XB0001338-50-17All plans offered and underwritten by Kaiser Foundation Health Plan of Washington or Kaiser Foundation Health Plan of Washington Options, Inc.
Effective March 2020
2020 Drug FormularyFor Federal Employees and Retirees on the Kaiser Foundation Health Plan of Washington
Federal Employees Health Benefits Program Options (FEHB Options)
Drug Formulary INTRODUCTION
What is a formulary? A formulary is a list of generic, brand, and specialty drugs. It is used by practitioners to identify drugs that offer the best overall value, considering effectiveness, safety, and cost.
How is the drug formulary developed? The formulary is developed by the Kaiser Permanente Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is composed of physicians from various medical specialties, pharmacists, and a consumer member. The P&T Committee reviews and selects the most appropriate drugs in each class for the formulary based on safety, effectiveness, and cost. The P&T Committee meets quarterly to review new and existing drugs to ensure that the formulary remains responsive to the needs of members and providers.
How do I search the formulary? Drugs on the formulary are listed by therapeutic class. An alphabetical index is included at the end of this document to assist in locating specific drugs.
Drugs are listed by generic name if a generic is available. If there is no generic available, drugs are listed by the brand name. Drugs are organized by class and drug formulary tier. Drugs administered in a provider’s office or in a clinic (e.g., drugs given intravenously) may not be listed on the formulary. For coverage of these drugs, refer to your Benefit Booklet.
How do I use the formulary to understand my drug coverage? Drug coverage is based on an individual’s contracted benefit. Coverage for a specific drug is subject to each member’s medical coverage agreement. Please consult your Benefit Booklet or call Member Service if you have questions about your drug coverage.
Kaiser Permanente will only cover FDA-approved drugs used for non-experimental therapies. Most plans exclude experimental and investigational drugs, over-the-counter drugs, drugs used in the treatment of sexual dysfunction disorders, drugs for anticipated illnesses while traveling, or drugs used for cosmetic purposes. Please consult your Benefit Booklet for limitations and exclusions.
Medications not listed in this document are not on the formulary at the time of publication. The most current information is online at www.kp.org/wa/formulary. Non-formulary drugs are not covered unless approved by the health plan as a coverage exception. The prescriber must contact Kaiser Permanente to determine the medical necessity of the non-formulary medication. An alternative formulary medication will be recommended when clinically appropriate. If a coverage exception is not approved, the patient is responsible for the full price of the drug.
Generic drugs are substituted when available and allowed by your prescriber. When a generic is available, the brand-name drug is generally considered non-formulary and subject to a higher cost share.
The drug formulary is updated periodically and is subject to change. If a drug will be removed from the formulary, members who filled the drug in the prior three months will be notified by letter of the upcoming change. A formulary change notice will also be posted on the member website at least 45 days prior to the effective date.
What are the methods that Kaiser Permanente uses to ensure appropriate and safe use of formulary drugs?
Prior Authorization (PA) The P&T Committee determines that certain drugs should require prior authorization before they will be covered. These drugs most often have alternatives on the formulary, safety concerns, or a high potential for inappropriate use. To request coverage for prior authorization drugs, you or your prescriber must contact Kaiser Permanente. Drugs requiring prior authorization are indicated with a “PA” superscript next to the drug name.
Quantity Limit (QL)
A quantity limit defines how much of a particular drug you can get during a specific time period or the maximum days supply that you can get at once. The P&T Committee determines if a drug should have a quantity limit. To request exceptions to quantity limits, your prescriber must contact Kaiser Permanente. Drugs with quantity limits are indicated with “QL” superscript next to the drug name.
High Dose Pain Medicine Prescriber Review
Members on high doses of certain pain medicines will need their prescriber to confirm safety standards are in place annually to continue coverage of therapy.
Drugs Limited to Select Pharmacies Some drugs are required to be dispensed from a preferred specialty pharmacy vendor. Members with an out-of-network benefit may use other pharmacies; however, they may pay a higher cost share. Please consult your Benefit Booklet for limitations and exclusions. Drugs limited to select pharmacies are listed on the www.kp.org/wa/formulary webpage.
Covered Diabetic Supplies Some diabetic supplies may be covered at a Tier 1 cost share if they are filled as a prescription. These items are:
• Preferred blood glucose strips:
o One Touch Verio o One Touch Ultra o Prodigy – prior authorization required o Contour Next – prior authorization required o Freestyle – prior authorization required
• Disposable insulin syringes and needles
• Lancing devices and lancets
Preferred blood glucose meters are covered only when filled through mail order pharmacy.
Mail Order Pharmacy Service Mail order is convenient and efficiently utilizes Kaiser Permanente’s resources. This service works best for drugs that must be taken on regular basis, such as birth control pills and drugs for high blood pressure, high cholesterol, or other chronic conditions.
To begin using mail order, ask your prescriber to send your prescription directly to the Mail Order Pharmacy. To transfer an existing prescription from a retail pharmacy, contact the Mail Order Pharmacy.
Address: Kaiser Permanente Mail Order Pharmacy PO Box
34383
Seattle, WA 98124-1383
Phone: 800-245-RXRX (1-800-245-7979)
Fax: 206-630-7950, or toll-free 1-800-350-1683
Specialty Drugs Specialty drugs are high-cost drugs prescribed by a physician for the treatment of complex conditions. Some specialty products are dispensed from a preferred specialty pharmacy vendor.
Over-the-Counter (OTC) Drugs A few plans offer coverage for OTC drugs. For these plans, a list of covered OTC drugs can be found in Appendix A. You may contact Member Service at 1-888-630-4636 to find if you have OTC drug coverage.
Preventative Medications and Preferred Contraceptives In accordance with the Affordable Care Act (ACA) requirements for preventive services, most plans cover preventative care medicines and contraceptives in full. If your plan offers ACA benefits, all prescribed FDA approved contraceptive methods from the Kaiser Permanente formulary list will be covered in full when obtained in-network. For plans with out-of-network (OON) benefits, contraceptives will be subject to the OON cost-share. The list of the preventative medications covered in full is available on the www.kp.org/wa/formulary webpage.
Please consult your Benefit Booklet under “Preventive Services” or call Member Service if you have questions about your coverage for these drugs.
If you request coverage for a non-preferred contraceptive, we will contact your provider to recommend a preferred generic or therapeutically equivalent product. If you and your provider determine that the preferred contraceptive(s) would be medically inappropriate, your provider must request a contraceptive waiver. If waiver is completed, the requested non-preferred contraceptive will be covered in full.
How do I get additional information? Please contact Member Service at 1-888-630-4636 with any questions or concerns regarding the information contained in this document.
The most current drug formulary is available at www.kp.org/wa/formulary.
9
Table of Contents
Analgesics - Drugs for Pain and Inflammation ........................................................................ 11
Analgesics - Drugs for Pain .......................................................................................................... 12
Anesthetics ....................................................................................................................................... 14
Anti-Addiction / Substance Abuse Treatment Agents........................................................... 16
Antibacterials .................................................................................................................................... 17
Anticoagulants ................................................................................................................................. 20
Anticonvulsants - Drugs for Seizures ........................................................................................ 21
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia .............................. 22
Antidepressants ............................................................................................................................... 23
Antiemetics - Drugs for Nausea and Vomiting ........................................................................ 24
Antifungals ........................................................................................................................................ 25
Antigout Agents ............................................................................................................................... 26
Anti-inflammatory Agents ............................................................................................................. 26
Antimigraine Agents ....................................................................................................................... 26
Antimyasthenic Agents .................................................................................................................. 27
Antimycobacterials ......................................................................................................................... 27
Antineoplastics - Drugs for Cancer ............................................................................................ 27
Antiparasitics .................................................................................................................................... 30
Antiparkinson Agents ..................................................................................................................... 30
Antiplatelets ...................................................................................................................................... 31
Antipsychotics - Drugs for Mood Disorders ............................................................................ 31
Antivirals ............................................................................................................................................ 32
Anxiolytics - Drugs for Anxiety .................................................................................................... 35
Bipolar Agents - Drugs for Mood Disorders ............................................................................. 35
Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders......... 35
Cardiovascular Agents - Drugs for Heart and Circulation Conditions ............................. 36
Central Nervous System Agents - Drugs for Attention Deficit Disorder ......................... 42
Central Nervous System Agents - Drugs for Multiple Sclerosis......................................... 42
Central Nervous System Agents - Miscellaneous .................................................................. 43
Dental and Oral Agents - Drugs for Mouth and Throat Conditions ................................... 43
Dermatological Agents - Drugs for Skin Conditions ............................................................. 44
Diabetes - Antidiabetic Agents .................................................................................................... 51
Diabetes - Glucose Monitoring .................................................................................................... 53
Diabetes - Glycemic Agents ......................................................................................................... 54
Diabetes - Insulins ........................................................................................................................... 54
Electrolytes / Minerals / Metals / Vitamins ................................................................................ 55
10
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer ................................................. 57
Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions ............ 58
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment .......... 59
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions ................... 60
Genitourinary Agents - Drugs for Prostate Conditions ......................................................... 61
Hormonal Agents - Adrenal .......................................................................................................... 61
Hormonal Agents - Men's Health ................................................................................................. 63
Hormonal Agents - Osteoporosis ............................................................................................... 63
Hormonal Agents - Pituitary ......................................................................................................... 63
Hormonal Agents - Prostaglandins ............................................................................................ 64
Hormonal Agents - Sex Hormones and Birth Control ........................................................... 64
Hormonal Agents - Thyroid ........................................................................................................... 69
Immunological Agents - Drugs for Immune System Stimulation or Suppression ........ 70
Immunological Agents - Drugs for Vaccination ...................................................................... 71
Inflammatory Bowel Disease Agents ......................................................................................... 72
Metabolic Bone Disease Agents - Drugs for Osteoporosis ................................................. 73
Metabolic Bone Disease Agents - Other ................................................................................... 73
Miscellaneous Therapeutic Agents ............................................................................................ 73
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation ........................ 76
Ophthalmic Agents - Drugs for Glaucoma ............................................................................... 77
Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions ......................................... 78
Otic Agents - Drugs for Ear Conditions ..................................................................................... 80
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold ..................... 80
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions .............................................................................................................................................................. 82
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis ................................... 84
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension ................ 84
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm ........................................ 85
Sleep Disorder Agents ................................................................................................................... 85
Index of Drugs .................................................................................................................................. 88
Effective Date: 03/01/2020 11
Drug Name Drug Tier
Notes
Analgesics - Drugs for Pain and Inflammation
ANAPROX DS 3
ARTHROTEC 3
CAMBIA 3 PA
CELEBREX 3
celecoxib oral 1
choline-mag trisalicylate 1
DAYPRO 3
DICLOFENAC EPOLAMINE
3
diclofenac potassium 1
diclofenac sodium er 1
DICLOFENAC SODIUM EXTERNAL CREAM 3 %
3
diclofenac sodium oral 1
diclofenac sodium transdermal gel 1 %
3
diclofenac sodium transdermal solution
3
diclofenac-misoprostol 3
DICLOFONO 3
diflunisal oral 1
DUEXIS 5 PA; QL
EC-NAPROSYN 3
ec-naproxen 3
etodolac 1
etodolac er 3
FELDENE 3
fenoprofen calcium oral 3
fenortho 3
FLECTOR 3
flurbiprofen oral 1
ibu 1
ibuprofen oral suspension 3
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
1
INDOCIN 3
Drug Name Drug Tier
Notes
indomethacin er 1
indomethacin oral capsule 25 mg, 50 mg
1
ketoprofen er 3
ketoprofen oral 3
ketorolac tromethamine injection
1
ketorolac tromethamine oral
3
KETOROLAC TROMETHAMINE SOLUTION 60 MG/2ML INTRAMUSCULAR
3
ketorolac tromethamine solution 60 mg/2ml intramuscular
1
klofensaid ii transdermal solution 1.5 %
3
LODINE 3
meclofenamate sodium oral
1
mefenamic acid oral 3
meloxicam oral 1
MOBIC 3
nabumetone oral 1
NALFON 3
NAPRELAN 3
NAPROSYN ORAL SUSPENSION
3
NAPROSYN ORAL TABLET 500 MG
3
naproxen dr 3
naproxen oral 1
naproxen sodium er 3
naproxen sodium oral tablet 275 mg, 550 mg
1
oxaprozin 3
PENNSAID 3
piroxicam oral 1
profeno oral tablet 600 mg
3
Effective Date: 03/01/2020 12
Drug Name Drug Tier
Notes
QMIIZ ODT 3
RELAFEN DS 3 PA
REXAPHENAC 3
salsalate oral 1
SPRIX 3
sulindac oral 1
TIVORBEX 3
tolmetin sodium oral capsule
1
tolmetin sodium oral tablet 200 mg
1
tolmetin sodium oral tablet 600 mg
3
VIMOVO 5 PA; QL
VIVLODEX 3
VOLTAREN 3
ZIPSOR 3 PA
ZORVOLEX 3 PA
Analgesics - Drugs for Pain
7T GUMMY ES 3
ABSTRAL 5 PA; QL
acetaminophen-codeine 1 QL
acetaminophen-codeine #2
1 QL
acetaminophen-codeine #3
1 QL
acetaminophen-codeine #4
1 QL
ACTIQ 5 PA; QL
ALLZITAL 3
APADAZ 3 QL
apap-caff-dihydrocodeine 3 QL
ARYMO ER 3 PA; QL
ascomp-codeine 3 QL
BELBUCA 3 PA; QL
BENZHYDROCODONE-ACETAMINOPHEN
3 QL
BUPAP 3
Drug Name Drug Tier
Notes
buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr
3 PA; QL
BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR
3 PA; QL
butalbital-acetaminophen oral capsule
3
butalbital-acetaminophen oral tablet 50-300 mg, 50-325 mg
3
butalbital-apap oral tablet 50-325 mg
3
butalbital-apap-caff-cod 3 QL
butalbital-apap-caffeine oral capsule
3
butalbital-apap-caffeine oral tablet
1
butalbital-asa-caff-codeine
3 QL
butalbital-aspirin-caffeine 1
butorphanol tartrate nasal 3
BUTRANS 3 PA; QL
carisoprodol-aspirin-codeine
3 PA
codeine sulfate 1 QL
CONZIP 3 PA; QL
DEMEROL ORAL TABLET 100 MG
3 QL
DILAUDID ORAL 3 QL
DOLOPHINE 3 PA; QL
DURAGESIC-100 3 PA; QL
DURAGESIC-12 3 PA; QL
DURAGESIC-25 3 PA; QL
DURAGESIC-50 3 PA; QL
DURAGESIC-75 3 PA; QL
duraxin 3
DVORAH 3 QL
Effective Date: 03/01/2020 13
Drug Name Drug Tier
Notes
EMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 MG, 20-0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG
3 PA
endocet 1 QL
ESGIC 3
EXALGO ORAL TABLET ER 24 HOUR ABUSE-DETERRENT 12 MG, 16 MG, 32 MG, 8 MG
3 PA; QL
fentanyl citrate buccal lozenge on a handle
5 PA; QL
FENTANYL CITRATE BUCCAL TABLET
5 PA; QL
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
1 PA; QL
fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr
3 PA; QL
FENTORA 5 PA; QL
FIORICET 3
FIORICET/CODEINE 3 QL
FIORINAL 3
FIORINAL/CODEINE #3 3 QL
hydrocodone bitartrate er 3 QL
hydrocodone-acetaminophen oral solution 10-325 mg/15ml
3 QL
hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml
1 QL
hydrocodone-acetaminophen oral tablet 10-300 mg, 2.5-325 mg, 5-300 mg, 7.5-300 mg
3 QL
Drug Name Drug Tier
Notes
hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg
1 QL
hydrocodone-ibuprofen 3 QL
hydromorphone hcl er 3 PA; QL
hydromorphone hcl oral 1 QL
hydromorphone hcl rectal 1
HYSINGLA ER 3 PA; QL
IBUDONE ORAL TABLET 10-200 MG
3 QL
ibudone oral tablet 5-200 mg
3 QL
IONSYS 3
KADIAN 3 PA; QL
LAZANDA 5 PA; QL
levorphanol tartrate oral 1 PA; QL
lorcet 1 QL
lorcet hd 1 QL
lorcet plus 1 QL
LORTAB 3 QL
meperidine hcl oral tablet 3 QL
methadone hcl intensol 1 PA; QL
methadone hcl oral 1 PA; QL
methadose oral concentrate 10 mg/ml
3 PA; QL
methadose oral tablet soluble
1 PA; QL
methadose sugar-free 3 PA; QL
MORPHABOND ER 3 PA; QL
morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml
1 QL
morphine sulfate er beads 3 PA; QL
morphine sulfate er oral capsule extended release 24 hour
3 PA; QL
morphine sulfate er oral tablet extended release
1 PA; QL
morphine sulfate oral 1 QL
morphine sulfate rectal 1
Effective Date: 03/01/2020 14
Drug Name Drug Tier
Notes
MS CONTIN 3 PA; QL
NALOCET 3 QL
NORCO 3 QL
NUCYNTA 3 PA; QL
NUCYNTA ER 3 PA; QL
OPANA 3 QL
OPANA ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 5 MG, 7.5 MG
3 PA; QL
OXAYDO ORAL TABLET ABUSE-DETERRENT 7.5 MG
3 QL
OXYCODONE HCL ER 2 PA; QL
oxycodone hcl oral capsule
3 QL
oxycodone hcl oral concentrate 100 mg/5ml
1 QL
oxycodone hcl oral solution
1 QL
oxycodone hcl oral tablet 1 QL
oxycodone-acetaminophen oral solution 5-325 mg/5ml
3 QL
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
1 QL
oxycodone-aspirin 1 QL
oxycodone-ibuprofen 3 QL
OXYCONTIN 2 PA; QL
oxymorphone hcl 3 QL
oxymorphone hcl er 3 PA; QL
panlor oral tablet 325-30-16 mg
3 QL
pentazocine-naloxone hcl 3
PERCOCET 3 QL
phrenilin forte oral capsule 50-300-40 mg
3
PRIMLEV 3 QL
Drug Name Drug Tier
Notes
REMATEX EXTERNAL CREAM 0.035-6-30 %
3
ROXICODONE 3 QL
SUBSYS 5 PA; QL
tencon 3
tramadol hcl er (biphasic) 3 PA; QL
TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG
3 PA; QL
tramadol hcl er oral capsule extended release 24 hour 150 mg
3 PA; QL
tramadol hcl er oral tablet extended release 24 hour
3 PA; QL
tramadol hcl ir 1 QL
tramadol-acetaminophen 1 QL
TREZIX 3 QL
TYLENOL WITH CODEINE #3
3 QL
TYLENOL WITH CODEINE #4
3 QL
ULTRACET 3 QL
ULTRAM 3 QL
VANATOL LQ 3
VANATOL S 3
vicodin hp 3 QL
XTAMPZA ER 5 PA; QL
ZEBUTAL 3
ZOHYDRO ER 3 PA; QL
Anesthetics
1ST MEDX-PATCH/ LIDOCAINE EXTERNAL PATCH 4-0.0375-5-20 %
3
7T LIDO 3
AGONEAZE 3
ANASTIA EXTERNAL LOTION 2.75 %
3
ANODYNE LPT 3
ASTERO 3
Effective Date: 03/01/2020 15
Drug Name Drug Tier
Notes
BENZO-LIDOCAINE-TETRACAINE
3
BUPIVACAINE HCL-NACL INJECTION SOLUTION 0.2-0.9 %
3
BUPIVACAINE HCL-NACL INJECTION SOLUTION PREFILLED SYRINGE 0.1-0.9 % (50 ML)
3
COCAINE HCL NASAL 3
DERMACINRX EMPRICAINE
3
DERMACINRX PRIZOPAK
3
EHA 3
ethyl chloride 3
FLEXIN 3
GEBAUERS PAIN EASE 3
GEBAUERS SPRAY AND STRETCH
3
GEN7T 3
glydo external gel 2 % 1
GOPRELTO 3
LDO PLUS 3
LEVA SET/OCCLUSIVE DRESSING EXTERNAL KIT 2.5-2.5 %
3
LEVATIO 3
LIDENZA EXTERNAL PATCH 4-1 %
3
LIDO BDK 3
lidocaine external ointment
3
lidocaine external patch 5 %
1
lidocaine hcl (pf) injection solution 0.5 %, 1 %, 1.5 %, 2 %
3
lidocaine hcl external cream 3 %, 3.88 %
3
Drug Name Drug Tier
Notes
LIDOCAINE HCL EXTERNAL CREAM 4.12 %
3
lidocaine hcl external gel 2 %
1
lidocaine hcl external lotion
3 PA
lidocaine hcl external solution
3
lidocaine hcl injection solution
1
LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE
3
lidocaine hcl urethral/mucosal external gel
1
lidocaine pak external ointment 5 %
3
lidocaine-epinephrine injection solution 1 %-1:100000
3
lidocaine-prilocaine 1
LIDOCAINE-TETRACAINE EXTERNAL CREAM 23-7 %
3
LIDODERM 3
LIDO-K EXTERNAL LOTION 3 %
3 PA
LIDOMAR 3
lidopin external cream 3 %
3
LIDOPRIL 3
LIDOPRIL XR 3
LIDO-PRILO CAINE PACK
3
LIDORX 3 PA
LIDO-SORB 3 PA
LIDOTHOL EXTERNAL PATCH
3
LIDOTRAL 3
LIDOTREX 3
Effective Date: 03/01/2020 16
Drug Name Drug Tier
Notes
LIDOVIN EXTERNAL CREAM 3.95 %
3
LIDOZION 3 PA
LIDOZOL EXTERNAL CREAM 3.75 %
3
LIPROZONEPAK EXTERNAL KIT 2.5-2.5 %
3
LIVIXIL PAK 3
LORENZA EXTERNAL PATCH 4-1 %
3
LP LITE PAK EXTERNAL KIT 2.5-2.5 %
3
MEDI-PATCH RX 3
MEDOLOR PAK EXTERNAL KIT 2.5-2.5 %
3
NUMBONEX EXTERNAL LOTION 2.75 %
3
NUVAKAAN 3
PERMAVAN EXTERNAL PATCH 4-4-10 %
3
PORT-PREP EXTERNAL KIT 2.5-2.5 %
3
premium lidocaine 3
PRIKAAN EXTERNAL KIT 2.5-2.5 %
3
PRIKAAN LITE EXTERNAL KIT 2.5-2.5 %
3
PRILOLID 3
PRILOVIX 3
PRILOVIX LITE 3
PRILOVIX PLUS 3
prilovix ultralite 1
prilovix ultralite plus 1
PRILOXX LP EXTERNAL KIT 2.5-2.5 %
3
RELADOR PAK 3
RELADOR PAK PLUS 3
RELEEVIA EXTERNAL PATCH 0.0375-5 %
3
Drug Name Drug Tier
Notes
RELEEVIA MC EXTERNAL PATCH 0.0375-5 %
3
RELEEVIA ML EXTERNAL PATCH 4-1 %
3
REMAXAZON EXTERNAL PATCH 4-0.0285-3-5 %
3
RENOVO 3
ROPIVACAINE HCL INJECTION SOLUTION 5 MG/ML
3
SOLULINE EXTERNAL KIT 2.5-2.5 %
3
SOLUPICC EXTERNAL KIT 2.5-2.5 %
3
SOOTHEE 3
SYNERA 3
SYNVEXIA EXTERNAL PATCH 4-1 %
3
TRANZAREL EXTERNAL GEL 4 %
3
VEXATROL 3
XYLOCAINE 3
XYLOCAINE/EPINEPHRINE INJECTION SOLUTION 1 %-1:100000
3
XYLOCAINE-MPF 3
ZERUVIA 3
ZIONODIL 3 PA
ZTLIDO 3
Anti-Addiction / Substance Abuse Treatment Agents
acamprosate calcium 1
ANTABUSE 3
BUNAVAIL 3
buprenorphine hcl sublingual
1 QL
buprenorphine hcl-naloxone hcl sublingual film
3
Effective Date: 03/01/2020 17
Drug Name Drug Tier
Notes
buprenorphine hcl-naloxone hcl sublingual tablet sublingual
1
bupropion hcl er (smoking det)
1
CHANTIX 2
CHANTIX CONTINUING MONTH PAK
2
CHANTIX STARTING MONTH PAK
2
disulfiram oral 1
EVZIO 3
LUCEMYRA 5 PA; QL
naloxone hcl injection solution
1
NALOXONE HCL INJECTION SOLUTION AUTO-INJECTOR
3
naloxone hcl injection solution cartridge
1
naloxone hcl injection solution prefilled syringe
1
naltrexone hcl oral 1
NARCAN 1
NICORETTE MOUTH/THROAT GUM 2 MG
2 PA
nicotine polacrilex mouth/throat
2 PA
nicotine step 1 1 PA
nicotine step 2 1 PA
nicotine step 3 1 PA
SUBOXONE 3
VIVITROL 4 QL
ZUBSOLV 3
ZYBAN ORAL TABLET EXTENDED RELEASE 12 HOUR 150 MG
3
Antibacterials
ACTICLATE 3
AEMCOLO 3 PA
ALTABAX 3
Drug Name Drug Tier
Notes
amoxicillin 1
amoxicillin-potassium clavulanate er
3
amoxicillin-potassium clavulanate oral
1
ampicillin 1
ampicillin sodium injection solution reconstituted 1 gm, 125 mg, 250 mg, 500 mg
1
ARIKAYCE 3
AUGMENTIN 3
AUGMENTIN ES-600 3
AUGMENTIN XR ORAL TABLET EXTENDED RELEASE 12 HOUR 1000-62.5 MG
3
AVELOX ORAL TABLET 400 MG
3
avidoxy 1
azithromycin oral 1
BACTRIM 3
BACTRIM DS 3
BACTROBAN EXTERNAL CREAM 2 %
3
BACTROBAN NASAL NASAL OINTMENT 2 %
3
BAXDELA ORAL 5 PA; QL
BICILLIN L-A 2
cefaclor 3
cefaclor er 3
cefadroxil 1
cefazolin sodium injection solution reconstituted 1 gm
1
cefdinir 1
cefditoren pivoxil 3
cefepime hcl injection solution reconstituted 1 gm
3
cefixime 1
Effective Date: 03/01/2020 18
Drug Name Drug Tier
Notes
cefpodoxime proxetil 3
cefprozil 1
ceftazidime injection solution reconstituted 1 gm
1
CEFTIN ORAL SUSPENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML
2
ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg
1
cefuroxime axetil 1
CENTANY 3
cephalexin oral capsule 250 mg, 500 mg
1
cephalexin oral capsule 750 mg
3
cephalexin oral suspension reconstituted
1
cephalexin oral tablet 3
CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%)
2
CIPRO ORAL SUSPENSION RECONSTITUTED 500 MG/5ML (10%)
3
CIPRO ORAL TABLET 3
ciprofloxacin hcl oral 1
ciprofloxacin oral suspension reconstituted 500 mg/5ml (10%)
1
ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 1000 mg, 500 mg
3
clarithromycin er 3
clarithromycin oral 1
CLEOCIN 3
Drug Name Drug Tier
Notes
CLEOCIN PHOSPHATE INJECTION SOLUTION 300 MG/2ML
3
clindamycin hcl oral 1
clindamycin palmitate hcl 1
clindamycin phosphate injection solution 300 mg/2ml
1
clindamycin phosphate vaginal
1
CLINDESSE 3
colistimethate sodium (cba)
3
COLY-MYCIN M 3
coremino 3 PA
DAXBIA ORAL CAPSULE 333 MG
3
demeclocycline hcl 3
dicloxacillin sodium 1
DIFICID 5 PA; QL
DORYX 3
DORYX MPC 3
doxycycline hyclate oral capsule
1
doxycycline hyclate oral tablet 100 mg, 150 mg, 50 mg, 75 mg
1
doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 200 mg, 50 mg, 75 mg
3
DOXYCYCLINE HYCLATE ORAL TABLET DELAYED RELEASE 80 MG
3
doxycycline monohydrate oral capsule
1
doxycycline monohydrate oral suspension reconstituted
3
doxycycline monohydrate oral tablet
1
E.E.S. 400 3
Effective Date: 03/01/2020 19
Drug Name Drug Tier
Notes
E.E.S. GRANULES 3
ERYPED 200 3
ERYPED 400 3
ERY-TAB 3
ERYTHROCIN STEARATE
3
erythromycin base 3
erythromycin ethylsuccinate oral
3
FIRST-VANCOMYCIN 3
FIRVANQ 2
FLAGYL 3
FURADANTIN ORAL SUSPENSION 25 MG/5ML
3
gentamicin sulfate external
1
gentamicin sulfate injection solution 40 mg/ml
1
HIPREX 3
KEFLEX 3
LEVAQUIN 3
levofloxacin oral 1
LINCOCIN 3
lincomycin hcl injection 3
linezolid oral suspension reconstituted
1 QL
linezolid oral tablet 1
MACROBID 3
MACRODANTIN 3
mafenide acetate external 3
MAXIPIME INJECTION SOLUTION RECONSTITUTED 1 GM
3
methenamine hippurate 1
methenamine mandelate oral
3
METROGEL-VAGINAL VAGINAL GEL 0.75 %
3
Drug Name Drug Tier
Notes
metronidazole oral capsule
3
metronidazole oral tablet 1
metronidazole vaginal 1
MINOCIN ORAL 3
minocycline hcl er 3 PA
minocycline hcl oral capsule
1
minocycline hcl oral tablet 3
MINOLIRA 3 PA
mondoxyne nl 1
MONUROL 3
morgidox oral 1
MOXATAG ORAL TABLET EXTENDED RELEASE 24 HOUR 775 MG
3
moxifloxacin hcl oral 1
mupirocin calcium 1
mupirocin external 1
neomycin sulfate oral 1
neomycin-polymyxin b gu 3
nitrofurantoin 1
nitrofurantoin macrocrystal oral
1
nitrofurantoin monohydrate macrocrystals
1
NUVESSA 3
NUZYRA ORAL 5 PA; QL
ofloxacin oral 3
okebo 1
paromomycin sulfate oral 3
PCE ORAL TABLET DELAYED RELEASE 333 MG, 500 MG
3
penicillin v potassium 1
PRIMSOL 2
SEYSARA 5 PA; QL
SILVADENE 3
Effective Date: 03/01/2020 20
Drug Name Drug Tier
Notes
silver nitrate external ointment 10 %
3
silver sulfadiazine external
1
SIVEXTRO ORAL 4 QL
SOLODYN 3 PA
SOLOSEC 3
SPECTRACEF 3
ssd 1
streptomycin sulfate intramuscular
3
sulfadiazine oral 3
sulfamethoxazole-trimethoprim oral
1
SULFAMYLON 3
sulfatrim pediatric 1
SUPRAX ORAL CAPSULE
3
SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML
3
SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML
2
SUPRAX ORAL TABLET CHEWABLE
3
TARGADOX 3
tazicef injection solution reconstituted 1 gm
1
tetracycline hcl oral 3
TINDAMAX ORAL TABLET 500 MG
3
tinidazole oral 3
trimethoprim oral 1
TRIMPEX ORAL SOLUTION 50 MG/5ML
2
VANCOCIN HCL 5 QL
vancomycin hcl oral capsule
1 QL
Drug Name Drug Tier
Notes
vancomycin hcl oral solution reconstituted
1
vandazole 1
VIBRAMYCIN 3
XENLETA ORAL 3 PA
XEPI 3
XIFAXAN 5 PA; QL
XIMINO 3 PA
ZITHROMAX ORAL 3
ZITHROMAX TRI-PAK 3
ZITHROMAX Z-PAK 3
ZYVOX ORAL SUSPENSION RECONSTITUTED
5 QL
ZYVOX ORAL TABLET 5
Anticoagulants
ARIXTRA 5 QL
COUMADIN 3
ELIQUIS 3 PA
ELIQUIS DVT/PE STARTER PACK
3 PA
enoxaparin sodium 1 QL
fondaparinux sodium 4 QL
FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML
3
FRAGMIN SUBCUTANEOUS SOLUTION 95000 UNIT/3.8ML
3 PA
heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 5000 unit/ml
1
heparin sodium (porcine) pf
1
Effective Date: 03/01/2020 21
Drug Name Drug Tier
Notes
jantoven 1
LOVENOX 1 QL
PRADAXA 2
SAVAYSA 3 PA
warfarin sodium oral 1
XARELTO 2 PA
XARELTO STARTER PACK
2 PA
Anticonvulsants - Drugs for Seizures
APTIOM 5 PA; QL
BANZEL 5 QL
BRIVIACT ORAL 5 PA
carbamazepine er 1
carbamazepine oral 1
CARBATROL 3
CELONTIN 2
clobazam 5
DEPAKENE ORAL CAPSULE 250 MG
3
DEPAKENE ORAL SOLUTION 250 MG/5ML
3
DEPAKOTE 3
DEPAKOTE ER 3
DEPAKOTE SPRINKLES 3
DIACOMIT 5 PA; QL
DIASTAT ACUDIAL 3
DIASTAT PEDIATRIC 1
diazepam rectal 1
DILANTIN INFATABS 3
DILANTIN ORAL CAPSULE 100 MG
3
DILANTIN ORAL CAPSULE 30 MG
2
DILANTIN ORAL SUSPENSION
3
divalproex sodium er 1
divalproex sodium oral 1
EPIDIOLEX 5 PA; QL
epitol 1
Drug Name Drug Tier
Notes
EQUETRO 3
ethosuximide oral 1
felbamate oral suspension
3
felbamate oral tablet 3 QL
FELBATOL ORAL SUSPENSION
5
FELBATOL ORAL TABLET
5 QL
FYCOMPA 3 PA; QL
gabapentin oral 1
GABITRIL 3
KEPPRA ORAL 3
KEPPRA XR 3
LAMICTAL 3
LAMICTAL ODT 3
LAMICTAL STARTER 3
LAMICTAL XR 3
lamotrigine er 3
lamotrigine oral kit 21 x 25 mg & 7 x 50 mg, 25 & 50 & 100 mg, 42 x 50 mg & 14x100 mg
3
lamotrigine oral tablet 1
lamotrigine oral tablet chewable
1
lamotrigine oral tablet dispersible
3
lamotrigine starter kit-blue 3
lamotrigine starter kit-green
3
lamotrigine starter kit-orange
3
levetiracetam er 1
levetiracetam oral 1
MYSOLINE 5 QL
NAYZILAM 5 PA; QL
NEMBUTAL 3
NEURONTIN 3
ONFI 5
Effective Date: 03/01/2020 22
Drug Name Drug Tier
Notes
oxcarbazepine 1
OXTELLAR XR 3
PEGANONE 3
pentobarbital sodium injection
3
phenobarbital oral 1
phenobarbital sodium injection solution 130 mg/ml
1
PHENYTEK 3
phenytoin infatabs 1
phenytoin oral 1
phenytoin sodium extended oral capsule 100 mg
1
phenytoin sodium extended oral capsule 200 mg, 300 mg
3
phenytoin sodium injection
1
primidone oral 1 QL
QUDEXY XR 3 PA
roweepra 1
roweepra xr 1
SABRIL ORAL PACKET 5
SABRIL ORAL TABLET 5 PA
SPRITAM 3
subvenite 1
subvenite starter kit-blue 3
subvenite starter kit-green 3
subvenite starter kit-orange
3
SYMPAZAN 5
TEGRETOL 3
TEGRETOL-XR 3
tiagabine hcl 3
TOPAMAX 3
TOPAMAX SPRINKLE 3
topiramate er 3 PA
Drug Name Drug Tier
Notes
topiramate oral 1
TRILEPTAL 3
TROKENDI XR 3 PA
valproate sodium oral solution 250 mg/5ml
1
valproic acid oral 1
VALTOCO 10 MG DOSE 2
VALTOCO 15 MG DOSE 2
VALTOCO 20 MG DOSE 2
VALTOCO 5 MG DOSE 2
vigabatrin oral packet 5
vigabatrin oral tablet 5 PA
vigadrone 5
VIMPAT ORAL 3
ZARONTIN 3
ZONEGRAN 3
zonisamide oral 1
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia
ARICEPT 3
donepezil hcl oral tablet 10 mg, 5 mg
1
donepezil hcl oral tablet 23 mg
3
donepezil hcl oral tablet dispersible
3
EXELON 3
galantamine hydrobromide
1
galantamine hydrobromide er
1
memantine hcl er 3 PA
memantine hcl oral solution
3
memantine hcl oral tablet 10 mg, 5 mg
1
memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg
3
NAMENDA 3
Effective Date: 03/01/2020 23
Drug Name Drug Tier
Notes
NAMENDA TITRATION PAK
3
NAMENDA XR 3 PA
NAMENDA XR TITRATION PACK
3 PA
NAMZARIC 3
RAZADYNE 3
RAZADYNE ER 3
rivastigmine 3
rivastigmine tartrate 1
Antidepressants
amitriptyline hcl oral 1
