Drug Name Drug Requirements/ Drug Name Drug ......HealthSelect MedicareRx Effective January 1, 2016 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under

HealthSelect MedicareRx Effective January 1, 2016

1PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered underMedicare B or D LA - Limited Access

Drug Name DrugTier

Requirements/Limits

ANALGESICSGOUTallopurinol tab 1ALOPRIM 3colchicine w/ probenecid 1COLCRYS 2probenecid 1ULORIC 2MISCELLANEOUSdiclofenac w/ misoprostol 1DUEXIS 3VIMOVO 3NSAIDScelecoxib CAPS 1diclofenac potassium 1diclofenac sodium TB24;TBEC

1

diflunisal 1etodolac 1etodolac er 1fenoprofen calcium TABS 1flurbiprofen TABS 1ibuprofen SUSP 1ibuprofen TABS 400mg,600mg, 800mg

1

ketoprofen CAPS; CP24 1mefenamic acid CAPS 1MELOXICAM SUSP 1meloxicam tabs 1nabumetone TABS 1NAPRELAN 375mg, 750mg 3naproxen SUSP; TABS;TBEC

1

naproxen sodium TABS275mg, 550mg

1

NAPROXEN SODIUM TB24 3oxaprozin 1piroxicam CAPS 1sulindac TABS 1tolmetin sodium 1ZIPSOR 3ZORVOLEX 3OPIOID ANALGESICS

Drug Name DrugTier

Requirements/Limits

acetaminophen w/ codeineSOLN

QL (5000 mL / 30 days)

1 QL

acetaminophen w/ codeineTABS

QL (400 tabs / 30 days)

1 QL

ASPIRIN-CAFFEINE-DIHYDROCODEINEBITARTRATE

1

butorphanol nasal sprayQL (10 mL / 30 days)

1 QL

butorphanol tartrate SOLN 1BUTRANS 2capital and codeine

QL (5000 mL / 30 days)3 QL

CONZIP 3nalbuphine hcl SOLN 1TRAMADOL HCL CP24 1tramadol hcl er TB24 100mg,200mg

1

TRAMADOL HCL ER TB24300mg

1

tramadol hcl er (biphasic)100mg

1


1


1

tramadol hcl tab 50 mg 1tramadol-acetaminophen

QL (240 tabs / 30 days)1 QL

trezixQL (360 caps / 30 days)

3 QL

OPIOID ANALGESICS, CIIABSTRAL

QL (120 tabs / 30 days)3 QL PA

CODEINE SULFATE 1DILAUDID-HP INJ 250MG 3 B/DDURAMORPH 1 B/DEMBEDA 3endocet


ENDODAN TAB 1fentanyl citrate LPOP

QL (120 lozenges / 30days)

3 QL PA

fentanyl patch 12 mcg/hr 1fentanyl patch 25 mcg/hr 1



Drug Name DrugTier

Requirements/Limits

fentanyl patch 50 mcg/hr 1fentanyl patch 75 mcg/hr 1fentanyl patch 100 mcg/hr 1FENTORA

QL (120 tabs / 30 days)3 QL PA

hydrocodone-acetaminophen2.5-325mg


1 QL

hydrocodone-acetaminophen5-300mg


1 QL



1 QL



1 QL

hydrocodone-acetaminophen7.5-325 mg/15ml

QL (5400 mL / 30 days)

1 QL



1 QL



1 QL

hydrocodone-acetaminophentab 10-325mg


1 QL

hydrocodone-ibuprofen tab2.5-200mg

1

hydrocodone-ibuprofen tab7.5-200 mg

1

hydromorphone hcl LIQD 1HYDROMORPHONE HCLSOLN 1mg/ml, 2mg/ml,4mg/ml

1 B/D

hydromorphone hcl SOLN500mg/50ml

1 B/D

hydromorphone hcl TABS 1hydromorphone tab 8mg er 1hydromorphone tab 12mg er 1hydromorphone tab 16mg er 3HYDROMORPHONE TABS32MG

3

HYSINGLA ER 3ibudone tab 5-200mg 1ibudone tab 10-200mg 1INFUMORPH 200 3 B/D

Drug Name DrugTier

Requirements/Limits

INFUMORPH 500 3 B/DKADIAN 40mg, 200mg 3LAZANDA

QL (30 bottles / 30 days)3 QL PA

levorphanol tartrate TABS 1lorcet hd tab 10-325mg


lorcet plus tab 7.5-325QL (360 tabs / 30 days)

1 QL

lorcet tab 5-325mgQL (360 tabs / 30 days)

1 QL

lortab tab 5-325mgQL (360 tabs / 30 days)

1 QL

lortab tab 7.5-325QL (360 tabs / 30 days)

1 QL

lortab tab 10-325mgQL (360 tabs / 30 days)

1 QL

methadone hcl CONC;SOLN; TABS

1

METHADONE INJ 10MG/ML 3MORPHINE SUL 20MG/MLORAL SOL

1

morphine sulfate CP2410mg, 20mg, 30mg, 50mg,60mg

1

morphine sulfate CP2480mg, 100mg

3

MORPHINE SULFATE SOLN1mg/ml, 10mg/ml, 15mg/ml

1 B/D

MORPHINE SULFATE SOLN2mg/ml, 4mg/ml, 8mg/ml

3 B/D

MORPHINE SULFATE SOLN10mg/5ml, 20mg/5ml

1

morphine sulfate SOLN.5mg/ml, 1mg/ml

1 B/D

MORPHINE SULFATE TABS 1morphine sulfate beads 1morphine sulfate ext-rel tab 1NUCYNTA 2NUCYNTA ER 2OPANA ER (CRUSHRESISTANT


2 QL

oxycodone hcl CAPS; CONC;TABS

1

OXYCODONE HCL SOLN 1oxycodone w/ acetaminophen2.5-325mg


1 QL



Drug Name DrugTier

Requirements/Limits

oxycodone w/ acetaminophen5-325mg


1 QL

oxycodone w/ acetaminophen7.5-325mg


1 QL

oxycodone w/ acetaminophen10-325mg


1 QL

oxycodone-aspirin 1oxycodone-ibuprofen 1OXYCONTIN 10mg, 15mg,20mg, 30mg

2

OXYCONTIN 40mg, 60mg,80mg


2 QL

oxymorphone hcl TABS 1reprexain tab 10-200mg 1roxicet soln

QL (1800 mL / 30 days)2 QL

roxicet tab 5-325mgQL (360 tabs / 30 days)

1 QL

SUBSYSQL (120 sprays / 30days)

3 QL PA

vicodinQL (400 tabs / 30 days)

1 QL

vicodin esQL (400 tabs / 30 days)

1 QL

vicodin hpQL (400 tabs / 30 days)

1 QL

XARTEMIS XRQL (120 tabs / 30 days)

3 QL

zamicetQL (5400 mL / 30 days)

1 QL

ZOHYDRO ER (ABUSEDETERRENT)

3

ANESTHETICSLOCAL ANESTHETICSlidocaine hcl (local anesth.)4%

1

lidocaine hcl (local anesth.).5%, 1%

1 B/D

lidocaine inj 0.5% 1 B/Dlidocaine inj 1% 1 B/Dlidocaine inj 1.5% 1 B/Dlidocaine inj 2% 1 B/DANTI-INFECTIVESANTI-BACTERIALS - MISCELLANEOUS

Drug Name DrugTier

Requirements/Limits

amikacin sulfate SOLN 1BETHKIS 3 B/Dgentamicin in saline 0.8 mg/ml 1gentamicin in saline 0.9mg/ml 3gentamicin in saline 1 mg/ml 1gentamicin in saline 1.2 mg/ml 1gentamicin in saline 1.4mg/ml 3gentamicin in saline 1.6 mg/ml 1gentamicin in saline 2 mg/ml 1gentamicin sulfate SOLN 1neomycin sulfate TABS 1paromomycin sulfate CAPS 1streptomycin sulfate SOLR 1sulfadiazine TABS 3TOBI PODHALER 3 LA PAtobramycin NEBU 3 B/Dtobramycin sulfate SOLN;SOLR

1

tobramycin sulfate in saline 3ANTI-INFECTIVES - MISCELLANEOUSALBENZA 2ALINIA 2atovaquone SUSP 3AZACTAM/DEX INJ 1GM 3AZACTAM/DEX INJ 2GM 3aztreonam 1BILTRICIDE 2CAYSTON 2 LA PAclindamycin hcl CAPS 1clindamycin palmitatehydrochloride

1

clindamycin phosphate SOLN 1clindamycin phosphate in d5w 1colistimethate sodium SOLR 1CUBICIN 3DALVANCE 3dapsone TABS 1DARAPRIM 3DORIBAX 3FLAGYL ER 3imipenem-cilastatin 1INVANZ 3ivermectin TABS 1linezolid SOLN 3



Drug Name DrugTier

Requirements/Limits

LINEZOLID TABS 3MACRODANTIN 25mg

90 day limit per calendaryear if 65 years and older

3 PA

meropenem 1methenamine hippurate 1METRO IV 3metronidazole CAPS; TABS 1metronidazole inj 1NEBUPENT 3 B/Dnitrofurantoin SUSP


1 PA

nitrofurantoin macrocrystal90 day limit per calendaryear if 65 years and older

3 PA

nitrofurantoin monohyd macro90 day limit per calendaryear if 65 years and older

3 PA

PENTAM 300 3polymyxin b sulfate SOLR 1PRIMSOL SOL 50MG/5ML 3SIVEXTRO 3sulfamethoxazole-trimethop 1sulfamethoxazole-trimethoprim inj

1

SYNERCID 3trimethoprim TABS 1TYGACIL 3vancomycin hcl CAPS 3vancomycin hcl inj 5gm 1vancomycin hcl inj 10gm 1vancomycin hcl inj 500mg 1vancomycin hcl inj 750mg 3vancomycin hcl inj 1000mg 1XIFAXAN TAB 200MG 3ZYVOX SUSR; TABS 3ANTIFUNGALSABELCET 3 B/DAMBISOME 3 B/DAMPHOTEC 3 B/Damphotericin b SOLR 1 B/DCANCIDAS 3CRESEMBA 3ERAXIS 3fluconazole SUSR; TABS 1

Drug Name DrugTier

Requirements/Limits

fluconazole in dextrose 1fluconazole in nacl 1flucytosine CAPS 3griseofulvin microsize 1griseofulvin ultramicrosize 1itraconazole CAPS 1ketoconazole TABS 1LAMISIL PACK 3MYCAMINE 3NOXAFIL 3nystatin TABS 1ONMEL 3SPORANOX SOL 10MG/ML 3terbinafine hcl TABS 1voriconazole SUSR; TABS 3voriconazole inj 200mg 1ANTIMALARIALSatovaquone-proguanil hcl tab62.5-25 mg

1

atovaquone-proguanil hcl tab250-100 mg

1

chloroquine phosphate TABS 1COARTEM 2mefloquine hcl 1PRIMAQUINE PHOSPHATE 3quinine sulfate CAPS 1ANTIRETROVIRAL AGENTSabacavir sulfate 1APTIVUS 3CRIXIVAN 3didanosine 1EDURANT 3EMTRIVA 2FUZEON 2INTELENCE 25mg 2INTELENCE 100mg, 200mg 3INVIRASE 3ISENTRESS CHEW 25mg 2ISENTRESS CHEW 100mg 3ISENTRESS PACK 2ISENTRESS TABS 3lamivudine 1LEXIVA 3NEVIRAPINE SUSP 1



Drug Name DrugTier

Requirements/Limits

nevirapine TABS; TB24 1NORVIR 2PREZISTA SUSP 3PREZISTA TABS 75mg,150mg

2

PREZISTA TABS 600mg,800mg

3

RESCRIPTOR 2RETROVIR IV INFUSION 3REYATAZ 3SELZENTRY 3stavudine 1SUSTIVA CAPS 2SUSTIVA TABS 3TIVICAY 3TYBOST 2VIDEX PEDIATRIC 3VIRACEPT 3VIRAMUNE XR 100mg 2VIREAD 3VITEKTA 3ZIAGEN SOLN 2zidovudine 1ANTIRETROVIRAL COMBINATIONAGENTSabacavir sulfate-lamivudine-zidovudine

3

ATRIPLA 3COMPLERA 3EPZICOM 3EVOTAZ 3KALETRA SOL 3KALETRA TAB 100-25MG 2KALETRA TAB 200-50MG 3lamivudine-zidovudine 3PREZCOBIX 3STRIBILD 3TRIUMEQ 3TRUVADA 3ANTITUBERCULAR AGENTSCAPASTAT SULFATE 3cycloserine CAPS 3ethambutol hcl TABS 1isoniazid SOLN; SYRP 1

Drug Name DrugTier

Requirements/Limits

isoniazid tabs 1paser d/r 3PRIFTIN 3pyrazinamide 1rifabutin 1rifamate 3rifampin CAPS; SOLR 1RIFATER 3SIRTURO 3 LATRECATOR 3ANTIVIRALSacyclovir CAPS; SUSP;TABS

1

acyclovir sodium SOLN 1 B/Dacyclovir sodium SOLR500mg

1 B/D

adefovir dipivoxil 3BARACLUDE SOLN 2cidofovir 3entecavir 3EPIVIR HBV SOLN 2famciclovir TABS 1foscarnet sodium 1ganciclovir inj 500mg 1 B/DHARVONI 3 PAlamivudine (hbv) 1moderiba pak MISC 3moderiba pak TABS 400mg 3MODERIBA PAK TABS600mg

3

moderiba tab 200mg 1PEG-INTRON 3 PAPEG-INTRON REDIPEN 3 PAPEGINTRON 80mcg/0.5ml,120mcg/0.5ml, 150mcg/0.5ml

3 PA

REBETOL SOLN 3RELENZA DISKHALER 2ribapak mis 600/day 3ribasphere CAPS 1ribasphere TABS 200mg,400mg

1

ribasphere TABS 600mg 3ribasphere ribapak 800 3ribasphere ribapak 1000 3ribasphere ribapak 1200 3



Drug Name DrugTier

Requirements/Limits

ribavirin 200mg 1rimantadine hydrochloride 1SOVALDI 3 PATAMIFLU 2TYZEKA 3valacyclovir hcl TABS 1VALCYTE SOLR 3valganciclovir hcl 3CEPHALOSPORINSAVYCAZ 3CEDAX SUSR 90mg/5ml 3cefaclor 1cefaclor er tab 500mg 3cefadroxil 1cefazolin inj 1cefazolin sodium 1gm, 20gm 1cefazolin/dextrose 3cefdinir 1CEFEPIME 1GM SOLN 3CEFEPIME 2GM SOLN 3CEFEPIME HCL ANDDEXTROSE

3

cefepime inj 1gm 1cefepime inj 2gm 1cefixime 1cefotaxime sodium 1gm,2gm, 500mg

1

cefotetan disodium 3cefoxitin sodium 1CEFOXITIN SODIUM INDEXTROSE

3

cefpodoxime proxetil 1cefprozil 1ceftazidime 1CEFTAZIDIME/DEXTROSE 3CEFTIBUTEN 1CEFTIN SUSR 3ceftriaxone sodium SOLR1gm, 2gm, 10gm, 250mg,500mg

1

cefuroxime axetil 1cefuroxime sodium 1.5gm,7.5gm, 750mg

1

cefuroxime sodium 7.5gm 3cephalexin 1

Drug Name DrugTier

Requirements/Limits

claforan 1gm, 2gm 3FORTAZ SOLN 3FORTAZ SOLR 500mg 3MAXIPIME 3SUPRAX CAPS 2suprax CHEW 2SUPRAX SUSR 500mg/5ml 2tazicef SOLR 1tazicef vial 1TEFLARO 3ZERBAXA 3ZINACEF SOLR 750mg 3ERYTHROMYCINS/MACROLIDESAZITHROMYCIN PACK 1azithromycin SOLR 500mg 1azithromycin SUSR 1azithromycin TABS 1clarithromycin SUSR; TABS;TB24

1

DIFICID 3e.e.s. 400 tab 400mg 1E.E.S. GRANULES 3ery-tab 3ERYPED 200 3ERYPED 400 3erythrocin lactobionate500mg

3

erythrocin stearate 1erythromycin base 1erythromycin cap 250mg ec 1erythromycin ethylsuccinate 1PCE 3ZMAX 3FLUOROQUINOLONESAVELOX SOLN 3ciprofloxacin SOLN200mg/20ml

1

ciprofloxacin SUSR 1ciprofloxacin er 1ciprofloxacin hcl TABS 1ciprofloxacin in d5w 1ciprofloxacn inj 400mg/40ml 1FACTIVE 3levofloxacin SOLN; TABS 1



Drug Name DrugTier

Requirements/Limits

levofloxacin in d5w 1moxifloxacin hcl TABS 1PENICILLINSamoxicillin 1amoxicillin & pot clavulanate 1ampicillin & sulbactam sodium 1ampicillin cap 250mg 1ampicillin cap 500 mg 1ampicillin inj 1ampicillin sodium 1ampicillin susp 1AUGMENTIN SUSR 3BACTOCILL INJ DEX 1GM 3BACTOCILL INJ DEX 2GM 3BICILLIN C-R 3BICILLIN L-A 3dicloxacillin sodium 1nafcillin sodium 1gm 1nafcillin sodium 2gm, 10gm 3NALLPEN ISO-OSMOTIC INDE

3

NALLPEN/DEXTROSE 3oxacillin sodium 1gm, 2gm 1oxacillin sodium 10gm 3PENICILLIN G POT INDEXTROSE

3

PENICILLIN G POTASSIUMIN

3

penicillin g procaine 3penicillin g sodium 1penicillin v potassium 1penicilln gk inj 5mu 1penicilln gk inj 20mu 1pfizerpen g inj 5mu 1pfizerpen-g inj 20mu 1piperacillin sodium-tazobactam sodium

1

ZOSYN SOLN 3TETRACYCLINESdemeclocycline hcl 1doxy 1doxycycline (monohydrate) 1doxycycline hyclate CAPS;SOLR; TABS; TBEC

1

Drug Name DrugTier

Requirements/Limits

minocycline hcl CAPS; TABS;TB24

1

SOLODYN 3TETRACYCLINE HCL CAPS 1VIBRAMYCIN SYRP 2ANTINEOPLASTIC AGENTSALKYLATING AGENTSBICNU 3 B/DBUSULFEX 3 B/DCYCLOPHOSPHAMIDECAPS

2 B/D

cyclophosphamide SOLR1gm, 500mg

3 B/D

cyclophosphamide SOLR2gm

1 B/D

dacarbazine 200mg 1 B/DEMCYT 2GLEOSTINE 3HEXALEN 3IFEX INJ 3GM 3 B/Difosfamide inj 1gm 1 B/Difosfamide inj 1gm/20ml 1 B/DIFOSFAMIDE INJ 3GM 3 B/Difosfamide inj 3gm/60ml 1 B/DLEUKERAN 2LOMUSTINE 1melphalan hcl 3 B/DMUSTARGEN 3 B/DTREANDA 3 B/DZANOSAR 3 B/DANTHRACYCLINESadriamyc inj 50mg 1 B/Ddaunorubicin hcl 1 B/Ddoxorubicin hcl 50mg 1 B/Ddoxorubicin hcl liposomal inj(for iv infusion) 2 mg/ml

3 B/D

doxorubicin inj 50mg 1 B/Depirubicin inj 50mg/25ml 1 B/Depirubicin inj 200mg 1 B/Didarubicin hcl 3 B/DANTIBIOTICSbleomycin sulfate 1 B/DCOSMEGEN 3 B/Dmitomycin SOLR 1 B/D



Drug Name DrugTier

Requirements/Limits

ANTIMETABOLITESadrucil 1 B/DALIMTA 3 B/DARRANON 3 B/Dazacitidine 3 B/Dcladribine 3 B/DCLOLAR 3 B/Dcytarabine inj 1 B/Ddecitabine 3 B/Dfludarabine phosphate 1 B/Dfluorouracil SOLN 1 B/DGEMCITABINE 3 B/Dgemcitabine hcl 3 B/Dmercaptopurine TABS 1methotrexate sodium inj 1 B/DNIPENT 3 B/DPURIXAN 3TABLOID 2ANTIMITOTIC, TAXOIDSABRAXANE 3 B/DDOCETAXEL CONC20mg/ml, 80mg/4ml

