceRIXUBIS INJ 1000UNIT (coagulation)
MED PA, SP Medical coinsuranceRIXUBIS INJ 2000UNIT (coagulation)
MED PA, SP Medical coinsuranceRIXUBIS INJ 250 UNIT (coagulation)
MED PA, SP Medical coinsuranceRIXUBIS INJ 3000UNIT (coagulation)
MED PA, SP Medical coinsuranceRIXUBIS INJ 500UNIT (coagulation)
T1tranex acid tab 650mg
MED PA, SP Medical coinsuranceWILATE INJ (antihemophilic)
MED PA, SP Medical coinsuranceWILATE 1,000-1,000 UNIT KIT (ANTIHEMOPHILIC)
MED PA, SP Medical coinsuranceWILATE 450-450 UNIT KIT (ANTIHEMOPHILIC)
MED PA, SP Medical coinsuranceWILATE 900-900 UNIT KIT (ANTIHEMOPHILIC)
MED PA, SP Medical coinsuranceXYNTHA INJ 1000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceXYNTHA INJ 2000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceXYNTHA INJ 250UNIT (antihemophilic)
MED PA, SP Medical coinsuranceXYNTHA INJ 500UNIT (antihemophilic)
ANTITHROMBOTIC AGENTSANTICOAGULANTS
T1coumadin tab 10mg (warfarin)
27Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T2 QL (60 caps/30 days)PRADAXA CAP 150MG (dabigatran)
28Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T2 QL (30 tabs/30 days)XARELTO STAR TAB 15/20MG (rivaroxaban)
PLATELET-AGGREGATION INHIBITORS
T2 QL (60 caps/30 days)AGGRENOX CAP 25-200MG (aspirin-dipyridamole)
T3 QL clopidogrelBRILINTA TAB 60MG (ticagrelor)
T3 PA, QL (60 tabs/30 days) clopidogrelBRILINTA TAB 90MG (ticagrelor)
T1cilostazol tab 100mg
T1cilostazol tab 50mg
T1clopidogrel tab 300mg
T1 QL (30 tabs/30 days)clopidogrel tab 75mg
T3 PA, QL (30 tabs/30 days) clopidogrelEFFIENT TAB 10MG (prasugrel)
T3 PA, QL (30 tabs/30 days) clopidogrelEFFIENT TAB 5MG (prasugrel)
T1ticlopidine tab 250mg
PLATELET-REDUCING AGENTS
T1anagrelide cap 0.5mg
T1anagrelide cap 1mg
HEMATOPOIETIC AGENTS
T4ARANESP INJ 100MCG (darbepoetin)
29Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
30Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T3 PA, QL (30 packets/30 days) cholestyramineWELCHOL PAK 3.75GM (colesevelam)
T3 PA, QL (210 tabs/30 days) cholestyramineWELCHOL TAB 625MG (colesevelam)
31Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSANTILIPEMIC AGENTS
CHOLESTEROL ABSORPTION INHIBITORS
T2 QL (30 tabs/30 days)ZETIA TAB 10MG (ezetimibe)
FIBRIC ACID DERIVATIVES
T1fenofibrate cap 130mg
T1fenofibrate cap 134mg
T1fenofibrate cap 200mg
T1fenofibrate cap 43mg
T1fenofibrate cap 67mg
T1fenofibrate tab 120mg
T1fenofibrate tab 145mg
T1fenofibrate tab 160mg
T1fenofibrate tab 40mg
T1fenofibrate tab 48mg
T1fenofibrate tab 54mg
T1fenofibric tab 105mg
T1fenofibric tab 35mg
T1gemfibrozil tab 600mg
HMG-COA REDUCTASE INHIBITORS
T3 QL (60 tabs/30 days)ADVICOR TAB 1000-20 (niacin-lovastatin)
T3 QL (60 tabs/30 days)ADVICOR TAB 1000-40 (niacin-lovastatin)
T3 QL (60 tabs/30 days)ADVICOR TAB 500-20MG (niacin-lovastatin)
T3 QL (60 tabs/30 days)ADVICOR TAB 750-20MG (niacin-lovastatin)
T1atorvastatin tab 10mg
T1atorvastatin tab 20mg
T1atorvastatin tab 40mg
T1atorvastatin tab 80mg
T3 QL (30 tabs/30 days), ST (atorvastatin 80MG)
atorvastatin, simvastatin
CRESTOR TAB 10MG (rosuvastatin)
T3 QL (30 tabs/30 days), ST (atorvastatin 80MG)
atorvastatin, simvastatin
CRESTOR TAB 20MG (rosuvastatin)
T3 QL (30 tabs/30 days), ST (atorvastatin 80MG)
atorvastatin, simvastatin
CRESTOR TAB 40MG (rosuvastatin)
T3 QL (30 tabs/30 days), ST (atorvastatin 80MG)
atorvastatin, simvastatin
CRESTOR TAB 5MG (rosuvastatin)
32Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T3 PA, QL (30 tabs/30 days) atorvastatin, pravastatin, simvastatin
LIVALO TAB 1MG (pitavastatin)
T3 PA, QL (30 tabs/30 days) atorvastatin, pravastatin, simvastatin
LIVALO TAB 2MG (pitavastatin)
T3 PA, QL (30 tabs/30 days) atorvastatin, pravastatin, simvastatin
LIVALO TAB 4MG (pitavastatin)
T1lovastatin tab 10mg
T1lovastatin tab 20mg
T1lovastatin tab 40mg
T1pravastatin tab 10mg
T1pravastatin tab 20mg
T1pravastatin tab 40mg
T1pravastatin tab 80mg
T1simvastatin tab 10mg
T1simvastatin tab 20mg
T1simvastatin tab 40mg
T1simvastatin tab 5mg
T1simvastatin tab 80mg
T3 QL (30 tabs/30 days), ST (simvastatin, atorvastatin 80MG)
atorvastatin, simvastatin
VYTORIN TAB 10-10MG (ezetimibe-simvastatin)
T3 QL (30 tabs/30 days), ST (simvastatin, atorvastatin 80MG)
atorvastatin, simvastatin
VYTORIN TAB 10-20MG (ezetimibe-simvastatin)
T3 QL (30 tabs/30 days), ST (simvastatin, atorvastatin 80MG)
atorvastatin, simvastatin
VYTORIN TAB 10-40MG (ezetimibe-simvastatin)
T3 QL (30 tabs/30 days), ST (simvastatin, atorvastatin 80MG)
atorvastatin, simvastatin
VYTORIN TAB 10-80MG (ezetimibe-simvastatin)
BETA-ADRENERGIC BLOCKING AGENTS
T1 atenololacebutolol cap 200mg
33Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
34Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
35Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
36Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
37Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
38Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
39Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T2 QL (120 caps/30 days)TIKOSYN CAP 125MCG (dofetilide)
T2 QL (120 caps/30 days)TIKOSYN CAP 250MCG (dofetilide)
T2 QL (120 caps/30 days)TIKOSYN CAP 500MCG (dofetilide)
CARDIAC DRUGS, MISCELLANEOUS
T3 QL (60 tabs/30 days)RANEXA TAB 1000MG (ranolazine)
T3 QL (60 tabs/30 days)RANEXA TAB 500MG (ranolazine)
CARDIOTONIC AGENTS
T1digitek tab 0.125mg (digoxin)
T1digitek tab 0.25mg (digoxin)
T1digox tab 0.125mg (digoxin)
T1digox tab 0.25mg (digoxin)
T1digoxin inj 0.25mg/1
T1digoxin sol 50mcg/ml
T1digoxin tab 0.125mg
T1digoxin tab 0.25mg
T1lanoxin tab 0.125mg (digoxin)
T1lanoxin tab 0.25mg (digoxin)
40Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSCARDIAC DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS, MISC
T4ENTRESTO TAB 24-26MG (sacubitril-valsartan)
T4ENTRESTO TAB 49-51MG (sacubitril-valsartan)
T4ENTRESTO TAB 97-103MG (sacubitril-valsartan)
HYPOTENSIVE AGENTSCENTRAL ALPHA-AGONISTS
T1clonidine dis 0.1/24hr
T1clonidine dis 0.2/24hr
T1clonidine dis 0.3/24hr
T1clonidine tab 0.1mg
T1clonidine tab 0.2mg
T1clonidine tab 0.3mg
T1guanfacine tab 1mg
T1guanfacine tab 2mg
T1methyldopa tab 250mg
T1methyldopa tab 500mg
DIRECT VASODILATORS
T1hydralazine inj 20mg/ml
T1hydralazine tab 100mg
T1hydralazine tab 10mg
T1hydralazine tab 25mg
T1hydralazine tab 50mg
T1minoxidil tab 10mg
T1minoxidil tab 2.5mg
DIURETICS (HYPOTENSIVE AGENTS)
T1acetazolamid tab 250mg
PERIPHERAL ADRENERGIC INHIBITORS
T1reserpine tab 0.1mg
T1reserpine tab 0.25mg
RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIBANGIOTENSIN II RECEPTOR ANTAGONISTS
T1candesa/hctz tab 16-12.5
T1candesa/hctz tab 32-12.5
41Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
42Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
43Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
44Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T3 PA, QL (30 tabs/30 days) irbesartan, lisinopril, losartan
TEKTURNA TAB 150MG (aliskiren)
T3 PA, QL (30 tabs/30 days) irbesartan, lisinopril, losartan
TEKTURNA TAB 300MG (aliskiren)
VASODILATING AGENTSNITRATES AND NITRITES
T1isoditrate tab 40mg er (isosorbide)
T3ISORDIL TAB 40MG (isosorbide)
T1isosorb din tab 10mg
T1isosorb din tab 20mg
T1isosorb din tab 30mg
T1isosorb din tab 40mg er
T1isosorb din tab 40mg sa
T1isosorb din tab 5mg
T1isosorb mono tab 10mg
T1isosorb mono tab 120mg er
T1isosorb mono tab 20mg
T1isosorb mono tab 30mg er
T1isosorb mono tab 60mg er
T3NITRO-BID OIN 2% (nitroglycerin)
T3NITRO-DUR DIS 0.3MG/HR (nitroglycerin)
T1nitroglycer aer 400mcg
T1nitroglycer cap 2.5mg er
T1nitroglycer cap 2.5mg sr
T1nitroglycer cap 6.5mg er
T1nitroglycer cap 6.5mg sr
T1nitroglycer cap 9mg er
T3NITRONAL SOL 1MG/ML (nitroglycerin)
45Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSVASODILATING AGENTS
NITRATES AND NITRITES
T3NITROSTAT SUB 0.3MG (nitroglycerin)
T3NITROSTAT SUB 0.4MG (nitroglycerin)
T3NITROSTAT SUB 0.6MG (nitroglycerin)
T1nitro-time cap 2.5mg cr (nitroglycerin)
T1nitro-time cap 6.5mg cr (nitroglycerin)
T1nitro-time cap 9mg cr (nitroglycerin)
PHOSPHODIESTERASE TYPE 5 INHIBITORS
T4 PAADCIRCA TAB 20MG (tadalafil)
T3 PA, QL (30 tabs/30 days) for BPH alfuzosin, finasteride, tamsulosin
CIALIS TAB 5MG (tadalafil)
T1 QLsildenafil tab 20mg
VASODILATING AGENTS, MISCELLANEOUS
T1dipyridamole inj 5mg/ml
T1dipyridamole tab 25mg
T1dipyridamole tab 50mg
T1dipyridamole tab 75mg
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
ANALGESICS AND ANTIPYRETICS, MISC.
T1 QLbut/apap/caf cap
T1 QL (120 tabs/30 days)but/apap/caf tab
T1zebutal cap (butalbital-acetaminophen-caffeine)
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
T0 QL HCR Rules for Coverageaspirin chew 81 mg
T0 QL HCR Rules for Coverageaspirin chew 81 mg
T0 HCR Rules for Coverageaspirin tab 324 mg
T0 HCR Rules for Coverageaspirin tab 325 mg
T0 HCR Rules for Coverageaspirin tab 325 mg
T0 QL HCR Rules for Coverageaspirin tab 81 mg
T0 QL HCR Rules for Coverageaspirin tab 81 mg
T1 QLBAYER CHILD CHW ASA 81MG (aspirin)
46Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
T1but/asa/caff cap
T1but/asa/caff tab
T1 QL, STcelecoxib cap 100mg
T1 QL, STcelecoxib cap 200mg
T1 QL, STcelecoxib cap 400mg
T1 QL, STcelecoxib cap 50mg
T1cho mag tris liq 500/5ml
T1cho mag tris tab 1000mg
T1diclo/misopr tab 50-0.2mg
T1diclo/misopr tab 75-0.2mg
T1diclofen pot tab 50mg
T1diclofenac tab 100mg er
T1diclofenac tab 100mg xr
T1diclofenac tab 25mg dr
T1diclofenac tab 50mg dr
T1diclofenac tab 75mg dr
T1diflunisal tab 500mg
T1etodolac cap 200mg
T1etodolac cap 300mg
T1etodolac tab 400mg
T1etodolac tab 500mg
T1etodolac er tab 400mg
T1etodolac er tab 500mg (etodolac)
T1etodolac er tab 600mg
T1fenoprofen tab 600mg
T1flurbiprofen tab 100mg
T1flurbiprofen tab 50mg
T1ibuprofen sus 100/5ml (ibuprofen)
T1ibuprofen tab 400mg
T1ibuprofen tab 600mg
T1ibuprofen tab 800mg
47Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
T1indomethacin cap 25mg
T1indomethacin cap 50mg
T1indomethacin cap 75mg cr
T1indomethacin cap 75mg er
T1indomethacin cap 75mg sa
T1indomethacin cap 75mg sr
T1ketoprofen cap 200mg er
T1ketoprofen cap 50mg
T1ketoprofen cap 75mg
T1ketorolac tab 10mg
T1meclofen sod cap 100mg
T1meclofen sod cap 50mg
T3MEDI-SELTZER TAB (aspirin)
T1mefenam acid cap 250mg
T1meloxicam sus 7.5/5ml
T1meloxicam tab 15mg
T1meloxicam tab 7.5mg
T1nabumetone tab 500mg
T1nabumetone tab 750mg
T1naproxen sus 125/5ml
T1naproxen tab 250mg
T1naproxen tab 375mg
T1naproxen tab 500mg (naproxen)
T1naproxen dr tab 375mg (naproxen)
T1naproxen dr tab 500mg (naproxen)
T1naproxen ec tab 375mg (naproxen)
T1naproxen ec tab 500mg (naproxen)
T1naproxen sod tab 220mg (naproxen)
T1naproxen sod tab 275mg
T1naproxen sod tab 550mg
T1orph/asa/caf tab
48Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
49Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
50Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
T1 PA, QL (30 caps/30 days)morphine sul cap 120mg er
T1 QL (60 caps/30 days)morphine sul cap 20mg er
T1 PA, QL (60 caps/30 days)morphine sul cap 30mg er
T1 QL (60 caps/30 days)morphine sul cap 30mg er
T1 PA, QL (60 caps/30 days)morphine sul cap 45mg er
T1 QL (90 caps/30 days)morphine sul cap 50mg er
T1 PA, QL (30 caps/30 days)morphine sul cap 60mg er
T1 QL (90 caps/30 days)morphine sul cap 60mg er
51Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
OPIATE AGONISTS
T1 PA, QL (30 caps/30 days)morphine sul cap 75mg er
T1 QL (90 caps/30 days)morphine sul cap 80mg er
T1 PA, QL (30 caps/30 days)morphine sul cap 90mg er
T1morphine sul inj 0.5mg/ml
T1morphine sul inj 10mg/ml
T1morphine sul inj 150/30ml
T1morphine sul inj 15mg/ml
T1morphine sul inj 1mg/ml
T1morphine sul inj 25mg/ml
T1morphine sul inj 2mg/ml
T1morphine sul inj 4mg/ml
T1morphine sul inj 50mg/ml
T1morphine sul inj 8mg/ml
T1morphine sul sol 10/0.5ml
T1morphine sul sol 100/5ml
T1morphine sul sol 10mg/5ml
T1morphine sul sol 20mg/5ml
T1morphine sul sol 20mg/ml
T1morphine sul sup 20mg
T1morphine sul sup 5mg
T1 QLmorphine sul tab 100mg cr
T1 QL (90 tabs/30 days)morphine sul tab 100mg er
T1 QL (120 tabs/30 days)morphine sul tab 15mg
T1 QLmorphine sul tab 15mg cr
T1 QL (90 tabs/30 days)morphine sul tab 15mg er
T1 QL (90 tabs/30 days)morphine sul tab 200mg er
T1 QL (120 tabs/30 days)morphine sul tab 30mg
T1 QLmorphine sul tab 30mg cr
T1 QL (90 tabs/30 days)morphine sul tab 30mg er
T1 QLmorphine sul tab 60mg cr
T1 QL (90 tabs/30 days)morphine sul tab 60mg er
52Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
OPIATE AGONISTS
T3 PA, QL (180 tabs/30 days) morphine, oxycodone
NUCYNTA TAB 100MG (tapentadol)
T3 PA, QL (180 tabs/30 days) morphine, oxycodone
NUCYNTA TAB 75MG (tapentadol)
T3 PA, QL (60 tabs/30 days) morphine, oxycodone
NUCYNTA ER TAB 100MG (tapentadol)
T3 PA, QL (60 tabs/30 days) morphine, oxycodone
NUCYNTA ER TAB 200MG (tapentadol)
T1 QL (180 abs/30 days)oxycod/apap tab 10-325mg
T1 QL (180 tabs/30 days)oxycod/apap tab 2.5-325
T1 QL (180 tabs/30 days)oxycod/apap tab 5-325mg
T1 QL (180 tabs/30 days)oxycod/apap tab 7.5-325
T1 QL (180 tabs/30 days)oxycod/apap tab 7.5-500
T1 QL (240 tabs/30 days)oxycod/ibu tab 5-400mg
T1 PA, QL (150 caps/30 days)oxycodone cap 5mg
T1 QL (500ml/30 days)oxycodone sol 5mg/5ml
T1 QL (120 tabs/30 days)oxycodone tab 10mg
T1 QLoxycodone tab 10mg er
T1 QL (120 tabs/30 days)oxycodone tab 15mg
T1 QL (120 tabs/30 days)oxycodone tab 20mg
T1 QLoxycodone tab 20mg er
T1 QL (120 tabs/30 days)oxycodone tab 30mg
T1 QLoxycodone tab 40mg er
T1 QL (120 tabs/30 days)oxycodone tab 5mg
T1 QLoxycodone tab 80mg er
T1 QLoxycontin tab 40mg cr (oxycodone)
T1 QLoxycontin tab 80mg cr (oxycodone)
T1 PA, QL (60 tabs/30 days)oxymorphone tab 10mg er
T1 PA, QL (60 tabs/30 days)oxymorphone tab 15mg er
T1 PA, QL (60 tabs/30 days)oxymorphone tab 20mg er
T1 PA, QL (60 tabs/30 days)oxymorphone tab 30mg er
T1 PA, QL (60 tabs/30 days)oxymorphone tab 40mg er
T1 PA, QL (60 tabs/30 days)oxymorphone tab 5mg er
53Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
OPIATE AGONISTS
T1 PA, QL (60 tabs/30 days)oxymorphone tab 7.5mg er
T3 PA, QL (4 patches/28 days)BUTRANS DIS 10MCG/HR (buprenorphine)
T3 PA, QL (4 patches/28 days)BUTRANS DIS 15MCG/HR (buprenorphine)
T3 PA, QL (4 patches/28 days)BUTRANS DIS 20MCG/HR (buprenorphine)
T3 PA, QL (4 patches/28 days)BUTRANS DIS 5MCG/HR (buprenorphine)
T3 PA, QL (4 patches/28 days)BUTRANS DIS 7.5/HR (buprenorphine)
T1penta/apap tab 25-650mg
T1pentaz/nalox tab 50-0.5mg
ANOREXIGENICS AGENTS AND RESPIRATORY AND CNS STIMULANTSAMPHETAMINES
T1 QL (60 caps/30 days)amphetamine cap 10mg er
T1 QL (60 caps/30 days)amphetamine cap 15mg er
T1 QL (60 caps/30 days)amphetamine cap 20mg er
T1 QL (60 caps/30 days)amphetamine cap 25mg er
T1 QL (60 caps/30 days)amphetamine cap 30mg er
T1 QL (60 caps/30 days)amphetamine cap 5mg er
54Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANOREXIGENICS AGENTS AND RESPIRATORY AND CNS STIMULANTS
T3 PA, QL (30 caps/30 days) amphetamine-dextroamphetamine
VYVANSE CAP 10MG (lisdexamfetamine)
T3 PA, QL (30 caps/30 days) amphetamine-dextroamphetamine
VYVANSE CAP 20MG (lisdexamfetamine)
T3 PA, QL (30 caps/30 days) amphetamine-dextroamphetamine
VYVANSE CAP 30MG (lisdexamfetamine)
T3 PA, QL (30 caps/30 days) amphetamine-dextroamphetamine
VYVANSE CAP 40MG (lisdexamfetamine)
T3 PA, QL (30 caps/30 days) amphetamine-dextroamphetamine
VYVANSE CAP 50MG (lisdexamfetamine)
T3 PA, QL (30 caps/30 days) amphetamine-dextroamphetamine
VYVANSE CAP 60MG (lisdexamfetamine)
T3 PA, QL (30 caps/30 days) amphetamine-dextroamphetamine
VYVANSE CAP 70MG (lisdexamfetamine)
ANOREXIGENIC AGENTS
T3 PABELVIQ TAB 10MG (lorcaserin)
T1diethylprop tab 75mg er
T1phentermine tab 37.5mg
55Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANOREXIGENICS AGENTS AND RESPIRATORY AND CNS STIMULANTS
RESPIRATORY AND CNS STIMULANTS
T3 PA, QL (30 patches/30 days) methylphenidateDAYTRANA DIS 10MG/9HR (methylphenidate)
T3 PA, QL (30 patches/30 days) methylphenidateDAYTRANA DIS 15MG/9HR (methylphenidate)
T3 PA, QL (30 patches/30 days) methylphenidateDAYTRANA DIS 20MG/9HR (methylphenidate)
T3 PA, QL (30 patches/30 days) methylphenidateDAYTRANA DIS 30MG/9HR (methylphenidate)
T1 PAdexmethylph cap 15mg er
T1 PAdexmethylph cap 30mg er
T1 PAdexmethylph cap 40mg er
T1 QL (90 tabs/30 days)dexmethylph tab 10mg
T1 QL (90 tabs/30 days)dexmethylph tab 2.5mg
T1 QL (90 tabs/30 days)dexmethylph tab 5mg
T1 PA, QLdexmethylphe cap 10mg er
T1 PA, QLdexmethylphe cap 20mg er
T1 PA, QLdexmethylphe cap 5mg er
T3 PA dexmethylphenidate, methylphenidate
FOCALIN XR CAP 10MG (dexmethylphenidate)
T3 PA dexmethylphenidate, methylphenidate
FOCALIN XR CAP 20MG (dexmethylphenidate)
T3 PA, QL dexmethylphenidate, methylphenidate
FOCALIN XR CAP 25MG (dexmethylphenidate)
T3 PA dexmethylphenidate, methylphenidate
FOCALIN XR CAP 35MG (dexmethylphenidate)
T1 QL (60 tabs/30 days)metadate tab 20mg er (methylphenidate)
T1 QL (28 tabs/28 days)methylphenid cap 10mg
T1 QL (28 tabs/28 days)methylphenid cap 20mg
T1 QL (60 tabs/30 days)methylphenid cap 20mg er
T1 QL (28 tabs/28 days)methylphenid cap 30mg
T1 QL (60 tabs/30 days)methylphenid cap 30mg er
T1 QL (60 caps/30 days)methylphenid cap 40mg
T1 QL (60 tabs/30 days)methylphenid cap 40mg er
T1 QL (60 caps/30 days)methylphenid cap 50mg
T1 QL (30 caps/30 days)methylphenid cap 60mg
T1methylphenid sol 10mg/5ml
T1methylphenid sol 5mg/5ml
56Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANOREXIGENICS AGENTS AND RESPIRATORY AND CNS STIMULANTS
RESPIRATORY AND CNS STIMULANTS
T1 QL (28 tabs/28 days)methylphenid tab 10mg
T1 QL (60 tabs/30 days)methylphenid tab 10mg er
T1 QLmethylphenid tab 18mg er
T1 QL (60 tabs/30 days)methylphenid tab 18mg er
T1 QL (28 tabs/28 days)methylphenid tab 20mg
T1 QL (60 tabs/30 days)methylphenid tab 20mg er
T1 QL (60 tabs/30 days)methylphenid tab 20mg sr
T1 QLmethylphenid tab 27mg er
T1 QL (60 tabs/30 days)methylphenid tab 27mg er
T1 QLmethylphenid tab 36mg er
T1 QL (60 tabs/30 days)methylphenid tab 36mg er
T1 QLmethylphenid tab 54mg er
T1 QL (60 tabs/30 days)methylphenid tab 54mg er
T1 QL (28 tabs/28 days)methylphenid tab 5mg
WAKEFULNESS-PROMOTING AGENTS
T1 PA, QL (60 tabs/30 days)modafinil tab 100mg
T1 PA, QL (60 tabs/30 days)modafinil tab 200mg
T3 PA, QL (30 tabs/30 days) modafinilNUVIGIL TAB 150MG (armodafinil)
T3 PA, QL (30 tabs/30 days) modafinilNUVIGIL TAB 200MG (armodafinil)
T3 PA, QL (30 tabs/30 days) modafinilNUVIGIL TAB 250MG (armodafinil)
57Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
T1carbamazepin cap 200mg er
T1carbamazepin cap 300mg er
T1carbamazepin chw 100mg
T1carbamazepin sus 100/5ml
T1carbamazepin tab 200mg
T1carbamazepin tab 200mg er
T1carbamazepin tab 400mg er
T1divalproex cap 125mg
T1divalproex tab 125mg dr
T1divalproex tab 250mg dr
T1divalproex tab 250mg er
T1divalproex tab 500mg dr
T1divalproex tab 500mg er
T1epitol tab 200mg (carbamazepine)
T1felbamate sus 600/5ml
T1felbamate tab 400mg
T1felbamate tab 600mg
T1gabapentin cap 100mg
T1gabapentin cap 300mg
T1gabapentin cap 400mg
T1gabapentin sol 250/5ml
T1gabapentin tab 600mg
T1gabapentin tab 800mg
T3 PAHORIZANT TAB 300MG (gabapentin)
T3 PAHORIZANT TAB 600MG (gabapentin)
T1 PALAMICTAL CHW 25MG (lamotrigine)
T1 PALAMICTAL CHW 5MG (lamotrigine)
T3 PA, QL (1 kit/fill, 1 fill per 365 days)
LAMICTAL KIT START 49 (lamotrigine)
T1 PAlamotrigine chw 25mg
T1 PAlamotrigine chw 5mg
T1lamotrigine tab 100mg
58Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
T1 QL (30 tabs/30 days)lamotrigine tab 100mg er
T1lamotrigine tab 150mg
T1lamotrigine tab 200mg
T1 QL (30 tabs/30 days)lamotrigine tab 200mg er
T1 QL (30 tabs/30 days)lamotrigine tab 250mg er
T1lamotrigine tab 25mg
T1 QL (30 tabs/30 days)lamotrigine tab 25mg er
T1 QL (30 tabs/30 days)lamotrigine tab 300mg er
T1 QL (30 tabs/30 days)lamotrigine tab 50mg er
T1levetiraceta sol 100mg/ml
T1levetiraceta sol 500/5ml
T1levetiraceta tab 1000mg
T1levetiraceta tab 250mg
T1levetiraceta tab 500mg
T1 QLlevetiraceta tab 500mg er
T1levetiraceta tab 750mg
T1 QLlevetiraceta tab 750mg er
T1levetiracetm inj 500/5ml
T3 PA, QL (60 caps/30 days) gabapentinLYRICA CAP 100MG (pregabalin)
T3 PA, QL (60 caps/30 days) gabapentinLYRICA CAP 150MG (pregabalin)
T3 PA, QL (60 caps/30 days) gabapentinLYRICA CAP 200MG (pregabalin)
T3 PA, QL (60 caps/30 days) gabapentinLYRICA CAP 225MG (pregabalin)
T3 PA, QL (60 caps/30 days) gabapentinLYRICA CAP 25MG (pregabalin)
T3 PA, QL (60 caps/30 days) gabapentinLYRICA CAP 300MG (pregabalin)
T3 PA, QL (60 caps/30 days) gabapentinLYRICA CAP 50MG (pregabalin)
T3 PA, QL (60 caps/30 days) gabapentinLYRICA CAP 75MG (pregabalin)
T1oxcarbazepin sus 300mg/5m
T1oxcarbazepin tab 150mg
T1oxcarbazepin tab 300mg
T1oxcarbazepin tab 600mg
59Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
60Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
T1tiagabine tab 4mg
T1topiragen tab 100mg (topiramate)
T1topiragen tab 200mg (topiramate)
T1topiragen tab 25mg (topiramate)
T1topiragen tab 50mg (topiramate)
T1topiramate cap 15mg
T1topiramate cap 25mg
T1topiramate tab 100mg
T1topiramate tab 200mg
T1topiramate tab 25mg
T1topiramate tab 50mg
T1valproate inj 100mg/ml
T1valproate inj 500/5ml
T1valproic acd cap 250mg
T1valproic acd sol 250/5ml
T1valproic acd syp 250/5ml
T3 carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide
61Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T3 QL (60 tabs/30 days) clonazepam, lamotrigine, topiramate
ONFI TAB 10MG (clobazam)
62Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANTICONVULSANTS
BENZODIAZEPINES (ANTICONVULSANTS)
T3 QL (60 tabs/30 days) clonazepam, lamotrigine, topiramate
ONFI TAB 20MG (clobazam)
T3 QL (60 tabs/30 days) clonazepam, lamotrigine, topiramate
ONFI TAB 5MG (clobazam)
HYDANTOINS
T2DILANTIN CAP 30MG (phenytoin)
T2DILANTIN CHW 50MG (phenytoin)
T2DILANTIN-125 SUS 125/5ML (phenytoin)
T2PEGANONE TAB 250MG (ethotoin)
T2PHENYTEK CAP 200MG (phenytoin)
T2PHENYTEK CAP 300MG (phenytoin)
T1phenytoin chw 50mg (phenytoin)
T1phenytoin inj 50mg/ml
T1phenytoin sus 125/5ml
T1phenytoin ex cap 100mg
T1phenytoin ex cap 200mg
T1phenytoin ex cap 300mg
SUCCINIMIDES
T2 QL (120 caps/30 days)CELONTIN CAP 300MG (methsuximide)
T1 QL (210 caps/30 days)ethosuximide cap 250mg
T1ethosuximide sol 250/5ml
ANTIMANIC AGENTS
T1lithium sol 8meq/5ml
T1lithium carb cap 150mg
T1lithium carb cap 300mg
T1lithium carb cap 600mg
T1lithium carb tab 300mg
T1lithium carb tab 300mg er
T1lithium carb tab 450mg er
63Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANTIMIGRAINE AGENTS
SELECTIVE SEROTONIN AGONISTS
T1 PAalmotrip mal tab 12.5mg
T1 PAalmotrip mal tab 6.25mg
T1 PAalmotriptan tab 12.5mg
T1 PAalmotriptan tab 6.25mg
T3 PA, QL (12 tabs/30 days) naratriptan, rizatriptan, sumatriptan
FROVA TAB 2.5MG (frovatriptan)
T3 QLIMITREX SPR 5MG/ACT (sumatriptan)
T1 QL (12 tabs/30 days)naratriptan tab 1mg
T1 QL (12 tabs/30 days)naratriptan tab 2.5mg
T3 PA, QL (12 tabs/30 days) naratriptan, rizatriptan, sumatriptan
RELPAX TAB 20MG (eletriptan)
T3 PA, QL (12 tabs/30 days) naratriptan, rizatriptan, sumatriptan
RELPAX TAB 40MG (eletriptan)
T1 QL (12 tabs/30 days)rizatriptan tab 10mg
T1 QL (12 tabs/30 days)rizatriptan tab 10mg odt
T1 QL (12 tabs/30 days)rizatriptan tab 5mg
T1 QL (12 tabs/30 days)rizatriptan tab 5mg odt
T1 QL (12 units/30 days)sumatriptan inj 4mg/0.5
T1 QLsumatriptan inj 4mg/0.5
T1 QL (12 units/30 days)sumatriptan inj 6mg/0.5
T1 QLsumatriptan spr 5mg/act
T1 QL (18 tabs/30 days)sumatriptan tab 100mg
T1 QL (18 tabs/30 days)sumatriptan tab 25mg
T1 QL (18 tabs/30 days)sumatriptan tab 50mg
T1 PA, QL (12 tabs/30 days)zolmitriptan tab 2.5mg
T1 PA, QL (12 tabs/30 days)zolmitriptan tab 5mg
ANTIPARKINSONIAN AGENTS (CNS)ADAMANTANES (CNS)
T1amantadine cap 100mg
T1amantadine syp 50mg/5ml
T1amantadine tab 100mg
64Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANTIPARKINSONIAN AGENTS (CNS)
ANTICHOLINERGIC AGENTS (CNS)
T1benztropine tab 0.5mg
T1trihexyphen elx 0.4mg/ml
T1trihexyphen tab 2mg
T1trihexyphen tab 5mg
CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.