amoxapine 1
ANAFRANIL 3
APLENZIN 3
BRISDELLE 3
bupropion hcl er (sr) 1
bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg
1
BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG
3 PA
bupropion hcl oral 1
CELEXA 3
chlordiazepoxide-amitriptyline
3
citalopram hydrobromide 1
clomipramine hcl oral 1
CYMBALTA 3
desipramine hcl oral 1
DESVENLAFAXINE ER 3 PA
desvenlafaxine succinate er
3 PA
doxepin hcl oral capsule 1
doxepin hcl oral concentrate
1
DRIZALMA SPRINKLE 3
duloxetine hcl oral 1
Drug Name Drug Tier
Notes
EFFEXOR XR 3
EMSAM 5
escitalopram oxalate 1
FETZIMA 3 PA
FETZIMA TITRATION 3 PA
fluoxetine hcl (pmdd) oral capsule 10 mg, 20 mg
1
fluoxetine hcl (pmdd) oral tablet
3
fluoxetine hcl oral capsule 1
fluoxetine hcl oral capsule delayed release
3
fluoxetine hcl oral solution 1
fluoxetine hcl oral tablet 1
fluvoxamine maleate 1
fluvoxamine maleate er 3
FORFIVO XL 3 PA
imipramine hcl oral 1
imipramine pamoate 3
KHEDEZLA ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 50 MG
3 PA
LEXAPRO 3
maprotiline hcl 1
MARPLAN 3
mirtazapine oral 1
NARDIL 3
nefazodone hcl 3
NORPRAMIN 3
nortriptyline hcl oral 1
olanzapine-fluoxetine hcl 3
PAMELOR 3
PARNATE 3
paroxetine hcl 1
paroxetine hcl er 3
paroxetine mesylate 3
PAXIL CR 3
Effective Date: 03/01/2020 24
Drug Name Drug Tier
Notes
PAXIL ORAL SUSPENSION
2
PAXIL ORAL TABLET 3
perphenazine-amitriptyline
1
PEXEVA 3
phenelzine sulfate oral 1
PRISTIQ 3 PA
protriptyline hcl 1
PROZAC 3
REMERON 3
REMERON SOLTAB 3
SARAFEM 3
sertraline hcl oral 1
SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG
3
SYMBYAX 3
TOFRANIL ORAL TABLET 10 MG, 25 MG, 50 MG
3
tranylcypromine sulfate 1
trazodone hcl oral 1
trimipramine maleate oral 3
TRINTELLIX 3 PA
venlafaxine hcl 1
venlafaxine hcl er oral capsule extended release 24 hour
1
venlafaxine hcl er oral tablet extended release 24 hour
3
VIIBRYD 3 PA
VIIBRYD STARTER PACK
3 PA
WELLBUTRIN SR 3
WELLBUTRIN XL 3
ZOLOFT 3
Antiemetics - Drugs for Nausea and Vomiting
Drug Name Drug Tier
Notes
AKYNZEO ORAL 3
ANZEMET 3
aprepitant oral capsule 125 mg, 80 & 125 mg, 80 mg
1
aprepitant oral capsule 40 mg
3
BONJESTA 3 PA
CESAMET ORAL CAPSULE 1 MG
3
compro 1
DICLEGIS 3 PA
dimenhydrinate injection 1
doxylamine-pyridoxine 3 PA
dronabinol 1
EMEND ORAL 3
EMEND TRI-PACK 3
granisetron hcl oral 3 PA
MARINOL ORAL CAPSULE 10 MG, 2.5 MG, 5 MG
3
meclizine hcl oral tablet 3
metoclopramide hcl injection
1
metoclopramide hcl oral solution
1
metoclopramide hcl oral tablet
1
metoclopramide hcl oral tablet dispersible
3
ondansetron hcl injection solution 40 mg/20ml
1
ondansetron hcl oral 1
ondansetron hcl solution 4 mg/2ml injection
1
ONDANSETRON HCL SOLUTION 4 MG/2ML INJECTION
3
ondansetron odt 1
perphenazine oral 1
prochlorperazine 1
Effective Date: 03/01/2020 25
Drug Name Drug Tier
Notes
prochlorperazine edisylate injection
1
prochlorperazine maleate oral
1
REGLAN 3
SANCUSO 3 PA
scopolamine 3
SYNDROS 3
TIGAN 3
TRANSDERM SCOP (1.5 MG)
3
TRANSDERM-SCOP (1.5 MG)
3
trimethobenzamide hcl oral
3
VARUBI 3 PA
ZOFRAN 3
ZOFRAN ODT ORAL TABLET DISPERSIBLE 4 MG, 8 MG
3
ZOFRAN ORAL SOLUTION 4 MG/5ML
3
ZUPLENZ 3
Antifungals
ANCOBON 5 QL
AVC VAGINAL 3
BIO-STATIN ORAL CAPSULE
3
bio-statin oral powder 3
ciclodan 1
ciclodan external cream 0.77 %
1
ciclopirox external gel 1
ciclopirox external shampoo
3
ciclopirox external solution
1
ciclopirox olamine external
1
clotrimazole external 3
clotrimazole mouth/throat 1
Drug Name Drug Tier
Notes
CRESEMBA ORAL 4 PA; QL
DIFLUCAN 3
econazole nitrate external 3
ECOZA 3
ERTACZO 3
EXELDERM 3
exoderm external lotion 3
EXTINA 3
fluconazole oral 1
flucytosine oral 4 QL
griseofulvin microsize oral 1
griseofulvin ultramicrosize 1
GRIS-PEG ORAL TABLET 125 MG, 250 MG
3
GYNAZOLE-1 3
HALOTIN EXTERNAL CREAM 1 %
3
itraconazole oral 1 PA
JUBLIA 3 PA
KERYDIN 3 PA
ketoconazole external cream
1
ketoconazole external foam
3
ketoconazole external shampoo
1
ketoconazole oral 1
ketodan external foam 3
LAMISIL 3
LOPROX EXTERNAL CREAM
3
LOPROX EXTERNAL KIT 0.77 % (SUSP)
3
LOPROX EXTERNAL SHAMPOO
3
LOPROX EXTERNAL SUSPENSION
3
LULICONAZOLE 3
LUZU 3
Effective Date: 03/01/2020 26
Drug Name Drug Tier
Notes
miconazole 3 vaginal suppository
3
MICONAZOLE-ZINC OXIDE-PETROLAT
3
naftifine hcl 3
NAFTIN 3
NIZORAL 3
NOXAFIL ORAL SUSPENSION
5 PA; QL
NOXAFIL ORAL TABLET DELAYED RELEASE
5 PA
nyamyc 1
nystatin external 1
nystatin mouth/throat 1
nystatin oral 1
nystatin-triamcinolone 1
nystop 1
ONMEL ORAL TABLET 200 MG
3 PA
ORAVIG 3
oxiconazole nitrate 3
OXISTAT 3
PENLAC EXTERNAL SOLUTION 8 %
3
posaconazole 5 PA
SPORANOX 3 PA
SPORANOX PULSEPAK 3 PA
TERAZOL 7 VAGINAL CREAM 0.4 %
3
terbinafine hcl oral 1
terconazole 3
TOLSURA 3 PA
VFEND 5 PA
voriconazole oral 1 PA
VUSION 3
XOLEGEL 3
Antigout Agents
allopurinol oral 1
Drug Name Drug Tier
Notes
COLCHICINE ORAL CAPSULE
2
colchicine tablet 0.6 mg oral
1
COLCHICINE TABLET 0.6 MG ORAL (authorized generic)
2
colchicine-probenecid 1
COLCRYS 2
DUZALLO ORAL TABLET 200-200 MG, 200-300 MG
3 PA
febuxostat oral tablet 40 mg
3 PA; QL
febuxostat oral tablet 80 mg
3 PA
GLOPERBA 3
MITIGARE 3
probenecid 1
ULORIC ORAL TABLET 40 MG
3 PA; QL
ULORIC ORAL TABLET 80 MG
3 PA
ZURAMPIC ORAL TABLET 200 MG
3 PA
ZYLOPRIM 3
Anti-inflammatory Agents
EMFLAZA 5 PA; QL
Antimigraine Agents
AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML, 70 MG/ML
3 PA
AJOVY 3 PA
almotriptan malate 3 PA
AMERGE 3
AXERT ORAL TABLET 12.5 MG, 6.25 MG
3 PA
CAFERGOT 3
D.H.E. 45 5 QL
Effective Date: 03/01/2020 27
Drug Name Drug Tier
Notes
dihydroergotamine mesylate injection
1 QL
dihydroergotamine mesylate nasal
4
eletriptan hydrobromide 3 PA
EMGALITY 3 PA
EMGALITY (300 MG DOSE)
3 PA
ERGOMAR 2
ergotamine-caffeine 1
FROVA 3 PA
frovatriptan succinate 3 PA
IMITREX 3
IMITREX STATDOSE REFILL
3
IMITREX STATDOSE SYSTEM
3
MAXALT 3
MAXALT-MLT 3
MIGERGOT 2
MIGRANAL 5
naratriptan hcl 1
RELPAX 3 PA
rizatriptan benzoate 1
sumatriptan nasal 1
sumatriptan succinate oral
1
sumatriptan succinate refill
1
sumatriptan succinate subcutaneous
1
sumatriptan-naproxen sodium
3 PA
TOSYMRA 3
TREXIMET ORAL TABLET 10-60 MG
3 PA
TREXIMET ORAL TABLET 85-500 MG
3 PA
UBRELVY 3 PA
ZEMBRACE SYMTOUCH 3
Drug Name Drug Tier
Notes
zolmitriptan oral 1
ZOMIG 3
ZOMIG ZMT 3
Antimyasthenic Agents
GUANIDINE HCL 3
MESTINON ORAL SYRUP 60 MG/5ML
2
MESTINON ORAL TABLET
3
MESTINON ORAL TABLET EXTENDED RELEASE
3
pyridostigmine bromide er 1
pyridostigmine bromide oral
1
Antimycobacterials
cycloserine oral 3
dapsone oral 1
ethambutol hcl oral 1
isoniazid oral 1
MYAMBUTOL 3
MYCOBUTIN 3
PASER 3
PRIFTIN 2
pyrazinamide oral 1
rifabutin 1
RIFADIN ORAL 3
RIFAMATE 3
rifampin oral 1
RIFATER 3
SIRTURO 5 PA; QL
TRECATOR 3
Antineoplastics - Drugs for Cancer
abiraterone acetate 1 QL
AFINITOR 2 PA; QL
AFINITOR DISPERZ 2 PA; QL
ALECENSA 3 PA; QL
ALKERAN ORAL 3 QL
Effective Date: 03/01/2020 28
Drug Name Drug Tier
Notes
ALUNBRIG 3 PA; QL
anastrozole oral 1
ARIMIDEX 3
AROMASIN 3
AYVAKIT 3 PA; QL
BALVERSA 3 PA; QL
bexarotene 3 PA; QL
bicalutamide 1
BOSULIF 3 PA; QL
BRAFTOVI 3 PA; QL
BRUKINSA 3 PA; QL
CABOMETYX 3 PA
CALQUENCE 3 PA; QL
capecitabine 1 QL
CAPRELSA 3 PA; QL
CASODEX 3
COMETRIQ (100 MG DAILY DOSE)
3 PA; QL
COMETRIQ (140 MG DAILY DOSE)
3 PA; QL
COMETRIQ (60 MG DAILY DOSE)
3 PA; QL
COPIKTRA 3 PA; QL
COTELLIC 2 PA; QL
cyclophosphamide oral 1
DAURISMO 3 PA; QL
DROXIA 2
EMCYT 3 QL
ERIVEDGE 3 PA
ERLEADA 3 PA; QL
erlotinib hcl 1 PA
etoposide oral 1 QL
everolimus 1 PA; QL
exemestane 1
FARESTON 3 PA
FARYDAK 3 PA; QL
FEMARA 3
flutamide 1
GILOTRIF 2 PA; QL
Drug Name Drug Tier
Notes
GLEEVEC 3 QL
GLEOSTINE 2
HEXALEN ORAL CAPSULE 50 MG
3 QL
HYCAMTIN ORAL 3 QL
HYDREA 3
hydroxyurea oral 1
IBRANCE 3 PA; QL
ICLUSIG 3 PA; QL
IDHIFA 3 PA; QL
imatinib mesylate 1 QL
IMBRUVICA 2 PA; QL
INLYTA 3 PA; QL
INREBIC 3 PA; QL
IRESSA 2 PA; QL
JAKAFI 3 PA
KISQALI (200 MG DOSE) 3 PA; QL
KISQALI (400 MG DOSE) 3 PA; QL
KISQALI (600 MG DOSE) 3 PA; QL
KISQALI FEMARA (400 MG DOSE)
3 PA; QL
KISQALI FEMARA (600 MG DOSE)
3 PA; QL
KISQALI FEMARA(200 MG DOSE)
3 PA; QL
LENVIMA (10 MG DAILY DOSE)
3 PA; QL
LENVIMA (12 MG DAILY DOSE)
3 PA; QL
LENVIMA (14 MG DAILY DOSE)
3 PA; QL
LENVIMA (18 MG DAILY DOSE)
3 PA
LENVIMA (20 MG DAILY DOSE)
3 PA; QL
LENVIMA (24 MG DAILY DOSE)
3 PA; QL
LENVIMA (4 MG DAILY DOSE)
3 PA; QL
LENVIMA (8 MG DAILY DOSE)
3 PA
Effective Date: 03/01/2020 29
Drug Name Drug Tier
Notes
letrozole oral 1
leucovorin calcium injection solution 100 mg/10ml
3
leucovorin calcium oral 1
LEUKERAN 2
LONSURF 3 PA; QL
LORBRENA 3 PA; QL
LYNPARZA ORAL CAPSULE 50 MG
3 PA; QL
LYSODREN 3 PA
MATULANE 2 QL
MEKINIST 2 PA; QL
MEKTOVI 3 PA; QL
melphalan 1 QL
mercaptopurine oral 1
mesna 1
MESNEX ORAL 2
MYLERAN 2 QL
NERLYNX 3 PA; QL
NEXAVAR 2 PA
NILANDRON 3 PA
nilutamide 3 PA
NINLARO 3 PA; QL
NUBEQA 3 PA; QL
ODOMZO 3 PA; QL
PANRETIN 3 PA; QL
PIQRAY (200 MG DAILY DOSE)
3 PA; QL
PIQRAY (250 MG DAILY DOSE)
3 PA; QL
PIQRAY (300 MG DAILY DOSE)
3 PA; QL
POMALYST 3 PA; QL
PURIXAN 3 PA
REVLIMID 2 PA; QL
ROZLYTREK 3 PA; QL
RUBRACA 3 PA; QL
RYDAPT 2 PA; QL
SIKLOS 5 PA; QL
Drug Name Drug Tier
Notes
SOLTAMOX 3
SPRYCEL 2 PA; QL
STIVARGA 2 PA
SUTENT 2 PA; QL
TABLOID 2
TAFINLAR 2 PA; QL
TAGRISSO 2 PA; QL
TALZENNA 3 PA; QL
tamoxifen citrate oral 1
TARCEVA 3 PA
TARGRETIN 3 PA; QL
TASIGNA 3 PA; QL
TAZVERIK 3
TEMODAR ORAL 3 QL
temozolomide 1 QL
THALOMID 2 PA; QL
TIBSOVO 3 PA; QL
toremifene citrate 3 PA
tretinoin oral 1 QL
TURALIO 3 PA; QL
TYKERB 2 PA; QL
VALCHLOR 5 PA; QL
VENCLEXTA 2 PA; QL
VENCLEXTA STARTING PACK
2 PA; QL
VERZENIO 3 PA; QL
VITRAKVI 3 PA; QL
VIZIMPRO 3 PA; QL
VOTRIENT 2 PA; QL
XALKORI 3 PA; QL
XELODA 3 QL
XOSPATA 3 PA; QL
XPOVIO (100 MG ONCE WEEKLY)
3 PA; QL
XPOVIO (60 MG ONCE WEEKLY)
3 PA; QL
XPOVIO (80 MG ONCE WEEKLY)
3 PA; QL
XPOVIO (80 MG TWICE WEEKLY)
3 PA; QL
Effective Date: 03/01/2020 30
Drug Name Drug Tier
Notes
XTANDI 2 PA; QL
YONSA 3 QL
ZEJULA 3 PA; QL
ZELBORAF 2 PA
ZOLINZA 3 PA; QL
ZYDELIG 2 PA; QL
ZYKADIA ORAL CAPSULE 150 MG
3 PA; QL
ZYTIGA ORAL TABLET 250 MG
3 QL
ZYTIGA ORAL TABLET 500 MG
2 QL
Antiparasitics
albendazole oral 1
ALBENZA 3
ALINIA 2
atovaquone oral 4
BENZNIDAZOLE 3 PA; QL
BILTRICIDE 3
chloroquine phosphate oral
1
COARTEM 3
crotan 2
DARAPRIM 4 PA; QL
ELIMITE 3
EMVERM 3
EURAX EXTERNAL CREAM 10 %
2
EURAX EXTERNAL LOTION 10 %
2
hydroxychloroquine sulfate oral
1
IMPAVIDO 5 PA; QL
ivermectin oral 3
KRINTAFEL 2
lindane 3
malathion 3
MEPRON 5
NATROBA 3
Drug Name Drug Tier
Notes
NEBUPENT 3
OVIDE 3
PENTAM 3
pentamidine isethionate 3
permethrin external 1
PLAQUENIL 3
praziquantel oral 1
primaquine phosphate 1
QUALAQUIN 3
quinine sulfate oral 3
SKLICE 3
spinosad 3
STROMECTOL 3
ULESFIA 2
Antiparkinson Agents
amantadine hcl oral 1
APOKYN 5 QL
AZILECT 3 PA
benztropine mesylate 1
bromocriptine mesylate oral
1
carbidopa oral 1
carbidopa-levodopa er 1
carbidopa-levodopa oral tablet
1
carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 mg
1
carbidopa-levodopa oral tablet dispersible 25-250 mg
3
carbidopa-levodopa-entacapone
1
COGENTIN 3
COMTAN 3
DUOPA 4 PA
ELDEPRYL ORAL CAPSULE 5 MG
3
entacapone 1
Effective Date: 03/01/2020 31
Drug Name Drug Tier
Notes
GOCOVRI 5 PA; QL
INBRIJA 5 PA; QL
LODOSYN 3
MIRAPEX 3
MIRAPEX ER 3
NEUPRO 3
NOURIANZ 5 PA; QL
OSMOLEX ER 3 PA
PARLODEL 3
pramipexole dihydrochloride
1
pramipexole dihydrochloride er
3
rasagiline mesylate oral 1 PA
REQUIP ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG, 5 MG
3
REQUIP XL 3
ropinirole hcl 1
ropinirole hcl er 3
RYTARY 3 PA
selegiline hcl oral 1
SINEMET 3
SINEMET CR 3
STALEVO 100 3
STALEVO 125 3
STALEVO 150 3
STALEVO 200 3
STALEVO 50 3
STALEVO 75 3
TASMAR 5 QL
tolcapone 5 QL
trihexyphenidyl hcl oral elixir
1
trihexyphenidyl hcl oral tablet
1
XADAGO 3 PA
ZELAPAR 5 QL
Antiplatelets
Drug Name Drug Tier
Notes
AGGRENOX 3
aspirin-dipyridamole er 1
BRILINTA 2
CABLIVI 5 PA; QL
cilostazol 1
clopidogrel bisulfate oral 1
dipyridamole oral 1
DURLAZA 3
EFFIENT 3
PLAVIX 3
prasugrel hcl 1
ZONTIVITY 3
Antipsychotics - Drugs for Mood Disorders
ABILIFY 3
ABILIFY MAINTENA 4 QL
ABILIFY MYCITE 3
aripiprazole oral solution 1
aripiprazole oral tablet 1
aripiprazole oral tablet dispersible
3
ARISTADA 4 QL
ARISTADA INITIO 4 QL
CAPLYTA 5 PA; QL
chlorpromazine hcl injection
1
chlorpromazine hcl oral 1
clozapine oral tablet 1
clozapine oral tablet dispersible
3
CLOZARIL 3
FANAPT 3 PA
FANAPT TITRATION PACK
3 PA
FAZACLO ORAL TABLET DISPERSIBLE 100 MG, 12.5 MG, 150 MG, 200 MG, 25 MG
3
fluphenazine decanoate injection
1
Effective Date: 03/01/2020 32
Drug Name Drug Tier
Notes
fluphenazine hcl 1
GEODON 3
HALDOL 3
HALDOL DECANOATE 3
haloperidol decanoate intramuscular
1
haloperidol lactate 1
haloperidol oral 1
INVEGA 3 PA
INVEGA SUSTENNA 4
INVEGA TRINZA 4 QL
LATUDA 5 PA
loxapine succinate 1
molindone hcl 3
NUPLAZID 5 PA; QL
olanzapine 1
ORAP ORAL TABLET 1 MG, 2 MG
3
paliperidone er 3 PA
PERSERIS 4
pimozide 1
quetiapine fumarate 1
quetiapine fumarate er 1
REXULTI 3 PA
RISPERDAL 3
RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG
2
RISPERDAL M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 3 MG, 4 MG
3
risperidone m-tab oral tablet dispersible 0.5 mg, 1 mg, 2 mg
3
risperidone oral solution 1
risperidone oral tablet 1
Drug Name Drug Tier
Notes
risperidone oral tablet dispersible
3
SAPHRIS 3 PA
SECUADO 3 PA
SEROQUEL 3
SEROQUEL XR 3
thioridazine hcl oral 3
thiothixene 1
trifluoperazine hcl 1
VERSACLOZ 3
VRAYLAR 5 PA; QL
ziprasidone hcl 1
ZYPREXA 3
ZYPREXA RELPREVV 2
ZYPREXA ZYDIS 3
Antivirals
abacavir sulfate 1
abacavir sulfate-lamivudine
1 QL
abacavir-lamivudine-zidovudine
4 QL
acyclovir external 3
acyclovir oral 1
adefovir dipivoxil 1 QL
APTIVUS ORAL CAPSULE
4 QL
APTIVUS ORAL SOLUTION
5 QL
atazanavir sulfate 1 QL
ATRIPLA 4 QL
BARACLUDE ORAL SOLUTION
4 QL
BARACLUDE ORAL TABLET
5 QL
BIKTARVY 4 QL
CIMDUO 4 QL
COMBIVIR 3
COMPLERA 4 PA; QL
CRIXIVAN 2
Effective Date: 03/01/2020 33
Drug Name Drug Tier
Notes
DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG
5 PA
DELSTRIGO 5 PA; QL
DENAVIR 3
DESCOVY 4 QL
didanosine 1
DOVATO 4 QL
EDURANT 2
efavirenz 1
EMTRIVA 2
entecavir 1 QL
EPCLUSA 4 PA; QL
EPIVIR 3
EPIVIR HBV ORAL SOLUTION
2
EPIVIR HBV ORAL TABLET
3
EPZICOM 5 QL
EVOTAZ 5 QL
famciclovir 3
FLUMADINE ORAL TABLET 100 MG
3
fosamprenavir calcium 4 QL
FUZEON 5 QL
GENVOYA 4
HARVONI 4 PA; QL
HEPSERA 5 QL
INTELENCE 2
INTRON A 2 QL
INVIRASE ORAL CAPSULE 200 MG
2
ISENTRESS HD 2
ISENTRESS ORAL PACKET
3
ISENTRESS ORAL TABLET
2
ISENTRESS ORAL TABLET CHEWABLE
2
JULUCA 4 QL
Drug Name Drug Tier
Notes
KALETRA ORAL SOLUTION
3
KALETRA ORAL TABLET 2
lamivudine 1
lamivudine-zidovudine 1
LEDIPASVIR-SOFOSBUVIR
4 PA; QL
LEXIVA ORAL SUSPENSION
4 QL
LEXIVA ORAL TABLET 5 QL
lopinavir-ritonavir 1
MAVYRET 5 PA; QL
MODERIBA 1200 DOSE PACK ORAL TABLET 600 MG
3 QL
MODERIBA 800 DOSE PACK ORAL TABLET 400 MG
3
moderiba oral tablet 200 mg
1 QL
MODERIBA ORAL TABLET THERAPY PACK 200 & 400 MG
3 QL
nevirapine er 1
nevirapine oral suspension
3
nevirapine oral tablet 1
NORVIR ORAL CAPSULE 100 MG
2
NORVIR ORAL PACKET 2
NORVIR ORAL SOLUTION
2
NORVIR ORAL TABLET 3
ODEFSEY 4 QL
OLYSIO ORAL CAPSULE 150 MG
5 PA; QL
oseltamivir phosphate oral
1
PEGASYS 4 QL
PEGASYS PROCLICK 4 QL
PEGINTRON 4 QL
PIFELTRO 5 PA; QL
Effective Date: 03/01/2020 34
Drug Name Drug Tier
Notes
PREVYMIS ORAL 5 PA; QL
PREZCOBIX 2 QL
PREZISTA 2
REBETOL ORAL CAPSULE 200 MG
3 QL
REBETOL ORAL SOLUTION 40 MG/ML
2 QL
RELENZA DISKHALER 2
RESCRIPTOR 2
RETROVIR ORAL 3
REYATAZ ORAL CAPSULE
5 QL
REYATAZ ORAL PACKET
2
ribasphere oral capsule 200 mg
1 QL
ribasphere oral tablet 200 mg
1 QL
RIBASPHERE ORAL TABLET 400 MG
3
RIBASPHERE ORAL TABLET 600 MG
3 QL
RIBASPHERE RIBAPAK ORAL TABLET 400 MG
3
RIBASPHERE RIBAPAK ORAL TABLET 600 MG
3 QL
RIBASPHERE RIBAPAK ORAL TABLET THERAPY PACK 200 & 400 MG, 400 & 600 MG
3 QL
ribavirin inhalation 3
ribavirin oral 1 QL
rimantadine hcl 1
ritonavir 1
SELZENTRY ORAL SOLUTION
4 QL
SELZENTRY ORAL TABLET 150 MG, 300 MG
4 QL
SELZENTRY ORAL TABLET 25 MG, 75 MG
4
SITAVIG 3
Drug Name Drug Tier
Notes
SOFOSBUVIR-VELPATASVIR
4 PA; QL
SOVALDI ORAL TABLET 200 MG
4 PA; QL
SOVALDI ORAL TABLET 400 MG
5 PA; QL
stavudine 1
STRIBILD 4 PA; QL
SUSTIVA 3
SYLATRON 3 QL
SYMFI 1
SYMFI LO 1
SYMTUZA 4 QL
TAMIFLU 2
TECHNIVIE ORAL TABLET 12.5-75-50 MG
5 PA; QL
tenofovir disoproxil fumarate
1
TIVICAY 2
TRIUMEQ 4 QL
TRIZIVIR 5 QL
TRUVADA 4 QL
TYBOST 2 PA
valacyclovir hcl oral 1
VALCYTE 5 QL
valganciclovir hcl 4 QL
VALTREX 3
VEMLIDY 5 PA; QL
VIDEX 2
VIDEX EC 3
VIEKIRA PAK 5 PA; QL
VIEKIRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 200-8.33-50- 33.33 MG
5 PA; QL
VIRACEPT 2
VIRAMUNE 3
VIRAMUNE XR 3
VIRAZOLE 3
VIREAD ORAL POWDER 2
Effective Date: 03/01/2020 35
Drug Name Drug Tier
Notes
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG
2
VIREAD ORAL TABLET 300 MG
3
VOSEVI 4 PA; QL
XERESE 3
XOFLUZA 3
ZEPATIER 5 PA; QL
ZERIT 3
ZERIT ORAL SOLUTION RECONSTITUTED 1 MG/ML
3
ZIAGEN 3
zidovudine 1
ZOVIRAX 3
ZOVIRAX ORAL CAPSULE 200 MG
3
Anxiolytics - Drugs for Anxiety
alprazolam er 1
alprazolam intensol 3
alprazolam oral tablet 1
alprazolam oral tablet dispersible
3
alprazolam xr 1
ATIVAN INJECTION SOLUTION 2 MG/ML
3
ATIVAN ORAL 3
buspirone hcl oral 1
chlordiazepoxide hcl 1
clonazepam oral 1
clorazepate dipotassium 1
diazepam intensol 3
diazepam intramuscular 1
diazepam oral concentrate
3
diazepam oral solution 1
diazepam oral tablet 1
diazepam solution 5 mg/ml injection
1
Drug Name Drug Tier
Notes
DIAZEPAM SOLUTION 5 MG/ML INJECTION
3
DORAL 3
estazolam 3
HALCION 3
hydroxyzine hcl oral 1
hydroxyzine pamoate oral 1
KLONOPIN 3
lorazepam injection solution 2 mg/ml
1
lorazepam intensol 1
lorazepam oral concentrate 2 mg/ml
1
lorazepam oral tablet 1
meprobamate 3
midazolam hcl injection solution 10 mg/2ml, 5 mg/ml
1
midazolam hcl oral 3
oxazepam 1
quazepam 3
TRANXENE-T 3
triazolam 1
VALIUM 3
VISTARIL 3
XANAX 3
XANAX XR 3
Bipolar Agents - Drugs for Mood Disorders
lithium 1
lithium carbonate er 1
lithium carbonate oral 1
LITHOBID 3
Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders
AGRYLIN 3
AMICAR 3
aminocaproic acid oral 3
anagrelide hcl 1
Effective Date: 03/01/2020 36
Drug Name Drug Tier
Notes
ARANESP (ALBUMIN FREE)
3 PA
DOPTELET 5 PA; QL
EPOGEN 2 PA
FULPHILA 5 PA; QL
GRANIX 5 QL
HEMLIBRA 4 PA; QL
LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG
2
LYSTEDA 3 QL
MIRCERA 3 PA
MULPLETA 5 PA; QL
NEULASTA 5 PA; QL
NEULASTA ONPRO 5 PA; QL
NEUPOGEN 4 QL
NIVESTYM 5 PA; QL
PROCRIT 2 PA
PROMACTA 5 PA; QL
RETACRIT 3 PA
TAVALISSE 5 PA; QL
tranexamic acid oral 1 QL
UDENYCA 5 PA; QL
ZARXIO 4 QL
ZIEXTENZO 5 PA; QL
Cardiovascular Agents - Drugs for Heart and Circulation Conditions
ACCUPRIL 3
ACCURETIC 3
acebutolol hcl oral 1
acetazolamide sodium 3
ADALAT CC 3
afeditab cr 1
ALDACTAZIDE ORAL TABLET 25-25 MG
3
ALDACTAZIDE ORAL TABLET 50-50 MG
2
ALDACTONE 3
Drug Name Drug Tier
Notes
aliskiren fumarate 3 PA
alprostadil injection 1
ALTACE 3
ALTOPREV 3
amiloride hcl oral 1
amiloride-hydrochlorothiazide
1
amiodarone hcl oral tablet 100 mg, 400 mg
3
amiodarone hcl oral tablet 200 mg
1
amlodipine besylate oral 1
amlodipine besylate-benazepril hcl
1
amlodipine besylate-valsartan
3 PA
amlodipine-atorvastatin 3
amlodipine-olmesartan 1
amlodipine-valsartan-hctz 3
ANTARA 3
ATACAND 3
ATACAND HCT 3
atenolol oral 1
atenolol-chlorthalidone 1
atorvastatin calcium oral 1
AVALIDE 3
AVAPRO 3
AZOR 3
benazepril hcl oral 1
benazepril-hydrochlorothiazide
1
BENICAR 3
BENICAR HCT 3
BETAPACE 3
BETAPACE AF 3
betaxolol hcl oral 1
BIDIL 3
bisoprolol fumarate 1
Effective Date: 03/01/2020 37
Drug Name Drug Tier
Notes
bisoprolol-hydrochlorothiazide
1
BRETYLIUM TOSYLATE 3
bumetanide oral 1
BUMEX 3
BYSTOLIC 3
BYVALSON ORAL TABLET 5-80 MG
3
CADUET 3
CALAN ORAL TABLET 120 MG, 80 MG
3
CALAN SR 3
candesartan cilexetil 3
candesartan cilexetil-hctz 3
captopril oral 1
captopril-hydrochlorothiazide
1
CARDIZEM 3
CARDIZEM CD 3
CARDIZEM LA 3
CARDURA 3
CAROSPIR 3
cartia xt 1
carvedilol 1
carvedilol phosphate er 3
CATAPRES 3
CATAPRES-TTS-1 3
CATAPRES-TTS-2 3
CATAPRES-TTS-3 3
chlorothiazide 1
chlorthalidone 1
cholestyramine light packets
1
cholestyramine oral packets
1
choline fenofibrate 3
clonidine 1
clonidine hcl oral 1
Drug Name Drug Tier
Notes
CLORPRES ORAL TABLET 0.1-15 MG, 0.2-15 MG, 0.3-15 MG
3
colesevelam hcl 3
COLESTID 3
COLESTID FLAVORED 3
colestipol hcl 1
CONSENSI 5 PA; QL
COREG 3
COREG CR 3
CORGARD 3
CORLANOR 3 PA
CORZIDE ORAL TABLET 40-5 MG, 80-5 MG
3
COZAAR 3
CRESTOR 3
DEMADEX ORAL TABLET 10 MG, 20 MG
3
DEMSER 3
DIBENZYLINE 5
digitek 1
digox 1
digoxin injection 1
digoxin oral 1
DILATRATE-SR 3
diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg
1
diltiazem hcl er 1
diltiazem hcl er beads 3
diltiazem hcl er coated beads oral capsule extended release 24 hour
1
diltiazem hcl er coated beads oral tablet extended release 24 hour
3
diltiazem hcl oral 1
dilt-xr 1
DIOVAN 3
Effective Date: 03/01/2020 38
Drug Name Drug Tier
Notes
DIOVAN HCT 3
disopyramide phosphate 1
DIURIL 2
dofetilide 3 PA
doxazosin mesylate oral 1
DUTOPROL 3
DYAZIDE 3
DYRENIUM 3
EDARBI 3 PA
EDARBYCLOR 3 PA
EDECRIN 3 PA
enalapril maleate oral 1
enalapril-hydrochlorothiazide
1
ENTRESTO 2 PA
EPANED 3
epinephrine injection solution 30 mg/30ml
1
epinephrine pf 1
eplerenone 1
eprosartan mesylate 3 PA
ethacrynic acid 1 PA
EXFORGE 3 PA
EXFORGE HCT 3
EZALLOR SPRINKLE 3
ezetimibe 1
ezetimibe-simvastatin 1
felodipine er 1
fenofibrate micronized 1
fenofibrate oral capsule 134 mg, 200 mg, 67 mg
1
fenofibrate oral capsule 150 mg, 50 mg
3
fenofibrate oral tablet 120 mg, 145 mg, 40 mg, 48 mg
3
fenofibrate oral tablet 160 mg, 54 mg
1
Drug Name Drug Tier
Notes
fenofibric acid oral capsule delayed release
3
fenofibric acid oral tablet 1
FENOGLIDE 3
FIBRICOR 3
flecainide acetate 1
FLOLIPID 3
fluvastatin sodium 3
fluvastatin sodium er 3
fosinopril sodium 1
fosinopril sodium-hctz 1
furosemide injection 1
furosemide oral 1
gemfibrozil oral 1
GONITRO 3
guanfacine hcl 1
HEMANGEOL 3 PA
hydralazine hcl oral 1
hydrochlorothiazide oral 1
HYZAAR 3
indapamide 1
INDERAL LA 3
INDERAL XL 3
INNOPRAN XL 3
INSPRA 3
irbesartan 1
irbesartan-hydrochlorothiazide
1
isoproterenol hcl injection 3
ISORDIL TITRADOSE ORAL TABLET 40 MG
2
ISORDIL TITRADOSE ORAL TABLET 5 MG
3
isosorbide dinitrate 1
isosorbide dinitrate er oral tablet extended release 40 mg
3
isosorbide mononitrate 1
Effective Date: 03/01/2020 39
Drug Name Drug Tier
Notes
isosorbide mononitrate er 1
isradipine 1
ISUPREL 3
JUXTAPID 5 PA; QL
KAPSPARGO SPRINKLE 3
KATERZIA 3
KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML
5 PA; QL
labetalol hcl oral 1
LANOXIN 3
LANOXIN PEDIATRIC 3
LASIX 3
LESCOL XL 3
LIPITOR 3
LIPOFEN 3
lisinopril oral 1
lisinopril-hydrochlorothiazide
1
LIVALO 3
LOPID 3
LOPRESSOR 3
LOPRESSOR HCT 3
losartan potassium 1
losartan potassium-hctz 1
LOTENSIN 3
LOTENSIN HCT 3
LOTREL 3
lovastatin 1
LOVAZA 3
matzim la 3
MAXZIDE 3
MAXZIDE-25 3
methyclothiazide oral tablet 5 mg
1
methyldopa 1
Drug Name Drug Tier
Notes
methyldopa-hydrochlorothiazide
3
metolazone 1
metoprolol succinate er 1
metoprolol tartrate oral 1
METOPROLOL-HCTZ ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG
3
metoprolol-hydrochlorothiazide
1
mexiletine hcl oral 1
MICARDIS 3
MICARDIS HCT 3
MICROZIDE ORAL CAPSULE 12.5 MG
3
midodrine hcl 1
MINIPRESS 3
minitran 1
minoxidil oral 1
moexipril hcl 1
moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg, 7.5-12.5 mg
1
MULTAQ 3
nadolol oral 1
nadolol-bendroflumethiazide oral tablet 40-5 mg
3
niacin (antihyperlipidemic) 3
niacin er (antihyperlipidemic)
3
niacor 3
NIASPAN 3
nicardipine hcl oral 1
nifedipine er 1
nifedipine er osmotic release
1
nifedipine oral 1
Effective Date: 03/01/2020 40
Drug Name Drug Tier
Notes
nimodipine oral 1
nisoldipine er 3
NITRO-BID 2
NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR
3
NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR
2
nitroglycerin er oral capsule extended release 9 mg
1
nitroglycerin sublingual 1
nitroglycerin transdermal 1
nitroglycerin translingual 3
NITROLINGUAL 3
NITROMIST 3
NITROSTAT 3
nitro-time oral capsule extended release 9 mg
1
NORPACE 3
NORPACE CR 2
NORTHERA 5 PA; QL
NORVASC 3
NYMALIZE 5 QL
olmesartan medoxomil oral
1
olmesartan medoxomil-hctz
1
olmesartan-amlodipine-hctz
3
omega-3-acid ethyl esters 3
pacerone oral tablet 100 mg, 400 mg
3
pacerone oral tablet 200 mg
1
papaverine hcl injection 1
pentoxifylline er 1
Drug Name Drug Tier
Notes
perindopril erbumine 1
phenoxybenzamine hcl oral
4
phentolamine mesylate injection
1
pindolol 1
PRALUENT 5 PA; QL
PRAVACHOL 3
pravastatin sodium 1
prazosin hcl oral 1
PRESTALIA 3
prevalite 1
PRINIVIL 3
procainamide hcl injection 1
PROCARDIA 3
PROCARDIA XL 3
propafenone hcl 1
propafenone hcl er 3
propranolol hcl er 1
propranolol hcl oral 1
propranolol-hctz 1
PROSTIN VR 3
QBRELIS 3
QUESTRAN 3
QUESTRAN LIGHT 3
quinapril hcl 1
quinapril-hydrochlorothiazide
1
quinidine gluconate er 1
QUINIDINE GLUCONATE INJECTION SOLUTION 80 MG/ML
3
quinidine sulfate 1
ramipril 1
RANEXA 3 PA
ranolazine er 3 PA
RECTIV 2
Effective Date: 03/01/2020 41
Drug Name Drug Tier
Notes
REPATHA 3 PA
REPATHA PUSHTRONEX SYSTEM
3 PA
REPATHA SURECLICK 3 PA
rosuvastatin calcium 1
RYTHMOL SR 3
SIMVASTATIN ORAL SUSPENSION
3
simvastatin oral tablet 1
sorine 1
sotalol hcl (af) 1
sotalol hcl oral 1
SOTYLIZE 3
spironolactone oral 1
spironolactone-hctz 1
SULAR 3
TARKA 3
taztia xt 3
TEKTURNA 3 PA
TEKTURNA HCT 3 PA
telmisartan 3
telmisartan-amlodipine 3
telmisartan-hctz 3
TENORETIC 100 3
TENORETIC 50 3
TENORMIN 3
tiadylt er 3
TIAZAC 3
TIKOSYN 3 PA
timolol maleate oral 1
TOPROL XL 3
torsemide 1
trandolapril 1
trandolapril-verapamil hcl er
3
triamterene oral 1
triamterene-hctz 1
Drug Name Drug Tier
Notes
TRIBENZOR 3
TRICOR 3
TRIGLIDE 3
triklo oral capsule 1 gm 3
TRILIPIX 3
TWYNSTA 3
valsartan 1
valsartan-hydrochlorothiazide
1
VASCEPA ORAL CAPSULE 0.5 GM
3 PA
VASCEPA ORAL CAPSULE 1 GM
3
VASERETIC 3
VASOTEC 3
VECAMYL 5
verapamil hcl er oral capsule extended release 24 hour 100 mg, 200 mg, 300 mg
3
verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg
1
verapamil hcl er oral tablet extended release
1
verapamil hcl oral 1
VERELAN 3
VERELAN PM 3
VYNDAMAX 5 PA; QL
VYNDAQEL 5 PA; QL
VYTORIN 3
WELCHOL 3
ZESTORETIC 3
ZESTRIL 3
ZETIA 3
ZIAC 3
ZOCOR 3
ZYPITAMAG 3
Effective Date: 03/01/2020 42
Drug Name Drug Tier
Notes
Central Nervous System Agents - Drugs for Attention Deficit Disorder
ADDERALL 3
ADDERALL XR 1 QL
ADHANSIA XR 3 PA; QL
ADZENYS ER 3 PA
ADZENYS XR-ODT 3 PA
AMPHETAMINE ER 3 PA
amphetamine sulfate 3 PA
amphetamine-dextroamphetamine
1
amphetamine-dextroamphetamine er
1 QL
APTENSIO XR 3 PA; QL
atomoxetine hcl 1 PA
clonidine hcl er 3
CONCERTA 3 QL
COTEMPLA XR-ODT 3 PA; QL
DAYTRANA 3 PA; QL
DESOXYN 3
DEXEDRINE 3 QL
dexmethylphenidate hcl 1
dexmethylphenidate hcl er
3 PA; QL
dextroamphetamine sulfate er
1 QL
dextroamphetamine sulfate oral solution
3
dextroamphetamine sulfate oral tablet
1
DYANAVEL XR 3 PA
EVEKEO 3 PA
EVEKEO ODT 3 PA
FOCALIN 3
FOCALIN XR 3 PA; QL
guanfacine hcl er 1
INTUNIV 3
JORNAY PM 3 PA; QL
KAPVAY 3
metadate er 1 QL
Drug Name Drug Tier
Notes
methamphetamine hcl 3
METHYLIN 3
methylphenidate hcl er 1 QL
methylphenidate hcl er (cd)
1 QL
methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg
3 PA; QL
methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg, 60 mg
1 PA; QL
methylphenidate hcl oral solution
3
methylphenidate hcl oral tablet
1
methylphenidate hcl oral tablet chewable
3
MYDAYIS 3 PA; QL
PROCENTRA 3
QUILLICHEW ER 3 PA
QUILLIVANT XR 3 PA; QL
relexxii 1 QL
RITALIN 3
RITALIN LA 3 PA; QL
STRATTERA 3 PA
VYVANSE 3 PA; QL
zenzedi oral tablet 10 mg, 5 mg
1
ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG
3
Central Nervous System Agents - Drugs for Multiple Sclerosis
AMPYRA 5 PA; QL
AUBAGIO 5 PA; QL
AVONEX PEN 4 PA; QL
AVONEX PREFILLED 4 PA; QL
AVONEX VIAL INTRAMUSCULAR KIT INTRAMUSCULAR KIT 30 MCG
4 PA; QL
Effective Date: 03/01/2020 43
Drug Name Drug Tier
Notes
BETASERON 5 PA; QL
COPAXONE 5 PA; QL
dalfampridine er 5 PA; QL
EXTAVIA 4 QL
GILENYA 4 PA; QL
glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml
4 QL
glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ml
5 QL
glatopa subcutaneous solution prefilled syringe 20 mg/ml
4 QL
glatopa subcutaneous solution prefilled syringe 40 mg/ml
5 QL
MAVENCLAD (10 TABS) 5 PA; QL
MAVENCLAD (4 TABS) 5 PA; QL
MAVENCLAD (5 TABS) 5 PA; QL
MAVENCLAD (6 TABS) 5 PA; QL
MAVENCLAD (7 TABS) 5 PA; QL
MAVENCLAD (8 TABS) 5 PA; QL
MAVENCLAD (9 TABS) 5 PA; QL
MAYZENT 5 PA; QL
MAYZENT STARTER PACK
5 PA; QL
PLEGRIDY 5 PA; QL
PLEGRIDY STARTER PACK
5 PA; QL
REBIF 4 PA; QL
REBIF REBIDOSE 4 PA; QL
REBIF REBIDOSE TITRATION PACK
4 PA; QL
REBIF TITRATION PACK 4 PA; QL
TECFIDERA 5 PA; QL
VUMERITY 5 PA; QL
VUMERITY (STARTER) 5 PA; QL
ZINBRYTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML
5 PA; QL
Drug Name Drug Tier
Notes
Central Nervous System Agents - Miscellaneous
AUSTEDO 5 PA; QL
caffeine citrate oral 1
CAFFEINE-SODIUM BENZOATE
3
GRALISE 3
GRALISE STARTER 3
HORIZANT 3
INGREZZA 5 PA; QL
LYRICA 3 QL
LYRICA CR 3 PA
NUEDEXTA 3 PA
pregabalin oral 1 QL
RILUTEK 5 QL
riluzole 1 QL
SAVELLA 3 PA
SAVELLA TITRATION PACK
3 PA
TEGSEDI 5 PA; QL
tetrabenazine 5 PA; QL
TIGLUTIK 5 QL
XENAZINE 5 PA; QL
Dental and Oral Agents - Drugs for Mouth and Throat Conditions
BOCASAL 3
cevimeline hcl 3
chlorhexidine gluconate mouth/throat
1
DEBACTEROL 3
EVOXAC 3
FIRST-MOUTHWASH BLM
3
lidocaine hcl mouth/throat 3
lidocaine viscous mouth/throat solution 2 %
1
MUCOSITISRX 3
NEUTRASAL 3
Effective Date: 03/01/2020 44
Drug Name Drug Tier
Notes
NUMOISYN MOUTH/THROAT LOZENGE
3
oralone 1
paroex 1
periogard 1
pilocarpine hcl oral tablet 5 mg
1
pilocarpine hcl oral tablet 7.5 mg
3
SALAGEN 3
SALIVAMAX 3
triamcinolone acetonide mouth/throat
1
XEROSTOMIA RELIEF SPRAY
3
Dermatological Agents - Drugs for Skin Conditions
7TOPIC EXTERNAL EMULSION
3
ABSORICA 3
ABSORICA LD 3
ACANYA 3
acitretin 1 QL
ACZONE 3
adapalene external cream 1
adapalene external gel 1
ADAPALENE EXTERNAL LOTION 0.1 %
2
ADAPALENE EXTERNAL PAD
3
adapalene solution 0.1 % external
3
ADAPALENE SOLUTION 0.1 % EXTERNAL
3
adapalene-benzoyl peroxide
3
ADAZIN EXTERNAL CREAM 2-0.035-2-10 %
3
ADVANCED ALLERGY COLLECTION
3
AKLIEF 3 PA
Drug Name Drug Tier
Notes
ALA SCALP 3
ala-cort external cream 1 %
3
ala-cort external cream 2.5 %
1
alclometasone dipropionate
1
ALDARA 3
ALTRENO 3
amcinonide 3
AMELUZ 2 QL
ammonium lactate external
3
amnesteem 1
AMZEEQ 3
ANACAINE 3
APEXICON E 3
arzol silver nit applicators 3
ATOPADERM 3
ATOPICLAIR 3
ATRALIN 3
avar cleanser 1
AVAR EXTERNAL FOAM 9.5-5 %
3
AVAR LS CLEANSER 3
AVAR LS EXTERNAL FOAM 10-2 %
3
AVAR-E EMOLLIENT 3
AVAR-E GREEN 3
AVAR-E LS 3
avita 1
azelaic acid external 1
AZELEX 2
BENSAL HP 3
BENZACLIN 3
BENZACLIN WITH PUMP 3
BENZAMYCIN 3
benzepro foaming cloths 3
Effective Date: 03/01/2020 45
Drug Name Drug Tier
Notes
BENZIQ 3
BENZIQ LS 3
BENZOYL PEROX-HYDROCORTISONE
3
BENZOYL PEROXIDE EXTERNAL GEL 6.5 %, 8 %
3
BENZOYL PEROXIDE FORTE- HC
3
benzoyl peroxide-erythromycin
1
beser external lotion 3
betamethasone dipropionate aug
1
betamethasone dipropionate external
1
betamethasone valerate external
1
bp 10-1 3
bp cleansing wash 3
bpo 3
bpo foaming cloths 3
BRYHALI 3
calcipotriene external cream
1
CALCIPOTRIENE EXTERNAL FOAM
3
calcipotriene external ointment
1
calcipotriene external solution
1
calcipotriene-betameth diprop external ointment
3
calcitrene 1
calcitriol external 3
CAPEX 2
CARAC 2
cem-urea 3
CERACADE 3
ceramax external cream 3
claravis 1
Drug Name Drug Tier
Notes
CLEOCIN-T 3
CLEOCIN-T EXTERNAL SOLUTION 1 %
3
CLEOCIN-T EXTERNAL SWAB 1 %
3
clindacin etz external swab
1
clindacin-p 1
CLINDAGEL 3
clindamycin phos-benzoyl perox external gel 1.2-2.5 %, 1.2-5 %, 2.5-1.2 %
3
clindamycin phos-benzoyl perox gel 1-5 % external
3
clindamycin phos-benzoyl perox gel 1-5 % external
1
clindamycin phosphate external foam
3
clindamycin phosphate external lotion
1
clindamycin phosphate external solution
1
clindamycin phosphate external swab
1
CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL
3
clindamycin phosphate gel 1 % external
1
clindamycin-tretinoin 3
clobetasol prop emollient base
1
clobetasol propionate e 1
clobetasol propionate emulsion
3
clobetasol propionate external cream
1
clobetasol propionate external foam
3
clobetasol propionate external gel
1
clobetasol propionate external liquid
3
Effective Date: 03/01/2020 46
Drug Name Drug Tier
Notes
clobetasol propionate external lotion
1
clobetasol propionate external ointment
1
clobetasol propionate external shampoo
3
clobetasol propionate external solution
1
CLOBEX 3
CLOBEX SPRAY 3
clocortolone pivalate 3
clocortolone pivalate pump external cream 0.1 %
3
clodan external shampoo 3
CLODERM 3
CLODERM PUMP EXTERNAL CREAM 0.1 %
3
clotrimazole-betamethasone
1
CONDYLOX 2
CORDRAN EXTERNAL CREAM
3
CORDRAN EXTERNAL LOTION
3
CORDRAN EXTERNAL OINTMENT
3
CORDRAN EXTERNAL TAPE
2
CORTISPORIN EXTERNAL CREAM
3
CORTISPORIN EXTERNAL OINTMENT
2
CUTIVATE 3
dapsone external gel 5 % 3
DAPSONE EXTERNAL GEL 7.5 %
3
DERMA-SMOOTHE/FS BODY
3
DERMA-SMOOTHE/FS SCALP
3
Drug Name Drug Tier
Notes
DERMASORB HC EXTERNAL KIT 2 %
3
DESONATE 3
desonide external 1
DESOWEN 3
DESOWEN EXTERNAL LOTION 0.05 %
3
desoximetasone external cream
1
desoximetasone external gel
1
desoximetasone external liquid
3
desoximetasone external ointment
1
DEXERYL 3
diclofenac sodium transdermal gel 3 %
3
DIFFERIN EXTERNAL CREAM
1
DIFFERIN EXTERNAL GEL
3
DIFFERIN EXTERNAL LOTION
2
diflorasone diacetate 3
DIPROLENE 3
DIPROLENE AF 3
DOVONEX 3
doxepin hcl external 3
doxycycline 3
DRITHO-CREME HP 3
DRYSOL 2
DUAC EXTERNAL GEL 1.2-5 %
3
DUPIXENT 5 PA; QL
EFUDEX 3
ELETONE 3
ELETONE TWINPACK EXTERNAL CREAM
3
ELIDEL 1
ELOCON 3
Effective Date: 03/01/2020 47
Drug Name Drug Tier
Notes
ELOCON EXTERNAL OINTMENT 0.1 %
3
EMULSION SB 3
ENSTILAR 3
ENTTY SPRAY EMULSION
3
EPICERAM 3
EPIDUO 3
EPIDUO FORTE 3
EPIFOAM 3
ery 3
ERYGEL 3
erythromycin external gel 1
erythromycin external pad 2 %
3
erythromycin external solution
1
EUCRISA 3 PA; QL
EVOCLIN 3
FABIOR 3
FINACEA EXTERNAL FOAM
2
FINACEA EXTERNAL GEL
3
fluocinolone acetonide body
1
fluocinolone acetonide external
1