3 B/D

docetaxel CONC 140mg/7ml 3 B/DDOCETAXEL SOLN80mg/8ml, 200mg/20ml

3 B/D

paclitaxel 1 B/DANTIMITOTIC, VINCA ALKALOIDSvinblastine sulfate 1 B/Dvincasar 1 B/Dvincristine sulfate 1 B/Dvinorelbine tartrate 1 B/DBIOLOGIC RESPONSE MODIFIERSARZERRA 3 B/DAVASTIN 3 B/D LABELEODAQ 3 PAERBITUX 3 B/DERIVEDGE 3 LA PAFARYDAK 3 LA PAHERCEPTIN 3 B/DIBRANCE 3 LA PAISTODAX 3 B/DKADCYLA 3 B/DKEYTRUDA 3 PALYNPARZA 3 LA PA

Drug Name DrugTier

Requirements/Limits

PERJETA 3 PAPROLEUKIN 3 B/DRITUXAN 2 LA PATORISEL 3 B/DVECTIBIX 3 B/DVELCADE 3 B/DYERVOY 3 PAZOLINZA 3 PAHORMONAL ANTINEOPLASTIC AGENTSanastrozole TABS 1bicalutamide 1DEPO-PROVERA INJ 400/ML 3 B/DELIGARD INJ 7.5MG 3 B/DELIGARD INJ 22.5MG 3 B/DELIGARD INJ 30MG 3 B/DELIGARD INJ 45MG 3 B/Dexemestane 1FARESTON 3FASLODEX 3 B/DFIRMAGON 3 B/Dflutamide 1letrozole TABS 1leuprolide acetate KIT 1 PALUPRON DEP INJ 11.25MG 3 PALUPRON DEP-PED INJ7.5MG

3 PA

LUPRON DEP-PED INJ11.25MG

3 PA

LUPRON DEP-PED INJ15MG

3 PA

LUPRON DEP-PED INJ30MG (3-MONTH)

3 PA

LUPRON DEPOT 3.75mg,7.5mg

3 PA

LUPRON DEPOT INJ 22.5MG(3-MONTH)

3 PA

LUPRON DEPOT INJ 30MG(3-MONTH)

3 PA

LYSODREN 2MEGACE ES 3megestrol acetate SUSP40mg/ml

PA if 65 years and older

3 PA

megestrol acetate TABSPA if 65 years and older

3 PA

NILANDRON 3



Drug Name DrugTier

Requirements/Limits

SOLTAMOX 3tamoxifen citrate TABS 1TRELSTAR MIXJECT 3 PAXTANDI 3 LA PAZYTIGA 3 LA PAKINASE INHIBITORSAFINITOR 3 PAAFINITOR DISPERZ 3 PABOSULIF 3 PACAPRELSA 3 LA PACOMETRIQ 3 LA PAGILOTRIF TAB 20MG 3 LA PAGILOTRIF TAB 30MG 3 LA PAGILOTRIF TAB 40MG 3 LA PAGLEEVEC 2 PAICLUSIG 3 LA PAIMBRUVICA CAP 140MG 3 LA PAINLYTA 3 LA PAJAKAFI 3 LA PALENVIMA 10MG DAILYDOSE

3 LA PA

LENVIMA 14MG DAILYDOSE

3 LA PA


3 LA PA


3 LA PA

MEKINIST 3 LA PANEXAVAR 3 LA PASPRYCEL 3 PASTIVARGA 3 LA PASUTENT 3 PATAFINLAR 3 LA PATARCEVA 3 LA PATASIGNA 3 PATYKERB 3 LA PAVOTRIENT 3 LA PAXALKORI 3 LA PAZELBORAF 3 LA PAZYDELIG 3 LA PAZYKADIA 3 LA PAMISCELLANEOUSDROXIA 3HALAVEN 3 B/D

Drug Name DrugTier

Requirements/Limits

hydroxyurea CAPS 1IXEMPRA KIT 3 B/DMATULANE 3 LAmitoxantrone hcl 1 B/DPOMALYST 3 LA PASYLATRON KIT 200MCG 3 PASYLATRON KIT 300MCG 3 PASYLATRON KIT 600MCG 3 PASYNRIBO 3 PATARGRETIN CAPS 3 PAtretinoin CAPS 2TRISENOX 3 B/DUVADEX 3 B/DPLATINUM-BASED AGENTScarboplatin 1 B/Dcisplatin 1 B/DELOXATIN 3 B/Doxaliplatin 3 B/DPROTECTIVE AGENTSamifostine crystalline 3 B/Ddexrazoxane 250mg 3 B/DELITEK 3 B/DFUSILEV 3 B/DKEPIVANCE 3 B/Dleucovorin calcium TABS 1leucovorin calcium inj 50mg 1 B/Dleucovorin calcium inj 100mg 1 B/Dleucovorin calcium inj 200mg 1 B/Dleucovorin calcium inj 350mg 1 B/Dleucovorin calcium inj 500mg 3 B/Dlevoleucovorin calcium 3 B/Dmesna 1 B/DMESNEX TABS 3TOPOISOMERASE INHIBITORSCAMPTOSAR 300mg/15ml 3 B/DETOPOPHOS 3 B/Detoposide SOLN 500mg/25ml 1 B/Dirinotecan inj 40mg/2ml 1 B/Dirinotecan inj 100/5ml 1 B/Dirinotecan inj 500mg/25ml 1 B/Dtoposar 1gm/50ml 1 B/Dtopotecan hcl SOLR 3 B/DCARDIOVASCULAR



Drug Name DrugTier

Requirements/Limits

ACE INHIBITOR COMBINATIONSamlodipine besylate-benazepril hcl

1

benazepril &hydrochlorothiazide

1

captopril &hydrochlorothiazide

1

enalapril maleate &hydrochlorothiazide

1

fosinopril sodium &hydrochlorothiazide

1

lisinopril &hydrochlorothiazide

1

moexipril-hydrochlorothiazide 1quinapril-hydrochlorothiazide 1trandolapril-verapamil hcl 1ACE INHIBITORSbenazepril hcl TABS 1captopril TABS 1enalapril maleate TABS 1fosinopril sodium 1lisinopril TABS 1moexipril hcl 1perindopril erbumine 1quinapril hcl 1ramipril 1trandolapril 1ALDOSTERONE RECEPTORANTAGONISTSeplerenone 1spironolactone TABS 1ALPHA BLOCKERSdoxazosin mesylate 1prazosin hcl 1terazosin hcl 1ANGIOTENSIN II RECEPTORANTAGONIST COMBINATIONSamlodipine besylate-valsartantab 5-160 mg

1

amlodipine besylate-valsartantab 5-320 mg

1


1


1

Drug Name DrugTier

Requirements/Limits

amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg

1

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg

1

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg

1


1


1

AZOR 2BENICAR HCT 2candesartan cilexetil-hydrochlorothiazide

1

EDARBYCLOR 3irbesartan-hydrochlorothiazide 1losartan-hydrochlorothiazide 1telmisartan-amlodipine 1telmisartan-hydrochlorothiazide

1

TEVETEN HCT 3TRIBENZOR 2valsartan-hydrochlorothiazide 1ANGIOTENSIN II RECEPTORANTAGONISTSBENICAR 2candesartan cilexetil 1EDARBI 3eprosartan mesylate 1irbesartan 1losartan potassium 1telmisartan 1valsartan 1ANTIARRHYTHMICSamiodarone hcl 1amiodarone inj 50mg/ml 1disopyramide phosphate

PA if 65 years and older3 PA

flecainide acetate 1mexiletine hcl 1MULTAQ 3



Drug Name DrugTier

Requirements/Limits

NORPACE CRPA if 65 years and older

3 PA

pacerone 1propafenone hcl 1propafenone hcl 12hr 1quinidine gluconate TBCR 1quinidine sulfate TABS 1sorine 1sotalol hcl 1sotalol hcl (afib/afl) 1TIKOSYN 2ANTILIPEMICS, HMG-CoA REDUCTASEINHIBITORSALTOPREV 3atorvastatin calcium TABS 1CRESTOR 2fluvastatin sodium 1LESCOL XL 3LIVALO 3lovastatin 1pravastatin sodium 1simvastatin TABS 1ANTILIPEMICS, MISCELLANEOUSADVICOR 3ANTARA 3cholestyramine 1cholestyramine light 1choline fenofibrate 1colestipol hcl 1FENOFIBRATE CAPS 1fenofibrate TABS 48mg,54mg, 145mg, 160mg

1

FENOFIBRATE TABS 120mg 1fenofibrate micronized 1FENOFIBRIC ACID 1FENOGLIDE 3gemfibrozil TABS 1JUXTAPID 3 LA PAKYNAMRO 3 PALIPTRUZET 3niacin er (antihyperlipidemic) 1niacor 1omega-3-acid ethyl esters 1prevalite 1

Drug Name DrugTier

Requirements/Limits

SIMCOR 2TRIGLIDE 3VASCEPA 3VYTORIN 2WELCHOL 2ZETIA TAB 10MG 2BETA-BLOCKER/DIURETICCOMBINATIONSatenolol & chlorthalidone 1bisoprolol &hydrochlorothiazide

1

DUTOPROL 3metoprolol & hctz tab 50-25mg

1

metoprolol & hctz tab 100-25mg

1

metoprolol & hctz tab 100-50mg

1

nadolol & bendroflumethiazide 1propranolol &hydrochlorothiazide

1

BETA-BLOCKERSacebutolol hcl CAPS 1atenolol TABS 1betaxolol hcl 1bisoprolol fumarate 1BYSTOLIC 2carvedilol 1COREG CR 2labetalol hcl SOLN; TABS 1metoprolol succinate 1metoprolol tartrate SOLN;TABS

1

nadolol TABS 1pindolol 1propranolol hcl er 1propranolol inj 1mg/ml 1propranolol sol 1propranolol tab 1SOTYLIZE 3timolol maleate TABS 1CALCIUM CHANNELBLOCKER/ANTILIPEMIC COMBINATIONSamlodipine besylate/atorv 1



Drug Name DrugTier

Requirements/Limits

CALCIUM CHANNEL BLOCKERSafeditab cr 1amlodipine besylate TABS 1CARDIZEM LA 120mg 3cartia xt 1dilt-xr cap 1diltiazem cap 120mg/24hr 1diltiazem cap er/12hr 1diltiazem hcl TABS 1diltiazem hcl coated beads 1diltiazem hcl er 1diltiazem hcl extended releasebeads

1

diltiazem inj 25mg/5ml 1diltiazem inj 50/10ml 1diltiazem inj 100mg 3diltiazem inj 125/25ml 1diltzac 1felodipine 1isradipine 1matzim la 1nicardipine hcl CAPS 1nifedical 1nifedipine TB24 1nifedipine er 1nimodipine CAPS 3nisoldipine 1NYMALIZE 3taztia xt 1verapamil hcl CP24 100mg,120mg, 180mg, 200mg,240mg, 300mg

1

VERAPAMIL HCL CP24360mg

1

verapamil hcl SOLN 1verapamil hcl TABS 1verapamil hcl TBCR 1DIGITALIS GLYCOSIDESdigitek .25mg


digitek .125mg 1digoxin 125mcg 1digoxin 250mcg


digoxin inj 1

Drug Name DrugTier

Requirements/Limits

DIGOXIN SOL 50MCG/MLPA if 65 years and older

1 PA

LANOXIN TABS 62.5mcg 2LANOXIN TABS 187.5mcg


LANOXIN PEDIATRIC 3DIRECT RENININHIBITORS/COMBINATIONSTEKTURNA 2TEKTURNA HCT 2DIURETICSacetazolamide CP12; TABS 1acetazolamide sodium 1ALDACTAZIDE TAB 50/50 3amiloride &hydrochlorothiazide

1

amiloride hcl 1bumetanide 1chlorothiazide tabs 1chlorthalidone 25mg, 50mg 1DIURIL SUS 250/5ML 3DYRENIUM 3EDECRIN 3furosemide SOLN; TABS 1furosemide inj 10mg/ml 1FUROSEMIDE INJ 10mg/ml 1furosemide oral soln 8 mg/ml 2hydrochlorothiazide CAPS;TABS

1

indapamide 1methazolamide TABS 1methyclothiazide 1metolazone 1spironolactone &hydrochlorothiazide

1

torsemide inj 50mg/5ml 3torsemide tabs 1triamt/hctz cap 37.5-25 1triamt/hctz cap 50-25mg 1triamt/hctz tab 37.5-25 1triamt/hctz tab 75-50mg 1MISCELLANEOUSBIDIL 2clonidine hcl PTWK; TABS 1



Drug Name DrugTier

Requirements/Limits

clorpres 1CORLANOR 3DEMSER 3DIBENZYLINE 3hydralazine hcl SOLN; TABS 1midodrine hcl 1minoxidil TABS 1RANEXA 2NITRATESDILATRATE SR 3ISORDIL TITRADOSE 40mg 2isosorbide dinitrate 1isosorbide dinitrate er 1isosorbide mononitrate 1isosorbide mononitrate er 1minitran 1nitro-bid 3NITRO-DUR .3mg/hr, .8mg/hr 2nitroglycerin .4mg/spray 1NITROGLYCERIN LINGUAL 1nitroglycerin patches 1NITROSTAT 2PULMONARY ARTERIAL HYPERTENSIONADCIRCA 3 PAADEMPAS 3 LA PALETAIRIS 3 LA PAOPSUMIT 3 LA PAORENITRAM TAB 0.25MG 3 LA PAORENITRAM TAB 0.125MG 3 LA PAORENITRAM TAB 1MG 3 LA PAORENITRAM TAB 2.5MG 3 LA PAREMODULIN 3 B/D LAREVATIO SUSR 3 PAsildenafil citrate (pulmonaryhypertension) TABS

1 PA

TRACLEER 3 LA PATYVASO 3 B/DVENTAVIS 3 B/DCENTRAL NERVOUS SYSTEMANTIANXIETYalprazolam CONC 3alprazolam TABS 1buspirone hcl TABS 1

Drug Name DrugTier

Requirements/Limits

fluvoxamine maleate 1fluvoxamine maleate er 1lorazepam CONC; SOLN;TABS

1

ANTICONVULSANTSAPTIOM 3BANZEL SUS 40MG/ML 3BANZEL TAB 200MG 3BANZEL TAB 400MG 3carbamazepine CHEW;CP12; SUSP; TABS; TB12

1

CELONTIN 3clonazepam TABS; TBDP 1clorazepate dipotassium 1diazepam CONC; SOLN;TABS

1

DIAZEPAM GEL(ANTICONVULSANT)

1

dilantin 3DILANTIN-125 3divalproex sodium 1epitol 1ethosuximide CAPS; SOLN 1felbamate SUSP 3felbamate TABS 1FYCOMPA 3gabapentin CAPS; SOLN;TABS

1

GABITRIL 12mg, 16mg 2LAMICTAL ODT KIT 3LAMICTAL STARTER 3LAMICTAL XR KIT 2lamotrigine CHEW; TABS;TB24; TBDP

1

levetiracetam SOLN; TABS;TB24

1

LEVETIRACETAM IV 3levetiracetam oral soln 100mg/ml

1

LYRICA 2ONFI 3oxcarbazepine 1OXTELLAR XR 3PEGANONE 3phenobarbital ELIX; TABS




Drug Name DrugTier

Requirements/Limits

PHENOBARBITAL SODIUM65mg/ml


3 PA

phenobarbital sodium130mg/ml


3 PA

phenytek 3phenytoin CHEW; SUSP 1phenytoin inj 50mg/ml 1phenytoin sodium extended 1POTIGA 3primidone TABS 1SABRIL 3 LA PATEGRETOL 3TEGRETOL-XR 3tiagabine hcl 1topiramate CPSP; TABS 1TOPIRAMATE CS24 1TROKENDI XR 3valproate sodium SOLN;SYRP

1

valproic acid CAPS 1VIMPAT SOLN 2VIMPAT TABS 50mg 2VIMPAT TABS 100mg,150mg, 200mg

3

zonisamide CAPS 1ANTIDEMENTIAdonepezil odt 5mg 1donepezil odt 10mg 1donepezil tab hcl 23mg 1donepezil tabs 5mg 1donepezil tabs 10mg 1EXELON PATCHES 2galantamine hydrobromide 1memantine hcl

PA if < 30 yrs1 PA

NAMENDA SOL 10MG/5MLPA if < 30 yrs

2 PA

NAMENDA TABPA if < 30 yrs

2 PA

NAMENDA XRPA if < 30 yrs

2 PA

NAMENDA XR TITRATIONPACK

PA if < 30 yrs

2 PA

NAMZARIC 3

Drug Name DrugTier

Requirements/Limits

rivastigmine tartrate 1ANTIDEPRESSANTSamitriptyline hcl TABS


amoxapine 1APLENZIN 3BRINTELLIX 2bupropion hcl TABS; TB12;TB24

1

citalopram hydrobromide 1clomipramine hcl CAPS


desipramine hcl TABS 1doxepin hcl CAPS; CONC


duloxetine hcl CPEP 20mg,30mg, 60mg

1

EMSAM 3escitalopram oxalate 1FETZIMA 3FETZIMA TITRATION PACK 3fluoxetine hcl CAPS 1fluoxetine hcl CPDR 1fluoxetine hcl SOLN 1fluoxetine hcl TABS 10mg,20mg

1

FLUOXETINE HCL TABS60mg

2

FORFIVO XL 3imipramine hcl TABS


imipramine pamoatePA if 65 years and older

3 PA

maprotiline hcl 1MARPLAN 3mirtazapine 1nefazodone hcl 1nortriptyline hcl CAPS; SOLN 1paroxetine er tab 1paroxetine hcl tabs 1PAXIL SUSP 3PEXEVA 3phenelzine sulfate TABS 1PRISTIQ 2protriptyline hcl 1sertraline hcl CONC; TABS 1



Drug Name DrugTier

Requirements/Limits

SURMONTILPA if 65 years and older

3 PA

tranylcypromine sulfate 1trazodone hcl TABS 1venlafaxine cap er 1venlafaxine hcl 1venlafaxine tab 1VENLAFAXINE TAB 225MGER

1

venlafaxine tab er 1VIIBRYD 2ANTIPARKINSONIAN AGENTSamantadine hcl CAPS;SYRP; TABS

1

APOKYN 3 LA PAAZILECT 2BENZTROPINE MESYLATESOLN

1

benztropine mesylate TABSPA if 65 years and older

3 PA

bromocriptine mesylateCAPS; TABS

1

carbidopa TABS 3carbidopa-levodopa 1CARBIDOPA/LEVODOPA/ENTACAPONE

1

DUOPA 3 B/DENTACAPONE 1MIRAPEX .75mg 3MIRAPEX ER .375mg,2.25mg, 3mg, 3.75mg, 4.5mg

2

NEUPRO 2pramipexole dihydrochloride 1ropinirole hydrochloride 1RYTARY 3selegiline hcl CAPS; TABS 1ZELAPAR 3ANTIPSYCHOTICSABILIFY DISCMELT TAB10MG

3

ABILIFY MAINTENA 3aripiprazole tabs 3chlorpromaz inj 25mg/ml 3chlorpromazine hcl TABS 1clozapine 1

Drug Name DrugTier

Requirements/Limits

CLOZAPINE ODT 12.5mg,25mg, 100mg

1

CLOZAPINE ODT 150mg,200mg

3

FANAPT 3FANAPT TITRATION PACK 3FAZACLO 150mg, 200mg 3fluphenazine decanoateSOLN

1

fluphenazine hcl 1GEODON INJ 3haloperidol TABS 1haloperidol decanoate SOLN 1haloperidol lactate 1haloperidol lactate inj 5 mg/ml 1INVEGA 3INVEGA SUST INJ 39MG/0.25 ML

