2016 Prescription Drug ListEffective September 1, 2016
Ambetter.mhsindiana.com
Formulary IntroductionFORMULARY
The Ambetter from MHS Formulary, or Preferred Drug List, is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription drug benefit. Generic drugs have the same active ingredients as their brand name counterparts and should be considered the first line of treatment. The FDA requires generics to be safe and work the same as brand name drugs. If there is no generic available, there may be more than one brand name drug to treat a condition. Preferred brand name drugs are listed on Tier 2 to help identify brand drugs that are clinically appropriate, safe, and cost-effective treatment options, if a generic medication on the formulary is not suitable for your condition.
Please note, the Formulary is not meant to be a complete list of the drugs covered under your prescription benefit. Not all dosage forms or strengths of a drug may be covered. This list is periodically reviewed and updated and may be subject to change. Drugs may be added or removed, or additional requirements may be added in order to approve continued usage of a specific drug.
Specific prescription benefit plan designs may not cover certain products or categories, regardless of their appearance in this document. Please check your benefits for coverage limitations and your share of cost for your drugs.
Drug List Key:
Brand name drugs are listed in CAPS and generic drugs are lower case.Drugs are covered under different copay tiers depending on your benefit:
Tier 0 - No copayment for those drugs that are used for prevention and are mandated by Affordable Care Act. Select oral contraceptives, vitamin D, folic acid for women of child bearing age, over-the-counter (OTC) aspirin, and smoking cessation products may be covered under this tier. Certain age or gender limits apply.
Tier 1 - Lowest copayment for those drugs that offer the greatest value compared to other drugs used to treat similarconditions. Select over-the-counter (OTC), generic or brand name drugs may be covered under this tier.
Tier 2 - Medium copayment covers brand name drugs that are generally more affordable, or may be preferred compared to other drugs to treat the same conditions.
Tier 3 - Highest copayment covers higher cost brand name drugs. This tier may also cover non-specialty drugs that are not on the Preferred Drug List but approval has been granted for coverage.
Tier 4 - Coverage for this tier is for “specialty” drugs used to treat complex, chronic conditions that may require specialhandling, storage or clinical management. For members who do not have a four Tier plan, these drugs may be covered under Tier 3.
Prior Authorization for Non-Formulary Drugs
To obtain prior authorization for a non-formulary drug, your provider must fill out the Prior Authorization form. US Script will respond via fax or phone within 48 hours of receipt of all necessary information, except during weekends and holidays. If the request is disapproved, the notice of disapproval will contain a clear explanation of the specific reasons for disapproving the prior authorization request, or if the request was incomplete, the explanation will identify the missing material information that is necessary to complete the request.
TIER DESCRIPTION
0 Preventative
1 Generic
2 Preferred Brand
3 Non-Preferred Brand
4 Specialty
TYPE DESCRIPTION
PA Prior Authorization Prior Authorization required before prescription can be filled.
ST Step TherapyRequires trial and failure of one or more preferred products
prior to coverage.
GL Gender Limit Drug is limited to specific gender.
AL Age Limit Drug is limited to specific age.
MDD Max Daily Dose A limit on the number of times the drug can be taken per day.
MPL Max Package Limit A limit on the amount of drug covered per prescription.
MFL Max Fill LimitThere is a limit on the number of times this drug can be
refilled.
MDS Max Days Supply There is a limit on the amount of this drug that is covered.
S Specialty Drug
Specialty drugs are high-cost drugs used to treat complex or
rare conditions, such as multiple sclerosis, rheumatoid
arthritis, hepatitis C, and hemophilia.
MDS2 Max Days Supply There is a limit on the amount of this drug that is covered.
PAGE 3 LAST UPDATED 09/2016
LIST OF COVERED PRESCRIPTION MEDICATIONSPRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
celecoxib cap 100 mg generic 1PA
MDD 2 per day
celecoxib cap 200 mg generic 1PA
MDD 2 per day
celecoxib cap 400 mg generic 1PA
MDD 1 per day
celecoxib cap 50 mg generic 1PA
MDD 2 per day
choline & mag trisalicylate tab 1000 mg generic 1
diclofenac potassium tab 50 mg generic 1
diclofenac sodium er tab er 24h 100 mg generic 1
diclofenac sodium tab dr 25 mg generic 1
diclofenac sodium tab dr 50 mg generic 1
diclofenac sodium tab dr 75 mg generic 1
diclofenac-misoprostol tab dr 50-0.2 mg generic 1
diclofenac-misoprostol tab dr 75-0.2 mg generic 1
diflunisal tab 500 mg generic 1
etodolac cap 200 mg generic 1
etodolac cap 300 mg generic 1
etodolac tab 400 mg generic 1
etodolac tab 500 mg generic 1
fenoprofen calcium tab 600 mg generic 1 MDD 1 per day
FLECTOR PATCH 1.3 %diclofenac epolamine
BRAND 3PA
MDD 2 per day
flurbiprofen tab 100 mg generic 1
PAGE 4 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
flurbiprofen tab 50 mg generic 1
ibu 800 mg generic 1
ibuprofen suspension 100 mg/5ml generic 1
ibuprofen tab 400 mg generic 1
ibuprofen tab 600 mg generic 1
ibuprofen tab 800 mg generic 1
indomethacin cap 25 mg generic 1
indomethacin cap 50 mg generic 1
indomethacin er cap er 75 mg generic 1
ketoprofen cap 50 mg generic 1
ketoprofen cap 75 mg generic 1
ketorolac tromethamine tab 10 mg generic 1 MDS 20 / 30 days
meclofenamate sodium cap 100 mg generic 1
meclofenamate sodium cap 50 mg generic 1
mefenamic acid cap 250 mg generic 1
meloxicam suspension 7.5 mg/5ml generic 1
meloxicam tab 15 mg generic 1 MDD 1 per day
meloxicam tab 7.5 mg generic 1 MDD 1 per day
MOBIC SUSPENSION 7.5 MG/5MLmeloxicam
BRAND 1
nabumetone tab 500 mg generic 1
nabumetone tab 750 mg generic 1
naproxen dr tab dr 500 mg generic 1
naproxen kit tab 500 mg generic 1
naproxen sodium tab 550 mg generic 1
naproxen suspension 125 mg/5ml generic 1
naproxen tab 250 mg generic 1
PAGE 5 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
naproxen tab 375 mg generic 1
naproxen tab 500 mg generic 1
oxaprozin tab 600 mg generic 1
piroxicam cap 10 mg generic 1
piroxicam cap 20 mg generic 1
salsalate tab 500 mg generic 1
salsalate tab 750 mg generic 1
sulindac tab 150 mg generic 1
sulindac tab 200 mg generic 1
tolmetin sodium cap 400 mg generic 1
tolmetin sodium tab 200 mg generic 1
tolmetin sodium tab 600 mg generic 1
OPIOID ANALGESICS, LONG-ACTING
BUTRANS PATCH WK 10 MCG/HRbuprenorphine
BRAND 3PA
MDS 4 / 28 Days
BUTRANS PATCH WK 15 MCG/HRbuprenorphine
BRAND 3PA
MDS 4 / 28 Days
BUTRANS PATCH WK 20 MCG/HRbuprenorphine
BRAND 3PA
MDS 4 / 28 Days
BUTRANS PATCH WK 5 MCG/HRbuprenorphine
BRAND 3PA
MDS 4 / 28 Days
BUTRANS PATCH WK 7.5 MCG/HRbuprenorphine
BRAND 3PA
MDS 4 / 28 Days
EMBEDA CAP ER 100-4 MGmorphine-naltrexone
BRAND 3PA
MDD 2 per day
EMBEDA CAP ER 20-0.8 MGmorphine-naltrexone
BRAND 3PA
MDD 2 per day
EMBEDA CAP ER 30-1.2 MGmorphine-naltrexone
BRAND 3PA
MDD 2 per day
PAGE 6 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
EMBEDA CAP ER 50-2 MGmorphine-naltrexone
BRAND 3PA
MDD 2 per day
EMBEDA CAP ER 60-2.4 MGmorphine-naltrexone
BRAND 3PA
MDD 2 per day
EMBEDA CAP ER 80-3.2 MGmorphine-naltrexone
BRAND 3PA
MDD 2 per day
EXALGO TB24 DETER 12 MGhydromorphone hcl
BRAND 2PA
MDD 2 per day
EXALGO TB24 DETER 16 MGhydromorphone hcl
BRAND 2PA
MDD 2 per day
EXALGO TB24 DETER 32 MGhydromorphone hcl
BRAND 2PA
MDD 1 per day
EXALGO TB24 DETER 8 MGhydromorphone hcl
BRAND 2PA
MDD 2 per day
fentanyl patch 72hr 100 mcg/hr generic 1 MDS 10 / 30 days
fentanyl patch 72hr 12 mcg/hr generic 1 MDS 10 / 30 days
fentanyl patch 72hr 25 mcg/hr generic 1 MDS 10 / 30 days
fentanyl patch 72hr 50 mcg/hr generic 1 MDS 10 / 30 days
fentanyl patch 72hr 75 mcg/hr generic 1 MDS 10 / 30 days
hydromorphone hcl er tb24 deter 12 mg generic 1PA
MDD 2 per day
hydromorphone hcl er tb24 deter 16 mg generic 1PA
MDD 2 per day
hydromorphone hcl er tb24 deter 32 mg generic 2PA
MDD 1 per day
hydromorphone hcl er tb24 deter 8 mg generic 1PA
MDD 2 per day
levorphanol tartrate tab 2 mg generic 1
PAGE 7 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
methadone hcl conc 10 mg/ml generic 1 MDS 300 / 30 days
methadone hcl intensol conc 10 mg/ml generic 1 MDS 300 / 30 days
methadone hcl solution 10 mg/5ml generic 1 MDS 1500 / 30 days
METHADONE HCL SOLUTION 10 MG/MLmethadone hcl
BRAND 1
methadone hcl solution 5 mg/5ml generic 1 MDS 3000 / 30 days
methadone hcl tab 10 mg generic 1 MDD 10 per day
methadone hcl tab 5 mg generic 1 MDD 4 per day
methadone hcl tab sol 40 mg generic 1 MDD 2 per day
METHADOSE CONC 10 MG/MLmethadone hcl
BRAND 1 MDS 300 / 30 days
METHADOSE SUGAR-FREE CONC 10MG/MLmethadone hcl
BRAND 1 MDS 300 / 30 days
methadose tab 10 mg generic 1 MDD 10 per day
methadose tab sol 40 mg generic 1 MDD 2 per day
morphine sulfate er cap er 24h 100 mg generic 1PA
MDD 2 per day
morphine sulfate er cap er 24h 20 mg generic 1PA
MDD 2 per day
morphine sulfate er cap er 24h 30 mg generic 1PA
MDD 2 per day
morphine sulfate er cap er 24h 50 mg generic 1PA
MDD 2 per day
morphine sulfate er cap er 24h 60 mg generic 1PA
MDD 2 per day
morphine sulfate er cap er 24h 80 mg generic 1PA
MDD 2 per day
morphine sulfate er tab er 100 mg generic 1 MDD 2 per day
PAGE 8 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
morphine sulfate er tab er 15 mg generic 1 MDD 2 per day
morphine sulfate er tab er 200 mg generic 1 MDD 2 per day
morphine sulfate er tab er 30 mg generic 1 MDD 2 per day
morphine sulfate er tab er 60 mg generic 1 MDD 2 per day
NUCYNTA ER TAB ER 12H 100 MGtapentadol hcl
BRAND 2PA
MDD 2 per day
NUCYNTA ER TAB ER 12H 150 MGtapentadol hcl
BRAND 2PA
MDD 2 per day
NUCYNTA ER TAB ER 12H 200 MGtapentadol hcl
BRAND 2PA
MDD 2 per day
NUCYNTA ER TAB ER 12H 250 MGtapentadol hcl
BRAND 2PA
MDD 2 per day
NUCYNTA ER TAB ER 12H 50 MGtapentadol hcl
BRAND 2PA
MDD 2 per day
oxycodone hcl er tb12 deter 10 mg generic 1PA
MDD 2 per day
oxycodone hcl er tb12 deter 20 mg generic 1PA
MDD 2 per day
oxycodone hcl er tb12 deter 40 mg generic 1PA
MDD 2 per day
oxycodone hcl er tb12 deter 80 mg generic 1PA
MDD 2 per day
OXYCONTIN TB12 DETER 10 MGoxycodone hcl
BRAND 3PA
MDD 2 per day
OXYCONTIN TB12 DETER 15 MGoxycodone hcl
BRAND 3 PA
OXYCONTIN TB12 DETER 20 MGoxycodone hcl
BRAND 3PA
MDD 2 per day
OXYCONTIN TB12 DETER 30 MGoxycodone hcl
BRAND 3 PA
PAGE 9 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
OXYCONTIN TB12 DETER 40 MGoxycodone hcl
BRAND 3PA
MDD 2 per day
OXYCONTIN TB12 DETER 60 MGoxycodone hcl
BRAND 3 PA
OXYCONTIN TB12 DETER 80 MGoxycodone hcl
BRAND 3PA
MDD 2 per day
oxymorphone hcl er tab er 12h 15 mg generic 3PA
MDD 2 per day
oxymorphone hcl er tab er 12h 30 mg generic 3PA
MDD 2 per day
oxymorphone hcl er tab er 12h 5 mg generic 3PA
MDD 2 per day
oxymorphone hcl er tab er 12h 7.5 mg generic 3PA
MDD 2 per day
tramadol hcl er (biphasic) tab er 24h 300mg
generic 1 MDD 1 per day
tramadol hcl er tab er 24h 100 mg generic 1 MDD 1 per day
tramadol hcl er tab er 24h 200 mg generic 1 MDD 1 per day
tramadol hcl er tab er 24h 300 mg generic 1 MDD 1 per day
ZOHYDRO ER CAP ER 12H 10 MGhydrocodone bitartrate
BRAND 3PA
MDD 2 per day
ZOHYDRO ER CAP ER 12H 15 MGhydrocodone bitartrate
BRAND 3PA
MDD 2 per day
ZOHYDRO ER CAP ER 12H 20 MGhydrocodone bitartrate
BRAND 3PA
MDD 2 per day
ZOHYDRO ER CAP ER 12H 30 MGhydrocodone bitartrate
BRAND 3PA
MDD 2 per day
ZOHYDRO ER CAP ER 12H 40 MGhydrocodone bitartrate
BRAND 3PA
MDD 2 per day
PAGE 10 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ZOHYDRO ER CAP ER 12H 50 MGhydrocodone bitartrate
BRAND 3PA
MDD 2 per day
ZOHYDRO ER CP12 DETER 10 MGhydrocodone bitartrate
BRAND 3PA
MDD 2 per day
ZOHYDRO ER CP12 DETER 15 MGhydrocodone bitartrate
BRAND 3PA
MDD 2 per day
ZOHYDRO ER CP12 DETER 20 MGhydrocodone bitartrate
BRAND 3PA
MDD 2 per day
ZOHYDRO ER CP12 DETER 30 MGhydrocodone bitartrate
BRAND 3PA
MDD 2 per day
ZOHYDRO ER CP12 DETER 40 MGhydrocodone bitartrate
BRAND 3PA
MDD 2 per day
ZOHYDRO ER CP12 DETER 50 MGhydrocodone bitartrate
BRAND 3PA
MDD 2 per day
OPIOID ANALGESICS, SHORT-ACTING
acetaminophen-codeine #2 tab 300-15 mg generic 1 MDD 13 per day
acetaminophen-codeine #3 tab 300-30 mg generic 1 MDD 12 per day
acetaminophen-codeine #4 tab 300-60 mg generic 1 MDD 6 per day
acetaminophen-codeine solution 120-12mg/5ml
generic 1 MDS 2250 / 30 days
acetaminophen-codeine tab 300-15 mg generic 1 MDD 13 per day
acetaminophen-codeine tab 300-30 mg generic 1 MDD 12 per day
acetaminophen-codeine tab 300-60 mg generic 1 MDD 6 per day
ascomp-codeine cap 50-325-40-30 mg generic 1 MDD 6 per day
astramorph solution 0.5 mg/ml generic 1
astramorph solution 1 mg/ml generic 1
butalbital-apap-caff-cod cap 50-325-40-30mg
generic 1 MDD 6 per day
PAGE 11 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
butalbital-asa-caff-codeine cap 50-325-40-30 mg
generic 1 MDD 6 per day
butorphanol tartrate solution 1 mg/ml generic 1
butorphanol tartrate solution 10 mg/ml generic 1PA
MPL 1 / 30 days
butorphanol tartrate solution 2 mg/ml generic 1
co-gesic tab 5-500 mg generic 1 MDD 8 per day
codeine sulfate 15 mg generic 1
codeine sulfate solution 30 mg/5ml generic 1
codeine sulfate tab 15 mg generic 1
duramorph solution 0.5 mg/ml generic 1
duramorph solution 1 mg/ml generic 1
endocet tab 10-325 mg generic 1 MDD 12 per day
endocet tab 5-325 mg generic 1 MDD 12 per day
endocet tab 7.5-325 mg generic 1 MDD 12 per day
endocet tab 7.5-500 mg generic 1 MDD 8 per day
fentanyl citrate loz handle 1200 mcg generic 1PA
MDD 4 per day
fentanyl citrate loz handle 1600 mcg generic 1PA
MDD 4 per day
fentanyl citrate loz handle 200 mcg generic 1PA
MDD 4 per day
fentanyl citrate loz handle 400 mcg generic 1PA
MDD 4 per day
fentanyl citrate loz handle 600 mcg generic 1PA
MDD 4 per day
fentanyl citrate loz handle 800 mcg generic 1PA
MDD 4 per day
PAGE 12 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
hydrocodone-acetaminophen 7.5-500mg/15ml
generic 1
hydrocodone-acetaminophen solution 10-325 mg/15ml
generic 1
hydrocodone-acetaminophen solution 2.5-108 mg/5ml
generic 1 MDS 5400 / 30 days
hydrocodone-acetaminophen solution 5-217 mg/10ml
generic 1 MDS 5400 / 30 days
hydrocodone-acetaminophen solution 7.5-325 mg/15ml
generic 1 MDS 5400 / 30 days
hydrocodone-acetaminophen solution 7.5-500 mg/15ml
generic 1
hydrocodone-acetaminophen tab 10-300mg
generic 1 MDD 13 per day
hydrocodone-acetaminophen tab 10-325mg
generic 1 MDD 12 per day
hydrocodone-acetaminophen tab 10-500mg
generic 1 MDD 8 per day
hydrocodone-acetaminophen tab 10-650mg
generic 1 MDD 6 per day
hydrocodone-acetaminophen tab 10-660mg
generic 1 MDD 6 per day
hydrocodone-acetaminophen tab 10-750mg
generic 1 MDD 5 per day
hydrocodone-acetaminophen tab 2.5-325mg
generic 1
hydrocodone-acetaminophen tab 2.5-500mg
generic 1 MDD 8 per day
hydrocodone-acetaminophen tab 5-300 mg generic 1 MDD 13 per day
hydrocodone-acetaminophen tab 5-325 mg generic 1 MDD 12 per day
hydrocodone-acetaminophen tab 5-500 mg generic 1 MDD 8 per day
hydrocodone-acetaminophen tab 7.5-300mg
generic 1 MDD 13 per day
PAGE 13 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
hydrocodone-acetaminophen tab 7.5-325mg
generic 1 MDD 12 per day
hydrocodone-acetaminophen tab 7.5-500mg
generic 1 MDD 8 per day
hydrocodone-acetaminophen tab 7.5-650mg
generic 1 MDD 6 per day
hydrocodone-acetaminophen tab 7.5-750mg
generic 1 MDD 5 per day
hydrocodone-ibuprofen tab 10-200 mg generic 1
hydrocodone-ibuprofen tab 2.5-200 mg generic 1
hydrocodone-ibuprofen tab 5-200 mg generic 1
hydrocodone-ibuprofen tab 7.5-200 mg generic 1 MDD 5 per day
hydromorphone hcl liquid 1 mg/ml generic 1
hydromorphone hcl pf solution 10 mg/ml generic 1
hydromorphone hcl pf solution 50 mg/5ml generic 1
hydromorphone hcl pf solution 500mg/50ml
generic 1
hydromorphone hcl tab 2 mg generic 1 MDD 8 per day
hydromorphone hcl tab 4 mg generic 1 MDD 8 per day
hydromorphone hcl tab 8 mg generic 1 MDD 8 per day
ibudone tab 5-200 mg generic 1
lorcet hd tab 10-325 mg generic 1 MDD 12 per day
lorcet plus tab 7.5-325 mg generic 1 MDD 12 per day
lorcet tab 5-325 mg generic 1 MDD 12 per day
lortab tab 10-325 mg generic 1 MDD 12 per day
lortab tab 5-325 mg generic 1 MDD 12 per day
lortab tab 7.5-325 mg generic 1 MDD 12 per day
meperidine hcl solution 100 mg/ml generic 1
PAGE 14 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
meperidine hcl solution 25 mg/ml generic 1
meperidine hcl solution 50 mg/5ml generic 1 MDS 500 / claim
meperidine hcl solution 50 mg/ml generic 1
meperidine hcl tab 100 mg generic 1 MDD 6 per day
meperidine hcl tab 50 mg generic 1 MDD 6 per day
morphine sulfate (pf) solution 0.5 mg/ml generic 1
morphine sulfate (pf) solution 1 mg/ml generic 1
morphine sulfate solution 10 mg/5ml generic 1 MDS 3000 / 30 days
morphine sulfate solution 20 mg/5ml generic 1 MDS 1500 / 30 days
morphine sulfate tab 15 mg generic 1 MDD 6 per day
morphine sulfate tab 30 mg generic 1 MDD 6 per day
nalbuphine hcl solution 10 mg/ml generic 1 MDD 8 per day
nalbuphine hcl solution 20 mg/ml generic 1 MDD 8 per day
NUCYNTA TAB 100 MGtapentadol hcl
BRAND 2PA
MDD 6 per day
NUCYNTA TAB 50 MGtapentadol hcl
BRAND 2PA
MDD 6 per day
NUCYNTA TAB 75 MGtapentadol hcl
BRAND 2PA
MDD 6 per day
oxycodone hcl tab 10 mg generic 1 MDD 12 per day
oxycodone hcl tab 15 mg generic 1 MDD 12 per day
oxycodone hcl tab 20 mg generic 1 MDD 12 per day
oxycodone hcl tab 30 mg generic 1 MDD 24 per day
oxycodone hcl tab 5 mg generic 1 MDD 12 per day
oxycodone-acetaminophen tab 10-325 mg generic 1 MDD 12 per day
oxycodone-acetaminophen tab 5-325 mg generic 1 MDD 12 per day
PAGE 15 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
oxycodone-acetaminophen tab 7.5-325 mg generic 1 MDD 12 per day
oxycodone-acetaminophen tab 7.5-500 mg generic 1 MDD 8 per day
oxycodone-ibuprofen tab 5-400 mg generic 1 MDD 1 per day
oxymorphone hcl tab 10 mg generic 1 MDD 12 per day
oxymorphone hcl tab 5 mg generic 1 MDD 12 per day
pentazocine-naloxone hcl tab 50-0.5 mg generic 1
reprexain tab 10-200 mg generic 1
roxicet tab 5-325 mg generic 1 MDD 12 per day
TALWIN SOLUTION 30 MG/MLpentazocine lactate
BRAND 3
tramadol hcl 50 mg generic 1 MDD 8 per day
tramadol hcl 50 mg generic 1 MDD 8 per day
tramadol hcl tab 50 mg generic 1 MDD 8 per day
tramadol-acetaminophen tab 37.5-325 mg generic 1 MDD 8 per day
verdrocet tab 2.5-325 mg generic 1
vicodin es tab 7.5-300 mg generic 1 MDD 13 per day
vicodin hp tab 10-300 mg generic 1 MDD 13 per day
vicodin hp tab 10-660 mg generic 1 MDD 6 per day
vicodin tab 5-300 mg generic 1 MDD 13 per day
xylon tab 10-200 mg generic 1
zamicet solution 10-325 mg/15ml generic 1
ZOLVIT SOLUTION 10-300 MG/15MLhydrocodone-acetaminophen
BRAND 2
ANESTHETICS
LOCAL ANESTHETICS
glydo gel 2 % generic 1
lidocaine hcl (pf) solution 0.5 % generic 1
PAGE 16 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
lidocaine hcl (pf) solution 1 % generic 1
lidocaine hcl (pf) solution 2 % generic 1
lidocaine hcl (pf) solution 4 % generic 1
lidocaine hcl gel 2 % generic 1
lidocaine hcl solution 0.5 % generic 1
lidocaine hcl solution 1 % generic 1
lidocaine hcl solution 4 % generic 1
lidocaine viscous solution 2 % generic 1 MDS 120 / 30 days
lidocaine-prilocaine cream 2.5-2.5 % generic 1
XYLOCAINE SOLUTION 1 %lidocaine hcl (local anesth.)
BRAND 3
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
acamprosate calcium tab dr 333 mg generic 1
CAMPRAL TAB DR 333 MGacamprosate calcium
BRAND 2
depade tab 50 mg generic 1
disulfiram tab 250 mg generic 1
disulfiram tab 500 mg generic 1
naltrexone hcl tab 50 mg generic 1
OPIOID DEPENDENCE TREATMENTS
buprenorphine hcl sl tab 2 mg generic 1PA
MDD 3 per day
buprenorphine hcl sl tab 8 mg generic 1PA
MDD 3 per day
buprenorphine hcl solution 0.3 mg/ml generic 1
buprenorphine hcl-naloxone hcl sl tab 8-2mg
generic 3PA
MDD 3 per day
PAGE 17 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SUBOXONE FILM 12-3 MGbuprenorphine hcl-naloxone hcl dihydrate
BRAND 3PA
MDD 2 per day
SUBOXONE FILM 2-0.5 MGbuprenorphine hcl-naloxone hcl dihydrate
BRAND 3PA
MDD 3 per day
SUBOXONE FILM 4-1 MGbuprenorphine hcl-naloxone hcl dihydrate
BRAND 3PA
MDD 3 per day
SUBOXONE FILM 8-2 MGbuprenorphine hcl-naloxone hcl dihydrate
BRAND 3PA
MDD 2 per day
OPIOID REVERSAL AGENTS
naloxone hcl solution 0.4 mg/ml generic 1
naloxone hcl solution 1 mg/ml generic 1
SMOKING CESSATION AGENTS
buproban tab er 12h 150 mg generic 0 MDD 2 per day
bupropion hcl er (smoking det) tab er 12h150 mg
generic 0 MDD 2 per day
CHANTIX CONTINUING MONTH PAK TAB 1MGvarenicline tartrate
BRAND 0 MDD 2 per day
CHANTIX STARTING MONTH PAK TAB 0.5MG X 11 & 1 MG X 42varenicline tartrate
BRAND 0
CHANTIX TAB 0.5 MGvarenicline tartrate
BRAND 0 MDD 2 per day
CHANTIX TAB 1 MGvarenicline tartrate
BRAND 0 MDD 2 per day
NICOTROL INHALER 10 MGnicotine
BRAND 0 MPL 1 / claim
NICOTROL NS SOLUTION 10 MG/MLnicotine
BRAND 0 MPL 1 / claim
ZYBAN TAB ER 12H 150 MGbupropion hcl (smoking deterrent)
BRAND 0 MDD 2 per day
PAGE 18 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ANTIBACTERIALS
AMINOGLYCOSIDES
amikacin sulfate solution 1 gm/4ml generic 1
amikacin sulfate solution 500 mg/2ml generic 1
garamycin ointment 0.3 % generic 1
gentak ointment 0.3 % generic 1
gentamicin in saline solution 0.8-0.9mg/ml-%
generic 1
GENTAMICIN IN SALINE SOLUTION 0.9-0.9MG/ML-%gentamicin in saline
BRAND 1
gentamicin in saline solution 1-0.9 mg/ml-%
generic 1
gentamicin in saline solution 1.2-0.9mg/ml-%
generic 1
GENTAMICIN IN SALINE SOLUTION 1.4-0.9MG/ML-%gentamicin in saline
BRAND 1
gentamicin in saline solution 1.6-0.9mg/ml-%
generic 1
gentamicin sulfate ointment 0.3 % generic 1
gentamicin sulfate solution 0.3 % generic 1
gentamicin sulfate solution 10 mg/ml generic 1
gentamicin sulfate solution 40 mg/ml generic 1
gentasol solution 0.3 % generic 1
kanamycin sulfate solution 333 mg/ml generic 3
neomycin sulfate tab 500 mg generic 1
paromomycin sulfate cap 250 mg generic 1
streptomycin sulfate recon soln 1 gm generic 3
TOBRADEX OINTMENT 0.3-0.1 %tobramycin-dexamethasone
BRAND 3
PAGE 19 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
tobramycin solution 0.3 % generic 1
TOBRAMYCIN SULFATE IN SALINESOLUTION 0.8-0.9 MG/ML-%tobramycin sulfate in saline
BRAND 1
TOBRAMYCIN SULFATE IN SALINESOLUTION 1.2-0.9 MG/ML-%tobramycin sulfate in saline
BRAND 1
tobramycin sulfate solution 10 mg/ml generic 1
tobramycin sulfate solution 80 mg/2ml generic 1
tobrasol solution 0.3 % generic 1
ANTIBACTERIALS, OTHER
acetic acid solution 0.25 % generic 1
ALTABAX 1 %retapamulin
BRAND 2
ALTABAX OINTMENT 1 %retapamulin
BRAND 2
bacitracin ointment 500 unit/gm generic 3
bacitracin recon soln 50000 unit generic 3
chloramphenicol sod succinate recon soln 1gm
generic 4PA
S
clindamax gel 1 % generic 1 AL At least 12 yrs old
clindamycin hcl cap 150 mg generic 1
clindamycin hcl cap 300 mg generic 1
clindamycin hcl cap 75 mg generic 1
clindamycin palmitate hcl recon soln 75mg/5ml
generic 1
clindamycin phosphate cream 2 % generic 1
clindamycin phosphate foam 1 % generic 1 AL At least 12 yrs old
clindamycin phosphate gel 1 % generic 1 AL At least 12 yrs old
PAGE 20 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
clindamycin phosphate lotion 1 % generic 1 AL At least 12 yrs old
clindamycin phosphate solution 1 % generic 1 AL At least 12 yrs old
clindamycin phosphate solution 150 mg/ml generic 1
clindamycin phosphate solution 300mg/2ml
generic 1
clindamycin phosphate solution 300mg/2ml
generic 1
clindamycin phosphate solution 600mg/4ml
generic 1
clindamycin phosphate solution 600mg/4ml
generic 1
clindamycin phosphate solution 9 gm/60ml generic 1
clindamycin phosphate solution 900mg/6ml
generic 1
clindamycin phosphate solution 900mg/6ml
generic 1
clindamycin phosphate solution 9000mg/60ml
generic 1
CUBICIN RECON SOLN 500 MGdaptomycin
BRAND 3
LINCOCIN SOLUTION 300 MG/MLlincomycin hcl
BRAND 3
LINEZOLID IN SODIUM CHLORIDESOLUTION 600-0.9 MG/300ML-%linezolid in sodium chloride
BRAND 1
linezolid recon susp 100 mg/5ml generic 1
linezolid solution 600 mg/300ml generic 1
linezolid tab 600 mg generic 1PA
MDD 2 per day
mafenide acetate packet 5 % generic 3
methenamine hippurate tab 1 gm generic 1
PAGE 21 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
metronidazole 250 mg generic 1
metronidazole 500 mg generic 1
metronidazole cream 0.75 % generic 1
metronidazole gel 0.75 % generic 1
metronidazole gel 0.75 % generic 1
metronidazole gel 1 % generic 1
metronidazole lotion 0.75 % generic 1
metronidazole tab 250 mg generic 1
metronidazole tab 500 mg generic 1
MONUROL PACKET 3 GMfosfomycin tromethamine
BRAND 3
mupirocin calcium cream 2 % generic 1
mupirocin ointment 2 % generic 1
nitrofurantoin macrocrystal cap 100 mg generic 1
nitrofurantoin macrocrystal cap 50 mg generic 1
nitrofurantoin monohyd macro cap 100 mg generic 1
nitrofurantoin suspension 25 mg/5ml generic 1
polymyxin b sulfate recon soln 500000 unit generic 1
rosadan cream 0.75 % generic 1
rosadan gel 0.75 % generic 1
SULFAMYLON CREAM 85 MG/GMmafenide acetate
BRAND 3
SULFAMYLON PACKET 5 %mafenide acetate
BRAND 3
trimethoprim tab 100 mg generic 1
TYGACIL RECON SOLN 50 MGtigecycline
BRAND 3
vancomycin hcl cap 125 mg generic 1 MDD 4 per day
vancomycin hcl cap 250 mg generic 1MDD 4 per dayMDS 40 / claim(s)
PAGE 22 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
vancomycin hcl recon soln 10 gm generic 1
vancomycin hcl recon soln 1000 mg generic 1
vancomycin hcl recon soln 500 mg generic 1
vandazole gel 0.75 % generic 1
VIBATIV RECON SOLN 750 MGtelavancin hcl
BRAND 3
vitazol cream 0.75 % generic 1
XIFAXAN TAB 200 MGrifaximin
BRAND 3PA
AL At least 12 yrs old
XIFAXAN TAB 550 MGrifaximin
BRAND 3PA
AL At least 12 yrs old
ZYVOX SOLUTION 200 MG/100MLlinezolid
BRAND 2
BETA-LACTAM, CEPHALOSPORINS
CEDAX CAP 400 MGceftibuten
BRAND 3
CEDAX RECON SUSP 180 MG/5MLceftibuten
BRAND 3
CEDAX RECON SUSP 90 MG/5MLceftibuten
BRAND 3
cefaclor cap 250 mg generic 1
cefaclor cap 500 mg generic 1
cefaclor er tab er 12h 500 mg generic 1
cefaclor recon susp 125 mg/5ml generic 1
cefaclor recon susp 250 mg/5ml generic 1
cefaclor recon susp 375 mg/5ml generic 1
cefadroxil cap 500 mg generic 1
cefadroxil recon susp 250 mg/5ml generic 1
cefadroxil recon susp 500 mg/5ml generic 1
PAGE 23 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
cefadroxil tab 1 gm generic 1
cefazolin sodium 500 mg generic 1
cefazolin sodium recon soln 1 gm generic 1
cefazolin sodium recon soln 10 gm generic 1
cefazolin sodium recon soln 20 gm generic 1
cefazolin sodium recon soln 500 mg generic 1
cefdinir cap 300 mg generic 1 AL At least 2 yrs old
cefdinir recon susp 125 mg/5ml generic 1 AL At least 2 yrs old
cefdinir recon susp 250 mg/5ml generic 1 AL At least 2 yrs old
cefditoren pivoxil tab 200 mg generic 3
CEFDITOREN PIVOXIL TAB 200 MGcefditoren pivoxil
BRAND 3
cefditoren pivoxil tab 400 mg generic 3
cefepime hcl recon soln 1 gm generic 1
cefepime hcl recon soln 2 gm generic 1
cefixime recon susp 100 mg/5ml generic 1
cefixime recon susp 200 mg/5ml generic 1
cefotaxime sodium recon soln 1 gm generic 1
cefotaxime sodium recon soln 10 gm generic 1
cefotaxime sodium recon soln 2 gm generic 1
cefotetan disodium recon soln 1 gm generic 3
cefotetan disodium recon soln 10 gm generic 3
cefotetan disodium recon soln 2 gm generic 3
cefoxitin sodium recon soln 1 gm generic 1
cefoxitin sodium recon soln 1 gm generic 1
cefoxitin sodium recon soln 10 gm generic 1
cefoxitin sodium recon soln 2 gm generic 1
PAGE 24 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
cefoxitin sodium recon soln 2 gm generic 1
cefpodoxime proxetil recon susp 100mg/5ml
generic 1
cefpodoxime proxetil recon susp 50mg/5ml
generic 1
cefpodoxime proxetil tab 100 mg generic 1
cefpodoxime proxetil tab 200 mg generic 1
cefprozil recon susp 125 mg/5ml generic 1
cefprozil recon susp 250 mg/5ml generic 1
cefprozil tab 250 mg generic 1
cefprozil tab 500 mg generic 1
ceftazidime recon soln 1 gm generic 1
ceftazidime recon soln 2 gm generic 1
ceftazidime recon soln 6 gm generic 1
CEFTIBUTEN CAP 400 MGceftibuten
BRAND 1
CEFTIBUTEN RECON SUSP 180 MG/5MLceftibuten
BRAND 3
CEFTIN RECON SUSP 125 MG/5MLcefuroxime axetil
BRAND 2
ceftriaxone sodium recon soln 1 gm generic 1
ceftriaxone sodium recon soln 2 gm generic 1
ceftriaxone sodium recon soln 250 mg generic 1
ceftriaxone sodium recon soln 500 mg generic 1
cefuroxime axetil recon susp 125 mg/5ml generic 1
cefuroxime axetil tab 250 mg generic 1
cefuroxime axetil tab 500 mg generic 1
cefuroxime sodium recon soln 1.5 gm generic 1
cefuroxime sodium recon soln 7.5 gm generic 1
PAGE 25 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
cefuroxime sodium recon soln 750 mg generic 1
cephalexin cap 250 mg generic 1
cephalexin cap 500 mg generic 1
cephalexin cap 750 mg generic 1
cephalexin recon susp 125 mg/5ml generic 1
cephalexin recon susp 250 mg/5ml generic 1
cephalexin tab 250 mg generic 1
cephalexin tab 500 mg generic 1
SPECTRACEF TAB 200 MGcefditoren pivoxil
BRAND 3
SPECTRACEF TAB 400 MGcefditoren pivoxil
BRAND 3
SUPRAX RECON SUSP 100 MG/5MLcefixime
BRAND 2
SUPRAX RECON SUSP 200 MG/5MLcefixime
BRAND 2
SUPRAX TAB 400 MGcefixime
BRAND 2
tazicef recon soln 1 gm generic 1
tazicef recon soln 2 gm generic 1
tazicef recon soln 6 gm generic 1
TEFLARO RECON SOLN 400 MGceftaroline fosamil
BRAND 3
TEFLARO RECON SOLN 600 MGceftaroline fosamil
BRAND 3
BETA-LACTAM, OTHER
AZACTAM IN DEXTROSE SOLUTION 1 GMaztreonam in dextrose
BRAND 3
AZACTAM IN DEXTROSE SOLUTION 2 GMaztreonam in dextrose
BRAND 3
PAGE 26 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
aztreonam recon soln 1 gm generic 1
aztreonam recon soln 2 gm generic 1
imipenem-cilastatin recon soln 250 mg generic 1
imipenem-cilastatin recon soln 500 mg generic 1
INVANZ RECON SOLN 1 GMertapenem sodium
BRAND 3
meropenem recon soln 1 gm generic 1
meropenem recon soln 500 mg generic 1
BETA-LACTAM, PENICILLINS
amoxicillin cap 250 mg generic 1
amoxicillin cap 500 mg generic 1
amoxicillin chew tab 125 mg generic 1
amoxicillin chew tab 250 mg generic 1
amoxicillin recon susp 125 mg/5ml generic 1
amoxicillin recon susp 200 mg/5ml generic 1
amoxicillin recon susp 250 mg/5ml generic 1
amoxicillin recon susp 400 mg/5ml generic 1
amoxicillin tab 500 mg generic 1
amoxicillin tab 875 mg generic 1
amoxicillin-pot clavulanate chew tab 200-28.5 mg
generic 1
amoxicillin-pot clavulanate chew tab 400-57 mg
generic 1
amoxicillin-pot clavulanate er tab er 12h1000-62.5 mg
generic 1
amoxicillin-pot clavulanate recon susp 200-28.5 mg/5ml
generic 1
amoxicillin-pot clavulanate recon susp 250-62.5 mg/5ml
generic 1
PAGE 27 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
amoxicillin-pot clavulanate recon susp 400-57 mg/5ml
generic 1
amoxicillin-pot clavulanate recon susp 600-42.9 mg/5ml
generic 1
amoxicillin-pot clavulanate tab 250-125 mg generic 1
amoxicillin-pot clavulanate tab 500-125 mg generic 1
amoxicillin-pot clavulanate tab 875-125 mg generic 1
ampicillin cap 250 mg generic 1
ampicillin cap 500 mg generic 1
AMPICILLIN RECON SUSP 125 MG/5MLampicillin
BRAND 1
AMPICILLIN RECON SUSP 250 MG/5MLampicillin
BRAND 1
ampicillin sodium recon soln 1 gm generic 1
ampicillin sodium recon soln 10 gm generic 1
ampicillin-sulbactam sodium recon soln 1.5(1-0.5) gm
generic 1
ampicillin-sulbactam sodium recon soln 15(10-5) gm
generic 1
ampicillin-sulbactam sodium recon soln 3(2-1) gm
generic 1
dicloxacillin sodium cap 250 mg generic 1
dicloxacillin sodium cap 500 mg generic 1
nafcillin sodium recon soln 1 gm generic 1
nafcillin sodium recon soln 10 gm generic 1
oxacillin sodium recon soln 1 gm generic 1
oxacillin sodium recon soln 10 gm generic 1
PENICILLIN G POT IN DEXTROSE SOLUTION40000 UNIT/MLpenicillin g pot in dextrose
BRAND 1
PAGE 28 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
PENICILLIN G POT IN DEXTROSE SOLUTION60000 UNIT/MLpenicillin g pot in dextrose
BRAND 1
penicillin g potassium recon soln 5000000unit
generic 1
PENICILLIN G PROCAINE SUSPENSION600000 UNIT/MLpenicillin g procaine
BRAND 3
penicillin g sodium recon soln 5000000 unit generic 3
penicillin v potassium recon soln 125mg/5ml
generic 1
penicillin v potassium recon soln 250mg/5ml
generic 1
penicillin v potassium tab 250 mg generic 1
penicillin v potassium tab 500 mg generic 1
pfizerpen-g recon soln 5000000 unit generic 1
piperacillin sod-tazobactam so recon soln2-0.25 gm
generic 1
piperacillin sod-tazobactam so recon soln2.25 (2-0.25) gm
generic 1
piperacillin sod-tazobactam so recon soln3-0.375 gm
generic 1
piperacillin sod-tazobactam so recon soln3.375 (3-0.375) gm
generic 1
piperacillin sod-tazobactam so recon soln36-4.5 gm
generic 1
piperacillin sod-tazobactam so recon soln4-0.5 gm
generic 1
piperacillin sod-tazobactam so recon soln4.5 (4-0.5) gm
generic 1
TIMENTIN RECON SOLN 3.1 GMticarcillin & pot clavulanate
BRAND 3
PAGE 29 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
MACROLIDES
AZASITE SOLUTION 1 %azithromycin (ophth)
BRAND 3
azithromycin packet 1 gm generic 1
azithromycin recon soln 500 mg generic 1
azithromycin recon susp 100 mg/5ml generic 1
azithromycin recon susp 200 mg/5ml generic 1 MPL 1 / claim
azithromycin tab 250 mg generic 1
azithromycin tab 500 mg generic 1
azithromycin tab 600 mg generic 1 MDS 8 / 28 Days
clarithromycin er tab er 24h 500 mg generic 1
clarithromycin recon susp 125 mg/5ml generic 1
clarithromycin recon susp 250 mg/5ml generic 1
clarithromycin tab 250 mg generic 1
clarithromycin tab 500 mg generic 1
DIFICID TAB 200 MGfidaxomicin
BRAND 2
E.E.S. 400 TAB 400 MGerythromycin ethylsuccinate
BRAND 3
E.E.S. GRANULES RECON SUSP 200MG/5MLerythromycin ethylsuccinate
BRAND 3
ery pad 2 % generic 1 AL At least 12 yrs old
ERY-TAB TAB DR 250 MGerythromycin base
BRAND 3
ERY-TAB TAB DR 333 MGerythromycin base
BRAND 3
ERY-TAB TAB DR 500 MGerythromycin base
BRAND 3
ERYPED 200 RECON SUSP 200 MG/5MLerythromycin ethylsuccinate
BRAND 3
PAGE 30 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ERYPED 400 RECON SUSP 400 MG/5MLerythromycin ethylsuccinate
BRAND 3
erythromycin base cp dr part 250 mg generic 3
ERYTHROMYCIN BASE TAB 250 MGerythromycin base
BRAND 3
ERYTHROMYCIN BASE TAB 500 MGerythromycin base
BRAND 3
ERYTHROMYCIN ETHYLSUCCINATE TAB 400MGerythromycin ethylsuccinate
BRAND 3
erythromycin ointment 5 mg/gm generic 1
erythromycin pad 2 % generic 1 AL At least 12 yrs old
erythromycin solution 2 % generic 1 AL At least 12 yrs old
ilotycin ointment 5 mg/gm generic 1
KETEK TAB 300 MGtelithromycin
BRAND 3 MDD 2 per day
KETEK TAB 400 MGtelithromycin
BRAND 3 MDD 2 per day
romycin ointment 5 mg/gm generic 1
ZITHROMAX PACKET 1 GMazithromycin
BRAND 1
QUINOLONES
AVELOX ABC PACK TAB 400 MGmoxifloxacin hcl
BRAND 3
AVELOX SOLUTION 400 MG/250MLmoxifloxacin hcl in sodium chloride
BRAND 3
AVELOX TAB 400 MGmoxifloxacin hcl
BRAND 3
BESIVANCE SUSPENSION 0.6 %besifloxacin hcl
BRAND 3
CETRAXAL SOLUTION 0.2 %ciprofloxacin hcl (otic)
BRAND 1
PAGE 31 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
CIPRO IN D5W SOLUTION 200 MG/100MLciprofloxacin in d5w
BRAND 3
ciprofloxacin hcl solution 0.2 % generic 1
ciprofloxacin hcl solution 0.3 % generic 1
ciprofloxacin hcl tab 100 mg generic 1
ciprofloxacin hcl tab 250 mg generic 1
ciprofloxacin hcl tab 500 mg generic 1
ciprofloxacin hcl tab 750 mg generic 1
ciprofloxacin in d5w solution 200mg/100ml
generic 3
ciprofloxacin recon susp 250 mg/5ml (5%) generic 1
ciprofloxacin recon susp 500 mg/5ml (10%) generic 1
ciprofloxacin solution 400 mg/40ml generic 1
ciprofloxacin-ciproflox hcl er tab er 24h1000 mg
generic 1
ciprofloxacin-ciproflox hcl er tab er 24h 500mg
generic 1
FACTIVE TAB 320 MGgemifloxacin mesylate
BRAND 3
gatifloxacin solution 0.5 % generic 1
levofloxacin in d5w solution 500 mg/100ml generic 1
levofloxacin solution 0.5 % generic 1
levofloxacin solution 25 mg/ml generic 1
levofloxacin solution 25 mg/ml generic 1
levofloxacin tab 250 mg generic 1
levofloxacin tab 500 mg generic 1
levofloxacin tab 750 mg generic 1
moxifloxacin hcl tab 400 mg generic 1
NOROXIN TAB 400 MGnorfloxacin
BRAND 3
PAGE 32 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ofloxacin solution 0.3 % generic 1
ofloxacin solution 0.3 % generic 1
ofloxacin tab 200 mg generic 1
ofloxacin tab 300 mg generic 1
ofloxacin tab 400 mg generic 1
ZYMAXID SOLUTION 0.5 %gatifloxacin (ophth)
BRAND 3
SULFONAMIDES
silver sulfadiazine cream 1 % generic 1
ssd af cream 1 % generic 1
ssd cream 1 % generic 1
sulfacetamide sodium solution 10 % generic 1 MPL 1 / Claim
sulfadiazine tab 500 mg generic 1
sulfamethoxazole-tmp ds tab 800-160 mg generic 1
sulfamethoxazole-trimethoprim solution400-80 mg/5ml
generic 1
sulfamethoxazole-trimethoprim suspension200-40 mg/5ml
generic 1
sulfamethoxazole-trimethoprim suspension800-160 mg/20ml
generic 1
sulfamethoxazole-trimethoprim tab 400-80mg
generic 1
sulfamethoxazole-trimethoprim tab 800-160 mg
generic 1
sulfatrim pediatric suspension 200-40mg/5ml
generic 1
thermazene cream 1 % generic 1
TETRACYCLINES
avidoxy tab 100 mg generic 1 MDD 2 per day
PAGE 33 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
demeclocycline hcl tab 150 mg generic 1
demeclocycline hcl tab 300 mg generic 1
doxy 100 recon soln 100 mg generic 1
doxycycline hyclate 100 mg generic 1 MDD 2 per day
doxycycline hyclate cap 100 mg generic 1 MDD 2 per day
doxycycline hyclate cap 50 mg generic 1 MDD 2 per day
doxycycline hyclate recon soln 100 mg generic 1
doxycycline hyclate tab 100 mg generic 1 MDD 2 per day
doxycycline hyclate tab 20 mg generic 1 MDD 2 per day
doxycycline monohydrate cap 100 mg generic 1 MDD 2 per day
doxycycline monohydrate cap 50 mg generic 1 MDD 2 per day
doxycycline monohydrate cap 75 mg generic 1
doxycycline monohydrate tab 100 mg generic 1 MDD 2 per day
minocycline hcl cap 100 mg generic 1 MDD 3 per day
minocycline hcl cap 50 mg generic 1 MDD 3 per day
minocycline hcl cap 75 mg generic 1 MDD 3 per day
minocycline hcl tab 100 mg generic 1 MDD 3 per day
minocycline hcl tab 50 mg generic 1 MDD 3 per day
minocycline hcl tab 75 mg generic 1 MDD 3 per day
mondoxyne nl cap 100 mg generic 1 MDD 2 per day
mondoxyne nl cap 50 mg generic 1 MDD 2 per day
mondoxyne nl cap 75 mg generic 1
morgidox cap 100 mg generic 1 MDD 2 per day
morgidox cap 50 mg generic 1 MDD 2 per day
tetracycline hcl cap 250 mg generic 1 MDD 8 per day
tetracycline hcl cap 500 mg generic 1 MDD 8 per day
PAGE 34 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
levetiracetam er tab er 24h 500 mg generic 1 MDD 4 per day
levetiracetam er tab er 24h 750 mg generic 1 MDD 4 per day
levetiracetam solution 100 mg/ml generic 1 MDS 900 / 30 days
levetiracetam solution 500 mg/5ml generic 1 MDS 900 / 30 days
levetiracetam tab 1000 mg generic 1 MDD 3 per day
levetiracetam tab 250 mg generic 1 MDD 4 per day
levetiracetam tab 500 mg generic 1 MDD 4 per day
levetiracetam tab 750 mg generic 1 MDD 4 per day
POTIGA TAB 200 MGezogabine
BRAND 3PA
MDD 3 per day
POTIGA TAB 300 MGezogabine
BRAND 3PA
MDD 3 per day
POTIGA TAB 400 MGezogabine
BRAND 3PA
MDD 3 per day
POTIGA TAB 50 MGezogabine
BRAND 3PA
MDD 3 per day
roweepra tab 500 mg generic 1 MDD 4 per day
CALCIUM CHANNEL MODIFYING AGENTS
CELONTIN CAP 300 MGmethsuximide
BRAND 3 MDD 4 per day
ethosuximide cap 250 mg generic 1 MDD 6 per day
ethosuximide solution 250 mg/5ml generic 1 MDS 900 / 30 days
ZARONTIN CAP 250 MGethosuximide
BRAND 3 MDD 6 per day
zonisamide cap 100 mg generic 1 MDD 6 per day
PAGE 35 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
zonisamide cap 25 mg generic 1 MDD 6 per day
zonisamide cap 50 mg generic 1 MDD 6 per day
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
DIASTAT ACUDIAL GEL 10 MGdiazepam (anticonvulsant)
BRAND 3 MPL 1 / claim
DIASTAT ACUDIAL GEL 20 MGdiazepam (anticonvulsant)
BRAND 3 MPL 1 / claim
DIASTAT PEDIATRIC GEL 2.5 MGdiazepam (anticonvulsant)
BRAND 3 MPL 1 / claim
diazepam gel 10 mg generic 3 MPL 1 / claim
diazepam gel 2.5 mg generic 3 MPL 1 / claim
diazepam gel 20 mg generic 3 MPL 1 / claim
divalproex sodium er tab er 24h 250 mg generic 1
divalproex sodium er tab er 24h 500 mg generic 1
divalproex sodium tab dr 125 mg generic 1
divalproex sodium tab dr 250 mg generic 1
divalproex sodium tab dr 500 mg generic 1
gabapentin cap 100 mg generic 1
gabapentin cap 300 mg generic 1
gabapentin cap 400 mg generic 1
gabapentin solution 250 mg/5ml generic 1 MDS 1800 / 30 days
gabapentin solution 300 mg/6ml generic 1 MDS 1800 / 30 days
gabapentin tab 600 mg generic 1
gabapentin tab 800 mg generic 1
ONFI SUSPENSION 2.5 MG/MLclobazam
BRAND 3PA
MDS 480 / 30 days
ONFI TAB 10 MGclobazam
BRAND 3PA
MDD 2 per day
PAGE 36 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ONFI TAB 20 MGclobazam
BRAND 3PA
MDD 2 per day
ONFI TAB 5 MGclobazam
BRAND 3PA
MDD 2 per day
phenobarbital elixir 20 mg/5ml generic 1
phenobarbital solution 20 mg/5ml generic 1
phenobarbital tab 100 mg generic 1
phenobarbital tab 16.2 mg generic 1
phenobarbital tab 30 mg generic 1
phenobarbital tab 32.4 mg generic 1
phenobarbital tab 64.8 mg generic 1
phenobarbital tab 97.2 mg generic 1
primidone tab 250 mg generic 1
primidone tab 50 mg generic 1
SABRIL PACKET 500 MGvigabatrin
BRAND 4
PA
MDD 6 per dayS
SABRIL TAB 500 MGvigabatrin
BRAND 4
PA
MDD 6 per dayS
tiagabine hcl tab 2 mg generic 1
tiagabine hcl tab 4 mg generic 1
valproate sodium solution 100 mg/ml generic 1
valproate sodium solution 500 mg/5ml generic 1
valproate sodium syrup 250 mg/5ml generic 1
valproic acid cap 250 mg generic 1
valproic acid solution 250 mg/5ml generic 1
valproic acid syrup 250 mg/5ml generic 1
PAGE 37 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
GLUTAMATE REDUCING AGENTS
felbamate suspension 600 mg/5ml generic 1 MDS 900 / 30 days
felbamate tab 400 mg generic 1 MDD 9 per day
felbamate tab 600 mg generic 1 MDD 6 per day
lamotrigine chew tab 25 mg generic 1
lamotrigine chew tab 5 mg generic 1
lamotrigine tab 100 mg generic 1
lamotrigine tab 150 mg generic 1
lamotrigine tab 200 mg generic 1
lamotrigine tab 25 mg generic 1
topiragen tab 100 mg generic 1 MDD 2 per day
topiragen tab 200 mg generic 1 MDD 2 per day
topiragen tab 25 mg generic 1 MDD 4 per day
topiragen tab 50 mg generic 1 MDD 4 per day
topiramate cap sprink 15 mg generic 1 MDD 6 per day
topiramate cap sprink 25 mg generic 1 MDD 8 per day
topiramate tab 100 mg generic 1 MDD 2 per day
topiramate tab 200 mg generic 1 MDD 2 per day
topiramate tab 25 mg generic 1 MDD 4 per day
topiramate tab 50 mg generic 1 MDD 4 per day
SODIUM CHANNEL AGENTS
BANZEL SUSPENSION 40 MG/MLrufinamide
BRAND 2PA
MDS 2400 / 30 days
BANZEL TAB 200 MGrufinamide
BRAND 2PA
MDD 2 per day
BANZEL TAB 400 MGrufinamide
BRAND 2PA
MDD 8 per day
PAGE 38 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
carbamazepine chew tab 100 mg generic 1
carbamazepine er cap er 12h 100 mg generic 1 ST
carbamazepine er cap er 12h 200 mg generic 1ST
MDD 6 per day
carbamazepine er cap er 12h 300 mg generic 1ST
MDD 4 per day
carbamazepine er tab er 12h 200 mg generic 1ST
MDD 6 per day
carbamazepine er tab er 12h 400 mg generic 1ST
MDD 4 per day
carbamazepine suspension 100 mg/5ml generic 1
carbamazepine tab 200 mg generic 1
DILANTIN CAP 100 MGphenytoin sodium extended
BRAND 2
