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CommunityHealthChoice.org/Medicare833.276.8306 or 713.295.5007 (TTY 711)October 1 through March 31, 8:00 am to 8:00 pm, 7 days a week and April 1 through September 30, Monday through Friday, 8:00 am to 8:00 pm
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Community Health Choice (HMO D-SNP)
2021 FORMULARYLIST OF COVERED DRUGSPLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN
This formulary was updated on 09/01/2020. For more recent information or other questions, please contact Community Health Choice Member Services, at 1-833-276-8306 or, for TTY users, 711, October 1 through March 31, 8:00 am to 8:00 pm, 7 days a week and April through September 30, Monday through Friday, 8:00 am to 8:00 pm, or visit www.communityhealthchoice.org/Medicare.
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Community Health Choice. When it refers to “plan” or “our plan,” it means Community Health Choice (HMO D-SNP).
This document includes list of the drugs (formulary) for our plan which is current as of 09/01/2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the year.
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What is the Community Health Choice (HMO D-SNP) Formulary?
A formulary is a list of covered drugs selected by Community Health Choice in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Community Health Choice will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Community Health Choice network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow the Medicare rules in making these changes.
Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:
• New generic drugs. We may immediately remove a brand name drug on our Drug List if weare replacing it with a new generic drug that will appear on the same or lower cost sharingtier and with the same or fewer restrictions. Also, when adding the new generic drug, we maydecide to keep the brand name drug on our Drug List, but immediately move it to a differentcost-sharing tier or add new restrictions. If you are currently taking that brand name drug, wemay not tell you in advance before we make that change, but we will later provide you withinformation about the specific change(s) we have made.
- If we make such a change, you or your prescriber can ask us to make an exception andcontinue to cover the brand name drug for you. The notice we provide you will also includeinformation on how to request an exception, and you can also find information in the sectionbelow entitled “How do I request an exception to the Community Health Choice (HMOD-SNP) Formulary?”
• Drugs removed from the market. If the Food and Drug Administration deems a drug on ourformulary to be unsafe or the drug’s manufacturer removes the drug from the market, we willimmediately remove the drug from our formulary and provide notice to members who take thedrug.
• Other changes. We may make other changes that affect members currently taking a drug.For instance, we may add a new generic drug to replace a brand name drug currently on theformulary; or add new restrictions to the brand name drug or move it to a different cost-sharingtier or both. Or we may make changes based on new clinical guidelines. If we remove drugsfrom our formulary, or add prior authorization, quantity limits and/or step therapy restrictionson a drug, we must notify affected members of the change at least 30 days before the changebecomes effective, or at the time the member requests a refill of the drug, at which time themember will receive a 30-day supply of the drug.
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- If we make these other changes, you or your prescriber can ask us to make an exception andcontinue to cover the brand name drug for you. The notice we provide you will also includeinformation on how to request an exception, and you can also find information in the sectionbelow entitled “How do I request an exception to the Community Health Choice (HMOD-SNP) Formulary?”
Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above. This means these drugs will remain available at the same cost sharing and with no new restrictions for those members taking them for the remainder of the coverage year. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is important to check the Drug List for the new benefit year for any changes to drugs.
The enclosed formulary is current as of 09/01/2020. To get updated information about the drugs covered by Community Health Choice, please contact us. Our contact information appears on the front and back cover pages.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page number 8. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on page 8. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
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What are generic drugs?
Community Health Choice covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
• Prior Authorization: Community Health Choice requires you or your physician to get priorauthorization for certain drugs. This means that you will need to get approval from CommunityHealth Choice before you fill your prescriptions. If you don’t get approval, we may not cover thedrug.
• Quantity Limits: For certain drugs, Community Health Choice limits the amount of the drugthat we will cover. For example, Community Health Choice provides 60 per prescription forcelecoxib. This may be in addition to a standard one-month or three-month supply.
• Step Therapy: In some cases, Community Health Choice requires you to first try certain drugs totreat your medical condition before we will cover another drug for that condition. For example,if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you tryDrug A first. If Drug A does not work for you, we will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
You can ask Community Health Choice to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Community Health Choice (HMO D-SNP) formulary?” on page 8 for information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. For more information, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
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If you learn that Community Health Choice does not cover your drug, you have two options:
• You can ask Member Services for a list of similar drugs that are covered by us. When youreceive the list, show it to your doctor and ask him or her to prescribe a similar drug that iscovered by Community Health Choice.
• You can ask us to make an exception and cover your drug. See below for information about howto request an exception.
How do I request an exception to the Community Health Choice (HMO D-SNP) Formulary?
You can ask Community Health Choice to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will becovered at a pre-determined cost-sharing level, and you would not be able to ask us to providethe drug at a lower cost-sharing level.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certaindrugs, Community Health Choice limits the amount of the drug that we will cover. If your drughas a quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request
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a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.
Exceptions are available for members who have experienced a change in the level of care they are receiving which requires them to transition from one facility or treatment center to another. Examples of situations in which members would be eligible for the one-time temporary fill exception when they are outside of their first 90 days of enrollment in our plan are as follows:
i. Members who enter LTC facilities from hospitals with a discharge list of medications from thehospital formulary with very short term planning taken into account (e.g., under 8 hours).
ii. Members who are discharged from a hospital to a home with very short-term planning takeninto account.
iii. Members who end their skilled nursing facility Medicare Part A stay (where payments includeall pharmacy charged) and who need to return to their Part D plan formulary.
iv. Members who give up hospice status to return to standard Medicare Part A and P benefits.
v. Members who end an LTC facility stay and return to the community.
vi. Members who are discharged from psychiatric hospitals with drug regimens that are highlyindividualized.
For more information
For more detailed information about your Community Health Choice prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about Community Health Choice, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.
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Community Health Choice (HMO D-SNP) Formulary
The abridged formulary below provides coverage information about some of the drugs covered by Community Health Choice. If you have trouble finding your drug in the list, turn to the Index that begins on page 8.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., HUMIRA) and generic drugs are listed in lower-case italics (e.g., celecoxib).
The information in the Requirements/Limits column tells you if Community Health Choice has any special requirements for coverage of your drug.
The following tables describes the abbreviations used in the Drug List Table.
ABBREVIATION ABBREVIATION MEANING
FF First Fill Limited to one-month supply: You may be able to receive greater than a 1-month supply of most of the drugs on your Formulary. Drugs noted with “FF” are limited to a 1-month supply for both Retail and Mail Order on your first fill only. After the first fill, an extended day supply would be available.
LD Limited Distribution: The symbol [LD] next to a drug name indicates that the drug has been noted as being restricted to certain pharmacies by the Food and Drug Administration. These drugs can only be obtained at specialty designated pharmacies able to appropriately handle the drugs.
NDS Non-Extended Day Supply: You may be able to receive greater than a 1-month supply of most of the drugs on your Formulary via mail order at areduced cost share. Drugs noted with “NDS” are limited to a 1-month supplyfor both Retail and Mail Order.
PA Prior Authorization: Community Health Choice requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, we may not cover the drug.
PA_BvD Prior Authorization Restriction for Part B vs Part D: This drug may be eligible for payment under Medicare Part B or Part D. You or your physician are required to get prior authorization from us to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, we may not cover this drug.
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ABBREVIATION ABBREVIATION MEANING
PA_NSO Prior Authorization Restriction for New Starts Only: If this drug is new to you, you (or your physician) are required to get prior authorization from Community Health Choice before you fill your prescription for this drug. Without prior approval, we may not cover this drug.
QL Quantity Limits: For certain drugs, we limit the amount of the drug that will be covered. This could include a: per fill, daily, monthly, or yearly limitation.
ST Step Therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
ST_NSO Step Therapy for New Starts Only: If this drug is new to you, you are required to first try certain drugs to treat your medical condition before we will cover another drug for that condition.
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSAMPHETAMINES
1amphetamine 10mg er cap
1amphetamine 10mg tab
1amphetamine 12.5mg tab
1amphetamine 15mg er cap
1amphetamine 15mg tab
1amphetamine 20mg er cap
1amphetamine 20mg tab
1amphetamine 25mg er cap
1amphetamine 30mg er cap
1amphetamine 30mg tab
1amphetamine 5mg er cap
1amphetamine 5mg tab
1amphetamine 7.5mg tab
1dextroamphetamine sulfate 10mg er cap
1dextroamphetamine sulfate 10mg tab
1dextroamphetamine sulfate 15mg er cap
1dextroamphetamine sulfate 5mg er cap
1dextroamphetamine sulfate 5mg tabATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS
1atomoxetine 100mg cap QL=60 EA/30 Days
1atomoxetine 10mg cap QL=60 EA/30 Days
1atomoxetine 18mg cap QL=60 EA/30 Days
1atomoxetine 25mg cap QL=60 EA/30 Days
1atomoxetine 40mg cap QL=60 EA/30 Days
1atomoxetine 60mg cap QL=60 EA/30 Days
1atomoxetine 80mg cap QL=60 EA/30 Days
1guanfacine 1mg er tab
1guanfacine 2mg er tab
1guanfacine 3mg er tab
1guanfacine 4mg er tabDOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS)
1SUNOSI 150MG TAB PA QL=30 EA/30 Days
1SUNOSI 75MG TAB PA QL=30 EA/30 DaysHISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS
1WAKIX 17.8MG TAB NDS PA QL=60 EA/30 Days
1WAKIX 4.45MG TAB NDS PA QL=60 EA/30 DaysSTIMULANTS - MISC.
1armodafinil 150mg tab PA QL=30 EA/30 Days
1armodafinil 200mg tab PA QL=30 EA/30 Days
1armodafinil 250mg tab PA QL=30 EA/30 Days
1armodafinil 50mg tab PA QL=30 EA/30 Days
1dexmethylphenidate 10mg er cap
1dexmethylphenidate 10mg tab
1dexmethylphenidate 15mg er cap
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
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DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1dexmethylphenidate 2.5mg tab
1dexmethylphenidate 20mg er cap
1dexmethylphenidate 25mg er cap
1dexmethylphenidate 30mg er cap
1dexmethylphenidate 35mg er cap
1dexmethylphenidate 40mg er cap
1dexmethylphenidate 5mg er cap
1dexmethylphenidate 5mg tab
1methylphenidate 10mg cr cap
1methylphenidate 10mg er tab
1methylphenidate 10mg la cap
1methylphenidate 10mg tab
1METHYLPHENIDATE 18MG ER TAB
1methylphenidate 18mg er tab
1methylphenidate 1mg/ml oral soln
1methylphenidate 20mg cr cap
1methylphenidate 20mg er tab
1methylphenidate 20mg la cap
1methylphenidate 20mg tab
1methylphenidate 27mg sr tab
1methylphenidate 2mg/ml oral soln
1methylphenidate 30mg cr cap
1methylphenidate 30mg la cap
1methylphenidate 36mg sr tab
1methylphenidate 40mg cr cap
1methylphenidate 40mg la cap
1methylphenidate 50mg cr cap
1methylphenidate 54mg sr tab
1methylphenidate 5mg tab
1methylphenidate 60mg cr cap
1modafinil 100mg tab PA QL=60 EA/30 Days
1modafinil 200mg tab PA QL=60 EA/30 Days
AMINOGLYCOSIDESAMINOGLYCOSIDES
1amikacin 250mg/ml inj
1ARIKAYCE 590MG/8.4ML INH SUSP NDS PA QL=252 ML/30 Days
1GENTAMICIN 0.8MG/ML INJ
1gentamicin 1.2mg/ml inj
1GENTAMICIN 1.6MG/ML INJ
1GENTAMICIN 1MG/ML INJ
1gentamicin 40mg/ml inj
1neomycin sulfate 500mg tab
1PAROMOMYCIN 250MG CAP
1STREPTOMYCIN 1000MG INJ
1TOBRAMYCIN 10MG/ML INJ
1tobramycin 40mg/ml inj
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
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DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1tobramycin 60mg/ml inh soln NDS PA QL=300 ML/30 Days
ANALGESICS - ANTI-INFLAMMATORYANTIRHEUMATIC - ENZYME INHIBITORS
1OLUMIANT 1MG TAB NDS PA
1OLUMIANT 2MG TAB NDS PA
1RINVOQ 15MG ER TAB NDS PA
1XELJANZ 10MG TAB NDS PA
1XELJANZ 5MG TAB NDS PA
1XELJANZ XR 11MG TAB NDS PA
1XELJANZ XR 22MG TAB NDS PAANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES
1HUMIRA 10MG/0.1ML SYRINGE NDS PA
1HUMIRA 10MG/0.2ML SYRINGE NDS PA
1HUMIRA 20MG/0.2ML SYRINGE NDS PA
1HUMIRA 20MG/0.4ML SYRINGE NDS PA
1HUMIRA 40MG/0.4ML AUTO-INJECTOR NDS PA
1HUMIRA 40MG/0.4ML SYRINGE NDS PA
1HUMIRA 40MG/0.8ML AUTO-INJECTOR NDS PA
1HUMIRA 40MG/0.8ML SYRINGE NDS PA
1HUMIRA PEDIATRIC CROHN'S STARTER PACK (3) 80MG/0.8ML INJ
NDS PA
1HUMIRA PEDIATRIC CROHN'S STARTER PACK SYRINGE (2) 40MG/0.4ML
NDS PA
1HUMIRA PEN - CROHN'S STARTER PACK 40MG/0.8ML INJ
NDS PA
1HUMIRA PEN - CROHN'S STARTER PACK 80MG/0.8ML INJ
NDS PA
1HUMIRA PEN - PSORIASIS STARTER PACK 40MG/0.8ML INJ
NDS PA
1HUMIRA PEN - PSORIASIS STARTER PACK 80MG/0.8ML INJ
NDS PA
1SIMPONI 100MG/ML AUTO-INJECTOR NDS PA
1SIMPONI 100MG/ML SYRINGE NDS PA
1SIMPONI 50MG/0.5ML AUTO-INJECTOR NDS PA
1SIMPONI 50MG/0.5ML SYRINGE NDS PAGOLD COMPOUNDS
1RIDAURA 3MG CAPINTERLEUKIN-1 BLOCKERS
1ARCALYST 220MG INJ NDS PAINTERLEUKIN-6 RECEPTOR INHIBITORS
1ACTEMRA 162MG/0.9ML AUTO-INJECTOR NDS PA
1ACTEMRA 162MG/0.9ML SYRINGE NDS PA
1KEVZARA 150MG/1.14ML AUTO-INJECTOR NDS PA
1KEVZARA 150MG/1.14ML SYRINGE NDS PA
1KEVZARA 200MG/1.14ML AUTO-INJECTOR NDS PA
1KEVZARA 200MG/1.14ML SYRINGE NDS PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
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DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)
1celecoxib 100mg cap QL=60 EA/30 Days
1celecoxib 200mg cap QL=60 EA/30 Days
1celecoxib 400mg cap QL=60 EA/30 Days
1celecoxib 50mg cap QL=60 EA/30 Days
1diclofenac potassium 50mg tab
1diclofenac sodium 100mg er tab
1diclofenac sodium 25mg dr tab
1diclofenac sodium 50mg dr tab
1diclofenac sodium 50mg/misoprostol 0.2mg dr tab
1diclofenac sodium 75mg dr tab
1diclofenac sodium 75mg/misoprostol 0.2mg dr tab
1etodolac 200mg cap
1etodolac 300mg cap
1etodolac 400mg er tab
1etodolac 400mg tab
1etodolac 500mg er tab
1etodolac 500mg tab
1etodolac 600mg er tab
1flurbiprofen 100mg tab
1ibu 600mg tab
1ibu 800mg tab
1ibuprofen 20mg/ml susp
1ibuprofen 400mg tab
1ibuprofen 600mg tab
1ibuprofen 800mg tab
1INDOCIN 50MG RECTAL SUPP
1indomethacin 25mg cap
1indomethacin 50mg cap
1indomethacin 75mg er cap
1ketorolac tromethamine 10mg tab QL=20 EA/5 Days
1meloxicam 15mg tab
1meloxicam 7.5mg tab
1nabumetone 500mg tab
1nabumetone 750mg tab
1naproxen 250mg tab
1naproxen 375mg dr tab
1naproxen 375mg tab
1naproxen 500mg dr tab
1naproxen 500mg tab
1naproxen sodium 275mg tab
1naproxen sodium 550mg tab
1oxaprozin 600mg tab
1piroxicam 10mg cap
1piroxicam 20mg cap
1sulindac 150mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
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DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1sulindac 200mg tabPHOSPHODIESTERASE 4 (PDE4) INHIBITORS
1OTEZLA 28-DAY STARTER PACK NDS PA
1OTEZLA 30MG TAB NDS PAPYRIMIDINE SYNTHESIS INHIBITORS
1leflunomide 10mg tab
1leflunomide 20mg tabSELECTIVE COSTIMULATION MODULATORS
1ORENCIA 125MG/ML AUTO-INJECTOR NDS PA
1ORENCIA 125MG/ML SYRINGE NDS PA
1ORENCIA 50MG/0.4ML SYRINGE NDS PA
1ORENCIA 87.5MG/0.7ML SYRINGE NDS PASOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS
1ENBREL 25MG INJ NDS PA
1ENBREL 25MG/0.5ML SYRINGE NDS PA
1ENBREL 50MG/ML AUTO-INJECTOR NDS PA
1ENBREL 50MG/ML CARTRIDGE NDS PA
1ENBREL 50MG/ML SYRINGE NDS PA
ANALGESICS - NONNARCOTICSALICYLATES
1diflunisal 500mg tab
ANALGESICS - OPIOIDOPIOID AGONISTS
1CODEINE SULFATE 15MG TAB QL=240 EA/30 Days
1codeine sulfate 30mg tab QL=240 EA/30 Days
1codeine sulfate 60mg tab QL=180 EA/30 Days
1duramorph 0.5mg/ml inj PA BvD
1duramorph 1mg/ml inj PA BvD
1fentanyl 0.012mg/hr patch QL=10 EA/30 Days
1fentanyl 0.025mg/hr patch QL=10 EA/30 Days
1fentanyl 0.05mg/hr patch QL=10 EA/30 Days
1fentanyl 0.075mg/hr patch QL=10 EA/30 Days
1FENTANYL 0.1MG BUCCAL TAB PA QL=120 EA/30 Days
1fentanyl 0.1mg/hr patch QL=10 EA/30 Days
1FENTANYL 0.2MG BUCCAL TAB PA QL=120 EA/30 Days
1fentanyl 0.2mg lozenge PA QL=120 EA/30 Days
1FENTANYL 0.4MG BUCCAL TAB PA QL=120 EA/30 Days
1fentanyl 0.4mg lozenge PA QL=120 EA/30 Days
1FENTANYL 0.6MG BUCCAL TAB PA QL=120 EA/30 Days
1fentanyl 0.6mg lozenge PA QL=120 EA/30 Days
1FENTANYL 0.8MG BUCCAL TAB PA QL=120 EA/30 Days
1fentanyl 0.8mg lozenge PA QL=120 EA/30 Days
1fentanyl 1.2mg lozenge PA QL=120 EA/30 Days
1fentanyl 1.6mg lozenge PA QL=120 EA/30 Days
1FENTORA 100MCG BUCCAL TAB PA QL=120 EA/30 Days
1FENTORA 200MCG BUCCAL TAB PA QL=120 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
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DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1FENTORA 400MCG BUCCAL TAB PA QL=120 EA/30 Days
1FENTORA 600MCG BUCCAL TAB PA QL=120 EA/30 Days
1FENTORA 800MCG BUCCAL TAB PA QL=120 EA/30 Days
1hydrocodone bitartrate 10mg er cap QL=60 EA/30 Days
1hydrocodone bitartrate 15mg er cap QL=60 EA/30 Days
1hydrocodone bitartrate 20mg er cap QL=60 EA/30 Days
1hydrocodone bitartrate 30mg er cap QL=60 EA/30 Days
1hydrocodone bitartrate 40mg er cap QL=60 EA/30 Days
1hydrocodone bitartrate 50mg er cap QL=60 EA/30 Days
1hydromorphone 10mg/ml (1ml) inj
1hydromorphone 10mg/ml (5ml) inj
1hydromorphone 1mg/ml oral soln QL=2400 ML/30 Days
1hydromorphone 2mg tab QL=450 EA/30 Days
1hydromorphone 4mg tab QL=240 EA/30 Days
1hydromorphone 8mg tab QL=120 EA/30 Days
1methadone 10mg tab QL=360 EA/30 Days
1methadone 5mg tab QL=360 EA/30 Days
1morphine sulfate 100mg er tab QL=120 EA/30 Days
1morphine sulfate 15mg er tab QL=120 EA/30 Days
1morphine sulfate 15mg tab QL=180 EA/30 Days
1morphine sulfate 200mg er tab QL=120 EA/30 Days
1morphine sulfate 20mg/ml oral soln QL=180 ML/30 Days
1morphine sulfate 2mg/ml oral soln QL=1800 ML/30 Days
1morphine sulfate 30mg er tab QL=120 EA/30 Days
1morphine sulfate 30mg tab QL=180 EA/30 Days
1morphine sulfate 4mg/ml oral soln QL=900 ML/30 Days
1morphine sulfate 60mg er tab QL=120 EA/30 Days
1NUCYNTA 100MG ER TAB QL=60 EA/30 Days
1NUCYNTA 150MG ER TAB QL=60 EA/30 Days
1NUCYNTA 200MG ER TAB QL=60 EA/30 Days
1NUCYNTA 250MG ER TAB QL=60 EA/30 Days
1NUCYNTA 50MG ER TAB QL=60 EA/30 Days
1oxycodone 10mg tab QL=180 EA/30 Days
1oxycodone 15mg tab QL=180 EA/30 Days
1oxycodone 1mg/ml oral soln QL=5400 ML/30 Days
1oxycodone 20mg tab QL=180 EA/30 Days
1oxycodone 20mg/ml oral soln QL=270 ML/30 Days
1oxycodone 30mg tab QL=180 EA/30 Days
1oxycodone 5mg cap QL=360 EA/30 Days
1oxycodone 5mg tab QL=360 EA/30 Days
1oxymorphone 10mg tab QL=360 EA/30 Days
1oxymorphone 5mg tab QL=360 EA/30 Days
1tramadol 100mg er tab QL=60 EA/30 Days
1tramadol 100mg er tab (matrix delivery) QL=60 EA/30 Days
1tramadol 200mg er tab QL=60 EA/30 Days
1tramadol 200mg er tab (matrix delivery) QL=60 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
13
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1tramadol 300mg er tab QL=60 EA/30 Days
1tramadol 300mg er tab (matrix delivery) QL=60 EA/30 Days
1tramadol 50mg tab QL=240 EA/30 Days
1XTAMPZA 13.5MG ER CAP QL=120 EA/30 Days
1XTAMPZA 18MG ER CAP QL=120 EA/30 Days
1XTAMPZA 27MG ER CAP QL=120 EA/30 Days
1XTAMPZA 36MG ER CAP QL=120 EA/30 Days
1XTAMPZA 9MG ER CAP QL=120 EA/30 DaysOPIOID COMBINATIONS
1acetaminophen 21.7mg/ml/hydrocodone bitartrate 0.5mg/ml oral soln
QL=5400 ML/30 Days
1acetaminophen 24mg/ml/codeine phosphate 2.4mg/ml oral soln
QL=4980 ML/30 Days
1acetaminophen 300mg/codeine phosphate 15mg tab QL=390 EA/30 Days
1acetaminophen 300mg/codeine phosphate 30mg tab QL=390 EA/30 Days
1acetaminophen 300mg/codeine phosphate 60mg tab QL=390 EA/30 Days
1acetaminophen 300mg/hydrocodone bitartrate 10mg tab
QL=390 EA/30 Days
1acetaminophen 300mg/hydrocodone bitartrate 5mg tab
QL=390 EA/30 Days
1acetaminophen 300mg/hydrocodone bitartrate 7.5mg tab
QL=390 EA/30 Days
1acetaminophen 325mg/hydrocodone bitartrate 10mg tab
QL=360 EA/30 Days
1acetaminophen 325mg/hydrocodone bitartrate 5mg tab
QL=360 EA/30 Days
1acetaminophen 325mg/hydrocodone bitartrate 7.5mg tab
QL=360 EA/30 Days
1acetaminophen 325mg/oxycodone 10mg tab QL=360 EA/30 Days
1acetaminophen 325mg/oxycodone 2.5mg tab QL=360 EA/30 Days
1acetaminophen 325mg/oxycodone 5mg tab QL=360 EA/30 Days
1acetaminophen 325mg/oxycodone 7.5mg tab QL=360 EA/30 Days
1acetaminophen 325mg/tramadol 37.5mg tab QL=360 EA/30 Days
1ASPIRIN 325MG/OXYCODONE 4.84MG TAB QL=360 EA/30 Days
1endocet 325-10mg tab QL=360 EA/30 Days
1endocet 325-5mg tab QL=360 EA/30 Days
1endocet 325-7.5mg tab QL=360 EA/30 Days
1hydrocodone bitartrate 10mg/ibuprofen 200mg tab QL=480 EA/30 Days
1hydrocodone bitartrate 5mg/ibuprofen 200mg tab QL=480 EA/30 Days
1hydrocodone bitartrate 7.5mg/ibuprofen 200mg tab QL=480 EA/30 Days
1lorcet 325-10mg tab QL=360 EA/30 Days
1lorcet 325-5mg tab QL=360 EA/30 Days
1lorcet 325-7.5mg tab QL=360 EA/30 DaysOPIOID PARTIAL AGONISTS
1buprenorphine 12mg/naloxone 3mg sublingual film
1buprenorphine 2mg sl tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
14
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1buprenorphine 2mg/naloxone 0.5mg sl tab
1buprenorphine 2mg/naloxone 0.5mg sublingual film
1buprenorphine 4mg/naloxone 1mg sublingual film
1buprenorphine 8mg sl tab
1buprenorphine 8mg/naloxone 2mg sl tab
1buprenorphine 8mg/naloxone 2mg sublingual film
1butorphanol tartrate 1mg/act nasal inhaler QL=10 ML/30 Days
1ZUBSOLV 1.4-0.36MG SL TAB QL=90 EA/30 Days
1ZUBSOLV 11.4-2.9MG SL TAB QL=60 EA/30 Days
1ZUBSOLV 2.9-0.71MG SL TAB QL=90 EA/30 Days
1ZUBSOLV 5.7-1.4MG SL TAB QL=90 EA/30 Days
1ZUBSOLV 8.6-2.1MG SL TAB QL=60 EA/30 Days
ANDROGENS-ANABOLICANABOLIC STEROIDS
1ANADROL-50 50MG TAB
1oxandrolone 10mg tab
1oxandrolone 2.5mg tabANDROGENS
1ANDRODERM 2MG/24HR PATCH PA QL=60 EA/30 Days
1ANDRODERM 4MG/24HR PATCH PA QL=30 EA/30 Days
1danazol 100mg cap
1danazol 200mg cap
1danazol 50mg cap
1testosterone 1% (25mg) gel PA QL=300 GM/30 Days
1testosterone 1% (50mg) gel PA QL=300 GM/30 Days
1testosterone 1.62% (1.25gm) gel PA QL=75 GM/30 Days
1testosterone 1.62% (2.5gm) gel PA QL=150 GM/30 Days
1TESTOSTERONE 12.5MG/ACT GEL PA QL=300 GM/30 Days
1testosterone 20.25mg/act gel PA QL=150 GM/30 Days
1testosterone cypionate 100mg/ml inj
1testosterone cypionate 200mg/ml (1ml) inj
1testosterone cypionate 200mg/ml inj
1TESTOSTERONE ENANTHATE 200MG/ML INJ
ANORECTAL AGENTSINTRARECTAL STEROIDS
1hydrocortisone 1.67mg/ml enema
1UCERIS 2MG/ACT RECTAL FOAM PAVASODILATING AGENTS
1RECTIV 0.4% RECTAL OINTMENT QL=30 GM/30 Days
ANORECTAL AND RELATED PRODUCTSRECTAL COMBINATIONS
1hydrocortisone/pramoxine 1-1% rectal creamRECTAL STEROIDS
1procto-med 2.5% cream
1procto-pak 1% rectal cream
1proctosol 2.5% cream
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
15
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1proctozone hc 2.5% cream
ANTHELMINTICSANTHELMINTICS
1albendazole 200mg tab
1BENZNIDAZOLE 100MG TAB PA
1BENZNIDAZOLE 12.5MG TAB PA
1ivermectin 3mg tab
ANTIANGINAL AGENTSANTIANGINALS-OTHER
1ranolazine 1000mg er tab
1ranolazine 500mg er tabNITRATES
1isosorbide dinitrate 10mg tab
1isosorbide dinitrate 20mg tab
1isosorbide dinitrate 30mg tab
1isosorbide dinitrate 5mg tab
1isosorbide mononitrate 10mg tab
1isosorbide mononitrate 120mg er tab
1isosorbide mononitrate 20mg tab
1isosorbide mononitrate 30mg er tab
1isosorbide mononitrate 60mg er tab
1minitran 0.1mg/hr patch
1minitran 0.2mg/hr patch
1minitran 0.4mg/hr patch
1minitran 0.6mg/hr patch
1NITRO-BID 2% OINTMENT
1NITRO-DUR 0.3MG/HR PATCH
1NITRO-DUR 0.8MG/HR PATCH
1nitroglycerin 0.1mg/hr patch
1nitroglycerin 0.2mg/hr patch
1nitroglycerin 0.3mg sl tab
1nitroglycerin 0.4mg sl tab
1nitroglycerin 0.4mg/act spray
1nitroglycerin 0.4mg/hr patch
1nitroglycerin 0.6mg sl tab
1nitroglycerin 0.6mg/hr patch
ANTIANXIETY AGENTSANTIANXIETY AGENTS - MISC.
1buspirone 10mg tab
1buspirone 15mg tab
1buspirone 30mg tab
1buspirone 5mg tab
1buspirone 7.5mg tab
1hydroxyzine 10mg tab
1hydroxyzine 25mg tab
1hydroxyzine 2mg/ml oral soln
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
16
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1hydroxyzine 50mg tab
1HYDROXYZINE PAMOATE 100MG CAP
1hydroxyzine pamoate 25mg cap
1hydroxyzine pamoate 50mg capBENZODIAZEPINES
1alprazolam 0.25mg odt
1alprazolam 0.25mg tab
1alprazolam 0.5mg er tab
1alprazolam 0.5mg odt
1alprazolam 0.5mg tab
1alprazolam 1mg er tab
1alprazolam 1mg odt
1alprazolam 1mg tab
1alprazolam 2mg er tab
1alprazolam 2mg odt
1alprazolam 2mg tab
1alprazolam 3mg er tab
1chlordiazepoxide 10mg cap
1chlordiazepoxide 25mg cap
1chlordiazepoxide 5mg cap
1clorazepate dipotassium 15mg tab
1clorazepate dipotassium 3.75mg tab
1clorazepate dipotassium 7.5mg tab
1diazepam 10mg tab
1DIAZEPAM 1MG/ML ORAL SOLN
1diazepam 2mg tab
1diazepam 5mg tab
1diazepam 5mg/ml oral soln
1lorazepam 0.5mg tab
1lorazepam 1mg tab
1lorazepam 2mg tab
1lorazepam 2mg/ml oral soln
1OXAZEPAM 10MG CAP
1OXAZEPAM 15MG CAP
1OXAZEPAM 30MG CAP
ANTIARRHYTHMICSANTIARRHYTHMICS TYPE I-A
1disopyramide 100mg cap
1disopyramide 150mg cap
1NORPACE 100MG ER CAP
1NORPACE 150MG ER CAP
1quinidine gluconate 324mg er tab
1QUINIDINE SULFATE 200MG TAB
1QUINIDINE SULFATE 300MG TABANTIARRHYTHMICS TYPE I-B
1mexiletine 150mg cap
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
17
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1mexiletine 200mg cap
1mexiletine 250mg capANTIARRHYTHMICS TYPE I-C
1flecainide acetate 100mg tab
1flecainide acetate 150mg tab
1flecainide acetate 50mg tab
1propafenone 150mg tab
1propafenone 225mg er cap
1propafenone 225mg tab
1propafenone 300mg tab
1propafenone 325mg er cap
1propafenone 425mg er capANTIARRHYTHMICS TYPE III
1amiodarone 200mg tab
1amiodarone 400mg tab
1dofetilide 0.125mg cap
1dofetilide 0.25mg cap
1dofetilide 0.5mg cap
1MULTAQ 400MG TAB
1pacerone 200mg tab
1pacerone 400mg tab
ANTIASTHMATIC AND BRONCHODILATOR AGENTSANTIASTHMATIC - MONOCLONAL ANTIBODIES
1FASENRA 30MG/ML AUTO-INJECTOR PA
1FASENRA 30MG/ML SYRINGE PA
1NUCALA 100MG INJ NDS PA
1NUCALA 100MG/ML AUTO-INJECTOR NDS PA
1NUCALA 100MG/ML SYRINGE NDS PA
1XOLAIR 150MG INJ NDS PA
1XOLAIR 150MG/ML SYRINGE NDS PA
1XOLAIR 75MG/0.5ML SYRINGE NDS PABRONCHODILATORS - ANTICHOLINERGICS
1ATROVENT 17MCG INH
1INCRUSE 62.5MCG/INH INH
1ipratropium bromide 0.2mg/ml inh soln PA BvD
1LONHALA 25MCG/ML INH SOLN ST
1SPIRIVA 1.25MCG INH ST QL=4 GM/30 DaysLEUKOTRIENE MODULATORS
1montelukast 10mg tab
1montelukast 4mg chew tab
1montelukast 4mg granules
1montelukast 5mg chew tab
1zafirlukast 10mg tab
1zafirlukast 20mg tabSELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS
1DALIRESP 250MCG TAB
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
18
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1DALIRESP 500MCG TABSTEROID INHALANTS
1ARNUITY 100MCG INH QL=30 EA/30 Days
1ARNUITY 200MCG INH QL=30 EA/30 Days
1ARNUITY 50MCG INH QL=30 EA/30 Days
1ASMANEX 100MCG INH QL=13 GM/30 Days
1ASMANEX 110MCG/INH INH QL=1 EA/30 Days
1ASMANEX 200MCG INH QL=13 GM/30 Days
1ASMANEX 220MCG (120ACT) INH QL=1 EA/30 Days
1ASMANEX 220MCG (30ACT) INH QL=1 EA/30 Days
1ASMANEX 220MCG (60ACT) INH QL=1 EA/30 Days
1ASMANEX 50MCG HFA INH QL=13 GM/30 Days
1budesonide 0.125mg/ml inh susp PA BvD QL=120 ML/30 Days
1budesonide 0.25mg/ml inh susp PA BvD QL=120 ML/30 Days
1budesonide 0.5mg/ml inh susp PA BvD QL=120 ML/30 Days
1FLOVENT 100MCG/BLIST INH QL=60 EA/30 Days
1FLOVENT 110MCG INH QL=24 GM/30 Days
1FLOVENT 220MCG INH QL=24 GM/30 Days
1FLOVENT 250MCG/BLIST INH QL=60 EA/30 Days
1FLOVENT 44MCG INH QL=21.20 GM/30 Days
1FLOVENT 50MCG/BLIST INH QL=60 EA/30 DaysSYMPATHOMIMETICS
1ADVAIR 0.045-0.021MG INH QL=12 GM/30 Days
1ADVAIR 0.115-0.021MG INH QL=12 GM/30 Days
1ADVAIR 0.23-0.021MG INH QL=12 GM/30 Days
1albuterol 0.21mg/ml inh soln PA BvD
1albuterol 0.417mg/ml inh soln PA BvD
1albuterol 0.4mg/ml oral soln
1albuterol 0.83mg/ml inh soln PA BvD
1albuterol 2mg tab
1ALBUTEROL 4MG ER TAB
1albuterol 4mg tab
1albuterol 5mg/ml inh soln PA BvD
1ALBUTEROL 8MG ER TAB
1ANORO 0.0625-0.025MG INH QL=60 EA/30 Days
1BREO 0.1-0.025MG INH QL=60 EA/30 Days
1BREO 0.2-0.025MG INH QL=60 EA/30 Days
1COMBIVENT 0.1-0.02MG INH
1DULERA 0.005-0.1MG INH QL=13 GM/30 Days
1DULERA 0.005-0.2MG INH QL=13 GM/30 Days
1DULERA 50-5MCG INH QL=13 GM/30 Days
1fluticasone propionate 0.1mg/salmeterol 0.05mg inh QL=60 EA/30 Days
1fluticasone propionate 0.25mg/salmeterol 0.05mg inh QL=60 EA/30 Days
1fluticasone propionate 0.5mg/salmeterol 0.05mg inh QL=60 EA/30 Days
1FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 113-14MCG/ACT POWDER INH
QL=1 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
19
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 232-14MCG/ACT POWDER INH
QL=1 EA/30 Days
1FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 55-14MCG/ACT POWDER INH
QL=1 EA/30 Days
1ipratropium/albuterol 0.5-2.5mg/3ml inh soln PA BvD
1levalbuterol 0.103mg/ml inh soln PA BvD
1levalbuterol 0.21mg/ml inh soln PA BvD
1levalbuterol 0.417mg/ml inh soln PA BvD
1levalbuterol 2.5mg/ml inh soln PA BvD
1METAPROTERENOL SULFATE 2MG/ML ORAL SOLN
1SEREVENT 50MCG/DOSE INH
1STIOLTO 0.0025-0.0025MG INH QL=4 GM/30 Days
1terbutaline sulfate 2.5mg tab
1terbutaline sulfate 5mg tab
1TRELEGY 0.1-0.0625-0.025MG INH QL=60 EA/30 Days
1VENTOLIN 108MCG INH QL=36 GM/30 Days
1wixela 0.1-0.05mg inh QL=60 EA/30 Days
1wixela 0.25-0.05mg inh QL=60 EA/30 Days
1wixela 0.5-0.05mg inh QL=60 EA/30 DaysXANTHINES
1THEOPHYLLINE 300MG ER TAB
1theophylline 400mg er tab
1theophylline 5.33mg/ml oral soln
1theophylline 600mg er tab
ANTICOAGULANTSCOUMARIN ANTICOAGULANTS
1jantoven 10mg tab
1jantoven 1mg tab
1jantoven 2.5mg tab
1jantoven 2mg tab
1jantoven 3mg tab
1jantoven 4mg tab
1jantoven 5mg tab
1jantoven 6mg tab
1jantoven 7.5mg tab
1warfarin sodium 10mg tab
1warfarin sodium 1mg tab
1warfarin sodium 2.5mg tab
1warfarin sodium 2mg tab
1warfarin sodium 3mg tab
1warfarin sodium 4mg tab
1warfarin sodium 5mg tab
1warfarin sodium 6mg tab
1warfarin sodium 7.5mg tabDIRECT FACTOR XA INHIBITORS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
20
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1ELIQUIS 2.5MG TAB
1ELIQUIS 30-DAY STARTER PACK 5MG
1ELIQUIS 5MG TAB
1XARELTO 10MG TAB
1XARELTO 15MG TAB
1XARELTO 2.5MG TAB
1XARELTO 20MG TAB
1XARELTO KIT PACKHEPARINS AND HEPARINOID-LIKE AGENTS
1enoxaparin sodium 100mg/ml (0.3ml) syringe QL=18 ML/30 Days
1enoxaparin sodium 100mg/ml (0.4ml) syringe QL=24 ML/30 Days
1enoxaparin sodium 100mg/ml (0.6ml) syringe QL=36 ML/30 Days
1enoxaparin sodium 100mg/ml (0.8ml) syringe QL=48 ML/30 Days
1enoxaparin sodium 100mg/ml (1ml) syringe QL=60 ML/30 Days
1enoxaparin sodium 150mg/ml (0.8ml) syringe QL=48 ML/30 Days
1enoxaparin sodium 150mg/ml (1ml) syringe QL=60 ML/30 Days
1fondaparinux sodium 12.5mg/ml (0.4ml) syringe
1fondaparinux sodium 12.5mg/ml (0.6ml) syringe
1fondaparinux sodium 12.5mg/ml (0.8ml) syringe
1fondaparinux sodium 5mg/ml syringe
1FRAGMIN 10000UNIT/ML SYRINGE
1FRAGMIN 12500UNIT/0.5ML SYRINGE
1FRAGMIN 15000UNIT/0.6ML SYRINGE
1FRAGMIN 18000UNT/0.72ML SYRINGE
1FRAGMIN 2500UNIT/0.2ML SYRINGE
1FRAGMIN 5000UNIT/0.2ML SYRINGE
1FRAGMIN 7500UNIT/0.3ML SYRINGE
1FRAGMIN 95000UNIT/3.8ML INJ
1heparin sodium porcine 10000unit/ml inj
1heparin sodium porcine 1000unit/ml inj
1heparin sodium porcine 20000unit/ml inj
1heparin sodium porcine 5000unit/ml injTHROMBIN INHIBITORS
1PRADAXA 110MG CAP
1PRADAXA 150MG CAP
1PRADAXA 75MG CAP
ANTICONVULSANTSAMPA GLUTAMATE RECEPTOR ANTAGONISTS
1FYCOMPA 0.5MG/ML SUSP PA NSO
1FYCOMPA 10MG TAB PA NSO
1FYCOMPA 12MG TAB PA NSO
1FYCOMPA 2MG TAB PA NSO
1FYCOMPA 4MG TAB PA NSO
1FYCOMPA 6MG TAB PA NSO
1FYCOMPA 8MG TAB PA NSOANTICONVULSANTS - BENZODIAZEPINES
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
21
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1clobazam 10mg tab
1clobazam 2.5mg/ml susp
1clobazam 20mg tab
1clonazepam 0.125mg odt
1clonazepam 0.25mg odt
1clonazepam 0.5mg odt
1clonazepam 0.5mg tab
1clonazepam 1mg odt
1clonazepam 1mg tab
1clonazepam 2mg odt
1clonazepam 2mg tab
1DIASTAT 10MG RECTAL GEL
1DIASTAT 2.5MG RECTAL GEL
1DIASTAT 20MG RECTAL GEL
1DIAZEPAM 10MG/2ML RECTAL GEL
1DIAZEPAM 2.5MG/0.5ML RECTAL GEL
1DIAZEPAM 20MG/4ML RECTAL GEL
1NAYZILAM 5MG/0.1ML NASAL SPRAY
1SYMPAZAN 10MG ORAL FILM ST_NSO
1SYMPAZAN 20MG ORAL FILM ST_NSO
1SYMPAZAN 5MG ORAL FILM ST_NSO
1VALTOCO 10MG DOSE KIT 10MG/0.1ML PACK
1VALTOCO 15MG DOSE KIT 7.5MG/0.1ML PACK
1VALTOCO 20MG DOSE KIT 10MG/0.1ML PACK
1VALTOCO 5MG DOSE KIT 5MG/0.1ML PACKANTICONVULSANTS - MISC.
1APTIOM 200MG TAB PA NSO
1APTIOM 400MG TAB PA NSO
1APTIOM 600MG TAB PA NSO
1APTIOM 800MG TAB PA NSO
1BANZEL 200MG TAB PA NSO
1BANZEL 400MG TAB PA NSO
1BANZEL 40MG/ML SUSP PA NSO
1BRIVIACT 100MG TAB PA NSO QL=60 EA/30 Days
1BRIVIACT 10MG TAB PA NSO QL=60 EA/30 Days
1BRIVIACT 10MG/ML ORAL SOLN PA NSO
1BRIVIACT 25MG TAB PA NSO QL=60 EA/30 Days
1BRIVIACT 50MG TAB PA NSO QL=60 EA/30 Days
1BRIVIACT 75MG TAB PA NSO QL=60 EA/30 Days
1carbamazepine 100mg chew tab
1carbamazepine 100mg er cap
1carbamazepine 100mg er tab
1carbamazepine 200mg er cap
1carbamazepine 200mg er tab
1carbamazepine 200mg tab
1carbamazepine 20mg/ml susp
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
22
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1carbamazepine 300mg er cap
1carbamazepine 400mg er tab
1EPIDIOLEX 100MG/ML ORAL SOLN PA NSO
1epitol 200mg tab
1gabapentin 100mg cap
1gabapentin 300mg cap
1gabapentin 400mg cap
1gabapentin 50mg/ml oral soln
1gabapentin 600mg tab
1gabapentin 800mg tab
1LAMICTAL XR BLUE KIT
1LAMICTAL XR GREEN KIT
1LAMICTAL XR ORANGE KIT
1lamotrigine 100mg er tab
1lamotrigine 100mg odt
1lamotrigine 100mg tab
1lamotrigine 150mg tab
1lamotrigine 200mg er tab
1lamotrigine 200mg odt
1lamotrigine 200mg tab
1lamotrigine 250mg er tab
1lamotrigine 25mg chew tab
1lamotrigine 25mg er tab
1lamotrigine 25mg odt
1lamotrigine 25mg pack
1lamotrigine 25mg tab
1lamotrigine 300mg er tab
1lamotrigine 50mg er tab
1lamotrigine 50mg odt
1lamotrigine 5mg chew tab
1lamotrigine tab 25mg (42)/100mg (7) starter pack
1lamotrigine tab 25mg (84)/100mg (14) starter pack
1levetiracetam 1000mg tab
1levetiracetam 100mg/ml oral soln
1levetiracetam 250mg tab
1levetiracetam 500mg er tab
1levetiracetam 500mg tab
1levetiracetam 750mg er tab
1levetiracetam 750mg tab
1oxcarbazepine 150mg tab
1oxcarbazepine 300mg tab
1oxcarbazepine 600mg tab
1oxcarbazepine 60mg/ml susp
1OXTELLAR 150MG ER TAB
1OXTELLAR 300MG ER TAB
1OXTELLAR 600MG ER TAB
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
23
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1pregabalin 100mg cap
1pregabalin 150mg cap
1pregabalin 200mg cap
1pregabalin 20mg/ml oral soln
1pregabalin 225mg cap
1pregabalin 25mg cap
1pregabalin 300mg cap
1pregabalin 50mg cap
1pregabalin 75mg cap
1primidone 250mg tab
1primidone 50mg tab
1QUDEXY 100MG ER CAP PA NSO
1QUDEXY 150MG ER CAP PA NSO
1QUDEXY 200MG ER CAP PA NSO
1QUDEXY 25MG ER CAP PA NSO
1QUDEXY 50MG ER CAP PA NSO
1roweepra 1000mg tab
1roweepra 500mg er tab
1roweepra 500mg tab
1roweepra 750mg er tab
1roweepra 750mg tab
1SPRITAM 1000MG TAB FOR ORAL SUSP PA NSO
1SPRITAM 250MG TAB FOR ORAL SUSP PA NSO
1SPRITAM 500MG TAB FOR ORAL SUSP PA NSO
1SPRITAM 750MG TAB FOR ORAL SUSP PA NSO
1TOPIRAMATE 100MG ER CAP PA NSO
1topiramate 100mg tab
1TOPIRAMATE 150MG ER CAP PA NSO
1topiramate 15mg cap
1TOPIRAMATE 200MG ER CAP PA NSO
1topiramate 200mg tab
1topiramate 25mg cap
1TOPIRAMATE 25MG ER CAP PA NSO
1topiramate 25mg tab
1TOPIRAMATE 50MG ER CAP PA NSO
1topiramate 50mg tab
1TROKENDI 100MG ER CAP PA NSO
1TROKENDI 200MG ER CAP PA NSO
1TROKENDI 25MG ER CAP PA NSO
1TROKENDI 50MG ER CAP PA NSO
1VIMPAT 100MG TAB QL=60 EA/30 Days
1VIMPAT 10MG/ML ORAL SOLN
1VIMPAT 150MG TAB QL=60 EA/30 Days
1VIMPAT 200MG TAB QL=60 EA/30 Days
1VIMPAT 50MG TAB QL=60 EA/30 Days
1zonisamide 100mg cap
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
24
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1zonisamide 25mg cap
1zonisamide 50mg capCARBAMATES
1felbamate 120mg/ml susp
1felbamate 400mg tab
1felbamate 600mg tab
1XCOPRI 100MG TAB PA NSO
1XCOPRI 12.5/25MG TITRATION PACK PA NSO
1XCOPRI 150/200MG TITRATION PACK PA NSO
1XCOPRI 150MG TAB PA NSO
1XCOPRI 200MG TAB PA NSO
1XCOPRI 50/100MG TITRATION PACK PA NSO
1XCOPRI 50MG TAB PA NSO
1XCOPRI TAB 150/200MG PACK PA NSO
1XCOPRI TAB 50/200MG PACK PA NSOGABA MODULATORS
1tiagabine 12mg tab
1tiagabine 16mg tab
1tiagabine 2mg tab
1tiagabine 4mg tab
1vigabatrin 500mg powder for oral soln NDS PA NSO
1vigabatrin 500mg tab NDS PA NSO
1vigadrone 500mg powder for oral soln NDS PA NSOHYDANTOINS
1DILANTIN 30MG ER CAP
1PEGANONE 250MG TAB
1phenytoin 25mg/ml susp
1phenytoin 50mg chew tab
1phenytoin sodium 100mg er cap
1phenytoin sodium 200mg er cap
1phenytoin sodium 300mg er capSUCCINIMIDES
1CELONTIN 300MG CAP
1ethosuximide 250mg cap
1ethosuximide 50mg/ml oral solnVALPROIC ACID
1divalproex sodium 125mg dr cap
1divalproex sodium 125mg dr tab
1divalproex sodium 250mg dr tab
1divalproex sodium 250mg er tab
1divalproex sodium 500mg dr tab
1divalproex sodium 500mg er tab
1valproic acid 250mg cap
1valproic acid 50mg/ml oral soln
ANTIDEPRESSANTSALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
25
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1mirtazapine 15mg odt
1mirtazapine 15mg tab
1mirtazapine 30mg odt
1mirtazapine 30mg tab
1mirtazapine 45mg odt
1mirtazapine 45mg tab
1mirtazapine 7.5mg tabANTIDEPRESSANTS - MISC.