3

INVEGA SUST INJ 78 MG/0.5ML

3

INVEGA SUST INJ 117MG/0.75 ML

3

INVEGA SUST INJ156MG/ML

3

INVEGA SUST INJ 234MG/1.5 ML

3

INVEGA TRINZA 3LATUDA 2loxapine succinate 1olanzapine 1olanzapine odt 1ORAP 3perphenazine TABS 1quetiapine fumarate 1RISPERDAL INJ 12.5MG 2RISPERDAL INJ 25MG 2RISPERDAL INJ 37.5MG 3RISPERDAL INJ 50MG 3risperidone 1risperidone odt 1SAPHRIS 3SEROQUEL XR 2thioridazine hcl TABS


thiothixene 1trifluoperazine hcl 1



Drug Name DrugTier

Requirements/Limits

VERSACLOZ 3ziprasidone hcl 1ZYPREXA RELPREVV 3ZYPREXA RELPREVV INJ210MG

3

ATTENTION DEFICIT HYPERACTIVITYDISORDERamphetamine cap 10mg er 1amphetamine cap 15mg er 1amphetamine cap 20mg er 1amphetamine cap 25mg er 1amphetamine cap 30mg er 1amphetamine-dextroamphetamine cap sr24hr 5 mg

1

amphetamine-dextroamphetamine tab 5 mg

1

amphetamine-dextroamphetamine tab 7.5mg

1

amphetamine-dextroamphetamine tab 10mg

1

amphetamine-dextroamphetamine tab 12.5mg

1


1


1


1

APTENSIO XR 3DAYTRANA 2guanfacine hcl (adhd)


metadate er tab 20mg 1methylphenidate hcl CHEW;CP24; CPCR; SOLN; TABS;TBCR

1

methylphenidate hcl er 1QUILLIVANT XR 2RITALIN LA 10mg, 60mg 3STRATTERA 2VYVANSE 2

Drug Name DrugTier

Requirements/Limits

HYPNOTICSHETLIOZ 3 LA PAROZEREM 3SILENOR 2temazepam 7.5mg

QL (30 caps / 30 days)90 day limit per calendaryear if 65 years and older

1 QL PA

temazepam 15mgQL (60 caps / 30 days)


1 QL PA

zolpidem tartrate TABSQL (30 tabs / 30 days)


3 QL PA

MIGRAINEalmotriptan malate 1ALSUMA 3AXERT 3cafergot tab 1-100mg 3dihydroergotamine mesylate1mg/ml

1

DIHYDROERGOTAMINEMESYLATE 4mg/ml

3

ergomar 3FROVA TAB 2.5MG 3migergot 3naratriptan hcl 1RELPAX 2rizatriptan benzoate 1SUMATRIPTAN INJ4MG/0.5ML

1

sumatriptan inj 6mg/0.5mlSOAJ; SOLN; SOSY

1

SUMATRIPTAN INJ6MG/0.5ML SOCT

1

SUMATRIPTAN SUCCINATESOLN 5mg/act, 20mg/act

1

sumatriptan succinate TABS 1SUMAVEL DOSEPRO 3TREXIMET 3zolmitriptan TABS 1zolmitriptan odt 1ZOMIG NASAL SPRAY 2MISCELLANEOUSBRISDELLE 2



Drug Name DrugTier

Requirements/Limits

EQUETRO 3GRALISE 2GRALISE STARTER 2HORIZANT 3lithium carbonate CAPS;TABS; TBCR

1

LITHIUM SOLN 8MEQ/5ML 3MESTINON SYRUP 2MESTINON TIMESPAN 2NUEDEXTA 2pyridostigmine bromideTABS; TBCR

1

riluzole 1SAVELLA 2SAVELLA TITRATION PACK 2XENAZINE 3 LA PAMULTIPLE SCLEROSIS AGENTSAMPYRA 3 LA PAAUBAGIO 3 LA PAAVONEX 3 PAAVONEX PEN 3 PABETASERON 3 PACOPAXONE INJ 40MG/ML 3 PAEXTAVIA 3 PAGILENYA CAP 0.5MG 3 PAglatopa 3 PALEMTRADA 3 LA PAPLEGRIDY 3 PAPLEGRIDY STARTER PACK 3 PAREBIF 3 PAREBIF REBIDOSE 3 PAREBIF REBIDOSETITRATION

3 PA

REBIF TITRATION PACK 3 PATECFIDERA CAP 120MG 3 LA PATECFIDERA CAP 240MG 3 LA PATECFIDERA MIS STARTER 3 LA PATYSABRI 3 LA PAMUSCULOSKELETAL THERAPY AGENTSbaclofen TABS 1BOTOX INJ 100UNIT 3 PABOTOX INJ 200UNIT 3 PAcyclobenzaprine hcl TABS5mg, 10mg


3 PA

Drug Name DrugTier

Requirements/Limits

dantrolene sodium CAPS 1tizanidine 1XEOMIN INJ 50 UNIT 3 PAXEOMIN INJ 100 UNIT 3 PANARCOLEPSY/CATAPLEXYmodafinil 100mg 1modafinil 200mg 3NUVIGIL 2XYREM 3 LA PAPSYCHOTHERAPEUTIC-MISCacamprosate calcium 1BUNAVAIL MIS 2.1-0.3MG 3BUNAVAIL MIS 4.2-0.7MG 3BUNAVAIL MIS 6.3-1MG 3buprenorphine hcl SUBL 1buprenorphine hcl-naloxonehcl sl

1

buproban 1CHANTIX 2CHANTIX CONTINUINGMONTH

2

CHANTIX STARTER PACK 2disulfiram TABS 1naloxone hcl SOLN 1naltrexone hcl TABS 1NICOTROL INHALER 3NICOTROL NS 3SARAFEM 3SUBOXONE MIS 2-0.5MG 3SUBOXONE MIS 4-1MG 3SUBOXONE MIS 8-2MG 3SUBOXONE MIS 12-3MG 3ZUBSOLV SUB 1.4-0.36MG 3ZUBSOLV SUB 5.7-1.4MG 3ZUBSOLV SUB 8.6-2.1MG 3ENDOCRINE AND METABOLICANDROGENSANDRODERM 2 PAANDROGEL 3 PAANDROGEL 1% 3 PAANDROGEL 1.62% 3 PAANDROGEL PUMP 3 PAAVEED 3 PAAXIRON 2 PA



Drug Name DrugTier

Requirements/Limits

depo-testosterone 100mg/ml 3 PAFORTESTA 3 PAoxandrolone TABS 2.5mg 1 PAoxandrolone TABS 10mg 3 PASTRIANT 3 PATESTIM 3 PAtestosterone cypionate SOLN 1 PAtestosterone enanthateSOLN

1 PA

VOGELXO 3 PAVOGELXO PUMP 3 PAANTIDIABETICS, INJECTABLEALCOHOL SWABS 2APIDRA 3APIDRA SOLOSTAR 3BYDUREON 3BYETTA 3GAUZE PADS 2X2 2HUMALOG 3HUMALOG KWIKPEN 3HUMALOG MIX 50/50 3HUMALOG MIX 50/50KWIKPEN

3

HUMALOG MIX 75/25 3HUMALOG MIX 75/25KWIKPEN

3

HUMULIN 70/30 3HUMULIN 70/30 KWIKPEN 3HUMULIN N 3HUMULIN N KWIKPEN 3HUMULIN R 3HUMULIN R U-500(CONCENTRATE)

3 B/D

INSULIN PEN NEEDLES 2INSULIN SAFETY NEEDLES 2INSULIN SYRINGES 2LANTUS 2LANTUS SOLOSTAR 2LEVEMIR 2LEVEMIR FLEXTOUCH 2NOVOLIN 70/30 2NOVOLIN 70/30 RELION 3NOVOLIN N 2NOVOLIN N RELION 3

Drug Name DrugTier

Requirements/Limits

NOVOLIN R 2NOVOLIN R RELION 3NOVOLOG 2NOVOLOG FLEXPEN 2NOVOLOG MIX 70/30 2NOVOLOG MIX 70/30PREFILL

2

NOVOLOG PENFILL 2SYMLINPEN 60 2SYMLINPEN 120 3TANZEUM 3TOUJEO SOLOSTAR 2TRULICITY 3VICTOZA 2ANTIDIABETICS, ORALacarbose 1ACTOPLUS MET XR 15-1000MG

3

ACTOPLUS MET XR 30-1000MG

3

FARXIGA 3glimepiride 1glipizide TABS 1glipizide er 1glipizide-metformin 2.5-250mg

1

glipizide-metformin 2.5-500mg

1

glipizide-metformin 5-500mg 1GLUMETZA 3GLYSET 3GLYXAMBI 3INVOKAMET TAB 50-500MG 3INVOKAMET TAB 50-1000 3INVOKAMET TAB 150-500 3INVOKAMET TAB 150-1000 3INVOKANA TAB 100MG 3INVOKANA TAB 300MG 3JANUMET 2JANUMET XR TAB 50-500MG

2

JANUMET XR TAB 50-1000 2JANUMET XR TAB 100-1000 2JANUVIA 2JARDIANCE 3



Drug Name DrugTier

Requirements/Limits

JENTADUETO 2KAZANO 3KOMBIGLYZE XR 2.5-1000MG

3

KOMBIGLYZE XR 5-500MG 3KOMBIGLYZE XR 5-1000MG 3metformin er 1metformin hcl TABS; TB24 1nateglinide 1NESINA 3ONGLYZA 3OSENI TAB 12.5-15MG 3OSENI TAB 12.5-30MG 3OSENI TAB 12.5-45MG 3OSENI TAB 25-15MG 3OSENI TAB 25-30MG 3OSENI TAB 25-45MG 3pioglitazone hcl 1pioglitazone hcl-glimepiride 1pioglitazone hcl-metformin hcl 1PRANDIMET 3repaglinide 1RIOMET 3TRADJENTA 2XIGDUO XR TAB 5-500MG 3XIGDUO XR TAB 5-1000MG 3XIGDUO XR TAB 10-500MG 3XIGDUO XR TAB 10-1000MG 3BISPHOSPHONATESalendronate sodium 1BINOSTO 3FOSAMAX PLUS D 3ibandronate sodium 1 B/Dibandronate tab 150mg 1 B/Dpamidronate disodium SOLN6mg/ml

3 B/D

pamidronate disodium SOLN30mg/10ml, 90mg/10ml

1 B/D

RISEDRONATE SODIUMTABS 5mg, 30mg

1

risedronate sodium TABS35mg, 150mg

1

risedronate sodium TBEC 1zoledronic inj 4mg/5ml 1 B/Dzoledronic inj 5/100ml 1 B/D

Drug Name DrugTier

Requirements/Limits

ZOMETA SOLN 3 B/DCALCIUM RECEPTOR AGONISTSSENSIPAR 2CHELATING AGENTSCHEMET 3DEPEN TITRATABS 3EXJADE 3 LA PAFERRIPROX 3 LA PAJADENU 3 PAkionex 1sodium polystyrene sulfonate 1sps susp 15gm/60ml 1SYPRINE 3CONTRACEPTIVESaltavera 1amethia 91 day 1amethyst 28 day 1apri 28 day 1aranelle 28 1ashlyna 91 day 1aubra 28 day 1aviane 28 1balziva 28 day 1BEYAZ 2briellyn 28 day 1camila 28 day 1CAMRESE LO TAB 1cryselle 28 1cyclafem 1/35 28 day 1cyclafem 7/7/7 28 day 1deblitane 28 day 1delyla 28 day 1DEPO-SUBQ PROVERA 104 2desogestrel-ethinyl estradiol(biphasic)

1

drospirenone-ethinyl estradiol 1ELLA 3emoquette 1enpresse 28 day 1errin 28 day 1falmina 28 day 1GIANVI TAB 3-0.02MG 1gildagia 1



Drug Name DrugTier

Requirements/Limits

gildess 1.5/30 21 day 1gildess 24 fe 28 day 1heather 1introvale 91 day 1JOLESSA TAB 0.15-0.03 MG 1JOLIVETTE 1junel 1.5/30 21 day 1junel 1/20 21 day 1junel fe 1.5/30 28 day 1junel fe 1/20 28 day 1junel fe 24 1/20 28 day 1kariva 28 day 1kelnor 1/35 28 day 1kimidess 1larin 1.5/30 1larin 1/20 1larin fe 1.5/30 1larin fe 1/20 1LEENA TAB 1lessina 28 day 1levonest 28 day 1levonorgestrel & eth estradiol 1levonorgestrel (emergencyoc)

1

levonorgestrel-ethinylestradiol (91-day)

1

levonorgestrel-ethinylestradiol (continuous)

1

levora 0.15/30 28 day 1LO LOESTRIN FE 2lomedia 24 fe 1loryna 28 day 1low-ogestrel 1lutera 28 day 1lyza 1marlissa 28 day 1medroxyprogesterone acetate(contraceptive)

1

MICROGESTIN 1.5/30 1MICROGESTIN 1/20 1MICROGESTIN FE 1.5/30 1MICROGESTIN FE 1/20 1MINASTRIN 24 FE 2MONONESSA 1

Drug Name DrugTier

Requirements/Limits

my way 1myzilra 1necon 0.5/35 28 day 1necon 1/35 28 day 1NECON 7/7/7 1necon 10/11 28 day 3NECON TAB 1/50-28 1next choice tab 1.5mg 1nikki 28 day 1NORA-BE TAB 1norethin acet & estrad-fe 1norethindrone & ethinylestradiol-fe

1

norethindrone (contraceptive) 1norgestimate-ethinyl estradiol(triphasic)

1

norlyroc 28 day 1nortrel 0.5/35 28 day 1nortrel 1/35 21 day 1nortrel 1/35 28 day 1nortrel 7/7/7 28 day 1NUVARING 2OCELLA TAB 3-0.03MG 1ogestrel 28 day 1orsythia 28 day 1ORTHO TRI-CYCLEN LO 2philith 1pimtrea pack 1pirmella 1/35 28 day 1portia 28 day 1previfem 28 day 1QUARTETTE 3quasense 91 day 1reclipsen 28 day 1sharobel 28 day 1SOLIA 1sprintec 28 day 1sronyx 28 day 1syeda 1tarina fe 1/20 28 day 1tri-legest 28 day 1tri-previfem 28 day 1tri-sprintec 28 day 1TRINESSA 1



Drug Name DrugTier

Requirements/Limits

trivora 28 day 1velivet 28 day 1vestura 1viorele 1vyfemla 28 day 1wymzya fe 1xulane dis 150-35 1zarah 1zenchent fe 28 day 1zenchent tab 1zovia 1/35e 28 day 1zovia 1/50e 28 day 1ENDOMETRIOSISdanazol CAPS 1LUPANETA PACK 3 PASYNAREL 3ENZYME REPLACEMENTSADAGEN 3 LA PAALDURAZYME 3 LA PACARBAGLU 3 LA PACERDELGA 3 PACEREZYME 3 LA PACYSTADANE 3 LACYSTAGON 3 LA PAELAPRASE 3 LA PAELELYSO 3 PAFABRAZYME 3 LA PAKUVAN 3 LA PAlevocarnitine (metabolicmodifiers)

1 B/D

LUMIZYME 3 LA PAMYOZYME 3 LA PANAGLAZYME 3 LA PAORFADIN 3 LA PAPROCYSBI 3 LA PARAVICTI 3 PAsodium phenylbutyrate 3VIMIZIM 3 PAVPRIV 3 PAZAVESCA 3 LA PAESTROGENSALORA


DELESTROGEN 10mg/ml 3

Drug Name DrugTier

Requirements/Limits

depo-estradiol 3estrace CREA 2estradiol PTTW; PTWK;TABS


3 PA

estradiol valerate OIL 1ESTRING 3FEMRING 3jinteli


MENOSTARPA if 65 years and older

3 PA

MINIVELLEPA if 65 years and older

3 PA

norethindrone acetate-ethinylestradiol


3 PA

PREMARIN CREAM 2PREMARIN INJ 3VAGIFEM 2GLUCOCORTICOIDSa-hydrocort 1cortisone acetate TABS 1DEPO-MEDROL INJ20MG/ML

3 B/D

dexamethasone CONC 3dexamethasone ELIX; SOLN;TABS

1

dexamethasone sodiumphosphate

1

dexpak taperpak 13 day 2FLO-PRED SUS 3 B/Dfludrocortisone acetate TABS 1hydrocortisone TABS 1MEDROL TAB 2MG 3 B/Dmethylpr ace inj 40mg/ml 1 B/Dmethylpr ace inj 80mg/ml 1 B/Dmethylpr ss inj 1gm 1 B/Dmethylpr ss inj 40mg 1 B/Dmethylpr ss inj 125mg 1 B/Dmethylpred pak 4mg 1 B/Dmethylpred tab 4mg 1 B/Dmethylpred tab 8mg 1 B/Dmethylpred tab 16mg 1 B/Dmethylpred tab 32mg 1 B/Dmillipred 3 B/D



Drug Name DrugTier

Requirements/Limits

pred sod pho sol 5mg/5ml 1 B/Dprednisolone sodiumphosphate

1 B/D

prednisolone sol 15mg/5ml 1 B/Dprednisolone sol 25mg/5ml 1 B/Dprednisolone syrup 15 mg/5ml 1 B/Dprednisone con 5mg/ml 3 B/Dprednisone pak 5mg 1 B/Dprednisone pak 10mg 1 B/Dprednisone sol 5mg/5ml 1 B/Dprednisone tab 1mg 1 B/Dprednisone tab 2.5mg 1 B/Dprednisone tab 5mg 1 B/Dprednisone tab 10mg 1 B/Dprednisone tab 20mg 1 B/Dprednisone tab 50mg 1 B/DRAYOS TAB 1MG 3 B/DRAYOS TAB 2MG 3 B/DRAYOS TAB 5MG 3 B/DSOLU-CORTEF 100MG 3SOLU-CORTEF 250MG 3SOLU-CORTEF 500MG 3SOLU-CORTEF 1000MG 3SOLU-MEDROL INJ 2GM 3 B/Dveripred 3 B/DGLUCOSE ELEVATING AGENTSGLUCAGEN HYPOKIT 2GLUCAGON EMERGENCYKIT

2

KORLYM 3 LA PAPROGLYCEM SUS 50MG/ML 3HUMAN GROWTH HORMONESGENOTROPIN 3 LA PAGENOTROPIN MINIQUICK 3 LA PAHUMATROPE 3 LA PAHUMATROPE COMBO PACK 3 LA PANORDITROPIN FLEXPRO 3 PANORDITROPIN NORDIFLEXPEN

3 PA

NUTROPIN AQ INJ20MG/2ML

3 LA PA

NUTROPIN AQ NUSPIN 5 3 LA PANUTROPIN AQ PEN 3 LA PAOMNITROPE 5.8MG 3 LA PA

Drug Name DrugTier

Requirements/Limits

OMNITROPE 5MG 3 LA PAOMNITROPE 10MG 3 LA PASAIZEN 3 LA PASAIZEN CLICK.EASY 3 LA PASEROSTIM 3 LA PAZOMACTON 3 PAZORBTIVE 3 PAMISCELLANEOUSAFREZZA 3cabergoline 1calcitonin (salmon) nasalspray

1

CHORIONICGONADOTROPIN SOLR

1 PA

EGRIFTA 1mg 3 LA PAFORTICAL SPR 200/ACT 3H.P. ACTHAR 3 LA PAINCRELEX 3 LA PAmethylergonovine maleateTABS

1

MIACALCIN INJ 200U/ML 3 B/DNOVAREL INJ 10000UNT 1 PAoctreotide acetate 50mcg/ml,100mcg/ml

1 PA

octreotide acetate200mcg/ml, 500mcg/ml,1000mcg/ml

3 PA

PREGNYL W/DILUENTBENZYL

1 PA

PROLIA 3raloxifene hcl 1SAMSCA 3 PASANDOSTATIN LAR DEPOT 3 PASIGNIFOR 3 LA PASIGNIFOR LAR 3 LA PASOMATULINE DEPOT 3 PASOMAVERT 3 LA PAXGEVA 3 PAPARATHYROID HORMONESFORTEO 3 PANATPARA 3 PAPHOSPHATE BINDER AGENTSAURYXIA 3calcium acetate (phosphatebinder)