fluocinolone acetonide scalp
1
fluocinonide emulsified base
1
fluocinonide external cream 0.05 %
1
fluocinonide external cream 0.1 %
3
fluocinonide external gel 1
fluocinonide external ointment
1
fluocinonide external solution
1
Drug Name Drug Tier
Notes
FLUOROPLEX 2
FLUOROURACIL EXTERNAL CREAM 0.5 %
2
fluorouracil external cream 5 %
1
fluorouracil external solution
1
flurandrenolide 3
fluticasone propionate external cream
1
fluticasone propionate external lotion
3
fluticasone propionate external ointment
3
grafco silver nit applicator 3
halcinonide 3
halobetasol propionate external cream
1
HALOBETASOL PROPIONATE EXTERNAL FOAM
3
halobetasol propionate external ointment
1
HALOG 3
HPR 3
HPR PLUS 3
HYDRO 35 EXTERNAL FOAM 35 %
3
HYDRO 40 3
hydrocortisone ace-pramoxine external
1
hydrocortisone butyr lipo base
3
hydrocortisone butyrate external cream
1
hydrocortisone butyrate external lotion
3
hydrocortisone butyrate external ointment
1
hydrocortisone butyrate external solution
1
Effective Date: 03/01/2020 48
Drug Name Drug Tier
Notes
hydrocortisone external cream 1 %
3
hydrocortisone external cream 2.5 %
1
hydrocortisone external lotion 2.5 %
1
hydrocortisone external ointment 1 %, 2.5 %
1
hydrocortisone in absorbase
1
hydrocortisone valerate 1
HYLAMIX EXTERNAL CREAM
3
HYLATOPIC PLUS EXTERNAL CREAM
3
HYLATOPIC PLUS EXTERNAL FOAM
3
HYLINATE 3
imiquimod external 1
IMIQUIMOD PUMP 3
IMPOYZ 3 PA
isotretinoin oral 1
ivermectin external 3
KAMDOY 3
KENALOG EXTERNAL 3
KERALAC 3
KERALYT EXTERNAL GEL 6 %
3
KIVIK 3
KLARON 3
LAC-HYDRIN EXTERNAL CREAM 12 %
3
LAC-HYDRIN EXTERNAL LOTION 12 %
3
lactic acid e 3
lactic acid external 3
LEVULAN KERASTICK 2 QL
LEXETTE 3
Drug Name Drug Tier
Notes
LIDOCAINE-HYDROCORTISONE ACE EXTERNAL
3
LOCOID 3
LOCOID EXTERNAL OINTMENT 0.1 %
3
LOCOID LIPOCREAM 3
LOTRISONE 3
LUXIQ 3
methoxsalen oral 4 QL
methoxsalen rapid 4 QL
metopic external cream 41 %
3
METROCREAM 3
METROGEL 3
METROLOTION 3
metronidazole external cream
1
metronidazole external gel 0.75 %
1
metronidazole external gel 1 %
3
metronidazole external lotion
3
MICORT-HC 3
MIMYX 3
MIRVASO 3
mometasone furoate external
1
myorisan 1
NEOCERA 3
NEOSALUS CP 3
NEOSALUS EXTERNAL CREAM
3
NEOSALUS EXTERNAL FOAM
3
NEO-SYNALAR EXTERNAL CREAM
3
neuac external gel 3
NIVATOPIC PLUS 3
nolix 3
Effective Date: 03/01/2020 49
Drug Name Drug Tier
Notes
NORITATE 3
NOVACORT 3
NUCORT 3
OLUX 3
OLUX-E 3
ONEXTON 3
ORACEA 3 PA
OVACE PLUS EXTERNAL CREAM
3
OVACE PLUS EXTERNAL FOAM
3
OVACE PLUS EXTERNAL SHAMPOO
3
OVACE PLUS WASH 3
OVACE WASH 3
OXSORALEN ULTRA 5 QL
PANDEL 3
PENLEN 3
PHLAG SPRAY 3
PICATO 2 QL
pimecrolimus cream 1 % external
1
PIMECROLIMUS CREAM 1 % EXTERNAL
2
PLEXION 3
PLEXION CLEANSER 3
PLEXION CLEANSING CLOTH
3
podocon 3
podofilox external 1
PRAMOSONE EXTERNAL CREAM 1-1 %
2
PRAMOSONE EXTERNAL CREAM 1-2.5 %
3
PRAMOSONE EXTERNAL LOTION
2
pramox 3
prednicarbate 3
Drug Name Drug Tier
Notes
PRESERA 3
PROTOPIC 3
PRUCLAIR 3
PRUDOXIN 3
PRUMYX 3
PSORCON 3
PYROGALLIC ACID 3
QBREXZA 3 PA
rea lo 40 external cream 40 %
1
RESORCINOL-SULFUR 3
RETIN-A 1
RETIN-A MICRO GEL 0.04 %, 0.1 %
1
RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.1 %
1
RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 %
3
RHOFADE 3
rosadan external cream 1
rosadan external gel 1
ROSADAN EXTERNAL KIT
3
rosanil cleanser external emulsion 10-5 %
1
RYNODERM EXTERNAL CREAM 37.5 %
3
SALEX EXTERNAL SHAMPOO
3
salicylic acid external cream
3
salicylic acid external foam
3
salicylic acid external gel 3
salicylic acid external liquid
3
salicylic acid external lotion
3
salicylic acid external shampoo
3
Effective Date: 03/01/2020 50
Drug Name Drug Tier
Notes
salicylic acid external solution 26 %
3
salicylic acid wart remover
3
salimez 3
SALIMEZ FORTE 3
salisol forte external solution 26 %
3
SALITECH EXTERNAL LOTION 5 %
3
salitech forte external lotion 6 %
3
SALVAX 3
SANTYL 2
seb-prev wash external liquid 10 %
3
selenium sulfide external lotion
1
selenium sulfide external shampoo 2.25 %
3
SERNIVO 3
SILMANIX PAIN RELIEIVING EXTERNAL CREAM 0.0375-3-0.035 %
3
sodium hyaluronate external
3
sodium sulfacetamide 1
sodium sulfacetamide wash liquid 10 % external
3
SODIUM SULFACETAMIDE WASH LIQUID 10 % EXTERNAL
3
SOOLANTRA 3
SORIATANE 5 QL
SORILUX 3
sss 10-5 3
sulfacetamide sodium (acne)
1
sulfacetamide sodium external
3
Drug Name Drug Tier
Notes
sulfacetamide sodium-sulfur external cream
3
sulfacetamide sodium-sulfur external emulsion
1
sulfacetamide sodium-sulfur external liquid
3
sulfacetamide sodium-sulfur external lotion 10-5 %
1
sulfacetamide sodium-sulfur external lotion 9.8-4.8 %
3
sulfacetamide sodium-sulfur external pad
3
sulfacetamide sodium-sulfur external suspension
3
sulfacetamide-sulfur in urea
1
sulfacleanse 8/4 3
sulfamez wash 3
SUMADAN WASH 3
SUMAXIN 3
SUMAXIN TS EXTERNAL SUSPENSION 8-4 %
3
SUMAXIN WASH 3
SUVICORT 3
synalar external cream 1
synalar external ointment 1
SYNALAR EXTERNAL SOLUTION
3
SYNERDERM 3
TACLONEX 3
tacrolimus external 1
tazarotene external 1
TAZORAC EXTERNAL CREAM 0.05 %
2
TAZORAC EXTERNAL CREAM 0.1 %
1
TAZORAC EXTERNAL GEL
2
TEMOVATE 3
Effective Date: 03/01/2020 51
Drug Name Drug Tier
Notes
TETRAVEX EXTERNAL GEL 2 %
3
TETRIX 3
TEXACORT 3
TOLAK 3
TOPICORT 3
TOPICORT SPRAY 3
tovet external foam 3
tretinoin external cream 1
tretinoin external gel 0.01 %, 0.025 %
1
tretinoin external gel 0.05 %
3
tretinoin microsphere 1
tretinoin microsphere pump
1
TRETIN-X EXTERNAL CREAM 0.075 %
3
triamcinolone acetonide external aerosol solution
3
triamcinolone acetonide external cream
1
triamcinolone acetonide external lotion
1
triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %
1
triamcinolone acetonide external ointment 0.05 %
3
trianex 3
triderm 1
TRIDESILON 3
ULTRAVATE EXTERNAL CREAM 0.05 %
3
ULTRAVATE EXTERNAL OINTMENT 0.05 %
3
UMECTA MOUSSE 3
URALISS EXTERNAL CREAM 35 %
3
URAMAXIN 3
Drug Name Drug Tier
Notes
urea external cream 39 %, 41 %, 45 %, 47 %, 50 %
3
urea external cream 40 % 1
UREA EXTERNAL FOAM 3
urea external suspension 3
urea hydrating 3
urea nail 3
uredeb 3
ure-k external cream 50 %
3
uremez-40 1
URESOL 3
UREVAZ EXTERNAL CREAM 44 %
3
UTOPIC 3
VANOS 3
VANOXIDE-HC 3
VECTICAL 1
VELTIN 3
VERDESO 3
VEREGEN 3
VIRASAL 3
WESTCORT EXTERNAL OINTMENT 0.2 %
3
XALIX 3
XERALUX 3
xurea 3
zaclir cleansing 3
zenatane 1
ZIANA 3
ZITHRANOL 3
ZONALON 3
ZYCLARA 3
ZYCLARA PUMP 3
Diabetes - Antidiabetic Agents
acarbose oral 1
ACTOPLUS MET 3
Effective Date: 03/01/2020 52
Drug Name Drug Tier
Notes
ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 15-1000 MG, 30-1000 MG
3
ACTOS 3
ADLYXIN 3 PA; QL
ADLYXIN STARTER PACK
3 PA; QL
ALOGLIPTIN BENZOATE 3 PA
ALOGLIPTIN-METFORMIN HCL
3 PA
ALOGLIPTIN-PIOGLITAZONE
3 PA
AMARYL 3
AVANDIA 3
BYDUREON 3 PA; QL
BYDUREON BCISE AUTOINJECTOR
3 PA; QL
BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER 2 MG
3 PA; QL
BYETTA 10 MCG PEN 3 PA; QL
BYETTA 5 MCG PEN 3 PA; QL
chlorpropamide oral tablet 100 mg, 250 mg
3
CYCLOSET 3 PA
DUETACT 3
FARXIGA 3 PA; QL
FORTAMET ORAL TABLET EXTENDED RELEASE 24 HOUR 1000 MG
3 PA
FORTAMET ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG
3
glimepiride 1
glipizide er 1
glipizide ir 1
glipizide xl 1
Drug Name Drug Tier
Notes
glipizide-metformin hcl 3
GLUCOPHAGE 3
GLUCOPHAGE XR 3
GLUCOTROL 3
GLUCOTROL XL 3
GLUCOVANCE ORAL TABLET 2.5-500 MG, 5-500 MG
3
GLUMETZA 3 PA
glyburide micronized 3
glyburide oral 1
glyburide-metformin 3
GLYNASE 3
GLYSET 3
GLYXAMBI 3 PA
INVOKAMET 3 PA; QL
INVOKAMET XR 3 PA; QL
INVOKANA 3 PA; QL
JANUMET 3 PA
JANUMET XR 3 PA
JANUVIA 3 PA
JARDIANCE 2 PA; QL
JENTADUETO 3 PA
JENTADUETO XR 3 PA
KAZANO 3 PA
KOMBIGLYZE XR 3 PA
metformin hcl er 1
metformin hcl er (mod) 3 PA
metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg
3 PA
metformin hcl er (osm) oral tablet extended release 24 hour 500 mg
3
METFORMIN HCL ORAL SOLUTION
2
metformin hcl oral tablet 1
miglitol 3
nateglinide 3
Effective Date: 03/01/2020 53
Drug Name Drug Tier
Notes
NESINA 3 PA
ONGLYZA 3 PA
OSENI 3 PA
OZEMPIC 3 PA; QL
pioglitazone hcl 3
pioglitazone hcl-glimepiride
3
pioglitazone hcl-metformin hcl
3
PRANDIN ORAL TABLET 1 MG, 2 MG
3
PRECOSE 3
QTERN 3 PA; QL
repaglinide 3
repaglinide-metformin hcl oral tablet 1-500 mg, 2-500 mg
3
RIOMET 2
RIOMET ER 3
RYBELSUS 3 PA
SEGLUROMET 3 PA; QL
SOLIQUA 3 PA; QL
STARLIX 3
STEGLATRO 3 PA; QL
STEGLUJAN 3 PA; QL
SYMLINPEN 120 3
SYMLINPEN 60 3
SYNJARDY 3 PA; QL
SYNJARDY XR 3 PA; QL
TANZEUM SUBCUTANEOUS PEN-INJECTOR 30 MG, 50 MG
3 PA
tolazamide oral tablet 250 mg, 500 mg
1
tolbutamide 1
TRADJENTA 3 PA
TRULICITY 3 PA; QL
VICTOZA 3 PA; QL
XIGDUO XR 3 PA; QL
Drug Name Drug Tier
Notes
XULTOPHY 3 PA
Diabetes - Glucose Monitoring
ACCU-CHEK AVIVA IN VITRO
1
ACCU-CHEK COMPACT PLUS CONTROL
1
ACCU-CHEK FASTCLIX LANCET KIT
1
ACCU-CHEK GUIDE CONTROL
1
ACCU-CHEK MULTICLIX LANCET DEVICE KIT
1
ACCU-CHEK SMARTVIEW CONTROL
1
ACCU-CHEK SOFTCLIX LANCET DEVICE KIT
1
AGAMATRIX CONTROL LEVEL 2
1
AGAMATRIX CONTROL LEVEL 4
1
AUTOLET LANCING DEVICE
1
BAYER CONTOUR IN VITRO LIQUID HIGH , LOW , NORMAL
1
CARETOUCH LANCING/EJECTOR
1
CONTOUR NEXT CONTROL
1
CONTOUR NEXT TEST 1 PA; QL
DIATHRIVE GLUCOSE CONTROL SOLN
1
DIATHRIVE LANCING DEVICE
1
EASYMAX CONTROL 1
EMBRACE TALK GLUCOSE CONTROL
1
FORTISCARE CONTROL 1
FREESTYLE TEST 1 PA; QL
GENTEEL LANCING KIT (BLUE)
1
GOJJI CONTROL 1
Effective Date: 03/01/2020 54
Drug Name Drug Tier
Notes
GOJJI LANCING DEVICE/CLEAR CAP
1
LANCETS 1
LANCETS KIT 1
MICROLET NEXT LANCING DEVICE
1
OMNIPOD DASH SYSTEM
3 PA
OMNIPOD STARTER 3 PA
ONETOUCH DELICA LANCING DEV
1
ONETOUCH DELICA PLUS LANCING
1
ONETOUCH ULTRA BLUE TEST STRIPS
1 QL
ONETOUCH VERIO IN VITRO SOLUTION HIGH
1
ONETOUCH VERIO TEST STRIPS
1 QL
SURESTEP PRO HIGH GLUCOSE
1
SURESTEP PRO LOW GLUCOSE
1
SURESTEP PRO NORMAL GLUCOSE
1
TRUE METRIX LEVEL 1 1
TRUE METRIX LEVEL 2 1
TRUE METRIX LEVEL 3 1
UNISTRIP CONTROL IN VITRO SOLUTION LOW
1
V-GO 20 3 PA
V-GO 30 3 PA
V-GO 40 3 PA
VIVAGUARD INO CONTROL SOLUTION
1
VIVAGUARD LANCING DEVICE
1
Diabetes - Glycemic Agents
BAQSIMI ONE PACK 3 PA
BAQSIMI TWO PACK 3 PA
GLUCAGEN HYPOKIT 2
Drug Name Drug Tier
Notes
GLUCAGON EMERGENCY INJECTION KIT
2
GLUCAGON EMERGENCY INJECTION SOLUTION RECONSTITUTED
3
GVOKE PFS 5 PA; QL
PROGLYCEM 2
Diabetes - Insulins
ADMELOG 3 PA
ADMELOG SOLOSTAR 3 PA
AFREZZA 3 PA
APIDRA SOLOSTAR 3
APIDRA VIAL 3
BASAGLAR KWIKPEN 3 PA
BD AUTOSHIELD DUO PEN NEEDLES
1
BD ULTRA-FINE INSULIN SYRINGES
1
BD ULTRA-FINE PEN NEEDLES
1
FIASP 3 PA
FIASP FLEXTOUCH 3 PA
FIASP PENFILL 3
HUMALOG 2
HUMALOG KWIKPEN 2
HUMALOG MIX 50/50 KWIKPEN
3
HUMALOG MIX 50/50 VIAL
3
HUMALOG MIX 75/25 KWIKPEN
3
HUMALOG MIX 75/25 VIAL
3
HUMALOG U-100 JUNIOR KWIKPEN
2
HUMULIN 70/30 KWIKPEN
1
HUMULIN 70/30 VIAL 1
HUMULIN N KWIKPEN 1
Effective Date: 03/01/2020 55
Drug Name Drug Tier
Notes
HUMULIN N VIAL 1
HUMULIN R U-500 KWIKPEN
1
HUMULIN R U-500 VIAL (CONCENTRATED)
1
HUMULIN R VIAL 1
INSULIN ASP PROT & ASP FLEXPEN
3
INSULIN ASPART 3
INSULIN ASPART FLEXPEN
3
INSULIN ASPART PENFILL
3
INSULIN ASPART PROT & ASPART
3
INSULIN PEN NEEDLES 1
INSULIN SYRINGES 1
LANTUS SOLOSTAR 2 PA
LANTUS U-100 VIAL 2 PA
LEVEMIR U-100 FLEXTOUCH
2 PA
LEVEMIR U-100 VIAL 2 PA
MAXICOMFORT SYR 27G X 1/2"
1
NOVOFINE AUTOCOVER PEN NEEDLE
1
NOVOFINE PEN NEEDLE
1
NOVOFINE PLUS PEN NEEDLE
1
NOVOLIN 70/30 RELION 3 PA
NOVOLIN 70/30 VIAL 3 PA
NOVOLIN N RELION 3 PA
NOVOLIN N VIAL 3 PA
NOVOLIN R RELION 3 PA
NOVOLIN R VIAL 3 PA
NOVOLOG FLEXPEN 3
NOVOLOG MIX 70/30 FLEXPEN
3
NOVOLOG MIX 70/30 VIAL
3
Drug Name Drug Tier
Notes
NOVOLOG PENFILL 3
NOVOLOG U-100 VIAL 3
NOVOTWIST PEN NEEDLE
1
PURE COMFORT PEN NEEDLE
1
TOUJEO MAX SOLOSTAR
3 PA
TOUJEO SOLOSTAR 3 PA
TRESIBA 3 PA
TRESIBA FLEXTOUCH 3 PA
ULTIGUARD SAFEPACK PEN NEEDLE
1
Electrolytes / Minerals / Metals / Vitamins
alcohol 3
argyle sterile saline 1
argyle sterile water 3
CARBAGLU 5 PA; QL
CARNITOR ORAL 1
CARNITOR SF 1
CHEMET 3
clovique 5 PA; QL
curity sterile saline 1
cyanocobalamin injection solution 1000 mcg/ml
1
cytra k crystals 1
deferasirox 5 PA; QL
dehydrated alcohol 3
DEXPANTHENOL INJECTION
3
DRISDOL 3
EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ
3
effer-k oral tablet effervescent 25 meq
3
effervescent pot chloride oral tablet effervescent 25 meq
3
ergocalciferol oral capsule 1
Effective Date: 03/01/2020 56
Drug Name Drug Tier
Notes
EXJADE 5 PA; QL
FERRIPROX ORAL SOLUTION
3 PA
FERRIPROX ORAL TABLET
5 PA; QL
FLUORABON 3
fluoritab oral solution 3
fluoritab oral tablet chewable 0.55 (0.25 f) mg, 2.2 (1 f) mg
1
fluoritab oral tablet chewable 1.1 (0.5 f) mg
3
FLURA-DROPS 2
folic acid injection 1
folic acid oral tablet 1 mg 1
FOLVITE-D 3
GENICIN VITA-D 3
iodine strong oral 3
JADENU 5 PA; QL
JADENU SPRINKLE 5 PA; QL
JYNARQUE 5 PA; QL
k-effervescent oral tablet effervescent 25 meq
3
kionex oral powder 1
klor-con 1
klor-con 10 1
klor-con m10 1
KLOR-CON M15 TABLET EXTENDED RELEASE 15 MEQ ORAL
1
KLOR-CON M15 TABLET EXTENDED RELEASE 15 MEQ ORAL
2
klor-con m20 1
klor-con sprinkle 1
klor-con/ef 3
K-PHOS 3
K-PHOS NO 2 3
K-PHOS-NEUTRAL 3
k-prime 3
Drug Name Drug Tier
Notes
K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ
1
K-TAB ORAL TABLET EXTENDED RELEASE 20 MEQ, 8 MEQ
2
k-vescent oral tablet effervescent 25 meq
3
levocarnitine oral solution 1
levocarnitine oral tablet 1
LOKELMA 5 PA; QL
ludent oral tablet chewable 0.55 (0.25 f) mg
1
ludent oral tablet chewable 1.1 (0.5 f) mg, 2.2 (1 f) mg
3
MAGNESIUM SULFATE INJECTION
3
MEPHYTON 1
MIFEPREX 3
mifepristone 3
nafrinse 1
nafrinse drops 3
ORACIT 2
phospha 250 neutral 1
phosphorous 1
phospho-trin 250 neutral 1
phytonadione injection 1
phytonadione oral 1
pot bicarb-pot chloride 3
potassium bicarbonate oral
3
potassium chloride crys er 1
potassium chloride er 1
potassium chloride oral 1
potassium citrate er 1
potassium citrate-citric acid
1
SAMSCA 5 PA; QL
sod citrate-citric acid 1
Effective Date: 03/01/2020 57
Drug Name Drug Tier
Notes
SODIUM BICARBONATE INJECTION SOLUTION 8.4 %
3
sodium chloride (pf) 1
sodium chloride irrigation 1
SODIUM CHLORIDE SOLUTION 0.9 % INJECTION
3
sodium fluoride oral solution
1
sodium fluoride oral tablet 1.1 (0.5 f) mg
1
sodium fluoride oral tablet 2.2 (1 f) mg
3
sodium fluoride oral tablet chewable
1
sodium polystyrene sulfonate oral
1
sodium polystyrene sulfonate rectal
3
sps 1
sterile water for irrigation 3
SYPRINE 5 PA; QL
taron-crystals 1
tricitrates 1
trientine hcl 5 PA; QL
UROCIT-K 10 3
UROCIT-K 15 3
UROCIT-K 5 3
VELTASSA 3 PA
virt-phos 250 neutral 1
vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)
1
vitamin k1 injection 1
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer
ACIPHEX 3 PA
ACIPHEX SPRINKLE 3 PA
CARAFATE ORAL SUSPENSION
1
Drug Name Drug Tier
Notes
CARAFATE ORAL TABLET
3
cimetidine hcl 1
cimetidine oral 1
CYTOTEC 3
DEXILANT 3 PA
ESOMEPRAZOLE STRONTIUM ORAL CAPSULE DELAYED RELEASE 49.3 MG
3 PA
famotidine oral suspension reconstituted
1
famotidine oral tablet 20 mg, 40 mg
1
FIRST-LANSOPRAZOLE 3
FIRST-OMEPRAZOLE 3
lansoprazole oral capsule delayed release
1 PA
lansoprazole oral tablet dispersible 15 mg, 30 mg
3 PA
misoprostol oral 1
NEXIUM ORAL PACKET 3 PA
nizatidine 3
omeprazole oral capsule delayed release
1
OMEPRAZOLE+SYRSPEND SF ALKA
3
omeprazole-sodium bicarbonate oral packet
3 PA
pantoprazole sodium oral 1
PEPCID 3
PEPCID ORAL SUSPENSION RECONSTITUTED 40 MG/5ML
3
PREVACID 3 PA
PREVACID SOLUTAB ORAL TABLET DISPERSIBLE 15 MG, 30 MG
3 PA
PRILOSEC 3
PROTONIX ORAL 3
Effective Date: 03/01/2020 58
Drug Name Drug Tier
Notes
rabeprazole sodium oral tablet delayed release
1 PA
ranitidine hcl oral capsule 3
ranitidine hcl oral syrup 1
ranitidine hcl oral tablet 150 mg, 300 mg
1
sucralfate oral 1
YOSPRALA 3
ZANTAC ORAL TABLET 300 MG
3
ZEGERID ORAL PACKET
3 PA
Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions
ACTIGALL 3
alosetron hcl 5 QL
AMITIZA 3 PA; QL
amoxicill-clarithro-lansopraz
3
ANASPAZ 3
belladonna alkaloids-opium
1
BENTYL 3
BENTYL ORAL CAPSULE 10 MG
3
CHENODAL 5
chlordiazepoxide-clidinium
1
CLENPIQ 3
COLYTE WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 240 GM
3
constulose 1
cromolyn sodium oral 3
CUVPOSA 3
dicyclomine hcl intramuscular
3
dicyclomine hcl oral 1
diphenoxylate-atropine 1
Drug Name Drug Tier
Notes
ed-spaz 3
ENTEREG 3
enulose 1
GASTROCROM 3
GATTEX 5 PA; QL
gavilyte-c 1
gavilyte-g 1
gavilyte-h 3
gavilyte-n with flavor pack 1
generlac 1
GLYCATE 3
glycopyrrolate injection solution
1
glycopyrrolate oral tablet 1 mg, 2 mg
1
GLYCOPYRROLATE ORAL TABLET 1.5 MG
3
GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM
2
GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM
3
hyoscyamine sulfate er 3
hyoscyamine sulfate injection
3
hyoscyamine sulfate oral 3
hyoscyamine sulfate sl 3
hyoscyamine sulfate sublingual
3
hyosyne 3
KRISTALOSE 3
lactulose encephalopathy 1
lactulose oral packet 3
lactulose oral solution 1
LEVBID 3
LEVSIN 3
LEVSIN/SL 3
Effective Date: 03/01/2020 59
Drug Name Drug Tier
Notes
LIBRAX 3
LINZESS ORAL CAPSULE 145 MCG, 290 MCG
3 PA; QL
LINZESS ORAL CAPSULE 72 MCG
3 PA
LOMOTIL 3
loperamide hcl oral capsule
1
LOTRONEX 5 QL
methscopolamine bromide oral
3
MOTEGRITY 3 PA
MOTOFEN 3
MOVANTIK 3 PA; QL
MOVIPREP 3
MYTESI 3
nulev 3
NULYTELY WITH FLAVOR PACKS
3
OMECLAMOX-PAK 3
opium 1
oscimin 3
oscimin oral tablet dispersible 0.125 mg
3
oscimin sr 3
OSMOPREP 3
paregoric 3
peg 3350/electrolytes oral solution reconstituted 240 gm
1
peg 3350-kcl-na bicarb-nacl
1
peg-3350/electrolytes 1
peg-prep 3
pegylax oral powder 1
PLENVU 3
polyethylene glycol 3350 oral
1
PREPOPIK 3
Drug Name Drug Tier
Notes
PREVPAC ORAL 3
PROBICHEW 3
propantheline bromide oral
1
PYLERA 2
RELISTOR ORAL 3 PA
RELISTOR SUBCUTANEOUS
2
ROBINUL INJECTION SOLUTION 0.2 MG/ML, 0.4 MG/2ML, 1 MG/5ML, 4 MG/20ML
3
ROBINUL ORAL TABLET 1 MG
3
ROBINUL-FORTE ORAL TABLET 2 MG
3
SEROSTIM 5 PA; QL
SUPREP BOWEL PREP KIT
3
SYMAX DUOTAB 3
symax-sl 3
symax-sr 3
SYMPROIC 3 PA
TALICIA 3
trilyte 1
TRULANCE 3 PA
URSO 250 3
URSO FORTE 3
ursodiol oral 1
VIBERZI 3 PA
XERMELO 5 PA; QL
ZELNORM 3 PA
ZORBTIVE 5 PA; QL
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment
BUPHENYL 5 QL
CERDELGA 4 PA; QL
CHOLBAM 5 PA; QL
CREON 2
CRYSVITA 5 PA; QL
Effective Date: 03/01/2020 60
Drug Name Drug Tier
Notes
CYSTADANE 3
CYSTAGON 2 PA
GALAFOLD 5 PA; QL
KUVAN 5 PA; QL
miglustat 5 PA; QL
MYALEPT 5 PA; QL
nitisinone 5 QL
NITYR 5 PA; QL
OCALIVA 5 PA; QL
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG
5 QL
ORFADIN ORAL CAPSULE 20 MG
5
ORFADIN ORAL SUSPENSION
5 PA; QL
PANCREAZE 3
PERTZYE 3
PROCYSBI 5 PA; QL
RAVICTI 5 PA; QL
sodium phenylbutyrate oral
5 QL
STRENSIQ 5 PA; QL
SUCRAID 5 PA
VIOKACE 3
ZAVESCA 5 PA; QL
ZENPEP 2
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions
acetic acid irrigation 1
AURYXIA 3 PA; QL
bethanechol chloride oral 1
calcium acetate (phos binder)
1
CERVIDIL 2
CUPRIMINE 4 PA; QL
darifenacin hydrobromide er
1
DEPEN TITRATABS 4 PA; QL
DETROL 3
Drug Name Drug Tier
Notes
DETROL LA 3
DITROPAN XL 3
D-PENAMINE ORAL TABLET 125 MG
4 PA; QL
ELMIRON 2
ENABLEX 3
FEM PH 3
flavoxate hcl 1
FOSRENOL ORAL PACKET
3
FOSRENOL ORAL TABLET CHEWABLE
5 QL
GELNIQUE 3 PA
GELNIQUE PUMP TRANSDERMAL GEL 10 %
3 PA
hyophen 3
INDIOMIN MB ORAL CAPSULE 120 MG
3
INTRAROSA 3 PA; QL
lanthanum carbonate 5 QL
LITHOSTAT 3
me/naphos/mb/hyo1 3
MYRBETRIQ 3 PA
oxybutynin chloride er 1
oxybutynin chloride oral 1
OXYTROL 3 PA
penicillamine oral 4 PA; QL
phenazo oral tablet 200 mg
1
phenazopyridine hcl oral tablet 100 mg, 200 mg
1
PHOSLYRA 3
phosphasal 3
PREPIDIL 2
PROSTIN E2 2
PYRIDIUM 3
RELAGARD VAGINAL GEL 0.9-0.025 %
3
RENACIDIN 3
Effective Date: 03/01/2020 61
Drug Name Drug Tier
Notes
RENAGEL 3
RENVELA 3
RIMSO-50 3
sevelamer carbonate 1
sevelamer hcl 1
solifenacin succinate 1
THIOLA 5
THIOLA EC 5 PA
tolterodine tartrate 1
tolterodine tartrate er 1
TOVIAZ 3 PA
trospium chloride 1
trospium chloride er 1
ur n-c oral tablet 81.6 mg 3
URECHOLINE 3
urelle 3
uretron d/s 3
uribel 3
URIMAR-T 3
urin ds 3
URO-458 3
UROGESIC-BLUE 3
uro-mp 3
URYL 3
ustell 3
UTA ORAL CAPSULE 120 MG
3
uticap 3
utira-c 3
utrona-c 3
VELPHORO 5 PA; QL
VESICARE 3
vilamit mb 3
VILEVEV MB 3
Genitourinary Agents - Drugs for Prostate Conditions
alfuzosin hcl er 1
Drug Name Drug Tier
Notes
AVODART 3
CARDURA XL 3
dutasteride oral 1
dutasteride-tamsulosin hcl 3
finasteride oral tablet 5 mg
1
FLOMAX 3
JALYN 3
PROSCAR 3
RAPAFLO 3
silodosin 3
tamsulosin hcl 1
terazosin hcl 1
UROXATRAL 3
Hormonal Agents - Adrenal
BETAMETHASONE SODIUM PHOSPHATE INJECTION
3
CORTEF 3
cortisone acetate oral 1
DECADRON ORAL ELIXIR 0.5 MG/5ML
3
DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML
2
DEPO-MEDROL INJECTION SUSPENSION 40 MG/ML, 80 MG/ML
3
DEXAMETHASONE (LA) 3
dexamethasone intensol 2
dexamethasone oral elixir 1
dexamethasone oral solution
1
dexamethasone oral tablet
1
dexamethasone oral tablet therapy pack
3
dexamethasone sod phosphate pf injection solution
1
Effective Date: 03/01/2020 62
Drug Name Drug Tier
Notes
dexamethasone sodium phosphate injection
1
DEXONTO 0.4% 3
DEXPAK 10 DAY 3
DEXPAK 13 DAY 3
DEXPAK 6 DAY 3
DXEVO 11-DAY 3
fludrocortisone acetate oral
1
HIDEX 6-DAY 3
hydrocortisone oral 1
KENALOG INJECTION 3
LOCORT 11-DAY ORAL TABLET THERAPY PACK 1.5 MG (41)
3
LOCORT 7-DAY ORAL TABLET THERAPY PACK 1.5 MG (27)
3
MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG
3
MEDROL ORAL TABLET 2 MG
2
MEDROL ORAL TABLET THERAPY PACK
3
METHYLPREDNISOLONE ACE-LIDO
3
METHYLPREDNISOLONE ACETATE INJECTION SUSPENSION 40 MG/ML, 80 MG/ML
3
methylprednisolone oral 1
methylprednisolone sodium succ injection solution reconstituted 125 mg
1
MILLIPRED DP 3
MILLIPRED DP 12-DAY 3
MILLIPRED ORAL SOLUTION 10 MG/5ML
3
ORAPRED ODT 3
PEDIAPRED 3
Drug Name Drug Tier
Notes
prednisolone oral 1
prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml
3
prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml
1
prednisolone sodium phosphate oral tablet dispersible
3
prednisone intensol 3
prednisone oral 1
RAYOS 3 PA
SOLU-CORTEF 2
SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 125 MG
3
TAPERDEX 12-DAY 3
TAPERDEX 6-DAY 3
TAPERDEX 7-DAY 3
TRIAMCINOLONE ACETONIDE INJECTION SUSPENSION 50 MG/ML
3
triamcinolone acetonide suspension 40 mg/ml injection
3
TRIAMCINOLONE ACETONIDE SUSPENSION 40 MG/ML INJECTION
3
TRIAMCINOLONE DIACETATE INJECTION
3
TRIAMCINOLONE DIACETATE PF INJECTION SUSPENSION 80 MG/2ML
3
VERIPRED 20 ORAL SOLUTION 20 MG/5ML
3
ZONACORT 11 DAY ORAL TABLET THERAPY PACK 1.5 MG (41)
3
Effective Date: 03/01/2020 63
Drug Name Drug Tier
Notes
ZONACORT 7 DAY ORAL TABLET THERAPY PACK 1.5 MG (27)
3
Hormonal Agents - Men's Health
ANADROL-50 5 QL
ANDRODERM 3 PA; QL
ANDROGEL 3 PA; QL
ANDROGEL PUMP 3 PA; QL
ANDROID ORAL CAPSULE 10 MG
5 PA
danazol oral 1
DEPO-TESTOSTERONE (brand testosterone cypionate intramuscular)
1 PA
FORTESTA 3 PA; QL
JATENZO 3 PA
METHITEST 3 PA
methyltestosterone oral 3 PA
NATESTO 3 PA; QL
OXANDRIN ORAL TABLET 10 MG, 2.5 MG
3
oxandrolone oral 3
STRIANT 3 PA; QL
TESTIM 3 PA; QL
TESTONE CIK 3
TESTOSTERONE CYPIONATE & PROP INJECTION SOLUTION 160-40 MG/ML
3 PA
TESTOSTERONE CYPIONATE INJECTION SOLUTION 100 MG/ML, 150 MG/ML, 50 MG/ML (may be used subcutaneously)
3 PA
TESTOSTERONE CYPIONATE INJECTION SOLUTION 200 MG/ML
1 PA
testosterone cypionate intramuscular
1 PA
Drug Name Drug Tier
Notes
TESTOSTERONE ENANTHATE INJECTION SOLUTION 200 MG/ML (may be used subcutaneously)
3 PA
testosterone enanthate intramuscular
1 PA
TESTOSTERONE PROPIONATE INJECTION SOLUTION 100 MG/ML
3 PA
testosterone transdermal gel 1.62 %, 10 mg/act (2%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 40.5 mg/2.5gm (1.62%)
3 PA; QL
testosterone transdermal gel 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)
1 PA; QL
testosterone transdermal solution
3 PA; QL
TESTRED ORAL CAPSULE 10 MG
5 PA
VOGELXO 3 PA; QL
VOGELXO PUMP 3 PA; QL
XYOSTED 3 PA
Hormonal Agents - Osteoporosis
EVISTA 3 PA
OSPHENA 3 PA
raloxifene hcl 1 PA
Hormonal Agents - Pituitary
ACTHAR 4 PA; QL
cabergoline 1
DDAVP 3
DDAVP RHINAL TUBE 3
desmopressin ace spray refrig
1
desmopressin acetate injection
1
desmopressin acetate oral
1
Effective Date: 03/01/2020 64
Drug Name Drug Tier
Notes
desmopressin acetate spray
1
EGRIFTA 5 QL
EGRIFTA SV 5 QL
ELIGARD 3
GENOTROPIN 5 PA; QL
GENOTROPIN MINIQUICK
5 PA; QL
HUMATROPE 5 PA; QL
INCRELEX 5 PA; QL
leuprolide acetate injection
1
LUPRON DEPOT (1-MONTH)
2
LUPRON DEPOT (3-MONTH)
2
LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG
2
LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG
2
LUPRON DEPOT-PED (1-MONTH)
2
LUPRON DEPOT-PED (3-MONTH)
2
NOCDURNA 3 PA
NOCTIVA 2
NORDITROPIN FLEXPRO
5 PA; QL
NUTROPIN AQ NUSPIN 10
5 PA; QL
NUTROPIN AQ NUSPIN 20
5 PA; QL
NUTROPIN AQ NUSPIN 5
5 PA; QL
octreotide acetate 1
OMNITROPE 4 PA; QL
ORILISSA 5 PA; QL
SAIZEN 5 PA; QL
Drug Name Drug Tier
Notes
SAIZEN CLICK.EASY INJECTION SOLUTION RECONSTITUTED 8.8 MG
5 PA; QL
SAIZENPREP 5 PA; QL
SANDOSTATIN 3
SANDOSTATIN LAR DEPOT
2 QL
SIGNIFOR 5 PA; QL
SOMATULINE DEPOT 5 PA
SOMAVERT 5 PA; QL
STIMATE 2
SYNAREL 3 QL
ZOMACTON 5 PA; QL
Hormonal Agents - Prostaglandins
KORLYM 5 PA; QL
Hormonal Agents - Sex Hormones and Birth Control
ACTIVELLA 3 PA
afirmelle 1
ALORA 3
altavera 1
alyacen 1/35 1
alyacen 7/7/7 1
amabelz 3 PA
amethia 3
amethia lo 3
amethyst 3
ANGELIQ 3 PA
ANNOVERA 3
apri 1
aranelle 1
ashlyna 3
aubra 1
aubra eq 1
aurovela 1.5/30 1
aurovela 1/20 1
aurovela 24 fe 3
Effective Date: 03/01/2020 65
Drug Name Drug Tier
Notes
aurovela fe 1.5/30 1
aurovela fe 1/20 1
aviane 1
AYGESTIN 3
ayuna 1
azurette 3
BALCOLTRA 3
balziva 1
bekyree 3
BEYAZ 3
BIJUVA 3 PA
blisovi 24 fe 3
blisovi fe 1.5/30 1
blisovi fe 1/20 1
briellyn 1
camila 1
camrese 3
camrese lo 3
caziant 1
chateal 1
chateal eq 1
CLIMARA 1
CLIMARA PRO 3 PA
COMBIPATCH 3 PA
covaryx 3
covaryx hs 3
CRINONE 3
cryselle-28 1
cyclafem 1/35 1
cyclafem 7/7/7 1
cyred 1
cyred eq 1
dasetta 1/35 1
dasetta 7/7/7 1
daysee 3
deblitane 1
Drug Name Drug Tier
Notes
DELESTROGEN 2
delyla 1
DEPO-ESTRADIOL 2
DEPO-PROVERA 3
DEPO-SUBQ PROVERA 104
3
DESOGEN ORAL TABLET 0.15-30 MG-MCG
3
desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)
3
desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg
1
DIVIGEL 3
dotti 3
drospiren-eth estrad-levomefol
3
drospirenone-ethinyl estradiol oral tablet 3-0.02 mg
3
drospirenone-ethinyl estradiol oral tablet 3-0.03 mg
1
DUAVEE 3
eemt 3
eemt hs 3
ELESTRIN 3
elinest 1
ELLA 2
eluryng 1
emoquette 1
ENDOMETRIN 3
enpresse-28 1
enskyce 1
errin 1
est estrogens-methyltest 3
est estrogens-methyltest ds
3
Effective Date: 03/01/2020 66
Drug Name Drug Tier
Notes
est estrogens-methyltest hs
3
estarylla 1
ESTRACE 3
estradiol oral 1
estradiol transdermal patch twice weekly
3
estradiol transdermal patch weekly
1
estradiol vaginal 1
estradiol valerate intramuscular
1
estradiol-norethindrone acet
3 PA
ESTRING 2
ESTROGEL 3
estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg
1
ESTROSTEP FE 3
ethynodiol diac-eth estradiol
1
etonogestrel-ethinyl estradiol
1
EVAMIST 3
falmina 1
fayosim 3
FEMHRT LOW DOSE 3 PA
FEMRING 2
femynor 1
FIRST-PROGESTERONE VGS
3
fyavolv 3 PA
GENERESS FE 3
gianvi 3
hailey 1.5/30 1
hailey 24 fe 3
heather 1
hydroxyprogesterone caproate intramuscular oil
4
Drug Name Drug Tier
Notes
IMVEXXY MAINTENANCE PACK
3 PA
IMVEXXY STARTER PACK
3 PA
incassia 1
introvale 3
isibloom 1
jaimiess 3
jasmiel 3
jencycla 1
jevantique lo oral tablet 0.5-2.5 mg-mcg
3 PA
jinteli 3 PA
jolessa 3
jolivette oral tablet 0.35 mg
1
juleber 1
junel 1.5/30 1
junel 1/20 1
junel fe 1.5/30 1
junel fe 1/20 1
junel fe 24 3
kaitlib fe 3
kalliga 1
kariva 3
kelnor 1/35 1
kelnor 1/50 1
kimidess oral tablet 0.15-0.02/0.01 mg (21/5)
3
kurvelo 1
larin 1.5/30 1
larin 1/20 1
larin 24 fe 3
larin fe 1.5/30 1
larin fe 1/20 1
larissia 1
layolis fe 3
leena 1
Effective Date: 03/01/2020 67
Drug Name Drug Tier
Notes
lessina 1
levonest 1
levonorgest-eth est & eth est
3
levonorgest-eth estrad 91-day
3
levonorgestrel 1
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg
1
levonorgestrel-ethinyl estrad oral tablet 90-20 mcg
3
levonorg-eth estrad triphasic oral tablet
1
levora 0.15/30 (28) 1
LILETTA (52 MG) 3
lillow 1
LO LOESTRIN FE 3
LOESTRIN 1.5/30 (21) 3
LOESTRIN 1/20 (21) 3
LOESTRIN FE 1.5/30 3
LOESTRIN FE 1/20 3
lojaimiess 3
lopreeza 3 PA
loryna 3
LOSEASONIQUE 3
low-ogestrel 1
lo-zumandimine 3
lutera 1
lyza 1
MAKENA INTRAMUSCULAR
5
MAKENA SUBCUTANEOUS
4 QL
marlissa 1
medroxyprogesterone acetate intramuscular
1
medroxyprogesterone acetate oral
1
Drug Name Drug Tier
Notes
MEGACE ES 3
megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml
1
megestrol acetate oral suspension 625 mg/5ml
3
megestrol acetate oral tablet
1
melodetta 24 fe 3
MENEST 3
MENOSTAR 3
mibelas 24 fe 3
microgestin 1.5/30 1
microgestin 1/20 1
microgestin fe 1.5/30 1
microgestin fe 1/20 1
mili 1
mimvey 3 PA
mimvey lo oral tablet 0.5-0.1 mg
3 PA
MINASTRIN 24 FE 3
MINIVELLE 3
MIRCETTE 3
MIRENA (52 MG) 2
mono-linyah 1
mononessa 1
myzilra oral tablet 50-30/75-40/ 125-30 mcg
1
NATAZIA 3
necon 0.5/35 (28) 1
necon 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg
1
nikki 3
nora-be 1
norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg(24)
3
norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg
1
Effective Date: 03/01/2020 68
Drug Name Drug Tier
Notes
norethin ace-eth estrad-fe oral tablet chewable
3
norethindrone acetate oral
1
norethindrone acet-ethinyl est oral tablet
1
norethindrone acet-ethinyl est oral tablet chewable 1-20 mg-mcg(24)
3
norethindrone oral 1
norethindrone-eth estradiol (generic Jinteli)
3 PA
norethin-eth estradiol-fe 3
norgestimate-eth estradiol 1
norgestimate-ethinyl estradiol triphasic
1
norlyda 1
norlyroc 1
nortrel 0.5/35 (28) 1
nortrel 1/35 (21) 1
nortrel 1/35 (28) 1
nortrel 7/7/7 1
NUVARING 2
ocella 1
ogestrel 1
orsythia 1
ORTHO MICRONOR 3
ORTHO TRI-CYCLEN (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG
3
ORTHO TRI-CYCLEN LO 3
ORTHO-CYCLEN (28) ORAL TABLET 0.25-35 MG-MCG
3
ORTHO-NOVUM 1/35 (28)
3
ORTHO-NOVUM 7/7/7 (28)
3
PARAGARD INTRAUTERINE COPPER
2
Drug Name Drug Tier
Notes
philith 1
pimtrea 3
pirmella 1/35 1
pirmella 7/7/7 1
PLAN B ONE-STEP 3
portia-28 1
PREFEST 3 PA
PREMARIN ORAL 3 PA
PREMARIN VAGINAL 2
PREMPHASE 3 PA
PREMPRO 3
preventeza 1
previfem 1
progesterone intramuscular
1
progesterone micronized oral
1
PROMETRIUM 3
PROVERA 3
QUARTETTE 3
quasense oral tablet 0.15-0.03 mg
3
rajani oral tablet 3-0.02-0.451 mg
3
reclipsen 1
rivelsa 3
SAFYRAL 3
SEASONIQUE 3
setlakin 3
sharobel 1
simliya 3
simpesse 3
SKYLA 2
SLYND 3
sprintec 28 1
sronyx 1
syeda 1
tarina 24 fe 3
Effective Date: 03/01/2020 69
Drug Name Drug Tier
Notes
tarina fe 1/20 1
tarina fe 1/20 eq 1
TAYTULLA 3
tilia fe 3
tri femynor 1
tri-estarylla 1
tri-legest fe 3
tri-linyah 1
tri-lo-estarylla 1
tri-lo-marzia 1
tri-lo-mili 1
tri-lo-sprintec 1
tri-mili 1
trinessa (28) 1
trinessa lo oral tablet 0.18/0.215/0.25 mg-25 mcg
1
TRI-NORINYL (28) ORAL TABLET 0.5/1/0.5-35 MG-MCG
3
tri-previfem 1
tri-sprintec 1
trivora (28) 1
tri-vylibra 1
tri-vylibra lo 1
tulana 1
tydemy 3
VAGIFEM 3
velivet 1
vestura oral tablet 3-0.02 mg
3
vienva 1
viorele 3
VIVELLE-DOT 3
volnea 3
vyfemla 1
vylibra 1
wera 1
Drug Name Drug Tier
Notes
wymzya fe 3
xulane 1
YASMIN 28 3
YAZ 3
yuvafem 1
zarah 1
zenchent oral tablet 0.4-35 mg-mcg
1
zovia 1/35e (28) 1
zumandimine 1
Hormonal Agents - Thyroid
ARMOUR THYROID 3
CYTOMEL 3
euthyrox 3
levo-t 3
levothyroxine sodium oral 1
levothyroxine-liothyronine oral tablet 30 mg, 60 mg, 90 mg
3
levoxyl 3
liothyronine sodium oral 1
methimazole oral 1
NATURE-THROID 3
np thyroid 3
propylthiouracil oral 1
SYNTHROID 3
TAPAZOLE 3
thyroid oral tablet 120 mg, 15 mg
3
THYROLAR-1 ORAL TABLET 60 (12.5-50) MG (MCG)
3
THYROLAR-1/2 ORAL TABLET 30 (6.25-25) MG (MCG)
3
THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5) MG (MCG)
3
Effective Date: 03/01/2020 70
Drug Name Drug Tier
Notes
THYROLAR-2 ORAL TABLET 120 (25-100) MG (MCG)
3
THYROLAR-3 ORAL TABLET 180 (37.5-150) MG (MCG)
3
TIROSINT 3
TIROSINT-SOL 3
unithroid 3
WESTHROID 3
WP THYROID 3
Immunological Agents - Drugs for Immune System Stimulation or Suppression
ACTEMRA ACTPEN 5 PA; QL
ACTEMRA SUBCUTANEOUS
5 PA; QL
ACTIMMUNE 5 QL
ALFERON N 3
ARAVA 3
ARCALYST 5 PA; QL
ASTAGRAF XL 3
AZASAN 3
azathioprine oral 1
BENLYSTA SUBCUTANEOUS
5 PA; QL
BERINERT 4 PA; QL
CELLCEPT 3
CIMZIA 5 PA; QL
CIMZIA PREFILLED KIT 5 PA; QL
CIMZIA STARTER KIT 5 PA; QL
CINRYZE 5 PA; QL
COSENTYX (300 MG DOSE)
4 PA; QL
COSENTYX 150 MG/ML 4 PA; QL
COSENTYX SENSOREADY (300 MG)
4 PA; QL
COSENTYX SENSOREADY PEN
4 PA; QL
CUTAQUIG 5 PA; QL
CUVITRU 4 PA; QL
Drug Name Drug Tier
Notes
cyclosporine modified 1
cyclosporine oral 1
ENBREL 4 PA; QL
ENBREL MINI 4 PA; QL
ENBREL SURECLICK 4 PA; QL
ENVARSUS XR 3
FIRAZYR 5 PA; QL
gengraf 1
HAEGARDA 5 PA; QL
HEPAGAM B 3
HIZENTRA 4 PA; QL
HUMIRA 4 PA; QL
HUMIRA PEDIATRIC CROHNS START
4 PA; QL
HUMIRA PEN 4 PA; QL
HUMIRA CITRATE FREE 4 PA; QL
HUMIRA PEN-PS/UV/ADOL HS START
4 PA; QL
HYPERHEP B S/D 2
HYPERRAB 3
HYPERRAB S/D 3
HYPERTET S/D 3
HYQVIA 4 PA; QL
icatibant acetate 4 QL
IMOGAM RABIES-HT 3
IMURAN 3
KEDRAB 3
KEVZARA 5 PA; QL
KINERET 5 PA; QL
leflunomide oral 1
methotrexate oral 1
methotrexate sodium 1
methotrexate sodium (pf) 1
mycophenolate mofetil 1
mycophenolate sodium 1
MYFORTIC 3
NABI-HB 2
NEORAL 3
Effective Date: 03/01/2020 71
Drug Name Drug Tier
Notes
OLUMIANT 5 PA; QL
ORENCIA CLICKJECT 4 PA; QL
ORENCIA SUBCUTANEOUS
4 PA; QL
OTEZLA 4 PA; QL
OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 22.5 MG/0.4ML, 25 MG/0.4ML
3 PA
OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 20 MG/0.4ML
3
PROGRAF ORAL 3
RAPAMUNE 3
RASUVO 2
RHOPHYLAC 3
RIDAURA 4 QL
RINVOQ 5 PA; QL
RUCONEST 5 PA; QL
SANDIMMUNE ORAL 3
SILIQ 5 PA; QL
SIMPONI 5 PA; QL
sirolimus oral 1
SKYRIZI (150 MG DOSE) 5 PA; QL
STELARA SUBCUTANEOUS
4 PA; QL
tacrolimus oral 1
TAKHZYRO 5 PA; QL
TALTZ 5 PA; QL
TREMFYA 5 PA; QL
TREXALL 3
VARIZIG 3
XATMEP 3 QL
XELJANZ 4 PA; QL
XELJANZ XR 4 PA; QL
XEMBIFY 5 PA; QL
Drug Name Drug Tier
Notes
ZORTRESS 5 QL
Immunological Agents - Drugs for Vaccination
ACTHIB 2
ADACEL 2
AFLURIA INTRAMUSCULAR SUSPENSION
1
AFLURIA PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML
1
AFLURIA QUADRIVALENT
1