1APLENZIN 174MG ER TAB ST_NSO
1APLENZIN 348MG ER TAB ST_NSO
1APLENZIN 522MG ER TAB ST_NSO
1bupropion 100mg er tab
1bupropion 100mg tab
1bupropion 150mg sr (12 hr) tab
1bupropion 150mg xl (24 hr) tab
1bupropion 200mg er tab
1bupropion 300mg er tab
1bupropion 75mg tab
1MAPROTILINE 25MG TAB
1MAPROTILINE 50MG TAB
1MAPROTILINE 75MG TABMONOAMINE OXIDASE INHIBITORS (MAOIS)
1EMSAM 12MG/24HR PATCH
1EMSAM 6MG/24HR PATCH
1EMSAM 9MG/24HR PATCH
1MARPLAN 10MG TAB
1phenelzine 15mg tab
1tranylcypromine 10mg tabSELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)
1citalopram 10mg tab
1citalopram 20mg tab
1citalopram 2mg/ml oral soln
1citalopram 40mg tab
1escitalopram 10mg tab
1escitalopram 1mg/ml oral soln
1escitalopram 20mg tab
1escitalopram 5mg tab
1fluoxetine 10mg cap
1fluoxetine 10mg tab
1fluoxetine 20mg cap
1fluoxetine 20mg tab
1fluoxetine 40mg cap
1fluoxetine 4mg/ml oral soln
1fluvoxamine maleate 100mg er cap ST_NSO
1fluvoxamine maleate 100mg tab
1fluvoxamine maleate 150mg er cap ST_NSO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
26
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1fluvoxamine maleate 25mg tab
1fluvoxamine maleate 50mg tab
1paroxetine 10mg tab
1paroxetine 12.5mg er tab
1paroxetine 20mg tab
1paroxetine 25mg er tab
1paroxetine 30mg tab
1paroxetine 37.5mg er tab
1paroxetine 40mg tab
1PAXIL 10MG/5ML SUSP
1PEXEVA 10MG TAB
1PEXEVA 20MG TAB
1PEXEVA 30MG TAB
1PEXEVA 40MG TAB
1sertraline 100mg tab
1sertraline 20mg/ml oral soln
1sertraline 25mg tab
1sertraline 50mg tabSEROTONIN MODULATORS
1NEFAZODONE 100MG TAB
1NEFAZODONE 150MG TAB
1NEFAZODONE 200MG TAB
1NEFAZODONE 250MG TAB
1NEFAZODONE 50MG TAB
1trazodone 100mg tab
1trazodone 150mg tab
1trazodone 300mg tab
1trazodone 50mg tab
1TRINTELLIX 10MG TAB ST_NSO QL=30 EA/30 Days
1TRINTELLIX 20MG TAB ST_NSO QL=30 EA/30 Days
1TRINTELLIX 5MG TAB ST_NSO QL=30 EA/30 Days
1VIIBRYD 10/20MG STARTER PACK ST_NSO QL=30 EA/30 Days
1VIIBRYD 10MG TAB ST_NSO QL=30 EA/30 Days
1VIIBRYD 20MG TAB ST_NSO QL=30 EA/30 Days
1VIIBRYD 40MG TAB ST_NSO QL=30 EA/30 DaysSEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)
1desvenlafaxine succinate 100mg er tab
1desvenlafaxine succinate 25mg er tab
1desvenlafaxine succinate 50mg er tab
1DRIZALMA 20MG DR CAP ST_NSO
1DRIZALMA 30MG DR CAP ST_NSO
1DRIZALMA 40MG DR CAP ST_NSO
1DRIZALMA 60MG DR CAP ST_NSO
1duloxetine 20mg dr cap
1duloxetine 30mg dr cap
1duloxetine 40mg dr cap ST_NSO QL=30 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
27
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1duloxetine 60mg dr cap
1FETZIMA 120MG ER CAP ST_NSO QL=30 EA/30 Days
1FETZIMA 20MG ER CAP ST_NSO QL=30 EA/30 Days
1FETZIMA 40MG ER CAP ST_NSO QL=30 EA/30 Days
1FETZIMA 80MG ER CAP ST_NSO QL=30 EA/30 Days
1FETZIMA PACK ST_NSO QL=30 EA/30 Days
1venlafaxine 100mg tab
1venlafaxine 150mg er cap
1venlafaxine 25mg tab
1venlafaxine 37.5mg er cap
1venlafaxine 37.5mg tab
1venlafaxine 50mg tab
1venlafaxine 75mg er cap
1venlafaxine 75mg tabTRICYCLIC AGENTS
1amitriptyline 100mg tab
1amitriptyline 10mg tab
1amitriptyline 150mg tab
1amitriptyline 25mg tab
1amitriptyline 50mg tab
1amitriptyline 75mg tab
1AMOXAPINE 100MG TAB
1AMOXAPINE 150MG TAB
1AMOXAPINE 25MG TAB
1AMOXAPINE 50MG TAB
1clomipramine 25mg cap
1clomipramine 50mg cap
1clomipramine 75mg cap
1desipramine 100mg tab
1desipramine 10mg tab
1desipramine 150mg tab
1desipramine 25mg tab
1desipramine 50mg tab
1desipramine 75mg tab
1doxepin 100mg cap
1doxepin 10mg cap
1doxepin 10mg/ml oral soln
1doxepin 150mg cap
1doxepin 25mg cap
1doxepin 50mg cap
1doxepin 75mg cap
1imipramine 10mg tab
1imipramine 25mg tab
1imipramine 50mg tab
1imipramine pamoate 100mg cap
1imipramine pamoate 125mg cap
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
28
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1imipramine pamoate 150mg cap
1imipramine pamoate 75mg cap
1nortriptyline 10mg cap
1nortriptyline 25mg cap
1NORTRIPTYLINE 2MG/ML ORAL SOLN
1nortriptyline 50mg cap
1nortriptyline 75mg cap
1protriptyline 10mg tab
1protriptyline 5mg tab
1trimipramine 100mg cap
1trimipramine 25mg cap
1trimipramine 50mg cap
ANTIDIABETICSALPHA-GLUCOSIDASE INHIBITORS
1acarbose 100mg tab
1acarbose 25mg tab
1acarbose 50mg tab
1miglitol 100mg tab
1miglitol 25mg tab
1miglitol 50mg tabANTIDIABETIC COMBINATIONS
1glipizide 2.5mg/metformin 250mg tab
1glipizide 2.5mg/metformin 500mg tab
1glipizide 5mg/metformin 500mg tab
1glyburide 1.25mg/metformin 250mg tab
1glyburide 2.5mg/metformin 500mg tab
1glyburide 5mg/metformin 500mg tab
1GLYXAMBI 10-5MG TAB QL=30 EA/30 Days
1GLYXAMBI 25-5MG TAB QL=30 EA/30 Days
1JANUMET 1000-100MG ER TAB QL=30 EA/30 Days
1JANUMET 1000-50MG ER TAB QL=60 EA/30 Days
1JANUMET 1000-50MG TAB QL=60 EA/30 Days
1JANUMET 500-50MG ER TAB QL=60 EA/30 Days
1JANUMET 500-50MG TAB QL=60 EA/30 Days
1JENTADUETO 2.5-1000MG ER TAB QL=30 EA/30 Days
1JENTADUETO 2.5-1000MG TAB QL=60 EA/30 Days
1JENTADUETO 2.5-500MG TAB QL=60 EA/30 Days
1JENTADUETO 2.5-850MG TAB QL=60 EA/30 Days
1JENTADUETO 5-1000MG ER TAB QL=30 EA/30 Days
1SOLIQUA 100UNIT-0.033MG/ML PEN INJ PA QL=15 ML/25 Days
1SYNJARDY 10-1000MG ER TAB QL=30 EA/30 Days
1SYNJARDY 12.5-1000MG ER TAB QL=60 EA/30 Days
1SYNJARDY 12.5-1000MG TAB QL=60 EA/30 Days
1SYNJARDY 12.5-500MG TAB QL=60 EA/30 Days
1SYNJARDY 25-1000MG ER TAB QL=30 EA/30 Days
1SYNJARDY 5-1000MG ER TAB QL=60 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
29
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1SYNJARDY 5-1000MG TAB QL=60 EA/30 Days
1SYNJARDY 5-500MG TAB QL=60 EA/30 Days
1TRIJARDY 10-5-1000MG ER TAB QL=30 EA/30 Days
1TRIJARDY 12.5-2.5-1000MG ER TAB QL=60 EA/30 Days
1TRIJARDY 25-5-1000MG ER TAB QL=30 EA/30 Days
1TRIJARDY 5-2.5-1000MG ER TAB QL=60 EA/30 Days
1XIGDUO 10-1000MG ER TAB QL=30 EA/30 Days
1XIGDUO 10-500MG ER TAB QL=30 EA/30 Days
1XIGDUO 2.5-1000MG ER TAB QL=60 EA/30 Days
1XIGDUO 5-1000MG ER TAB QL=60 EA/30 Days
1XIGDUO 5-500MG ER TAB QL=30 EA/30 Days
1XULTOPHY 100UNIT-3.6MG/ML PEN INJ PA QL=15 ML/30 DaysBIGUANIDES
1metformin 1000mg tab
1metformin 500mg er tab
1metformin 500mg tab
1metformin 750mg er tab
1metformin 850mg tabDIABETIC OTHER
1BAQSIMI 3MG/DOSE NASAL POWDER QL=2 EA/7 Days
1diazoxide 50mg/ml susp
1GLUCAGEN 1MG INJ QL=2 EA/7 Days
1GLUCAGON (RDNA) 1MG INJ QL=2 EA/7 Days
1GVOKE 0.5MG/0.1ML AUTO-INJECTOR QL=.20 ML/7 Days
1GVOKE 0.5MG/0.1ML SYRINGE QL=.20 ML/7 Days
1GVOKE 1MG/0.2ML AUTO-INJECTOR QL=.40 ML/7 Days
1GVOKE 1MG/0.2ML SYRINGE QL=.40 ML/7 Days
1KORLYM 300MG TAB NDS PADIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS
1JANUVIA 100MG TAB QL=30 EA/30 Days
1JANUVIA 25MG TAB QL=30 EA/30 Days
1JANUVIA 50MG TAB QL=30 EA/30 Days
1TRADJENTA 5MG TAB QL=30 EA/30 DaysINCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)
1BYDUREON 2MG PEN INJ QL=4 EA/28 Days
1BYDUREON 2MG/0.85ML AUTO-INJECTOR QL=3.40 ML/28 Days
1OZEMPIC 2MG/1.5ML PEN INJ QL=1.50 ML/28 Days
1OZEMPIC 2MG/1.5ML PEN INJ (1MG DOSE) QL=3 ML/28 Days
1RYBELSUS 14MG TAB QL=30 EA/30 Days
1RYBELSUS 3MG TAB QL=30 EA/30 Days
1RYBELSUS 7MG TAB QL=30 EA/30 Days
1TRULICITY 0.75MG/0.5ML AUTO-INJECTOR QL=2 ML/28 Days
1TRULICITY 1.5MG/0.5ML AUTO-INJECTOR QL=2 ML/28 Days
1VICTOZA 18MG/3ML PEN INJ QL=9 ML/30 DaysINSULIN
1FIASP 100UNIT/ML CARTRIDGE
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
30
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1FIASP 100UNIT/ML INJ PA BvD
1FIASP 100UNIT/ML PEN INJ
1HUMALOG 100UNIT/ML CARTRIDGE
1HUMALOG 100UNIT/ML INJ
1HUMALOG 100UNIT/ML KWIKPEN SYRINGE
1HUMALOG 200UNIT/ML PEN INJ
1HUMALOG JR PEN INJ
1HUMALOG MIX 25-75UNIT/ML INJ
1HUMALOG MIX 25-75UNIT/ML PEN INJ
1HUMALOG MIX 50-50UNIT/ML INJ
1HUMALOG MIX 50-50UNIT/ML PEN INJ
1HUMULIN 70-30UNIT/ML PEN INJ
1HUMULIN R 500UNIT/ML INJ PA BvD
1HUMULIN R 500UNIT/ML PEN INJ
1LANTUS 100UNIT/ML INJ
1LANTUS 100UNIT/ML PEN INJ
1LEVEMIR 100UNIT/ML INJ
1LEVEMIR 100UNIT/ML PEN INJ
1NOVOLIN 70-30UNIT/ML INJ
1NOVOLIN N 100UNIT/ML INJ
1NOVOLIN N 100UNIT/ML PEN INJ
1NOVOLIN R 100UNIT/ML INJ
1NOVOLIN R 100UNIT/ML PEN INJ
1NOVOLOG 100UNIT/ML CARTRIDGE
1NOVOLOG 100UNIT/ML INJ PA BvD
1NOVOLOG 100UNIT/ML PEN INJ
1NOVOLOG MIX 70-30UNIT/ML INJ
1NOVOLOG MIX 70-30UNIT/ML PEN INJ
1TOUJEO 300UNIT/ML PEN INJ
1TOUJEO MAX 300UNIT/ML PEN INJ (3ML)
1TRESIBA 100UNIT/ML INJ
1TRESIBA 100UNIT/ML PEN INJ
1TRESIBA 200UNIT/ML PEN INJINSULIN SENSITIZING AGENTS
1AVANDIA 2MG TAB
1AVANDIA 4MG TAB
1pioglitazone 15mg tab
1pioglitazone 30mg tab
1pioglitazone 45mg tabMEGLITINIDE ANALOGUES
1nateglinide 120mg tab
1nateglinide 60mg tab
1repaglinide 0.5mg tab
1repaglinide 1mg tab
1repaglinide 2mg tabSODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
31
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1FARXIGA 10MG TAB QL=30 EA/30 Days
1FARXIGA 5MG TAB QL=30 EA/30 Days
1JARDIANCE 10MG TAB QL=30 EA/30 Days
1JARDIANCE 25MG TAB QL=30 EA/30 DaysSULFONYLUREAS
1glimepiride 1mg tab
1glimepiride 2mg tab
1glimepiride 4mg tab
1glipizide 10mg er tab
1glipizide 10mg tab
1glipizide 2.5mg er tab
1glipizide 5mg er tab
1glipizide 5mg tab
1glyburide 1.25mg tab
1glyburide 1.5mg tab
1glyburide 2.5mg tab
1glyburide 3mg tab
1glyburide 5mg tab
1glyburide 6mg tab
ANTIDIARRHEAL/PROBIOTIC AGENTSANTIPERISTALTIC AGENTS
1atropine sulfate 0.005mg/ml/diphenoxylate 0.5mg/ml oral soln
1atropine sulfate 0.025mg/diphenoxylate 2.5mg tab
1loperamide 2mg cap
ANTIDOTES AND SPECIFIC ANTAGONISTSANTIDOTES - CHELATING AGENTS
1CHEMET 100MG CAP
1deferasirox 125mg tab for oral susp
1deferasirox 180mg tab
1deferasirox 250mg tab for oral susp
1deferasirox 360mg tab
1deferasirox 500mg tab for oral susp
1deferasirox 90mg tab
1FERRIPROX 1000MG TAB NDS PA
1FERRIPROX 100MG/ML ORAL SOLN NDS PA
1FERRIPROX 500MG TAB NDS PA
1JADENU 180MG GRANULES NDS
1JADENU 360MG GRANULES NDS
1JADENU 90MG GRANULES NDSOPIOID ANTAGONISTS
1NALOXONE 0.4MG/ML CARTRIDGE QL=2 ML/2 Days
1naloxone 0.4mg/ml inj QL=2 ML/2 Days
1naloxone 1mg/ml syringe
1naltrexone 50mg tab
1NARCAN 4MG/0.1ML NASAL SPRAY
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
32
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1VIVITROL 380MG INJ NDS
ANTIEMETICS5-HT3 RECEPTOR ANTAGONISTS
1granisetron 1mg tab PA BvD QL=60 EA/30 Days
1ondansetron 0.8mg/ml oral soln PA BvD
1ONDANSETRON 24MG TAB PA BvD
1ondansetron 4mg odt PA BvD
1ondansetron 4mg tab PA BvD
1ondansetron 8mg odt PA BvD
1ondansetron 8mg tab PA BvDANTIEMETICS - ANTICHOLINERGIC
1meclizine 12.5mg tab
1meclizine 25mg tab
1scopolamine 0.0139mg/hr patch
1trimethobenzamide 300mg capANTIEMETICS - MISCELLANEOUS
1doxylamine succinate 10mg/pyridoxine 10mg dr tab QL=120 EA/30 Days
1dronabinol 10mg cap PA
1dronabinol 2.5mg cap PA
1dronabinol 5mg cap PASUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS
1aprepitant 125mg cap PA BvD QL=3 EA/2 Days
1aprepitant 125mg/aprepitant 80mg pack PA BvD QL=6 EA/4 Days
1aprepitant 40mg cap PA BvD QL=3 EA/2 Days
1aprepitant 80mg cap PA BvD QL=6 EA/4 Days
1VARUBI 90MG TAB PA BvD QL=4 EA/28 Days
ANTIFUNGALSANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)
1caspofungin acetate 50mg inj NDS
1caspofungin acetate 70mg inj NDS
1ERAXIS 100MG INJ
1ERAXIS 50MG INJ
1micafungin sodium 100mg inj
1micafungin sodium 50mg injANTIFUNGALS
1ABELCET 5MG/ML INJ PA BvD
1AMBISOME 50MG INJ PA BvD
1AMPHOTERICIN B 50MG INJ PA BvD
1flucytosine 250mg cap
1flucytosine 500mg cap
1griseofulvin 125mg tab
1griseofulvin 250mg tab
1griseofulvin 25mg/ml susp
1griseofulvin 500mg tab
1nystatin 500000unit tab
1terbinafine 250mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
33
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
IMIDAZOLE-RELATED ANTIFUNGALS
1fluconazole 100mg tab
1fluconazole 10mg/ml susp
1fluconazole 150mg tab
1fluconazole 200mg tab
1fluconazole 2mg/ml (100ml) inj
1fluconazole 2mg/ml (200ml) inj
1fluconazole 40mg/ml susp
1fluconazole 50mg tab
1itraconazole 100mg cap PA
1ketoconazole 200mg tab
1NOXAFIL 40MG/ML SUSP PA
1posaconazole 100mg dr tab PA
1voriconazole 200mg inj PA
1voriconazole 200mg tab NDS PA
1voriconazole 40mg/ml susp PA
1voriconazole 50mg tab NDS PA
ANTIHISTAMINESANTIHISTAMINES - NON-SEDATING
1cetirizine 1mg/ml oral soln
1desloratadine 5mg tab
1levocetirizine 0.5mg/ml oral soln
1levocetirizine 5mg tabANTIHISTAMINES - PHENOTHIAZINES
1promethazine 1.25mg/ml oral soln
1promethazine 12.5mg rectal supp
1promethazine 12.5mg tab
1promethazine 25mg rectal supp
1promethazine 25mg tab
1promethazine 50mg tab
1promethegan 25mg rectal supp
1PROMETHEGAN 50MG RECTAL SUPPANTIHISTAMINES - PIPERIDINES
1cyproheptadine 0.4mg/ml oral soln
1cyproheptadine 4mg tab
ANTIHYPERLIPIDEMICSANTIHYPERLIPIDEMICS - MISC.
1omega-3 acid ethyl esters (usp) 1000mg cap
1VASCEPA 0.5GM CAP QL=120 EA/30 Days
1VASCEPA 1GM CAP QL=120 EA/30 DaysBILE ACID SEQUESTRANTS
1cholestyramine resin 4gm sf powder for oral susp
1cholestyramine resin 4gm sf powder for oral susp (sugar free)
1colesevelam 3750mg powder for oral susp
1colesevelam 625mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
34
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1colestipol 1000mg tab
1colestipol 5000mg granules for oral susp
1prevalite 4gm powder for oral suspFIBRIC ACID DERIVATIVES
1fenofibrate 134mg cap
1fenofibrate 145mg tab
1FENOFIBRATE 150MG CAP
1fenofibrate 160mg tab
1fenofibrate 200mg cap
1fenofibrate 48mg tab
1FENOFIBRATE 50MG CAP
1fenofibrate 54mg tab
1fenofibrate 67mg cap
1fenofibric acid 135mg dr cap
1fenofibric acid 45mg dr cap
1gemfibrozil 600mg tab
1TRIGLIDE 160MG TABHMG COA REDUCTASE INHIBITORS
1atorvastatin 10mg tab
1atorvastatin 20mg tab
1atorvastatin 40mg tab
1atorvastatin 80mg tab
1fluvastatin 20mg cap
1fluvastatin 40mg cap
1fluvastatin 80mg er tab
1lovastatin 10mg tab
1lovastatin 20mg tab
1lovastatin 40mg tab
1pravastatin sodium 10mg tab
1pravastatin sodium 20mg tab
1pravastatin sodium 40mg tab
1pravastatin sodium 80mg tab
1rosuvastatin calcium 10mg tab
1rosuvastatin calcium 20mg tab
1rosuvastatin calcium 40mg tab
1rosuvastatin calcium 5mg tab
1simvastatin 10mg tab
1simvastatin 20mg tab
1simvastatin 40mg tab
1simvastatin 5mg tab
1simvastatin 80mg tabINTESTINAL CHOLESTEROL ABSORPTION INHIBITORS
1ezetimibe 10mg tab QL=30 EA/30 DaysMICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP) INHIBITORS
1JUXTAPID 10MG CAP NDS PA
1JUXTAPID 20MG CAP NDS PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
35
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1JUXTAPID 30MG CAP NDS PA
1JUXTAPID 40MG CAP NDS PA
1JUXTAPID 5MG CAP NDS PA
1JUXTAPID 60MG CAP NDS PANICOTINIC ACID DERIVATIVES
1niacin 1000mg er tab
1niacin 500mg er tab
1niacin 750mg er tabPROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS
1PRALUENT 150MG/ML AUTO-INJECTOR PA QL=2 ML/28 Days
1PRALUENT 75MG/ML AUTO-INJECTOR PA QL=2 ML/28 Days
1REPATHA 140MG/ML AUTO-INJECTOR PA QL=2 ML/28 Days
1REPATHA 140MG/ML SYRINGE PA QL=2 ML/28 Days
1REPATHA 420MG/3.5ML CARTRIDGE PA QL=3.50 ML/28 Days
ANTIHYPERTENSIVESACE INHIBITORS
1benazepril 10mg tab
1benazepril 20mg tab
1benazepril 40mg tab
1benazepril 5mg tab
1captopril 100mg tab
1captopril 12.5mg tab
1captopril 25mg tab
1captopril 50mg tab
1enalapril maleate 10mg tab
1enalapril maleate 2.5mg tab
1enalapril maleate 20mg tab
1enalapril maleate 5mg tab
1fosinopril sodium 10mg tab
1fosinopril sodium 20mg tab
1fosinopril sodium 40mg tab
1lisinopril 10mg tab
1lisinopril 2.5mg tab
1lisinopril 20mg tab
1lisinopril 30mg tab
1lisinopril 40mg tab
1lisinopril 5mg tab
1moexipril 15mg tab
1moexipril 7.5mg tab
1perindopril erbumine 2mg tab
1perindopril erbumine 4mg tab
1perindopril erbumine 8mg tab
1QBRELIS 1MG/ML ORAL SOLN PA
1quinapril 10mg tab
1quinapril 20mg tab
1quinapril 40mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
36
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1quinapril 5mg tab
1ramipril 1.25mg cap
1ramipril 10mg cap
1ramipril 2.5mg cap
1ramipril 5mg cap
1trandolapril 1mg tab
1trandolapril 2mg tab
1trandolapril 4mg tabAGENTS FOR PHEOCHROMOCYTOMA
1DEMSER 250MG CAP NDS
1phenoxybenzamine 10mg capANGIOTENSIN II RECEPTOR ANTAGONISTS
1irbesartan 150mg tab
1irbesartan 300mg tab
1irbesartan 75mg tab
1losartan potassium 100mg tab
1losartan potassium 25mg tab
1losartan potassium 50mg tab
1olmesartan medoxomil 20mg tab
1olmesartan medoxomil 40mg tab
1olmesartan medoxomil 5mg tab
1telmisartan 20mg tab
1telmisartan 40mg tab
1telmisartan 80mg tab
1valsartan 160mg tab
1valsartan 320mg tab
1valsartan 40mg tab
1valsartan 80mg tabANTIADRENERGIC ANTIHYPERTENSIVES
1clonidine 0.00417mg/hr weekly patch
1clonidine 0.00833mg/hr weekly patch
1clonidine 0.0125mg/hr weekly patch
1clonidine 0.1mg tab
1clonidine 0.2mg tab
1clonidine 0.3mg tab
1doxazosin 1mg tab
1doxazosin 2mg tab
1doxazosin 4mg tab
1doxazosin 8mg tab
1guanfacine 1mg tab
1guanfacine 2mg tab
1methyldopa 250mg tab
1methyldopa 500mg tab
1prazosin 1mg cap
1prazosin 2mg cap
1prazosin 5mg cap
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
37
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1terazosin 10mg cap
1terazosin 1mg cap
1terazosin 2mg cap
1terazosin 5mg capANTIHYPERTENSIVE COMBINATIONS
1amlodipine 10mg/benazepril 20mg cap
1amlodipine 10mg/benazepril 40mg cap
1amlodipine 10mg/hydrochlorothiazide 12.5mg/valsartan 160mg tab
1amlodipine 10mg/hydrochlorothiazide 25mg/valsartan 160mg tab
1amlodipine 10mg/hydrochlorothiazide 25mg/valsartan 320mg tab
1amlodipine 10mg/olmesartan medoxomil 20mg tab
1amlodipine 10mg/olmesartan medoxomil 40mg tab
1amlodipine 10mg/valsartan 160mg tab
1amlodipine 10mg/valsartan 320mg tab
1amlodipine 2.5mg/benazepril 10mg cap
1amlodipine 5mg/benazepril 10mg cap
1amlodipine 5mg/benazepril 20mg cap
1amlodipine 5mg/benazepril 40mg cap
1amlodipine 5mg/hydrochlorothiazide 12.5mg/valsartan 160mg tab
1amlodipine 5mg/hydrochlorothiazide 25mg/valsartan 160mg tab
1amlodipine 5mg/olmesartan medoxomil 20mg tab
1amlodipine 5mg/olmesartan medoxomil 40mg tab
1amlodipine 5mg/valsartan 160mg tab
1amlodipine 5mg/valsartan 320mg tab
1atenolol 100mg/chlorthalidone 25mg tab
1atenolol 50mg/chlorthalidone 25mg tab
1benazepril 10mg/hydrochlorothiazide 12.5mg tab
1benazepril 20mg/hydrochlorothiazide 12.5mg tab
1benazepril 20mg/hydrochlorothiazide 25mg tab
1benazepril 5mg/hydrochlorothiazide 6.25mg tab
1bisoprolol fumarate 10mg/hydrochlorothiazide 6.25mg tab
1bisoprolol fumarate 2.5mg/hydrochlorothiazide 6.25mg tab
1bisoprolol fumarate 5mg/hydrochlorothiazide 6.25mg tab
1captopril 25mg/hydrochlorothiazide 15mg tab
1CAPTOPRIL 25MG/HYDROCHLOROTHIAZIDE 25MG TAB
1captopril 50mg/hydrochlorothiazide 15mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
38
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1CAPTOPRIL 50MG/HYDROCHLOROTHIAZIDE 25MG TAB
1enalapril maleate 10mg/hydrochlorothiazide 25mg tab
1enalapril maleate 5mg/hydrochlorothiazide 12.5mg tab
1fosinopril sodium 10mg/hydrochlorothiazide 12.5mg tab
1fosinopril sodium 20mg/hydrochlorothiazide 12.5mg tab
1hydrochlorothiazide 12.5mg/irbesartan 150mg tab
1hydrochlorothiazide 12.5mg/irbesartan 300mg tab
1hydrochlorothiazide 12.5mg/lisinopril 10mg tab
1hydrochlorothiazide 12.5mg/lisinopril 20mg tab
1hydrochlorothiazide 12.5mg/losartan potassium 100mg tab
1hydrochlorothiazide 12.5mg/losartan potassium 50mg tab
1hydrochlorothiazide 12.5mg/olmesartan medoxomil 20mg tab
1hydrochlorothiazide 12.5mg/olmesartan medoxomil 40mg tab
1hydrochlorothiazide 12.5mg/quinapril 10mg tab
1hydrochlorothiazide 12.5mg/quinapril 20mg tab
1hydrochlorothiazide 12.5mg/valsartan 160mg tab
1hydrochlorothiazide 12.5mg/valsartan 320mg tab
1hydrochlorothiazide 12.5mg/valsartan 80mg tab
1hydrochlorothiazide 15mg/methyldopa 250mg tab
1hydrochlorothiazide 25mg/lisinopril 20mg tab
1hydrochlorothiazide 25mg/losartan potassium 100mg tab
1hydrochlorothiazide 25mg/methyldopa 250mg tab
1hydrochlorothiazide 25mg/metoprolol tartrate 100mg tab
1hydrochlorothiazide 25mg/metoprolol tartrate 50mg tab
1hydrochlorothiazide 25mg/olmesartan medoxomil 40mg tab
1hydrochlorothiazide 25mg/propranolol 40mg tab
1hydrochlorothiazide 25mg/propranolol 80mg tab
1hydrochlorothiazide 25mg/quinapril 20mg tab
1hydrochlorothiazide 25mg/valsartan 160mg tab
1hydrochlorothiazide 25mg/valsartan 320mg tab
1hydrochlorothiazide 50mg/metoprolol tartrate 100mg tab
1TRANDOLAPRIL 1MG/VERAPAMIL 240MG ER TAB
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
39
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1trandolapril 2mg/verapamil 180mg er tab
1trandolapril 2mg/verapamil 240mg er tab
1trandolapril 4mg/verapamil 240mg er tabDIRECT RENIN INHIBITORS
1aliskiren 150mg tab
1aliskiren 300mg tabSELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)
1eplerenone 25mg tab
1eplerenone 50mg tabVASODILATORS
1hydralazine 100mg tab
1hydralazine 10mg tab
1hydralazine 25mg tab
1hydralazine 50mg tab
1minoxidil 10mg tab
1minoxidil 2.5mg tab
ANTI-INFECTIVE AGENTS - MISC.ANTI-INFECTIVE AGENTS - MISC.
1metronidazole 250mg tab
1metronidazole 375mg cap
1metronidazole 500mg tab
1metronidazole 5mg/ml inj
1pentamidine isethionate 300mg inj
1pentamidine isethionate 50mg/ml inh soln PA BvD
1tinidazole 250mg tab
1tinidazole 500mg tab
1trimethoprim 100mg tab
1XIFAXAN 200MG TAB QL=9 EA/3 Days
1XIFAXAN 550MG TAB PA QL=60 EA/30 DaysANTI-INFECTIVE MISC. - COMBINATIONS
1sulfamethoxazole 400mg/trimethoprim 80mg tab
1sulfamethoxazole 40mg/ml/trimethoprim 8mg/ml susp
1sulfamethoxazole 800mg/trimethoprim 160mg tabANTIPROTOZOAL AGENTS
1ALINIA 100MG/5ML SUSP PA QL=150 ML/3 Days
1ALINIA 500MG TAB PA QL=6 EA/3 Days
1atovaquone 150mg/ml suspCARBAPENEMS
1CILASTATIN 250MG/IMIPENEM 250MG INJ
1cilastatin 500mg/imipenem 500mg inj
1ertapenem 1000mg inj
1meropenem 1000mg inj
1meropenem 500mg injCYCLIC LIPOPEPTIDES
1daptomycin 500mg inj NDSGLYCOPEPTIDES
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
40
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1DALVANCE 500MG INJ NDS
1FIRVANQ 25MG/ML ORAL SOLN
1FIRVANQ 50MG/ML ORAL SOLN
1vancomycin 1000mg inj
1vancomycin 100mg/ml inj
1vancomycin 125mg cap QL=120 EA/30 Days
1vancomycin 250mg cap QL=120 EA/30 Days
1VANCOMYCIN 250MG INJ
1vancomycin 500mg inj
1vancomycin 750mg injLEPROSTATICS
1dapsone 100mg tab
1dapsone 25mg tabLINCOSAMIDES
1clindamycin 12mg/ml inj
1clindamycin 150mg cap
1clindamycin 150mg/ml (2ml) inj
1clindamycin 150mg/ml (4ml) inj
1clindamycin 150mg/ml (6ml) inj
1clindamycin 15mg/ml oral soln
1clindamycin 18mg/ml inj
1clindamycin 300mg cap
1clindamycin 6mg/ml inj
1clindamycin 75mg capMONOBACTAMS
1aztreonam 1000mg inj
1CAYSTON 75MG INH SOLN NDS PAOXAZOLIDINONES
1linezolid 20mg/ml susp
1linezolid 2mg/ml inj
1linezolid 600mg tab
1SIVEXTRO 200MG INJ NDS PA QL=6 EA/6 Days
1SIVEXTRO 200MG TAB NDS PA QL=6 EA/6 DaysPLEUROMUTILINS
1XENLETA 600MG TAB PA QL=14 EA/7 DaysPOLYMYXINS
1colistin 75mg/ml inj
1polymyxin b 250000unit/ml inj
ANTIMALARIALSANTIMALARIAL COMBINATIONS
1atovaquone 250mg/proguanil 100mg tab
1atovaquone 62.5mg/proguanil 25mg tab
1COARTEM 20-120MG TABANTIMALARIALS
1CHLOROQUINE PHOSPHATE 250MG TAB
1chloroquine phosphate 500mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
41
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1hydroxychloroquine sulfate 200mg tab
1KRINTAFEL 150MG TAB
1MEFLOQUINE 250MG TAB
1PRIMAQUINE PHOSPHATE 26.3MG TAB
1quinine sulfate 324mg cap PA
ANTIMYASTHENIC/CHOLINERGIC AGENTSANTIMYASTHENIC/CHOLINERGIC AGENTS
1GUANIDINE 125MG TAB
1pyridostigmine bromide 180mg er tab
1pyridostigmine bromide 60mg tab
1RUZURGI 10MG TAB NDS PA
ANTIMYCOBACTERIAL AGENTSANTIMYCOBACTERIAL AGENTS
1ethambutol 100mg tab
1ethambutol 400mg tab
1isoniazid 100mg tab
1ISONIAZID 10MG/ML ORAL SOLN
1isoniazid 300mg tab
1PASER D/R 4GM GRANULES
1PRIFTIN 150MG TAB
1pyrazinamide 500mg tab
1rifabutin 150mg cap
1rifampin 150mg cap
1rifampin 300mg cap
1rifampin 600mg inj
1SIRTURO 100MG TAB NDS PA
1TRECATOR 250MG TAB
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIESALKYLATING AGENTS
1CYCLOPHOSPHAMIDE 25MG CAP PA BvD
1CYCLOPHOSPHAMIDE 50MG CAP PA BvD
1LEUKERAN 2MG TABANTIMETABOLITES
1mercaptopurine 50mg tab
1methotrexate 2.5mg tab
1methotrexate 25mg/ml (2ml) inj
1methotrexate 25mg/ml inj
1PURIXAN 2000MG/100ML SUSP
1TABLOID 40MG TAB
1XATMEP 2.5MG/ML ORAL SOLN PAANTINEOPLASTIC - BCL-2 INHIBITORS
1VENCLEXTA 100MG TAB NDS PA NSO
1VENCLEXTA 10MG TAB PA NSO
1VENCLEXTA 50MG TAB PA NSO
1VENCLEXTA STARTING PACK NDS PA NSOANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
42
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1DAURISMO 100MG TAB NDS PA NSO
1DAURISMO 25MG TAB NDS PA NSO
1ERIVEDGE 150MG CAP NDS PA NSO
1ODOMZO 200MG CAP NDS PA NSOANTINEOPLASTIC - HORMONAL AND RELATED AGENTS
1abiraterone acetate 250mg tab QL=120 EA/30 Days
1anastrozole 1mg tab
1bicalutamide 50mg tab
1DEPO-PROVERA 400MG/ML INJ
1ELIGARD 22.5MG SYRINGE
1ELIGARD 30MG SYRINGE
1ELIGARD 45MG SYRINGE
1ELIGARD 7.5MG SYRINGE
1EMCYT 140MG CAP
1ERLEADA 60MG TAB NDS PA NSO QL=120 EA/30 Days
1exemestane 25mg tab
1FIRMAGON 120MG INJ PA NSO
1FIRMAGON 80MG INJ PA NSO
1flutamide 125mg cap
1letrozole 2.5mg tab
1leuprolide acetate 5mg/ml inj
1LUPRON 11.25MG SYRINGE
1LUPRON 22.5MG SYRINGE
1LUPRON 3.75MG SYRINGE
1LUPRON 30MG SYRINGE
1LUPRON 45MG SYRINGE
1LUPRON 7.5MG SYRINGE
1LYSODREN 500MG TAB
1megestrol acetate 20mg tab PA NSO
1megestrol acetate 40mg tab PA NSO
1megestrol acetate 40mg/ml susp PA
1nilutamide 150mg tab NDS
1NUBEQA 300MG TAB NDS PA NSO QL=120 EA/30 Days
1SOLTAMOX 10MG/5ML ORAL SOLN PA NSO
1tamoxifen 10mg tab
1tamoxifen 20mg tab
1toremifene 60mg tab
1TRELSTAR 11.25MG INJ
1TRELSTAR 22.5MG INJ
1TRELSTAR 3.75MG INJ
1XTANDI 40MG CAP NDS PA NSO QL=120 EA/30 DaysANTINEOPLASTIC - IMMUNOMODULATORS
1POMALYST 1MG CAP NDS PA NSO
1POMALYST 2MG CAP NDS PA NSO
1POMALYST 3MG CAP NDS PA NSO
1POMALYST 4MG CAP NDS PA NSO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
43
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
ANTINEOPLASTIC - XPO1 INHIBITORS
1XPOVIO 100 MG ONCE WEEKLY NDS PA NSO QL=32 EA/28 Days
1XPOVIO 60 MG ONCE WEEKLY NDS PA NSO QL=32 EA/28 Days
1XPOVIO 80 MG ONCE WEEKLY NDS PA NSO QL=32 EA/28 Days
1XPOVIO 80 MG TWICE WEEKLY NDS PA NSO QL=32 EA/28 DaysANTINEOPLASTIC COMBINATIONS
1KISQALI FEMARA CO-PACK 200 PACK NDS PA NSO QL=49 EA/28 Days
1KISQALI FEMARA CO-PACK 400 PACK NDS PA NSO QL=70 EA/28 Days
1KISQALI FEMARA CO-PACK 600 PACK NDS PA NSO QL=91 EA/28 Days
1LONSURF 6.14-15MG TAB NDS PA NSO
1LONSURF 8.19-20MG TAB NDS PA NSOANTINEOPLASTIC ENZYME INHIBITORS
1AFINITOR 10MG TAB NDS PA NSO QL=30 EA/30 Days
1AFINITOR 2MG TAB FOR ORAL SUSP NDS PA NSO
1AFINITOR 3MG TAB FOR ORAL SUSP NDS PA NSO
1AFINITOR 5MG TAB FOR ORAL SUSP NDS PA NSO
1ALECENSA 150MG CAP NDS PA NSO QL=240 EA/30 Days
1ALUNBRIG 180MG TAB NDS PA NSO QL=30 EA/30 Days
1ALUNBRIG 30MG TAB NDS PA NSO QL=120 EA/30 Days
1ALUNBRIG 90MG TAB NDS PA NSO QL=30 EA/30 Days
1ALUNBRIG INITIATION PACK NDS PA NSO QL=30 EA/30 Days
1AYVAKIT 100MG TAB NDS PA NSO QL=30 EA/30 Days
1AYVAKIT 200MG TAB NDS PA NSO QL=30 EA/30 Days
1AYVAKIT 300MG TAB NDS PA NSO QL=30 EA/30 Days
1BALVERSA 3MG TAB NDS PA NSO QL=60 EA/30 Days
1BALVERSA 4MG TAB NDS PA NSO QL=60 EA/30 Days
1BALVERSA 5MG TAB NDS PA NSO QL=30 EA/30 Days
1BOSULIF 100MG TAB NDS PA NSO
1BOSULIF 400MG TAB NDS PA NSO
1BOSULIF 500MG TAB NDS PA NSO
1BRAFTOVI 75MG CAP NDS PA NSO QL=180 EA/30 Days
1BRUKINSA 80MG CAP NDS PA NSO QL=120 EA/30 Days
1CABOMETYX 20MG TAB NDS PA NSO
1CABOMETYX 40MG TAB NDS PA NSO
1CABOMETYX 60MG TAB NDS PA NSO
1CALQUENCE 100MG CAP NDS PA NSO QL=60 EA/30 Days
1CAPRELSA 100MG TAB NDS PA NSO QL=60 EA/30 Days
1CAPRELSA 300MG TAB NDS PA NSO QL=30 EA/30 Days
1COMETRIQ 100MG DAILY DOSE CARTON PACK NDS PA NSO
1COMETRIQ 140MG DAILY DOSE CARTON PACK NDS PA NSO
1COMETRIQ 60MG DAILY DOSE CARTON PACK NDS PA NSO
1COPIKTRA 15MG CAP NDS PA NSO QL=60 EA/30 Days
1COPIKTRA 25MG CAP NDS PA NSO QL=60 EA/30 Days
1COTELLIC 20MG TAB NDS PA NSO QL=63 EA/28 Days
1erlotinib 100mg tab PA NSO
1erlotinib 150mg tab PA NSO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
44
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1erlotinib 25mg tab PA NSO
1everolimus 2.5mg tab PA NSO QL=30 EA/30 Days
1everolimus 5mg tab PA NSO QL=30 EA/30 Days
1everolimus 7.5mg tab PA NSO QL=30 EA/30 Days
1FARYDAK 10MG CAP NDS PA NSO
1FARYDAK 20MG CAP NDS PA NSO
1GILOTRIF 20MG TAB NDS PA NSO QL=30 EA/30 Days
1GILOTRIF 30MG TAB NDS PA NSO QL=30 EA/30 Days
1GILOTRIF 40MG TAB NDS PA NSO QL=30 EA/30 Days
1IBRANCE 100MG CAP NDS PA NSO QL=21 EA/28 Days
1IBRANCE 100MG TAB NDS PA NSO QL=21 EA/28 Days
1IBRANCE 125MG CAP NDS PA NSO QL=21 EA/28 Days
1IBRANCE 125MG TAB NDS PA NSO QL=21 EA/28 Days
1IBRANCE 75MG CAP NDS PA NSO QL=21 EA/28 Days
1IBRANCE 75MG TAB NDS PA NSO QL=21 EA/28 Days
1ICLUSIG 15MG TAB NDS PA NSO QL=60 EA/30 Days
1ICLUSIG 45MG TAB NDS PA NSO QL=30 EA/30 Days
1IDHIFA 100MG TAB NDS PA NSO QL=30 EA/30 Days
1IDHIFA 50MG TAB NDS PA NSO QL=30 EA/30 Days
1imatinib 100mg tab
1imatinib 400mg tab
1IMBRUVICA 140MG CAP NDS PA NSO QL=90 EA/30 Days
1IMBRUVICA 140MG TAB NDS PA NSO QL=30 EA/30 Days
1IMBRUVICA 280MG TAB NDS PA NSO QL=30 EA/30 Days
1IMBRUVICA 420MG TAB NDS PA NSO QL=30 EA/30 Days
1IMBRUVICA 560MG TAB NDS PA NSO QL=30 EA/30 Days
1IMBRUVICA 70MG CAP NDS PA NSO QL=30 EA/30 Days
1INLYTA 1MG TAB NDS PA NSO
1INLYTA 5MG TAB NDS PA NSO
1INREBIC 100MG CAP NDS PA NSO QL=120 EA/30 Days
1IRESSA 250MG TAB NDS PA NSO
1JAKAFI 10MG TAB NDS PA NSO QL=60 EA/30 Days
1JAKAFI 15MG TAB NDS PA NSO QL=60 EA/30 Days
1JAKAFI 20MG TAB NDS PA NSO QL=60 EA/30 Days
1JAKAFI 25MG TAB NDS PA NSO QL=60 EA/30 Days
1JAKAFI 5MG TAB NDS PA NSO QL=60 EA/30 Days
1KISQALI 200MG DAILY DOSE PACK NDS PA NSO QL=21 EA/28 Days
1KISQALI 400MG DAILY DOSE PACK NDS PA NSO QL=42 EA/28 Days
1KISQALI 600MG DAILY DOSE PACK NDS PA NSO QL=63 EA/28 Days
1KOSELUGO 10MG CAP NDS PA NSO
1KOSELUGO 25MG CAP NDS PA NSO
1LENVIMA 10 10MG PACK NDS PA NSO QL=30 EA/30 Days
1LENVIMA 12 4MG PACK NDS PA NSO QL=90 EA/30 Days
1LENVIMA 14 PACK NDS PA NSO QL=60 EA/30 Days
1LENVIMA 18 PACK NDS PA NSO QL=90 EA/30 Days
1LENVIMA 20 10MG PACK NDS PA NSO QL=60 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
45
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1LENVIMA 24 PACK NDS PA NSO QL=90 EA/30 Days
1LENVIMA 4 4MG PACK NDS PA NSO QL=30 EA/30 Days
1LENVIMA 8 4MG PACK NDS PA NSO QL=60 EA/30 Days
1LORBRENA 100MG TAB NDS PA NSO QL=30 EA/30 Days
1LORBRENA 25MG TAB NDS PA NSO QL=90 EA/30 Days
1LYNPARZA 100MG TAB NDS PA NSO QL=120 EA/30 Days
1LYNPARZA 150MG TAB NDS PA NSO QL=120 EA/30 Days
1MEKINIST 0.5MG TAB NDS PA NSO QL=90 EA/30 Days
1MEKINIST 2MG TAB NDS PA NSO QL=30 EA/30 Days
1MEKTOVI 15MG TAB NDS PA NSO QL=180 EA/30 Days
1NERLYNX 40MG TAB NDS PA NSO
1NEXAVAR 200MG TAB NDS PA NSO
1NINLARO 2.3MG CAP NDS PA NSO
1NINLARO 3MG CAP NDS PA NSO
1NINLARO 4MG CAP NDS PA NSO
1PEMAZYRE 13.5MG TAB NDS PA NSO QL=14 EA/21 Days
1PEMAZYRE 4.5MG TAB NDS PA NSO QL=14 EA/21 Days
1PEMAZYRE 9MG TAB NDS PA NSO QL=14 EA/21 Days
1PIQRAY 200MG DAILY DOSE PACK NDS PA NSO QL=30 EA/30 Days
1PIQRAY 250MG DAILY DOSE PACK NDS PA NSO QL=60 EA/30 Days
1PIQRAY 300MG DAILY DOSE 150MG PACK NDS PA NSO QL=60 EA/30 Days
1QINLOCK 50MG TAB NDS PA NSO QL=90 EA/30 Days
1RETEVMO 40MG CAP NDS PA NSO QL=180 EA/30 Days
1RETEVMO 80MG CAP NDS PA NSO QL=120 EA/30 Days
1ROZLYTREK 100MG CAP NDS PA NSO QL=30 EA/30 Days
1ROZLYTREK 200MG CAP NDS PA NSO QL=90 EA/30 Days
1RUBRACA 200MG TAB NDS PA NSO QL=120 EA/30 Days
1RUBRACA 250MG TAB NDS PA NSO QL=120 EA/30 Days
1RUBRACA 300MG TAB NDS PA NSO QL=120 EA/30 Days
1RYDAPT 25MG CAP NDS PA NSO
1SPRYCEL 100MG TAB NDS PA NSO
1SPRYCEL 140MG TAB NDS PA NSO
1SPRYCEL 20MG TAB NDS PA NSO
1SPRYCEL 50MG TAB NDS PA NSO
1SPRYCEL 70MG TAB NDS PA NSO
1SPRYCEL 80MG TAB NDS PA NSO
1STIVARGA 40MG TAB NDS PA NSO QL=84 EA/28 Days
1SUTENT 12.5MG CAP NDS PA NSO
1SUTENT 25MG CAP NDS PA NSO
1SUTENT 37.5MG CAP NDS PA NSO
1SUTENT 50MG CAP NDS PA NSO
1TABRECTA 150MG TAB NDS PA NSO QL=120 EA/30 Days
1TABRECTA 200MG TAB NDS PA NSO QL=120 EA/30 Days
1TAFINLAR 50MG CAP NDS PA NSO QL=120 EA/30 Days
1TAFINLAR 75MG CAP NDS PA NSO QL=120 EA/30 Days
1TAGRISSO 40MG TAB NDS PA NSO
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
46
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1TAGRISSO 80MG TAB NDS PA NSO
1TALZENNA 0.25MG CAP NDS PA NSO QL=90 EA/30 Days
1TALZENNA 1MG CAP NDS PA NSO QL=30 EA/30 Days
1TASIGNA 150MG CAP NDS PA NSO
1TASIGNA 200MG CAP NDS PA NSO
1TASIGNA 50MG CAP NDS PA NSO
1TAZVERIK 200MG TAB NDS PA NSO QL=240 EA/30 Days
1TIBSOVO 250MG TAB NDS PA NSO QL=60 EA/30 Days
1TUKYSA 150MG TAB NDS PA NSO QL=120 EA/30 Days
1TUKYSA 50MG TAB NDS PA NSO QL=120 EA/30 Days
1TURALIO 200MG CAP NDS PA NSO QL=120 EA/30 Days
1TYKERB 250MG TAB NDS PA NSO
1VERZENIO 100MG TAB NDS PA NSO QL=56 EA/28 Days
1VERZENIO 150MG TAB NDS PA NSO QL=56 EA/28 Days
1VERZENIO 200MG TAB NDS PA NSO QL=56 EA/28 Days
1VERZENIO 50MG TAB NDS PA NSO QL=56 EA/28 Days
1VITRAKVI 100MG CAP NDS PA NSO
1VITRAKVI 20MG/ML ORAL SOLN NDS PA NSO
1VITRAKVI 25MG CAP NDS PA NSO
1VIZIMPRO 15MG TAB NDS PA NSO QL=30 EA/30 Days
1VIZIMPRO 30MG TAB NDS PA NSO QL=30 EA/30 Days
1VIZIMPRO 45MG TAB NDS PA NSO QL=30 EA/30 Days
1VOTRIENT 200MG TAB NDS PA NSO
1XALKORI 200MG CAP NDS PA NSO QL=60 EA/30 Days
1XALKORI 250MG CAP NDS PA NSO QL=60 EA/30 Days
1XOSPATA 40MG TAB NDS PA NSO
1ZEJULA 100MG CAP NDS PA NSO QL=90 EA/30 Days
1ZELBORAF 240MG TAB NDS PA NSO QL=240 EA/30 Days
1ZOLINZA 100MG CAP NDS PA NSO
1ZYDELIG 100MG TAB NDS PA NSO QL=60 EA/30 Days
1ZYDELIG 150MG TAB NDS PA NSO QL=60 EA/30 Days
1ZYKADIA 150MG TAB NDS PA NSO QL=90 EA/30 DaysANTINEOPLASTICS MISC.