1



Drug Name DrugTier

Requirements/Limits

FOSRENOL 3PHOSLYRA 2RENAGEL 3RENVELA PAK 2RENVELA TAB 800MG 2VELPHORO 3PROGESTINSCRINONE 2medroxyprogesterone acetate 1norethindrone acetate TABS 1progesterone micronizedCAPS

1

THYROID AGENTSlevothyroxine sodium TABS 1LEVOXYL 1liothyronine sodium SOLN;TABS

1

methimazole TABS 1propylthiouracil TABS 1SYNTHROID 2TIROSINT 3UNITHROID 1VASOPRESSINSDESMOPRESSIN ACETATESOLN

1

desmopressin acetate TABS 1desmopressin acetate inj 1desmopressin acetate spray 1desmopressin acetate sprayrefrigerated

1

STIMATE 3GASTROINTESTINALANTIEMETICSAKYNZEO 3 B/DALOXI 3CESAMET 3 B/Dcompro supp 1dronabinol 2.5mg, 5mg 1 B/Ddronabinol 10mg 3 B/DEMEND CAP 40MG 3 B/DEMEND CAP 80MG 3 B/DEMEND CAP 125MG 3 B/DEMEND PAK 80 & 125 3 B/Dgranisetron hcl SOLN 1

Drug Name DrugTier

Requirements/Limits

granisetron hcl TABS 1 B/Dmeclizine hcl TABS 1metoclopramide hcl SOLN;TABS; TBDP

1

metoclopramide hcl inj 5mg/ml

1

ondansetron hcl TABS 1 B/Dondansetron hcl inj 1ondansetron hcl oral soln 1 B/Dondansetron odt 1 B/Dphenadoz


phenergan SUPPPA if 65 years and older

3 PA

prochlorperazine inj 5 mg/ml 1prochlorperazine maleateTABS

1

prochlorperazine supp 1promethazine hcl SOLN;SUPP; SYRP; TABS


3 PA

prometheganPA if 65 years and older

3 PA

SANCUSO 3TRANSDERM-SCOP


ZUPLENZ 3 B/DANTISPASMODICSATROPINE SULFATE SOLN.05mg/ml, .1mg/ml

1

BENTYL SOLN 3CANTIL 3CUVPOSA 3dicyclomine hcl 1GLYCATE 3glycopyrrolate SOLN; TABS 1methscopolamine bromideTABS

1

H2-RECEPTOR ANTAGONISTScimetidine TABS 1cimetidine sol 300/5ml 1famotidine SUSR 1famotidine TABS 20mg,40mg

1

famotidine inj 1nizatidine 1



Drug Name DrugTier

Requirements/Limits

ranitidine hcl CAPS 1ranitidine hcl SOLN 1ranitidine hcl SYRP 1ranitidine hcl TABS 150mg,300mg

1

INFLAMMATORY BOWEL DISEASEAPRISO 2ASACOL HD 3balsalazide disodium 1budesonide CP24 3CANASA 3colocort 1DELZICOL 3DIPENTUM 3ENTYVIO 3 PAGIAZO 3HYDROCORTISONE(INTRARECTAL)

1

LIALDA 2mesalamine enema 1PENTASA 2SF-ROWASA 3sulfasalazine dr 1sulfasalazine ir 1UCERIS AER 2MG/ACT 3UCERIS TAB 9MG 3LAXATIVESCOLYTE-FLAVOR PACKS 3constulose 1enulose 1gaviltye-g 1gavilyte-c 1gavilyte-h 1gavilyte-n 1generlac 1GOLYTELY 3kristalose 3lactulose 1lactulose (encephalopathy) 1MOVIPREP 2NULYTELY/FLAVOR PACKS 3OSMOPREP 3

Drug Name DrugTier

Requirements/Limits

PEG 3350-KCL-SODBICARB-SOD CHLORIDE-SOD SULFATE

1

peg 3350-potassium chloride-sod bicarbonate-sod chloride

1

polyethylene glycol 3350PACK; POWD

1

PREPOPIK 3RELISTOR 3SUCLEAR 2SUPREP BOWEL PREP 2trilyte 1MISCELLANEOUSalosetron hcl 3AMITIZA 2amoxicillin-clarithromycin w/lansoprazole

1

CARAFATE SUSP 2cromolyn sodium(mastocytosis)

3

diphenoxylate w/ atropine 1GATTEX 3 LA PALINZESS 2loperamide hcl CAPS 1misoprostol TABS 1MOVANTIK 2OMECLAMOX-PAK 3PYLERA 3SUCRAID 3 LAsucralfate TABS 1ursodiol CAPS; TABS 1XIFAXAN TAB 550MG 3PANCREATIC ENZYMESCREON 2PANCREAZE 3PERTZYE 3ULTRESA 2VIOKACE 10 2VIOKACE 20 3ZENPEP 2PROTON PUMP INHIBITORSACIPHEX SPR CAP 5MG 3ACIPHEX SPR CAP 10MG 3DEXILANT 3esomeprazole sodium inj 1



Drug Name DrugTier

Requirements/Limits

lansoprazole CPDR 1NEXIUM CAP 20MG 3NEXIUM CAP 40MG 3NEXIUM GRA 2.5MG DR 3NEXIUM GRA 5MG DR 3NEXIUM GRA 10MG DR 3NEXIUM GRA 20MG DR 3NEXIUM GRA 40MG DR 3omeprazole CPDR 1OMEPRAZOLE-SODIUMBICARBONATE

1

pantoprazole sodium 1PREVACID SOLUTAB 3PRILOSEC PACK 3PROTONIX PACK 3rabeprazole sodium 1ZEGERID PACK 3GENITOURINARYBENIGN PROSTATIC HYPERPLASIAalfuzosin hcl 1AVODART 2CARDURA XL 3finasteride TABS 5mg 1JALYN 3RAPAFLO 2tamsulosin hcl 1MISCELLANEOUSbethanechol chloride TABS 1ELMIRON 3potassium citrate (alkalinizer)15meq

1

POTASSIUM CITRATE(ALKALINIZER) 540mg,1080mg

1

URINARY ANTISPASMODICSENABLEX 3GELNIQUE 2MYRBETRIQ 2oxybutynin chloride 1OXYTROL 3tolterodine tartrate er 1tolterodine tartrate tab 1 mg 1tolterodine tartrate tab 2 mg 1TOVIAZ 3

Drug Name DrugTier

Requirements/Limits

trospium chloride 1trospium chloride er 1VESICARE 2VAGINAL ANTI-INFECTIVESAVC 3CLEOCIN VAG SUPP 100MG 3clindamycin cre 2% vag 1metronidazole vaginal 1miconazole 3 sup 200mg 1NUVESSA 3terconazole vaginal 1VANDAZOLE 1zazole .4% 1ZAZOLE .8% 1HEMATOLOGICANTICOAGULANTSCOUMADIN 3ELIQUIS TAB 2.5MG 2ELIQUIS TAB 5MG 2enoxaparin sodium30mg/0.3ml, 40mg/0.4ml,60mg/0.6ml, 80mg/0.8ml,300mg/3ml

1

enoxaparin sodium100mg/ml, 120mg/0.8ml,150mg/ml

3

fondaparinux sodium2.5mg/0.5ml

1

fondaparinux sodium5mg/0.4ml, 7.5mg/0.6ml,10mg/0.8ml

3

FRAGMIN 2500unit/0.2ml,5000unit/0.2ml

2

FRAGMIN 7500unit/0.3ml,10000unit/ml,12500unit/0.5ml,15000unit/0.6ml,18000unt/0.72ml,95000unit/3.8ml

3

HEP SOD/NACL INJ 25000 1HEPARIN (PORCINE) INSODIUM CHLORIDE100U/ML

1

heparin sod inj 1000u/ml 1 B/DHEPARIN SOD INJ2000U/ML

3 B/D

HEPARIN SOD INJ2500U/ML

3 B/D



Drug Name DrugTier

Requirements/Limits

heparin sod inj 5000u/0.5ml 1 B/Dheparin sod inj 5000u/ml 1 B/Dheparin sod inj 10000u/ml 1 B/Dheparin sod inj 20000u/ml 1 B/DHEPARIN SODIUM/D5W 1HEPARIN SODIUM/NACL0.45%

3

jantoven 1PRADAXA 2SAVAYSA 3warfarin sodium 1XARELTO 2XARELTO STARTER PACK 2HEMATOPOIETIC GROWTH FACTORSARANESP ALBUMIN FREE 2 PAEPOGEN 3 PAGRANIX 3 PALEUKINE 3 PAMIRCERA 3 PAMOZOBIL 3 PANEULASTA 3 PANEUMEGA 3 PANEUPOGEN 3 PAPROCRIT 2 PAMISCELLANEOUSanagrelide hcl 1BERINERT 3 PAcilostazol 1CINRYZE 3 LA PAFIRAZYR 2 PApentoxifylline TBCR 1PROMACTA 3 LA PARUCONEST 3 PAtranexamic acid SOLN; TABS 1PLATELET AGGREGATION INHIBITORSAGGRENOX 2ASPIRIN-DIPYRIDAMOLE 1BRILINTA 90mg 2clopidogrel bisulfate 1EFFIENT 2ZONTIVITY 3IMMUNOLOGIC AGENTS

Drug Name DrugTier

Requirements/Limits

DISEASE-MODIFYING ANTI-RHEUMATICDRUGS (DMARDS)ACTEMRA 3 PACIMZIA 3 PAENBREL 3 PAENBREL SURECLICK 3 PAHUMIRA 3 PAHUMIRA PEN 3 PAHUMIRA PEN-CROHNSSTARTER KIT

3 PA

HUMIRA PEN-PSORIASISSTARTER KIT

3 PA

hydroxychloroquine sulfate 1KINERET 3 PAleflunomide TABS 1methotrexate sodium tabs 1ORENCIA 3 PAOTEZLA 3 PAREMICADE 3 PARHEUMATREX 2SIMPONI 3 PASIMPONI ARIA 3 PAtrexall 2 B/DXELJANZ 3 PAIMMUNOGLOBULINSBIVIGAM 3 PACARIMUNE NANOFILTERED12gm

3 PA

FLEBOGAMMA 3 PAFLEBOGAMMA DIF 3 PAGAMASTAN S/D 2 B/DGAMMAGARD LIQUID 3 PAGAMMAGARD S/D 3 PAGAMMAGARD S/D IGA LESSTH

3 PA

GAMMAKED 3 PAGAMMAPLEX 2.5gm/50ml,5gm/100ml, 10gm/200ml

3 PA

GAMUNEX-C 3 PAOCTAGAM 1gm/20ml,2gm/20ml, 2.5gm/50ml,5gm/100ml, 10gm/200ml,25gm/500ml

3 PA

PRIVIGEN 3 PAIMMUNOMODULATORS



Drug Name DrugTier

Requirements/Limits

ACTIMMUNE 3 LA PAARCALYST 3 PAGRASTEK 2INTRON-A INJ 10MU 3 B/DINTRON-A INJ 18MU 3 B/DINTRON-A INJ 25MU 3 B/DINTRON-A INJ 50MU 3 B/DRAGWITEK 2REVLIMID 3 LA PATHALOMID 2 PAIMMUNOSUPPRESSANTSASTAGRAF XL 3 B/DATGAM 3 B/Dazasan 2 B/Dazathioprine TABS 1 B/DBENLYSTA 3 PACELLCEPT INTRAVENOUS 3 B/Dcyclosporine CAPS; SOLN 1 B/Dcyclosporine modified (formicroemulsion)

1 B/D

gengraf 1 B/Dmycophenolate mofetilCAPS; TABS

1 B/D

mycophenolate mofetil SUSR 3 B/Dmycophenolate sodium180mg

1 B/D

mycophenolate sodium360mg

3 B/D

NEORAL 2 B/DNULOJIX 3 B/DPROGRAF CAPS 5mg 3 B/DPROGRAF CAPS .5mg, 1mg 2 B/DPROGRAF SOLN 3 B/DRAPAMUNE SOLN 3 B/DSANDIMMUNE SOLN 2 B/DSIMULECT 3 B/DSIROLIMUS TABS 2mg 3 B/Dsirolimus TABS .5mg, 1mg 1 B/Dtacrolimus CAPS 5mg 3 B/Dtacrolimus CAPS .5mg, 1mg 1 B/DTHYMOGLOBULIN 3 B/DZORTRESS TAB 0.5MG 3 B/DZORTRESS TAB 0.25MG 3 B/DZORTRESS TAB 0.75MG 3 B/D

Drug Name DrugTier

Requirements/Limits

VACCINESACTHIB 3ADACEL 3BCG VACCINE 3BEXSERO 3BOOSTRIX 3CERVARIX 3COMVAX 3DAPTACEL 3DIPHTHERIA/TETANUSTOXOID

3 B/D

ENGERIX-B SUSP 3 B/DGARDASIL 3GARDASIL 9 3HAVRIX 3HIBERIX 3IMOVAX RABIES (H.D.C.V.) 3INFANRIX 3IPOL INACTIVATED IPV 2IXIARO 3KINRIX 3M-M-R II 3MENACTRA 3MENOMUNE-A/C/Y/W-135 3MENVEO 3PEDVAX HIB 3PROQUAD 3QUADRACEL 3RABAVERT 3RECOMBIVAX HB 3 B/DROTARIX 2ROTATEQ 3SYNAGIS 3TENIVAC 3 B/DTETANUS/DIPHTHERIATOXOID

3 B/D

TRUMENBA 3TWINRIX INJ 3TYPHIM VI 3VAQTA 3VARIVAX 3YF-VAX 3ZOSTAVAX 3NUTRITIONAL/SUPPLEMENTS



Drug Name DrugTier

Requirements/Limits

ELECTROLYTESammonium chloride SOLN 3KLOR-CON 8 1KLOR-CON 10 1klor-con m15 3klor-con m20 1klor-con pow 20meq 1MAGNESIUM SULFATESOLN 40mg/ml, 80mg/ml

3

magnesium sulfate SOLN50%

1

MAGNESIUM SULFATE IND5W

3

MAGNESIUM SULFATE INJ50%

1

POTASSIUM CHLORIDELIQD

1

potassium chloride TBCR8meq

1

POTASSIUM CHLORIDETBCR 20meq

1

potassium chloride caps er 1potassium chloridemicroencapsulated crystals cr

1

POTASSIUM CHLORIDETAB CR 10 MEQ

1

SODIUM CHLORIDE SOLN2.5meq/ml

1

SODIUM FLUORIDE CHEW;TAB; 1.1 (0.5 F) MG/MLSOLN

1

TPN ELECTROLYTES 1 B/DIV NUTRITIONAMINOSYN 3 B/DAMINOSYN7%/ELECTROLYTES

3 B/D

AMINOSYN II 3 B/DAMINOSYN II8.5%/ELECTROL

1 B/D

AMINOSYN INJ 8.5/LYTE 1 B/DAMINOSYN M 3 B/DAMINOSYN-HBC 3 B/DAMINOSYN-PF 7% 3 B/DAMINOSYN-PF INJ 10% 3 B/DAMINOSYN-RF 3 B/DCLINIMIX 2.75%/DEXTROSE5%

3 B/D

Drug Name DrugTier

Requirements/Limits

CLINIMIX 4.25%/DEXTROSE5%

3 B/D


3 B/D


3 B/D


3 B/D

CLINIMIX 5%/DEXTROSE15%

3 B/D


3 B/D


3 B/D

CLINIMIX E2.75%/DEXTROSE 5%

3 B/D


3 B/D

CLINIMIX E 4.25%/D10 3 B/DCLINIMIX E4.25%/DEXTROSE 5%

3 B/D


3 B/D

CLINIMIX E 5%/DEXTROSE15%

3 B/D


3 B/D


3 B/D

clinisol 15 1 B/DFREAMINE HBC 6.9% 3 B/DFREAMINE III 3 B/DHEPATAMINE 1 B/DINTRALIPID INJ 20% 1 B/DINTRALIPID INJ 30% 3 B/DLIPOSYN III 3 B/DNEPHRAMINE 3 B/DNUTRILIPID INJ 20% 1 B/Dpremasol 6% 1 B/Dpremasol 10% 3 B/DPROCALAMINE 3 B/DPROSOL 3 B/DTRAVASOL 3 B/DTROPHAMINE INJ 10% 3 B/DIV REPLACEMENT SOLUTIONSDEXTROSE SOLN 1



Drug Name DrugTier

Requirements/Limits

DEXTROSE 2.5%/NACL0.45%

1

DEXTROSE 5% 1DEXTROSE 5%/ELECTROLYTE

3

DEXTROSE 5%/LACTATEDRING

1

DEXTROSE 5%/NACL 0.2% 1DEXTROSE 5%/NACL 0.3% 3DEXTROSE 5%/NACL 0.9% 1DEXTROSE 5%/NACL 0.33% 1DEXTROSE 5%/NACL 0.45% 1DEXTROSE 5%/NACL0.225%

1

DEXTROSE 5%/POTASSIUMCHL

1

DEXTROSE 10% FLEXCONTAIN

1

DEXTROSE 10% W/SODIUM CHLORIDE 0.2%

3

DEXTROSE 10%/NACL0.45%

1

ELECTROLYTE-R INDEXTROSE

3

IONOSOL-B/DEXTROSE 5% 3IONOSOL-MB/DEXTROSE5%

3

ISOLYTE P 3ISOLYTE S 3KCL0.15%/D5W/NACL0.2% 1KCL0.15%/D5W/NACL0.225%

3

KCL 0.3%/D5W/LR IV LAC RI 3KCL 0.3%/D5W/NACL 0.9% 3KCL 0.3%/D5W/NACL 0.45% 1KCL 0.15%/D5W/LR 3KCL 0.15%/D5W/NACL 0.9% 1KCL 0.075%/D5W/NACL0.45%

1

KCL IN NACL INJ .15-0.45 1KCL/D5W/NACL INJ0.22%/0.45%

1

KCL/D5W/NACL INJ .15/.33% 1KCL/D5W/NACL INJ .15/.45% 1KCL/NACL INJ 0.15%-0.9% 1LACTATED RINGERSVIAFLEX

1

Drug Name DrugTier

Requirements/Limits

NORMOSOL-M IN D5W 1NORMOSOL-R 3PLASMA-LYTE A 3PLASMA-LYTE-56/D5W 3PLASMA-LYTE-148 3pot chloride inj 2meq/ml 1POTASSIUM CHLORIDESOLN

1

POTASSIUM CHLORIDE0.3%/D

1

potassium chloride in nacl 1POTASSIUM CHLORIDE INNACL

1

RINGER'S 1SODIUM CHLORIDE SOLN.9%, 3%, 5%

1

SODIUM CHLORIDE 0.45%VIA

1

VITAMINScalcitriol CAPS; SOLN 1 B/Ddoxercalciferol CAPS 1mcg,2.5mcg

3 B/D

doxercalciferol CAPS .5mcg 1 B/Ddoxercalciferol SOLN 1 B/DHECTOROL SOLN 2mcg/ml 3 B/Dparicalcitol CAPS 1 B/DPARICALCITOL SOLN 3 B/DPRENATAL VITAMIN/FOLICACID > 0.8 MG (GENERIC)

1

ZEMPLAR SOLN 2mcg/ml 3 B/DOPHTHALMICANTI-INFECTIVE/ANTI-INFLAMMATORYbacitracin-poly-neomycin-hc 1blephamide OINT 3BLEPHAMIDE SUSP 3neomycin-polymy-dexameth 1neomycin-polymyxin-hc(ophth)