BEXSERO 2
BIOTHRAX 3
BOOSTRIX 2
DAPTACEL 2
DIPHTHERIA-TETANUS TOXOIDS DT
2
ENGERIX-B 2
EZ FLU SHOT-FLUCELVAX QUAD INTRAMUSCULAR PREFILLED SYRINGE KIT 0.5 ML
1
FLUAD 1
FLUARIX QUADRIVALENT
1
FLUBLOK INTRAMUSCULAR SOLUTION
1
FLUBLOK QUADRIVALENT
1
FLUCELVAX QUADRIVALENT
1
FLULAVAL QUADRIVALENT
1
FLUMIST QUADRIVALENT
1
Effective Date: 03/01/2020 72
Drug Name Drug Tier
Notes
FLUVIRIN INTRAMUSCULAR SUSPENSION
1
FLUVIRIN INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML
1
FLUZONE HIGH-DOSE 1
FLUZONE QUADRIVALENT
1
FLUZONE QUADRIVALENT INTRADERMAL SUSPENSION PEN-INJECTOR 9 MCG/STRAIN
1
GARDASIL 9 2
HAVRIX 2
HEPLISAV-B INTRAMUSCULAR SOLUTION 20 MCG/0.5ML
2
HIBERIX 2
INFANRIX 2
IPOL 2
KINRIX 2
MENACTRA 2
MENVEO 2
M-M-R II SUBCUTANEOUS INJECTABLE
2
PEDIARIX 2
PEDVAX HIB 2
PENTACEL 2
PNEUMOVAX 23 2
PREVNAR 13 2
PROQUAD SUBCUTANEOUS INJECTABLE
2
QUADRACEL 2
RECOMBIVAX HB 2
Drug Name Drug Tier
Notes
ROTARIX 2
ROTATEQ 2
SHINGRIX 2
TDVAX 2
TENIVAC 2
TRUMENBA 2
TWINRIX 3
VAQTA INTRAMUSCULAR SUSPENSION 50 UNIT/ML
2
VARIVAX 2
ZOSTAVAX 2
Inflammatory Bowel Disease Agents
ANALPRAM-HC 3
anucort-hc 3
ANUSOL-HC RECTAL CREAM
3
anusol-hc rectal suppository
3
APRISO 3 PA
ASACOL HD 3 PA
AZULFIDINE 3
AZULFIDINE EN-TABS 3
balsalazide disodium 1
budesonide er 5 PA; QL
budesonide oral 3 PA
CANASA 3
COLAZAL 3
colocort 1
CORTENEMA 3
CORTIFOAM 2
DELZICOL 3 PA
DIPENTUM 5 PA; QL
ENTOCORT EC 5 PA
GIAZO ORAL TABLET 1.1 GM
3
hemmorex-hc 3
Effective Date: 03/01/2020 73
Drug Name Drug Tier
Notes
hydrocortisone ace-pramoxine rectal cream 1-1 %
3
hydrocortisone acetate rectal
3
hydrocortisone rectal cream 1 %
3
hydrocortisone rectal cream 2.5 %
1
hydrocortisone rectal enema
1
LIALDA 3 PA
lidocaine-hydrocortisone ace rectal cream
3
LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL
3
lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-1 %
3
mesalamine er 3 PA
mesalamine oral capsule delayed release
3 PA
mesalamine oral tablet delayed release
1 PA
mesalamine rectal 1
mesalamine-cleanser 3
PENTASA 2 PA
PROCORT 3
PROCTOCORT 3
PROCTOFOAM HC 2
procto-med hc 1
procto-pak 3
proctosol hc 1
proctozone-hc 1
ROWASA 3
SFROWASA 3
sulfasalazine oral 1
UCERIS ORAL 5 PA; QL
UCERIS RECTAL 3
Drug Name Drug Tier
Notes
Metabolic Bone Disease Agents - Drugs for Osteoporosis
ACTONEL 3 PA
alendronate sodium 1
ATELVIA 3 PA
BINOSTO 3
BONIVA ORAL 3
calcitonin (salmon) 3
FORTEO 5 PA; QL
FOSAMAX 3
FOSAMAX PLUS D 3
ibandronate sodium oral 1
MIACALCIN INJECTION 3
RAYALDEE 3 PA
risedronate sodium oral tablet
1 PA
risedronate sodium oral tablet delayed release
3 PA
TYMLOS 5 PA
Metabolic Bone Disease Agents - Other
calcitriol oral 1
cinacalcet hcl 1 PA
doxercalciferol oral 3
etidronate disodium oral tablet 200 mg, 400 mg
1
HECTOROL ORAL CAPSULE 0.5 MCG, 1 MCG, 2.5 MCG
3
NATPARA 5 PA; QL
paricalcitol oral 3
ROCALTROL 3
SENSIPAR 3 PA
ZEMPLAR ORAL 3
Miscellaneous Therapeutic Agents
ACACIA SUBCUTANEOUS
3
ACREMONIUM 3
ALCOHOL PREP PADS PAD , 70 %
1
Effective Date: 03/01/2020 74
Drug Name Drug Tier
Notes
ALDER 3
ALK SQ CAT HAIR INJECTION SOLUTION RECONSTITUTED 5000 BAU/ML
3
AMERICAN BEECH 3
ANTIVENIN LATRODECTUS MACTANS
3
ARIZONA CYPRESS 3
AUREOBASIDIUM 3
AUSTRALIAN PINE 3
BALD CYPRESS 3
BOTRYTIS 3
BREATHE EASE LARGE 2
BREATHE EASE MEDIUM
2
BREATHE EASE SMALL 2
BREATHERITE 2
BROME 3
CALCIUM DISODIUM VERSENATE
3
CALIFORNIA PEPPER TREE
3
CANDIDA ALBICANS EXTRACT INJECTION
3
CANDIDA ALBICANS EXTRACT SUBCUTANEOUS SOLUTION 10000 PNU/ML
3
CATTLE EPITHELIUM 3
CAYA 2
CEDAR ELM 3
CLADOSPORIUM CLADOSPORIOIDES
3
CLADOSPORIUM SPHAEROSPERMUM
3
COMPACT SPACE CHAMBER/LG MASK
2
COMPACT SPACE CHAMBER/MED MASK
2
Drug Name Drug Tier
Notes
COMPACT SPACE CHAMBER/SM MASK
2
CURVULARIA 3
CYTOTINE ORAL POWDER
3
deferoxamine mesylate injection solution reconstituted 500 mg
1
DESFERAL 3
DOG EPITHELIUM SUBCUTANEOUS SOLUTION 1:20
3
DRECHSLERA 3
DUST MITE MIXED ALLERGEN EXT
3
EASIVENT 2
ENDARI 5 PA; QL
ENLON INJECTION SOLUTION 10 MG/ML
3
EPICOCCUM 3
ergoloid mesylates oral 3
FEMCAP 2
FIRDAPSE 5 PA; QL
FIRE ANT 3
FLEXICHAMBER ADULT MASK/SMALL
2
FLEXICHAMBER CHILD MASK/LARGE
2
FLEXICHAMBER CHILD MASK/SMALL
2
FUSARIUM 3
GERMAN COCKROACH 3
GLUCAGEN DIAGNOSTIC
2
GLUCAGON HCL (DIAGNOSTIC)
2
GRASTEK 3 PA
HACKBERRY 3
HONEY BEE TREATMENT INJECTION KIT 100 MCG
3
Effective Date: 03/01/2020 75
Drug Name Drug Tier
Notes
HONEY BEE VENOM INJECTION SOLUTION RECONSTITUTED 1000 MCG
3
HONEY BEE VENOM PROTEIN
3
HORSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:10
3
JUNE GRASS POLLEN STANDARDIZED
3
KAPOK 3
MASK VORTEX 2
MELALEUCA 3
methergine 1
methylergonovine maleate
1
MIXED ASPERGILLUS 3
MIXED FEATHERS 3
MIXED VESPID VENOM PROTEIN INJECTION KIT 100-100-100 MCG, 1000-1000-1000 MCG
3
MUCOR 3
ODACTRA 3 PA
OLIVE TREE 3
OMNIPOD 5 PACK 3 PA
OMNIPOD DASH 5 PACK
3 PA
ORALAIR 3 PA
ORALAIR ADULT SAMPLE KIT
3 PA
ORALAIR ADULT STARTER PACK
3 PA
ORALAIR CHILDRENS SAMPLE KIT
3 PA
ORALAIR CHILDRENS STARTER PACK
3 PA
OXBRYTA 5 PA; QL
PANDA MASK LARGE 2
PANDA MASK MEDIUM 2
PANDA MASK SMALL 2
Drug Name Drug Tier
Notes
PEDIATRIC PANDA MASK
2
PENICILLIUM NOTATUM SUBCUTANEOUS SOLUTION 20000 PNU/ML
3
PERENNIAL RYE GRASS POLLEN
3
pocket spacer 2
PRO COMFORT SPACER ADULT
2
PRO COMFORT SPACER CHILD
2
PROCARE SPACER/ADULT MASK
2
PROCARE SPACER/CHILD MASK
2
PURE COMFORT ALCOHOL PREP
1
QUEEN PALM 3
RABBIT EPITHELIUM SUBCUTANEOUS SOLUTION 1:10
3
RAGWITEK 3 PA
RED MAPLE 3
RHIZOPUS 3
RUZURGI 5 PA; QL
SACCHAROMYCES CEREVISIAE
3
SPINY PIGWEED 3
STEMPHYLIUM 3
SWEET GUM 3
SWEET VERNAL GRASS POLLEN
3
TALL RAGWEED 3
TRICHOPHYTON 3
VENOMIL HONEY BEE VENOM
3
VENOMIL MIXED VESPID VENOM
3
VENOMIL WASP VENOM
3
Effective Date: 03/01/2020 76
Drug Name Drug Tier
Notes
VENOMIL WHITE FACED HORNET
3
VENOMIL YELLOW HORNET VENOM
3
VENOMIL YELLOW JACKET VENOM
3
VISTOGARD 5 PA; QL
WASP VENOM PROTEIN 3
WASP VENOM PROTEIN INJECTION KIT 100 MCG
3
WESTERN JUNIPER 3
WHITE BIRCH 3
WHITE FACED HORNET VENOM
3
WHITE FACED HORNET VENOM PROT INJECTION KIT 100 MCG
3
WHITE FACED HORNET VENOM PROT INJECTION SOLUTION RECONSTITUTED 1000 MCG
3
WHITE MULBERRY 3
WHITE-FACED HORNET VENOM
3
WIDE-SEAL DIAPHRAGM 60
2
YELLOW HORNET VENOM PROTEIN
3
YELLOW HORNET VENOM PROTEIN INJECTION KIT 100 MCG
3
YELLOW JACKET VENOM PROTEIN
3
YELLOW JACKET VENOM PROTEIN INJECTION KIT 100 MCG
3
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation
ACULAR 3
Drug Name Drug Tier
Notes
ACULAR LS 3
ACUVAIL 3
ALOCRIL 3
ALOMIDE 2
ALREX 3
AZASITE 3
azelastine hcl ophthalmic 1
bacitracin ophthalmic 1
BEPREVE 3
BESIVANCE 3
BETADINE OPHTHALMIC PREP
3
BLEPH-10 3
bromfenac sodium (once-daily)
3
BROMSITE 3
CILOXAN OPHTHALMIC OINTMENT
2
CILOXAN OPHTHALMIC SOLUTION
3
ciprofloxacin hcl ophthalmic
1
cromolyn sodium ophthalmic
1
dexamethasone sodium phosphate ophthalmic
1
diclofenac sodium ophthalmic
1
DUREZOL 2
ELESTAT OPHTHALMIC SOLUTION 0.05 %
3
EMADINE OPHTHALMIC SOLUTION 0.05 %
3
epinastine hcl 3
erythromycin ophthalmic 1
FLAREX 3
fluorometholone 1
flurbiprofen sodium 1
FML 2
FML FORTE 2
Effective Date: 03/01/2020 77
Drug Name Drug Tier
Notes
FML LIQUIFILM 3
gatifloxacin ophthalmic 1
gentak 1
gentamicin sulfate ophthalmic
1
ILEVRO 3
INVELTYS 3
ketorolac tromethamine ophthalmic
1
KLARITY-A 3
KLARITY-B 3
KLARITY-L 3
levofloxacin ophthalmic 3
LOTEMAX 3
LOTEMAX SM 3
loteprednol etabonate 3
MAXIDEX 3
MOXEZA 2
moxifloxacin hcl ophthalmic
1
NATACYN 2
NEVANAC 3
OCUFLOX 3
ofloxacin ophthalmic 1
olopatadine hcl ophthalmic solution 0.1 %
1
olopatadine hcl ophthalmic solution 0.2 %
3
OMNIPRED OPHTHALMIC SUSPENSION 1 %
3
PATADAY 3
PATANOL 3
PAZEO 3
POVIDONE-IODINE OPHTHALMIC
3
PRED FORTE 3
PRED MILD 2
Drug Name Drug Tier
Notes
PREDNISOL ACE-MOXIFLOX-BROMFEN
3
prednisolone acetate ophthalmic
1
prednisolone acetate p-f 1
prednisolone sodium phosphate ophthalmic
3
PREDNISOLON-MOXIFLOX-BROMFENAC OPHTHALMIC SOLUTION 1-0.5-0.09 %
3
PREDNISOLON-MOXIFLOX-KETOROLAC OPHTHALMIC SOLUTION 1-0.5-0.5 %
3
PREDNISOLON-MOXIFLOX-NEPAFENAC
3
PROLENSA 3
sulfacetamide sodium ophthalmic
1
tobramycin ophthalmic 1
TOBREX OPHTHALMIC OINTMENT
2
TOBREX OPHTHALMIC SOLUTION
3
trifluridine 1
VIGAMOX 2
VIROPTIC OPHTHALMIC SOLUTION 1 %
3
ZIRGAN 3
ZYMAXID 3
Ophthalmic Agents - Drugs for Glaucoma
acetazolamide er 1
acetazolamide oral 1
ALPHAGAN P 3
apraclonidine hcl 3
AZOPT 2
BETAGAN OPHTHALMIC SOLUTION 0.5 %
3
betaxolol hcl ophthalmic 1
Effective Date: 03/01/2020 78
Drug Name Drug Tier
Notes
BETIMOL 3
BETOPTIC-S 2
bimatoprost ophthalmic 1
brimonidine tartrate ophthalmic solution 0.15 %
3
brimonidine tartrate ophthalmic solution 0.2 %
1
BRIMONIDINE-DORZOLAMIDE
3
carteolol hcl 1
COMBIGAN 3
COSOPT 3
COSOPT PF OPHTHALMIC SOLUTION 22.3-6.8 MG/ML
3
DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC
3
dorzolamide hcl solution 2 % ophthalmic
1
dorzolamide hcl-timolol mal
1
dorzolamide hcl-timolol mal pf ophthalmic solution 22.3-6.8 mg/ml
3
IOPIDINE 3
ISOPTO CARPINE 3
ISTALOL 3
KEVEYIS 5 PA; QL
latanoprost ophthalmic 1
LATANOPROST-TIMOLOL MALEATE
3
levobunolol hcl 1
LUMIGAN 2
methazolamide oral 1
metipranolol ophthalmic solution 0.3 %
1
NEPTAZANE ORAL TABLET 25 MG
3
PHOSPHOLINE IODIDE 3
Drug Name Drug Tier
Notes
pilocarpine hcl ophthalmic 1
RESCULA OPHTHALMIC SOLUTION 0.15 %
3
RHOPRESSA 3 PA
ROCKLATAN 3 PA
SIMBRINZA 3
timolol maleate ophthalmic gel forming solution
1
timolol maleate ophthalmic solution 0.25 %, 0.5 %
1
timolol maleate ophthalmic solution 0.5 % (daily)
3
TIMOLOL-BRIMON-DORZOL-LATANOPR
3
TIMOLOL-BRIMONIDINE-DORZOLAMID
3
TIMOLOL-DORZOLAMID-LATANOPROST
3
TIMOPTIC 3
TIMOPTIC OCUDOSE 3
TIMOPTIC-XE 3
TRAVATAN Z 1
travoprost (bak free) 1
TRUSOPT 3
VYZULTA 3 PA
XALATAN 3
XELPROS 3
ZIOPTAN 3
Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions
ACUICYN EXTERNAL LIQUID , 0.01 %
3
ak-poly-bac 1
AKTEN 3
ALCAINE 3
altacaine 3
Effective Date: 03/01/2020 79
Drug Name Drug Tier
Notes
altafrin 1
ATROPINE SULFATE OPHTHALMIC EMULSION
1
atropine sulfate ophthalmic ointment
1
atropine sulfate ophthalmic solution
1
ATROPINE SULFATE-NACL OPHTHALMIC SOLUTION 0.01-0.9 %
2
AVENOVA 3
AVENOVA/NEUTROX EXTERNAL SOLUTION 0.01 %
3
bacitracin-polymyxin b ophthalmic
1
bacitra-neomycin-polymyxin-hc
1
BLEPHAMIDE 2
BLEPHAMIDE S.O.P. 2
CEQUA 3 PA
CYCLOGYL 3
CYCLOMYDRIL 3
cyclopentolate hcl ophthalmic
1
CYCLOSPORINE IN KLARITY
2 PA
CYSTARAN 5
GATIFLOXACIN-DEXAMETHASONE
3
GELFILM OPHTHALMIC 3
homatropaire 1
homatropine hbr 1
HYPOCYN EXTERNAL LIQUID
3
LACRISERT 2
LASTACAFT 3
MAXITROL 3
neomycin-bacitracin zn-polymyx
3
Drug Name Drug Tier
Notes
neomycin-polymyxin-dexameth ophthalmic ointment
1
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1
1
neomycin-polymyxin-gramicidin
1
neomycin-polymyxin-hc ophthalmic
3
neo-polycin 3
neo-polycin hc 1
NEOSPORIN OPHTHALMIC SOLUTION 1.75-10000-.025
3
OXERVATE 5 PA; QL
phenylephrine hcl ophthalmic
1
polycin 1
polymyxin b-trimethoprim 1
POLYTRIM 3
PRED-G 2
PRED-G S.O.P. 2
PREDNISOLONE ACETATE-NEPAFENAC
3
PREDNISOLONE ACET-MOXIFLOXACIN
3
PREDNISOLONE-BROMFENAC
3
PREDNISOLONE-GATIFLOXACIN
3
PREDNISOLONE-MOXIFLOXACIN
3
PREDNISOLON-GATIFLOX-BROMFENAC
3
PREDNISOLON-MOXIFLOX-BROMFENAC
3
proparacaine hcl ophthalmic
3
RESTASIS 2 PA
Effective Date: 03/01/2020 80
Drug Name Drug Tier
Notes
RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 %
2 PA
sulfacetamide-prednisolone ophthalmic solution
1
tetcaine 3
tetracaine hcl ophthalmic 3
tetravisc 3
tetravisc forte 3
TOBRADEX OPHTHALMIC OINTMENT
2
TOBRADEX OPHTHALMIC SUSPENSION
3
TOBRADEX ST 3
tobramycin-dexamethasone
1
TROPICAMIDE-CYCLOPENTOLATE-PE
3
TROPICAMIDE-PHENYLEPHRINE
3
TROPIC-PROPARACA-PE-KETOROLAC
3
XIIDRA 2 PA
ZYLET 3
Otic Agents - Drugs for Ear Conditions
ACETASOL HC 3
acetic acid otic 1
CETRAXAL 3
CIPRO HC 2
CIPRODEX 2
ciprofloxacin hcl otic 3
COLY-MYCIN S 3
DERMOTIC 3
flac 3
FLOXIN OTIC OTIC SOLUTION 0.3 %
3
fluocinolone acetonide otic
3
Drug Name Drug Tier
Notes
hydrocortisone-acetic acid 3
neomycin-polymyxin-hc otic
1
ofloxacin otic 1
OTOVEL 3
PRAMOTIC 3
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold
ADRENALIN NASAL 3
ASTEPRO 3
azelastine hcl nasal 1
BECONASE AQ 3 PA
benzonatate oral capsule 100 mg, 200 mg
1
benzonatate oral capsule 150 mg
3
biotuss oral liquid 10-15-300 mg/5ml
3
bromfed dm 3
BROMPHENIRAMINE MALEATE INTRAMUSCULAR
3
brompheniramine tannate 3
CARBAPHEN 12 ORAL LIQUID 10-4-27.5 MG/5ML
3
CARBAPHEN 12 PED ORAL SUSPENSION 2.5-1.25-7.5 MG/ML
3
carbinoxamine maleate 1
cetirizine hcl oral solution 3
CLARINEX 3
CLARINEX ORAL SYRUP 0.5 MG/ML
3
CLARINEX-D 12 HOUR 3
clemastine fumarate oral tablet 2.68 mg
1
CUROSURF 3
cyproheptadine hcl oral 1
DERMACINRX AZENASE PAK
3
Effective Date: 03/01/2020 81
Drug Name Drug Tier
Notes
desloratadine 1
dexchlorpheniramine maleate oral
3
diphen oral elixir 3
diphenhydramine hcl injection
1
diphenhydramine hcl oral elixir
3
DYMISTA 3
FASENRA PEN 5 PA; QL
FLOWTUSS ORAL SOLUTION 2.5-200 MG/5ML
3
flunisolide nasal 1
HYCOFENIX ORAL SOLUTION 30-2.5-200 MG/5ML
3
hydrocodone polst-cpm polst er
3
HYDROCODONE-GUAIFENESIN ORAL SOLUTION 2.5-200 MG/5ML
3
hydrocodone-homatropine
1
hydromet 1
HYPERSAL 3
INFASURF 3
ipratropium bromide nasal 1
KARBINAL ER 3
levocetirizine dihydrochloride oral
1
mometasone furoate nasal
3 PA
NASONEX 3 PA
nebusal inhalation nebulization solution 3 %
1
NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %
3
nortuss-ex oral liquid 20-200 mg/5ml
3
Drug Name Drug Tier
Notes
NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR
5 PA; QL
NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
5 PA; QL
OBREDON ORAL SOLUTION 2.5-200 MG/5ML
3
olopatadine hcl nasal 3
OMNARIS 3 PA
PATANASE 3
phenadoz 1
PHENERGAN 3
promethazine hcl injection 3
promethazine hcl oral 1
promethazine hcl rectal 1
promethazine vc plain oral solution 6.25-5 mg/5ml
1
promethazine vc/codeine 3 PA
promethazine-codeine 3 PA
promethazine-dm 1
promethazine-dm oral solution 6.25-15 mg/5ml
1
promethazine-phenyleph-codeine
3 PA
promethazine-phenylephrine
1
promethegan 1
pseudoeph-chlorphen-hydrocod oral solution 60-4-5 mg/5ml
3
pseudoephedrine-bromphen-dm
3
pulmosal 1
QNASL 3 PA
QNASL CHILDRENS 3 PA
RYCLORA 3
ryvent 1
Effective Date: 03/01/2020 82
Drug Name Drug Tier
Notes
SEMPREX-D 3
sodium chloride inhalation nebulization solution 0.9 %, 3 %, 7 %
1
sodium chloride inhalation nebulization solution 10 %
3
SSKI 2
SURVANTA 2
TESSALON PERLES 3
TICALAST NASAL KIT 137-50 & 0.9 MCG/ACT-%
3
TUSSICAPS 3
tussigon oral tablet 5-1.5 mg
1
TUSSIONEX PENNKINETIC ER ORAL SUSPENSION EXTENDED RELEASE 10-8 MG/5ML
3
TUXARIN ER 3 PA; QL
TUZISTRA XR 3 PA
XHANCE 3 PA
ZETONNA 3 PA
ZUTRIPRO ORAL SOLUTION 60-4-5 MG/5ML
3
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions
ACCOLATE 3
acetylcysteine inhalation 1
ADVAIR DISKUS 1 PA
ADVAIR HFA 2 PA
ADYPHREN 3
ADYPHREN AMP 3
ADYPHREN AMP II 3
ADYPHREN II 3
AIRDUO RESPICLICK 113/14
3 PA
AIRDUO RESPICLICK 232/14
3 PA
Drug Name Drug Tier
Notes
AIRDUO RESPICLICK 55/14
3 PA
albuterol sulfate er 3
ALBUTEROL SULFATE HFA
3 QL
albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml
1
albuterol sulfate oral 1
ALVESCO 2
ANORO ELLIPTA 3 PA
ARCAPTA NEOHALER 3
ARMONAIR RESPICLICK 113 INHALATION AEROSOL POWDER BREATH ACTIVATED 113 MCG/ACT
3 PA
ARMONAIR RESPICLICK 232 INHALATION AEROSOL POWDER BREATH ACTIVATED 232 MCG/ACT
3 PA
ARMONAIR RESPICLICK 55 INHALATION AEROSOL POWDER BREATH ACTIVATED 55 MCG/ACT
3 PA
ARNUITY ELLIPTA 3 PA
ASMANEX (120 METERED DOSES)
2 PA
ASMANEX (14 METERED DOSES)
2 PA
ASMANEX (30 METERED DOSES)
2 PA
ASMANEX (60 METERED DOSES)
2 PA
ASMANEX (7 METERED DOSES)
2 PA
ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT
2 PA
Effective Date: 03/01/2020 83
Drug Name Drug Tier
Notes
ASMANEX HFA INHALATION AEROSOL 50 MCG/ACT
2
ATROVENT HFA 2
AUVI-Q 3 PA
BEVESPI AEROSPHERE 3 PA
BREO ELLIPTA 3 PA
BROVANA 3 PA
budesonide inhalation 1
BUDESONIDE-FORMOTEROL FUMARATE
3 PA
COMBIVENT RESPIMAT 2
cromolyn sodium inhalation
1
DALIRESP 3
difil-g forte 3
DUAKLIR PRESSAIR 3 PA
DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT
3 PA
DULERA INHALATION AEROSOL 50-5 MCG/ACT
3
ELIXOPHYLLIN 3
epinephrine injection solution 0.3 mg/0.3ml
1
epinephrine injection solution auto-injector
1
EPINEPHRINE PROFESSIONAL
3
EPINEPHRINESNAP-EMS
3
EPINEPHRINESNAP-V 3
EPIPEN 2-PAK 2
EPIPEN JR 2-PAK 3
EPISNAP 3
ESBRIET 4 PA; QL
FLOVENT DISKUS 2 PA
Drug Name Drug Tier
Notes
FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT
2 PA
FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT
2
fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose
1 PA
FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT
3 PA
INCRUSE ELLIPTA 3 PA
ipratropium bromide inhalation
1
ipratropium-albuterol 1
levalbuterol hcl inhalation 3
LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT
3 QL
LONHALA MAGNAIR REFILL KIT
3 PA
LONHALA MAGNAIR STARTER KIT
3 PA
metaproterenol sulfate oral
1
metaproterenol sulfate oral tablet 10 mg, 20 mg
1
montelukast sodium oral 1
OFEV 4 PA; QL
PERFOROMIST 3
PROAIR DIGIHALER 3 QL
PROAIR HFA 3 QL
PROAIR RESPICLICK 3 QL
PROVENTIL HFA 3 QL
Effective Date: 03/01/2020 84
Drug Name Drug Tier
Notes
PULMICORT FLEXHALER
3 PA
PULMICORT SUSPENSION
3
QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT
2
QVAR REDIHALER 3 PA
SEEBRI NEOHALER 3 PA
SEREVENT DISKUS 2 PA
SINGULAIR 3
SPIRIVA HANDIHALER 2
SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT
2 PA
SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT
2
STIOLTO RESPIMAT 2
STRIVERDI RESPIMAT 2 PA
SYMBICORT 3 PA
SYMJEPI 3
terbutaline sulfate injection
3
terbutaline sulfate oral 1
THEO-24 3
theophylline 1
theophylline er 1
TRELEGY ELLIPTA 3 PA
TUDORZA PRESSAIR 3
UTIBRON NEOHALER 3 PA
VENTOLIN HFA 2 QL
XOPENEX 3
XOPENEX CONCENTRATE
3
XOPENEX HFA 3 QL
YUPELRI 3 PA
zafirlukast 3
Drug Name Drug Tier
Notes
zileuton er 5 PA; QL
ZYFLO 5 PA; QL
ZYFLO CR ORAL TABLET EXTENDED RELEASE 12 HOUR 600 MG
5 PA; QL
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis
BETHKIS 5 PA; QL
CAYSTON 5 PA; QL
KALYDECO 5 PA; QL
KITABIS PAK 5 PA; QL
ORKAMBI 5 PA; QL
PULMOZYME 2
SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 MG
3 PA; QL
SYMDEKO ORAL TABLET THERAPY PACK 50-75 & 75 MG
5 PA; QL
TOBI NEBULIZER 5 PA; QL
TOBI PODHALER 5 PA; QL
tobramycin nebulization solution 300 mg/5ml inhalation
4 PA; QL
TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION
5 PA; QL
TRIKAFTA 5 PA; QL
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension
ADCIRCA 5 PA; QL
ADEMPAS 5 PA; QL
alyq 5 PA; QL
ambrisentan 1 PA; QL
bosentan 1 PA; QL
LETAIRIS 5 PA; QL
OPSUMIT 4 PA; QL
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG
3 PA; QL
Effective Date: 03/01/2020 85
Drug Name Drug Tier
Notes
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG
5 PA; QL
REVATIO ORAL SUSPENSION RECONSTITUTED
5 PA; QL
REVATIO ORAL TABLET 5 PA
sildenafil citrate oral suspension reconstituted
5 PA; QL
sildenafil citrate oral tablet 20 mg
4 PA
tadalafil (pah) 5 PA; QL
TRACLEER 62.5 MG, 125 MG
3 PA; QL
TRACLEER 32 MG 5 PA; QL
TYVASO 2 PA; QL
TYVASO REFILL 2 PA; QL
TYVASO STARTER 2 PA; QL
UPTRAVI 4 PA; QL
VENTAVIS 4 PA; QL
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm
AMRIX 3 PA; QL
baclofen oral 1
carisoprodol oral 3 PA; QL
carisoprodol-aspirin 3 PA
chlorzoxazone oral tablet 250 mg
3
chlorzoxazone oral tablet 375 mg, 500 mg, 750 mg
3 QL
cyclobenzaprine hcl er 3 PA; QL
cyclobenzaprine hcl oral tablet 10 mg, 5 mg
1 QL
cyclobenzaprine hcl oral tablet 7.5 mg
3 QL
DANTRIUM ORAL 3
dantrolene sodium oral 1
FEXMID 3 QL
FIRST-BACLOFEN 3
LORZONE 3 QL
Drug Name Drug Tier
Notes
metaxall oral tablet 800 mg
3 QL
metaxalone 3 QL
methocarbamol injection 1
methocarbamol oral 1 QL
NORGESIC FORTE 3 QL
orphenadrine citrate er 1 QL
orphenadrine citrate injection
3
orphenadrine-aspirin-caffeine
3 QL
ORPHENGESIC FORTE 3 QL
OZOBAX 3
ROBAXIN INJECTION 3
ROBAXIN ORAL TABLET 500 MG
3 QL
ROBAXIN-750 3 QL
SKELAXIN 3 QL
SOMA 3 PA; QL
tizanidine hcl oral capsule 3
tizanidine hcl oral tablet 1
ZANAFLEX 3
Sleep Disorder Agents
AMBIEN 3
AMBIEN CR 3
AMYTAL SODIUM 3
armodafinil 3 PA
BELSOMRA 3 PA
BUTISOL SODIUM ORAL TABLET 30 MG
3
doxepin hcl oral tablet 3
EDLUAR 3
eszopiclone 1
flurazepam hcl 1
HETLIOZ 5 PA; QL
INTERMEZZO 3
LUNESTA 3
modafinil 1
NUVIGIL 3 PA
Effective Date: 03/01/2020 86
Drug Name Drug Tier
Notes
PROVIGIL 3
ramelteon 3
RESTORIL 3
ROZEREM 3
SECONAL 2
SILENOR 3
SONATA ORAL CAPSULE 10 MG, 5 MG
3
SUNOSI 5 PA; QL
temazepam oral capsule 15 mg, 30 mg, 7.5 mg
1
temazepam oral capsule 22.5 mg
3
WAKIX 5 PA; QL
XYREM 5 PA; QL
zaleplon 1
zolpidem tartrate er 3
zolpidem tartrate oral 1
zolpidem tartrate sublingual
3
ZOLPIMIST 3
88
Index of Drugs
1 1ST MEDX-PATCH/
LIDOCAINE ................. 14 7 7T GUMMY ES ................ 12 7T LIDO ........................... 14 7TOPIC ........................... 44 A abacavir sulfate ............... 32 abacavir sulfate-lamivudine
.................................... 32 abacavir-lamivudine-
zidovudine ................... 32 ABILIFY ........................... 31 ABILIFY MAINTENA ........ 31 ABILIFY MYCITE ............ 31 abiraterone acetate.......... 27 ABSORICA ...................... 44 ABSORICA LD ................ 44 ABSTRAL ........................ 12 ACACIA ........................... 73 acamprosate calcium ....... 16 ACANYA ......................... 44 acarbose ......................... 51 ACCOLATE ..................... 82 ACCU-CHEK AVIVA
DEVICE ....................... 53 ACCU-CHEK COMPACT
PLUS CONTROL ......... 53 ACCU-CHEK FASTCLIX
LANCET KIT ................ 53 ACCU-CHEK GUIDE
CONTROL ................... 53 ACCU-CHEK MULTICLIX
LANCET DEVICE KIT .. 53 ACCU-CHEK SMARTVIEW
CONTROL ................... 53 ACCU-CHEK SOFTCLIX
LANCET DEVICE KIT .. 53 ACCUPRIL ...................... 36 ACCURETIC ................... 36 acebutolol hcl .................. 36 acetaminophen-codeine .. 12 acetaminophen-codeine #2
.................................... 12 acetaminophen-codeine #3
.................................... 12 acetaminophen-codeine #4
.................................... 12 ACETASOL HC ............... 80 acetazolamide ................. 77 acetazolamide er ............. 77 acetazolamide sodium ..... 36
acetic acid ................. 60, 80 acetylcysteine .................. 82 ACIPHEX ........................ 57 ACIPHEX SPRINKLE ...... 57 acitretin ........................... 44 ACREMONIUM ............... 73 ACTEMRA....................... 70 ACTEMRA ACTPEN ....... 70 ACTHAR ......................... 63 ACTHIB ........................... 71 ACTICLATE .................... 17 ACTIGALL ....................... 58 ACTIMMUNE .................. 70 ACTIQ ............................. 12 ACTIVELLA ..................... 64 ACTONEL ....................... 73 ACTOPLUS MET ............ 51 ACTOPLUS MET XR ...... 52 ACTOS ............................ 52 ACUICYN ........................ 78 ACULAR ......................... 76 ACULAR LS .................... 76 ACUVAIL ......................... 76 acyclovir .......................... 32 ACZONE ......................... 44 ADACEL .......................... 71 ADALAT CC .................... 36 adapalene ....................... 44 ADAPALENE ................... 44 adapalene-benzoyl peroxide
.................................... 44 ADAZIN ........................... 44 ADCIRCA ........................ 84 ADDERALL ..................... 41 ADDERALL XR ............... 41 adefovir dipivoxil .............. 32 ADEMPAS....................... 84 ADHANSIA XR ................ 42 ADLYXIN ......................... 52 ADLYXIN STARTER PACK
.................................... 52 ADMELOG ...................... 54 ADMELOG SOLOSTAR .. 54 ADRENALIN .................... 80 ADVAIR DISKUS............. 82 ADVAIR HFA ................... 82 ADVANCED ALLERGY
COLLECTION ............. 44 ADYPHREN .................... 82 ADYPHREN AMP............ 82 ADYPHREN AMP II ......... 82 ADYPHREN II ................. 82 ADZENYS ER ................. 42
ADZENYS XR-ODT ........ 42 AEMCOLO ...................... 17 afeditab cr ....................... 36 AFINITOR ....................... 27 AFINITOR DISPERZ ....... 27 afirmelle .......................... 64 AFLURIA ......................... 71 AFLURIA PRESERVATIVE
FREE .......................... 71 AFLURIA QUADRIVALENT
.................................... 71 AFREZZA........................ 54 AGAMATRIX CONTROL
LEVEL 2 ...................... 53 AGAMATRIX CONTROL
LEVEL 4 ...................... 53 AGGRENOX ................... 31 AGONEAZE .................... 14 AGRYLIN ........................ 35 AIMOVIG......................... 26 AIRDUO RESPICLICK
113/14 ......................... 82 AIRDUO RESPICLICK
232/14 ......................... 82 AIRDUO RESPICLICK
55/14 ........................... 82 AJOVY ............................ 26 AKLIEF ........................... 44 ak-poly-bac ..................... 78 AKTEN ............................ 78 AKYNZEO ....................... 24 ALA SCALP .................... 44 ala-cort ............................ 44 albendazole ..................... 30 ALBENZA........................ 30 albuterol sulfate ............... 82 albuterol sulfate er ........... 82 ALBUTEROL SULFATE
HFA ............................. 82 ALCAINE......................... 78 alclometasone dipropionate
.................................... 44 alcohol ............................ 55 ALCOHOL PREP PADS .. 73 ALDACTAZIDE ............... 36 ALDACTONE .................. 36 ALDARA ......................... 44 ALDER ............................ 73 ALECENSA ..................... 27 alendronate sodium ......... 73 ALFERON N ................... 70 alfuzosin hcl er ................ 61 ALINIA ............................ 30
89
aliskiren fumarate ............ 36 ALK SQ CAT HAIR .......... 73 ALKERAN ....................... 27 allopurinol ........................ 26 ALLZITAL ........................ 12 almotriptan malate ........... 26 ALOCRIL ......................... 76 ALOGLIPTIN BENZOATE
.................................... 52 ALOGLIPTIN-METFORMIN
HCL ............................. 52 ALOGLIPTIN-
PIOGLITAZONE .......... 52 ALOMIDE ........................ 76 ALORA ............................ 64 alosetron hcl .................... 58 ALPHAGAN P ................. 77 alprazolam ....................... 35 alprazolam er ................... 35 alprazolam intensol.......... 35 alprazolam xr ................... 35 alprostadil ........................ 36 ALREX ............................ 76 ALTABAX ........................ 17 altacaine .......................... 78 ALTACE .......................... 36 altafrin ............................. 78 altavera ........................... 64 ALTOPREV ..................... 36 ALTRENO ....................... 44 ALUNBRIG ...................... 27 ALVESCO ....................... 82 alyacen 1/35 .................... 64 alyacen 7/7/7 ................... 64 alyq ................................. 84 amabelz ........................... 64 amantadine hcl ................ 30 AMARYL ......................... 52 AMBIEN .......................... 85 AMBIEN CR .................... 85 ambrisentan..................... 84 amcinonide ...................... 44 AMELUZ .......................... 44 AMERGE ......................... 26 AMERICAN BEECH ........ 73 amethia ........................... 64 amethia lo ........................ 64 amethyst .......................... 64 AMICAR .......................... 35 amiloride hcl .................... 36 amiloride-
hydrochlorothiazide ..... 36 aminocaproic acid ........... 35 amiodarone hcl ................ 36 AMITIZA .......................... 58
amitriptyline hcl ............... 23 amlodipine besylate ......... 36 amlodipine besylate-
benazepril hcl .............. 36 amlodipine besylate-
valsartan ...................... 36 amlodipine-atorvastatin ... 36 amlodipine-olmesartan .... 36 amlodipine-valsartan-hctz 36 ammonium lactate ........... 44 amnesteem ..................... 44 amoxapine....................... 23 amoxicill-clarithro-lansopraz
.................................... 58 amoxicillin ....................... 17 amoxicillin-potassium
clavulanate .................. 17 amoxicillin-potassium
clavulanate er .............. 17 AMPHETAMINE ER ........ 42 amphetamine sulfate ....... 42 amphetamine-
dextroamphetamine ..... 42 amphetamine-
dextroamphetamine er . 42 ampicillin ......................... 17 ampicillin sodium ............. 17 AMPYRA ......................... 42 AMRIX ............................. 85 AMYTAL SODIUM ........... 85 AMZEEQ ......................... 44 ANACAINE ...................... 44 ANADROL-50 .................. 63 ANAFRANIL .................... 23 anagrelide hcl .................. 35 ANALPRAM-HC .............. 72 ANAPROX DS ................. 11 ANASPAZ ....................... 58 ANASTIA ......................... 14 anastrozole...................... 27 ANCOBON ...................... 25 ANDRODERM ................. 63 ANDROGEL .................... 63 ANDROGEL PUMP ......... 63 ANDROID ....................... 63 ANGELIQ ........................ 64 ANNOVERA .................... 64 ANODYNE LPT ............... 14 ANORO ELLIPTA ............ 82 ANTABUSE ..................... 16 ANTARA ......................... 36 ANTIVENIN
LATRODECTUS MACTANS ................... 73
anucort-hc ....................... 72
anusol-hc ........................ 72 ANUSOL-HC ................... 72 ANZEMET ....................... 24 APADAZ ......................... 12 apap-caff-dihydrocodeine 12 APEXICON E .................. 44 APIDRA SOLOSTAR ...... 54 APIDRA VIAL .................. 54 APLENZIN ...................... 23 APOKYN ......................... 30 apraclonidine hcl ............. 77 aprepitant ........................ 24 apri .................................. 64 APRISO .......................... 72 APTENSIO XR ................ 42 APTIOM .......................... 21 APTIVUS......................... 32 aranelle ........................... 64 ARANESP (ALBUMIN
FREE) ......................... 35 ARAVA ............................ 70 ARCALYST ..................... 70 ARCAPTA NEOHALER ... 82 argyle sterile saline ......... 55 argyle sterile water .......... 55 ARICEPT ........................ 22 ARIKAYCE ...................... 17 ARIMIDEX ....................... 28 aripiprazole ..................... 31 ARISTADA ...................... 31 ARISTADA INITIO ........... 31 ARIXTRA ........................ 20 ARIZONA CYPRESS ...... 74 armodafinil ...................... 85 ARMONAIR RESPICLICK
113 .............................. 82 ARMONAIR RESPICLICK
232 .............................. 82 ARMONAIR RESPICLICK
55 ................................ 82 ARMOUR THYROID ....... 69 ARNUITY ELLIPTA ......... 82 AROMASIN ..................... 28 ARTHROTEC .................. 11 ARYMO ER ..................... 12 arzol silver nit applicators 44 ASACOL HD ................... 72 ascomp-codeine .............. 12 ashlyna ........................... 64 ASMANEX (120 METERED
DOSES) ...................... 82 ASMANEX (14 METERED
DOSES) ...................... 82 ASMANEX (30 METERED
DOSES) ...................... 82
90
ASMANEX (60 METERED DOSES) ....................... 82
ASMANEX (7 METERED DOSES) ....................... 82
ASMANEX HFA ............... 82 aspirin-dipyridamole er .... 31 ASTAGRAF XL ................ 70 ASTEPRO ....................... 80 ASTERO ......................... 14 ATACAND ....................... 36 ATACAND HCT ............... 36 atazanavir sulfate ............ 32 ATELVIA ......................... 73 atenolol ............................ 36 atenolol-chlorthalidone .... 36 ATIVAN ........................... 35 atomoxetine hcl ............... 42 ATOPADERM .................. 44 ATOPICLAIR ................... 44 atorvastatin calcium ......... 36 atovaquone ..................... 30 ATRALIN ......................... 44 ATRIPLA ......................... 32 atropine sulfate .......... 78, 79 ATROPINE SULFATE ..... 78 ATROPINE SULFATE-
NACL ........................... 79 ATROVENT HFA ............. 82 AUBAGIO ........................ 42 aubra ............................... 64 aubra eq .......................... 64 AUGMENTIN ................... 17 AUGMENTIN ES-600 ...... 17 AUGMENTIN XR ............. 17 AUREOBASIDIUM .......... 74 aurovela 1.5/30 ................ 64 aurovela 1/20................... 64 aurovela 24 fe .................. 64 aurovela fe 1.5/30 ............ 64 aurovela fe 1/20 ............... 64 AURYXIA ........................ 60 AUSTEDO ....................... 43 AUSTRALIAN PINE ......... 74 AUTOLET LANCING
DEVICE ....................... 53 AUVI-Q ............................ 83 AVALIDE ......................... 36 AVANDIA ........................ 52 AVAPRO ......................... 36 AVAR .............................. 44 avar cleanser ................... 44 AVAR LS ......................... 44 AVAR LS CLEANSER ..... 44 AVAR-E EMOLLIENT ...... 44 AVAR-E GREEN ............. 44
AVAR-E LS ..................... 44 AVC VAGINAL ................ 25 AVELOX .......................... 17 AVENOVA ....................... 79 AVENOVA/NEUTROX .... 79 aviane ............................. 64 avidoxy ............................ 17 avita ................................ 44 AVODART ....................... 61 AVONEX PEN ................. 42 AVONEX PREFILLED ..... 42 AVONEX VIAL
INTRAMUSCULAR KIT .................................... 42
AXERT ............................ 26 AYGESTIN ...................... 64 ayuna .............................. 64 AYVAKIT ......................... 28 AZASAN .......................... 70 AZASITE ......................... 76 azathioprine ..................... 70 azelaic acid ..................... 44 azelastine hcl ............ 76, 80 AZELEX .......................... 44 AZILECT ......................... 30 azithromycin .................... 17 AZOPT ............................ 77 AZOR .............................. 36 AZULFIDINE ................... 72 AZULFIDINE EN-TABS ... 72 azurette ........................... 64 B bacitracin ......................... 76 bacitracin-polymyxin b ..... 79 bacitra-neomycin-