T1entacapone tab 200mg
T1tolcapone tab 100mg
DOPAMINE PRECURSORS
T1carb/levo tab 10-100mg
T1carb/levo tab 25-250mg
T1carb/levo 50 tab /entacap
T1carb/levo 75 tab /entacap
T1carb/levo er tab 25-100mg
T1carb/levo er tab 50-200mg
T1carb/levo sr tab 50-200mg
T1carb/levo100 tab /entacap
T1carb/levo125 tab /entacap
T1carb/levo150 tab /entacap
T1carb/levo200 tab /entacap
T1carbidopa tab 25mg
DOPAMINE RECEPTOR AGONISTS
T1bromocriptin cap 5mg
T1bromocriptin tab 2.5mg
T1cabergoline tab 0.5mg
T3 QL (30 tabs/30 days)MIRAPEX ER TAB 2.25MG (pramipexole)
T3NEUPRO DIS 1MG/24HR (rotigotine)
T3NEUPRO DIS 2MG/24HR (rotigotine)
T3NEUPRO DIS 3MG/24HR (rotigotine)
T3 PA, QL (30 patches/30 days)NEUPRO DIS 4MG/24HR (rotigotine)
T3 PA, QL (30 patches/30 days)NEUPRO DIS 6MG/24HR (rotigotine)
T3 PA, QL (30 patches/30 days)NEUPRO DIS 8MG/24HR (rotigotine)
T1pramipexole tab 0.125mg
65Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANTIPARKINSONIAN AGENTS (CNS)
DOPAMINE RECEPTOR AGONISTS
T1pramipexole tab 0.25mg
T1 QLpramipexole tab 0.375mg
T1pramipexole tab 0.5mg
T1pramipexole tab 0.75mg
T1pramipexole tab 1.5mg
T1pramipexole tab 1mg
T1requip tab 1mg (ropinirole)
T1ropinirole tab 0.25mg
T1ropinirole tab 0.5mg
T1ropinirole tab 12mg er
T1ropinirole tab 1mg
T1ropinirole tab 2mg
T1ropinirole tab 2mg er
T1ropinirole tab 3mg
T1ropinirole tab 4mg
T1ropinirole tab 4mg er
T1ropinirole tab 5mg
T1ropinirole tab 6mg er
T1ropinirole tab 8mg er
MONOAMINE OXIDASE B INHIBITORS
T3 QL (30 tabs/30 days)AZILECT TAB 0.5MG (rasagiline)
T3 QL (30 tabs/30 days)AZILECT TAB 1MG (rasagiline)
T3 PA, QL (30 patches/30 days) amitriptyline, duloxetine, paroxetine, venlafaxine
EMSAM DIS 12MG/24H (selegiline)
T3 PA, QL (30 patches/30 days) amitriptyline, duloxetine, paroxetine, venlafaxine
EMSAM DIS 6MG/24HR (selegiline)
T3 PA, QL (30 patches/30 days) amitriptyline, duloxetine, paroxetine, venlafaxine
EMSAM DIS 9MG/24HR (selegiline)
T1selegiline cap 5mg
66Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANXIOLYTICS, SEDATIVES AND HYPNOTICS
T3 PA, QL (30 tabs/30 days) zolpidemROZEREM TAB 8MG (ramelteon)
T1zaleplon cap 10mg
T1zaleplon cap 5mg
T1 QL (30 tabs/30 days)zolpidem tab 10mg
T1 QL (30 tabs/30 days)zolpidem tab 5mg
T1zolpidem er tab 12.5mg
T1 QL (30 tabs/30 days)zolpidem er tab 6.25mg
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)
T1phenobarb elx 20mg/5ml
T1phenobarb sol 20mg/5ml
T1phenobarb tab 100mg
T1phenobarb tab 15mg
T1phenobarb tab 16.2mg
67Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANXIOLYTICS, SEDATIVES AND HYPNOTICS
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)
T1phenobarb tab 30mg
T1phenobarb tab 32.4mg
T1phenobarb tab 60mg
T1phenobarb tab 64.8mg
T1phenobarb tab 97.2mg
BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)
T1alprazolam tab 0.25 odt
T1alprazolam tab 0.25mg
T1alprazolam tab 0.5mg
T1alprazolam tab 0.5mg er
T1alprazolam tab 0.5mg od
T1alprazolam tab 0.5mg xr (alprazolam)
T1alprazolam tab 1mg
T1alprazolam tab 1mg er
T1alprazolam tab 1mg odt
T1alprazolam tab 1mg xr (alprazolam)
T1alprazolam tab 2mg
T1alprazolam tab 2mg er
T1alprazolam tab 2mg odt
T1alprazolam tab 2mg xr (alprazolam)
T1alprazolam tab 3mg er
T1alprazolam tab 3mg xr (alprazolam)
T1chlordiazep cap 10mg
T1chlordiazep cap 25mg
T1chlordiazep cap 5mg
T1cloraz dipot tab 15mg
T1cloraz dipot tab 3.75mg
T1cloraz dipot tab 7.5mg
T1diazepam gel 10mg
T1diazepam gel 2.5mg
T1diazepam gel 20mg
68Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANXIOLYTICS, SEDATIVES AND HYPNOTICS
BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)
T1diazepam inj 5mg/ml
T1diazepam sol 1mg/ml
T1diazepam sol 5mg/5ml
T1diazepam tab 10mg
T1diazepam tab 2mg
T1diazepam tab 5mg
T1estazolam tab 1mg
T1estazolam tab 2mg
T1flurazepam cap 15mg
T1flurazepam cap 30mg
T1lorazepam tab 0.5mg
T1lorazepam tab 1mg
T1lorazepam tab 2mg
T1midazolam syp 2mg/ml
T1oxazepam cap 10mg
T1oxazepam cap 15mg
T1oxazepam cap 30mg
T1temazepam cap 15mg
T1temazepam cap 22.5mg
T1temazepam cap 30mg
T1temazepam cap 7.5mg
T1triazolam tab 0.125mg
T1triazolam tab 0.25mg
CENTRAL NERVOUS SYSTEM AGENTS, MISC.
T1acampro cal tab 333mg
T1 PAguanfacine tab 1mg er
T1 PAguanfacine tab 2mg er
T1 PAguanfacine tab 3mg er
T1 PAguanfacine tab 4mg er
T1memantine tab hcl 5mg
T1memantine hc tab 10mg
69Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSCENTRAL NERVOUS SYSTEM AGENTS, MISC.
T3 ST (donepezil)NAMENDA SOL 10MG/5ML (memantine)
T3 ST (donepezil)NAMENDA TAB 10MG (memantine)
T3 ST (donepezil)NAMENDA TAB 5MG (memantine)
T3 PA, QL (60 caps/30 days)NUEDEXTA CAP 20-10MG (dextromethorphan)
T1riluzole tab 50mg
T3 PA, QL (30 caps/30 days)STRATTERA CAP 100MG (atomoxetine)
T3 PA, QL (60 caps/30 days)STRATTERA CAP 10MG (atomoxetine)
T3 PA, QL (60 caps/30 days)STRATTERA CAP 18MG (atomoxetine)
T3 PA, QL (60 caps/30 days)STRATTERA CAP 25MG (atomoxetine)
T3 PA, QL (60 caps/30 days)STRATTERA CAP 40MG (atomoxetine)
T3 PA, QL (60 caps/30 days)STRATTERA CAP 60MG (atomoxetine)
T3 PA, QL (30 caps/30 days)STRATTERA CAP 80MG (atomoxetine)
T4 PAtetrabenazin tab 12.5mg
T4 PAtetrabenazin tab 25mg
T4 PA, QL (540 ml/30 days)XYREM SOL 500MG/ML (sodium)
FIBROMYALGIA AGENTS
T3 PA, QL (60 tabs/30 days)SAVELLA MIS TITR PAK (milnacipran)
T3 PA, QL (60 tabs/30 days)SAVELLA TAB 100MG (milnacipran)
T3 PA, QL (60 tabs/30 days)SAVELLA TAB 25MG (milnacipran)
T3 PA, QL (60 tabs/30 days)SAVELLA TAB 50MG (milnacipran)
OPIATE ANTAGONISTS
T1naloxone inj 1mg/ml
T1naltrexone tab 50mg
MED PA, SP Medical coinsuranceVIVITROL INJ 380MG (naltrexone)
PSYCHOTHERAPEUTIC AGENTSANTIDEPRESSANTS
T1amitriptylin tab 100mg
T1amitriptylin tab 10mg
T1amitriptylin tab 150mg
T1amitriptylin tab 25mg
T1amitriptylin tab 50mg
T1amitriptylin tab 75mg
70Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
71Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
T1 PAdesvenlafax tab 50mg er
T1doxepin hcl cap 100mg
T1doxepin hcl cap 10mg
T1doxepin hcl cap 150mg
T1doxepin hcl cap 25mg
T1doxepin hcl cap 50mg
T1doxepin hcl cap 75mg
T1doxepin hcl con 10mg/ml
T1 QL (60 caps/30 days)duloxetine cap 20mg
T1 QL (60 caps/30 days)duloxetine cap 30mg
T1 QL (60 caps/30 days)duloxetine cap 60mg
T1escitalopram sol 5mg/5ml
T1escitalopram tab 10mg
T1escitalopram tab 20mg
T1escitalopram tab 5mg
T1fluoxetine cap 10mg
T1fluoxetine cap 20mg
T1fluoxetine cap 40mg
T1 PAfluoxetine cap 90mg dr
T1fluoxetine sol 20mg/5ml
T1fluoxetine tab 10mg
T1fluoxetine tab 20mg
T1fluvoxamine tab 100mg
T1fluvoxamine tab 25mg
T1fluvoxamine tab 50mg
T1imipram hcl tab 10mg
T1imipram hcl tab 25mg
T1imipram hcl tab 50mg
T1imipram pam cap 100mg
T1imipram pam cap 125mg
T1imipram pam cap 150mg
72Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
T1imipram pam cap 75mg
T1 PAmaprotiline tab 25mg
T1 PAmaprotiline tab 50mg
T1 PAmaprotiline tab 75mg
T3 QL (180 tabs/30 days) amitriptyline, duloxetine, paroxetine, venlafaxine
MARPLAN TAB 10MG (isocarboxazid)
T1mirtazapine tab 15mg
T1mirtazapine tab 15mg odt
T1mirtazapine tab 30mg
T1mirtazapine tab 30mg odt
T1mirtazapine tab 45mg
T1mirtazapine tab 45mg odt
T1mirtazapine tab 7.5mg
T1nefazodone tab 100mg
T1nefazodone tab 150mg
T1nefazodone tab 200mg
T1nefazodone tab 250mg
T1nefazodone tab 50mg
T1nortriptylin cap 10mg
T1nortriptylin cap 25mg
T1nortriptylin cap 50mg
T1nortriptylin cap 75mg
T1nortriptylin sol 10mg/5ml
T1 QL (30 caps/30 days)olanza/fluox cap 12-25mg
T1 QL (30 caps/30 days)olanza/fluox cap 12-50mg
T1 QL (30 caps/30 days)olanza/fluox cap 6-25mg
T1 QL (30 caps/30 days)olanza/fluox cap 6-50mg
T1 QL (30 tabs/30 days)paroxetine tab 10mg
T1 QL (30 tabs/30 days)paroxetine tab 20mg
T1 QL (30 tabs/30 days)paroxetine tab 30mg
T1 QL (30 tabs/30 days)paroxetine tab 40mg
73Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
T1phenelzine tab 15mg
T3 PA, QL (30 tabs/30 days) venlafaxinePRISTIQ TAB 100MG (desvenlafaxine)
T3 QL (30 tabs/30 days) venlafaxinePRISTIQ TAB 100MG (desvenlafaxine)
T3 venlafaxinePRISTIQ TAB 25MG (desvenlafaxine)
T3 PA, QL (30 tabs/30 days) venlafaxinePRISTIQ TAB 50MG (desvenlafaxine)
T3 QL (30 tabs/30 days) venlafaxinePRISTIQ TAB 50MG (desvenlafaxine)
T1protriptylin tab 10mg
T1protriptylin tab 5mg
T1sertraline con 20mg/ml
T1sertraline tab 100mg
T1sertraline tab 25mg
T1sertraline tab 50mg
T1tranylcyprom tab 10mg
T1trazodone tab 100mg
T1trazodone tab 150mg
T1trazodone tab 300mg
T1trazodone tab 50mg
T1 QL (60 caps/30 days)venlafaxine cap 150mg er
T1 QL (60 caps/30 days)venlafaxine cap 37.5 er
T1 QL (60 caps/30 days)venlafaxine cap 37.5mg
T1 QL (60 caps/30 days)venlafaxine cap 75mg er
T1 QLvenlafaxine tab 100mg
T1 QLvenlafaxine tab 150mg er
T1 QLvenlafaxine tab 225mg er
T1 QLvenlafaxine tab 25mg
T1 QLvenlafaxine tab 37.5 er
T1 QLvenlafaxine tab 37.5mg
T1 QLvenlafaxine tab 50mg
T1 QLvenlafaxine tab 75mg
T1 QLvenlafaxine tab 75mg er
74Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
T3 PA, QL (30 tabs/30 days) amitriptyline, duloxetine, paroxetine, venlafaxine
VIIBRYD TAB 10MG (vilazodone)
T3 PA, QL (30 tabs/30 days) amitriptyline, duloxetine, paroxetine, venlafaxine
VIIBRYD TAB 20MG (vilazodone)
T3 PA, QL (30 tabs/30 days) amitriptyline, duloxetine, paroxetine, venlafaxine
VIIBRYD TAB 40MG (vilazodone)
ANTIPSYCHOTIC AGENTS
T3 olanzapine, quetiapine, risperidone
ABILIFY INJ 9.75MG (aripiprazole)
T3 QL (700ml/30 days), ST (risperidone, olanzapine, quetiapine)
olanzapine, quetiapine, risperidone
ABILIFY SOL 1MG/ML (aripiprazole)
T3 QL (60 tabs/30 days), ST (risperidone, olanzapine, quetiapine)
olanzapine, quetiapine, risperidone
ABILIFY TAB 10MG (aripiprazole)
T3 QL (60 tabs/30 days), ST (risperidone, olanzapine, quetiapine)
olanzapine, quetiapine, risperidone
ABILIFY TAB 15MG (aripiprazole)
T3 QL (60 tabs/30 days), ST (risperidone, olanzapine, quetiapine)
olanzapine, quetiapine, risperidone
ABILIFY TAB 20MG (aripiprazole)
T3 QL (60 tabs/30 days), ST (risperidone, olanzapine, quetiapine)
olanzapine, quetiapine, risperidone
ABILIFY TAB 2MG (aripiprazole)
T3 QL (60 tabs/30 days), ST (risperidone, olanzapine, quetiapine)
olanzapine, quetiapine, risperidone
ABILIFY TAB 30MG (aripiprazole)
T3 QL (60 tabs/30 days), ST (risperidone, olanzapine, quetiapine)
olanzapine, quetiapine, risperidone
ABILIFY TAB 5MG (aripiprazole)
T1 QL olanzapine, quetiapine, risperidone
aripiprazole tab 10mg
75Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
ANTIPSYCHOTIC AGENTS
T1 QL olanzapine, quetiapine, risperidone
aripiprazole tab 15mg
T1 QL olanzapine, quetiapine, risperidone
aripiprazole tab 20mg
T1 QL olanzapine, quetiapine, risperidone
aripiprazole tab 2mg
T1 QL olanzapine, quetiapine, risperidone
aripiprazole tab 30mg
T1 QL olanzapine, quetiapine, risperidone
aripiprazole tab 5mg
T1chlorpromaz inj 25mg/ml
T1chlorpromaz inj 50mg/2ml
T1chlorpromaz tab 100mg
T1chlorpromaz tab 10mg
T1chlorpromaz tab 200mg
T1chlorpromaz tab 25mg
T1chlorpromaz tab 50mg
T1 QL (150 tabs/30 days)clozapine tab 100mg
T1 QL (150 tabs/30 days)clozapine tab 200mg
T1 QL (150 tabs/30 days)clozapine tab 25mg
T1 QL (150 tabs/30 days)clozapine tab 50mg
T1compazine sup 25mg (prochlorperazine)
T1compro sup 25mg (prochlorperazine)
T3FANAPT TAB 10MG (iloperidone)
T3FANAPT TAB 12MG (iloperidone)
T3FANAPT TAB 1MG (iloperidone)
T3FANAPT TAB 2MG (iloperidone)
T3FANAPT TAB 4MG (iloperidone)
T3FANAPT TAB 6MG (iloperidone)
T3FANAPT TAB 8MG (iloperidone)
76Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
ANTIPSYCHOTIC AGENTS
T1fluphenazine tab 10mg
T1fluphenazine tab 1mg
T1fluphenazine tab 2.5mg
T1fluphenazine tab 5mg
T1haloperidol con 2mg/ml
T1haloperidol tab 0.5mg
T1haloperidol tab 10mg
T1haloperidol tab 1mg
T1haloperidol tab 20mg
T1haloperidol tab 2mg
T1haloperidol tab 5mg
T3 PA, QL (30 tabs/30 days) olanzapine, risperidone
INVEGA TAB 1.5MG (paliperidone)
T3 PA, QL (30 tabs/30 days) olanzapine, risperidone
INVEGA TAB 3MG (paliperidone)
T3 PA, QL (30 tabs/30 days) olanzapine, risperidone
INVEGA TAB 6MG (paliperidone)
T3 PA, QL (30 tabs/30 days) olanzapine, risperidone
T3 PA, QL (30 tabs/30 days)LATUDA TAB 80MG (lurasidone)
T1loxapine cap 10mg
T1loxapine cap 25mg
T1loxapine cap 50mg
T1loxapine cap 5mg
T1 QL (30 tabs/30 days)olanzapine tab 10mg
T1 QL (30 tabs/30 days)olanzapine tab 10mg odt
T1 QL (30 tabs/30 days)olanzapine tab 15mg
T1 QL (30 tabs/30 days)olanzapine tab 15mg odt
T1 QL (30 tabs/30 days)olanzapine tab 2.5mg
77Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
PA, QL (30tabs/30days)
PA, QL (30tabs/30days)
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
ANTIPSYCHOTIC AGENTS
T1 QL (30 tabs/30 days)olanzapine tab 20mg
T1 QL (30 tabs/30 days)olanzapine tab 20mg odt
T1 QL (30 tabs/30 days)olanzapine tab 5mg
T1 QL (30 tabs/30 days)olanzapine tab 5mg odt
T1 QL (30 tabs/30 days)olanzapine tab 7.5mg
T2ORAP TAB 1MG (PIMOZIDE)
T2ORAP TAB 2MG (PIMOZIDE)
T4 PApaliperidone tab er 1.5mg
T4paliperidone tab er 3mg
T4paliperidone tab er 6mg
T4paliperidone tab er 9mg
T1perphenazine tab 16mg
T1perphenazine tab 2mg
T1perphenazine tab 4mg
T1perphenazine tab 8mg
T1prochlorper sup 25mg
T1prochlorper tab 10mg
T1prochlorper tab 5mg
T1 QL (60 tabs/30 days)quetiapine tab 100mg
T1 QL (60 tabs/30 days)quetiapine tab 200mg
T1 QL (60 tabs/30 days)quetiapine tab 25mg
T1 QL (60 tabs/30 days)quetiapine tab 300mg
T1 QL (60 tabs/30 days)quetiapine tab 400mg
T1 QL (60 tabs/30 days)quetiapine tab 50mg
T1risperidone sol 1mg/ml
T1risperidone tab 0.25 odt
T1 QL (280 tabs/30 days)risperidone tab 0.25mg
T1 QL (280 tabs/30 days)risperidone tab 0.5mg
T1risperidone tab 0.5mg od (risperidone)
T1 QL (280 tabs/30 days)risperidone tab 1 mg
T1 QL (280 tabs/30 days)risperidone tab 1mg
78Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
ANTIPSYCHOTIC AGENTS
T1 QL (280 tabs/30 days)risperidone tab 1mg odt
T1 QL (280 tabs/30 days)risperidone tab 2mg
T1 QL (280 tabs/30 days)risperidone tab 2mg odt
T1 QL (280 tabs/30 days)risperidone tab 3mg
T1 QL (280 tabs/30 days)risperidone tab 3mg odt
T1 QL (280 tabs/30 days)risperidone tab 4mg
T1 QL (280 tabs/30 days)risperidone tab 4mg odt
T3 PA, QL (60 tabs/30 days)SAPHRIS SUB 10MG (asenapine)
T3 PASAPHRIS SUB 2.5MG (asenapine)
T3 PASAPHRIS SUB 5MG (asenapine)
T3 PA, QL (30 tabs/30 days)SEROQUEL XR TAB 150MG (quetiapine)
T3 PA, QL (30 tabs/30 days)SEROQUEL XR TAB 200MG (quetiapine)
T3 PA, QL (30 tabs/30 days)SEROQUEL XR TAB 300MG (quetiapine)
T3 PA, QL (30 tabs/30 days)SEROQUEL XR TAB 400MG (quetiapine)
T3 PA, QL (30 tabs/30 days)SEROQUEL XR TAB 50MG (quetiapine)
T1thioridazine tab 100mg
T1thioridazine tab 10mg
T1thioridazine tab 25mg
T1thioridazine tab 50mg
T1thiothixene cap 10mg
T1thiothixene cap 1mg
T1thiothixene cap 2mg
T1thiothixene cap 5mg
T1trifluoperaz tab 10mg
T1trifluoperaz tab 1mg
T1trifluoperaz tab 2mg
T1trifluoperaz tab 5mg
T1 QL (60 caps/30 days)ziprasidone cap 20mg
T1 QL (120 caps/30 days)ziprasidone cap 40mg
T1 QL (60 caps/30 days)ziprasidone cap 60mg
T1 QL (120 caps/30 days)ziprasidone cap 80mg
79Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
T0 HCR Rules for Coverageencare sup 100mg (nonoxynol-9)
T3SHUR-SEAL GEL 2% (nonoxynol-9)
T0 HCR Rules for Coveragevcf vaginal aer contracp (nonoxynol-9)
T0 HCR Rules for Coveragevcf vaginal gel contrace (nonoxynol-9)
ELECTROLYTIC, CALORIC, AND WATER BALANCEALKALINIZING AGENTS
T1cytra-k sol (potassium)
T1k citrate sol citr acd
T1pot citrate tab 1080mg
T1pot citrate tab 1620mg
T1pot citrate tab 540mg er
T1virtrate-k sol (potassium)
T1virtrate-k sol 1100-334 (potassium)
AMMONIA DETOXICANTS
T4 PA, SPBUPHENYL TAB 500MG (sodium)
T1constulose sol 10gm/15 (lactulose)
T1enulose sol 10gm/15 (lactulose)
T1generlac sol 10gm/15 (lactulose)
T2KRISTALOSE PAK 10GM (lactulose)
T2KRISTALOSE PAK 20GM (lactulose)
T1lactulose sol 10gm/15
T1lactulose sol 20gm/30
DIURETICSLOOP DIURETICS
T1bumetanide inj 0.25/ml
T1bumetanide tab 0.5mg
T1bumetanide tab 1mg
T1bumetanide tab 2mg
T3 QL (480 tabs/30 days)EDECRIN TAB 25MG (ethacrynic)
T1furosemide inj 100/10ml
T1furosemide inj 10mg/ml
T1furosemide inj 20mg/2ml
T1furosemide inj 40mg/4ml
80Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ELECTROLYTIC, CALORIC, AND WATER BALANCEDIURETICS
LOOP DIURETICS
T1furosemide sol 10mg/ml
T1furosemide sol 40mg/4ml
T1furosemide sol 8mg/ml
T1furosemide tab 20mg
T1furosemide tab 40mg
T1furosemide tab 80mg
T1torsemide tab 100mg
T1torsemide tab 10mg
T1torsemide tab 20mg
T1torsemide tab 5mg
POTASSIUM-SPARING DIURETICS
T1amilor/hctz tab 5-50
T1amiloride tab 5mg
T3 PA, QL (120 caps/30 days)DYRENIUM CAP 100MG (triamterene)
T3 PA, QL (120 caps/30 days)DYRENIUM CAP 50MG (triamterene)
T1triamt/hctz cap 37.5-25
T1triamt/hctz cap 50-25mg
T1triamt/hctz tab 37.5-25
T1triamt/hctz tab 75-50mg
THIAZIDE DIURETICS
T1chlorothiaz tab 250mg
T1chlorothiaz tab 500mg
T1hydrochlorot cap 12.5mg
T1hydrochlorot tab 12.5mg
T1hydrochlorot tab 25mg
T1hydrochlorot tab 50mg
T1methyclothia tab 5mg
THIAZIDE-LIKE DIURETICS
T1chlorthalid tab 100mg
T1chlorthalid tab 25mg
T1chlorthalid tab 50mg
T1indapamide tab 1.25mg
81Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ELECTROLYTIC, CALORIC, AND WATER BALANCEDIURETICS
THIAZIDE-LIKE DIURETICS
T1indapamide tab 2.5mg
T1metolazone tab 10mg
T1metolazone tab 2.5mg
T1metolazone tab 5mg
VASOPRESSIN ANTAGONISTS
T4 PASAMSCA TAB 15MG (tolvaptan)
T4 PASAMSCA TAB 30MG (tolvaptan)
ION-REMOVING AGENTSPHOSPHATE-REMOVING AGENTS
T3 QL (150 tabs/30 days)FOSRENOL CHW 1000MG (lanthanum)
T3 QL (150 tabs/30 days)FOSRENOL CHW 500MG (lanthanum)
T3 QL (150 tabs/30 days)FOSRENOL CHW 750MG (lanthanum)
T3 QL (120 tabs/30 days)RENAGEL TAB 400MG (sevelamer)
T3 QL (120 tabs/30 days)RENAGEL TAB 800MG (sevelamer)
T3RENVELA PAK 0.8GM (sevelamer)
T3 QL (540 packs/30 days)RENVELA PAK 2.4GM (sevelamer)
T1 QL (540 tabs/30 days)sevelamer tab 800mg
POTASSIUM-REMOVING AGENTS
T1kionex sus 15gm/60 (sodium)
T1sod poly sul sus 15gm/60
T1sod poly sul sus 30/120ml
T1sod poly sul sus 50/200ml
T1sps sus 15gm/60 (sodium)
REPLACEMENT PREPARATIONS
T1calc acetate cap 667mg
T1chloromag inj 20% (magnesium)
T2EFFER-K TAB 10MEQ (potassium)
T2EFFER-K TAB 20MEQ (potassium)
T1effer-k tab 25meq ef (potassium)
T1k-effervesce tab 25meq ef (potassium)
T1klor-con 10 tab 10meq er (potassium)
82Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ELECTROLYTIC, CALORIC, AND WATER BALANCEREPLACEMENT PREPARATIONS
T1klor-con 8 tab 8meq er (potassium)
T1klor-con m10 tab 10meq er (potassium)
T3KLOR-CON M15 TAB (potassium)
T3KLOR-CON M15 TAB 15MEQ ER (potassium)
T1klor-con m20 tab 20meq er (potassium)
T1klor-con spr cap 10meq (potassium)
T1klor-con spr cap 8meq (potassium)
T1klor-con/ef tab 25meq ef (potassium)
T1klor-con/ef tab 25meq fr (potassium)
T1k-prime tab 25meq ef (potassium)
T1k-sol sol 10% (potassium)
T1k-sol sol 20% (potassium)
T1k-vescent tab 25meq ef (potassium)
T1magnesium cl inj 20%
T3PHOSLYRA SOL (calcium)
T1 QLphospha 250 tab neutral (potassium)
T1pot bicarbon tab 25meq ef
T1pot chloride cap 10meq er
T1pot chloride cap 8meq er
T1pot chloride inj 10meq
T1pot chloride inj 20meq
T1pot chloride inj 2meq/ml
T1pot chloride inj 40meq
T1pot chloride sol 10%
T1pot chloride sol 10% sf
T1pot chloride sol 20%
T1pot chloride sol 20% sf
T1pot chloride tab 10meq cr
T1pot chloride tab 10meq er
T1pot chloride tab 20meq er
T1pot chloride tab 25meq ef (potassium)
T1pot chloride tab 8meq cr
83Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ELECTROLYTIC, CALORIC, AND WATER BALANCEREPLACEMENT PREPARATIONS