DILANTIN CAP 30 MGphenytoin sodium extended
BRAND 2
DILANTIN INFATABS CHEW TAB 50 MGphenytoin
BRAND 2
DILANTIN SUSPENSION 125 MG/5MLphenytoin
BRAND 2
epitol tab 200 mg generic 1
fosphenytoin sodium solution 100 mgpe/2ml
generic 1
fosphenytoin sodium solution 500 mgpe/10ml
generic 1
oxcarbazepine suspension 300 mg/5ml generic 1 MDS 1200 / 30 days
oxcarbazepine tab 150 mg generic 1 MDD 3 per day
oxcarbazepine tab 300 mg generic 1 MDD 3 per day
oxcarbazepine tab 600 mg generic 1 MDD 4 per day
PAGE 39 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
PEGANONE TAB 250 MGethotoin
BRAND 3
PHENYTEK CAP 200 MGphenytoin sodium extended
BRAND 2
PHENYTEK CAP 300 MGphenytoin sodium extended
BRAND 3
phenytoin chew tab 50 mg generic 1
phenytoin infatabs chew tab 50 mg generic 1
phenytoin sodium extended cap 100 mg generic 1
phenytoin sodium extended cap 200 mg generic 1
phenytoin sodium extended cap 300 mg generic 1
phenytoin sodium solution 50 mg/ml generic 1
phenytoin suspension 125 mg/5ml generic 1
TEGRETOL CHEW TAB 100 MGcarbamazepine
BRAND 2
TEGRETOL SUSPENSION 100 MG/5MLcarbamazepine
BRAND 2
TEGRETOL TAB 200 MGcarbamazepine
BRAND 2
VIMPAT SOLUTION 10 MG/MLlacosamide
BRAND 3PA
MDS 1200 / 30 days
VIMPAT SOLUTION 200 MG/20MLlacosamide
BRAND 3 MDS 1200 / 30 days
VIMPAT TAB 100 MGlacosamide
BRAND 3PA
MDD 2 per day
VIMPAT TAB 150 MGlacosamide
BRAND 3PA
MDD 2 per day
VIMPAT TAB 200 MGlacosamide
BRAND 3PA
MDD 2 per day
VIMPAT TAB 50 MGlacosamide
BRAND 3PA
MDD 2 per day
PAGE 40 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS, OTHER
ergoloid mesylates 1 mg generic 3
ergoloid mesylates tab 1 mg generic 3
CHOLINESTERASE INHIBITORS
donepezil hcl tab 10 mg generic 1 MDD 2 per day
donepezil hcl tab 5 mg generic 1 MDD 1 per day
donepezil hcl tab disp 10 mg generic 1 MDD 2 per day
donepezil hcl tab disp 5 mg generic 1 MDD 1 per day
galantamine hydrobromide er cap er 24h16 mg
generic 1 MDD 1 per day
galantamine hydrobromide er cap er 24h24 mg
generic 1 MDD 1 per day
galantamine hydrobromide er cap er 24h 8mg
generic 1 MDD 1 per day
galantamine hydrobromide solution 4mg/ml
generic 1 MDD 6 per day
galantamine hydrobromide tab 12 mg generic 1 MDD 2 per day
galantamine hydrobromide tab 4 mg generic 1 MDD 2 per day
galantamine hydrobromide tab 8 mg generic 1 MDD 2 per day
rivastigmine tartrate cap 1.5 mg generic 1
rivastigmine tartrate cap 3 mg generic 1
rivastigmine tartrate cap 4.5 mg generic 1
rivastigmine tartrate cap 6 mg generic 1
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
memantine hcl solution 2 mg/ml generic 1
memantine hcl tab 10 mg generic 1 MDD 2 per day
PAGE 41 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
memantine hcl tab 5 (28)-10 (21) mg generic 1
memantine hcl tab 5 mg generic 1 MDD 1 per day
NAMENDA SOLUTION 10 MG/5MLmemantine hcl
BRAND 2
NAMENDA TITRATION PAK TAB 5 (28)-10(21) MGmemantine hcl
BRAND 2
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
budeprion sr tab er 12h 100 mg generic 1 MDD 2 per day
budeprion sr tab er 12h 150 mg generic 1 MDD 2 per day
budeprion xl tab er 24h 150 mg generic 1 MDD 1 per day
budeprion xl tab er 24h 300 mg generic 1 MDD 1 per day
bupropion hcl er (sr) tab er 12h 100 mg generic 1 MDD 2 per day
bupropion hcl er (sr) tab er 12h 150 mg generic 1 MDD 2 per day
bupropion hcl er (sr) tab er 12h 200 mg generic 1 MDD 2 per day
bupropion hcl er (xl) tab er 24h 150 mg generic 1 MDD 1 per day
bupropion hcl er (xl) tab er 24h 300 mg generic 1 MDD 1 per day
bupropion hcl tab 100 mg generic 1 MDD 3 per day
bupropion hcl tab 75 mg generic 1 MDD 3 per day
mirtazapine tab 15 mg generic 1 MDD 1 per day
mirtazapine tab 30 mg generic 1 MDD 1 per day
mirtazapine tab 45 mg generic 1 MDD 1 per day
mirtazapine tab 7.5 mg generic 1 MDD 1 per day
mirtazapine tab disp 15 mg generic 1 MDD 1 per day
mirtazapine tab disp 30 mg generic 1 MDD 1 per day
mirtazapine tab disp 45 mg generic 1 MDD 1 per day
PAGE 42 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
perphenazine-amitriptyline tab 2-10 mg generic 1 MDD 4 per day
perphenazine-amitriptyline tab 2-25 mg generic 1 MDD 4 per day
perphenazine-amitriptyline tab 4-10 mg generic 1 MDD 4 per day
perphenazine-amitriptyline tab 4-25 mg generic 1 MDD 4 per day
perphenazine-amitriptyline tab 4-50 mg generic 1 MDD 4 per day
WELLBUTRIN SR TAB ER 12H 100 MGbupropion hcl
BRAND 3 MDD 2 per day
WELLBUTRIN SR TAB ER 12H 150 MGbupropion hcl
BRAND 3 MDD 2 per day
WELLBUTRIN TAB 75 MGbupropion hcl
BRAND 3 MDD 3 per day
MONOAMINE OXIDASE INHIBITORS
EMSAM 9 MG/24HRselegiline
BRAND 3 MDD 1 per day
EMSAM PATCH 24HR 12 MG/24HRselegiline
BRAND 3 MDD 1 per day
EMSAM PATCH 24HR 6 MG/24HRselegiline
BRAND 3 MDD 1 per day
EMSAM PATCH 24HR 9 MG/24HRselegiline
BRAND 3 MDD 1 per day
MARPLAN TAB 10 MGisocarboxazid
BRAND 2 MDD 6 per day
phenelzine sulfate tab 15 mg generic 1
tranylcypromine sulfate tab 10 mg generic 1
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN ANDNOREPINEPHRINE REUPTAKE INHIBITOR
BRINTELLIX TAB 10 MGvortioxetine hbr
BRAND 3PA
MDD 1 per day
BRINTELLIX TAB 20 MGvortioxetine hbr
BRAND 3PA
MDD 1 per day
PAGE 43 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
BRINTELLIX TAB 5 MGvortioxetine hbr
BRAND 3PA
MDD 1 per day
citalopram hydrobromide solution 10mg/5ml
generic 1 MDS 600 / 30 days
citalopram hydrobromide tab 10 mg generic 1 MDD 1.5 per day
citalopram hydrobromide tab 20 mg generic 1 MDD 1.5 per day
citalopram hydrobromide tab 40 mg generic 1 MDD 1 per day
escitalopram oxalate solution 5 mg/5ml generic 1 MDS 600 / 30 days
escitalopram oxalate tab 10 mg generic 1 MDD 1.5 per day
escitalopram oxalate tab 20 mg generic 1 MDD 1 per day
escitalopram oxalate tab 5 mg generic 1 MDD 1.5 per day
fluoxetine hcl (pmdd) cap 10 mg generic 1 MDD 1 per day
fluoxetine hcl (pmdd) cap 20 mg generic 1 MDD 3 per day
fluoxetine hcl cap 10 mg generic 1 MDD 1 per day
fluoxetine hcl cap 20 mg generic 1 MDD 3 per day
fluoxetine hcl cap 40 mg generic 1 MDD 2 per day
fluoxetine hcl solution 20 mg/5ml generic 1 MDS 600 / 30 days
fluoxetine hcl tab 10 mg generic 1 MDD 1 per day
fluoxetine hcl tab 20 mg generic 1 MDD 3 per day
fluoxetine hcl tab 60 mg generic 1 MDD 1 per day
fluvoxamine maleate tab 100 mg generic 1 MDD 3 per day
fluvoxamine maleate tab 25 mg generic 1 MDD 2 per day
fluvoxamine maleate tab 50 mg generic 1 MDD 2 per day
maprotiline hcl tab 25 mg generic 3
maprotiline hcl tab 50 mg generic 3
maprotiline hcl tab 75 mg generic 3
PAGE 44 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
nefazodone hcl tab 100 mg generic 3
nefazodone hcl tab 150 mg generic 3
nefazodone hcl tab 200 mg generic 3
nefazodone hcl tab 250 mg generic 3
nefazodone hcl tab 50 mg generic 3
OLEPTRO TAB ER 24H 150 MGtrazodone hcl
BRAND 3ST
MDD 1 per day
OLEPTRO TAB ER 24H 300 MGtrazodone hcl
BRAND 3ST
MDD 1 per day
paroxetine hcl er tab er 24h 12.5 mg generic 1PA
MDD 1 per day
paroxetine hcl er tab er 24h 25 mg generic 1PA
MDD 2 per day
paroxetine hcl er tab er 24h 37.5 mg generic 1PA
MDD 2 per day
paroxetine hcl suspension 10 mg/5ml generic 3PA
MDS 900 / 30 days
paroxetine hcl tab 10 mg generic 1 MDD 1 per day
paroxetine hcl tab 20 mg generic 1 MDD 1 per day
paroxetine hcl tab 30 mg generic 1 MDD 2 per day
paroxetine hcl tab 40 mg generic 1 MDD 1 per day
PAXIL SUSPENSION 10 MG/5MLparoxetine hcl
BRAND 3PA
MDS 900 / 30 days
PRISTIQ TAB ER 24H 100 MGdesvenlafaxine succinate
BRAND 2ST
MDD 4 per day
PRISTIQ TAB ER 24H 25 MGdesvenlafaxine succinate
BRAND 2ST
MDD 1 per day
PRISTIQ TAB ER 24H 50 MGdesvenlafaxine succinate
BRAND 2ST
MDD 1 per day
PAGE 45 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
selfemra cap 10 mg generic 1 MDD 1 per day
selfemra cap 20 mg generic 1 MDD 3 per day
sertraline hcl conc 20 mg/ml generic 1 MDS 300 / 30 days
sertraline hcl tab 100 mg generic 1 MDD 2 per day
sertraline hcl tab 25 mg generic 1 MDD 1.5 per day
sertraline hcl tab 50 mg generic 1 MDD 1.5 per day
trazodone hcl tab 100 mg generic 1
trazodone hcl tab 150 mg generic 1
trazodone hcl tab 300 mg generic 1
trazodone hcl tab 50 mg generic 1
venlafaxine hcl er cap er 24h 150 mg generic 1 MDD 2 per day
venlafaxine hcl er cap er 24h 37.5 mg generic 1 MDD 1 per day
venlafaxine hcl er cap er 24h 75 mg generic 1 MDD 1 per day
venlafaxine hcl er tab er 24h 150 mg generic 1 MDD 2 per day
VENLAFAXINE HCL ER TAB ER 24H 150 MGvenlafaxine hcl
BRAND 1 MDD 2 per day
VENLAFAXINE HCL ER TAB ER 24H 225 MGvenlafaxine hcl
BRAND 1 MDD 1 per day
venlafaxine hcl er tab er 24h 37.5 mg generic 1 MDD 1 per day
VENLAFAXINE HCL ER TAB ER 24H 37.5 MGvenlafaxine hcl
BRAND 3 MDD 1 per day
venlafaxine hcl er tab er 24h 75 mg generic 1 MDD 1 per day
VENLAFAXINE HCL ER TAB ER 24H 75 MGvenlafaxine hcl
BRAND 3 MDD 1 per day
venlafaxine hcl tab 100 mg generic 1 MDD 3 per day
venlafaxine hcl tab 25 mg generic 1 MDD 3 per day
venlafaxine hcl tab 37.5 mg generic 1 MDD 3 per day
venlafaxine hcl tab 50 mg generic 1 MDD 3 per day
PAGE 46 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
venlafaxine hcl tab 75 mg generic 1 MDD 3 per day
VIIBRYD KIT 10 & 20 & 40 MGvilazodone hcl
BRAND 2 MDS 1 / 365 days
VIIBRYD TAB 10 MGvilazodone hcl
BRAND 2 MDD 1 per day
VIIBRYD TAB 20 MGvilazodone hcl
BRAND 2 MDD 1 per day
VIIBRYD TAB 40 MGvilazodone hcl
BRAND 2 MDD 1 per day
TRICYCLICS
amitriptyline hcl tab 10 mg generic 1
amitriptyline hcl tab 100 mg generic 1
amitriptyline hcl tab 150 mg generic 1
amitriptyline hcl tab 25 mg generic 1
amitriptyline hcl tab 50 mg generic 1
amitriptyline hcl tab 75 mg generic 1
amoxapine tab 100 mg generic 3
amoxapine tab 150 mg generic 3
amoxapine tab 25 mg generic 3
amoxapine tab 50 mg generic 3
clomipramine hcl cap 25 mg generic 1
clomipramine hcl cap 50 mg generic 1
clomipramine hcl cap 75 mg generic 1
desipramine hcl tab 10 mg generic 1
desipramine hcl tab 100 mg generic 1
desipramine hcl tab 150 mg generic 1
desipramine hcl tab 25 mg generic 1
desipramine hcl tab 50 mg generic 1
PAGE 47 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
desipramine hcl tab 75 mg generic 1
doxepin hcl cap 10 mg generic 1
doxepin hcl cap 100 mg generic 1
doxepin hcl cap 150 mg generic 1
doxepin hcl cap 25 mg generic 1
doxepin hcl cap 50 mg generic 1
doxepin hcl cap 75 mg generic 1
doxepin hcl conc 10 mg/ml generic 1
imipramine hcl tab 10 mg generic 1
imipramine hcl tab 25 mg generic 1
imipramine hcl tab 50 mg generic 1
imipramine pamoate cap 100 mg generic 1
imipramine pamoate cap 125 mg generic 1
imipramine pamoate cap 150 mg generic 1
imipramine pamoate cap 75 mg generic 1
nortriptyline hcl cap 10 mg generic 1
nortriptyline hcl cap 25 mg generic 1
nortriptyline hcl cap 50 mg generic 1
nortriptyline hcl cap 75 mg generic 1
protriptyline hcl tab 10 mg generic 1
protriptyline hcl tab 5 mg generic 1
trimipramine maleate cap 100 mg generic 1
trimipramine maleate cap 25 mg generic 1
trimipramine maleate cap 50 mg generic 1
ANTIEMETICS
ANTIEMETICS, OTHER
compazine suppos 25 mg generic 1
PAGE 48 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
compro suppos 25 mg generic 1
meclizine hcl tab 12.5 mg generic 1
meclizine hcl tab 25 mg generic 1
metoclopramide hcl solution 10 mg/10ml generic 1 MDD 60 per day
metoclopramide hcl solution 5 mg/5ml generic 1 MDD 60 per day
metoclopramide hcl solution 5 mg/ml generic 1
metoclopramide hcl tab 10 mg generic 1 MDD 6 per day
metoclopramide hcl tab 5 mg generic 1 MDD 6 per day
perphenazine tab 16 mg generic 1
perphenazine tab 2 mg generic 1
perphenazine tab 4 mg generic 1
perphenazine tab 8 mg generic 1
prochlorperazine maleate tab 10 mg generic 1
prochlorperazine maleate tab 5 mg generic 1
prochlorperazine suppos 25 mg generic 1
TRANSDERM-SCOP PATCH 72HR 1MG/3DAYSscopolamine
BRAND 2
trimethobenzamide hcl cap 300 mg generic 1
EMETOGENIC THERAPY ADJUNCTS
ALOXI SOLUTION 0.25 MG/5MLpalonosetron hcl
BRAND 3
ANZEMET SOLUTION 20 MG/MLdolasetron mesylate
BRAND 3
ANZEMET TAB 100 MGdolasetron mesylate
BRAND 3PA
MDS 5 / 30 days
ANZEMET TAB 50 MGdolasetron mesylate
BRAND 3PA
MDS 5 / 30 days
PAGE 49 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
CESAMET CAP 1 MGnabilone
BRAND 3
dronabinol cap 10 mg generic 1
dronabinol cap 2.5 mg generic 1
dronabinol cap 5 mg generic 1
EMEND CAP 125 MGaprepitant
BRAND 2PA
MDS 2 / 30 days
EMEND CAP 40 MGaprepitant
BRAND 2PA
MDS 2 / 30 days
EMEND CAP 80 MGaprepitant
BRAND 2PA
MDS 4 / 30 days
granisetron hcl solution 0.1 mg/ml generic 1
granisetron hcl solution 1 mg/ml generic 1
granisetron hcl tab 1 mg generic 1 MDS 10 / 30 days
ondansetron hcl solution 4 mg/2ml generic 1
ondansetron hcl solution 4 mg/5ml generic 1 MDS 100 / 30 days
ondansetron hcl tab 24 mg generic 1 MDS 4 / 28 days
ondansetron hcl tab 4 mg generic 1 MDS 30 / 30 days
ondansetron hcl tab 8 mg generic 1 MDS 30 / 30 days
ondansetron tab disp 4 mg generic 1 MDS 30 / 30 days
ondansetron tab disp 8 mg generic 1 MDS 30 / 30 days
ANTIFUNGALS
ABELCET SUSPENSION 5 MG/MLamphotericin b lipid
BRAND 3
AMBISOME RECON SUSP 50 MGamphotericin b liposome
BRAND 3
AMPHOTEC RECON SUSP 50 MGamphotericin b cholesteryl sulfate complex
BRAND 3
PAGE 50 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
amphotericin b recon soln 50 mg generic 3
CANCIDAS RECON SOLN 50 MGcaspofungin acetate
BRAND 3
CANCIDAS RECON SOLN 70 MGcaspofungin acetate
BRAND 3
ciclodan cream 0.77 % generic 1
ciclodan solution 8 % generic 1
ciclopirox gel 0.77 % generic 1
ciclopirox olamine cream 0.77 % generic 1
ciclopirox olamine suspension 0.77 % generic 1
ciclopirox shampoo 1 % generic 1
ciclopirox solution 8 % generic 1
ciclopirox-vitamin e kit 8 & 5 % generic 1
clotrimazole cream 1 % generic 1
clotrimazole lozenge 10 mg generic 1
clotrimazole solution 1 % generic 1
clotrimazole troche 10 mg generic 1
econazole nitrate cream 1 % generic 1
ERAXIS 100 MGanidulafungin
BRAND 3
ERAXIS 50 MGanidulafungin
BRAND 3
ERAXIS RECON SOLN 100 MGanidulafungin
BRAND 3
ERAXIS RECON SOLN 50 MGanidulafungin
BRAND 3
ERTACZO CREAM 2 %sertaconazole nitrate
BRAND 3 MPL 1 / 30 days
EXELDERM CREAM 1 %sulconazole nitrate
BRAND 3 MPL 1 / 30 days
PAGE 51 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
EXELDERM SOLUTION 1 %sulconazole nitrate
BRAND 3 MPL 1 / 30 days
fluconazole recon susp 10 mg/ml generic 1
fluconazole recon susp 40 mg/ml generic 1
fluconazole tab 100 mg generic 1
fluconazole tab 150 mg generic 1
fluconazole tab 200 mg generic 1
fluconazole tab 50 mg generic 1
flucytosine cap 250 mg generic 1
flucytosine cap 500 mg generic 1
griseofulvin microsize suspension 125mg/5ml
generic 1ST
AL At least 2 yrs old
griseofulvin microsize tab 500 mg generic 1
griseofulvin ultramicrosize tab 125 mg generic 1
griseofulvin ultramicrosize tab 250 mg generic 1
GYNAZOLE-1 CREAM 2 %butoconazole nitrate (one dose)
BRAND 3
itraconazole cap 100 mg generic 1PA
MDD 4 per day
ketoconazole cream 2 % generic 1
ketoconazole shampoo 2 % generic 1
ketoconazole tab 200 mg generic 1
MENTAX CREAM 1 %butenafine hcl
BRAND 2 MPL 1 / 30 days
MICONAZOLE 3 SUPPOS 200 MGmiconazole nitrate vaginal
BRAND 3
MYCAMINE RECON SOLN 100 MGmicafungin sodium
BRAND 3
MYCAMINE RECON SOLN 50 MGmicafungin sodium
BRAND 3
PAGE 52 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
NAFTIFINE HCL CREAM 1 %naftifine hcl
BRAND 1 MPL 1 / 30 days
NAFTIN CREAM 1 %naftifine hcl
BRAND 3 MPL 1 / 30 days
NAFTIN CREAM 2 %naftifine hcl
BRAND 3 MPL 1 / 30 days
NAFTIN GEL 1 %naftifine hcl
BRAND 3 MPL 1 / 30 days
NATACYN SUSPENSION 5 %natamycin
BRAND 2 MPL 1 / 30 days
NOXAFIL SUSPENSION 40 MG/MLposaconazole
BRAND 3 MDS 600 / 30 Days
nyamyc powder 100000 unit/gm generic 1
nystatin cream 100000 unit/gm generic 1
nystatin ointment 100000 unit/gm generic 1
nystatin powder generic 1
nystatin powder 100000 unit/gm generic 1
nystatin suspension 100000 unit/ml generic 1
nystatin tab 500000 unit generic 1
nystatin-triamcinolone cream 100000-0.1unit/gm-%
generic 1
nystatin-triamcinolone ointment 100000-0.1 unit/gm-%
generic 1
nystop powder 100000 unit/gm generic 1
OXISTAT CREAM 1 %oxiconazole nitrate
BRAND 2 MPL 1 / 30 days
OXISTAT LOTION 1 %oxiconazole nitrate
BRAND 2 MPL 1 / 30 days
pedi-dri powder 100000 unit/gm generic 1
SPORANOX SOLUTION 10 MG/MLitraconazole
BRAND 3PA
MDS 600 / 30 days
PAGE 53 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
terbinafine hcl 250 mg generic 1 MDD 1 per day
terbinafine hcl tab 250 mg generic 1 MDD 1 per day
terconazole cream 0.4 % generic 1 MPL 1 / Claim
terconazole cream 0.8 % generic 1 MPL 1 / Claim
terconazole suppos 80 mg generic 1 MPL 1 / Claim
voriconazole tab 200 mg generic 1 MDD 4 per day
voriconazole tab 50 mg generic 1 MDD 4 per day
zazole cream 0.4 % generic 1 MPL 1 / Claim
zazole cream 0.8 % generic 1 MPL 1 / Claim
zazole suppos 80 mg generic 1 MPL 1 / Claim
ANTIGOUT AGENTS
allopurinol tab 100 mg generic 1
allopurinol tab 300 mg generic 1
colchicine tab 0.6 mg generic 2 MDS 6 / claim(s)
COLCHICINE TAB 0.6 MGcolchicine
BRAND 2 MDS 6 / claim(s)
colchicine-probenecid tab 0.5-500 mg generic 1
COLCRYS TAB 0.6 MGcolchicine
BRAND 2 MDS 6 / claim(s)
probenecid tab 500 mg generic 1
ULORIC TAB 40 MGfebuxostat
BRAND 3PA
MDD 1 per day
ULORIC TAB 80 MGfebuxostat
BRAND 3PA
MDD 1 per day
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
CAFERGOT TAB 1-100 MGergotamine w/ caffeine
BRAND 2
PAGE 54 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
D.H.E. 45 SOLUTION 1 MG/MLdihydroergotamine mesylate
BRAND 2
dihydroergotamine mesylate solution 1mg/ml
generic 1
dihydroergotamine mesylate solution 4mg/ml
generic 1ST
MDS 8 / 30 days
ERGOMAR SL TAB 2 MGergotamine tartrate
BRAND 3 MDS 20 / 30 Days
MIGRANAL SOLUTION 4 MG/MLdihydroergotamine mesylate
BRAND 2ST
MDS 8 / 30 days
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
almotriptan malate tab 12.5 mg generic 3
ST
AL At least 12 yrs oldMDS 12 / 30 days
almotriptan malate tab 6.25 mg generic 3
ST
AL At least 12 yrs oldMDS 9 / 30 days
AXERT TAB 12.5 MGalmotriptan malate
BRAND 3
ST
AL At least 12 yrs oldMDS 12 / 30 days
AXERT TAB 6.25 MGalmotriptan malate
BRAND 3
ST
AL At least 12 yrs oldMDS 9 / 30 days
FROVA TAB 2.5 MGfrovatriptan succinate
BRAND 3
ST
AL At least 18 yrs oldMDS 12 / 30 days
IMITREX SOLUTION 20 MG/ACTsumatriptan
BRAND 1 AL At least 18 yrs old
IMITREX SOLUTION 5 MG/ACTsumatriptan
BRAND 1 AL At least 18 yrs old
naratriptan hcl tab 1 mg generic 1AL At least 18 yrs old
MDS 9 / 30 days
PAGE 55 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
naratriptan hcl tab 2.5 mg generic 1AL At least 18 yrs old
MDS 9 / 30 days
RELPAX TAB 20 MGeletriptan hydrobromide
BRAND 3
ST
AL At least 18 yrs oldMDS 6 / 30 days
RELPAX TAB 40 MGeletriptan hydrobromide
BRAND 3
ST
AL At least 18 yrs oldMDS 6 / 30 days
rizatriptan benzoate tab 10 mg generic 1AL At least 6 yrs old
MDS 18 / 30 days
rizatriptan benzoate tab 10 mg generic 1AL At least 6 yrs old
MDS 18 / 30 days
rizatriptan benzoate tab 5 mg generic 1AL At least 6 yrs old
MDS 12 / 30 days
rizatriptan benzoate tab 5 mg generic 1AL At least 6 yrs old
MDS 12 / 30 days
rizatriptan benzoate tab disp 10 mg generic 1AL At least 6 yrs old
MDS 18 / 30 days
rizatriptan benzoate tab disp 10 mg generic 1AL At least 6 yrs old
MDS 18 / 30 days
rizatriptan benzoate tab disp 5 mg generic 1
AL At least 6 yrs oldMDS 12 / 30 Days
MDS2 36 / 90 Days
rizatriptan benzoate tab disp 5 mg generic 1
AL At least 6 yrs oldMDS 12 / 30 Days
MDS2 36 / 90 Days
sumatriptan solution 20 mg/act generic 1AL At least 18 yrs old
MDS 6 / 30 days
sumatriptan solution 5 mg/act generic 1AL At least 18 yrs old
MDS 6 / 30 days
PAGE 56 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
sumatriptan succinate refill soln cart 4mg/0.5ml
generic 1AL At least 18 yrs old
MDS 4 / 30 days
sumatriptan succinate refill soln cart 6mg/0.5ml
generic 1AL At least 18 yrs old
MDS 4 / 30 days
sumatriptan succinate soln a-inj 4mg/0.5ml
generic 1AL At least 18 yrs old
MDS 4 / 30 days
sumatriptan succinate soln a-inj 6mg/0.5ml
generic 1AL At least 18 yrs old
MDS 4 / 30 days
sumatriptan succinate soln prsyr 4mg/0.5ml
generic 1AL At least 18 yrs old
MDS 4 / 30 days
sumatriptan succinate soln prsyr 6mg/0.5ml
generic 1AL At least 18 yrs old
MDS 4 / 30 days
sumatriptan succinate solution 4 mg/0.5ml generic 1AL At least 18 yrs old
MPL 2 / 30 days
sumatriptan succinate solution 6 mg/0.5ml generic 1AL At least 18 yrs old
MDS 4 / 30 days
sumatriptan succinate tab 100 mg generic 1AL At least 18 yrs old
MDS 9 / 30 days
sumatriptan succinate tab 25 mg generic 1AL At least 18 yrs old
MDS 9 / 30 days
sumatriptan succinate tab 50 mg generic 1AL At least 18 yrs old
MDS 9 / 30 days
zolmitriptan tab 2.5 mg generic 1
ST
AL At least 12 yrs oldMDS 9 / 30 days
zolmitriptan tab 5 mg generic 1
ST
AL At least 12 yrs oldMDS 9 / 30 days
PAGE 57 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
zolmitriptan tab disp 5 mg generic 1
ST
AL At least 12 yrs oldMDS 9 / 30 days
ZOMIG SOLUTION 2.5 MGzolmitriptan
BRAND 2
ST
AL At least 12 yrs oldMDS 6 / 30 days
ZOMIG SOLUTION 5 MGzolmitriptan
BRAND 2
ST
AL At least 12 yrs oldMDS 6 / 30 days
ZOMIG TAB 2.5 MGzolmitriptan
BRAND 2
ST
AL At least 12 yrs oldMDS 9 / 30 days
ZOMIG TAB 5 MGzolmitriptan
BRAND 2
ST
AL At least 12 yrs oldMDS 9 / 30 days
ZOMIG ZMT TAB DISP 2.5 MGzolmitriptan
BRAND 2
ST
AL At least 12 yrs oldMDS 9 / 30 days
ZOMIG ZMT TAB DISP 5 MGzolmitriptan
BRAND 2
ST
AL At least 12 yrs oldMDS 9 / 30 days
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
guanidine hcl tab 125 mg generic 2
MESTINON SYRUP 60 MG/5MLpyridostigmine bromide
BRAND 2
MESTINON TAB ER 180 MGpyridostigmine bromide
BRAND 2
MYTELASE TAB 10 MGambenonium chloride
BRAND 3
PAGE 58 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
pyridostigmine bromide er tab er 180 mg generic 1
pyridostigmine bromide tab 60 mg generic 1
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
dapsone tab 100 mg generic 3
dapsone tab 25 mg generic 3
MYCOBUTIN CAP 150 MGrifabutin
BRAND 3 PA
rifabutin cap 150 mg generic 1
ANTITUBERCULARS
CAPASTAT SULFATE RECON SOLN 1 GMcapreomycin sulfate
BRAND 3
CYCLOSERINE CAP 250 MGcycloserine
BRAND 3 MDD 4 per day
ethambutol hcl tab 100 mg generic 1
ethambutol hcl tab 400 mg generic 1
isoniazid solution 100 mg/ml generic 1
ISONIAZID SYRUP 50 MG/5MLisoniazid
BRAND 1
isoniazid tab 100 mg generic 1
isoniazid tab 300 mg generic 1
PASER PACKET 4 GMaminosalicylic acid
BRAND 3 MDD 3 per day
PRIFTIN TAB 150 MGrifapentine
BRAND 3
pyrazinamide tab 500 mg generic 1
RIFAMATE CAP 150-300 MGisoniazid & rifampin
BRAND 3
rifampin cap 150 mg generic 1
PAGE 59 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
rifampin cap 300 mg generic 1
rifampin recon soln 600 mg generic 1
RIFATER TAB 50-120-300 MGisoniazid-rifampin w/ pyrazinamide
BRAND 3 MDD 6 per day
SEROMYCIN CAP 250 MGcycloserine
BRAND 3 MDD 4 per day
TRECATOR TAB 250 MGethionamide
BRAND 3 MDD 4 per day
ANTINEOPLASTICS
ALKYLATING AGENTS
ALKERAN TAB 2 MGmelphalan
BRAND 2
BICNU RECON SOLN 100 MGcarmustine
BRAND 4PA
S
BUSULFEX SOLUTION 6 MG/MLbusulfan
BRAND 4PA
S
CEENU CAP 10 MGlomustine
BRAND 4PA
S
CEENU CAP 100 MGlomustine
BRAND 4PA
S
CEENU CAP 40 MGlomustine
BRAND 4PA
S
cyclophosphamide cap 25 mg generic 4PA
S
cyclophosphamide cap 50 mg generic 4PA
S
cyclophosphamide recon soln 1 gm generic 4PA
S
cyclophosphamide recon soln 2 gm generic 4PA
S
PAGE 60 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
cyclophosphamide recon soln 500 mg generic 4PA
S
cyclophosphamide tab 25 mg generic 4PA
S
cyclophosphamide tab 50 mg generic 4PA
S
dacarbazine recon soln 200 mg generic 4PA
S
DAUNOXOME INJECTABLE 2 MG/MLdaunorubicin citrate liposome
BRAND 4PA
S
HEXALEN CAP 50 MGaltretamine
BRAND 4PA
S
IFEX RECON SOLN 1 GMifosfamide
BRAND 4PA
S
ifosfamide recon soln 1 gm generic 4PA
S
ifosfamide solution 1 gm/20ml generic 4PA
S
ifosfamide-mesna kit 1-1 gm generic 4PA
S
LEUKERAN TAB 2 MGchlorambucil
BRAND 4PA
S
lomustine cap 10 mg generic 4PA
S
lomustine cap 100 mg generic 4PA
S
lomustine cap 40 mg generic 4PA
S
MATULANE CAP 50 MGprocarbazine hcl
BRAND 4PA
S
PAGE 61 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
melphalan hcl recon soln 50 mg generic 1
MUSTARGEN RECON SOLN 10 MGmechlorethamine hcl
BRAND 4PA
S
MYLERAN TAB 2 MGbusulfan
BRAND 4PA
S
TEMODAR CAP 100 MGtemozolomide
BRAND 4PA
S
TEMODAR CAP 140 MGtemozolomide
BRAND 4PA
S
TEMODAR CAP 180 MGtemozolomide
BRAND 4PA
S
TEMODAR CAP 20 MGtemozolomide
BRAND 4PA
S
TEMODAR CAP 250 MGtemozolomide
BRAND 4PA
S
TEMODAR CAP 5 MGtemozolomide
BRAND 4PA
S
TEMODAR RECON SOLN 100 MGtemozolomide
BRAND 4PA
S
temozolomide cap 100 mg generic 4PA
S
temozolomide cap 140 mg generic 4PA
S
temozolomide cap 180 mg generic 4PA
S
temozolomide cap 20 mg generic 4PA
S
temozolomide cap 250 mg generic 4PA
S
PAGE 62 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
temozolomide cap 5 mg generic 4PA
S
TREANDA RECON SOLN 100 MGbendamustine hcl
BRAND 4PA
S
TREANDA RECON SOLN 25 MGbendamustine hcl
BRAND 4PA
S
ZANOSAR RECON SOLN 1 GMstreptozocin
BRAND 4PA
S
ANTIANDROGENS
bicalutamide tab 50 mg generic 4PA
S
CASODEX TAB 50 MGbicalutamide
BRAND 4PA
S
flutamide cap 125 mg generic 4PA
S
NILANDRON TAB 150 MGnilutamide
BRAND 3 MDD 2 per day
XTANDI CAP 40 MGenzalutamide
BRAND 4PA
S
ZYTIGA TAB 250 MGabiraterone acetate
BRAND 4PA
S
ANTIANGIOGENIC AGENTS
REVLIMID CAP 10 MGlenalidomide
BRAND 4PA
S
REVLIMID CAP 15 MGlenalidomide
BRAND 4PA
S
REVLIMID CAP 2.5 MGlenalidomide
BRAND 4PA
S
REVLIMID CAP 25 MGlenalidomide
BRAND 4PA
S
PAGE 63 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
REVLIMID CAP 5 MGlenalidomide
BRAND 4PA
S
THALOMID CAP 100 MGthalidomide
BRAND 4PA
S
THALOMID CAP 150 MGthalidomide
BRAND 4PA
S
THALOMID CAP 200 MGthalidomide
BRAND 4PA
S
THALOMID CAP 50 MGthalidomide
BRAND 4PA
S
ANTIESTROGENS/MODIFIERS
EMCYT CAP 140 MGestramustine phosphate sodium
BRAND 4 S
FARESTON TAB 60 MGtoremifene citrate
BRAND 2
FASLODEX 125 MG/2.5MLfulvestrant
BRAND 4PA
S
FASLODEX SOLUTION 250 MG/5MLfulvestrant
BRAND 4PA
S
SOLTAMOX SOLUTION 10 MG/5MLtamoxifen citrate
BRAND 3 PA
tamoxifen citrate tab 10 mg generic 0
tamoxifen citrate tab 20 mg generic 0
ANTIMETABOLITES
adrucil solution 500 mg/10ml generic 4PA
S
ALIMTA RECON SOLN 500 MGpemetrexed disodium
BRAND 4PA
S
capecitabine tab 150 mg generic 4PA
S
PAGE 64 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
capecitabine tab 500 mg generic 4PA
S
cladribine solution 10 mg/10ml generic 4
CLOLAR SOLUTION 1 MG/MLclofarabine
BRAND 4PA
S
cytarabine (pf) solution 100 mg/ml generic 4PA
S
cytarabine (pf) solution 20 mg/ml generic 4PA
S
cytarabine recon soln 100 mg generic 4PA
S
cytarabine recon soln 500 mg generic 4PA
S
DEPOCYT SUSPENSION 50 MG/5MLcytarabine liposome
BRAND 4PA
S
DROXIA CAP 200 MGhydroxyurea (sickle cell anemia)
BRAND 3
DROXIA CAP 300 MGhydroxyurea (sickle cell anemia)
BRAND 3
DROXIA CAP 400 MGhydroxyurea (sickle cell anemia)
BRAND 3
floxuridine recon soln 0.5 gm generic 4PA
S
fluorouracil solution 500 mg/10ml generic 4PA
S
FOLOTYN SOLUTION 20 MG/MLpralatrexate
BRAND 4PA
S
gemcitabine hcl recon soln 2 gm generic 4PA
S
gemcitabine hcl recon soln 200 mg generic 4PA
S
PAGE 65 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
GEMZAR RECON SOLN 200 MGgemcitabine hcl
BRAND 4PA
S
HYDREA CAP 500 MGhydroxyurea
BRAND 3
hydroxyurea cap 500 mg generic 1
mercaptopurine tab 50 mg generic 1
NIPENT RECON SOLN 10 MGpentostatin
BRAND 4PA
S
pentostatin recon soln 10 mg generic 4PA
S
PURINETHOL TAB 50 MGmercaptopurine
BRAND 3
TABLOID TAB 40 MGthioguanine
BRAND 4PA
S
XELODA TAB 150 MGcapecitabine
BRAND 4PA
S
XELODA TAB 500 MGcapecitabine
BRAND 4PA
S
ANTINEOPLASTICS, OTHER
ABRAXANE RECON SUSP 100 MGpaclitaxel protein-bound particles
BRAND 4PA
S
adriamycin recon soln 10 mg generic 4PA
S
ARRANON SOLUTION 5 MG/MLnelarabine
BRAND 4PA
S
azacitidine recon susp 100 mg generic 4PA
S
bleomycin sulfate recon soln 15 unit generic 4PA
S
PAGE 66 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
CAMPATH SOLUTION 30 MG/MLalemtuzumab
BRAND 4PA
S
CAMPTOSAR SOLUTION 100 MG/5MLirinotecan hcl
BRAND 4PA
S
CAMPTOSAR SOLUTION 40 MG/2MLirinotecan hcl
BRAND 4PA
S
carboplatin solution 50 mg/5ml generic 4PA
S
CERUBIDINE RECON SOLN 20 MGdaunorubicin hcl
BRAND 4PA
S
cisplatin solution 100 mg/100ml generic 4PA
S
COSMEGEN RECON SOLN 0.5 MGdactinomycin
BRAND 4PA
S
DACOGEN RECON SOLN 50 MGdecitabine
BRAND 4PA
S
dactinomycin recon soln 0.5 mg generic 4PA
S
daunorubicin hcl injectable 5 mg/ml generic 4PA
S
daunorubicin hcl recon soln 20 mg generic 4PA
S
decitabine recon soln 50 mg generic 4PA
S
DOCEFREZ RECON SOLN 20 MGdocetaxel
BRAND 4PA
S
DOCEFREZ RECON SOLN 80 MGdocetaxel
BRAND 4PA
S
docetaxel conc 20 mg/0.5ml generic 4PA
S
PAGE 67 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
DOCETAXEL CONC 20 MG/0.5MLdocetaxel
BRAND 4PA
S
docetaxel conc 20 mg/ml generic 4PA
S
DOCETAXEL CONC 20 MG/MLdocetaxel
BRAND 4PA
S
docetaxel solution 20 mg/2ml generic 4PA
S
DOCETAXEL SOLUTION 20 MG/2MLdocetaxel
BRAND 4PA
S
DOXIL INJECTABLE 2 MG/MLdoxorubicin hcl liposomal
BRAND 4PA
S
doxorubicin hcl liposomal injectable 2mg/ml
generic 4PA
S
doxorubicin hcl recon soln 10 mg generic 4PA
S
DOXORUBICIN HCL RECON SOLN 10 MGdoxorubicin hcl
BRAND 4PA
S
doxorubicin hcl recon soln 50 mg generic 4PA
S
DOXORUBICIN HCL RECON SOLN 50 MGdoxorubicin hcl
BRAND 4PA
S
doxorubicin hcl solution 2 mg/ml generic 4PA
S
ELOXATIN SOLUTION 100 MG/20MLoxaliplatin
BRAND 4PA
S
ELOXATIN SOLUTION 50 MG/10MLoxaliplatin
BRAND 4PA
S
ELSPAR RECON SOLN 10000 UNITasparaginase
BRAND 4PA
S
PAGE 68 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
epirubicin hcl solution 50 mg/25ml generic 4PA
S
epirubicin hcl solution 50 mg/25ml generic 4PA
S
ERWINAZE RECON SOLN 10000 UNITasparaginase erwinia chrysanthemi
BRAND 4PA
S
FLUDARA RECON SOLN 50 MGfludarabine phosphate
BRAND 4PA
S
fludarabine phosphate recon soln 50 mg generic 4PA
S
fludarabine phosphate solution 50 mg/2ml generic 4PA
S
HALAVEN SOLUTION 1 MG/2MLeribulin mesylate
BRAND 4PA
S
IDAMYCIN PFS SOLUTION 10 MG/10MLidarubicin hcl
BRAND 4PA
S
IDAMYCIN PFS SOLUTION 5 MG/5MLidarubicin hcl
BRAND 4PA
S
idarubicin hcl solution 10 mg/10ml generic 4PA
S
idarubicin hcl solution 5 mg/5ml generic 4PA
S
irinotecan hcl solution 100 mg/5ml generic 4PA
S
irinotecan hcl solution 40 mg/2ml generic 4PA
S
ISTODAX RECON SOLN 10 MGromidepsin
BRAND 4PA
S
IXEMPRA KIT RECON SOLN 15 MGixabepilone
BRAND 4PA
S
PAGE 69 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
JEVTANA SOLUTION 60 MG/1.5MLcabazitaxel
BRAND 4PA
S
leucovorin calcium recon soln 100 mg generic 1
leucovorin calcium recon soln 200 mg generic 1
leucovorin calcium recon soln 350 mg generic 1
leucovorin calcium recon soln 50 mg generic 1
LEUCOVORIN CALCIUM RECON SOLN 50MGleucovorin calcium
BRAND 1
leucovorin calcium recon soln 500 mg generic 1
leucovorin calcium solution 10 mg/ml generic 1
leucovorin calcium tab 10 mg generic 1
leucovorin calcium tab 15 mg generic 1
leucovorin calcium tab 25 mg generic 1
leucovorin calcium tab 5 mg generic 1
lipodox 50 injectable 2 mg/ml generic 4PA
S
lipodox injectable 2 mg/ml generic 4PA
S
LYSODREN TAB 500 MGmitotane
BRAND 4PA
S
mitomycin recon soln 20 mg generic 4PA
S
mitoxantrone hcl conc 25 mg/12.5ml generic 4PA
S
NAVELBINE SOLUTION 10 MG/MLvinorelbine tartrate
BRAND 4PA
S
OFORTA TAB 10 MGfludarabine phosphate
BRAND 4PA
S
PAGE 70 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ONCASPAR SOLUTION 750 UNIT/MLpegaspargase
BRAND 4PA
S
ONTAK SOLUTION 150 MCG/MLdenileukin diftitox
BRAND 4PA
S
oxaliplatin solution 100 mg/20ml generic 4PA
S
oxaliplatin solution 100 mg/20ml generic 4PA
S
oxaliplatin solution 50 mg/10ml generic 4PA
S
oxaliplatin solution 50 mg/10ml generic 4PA
S
paclitaxel conc 100 mg/16.7ml generic 4PA
S
paclitaxel conc 150 mg/25ml generic 4PA
S
PHOTOFRIN RECON SOLN 75 MGporfimer sodium
BRAND 4PA
S
PROLEUKIN RECON SOLN 22000000 UNITaldesleukin
BRAND 4PA
S
SYLATRON KIT 200 MCGpeginterferon alfa-2b (antineoplastic)
BRAND 4PA
S
SYLATRON KIT 300 MCGpeginterferon alfa-2b (antineoplastic)
BRAND 4PA
S
SYLATRON KIT 4 X 200 MCGpeginterferon alfa-2b (antineoplastic)
BRAND 4PA
S
SYLATRON KIT 4 X 300 MCGpeginterferon alfa-2b (antineoplastic)
BRAND 4PA
S
SYLATRON KIT 4 X 600 MCGpeginterferon alfa-2b (antineoplastic)
BRAND 4PA
S
PAGE 71 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SYLATRON KIT 600 MCGpeginterferon alfa-2b (antineoplastic)
BRAND 4PA
S
SYNRIBO RECON SOLN 3.5 MGomacetaxine mepesuccinate
BRAND 4PA
S
TAXOTERE CONC 20 MG/0.5MLdocetaxel
BRAND 4PA
S
TAXOTERE CONC 20 MG/MLdocetaxel
BRAND 4PA
S
TENIPOSIDE SOLUTION 10 MG/MLteniposide
BRAND 4PA
S
thiotepa recon soln 15 mg generic 4PA
S
TRISENOX SOLUTION 10 MG/10MLarsenic trioxide
BRAND 4PA
S
UVADEX SOLUTION 20 MCG/MLmethoxsalen (photopheresis)
BRAND 4PA
S
VALSTAR SOLUTION 40 MG/MLvalrubicin
BRAND 4PA
S
VELCADE RECON SOLN 3.5 MGbortezomib
BRAND 4PA
S
VIDAZA RECON SUSP 100 MGazacitidine
BRAND 4PA
S
vinblastine sulfate recon soln 10 mg generic 4PA
S
vincasar pfs solution 1 mg/ml generic 4PA
S
vincristine sulfate solution 1 mg/ml generic 4PA
S
vinorelbine tartrate solution 10 mg/ml generic 4PA
S
PAGE 72 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
vinorelbine tartrate solution 10 mg/ml generic 4PA
S
VORAXAZE RECON SOLN 1000 UNITglucarpidase
BRAND 4PA
S
VUMON SOLUTION 10 MG/MLteniposide
BRAND 4PA
S
ZALTRAP SOLUTION 100 MG/4MLziv-aflibercept
BRAND 4PA
S
ZOLINZA CAP 100 MGvorinostat
BRAND 4PA
S
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole tab 1 mg generic 1
ARIMIDEX TAB 1 MGanastrozole
BRAND 4
AROMASIN TAB 25 MGexemestane
BRAND 4PA
S
exemestane tab 25 mg generic 4 S
FEMARA TAB 2.5 MGletrozole
BRAND 4 PA
letrozole tab 2.5 mg generic 1
ENZYME INHIBITORS
ETOPOPHOS RECON SOLN 100 MGetoposide phosphate
BRAND 4PA
S
etoposide cap 50 mg generic 4PA
S
etoposide solution 1 gm/50ml generic 4PA
S
etoposide solution 100 mg/5ml generic 4PA
S
PAGE 73 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
etoposide solution 500 mg/25ml generic 4PA
S
HYCAMTIN CAP 0.25 MGtopotecan hcl
BRAND 4PA
S
HYCAMTIN CAP 1 MGtopotecan hcl
BRAND 4PA
S
HYCAMTIN RECON SOLN 4 MGtopotecan hcl
BRAND 4PA
S
toposar solution 1 gm/50ml generic 4PA
S
toposar solution 100 mg/5ml generic 4PA
S
toposar solution 500 mg/25ml generic 4PA
S
topotecan hcl recon soln 4 mg generic 4PA
S
MOLECULAR TARGET INHIBITORS
AFINITOR TAB 10 MGeverolimus
BRAND 4PA
S
AFINITOR TAB 2.5 MGeverolimus
BRAND 4PA
S
AFINITOR TAB 5 MGeverolimus
BRAND 4PA
S
AFINITOR TAB 7.5 MGeverolimus
BRAND 4PA
S
BOSULIF TAB 100 MGbosutinib
BRAND 4PA
S
BOSULIF TAB 500 MGbosutinib
BRAND 4PA
S
PAGE 74 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
CAPRELSA TAB 100 MGvandetanib
BRAND 4PA
S
CAPRELSA TAB 300 MGvandetanib
BRAND 4PA
S
COMETRIQ (100 MG DAILY DOSE) KIT 1 X80 & 1 X 20 MGcabozantinib s-malate
BRAND 4PA
S
COMETRIQ (140 MG DAILY DOSE) KIT 1 X80 & 3 X 20 MGcabozantinib s-malate
BRAND 4PA
S
COMETRIQ (60 MG DAILY DOSE) KIT 20 MGcabozantinib s-malate
BRAND 4PA
S
ERIVEDGE CAP 150 MGvismodegib
BRAND 4PA
S
GLEEVEC TAB 100 MGimatinib mesylate
BRAND 4PA
S
GLEEVEC TAB 400 MGimatinib mesylate
BRAND 4PA
S
imatinib mesylate tab 100 mg generic 4PA
S
imatinib mesylate tab 400 mg generic 4PA
S
INLYTA TAB 1 MGaxitinib
BRAND 4PA
S
INLYTA TAB 5 MGaxitinib
BRAND 4PA
S
JAKAFI TAB 10 MGruxolitinib phosphate
BRAND 4PA
S
JAKAFI TAB 15 MGruxolitinib phosphate
BRAND 4PA
S
PAGE 75 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
JAKAFI TAB 20 MGruxolitinib phosphate
BRAND 4PA
S
JAKAFI TAB 25 MGruxolitinib phosphate
BRAND 4PA
S
JAKAFI TAB 5 MGruxolitinib phosphate
BRAND 4PA
S
KYPROLIS RECON SOLN 60 MGcarfilzomib
BRAND 4PA
S
NEXAVAR TAB 200 MGsorafenib tosylate
BRAND 4PA
S
NINLARO CAP 2.3 MGixazomib citrate
BRAND 4PA
MDS 4 / 28 Days
NINLARO CAP 3 MGixazomib citrate
BRAND 4PA
MDS 4 / 28 Days
NINLARO CAP 4 MGixazomib citrate
BRAND 4PA
MDS 4 / 28 Days
SPRYCEL TAB 100 MGdasatinib
BRAND 4PA
S
SPRYCEL TAB 140 MGdasatinib
BRAND 4PA
S
SPRYCEL TAB 20 MGdasatinib
BRAND 4PA
S
SPRYCEL TAB 50 MGdasatinib
BRAND 4PA
S
SPRYCEL TAB 70 MGdasatinib
BRAND 4PA
S
SPRYCEL TAB 80 MGdasatinib
BRAND 4PA
S
STIVARGA TAB 40 MGregorafenib
BRAND 4PA
S
PAGE 76 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SUTENT CAP 12.5 MGsunitinib malate
BRAND 4PA
S
SUTENT CAP 25 MGsunitinib malate
BRAND 4PA
S
SUTENT CAP 50 MGsunitinib malate
BRAND 4PA
S
TARCEVA TAB 100 MGerlotinib hcl
BRAND 4PA
S
TARCEVA TAB 150 MGerlotinib hcl
BRAND 4PA
S
TARCEVA TAB 25 MGerlotinib hcl
BRAND 4PA
S
TASIGNA CAP 150 MGnilotinib hcl
BRAND 4PA
S
TASIGNA CAP 200 MGnilotinib hcl
BRAND 4PA
S
TORISEL SOLUTION 25 MG/MLtemsirolimus
BRAND 4PA
S
TYKERB TAB 250 MGlapatinib ditosylate
BRAND 4PA
S
VANDETANIB TAB 100 MGvandetanib
BRAND 4PA
S
VANDETANIB TAB 300 MGvandetanib
BRAND 4PA
S
VOTRIENT TAB 200 MGpazopanib hcl
BRAND 4PA
S
XALKORI CAP 200 MGcrizotinib
BRAND 4PA
S
XALKORI CAP 250 MGcrizotinib
BRAND 4PA
S
PAGE 77 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ZELBORAF TAB 240 MGvemurafenib
BRAND 4PA
S
MONOCLONAL ANTIBODIES
ADCETRIS RECON SOLN 50 MGbrentuximab vedotin
BRAND 4PA
S
ARZERRA CONC 100 MG/5MLofatumumab
BRAND 4PA
S
ARZERRA CONC 1000 MG/50MLofatumumab
BRAND 4PA
S
AVASTIN SOLUTION 100 MG/4MLbevacizumab
BRAND 4PA
S
BEXXAR CONC 14 MG/MLtositumomab
BRAND 4PA
S
ERBITUX SOLUTION 100 MG/50MLcetuximab
BRAND 4PA
S
ERBITUX SOLUTION 200 MG/100MLcetuximab
BRAND 4PA
S
HERCEPTIN RECON SOLN 440 MGtrastuzumab
BRAND 4PA
S
PERJETA SOLUTION 420 MG/14MLpertuzumab
BRAND 4PA
S
RITUXAN SOLUTION 100 MG/10MLrituximab
BRAND 4PA
S
RITUXAN SOLUTION 500 MG/50MLrituximab
BRAND 4PA
S
VECTIBIX SOLUTION 100 MG/5MLpanitumumab
BRAND 4PA
S
YERVOY SOLUTION 200 MG/40MLipilimumab
BRAND 4PA
S
PAGE 78 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
YERVOY SOLUTION 50 MG/10MLipilimumab
BRAND 4PA
S
RETINOIDS
bexarotene cap 75 mg generic 4
PA
MPL 1 / 30 daysS
PANRETIN GEL 0.1 %alitretinoin
BRAND 3
TARGRETIN CAP 75 MGbexarotene
BRAND 4
PA
MPL 1 / 30 daysS
TARGRETIN GEL 1 %bexarotene (topical)
BRAND 4PA
S
tretinoin cap 10 mg generic 1
ANTIPARASITICS
ANTIHELMINTHICS
ALBENZA TAB 200 MGalbendazole
BRAND 3
BILTRICIDE TAB 600 MGpraziquantel
BRAND 3
ivermectin tab 3 mg generic 1
mebendazole chew tab 100 mg generic 1
SKLICE LOTION 0.5 %ivermectin (pediculicide)
BRAND 3
STROMECTOL TAB 3 MGivermectin
BRAND 3
ANTIPROTOZOALS
ALINIA RECON SUSP 100 MG/5MLnitazoxanide
BRAND 2
ALINIA TAB 500 MGnitazoxanide
BRAND 2
PAGE 79 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
atovaquone suspension 750 mg/5ml generic 1
atovaquone-proguanil hcl tab 250-100 mg generic 1 MDS 12 / 3 days
atovaquone-proguanil hcl tab 62.5-25 mg generic 1 MDS 12 / 3 days
chloroquine phosphate tab 250 mg generic 1
chloroquine phosphate tab 500 mg generic 1
COARTEM TAB 20-120 MGartemether-lumefantrine
BRAND 2 MDS 24 / 3 days
DARAPRIM TAB 25 MGpyrimethamine
BRAND 3 MDD 3 per day
hydroxychloroquine sulfate tab 200 mg generic 1
MALARONE TAB 250-100 MGatovaquone-proguanil hcl
BRAND 2 MDS 12 / 3 days
MALARONE TAB 62.5-25 MGatovaquone-proguanil hcl
BRAND 2 MDS 12 / 3 days
mefloquine hcl tab 250 mg generic 1
MEPRON SUSPENSION 750 MG/5MLatovaquone
BRAND 3
NEBUPENT RECON SOLN 300 MGpentamidine isethionate
BRAND 3
PENTAM RECON SOLN 300 MGpentamidine isethionate
BRAND 3
primaquine phosphate tab 26.3 mg generic 3
PRIMAQUINE PHOSPHATE TAB 26.3 MGprimaquine phosphate
BRAND 3
quinine sulfate cap 324 mg generic 1 MDS 84.0 days supplywithin 365 Days
PEDICULICIDES/SCABICIDES
acticin cream 5 % generic 1
EURAX CREAM 10 %crotamiton
BRAND 3
EURAX LOTION 10 %crotamiton
BRAND 3
PAGE 80 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
lindane lotion 1 % generic 3
lindane shampoo 1 % generic 3
malathion lotion 0.5 % generic 1
NATROBA SUSPENSION 0.9 %spinosad
BRAND 1
permethrin cream 5 % generic 1
SPINOSAD SUSPENSION 0.9 %spinosad
BRAND 2
ULESFIA LOTION 5 %benzyl alcohol (pediculicide)
BRAND 3
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine mesylate solution 1 mg/ml generic 1
benztropine mesylate tab 0.5 mg generic 1
benztropine mesylate tab 1 mg generic 1
benztropine mesylate tab 2 mg generic 1
trihexyphenidyl hcl elixir 0.4 mg/ml generic 1
trihexyphenidyl hcl tab 2 mg generic 1
trihexyphenidyl hcl tab 5 mg generic 1
ANTIPARKINSON AGENTS, OTHER
amantadine hcl cap 100 mg generic 1
amantadine hcl syrup 50 mg/5ml generic 1
amantadine hcl tab 100 mg generic 1
carbidopa-levodopa-entacapone tab 12.5-50-200 mg
generic 1
CARBIDOPA-LEVODOPA-ENTACAPONE TAB12.5-50-200 MGcarbidopa-levodopa-entacapone
BRAND 1
carbidopa-levodopa-entacapone tab 18.75-75-200 mg
generic 1
PAGE 81 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
CARBIDOPA-LEVODOPA-ENTACAPONE TAB18.75-75-200 MGcarbidopa-levodopa-entacapone
BRAND 1
carbidopa-levodopa-entacapone tab 25-100-200 mg
generic 1
CARBIDOPA-LEVODOPA-ENTACAPONE TAB25-100-200 MGcarbidopa-levodopa-entacapone
BRAND 1
carbidopa-levodopa-entacapone tab 31.25-125-200 mg
generic 1
CARBIDOPA-LEVODOPA-ENTACAPONE TAB31.25-125-200 MGcarbidopa-levodopa-entacapone
BRAND 1
carbidopa-levodopa-entacapone tab 37.5-150-200 mg
generic 1
CARBIDOPA-LEVODOPA-ENTACAPONE TAB37.5-150-200 MGcarbidopa-levodopa-entacapone
BRAND 1
carbidopa-levodopa-entacapone tab 50-200-200 mg
generic 1
CARBIDOPA-LEVODOPA-ENTACAPONE TAB50-200-200 MGcarbidopa-levodopa-entacapone
BRAND 1
entacapone tab 200 mg generic 1 MDD 8 per day
STALEVO 100 TAB 25-100-200 MGcarbidopa-levodopa-entacapone
BRAND 1
STALEVO 125 TAB 31.25-125-200 MGcarbidopa-levodopa-entacapone
BRAND 1
STALEVO 150 TAB 37.5-150-200 MGcarbidopa-levodopa-entacapone
BRAND 1
STALEVO 200 TAB 50-200-200 MGcarbidopa-levodopa-entacapone
BRAND 1
STALEVO 50 TAB 12.5-50-200 MGcarbidopa-levodopa-entacapone
BRAND 1
PAGE 82 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
STALEVO 75 TAB 18.75-75-200 MGcarbidopa-levodopa-entacapone
BRAND 1
TASMAR TAB 100 MGtolcapone
BRAND 3
DOPAMINE AGONISTS
APOKYN SOLUTION 10 MG/MLapomorphine hydrochloride
BRAND 4PA
S
bromocriptine mesylate cap 5 mg generic 1
bromocriptine mesylate tab 2.5 mg generic 1
NEUPRO PATCH 24HR 1 MG/24HRrotigotine
BRAND 2
NEUPRO PATCH 24HR 2 MG/24HRrotigotine
BRAND 2
NEUPRO PATCH 24HR 3 MG/24HRrotigotine
BRAND 2
NEUPRO PATCH 24HR 4 MG/24HRrotigotine
BRAND 2
NEUPRO PATCH 24HR 6 MG/24HRrotigotine
BRAND 2
NEUPRO PATCH 24HR 8 MG/24HRrotigotine
BRAND 2
pramipexole dihydrochloride tab 0.125 mg generic 1 MDD 4 per day
pramipexole dihydrochloride tab 0.25 mg generic 1
pramipexole dihydrochloride tab 0.5 mg generic 1
pramipexole dihydrochloride tab 0.75 mg generic 1
pramipexole dihydrochloride tab 1 mg generic 1
pramipexole dihydrochloride tab 1.5 mg generic 1
ropinirole hcl er tab er 24h 12 mg generic 1ST
MDD 2 per day
ropinirole hcl er tab er 24h 2 mg generic 1ST
MDD 1 per day
PAGE 83 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ropinirole hcl er tab er 24h 4 mg generic 1ST
MDD 1 per day
ropinirole hcl er tab er 24h 6 mg generic 1ST
MDD 1 per day
ropinirole hcl er tab er 24h 8 mg generic 1ST
MDD 2 per day
ropinirole hcl tab 0.25 mg generic 1
ropinirole hcl tab 0.5 mg generic 1
ropinirole hcl tab 1 mg generic 1
ropinirole hcl tab 2 mg generic 1
ropinirole hcl tab 3 mg generic 1
ropinirole hcl tab 4 mg generic 1
ropinirole hcl tab 5 mg generic 1
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa tab 25 mg generic 1
carbidopa-levodopa er tab er 25-100 mg generic 1
carbidopa-levodopa er tab er 50-200 mg generic 1
carbidopa-levodopa tab 10-100 mg generic 1
carbidopa-levodopa tab 25-100 mg generic 1
carbidopa-levodopa tab 25-250 mg generic 1
carbidopa-levodopa tab disp 10-100 mg generic 1
carbidopa-levodopa tab disp 25-100 mg generic 1
carbidopa-levodopa tab disp 25-250 mg generic 1