1

PRED-G 3PRED-G S.O.P. 3sulfacetamide sod-prednisolone

1

TOBRADEX OINT 2TOBRADEX ST 2tobramycin-dexamethasone 1ZYLET 2



Drug Name DrugTier

Requirements/Limits

ANTI-INFECTIVESAZASITE 3bacitracin (ophthalmic) 1bacitracin-polymyxin b (ophth) 1BESIVANCE 2CILOXAN OIN 0.3% OP 3ciprofloxacin hcl (ophth) 1erythromycin (ophth) 1gatifloxacin (ophth) 1gentak 1gentamicin sulfate (ophth) 1ilotycin 1levofloxacin (ophth) 1MOXEZA 2NATACYN 3neomycin-bacitracin zn-polymyxin

1

neomycin-polymyxin-gramicidin

1

ofloxacin (ophth) 1polymyxin b-trimethoprim 1sulfacet sod oin 10% op 1sulfacetamide sodium (ophth) 1tobramycin (ophth) 1TOBREX OINT 0.3% 3trifluridine SOLN 1VIGAMOX 2ZIRGAN 3ANTI-INFLAMMATORIESACUVAIL 3ALREX 2bromfenac sodium (ophth) 1BROMFENAC SODIUM(OPHTH)(ONCE-DAILY)

1

dexamethasone sodiumphosphate (ophth)

1

diclofenac sodium (ophth) 1DUREZOL 2FLAREX 3FLUOROMETHOLONE(OPHTH)

1

flurbiprofen sodium 1FML 3FML FORTE 3ILEVRO 3

Drug Name DrugTier

Requirements/Limits

ketorolac tromethamine(ophth)

1

LOTEMAX 2MAXIDEX 3PRED MILD 3PREDNISOLONE ACETATE(OPHTH)

1

prednisolone sodiumphosphate (ophth)

3

VEXOL 3ANTIALLERGICSALOCRIL 3ALOMIDE 3azelastine drop 0.05% 1BEPREVE 3cromolyn sodium (ophth) 1EMADINE 3epinastine hcl (ophth) 1LASTACAFT 3PATADAY 2PATANOL 2PAZEO 3ANTIGLAUCOMAALPHAGAN P 2ALPHAGAN P 0.1% 2AZOPT 2betaxolol hcl (ophth) 1BETIMOL 2BETOPTIC-S 2brimonidine sol 0.2% 1BRIMONIDINE SOL 0.15% 1carteolol hcl (ophth) 1COMBIGAN 2COSOPT PF 2dorzolamide hcl 1dorzolamide hcl-timololmaleate

1

ISTALOL 3latanoprost SOLN 1levobunolol hcl .5% 1LEVOBUNOLOL HCL .25% 1LUMIGAN 3metipranolol 1PHOSPHOLINE IODIDE 3



Drug Name DrugTier

Requirements/Limits

PILOCARPINE HCL SOLN 1SIMBRINZA SUS 1-0.2% 2timolol maleate (ophth) 1TIMOLOL MALEATE GEL 1TIMOPTIC OCUDOSE 3TRAVATAN Z 2ZIOPTAN 2MISCELLANEOUSLACRISERT 3naphazoline 0.1% 1PROLENSA 2proparacaine hcl SOLN 1RESTASIS 2RESPIRATORYANTICHOLINERGIC/BETA AGONISTCOMBINATIONSANORO ELLIPT AER 62.5-25 2COMBIVENT RESPIMAT 2ipratropium-albuterol 1 B/DSTIOLTO RESPIMAT 3ANTICHOLINERGICSATROVENT HFA 3INCRUSE ELLIPTA 3ipratropium bromide (nasal) 1ipratropium sol inhal 1 B/DSPIRIVA HANDIHALER 2SPIRIVA RESPIMAT 2TUDORZA PRESSAIR 3TUDORZA PRESSAIR(INSTITUTIONAL PACK)

3

ANTIHISTAMINE COMBINATIONSCLARINEX-D TAB 2.5-120 3DYMISTA SPR 137-50 3SEMPREX-D 3ANTIHISTAMINESASTEPRO 3azelastine spr 0.1% 1azelastine spr 0.15% 1cetirizine syrup 1CLARINEX SYRP 3desloratadine 1diphenhydram inj 50mg/ml 1

Drug Name DrugTier

Requirements/Limits

hydroxyzine hcl SOLN25mg/ml, 50mg/ml


3 PA

levocetirizine soln 2.5mg/5ml 1levocetirizine tab 5 mg 1olopatadine hcl (nasal) 1BETA AGONISTSalbuterol sulfate NEBU 1 B/Dalbuterol sulfate SYRP; TABS 1albuterol sulfate er 1ARCAPTA NEOHALER 2BROVANA 3 B/DFORADIL AEROLIZER 2levalbuterol conc1.25mg/0.5ml

1 B/D

LEVALBUTEROL HCL NEBU1.25mg/3ml

1 B/D

levalbuterol hcl NEBU.31mg/3ml, .63mg/3ml

1 B/D

PERFOROMIST 2 B/DPROAIR HFA 2PROAIR RESPICLICK 3PROVENTIL HFA 3SEREVENT DISKUS 2STRIVERDI RESPIMAT 3terbutaline sulfate SOLN 3terbutaline sulfate TABS 1VENTOLIN HFA 3XOPENEX HFA 3LEUKOTRIENE RECEPTORANTAGONISTSmontelukast sodium CHEW;PACK; TABS

1

zafirlukast 1ZYFLO CR 3MAST CELL STABILIZERScromolyn sodium NEBU 1 B/DMISCELLANEOUSacetylcysteine SOLN 10%,20%

1 B/D

ARALAST NP 3 LA PAAUVI-Q 2DALIRESP 2EPINEPHRINE SOAJ.3mg/0.3ml

1



Drug Name DrugTier

Requirements/Limits

epinephrine SOAJ.15mg/0.15ml

1

EPIPEN 2-PAK 2EPIPEN-JR 2-PAK 2ESBRIET 3 PAGLASSIA 3 LA PAKALYDECO 3 PAOFEV 3 PAORKAMBI 3 PAPROLASTIN-C 3 LA PAPULMOZYME 3 B/Dtyzine .05% 3XOLAIR 3 LA PAZEMAIRA 3 LA PANASAL STEROIDSBECONASE AQ 3budesonide (nasal) 1flunisolide (nasal) 1fluticasone propionate (nasal) 1NASONEX 2OMNARIS 3QNASL 3QNASL CHILDRENS 3triamcinolone acetonide(nasal)

1

VERAMYST 3ZETONNA 3STEROID INHALANTSAEROSPAN 3ALVESCO 3ARNUITY ELLIPTA 3ASMANEX 2ASMANEX HFA 2budesonide (inhalation) 1 B/DFLOVENT DISKUS 2FLOVENT HFA 2PULMICORT FLEXHALER 2PULMICORT INH SUSP1MG/2ML

3 B/D

QVAR 2STEROID/BETA-AGONISTCOMBINATIONSADVAIR DISKUS 2ADVAIR HFA 2

Drug Name DrugTier

Requirements/Limits

BREO ELLIPTA 3DULERA 2SYMBICORT 3XANTHINESaminophylline inj 1elixophyllin 3theo-24 3theophylline 1TOPICALDERMATOLOGY, ACNEABSORICA 3ACANYA 2ACZONE 3adapalene CREA; GEL 1amnesteem 1ATRALIN 2AVITA 1AZELEX 3benzoyl peroxide-erythromycin

1

claravis 1CLINDAGEL 3clindamax 1clindamycin phosphate(topical)

1

clindamycin phosphate-benzoyl peroxide

1

clindamycin phosphate-benzoyl peroxide (refrigerate)

1

DIFFERIN LOTN 2EPIDUO 2ery pad 2% 1erythromycin (acne aid) 1FABIOR 3myorisan 1neuac gel 1.2-5% 1ONEXTON 3RETIN-A MICRO PUMP.08%

2

sulfacetamide sodium (acne) 1tretin-x CREA 3tretinoin CREA 1TRETINOIN GEL .01% 1tretinoin GEL .025% 1tretinoin microsphere .1% 1



Drug Name DrugTier

Requirements/Limits

TRETINOIN MICROSPHERE.04%

1

VELTIN 3zenatane 10mg, 20mg, 40mg 1ZENATANE 30mg 1ZIANA 3DERMATOLOGY, ANTIBIOTICSALTABAX 3BACTROBAN NASAL 3CENTANY 3CORTISPORIN CREA; OINT 3gentamicin sulfate (topical) 1mupirocin OINT 1mupirocin calcium (topical) 1SILVER SULFADIAZINECREA

1

SSD 1SULFAMYLON 3DERMATOLOGY, ANTIFUNGALSciclopirox GEL 1ciclopirox cre 0.77% 1ciclopirox shampoo 1% 1ciclopirox sus 0.77% 1clotrimazole (topical) 1econazole nitrate CREA 1ERTACZO 3EXELDERM 3ketoconazole (topical) 1ketodan aer 2% 1LUZU 2MENTAX 3NAFTIFINE HCL 1NAFTIN 2nyamyc 1nystatin (topical) 1nystatin pow 100000 1nystop 1OXISTAT 3DERMATOLOGY, ANTIPRURITICCORTIFOAM 2procto-pak 1proctosol hc 2.5 % 1proctozone hc 1PRUDOXIN CRE 5% 1

Drug Name DrugTier

Requirements/Limits

DERMATOLOGY, ANTIPSORIATICSacitretin 3calcipotriene CREA; OINT;SOLN

1

calcitrene oin 0.005% 1CALCITRIOL OINT 1COSENTYX 3 PACOSENTYX SENSOREADYPEN

3 PA

methoxsalen rapid 38-MOP 3SORILUX 2STELARA 3 PATAZORAC 2DERMATOLOGY, ANTISEBORRHEICSketoconazole shampoo 1selenium sulfide LOTN 1DERMATOLOGY, CORTICOSTEROIDSala-cort 1alclometasone dipropionate 1amcinonide CREA; LOTN 1amcinonide OINT 3apexicon 1apexicon e cream 3betamethasone dipropionate(topical)

1

betamethasone dipropionateaugmented

1

betamethasone valerateCREA; FOAM; LOTN; OINT

1

calcipotriene/betamethasone 3CAPEX 2clobetasol e cream 0.05% 1clobetasol propionate CREA;FOAM; GEL; LIQD; LOTN;OINT; SHAM; SOLN

1

clobetasol propionateemulsion

1

clocortolone pivalate 1clodan sha 0.05% 1CORDRAN TAPE 3cormax 1DESONATE 3DESONIDE CREA 1desonide LOTN; OINT 1



Drug Name DrugTier

Requirements/Limits

desoximetasone CREA 1desoximetasone GEL 1DESOXIMETASONE OINT.05%

1

desoximetasone OINT .25% 1diflorasone diacetate 1fluocinolone acetonideCREA; OIL; OINT; SOLN

1

fluocinonide CREA .1% 3fluocinonide CREA .05% 1fluocinonide GEL 1fluocinonide OINT 1fluocinonide SOLN 1fluocinonide emulsified base 1fluticasone propionate CREA;LOTN; OINT

1

halobetasol propionate 1HALOG 3hydrocortisone (topical) 1hydrocortisone butyrate 1hydrocortisone butyratehydrophilic lipo base

1

hydrocortisone valerate 1LOCOID LOTN 2lokara 1mometasone furoate CREA;OINT; SOLN

1

PANDEL 3PREDNICARBATE CREA 1prednicarbate OINT 1TACLONEX SUSP 3texacort 2TOPICORT SPRAY 0.25% 3triamcinolone acetonide(topical)

1

trianex 3triderm 1DERMATOLOGY, LOCAL ANESTHETICSlidocaine OINT 1lidocaine PTCH 1 PAlidocaine hcl GEL 1lidocaine hcl SOLN 4% 1lidocaine-prilocaine 1 B/DSYNERA 3

Drug Name DrugTier

Requirements/Limits

DERMATOLOGY, MISCELLANEOUS SKINAND MUCOUS MEMBRANEacyclovir topical 1ammonium lactate CREA;LOTN

1

CONDYLOX GEL 2DENAVIR 3diclofenac sodium (actinickeratoses)

3

diclofenac sodium (topical) 1DOXYCYCLINE (ROSACEA) 1ELIDEL 2FINACEA GEL 15% 2fluorouracil (topical) CREA5%

1

FLUOROURACIL (TOPICAL)CREA .5%

3

fluorouracil (topical) SOLN 1imiquimod CREA 1laclotion lot 12% 1metronidazole (topical) 1NORITATE 3ORACEA 2PANRETIN 3PENNSAID 3PICATO 3podofilox SOLN 1RECTIV 3rosadan cre 0.75% 1SOOLANTRA 2tacrolimus (topical) 1TARGRETIN GEL 3 PAVALCHLOR 3 LA PAVOLTAREN GEL 1% 2XERESE 3ZOVIRAX CREA 3ZYCLARA 3DERMATOLOGY, SCABICIDES ANDPEDICULIDESEURAX 3malathion 1permethrin 1SKLICE 3DERMATOLOGY, WOUND CARE AGENTS



Drug Name DrugTier

Requirements/Limits

acetic acid .25% 1neomycin/polymyxin b gu 1REGRANEX 3SANTYL 3SODIUM CHLORIDE 0.9% 1STERILE WATERIRRIGATION

1

MOUTH/THROAT/DENTAL AGENTScevimeline hcl 1chlorhexidine gluconate(mouth-throat)

1

clotrimazole TROC 1lidocaine hcl (mouth-throat) 1nystatin (mouth-throat) 1periogard soln 0.12% 1PILOCARPINE HCL (ORAL)5mg

1

pilocarpine hcl (oral) 7.5mg 1triamcinolone acetonide(mouth)

1

OTICacetasol hc 1acetic acid (otic) 1acetic acid sol/hc 1acetic acid-aluminum acetate 1CIPRO HC 3CIPRODEX 2COLY-MYCIN S 3CORTISPORIN-TC 3fluocinolone acetonide (otic) 1neomycin-polymyxin-hc (otic) 1ofloxacin (otic) 1


36

Index

88-MOP 33

Aa-hydrocort 21abacavir sulfate 4abacavir sulfate-lamivudine-

zidovudine 5ABELCET 4ABILIFY DISCMELT TAB

10MG 15ABILIFY MAINTENA 15ABRAXANE 8ABSORICA 32ABSTRAL 1acamprosate calcium 17ACANYA 32acarbose 18acebutolol hcl 11acetaminophen w/ codeine 1acetasol hc 35acetazolamide 12acetazolamide sodium 12acetic acid 35acetic acid (otic) 35acetic acid sol/hc 35acetic acid-aluminum

acetate 35acetylcysteine 31ACIPHEX SPR CAP 10MG24ACIPHEX SPR CAP 5MG 24acitretin 33ACTEMRA 26ACTHIB 27ACTIMMUNE 27ACTOPLUS MET XR 15-

1000MG 18ACTOPLUS MET XR 30-

1000MG 18ACUVAIL 30acyclovir 5acyclovir sodium 5acyclovir topical 34ACZONE 32ADACEL 27ADAGEN 21adapalene 32ADCIRCA 13adefovir dipivoxil 5ADEMPAS 13adriamyc inj 50mg 7adrucil 8ADVAIR DISKUS 32ADVAIR HFA 32ADVICOR 11AEROSPAN 32afeditab cr 12

AFINITOR 9AFINITOR DISPERZ 9AFREZZA 22AGGRENOX 26AKYNZEO 23ala-cort 33ALBENZA 3albuterol sulfate 31albuterol sulfate er 31alclometasone

dipropionate 33ALCOHOL SWABS 18ALDACTAZIDE TAB 50/50 12ALDURAZYME 21alendronate sodium 19alfuzosin hcl 25ALIMTA 8ALINIA 3allopurinol tab 1almotriptan malate 16ALOCRIL 30ALOMIDE 30ALOPRIM 1ALORA 21alosetron hcl 24ALOXI 23ALPHAGAN P 30ALPHAGAN P 0.1% 30alprazolam 13ALREX 30ALSUMA 16ALTABAX 33altavera 19ALTOPREV 11ALVESCO 32amantadine hcl 15AMBISOME 4amcinonide 33amethia 91 day 19amethyst 28 day 19amifostine crystalline 9amikacin sulfate 3amiloride &

hydrochlorothiazide 12amiloride hcl 12aminophylline inj 32AMINOSYN 28AMINOSYN

7%/ELECTROLYTES 28AMINOSYN II 28AMINOSYN II

8.5%/ELECTROL 28AMINOSYN INJ 8.5/LYTE 28AMINOSYN M 28AMINOSYN-HBC 28AMINOSYN-PF 7% 28AMINOSYN-PF INJ 10% 28AMINOSYN-RF 28amiodarone hcl 10amiodarone inj 50mg/ml 10

AMITIZA 24amitriptyline hcl 14amlodipine besylate 12amlodipine besylate-

benazepril hcl 10amlodipine besylate-valsartan

tab 10-160 mg 10amlodipine besylate-valsartan



tab 5-320 mg 10amlodipine besylate/atorv 11amlodipine-valsartan-

hydrochlorothiazide 10-160-12.5mg 10

amlodipine-valsartan-hydrochlorothiazide 10-160-25mg 10


amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg 10


ammonium chloride 28ammonium lactate 34amnesteem 32amoxapine 14amoxicillin 7amoxicillin & pot clavulanate 7amoxicillin-clarithromycin w/

lansoprazole 24amphetamine cap 10mg er 16amphetamine cap 15mg er 16amphetamine cap 20mg er 16amphetamine cap 25mg er 16amphetamine cap 30mg er 16amphetamine-

dextroamphetamine capsr 24hr 5 mg 16

amphetamine-dextroamphetamine tab10 mg 16

amphetamine-dextroamphetamine tab12.5 mg 16




amphetamine-dextroamphetamine tab 5


37

mg 16amphetamine-

dextroamphetamine tab7.5 mg 16

AMPHOTEC 4amphotericin b 4ampicillin & sulbactam

sodium 7ampicillin cap 250mg 7ampicillin cap 500 mg 7ampicillin inj 7ampicillin sodium 7ampicillin susp 7AMPYRA 17anagrelide hcl 26anastrozole 8ANDRODERM 17ANDROGEL 17ANDROGEL 1% 17ANDROGEL 1.62% 17ANDROGEL PUMP 17ANORO ELLIPT AER 62.5-

25 31ANTARA 11apexicon 33apexicon e cream 33APIDRA 18APIDRA SOLOSTAR 18APLENZIN 14APOKYN 15apri 28 day 19APRISO 24APTENSIO XR 16APTIOM 13APTIVUS 4ARALAST NP 31aranelle 28 19ARANESP ALBUMIN

FREE 26ARCALYST 27ARCAPTA NEOHALER 31aripiprazole tabs 15ARNUITY ELLIPTA 32ARRANON 8ARZERRA 8ASACOL HD 24ashlyna 91 day 19ASMANEX 32ASMANEX HFA 32ASPIRIN-CAFFEINE-

DIHYDROCODEINEBITARTRATE 1

ASPIRIN-DIPYRIDAMOLE 26ASTAGRAF XL 27ASTEPRO 31atenolol 11atenolol & chlorthalidone 11ATGAM 27atorvastatin calcium 11atovaquone 3

atovaquone-proguanil hcl tab250-100 mg 4

atovaquone-proguanil hcl tab62.5-25 mg 4

ATRALIN 32ATRIPLA 5ATROPINE SULFATE 23ATROVENT HFA 31AUBAGIO 17aubra 28 day 19AUGMENTIN 7AURYXIA 22AUVI-Q 31AVASTIN 8AVC 25AVEED 17AVELOX 6aviane 28 19AVITA 32AVODART 25AVONEX 17AVONEX PEN 17AVYCAZ 6AXERT 16AXIRON 17azacitidine 8AZACTAM/DEX INJ 1GM 3AZACTAM/DEX INJ 2GM 3azasan 27AZASITE 30azathioprine 27azelastine drop 0.05% 30azelastine spr 0.1% 31azelastine spr 0.15% 31AZELEX 32AZILECT 15AZITHROMYCIN 6azithromycin 6AZOPT 30AZOR 10aztreonam 3