T1pot chloride tab 8meq er
T1pot chloride tab 8meq sa
T1pot chloride tab 8meq sr
T1pot cl micro tab 10meq cr
T1pot cl micro tab 10meq er
T1pot cl micro tab 20meq cr
T1pot cl micro tab 20meq er
T1pot/chloride tab 25meq ef
T1potassium tab 25meq ef
T1 QLvirt-phos tab 250 neut (potassium)
T1zinc sulfate cap 220mg
URICOSURIC AGENTS
T1proben/colch tab 500-0.5
T1probenecid tab 500mg
EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTIALLERGIC AGENTS
T3 QL (5 ml/fill)ALOCRIL SOL 2% (nedocromil)
T2ALOMIDE SOL 0.1% OP (lodoxamide)
T1azelastine dro 0.05%
T1azelastine spr 0.1%
T1azelastine spr 0.15%
T3 PABEPREVE DRO 1.5% (bepotastine)
T1cromolyn sod sol 4% op
T3 QL (5 ml/fill)EMADINE SOL 0.05% OP (emedastine)
T1epinastine dro 0.05%
T1ketotif fum dro 0.025%op
T3 QL (3 ml/fill)LASTACAFT SOL 0.25% (alcaftadine)
84Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTIGLAUCOMA AGENTS
ALPHA-ADRENERGIC AGONISTS (EENT)
T1brimonidine sol 0.2% op
T3 QL (10 ml/fill)COMBIGAN SOL 0.2/0.5% (brimonidine)
T3 PASIMBRINZA SUS 1-0.2% (brinzolamide-brimonidine)
BETA-ADRENERGIC BLOCKING AGENTS (EENT)
T1betaxolol sol 0.5% op
T3 QL (10 ml/fill) betaxololBETOPTIC-S SUS 0.25% OP (betaxolol)
T1carteolol sol 1% op
T1levobunolol sol 0.25% op
T1levobunolol sol 0.5% op
T1metipranolol sol 0.3% oph
T1timolol gel sol 0.25% op
T1timolol gel sol 0.5% op
T1timolol mal sol 0.25% op
T1timolol mal sol 0.5% op
CARBONIC ANHYDRASE INHIBITORS (EENT)
T1acetazolamid cap 500mg er
T1acetazolamid tab 125mg
T2 QL (10 ml/fill)AZOPT SUS 1% OP (brinzolamide)
T1dorzol/timol sol 22.3-6.8
T1dorzolamide sol 2% op
T1methazolamid tab 25mg
T1methazolamid tab 50mg
MIOTICS
T3PHOSPHOLINE SOL 0.125%OP (echothiophate)
T1pilocarpine sol 1% op
T1pilocarpine sol 2% op
T1pilocarpine sol 4% op
PROSTAGLANDIN ANALOGS
T1latanoprost sol 0.005%
T2 QL (5 ml/fill), ST (latanoprost)LUMIGAN SOL 0.01% (bimatoprost)
T2 QL (5 ml/fill), ST (latanoprost)TRAVATAN Z DRO 0.004% (travoprost)
T1 QL, ST (latanoprost)travoprost dro 0.004%
85Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTIGLAUCOMA AGENTS
PROSTAGLANDIN ANALOGS
T3 PA, QL (3 pouches/fill)ZIOPTAN DRO 0.0015% (tafluprost)
ANTI-INFECTIVES (EENT)ANTIBACTERIALS (EENT)
T2 QL (2.5 ml/30 days)AZASITE SOL 1% (azithromycin)
T1bacitracin oin op
T3 QL (5 ml/30 days)BESIVANCE SUS 0.6% (besifloxacin)
T2CILOXAN OIN 0.3% OP (ciprofloxacin)
T1ciprofloxacn sol 0.2%
T1ciprofloxacn sol 0.3% op
T1erythromycin oin 5mg/gm
T1erythromycin oin op
T1garamycin oin 0.3% op (gentamicin)
T1 QLgatifloxacin sol 0.5%
T1gentak oin 0.3% op (gentamicin)
T1gentamicin oin 0.3% op
T1gentamicin sol 0.3% op
T1ilotycin oin op (erythromycin)
T1 QL (5 ml/30 days)levofloxacin sol 0.5%
T3 QL (3 ml (1 bottle)/fill)MOXEZA SOL 0.5% (moxifloxacin)
T1ofloxacin dro 0.3% op
T1ofloxacin dro 0.3%otic
T1polymyxin b/ sol trimethp
T1polytrim sol op (polymyxin)
T1romycin oin op (erythromycin)
T1sod sulfacet sol 10% op
T1sulfacet sod sol 10% op
T1tobramycin sol 0.3% op
T3 QL (1 tube/fill)TOBREX OIN 0.3% OP (tobramycin)
T1tobrex sol 0.3% op (tobramycin)
T1trimethoprim sol polymyxn
T2 QL (3 ml (1 bottle)/fill)VIGAMOX DRO 0.5% (moxifloxacin)
86Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTI-INFECTIVES (EENT)
ANTIVIRALS (EENT)
T1trifluridine sol 1% op
T3 QL (5 gram/ fill)ZIRGAN GEL 0.15% (ganciclovir)
T1antibiot ear sol 1% otic (neomycin-polymyxin-hc)
T3 ST (fluticasone nasal spray, triamcinolone nasal spray)
fluticasone, triamcinolone
BECONASE AQ SUS 0.042% (beclomethasone)
T2 QLBLEPHAMIDE SUS LIQUIFLM (sulfacetamide)
T2 QLBLEPHAMIDE SUS OP (sulfacetamide)
T1budesonide sus 32mcg
T3 QL (1 bottle/fill)CIPRO HC SUS OTIC (ciprofloxacin-hydrocortisone)
T2 QL (7.5ml/ fill)CIPRODEX SUS 0.3-0.1% (ciprofloxacin-dexamethasone)
T2COLY-MYCIN S SUS OTIC (neomycin-colistin-hc-thonzonium)
T2CORTISPORIN SUS -TC OTIC (neomycin-colistin-hc-thonzonium)
T1dexameth pho sol 0.1% op
T2DUREZOL EMU 0.05% (difluprednate)
T2FLAREX SUS 0.1% OP (fluorometholone)
T1flunisolide spr 0.025%
T1fluocin acet oil 0.01%
T1fluocin acet oil ear0.01%
T1fluoromethol sus 0.1% op
T1fluticasone spr 50mcg
T1 hc = hydrocortisonehc/acet acid sol otic
T3LOTEMAX SUS 0.5% (loteprednol)
87Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTI-INFLAMMATORY AGENTS (EENT)
CORTICOSTEROIDS (EENT)
T2MAXIDEX SUS 0.1% OP (dexamethasone)
T3 ST (fluticasone nasal spray, triamcinolone nasal spray)
T3 ST (fluticasone nasal spray, triamcinolone nasal spray)
fluticasone, triamcinolone
ZETONNA AER 37MCG (ciclesonide)
EENT NONSTEROIDAL ANTI-INFLAM. AGENTS
T3ACUVAIL SOL 0.45% (ketorolac)
T1bromfenac sol 0.09%
T1bromfenac sol 0.09% op
T1diclofenac sol 0.1% op
T1flurbiprofen sol 0.03% op
T2 QL (1.7 ml/fill)ILEVRO DRO 0.3% OP (nepafenac)
T1ketorolac sol 0.4%
T1ketorolac sol 0.5%
T2NEVANAC SUS 0.1% (nepafenac)
EENT DRUGS, MISCELLANEOUS
T1acetic acid sol 2% otic
T1apraclonidin sol 0.5% op
T2IOPIDINE SOL 1% OP (apraclonidine)
88Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
EYE, EAR, NOSE AND THROAT (EENT) PREPS.LOCAL ANESTHETICS (EENT)
T1a/b sol otic (antipyrine-benzocaine)
T1altacaine sol 0.5% op (tetracaine)
T1antipy/benzo sol otic
T1aurodex sol otic (antipyrine-benzocaine)
T1auroguard sol otic (antipyrine-benzocaine)
T1lidocaine sol 2% visc
T1parcaine sol 0.5% op (proparacaine)
T1proparacaine sol 0.5% op
T1tetcaine sol 0.5% op (tetracaine)
T1tetracaine sol 0.5% op
T1tetravisc sol 0.5% op (tetracaine)
T1tetravisc sol forte (tetracaine)
MYDRIATICS
T1atropin-care sol 1% op (atropine)
T1atropine sul oin 1% op
T1atropine sul sol 1% op
T1cyclopentol sol 1% op
T1cyclopentol sol 2% op
T1homatropaire sol 5% op (homatropine)
T1homatropine sol 5% op
T1mydral sol 0.5% op (tropicamide)
T1mydral sol 1% op (tropicamide)
T1tropicamide sol 0.5% op
T1tropicamide sol 1% op
VASOCONSTRICTORS
T1altafrin sol 10% op (phenylephrine)
T1altafrin sol 2.5% op (phenylephrine)
T1naphazoline sol 0.1% op
T1neofrin sol 10% op (phenylephrine)
T1neofrin sol 2.5% op (phenylephrine)
T1phenylephrin sol 10% op
T1phenylephrin sol 2.5% op
89Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
EYE, EAR, NOSE AND THROAT (EENT) PREPS.VASOCONSTRICTORS
T3TYZINE PED DRO 0.05% (tetrahydrozoline)
GASTROINTESTINAL DRUGSANTIDIARRHEA AGENTS
T1diphen/atrop liq 2.5/5
T1diphen/atrop tab 2.5mg
T1diphenatol tab 2.5mg (diphenoxylate)
T1kaopectate tab (bismuth)
T1lofene tab 2.5mg (diphenoxylate)
T1lonox tab 2.5mg (diphenoxylate)
T1 QLloperamide cap 2mg (loperamide)
ANTIEMETICS5-HT3 RECEPTOR ANTAGONISTS
T3 QL (3 tabs/21 days), ST (ondansetron, granisetron)
ondansetronANZEMET TAB 100MG (dolasetron)
T3 QL (3 tabs/21 days), ST (ondansetron, granisetron)
90Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
GASTROINTESTINAL DRUGSANTIEMETICS
ANTIEMETICS, MISCELLANEOUS
T3 QL (1 capsule/fill)EMEND PAK 80 & 125 (aprepitant)
T3 QL (3 patches/fill)TRANSDERM-SC DIS 1.5MG (scopolamine)
T3 QL (3 patches/fill)TRANSDERM-SC DIS 1MG (scopolamine)
ANTIHISTAMINES (GI DRUGS)
T1meclizine tab 12.5mg
T1meclizine tab 25mg
T1trimethobenz cap 300mg
ANTI-INFLAMMATORY AGENTS (GI DRUGS)
T1balsalazide cap 750mg
T3 QL (70 supp/30 days)CANASA SUP 1000MG (mesalamine)
T2 QL (180 caps/30 days)DELZICOL CAP 400MG (mesalamine)
T2DIPENTUM CAP 250MG (olsalazine)
T3 QL (180 tabs/30 days)LIALDA TAB 1.2GM (mesalamine)
T1mesalamine ene 4gm
T1 QL (1 kit/fill)mesalamine kit 4gm
T3 QL (360 caps/30 days)PENTASA CAP 250MG CR (mesalamine)
T3 QL (360 caps/30 days)PENTASA CAP 500MG CR (mesalamine)
ANTIULCER AGENTS AND ACID SUPPRESSANTSHISTAMINE H2-ANTAGONISTS
T1cimetidine tab 200mg (cimetidine)
T1cimetidine tab 300mg
T1cimetidine tab 400mg
T1cimetidine tab 800mg
T1famotidine tab 20mg (famotidine)
T1famotidine tab 40mg
T1nizatidine cap 150mg
T1nizatidine cap 300mg
T1nizatidine sol 15mg/ml
T1ranitidine syp 150/10ml
T1ranitidine syp 15mg/ml
T1ranitidine syp 75mg/5ml
91Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
GASTROINTESTINAL DRUGSANTIULCER AGENTS AND ACID SUPPRESSANTS
92Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
GASTROINTESTINAL DRUGSCATHARTICS AND LAXATIVES
T1 QLtrilyte sol (peg)
CHOLELITHOLYTIC AGENTS
T1ursodiol cap 300mg
T1ursodiol tab 250mg
T1ursodiol tab 500mg
DIGESTANTS
T3CREON CAP 12000UNT (pancrelipase)
T3CREON CAP 24000UNT (pancrelipase)
T3CREON CAP 3000UNIT (pancrelipase)
T3CREON CAP 36000UNT (pancrelipase)
T3CREON CAP 6000UNIT (pancrelipase)
T3PANCREAZE CAP 10500UNT (pancrelipase)
T3PANCREAZE CAP 16800UNT (pancrelipase)
T3PANCREAZE CAP 21000UNT (pancrelipase)
T3PANCREAZE CAP 4200UNIT (pancrelipase)
T1pancrelipase cap 5000unit
T3PERTZYE CAP (pancrelipase)
T3ZENPEP CAP 10000UNT (pancrelipase)
T3ZENPEP CAP 15000UNT (pancrelipase)
T3ZENPEP CAP 20000UNT (pancrelipase)
T3ZENPEP CAP 25000UNT (pancrelipase)
T3ZENPEP CAP 3000UNIT (pancrelipase)
T3ZENPEP CAP 40000UNT (pancrelipase)
T3ZENPEP CAP 5000UNIT (pancrelipase)
GI DRUGS, MISCELLANEOUS
T3 PA, QL (60 caps/30 days)AMITIZA CAP 24MCG (lubiprostone)
T3 PA, QL (60 caps/30 days)AMITIZA CAP 8MCG (lubiprostone)
T4 PAENTYVIO INJ 300MG (vedolizumab)
T4 PA, SPGATTEX KIT 5MG (teduglutide)
T3 PA, QL (30 caps/30 days)LINZESS CAP 145MCG (linaclotide)
T3 PA, QL (30 caps/30 days)LINZESS CAP 290MCG (linaclotide)
T3 PAXENICAL CAP 120MG (orlistat)
93Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
GASTROINTESTINAL DRUGSPROKINETIC AGENTS
T1metoclopram inj 10mg/2ml
T1metoclopram inj 5mg/ml
T1metoclopram sol 10/10ml
T1metoclopram sol 5mg/5ml
T1metoclopram tab 10mg
T1metoclopram tab 5mg
GOLD COMPOUNDS
T2RIDAURA CAP 3MG (auranofin)
HEAVY METAL ANTAGONISTS
T2CHEMET CAP 100MG (succimer)
T3CUPRIMINE CAP 250MG (penicillamine)
T2DEPEN TITRA TAB 250MG (penicillamine)
T4 PA, SPEXJADE TAB 125MG (deferasirox)
T4 PA, SPEXJADE TAB 250MG (deferasirox)
T4 PA, SPEXJADE TAB 500MG (deferasirox)
T3SYPRINE CAP 250MG (trientine)
HORMONES AND SYNTHETIC SUBSTITUTESADRENALS
T3 QL (1 inhaler/30 days) ADVAIR DISKUS, FLOVENT DISKUS, QVAR
ALVESCO AER 160MCG (ciclesonide)
T3 QL (1 inhaler/30 days) ADVAIR DISKUS, FLOVENT DISKUS, QVAR
ALVESCO AER 80MCG (ciclesonide)
T3 QL (1 inhaler/30 days) ADVAIR DISKUS, FLOVENT DISKUS, QVAR
ASMANEX 120 AER 220MCG (mometasone)
T3 QLASMANEX 30 AER 110MCG (mometasone)
T3ASMANEX 30 AER 220MCG (mometasone)
T3 QL (1 inhaler/30 days) ADVAIR DISKUS, FLOVENT DISKUS, QVAR
ASMANEX 60 AER 220MCG (mometasone)
T3 QLASMANEX 7 AER 110MCG (mometasone)
T3ASMANEX HFA AER 100 MCG (mometasone)
94Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESADRENALS
T3ASMANEX HFA AER 200 MCG (mometasone)
T1 QLbaycadron elx 0.5/5ml (dexamethasone)
T1 PAbudesonide cap 3mg/24hr
T1budesonide sus 0.25mg/2
T1budesonide sus 0.5mg/2
T1budesonide sus 1mg/2ml
T1cortisone ac tab 25mg
T1deltasone tab 20mg (prednisone)
T2 QL (30 ml/ fill)DEXAMETHASON CON 1MG/ML (dexamethasone)
T1 QLdexamethason elx 0.5/5ml
T1dexamethason sol 0.5/5ml
T1dexamethason tab 0.5mg
T1dexamethason tab 0.75mg
T1dexamethason tab 1.5mg
T1dexamethason tab 1mg
T1dexamethason tab 2mg
T1dexamethason tab 4mg
T1dexamethason tab 6mg
T3 QL (1 inhaler/30 days) ADVAIR DISKUS, FLOVENT DISKUS, QVAR
DULERA AER 100-5MCG (mometasone)
T3 QL (1 inhaler/30 days) ADVAIR DISKUS, FLOVENT DISKUS, QVAR
DULERA AER 200-5MCG (mometasone)
T2FLOVENT DISK AER 100MCG (fluticasone)
T2FLOVENT DISK AER 250MCG (fluticasone)
T2FLOVENT DISK AER 50MCG (fluticasone)
T2FLOVENT HFA AER 110MCG (fluticasone)
T2FLOVENT HFA AER 220MCG (fluticasone)
T2FLOVENT HFA AER 44MCG (fluticasone)
T1fludrocort tab 0.1mg
T1hydrocort tab 10mg
T1hydrocort tab 20mg
T1hydrocort tab 5mg
95Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T3 QL (1 inhaler/30 days) ADVAIR DISKUS, FLOVENT DISKUS, QVAR
SYMBICORT AER 160-4.5 (budesonide-formoterol)
T3 QL (1 inhaler/30 days) ADVAIR DISKUS, FLOVENT DISKUS, QVAR
SYMBICORT AER 80-4.5 (budesonide-formoterol)
T2 QL (480ml/30 days)VERIPRED 20 SOL 20MG/5ML (prednisolone)
ANDROGENS
T3 PA, QL (60 packets/30 days)ANDROGEL GEL 1%(25MG) (testosterone)
96Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESANDROGENS
T3 PAANDROGEL GEL 1.62% (testosterone)
T3 PA, QL (2 bottles/30 days)ANDROGEL GEL PUMP 1% (testosterone)
T1 PAdanazol cap 100mg
T1 PAdanazol cap 200mg
T1 PAdanazol cap 50mg
T3NATESTO GEL 5.5MG (testosterone)
T1oxandrolone tab 10mg
T1oxandrolone tab 2.5mg
T1 PA, QLtestosterone gel 1%(25mg)
T1 PA, QLtestosterone gel 1%(50mg)
T1 PA, QLtestosterone gel pump 1%
ANTIDIABETIC AGENTSALPHA-GLUCOSIDASE INHIBITORS
T1acarbose tab 100mg
T1acarbose tab 25mg
T1acarbose tab 50mg
T3 acarboseGLYSET TAB 100MG (miglitol)
T3 acarboseGLYSET TAB 25MG (miglitol)
T3 acarboseGLYSET TAB 50MG (miglitol)
AMYLINOMIMETICS
T3 PASYMLINPEN 60 INJ 1000MCG (pramlintide)
ANTIDIABETIC AGENTS, MISCELLANEOUS
T3 PA, QL (180 tabs/30 days)CYCLOSET TAB 0.8MG (bromocriptine)
97Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESANTIDIABETIC AGENTS
T3 QL (60ml/30 days) NOVOLOGHUMALOG INJ 100/ML (insulin)
T3 QL (60ml/30 days) NOVOLOG, NOVOLOG MIX 70/30
HUMALOG KWIK INJ 100/ML (insulin)
T3 QL (60ml/30 days) NOVOLOG, NOVOLOG MIX 70/30
HUMALOG MIX INJ 50/50 (insulin)
T3 QL (60ml/30 days) NOVOLOG, NOVOLOG MIX 70/30
HUMALOG MIX INJ 50/50KWP (insulin)
T3 QL (60ml/30 days) NOVOLOG, NOVOLOG MIX 70/30
HUMALOG MIX INJ 75/25KWP (insulin)
T3 QL (60ml/30 days) NOVOLOG, NOVOLOG MIX 70/30
HUMALOG MIX SUS 75/25 (insulin)
T3 QL (60 ml/30 days)HUMULIN INJ 70/30 (insulin)
T3 QL (60 ml/30 days)HUMULIN INJ 70/30KWP (insulin)
T3 QL (60 ml/30 days)HUMULIN N INJ U-100 (insulin)
T3 QL (60 ml/30 days)HUMULIN N INJ U-100KWP (insulin)
T3 QL (60 ml/30 days)HUMULIN N PN INJ U-100 (insulin)
T3 QL (60 ml/30 days)HUMULIN PEN INJ 70/30 (insulin)
98Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESANTIDIABETIC AGENTS
INSULINS
T3 QL (60 ml/30 days) NOVOLOG, NOVOLOG MIX 70/30, quetiapine
99Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESANTIDIABETIC AGENTS
100Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESANTIDIABETIC AGENTS
101Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
102Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
103Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
104Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T0 QL (28 tabs/28 days) HCR Rules for Coveragezenchent fe chw 0.4mg-35 (norethindrone)
105Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
ESTROGENS AND ANTIESTROGENSESTROGEN AGONIST-ANTAGONISTS
T1 QLclomiphene tab 50mg
T3EVISTA TAB 60MG (raloxifene)
T0 HCR Rules for Coverageraloxifene hcl tab 60 mg
T1 QLserophene tab 50mg (clomiphene)
ESTROGENS
T3 QL (30 tabs/30 days)CENESTIN TAB 0.3MG (estrogens,)
T3 QL (30 tabs/30 days)CENESTIN TAB 0.45MG (estrogens,)
T3 QL (30 tabs/30 days)CENESTIN TAB 0.625MG (estrogens,)
T3 QL (30 tabs/30 days)CENESTIN TAB 0.9MG (estrogens,)
T3 QL (30 tabs/30 days)CENESTIN TAB 1.25MG (estrogens,)
T3 QL (4/30 days)CLIMARA PRO DIS WEEKLY (estradiol-levonorgestrel)
T3 QL (8 patches/28 days)COMBIPATCH DIS .05/.14 (estradiol)
T3 QL (8 patches/28 days)COMBIPATCH DIS .05/.25 (estradiol)
T3 QL (1 bottle/30 days)DIVIGEL GEL 0.25MG (estradiol)
T3 QL (1 bottle/30 days)DIVIGEL GEL 0.5MG (estradiol)
T3 QL (1 bottle/30 days)DIVIGEL GEL 1MG/GM (estradiol)
T3 QL (1 bottle/30 days)ELESTRIN GEL 0.06% (estradiol)
T3 QL (30 tabs/30 days)ENJUVIA TAB 0.3MG (estrogens,)
T3 QL (30 tabs/30 days)ENJUVIA TAB 0.45MG (estrogens,)
T3 QL (30 tabs/30 days)ENJUVIA TAB 0.625MG (estrogens,)
T3 QL (30 tabs/30 days)ENJUVIA TAB 0.9MG (estrogens,)
T3 QL (30 tabs/30 days)ENJUVIA TAB 1.25MG (estrogens,)
T1estra/noreth tab 0.5-0.1
T1estra/noreth tab 1-0.5mg
T3 QL (1 tube = 42.5gm/fill)ESTRACE VAG CRE 0.1MG/GM (estradiol)
T1 QLestradiol dis 0.025mg
T1 QLestradiol dis 0.0375mg
T1 QLestradiol dis 0.05mg
106Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESESTROGENS AND ANTIESTROGENS
ESTROGENS
T1 QLestradiol dis 0.06mg
T1 QLestradiol dis 0.075mg
T1 QLestradiol dis 0.1mg
T1estradiol tab 0.5mg
T1estradiol tab 1mg
T1estradiol tab 2mg
T3ESTRASORB EMU (estradiol)
T3 QL (1 ring/90 days)ESTRING MIS 2MG (estradiol)
T3 QL (1 bottle/30 days)ESTROGEL GEL (estradiol)
T1estropipate tab 0.75mg
T1estropipate tab 1.5mg
T1estropipate tab 3mg
T3 QL (1 bottle/30 days)EVAMIST SPR 1.53MG (estradiol)
T3 PA, QL (1 ring/90 days)FEMRING MIS 0.05/24H (estradiol)
T3 PA, QL (1 ring/90 days)FEMRING MIS 0.1MG/24 (estradiol)
T1jinteli tab 1mg-5mcg (norethindrone)
T1lopreeza tab 0.5-0.1 (estradiol)
T1lopreeza tab 1-0.5mg (estradiol)
T2MENEST TAB 0.3MG (esterified)
T2MENEST TAB 0.625MG (esterified)
T2MENEST TAB 1.25MG (esterified)
T2MENEST TAB 2.5MG (esterified)
T3 QL (4 patches/28 days)MENOSTAR DIS 14MCG (estradiol)
T1mimvey tab 1-0.5mg (estradiol)
T1mimvey lo tab 0.5-0.1 (estradiol)
T1noreth/ethin tab 0.5-2.5
T1noreth/ethin tab 1mg-5mcg
T1ortho-est tab 0.625 (estropipate)
T1ortho-est tab 1.25 (estropipate)
T3PREFEST TAB (estradiol-norgestimate)
T2PREMARIN TAB 0.3MG (estrogens,)
107Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESESTROGENS AND ANTIESTROGENS
108Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESPROGESTINS
T2CRINONE GEL 4% VAG (progesterone)
T2CRINONE GEL 8% VAG (progesterone)
T3DEPO-PROVERA INJ 400/ML (medroxyprogesterone)
T3ENDOMETRIN SUP 100MG (progesterone)
T0 QL HCR Rules for Coveragemedroxypr ac inj 150mg/ml
T1medroxypr ac tab 10mg
T1medroxypr ac tab 2.5mg
T1medroxypr ac tab 5mg
T3 QL (175ml/30 days)MEGACE ES SUS (megestrol)
T1megestrol sus 625mg/5m
T1norethin ace tab 5mg
T1progesterone cap 100mg
T1progesterone cap 200mg
T1progesterone inj 50mg/ml
SOMATOSTATIN AGONISTS AND ANTAGONISTSSOMATOSTATIN AGONISTS
T4 PA, SPSIGNIFOR INJ 0.3MG/ML (pasireotide)
T4 PA, SPSIGNIFOR INJ 0.6MG/ML (pasireotide)
T4 PA, SPSIGNIFOR INJ 0.9MG/ML (pasireotide)
T3 PA, QLSOMATULINE INJ 90/0.3ML (lanreotide)
SOMATOTROPIN AGONISTS AND ANTAGONISTSSOMATOTROPIN AGONISTS
T4 PAINCRELEX INJ 40MG/4ML (mecasermin)
T4 PA, SPNUTROPIN INJ 10MG (somatropin)
T4 PA, SPNUTROPIN AQ INJ 10MG/2ML (somatropin)
T4 PANUTROPIN AQ INJ 20MG/2ML (somatropin)
T4 PA, SPNUTROPIN AQ INJ NUSPIN 5 (somatropin)
T4 PAZOMACTON INJ 10MG (somatropin)
SOMATOTROPIN ANTAGONISTS
T3 PASOMAVERT INJ 10MG (pegvisomant)
T3 PASOMAVERT INJ 15MG (pegvisomant)
T3 PASOMAVERT INJ 20MG (pegvisomant)
109Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESSOMATOTROPIN AGONISTS AND ANTAGONISTS
110Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESTHYROID AND ANTITHYROID AGENTS
111Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESTHYROID AND ANTITHYROID AGENTS
112Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESTHYROID AND ANTITHYROID AGENTS
THYROID AGENTS
T1 QLunith direct tab 75mcg (levothyroxine)
T1 QLunith direct tab 88mcg (levothyroxine)
T2 QLunithroid tab 100mcg (levothyroxine)
T2 QLunithroid tab 112mcg (levothyroxine)
T2 QLunithroid tab 125mcg (levothyroxine)
T2 QLunithroid tab 137mcg (levothyroxine)
T2 QLunithroid tab 150mcg (levothyroxine)
T2 QLunithroid tab 175mcg (levothyroxine)
T2 QLunithroid tab 200mcg (levothyroxine)
T2 QLunithroid tab 25mcg (levothyroxine)
T2 QLunithroid tab 300mcg (levothyroxine)
T2 QLunithroid tab 50mcg (levothyroxine)
T2 QLunithroid tab 75mcg (levothyroxine)
T2 QLunithroid tab 88mcg (levothyroxine)
T2 QLwesthroid tab 130mg (thyroid)
T1 QLwesthroid tab 32.5mg (thyroid)
T1 QLwesthroid tab 65mg (thyroid)
T2 QLWP THYROID TAB 130MG (thyroid)
LOCAL ANESTHETICS (PARENTERAL)
T1chloroproc inj 2%
T1chloroproc inj 3%
T1tetracaine inj 1%