LODOSYN TAB 25 MGcarbidopa
BRAND 1
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
AZILECT TAB 0.5 MGrasagiline mesylate
BRAND 2PA
MDD 1 per day
PAGE 84 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
AZILECT TAB 1 MGrasagiline mesylate
BRAND 2PA
MDD 1 per day
selegiline hcl cap 5 mg generic 1
selegiline hcl tab 5 mg generic 1
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
chlorpromazine hcl solution 25 mg/ml generic 3
chlorpromazine hcl solution 50 mg/2ml generic 3
chlorpromazine hcl tab 10 mg generic 1
chlorpromazine hcl tab 100 mg generic 1
chlorpromazine hcl tab 200 mg generic 1
chlorpromazine hcl tab 25 mg generic 1
chlorpromazine hcl tab 50 mg generic 1
fluphenazine hcl conc 5 mg/ml generic 1
fluphenazine hcl elixir 2.5 mg/5ml generic 1
fluphenazine hcl solution 2.5 mg/ml generic 1
fluphenazine hcl tab 1 mg generic 1
fluphenazine hcl tab 10 mg generic 1
fluphenazine hcl tab 2.5 mg generic 1
fluphenazine hcl tab 5 mg generic 1
haloperidol decanoate solution 100 mg/ml generic 1 MFL 1 / 28 days
haloperidol decanoate solution 50 mg/ml generic 1 MFL 1 / 28 days
haloperidol lactate solution 5 mg/ml generic 1
haloperidol tab 0.5 mg generic 1
haloperidol tab 1 mg generic 1
haloperidol tab 10 mg generic 1
haloperidol tab 2 mg generic 1
PAGE 85 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
haloperidol tab 20 mg generic 1
haloperidol tab 5 mg generic 1
loxapine succinate cap 10 mg generic 1
loxapine succinate cap 25 mg generic 1
loxapine succinate cap 5 mg generic 1
loxapine succinate cap 50 mg generic 1
ORAP TAB 1 MGpimozide
BRAND 3
ORAP TAB 2 MGpimozide
BRAND 3
pimozide tab 1 mg generic 1
pimozide tab 2 mg generic 1
thioridazine hcl tab 10 mg generic 1
thioridazine hcl tab 100 mg generic 1
thioridazine hcl tab 25 mg generic 1
thioridazine hcl tab 50 mg generic 1
thiothixene cap 1 mg generic 1
thiothixene cap 10 mg generic 1
thiothixene cap 2 mg generic 1
thiothixene cap 5 mg generic 1
trifluoperazine hcl tab 1 mg generic 1
trifluoperazine hcl tab 10 mg generic 1
trifluoperazine hcl tab 2 mg generic 1
trifluoperazine hcl tab 5 mg generic 1
2ND GENERATION/ATYPICAL
aripiprazole solution 1 mg/ml generic 3
PA
AL At least 6 yrs oldMDS 900 / 30 days
PAGE 86 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
aripiprazole tab 10 mg generic 3
PA
AL At least 6 yrs oldMDD 1 per day
aripiprazole tab 15 mg generic 3
PA
AL At least 6 yrs oldMDD 1 per day
aripiprazole tab 2 mg generic 3
PA
AL At least 6 yrs oldMDD 1 per day
aripiprazole tab 20 mg generic 3
PA
AL At least 6 yrs oldMDD 1 per day
aripiprazole tab 30 mg generic 3
PA
AL At least 6 yrs oldMDD 1 per day
aripiprazole tab 5 mg generic 3
PA
AL At least 6 yrs oldMDD 1 per day
FANAPT TAB 1 MGiloperidone
BRAND 2PA
MDD 2 per day
FANAPT TAB 10 MGiloperidone
BRAND 2PA
MDD 2 per day
FANAPT TAB 12 MGiloperidone
BRAND 2PA
MDD 2 per day
FANAPT TAB 2 MGiloperidone
BRAND 2PA
MDD 2 per day
FANAPT TAB 4 MGiloperidone
BRAND 2PA
MDD 2 per day
FANAPT TAB 6 MGiloperidone
BRAND 2PA
MDD 2 per day
PAGE 87 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
FANAPT TAB 8 MGiloperidone
BRAND 2PA
MDD 2 per day
FANAPT TITRATION PACK TAB 1 & 2 & 4 &6 MGiloperidone
BRAND 2PA
MPL 2 / 365 days
INVEGA TAB ER 24H 1.5 MGpaliperidone
BRAND 2PA
MDD 1 per day
INVEGA TAB ER 24H 3 MGpaliperidone
BRAND 2PA
MDD 1 per day
INVEGA TAB ER 24H 6 MGpaliperidone
BRAND 2PA
MDD 2 per day
INVEGA TAB ER 24H 9 MGpaliperidone
BRAND 2PA
MDD 1 per day
LATUDA TAB 120 MGlurasidone hcl
BRAND 3PA
MDD 1 per day
LATUDA TAB 20 MGlurasidone hcl
BRAND 3PA
MDD 1 per day
LATUDA TAB 40 MGlurasidone hcl
BRAND 3PA
MDD 1 per day
LATUDA TAB 60 MGlurasidone hcl
BRAND 3PA
MDD 1 per day
LATUDA TAB 80 MGlurasidone hcl
BRAND 3PA
MDD 1 per day
olanzapine recon soln 10 mg generic 1 MDS 6 / 28 days
olanzapine tab 10 mg generic 1 MDD 1 per day
olanzapine tab 15 mg generic 1 MDD 2 per day
olanzapine tab 2.5 mg generic 1 MDD 1 per day
olanzapine tab 20 mg generic 1 MDD 2 per day
olanzapine tab 5 mg generic 1 MDD 1 per day
PAGE 88 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
olanzapine tab 7.5 mg generic 1 MDD 1 per day
quetiapine fumarate tab 100 mg generic 1AL At least 10 yrs old
MDD 2 per day
quetiapine fumarate tab 200 mg generic 1AL At least 10 yrs old
MDD 2 per day
quetiapine fumarate tab 25 mg generic 1AL At least 10 yrs old
MDD 2 per day
quetiapine fumarate tab 300 mg generic 1AL At least 10 yrs old
MDD 2 per day
quetiapine fumarate tab 400 mg generic 1AL At least 10 yrs old
MDD 2 per day
quetiapine fumarate tab 50 mg generic 1AL At least 10 yrs old
MDD 2 per day
RISPERDAL CONSTA RECON SUSP 12.5 MGrisperidone microspheres
BRAND 2PA
MFL 2 / 28 days
RISPERDAL CONSTA RECON SUSP 25 MGrisperidone microspheres
BRAND 2PA
MFL 2 / 28 days
RISPERDAL CONSTA RECON SUSP 37.5 MGrisperidone microspheres
BRAND 2PA
MFL 2 / 28 days
RISPERDAL CONSTA RECON SUSP 50 MGrisperidone microspheres
BRAND 2PA
MFL 2 / 28 days
risperidone m-tab tab disp 0.5 mg generic 1PA
MDD 2 per day
risperidone m-tab tab disp 1 mg generic 1PA
MDD 2 per day
risperidone m-tab tab disp 2 mg generic 1PA
MDD 2 per day
risperidone m-tab tab disp 3 mg generic 1PA
MDD 2 per day
PAGE 89 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
risperidone m-tab tab disp 4 mg generic 1PA
MDD 2 per day
risperidone solution 1 mg/ml generic 1PA
MDS 240 / 30 days
risperidone tab 0.25 mg generic 1 MDD 2 per day
risperidone tab 0.5 mg generic 1 MDD 2 per day
risperidone tab 1 mg generic 1 MDD 2 per day
risperidone tab 2 mg generic 1 MDD 2 per day
risperidone tab 3 mg generic 1 MDD 2 per day
risperidone tab 4 mg generic 1 MDD 4 per day
risperidone tab disp 0.25 mg generic 1PA
MDD 2 per day
risperidone tab disp 0.5 mg generic 1PA
MDD 2 per day
risperidone tab disp 1 mg generic 1PA
MDD 2 per day
risperidone tab disp 2 mg generic 1PA
MDD 2 per day
risperidone tab disp 3 mg generic 1PA
MDD 2 per day
risperidone tab disp 4 mg generic 1PA
MDD 2 per day
SAPHRIS SL TAB 10 MGasenapine maleate
BRAND 2PA
MDD 2 per day
SAPHRIS SL TAB 5 MGasenapine maleate
BRAND 2PA
MDD 2 per day
SEROQUEL XR TAB ER 24H 150 MGquetiapine fumarate
BRAND 2
PA
AL At least 10 yrs oldMDD 1 per day
PAGE 90 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SEROQUEL XR TAB ER 24H 200 MGquetiapine fumarate
BRAND 2
PA
AL At least 10 yrs oldMDD 1 per day
SEROQUEL XR TAB ER 24H 300 MGquetiapine fumarate
BRAND 2
PA
AL At least 10 yrs oldMDD 2 per day
SEROQUEL XR TAB ER 24H 400 MGquetiapine fumarate
BRAND 2
PA
AL At least 10 yrs oldMDD 2 per day
SEROQUEL XR TAB ER 24H 50 MGquetiapine fumarate
BRAND 2
PA
AL At least 10 yrs oldMDD 1 per day
ziprasidone hcl cap 20 mg generic 1AL At least 18 yrs old
MDD 2 per day
ziprasidone hcl cap 40 mg generic 1AL At least 18 yrs old
MDD 2 per day
ziprasidone hcl cap 60 mg generic 1AL At least 18 yrs old
MDD 2 per day
ziprasidone hcl cap 80 mg generic 1AL At least 18 yrs old
MDD 2 per day
TREATMENT-RESISTANT
clozapine tab 100 mg generic 1
clozapine tab 200 mg generic 1
clozapine tab 25 mg generic 1
clozapine tab 50 mg generic 1
ANTISPASTICITY AGENTS
baclofen tab 10 mg generic 1
baclofen tab 20 mg generic 1
dantrolene sodium cap 100 mg generic 1 MDD 4 per day
PAGE 91 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
dantrolene sodium cap 25 mg generic 1 MDD 4 per day
dantrolene sodium cap 50 mg generic 1 MDD 4 per day
ed baclofen tab 10 mg generic 1
tizanidine hcl 2 mg generic 1
tizanidine hcl 4 mg generic 1
tizanidine hcl cap 2 mg generic 1
tizanidine hcl cap 4 mg generic 1
tizanidine hcl cap 6 mg generic 1
tizanidine hcl tab 2 mg generic 1
tizanidine hcl tab 2 mg generic 1
tizanidine hcl tab 4 mg generic 1
tizanidine hcl tab 4 mg generic 1
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
cidofovir solution 75 mg/ml generic 3
FOSCAVIR SOLUTION 6000 MG/250MLfoscarnet sodium
BRAND 3
ganciclovir sodium recon soln 500 mg generic 1
VALCYTE RECON SOLN 50 MG/MLvalganciclovir hcl
BRAND 2PA
MDS 540 / 30 days
VALCYTE TAB 450 MGvalganciclovir hcl
BRAND 2PA
MDD 4 per day
valganciclovir hcl tab 450 mg generic 1PA
MDD 4 per day
valganciclovir hcl tab 450 mg generic 1PA
MDD 4 per day
VISTIDE SOLUTION 75 MG/MLcidofovir
BRAND 3
PAGE 92 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ZIRGAN GEL 0.15 %ganciclovir ophthalmic
BRAND 2
ANTI-HEPATITIS B (HBV) AGENTS
adefovir dipivoxil tab 10 mg generic 4
PA
MDD 1 per dayS
BARACLUDE SOLUTION 0.05 MG/MLentecavir
BRAND 4
PA
MDS 600 / 30 daysS
BARACLUDE TAB 0.5 MGentecavir
BRAND 4
PA
MDD 1 per dayS
BARACLUDE TAB 1 MGentecavir
BRAND 4
PA
MDD 1 per dayS
entecavir tab 0.5 mg generic 4
PA
MDD 1 per dayS
entecavir tab 1 mg generic 4
PA
MDD 1 per dayS
EPIVIR HBV SOLUTION 5 MG/MLlamivudine (hbv)
BRAND 4MDS 1800 / 30 days
S
EPIVIR HBV TAB 100 MGlamivudine (hbv)
BRAND 4MDD 3 per day
S
HEPSERA TAB 10 MGadefovir dipivoxil
BRAND 4
PA
MDD 1 per dayS
lamivudine tab 100 mg generic 1MDD 3 per day
S
PAGE 93 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
TYZEKA TAB 600 MGtelbivudine
BRAND 4
PA
MDD 1 per dayS
ANTI-HEPATITIS C (HCV) AGENTS
EPCLUSA TAB 400-100 MGsofosbuvir-velpatasvir
BRAND 4 PA
HARVONI TAB 90-400 MGledipasvir-sofosbuvir
BRAND 4
PA
MDD 1 per dayS
INCIVEK TAB 375 MGtelaprevir
BRAND 4MDD 6 per day
S
INFERGEN INJECTABLE 15 MCG/0.5MLinterferon alfacon-1
BRAND 4PA
S
INFERGEN INJECTABLE 9 MCG/0.3MLinterferon alfacon-1
BRAND 4PA
S
INTRON A RECON SOLN 18000000 UNITinterferon alfa-2b
BRAND 4PA
S
moderiba tab 200 mg generic 1 MDD 7 per day
PEG-INTRON KIT 120 MCG/0.5MLpeginterferon alfa-2b
BRAND 4
PA
MDS 4 / 28 daysS
PEG-INTRON KIT 150 MCG/0.5MLpeginterferon alfa-2b
BRAND 4
PA
MDS 4 / 28 daysS
PEG-INTRON KIT 50 MCG/0.5MLpeginterferon alfa-2b
BRAND 4
PA
MDS 4 / 28 daysS
PEG-INTRON KIT 80 MCG/0.5MLpeginterferon alfa-2b
BRAND 4
PA
MDS 4 / 28 daysS
PAGE 94 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
PEG-INTRON REDIPEN KIT 120 MCG/0.5MLpeginterferon alfa-2b
BRAND 4
PA
MDS 4 / 28 daysS
PEG-INTRON REDIPEN KIT 150 MCG/0.5MLpeginterferon alfa-2b
BRAND 4
PA
MDS 4 / 28 daysS
PEG-INTRON REDIPEN KIT 50 MCG/0.5MLpeginterferon alfa-2b
BRAND 4
PA
MDS 4 / 28 daysS
PEG-INTRON REDIPEN KIT 80 MCG/0.5MLpeginterferon alfa-2b
BRAND 4
PA
MDS 4 / 28 daysS
PEG-INTRON REDIPEN PAK 4 KIT 120MCG/0.5MLpeginterferon alfa-2b
BRAND 4
PA
MDS 4 / 28 daysS
PEG-INTRON REDIPEN PAK 4 KIT 150MCG/0.5MLpeginterferon alfa-2b
BRAND 4
PA
MDS 4 / 28 daysS
PEG-INTRON REDIPEN PAK 4 KIT 50MCG/0.5MLpeginterferon alfa-2b
BRAND 4
PA
MDS 4 / 28 daysS
PEG-INTRON REDIPEN PAK 4 KIT 80MCG/0.5MLpeginterferon alfa-2b
BRAND 4
PA
MDS 4 / 28 daysS
PEGASYS KIT 180 MCG/0.5MLpeginterferon alfa-2a
BRAND 4
PA
MDS 1 / 28 daysS
PEGASYS PROCLICK SOLUTION 135MCG/0.5MLpeginterferon alfa-2a
BRAND 4
PA
MPL 2 / 28 daysS
PAGE 95 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
PEGASYS PROCLICK SOLUTION 180MCG/0.5MLpeginterferon alfa-2a
BRAND 4
PA
MPL 2 / 28 daysS
PEGASYS SOLUTION 180 MCG/0.5MLpeginterferon alfa-2a
BRAND 4
PA
MPL 2 / 28 daysS
PEGASYS SOLUTION 180 MCG/MLpeginterferon alfa-2a
BRAND 4
PA
MPL 4 / 28 daysS
PEGINTRON KIT 120 MCG/0.5MLpeginterferon alfa-2b
BRAND 4
PA
MDS 4 / 28 daysS
PEGINTRON KIT 150 MCG/0.5MLpeginterferon alfa-2b
BRAND 4
PA
MDS 4 / 28 daysS
PEGINTRON KIT 50 MCG/0.5MLpeginterferon alfa-2b
BRAND 4
PA
MDS 4 / 28 daysS
PEGINTRON KIT 80 MCG/0.5MLpeginterferon alfa-2b
BRAND 4
PA
MDS 4 / 28 daysS
REBETOL SOLUTION 40 MG/MLribavirin (hepatitis c)
BRAND 4
PA
MDS 1050 / 30 daysS
ribasphere cap 200 mg generic 1 MDD 7 per day
ribasphere tab 200 mg generic 1 MDD 7 per day
ribavirin cap 200 mg generic 1 MDD 7 per day
ribavirin tab 200 mg generic 1 MDD 7 per day
SOVALDI TAB 400 MGsofosbuvir
BRAND 4
PA
MDD 1 per dayS
PAGE 96 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
VICTRELIS CAP 200 MGboceprevir
BRAND 4
PA
MDD 12 per dayS
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
GENVOYA TAB 150-150-200-10 MGelvitegravir-cobicistat-emtricitabine-tenofovir alafenamide
BRAND 3 MDD 1 per day
ISENTRESS CHEW TAB 100 MGraltegravir potassium
BRAND 2
ISENTRESS CHEW TAB 25 MGraltegravir potassium
BRAND 2
ISENTRESS TAB 400 MGraltegravir potassium
BRAND 2 MDD 2 per day
STRIBILD TAB 150-150-200-300 MGelvitegravir-cobicistat-emtricitabine-tenofovir
BRAND 3 MDD 1 per day
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
ATRIPLA TAB 600-200-300 MGefavirenz-emtricitabine-tenofovir disoproxilfumarate
BRAND 3 MDD 1 per day
COMPLERA TAB 200-25-300 MGemtricitabine-rilpivirine-tenofovir disoproxilfumarate
BRAND 3 MDD 1 per day
EDURANT TAB 25 MGrilpivirine hcl
BRAND 2 MDD 1 per day
INTELENCE TAB 100 MGetravirine
BRAND 2 MDD 4 per day
INTELENCE TAB 200 MGetravirine
BRAND 2 MDD 2 per day
INTELENCE TAB 25 MGetravirine
BRAND 2 MDD 8 per day
nevirapine er tab er 24h 400 mg generic 1 MDD 1 per day
PAGE 97 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
nevirapine suspension 50 mg/5ml generic 1 MDS 1200 / 30 days
nevirapine tab 200 mg generic 1 MDD 2 per day
ODEFSEY TAB 200-25-25 MGemtricitabine-rilpivirine-tenofoviralafenamide fumarate
BRAND 3 MDD 1 per day
RESCRIPTOR TAB 100 MGdelavirdine mesylate
BRAND 2 MDD 12 per day
RESCRIPTOR TAB 200 MGdelavirdine mesylate
BRAND 2 MDD 6 per day
SUSTIVA CAP 200 MGefavirenz
BRAND 2 MDD 2 per day
SUSTIVA CAP 50 MGefavirenz
BRAND 2 MDD 3 per day
SUSTIVA TAB 600 MGefavirenz
BRAND 2 MDD 1 per day
VIRAMUNE SUSPENSION 50 MG/5MLnevirapine
BRAND 2 MDS 1200 / 30 days
VIRAMUNE XR TAB ER 24H 100 MGnevirapine
BRAND 2 MDD 3 per day
VIRAMUNE XR TAB ER 24H 400 MGnevirapine
BRAND 2 MDD 1 per day
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASEINHIBITORS (NRTI)
abacavir sulfate tab 300 mg generic 1 MDD 2 per day
abacavir-lamivudine-zidovudine tab 300-150-300 mg
generic 1 MDD 2 per day
DESCOVY TAB 200-25 MGemtricitabine-tenofovir alafenamidefumarate
BRAND 2 MDD 1 per day
didanosine cap dr 125 mg generic 1 MDD 2 per day
didanosine cap dr 200 mg generic 1 MDD 2 per day
didanosine cap dr 250 mg generic 1 MDD 1 per day
PAGE 98 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
didanosine cap dr 400 mg generic 1 MDD 1 per day
EMTRIVA CAP 200 MGemtricitabine
BRAND 2 MDD 1 per day
EMTRIVA SOLUTION 10 MG/MLemtricitabine
BRAND 2
EPIVIR SOLUTION 10 MG/MLlamivudine
BRAND 3 MDS 900 / 30 days
EPIVIR TAB 150 MGlamivudine
BRAND 3 MDD 2 per day
EPIVIR TAB 300 MGlamivudine
BRAND 3 MDD 1 per day
EPZICOM TAB 600-300 MGabacavir sulfate-lamivudine
BRAND 2 MDD 1 per day
lamivudine solution 10 mg/ml generic 1 MDS 900 / 30 days
lamivudine tab 150 mg generic 1 MDD 2 per day
lamivudine tab 300 mg generic 1 MDD 1 per day
lamivudine-zidovudine tab 150-300 mg generic 1 MDD 2 per day
RETROVIR SOLUTION 10 MG/MLzidovudine
BRAND 1
stavudine cap 15 mg generic 1 MDD 2 per day
stavudine cap 20 mg generic 1 MDD 2 per day
stavudine cap 30 mg generic 1 MDD 2 per day
stavudine cap 40 mg generic 1 MDD 2 per day
stavudine recon soln 1 mg/ml generic 1 MDS 2400 / 30 days
TRIZIVIR TAB 300-150-300 MGabacavir sulfate-lamivudine-zidovudine
BRAND 2 MDD 2 per day
TRUVADA TAB 200-300 MGemtricitabine-tenofovir disoproxil fumarate
BRAND 2PA
MDD 1 per day
VIDEX RECON SOLN 2 GMdidanosine
BRAND 2
PAGE 99 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
VIDEX RECON SOLN 4 GMdidanosine
BRAND 2
VIREAD POWDER 40 MG/GMtenofovir disoproxil fumarate
BRAND 2
VIREAD TAB 150 MGtenofovir disoproxil fumarate
BRAND 2 MDD 1 per day
VIREAD TAB 200 MGtenofovir disoproxil fumarate
BRAND 2 MDD 1 per day
VIREAD TAB 250 MGtenofovir disoproxil fumarate
BRAND 2 MDD 1 per day
VIREAD TAB 300 MGtenofovir disoproxil fumarate
BRAND 2
ZIAGEN SOLUTION 20 MG/MLabacavir sulfate
BRAND 2
zidovudine cap 100 mg generic 1 MDD 6 per day
zidovudine syrup 50 mg/5ml generic 1 MDS 1800 / 30 days
zidovudine tab 300 mg generic 1 MDD 2 per day
ANTI-HIV AGENTS, OTHER
FUZEON KIT 90 MGenfuvirtide
BRAND 4
PA
MPL 1 / 30 daysS
FUZEON RECON SOLN 90 MGenfuvirtide
BRAND 4
PA
MPL 1 / 30 daysS
SELZENTRY TAB 150 MGmaraviroc
BRAND 2 MDD 2 per day
SELZENTRY TAB 300 MGmaraviroc
BRAND 2 MDD 4 per day
TRIUMEQ TAB 600-50-300 MGabacavir-dolutegravir-lamivudine
BRAND 3 MDD 1 per day
TYBOST TAB 150 MGcobicistat
BRAND 2 MDD 1 per day
PAGE 100 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ANTI-HIV AGENTS, PROTEASE INHIBITORS
APTIVUS CAP 250 MGtipranavir
BRAND 2 MDD 4 per day
APTIVUS SOLUTION 100 MG/MLtipranavir
BRAND 2 MDS 300 / 30 days
CRIXIVAN CAP 200 MGindinavir sulfate
BRAND 2 MDD 9 per day
CRIXIVAN CAP 400 MGindinavir sulfate
BRAND 2 MDD 6 per day
INVIRASE CAP 200 MGsaquinavir mesylate
BRAND 2 MDD 10 per day
INVIRASE TAB 500 MGsaquinavir mesylate
BRAND 2 MDD 4 per day
KALETRA SOLUTION 400-100 MG/5MLlopinavir-ritonavir
BRAND 2 MDS 375 / 30 days
KALETRA TAB 100-25 MGlopinavir-ritonavir
BRAND 2 MDD 4 per day
KALETRA TAB 200-50 MGlopinavir-ritonavir
BRAND 2 MDD 4 per day
LEXIVA SUSPENSION 50 MG/MLfosamprenavir calcium
BRAND 2 MDS 1680 / 30 days
LEXIVA TAB 700 MGfosamprenavir calcium
BRAND 2 MDD 4 per day
NORVIR CAP 100 MGritonavir
BRAND 2 MDD 12 per day
NORVIR SOLUTION 80 MG/MLritonavir
BRAND 2 MDS 450 / 30 days
NORVIR TAB 100 MGritonavir
BRAND 2 MDD 12 per day
PREZISTA SUSPENSION 100 MG/MLdarunavir ethanolate
BRAND 2 MDS 360 / 30 days
PREZISTA TAB 150 MGdarunavir ethanolate
BRAND 2 MDD 2 per day
PAGE 101 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
PREZISTA TAB 400 MGdarunavir ethanolate
BRAND 2 MDD 2 per day
PREZISTA TAB 600 MGdarunavir ethanolate
BRAND 2 MDD 2 per day
PREZISTA TAB 75 MGdarunavir ethanolate
BRAND 2 MDD 2 per day
PREZISTA TAB 800 MGdarunavir ethanolate
BRAND 2 MDD 1 per day
REYATAZ CAP 100 MGatazanavir sulfate
BRAND 2 MDD 4 per day
REYATAZ CAP 150 MGatazanavir sulfate
BRAND 2 MDD 2 per day
REYATAZ CAP 200 MGatazanavir sulfate
BRAND 2 MDD 2 per day
REYATAZ CAP 300 MGatazanavir sulfate
BRAND 2 MDD 1 per day
VIRACEPT TAB 250 MGnelfinavir mesylate
BRAND 2 MDD 10 per day
VIRACEPT TAB 625 MGnelfinavir mesylate
BRAND 2 MDD 4 per day
ANTI-INFLUENZA AGENTS
RELENZA DISKHALER AER POW BA 5MG/BLISTERzanamivir
BRAND 2 MPL 1 / 30 days
rimantadine hcl tab 100 mg generic 1 MDD 2 per day
TAMIFLU CAP 30 MGoseltamivir phosphate
BRAND 2 MDS 20 / 30 days
TAMIFLU CAP 45 MGoseltamivir phosphate
BRAND 2 MDS 10 / 30 days
TAMIFLU CAP 75 MGoseltamivir phosphate
BRAND 2 MDS 10 / 30 days
TAMIFLU RECON SUSP 6 MG/MLoseltamivir phosphate
BRAND 2 MDS 120 / 30 days
PAGE 102 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ANTIHERPETIC AGENTS
acyclovir cap 200 mg generic 1 MDS 50 / 30 days
acyclovir ointment 5 % generic 1
acyclovir suspension 200 mg/5ml generic 1 MDS 400 / 30 days
acyclovir tab 400 mg generic 1 MDD 5 per day
acyclovir tab 800 mg generic 1 MDD 5 per day
DENAVIR CREAM 1 %penciclovir
BRAND 3
famciclovir tab 125 mg generic 1PA
MDD 3 per day
famciclovir tab 250 mg generic 1PA
MDD 3 per day
famciclovir tab 500 mg generic 1PA
MDD 4 per day
trifluridine solution 1 % generic 1
valacyclovir hcl tab 1 gm generic 1 MDD 4 per day
valacyclovir hcl tab 500 mg generic 1 MDD 2 per day
ZOVIRAX CREAM 5 %acyclovir topical
BRAND 3
ANXIOLYTICS
ANXIOLYTICS, OTHER
buspirone hcl tab 10 mg generic 1
buspirone hcl tab 15 mg generic 1
buspirone hcl tab 30 mg generic 1
buspirone hcl tab 5 mg generic 1 MDD 1 per day
buspirone hcl tab 7.5 mg generic 1
meprobamate tab 200 mg generic 1
PAGE 103 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
meprobamate tab 400 mg generic 1
BENZODIAZEPINES
alprazolam tab 0.25 mg generic 1 MDD 4 per day
alprazolam tab 0.5 mg generic 1 MDD 4 per day
alprazolam tab 1 mg generic 1 MDD 4 per day
alprazolam tab 2 mg generic 1 MDD 4 per day
clonazepam tab 0.5 mg generic 1
clonazepam tab 1 mg generic 1
clonazepam tab 2 mg generic 1
diazepam tab 10 mg generic 1 MDD 4 per day
diazepam tab 2 mg generic 1 MDD 4 per day
diazepam tab 5 mg generic 1 MDD 4 per day
lorazepam tab 0.5 mg generic 1 MDD 3 per day
lorazepam tab 1 mg generic 1 MDD 4 per day
lorazepam tab 2 mg generic 1 MDD 3 per day
BIPOLAR AGENTS
MOOD STABILIZERS
EQUETRO CAP ER 12H 100 MGcarbamazepine (antipsychotic)
BRAND 3ST
MDD 2 per day
EQUETRO CAP ER 12H 200 MGcarbamazepine (antipsychotic)
BRAND 3ST
MDD 8 per day
EQUETRO CAP ER 12H 300 MGcarbamazepine (antipsychotic)
BRAND 3ST
MDD 4 per day
lithium carbonate cap 150 mg generic 1
lithium carbonate cap 300 mg generic 1
lithium carbonate cap 600 mg generic 1
PAGE 104 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
lithium carbonate er tab er 300 mg generic 1
lithium carbonate er tab er 450 mg generic 1
lithium carbonate tab 300 mg generic 1
lithium solution 8 meq/5ml generic 1
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
acarbose tab 100 mg generic 1 MDD 3 per day
acarbose tab 25 mg generic 1 MDD 3 per day
acarbose tab 50 mg generic 1 MDD 3 per day
ACTOPLUS MET TAB 15-500 MGpioglitazone hcl-metformin hcl
BRAND 2 MDD 2 per day
ACTOPLUS MET TAB 15-850 MGpioglitazone hcl-metformin hcl
BRAND 2 MDD 2 per day
AVANDIA TAB 2 MGrosiglitazone maleate
BRAND 3 MDD 1 per day
AVANDIA TAB 4 MGrosiglitazone maleate
BRAND 3 MDD 1 per day
AVANDIA TAB 8 MGrosiglitazone maleate
BRAND 3 MDD 1 per day
BYETTA 10 MCG PEN SOLN PEN 10MCG/0.04MLexenatide
BRAND 2PA
MDS 1.2 / 30 days
BYETTA 5 MCG PEN SOLN PEN 5MCG/0.02MLexenatide
BRAND 2PA
MDS 2.4 / 30 days
chlorpropamide tab 100 mg generic 1 MDD 3 per day
CYCLOSET TAB 0.8 MGbromocriptine mesylate (diabetes)
BRAND 3 MDD 6 per day
glimepiride tab 1 mg generic 1 MDD 1 per day
glimepiride tab 2 mg generic 1 MDD 1 per day
PAGE 105 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
glimepiride tab 4 mg generic 1 MDD 2 per day
glipizide er tab er 24h 10 mg generic 1 MDD 2 per day
glipizide er tab er 24h 2.5 mg generic 1 MDD 2 per day
glipizide er tab er 24h 5 mg generic 1 MDD 2 per day
glipizide tab 10 mg generic 1 MDD 4 per day
glipizide tab 5 mg generic 1 MDD 4 per day
glipizide xl tab er 24h 10 mg generic 1 MDD 2 per day
glipizide xl tab er 24h 2.5 mg generic 1 MDD 2 per day
glipizide xl tab er 24h 5 mg generic 1 MDD 2 per day
glipizide-metformin hcl tab 2.5-250 mg generic 1 MDD 2 per day
glipizide-metformin hcl tab 2.5-500 mg generic 1 MDD 2 per day
glipizide-metformin hcl tab 5-500 mg generic 1 MDD 4 per day
glyburide micronized tab 1.5 mg generic 1 MDD 4 per day
glyburide micronized tab 3 mg generic 1 MDD 4 per day
glyburide micronized tab 6 mg generic 1 MDD 4 per day
glyburide tab 1.25 mg generic 1 MDD 4 per day
glyburide tab 2.5 mg generic 1 MDD 4 per day
glyburide tab 5 mg generic 1 MDD 4 per day
GLYBURIDE TAB 5 MGglyburide
BRAND 1 MDD 4 per day
glyburide-metformin tab 1.25-250 mg generic 1 MDD 2 per day
glyburide-metformin tab 2.5-500 mg generic 1 MDD 2 per day
glyburide-metformin tab 5-500 mg generic 1 MDD 4 per day
GLYSET TAB 100 MGmiglitol
BRAND 3
GLYSET TAB 25 MGmiglitol
BRAND 3
PAGE 106 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
GLYSET TAB 50 MGmiglitol
BRAND 3
INVOKANA TAB 100 MGcanagliflozin
BRAND 3PA
MDD 1 per day
INVOKANA TAB 300 MGcanagliflozin
BRAND 3PA
MDD 1 per day
JANUVIA TAB 100 MGsitagliptin phosphate
BRAND 2PA
MDD 1 per day
JANUVIA TAB 25 MGsitagliptin phosphate
BRAND 2PA
MDD 1 per day
JANUVIA TAB 50 MGsitagliptin phosphate
BRAND 2PA
MDD 1 per day
lidocaine ointment 5 % generic 1
metformin hcl er (osm) tab er 24h 1000 mg generic 1 MDD 2 per day
metformin hcl er tab er 24h 500 mg generic 1 MDD 4 per day
metformin hcl er tab er 24h 750 mg generic 1 MDD 2 per day
metformin hcl tab 1000 mg generic 1 MDD 2.5 per day
metformin hcl tab 500 mg generic 1 MDD 5 per day
metformin hcl tab 850 mg generic 1 MDD 3 per day
nateglinide tab 120 mg generic 1 MDD 3 per day
nateglinide tab 60 mg generic 1 MDD 3 per day
ONGLYZA TAB 2.5 MGsaxagliptin hcl
BRAND 3 MDD 1 per day
ONGLYZA TAB 5 MGsaxagliptin hcl
BRAND 3 MDD 1 per day
pioglitazone hcl tab 15 mg generic 1 MDD 1 per day
pioglitazone hcl tab 30 mg generic 1 MDD 1 per day
pioglitazone hcl tab 45 mg generic 1 MDD 1 per day
PAGE 107 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
pioglitazone hcl-metformin hcl tab 15-500mg
generic 1 MDD 2 per day
pioglitazone hcl-metformin hcl tab 15-850mg
generic 1 MDD 2 per day
PRANDIMET TAB 1-500 MGrepaglinide-metformin hcl
BRAND 3 MDD 2 per day
PRANDIMET TAB 2-500 MGrepaglinide-metformin hcl
BRAND 3 MDD 2 per day
PRANDIN TAB 0.5 MGrepaglinide
BRAND 3 MDD 4 per day
PRANDIN TAB 1 MGrepaglinide
BRAND 3 MDD 4 per day
PRANDIN TAB 2 MGrepaglinide
BRAND 3 MDD 4 per day
repaglinide tab 0.5 mg generic 1 MDD 4 per day
repaglinide tab 1 mg generic 1 MDD 4 per day
repaglinide tab 2 mg generic 1 MDD 4 per day
SYMLINPEN 120 SOLN PEN 2700MCG/2.7MLpramlintide acetate
BRAND 2PA
MDS 10.8 / 30 days
SYMLINPEN 60 SOLN PEN 1500MCG/1.5MLpramlintide acetate
BRAND 2PA
MDS 6 / 30 days
tolazamide tab 250 mg generic 1 MDD 4 per day
tolazamide tab 500 mg generic 1 MDD 4 per day
tolbutamide tab 500 mg generic 1 MDD 6 per day
TRADJENTA TAB 5 MGlinagliptin
BRAND 2 MDD 1 per day
VICTOZA SOLN PEN 18 MG/3MLliraglutide
BRAND 2PA
MDS 9 / 30 days
PAGE 108 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
GLYCEMIC AGENTS
GLUCAGEN DIAGNOSTIC RECON SOLN 1MGglucagon hcl rdna (diagnostic)
BRAND 3 MPL 12 / 365 days
GLUCAGEN HYPOKIT RECON SOLN 1 MGglucagon hcl (rdna)
BRAND 3 MPL 12 / 365 days
GLUCAGON EMERGENCY KIT 1 MGglucagon (rdna)
BRAND 3 MPL 12 / 365 days
PROGLYCEM SUSPENSION 50 MG/MLdiazoxide
BRAND 3
INSULINS
APIDRA SOLOSTAR SOLN PEN 100 UNIT/MLinsulin glulisine
BRAND 3
APIDRA SOLUTION 100 UNIT/MLinsulin glulisine
BRAND 2
HUMALOG KWIKPEN SOLN PEN 100UNIT/MLinsulin lispro (human)
BRAND 2
HUMALOG MIX 50/50 KWIKPEN SUSP PEN(50-50) 100 UNIT/MLinsulin lispro protamine & lispro (human)
BRAND 2
HUMALOG MIX 50/50 PEN SUSP PEN (50-50) 100 UNIT/MLinsulin lispro protamine & lispro (human)
BRAND 2
HUMALOG MIX 50/50 SUSPENSION (50-50)100 UNIT/MLinsulin lispro protamine & lispro (human)
BRAND 2
HUMALOG MIX 75/25 KWIKPEN SUSP PEN(75-25) 100 UNIT/MLinsulin lispro protamine & lispro (human)
BRAND 2
HUMALOG MIX 75/25 PEN SUSP PEN (75-25) 100 UNIT/MLinsulin lispro protamine & lispro (human)
BRAND 2
PAGE 109 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
HUMALOG PEN SOLN PEN 100 UNIT/MLinsulin lispro (human)
BRAND 2
HUMALOG SOLN CART 100 UNIT/MLinsulin lispro (human)
BRAND 2
HUMALOG SOLUTION 100 UNIT/MLinsulin lispro (human)
BRAND 2
HUMULIN 70/30 KWIKPEN SUSP PEN (70-30) 100 UNIT/MLinsulin nph isophane & reg (human)
BRAND 2
HUMULIN 70/30 PEN SUSP PEN (70-30)100 UNIT/MLinsulin isophane & reg (human)
BRAND 2
HUMULIN 70/30 SUSPENSION (70-30) 100UNIT/MLinsulin isophane & reg (human)
BRAND 2
HUMULIN N KWIKPEN SUSP PEN 100UNIT/MLinsulin isophane (human)
BRAND 2
HUMULIN N PEN SUSP PEN 100 UNIT/MLinsulin isophane (human)
BRAND 2
HUMULIN N SUSPENSION 100 UNIT/MLinsulin isophane (human)
BRAND 2
HUMULIN R SOLUTION 100 UNIT/MLinsulin regular (human)
BRAND 2
HUMULIN R U-500 (CONCENTRATED)SOLUTION 500 UNIT/MLinsulin regular (human)
BRAND 2
LANTUS SOLOSTAR SOLN PEN 100UNIT/MLinsulin glargine
BRAND 2
LANTUS SOLUTION 100 UNIT/MLinsulin glargine
BRAND 2
LEVEMIR FLEXPEN SOLN PEN 100 UNIT/MLinsulin detemir
BRAND 2
PAGE 110 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
LEVEMIR FLEXTOUCH SOLN PEN 100UNIT/MLinsulin detemir
BRAND 2
LEVEMIR SOLUTION 100 UNIT/MLinsulin detemir
BRAND 2
NOVOLIN 70/30 RELION SUSPENSION (70-30) 100 UNIT/MLinsulin isophane & reg (human)
BRAND 2
NOVOLIN 70/30 SUSPENSION (70-30) 100UNIT/MLinsulin isophane & reg (human)
BRAND 2
NOVOLIN N RELION SUSPENSION 100UNIT/MLinsulin isophane (human)
BRAND 2
NOVOLIN N SUSPENSION 100 UNIT/MLinsulin nph (human) (isophane)
BRAND 2
NOVOLIN R RELION SOLUTION 100UNIT/MLinsulin regular (human)
BRAND 2
NOVOLIN R SOLUTION 100 UNIT/MLinsulin regular (human)
BRAND 2
NOVOLOG FLEXPEN SOLN PEN 100UNIT/MLinsulin aspart
BRAND 2
NOVOLOG MIX 70/30 FLEXPEN SUSP PEN(70-30) 100 UNIT/MLinsulin aspart protamine & aspart (human)
BRAND 2
NOVOLOG MIX 70/30 SUSPENSION (70-30)100 UNIT/MLinsulin aspart protamine & aspart (human)
BRAND 2
NOVOLOG PENFILL SOLN CART 100UNIT/MLinsulin aspart
BRAND 2
NOVOLOG SOLUTION 100 UNIT/MLinsulin aspart
BRAND 2
PAGE 111 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
RELION 70/30 SUSPENSION (70-30) 100UNIT/MLinsulin isophane & reg (human)
BRAND 2
RELION N SUSPENSION 100 UNIT/MLinsulin isophane (human)
BRAND 2
RELION R SOLUTION 100 UNIT/MLinsulin regular (human)
BRAND 2
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
COUMADIN RECON SOLN 5 MGwarfarin sodium
BRAND 2
COUMADIN TAB 1 MGwarfarin sodium
BRAND 2
COUMADIN TAB 10 MGwarfarin sodium
BRAND 2
COUMADIN TAB 2 MGwarfarin sodium
BRAND 2
COUMADIN TAB 2.5 MGwarfarin sodium
BRAND 2
COUMADIN TAB 3 MGwarfarin sodium
BRAND 2
COUMADIN TAB 4 MGwarfarin sodium
BRAND 2
COUMADIN TAB 5 MGwarfarin sodium
BRAND 2
COUMADIN TAB 6 MGwarfarin sodium
BRAND 2
COUMADIN TAB 7.5 MGwarfarin sodium
BRAND 2
ELIQUIS TAB 2.5 MGapixaban
BRAND 2 MDS 74 / 30 days
ELIQUIS TAB 5 MGapixaban
BRAND 2 MDS 74 / 30 days
PAGE 112 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
enoxaparin sodium solution 100 mg/ml generic 4MDS 60 / 30 Days
S
enoxaparin sodium solution 120 mg/0.8ml generic 4MDS 48 / 30 Days
S
enoxaparin sodium solution 150 mg/ml generic 4MDS 60 / 30 Days
S
enoxaparin sodium solution 30 mg/0.3ml generic 4MDS 18 / 30 Days
S
enoxaparin sodium solution 300 mg/3ml generic 4MDS 180 / 30 days
S
enoxaparin sodium solution 40 mg/0.4ml generic 4MDS 24 / 30 Days
S
enoxaparin sodium solution 60 mg/0.6ml generic 4MDS 36 / 30 Days
S
enoxaparin sodium solution 80 mg/0.8ml generic 4MDS 48 / 30 Days
S
fondaparinux sodium solution 10 mg/0.8ml generic 4PA
S
fondaparinux sodium solution 2.5mg/0.5ml
generic 4PA
S
fondaparinux sodium solution 2.5mg/0.5ml
generic 4PA
S
fondaparinux sodium solution 5 mg/0.4ml generic 4PA
S
fondaparinux sodium solution 7.5mg/0.6ml
generic 4
PA
MDS 5.4 / 9 DaysS
MDS2 5.4 / 180 Days
FRAGMIN SOLUTION 10000 UNIT/MLdalteparin sodium
BRAND 4PA
S
PAGE 113 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
FRAGMIN SOLUTION 12500 UNIT/0.5MLdalteparin sodium
BRAND 4PA
S
FRAGMIN SOLUTION 15000 UNIT/0.6MLdalteparin sodium
BRAND 4PA
S
FRAGMIN SOLUTION 18000 UNT/0.72MLdalteparin sodium
BRAND 4PA
S
FRAGMIN SOLUTION 2500 UNIT/0.2MLdalteparin sodium
BRAND 4PA
S
FRAGMIN SOLUTION 25000 UNIT/MLdalteparin sodium
BRAND 4PA
S
FRAGMIN SOLUTION 5000 UNIT/0.2MLdalteparin sodium
BRAND 4PA
S
FRAGMIN SOLUTION 7500 UNIT/0.3MLdalteparin sodium
BRAND 4PA
S
heparin (porcine) in d5w solution 40-5unit/ml-%
generic 1
HEPARIN (PORCINE) IN NACL SOLUTION100-0.45 UNIT/ML-%heparin (porcine) in sodium chloride
BRAND 1
HEPARIN (PORCINE) IN NACL SOLUTION50-0.45 UNIT/ML-%heparin (porcine) in sodium chloride
BRAND 1
heparin sodium (porcine) solution 10000unit/ml
generic 1
heparin sodium (porcine) solution 20000unit/ml
generic 1
heparin sodium (porcine) solution 5000unit/ml
generic 1
jantoven tab 1 mg generic 1
jantoven tab 10 mg generic 1
jantoven tab 2 mg generic 1
PAGE 114 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
jantoven tab 2.5 mg generic 1
jantoven tab 3 mg generic 1
jantoven tab 4 mg generic 1
jantoven tab 5 mg generic 1
jantoven tab 6 mg generic 1
jantoven tab 7.5 mg generic 1
PRADAXA CAP 150 MGdabigatran etexilate mesylate
BRAND 2 MDD 2 per day
PRADAXA CAP 75 MGdabigatran etexilate mesylate
BRAND 2 MDD 2 per day
warfarin sodium tab 1 mg generic 1
warfarin sodium tab 10 mg generic 1
warfarin sodium tab 2 mg generic 1
warfarin sodium tab 2.5 mg generic 1
warfarin sodium tab 3 mg generic 1
warfarin sodium tab 4 mg generic 1
warfarin sodium tab 5 mg generic 1
warfarin sodium tab 6 mg generic 1
warfarin sodium tab 7.5 mg generic 1
XARELTO TAB 10 MGrivaroxaban
BRAND 2 MDD 1 per day
XARELTO TAB 15 MGrivaroxaban
BRAND 2 MDD 2 per day
XARELTO TAB 20 MGrivaroxaban
BRAND 2 MDD 1 per day
BLOOD FORMATION MODIFIERS
anagrelide hcl cap 0.5 mg generic 1
anagrelide hcl cap 1 mg generic 1
PAGE 115 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ARANESP (ALBUMIN FREE) SOLN PRSYR200 MCG/0.4MLdarbepoetin alfa
BRAND 4PA
S
ARANESP (ALBUMIN FREE) SOLN PRSYR300 MCG/0.6MLdarbepoetin alfa
BRAND 4PA
S
ARANESP (ALBUMIN FREE) SOLN PRSYR500 MCG/MLdarbepoetin alfa
BRAND 4PA
S
ARANESP (ALBUMIN FREE) SOLUTION 100MCG/MLdarbepoetin alfa
BRAND 4PA
S
ARANESP (ALBUMIN FREE) SOLUTION 25MCG/MLdarbepoetin alfa
BRAND 4 S
ARANESP (ALBUMIN FREE) SOLUTION 40MCG/MLdarbepoetin alfa
BRAND 4PA
S
ARANESP (ALBUMIN FREE) SOLUTION 60MCG/MLdarbepoetin alfa
BRAND 4PA
S
EPOGEN SOLUTION 10000 UNIT/MLepoetin alfa
BRAND 4PA
S
EPOGEN SOLUTION 2000 UNIT/MLepoetin alfa
BRAND 4PA
S
EPOGEN SOLUTION 20000 UNIT/MLepoetin alfa
BRAND 4PA
S
EPOGEN SOLUTION 3000 UNIT/MLepoetin alfa
BRAND 4PA
S
EPOGEN SOLUTION 4000 UNIT/MLepoetin alfa
BRAND 4PA
S
LEUKINE RECON SOLN 250 MCGsargramostim
BRAND 4PA
S
PAGE 116 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
LEUKINE SOLUTION 500 MCG/MLsargramostim
BRAND 4PA
S
MOZOBIL SOLUTION 24 MG/1.2MLplerixafor
BRAND 4PA
S
NEULASTA ONPRO PREF SY KT 6 MG/0.6MLpegfilgrastim
BRAND 4PA
S
NEULASTA SOLN PRSYR 6 MG/0.6MLpegfilgrastim
BRAND 4PA
S
NEUPOGEN SOLN PRSYR 300 MCG/0.5MLfilgrastim
BRAND 4PA
S
NEUPOGEN SOLN PRSYR 480 MCG/0.8MLfilgrastim
BRAND 4PA
S
NEUPOGEN SOLUTION 300 MCG/MLfilgrastim
BRAND 4PA
S
NEUPOGEN SOLUTION 480 MCG/1.6MLfilgrastim
BRAND 4PA
S
NPLATE RECON SOLN 250 MCGromiplostim
BRAND 4PA
S
NPLATE RECON SOLN 500 MCGromiplostim
BRAND 4PA
S
OMONTYS SOLUTION 10 MG/MLpeginesatide acetate
BRAND 3
PROCRIT SOLUTION 10000 UNIT/MLepoetin alfa
BRAND 4PA
S
PROCRIT SOLUTION 2000 UNIT/MLepoetin alfa
BRAND 4PA
S
PROCRIT SOLUTION 20000 UNIT/MLepoetin alfa
BRAND 4PA
S
PROCRIT SOLUTION 3000 UNIT/MLepoetin alfa
BRAND 4PA
S
PAGE 117 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
PROCRIT SOLUTION 4000 UNIT/MLepoetin alfa
BRAND 4PA
S
PROCRIT SOLUTION 40000 UNIT/MLepoetin alfa
BRAND 4PA
S
PROMACTA TAB 12.5 MGeltrombopag olamine
BRAND 4PA
S
PROMACTA TAB 25 MGeltrombopag olamine
BRAND 4PA
S
PROMACTA TAB 50 MGeltrombopag olamine
BRAND 4PA
S
PROMACTA TAB 75 MGeltrombopag olamine
BRAND 4PA
S
COAGULANTS
tranexamic acid solution 1000 mg/10ml generic 1
tranexamic acid tab 650 mg generic 1
PLATELET MODIFYING AGENTS
AGGRENOX CAP ER 12H 25-200 MGaspirin-dipyridamole
BRAND 2PA
MDD 2 per day
aspirin-dipyridamole er cap er 12h 25-200mg
generic 1PA
MDD 2 per day
BRILINTA TAB 90 MGticagrelor
BRAND 2
cilostazol tab 100 mg generic 1
cilostazol tab 50 mg generic 1
clopidogrel bisulfate tab 300 mg generic 1
clopidogrel bisulfate tab 75 mg generic 1 MDD 1 per day
dipyridamole tab 25 mg generic 1
dipyridamole tab 50 mg generic 1
PAGE 118 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
dipyridamole tab 75 mg generic 1
EFFIENT TAB 10 MGprasugrel hcl
BRAND 2 MDD 1 per day
EFFIENT TAB 5 MGprasugrel hcl
BRAND 2 MDD 1 per day
REOPRO SOLUTION 2 MG/MLabciximab
BRAND 3
ticlopidine hcl tab 250 mg generic 1
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
clonidine hcl tab 0.1 mg generic 1 MDD 8 per day
clonidine hcl tab 0.2 mg generic 1 MDD 8 per day
clonidine hcl tab 0.3 mg generic 1 MDD 8 per day
guanabenz acetate tab 4 mg generic 1
guanabenz acetate tab 8 mg generic 1
guanfacine hcl tab 1 mg generic 1
guanfacine hcl tab 2 mg generic 1
methyldopa tab 250 mg generic 1 MDD 6 per day
methyldopa tab 500 mg generic 1 MDD 6 per day
methyldopate hcl solution 250 mg/5ml generic 3
midodrine hcl tab 10 mg generic 1
midodrine hcl tab 2.5 mg generic 1
midodrine hcl tab 5 mg generic 1
ALPHA-ADRENERGIC BLOCKING AGENTS
DIBENZYLINE CAP 10 MGphenoxybenzamine hcl
BRAND 3
doxazosin mesylate tab 1 mg generic 1
doxazosin mesylate tab 2 mg generic 1
PAGE 119 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
doxazosin mesylate tab 4 mg generic 1
doxazosin mesylate tab 8 mg generic 1
phenoxybenzamine hcl cap 10 mg generic 3
prazosin hcl cap 1 mg generic 1 MDD 4 per day
prazosin hcl cap 2 mg generic 1 MDD 4 per day
prazosin hcl cap 5 mg generic 1 MDD 4 per day
ANGIOTENSIN II RECEPTOR ANTAGONISTS
BENICAR TAB 20 MGolmesartan medoxomil
BRAND 2 MDD 1 per day
BENICAR TAB 40 MGolmesartan medoxomil
BRAND 2 MDD 1 per day
BENICAR TAB 5 MGolmesartan medoxomil
BRAND 2 MDD 1 per day
candesartan cilexetil tab 16 mg generic 1 MDD 1 per day
candesartan cilexetil tab 32 mg generic 1 MDD 1 per day
candesartan cilexetil tab 4 mg generic 1 MDD 1 per day
candesartan cilexetil tab 8 mg generic 1 MDD 1 per day
EDARBI TAB 40 MGazilsartan medoxomil
BRAND 3ST
MDD 1 per day
EDARBI TAB 80 MGazilsartan medoxomil
BRAND 3ST
MDD 1 per day
eprosartan mesylate tab 600 mg generic 1 MDD 1 per day
irbesartan tab 150 mg generic 1 MDD 1 per day
irbesartan tab 300 mg generic 1 MDD 1 per day
irbesartan tab 75 mg generic 1 MDD 1 per day
losartan potassium tab 100 mg generic 1 MDD 1 per day
losartan potassium tab 25 mg generic 1 MDD 1 per day
PAGE 120 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
losartan potassium tab 50 mg generic 1 MDD 1 per day
MICARDIS TAB 20 MGtelmisartan
BRAND 3 MDD 1 per day
MICARDIS TAB 40 MGtelmisartan
BRAND 3 MDD 1 per day
MICARDIS TAB 80 MGtelmisartan
BRAND 3 MDD 1 per day
telmisartan tab 20 mg generic 1 MDD 1 per day
telmisartan tab 40 mg generic 1 MDD 1 per day
telmisartan tab 80 mg generic 1 MDD 1 per day
TEVETEN TAB 400 MGeprosartan mesylate
BRAND 3ST
MDD 2 per day
TEVETEN TAB 600 MGeprosartan mesylate
BRAND 3ST
MDD 1 per day
valsartan tab 160 mg generic 1 MDD 1 per day
valsartan tab 320 mg generic 1 MDD 1 per day
valsartan tab 40 mg generic 1 MDD 1 per day
valsartan tab 80 mg generic 1 MDD 1 per day
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
benazepril hcl tab 10 mg generic 1
benazepril hcl tab 20 mg generic 1
benazepril hcl tab 40 mg generic 1
benazepril hcl tab 5 mg generic 1
captopril tab 100 mg generic 1
captopril tab 12.5 mg generic 1
captopril tab 25 mg generic 1
captopril tab 50 mg generic 1
enalapril maleate 10 mg generic 1
PAGE 121 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
enalapril maleate 5 mg generic 1
enalapril maleate tab 10 mg generic 1
enalapril maleate tab 2.5 mg generic 1
enalapril maleate tab 20 mg generic 1
enalapril maleate tab 5 mg generic 1
fosinopril sodium 10 mg generic 1
fosinopril sodium 20 mg generic 1
fosinopril sodium 40 mg generic 1
fosinopril sodium tab 10 mg generic 1
fosinopril sodium tab 20 mg generic 1
fosinopril sodium tab 40 mg generic 1
lisinopril 2.5 mg generic 1
lisinopril 20 mg generic 1
lisinopril 40 mg generic 1
lisinopril 5 mg generic 1
lisinopril tab 10 mg generic 1
lisinopril tab 2.5 mg generic 1
lisinopril tab 20 mg generic 1
lisinopril tab 30 mg generic 1
lisinopril tab 40 mg generic 1
lisinopril tab 5 mg generic 1
moexipril hcl tab 15 mg generic 1
moexipril hcl tab 7.5 mg generic 1
perindopril erbumine tab 2 mg generic 1
perindopril erbumine tab 4 mg generic 1
perindopril erbumine tab 8 mg generic 1
quinapril hcl tab 10 mg generic 1
PAGE 122 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
quinapril hcl tab 20 mg generic 1
quinapril hcl tab 40 mg generic 1
quinapril hcl tab 5 mg generic 1
ramipril cap 1.25 mg generic 1
ramipril cap 10 mg generic 1
ramipril cap 2.5 mg generic 1
ramipril cap 5 mg generic 1
trandolapril tab 1 mg generic 1
trandolapril tab 2 mg generic 1
trandolapril tab 4 mg generic 1
ANTIARRHYTHMICS
amiodarone hcl 150 mg/3ml generic 1
amiodarone hcl solution 150 mg/3ml generic 1
AMIODARONE HCL SOLUTION 900MG/18MLamiodarone hcl
BRAND 1
amiodarone hcl tab 100 mg generic 1
amiodarone hcl tab 200 mg generic 1
amiodarone hcl tab 400 mg generic 1
disopyramide phosphate cap 100 mg generic 1
disopyramide phosphate cap 150 mg generic 1
flecainide acetate tab 100 mg generic 1
flecainide acetate tab 150 mg generic 1
flecainide acetate tab 50 mg generic 1
mexiletine hcl cap 150 mg generic 1
mexiletine hcl cap 200 mg generic 1
mexiletine hcl cap 250 mg generic 1
MULTAQ TAB 400 MGdronedarone hcl
BRAND 3
PAGE 123 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
pacerone tab 100 mg generic 1
pacerone tab 200 mg generic 1
pacerone tab 400 mg generic 1
PROCAINAMIDE HCL SOLUTION 500MG/MLprocainamide hcl
BRAND 1
propafenone hcl er cap er 12h 225 mg generic 1
propafenone hcl er cap er 12h 325 mg generic 1
propafenone hcl er cap er 12h 425 mg generic 1
propafenone hcl tab 150 mg generic 1
propafenone hcl tab 225 mg generic 1
propafenone hcl tab 300 mg generic 1
quinidine sulfate er tab er 300 mg generic 1
quinidine sulfate tab 200 mg generic 1
quinidine sulfate tab 300 mg generic 1
sorine tab 120 mg generic 1 MDD 2 per day
sorine tab 160 mg generic 1 MDD 2 per day
sorine tab 240 mg generic 1
sorine tab 80 mg generic 1 MDD 2 per day
sotalol hcl tab 120 mg generic 1 MDD 2 per day
sotalol hcl tab 160 mg generic 1 MDD 2 per day
sotalol hcl tab 240 mg generic 1
sotalol hcl tab 80 mg generic 1 MDD 2 per day
TIKOSYN CAP 125 MCGdofetilide
BRAND 2
TIKOSYN CAP 250 MCGdofetilide
BRAND 2
TIKOSYN CAP 500 MCGdofetilide
BRAND 2
PAGE 124 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl cap 200 mg generic 1
acebutolol hcl cap 400 mg generic 1
atenolol tab 100 mg generic 1
atenolol tab 25 mg generic 1
atenolol tab 50 mg generic 1
betaxolol hcl tab 10 mg generic 1
betaxolol hcl tab 20 mg generic 1
bisoprolol fumarate tab 10 mg generic 1
bisoprolol fumarate tab 5 mg generic 1
BYSTOLIC TAB 10 MGnebivolol hcl
BRAND 2 MDD 1 per day
BYSTOLIC TAB 2.5 MGnebivolol hcl
BRAND 2 MDD 1 per day
BYSTOLIC TAB 20 MGnebivolol hcl
BRAND 2 MDD 2 per day
BYSTOLIC TAB 5 MGnebivolol hcl
BRAND 2 MDD 1 per day
carvedilol tab 12.5 mg generic 1
carvedilol tab 25 mg generic 1
carvedilol tab 3.125 mg generic 1
carvedilol tab 6.25 mg generic 1
labetalol hcl solution 5 mg/ml generic 1
labetalol hcl tab 100 mg generic 1
labetalol hcl tab 200 mg generic 1
labetalol hcl tab 300 mg generic 1
LEVATOL TAB 20 MGpenbutolol sulfate
BRAND 3
metoprolol succinate er tab er 24h 100 mg generic 1
PAGE 125 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
metoprolol succinate er tab er 24h 200 mg generic 1
metoprolol succinate er tab er 24h 25 mg generic 1
metoprolol succinate er tab er 24h 50 mg generic 1
metoprolol tartrate solution 1 mg/ml generic 1
metoprolol tartrate solution 5 mg/5ml generic 1
metoprolol tartrate tab 100 mg generic 1
metoprolol tartrate tab 25 mg generic 1
metoprolol tartrate tab 50 mg generic 1
nadolol tab 20 mg generic 1
nadolol tab 40 mg generic 1
nadolol tab 80 mg generic 1
pindolol tab 10 mg generic 1
pindolol tab 5 mg generic 1
propranolol hcl er cap er 24h 120 mg generic 1
propranolol hcl er cap er 24h 160 mg generic 1
propranolol hcl er cap er 24h 60 mg generic 1
propranolol hcl er cap er 24h 80 mg generic 1
propranolol hcl solution 1 mg/ml generic 1
propranolol hcl solution 20 mg/5ml generic 1
propranolol hcl solution 40 mg/5ml generic 1
propranolol hcl tab 10 mg generic 1
propranolol hcl tab 20 mg generic 1
propranolol hcl tab 40 mg generic 1
propranolol hcl tab 60 mg generic 1
propranolol hcl tab 80 mg generic 1
timolol maleate tab 10 mg generic 1
timolol maleate tab 20 mg generic 1
PAGE 126 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
timolol maleate tab 5 mg generic 1
CALCIUM CHANNEL BLOCKING AGENTS
afeditab cr tab er 24h 30 mg generic 1
afeditab cr tab er 24h 60 mg generic 1
amlodipine besylate tab 10 mg generic 1
amlodipine besylate tab 2.5 mg generic 1
amlodipine besylate tab 5 mg generic 1
cartia xt cap er 24h 120 mg generic 1
cartia xt cap er 24h 180 mg generic 1
cartia xt cap er 24h 240 mg generic 1
cartia xt cap er 24h 300 mg generic 1
dilt-cd cap er 24h 120 mg generic 1
dilt-cd cap er 24h 180 mg generic 1
dilt-cd cap er 24h 240 mg generic 1
dilt-cd cap er 24h 300 mg generic 1
dilt-xr cap er 24h 120 mg generic 1
dilt-xr cap er 24h 180 mg generic 1