polymyxin-hc ............... 79 baclofen .......................... 85 BACTRIM ........................ 17 BACTRIM DS .................. 17 BACTROBAN .................. 17 BACTROBAN NASAL ..... 17 BALCOLTRA ................... 64 BALD CYPRESS ............. 74 balsalazide disodium ....... 72 BALVERSA ..................... 28 balziva ............................. 65 BANZEL .......................... 21 BAQSIMI ONE PACK ...... 54 BAQSIMI TWO PACK ..... 54 BARACLUDE .................. 32 BASAGLAR KWIKPEN.... 54 BAXDELA ....................... 17 BAYER CONTOUR ......... 53 BD AUTOSHIELD DUO
PEN NEEDLES ........... 54
BD ULTRA-FINE INSULIN SYRINGES.................. 54
BD ULTRA-FINE PEN NEEDLES ................... 54
BECONASE AQ .............. 80 bekyree ........................... 65 BELBUCA ....................... 12 belladonna alkaloids-opium
.................................... 58 BELSOMRA .................... 85 benazepril hcl .................. 36 benazepril-
hydrochlorothiazide ..... 36 BENICAR ........................ 36 BENICAR HCT ................ 36 BENLYSTA ..................... 70 BENSAL HP .................... 44 BENTYL .......................... 58 BENZACLIN .................... 44 BENZACLIN WITH PUMP
.................................... 44 BENZAMYCIN ................ 44 benzepro foaming cloths . 44 BENZHYDROCODONE-
ACETAMINOPHEN ..... 12 BENZIQ .......................... 44 BENZIQ LS ..................... 44 BENZNIDAZOLE ............. 30 BENZO-LIDOCAINE-
TETRACAINE ............. 15 benzonatate .................... 80 BENZOYL PEROX-
HYDROCORTISONE .. 44 BENZOYL PEROXIDE .... 45 BENZOYL PEROXIDE
FORTE- HC ................. 45 benzoyl peroxide-
erythromycin ................ 45 benztropine mesylate ...... 30 BEPREVE ....................... 76 BERINERT ...................... 70 beser ............................... 45 BESIVANCE ................... 76 BETADINE OPHTHALMIC
PREP .......................... 76 BETAGAN ....................... 77 betamethasone
dipropionate ................ 45 betamethasone
dipropionate aug ......... 45 BETAMETHASONE
SODIUM PHOSPHATE61 betamethasone valerate .. 45 BETAPACE ..................... 36 BETAPACE AF ............... 36
91
BETASERON .................. 42 betaxolol hcl .............. 36, 77 bethanechol chloride ....... 60 BETHKIS ......................... 84 BETIMOL ........................ 77 BETOPTIC-S ................... 77 BEVESPI AEROSPHERE83 bexarotene ...................... 28 BEXSERO ....................... 71 BEYAZ ............................ 65 bicalutamide .................... 28 BICILLIN L-A ................... 17 BIDIL ............................... 36 BIJUVA ............................ 65 BIKTARVY ...................... 32 BILTRICIDE..................... 30 bimatoprost ..................... 77 BINOSTO ........................ 73 bio-statin .......................... 25 BIO-STATIN .................... 25 BIOTHRAX ...................... 71 biotuss ............................. 80 bisoprolol fumarate .......... 36 bisoprolol-
hydrochlorothiazide ..... 36 BLEPH-10 ....................... 76 BLEPHAMIDE ................. 79 BLEPHAMIDE S.O.P. ...... 79 blisovi 24 fe ..................... 65 blisovi fe 1.5/30 ............... 65 blisovi fe 1/20 .................. 65 BOCASAL ....................... 43 BONIVA ........................... 73 BONJESTA ..................... 24 BOOSTRIX ...................... 71 bosentan ......................... 84 BOSULIF ......................... 28 BOTRYTIS ...................... 74 bp 10-1 ............................ 45 bp cleansing wash ........... 45 bpo .................................. 45 bpo foaming cloths .......... 45 BRAFTOVI ...................... 28 BREATHE EASE LARGE 74 BREATHE EASE MEDIUM
.................................... 74 BREATHE EASE SMALL 74 BREATHERITE ............... 74 BREO ELLIPTA ............... 83 BRETYLIUM TOSYLATE 36 briellyn ............................. 65 BRILINTA ........................ 31 brimonidine tartrate.... 77, 78 BRIMONIDINE-
DORZOLAMIDE .......... 78
BRISDELLE .................... 23 BRIVIACT ....................... 21 BROME ........................... 74 bromfed dm ..................... 80 bromfenac sodium (once-
daily) ........................... 76 bromocriptine mesylate ... 30 BROMPHENIRAMINE
MALEATE ................... 80 brompheniramine tannate 80 BROMSITE ..................... 76 BROVANA....................... 83 BRUKINSA ...................... 28 BRYHALI ......................... 45 budesonide................ 72, 83 budesonide er ................. 72 BUDESONIDE-
FORMOTEROL FUMARATE................. 83
bumetanide ..................... 37 BUMEX ........................... 37 BUNAVAIL ...................... 16 BUPAP ............................ 12 BUPHENYL ..................... 59 BUPIVACAINE HCL-NACL
.................................... 15 buprenorphine ................. 12 BUPRENORPHINE ......... 12 buprenorphine hcl............ 16 buprenorphine hcl-naloxone
hcl ......................... 16, 17 bupropion hcl ................... 23 bupropion hcl er (smoking
det) .............................. 17 bupropion hcl er (sr) ........ 23 bupropion hcl er (xl) ......... 23 BUPROPION HCL ER (XL)
.................................... 23 buspirone hcl ................... 35 butalbital-acetaminophen 12 butalbital-apap ................. 12 butalbital-apap-caff-cod ... 12 butalbital-apap-caffeine ... 12 butalbital-asa-caff-codeine
.................................... 12 butalbital-aspirin-caffeine . 12 BUTISOL SODIUM .......... 85 butorphanol tartrate ......... 12 BUTRANS ....................... 12 BYDUREON .................... 52 BYDUREON BCISE
AUTOINJECTOR ........ 52 BYETTA 10 MCG PEN .... 52 BYETTA 5 MCG PEN ...... 52 BYSTOLIC ...................... 37
BYVALSON ..................... 37 C cabergoline ..................... 63 CABLIVI .......................... 31 CABOMETYX ................. 28 CADUET ......................... 37 CAFERGOT .................... 26 caffeine citrate ................. 43 CAFFEINE-SODIUM
BENZOATE ................. 43 CALAN ............................ 37 CALAN SR ...................... 37 calcipotriene .................... 45 CALCIPOTRIENE ........... 45 calcipotriene-betameth
diprop .......................... 45 calcitonin (salmon) .......... 73 calcitrene......................... 45 calcitriol ..................... 45, 73 calcium acetate (phos
binder) ......................... 60 CALCIUM DISODIUM
VERSENATE .............. 74 CALIFORNIA PEPPER
TREE .......................... 74 CALQUENCE .................. 28 CAMBIA .......................... 11 camila ............................. 65 camrese .......................... 65 camrese lo ...................... 65 CANASA ......................... 72 candesartan cilexetil ........ 37 candesartan cilexetil-hctz 37 CANDIDA ALBICANS
EXTRACT ................... 74 capecitabine .................... 28 CAPEX ............................ 45 CAPLYTA........................ 31 CAPRELSA ..................... 28 captopril .......................... 37 captopril-
hydrochlorothiazide ..... 37 CARAC ........................... 45 CARAFATE ..................... 57 CARBAGLU .................... 55 carbamazepine ............... 21 carbamazepine er ........... 21 CARBAPHEN 12 ............. 80 CARBAPHEN 12 PED..... 80 CARBATROL .................. 21 carbidopa ........................ 30 carbidopa-levodopa ......... 30 carbidopa-levodopa er..... 30 carbidopa-levodopa-
entacapone ................. 30
92
carbinoxamine maleate ... 80 CARDIZEM ..................... 37 CARDIZEM CD ............... 37 CARDIZEM LA ................ 37 CARDURA ...................... 37 CARDURA XL ................. 61 CARETOUCH
LANCING/EJECTOR ... 53 carisoprodol ..................... 85 carisoprodol-aspirin ......... 85 carisoprodol-aspirin-codeine
.................................... 12 CARNITOR ..................... 55 CARNITOR SF ................ 55 CAROSPIR ..................... 37 carteolol hcl ..................... 78 cartia xt ............................ 37 carvedilol ......................... 37 carvedilol phosphate er ... 37 CASODEX ....................... 28 CATAPRES ..................... 37 CATAPRES-TTS-1 .......... 37 CATAPRES-TTS-2 .......... 37 CATAPRES-TTS-3 .......... 37 CATTLE EPITHELIUM .... 74 CAYA .............................. 74 CAYSTON ....................... 84 caziant ............................. 65 CEDAR ELM ................... 74 cefaclor ............................ 17 cefaclor er ....................... 17 cefadroxil ......................... 17 cefazolin sodium .............. 17 cefdinir............................. 17 cefditoren pivoxil .............. 17 cefepime hcl .................... 17 cefixime ........................... 17 cefpodoxime proxetil ........ 18 cefprozil ........................... 18 ceftazidime ...................... 18 CEFTIN ........................... 18 ceftriaxone sodium .......... 18 cefuroxime axetil ............. 18 CELEBREX ..................... 11 celecoxib ......................... 11 CELEXA .......................... 23 CELLCEPT ...................... 70 CELONTIN ...................... 21 cem-urea ......................... 45 CENTANY ....................... 18 cephalexin ....................... 18 CEQUA ........................... 79 CERACADE .................... 45 ceramax .......................... 45 CERDELGA..................... 59
CERVIDIL ....................... 60 CESAMET ....................... 24 cetirizine hcl .................... 80 CETRAXAL ..................... 80 cevimeline hcl .................. 43 CHANTIX ........................ 17 CHANTIX CONTINUING
MONTH PAK ............... 17 CHANTIX STARTING
MONTH PAK ............... 17 chateal ............................ 65 chateal eq ....................... 65 CHEMET ......................... 55 CHENODAL .................... 58 chlordiazepoxide hcl ........ 35 chlordiazepoxide-
amitriptyline ................. 23 chlordiazepoxide-clidinium
.................................... 58 chlorhexidine gluconate ... 43 chloroquine phosphate .... 30 chlorothiazide .................. 37 chlorpromazine hcl .......... 31 chlorpropamide ............... 52 chlorthalidone .................. 37 chlorzoxazone ................. 85 CHOLBAM ...................... 59 cholestyramine ................ 37 cholestyramine light ......... 37 choline fenofibrate ........... 37 choline-mag trisalicylate .. 11 ciclodan ........................... 25 ciclopirox ......................... 25 ciclopirox olamine ............ 25 cilostazol ......................... 31 CILOXAN ........................ 76 CIMDUO ......................... 32 cimetidine ........................ 57 cimetidine hcl .................. 57 CIMZIA ............................ 70 CIMZIA PREFILLED KIT . 70 CIMZIA STARTER KIT .... 70 cinacalcet hcl ................... 73 CINRYZE ........................ 70 CIPRO ............................. 18 CIPRO HC....................... 80 CIPRODEX ..................... 80 ciprofloxacin .................... 18 ciprofloxacin hcl ... 18, 76, 80 ciprofloxacin-ciproflox hcl er
.................................... 18 citalopram hydrobromide . 23 CLADOSPORIUM
CLADOSPORIOIDES .. 74
CLADOSPORIUM SPHAEROSPERMUM 74
claravis ............................ 45 CLARINEX ...................... 80 CLARINEX-D 12 HOUR .. 80 clarithromycin .................. 18 clarithromycin er .............. 18 clemastine fumarate ........ 80 CLENPIQ ........................ 58 CLEOCIN ........................ 18 CLEOCIN PHOSPHATE . 18 CLEOCIN-T ..................... 45 CLIMARA ........................ 65 CLIMARA PRO ............... 65 clindacin etz .................... 45 clindacin-p ....................... 45 CLINDAGEL .................... 45 clindamycin hcl ................ 18 clindamycin palmitate hcl 18 clindamycin phosphate ... 18,
45 CLINDAMYCIN
PHOSPHATE .............. 45 clindamycin phosphate-
benzoyl peroxide ......... 45 clindamycin-tretinoin ....... 45 CLINDESSE .................... 18 clobazam......................... 21 clobetasol prop emollient
base ............................ 45 clobetasol propionate 45, 46 clobetasol propionate e ... 45 clobetasol propionate
emulsion ...................... 45 CLOBEX ......................... 46 CLOBEX SPRAY ............ 46 clocortolone pivalate ....... 46 clocortolone pivalate pump
.................................... 46 clodan ............................. 46 CLODERM ...................... 46 CLODERM PUMP ........... 46 clomipramine hcl ............. 23 clonazepam ..................... 35 clonidine .......................... 37 clonidine hcl .................... 37 clonidine hcl er ................ 42 clopidogrel bisulfate ........ 31 clorazepate dipotassium .. 35 CLORPRES .................... 37 clotrimazole ..................... 25 clotrimazole-betamethasone
.................................... 46 clovique ........................... 55 clozapine ......................... 31
93
CLOZARIL ....................... 31 COARTEM ...................... 30 COCAINE HCL ................ 15 codeine sulfate ................ 12 COGENTIN ..................... 30 COLAZAL ........................ 72 colchicine ........................ 26 COLCHICINE .................. 26 colchicine-probenecid ...... 26 COLCRYS ....................... 26 colesevelam hcl ............... 37 COLESTID ...................... 37 COLESTID FLAVORED .. 37 colestipol hcl .................... 37 colistimethate sodium (cba)
.................................... 18 colocort ............................ 72 COLY-MYCIN M .............. 18 COLY-MYCIN S .............. 80 COLYTE WITH FLAVOR
PACKS ........................ 58 COMBIGAN ..................... 78 COMBIPATCH ................ 65 COMBIVENT RESPIMAT 83 COMBIVIR ...................... 32 COMETRIQ (100 MG
DAILY DOSE) .............. 28 COMETRIQ (140 MG
DAILY DOSE) .............. 28 COMETRIQ (60 MG DAILY
DOSE) ......................... 28 COMPACT SPACE
CHAMBER/LG MASK .. 74 COMPACT SPACE
CHAMBER/MED MASK .................................... 74
COMPACT SPACE CHAMBER/SM MASK . 74
COMPLERA .................... 32 compro ............................ 24 COMTAN ......................... 30 CONCERTA .................... 42 CONDYLOX .................... 46 CONSENSI ..................... 37 constulose ....................... 58 CONTOUR NEXT
CONTROL ................... 53 CONTOUR NEXT TEST .. 53 CONZIP ........................... 12 COPAXONE .................... 42 COPIKTRA ...................... 28 CORDRAN ...................... 46 COREG ........................... 37 COREG CR ..................... 37 coremino ......................... 18
CORGARD ...................... 37 CORLANOR .................... 37 CORTEF ......................... 61 CORTENEMA ................. 72 CORTIFOAM ................... 72 cortisone acetate ............. 61 CORTISPORIN ............... 46 CORZIDE ........................ 37 COSENTYX (300 MG
DOSE) ......................... 70 COSENTYX 150 MG/ML . 70 COSENTYX
SENSOREADY (300 MG) .................................... 70
COSENTYX SENSOREADY PEN ... 70
COSOPT ......................... 78 COSOPT PF ................... 78 COTELLIC....................... 28 COTEMPLA XR-ODT ...... 42 COUMADIN ..................... 20 covaryx ............................ 65 covaryx hs ....................... 65 COZAAR ......................... 37 CREON ........................... 59 CRESEMBA .................... 25 CRESTOR....................... 37 CRINONE ....................... 65 CRIXIVAN ....................... 32 cromolyn sodium . 58, 76, 83 crotan .............................. 30 cryselle-28 ....................... 65 CRYSVITA ...................... 59 CUPRIMINE .................... 60 curity sterile saline ........... 55 CUROSURF .................... 80 CURVULARIA ................. 74 CUTAQUIG ..................... 70 CUTIVATE ...................... 46 CUVITRU ........................ 70 CUVPOSA....................... 58 cyanocobalamin .............. 55 cyclafem 1/35 .................. 65 cyclafem 7/7/7 ................. 65 cyclobenzaprine hcl ......... 85 cyclobenzaprine hcl er ..... 85 CYCLOGYL ..................... 79 CYCLOMYDRIL .............. 79 cyclopentolate hcl ............ 79 cyclophosphamide ........... 28 cycloserine ...................... 27 CYCLOSET ..................... 52 cyclosporine .................... 70 CYCLOSPORINE IN
KLARITY ..................... 79
cyclosporine modified ...... 70 CYMBALTA ..................... 23 cyproheptadine hcl .......... 80 cyred ............................... 65 cyred eq .......................... 65 CYSTADANE .................. 60 CYSTAGON .................... 60 CYSTARAN .................... 79 CYTOMEL ....................... 69 CYTOTEC ....................... 57 CYTOTINE ...................... 74 cytra k crystals ................ 55 D D.H.E. 45 ........................ 26 DAKLINZA ...................... 32 dalfampridine er .............. 42 DALIRESP ...................... 83 danazol ........................... 63 DANTRIUM ..................... 85 dantrolene sodium ........... 85 dapsone .................... 27, 46 DAPSONE ...................... 46 DAPTACEL ..................... 71 DARAPRIM ..................... 30 darifenacin hydrobromide er
.................................... 60 dasetta 1/35 .................... 65 dasetta 7/7/7 ................... 65 DAURISMO ..................... 28 DAXBIA ........................... 18 DAYPRO ......................... 11 daysee ............................ 65 DAYTRANA .................... 42 DDAVP ........................... 63 DDAVP RHINAL TUBE ... 63 DEBACTEROL ................ 43 deblitane ......................... 65 DECADRON ................... 61 deferasirox ...................... 55 deferoxamine mesylate ... 74 dehydrated alcohol .......... 55 DELESTROGEN ............. 65 DELSTRIGO ................... 33 delyla .............................. 65 DELZICOL ...................... 72 DEMADEX ...................... 37 demeclocycline hcl .......... 18 DEMEROL ...................... 12 DEMSER......................... 37 DENAVIR ........................ 33 DEPAKENE .................... 21 DEPAKOTE .................... 21 DEPAKOTE ER............... 21 DEPAKOTE SPRINKLES 21 DEPEN TITRATABS ....... 60
94
DEPO-ESTRADIOL ......... 65 DEPO-MEDROL .............. 61 DEPO-PROVERA ........... 65 DEPO-SUBQ PROVERA
104 .............................. 65 DEPO-TESTOSTERONE 63 DERMACINRX AZENASE
PAK ............................. 80 DERMACINRX
EMPRICAINE .............. 15 DERMACINRX PRIZOPAK
.................................... 15 DERMA-SMOOTHE/FS
BODY .......................... 46 DERMA-SMOOTHE/FS
SCALP ........................ 46 DERMASORB HC ........... 46 DERMOTIC ..................... 80 DESCOVY ....................... 33 DESFERAL ..................... 74 desipramine hcl ............... 23 desloratadine ................... 80 desmopressin ace spray
refrig ............................ 63 desmopressin acetate ..... 63 desmopressin acetate spray
.................................... 63 DESOGEN ...................... 65 desogestrel-ethinyl estradiol
.................................... 65 DESONATE..................... 46 desonide .......................... 46 DESOWEN ...................... 46 desoximetasone .............. 46 DESOXYN ....................... 42 DESVENLAFAXINE ER .. 23 desvenlafaxine succinate er
.................................... 23 DETROL .......................... 60 DETROL LA .................... 60 dexamethasone ............... 61 DEXAMETHASONE (LA) 61 dexamethasone intensol .. 61 dexamethasone sod
phosphate pf ................ 61 dexamethasone sodium
phosphate .............. 62, 76 dexchlorpheniramine
maleate........................ 80 DEXEDRINE ................... 42 DEXERYL ....................... 46 DEXILANT ....................... 57 dexmethylphenidate hcl ... 42 dexmethylphenidate hcl er
.................................... 42
DEXONTO 0.4% ............. 62 DEXPAK 10 DAY ............ 62 DEXPAK 13 DAY ............ 62 DEXPAK 6 DAY .............. 62 DEXPANTHENOL ........... 55 dextroamphetamine sulfate
.................................... 42 dextroamphetamine sulfate
er ................................. 42 DIACOMIT....................... 21 DIASTAT ACUDIAL ......... 21 DIASTAT PEDIATRIC ..... 21 DIATHRIVE GLUCOSE
CONTROL SOLN ........ 53 DIATHRIVE LANCING
DEVICE ....................... 53 diazepam .................. 21, 35 DIAZEPAM ...................... 35 diazepam intensol ........... 35 DIBENZYLINE ................. 37 DICLEGIS ....................... 24 DICLOFENAC EPOLAMINE
.................................... 11 diclofenac potassium ....... 11 diclofenac sodium 11, 46, 76 DICLOFENAC SODIUM .. 11 diclofenac sodium er ....... 11 diclofenac-misoprostol ..... 11 DICLOFONO ................... 11 dicloxacillin sodium .......... 18 dicyclomine hcl ................ 58 didanosine ....................... 33 DIFFERIN ....................... 46 DIFICID ........................... 18 difil-g forte ....................... 83 diflorasone diacetate ....... 46 DIFLUCAN ...................... 25 diflunisal .......................... 11 digitek .............................. 37 digox ............................... 37 digoxin ............................. 37 dihydroergotamine mesylate
.............................. 26, 27 DILANTIN ........................ 21 DILANTIN INFATABS ..... 21 DILATRATE-SR .............. 37 DILAUDID ....................... 12 diltiazem cd ..................... 37 diltiazem hcl .................... 37 diltiazem hcl er ................ 37 diltiazem hcl er beads ...... 37 diltiazem hcl er coated
beads .......................... 37 dilt-xr ............................... 37 dimenhydrinate ................ 24
DIOVAN .......................... 37 DIOVAN HCT .................. 37 DIPENTUM ..................... 72 diphen ............................. 80 diphenhydramine hcl ....... 81 diphenoxylate-atropine .... 58 DIPHTHERIA-TETANUS
TOXOIDS DT .............. 71 DIPROLENE ................... 46 DIPROLENE AF .............. 46 dipyridamole .................... 31 disopyramide phosphate . 37 disulfiram......................... 17 DITROPAN XL ................ 60 DIURIL ............................ 37 divalproex sodium ........... 21 divalproex sodium er ....... 21 DIVIGEL .......................... 65 dofetilide ......................... 37 DOG EPITHELIUM ......... 74 DOLOPHINE ................... 12 donepezil hcl ................... 22 DOPTELET ..................... 36 DORAL ........................... 35 DORYX ........................... 18 DORYX MPC .................. 18 dorzolamide hcl ............... 78 DORZOLAMIDE HCL ...... 78 dorzolamide hcl-timolol mal
.................................... 78 dorzolamide hcl-timolol mal
pf ................................. 78 dotti ................................. 65 DOVATO ......................... 33 DOVONEX ...................... 46 doxazosin mesylate ......... 38 doxepin hcl .......... 23, 46, 85 doxercalciferol ................. 73 doxycycline ..................... 46 doxycycline hyclate ......... 18 DOXYCYCLINE HYCLATE
.................................... 18 doxycycline monohydrate 18 doxylamine-pyridoxine..... 24 D-PENAMINE ................. 60 DRECHSLERA ............... 74 DRISDOL ........................ 55 DRITHO-CREME HP ...... 46 DRIZALMA SPRINKLE ... 23 dronabinol ....................... 24 drospiren-eth estrad-
levomefol ..................... 65 drospirenone-ethinyl
estradiol ...................... 65 DROXIA .......................... 28
95
DRYSOL ......................... 46 DUAC .............................. 46 DUAKLIR PRESSAIR ...... 83 DUAVEE ......................... 65 DUETACT ....................... 52 DUEXIS ........................... 11 DULERA .......................... 83 duloxetine hcl .................. 23 DUOPA ........................... 30 DUPIXENT ...................... 46 DURAGESIC-100 ............ 12 DURAGESIC-12 .............. 12 DURAGESIC-25 .............. 12 DURAGESIC-50 .............. 12 DURAGESIC-75 .............. 12 duraxin ............................ 12 DUREZOL ....................... 76 DURLAZA ....................... 31 DUST MITE MIXED
ALLERGEN EXT ......... 74 dutasteride ...................... 61 dutasteride-tamsulosin hcl
.................................... 61 DUTOPROL .................... 38 DUZALLO ........................ 26 DVORAH ......................... 12 DXEVO 11-DAY .............. 62 DYANAVEL XR ............... 42 DYAZIDE ......................... 38 DYMISTA ........................ 81 DYRENIUM ..................... 38 E E.E.S. 400 ....................... 18 E.E.S. GRANULES.......... 19 EASIVENT ...................... 74 EASYMAX CONTROL ..... 53 EC-NAPROSYN .............. 11 ec-naproxen .................... 11 econazole nitrate ............. 25 ECOZA ............................ 25 EDARBI ........................... 38 EDARBYCLOR ................ 38 EDECRIN ........................ 38 EDLUAR .......................... 85 ed-spaz ........................... 58 EDURANT ....................... 33 eemt ................................ 65 eemt hs ........................... 65 efavirenz .......................... 33 effer-k .............................. 55 EFFER-K ......................... 55 effervescent pot chloride . 55 EFFEXOR XR ................. 23 EFFIENT ......................... 31 EFUDEX .......................... 46
EGRIFTA ........................ 63 EGRIFTA SV ................... 63 EHA................................. 15 ELDEPRYL ..................... 30 ELESTAT ........................ 76 ELESTRIN....................... 65 ELETONE ....................... 46 ELETONE TWINPACK .... 46 eletriptan hydrobromide ... 27 ELIDEL ............................ 46 ELIGARD ........................ 63 ELIMITE .......................... 30 elinest .............................. 65 ELIQUIS .......................... 20 ELIQUIS DVT/PE
STARTER PACK ......... 20 ELIXOPHYLLIN ............... 83 ELLA ............................... 65 ELMIRON ........................ 60 ELOCON ......................... 46 eluryng ............................ 65 EMADINE ........................ 76 EMBEDA ......................... 13 EMBRACE TALK
GLUCOSE CONTROL 53 EMCYT ........................... 28 EMEND ........................... 24 EMEND TRI-PACK .......... 24 EMFLAZA ....................... 26 EMGALITY ...................... 27 EMGALITY (300 MG
DOSE) ......................... 27 emoquette ....................... 65 EMSAM ........................... 23 EMTRIVA ........................ 33 EMULSION SB ................ 46 EMVERM ........................ 30 ENABLEX ....................... 60 enalapril maleate ............. 38 enalapril-
hydrochlorothiazide ..... 38 ENBREL .......................... 70 ENBREL MINI ................. 70 ENBREL SURECLICK .... 70 ENDARI .......................... 74 endocet ........................... 13 ENDOMETRIN ................ 65 ENGERIX-B .................... 71 ENLON ............................ 74 enoxaparin sodium .......... 20 enpresse-28 .................... 65 enskyce ........................... 65 ENSTILAR....................... 46 entacapone ..................... 30 entecavir ......................... 33
ENTEREG ....................... 58 ENTOCORT EC .............. 72 ENTRESTO .................... 38 ENTTY SPRAY EMULSION
.................................... 47 enulose ........................... 58 ENVARSUS XR .............. 70 EPANED ......................... 38 EPCLUSA ....................... 33 EPICERAM ..................... 47 EPICOCCUM .................. 74 EPIDIOLEX ..................... 21 EPIDUO .......................... 47 EPIDUO FORTE ............. 47 EPIFOAM ........................ 47 epinastine hcl .................. 76 epinephrine ............... 38, 83 epinephrine pf ................. 38 EPINEPHRINE
PROFESSIONAL ........ 83 EPINEPHRINESNAP-EMS
.................................... 83 EPINEPHRINESNAP-V ... 83 EPIPEN 2-PAK ............... 83 EPIPEN JR 2-PAK .......... 83 EPISNAP ........................ 83 epitol ............................... 21 EPIVIR ............................ 33 EPIVIR HBV .................... 33 eplerenone ...................... 38 EPOGEN......................... 36 eprosartan mesylate ........ 38 EPZICOM........................ 33 EQUETRO ...................... 21 ergocalciferol ................... 55 ergoloid mesylates .......... 74 ERGOMAR ..................... 27 ergotamine-caffeine ........ 27 ERIVEDGE ..................... 28 ERLEADA ....................... 28 erlotinib hcl ...................... 28 errin ................................. 65 ERTACZO ....................... 25 ery ................................... 47 ERYGEL ......................... 47 ERYPED 200 .................. 19 ERYPED 400 .................. 19 ERY-TAB ........................ 19 ERYTHROCIN STEARATE
.................................... 19 erythromycin ............. 47, 76 erythromycin base ........... 19 erythromycin ethylsuccinate
.................................... 19 ESBRIET......................... 83
96
escitalopram oxalate ........ 23 ESGIC ............................. 13 ESOMEPRAZOLE
STRONTIUM ............... 57 est estrogens-methyltest . 65 est estrogens-methyltest ds
.................................... 65 est estrogens-methyltest hs
.................................... 65 estarylla ........................... 65 estazolam ........................ 35 ESTRACE ....................... 65 estradiol ..................... 65, 66 estradiol valerate ............. 66 estradiol-norethindrone acet
.................................... 66 ESTRING ........................ 66 ESTROGEL ..................... 66 estropipate ...................... 66 ESTROSTEP FE ............. 66 eszopiclone ..................... 85 ethacrynic acid ................ 38 ethambutol hcl ................. 27 ethosuximide ................... 21 ethyl chloride ................... 15 ethynodiol diac-eth estradiol
.................................... 66 etidronate disodium ......... 73 etodolac ........................... 11 etodolac er ...................... 11 etonogestrel-ethinyl
estradiol ....................... 66 etoposide ......................... 28 EUCRISA ........................ 47 EURAX ............................ 30 euthyrox .......................... 69 EVAMIST ........................ 66 EVEKEO ......................... 42 EVEKEO ODT ................. 42 everolimus ....................... 28 EVISTA ........................... 63 EVOCLIN ........................ 47 EVOTAZ .......................... 33 EVOXAC ......................... 43 EVZIO ............................. 17 EXALGO ......................... 13 EXELDERM..................... 25 EXELON .......................... 22 exemestane ..................... 28 EXFORGE ....................... 38 EXFORGE HCT .............. 38 EXJADE .......................... 56 exoderm .......................... 25 EXTAVIA ......................... 42 EXTINA ........................... 25
EZ FLU SHOT-FLUCELVAX QUAD .... 71
EZALLOR SPRINKLE ..... 38 ezetimibe ......................... 38 ezetimibe-simvastatin ...... 38 F FABIOR ........................... 47 falmina ............................ 66 famciclovir ....................... 33 famotidine ....................... 57 FANAPT .......................... 31 FANAPT TITRATION PACK
.................................... 31 FARESTON ..................... 28 FARXIGA ........................ 52 FARYDAK ....................... 28 FASENRA PEN ............... 81 fayosim ............................ 66 FAZACLO ....................... 31 febuxostat ....................... 26 felbamate ........................ 21 FELBATOL ...................... 21 FELDENE ....................... 11 felodipine er ..................... 38 FEM PH .......................... 60 FEMARA ......................... 28 FEMCAP ......................... 74 FEMHRT LOW DOSE ..... 66 FEMRING ....................... 66 femynor ........................... 66 fenofibrate ....................... 38 fenofibrate micronized ..... 38 fenofibric acid .................. 38 FENOGLIDE ................... 38 fenoprofen calcium .......... 11 fenortho ........................... 11 fentanyl ........................... 13 fentanyl citrate ................. 13 FENTANYL CITRATE ..... 13 FENTORA ....................... 13 FERRIPROX ................... 56 FETZIMA ......................... 23 FETZIMA TITRATION ..... 23 FEXMID .......................... 85 FIASP .............................. 54 FIASP FLEXTOUCH ....... 54 FIASP PENFILL .............. 54 FIBRICOR ....................... 38 FINACEA ........................ 47 finasteride ....................... 61 FIORICET ....................... 13 FIORICET/CODEINE ...... 13 FIORINAL ....................... 13 FIORINAL/CODEINE #3 .. 13 FIRAZYR ......................... 70
FIRDAPSE ...................... 74 FIRE ANT........................ 74 FIRST-BACLOFEN ......... 85 FIRST-LANSOPRAZOLE 57 FIRST-MOUTHWASH BLM
.................................... 43 FIRST-OMEPRAZOLE .... 57 FIRST-PROGESTERONE
VGS ............................ 66 FIRST-VANCOMYCIN .... 19 FIRVANQ ........................ 19 flac .................................. 80 FLAGYL .......................... 19 FLAREX .......................... 76 flavoxate hcl .................... 60 flecainide acetate ............ 38 FLECTOR ....................... 11 FLEXICHAMBER ADULT
MASK/SMALL ............. 74 FLEXICHAMBER CHILD
MASK/LARGE ............. 74 FLEXICHAMBER CHILD
MASK/SMALL ............. 74 FLEXIN ........................... 15 FLOLIPID ........................ 38 FLOMAX ......................... 61 FLOVENT DISKUS ......... 83 FLOVENT HFA ............... 83 FLOWTUSS .................... 81 FLOXIN OTIC ................. 80 FLUAD ............................ 71 FLUARIX QUADRIVALENT