MISCELLANEOUS THERAPEUTIC AGENTS
T1colchicine tab 0.6mg
T1leucovor ca tab 15mg
T1leucovor ca tab 25mg
T1leucovor ca tab 5mg
5-ALPHA-REDUCTASE INHIBITORS
T1 QL (30 caps/30 days), ST (finasteride)
Dutasteride 0.5MG
T1finasteride tab 5mg
113Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Medical coinsuranceTYSABRI INJ 300/15ML (natalizumab)
114Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T3 QL (4 tabs/28 days), ST (alendronate, ibandronate)
alendronateACTONEL TAB 35MG (risedronate)
T1alendronate tab 10mg
T1alendronate tab 35mg
T1alendronate tab 40mg
T1alendronate tab 5mg
T1alendronate tab 70mg
T1etidron disd tab 200mg
T1etidron disd tab 400mg
T3 QL (4 tabs/28 days), ST (alendronate, ibandronate)
FOSAMAX + D TAB 70-2800 (alendronate)
T3 QL (4 tabs/28 days), ST (alendronate, ibandronate)
FOSAMAX + D TAB 70-5600 (alendronate)
T1 QL (1 tab/28 days)ibandronate tab 150mg
MED PA, SP Medical coinsurancePROLIA SOL 60MG/ML (denosumab)
T1 QL (1 tab/28 days)risedronate tab 150mg
MED PA, SP Medical coinsuranceXGEVA INJ (denosumab)
CARIOSTATIC AGENTS
T0 HCR Rules for Coveragesodium fluoride chew 0.25 mg
T0 HCR Rules for Coveragesodium fluoride chew 0.5 mg
T0 HCR Rules for Coveragesodium fluoride chew 1 mg
T0 HCR Rules for Coveragesodium fluoride chew 1.1 mg
T0 HCR Rules for Coveragesodium fluoride chew 2.2 mg
T0 HCR Rules for Coveragesodium fluoride lozg 1 mg
T0 HCR Rules for Coveragesodium fluoride soln 0.125 mg/drop
T0 HCR Rules for Coveragesodium fluoride soln 0.25 mg/drop
T0 HCR Rules for Coveragesodium fluoride soln 0.5 mg/ml
T0 HCR Rules for Coveragesodium fluoride tab 0.5 mg
T0 HCR Rules for Coveragesodium fluoride tab 1 mg
COMPLEMENT INHIBITORS
MED PA, SP Medical coinsuranceBERINERT INJ 500UNIT (c1)
MED PA, SP Medical coinsuranceCINRYZE SOL 500 UNIT (c1)
115Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
MED PA, SP Medical coinsuranceREMICADE INJ 100MG (infliximab)
T4 PASIMPONI INJ 100MG/ML (golimumab)
T4 PA, SPSIMPONI INJ 50/0.5ML (golimumab)
T4SIMPONI ARIA SOL 50MG/4ML (golimumab)
T4 PA, SP ENBREL, leflunomide, methotrexate
XELJANZ TAB 5MG (tofacitinib)
116Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
MED PA, SP Medical coinsuranceBENLYSTA INJ 120MG (belimumab)
MED PA, SP Medical coinsuranceBENLYSTA INJ 400MG (belimumab)
T1cyclosporine cap 100mg
T1cyclosporine cap 100mg md
T1cyclosporine cap 25mg
T1cyclosporine cap 25mg mod
T1cyclosporine cap 50mg mod
T1gengraf cap 100mg (cyclosporine)
T1gengraf cap 25mg (cyclosporine)
T1hecoria cap 0.5mg (tacrolimus)
T1hecoria cap 1mg (tacrolimus)
T1hecoria cap 5mg (tacrolimus)
T1mycophenolat cap 250mg
T1mycophenolat sus 200mg/ml
T1mycophenolat tab 500mg
T1mycophenolic tab 180mg dr
T1mycophenolic tab 360mg dr
T2RAPAMUNE SOL 1MG/ML (sirolimus)
T3SANDIMMUNE SOL 100MG/ML (cyclosporine)
T1sirolimus tab 0.5mg
T1sirolimus tab 1mg
T1sirolimus tab 2mg
T1tacrolimus cap 0.5mg
T1tacrolimus cap 1mg
T1tacrolimus cap 5mg
T3 PAZORTRESS TAB 0.25MG (everolimus)
T3 PAZORTRESS TAB 0.5MG (everolimus)
T3 PAZORTRESS TAB 0.75MG (everolimus)
117Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T3 QL (120 tabs/30 days) montelukastZYFLO CR TAB 600MG (zileuton)
MAST-CELL STABILIZERS
T1cromolyn sod con 100/5ml
ANTITUSSIVES
T1benzonatate cap 100mg
T1benzonatate cap 150mg
T1 QLbenzonatate cap 200mg
T1chlor/phen dro dm
118Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T4 PA, QL (28 units / 30 days)TYVASO SOL 0.6MG/ML (treprostinil)
T4 PA, QL (28 units / 30 days)TYVASO REFIL SOL 0.6MG/ML (treprostinil)
T4 PA, QL (28 units / 30 days)TYVASO START SOL 0.6MG/ML (treprostinil)
T4 PA, QL (270 ampules/ 30 days)VENTAVIS SOL 10MCG/ML (iloprost)
T4 PA, QL (270 ampules/ 30 days)VENTAVIS SOL 20MCG/ML (iloprost)
119Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SERUMS, TOXOIDS, AND VACCINESSERUMS
MED PA, SP Medical coinsuranceBIVIGAM INJ 10% (immune)
MED PA, SP Medical coinsurancecarimune nf inj 12gm (immune)
MED PA, SP Medical coinsurancecarimune nf inj 3gm (immune)
MED PA, SP Medical coinsurancecarimune nf inj 6gm (immune)
MED PA, SP Medical coinsuranceFLEBOGAMMA INJ 20/400ML (immune)
MED PA, SP Medical coinsuranceflebogamma 5% vial
MED PA, SP Medical coinsurancegamastan s/d inj (immune)
MED PA, SP Medical coinsurancegammagard inj 1gm/10ml (immune)
MED PA, SP Medical coinsurancegammagard inj 2.5gm/25 (immune)
MED PA, SP Medical coinsurancegammagard inj 20gm/200 (immune)
MED PA, SP Medical coinsurancegammagard inj 5gm/50ml (immune)
MED PA, SP Medical coinsuranceGAMMAGARD S-D 10 G (IGA<1) SOL
MED PA, SP Medical coinsurancegammagard s-d 2.5 gm vl w/st
MED PA, SP Medical coinsuranceGAMMAGARD S-D 5 G (IGA<1) SOLN
MED PA, SP Medical coinsuranceGAMMAKED INJ 10GM/100 (immune)
MED PA, SP Medical coinsuranceGAMMAKED INJ 1GM/10ML (immune)
MED PA, SP Medical coinsuranceGAMMAKED INJ 2.5GM/25 (immune)
MED PA, SP Medical coinsuranceGAMMAKED INJ 20GM/200 (immune)
MED PA, SP Medical coinsuranceGAMMAKED INJ 5GM/50ML (immune)
MED PA, SP Medical coinsuranceGAMMAPLEX INJ 10GM (immune)
MED PA, SP Medical coinsuranceGAMMAPLEX INJ 2.5GM (immune)
MED PA, SP Medical coinsuranceGAMMAPLEX INJ 5GM (immune)
MED PA, SP Medical coinsuranceGAMUNEX 10% VIAL (IMMUNE)
MED PA, SP Medical coinsuranceHIZENTRA INJ 1GM/5ML (immune)
MED PA, SP Medical coinsuranceHIZENTRA INJ 2GM/10ML (immune)
MED PA, SP Medical coinsuranceHIZENTRA INJ 4GM/20ML (immune)
MED PA, SP Medical coinsuranceOCTAGAM INJ 10GM (immune)
MED PA, SP Medical coinsuranceOCTAGAM INJ 1GM (immune)
MED PA, SP Medical coinsuranceOCTAGAM INJ 2.5GM (immune)
MED PA, SP Medical coinsuranceOCTAGAM INJ 25GM (immune)
MED PA, SP Medical coinsuranceOCTAGAM INJ 5GM (immune)
MED PA, SP Medical coinsurancePRIVIGEN INJ 10GRAMS (immune)
120Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SERUMS, TOXOIDS, AND VACCINESSERUMS
MED PA, SP Medical coinsurancePRIVIGEN INJ 20GRAMS (immune)
MED PA, SP Medical coinsurancePRIVIGEN INJ 5 GRAMS (immune)
MED PA, SP Medical coinsuranceVIVAGLOBIN SOL 160MG/ML (immune)
TOXOIDS
T0 HCR Rules for Coveragetetanus-diphtheria toxoids (td) suspension
VACCINES
T0 HCR Rules for CoverageAFLURIA INJ 2015-16 (influenza)
T0 HCR Rules for CoverageAFLURIA INJ PF 12-13 (influenza)
T0 HCR Rules for CoverageAFLURIA INJ PF 13-14 (influenza)
T0 HCR Rules for CoverageAFLURIA INJ PF 14-15 (influenza)
T0 HCR Rules for CoverageAFLURIA INJ PF 15-16 (influenza)
T2BEXSERO INJ (meningococcal)
T0 HCR Rules for CoverageEZ FLU SHOT INJ 2015-16 (influenza)
T0 HCR Rules for CoverageFLUARIX PF INJ 2013-14 (influenza)
T0 HCR Rules for CoverageFLUARIX PF INJ 2014-15 (influenza)
T0 HCR Rules for CoverageFLUARIX QUAD INJ 2013-14 (influenza)
T0 HCR Rules for CoverageFLUARIX QUAD INJ 2014-15 (influenza)
T0 HCR Rules for CoverageFLUARIX QUAD INJ 2015-16 (influenza)
T0 HCR Rules for CoverageFLUBLOK SOL 2013-14 (influenza)
T0 HCR Rules for CoverageFLUBLOK SOL 2014-15 (influenza)
T0 HCR Rules for CoverageFLUBLOK SOL 2015-16 (influenza)
T0 HCR Rules for CoverageFLUCELVAX INJ 2013-14 (influenza)
T0 HCR Rules for CoverageFLUCELVAX INJ 2014-15 (influenza)
T0 HCR Rules for CoverageFLUCELVAX INJ 2015-16 (influenza)
T0 HCR Rules for CoverageFLULAVAL INJ 2013-14 (influenza)
T0 HCR Rules for CoverageFLULAVAL QUA INJ 2013-14 (influenza)
T0 HCR Rules for CoverageFLULAVAL QUA INJ 2014-15 (influenza)
T0 HCR Rules for CoverageFLULAVAL QUA INJ 2015-16 (influenza)
T0 HCR Rules for CoverageFLUMIST QUAD SUS 2013-14 (influenza)
T0 HCR Rules for CoverageFLUMIST QUAD SUS 2014-15 (influenza)
T0 HCR Rules for CoverageFLUMIST QUAD SUS 2015-16 (influenza)
T0 HCR Rules for CoverageFLUVIRIN INJ 2013-14 (influenza)
121Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SERUMS, TOXOIDS, AND VACCINESVACCINES
T0 HCR Rules for CoverageFLUVIRIN INJ 2015-16 (influenza)
T0 HCR Rules for CoverageFLUVIRIN INJ PF 13-14 (influenza)
T0 HCR Rules for CoverageFLUVIRIN PF INJ 2014-15 (influenza)
T0 HCR Rules for CoverageFLUZONE INJ INTRADRM (influenza)
T0 HCR Rules for CoverageFLUZONE INJ PF 13-14 (influenza)
T0 HCR Rules for CoverageFLUZONE INJ PF 14-15 (influenza)
T0 HCR Rules for CoverageFLUZONE HD INJ PF 13-14 (influenza)
T0 HCR Rules for CoverageFLUZONE HD INJ PF 14-15 (influenza)
T0 HCR Rules for CoverageFLUZONE HD INJ PF 15-16 (influenza)
T0 HCR Rules for CoverageFLUZONE PED/ INJ PF 13-14 (influenza)
T0 HCR Rules for CoverageFLUZONE QUAD INJ 13-14 (influenza)
T0 HCR Rules for CoverageFLUZONE QUAD INJ 14-15 (influenza)
T0 HCR Rules for CoverageFLUZONE QUAD INJ 15-16 (influenza)
T0 HCR Rules for CoverageFLUZONE QUAD INJ 2015-16 (influenza)
T0 HCR Rules for CoverageFLUZONE QUAD INJ 9MCG (influenza)
T0 HCR Rules for CoverageFLUZONE SPLT INJ 2015-16 (influenza)
T2GARDASIL 9 INJ (human)
T0 HCR Rules for CoverageINFLUENZA FIRUS VACCINE (INFLUENZA)
T2MENHIBRIX INJ (meningococcal)
T2TRUMENBA INJ (meningococcal)
SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)
T3 QL (1 tube/fill) clindamycin, erythromycin
ALTABAX OIN 1% (retapamulin)
T2BACTROBAN OIN NASAL 2% (mupirocin)
T1clindacin mis etz 1% (clindamycin)
T1clindacin-p pad 1% (clindamycin)
T1clindamax gel 1% (clindamycin)
T1clindamax lot 10mg/ml (clindamycin)
T1 QLclindamy/ben gel 1.2-5%
T1clindamy/ben gel 1-5%
T1clindamycin cre 2% vag
122Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)
T1clindamycin gel 1%
T1clindamycin lot 1%
T1clindamycin lot 10mg/ml
T1clindamycin pad 1%
T1clindamycin sol 1%
T1ery pad 2% (erythromycin)
T1erythromycin gel /benzoyl
T1erythromycin gel 2%
T1erythromycin pad 2%
T1erythromycin sol 2%
T1gentamicin cre 0.1%
T1gentamicin oin 0.1%
T1metronidazol cre 0.75%
T1metronidazol gel 0.75%vag
T1metronidazol lot 0.75%
T1 QLmupirocin cre 2%
T1mupirocin oin 2%
T1 QLmupirocin ca cre 2%
T1 QLneuac gel 1.2-5% (clindamycin)
T1rosadan cre 0.75% (metronidazole)
T1sulfacetamid lot 10%
T1sulfacetamid sus 10%
T1vandazole gel 0.75% (metronidazole)
ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)
T1ciclodan cre 0.77% (ciclopirox)
T1ciclodan sol 8% (ciclopirox)
T1ciclopirox cre 0.77%
T1ciclopirox gel 0.77%
T1ciclopirox sha 1%
T1ciclopirox sol 8%
T1ciclopirox sus 0.77%
123Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)
T1 QL (60 gram tube/fill)clotrim/beta cre 1-0.05%
T1 QL (60 gram tube/fill)clotrim/beta cre diprop
T1clotrim/beta lot diprop
T1 QLclotrimazole cre 1% (clotrimazole)
T1clotrimazole loz 10mg
T1clotrimazole tro 10mg
T1econazole cre 1%
T3 QL (60 gm/fill) ciclopirox, econazole, ketoconazole, nystatin
ERTACZO CRE 2% (sertaconazole)
T3 QL (30 gram tube/fill)EXELDERM SOL 1% (sulconazole)
T1ketoconazole aer 2%
T1ketoconazole cre 2%
T1ketoconazole sha 2%
T1ketodan aer 2% (ketoconazole)
T3 QL (30 gram tube/fill) ciclopirox, nystatinMENTAX CRE 1% (butenafine)
T1nyamyc pow 100000 (nystatin)
T1nystatin cre 100000
T1nystatin oin 100000
T1nystatin pow 100000
T1nystop pow 100000 (nystatin)
T3 QL (60 gm/fill) ciclopirox, nystatinOXISTAT CRE 1% (oxiconazole)
T3 QL (60 gm/fill) ciclopirox, nystatinOXISTAT LOT 1% (oxiconazole)
T1pedi-dri pow 100000 (nystatin)
T1 QLterconazole cre 0.4%
T1 QLterconazole cre 0.8%
T1terconazole sup 80mg
T1 QLzazole cre 0.4% (terconazole)
T1 QLzazole cre 0.8% (terconazole)
T1zazole sup 80mg (terconazole)
ANTIVIRALS (SKIN & MUCOUS MEMBRANE)
T1 QL (60gm/30 days)acyclovir oin 5%
124Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
ANTIVIRALS (SKIN & MUCOUS MEMBRANE)
T3 QL (5gram / fill) acyclovirDENAVIR CRE 1% (penciclovir)
LOCAL ANTI-INFECTIVES, MISCELLANEOUS
T1 QLacne medicat gel 10% (benzoyl)
T1 QLacne medicat gel 5% (benzoyl)
T1 QLacne pimple gel 10% (benzoyl)
T1 QLacne treatmn gel 10% (benzoyl)
T1 QLacne-clear gel 10% (benzoyl)
T1benzepro aer 5.3% (benzoyl)
T1benzepro liq creamy (benzoyl)
T1benzepro sc aer 9.8% (benzoyl)
T1benziq wash liq 5.25% (benzoyl)
T1benzoyl per aer 5.3%
T1benzoyl per aer 9.8%
T1 QLbenzoyl per gel 10% (benzoyl)
T1 QLbenzoyl per gel 5% (benzoyl)
T1benzoyl per liq 10% wash (benzoyl)
T1benzoyl pero aer 9.8%
T1benzoyl pero kit acne pck (benzoyl)
T1bp foam aer 5.3% (benzoyl)
T1bp foam aer 9.8% (benzoyl)
T1bp foaming liq wash 10% (benzoyl)
T1 QLbp gel gel 10% (benzoyl)
T1 QLbp gel gel 5% (benzoyl)
T1bp wash liq 2.5% (benzoyl)
T1bp wash liq 7% (benzoyl)
T1bpo gel 4% (benzoyl)
T1bpo gel 8% (benzoyl)
T1bpo creamy kit 4% wash (benzoyl)
T1bpo creamy kit 8% wash (benzoyl)
T1 QLclearplex v gel 5% (benzoyl)
T1 QLclearplex x gel 10% (benzoyl)
125Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
LOCAL ANTI-INFECTIVES, MISCELLANEOUS
T1 QLpersa-gel gel 10% (benzoyl)
T1 QLpersa-gel xs gel 5% (benzoyl)
T1pr benzoyl liq 7% wash (benzoyl)
T1 QLra renewal gel 10% (benzoyl)
T1se bpo wash liq 7% (benzoyl)
T1selenium sul lot 2.5%
T1selenium sul sha 2.25%
T1selenium sul sha 2.5%
T1silver sulfa cre 1%
T1ssd cre 1% (silver)
T1thermazene cre 1% (silver)
SCABICIDES AND PEDICULICIDES
T1acticin cre 5% (permethrin)
T2EURAX CRE 10% (crotamiton)
T2 QL (454 ml/30 days)EURAX LOT 10% (crotamiton)
T1lindane lot 1%
T1lindane sha 1%
T1malathion lot 0.5%
T1permethrin cre 5%
T3SKLICE LOT 0.5% (ivermectin)
T3 QL (227 ml/30 days)ULESFIA LOT 5% (benzyl)
ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
T1ala cort cre 1% (hydrocortisone)
T1alclometason cre 0.05%
T1alclometason oin 0.05%
T1 QL (60 gram tube/fill)alphatrex gel 0.05% (betamethasone)
T1amcinonide cre 0.1%
T1amcinonide lot 0.1%
T1amcinonide oin 0.1%
T1 QLanucort-hc sup 25mg (hydrocortisone)
T2 QL (30 gm/fill)APEXICON E CRE 0.05% (diflorasone)
126Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
T1 QL (60 gram tube/fill)aug betamet cre 0.05%
T1 QL (60 gram tube/fill)aug betamet gel 0.05%
T1 QL (60 gram tube/fill)aug betamet lot 0.05%
T1 QL (60 gram tube/fill)aug betamet oin 0.05%
T1beta diprop gel 0.05%
T1 QL (60 gram tube/fill)betameth dip cre 0.05%
T1 QL (60 gram tube/fill)betameth dip lot 0.05%
T1 QL (60 gram tube/fill)betameth dip oin 0.05%
T1 QL (60 gram tube/fill)betameth val cre 0.1%
T1 PA, QL (60 gram tube/fill)betameth val lot 0.1%
T1 PA, QL (60 gram tube/fill)betameth val oin 0.1%
T3 QL (45gm/fill) betamethasoneCLODERM CRE 0.1% (clocortolone)
T3 QL betamethasoneCLODERM CRE 0.1% PMP (clocortolone)
T3 QL (30 grams/fill) betamethasoneCORDRAN CRE 0.05% (flurandrenolide)
T1 QL (60gram/30 days)cormax scalp sol 0.05% (clobetasol)
T3 PACORTISPORIN CRE 0.5% (neomycin-polymyxin-hc)
T2 QL (60gm/fill) desonideDESONATE GEL 0.05% (desonide)
T1desonide cre 0.05%
T1desonide lot 0.05%
T1desonide oin 0.05%
T1 QL (30 gram tube /fill)diflorasone cre 0.05%
T1 QL (30 gram tube /fill)diflorasone oin 0.05%
127Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
T1fluocin acet cre 0.01%
T1fluocin acet oil 0.01% sc (fluocinolone)
T1fluocin acet oil body (fluocinolone)
T1fluocin acet oil scalp (fluocinolone)
T1fluocin acet sol 0.01%
T1fluocinonide cre 0.05%
T1 PAfluocinonide cre 0.1%
T1fluocinonide gel 0.05%
T1fluocinonide oin 0.05%
T1fluocinonide sol 0.05%
T1fluticasone cre 0.05%
T1fluticasone lot 0.05%
T1fluticasone oin 0.005%
T1 QLgrx hicort sup 25mg (hydrocortisone)
T1halobetasol cre 0.05%
T1halobetasol oin 0.05%
T3 QL (30 grams/fill) betamethasone, clobetasol
HALOG CRE 0.1% (halcinonide)
T1 hc = hydrocortisonehc butyrate cre 0.1%
T1 hc = hydrocortisonehc butyrate oin 0.1%
T1 hc = hydrocortisonehc butyrate sol 0.1%
T1 QL hc = hydrocortisonehc pramoxine cre 1-2.5%
T1 QL hc = hydrocortisonehc pramoxine cre 2.5-1%
T1 hc = hydrocortisonehc valerate cre 0.2%
T1 hc = hydrocortisonehc valerate oin 0.2%
T1 QLhemorrhoidal sup -hc 25mg (hydrocortisone)
T1hydrocort cre 1% (hydrocortisone)
T1hydrocort cre 2.5%
T1hydrocort lot 2.5%
T1hydrocort oin 1%
T1hydrocort oin 2.5%
T1 QLhydrocort ac sup 25mg
T1hydrocort/ab oin 1%
128Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
T1 QLhydrocortiso cre 2.5%
T3KENALOG AER SPRAY (triamcinolone)
T1locoid cre 0.1% (hydrocortisone)
T1lokara lot 0.05% (desonide)
T1mometasone cre 0.1%
T1mometasone oin 0.1%
T1mometasone sol 0.1%
T1nystat/triam cre
T1nystat/triam oin
T1oralone pst 0.1% (triamcinolone)
T1prednicarbat cre 0.1%
T1 QLproctocare cre -hc 2.5% (hydrocortisone)
T1 QLprocto-pak cre 1% (hydrocortisone)
T1 QLproctosol hc cre 2.5% (hydrocortisone)
T1 QLproctozone cre -hc 2.5% (hydrocortisone)
T1proctozone cre -hc 2.5% (hydrocortisone)
T1 QLrectacort-hc sup 25mg (hydrocortisone)
T1scalacort lot 2% (hydrocortisone)
T1triamcin/ora pst 0.1%
T1triamcinolon aer spray
T1triamcinolon cre 0.025%
T1 QLtriamcinolon cre 0.1%
T1triamcinolon cre 0.5%
T1triamcinolon lot 0.025%
T1triamcinolon lot 0.1%
T1triamcinolon oin 0.025%
T1triamcinolon oin 0.1%
T1triamcinolon oin 0.5%
T1triamcinolon pst 0.1%
T1 QLtriderm cre 0.1% (triamcinolone)
ANTIPRURITICS AND LOCAL ANESTHETICS
T1 QLanecream cre 4% (lidocaine)
129Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTIPRURITICS AND LOCAL ANESTHETICS
T1 QLaspercreme cre lidocain (lidocaine)
T1 QLazo dine tab 95mg (phenazopyridine)
T1 QLazo dine tab max st (phenazopyridine)
T1 QLazo pain rel tab 95mg (phenazopyridine)
T1 QLazo tabs tab 95mg (phenazopyridine)
T1 QLazo urinary tab 97.5mg (phenazopyridine)
T1azo urinary tab 97.5mg (phenazopyridine)
T1 QLazo-standard tab 95mg (phenazopyridine)
T1glydo gel 2% (lidocaine)
T1 QLlc-4 lidocne cre 4% (lidocaine)
T1lido/prilocn cre 2.5-2.5%
T1lido/prilocn kit 2.5-2.5%
T1 QLlidocaine cre 3%
T1 QLlidocaine cre 4%
T1lidocaine gel 2%
T1lidocaine gel 2% jelly
T1 QLlidocaine oin 5%
T1lidocaine sol 4%
T1 QLlidocream cre 4% (lidocaine)
T1 QLlidopin cre 3% (lidocaine)
T1livixil pak kit 2.5-2.5% (lidocaine-prilocaine)
T1lp lite pak kit 2.5-2.5% (lidocaine-prilocaine)
T1 QLphenazo tab 200mg (phenazopyridine)
T1 QLphenazo tab 95mg (phenazopyridine)
T1 QLphenazopyrid tab 100mg
T1 QLphenazopyrid tab 200mg
T1 QLphenazopyrid tab 95mg
T1 QLphenazoyrid tab 95mg
T3PROZENA PAD 4% (lidocaine)
T1 QLqc azo tab 95mg (phenazopyridine)
T1 QLra urinary tab 95mg (phenazopyridine)
T1 QLra urinary tab pain max (phenazopyridine)
130Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTIPRURITICS AND LOCAL ANESTHETICS
T1relador pak kit 2.5-2.5% (lidocaine-prilocaine)
T1relador pak kit plus (lidocaine-prilocaine)
T1 QLsb urinary tab pain max (phenazopyridine)
T1 QLsm urinary tab pain max (phenazopyridine)
T1 QLurinary pain tab 95mg (phenazopyridine)
T1 QLurinary pain tab 97.5mg (phenazopyridine)
T1 QLuti relief tab 97.2mg (phenazopyridine)
ASTRINGENTS
T1hypercare sol 20% (aluminum)
CELL STIMULANTS AND PROLIFERANTS
T1 QL (45 gm/30 days)avita cre 0.025% (tretinoin)
T1 QL (45 gm/30 days)avita gel 0.025% (tretinoin)
T1 QL (45 gm/30 days)tretinoin cre 0.025%
T1 QL (45 gm/30 days)tretinoin cre 0.05%
T1 QL (45 gm/30 days)tretinoin cre 0.1%
T1 QL (45 gm/30 days)tretinoin gel 0.01%
T1 QL (45 gm/30 days)tretinoin gel 0.025%
T1tretinoin gel 0.05%
DEPIGMENTING AND PIGMENTING AGENTSPIGMENTING AGENTS
T2OXSORALEN LOT 1% (methoxsalen)
EMOLLIENTS, DEMULCENTS, AND PROTECTANTSBASIC LOTIONS AND LINIMENTS
T1ammonium lac cre 12%
T1ammonium lac lot 12%
T1laclotion lot 12% (lactic)
T1lactic acid lot 10%
KERATOLYTIC AGENTS
T1 QLavar cleanse emu 10-5% (sulfacetamide)
T1 QLbp 10-1 emu (sulfacetamide)
T1 QLcerisa wash emu 10-1% (sulfacetamide)
T1 QLprascion emu (sulfacetamide)
131Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSKERATOLYTIC AGENTS
T1 QLrosanil emu cleanser (sulfacetamide)
T1 QLsod sul/sulf emu 10-5%
T1urea cre 47%
SKIN AND MUCOUS MEMBRANE AGENTS, MISC.