dilt-xr cap er 24h 240 mg generic 1
diltiazem cd cap er 24h 120 mg generic 1
diltiazem cd cap er 24h 180 mg generic 1
diltiazem cd cap er 24h 240 mg generic 1
diltiazem hcl er beads cap er 24h 120 mg generic 1
diltiazem hcl er beads cap er 24h 180 mg generic 1
diltiazem hcl er beads cap er 24h 240 mg generic 1
diltiazem hcl er beads cap er 24h 300 mg generic 1
diltiazem hcl er beads cap er 24h 360 mg generic 1
diltiazem hcl er cap er 12h 120 mg generic 1
PAGE 127 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
diltiazem hcl er cap er 12h 60 mg generic 1
diltiazem hcl er cap er 12h 90 mg generic 1
diltiazem hcl er cap er 24h 120 mg generic 1
diltiazem hcl er cap er 24h 180 mg generic 1
diltiazem hcl er cap er 24h 240 mg generic 1
diltiazem hcl er coated beads cap er 24h120 mg
generic 1
diltiazem hcl er coated beads cap er 24h180 mg
generic 1
diltiazem hcl er coated beads cap er 24h240 mg
generic 1
diltiazem hcl er coated beads cap er 24h300 mg
generic 1
diltiazem hcl er coated beads cap er 24h360 mg
generic 1
diltiazem hcl er coated beads tab er 24h180 mg
generic 1
diltiazem hcl er coated beads tab er 24h240 mg
generic 1
diltiazem hcl er coated beads tab er 24h300 mg
generic 1
diltiazem hcl er coated beads tab er 24h360 mg
generic 1
diltiazem hcl er coated beads tab er 24h420 mg
generic 1
DILTIAZEM HCL RECON SOLN 100 MGdiltiazem hcl
BRAND 1
diltiazem hcl solution 50 mg/10ml generic 1
diltiazem hcl tab 120 mg generic 1
diltiazem hcl tab 30 mg generic 1
diltiazem hcl tab 60 mg generic 1
PAGE 128 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
diltiazem hcl tab 90 mg generic 1
diltzac cap er 24h 120 mg generic 1
diltzac cap er 24h 180 mg generic 1
diltzac cap er 24h 240 mg generic 1
diltzac cap er 24h 300 mg generic 1
diltzac cap er 24h 360 mg generic 1
felodipine er tab er 24h 10 mg generic 1
felodipine er tab er 24h 2.5 mg generic 1
felodipine er tab er 24h 5 mg generic 1
isradipine cap 2.5 mg generic 1
isradipine cap 5 mg generic 1
matzim la tab er 24h 180 mg generic 1
matzim la tab er 24h 240 mg generic 1
matzim la tab er 24h 300 mg generic 1
matzim la tab er 24h 360 mg generic 1
matzim la tab er 24h 420 mg generic 1
nicardipine hcl cap 20 mg generic 1
nicardipine hcl cap 30 mg generic 1
nicardipine hcl solution 2.5 mg/ml generic 1
nifediac cc tab er 24h 30 mg generic 1
nifediac cc tab er 24h 60 mg generic 1
nifediac cc tab er 24h 90 mg generic 1
nifedical xl tab er 24h 30 mg generic 1
nifedical xl tab er 24h 60 mg generic 1
nifedipine cap 10 mg generic 1
nifedipine cap 20 mg generic 1
nifedipine er osmotic release tab er 24h 30mg
generic 1
PAGE 129 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
nifedipine er osmotic release tab er 24h 60mg
generic 1
nifedipine er osmotic tab er 24h 30 mg generic 1
nifedipine er osmotic tab er 24h 60 mg generic 1
nifedipine er osmotic tab er 24h 90 mg generic 1
nifedipine er tab er 24h 30 mg generic 1
nifedipine er tab er 24h 60 mg generic 1
nifedipine er tab er 24h 90 mg generic 1
nimodipine cap 30 mg generic 1
nisoldipine er tab er 24h 17 mg generic 1
nisoldipine er tab er 24h 20 mg generic 1
nisoldipine er tab er 24h 30 mg generic 1
nisoldipine er tab er 24h 34 mg generic 1
nisoldipine er tab er 24h 40 mg generic 1
nisoldipine er tab er 24h 8.5 mg generic 1
taztia xt cap er 24h 120 mg generic 1
taztia xt cap er 24h 180 mg generic 1
taztia xt cap er 24h 240 mg generic 1
taztia xt cap er 24h 300 mg generic 1
taztia xt cap er 24h 360 mg generic 1
verapamil hcl er 120 mg generic 1
verapamil hcl er cap er 24h 100 mg generic 1
verapamil hcl er cap er 24h 120 mg generic 1
verapamil hcl er cap er 24h 180 mg generic 1
verapamil hcl er cap er 24h 200 mg generic 1
verapamil hcl er cap er 24h 240 mg generic 1
verapamil hcl er cap er 24h 300 mg generic 1
verapamil hcl er cap er 24h 360 mg generic 1
PAGE 130 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
verapamil hcl er tab er 120 mg generic 1
verapamil hcl er tab er 180 mg generic 1
verapamil hcl er tab er 240 mg generic 1
verapamil hcl solution 2.5 mg/ml generic 1
verapamil hcl tab 120 mg generic 1
verapamil hcl tab 40 mg generic 1
verapamil hcl tab 80 mg generic 1
CARDIOVASCULAR AGENTS, OTHER
amiloride-hydrochlorothiazide tab 5-50 mg generic 1
amlodipine besy-benazepril hcl cap 10-20mg
generic 1
amlodipine besy-benazepril hcl cap 10-40mg
generic 1
amlodipine besy-benazepril hcl cap 2.5-10mg
generic 1
amlodipine besy-benazepril hcl cap 5-10mg
generic 1
amlodipine besy-benazepril hcl cap 5-20mg
generic 1
amlodipine besy-benazepril hcl cap 5-40mg
generic 1
atenolol-chlorthalidone tab 100-25 mg generic 1
atenolol-chlorthalidone tab 50-25 mg generic 1
benazepril-hydrochlorothiazide 20-12.5 mg generic 1
benazepril-hydrochlorothiazide 20-25 mg generic 1
benazepril-hydrochlorothiazide tab 10-12.5mg
generic 1
benazepril-hydrochlorothiazide tab 20-12.5mg
generic 1
benazepril-hydrochlorothiazide tab 20-25mg
generic 1
PAGE 131 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
benazepril-hydrochlorothiazide tab 5-6.25mg
generic 1
BIDIL TAB 20-37.5 MGisosorbide dinitrate-hydralazine hcl
BRAND 2
digitek tab 125 mcg generic 1
digitek tab 250 mcg generic 1
digox tab 125 mcg generic 1
digox tab 250 mcg generic 1
digoxin solution 0.05 mg/ml generic 1
digoxin solution 0.25 mg/ml generic 1
digoxin tab 125 mcg generic 1
digoxin tab 250 mcg generic 1
enalapril-hydrochlorothiazide tab 10-25 mg generic 1
enalapril-hydrochlorothiazide tab 5-12.5mg
generic 1
fosinopril sodium-hctz tab 10-12.5 mg generic 1
fosinopril sodium-hctz tab 20-12.5 mg generic 1
LANOXIN SOLUTION 0.25 MG/MLdigoxin
BRAND 2
LANOXIN TAB 125 MCGdigoxin
BRAND 2
LANOXIN TAB 187.5 MCGdigoxin
BRAND 2
LANOXIN TAB 250 MCGdigoxin
BRAND 2
LANOXIN TAB 62.5 MCGdigoxin
BRAND 2
lisinopril-hydrochlorothiazide 10-12.5 mg generic 1
lisinopril-hydrochlorothiazide 20-12.5 mg generic 1
lisinopril-hydrochlorothiazide 20-25 mg generic 1
PAGE 132 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
lisinopril-hydrochlorothiazide tab 10-12.5mg
generic 1
lisinopril-hydrochlorothiazide tab 20-12.5mg
generic 1
lisinopril-hydrochlorothiazide tab 20-25 mg generic 1
losartan potassium-hctz tab 100-12.5 mg generic 1 MDD 1 per day
losartan potassium-hctz tab 100-25 mg generic 1 MDD 1 per day
losartan potassium-hctz tab 50-12.5 mg generic 1 MDD 1 per day
pentoxifylline er tab er 400 mg generic 1 MDD 3 per day
RANEXA TAB ER 12H 500 MGranolazine
BRAND 2 MDD 3 per day
spironolactone-hctz tab 25-25 mg generic 1
TEKTURNA TAB 150 MGaliskiren fumarate
BRAND 2 MDD 1 per day
TEKTURNA TAB 300 MGaliskiren fumarate
BRAND 2 MDD 1 per day
triamterene-hctz cap 37.5-25 mg generic 1
triamterene-hctz tab 37.5-25 mg generic 1
triamterene-hctz tab 75-50 mg generic 1
valsartan-hydrochlorothiazide tab 160-12.5mg
generic 1
valsartan-hydrochlorothiazide tab 160-25mg
generic 1
valsartan-hydrochlorothiazide tab 320-12.5mg
generic 1
valsartan-hydrochlorothiazide tab 320-25mg
generic 1
valsartan-hydrochlorothiazide tab 80-12.5mg
generic 1
PAGE 133 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
acetazolamide er cap er 12h 500 mg generic 1 MDD 2 per day
acetazolamide sodium recon soln 500 mg generic 1
acetazolamide tab 125 mg generic 1 MDD 8 per day
acetazolamide tab 250 mg generic 1 MDD 4 per day
DIURETICS, LOOP
bumetanide solution 0.25 mg/ml generic 1
bumetanide tab 0.5 mg generic 1 MDD 5 per day
bumetanide tab 1 mg generic 1 MDD 5 per day
bumetanide tab 2 mg generic 1 MDD 5 per day
EDECRIN TAB 25 MGethacrynic acid
BRAND 3 MDD 16 per day
furosemide solution 10 mg/ml generic 1
furosemide solution 10 mg/ml generic 1
furosemide solution 8 mg/ml generic 1
furosemide tab 20 mg generic 1
furosemide tab 40 mg generic 1
furosemide tab 80 mg generic 1
torsemide solution 20 mg/2ml generic 1
torsemide tab 10 mg generic 1
torsemide tab 100 mg generic 1
torsemide tab 20 mg generic 1
torsemide tab 5 mg generic 1
DIURETICS, POTASSIUM-SPARING
amiloride hcl tab 5 mg generic 1
DYRENIUM CAP 100 MGtriamterene
BRAND 3 MDD 3 per day
PAGE 134 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
DYRENIUM CAP 50 MGtriamterene
BRAND 3 MDD 3 per day
eplerenone tab 25 mg generic 1
eplerenone tab 50 mg generic 1
spironolactone tab 100 mg generic 1
spironolactone tab 25 mg generic 1
spironolactone tab 50 mg generic 1
DIURETICS, THIAZIDE
chlorothiazide tab 250 mg generic 1
chlorothiazide tab 500 mg generic 1
chlorthalidone tab 25 mg generic 1
chlorthalidone tab 50 mg generic 1
hydrochlorothiazide cap 12.5 mg generic 1 MDD 2 per day
hydrochlorothiazide tab 12.5 mg generic 1 MDD 2 per day
hydrochlorothiazide tab 25 mg generic 1 MDD 2 per day
hydrochlorothiazide tab 50 mg generic 1 MDD 2 per day
indapamide tab 1.25 mg generic 1 MDD 1 per day
indapamide tab 2.5 mg generic 1 MDD 2 per day
methyclothiazide tab 5 mg generic 1
metolazone tab 10 mg generic 1 MDD 2 per day
metolazone tab 2.5 mg generic 1 MDD 2 per day
metolazone tab 5 mg generic 1 MDD 2 per day
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
fenofibrate micronized cap 134 mg generic 1 MDD 1 per day
fenofibrate micronized cap 200 mg generic 1 MDD 1 per day
fenofibrate micronized cap 67 mg generic 1 MDD 1 per day
PAGE 135 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
fenofibrate tab 145 mg generic 1 MDD 1 per day
fenofibrate tab 160 mg generic 1 MDD 1 per day
fenofibrate tab 48 mg generic 1 MDD 1 per day
fenofibrate tab 54 mg generic 1 MDD 1 per day
gemfibrozil tab 600 mg generic 1 MDD 2 per day
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
ALTOPREV TAB ER 24H 20 MGlovastatin
BRAND 3 MDD 1 per day
ALTOPREV TAB ER 24H 40 MGlovastatin
BRAND 3 MDD 1 per day
ALTOPREV TAB ER 24H 60 MGlovastatin
BRAND 3 MDD 1 per day
atorvastatin calcium tab 10 mg generic 1 MDD 1 per day
atorvastatin calcium tab 20 mg generic 1 MDD 1 per day
atorvastatin calcium tab 40 mg generic 1 MDD 1 per day
atorvastatin calcium tab 80 mg generic 1 MDD 1 per day
CRESTOR TAB 10 MGrosuvastatin calcium
BRAND 2 ST
CRESTOR TAB 20 MGrosuvastatin calcium
BRAND 2 ST
CRESTOR TAB 40 MGrosuvastatin calcium
BRAND 2 ST
CRESTOR TAB 5 MGrosuvastatin calcium
BRAND 2 ST
fluvastatin sodium cap 20 mg generic 3 MDD 1 per day
fluvastatin sodium cap 40 mg generic 3 MDD 2 per day
LIVALO TAB 1 MGpitavastatin calcium
BRAND 3ST
MDD 1 per day
LIVALO TAB 2 MGpitavastatin calcium
BRAND 3ST
MDD 1 per day
PAGE 136 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
LIVALO TAB 4 MGpitavastatin calcium
BRAND 3ST
MDD 1 per day
lovastatin tab 10 mg generic 1 MDD 1 per day
lovastatin tab 20 mg generic 1 MDD 1 per day
lovastatin tab 40 mg generic 1 MDD 2 per day
pravastatin sodium 40 mg generic 1 MDD 1 per day
pravastatin sodium tab 10 mg generic 1 MDD 1 per day
pravastatin sodium tab 20 mg generic 1 MDD 1 per day
pravastatin sodium tab 40 mg generic 1 MDD 1 per day
pravastatin sodium tab 80 mg generic 1 MDD 1 per day
simvastatin tab 10 mg generic 1 MDD 1 per day
simvastatin tab 20 mg generic 1 MDD 1 per day
simvastatin tab 40 mg generic 1 MDD 1 per day
simvastatin tab 5 mg generic 1 MDD 1 per day
simvastatin tab 80 mg generic 1 MDD 1 per day
DYSLIPIDEMICS, OTHER
ADVICOR TAB ER 24H 1000-20 MGniacin-lovastatin
BRAND 3PA
MDD 2 per day
ADVICOR TAB ER 24H 1000-40 MGniacin-lovastatin
BRAND 3PA
MDD 1 per day
ADVICOR TAB ER 24H 500-20 MGniacin-lovastatin
BRAND 3PA
MDD 1 per day
ADVICOR TAB ER 24H 750-20 MGniacin-lovastatin
BRAND 3PA
MDD 1 per day
cholestyramine light packet 4 gm generic 1 MDD 6 per day
cholestyramine light powder 4 gm/dose generic 1 MDS 720 / 30 days
cholestyramine packet 4 gm generic 1 MDD 6 per day
PAGE 137 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
cholestyramine powder 4 gm/dose generic 1 MDS 756 / 30 days
colestipol hcl granules 5 gm generic 1 MDD 6 per day
colestipol hcl packet 5 gm generic 1 MDD 6 per day
colestipol hcl tab 1 gm generic 1 MDD 16 per day
niacin er (antihyperlipidemic) tab er 1000mg
generic 1 MDD 2 per day
niacin er (antihyperlipidemic) tab er 500mg
generic 1 MDD 2 per day
niacin er (antihyperlipidemic) tab er 750mg
generic 1 MDD 2 per day
NIASPAN TAB ER 1000 MGniacin (antihyperlipidemic)
BRAND 2ST
MDD 2 per day
NIASPAN TAB ER 500 MGniacin (antihyperlipidemic)
BRAND 2 MDD 2 per day
NIASPAN TAB ER 750 MGniacin (antihyperlipidemic)
BRAND 2 MDD 2 per day
omega-3-acid ethyl esters cap 1 gm generic 1ST
MDD 4 per day
prevalite packet 4 gm generic 1 MDD 6 per day
prevalite powder 4 gm/dose generic 1 MDS 720 / 30 days
SIMCOR TAB ER 24H 1000-20 MGniacin-simvastatin
BRAND 2PA
MDD 2 per day
SIMCOR TAB ER 24H 1000-40 MGniacin-simvastatin
BRAND 2PA
MDD 1 per day
SIMCOR TAB ER 24H 500-20 MGniacin-simvastatin
BRAND 2PA
MDD 1 per day
SIMCOR TAB ER 24H 500-40 MGniacin-simvastatin
BRAND 2PA
MDD 1 per day
SIMCOR TAB ER 24H 750-20 MGniacin-simvastatin
BRAND 2PA
MDD 1 per day
PAGE 138 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
VYTORIN TAB 10-10 MGezetimibe-simvastatin
BRAND 2ST
MDD 1 per day
VYTORIN TAB 10-20 MGezetimibe-simvastatin
BRAND 2ST
MDD 1 per day
VYTORIN TAB 10-40 MGezetimibe-simvastatin
BRAND 2ST
MDD 1 per day
VYTORIN TAB 10-80 MGezetimibe-simvastatin
BRAND 2ST
MDD 1 per day
WELCHOL PACKET 3.75 GMcolesevelam hcl
BRAND 2 MDD 1 per day
WELCHOL TAB 625 MGcolesevelam hcl
BRAND 2 MDD 7 per day
ZETIA TAB 10 MGezetimibe
BRAND 2ST
MDD 1 per day
VASODILATORS, DIRECT-ACTING ARTERIAL
hydralazine hcl solution 20 mg/ml generic 1
hydralazine hcl tab 10 mg generic 1
hydralazine hcl tab 100 mg generic 1
hydralazine hcl tab 25 mg generic 1
hydralazine hcl tab 50 mg generic 1
minoxidil tab 10 mg generic 1
minoxidil tab 2.5 mg generic 1
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
isochron tab er 40 mg generic 1
isoditrate er tab er 40 mg generic 1
isosorbide dinitrate er tab er 40 mg generic 1
isosorbide dinitrate tab 10 mg generic 1
isosorbide dinitrate tab 20 mg generic 1
PAGE 139 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
isosorbide dinitrate tab 30 mg generic 1
isosorbide dinitrate tab 5 mg generic 1
isosorbide mononitrate er tab er 24h 120mg
generic 1
isosorbide mononitrate er tab er 24h 30 mg generic 1
isosorbide mononitrate er tab er 24h 60 mg generic 1
isosorbide mononitrate tab 20 mg generic 1
minitran patch 24hr 0.1 mg/hr generic 1
minitran patch 24hr 0.2 mg/hr generic 1
minitran patch 24hr 0.4 mg/hr generic 1
minitran patch 24hr 0.6 mg/hr generic 1
MONOKET TAB 20 MGisosorbide mononitrate
BRAND 3
NITRO-BID OINTMENT 2 %nitroglycerin
BRAND 3
nitroglycerin patch 24hr 0.1 mg/hr generic 1
nitroglycerin patch 24hr 0.2 mg/hr generic 1
nitroglycerin patch 24hr 0.4 mg/hr generic 1
nitroglycerin patch 24hr 0.6 mg/hr generic 1
nitroglycerin solution 5 mg/ml generic 1
NITROSTAT SL TAB 0.3 MGnitroglycerin
BRAND 2
NITROSTAT SL TAB 0.4 MGnitroglycerin
BRAND 2
NITROSTAT SL TAB 0.6 MGnitroglycerin
BRAND 2
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
amphetamine-dextroamphet er cap er 24h10 mg
generic 1AL 6 to 18 yrs old
MDD 1 per day
PAGE 140 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
amphetamine-dextroamphet er cap er 24h15 mg
generic 1 AL 6 to 18 yrs old
amphetamine-dextroamphet er cap er 24h20 mg
generic 1AL 6 to 18 yrs old
MDD 2 per day
amphetamine-dextroamphet er cap er 24h25 mg
generic 1AL 6 to 18 yrs old
MDD 2 per day
amphetamine-dextroamphet er cap er 24h30 mg
generic 1AL 6 to 18 yrs old
MDD 2 per day
amphetamine-dextroamphet er cap er 24h5 mg
generic 1AL 6 to 18 yrs old
MDD 1 per day
amphetamine-dextroamphetamine tab 10mg
generic 1AL At least 6 yrs old
MDD 3 per day
amphetamine-dextroamphetamine tab12.5 mg
generic 1AL At least 6 yrs old
MDD 3 per day
amphetamine-dextroamphetamine tab 15mg
generic 1AL At least 6 yrs old
MDD 3 per day
amphetamine-dextroamphetamine tab 20mg
generic 1AL At least 6 yrs old
MDD 3 per day
amphetamine-dextroamphetamine tab 30mg
generic 1 AL At least 6 yrs old
amphetamine-dextroamphetamine tab 5mg
generic 1AL At least 6 yrs old
MDD 3 per day
amphetamine-dextroamphetamine tab 7.5mg
generic 1AL At least 6 yrs old
MDD 3 per day
DESOXYN TAB 5 MGmethamphetamine hcl
BRAND 3AL At least 6 yrs old
MDD 5 per day
dexedrine tab 10 mg generic 1AL At least 6 yrs old
MDD 4 per day
dexedrine tab 5 mg generic 1AL At least 6 yrs old
MDD 4 per day
PAGE 141 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
dextroamphetamine sulfate er cap er 24h10 mg
generic 1AL 6 to 18 yrs old
MDD 4 per day
dextroamphetamine sulfate er cap er 24h15 mg
generic 1AL 6 to 18 yrs old
MDD 4 per day
dextroamphetamine sulfate er cap er 24h 5mg
generic 1 AL 6 to 18 yrs old
dextroamphetamine sulfate tab 10 mg generic 1AL At least 6 yrs old
MDD 4 per day
dextroamphetamine sulfate tab 5 mg generic 1AL At least 6 yrs old
MDD 4 per day
methamphetamine hcl tab 5 mg generic 3AL At least 6 yrs old
MDD 5 per day
VYVANSE CAP 10 MGlisdexamfetamine dimesylate
BRAND 2AL 6 to 17 yrs old
MDD 1 per day
VYVANSE CAP 20 MGlisdexamfetamine dimesylate
BRAND 2AL 6 to 17 yrs old
MDD 1 per day
VYVANSE CAP 30 MGlisdexamfetamine dimesylate
BRAND 2AL 6 to 17 yrs old
MDD 1 per day
VYVANSE CAP 40 MGlisdexamfetamine dimesylate
BRAND 2AL 6 to 17 yrs old
MDD 1 per day
VYVANSE CAP 50 MGlisdexamfetamine dimesylate
BRAND 2AL 6 to 17 yrs old
MDD 1 per day
VYVANSE CAP 60 MGlisdexamfetamine dimesylate
BRAND 2AL 6 to 17 yrs old
MDD 1 per day
VYVANSE CAP 70 MGlisdexamfetamine dimesylate
BRAND 2AL 6 to 17 yrs old
MDD 1 per day
zenzedi tab 10 mg generic 1AL At least 6 yrs old
MDD 4 per day
zenzedi tab 5 mg generic 1AL At least 6 yrs old
MDD 4 per day
PAGE 142 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
dexmethylphenidate hcl tab 10 mg generic 1AL At least 6 yrs old
MDD 2 per day
dexmethylphenidate hcl tab 2.5 mg generic 1AL At least 6 yrs old
MDD 2 per day
dexmethylphenidate hcl tab 5 mg generic 1AL At least 6 yrs old
MDD 2 per day
guanfacine hcl er tab er 24h 1 mg generic 1
PA
AL At least 6 yrs oldMDD 1 per day
guanfacine hcl er tab er 24h 2 mg generic 1
PA
AL At least 6 yrs oldMDD 1 per day
guanfacine hcl er tab er 24h 3 mg generic 1
PA
AL At least 6 yrs oldMDD 1 per day
guanfacine hcl er tab er 24h 4 mg generic 1
PA
AL At least 6 yrs oldMDD 1 per day
INTUNIV TAB ER 24H 1 MGguanfacine hcl (adhd)
BRAND 2
PA
AL At least 6 yrs oldMDD 1 per day
INTUNIV TAB ER 24H 2 MGguanfacine hcl (adhd)
BRAND 2
PA
AL At least 6 yrs oldMDD 1 per day
INTUNIV TAB ER 24H 3 MGguanfacine hcl (adhd)
BRAND 2
PA
AL At least 6 yrs oldMDD 1 per day
INTUNIV TAB ER 24H 4 MGguanfacine hcl (adhd)
BRAND 2
PA
AL At least 6 yrs oldMDD 1 per day
PAGE 143 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
metadate er tab er 20 mg generic 1AL 6 to 18 yrs old
MDD 3 per day
methylin er tab er 10 mg generic 1AL 6 to 18 yrs old
MDD 3 per day
methylin er tab er 20 mg generic 1AL 6 to 18 yrs old
MDD 3 per day
methylin tab 10 mg generic 1AL At least 6 yrs old
MDD 5 per day
methylin tab 20 mg generic 1AL At least 6 yrs old
MDD 5 per day
methylin tab 5 mg generic 1AL At least 6 yrs old
MDD 5 per day
methylphenidate hcl er (cd) cap er 10 mg generic 1AL 6 to 18 yrs old
MDD 1 per day
methylphenidate hcl er (cd) cap er 20 mg generic 1AL 6 to 18 yrs old
MDD 1 per day
methylphenidate hcl er (cd) cap er 30 mg generic 1AL 6 to 18 yrs old
MDD 1 per day
methylphenidate hcl er (cd) cap er 40 mg generic 1AL 6 to 18 yrs old
MDD 1 per day
methylphenidate hcl er (cd) cap er 50 mg generic 1AL 6 to 18 yrs old
MDD 1 per day
methylphenidate hcl er (cd) cap er 60 mg generic 1AL 6 to 18 yrs old
MDD 1 per day
methylphenidate hcl er (la) cap er 24h 20mg
generic 1 AL 6 to 18 yrs old
methylphenidate hcl er (la) cap er 24h 20mg
generic 1 AL 6 to 18 yrs old
methylphenidate hcl er (la) cap er 24h 30mg
generic 1AL 6 to 18 yrs old
MDD 3 per day
PAGE 144 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
methylphenidate hcl er (la) cap er 24h 30mg
generic 1AL 6 to 18 yrs old
MDD 3 per day
methylphenidate hcl er (la) cap er 24h 40mg
generic 1 AL 6 to 18 yrs old
methylphenidate hcl er (la) cap er 24h 40mg
generic 1 AL 6 to 18 yrs old
methylphenidate hcl er tab er 10 mg generic 1AL 6 to 18 yrs old
MDD 3 per day
methylphenidate hcl er tab er 18 mg generic 1AL 6 to 18 yrs old
MDD 1 per day
methylphenidate hcl er tab er 20 mg generic 1AL 6 to 18 yrs old
MDD 3 per day
methylphenidate hcl er tab er 24h 18 mg generic 1AL 6 to 18 yrs old
MDD 1 per day
methylphenidate hcl er tab er 24h 27 mg generic 1AL 6 to 18 yrs old
MDD 1 per day
METHYLPHENIDATE HCL ER TAB ER 24H 27MGmethylphenidate hcl
BRAND 1AL 6 to 18 yrs old
MDD 1 per day
methylphenidate hcl er tab er 24h 36 mg generic 1AL 6 to 18 yrs old
MDD 2 per day
METHYLPHENIDATE HCL ER TAB ER 24H 36MGmethylphenidate hcl
BRAND 1AL 6 to 18 yrs old
MDD 2 per day
methylphenidate hcl er tab er 24h 54 mg generic 1AL 6 to 18 yrs old
MDD 2 per day
METHYLPHENIDATE HCL ER TAB ER 24H 54MGmethylphenidate hcl
BRAND 1AL 6 to 18 yrs old
MDD 2 per day
methylphenidate hcl er tab er 27 mg generic 1AL 6 to 18 yrs old
MDD 1 per day
PAGE 145 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
methylphenidate hcl er tab er 36 mg generic 1AL 6 to 18 yrs old
MDD 2 per day
methylphenidate hcl er tab er 54 mg generic 1AL 6 to 18 yrs old
MDD 2 per day
methylphenidate hcl solution 10 mg/5ml generic 1AL At least 6 yrs old
MDS 900 / 30 Days
methylphenidate hcl solution 5 mg/5ml generic 1AL At least 6 yrs old
MDS 900 / 30 Days
methylphenidate hcl tab 10 mg generic 1AL At least 6 yrs old
MDD 5 per day
methylphenidate hcl tab 20 mg generic 1AL At least 6 yrs old
MDD 5 per day
methylphenidate hcl tab 5 mg generic 1AL At least 6 yrs old
MDD 5 per day
STRATTERA CAP 10 MGatomoxetine hcl
BRAND 2
PA
AL At least 6 yrs oldMDD 2 per day
STRATTERA CAP 100 MGatomoxetine hcl
BRAND 2
PA
AL At least 6 yrs oldMDD 1 per day
STRATTERA CAP 18 MGatomoxetine hcl
BRAND 2
PA
AL At least 6 yrs oldMDD 2 per day
STRATTERA CAP 25 MGatomoxetine hcl
BRAND 2
PA
AL At least 6 yrs oldMDD 2 per day
STRATTERA CAP 40 MGatomoxetine hcl
BRAND 2
PA
AL At least 6 yrs oldMDD 2 per day
PAGE 146 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
STRATTERA CAP 80 MGatomoxetine hcl
BRAND 2
PA
AL At least 6 yrs oldMDD 1 per day
CENTRAL NERVOUS SYSTEM, OTHER
butalbital-apap-caffeine cap 50-300-40 mg generic 1
butalbital-apap-caffeine cap 50-325-40 mg generic 1
butalbital-apap-caffeine tab 50-325-40 mg generic 1
butalbital-apap-caffeine tab 50-500-40 mg generic 1
butalbital-asa-caffeine cap 50-325-40 mg generic 1
butalbital-aspirin-caffeine cap 50-325-40mg
generic 1
capacet cap 50-325-40 mg generic 1
esgic cap 50-325-40 mg generic 1
HORIZANT TAB ER 600 MGgabapentin enacarbil
BRAND 3
margesic cap 50-325-40 mg generic 1
NUEDEXTA CAP 20-10 MGdextromethorphan hbr-quinidine sulfate
BRAND 3
ORBIVAN CAP 50-300-40 MGbutalbital-acetaminophen-caffeine
BRAND 2
repan tab 50-325-40 mg generic 1
RILUTEK TAB 50 MGriluzole
BRAND 3
riluzole tab 50 mg generic 3
tetrabenazine tab 12.5 mg generic 4PA
S
tetrabenazine tab 25 mg generic 4PA
S
XENAZINE TAB 12.5 MGtetrabenazine
BRAND 4PA
S
PAGE 147 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
XENAZINE TAB 25 MGtetrabenazine
BRAND 4PA
S
zebutal cap 50-325-40 mg generic 1
zebutal cap 50-500-40 mg generic 1
FIBROMYALGIA AGENTS
duloxetine hcl cp dr part 20 mg generic 1 MDD 2 per day
duloxetine hcl cp dr part 30 mg generic 1 MDD 2 per day
duloxetine hcl cp dr part 60 mg generic 1 MDD 2 per day
LYRICA CAP 100 MGpregabalin
BRAND 2PA
MDD 3 per day
LYRICA CAP 150 MGpregabalin
BRAND 2PA
MDD 3 per day
LYRICA CAP 200 MGpregabalin
BRAND 2PA
MDD 3 per day
LYRICA CAP 225 MGpregabalin
BRAND 2PA
MDD 2 per day
LYRICA CAP 25 MGpregabalin
BRAND 2PA
MDD 3 per day
LYRICA CAP 300 MGpregabalin
BRAND 2PA
MDD 2 per day
LYRICA CAP 50 MGpregabalin
BRAND 2PA
MDD 3 per day
LYRICA CAP 75 MGpregabalin
BRAND 2PA
MDD 3 per day
LYRICA SOLUTION 20 MG/MLpregabalin
BRAND 2 MDS 900 / 30 days
SAVELLA TAB 100 MGmilnacipran hcl
BRAND 2PA
MDD 2 per day
PAGE 148 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SAVELLA TAB 12.5 MGmilnacipran hcl
BRAND 2PA
MDD 2 per day
SAVELLA TAB 25 MGmilnacipran hcl
BRAND 2PA
MDD 2 per day
SAVELLA TAB 50 MGmilnacipran hcl
BRAND 2PA
MDD 2 per day
SAVELLA TITRATION PACK MISC 12.5 & 25& 50 MGmilnacipran hcl
BRAND 2 PA
MULTIPLE SCLEROSIS AGENTS
AMPYRA TAB ER 12H 10 MGdalfampridine
BRAND 4PA
S
AVONEX KIT 30 MCGinterferon beta-1a
BRAND 4PA
S
AVONEX PEN AUT-IJ KIT 30 MCG/0.5MLinterferon beta-1a
BRAND 4PA
S
AVONEX PREFILLED PREF SY KT 30MCG/0.5MLinterferon beta-1a
BRAND 4PA
S
AVONEX PREFILLED PREF SY KT 30MCG/0.5MLinterferon beta-1a
BRAND 4PA
S
BETASERON KIT 0.3 MGinterferon beta-1b
BRAND 4PA
S
COPAXONE SOLN PRSYR 20 MG/MLglatiramer acetate
BRAND 4PA
S
COPAXONE SOLN PRSYR 40 MG/MLglatiramer acetate
BRAND 4PA
S
EXTAVIA KIT 0.3 MGinterferon beta-1b
BRAND 4PA
S
PAGE 149 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
GILENYA CAP 0.5 MGfingolimod hcl
BRAND 4PA
S
glatopa soln prsyr 20 mg/ml generic 4PA
S
REBIF REBIDOSE SOLN A-INJ 22MCG/0.5MLinterferon beta-1a
BRAND 4PA
S
REBIF REBIDOSE SOLN A-INJ 44MCG/0.5MLinterferon beta-1a
BRAND 4PA
S
REBIF REBIDOSE TITRATION PACK SOLN A-INJ 6X8.8 & 6X22 MCGinterferon beta-1a
BRAND 4PA
S
REBIF SOLN PRSYR 22 MCG/0.5MLinterferon beta-1a
BRAND 4PA
S
REBIF SOLN PRSYR 44 MCG/0.5MLinterferon beta-1a
BRAND 4PA
S
REBIF TITRATION PACK SOLN PRSYR 6X8.8& 6X22 MCGinterferon beta-1a
BRAND 4PA
S
TYSABRI CONC 300 MG/15MLnatalizumab
BRAND 4PA
S
ZINBRYTA SOLN PRSYR 150 MG/MLdaclizumab (multiple sclerosis)
BRAND 4 PA
DENTAL AND ORAL AGENTS
ARESTIN MISC 1 MGminocycline hcl (subgingival)
BRAND 3 PA
cevimeline hcl cap 30 mg generic 1
chlorhexidine gluconate solution 0.12 % generic 1
GEL-KAM ORAL CARE RINSE CONC 0.63 %stannous fluoride
BRAND 0
KEPIVANCE RECON SOLN 6.25 MGpalifermin
BRAND 4PA
S
PAGE 150 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
paroex solution 0.12 % generic 1
periogard solution 0.12 % generic 1
pilocarpine hcl tab 5 mg generic 1
pilocarpine hcl tab 7.5 mg generic 1
stannous fluoride conc 0.63 % generic 0
DERMATOLOGICAL AGENTS
acitretin cap 10 mg generic 1 MDD 1 per day
acitretin cap 17.5 mg generic 1 MDD 1 per day
acitretin cap 25 mg generic 1 MDD 2 per day
adapalene cream 0.1 % generic 1PA
AL At least 12 yrs old
adapalene gel 0.1 % generic 1PA
AL At least 12 yrs old
adapalene gel 0.3 % generic 1ST
AL At least 12 yrs old
ADAPALENE LOTION 0.1 %adapalene
BRAND 1ST
AL At least 12 yrs old
ala cort cream 1 % generic 1
ammonium lactate cream 12 % generic 1
ammonium lactate lotion 12 % generic 1
amnesteem cap 10 mg generic 3PA
AL At least 12 yrs old
amnesteem cap 20 mg generic 3PA
AL At least 12 yrs old
amnesteem cap 40 mg generic 3PA
AL At least 12 yrs old
avar cleanser emulsion 10-5 % generic 1 AL At least 12 yrs old
avar-e emollient cream 10-5 % generic 1ST
AL At least 12 yrs old
PAGE 151 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
avar-e green cream 10-5 % generic 1ST
AL At least 12 yrs old
avita cream 0.025 % generic 1 AL At least 12 yrs old
avita gel 0.025 % generic 1 AL At least 12 yrs old
AZELEX CREAM 20 %azelaic acid (acne)
BRAND 3ST
AL At least 12 yrs old
benzepro creamy wash liquid 7 % generic 1 AL At least 12 yrs old
benzepro foam 5.3 % generic 1 AL At least 12 yrs old
benzepro short contact foam 9.8 % generic 1 AL At least 12 yrs old
benzoyl peroxide cleanser lotion 6 % generic 1 AL At least 12 yrs old
benzoyl peroxide creamy wash liquid 4 % generic 1 AL At least 12 yrs old
benzoyl peroxide foam 5.3 % generic 1 AL At least 12 yrs old
benzoyl peroxide foam 9.8 % generic 1 AL At least 12 yrs old
benzoyl peroxide gel 10 % generic 1 AL At least 12 yrs old
benzoyl peroxide gel 5 % generic 1 AL At least 12 yrs old
benzoyl peroxide short contact foam 9.8 % generic 1 AL At least 12 yrs old
benzoyl peroxide wash liquid 10 % generic 1 AL At least 12 yrs old
benzoyl peroxide wash liquid 7 % generic 1 AL At least 12 yrs old
benzoyl peroxide-erythromycin gel 5-3 % generic 1
PA
AL At least 12 yrs oldMPL 1 / Claim
bp foam foam 5.3 % generic 1 AL At least 12 yrs old
bp foam foam 9.8 % generic 1 AL At least 12 yrs old
bp foaming wash liquid 10 % generic 1 AL At least 12 yrs old
bp wash liquid 7 % generic 1 AL At least 12 yrs old
bp wash liquid 7 % generic 1 AL At least 12 yrs old
PAGE 152 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
calcipotriene cream 0.005 % generic 1 MPL 1 / claim
calcipotriene ointment 0.005 % generic 1 MPL 1 / claim
calcipotriene solution 0.005 % generic 1 MPL 1 / claim
calcipotriene-betameth diprop ointment0.005-0.064 %
generic 1 ST
calcitrene ointment 0.005 % generic 1 MPL 1 / claim
calcitriol ointment 3 mcg/gm generic 1 MPL 1 / Claim
claravis cap 10 mg generic 3PA
AL At least 12 yrs old
claravis cap 20 mg generic 3PA
AL At least 12 yrs old
claravis cap 30 mg generic 3PA
AL At least 12 yrs old
claravis cap 40 mg generic 3PA
AL At least 12 yrs old
clenia cream 10-5 % generic 1ST
AL At least 12 yrs old
clenia foaming wash emulsion 10-5 % generic 1 AL At least 12 yrs old
clindacin etz swab 1 % generic 1 AL At least 12 yrs old
clindacin-p swab 1 % generic 1 AL At least 12 yrs old
clindamycin phos-benzoyl perox gel 1-5 % generic 1PA
AL At least 12 yrs old
clindamycin phos-benzoyl perox gel 1.2-5 % generic 1PA
AL At least 12 yrs old
clindamycin phosphate swab 1 % generic 1 AL At least 12 yrs old
clotrimazole-betamethasone cream 1-0.05%
generic 1
clotrimazole-betamethasone lotion 1-0.05%
generic 1
PAGE 153 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
CORTISPORIN CREAM 3.5-10000-0.5neomycin-polymyxin-hc
BRAND 2
CORTISPORIN OINTMENT 1 %bacitracin-polymyxin-neomycin hc
BRAND 2
diclofenac sodium gel 1 % generic 1
diclofenac sodium gel 3 % generic 1 MPL 1 / claim
DIFFERIN LOTION 0.1 %adapalene
BRAND 2ST
AL At least 12 yrs old
ELIDEL CREAM 1 %pimecrolimus
BRAND 2
PA
AL At least 2 yrs oldMPL 1 / 30 days
EPIDUO GEL 0.1-2.5 %adapalene-benzoyl peroxide
BRAND 3ST
AL At least 12 yrs old
FINACEA GEL 15 %azelaic acid
BRAND 2
finasteride tab 1 mg generic 1
fluorouracil cream 5 % generic 1 MPL 1 / Claim
fluorouracil solution 2 % generic 1 MPL 1 / claim
fluorouracil solution 5 % generic 1 MPL 1 / claim
hydrocortisone cream 1 % generic 1
hydrocortisone cream 2.5 % generic 1
hydrocortisone lotion 2.5 % generic 1
hydrocortisone ointment 1 % generic 1
hydrocortisone ointment 2.5 % generic 1
imiquimod cream 5 % generic 1 MDS 12 / claim
laclotion lotion 12 % generic 1
lavoclen-4 creamy wash liquid 4 % generic 1 AL At least 12 yrs old
lidocaine hcl solution 4 % generic 1
PAGE 154 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
lidocaine ointment 5 % generic 1
lidocaine pak ointment 5 % generic 1
lidocaine patch 5 % generic 1
LIDODERM PATCH 5 %lidocaine
BRAND 2
methoxsalen rapid cap 10 mg generic 1 MDD 4 per day
myorisan cap 10 mg generic 3PA
AL At least 12 yrs old
myorisan cap 20 mg generic 3PA
AL At least 12 yrs old
myorisan cap 30 mg generic 3PA
AL At least 12 yrs old
myorisan cap 40 mg generic 3PA
AL At least 12 yrs old
neuac gel 1.2-5 % generic 1PA
AL At least 12 yrs old
oscion cleanser lotion 6 % generic 1 AL At least 12 yrs old
OXSORALEN LOTION 1 %methoxsalen (topical)
BRAND 2
OXSORALEN ULTRA CAP 10 MGmethoxsalen rapid
BRAND 2 MDD 4 per day
pacnex wash liquid 7 % generic 1 AL At least 12 yrs old
PICATO GEL 0.015 %ingenol mebutate
BRAND 2
PICATO GEL 0.05 %ingenol mebutate
BRAND 2
podofilox solution 0.5 % generic 1
pr benzoyl peroxide wash liquid 7 % generic 1 AL At least 12 yrs old
pr benzoyl peroxide wash liquid 7 % generic 1 AL At least 12 yrs old
PAGE 155 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
prascion emulsion 10-5 % generic 1 AL At least 12 yrs old
premium lidocaine ointment 5 % generic 1
PRUDOXIN CREAM 5 %doxepin hcl (antipruritic)
BRAND 3
RECTIV OINTMENT 0.4 %nitroglycerin (intra-anal)
BRAND 3
REGRANEX GEL 0.01 %becaplermin
BRAND 3
rosaderm emulsion 10-5 % generic 1 AL At least 12 yrs old
rosanil cleanser emulsion 10-5 % generic 1 AL At least 12 yrs old
SANTYL OINTMENT 250 UNIT/GMcollagenase
BRAND 3
se 10-5 ss cream 10-5 % generic 1ST
AL At least 12 yrs old
se bpo wash liquid 7 % generic 1 AL At least 12 yrs old
selenium sulfide lotion 2.5 % generic 1 MPL 1 / Claim
SOLARAZE GEL 3 %diclofenac sodium (actinic keratoses)
BRAND 2 MPL 1 / claim
SORIATANE CAP 10 MGacitretin
BRAND 2 MDD 1 per day
SORIATANE CAP 17.5 MGacitretin
BRAND 2 MDD 1 per day
SORIATANE CAP 25 MGacitretin
BRAND 2 MDD 2 per day
sotret cap 20 mg generic 3PA
AL At least 12 yrs old
sss 10-5 cream 10-5 % generic 1ST
AL At least 12 yrs old
STELARA SOLN PRSYR 45 MG/0.5MLustekinumab
BRAND 4PA
S
PAGE 156 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
STELARA SOLN PRSYR 90 MG/MLustekinumab
BRAND 4PA
S
sulfacetamide sod-sulfur wash emulsion10-5 %
generic 1 AL At least 12 yrs old
sulfacetamide sodium (acne) lotion 10 % generic 1AL At least 12 yrs old
MPL 1 / Claim
sulfacetamide sodium suspension 10 % generic 1AL At least 12 yrs old
MPL 1 / Claim
sulfacetamide sodium-sulfur cream 10-5 % generic 1ST
AL At least 12 yrs old
sulfacetamide sodium-sulfur emulsion 10-5%
generic 1 AL At least 12 yrs old
sulfacetamide sodium-sulfur liquid 9-4.5 % generic 1ST
AL At least 12 yrs old
suphera cream 10-5 % generic 1ST
AL At least 12 yrs old
SYNERA PATCH 70-70 MGlidocaine-tetracaine
BRAND 3
TACLONEX OINTMENT 0.005-0.064 %calcipotriene-betamethasone dipropionate
BRAND 3 ST
TACLONEX SUSPENSION 0.005-0.064 %calcipotriene-betamethasone dipropionate
BRAND 3 ST
tacrolimus ointment 0.03 % generic 1AL At least 2 yrs old
MPL 1 / 30 days
tacrolimus ointment 0.1 % generic 1AL At least 2 yrs old
MPL 1 / 30 days
TAZORAC CREAM 0.05 %tazarotene
BRAND 2
TAZORAC CREAM 0.1 %tazarotene
BRAND 2
TAZORAC GEL 0.05 %tazarotene
BRAND 2
PAGE 157 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
TAZORAC GEL 0.1 %tazarotene
BRAND 2
topisulf cream 10-5 % generic 1ST
AL At least 12 yrs old
tretinoin cream 0.025 % generic 1 AL At least 12 yrs old
tretinoin cream 0.05 % generic 1 AL At least 12 yrs old
tretinoin cream 0.1 % generic 1 AL At least 12 yrs old
tretinoin gel 0.01 % generic 1 AL At least 12 yrs old
tretinoin gel 0.025 % generic 1 AL At least 12 yrs old
tretinoin microsphere gel 0.1 % generic 1PA
AL At least 12 yrs old
tretinoin microsphere pump gel 0.1 % generic 1PA
AL At least 12 yrs old
VECTICAL OINTMENT 3 MCG/GMcalcitriol (topical)
BRAND 1 MPL 1 / Claim
VELTIN GEL 1.2-0.025 %clindamycin phosphate-tretinoin
BRAND 3ST
AL At least 12 yrs old
VEREGEN OINTMENT 15 %sinecatechins
BRAND 3
virti-sulf cream 10-5 % generic 1ST
AL At least 12 yrs old
VOLTAREN GEL 1 %diclofenac sodium (topical)
BRAND 2
zenatane cap 10 mg generic 3PA
AL At least 12 yrs old
zenatane cap 20 mg generic 3PA
AL At least 12 yrs old
zenatane cap 30 mg generic 3PA
AL At least 12 yrs old
PAGE 158 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
zenatane cap 40 mg generic 3PA
AL At least 12 yrs old
ZIANA GEL 1.2-0.025 %clindamycin phosphate-tretinoin
BRAND 3ST
AL At least 12 yrs old
ZONALON CREAM 5 %doxepin hcl (antipruritic)
BRAND 3
ENZYME REPLACEMENT/MODIFIERS
ADAGEN SOLUTION 250 UNIT/MLpegademase bovine
BRAND 4PA
S
ALDURAZYME SOLUTION 2.9 MG/5MLlaronidase
BRAND 4PA
S
BUPHENYL POWDER 3 GM/TSPsodium phenylbutyrate
BRAND 3
BUPHENYL TAB 500 MGsodium phenylbutyrate
BRAND 3
CARBAGLU TAB 200 MGcarglumic acid
BRAND 4PA
S
CEREZYME RECON SOLN 200 UNITimiglucerase
BRAND 4PA
S
CEREZYME RECON SOLN 400 UNITimiglucerase
BRAND 4PA
S
CREON CP DR PART 12000 UNITpancrelipase (lipase-protease-amylase)
BRAND 2
CREON CP DR PART 24000 UNITpancrelipase (lipase-protease-amylase)
BRAND 2
CREON CP DR PART 3000-9500 UNITpancrelipase (lipase-protease-amylase)
BRAND 2
CREON CP DR PART 36000 UNITpancrelipase (lipase-protease-amylase)
BRAND 2
CREON CP DR PART 6000 UNITpancrelipase (lipase-protease-amylase)
BRAND 2
PAGE 159 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
CYSTADANE POWDERbetaine
BRAND 4PA
S
ELAPRASE SOLUTION 6 MG/3MLidursulfase
BRAND 4PA
S
ELELYSO RECON SOLN 200 UNITtaliglucerase alfa
BRAND 4PA
S
FABRAZYME RECON SOLN 35 MGagalsidase beta
BRAND 4PA
S
KUVAN TAB SOL 100 MGsapropterin dihydrochloride
BRAND 4PA
S
LUMIZYME RECON SOLN 50 MGalglucosidase alfa
BRAND 4PA
S
MYOZYME RECON SOLN 50 MGalglucosidase alfa
BRAND 4PA
S
NAGLAZYME SOLUTION 1 MG/MLgalsulfase
BRAND 4PA
S
ORFADIN CAP 10 MGnitisinone
BRAND 4PA
S
ORFADIN CAP 2 MGnitisinone
BRAND 4PA
S
ORFADIN CAP 5 MGnitisinone
BRAND 4PA
S
PANCREAZE CP DR PART 10500 UNITpancrelipase (lipase-protease-amylase)
BRAND 2
PANCREAZE CP DR PART 16800 UNITpancrelipase (lipase-protease-amylase)
BRAND 2
PANCREAZE CP DR PART 21000 UNITpancrelipase (lipase-protease-amylase)
BRAND 2
PANCREAZE CP DR PART 4200 UNITpancrelipase (lipase-protease-amylase)
BRAND 2
PAGE 160 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
pancrelipase (lip-prot-amyl) cp dr part5000 unit
generic 1
sodium phenylbutyrate powder 3 gm/tsp generic 3
SUCRAID SOLUTION 8500 UNIT/MLsacrosidase
BRAND 3
VPRIV RECON SOLN 400 UNITvelaglucerase alfa
BRAND 4PA
S
ZAVESCA CAP 100 MGmiglustat
BRAND 4PA
S
ZENPEP CP DR PART 10000 UNITpancrelipase (lipase-protease-amylase)
BRAND 2
ZENPEP CP DR PART 15000 UNITpancrelipase (lipase-protease-amylase)
BRAND 2
ZENPEP CP DR PART 20000 UNITpancrelipase (lipase-protease-amylase)
BRAND 2
ZENPEP CP DR PART 25000 UNITpancrelipase (lipase-protease-amylase)
BRAND 2
ZENPEP CP DR PART 3000-10000 UNITpancrelipase (lipase-protease-amylase)
BRAND 2
ZENPEP CP DR PART 5000 UNITpancrelipase (lipase-protease-amylase)
BRAND 2
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
ATROPINE SULFATE SOLUTION 0.05MG/MLatropine sulfate
BRAND 1
atropine sulfate solution 0.1 mg/ml generic 1
atropine sulfate solution 0.4 mg/ml generic 1
atropine sulfate solution 1 mg/ml generic 1
CANTIL TAB 25 MGmepenzolate bromide
BRAND 3
PAGE 161 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
chlordiazepoxide-clidinium cap 5-2.5 mg generic 1
dicyclomine hcl cap 10 mg generic 1
dicyclomine hcl solution 10 mg/5ml generic 1
dicyclomine hcl tab 20 mg generic 1
glycopyrrolate solution 4 mg/20ml generic 1
glycopyrrolate tab 1 mg generic 1
glycopyrrolate tab 2 mg generic 1
methscopolamine bromide tab 2.5 mg generic 1
methscopolamine bromide tab 5 mg generic 1
GASTROINTESTINAL AGENTS, OTHER
CHOLBAM CAP 250 MGcholic acid
BRAND 4PA
S
CHOLBAM CAP 50 MGcholic acid
BRAND 4PA
S
diphenoxylate-atropine liquid 2.5-0.025mg/5ml
generic 1
diphenoxylate-atropine tab 2.5-0.025 mg generic 1
ENTEREG CAP 12 MGalvimopan
BRAND 3
lofene tab 2.5-0.025 mg generic 1
lonox tab 2.5-0.025 mg generic 1
loperamide hcl cap 2 mg generic 1
MOTOFEN TAB 1-0.025 MGdifenoxin w/ atropine
BRAND 3
RELISTOR KIT 12 MG/0.6MLmethylnaltrexone bromide
BRAND 2
RELISTOR SOLUTION 12 MG/0.6MLmethylnaltrexone bromide
BRAND 2
RELISTOR SOLUTION 8 MG/0.4MLmethylnaltrexone bromide
BRAND 2
PAGE 162 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ursodiol cap 300 mg generic 1
ursodiol tab 250 mg generic 1
ursodiol tab 500 mg generic 1
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
cimetidine hcl solution 300 mg/5ml generic 1 MDS 600 / 30 days
cimetidine tab 200 mg generic 1
cimetidine tab 300 mg generic 1
cimetidine tab 400 mg generic 1
cimetidine tab 800 mg generic 1
FAMOTIDINE PREMIXED SOLUTION 20-0.9MG/50ML-%famotidine in nacl
BRAND 1
famotidine recon susp 40 mg/5ml generic 1 MDS 300 / 30 days
famotidine solution 20 mg/2ml generic 1
famotidine solution 200 mg/20ml generic 1
famotidine solution 40 mg/4ml generic 1
famotidine solution 500 mg/50ml generic 1
famotidine tab 20 mg generic 1
famotidine tab 40 mg generic 1
nizatidine cap 150 mg generic 1
nizatidine cap 300 mg generic 1
nizatidine solution 15 mg/ml generic 1 MDS 600 / 30 days
ranitidine hcl 150 mg generic 1
ranitidine hcl cap 150 mg generic 1
ranitidine hcl cap 300 mg generic 1
ranitidine hcl solution 150 mg/6ml generic 1
ranitidine hcl solution 50 mg/2ml generic 1
ranitidine hcl syrup 15 mg/ml generic 1 MDS 600 / 30 days
PAGE 163 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ranitidine hcl syrup 150 mg/10ml generic 1 MDS 600 / 30 days
ranitidine hcl syrup 75 mg/5ml generic 1 MDS 600 / 30 days
ranitidine hcl tab 150 mg generic 1
ranitidine hcl tab 300 mg generic 1
IRRITABLE BOWEL SYNDROME AGENTS
alosetron hcl tab 0.5 mg generic 1
alosetron hcl tab 1 mg generic 1
AMITIZA CAP 24 MCGlubiprostone
BRAND 2PA
MDD 2 per day
AMITIZA CAP 8 MCGlubiprostone
BRAND 2PA
MDD 2 per day
LOTRONEX TAB 0.5 MGalosetron hcl
BRAND 2
LOTRONEX TAB 1 MGalosetron hcl
BRAND 2
LAXATIVES
constulose solution 10 gm/15ml generic 1
enulose solution 10 gm/15ml generic 1
gavilyte-g recon soln 236 gm generic 0
generlac solution 10 gm/15ml generic 1
GOLYTELY RECON SOLN 236 GMpeg 3350-kcl-sod bicarb-sod chloride-sodsulfate
BRAND 0
lactulose 10 gm/15ml generic 1
lactulose encephalopathy solution 10gm/15ml
generic 1
lactulose solution 10 gm/15ml generic 1
lactulose solution 20 gm/30ml generic 1
PAGE 164 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
OSMOPREP TAB 1.102-0.398 GMsodium phosphate monobasic-sodiumphosphate dibasic
BRAND 3
peg-3350/electrolytes recon soln 236 gm generic 0
peg-3350/electrolytes recon soln 236 gm generic 0
PREPOPIK PACKET 10-3.5-12 MG-GM-GMsodium picosulfate-magnesium oxide-anhydrous citric acid
BRAND 3
SUPREP BOWEL PREP SOLUTIONsodium sulfate-potassium sulfate-magnesium sulfate
BRAND 0
VISICOL TAB 1.102-0.398 GMsodium phosphate monobasic-sodiumphosphate dibasic-mcc
BRAND 3 MDS 40 / 180 days
PROTECTANTS
CARAFATE SUSPENSION 1 GM/10MLsucralfate
BRAND 2 MDS 1200 / 30 days
CARAFATE TAB 1 GMsucralfate
BRAND 2 MDD 4 per day
misoprostol tab 100 mcg generic 1 MDD 4 per day
misoprostol tab 200 mcg generic 1 MDD 4 per day
sucralfate tab 1 gm generic 1 MDD 4 per day
PROTON PUMP INHIBITORS
DEXILANT CAP DR 30 MGdexlansoprazole
BRAND 3ST
MDD 1 per day
DEXILANT CAP DR 60 MGdexlansoprazole
BRAND 3ST
MDD 1 per day
esomeprazole magnesium cap dr 20 mg generic 1 MDD 2 per day
esomeprazole magnesium cap dr 40 mg generic 3ST
MDD 1 per day
lansoprazole cap dr 15 mg generic 1 MDD 1 per day
PAGE 165 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
lansoprazole cap dr 30 mg generic 1
NEXIUM CAP DR 20 MGesomeprazole magnesium
BRAND 1 MDD 2 per day
omeprazole 20 mg generic 1 MDD 2 per day
omeprazole cap dr 10 mg generic 1 MDD 2 per day
omeprazole cap dr 20 mg generic 1 MDD 2 per day
omeprazole cap dr 40 mg generic 1 MDD 2 per day
omeprazole-sodium bicarbonate cap 20-1100 mg
generic 1 MDD 1 per day
pantoprazole sodium tab dr 20 mg generic 1 MDD 1 per day
pantoprazole sodium tab dr 40 mg generic 1
rabeprazole sodium tab dr 20 mg generic 1 MDD 1 per day
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
DETROL LA CAP ER 24H 2 MGtolterodine tartrate
BRAND 3PA
MDD 1 per day
DETROL LA CAP ER 24H 4 MGtolterodine tartrate
BRAND 3PA
MDD 1 per day
ENABLEX TAB ER 24H 15 MGdarifenacin hydrobromide
BRAND 3PA
MDD 1 per day
ENABLEX TAB ER 24H 7.5 MGdarifenacin hydrobromide
BRAND 3PA
MDD 1 per day
flavoxate hcl tab 100 mg generic 1
MYRBETRIQ TAB ER 24H 25 MGmirabegron
BRAND 3 PA
MYRBETRIQ TAB ER 24H 50 MGmirabegron
BRAND 3 PA
oxybutynin chloride er tab er 24h 10 mg generic 1
PAGE 166 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
oxybutynin chloride er tab er 24h 15 mg generic 1
oxybutynin chloride er tab er 24h 5 mg generic 1
oxybutynin chloride syrup 5 mg/5ml generic 1
oxybutynin chloride tab 5 mg generic 1
tolterodine tartrate er cap er 24h 2 mg generic 1 MDD 1 per day
tolterodine tartrate er cap er 24h 4 mg generic 1 MDD 1 per day
tolterodine tartrate tab 1 mg generic 1
tolterodine tartrate tab 2 mg generic 1