.................................... 71 FLUBLOK........................ 71 FLUBLOK QUADRIVALENT
.................................... 71 FLUCELVAX
QUADRIVALENT ........ 71 fluconazole ...................... 25 flucytosine ....................... 25 fludrocortisone acetate .... 62 FLULAVAL
QUADRIVALENT ........ 71 FLUMADINE ................... 33 FLUMIST QUADRIVALENT
.................................... 71 flunisolide ........................ 81 fluocinolone acetonide.... 47,
80 fluocinolone acetonide body
.................................... 47 fluocinolone acetonide scalp
.................................... 47 fluocinonide ..................... 47
97
fluocinonide emulsified base .................................... 47
FLUORABON .................. 56 fluoritab ........................... 56 fluorometholone ............... 76 FLUOROPLEX ................ 47 fluorouracil ....................... 47 FLUOROURACIL ............ 47 fluoxetine hcl ................... 23 fluoxetine hcl (pmdd) ....... 23 fluphenazine decanoate .. 31 fluphenazine hcl .............. 31 FLURA-DROPS ............... 56 flurandrenolide ................. 47 flurazepam hcl ................. 85 flurbiprofen ...................... 11 flurbiprofen sodium .......... 76 flutamide .......................... 28 fluticasone propionate ..... 47 fluticasone-salmeterol ...... 83 FLUTICASONE-
SALMETEROL ............ 83 fluvastatin sodium ............ 38 fluvastatin sodium er ........ 38 FLUVIRIN ........................ 71 fluvoxamine maleate ........ 23 fluvoxamine maleate er ... 23 FLUZONE HIGH-DOSE .. 72 FLUZONE
QUADRIVALENT ......... 72 FML ................................. 76 FML FORTE .................... 76 FML LIQUIFILM ............... 76 FOCALIN ......................... 42 FOCALIN XR ................... 42 folic acid .......................... 56 FOLVITE-D ..................... 56 fondaparinux sodium ....... 20 FORFIVO XL ................... 23 FORTAMET..................... 52 FORTEO ......................... 73 FORTESTA ..................... 63 FORTISCARE CONTROL
.................................... 53 FOSAMAX ....................... 73 FOSAMAX PLUS D ......... 73 fosamprenavir calcium ..... 33 fosinopril sodium ............. 38 fosinopril sodium-hctz ...... 38 FOSRENOL..................... 60 FRAGMIN ........................ 20 FREESTYLE TEST ......... 53 FROVA ............................ 27 frovatriptan succinate ...... 27 FULPHILA ....................... 36
FURADANTIN ................. 19 furosemide ...................... 38 FUSARIUM ..................... 74 FUZEON ......................... 33 fyavolv ............................. 66 FYCOMPA ...................... 21 G gabapentin ...................... 21 GABITRIL ........................ 21 GALAFOLD ..................... 60 galantamine hydrobromide
.................................... 22 galantamine hydrobromide
er ................................. 22 GARDASIL 9 ................... 72 GASTROCROM .............. 58 gatifloxacin ...................... 76 GATIFLOXACIN-
DEXAMETHASONE .... 79 GATTEX .......................... 58 gavilyte-c ......................... 58 gavilyte-g ......................... 58 gavilyte-h ......................... 58 gavilyte-n with flavor pack 58 GEBAUERS PAIN EASE . 15 GEBAUERS SPRAY AND
STRETCH ................... 15 GELFILM ......................... 79 GELNIQUE...................... 60 GELNIQUE PUMP .......... 60 gemfibrozil ....................... 38 GEN7T ............................ 15 GENERESS FE ............... 66 generlac .......................... 58 gengraf ............................ 70 GENICIN VITA-D............. 56 GENOTROPIN ................ 63 GENOTROPIN MINIQUICK
.................................... 64 gentak ............................. 76 gentamicin sulfate ..... 19, 76 GENTEEL LANCING KIT
(BLUE) ........................ 53 GENVOYA ...................... 33 GEODON ........................ 32 GERMAN COCKROACH 74 gianvi............................... 66 GIAZO ............................. 72 GILENYA ........................ 43 GILOTRIF ....................... 28 glatiramer acetate............ 43 glatopa ............................ 43 GLEEVEC ....................... 28 GLEOSTINE .................... 28 glimepiride ....................... 52
glipizide er ....................... 52 glipizide ir ........................ 52 glipizide xl ....................... 52 glipizide-metformin hcl..... 52 GLOPERBA .................... 26 GLUCAGEN DIAGNOSTIC
.................................... 74 GLUCAGEN HYPOKIT ... 54 GLUCAGON EMERGENCY
.................................... 54 GLUCAGON HCL
(DIAGNOSTIC) ........... 74 GLUCOPHAGE ............... 52 GLUCOPHAGE XR ......... 52 GLUCOTROL .................. 52 GLUCOTROL XL ............ 52 GLUCOVANCE ............... 52 GLUMETZA .................... 52 glyburide ......................... 52 glyburide micronized ....... 52 glyburide-metformin ........ 52 GLYCATE ....................... 58 glycopyrrolate .................. 58 GLYCOPYRROLATE ...... 58 glydo ............................... 15 GLYNASE ....................... 52 GLYSET .......................... 52 GLYXAMBI ...................... 52 GOCOVRI ....................... 30 GOJJI CONTROL ........... 53 GOJJI LANCING
DEVICE/CLEAR CAP .. 54 GOLYTELY ..................... 58 GONITRO ....................... 38 GOPRELTO .................... 15 grafco silver nit applicator 47 GRALISE ........................ 43 GRALISE STARTER ....... 43 granisetron hcl ................ 24 GRANIX .......................... 36 GRASTEK ....................... 74 griseofulvin microsize ...... 25 griseofulvin ultramicrosize25 GRIS-PEG ...................... 25 guanfacine hcl ................. 38 guanfacine hcl er ............. 42 GUANIDINE HCL ............ 27 GVOKE PFS ................... 54 GYNAZOLE-1 ................. 25 H HACKBERRY .................. 74 HAEGARDA .................... 70 hailey 1.5/30 .................... 66 hailey 24 fe ...................... 66 halcinonide ...................... 47
98
HALCION ........................ 35 HALDOL .......................... 32 HALDOL DECANOATE ... 32 halobetasol propionate .... 47 HALOBETASOL
PROPIONATE ............. 47 HALOG ............................ 47 haloperidol ....................... 32 haloperidol decanoate ..... 32 haloperidol lactate ........... 32 HALOTIN ......................... 25 HARVONI ........................ 33 HAVRIX ........................... 72 heather ............................ 66 HECTOROL .................... 73 HEMANGEOL ................. 38 HEMLIBRA ...................... 36 hemmorex-hc .................. 72 HEPAGAM B ................... 70 heparin sodium (porcine) . 20 heparin sodium (porcine) pf
.................................... 20 HEPLISAV-B ................... 72 HEPSERA ....................... 33 HETLIOZ ......................... 85 HEXALEN ....................... 28 HIBERIX .......................... 72 HIDEX 6-DAY .................. 62 HIPREX ........................... 19 HIZENTRA ...................... 70 homatropaire ................... 79 homatropine hbr .............. 79 HONEY BEE TREATMENT
.................................... 74 HONEY BEE VENOM ..... 74 HONEY BEE VENOM
PROTEIN .................... 74 HORIZANT ...................... 43 HORSE EPITHELIUM ..... 74 HPR ................................ 47 HPR PLUS ...................... 47 HUMALOG ...................... 54 HUMALOG KWIKPEN ..... 54 HUMALOG MIX 50/50
KWIKPEN .................... 54 HUMALOG MIX 50/50 VIAL
.................................... 54 HUMALOG MIX 75/25
KWIKPEN .................... 54 HUMALOG MIX 75/25 VIAL
.................................... 54 HUMALOG U-100 JUNIOR
KWIKPEN .................... 54 HUMATROPE ................. 64 HUMIRA .......................... 70
HUMIRA PEDIATRIC CROHNS START ........ 70
HUMIRA PEN .................. 70 HUMIRA PEN-CD/UC/HS
STARTER ................... 70 HUMIRA PEN-PS/UV/ADOL
HS START .................. 70 HUMULIN 70/30 KWIKPEN
.................................... 54 HUMULIN 70/30 VIAL ..... 54 HUMULIN N KWIKPEN ... 54 HUMULIN N VIAL............ 55 HUMULIN R U-500
KWIKPEN .................... 55 HUMULIN R U-500 VIAL
(CONCENTRATED) .... 55 HUMULIN R VIAL............ 55 HYCAMTIN ..................... 28 HYCOFENIX ................... 81 hydralazine hcl ................ 38 HYDREA ......................... 28 HYDRO 35 ...................... 47 HYDRO 40 ...................... 47 hydrochlorothiazide ......... 38 hydrocodone bitartrate er 13 hydrocodone polst-cpm
polst er ........................ 81 hydrocodone-
acetaminophen ............ 13 HYDROCODONE-
GUAIFENESIN ............ 81 hydrocodone-homatropine
.................................... 81 hydrocodone-ibuprofen ... 13 hydrocortisone .... 47, 48, 62,
72, 73 hydrocortisone ace-
pramoxine ............. 47, 72 hydrocortisone acetate .... 72 hydrocortisone butyr lipo
base ............................ 47 hydrocortisone butyrate ... 47 hydrocortisone in absorbase
.................................... 48 hydrocortisone valerate ... 48 hydrocortisone-acetic acid
.................................... 80 hydromet ......................... 81 hydromorphone hcl .......... 13 hydromorphone hcl er ..... 13 hydroxychloroquine sulfate
.................................... 30 hydroxyprogesterone
caproate ...................... 66 hydroxyurea .................... 28
hydroxyzine hcl ............... 35 hydroxyzine pamoate ...... 35 HYLAMIX ........................ 48 HYLATOPIC PLUS ......... 48 HYLINATE ...................... 48 hyophen .......................... 60 hyoscyamine sulfate ........ 58 hyoscyamine sulfate er.... 58 hyoscyamine sulfate sl .... 58 hyosyne .......................... 58 HYPERHEP B S/D .......... 70 HYPERRAB .................... 70 HYPERRAB S/D ............. 70 HYPERSAL ..................... 81 HYPERTET S/D .............. 70 HYPOCYN ...................... 79 HYQVIA .......................... 70 HYSINGLA ER ................ 13 HYZAAR ......................... 38 I ibandronate sodium ......... 73 IBRANCE ........................ 28 ibu ................................... 11 ibudone ........................... 13 IBUDONE........................ 13 ibuprofen ......................... 11 icatibant acetate .............. 70 ICLUSIG ......................... 28 IDHIFA ............................ 28 ILEVRO ........................... 76 imatinib mesylate ............ 28 IMBRUVICA .................... 28 imipramine hcl ................. 23 imipramine pamoate ........ 23 imiquimod........................ 48 IMIQUIMOD PUMP ......... 48 IMITREX ......................... 27 IMITREX STATDOSE
REFILL ........................ 27 IMITREX STATDOSE
SYSTEM ..................... 27 IMOGAM RABIES-HT ..... 70 IMPAVIDO ...................... 30 IMPOYZ .......................... 48 IMURAN .......................... 70 IMVEXXY MAINTENANCE
PACK .......................... 66 IMVEXXY STARTER PACK
.................................... 66 INBRIJA .......................... 31 incassia ........................... 66 INCRELEX ...................... 64 INCRUSE ELLIPTA ......... 83 indapamide ..................... 38 INDERAL LA ................... 38
99
INDERAL XL ................... 38 INDIOMIN MB ................. 60 INDOCIN ......................... 11 indomethacin ................... 11 indomethacin er ............... 11 INFANRIX ....................... 72 INFASURF ...................... 81 INGREZZA ...................... 43 INLYTA ............................ 28 INNOPRAN XL ................ 38 INREBIC .......................... 28 INSPRA ........................... 38 INSULIN ASP PROT & ASP
FLEXPEN .................... 55 INSULIN ASPART ........... 55 INSULIN ASPART
FLEXPEN .................... 55 INSULIN ASPART PENFILL
.................................... 55 INSULIN ASPART PROT &
ASPART ...................... 55 INSULIN PEN NEEDLES 55 INSULIN SYRINGES ....... 55 INTELENCE .................... 33 INTERMEZZO ................. 85 INTRAROSA ................... 60 INTRON A ....................... 33 introvale ........................... 66 INTUNIV .......................... 42 INVEGA ........................... 32 INVEGA SUSTENNA ...... 32 INVEGA TRINZA ............. 32 INVELTYS ....................... 76 INVIRASE ....................... 33 INVOKAMET ................... 52 INVOKAMET XR ............. 52 INVOKANA ...................... 52 iodine strong .................... 56 IONSYS ........................... 13 IOPIDINE ........................ 78 IPOL ................................ 72 ipratropium bromide ... 81, 83 ipratropium-albuterol ........ 83 irbesartan ........................ 38 irbesartan-
hydrochlorothiazide ..... 38 IRESSA ........................... 28 ISENTRESS .................... 33 ISENTRESS HD .............. 33 isibloom ........................... 66 isoniazid .......................... 27 isoproterenol hcl .............. 38 ISOPTO CARPINE .......... 78 ISORDIL TITRADOSE ..... 38 isosorbide dinitrate .......... 38
isosorbide dinitrate er ...... 38 isosorbide mononitrate .... 38 isosorbide mononitrate er 38 isotretinoin ....................... 48 isradipine ......................... 38 ISTALOL ......................... 78 ISUPREL ......................... 38 itraconazole ..................... 25 ivermectin .................. 30, 48 J JADENU .......................... 56 JADENU SPRINKLE ....... 56 jaimiess ........................... 66 JAKAFI ............................ 28 JALYN ............................. 61 jantoven .......................... 21 JANUMET ....................... 52 JANUMET XR ................. 52 JANUVIA ......................... 52 JARDIANCE .................... 52 jasmiel ............................. 66 JATENZO ........................ 63 jencycla ........................... 66 JENTADUETO ................ 52 JENTADUETO XR .......... 52 jevantique lo .................... 66 jinteli ................................ 66 jolessa ............................. 66 jolivette ............................ 66 JORNAY PM ................... 42 JUBLIA ............................ 25 juleber ............................. 66 JULUCA .......................... 33 JUNE GRASS POLLEN
STANDARDIZED ........ 75 junel 1.5/30...................... 66 junel 1/20 ........................ 66 junel fe 1.5/30 .................. 66 junel fe 1/20..................... 66 junel fe 24 ....................... 66 JUXTAPID ....................... 38 JYNARQUE ..................... 56 K KADIAN ........................... 13 kaitlib fe ........................... 66 KALETRA ........................ 33 kalliga .............................. 66 KALYDECO ..................... 84 KAMDOY ........................ 48 KAPOK ............................ 75 KAPSPARGO SPRINKLE38 KAPVAY .......................... 42 KARBINAL ER ................ 81 kariva .............................. 66 KATERZIA....................... 39
KAZANO ......................... 52 KEDRAB ......................... 70 k-effervescent ................. 56 KEFLEX .......................... 19 kelnor 1/35 ...................... 66 kelnor 1/50 ...................... 66 KENALOG ................. 48, 62 KEPPRA ......................... 21 KEPPRA XR ................... 21 KERALAC ....................... 48 KERALYT........................ 48 KERYDIN ........................ 25 ketoconazole ................... 25 ketodan ........................... 25 ketoprofen ....................... 11 ketoprofen er ................... 11 ketorolac tromethamine .. 11,
77 KETOROLAC
TROMETHAMINE ....... 11 KEVEYIS......................... 78 KEVZARA ....................... 70 KHEDEZLA ..................... 23 kimidess .......................... 66 KINERET ........................ 70 KINRIX ............................ 72 kionex ............................. 56 KISQALI (200 MG DOSE)28 KISQALI (400 MG DOSE)28 KISQALI (600 MG DOSE)28 KISQALI FEMARA (400 MG
DOSE) ......................... 28 KISQALI FEMARA (600 MG
DOSE) ......................... 28 KISQALI FEMARA(200 MG
DOSE) ......................... 28 KITABIS PAK .................. 84 KIVIK ............................... 48 KLARITY-A ..................... 77 KLARITY-B ..................... 77 KLARITY-L ...................... 77 KLARON ......................... 48 klofensaid ii ..................... 11 KLONOPIN ..................... 35 klor-con ........................... 56 klor-con 10 ...................... 56 klor-con m10 ................... 56 KLOR-CON M15 ............. 56 klor-con m20 ................... 56 klor-con sprinkle .............. 56 klor-con/ef ....................... 56 KOMBIGLYZE XR ........... 52 KORLYM ......................... 64 K-PHOS .......................... 56 K-PHOS NO 2 ................. 56
100
K-PHOS-NEUTRAL ......... 56 k-prime ............................ 56 KRINTAFEL..................... 30 KRISTALOSE .................. 58 K-TAB.............................. 56 kurvelo............................. 66 KUVAN ............................ 60 k-vescent ......................... 56 KYNAMRO ...................... 39 L labetalol hcl ..................... 39 LAC-HYDRIN .................. 48 LACRISERT .................... 79 lactic acid ........................ 48 lactic acid e ..................... 48 lactulose .......................... 58 lactulose encephalopathy 58 LAMICTAL ....................... 21 LAMICTAL ODT .............. 21 LAMICTAL STARTER ..... 21 LAMICTAL XR ................. 21 LAMISIL .......................... 25 lamivudine ....................... 33 lamivudine-zidovudine ..... 33 lamotrigine ....................... 21 lamotrigine er ................... 21 lamotrigine starter kit-blue21 lamotrigine starter kit-green
.................................... 21 lamotrigine starter kit-
orange ......................... 21 LANCETS ........................ 54 LANOXIN ........................ 39 LANOXIN PEDIATRIC ..... 39 lansoprazole .................... 57 lanthanum carbonate ....... 60 LANTUS SOLOSTAR ...... 55 LANTUS U-100 VIAL ....... 55 larin 1.5/30 ...................... 66 larin 1/20 ......................... 66 larin 24 fe ........................ 66 larin fe 1.5/30................... 66 larin fe 1/20 ..................... 66 larissia ............................. 66 LASIX .............................. 39 LASTACAFT.................... 79 latanoprost ...................... 78 LATANOPROST-TIMOLOL
MALEATE .................... 78 LATUDA .......................... 32 layolis fe .......................... 66 LAZANDA ........................ 13 LDO PLUS ...................... 15 LEDIPASVIR-
SOFOSBUVIR ............. 33
leena ............................... 66 leflunomide ...................... 70 LENVIMA (10 MG DAILY
DOSE) ......................... 28 LENVIMA (12 MG DAILY
DOSE) ......................... 28 LENVIMA (14 MG DAILY
DOSE) ......................... 28 LENVIMA (18 MG DAILY
DOSE) ......................... 28 LENVIMA (20 MG DAILY
DOSE) ......................... 28 LENVIMA (24 MG DAILY
DOSE) ......................... 28 LENVIMA (4 MG DAILY
DOSE) ......................... 28 LENVIMA (8 MG DAILY
DOSE) ......................... 28 LESCOL XL ..................... 39 lessina ............................. 66 LETAIRIS ........................ 84 letrozole .......................... 28 leucovorin calcium ........... 29 LEUKERAN ..................... 29 LEUKINE ......................... 36 leuprolide acetate ............ 64 LEVA SET/OCCLUSIVE
DRESSING ................. 15 levalbuterol hcl ................ 83 LEVALBUTEROL HFA .... 83 LEVAQUIN ...................... 19 LEVATIO ......................... 15 LEVBID ........................... 58 LEVEMIR U-100
FLEXTOUCH ............... 55 LEVEMIR U-100 VIAL ..... 55 levetiracetam ................... 21 levetiracetam er ............... 21 levobunolol hcl ................ 78 levocarnitine .................... 56 levocetirizine
dihydrochloride ............ 81 levofloxacin ............... 19, 77 levonest ........................... 66 levonorgest-eth est & eth
est ............................... 66 levonorgest-eth estrad 91-
day .............................. 66 levonorgestrel .................. 66 levonorgestrel-ethinyl estrad
.................................... 67 levonorg-eth estrad triphasic
.................................... 67 levora 0.15/30 (28) .......... 67 levorphanol tartrate ......... 13
levo-t ............................... 69 levothyroxine sodium ...... 69 levothyroxine-liothyronine 69 levoxyl ............................. 69 LEVSIN ........................... 58 LEVSIN/SL ...................... 58 LEVULAN KERASTICK ... 48 LEXAPRO ....................... 23 LEXETTE ........................ 48 LEXIVA ........................... 33 LIALDA ........................... 73 LIBRAX ........................... 59 LIDENZA ......................... 15 LIDO BDK ....................... 15 lidocaine .......................... 15 lidocaine hcl .............. 15, 43 LIDOCAINE HCL ............. 15 lidocaine hcl (pf) .............. 15 lidocaine hcl
urethral/mucosal .......... 15 lidocaine pak ................... 15 lidocaine viscous ............. 43 lidocaine-epinephrine ...... 15 lidocaine-hydrocortisone
ace .............................. 73 LIDOCAINE-
HYDROCORTISONE ACE....................... 48, 73
lidocaine-prilocaine ......... 15 LIDOCAINE-TETRACAINE
.................................... 15 LIDODERM ..................... 15 LIDO-K ............................ 15 LIDOMAR........................ 15 lidopin ............................. 15 LIDOPRIL........................ 15 LIDOPRIL XR .................. 15 LIDO-PRILO CAINE PACK
.................................... 15 LIDORX .......................... 15 LIDO-SORB .................... 15 LIDOTHOL ...................... 15 LIDOTRAL ...................... 15 LIDOTREX ...................... 15 LIDOVIN ......................... 16 LIDOZION ....................... 16 LIDOZOL......................... 16 LILETTA (52 MG) ............ 67 lillow ................................ 67 LINCOCIN ....................... 19 lincomycin hcl .................. 19 lindane ............................ 30 linezolid ........................... 19 LINZESS ......................... 59 liothyronine sodium ......... 69
101
LIPITOR .......................... 39 LIPOFEN ......................... 39 LIPROZONEPAK ............ 16 lisinopril ........................... 39 lisinopril-hydrochlorothiazide
.................................... 39 lithium .............................. 35 lithium carbonate ............. 35 lithium carbonate er ......... 35 LITHOBID ........................ 35 LITHOSTAT..................... 60 LIVALO ............................ 39 LIVIXIL PAK .................... 16 LO LOESTRIN FE ........... 67 LOCOID .......................... 48 LOCOID LIPOCREAM ..... 48 LOCORT 11-DAY ............ 62 LOCORT 7-DAY .............. 62 LODINE ........................... 11 LODOSYN ....................... 31 LOESTRIN 1.5/30 (21) .... 67 LOESTRIN 1/20 (21) ....... 67 LOESTRIN FE 1.5/30 ...... 67 LOESTRIN FE 1/20 ......... 67 lojaimiess ........................ 67 LOKELMA ....................... 56 LOMOTIL ........................ 59 LONHALA MAGNAIR
REFILL KIT .................. 83 LONHALA MAGNAIR
STARTER KIT ............. 83 LONSURF ....................... 29 loperamide hcl ................. 59 LOPID ............................. 39 lopinavir-ritonavir ............. 33 lopreeza .......................... 67 LOPRESSOR .................. 39 LOPRESSOR HCT .......... 39 LOPROX ......................... 25 lorazepam ....................... 35 lorazepam intensol .......... 35 LORBRENA..................... 29 lorcet ............................... 13 lorcet hd .......................... 13 lorcet plus ........................ 13 LORENZA ....................... 16 LORTAB .......................... 13 loryna .............................. 67 LORZONE ....................... 85 losartan potassium .......... 39 losartan potassium-hctz ... 39 LOSEASONIQUE ............ 67 LOTEMAX ....................... 77 LOTEMAX SM ................. 77 LOTENSIN ...................... 39
LOTENSIN HCT .............. 39 loteprednol etabonate ...... 77 LOTREL .......................... 39 LOTRISONE ................... 48 LOTRONEX .................... 59 lovastatin ......................... 39 LOVAZA .......................... 39 LOVENOX ....................... 21 low-ogestrel ..................... 67 loxapine succinate ........... 32 lo-zumandimine ............... 67 LP LITE PAK ................... 16 LUCEMYRA .................... 17 ludent .............................. 56 LULICONAZOLE ............. 25 LUMIGAN ........................ 78 LUNESTA ....................... 85 LUPRON DEPOT (1-
MONTH) ...................... 64 LUPRON DEPOT (3-
MONTH) ...................... 64 LUPRON DEPOT (4-
MONTH) INTRAMUSCULAR KIT 30MG .......................... 64
LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG .......................... 64
LUPRON DEPOT-PED (1-MONTH) ...................... 64
LUPRON DEPOT-PED (3-MONTH) ...................... 64
lutera ............................... 67 LUXIQ ............................. 48 LUZU ............................... 25 LYNPARZA ..................... 29 LYRICA ........................... 43 LYRICA CR ..................... 43 LYSODREN .................... 29 LYSTEDA ........................ 36 lyza ................................. 67 M MACROBID ..................... 19 MACRODANTIN.............. 19 mafenide acetate ............. 19 MAGNESIUM SULFATE . 56 MAKENA ......................... 67 malathion ........................ 30 maprotiline hcl ................. 23 MARINOL ........................ 24 marlissa ........................... 67 MARPLAN ....................... 23 MASK VORTEX .............. 75 MATULANE ..................... 29
matzim la......................... 39 MAVENCLAD (10 TABS) 43 MAVENCLAD (4 TABS) .. 43 MAVENCLAD (5 TABS) .. 43 MAVENCLAD (6 TABS) .. 43 MAVENCLAD (7 TABS) .. 43 MAVENCLAD (8 TABS) .. 43 MAVENCLAD (9 TABS) .. 43 MAVYRET ....................... 33 MAXALT ......................... 27 MAXALT-MLT ................. 27 MAXICOMFORT SYR 27G
X 1/2............................ 55 MAXIDEX ........................ 77 MAXIPIME ...................... 19 MAXITROL ...................... 79 MAXZIDE ........................ 39 MAXZIDE-25 ................... 39 MAYZENT ....................... 43 MAYZENT STARTER
PACK .......................... 43 me/naphos/mb/hyo1 ........ 60 meclizine hcl ................... 24 meclofenamate sodium ... 11 MEDI-PATCH RX ............ 16 MEDOLOR PAK .............. 16 MEDROL......................... 62 medroxyprogesterone
acetate ........................ 67 mefenamic acid ............... 11 MEGACE ES ................... 67 megestrol acetate ............ 67 MEKINIST ....................... 29 MEKTOVI ........................ 29 MELALEUCA .................. 75 melodetta 24 fe ............... 67 meloxicam ....................... 11 melphalan ....................... 29 memantine hcl ................. 22 memantine hcl er ............. 22 MENACTRA .................... 72 MENEST ......................... 67 MENOSTAR .................... 67 MENVEO ........................ 72 meperidine hcl ................. 13 MEPHYTON .................... 56 meprobamate .................. 35 MEPRON ........................ 30 mercaptopurine ............... 29 mesalamine ..................... 73 mesalamine er ................ 73 mesalamine-cleanser ...... 73 mesna ............................. 29 MESNEX ......................... 29 MESTINON ..................... 27
102
metadate er ..................... 42 metaproterenol sulfate ..... 83 metaxall ........................... 85 metaxalone ...................... 85 metformin hcl er ............... 52 metformin hcl er (mod) .... 52 metformin hcl er (osm) ..... 52 metformin hcl ir ................ 52 METFORMIN HCL IR ...... 52 methadone hcl ................. 13 methadone hcl intensol .... 13 methadose ...................... 13 methadose sugar-free ..... 13 methamphetamine hcl ..... 42 methazolamide ................ 78 methenamine hippurate ... 19 methenamine mandelate . 19 methergine ...................... 75 methimazole .................... 69 METHITEST .................... 63 methocarbamol ................ 85 methotrexate ................... 70 methotrexate sodium ....... 70 methotrexate sodium (pf) . 70 methoxsalen .................... 48 methoxsalen rapid ........... 48 methscopolamine bromide
.................................... 59 methyclothiazide .............. 39 methyldopa ...................... 39 methyldopa-
hydrochlorothiazide ..... 39 methylergonovine maleate
.................................... 75 METHYLIN ...................... 42 methylphenidate hcl ......... 42 methylphenidate hcl er .... 42 methylphenidate hcl er (cd)
.................................... 42 methylphenidate hcl er (la)
.................................... 42 methylprednisolone ......... 62 METHYLPREDNISOLONE
ACE-LIDO ................... 62 METHYLPREDNISOLONE
ACETATE .................... 62 methylprednisolone sodium
succ ............................. 62 methyltestosterone .......... 63 metipranolol ..................... 78 metoclopramide hcl ......... 24 metolazone ...................... 39 metopic ............................ 48 metoprolol succinate er ... 39 metoprolol tartrate ........... 39
METOPROLOL-HCTZ ER .................................... 39
metoprolol-hydrochlorothiazide ..... 39
METROCREAM .............. 48 METROGEL .................... 48 METROGEL-VAGINAL.... 19 METROLOTION .............. 48 metronidazole ............ 19, 48 mexiletine hcl .................. 39 MIACALCIN ..................... 73 mibelas 24 fe ................... 67 MICARDIS....................... 39 MICARDIS HCT .............. 39 miconazole 3 ................... 26 MICONAZOLE-ZINC
OXIDE-PETROLAT ..... 26 MICORT-HC .................... 48 microgestin 1.5/30 ........... 67 microgestin 1/20 .............. 67 microgestin fe 1.5/30 ....... 67 microgestin fe 1/20 .......... 67 MICROLET NEXT
LANCING DEVICE ...... 54 MICROZIDE .................... 39 midazolam hcl ................. 35 midodrine hcl ................... 39 MIFEPREX ...................... 56 mifepristone ..................... 56 MIGERGOT ..................... 27 miglitol ............................. 52 miglustat .......................... 60 MIGRANAL ..................... 27 mili .................................. 67 MILLIPRED ..................... 62 MILLIPRED DP ............... 62 MILLIPRED DP 12-DAY .. 62 mimvey ............................ 67 mimvey lo ........................ 67 MIMYX ............................ 48 MINASTRIN 24 FE .......... 67 MINIPRESS .................... 39 minitran ........................... 39 MINIVELLE ..................... 67 MINOCIN ........................ 19 minocycline hcl ................ 19 minocycline hcl er ............ 19 MINOLIRA ....................... 19 minoxidil .......................... 39 MIRAPEX ........................ 31 MIRAPEX ER .................. 31 MIRCERA ....................... 36 MIRCETTE ...................... 67 MIRENA (52 MG) ............ 67 mirtazapine...................... 23
MIRVASO ....................... 48 misoprostol ...................... 57 MITIGARE ....................... 26 MIXED ASPERGILLUS ... 75 MIXED FEATHERS ......... 75 MIXED VESPID VENOM
PROTEIN .................... 75 M-M-R II .......................... 72 MOBIC ............................ 11 modafinil ......................... 85 moderiba ......................... 33 MODERIBA ..................... 33 MODERIBA 1200 DOSE
PACK .......................... 33 MODERIBA 800 DOSE
PACK .......................... 33 moexipril hcl .................... 39 moexipril-
hydrochlorothiazide ..... 39 molindone hcl .................. 32 mometasone furoate . 48, 81 mondoxyne nl .................. 19 mono-linyah .................... 67 mononessa ..................... 67 montelukast sodium ........ 83 MONUROL ...................... 19 morgidox ......................... 19 MORPHABOND ER ........ 13 morphine sulfate.............. 13 morphine sulfate
(concentrate) ............... 13 morphine sulfate er ......... 13 morphine sulfate er beads
.................................... 13 MOTEGRITY ................... 59 MOTOFEN ...................... 59 MOVANTIK ..................... 59 MOVIPREP ..................... 59 MOXATAG ...................... 19 MOXEZA ......................... 77 moxifloxacin hcl ......... 19, 77 MS CONTIN .................... 14 MUCOR .......................... 75 MUCOSITISRX ............... 43 MULPLETA ..................... 36 MULTAQ ......................... 39 mupirocin ........................ 19 mupirocin calcium ........... 19 MYALEPT ....................... 60 MYAMBUTOL ................. 27 MYCOBUTIN .................. 27 mycophenolate mofetil .... 70 mycophenolate sodium ... 70 MYDAYIS ........................ 42 MYFORTIC ..................... 70
103
MYLERAN ....................... 29 myorisan .......................... 48 MYRBETRIQ ................... 60 MYSOLINE ...................... 21 MYTESI ........................... 59 myzilra ............................. 67 N NABI-HB .......................... 70 nabumetone .................... 11 nadolol............................. 39 nadolol-bendroflumethiazide
.................................... 39 nafrinse ........................... 56 nafrinse drops .................. 56 naftifine hcl ...................... 26 NAFTIN ........................... 26 NALFON .......................... 11 NALOCET ....................... 14 naloxone hcl .................... 17 NALOXONE HCL ............ 17 naltrexone hcl .................. 17 NAMENDA ...................... 22 NAMENDA TITRATION