Bbacitracin (ophthalmic) 30bacitracin-poly-neomycin-

hc 29bacitracin-polymyxin b

(ophth) 30baclofen 17BACTOCILL INJ DEX 1GM 7BACTOCILL INJ DEX 2GM 7BACTROBAN NASAL 33balsalazide disodium 24balziva 28 day 19BANZEL SUS 40MG/ML 13BANZEL TAB 200MG 13BANZEL TAB 400MG 13BARACLUDE 5BCG VACCINE 27BECONASE AQ 32

BELEODAQ 8benazepril &

hydrochlorothiazide 10benazepril hcl 10BENICAR 10BENICAR HCT 10BENLYSTA 27BENTYL 23benzoyl peroxide-

erythromycin 32BENZTROPINE

MESYLATE 15benztropine mesylate 15BEPREVE 30BERINERT 26BESIVANCE 30betamethasone dipropionate

(topical) 33betamethasone dipropionate

augmented 33betamethasone valerate 33BETASERON 17betaxolol hcl 11betaxolol hcl (ophth) 30bethanechol chloride 25BETHKIS 3BETIMOL 30BETOPTIC-S 30BEXSERO 27BEYAZ 19bicalutamide 8BICILLIN C-R 7BICILLIN L-A 7BICNU 7BIDIL 12BILTRICIDE 3BINOSTO 19bisoprolol &

hydrochlorothiazide 11bisoprolol fumarate 11BIVIGAM 26bleomycin sulfate 7BLEPHAMIDE 29blephamide 29BOOSTRIX 27BOSULIF 9BOTOX INJ 100UNIT 17BOTOX INJ 200UNIT 17BREO ELLIPTA 32briellyn 28 day 19BRILINTA 26BRIMONIDINE SOL 0.15%30brimonidine sol 0.2% 30BRINTELLIX 14BRISDELLE 16bromfenac sodium (ophth) 30BROMFENAC SODIUM

(OPHTH)(ONCE-DAILY) 30

bromocriptine mesylate 15


38

BROVANA 31budesonide 24budesonide (inhalation) 32budesonide (nasal) 32bumetanide 12BUNAVAIL MIS 2.1-0.3MG 17BUNAVAIL MIS 4.2-0.7MG 17BUNAVAIL MIS 6.3-1MG 17buprenorphine hcl 17buprenorphine hcl-naloxone

hcl sl 17buproban 17bupropion hcl 14buspirone hcl 13BUSULFEX 7butorphanol nasal spray 1butorphanol tartrate 1BUTRANS 1BYDUREON 18BYETTA 18BYSTOLIC 11

Ccabergoline 22cafergot tab 1-100mg 16calcipotriene 33calcipotriene/betamethasone

33calcitonin (salmon) nasal

spray 22calcitrene oin 0.005% 33CALCITRIOL 33calcitriol 29calcium acetate (phosphate

binder) 22camila 28 day 19CAMPTOSAR 9CAMRESE LO TAB 19CANASA 24CANCIDAS 4candesartan cilexetil 10candesartan cilexetil-

hydrochlorothiazide 10CANTIL 23CAPASTAT SULFATE 5CAPEX 33capital

and codeine 1CAPRELSA 9captopril 10captopril &

hydrochlorothiazide 10CARAFATE 24CARBAGLU 21carbamazepine 13carbidopa 15carbidopa-levodopa 15CARBIDOPA/LEVODOPA/E

NTACAPONE 15carboplatin 9

CARDIZEM LA 12CARDURA XL 25CARIMUNE

NANOFILTERED 26carteolol hcl (ophth) 30cartia xt 12carvedilol 11CAYSTON 3CEDAX 6cefaclor 6cefaclor er tab 500mg 6cefadroxil 6cefazolin inj 6cefazolin sodium 6cefazolin/dextrose 6cefdinir 6CEFEPIME 1GM SOLN 6CEFEPIME 2GM SOLN 6CEFEPIME HCL AND

DEXTROSE 6cefepime inj 1gm 6cefepime inj 2gm 6cefixime 6cefotaxime sodium 6cefotetan disodium 6cefoxitin sodium 6CEFOXITIN SODIUM IN

DEXTROSE 6cefpodoxime proxetil 6cefprozil 6ceftazidime 6CEFTAZIDIME/DEXTROSE 6CEFTIBUTEN 6CEFTIN 6ceftriaxone sodium 6cefuroxime axetil 6cefuroxime sodium 6celecoxib 1CELLCEPT

INTRAVENOUS 27CELONTIN 13CENTANY 33cephalexin 6CERDELGA 21CEREZYME 21CERVARIX 27CESAMET 23cetirizine syrup 31cevimeline hcl 35CHANTIX 17CHANTIX CONTINUING

MONTH 17CHANTIX STARTER

PACK 17CHEMET 19chlorhexidine gluconate

(mouth-throat) 35chloroquine phosphate 4chlorothiazide tabs 12chlorpromaz inj 25mg/ml 15

chlorpromazine hcl 15chlorthalidone 12cholestyramine 11cholestyramine light 11choline fenofibrate 11CHORIONIC

GONADOTROPIN 22ciclopirox 33ciclopirox cre 0.77% 33ciclopirox shampoo 1% 33ciclopirox sus 0.77% 33cidofovir 5cilostazol 26CILOXAN OIN 0.3% OP 30cimetidine 23cimetidine sol 300/5ml 23CIMZIA 26CINRYZE 26CIPRO HC 35CIPRODEX 35ciprofloxacin 6ciprofloxacin er 6ciprofloxacin hcl 6ciprofloxacin hcl (ophth) 30ciprofloxacin in d5w 6ciprofloxacn inj 400mg/40ml 6cisplatin 9citalopram hydrobromide 14cladribine 8claforan 6claravis 32CLARINEX 31CLARINEX-D TAB 2.5-120 31clarithromycin 6CLEOCIN VAG SUPP

100MG 25CLINDAGEL 32clindamax 32clindamycin cre 2% vag 25clindamycin hcl 3clindamycin palmitate

hydrochloride 3clindamycin phosphate 3clindamycin phosphate

(topical) 32clindamycin phosphate in

d5w 3clindamycin phosphate-

benzoyl peroxide 32clindamycin phosphate-

benzoyl peroxide(refrigerate) 32

CLINIMIX 2.75%/DEXTROSE5% 28




CLINIMIX 4.25%/DEXTROSE


39

5% 28CLINIMIX 5%/DEXTROSE



25% 28CLINIMIX E

2.75%/DEXTROSE10% 28

CLINIMIX E2.75%/DEXTROSE 5% 28

CLINIMIX E 4.25%/D10 28CLINIMIX E

4.25%/DEXTROSE25% 28

CLINIMIX E4.25%/DEXTROSE 5% 28

CLINIMIX E 5%/DEXTROSE15% 28



clinisol 15 28clobetasol e cream 0.05% 33clobetasol propionate 33clobetasol propionate

emulsion 33clocortolone pivalate 33clodan sha 0.05% 33CLOLAR 8clomipramine hcl 14clonazepam 13clonidine hcl 12clopidogrel bisulfate 26clorazepate dipotassium 13clorpres 13clotrimazole 35clotrimazole (topical) 33clozapine 15CLOZAPINE ODT 15COARTEM 4codeine

and capital 1CODEINE SULFATE 1colchicine w/ probenecid 1COLCRYS 1colestipol hcl 11colistimethate sodium 3colocort 24COLY-MYCIN S 35COLYTE-FLAVOR PACKS 24COMBIGAN 30COMBIVENT RESPIMAT 31COMETRIQ 9COMPLERA 5compro supp 23COMVAX 27CONDYLOX 34constulose 24

CONZIP 1COPAXONE INJ 40MG/ML17CORDRAN 33COREG CR 11CORLANOR 13cormax 33CORTIFOAM 33cortisone acetate 21CORTISPORIN 33CORTISPORIN-TC 35COSENTYX 33COSENTYX SENSOREADY

PEN 33COSMEGEN 7COSOPT PF 30COUMADIN 25CREON 24CRESEMBA 4CRESTOR 11CRINONE 23CRIXIVAN 4cromolyn sodium 31cromolyn sodium

(mastocytosis) 24cromolyn sodium (ophth) 30cryselle 28 19CUBICIN 3CUVPOSA 23cyclafem 1/35 28 day 19cyclafem 7/7/7 28 day 19cyclobenzaprine hcl 17CYCLOPHOSPHAMIDE 7cyclophosphamide 7cycloserine 5cyclosporine 27cyclosporine modified (for

microemulsion) 27CYSTADANE 21CYSTAGON 21cytarabine inj 8

Ddacarbazine 7DALIRESP 31DALVANCE 3danazol 21dantrolene sodium 17dapsone 3DAPTACEL 27DARAPRIM 3daunorubicin hcl 7DAYTRANA 16deblitane 28 day 19decitabine 8DELESTROGEN 21delyla 28 day 19DELZICOL 24demeclocycline hcl 7DEMSER 13DENAVIR 34

DEPEN TITRATABS 19depo-estradiol 21DEPO-MEDROL INJ

20MG/ML 21DEPO-PROVERA INJ

400/ML 8DEPO-SUBQ PROVERA

104 19depo-testosterone 18desipramine hcl 14desloratadine 31DESMOPRESSIN

ACETATE 23desmopressin acetate 23desmopressin acetate inj 23desmopressin acetate

spray 23desmopressin acetate spray

refrigerated 23desogestrel-ethinyl estradiol

(biphasic) 19DESONATE 33DESONIDE 33desonide 33DESOXIMETASONE 34desoximetasone 34dexamethasone 21dexamethasone sodium

phosphate 21dexamethasone sodium

phosphate (ophth) 30DEXILANT 24dexpak taperpak 13 day 21dexrazoxane 9DEXTROSE 28DEXTROSE 10% FLEX

CONTAIN 29DEXTROSE 10% W/

SODIUM CHLORIDE0.2% 29

DEXTROSE 10%/NACL0.45% 29

DEXTROSE 2.5%/NACL0.45% 29

DEXTROSE 5% 29DEXTROSE 5%

/ELECTROLYTE 29DEXTROSE 5%/LACTATED

RING 29DEXTROSE 5%/NACL

0.2% 29DEXTROSE 5%/NACL





0.9% 29DEXTROSE


40

5%/POTASSIUM CHL 29diazepam 13DIAZEPAM GEL

(ANTICONVULSANT) 13DIBENZYLINE 13diclofenac potassium 1diclofenac sodium 1diclofenac sodium (actinic

keratoses) 34diclofenac sodium (ophth) 30diclofenac sodium (topical) 34diclofenac w/ misoprostol 1dicloxacillin sodium 7dicyclomine hcl 23didanosine 4DIFFERIN 32DIFICID 6diflorasone diacetate 34diflunisal 1digitek 12digoxin 12digoxin inj 12DIGOXIN SOL 50MCG/ML 12DIHYDROERGOTAMINE

MESYLATE 16dihydroergotamine

mesylate 16dilantin 13DILANTIN-125 13DILATRATE SR 13DILAUDID-HP INJ 250MG 1dilt-xr cap 12diltiazem cap 120mg/24hr 12diltiazem cap er/12hr 12diltiazem hcl 12diltiazem hcl coated beads 12diltiazem hcl er 12diltiazem hcl extended

release beads 12diltiazem inj 100mg 12diltiazem inj 125/25ml 12diltiazem inj 25mg/5ml 12diltiazem inj 50/10ml 12diltzac 12DIPENTUM 24diphenhydram inj 50mg/ml 31diphenoxylate w/ atropine 24DIPHTHERIA/TETANUS

TOXOID 27disopyramide phosphate 10disulfiram 17DIURIL SUS 250/5ML 12divalproex sodium 13DOCETAXEL 8docetaxel 8donepezil odt 10mg 14donepezil odt 5mg 14donepezil tab hcl 23mg 14donepezil tabs 10mg 14donepezil tabs 5mg 14

DORIBAX 3dorzolamide hcl 30dorzolamide hcl-timolol

maleate 30doxazosin mesylate 10doxepin hcl 14doxercalciferol 29doxorubicin hcl 7doxorubicin hcl liposomal inj

(for iv infusion) 2 mg/ml 7doxorubicin inj 50mg 7doxy 7doxycycline (monohydrate) 7DOXYCYCLINE

(ROSACEA) 34doxycycline hyclate 7dronabinol 23drospirenone-ethinyl

estradiol 19DROXIA 9DUEXIS 1DULERA 32duloxetine hcl 14DUOPA 15DURAMORPH 1DUREZOL 30DUTOPROL 11DYMISTA SPR 137-50 31DYRENIUM 12

Ee.e.s. 400 tab 400mg 6E.E.S. GRANULES 6econazole nitrate 33EDARBI 10EDARBYCLOR 10EDECRIN 12EDURANT 4EFFIENT 26EGRIFTA 22ELAPRASE 21ELECTROLYTE-R IN

DEXTROSE 29ELELYSO 21ELIDEL 34ELIGARD INJ 22.5MG 8ELIGARD INJ 30MG 8ELIGARD INJ 45MG 8ELIGARD INJ 7.5MG 8ELIQUIS TAB 2.5MG 25ELIQUIS TAB 5MG 25ELITEK 9elixophyllin 32ELLA 19ELMIRON 25ELOXATIN 9EMADINE 30EMBEDA 1EMCYT 7EMEND CAP 125MG 23

EMEND CAP 40MG 23EMEND CAP 80MG 23EMEND PAK 80 & 125 23emoquette 19EMSAM 14EMTRIVA 4ENABLEX 25enalapril maleate 10enalapril maleate &

hydrochlorothiazide 10ENBREL 26ENBREL SURECLICK 26endocet 1ENDODAN TAB 1ENGERIX-B 27enoxaparin sodium 25enpresse 28 day 19ENTACAPONE 15entecavir 5ENTYVIO 24enulose 24EPIDUO 32epinastine hcl (ophth) 30EPINEPHRINE 31epinephrine 32EPIPEN 2-PAK 32EPIPEN-JR 2-PAK 32epirubicin inj 200mg 7epirubicin inj 50mg/25ml 7epitol 13EPIVIR HBV 5eplerenone 10EPOGEN 26eprosartan mesylate 10EPZICOM 5EQUETRO 17ERAXIS 4ERBITUX 8ergomar 16ERIVEDGE 8errin 28 day 19ERTACZO 33ery pad 2% 32ery-tab 6ERYPED 200 6ERYPED 400 6erythrocin lactobionate 6erythrocin stearate 6erythromycin (acne aid) 32erythromycin (ophth) 30erythromycin base 6erythromycin cap 250mg ec 6erythromycin ethylsuccinate 6ESBRIET 32escitalopram oxalate 14esomeprazole sodium inj 24estrace 21estradiol 21estradiol valerate 21ESTRING 21


41

ethambutol hcl 5ethosuximide 13etodolac 1etodolac er 1ETOPOPHOS 9etoposide 9EURAX 34EVOTAZ 5EXELDERM 33EXELON PATCHES 14exemestane 8EXJADE 19EXTAVIA 17

FFABIOR 32FABRAZYME 21FACTIVE 6falmina 28 day 19famciclovir 5famotidine 23famotidine inj 23FANAPT 15FANAPT TITRATION

PACK 15FARESTON 8FARXIGA 18FARYDAK 8FASLODEX 8FAZACLO 15felbamate 13felodipine 12FEMRING 21FENOFIBRATE 11fenofibrate 11fenofibrate micronized 11FENOFIBRIC ACID 11FENOGLIDE 11fenoprofen calcium 1fentanyl citrate 1fentanyl patch 100 mcg/hr 2fentanyl patch 12 mcg/hr 1fentanyl patch 25 mcg/hr 1fentanyl patch 50 mcg/hr 2fentanyl patch 75 mcg/hr 2FENTORA 2FERRIPROX 19FETZIMA 14FETZIMA TITRATION

PACK 14FINACEA GEL 15% 34finasteride 25FIRAZYR 26FIRMAGON 8FLAGYL ER 3FLAREX 30FLEBOGAMMA 26FLEBOGAMMA DIF 26flecainide acetate 10FLO-PRED SUS 21

FLOVENT DISKUS 32FLOVENT HFA 32fluconazole 4fluconazole in dextrose 4fluconazole in nacl 4flucytosine 4fludarabine phosphate 8fludrocortisone acetate 21flunisolide (nasal) 32fluocinolone acetonide 34fluocinolone acetonide

(otic) 35fluocinonide 34fluocinonide emulsified

base 34FLUOROMETHOLONE

(OPHTH) 30fluorouracil 8FLUOROURACIL

(TOPICAL) 34fluorouracil (topical) 34FLUOXETINE HCL 14fluoxetine hcl 14fluphenazine decanoate 15fluphenazine hcl 15flurbiprofen 1flurbiprofen sodium 30flutamide 8fluticasone propionate 34fluticasone propionate

(nasal) 32fluvastatin sodium 11fluvoxamine maleate 13fluvoxamine maleate er 13FML 30FML FORTE 30fondaparinux sodium 25FORADIL AEROLIZER 31FORFIVO XL 14FORTAZ 6FORTEO 22FORTESTA 18FORTICAL SPR 200/ACT 22FOSAMAX PLUS D 19foscarnet sodium 5fosinopril sodium 10fosinopril sodium &

hydrochlorothiazide 10FOSRENOL 23FRAGMIN 25FREAMINE HBC 6.9% 28FREAMINE III 28FROVA TAB 2.5MG 16furosemide 12FUROSEMIDE INJ 12furosemide inj 12furosemide oral soln 8

mg/ml 12FUSILEV 9FUZEON 4

FYCOMPA 13

Ggabapentin 13GABITRIL 13galantamine hydrobromide 14GAMASTAN S/D 26GAMMAGARD LIQUID 26GAMMAGARD S/D 26GAMMAGARD S/D IGA

LESS TH 26GAMMAKED 26GAMMAPLEX 26GAMUNEX-C 26ganciclovir inj 500mg 5GARDASIL 27GARDASIL 9 27gatifloxacin (ophth) 30GATTEX 24GAUZE PADS 2X2 18gaviltye-g 24gavilyte-c 24gavilyte-h 24gavilyte-n 24GELNIQUE 25GEMCITABINE 8gemcitabine hcl 8gemfibrozil 11generlac 24gengraf 27GENOTROPIN 22GENOTROPIN

MINIQUICK 22gentak 30gentamicin in saline 0.8

mg/ml 3gentamicin in saline

0.9mg/ml 3gentamicin in saline 1 mg/ml3gentamicin in saline 1.2

mg/ml 3gentamicin in saline

1.4mg/ml 3gentamicin in saline 1.6

mg/ml 3gentamicin in saline 2 mg/ml3gentamicin sulfate 3gentamicin sulfate (ophth) 30gentamicin sulfate (topical) 33GEODON INJ 15GIANVI TAB 3-0.02MG 19GIAZO 24gildagia 19gildess 1.5/30 21 day 20gildess 24 fe 28 day 20GILENYA CAP 0.5MG 17GILOTRIF TAB 20MG 9GILOTRIF TAB 30MG 9GILOTRIF TAB 40MG 9GLASSIA 32


42

glatopa 17GLEEVEC 9GLEOSTINE 7glimepiride 18glipizide 18glipizide er 18glipizide-metformin 2.5-250

mg 18glipizide-metformin 2.5-500

mg 18glipizide-metformin 5-

500mg 18GLUCAGEN HYPOKIT 22GLUCAGON EMERGENCY

KIT 22GLUMETZA 18GLYCATE 23glycopyrrolate 23GLYSET 18GLYXAMBI 18GOLYTELY 24GRALISE 17GRALISE STARTER 17granisetron hcl 23GRANIX 26GRASTEK 27griseofulvin microsize 4griseofulvin ultramicrosize 4guanfacine hcl (adhd) 16

HH.P. ACTHAR 22HALAVEN 9halobetasol propionate 34HALOG 34haloperidol 15haloperidol decanoate 15haloperidol lactate 15haloperidol lactate inj 5

mg/ml 15HARVONI 5HAVRIX 27heather 20HECTOROL 29HEP SOD/NACL INJ

25000 25HEPARIN (PORCINE) IN

SODIUM CHLORIDE100U/ML 25

heparin sod inj 10000u/ml 26heparin sod inj 1000u/ml 25heparin sod inj 20000u/ml 26HEPARIN SOD INJ