TOVIAZ TAB ER 24H 4 MGfesoterodine fumarate
BRAND 3PA
MDD 1 per day
TOVIAZ TAB ER 24H 8 MGfesoterodine fumarate
BRAND 3PA
MDD 1 per day
trospium chloride er cap er 24h 60 mg generic 1 MDD 1 per day
trospium chloride tab 20 mg generic 1
VESICARE TAB 10 MGsolifenacin succinate
BRAND 2PA
MDD 1 per day
VESICARE TAB 5 MGsolifenacin succinate
BRAND 2PA
MDD 1 per day
BENIGN PROSTATIC HYPERTROPHY AGENTS
alfuzosin hcl er tab er 24h 10 mg generic 1 MDD 1 per day
AVODART CAP 0.5 MGdutasteride
BRAND 2PA
MDD 1 per day
CIALIS TAB 5 MGtadalafil
BRAND 3PA
MDD 1 per day
dutasteride cap 0.5 mg generic 1PA
MDD 1 per day
finasteride tab 5 mg generic 1
RAPAFLO CAP 4 MGsilodosin
BRAND 2
PAGE 167 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
RAPAFLO CAP 8 MGsilodosin
BRAND 2
tamsulosin hcl cap 0.4 mg generic 1
terazosin hcl cap 1 mg generic 1
terazosin hcl cap 10 mg generic 1
terazosin hcl cap 2 mg generic 1
terazosin hcl cap 5 mg generic 1
GENITOURINARY AGENTS, OTHER
aminoacetic acid solution 1.5 % generic 1
argyle sterile saline solution 0.9 % generic 1
bethanechol chloride tab 10 mg generic 1 MDD 4 per day
bethanechol chloride tab 25 mg generic 1 MDD 4 per day
bethanechol chloride tab 5 mg generic 1 MDD 4 per day
bethanechol chloride tab 50 mg generic 1 MDD 4 per day
citric acid-sodium citrate solution 334-500mg/5ml
generic 1
CUPRIMINE CAP 250 MGpenicillamine
BRAND 3
curity sterile saline solution 0.9 % generic 1
CYSTAGON CAP 150 MGcysteamine bitartrate
BRAND 3 PA
CYSTAGON CAP 50 MGcysteamine bitartrate
BRAND 3 PA
cytra-2 solution 500-334 mg/5ml generic 1
ELMIRON CAP 100 MGpentosan polysulfate sodium
BRAND 2
glycine solution 1.5 % generic 1
glycine urologic solution 1.5 % generic 1
liqui-dualcitra 500-334 mg/5ml generic 1
PAGE 168 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
phenazo tab 200 mg generic 1
phenazopyridine hcl tab 100 mg generic 1
phenazopyridine hcl tab 200 mg generic 1
potassium citrate er tab er 10 meq (1080mg)
generic 1
RESECTISOL SOLUTION 5 %mannitol (gu irrigant)
BRAND 1
sod citrate-citric acid solution 500-334mg/5ml
generic 1
sodium chloride solution 0.9 % generic 1
SORBITOL SOLUTION 3 %sorbitol irrigation
BRAND 1
SORBITOL SOLUTION 3.3 %sorbitol irrigation
BRAND 1
SORBITOL-MANNITOL SOLUTION 2.7-0.54GM/100MLsorbitol-mannitol
BRAND 1
STENDRA TAB 100 MGavanafil
BRAND 3 MDS 4 / 30 Days
STENDRA TAB 200 MGavanafil
BRAND 3 MDS 4 / 30 Days
STENDRA TAB 50 MGavanafil
BRAND 3 MDS 4 / 30 Days
virtrate-2 solution 500-334 mg/5ml generic 1
PHOSPHATE BINDERS
calcium acetate (phos binder) cap 667 mg generic 1
calcium acetate (phos binder) tab 667 mg generic 1
calcium acetate cap 667 mg generic 1
FOSRENOL CHEW TAB 1000 MGlanthanum carbonate
BRAND 2
FOSRENOL CHEW TAB 500 MGlanthanum carbonate
BRAND 2
PAGE 169 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
FOSRENOL CHEW TAB 750 MGlanthanum carbonate
BRAND 2
PHOSLYRA SOLUTION 667 MG/5MLcalcium acetate (phosphate binder)
BRAND 2
RENAGEL TAB 400 MGsevelamer hcl
BRAND 3
RENAGEL TAB 800 MGsevelamer hcl
BRAND 3
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
A-HYDROCORT RECON SOLN 100 MGhydrocortisone sod succinate
BRAND 1
a-methapred 125 mg generic 1
a-methapred recon soln 125 mg generic 1
a-methapred recon soln 40 mg generic 1
alclometasone dipropionate cream 0.05 % generic 1
alclometasone dipropionate ointment 0.05%
generic 1
amcinonide cream 0.1 % generic 1
amcinonide lotion 0.1 % generic 3
amcinonide ointment 0.1 % generic 3
anucort-hc suppos 25 mg generic 1
anusol-hc suppos 25 mg generic 1
apexicon ointment 0.05 % generic 1
asmalpred plus solution 15 mg/5ml generic 1
asmalpred solution 15 mg/5ml generic 1
baycadron elixir 0.5 mg/5ml generic 1
beta-val cream 0.1 % generic 1
beta-val lotion 0.1 % generic 1
betamethasone dipropionate aug cream0.05 %
generic 1
PAGE 170 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
betamethasone dipropionate aug lotion0.05 %
generic 1
betamethasone dipropionate aug ointment0.05 %
generic 1
betamethasone dipropionate cream 0.05 % generic 1
betamethasone dipropionate lotion 0.05 % generic 1
betamethasone dipropionate ointment0.05 %
generic 1
betamethasone valerate cream 0.1 % generic 1
betamethasone valerate foam 0.12 % generic 1
betamethasone valerate lotion 0.1 % generic 1
betamethasone valerate ointment 0.1 % generic 1
clobetasol propionate cream 0.05 % generic 1
clobetasol propionate e cream 0.05 % generic 1
clobetasol propionate foam 0.05 % generic 1
clobetasol propionate gel 0.05 % generic 1
clobetasol propionate ointment 0.05 % generic 1
clobetasol propionate solution 0.05 % generic 1
CLODERM CREAM 0.1 %clocortolone pivalate
BRAND 3
CLODERM PUMP CREAM 0.1 %clocortolone pivalate
BRAND 3
CORDRAN CREAM 0.05 %flurandrenolide
BRAND 3
CORDRAN LOTION 0.05 %flurandrenolide
BRAND 3
CORDRAN TAPE 4 MCG/SQCMflurandrenolide
BRAND 3
cormax ointment 0.05 % generic 1
cormax scalp application solution 0.05 % generic 1
PAGE 171 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
cormax solution 0.05 % generic 1
cortisone acetate tab 25 mg generic 1
deltasone tab 20 mg generic 1
DEPO-MEDROL SUSPENSION 20 MG/MLmethylprednisolone acetate
BRAND 3
desonide cream 0.05 % generic 1
desonide lotion 0.05 % generic 1
desonide ointment 0.05 % generic 1
desoximetasone cream 0.25 % generic 1
desoximetasone gel 0.05 % generic 1
desoximetasone ointment 0.25 % generic 1
dexamethasone elixir 0.5 mg/5ml generic 1
DEXAMETHASONE INTENSOL CONC 1MG/MLdexamethasone
BRAND 1
dexamethasone sodium phosphate solution120 mg/30ml
generic 1
dexamethasone sodium phosphate solution20 mg/5ml
generic 1
dexamethasone sodium phosphate solution4 mg/ml
generic 1
dexamethasone solution 0.5 mg/5ml generic 1
dexamethasone tab 0.5 mg generic 1
dexamethasone tab 0.75 mg generic 1
dexamethasone tab 1 mg generic 1
dexamethasone tab 1.5 mg generic 1
dexamethasone tab 2 mg generic 1
dexamethasone tab 4 mg generic 1
dexamethasone tab 6 mg generic 1
PAGE 172 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
diflorasone diacetate cream 0.05 % generic 2
diflorasone diacetate ointment 0.05 % generic 1
fludrocortisone acetate tab 0.1 mg generic 1
fluocinolone acetonide cream 0.01 % generic 1
fluocinolone acetonide cream 0.025 % generic 1
fluocinolone acetonide ointment 0.025 % generic 1
fluocinolone acetonide scalp oil 0.01 % generic 1
fluocinolone acetonide solution 0.01 % generic 1
fluocinonide cream 0.05 % generic 1
fluocinonide gel 0.05 % generic 1
fluocinonide ointment 0.05 % generic 1
fluocinonide solution 0.05 % generic 1
fluocinonide-e cream 0.05 % generic 1
fluticasone propionate cream 0.05 % generic 1
fluticasone propionate lotion 0.05 % generic 1
fluticasone propionate ointment 0.005 % generic 1
grx hicort 25 suppos 25 mg generic 1
halobetasol propionate cream 0.05 % generic 1
halobetasol propionate ointment 0.05 % generic 1
HALOG CREAM 0.1 %halcinonide
BRAND 3
HALOG OINTMENT 0.1 %halcinonide
BRAND 3
hemmorex-hc suppos 25 mg generic 1
hemmorex-hc suppos 30 mg generic 1
hemorrhoidal-hc suppos 25 mg generic 1
hemril-30 suppos 30 mg generic 1
hydrocortisone acetate suppos 25 mg generic 1
PAGE 173 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
hydrocortisone acetate suppos 30 mg generic 1
hydrocortisone butyrate cream 0.1 % generic 1
hydrocortisone butyrate ointment 0.1 % generic 1
hydrocortisone butyrate solution 0.1 % generic 1
hydrocortisone tab 10 mg generic 1
hydrocortisone tab 20 mg generic 1
hydrocortisone tab 5 mg generic 1
hydrocortisone valerate cream 0.2 % generic 1
hydrocortisone valerate ointment 0.2 % generic 1
KENALOG SUSPENSION 40 MG/MLtriamcinolone acetonide
BRAND 3
lokara lotion 0.05 % generic 1
MEDROL TAB 2 MGmethylprednisolone
BRAND 3
methylprednisolone (pak) 4 mg generic 1
methylprednisolone (pak) tab 4 mg generic 1
methylprednisolone acetate suspension 40mg/ml
generic 1
methylprednisolone acetate suspension 80mg/ml
generic 1
methylprednisolone sodium succ recon soln1000 mg
generic 1
methylprednisolone sodium succ recon soln125 mg
generic 1
methylprednisolone sodium succ recon soln40 mg
generic 1
methylprednisolone sodium succ recon soln500 mg
generic 1
methylprednisolone tab 16 mg generic 1
methylprednisolone tab 32 mg generic 1
PAGE 174 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
methylprednisolone tab 4 mg generic 1
methylprednisolone tab 8 mg generic 1
methylprednisolone tab thpk 4 mg generic 1
MILLIPRED DP 12-DAY TAB THPK 5 MG (48)prednisolone
BRAND 3
MILLIPRED DP TAB THPK 5 MG (21)prednisolone
BRAND 3
MILLIPRED DP TAB THPK 5 MG (48)prednisolone
BRAND 3
MILLIPRED SOLUTION 10 MG/5MLprednisolone sodium phosphate
BRAND 3
MILLIPRED TAB 5 MGprednisolone
BRAND 3
mometasone furoate cream 0.1 % generic 1
mometasone furoate ointment 0.1 % generic 1
mometasone furoate solution 0.1 % generic 1
oralone paste 0.1 % generic 1
ORAPRED ODT TAB DISP 10 MGprednisolone sodium phosphate
BRAND 3
ORAPRED ODT TAB DISP 15 MGprednisolone sodium phosphate
BRAND 3
ORAPRED ODT TAB DISP 30 MGprednisolone sodium phosphate
BRAND 3
prednicarbate cream 0.1 % generic 1
prednicarbate ointment 0.1 % generic 1
prednisolone sodium phosphate solution 15mg/5ml
generic 1
PREDNISOLONE SODIUM PHOSPHATESOLUTION 25 MG/5MLprednisolone sodium phosphate
BRAND 1
prednisolone sodium phosphate solution6.7 (5 base) mg/5ml
generic 1
PAGE 175 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
prednisolone solution 15 mg/5ml generic 1
prednisolone syrup 15 mg/5ml generic 1
prednisone solution 5 mg/5ml generic 1
prednisone tab 1 mg generic 1
prednisone tab 10 mg generic 1
prednisone tab 2.5 mg generic 1
prednisone tab 20 mg generic 1
prednisone tab 5 mg generic 1
prednisone tab 50 mg generic 1
rectacort-hc suppos 25 mg generic 1
SOLU-CORTEF RECON SOLN 250 MGhydrocortisone sod succinate
BRAND 3
SOLU-MEDROL RECON SOLN 2 GMmethylprednisolone sod succ
BRAND 3
triamcinolone acetonide cream 0.025 % generic 1
triamcinolone acetonide cream 0.1 % generic 1
triamcinolone acetonide cream 0.5 % generic 1
triamcinolone acetonide lotion 0.025 % generic 1
triamcinolone acetonide lotion 0.1 % generic 1
triamcinolone acetonide ointment 0.025 % generic 1
triamcinolone acetonide ointment 0.1 % generic 1
triamcinolone acetonide ointment 0.5 % generic 1
triamcinolone acetonide paste 0.1 % generic 1
triderm cream 0.1 % generic 1
VERIPRED 20 SOLUTION 20 MG/5MLprednisolone sodium phosphate
BRAND 3
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
chorionic gonadotropin recon soln 10000unit
generic 4PA
S
PAGE 176 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
desmopressin ace spray refrig solution 0.01%
generic 1
desmopressin acetate solution 4 mcg/ml generic 1 PA
desmopressin acetate spray solution 0.01%
generic 1
desmopressin acetate tab 0.1 mg generic 1PA
MDD 6 per day
desmopressin acetate tab 0.2 mg generic 1PA
MDD 8 per day
GENOTROPIN MINIQUICK RECON SOLN 0.2MGsomatropin
BRAND 4PA
S
GENOTROPIN RECON SOLN 5 MGsomatropin
BRAND 4PA
S
HUMATROPE RECON SOLN 12 MGsomatropin
BRAND 4PA
S
HUMATROPE RECON SOLN 24 MGsomatropin
BRAND 4PA
S
HUMATROPE RECON SOLN 5 MGsomatropin
BRAND 4PA
S
HUMATROPE RECON SOLN 6 MGsomatropin
BRAND 4PA
S
INCRELEX SOLUTION 40 MG/4MLmecasermin
BRAND 4PA
S
NORDITROPIN FLEXPRO SOLUTION 10MG/1.5MLsomatropin
BRAND 4PA
S
NORDITROPIN FLEXPRO SOLUTION 15MG/1.5MLsomatropin
BRAND 4PA
S
NORDITROPIN FLEXPRO SOLUTION 5MG/1.5MLsomatropin
BRAND 4PA
S
PAGE 177 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
NORDITROPIN NORDIFLEX PEN SOLUTION10 MG/1.5MLsomatropin
BRAND 4PA
S
NORDITROPIN NORDIFLEX PEN SOLUTION15 MG/1.5MLsomatropin
BRAND 4PA
S
NORDITROPIN NORDIFLEX PEN SOLUTION5 MG/1.5MLsomatropin
BRAND 4PA
S
NORDITROPIN SOLUTION 15 MG/1.5MLsomatropin
BRAND 4PA
S
NORDITROPIN SOLUTION 5 MG/1.5MLsomatropin
BRAND 4PA
S
novarel recon soln 10000 unit generic 4PA
S
NUTROPIN AQ NUSPIN 10 SOLUTION 10MG/2MLsomatropin
BRAND 4PA
S
NUTROPIN AQ PEN SOLUTION 10 MG/2MLsomatropin
BRAND 4PA
S
NUTROPIN AQ SOLUTION 10 MG/2MLsomatropin
BRAND 4PA
S
NUTROPIN RECON SOLN 10 MGsomatropin
BRAND 4PA
S
OMNITROPE SOLUTION 10 MG/1.5MLsomatropin
BRAND 4PA
S
OMNITROPE SOLUTION 5 MG/1.5MLsomatropin
BRAND 4PA
S
pregnyl recon soln 10000 unit generic 4PA
S
SAIZEN CLICK.EASY RECON SOLN 8.8 MGsomatropin (non-refrigerated)
BRAND 4PA
S
PAGE 178 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SAIZEN RECON SOLN 5 MGsomatropin (non-refrigerated)
BRAND 4PA
S
SAIZEN RECON SOLN 8.8 MGsomatropin (non-refrigerated)
BRAND 4PA
S
SEROSTIM RECON SOLN 4 MGsomatropin (non-refrigerated)
BRAND 4PA
S
SEROSTIM RECON SOLN 5 MGsomatropin (non-refrigerated)
BRAND 4PA
S
SEROSTIM RECON SOLN 6 MGsomatropin (non-refrigerated)
BRAND 4PA
S
STIMATE SOLUTION 1.5 MG/MLdesmopressin acetate
BRAND 4PA
S
TEV-TROPIN RECON SOLN 5 MGsomatropin
BRAND 4PA
S
ZOMACTON RECON SOLN 10 MGsomatropin
BRAND 4PA
S
ZOMACTON RECON SOLN 5 MGsomatropin
BRAND 4PA
S
ZORBTIVE RECON SOLN 8.8 MGsomatropin (non-refrigerated)
BRAND 4PA
S
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEXHORMONES/MODIFIERS)
ANABOLIC STEROIDS
ANADROL-50 TAB 50 MGoxymetholone
BRAND 3
oxandrolone tab 10 mg generic 1
oxandrolone tab 2.5 mg generic 1
ANDROGENS
ANDRODERM PATCH 24HR 2 MG/24HRtestosterone
BRAND 2PA
MDD 1 per day
PAGE 179 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ANDRODERM PATCH 24HR 4 MG/24HRtestosterone
BRAND 2PA
MDD 1 per day
ANDROXY TAB 10 MGfluoxymesterone
BRAND 3
danazol cap 100 mg generic 1
danazol cap 200 mg generic 1
danazol cap 50 mg generic 1
METHITEST TAB 10 MGmethyltestosterone
BRAND 3
testosterone cypionate solution 100 mg/ml generic 1
testosterone cypionate solution 200 mg/ml generic 1
testosterone enanthate solution 200mg/ml
generic 1
ESTROGENS
ALORA PATCH TW 0.025 MG/24HRestradiol
BRAND 3 GL Female
ALORA PATCH TW 0.05 MG/24HRestradiol
BRAND 3 GL Female
ALORA PATCH TW 0.075 MG/24HRestradiol
BRAND 3 GL Female
ALORA PATCH TW 0.1 MG/24HRestradiol
BRAND 3 GL Female
altavera tab 0.15-30 mg-mcg generic 0 GL Female
alyacen 1/35 tab 1-35 mg-mcg generic 0 GL Female
alyacen 7/7/7 tab 0.5/0.75/1-35 mg-mcg generic 0 GL Female
amethia lo tab 0.1-0.02 & 0.01 mg generic 0 GL Female
amethia tab 0.15-0.03 &0.01 mg generic 0 GL Female
amethyst tab 90-20 mcg generic 0 GL Female
apri tab 0.15-30 mg-mcg generic 0 GL Female
PAGE 180 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
aranelle tab 0.5/1/0.5-35 mg-mcg generic 0 GL Female
ashlyna tab 0.15-0.03 &0.01 mg generic 0 GL Female
aubra tab 0.1-20 mg-mcg generic 0 GL Female
aviane tab 0.1-20 mg-mcg generic 0 GL Female
azurette tab 0.15-0.02/0.01 mg (21/5) generic 0 GL Female
balziva tab 0.4-35 mg-mcg generic 0 GL Female
bekyree tab 0.15-0.02/0.01 mg (21/5) generic 0 GL Female
BEYAZ TAB 3-0.02-0.451 MGdrospirenone-ethinyl estradiol-levomefolate calcium
BRAND 0 GL Female
blisovi 24 fe tab 1-20 mg-mcg(24) generic 0 GL Female
blisovi fe 1.5/30 tab 1.5-30 mg-mcg generic 0 GL Female
blisovi fe 1/20 tab 1-20 mg-mcg generic 0 GL Female
BREVICON (28) TAB 0.5-35 MG-MCGnorethindrone & eth estradiol
BRAND 0 GL Female
briellyn tab 0.4-35 mg-mcg generic 0 GL Female
camrese lo tab 0.1-0.02 & 0.01 mg generic 0 GL Female
camrese tab 0.15-0.03 &0.01 mg generic 0 GL Female
caziant tab 0.1/0.125/0.15 -0.025 mg generic 0 GL Female
CENESTIN TAB 0.3 MGestrogens, conjugated synthetic a
BRAND 3 GL Female
CENESTIN TAB 0.45 MGestrogens, conjugated synthetic a
BRAND 3 GL Female
CENESTIN TAB 0.625 MGestrogens, conjugated synthetic a
BRAND 3 GL Female
CENESTIN TAB 0.9 MGestrogens, conjugated synthetic a
BRAND 3 GL Female
CENESTIN TAB 1.25 MGestrogens, conjugated synthetic a
BRAND 3 GL Female
PAGE 181 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
cesia tab 0.1/0.125/0.15 -0.025 mg generic 0 GL Female
chateal tab 0.15-30 mg-mcg generic 0 GL Female
CLIMARA PRO PATCH WK 0.045-0.015MG/DAYestradiol-levonorgestrel
BRAND 3 GL Female
cryselle-28 tab 0.3-30 mg-mcg generic 0 GL Female
cyclafem 1/35 tab 1-35 mg-mcg generic 0 GL Female
cyclafem 7/7/7 tab 0.5/0.75/1-35 mg-mcg generic 0 GL Female
CYCLESSA TAB 0.1/0.125/0.15 -0.025 MGdesogestrel-ethinyl estradiol (triphasic)
BRAND 0 GL Female
cyred tab 0.15-30 mg-mcg generic 0 GL Female
dasetta 1/35 tab 1-35 mg-mcg generic 0 GL Female
dasetta 7/7/7 tab 0.5/0.75/1-35 mg-mcg generic 0 GL Female
daysee tab 0.15-0.03 &0.01 mg generic 0 GL Female
delyla tab 0.1-20 mg-mcg generic 0 GL Female
DEPO-ESTRADIOL OIL 5 MG/MLestradiol cypionate
BRAND 3 GL Female
DESOGEN TAB 0.15-30 MG-MCGdesogestrel & ethinyl estradiol
BRAND 0 GL Female
desogestrel-ethinyl estradiol tab 0.15-0.02/0.01 mg (21/5)
generic 0 GL Female
desogestrel-ethinyl estradiol tab 0.15-30mg-mcg
generic 0 GL Female
DIVIGEL GEL 0.25 MG/0.25GMestradiol
BRAND 3 GL Female
DIVIGEL GEL 0.5 MG/0.5GMestradiol
BRAND 3 GL Female
DIVIGEL GEL 1 MG/GMestradiol
BRAND 3 GL Female
drospirenone-ethinyl estradiol tab 3-0.02mg
generic 0 GL Female
PAGE 182 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
drospirenone-ethinyl estradiol tab 3-0.03mg
generic 0 GL Female
ELESTRIN GEL 0.52 MG/0.87 GM (0.06%)estradiol
BRAND 3 GL Female
elinest tab 0.3-30 mg-mcg generic 0 GL Female
emoquette tab 0.15-30 mg-mcg generic 0 GL Female
ENJUVIA TAB 0.3 MGestrogens, conjugated synthetic b
BRAND 3 GL Female
ENJUVIA TAB 0.45 MGestrogens, conjugated synthetic b
BRAND 3 GL Female
ENJUVIA TAB 0.625 MGestrogens, conjugated synthetic b
BRAND 3 GL Female
ENJUVIA TAB 0.9 MGestrogens, conjugated synthetic b
BRAND 3 GL Female
ENJUVIA TAB 1.25 MGestrogens, conjugated synthetic b
BRAND 3 GL Female
enpresse-28 tab generic 0 GL Female
enskyce tab 0.15-30 mg-mcg generic 0 GL Female
estarylla tab 0.25-35 mg-mcg generic 0 GL Female
ESTRACE CREAM 0.1 MG/GMestradiol vaginal
BRAND 3 GL Female
ESTRADERM PATCH TW 0.05 MG/24HRestradiol
BRAND 3 GL Female
ESTRADERM PATCH TW 0.1 MG/24HRestradiol
BRAND 3 GL Female
estradiol patch tw 0.025 mg/24hr generic 1 GL Female
estradiol patch tw 0.0375 mg/24hr generic 1 GL Female
estradiol patch tw 0.05 mg/24hr generic 1 GL Female
estradiol patch tw 0.075 mg/24hr generic 1 GL Female
estradiol patch tw 0.1 mg/24hr generic 1 GL Female
PAGE 183 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
estradiol patch wk 0.025 mg/24hr generic 1 GL Female
estradiol patch wk 0.0375 mg/24hr generic 1 GL Female
estradiol patch wk 0.05 mg/24hr generic 1 GL Female
estradiol patch wk 0.06 mg/24hr generic 1 GL Female
estradiol patch wk 0.075 mg/24hr generic 1 GL Female
estradiol patch wk 0.1 mg/24hr generic 1 GL Female
estradiol tab 0.5 mg generic 1 GL Female
estradiol tab 1 mg generic 1 GL Female
estradiol tab 2 mg generic 1 GL Female
estradiol valerate oil 10 mg/ml generic 1 GL Female
estradiol valerate oil 20 mg/ml generic 1 GL Female
estradiol valerate oil 40 mg/ml generic 1 GL Female
ESTRASORB EMULSION 4.35 MG/1.74GMestradiol
BRAND 3 GL Female
ESTROGEL GEL 0.75 MG/1.25 GM (0.06%)estradiol
BRAND 3 GL Female
estropipate tab 0.75 mg generic 1 GL Female
estropipate tab 1.5 mg generic 1 GL Female
estropipate tab 3 mg generic 1 GL Female
ESTROSTEP FE TAB 1-20/1-30/1-35 MG-MCGnorethindrone acetate-ethinyl estradiol-fe
BRAND 0 GL Female
EVAMIST SOLUTION 1.53 MG/SPRAYestradiol
BRAND 3 GL Female
falmina tab 0.1-20 mg-mcg generic 0 GL Female
FEMCON FE CHEW TAB 0.4-35 MG-MCGnorethindrone & ethinyl estradiol-fe
BRAND 0 GL Female
FEMRING RING 0.05 MG/24HRestradiol acetate vaginal
BRAND 3 GL Female
PAGE 184 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
FEMRING RING 0.1 MG/24HRestradiol acetate vaginal
BRAND 3 GL Female
GENERESS FE CHEW TAB 0.8-25 MG-MCGnorethindrone & ethinyl estradiol-fe
BRAND 0 GL Female
gianvi tab 3-0.02 mg generic 0 GL Female
gildagia tab 0.4-35 mg-mcg generic 0 GL Female
gildess 1.5/30 tab 1.5-30 mg-mcg generic 0 GL Female
gildess 1/20 tab 1-20 mg-mcg generic 0 GL Female
gildess 24 fe tab 1-20 mg-mcg(24) generic 0 GL Female
gildess fe 1.5/30 tab 1.5-30 mg-mcg generic 0 GL Female
gildess fe 1/20 tab 1-20 mg-mcg generic 0 GL Female
introvale tab 0.15-0.03 mg generic 0 GL Female
jolessa tab 0.15-0.03 mg generic 0 GL Female
juleber tab 0.15-30 mg-mcg generic 0 GL Female
junel 1.5/30 tab 1.5-30 mg-mcg generic 0 GL Female
junel 1/20 tab 1-20 mg-mcg generic 0 GL Female
junel fe 1.5/30 tab 1.5-30 mg-mcg generic 0 GL Female
junel fe 1/20 tab 1-20 mg-mcg generic 0 GL Female
junel fe 24 tab 1-20 mg-mcg(24) generic 0 GL Female
kariva tab 0.15-0.02/0.01 mg (21/5) generic 0 GL Female
kelnor 1/35 tab 1-35 mg-mcg generic 0 GL Female
kimidess tab 0.15-0.02/0.01 mg (21/5) generic 0 GL Female
kurvelo tab 0.15-30 mg-mcg generic 0 GL Female
larin 1.5/30 tab 1.5-30 mg-mcg generic 0 GL Female
larin 1/20 tab 1-20 mg-mcg generic 0 GL Female
larin 24 fe tab 1-20 mg-mcg(24) generic 0 GL Female
PAGE 185 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
larin fe 1.5/30 tab 1.5-30 mg-mcg generic 0 GL Female
larin fe 1/20 tab 1-20 mg-mcg generic 0 GL Female
layolis fe chew tab 0.8-25 mg-mcg generic 0 GL Female
leena tab 0.5/1/0.5-35 mg-mcg generic 0 GL Female
lessina tab 0.1-20 mg-mcg generic 0 GL Female
levonest tab generic 0 GL Female
levonorgest-eth estrad 91-day tab 0.1-0.02& 0.01 mg
generic 0 GL Female
levonorgest-eth estrad 91-day tab 0.15-0.03 &0.01 mg
generic 0 GL Female
levonorgest-eth estrad 91-day tab 0.15-0.03 mg
generic 0 GL Female
levonorgestrel-ethinyl estrad tab 0.1-20mg-mcg
generic 0 GL Female
levonorgestrel-ethinyl estrad tab 0.15-30mg-mcg
generic 0 GL Female
levonorgestrel-ethinyl estrad tab 90-20mcg
generic 0 GL Female
levora 0.15/30 (28) tab 0.15-30 mg-mcg generic 0 GL Female
LO LOESTRIN FE TAB 1 MG-10 MCG / 10MCGnorethindrone acetate-ethinyl estradiol-fefum (biphasic)
BRAND 0 GL Female
LO/OVRAL (28) TAB 0.3-30 MG-MCGnorgestrel & ethinyl estradiol
BRAND 0 GL Female
LOESTRIN 1.5/30 (21) TAB 1.5-30 MG-MCGnorethindrone acet & eth estra
BRAND 0 GL Female
LOESTRIN 1/20 (21) TAB 1-20 MG-MCGnorethindrone acet & eth estra
BRAND 0 GL Female
LOESTRIN 24 FE TAB 1-20 MG-MCGnorethin acet & estrad-fe
BRAND 0 GL Female
PAGE 186 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
LOESTRIN FE 1.5/30 TAB 1.5-30 MG-MCGnorethin acet & estrad-fe
BRAND 0 GL Female
LOESTRIN FE 1/20 TAB 1-20 MG-MCGnorethin acet & estrad-fe
BRAND 0 GL Female
lomedia 24 fe tab 1-20 mg-mcg(24) generic 0 GL Female
loryna tab 3-0.02 mg generic 0 GL Female
LOSEASONIQUE TAB 0.1-0.02 & 0.01 MGlevonorgestrel-ethinyl estradiol (91-day)
BRAND 0 GL Female
low-ogestrel tab 0.3-30 mg-mcg generic 0 GL Female
lutera tab 0.1-20 mg-mcg generic 0 GL Female
marlissa tab 0.15-30 mg-mcg generic 0 GL Female
MENEST TAB 0.3 MGesterified estrogens
BRAND 3 GL Female
MENEST TAB 0.625 MGesterified estrogens
BRAND 3 GL Female
MENEST TAB 1.25 MGesterified estrogens
BRAND 3 GL Female
MENEST TAB 2.5 MGesterified estrogens
BRAND 3 GL Female
MENOSTAR PATCH WK 14 MCG/24HRestradiol
BRAND 3 GL Female
microgestin 1.5/30 tab 1.5-30 mg-mcg generic 0 GL Female
microgestin 1/20 tab 1-20 mg-mcg generic 0 GL Female
microgestin 24 fe tab 1-20 mg-mcg generic 0 GL Female
microgestin fe 1.5/30 tab 1.5-30 mg-mcg generic 0 GL Female
microgestin fe 1/20 tab 1-20 mg-mcg generic 0 GL Female
MINASTRIN 24 FE CHEW TAB 1-20 MG-MCG(24)norethin acet & estrad-fe
BRAND 0 GL Female
MINIVELLE PATCH TW 0.0375 MG/24HRestradiol
BRAND 3 GL Female
PAGE 187 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
MINIVELLE PATCH TW 0.05 MG/24HRestradiol
BRAND 3 GL Female
MINIVELLE PATCH TW 0.075 MG/24HRestradiol
BRAND 3 GL Female
MINIVELLE PATCH TW 0.1 MG/24HRestradiol
BRAND 3 GL Female
MIRCETTE TAB 0.15-0.02/0.01 MG (21/5)desogestrel-ethinyl estradiol (biphasic)
BRAND 0 GL Female
MODICON (28) TAB 0.5-35 MG-MCGnorethindrone & eth estradiol
BRAND 0 GL Female
mono-linyah tab 0.25-35 mg-mcg generic 0 GL Female
mononessa tab 0.25-35 mg-mcg generic 0 GL Female
myzilra tab generic 0 GL Female
NATAZIA TAB 3/2-2/2-3/1 MGestradiol valerate-dienogest
BRAND 0 GL Female
necon 0.5/35 (28) tab 0.5-35 mg-mcg generic 0 GL Female
necon 1/35 (28) tab 1-35 mg-mcg generic 0 GL Female
NECON 1/50 (28) TAB 1-50 MG-MCGnorethindrone & mestranol
BRAND 0 GL Female
NECON 10/11 (28) TAB 35 MCGnorethindrone-eth estradiol (biphasic)
BRAND 0 GL Female
necon 7/7/7 tab 0.5/0.75/1-35 mg-mcg generic 0 GL Female
nikki tab 3-0.02 mg generic 0 GL Female
NORDETTE (28) TAB 0.15-30 MG-MCGlevonorgestrel & eth estradiol
BRAND 0 GL Female
norethin ace-eth estrad-fe tab 1-20 mg-mcg
generic 0 GL Female
norethin ace-eth estrad-fe tab 1-20 mg-mcg(24)
generic 0 GL Female
norethin-eth estradiol-fe chew tab 0.8-25mg-mcg
generic 0 GL Female
PAGE 188 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
norethindrone acet-ethinyl est tab 1-20mg-mcg
generic 0 GL Female
norgestim-eth estrad triphasic tab0.18/0.215/0.25 mg-25 mcg
generic 0 GL Female
norgestim-eth estrad triphasic tab0.18/0.215/0.25 mg-35 mcg
generic 0 GL Female
norgestimate-eth estradiol tab 0.25-35 mg-mcg
generic 0 GL Female
norgestrel-ethinyl estradiol tab 0.3-30 mg-mcg
generic 0 GL Female
NORINYL 1+35 (28) TAB 1-35 MG-MCGnorethindrone & eth estradiol
BRAND 0 GL Female
NORINYL 1+50 (28) TAB 1-50 MG-MCGnorethindrone & mestranol
BRAND 0 GL Female
nortrel 0.5/35 (28) tab 0.5-35 mg-mcg generic 0 GL Female
nortrel 1/35 (21) tab 1-35 mg-mcg generic 0 GL Female
nortrel 1/35 (28) tab 1-35 mg-mcg generic 0 GL Female
nortrel 7/7/7 tab 0.5/0.75/1-35 mg-mcg generic 0 GL Female
NUVARING RING 0.12-0.015 MG/24HRetonogestrel-ethinyl estradiol
BRAND 0 GL Female
ocella tab 3-0.03 mg generic 0 GL Female
OGESTREL TAB 0.5-50 MG-MCGnorgestrel & ethinyl estradiol
BRAND 0 GL Female
orsythia tab 0.1-20 mg-mcg generic 0 GL Female
ORTHO EVRA PATCH WK 150-35MCG/24HRnorelgestromin-ethinyl estradiol
BRAND 0 GL Female
ORTHO TRI-CYCLEN (28) TAB0.18/0.215/0.25 MG-35 MCGnorgestimate-ethinyl estradiol (triphasic)
BRAND 0 GL Female
ORTHO TRI-CYCLEN LO TAB0.18/0.215/0.25 MG-25 MCGnorgestimate-ethinyl estradiol (triphasic)
BRAND 0 GL Female
PAGE 189 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ORTHO-CEPT (28) TAB 0.15-30 MG-MCGdesogestrel & ethinyl estradiol
BRAND 0 GL Female
ORTHO-CYCLEN (28) TAB 0.25-35 MG-MCGnorgestimate-ethinyl estradiol
BRAND 0 GL Female
ORTHO-NOVUM 1/35 (28) TAB 1-35 MG-MCGnorethindrone & eth estradiol
BRAND 0 GL Female
ORTHO-NOVUM 7/7/7 (28) TAB0.5/0.75/1-35 MG-MCGnorethindrone-eth estradiol (triphasic)
BRAND 0 GL Female
OVCON-35 (28) TAB 0.4-35 MG-MCGnorethindrone & eth estradiol
BRAND 0 GL Female
philith tab 0.4-35 mg-mcg generic 0 GL Female
pimtrea tab 0.15-0.02/0.01 mg (21/5) generic 0 GL Female
pirmella 1/35 tab 1-35 mg-mcg generic 0 GL Female
pirmella 7/7/7 tab 0.5/0.75/1-35 mg-mcg generic 0 GL Female
portia-28 tab 0.15-30 mg-mcg generic 0 GL Female
PREMARIN CREAM 0.625 MG/GMestrogens, conjugated vaginal
BRAND 2 GL Female
PREMARIN RECON SOLN 25 MGestrogens, conjugated
BRAND 2 GL Female
PREMARIN TAB 0.3 MGestrogens, conjugated
BRAND 2 GL Female
PREMARIN TAB 0.45 MGestrogens, conjugated
BRAND 2 GL Female
PREMARIN TAB 0.625 MGestrogens, conjugated
BRAND 2 GL Female
PREMARIN TAB 0.9 MGestrogens, conjugated
BRAND 2 GL Female
PREMARIN TAB 1.25 MGestrogens, conjugated
BRAND 2 GL Female
PAGE 190 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
PREMPRO TAB 0.3-1.5 MGconjugated estrogens-medroxyprogesterone acetate
BRAND 2 GL Female
PREMPRO TAB 0.45-1.5 MGconjugated estrogens-medroxyprogesterone acetate
BRAND 2 GL Female
PREMPRO TAB 0.625-2.5 MGconjugated estrogens-medroxyprogesterone acetate
BRAND 2 GL Female
PREMPRO TAB 0.625-5 MGconjugated estrogens-medroxyprogesterone acetate
BRAND 2 GL Female
previfem tab 0.25-35 mg-mcg generic 0 GL Female
quasense tab 0.15-0.03 mg generic 0 GL Female
reclipsen tab 0.15-30 mg-mcg generic 0 GL Female
SAFYRAL TAB 3-0.03-0.451 MGdrospirenone-ethinyl estradiol-levomefolate calcium
BRAND 0 GL Female
SEASONALE TAB 0.15-0.03 MGlevonorgestrel-ethinyl estradiol (91-day)
BRAND 0 GL Female
SEASONIQUE TAB 0.15-0.03 &0.01 MGlevonorgestrel-ethinyl estradiol (91-day)
BRAND 0 GL Female
setlakin tab 0.15-0.03 mg generic 0 GL Female
solia tab 0.15-30 mg-mcg generic 0 GL Female
sprintec 28 tab 0.25-35 mg-mcg generic 0 GL Female
sronyx tab 0.1-20 mg-mcg generic 0 GL Female
syeda tab 3-0.03 mg generic 0 GL Female
tarina fe 1/20 tab 1-20 mg-mcg generic 0 GL Female
tilia fe tab 1-20/1-30/1-35 mg-mcg generic 0 GL Female
tri-estarylla tab 0.18/0.215/0.25 mg-35mcg
generic 0 GL Female
PAGE 191 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
tri-legest fe tab 1-20/1-30/1-35 mg-mcg generic 0 GL Female
tri-linyah tab 0.18/0.215/0.25 mg-35 mcg generic 0 GL Female
tri-lo-estarylla tab 0.18/0.215/0.25 mg-25mcg
generic 0 GL Female
tri-lo-marzia tab 0.18/0.215/0.25 mg-25mcg
generic 0 GL Female
tri-lo-sprintec tab 0.18/0.215/0.25 mg-25mcg
generic 0 GL Female
TRI-NORINYL (28) TAB 0.5/1/0.5-35 MG-MCGnorethindrone-eth estradiol (triphasic)
BRAND 0 GL Female
tri-previfem tab 0.18/0.215/0.25 mg-35mcg
generic 0 GL Female
tri-sprintec tab 0.18/0.215/0.25 mg-35 mcg generic 0 GL Female
trinessa (28) tab 0.18/0.215/0.25 mg-35mcg
generic 0 GL Female
trinessa lo tab 0.18/0.215/0.25 mg-25 mcg generic 0 GL Female
trivora (28) tab generic 0 GL Female
velivet tab 0.1/0.125/0.15 -0.025 mg generic 0 GL Female
vestura tab 3-0.02 mg generic 0 GL Female
viorele tab 0.15-0.02/0.01 mg (21/5) generic 0 GL Female
VIVELLE-DOT PATCH TW 0.025 MG/24HRestradiol
BRAND 3 GL Female
VIVELLE-DOT PATCH TW 0.0375 MG/24HRestradiol
BRAND 3 GL Female
VIVELLE-DOT PATCH TW 0.05 MG/24HRestradiol
BRAND 3 GL Female
VIVELLE-DOT PATCH TW 0.075 MG/24HRestradiol
BRAND 3 GL Female
VIVELLE-DOT PATCH TW 0.1 MG/24HRestradiol
BRAND 3 GL Female
PAGE 192 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
vyfemla tab 0.4-35 mg-mcg generic 0 GL Female
wera tab 0.5-35 mg-mcg generic 0 GL Female
wymzya fe chew tab 0.4-35 mg-mcg generic 0 GL Female
XULANE PATCH WK 150-35 MCG/24HRnorelgestromin-ethinyl estradiol
BRAND 0 GL Female
YASMIN 28 TAB 3-0.03 MGdrospirenone-ethinyl estradiol
BRAND 0 GL Female
YAZ TAB 3-0.02 MGdrospirenone-ethinyl estradiol
BRAND 0 GL Female
zarah tab 3-0.03 mg generic 0 GL Female
zenchent fe chew tab 0.4-35 mg-mcg generic 0 GL Female
zenchent tab 0.4-35 mg-mcg generic 0 GL Female
zeosa chew tab 0.4-35 mg-mcg generic 0 GL Female
zovia 1/35e (28) tab 1-35 mg-mcg generic 0 GL Female
ZOVIA 1/50E (28) TAB 1-50 MG-MCGethynodiol diacet & eth estrad
BRAND 0 GL Female
PROGESTERONE AGONISTS/ANTAGONISTS
ELLA TAB 30 MGulipristal acetate
BRAND 0 GL Female
PROGESTINS
AYGESTIN TAB 5 MGnorethindrone acetate
BRAND 0
camila tab 0.35 mg generic 0 GL Female
deblitane tab 0.35 mg generic 0 GL Female
DEPO-PROVERA SUSPENSION 150 MG/MLmedroxyprogesterone acetate(contraceptive)
BRAND 0 GL Female
DEPO-SUBQ PROVERA 104 SUSPENSION104 MG/0.65MLmedroxyprogesterone acetate(contraceptive)
BRAND 0 GL Female
PAGE 193 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
errin tab 0.35 mg generic 0 GL Female
heather tab 0.35 mg generic 0 GL Female
IMPLANON IMPLANT 68 MGetonogestrel
BRAND 0 GL Female
jencycla tab 0.35 mg generic 0 GL Female
jolivette tab 0.35 mg generic 0 GL Female
levonorgestrel tab 0.75 mg generic 0 GL Female
levonorgestrel tab 1.5 mg generic 0 GL Female
LILETTA (52 MG) IUD 18.6 MCG/DAYlevonorgestrel (iud)
BRAND 0 GL Female
lyza tab 0.35 mg generic 0 GL Female
medroxyprogesterone acetate suspension150 mg/ml
generic 0 GL Female
medroxyprogesterone acetate tab 10 mg generic 1
medroxyprogesterone acetate tab 2.5 mg generic 1
medroxyprogesterone acetate tab 5 mg generic 1
MEGACE ES SUSPENSION 625 MG/5MLmegestrol acetate (appetite)
BRAND 3
MEGACE ORAL SUSPENSION 40 MG/MLmegestrol acetate
BRAND 3
megestrol acetate suspension 40 mg/ml generic 1
megestrol acetate suspension 400mg/10ml
generic 1
megestrol acetate suspension 625 mg/5ml generic 3
megestrol acetate tab 20 mg generic 1
megestrol acetate tab 40 mg generic 1
MIRENA IUD 20 MCG/24HRlevonorgestrel (iud)
BRAND 0 GL Female
my way tab 1.5 mg generic 0 GL Female
PAGE 194 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
NEXPLANON IMPLANT 68 MGetonogestrel
BRAND 0 GL Female
next choice one dose tab 1.5 mg generic 0 GL Female
next choice tab 0.75 mg generic 0 GL Female
NOR-QD TAB 0.35 MGnorethindrone (contraceptive)
BRAND 0 GL Female
nora-be tab 0.35 mg generic 0 GL Female
norethindrone acetate tab 5 mg generic 0
norethindrone tab 0.35 mg generic 0 GL Female
norlyroc tab 0.35 mg generic 0 GL Female
ORTHO MICRONOR TAB 0.35 MGnorethindrone (contraceptive)
BRAND 0 GL Female
PLAN B ONE-STEP TAB 1.5 MGlevonorgestrel (emergency oc)
BRAND 0 GL Female
PLAN B TAB 0.75 MGlevonorgestrel (emergency oc)
BRAND 0 GL Female
progesterone micronized cap 100 mg generic 1
progesterone micronized cap 200 mg generic 1
sharobel tab 0.35 mg generic 0 GL Female
SKYLA IUD 13.5 MGlevonorgestrel (iud)
BRAND 0 GL Female
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
EVISTA 60 MGraloxifene hcl
BRAND 2GL Female
MDD 1 per day
EVISTA TAB 60 MGraloxifene hcl
BRAND 2GL Female
MDD 1 per day
raloxifene hcl tab 60 mg generic 0GL Female
MDD 1 per day
PAGE 195 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
levo-t tab 100 mcg generic 1
levo-t tab 112 mcg generic 1
levo-t tab 125 mcg generic 1
levo-t tab 137 mcg generic 1
levo-t tab 150 mcg generic 1
levo-t tab 175 mcg generic 1
levo-t tab 200 mcg generic 1
levo-t tab 25 mcg generic 1
levo-t tab 300 mcg generic 1
levo-t tab 50 mcg generic 1
levo-t tab 75 mcg generic 1
levo-t tab 88 mcg generic 1
levothroid tab 100 mcg generic 1
levothroid tab 112 mcg generic 1
levothroid tab 125 mcg generic 1
levothroid tab 137 mcg generic 1
levothroid tab 150 mcg generic 1
levothroid tab 175 mcg generic 1
levothroid tab 200 mcg generic 1
levothroid tab 25 mcg generic 1
levothroid tab 300 mcg generic 1
levothroid tab 50 mcg generic 1
levothroid tab 75 mcg generic 1
levothroid tab 88 mcg generic 1
levothyroxine sodium 100 mcg generic 1
levothyroxine sodium 125 mcg generic 1
PAGE 196 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
levothyroxine sodium 150 mcg generic 1
levothyroxine sodium 25 mcg generic 1
levothyroxine sodium 50 mcg generic 1
levothyroxine sodium 75 mcg generic 1
levothyroxine sodium recon soln 100 mcg generic 1
levothyroxine sodium recon soln 500 mcg generic 1
levothyroxine sodium tab 100 mcg generic 1
levothyroxine sodium tab 112 mcg generic 1
levothyroxine sodium tab 125 mcg generic 1
levothyroxine sodium tab 137 mcg generic 1
levothyroxine sodium tab 150 mcg generic 1
levothyroxine sodium tab 175 mcg generic 1
levothyroxine sodium tab 200 mcg generic 1
levothyroxine sodium tab 25 mcg generic 1
levothyroxine sodium tab 300 mcg generic 1
levothyroxine sodium tab 50 mcg generic 1
levothyroxine sodium tab 75 mcg generic 1
levothyroxine sodium tab 88 mcg generic 1
levoxyl tab 100 mcg generic 1
levoxyl tab 112 mcg generic 1
levoxyl tab 125 mcg generic 1
levoxyl tab 137 mcg generic 1
levoxyl tab 150 mcg generic 1
levoxyl tab 175 mcg generic 1
levoxyl tab 200 mcg generic 1
levoxyl tab 25 mcg generic 1
levoxyl tab 50 mcg generic 1
PAGE 197 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
levoxyl tab 75 mcg generic 1
levoxyl tab 88 mcg generic 1
liothyronine sodium solution 10 mcg/ml generic 1
liothyronine sodium tab 25 mcg generic 1
liothyronine sodium tab 5 mcg generic 1
liothyronine sodium tab 50 mcg generic 1
THYROLAR-1 TAB 60 (12.5-50) MG (MCG)liotrix (t3-t4)
BRAND 3
THYROLAR-1/2 TAB 30 (6.25-25) MG (MCG)liotrix (t3-t4)
BRAND 3
THYROLAR-1/4 TAB 15 (3.1-12.5) MG(MCG)liotrix (t3-t4)
BRAND 3
THYROLAR-2 TAB 120 (25-100) MG (MCG)liotrix (t3-t4)
BRAND 3
THYROLAR-3 TAB 180 (37.5-150) MG(MCG)liotrix (t3-t4)
BRAND 3
unithroid direct tab 100 mcg generic 1
unithroid direct tab 112 mcg generic 1
unithroid direct tab 125 mcg generic 1
unithroid direct tab 150 mcg generic 1
unithroid direct tab 175 mcg generic 1
unithroid direct tab 200 mcg generic 1
unithroid direct tab 25 mcg generic 1
unithroid direct tab 300 mcg generic 1
unithroid direct tab 50 mcg generic 1
unithroid direct tab 75 mcg generic 1
unithroid direct tab 88 mcg generic 1
unithroid tab 100 mcg generic 1
PAGE 198 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
unithroid tab 112 mcg generic 1
unithroid tab 125 mcg generic 1
unithroid tab 137 mcg generic 1
unithroid tab 150 mcg generic 1
unithroid tab 175 mcg generic 1
unithroid tab 200 mcg generic 1
unithroid tab 25 mcg generic 1
unithroid tab 300 mcg generic 1
unithroid tab 50 mcg generic 1
unithroid tab 75 mcg generic 1
unithroid tab 88 mcg generic 1
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)
SENSIPAR TAB 30 MGcinacalcet hcl
BRAND 4PA
S
SENSIPAR TAB 60 MGcinacalcet hcl
BRAND 4PA
S
SENSIPAR TAB 90 MGcinacalcet hcl
BRAND 4PA
S
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
cabergoline tab 0.5 mg generic 1
ELIGARD KIT 22.5 MGleuprolide acetate (3 month)
BRAND 4PA
S
ELIGARD KIT 30 MGleuprolide acetate (4 month)
BRAND 4PA
S
ELIGARD KIT 45 MGleuprolide acetate (6 month)
BRAND 4PA
S
ELIGARD KIT 7.5 MGleuprolide acetate
BRAND 4PA
S
PAGE 199 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
FIRMAGON RECON SOLN 120 MGdegarelix acetate
BRAND 4PA
S
FIRMAGON RECON SOLN 80 MGdegarelix acetate
BRAND 4PA
S
leuprolide acetate kit 1 mg/0.2ml generic 4PA
S
LUPRON DEPOT KIT 11.25 MGleuprolide acetate (3 month)
BRAND 4PA
S
LUPRON DEPOT KIT 22.5 MGleuprolide acetate (3 month)
BRAND 4PA
S
LUPRON DEPOT KIT 3.75 MGleuprolide acetate
BRAND 4PA
S
LUPRON DEPOT KIT 30 MGleuprolide acetate (4 month)
BRAND 4PA
S
LUPRON DEPOT KIT 45 MGleuprolide acetate (6 month)
BRAND 4PA
S
LUPRON DEPOT KIT 7.5 MGleuprolide acetate
BRAND 4PA
S
LUPRON DEPOT-PED KIT 11.25 MGleuprolide acetate (cpp)
BRAND 4PA
S
LUPRON DEPOT-PED KIT 15 MGleuprolide acetate (cpp)
BRAND 4PA
S
LUPRON DEPOT-PED KIT 30 MG (PED)leuprolide acetate (cpp) (3 month)
BRAND 4PA
S
LUPRON DEPOT-PED KIT 7.5 MGleuprolide acetate (cpp)
BRAND 4PA
S
octreotide acetate solution 100 mcg/ml generic 4PA
S
octreotide acetate solution 1000 mcg/5ml generic 4PA
S
PAGE 200 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
octreotide acetate solution 1000 mcg/ml generic 4PA
S
octreotide acetate solution 200 mcg/ml generic 4PA
S
octreotide acetate solution 50 mcg/ml generic 4PA
S
octreotide acetate solution 500 mcg/ml generic 4PA
S
SANDOSTATIN SOLUTION 100 MCG/MLoctreotide acetate
BRAND 4PA
S
SANDOSTATIN SOLUTION 1000 MCG/MLoctreotide acetate
BRAND 4PA
S
SANDOSTATIN SOLUTION 200 MCG/MLoctreotide acetate
BRAND 4PA
S
SANDOSTATIN SOLUTION 50 MCG/MLoctreotide acetate
BRAND 4PA
S
SANDOSTATIN SOLUTION 500 MCG/MLoctreotide acetate
BRAND 4PA
S
SOMATULINE DEPOT SOLUTION 120MG/0.5MLlanreotide acetate
BRAND 4PA
S
SOMATULINE DEPOT SOLUTION 60MG/0.2MLlanreotide acetate
BRAND 4PA
S
SOMATULINE DEPOT SOLUTION 90MG/0.3MLlanreotide acetate
BRAND 4PA
S
SOMAVERT RECON SOLN 10 MGpegvisomant
BRAND 4PA
S
SOMAVERT RECON SOLN 15 MGpegvisomant
BRAND 4PA
S
PAGE 201 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SOMAVERT RECON SOLN 20 MGpegvisomant
BRAND 4PA
S
SYNAREL SOLUTION 2 MG/MLnafarelin acetate
BRAND 4PA
S
TRELSTAR DEPOT MIXJECT RECON SUSP3.75 MGtriptorelin pamoate
BRAND 4PA
S
TRELSTAR LA MIXJECT RECON SUSP 11.25MGtriptorelin pamoate
BRAND 4PA
S
TRELSTAR MIXJECT RECON SUSP 22.5 MGtriptorelin pamoate
BRAND 4PA
S
TRELSTAR RECON SUSP 11.25 MGtriptorelin pamoate
BRAND 4PA
S
TRELSTAR RECON SUSP 3.75 MGtriptorelin pamoate
BRAND 4PA
S
ZOLADEX IMPLANT 10.8 MGgoserelin acetate
BRAND 4PA
S
ZOLADEX IMPLANT 3.6 MGgoserelin acetate
BRAND 4PA
S
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole tab 10 mg generic 1
methimazole tab 5 mg generic 1
propylthiouracil tab 50 mg generic 1
IMMUNOLOGICAL AGENTS
IMMUNE SUPPRESSANTS
AZASAN TAB 100 MGazathioprine
BRAND 3
PAGE 202 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
AZASAN TAB 75 MGazathioprine
BRAND 3
azathioprine sodium recon soln 100 mg generic 1
azathioprine tab 50 mg generic 1
CELLCEPT INTRAVENOUS RECON SOLN 500MGmycophenolate mofetil hcl
BRAND 3
CIMZIA KIT 2 X 200 MGcertolizumab pegol
BRAND 4PA
S
CIMZIA PREFILLED KIT 2 X 200 MG/MLcertolizumab pegol
BRAND 4PA
S
CIMZIA STARTER KIT KIT 6 X 200 MG/MLcertolizumab pegol
BRAND 4PA
S
cyclosporine cap 100 mg generic 1
cyclosporine cap 25 mg generic 1
cyclosporine modified cap 100 mg generic 1
cyclosporine modified cap 25 mg generic 1
cyclosporine modified cap 50 mg generic 1
cyclosporine modified solution 100 mg/ml generic 1
cyclosporine solution 50 mg/ml generic 1
ENBREL RECON SOLN 25 MGetanercept
BRAND 4 S
ENBREL SOLN PRSYR 25 MG/0.5MLetanercept
BRAND 4PA
S
ENBREL SOLN PRSYR 50 MG/MLetanercept
BRAND 4PA
S
ENBREL SURECLICK SOLN A-INJ 50 MG/MLetanercept
BRAND 4PA
S
gengraf cap 100 mg generic 1
PAGE 203 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
gengraf cap 25 mg generic 1
gengraf cap 50 mg generic 1
gengraf solution 100 mg/ml generic 1
hecoria cap 0.5 mg generic 1
hecoria cap 1 mg generic 1
hecoria cap 5 mg generic 1
HUMIRA PEDIATRIC CROHNS START PREFSY KT 40 MG/0.8MLadalimumab
BRAND 4PA
S
HUMIRA PEN PEN KIT 40 MG/0.8MLadalimumab
BRAND 4PA
S
HUMIRA PEN-CROHNS STARTER PEN KIT 40MG/0.8MLadalimumab
BRAND 4PA
S
HUMIRA PEN-PSORIASIS STARTER PEN KIT40 MG/0.8MLadalimumab
BRAND 4PA
S
HUMIRA PREF SY KT 20 MG/0.4MLadalimumab
BRAND 4PA
S
HUMIRA PREF SY KT 40 MG/0.8MLadalimumab
BRAND 4PA
S
KINERET SOLN PRSYR 100 MG/0.67MLanakinra
BRAND 4PA
S
methotrexate sodium (pf) solution 250mg/10ml
generic 1 S
methotrexate sodium (pf) solution 50mg/2ml
generic 1 S
methotrexate sodium recon soln 1 gm generic 1 S
methotrexate sodium solution 25 mg/ml generic 1 S
methotrexate sodium solution 250mg/10ml
generic 1 S
PAGE 204 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
methotrexate sodium solution 50 mg/2ml generic 1 S
methotrexate tab 2.5 mg generic 1 S
mycophenolate mofetil cap 250 mg generic 1
mycophenolate mofetil tab 500 mg generic 1
mycophenolic acid tab dr 180 mg generic 1
mycophenolic acid tab dr 360 mg generic 1
MYFORTIC TAB DR 180 MGmycophenolate sodium
BRAND 2
MYFORTIC TAB DR 360 MGmycophenolate sodium
BRAND 2
NULOJIX RECON SOLN 250 MGbelatacept
BRAND 4PA
S
ORENCIA RECON SOLN 250 MGabatacept
BRAND 4PA
S
ORENCIA SOLN PRSYR 125 MG/MLabatacept
BRAND 4PA
S
PROGRAF CAP 1 MGtacrolimus
BRAND 2
PROGRAF SOLUTION 5 MG/MLtacrolimus
BRAND 2
RAPAMUNE SOLUTION 1 MG/MLsirolimus
BRAND 2
REMICADE RECON SOLN 100 MGinfliximab
BRAND 4PA
S
RHEUMATREX TAB 2.5 MGmethotrexate sodium (antirheumatic)
BRAND 4PA
S
SIMPONI SOLN A-INJ 50 MG/0.5MLgolimumab
BRAND 4PA
S
SIMPONI SOLN PRSYR 50 MG/0.5MLgolimumab
BRAND 4PA
S
PAGE 205 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
sirolimus tab 0.5 mg generic 1
sirolimus tab 1 mg generic 1
sirolimus tab 2 mg generic 1
tacrolimus cap 0.5 mg generic 1
tacrolimus cap 1 mg generic 1
tacrolimus cap 5 mg generic 1
TREXALL TAB 10 MGmethotrexate sodium
BRAND 4PA
S
TREXALL TAB 15 MGmethotrexate sodium
BRAND 4PA
S
TREXALL TAB 5 MGmethotrexate sodium
BRAND 4PA
S
TREXALL TAB 7.5 MGmethotrexate sodium
BRAND 4PA
S
XELJANZ TAB 5 MGtofacitinib citrate
BRAND 4PA
S
ZORTRESS TAB 0.25 MGeverolimus (immunosuppressant)
BRAND 4PA
S
ZORTRESS TAB 0.5 MGeverolimus (immunosuppressant)
BRAND 4PA
S
ZORTRESS TAB 0.75 MGeverolimus (immunosuppressant)
BRAND 4PA
S
IMMUNIZING AGENTS, PASSIVE
ATGAM INJECTABLE 50 MG/MLlymphocyte immune globulin,anti-thymocyte globulin (equine)
BRAND 4PA
S
CARIMUNE NF RECON SOLN 3 GMimmune globulin (human) iv
BRAND 4PA
S
PAGE 206 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
GAMMAGARD S/D LESS IGA RECON SOLN 5GMimmune globulin (human) iv
BRAND 4PA
S
GAMMAGARD S/D RECON SOLN 10 GMimmune globulin (human) iv
BRAND 4PA
S
GAMMAGARD S/D RECON SOLN 2.5 GMimmune globulin (human) iv