1ACTIMMUNE 2000000UNIT/0.5ML INJ NDS PA NSO
1bexarotene 75mg cap PA NSO
1hydroxyurea 500mg cap
1INTRON A 10MU INJ
1INTRON A 10MU/ML INJ
1INTRON A 18MU INJ NDS
1INTRON A 50MU INJ NDS
1INTRON A 6000000UNIT/ML INJ
1MATULANE 50MG CAP NDS
1SYLATRON 200MCG INJ NDS PA NSO
1SYLATRON 300MCG INJ NDS PA NSO
1SYNRIBO 3.5MG INJ NDS
1tretinoin 10mg cap
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
47
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS
1LEUCOVORIN 10MG TAB
1LEUCOVORIN 15MG TAB
1leucovorin 25mg tab
1leucovorin 5mg tab
1MESNEX 400MG TAB
ANTIPARKINSON AGENTSANTIPARKINSON ANTICHOLINERGICS
1benztropine mesylate 2mg tab
1trihexyphenidyl 2mg tab
1trihexyphenidyl 5mg tabANTIPARKINSON DOPAMINERGICS
1amantadine 10mg/ml oral soln
1bromocriptine 2.5mg tab
1bromocriptine 5mg cap
1carbidopa 10mg/levodopa 100mg odt
1carbidopa 10mg/levodopa 100mg tab
1carbidopa 25mg/levodopa 100mg er tab
1carbidopa 25mg/levodopa 100mg odt
1carbidopa 25mg/levodopa 100mg tab
1carbidopa 25mg/levodopa 250mg odt
1carbidopa 50mg/levodopa 200mg er tab
1NEUPRO 1MG/24HR PATCH
1NEUPRO 2MG/24HR PATCH
1NEUPRO 3MG/24HR PATCH
1NEUPRO 4MG/24HR PATCH
1NEUPRO 6MG/24HR PATCH
1NEUPRO 8MG/24HR PATCH
1pramipexole 0.125mg tab
1pramipexole 0.25mg tab
1pramipexole 0.375mg er tab
1pramipexole 0.5mg tab
1pramipexole 0.75mg er tab
1pramipexole 0.75mg tab
1pramipexole 1.5mg er tab
1pramipexole 1.5mg tab
1pramipexole 1mg tab
1pramipexole 2.25mg er tab
1pramipexole 3.75mg er tab
1pramipexole 3mg er tab
1pramipexole 4.5mg er tab
1ropinirole 0.25mg tab
1ropinirole 0.5mg tab
1ropinirole 12mg er tab
1ropinirole 2mg er tab
1ropinirole 3mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
48
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1ropinirole 4mg er tab
1ropinirole 4mg tab
1ropinirole 5mg tab
1ropinirole 6mg er tab
1ropinirole 8mg er tab
ANTIPARKINSON AND RELATED THERAPY AGENTSANTIPARKINSON ADJUNCTIVE THERAPY
1carbidopa 25mg tab
1NOURIANZ 20MG TAB PA QL=30 EA/30 Days
1NOURIANZ 40MG TAB PA QL=30 EA/30 DaysANTIPARKINSON ANTICHOLINERGICS
1benztropine mesylate 0.5mg tab
1benztropine mesylate 1mg tab
1trihexyphenidyl 0.4mg/ml oral solnANTIPARKINSON COMT INHIBITORS
1entacapone 200mg tab
1tolcapone 100mg tabANTIPARKINSON DOPAMINERGICS
1amantadine 100mg cap
1amantadine 100mg tab
1APOKYN 30MG/3ML CARTRIDGE NDS
1CARBIDOPA 12.5MG/ENTACAPONE 200MG/LEVODOPA 50MG TAB
1CARBIDOPA 18.75MG/ENTACAPONE 200MG/LEVODOPA 75MG TAB
1CARBIDOPA 25MG/ENTACAPONE 200MG/LEVODOPA 100MG TAB
1carbidopa 25mg/levodopa 250mg tab
1CARBIDOPA 31.25MG/ENTACAPONE 200MG/LEVODOPA 125MG TAB
1CARBIDOPA 37.5MG/ENTACAPONE 200MG/LEVODOPA 150MG TAB
1CARBIDOPA 50MG/ENTACAPONE 200MG/LEVODOPA 200MG TAB
1ropinirole 1mg tab
1ropinirole 2mg tabANTIPARKINSON MONOAMINE OXIDASE INHIBITORS
1rasagiline 0.5mg tab
1rasagiline 1mg tab
1selegiline 5mg cap
1selegiline 5mg tab
ANTIPSYCHOTICS/ANTIMANIC AGENTSANTIMANIC AGENTS
1lithium carbonate 150mg cap
1lithium carbonate 300mg cap
1lithium carbonate 300mg er tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
49
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1lithium carbonate 300mg tab
1lithium carbonate 450mg er tab
1lithium carbonate 600mg cap
1lithium citrate 60mg/ml oral solnANTIPSYCHOTICS - MISC.
1CAPLYTA 42MG CAP PA NSO QL=30 EA/30 Days
1EQUETRO 100MG ER CAP
1EQUETRO 200MG ER CAP
1EQUETRO 300MG ER CAP
1LATUDA 120MG TAB ST_NSO QL=30 EA/30 Days
1LATUDA 20MG TAB ST_NSO QL=30 EA/30 Days
1LATUDA 40MG TAB ST_NSO QL=30 EA/30 Days
1LATUDA 60MG TAB ST_NSO QL=30 EA/30 Days
1LATUDA 80MG TAB ST_NSO QL=30 EA/30 Days
1NUPLAZID 10MG TAB PA NSO QL=30 EA/30 Days
1NUPLAZID 34MG CAP PA NSO QL=30 EA/30 Days
1VRAYLAR 1.5/3MG MIXED PACK PA NSO QL=30 EA/30 Days
1VRAYLAR 1.5MG CAP PA NSO QL=30 EA/30 Days
1VRAYLAR 3MG CAP PA NSO QL=30 EA/30 Days
1VRAYLAR 4.5MG CAP PA NSO QL=30 EA/30 Days
1VRAYLAR 6MG CAP PA NSO QL=30 EA/30 Days
1ziprasidone 20mg cap
1ziprasidone 20mg inj
1ziprasidone 40mg cap
1ziprasidone 60mg cap
1ziprasidone 80mg capBENZISOXAZOLES
1FANAPT 10MG TAB PA NSO QL=60 EA/30 Days
1FANAPT 12MG TAB PA NSO QL=60 EA/30 Days
1FANAPT 1MG TAB PA NSO QL=60 EA/30 Days
1FANAPT 2MG TAB PA NSO QL=60 EA/30 Days
1FANAPT 4MG TAB PA NSO QL=60 EA/30 Days
1FANAPT 6MG TAB PA NSO QL=60 EA/30 Days
1FANAPT 8MG TAB PA NSO QL=60 EA/30 Days
1FANAPT TITRATION PACK PA NSO QL=60 EA/30 Days
1INVEGA 117MG/0.75ML SYRINGE
1INVEGA 156MG/ML SYRINGE
1INVEGA 234MG/1.5ML SYRINGE
1INVEGA 273MG/0.875ML SYRINGE
1INVEGA 39MG/0.25ML SYRINGE
1INVEGA 410MG/1.315ML SYRINGE
1INVEGA 546MG/1.75ML SYRINGE
1INVEGA 78MG/0.5ML SYRINGE
1INVEGA 819MG/2.625ML SYRINGE
1paliperidone 1.5mg er tab PA NSO QL=30 EA/30 Days
1paliperidone 3mg er tab PA NSO QL=30 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
50
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1paliperidone 6mg er tab PA NSO QL=60 EA/30 Days
1paliperidone 9mg er tab PA NSO QL=30 EA/30 Days
1PERSERIS 120MG SYRINGE NDS
1PERSERIS 90MG SYRINGE NDS
1RISPERDAL 12.5MG INJ
1RISPERDAL 25MG INJ
1RISPERDAL 37.5MG INJ
1RISPERDAL 50MG INJ
1risperidone 0.25mg odt
1risperidone 0.25mg tab
1risperidone 0.5mg odt
1risperidone 0.5mg tab
1risperidone 1mg odt
1risperidone 1mg tab
1risperidone 1mg/ml oral soln
1risperidone 2mg odt
1risperidone 2mg tab
1risperidone 3mg odt
1risperidone 3mg tab
1risperidone 4mg odt
1risperidone 4mg tabBUTYROPHENONES
1azelastine/fluticasone 137-50mcg/act nasal spray
1haloperidol 0.5mg tab
1haloperidol 10mg tab
1haloperidol 1mg tab
1haloperidol 20mg tab
1haloperidol 2mg tab
1haloperidol 2mg/ml oral soln
1haloperidol 5mg tab
1haloperidol 5mg/ml inj
1haloperidol decanoate 100mg/ml (1ml) inj
1haloperidol decanoate 100mg/ml inj
1haloperidol decanoate 50mg/ml injDIBENZAPINES
1clozapine 100mg odt
1clozapine 100mg tab
1CLOZAPINE 12.5MG ODT
1CLOZAPINE 150MG ODT
1CLOZAPINE 200MG ODT
1clozapine 200mg tab
1clozapine 25mg odt
1clozapine 25mg tab
1clozapine 50mg tab
1loxapine 10mg cap
1loxapine 25mg cap
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
51
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1loxapine 50mg cap
1loxapine 5mg cap
1olanzapine 10mg inj
1olanzapine 10mg odt
1olanzapine 10mg tab
1olanzapine 15mg odt
1olanzapine 15mg tab
1olanzapine 2.5mg tab
1olanzapine 20mg odt
1olanzapine 20mg tab
1olanzapine 5mg odt
1olanzapine 5mg tab
1olanzapine 7.5mg tab
1quetiapine 100mg tab
1quetiapine 150mg er tab
1quetiapine 200mg er tab
1quetiapine 200mg tab
1quetiapine 25mg tab
1quetiapine 300mg er tab
1quetiapine 300mg tab
1quetiapine 400mg er tab
1quetiapine 400mg tab
1quetiapine 50mg er tab
1quetiapine 50mg tab
1SAPHRIS 10MG SL TAB PA NSO QL=60 EA/30 Days
1SAPHRIS 2.5MG SL TAB PA NSO QL=60 EA/30 Days
1SAPHRIS 5MG SL TAB PA NSO QL=60 EA/30 Days
1SECUADO 3.8MG/24HR PATCH PA NSO QL=30 EA/30 Days
1SECUADO 5.7MG/24HR PATCH PA NSO QL=30 EA/30 Days
1SECUADO 7.6MG/24HR PATCH PA NSO QL=30 EA/30 Days
1VERSACLOZ 50MG/ML SUSP
1ZYPREXA 210MG INJDIHYDROINDOLONES
1MOLINDONE 10MG TAB
1MOLINDONE 25MG TAB
1MOLINDONE 5MG TABPHENOTHIAZINES
1chlorpromazine 100mg tab
1chlorpromazine 10mg tab
1chlorpromazine 200mg tab
1chlorpromazine 25mg tab
1chlorpromazine 50mg tab
1compro 25mg rectal supp
1FLUPHENAZINE 0.5MG/ML ORAL SOLN
1fluphenazine 10mg tab
1fluphenazine 1mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
52
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1fluphenazine 2.5mg tab
1FLUPHENAZINE 2.5MG/ML INJ
1fluphenazine 5mg tab
1FLUPHENAZINE 5MG/ML ORAL SOLN
1fluphenazine decanoate 25mg/ml inj
1perphenazine 16mg tab
1perphenazine 2mg tab
1perphenazine 4mg tab
1perphenazine 8mg tab
1prochlorperazine 10mg tab
1prochlorperazine 25mg rectal supp
1prochlorperazine 5mg tab
1thioridazine 100mg tab
1thioridazine 10mg tab
1thioridazine 25mg tab
1thioridazine 50mg tab
1trifluoperazine 10mg tab
1trifluoperazine 1mg tab
1trifluoperazine 2mg tab
1trifluoperazine 5mg tabQUINOLINONE DERIVATIVES
1ABILIFY 300MG INJ NDS
1ABILIFY 300MG SYRINGE NDS
1ABILIFY 400MG INJ NDS
1ABILIFY 400MG SYRINGE NDS
1aripiprazole 10mg odt PA NSO QL=60 EA/30 Days
1aripiprazole 10mg tab
1aripiprazole 15mg odt PA NSO QL=60 EA/30 Days
1aripiprazole 15mg tab
1aripiprazole 1mg/ml oral soln PA NSO
1aripiprazole 20mg tab
1aripiprazole 2mg tab
1aripiprazole 30mg tab
1aripiprazole 5mg tab
1ARISTADA 1064MG/3.9ML SYRINGE
1ARISTADA 441MG/1.6ML SYRINGE NDS
1ARISTADA 662MG/2.4ML SYRINGE NDS
1ARISTADA 675MG/2.4ML SYRINGE NDS
1ARISTADA 882MG/3.2ML SYRINGE
1REXULTI 0.25MG TAB PA NSO QL=30 EA/30 Days
1REXULTI 0.5MG TAB PA NSO QL=30 EA/30 Days
1REXULTI 1MG TAB PA NSO QL=30 EA/30 Days
1REXULTI 2MG TAB PA NSO QL=30 EA/30 Days
1REXULTI 3MG TAB PA NSO QL=30 EA/30 Days
1REXULTI 4MG TAB PA NSO QL=30 EA/30 DaysTHIOXANTHENES
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
53
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1thiothixene 10mg cap
1thiothixene 1mg cap
1thiothixene 2mg cap
1thiothixene 5mg cap
ANTIVIRALSANTIRETROVIRALS
1abacavir 20mg/ml oral soln
1abacavir 300mg tab
1abacavir 300mg/lamivudine 150mg/zidovudine 300mg tab
1abacavir 600mg/lamivudine 300mg tab NDS
1APTIVUS 100MG/ML ORAL SOLN NDS
1APTIVUS 250MG CAP NDS
1atazanavir 150mg cap
1atazanavir 200mg cap
1atazanavir 300mg cap
1ATRIPLA 600-200-300MG TAB NDS
1BIKTARVY 50-200-25MG TAB NDS
1CIMDUO 300-300MG TAB NDS
1COMPLERA 200-25-300MG TAB NDS
1CRIXIVAN 200MG CAP
1CRIXIVAN 400MG CAP
1DELSTRIGO 100-300-300MG TAB NDS
1DESCOVY 200-25MG TAB NDS
1DIDANOSINE 250MG DR CAP
1DIDANOSINE 400MG DR CAP
1DOVATO 50-300MG TAB NDS
1EDURANT 25MG TAB NDS
1efavirenz 200mg cap
1efavirenz 50mg cap
1efavirenz 600mg tab
1EMTRIVA 10MG/ML ORAL SOLN
1EMTRIVA 200MG CAP
1EVOTAZ 300-150MG TAB NDS
1fosamprenavir 700mg tab NDS
1FUZEON 90MG INJ NDS
1GENVOYA 150-150-200-10MG TAB NDS
1INTELENCE 100MG TAB NDS
1INTELENCE 200MG TAB NDS
1INTELENCE 25MG TAB NDS
1INVIRASE 500MG TAB NDS
1ISENTRESS 100MG CHEW TAB NDS
1ISENTRESS 100MG GRANULES FOR ORAL SUSP
1ISENTRESS 25MG CHEW TAB
1ISENTRESS 400MG TAB NDS
1ISENTRESS 600MG TAB NDS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
54
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1JULUCA 50-25MG TAB NDS
1KALETRA 100-25MG TAB
1KALETRA 200-50MG TAB NDS
1lamivudine 10mg/ml oral soln
1lamivudine 150mg tab
1lamivudine 150mg/zidovudine 300mg tab
1lamivudine 300mg tab
1LEXIVA 50MG/ML SUSP
1lopinavir 80mg/ml/ritonavir 20mg/ml oral solution NDS
1NEVIRAPINE 100MG ER TAB
1nevirapine 10mg/ml susp
1nevirapine 200mg tab
1nevirapine 400mg er tab
1NORVIR 100MG ORAL POWDER
1NORVIR 80MG/ML ORAL SOLN
1ODEFSEY 200-25-25MG TAB NDS
1PIFELTRO 100MG TAB NDS
1PREZCOBIX 150-800MG TAB NDS
1PREZISTA 100MG/ML SUSP
1PREZISTA 150MG TAB
1PREZISTA 600MG TAB NDS
1PREZISTA 75MG TAB
1PREZISTA 800MG TAB NDS
1REYATAZ 50MG ORAL POWDER NDS
1ritonavir 100mg tab
1SELZENTRY 150MG TAB NDS
1SELZENTRY 20MG/ML ORAL SOLN NDS
1SELZENTRY 25MG TAB
1SELZENTRY 300MG TAB NDS
1SELZENTRY 75MG TAB NDS
1stavudine 15mg cap
1stavudine 20mg cap
1stavudine 30mg cap
1stavudine 40mg cap
1STRIBILD 150-150-200-300MG TAB NDS
1SYMFI 400-300-300MG TAB
1SYMFI 600-300-300MG TAB
1SYMTUZA 800-150-200-10MG TAB NDS
1tenofovir disoproxil fumarate 300mg tab NDS
1TIVICAY 10MG TAB
1TIVICAY 25MG TAB
1TIVICAY 50MG TAB NDS
1TRIUMEQ 600-50-300MG TAB NDS
1TRUVADA 100-150MG TAB NDS
1TRUVADA 133-200MG TAB NDS
1TRUVADA 167-250MG TAB NDS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
55
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1TRUVADA 200-300MG TAB NDS
1TYBOST 150MG TAB
1VIRACEPT 250MG TAB NDS
1VIRACEPT 625MG TAB NDS
1VIREAD 150MG TAB NDS
1VIREAD 200MG TAB NDS
1VIREAD 250MG TAB NDS
1VIREAD 40MG/GM ORAL POWDER
1zidovudine 100mg cap
1zidovudine 10mg/ml oral soln
1zidovudine 300mg tabCMV AGENTS
1PREVYMIS 240MG TAB NDS PA QL=30 EA/30 Days
1PREVYMIS 480MG TAB NDS PA QL=30 EA/30 Days
1valganciclovir 450mg tab NDS
1valganciclovir 50mg/ml oral soln NDSHEPATITIS AGENTS
1adefovir dipivoxil 10mg tab
1entecavir 0.5mg tab
1entecavir 1mg tab
1EPIVIR HBV 5MG/ML ORAL SOLN
1lamivudine 100mg tab
1MAVYRET 100-40MG TAB NDS PA QL=90 EA/30 Days
1PEGASYS 180MCG/0.5ML AUTO-INJECTOR NDS
1PEGASYS 180MCG/0.5ML SYRINGE NDS
1PEGASYS 180MCG/ML INJ NDS
1ribavirin 200mg cap
1ribavirin 200mg tab
1SOFOSBUVIR 400MG/VELPATASVIR 100MG TAB NDS PA QL=30 EA/30 Days
1VEMLIDY 25MG TAB NDS
1VOSEVI 400-100-100MG TAB NDS PA QL=30 EA/30 DaysHERPES AGENTS
1acyclovir 200mg cap
1acyclovir 400mg tab
1acyclovir 40mg/ml susp
1acyclovir 50mg/ml inj PA BvD
1acyclovir 800mg tab
1famciclovir 125mg tab
1famciclovir 250mg tab
1famciclovir 500mg tab
1valacyclovir 1000mg tab
1valacyclovir 500mg tabINFLUENZA AGENTS
1oseltamivir 30mg cap QL=84 EA/180 Days
1oseltamivir 45mg cap QL=42 EA/180 Days
1oseltamivir 6mg/ml susp QL=540 ML/180 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
56
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1oseltamivir 75mg cap QL=42 EA/180 Days
1RELENZA 5MG/BLISTER INH QL=120 EA/30 Days
1RIMANTADINE 100MG TAB
1XOFLUZA 20MG THERAPY PACK QL=2 EA/30 Days
1XOFLUZA 40MG THERAPY PACK QL=2 EA/30 Days
ASSORTED CLASSESIMMUNOSUPPRESSIVE AGENTS
1AZASAN 100MG TAB PA BvD
1AZASAN 75MG TAB PA BvD
1cyclosporine 100mg cap PA BvD
1cyclosporine 25mg cap PA BvD
1cyclosporine modified 100mg cap PA BvD
1cyclosporine modified 25mg cap PA BvD
1gengraf 100mg cap PA BvD
1gengraf 100mg/ml oral soln PA BvD
1gengraf 25mg cap PA BvD
1mycophenolate mofetil 200mg/ml susp PA BvD
1mycophenolate mofetil 250mg cap PA BvD
1mycophenolate mofetil 500mg tab PA BvD
1SANDIMMUNE 100MG/ML ORAL SOLN PA BvD
1sirolimus 0.5mg tab PA BvD
1sirolimus 1mg tab PA BvD
1sirolimus 2mg tab PA BvD
1tacrolimus 0.5mg cap PA BvD
1tacrolimus 1mg cap PA BvD
1tacrolimus 5mg cap PA BvD
BETA BLOCKERSALPHA-BETA BLOCKERS
1carvedilol 12.5mg tab
1carvedilol 25mg tab
1carvedilol 3.125mg tab
1carvedilol 6.25mg tab
1labetalol 100mg tab
1labetalol 200mg tab
1labetalol 300mg tabBETA BLOCKERS CARDIO-SELECTIVE
1acebutolol 200mg cap
1acebutolol 400mg cap
1atenolol 100mg tab
1atenolol 25mg tab
1atenolol 50mg tab
1betaxolol 10mg tab
1betaxolol 20mg tab
1bisoprolol fumarate 10mg tab
1bisoprolol fumarate 5mg tab
1BYSTOLIC 10MG TAB
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
57
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1BYSTOLIC 2.5MG TAB
1BYSTOLIC 20MG TAB
1BYSTOLIC 5MG TAB
1metoprolol succinate 100mg er tab
1metoprolol succinate 200mg er tab
1metoprolol succinate 25mg er tab
1metoprolol succinate 50mg er tab
1metoprolol tartrate 100mg tab
1metoprolol tartrate 25mg tab
1metoprolol tartrate 50mg tabBETA BLOCKERS NON-SELECTIVE
1INNOPRAN 120MG ER CAP
1INNOPRAN 80MG ER CAP
1nadolol 20mg tab
1nadolol 40mg tab
1nadolol 80mg tab
1pindolol 10mg tab
1pindolol 5mg tab
1propranolol 10mg tab
1propranolol 120mg er cap
1propranolol 160mg er cap
1propranolol 20mg tab
1propranolol 40mg tab
1PROPRANOLOL 4MG/ML ORAL SOLN
1propranolol 60mg er cap
1propranolol 60mg tab
1propranolol 80mg er cap
1propranolol 80mg tab
1PROPRANOLOL 8MG/ML ORAL SOLN
1sorine 120mg tab
1sorine 160mg tab
1sorine 240mg tab
1sorine 80mg tab
1sotalol 120mg tab
1sotalol 160mg tab
1sotalol 240mg tab
1sotalol 80mg tab
1sotalol af 120mg tab
1sotalol AF 160mg tab
1sotalol AF 80mg tab
1timolol 10mg tab
1timolol 20mg tab
1timolol 5mg tab
CALCIUM CHANNEL BLOCKERSCALCIUM CHANNEL BLOCKERS
1amlodipine 10mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
58
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1amlodipine 2.5mg tab
1amlodipine 5mg tab
1cartia 120mg er cap
1cartia 180mg er cap
1cartia 240mg er cap
1cartia 300mg er cap
1DILT 120MG ER CAP
1DILT 180MG ER CAP
1DILT 240MG ER CAP
1diltiazem 120mg er (12 hr) cap
1diltiazem 120mg er (24 hr) cap
1diltiazem 120mg tab
1diltiazem 180mg er cap
1diltiazem 240mg er cap
1diltiazem 300mg er cap
1diltiazem 30mg tab
1diltiazem 360mg er cap
1diltiazem 420mg er cap
1diltiazem 60mg er cap
1diltiazem 60mg tab
1diltiazem 90mg er cap
1diltiazem 90mg tab
1felodipine 10mg er tab
1felodipine 2.5mg er tab
1felodipine 5mg er tab
1isradipine 2.5mg cap
1isradipine 5mg cap
1matzim 180mg er tab
1matzim 240mg er tab
1matzim 300mg er tab
1matzim 360mg er tab
1matzim 420mg er tab
1nicardipine 20mg cap
1nicardipine 30mg cap
1nifedipine 30mg er tab
1nifedipine 30mg osmotic er tab
1nifedipine 60mg er tab
1nifedipine 60mg osmotic er tab
1nifedipine 90mg er tab
1nifedipine 90mg osmotic er tab
1nimodipine 30mg cap
1nisoldipine 17mg er tab
1nisoldipine 20mg er tab
1NISOLDIPINE 25.5MG ER TAB
1nisoldipine 30mg er tab
1nisoldipine 34mg er tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
59
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1nisoldipine 40mg er tab
1nisoldipine 8.5mg er tab
1taztia 120mg er cap
1taztia 180mg er cap
1taztia 240mg er cap
1taztia 300mg er cap
1taztia 360mg er cap
1tiadylt 120mg er cap
1tiadylt 180mg er cap
1tiadylt 240mg er cap
1tiadylt 300mg er cap
1tiadylt 360mg er cap
1tiadylt 420mg er cap
1VERAPAMIL 100MG ER CAP
1verapamil 120mg er cap
1verapamil 120mg er tab
1verapamil 120mg tab
1verapamil 180mg er cap
1verapamil 180mg er tab
1VERAPAMIL 200MG ER CAP
1verapamil 240mg er cap
1verapamil 240mg er tab
1VERAPAMIL 300MG ER CAP
1VERAPAMIL 360MG ER CAP
1verapamil 40mg tab
1verapamil 80mg tab
CARDIOTONICSCARDIAC GLYCOSIDES
1digitek 0.125mg tab
1digitek 0.25mg tab
1digox 125mcg tab
1digox 250mcg tab
1digoxin 0.05mg/ml oral soln
1digoxin 0.125mg tab
1digoxin 0.25mg tab
CARDIOVASCULAR AGENTS - MISC.CARDIOVASCULAR AGENTS MISC. - COMBINATIONS
1amlodipine 10mg/atorvastatin 10mg tab
1amlodipine 10mg/atorvastatin 20mg tab
1amlodipine 10mg/atorvastatin 40mg tab
1amlodipine 10mg/atorvastatin 80mg tab
1amlodipine 2.5mg/atorvastatin 10mg tab
1amlodipine 2.5mg/atorvastatin 20mg tab
1amlodipine 2.5mg/atorvastatin 40mg tab
1amlodipine 5mg/atorvastatin 10mg tab
1amlodipine 5mg/atorvastatin 20mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
60
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1amlodipine 5mg/atorvastatin 40mg tab
1amlodipine 5mg/atorvastatin 80mg tab
1BIDIL 37.5-20MG TAB
1ENTRESTO 24-26MG TAB QL=60 EA/30 Days
1ENTRESTO 49-51MG TAB QL=60 EA/30 Days
1ENTRESTO 97-103MG TAB QL=60 EA/30 DaysPROSTAGLANDIN VASODILATORS
1ORENITRAM 0.125MG ER TAB PA
1ORENITRAM 0.25MG ER TAB NDS PA
1ORENITRAM 1MG ER TAB NDS PA
1ORENITRAM 2.5MG ER TAB NDS PA
1ORENITRAM 5MG ER TAB NDS PA
1VENTAVIS 10MCG/ML INH SOLN NDS PA
1VENTAVIS 20MCG/ML INH SOLN NDS PAPULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS
1ambrisentan 10mg tab PA QL=30 EA/30 Days
1ambrisentan 5mg tab PA QL=30 EA/30 Days
1bosentan 125mg tab PA QL=60 EA/30 Days
1bosentan 62.5mg tab PA QL=60 EA/30 Days
1OPSUMIT 10MG TAB NDS PA QL=30 EA/30 Days
1TRACLEER 32MG TAB FOR ORAL SUSP NDS PA QL=120 EA/30 DaysPULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS
1alyq 20mg tab PA
1sildenafil 20mg tab PA
1tadalafil 20mg tab PAPULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST
1UPTRAVI 1000MCG TAB NDS PA
1UPTRAVI 1200MCG TAB NDS PA
1UPTRAVI 1400MCG TAB NDS PA
1UPTRAVI 1600MCG TAB NDS PA
1UPTRAVI 200MCG TAB NDS PA
1UPTRAVI 400MCG TAB NDS PA
1UPTRAVI 600MCG TAB NDS PA
1UPTRAVI 800MCG TAB NDS PA
1UPTRAVI TITRATION PACK NDS PA QL=200 EA/28 DaysPULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR
1ADEMPAS 0.5MG TAB NDS PA
1ADEMPAS 1.5MG TAB NDS PA
1ADEMPAS 1MG TAB NDS PA
1ADEMPAS 2.5MG TAB NDS PA
1ADEMPAS 2MG TAB NDS PASINUS NODE INHIBITORS
1CORLANOR 5MG TAB PA
1CORLANOR 5MG/5ML ORAL SOLN PA
1CORLANOR 7.5MG TAB PATRANSTHYRETIN STABILIZERS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
61
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1VYNDAMAX 61MG CAP NDS PA QL=30 EA/30 Days
1VYNDAQEL 20MG CAP NDS PA QL=120 EA/30 Days
CEPHALOSPORINSCEPHALOSPORIN COMBINATIONS
1AVYCAZ 500-2000MG INJ NDS
1ZERBAXA 1000-500MG INJ NDSCEPHALOSPORINS - 1ST GENERATION
1cefadroxil 1000mg tab
1cefadroxil 100mg/ml susp
1cefadroxil 500mg cap
1cefadroxil 50mg/ml susp
1cefazolin 1000mg inj
1cefazolin 200mg/ml inj
1cefazolin 500mg inj
1cephalexin 250mg cap
1cephalexin 25mg/ml susp
1cephalexin 500mg cap
1cephalexin 50mg/ml suspCEPHALOSPORINS - 2ND GENERATION
1cefaclor 250mg cap
1cefaclor 500mg cap
1cefotetan 1000mg inj
1cefotetan 2000mg inj
1cefoxitin 1000mg inj
1cefoxitin 2000mg inj
1cefoxitin 200mg/ml inj
1cefprozil 250mg tab
1cefprozil 25mg/ml susp
1cefprozil 500mg tab
1cefprozil 50mg/ml susp
1cefuroxime 1500mg inj
1cefuroxime 250mg tab
1cefuroxime 500mg tab
1cefuroxime 750mg inj
1cefuroxime 95mg/ml injCEPHALOSPORINS - 3RD GENERATION
1cefdinir 25mg/ml susp
1cefdinir 300mg cap
1cefdinir 50mg/ml susp
1cefixime 20mg/ml susp
1cefixime 400mg cap
1cefixime 40mg/ml susp
1cefpodoxime 100mg tab
1cefpodoxime 10mg/ml susp
1cefpodoxime 200mg tab
1cefpodoxime 20mg/ml susp
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
62
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1ceftazidime 1000mg inj
1ceftazidime 2000mg inj
1ceftazidime 200mg/ml inj
1ceftriaxone 1000mg inj
1ceftriaxone 100mg/ml inj
1ceftriaxone 2000mg inj
1ceftriaxone 250mg inj
1ceftriaxone 500mg inj
1tazicef 1gm inj
1tazicef 2gm inj
1tazicef 6gm injCEPHALOSPORINS - 4TH GENERATION
1cefepime 1000mg inj
1cefepime 2000mg injCEPHALOSPORINS - 5TH GENERATION
1TEFLARO 400MG INJ NDS
1TEFLARO 600MG INJ NDS
CONTRACEPTIVESCOMBINATION CONTRACEPTIVES - ORAL
1altavera 28 day pack
1alyacen 1/35 28 day pack
1amethia 91 day pack
1apri 28 day pack
1aranelle 28 pack
1ashlyna 91 day pack
1aubra 28 day pack
1aviane 28 pack
1balziva 28 day pack
1blisovi 21 fe 1.5/30 28 day
1blisovi 24 fe 1/20 28 day pack
1briellyn 28 day pack
1camreselo 91 day pack
1caziant 28 day pack
1cryselle 28 pack
1cyclafem 1/35 28 day pack
1cyclafem 7/7/7 28 day pack
1cyred 28 day pack
1desogestrel/ethinyl estradiol 28 day pack
1desogestrel/ethinyl estradiol pack
1drospirenone 3mg/ethinyl estradiol 0.02mg/inert 1 mg pack
1drospirenone 3mg/ethinyl estradiol 0.03mg/inert ingredients 1mg pack
1emoquette pack
1enpresse 28 day pack
1enskyce 28 day pack
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
63
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1estarylla 28 day pack
1ethinyl estradiol 0.01mg/ethinyl estradiol 0.02mg/levonorgestrel 0.1mg 91 day pack
1ethinyl estradiol 0.01mg/ethinyl estradiol 0.03mg/levonorgestrel 0.15mg pack
1ethinyl estradiol 0.025mg/ferrous fumarate 75mg/norethindrone 0.8mg pack
1ethinyl estradiol 0.025mg/inert/norgestimate 0.18mg/0.215mg/0.25mg pack
1ethinyl estradiol 0.02mg/inert ingredients 1mg/levonorgestrel 0.1mg pack
1ethinyl estradiol 0.02mg/norethindrone acetate 1mg pack
1ethinyl estradiol 0.035mg/ethynodiol 1mg 28 day pack
1ethinyl estradiol 0.035mg/ferrous fumarate 75mg/norethindrone 0.4mg pack
1ethinyl estradiol 0.035mg/inert/norgestimate 0.18mg/0.215mg/0.25mg pack
1ethinyl estradiol 0.035mg/norgestimate 0.25mg pack
1ethinyl estradiol 0.03mg/0.04mg /inert/levonorgestrel 0.05mg/ 0.075mg pack
1ethinyl estradiol 0.03mg/inert ingredients 1mg/levonorgestrel 0.15mg pack
1ethinyl estradiol 0.03mg/levonorgestrel 0.15mg tab 28 day pack
1ethinyl estradiol 0.05mg/ethynodiol 1mg/inert ingredients 1mg 28 day pack
1ethinyl estradiol/levonorgestrel 91 day pack
1falmina 28 day pack
1fayosim 91 day pack
1femynor 28 day pack
1gianvi 28-day pack
1hailey 24 fe 28 day pack
1introvale 91 day pack
1isibloom 28 day pack
1jasmiel 28 day pack
1juleber 28 day pack
1junel 1.5/30 21 day pack
1junel 1/20 21 day pack
1junel fe 1.5/30 28 day pack
1junel fe 1/20 28 day pack
1junel fe 24 1/20 28 day pack
1kaitlib fe 28 day pack
1kariva 28 day pack
1kelnor 1/35 28 day pack
1kelnor 1/50 28 day pack
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
64
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1kurvelo pack
1larin 1.5/30 pack
1larin 1/20 pack
1larin fe 1.5/30 pack
1larin fe 1/20 pack
1larissia 28 day pack
1layolis fe 28 pack
1leena 28 day pack
1lessina 28 day pack
1levonest 28 day pack
1levora 0.15/30 28 day pack
1loryna 28 day pack
1low-ogestrel 28 day pack
1lutera 28 day pack
1marlissa 28 day pack
1microgestin 1.5/30 21 day pack
1microgestin 1/20 21 day pack
1microgestin fe 1.5/30 28 day pack
1microgestin fe 1/20 28 day pack
1mili 28 day pack
1NATAZIA 28 DAY PACK
1necon 0.5/35 28 day pack
1nikki 28 day pack
1nortrel 0.5/35 28 day pack
1nortrel 1/35 21 day pack
1nortrel 1/35 28 day pack
1nortrel 7/7/7 28 day pack
1ocella 28 day pack
1orsythia 28 day pack
1pimtrea pack
1pirmella 1/35 28 day pack
1portia 28 day pack
1previfem 28 day pack
1reclipsen 28 day pack
1rivelsa 91 day pack
1setlakin 91 day pack
1sprintec 28 day pack
1sronyx 28 day pack
1syeda 28 day pack
1tarina 24 fe 1/20 28 day pack
1tarina fe 1/20 28 day pack
1tri-estarylla 28 day pack
1tri-legest 28 day pack
1tri-lo-estarylla 28 day pack
1tri-lo-sprintec 28 day pack
1tri-mili 28 day pack
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
65
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1tri-previfem 28 day pack
1tri-sprintec 28 day pack
1tri-vylibra 28 day pack
1tri-vylibra lo 28 day pack
1trivora 28 day pack
1velivet 28 day pack
1vienva 28 day pack
1vyfemla 28 day pack
1vylibra 28 day pack
1wymzya fe 28 day pack
1zarah pack
1zovia 1/35e 28 day packCOMBINATION CONTRACEPTIVES - TRANSDERMAL
1XULANE 0.00146-0.00625MG/HR PATCHCOMBINATION CONTRACEPTIVES - VAGINAL
1eluryng 0.000625-0.005mg/hr vaginal system
1etonogestrel-ethinyl estradiol 0.120-0.015mg/24hr vaginal ring
PROGESTIN CONTRACEPTIVES - INJECTABLE
1medroxyprogesterone acetate 150mg/ml inj
1medroxyprogesterone acetate 150mg/ml syringePROGESTIN CONTRACEPTIVES - ORAL
1camila 28 day 0.35mg pack
1deblitane 28 day 0.35mg pack
1errin 28 day 0.35mg pack
1incassia 28 day 0.35mg pack
1lyza 0.35mg pack
1nora-be 28 day 0.35mg pack
1norethindrone 0.35mg pack
1sharobel 28 day 0.35mg pack
1SLYND 4MG TAB
CORTICOSTEROIDSGLUCOCORTICOSTEROIDS
1budesonide 3mg dr cap
1budesonide 9mg er tab PA QL=30 EA/30 Days
1CORTISONE ACETATE 25MG TAB
1dexamethasone 0.1mg/ml oral soln
1dexamethasone 0.5mg tab
1dexamethasone 0.75mg tab
1dexamethasone 1.5mg tab
1DEXAMETHASONE 1MG TAB
1DEXAMETHASONE 1MG/ML ORAL SOLN
1DEXAMETHASONE 2MG TAB
1dexamethasone 4mg tab
1dexamethasone 6mg tab
1hydrocortisone 10mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
66
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1hydrocortisone 20mg tab
1hydrocortisone 5mg tab
1MEDROL 2MG TAB PA BvD
1methylprednisolone 16mg tab PA BvD
1methylprednisolone 32mg tab PA BvD
1methylprednisolone 4mg pack
1methylprednisolone 4mg tab PA BvD
1methylprednisolone 8mg tab PA BvD
1prednisolone 10mg odt PA BvD
1prednisolone 15mg odt PA BvD
1prednisolone 1mg/ml oral soln PA BvD
1prednisolone 30mg odt PA BvD
1PREDNISOLONE 3MG/ML ORAL SOLN PA BvD
1prednisone 10mg tab PA BvD
1prednisone 1mg tab PA BvD
1PREDNISONE 1MG/ML ORAL SOLN PA BvD
1prednisone 2.5mg tab PA BvD
1prednisone 20mg tab PA BvD
1prednisone 50mg tab PA BvD
1prednisone 5mg tab PA BvD
1PREDNISONE 5MG/ML ORAL SOLN PA BvDMINERALOCORTICOIDS
1fludrocortisone 0.1mg tab
COUGH/COLD/ALLERGYCOUGH/COLD/ALLERGY COMBINATIONS
1CLARINEX-D 2.5-120MG ER TAB
1PHENYLEPHRINE 1MG/ML/PROMETHAZINE 1.25MG/ML ORAL SOLN
MUCOLYTICS
1acetylcysteine 100mg/ml inh soln PA BvD
1acetylcysteine 200mg/ml inh soln PA BvD
DERMATOLOGICALSACNE PRODUCTS
1adapalene 0.1% cream PA
1adapalene 0.1% gel PA
1adapalene 0.3% gel PA
1adapalene/benzoyl peroxide 0.1-2.5% gel PA
1amnesteem 10mg cap
1amnesteem 20mg cap
1amnesteem 40mg cap
1avita 0.025% cream PA
1avita 0.025% gel PA
1claravis 10mg cap
1claravis 20mg cap
1claravis 30mg cap
1claravis 40mg cap
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
67
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1clindacin 1% pad QL=120 EA/30 Days
1clindamycin 1% gel QL=180 GM/30 Days
1clindamycin 1% lotion QL=180 ML/30 Days
1clindamycin 1% pad QL=120 EA/30 Days
1clindamycin 1% topical soln QL=300 ML/30 Days
1clindamycin/benzoyl peroxide 1-5% gel QL=100 GM/30 Days
1EPIDUO 0.3-2.5% GEL PA
1ERY 2% PAD
1erythromycin 2% gel
1erythromycin 2% topical soln
1erythromycin/benzoyl peroxide 5-3% gel
1isotretinoin 10mg cap
1isotretinoin 20mg cap
1isotretinoin 30mg cap
1isotretinoin 40mg cap
1myorisan 10mg cap
1myorisan 20mg cap
1myorisan 30mg cap
1myorisan 40mg cap
1sulfacetamide sodium 10% lotion
1tretinoin 0.01% gel PA
1tretinoin 0.025% cream PA
1tretinoin 0.025% gel PA
1tretinoin 0.04% gel PA
1tretinoin 0.05% cream PA
1tretinoin 0.05% gel PA
1tretinoin 0.1% cream PA
1tretinoin 0.1% gel PA
1zenatane 10mg cap
1zenatane 20mg cap
1zenatane 30mg cap
1zenatane 40mg capANTIBIOTICS - TOPICAL
1gentamicin 0.1% cream QL=120 GM/30 Days
1gentamicin 0.1% ointment QL=120 GM/30 Days
1mupirocin 2% ointment QL=220 GM/30 DaysANTIFUNGALS - TOPICAL
1betamethasone/clotrimazole 1-0.05% cream QL=270 GM/30 Days
1betamethasone/clotrimazole 1-0.05% lotion QL=180 ML/30 Days
1ciclopirox 0.77% cream QL=270 GM/30 Days
1ciclopirox 0.77% gel QL=300 GM/30 Days
1ciclopirox 0.77% lotion QL=240 ML/30 Days
1ciclopirox 1% shampoo QL=240 ML/30 Days
1ciclopirox 8% topical soln QL=13.20 ML/30 Days
1clotrimazole 1% cream QL=180 GM/30 Days
1clotrimazole 1% topical soln QL=240 ML/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
68
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1econazole nitrate 1% cream QL=255 GM/30 Days
1ketoconazole 2% cream QL=240 GM/30 Days
1ketoconazole 2% foam QL=300 GM/30 Days
1ketoconazole 2% shampoo QL=360 ML/30 Days
1ketodan 2% foam QL=300 GM/30 Days
1naftifine 1% cream QL=270 GM/30 Days
1naftifine 2% cream QL=240 GM/30 Days
1nyamyc 100000unit/gm topical powder QL=480 GM/30 Days
1nystatin 100000unit/ml cream QL=240 GM/30 Days
1nystatin 100unit/mg ointment QL=240 GM/30 Days
1nystatin 100unit/mg topical powder QL=480 GM/30 Days
1nystop 100000unit/gm topical powder QL=480 GM/30 DaysANTI-INFLAMMATORY AGENTS - TOPICAL
1diclofenac sodium 1% gel QL=1000 GM/30 Days
1diclofenac sodium 1.5% topical soln QL=450 ML/30 DaysANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL
1diclofenac sodium 3% gel PA QL=300 GM/30 Days
1FLUOROPLEX 1% CREAM
1FLUOROURACIL 2% TOPICAL SOLN
1fluorouracil 5% cream
1FLUOROURACIL 5% TOPICAL SOLN
1PICATO 0.015% GEL QL=3 EA/10 Days
1PICATO 0.05% GEL QL=2 EA/10 Days
1TARGRETIN 1% GEL NDS PA NSO
1VALCHLOR 0.016% GEL NDS PA NSO QL=240 GM/30 DaysANTIPSORIATICS
1acitretin 10mg cap
1acitretin 17.5mg cap
1acitretin 25mg cap
1calcipotriene 0.005% cream PA QL=240 GM/30 Days
1calcipotriene 0.005% ointment PA QL=240 GM/30 Days
1calcipotriene 0.005% topical soln PA
1methoxsalen 10mg cap
1SKYRIZI 150MG DOSE PACK 75MG/0.83ML PA
1STELARA 45MG/0.5ML INJ PA
1STELARA 45MG/0.5ML SYRINGE PA
1STELARA 90MG/ML SYRINGE PA
1TALTZ 80MG/ML AUTO-INJECTOR NDS PA
1TALTZ 80MG/ML SYRINGE NDS PA
1tazarotene 0.1% cream
1TAZORAC 0.05% CREAM
1TAZORAC 0.05% GEL
1TAZORAC 0.1% GELANTISEBORRHEIC PRODUCTS
1selenium sulfide 2.5% shampooANTIVIRALS - TOPICAL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
69
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1acyclovir 5% ointment QL=60 GM/30 Days
1DENAVIR 1% CREAM QL=5 GM/7 DaysBURN PRODUCTS
1silver sulfadiazine 1% cream
1ssd 1% cream
1SULFAMYLON 85MG/GM CREAMCORTICOSTEROIDS - TOPICAL