2000U/ML 25HEPARIN SOD INJ

2500U/ML 25heparin sod inj

5000u/0.5ml 26heparin sod inj 5000u/ml 26HEPARIN SODIUM/D5W 26

HEPARIN SODIUM/NACL0.45% 26

HEPATAMINE 28HERCEPTIN 8HETLIOZ 16HEXALEN 7HIBERIX 27HORIZANT 17HUMALOG 18HUMALOG KWIKPEN 18HUMALOG MIX 50/50 18HUMALOG MIX 50/50

KWIKPEN 18HUMALOG MIX 75/25 18HUMALOG MIX 75/25

KWIKPEN 18HUMATROPE 22HUMATROPE COMBO

PACK 22HUMIRA 26HUMIRA PEN 26HUMIRA PEN-CROHNS

STARTER KIT 26HUMIRA PEN-PSORIASIS

STARTER KIT 26HUMULIN 70/30 18HUMULIN 70/30

KWIKPEN 18HUMULIN N 18HUMULIN N KWIKPEN 18HUMULIN R 18HUMULIN R U-500

(CONCENTRATE) 18hydralazine hcl 13hydrochlorothiazide 12hydrocodone-acetaminophen

10-300mg 2hydrocodone-acetaminophen

2.5-325mg 2hydrocodone-acetaminophen




7.5-325 mg/15ml 2hydrocodone-acetaminophen


tab 10-325mg 2hydrocodone-ibuprofen tab

2.5-200mg 2hydrocodone-ibuprofen tab

7.5-200 mg 2hydrocortisone 21HYDROCORTISONE

(INTRARECTAL) 24hydrocortisone (topical) 34hydrocortisone butyrate 34hydrocortisone butyrate

hydrophilic lipo base 34hydrocortisone valerate 34HYDROMORPHONE HCL 2hydromorphone hcl 2hydromorphone tab 12mg er2hydromorphone tab 16mg er2hydromorphone tab 8mg er 2HYDROMORPHONE TABS

32MG 2hydroxychloroquine sulfate 26hydroxyurea 9hydroxyzine hcl 31HYSINGLA ER 2

Iibandronate sodium 19ibandronate tab 150mg 19IBRANCE 8ibudone tab 10-200mg 2ibudone tab 5-200mg 2ibuprofen 1ICLUSIG 9idarubicin hcl 7IFEX INJ 3GM 7ifosfamide inj 1gm 7ifosfamide inj 1gm/20ml 7IFOSFAMIDE INJ 3GM 7ifosfamide inj 3gm/60ml 7ILEVRO 30ilotycin 30IMBRUVICA CAP 140MG 9imipenem-cilastatin 3imipramine hcl 14imipramine pamoate 14imiquimod 34IMOVAX RABIES

(H.D.C.V.) 27INCRELEX 22INCRUSE ELLIPTA 31indapamide 12INFANRIX 27INFUMORPH 200 2INFUMORPH 500 2INLYTA 9INSULIN PEN NEEDLES 18INSULIN SAFETY

NEEDLES 18INSULIN SYRINGES 18INTELENCE 4INTRALIPID INJ 20% 28INTRALIPID INJ 30% 28INTRON-A INJ 10MU 27INTRON-A INJ 18MU 27INTRON-A INJ 25MU 27INTRON-A INJ 50MU 27introvale 91 day 20INVANZ 3INVEGA 15INVEGA SUST INJ 117

MG/0.75 ML 15


43

INVEGA SUST INJ156MG/ML 15

INVEGA SUST INJ 234MG/1.5 ML 15



INVEGA TRINZA 15INVIRASE 4INVOKAMET TAB 150-

1000 18INVOKAMET TAB 150-50018INVOKAMET TAB 50-100018INVOKAMET TAB 50-

500MG 18INVOKANA TAB 100MG 18INVOKANA TAB 300MG 18IONOSOL-B/DEXTROSE

5% 29IONOSOL-MB/DEXTROSE

5% 29IPOL INACTIVATED IPV 27ipratropium bromide

(nasal) 31ipratropium sol inhal 31ipratropium-albuterol 31irbesartan 10irbesartan-

hydrochlorothiazide 10irinotecan inj 100/5ml 9irinotecan inj 40mg/2ml 9irinotecan inj 500mg/25ml 9ISENTRESS 4ISOLYTE P 29ISOLYTE S 29isoniazid 5isoniazid tabs 5ISORDIL TITRADOSE 13isosorbide dinitrate 13isosorbide dinitrate er 13isosorbide mononitrate 13isosorbide mononitrate er 13isradipine 12ISTALOL 30ISTODAX 8itraconazole 4ivermectin 3IXEMPRA KIT 9IXIARO 27

JJADENU 19JAKAFI 9JALYN 25jantoven 26JANUMET 18JANUMET XR TAB 100-

1000 18JANUMET XR TAB 50-

1000 18JANUMET XR TAB 50-

500MG 18JANUVIA 18JARDIANCE 18JENTADUETO 19jinteli 21JOLESSA TAB 0.15-0.03

MG 20JOLIVETTE 20junel 1.5/30 21 day 20junel 1/20 21 day 20junel fe 1.5/30 28 day 20junel fe 1/20 28 day 20junel fe 24 1/20 28 day 20JUXTAPID 11

KKADCYLA 8KADIAN 2KALETRA SOL 5KALETRA TAB 100-25MG 5KALETRA TAB 200-50MG 5KALYDECO 32kariva 28 day 20KAZANO 19KCL 0.075%/D5W/NACL

0.45% 29KCL 0.15%/D5W/LR 29KCL 0.15%/D5W/NACL

0.9% 29KCL 0.3%/D5W/LR IV LAC

RI 29KCL 0.3%/D5W/NACL

0.45% 29KCL 0.3%/D5W/NACL

0.9% 29KCL IN NACL INJ .15-0.45 29KCL/D5W/NACL INJ

.15/.33% 29KCL/D5W/NACL INJ

.15/.45% 29KCL/D5W/NACL INJ

0.22%/0.45% 29KCL/NACL INJ 0.15%-

0.9% 29KCL0.15%/D5W/NACL0.2% 2

9KCL0.15%/D5W/NACL0.225

% 29kelnor 1/35 28 day 20KEPIVANCE 9ketoconazole 4ketoconazole (topical) 33ketoconazole shampoo 33ketodan aer 2% 33ketoprofen 1ketorolac tromethamine

(ophth) 30KEYTRUDA 8kimidess 20

KINERET 26KINRIX 27kionex 19KLOR-CON 10 28KLOR-CON 8 28klor-con m15 28klor-con m20 28klor-con pow 20meq 28KOMBIGLYZE XR 2.5-

1000MG 19KOMBIGLYZE XR 5-

1000MG 19KOMBIGLYZE XR 5-

500MG 19KORLYM 22kristalose 24KUVAN 21KYNAMRO 11

Llabetalol hcl 11laclotion lot 12% 34LACRISERT 31LACTATED RINGERS

VIAFLEX 29lactulose 24lactulose (encephalopathy) 24LAMICTAL ODT 13LAMICTAL STARTER 13LAMICTAL XR 13LAMISIL 4lamivudine 4lamivudine (hbv) 5lamivudine-zidovudine 5lamotrigine 13LANOXIN 12LANOXIN PEDIATRIC 12lansoprazole 25LANTUS 18LANTUS SOLOSTAR 18larin 1.5/30 20larin 1/20 20larin fe 1.5/30 20larin fe 1/20 20LASTACAFT 30latanoprost 30LATUDA 15LAZANDA 2LEENA TAB 20leflunomide 26LEMTRADA 17LENVIMA 10MG DAILY

DOSE 9LENVIMA 14MG DAILY



DOSE 9LESCOL XL 11


44

lessina 28 day 20LETAIRIS 13letrozole 8leucovorin calcium 9leucovorin calcium inj

100mg 9leucovorin calcium inj



500mg 9leucovorin calcium inj 50mg 9LEUKERAN 7LEUKINE 26leuprolide acetate 8levalbuterol conc

1.25mg/0.5ml 31LEVALBUTEROL HCL 31levalbuterol hcl 31LEVEMIR 18LEVEMIR FLEXTOUCH 18levetiracetam 13LEVETIRACETAM IV 13levetiracetam oral soln 100

mg/ml 13LEVOBUNOLOL HCL 30levobunolol hcl 30levocarnitine (metabolic

modifiers) 21levocetirizine soln

2.5mg/5ml 31levocetirizine tab 5 mg 31levofloxacin 6levofloxacin (ophth) 30levofloxacin in d5w 7levoleucovorin calcium 9levonest 28 day 20levonorgestrel & eth

estradiol 20levonorgestrel (emergency

oc) 20levonorgestrel-ethinyl

estradiol (91-day) 20levonorgestrel-ethinyl

estradiol (continuous) 20levora 0.15/30 28 day 20levorphanol tartrate 2levothyroxine sodium 23LEVOXYL 23LEXIVA 4LIALDA 24lidocaine 34lidocaine hcl 34lidocaine hcl (local anesth.) 3lidocaine hcl (mouth-throat)35lidocaine inj 0.5% 3lidocaine inj 1% 3lidocaine inj 1.5% 3lidocaine inj 2% 3lidocaine-prilocaine 34

LINEZOLID 4linezolid 3LINZESS 24liothyronine sodium 23LIPOSYN III 28LIPTRUZET 11lisinopril 10lisinopril &

hydrochlorothiazide 10lithium carbonate 17LITHIUM SOLN

8MEQ/5ML 17LIVALO 11LO LOESTRIN FE 20LOCOID 34lokara 34lomedia 24 fe 20LOMUSTINE 7loperamide hcl 24lorazepam 13lorcet hd tab 10-325mg 2lorcet plus tab 7.5-325 2lorcet tab 5-325mg 2lortab tab 10-325mg 2lortab tab 5-325mg 2lortab tab 7.5-325 2loryna 28 day 20losartan potassium 10losartan-

hydrochlorothiazide 10LOTEMAX 30lovastatin 11low-ogestrel 20loxapine succinate 15LUMIGAN 30LUMIZYME 21LUPANETA PACK 21LUPRON DEP INJ 11.25MG8LUPRON DEP-PED INJ

11.25MG 8LUPRON DEP-PED INJ

15MG 8LUPRON DEP-PED INJ

30MG (3-MONTH) 8LUPRON DEP-PED INJ

7.5MG 8LUPRON DEPOT 8LUPRON DEPOT INJ

22.5MG (3-MONTH) 8LUPRON DEPOT INJ 30MG

(3-MONTH) 8lutera 28 day 20LUZU 33LYNPARZA 8LYRICA 13LYSODREN 8lyza 20

MM-M-R II 27

MACRODANTIN 4MAGNESIUM SULFATE 28magnesium sulfate 28MAGNESIUM SULFATE IN

D5W 28MAGNESIUM SULFATE INJ

50% 28malathion 34maprotiline hcl 14marlissa 28 day 20MARPLAN 14MATULANE 9matzim la 12MAXIDEX 30MAXIPIME 6meclizine hcl 23MEDROL TAB 2MG 21medroxyprogesterone

acetate 23medroxyprogesterone

acetate (contraceptive) 20mefenamic acid 1mefloquine hcl 4MEGACE ES 8megestrol acetate 8MEKINIST 9MELOXICAM 1meloxicam tabs 1melphalan hcl 7memantine hcl 14MENACTRA 27MENOMUNE-A/C/Y/W-13527MENOSTAR 21MENTAX 33MENVEO 27mercaptopurine 8meropenem 4mesalamine enema 24mesna 9MESNEX 9MESTINON SYRUP 17MESTINON TIMESPAN 17metadate er tab 20mg 16metformin er 19metformin hcl 19methadone hcl 2METHADONE INJ

10MG/ML 2methazolamide 12methenamine hippurate 4methimazole 23methotrexate sodium inj 8methotrexate sodium tabs 26methoxsalen rapid 33methscopolamine bromide 23methyclothiazide 12methylergonovine maleate 22methylphenidate hcl 16methylphenidate hcl er 16methylpr ace inj 40mg/ml 21


45

methylpr ace inj 80mg/ml 21methylpr ss inj 125mg 21methylpr ss inj 1gm 21methylpr ss inj 40mg 21methylpred pak 4mg 21methylpred tab 16mg 21methylpred tab 32mg 21methylpred tab 4mg 21methylpred tab 8mg 21metipranolol 30metoclopramide hcl 23metoclopramide hcl inj 5

mg/ml 23metolazone 12metoprolol & hctz tab 100-

25mg 11metoprolol & hctz tab 100-

50mg 11metoprolol & hctz tab 50-

25mg 11metoprolol succinate 11metoprolol tartrate 11METRO IV 4metronidazole 4metronidazole (topical) 34metronidazole inj 4metronidazole vaginal 25mexiletine hcl 10MIACALCIN INJ 200U/ML 22miconazole 3 sup 200mg 25MICROGESTIN 1.5/30 20MICROGESTIN 1/20 20MICROGESTIN FE 1.5/30 20MICROGESTIN FE 1/20 20midodrine hcl 13migergot 16millipred 21MINASTRIN 24 FE 20minitran 13MINIVELLE 21minocycline hcl 7minoxidil 13MIRAPEX 15MIRAPEX ER 15MIRCERA 26mirtazapine 14misoprostol 24mitomycin 7mitoxantrone hcl 9modafinil 17MODERIBA PAK 5moderiba pak 5moderiba tab 200mg 5moexipril hcl 10moexipril-

hydrochlorothiazide 10mometasone furoate 34MONONESSA 20montelukast sodium 31MORPHINE SUL 20MG/ML

ORAL SOL 2MORPHINE SULFATE 2morphine sulfate 2morphine sulfate beads 2morphine sulfate ext-rel tab 2MOVANTIK 24MOVIPREP 24MOXEZA 30moxifloxacin hcl 7MOZOBIL 26MULTAQ 10mupirocin 33mupirocin calcium (topical) 33MUSTARGEN 7my way 20MYCAMINE 4mycophenolate mofetil 27mycophenolate sodium 27myorisan 32MYOZYME 21MYRBETRIQ 25myzilra 20

Nnabumetone 1nadolol 11nadolol &

bendroflumethiazide 11nafcillin sodium 7NAFTIFINE HCL 33NAFTIN 33NAGLAZYME 21nalbuphine hcl 1NALLPEN ISO-OSMOTIC IN

DE 7NALLPEN/DEXTROSE 7naloxone hcl 17naltrexone hcl 17NAMENDA SOL

10MG/5ML 14NAMENDA TAB 14NAMENDA XR 14NAMENDA XR TITRATION

PACK 14NAMZARIC 14naphazoline 0.1% 31NAPRELAN 1naproxen 1NAPROXEN SODIUM 1naproxen sodium 1naratriptan hcl 16NASONEX 32NATACYN 30nateglinide 19NATPARA 22NEBUPENT 4necon 0.5/35 28 day 20necon 1/35 28 day 20necon 10/11 28 day 20NECON 7/7/7 20

NECON TAB 1/50-28 20nefazodone hcl 14neomycin sulfate 3neomycin-bacitracin zn-

polymyxin 30neomycin-polymy-

dexameth 29neomycin-polymyxin-

gramicidin 30neomycin-polymyxin-hc

(ophth) 29neomycin-polymyxin-hc

(otic) 35neomycin/polymyxin b gu 35NEORAL 27NEPHRAMINE 28NESINA 19neuac gel 1.2-5% 32NEULASTA 26NEUMEGA 26NEUPOGEN 26NEUPRO 15NEVIRAPINE 4nevirapine 5NEXAVAR 9NEXIUM CAP 20MG 25NEXIUM CAP 40MG 25NEXIUM GRA 10MG DR 25NEXIUM GRA 2.5MG DR 25NEXIUM GRA 20MG DR 25NEXIUM GRA 40MG DR 25NEXIUM GRA 5MG DR 25next choice tab 1.5mg 20niacin er

(antihyperlipidemic) 11niacor 11nicardipine hcl 12NICOTROL INHALER 17NICOTROL NS 17nifedical 12nifedipine 12nifedipine er 12nikki 28 day 20NILANDRON 8nimodipine 12NIPENT 8nisoldipine 12nitro-bid 13NITRO-DUR 13nitrofurantoin 4nitrofurantoin macrocrystal 4nitrofurantoin monohyd

macro 4nitroglycerin 13NITROGLYCERIN

LINGUAL 13nitroglycerin patches 13NITROSTAT 13nizatidine 23NORA-BE TAB 20


46

NORDITROPIN FLEXPRO 22NORDITROPIN NORDIFLEX

PEN 22norethin acet & estrad-fe 20norethindrone & ethinyl

estradiol-fe 20norethindrone

(contraceptive) 20norethindrone acetate 23norethindrone acetate-ethinyl

estradiol 21norgestimate-ethinyl estradiol

(triphasic) 20NORITATE 34norlyroc 28 day 20NORMOSOL-M IN D5W 29NORMOSOL-R 29NORPACE CR 11nortrel 0.5/35 28 day 20nortrel 1/35 21 day 20nortrel 1/35 28 day 20nortrel 7/7/7 28 day 20nortriptyline hcl 14NORVIR 5NOVAREL INJ 10000UNT 22NOVOLIN 70/30 18NOVOLIN 70/30 RELION 18NOVOLIN N 18NOVOLIN N RELION 18NOVOLIN R 18NOVOLIN R RELION 18NOVOLOG 18NOVOLOG FLEXPEN 18NOVOLOG MIX 70/30 18NOVOLOG MIX 70/30

PREFILL 18NOVOLOG PENFILL 18NOXAFIL 4NUCYNTA 2NUCYNTA ER 2NUEDEXTA 17NULOJIX 27NULYTELY/FLAVOR

PACKS 24NUTRILIPID INJ 20% 28NUTROPIN AQ INJ

20MG/2ML 22NUTROPIN AQ NUSPIN 5 22NUTROPIN AQ PEN 22NUVARING 20NUVESSA 25NUVIGIL 17nyamyc 33NYMALIZE 12nystatin 4nystatin (mouth-throat) 35nystatin (topical) 33nystatin pow 100000 33nystop 33

OOCELLA TAB 3-0.03MG 20OCTAGAM 26octreotide acetate 22OFEV 32ofloxacin (ophth) 30ofloxacin (otic) 35ogestrel 28 day 20olanzapine 15olanzapine odt 15olopatadine hcl (nasal) 31OMECLAMOX-PAK 24omega-3-acid ethyl esters 11omeprazole 25OMEPRAZOLE-SODIUM

BICARBONATE 25OMNARIS 32OMNITROPE 10MG 22OMNITROPE 5.8MG 22OMNITROPE 5MG 22ondansetron hcl 23ondansetron hcl inj 23ondansetron hcl oral soln 23ondansetron odt 23ONEXTON 32ONFI 13ONGLYZA 19ONMEL 4OPANA ER (CRUSH

RESISTANT 2OPSUMIT 13ORACEA 34ORAP 15ORENCIA 26ORENITRAM TAB

0.125MG 13ORENITRAM TAB 0.25MG13ORENITRAM TAB 1MG 13ORENITRAM TAB 2.5MG 13ORFADIN 21ORKAMBI 32orsythia 28 day 20ORTHO TRI-CYCLEN LO 20OSENI TAB 12.5-15MG 19OSENI TAB 12.5-30MG 19OSENI TAB 12.5-45MG 19OSENI TAB 25-15MG 19OSENI TAB 25-30MG 19OSENI TAB 25-45MG 19OSMOPREP 24OTEZLA 26oxacillin sodium 7oxaliplatin 9oxandrolone 18oxaprozin 1oxcarbazepine 13OXISTAT 33OXTELLAR XR 13oxybutynin chloride 25OXYCODONE HCL 2

oxycodone hcl 2oxycodone w/ acetaminophen

10-325mg 3oxycodone w/ acetaminophen

2.5-325mg 2oxycodone w/ acetaminophen

5-325mg 3oxycodone w/ acetaminophen

7.5-325mg 3oxycodone-aspirin 3oxycodone-ibuprofen 3OXYCONTIN 3oxymorphone hcl 3OXYTROL 25