BRAND 4PA
S
GAMMAGARD S/D RECON SOLN 5 GMimmune globulin (human) iv
BRAND 4PA
S
GAMMAGARD SOLUTION 1 GM/10MLimmune globulin (human) iv orsubcutaneous
BRAND 4PA
S
GAMMAKED SOLUTION 1 GM/10MLimmune globulin (human) iv orsubcutaneous
BRAND 4PA
S
GAMUNEX-C SOLUTION 1 GM/10MLimmune globulin (human) iv orsubcutaneous
BRAND 4PA
S
HIZENTRA 20% SOLUTION 1 GM/5MLimmune globulin (human) subcutaneous
BRAND 4PA
S
HIZENTRA 20% SOLUTION 2 GM/10MLimmune globulin (human) subcutaneous
BRAND 4PA
S
HIZENTRA 20% SOLUTION 4 GM/20MLimmune globulin (human) subcutaneous
BRAND 4PA
S
HIZENTRA SOLUTION 10 GM/50MLimmune globulin (human) subcutaneous
BRAND 4PA
S
THYMOGLOBULIN RECON SOLN 25 MGanti-thymocyte globulin (rabbit),lymphocyte immune globulin
BRAND 4PA
S
IMMUNOMODULATORS
ACTEMRA SOLUTION 200 MG/10MLtocilizumab
BRAND 4PA
S
PAGE 207 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ACTEMRA SOLUTION 400 MG/20MLtocilizumab
BRAND 4PA
S
ACTEMRA SOLUTION 80 MG/4MLtocilizumab
BRAND 4PA
S
ACTIMMUNE SOLUTION 2000000UNIT/0.5MLinterferon gamma-1b
BRAND 4PA
S
ARCALYST RECON SOLN 220 MGrilonacept
BRAND 4PA
S
leflunomide tab 10 mg generic 1 MDD 1 per day
leflunomide tab 20 mg generic 1 MDD 1 per day
RIDAURA CAP 3 MGauranofin
BRAND 3
SIMULECT RECON SOLN 10 MGbasiliximab
BRAND 3
SIMULECT RECON SOLN 20 MGbasiliximab
BRAND 3
VACCINES
ADACEL SUSPENSION 5-2-15.5 LF-MCG/0.5tetanus toxoid-diphtheria-acellularpertussis adsorb (tdap)
BRAND 0
AFLURIA PRESERVATIVE FREE SUSP PRSYR0.5 MLinfluenza virus vaccine split preservativefree
BRAND 0
AFLURIA SUSPENSIONinfluenza virus vaccine split
BRAND 0
AGRIFLU SUSP PRSYR 0.5 MLinfluenza virus vaccine types a & bpreservative free
BRAND 0
BOOSTRIX SUSPENSION 5-2.5-18.5tetanus toxoid-diphtheria-acellularpertussis adsorb (tdap)
BRAND 0
PAGE 208 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
FLUARIX QUADRIVALENT SUSP PRSYR 0.5MLinfluenza virus vaccine split quadrivalent
BRAND 0
FLUARIX SUSP PRSYR 0.5 MLinfluenza virus vaccine split preservativefree
BRAND 0
FLUCELVAX SUSP PRSYR 0.5 MLinfluenza virus vaccine tissue-culturedsubunit
BRAND 0
FLULAVAL QUADRIVALENT SUSP PRSYR 0.5MLinfluenza virus vaccine split quadrivalent
BRAND 0
FLULAVAL QUADRIVALENT SUSPENSIONinfluenza virus vaccine split quadrivalent
BRAND 0
FLULAVAL SUSPENSIONinfluenza virus vaccine split
BRAND 0
FLUVIRIN PRESERVATIVE FREE SUSP PRSYR0.5 MLinfluenza virus vaccine types a & bpreservative free
BRAND 0
FLUVIRIN SUSP PRSYR 0.5 MLinfluenza virus vaccine types a & b surfaceantigen
BRAND 0
FLUVIRIN SUSPENSIONinfluenza virus vaccine types a & b surfaceantigen
BRAND 0
FLUZONE HIGH-DOSE SUSP PRSYR 0.5 MLinfluenza virus vaccine split high-dosepreservative free
BRAND 0
FLUZONE PEDIATRIC PF SUSP PRSYR 0.25MLinfluenza virus vaccine split preservativefree
BRAND 0
FLUZONE PRESERVATIVE FREE SUSP PRSYR0.5 MLinfluenza virus vaccine split preservativefree
BRAND 0
PAGE 209 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
FLUZONE PRESERVATIVE FREESUSPENSIONinfluenza virus vaccine split preservativefree
BRAND 0
FLUZONE QUADRIVALENT SUSP PRSYR 0.5MLinfluenza virus vaccine split quadrivalent
BRAND 0
FLUZONE QUADRIVALENT SUSPENSIONinfluenza virus vaccine split quadrivalent
BRAND 0
FLUZONE QUADRIVALENT SUSPENSION 0.5MLinfluenza virus vaccine split quadrivalent
BRAND 0
FLUZONE SUSP PEN 9 MCG/STRAINinfluenza virus vaccine split
BRAND 0
FLUZONE SUSPENSIONinfluenza virus vaccine split
BRAND 0
MENACTRA INJECTABLEmeningococcal (a,c,y&w-135)polysaccharide conjugate vaccine
BRAND 0
MENOMUNE INJECTABLEmeningococcal vac a,c,y&w-135
BRAND 0
MENVEO RECON SOLNmeningococcal (a,c,y&w-135)oligosaccharide conjugate vac
BRAND 0
PNEUMOVAX 23 INJECTABLE 25MCG/0.5MLpneumococcal vac polyvalent
BRAND 0
PREVNAR 13 SUSPENSIONpneumococcal 13-valent conjugate vaccine
BRAND 0
ZOSTAVAX RECON SOLN 19400UNT/0.65MLzoster vaccine live
BRAND 0 AL At least 50 yrs old
PAGE 210 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
APRISO CAP ER 24H 0.375 GMmesalamine
BRAND 2
ASACOL HD TAB DR 800 MGmesalamine
BRAND 2 MDD 6 per day
ASACOL TAB DR 400 MGmesalamine
BRAND 2 MDD 12 per day
balsalazide disodium cap 750 mg generic 1
CANASA SUPPOS 1000 MGmesalamine
BRAND 2
DIPENTUM CAP 250 MGolsalazine sodium
BRAND 2
LIALDA TAB DR 1.2 GMmesalamine
BRAND 2
mesalamine enema 4 gm generic 1
PENTASA CAP ER 250 MGmesalamine
BRAND 2
PENTASA CAP ER 500 MGmesalamine
BRAND 2
GLUCOCORTICOIDS
budesonide cp dr part 3 mg generic 1
colocort enema 100 mg/60ml generic 1
hydrocortisone cream 1 % generic 1
hydrocortisone cream 2.5 % generic 1
hydrocortisone enema 100 mg/60ml generic 1
procto-med hc cream 2.5 % generic 1
proctocream hc cream 2.5 % generic 1
proctosol hc cream 2.5 % generic 1
proctozone-hc cream 2.5 % generic 1
PAGE 211 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SULFONAMIDES
sulfasalazine tab 500 mg generic 1
sulfasalazine tab dr 500 mg generic 1
METABOLIC BONE DISEASE AGENTS
ACTONEL TAB 150 MGrisedronate sodium
BRAND 2PA
MDS 1 / 28 days
ACTONEL TAB 30 MGrisedronate sodium
BRAND 2PA
MDD 1 per day
alendronate sodium tab 10 mg generic 1 MDD 1 per day
alendronate sodium tab 35 mg generic 1 MDS 4 / 28 days
alendronate sodium tab 40 mg generic 1 MDD 1 per day
alendronate sodium tab 5 mg generic 1 MDD 1 per day
alendronate sodium tab 70 mg generic 1 MDS 4 / 28 days
AREDIA RECON SOLN 30 MGpamidronate disodium
BRAND 4PA
S
ATELVIA TAB DR 35 MGrisedronate sodium
BRAND 2 PA
BONIVA SOLUTION 3 MG/3MLibandronate sodium
BRAND 4PA
S
calcitonin (salmon) solution 200 unit/act generic 1 MPL 1 / 30 days
calcitriol cap 0.25 mcg generic 1
calcitriol cap 0.5 mcg generic 1
calcitriol solution 1 mcg/ml generic 1
calcitriol solution 1 mcg/ml generic 1
doxercalciferol cap 0.5 mcg generic 1
doxercalciferol cap 1 mcg generic 1
doxercalciferol cap 2.5 mcg generic 1
PAGE 212 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
doxercalciferol solution 4 mcg/2ml generic 1
etidronate disodium tab 200 mg generic 1
etidronate disodium tab 400 mg generic 1
FORTEO SOLUTION 600 MCG/2.4MLteriparatide (recombinant)
BRAND 4
PA
MPL 1 / 28 daysS
FOSAMAX PLUS D TAB 70-2800 MG-UNITalendronate sodium-cholecalciferol
BRAND 3PA
MDS 4 / 28 days
FOSAMAX PLUS D TAB 70-5600 MG-UNITalendronate sodium-cholecalciferol
BRAND 3PA
MDS 4 / 28 days
ibandronate sodium solution 3 mg/3ml generic 4PA
S
ibandronate sodium tab 150 mg generic 1 MDS 1 / 28 days
pamidronate disodium recon soln 30 mg generic 4PA
S
pamidronate disodium recon soln 90 mg generic 4PA
S
pamidronate disodium solution 30mg/10ml
generic 4PA
S
PAMIDRONATE DISODIUM SOLUTION 6MG/MLpamidronate disodium
BRAND 4PA
S
pamidronate disodium solution 90mg/10ml
generic 4PA
S
paricalcitol cap 1 mcg generic 1
paricalcitol cap 2 mcg generic 1
paricalcitol cap 4 mcg generic 1
paricalcitol solution 2 mcg/ml generic 1
paricalcitol solution 5 mcg/ml generic 1
PAGE 213 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
PROLIA SOLUTION 60 MG/MLdenosumab
BRAND 4PA
S
RECLAST SOLUTION 5 MG/100MLzoledronic acid
BRAND 4PA
S
risedronate sodium tab 150 mg generic 1PA
MDS 1 / 28 days
risedronate sodium tab 30 mg generic 1PA
MDD 1 per day
risedronate sodium tab 35 mg generic 1PA
MDS 4 / 28 days
risedronate sodium tab 5 mg generic 1PA
MDD 1 per day
risedronate sodium tab dr 35 mg generic 1 PA
SKELID TAB 200 MGtiludronate disodium
BRAND 3
XGEVA SOLUTION 120 MG/1.7MLdenosumab
BRAND 4PA
S
ZEMPLAR CAP 1 MCGparicalcitol
BRAND 3
ZEMPLAR CAP 2 MCGparicalcitol
BRAND 3
ZEMPLAR CAP 4 MCGparicalcitol
BRAND 3
ZEMPLAR SOLUTION 2 MCG/MLparicalcitol
BRAND 3
ZEMPLAR SOLUTION 5 MCG/MLparicalcitol
BRAND 3
zoledronic acid conc 4 mg/5ml generic 4PA
S
ZOLEDRONIC ACID RECON SOLN 4 MGzoledronic acid
BRAND 4PA
S
PAGE 214 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ZOLEDRONIC ACID SOLUTION 4 MG/100MLzoledronic acid
BRAND 4PA
S
zoledronic acid solution 5 mg/100ml generic 4PA
S
ZOMETA CONC 4 MG/5MLzoledronic acid
BRAND 4PA
S
ZOMETA SOLUTION 4 MG/100MLzoledronic acid
BRAND 4PA
S
MISCELLANEOUS THERAPEUTIC AGENTS
1ST CHOICE LANCETS SUPER THIN MISClancets
BRAND 1 MDS 200 / 30 days
1ST CHOICE LANCETS THIN MISClancets
BRAND 1 MDS 200 / 30 days
1ST CHOICE LANCETS ULTRA THIN MISClancets
BRAND 1 MDS 200 / 30 days
1ST CHOICE PEN NEEDLES MISC 31G X 6MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
1ST CHOICE PEN NEEDLES MISC 31G X 8MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
1ST TIER UNIFINE PENTIPS MISC 29G X12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
1ST TIER UNIFINE PENTIPS MISC 31G X 5MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
1ST TIER UNIFINE PENTIPS MISC 31G X 6MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
1ST TIER UNIFINE PENTIPS MISC 31G X 8MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PAGE 215 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
1ST TIER UNIFINE PENTIPS MISC 32G X 4MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
1ST TIER UNIFINE PENTIPS PLUS MISC 29GX 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
1ST TIER UNIFINE PENTIPS PLUS MISC 31GX 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
1ST TIER UNIFINE PENTIPS PLUS MISC 31GX 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
1ST TIER UNIFINE PENTIPS PLUS MISC 31GX 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
1ST TIER UNIFINE PENTIPS PLUS MISC 32GX 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
1ST TIER UNILET COMFORTOUCH MISClancets
BRAND 1 MDS 200 / 30 days
ACCU-CHEK ACTIVE GLUCOSE CONT LIQUIDblood glucose calibration
BRAND 1
ACCU-CHEK AVIVA SOLUTIONblood glucose calibration
BRAND 1
ACCU-CHEK COMFORT CURVE LINEARSOLUTIONblood glucose calibration
BRAND 1
ACCU-CHEK COMFORT CURVE SOLUTIONblood glucose calibration
BRAND 1
ACCU-CHEK COMPACT BLUE CONTROLLIQUIDblood glucose calibration
BRAND 1
ACCU-CHEK COMPACT PLUS CONTROLSOLUTIONblood glucose calibration
BRAND 1
PAGE 216 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ACCU-CHEK FASTCLIX LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
ACCU-CHEK INSTANT CONTROL LIQUIDblood glucose calibration
BRAND 1
ACCU-CHEK MULTICLIX LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
ACCU-CHEK SAFE-T PRO LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
ACCU-CHEK SMARTVIEW CONTROL LIQUIDblood glucose calibration
BRAND 1
ACCU-CHEK SOFT TOUCH LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
ACCU-CHEK SOFTCLIX LANCET DEV MISClancet devices
BRAND 1
ACCU-CHEK SOFTCLIX LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
ACCUSURE INSULIN SYRINGE 29G X 1/2"0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ACCUSURE INSULIN SYRINGE 29G X 1/2" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ACCUSURE INSULIN SYRINGE 30G X 5/16"0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ACCUSURE INSULIN SYRINGE 30G X 5/16" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
accusure insulin syringe 31g x 5/16" 0.5 ml generic 1 MDS 450 / 90 days
accusure insulin syringe 31g x 5/16" 1 ml generic 1 MDS 450 / 90 days
ACCUTREND GLUCOSE CONTROLSOLUTIONblood glucose calibration
BRAND 1
PAGE 217 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ACTI-LANCE 28G MISClancets
BRAND 1 MDS 200 / 30 days
ACTI-LANCE LITE LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
ACTI-LANCE SPECIAL LANCETS 17G MISClancets
BRAND 1 MDS 200 / 30 days
ACTI-LANCE UNIVERSAL 23G MISClancets
BRAND 1 MDS 200 / 30 days
ACURA CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
ACURA CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
ADJUSTABLE LANCING DEVICE MISClancet devices
BRAND 1
ADVANCE INTUITION CONTROL LIQUIDNORMALblood glucose calibration
BRAND 1
ADVOCATE CONTROL SOLUTION LIQUIDLOWblood glucose calibration
BRAND 1
ADVOCATE INSULIN PEN NEEDLES MISC29G X 12.7MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
ADVOCATE INSULIN PEN NEEDLES MISC31G X 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
ADVOCATE INSULIN PEN NEEDLES MISC31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
ADVOCATE INSULIN SYRINGE MISC 29G X1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ADVOCATE INSULIN SYRINGE MISC 29G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 218 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ADVOCATE INSULIN SYRINGE MISC 29G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ADVOCATE INSULIN SYRINGE MISC 30G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ADVOCATE INSULIN SYRINGE MISC 30G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ADVOCATE INSULIN SYRINGE MISC 30G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ADVOCATE INSULIN SYRINGE MISC 31G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ADVOCATE INSULIN SYRINGE MISC 31G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ADVOCATE INSULIN SYRINGE MISC 31G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ADVOCATE LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
ADVOCATE LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
ADVOCATE LANCING DEVICE MISClancet devices
BRAND 1
ADVOCATE RAPID-SAFE LANCING MISClancet devices
BRAND 1
ADVOCATE REDI-CODE+ CONTROLSOLUTION LOWblood glucose calibration
BRAND 1
ADVOCATE SAFETY LANCETS 26G MISClancets
BRAND 1 MDS 200 / 30 days
ADVOCATE SAFETY LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 219 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
AF LANCETS SUPER THIN MISClancets
BRAND 1 MDS 200 / 30 days
AGAMATRIX CONTROL SOLUTIONblood glucose calibration
BRAND 1
AGAMATRIX CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
AGAMATRIX ULTRA-THIN LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
ALTERNATE SITE LANCING DEVICE MISClancet devices
BRAND 1
amiodarone hcl powder generic 1
ANTI-STICK INSULIN SYRINGE MISC 29G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
AQUA LANCE ADJUSTABLE LANCINGDEVICElancet devices
BRAND 1
argyle sterile water solution generic 1
ASCENSIA AUTODISC CONTROL LIQUIDNORMALblood glucose calibration
BRAND 1
ASCENSIA AUTODISC CONTROLS LIQUIDblood glucose calibration
BRAND 1
ASSURE 3 CONTROL LIQUIDblood glucose calibration
BRAND 1
ASSURE 4 CONTROL LEVEL 1 & 2 LIQUIDblood glucose calibration
BRAND 1
ASSURE COMFORT LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
ASSURE COMFORT LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
ASSURE DOSE CONTROL SOLUTIONNORMALblood glucose calibration
BRAND 1
PAGE 220 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ASSURE DOSE NORM/HIGH CONTROLSOLUTIONblood glucose calibration
BRAND 1
ASSURE HAEMOLANCE PLUS HIGH MISClancets
BRAND 1 MDS 200 / 30 days
ASSURE HAEMOLANCE PLUS LOW MISClancets
BRAND 1 MDS 200 / 30 days
ASSURE HAEMOLANCE PLUS MICRO MISClancets
BRAND 1 MDS 200 / 30 days
ASSURE HAEMOLANCE PLUS NORMALMISClancets
BRAND 1 MDS 200 / 30 days
ASSURE HAEMOLANCE PLUS PED MISClancets
BRAND 1 MDS 200 / 30 days
ASSURE ID INSULIN SAFETY SYR MISC 29GX 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ASSURE ID INSULIN SAFETY SYR MISC 29GX 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ASSURE LANCE LANCETS 21G MISClancets
BRAND 1 MDS 200 / 30 days
ASSURE LANCE LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
ASSURE LANCE PLUS SAFETY 25G MISClancets
BRAND 1 MDS 200 / 30 days
ASSURE LANCE PLUS SAFETY 30G MISClancets
BRAND 1 MDS 200 / 30 days
ASSURE LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
ASSURE PRISM CONTROL LEVEL 1&2SOLUTIONblood glucose calibration
BRAND 1
ASSURE PRO CONTROL LEVEL 1 & 2 LIQUIDblood glucose calibration
BRAND 1
PAGE 221 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ATOVAQUONE POWDERatovaquone (bulk)
BRAND 1
AURORA HEALTHCARE LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
AURORA LANCET SUPER THIN 30G MISClancets
BRAND 1 MDS 200 / 30 days
AURORA LANCET THIN 23G MISClancets
BRAND 1 MDS 200 / 30 days
AURORA PEN NEEDLES MISC 29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
AURORA PEN NEEDLES MISC 31G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
AURORA PEN NEEDLES MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
AURORA UNIFINE PENTIPS MISC 31G X 5MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
AURORA UNIFINE PENTIPS MISC 32G X 4MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
AUTO-LANCET MINI MISClancet devices
BRAND 1
AUTO-LANCET MISClancet devices
BRAND 1
AUTOLET IMPRESSION MISClancet devices
BRAND 1
AUTOLET LANCING DEVICE MISClancet devices
BRAND 1
AUTOLET MINI MISClancet devices
BRAND 1
BAYER BREEZE 2 CONTROL LIQUID LOWblood glucose calibration
BRAND 1
BAYER BREEZE 2 CONTROL LIQUIDNORMALblood glucose calibration
BRAND 1
PAGE 222 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
BAYER CONTOUR LIQUID LOWblood glucose calibration
BRAND 1
BAYER CONTOUR LIQUID NORMALblood glucose calibration
BRAND 1
BAYER CONTOUR NEXT CONTROLSOLUTION LOWblood glucose calibration
BRAND 1
BAYER CONTOUR NEXT CONTROLSOLUTION NORMALblood glucose calibration
BRAND 1
BAYER MICROLET 2 LANCING DEVIC MISClancet devices
BRAND 1
BAYER MICROLET LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
BD AUTOSHIELD MISC 29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
BD AUTOSHIELD MISC 29G X 8MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
BD INSULIN SYR ULTRAFINE II MISC 31G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYR ULTRAFINE II MISC 31G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE HALF-UNIT MISC 31GX 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE MICROFINE MISC 27GX 5/8" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE MICROFINE MISC 28GX 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE MICROFINE MISC 28GX 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 223 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
BD INSULIN SYRINGE MICROFINE MISC 28GX 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE MISC 25G X 1" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE MISC 25G X 5/8" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE MISC 26G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE MISC 27G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE MISC 28G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE MISC 29G X 1/2" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE MISC 29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE MISC 30G X 1/2" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE MISC 31G X 5/16" 0.3MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE MISC U-100 1 MLinsulin syringes (disposable)
BRAND 1 MDS 150 / 30 days
BD INSULIN SYRINGE ULTRAFINE MISC 29GX 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE ULTRAFINE MISC 29GX 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE ULTRAFINE MISC 29GX 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 224 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
BD INSULIN SYRINGE ULTRAFINE MISC 30GX 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE ULTRAFINE MISC 30GX 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE ULTRAFINE MISC 30GX 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE ULTRAFINE MISC 31GX 15/64" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE ULTRAFINE MISC 31GX 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE ULTRAFINE MISC 31GX 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INSULIN SYRINGE ULTRAFINE MISC 31GX 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INTEGRA INSULIN SYRINGE MISC 29G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD INTEGRA SYRINGE MISC 25G X 1" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD LANCET DEVICE MISClancet devices
BRAND 1
BD LANCET ULTRAFINE 30G MISClancets
BRAND 1 MDS 200 / 30 days
BD LANCET ULTRAFINE 33G MISClancets
BRAND 1 MDS 200 / 30 days
BD MICROTAINER LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 225 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
BD PEN NEEDLE NANO U/F MISC 32G X 4MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
BD PEN NEEDLE SHORT U/F MISC 31G X 8MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
BD PEN NEEDLE ULTRAFINE MISC 29G X12.7MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
BD SAFETY-LOK INSULIN SYRINGE MISC29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD SAFETYGLIDE INSULIN SYRINGE MISC29G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
BD SAFETYGLIDE INSULIN SYRINGE MISC30G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
blood glucose system pak kit generic 1 MDS 1 / 730 days
blood glucose test strip generic 1 MDS 100 / 30 days
BULLSEYE MINI SAFETY LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
BULLSEYE SAFETY LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
CARDIOCOM LANCING DEVICE MISClancet devices
BRAND 1
CAREFINE PEN NEEDLES MISC 29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
CAREFINE PEN NEEDLES MISC 30G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
CAREFINE PEN NEEDLES MISC 31G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
CAREFINE PEN NEEDLES MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PAGE 226 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
CAREFINE PEN NEEDLES MISC 32G X 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
CAREFINE PEN NEEDLES MISC 32G X 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
CAREFINE PEN NEEDLES MISC 32G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
CAREONE ADVANCED LANCING DEV MISClancet devices
BRAND 1
CAREONE INSULIN SYRINGE MISC 30G X1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
CAREONE INSULIN SYRINGE MISC 30G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
CAREONE INSULIN SYRINGE MISC 30G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
CAREONE INSULIN SYRINGE MISC 31G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
CAREONE INSULIN SYRINGE MISC 31G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
CAREONE INSULIN SYRINGE MISC 31G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
CAREONE LANCET THIN 23G MISClancets
BRAND 1 MDS 200 / 30 days
CAREONE LANCET ULTRA THIN 28G MISClancets
BRAND 1 MDS 200 / 30 days
CAREONE ULTIGUARD INSULIN SYR MISC29G X 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
CAREONE ULTIGUARD INSULIN SYR MISC29G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 227 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
CAREONE ULTIGUARD INSULIN SYR MISC29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
CAREONE ULTIGUARD INSULIN SYR MISC30G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
CAREONE ULTIGUARD INSULIN SYR MISC30G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
CAREONE ULTIGUARD INSULIN SYR MISC30G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
CAREONE UNIFINE PENTIPS MISC 29G X12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
CAREONE UNIFINE PENTIPS MISC 31G X 5MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
CAREONE UNIFINE PENTIPS MISC 31G X 6MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
CAREONE UNIFINE PENTIPS MISC 31G X 8MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
CAREONE UNIFINE PENTIPS MISC 32G X 4MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
CAREONE UNIFINE PENTIPS PLUS MISC 29GX 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
CAREONE UNIFINE PENTIPS PLUS MISC 31GX 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
CAREONE UNIFINE PENTIPS PLUS MISC 31GX 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PAGE 228 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
CAREONE UNIFINE PENTIPS PLUS MISC 31GX 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
CAREONE UNIFINE PENTIPS PLUS MISC 32GX 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
CARESENS CONTROL A SOLUTIONblood glucose calibration
BRAND 1
CAYA DIAPHRAGMdiaphragm arc-spring
BRAND 0
CHEK-STIX CONTROL STRIPacetone (urine) test
BRAND 1 MPL 1 / 30 Days
CHEMSTRIP K STRIPacetone (urine) test
BRAND 1 MPL 1 / 30 Days
CLEANLET LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
CLEVER CHEK LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
CLEVER CHOICE GLUCOSE CONTROLLIQUID LOWblood glucose calibration
BRAND 1
CLICKFINE PEN NEEDLES MISC 31G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
CLICKFINE PEN NEEDLES MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
CLICKFINE PEN NEEDLES MISC 32G X 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
clindamycin phosphate powder generic 1
CLINDAMYCIN PHOSPHATE POWDERclindamycin phosphate (bulk)
BRAND 1
CLOSERCARE MISClancet devices
BRAND 1
COAGUCHEK LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 229 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
COMFORT ASSIST INSULIN SYRINGE MISC29G X 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT ASSIST INSULIN SYRINGE MISC29G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT ASSIST INSULIN SYRINGE MISC29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT ASSIST INSULIN SYRINGE MISC30G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT ASSIST INSULIN SYRINGE MISC30G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT ASSIST INSULIN SYRINGE MISC30G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT ASSIST INSULIN SYRINGE MISC31G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT ASSIST INSULIN SYRINGE MISC31G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT ASSIST INSULIN SYRINGE MISC31G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT ASSURED LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
COMFORT ASSURED LANCETS 33G MISClancets
BRAND 1 MDS 200 / 30 days
COMFORT EZ INSULIN SYRINGE MISC 28G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT EZ INSULIN SYRINGE MISC 28G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 230 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
COMFORT EZ INSULIN SYRINGE MISC 29G X1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT EZ INSULIN SYRINGE MISC 29G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT EZ INSULIN SYRINGE MISC 29G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT EZ INSULIN SYRINGE MISC 30G X1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT EZ INSULIN SYRINGE MISC 30G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT EZ INSULIN SYRINGE MISC 30G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT EZ INSULIN SYRINGE MISC 30G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT EZ INSULIN SYRINGE MISC 30G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT EZ INSULIN SYRINGE MISC 30G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT EZ INSULIN SYRINGE MISC 31G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT EZ INSULIN SYRINGE MISC 31G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
COMFORT EZ INSULIN SYRINGE MISC 31G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 231 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
COMFORT EZ PEN NEEDLES MISC 31G X 5MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
COMFORT EZ PEN NEEDLES MISC 31G X 6MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
COMFORT EZ PEN NEEDLES MISC 31G X 8MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
COMFORT EZ PEN NEEDLES MISC 32G X 4MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
COMFORT EZ PEN NEEDLES MISC 32G X 5MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
COMFORT EZ PEN NEEDLES MISC 32G X 6MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
COMFORT LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
CVS INSULIN SYRINGE MISC 29G X 1/2" 0.3MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
CVS INSULIN SYRINGE MISC 29G X 1/2" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
CVS INSULIN SYRINGE MISC 29G X 1/2" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
CVS INSULIN SYRINGE MISC 30G X 1/2" 0.3MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
CVS INSULIN SYRINGE MISC 30G X 1/2" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 232 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
CVS LANCETS 21G MISClancets
BRAND 1 MDS 200 / 30 days
CVS LANCETS MICRO THIN 33G MISClancets
BRAND 1 MDS 200 / 30 days
CVS LANCETS ORIGINAL MISClancets
BRAND 1 MDS 200 / 30 days
CVS LANCETS THIN 26G MISClancets
BRAND 1 MDS 200 / 30 days
CVS LANCETS THIN MISClancets
BRAND 1 MDS 200 / 30 days
CVS LANCETS ULTRA THIN 30G MISClancets
BRAND 1 MDS 200 / 30 days
CVS LANCING DEVICE MISClancet devices
BRAND 1
CVS ULTRA THIN LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
DIASTAR EASY TEST II LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
DIASTAR EASY TEST LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
DIATRUE CONTROL LEVEL 1 SOLUTIONLOWblood glucose calibration
BRAND 1
DIATRUE CONTROL LEVEL 2 SOLUTIONNORMALblood glucose calibration
BRAND 1
DROPLET LANCETS ULTRA THIN 30G MISClancets
BRAND 1 MDS 200 / 30 days
DROPLET LANCING DEVICE MISClancet devices
BRAND 1
DRUG MART LANCETS THIN 26G MISClancets
BRAND 1 MDS 200 / 30 days
DRUG MART LANCETS ULTRA THIN MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 233 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
DRUG MART LANCING DEVICE MISClancet devices
BRAND 1
DRUG MART ON-THE-GO LANCET 30GMISClancets
BRAND 1 MDS 200 / 30 days
DRUG MART ULTRA COMFORT SYR MISC29G X 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
DRUG MART ULTRA COMFORT SYR MISC29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
DRUG MART ULTRA COMFORT SYR MISC30G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
DRUG MART ULTRA COMFORT SYR MISC30G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
DRUG MART ULTRA COMFORT SYR MISC30G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
DRUG MART ULTRA COMFORT SYR MISC31G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
DRUG MART ULTRA COMFORT SYR MISC31G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
DRUG MART UNIFINE PENTIPS MISC 29G X12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
DRUG MART UNIFINE PENTIPS MISC 31G X5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
DRUG MART UNIFINE PENTIPS MISC 31G X6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PAGE 234 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
DRUG MART UNIFINE PENTIPS MISC 31G X8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
DRUG MART UNIFINE PENTIPS MISC 32G X4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
DRUG MART UNIFINE PENTIPS PLUS MISC32G X 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
DRUG MART UNILET LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
DRUG MART UNILET LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
DUANE READE LANCET ALTERN SITE MISClancets
BRAND 1 MDS 200 / 30 days
DUANE READE LANCET SUPER THIN MISClancets
BRAND 1 MDS 200 / 30 days
DUANE READE LANCET ULTRA THIN MISClancets
BRAND 1 MDS 200 / 30 days
DUANE READE UNIFINE PENTIPS MISC 29GX 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
DUANE READE UNIFINE PENTIPS MISC 31GX 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
DUANE READE UNIFINE PENTIPS MISC 31GX 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
E-Z JECT LANCET MICRO-THIN 33G MISClancets
BRAND 1 MDS 200 / 30 days
E-Z JECT LANCET SUPER THIN 30G MISClancets
BRAND 1 MDS 200 / 30 days
E-Z JECT LANCETS 21G MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 235 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
E-Z JECT LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
E-Z JECT LANCETS THIN 26G MISClancets
BRAND 1 MDS 200 / 30 days
EASY COMFORT INSULIN SYRINGE MISC30G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY COMFORT INSULIN SYRINGE MISC30G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY COMFORT INSULIN SYRINGE MISC30G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY COMFORT INSULIN SYRINGE MISC30G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY COMFORT INSULIN SYRINGE MISC30G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY COMFORT INSULIN SYRINGE MISC31G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY COMFORT INSULIN SYRINGE MISC31G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY COMFORT LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
EASY COMFORT PEN NEEDLES MISC 31G X5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
EASY COMFORT PEN NEEDLES MISC 31G X6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
EASY COMFORT PEN NEEDLES MISC 31G X8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PAGE 236 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
EASY COMFORT PEN NEEDLES MISC 32G X4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
EASY MINI LANCING DEVICE MISClancet devices
BRAND 1
EASY PLUS CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
EASY PLUS CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
EASY PLUS II CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
EASY STEP CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
EASY STEP CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
EASY TALK CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
EASY TALK CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
EASY TOUCH CONTROL HIGH & LOWSOLUTIONblood glucose calibration
BRAND 1
EASY TOUCH HEALTHPRO CONTROLSOLUTIONblood glucose calibration
BRAND 1
EASY TOUCH INSULIN SAFETY SYR MISC29G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY TOUCH INSULIN SAFETY SYR MISC29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY TOUCH INSULIN SAFETY SYR MISC30G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 237 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
EASY TOUCH INSULIN SAFETY SYR MISC30G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY TOUCH INSULIN SYRINGE MISC 27G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY TOUCH INSULIN SYRINGE MISC 27G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY TOUCH INSULIN SYRINGE MISC 28G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY TOUCH INSULIN SYRINGE MISC 28G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY TOUCH INSULIN SYRINGE MISC 29G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY TOUCH INSULIN SYRINGE MISC 29G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY TOUCH INSULIN SYRINGE MISC 30G X1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY TOUCH INSULIN SYRINGE MISC 30G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY TOUCH INSULIN SYRINGE MISC 30G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY TOUCH INSULIN SYRINGE MISC 30G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY TOUCH INSULIN SYRINGE MISC 30G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 238 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
EASY TOUCH INSULIN SYRINGE MISC 30G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY TOUCH INSULIN SYRINGE MISC 31G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY TOUCH INSULIN SYRINGE MISC 31G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY TOUCH INSULIN SYRINGE MISC 31G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EASY TOUCH LANCETS 21G MISClancets
BRAND 1 MDS 200 / 30 days
EASY TOUCH LANCETS 23G MISClancets
BRAND 1 MDS 200 / 30 days
EASY TOUCH LANCETS 26G MISClancets
BRAND 1 MDS 200 / 30 days
EASY TOUCH LANCETS 26G/TWIST MISClancets
BRAND 1 MDS 200 / 30 days
EASY TOUCH LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
EASY TOUCH LANCETS 28G/TWIST MISClancets
BRAND 1 MDS 200 / 30 days
EASY TOUCH LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
EASY TOUCH LANCETS 30G/TWIST MISClancets
BRAND 1 MDS 200 / 30 days
EASY TOUCH LANCETS 32G MISClancets
BRAND 1 MDS 200 / 30 days
EASY TOUCH LANCETS 32G/TWIST MISClancets
BRAND 1 MDS 200 / 30 days
EASY TOUCH LANCETS 33G/TWIST MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 239 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
EASY TOUCH LANCING DEVICE MISClancet devices
BRAND 1
EASY TOUCH PEN NEEDLES MISC 29G X12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
EASY TOUCH PEN NEEDLES MISC 31G X 5MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
EASY TOUCH PEN NEEDLES MISC 31G X 6MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
EASY TOUCH PEN NEEDLES MISC 31G X 8MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
EASY TOUCH PEN NEEDLES MISC 32G X 4MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
EASY TOUCH PEN NEEDLES MISC 32G X 5MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
EASY TOUCH PEN NEEDLES MISC 32G X 6MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
EASY TOUCH SAFETY LANCETS 21G MISClancets
BRAND 1 MDS 200 / 30 days
EASY TOUCH SAFETY LANCETS 23G MISClancets
BRAND 1 MDS 200 / 30 days
EASY TOUCH SAFETY LANCETS 26G MISClancets
BRAND 1 MDS 200 / 30 days
EASY TOUCH SAFETY LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
EASY TRAK CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
EASY TRAK CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
PAGE 240 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
EASY TWIST & CAP LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
EASYGLUCO CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
EASYGLUCO CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
EASYMAX 15 LEVEL 1 CONTROL SOLUTIONblood glucose calibration
BRAND 1
EASYMAX 15 LEVEL 2 CONTROL SOLUTIONblood glucose calibration
BRAND 1
EASYMAX CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
EASYMAX CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
ECLIPSE CONTROL LIQUID LOWblood glucose calibration
BRAND 1
ECLIPSE CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
ELEMENT COMPACT CONTROL 2 SOLUTIONblood glucose calibration
BRAND 1
ELEMENT COMPACT CONTROL 3 SOLUTIONblood glucose calibration
BRAND 1
ELEMENT CONTROL LIQUID LOWblood glucose calibration
BRAND 1
ELEMENT CONTROL LIQUID NORMALblood glucose calibration
BRAND 1
ELEMENT PLUS CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
ELEMENT PLUS CONTROL SOLUTIONNORMALblood glucose calibration
BRAND 1
EMBRACE CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
PAGE 241 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
EMBRACE EVO CONTROL LEVEL 1 LIQUIDLOWblood glucose calibration
BRAND 1
EMBRACE EVO CONTROL LEVEL 2 LIQUIDNORMALblood glucose calibration
BRAND 1
EMBRACE LANCETS ULTRA THIN 30G MISClancets
BRAND 1 MDS 200 / 30 days
EMBRACE PRO GLUCOSE CONTROL LIQUIDblood glucose calibration
BRAND 1
ENVISION CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
ENVISION CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
EQL COLOR LANCETS 21G MISClancets
BRAND 1 MDS 200 / 30 days
EQL COLOR LANCETS MICRO 33G MISClancets
BRAND 1 MDS 200 / 30 days
EQL INSULIN SYRINGE MISC 29G X 1/2" 0.3MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EQL INSULIN SYRINGE MISC 29G X 1/2" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EQL INSULIN SYRINGE MISC 29G X 1/2" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EQL INSULIN SYRINGE MISC 30G X 5/16"0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EQL INSULIN SYRINGE MISC 30G X 5/16"0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EQL INSULIN SYRINGE MISC 30G X 5/16" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 242 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
EQL INSULIN SYRINGE MISC 31G X 5/16"0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EQL INSULIN SYRINGE MISC 31G X 5/16"0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EQL INSULIN SYRINGE MISC 31G X 5/16" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EQL SHORT PEN NEEDLE MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
EQL SUPER THIN LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
EQL THIN LANCETS 26G MISClancets
BRAND 1 MDS 200 / 30 days
EQL ULTRA COMFORT INSULIN SYR MISC30G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EQL ULTRA COMFORT INSULIN SYR MISC31G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EQL ULTRA SHORT PEN NEEDLE MISC 31GX 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
EVENCARE CONTROL LOW/HIGH LIQUIDblood glucose calibration
BRAND 1
EVENCARE G2 LOW/HIGH CONTROLSOLUTIONblood glucose calibration
BRAND 1
EVENCARE G3 LOW/HIGH CONTROLSOLUTIONblood glucose calibration
BRAND 1
EVOLUTION CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
PAGE 243 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
EXEL COMFORT POINT INSULIN SYR MISC28G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EXEL COMFORT POINT INSULIN SYR MISC29G X 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EXEL COMFORT POINT INSULIN SYR MISC29G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EXEL COMFORT POINT INSULIN SYR MISC29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EXEL COMFORT POINT INSULIN SYR MISC30G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EXEL COMFORT POINT INSULIN SYR MISC30G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EXEL COMFORT POINT INSULIN SYR MISC30G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
EXEL COMFORT POINT PEN NEEDLE MISC29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
EXEL COMFORT POINT PEN NEEDLE MISC31G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
EXEL COMFORT POINT PEN NEEDLE MISC31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
EZ SMART BLOOD GLUCOSE LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
EZ-LETS LANCETS 21G MISClancets
BRAND 1 MDS 200 / 30 days
ez-lets lancets 23g misc generic 1 MDS 200 / 30 days
PAGE 244 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
EZ-LETS LANCETS 26G MISClancets
BRAND 1 MDS 200 / 30 days
EZ-LETS LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
EZ-LETS LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
FEMCAP DEVICE 22 MMcervical caps
BRAND 0
FEMCAP DEVICE 26 MMcervical caps
BRAND 0
FEMCAP DEVICE 30 MMcervical caps
BRAND 0
FIFTY50 CONTROL 2.0 SOLUTIONblood glucose calibration
BRAND 1
FIFTY50 LANCING DEVICE MISClancet devices
BRAND 1
FIFTY50 PEN NEEDLES MISC 31G X 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
FIFTY50 PEN NEEDLES MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
FIFTY50 SAFETY SEAL LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
FIFTY50 SUPERIOR COMFORT SYR MISC31G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
FIFTY50 SUPERIOR COMFORT SYR MISC31G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
FIFTY50 SUPERIOR COMFORT SYR MISC31G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
FINE 30 MISClancets
BRAND 1 MDS 200 / 30 days
FINGERSTIX LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 245 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
fluticasone propionate powder generic 1
FLUTICASONE PROPIONATE POWDERfluticasone propionate (bulk)
BRAND 1
FORA CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
FORA CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
FORA LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
FORA LANCING DEVICE MISClancet devices
BRAND 1
FORACARE GDH CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
FORACARE GDH CONTROL SOLUTIONNORMALblood glucose calibration
BRAND 1
FORTISCARE CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
FORTISCARE CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
FREDS PHARMACY AUTOLET LANCINGMISClancet devices
BRAND 1
FREDS PHARMACY UNIFINE PENTIP+ MISC31G X 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
FREDS PHARMACY UNIFINE PENTIP+ MISC31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
FREDS PHARMACY UNIFINE PENTIPS MISC32G X 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