PAK ............................. 23 NAMENDA XR ................ 23 NAMENDA XR TITRATION
PACK .......................... 23 NAMZARIC ..................... 23 NAPRELAN ..................... 11 NAPROSYN .................... 11 naproxen ......................... 11 naproxen dr ..................... 11 naproxen sodium ............. 11 naproxen sodium er ......... 11 naratriptan hcl .................. 27 NARCAN ......................... 17 NARDIL ........................... 23 NASONEX ....................... 81 NATACYN ....................... 77 NATAZIA ......................... 67 nateglinide ....................... 52 NATESTO ....................... 63 NATPARA ....................... 73 NATROBA ....................... 30 NATURE-THROID ........... 69 NAYZILAM ...................... 21 NEBUPENT ..................... 30 nebusal ............................ 81 NEBUSAL ....................... 81 necon 0.5/35 (28) ............ 67 necon 7/7/7 ..................... 67 nefazodone hcl ................ 23 NEMBUTAL ..................... 21 NEOCERA ...................... 48 neomycin sulfate ............. 19
neomycin-bacitracin zn-polymyx ....................... 79
neomycin-polymyxin b gu 19 neomycin-polymyxin-
dexameth .................... 79 neomycin-polymyxin-
gramicidin .................... 79 neomycin-polymyxin-hc .. 79,
80 neo-polycin ...................... 79 neo-polycin hc ................. 79 NEORAL ......................... 70 NEOSALUS ..................... 48 NEOSALUS CP ............... 48 NEOSPORIN ................... 79 NEO-SYNALAR .............. 48 NEPTAZANE ................... 78 NERLYNX ....................... 29 NESINA ........................... 53 neuac .............................. 48 NEULASTA ..................... 36 NEULASTA ONPRO ....... 36 NEUPOGEN .................... 36 NEUPRO ......................... 31 NEURONTIN ................... 21 NEUTRASAL ................... 43 NEVANAC ....................... 77 nevirapine ....................... 33 nevirapine er ................... 33 NEXAVAR ....................... 29 NEXIUM .......................... 57 niacin (antihyperlipidemic)
.................................... 39 niacin er
(antihyperlipidemic) ..... 39 niacor .............................. 39 NIASPAN ........................ 39 nicardipine hcl ................. 39 NICORETTE ................... 17 nicotine polacrilex ............ 17 nicotine step 1 ................. 17 nicotine step 2 ................. 17 nicotine step 3 ................. 17 nifedipine ......................... 39 nifedipine er ..................... 39 nifedipine er osmotic
release ........................ 39 nikki ................................. 67 NILANDRON ................... 29 nilutamide ........................ 29 nimodipine ....................... 39 NINLARO ........................ 29 nisoldipine er ................... 39 nitisinone ......................... 60 NITRO-BID ...................... 39
NITRO-DUR .................... 40 nitrofurantoin ................... 19 nitrofurantoin macrocrystal
.................................... 19 nitrofurantoin monohydrate
macrocrystals .............. 19 nitroglycerin ..................... 40 nitroglycerin er ................ 40 NITROLINGUAL .............. 40 NITROMIST .................... 40 NITROSTAT .................... 40 nitro-time ......................... 40 NITYR ............................. 60 NIVATOPIC PLUS .......... 48 NIVESTYM ...................... 36 nizatidine ......................... 57 NIZORAL ........................ 26 NOCDURNA ................... 64 NOCTIVA ........................ 64 nolix ................................ 48 nora-be ........................... 67 NORCO .......................... 14 NORDITROPIN FLEXPRO
.................................... 64 norethin ace-eth estrad-fe 67 norethindrone .................. 68 norethindrone acetate ..... 67 norethindrone acet-ethinyl
est ......................... 67, 68 norethindrone-eth estradiol
.................................... 68 norethin-eth estradiol-fe .. 68 NORGESIC FORTE ........ 85 norgestimate-eth estradiol
.................................... 68 norgestimate-ethinyl
estradiol triphasic ........ 68 NORITATE ...................... 48 norlyda ............................ 68 norlyroc ........................... 68 NORPACE ...................... 40 NORPACE CR ................ 40 NORPRAMIN .................. 23 NORTHERA .................... 40 nortrel 0.5/35 (28) ............ 68 nortrel 1/35 (21)............... 68 nortrel 1/35 (28)............... 68 nortrel 7/7/7 ..................... 68 nortriptyline hcl ................ 23 nortuss-ex ....................... 81 NORVASC ...................... 40 NORVIR .......................... 33 NOURIANZ ..................... 31 NOVACORT .................... 48
104
NOVOFINE AUTOCOVER PEN NEEDLE .............. 55
NOVOFINE PEN NEEDLE .................................... 55
NOVOFINE PLUS PEN NEEDLE ...................... 55
NOVOLIN 70/30 RELION 55 NOVOLIN 70/30 VIAL ...... 55 NOVOLIN N RELION ...... 55 NOVOLIN N VIAL ............ 55 NOVOLIN R RELION ...... 55 NOVOLIN R VIAL ............ 55 NOVOLOG FLEXPEN ..... 55 NOVOLOG MIX 70/30
FLEXPEN .................... 55 NOVOLOG MIX 70/30 VIAL
.................................... 55 NOVOLOG PENFILL ....... 55 NOVOLOG U-100 VIAL ... 55 NOVOTWIST PEN
NEEDLE ...................... 55 NOXAFIL ......................... 26 np thyroid ........................ 69 NUBEQA ......................... 29 NUCALA .......................... 81 NUCORT ......................... 48 NUCYNTA ....................... 14 NUCYNTA ER ................. 14 NUEDEXTA ..................... 43 nulev ............................... 59 NULYTELY WITH FLAVOR
PACKS ........................ 59 NUMBONEX.................... 16 NUMOISYN ..................... 43 NUPLAZID ...................... 32 NUTROPIN AQ NUSPIN 10
.................................... 64 NUTROPIN AQ NUSPIN 20
.................................... 64 NUTROPIN AQ NUSPIN 5
.................................... 64 NUVAKAAN..................... 16 NUVARING ..................... 68 NUVESSA ....................... 19 NUVIGIL .......................... 85 NUZYRA ......................... 19 nyamyc ............................ 26 NYMALIZE ...................... 40 nystatin ............................ 26 nystatin-triamcinolone ...... 26 nystop.............................. 26 O OBREDON ...................... 81 OCALIVA ......................... 60 ocella ............................... 68
octreotide acetate ............ 64 OCUFLOX ....................... 77 ODACTRA....................... 75 ODEFSEY ....................... 33 ODOMZO ........................ 29 OFEV .............................. 83 ofloxacin .............. 19, 77, 80 ogestrel ........................... 68 okebo .............................. 19 olanzapine ....................... 32 olanzapine-fluoxetine hcl . 23 OLIVE TREE ................... 75 olmesartan medoxomil .... 40 olmesartan medoxomil-hctz
.................................... 40 olmesartan-amlodipine-hctz
.................................... 40 olopatadine hcl .......... 77, 81 OLUMIANT...................... 70 OLUX .............................. 49 OLUX-E ........................... 49 OLYSIO ........................... 33 OMECLAMOX-PAK ......... 59 omega-3-acid ethyl esters40 omeprazole ..................... 57 OMEPRAZOLE+SYRSPEN
D SF ALKA .................. 57 omeprazole-sodium
bicarbonate ................. 57 OMNARIS ....................... 81 OMNIPOD 5 PACK ......... 75 OMNIPOD DASH 5 PACK
.................................... 75 OMNIPOD DASH SYSTEM
.................................... 54 OMNIPOD STARTER ..... 54 OMNIPRED ..................... 77 OMNITROPE .................. 64 ondansetron hcl ............... 24 ONDANSETRON HCL .... 24 ondansetron odt .............. 24 ONE TOUCH VERIO KIT
W/DEVICE .................. 54 ONETOUCH DELICA
LANCING DEV ............ 54 ONETOUCH DELICA PLUS
LANCING .................... 54 ONETOUCH ULTRA BLUE
TEST STRIPS ............. 54 ONEXTON ...................... 49 ONFI ............................... 21 ONGLYZA ....................... 53 ONMEL ........................... 26 OPANA ........................... 14 OPANA ER...................... 14
opium .............................. 59 OPSUMIT........................ 84 ORACEA ......................... 49 ORACIT .......................... 56 ORALAIR ........................ 75 ORALAIR ADULT SAMPLE
KIT .............................. 75 ORALAIR ADULT
STARTER PACK ......... 75 ORALAIR CHILDRENS
SAMPLE KIT ............... 75 ORALAIR CHILDRENS
STARTER PACK ......... 75 oralone ............................ 43 ORAP .............................. 32 ORAPRED ODT .............. 62 ORAVIG .......................... 26 ORENCIA........................ 70 ORENCIA CLICKJECT ... 70 ORENITRAM ............ 84, 85 ORFADIN ........................ 60 ORILISSA ....................... 64 ORKAMBI ....................... 84 orphenadrine citrate ........ 85 orphenadrine citrate er .... 85 orphenadrine-aspirin-
caffeine ....................... 85 ORPHENGESIC FORTE . 85 orsythia ........................... 68 ORTHO MICRONOR ...... 68 ORTHO TRI-CYCLEN (28)
.................................... 68 ORTHO TRI-CYCLEN LO68 ORTHO-CYCLEN (28) .... 68 ORTHO-NOVUM 1/35 (28)
.................................... 68 ORTHO-NOVUM 7/7/7 (28)
.................................... 68 oscimin ............................ 59 oscimin sr ........................ 59 oseltamivir phosphate ..... 33 OSENI ............................. 53 OSMOLEX ER ................ 31 OSMOPREP ................... 59 OSPHENA ...................... 63 OTEZLA .......................... 70 OTOVEL ......................... 80 OTREXUP ....................... 71 OVACE PLUS ................. 49 OVACE PLUS WASH...... 49 OVACE WASH ................ 49 OVIDE ............................. 30 OXANDRIN ..................... 63 oxandrolone .................... 63 oxaprozin ........................ 11
105
OXAYDO ......................... 14 oxazepam ........................ 35 OXBRYTA ....................... 75 oxcarbazepine ................. 22 OXERVATE ..................... 79 oxiconazole nitrate........... 26 OXISTAT ......................... 26 OXSORALEN ULTRA ..... 49 OXTELLAR XR ................ 22 oxybutynin chloride .......... 60 oxybutynin chloride er ...... 60 oxycodone hcl ................. 14 OXYCODONE HCL ER ... 14 oxycodone-acetaminophen
.................................... 14 oxycodone-aspirin ........... 14 oxycodone-ibuprofen ....... 14 OXYCONTIN ................... 14 oxymorphone hcl ............. 14 oxymorphone hcl er ......... 14 OXYTROL ....................... 60 OZEMPIC ........................ 53 OZOBAX ......................... 85 P pacerone ......................... 40 paliperidone er ................. 32 PAMELOR ....................... 23 PANCREAZE .................. 60 PANDA MASK LARGE .... 75 PANDA MASK MEDIUM.. 75 PANDA MASK SMALL .... 75 PANDEL .......................... 49 panlor .............................. 14 PANRETIN ...................... 29 pantoprazole sodium ....... 57 papaverine hcl ................. 40 PARAGARD
INTRAUTERINE COPPER ..................... 68
paregoric ......................... 59 paricalcitol ....................... 73 PARLODEL ..................... 31 PARNATE ....................... 23 paroex ............................. 43 paromomycin sulfate ....... 19 paroxetine hcl .................. 23 paroxetine hcl er .............. 23 paroxetine mesylate ........ 23 PASER ............................ 27 PATADAY ....................... 77 PATANASE ..................... 81 PATANOL ....................... 77 PAXIL .............................. 24 PAXIL CR ........................ 23 PAZEO ............................ 77
PCE................................. 19 PEDIAPRED ................... 62 PEDIARIX ....................... 72 PEDIATRIC PANDA MASK
.................................... 75 PEDVAX HIB ................... 72 peg 3350/electrolytes ...... 59 peg 3350-kcl-na bicarb-nacl
.................................... 59 peg-3350/electrolytes ...... 59 PEGANONE .................... 22 PEGASYS ....................... 33 PEGASYS PROCLICK .... 33 PEGINTRON ................... 33 peg-prep .......................... 59 pegylax ............................ 59 penicillamine ................... 60 penicillin v potassium ...... 19 PENICILLIUM NOTATUM75 PENLAC .......................... 26 PENLEN .......................... 49 PENNSAID ...................... 11 PENTACEL ..................... 72 PENTAM ......................... 30 pentamidine isethionate... 30 PENTASA ....................... 73 pentazocine-naloxone hcl 14 pentobarbital sodium ....... 22 pentoxifylline er ............... 40 PEPCID ........................... 57 PERCOCET .................... 14 PERENNIAL RYE GRASS
POLLEN ...................... 75 PERFOROMIST .............. 83 perindopril erbumine ........ 40 periogard ......................... 43 PERMAVAN .................... 16 permethrin ....................... 30 perphenazine .................. 24 perphenazine-amitriptyline
.................................... 24 PERSERIS ...................... 32 PERTZYE ....................... 60 PEXEVA .......................... 24 phenadoz ........................ 81 phenazo .......................... 60 phenazopyridine hcl ........ 60 phenelzine sulfate ........... 24 PHENERGAN ................. 81 phenobarbital .................. 22 phenobarbital sodium ...... 22 phenoxybenzamine hcl .... 40 phentolamine mesylate ... 40 phenylephrine hcl ............ 79 PHENYTEK ..................... 22
phenytoin ........................ 22 phenytoin infatabs ........... 22 phenytoin sodium ............ 22 phenytoin sodium extended
.................................... 22 philith .............................. 68 PHLAG SPRAY ............... 49 PHOSLYRA .................... 60 phospha 250 neutral ....... 56 phosphasal ...................... 60 PHOSPHOLINE IODIDE . 78 phosphorous ................... 56 phospho-trin 250 neutral . 56 phrenilin forte .................. 14 phytonadione .................. 56 PICATO .......................... 49 PIFELTRO ...................... 33 pilocarpine hcl ........... 44, 78 pimecrolimus ................... 49 PIMECROLIMUS ............ 49 pimozide ......................... 32 pimtrea ............................ 68 pindolol ........................... 40 pioglitazone hcl ............... 53 pioglitazone hcl-glimepiride
.................................... 53 pioglitazone hcl-metformin
hcl ............................... 53 PIQRAY (200 MG DAILY
DOSE) ......................... 29 PIQRAY (250 MG DAILY
DOSE) ......................... 29 PIQRAY (300 MG DAILY
DOSE) ......................... 29 pirmella 1/35 ................... 68 pirmella 7/7/7 .................. 68 piroxicam......................... 11 PLAN B ONE-STEP ........ 68 PLAQUENIL .................... 30 PLAVIX ........................... 31 PLEGRIDY ...................... 43 PLEGRIDY STARTER
PACK .......................... 43 PLENVU ......................... 59 PLEXION ........................ 49 PLEXION CLEANSER .... 49 PLEXION CLEANSING
CLOTH ........................ 49 PNEUMOVAX 23 ............ 72 pocket spacer .................. 75 podocon .......................... 49 podofilox ......................... 49 polycin ............................. 79 polyethylene glycol 3350 . 59 polymyxin b-trimethoprim 79
106
POLYTRIM ...................... 79 POMALYST ..................... 29 portia-28 .......................... 68 PORT-PREP ................... 16 posaconazole .................. 26 pot bicarb-pot chloride ..... 56 potassium bicarbonate .... 56 potassium chloride........... 56 potassium chloride crys er
.................................... 56 potassium chloride er ...... 56 potassium citrate er ......... 56 potassium citrate-citric acid
.................................... 56 POVIDONE-IODINE ........ 77 PRADAXA ....................... 21 PRALUENT ..................... 40 pramipexole dihydrochloride
.................................... 31 pramipexole dihydrochloride
er ................................. 31 PRAMOSONE ................. 49 PRAMOTIC ..................... 80 pramox ............................ 49 PRANDIN ........................ 53 prasugrel hcl .................... 31 PRAVACHOL .................. 40 pravastatin sodium .......... 40 praziquantel ..................... 30 prazosin hcl ..................... 40 PRECOSE ....................... 53 PRED FORTE ................. 77 PRED MILD ..................... 77 PRED-G .......................... 79 PRED-G S.O.P. ............... 79 prednicarbate .................. 49 PREDNISOL ACE-
MOXIFLOX-BROMFEN .................................... 77
prednisolone .................... 62 prednisolone acetate ....... 77 prednisolone acetate p-f .. 77 PREDNISOLONE
ACETATE-NEPAFENAC .................................... 79
PREDNISOLONE ACET-MOXIFLOXACIN ......... 79
prednisolone sodium phosphate .............. 62, 77
PREDNISOLONE-BROMFENAC.............. 79
PREDNISOLONE-GATIFLOXACIN .......... 79
PREDNISOLONE-MOXIFLOXACIN ......... 79
PREDNISOLON-GATIFLOX-BROMFENAC ............. 79
PREDNISOLON-MOXIFLOX-BROMFENAC ....... 77, 79
PREDNISOLON-MOXIFLOX-KETOROLAC .............. 77
PREDNISOLON-MOXIFLOX-NEPAFENAC .............. 77
prednisone ...................... 62 prednisone intensol ......... 62 PREFEST ....................... 68 pregabalin ....................... 43 PREMARIN ..................... 68 premium lidocaine ........... 16 PREMPHASE .................. 68 PREMPRO ...................... 68 PREPIDIL ........................ 60 PREPOPIK ...................... 59 PRESERA ....................... 49 PRESTALIA .................... 40 PREVACID ...................... 57 PREVACID SOLUTAB .... 57 prevalite .......................... 40 preventeza ...................... 68 previfem .......................... 68 PREVNAR 13 .................. 72 PREVPAC ....................... 59 PREVYMIS...................... 33 PREZCOBIX ................... 33 PREZISTA....................... 33 PRIFTIN .......................... 27 PRIKAAN ........................ 16 PRIKAAN LITE ................ 16 PRILOLID ........................ 16 PRILOSEC ...................... 57 PRILOVIX ....................... 16 PRILOVIX LITE ............... 16 PRILOVIX PLUS ............. 16 prilovix ultralite ................ 16 prilovix ultralite plus ......... 16 PRILOXX LP ................... 16 primaquine phosphate ..... 30 primidone ........................ 22 PRIMLEV ........................ 14 PRIMSOL ........................ 19 PRINIVIL ......................... 40 PRISTIQ .......................... 24 PRO COMFORT SPACER
ADULT ........................ 75 PRO COMFORT SPACER
CHILD ......................... 75
PROAIR DIGIHALER ...... 83 PROAIR HFA .................. 83 PROAIR RESPICLICK .... 83 probenecid ...................... 26 PROBICHEW .................. 59 procainamide hcl ............. 40 PROCARDIA ................... 40 PROCARDIA XL ............. 40 PROCARE
SPACER/ADULT MASK .................................... 75
PROCARE SPACER/CHILD MASK .......................... 75
PROCENTRA ................. 42 prochlorperazine ............. 24 prochlorperazine edisylate
.................................... 25 prochlorperazine maleate 25 PROCORT ...................... 73 PROCRIT ........................ 36 PROCTOCORT............... 73 PROCTOFOAM HC ........ 73 procto-med hc ................. 73 procto-pak ....................... 73 proctosol hc ..................... 73 proctozone-hc ................. 73 PROCYSBI ..................... 60 profeno ............................ 11 progesterone ................... 68 progesterone micronized . 68 PROGLYCEM ................. 54 PROGRAF ...................... 71 PROLENSA .................... 77 PROMACTA .................... 36 promethazine hcl ............. 81 promethazine vc plain ..... 81 promethazine vc/codeine 81 promethazine-codeine ..... 81 promethazine-dm ............ 81 promethazine-phenyleph-
codeine ....................... 81 promethazine-
phenylephrine .............. 81 promethegan ................... 81 PROMETRIUM................ 68 propafenone hcl .............. 40 propafenone hcl er .......... 40 propantheline bromide..... 59 proparacaine hcl.............. 79 propranolol hcl ................ 40 propranolol hcl er ............ 40 propranolol-hctz .............. 40 propylthiouracil ................ 69 PROQUAD ...................... 72 PROSCAR ...................... 61
107
PROSTIN E2 ................... 60 PROSTIN VR .................. 40 PROTONIX ..................... 57 PROTOPIC ..................... 49 protriptyline hcl ................ 24 PROVENTIL HFA ............ 83 PROVERA ....................... 68 PROVIGIL ....................... 86 PROZAC ......................... 24 PRUCLAIR ...................... 49 PRUDOXIN ..................... 49 PRUMYX ......................... 49 pseudoeph-chlorphen-
hydrocod ...................... 81 pseudoephedrine-
bromphen-dm .............. 81 PSORCON ...................... 49 PULMICORT FLEXHALER
.................................... 83 PULMICORT
SUSPENSION ............. 83 pulmosal .......................... 81 PULMOZYME .................. 84 PURE COMFORT
ALCOHOL PREP ......... 75 PURE COMFORT PEN
NEEDLE ...................... 55 PURIXAN ........................ 29 PYLERA .......................... 59 pyrazinamide ................... 27 PYRIDIUM ....................... 60 pyridostigmine bromide ... 27 pyridostigmine bromide er27 PYROGALLIC ACID ........ 49 Q QBRELIS ......................... 40 QBREXZA ....................... 49 QMIIZ ODT ...................... 12 QNASL ............................ 81 QNASL CHILDRENS ....... 81 QTERN ............................ 53 QUADRACEL .................. 72 QUALAQUIN ................... 30 QUARTETTE ................... 68 quasense ......................... 68 quazepam ....................... 35 QUDEXY XR ................... 22 QUEEN PALM ................. 75 QUESTRAN .................... 40 QUESTRAN LIGHT ......... 40 quetiapine fumarate ......... 32 quetiapine fumarate er ..... 32 QUILLICHEW ER ............ 42 QUILLIVANT XR ............. 42 quinapril hcl ..................... 40
quinapril-hydrochlorothiazide ..... 40
QUINIDINE GLUCONATE .................................... 40
quinidine gluconate er ..... 40 quinidine sulfate .............. 40 quinine sulfate ................. 30 QVAR .............................. 84 QVAR REDIHALER ......... 84 R RABBIT EPITHELIUM ..... 75 rabeprazole sodium ......... 58 RAGWITEK ..................... 75 rajani ............................... 68 raloxifene hcl ................... 63 ramelteon ........................ 86 ramipril ............................ 40 RANEXA ......................... 40 ranitidine hcl .................... 58 ranolazine er ................... 40 RAPAFLO ....................... 61 RAPAMUNE .................... 71 rasagiline mesylate .......... 31 RASUVO ......................... 71 RAVICTI .......................... 60 RAYALDEE ..................... 73 RAYOS ........................... 62 RAZADYNE ..................... 23 RAZADYNE ER ............... 23 rea lo 40 .......................... 49 REBETOL ....................... 34 REBIF ............................. 43 REBIF REBIDOSE .......... 43 REBIF REBIDOSE
TITRATION PACK ....... 43 REBIF TITRATION PACK43 reclipsen .......................... 68 RECOMBIVAX HB .......... 72 RECTIV ........................... 40 RED MAPLE ................... 75 REGLAN ......................... 25 RELADOR PAK ............... 16 RELADOR PAK PLUS .... 16 RELAFEN DS .................. 12 RELAGARD .................... 60 RELEEVIA....................... 16 RELEEVIA MC ................ 16 RELEEVIA ML ................. 16 RELENZA DISKHALER... 34 relexxii ............................. 42 RELISTOR ...................... 59 RELPAX .......................... 27 REMATEX ....................... 14 REMAXAZON ................. 16 REMERON ...................... 24
REMERON SOLTAB ....... 24 RENACIDIN .................... 60 RENAGEL ....................... 61 RENOVO ........................ 16 RENVELA ....................... 61 repaglinide ...................... 53 repaglinide-metformin hcl 53 REPATHA ....................... 40 REPATHA PUSHTRONEX
SYSTEM ..................... 40 REPATHA SURECLICK .. 41 REQUIP .......................... 31 REQUIP XL ..................... 31 RESCRIPTOR ................ 34 RESCULA ....................... 78 RESORCINOL-SULFUR . 49 RESTASIS ...................... 79 RESTASIS MULTIDOSE . 79 RESTORIL ...................... 86 RETACRIT ...................... 36 RETIN-A ......................... 49 RETIN-A MICRO GEL 0.04
%, 0.1 % ...................... 49 RETIN-A MICRO PUMP .. 49 RETROVIR ..................... 34 REVATIO ........................ 85 REVLIMID ....................... 29 REXAPHENAC ............... 12 REXULTI ......................... 32 REYATAZ ....................... 34 RHIZOPUS ..................... 75 RHOFADE ...................... 49 RHOPHYLAC .................. 71 RHOPRESSA ................. 78 ribasphere ....................... 34 RIBASPHERE ................. 34 RIBASPHERE RIBAPAK . 34 ribavirin ........................... 34 RIDAURA ........................ 71 rifabutin ........................... 27 RIFADIN ......................... 27 RIFAMATE ...................... 27 rifampin ........................... 27 RIFATER......................... 27 RILUTEK ......................... 43 riluzole ............................ 43 rimantadine hcl ................ 34 RIMSO-50 ....................... 61 RINVOQ .......................... 71 RIOMET .......................... 53 RIOMET ER .................... 53 risedronate sodium .......... 73 RISPERDAL .................... 32 RISPERDAL CONSTA .... 32 RISPERDAL M-TAB ........ 32
108
risperidone ...................... 32 risperidone m-tab ............ 32 RITALIN .......................... 42 RITALIN LA ..................... 42 ritonavir ........................... 34 rivastigmine ..................... 23 rivastigmine tartrate ......... 23 rivelsa .............................. 68 rizatriptan benzoate ......... 27 ROBAXIN ........................ 85 ROBAXIN-750 ................. 85 ROBINUL ........................ 59 ROBINUL-FORTE ........... 59 ROCALTROL .................. 73 ROCKLATAN .................. 78 ropinirole hcl .................... 31 ropinirole hcl er ................ 31 ROPIVACAINE HCL ........ 16 rosadan ........................... 49 ROSADAN ...................... 49 rosanil cleanser ............... 49 rosuvastatin calcium ........ 41 ROTARIX ........................ 72 ROTATEQ ....................... 72 ROWASA ........................ 73 roweepra ......................... 22 roweepra xr ..................... 22 ROXICODONE ................ 14 ROZEREM ...................... 86 ROZLYTREK ................... 29 RUBRACA ....................... 29 RUCONEST .................... 71 RUZURGI ........................ 75 RYBELSUS ..................... 53 RYCLORA ....................... 81 RYDAPT .......................... 29 RYNODERM ................... 49 RYTARY .......................... 31 RYTHMOL SR ................. 41 ryvent .............................. 81 S SABRIL ........................... 22 SACCHAROMYCES
CEREVISIAE ............... 75 SAFYRAL ........................ 68 SAIZEN ........................... 64 SAIZEN CLICK.EASY ..... 64 SAIZENPREP .................. 64 SALAGEN ....................... 44 SALEX............................. 49 salicylic acid .................... 49 salicylic acid wart remover
.................................... 50 salimez ............................ 50 SALIMEZ FORTE ............ 50
salisol forte ...................... 50 SALITECH....................... 50 salitech forte .................... 50 SALIVAMAX .................... 44 salsalate .......................... 12 SALVAX .......................... 50 SAMSCA ......................... 56 SANCUSO ...................... 25 SANDIMMUNE ................ 71 SANDOSTATIN ............... 64 SANDOSTATIN LAR
DEPOT ........................ 64 SANTYL .......................... 50 SAPHRIS ........................ 32 SARAFEM ....................... 24 SAVAYSA ....................... 21 SAVELLA ........................ 43 SAVELLA TITRATION
PACK .......................... 43 scopolamine .................... 25 SEASONIQUE ................ 68 seb-prev wash ................. 50 SECONAL ....................... 86 SECUADO ...................... 32 SEEBRI NEOHALER ...... 84 SEGLUROMET ............... 53 selegiline hcl .................... 31 selenium sulfide .............. 50 SELZENTRY ................... 34 SEMPREX-D ................... 81 SENSIPAR ...................... 73 SEREVENT DISKUS ....... 84 SERNIVO ........................ 50 SEROQUEL .................... 32 SEROQUEL XR .............. 32 SEROSTIM ..................... 59 sertraline hcl .................... 24 setlakin ............................ 68 sevelamer carbonate ....... 61 sevelamer hcl .................. 61 SEYSARA ....................... 19 SFROWASA .................... 73 sharobel .......................... 68 SHINGRIX ....................... 72 SIGNIFOR ....................... 64 SIKLOS ........................... 29 sildenafil citrate ............... 85 SILENOR ........................ 86 SILIQ ............................... 71 SILMANIX PAIN
RELIEIVING ................ 50 silodosin .......................... 61 SILVADENE .................... 19 silver nitrate ..................... 20 silver sulfadiazine ............ 20
SIMBRINZA .................... 78 simliya ............................. 68 simpesse ......................... 68 SIMPONI ......................... 71 simvastatin ...................... 41 SIMVASTATIN ................ 41 SINEMET ........................ 31 SINEMET CR .................. 31 SINGULAIR ..................... 84 sirolimus .......................... 71 SIRTURO ........................ 27 SITAVIG .......................... 34 SIVEXTRO ...................... 20 SKELAXIN ...................... 85 SKLICE ........................... 30 SKYLA ............................ 68 SKYRIZI (150 MG DOSE)71 SLYND ............................ 68 sod citrate-citric acid ....... 56 SODIUM BICARBONATE 57 sodium chloride ... 57, 81, 82 SODIUM CHLORIDE ...... 57 sodium chloride (pf) ......... 57 sodium fluoride ................ 57 sodium hyaluronate ......... 50 sodium phenylbutyrate .... 60 sodium polystyrene
sulfonate ..................... 57 sodium sulfacetamide ..... 50 sodium sulfacetamide wash
.................................... 50 SODIUM
SULFACETAMIDE WASH ......................... 50
SOFOSBUVIR-VELPATASVIR ............ 34
solifenacin succinate ....... 61 SOLIQUA ........................ 53 SOLODYN ...................... 20 SOLOSEC ....................... 20 SOLTAMOX .................... 29 SOLU-CORTEF .............. 62 SOLULINE ...................... 16 SOLU-MEDROL .............. 62 SOLUPICC ...................... 16 SOMA ............................. 85 SOMATULINE DEPOT .... 64 SOMAVERT .................... 64 SONATA ......................... 86 SOOLANTRA .................. 50 SOOTHEE ...................... 16 SORIATANE ................... 50 SORILUX ........................ 50 sorine .............................. 41 sotalol hcl ........................ 41
109
sotalol hcl (af) .................. 41 SOTYLIZE ....................... 41 SOVALDI ......................... 34 SPECTRACEF ................ 20 spinosad .......................... 30 SPINY PIGWEED ............ 75 SPIRIVA HANDIHALER .. 84 SPIRIVA RESPIMAT ....... 84 spironolactone ................. 41 spironolactone-hctz ......... 41 SPORANOX .................... 26 SPORANOX PULSEPAK 26 sprintec 28 ....................... 68 SPRITAM ........................ 22 SPRIX ............................. 12 SPRYCEL ....................... 29 sps .................................. 57 sronyx.............................. 68 ssd .................................. 20 SSKI ................................ 82 sss 10-5 ........................... 50 STALEVO 100 ................. 31 STALEVO 125 ................. 31 STALEVO 150 ................. 31 STALEVO 200 ................. 31 STALEVO 50 ................... 31 STALEVO 75 ................... 31 STARLIX ......................... 53 stavudine ......................... 34 STEGLATRO ................... 53 STEGLUJAN ................... 53 STELARA ........................ 71 STEMPHYLIUM .............. 75 sterile water for irrigation . 57 STIMATE ......................... 64 STIOLTO RESPIMAT ...... 84 STIVARGA ...................... 29 STRATTERA ................... 42 STRENSIQ ...................... 60 streptomycin sulfate ......... 20 STRIANT ......................... 63 STRIBILD ........................ 34 STRIVERDI RESPIMAT .. 84 STROMECTOL ............... 30 SUBOXONE .................... 17 SUBSYS .......................... 14 subvenite ......................... 22 subvenite starter kit-blue . 22 subvenite starter kit-green
.................................... 22 subvenite starter kit-orange
.................................... 22 SUCRAID ........................ 60 sucralfate ......................... 58 SULAR ............................ 41
sulfacetamide sodium 50, 77 sulfacetamide sodium
(acne) .......................... 50 sulfacetamide sodium-sulfur
.................................... 50 sulfacetamide-prednisolone
.................................... 79 sulfacetamide-sulfur in urea
.................................... 50 sulfacleanse 8/4 .............. 50 sulfadiazine ..................... 20 sulfamethoxazole-