T3 PA, QL (30gram /30 days) clindamycin, erythromycin
ACZONE GEL 5% (dapsone)
T1 QL (45 gram/ 30 days)adapalene cre 0.1%
T1 QL (45 gram/ 30 days)adapalene gel 0.1%
T1 QLadapalene gel 0.3%
MED PA, SP Medical coinsuranceAMEVIVE 15 MG VIAL (ALEFACEPT)
132Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSSKIN AND MUCOUS MEMBRANE AGENTS, MISC.
T3 fluorouracilPICATO GEL 0.015% (ingenol)
T3 fluorouracilPICATO GEL 0.05% (ingenol)
T1podofilox sol 0.5%
T3RECTIV OIN 0.4% (nitroglycerin)
T3 PA, QLREGRANEX GEL 0.01% (becaplermin)
T2SANTYL OIN 250/GM (collagenase)
MED PA, SP Medical coinsuranceSTELARA INJ 45MG/0.5 (ustekinumab)
T1 PAtacrolimus oin 0.03%
T1 PAtacrolimus oin 0.1%
T3 PA calcipotrieneTAZORAC CRE 0.05% (tazarotene)
T3 PA calcipotrieneTAZORAC CRE 0.1% (tazarotene)
T3 PA calcipotrieneTAZORAC GEL 0.05% (tazarotene)
T3 PA calcipotrieneTAZORAC GEL 0.1% (tazarotene)
T3 PA, QL (15gm/fill)VEREGEN OIN 15% (sinecatechins)
133Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
T3 QL (30 tabs/30 days), ST (Oxybutynin ER, tolterodine)
oxybutynin, tolterodine
MYRBETRIQ TAB 25MG (mirabegron)
T3 QL (30 tabs/30 days), ST (Oxybutynin ER, tolterodine)
oxybutynin, tolterodine
MYRBETRIQ TAB 50MG (mirabegron)
RESPIRATORY SMOOTH MUSCLE RELAXANTS
T1aminophyllin inj 25mg/ml
T3THEO-24 CAP 100MG CR (theophylline)
T3THEO-24 CAP 200MG CR (theophylline)
T3THEO-24 CAP 300MG CR (theophylline)
T3THEO-24 CAP 400MG ER (theophylline)
T1theochron tab 100mg cr (theophylline)
T1theochron tab 200mg cr (theophylline)
T1theochron tab 300mg cr (theophylline)
T1theophylline elx 80/15ml
T1theophylline tab 100mg cr (theophylline)
T1theophylline tab 100mg er
T1theophylline tab 200mg cr
T1theophylline tab 200mg er
T1theophylline tab 200mg sr
T1theophylline tab 300mg cr
T1theophylline tab 300mg er
T1theophylline tab 300mg sr
T1theophylline tab 400mg er
T1theophylline tab 450mg er (theophylline)
T1theophylline tab 600mg er
VITAMINSMULTIVITAMIN PREPARATIONS
T0 HCR Rules for Coverageprenatal multivit-min w/fe-fa tab
T0 HCR Rules for Coverageprenatal vit w/ ferrous fumarate-folic acid cap
134Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
VITAMINSMULTIVITAMIN PREPARATIONS
T0 HCR Rules for Coverageprenatal vit w/ ferrous fumarate-folic acid tab
T0 HCR Rules for Coverageprenatal vit w/ ferrous gluconate-folic acid tab
VITAMIN B COMPLEX
T1 QL (30 tabs/ 30 days)folic acid tab 1mg
T0 HCR Rules for Coveragefolic acid tab 400 mcg
T0 HCR Rules for Coveragefolic acid tab 800 mcg
VITAMIN D
T1calcitriol cap 0.25mcg
T1calcitriol cap 0.5mcg
T0 HCR Rules for Coveragecholecalciferol cap 1000 unit
T0 HCR Rules for Coveragecholecalciferol cap 10000 unit
T0 HCR Rules for Coveragecholecalciferol cap 2000 unit
T0 HCR Rules for Coveragecholecalciferol cap 400 unit
T0 HCR Rules for Coveragecholecalciferol cap 5000 unit
T0 HCR Rules for Coveragecholecalciferol cap 50000 unit
T0 HCR Rules for Coveragecholecalciferol chew 1000 unit
T0 HCR Rules for Coveragecholecalciferol chew 2000 unit
T0 HCR Rules for Coveragecholecalciferol chew 400 unit
T0 HCR Rules for Coveragecholecalciferol chew 5000 unit
T0 HCR Rules for Coveragecholecalciferol liqd 1000 unit/spray
T0 HCR Rules for Coveragecholecalciferol liqd 1200 unit/15ml
T0 HCR Rules for Coveragecholecalciferol liqd 2000 unt/0.03ml
T0 HCR Rules for Coveragecholecalciferol liqd 400 unit/ml
T0 HCR Rules for Coveragecholecalciferol liqd 400 unt/0.03ml
T0 HCR Rules for Coveragecholecalciferol liqd 5000 unit/ml
T0 HCR Rules for Coveragecholecalciferol tab 1000 unit
T0 HCR Rules for Coveragecholecalciferol tab 3000 unit
T0 HCR Rules for Coveragecholecalciferol tab 400 unit
T0 HCR Rules for Coveragecholecalciferol tab 5000 unit
T1doxercalcif cap 0.5mcg
T1doxercalcif cap 1mcg
T1doxercalcif cap 2.5mcg
135Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
VITAMINSVITAMIN D
T1 QL (30 caps/ 30 days)ergocalcifer cap 50000unt
T1 QL (60 caps/30 days)paricalcitol cap 1 mcg
T1paricalcitol cap 2 mcg
T1paricalcitol cap 4 mcg
T1 QL (28 tabs/28 days)vitamin d cap 50000unt
136Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Index
Drug Name Page # Drug Name Page #
89a/b sol otic
9abacav/lamiv tab /zidovud
9abacavir tab 300mg
75ABILIFY INJ 9.75MG
75ABILIFY SOL 1MG/ML
75ABILIFY TAB 10MG
75ABILIFY TAB 15MG
75ABILIFY TAB 20MG
75ABILIFY TAB 2MG
75ABILIFY TAB 30MG
75ABILIFY TAB 5MG
69acampro cal tab 333mg
97acarbose tab 100mg
97acarbose tab 25mg
97acarbose tab 50mg
33acebutolol cap 200mg
34acebutolol cap 400mg
87acetasol hc sol otic
85acetazolamid cap 500mg er
85acetazolamid tab 125mg
41acetazolamid tab 250mg
88acetic acid sol 2% otic
125acne medicat gel 10%
125acne medicat gel 5%
125acne pimple gel 10%
125acne treatmn gel 10%
125acne-clear gel 10%
116ACTEMRA INJ 162/0.9
116ACTEMRA INJ 200/10ML
116ACTEMRA INJ 400/20ML
116ACTEMRA INJ 80MG/4ML
126acticin cre 5%
114ACTIMMUNE INJ 2MU/0.5
115ACTONEL TAB 35MG
88ACUVAIL SOL 0.45%
13acyclovir cap 200mg
124acyclovir oin 5%
13acyclovir sus 200/5ml
13acyclovir tab 400mg
13acyclovir tab 800mg
132ACZONE GEL 5%
132adapalene cre 0.1%
132adapalene gel 0.1%
132adapalene gel 0.3%
46ADCIRCA TAB 20MG
13adefov dipiv tab 10mg
119ADEMPAS TAB 0.5MG
119ADEMPAS TAB 1.5MG
119ADEMPAS TAB 1MG
119ADEMPAS TAB 2.5MG
119ADEMPAS TAB 2MG
22ADVAIR DISKU AER 100/50
22ADVAIR DISKU AER 250/50
22ADVAIR DISKU AER 500/50
22ADVAIR HFA AER 115/21
22ADVAIR HFA AER 230/21
22ADVAIR HFA AER 45/21
25ADVATE INJ 1000UNIT
25ADVATE INJ 1500UNIT
25ADVATE INJ 2000UNIT
25ADVATE INJ 250UNIT
25ADVATE INJ 3000UNIT
25ADVATE INJ 500UNIT
32ADVICOR TAB 1000-20
32ADVICOR TAB 1000-40
32ADVICOR TAB 500-20MG
32ADVICOR TAB 750-20MG
38afeditab tab 30mg cr
38afeditab tab 60mg cr
14AFINITOR TAB 10MG
14AFINITOR TAB 2.5MG
14AFINITOR TAB 5MG
14AFINITOR TAB 7.5MG
121AFLURIA INJ 2015-16
121AFLURIA INJ PF 12-13
121AFLURIA INJ PF 13-14
121AFLURIA INJ PF 14-15
121AFLURIA INJ PF 15-16
101aftera tab 1.5mg
29AGGRENOX CAP 25-200MG
126ala cort cre 1%
1ALBENZA TAB 200MG
22albuterol neb 0.083%
23albuterol neb 0.5%
23albuterol neb 0.63mg/3
23albuterol neb 1.25mg/3
23albuterol syp 2mg/5ml
23albuterol tab 2mg
Drug Name Page # Drug Name Page #
23albuterol tab 4mg
23albuterol tab 4mg er
126alclometason cre 0.05%
126alclometason oin 0.05%
115alendronate tab 10mg
115alendronate tab 35mg
115alendronate tab 40mg
115alendronate tab 5mg
115alendronate tab 70mg
22alfuzosin tab 10mg
9ALINIA SUS 100/5ML
9ALINIA TAB 500MG
14ALKERAN TAB 2MG
114allopurinol tab 100mg
114allopurinol tab 300mg
64almotrip mal tab 12.5mg
64almotrip mal tab 6.25mg
64almotriptan tab 12.5mg
64almotriptan tab 6.25mg
84ALOCRIL SOL 2%
84ALOMIDE SOL 0.1% OP
25ALPHANATE 1,000-400 UNIT VIAL
25ALPHANATE 1,500-600 UNIT VIAL
25ALPHANATE 500-200 UNIT VIAL
25ALPHANATE INJ VWF/HUM
25ALPHANINE SD INJ 1000UNIT
25ALPHANINE SD INJ 1500UNIT
126alphatrex gel 0.05%
68alprazolam tab 0.25 odt
68alprazolam tab 0.25mg
68alprazolam tab 0.5mg
68alprazolam tab 0.5mg er
68alprazolam tab 0.5mg od
68alprazolam tab 0.5mg xr
68alprazolam tab 1mg
68alprazolam tab 1mg er
68alprazolam tab 1mg odt
68alprazolam tab 1mg xr
68alprazolam tab 2mg
68alprazolam tab 2mg er
68alprazolam tab 2mg odt
68alprazolam tab 2mg xr
68alprazolam tab 3mg er
68alprazolam tab 3mg xr
87ALREX SUS 0.2%
122ALTABAX OIN 1%
89altacaine sol 0.5% op
89altafrin sol 10% op
89altafrin sol 2.5% op
101altavera tab
94ALVESCO AER 160MCG
94ALVESCO AER 80MCG
101alyacen tab 1/35
101alyacen tab 7/7/7
64amantadine cap 100mg
64amantadine syp 50mg/5ml
64amantadine tab 100mg
126amcinonide cre 0.1%
126amcinonide lot 0.1%
126amcinonide oin 0.1%
101amethia lo tab
101amethia tab
101amethyst tab 90-20mcg
132AMEVIVE 15 MG VIAL
81amilor/hctz tab 5-50
81amiloride tab 5mg
134aminophyllin inj 25mg/ml
39amiodarone tab 200mg
39amiodarone tab 400mg
93AMITIZA CAP 24MCG
93AMITIZA CAP 8MCG
70amitriptylin tab 100mg
70amitriptylin tab 10mg
70amitriptylin tab 150mg
70amitriptylin tab 25mg
70amitriptylin tab 50mg
70amitriptylin tab 75mg
38amlod/benazp cap 10-20mg
38amlod/benazp cap 10-40mg
38amlod/benazp cap 2.5-10mg
38amlod/benazp cap 5-10mg
38amlod/benazp cap 5-20mg
38amlod/benazp cap 5-40mg
38amlod/valsar tab /hctz
38amlodipine tab 10mg
38amlodipine tab 2.5mg
38amlodipine tab 5mg
131ammonium lac cre 12%
131ammonium lac lot 12%
4amox/k clav chw 200mg
4amox/k clav chw 400mg
4amox/k clav sus 200/5ml
4amox/k clav sus 250/5ml
4amox/k clav sus 400/5ml
Drug Name Page # Drug Name Page #
4amox/k clav sus 600/5ml
4amox/k clav tab 250mg
4amox/k clav tab 500mg
4amox/k clav tab 875mg
71amoxapine tab 100mg
71amoxapine tab 150mg
71amoxapine tab 25mg
71amoxapine tab 50mg
4amoxicillin cap 250mg
4amoxicillin cap 500mg
4amoxicillin chw 125mg
4amoxicillin chw 250mg
4amoxicillin sus 125/5ml
4amoxicillin sus 200/5ml
5amoxicillin sus 250/5ml
5amoxicillin sus 250mg/5m
5amoxicillin sus 400/5ml
5amoxicillin tab 500mg
5amoxicillin tab 875mg
5amox-pot cla tab er
54amphetamine cap 10mg er
54amphetamine cap 15mg er
54amphetamine cap 20mg er
54amphetamine cap 25mg er
54amphetamine cap 30mg er
54amphetamine cap 5mg er
55amphetamine tab 10mg
55amphetamine tab 12.5mg
55amphetamine tab 15mg
55amphetamine tab 20mg
55amphetamine tab 30mg
55amphetamine tab 5mg
55amphetamine tab 7.5mg
5ampicillin cap 250mg
5ampicillin cap 500mg
5ampicillin sus 125/5ml
5ampicillin sus 250/5ml
118AMPYRA TAB 10MG
29anagrelide cap 0.5mg
29anagrelide cap 1mg
14anastrozole tab 1mg
96ANDROGEL GEL 1%(25MG)
97ANDROGEL GEL 1.62%
97ANDROGEL GEL PUMP 1%
129anecream cre 4%
18ANORO ELLIPT AER 62.5-25
87antibiot ear sol 1% otic
89antipy/benzo sol otic
126anucort-hc sup 25mg
90ANZEMET TAB 100MG
90ANZEMET TAB 50MG
49apap/caff/di tab hydrocod
49apap/codeine sol 120-12/5
49apap/codeine tab 300-15mg
49apap/codeine tab 300-30mg
49apap/codeine tab 300-60mg
126APEXICON E CRE 0.05%
98APIDRA INJ SOLOSTAR
98APIDRA INJ U-100
88apraclonidin sol 0.5% op
101apri tab
9APTIVUS CAP 250MG
9APTIVUS SOL
101aranelle tab
29ARANESP INJ 100MCG
30ARANESP INJ 10MCG
30ARANESP INJ 150MCG
30ARANESP INJ 200MCG
30ARANESP INJ 25MCG
30ARANESP INJ 300MCG
30ARANESP INJ 40MCG
30ARANESP INJ 500MCG
30ARANESP INJ 60MCG
118ARCALYST INJ 220MG
23ARCAPTA CAP 75MCG
75aripiprazole tab 10mg
76aripiprazole tab 15mg
76aripiprazole tab 20mg
76aripiprazole tab 2mg
76aripiprazole tab 30mg
76aripiprazole tab 5mg
110ARMOUR THYRO TAB 120MG
110armour thyro tab 120mg
110ARMOUR THYRO TAB 15MG
110armour thyro tab 180mg
110ARMOUR THYRO TAB 180MG
110ARMOUR THYRO TAB 240MG
110ARMOUR THYRO TAB 300MG
110ARMOUR THYRO TAB 30MG
110armour thyro tab 30mg
110armour thyro tab 60mg
110ARMOUR THYRO TAB 60MG
110ARMOUR THYRO TAB 90MG
49asa/caff/but cap cod 30mg
Drug Name Page # Drug Name Page #
49ascomp/cod cap 30mg
101ashlyna tab
94ASMANEX 120 AER 220MCG
94ASMANEX 30 AER 110MCG
94ASMANEX 30 AER 220MCG
94ASMANEX 60 AER 220MCG
94ASMANEX 7 AER 110MCG
94ASMANEX HFA AER 100 MCG
95ASMANEX HFA AER 200 MCG
130aspercreme cre lidocain
46aspirin chew 81 mg
46aspirin chew 81 mg
46aspirin tab 324 mg
46aspirin tab 325 mg
46aspirin tab 325 mg
46aspirin tab 81 mg
46aspirin tab 81 mg
34atenol/chlor tab 100-25mg
34atenol/chlor tab 50-25mg
34atenolol tab 100mg
34atenolol tab 25mg
34atenolol tab 50mg
32atorvastatin tab 10mg
32atorvastatin tab 20mg
32atorvastatin tab 40mg
32atorvastatin tab 80mg
8atovaq/progu tab 250-100
8atovaq/progu tab 62.5-25
9atovaquone sus 750/5ml
9ATRIPLA TAB
89atropin-care sol 1% op
18atropine sul inj 0.05mg/1
18atropine sul inj 0.1mg/ml
18atropine sul inj 0.4/0.5
89atropine sul oin 1% op
89atropine sul sol 1% op
18ATROVENT HFA AER 17MCG
114AUBAGIO TAB 14MG
114AUBAGIO TAB 7MG
101aubra tab 0.1-0.02
127aug betamet cre 0.05%
127aug betamet gel 0.05%
127aug betamet lot 0.05%
127aug betamet oin 0.05%
89aurodex sol otic
89auroguard sol otic
100AVANDIA TAB 2MG
100AVANDIA TAB 4MG
100AVANDIA TAB 8MG
131avar cleanse emu 10-5%
101aviane tab
131avita cre 0.025%
131avita gel 0.025%
114AVONEX KIT 30MCG
114AVONEX PEN KIT 30MCG
114AVONEX PREFL KIT 30MCG
86AZASITE SOL 1%
117azathioprine tab 50mg
84azelastine dro 0.05%
84azelastine spr 0.1%
84azelastine spr 0.15%
66AZILECT TAB 0.5MG
66AZILECT TAB 1MG
3azithromycin pow 1gm pak
3azithromycin sus 100/5ml
3azithromycin sus 200/5ml
3azithromycin tab 250mg
3azithromycin tab 500mg
3azithromycin tab 600mg
130azo dine tab 95mg
130azo dine tab max st
130azo pain rel tab 95mg
130azo tabs tab 95mg
130azo urinary tab 97.5mg
130azo urinary tab 97.5mg
85AZOPT SUS 1% OP
130azo-standard tab 95mg
101azurette tab 28 day
2baciim inj 50000unt
2bacitracin inj 50000unt
86bacitracin oin op
21baclofen tab 10mg
22baclofen tab 20mg
122BACTROBAN OIN NASAL 2%
91balsalazide cap 750mg
101balziva tab
57BANZEL TAB 200MG
57BANZEL TAB 400MG
13BARACLUDE SOL .05MG/ML
95baycadron elx 0.5/5ml
46BAYER CHILD CHW ASA 81MG
25BEBULIN INJ 200-1200
25BEBULIN VH IMMU 200-1,200 UNIT
87BECONASE AQ SUS 0.042%
Drug Name Page # Drug Name Page #
55BELVIQ TAB 10MG
43benazep/hctz tab 10-12.5
43benazep/hctz tab 20-12.5
43benazep/hctz tab 20-25mg
43benazep/hctz tab 5-6.25
43benazepril tab 10mg
43benazepril tab 20mg
43benazepril tab 40mg
43benazepril tab 5mg
25BENEFIX INJ 1000UNIT
25BENEFIX INJ 2000UNIT
25BENEFIX INJ 250UNIT
25BENEFIX INJ 500UNIT
117BENLYSTA INJ 120MG
117BENLYSTA INJ 400MG
125benzepro aer 5.3%
125benzepro liq creamy
125benzepro sc aer 9.8%
125benziq wash liq 5.25%
118benzonatate cap 100mg
118benzonatate cap 150mg
118benzonatate cap 200mg
125benzoyl per aer 5.3%
125benzoyl per aer 9.8%
125benzoyl per gel 10%
125benzoyl per gel 5%
125benzoyl per liq 10% wash
125benzoyl pero aer 9.8%
125benzoyl pero kit acne pck
55benzphetamin tab 50mg
65benztropine tab 0.5mg
19benztropine tab 1mg
19benztropine tab 2mg
84BEPREVE DRO 1.5%
115BERINERT INJ 500UNIT
86BESIVANCE SUS 0.6%
127beta diprop gel 0.05%
127betameth dip cre 0.05%
127betameth dip lot 0.05%
127betameth dip oin 0.05%
127betameth val cre 0.1%
127betameth val lot 0.1%
127betameth val oin 0.1%
114BETASERON INJ 0.3MG
85betaxolol sol 0.5% op
34betaxolol tab 10mg
34betaxolol tab 20mg
85BETOPTIC-S SUS 0.25% OP
14bexarotene cap 75mg
121BEXSERO INJ
14bicalutamide tab 50mg
34bisoprl/hctz tab 10/6.25
34bisoprl/hctz tab 2.5/6.25
34bisoprl/hctz tab 5-6.25mg
34bisoprol fum tab 10mg
34bisoprol fum tab 5mg
120BIVIGAM INJ 10%
87BLEPHAMIDE SUS LIQUIFLM
87BLEPHAMIDE SUS OP
14BOSULIF TAB 100MG
14BOSULIF TAB 500MG
131bp 10-1 emu
125bp foam aer 5.3%
125bp foam aer 9.8%
125bp foaming liq wash 10%
125bp gel gel 10%
125bp gel gel 5%
125bp wash liq 2.5%
125bp wash liq 7%
125bpo gel 4%
125bpo gel 8%
125bpo creamy kit 4% wash
125bpo creamy kit 8% wash
101briellyn tab
29BRILINTA TAB 60MG
29BRILINTA TAB 90MG
84brimonidine sol 0.15%
85brimonidine sol 0.2% op
88bromfenac sol 0.09%
88bromfenac sol 0.09% op
65bromocriptin cap 5mg
65bromocriptin tab 2.5mg
23BROVANA NEB 15MCG
71budeprion tab 100mg sr
71budeprion tab 150mg sr
95budesonide cap 3mg/24hr
95budesonide sus 0.25mg/2
95budesonide sus 0.5mg/2
95budesonide sus 1mg/2ml
87budesonide sus 32mcg
80bumetanide inj 0.25/ml
80bumetanide tab 0.5mg
80bumetanide tab 1mg
80bumetanide tab 2mg
Drug Name Page # Drug Name Page #
80BUPHENYL TAB 500MG
54bupren/nalox sub 2-0.5mg
54bupren/nalox sub 8-2mg
54buprenorphin inj 0.3mg/ml
54buprenorphin sub 2mg
54buprenorphin sub 8mg
71bupropion hcl (smoking deterrent) tab 150 mg
71bupropion tab 100mg
71bupropion tab 100mg er
71bupropion tab 100mg sr
71bupropion tab 150mg er
71bupropion tab 150mg sr
71bupropion tab 200mg er
71bupropion tab 200mg sr
71bupropion tab 75mg
71bupropn hcl tab 150mg xl
71bupropn hcl tab 300mg xl
67buspirone tab 10mg
67buspirone tab 15mg
67buspirone tab 30mg
67buspirone tab 5mg
67buspirone tab 7.5mg
46but/apap/caf cap
49but/apap/caf cap codeine
46but/apap/caf tab
49but/asa/caf/ cap cod 30mg
47but/asa/caff cap
47but/asa/caff tab
49butal cpd/ cap codeine
54butorphanol inj 1mg/ml
54butorphanol sol 10mg/ml
54BUTRANS DIS 10MCG/HR
54BUTRANS DIS 15MCG/HR
54BUTRANS DIS 20MCG/HR
54BUTRANS DIS 5MCG/HR
54BUTRANS DIS 7.5/HR
98BYDUREON INJ
98BYDUREON INJ
98BYETTA INJ 5MCG
34BYSTOLIC TAB 10MG
34BYSTOLIC TAB 2.5MG
34BYSTOLIC TAB 20MG
34BYSTOLIC TAB 5MG
65cabergoline tab 0.5mg
82calc acetate cap 667mg
132calcipotrien cre 0.005%
132calcipotrien oin 0.005%
132calcipotrien sol 0.005%
132calcitrene oin 0.005%
135calcitriol cap 0.25mcg
135calcitriol cap 0.5mcg
132calcitriol oin 3mcg/gm
101camila tab 0.35mg
101camrese lo tab
101camrese tab
91CANASA SUP 1000MG
41candesa/hctz tab 16-12.5
41candesa/hctz tab 32-12.5
42candesa/hctz tab 32-25mg
42candesartan tab 16mg
42candesartan tab 32mg
42candesartan tab 4mg
42candesartan tab 8mg
14capecitabine tab 150mg
14capecitabine tab 500mg
127CAPEX SHA 0.01%
15CAPRELSA TAB 100MG
15CAPRELSA TAB 300MG
43captopr/hctz tab 25-15mg
43captopr/hctz tab 25-25mg
43captopr/hctz tab 50-15mg
43captopr/hctz tab 50-25mg
43captopril tab 100mg
43captopril tab 12.5mg
43captopril tab 25mg
43captopril tab 50mg
92CARAFATE SUS 1GM/10ML
65carb/levo 50 tab /entacap
65carb/levo 75 tab /entacap
65carb/levo er tab 25-100mg
65carb/levo er tab 50-200mg
65carb/levo sr tab 50-200mg
65carb/levo tab 10-100mg
65carb/levo tab 25-250mg
65carb/levo100 tab /entacap
65carb/levo125 tab /entacap
65carb/levo150 tab /entacap
65carb/levo200 tab /entacap
57carbamazepin cap 100mg er
58carbamazepin cap 200mg er
58carbamazepin cap 300mg er
58carbamazepin chw 100mg
58carbamazepin sus 100/5ml
Drug Name Page # Drug Name Page #
58carbamazepin tab 200mg
58carbamazepin tab 200mg er
58carbamazepin tab 400mg er
65carbidopa tab 25mg
24carbonyl iron chew 15 mg
24carbonyl iron suspension 15 mg/1.25ml
31CARDURA XL TAB 4MG
120carimune nf inj 12gm
120carimune nf inj 3gm
120carimune nf inj 6gm
21carisopr/asa tab 200-325
21carisoprodol tab 250mg
21carisoprodol tab 350mg
21carisoprodol tab asa/cod
85carteolol sol 1% op
36cartia xt cap 120/24hr
36cartia xt cap 180/24hr
36cartia xt cap 240/24hr
36cartia xt cap 300/24hr
34carvedilol tab 12.5mg
34carvedilol tab 25mg
34carvedilol tab 3.125mg
34carvedilol tab 6.25mg
4CAYSTON INH 75MG
101caziant pak
2CEDAX CAP 400MG
2cefaclor cap 250mg
2cefaclor cap 500mg
2cefaclor er tab 500mg
2cefadroxil cap 500mg
2cefadroxil sus 250/5ml
2cefadroxil sus 500/5ml
2cefadroxil tab 1gm
2cefdinir cap 300mg
2cefdinir sus 125/5ml
2cefdinir sus 250/5ml
2cefditoren tab 200mg
2cefditoren tab 400mg
3cefixime sus 100/5ml
3cefixime sus 200/5ml
3cefpodo prox sus 100/5ml
3cefpodo prox sus 50mg/5ml
3cefpodoxime tab 100mg
3cefpodoxime tab 200mg
3cefprozil sus 125/5ml
3cefprozil sus 250/5ml