1ala-cort 1% cream
1alclometasone dipropionate 0.05% cream
1alclometasone dipropionate 0.05% ointment
1betamethasone 0.05% aug cream
1betamethasone 0.05% aug lotion
1betamethasone 0.05% aug ointment
1betamethasone 0.05% cream
1BETAMETHASONE 0.05% GEL
1betamethasone 0.05% lotion
1betamethasone 0.05% ointment
1betamethasone 0.1% cream
1betamethasone 0.1% lotion
1betamethasone 0.1% ointment
1calcipotriene/betamethasone 0.005-0.064% ointment PA QL=420 GM/30 Days
1clobetasol propionate 0.05% cream
1clobetasol propionate 0.05% e cream
1clobetasol propionate 0.05% foam
1clobetasol propionate 0.05% gel
1clobetasol propionate 0.05% lotion
1clobetasol propionate 0.05% ointment
1clobetasol propionate 0.05% shampoo
1clobetasol propionate 0.05% spray
1clobetasol propionate 0.05% topical soln QL=450 ML/30 Days
1clodan 0.05% shampoo
1desonide 0.05% ointment
1desoximetasone 0.05% gel QL=240 GM/30 Days
1desoximetasone 0.25% cream QL=300 GM/30 Days
1desoximetasone 0.25% ointment QL=300 GM/30 Days
1fluocinolone acetonide 0.01% cream
1fluocinolone acetonide 0.01% topical soln
1fluocinolone acetonide 0.025% cream
1fluocinolone acetonide 0.025% ointment
1fluocinolone acetonide 0.1mg/ml oil
1fluocinonide 0.05% e cream
1fluocinonide 0.05% gel
1fluocinonide 0.05% ointment
1fluocinonide 0.05% topical soln
1fluticasone propionate 0.005% ointment
1fluticasone propionate 0.05% cream
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
70
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1halobetasol propionate 0.05% cream
1halobetasol propionate 0.05% ointment
1hydrocortisone 1% cream
1hydrocortisone 2.5% cream
1hydrocortisone 2.5% lotion
1hydrocortisone 2.5% ointment
1mometasone furoate 0.1% cream
1mometasone furoate 0.1% lotion
1mometasone furoate 0.1% ointment
1PREDNICARBATE 0.1% CREAM
1PREDNICARBATE 0.1% OINTMENT
1triamcinolone acetonide 0.0147% spray
1triamcinolone acetonide 0.025% cream
1triamcinolone acetonide 0.025% lotion
1triamcinolone acetonide 0.025% ointment
1triamcinolone acetonide 0.1% cream
1triamcinolone acetonide 0.1% lotion
1triamcinolone acetonide 0.1% ointment
1triamcinolone acetonide 0.5% cream
1triamcinolone acetonide 0.5% ointment
1triderm 0.1% creamECZEMA AGENTS
1DUPIXENT 200MG/1.14ML SYRINGE NDS PA
1DUPIXENT 300MG/2ML SYRINGE NDS PAEMOLLIENTS
1ammonium lactate 12% cream
1ammonium lactate 12% lotionENZYMES - TOPICAL
1SANTYL 250UNIT/GM OINTMENT QL=90 GM/30 DaysIMMUNOMODULATING AGENTS - TOPICAL
1imiquimod 5% cream
1ZYCLARA 2.5% CREAMIMMUNOSUPPRESSIVE AGENTS - TOPICAL
1pimecrolimus 1% cream
1tacrolimus 0.03% ointment QL=100 GM/30 Days
1tacrolimus 0.1% ointment QL=100 GM/30 DaysKERATOLYTIC/ANTIMITOTIC AGENTS
1podofilox 0.5% topical solnLOCAL ANESTHETICS - TOPICAL
1LIDOCAINE 2% GEL
1lidocaine 4% topical soln
1lidocaine 5% ointment PA QL=107 GM/30 Days
1lidocaine 5% patch PA QL=90 EA/30 Days
1lidocaine/prilocaine 2.5-2.5% cream QL=60 GM/30 DaysROSACEA AGENTS
1azelaic acid 15% gel
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
71
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1FINACEA 15% FOAM
1metronidazole 0.75% cream
1metronidazole 0.75% gel
1metronidazole 0.75% lotion
1metronidazole 1% gelSCABICIDES & PEDICULICIDES
1lindane 1% shampoo
1malathion 0.5% lotion
1permethrin 5% creamWOUND CARE PRODUCTS
1REGRANEX 0.01% GEL QL=30 GM/15 Days
DIGESTIVE AIDSDIGESTIVE ENZYMES
1CREON 120000-76000-24000UNIT DR CAP
1CREON 15000-9500-3000UNIT DR CAP
1CREON 30000-19000-6000UNIT DR CAP
1CREON 36000-114000-180000UNIT DR CAP
1CREON 60000-38000-12000UNIT DR CAP
1SUCRAID 8500UNIT/ML ORAL SOLN NDS PA
1ZENPEP 105000-79000-25000UNIT DR CAP ST
1ZENPEP 14000-10000-3000UNIT DR CAP ST
1ZENPEP 24000-17000-5000UNIT DR CAP ST
1ZENPEP 40000-126000-168000UNIT DR CAP ST
1ZENPEP 42000-32000-10000UNIT DR CAP ST
1ZENPEP 63000-47000-15000UNIT DR CAP ST
1ZENPEP 84000-63000-20000UNIT DR CAP ST
DIURETICSCARBONIC ANHYDRASE INHIBITORS
1acetazolamide 125mg tab
1acetazolamide 250mg tab
1acetazolamide 500mg er cap
1methazolamide 25mg tab
1methazolamide 50mg tabDIURETIC COMBINATIONS
1amiloride 5mg/hydrochlorothiazide 50mg tab
1hydrochlorothiazide 25mg/spironolactone 25mg tab
1hydrochlorothiazide 25mg/triamterene 37.5mg cap
1hydrochlorothiazide 25mg/triamterene 37.5mg tab
1hydrochlorothiazide 50mg/triamterene 75mg tabLOOP DIURETICS
1bumetanide 0.25mg/ml inj
1bumetanide 0.5mg tab
1bumetanide 1mg tab
1bumetanide 2mg tab
1ethacrynic acid 25mg tab
1furosemide 10mg/ml inj
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
72
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1furosemide 10mg/ml oral soln
1furosemide 10mg/ml syringe
1furosemide 20mg tab
1furosemide 40mg tab
1furosemide 80mg tab
1FUROSEMIDE 8MG/ML ORAL SOLN
1torsemide 100mg tab
1torsemide 10mg tab
1torsemide 20mg tab
1torsemide 5mg tabPOTASSIUM SPARING DIURETICS
1amiloride 5mg tab
1spironolactone 100mg tab
1spironolactone 25mg tab
1spironolactone 50mg tab
1triamterene 100mg cap
1triamterene 50mg capTHIAZIDES AND THIAZIDE-LIKE DIURETICS
1chlorthalidone 25mg tab
1chlorthalidone 50mg tab
1DIURIL 250MG/5ML SUSP
1hydrochlorothiazide 12.5mg cap
1hydrochlorothiazide 12.5mg tab
1hydrochlorothiazide 25mg tab
1hydrochlorothiazide 50mg tab
1indapamide 1.25mg tab
1indapamide 2.5mg tab
1metolazone 10mg tab
1metolazone 2.5mg tab
1metolazone 5mg tab
ENDOCRINE AND METABOLIC AGENTS - MISC.BONE DENSITY REGULATORS
1ALENDRONIC ACID 0.933MG/ML ORAL SOLN
1alendronic acid 10mg tab
1alendronic acid 35mg tab
1alendronic acid 70mg tab
1FORTEO 600MCG/2.4ML PEN INJ NDS
1ibandronic acid 150mg tab QL=1 EA/30 Days
1NATPARA 100MCG CARTRIDGE NDS PA
1NATPARA 25MCG CARTRIDGE NDS PA
1NATPARA 50MCG CARTRIDGE NDS PA
1NATPARA 75MCG CARTRIDGE NDS PA
1PROLIA 60MG/ML SYRINGE PA
1risedronate sodium 150mg tab
1risedronate sodium 30mg tab
1risedronate sodium 35mg (12) pack
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
73
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1risedronate sodium 35mg (4) pack
1risedronate sodium 35mg tab
1risedronate sodium 5mg tab
1salmon calcitonin 200unit/act nasal spray
1TYMLOS 3120MCG/1.56ML PEN INJ NDS
1XGEVA 120MG/1.7ML INJ NDS PAGNRH/LHRH ANTAGONISTS
1ORILISSA 150MG TAB PA QL=30 EA/30 Days
1ORILISSA 200MG TAB PA QL=60 EA/30 DaysGROWTH HORMONE RECEPTOR ANTAGONISTS
1SOMAVERT 10MG INJ NDS PA
1SOMAVERT 15MG INJ NDS PA
1SOMAVERT 20MG INJ NDS PA
1SOMAVERT 25MG INJ NDS PA
1SOMAVERT 30MG INJ NDS PAGROWTH HORMONES
1GENOTROPIN 0.2MG SYRINGE NDS PA
1GENOTROPIN 0.4MG SYRINGE NDS PA
1GENOTROPIN 0.6MG SYRINGE NDS PA
1GENOTROPIN 0.8MG SYRINGE NDS PA
1GENOTROPIN 1.2MG SYRINGE NDS PA
1GENOTROPIN 1.4MG SYRINGE NDS PA
1GENOTROPIN 1.6MG SYRINGE NDS PA
1GENOTROPIN 1.8MG SYRINGE NDS PA
1GENOTROPIN 12MG CARTRIDGE NDS PA
1GENOTROPIN 1MG SYRINGE NDS PA
1GENOTROPIN 2MG SYRINGE NDS PA
1GENOTROPIN 5MG CARTRIDGE NDS PAHORMONE RECEPTOR MODULATORS
1OSPHENA 60MG TAB PA
1raloxifene 60mg tabINSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)
1INCRELEX 40MG/4ML INJ NDS PALHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS
1LUPANETA PACK 1-MONTH PACK NDS
1LUPANETA PACK 3-MONTH PACK
1SYNAREL 2MG/ML NASAL INHALER NDSMETABOLIC MODIFIERS
1calcitriol 0.00025mg cap
1calcitriol 0.0005mg cap
1calcitriol 0.001mg/ml oral soln
1CARBAGLU 200MG TAB FOR ORAL SUSP PA
1cinacalcet 30mg tab
1cinacalcet 60mg tab
1cinacalcet 90mg tab
1doxercalciferol 0.0005mg cap
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
74
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1doxercalciferol 0.001mg cap
1doxercalciferol 0.0025mg cap
1GALAFOLD 28 DAY WALLET 123MG PACK NDS PA QL=15 EA/30 Days
1KUVAN 100MG POWDER FOR ORAL SOLN NDS PA
1KUVAN 100MG TAB NDS PA
1KUVAN 500MG POWDER FOR ORAL SOLN NDS PA
1levocarnitine 100mg/ml oral soln
1levocarnitine 330mg tab
1nitisinone 10mg cap NDS PA
1nitisinone 2mg cap NDS PA
1nitisinone 5mg cap NDS PA
1ORFADIN 20MG CAP NDS PA
1ORFADIN 4MG/ML SUSP NDS PA
1PALYNZIQ 10MG/0.5ML SYRINGE NDS PA
1PALYNZIQ 2.5MG/0.5ML SYRINGE NDS PA
1PALYNZIQ 20MG/ML SYRINGE NDS PA
1paricalcitol 0.001mg cap
1paricalcitol 0.002mg cap
1paricalcitol 0.004mg cap
1RAVICTI 1.1GM/ML ORAL SOLN NDS PA
1sodium phenylbutyrate 0.94mg/mg oral powderPOSTERIOR PITUITARY HORMONES
1desmopressin acetate 0.01mg/act nasal spray
1desmopressin acetate 0.1mg tab
1desmopressin acetate 0.2mg tab
1STIMATE 1.5MG/ML NASAL INHALERPROLACTIN INHIBITORS
1cabergoline 0.5mg tabSOMATOSTATIC AGENTS
1octreotide 0.05mg/ml inj
1octreotide 0.1mg/ml inj
1octreotide 0.2mg/ml inj
1octreotide 0.5mg/ml inj
1octreotide 1mg/ml inj
1SIGNIFOR 0.3MG/ML INJ NDS PA QL=60 ML/30 Days
1SIGNIFOR 0.6MG/ML INJ NDS PA QL=60 ML/30 Days
1SIGNIFOR 0.9MG/ML INJ NDS PA QL=60 ML/30 Days
1SOMATULINE 120MG/0.5ML SYRINGE NDS
1SOMATULINE 60MG/0.2ML SYRINGE NDS
1SOMATULINE 90MG/0.3ML SYRINGE NDSVASOPRESSIN RECEPTOR ANTAGONISTS
1JYNARQUE 15MG TAB NDS PA QL=120 EA/30 Days
1JYNARQUE 30MG TAB NDS PA QL=120 EA/30 Days
1JYNARQUE 45/15 THERAPY PACK NDS PA QL=60 EA/30 Days
1JYNARQUE 60/30 THERAPY PACK NDS PA QL=60 EA/30 Days
1JYNARQUE 90/30 THERAPY PACK NDS PA QL=60 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
75
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1JYNARQUE TAB 15/15MG THERAPY PACK NDS PA QL=60 EA/30 Days
1JYNARQUE TAB 30/15MG THERAPY PACK NDS PA QL=60 EA/30 Days
ESTROGENSESTROGEN COMBINATIONS
1amabelz 0.5/0.1mg 28 day pack
1amabelz 1/0.5mg 28 day pack
1COMBIPATCH 0.00208-0.00583MG/HR PATCH
1COMBIPATCH 0.00208-0.0104MG/HR PATCH
1estradiol 0.5mg/norethindrone acetate 0.1mg pack
1estradiol 1mg/norethindrone acetate 0.5mg pack
1ethinyl estradiol 0.0025mg/norethindrone acetate 0.5mg pack
1ethinyl estradiol 0.005mg/norethindrone acetate 1mg pack
1fyavolv 0.0025-0.5mg tab
1fyavolv 0.005-1mg tab
1jinteli 0.005-1mg tab
1lopreeza 1/0.5mg 28 day pack
1mimvey pack
1PREMPHASE 28 DAY PACK
1PREMPRO 0.3/1.5MG 28 DAY PACK
1PREMPRO 0.45/1.5 28 DAY PACK
1PREMPRO 0.625/2.5MG 28 DAY PACK
1PREMPRO 0.625/5MG 28 DAY PACKESTROGENS
1dotti 0.025mg/24hr patch
1dotti 0.0375mg/24hr patch
1dotti 0.05mg/24hr patch
1dotti 0.075mg/24hr patch
1dotti 0.1mg/24hr patch
1estradiol 0.00104mg/hr twice weekly patch
1estradiol 0.00104mg/hr weekly patch
1estradiol 0.00156mg/hr twice weekly patch
1estradiol 0.00156mg/hr weekly patch
1estradiol 0.00208mg/hr twice weekly patch
1estradiol 0.00208mg/hr weekly patch
1estradiol 0.0025mg/hr weekly patch
1estradiol 0.00312mg/hr weekly patch
1estradiol 0.00313mg/hr twice weekly patch
1estradiol 0.00417mg/hr twice weekly patch
1estradiol 0.00417mg/hr weekly patch
1estradiol 0.5mg tab
1estradiol 1mg tab
1estradiol 2mg tab
1estradiol valerate 20mg/ml inj
1estradiol valerate 40mg/ml inj
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
76
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1PREMARIN 0.3MG TAB
1PREMARIN 0.45MG TAB
1PREMARIN 0.625MG TAB
1PREMARIN 0.9MG TAB
1PREMARIN 1.25MG TAB
FLUOROQUINOLONESFLUOROQUINOLONES
1BAXDELA 450MG TAB PA QL=60 EA/30 Days
1ciprofloxacin 250mg tab
1ciprofloxacin 2mg/ml inj
1ciprofloxacin 500mg tab
1ciprofloxacin 750mg tab
1levofloxacin 250mg tab
1levofloxacin 25mg/ml inj
1levofloxacin 25mg/ml oral soln
1levofloxacin 500mg tab
1levofloxacin 5mg/ml (100ml) inj
1levofloxacin 5mg/ml (150ml) inj
1levofloxacin 750mg tab
1moxifloxacin 1.6mg/ml inj
1moxifloxacin 400mg tab
1ofloxacin 400mg tab
GASTROINTESTINAL AGENTS - MISC.AGENTS FOR CHRONIC IDIOPATHIC CONSTIPATION (CIC)
1TRULANCE 3MG TAB PABILE ACID SYNTHESIS DISORDER AGENTS
1CHOLBAM 250MG CAP NDS PA
1CHOLBAM 50MG CAP NDS PAFARNESOID X RECEPTOR (FXR) AGONISTS
1OCALIVA 10MG TAB NDS PA QL=30 EA/30 Days
1OCALIVA 5MG TAB NDS PA QL=30 EA/30 DaysGALLSTONE SOLUBILIZING AGENTS
1CHENODAL 250MG TAB NDS
1ursodiol 250mg tab
1ursodiol 300mg cap
1ursodiol 500mg tabGASTROINTESTINAL ANTIALLERGY AGENTS
1cromolyn sodium 20mg/ml oral solnGASTROINTESTINAL STIMULANTS
1metoclopramide 10mg tab
1metoclopramide 1mg/ml oral soln
1metoclopramide 5mg tabINFLAMMATORY BOWEL AGENTS
1balsalazide disodium 750mg cap
1CIMZIA 200MG INJ NDS PA
1CIMZIA 200MG/ML SYRINGE NDS PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
77
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1DIPENTUM 250MG CAP
1mesalamine 1000mg rectal supp
1mesalamine 1200mg dr tab
1mesalamine 375mg er cap
1mesalamine 400mg dr cap
1mesalamine 66.7mg/ml enema
1mesalamine 800mg dr tab
1sulfasalazine 500mg dr tab
1sulfasalazine 500mg tabINTESTINAL ACIDIFIERS
1enulose 10gm/15ml oral soln
1generlac 10gm/15ml oral solnIRRITABLE BOWEL SYNDROME (IBS) AGENTS
1alosetron 0.5mg tab
1alosetron 1mg tab
1VIBERZI 100MG TAB PA
1VIBERZI 75MG TAB PAPERIPHERAL OPIOID RECEPTOR ANTAGONISTS
1MOVANTIK 12.5MG TAB PA
1MOVANTIK 25MG TAB PA
1RELISTOR 12MG/0.6ML INJ PA
1RELISTOR 12MG/0.6ML SYRINGE PA
1RELISTOR 8MG/0.4ML SYRINGE PA
1SYMPROIC 0.2MG TAB PAPHOSPHATE BINDER AGENTS
1AURYXIA 210MG TAB PA
1calcium acetate 667mg cap
1calcium acetate 667mg tab
1FOSRENOL 1000MG ORAL POWDER
1FOSRENOL 750MG ORAL POWDER
1lanthanum carbonate 1000mg chew tab
1lanthanum carbonate 500mg chew tab
1lanthanum carbonate 750mg chew tab
1PHOSLYRA 667MG/5ML ORAL SOLN
1sevelamer carbonate 2400mg powder for oral susp
1sevelamer carbonate 800mg powder for oral susp
1sevelamer carbonate 800mg tabSHORT BOWEL SYNDROME (SBS) AGENTS
1GATTEX 5MG INJ NDS PA
GENITOURINARY AGENTS - MISCELLANEOUSALKALINIZERS
1potassium citrate 10meq er tab
1potassium citrate 15meq er tab
1potassium citrate 5meq er tabCYSTINOSIS AGENTS
1CYSTAGON 150MG CAP
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
78
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1CYSTAGON 50MG CAPGENITOURINARY IRRIGANTS
1sodium chloride 0.154meq/ml solnINTERSTITIAL CYSTITIS AGENTS
1ELMIRON 100MG CAPPROSTATIC HYPERTROPHY AGENTS
1alfuzosin 10mg er tab
1dutasteride 0.5mg cap
1dutasteride 0.5mg/tamsulosin 0.4mg cap
1finasteride 5mg tab
1silodosin 4mg cap
1silodosin 8mg cap
1tamsulosin 0.4mg capURINARY STONE AGENTS
1LITHOSTAT 250MG TAB
1THIOLA 100MG DR TAB
1THIOLA 100MG TAB
1THIOLA 300MG DR TAB
GOUT AGENTSGOUT AGENT COMBINATIONS
1colchicine 0.5mg/probenecid 500mg tabGOUT AGENTS
1allopurinol 100mg tab
1allopurinol 300mg tab
1febuxostat 40mg tab ST
1febuxostat 80mg tab ST
1MITIGARE 0.6MG CAPURICOSURICS
1probenecid 500mg tab
HEMATOLOGICAL AGENTS - MISC.BRADYKININ B2 RECEPTOR ANTAGONISTS
1icatibant 10mg/ml syringe NDS PACOMPLEMENT INHIBITORS
1BERINERT 500UNIT INJ NDS PA
1CINRYZE 500UNIT INJ NDS PA
1HAEGARDA 2000UNIT INJ NDS PA
1HAEGARDA 3000UNIT INJ NDS PA
1RUCONEST 2100UNIT INJ NDS PAHEMATAOLOGIC - TYROSINE KINASE INHIBITORS
1TAVALISSE 100MG TAB NDS PA QL=60 EA/30 Days
1TAVALISSE 150MG TAB NDS PA QL=60 EA/30 DaysHEMATORHEOLOGIC AGENTS
1pentoxifylline 400mg er tabPLASMA KALLIKREIN INHIBITORS
1TAKHZYRO 300MG/2ML INJ NDS PA QL=4 ML/28 DaysPLATELET AGGREGATION INHIBITORS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
79
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1anagrelide 0.5mg cap
1anagrelide 1mg cap
1aspirin 25mg/dipyridamole 200mg er cap
1BRILINTA 60MG TAB
1BRILINTA 90MG TAB
1CABLIVI 11MG INJ NDS PA QL=30 EA/30 Days
1cilostazol 100mg tab
1cilostazol 50mg tab
1clopidogrel 75mg tab
1dipyridamole 25mg tab
1dipyridamole 50mg tab
1dipyridamole 75mg tab
1prasugrel 10mg tab
1prasugrel 5mg tab
HEMATOPOIETIC AGENTSAGENTS FOR GAUCHER DISEASE
1CERDELGA 84MG CAP NDS PA QL=60 EA/30 Days
1miglustat 100mg cap NDS PAAGENTS FOR SICKLE CELL ANEMIA
1DROXIA 200MG CAP
1DROXIA 300MG CAP
1DROXIA 400MG CAP
1ENDARI 5GM POWDER FOR ORAL SOLN NDS PA QL=180 EA/30 Days
1OXBRYTA 500MG TAB NDS PA QL=90 EA/30 DaysHEMATOPOIETIC GROWTH FACTORS
1ARANESP 100MCG/0.5ML SYRINGE PA BvD ST
1ARANESP 100MCG/ML INJ PA BvD ST
1ARANESP 10MCG/0.4ML SYRINGE PA BvD ST
1ARANESP 150MCG/0.3ML SYRINGE PA BvD ST
1ARANESP 200MCG/0.4ML SYRINGE PA BvD ST
1ARANESP 200MCG/ML INJ PA BvD ST
1ARANESP 25MCG/0.42ML SYRINGE PA BvD ST
1ARANESP 25MCG/ML INJ PA BvD ST
1ARANESP 300MCG/0.6ML SYRINGE PA BvD ST
1ARANESP 300MCG/ML INJ PA BvD ST
1ARANESP 40MCG/0.4ML SYRINGE PA BvD ST
1ARANESP 40MCG/ML INJ PA BvD ST
1ARANESP 500MCG/ML SYRINGE PA BvD ST
1ARANESP 60MCG/0.3ML SYRINGE PA BvD ST
1ARANESP 60MCG/ML INJ PA BvD ST
1DOPTELET 20MG TAB NDS PA QL=60 EA/30 Days
1DOPTELET 40MG DAILY DOSE PACK NDS PA QL=10 EA/5 Days
1DOPTELET 60MG DAILY DOSE PACK NDS PA QL=15 EA/5 Days
1FULPHILA 6MG/0.6ML SYRINGE NDS
1NIVESTYM 300MCG/0.5ML SYRINGE NDS
1NIVESTYM 300MCG/ML INJ NDS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
80
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1NIVESTYM 480MCG/0.8ML SYRINGE NDS
1NIVESTYM 480MCG/1.6ML INJ NDS
1PROMACTA 12.5MG POWDER FOR ORAL SUSP NDS PA
1PROMACTA 12.5MG TAB NDS PA
1PROMACTA 25MG POWDER FOR ORAL SUSP NDS PA
1PROMACTA 25MG TAB NDS PA
1PROMACTA 50MG TAB NDS PA
1PROMACTA 75MG TAB NDS PA
1RETACRIT 10000UNIT/ML INJ PA BvD
1RETACRIT 2000UNIT/ML INJ PA BvD
1RETACRIT 3000UNIT/ML INJ PA BvD
1RETACRIT 40000UNIT/ML INJ PA BvD
1RETACRIT 4000UNIT/ML INJ PA BvD
1ZARXIO 300MCG/0.5ML SYRINGE NDS
1ZARXIO 480MCG/0.8ML SYRINGE NDS
1ZIEXTENZO 6MG/0.6ML SYRINGE NDS
HEMOSTATICSHEMOSTATICS - SYSTEMIC
1tranexamic acid 650mg tab
HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTSBARBITURATE HYPNOTICS
1phenobarbital 100mg tab
1phenobarbital 15mg tab
1phenobarbital 16.2mg tab
1phenobarbital 30mg tab
1phenobarbital 32.4mg tab
1phenobarbital 4mg/ml oral soln
1phenobarbital 60mg tab
1phenobarbital 64.8mg tab
1phenobarbital 97.2mg tabNON-BARBITURATE HYPNOTICS
1estazolam 1mg tab
1estazolam 2mg tab
1eszopiclone 1mg tab QL=30 EA/30 Days
1eszopiclone 2mg tab QL=30 EA/30 Days
1eszopiclone 3mg tab QL=30 EA/30 Days
1FLURAZEPAM 15MG CAP
1FLURAZEPAM 30MG CAP
1temazepam 15mg cap
1temazepam 22.5mg cap
1temazepam 30mg cap
1temazepam 7.5mg cap
1triazolam 0.125mg tab
1triazolam 0.25mg tab
1zaleplon 10mg cap QL=30 EA/30 Days
1zaleplon 5mg cap QL=30 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
81
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1zolpidem tartrate 10mg tab QL=30 EA/30 Days
1zolpidem tartrate 5mg tab QL=60 EA/30 DaysSELECTIVE MELATONIN RECEPTOR AGONISTS
1HETLIOZ 20MG CAP NDS PA QL=30 EA/30 Days
1ramelteon 8mg tab QL=30 EA/30 Days
LAXATIVESLAXATIVE COMBINATIONS
1CLENPIQ 75-21.9-0.0625MG/ML ORAL SOLN
1GAVILYTE-C ORAL SOLN
1gavilyte-g powder for oral soln
1gavilyte-n powder for oral soln
1peg 3350/electrolyte oral soln
1peg 3350/kcl/sodium bicarbonate/sodium chloride powder for oral soln
1trilyte powder for oral solnLAXATIVES - MISCELLANEOUS
1constulose 10gm/15ml oral soln
1lactulose 667mg/ml oral soln
MACROLIDESAZITHROMYCIN
1azithromycin 20mg/ml susp
1azithromycin 250mg pack
1azithromycin 250mg tab
1azithromycin 40mg/ml susp
1azithromycin 500mg inj
1azithromycin 500mg pack
1azithromycin 500mg tab
1azithromycin 600mg tabCLARITHROMYCIN
1clarithromycin 250mg tab
1CLARITHROMYCIN 25MG/ML SUSP
1clarithromycin 500mg er tab
1clarithromycin 500mg tab
1CLARITHROMYCIN 50MG/ML SUSPERYTHROMYCINS
1ERYTHROCIN 500MG INJ
1erythromycin 250mg dr cap
1erythromycin 250mg tab
1erythromycin 500mg tab
1erythromycin ethylsuccinate 40mg/ml susp
1erythromycin ethylsuccinate 80mg/ml susp
MEDICAL DEVICESPARENTERAL THERAPY SUPPLIES
1INSULIN SYRINGE (DISP) U-100 1/2ML
MEDICAL DEVICES AND SUPPLIES
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
82
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
BANDAGES-DRESSINGS-TAPE
1GAUZE PADS & DRESSINGS - PADS 2 X 2MISC. DEVICES
1ISOPROPYL ALCOHOL 0.7ML/ML PADPARENTERAL THERAPY SUPPLIES
1INSULIN PEN NEEDLE
1INSULIN SYRINGE (DISP) U-100 0.3ML
1INSULIN SYRINGE (DISP) U-100 1ML
1NEEDLES INSULIN DISP. SAFETY
MIGRAINE PRODUCTSCALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG
1AIMOVIG 140MG/ML AUTO-INJECTOR PA
1AIMOVIG 70MG/ML AUTO-INJECTOR PA
1EMGALITY 100MG/ML SYRINGE PA
1EMGALITY 120MG/ML AUTO-INJECTOR PA
1EMGALITY 120MG/ML SYRINGE PAMIGRAINE PRODUCTS
1dihydroergotamine mesylate 0.5mg/act nasal inhaler QL=16 ML/30 DaysSEROTONIN AGONISTS
1eletriptan 20mg tab QL=18 EA/30 Days
1eletriptan 40mg tab QL=18 EA/30 Days
1naratriptan 1mg tab QL=18 EA/30 Days
1naratriptan 2.5mg tab QL=18 EA/30 Days
1rizatriptan 10mg odt QL=36 EA/60 Days
1rizatriptan 10mg tab QL=36 EA/60 Days
1rizatriptan 5mg odt QL=36 EA/60 Days
1rizatriptan 5mg tab QL=36 EA/60 Days
1sumatriptan 100mg tab QL=18 EA/30 Days
1sumatriptan 12mg/ml auto-injector QL=5 ML/30 Days
1sumatriptan 12mg/ml cartridge QL=5 ML/30 Days
1sumatriptan 12mg/ml inj QL=5 ML/30 Days
1SUMATRIPTAN 12MG/ML SYRINGE QL=5 ML/30 Days
1sumatriptan 20mg/act nasal spray QL=12 EA/30 Days
1sumatriptan 25mg tab QL=18 EA/30 Days
1sumatriptan 50mg tab QL=18 EA/30 Days
1sumatriptan 5mg/act nasal spray QL=12 EA/30 Days
1sumatriptan 8mg/ml auto-injector QL=5 ML/30 Days
1sumatriptan 8mg/ml cartridge QL=5 ML/30 Days
1zolmitriptan 2.5mg odt QL=18 EA/30 Days
1zolmitriptan 2.5mg tab QL=18 EA/30 Days
1zolmitriptan 5mg odt QL=18 EA/30 Days
1zolmitriptan 5mg tab QL=18 EA/30 Days
1ZOMIG 2.5MG NASAL SPRAY QL=16 EA/30 Days
1ZOMIG 5MG NASAL SPRAY QL=12 EA/30 Days
MINERALS & ELECTROLYTESELECTROLYTE MIXTURES
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
83
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1GLUCOSE 100MG/ML/SODIUM CHLORIDE 0.0342 MEQ/ML INJ
PA BvD
1GLUCOSE 100MG/ML/SODIUM CHLORIDE 0.0769 MEQ/ML INJ
PA BvD
1GLUCOSE 25MG/ML/SODIUM CHLORIDE 0.0769 MEQ/ML INJ
1glucose 50 mg/ml/potassium chloride 0.04meq/ml/sodium chloride 4.5mg/ml inj
1glucose 50mg/ml/potassium chloride 0.01 meq/ml/sodium chloride 0.0769 meq/ml inj
1glucose 50mg/ml/potassium chloride 0.02 meq/ml inj
1glucose 50mg/ml/potassium chloride 0.02 meq/ml/sodium chloride 0.0342 meq/ml inj
1glucose 50mg/ml/potassium chloride 0.02 meq/ml/sodium chloride 0.154 meq/ml inj
1glucose 50mg/ml/potassium chloride 0.02meq/ml/sodium chloride 4.5mg/ml inj
1glucose 50mg/ml/potassium chloride 0.03 meq/ml/sodium chloride 0.0769 meq/ml inj
1GLUCOSE 50MG/ML/POTASSIUM CHLORIDE 0.04 MEQ/ML/SODIUM CHLORIDE 0.154 MEQ/ML INJ
1glucose 50mg/ml/sodium chloride 0.0342 meq/ml inj
1GLUCOSE 50MG/ML/SODIUM CHLORIDE 0.0385 MEQ/ML INJ
1glucose 50mg/ml/sodium chloride 4.5mg/ml inj
1glucose 50mg/ml/sodium chloride 9mg/ml inj
1ISOLYTE P INJ
1ISOLYTE S INJ
1KCL/D5W/LR INJ 0.15%
1NORMOSOL-M INJ
1NORMOSOL-R INJ
1PLASMA-LYTE 148 INJ
1PLASMALYTE A INJ
1potassium chloride 0.02 meq/ml/sodium chloride 0.0769 meq/ml inj
1potassium chloride 0.02 meq/ml/sodium chloride 0.154 meq/ml inj
1POTASSIUM CHLORIDE 0.04 MEQ/ML/SODIUM CHLORIDE 0.154 MEQ/ML INJ
MAGNESIUM
1magnesium sulfate 500mg/ml inj
1magnesium sulfate 500mg/ml syringePOTASSIUM
1K-TAB 8MEQ ER TAB
1klor-con 10meq er tab
1klor-con 10meq micro er tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
84
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1KLOR-CON 15MEQ MICRO ER TAB
1klor-con 20meq micro er tab
1klor-con 20meq powder for oral soln
1klor-con 8meq er tab
1POTASSIUM CHLORIDE 0.1MEQ/ML INJ
1POTASSIUM CHLORIDE 0.2MEQ/ML INJ
1POTASSIUM CHLORIDE 0.4MEQ/ML INJ
1potassium chloride 1.33meq/ml oral soln
1potassium chloride 10meq er cap
1potassium chloride 10meq er tab
1potassium chloride 10meq micro er tab
1potassium chloride 2.67meq/ml oral soln
1potassium chloride 20meq er tab
1potassium chloride 20meq micro er tab
1potassium chloride 20meq powder for oral soln
1potassium chloride 2meq/ml (20ml) inj
1potassium chloride 2meq/ml inj
1potassium chloride 8meq er cap
1potassium chloride 8meq er tabSODIUM
1sodium chloride 30mg/ml inj
1sodium chloride 4.5mg/ml inj
1sodium chloride 50mg/ml inj
1sodium chloride 9mg/ml inj
MISCELLANEOUS THERAPEUTIC CLASSESCHELATING AGENTS
1clovique 250mg cap PA
1penicillamine 250mg tab
1trientine 250mg cap PAIMMUNOMODULATORS
1REVLIMID 10MG CAP NDS PA NSO QL=30 EA/30 Days
1REVLIMID 15MG CAP NDS PA NSO QL=30 EA/30 Days
1REVLIMID 2.5MG CAP NDS PA NSO QL=30 EA/30 Days
1REVLIMID 20MG CAP NDS PA NSO QL=30 EA/30 Days
1REVLIMID 25MG CAP NDS PA NSO QL=30 EA/30 Days
1REVLIMID 5MG CAP NDS PA NSO QL=30 EA/30 Days
1THALOMID 100MG CAP NDS PA NSO
1THALOMID 150MG CAP NDS PA NSO
1THALOMID 200MG CAP NDS PA NSO
1THALOMID 50MG CAP NDS PA NSOIMMUNOSUPPRESSIVE AGENTS
1ASTAGRAF 0.5MG ER CAP PA BvD
1ASTAGRAF 1MG ER CAP PA BvD
1ASTAGRAF 5MG ER CAP PA BvD
1azathioprine 50mg tab PA BvD
1cyclosporine modified 100mg/ml oral soln PA BvD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
85
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1cyclosporine modified 50mg cap PA BvD
1ENVARSUS 0.75MG ER TAB PA BvD
1ENVARSUS 1MG ER TAB PA BvD
1ENVARSUS 4MG ER TAB PA BvD
1everolimus 0.25mg tab PA BvD
1everolimus 0.5mg tab PA BvD
1everolimus 0.75mg tab PA BvD
1mycophenolic acid 180mg dr tab PA BvD
1mycophenolic acid 360mg dr tab PA BvD
1PROGRAF 0.2MG GRANULES FOR ORAL SUSP PA BvD
1PROGRAF 1MG GRANULES FOR ORAL SUSP PA BvD
1sirolimus 1mg/ml oral soln PA BvDPOTASSIUM REMOVING AGENTS
1kionex 15gm/60ml susp
1LOKELMA 10GM POWDER FOR ORAL SUSP PA
1LOKELMA 5GM POWDER FOR ORAL SUSP PA
1sodium polystyrene sulfonate 15000mg powder for oral susp
1sodium polystyrene sulfonate 250mg/ml susp
1sps 15gm/60ml susp
1VELTASSA 16.8GM POWDER FOR ORAL SUSP PA
1VELTASSA 25.2GM POWDER FOR ORAL SUSP PA
1VELTASSA 8.4GM POWDER FOR ORAL SUSP PASYSTEMIC LUPUS ERYTHEMATOSUS AGENTS
1BENLYSTA 200MG/ML AUTO-INJECTOR NDS PA QL=4 ML/28 Days
1BENLYSTA 200MG/ML SYRINGE NDS PA QL=4 ML/28 Days
MOUTH/THROAT/DENTAL AGENTSANESTHETICS TOPICAL ORAL
1lidocaine 2% topical solnANTI-INFECTIVES - THROAT
1clotrimazole 10mg lozenge
1nystatin 100000unit/ml suspANTISEPTICS - MOUTH/THROAT
1chlorhexidine gluconate 0.12% mouthwashSTEROIDS - MOUTH/THROAT/DENTAL
1triamcinolone acetonide 0.1% oral pasteTHROAT PRODUCTS - MISC.
1cevimeline 30mg cap
1pilocarpine 5mg tab
1pilocarpine 7.5mg tab
MUSCULOSKELETAL THERAPY AGENTSCENTRAL MUSCLE RELAXANTS
1baclofen 10mg tab
1baclofen 20mg tab
1carisoprodol 350mg tab
1chlorzoxazone 500mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
86
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1cyclobenzaprine 10mg tab
1cyclobenzaprine 5mg tab
1METAXALONE 400MG TAB
1metaxalone 800mg tab
1methocarbamol 500mg tab
1methocarbamol 750mg tab
1orphenadrine citrate 100mg er tab
1tizanidine 2mg cap
1tizanidine 2mg tab
1tizanidine 4mg cap
1tizanidine 4mg tab
1tizanidine 6mg capDIRECT MUSCLE RELAXANTS
1dantrolene sodium 100mg cap
1dantrolene sodium 25mg cap
1dantrolene sodium 50mg cap
NASAL AGENTS - SYSTEMIC AND TOPICALNASAL ANTIALLERGY
1azelastine 0.137mg/act nasal inhaler
1azelastine 0.206mg/act nasal inhaler
1olopatadine 0.665mg/act nasal inhalerNASAL ANTICHOLINERGICS
1ipratropium bromide 0.021mg/act nasal inhaler
1ipratropium bromide 0.042mg/act nasal inhalerNASAL STEROIDS
1FLUNISOLIDE 0.025MG/ACT NASAL INHALER QL=50 ML/30 Days
1fluticasone propionate 0.05mg/act nasal inhaler QL=32 GM/30 Days
NEUROMUSCULAR AGENTSALS AGENTS
1riluzole 50mg tab
NUTRIENTSCARBOHYDRATES
1glucose 100mg/ml inj PA BvD
1glucose 50mg/ml injLIPIDS
1INTRALIPID 20GM/100ML INJ PA BvD
1NUTRILIPID 20GM/100ML INJ PA BvDPROTEINS
1AMINOSYN II 10% INJ PA BvD
1AMINOSYN-PF 7% INJ PA BvD
1CLINIMIX 4.25/10 INJ PA BvD
1CLINIMIX 4.25/5 INJ PA BvD
1CLINIMIX 5/15 INJ PA BvD
1CLINIMIX 5/20 INJ PA BvD
1CLINIMIX E 2.75/5 INJ PA BvD
1CLINIMIX E 4.25/10 INJ PA BvD
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
87
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1CLINIMIX E 4.25/5 INJ PA BvD
1CLINIMIX E 5/15 INJ PA BvD
1CLINIMIX E 5/20 INJ PA BvD
1clinisol 15% inj PA BvD
1FREAMINE 6.9% INJ PA BvD
1HEPATAMINE 8% INJ PA BvD
1NEPHRAMINE 5.4% INJ PA BvD
1plenamine 15% inj PA BvD
1PREMASOL 10% INJ PA BvD
1PROCALAMINE 3% INJ PA BvD
1PROSOL 20% INJ PA BvD
1TRAVASOL 10% INJ PA BvD
1TROPHAMINE 10% INJ PA BvD
OPHTHALMIC AGENTSBETA-BLOCKERS - OPHTHALMIC
1betaxolol 0.5% ophth soln
1BETIMOL 0.25% OPHTH SOLN
1BETIMOL 0.5% OPHTH SOLN
1BETOPTIC S 0.25% OPHTH SUSP
1CARTEOLOL 1% OPHTH SOLN
1COMBIGAN 2-5MG/ML OPHTH SOLN
1dorzolamide 20mg/ml/timolol 5mg/ml ophth soln
1dorzolamide/timolol 22.3-6.8mg/ml ophth soln (preservative-free)
1LEVOBUNOLOL 0.5% OPHTH SOLN
1TIMOLOL 0.25% OPHTH GEL
1timolol 0.25% ophth soln
1TIMOLOL 0.5% OPHTH GEL
1timolol 0.5% ophth soln
1timolol 5mg/ml ophth 24hr ophth soln
1TIMOPTIC 0.25% OPHTH GEL
1TIMOPTIC 0.5% OPHTH GELCYCLOPLEGIC MYDRIATICS
1ATROPINE SULFATE 1% OPHTH SOLNMIOTICS
1PHOSPHOLINE IODIDE 0.125% OPHTH SOLN
1pilocarpine 1% ophth soln
1pilocarpine 2% ophth soln
1pilocarpine 4% ophth solnOPHTHALMIC ADRENERGIC AGENTS
1ALPHAGAN 0.1% OPHTH SOLN
1apraclonidine 0.5% ophth soln
1brimonidine tartrate 0.15% ophth soln
1brimonidine tartrate 0.2% ophth soln
1IOPIDINE 1% OPHTH SOLN
1SIMBRINZA 0.2-1% OPHTH SUSP
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
88
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
OPHTHALMIC ANTI-INFECTIVES
1AZASITE 1% OPHTH SOLN
1BACITRACIN 0.5UNIT/MG OPHTH OINTMENT
1bacitracin 0.5unit/mg/polymyxin b 10unit/mg ophth ointment
QL=7 GM/7 Days
1ciprofloxacin 0.3% ophth soln QL=60 ML/30 Days
1erythromycin 0.5% ophth ointment QL=7 GM/7 Days
1gatifloxacin 0.5% ophth soln QL=5 ML/7 Days
1GENTAK 0.3% OPHTH OINTMENT QL=7 GM/7 Days
1gentamicin 0.3% ophth soln QL=10 ML/7 Days
1GRAMICIDIN 0.025MG/ML/NEOMYCIN 1.75MG/ML/POLYMYXIN B 10000UNIT/ML OPHTH SOLN
QL=10 ML/7 Days
1levofloxacin 0.5% ophth soln QL=60 ML/30 Days
1moxifloxacin 0.5% ophth soln QL=6 ML/7 Days
1NATACYN 5% OPHTH SUSP QL=15 ML/7 Days
1neomycin/bacitracin/polymyxin ophth ointment 5(3.5)mg-400unit-10000unit
QL=7 GM/7 Days
1ofloxacin 0.3% ophth soln QL=60 ML/30 Days
1polymyxin b 10000unit/ml/trimethoprim 1mg/ml ophth soln
QL=10 ML/7 Days
1SULFACETAMIDE SODIUM 10% OPHTH OINTMENT QL=7 GM/7 Days
1sulfacetamide sodium 10% ophth soln QL=15 ML/7 Days
1tobramycin 0.3% ophth soln QL=60 ML/30 Days
1TRIFLURIDINE 1% OPHTH SOLN QL=15 ML/7 Days
1ZIRGAN 0.15% OPHTH GEL QL=10 GM/7 DaysOPHTHALMIC IMMUNOMODULATORS
1RESTASIS 0.05% OPHTH SUSPOPHTHALMIC KINASE INHIBITORS
1RHOPRESSA 0.02% OPHTH SOLN QL=5 ML/30 Days
1ROCKLATAN 0.05-0.2MG/ML OPHTH SOLN QL=5 ML/30 DaysOPHTHALMIC LOCAL ANESTHETICS
1proparacaine 0.5% ophth solnOPHTHALMIC NERVE GROWTH FACTORS
1OXERVATE 0.002% OPHTH SOLN NDS PA QL=112 ML/365 DaysOPHTHALMIC STEROIDS
1ALREX 0.2% OPHTH SUSP
1BLEPHAMIDE 0.2-10% OPHTH SUSP
1DEXAMETHASONE PHOSPHATE 0.1% OPHTH SOLN
1dexamethasone/neomycin/polymyxin b 0.1% ophth ointment
1dexamethasone/neomycin/polymyxin b 0.1% ophth susp
1dexamethasone/tobramycin 0.3-0.1% ophth susp
1DUREZOL 0.05% OPHTH SUSP
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
89
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1fluorometholone 0.1% ophth susp
1hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml ophth susp
1LOTEMAX 0.5% OPHTH GEL
1LOTEMAX 0.5% OPHTH OINTMENT
1loteprednol etabonate 0.5% ophth susp
1MAXIDEX 0.1% OPHTH SUSP
1neomycin/polymyxin/bacitracin/hydrocortisone ophth ointmentment 1%
1PRED MILD 0.12% OPHTH SUSP
1PRED-G 0.3-1% OPHTH SUSP
1PREDNISOLONE 1% OPHTH SOLN
1PREDNISOLONE ACETATE 1% OPHTH SUSP
1PREDNISOLONE SODIUM PHOSPHATE 2.5MG/ML/SULFACETAMIDE SODIUM 100MG/ML OPHTH SOLN
1TOBRADEX 0.1-0.3% OPHTH OINTMENT
1ZYLET 0.5-0.3% OPHTH SUSPOPHTHALMICS - MISC.