FREDS PHARMACY UNILET LANC 28G MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 246 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
FREDS PHARMACY UNILET LANC 30G MISClancets
BRAND 1 MDS 200 / 30 days
FREESTYLE CONTROL SOLUTION LIQUIDblood glucose calibration
BRAND 1
FREESTYLE LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
FREESTYLE PRECISION INS SYR MISC 30G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
FREESTYLE PRECISION INS SYR MISC 30G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
FREESTYLE PRECISION INS SYR MISC 31G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
FREESTYLE PRECISION INS SYR MISC 31G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
freestyle test generic 1 MDS 100 / 30 days
FREESTYLE UNISTICK II LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
GE100 CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
GLOBAL EASE INJECT PEN NEEDLES MISC29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
GLOBAL EASE INJECT PEN NEEDLES MISC31G X 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
GLOBAL EASE INJECT PEN NEEDLES MISC31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
GLOBAL EASE INJECT PEN NEEDLES MISC32G X 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PAGE 247 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
GLOBAL INJECT EASE INSULIN SYR MISC28G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLOBAL INJECT EASE INSULIN SYR MISC28G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLOBAL INJECT EASE INSULIN SYR MISC29G X 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLOBAL INJECT EASE INSULIN SYR MISC29G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLOBAL INJECT EASE INSULIN SYR MISC29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLOBAL INJECT EASE INSULIN SYR MISC30G X 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLOBAL INJECT EASE INSULIN SYR MISC30G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLOBAL INJECT EASE INSULIN SYR MISC30G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLOBAL INJECT EASE INSULIN SYR MISC30G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLOBAL INJECT EASE INSULIN SYR MISC30G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLOBAL INJECT EASE INSULIN SYR MISC30G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLOBAL INJECT EASE INSULIN SYR MISC31G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 248 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
GLOBAL INJECT EASE INSULIN SYR MISC31G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLOBAL INJECT EASE INSULIN SYR MISC31G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLOBAL INJECT EASE LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
GLOBAL INJECT EASE LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
GLOBAL LANCING DEVICE MISClancet devices
BRAND 1
GLUCOCARD 01 CONTROL LIQUIDblood glucose calibration
BRAND 1
GLUCOCARD 01 CONTROL SOLUTIONNORMALblood glucose calibration
BRAND 1
GLUCOCARD EXPRESSION CONTROLSOLUTIONblood glucose calibration
BRAND 1
GLUCOCARD SHINE CONTROL SOLUTIONblood glucose calibration
BRAND 1
GLUCOCARD X-SENSOR CONTROLSOLUTION NORMALblood glucose calibration
BRAND 1
GLUCOCOM CONTROL LIQUID NORMALblood glucose calibration
BRAND 1
GLUCOCOM LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
GLUCOCOM LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
GLUCOCOM LANCETS 33G MISClancets
BRAND 1 MDS 200 / 30 days
GLUCOLAB CONTROL LIQUID LOWblood glucose calibration
BRAND 1
PAGE 249 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
GLUCOLAB CONTROL LIQUID NORMALblood glucose calibration
BRAND 1
GLUCOLET 2 AUTOMATIC LANCING MISClancet devices
BRAND 1
GLUCOPRO INSULIN SYRINGE MISC 30G X1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLUCOPRO INSULIN SYRINGE MISC 30G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLUCOPRO INSULIN SYRINGE MISC 30G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLUCOPRO INSULIN SYRINGE MISC 30G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLUCOPRO INSULIN SYRINGE MISC 30G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLUCOPRO INSULIN SYRINGE MISC 30G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLUCOPRO INSULIN SYRINGE MISC 31G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLUCOPRO INSULIN SYRINGE MISC 31G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GLUCOPRO INSULIN SYRINGE MISC 31G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
glucose control solution generic 1
GLUCOSE CONTROL SOLUTIONblood glucose calibration
BRAND 1
glucose control solution normal generic 1
PAGE 250 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
GLUCOSOURCE LANCET DEVICE MISClancet devices
BRAND 1
GLUCOSOURCE LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
GMATE CONTROL LEVEL 2 SOLUTIONblood glucose calibration
BRAND 1
GNP CLICKFINE PEN NEEDLES MISC 31G X 6MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
GNP CLICKFINE PEN NEEDLES MISC 31G X 8MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
GNP INSULIN SYRINGE MISC 28G X 1/2" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP INSULIN SYRINGE MISC 28G X 1/2" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP INSULIN SYRINGE MISC 29G X 1/2" 0.3MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP INSULIN SYRINGE MISC 29G X 1/2" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP INSULIN SYRINGE MISC 29G X 1/2" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP INSULIN SYRINGE MISC 30G X 5/16"0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP INSULIN SYRINGE MISC 30G X 5/16"0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP INSULIN SYRINGE MISC 30G X 5/16" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 251 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
GNP INSULIN SYRINGE MISC 31G X 5/16"0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP INSULIN SYRINGE MISC 31G X 5/16"0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP INSULIN SYRINGE MISC 31G X 5/16" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP LANCETS 21G MISClancets
BRAND 1 MDS 200 / 30 days
GNP LANCETS MICRO THIN 33G MISClancets
BRAND 1 MDS 200 / 30 days
GNP LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
GNP LANCETS SUPER THIN 30G MISClancets
BRAND 1 MDS 200 / 30 days
GNP LANCETS THIN 26G MISClancets
BRAND 1 MDS 200 / 30 days
GNP LANCETS THIN MISClancets
BRAND 1 MDS 200 / 30 days
GNP MICRO THIN LANCETS 33G MISClancets
BRAND 1 MDS 200 / 30 days
GNP SUPER THIN LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
GNP ULTRA COM INSULIN SYRINGE MISC28G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP ULTRA COM INSULIN SYRINGE MISC28G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP ULTRA COM INSULIN SYRINGE MISC29G X 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 252 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
GNP ULTRA COM INSULIN SYRINGE MISC29G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP ULTRA COM INSULIN SYRINGE MISC29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP ULTRA COM INSULIN SYRINGE MISC30G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP ULTRA COM INSULIN SYRINGE MISC30G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP ULTRA COM INSULIN SYRINGE MISC30G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP ULTRA COM INSULIN SYRINGE MISC31G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP ULTRA COM INSULIN SYRINGE MISC31G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
GNP ULTRA COM INSULIN SYRINGE MISC31G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
H&H THINLET LANCETS 26G MISClancets
BRAND 1 MDS 200 / 30 days
H&H THINLET LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
H-E-B INCONTROL ADV LANCING MISClancet devices
BRAND 1
H-E-B INCONTROL LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
H-E-B INCONTROL LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 253 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
H-E-B INCONTROL PEN NEEDLES MISC 31GX 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
H-E-B INCONTROL PEN NEEDLES MISC 31GX 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
H-E-B INCONTROL PEN NEEDLES MISC 31GX 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
H-E-B INCONTROL PEN NEEDLES MISC 32GX 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
HAEMOLANCE LOW FLOW LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
HAEMOLANCE MISClancets
BRAND 1 MDS 200 / 30 days
HAEMOLANCE PLUS HIGH FLOW MISClancets
BRAND 1 MDS 200 / 30 days
HAEMOLANCE PLUS LOW FLOW MISClancets
BRAND 1 MDS 200 / 30 days
HAEMOLANCE PLUS MAX FLOW MISClancets
BRAND 1 MDS 200 / 30 days
HAEMOLANCE PLUS MISClancets
BRAND 1 MDS 200 / 30 days
HAEMOLANCE PLUS PEDIATRIC FLOW MISClancets
BRAND 1 MDS 200 / 30 days
HEALTH CARE LANCING DEVICE MISClancet devices
BRAND 1
HEALTHWISE LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
HEALTHWISE LANCING PEN MISClancet devices
BRAND 1
HEALTHWISE MINI PEN NEEDLES MISC 31GX 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PAGE 254 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
HEALTHWISE PEN NEEDLES MISC 29G X12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
HEALTHWISE SHORT PEN NEEDLES MISC31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
HEALTHWISE UNIFINE PENTIPS MISC 32G X4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
HEALTHY ACCENTS LANCING DEVICE MISClancet devices
BRAND 1
HEALTHY ACCENTS UNIFINE PENTIP MISC29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
HEALTHY ACCENTS UNIFINE PENTIP MISC31G X 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
HEALTHY ACCENTS UNIFINE PENTIP MISC31G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
HEALTHY ACCENTS UNIFINE PENTIP MISC31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
HEALTHY ACCENTS UNIFINE PENTIP MISC32G X 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
HEALTHY ACCENTS UNILET LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
HM LANCETS MICRO THIN 33G MISClancets
BRAND 1 MDS 200 / 30 days
HM LANCETS ULTRA THIN 30G MISClancets
BRAND 1 MDS 200 / 30 days
HY-VEE INSULIN SYRINGE 29G X 1/2" 0.3MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 255 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
HY-VEE INSULIN SYRINGE 29G X 1/2" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
HY-VEE INSULIN SYRINGE 29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
HY-VEE INSULIN SYRINGE 30G X 1/2" 0.3MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
HY-VEE INSULIN SYRINGE 30G X 1/2" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
HY-VEE INSULIN SYRINGE 30G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
hy-vee lancets generic 1 MDS 200 / 30 days
hy-vee thin lancets generic 1 MDS 200 / 30 days
IN TOUCH GLUCOSE CONTROL SOLUTIONblood glucose calibration
BRAND 1
IN TOUCH LANCING DEVICE MISClancet devices
BRAND 1
IN TOUCH STERILE LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
INFINITY CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
INFINITY CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
insulin syringe misc 28g x 1/2" 0.5 ml generic 1 MDS 450 / 90 days
INSULIN SYRINGE MISC 28G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
INSULIN SYRINGE MISC 28G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
INSULIN SYRINGE MISC 29G X 1" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
insulin syringe misc 29g x 1/2" 0.3 ml generic 1 MDS 450 / 90 days
PAGE 256 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
INSULIN SYRINGE MISC 29G X 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
insulin syringe misc 29g x 1/2" 0.5 ml generic 1 MDS 450 / 90 days
INSULIN SYRINGE MISC 29G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
insulin syringe misc 29g x 1/2" 1 ml generic 1 MDS 450 / 90 days
INSULIN SYRINGE MISC 29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
INSULIN SYRINGE MISC 30G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
insulin syringe misc 30g x 5/16" 0.3 ml generic 1 MDS 450 / 90 days
insulin syringe misc 30g x 5/16" 0.5 ml generic 1 MDS 450 / 90 days
INSULIN SYRINGE MISC 30G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
insulin syringe misc 30g x 5/16" 1 ml generic 1 MDS 450 / 90 days
INSULIN SYRINGE MISC 30G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
insulin syringe misc 31g x 5/16" 0.3 ml generic 1 MDS 450 / 90 days
INSULIN SYRINGE MISC 31G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
insulin syringe misc 31g x 5/16" 0.5 ml generic 1 MDS 450 / 90 days
INSULIN SYRINGE MISC 31G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
insulin syringe misc 31g x 5/16" 1 ml generic 1 MDS 450 / 90 days
INSULIN SYRINGE MISC 31G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
INSULIN SYRINGE/NEEDLE 28G X 1/2" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
INSULIN SYRINGE/NEEDLE 28G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 257 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
INSULIN SYRINGE/NEEDLE MISC 27G X 1/2"0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
INSULIN SYRINGE/NEEDLE MISC 28G X 1/2"0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
insulin syringe/needle misc 28g x 1/2" 1 ml generic 1 MDS 450 / 90 days
INSULIN SYRINGE/NEEDLE MISC 28G X 1/2"1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
INSUPEN PEN NEEDLES MISC 32G X 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
INSUPEN SENSITIVE MISC 32G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
INSUPEN ULTRAFIN MISC 29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
INSUPEN ULTRAFIN MISC 30G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
INSUPEN ULTRAFIN MISC 31G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
INSUPEN ULTRAFIN MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
KETOCAREacetone (urine) test
BRAND 1 MPL 1 / 30 Days
KETOCARE STRIPacetone (urine) test
BRAND 1 MPL 1 / 30 Days
ketone test strip generic 1 MPL 1 / 30 Days
KETOSTIX STRIPacetone (urine) test
BRAND 1 MPL 1 / 30 Days
KINNEY LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
KINNEY THIN LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 258 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
KINRAY INSULIN SYRINGE MISC 29G X 1/2"0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
KINRAY INSULIN SYRINGE MISC 31G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
KINRAY INSULIN SYRINGE MISC 31G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
KINRAY INSULIN SYRINGE MISC 31G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
KMART VALU INSULIN SYRINGE 29G MISCU-100 1 MLinsulin syringes (disposable)
BRAND 1 MDS 150 / 30 days
KMART VALU INSULIN SYRINGE 30G MISCU-100 1 MLinsulin syringes (disposable)
BRAND 1 MDS 150 / 30 days
KROGER INSULIN SYRINGE MISC 29G X 1/2"0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
KROGER INSULIN SYRINGE MISC 29G X 1/2"0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
KROGER INSULIN SYRINGE MISC 29G X 1/2"1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
KROGER INSULIN SYRINGE MISC 30G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
KROGER INSULIN SYRINGE MISC 30G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
KROGER INSULIN SYRINGE MISC 30G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 259 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
KROGER INSULIN SYRINGE MISC 31G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
KROGER INSULIN SYRINGE MISC 31G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
KROGER INSULIN SYRINGE MISC 31G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
KROGER LANCETS 21G MISClancets
BRAND 1 MDS 200 / 30 days
KROGER LANCETS MICRO THIN 33G MISClancets
BRAND 1 MDS 200 / 30 days
kroger lancets misc generic 1 MDS 200 / 30 days
KROGER LANCETS SUPER THIN MISClancets
BRAND 1 MDS 200 / 30 days
KROGER LANCETS THIN 26G MISClancets
BRAND 1 MDS 200 / 30 days
kroger lancets thin misc generic 1 MDS 200 / 30 days
KROGER LANCETS ULTRATHIN 30G MISClancets
BRAND 1 MDS 200 / 30 days
KROGER LANCING DEVICE MISClancet devices
BRAND 1
KROGER PEN NEEDLES MISC 29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
KROGER PEN NEEDLES MISC 31G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
KROGER PEN NEEDLES MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
LADY LITE LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
LANCET DEVICE MISClancet devices
BRAND 1
PAGE 260 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
LANCET DEVICE WITH EJECTOR MISClancet devices
BRAND 1
LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
LANCETS MICRO THIN 33G MISClancets
BRAND 1 MDS 200 / 30 days
lancets misc generic 1 MDS 200 / 30 days
LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
LANCETS SUPER THIN 28G MISClancets
BRAND 1 MDS 200 / 30 days
lancets thin misc generic 1 MDS 200 / 30 days
LANCETS THIN MISClancets
BRAND 1 MDS 200 / 30 days
LANCETS ULTRA FINE MISClancets
BRAND 1 MDS 200 / 30 days
LANCETS ULTRA THIN 30G MISClancets
BRAND 1 MDS 200 / 30 days
LANCETS ULTRA THIN MISClancets
BRAND 1 MDS 200 / 30 days
lancing device misc generic 1
LANCING DEVICE MISClancet devices
BRAND 1
LANZO MISClancet devices
BRAND 1
LEADER ADVANCED LANCING DEVICE MISClancet devices
BRAND 1
LEADER INSULIN SYRINGE MISC 28G X 1/2"0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 261 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
LEADER INSULIN SYRINGE MISC 28G X 1/2"1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LEADER INSULIN SYRINGE MISC 29G X 1/2"0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LEADER INSULIN SYRINGE MISC 29G X 1/2"0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LEADER INSULIN SYRINGE MISC 29G X 1/2"1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LEADER INSULIN SYRINGE MISC 30G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LEADER INSULIN SYRINGE MISC 30G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LEADER INSULIN SYRINGE MISC 30G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LEADER INSULIN SYRINGE MISC 31G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LEADER INSULIN SYRINGE MISC 31G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LEADER INSULIN SYRINGE MISC 31G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LEADER UNIFINE PENTIPS MISC 31G X 5MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
LEADER UNIFINE PENTIPS MISC 32G X 4MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PAGE 262 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
LEADER UNIFINE PENTIPS PLUS MISC 31G X5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
LEADER UNIFINE PENTIPS PLUS MISC 31G X8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
LEADER UNIFINE PENTIPS PLUS MISC 32G X4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
LIBERTY GLUCOSE CONTROL LIQUIDNORMALblood glucose calibration
BRAND 1
LIBERTY GLUCOSE CONTROL MIDSOLUTIONblood glucose calibration
BRAND 1
LIBERTY GLUCOSE CONTROL SOLUTIONblood glucose calibration
BRAND 1
LIBERTY GLUCOSE CONTROL SOLUTIONNORMALblood glucose calibration
BRAND 1
LIBERTY MEDICAL LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
LIBERTY MINI LANCING DEVICE MISClancet devices
BRAND 1
LITE TOUCH LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
LITE TOUCH LANCING DEVICE MISClancet devices
BRAND 1
LITE TOUCH LANCING PEN MISClancet devices
BRAND 1
LITE TOUCH PEN NEEDLES MISC 31G X 5MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
LITETOUCH INSULIN SYRINGE MISC 28G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 263 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
LITETOUCH INSULIN SYRINGE MISC 28G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LITETOUCH INSULIN SYRINGE MISC 29G X1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LITETOUCH INSULIN SYRINGE MISC 29G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LITETOUCH INSULIN SYRINGE MISC 29G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LITETOUCH INSULIN SYRINGE MISC 30G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LITETOUCH INSULIN SYRINGE MISC 30G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LITETOUCH INSULIN SYRINGE MISC 30G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LITETOUCH INSULIN SYRINGE MISC 31G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LITETOUCH INSULIN SYRINGE MISC 31G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LITETOUCH INSULIN SYRINGE MISC 31G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LITETOUCH LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
LITETOUCH PEN NEEDLES MISC 29G X12.7MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PAGE 264 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
LITETOUCH PEN NEEDLES MISC 31G X 6MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
LITETOUCH PEN NEEDLES MISC 31G X 8MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
LIVE BETTER ADV LANCING DEVICE MISClancet devices
BRAND 1
LIVE BETTER LANCET SUPER THIN MISClancets
BRAND 1 MDS 200 / 30 days
LIVE BETTER LANCET ULTRA THIN MISClancets
BRAND 1 MDS 200 / 30 days
LIVE BETTER PEN NEEDLES MISC 29G X12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
LIVE BETTER PEN NEEDLES MISC 31G X 6MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
LIVE BETTER PEN NEEDLES MISC 31G X 8MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
LONGS INSULIN SYRINGE MISC 31G X 5/16"0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
LONGS LANCETS STANDARD MISClancets
BRAND 1 MDS 200 / 30 days
LONGS LANCETS THIN MISClancets
BRAND 1 MDS 200 / 30 days
LONGS LANCETS ULTRA THIN MISClancets
BRAND 1 MDS 200 / 30 days
MAGELLAN INSULIN SAFETY SYR MISC 29GX 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MAGELLAN INSULIN SAFETY SYR MISC 29GX 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 265 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
MAGELLAN INSULIN SAFETY SYR MISC 29GX 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MAGELLAN INSULIN SAFETY SYR MISC 30GX 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MAGELLAN INSULIN SAFETY SYR MISC 30GX 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MAGELLAN INSULIN SAFETY SYR MISC 30GX 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MAJOR COMFORT LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
MAXI-COMFORT INSULIN SYRINGE MISC28G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MAXI-COMFORT INSULIN SYRINGE MISC28G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MAXIMA CONTROL SOLUTIONblood glucose calibration
BRAND 1
MAXIMA CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
MEDI-LANCE LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
MEDIC INSULIN SYRINGE MISC 30G X 5/16"0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MEDIC INSULIN SYRINGE MISC 30G X 5/16"0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MEDICHOICE SAFETY LANCET EXTRA MISClancets
BRAND 1 MDS 200 / 30 days
MEDICHOICE SAFETY LANCET MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 266 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
MEDICHOICE SAFETY LANCET NORM MISClancets
BRAND 1 MDS 200 / 30 days
MEDICINE SHOPPE LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
MEDICINE SHOPPE LANCETS THIN MISClancets
BRAND 1 MDS 200 / 30 days
MEDICINE SHOPPE PEN NEEDLES MISC 29GX 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
MEDICINE SHOPPE PEN NEEDLES MISC 31GX 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
MEDICINE SHOPPE PEN NEEDLES MISC 31GX 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
MEDISENSE GLUCOSE KETONE CONTRLIQUIDblood glucose calibration
BRAND 1
MEDISENSE HI/MID/LOW CONTROL LIQUIDblood glucose calibration
BRAND 1
MEDISENSE HIGH/LOW CONTROL LIQUIDblood glucose calibration
BRAND 1
MEDISENSE MID CONTROL LIQUIDblood glucose calibration
BRAND 1
MEDISENSE THIN LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
MEDLANCE EXTRA 21G MISClancets
BRAND 1 MDS 200 / 30 days
MEDLANCE LITE 25G MISClancets
BRAND 1 MDS 200 / 30 days
MEDLANCE PLUS EXTRA 21G MISClancets
BRAND 1 MDS 200 / 30 days
MEDLANCE PLUS LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 267 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
MEDLANCE PLUS LITE 25G MISClancets
BRAND 1 MDS 200 / 30 days
MEDLANCE PLUS SPECIAL 0.8MM MISClancets
BRAND 1 MDS 200 / 30 days
MEDLANCE PLUS SUPERLITE 30G MISClancets
BRAND 1 MDS 200 / 30 days
MEDLANCE PLUS UNIVERSAL 21G MISClancets
BRAND 1 MDS 200 / 30 days
MEDLANCE UNIVERSAL 21G MISClancets
BRAND 1 MDS 200 / 30 days
MEIJER LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
MEIJER LANCETS THIN MISClancets
BRAND 1 MDS 200 / 30 days
MEIJER LANCETS UNIVERSAL 30G MISClancets
BRAND 1 MDS 200 / 30 days
MEIJER LANCETS UNIVERSAL 33G MISClancets
BRAND 1 MDS 200 / 30 days
MEIJER PEN NEEDLES MISC 29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
MEIJER PEN NEEDLES MISC 31G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
MEIJER PEN NEEDLES MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
MEIJER SUPER THIN LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
metaproterenol sulfate powder generic 1
MICRODOT CONTROL HIGH/LOWSOLUTIONblood glucose calibration
BRAND 1
MICRODOT CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
MICROLET LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 268 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
MICROTAINER SAFETY FLOW LANCET MISClancets
BRAND 1 MDS 200 / 30 days
MINI LANCING DEVICE MISClancet devices
BRAND 1
MONOJECT INSULIN SYRINGE MISC 25G X5/8" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT INSULIN SYRINGE MISC 27G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT INSULIN SYRINGE MISC 28G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT INSULIN SYRINGE MISC 28G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT INSULIN SYRINGE MISC 29G X1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT INSULIN SYRINGE MISC 29G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT INSULIN SYRINGE MISC 29G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT INSULIN SYRINGE MISC 30G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT INSULIN SYRINGE MISC 30G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT INSULIN SYRINGE MISC 30G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT INSULIN SYRINGE MISC 31G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 269 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
MONOJECT INSULIN SYRINGE MISC U-1001 MLinsulin syringes (disposable)
BRAND 1 MDS 150 / 30 days
MONOJECT ULTRA COMFORT SYRINGEMISC 28G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT ULTRA COMFORT SYRINGEMISC 28G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT ULTRA COMFORT SYRINGEMISC 29G X 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT ULTRA COMFORT SYRINGEMISC 29G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT ULTRA COMFORT SYRINGEMISC 29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT ULTRA COMFORT SYRINGEMISC 30G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT ULTRA COMFORT SYRINGEMISC 30G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT ULTRA COMFORT SYRINGEMISC 31G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOJECT ULTRA COMFORT SYRINGEMISC 31G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MONOLET LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
MONOLET OPD LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
MONOLETTOR SAFETY LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 270 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
MOORE MONO INSULIN SYRINGE MISC28G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MOORE MONO INSULIN SYRINGE MISC28G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MOORE MONO INSULIN SYRINGE MISC29G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MOORE MONO INSULIN SYRINGE MISC29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MS INSULIN SYRINGE MISC 29G X 1/2" 0.3MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MS INSULIN SYRINGE MISC 29G X 1/2" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MS INSULIN SYRINGE MISC 29G X 1/2" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MS INSULIN SYRINGE MISC 30G X 5/16" 0.3MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MS INSULIN SYRINGE MISC 30G X 5/16" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MS INSULIN SYRINGE MISC 30G X 5/16" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MS INSULIN SYRINGE MISC 31G X 5/16" 0.3MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
MS INSULIN SYRINGE MISC 31G X 5/16" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 271 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
MS INSULIN SYRINGE MISC 31G X 5/16" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
multi-lancet device misc generic 1
MYGLUCOHEALTH CONTROL SOLUTIONblood glucose calibration
BRAND 1
MYGLUCOHEALTH LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
NETGROUP LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
NEUTEK 2TEK CONTROL SOLUTIONblood glucose calibration
BRAND 1
NOVA MAX PLUS GLU/KET CONTROLLIQUIDblood glucose calibration
BRAND 1
NOVA SAFETY LANCETS 23G MISClancets
BRAND 1 MDS 200 / 30 days
NOVA SAFETY LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
NOVA SUREFLEX LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
NOVA SUREFLEX LANCING DEVICE MISClancet devices
BRAND 1
NOVOFINE AUTOCOVER MISC 30G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
NOVOFINE MISC 30G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
NOVOFINE MISC 32G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
NOVOFINE PLUS MISC 32G X 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
NOVOTWIST MISC 30G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PAGE 272 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
NOVOTWIST MISC 32G X 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
nystatin domestic powder generic 1
nystatin powder generic 1
OMNIFLEX DIAPHRAGM DIAPHRAGMdiaphragms
BRAND 0
ON CALL EXPRESS GLUCOSE CONTRSOLUTIONblood glucose calibration
BRAND 1
ON CALL LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
ON CALL LANCING DEVICE MISClancet devices
BRAND 1
ON CALL PLUS GLUCOSE CONTROLSOLUTIONblood glucose calibration
BRAND 1
ON CALL PLUS LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
ON CALL PLUS LANCING DEVICE MISClancet devices
BRAND 1
ON CALL VIVID GLUCOSE CONTROLSOLUTIONblood glucose calibration
BRAND 1
ONETOUCH DELICA LANCETS 33G MISClancets
BRAND 1 MDS 200 / 30 days
ONETOUCH DELICA LANCETS FINE MISClancets
BRAND 1 MDS 200 / 30 days
ONETOUCH DELICA LANCING DEV MISClancet devices
BRAND 1
ONETOUCH FINEPOINT LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
ONETOUCH LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 273 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ONETOUCH ULTRA CONTROL SOLUTIONblood glucose calibration
BRAND 1
ONETOUCH ULTRASOFT LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
ONETOUCH VERIO SOLUTIONblood glucose calibration
BRAND 1
OPTUMRX GLUCOSE CONTROL SOLUTIONblood glucose calibration
BRAND 1
ORSINI INSULIN SYRINGE MISC 29G X 1/2"0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ORSINI INSULIN SYRINGE MISC 30G X 5/16"0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ORSINI INSULIN SYRINGE MISC 30G X 5/16"1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ORTHO DIAPHRAGM ALL-FLEXDIAPHRAGM 65 MMdiaphragm arc-spring
BRAND 0
ORTHO DIAPHRAGM ALL-FLEXDIAPHRAGM 70 MMdiaphragm arc-spring
BRAND 0
ORTHO DIAPHRAGM ALL-FLEXDIAPHRAGM 75 MMdiaphragm arc-spring
BRAND 0
ORTHO DIAPHRAGM ALL-FLEXDIAPHRAGM 80 MMdiaphragm arc-spring
BRAND 0
ORTHO DIAPHRAGM COIL KIT 100 MMdiaphragm coil spring
BRAND 0
ORTHO DIAPHRAGM COIL KIT 105 MMdiaphragm coil spring
BRAND 0
ORTHO DIAPHRAGM COIL KIT 50 MMdiaphragm coil spring
BRAND 0
PAGE 274 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ORTHO DIAPHRAGM FLAT KIT 55 MMdiaphragm flat spring
BRAND 0
ORTHO DIAPHRAGM FLAT KIT 60 MMdiaphragm flat spring
BRAND 0
ORTHO DIAPHRAGM FLAT KIT 65 MMdiaphragm flat spring
BRAND 0
ORTHO DIAPHRAGM FLAT KIT 70 MMdiaphragm flat spring
BRAND 0
ORTHO DIAPHRAGM FLAT KIT 75 MMdiaphragm flat spring
BRAND 0
ORTHO DIAPHRAGM FLAT KIT 80 MMdiaphragm flat spring
BRAND 0
ORTHO DIAPHRAGM FLAT KIT 85 MMdiaphragm flat spring
BRAND 0
ORTHO DIAPHRAGM FLAT KIT 90 MMdiaphragm flat spring
BRAND 0
ORTHO DIAPHRAGM FLAT KIT 95 MMdiaphragm flat spring
BRAND 0
PARAGARD INTRAUTERINE COPPER IUDcopper (iud)
BRAND 0 GL Female
PC LANCETS SUPER THIN 30G MISClancets
BRAND 1 MDS 200 / 30 days
PC UNIFINE PENTIPS MISC 29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PC UNIFINE PENTIPS MISC 31G X 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PC UNIFINE PENTIPS MISC 31G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PC UNIFINE PENTIPS MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
pen needles 1/2" misc 29g x 12mm generic 1 MDS 150 / 30 days
PEN NEEDLES 3/16" MISC 31G X 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PAGE 275 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
PEN NEEDLES 5/16" MISC 30G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
pen needles 5/16" misc 31g x 8 mm generic 1 MDS 150 / 30 days
PEN NEEDLES 5/16" MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PEN NEEDLES MISC 29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
pen needles misc 31g x 6 mm generic 1 MDS 150 / 30 days
PEN NEEDLES MISC 31G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PENTIPS MISC 31G X 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PENTIPS MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PENTIPS MISC 32G X 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PERFECT LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
PERFECT LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
PHARMACIST CHOICE LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
PHARMACY COUNTER LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
PHISOHEX LIQUID 3 %hexachlorophene
BRAND 1
POCKETCHEM EZ CONTROL SOLUTIONblood glucose calibration
BRAND 1
PRECISION GLUCOSE KETONE CONTRLIQUIDblood glucose calibration
BRAND 1
PRECISION SURE-DOSE SYRINGE MISC 28GX 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 276 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
PRECISION SURE-DOSE SYRINGE MISC 28GX 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PRECISION SURE-DOSE SYRINGE MISC 29GX 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PRECISION SURE-DOSE SYRINGE MISC 30GX 3/8" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PRECISION SURE-DOSE SYRINGE MISC 30GX 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PRECISION SUREDOSE PLUS SYR MISC 29GX 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PRECISION SUREDOSE PLUS SYR MISC 29GX 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PREFERRED PLUS INSULIN SYRINGE MISC28G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PREFERRED PLUS INSULIN SYRINGE MISC28G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PREFERRED PLUS INSULIN SYRINGE MISC29G X 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PREFERRED PLUS INSULIN SYRINGE MISC29G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PREFERRED PLUS INSULIN SYRINGE MISC29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PREFERRED PLUS INSULIN SYRINGE MISC30G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 277 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
PREFERRED PLUS INSULIN SYRINGE MISC30G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PREFERRED PLUS INSULIN SYRINGE MISC30G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PREFERRED PLUS LANCETS COLORED MISClancets
BRAND 1 MDS 200 / 30 days
PREFERRED PLUS LANCETS THIN MISClancets
BRAND 1 MDS 200 / 30 days
PREFERRED PLUS UNIFINE PENTIPS MISC29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PREFERRED PLUS UNIFINE PENTIPS MISC31G X 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PREFERRED PLUS UNIFINE PENTIPS MISC31G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PREFERRED PLUS UNIFINE PENTIPS MISC31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PREFERRED PLUS UNIFINE PENTIPS MISC32G X 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PRENTIF FITTING SET MISCcervical caps
BRAND 0
PRESTIGE GLUCOSE CONTROL LIQUID LOWblood glucose calibration
BRAND 1
PRODIGY CONTROL SOLUTION SOLUTIONLOWblood glucose calibration
BRAND 1
PRODIGY INSULIN SYRINGE MISC 28G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 278 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
PRODIGY INSULIN SYRINGE MISC 31G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PRODIGY INSULIN SYRINGE MISC 31G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PRODIGY LANCETS 21G MISClancets
BRAND 1 MDS 200 / 30 days
PRODIGY LANCETS 26G MISClancets
BRAND 1 MDS 200 / 30 days
PRODIGY LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
PRODIGY LANCING DEVICE MISClancet devices
BRAND 1
PRODIGY MINI PEN NEEDLES MISC 31G X 5MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PRODIGY SAFETY LANCETS 26G MISClancets
BRAND 1 MDS 200 / 30 days
PRODIGY SHORT PEN NEEDLES MISC 31G X8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PRODIGY TWIST TOP LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
PX ADVANCED LANCING DEVICE MISClancet devices
BRAND 1
PX EXTRA SHORT PEN NEEDLES MISC 31G X6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PX INSULIN SYRINGE MISC 30G X 1/2" 0.3MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PX INSULIN SYRINGE MISC 30G X 1/2" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 279 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
PX INSULIN SYRINGE MISC 30G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PX INSULIN SYRINGE MISC 31G X 5/16" 0.3MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PX INSULIN SYRINGE MISC 31G X 5/16" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PX INSULIN SYRINGE MISC 31G X 5/16" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PX LANCET AUTO INJECTOR MISClancet devices
BRAND 1
PX LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
PX LANCETS ULTRA THIN MISClancets
BRAND 1 MDS 200 / 30 days
PX MINI PEN NEEDLES MISC 31G X 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PX PEN NEEDLE MISC 29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PX PEN NEEDLE MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
QC ADVANCED LANCING DEVICE MISClancet devices
BRAND 1
QC INSULIN SYRINGE MISC 29G X 1/2" 0.3MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
QC INSULIN SYRINGE MISC 29G X 1/2" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
QC INSULIN SYRINGE MISC 29G X 1/2" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 280 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
QC INSULIN SYRINGE MISC 31G X 5/16" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
QC INSULIN SYRINGE MISC 31G X 5/16" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
QC LANCETS SUPER THIN 30G MISClancets
BRAND 1 MDS 200 / 30 days
QC LANCETS ULTRA THIN MISClancets
BRAND 1 MDS 200 / 30 days
QC PEN NEEDLES MISC 29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
QC PEN NEEDLES MISC 31G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
QC PEN NEEDLES MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
QC UNIFINE PENTIPS MISC 32G X 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
QUICKTEK CONTROL SOLUTION LIQUIDblood glucose calibration
BRAND 1
QUINTET CONTROL HIGH/NORMALSOLUTIONblood glucose calibration
BRAND 1
RA E-ZJECT COLOR LANCETS 33G MISClancets
BRAND 1 MDS 200 / 30 days
RA E-ZJECT LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
RA E-ZJECT LANCETS THIN 26G MISClancets
BRAND 1 MDS 200 / 30 days
RA E-ZJECT LANCETS THIN 28G MISClancets
BRAND 1 MDS 200 / 30 days
RA E-ZJECT LANCETS ULTRA THIN MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 281 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
RA INSULIN SYRINGE MISC 29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
RA INSULIN SYRINGE MISC 30G X 5/16" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
RA INSULIN SYRINGE MISC 30G X 5/16" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
RA LANCING DEVICE MISClancet devices
BRAND 1
RA PEN NEEDLES MISC 31G X 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
RA PEN NEEDLES MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
REFUAH PLUS GLUCOSE CONTROLSOLUTIONblood glucose calibration
BRAND 1
RELI-ON INSULIN SYRINGE MISC 29G X 1/2"1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
RELION INSULIN SYRINGE MISC 29G X 1/2"0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
RELION INSULIN SYRINGE MISC 29G X 1/2"0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
RELION INSULIN SYRINGE MISC 29G X 1/2"1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
RELION INSULIN SYRINGE MISC 30G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
RELION INSULIN SYRINGE MISC 30G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 282 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
RELION INSULIN SYRINGE MISC 30G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
RELION INSULIN SYRINGE MISC 31G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
RELION INSULIN SYRINGE MISC 31G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
RELION INSULIN SYRINGE MISC 31G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
RELION LANCETS MICRO-THIN 33G MISClancets
BRAND 1 MDS 200 / 30 days
RELION LANCETS STANDARD 21G MISClancets
BRAND 1 MDS 200 / 30 days
RELION LANCETS THIN 26G MISClancets
BRAND 1 MDS 200 / 30 days
RELION LANCETS ULTRA-THIN 30G MISClancets
BRAND 1 MDS 200 / 30 days
RELION LANCING DEVICE MISClancet devices
BRAND 1
RELION MINI PEN NEEDLES MISC 31G X 6MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
RELION PEN NEEDLES MISC 29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
RELION PEN NEEDLES MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
RELION PEN NEEDLES MISC 32G X 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
RELION SHORT PEN NEEDLES MISC 31G X 8MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PAGE 283 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
RELION ULTRA THIN LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
RELION ULTRA THIN PLUS LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
RENEW ADV CARTRIDGE REFILLS MISClancets
BRAND 1 MDS 200 / 30 days
RENEW ADVANCED LANCING DEVICE MISClancet devices
BRAND 1
REXALL LANCETS ULTRA THIN 30G MISClancets
BRAND 1 MDS 200 / 30 days
RIGHTEST GC300 CONTROL LIQUIDNORMALblood glucose calibration
BRAND 1
RIGHTEST GD500 LANCING DEVICE MISClancet devices
BRAND 1
RIGHTEST GL300 LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
SAFESNAP INSULIN SYRINGE MISC 28G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SAFESNAP INSULIN SYRINGE MISC 29G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SAFESNAP INSULIN SYRINGE MISC 29G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SAFESNAP INSULIN SYRINGE MISC 30G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SAFESNAP INSULIN SYRINGE MISC 30G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SAFETY LANCET 21G/PRESSURE ACT MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 284 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SAFETY LANCET 28G/PRESSURE ACT MISClancets