3cefprozil tab 250mg
3cefprozil tab 500mg
3cefuroxime tab 250mg
3cefuroxime tab 500mg
47celecoxib cap 100mg
47celecoxib cap 200mg
47celecoxib cap 400mg
47celecoxib cap 50mg
63CELONTIN CAP 300MG
106CENESTIN TAB 0.3MG
106CENESTIN TAB 0.45MG
106CENESTIN TAB 0.625MG
106CENESTIN TAB 0.9MG
106CENESTIN TAB 1.25MG
3cephalexin cap 250mg
3cephalexin cap 500mg
3cephalexin cap 750mg
3cephalexin sus 125/5ml
3cephalexin sus 250/5ml
131cerisa wash emu 10-1%
90CESAMET CAP 1MG
101cesia pak
117CETROTIDE KIT 0.25MG
20cevimeline cap 30mg
19CHANTIX PAK 0.5& 1MG
19CHANTIX PAK 1MG
19CHANTIX TAB 0.5MG
19CHANTIX TAB 1MG
101chateal tab 0.15/30
94CHEMET CAP 100MG
118chlor/phen dro dm
19chlord/clidi cap 5-2.5mg
68chlordiazep cap 10mg
68chlordiazep cap 25mg
68chlordiazep cap 5mg
87chlorhex glu sol 0.12%
82chloromag inj 20%
113chloroproc inj 2%
113chloroproc inj 3%
8chloroquine tab 250mg
8chloroquine tab 500mg
81chlorothiaz tab 250mg
81chlorothiaz tab 500mg
76chlorpromaz inj 25mg/ml
76chlorpromaz inj 50mg/2ml
76chlorpromaz tab 100mg
76chlorpromaz tab 10mg
76chlorpromaz tab 200mg
Drug Name Page # Drug Name Page #
76chlorpromaz tab 25mg
76chlorpromaz tab 50mg
99chlorpropam tab 100mg
99chlorpropam tab 250mg
81chlorthalid tab 100mg
81chlorthalid tab 25mg
81chlorthalid tab 50mg
21chlorzoxazon tab 500mg
47cho mag tris liq 500/5ml
47cho mag tris tab 1000mg
135cholecalciferol cap 1000 unit
135cholecalciferol cap 10000 unit
135cholecalciferol cap 2000 unit
135cholecalciferol cap 400 unit
135cholecalciferol cap 5000 unit
135cholecalciferol cap 50000 unit
135cholecalciferol chew 1000 unit
135cholecalciferol chew 2000 unit
135cholecalciferol chew 400 unit
135cholecalciferol chew 5000 unit
135cholecalciferol liqd 1000 unit/spray
135cholecalciferol liqd 1200 unit/15ml
135cholecalciferol liqd 2000 unt/0.03ml
135cholecalciferol liqd 400 unit/ml
135cholecalciferol liqd 400 unt/0.03ml
135cholecalciferol liqd 5000 unit/ml
135cholecalciferol tab 1000 unit
135cholecalciferol tab 3000 unit
135cholecalciferol tab 400 unit
135cholecalciferol tab 5000 unit
31cholestyram pow 4gm
31cholestyram pow 4gm lite
108chor gonadot inj 10000unt
46CIALIS TAB 5MG
123ciclodan cre 0.77%
123ciclodan sol 8%
123ciclopirox cre 0.77%
123ciclopirox gel 0.77%
123ciclopirox sha 1%
123ciclopirox sol 8%
123ciclopirox sus 0.77%
29cilostazol tab 100mg
29cilostazol tab 50mg
86CILOXAN OIN 0.3% OP
91cimetidine tab 200mg
91cimetidine tab 300mg
91cimetidine tab 400mg
91cimetidine tab 800mg
116CIMZIA KIT
116CIMZIA KIT STARTER
116CIMZIA PREFL KIT 200MG/ML
115CINRYZE SOL 500 UNIT
87CIPRO HC SUS OTIC
87CIPRODEX SUS 0.3-0.1%
86ciprofloxacn sol 0.2%
86ciprofloxacn sol 0.3% op
5ciprofloxacn sus 250mg/5
5ciprofloxacn sus 500mg/5
5ciprofloxacn tab 1000mg
5ciprofloxacn tab 100mg
5ciprofloxacn tab 250mg
5ciprofloxacn tab 500mg
5ciprofloxacn tab 500mg er
5ciprofloxacn tab 750mg
71citalopram sol 10mg/5ml
71citalopram tab 10mg
71citalopram tab 20mg
71citalopram tab 40mg
132claravis cap 10mg
132claravis cap 20mg
132claravis cap 30mg
132claravis cap 40mg
3clarithromyc sus 125/5ml
3clarithromyc sus 250/5ml
3clarithromyc tab 250mg
4clarithromyc tab 500mg
4clarithromyc tab 500mg er
125clearplex v gel 5%
125clearplex x gel 10%
1clemastine syp 0.5/5ml
1clemastine tab 2.68mg
19clidi/chlord cap 2.5-5mg
106CLIMARA PRO DIS WEEKLY
122clindacin mis etz 1%
122clindacin-p pad 1%
122clindamax gel 1%
122clindamax lot 10mg/ml
122clindamy/ben gel 1.2-5%
122clindamy/ben gel 1-5%
2clindamycin cap 150mg
2clindamycin cap 300mg
2clindamycin cap 75mg
122clindamycin cre 2% vag
123clindamycin gel 1%
Drug Name Page # Drug Name Page #
123clindamycin lot 1%
123clindamycin lot 10mg/ml
123clindamycin pad 1%
123clindamycin sol 1%
2clindamycin sol 75mg/5ml
127clobetasol aer 0.05%
127clobetasol cre 0.05%
127clobetasol e cre 0.05%
127clobetasol gel 0.05%
127clobetasol lot 0.05%
127clobetasol oin 0.05%
127clobetasol sha 0.05%
127clobetasol sol 0.05%
127clodan sha 0.05%
127CLODERM CRE 0.1%
127CLODERM CRE 0.1% PMP
106clomiphene tab 50mg
71clomipramine cap 25mg
71clomipramine cap 50mg
71clomipramine cap 75mg
62clonazep odt tab 0.125mg
62clonazep odt tab 0.25mg
62clonazep odt tab 0.5mg
62clonazep odt tab 1mg
62clonazep odt tab 2mg
62clonazepam tab 0.5mg
62clonazepam tab 1mg
62clonazepam tab 2mg
41clonidine dis 0.1/24hr
41clonidine dis 0.2/24hr
41clonidine dis 0.3/24hr
41clonidine tab 0.1mg
41clonidine tab 0.2mg
41clonidine tab 0.3mg
29clopidogrel tab 300mg
29clopidogrel tab 75mg
68cloraz dipot tab 15mg
68cloraz dipot tab 3.75mg
68cloraz dipot tab 7.5mg
124clotrim/beta cre 1-0.05%
124clotrim/beta cre diprop
124clotrim/beta lot diprop
124clotrimazole cre 1%
124clotrimazole loz 10mg
124clotrimazole tro 10mg
76clozapine tab 100mg
76clozapine tab 200mg
76clozapine tab 25mg
76clozapine tab 50mg
8COARTEM TAB 20-120MG
49codeine sulf tab 15mg
49codeine sulf tab 30mg
49codeine sulf tab 60mg
49codeine/apap tab 15-300mg
49codeine/apap tab 30-300mg
49codeine/apap tab 60-300mg
114colchicine cap 0.6mg
113colchicine tab 0.6mg
31colestipol gra 5gm
31colestipol tab 1gm
87COLY-MYCIN S SUS OTIC
85COMBIGAN SOL 0.2/0.5%
106COMBIPATCH DIS .05/.14
106COMBIPATCH DIS .05/.25
23COMBIVENT AER RESPIMAT
15COMETRIQ KIT 100MG
15COMETRIQ KIT 140MG
15COMETRIQ KIT 60MG
76compazine sup 25mg
9COMPLERA TAB
76compro sup 25mg
80constulose sol 10gm/15
114COPAXONE INJ 20MG/ML
127CORDRAN CRE 0.05%
25CORIFACT KIT
127cormax scalp sol 0.05%
95cortisone ac tab 25mg
127CORTISPORIN CRE 0.5%
87CORTISPORIN SUS -TC OTIC
27coumadin tab 10mg
28coumadin tab 1mg
28coumadin tab 2.5mg
28coumadin tab 2mg
28coumadin tab 3mg
28coumadin tab 4mg
28coumadin tab 5mg
28coumadin tab 6mg
28coumadin tab 7.5mg
93CREON CAP 12000UNT
93CREON CAP 24000UNT
93CREON CAP 3000UNIT
93CREON CAP 36000UNT
93CREON CAP 6000UNIT
32CRESTOR TAB 10MG
Drug Name Page # Drug Name Page #
32CRESTOR TAB 20MG
32CRESTOR TAB 40MG
32CRESTOR TAB 5MG
109CRINONE GEL 4% VAG
109CRINONE GEL 8% VAG
9CRIXIVAN CAP 200MG
9CRIXIVAN CAP 400MG
9CRIXIVAN 100 MG CAPSULE
118cromolyn sod con 100/5ml
84cromolyn sod sol 4% op
101cryselle-28 tab 28 tabs
94CUPRIMINE CAP 250MG
102cyclafem tab 1/35
102cyclafem tab 7/7/7
21cyclobenzapr tab 10mg
21cyclobenzapr tab 5mg
89cyclopentol sol 1% op
89cyclopentol sol 2% op
15cyclophosph cap 25mg
15cyclophosph tab 25mg
15cyclophosph tab 50mg
8cycloserine cap 250mg
97CYCLOSET TAB 0.8MG
117cyclosporine cap 100mg
117cyclosporine cap 100mg md
117cyclosporine cap 25mg
117cyclosporine cap 25mg mod
117cyclosporine cap 50mg mod
1cyproheptad syp 2mg/5ml
1cyproheptad tab 4mg
102cyred tab
118CYSTAGON CAP 150MG
118CYSTAGON CAP 50MG
80cytra-k sol
119DALIRESP TAB 500MCG
97danazol cap 100mg
97danazol cap 200mg
97danazol cap 50mg
21dantrolene cap 100mg
21dantrolene cap 25mg
21dantrolene cap 50mg
8dapsone tab 100mg
8dapsone tab 25mg
9DARAPRIM TAB 25MG
102dasetta tab 1/35
102dasetta tab 7/7/7
102daysee tab
56DAYTRANA DIS 10MG/9HR
56DAYTRANA DIS 15MG/9HR
56DAYTRANA DIS 20MG/9HR
56DAYTRANA DIS 30MG/9HR
102deblitane tab 0.35mg
95deltasone tab 20mg
102delyla tab 0.1-0.02
91DELZICOL CAP 400MG
6demeclocycl tab 150mg
6demeclocycl tab 300mg
125DENAVIR CRE 1%
94DEPEN TITRA TAB 250MG
109DEPO-PROVERA INJ 400/ML
71desipramine tab 100mg
71desipramine tab 10mg
71desipramine tab 150mg
71desipramine tab 25mg
71desipramine tab 50mg
71desipramine tab 75mg
1desloratadin tab 5mg
108desmopressin sol 0.01%
108desmopressin tab 0.1mg
108desmopressin tab 0.2mg
102deso/ethinyl tab estradio
127DESONATE GEL 0.05%
127desonide cre 0.05%
127desonide lot 0.05%
127desonide oin 0.05%
71desvenlafax tab 100mg er
72desvenlafax tab 50mg er
87dexameth pho sol 0.1% op
95DEXAMETHASON CON 1MG/ML
95dexamethason elx 0.5/5ml
95dexamethason sol 0.5/5ml
95dexamethason tab 0.5mg
95dexamethason tab 0.75mg
95dexamethason tab 1.5mg
95dexamethason tab 1mg
95dexamethason tab 2mg
95dexamethason tab 4mg
95dexamethason tab 6mg
1dexchlorphen syp 2mg/5ml
55dexedrine tab 10mg
55dexedrine tab 5mg
56dexmethylph cap 15mg er
56dexmethylph cap 30mg er
56dexmethylph cap 40mg er
Drug Name Page # Drug Name Page #
56dexmethylph tab 10mg
56dexmethylph tab 2.5mg
56dexmethylph tab 5mg
56dexmethylphe cap 10mg er
56dexmethylphe cap 20mg er
56dexmethylphe cap 5mg er
55dextroamphet cap 10mg er
55dextroamphet cap 15mg er
55dextroamphet cap 5mg er
55dextroamphet tab 10mg
55dextroamphet tab 5mg
68diazepam gel 10mg
68diazepam gel 2.5mg
68diazepam gel 20mg
69diazepam inj 5mg/ml
69diazepam sol 1mg/ml
69diazepam sol 5mg/5ml
69diazepam tab 10mg
69diazepam tab 2mg
69diazepam tab 5mg
90DICLEGIS TAB 10-10MG
47diclo/misopr tab 50-0.2mg
47diclo/misopr tab 75-0.2mg
47diclofen pot tab 50mg
88diclofenac sol 0.1% op
47diclofenac tab 100mg er
47diclofenac tab 100mg xr
47diclofenac tab 25mg dr
47diclofenac tab 50mg dr
47diclofenac tab 75mg dr
5dicloxacill cap 250mg
5dicloxacill cap 500mg
19dicyclomine cap 10mg
19dicyclomine sol 10mg/5ml
19dicyclomine tab 20mg
9didanosine cap 125mg
9didanosine cap 200mg
9didanosine cap 250mg
9didanosine cap 400mg
55diethylprop tab 75mg er
4DIFICID TAB 200MG
127diflorasone cre 0.05%
127diflorasone oin 0.05%
47diflunisal tab 500mg
40digitek tab 0.125mg
40digitek tab 0.25mg
40digox tab 0.125mg
40digox tab 0.25mg
40digoxin inj 0.25mg/1
40digoxin sol 50mcg/ml
40digoxin tab 0.125mg
40digoxin tab 0.25mg
63DILANTIN CAP 30MG
63DILANTIN CHW 50MG
63DILANTIN-125 SUS 125/5ML
36dilt-cd cap 120mg
36dilt-cd cap 180mg
36dilt-cd cap 240mg
36dilt-cd cap 300mg
36diltiazem cap 120mg cd
36diltiazem cap 120mg er
36diltiazem cap 120mg er
36diltiazem cap 180mg cd
36diltiazem cap 180mg er
36diltiazem cap 180mg er
36diltiazem cap 180mg/24
36diltiazem cap 240mg cd
36diltiazem cap 240mg er
36diltiazem cap 240mg er
36diltiazem cap 240mg/24
36diltiazem cap 300mg cd
36diltiazem cap 300mg er
36diltiazem cap 300mg/24
36diltiazem cap 360mg cd
36diltiazem cap 360mg er
36diltiazem cap 360mg/24
36diltiazem cap 420mg/24
36diltiazem cap 60mg er
36diltiazem cap 90mg er
37diltiazem er tab 180mg
37diltiazem er tab 240mg
37diltiazem er tab 300mg
37diltiazem er tab 360mg
37diltiazem er tab 420mg
36diltiazem tab 120mg
36diltiazem tab 30mg
36diltiazem tab 60mg
37diltiazem tab 90mg
37dilt-xr cap 120mg
37dilt-xr cap 180mg
37dilt-xr cap 240mg
37diltzac cap 180mg/24
37diltzac cap 240mg/24
37diltzac cap 300mg/24
Drug Name Page # Drug Name Page #
37diltzac cap 360mg/24
91DIPENTUM CAP 250MG
90diphen/atrop liq 2.5/5
90diphen/atrop tab 2.5mg
90diphenatol tab 2.5mg
46dipyridamole inj 5mg/ml
46dipyridamole tab 25mg
46dipyridamole tab 50mg
46dipyridamole tab 75mg
39disopyramide cap 100mg
39disopyramide cap 150mg
114disulfiram tab 250mg
114disulfiram tab 500mg
58divalproex cap 125mg
58divalproex tab 125mg dr
58divalproex tab 250mg dr
58divalproex tab 250mg er
58divalproex tab 500mg dr
58divalproex tab 500mg er
106DIVIGEL GEL 0.25MG
106DIVIGEL GEL 0.5MG
106DIVIGEL GEL 1MG/GM
119dm/cpm/pe dro
20donepezil tab 10mg
20donepezil tab 10mg odt
20donepezil tab 5mg
20donepezil tab 5mg odt
85dorzol/timol sol 22.3-6.8
85dorzolamide sol 2% op
31doxazosin tab 1mg
31doxazosin tab 2mg
31doxazosin tab 4mg
31doxazosin tab 8mg
72doxepin hcl cap 100mg
72doxepin hcl cap 10mg
72doxepin hcl cap 150mg
72doxepin hcl cap 25mg
72doxepin hcl cap 50mg
72doxepin hcl cap 75mg
72doxepin hcl con 10mg/ml
135doxercalcif cap 0.5mcg
135doxercalcif cap 1mcg
135doxercalcif cap 2.5mcg
6doxycyc mono cap 100mg
6doxycycl hyc cap 100mg
6doxycycl hyc cap 50mg
6doxycycl hyc tab 100mg
90dronabinol cap 10mg
90dronabinol cap 2.5mg
90dronabinol cap 5mg
102drospir/ethi tab 3-0.03mg
102drospirenone tab ethy est
15DROXIA CAP 200MG
15DROXIA CAP 300MG
15DROXIA CAP 400MG
95DULERA AER 100-5MCG
95DULERA AER 200-5MCG
72duloxetine cap 20mg
72duloxetine cap 30mg
72duloxetine cap 60mg
49duramorph inj 0.5mg/ml
49duramorph inj 1mg/ml
87DUREZOL EMU 0.05%
113Dutasteride 0.5MG
81DYRENIUM CAP 100MG
81DYRENIUM CAP 50MG
4e.e.s. 400 tab 400mg
4E.E.S. GRAN SUS 200/5ML
124econazole cre 1%
102econtra ez tab 1.5mg
42EDARBI TAB 40MG
42EDARBI TAB 80MG
80EDECRIN TAB 25MG
10EDURANT TAB 25MG
82EFFER-K TAB 10MEQ
82EFFER-K TAB 20MEQ
82effer-k tab 25meq ef
29EFFIENT TAB 10MG
29EFFIENT TAB 5MG
106ELESTRIN GEL 0.06%
132ELIDEL CRE 1%
102elinest tab
28ELIQUIS TAB 2.5MG
28ELIQUIS TAB 5MG
102ELLA TAB 30MG
118ELMIRON CAP 100MG
25ELOCTATE INJ 1000UNIT
25ELOCTATE INJ 1500UNIT
25ELOCTATE INJ 2000UNIT
25ELOCTATE INJ 250UNIT
25ELOCTATE INJ 3000UNIT
26ELOCTATE INJ 500UNIT
26ELOCTATE INJ 750UNIT
84EMADINE SOL 0.05% OP
Drug Name Page # Drug Name Page #
15EMCYT CAP 140MG
90EMEND CAP 125MG
90EMEND CAP 40MG
90EMEND CAP 80MG
91EMEND PAK 80 & 125
102emoquette tab
66EMSAM DIS 12MG/24H
66EMSAM DIS 6MG/24HR
66EMSAM DIS 9MG/24HR
10EMTRIVA CAP 200MG
10EMTRIVA SOL 10MG/ML
133ENABLEX TAB 15MG
133ENABLEX TAB 7.5MG
43enalapr/hctz tab 10-25mg
43enalapr/hctz tab 5-12.5mg
43enalapril tab 10mg
43enalapril tab 2.5mg
43enalapril tab 20mg
43enalapril tab 5mg
116ENBREL INJ 25/0.5ML
116ENBREL INJ 25MG
116ENBREL INJ 50MG/ML
116ENBREL SRCLK INJ 50MG/ML
80encare sup 100mg
49endocet tab 10-325mg
49endocet tab 10-650mg
50endocet tab 5-325mg
50endocet tab 7.5-325
50endocet tab 7.5-500m
109ENDOMETRIN SUP 100MG
106ENJUVIA TAB 0.3MG
106ENJUVIA TAB 0.45MG
106ENJUVIA TAB 0.625MG
106ENJUVIA TAB 0.9MG
106ENJUVIA TAB 1.25MG
28enoxaparin inj 100mg/ml
28enoxaparin inj 120/0.8
28enoxaparin inj 150mg/ml
28enoxaparin inj 30/0.3ml
28enoxaparin inj 300/3ml
28enoxaparin inj 40/0.4ml
28enoxaparin inj 60/0.6ml
28enoxaparin inj 80/0.8ml
102enpresse-28 tab
102enskyce tab
65entacapone tab 200mg
13entecavir tab 0.5mg
13entecavir tab 1mg
41ENTRESTO TAB 24-26MG
41ENTRESTO TAB 49-51MG
41ENTRESTO TAB 97-103MG
93ENTYVIO INJ 300MG
80enulose sol 10gm/15
132EPIDUO FORTE GEL 0.3-2.5%
84epinastine dro 0.05%
22epinephrine inj 0.1mg/ml
22epinephrine inj 1mg/ml
22EPIPEN 2-PAK INJ 0.3MG
22EPIPEN-JR INJ 2-PAK
58epitol tab 200mg
10EPIVIR HBV SOL 5MG/ML
44eplerenone tab 25mg
44eplerenone tab 50mg
30EPOGEN INJ 10000/ML
30EPOGEN INJ 2000/ML
30EPOGEN INJ 20000/ML
30EPOGEN INJ 3000/ML
30EPOGEN INJ 4000/ML
42eprosart mes tab 600mg
10EPZICOM TAB
10EPZICOM TAB 600-300
136ergocalcifer cap 50000unt
22ergoloid mes tab 1mg oral
15ERIVEDGE CAP 150MG
102errin tab 0.35mg
124ERTACZO CRE 2%
123ery pad 2%
4ERYPED SUS 200/5ML
4ERYPED SUS 400/5ML
4erythrom eth tab 400mg
123erythromycin gel /benzoyl
123erythromycin gel 2%
86erythromycin oin 5mg/gm
86erythromycin oin op
123erythromycin pad 2%
123erythromycin sol 2%
4erythromycin tab 250mg bs
4erythromycin tab 500mg bs
118ESBRIET CAP 267MG
72escitalopram sol 5mg/5ml
72escitalopram tab 10mg
72escitalopram tab 20mg
72escitalopram tab 5mg
102estarylla tab 0.25-35
Drug Name Page # Drug Name Page #
69estazolam tab 1mg
69estazolam tab 2mg
106estra/noreth tab 0.5-0.1
106estra/noreth tab 1-0.5mg
106ESTRACE VAG CRE 0.1MG/GM
106estradiol dis 0.025mg
106estradiol dis 0.0375mg
106estradiol dis 0.05mg
107estradiol dis 0.06mg
107estradiol dis 0.075mg
107estradiol dis 0.1mg
107estradiol tab 0.5mg
107estradiol tab 1mg
107estradiol tab 2mg
107ESTRASORB EMU
107ESTRING MIS 2MG
107ESTROGEL GEL
107estropipate tab 0.75mg
107estropipate tab 1.5mg
107estropipate tab 3mg
67eszopiclone tab 1mg
67eszopiclone tab 2mg
67eszopiclone tab 3mg
8ethambutol tab 100mg
8ethambutol tab 400mg
63ethosuximide cap 250mg
63ethosuximide sol 250/5ml
115etidron disd tab 200mg
115etidron disd tab 400mg
47etodolac cap 200mg
47etodolac cap 300mg
47etodolac tab 400mg
47etodolac tab 500mg
47etodolac er tab 400mg
47etodolac er tab 500mg
47etodolac er tab 600mg
15etoposide cap 50mg
126EURAX CRE 10%
126EURAX LOT 10%
107EVAMIST SPR 1.53MG
106EVISTA TAB 60MG
124EXELDERM SOL 1%
15exemestane tab 25mg
94EXJADE TAB 125MG
94EXJADE TAB 250MG
94EXJADE TAB 500MG
114EXTAVIA INJ 0.3MG
121EZ FLU SHOT INJ 2015-16
5FACTIVE TAB 320MG
102fallback tab 1.5mg
102falmina tab
13famciclovir tab 125mg
13famciclovir tab 250mg
13famciclovir tab 500mg
91famotidine tab 20mg
91famotidine tab 40mg
76FANAPT TAB 10MG
76FANAPT TAB 12MG
76FANAPT TAB 1MG
76FANAPT TAB 2MG
76FANAPT TAB 4MG
76FANAPT TAB 6MG
76FANAPT TAB 8MG
15FARESTON TAB 60MG
99FARXIGA TAB 10MG
99FARXIGA TAB 5MG
24fe c plus tab
26FEIBA VH IMMU 1,750-3,250 UNIT
58felbamate sus 600/5ml
58felbamate tab 400mg
58felbamate tab 600mg
38felodipine tab 10mg er
38felodipine tab 2.5mg er
38felodipine tab 5mg er
107FEMRING MIS 0.05/24H
107FEMRING MIS 0.1MG/24
32fenofibrate cap 130mg
32fenofibrate cap 134mg
32fenofibrate cap 200mg
32fenofibrate cap 43mg
32fenofibrate cap 67mg
32fenofibrate tab 120mg
32fenofibrate tab 145mg
32fenofibrate tab 160mg
32fenofibrate tab 40mg
32fenofibrate tab 48mg
32fenofibrate tab 54mg
32fenofibric tab 105mg
32fenofibric tab 35mg
47fenoprofen tab 600mg
50fentanyl dis 100mcg/h
50fentanyl dis 12mcg/hr
50fentanyl dis 25mcg/hr
50fentanyl dis 37.5mcg
Drug Name Page # Drug Name Page #
50fentanyl dis 50mcg/hr
50fentanyl dis 62.5mcg
50fentanyl dis 75mcg/hr
50fentanyl dis 87.5mcg
50fentanyl ot loz 1200mcg
50fentanyl ot loz 1600mcg
50fentanyl ot loz 200mcg
50fentanyl ot loz 400mcg
50fentanyl ot loz 600mcg
50fentanyl ot loz 800mcg
24ferrous aspartate tab 112 mg
24ferrous fumarate cap 86 mg
24ferrous fumarate tab 18 mg
24ferrous fumarate tab 29 mg
24ferrous fumarate tab 324 mg
24ferrous fumarate tab 325 mg
24ferrous fumarate tab 90 mg
24ferrous gluconate tab 225 mg
24ferrous gluconate tab 240 mg
24ferrous gluconate tab 27 mg
24ferrous gluconate tab 324 mg
24ferrous gluconate tab 325 mg
24ferrous sulfate elixir 220 mg/5ml
24ferrous sulfate soln 15 mg/ml
24ferrous sulfate syrup 300 mg/5ml
24ferrous sulfate tab 134 mg
24ferrous sulfate tab 140 mg
24ferrous sulfate tab 142 mg
24ferrous sulfate tab 143 mg
24ferrous sulfate tab 160 mg
24ferrous sulfate tab 200 mg
24ferrous sulfate tab 27 mg
24ferrous sulfate tab 28 mg
24ferrous sulfate tab 324 mg
24ferrous sulfate tab 325 mg
24ferrous sulfate tab 45 mg
24ferrous sulfate tab 47.5 mg
24ferrous sulfate tab 50 mg
25ferrous sulfate tab 65 mg
25ferrous sulfate tab 90 mg
113finasteride tab 5mg
87FLAREX SUS 0.1% OP
133flavoxate tab 100mg
120flebogamma 5% vial
120FLEBOGAMMA INJ 20/400ML
39flecainide tab 100mg
39flecainide tab 150mg
39flecainide tab 50mg
95FLOVENT DISK AER 100MCG
95FLOVENT DISK AER 250MCG
95FLOVENT DISK AER 50MCG
95FLOVENT HFA AER 110MCG
95FLOVENT HFA AER 220MCG
95FLOVENT HFA AER 44MCG
15floxuridine inj 0.5gm
121FLUARIX PF INJ 2013-14
121FLUARIX PF INJ 2014-15
121FLUARIX QUAD INJ 2013-14
121FLUARIX QUAD INJ 2014-15
121FLUARIX QUAD INJ 2015-16