1ALOCRIL 2% OPHTH SOLN
1ALOMIDE 0.1% OPHTH SOLN
1azelastine 0.05% ophth soln
1AZOPT 1% OPHTH SUSP
1bromfenac 0.09% ophth soln
1cromolyn sodium 4% ophth soln
1CYSTARAN 0.44% OPHTH SOLN NDS PA QL=60 ML/30 Days
1diclofenac sodium 0.1% ophth soln
1dorzolamide 2% ophth soln
1epinastine 0.05% ophth soln
1FLURBIPROFEN SODIUM 0.03% OPHTH SOLN
1ILEVRO 0.3% OPHTH SUSP
1ketorolac tromethamine 0.4% ophth soln
1ketorolac tromethamine 0.5% ophth soln
1NEVANAC 0.1% OPHTH SUSP
1olopatadine 0.1% ophth soln
1olopatadine 0.2% ophth solnPROSTAGLANDINS - OPHTHALMIC
1bimatoprost 0.03% ophth soln QL=5 ML/30 Days
1latanoprost 0.005% ophth soln QL=5 ML/30 Days
1LUMIGAN 0.01% OPHTH SOLN QL=5 ML/30 Days
1travoprost 0.004% ophth soln QL=5 ML/30 Days
OTIC AGENTSOTIC AGENTS - MISCELLANEOUS
1acetic acid 2% otic solnOTIC ANTI-INFECTIVES
1CETRAXAL 0.2% OTIC SOLN
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
90
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1CIPROFLOXACIN 0.2% OTIC SOLN
1ofloxacin 0.3% otic solnOTIC COMBINATIONS
1CIPRODEX 0.3-0.1% OTIC SUSP
1hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml otic soln
1hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml otic susp
OTIC STEROIDS
1acetic acid/hydrocortisone 1-2% otic soln
1flac 0.01% otic soln
1fluocinolone acetonide 0.01% otic soln
PASSIVE IMMUNIZING AND TREATMENT AGENTSIMMUNE SERUMS
1BIVIGAM 5GM/50ML INJ NDS PA
1FLEBOGAMMA 5GM/50ML INJ NDS PA
1GAMMAGARD 10GM INJ NDS PA
1GAMMAGARD 2.5GM/25ML INJ NDS PA
1GAMMAGARD 5GM INJ NDS PA
1GAMMAKED 1GM/10ML INJ NDS PA
1GAMMAPLEX 10GM/100ML INJ NDS PA
1GAMMAPLEX 10GM/200ML INJ NDS PA
1GAMMAPLEX 20GM/200ML INJ NDS PA
1GAMMAPLEX 5GM/50ML INJ NDS PA
1GAMUNEX 1GM/10ML INJ NDS PA
1OCTAGAM 1GM/20ML INJ NDS PA
1OCTAGAM 2GM/20ML INJ NDS PA
1PANZYGA 10GM/100ML INJ NDS PA
1PANZYGA 1GM/10ML INJ NDS PA
1PANZYGA 2.5GM/25ML INJ NDS PA
1PANZYGA 20GM/200ML INJ NDS PA
1PANZYGA 30GM/300ML INJ NDS PA
1PANZYGA 5GM/50ML INJ NDS PA
1PRIVIGEN 20GM/200ML INJ NDS PA
1VARIZIG 125UNIT/1.2ML INJ NDS
PENICILLINSAMINOPENICILLINS
1amoxicillin 125mg chew tab
1amoxicillin 250mg cap
1AMOXICILLIN 250MG CHEW TAB
1amoxicillin 25mg/ml susp
1amoxicillin 40mg/ml susp
1amoxicillin 500mg cap
1amoxicillin 500mg tab
1amoxicillin 50mg/ml susp
1amoxicillin 80mg/ml susp
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
91
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1amoxicillin 875mg tab
1ampicillin 1000mg inj
1ampicillin 100mg/ml inj
1AMPICILLIN 125MG INJ
1AMPICILLIN 500MG CAPNATURAL PENICILLINS
1BICILLIN L-A 1200000UNIT/2ML SYRINGE
1BICILLIN L-A 2400000UNIT/4ML SYRINGE
1BICILLIN L-A 600000UNIT/ML SYRINGE
1penicillin g potassium 1000000unit/ml inj
1PENICILLIN G POTASSIUM 40000UNIT/ML INJ
1PENICILLIN G POTASSIUM 60000UNIT/ML INJ
1PENICILLIN G PROCAINE 600000UNIT/ML SYRINGE
1PENICILLIN G SODIUM 100000UNIT/ML INJ
1penicillin v potassium 250mg tab
1PENICILLIN V POTASSIUM 25MG/ML ORAL SOLN
1penicillin v potassium 500mg tab
1PENICILLIN V POTASSIUM 50MG/ML ORAL SOLNPENICILLIN COMBINATIONS
1AMOXICILLIN 1000MG/CLAVULANATE 62.5MG ER TAB
1amoxicillin 120mg/ml/clavulanate 8.58mg/ml susp
1AMOXICILLIN 200MG/CLAVULANATE 28.5MG CHEW TAB
1amoxicillin 250mg/clavulanate 125mg tab
1AMOXICILLIN 400MG/CLAVULANATE 57MG CHEW TAB
1amoxicillin 40mg/ml/clavulanate 5.7mg/ml susp
1amoxicillin 500mg/clavulanate 125mg tab
1amoxicillin 50mg/ml/clavulanate 12.5mg/ml susp
1amoxicillin 80mg/ml/clavulanate 11.4mg/ml susp
1amoxicillin 875mg/clavulanate 125mg tab
1ampicillin 1000mg/sulbactam 500mg inj
1ampicillin 100mg/ml/sulbactam 50mg/ml inj
1ampicillin 2000mg/sulbactam 1000mg inj
1BICILLIN 300000-300000UNIT/ML SYRINGE
1BICILLIN 450000-150000UNIT/ML SYRINGE
1piperacillin 2000mg/tazobactam 250mg inj
1piperacillin 200mg/ml/tazobactam 25mg/ml inj
1piperacillin 3000mg/tazobactam 375mg inj
1piperacillin 4000mg/tazobactam 500mg inj
1ZOSYN 2000-250MG INJ
1ZOSYN 3000-375MG INJPENICILLINASE-RESISTANT PENICILLINS
1dicloxacillin 250mg cap
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
92
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1dicloxacillin 500mg cap
1nafcillin 1000mg inj
1nafcillin 100mg/ml inj
1nafcillin 2000mg inj
1oxacillin 1000mg inj
1oxacillin 100mg/ml inj
1oxacillin 2000mg inj
1OXACILLIN 20MG/ML INJ
1OXACILLIN 40MG/ML INJ
PROGESTINSPROGESTINS
1medroxyprogesterone acetate 10mg tab
1medroxyprogesterone acetate 2.5mg tab
1medroxyprogesterone acetate 5mg tab
1megestrol acetate 125mg/ml susp PA
1norethindrone acetate 5mg tab
1progesterone 100mg cap
1progesterone 200mg cap
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.AGENTS FOR CHEMICAL DEPENDENCY
1acamprosate calcium 333mg dr tab
1disulfiram 250mg tab
1disulfiram 500mg tabANTI-CATAPLECTIC AGENTS
1XYREM 500MG/ML ORAL SOLN NDS PA QL=540 ML/30 DaysANTIDEMENTIA AGENTS
1donepezil 10mg odt QL=30 EA/30 Days
1donepezil 10mg tab
1donepezil 23mg tab QL=30 EA/30 Days
1donepezil 5mg odt QL=30 EA/30 Days
1donepezil 5mg tab
1galantamine 12mg tab
1galantamine 4mg tab
1galantamine 8mg tab
1galantamine hydrobromide 16mg er cap
1galantamine hydrobromide 24mg er cap
1GALANTAMINE HYDROBROMIDE 4MG/ML ORAL SOLN
1galantamine hydrobromide 8mg er cap
1memantine 10mg tab
1memantine 10mg/memantine 5mg pack
1memantine 14mg er cap
1memantine 21mg er cap
1memantine 28mg er cap
1memantine 2mg/ml oral soln
1memantine 5mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
93
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1memantine 7mg er cap
1rivastigmine 0.192mg/hr patch
1rivastigmine 0.396mg/hr patch
1rivastigmine 0.554mg/hr patch
1rivastigmine 1.5mg cap
1rivastigmine 3mg cap
1rivastigmine 4.5mg cap
1rivastigmine 6mg capCOMBINATION PSYCHOTHERAPEUTICS
1AMITRIPTYLINE 10MG/PERPHENAZINE 2MG TAB
1AMITRIPTYLINE 10MG/PERPHENAZINE 4MG TAB
1amitriptyline 12.5mg/chlordiazepoxide 5mg tab
1amitriptyline 25mg/chlordiazepoxide 10mg tab
1AMITRIPTYLINE 25MG/PERPHENAZINE 2MG TAB
1AMITRIPTYLINE 25MG/PERPHENAZINE 4MG TAB
1AMITRIPTYLINE 50MG/PERPHENAZINE 4MG TAB
1fluoxetine 25mg/olanzapine 12mg cap
1fluoxetine 25mg/olanzapine 3mg cap
1fluoxetine 25mg/olanzapine 6mg cap
1fluoxetine 50mg/olanzapine 12mg cap
1fluoxetine 50mg/olanzapine 6mg capFIBROMYALGIA AGENTS
1SAVELLA 100MG TAB QL=60 EA/30 Days
1SAVELLA 12.5MG TAB QL=60 EA/30 Days
1SAVELLA 25MG TAB QL=60 EA/30 Days
1SAVELLA 4-WEEK TITRATION PACK
1SAVELLA 50MG TAB QL=60 EA/30 DaysMOVEMENT DISORDER DRUG THERAPY
1AUSTEDO 12MG TAB NDS PA
1AUSTEDO 6MG TAB NDS PA
1AUSTEDO 9MG TAB NDS PA
1INGREZZA 40MG CAP NDS PA
1INGREZZA 80MG CAP NDS PA
1tetrabenazine 12.5mg tab PA
1tetrabenazine 25mg tab PAMULTIPLE SCLEROSIS AGENTS
1AUBAGIO 14MG TAB NDS
1AUBAGIO 7MG TAB NDS
1AVONEX 30MCG/0.5ML AUTO-INJECTOR NDS
1AVONEX 30MCG/0.5ML SYRINGE NDS
1dalfampridine 10mg er tab QL=60 EA/30 Days
1EXTAVIA 0.3MG INJ NDS
1GILENYA 0.5MG CAP NDS
1glatiramer acetate 20mg/ml syringe
1glatiramer acetate 40mg/ml syringe
1glatopa 20mg/ml syringe
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
94
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1glatopa 40mg/ml syringe
1MAYZENT 0.25MG TAB NDS
1MAYZENT 2MG TAB NDS
1PLEGRIDY 125MCG/0.5ML AUTO-INJECTOR NDS
1PLEGRIDY 125MCG/0.5ML SYRINGE NDS
1PLEGRIDY PEN STARTER PACK NDS
1PLEGRIDY STARTER PACK NDS
1REBIF 22MCG/0.5ML AUTO-INJECTOR NDS
1REBIF 22MCG/0.5ML SYRINGE NDS
1REBIF 44MCG/0.5ML AUTO-INJECTOR NDS
1REBIF 44MCG/0.5ML SYRINGE NDS
1REBIF REBIDOSE PACK NDS
1REBIF TITRATION PACK NDS
1TECFIDERA 120MG DR CAP NDS
1TECFIDERA 240MG DR CAP NDS
1TECFIDERA 30-DAY STARTER PACK NDSPSEUDOBULBAR AFFECT (PBA) AGENTS
1NUEDEXTA 20-10MG CAP PA QL=60 EA/30 DaysPSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
1ERGOLOID MESYLATES USP 1MG TAB
1PIMOZIDE 1MG TAB
1PIMOZIDE 2MG TABSMOKING DETERRENTS
1bupropion 150mg sr tab
1CHANTIX 0.5MG TAB
1CHANTIX 1MG TAB
1CHANTIX CONTINUING MONTHS OF THERAPY 1MG PACK
1CHANTIX FIRST MONTH OF THERAPY PACK
1NICOTROL 10MG INH SOLN
1NICOTROL 10MG/ML NASAL INHALERTRANSTHYRETIN AMYLOIDOSIS AGENTS
1TEGSEDI 284MG/1.5ML SYRINGE NDS PA QL=6 ML/28 Days
RESPIRATORY AGENTS - MISC.ALPHA-PROTEINASE INHIBITOR (HUMAN)
1ARALAST 1000MG INJ NDS
1GLASSIA 1000MG/50ML INJ NDS
1PROLASTIN 1000MG INJ NDS
1ZEMAIRA 1000MG INJ NDSCYSTIC FIBROSIS AGENTS
1KALYDECO 150MG TAB NDS PA QL=60 EA/30 Days
1KALYDECO 25MG GRANULES NDS PA QL=60 EA/30 Days
1KALYDECO 50MG GRANULES NDS PA QL=60 EA/30 Days
1KALYDECO 75MG GRANULES NDS PA QL=60 EA/30 Days
1ORKAMBI 125-100MG GRANULES NDS PA QL=60 EA/30 Days
1ORKAMBI 125-100MG TAB NDS PA QL=120 EA/30 Days
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
95
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1ORKAMBI 125-200MG TAB NDS PA QL=120 EA/30 Days
1ORKAMBI 188-150MG GRANULES NDS PA QL=60 EA/30 Days
1PULMOZYME 1MG/ML INH SOLN NDS PA BvD
1SYMDEKO 50-75MG/75MG PACK NDS PA QL=60 EA/30 Days
1SYMDEKO TAB 4-WEEK PACK NDS PA QL=60 EA/30 Days
1TRIKAFTA 100-50-75MG/150MG PACK NDS PA QL=90 EA/30 DaysPULMONARY FIBROSIS AGENTS
1ESBRIET 267MG CAP NDS PA
1ESBRIET 267MG TAB NDS PA
1ESBRIET 801MG TAB NDS PA
1OFEV 100MG CAP NDS PA
1OFEV 150MG CAP NDS PA
SULFONAMIDESSULFONAMIDES
1SULFADIAZINE 500MG TAB
TETRACYCLINESAMINOMETHYLCYCLINES
1NUZYRA 150MG TAB NDS PA QL=30 EA/14 DaysGLYCYLCYCLINES
1TIGECYCLINE 50MG INJ NDSTETRACYCLINES
1demeclocycline 150mg tab
1demeclocycline 300mg tab
1doxy 100mg inj
1doxycycline hyclate 100mg cap
1doxycycline hyclate 100mg tab
1doxycycline hyclate 20mg tab
1doxycycline hyclate 50mg cap
1doxycycline monohydrate 100mg cap
1doxycycline monohydrate 100mg tab
1doxycycline monohydrate 50mg cap
1doxycycline monohydrate 50mg tab
1doxycycline monohydrate 5mg/ml susp
1minocycline 100mg cap
1minocycline 100mg tab
1minocycline 50mg cap
1minocycline 50mg tab
1minocycline 75mg cap
1minocycline 75mg tab
1mondoxyne 100mg cap
1tetracycline 250mg cap
1tetracycline 500mg cap
THYROID AGENTSANTITHYROID AGENTS
1methimazole 10mg tab
1methimazole 5mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
96
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1propylthiouracil 50mg tabTHYROID HORMONES
1euthyrox 100mcg tab
1euthyrox 112mcg tab
1euthyrox 125mcg tab
1euthyrox 137mcg tab
1euthyrox 150mcg tab
1euthyrox 175mcg tab
1euthyrox 200mcg tab
1euthyrox 25mcg tab
1euthyrox 50mcg tab
1euthyrox 75mcg tab
1euthyrox 88mcg tab
1levo-t 100mcg tab
1levo-t 112mcg tab
1levo-t 125mcg tab
1levo-t 137mcg tab
1levo-t 150mcg tab
1levo-t 175mcg tab
1levo-t 200mcg tab
1levo-t 25mcg tab
1levo-t 300mcg tab
1levo-t 50mcg tab
1levo-t 75mcg tab
1levo-t 88mcg tab
1levothyroxine sodium 0.025mg tab
1levothyroxine sodium 0.05mg tab
1levothyroxine sodium 0.075mg tab
1levothyroxine sodium 0.088mg tab
1levothyroxine sodium 0.112mg tab
1levothyroxine sodium 0.125mg tab
1levothyroxine sodium 0.137mg tab
1levothyroxine sodium 0.15mg tab
1levothyroxine sodium 0.175mg tab
1levothyroxine sodium 0.1mg tab
1levothyroxine sodium 0.2mg tab
1levothyroxine sodium 0.3mg tab
1levoxyl 100mcg tab
1levoxyl 112mcg tab
1levoxyl 125mcg tab
1levoxyl 137mcg tab
1levoxyl 150mcg tab
1levoxyl 175mcg tab
1levoxyl 200mcg tab
1levoxyl 25mcg tab
1levoxyl 50mcg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
97
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1levoxyl 75mcg tab
1levoxyl 88mcg tab
1liothyronine sodium 0.005mg tab
1liothyronine sodium 0.025mg tab
1liothyronine sodium 0.05mg tab
1SYNTHROID 100MCG TAB
1SYNTHROID 112MCG TAB
1SYNTHROID 125MCG TAB
1SYNTHROID 137MCG TAB
1SYNTHROID 150MCG TAB
1SYNTHROID 175MCG TAB
1SYNTHROID 200MCG TAB
1SYNTHROID 25MCG TAB
1SYNTHROID 300MCG TAB
1SYNTHROID 50MCG TAB
1SYNTHROID 75MCG TAB
1SYNTHROID 88MCG TAB
1unithroid 100mcg tab
1unithroid 112mcg tab
1unithroid 125mcg tab
1unithroid 150mcg tab
1unithroid 175mcg tab
1unithroid 200mcg tab
1unithroid 25mcg tab
1unithroid 300mcg tab
1unithroid 50mcg tab
1unithroid 75mcg tab
1unithroid 88mcg tab
TOXOIDSTOXOID COMBINATIONS
1ADACEL INJ
1ADACEL SYRINGE
1BOOSTRIX INJ
1BOOSTRIX SYRINGE
1DAPTACEL INJ
1DIPHTHERIA/TETANUS TOXOID INJ PA BvD
1INFANRIX INJ
1KINRIX INJ
1KINRIX PF INJ
1PEDIARIX INJ
1QUADRACEL INJ
1TDVAX 4-4UNIT/ML INJ PA BvD
1TENIVAC 4-10UNIT/ML SYRINGE PA BvD
ULCER DRUGSANTISPASMODICS
1dicyclomine 10mg cap
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
98
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1dicyclomine 20mg tab
1glycopyrrolate 1mg tab
1glycopyrrolate 2mg tabH-2 ANTAGONISTS
1cimetidine 200mg tab
1cimetidine 300mg tab
1cimetidine 400mg tab
1cimetidine 800mg tab
1famotidine 20mg tab
1famotidine 8mg/ml susp
1nizatidine 150mg cap
1nizatidine 300mg capMISC. ANTI-ULCER
1sucralfate 1000mg tabPROTON PUMP INHIBITORS
1esomeprazole 20mg dr cap
1lansoprazole 15mg dr cap
1lansoprazole 30mg dr cap
1omeprazole 20mg dr cap
1pantoprazole 20mg dr tab
1rabeprazole sodium 20mg dr tab
ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICSANTISPASMODICS
1dicyclomine 2mg/ml oral soln
1METHSCOPOLAMINE BROMIDE 2.5MG TAB
1METHSCOPOLAMINE BROMIDE 5MG TABH-2 ANTAGONISTS
1CIMETIDINE 60MG/ML ORAL SOLN
1famotidine 40mg tabMISC. ANTI-ULCER
1sucralfate 100mg/ml suspPROTON PUMP INHIBITORS
1esomeprazole 40mg dr cap
1omeprazole 10mg dr cap
1omeprazole 40mg dr cap
1pantoprazole 40mg dr tabULCER DRUGS - PROSTAGLANDINS
1misoprostol 0.1mg tab
1misoprostol 0.2mg tabULCER THERAPY COMBINATIONS
1amoxicillin 500mg/clarithromycin 500mg/lansoprazole 30mg pack
1PYLERA 140-125-125MG CAP
URINARY ANTI-INFECTIVESURINARY ANTI-INFECTIVES
1methenamine hippurate 1000mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
99
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1nitrofurantoin macro 25mg/nitrofurantoin mono 75mg cap
1nitrofurantoin macrocrystals 100mg cap
1nitrofurantoin macrocrystals 50mg cap
URINARY ANTISPASMODICSURINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)
1oxybutynin chloride 10mg er tab
1oxybutynin chloride 15mg er tab
1oxybutynin chloride 1mg/ml oral soln
1oxybutynin chloride 5mg er tab
1oxybutynin chloride 5mg tab
1solifenacin succinate 10mg tab
1solifenacin succinate 5mg tab
1tolterodine tartrate 1mg tab
1tolterodine tartrate 2mg er cap
1tolterodine tartrate 2mg tab
1tolterodine tartrate 4mg er cap
1trospium chloride 20mg tab
1trospium chloride 60mg er capURINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS
1MYRBETRIQ 25MG ER TAB
1MYRBETRIQ 50MG ER TABURINARY ANTISPASMODICS - CHOLINERGIC AGONISTS
1bethanechol chloride 10mg tab
1bethanechol chloride 25mg tab
1bethanechol chloride 50mg tab
1bethanechol chloride 5mg tabURINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS
1flavoxate 100mg tab
VACCINESBACTERIAL VACCINES
1ACTHIB INJ
1BCG LIVE TICE STRAIN 50MG INJ
1BEXSERO SYRINGE
1HIBERIX 10MCG INJ
1MENACTRA INJ
1MENVEO INJ
1PEDVAXHIB 7.5MCG/0.5ML INJ
1TRUMENBA SYRINGE
1TYPHIM VI 25MCG/0.5ML INJ
1TYPHIM VI 25MCG/0.5ML SYRINGEVIRAL VACCINES
1ENGERIX-B 10MCG/0.5ML SYRINGE PA BvD
1ENGERIX-B 20MCG/ML SYRINGE PA BvD
1GARDASIL 9 INJ
1GARDASIL 9 SYRINGE
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
100
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1HAVRIX 1440ELU/ML INJ
1HAVRIX 1440ELU/ML SYRINGE
1HAVRIX 720ELU/0.5ML SYRINGE
1IMOVAX 2.5UNIT/ML INJ PA BvD
1IPOL INJ
1IXIARO 0.012MG/ML SYRINGE
1M-M-R II INJ
1PROQUAD INJ
1RABAVERT 2.5UNIT/ML INJ PA BvD
1RECOMBIVAX 10MCG/ML INJ PA BvD
1RECOMBIVAX 10MCG/ML SYRINGE PA BvD
1RECOMBIVAX 40MCG/ML INJ PA BvD
1RECOMBIVAX 5MCG/0.5ML SYRINGE PA BvD
1ROTARIX SUSP
1ROTATEQ SUSP
1SHINGRIX 50MCG/0.5ML INJ
1TWINRIX 720UNIT SYRINGE
1VAQTA 25UNIT/0.5ML INJ
1VAQTA 25UNIT/0.5ML SYRINGE
1VAQTA 50UNIT/ML INJ
1VAQTA 50UNIT/ML SYRINGE
1VARIVAX 1350PFU/0.5ML INJ
1YF-VAX 4000UNIT/ML INJ
1ZOSTAVAX 19400UNT/0.65ML INJ
VAGINAL AND RELATED PRODUCTSVAGINAL ANTI-INFECTIVES
1clindamycin 2% vaginal cream
1metronidazole 0.75% vaginal gel
1terconazole 0.4% vaginal cream
1TERCONAZOLE 0.8% VAGINAL CREAM
1terconazole 80mg vaginal insert
1vandazole 0.75% vaginal gelVAGINAL ESTROGENS
1estradiol 0.01% vaginal cream
1ESTRING 2MG VAGINAL SYSTEM ST
1PREMARIN 0.625MG/GM VAGINAL CREAMVAGINAL PROGESTINS
1CRINONE 4% VAGINAL GEL PA
1CRINONE 8% VAGINAL GEL PA
VASOPRESSORSANAPHYLAXIS THERAPY AGENTS
1epinephrine 0.5mg/ml auto-injector QL=2 EA/15 Days
1epinephrine 1mg/ml auto-injector QL=2 EA/15 Days
1SYMJEPI 0.15MG/0.3ML SYRINGE QL=2 EA/15 Days
1SYMJEPI 0.3MG/0.3ML SYRINGE QL=2 EA/15 DaysNEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
101
DRUG NAME DRUG TIER REQUIREMENTS/LIMITS
1NORTHERA 100MG CAP NDS PA
1NORTHERA 200MG CAP NDS PA
1NORTHERA 300MG CAP NDS PAVASOPRESSORS
1midodrine 10mg tab
1midodrine 2.5mg tab
1midodrine 5mg tab
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
102
ALPHABETICAL LISTING OF DRUGS
A
abacavir 20mg/ml oral soln
54
abacavir 300mg tab 54 abacavir 300mg/lamivudine 150mg/zidovudine 300mg tab
54
abacavir 600mg/lamivudine 300mg tab
54
ABELCET 5MG/ML INJ 33 ABILIFY 300MG INJ 53 ABILIFY 300MG SYRINGE
53
ABILIFY 400MG INJ 53 ABILIFY 400MG SYRINGE
53
abiraterone acetate 250mg tab
43
acamprosate calcium 333mg dr tab
93
acarbose 100mg tab 29 acarbose 25mg tab 29 acarbose 50mg tab 29 acebutolol 200mg cap 57 acebutolol 400mg cap 57 acetaminophen 21.7mg/ml/hydrocodone bitartrate 0.5mg/ml oral soln
14
acetaminophen 24mg/ml/codeine phosphate 2.4mg/ml oral soln
14
acetaminophen 300mg/codeine phosphate 15mg tab
14
acetaminophen 300mg/codeine phosphate 30mg tab
14
acetaminophen 300mg/codeine phosphate 60mg tab
14
acetaminophen 300mg/hydrocodone bitartrate 10mg tab
14
acetaminophen 300mg/hydrocodone bitartrate 5mg tab
14
acetaminophen 300mg/hydrocodone bitartrate 7.5mg tab
14
acetaminophen 325mg/hydrocodone bitartrate 10mg tab
14
acetaminophen 325mg/hydrocodone bitartrate 5mg tab
14
acetaminophen 325mg/hydrocodone bitartrate 7.5mg tab
14
acetaminophen 325mg/oxycodone 10mg tab
14
acetaminophen 325mg/oxycodone 2.5mg tab
14
acetaminophen 325mg/oxycodone 5mg tab
14
acetaminophen 325mg/oxycodone 7.5mg tab
14
acetaminophen 325mg/tramadol 37.5mg tab
14
acetazolamide 125mg tab 72 acetazolamide 250mg tab 72 acetazolamide 500mg er cap
72
acetic acid 2% otic soln 90 acetic acid/hydrocortisone 1-2% otic soln
91
acetylcysteine 100mg/ml inh soln
67
acetylcysteine 200mg/ml inh soln
67
acitretin 10mg cap 69 acitretin 17.5mg cap 69 acitretin 25mg cap 69 ACTEMRA 162MG/0.9ML AUTO-INJECTOR
10
ACTEMRA 162MG/0.9ML SYRINGE
10
ACTHIB INJ 100 ACTIMMUNE 2000000UNIT/0.5ML INJ
47
acyclovir 200mg cap 56 acyclovir 400mg tab 56 acyclovir 40mg/ml susp 56 acyclovir 5% ointment 70 acyclovir 50mg/ml inj 56 acyclovir 800mg tab 56 ADACEL INJ 98 ADACEL SYRINGE 98 adapalene 0.1% cream 67 adapalene 0.1% gel 67 adapalene 0.3% gel 67 adapalene/benzoyl peroxide 0.1-2.5% gel
67
adefovir dipivoxil 10mg tab
56
ADEMPAS 0.5MG TAB 61 ADEMPAS 1.5MG TAB 61 ADEMPAS 1MG TAB 61 ADEMPAS 2.5MG TAB 61 ADEMPAS 2MG TAB 61 ADVAIR 0.045-0.021MG INH
19
ADVAIR 0.115-0.021MG INH
19
ADVAIR 0.23-0.021MG INH
19
AFINITOR 10MG TAB 44 AFINITOR 2MG TAB FOR ORAL SUSP
44
AFINITOR 3MG TAB FOR ORAL SUSP
44
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
103
ALPHABETICAL LISTING OF DRUGS
AFINITOR 5MG TAB FOR ORAL SUSP
44
AIMOVIG 140MG/ML AUTO-INJECTOR
83
AIMOVIG 70MG/ML AUTO-INJECTOR
83
ala-cort 1% cream 70 albendazole 200mg tab 16 albuterol 0.21mg/ml inh soln
19
albuterol 0.417mg/ml inh soln
19
albuterol 0.4mg/ml oral soln
19
albuterol 0.83mg/ml inh soln
19
albuterol 2mg tab 19 ALBUTEROL 4MG ER TAB
19
albuterol 4mg tab 19 albuterol 5mg/ml inh soln 19 ALBUTEROL 8MG ER TAB
19
alclometasone dipropionate 0.05% cream
70
alclometasone dipropionate 0.05% ointment
70
ALECENSA 150MG CAP 44 ALENDRONIC ACID 0.933MG/ML ORAL SOLN
73
alendronic acid 10mg tab 73 alendronic acid 35mg tab 73 alendronic acid 70mg tab 73 alfuzosin 10mg er tab 79 ALINIA 100MG/5ML SUSP
40
ALINIA 500MG TAB 40 aliskiren 150mg tab 40 aliskiren 300mg tab 40 allopurinol 100mg tab 79 allopurinol 300mg tab 79
ALOCRIL 2% OPHTH SOLN
90
ALOMIDE 0.1% OPHTH SOLN
90
alosetron 0.5mg tab 78 alosetron 1mg tab 78 ALPHAGAN 0.1% OPHTH SOLN
88
alprazolam 0.25mg odt 17 alprazolam 0.25mg tab 17 alprazolam 0.5mg er tab 17 alprazolam 0.5mg odt 17 alprazolam 0.5mg tab 17 alprazolam 1mg er tab 17 alprazolam 1mg odt 17 alprazolam 1mg tab 17 alprazolam 2mg er tab 17 alprazolam 2mg odt 17 alprazolam 2mg tab 17 alprazolam 3mg er tab 17 ALREX 0.2% OPHTH SUSP
89
altavera 28 day pack 63 ALUNBRIG 180MG TAB 44 ALUNBRIG 30MG TAB 44 ALUNBRIG 90MG TAB 44 ALUNBRIG INITIATION PACK
44
alyacen 1/35 28 day pack 63 alyq 20mg tab 61 amabelz 0.5/0.1mg 28 day pack
76
amabelz 1/0.5mg 28 day pack
76
amantadine 100mg cap 49 amantadine 100mg tab 49 amantadine 10mg/ml oral soln
48
AMBISOME 50MG INJ 33 ambrisentan 10mg tab 61 ambrisentan 5mg tab 61 amethia 91 day pack 63 amikacin 250mg/ml inj 9 amiloride 5mg tab 73
amiloride 5mg/hydrochlorothiazide 50mg tab
72
AMINOSYN II 10% INJ 87 AMINOSYN-PF 7% INJ 87 amiodarone 200mg tab 18 amiodarone 400mg tab 18 amitriptyline 100mg tab 28 amitriptyline 10mg tab 28 AMITRIPTYLINE 10MG/PERPHENAZINE 2MG TAB
94
AMITRIPTYLINE 10MG/PERPHENAZINE 4MG TAB
94
amitriptyline 12.5mg/chlordiazepoxide 5mg tab
94
amitriptyline 150mg tab 28 amitriptyline 25mg tab 28 amitriptyline 25mg/chlordiazepoxide 10mg tab
94
AMITRIPTYLINE 25MG/PERPHENAZINE 2MG TAB
94
AMITRIPTYLINE 25MG/PERPHENAZINE 4MG TAB
94
amitriptyline 50mg tab 28 AMITRIPTYLINE 50MG/PERPHENAZINE 4MG TAB
94
amitriptyline 75mg tab 28 amlodipine 10mg tab 58 amlodipine 10mg/atorvastatin 10mg tab
60
amlodipine 10mg/atorvastatin 20mg tab
60
amlodipine 10mg/atorvastatin 40mg tab
60
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
104
ALPHABETICAL LISTING OF DRUGS
amlodipine 10mg/atorvastatin 80mg tab
60
amlodipine 10mg/benazepril 20mg cap
38
amlodipine 10mg/benazepril 40mg cap
38
amlodipine 10mg/hydrochlorothiazide 12.5mg/valsartan 160mg tab
38
amlodipine 10mg/hydrochlorothiazide 25mg/valsartan 160mg tab
38
amlodipine 10mg/hydrochlorothiazide 25mg/valsartan 320mg tab
38
amlodipine 10mg/olmesartan medoxomil 20mg tab
38
amlodipine 10mg/olmesartan medoxomil 40mg tab
38
amlodipine 10mg/valsartan 160mg tab
38
amlodipine 10mg/valsartan 320mg tab
38
amlodipine 2.5mg tab 59 amlodipine 2.5mg/atorvastatin 10mg tab
60
amlodipine 2.5mg/atorvastatin 20mg tab
60
amlodipine 2.5mg/atorvastatin 40mg tab
60
amlodipine 2.5mg/benazepril 10mg cap
38
amlodipine 5mg tab 59 amlodipine 5mg/atorvastatin 10mg tab
60
amlodipine 5mg/atorvastatin 20mg tab
60
amlodipine 5mg/atorvastatin 40mg tab
61
amlodipine 5mg/atorvastatin 80mg tab
61
amlodipine 5mg/benazepril 10mg cap
38
amlodipine 5mg/benazepril 20mg cap
38
amlodipine 5mg/benazepril 40mg cap
38
amlodipine 5mg/hydrochlorothiazide 12.5mg/valsartan 160mg tab
38
amlodipine 5mg/hydrochlorothiazide 25mg/valsartan 160mg tab
38
amlodipine 5mg/olmesartan medoxomil 20mg tab
38
amlodipine 5mg/olmesartan medoxomil 40mg tab
38
amlodipine 5mg/valsartan 160mg tab
38
amlodipine 5mg/valsartan 320mg tab
38
ammonium lactate 12% cream
71
ammonium lactate 12% lotion
71
amnesteem 10mg cap 67
amnesteem 20mg cap 67 amnesteem 40mg cap 67 AMOXAPINE 100MG TAB
28
AMOXAPINE 150MG TAB
28
AMOXAPINE 25MG TAB 28 AMOXAPINE 50MG TAB 28 AMOXICILLIN 1000MG/CLAVULANATE 62.5MG ER TAB
92
amoxicillin 120mg/ml/clavulanate 8.58mg/ml susp
92
amoxicillin 125mg chew tab
91
AMOXICILLIN 200MG/CLAVULANATE 28.5MG CHEW TAB
92
amoxicillin 250mg cap 91 AMOXICILLIN 250MG CHEW TAB
91
amoxicillin 250mg/clavulanate 125mg tab
92
amoxicillin 25mg/ml susp 91 AMOXICILLIN 400MG/CLAVULANATE 57MG CHEW TAB
92
amoxicillin 40mg/ml susp 91 amoxicillin 40mg/ml/clavulanate 5.7mg/ml susp
92
amoxicillin 500mg cap 91 amoxicillin 500mg tab 91 amoxicillin 500mg/clarithromycin 500mg/lansoprazole 30mg pack
99
amoxicillin 500mg/clavulanate 125mg tab
92
amoxicillin 50mg/ml susp 91
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
105
ALPHABETICAL LISTING OF DRUGS
amoxicillin 50mg/ml/clavulanate 12.5mg/ml susp
92
amoxicillin 80mg/ml susp 91 amoxicillin 80mg/ml/clavulanate 11.4mg/ml susp
92
amoxicillin 875mg tab 92 amoxicillin 875mg/clavulanate 125mg tab
92
amphetamine 10mg er cap
8
amphetamine 10mg tab 8 amphetamine 12.5mg tab 8 amphetamine 15mg er cap
8
amphetamine 15mg tab 8 amphetamine 20mg er cap
8
amphetamine 20mg tab 8 amphetamine 25mg er cap
8
amphetamine 30mg er cap
8
amphetamine 30mg tab 8 amphetamine 5mg er cap 8 amphetamine 5mg tab 8 amphetamine 7.5mg tab 8 AMPHOTERICIN B 50MG INJ
33
ampicillin 1000mg inj 92 ampicillin 1000mg/sulbactam 500mg inj
92
ampicillin 100mg/ml inj 92 ampicillin 100mg/ml/sulbactam 50mg/ml inj
92
AMPICILLIN 125MG INJ 92 ampicillin 2000mg/sulbactam 1000mg inj
92
AMPICILLIN 500MG CAP
92
ANADROL-50 50MG TAB
15
anagrelide 0.5mg cap 80 anagrelide 1mg cap 80 anastrozole 1mg tab 43 ANDRODERM 2MG/24HR PATCH
15
ANDRODERM 4MG/24HR PATCH
15
ANORO 0.0625-0.025MG INH
19
APLENZIN 174MG ER TAB
26
APLENZIN 348MG ER TAB
26
APLENZIN 522MG ER TAB
26
APOKYN 30MG/3ML CARTRIDGE
49
apraclonidine 0.5% ophth soln
88
aprepitant 125mg cap 33 aprepitant 125mg/aprepitant 80mg pack
33
aprepitant 40mg cap 33 aprepitant 80mg cap 33 apri 28 day pack 63 APTIOM 200MG TAB 22 APTIOM 400MG TAB 22 APTIOM 600MG TAB 22 APTIOM 800MG TAB 22 APTIVUS 100MG/ML ORAL SOLN
54
APTIVUS 250MG CAP 54 ARALAST 1000MG INJ 95 aranelle 28 pack 63 ARANESP 100MCG/0.5ML SYRINGE
80
ARANESP 100MCG/ML INJ
80
ARANESP 10MCG/0.4ML SYRINGE
80
ARANESP 150MCG/0.3ML SYRINGE
80
ARANESP 200MCG/0.4ML SYRINGE
80
ARANESP 200MCG/ML INJ
80
ARANESP 25MCG/0.42ML SYRINGE
80
ARANESP 25MCG/ML INJ
80
ARANESP 300MCG/0.6ML SYRINGE
80
ARANESP 300MCG/ML INJ
80
ARANESP 40MCG/0.4ML SYRINGE
80
ARANESP 40MCG/ML INJ
80
ARANESP 500MCG/ML SYRINGE
80
ARANESP 60MCG/0.3ML SYRINGE
80
ARANESP 60MCG/ML INJ
80
ARCALYST 220MG INJ 10 ARIKAYCE 590MG/8.4ML INH SUSP
9
aripiprazole 10mg odt 53 aripiprazole 10mg tab 53 aripiprazole 15mg odt 53 aripiprazole 15mg tab 53 aripiprazole 1mg/ml oral soln
53
aripiprazole 20mg tab 53 aripiprazole 2mg tab 53 aripiprazole 30mg tab 53 aripiprazole 5mg tab 53 ARISTADA 1064MG/3.9ML SYRINGE
53
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
106
ALPHABETICAL LISTING OF DRUGS
ARISTADA 441MG/1.6ML SYRINGE
53
ARISTADA 662MG/2.4ML SYRINGE
53
ARISTADA 675MG/2.4ML SYRINGE
53
ARISTADA 882MG/3.2ML SYRINGE
53
armodafinil 150mg tab 8 armodafinil 200mg tab 8 armodafinil 250mg tab 8 armodafinil 50mg tab 8 ARNUITY 100MCG INH 19 ARNUITY 200MCG INH 19 ARNUITY 50MCG INH 19 ashlyna 91 day pack 63 ASMANEX 100MCG INH 19 ASMANEX 110MCG/INH INH
19
ASMANEX 200MCG INH 19 ASMANEX 220MCG (120ACT) INH
19
ASMANEX 220MCG (30ACT) INH
19
ASMANEX 220MCG (60ACT) INH
19
ASMANEX 50MCG HFA INH
19
aspirin 25mg/dipyridamole 200mg er cap
80
ASPIRIN 325MG/OXYCODONE 4.84MG TAB
14
ASTAGRAF 0.5MG ER CAP
85
ASTAGRAF 1MG ER CAP 85 ASTAGRAF 5MG ER CAP 85 atazanavir 150mg cap 54 atazanavir 200mg cap 54 atazanavir 300mg cap 54 atenolol 100mg tab 57 atenolol 100mg/chlorthalidone 25mg tab
38
atenolol 25mg tab 57 atenolol 50mg tab 57 atenolol 50mg/chlorthalidone 25mg tab
38
atomoxetine 100mg cap 8 atomoxetine 10mg cap 8 atomoxetine 18mg cap 8 atomoxetine 25mg cap 8 atomoxetine 40mg cap 8 atomoxetine 60mg cap 8 atomoxetine 80mg cap 8 atorvastatin 10mg tab 35 atorvastatin 20mg tab 35 atorvastatin 40mg tab 35 atorvastatin 80mg tab 35 atovaquone 150mg/ml susp
40
atovaquone 250mg/proguanil 100mg tab
41
atovaquone 62.5mg/proguanil 25mg tab
41
ATRIPLA 600-200-300MG TAB
54
atropine sulfate 0.005mg/ml/diphenoxylate 0.5mg/ml oral soln
32
atropine sulfate 0.025mg/diphenoxylate 2.5mg tab
32
ATROPINE SULFATE 1% OPHTH SOLN
88
ATROVENT 17MCG INH 18 AUBAGIO 14MG TAB 94 AUBAGIO 7MG TAB 94 aubra 28 day pack 63 AURYXIA 210MG TAB 78 AUSTEDO 12MG TAB 94 AUSTEDO 6MG TAB 94 AUSTEDO 9MG TAB 94 AVANDIA 2MG TAB 31 AVANDIA 4MG TAB 31 aviane 28 pack 63
avita 0.025% cream 67 avita 0.025% gel 67 AVONEX 30MCG/0.5ML AUTO-INJECTOR
94
AVONEX 30MCG/0.5ML SYRINGE
94
AVYCAZ 500-2000MG INJ
62
AYVAKIT 100MG TAB 44 AYVAKIT 200MG TAB 44 AYVAKIT 300MG TAB 44 AZASAN 100MG TAB 57 AZASAN 75MG TAB 57 AZASITE 1% OPHTH SOLN
89
azathioprine 50mg tab 85 azelaic acid 15% gel 71 azelastine 0.05% ophth soln
90
azelastine 0.137mg/act nasal inhaler
87
azelastine 0.206mg/act nasal inhaler
87
azelastine/fluticasone 137-50mcg/act nasal spray
51
azithromycin 20mg/ml susp
82
azithromycin 250mg pack 82 azithromycin 250mg tab 82 azithromycin 40mg/ml susp
82
azithromycin 500mg inj 82 azithromycin 500mg pack 82 azithromycin 500mg tab 82 azithromycin 600mg tab 82 AZOPT 1% OPHTH SUSP 90 aztreonam 1000mg inj 41
B
BACITRACIN 0.5UNIT/MG OPHTH OINTMENT
89
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
107
ALPHABETICAL LISTING OF DRUGS
bacitracin 0.5unit/mg/polymyxin b 10unit/mg ophth ointment
89
baclofen 10mg tab 86 baclofen 20mg tab 86 balsalazide disodium 750mg cap
77
BALVERSA 3MG TAB 44 BALVERSA 4MG TAB 44 BALVERSA 5MG TAB 44 balziva 28 day pack 63 BANZEL 200MG TAB 22 BANZEL 400MG TAB 22 BANZEL 40MG/ML SUSP
22
BAQSIMI 3MG/DOSE NASAL POWDER
30
BAXDELA 450MG TAB 77 BCG LIVE TICE STRAIN 50MG INJ
100
benazepril 10mg tab 36 benazepril 10mg/hydrochlorothiazide 12.5mg tab
38
benazepril 20mg tab 36 benazepril 20mg/hydrochlorothiazide 12.5mg tab
38
benazepril 20mg/hydrochlorothiazide 25mg tab
38
benazepril 40mg tab 36 benazepril 5mg tab 36 benazepril 5mg/hydrochlorothiazide 6.25mg tab
38
BENLYSTA 200MG/ML AUTO-INJECTOR
86
BENLYSTA 200MG/ML SYRINGE
86
BENZNIDAZOLE 100MG TAB
16
BENZNIDAZOLE 12.5MG TAB
16
benztropine mesylate 0.5mg tab
49
benztropine mesylate 1mg tab
49
benztropine mesylate 2mg tab
48
BERINERT 500UNIT INJ 79 betamethasone 0.05% aug cream
70
betamethasone 0.05% aug lotion
70
betamethasone 0.05% aug ointment
70
betamethasone 0.05% cream
70
BETAMETHASONE 0.05% GEL
70
betamethasone 0.05% lotion
70
betamethasone 0.05% ointment
70
betamethasone 0.1% cream
70
betamethasone 0.1% lotion
70
betamethasone 0.1% ointment
70
betamethasone/clotrimazole 1-0.05% cream
68
betamethasone/clotrimazole 1-0.05% lotion
68
betaxolol 0.5% ophth soln
88
betaxolol 10mg tab 57 betaxolol 20mg tab 57 bethanechol chloride 10mg tab
100
bethanechol chloride 25mg tab
100
bethanechol chloride 50mg tab
100
bethanechol chloride 5mg tab
100
BETIMOL 0.25% OPHTH SOLN
88
BETIMOL 0.5% OPHTH SOLN
88
BETOPTIC S 0.25% OPHTH SUSP
88
bexarotene 75mg cap 47 BEXSERO SYRINGE 100 bicalutamide 50mg tab 43 BICILLIN 300000-300000UNIT/ML SYRINGE
92
BICILLIN 450000-150000UNIT/ML SYRINGE
92
BICILLIN L-A 1200000UNIT/2ML SYRINGE
92
BICILLIN L-A 2400000UNIT/4ML SYRINGE
92
BICILLIN L-A 600000UNIT/ML SYRINGE
92
BIDIL 37.5-20MG TAB 61 BIKTARVY 50-200-25MG TAB
54
bimatoprost 0.03% ophth soln
90
bisoprolol fumarate 10mg tab
57
bisoprolol fumarate 10mg/hydrochlorothiazide 6.25mg tab
38
bisoprolol fumarate 2.5mg/hydrochlorothiazide 6.25mg tab
38
bisoprolol fumarate 5mg tab
57
bisoprolol fumarate 5mg/hydrochlorothiazide 6.25mg tab
38
BIVIGAM 5GM/50ML INJ
91
BLEPHAMIDE 0.2-10% OPHTH SUSP
89
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
108
ALPHABETICAL LISTING OF DRUGS
blisovi 21 fe 1.5/30 28 day
63
blisovi 24 fe 1/20 28 day pack
63
BOOSTRIX INJ 98 BOOSTRIX SYRINGE 98 bosentan 125mg tab 61 bosentan 62.5mg tab 61 BOSULIF 100MG TAB 44 BOSULIF 400MG TAB 44 BOSULIF 500MG TAB 44 BRAFTOVI 75MG CAP 44 BREO 0.1-0.025MG INH 19 BREO 0.2-0.025MG INH 19 briellyn 28 day pack 63 BRILINTA 60MG TAB 80 BRILINTA 90MG TAB 80 brimonidine tartrate 0.15% ophth soln
88
brimonidine tartrate 0.2% ophth soln
88
BRIVIACT 100MG TAB 22 BRIVIACT 10MG TAB 22 BRIVIACT 10MG/ML ORAL SOLN
22
BRIVIACT 25MG TAB 22 BRIVIACT 50MG TAB 22 BRIVIACT 75MG TAB 22 bromfenac 0.09% ophth soln
90
bromocriptine 2.5mg tab 48 bromocriptine 5mg cap 48 BRUKINSA 80MG CAP 44 budesonide 0.125mg/ml inh susp
19
budesonide 0.25mg/ml inh susp
19
budesonide 0.5mg/ml inh susp
19
budesonide 3mg dr cap 66 budesonide 9mg er tab 66 bumetanide 0.25mg/ml inj 72 bumetanide 0.5mg tab 72 bumetanide 1mg tab 72 bumetanide 2mg tab 72
buprenorphine 12mg/naloxone 3mg sublingual film
14
buprenorphine 2mg sl tab 14 buprenorphine 2mg/naloxone 0.5mg sl tab
15
buprenorphine 2mg/naloxone 0.5mg sublingual film
15
buprenorphine 4mg/naloxone 1mg sublingual film
15
buprenorphine 8mg sl tab 15 buprenorphine 8mg/naloxone 2mg sl tab
15
buprenorphine 8mg/naloxone 2mg sublingual film
15
bupropion 100mg er tab 26 bupropion 100mg tab 26 bupropion 150mg sr (12 hr) tab
26
bupropion 150mg sr tab 95 bupropion 150mg xl (24 hr) tab
26
bupropion 200mg er tab 26 bupropion 300mg er tab 26 bupropion 75mg tab 26 buspirone 10mg tab 16 buspirone 15mg tab 16 buspirone 30mg tab 16 buspirone 5mg tab 16 buspirone 7.5mg tab 16 butorphanol tartrate 1mg/act nasal inhaler
15
BYDUREON 2MG PEN INJ
30
BYDUREON 2MG/0.85ML AUTO-INJECTOR
30
BYSTOLIC 10MG TAB 57 BYSTOLIC 2.5MG TAB 58 BYSTOLIC 20MG TAB 58 BYSTOLIC 5MG TAB 58
C
cabergoline 0.5mg tab 75 CABLIVI 11MG INJ 80 CABOMETYX 20MG TAB
44
CABOMETYX 40MG TAB
44
CABOMETYX 60MG TAB
44