Ppacerone 11paclitaxel 8pamidronate disodium 19PANCREAZE 24PANDEL 34PANRETIN 34pantoprazole sodium 25PARICALCITOL 29paricalcitol 29paromomycin sulfate 3paroxetine er tab 14paroxetine hcl tabs 14paser d/r 5PATADAY 30PATANOL 30PAXIL 14PAZEO 30PCE 6PEDVAX HIB 27PEG 3350-KCL-SOD

BICARB-SODCHLORIDE-SODSULFATE 24

peg 3350-potassium chloride-sod bicarbonate-sodchloride 24

PEG-INTRON 5PEG-INTRON REDIPEN 5PEGANONE 13PEGINTRON 5PENICILLIN G POT IN

DEXTROSE 7PENICILLIN G POTASSIUM

IN 7penicillin g procaine 7penicillin g sodium 7penicillin v potassium 7penicilln gk inj 20mu 7penicilln gk inj 5mu 7PENNSAID 34PENTAM 300 4PENTASA 24pentoxifylline 26PERFOROMIST 31


47

perindopril erbumine 10periogard soln 0.12% 35PERJETA 8permethrin 34perphenazine 15PERTZYE 24PEXEVA 14pfizerpen g inj 5mu 7pfizerpen-g inj 20mu 7phenadoz 23phenelzine sulfate 14phenergan 23phenobarbital 13PHENOBARBITAL

SODIUM 14phenobarbital sodium 14phenytek 14phenytoin 14phenytoin inj 50mg/ml 14phenytoin sodium

extended 14philith 20PHOSLYRA 23PHOSPHOLINE IODIDE 30PICATO 34PILOCARPINE HCL 31PILOCARPINE HCL

(ORAL) 35pilocarpine hcl (oral) 35pimtrea pack 20pindolol 11pioglitazone hcl 19pioglitazone hcl-glimepiride19pioglitazone hcl-metformin

hcl 19piperacillin sodium-

tazobactam sodium 7pirmella 1/35 28 day 20piroxicam 1PLASMA-LYTE A 29PLASMA-LYTE-148 29PLASMA-LYTE-56/D5W 29PLEGRIDY 17PLEGRIDY STARTER

PACK 17podofilox 34polyethylene glycol 3350 24polymyxin b sulfate 4polymyxin b-trimethoprim 30POMALYST 9portia 28 day 20pot chloride inj 2meq/ml 29POTASSIUM CHLORIDE 28,

29potassium chloride 28POTASSIUM CHLORIDE

0.3%/D 29potassium chloride caps er 28POTASSIUM CHLORIDE IN

NACL 29

potassium chloride in nacl 29potassium chloride

microencapsulatedcrystals cr 28

POTASSIUM CHLORIDETAB CR 10 MEQ 28

POTASSIUM CITRATE(ALKALINIZER) 25

potassium citrate(alkalinizer) 25

POTIGA 14PRADAXA 26pramipexole

dihydrochloride 15PRANDIMET 19pravastatin sodium 11prazosin hcl 10PRED MILD 30pred sod pho sol 5mg/5ml 22PRED-G 29PRED-G S.O.P. 29PREDNICARBATE 34prednicarbate 34PREDNISOLONE ACETATE

(OPHTH) 30prednisolone sodium

phosphate 22prednisolone sodium

phosphate (ophth) 30prednisolone sol 15mg/5ml 22prednisolone sol 25mg/5ml 22prednisolone syrup 15

mg/5ml 22prednisone con 5mg/ml 22prednisone pak 10mg 22prednisone pak 5mg 22prednisone sol 5mg/5ml 22prednisone tab 10mg 22prednisone tab 1mg 22prednisone tab 2.5mg 22prednisone tab 20mg 22prednisone tab 50mg 22prednisone tab 5mg 22PREGNYL W/DILUENT

BENZYL 22PREMARIN CREAM 21PREMARIN INJ 21premasol 10% 28premasol 6% 28PRENATAL VITAMIN/FOLIC

ACID > 0.8 MG(GENERIC) 29

PREPOPIK 24PREVACID SOLUTAB 25prevalite 11previfem 28 day 20PREZCOBIX 5PREZISTA 5PRIFTIN 5PRILOSEC 25PRIMAQUINE

PHOSPHATE 4primidone 14PRIMSOL SOL 50MG/5ML 4PRISTIQ 14PRIVIGEN 26PROAIR HFA 31PROAIR RESPICLICK 31probenecid 1PROCALAMINE 28prochlorperazine inj 5

mg/ml 23prochlorperazine maleate 23prochlorperazine supp 23PROCRIT 26procto-pak 33proctosol hc 2.5 % 33proctozone hc 33PROCYSBI 21progesterone micronized 23PROGLYCEM SUS

50MG/ML 22PROGRAF 27PROLASTIN-C 32PROLENSA 31PROLEUKIN 8PROLIA 22PROMACTA 26promethazine hcl 23promethegan 23propafenone hcl 11propafenone hcl 12hr 11proparacaine hcl 31propranolol &

hydrochlorothiazide 11propranolol hcl er 11propranolol inj 1mg/ml 11propranolol sol 11propranolol tab 11propylthiouracil 23PROQUAD 27PROSOL 28PROTONIX 25protriptyline hcl 14PROVENTIL HFA 31PRUDOXIN CRE 5% 33PULMICORT FLEXHALER 32PULMICORT INH SUSP

1MG/2ML 32PULMOZYME 32PURIXAN 8PYLERA 24pyrazinamide 5pyridostigmine bromide 17

QQNASL 32QNASL CHILDRENS 32QUADRACEL 27QUARTETTE 20quasense 91 day 20


48

quetiapine fumarate 15QUILLIVANT XR 16quinapril hcl 10quinapril-

hydrochlorothiazide 10quinidine gluconate 11quinidine sulfate 11quinine sulfate 4QVAR 32

RRABAVERT 27rabeprazole sodium 25RAGWITEK 27raloxifene hcl 22ramipril 10RANEXA 13ranitidine hcl 24RAPAFLO 25RAPAMUNE 27RAVICTI 21RAYOS TAB 1MG 22RAYOS TAB 2MG 22RAYOS TAB 5MG 22REBETOL 5REBIF 17REBIF REBIDOSE 17REBIF REBIDOSE

TITRATION 17REBIF TITRATION PACK 17reclipsen 28 day 20RECOMBIVAX HB 27RECTIV 34REGRANEX 35RELENZA DISKHALER 5RELISTOR 24RELPAX 16REMICADE 26REMODULIN 13RENAGEL 23RENVELA PAK 23RENVELA TAB 800MG 23repaglinide 19reprexain tab 10-200mg 3RESCRIPTOR 5RESTASIS 31RETIN-A MICRO PUMP 32RETROVIR IV INFUSION 5REVATIO 13REVLIMID 27REYATAZ 5RHEUMATREX 26ribapak mis 600/day 5ribasphere 5ribasphere ribapak 1000 5ribasphere ribapak 1200 5ribasphere ribapak 800 5ribavirin 200mg 6rifabutin 5rifamate 5

rifampin 5RIFATER 5riluzole 17rimantadine hydrochloride 6RINGER'S 29RIOMET 19RISEDRONATE SODIUM 19risedronate sodium 19RISPERDAL INJ 12.5MG 15RISPERDAL INJ 25MG 15RISPERDAL INJ 37.5MG 15RISPERDAL INJ 50MG 15risperidone 15risperidone odt 15RITALIN LA 16RITUXAN 8rivastigmine tartrate 14rizatriptan benzoate 16ropinirole hydrochloride 15rosadan cre 0.75% 34ROTARIX 27ROTATEQ 27roxicet soln 3roxicet tab 5-325mg 3ROZEREM 16RUCONEST 26RYTARY 15

SSABRIL 14SAIZEN 22SAIZEN CLICK.EASY 22SAMSCA 22SANCUSO 23SANDIMMUNE SOLN 27SANDOSTATIN LAR

DEPOT 22SANTYL 35SAPHRIS 15SARAFEM 17SAVAYSA 26SAVELLA 17SAVELLA TITRATION

PACK 17selegiline hcl 15selenium sulfide 33SELZENTRY 5SEMPREX-D 31SENSIPAR 19SEREVENT DISKUS 31SEROQUEL XR 15SEROSTIM 22sertraline hcl 14SF-ROWASA 24sharobel 28 day 20SIGNIFOR 22SIGNIFOR LAR 22sildenafil citrate (pulmonary

hypertension) 13SILENOR 16

SILVER SULFADIAZINE 33SIMBRINZA SUS 1-0.2% 31SIMCOR 11SIMPONI 26SIMPONI ARIA 26SIMULECT 27simvastatin 11SIROLIMUS 27sirolimus 27SIRTURO 5SIVEXTRO 4SKLICE 34SODIUM CHLORIDE 28, 29SODIUM CHLORIDE 0.45%

VIA 29SODIUM CHLORIDE 0.9% 35SODIUM FLUORIDE CHEW;

TAB; 1.1 (0.5 F) MG/MLSOLN 28

sodium phenylbutyrate 21sodium polystyrene

sulfonate 19SOLIA 20SOLODYN 7SOLTAMOX 9SOLU-CORTEF 1000MG 22SOLU-CORTEF 100MG 22SOLU-CORTEF 250MG 22SOLU-CORTEF 500MG 22SOLU-MEDROL INJ 2GM 22SOMATULINE DEPOT 22SOMAVERT 22SOOLANTRA 34SORILUX 33sorine 11sotalol hcl 11sotalol hcl (afib/afl) 11SOTYLIZE 11SOVALDI 6SPIRIVA HANDIHALER 31SPIRIVA RESPIMAT 31spironolactone 10spironolactone &

hydrochlorothiazide 12SPORANOX SOL 10MG/ML4sprintec 28 day 20SPRYCEL 9sps susp 15gm/60ml 19sronyx 28 day 20SSD 33stavudine 5STELARA 33STERILE WATER

IRRIGATION 35STIMATE 23STIOLTO RESPIMAT 31STIVARGA 9STRATTERA 16streptomycin sulfate 3STRIANT 18


49

STRIBILD 5STRIVERDI RESPIMAT 31SUBOXONE MIS 12-3MG 17SUBOXONE MIS 2-0.5MG 17SUBOXONE MIS 4-1MG 17SUBOXONE MIS 8-2MG 17SUBSYS 3SUCLEAR 24SUCRAID 24sucralfate 24sulfacet sod oin 10% op 30sulfacetamide sod-

prednisolone 29sulfacetamide sodium

(acne) 32sulfacetamide sodium

(ophth) 30sulfadiazine 3sulfamethoxazole-trimethop 4sulfamethoxazole-

trimethoprim inj 4SULFAMYLON 33sulfasalazine dr 24sulfasalazine ir 24sulindac 1SUMATRIPTAN INJ

4MG/0.5ML 16SUMATRIPTAN INJ

6MG/0.5ML 16sumatriptan inj 6mg/0.5ml 16SUMATRIPTAN

SUCCINATE 16sumatriptan succinate 16SUMAVEL DOSEPRO 16SUPRAX 6suprax 6SUPREP BOWEL PREP 24SURMONTIL 15SUSTIVA 5SUTENT 9syeda 20SYLATRON KIT 200MCG 9SYLATRON KIT 300MCG 9SYLATRON KIT 600MCG 9SYMBICORT 32SYMLINPEN 120 18SYMLINPEN 60 18SYNAGIS 27SYNAREL 21SYNERA 34SYNERCID 4SYNRIBO 9SYNTHROID 23SYPRINE 19

TTABLOID 8TACLONEX 34tacrolimus 27tacrolimus (topical) 34

TAFINLAR 9TAMIFLU 6tamoxifen citrate 9tamsulosin hcl 25TANZEUM 18TARCEVA 9TARGRETIN 9, 34tarina fe 1/20 28 day 20TASIGNA 9tazicef 6tazicef vial 6TAZORAC 33taztia xt 12TECFIDERA CAP 120MG 17TECFIDERA CAP 240MG 17TECFIDERA MIS

STARTER 17TEFLARO 6TEGRETOL 14TEGRETOL-XR 14TEKTURNA 12TEKTURNA HCT 12telmisartan 10telmisartan-amlodipine 10telmisartan-

hydrochlorothiazide 10temazepam 16TENIVAC 27terazosin hcl 10terbinafine hcl 4terbutaline sulfate 31terconazole vaginal 25TESTIM 18testosterone cypionate 18testosterone enanthate 18TETANUS/DIPHTHERIA

TOXOID 27TETRACYCLINE HCL 7TEVETEN HCT 10texacort 34THALOMID 27theo-24 32theophylline 32thioridazine hcl 15thiothixene 15THYMOGLOBULIN 27tiagabine hcl 14TIKOSYN 11timolol maleate 11timolol maleate (ophth) 31TIMOLOL MALEATE GEL 31TIMOPTIC OCUDOSE 31TIROSINT 23TIVICAY 5tizanidine 17TOBI PODHALER 3TOBRADEX 29TOBRADEX ST 29tobramycin 3tobramycin (ophth) 30

tobramycin sulfate 3tobramycin sulfate in saline 3tobramycin-

dexamethasone 29TOBREX OINT 0.3% 30tolmetin sodium 1tolterodine tartrate er 25tolterodine tartrate tab 1

mg 25tolterodine tartrate tab 2

mg 25TOPICORT SPRAY 0.25% 34TOPIRAMATE 14topiramate 14toposar 9topotecan hcl 9TORISEL 8torsemide inj 50mg/5ml 12torsemide tabs 12TOUJEO SOLOSTAR 18TOVIAZ 25TPN ELECTROLYTES 28TRACLEER 13TRADJENTA 19TRAMADOL HCL 1TRAMADOL HCL ER 1tramadol hcl er 1tramadol hcl er (biphasic)

100mg 1tramadol hcl er (biphasic)

200mg 1tramadol hcl er (biphasic)

300mg 1tramadol hcl tab 50 mg 1tramadol-acetaminophen 1trandolapril 10trandolapril-verapamil hcl 10tranexamic acid 26TRANSDERM-SCOP 23tranylcypromine sulfate 15TRAVASOL 28TRAVATAN Z 31trazodone hcl 15TREANDA 7TRECATOR 5TRELSTAR MIXJECT 9tretin-x 32TRETINOIN 32tretinoin 9, 32TRETINOIN

MICROSPHERE 33tretinoin microsphere 32trexall 26TREXIMET 16trezix 1tri-legest 28 day 20tri-previfem 28 day 20tri-sprintec 28 day 20triamcinolone acetonide

(mouth) 35


50

triamcinolone acetonide(nasal) 32

triamcinolone acetonide(topical) 34

triamt/hctz cap 37.5-25 12triamt/hctz cap 50-25mg 12triamt/hctz tab 37.5-25 12triamt/hctz tab 75-50mg 12trianex 34TRIBENZOR 10triderm 34trifluoperazine hcl 15trifluridine 30TRIGLIDE 11trilyte 24trimethoprim 4TRINESSA 20TRISENOX 9TRIUMEQ 5trivora 28 day 21TROKENDI XR 14TROPHAMINE INJ 10% 28trospium chloride 25trospium chloride er 25TRULICITY 18TRUMENBA 27TRUVADA 5TUDORZA PRESSAIR 31TUDORZA PRESSAIR

(INSTITUTIONALPACK) 31

TWINRIX INJ 27TYBOST 5TYGACIL 4TYKERB 9TYPHIM VI 27TYSABRI 17TYVASO 13TYZEKA 6tyzine 32

UUCERIS AER 2MG/ACT 24UCERIS TAB 9MG 24ULORIC 1ULTRESA 24UNITHROID 23ursodiol 24UVADEX 9

VVAGIFEM 21valacyclovir hcl 6VALCHLOR 34VALCYTE 6valganciclovir hcl 6valproate sodium 14valproic acid 14valsartan 10valsartan-

hydrochlorothiazide 10vancomycin hcl 4vancomycin hcl inj 1000mg 4vancomycin hcl inj 10gm 4vancomycin hcl inj 500mg 4vancomycin hcl inj 5gm 4vancomycin hcl inj 750mg 4VANDAZOLE 25VAQTA 27VARIVAX 27VASCEPA 11VECTIBIX 8VELCADE 8velivet 28 day 21VELPHORO 23VELTIN 33venlafaxine cap er 15venlafaxine hcl 15venlafaxine tab 15VENLAFAXINE TAB 225MG

ER 15venlafaxine tab er 15VENTAVIS 13VENTOLIN HFA 31VERAMYST 32VERAPAMIL HCL 12verapamil hcl 12veripred 22VERSACLOZ 16VESICARE 25vestura 21VEXOL 30VIBRAMYCIN 7vicodin 3vicodin es 3vicodin hp 3VICTOZA 18VIDEX PEDIATRIC 5VIGAMOX 30VIIBRYD 15VIMIZIM 21VIMOVO 1VIMPAT 14vinblastine sulfate 8vincasar 8vincristine sulfate 8vinorelbine tartrate 8VIOKACE 10 24VIOKACE 20 24viorele 21VIRACEPT 5VIRAMUNE XR 5VIREAD 5VITEKTA 5VOGELXO 18VOGELXO PUMP 18VOLTAREN GEL 1% 34voriconazole 4voriconazole inj 200mg 4VOTRIENT 9

VPRIV 21vyfemla 28 day 21VYTORIN 11VYVANSE 16

Wwarfarin sodium 26WELCHOL 11wymzya fe 21

XXALKORI 9XARELTO 26XARELTO STARTER

PACK 26XARTEMIS XR 3XELJANZ 26XENAZINE 17XEOMIN INJ 100 UNIT 17XEOMIN INJ 50 UNIT 17XERESE 34XGEVA 22XIFAXAN TAB 200MG 4XIFAXAN TAB 550MG 24XIGDUO XR TAB 10-

1000MG 19XIGDUO XR TAB 10-



500MG 19XOLAIR 32XOPENEX HFA 31XTANDI 9xulane dis 150-35 21XYREM 17

YYERVOY 8YF-VAX 27

Zzafirlukast 31zamicet 3ZANOSAR 7zarah 21ZAVESCA 21ZAZOLE 25zazole 25ZEGERID 25ZELAPAR 15ZELBORAF 9ZEMAIRA 32ZEMPLAR 29ZENATANE 33zenatane 33zenchent fe 28 day 21zenchent tab 21


51

ZENPEP 24ZERBAXA 6ZETIA TAB 10MG 11ZETONNA 32ZIAGEN 5ZIANA 33zidovudine 5ZINACEF 6ZIOPTAN 31ziprasidone hcl 16ZIPSOR 1ZIRGAN 30ZMAX 6ZOHYDRO ER (ABUSE

DETERRENT) 3zoledronic inj 4mg/5ml 19zoledronic inj 5/100ml 19ZOLINZA 8zolmitriptan 16zolmitriptan odt 16zolpidem tartrate 16ZOMACTON 22ZOMETA 19ZOMIG NASAL SPRAY 16zonisamide 14ZONTIVITY 26ZORBTIVE 22ZORTRESS TAB 0.25MG 27ZORTRESS TAB 0.5MG 27ZORTRESS TAB 0.75MG 27ZORVOLEX 1ZOSTAVAX 27ZOSYN 7zovia 1/35e 28 day 21zovia 1/50e 28 day 21ZOVIRAX 34ZUBSOLV SUB 1.4-

0.36MG 17ZUBSOLV SUB 5.7-1.4MG 17ZUBSOLV SUB 8.6-2.1MG 17ZUPLENZ 23ZYCLARA 34ZYDELIG 9ZYFLO CR 31ZYKADIA 9ZYLET 29ZYPREXA RELPREVV 16ZYPREXA RELPREVV INJ

210MG 16ZYTIGA 9ZYVOX 4

Drug Name Drug Requirements/ Drug Name Drug ......HealthSelect MedicareRx Effective January 1, 2016 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under

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