121FLUBLOK SOL 2013-14
121FLUBLOK SOL 2014-15
121FLUBLOK SOL 2015-16
121FLUCELVAX INJ 2013-14
121FLUCELVAX INJ 2014-15
121FLUCELVAX INJ 2015-16
7fluconazole sus 10mg/ml
7fluconazole sus 40mg/ml
7fluconazole tab 100mg
7fluconazole tab 150mg
7fluconazole tab 200mg
7fluconazole tab 50mg
8flucytosine cap 250mg
8flucytosine cap 500mg
95fludrocort tab 0.1mg
121FLULAVAL INJ 2013-14
121FLULAVAL QUA INJ 2013-14
121FLULAVAL QUA INJ 2014-15
121FLULAVAL QUA INJ 2015-16
121FLUMIST QUAD SUS 2013-14
121FLUMIST QUAD SUS 2014-15
121FLUMIST QUAD SUS 2015-16
87flunisolide spr 0.025%
128fluocin acet cre 0.01%
87fluocin acet oil 0.01%
128fluocin acet oil 0.01% sc
128fluocin acet oil body
87fluocin acet oil ear0.01%
128fluocin acet oil scalp
128fluocin acet sol 0.01%
128fluocinonide cre 0.05%
128fluocinonide cre 0.1%
128fluocinonide gel 0.05%
128fluocinonide oin 0.05%
Drug Name Page # Drug Name Page #
128fluocinonide sol 0.05%
87fluoromethol sus 0.1% op
132fluorouracil cre 0.5%
132fluorouracil cre 5%
132fluorouracil dro 2%
132fluorouracil dro 5%
132fluorouracil sol 2%
132fluorouracil sol 5%
72fluoxetine cap 10mg
72fluoxetine cap 20mg
72fluoxetine cap 40mg
72fluoxetine cap 90mg dr
72fluoxetine sol 20mg/5ml
72fluoxetine tab 10mg
72fluoxetine tab 20mg
77fluphenazine tab 10mg
77fluphenazine tab 1mg
77fluphenazine tab 2.5mg
77fluphenazine tab 5mg
69flurazepam cap 15mg
69flurazepam cap 30mg
88flurbiprofen sol 0.03% op
47flurbiprofen tab 100mg
47flurbiprofen tab 50mg
15flutamide cap 125mg
128fluticasone cre 0.05%
128fluticasone lot 0.05%
128fluticasone oin 0.005%
87fluticasone spr 50mcg
33Fluvastatin TAB 80MG
33fluvastatin cap 20mg
33fluvastatin cap 40mg
121FLUVIRIN INJ 2013-14
122FLUVIRIN INJ 2015-16
122FLUVIRIN INJ PF 13-14
122FLUVIRIN PF INJ 2014-15
72fluvoxamine tab 100mg
72fluvoxamine tab 25mg
72fluvoxamine tab 50mg
122FLUZONE HD INJ PF 13-14
122FLUZONE HD INJ PF 14-15
122FLUZONE HD INJ PF 15-16
122FLUZONE INJ INTRADRM
122FLUZONE INJ PF 13-14
122FLUZONE INJ PF 14-15
122FLUZONE PED/ INJ PF 13-14
122FLUZONE QUAD INJ 13-14
122FLUZONE QUAD INJ 14-15
122FLUZONE QUAD INJ 15-16
122FLUZONE QUAD INJ 2015-16
122FLUZONE QUAD INJ 9MCG
122FLUZONE SPLT INJ 2015-16
56FOCALIN XR CAP 10MG
56FOCALIN XR CAP 20MG
56FOCALIN XR CAP 25MG
56FOCALIN XR CAP 35MG
135folic acid tab 1mg
135folic acid tab 400 mcg
135folic acid tab 800 mcg
28fondaparinux inj 10/0.8ml
28fondaparinux inj 2.5/0.5
28fondaparinux inj 5/0.4ml
28fondaparinux inj 7.5/0.6
23FORADIL CAP AEROLIZE
108FORTEO SOL 600/2.4
115FOSAMAX + D TAB 70-2800
115FOSAMAX + D TAB 70-5600
43fosinop/hctz tab 10/12.5
43fosinop/hctz tab 20/12.5
43fosinopril tab 10mg
43fosinopril tab 20mg
43fosinopril tab 40mg
82FOSRENOL CHW 1000MG
82FOSRENOL CHW 500MG
82FOSRENOL CHW 750MG
28FRAGMIN INJ 10000/ML
28FRAGMIN INJ 12500UNT
28FRAGMIN INJ 15000UNT
28FRAGMIN INJ 18000UNT
28FRAGMIN INJ 2500/0.2
28FRAGMIN INJ 5000/0.2
28FRAGMIN INJ 7500/0.3
28FRAGMIN INJ 95000UNT
64FROVA TAB 2.5MG
80furosemide inj 100/10ml
80furosemide inj 10mg/ml
80furosemide inj 20mg/2ml
80furosemide inj 40mg/4ml
81furosemide sol 10mg/ml
81furosemide sol 40mg/4ml
81furosemide sol 8mg/ml
81furosemide tab 20mg
81furosemide tab 40mg
81furosemide tab 80mg
Drug Name Page # Drug Name Page #
10FUZEON INJ 90MG
10FUZEON CONVENIENCE KIT
58gabapentin cap 100mg
58gabapentin cap 300mg
58gabapentin cap 400mg
58gabapentin sol 250/5ml
58gabapentin tab 600mg
58gabapentin tab 800mg
20galantamine cap 16mg er
20galantamine cap 24mg er
20galantamine cap 8mg er
20galantamine sol 4mg/ml
20galantamine tab 12mg
20galantamine tab 4mg
20galantamine tab 8mg
120gamastan s/d inj
120gammagard inj 1gm/10ml
120gammagard inj 2.5gm/25
120gammagard inj 20gm/200
120gammagard inj 5gm/50ml
120GAMMAGARD S-D 10 G (IGA<1) SOL
120gammagard s-d 2.5 gm vl w/st
120GAMMAGARD S-D 5 G (IGA<1) SOLN
120GAMMAKED INJ 10GM/100
120GAMMAKED INJ 1GM/10ML
120GAMMAKED INJ 2.5GM/25
120GAMMAKED INJ 20GM/200
120GAMMAKED INJ 5GM/50ML
120GAMMAPLEX INJ 10GM
120GAMMAPLEX INJ 2.5GM
120GAMMAPLEX INJ 5GM
120GAMUNEX 10% VIAL
13ganciclovir cap 250 mg
117ganirelix ac inj
86garamycin oin 0.3% op
122GARDASIL 9 INJ
86gatifloxacin sol 0.5%
93GATTEX KIT 5MG
92gavilyte-c sol
92gavilyte-g sol
92gavilyte-n sol flav pk
32gemfibrozil tab 600mg
80generlac sol 10gm/15
117gengraf cap 100mg
117gengraf cap 25mg
86gentak oin 0.3% op
123gentamicin cre 0.1%
123gentamicin oin 0.1%
86gentamicin oin 0.3% op
86gentamicin sol 0.3% op
102gianvi tab 3-0.02mg
102gildagia tab 0.4-35
102gildess 24 tab fe 1/20
102gildess fe tab 1.5/30
102gildess fe tab 1/20
102gildess tab 1.5/30
102gildess tab 1/20
114GILENYA CAP 0.5MG
15GILOTRIF TAB 20MG
15GILOTRIF TAB 30MG
15GILOTRIF TAB 40MG
114glatopa inj 20mg/ml
15GLEEVEC TAB 100MG
15GLEEVEC TAB 400MG
15GLEOSTINE CAP 100MG
15GLEOSTINE CAP 10MG
15GLEOSTINE CAP 40MG
99glimepiride tab 1mg
99glimepiride tab 2mg
100glimepiride tab 4mg
100glip/metform tab 2.5-250m
100glip/metform tab 2.5-500m
100glip/metform tab 5-500mg
100glipizide er tab 10mg
100glipizide er tab 2.5mg
100glipizide er tab 5mg
100glipizide tab 10mg
100glipizide tab 5mg
100glipizide xl tab 10mg
100glipizide xl tab 2.5mg
100glipizide xl tab 5mg
101GLUCAGEN INJ HYPOKIT
101GLUCAGON KIT 1MG
100glyb/metform tab 1.25-250
100glyb/metform tab 2.5-500
100glyb/metform tab 5-500mg
100glyburid mcr tab 1.5mg
100glyburid mcr tab 3mg
100glyburid mcr tab 6mg
100glyburide tab 1.25mg
100glyburide tab 2.5mg
100glyburide tab 5mg
19glycopyrrol tab 1mg
19glycopyrrol tab 2mg
Drug Name Page # Drug Name Page #
130glydo gel 2%
97GLYSET TAB 100MG
97GLYSET TAB 25MG
97GLYSET TAB 50MG
108GONAL-F RFF INJ 300
108GONAL-F RFF INJ 300/0.5
108GONAL-F RFF INJ 450
108GONAL-F RFF INJ 450/0.75
108GONAL-F RFF INJ 900
108GONAL-F RFF INJ 900/1.5
90granisetron tab 1mg
7griseofulvin sus 125/5ml
7griseofulvin tab micr 500
7griseofulvin tab ultr 125
7griseofulvin tab ultr 250
128grx hicort sup 25mg
41guanfacine tab 1mg
69guanfacine tab 1mg er
41guanfacine tab 2mg
69guanfacine tab 2mg er
69guanfacine tab 3mg er
69guanfacine tab 4mg er
21guanidine tab 125mg
128halobetasol cre 0.05%
128halobetasol oin 0.05%
128HALOG CRE 0.1%
77haloperidol con 2mg/ml
77haloperidol tab 0.5mg
77haloperidol tab 10mg
77haloperidol tab 1mg
77haloperidol tab 20mg
77haloperidol tab 2mg
77haloperidol tab 5mg
12HARVONI TAB 90-400MG
128hc butyrate cre 0.1%
128hc butyrate oin 0.1%
128hc butyrate sol 0.1%
128hc pramoxine cre 1-2.5%
128hc pramoxine cre 2.5-1%
128hc valerate cre 0.2%
128hc valerate oin 0.2%
87hc/acet acid sol otic
102heather tab 0.35mg
117hecoria cap 0.5mg
117hecoria cap 1mg
117hecoria cap 5mg
26HELIXATE FS INJ 1000UNIT
26HELIXATE FS INJ 2000UNIT
26HELIXATE FS INJ 250UNIT
26HELIXATE FS INJ 500UNIT
26HEMOFIL M INJ 1700UNIT
26HEMOFIL M INJ 220-400
26HEMOFIL M INJ 401-800
26HEMOFIL M SOL 501-2000
26HEMOFIL M SOL 801-1500
128hemorrhoidal sup -hc 25mg
15HEXALEN CAP 50MG
120HIZENTRA INJ 1GM/5ML
120HIZENTRA INJ 2GM/10ML
120HIZENTRA INJ 4GM/20ML
89homatropaire sol 5% op
89homatropine sol 5% op
58HORIZANT TAB 300MG
58HORIZANT TAB 600MG
98HUMALOG INJ 100/ML
98HUMALOG KWIK INJ 100/ML
98HUMALOG MIX INJ 50/50
98HUMALOG MIX INJ 50/50KWP
98HUMALOG MIX INJ 75/25KWP
98HUMALOG MIX SUS 75/25
26HUMATE-P SOL 2400UNIT
26HUMATE-P SOL 250-600
26HUMATE-P SOL 500-1200
116HUMIRA INJ 10MG/0.2
116HUMIRA INJ 40MG/0.8
116HUMIRA KIT 20MG/0.4
116HUMIRA PEDIA INJ CROHNS
116HUMIRA PEN INJ 40MG/0.8
116HUMIRA PEN INJ CROHNS
116HUMIRA PEN INJ PSORIASI
98HUMULIN INJ 70/30
98HUMULIN INJ 70/30KWP
98HUMULIN N INJ U-100
98HUMULIN N INJ U-100KWP
98HUMULIN N PN INJ U-100
98HUMULIN PEN INJ 70/30
99HUMULIN R INJ U-100
99HUMULIN R INJ U-500
119hyd pol/cpm liq 10-8/5ml
41hydralazine inj 20mg/ml
41hydralazine tab 100mg
41hydralazine tab 10mg
41hydralazine tab 25mg
41hydralazine tab 50mg
Drug Name Page # Drug Name Page #
81hydrochlorot cap 12.5mg
81hydrochlorot tab 12.5mg
81hydrochlorot tab 25mg
81hydrochlorot tab 50mg
50hydroco/apap sol 5-217/10
50hydroco/apap sol 7.5-325
50hydroco/apap tab 10-325mg
50hydroco/apap tab 5-325mg
50hydroco/apap tab 7.5-325
50hydrocod/ibu tab 2.5-200
50hydrocod/ibu tab 7.5-200
128hydrocort ac sup 25mg
128hydrocort cre 1%
128hydrocort cre 2.5%
128hydrocort lot 2.5%
128hydrocort oin 1%
128hydrocort oin 2.5%
95hydrocort tab 10mg
95hydrocort tab 20mg
95hydrocort tab 5mg
128hydrocort/ab oin 1%
129hydrocortiso cre 2.5%
50hydromorphon liq 1mg/ml
50hydromorphon sup 3mg
50hydromorphon tab 2mg
50hydromorphon tab 4mg
50hydromorphon tab 8mg
9hydroxychlor tab 200mg
15hydroxyurea cap 500mg
67hydroxyz hcl sol 10mg/5ml
67hydroxyz hcl syp 10mg/5ml
67hydroxyz hcl tab 10mg
67hydroxyz hcl tab 25mg
67hydroxyz hcl tab 50mg
67hydroxyz pam cap 100mg
67hydroxyz pam cap 25mg
67hydroxyz pam cap 50mg
14hyophen tab
19hyoscyamine sub 0.125mg
19hyoscyamine tab 0.125mg
131hypercare sol 20%
115ibandronate tab 150mg
15IBRANCE CAP 100MG
15IBRANCE CAP 125MG
15IBRANCE CAP 75MG
50IBUDONE TAB 10-200MG
47ibuprofen sus 100/5ml
47ibuprofen tab 400mg
47ibuprofen tab 600mg
47ibuprofen tab 800mg
15ICLUSIG TAB 15MG
15ICLUSIG TAB 45MG
88ILEVRO DRO 0.3% OP
86ilotycin oin op
16IMBRUVICA CAP 140MG
72imipram hcl tab 10mg
72imipram hcl tab 25mg
72imipram hcl tab 50mg
72imipram pam cap 100mg
72imipram pam cap 125mg
72imipram pam cap 150mg
73imipram pam cap 75mg
132imiquimod cre 5%
64IMITREX SPR 5MG/ACT
12INCIVEK TAB 375MG
109INCRELEX INJ 40MG/4ML
81indapamide tab 1.25mg
82indapamide tab 2.5mg
48indomethacin cap 25mg
48indomethacin cap 50mg
48indomethacin cap 75mg cr
48indomethacin cap 75mg er
48indomethacin cap 75mg sa
48indomethacin cap 75mg sr
12INFERGEN INJ 15MCG
12INFERGEN INJ 9MCG
122INFLUENZA FIRUS VACCINE
16INLYTA TAB 1MG
16INLYTA TAB 5MG
10INTELENCE TAB 100MG
10INTELENCE TAB 200MG
10INTELENCE TAB 25MG
16INTRON A INJ 10MU
16INTRON A INJ 18MU
16INTRON A INJ 18MU
16INTRON A INJ 25MU
16INTRON A INJ 50MU
102introvale tab
77INVEGA TAB 1.5MG
77INVEGA TAB 3MG
77INVEGA TAB 6MG
77INVEGA TAB 9MG
88IOPIDINE SOL 1% OP
19ipratropium sol 0.02%inh
Drug Name Page # Drug Name Page #
19ipratropium spr 0.03%
19ipratropium spr 0.06%
42irbesar/hctz tab 150-12.5
42irbesar/hctz tab 300-12.5
42irbesartan tab 150mg
42irbesartan tab 300mg
42irbesartan tab 75mg
16IRESSA TAB 250MG
10ISENTRESS TAB 400MG
45isoditrate tab 40mg er
8isoniazid syp 50mg/5ml
8isoniazid tab 100mg
8isoniazid tab 300mg
45ISORDIL TAB 40MG
45isosorb din tab 10mg
45isosorb din tab 20mg
45isosorb din tab 30mg
45isosorb din tab 40mg er
45isosorb din tab 40mg sa
45isosorb din tab 5mg
45isosorb mono tab 10mg
45isosorb mono tab 120mg er
45isosorb mono tab 20mg
45isosorb mono tab 30mg er
45isosorb mono tab 60mg er
38isradipine cap 2.5mg
38isradipine cap 5mg
7itraconazole cap 100mg
16JAKAFI TAB 10MG
16JAKAFI TAB 15MG
16JAKAFI TAB 20MG
16JAKAFI TAB 25MG
16JAKAFI TAB 5MG
97JANUVIA TAB 100MG
97JANUVIA TAB 25MG
98JANUVIA TAB 50MG
102jencycla tab 0.35mg
107jinteli tab 1mg-5mcg
102jolessa tab
103jolivette tab 0.35mg
103junel 1.5/30 tab
103junel 1/20 tab
103junel fe tab 1.5/30
103junel fe tab 1/20
103junel fe 24 tab 1/20
80k citrate sol citr acd
10KALETRA SOL
10KALETRA TAB 100-25MG
10KALETRA TAB 200-50MG
119KALYDECO TAB 150MG
90kaopectate tab
103kariva tab 28 day
26KCENTRA KIT 1000UNIT
26KCENTRA KIT 500UNIT
82k-effervesce tab 25meq ef
103kelnor tab 1/35
129KENALOG AER SPRAY
4KETEK TAB 300MG
4KETEK TAB 400MG
124ketoconazole aer 2%
124ketoconazole cre 2%
124ketoconazole sha 2%
7ketoconazole tab 200mg
124ketodan aer 2%
48ketoprofen cap 200mg er
48ketoprofen cap 50mg
48ketoprofen cap 75mg
88ketorolac sol 0.4%
88ketorolac sol 0.5%
48ketorolac tab 10mg
84ketotif fum dro 0.025%op
103kimidess tab
82kionex sus 15gm/60
82klor-con 10 tab 10meq er
83klor-con 8 tab 8meq er
83klor-con m10 tab 10meq er
83KLOR-CON M15 TAB
83KLOR-CON M15 TAB 15MEQ ER
83klor-con m20 tab 20meq er
83klor-con spr cap 10meq
83klor-con spr cap 8meq
83klor-con/ef tab 25meq ef
83klor-con/ef tab 25meq fr
26koate-dvi inj 1000unit
26koate-dvi inj 250unit
26KOATE-DVI INJ 500UNIT
26KOGENATE FS INJ 1000/BS
26KOGENATE FS INJ 1000UNIT
26KOGENATE FS INJ 2000/BS
26KOGENATE FS INJ 2000UNIT
26KOGENATE FS INJ 250/BS
26KOGENATE FS INJ 250UNIT
26KOGENATE FS INJ 3000/BS
26KOGENATE FS INJ 3000UNIT
Drug Name Page # Drug Name Page #
26KOGENATE FS INJ 500/BS
26KOGENATE FS INJ 500UNIT
83k-prime tab 25meq ef
80KRISTALOSE PAK 10GM
80KRISTALOSE PAK 20GM
83k-sol sol 10%
83k-sol sol 20%
103kurvelo tab 0.15/30
83k-vescent tab 25meq ef
34labetalol tab 100mg
34labetalol tab 200mg
34labetalol tab 300mg
131laclotion lot 12%
131lactic acid lot 10%
80lactulose sol 10gm/15
80lactulose sol 20gm/30
58LAMICTAL CHW 25MG
58LAMICTAL CHW 5MG
58LAMICTAL KIT START 49
10lamivud/zido tab 150-300
10lamivudine sol 10mg/ml
10lamivudine tab 100mg
10lamivudine tab 150mg
10lamivudine tab 300mg
58lamotrigine chw 25mg
58lamotrigine chw 5mg
58lamotrigine tab 100mg
59lamotrigine tab 100mg er
59lamotrigine tab 150mg
59lamotrigine tab 200mg
59lamotrigine tab 200mg er
59lamotrigine tab 250mg er
59lamotrigine tab 25mg
59lamotrigine tab 25mg er
59lamotrigine tab 300mg er
59lamotrigine tab 50mg er
40lanoxin tab 0.125mg
40lanoxin tab 0.25mg
92lansoprazole cap 15mg dr
92lansoprazole cap 30mg dr
92LANSOPRAZOLE SUS 3MG/ML
99LANTUS INJ 100/ML
99LANTUS INJ SOLOSTAR
103larin tab 1.5/30
103larin tab 1/20
103larin 24 tab fe 1/20
103larin fe tab 1.5/30
103larin fe tab 1/20
84LASTACAFT SOL 0.25%
85latanoprost sol 0.005%
77LATUDA TAB 120MG
77LATUDA TAB 20MG
77LATUDA TAB 40MG
77LATUDA TAB 60MG
77LATUDA TAB 80MG
103layolis fe chw
130lc-4 lidocne cre 4%
103leena tab
116leflunomide tab 10mg
116leflunomide tab 20mg
103lessina tab
119LETAIRIS TAB 10MG
119LETAIRIS TAB 5MG
16letrozole tab 2.5mg
114leucovor ca tab 10mg
113leucovor ca tab 15mg
113leucovor ca tab 25mg
113leucovor ca tab 5mg
16LEUKERAN TAB 2MG
30LEUKINE INJ 250MCG
30LEUKINE INJ 500 MCG
23levalbuterol neb 0.31mg
23levalbuterol neb 0.63mg
23levalbuterol neb 1.25/0.5
23levalbuterol neb 1.25mg
34LEVATOL TAB 20MG
99LEVEMIR INJ
99LEVEMIR INJ FLEXPEN
99LEVEMIR INJ FLEXTOUC
59levetiraceta sol 100mg/ml
59levetiraceta sol 500/5ml
59levetiraceta tab 1000mg
59levetiraceta tab 250mg
59levetiraceta tab 500mg
59levetiraceta tab 500mg er
59levetiraceta tab 750mg
59levetiraceta tab 750mg er
59levetiracetm inj 500/5ml
85levobunolol sol 0.25% op
85levobunolol sol 0.5% op
1levocetirizi sol 2.5/5ml
1levocetirizi tab 5mg
103levo-eth est tab 90-20mcg
5levofloxacin inj 25mg/ml
Drug Name Page # Drug Name Page #
86levofloxacin sol 0.5%
5levofloxacin sol 25mg/ml
5levofloxacin tab 250mg
5levofloxacin tab 500mg
5levofloxacin tab 750mg
103levonest tab
103levonor/ethi tab 0.1-0.02
103levonor/ethi tab estradio
103levonorgestr tab 0.75mg
103levonorgestr tab 1.5mg
103levora-28 tab 0.15/30
50levorphanol tab 2mg
110levothyroxin inj 100mcg
110levothyroxin inj 200mcg
110levothyroxin inj 500mcg
110levothyroxin tab 100mcg
110levothyroxin tab 112mcg
110levothyroxin tab 125mcg
110levothyroxin tab 137mcg
110levothyroxin tab 150mcg
110levothyroxin tab 175mcg
110levothyroxin tab 200mcg
110levothyroxin tab 25mcg
110levothyroxin tab 300mcg
111levothyroxin tab 50mcg
111levothyroxin tab 75mcg
111levothyroxin tab 88mcg
111levothyroxine tab 0.075mg
111levoxyl tab 100mcg
111levoxyl tab 112mcg
111levoxyl tab 125mcg
111levoxyl tab 137mcg
111levoxyl tab 150mcg
111levoxyl tab 175mcg
111levoxyl tab 200mcg
111levoxyl tab 25mcg
111levoxyl tab 50mcg
111levoxyl tab 75mcg
111levoxyl tab 88mcg
10LEXIVA SUS 50MG/ML
10LEXIVA TAB 700MG
91LIALDA TAB 1.2GM
130lido/prilocn cre 2.5-2.5%
130lido/prilocn kit 2.5-2.5%
130lidocaine cre 3%
130lidocaine cre 4%
130lidocaine gel 2%
130lidocaine gel 2% jelly
130lidocaine oin 5%
89lidocaine sol 2% visc
130lidocaine sol 4%
130lidocream cre 4%
130lidopin cre 3%
126lindane lot 1%
126lindane sha 1%
2linezolid tab 600mg
93LINZESS CAP 145MCG
93LINZESS CAP 290MCG
111liothyronine tab 25mcg
111liothyronine tab 50mcg
111liothyronine tab 5mcg
43lisinop/hctz tab 10-12.5
43lisinop/hctz tab 20-12.5
43lisinop/hctz tab 20-25mg
43lisinopril tab 10mg
44lisinopril tab 2.5mg
44lisinopril tab 20mg
44lisinopril tab 30mg
44lisinopril tab 40mg
44lisinopril tab 5mg
63lithium carb cap 150mg
63lithium carb cap 300mg
63lithium carb cap 600mg
63lithium carb tab 300mg
63lithium carb tab 300mg er
63lithium carb tab 450mg er
63lithium sol 8meq/5ml
33LIVALO TAB 1MG
33LIVALO TAB 2MG
33LIVALO TAB 4MG
130livixil pak kit 2.5-2.5%
129locoid cre 0.1%
90lofene tab 2.5mg
129lokara lot 0.05%
103lomedia 24 tab fe
90lonox tab 2.5mg
90loperamide cap 2mg
107lopreeza tab 0.5-0.1
107lopreeza tab 1-0.5mg
69lorazepam tab 0.5mg
69lorazepam tab 1mg
69lorazepam tab 2mg
51lorcet tab 5-325mg
51lorcet hd tab 10-325mg
Drug Name Page # Drug Name Page #
51lorcet plus tab 7.5-325
51lortab tab 10-325mg
51lortab tab 5-325mg
51lortab tab 7.5-325
103loryna tab 3-0.02mg
21LORZONE TAB 750MG
42losartan pot tab 100mg
42losartan pot tab 25mg
42losartan pot tab 50mg
42losartan/hct tab 100-12.5
42losartan/hct tab 100-25
42losartan/hct tab 50-12.5
87LOTEMAX SUS 0.5%
33lovastatin tab 10mg
33lovastatin tab 20mg
33lovastatin tab 40mg
103low-ogestrel tab
77loxapine cap 10mg
77loxapine cap 25mg
77loxapine cap 50mg
77loxapine cap 5mg
130lp lite pak kit 2.5-2.5%
85LUMIGAN SOL 0.01%
103lutera tab
59LYRICA CAP 100MG
59LYRICA CAP 150MG
59LYRICA CAP 200MG
59LYRICA CAP 225MG
59LYRICA CAP 25MG
59LYRICA CAP 300MG
59LYRICA CAP 50MG
59LYRICA CAP 75MG
16LYSODREN TAB 500MG
103lyza tab 0.35mg
83magnesium cl inj 20%
126malathion lot 0.5%
73maprotiline tab 25mg
73maprotiline tab 50mg
73maprotiline tab 75mg
103marlissa tab 0.15/30
73MARPLAN TAB 10MG
16MATULANE CAP 50MG
37matzim la tab 180mg/24
37matzim la tab 240mg/24
37matzim la tab 300mg/24
37matzim la tab 360mg/24
37matzim la tab 420mg/24
23MAXAIR AUTOH AER 200MCG
88MAXIDEX SUS 0.1% OP
91meclizine tab 12.5mg
91meclizine tab 25mg
48meclofen sod cap 100mg
48meclofen sod cap 50mg
48MEDI-SELTZER TAB
109medroxypr ac inj 150mg/ml
109medroxypr ac tab 10mg
109medroxypr ac tab 2.5mg
109medroxypr ac tab 5mg
48mefenam acid cap 250mg
9mefloquine tab 250mg
109MEGACE ES SUS
16megestrol ac sus 400mg/10
16megestrol ac sus 40mg/ml
16megestrol ac sus 800mg/20
16megestrol ac tab 20mg
16megestrol ac tab 40mg
109megestrol sus 625mg/5m
16MEKINIST TAB 0.5MG
16MEKINIST TAB 2MG
48meloxicam sus 7.5/5ml
48meloxicam tab 15mg
48meloxicam tab 7.5mg
69memantine hc tab 10mg
69memantine tab hcl 5mg
107MENEST TAB 0.3MG
107MENEST TAB 0.625MG
107MENEST TAB 1.25MG
107MENEST TAB 2.5MG
122MENHIBRIX INJ
108MENOPUR INJ 75UNIT