calcipotriene 0.005% cream
69
calcipotriene 0.005% ointment
69
calcipotriene 0.005% topical soln
69
calcipotriene/betamethasone 0.005-0.064% ointment
70
calcitriol 0.00025mg cap 74 calcitriol 0.0005mg cap 74 calcitriol 0.001mg/ml oral soln
74
calcium acetate 667mg cap
78
calcium acetate 667mg tab
78
CALQUENCE 100MG CAP
44
camila 28 day 0.35mg pack
66
camreselo 91 day pack 63 CAPLYTA 42MG CAP 50 CAPRELSA 100MG TAB 44 CAPRELSA 300MG TAB 44 captopril 100mg tab 36 captopril 12.5mg tab 36 captopril 25mg tab 36 captopril 25mg/hydrochlorothiazide 15mg tab
38
CAPTOPRIL 25MG/HYDROCHLOROTHIAZIDE 25MG TAB
38
captopril 50mg tab 36
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
109
ALPHABETICAL LISTING OF DRUGS
captopril 50mg/hydrochlorothiazide 15mg tab
38
CAPTOPRIL 50MG/HYDROCHLOROTHIAZIDE 25MG TAB
39
CARBAGLU 200MG TAB FOR ORAL SUSP
74
carbamazepine 100mg chew tab
22
carbamazepine 100mg er cap
22
carbamazepine 100mg er tab
22
carbamazepine 200mg er cap
22
carbamazepine 200mg er tab
22
carbamazepine 200mg tab
22
carbamazepine 20mg/ml susp
22
carbamazepine 300mg er cap
23
carbamazepine 400mg er tab
23
carbidopa 10mg/levodopa 100mg odt
48
carbidopa 10mg/levodopa 100mg tab
48
CARBIDOPA 12.5MG/ENTACAPONE 200MG/LEVODOPA 50MG TAB
49
CARBIDOPA 18.75MG/ENTACAPONE 200MG/LEVODOPA 75MG TAB
49
carbidopa 25mg tab 49 CARBIDOPA 25MG/ENTACAPONE 200MG/LEVODOPA 100MG TAB
49
carbidopa 25mg/levodopa 100mg er tab
48
carbidopa 25mg/levodopa 100mg odt
48
carbidopa 25mg/levodopa 100mg tab
48
carbidopa 25mg/levodopa 250mg odt
48
carbidopa 25mg/levodopa 250mg tab
49
CARBIDOPA 31.25MG/ENTACAPONE 200MG/LEVODOPA 125MG TAB
49
CARBIDOPA 37.5MG/ENTACAPONE 200MG/LEVODOPA 150MG TAB
49
CARBIDOPA 50MG/ENTACAPONE 200MG/LEVODOPA 200MG TAB
49
carbidopa 50mg/levodopa 200mg er tab
48
carisoprodol 350mg tab 86 CARTEOLOL 1% OPHTH SOLN
88
cartia 120mg er cap 59 cartia 180mg er cap 59 cartia 240mg er cap 59 cartia 300mg er cap 59 carvedilol 12.5mg tab 57 carvedilol 25mg tab 57 carvedilol 3.125mg tab 57 carvedilol 6.25mg tab 57 caspofungin acetate 50mg inj
33
caspofungin acetate 70mg inj
33
CAYSTON 75MG INH SOLN
41
caziant 28 day pack 63 cefaclor 250mg cap 62 cefaclor 500mg cap 62 cefadroxil 1000mg tab 62 cefadroxil 100mg/ml susp 62 cefadroxil 500mg cap 62 cefadroxil 50mg/ml susp 62 cefazolin 1000mg inj 62 cefazolin 200mg/ml inj 62 cefazolin 500mg inj 62 cefdinir 25mg/ml susp 62 cefdinir 300mg cap 62 cefdinir 50mg/ml susp 62 cefepime 1000mg inj 63 cefepime 2000mg inj 63 cefixime 20mg/ml susp 62 cefixime 400mg cap 62 cefixime 40mg/ml susp 62 cefotetan 1000mg inj 62 cefotetan 2000mg inj 62 cefoxitin 1000mg inj 62 cefoxitin 2000mg inj 62 cefoxitin 200mg/ml inj 62 cefpodoxime 100mg tab 62 cefpodoxime 10mg/ml susp
62
cefpodoxime 200mg tab 62 cefpodoxime 20mg/ml susp
62
cefprozil 250mg tab 62 cefprozil 25mg/ml susp 62 cefprozil 500mg tab 62 cefprozil 50mg/ml susp 62 ceftazidime 1000mg inj 63 ceftazidime 2000mg inj 63 ceftazidime 200mg/ml inj 63 ceftriaxone 1000mg inj 63 ceftriaxone 100mg/ml inj 63 ceftriaxone 2000mg inj 63 ceftriaxone 250mg inj 63 ceftriaxone 500mg inj 63 cefuroxime 1500mg inj 62 cefuroxime 250mg tab 62
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
110
ALPHABETICAL LISTING OF DRUGS
cefuroxime 500mg tab 62 cefuroxime 750mg inj 62 cefuroxime 95mg/ml inj 62 celecoxib 100mg cap 11 celecoxib 200mg cap 11 celecoxib 400mg cap 11 celecoxib 50mg cap 11 CELONTIN 300MG CAP 25 cephalexin 250mg cap 62 cephalexin 25mg/ml susp 62 cephalexin 500mg cap 62 cephalexin 50mg/ml susp 62 CERDELGA 84MG CAP 80 cetirizine 1mg/ml oral soln
34
CETRAXAL 0.2% OTIC SOLN
90
cevimeline 30mg cap 86 CHANTIX 0.5MG TAB 95 CHANTIX 1MG TAB 95 CHANTIX CONTINUING MONTHS OF THERAPY 1MG PACK
95
CHANTIX FIRST MONTH OF THERAPY PACK
95
CHEMET 100MG CAP 32 CHENODAL 250MG TAB 77 chlordiazepoxide 10mg cap
17
chlordiazepoxide 25mg cap
17
chlordiazepoxide 5mg cap
17
chlorhexidine gluconate 0.12% mouthwash
86
CHLOROQUINE PHOSPHATE 250MG TAB
41
chloroquine phosphate 500mg tab
41
chlorpromazine 100mg tab
52
chlorpromazine 10mg tab 52 chlorpromazine 200mg tab
52
chlorpromazine 25mg tab 52 chlorpromazine 50mg tab 52 chlorthalidone 25mg tab 73 chlorthalidone 50mg tab 73 chlorzoxazone 500mg tab 86 CHOLBAM 250MG CAP 77 CHOLBAM 50MG CAP 77 cholestyramine resin 4gm sf powder for oral susp
34
cholestyramine resin 4gm sf powder for oral susp (sugar free)
34
ciclopirox 0.77% cream 68 ciclopirox 0.77% gel 68 ciclopirox 0.77% lotion 68 ciclopirox 1% shampoo 68 ciclopirox 8% topical soln 68 CILASTATIN 250MG/IMIPENEM 250MG INJ
40
cilastatin 500mg/imipenem 500mg inj
40
cilostazol 100mg tab 80 cilostazol 50mg tab 80 CIMDUO 300-300MG TAB
54
cimetidine 200mg tab 99 cimetidine 300mg tab 99 cimetidine 400mg tab 99 CIMETIDINE 60MG/ML ORAL SOLN
99
cimetidine 800mg tab 99 CIMZIA 200MG INJ 77 CIMZIA 200MG/ML SYRINGE
77
cinacalcet 30mg tab 74 cinacalcet 60mg tab 74 cinacalcet 90mg tab 74 CINRYZE 500UNIT INJ 79 CIPRODEX 0.3-0.1% OTIC SUSP
91
CIPROFLOXACIN 0.2% OTIC SOLN
91
ciprofloxacin 0.3% ophth soln
89
ciprofloxacin 250mg tab 77 ciprofloxacin 2mg/ml inj 77 ciprofloxacin 500mg tab 77 ciprofloxacin 750mg tab 77 citalopram 10mg tab 26 citalopram 20mg tab 26 citalopram 2mg/ml oral soln
26
citalopram 40mg tab 26 claravis 10mg cap 67 claravis 20mg cap 67 claravis 30mg cap 67 claravis 40mg cap 67 CLARINEX-D 2.5-120MG ER TAB
67
clarithromycin 250mg tab 82 CLARITHROMYCIN 25MG/ML SUSP
82
clarithromycin 500mg er tab
82
clarithromycin 500mg tab 82 CLARITHROMYCIN 50MG/ML SUSP
82
CLENPIQ 75-21.9-0.0625MG/ML ORAL SOLN
82
clindacin 1% pad 68 clindamycin 1% gel 68 clindamycin 1% lotion 68 clindamycin 1% pad 68 clindamycin 1% topical soln
68
clindamycin 12mg/ml inj 41 clindamycin 150mg cap 41 clindamycin 150mg/ml (2ml) inj
41
clindamycin 150mg/ml (4ml) inj
41
clindamycin 150mg/ml (6ml) inj
41
clindamycin 15mg/ml oral soln
41
clindamycin 18mg/ml inj 41
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
111
ALPHABETICAL LISTING OF DRUGS
clindamycin 2% vaginal cream
101
clindamycin 300mg cap 41 clindamycin 6mg/ml inj 41 clindamycin 75mg cap 41 clindamycin/benzoyl peroxide 1-5% gel
68
CLINIMIX 4.25/10 INJ 87 CLINIMIX 4.25/5 INJ 87 CLINIMIX 5/15 INJ 87 CLINIMIX 5/20 INJ 87 CLINIMIX E 2.75/5 INJ 87 CLINIMIX E 4.25/10 INJ 87 CLINIMIX E 4.25/5 INJ 88 CLINIMIX E 5/15 INJ 88 CLINIMIX E 5/20 INJ 88 clinisol 15% inj 88 clobazam 10mg tab 22 clobazam 2.5mg/ml susp 22 clobazam 20mg tab 22 clobetasol propionate 0.05% cream
70
clobetasol propionate 0.05% e cream
70
clobetasol propionate 0.05% foam
70
clobetasol propionate 0.05% gel
70
clobetasol propionate 0.05% lotion
70
clobetasol propionate 0.05% ointment
70
clobetasol propionate 0.05% shampoo
70
clobetasol propionate 0.05% spray
70
clobetasol propionate 0.05% topical soln
70
clodan 0.05% shampoo 70 clomipramine 25mg cap 28 clomipramine 50mg cap 28 clomipramine 75mg cap 28 clonazepam 0.125mg odt 22 clonazepam 0.25mg odt 22 clonazepam 0.5mg odt 22
clonazepam 0.5mg tab 22 clonazepam 1mg odt 22 clonazepam 1mg tab 22 clonazepam 2mg odt 22 clonazepam 2mg tab 22 clonidine 0.00417mg/hr weekly patch
37
clonidine 0.00833mg/hr weekly patch
37
clonidine 0.0125mg/hr weekly patch
37
clonidine 0.1mg tab 37 clonidine 0.2mg tab 37 clonidine 0.3mg tab 37 clopidogrel 75mg tab 80 clorazepate dipotassium 15mg tab
17
clorazepate dipotassium 3.75mg tab
17
clorazepate dipotassium 7.5mg tab
17
clotrimazole 1% cream 68 clotrimazole 1% topical soln
68
clotrimazole 10mg lozenge
86
clovique 250mg cap 85 clozapine 100mg odt 51 clozapine 100mg tab 51 CLOZAPINE 12.5MG ODT
51
CLOZAPINE 150MG ODT
51
CLOZAPINE 200MG ODT
51
clozapine 200mg tab 51 clozapine 25mg odt 51 clozapine 25mg tab 51 clozapine 50mg tab 51 COARTEM 20-120MG TAB
41
CODEINE SULFATE 15MG TAB
12
codeine sulfate 30mg tab 12 codeine sulfate 60mg tab 12
colchicine 0.5mg/probenecid 500mg tab
79
colesevelam 3750mg powder for oral susp
34
colesevelam 625mg tab 34 colestipol 1000mg tab 35 colestipol 5000mg granules for oral susp
35
colistin 75mg/ml inj 41 COMBIGAN 2-5MG/ML OPHTH SOLN
88
COMBIPATCH 0.00208-0.00583MG/HR PATCH
76
COMBIPATCH 0.00208-0.0104MG/HR PATCH
76
COMBIVENT 0.1-0.02MG INH
19
COMETRIQ 100MG DAILY DOSE CARTON PACK
44
COMETRIQ 140MG DAILY DOSE CARTON PACK
44
COMETRIQ 60MG DAILY DOSE CARTON PACK
44
COMPLERA 200-25-300MG TAB
54
compro 25mg rectal supp 52 constulose 10gm/15ml oral soln
82
COPIKTRA 15MG CAP 44 COPIKTRA 25MG CAP 44 CORLANOR 5MG TAB 61 CORLANOR 5MG/5ML ORAL SOLN
61
CORLANOR 7.5MG TAB 61 CORTISONE ACETATE 25MG TAB
66
COTELLIC 20MG TAB 44
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
112
ALPHABETICAL LISTING OF DRUGS
CREON 120000-76000-24000UNIT DR CAP
72
CREON 15000-9500-3000UNIT DR CAP
72
CREON 30000-19000-6000UNIT DR CAP
72
CREON 36000-114000-180000UNIT DR CAP
72
CREON 60000-38000-12000UNIT DR CAP
72
CRINONE 4% VAGINAL GEL
101
CRINONE 8% VAGINAL GEL
101
CRIXIVAN 200MG CAP 54 CRIXIVAN 400MG CAP 54 cromolyn sodium 20mg/ml oral soln
77
cromolyn sodium 4% ophth soln
90
cryselle 28 pack 63 cyclafem 1/35 28 day pack
63
cyclafem 7/7/7 28 day pack
63
cyclobenzaprine 10mg tab
87
cyclobenzaprine 5mg tab 87 CYCLOPHOSPHAMIDE 25MG CAP
42
CYCLOPHOSPHAMIDE 50MG CAP
42
cyclosporine 100mg cap 57 cyclosporine 25mg cap 57 cyclosporine modified 100mg cap
57
cyclosporine modified 100mg/ml oral soln
85
cyclosporine modified 25mg cap
57
cyclosporine modified 50mg cap
86
cyproheptadine 0.4mg/ml oral soln
34
cyproheptadine 4mg tab 34 cyred 28 day pack 63 CYSTAGON 150MG CAP 78 CYSTAGON 50MG CAP 79 CYSTARAN 0.44% OPHTH SOLN
90
D
dalfampridine 10mg er tab
94
DALIRESP 250MCG TAB 18 DALIRESP 500MCG TAB 19 DALVANCE 500MG INJ 41 danazol 100mg cap 15 danazol 200mg cap 15 danazol 50mg cap 15 dantrolene sodium 100mg cap
87
dantrolene sodium 25mg cap
87
dantrolene sodium 50mg cap
87
dapsone 100mg tab 41 dapsone 25mg tab 41 DAPTACEL INJ 98 daptomycin 500mg inj 40 DAURISMO 100MG TAB 43 DAURISMO 25MG TAB 43 deblitane 28 day 0.35mg pack
66
deferasirox 125mg tab for oral susp
32
deferasirox 180mg tab 32 deferasirox 250mg tab for oral susp
32
deferasirox 360mg tab 32 deferasirox 500mg tab for oral susp
32
deferasirox 90mg tab 32 DELSTRIGO 100-300-300MG TAB
54
demeclocycline 150mg tab
96
demeclocycline 300mg tab
96
DEMSER 250MG CAP 37 DENAVIR 1% CREAM 70 DEPO-PROVERA 400MG/ML INJ
43
DESCOVY 200-25MG TAB
54
desipramine 100mg tab 28 desipramine 10mg tab 28 desipramine 150mg tab 28 desipramine 25mg tab 28 desipramine 50mg tab 28 desipramine 75mg tab 28 desloratadine 5mg tab 34 desmopressin acetate 0.01mg/act nasal spray
75
desmopressin acetate 0.1mg tab
75
desmopressin acetate 0.2mg tab
75
desogestrel/ethinyl estradiol 28 day pack
63
desogestrel/ethinyl estradiol pack
63
desonide 0.05% ointment 70 desoximetasone 0.05% gel
70
desoximetasone 0.25% cream
70
desoximetasone 0.25% ointment
70
desvenlafaxine succinate 100mg er tab
27
desvenlafaxine succinate 25mg er tab
27
desvenlafaxine succinate 50mg er tab
27
dexamethasone 0.1mg/ml oral soln
66
dexamethasone 0.5mg tab 66 dexamethasone 0.75mg tab
66
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
113
ALPHABETICAL LISTING OF DRUGS
dexamethasone 1.5mg tab 66 DEXAMETHASONE 1MG TAB
66
DEXAMETHASONE 1MG/ML ORAL SOLN
66
DEXAMETHASONE 2MG TAB
66
dexamethasone 4mg tab 66 dexamethasone 6mg tab 66 DEXAMETHASONE PHOSPHATE 0.1% OPHTH SOLN
89
dexamethasone/neomycin/polymyxin b 0.1% ophth ointment
89
dexamethasone/neomycin/polymyxin b 0.1% ophth susp
89
dexamethasone/tobramycin 0.3-0.1% ophth susp
89
dexmethylphenidate 10mg er cap
8
dexmethylphenidate 10mg tab
8
dexmethylphenidate 15mg er cap
8
dexmethylphenidate 2.5mg tab
9
dexmethylphenidate 20mg er cap
9
dexmethylphenidate 25mg er cap
9
dexmethylphenidate 30mg er cap
9
dexmethylphenidate 35mg er cap
9
dexmethylphenidate 40mg er cap
9
dexmethylphenidate 5mg er cap
9
dexmethylphenidate 5mg tab
9
dextroamphetamine sulfate 10mg er cap
8
dextroamphetamine sulfate 10mg tab
8
dextroamphetamine sulfate 15mg er cap
8
dextroamphetamine sulfate 5mg er cap
8
dextroamphetamine sulfate 5mg tab
8
DIASTAT 10MG RECTAL GEL
22
DIASTAT 2.5MG RECTAL GEL
22
DIASTAT 20MG RECTAL GEL
22
diazepam 10mg tab 17 DIAZEPAM 10MG/2ML RECTAL GEL
22
DIAZEPAM 1MG/ML ORAL SOLN
17
DIAZEPAM 2.5MG/0.5ML RECTAL GEL
22
DIAZEPAM 20MG/4ML RECTAL GEL
22
diazepam 2mg tab 17 diazepam 5mg tab 17 diazepam 5mg/ml oral soln
17
diazoxide 50mg/ml susp 30 diclofenac potassium 50mg tab
11
diclofenac sodium 0.1% ophth soln
90
diclofenac sodium 1% gel 69 diclofenac sodium 1.5% topical soln
69
diclofenac sodium 100mg er tab
11
diclofenac sodium 25mg dr tab
11
diclofenac sodium 3% gel 69 diclofenac sodium 50mg dr tab
11
diclofenac sodium 50mg/misoprostol 0.2mg dr tab
11
diclofenac sodium 75mg dr tab
11
diclofenac sodium 75mg/misoprostol 0.2mg dr tab
11
dicloxacillin 250mg cap 92 dicloxacillin 500mg cap 93 dicyclomine 10mg cap 98 dicyclomine 20mg tab 99 dicyclomine 2mg/ml oral soln
99
DIDANOSINE 250MG DR CAP
54
DIDANOSINE 400MG DR CAP
54
diflunisal 500mg tab 12 digitek 0.125mg tab 60 digitek 0.25mg tab 60 digox 125mcg tab 60 digox 250mcg tab 60 digoxin 0.05mg/ml oral soln
60
digoxin 0.125mg tab 60 digoxin 0.25mg tab 60 dihydroergotamine mesylate 0.5mg/act nasal inhaler
83
DILANTIN 30MG ER CAP
25
DILT 120MG ER CAP 59 DILT 180MG ER CAP 59 DILT 240MG ER CAP 59 diltiazem 120mg er (12 hr) cap
59
diltiazem 120mg er (24 hr) cap
59
diltiazem 120mg tab 59 diltiazem 180mg er cap 59 diltiazem 240mg er cap 59 diltiazem 300mg er cap 59 diltiazem 30mg tab 59 diltiazem 360mg er cap 59
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
114
ALPHABETICAL LISTING OF DRUGS
diltiazem 420mg er cap 59 diltiazem 60mg er cap 59 diltiazem 60mg tab 59 diltiazem 90mg er cap 59 diltiazem 90mg tab 59 DIPENTUM 250MG CAP 78 DIPHTHERIA/TETANUS TOXOID INJ
98
dipyridamole 25mg tab 80 dipyridamole 50mg tab 80 dipyridamole 75mg tab 80 disopyramide 100mg cap 17 disopyramide 150mg cap 17 disulfiram 250mg tab 93 disulfiram 500mg tab 93 DIURIL 250MG/5ML SUSP
73
divalproex sodium 125mg dr cap
25
divalproex sodium 125mg dr tab
25
divalproex sodium 250mg dr tab
25
divalproex sodium 250mg er tab
25
divalproex sodium 500mg dr tab
25
divalproex sodium 500mg er tab
25
dofetilide 0.125mg cap 18 dofetilide 0.25mg cap 18 dofetilide 0.5mg cap 18 donepezil 10mg odt 93 donepezil 10mg tab 93 donepezil 23mg tab 93 donepezil 5mg odt 93 donepezil 5mg tab 93 DOPTELET 20MG TAB 80 DOPTELET 40MG DAILY DOSE PACK
80
DOPTELET 60MG DAILY DOSE PACK
80
dorzolamide 2% ophth soln
90
dorzolamide 20mg/ml/timolol 5mg/ml ophth soln
88
dorzolamide/timolol 22.3-6.8mg/ml ophth soln (preservative-free)
88
dotti 0.025mg/24hr patch 76 dotti 0.0375mg/24hr patch
76
dotti 0.05mg/24hr patch 76 dotti 0.075mg/24hr patch 76 dotti 0.1mg/24hr patch 76 DOVATO 50-300MG TAB 54 doxazosin 1mg tab 37 doxazosin 2mg tab 37 doxazosin 4mg tab 37 doxazosin 8mg tab 37 doxepin 100mg cap 28 doxepin 10mg cap 28 doxepin 10mg/ml oral soln
28
doxepin 150mg cap 28 doxepin 25mg cap 28 doxepin 50mg cap 28 doxepin 75mg cap 28 doxercalciferol 0.0005mg cap
74
doxercalciferol 0.001mg cap
75
doxercalciferol 0.0025mg cap
75
doxy 100mg inj 96 doxycycline hyclate 100mg cap
96
doxycycline hyclate 100mg tab
96
doxycycline hyclate 20mg tab
96
doxycycline hyclate 50mg cap
96
doxycycline monohydrate 100mg cap
96
doxycycline monohydrate 100mg tab
96
doxycycline monohydrate 50mg cap
96
doxycycline monohydrate 50mg tab
96
doxycycline monohydrate 5mg/ml susp
96
doxylamine succinate 10mg/pyridoxine 10mg dr tab
33
DRIZALMA 20MG DR CAP
27
DRIZALMA 30MG DR CAP
27
DRIZALMA 40MG DR CAP
27
DRIZALMA 60MG DR CAP
27
dronabinol 10mg cap 33 dronabinol 2.5mg cap 33 dronabinol 5mg cap 33 drospirenone 3mg/ethinyl estradiol 0.02mg/inert 1 mg pack
63
drospirenone 3mg/ethinyl estradiol 0.03mg/inert ingredients 1mg pack
63
DROXIA 200MG CAP 80 DROXIA 300MG CAP 80 DROXIA 400MG CAP 80 DULERA 0.005-0.1MG INH
19
DULERA 0.005-0.2MG INH
19
DULERA 50-5MCG INH 19 duloxetine 20mg dr cap 27 duloxetine 30mg dr cap 27 duloxetine 40mg dr cap 27 duloxetine 60mg dr cap 28 DUPIXENT 200MG/1.14ML SYRINGE
71
DUPIXENT 300MG/2ML SYRINGE
71
duramorph 0.5mg/ml inj 12 duramorph 1mg/ml inj 12
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
115
ALPHABETICAL LISTING OF DRUGS
DUREZOL 0.05% OPHTH SUSP
89
dutasteride 0.5mg cap 79 dutasteride 0.5mg/tamsulosin 0.4mg cap
79
E
econazole nitrate 1% cream
69
EDURANT 25MG TAB 54 efavirenz 200mg cap 54 efavirenz 50mg cap 54 efavirenz 600mg tab 54 eletriptan 20mg tab 83 eletriptan 40mg tab 83 ELIGARD 22.5MG SYRINGE
43
ELIGARD 30MG SYRINGE
43
ELIGARD 45MG SYRINGE
43
ELIGARD 7.5MG SYRINGE
43
ELIQUIS 2.5MG TAB 21 ELIQUIS 30-DAY STARTER PACK 5MG
21
ELIQUIS 5MG TAB 21 ELMIRON 100MG CAP 79 eluryng 0.000625-0.005mg/hr vaginal system
66
EMCYT 140MG CAP 43 EMGALITY 100MG/ML SYRINGE
83
EMGALITY 120MG/ML AUTO-INJECTOR
83
EMGALITY 120MG/ML SYRINGE
83
emoquette pack 63 EMSAM 12MG/24HR PATCH
26
EMSAM 6MG/24HR PATCH
26
EMSAM 9MG/24HR PATCH
26
EMTRIVA 10MG/ML ORAL SOLN
54
EMTRIVA 200MG CAP 54 enalapril maleate 10mg tab
36
enalapril maleate 10mg/hydrochlorothiazide 25mg tab
39
enalapril maleate 2.5mg tab
36
enalapril maleate 20mg tab
36
enalapril maleate 5mg tab
36
enalapril maleate 5mg/hydrochlorothiazide 12.5mg tab
39
ENBREL 25MG INJ 12 ENBREL 25MG/0.5ML SYRINGE
12
ENBREL 50MG/ML AUTO-INJECTOR
12
ENBREL 50MG/ML CARTRIDGE
12
ENBREL 50MG/ML SYRINGE
12
ENDARI 5GM POWDER FOR ORAL SOLN
80
endocet 325-10mg tab 14 endocet 325-5mg tab 14 endocet 325-7.5mg tab 14 ENGERIX-B 10MCG/0.5ML SYRINGE
100
ENGERIX-B 20MCG/ML SYRINGE
100
enoxaparin sodium 100mg/ml (0.3ml) syringe
21
enoxaparin sodium 100mg/ml (0.4ml) syringe
21
enoxaparin sodium 100mg/ml (0.6ml) syringe
21
enoxaparin sodium 100mg/ml (0.8ml) syringe
21
enoxaparin sodium 100mg/ml (1ml) syringe
21
enoxaparin sodium 150mg/ml (0.8ml) syringe
21
enoxaparin sodium 150mg/ml (1ml) syringe
21
enpresse 28 day pack 63 enskyce 28 day pack 63 entacapone 200mg tab 49 entecavir 0.5mg tab 56 entecavir 1mg tab 56 ENTRESTO 24-26MG TAB
61
ENTRESTO 49-51MG TAB
61
ENTRESTO 97-103MG TAB
61
enulose 10gm/15ml oral soln
78
ENVARSUS 0.75MG ER TAB
86
ENVARSUS 1MG ER TAB 86 ENVARSUS 4MG ER TAB 86 EPIDIOLEX 100MG/ML ORAL SOLN
23
EPIDUO 0.3-2.5% GEL 68 epinastine 0.05% ophth soln
90
epinephrine 0.5mg/ml auto-injector
101
epinephrine 1mg/ml auto-injector
101
epitol 200mg tab 23 EPIVIR HBV 5MG/ML ORAL SOLN
56
eplerenone 25mg tab 40 eplerenone 50mg tab 40 EQUETRO 100MG ER CAP
50
EQUETRO 200MG ER CAP
50
EQUETRO 300MG ER CAP
50
ERAXIS 100MG INJ 33 ERAXIS 50MG INJ 33
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
116
ALPHABETICAL LISTING OF DRUGS
ERGOLOID MESYLATES USP 1MG TAB
95
ERIVEDGE 150MG CAP 43 ERLEADA 60MG TAB 43 erlotinib 100mg tab 44 erlotinib 150mg tab 44 erlotinib 25mg tab 45 errin 28 day 0.35mg pack 66 ertapenem 1000mg inj 40 ERY 2% PAD 68 ERYTHROCIN 500MG INJ
82
erythromycin 0.5% ophth ointment
89
erythromycin 2% gel 68 erythromycin 2% topical soln
68
erythromycin 250mg dr cap
82
erythromycin 250mg tab 82 erythromycin 500mg tab 82 erythromycin ethylsuccinate 40mg/ml susp
82
erythromycin ethylsuccinate 80mg/ml susp
82
erythromycin/benzoyl peroxide 5-3% gel
68
ESBRIET 267MG CAP 96 ESBRIET 267MG TAB 96 ESBRIET 801MG TAB 96 escitalopram 10mg tab 26 escitalopram 1mg/ml oral soln
26
escitalopram 20mg tab 26 escitalopram 5mg tab 26 esomeprazole 20mg dr cap
99
esomeprazole 40mg dr cap
99
estarylla 28 day pack 64 estazolam 1mg tab 81 estazolam 2mg tab 81
estradiol 0.00104mg/hr twice weekly patch
76
estradiol 0.00104mg/hr weekly patch
76
estradiol 0.00156mg/hr twice weekly patch
76
estradiol 0.00156mg/hr weekly patch
76
estradiol 0.00208mg/hr twice weekly patch
76
estradiol 0.00208mg/hr weekly patch
76
estradiol 0.0025mg/hr weekly patch
76
estradiol 0.00312mg/hr weekly patch
76
estradiol 0.00313mg/hr twice weekly patch
76
estradiol 0.00417mg/hr twice weekly patch
76
estradiol 0.00417mg/hr weekly patch
76
estradiol 0.01% vaginal cream
101
estradiol 0.5mg tab 76 estradiol 0.5mg/norethindrone acetate 0.1mg pack
76
estradiol 1mg tab 76 estradiol 1mg/norethindrone acetate 0.5mg pack
76
estradiol 2mg tab 76 estradiol valerate 20mg/ml inj
76
estradiol valerate 40mg/ml inj
76
ESTRING 2MG VAGINAL SYSTEM
101
eszopiclone 1mg tab 81 eszopiclone 2mg tab 81 eszopiclone 3mg tab 81 ethacrynic acid 25mg tab 72 ethambutol 100mg tab 42 ethambutol 400mg tab 42
ethinyl estradiol 0.0025mg/norethindrone acetate 0.5mg pack
76
ethinyl estradiol 0.005mg/norethindrone acetate 1mg pack
76
ethinyl estradiol 0.01mg/ethinyl estradiol 0.02mg/levonorgestrel 0.1mg 91 day pack
64
ethinyl estradiol 0.01mg/ethinyl estradiol 0.03mg/levonorgestrel 0.15mg pack
64
ethinyl estradiol 0.025mg/ferrous fumarate 75mg/norethindrone 0.8mg pack
64
ethinyl estradiol 0.025mg/inert/norgestimate 0.18mg/0.215mg/0.25mg pack
64
ethinyl estradiol 0.02mg/inert ingredients 1mg/levonorgestrel 0.1mg pack
64
ethinyl estradiol 0.02mg/norethindrone acetate 1mg pack
64
ethinyl estradiol 0.035mg/ethynodiol 1mg 28 day pack
64
ethinyl estradiol 0.035mg/ferrous fumarate 75mg/norethindrone 0.4mg pack
64
ethinyl estradiol 0.035mg/inert/norgestimate 0.18mg/0.215mg/0.25mg pack
64
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
117
ALPHABETICAL LISTING OF DRUGS
ethinyl estradiol 0.035mg/norgestimate 0.25mg pack
64
ethinyl estradiol 0.03mg/0.04mg /inert/levonorgestrel 0.05mg/ 0.075mg pack
64
ethinyl estradiol 0.03mg/inert ingredients 1mg/levonorgestrel 0.15mg pack
64
ethinyl estradiol 0.03mg/levonorgestrel 0.15mg tab 28 day pack
64
ethinyl estradiol 0.05mg/ethynodiol 1mg/inert ingredients 1mg 28 day pack
64
ethinyl estradiol/levonorgestrel 91 day pack
64
ethosuximide 250mg cap 25 ethosuximide 50mg/ml oral soln
25
etodolac 200mg cap 11 etodolac 300mg cap 11 etodolac 400mg er tab 11 etodolac 400mg tab 11 etodolac 500mg er tab 11 etodolac 500mg tab 11 etodolac 600mg er tab 11 etonogestrel-ethinyl estradiol 0.120-0.015mg/24hr vaginal ring
66
euthyrox 100mcg tab 97 euthyrox 112mcg tab 97 euthyrox 125mcg tab 97 euthyrox 137mcg tab 97 euthyrox 150mcg tab 97 euthyrox 175mcg tab 97 euthyrox 200mcg tab 97 euthyrox 25mcg tab 97 euthyrox 50mcg tab 97 euthyrox 75mcg tab 97
euthyrox 88mcg tab 97 everolimus 0.25mg tab 86 everolimus 0.5mg tab 86 everolimus 0.75mg tab 86 everolimus 2.5mg tab 45 everolimus 5mg tab 45 everolimus 7.5mg tab 45 EVOTAZ 300-150MG TAB
54
exemestane 25mg tab 43 EXTAVIA 0.3MG INJ 94 ezetimibe 10mg tab 35
F
falmina 28 day pack 64 famciclovir 125mg tab 56 famciclovir 250mg tab 56 famciclovir 500mg tab 56 famotidine 20mg tab 99 famotidine 40mg tab 99 famotidine 8mg/ml susp 99 FANAPT 10MG TAB 50 FANAPT 12MG TAB 50 FANAPT 1MG TAB 50 FANAPT 2MG TAB 50 FANAPT 4MG TAB 50 FANAPT 6MG TAB 50 FANAPT 8MG TAB 50 FANAPT TITRATION PACK
50
FARXIGA 10MG TAB 32 FARXIGA 5MG TAB 32 FARYDAK 10MG CAP 45 FARYDAK 20MG CAP 45 FASENRA 30MG/ML AUTO-INJECTOR
18
FASENRA 30MG/ML SYRINGE
18
fayosim 91 day pack 64 febuxostat 40mg tab 79 febuxostat 80mg tab 79 felbamate 120mg/ml susp 25 felbamate 400mg tab 25 felbamate 600mg tab 25 felodipine 10mg er tab 59
felodipine 2.5mg er tab 59 felodipine 5mg er tab 59 femynor 28 day pack 64 fenofibrate 134mg cap 35 fenofibrate 145mg tab 35 FENOFIBRATE 150MG CAP
35
fenofibrate 160mg tab 35 fenofibrate 200mg cap 35 fenofibrate 48mg tab 35 FENOFIBRATE 50MG CAP
35
fenofibrate 54mg tab 35 fenofibrate 67mg cap 35 fenofibric acid 135mg dr cap
35
fenofibric acid 45mg dr cap
35
fentanyl 0.012mg/hr patch
12
fentanyl 0.025mg/hr patch
12
fentanyl 0.05mg/hr patch 12 fentanyl 0.075mg/hr patch
12
FENTANYL 0.1MG BUCCAL TAB
12
fentanyl 0.1mg/hr patch 12 FENTANYL 0.2MG BUCCAL TAB
12
fentanyl 0.2mg lozenge 12 FENTANYL 0.4MG BUCCAL TAB
12
fentanyl 0.4mg lozenge 12 FENTANYL 0.6MG BUCCAL TAB
12
fentanyl 0.6mg lozenge 12 FENTANYL 0.8MG BUCCAL TAB
12
fentanyl 0.8mg lozenge 12 fentanyl 1.2mg lozenge 12 fentanyl 1.6mg lozenge 12 FENTORA 100MCG BUCCAL TAB
12
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
118
ALPHABETICAL LISTING OF DRUGS
FENTORA 200MCG BUCCAL TAB
12
FENTORA 400MCG BUCCAL TAB
13
FENTORA 600MCG BUCCAL TAB
13
FENTORA 800MCG BUCCAL TAB
13
FERRIPROX 1000MG TAB
32
FERRIPROX 100MG/ML ORAL SOLN
32
FERRIPROX 500MG TAB 32 FETZIMA 120MG ER CAP
28
FETZIMA 20MG ER CAP 28 FETZIMA 40MG ER CAP 28 FETZIMA 80MG ER CAP 28 FETZIMA PACK 28 FIASP 100UNIT/ML CARTRIDGE
30
FIASP 100UNIT/ML INJ 31 FIASP 100UNIT/ML PEN INJ
31
FINACEA 15% FOAM 72 finasteride 5mg tab 79 FIRMAGON 120MG INJ 43 FIRMAGON 80MG INJ 43 FIRVANQ 25MG/ML ORAL SOLN
41
FIRVANQ 50MG/ML ORAL SOLN
41
flac 0.01% otic soln 91 flavoxate 100mg tab 100 FLEBOGAMMA 5GM/50ML INJ
91
flecainide acetate 100mg tab
18
flecainide acetate 150mg tab
18
flecainide acetate 50mg tab
18
FLOVENT 100MCG/BLIST INH
19
FLOVENT 110MCG INH 19
FLOVENT 220MCG INH 19 FLOVENT 250MCG/BLIST INH
19
FLOVENT 44MCG INH 19 FLOVENT 50MCG/BLIST INH
19
fluconazole 100mg tab 34 fluconazole 10mg/ml susp 34 fluconazole 150mg tab 34 fluconazole 200mg tab 34 fluconazole 2mg/ml (100ml) inj
34
fluconazole 2mg/ml (200ml) inj
34
fluconazole 40mg/ml susp 34 fluconazole 50mg tab 34 flucytosine 250mg cap 33 flucytosine 500mg cap 33 fludrocortisone 0.1mg tab 67 FLUNISOLIDE 0.025MG/ACT NASAL INHALER
87
fluocinolone acetonide 0.01% cream
70
fluocinolone acetonide 0.01% otic soln
91
fluocinolone acetonide 0.01% topical soln
70
fluocinolone acetonide 0.025% cream
70
fluocinolone acetonide 0.025% ointment
70
fluocinolone acetonide 0.1mg/ml oil
70
fluocinonide 0.05% e cream
70
fluocinonide 0.05% gel 70 fluocinonide 0.05% ointment
70
fluocinonide 0.05% topical soln
70
fluorometholone 0.1% ophth susp
90
FLUOROPLEX 1% CREAM
69
FLUOROURACIL 2% TOPICAL SOLN
69
fluorouracil 5% cream 69 FLUOROURACIL 5% TOPICAL SOLN
69
fluoxetine 10mg cap 26 fluoxetine 10mg tab 26 fluoxetine 20mg cap 26 fluoxetine 20mg tab 26 fluoxetine 25mg/olanzapine 12mg cap
94
fluoxetine 25mg/olanzapine 3mg cap
94
fluoxetine 25mg/olanzapine 6mg cap
94
fluoxetine 40mg cap 26 fluoxetine 4mg/ml oral soln
26
fluoxetine 50mg/olanzapine 12mg cap
94
fluoxetine 50mg/olanzapine 6mg cap
94
FLUPHENAZINE 0.5MG/ML ORAL SOLN
52
fluphenazine 10mg tab 52 fluphenazine 1mg tab 52 fluphenazine 2.5mg tab 53 FLUPHENAZINE 2.5MG/ML INJ
53
fluphenazine 5mg tab 53 FLUPHENAZINE 5MG/ML ORAL SOLN
53
fluphenazine decanoate 25mg/ml inj
53
FLURAZEPAM 15MG CAP
81
FLURAZEPAM 30MG CAP
81
flurbiprofen 100mg tab 11
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
119
ALPHABETICAL LISTING OF DRUGS
FLURBIPROFEN SODIUM 0.03% OPHTH SOLN
90
flutamide 125mg cap 43 fluticasone propionate 0.005% ointment
70
fluticasone propionate 0.05% cream
70
fluticasone propionate 0.05mg/act nasal inhaler
87
fluticasone propionate 0.1mg/salmeterol 0.05mg inh
19
fluticasone propionate 0.25mg/salmeterol 0.05mg inh
19
fluticasone propionate 0.5mg/salmeterol 0.05mg inh
19
FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 113-14MCG/ACT POWDER INH
19
FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 232-14MCG/ACT POWDER INH
20
FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 55-14MCG/ACT POWDER INH
20
fluvastatin 20mg cap 35 fluvastatin 40mg cap 35 fluvastatin 80mg er tab 35 fluvoxamine maleate 100mg er cap
26
fluvoxamine maleate 100mg tab
26
fluvoxamine maleate 150mg er cap
26
fluvoxamine maleate 25mg tab
27
fluvoxamine maleate 50mg tab
27
fondaparinux sodium 12.5mg/ml (0.4ml) syringe
21
fondaparinux sodium 12.5mg/ml (0.6ml) syringe
21
fondaparinux sodium 12.5mg/ml (0.8ml) syringe
21
fondaparinux sodium 5mg/ml syringe
21
FORTEO 600MCG/2.4ML PEN INJ
73
fosamprenavir 700mg tab 54 fosinopril sodium 10mg tab
36
fosinopril sodium 10mg/hydrochlorothiazide 12.5mg tab
39
fosinopril sodium 20mg tab
36
fosinopril sodium 20mg/hydrochlorothiazide 12.5mg tab
39
fosinopril sodium 40mg tab
36
FOSRENOL 1000MG ORAL POWDER
78
FOSRENOL 750MG ORAL POWDER
78
FRAGMIN 10000UNIT/ML SYRINGE
21
FRAGMIN 12500UNIT/0.5ML SYRINGE
21
FRAGMIN 15000UNIT/0.6ML SYRINGE
21
FRAGMIN 18000UNT/0.72ML SYRINGE
21
FRAGMIN 2500UNIT/0.2ML SYRINGE
21
FRAGMIN 5000UNIT/0.2ML SYRINGE
21
FRAGMIN 7500UNIT/0.3ML SYRINGE
21
FRAGMIN 95000UNIT/3.8ML INJ
21
FREAMINE 6.9% INJ 88 FULPHILA 6MG/0.6ML SYRINGE
80
furosemide 10mg/ml inj 72 furosemide 10mg/ml oral soln
73
furosemide 10mg/ml syringe
73
furosemide 20mg tab 73 furosemide 40mg tab 73 furosemide 80mg tab 73 FUROSEMIDE 8MG/ML ORAL SOLN
73
FUZEON 90MG INJ 54 fyavolv 0.0025-0.5mg tab 76 fyavolv 0.005-1mg tab 76 FYCOMPA 0.5MG/ML SUSP
21
FYCOMPA 10MG TAB 21 FYCOMPA 12MG TAB 21 FYCOMPA 2MG TAB 21 FYCOMPA 4MG TAB 21 FYCOMPA 6MG TAB 21 FYCOMPA 8MG TAB 21
G
gabapentin 100mg cap 23 gabapentin 300mg cap 23 gabapentin 400mg cap 23 gabapentin 50mg/ml oral soln
23
gabapentin 600mg tab 23 gabapentin 800mg tab 23 GALAFOLD 28 DAY WALLET 123MG PACK
75
galantamine 12mg tab 93 galantamine 4mg tab 93
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
120
ALPHABETICAL LISTING OF DRUGS
galantamine 8mg tab 93 galantamine hydrobromide 16mg er cap
93
galantamine hydrobromide 24mg er cap
93
GALANTAMINE HYDROBROMIDE 4MG/ML ORAL SOLN
93
galantamine hydrobromide 8mg er cap
93
GAMMAGARD 10GM INJ
91
GAMMAGARD 2.5GM/25ML INJ
91
GAMMAGARD 5GM INJ 91 GAMMAKED 1GM/10ML INJ
91
GAMMAPLEX 10GM/100ML INJ
91
GAMMAPLEX 10GM/200ML INJ
91
GAMMAPLEX 20GM/200ML INJ
91
GAMMAPLEX 5GM/50ML INJ
91
GAMUNEX 1GM/10ML INJ
91
GARDASIL 9 INJ 100 GARDASIL 9 SYRINGE 100 gatifloxacin 0.5% ophth soln
89
GATTEX 5MG INJ 78 GAUZE PADS & DRESSINGS - PADS 2 X 2
83
GAVILYTE-C ORAL SOLN
82
gavilyte-g powder for oral soln
82
gavilyte-n powder for oral soln
82
gemfibrozil 600mg tab 35
generlac 10gm/15ml oral soln
78
gengraf 100mg cap 57 gengraf 100mg/ml oral soln
57
gengraf 25mg cap 57 GENOTROPIN 0.2MG SYRINGE
74
GENOTROPIN 0.4MG SYRINGE
74
GENOTROPIN 0.6MG SYRINGE
74
GENOTROPIN 0.8MG SYRINGE
74
GENOTROPIN 1.2MG SYRINGE
74
GENOTROPIN 1.4MG SYRINGE
74
GENOTROPIN 1.6MG SYRINGE
74
GENOTROPIN 1.8MG SYRINGE
74
GENOTROPIN 12MG CARTRIDGE
74
GENOTROPIN 1MG SYRINGE
74
GENOTROPIN 2MG SYRINGE
74
GENOTROPIN 5MG CARTRIDGE
74
GENTAK 0.3% OPHTH OINTMENT
89
gentamicin 0.1% cream 68 gentamicin 0.1% ointment 68 gentamicin 0.3% ophth soln
89
GENTAMICIN 0.8MG/ML INJ
9
gentamicin 1.2mg/ml inj 9 GENTAMICIN 1.6MG/ML INJ
9
GENTAMICIN 1MG/ML INJ
9
gentamicin 40mg/ml inj 9
GENVOYA 150-150-200-10MG TAB
54
gianvi 28-day pack 64 GILENYA 0.5MG CAP 94 GILOTRIF 20MG TAB 45 GILOTRIF 30MG TAB 45 GILOTRIF 40MG TAB 45 GLASSIA 1000MG/50ML INJ
95
glatiramer acetate 20mg/ml syringe
94
glatiramer acetate 40mg/ml syringe
94
glatopa 20mg/ml syringe 94 glatopa 40mg/ml syringe 95 glimepiride 1mg tab 32 glimepiride 2mg tab 32 glimepiride 4mg tab 32 glipizide 10mg er tab 32 glipizide 10mg tab 32 glipizide 2.5mg er tab 32 glipizide 2.5mg/metformin 250mg tab
29
glipizide 2.5mg/metformin 500mg tab
29
glipizide 5mg er tab 32 glipizide 5mg tab 32 glipizide 5mg/metformin 500mg tab
29
GLUCAGEN 1MG INJ 30 GLUCAGON (RDNA) 1MG INJ
30
glucose 100mg/ml inj 87 GLUCOSE 100MG/ML/SODIUM CHLORIDE 0.0342 MEQ/ML INJ
84
GLUCOSE 100MG/ML/SODIUM CHLORIDE 0.0769 MEQ/ML INJ
84
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
121
ALPHABETICAL LISTING OF DRUGS
GLUCOSE 25MG/ML/SODIUM CHLORIDE 0.0769 MEQ/ML INJ
84
glucose 50 mg/ml/potassium chloride 0.04meq/ml/sodium chloride 4.5mg/ml inj
84
glucose 50mg/ml inj 87 glucose 50mg/ml/potassium chloride 0.01 meq/ml/sodium chloride 0.0769 meq/ml inj
84
glucose 50mg/ml/potassium chloride 0.02 meq/ml inj
84
glucose 50mg/ml/potassium chloride 0.02 meq/ml/sodium chloride 0.0342 meq/ml inj
84
glucose 50mg/ml/potassium chloride 0.02 meq/ml/sodium chloride 0.154 meq/ml inj
84
glucose 50mg/ml/potassium chloride 0.02meq/ml/sodium chloride 4.5mg/ml inj
84
glucose 50mg/ml/potassium chloride 0.03 meq/ml/sodium chloride 0.0769 meq/ml inj
84
GLUCOSE 50MG/ML/POTASSIUM CHLORIDE 0.04 MEQ/ML/SODIUM CHLORIDE 0.154 MEQ/ML INJ
84
glucose 50mg/ml/sodium chloride 0.0342 meq/ml inj
84
GLUCOSE 50MG/ML/SODIUM CHLORIDE 0.0385 MEQ/ML INJ
84
glucose 50mg/ml/sodium chloride 4.5mg/ml inj
84
glucose 50mg/ml/sodium chloride 9mg/ml inj
84
glyburide 1.25mg tab 32 glyburide 1.25mg/metformin 250mg tab
29
glyburide 1.5mg tab 32 glyburide 2.5mg tab 32 glyburide 2.5mg/metformin 500mg tab
29
glyburide 3mg tab 32 glyburide 5mg tab 32 glyburide 5mg/metformin 500mg tab
29
glyburide 6mg tab 32 glycopyrrolate 1mg tab 99 glycopyrrolate 2mg tab 99 GLYXAMBI 10-5MG TAB
29
GLYXAMBI 25-5MG TAB
29
GRAMICIDIN 0.025MG/ML/NEOMYCIN 1.75MG/ML/POLYMYXIN B 10000UNIT/ML OPHTH SOLN
89
granisetron 1mg tab 33 griseofulvin 125mg tab 33 griseofulvin 250mg tab 33 griseofulvin 25mg/ml susp
33
griseofulvin 500mg tab 33 guanfacine 1mg er tab 8 guanfacine 1mg tab 37
guanfacine 2mg er tab 8 guanfacine 2mg tab 37 guanfacine 3mg er tab 8 guanfacine 4mg er tab 8 GUANIDINE 125MG TAB 42 GVOKE 0.5MG/0.1ML AUTO-INJECTOR