trimethoprim ................ 20 sulfamez wash ................ 50 SULFAMYLON ................ 20 sulfasalazine ................... 73 sulfatrim pediatric ............ 20 sulindac ........................... 12 SUMADAN WASH ........... 50 sumatriptan ..................... 27 sumatriptan succinate ..... 27 sumatriptan succinate refill
.................................... 27 sumatriptan-naproxen
sodium......................... 27 SUMAXIN ........................ 50 SUMAXIN TS .................. 50 SUMAXIN WASH ............ 50 SUNOSI .......................... 86 SUPRAX ......................... 20 SUPREP BOWEL PREP
KIT .............................. 59 SURESTEP PRO HIGH
GLUCOSE ................... 54 SURESTEP PRO LOW
GLUCOSE ................... 54 SURESTEP PRO NORMAL
GLUCOSE ................... 54 SURMONTIL ................... 24 SURVANTA ..................... 82 SUSTIVA ......................... 34 SUTENT .......................... 29 SUVICORT...................... 50 SWEET GUM .................. 75 SWEET VERNAL GRASS
POLLEN ...................... 75 syeda .............................. 68 SYLATRON ..................... 34 SYMAX DUOTAB ............ 59 symax-sl .......................... 59 symax-sr ......................... 59 SYMBICORT ................... 84 SYMBYAX ....................... 24 SYMDEKO ...................... 84 SYMFI ............................. 34
SYMFI LO ....................... 34 SYMJEPI......................... 84 SYMLINPEN 120 ............ 53 SYMLINPEN 60 .............. 53 SYMPAZAN .................... 22 SYMPROIC ..................... 59 SYMTUZA ....................... 34 synalar ............................ 50 SYNALAR ....................... 50 SYNAREL ....................... 64 SYNDROS ...................... 25 SYNERA ......................... 16 SYNERDERM ................. 50 SYNJARDY ..................... 53 SYNJARDY XR ............... 53 SYNTHROID ................... 69 SYNVEXIA ...................... 16 SYPRINE ........................ 57 T TABLOID......................... 29 TACLONEX ..................... 50 tacrolimus.................. 50, 71 tadalafil (pah) .................. 85 TAFINLAR ....................... 29 TAGRISSO ..................... 29 TAKHZYRO .................... 71 TALICIA .......................... 59 TALL RAGWEED ............ 75 TALTZ ............................. 71 TALZENNA ..................... 29 TAMIFLU......................... 34 tamoxifen citrate .............. 29 tamsulosin hcl ................. 61 TANZEUM ....................... 53 TAPAZOLE ..................... 69 TAPERDEX 12-DAY ....... 62 TAPERDEX 6-DAY ......... 62 TAPERDEX 7-DAY ......... 62 TARCEVA ....................... 29 TARGADOX .................... 20 TARGRETIN ................... 29 tarina 24 fe ...................... 68 tarina fe 1/20 ................... 68 tarina fe 1/20 eq .............. 68 TARKA ............................ 41 taron-crystals .................. 57 TASIGNA ........................ 29 TASMAR ......................... 31 TAVALISSE .................... 36 TAYTULLA ...................... 68 tazarotene ....................... 50 tazicef ............................. 20 TAZORAC ....................... 50 taztia xt ........................... 41 TAZVERIK ...................... 29
110
TDVAX ............................ 72 TECFIDERA .................... 43 TECHNIVIE ..................... 34 TEGRETOL ..................... 22 TEGRETOL-XR ............... 22 TEGSEDI ........................ 43 TEKTURNA ..................... 41 TEKTURNA HCT ............. 41 telmisartan ....................... 41 telmisartan-amlodipine .... 41 telmisartan-hctz ............... 41 temazepam ..................... 86 TEMODAR ...................... 29 TEMOVATE..................... 50 temozolomide .................. 29 tencon ............................. 14 TENIVAC ......................... 72 tenofovir disoproxil fumarate
.................................... 34 TENORETIC 100 ............. 41 TENORETIC 50 ............... 41 TENORMIN ..................... 41 TERAZOL 7 ..................... 26 terazosin hcl .................... 61 terbinafine hcl .................. 26 terbutaline sulfate ............ 84 terconazole ...................... 26 TESSALON PERLES ...... 82 TESTIM ........................... 63 TESTONE CIK ................ 63 testosterone .................... 63 testosterone cypionate .... 63 TESTOSTERONE
CYPIONATE ................ 63 TESTOSTERONE
CYPIONATE & PROP . 63 testosterone enanthate .... 63 TESTOSTERONE
ENANTHATE ............... 63 TESTOSTERONE
PROPIONATE ............. 63 TESTRED ....................... 63 tetcaine ............................ 80 tetrabenazine................... 43 tetracaine hcl ................... 80 tetracycline hcl ................. 20 TETRAVEX ..................... 50 tetravisc ........................... 80 tetravisc forte ................... 80 TETRIX ........................... 51 TEXACORT ..................... 51 THALOMID ...................... 29 THEO-24 ......................... 84 theophylline ..................... 84 theophylline er ................. 84
THIOLA ........................... 61 THIOLA EC ..................... 61 thioridazine hcl ................ 32 thiothixene ....................... 32 thyroid ............................. 69 THYROLAR-1 ................. 69 THYROLAR-1/2 .............. 69 THYROLAR-1/4 .............. 69 THYROLAR-2 ................. 69 THYROLAR-3 ................. 69 tiadylt er .......................... 41 tiagabine hcl .................... 22 TIAZAC ........................... 41 TIBSOVO ........................ 29 TICALAST ....................... 82 TIGAN ............................. 25 TIGLUTIK ........................ 43 TIKOSYN ........................ 41 tilia fe ............................... 68 timolol maleate .......... 41, 78 TIMOLOL-BRIMON-
DORZOL-LATANOPR . 78 TIMOLOL-BRIMONIDINE-
DORZOLAMID ............ 78 TIMOLOL-DORZOLAMID-
LATANOPROST .......... 78 TIMOPTIC ....................... 78 TIMOPTIC OCUDOSE .... 78 TIMOPTIC-XE ................. 78 TINDAMAX...................... 20 tinidazole ......................... 20 TIROSINT ....................... 69 TIROSINT-SOL ............... 69 TIVICAY .......................... 34 TIVORBEX ...................... 12 tizanidine hcl ................... 85 TOBI NEBULIZER ........... 84 TOBI PODHALER ........... 84 TOBRADEX .................... 80 TOBRADEX ST ............... 80 tobramycin................. 77, 84 TOBRAMYCIN ................ 84 tobramycin-dexamethasone
.................................... 80 TOBREX ......................... 77 TOFRANIL ...................... 24 TOLAK ............................ 51 tolazamide ....................... 53 tolbutamide...................... 53 tolcapone ........................ 31 tolmetin sodium ............... 12 TOLSURA ....................... 26 tolterodine tartrate ........... 61 tolterodine tartrate er ....... 61 TOPAMAX....................... 22
TOPAMAX SPRINKLE .... 22 TOPICORT ..................... 51 TOPICORT SPRAY ........ 51 topiramate ....................... 22 topiramate er ................... 22 TOPROL XL .................... 41 toremifene citrate ............ 29 torsemide ........................ 41 TOSYMRA ...................... 27 TOUJEO MAX SOLOSTAR
.................................... 55 TOUJEO SOLOSTAR ..... 55 tovet ................................ 51 TOVIAZ ........................... 61 TRACLEER ..................... 85 TRADJENTA ................... 53 tramadol hcl er ................ 14 TRAMADOL HCL ER ...... 14 tramadol hcl er (biphasic) 14 tramadol hcl ir ................. 14 tramadol-acetaminophen . 14 trandolapril ...................... 41 trandolapril-verapamil hcl er
.................................... 41 tranexamic acid ............... 36 TRANSDERM SCOP (1.5
MG) ............................. 25 TRANSDERM-SCOP (1.5
MG) ............................. 25 TRANXENE-T ................. 35 tranylcypromine sulfate ... 24 TRANZAREL ................... 16 TRAVATAN Z .................. 78 travoprost (bak free) ........ 78 trazodone hcl .................. 24 TRECATOR .................... 27 TRELEGY ELLIPTA ........ 84 TREMFYA ....................... 71 TRESIBA......................... 55 TRESIBA FLEXTOUCH .. 55 tretinoin ..................... 29, 51 tretinoin microsphere ....... 51 tretinoin microsphere pump
.................................... 51 TRETIN-X ....................... 51 TREXALL ........................ 71 TREXIMET ...................... 27 TREZIX ........................... 14 tri femynor ....................... 68 triamcinolone acetonide . 44,
51, 62 TRIAMCINOLONE
ACETONIDE ............... 62 TRIAMCINOLONE
DIACETATE ................ 62
111
TRIAMCINOLONE DIACETATE PF ........... 62
triamterene ...................... 41 triamterene-hctz .............. 41 trianex ............................. 51 triazolam .......................... 35 TRIBENZOR.................... 41 TRICHOPHYTON ............ 75 tricitrates .......................... 57 TRICOR .......................... 41 triderm ............................. 51 TRIDESILON ................... 51 trientine hcl ...................... 57 tri-estarylla ....................... 69 trifluoperazine hcl ............ 32 trifluridine ......................... 77 TRIGLIDE ........................ 41 trihexyphenidyl hcl ........... 31 TRIKAFTA ....................... 84 triklo ................................ 41 tri-legest fe ...................... 69 TRILEPTAL ..................... 22 tri-linyah ........................... 69 TRILIPIX .......................... 41 tri-lo-estarylla ................... 69 tri-lo-marzia ..................... 69 tri-lo-mili ........................... 69 tri-lo-sprintec.................... 69 trilyte ............................... 59 trimethobenzamide hcl .... 25 trimethoprim .................... 20 tri-mili............................... 69 trimipramine maleate ....... 24 TRIMPEX ........................ 20 trinessa (28) .................... 69 trinessa lo ........................ 69 TRI-NORINYL (28) .......... 69 TRINTELLIX .................... 24 tri-previfem ...................... 69 tri-sprintec ....................... 69 TRIUMEQ ........................ 34 trivora (28) ....................... 69 tri-vylibra .......................... 69 tri-vylibra lo ...................... 69 TRIZIVIR ......................... 34 TROKENDI XR ................ 22 TROPICAMIDE-
CYCLOPENTOLATE-PE .................................... 80
TROPICAMIDE-PHENYLEPHRINE ...... 80
TROPIC-PROPARACA-PE-KETOROLAC .............. 80
trospium chloride ............. 61 trospium chloride er ......... 61
TRUE METRIX LEVEL 1 . 54 TRUE METRIX LEVEL 2 . 54 TRUE METRIX LEVEL 3 . 54 TRULANCE ..................... 59 TRULICITY...................... 53 TRUMENBA .................... 72 TRUSOPT ....................... 78 TRUVADA ....................... 34 TUDORZA PRESSAIR .... 84 tulana .............................. 69 TURALIO ........................ 29 TUSSICAPS .................... 82 tussigon ........................... 82 TUSSIONEX
PENNKINETIC ER ...... 82 TUXARIN ER .................. 82 TUZISTRA XR ................. 82 TWINRIX ......................... 72 TWYNSTA....................... 41 TYBOST .......................... 34 tydemy ............................ 69 TYKERB .......................... 29 TYLENOL WITH CODEINE
#3 ................................ 14 TYLENOL WITH CODEINE
#4 ................................ 14 TYMLOS ......................... 73 TYVASO ......................... 85 TYVASO REFILL............. 85 TYVASO STARTER ........ 85 U UBRELVY ....................... 27 UCERIS .......................... 73 UDENYCA....................... 36 ULESFIA ......................... 30 ULORIC .......................... 26 ULTIGUARD SAFEPACK
PEN NEEDLE .............. 55 ULTRACET ..................... 14 ULTRAM ......................... 14 ULTRAVATE ................... 51 UMECTA MOUSSE ......... 51 UNISTRIP CONTROL ..... 54 unithroid .......................... 70 UPTRAVI ........................ 85 ur n-c ............................... 61 URALISS ......................... 51 URAMAXIN ..................... 51 urea ................................. 51 UREA .............................. 51 urea hydrating ................. 51 urea nail .......................... 51 URECHOLINE ................. 61 uredeb ............................. 51 ure-k ................................ 51
urelle ............................... 61 uremez-40 ....................... 51 URESOL ......................... 51 uretron d/s ....................... 61 UREVAZ ......................... 51 uribel ............................... 61 URIMAR-T ...................... 61 urin ds ............................. 61 URO-458 ......................... 61 UROCIT-K 10 .................. 57 UROCIT-K 15 .................. 57 UROCIT-K 5 .................... 57 UROGESIC-BLUE .......... 61 uro-mp ............................ 61 UROXATRAL .................. 61 URSO 250 ....................... 59 URSO FORTE ................ 59 ursodiol ........................... 59 URYL .............................. 61 ustell ............................... 61 UTA ................................. 61 UTIBRON NEOHALER ... 84 uticap .............................. 61 utira-c .............................. 61 UTOPIC .......................... 51 utrona-c ........................... 61 V VAGIFEM ........................ 69 valacyclovir hcl ................ 34 VALCHLOR ..................... 29 VALCYTE........................ 34 valganciclovir hcl ............. 34 VALIUM .......................... 35 valproate sodium ............. 22 valproic acid .................... 22 valsartan ......................... 41 valsartan-
hydrochlorothiazide ..... 41 VALTOCO 10 MG DOSE 22 VALTOCO 15 MG DOSE 22 VALTOCO 20 MG DOSE 22 VALTOCO 5 MG DOSE .. 22 VALTREX........................ 34 VANATOL LQ ................. 14 VANATOL S .................... 14 VANCOCIN HCL ............. 20 vancomycin hcl ............... 20 vandazole........................ 20 VANOS ........................... 51 VANOXIDE-HC ............... 51 VAQTA ............................ 72 VARIVAX ........................ 72 VARIZIG ......................... 71 VARUBI .......................... 25 VASCEPA ....................... 41
112
VASERETIC .................... 41 VASOTEC ....................... 41 VECAMYL ....................... 41 VECTICAL ....................... 51 velivet .............................. 69 VELPHORO .................... 61 VELTASSA ...................... 57 VELTIN ............................ 51 VEMLIDY ........................ 34 VENCLEXTA ................... 29 VENCLEXTA STARTING
PACK .......................... 29 venlafaxine hcl ................. 24 venlafaxine hcl er ............ 24 VENOMIL HONEY BEE
VENOM ....................... 75 VENOMIL MIXED VESPID
VENOM ....................... 75 VENOMIL WASP VENOM
.................................... 75 VENOMIL WHITE FACED
HORNET ..................... 75 VENOMIL YELLOW
HORNET VENOM ....... 75 VENOMIL YELLOW
JACKET VENOM ......... 75 VENTAVIS ...................... 85 VENTOLIN HFA .............. 84 verapamil hcl ................... 41 verapamil hcl er ............... 41 VERDESO ....................... 51 VEREGEN ....................... 51 VERELAN ....................... 41 VERELAN PM ................. 41 VERIPRED 20 ................. 62 VERSACLOZ ................... 32 VERZENIO ...................... 29 VESICARE ...................... 61 vestura ............................ 69 VEXATROL ..................... 16 VFEND ............................ 26 V-GO 20 .......................... 54 V-GO 30 .......................... 54 V-GO 40 .......................... 54 VIBERZI .......................... 59 VIBRAMYCIN .................. 20 vicodin hp ........................ 14 VICTOZA ......................... 53 VIDEX ............................. 34 VIDEX EC ....................... 34 VIEKIRA PAK .................. 34 VIEKIRA XR .................... 34 vienva .............................. 69 vigabatrin ......................... 22 vigadrone ........................ 22
VIGAMOX ....................... 77 VIIBRYD .......................... 24 VIIBRYD STARTER PACK
.................................... 24 vilamit mb ........................ 61 VILEVEV MB ................... 61 VIMOVO .......................... 12 VIMPAT ........................... 22 VIOKACE ........................ 60 viorele ............................. 69 VIRACEPT ...................... 34 VIRAMUNE ..................... 34 VIRAMUNE XR ............... 34 VIRASAL ......................... 51 VIRAZOLE ...................... 34 VIREAD ..................... 34, 35 VIROPTIC ....................... 77 virt-phos 250 neutral ........ 57 VISTARIL ........................ 35 VISTOGARD ................... 75 vitamin d (ergocalciferol) . 57 vitamin k1 ........................ 57 VITRAKVI ........................ 29 VIVAGUARD INO
CONTROL SOLUTION 54 VIVAGUARD LANCING
DEVICE ....................... 54 VIVELLE-DOT ................. 69 VIVITROL ........................ 17 VIVLODEX ...................... 12 VIZIMPRO ....................... 29 VOGELXO....................... 63 VOGELXO PUMP ........... 63 volnea ............................. 69 VOLTAREN ..................... 12 voriconazole .................... 26 VOSEVI ........................... 35 VOTRIENT ...................... 29 VRAYLAR ....................... 32 VUMERITY...................... 43 VUMERITY (STARTER) .. 43 VUSION .......................... 26 vyfemla ............................ 69 vylibra .............................. 69 VYNDAMAX .................... 41 VYNDAQEL ..................... 41 VYTORIN ........................ 41 VYVANSE ....................... 42 VYZULTA ........................ 78 W WAKIX ............................ 86 warfarin sodium ............... 21 WASP VENOM PROTEIN
.............................. 75, 76 WELCHOL ...................... 41
WELLBUTRIN SR ........... 24 WELLBUTRIN XL ............ 24 wera ................................ 69 WESTCORT ................... 51 WESTERN JUNIPER ...... 76 WESTHROID .................. 70 WHITE BIRCH ................ 76 WHITE FACED HORNET
VENOM ....................... 76 WHITE FACED HORNET
VENOM PROT ............ 76 WHITE MULBERRY ........ 76 WHITE-FACED HORNET
VENOM ....................... 76 WIDE-SEAL DIAPHRAGM
60 ................................ 76 WP THYROID ................. 70 wymzya fe ....................... 69 X XADAGO......................... 31 XALATAN........................ 78 XALIX .............................. 51 XALKORI ........................ 29 XANAX ............................ 35 XANAX XR ...................... 35 XARELTO ....................... 21 XARELTO STARTER PACK
.................................... 21 XATMEP ......................... 71 XELJANZ ........................ 71 XELJANZ XR .................. 71 XELODA ......................... 29 XELPROS ....................... 78 XEMBIFY ........................ 71 XENAZINE ...................... 43 XENLETA........................ 20 XEPI ................................ 20 XERALUX ....................... 51 XERESE ......................... 35 XERMELO ...................... 59 XEROSTOMIA RELIEF
SPRAY ........................ 44 XHANCE ......................... 82 XIFAXAN......................... 20 XIGDUO XR .................... 53 XIIDRA ............................ 80 XIMINO ........................... 20 XOFLUZA ....................... 35 XOLEGEL ....................... 26 XOPENEX ....................... 84 XOPENEX
CONCENTRATE ......... 84 XOPENEX HFA............... 84 XOSPATA ....................... 29
113
XPOVIO (100 MG ONCE WEEKLY) .................... 29
XPOVIO (60 MG ONCE WEEKLY) .................... 29
XPOVIO (80 MG ONCE WEEKLY) .................... 29
XPOVIO (80 MG TWICE WEEKLY) .................... 29
XTAMPZA ER ................. 14 XTANDI ........................... 29 xulane.............................. 69 XULTOPHY ..................... 53 xurea ............................... 51 XYLOCAINE .................... 16 XYLOCAINE/EPINEPHRIN
E .................................. 16 XYLOCAINE-MPF ........... 16 XYOSTED ....................... 63 XYREM ........................... 86 Y YASMIN 28 ..................... 69 YAZ ................................. 69 YELLOW HORNET VENOM
PROTEIN .................... 76 YELLOW JACKET VENOM
PROTEIN .................... 76 YONSA ............................ 30 YOSPRALA ..................... 58 YUPELRI ......................... 84 yuvafem ........................... 69 Z zaclir cleansing ................ 51 zafirlukast ........................ 84 zaleplon ........................... 86 ZANAFLEX ...................... 85 ZANTAC .......................... 58 zarah ............................... 69 ZARONTIN ...................... 22 ZARXIO ........................... 36 ZAVESCA ....................... 60 ZEBUTAL ........................ 14 ZEGERID ........................ 58
ZEJULA ........................... 30 ZELAPAR ........................ 31 ZELBORAF ..................... 30 ZELNORM....................... 59 ZEMBRACE SYMTOUCH
.................................... 27 ZEMPLAR ....................... 73 zenatane ......................... 51 zenchent ......................... 69 ZENPEP .......................... 60 zenzedi ............................ 42 ZENZEDI ......................... 42 ZEPATIER....................... 35 ZERIT .............................. 35 ZERUVIA ........................ 16 ZESTORETIC ................. 41 ZESTRIL ......................... 41 ZETIA .............................. 41 ZETONNA ....................... 82 ZIAC ................................ 41 ZIAGEN ........................... 35 ZIANA ............................. 51 zidovudine ....................... 35 ZIEXTENZO .................... 36 zileuton er ....................... 84 ZINBRYTA ...................... 43 ZIONODIL ....................... 16 ZIOPTAN ........................ 78 ziprasidone hcl ................ 32 ZIPSOR ........................... 12 ZIRGAN .......................... 77 ZITHRANOL .................... 51 ZITHROMAX ................... 20 ZITHROMAX TRI-PAK .... 20 ZITHROMAX Z-PAK ........ 20 ZOCOR ........................... 41 ZOFRAN ......................... 25 ZOFRAN ODT ................. 25 ZOHYDRO ER ................ 14 ZOLINZA ......................... 30 zolmitriptan ...................... 27 ZOLOFT .......................... 24
zolpidem tartrate ............. 86 zolpidem tartrate er ......... 86 ZOLPIMIST ..................... 86 ZOMACTON ................... 64 ZOMIG ............................ 27 ZOMIG ZMT .................... 27 ZONACORT 11 DAY ....... 62 ZONACORT 7 DAY ......... 63 ZONALON ....................... 51 ZONEGRAN .................... 22 zonisamide ...................... 22 ZONTIVITY ..................... 31 ZORBTIVE ...................... 59 ZORTRESS .................... 71 ZORVOLEX .................... 12 ZOSTAVAX ..................... 72 zovia 1/35e (28) .............. 69 ZOVIRAX ........................ 35 ZTLIDO ........................... 16 ZUBSOLV ....................... 17 zumandimine ................... 69 ZUPLENZ........................ 25 ZURAMPIC ..................... 26 ZUTRIPRO ...................... 82 ZYBAN ............................ 17 ZYCLARA ....................... 51 ZYCLARA PUMP ............ 51 ZYDELIG......................... 30 ZYFLO ............................ 84 ZYFLO CR ...................... 84 ZYKADIA......................... 30 ZYLET ............................. 80 ZYLOPRIM ...................... 26 ZYMAXID ........................ 77 ZYPITAMAG ................... 41 ZYPREXA ....................... 32 ZYPREXA RELPREVV ... 32 ZYPREXA ZYDIS ............ 32 ZYTIGA ........................... 30 ZYVOX ............................ 20
Appendix A: OVER-THE-COUNTER (OTC) MEDICATION
BENEFIT LIST
The medications listed below are covered only for members who have purchased a special benefit offered through Kaiser Permanente
Washington called the Over-the-Counter Pharmacy Benefit.
***Typically, if a generic product is available for a drug, the Brand Name product may not be covered.***
Generic Product Name ***Brand Name*** Forms
ALLERGY COUGH AND COLD
Antihistamines CHLORPHENIRAMINE CHLOR-TRIMETON® Tab, Liquid
CLEMASTINE TAVIST® Tab, Liquid
DIPHENHYDRAMINE BENADRYL® Cap, Liquid
LORATADINE CLARITIN® Tab, Liquid
Decongestants OXYMETAZOLINE NASAL SPRAY AFRIN® Spray
PHENYLEPHRINE NASAL SPRAY NEO-SYNEPHRINE® Spray
PSEUDOEPHEDRINE SUDAFED® Tablet
Antihistamine/Decongestant Combinations TRIPROLIDINE/PSEUDOEPHEDRINE ACTIFED® Tablet
BROMPHENIRAMINE/PSEUDOEPHEDRINE DIMETAPP® Liquid
Expectorants/Cough Agents GUAIFENESIN ROBITUSSIN® Liquid
GUAIFENESIN/DEXTROMETHORPHAN ROBITUSSIN-DM® Liquid
DEXTROMETHORPHAN ROBITUSSIN COUGH® Liquid
DEXTROMETHORPHAN EXTEND RELEASE DELSYM® Liquid
AUTONOMICS AND CNS
Analgesics, Miscellaneous ACETAMINOPHEN TYLENOL® Tab, Chew, Supp,
Liquid
Non-Steroidal Anti-Inflammatories IBUPROFEN MOTRIN®, ADVIL® Tab, Liquid
Salicylates ASPIRIN BAYER®, ASCRIPTIN® Tab, Supp
DERMATOLOGICAL/ TOPICAL AGENTS
Acne/Psoriasis, Topical BENZOYL PEROXIDE 5%, 10% BENZAC® Gel, Wash, Lotion
COAL TAR Solution
Anesthetic Agents, Topical BENZOCAINE HURRICAINE® Gel
PRAMOXINE ANUSOL® Ointment
Antifungals, Topical
CLOTRIMAZOLE 1% LOTRIMIN® Cream, Solution
MICONAZOLE 2% MICATIN®, DESENEX® Cream, Powder
Anti-Infectives, Topical BACITRACIN BACIGUENT® Ointment
BACITRACIN, POLYMIXIN B POLYSPORIN® Ointment
BACITRACIN, NEOMYCIN, POLYMYXIN B NEOSPORIN® Ointment
OATMEAL, COLLOIDAL AVEENO® BATH POWDER Powder
Anti-Itch, Topical CALAMINE CALAMINE Lotion
CAMPHOR/ MENTHOL SARNA® Lotion
CAPSAICIN ZOSTRIX®, ZOSTRIX-HP® Cream
Anti-Virals, Topical DOCOSANOL 10% ABREVA® Cream
Corticosteroids, Topical, Low Potency HYDROCORTISONE 0.5%, 1% CORTIZONE® Cream, Oint,
Lotion
Keratolytics SALICYLIC ACID 17% DUOFILM® Liquid
SALICYLIC ACID 40% MEDIPLAST® Plaster
UREA 10%, 20% UREACIN®, CARMOL® 20 Cream, Lotion
Dermatologics, Miscellaneous ALUMINUM ACETATE BUROWS® Liquid
AMMONIUM LACTATE 12% AMLACTIN® Cream, Lotion
HYDROGEN PEROXIDE HYDROGEN PEROXIDE Liquid
VITAMIN A&D A AND D® OINTMENT Ointment
WITCH HAZEL TUCKS® Solution, Pads
ZINC OXIDE, COD LIVER OIL & LANOLIN DESITIN® Oint, Paste
ZINC OXIDE 20% BALMEX® Ointment
Scabicides PERMETHRIN NIX® Rinse
PYRETHRINS, PIPERONYL BUTOXIDE RID®, R & C® Shampoo
Skin Protectants LANOLIN, HYDROUS LANOLIN Ointment
PETROLATUM, GLYCERIN,BENZYL ALC MOISTUREL® Lotion
PETROLATUM, MINERAL OIL/WAX, ETC. AQUAPHOR®, EUCERIN® Ointment
EYE, EAR, NOSE AND THROAT
Otics CARBAMIDE DEBROX® Solution
Nasal Agents CROMOLYN NASALCROM® Spray
Ophthalmics ARTIFICIAL TEARS HYOPTEARS®, PURALUBE® Drops, Ointment
CARBOXYMETHYLCELLULOSE CELLUVISC®, REFRESH PLUS® Drops
HYDROXYPROPYL METHYLCELLULOSE TEARS NATURALE II® Drops
KETOTIFEN FUMARATE 0.025% ZADITOR® Drops
NAPHAZOLINE/ PHENIRAMINE OPCON-A® Drops
POLYVINYL ALCOHOL, POVIDONE REFRESH® PF Drops
SODIUM CHLORIDE 5% MURO®-128 Drops, Ointment
Throat and Mouth Agents
CETYLPYRIDINIUM CL, BENZYL ALCOHOL CEPACOL® Lozenge
GASTROINTESTINAL AGENTS
Antacids/Adsorbents CHARCOAL, ACTIVATED W/O SORBITOL ACTIDOSE Liquid
ALUMINUM/ MAGNESIUM MAALOX® Tablet, Liquid
ALUMINUM/ MAGNESIUM/ SIMETHICONE MINTOX® PLUS, MI-ACID Tablet, Liquid
ALUM/ MAGN/TRISILIS/ALG AC/SOD BICAR GAVISCON®, GENATON Tablet
ALUMINUM HYDROXIDE ALTERNAGEL®, AMPHOGEL® Liquid
MAGNESIUM OXIDE MAG-OX® Tablet
Antidiarrheals BISMUTH SUBSALICYLATE PEPTO BISMOL® Tablet, Liquid
LOPERAMIDE IMMODIUM® Tablet, Liquid
Antinauseants DIMENHYDRINATE DRAMAMINE® Tablet, Liquid
MECLIZINE BONINE®, ANTIVERT® Tablet
Laxatives/Cathartics BISACODYL DULCOLAX® Tablet, Supp
DOCUSATE SODIUM COLACE® Tablet, Liquid
GLYCERIN GLYCERIN Liquid, Supp
MAGNESIUM CITRATE CITRO-MAG® Liquid
MILK OF MAGNESIA MILK OF MAGNESIA Liquid
MINERAL OIL FLEET® MINERAL OIL Liquid
PSYLLIUM METAMUCIL® Powder
POLYETHYLENE GLYCOL MIRALAX® Powder
SENNA SENOKOT® Tablet, Liquid
Histamine H2 Blockers RANITIDINE ZANTAC® Tablet
Gastrointestinal, Miscellaneous SIMETHICONE MYLICON® Tablet
LACTOBACILLUS BACID® Capsule
SHARK LIVER OIL, COCOA BUTTER, PHENYLEPHRINE
HEMORRHOIDAL SUPPOSITORIES
Supp
Proton Pump Inhibitors OMEPRAZOLE PRILOSEC OTC Tablet
GENITOURINARY
Overactive bladder treatment OXYBUTYNIN OXYTROL® PATCH Patch
HORMONES
Contraceptive LEVONORGESTROL PLAN B ONE STEP Tablet
LIPID LOWERING AGENTS
Non-Prescription Agents NIACIN NIACIN Tablet
NIACIN EXTENDED-RELEASE SLO-NIACIN® Tablet
FISH OILS SEA-OMEGA®-50 Capsule
NUTRITIONALS AND SUPPLEMENTS
Vitamins/Dietary Supplements ACETYLCYSTEINE NAC® Capsule
ASCORBIC ACID (VIT C) Tablet
CYANOCOBALAMIN (VIT B12) Tablet
CHOLECALCIFEROL (VIT D) Tablet
FOLIC ACID Tablet
NIACINAMIDE (VIT B3) Tablet
PRENATAL VITAMINS W/ FOLIC ACID Tablet
PYRIDOXINE (VIT B6) Tablet
THIAMINE (VIT B1) Tablet
VITAMIN A Capsule
VITAMIN B COMPLEX Tablet
VITAMIN B COMPLEX W/C Tablet
VITAMIN E Capsule
Electrolytes, Iron, & Minerals CALCIUM CARBONATE TUMS® Chew tabs, Liquid
CALCIUM CITRATE CAL-CITRATE® Tablet
CALCIUM CITRATE w/VITAMIN D CITRACAL® Tablet
ELECTROLYTE ORAL PEDIALYTE® Liquid
FERROUS GLUCONATE FERGON® Tablet
FERROUS SULFATE FER-IN-SOL® Tablet, Liquid
MAGNESIUM OXIDE URO-MAG® Capsule
SODIUM BICARBONATE Tablet
ZINC SULFATE ZINCATE® Capsule
VAGINAL PREPARATIONS
Vaginal Anti-Infectives POVIDONE-IODINE BETADINE® Douche
Vaginal Antifungals CLOTRIMAZOLE MYCELEX®-7, GYNE-LOTRIMIN®-
3 Cream, Vag tabs
MICONAZOLE MONISTAT® Cream
Miscellaneous LUBRICATING JELLY K-Y JELLY® JELLY
Kaiser Permanente Nondiscrimination Notice and Language Access Services
KAISER PERMANENTE NONDISCRIMINATION NOTICE
Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (“Kaiser Permanente”) comply with applicable federal civil rights laws and do not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity, or any other basis protected by applicable federal, state, or local law. We also:
Provide free aids and services to people with disabilities to help ensure effective communication, such as:
• Qualified sign language interpreters• Written information in other formats (large print, audio, and accessible electronic formats)• Assistive devices (magnifiers, Pocket Talkers, and other aids)
Provide free language services to people whose primary language is not English, such as:
• Qualified interpreters• Information written in other languages
If you need these services, contact Kaiser Permanente.
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance. Please call us if you need help submitting a grievance. The Civil Rights Coordinator will be notified of all grievances related to discrimination.
Kaiser Permanente Phone: 206-630-4636 Toll-free: 1-888-901-4636
TTY Washington Relay Service: 1-800-833-6388 or 711 TTY Idaho Relay Service: 1-800-377-3529 or 711
Electronically: kp.org/wa/feedback
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F HHH Building Washington, DC 20201 1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
For Medicare Advantage Plans Only: Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal.
© 2018 Kaiser Foundation Health Plan of Washington H5050_XB0001444_56_18 accepted2018-XB-7_ACA_Notice_Taglines
LANGUAGE ACCESS SERVICES
English: ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-888-901-4636 (TTY: 1-800-833-6388 or 711).
Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
中文 (Chinese):注意:如果您使用繁體中文,您可 以免費獲得語言援助服務。請致電 1-888-901-4636 (TTY: 1-800-833-6388 / 711)。
Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
한국어(Korean): 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-888-901-4636 (TTY: 1-800-833-6388 / 711) 번으로 전화해 주십시오.
Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-901-4636 (телетайп: 1-800-833-6388 / 711).
Filipino (Tagalog): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
Українська (Ukrainian): УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-888-901-4636 (телетайп: 1-800-833-6388 / 711).
ភាសាខ្មែរ (Khmer)៖ របយ័ត៖ េ េបើសិនអកនិខ្យមរ, េ សជំនួខ្យផក េ យមិនគិតល គឺចនសំប់បំេ រអក។ ចូរទូ រស័ព 1-888-901-4636 (TTY: 1-800-833-6388 / 711)។日本語 (Japanese): 注意事項:日本語を話される場 合、無料の言語支援をご利用いただけます。1-888-901-4636 (TTY: 1-800-833-6388 / 711) まで、 お電話にてご連絡ください。
አማርኛ (Amharic) ፥ ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-901-4636 (መስማት ለተሳናቸው: 1-800-833-6388 / 711).
Oromiffa (Oromo): XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
ਪੰਜਾਬੀ (Punjabi) ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿ ੇਹੋ, ਤਾਂ ਭਾਸਾ ਧ ਿੱ ਚ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ।1-888-901-4636 (TTY: 1-800-833-6388 / 711) ‘ਤੇ ਕਾਲ ਕਰੋ।
تتوافر اللغوية المساعدة خدمات فإن اللغة، اذكر تتحدث كنت إذا :ملحوظة في ومعلومات مساعدة على الحصول حق لديكم :(Arabic) العربية: (6388-833-800-1 / 711) .والبكم الصم هاتف رقم 4636-901-888-1 برقم اتصل .بالمجان لك
Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
ພາສາລາວ (Lao): ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາລາວ, ການບໍ ລິ ການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ,ແມ່ນມີ ພ້ອມ ໃຫ້ທ່ານ. ໂທຣ 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
Srpsko-hrvatski (Serbo-Croatian): OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-888-901-4636 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 1-800-833-6388 / 711).
Français (French): ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-888-901-4636 (ATS: 1-800-833-6388 / 711).
Română (Romanian): ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
Adamawa (Fulfulde): MAANDO: To a waawi Adamawa, e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
می فراهم شما برای رايگان بصورت زبانی تسهيالت کنيد، می گفتگو فارسی زبان به اگر :توجه :(Farsi) فارسی.بگيريد تماس (TTY: 1-800-833-6388 / 711) 4636-901-888-1 با .باشد
XB0001444-56-18