107MENOSTAR DIS 14MCG
124MENTAX CRE 1%
51meperidine inj 100mg/ml
51meperidine inj 10mg/ml
51meperidine inj 25mg/ml
51meperidine inj 50mg/ml
51meperidine sol 50mg/5ml
51meperidine tab 100mg
51meperidine tab 50mg
51meperitab tab 100mg
51meperitab tab 50mg
67meprobamate tab 200mg
67meprobamate tab 400mg
16mercaptopur tab 50mg
Drug Name Page # Drug Name Page #
91mesalamine ene 4gm
91mesalamine kit 4gm
21MESTINON SYP 60MG/5ML
56metadate tab 20mg er
23metaproteren syp 10mg/5ml
23metaproteren tab 10mg
23metaproteren tab 20mg
21metaxalone tab 400mg
21metaxalone tab 800mg
97metformin tab 1000mg
97metformin tab 500mg
97metformin tab 500mg er
97metformin tab 750mg er
97metformin tab 850mg
51methadone sol 10mg/5ml
51methadone sol 5mg/5ml
51methadone tab 10mg
51methadone tab 5mg
55methamphetam tab 5mg
85methazolamid tab 25mg
85methazolamid tab 50mg
14methenam hip tab 1gm
110methimazole tab 10mg
110methimazole tab 5mg
21methocarbam tab 500mg
21methocarbam tab 750mg
16methotrexate tab 2.5mg
19methscopolam tab 2.5mg
19methscopolam tab 5mg
81methyclothia tab 5mg
41methyldopa tab 250mg
41methyldopa tab 500mg
56methylphenid cap 10mg
56methylphenid cap 20mg
56methylphenid cap 20mg er
56methylphenid cap 30mg
56methylphenid cap 30mg er
56methylphenid cap 40mg
56methylphenid cap 40mg er
56methylphenid cap 50mg
56methylphenid cap 60mg
56methylphenid sol 10mg/5ml
56methylphenid sol 5mg/5ml
57methylphenid tab 10mg
57methylphenid tab 10mg er
57methylphenid tab 18mg er
57methylphenid tab 18mg er
57methylphenid tab 20mg
57methylphenid tab 20mg er
57methylphenid tab 20mg sr
57methylphenid tab 27mg er
57methylphenid tab 27mg er
57methylphenid tab 36mg er
57methylphenid tab 36mg er
57methylphenid tab 54mg er
57methylphenid tab 54mg er
57methylphenid tab 5mg
96methylpred pak 4mg
96methylpred tab 16mg
96methylpred tab 32mg
96methylpred tab 4mg
96methylpred tab 8mg
85metipranolol sol 0.3% oph
94metoclopram inj 10mg/2ml
94metoclopram inj 5mg/ml
94metoclopram sol 10/10ml
94metoclopram sol 5mg/5ml
94metoclopram tab 10mg
94metoclopram tab 5mg
82metolazone tab 10mg
82metolazone tab 2.5mg
82metolazone tab 5mg
34metoprl/hctz tab 100-25mg
34metoprl/hctz tab 100-50mg
34metoprl/hctz tab 50-25mg
34metoprol tar tab 100mg
34metoprol tar tab 25mg
34metoprol tar tab 50mg
34metoprolol tab 100mg er
35metoprolol tab 200mg er
35metoprolol tab 25mg er
35metoprolol tab 50mg er
9metronidazol cap 375mg
123metronidazol cre 0.75%
123metronidazol gel 0.75%vag
123metronidazol lot 0.75%
9metronidazol tab 250mg
9metronidazol tab 500mg
39mexiletine cap 150mg
39mexiletine cap 200mg
39mexiletine cap 250mg
103microgestin tab 1.5/30
104microgestin tab 1/20
104microgestin tab fe 1/20
Drug Name Page # Drug Name Page #
104microgestin tab fe1.5/30
69midazolam syp 2mg/ml
22midodrine tab 10mg
22midodrine tab 2.5mg
22midodrine tab 5mg
22MIGRANAL SPR 4MG/ML
107mimvey tab 1-0.5mg
107mimvey lo tab 0.5-0.1
6minocycline cap 100mg
6minocycline cap 50mg
6minocycline cap 75mg
6minocycline tab 100mg
132minocycline tab 135mg er
132minocycline tab 45mg er
6minocycline tab 50mg
6minocycline tab 75mg
132minocycline tab 90mg er
41minoxidil tab 10mg
41minoxidil tab 2.5mg
65MIRAPEX ER TAB 2.25MG
73mirtazapine tab 15mg
73mirtazapine tab 15mg odt
73mirtazapine tab 30mg
73mirtazapine tab 30mg odt
73mirtazapine tab 45mg
73mirtazapine tab 45mg odt
73mirtazapine tab 7.5mg
132MIRVASO GEL 0.33%
92misoprostol tab 100mcg
92misoprostol tab 200mcg
57modafinil tab 100mg
57modafinil tab 200mg
13moderiba tab 200mg
44moexipr/hctz tab 15-12.5
44moexipr/hctz tab 15-25mg
44moexipr/hctz tab 7.5-12.5
44moexipril tab 15mg
44moexipril tab 7.5mg
129mometasone cre 0.1%
129mometasone oin 0.1%
129mometasone sol 0.1%
26MONOCLATE-P INJ 250UNIT
27MONOCLATE-P INJ 500UNIT
104mono-linyah tab 0.25-35
104mononessa tab
27MONONINE INJ 500UNIT
118montelukast chw 4mg
118montelukast chw 5mg
118montelukast gra 4mg
118montelukast tab 10mg
14MONUROL PAK GRANULES
51morphine sul cap 100mg er
51morphine sul cap 120mg er
51morphine sul cap 20mg er
51morphine sul cap 30mg er
51morphine sul cap 30mg er
51morphine sul cap 45mg er
51morphine sul cap 50mg er
51morphine sul cap 60mg er
51morphine sul cap 60mg er
52morphine sul cap 75mg er
52morphine sul cap 80mg er
52morphine sul cap 90mg er
52morphine sul inj 0.5mg/ml
52morphine sul inj 10mg/ml
52morphine sul inj 150/30ml
52morphine sul inj 15mg/ml
52morphine sul inj 1mg/ml
52morphine sul inj 25mg/ml
52morphine sul inj 2mg/ml
52morphine sul inj 4mg/ml
52morphine sul inj 50mg/ml
52morphine sul inj 8mg/ml
52morphine sul sol 10/0.5ml
52morphine sul sol 100/5ml
52morphine sul sol 10mg/5ml
52morphine sul sol 20mg/5ml
52morphine sul sol 20mg/ml
52morphine sul sup 20mg
52morphine sul sup 5mg
52morphine sul tab 100mg cr
52morphine sul tab 100mg er
52morphine sul tab 15mg
52morphine sul tab 15mg cr
52morphine sul tab 15mg er
52morphine sul tab 200mg er
52morphine sul tab 30mg
52morphine sul tab 30mg cr
52morphine sul tab 30mg er
52morphine sul tab 60mg cr
52morphine sul tab 60mg er
86MOXEZA SOL 0.5%
6moxifloxacin tab 400mg
40MULTAQ TAB 400MG
Drug Name Page # Drug Name Page #
123mupirocin ca cre 2%
123mupirocin cre 2%
123mupirocin oin 2%
104my way tab 1.5mg
117mycophenolat cap 250mg
117mycophenolat sus 200mg/ml
117mycophenolat tab 500mg
117mycophenolic tab 180mg dr
117mycophenolic tab 360mg dr
89mydral sol 0.5% op
89mydral sol 1% op
16MYLERAN TAB 2MG
134MYRBETRIQ TAB 25MG
134MYRBETRIQ TAB 50MG
104myzilra tab
48nabumetone tab 500mg
48nabumetone tab 750mg
35nadolol tab 20mg
35nadolol tab 40mg
35nadolol tab 80mg
70naloxone inj 1mg/ml
70naltrexone tab 50mg
70NAMENDA SOL 10MG/5ML
70NAMENDA TAB 10MG
70NAMENDA TAB 5MG
89naphazoline sol 0.1% op
48naproxen sus 125/5ml
48naproxen tab 250mg
48naproxen tab 375mg
48naproxen tab 500mg
48naproxen dr tab 375mg
48naproxen dr tab 500mg
48naproxen ec tab 375mg
48naproxen ec tab 500mg
48naproxen sod tab 220mg
48naproxen sod tab 275mg
48naproxen sod tab 550mg
64naratriptan tab 1mg
64naratriptan tab 2.5mg
88NASONEX SPR 50MCG/AC
99nateglinide tab 120mg
99nateglinide tab 60mg
97NATESTO GEL 5.5MG
111nature-throi tab 130mg
111nature-throi tab 16.25mg
111nature-throi tab 195mg
111nature-throi tab 32.5mg
111nature-throi tab 65mg
9NEBUPENT INH 300MG
104necon tab 0.5/35
104necon tab 1/35
104necon tab 1/50-28
104necon tab 10/11-28
104necon tab 7/7/7
73nefazodone tab 100mg
73nefazodone tab 150mg
73nefazodone tab 200mg
73nefazodone tab 250mg
73nefazodone tab 50mg
88neo/poly/dex sus 0.1% op
88neo/poly/hc sol 1% otic
88neo/poly/hc sus 1% otic
89neofrin sol 10% op
89neofrin sol 2.5% op
2neomycin tab 500mg
123neuac gel 1.2-5%
30NEULASTA INJ 6MG/0.6M
30NEULASTA KIT 6MG/0.6M
30NEUPOGEN INJ 300/0.5
30NEUPOGEN INJ 300MCG
30NEUPOGEN INJ 480/0.8
30NEUPOGEN INJ 480MCG
65NEUPRO DIS 1MG/24HR
65NEUPRO DIS 2MG/24HR
65NEUPRO DIS 3MG/24HR
65NEUPRO DIS 4MG/24HR
65NEUPRO DIS 6MG/24HR
65NEUPRO DIS 8MG/24HR
88NEVANAC SUS 0.1%
10nevirapine sus 50mg/5ml
10nevirapine tab 200mg
10nevirapine tab 400mg er
16NEXAVAR TAB 200MG
104next choice tab 1.5mg
31niacin tab 500mg er
31niacin er tab 1000mg
31niacin er tab 500mg
31niacin er tab 750mg
39nicardipine cap 20mg
39nicardipine cap 30mg
20nicotine kit
20nicotine patch 14 mg/24hr
20nicotine patch 14 mg/24hr
20nicotine patch 21 mg/24hr
Drug Name Page # Drug Name Page #
20nicotine patch 21 mg/24hr
20nicotine patch 7 mg/24hr
20nicotine patch 7 mg/24hr
20nicotine polacrilex gum 2 mg
20nicotine polacrilex gum 2 mg
20nicotine polacrilex lozg 2 mg
20nicotine polacrilex lozg 2 mg
20nicotine polacrilex lozg 4 mg
20nicotine polacrilex lozg 4 mg
20NICOTROL INH
20NICOTROL NS SPR 10MG/ML
39nifediac cc tab 30mg er
39nifediac cc tab 60mg er
39nifedical xl tab 30mg
39nifedical xl tab 60mg
39nifedipine cap 10mg
39nifedipine cap 20mg
39nifedipine tab 30mg er
39nifedipine tab 60mg er
39nifedipine tab 90mg er
104nikki tab 3-0.02mg
16NILANDRON TAB 150MG
39nimodipine cap 30mg
39nisoldipine tab 17mg er
39nisoldipine tab 20mg
39nisoldipine tab 25.5mg
39nisoldipine tab 30mg
39nisoldipine tab 34mg er
39nisoldipine tab 40mg
39nisoldipine tab 8.5mg er
45NITRO-BID OIN 2%
45NITRO-DUR DIS 0.3MG/HR
14nitrofur mac cap 100mg
14nitrofur mac cap 50mg
14nitrofurantn cap 100mg
14nitrofurantn sus 25mg/5ml
14nitrofuranto cap 100mg
45nitroglycer aer 400mcg
45nitroglycer cap 2.5mg er
45nitroglycer cap 2.5mg sr
45nitroglycer cap 6.5mg er
45nitroglycer cap 6.5mg sr
45nitroglycer cap 9mg er
45NITRONAL SOL 1MG/ML
46NITROSTAT SUB 0.3MG
46NITROSTAT SUB 0.4MG
46NITROSTAT SUB 0.6MG
46nitro-time cap 2.5mg cr
46nitro-time cap 6.5mg cr
46nitro-time cap 9mg cr
91nizatidine cap 150mg
91nizatidine cap 300mg
91nizatidine sol 15mg/ml
119nohist-dm liq
104nora-be tab 0.35mg
104noreth/ethin chw fe
107noreth/ethin tab 0.5-2.5
104noreth/ethin tab 1/20
107noreth/ethin tab 1mg-5mcg
104noreth/ethin tab fe 1/20
109norethin ace tab 5mg
104norethindron tab 0.35mg
104norgest/ethi tab 0.25/35
104norgest/ethi tab estradio
104norlyroc tab 0.35mg
6NOROXIN TAB 400MG
40NORPACE CAP 100MG CR
104nortrel tab 0.5/35
104nortrel tab 1/35
104nortrel tab 7/7/7
73nortriptylin cap 10mg
73nortriptylin cap 25mg
73nortriptylin cap 50mg
73nortriptylin cap 75mg
73nortriptylin sol 10mg/5ml
10NORVIR CAP 100MG
10NORVIR SOL 80MG/ML
10NORVIR TAB 100MG
108novarel inj 10000unt
99NOVOLIN INJ 70/30
99NOVOLIN N INJ U-100
99NOVOLIN R INJ U-100
99NOVOLOG INJ 100/ML
99NOVOLOG INJ FLEXPEN
99NOVOLOG INJ PENFILL
99NOVOLOG MIX INJ 70/30
99NOVOLOG MIX INJ FLEXPEN
27NOVOSEVEN 1,200 MCG VIAL
27NOVOSEVEN 4,800 MCG VIAL
27NOVOSEVEN INJ 2400MCG
27NOVOSEVEN RT INJ 1MG
27NOVOSEVEN RT INJ 2MG
27NOVOSEVEN RT INJ 5MG
27NOVOSEVEN RT INJ 8MG
Drug Name Page # Drug Name Page #
7NOXAFIL SUS 40MG/ML
111np thyroid tab 30mg
111np thyroid tab 60mg
111np thyroid tab 90mg
53NUCYNTA ER TAB 100MG
53NUCYNTA ER TAB 200MG
53NUCYNTA TAB 100MG
53NUCYNTA TAB 75MG
70NUEDEXTA CAP 20-10MG
19nulev tab 0.125mg
109NUTROPIN INJ 10MG
109NUTROPIN AQ INJ 10MG/2ML
109NUTROPIN AQ INJ 20MG/2ML
109NUTROPIN AQ INJ NUSPIN 5
104NUVARING MIS
57NUVIGIL TAB 150MG
57NUVIGIL TAB 200MG
57NUVIGIL TAB 250MG
124nyamyc pow 100000
129nystat/triam cre
129nystat/triam oin
124nystatin cre 100000
124nystatin oin 100000
7nystatin pow
124nystatin pow 100000
7nystatin pow 10bu
7nystatin pow 150mu
7nystatin pow 1bu
7nystatin pow 2bu
7nystatin pow 500mu
7nystatin pow 50mu
7nystatin pow 5bu
7nystatin sus 100000
8nystatin tab 500000
124nystop pow 100000
104ocella tab 3-0.03mg
120OCTAGAM INJ 10GM
120OCTAGAM INJ 1GM
120OCTAGAM INJ 2.5GM
120OCTAGAM INJ 25GM
120OCTAGAM INJ 5GM
118OFEV CAP 100MG
118OFEV CAP 150MG
86ofloxacin dro 0.3% op
86ofloxacin dro 0.3%otic
6ofloxacin tab 200mg
6ofloxacin tab 300mg
6ofloxacin tab 400mg
104ogestrel tab
73olanza/fluox cap 12-25mg
73olanza/fluox cap 12-50mg
73olanza/fluox cap 6-25mg
73olanza/fluox cap 6-50mg
77olanzapine tab 10mg
77olanzapine tab 10mg odt
77olanzapine tab 15mg
77olanzapine tab 15mg odt
77olanzapine tab 2.5mg
78olanzapine tab 20mg
78olanzapine tab 20mg odt
78olanzapine tab 5mg
78olanzapine tab 5mg odt
78olanzapine tab 7.5mg
84Olopatadine SOL 0.1% OP
31omega-3-acid cap 1gm
92omeprazole cap 10mg
92omeprazole cap 20mg
92omeprazole cap 40mg
90ondansetron inj 4mg/2ml
90ondansetron sol 4mg/5ml
90ondansetron tab 24mg
90ondansetron tab 4mg
90ondansetron tab 4mg odt
90ondansetron tab 8mg
90ondansetron tab 8mg odt
62ONFI TAB 10MG
63ONFI TAB 20MG
63ONFI TAB 5MG
98ONGLYZA TAB 2.5MG
98ONGLYZA TAB 5MG
104opcicon tab 1.5mg
119OPSUMIT TAB 10MG
129oralone pst 0.1%
78ORAP TAB 1MG
78ORAP TAB 2MG
116ORENCIA INJ 125MG/ML
118ORFADIN CAP 10MG
118ORFADIN CAP 2MG
118ORFADIN CAP 5MG
48orph/asa/caf tab
22orphenadrine inj 30mg/ml
22orphenadrine tab 100mg cr
22orphenadrine tab 100mg er
104orsythia tab
Drug Name Page # Drug Name Page #
107ortho-est tab 0.625
107ortho-est tab 1.25
19oscimin sub 0.125mg
19oscimin tab 0.125mg
92OSMOPREP TAB 1.5GM
116OTEZLA TAB 10/20/30
116OTEZLA TAB 30MG
108OVIDREL INJ
97oxandrolone tab 10mg
97oxandrolone tab 2.5mg
49oxaprozin tab 600mg
69oxazepam cap 10mg
69oxazepam cap 15mg
69oxazepam cap 30mg
59oxcarbazepin sus 300mg/5m
59oxcarbazepin tab 150mg
59oxcarbazepin tab 300mg
59oxcarbazepin tab 600mg
124OXISTAT CRE 1%
124OXISTAT LOT 1%
131OXSORALEN LOT 1%
133oxybutynin syp 5mg/5ml
133oxybutynin tab 10mg er
133oxybutynin tab 15mg er
133oxybutynin tab 5mg
133oxybutynin tab 5mg er
53oxycod/apap tab 10-325mg
53oxycod/apap tab 2.5-325
53oxycod/apap tab 5-325mg
53oxycod/apap tab 7.5-325
53oxycod/apap tab 7.5-500
53oxycod/ibu tab 5-400mg
53oxycodone cap 5mg
53oxycodone sol 5mg/5ml
53oxycodone tab 10mg
53oxycodone tab 10mg er
53oxycodone tab 15mg
53oxycodone tab 20mg
53oxycodone tab 20mg er
53oxycodone tab 30mg
53oxycodone tab 40mg er
53oxycodone tab 5mg
53oxycodone tab 80mg er
53oxycontin tab 40mg cr
53oxycontin tab 80mg cr
53oxymorphone tab 10mg er
53oxymorphone tab 15mg er
53oxymorphone tab 20mg er
53oxymorphone tab 30mg er
53oxymorphone tab 40mg er
53oxymorphone tab 5mg er
54oxymorphone tab 7.5mg er
54oxymorphone tab hcl 10mg
54oxymorphone tab hcl 5mg
40pacerone tab 200mg
40pacerone tab 400mg
78paliperidone tab er 1.5mg
78paliperidone tab er 3mg
78paliperidone tab er 6mg
78paliperidone tab er 9mg
93PANCREAZE CAP 10500UNT
93PANCREAZE CAP 16800UNT
93PANCREAZE CAP 21000UNT
93PANCREAZE CAP 4200UNIT
93pancrelipase cap 5000unit
92pantoprazole tab 20mg
92pantoprazole tab 40mg
89parcaine sol 0.5% op
136paricalcitol cap 1 mcg
136paricalcitol cap 2 mcg
136paricalcitol cap 4 mcg
87paroex sol 0.12%
8paromomycin cap 250mg
73paroxetine tab 10mg
73paroxetine tab 20mg
73paroxetine tab 30mg
73paroxetine tab 40mg
84PATADAY SOL 0.2%
4PCE TAB 333MG EC
4PCE TAB 500MG EC
124pedi-dri pow 100000
92peg 3350 sol electrol
92peg-3350 sol electrol
92peg-3350/kcl sol /sodium
63PEGANONE TAB 250MG
12PEGASYS 180 MCG/0.5 ML CONV.PK
12PEG-INTRON KIT 120 RP
12PEGINTRON KIT 120MCG
12PEG-INTRON KIT 120MCG
12PEG-INTRON KIT 150 RP
12PEGINTRON KIT 150MCG
12PEG-INTRON KIT 150MCG
12PEGINTRON KIT 50MCG
12PEG-INTRON KIT 50MCG
Drug Name Page # Drug Name Page #
12PEG-INTRON KIT 50MCG RP
12PEGINTRON KIT 80MCG
12PEG-INTRON KIT 80MCG
12PEG-INTRON KIT 80MCG RP
92pegylax pow
5penicilln vk sol 125/5ml
5penicilln vk sol 250/5ml
5penicilln vk tab 250mg
5penicilln vk tab 500mg
54penta/apap tab 25-650mg
91PENTASA CAP 250MG CR
91PENTASA CAP 500MG CR
54pentaz/nalox tab 50-0.5mg
31pentoxifylli tab 400mg cr
31pentoxifylli tab 400mg er
23PERFOROMIST NEB 20MCG
44perindopril tab 2mg
44perindopril tab 4mg
44perindopril tab 8mg
87periogard sol 0.12%
126permethrin cre 5%
78perphenazine tab 16mg
78perphenazine tab 2mg
78perphenazine tab 4mg
78perphenazine tab 8mg
126persa-gel gel 10%
126persa-gel xs gel 5%
93PERTZYE CAP
1phenadoz sup 25mg
130phenazo tab 200mg
130phenazo tab 95mg
130phenazopyrid tab 100mg
130phenazopyrid tab 200mg
130phenazopyrid tab 95mg
130phenazoyrid tab 95mg
74phenelzine tab 15mg
1phenergan sup 25mg
1phenergan sup 50mg
67phenobarb elx 20mg/5ml
67phenobarb sol 20mg/5ml
67phenobarb tab 100mg
67phenobarb tab 15mg
67phenobarb tab 16.2mg
68phenobarb tab 30mg
68phenobarb tab 32.4mg
68phenobarb tab 60mg
68phenobarb tab 64.8mg
68phenobarb tab 97.2mg
55phentermine tab 37.5mg
89phenylephrin sol 10% op
89phenylephrin sol 2.5% op
63PHENYTEK CAP 200MG
63PHENYTEK CAP 300MG
63phenytoin chw 50mg
63phenytoin ex cap 100mg
63phenytoin ex cap 200mg
63phenytoin ex cap 300mg
63phenytoin inj 50mg/ml
63phenytoin sus 125/5ml
104philith tab 0.4-35
83PHOSLYRA SOL
83phospha 250 tab neutral
85PHOSPHOLINE SOL 0.125%OP
133PICATO GEL 0.015%
133PICATO GEL 0.05%
85pilocarpine sol 1% op
85pilocarpine sol 2% op
85pilocarpine sol 4% op
21pilocarpine tab 5mg
21pilocarpine tab 7.5mg
104pimtrea tab
35pindolol tab 10mg
35pindolol tab 5mg
100pioglita/met tab 15-500mg
100pioglita/met tab 15-850mg
100pioglitazone tab 15mg
101pioglitazone tab 30mg
101pioglitazone tab 45mg
105pirmella tab 1/35
105pirmella tab 7/7/7
49piroxicam cap 10mg
49piroxicam cap 20mg
133podofilox sol 0.5%
92polyeth glyc pow 3350 nf
86polymyxin b/ sol trimethp
25polysaccharide iron complex cap 150 mg
25polysaccharide iron complex cap 200 mg
86polytrim sol op
16POMALYST CAP 1MG
16POMALYST CAP 2MG
16POMALYST CAP 3MG
17POMALYST CAP 4MG
105portia-28 tab
83pot bicarbon tab 25meq ef
Drug Name Page # Drug Name Page #
83pot chloride cap 10meq er
83pot chloride cap 8meq er
83pot chloride inj 10meq
83pot chloride inj 20meq
83pot chloride inj 2meq/ml
83pot chloride inj 40meq
83pot chloride sol 10%
83pot chloride sol 10% sf
83pot chloride sol 20%
83pot chloride sol 20% sf
83pot chloride tab 10meq cr
83pot chloride tab 10meq er
83pot chloride tab 20meq er
83pot chloride tab 25meq ef
83pot chloride tab 8meq cr
84pot chloride tab 8meq er
84pot chloride tab 8meq sa
84pot chloride tab 8meq sr
80pot citrate tab 1080mg
80pot citrate tab 1620mg
80pot citrate tab 540mg er
84pot cl micro tab 10meq cr
84pot cl micro tab 10meq er
84pot cl micro tab 20meq cr
84pot cl micro tab 20meq er
84pot/chloride tab 25meq ef
84potassium tab 25meq ef
60POTIGA TAB 200MG
60POTIGA TAB 300MG
60POTIGA TAB 400MG
60POTIGA TAB 50MG
126pr benzoyl liq 7% wash
28PRADAXA CAP 150MG
29PRADAXA CAP 75MG
65pramipexole tab 0.125mg
66pramipexole tab 0.25mg
66pramipexole tab 0.375mg
66pramipexole tab 0.5mg
66pramipexole tab 0.75mg
66pramipexole tab 1.5mg
66pramipexole tab 1mg
131prascion emu
33pravastatin tab 10mg
33pravastatin tab 20mg
33pravastatin tab 40mg
33pravastatin tab 80mg
31prazosin hcl cap 1mg
31prazosin hcl cap 2mg
31prazosin hcl cap 5mg
88PRED MILD SUS 0.12% OP
88pred sod pho sol 1% op
96pred sod pho sol 5mg/5ml
129prednicarbat cre 0.1%
96prednisolone sol 15mg/5ml
96prednisolone sol 15mg/5ml
96prednisolone sol 25mg/5ml
88prednisolone sus 1% op
96prednisolone syp 15mg/5ml
96PREDNISONE CON 5MG/ML
96prednisone pak 10mg
96prednisone pak 5mg
96prednisone sol 5mg/5ml
96prednisone tab 10mg
96prednisone tab 1mg
96prednisone tab 2.5mg
96prednisone tab 20mg
96prednisone tab 50mg
96prednisone tab 5mg
107PREFEST TAB
108pregnyl inj 10000unt
107PREMARIN TAB 0.3MG
108PREMARIN TAB 0.45MG
108PREMARIN TAB 0.625MG
108PREMARIN TAB 0.9MG
108PREMARIN TAB 1.25MG
108PREMARIN VAG CRE 0.625MG
108PREMPHASE TAB
108PREMPRO TAB .625-2.5
108PREMPRO TAB 0.3-1.5
108PREMPRO TAB 0.45-1.5
108PREMPRO TAB 0.625-5
134prenatal multivit-min w/fe-fa tab
134prenatal vit w/ ferrous fumarate-folic acid cap
135prenatal vit w/ ferrous fumarate-folic acid tab
135prenatal vit w/ ferrous gluconate-folic acid tab