30
GVOKE 0.5MG/0.1ML SYRINGE
30
GVOKE 1MG/0.2ML AUTO-INJECTOR
30
GVOKE 1MG/0.2ML SYRINGE
30
H
HAEGARDA 2000UNIT INJ
79
HAEGARDA 3000UNIT INJ
79
hailey 24 fe 28 day pack 64 halobetasol propionate 0.05% cream
71
halobetasol propionate 0.05% ointment
71
haloperidol 0.5mg tab 51 haloperidol 10mg tab 51 haloperidol 1mg tab 51 haloperidol 20mg tab 51 haloperidol 2mg tab 51 haloperidol 2mg/ml oral soln
51
haloperidol 5mg tab 51 haloperidol 5mg/ml inj 51 haloperidol decanoate 100mg/ml (1ml) inj
51
haloperidol decanoate 100mg/ml inj
51
haloperidol decanoate 50mg/ml inj
51
HAVRIX 1440ELU/ML INJ
101
HAVRIX 1440ELU/ML SYRINGE
101
HAVRIX 720ELU/0.5ML SYRINGE
101
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
122
ALPHABETICAL LISTING OF DRUGS
heparin sodium porcine 10000unit/ml inj
21
heparin sodium porcine 1000unit/ml inj
21
heparin sodium porcine 20000unit/ml inj
21
heparin sodium porcine 5000unit/ml inj
21
HEPATAMINE 8% INJ 88 HETLIOZ 20MG CAP 82 HIBERIX 10MCG INJ 100 HUMALOG 100UNIT/ML CARTRIDGE
31
HUMALOG 100UNIT/ML INJ
31
HUMALOG 100UNIT/ML KWIKPEN SYRINGE
31
HUMALOG 200UNIT/ML PEN INJ
31
HUMALOG JR PEN INJ 31 HUMALOG MIX 25-75UNIT/ML INJ
31
HUMALOG MIX 25-75UNIT/ML PEN INJ
31
HUMALOG MIX 50-50UNIT/ML INJ
31
HUMALOG MIX 50-50UNIT/ML PEN INJ
31
HUMIRA 10MG/0.1ML SYRINGE
10
HUMIRA 10MG/0.2ML SYRINGE
10
HUMIRA 20MG/0.2ML SYRINGE
10
HUMIRA 20MG/0.4ML SYRINGE
10
HUMIRA 40MG/0.4ML AUTO-INJECTOR
10
HUMIRA 40MG/0.4ML SYRINGE
10
HUMIRA 40MG/0.8ML AUTO-INJECTOR
10
HUMIRA 40MG/0.8ML SYRINGE
10
HUMIRA PEDIATRIC CROHN'S STARTER PACK (3) 80MG/0.8ML INJ
10
HUMIRA PEDIATRIC CROHN'S STARTER PACK SYRINGE (2) 40MG/0.4ML
10
HUMIRA PEN - CROHN'S STARTER PACK 40MG/0.8ML INJ
10
HUMIRA PEN - CROHN'S STARTER PACK 80MG/0.8ML INJ
10
HUMIRA PEN - PSORIASIS STARTER PACK 40MG/0.8ML INJ
10
HUMIRA PEN - PSORIASIS STARTER PACK 80MG/0.8ML INJ
10
HUMULIN 70-30UNIT/ML PEN INJ
31
HUMULIN R 500UNIT/ML INJ
31
HUMULIN R 500UNIT/ML PEN INJ
31
hydralazine 100mg tab 40 hydralazine 10mg tab 40 hydralazine 25mg tab 40 hydralazine 50mg tab 40 hydrochlorothiazide 12.5mg cap
73
hydrochlorothiazide 12.5mg tab
73
hydrochlorothiazide 12.5mg/irbesartan 150mg tab
39
hydrochlorothiazide 12.5mg/irbesartan 300mg tab
39
hydrochlorothiazide 12.5mg/lisinopril 10mg tab
39
hydrochlorothiazide 12.5mg/lisinopril 20mg tab
39
hydrochlorothiazide 12.5mg/losartan potassium 100mg tab
39
hydrochlorothiazide 12.5mg/losartan potassium 50mg tab
39
hydrochlorothiazide 12.5mg/olmesartan medoxomil 20mg tab
39
hydrochlorothiazide 12.5mg/olmesartan medoxomil 40mg tab
39
hydrochlorothiazide 12.5mg/quinapril 10mg tab
39
hydrochlorothiazide 12.5mg/quinapril 20mg tab
39
hydrochlorothiazide 12.5mg/valsartan 160mg tab
39
hydrochlorothiazide 12.5mg/valsartan 320mg tab
39
hydrochlorothiazide 12.5mg/valsartan 80mg tab
39
hydrochlorothiazide 15mg/methyldopa 250mg tab
39
hydrochlorothiazide 25mg tab
73
hydrochlorothiazide 25mg/lisinopril 20mg tab
39
hydrochlorothiazide 25mg/losartan potassium 100mg tab
39
hydrochlorothiazide 25mg/methyldopa 250mg tab
39
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
123
ALPHABETICAL LISTING OF DRUGS
hydrochlorothiazide 25mg/metoprolol tartrate 100mg tab
39
hydrochlorothiazide 25mg/metoprolol tartrate 50mg tab
39
hydrochlorothiazide 25mg/olmesartan medoxomil 40mg tab
39
hydrochlorothiazide 25mg/propranolol 40mg tab
39
hydrochlorothiazide 25mg/propranolol 80mg tab
39
hydrochlorothiazide 25mg/quinapril 20mg tab
39
hydrochlorothiazide 25mg/spironolactone 25mg tab
72
hydrochlorothiazide 25mg/triamterene 37.5mg cap
72
hydrochlorothiazide 25mg/triamterene 37.5mg tab
72
hydrochlorothiazide 25mg/valsartan 160mg tab
39
hydrochlorothiazide 25mg/valsartan 320mg tab
39
hydrochlorothiazide 50mg tab
73
hydrochlorothiazide 50mg/metoprolol tartrate 100mg tab
39
hydrochlorothiazide 50mg/triamterene 75mg tab
72
hydrocodone bitartrate 10mg er cap
13
hydrocodone bitartrate 10mg/ibuprofen 200mg tab
14
hydrocodone bitartrate 15mg er cap
13
hydrocodone bitartrate 20mg er cap
13
hydrocodone bitartrate 30mg er cap
13
hydrocodone bitartrate 40mg er cap
13
hydrocodone bitartrate 50mg er cap
13
hydrocodone bitartrate 5mg/ibuprofen 200mg tab
14
hydrocodone bitartrate 7.5mg/ibuprofen 200mg tab
14
hydrocortisone 1% cream 71 hydrocortisone 1.67mg/ml enema
15
hydrocortisone 10mg tab 66 hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml ophth susp
90
hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml otic soln
91
hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml otic susp
91
hydrocortisone 2.5% cream
71
hydrocortisone 2.5% lotion
71
hydrocortisone 2.5% ointment
71
hydrocortisone 20mg tab 67 hydrocortisone 5mg tab 67 hydrocortisone/pramoxine 1-1% rectal cream
15
hydromorphone 10mg/ml (1ml) inj
13
hydromorphone 10mg/ml (5ml) inj
13
hydromorphone 1mg/ml oral soln
13
hydromorphone 2mg tab 13 hydromorphone 4mg tab 13 hydromorphone 8mg tab 13 hydroxychloroquine sulfate 200mg tab
42
hydroxyurea 500mg cap 47 hydroxyzine 10mg tab 16 hydroxyzine 25mg tab 16 hydroxyzine 2mg/ml oral soln
16
hydroxyzine 50mg tab 17 HYDROXYZINE PAMOATE 100MG CAP
17
hydroxyzine pamoate 25mg cap
17
hydroxyzine pamoate 50mg cap
17
I
ibandronic acid 150mg tab
73
IBRANCE 100MG CAP 45 IBRANCE 100MG TAB 45 IBRANCE 125MG CAP 45 IBRANCE 125MG TAB 45 IBRANCE 75MG CAP 45 IBRANCE 75MG TAB 45 ibu 600mg tab 11 ibu 800mg tab 11 ibuprofen 20mg/ml susp 11 ibuprofen 400mg tab 11 ibuprofen 600mg tab 11 ibuprofen 800mg tab 11 icatibant 10mg/ml syringe 79 ICLUSIG 15MG TAB 45 ICLUSIG 45MG TAB 45 IDHIFA 100MG TAB 45 IDHIFA 50MG TAB 45 ILEVRO 0.3% OPHTH SUSP
90
imatinib 100mg tab 45 imatinib 400mg tab 45
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
124
ALPHABETICAL LISTING OF DRUGS
IMBRUVICA 140MG CAP
45
IMBRUVICA 140MG TAB 45 IMBRUVICA 280MG TAB 45 IMBRUVICA 420MG TAB 45 IMBRUVICA 560MG TAB 45 IMBRUVICA 70MG CAP 45 imipramine 10mg tab 28 imipramine 25mg tab 28 imipramine 50mg tab 28 imipramine pamoate 100mg cap
28
imipramine pamoate 125mg cap
28
imipramine pamoate 150mg cap
29
imipramine pamoate 75mg cap
29
imiquimod 5% cream 71 IMOVAX 2.5UNIT/ML INJ
101
incassia 28 day 0.35mg pack
66
INCRELEX 40MG/4ML INJ
74
INCRUSE 62.5MCG/INH INH
18
indapamide 1.25mg tab 73 indapamide 2.5mg tab 73 INDOCIN 50MG RECTAL SUPP
11
indomethacin 25mg cap 11 indomethacin 50mg cap 11 indomethacin 75mg er cap
11
INFANRIX INJ 98 INGREZZA 40MG CAP 94 INGREZZA 80MG CAP 94 INLYTA 1MG TAB 45 INLYTA 5MG TAB 45 INNOPRAN 120MG ER CAP
58
INNOPRAN 80MG ER CAP
58
INREBIC 100MG CAP 45
INSULIN PEN NEEDLE 83 INSULIN SYRINGE (DISP) U-100 0.3ML
83
INSULIN SYRINGE (DISP) U-100 1/2ML
82
INSULIN SYRINGE (DISP) U-100 1ML
83
INTELENCE 100MG TAB 54 INTELENCE 200MG TAB 54 INTELENCE 25MG TAB 54 INTRALIPID 20GM/100ML INJ
87
INTRON A 10MU INJ 47 INTRON A 10MU/ML INJ 47 INTRON A 18MU INJ 47 INTRON A 50MU INJ 47 INTRON A 6000000UNIT/ML INJ
47
introvale 91 day pack 64 INVEGA 117MG/0.75ML SYRINGE
50
INVEGA 156MG/ML SYRINGE
50
INVEGA 234MG/1.5ML SYRINGE
50
INVEGA 273MG/0.875ML SYRINGE
50
INVEGA 39MG/0.25ML SYRINGE
50
INVEGA 410MG/1.315ML SYRINGE
50
INVEGA 546MG/1.75ML SYRINGE
50
INVEGA 78MG/0.5ML SYRINGE
50
INVEGA 819MG/2.625ML SYRINGE
50
INVIRASE 500MG TAB 54 IOPIDINE 1% OPHTH SOLN
88
IPOL INJ 101
ipratropium bromide 0.021mg/act nasal inhaler
87
ipratropium bromide 0.042mg/act nasal inhaler
87
ipratropium bromide 0.2mg/ml inh soln
18
ipratropium/albuterol 0.5-2.5mg/3ml inh soln
20
irbesartan 150mg tab 37 irbesartan 300mg tab 37 irbesartan 75mg tab 37 IRESSA 250MG TAB 45 ISENTRESS 100MG CHEW TAB
54
ISENTRESS 100MG GRANULES FOR ORAL SUSP
54
ISENTRESS 25MG CHEW TAB
54
ISENTRESS 400MG TAB 54 ISENTRESS 600MG TAB 54 isibloom 28 day pack 64 ISOLYTE P INJ 84 ISOLYTE S INJ 84 isoniazid 100mg tab 42 ISONIAZID 10MG/ML ORAL SOLN
42
isoniazid 300mg tab 42 ISOPROPYL ALCOHOL 0.7ML/ML PAD
83
isosorbide dinitrate 10mg tab
16
isosorbide dinitrate 20mg tab
16
isosorbide dinitrate 30mg tab
16
isosorbide dinitrate 5mg tab
16
isosorbide mononitrate 10mg tab
16
isosorbide mononitrate 120mg er tab
16
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
125
ALPHABETICAL LISTING OF DRUGS
isosorbide mononitrate 20mg tab
16
isosorbide mononitrate 30mg er tab
16
isosorbide mononitrate 60mg er tab
16
isotretinoin 10mg cap 68 isotretinoin 20mg cap 68 isotretinoin 30mg cap 68 isotretinoin 40mg cap 68 isradipine 2.5mg cap 59 isradipine 5mg cap 59 itraconazole 100mg cap 34 ivermectin 3mg tab 16 IXIARO 0.012MG/ML SYRINGE
101
J
JADENU 180MG GRANULES
32
JADENU 360MG GRANULES
32
JADENU 90MG GRANULES
32
JAKAFI 10MG TAB 45 JAKAFI 15MG TAB 45 JAKAFI 20MG TAB 45 JAKAFI 25MG TAB 45 JAKAFI 5MG TAB 45 jantoven 10mg tab 20 jantoven 1mg tab 20 jantoven 2.5mg tab 20 jantoven 2mg tab 20 jantoven 3mg tab 20 jantoven 4mg tab 20 jantoven 5mg tab 20 jantoven 6mg tab 20 jantoven 7.5mg tab 20 JANUMET 1000-100MG ER TAB
29
JANUMET 1000-50MG ER TAB
29
JANUMET 1000-50MG TAB
29
JANUMET 500-50MG ER TAB
29
JANUMET 500-50MG TAB
29
JANUVIA 100MG TAB 30 JANUVIA 25MG TAB 30 JANUVIA 50MG TAB 30 JARDIANCE 10MG TAB 32 JARDIANCE 25MG TAB 32 jasmiel 28 day pack 64 JENTADUETO 2.5-1000MG ER TAB
29
JENTADUETO 2.5-1000MG TAB
29
JENTADUETO 2.5-500MG TAB
29
JENTADUETO 2.5-850MG TAB
29
JENTADUETO 5-1000MG ER TAB
29
jinteli 0.005-1mg tab 76 juleber 28 day pack 64 JULUCA 50-25MG TAB 55 junel 1.5/30 21 day pack 64 junel 1/20 21 day pack 64 junel fe 1.5/30 28 day pack
64
junel fe 1/20 28 day pack 64 junel fe 24 1/20 28 day pack
64
JUXTAPID 10MG CAP 35 JUXTAPID 20MG CAP 35 JUXTAPID 30MG CAP 36 JUXTAPID 40MG CAP 36 JUXTAPID 5MG CAP 36 JUXTAPID 60MG CAP 36 JYNARQUE 15MG TAB 75 JYNARQUE 30MG TAB 75 JYNARQUE 45/15 THERAPY PACK
75
JYNARQUE 60/30 THERAPY PACK
75
JYNARQUE 90/30 THERAPY PACK
75
JYNARQUE TAB 15/15MG THERAPY PACK
76
JYNARQUE TAB 30/15MG THERAPY PACK
76
K
kaitlib fe 28 day pack 64 KALETRA 100-25MG TAB
55
KALETRA 200-50MG TAB
55
KALYDECO 150MG TAB 95 KALYDECO 25MG GRANULES
95
KALYDECO 50MG GRANULES
95
KALYDECO 75MG GRANULES
95
kariva 28 day pack 64 KCL/D5W/LR INJ 0.15% 84 kelnor 1/35 28 day pack 64 kelnor 1/50 28 day pack 64 ketoconazole 2% cream 69 ketoconazole 2% foam 69 ketoconazole 2% shampoo
69
ketoconazole 200mg tab 34 ketodan 2% foam 69 ketorolac tromethamine 0.4% ophth soln
90
ketorolac tromethamine 0.5% ophth soln
90
ketorolac tromethamine 10mg tab
11
KEVZARA 150MG/1.14ML AUTO-INJECTOR
10
KEVZARA 150MG/1.14ML SYRINGE
10
KEVZARA 200MG/1.14ML AUTO-INJECTOR
10
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
126
ALPHABETICAL LISTING OF DRUGS
KEVZARA 200MG/1.14ML SYRINGE
10
KINRIX INJ 98 KINRIX PF INJ 98 kionex 15gm/60ml susp 86 KISQALI 200MG DAILY DOSE PACK
45
KISQALI 400MG DAILY DOSE PACK
45
KISQALI 600MG DAILY DOSE PACK
45
KISQALI FEMARA CO-PACK 200 PACK
44
KISQALI FEMARA CO-PACK 400 PACK
44
KISQALI FEMARA CO-PACK 600 PACK
44
klor-con 10meq er tab 84 klor-con 10meq micro er tab
84
KLOR-CON 15MEQ MICRO ER TAB
85
klor-con 20meq micro er tab
85
klor-con 20meq powder for oral soln
85
klor-con 8meq er tab 85 KORLYM 300MG TAB 30 KOSELUGO 10MG CAP 45 KOSELUGO 25MG CAP 45 KRINTAFEL 150MG TAB 42 K-TAB 8MEQ ER TAB 84 kurvelo pack 65 KUVAN 100MG POWDER FOR ORAL SOLN
75
KUVAN 100MG TAB 75 KUVAN 500MG POWDER FOR ORAL SOLN
75
L
labetalol 100mg tab 57 labetalol 200mg tab 57
labetalol 300mg tab 57 lactulose 667mg/ml oral soln
82
LAMICTAL XR BLUE KIT
23
LAMICTAL XR GREEN KIT
23
LAMICTAL XR ORANGE KIT
23
lamivudine 100mg tab 56 lamivudine 10mg/ml oral soln
55
lamivudine 150mg tab 55 lamivudine 150mg/zidovudine 300mg tab
55
lamivudine 300mg tab 55 lamotrigine 100mg er tab 23 lamotrigine 100mg odt 23 lamotrigine 100mg tab 23 lamotrigine 150mg tab 23 lamotrigine 200mg er tab 23 lamotrigine 200mg odt 23 lamotrigine 200mg tab 23 lamotrigine 250mg er tab 23 lamotrigine 25mg chew tab
23
lamotrigine 25mg er tab 23 lamotrigine 25mg odt 23 lamotrigine 25mg pack 23 lamotrigine 25mg tab 23 lamotrigine 300mg er tab 23 lamotrigine 50mg er tab 23 lamotrigine 50mg odt 23 lamotrigine 5mg chew tab 23 lamotrigine tab 25mg (42)/100mg (7) starter pack
23
lamotrigine tab 25mg (84)/100mg (14) starter pack
23
lansoprazole 15mg dr cap 99 lansoprazole 30mg dr cap 99 lanthanum carbonate 1000mg chew tab
78
lanthanum carbonate 500mg chew tab
78
lanthanum carbonate 750mg chew tab
78
LANTUS 100UNIT/ML INJ
31
LANTUS 100UNIT/ML PEN INJ
31
larin 1.5/30 pack 65 larin 1/20 pack 65 larin fe 1.5/30 pack 65 larin fe 1/20 pack 65 larissia 28 day pack 65 latanoprost 0.005% ophth soln
90
LATUDA 120MG TAB 50 LATUDA 20MG TAB 50 LATUDA 40MG TAB 50 LATUDA 60MG TAB 50 LATUDA 80MG TAB 50 layolis fe 28 pack 65 leena 28 day pack 65 leflunomide 10mg tab 12 leflunomide 20mg tab 12 LENVIMA 10 10MG PACK
45
LENVIMA 12 4MG PACK 45 LENVIMA 14 PACK 45 LENVIMA 18 PACK 45 LENVIMA 20 10MG PACK
45
LENVIMA 24 PACK 46 LENVIMA 4 4MG PACK 46 LENVIMA 8 4MG PACK 46 lessina 28 day pack 65 letrozole 2.5mg tab 43 LEUCOVORIN 10MG TAB
48
LEUCOVORIN 15MG TAB
48
leucovorin 25mg tab 48 leucovorin 5mg tab 48 LEUKERAN 2MG TAB 42 leuprolide acetate 5mg/ml inj
43
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
127
ALPHABETICAL LISTING OF DRUGS
levalbuterol 0.103mg/ml inh soln
20
levalbuterol 0.21mg/ml inh soln
20
levalbuterol 0.417mg/ml inh soln
20
levalbuterol 2.5mg/ml inh soln
20
LEVEMIR 100UNIT/ML INJ
31
LEVEMIR 100UNIT/ML PEN INJ
31
levetiracetam 1000mg tab 23 levetiracetam 100mg/ml oral soln
23
levetiracetam 250mg tab 23 levetiracetam 500mg er tab
23
levetiracetam 500mg tab 23 levetiracetam 750mg er tab
23
levetiracetam 750mg tab 23 LEVOBUNOLOL 0.5% OPHTH SOLN
88
levocarnitine 100mg/ml oral soln
75
levocarnitine 330mg tab 75 levocetirizine 0.5mg/ml oral soln
34
levocetirizine 5mg tab 34 levofloxacin 0.5% ophth soln
89
levofloxacin 250mg tab 77 levofloxacin 25mg/ml inj 77 levofloxacin 25mg/ml oral soln
77
levofloxacin 500mg tab 77 levofloxacin 5mg/ml (100ml) inj
77
levofloxacin 5mg/ml (150ml) inj
77
levofloxacin 750mg tab 77 levonest 28 day pack 65 levora 0.15/30 28 day pack
65
levo-t 100mcg tab 97 levo-t 112mcg tab 97 levo-t 125mcg tab 97 levo-t 137mcg tab 97 levo-t 150mcg tab 97 levo-t 175mcg tab 97 levo-t 200mcg tab 97 levo-t 25mcg tab 97 levo-t 300mcg tab 97 levo-t 50mcg tab 97 levo-t 75mcg tab 97 levo-t 88mcg tab 97 levothyroxine sodium 0.025mg tab
97
levothyroxine sodium 0.05mg tab
97
levothyroxine sodium 0.075mg tab
97
levothyroxine sodium 0.088mg tab
97
levothyroxine sodium 0.112mg tab
97
levothyroxine sodium 0.125mg tab
97
levothyroxine sodium 0.137mg tab
97
levothyroxine sodium 0.15mg tab
97
levothyroxine sodium 0.175mg tab
97
levothyroxine sodium 0.1mg tab
97
levothyroxine sodium 0.2mg tab
97
levothyroxine sodium 0.3mg tab
97
levoxyl 100mcg tab 97 levoxyl 112mcg tab 97 levoxyl 125mcg tab 97 levoxyl 137mcg tab 97 levoxyl 150mcg tab 97 levoxyl 175mcg tab 97 levoxyl 200mcg tab 97 levoxyl 25mcg tab 97 levoxyl 50mcg tab 97
levoxyl 75mcg tab 98 levoxyl 88mcg tab 98 LEXIVA 50MG/ML SUSP 55 LIDOCAINE 2% GEL 71 lidocaine 2% topical soln 86 lidocaine 4% topical soln 71 lidocaine 5% ointment 71 lidocaine 5% patch 71 lidocaine/prilocaine 2.5-2.5% cream
71
lindane 1% shampoo 72 linezolid 20mg/ml susp 41 linezolid 2mg/ml inj 41 linezolid 600mg tab 41 liothyronine sodium 0.005mg tab
98
liothyronine sodium 0.025mg tab
98
liothyronine sodium 0.05mg tab
98
lisinopril 10mg tab 36 lisinopril 2.5mg tab 36 lisinopril 20mg tab 36 lisinopril 30mg tab 36 lisinopril 40mg tab 36 lisinopril 5mg tab 36 lithium carbonate 150mg cap
49
lithium carbonate 300mg cap
49
lithium carbonate 300mg er tab
49
lithium carbonate 300mg tab
50
lithium carbonate 450mg er tab
50
lithium carbonate 600mg cap
50
lithium citrate 60mg/ml oral soln
50
LITHOSTAT 250MG TAB 79 LOKELMA 10GM POWDER FOR ORAL SUSP
86
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
128
ALPHABETICAL LISTING OF DRUGS
LOKELMA 5GM POWDER FOR ORAL SUSP
86
LONHALA 25MCG/ML INH SOLN
18
LONSURF 6.14-15MG TAB
44
LONSURF 8.19-20MG TAB
44
loperamide 2mg cap 32 lopinavir 80mg/ml/ritonavir 20mg/ml oral solution
55
lopreeza 1/0.5mg 28 day pack
76
lorazepam 0.5mg tab 17 lorazepam 1mg tab 17 lorazepam 2mg tab 17 lorazepam 2mg/ml oral soln
17
LORBRENA 100MG TAB 46 LORBRENA 25MG TAB 46 lorcet 325-10mg tab 14 lorcet 325-5mg tab 14 lorcet 325-7.5mg tab 14 loryna 28 day pack 65 losartan potassium 100mg tab
37
losartan potassium 25mg tab
37
losartan potassium 50mg tab
37
LOTEMAX 0.5% OPHTH GEL
90
LOTEMAX 0.5% OPHTH OINTMENT
90
loteprednol etabonate 0.5% ophth susp
90
lovastatin 10mg tab 35 lovastatin 20mg tab 35 lovastatin 40mg tab 35 low-ogestrel 28 day pack 65 loxapine 10mg cap 51 loxapine 25mg cap 51 loxapine 50mg cap 52
loxapine 5mg cap 52 LUMIGAN 0.01% OPHTH SOLN
90
LUPANETA PACK 1-MONTH PACK
74
LUPANETA PACK 3-MONTH PACK
74
LUPRON 11.25MG SYRINGE
43
LUPRON 22.5MG SYRINGE
43
LUPRON 3.75MG SYRINGE
43
LUPRON 30MG SYRINGE
43
LUPRON 45MG SYRINGE
43
LUPRON 7.5MG SYRINGE
43
lutera 28 day pack 65 LYNPARZA 100MG TAB 46 LYNPARZA 150MG TAB 46 LYSODREN 500MG TAB 43 lyza 0.35mg pack 66
M
magnesium sulfate 500mg/ml inj
84
magnesium sulfate 500mg/ml syringe
84
malathion 0.5% lotion 72 MAPROTILINE 25MG TAB
26
MAPROTILINE 50MG TAB
26
MAPROTILINE 75MG TAB
26
marlissa 28 day pack 65 MARPLAN 10MG TAB 26 MATULANE 50MG CAP 47 matzim 180mg er tab 59 matzim 240mg er tab 59 matzim 300mg er tab 59 matzim 360mg er tab 59 matzim 420mg er tab 59
MAVYRET 100-40MG TAB
56
MAXIDEX 0.1% OPHTH SUSP
90
MAYZENT 0.25MG TAB 95 MAYZENT 2MG TAB 95 meclizine 12.5mg tab 33 meclizine 25mg tab 33 MEDROL 2MG TAB 67 medroxyprogesterone acetate 10mg tab
93
medroxyprogesterone acetate 150mg/ml inj
66
medroxyprogesterone acetate 150mg/ml syringe
66
medroxyprogesterone acetate 2.5mg tab
93
medroxyprogesterone acetate 5mg tab
93
MEFLOQUINE 250MG TAB
42
megestrol acetate 125mg/ml susp
93
megestrol acetate 20mg tab
43
megestrol acetate 40mg tab
43
megestrol acetate 40mg/ml susp
43
MEKINIST 0.5MG TAB 46 MEKINIST 2MG TAB 46 MEKTOVI 15MG TAB 46 meloxicam 15mg tab 11 meloxicam 7.5mg tab 11 memantine 10mg tab 93 memantine 10mg/memantine 5mg pack
93
memantine 14mg er cap 93 memantine 21mg er cap 93 memantine 28mg er cap 93 memantine 2mg/ml oral soln
93
memantine 5mg tab 93 memantine 7mg er cap 94
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
129
ALPHABETICAL LISTING OF DRUGS
MENACTRA INJ 100 MENVEO INJ 100 mercaptopurine 50mg tab 42 meropenem 1000mg inj 40 meropenem 500mg inj 40 mesalamine 1000mg rectal supp
78
mesalamine 1200mg dr tab
78
mesalamine 375mg er cap 78 mesalamine 400mg dr cap 78 mesalamine 66.7mg/ml enema
78
mesalamine 800mg dr tab 78 MESNEX 400MG TAB 48 METAPROTERENOL SULFATE 2MG/ML ORAL SOLN
20
METAXALONE 400MG TAB
87
metaxalone 800mg tab 87 metformin 1000mg tab 30 metformin 500mg er tab 30 metformin 500mg tab 30 metformin 750mg er tab 30 metformin 850mg tab 30 methadone 10mg tab 13 methadone 5mg tab 13 methazolamide 25mg tab 72 methazolamide 50mg tab 72 methenamine hippurate 1000mg tab
99
methimazole 10mg tab 96 methimazole 5mg tab 96 methocarbamol 500mg tab
87
methocarbamol 750mg tab
87
methotrexate 2.5mg tab 42 methotrexate 25mg/ml (2ml) inj
42
methotrexate 25mg/ml inj 42 methoxsalen 10mg cap 69 METHSCOPOLAMINE BROMIDE 2.5MG TAB
99
METHSCOPOLAMINE BROMIDE 5MG TAB
99
methyldopa 250mg tab 37 methyldopa 500mg tab 37 methylphenidate 10mg cr cap
9
methylphenidate 10mg er tab
9
methylphenidate 10mg la cap
9
methylphenidate 10mg tab
9
METHYLPHENIDATE 18MG ER TAB
9
methylphenidate 18mg er tab
9
methylphenidate 1mg/ml oral soln
9
methylphenidate 20mg cr cap
9
methylphenidate 20mg er tab
9
methylphenidate 20mg la cap
9
methylphenidate 20mg tab
9
methylphenidate 27mg sr tab
9
methylphenidate 2mg/ml oral soln
9
methylphenidate 30mg cr cap
9
methylphenidate 30mg la cap
9
methylphenidate 36mg sr tab
9
methylphenidate 40mg cr cap
9
methylphenidate 40mg la cap
9
methylphenidate 50mg cr cap
9
methylphenidate 54mg sr tab
9
methylphenidate 5mg tab 9
methylphenidate 60mg cr cap
9
methylprednisolone 16mg tab
67
methylprednisolone 32mg tab
67
methylprednisolone 4mg pack
67
methylprednisolone 4mg tab
67
methylprednisolone 8mg tab
67
metoclopramide 10mg tab 77 metoclopramide 1mg/ml oral soln
77
metoclopramide 5mg tab 77 metolazone 10mg tab 73 metolazone 2.5mg tab 73 metolazone 5mg tab 73 metoprolol succinate 100mg er tab
58
metoprolol succinate 200mg er tab
58
metoprolol succinate 25mg er tab
58
metoprolol succinate 50mg er tab
58
metoprolol tartrate 100mg tab
58
metoprolol tartrate 25mg tab
58
metoprolol tartrate 50mg tab
58
metronidazole 0.75% cream
72
metronidazole 0.75% gel 72 metronidazole 0.75% lotion
72
metronidazole 0.75% vaginal gel
101
metronidazole 1% gel 72 metronidazole 250mg tab 40 metronidazole 375mg cap 40 metronidazole 500mg tab 40 metronidazole 5mg/ml inj 40
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
130
ALPHABETICAL LISTING OF DRUGS
mexiletine 150mg cap 17 mexiletine 200mg cap 18 mexiletine 250mg cap 18 micafungin sodium 100mg inj
33
micafungin sodium 50mg inj
33
microgestin 1.5/30 21 day pack
65
microgestin 1/20 21 day pack
65
microgestin fe 1.5/30 28 day pack
65
microgestin fe 1/20 28 day pack
65
midodrine 10mg tab 102 midodrine 2.5mg tab 102 midodrine 5mg tab 102 miglitol 100mg tab 29 miglitol 25mg tab 29 miglitol 50mg tab 29 miglustat 100mg cap 80 mili 28 day pack 65 mimvey pack 76 minitran 0.1mg/hr patch 16 minitran 0.2mg/hr patch 16 minitran 0.4mg/hr patch 16 minitran 0.6mg/hr patch 16 minocycline 100mg cap 96 minocycline 100mg tab 96 minocycline 50mg cap 96 minocycline 50mg tab 96 minocycline 75mg cap 96 minocycline 75mg tab 96 minoxidil 10mg tab 40 minoxidil 2.5mg tab 40 mirtazapine 15mg odt 26 mirtazapine 15mg tab 26 mirtazapine 30mg odt 26 mirtazapine 30mg tab 26 mirtazapine 45mg odt 26 mirtazapine 45mg tab 26 mirtazapine 7.5mg tab 26 misoprostol 0.1mg tab 99 misoprostol 0.2mg tab 99
MITIGARE 0.6MG CAP 79 M-M-R II INJ 101 modafinil 100mg tab 9 modafinil 200mg tab 9 moexipril 15mg tab 36 moexipril 7.5mg tab 36 MOLINDONE 10MG TAB 52 MOLINDONE 25MG TAB 52 MOLINDONE 5MG TAB 52 mometasone furoate 0.1% cream
71
mometasone furoate 0.1% lotion
71
mometasone furoate 0.1% ointment
71
mondoxyne 100mg cap 96 montelukast 10mg tab 18 montelukast 4mg chew tab
18
montelukast 4mg granules
18
montelukast 5mg chew tab
18
morphine sulfate 100mg er tab
13
morphine sulfate 15mg er tab
13
morphine sulfate 15mg tab
13
morphine sulfate 200mg er tab
13
morphine sulfate 20mg/ml oral soln
13
morphine sulfate 2mg/ml oral soln
13
morphine sulfate 30mg er tab
13
morphine sulfate 30mg tab
13
morphine sulfate 4mg/ml oral soln
13
morphine sulfate 60mg er tab
13
MOVANTIK 12.5MG TAB 78 MOVANTIK 25MG TAB 78
moxifloxacin 0.5% ophth soln
89
moxifloxacin 1.6mg/ml inj 77 moxifloxacin 400mg tab 77 MULTAQ 400MG TAB 18 mupirocin 2% ointment 68 mycophenolate mofetil 200mg/ml susp
57
mycophenolate mofetil 250mg cap
57
mycophenolate mofetil 500mg tab
57
mycophenolic acid 180mg dr tab
86
mycophenolic acid 360mg dr tab
86
myorisan 10mg cap 68 myorisan 20mg cap 68 myorisan 30mg cap 68 myorisan 40mg cap 68 MYRBETRIQ 25MG ER TAB
100
MYRBETRIQ 50MG ER TAB
100
N
nabumetone 500mg tab 11 nabumetone 750mg tab 11 nadolol 20mg tab 58 nadolol 40mg tab 58 nadolol 80mg tab 58 nafcillin 1000mg inj 93 nafcillin 100mg/ml inj 93 nafcillin 2000mg inj 93 naftifine 1% cream 69 naftifine 2% cream 69 NALOXONE 0.4MG/ML CARTRIDGE
32
naloxone 0.4mg/ml inj 32 naloxone 1mg/ml syringe 32 naltrexone 50mg tab 32 naproxen 250mg tab 11 naproxen 375mg dr tab 11 naproxen 375mg tab 11 naproxen 500mg dr tab 11
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
131
ALPHABETICAL LISTING OF DRUGS
naproxen 500mg tab 11 naproxen sodium 275mg tab
11
naproxen sodium 550mg tab
11
naratriptan 1mg tab 83 naratriptan 2.5mg tab 83 NARCAN 4MG/0.1ML NASAL SPRAY
32
NATACYN 5% OPHTH SUSP
89
NATAZIA 28 DAY PACK 65 nateglinide 120mg tab 31 nateglinide 60mg tab 31 NATPARA 100MCG CARTRIDGE
73
NATPARA 25MCG CARTRIDGE
73
NATPARA 50MCG CARTRIDGE
73
NATPARA 75MCG CARTRIDGE
73
NAYZILAM 5MG/0.1ML NASAL SPRAY
22
necon 0.5/35 28 day pack 65 NEEDLES INSULIN DISP. SAFETY
83
NEFAZODONE 100MG TAB
27
NEFAZODONE 150MG TAB
27
NEFAZODONE 200MG TAB
27
NEFAZODONE 250MG TAB
27
NEFAZODONE 50MG TAB
27
neomycin sulfate 500mg tab
9
neomycin/bacitracin/polymyxin ophth ointment 5(3.5)mg-400unit-10000unit
89
neomycin/polymyxin/bacitracin/hydrocortisone ophth ointmentment 1%
90
NEPHRAMINE 5.4% INJ 88 NERLYNX 40MG TAB 46 NEUPRO 1MG/24HR PATCH
48
NEUPRO 2MG/24HR PATCH
48
NEUPRO 3MG/24HR PATCH
48
NEUPRO 4MG/24HR PATCH
48
NEUPRO 6MG/24HR PATCH
48
NEUPRO 8MG/24HR PATCH
48
NEVANAC 0.1% OPHTH SUSP
90
NEVIRAPINE 100MG ER TAB
55
nevirapine 10mg/ml susp 55 nevirapine 200mg tab 55 nevirapine 400mg er tab 55 NEXAVAR 200MG TAB 46 niacin 1000mg er tab 36 niacin 500mg er tab 36 niacin 750mg er tab 36 nicardipine 20mg cap 59 nicardipine 30mg cap 59 NICOTROL 10MG INH SOLN
95
NICOTROL 10MG/ML NASAL INHALER
95
nifedipine 30mg er tab 59 nifedipine 30mg osmotic er tab
59
nifedipine 60mg er tab 59 nifedipine 60mg osmotic er tab
59
nifedipine 90mg er tab 59 nifedipine 90mg osmotic er tab
59
nikki 28 day pack 65 nilutamide 150mg tab 43
nimodipine 30mg cap 59 NINLARO 2.3MG CAP 46 NINLARO 3MG CAP 46 NINLARO 4MG CAP 46 nisoldipine 17mg er tab 59 nisoldipine 20mg er tab 59 NISOLDIPINE 25.5MG ER TAB
59
nisoldipine 30mg er tab 59 nisoldipine 34mg er tab 59 nisoldipine 40mg er tab 60 nisoldipine 8.5mg er tab 60 nitisinone 10mg cap 75 nitisinone 2mg cap 75 nitisinone 5mg cap 75 NITRO-BID 2% OINTMENT
16
NITRO-DUR 0.3MG/HR PATCH
16
NITRO-DUR 0.8MG/HR PATCH
16
nitrofurantoin macro 25mg/nitrofurantoin mono 75mg cap
100
nitrofurantoin macrocrystals 100mg cap
100
nitrofurantoin macrocrystals 50mg cap
100
nitroglycerin 0.1mg/hr patch
16
nitroglycerin 0.2mg/hr patch
16
nitroglycerin 0.3mg sl tab 16 nitroglycerin 0.4mg sl tab 16 nitroglycerin 0.4mg/act spray
16
nitroglycerin 0.4mg/hr patch
16
nitroglycerin 0.6mg sl tab 16 nitroglycerin 0.6mg/hr patch
16
NIVESTYM 300MCG/0.5ML SYRINGE
80
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
132
ALPHABETICAL LISTING OF DRUGS
NIVESTYM 300MCG/ML INJ
80
NIVESTYM 480MCG/0.8ML SYRINGE
81
NIVESTYM 480MCG/1.6ML INJ
81
nizatidine 150mg cap 99 nizatidine 300mg cap 99 nora-be 28 day 0.35mg pack
66
norethindrone 0.35mg pack
66
norethindrone acetate 5mg tab
93
NORMOSOL-M INJ 84 NORMOSOL-R INJ 84 NORPACE 100MG ER CAP
17
NORPACE 150MG ER CAP
17
NORTHERA 100MG CAP 102 NORTHERA 200MG CAP 102 NORTHERA 300MG CAP 102 nortrel 0.5/35 28 day pack
65
nortrel 1/35 21 day pack 65 nortrel 1/35 28 day pack 65 nortrel 7/7/7 28 day pack 65 nortriptyline 10mg cap 29 nortriptyline 25mg cap 29 NORTRIPTYLINE 2MG/ML ORAL SOLN
29
nortriptyline 50mg cap 29 nortriptyline 75mg cap 29 NORVIR 100MG ORAL POWDER
55
NORVIR 80MG/ML ORAL SOLN
55
NOURIANZ 20MG TAB 49 NOURIANZ 40MG TAB 49 NOVOLIN 70-30UNIT/ML INJ
31
NOVOLIN N 100UNIT/ML INJ
31
NOVOLIN N 100UNIT/ML PEN INJ
31
NOVOLIN R 100UNIT/ML INJ
31
NOVOLIN R 100UNIT/ML PEN INJ
31
NOVOLOG 100UNIT/ML CARTRIDGE
31
NOVOLOG 100UNIT/ML INJ
31
NOVOLOG 100UNIT/ML PEN INJ
31
NOVOLOG MIX 70-30UNIT/ML INJ
31
NOVOLOG MIX 70-30UNIT/ML PEN INJ
31
NOXAFIL 40MG/ML SUSP
34
NUBEQA 300MG TAB 43 NUCALA 100MG INJ 18 NUCALA 100MG/ML AUTO-INJECTOR
18
NUCALA 100MG/ML SYRINGE
18
NUCYNTA 100MG ER TAB
13
NUCYNTA 150MG ER TAB
13
NUCYNTA 200MG ER TAB
13
NUCYNTA 250MG ER TAB
13
NUCYNTA 50MG ER TAB
13
NUEDEXTA 20-10MG CAP
95
NUPLAZID 10MG TAB 50 NUPLAZID 34MG CAP 50 NUTRILIPID 20GM/100ML INJ
87
NUZYRA 150MG TAB 96 nyamyc 100000unit/gm topical powder
69
nystatin 100000unit/ml cream
69
nystatin 100000unit/ml susp
86
nystatin 100unit/mg ointment
69
nystatin 100unit/mg topical powder
69
nystatin 500000unit tab 33 nystop 100000unit/gm topical powder
69
O
OCALIVA 10MG TAB 77 OCALIVA 5MG TAB 77 ocella 28 day pack 65 OCTAGAM 1GM/20ML INJ
91
OCTAGAM 2GM/20ML INJ
91
octreotide 0.05mg/ml inj 75 octreotide 0.1mg/ml inj 75 octreotide 0.2mg/ml inj 75 octreotide 0.5mg/ml inj 75 octreotide 1mg/ml inj 75 ODEFSEY 200-25-25MG TAB
55
ODOMZO 200MG CAP 43 OFEV 100MG CAP 96 OFEV 150MG CAP 96 ofloxacin 0.3% ophth soln 89 ofloxacin 0.3% otic soln 91 ofloxacin 400mg tab 77 olanzapine 10mg inj 52 olanzapine 10mg odt 52 olanzapine 10mg tab 52 olanzapine 15mg odt 52 olanzapine 15mg tab 52 olanzapine 2.5mg tab 52 olanzapine 20mg odt 52 olanzapine 20mg tab 52 olanzapine 5mg odt 52 olanzapine 5mg tab 52 olanzapine 7.5mg tab 52 olmesartan medoxomil 20mg tab
37
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
133
ALPHABETICAL LISTING OF DRUGS
olmesartan medoxomil 40mg tab
37
olmesartan medoxomil 5mg tab
37
olopatadine 0.1% ophth soln
90
olopatadine 0.2% ophth soln
90
olopatadine 0.665mg/act nasal inhaler
87
OLUMIANT 1MG TAB 10 OLUMIANT 2MG TAB 10 omega-3 acid ethyl esters (usp) 1000mg cap
34
omeprazole 10mg dr cap 99 omeprazole 20mg dr cap 99 omeprazole 40mg dr cap 99 ondansetron 0.8mg/ml oral soln
33
ONDANSETRON 24MG TAB
33
ondansetron 4mg odt 33 ondansetron 4mg tab 33 ondansetron 8mg odt 33 ondansetron 8mg tab 33 OPSUMIT 10MG TAB 61 ORENCIA 125MG/ML AUTO-INJECTOR
12
ORENCIA 125MG/ML SYRINGE
12
ORENCIA 50MG/0.4ML SYRINGE
12
ORENCIA 87.5MG/0.7ML SYRINGE
12
ORENITRAM 0.125MG ER TAB
61
ORENITRAM 0.25MG ER TAB
61
ORENITRAM 1MG ER TAB
61
ORENITRAM 2.5MG ER TAB
61
ORENITRAM 5MG ER TAB
61
ORFADIN 20MG CAP 75
ORFADIN 4MG/ML SUSP
75
ORILISSA 150MG TAB 74 ORILISSA 200MG TAB 74 ORKAMBI 125-100MG GRANULES
95
ORKAMBI 125-100MG TAB
95
ORKAMBI 125-200MG TAB
96
ORKAMBI 188-150MG GRANULES
96
orphenadrine citrate 100mg er tab
87
orsythia 28 day pack 65 oseltamivir 30mg cap 56 oseltamivir 45mg cap 56 oseltamivir 6mg/ml susp 56 oseltamivir 75mg cap 57 OSPHENA 60MG TAB 74 OTEZLA 28-DAY STARTER PACK
12
OTEZLA 30MG TAB 12 oxacillin 1000mg inj 93 oxacillin 100mg/ml inj 93 oxacillin 2000mg inj 93 OXACILLIN 20MG/ML INJ
93
OXACILLIN 40MG/ML INJ
93
oxandrolone 10mg tab 15 oxandrolone 2.5mg tab 15 oxaprozin 600mg tab 11 OXAZEPAM 10MG CAP 17 OXAZEPAM 15MG CAP 17 OXAZEPAM 30MG CAP 17 OXBRYTA 500MG TAB 80 oxcarbazepine 150mg tab 23 oxcarbazepine 300mg tab 23 oxcarbazepine 600mg tab 23 oxcarbazepine 60mg/ml susp
23
OXERVATE 0.002% OPHTH SOLN
89
OXTELLAR 150MG ER TAB
23
OXTELLAR 300MG ER TAB
23
OXTELLAR 600MG ER TAB
23
oxybutynin chloride 10mg er tab
100
oxybutynin chloride 15mg er tab
100
oxybutynin chloride 1mg/ml oral soln
100
oxybutynin chloride 5mg er tab
100
oxybutynin chloride 5mg tab
100
oxycodone 10mg tab 13 oxycodone 15mg tab 13 oxycodone 1mg/ml oral soln
13
oxycodone 20mg tab 13 oxycodone 20mg/ml oral soln
13
oxycodone 30mg tab 13 oxycodone 5mg cap 13 oxycodone 5mg tab 13 oxymorphone 10mg tab 13 oxymorphone 5mg tab 13 OZEMPIC 2MG/1.5ML PEN INJ
30
OZEMPIC 2MG/1.5ML PEN INJ (1MG DOSE)
30
P
pacerone 200mg tab 18 pacerone 400mg tab 18 paliperidone 1.5mg er tab 50 paliperidone 3mg er tab 50 paliperidone 6mg er tab 51 paliperidone 9mg er tab 51 PALYNZIQ 10MG/0.5ML SYRINGE
75
PALYNZIQ 2.5MG/0.5ML SYRINGE
75
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
134
ALPHABETICAL LISTING OF DRUGS
PALYNZIQ 20MG/ML SYRINGE
75
pantoprazole 20mg dr tab 99 pantoprazole 40mg dr tab 99 PANZYGA 10GM/100ML INJ
91
PANZYGA 1GM/10ML INJ
91
PANZYGA 2.5GM/25ML INJ
91
PANZYGA 20GM/200ML INJ
91
PANZYGA 30GM/300ML INJ
91
PANZYGA 5GM/50ML INJ
91
paricalcitol 0.001mg cap 75 paricalcitol 0.002mg cap 75 paricalcitol 0.004mg cap 75 PAROMOMYCIN 250MG CAP
9
paroxetine 10mg tab 27 paroxetine 12.5mg er tab 27 paroxetine 20mg tab 27 paroxetine 25mg er tab 27 paroxetine 30mg tab 27 paroxetine 37.5mg er tab 27 paroxetine 40mg tab 27 PASER D/R 4GM GRANULES
42
PAXIL 10MG/5ML SUSP 27 PEDIARIX INJ 98 PEDVAXHIB 7.5MCG/0.5ML INJ
100
peg 3350/electrolyte oral soln
82
peg 3350/kcl/sodium bicarbonate/sodium chloride powder for oral soln
82
PEGANONE 250MG TAB 25 PEGASYS 180MCG/0.5ML AUTO-INJECTOR
56
PEGASYS 180MCG/0.5ML SYRINGE
56
PEGASYS 180MCG/ML INJ
56
PEMAZYRE 13.5MG TAB 46 PEMAZYRE 4.5MG TAB 46 PEMAZYRE 9MG TAB 46 penicillamine 250mg tab 85 penicillin g potassium 1000000unit/ml inj
92
PENICILLIN G POTASSIUM 40000UNIT/ML INJ
92
PENICILLIN G POTASSIUM 60000UNIT/ML INJ
92
PENICILLIN G PROCAINE 600000UNIT/ML SYRINGE
92
PENICILLIN G SODIUM 100000UNIT/ML INJ
92
penicillin v potassium 250mg tab
92
PENICILLIN V POTASSIUM 25MG/ML ORAL SOLN
92
penicillin v potassium 500mg tab
92
PENICILLIN V POTASSIUM 50MG/ML ORAL SOLN
92
pentamidine isethionate 300mg inj
40
pentamidine isethionate 50mg/ml inh soln
40
pentoxifylline 400mg er tab
79
perindopril erbumine 2mg tab
36
perindopril erbumine 4mg tab
36
perindopril erbumine 8mg tab
36
permethrin 5% cream 72 perphenazine 16mg tab 53 perphenazine 2mg tab 53 perphenazine 4mg tab 53 perphenazine 8mg tab 53 PERSERIS 120MG SYRINGE
51
PERSERIS 90MG SYRINGE
51
PEXEVA 10MG TAB 27 PEXEVA 20MG TAB 27 PEXEVA 30MG TAB 27 PEXEVA 40MG TAB 27 phenelzine 15mg tab 26 phenobarbital 100mg tab 81 phenobarbital 15mg tab 81 phenobarbital 16.2mg tab 81 phenobarbital 30mg tab 81 phenobarbital 32.4mg tab 81 phenobarbital 4mg/ml oral soln
81
phenobarbital 60mg tab 81 phenobarbital 64.8mg tab 81 phenobarbital 97.2mg tab 81 phenoxybenzamine 10mg cap
37
PHENYLEPHRINE 1MG/ML/PROMETHAZINE 1.25MG/ML ORAL SOLN
67
phenytoin 25mg/ml susp 25 phenytoin 50mg chew tab 25 phenytoin sodium 100mg er cap
25
phenytoin sodium 200mg er cap
25
phenytoin sodium 300mg er cap
25
PHOSLYRA 667MG/5ML ORAL SOLN
78
PHOSPHOLINE IODIDE 0.125% OPHTH SOLN
88
PICATO 0.015% GEL 69 PICATO 0.05% GEL 69 PIFELTRO 100MG TAB 55
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
135
ALPHABETICAL LISTING OF DRUGS
pilocarpine 1% ophth soln
88
pilocarpine 2% ophth soln
88
pilocarpine 4% ophth soln
88
pilocarpine 5mg tab 86 pilocarpine 7.5mg tab 86 pimecrolimus 1% cream 71 PIMOZIDE 1MG TAB 95 PIMOZIDE 2MG TAB 95 pimtrea pack 65 pindolol 10mg tab 58 pindolol 5mg tab 58 pioglitazone 15mg tab 31 pioglitazone 30mg tab 31 pioglitazone 45mg tab 31 piperacillin 2000mg/tazobactam 250mg inj
92
piperacillin 200mg/ml/tazobactam 25mg/ml inj
92
piperacillin 3000mg/tazobactam 375mg inj
92
piperacillin 4000mg/tazobactam 500mg inj
92
PIQRAY 200MG DAILY DOSE PACK
46
PIQRAY 250MG DAILY DOSE PACK
46
PIQRAY 300MG DAILY DOSE 150MG PACK
46
pirmella 1/35 28 day pack 65 piroxicam 10mg cap 11 piroxicam 20mg cap 11 PLASMA-LYTE 148 INJ 84 PLASMALYTE A INJ 84 PLEGRIDY 125MCG/0.5ML AUTO-INJECTOR
95
PLEGRIDY 125MCG/0.5ML SYRINGE
95
PLEGRIDY PEN STARTER PACK
95
PLEGRIDY STARTER PACK
95
plenamine 15% inj 88 podofilox 0.5% topical soln
71
polymyxin b 10000unit/ml/trimethoprim 1mg/ml ophth soln
89
polymyxin b 250000unit/ml inj
41
POMALYST 1MG CAP 43 POMALYST 2MG CAP 43 POMALYST 3MG CAP 43 POMALYST 4MG CAP 43 portia 28 day pack 65 posaconazole 100mg dr tab
34
potassium chloride 0.02 meq/ml/sodium chloride 0.0769 meq/ml inj
84
potassium chloride 0.02 meq/ml/sodium chloride 0.154 meq/ml inj
84
POTASSIUM CHLORIDE 0.04 MEQ/ML/SODIUM CHLORIDE 0.154 MEQ/ML INJ
84
POTASSIUM CHLORIDE 0.1MEQ/ML INJ
85
POTASSIUM CHLORIDE 0.2MEQ/ML INJ
85
POTASSIUM CHLORIDE 0.4MEQ/ML INJ
85
potassium chloride 1.33meq/ml oral soln
85
potassium chloride 10meq er cap
85
potassium chloride 10meq er tab
85
potassium chloride 10meq micro er tab
85
potassium chloride 2.67meq/ml oral soln
85
potassium chloride 20meq er tab
85
potassium chloride 20meq micro er tab
85
potassium chloride 20meq powder for oral soln
85
potassium chloride 2meq/ml (20ml) inj
85
potassium chloride 2meq/ml inj
85
potassium chloride 8meq er cap
85
potassium chloride 8meq er tab
85
potassium citrate 10meq er tab
78
potassium citrate 15meq er tab
78
potassium citrate 5meq er tab
78
PRADAXA 110MG CAP 21 PRADAXA 150MG CAP 21 PRADAXA 75MG CAP 21 PRALUENT 150MG/ML AUTO-INJECTOR
36
PRALUENT 75MG/ML AUTO-INJECTOR
36
pramipexole 0.125mg tab 48 pramipexole 0.25mg tab 48 pramipexole 0.375mg er tab
48
pramipexole 0.5mg tab 48 pramipexole 0.75mg er tab
48
pramipexole 0.75mg tab 48 pramipexole 1.5mg er tab 48 pramipexole 1.5mg tab 48 pramipexole 1mg tab 48 pramipexole 2.25mg er tab
48
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
136
ALPHABETICAL LISTING OF DRUGS
pramipexole 3.75mg er tab
48
pramipexole 3mg er tab 48 pramipexole 4.5mg er tab 48 prasugrel 10mg tab 80 prasugrel 5mg tab 80 pravastatin sodium 10mg tab
35
pravastatin sodium 20mg tab
35
pravastatin sodium 40mg tab
35
pravastatin sodium 80mg tab
35
prazosin 1mg cap 37 prazosin 2mg cap 37 prazosin 5mg cap 37 PRED MILD 0.12% OPHTH SUSP
90
PRED-G 0.3-1% OPHTH SUSP
90
PREDNICARBATE 0.1% CREAM
71
PREDNICARBATE 0.1% OINTMENT
71
PREDNISOLONE 1% OPHTH SOLN
90
prednisolone 10mg odt 67 prednisolone 15mg odt 67 prednisolone 1mg/ml oral soln
67
prednisolone 30mg odt 67 PREDNISOLONE 3MG/ML ORAL SOLN
67
PREDNISOLONE ACETATE 1% OPHTH SUSP
90
PREDNISOLONE SODIUM PHOSPHATE 2.5MG/ML/SULFACETAMIDE SODIUM 100MG/ML OPHTH SOLN
90
prednisone 10mg tab 67 prednisone 1mg tab 67
PREDNISONE 1MG/ML ORAL SOLN
67
prednisone 2.5mg tab 67 prednisone 20mg tab 67 prednisone 50mg tab 67 prednisone 5mg tab 67 PREDNISONE 5MG/ML ORAL SOLN
67
pregabalin 100mg cap 24 pregabalin 150mg cap 24 pregabalin 200mg cap 24 pregabalin 20mg/ml oral soln
24
pregabalin 225mg cap 24 pregabalin 25mg cap 24 pregabalin 300mg cap 24 pregabalin 50mg cap 24 pregabalin 75mg cap 24 PREMARIN 0.3MG TAB 77 PREMARIN 0.45MG TAB 77 PREMARIN 0.625MG TAB
77
PREMARIN 0.625MG/GM VAGINAL CREAM
101
PREMARIN 0.9MG TAB 77 PREMARIN 1.25MG TAB 77 PREMASOL 10% INJ 88 PREMPHASE 28 DAY PACK
76
PREMPRO 0.3/1.5MG 28 DAY PACK
76
PREMPRO 0.45/1.5 28 DAY PACK
76
PREMPRO 0.625/2.5MG 28 DAY PACK
76
PREMPRO 0.625/5MG 28 DAY PACK
76
prevalite 4gm powder for oral susp
35
previfem 28 day pack 65 PREVYMIS 240MG TAB 56 PREVYMIS 480MG TAB 56 PREZCOBIX 150-800MG TAB
55
PREZISTA 100MG/ML SUSP
55
PREZISTA 150MG TAB 55 PREZISTA 600MG TAB 55 PREZISTA 75MG TAB 55 PREZISTA 800MG TAB 55 PRIFTIN 150MG TAB 42 PRIMAQUINE PHOSPHATE 26.3MG TAB
42
primidone 250mg tab 24 primidone 50mg tab 24 PRIVIGEN 20GM/200ML INJ
91
probenecid 500mg tab 79 PROCALAMINE 3% INJ 88 prochlorperazine 10mg tab
53
prochlorperazine 25mg rectal supp
53
prochlorperazine 5mg tab 53 procto-med 2.5% cream 15 procto-pak 1% rectal cream
15
proctosol 2.5% cream 15 proctozone hc 2.5% cream
16
progesterone 100mg cap 93 progesterone 200mg cap 93 PROGRAF 0.2MG GRANULES FOR ORAL SUSP
86
PROGRAF 1MG GRANULES FOR ORAL SUSP
86
PROLASTIN 1000MG INJ 95 PROLIA 60MG/ML SYRINGE
73
PROMACTA 12.5MG POWDER FOR ORAL SUSP
81
PROMACTA 12.5MG TAB
81
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
137
ALPHABETICAL LISTING OF DRUGS
PROMACTA 25MG POWDER FOR ORAL SUSP
81
PROMACTA 25MG TAB 81 PROMACTA 50MG TAB 81 PROMACTA 75MG TAB 81 promethazine 1.25mg/ml oral soln
34
promethazine 12.5mg rectal supp
34
promethazine 12.5mg tab 34 promethazine 25mg rectal supp
34
promethazine 25mg tab 34 promethazine 50mg tab 34 promethegan 25mg rectal supp
34
PROMETHEGAN 50MG RECTAL SUPP
34
propafenone 150mg tab 18 propafenone 225mg er cap
18
propafenone 225mg tab 18 propafenone 300mg tab 18 propafenone 325mg er cap
18
propafenone 425mg er cap
18
proparacaine 0.5% ophth soln
89
propranolol 10mg tab 58 propranolol 120mg er cap
58
propranolol 160mg er cap
58
propranolol 20mg tab 58 propranolol 40mg tab 58 PROPRANOLOL 4MG/ML ORAL SOLN
58
propranolol 60mg er cap 58 propranolol 60mg tab 58 propranolol 80mg er cap 58 propranolol 80mg tab 58 PROPRANOLOL 8MG/ML ORAL SOLN
58
propylthiouracil 50mg tab
97
PROQUAD INJ 101 PROSOL 20% INJ 88 protriptyline 10mg tab 29 protriptyline 5mg tab 29 PULMOZYME 1MG/ML INH SOLN
96
PURIXAN 2000MG/100ML SUSP
42
PYLERA 140-125-125MG CAP
99
pyrazinamide 500mg tab 42 pyridostigmine bromide 180mg er tab
42
pyridostigmine bromide 60mg tab
42
Q
QBRELIS 1MG/ML ORAL SOLN
36
QINLOCK 50MG TAB 46 QUADRACEL INJ 98 QUDEXY 100MG ER CAP
24
QUDEXY 150MG ER CAP
24
QUDEXY 200MG ER CAP
24
QUDEXY 25MG ER CAP 24 QUDEXY 50MG ER CAP 24 quetiapine 100mg tab 52 quetiapine 150mg er tab 52 quetiapine 200mg er tab 52 quetiapine 200mg tab 52 quetiapine 25mg tab 52 quetiapine 300mg er tab 52 quetiapine 300mg tab 52 quetiapine 400mg er tab 52 quetiapine 400mg tab 52 quetiapine 50mg er tab 52 quetiapine 50mg tab 52 quinapril 10mg tab 36 quinapril 20mg tab 36 quinapril 40mg tab 36
quinapril 5mg tab 37 quinidine gluconate 324mg er tab
17
QUINIDINE SULFATE 200MG TAB
17
QUINIDINE SULFATE 300MG TAB
17
quinine sulfate 324mg cap
42
R
RABAVERT 2.5UNIT/ML INJ
101
rabeprazole sodium 20mg dr tab
99
raloxifene 60mg tab 74 ramelteon 8mg tab 82 ramipril 1.25mg cap 37 ramipril 10mg cap 37 ramipril 2.5mg cap 37 ramipril 5mg cap 37 ranolazine 1000mg er tab 16 ranolazine 500mg er tab 16 rasagiline 0.5mg tab 49 rasagiline 1mg tab 49 RAVICTI 1.1GM/ML ORAL SOLN
75
REBIF 22MCG/0.5ML AUTO-INJECTOR
95
REBIF 22MCG/0.5ML SYRINGE
95
REBIF 44MCG/0.5ML AUTO-INJECTOR
95
REBIF 44MCG/0.5ML SYRINGE
95
REBIF REBIDOSE PACK 95 REBIF TITRATION PACK 95 reclipsen 28 day pack 65 RECOMBIVAX 10MCG/ML INJ
101
RECOMBIVAX 10MCG/ML SYRINGE
101
RECOMBIVAX 40MCG/ML INJ
101
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
138
ALPHABETICAL LISTING OF DRUGS
RECOMBIVAX 5MCG/0.5ML SYRINGE
101
RECTIV 0.4% RECTAL OINTMENT
15
REGRANEX 0.01% GEL 72 RELENZA 5MG/BLISTER INH
57
RELISTOR 12MG/0.6ML INJ
78
RELISTOR 12MG/0.6ML SYRINGE
78
RELISTOR 8MG/0.4ML SYRINGE
78
repaglinide 0.5mg tab 31 repaglinide 1mg tab 31 repaglinide 2mg tab 31 REPATHA 140MG/ML AUTO-INJECTOR
36
REPATHA 140MG/ML SYRINGE
36
REPATHA 420MG/3.5ML CARTRIDGE
36
RESTASIS 0.05% OPHTH SUSP
89
RETACRIT 10000UNIT/ML INJ
81
RETACRIT 2000UNIT/ML INJ
81
RETACRIT 3000UNIT/ML INJ
81
RETACRIT 40000UNIT/ML INJ
81
RETACRIT 4000UNIT/ML INJ
81
RETEVMO 40MG CAP 46 RETEVMO 80MG CAP 46 REVLIMID 10MG CAP 85 REVLIMID 15MG CAP 85 REVLIMID 2.5MG CAP 85 REVLIMID 20MG CAP 85 REVLIMID 25MG CAP 85 REVLIMID 5MG CAP 85 REXULTI 0.25MG TAB 53 REXULTI 0.5MG TAB 53 REXULTI 1MG TAB 53
REXULTI 2MG TAB 53 REXULTI 3MG TAB 53 REXULTI 4MG TAB 53 REYATAZ 50MG ORAL POWDER
55
RHOPRESSA 0.02% OPHTH SOLN
89
ribavirin 200mg cap 56 ribavirin 200mg tab 56 RIDAURA 3MG CAP 10 rifabutin 150mg cap 42 rifampin 150mg cap 42 rifampin 300mg cap 42 rifampin 600mg inj 42 riluzole 50mg tab 87 RIMANTADINE 100MG TAB
57
RINVOQ 15MG ER TAB 10 risedronate sodium 150mg tab
73
risedronate sodium 30mg tab
73
risedronate sodium 35mg (12) pack
73
risedronate sodium 35mg (4) pack
74
risedronate sodium 35mg tab
74
risedronate sodium 5mg tab
74
RISPERDAL 12.5MG INJ 51 RISPERDAL 25MG INJ 51 RISPERDAL 37.5MG INJ 51 RISPERDAL 50MG INJ 51 risperidone 0.25mg odt 51 risperidone 0.25mg tab 51 risperidone 0.5mg odt 51 risperidone 0.5mg tab 51 risperidone 1mg odt 51 risperidone 1mg tab 51 risperidone 1mg/ml oral soln
51
risperidone 2mg odt 51 risperidone 2mg tab 51 risperidone 3mg odt 51
risperidone 3mg tab 51 risperidone 4mg odt 51 risperidone 4mg tab 51 ritonavir 100mg tab 55 rivastigmine 0.192mg/hr patch
94
rivastigmine 0.396mg/hr patch
94
rivastigmine 0.554mg/hr patch
94
rivastigmine 1.5mg cap 94 rivastigmine 3mg cap 94 rivastigmine 4.5mg cap 94 rivastigmine 6mg cap 94 rivelsa 91 day pack 65 rizatriptan 10mg odt 83 rizatriptan 10mg tab 83 rizatriptan 5mg odt 83 rizatriptan 5mg tab 83 ROCKLATAN 0.05-0.2MG/ML OPHTH SOLN
89
ropinirole 0.25mg tab 48 ropinirole 0.5mg tab 48 ropinirole 12mg er tab 48 ropinirole 1mg tab 49 ropinirole 2mg er tab 48 ropinirole 2mg tab 49 ropinirole 3mg tab 48 ropinirole 4mg er tab 49 ropinirole 4mg tab 49 ropinirole 5mg tab 49 ropinirole 6mg er tab 49 ropinirole 8mg er tab 49 rosuvastatin calcium 10mg tab
35
rosuvastatin calcium 20mg tab
35
rosuvastatin calcium 40mg tab
35
rosuvastatin calcium 5mg tab
35
ROTARIX SUSP 101 ROTATEQ SUSP 101 roweepra 1000mg tab 24
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
139
ALPHABETICAL LISTING OF DRUGS
roweepra 500mg er tab 24 roweepra 500mg tab 24 roweepra 750mg er tab 24 roweepra 750mg tab 24 ROZLYTREK 100MG CAP
46
ROZLYTREK 200MG CAP
46
RUBRACA 200MG TAB 46 RUBRACA 250MG TAB 46 RUBRACA 300MG TAB 46 RUCONEST 2100UNIT INJ
79
RUZURGI 10MG TAB 42 RYBELSUS 14MG TAB 30 RYBELSUS 3MG TAB 30 RYBELSUS 7MG TAB 30 RYDAPT 25MG CAP 46
S
salmon calcitonin 200unit/act nasal spray
74
SANDIMMUNE 100MG/ML ORAL SOLN
57
SANTYL 250UNIT/GM OINTMENT
71
SAPHRIS 10MG SL TAB 52 SAPHRIS 2.5MG SL TAB 52 SAPHRIS 5MG SL TAB 52 SAVELLA 100MG TAB 94 SAVELLA 12.5MG TAB 94 SAVELLA 25MG TAB 94 SAVELLA 4-WEEK TITRATION PACK
94
SAVELLA 50MG TAB 94 scopolamine 0.0139mg/hr patch
33
SECUADO 3.8MG/24HR PATCH
52
SECUADO 5.7MG/24HR PATCH
52
SECUADO 7.6MG/24HR PATCH
52
selegiline 5mg cap 49 selegiline 5mg tab 49
selenium sulfide 2.5% shampoo
69
SELZENTRY 150MG TAB 55 SELZENTRY 20MG/ML ORAL SOLN
55
SELZENTRY 25MG TAB 55 SELZENTRY 300MG TAB 55 SELZENTRY 75MG TAB 55 SEREVENT 50MCG/DOSE INH
20
sertraline 100mg tab 27 sertraline 20mg/ml oral soln
27
sertraline 25mg tab 27 sertraline 50mg tab 27 setlakin 91 day pack 65 sevelamer carbonate 2400mg powder for oral susp
78
sevelamer carbonate 800mg powder for oral susp
78
sevelamer carbonate 800mg tab
78
sharobel 28 day 0.35mg pack
66
SHINGRIX 50MCG/0.5ML INJ
101
SIGNIFOR 0.3MG/ML INJ
75
SIGNIFOR 0.6MG/ML INJ
75
SIGNIFOR 0.9MG/ML INJ
75
sildenafil 20mg tab 61 silodosin 4mg cap 79 silodosin 8mg cap 79 silver sulfadiazine 1% cream
70
SIMBRINZA 0.2-1% OPHTH SUSP
88
SIMPONI 100MG/ML AUTO-INJECTOR
10
SIMPONI 100MG/ML SYRINGE
10
SIMPONI 50MG/0.5ML AUTO-INJECTOR
10
SIMPONI 50MG/0.5ML SYRINGE
10
simvastatin 10mg tab 35 simvastatin 20mg tab 35 simvastatin 40mg tab 35 simvastatin 5mg tab 35 simvastatin 80mg tab 35 sirolimus 0.5mg tab 57 sirolimus 1mg tab 57 sirolimus 1mg/ml oral soln
86
sirolimus 2mg tab 57 SIRTURO 100MG TAB 42 SIVEXTRO 200MG INJ 41 SIVEXTRO 200MG TAB 41 SKYRIZI 150MG DOSE PACK 75MG/0.83ML
69
SLYND 4MG TAB 66 sodium chloride 0.154meq/ml soln
79
sodium chloride 30mg/ml inj
85
sodium chloride 4.5mg/ml inj
85
sodium chloride 50mg/ml inj
85
sodium chloride 9mg/ml inj
85
sodium phenylbutyrate 0.94mg/mg oral powder
75
sodium polystyrene sulfonate 15000mg powder for oral susp
86
sodium polystyrene sulfonate 250mg/ml susp
86
SOFOSBUVIR 400MG/VELPATASVIR 100MG TAB
56
solifenacin succinate 10mg tab
100
solifenacin succinate 5mg tab
100
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
140
ALPHABETICAL LISTING OF DRUGS
SOLIQUA 100UNIT-0.033MG/ML PEN INJ
29
SOLTAMOX 10MG/5ML ORAL SOLN
43
SOMATULINE 120MG/0.5ML SYRINGE
75
SOMATULINE 60MG/0.2ML SYRINGE
75
SOMATULINE 90MG/0.3ML SYRINGE
75
SOMAVERT 10MG INJ 74 SOMAVERT 15MG INJ 74 SOMAVERT 20MG INJ 74 SOMAVERT 25MG INJ 74 SOMAVERT 30MG INJ 74 sorine 120mg tab 58 sorine 160mg tab 58 sorine 240mg tab 58 sorine 80mg tab 58 sotalol 120mg tab 58 sotalol 160mg tab 58 sotalol 240mg tab 58 sotalol 80mg tab 58 sotalol af 120mg tab 58 sotalol AF 160mg tab 58 sotalol AF 80mg tab 58 SPIRIVA 1.25MCG INH 18 spironolactone 100mg tab
73
spironolactone 25mg tab 73 spironolactone 50mg tab 73 sprintec 28 day pack 65 SPRITAM 1000MG TAB FOR ORAL SUSP
24
SPRITAM 250MG TAB FOR ORAL SUSP
24
SPRITAM 500MG TAB FOR ORAL SUSP
24
SPRITAM 750MG TAB FOR ORAL SUSP
24
SPRYCEL 100MG TAB 46 SPRYCEL 140MG TAB 46 SPRYCEL 20MG TAB 46 SPRYCEL 50MG TAB 46
SPRYCEL 70MG TAB 46 SPRYCEL 80MG TAB 46 sps 15gm/60ml susp 86 sronyx 28 day pack 65 ssd 1% cream 70 stavudine 15mg cap 55 stavudine 20mg cap 55 stavudine 30mg cap 55 stavudine 40mg cap 55 STELARA 45MG/0.5ML INJ
69
STELARA 45MG/0.5ML SYRINGE
69
STELARA 90MG/ML SYRINGE
69
STIMATE 1.5MG/ML NASAL INHALER
75
STIOLTO 0.0025-0.0025MG INH
20
STIVARGA 40MG TAB 46 STREPTOMYCIN 1000MG INJ
9
STRIBILD 150-150-200-300MG TAB
55
SUCRAID 8500UNIT/ML ORAL SOLN
72
sucralfate 1000mg tab 99 sucralfate 100mg/ml susp 99 sulfacetamide sodium 10% lotion
68
SULFACETAMIDE SODIUM 10% OPHTH OINTMENT
89
sulfacetamide sodium 10% ophth soln
89
SULFADIAZINE 500MG TAB
96
sulfamethoxazole 400mg/trimethoprim 80mg tab
40
sulfamethoxazole 40mg/ml/trimethoprim 8mg/ml susp
40
sulfamethoxazole 800mg/trimethoprim 160mg tab
40
SULFAMYLON 85MG/GM CREAM
70
sulfasalazine 500mg dr tab
78
sulfasalazine 500mg tab 78 sulindac 150mg tab 11 sulindac 200mg tab 12 sumatriptan 100mg tab 83 sumatriptan 12mg/ml auto-injector
83
sumatriptan 12mg/ml cartridge
83
sumatriptan 12mg/ml inj 83 SUMATRIPTAN 12MG/ML SYRINGE
83
sumatriptan 20mg/act nasal spray
83
sumatriptan 25mg tab 83 sumatriptan 50mg tab 83 sumatriptan 5mg/act nasal spray
83
sumatriptan 8mg/ml auto-injector
83
sumatriptan 8mg/ml cartridge
83
SUNOSI 150MG TAB 8 SUNOSI 75MG TAB 8 SUTENT 12.5MG CAP 46 SUTENT 25MG CAP 46 SUTENT 37.5MG CAP 46 SUTENT 50MG CAP 46 syeda 28 day pack 65 SYLATRON 200MCG INJ 47 SYLATRON 300MCG INJ 47 SYMDEKO 50-75MG/75MG PACK
96
SYMDEKO TAB 4-WEEK PACK
96
SYMFI 400-300-300MG TAB
55
SYMFI 600-300-300MG TAB
55
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
141
ALPHABETICAL LISTING OF DRUGS
SYMJEPI 0.15MG/0.3ML SYRINGE
101
SYMJEPI 0.3MG/0.3ML SYRINGE
101
SYMPAZAN 10MG ORAL FILM
22
SYMPAZAN 20MG ORAL FILM
22
SYMPAZAN 5MG ORAL FILM
22
SYMPROIC 0.2MG TAB 78 SYMTUZA 800-150-200-10MG TAB
55
SYNAREL 2MG/ML NASAL INHALER
74
SYNJARDY 10-1000MG ER TAB
29
SYNJARDY 12.5-1000MG ER TAB
29
SYNJARDY 12.5-1000MG TAB
29
SYNJARDY 12.5-500MG TAB
29
SYNJARDY 25-1000MG ER TAB
29
SYNJARDY 5-1000MG ER TAB
29
SYNJARDY 5-1000MG TAB
30
SYNJARDY 5-500MG TAB
30
SYNRIBO 3.5MG INJ 47 SYNTHROID 100MCG TAB
98
SYNTHROID 112MCG TAB
98
SYNTHROID 125MCG TAB
98
SYNTHROID 137MCG TAB
98
SYNTHROID 150MCG TAB
98
SYNTHROID 175MCG TAB
98
SYNTHROID 200MCG TAB
98
SYNTHROID 25MCG TAB
98
SYNTHROID 300MCG TAB
98
SYNTHROID 50MCG TAB
98
SYNTHROID 75MCG TAB
98
SYNTHROID 88MCG TAB
98
T
TABLOID 40MG TAB 42 TABRECTA 150MG TAB 46 TABRECTA 200MG TAB 46 tacrolimus 0.03% ointment
71
tacrolimus 0.1% ointment 71 tacrolimus 0.5mg cap 57 tacrolimus 1mg cap 57 tacrolimus 5mg cap 57 tadalafil 20mg tab 61 TAFINLAR 50MG CAP 46 TAFINLAR 75MG CAP 46 TAGRISSO 40MG TAB 46 TAGRISSO 80MG TAB 47 TAKHZYRO 300MG/2ML INJ
79
TALTZ 80MG/ML AUTO-INJECTOR
69
TALTZ 80MG/ML SYRINGE
69
TALZENNA 0.25MG CAP 47 TALZENNA 1MG CAP 47 tamoxifen 10mg tab 43 tamoxifen 20mg tab 43 tamsulosin 0.4mg cap 79 TARGRETIN 1% GEL 69 tarina 24 fe 1/20 28 day pack
65
tarina fe 1/20 28 day pack
65
TASIGNA 150MG CAP 47
TASIGNA 200MG CAP 47 TASIGNA 50MG CAP 47 TAVALISSE 100MG TAB 79 TAVALISSE 150MG TAB 79 tazarotene 0.1% cream 69 tazicef 1gm inj 63 tazicef 2gm inj 63 tazicef 6gm inj 63 TAZORAC 0.05% CREAM
69
TAZORAC 0.05% GEL 69 TAZORAC 0.1% GEL 69 taztia 120mg er cap 60 taztia 180mg er cap 60 taztia 240mg er cap 60 taztia 300mg er cap 60 taztia 360mg er cap 60 TAZVERIK 200MG TAB 47 TDVAX 4-4UNIT/ML INJ 98 TECFIDERA 120MG DR CAP
95
TECFIDERA 240MG DR CAP
95
TECFIDERA 30-DAY STARTER PACK
95
TEFLARO 400MG INJ 63 TEFLARO 600MG INJ 63 TEGSEDI 284MG/1.5ML SYRINGE
95
telmisartan 20mg tab 37 telmisartan 40mg tab 37 telmisartan 80mg tab 37 temazepam 15mg cap 81 temazepam 22.5mg cap 81 temazepam 30mg cap 81 temazepam 7.5mg cap 81 TENIVAC 4-10UNIT/ML SYRINGE
98
tenofovir disoproxil fumarate 300mg tab
55
terazosin 10mg cap 38 terazosin 1mg cap 38 terazosin 2mg cap 38 terazosin 5mg cap 38 terbinafine 250mg tab 33
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
142
ALPHABETICAL LISTING OF DRUGS
terbutaline sulfate 2.5mg tab
20
terbutaline sulfate 5mg tab
20
terconazole 0.4% vaginal cream
101
TERCONAZOLE 0.8% VAGINAL CREAM
101
terconazole 80mg vaginal insert
101
testosterone 1% (25mg) gel
15
testosterone 1% (50mg) gel
15
testosterone 1.62% (1.25gm) gel
15
testosterone 1.62% (2.5gm) gel
15
TESTOSTERONE 12.5MG/ACT GEL
15
testosterone 20.25mg/act gel
15
testosterone cypionate 100mg/ml inj
15
testosterone cypionate 200mg/ml (1ml) inj
15
testosterone cypionate 200mg/ml inj
15
TESTOSTERONE ENANTHATE 200MG/ML INJ
15
tetrabenazine 12.5mg tab 94 tetrabenazine 25mg tab 94 tetracycline 250mg cap 96 tetracycline 500mg cap 96 THALOMID 100MG CAP 85 THALOMID 150MG CAP 85 THALOMID 200MG CAP 85 THALOMID 50MG CAP 85 THEOPHYLLINE 300MG ER TAB
20
theophylline 400mg er tab
20
theophylline 5.33mg/ml oral soln
20
theophylline 600mg er tab
20
THIOLA 100MG DR TAB 79 THIOLA 100MG TAB 79 THIOLA 300MG DR TAB 79 thioridazine 100mg tab 53 thioridazine 10mg tab 53 thioridazine 25mg tab 53 thioridazine 50mg tab 53 thiothixene 10mg cap 54 thiothixene 1mg cap 54 thiothixene 2mg cap 54 thiothixene 5mg cap 54 tiadylt 120mg er cap 60 tiadylt 180mg er cap 60 tiadylt 240mg er cap 60 tiadylt 300mg er cap 60 tiadylt 360mg er cap 60 tiadylt 420mg er cap 60 tiagabine 12mg tab 25 tiagabine 16mg tab 25 tiagabine 2mg tab 25 tiagabine 4mg tab 25 TIBSOVO 250MG TAB 47 TIGECYCLINE 50MG INJ 96 TIMOLOL 0.25% OPHTH GEL
88
timolol 0.25% ophth soln 88 TIMOLOL 0.5% OPHTH GEL
88
timolol 0.5% ophth soln 88 timolol 10mg tab 58 timolol 20mg tab 58 timolol 5mg tab 58 timolol 5mg/ml ophth 24hr ophth soln
88
TIMOPTIC 0.25% OPHTH GEL
88
TIMOPTIC 0.5% OPHTH GEL
88
tinidazole 250mg tab 40 tinidazole 500mg tab 40 TIVICAY 10MG TAB 55 TIVICAY 25MG TAB 55 TIVICAY 50MG TAB 55
tizanidine 2mg cap 87 tizanidine 2mg tab 87 tizanidine 4mg cap 87 tizanidine 4mg tab 87 tizanidine 6mg cap 87 TOBRADEX 0.1-0.3% OPHTH OINTMENT
90
tobramycin 0.3% ophth soln
89
TOBRAMYCIN 10MG/ML INJ
9
tobramycin 40mg/ml inj 9 tobramycin 60mg/ml inh soln
10
tolcapone 100mg tab 49 tolterodine tartrate 1mg tab
100
tolterodine tartrate 2mg er cap
100
tolterodine tartrate 2mg tab
100
tolterodine tartrate 4mg er cap
100
TOPIRAMATE 100MG ER CAP
24
topiramate 100mg tab 24 TOPIRAMATE 150MG ER CAP
24
topiramate 15mg cap 24 TOPIRAMATE 200MG ER CAP
24
topiramate 200mg tab 24 topiramate 25mg cap 24 TOPIRAMATE 25MG ER CAP
24
topiramate 25mg tab 24 TOPIRAMATE 50MG ER CAP
24
topiramate 50mg tab 24 toremifene 60mg tab 43 torsemide 100mg tab 73 torsemide 10mg tab 73 torsemide 20mg tab 73 torsemide 5mg tab 73
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
143
ALPHABETICAL LISTING OF DRUGS
TOUJEO 300UNIT/ML PEN INJ
31
TOUJEO MAX 300UNIT/ML PEN INJ (3ML)
31
TRACLEER 32MG TAB FOR ORAL SUSP
61
TRADJENTA 5MG TAB 30 tramadol 100mg er tab 13 tramadol 100mg er tab (matrix delivery)
13
tramadol 200mg er tab 13 tramadol 200mg er tab (matrix delivery)
13
tramadol 300mg er tab 14 tramadol 300mg er tab (matrix delivery)
14
tramadol 50mg tab 14 trandolapril 1mg tab 37 TRANDOLAPRIL 1MG/VERAPAMIL 240MG ER TAB
39
trandolapril 2mg tab 37 trandolapril 2mg/verapamil 180mg er tab
40
trandolapril 2mg/verapamil 240mg er tab
40
trandolapril 4mg tab 37 trandolapril 4mg/verapamil 240mg er tab
40
tranexamic acid 650mg tab
81
tranylcypromine 10mg tab
26
TRAVASOL 10% INJ 88 travoprost 0.004% ophth soln
90
trazodone 100mg tab 27 trazodone 150mg tab 27 trazodone 300mg tab 27 trazodone 50mg tab 27 TRECATOR 250MG TAB 42
TRELEGY 0.1-0.0625-0.025MG INH
20
TRELSTAR 11.25MG INJ 43 TRELSTAR 22.5MG INJ 43 TRELSTAR 3.75MG INJ 43 TRESIBA 100UNIT/ML INJ
31
TRESIBA 100UNIT/ML PEN INJ
31
TRESIBA 200UNIT/ML PEN INJ
31
tretinoin 0.01% gel 68 tretinoin 0.025% cream 68 tretinoin 0.025% gel 68 tretinoin 0.04% gel 68 tretinoin 0.05% cream 68 tretinoin 0.05% gel 68 tretinoin 0.1% cream 68 tretinoin 0.1% gel 68 tretinoin 10mg cap 47 triamcinolone acetonide 0.0147% spray
71
triamcinolone acetonide 0.025% cream
71
triamcinolone acetonide 0.025% lotion
71
triamcinolone acetonide 0.025% ointment
71
triamcinolone acetonide 0.1% cream
71
triamcinolone acetonide 0.1% lotion
71
triamcinolone acetonide 0.1% ointment
71
triamcinolone acetonide 0.1% oral paste
86
triamcinolone acetonide 0.5% cream
71
triamcinolone acetonide 0.5% ointment
71
triamterene 100mg cap 73 triamterene 50mg cap 73 triazolam 0.125mg tab 81 triazolam 0.25mg tab 81 triderm 0.1% cream 71
trientine 250mg cap 85 tri-estarylla 28 day pack 65 trifluoperazine 10mg tab 53 trifluoperazine 1mg tab 53 trifluoperazine 2mg tab 53 trifluoperazine 5mg tab 53 TRIFLURIDINE 1% OPHTH SOLN
89
TRIGLIDE 160MG TAB 35 trihexyphenidyl 0.4mg/ml oral soln
49
trihexyphenidyl 2mg tab 48 trihexyphenidyl 5mg tab 48 TRIJARDY 10-5-1000MG ER TAB
30
TRIJARDY 12.5-2.5-1000MG ER TAB
30
TRIJARDY 25-5-1000MG ER TAB
30
TRIJARDY 5-2.5-1000MG ER TAB
30
TRIKAFTA 100-50-75MG/150MG PACK
96
tri-legest 28 day pack 65 tri-lo-estarylla 28 day pack
65
tri-lo-sprintec 28 day pack
65
trilyte powder for oral soln
82
trimethobenzamide 300mg cap
33
trimethoprim 100mg tab 40 tri-mili 28 day pack 65 trimipramine 100mg cap 29 trimipramine 25mg cap 29 trimipramine 50mg cap 29 TRINTELLIX 10MG TAB 27 TRINTELLIX 20MG TAB 27 TRINTELLIX 5MG TAB 27 tri-previfem 28 day pack 66 tri-sprintec 28 day pack 66
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
144
ALPHABETICAL LISTING OF DRUGS
TRIUMEQ 600-50-300MG TAB
55
trivora 28 day pack 66 tri-vylibra 28 day pack 66 tri-vylibra lo 28 day pack 66 TROKENDI 100MG ER CAP
24
TROKENDI 200MG ER CAP
24
TROKENDI 25MG ER CAP
24
TROKENDI 50MG ER CAP
24
TROPHAMINE 10% INJ 88 trospium chloride 20mg tab
100
trospium chloride 60mg er cap
100
TRULANCE 3MG TAB 77 TRULICITY 0.75MG/0.5ML AUTO-INJECTOR
30
TRULICITY 1.5MG/0.5ML AUTO-INJECTOR
30
TRUMENBA SYRINGE 100 TRUVADA 100-150MG TAB
55
TRUVADA 133-200MG TAB
55
TRUVADA 167-250MG TAB
55
TRUVADA 200-300MG TAB
56
TUKYSA 150MG TAB 47 TUKYSA 50MG TAB 47 TURALIO 200MG CAP 47 TWINRIX 720UNIT SYRINGE
101
TYBOST 150MG TAB 56 TYKERB 250MG TAB 47 TYMLOS 3120MCG/1.56ML PEN INJ
74
TYPHIM VI 25MCG/0.5ML INJ
100
TYPHIM VI 25MCG/0.5ML SYRINGE
100
U
UCERIS 2MG/ACT RECTAL FOAM
15
unithroid 100mcg tab 98 unithroid 112mcg tab 98 unithroid 125mcg tab 98 unithroid 150mcg tab 98 unithroid 175mcg tab 98 unithroid 200mcg tab 98 unithroid 25mcg tab 98 unithroid 300mcg tab 98 unithroid 50mcg tab 98 unithroid 75mcg tab 98 unithroid 88mcg tab 98 UPTRAVI 1000MCG TAB 61 UPTRAVI 1200MCG TAB 61 UPTRAVI 1400MCG TAB 61 UPTRAVI 1600MCG TAB 61 UPTRAVI 200MCG TAB 61 UPTRAVI 400MCG TAB 61 UPTRAVI 600MCG TAB 61 UPTRAVI 800MCG TAB 61 UPTRAVI TITRATION PACK
61
ursodiol 250mg tab 77 ursodiol 300mg cap 77 ursodiol 500mg tab 77
V
valacyclovir 1000mg tab 56 valacyclovir 500mg tab 56 VALCHLOR 0.016% GEL 69 valganciclovir 450mg tab 56 valganciclovir 50mg/ml oral soln
56
valproic acid 250mg cap 25 valproic acid 50mg/ml oral soln
25
valsartan 160mg tab 37 valsartan 320mg tab 37 valsartan 40mg tab 37
valsartan 80mg tab 37 VALTOCO 10MG DOSE KIT 10MG/0.1ML PACK
22
VALTOCO 15MG DOSE KIT 7.5MG/0.1ML PACK
22
VALTOCO 20MG DOSE KIT 10MG/0.1ML PACK
22
VALTOCO 5MG DOSE KIT 5MG/0.1ML PACK
22
vancomycin 1000mg inj 41 vancomycin 100mg/ml inj 41 vancomycin 125mg cap 41 vancomycin 250mg cap 41 VANCOMYCIN 250MG INJ
41
vancomycin 500mg inj 41 vancomycin 750mg inj 41 vandazole 0.75% vaginal gel
101
VAQTA 25UNIT/0.5ML INJ
101
VAQTA 25UNIT/0.5ML SYRINGE
101
VAQTA 50UNIT/ML INJ 101 VAQTA 50UNIT/ML SYRINGE
101
VARIVAX 1350PFU/0.5ML INJ
101
VARIZIG 125UNIT/1.2ML INJ
91
VARUBI 90MG TAB 33 VASCEPA 0.5GM CAP 34 VASCEPA 1GM CAP 34 velivet 28 day pack 66 VELTASSA 16.8GM POWDER FOR ORAL SUSP
86
VELTASSA 25.2GM POWDER FOR ORAL SUSP
86
VELTASSA 8.4GM POWDER FOR ORAL SUSP
86
VEMLIDY 25MG TAB 56
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
145
ALPHABETICAL LISTING OF DRUGS
VENCLEXTA 100MG TAB
42
VENCLEXTA 10MG TAB 42 VENCLEXTA 50MG TAB 42 VENCLEXTA STARTING PACK
42
venlafaxine 100mg tab 28 venlafaxine 150mg er cap 28 venlafaxine 25mg tab 28 venlafaxine 37.5mg er cap
28
venlafaxine 37.5mg tab 28 venlafaxine 50mg tab 28 venlafaxine 75mg er cap 28 venlafaxine 75mg tab 28 VENTAVIS 10MCG/ML INH SOLN
61
VENTAVIS 20MCG/ML INH SOLN
61
VENTOLIN 108MCG INH 20 VERAPAMIL 100MG ER CAP
60
verapamil 120mg er cap 60 verapamil 120mg er tab 60 verapamil 120mg tab 60 verapamil 180mg er cap 60 verapamil 180mg er tab 60 VERAPAMIL 200MG ER CAP
60
verapamil 240mg er cap 60 verapamil 240mg er tab 60 VERAPAMIL 300MG ER CAP
60
VERAPAMIL 360MG ER CAP
60
verapamil 40mg tab 60 verapamil 80mg tab 60 VERSACLOZ 50MG/ML SUSP
52
VERZENIO 100MG TAB 47 VERZENIO 150MG TAB 47 VERZENIO 200MG TAB 47 VERZENIO 50MG TAB 47 VIBERZI 100MG TAB 78 VIBERZI 75MG TAB 78
VICTOZA 18MG/3ML PEN INJ
30
vienva 28 day pack 66 vigabatrin 500mg powder for oral soln
25
vigabatrin 500mg tab 25 vigadrone 500mg powder for oral soln
25
VIIBRYD 10/20MG STARTER PACK
27
VIIBRYD 10MG TAB 27 VIIBRYD 20MG TAB 27 VIIBRYD 40MG TAB 27 VIMPAT 100MG TAB 24 VIMPAT 10MG/ML ORAL SOLN
24
VIMPAT 150MG TAB 24 VIMPAT 200MG TAB 24 VIMPAT 50MG TAB 24 VIRACEPT 250MG TAB 56 VIRACEPT 625MG TAB 56 VIREAD 150MG TAB 56 VIREAD 200MG TAB 56 VIREAD 250MG TAB 56 VIREAD 40MG/GM ORAL POWDER
56
VITRAKVI 100MG CAP 47 VITRAKVI 20MG/ML ORAL SOLN
47
VITRAKVI 25MG CAP 47 VIVITROL 380MG INJ 33 VIZIMPRO 15MG TAB 47 VIZIMPRO 30MG TAB 47 VIZIMPRO 45MG TAB 47 voriconazole 200mg inj 34 voriconazole 200mg tab 34 voriconazole 40mg/ml susp
34
voriconazole 50mg tab 34 VOSEVI 400-100-100MG TAB
56
VOTRIENT 200MG TAB 47 VRAYLAR 1.5/3MG MIXED PACK
50
VRAYLAR 1.5MG CAP 50
VRAYLAR 3MG CAP 50 VRAYLAR 4.5MG CAP 50 VRAYLAR 6MG CAP 50 vyfemla 28 day pack 66 vylibra 28 day pack 66 VYNDAMAX 61MG CAP 62 VYNDAQEL 20MG CAP 62
W
WAKIX 17.8MG TAB 8 WAKIX 4.45MG TAB 8 warfarin sodium 10mg tab
20
warfarin sodium 1mg tab 20 warfarin sodium 2.5mg tab
20
warfarin sodium 2mg tab 20 warfarin sodium 3mg tab 20 warfarin sodium 4mg tab 20 warfarin sodium 5mg tab 20 warfarin sodium 6mg tab 20 warfarin sodium 7.5mg tab
20
wixela 0.1-0.05mg inh 20 wixela 0.25-0.05mg inh 20 wixela 0.5-0.05mg inh 20 wymzya fe 28 day pack 66
X
XALKORI 200MG CAP 47 XALKORI 250MG CAP 47 XARELTO 10MG TAB 21 XARELTO 15MG TAB 21 XARELTO 2.5MG TAB 21 XARELTO 20MG TAB 21 XARELTO KIT PACK 21 XATMEP 2.5MG/ML ORAL SOLN
42
XCOPRI 100MG TAB 25 XCOPRI 12.5/25MG TITRATION PACK
25
XCOPRI 150/200MG TITRATION PACK
25
XCOPRI 150MG TAB 25 XCOPRI 200MG TAB 25
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
146
ALPHABETICAL LISTING OF DRUGS
XCOPRI 50/100MG TITRATION PACK
25
XCOPRI 50MG TAB 25 XCOPRI TAB 150/200MG PACK
25
XCOPRI TAB 50/200MG PACK
25
XELJANZ 10MG TAB 10 XELJANZ 5MG TAB 10 XELJANZ XR 11MG TAB 10 XELJANZ XR 22MG TAB 10 XENLETA 600MG TAB 41 XGEVA 120MG/1.7ML INJ
74
XIFAXAN 200MG TAB 40 XIFAXAN 550MG TAB 40 XIGDUO 10-1000MG ER TAB
30
XIGDUO 10-500MG ER TAB
30
XIGDUO 2.5-1000MG ER TAB
30
XIGDUO 5-1000MG ER TAB
30
XIGDUO 5-500MG ER TAB
30
XOFLUZA 20MG THERAPY PACK
57
XOFLUZA 40MG THERAPY PACK
57
XOLAIR 150MG INJ 18 XOLAIR 150MG/ML SYRINGE
18
XOLAIR 75MG/0.5ML SYRINGE
18
XOSPATA 40MG TAB 47 XPOVIO 100 MG ONCE WEEKLY
44
XPOVIO 60 MG ONCE WEEKLY
44
XPOVIO 80 MG ONCE WEEKLY
44
XPOVIO 80 MG TWICE WEEKLY
44
XTAMPZA 13.5MG ER CAP
14
XTAMPZA 18MG ER CAP
14
XTAMPZA 27MG ER CAP
14
XTAMPZA 36MG ER CAP
14
XTAMPZA 9MG ER CAP 14 XTANDI 40MG CAP 43 XULANE 0.00146-0.00625MG/HR PATCH
66
XULTOPHY 100UNIT-3.6MG/ML PEN INJ
30
XYREM 500MG/ML ORAL SOLN
93
Y
YF-VAX 4000UNIT/ML INJ
101
Z
zafirlukast 10mg tab 18 zafirlukast 20mg tab 18 zaleplon 10mg cap 81 zaleplon 5mg cap 81 zarah pack 66 ZARXIO 300MCG/0.5ML SYRINGE
81
ZARXIO 480MCG/0.8ML SYRINGE
81
ZEJULA 100MG CAP 47 ZELBORAF 240MG TAB 47 ZEMAIRA 1000MG INJ 95 zenatane 10mg cap 68 zenatane 20mg cap 68 zenatane 30mg cap 68 zenatane 40mg cap 68 ZENPEP 105000-79000-25000UNIT DR CAP
72
ZENPEP 14000-10000-3000UNIT DR CAP
72
ZENPEP 24000-17000-5000UNIT DR CAP
72
ZENPEP 40000-126000-168000UNIT DR CAP
72
ZENPEP 42000-32000-10000UNIT DR CAP
72
ZENPEP 63000-47000-15000UNIT DR CAP
72
ZENPEP 84000-63000-20000UNIT DR CAP
72
ZERBAXA 1000-500MG INJ
62
zidovudine 100mg cap 56 zidovudine 10mg/ml oral soln
56
zidovudine 300mg tab 56 ZIEXTENZO 6MG/0.6ML SYRINGE
81
ziprasidone 20mg cap 50 ziprasidone 20mg inj 50 ziprasidone 40mg cap 50 ziprasidone 60mg cap 50 ziprasidone 80mg cap 50 ZIRGAN 0.15% OPHTH GEL
89
ZOLINZA 100MG CAP 47 zolmitriptan 2.5mg odt 83 zolmitriptan 2.5mg tab 83 zolmitriptan 5mg odt 83 zolmitriptan 5mg tab 83 zolpidem tartrate 10mg tab
82
zolpidem tartrate 5mg tab 82 ZOMIG 2.5MG NASAL SPRAY
83
ZOMIG 5MG NASAL SPRAY
83
zonisamide 100mg cap 24 zonisamide 25mg cap 25 zonisamide 50mg cap 25
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
147
ALPHABETICAL LISTING OF DRUGS
ZOSTAVAX 19400UNT/0.65ML INJ
101
ZOSYN 2000-250MG INJ 92 ZOSYN 3000-375MG INJ 92 zovia 1/35e 28 day pack 66 ZUBSOLV 1.4-0.36MG SL TAB
15
ZUBSOLV 11.4-2.9MG SL TAB
15
ZUBSOLV 2.9-0.71MG SL TAB
15
ZUBSOLV 5.7-1.4MG SL TAB
15
ZUBSOLV 8.6-2.1MG SL TAB
15
ZYCLARA 2.5% CREAM 71 ZYDELIG 100MG TAB 47 ZYDELIG 150MG TAB 47 ZYKADIA 150MG TAB 47 ZYLET 0.5-0.3% OPHTH SUSP
90
ZYPREXA 210MG INJ 52
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
148
Community Health Choice (HMO D-SNP)
CommunityHealthChoice.org/Medicare
Member Services
Method Member Services – Contact InformationCALL (833) 276-8306
Calls to this number are free. Community Health Choice HMO D-SNP is open Octo-ber 1 to March 31, 8:00 am to 8:00 pm, 7 days a week and April 1 through September 30, Monday through Friday, 8:00 am to 8:00 pm. On certain holidays your call will be handled by our automated phone system. Member Services also has free language interpreter services available for non-Eng-lish speakers.
TTY 711This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. The National Relay is available 24 hours a day, 7 days a week.
FAX (713) 295-7041WRITE P.O. Box 301413
Houston, TX 77230WEBSITE www.communityhealthchoice.org
Texas Health Information, Counseling and Advocacy Program (HICAP)
Health Information, Counseling and Advocacy Program (HICAP) is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare.
Method Contact InformationCALL (800) 252-9240TTY 711 WRITE Health Information, Counseling and Advocacy Program (HICAP)
P.O. Box 149104 Austin, TX 78714-9030
WEBSITE https://www.tdi.texas.gov/consumer/hicap/index.html
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