BRAND 1 MDS 200 / 30 days
SAFETY LANCET 2MM MISClancets
BRAND 1 MDS 200 / 30 days
SAFETY LANCETS 21G MISClancets
BRAND 1 MDS 200 / 30 days
SAFETY LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
SAFETY LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
SAFETY LET LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
SAFETY SEAL LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
SAFETY-GLIDE SYRINGE MISC 29G X 1/2"0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SAPSCARE TWIST TOP LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
SB INSULIN SYRINGE MISC 29G X 1/2" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SB INSULIN SYRINGE MISC 29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SB INSULIN SYRINGE MISC 30G X 5/16" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SB INSULIN SYRINGE MISC 30G X 5/16" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SB INSULIN SYRINGE MISC 31G X 5/16" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SB LANCETS THIN MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 285 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SB LANCETS ULTRA THIN MISClancets
BRAND 1 MDS 200 / 30 days
SCHNUCKS INSULIN SYRINGE MISC 29G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SCHNUCKS INSULIN SYRINGE MISC 30G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
select-lite lancing device misc generic 1
SHOPKO AUTOLET LANCING DEVICE MISClancet devices
BRAND 1
SHOPKO ON-THE-GO LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
SHOPKO UNIFINE PENTIPS MISC 29G X12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
SHOPKO UNIFINE PENTIPS MISC 31G X 5MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
SHOPKO UNIFINE PENTIPS MISC 31G X 8MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
SHOPKO UNIFINE PENTIPS MISC 32G X 4MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
SHOPKO UNILET LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
SHOPKO UNILET LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
SIMPLE DIAGNOSTICS LANCING DEV MISClancet devices
BRAND 1
SM INSULIN SYRINGE MISC 28G X 1/2" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 286 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SM INSULIN SYRINGE MISC 28G X 1/2" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SM INSULIN SYRINGE MISC 29G X 1/2" 0.3MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SM INSULIN SYRINGE MISC 29G X 1/2" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SM INSULIN SYRINGE MISC 29G X 1/2" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SM INSULIN SYRINGE MISC 30G X 5/16" 0.3MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SM INSULIN SYRINGE MISC 30G X 5/16" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SM INSULIN SYRINGE MISC 30G X 5/16" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SM INSULIN SYRINGE MISC 31G X 5/16" 0.3MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SM INSULIN SYRINGE MISC 31G X 5/16" 0.5MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SM INSULIN SYRINGE MISC 31G X 5/16" 1MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SM LANCETS 21G MISClancets
BRAND 1 MDS 200 / 30 days
SM LANCETS 33G MISClancets
BRAND 1 MDS 200 / 30 days
SM SUPER THIN LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 287 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SM THIN LANCETS 26G MISClancets
BRAND 1 MDS 200 / 30 days
SMART DIABETES VANTAGE LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
SMART DIABETES VANTAGE LANCING MISClancet devices
BRAND 1
SMART SENSE COLOR LANCETS 33G MISClancets
BRAND 1 MDS 200 / 30 days
SMART SENSE STANDARD LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
SMART SENSE SUPER THIN LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
SMART SENSE THIN LANCETS 26G MISClancets
BRAND 1 MDS 200 / 30 days
SMARTEST CONTROL MEDIUM SOLUTIONblood glucose calibration
BRAND 1
SMARTEST LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
sodium polystyrene sulfonate powder generic 1
SOLARTEK GLUCOSE CONTROL LIQUIDblood glucose calibration
BRAND 1
SOLUS V2 CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
SOLUS V2 LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
SOLUS V2 LANCING DEVICE MISClancet devices
BRAND 1
SOLUS V2 TWIST LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
stannous fluoride powder generic 0
STERILANCE TL MISClancets
BRAND 1 MDS 200 / 30 days
sterile water for irrigation solution generic 1
PAGE 288 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SUPER THIN LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
SURE COMFORT INSULIN SYRINGE MISC28G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE COMFORT INSULIN SYRINGE MISC28G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE COMFORT INSULIN SYRINGE MISC29G X 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE COMFORT INSULIN SYRINGE MISC29G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE COMFORT INSULIN SYRINGE MISC29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE COMFORT INSULIN SYRINGE MISC30G X 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE COMFORT INSULIN SYRINGE MISC30G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE COMFORT INSULIN SYRINGE MISC30G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE COMFORT INSULIN SYRINGE MISC30G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE COMFORT INSULIN SYRINGE MISC30G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE COMFORT INSULIN SYRINGE MISC30G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 289 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SURE COMFORT INSULIN SYRINGE MISC31G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE COMFORT INSULIN SYRINGE MISC31G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE COMFORT INSULIN SYRINGE MISC31G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE COMFORT LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
SURE COMFORT LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
SURE COMFORT LANCING PEN MISClancet devices
BRAND 1
SURE COMFORT PEN NEEDLES MISC 29G X12.7MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
SURE COMFORT PEN NEEDLES MISC 30G X8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
SURE COMFORT PEN NEEDLES MISC 31G X5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
SURE COMFORT PEN NEEDLES MISC 31G X8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
SURE COMFORT PEN NEEDLES MISC 32G X4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
SURE COMFORT PEN NEEDLES MISC 32G X6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
SURE EDGE GLUCOSE CONTROL SOLUTIONLOWblood glucose calibration
BRAND 1
PAGE 290 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SURE EDGE GLUCOSE CONTROL SOLUTIONNORMALblood glucose calibration
BRAND 1
SURE-FINE PEN NEEDLES MISC 29G X12.7MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
SURE-FINE PEN NEEDLES MISC 31G X 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
SURE-FINE PEN NEEDLES MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
SURE-JECT INSULIN SYRINGE MISC 28G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE-JECT INSULIN SYRINGE MISC 28G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE-JECT INSULIN SYRINGE MISC 29G X1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE-JECT INSULIN SYRINGE MISC 29G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE-JECT INSULIN SYRINGE MISC 29G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE-JECT INSULIN SYRINGE MISC 30G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE-JECT INSULIN SYRINGE MISC 30G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE-JECT INSULIN SYRINGE MISC 30G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE-JECT INSULIN SYRINGE MISC 31G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 291 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SURE-JECT INSULIN SYRINGE MISC 31G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE-JECT INSULIN SYRINGE MISC 31G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
SURE-LANCE FLAT LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
SURE-LANCE LANCETS 26G MISClancets
BRAND 1 MDS 200 / 30 days
SURE-LANCE THIN LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
SURE-LANCE ULTRA THIN LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
SURE-PEN MISClancet devices
BRAND 1
SURE-TEST EASYPLUS CONTROL SOLUTIONNORMALblood glucose calibration
BRAND 1
SURE-TOUCH LANCETS UNIVERSAL MISClancets
BRAND 1 MDS 200 / 30 days
SURECHEK CONTROL SOLUTION LIQUIDLOWblood glucose calibration
BRAND 1
SURECHEK CONTROL SOLUTION LIQUIDNORMALblood glucose calibration
BRAND 1
surelite lancets generic 1 MDS 200 / 30 days
SURELITE LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
SURESTEP GLUCOSE CONTROL SOLUTIONblood glucose calibration
BRAND 1
SURESTEP PRO LOW GLUCOSE LIQUIDblood glucose calibration
BRAND 1
PAGE 292 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SURESTEP PRO NORMAL GLUCOSE LIQUIDblood glucose calibration
BRAND 1
TAI DOC CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
TECHLITE AST LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
TECHLITE LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
TECHLITE LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
TELCARE GLUCOSE CONTROL SOLUTIONblood glucose calibration
BRAND 1
TERUMO INSULIN SYRINGE MISC 27G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TERUMO INSULIN SYRINGE MISC 27G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TERUMO INSULIN SYRINGE MISC 28G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TERUMO INSULIN SYRINGE MISC 28G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TERUMO INSULIN SYRINGE MISC 29G X1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TERUMO INSULIN SYRINGE MISC 29G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TERUMO INSULIN SYRINGE MISC 29G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TERUMO INSULIN SYRINGE MISC 30G X3/8" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 293 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
TERUMO INSULIN SYRINGE MISC 30G X3/8" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TERUMO SURGUARD INSULIN SYR MISC28G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TERUMO SURGUARD INSULIN SYR MISC28G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TERUMO SURGUARD INSULIN SYR MISC29G X 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TERUMO SURGUARD INSULIN SYR MISC29G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TERUMO SURGUARD INSULIN SYR MISC29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TGT ADVANCED LANCING DEVICE MISClancet devices
BRAND 1
TGT LANCET ALTERNATE SITE MISClancets
BRAND 1 MDS 200 / 30 days
TGT LANCET MICRO THIN 33G MISClancets
BRAND 1 MDS 200 / 30 days
TGT LANCET SUPER THIN 30G MISClancets
BRAND 1 MDS 200 / 30 days
TGT LANCET THIN 23G MISClancets
BRAND 1 MDS 200 / 30 days
TGT LANCET THIN 26G MISClancets
BRAND 1 MDS 200 / 30 days
TGT LANCET ULTRA THIN 28G MISClancets
BRAND 1 MDS 200 / 30 days
TGT LANCET ULTRA THIN 30G MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 294 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
TGT LANCING DEVICE MISClancet devices
BRAND 1
THINPRO INSULIN SYRINGE MISC 28G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
THINPRO INSULIN SYRINGE MISC 28G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
THINPRO INSULIN SYRINGE MISC 29G X1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
THINPRO INSULIN SYRINGE MISC 29G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
THINPRO INSULIN SYRINGE MISC 29G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
THINPRO INSULIN SYRINGE MISC 30G X3/8" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
THINPRO INSULIN SYRINGE MISC 30G X3/8" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TODAYS HEALTH LANCING DEVICE MISClancet devices
BRAND 1
TODAYS HEALTH MINI PEN NEEDLES MISC31G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
TODAYS HEALTH PEN NEEDLES MISC 29G X12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
TODAYS HEALTH SHORT PEN NEEDLE MISC31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
TODAYS HEALTH THIN LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 295 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
TODAYS HEALTH THIN LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
TOPCARE CLICKFINE PEN NEEDLES MISC31G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
TOPCARE CLICKFINE PEN NEEDLES MISC31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
TOPCARE ULTRA COMFORT INS SYR MISC29G X 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TOPCARE ULTRA COMFORT INS SYR MISC29G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TOPCARE ULTRA COMFORT INS SYR MISC29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TOPCARE ULTRA COMFORT INS SYR MISC30G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TOPCARE ULTRA COMFORT INS SYR MISC30G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TOPCARE ULTRA COMFORT INS SYR MISC30G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TOPCARE ULTRA COMFORT INS SYR MISC31G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TOPCARE ULTRA COMFORT INS SYR MISC31G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TOPCARE ULTRA COMFORT INS SYR MISC31G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 296 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
TRAVEL LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
TRUE METRIX AIR GLUCOSE METER KITW/DEVICEblood glucose monitoring supplies
BRAND 1 MDS 1 / 730 days
TRUE METRIX AIR KIT W/DEVICEblood glucose monitoring supplies
BRAND 1 MDS 1 / 730 days
TRUE METRIX BLOOD GLUCOSE TEST STRIPglucose blood
BRAND 1 MDS 100 / 30 days
TRUE METRIX LEVEL 1 SOLUTION LOWblood glucose calibration
BRAND 1
TRUE METRIX LEVEL 2 SOLUTION NORMALblood glucose calibration
BRAND 1
TRUE METRIX METER KIT W/DEVICEblood glucose monitoring supplies
BRAND 1 MDS 1 / 730 days
TRUECONTROL GLUCOSE CONT LEV 0LIQUIDblood glucose calibration
BRAND 1
TRUECONTROL GLUCOSE CONT LEV 1LIQUIDblood glucose calibration
BRAND 1
TRUEDRAW LANCING DEVICE MISClancet devices
BRAND 1
TRUEPLUS INSULIN SYRINGE MISC 28G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TRUEPLUS INSULIN SYRINGE MISC 28G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TRUEPLUS INSULIN SYRINGE MISC 29G X1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TRUEPLUS INSULIN SYRINGE MISC 29G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 297 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
TRUEPLUS INSULIN SYRINGE MISC 29G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TRUEPLUS INSULIN SYRINGE MISC 30G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TRUEPLUS INSULIN SYRINGE MISC 30G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TRUEPLUS INSULIN SYRINGE MISC 30G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TRUEPLUS INSULIN SYRINGE MISC 31G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TRUEPLUS INSULIN SYRINGE MISC 31G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TRUEPLUS INSULIN SYRINGE MISC 31G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
TRUEPLUS LANCETS 26G MISClancets
BRAND 1 MDS 200 / 30 days
TRUEPLUS LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
TRUEPLUS LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
TRUEPLUS LANCETS 33G MISClancets
BRAND 1 MDS 200 / 30 days
TRUEPLUS SAFETY LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
TRUERESULT BLOOD GLUCOSE KITW/DEVICEblood glucose monitoring supplies
BRAND 1 MDS 1 / 730 days
TRUETEST CONTROL LEVEL 1 LIQUIDblood glucose calibration
BRAND 1
PAGE 298 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
TRUETEST CONTROL LEVEL 2 LIQUIDblood glucose calibration
BRAND 1
TRUETEST CONTROL LEVEL 3 LIQUIDblood glucose calibration
BRAND 1
TRUETEST TEST STRIPglucose blood
BRAND 1 MDS 100 / 30 days
TRUETRACK GLUCOSE CONTROL LIQUIDblood glucose calibration
BRAND 1
TRUETRACK GLUCOSE CONTROL LIQUIDLOWblood glucose calibration
BRAND 1
TRUETRACK TEST STRIPglucose blood
BRAND 1 MDS 100 / 30 days
ULTI-LANCE AUTO-ADJUST DEVICE MISClancet devices
BRAND 1
ULTI-LANCE AUTOMATIC MISClancet devices
BRAND 1
ULTI-LANCE MINI ADJUSTABLE MISClancet devices
BRAND 1
ULTICARE INSULIN SAFETY SYR MISC 29G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTICARE INSULIN SAFETY SYR MISC 29G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTICARE INSULIN SYRINGE MISC 28G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTICARE INSULIN SYRINGE MISC 28G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTICARE INSULIN SYRINGE MISC 29G X1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 299 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ULTICARE INSULIN SYRINGE MISC 29G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTICARE INSULIN SYRINGE MISC 29G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTICARE INSULIN SYRINGE MISC 30G X1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTICARE INSULIN SYRINGE MISC 30G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTICARE INSULIN SYRINGE MISC 30G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTICARE INSULIN SYRINGE MISC 30G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTICARE INSULIN SYRINGE MISC 30G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTICARE INSULIN SYRINGE MISC 30G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTICARE INSULIN SYRINGE MISC 31G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTICARE INSULIN SYRINGE MISC 31G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTICARE INSULIN SYRINGE MISC 31G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTICARE MICRO PEN NEEDLES MISC 32GX 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PAGE 300 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ULTICARE MINI PEN NEEDLES MISC 31G X 6MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
ULTICARE PEN NEEDLES MISC 29G X12.7MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
ULTICARE PEN NEEDLES MISC 29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
ULTICARE SHORT PEN NEEDLES MISC 31G X8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
ULTICARE THIN LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
ULTILET BASIC LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
ULTILET CLASSIC LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
ULTILET INSULIN SYRINGE MISC 29G X7/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTILET INSULIN SYRINGE MISC 29G X7/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTILET INSULIN SYRINGE MISC 29G X7/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTILET INSULIN SYRINGE SHORT MISC30G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTILET INSULIN SYRINGE SHORT MISC30G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTILET INSULIN SYRINGE SHORT MISC30G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 301 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ULTILET INSULIN SYRINGE SHORT MISC31G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTILET INSULIN SYRINGE SHORT MISC31G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTILET INSULIN SYRINGE SHORT MISC31G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTILET LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
ULTILET PEN NEEDLE MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
ULTILET SAFETY LANCETS 23G MISClancets
BRAND 1 MDS 200 / 30 days
ULTRA COMFORT INSULIN SYRINGE MISC29G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA COMFORT INSULIN SYRINGE MISC29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA COMFORT INSULIN SYRINGE MISC30G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA COMFORT INSULIN SYRINGE MISC30G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA COMFORT INSULIN SYRINGE MISC30G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA COMFORT INSULIN SYRINGE MISC31G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA COMFORT INSULIN SYRINGE MISC31G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 302 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ULTRA THIN LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
ULTRA THIN LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
ULTRA-COMFORT INSULIN SYRINGE MISC28G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-COMFORT INSULIN SYRINGE MISC28G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-COMFORT INSULIN SYRINGE MISC29G X 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-COMFORT INSULIN SYRINGE MISC29G X 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-COMFORT INSULIN SYRINGE MISC29G X 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-COMFORT INSULIN SYRINGE MISC30G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-COMFORT INSULIN SYRINGE MISC30G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-COMFORT INSULIN SYRINGE MISC30G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-COMFORT INSULIN SYRINGE MISC31G X 5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-COMFORT INSULIN SYRINGE MISC31G X 5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-COMFORT INSULIN SYRINGE MISC31G X 5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 303 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ULTRA-THIN II AUTO LANCET MISClancets
BRAND 1 MDS 200 / 30 days
ULTRA-THIN II INS SYR SHORT MISC 30G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-THIN II INS SYR SHORT MISC 30G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-THIN II INS SYR SHORT MISC 30G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-THIN II INS SYR SHORT MISC 31G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-THIN II INS SYR SHORT MISC 31G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-THIN II INS SYR SHORT MISC 31G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-THIN II INSULIN SYRINGE MISC 29GX 1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-THIN II INSULIN SYRINGE MISC 29GX 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-THIN II INSULIN SYRINGE MISC 29GX 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
ULTRA-THIN II LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
ULTRA-THIN II MINI PEN NEEDLE MISC 31GX 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
ULTRA-THIN II PEN NEEDLE SHORT MISC31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PAGE 304 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ULTRA-THIN II PEN NEEDLES MISC 29G X12.7MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
ULTRATRAK PRO CONTROL SOLUTIONblood glucose calibration
BRAND 1
ULTRATRAK PRO CONTROL SOLUTIONNORMALblood glucose calibration
BRAND 1
ULTRATRAK ULTIMATE CONTROLSOLUTIONblood glucose calibration
BRAND 1
UNIFINE PENTIPS MISC 29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
UNIFINE PENTIPS MISC 31G X 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
UNIFINE PENTIPS MISC 31G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
UNIFINE PENTIPS MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
UNIFINE PENTIPS MISC 32G X 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
UNIFINE PENTIPS PLUS MISC 29G X 12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
UNIFINE PENTIPS PLUS MISC 31G X 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
UNIFINE PENTIPS PLUS MISC 31G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
UNIFINE PENTIPS PLUS MISC 31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
UNIFINE PENTIPS PLUS MISC 32G X 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
UNILET COMFORTOUCH LANCET MISClancets
BRAND 1 MDS 200 / 30 days
UNILET EXCELITE II MISClancets
BRAND 1 MDS 200 / 30 days
PAGE 305 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
UNILET EXCELITE MISClancets
BRAND 1 MDS 200 / 30 days
UNILET G.P. LANCET MISClancets
BRAND 1 MDS 200 / 30 days
UNILET G.P. SUPERLITE LANCET MISClancets
BRAND 1 MDS 200 / 30 days
UNILET GP 28 ULTRA THIN MISClancets
BRAND 1 MDS 200 / 30 days
UNILET LANCET MISClancets
BRAND 1 MDS 200 / 30 days
UNILET MICRO-THIN 33G MISClancets
BRAND 1 MDS 200 / 30 days
UNILET SUPER-THIN 30G MISClancets
BRAND 1 MDS 200 / 30 days
UNILET SUPERLITE LANCET MISClancets
BRAND 1 MDS 200 / 30 days
UNILET ULTRA-THIN 28G MISClancets
BRAND 1 MDS 200 / 30 days
UNISTIK 3 GENTLE MISClancets
BRAND 1 MDS 200 / 30 days
UNISTIK SAFETY LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
UNISTIK SAFETY LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
UNISTRIP CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
UNIVERSAL 1 LANCETS THIN 26G MISClancets
BRAND 1 MDS 200 / 30 days
UNIVERSAL 1 LANCETS ULTRA THIN MISClancets
BRAND 1 MDS 200 / 30 days
V-R MONO INSULIN SYRINGE MISC 28G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 306 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
V-R MONO INSULIN SYRINGE MISC 28G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
V-R MONO INSULIN SYRINGE MISC 29G X1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
V-R MONO INSULIN SYRINGE MISC 29G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
V-R MONO INSULIN SYRINGE MISC 29G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
VALUE HEALTH INSULIN SYRINGE MISC 29GX 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
VALUE HEALTH INSULIN SYRINGE MISC 29GX 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
VALUE PLUS LANCET STANDARD 21G MISClancets
BRAND 1 MDS 200 / 30 days
VALUE PLUS LANCETS SUPER THIN MISClancets
BRAND 1 MDS 200 / 30 days
VALUE PLUS LANCETS THIN 26G MISClancets
BRAND 1 MDS 200 / 30 days
VALUE PLUS LANCING DEVICE MISClancet devices
BRAND 1
VALUMARK LANCET SUPER THIN 30G MISClancets
BRAND 1 MDS 200 / 30 days
VALUMARK LANCET ULTRA THIN 28G MISClancets
BRAND 1 MDS 200 / 30 days
VALUMARK PEN NEEDLES MISC 29G X12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
VALUMARK PEN NEEDLES MISC 31G X 6MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
PAGE 307 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
VALUMARK PEN NEEDLES MISC 31G X 8MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
VANISHPOINT INSULIN SYRINGE MISC 29GX 1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
VANISHPOINT INSULIN SYRINGE MISC 30GX 1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
VICTORY CONTROL LEVEL 1/2 SOLUTIONblood glucose calibration
BRAND 1
VIDA MIA AUTOLET LANCING DEV MISClancet devices
BRAND 1
VIDA MIA UNIFINE PENTIPS MISC 29G X12MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
VIDA MIA UNIFINE PENTIPS MISC 31G X 6MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
VIDA MIA UNIFINE PENTIPS MISC 31G X 8MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
VIDA MIA UNIFINE PENTIPS MISC 32G X 4MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
VIDA MIA UNILET LANCETS 28G MISClancets
BRAND 1 MDS 200 / 30 days
VIDA MIA UNILET LANCETS 30G MISClancets
BRAND 1 MDS 200 / 30 days
VISTOGARD PACKET 10 GMuridine triacetate (emergency treatment)
BRAND 4
VOCAL POINT CONTROL SOLUTION LOWblood glucose calibration
BRAND 1
VP INSULIN SYRINGE MISC 29G X 1/2" 0.3MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 308 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
W&F LANCETS 26G MISClancets
BRAND 1 MDS 200 / 30 days
W&F LANCETS COLORED 21G MISClancets
BRAND 1 MDS 200 / 30 days
WALGREENS ADV TRAVEL LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
WALGREENS LANCETS MICRO THIN MISClancets
BRAND 1 MDS 200 / 30 days
WALGREENS LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
WALGREENS LANCETS SUPER THIN MISClancets
BRAND 1 MDS 200 / 30 days
WALGREENS LANCING DEVICE MISClancet devices
BRAND 1
WALGREENS THIN LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
WALGREENS ULTRA THIN LANCETS MISClancets
BRAND 1 MDS 200 / 30 days
WD MEDIC INSULIN SYRINGE MISC 29G X1/2" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
WD MEDIC INSULIN SYRINGE MISC 29G X1/2" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
WD MEDIC INSULIN SYRINGE MISC 29G X1/2" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
WD MEDIC INSULIN SYRINGE MISC 30G X5/16" 0.3 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
WD MEDIC INSULIN SYRINGE MISC 30G X5/16" 0.5 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
WD MEDIC INSULIN SYRINGE MISC 30G X5/16" 1 MLinsulin syringe/needle u-100
BRAND 1 MDS 450 / 90 days
PAGE 309 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
WEGMANS UNIFINE PENTIPS PLUS MISC31G X 5 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
WEGMANS UNIFINE PENTIPS PLUS MISC31G X 6 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
WEGMANS UNIFINE PENTIPS PLUS MISC31G X 8 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
WEGMANS UNIFINE PENTIPS PLUS MISC32G X 4 MMinsulin pen needle
BRAND 1 MDS 150 / 30 days
WIDE-SEAL DIAPHRAGM 60 DIAPHRAGM 2%diaphragm wide seal
BRAND 0
WIDE-SEAL DIAPHRAGM 65 DIAPHRAGM 2%diaphragm wide seal
BRAND 0
WIDE-SEAL DIAPHRAGM 70 DIAPHRAGM 2%diaphragm wide seal
BRAND 0
WIDE-SEAL DIAPHRAGM 75 DIAPHRAGM 2%diaphragm wide seal
BRAND 0
WIDE-SEAL DIAPHRAGM 80 DIAPHRAGM 2%diaphragm wide seal
BRAND 0
WIDE-SEAL DIAPHRAGM 85 DIAPHRAGM 2%diaphragm wide seal
BRAND 0
WIDE-SEAL DIAPHRAGM 90 DIAPHRAGM 2%diaphragm wide seal
BRAND 0
WIDE-SEAL DIAPHRAGM 95 DIAPHRAGM 2%diaphragm wide seal
BRAND 0
PAGE 310 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
XPRES CONTROL SOLUTION NORMALblood glucose calibration
BRAND 1
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
LACRISERT INSERT 5 MGartificial tear insert
BRAND 3
LASTACAFT SOLUTION 0.25 %alcaftadine
BRAND 2
mydral solution 0.5 % generic 1
mydral solution 1 % generic 1
neo-polycin ointment 3.5-400-10000 generic 1
neomycin-bacitracin zn-polymyx ointment5-400-10000
generic 1
neomycin-polymyxin-dexameth ointment3.5-10000-0.1
generic 1
neomycin-polymyxin-dexameth suspension3.5-10000-0.1
generic 1
neomycin-polymyxin-hc suspension 3.5-10000-1
generic 1
parcaine solution 0.5 % generic 1
poly-dex ointment 3.5-10000-0.1 generic 1
polymyxin b-trimethoprim solution 10000-0.1 unit/ml-%
generic 1
proparacaine hcl solution 0.5 % generic 1
RESTASIS EMULSION 0.05 %cyclosporine (ophth)
BRAND 2
tobramycin-dexamethasone suspension0.3-0.1 %
generic 1
tropicamide solution 0.5 % generic 1
tropicamide solution 1 % generic 1
PAGE 311 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
OPHTHALMIC ANTI-ALLERGY AGENTS
ALOCRIL SOLUTION 2 %nedocromil sodium (ophth)
BRAND 3
ALOMIDE SOLUTION 0.1 %lodoxamide tromethamine
BRAND 3
azelastine hcl solution 0.05 % generic 1 MPL 1 / claim
BEPREVE SOLUTION 1.5 %bepotastine besilate
BRAND 3
cromolyn sodium solution 4 % generic 1
EMADINE SOLUTION 0.05 %emedastine difumarate
BRAND 3
epinastine hcl solution 0.05 % generic 1
PATADAY SOLUTION 0.2 %olopatadine hcl
BRAND 2
PATANOL SOLUTION 0.1 %olopatadine hcl
BRAND 3
OPHTHALMIC ANTI-INFLAMMATORIES
ALREX SUSPENSION 0.2 %loteprednol etabonate
BRAND 2
bromfenac sodium (once-daily) solution0.09 %
generic 1
bromfenac sodium solution 0.09 % generic 1
dexamethasone sodium phosphate solution0.1 %
generic 1
diclofenac sodium solution 0.1 % generic 1
DUREZOL EMULSION 0.05 %difluprednate
BRAND 2
fluorometholone suspension 0.1 % generic 1
flurbiprofen sodium solution 0.03 % generic 1
FML FORTE SUSPENSION 0.25 %fluorometholone (ophth)
BRAND 3
PAGE 312 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
FML OINTMENT 0.1 %fluorometholone (ophth)
BRAND 3
ILEVRO SUSPENSION 0.3 %nepafenac
BRAND 3
ketorolac tromethamine solution 0.4 % generic 1 MPL 1 / claim
ketorolac tromethamine solution 0.5 % generic 1 MPL 1 / Claim
LOTEMAX GEL 0.5 %loteprednol etabonate
BRAND 2
LOTEMAX OINTMENT 0.5 %loteprednol etabonate
BRAND 2
LOTEMAX SUSPENSION 0.5 %loteprednol etabonate
BRAND 2
MAXIDEX SUSPENSION 0.1 %dexamethasone (ophth)
BRAND 3
NEVANAC SUSPENSION 0.1 %nepafenac
BRAND 3
PRED MILD SUSPENSION 0.12 %prednisolone acetate (ophth)
BRAND 3
prednisolone acetate suspension 1 % generic 1
PREDNISOLONE SODIUM PHOSPHATESOLUTION 1 %prednisolone sodium phosphate (ophth)
BRAND 3
VEXOL SUSPENSION 1 %rimexolone
BRAND 3
OPHTHALMIC ANTIGLAUCOMA AGENTS
apraclonidine hcl solution 0.5 % generic 1
AZOPT SUSPENSION 1 %brinzolamide
BRAND 2 MPL 1 / Claim
betaxolol hcl solution 0.5 % generic 1 MPL 1 / Claim
brimonidine tartrate solution 0.15 % generic 1 MPL 1 / Claim
brimonidine tartrate solution 0.2 % generic 1 MPL 1 / Claim
PAGE 313 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
carteolol hcl solution 1 % generic 1
COMBIGAN SOLUTION 0.2-0.5 %brimonidine tartrate-timolol maleate
BRAND 2
dorzolamide hcl solution 2 % generic 1 MPL 1 / Claim
dorzolamide hcl-timolol mal solution 22.3-6.8 mg/ml
generic 1 MPL 1 / Claim
IOPIDINE SOLUTION 1 %apraclonidine hcl
BRAND 3
levobunolol hcl solution 0.25 % generic 1 MPL 1 / Claim
levobunolol hcl solution 0.5 % generic 1 MPL 1 / Claim
methazolamide tab 25 mg generic 1 MDD 6 per day
methazolamide tab 50 mg generic 1 MDD 6 per day
metipranolol solution 0.3 % generic 1
PHOSPHOLINE IODIDE RECON SOLN 0.125%echothiophate iodide
BRAND 3
pilocarpine hcl solution 1 % generic 1
pilocarpine hcl solution 2 % generic 1
pilocarpine hcl solution 4 % generic 1
timolol maleate gel f soln 0.25 % generic 1
timolol maleate gel f soln 0.5 % generic 1
timolol maleate solution 0.25 % generic 1
timolol maleate solution 0.5 % generic 1
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
bimatoprost solution 0.03 % generic 3 ST
latanoprost solution 0.005 % generic 1
LUMIGAN SOLUTION 0.01 %bimatoprost
BRAND 3 ST
TRAVATAN Z SOLUTION 0.004 %travoprost
BRAND 2
PAGE 314 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ZIOPTAN SOLUTION 0.0015 %tafluprost
BRAND 2
OTIC AGENTS
acetasol hc solution 2-1 % generic 1
acetic acid solution 2 % generic 1
antipyrine-benzocaine solution 5.4-1.4 % generic 1
antipyrine-benzocaine solution 54-14mg/ml
generic 1
aurodex solution 5.4-1.4 % generic 1
CIPRO HC SUSPENSION 0.2-1 %ciprofloxacin-hydrocortisone
BRAND 3
CIPRODEX SUSPENSION 0.3-0.1 %ciprofloxacin-dexamethasone
BRAND 2
COLY-MYCIN S SUSPENSION 3.3-3-10-0.5MG/MLneomycin-colistin-hc-thonzonium
BRAND 3
CORTISPORIN SOLUTION 3.5-10000-1neomycin-polymyxin-hc (otic)
BRAND 2
CORTISPORIN-TC SUSPENSION 3.3-3-10-0.5MG/MLneomycin-colistin-hc-thonzonium
BRAND 3
cortomycin solution 3.5-10000-1 generic 1
cortomycin suspension 3.5-10000-1 generic 1
fluocinolone acetonide oil 0.01 % generic 1
hydrocortisone-acetic acid solution 1-2 % generic 1
neomycin-polymyxin-hc solution 1 % generic 1
neomycin-polymyxin-hc solution 3.5-10000-1
generic 1
neomycin-polymyxin-hc suspension 3.5-10000-1
generic 1
PAGE 315 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
ALVESCO AERO SOLN 160 MCG/ACTciclesonide
BRAND 3PA
MPL 1 / 30 days
ALVESCO AERO SOLN 80 MCG/ACTciclesonide
BRAND 3PA
MPL 1 / 30 days
ASMANEX 120 METERED DOSES AER POWBA 220 MCG/INHmometasone furoate (inhalation)
BRAND 2 MPL 1 / 30 days
ASMANEX 14 METERED DOSES AER POWBA 220 MCG/INHmometasone furoate (inhalation)
BRAND 2 MPL 1 / 30 days
ASMANEX 30 METERED DOSES AER POWBA 110 MCG/INHmometasone furoate (inhalation)
BRAND 2 MPL 1 / 30 days
ASMANEX 30 METERED DOSES AER POWBA 220 MCG/INHmometasone furoate (inhalation)
BRAND 2 MPL 1 / 30 days
ASMANEX 60 METERED DOSES AER POWBA 220 MCG/INHmometasone furoate (inhalation)
BRAND 2 MPL 1 / 30 days
ASMANEX 7 METERED DOSES AER POW BA110 MCG/INHmometasone furoate (inhalation)
BRAND 2 MPL 1 / 30 days
budesonide suspension 0.25 mg/2ml generic 3PA
MDS 120 / 30 days
budesonide suspension 0.5 mg/2ml generic 3PA
MDS 120 / 30 days
budesonide suspension 1 mg/2ml generic 1PA
MDS 120 / 30 days
budesonide suspension 32 mcg/act generic 1PA
MPL 1 / 30 days
PAGE 316 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
FLOVENT DISKUS AER POW BA 100MCG/BLISTfluticasone propionate (inhalation)
BRAND 3 MPL 1 / 30 days
FLOVENT DISKUS AER POW BA 250MCG/BLISTfluticasone propionate (inhalation)
BRAND 3 MPL 1 / 30 days
FLOVENT DISKUS AER POW BA 50MCG/BLISTfluticasone propionate (inhalation)
BRAND 3 MPL 1 / 30 days
FLOVENT HFA AEROSOL 110 MCG/ACTfluticasone propionate hfa
BRAND 3 MPL 1 / 30 days
FLOVENT HFA AEROSOL 220 MCG/ACTfluticasone propionate hfa
BRAND 3 MPL 1 / 30 days
FLOVENT HFA AEROSOL 44 MCG/ACTfluticasone propionate hfa
BRAND 3 MPL 1 / 30 days
flunisolide solution 25 mcg/act (0.025%) generic 1 MPL 1 / 30 days
flunisolide solution 29 mcg/act (0.025%) generic 1 MPL 1 / 30 days
fluticasone propionate suspension 50mcg/act
generic 1 MPL 1 / 30 days
mometasone furoate suspension 50mcg/act
generic 1PA
MPL 2 / 30 days
NASONEX SUSPENSION 50 MCG/ACTmometasone furoate (nasal)
BRAND 2PA
MPL 2 / 30 days
PULMICORT FLEXHALER AER POW BA 180MCG/ACTbudesonide (inhalation)
BRAND 2PA
MPL 1 / 30 days
PULMICORT FLEXHALER AER POW BA 90MCG/ACTbudesonide (inhalation)
BRAND 2PA
MPL 1 / 30 Days
PULMICORT SUSPENSION 0.5 MG/2MLbudesonide (inhalation)
BRAND 3PA
MDS 120 / 30 days
PULMICORT SUSPENSION 1 MG/2MLbudesonide (inhalation)
BRAND 2PA
MDS 120 / 30 days
PAGE 317 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
QVAR AERO SOLN 40 MCG/ACTbeclomethasone dipropionate
BRAND 2 MPL 1 / 30 days
QVAR AERO SOLN 80 MCG/ACTbeclomethasone dipropionate
BRAND 2 MPL 1 / 30 days
RHINOCORT AQUA SUSPENSION 32MCG/ACTbudesonide (nasal)
BRAND 3PA
MPL 1 / 30 days
ANTIHISTAMINES
ALLEGRA TAB 60 MGfexofenadine hcl
BRAND 1 MDD 2 per day
arbinoxa solution 4 mg/5ml generic 1
arbinoxa tab 4 mg generic 1
ASTELIN SOLUTION 137 MCG/SPRAYazelastine hcl
BRAND 2 MPL 1 / 30 days
ASTEPRO SOLUTION 0.15 %azelastine hcl
BRAND 2 MPL 1 / 30 days
azelastine hcl solution 0.1 % generic 1 MPL 1 / 30 days
azelastine hcl solution 0.15 % generic 1 MPL 1 / 30 days
azelastine hcl solution 137 mcg/spray generic 1 MPL 1 / 30 days
carbinoxamine maleate solution 4 mg/5ml generic 1
carbinoxamine maleate tab 4 mg generic 1
cetirizine hcl solution 1 mg/ml generic 1 MDS 300 / 30 days
cetirizine hcl syrup 1 mg/ml generic 1 MDS 300 / 30 days
cetirizine hcl syrup 5 mg/5ml generic 1 MDS 300 / 30 days
clemastine fumarate syrup 0.67 mg/5ml generic 1
clemastine fumarate tab 2.68 mg generic 1
cyproheptadine hcl 4 mg generic 1
cyproheptadine hcl syrup 2 mg/5ml generic 1
cyproheptadine hcl tab 4 mg generic 1
PAGE 318 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
desloratadine tab 5 mg generic 1 MDD 1 per day
desloratadine tab disp 2.5 mg generic 1 MDD 1 per day
desloratadine tab disp 5 mg generic 1 MDD 1 per day
DEXCHLORPHENIRAMINE MALEATE SYRUP2 MG/5MLdexchlorpheniramine maleate
BRAND 3
diphenhydramine hcl cap 50 mg generic 1
diphenhydramine hcl elixir 12.5 mg/5ml generic 1
diphenhydramine hcl solution 50 mg/ml generic 1
hydroxyzine hcl solution 10 mg/5ml generic 1
hydroxyzine hcl solution 50 mg/ml generic 1
hydroxyzine hcl syrup 10 mg/5ml generic 1
hydroxyzine hcl tab 10 mg generic 1
hydroxyzine hcl tab 25 mg generic 1
hydroxyzine hcl tab 50 mg generic 1
hydroxyzine pamoate cap 100 mg generic 1
hydroxyzine pamoate cap 25 mg generic 1
hydroxyzine pamoate cap 50 mg generic 1
levocetirizine dihydrochloride solution 2.5mg/5ml
generic 1 MDS 300 / 30 days
levocetirizine dihydrochloride tab 5 mg generic 1 MDD 1 per day
olopatadine hcl solution 0.6 % generic 1
pharbedryl cap 50 mg generic 1
phenadoz suppos 12.5 mg generic 1
phenadoz suppos 25 mg generic 1
phenergan suppos 12.5 mg generic 1
phenergan suppos 25 mg generic 1
promethazine hcl solution 25 mg/ml generic 1
PAGE 319 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
promethazine hcl solution 50 mg/ml generic 1
promethazine hcl solution 6.25 mg/5ml generic 1
promethazine hcl suppos 12.5 mg generic 1
promethazine hcl suppos 25 mg generic 1
promethazine hcl syrup 6.25 mg/5ml generic 1
promethazine hcl tab 12.5 mg generic 1
promethazine hcl tab 25 mg generic 1
promethazine hcl tab 50 mg generic 1
promethegan suppos 12.5 mg generic 1
promethegan suppos 25 mg generic 1
ANTILEUKOTRIENES
montelukast sodium chew tab 4 mg generic 1 MDD 1 per day
montelukast sodium chew tab 5 mg generic 1 MDD 1 per day
montelukast sodium packet 4 mg generic 1 MDD 1 per day
montelukast sodium tab 10 mg generic 1 MDD 1 per day
zafirlukast tab 10 mg generic 1 MDD 2 per day
zafirlukast tab 20 mg generic 1 MDD 2 per day
ZYFLO CR TAB ER 12H 600 MGzileuton
BRAND 3 MDD 4 per day
BRONCHODILATORS, ANTICHOLINERGIC
ATROVENT HFA AERO SOLN 17 MCG/ACTipratropium bromide hfa
BRAND 3 MPL 2 / 30 days
INCRUSE ELLIPTA AER POW BA 62.5MCG/INHumeclidinium bromide
BRAND 2 MPL 1 / 30 days
ipratropium bromide solution 0.02 % generic 1 MDS 450 / 30 days
ipratropium bromide solution 0.03 % generic 1 MDS 30 / 30 days
ipratropium bromide solution 0.06 % generic 1
PAGE 320 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
SPIRIVA HANDIHALER CAP 18 MCGtiotropium bromide monohydrate
BRAND 2 MDD 1 per day
SPIRIVA RESPIMAT AERO SOLN 1.25MCG/ACTtiotropium bromide monohydrate
BRAND 2 MPL 1 / 30 days
SPIRIVA RESPIMAT AERO SOLN 2.5MCG/ACTtiotropium bromide monohydrate
BRAND 2 MPL 1 / 30 days
BRONCHODILATORS, SYMPATHOMIMETIC
ADRENACLICK SOLN A-INJ 0.3 MG/0.3MLepinephrine
BRAND 2 MPL 1 / claim(s)
albuterol sulfate er tab er 12h 4 mg generic 1
albuterol sulfate er tab er 12h 8 mg generic 1
albuterol sulfate nebu soln (2.5 mg/3ml)0.083%
generic 1 MDS 450 / 30 days
albuterol sulfate nebu soln (5 mg/ml) 0.5% generic 1 MPL 3 / 30 days
albuterol sulfate nebu soln (5 mg/ml) 0.5% generic 1 MPL 3 / 30 days
albuterol sulfate nebu soln 0.63 mg/3ml generic 1 MDS 450 / 30 days
albuterol sulfate nebu soln 1.25 mg/3ml generic 1 MDS 450 / 30 days
albuterol sulfate syrup 2 mg/5ml generic 1
albuterol sulfate tab 2 mg generic 1
albuterol sulfate tab 4 mg generic 1
ARCAPTA NEOHALER CAP 75 MCGindacaterol maleate
BRAND 2PA
MPL 1 / 30 days
AUVI-Q SOLN A-INJ 0.3 MG/0.3MLepinephrine
BRAND 2 MPL 1 / claim(s)
BROVANA NEBU SOLN 15 MCG/2MLarformoterol tartrate
BRAND 3PA
MDS 120 / 30 days
epinephrine hcl soln prsyr 0.1 mg/ml generic 1
epinephrine hcl solution 1 mg/ml generic 1
PAGE 321 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
EPINEPHRINE SOLN A-INJ 0.3 MG/0.3MLepinephrine
BRAND 2 MPL 1 / claim(s)
EPIPEN 2-PAK SOLN A-INJ 0.3 MG/0.3MLepinephrine
BRAND 2 MPL 1 / claim(s)
EPIPEN JR 2-PAK SOLN A-INJ 0.15MG/0.3MLepinephrine
BRAND 2 MPL 1 / claim(s)
EPIPEN JR SOLN A-INJ 0.15 MG/0.3MLepinephrine
BRAND 2 MPL 1 / claim(s)
EPIPEN SOLN A-INJ 0.3 MG/0.3MLepinephrine
BRAND 2 MPL 1 / claim(s)
FORADIL AEROLIZER CAP 12 MCGformoterol fumarate
BRAND 2PA
MDD 2 per day
levalbuterol hcl nebu soln 0.31 mg/3ml generic 1 MDS 360 / 30 days
levalbuterol hcl nebu soln 0.63 mg/3ml generic 1 MDS 360 / 30 days
levalbuterol hcl nebu soln 1.25 mg/0.5ml generic 1
levalbuterol hcl nebu soln 1.25 mg/3ml generic 1 MDS 360 / 30 days
MAXAIR AUTOHALER AERO BA 200MCG/INHpirbuterol acetate
BRAND 2 MPL 1 / 30 days
metaproterenol sulfate syrup 10 mg/5ml generic 1
metaproterenol sulfate tab 10 mg generic 1
metaproterenol sulfate tab 20 mg generic 1
PROAIR HFA AERO SOLN 108 (90 BASE)MCG/ACTalbuterol sulfate
BRAND 2 MPL 2 / 30 days
PROVENTIL HFA AERO SOLN 108 (90 BASE)MCG/ACTalbuterol sulfate
BRAND 2 MPL 2 / 30 days
SEREVENT DISKUS AER POW BA 50MCG/DOSEsalmeterol xinafoate
BRAND 2 MPL 1 / 30 days
PAGE 322 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
terbutaline sulfate solution 1 mg/ml generic 1
terbutaline sulfate tab 2.5 mg generic 1
terbutaline sulfate tab 5 mg generic 1
TWINJECT SOLN A-INJ 0.3 MG/0.3MLepinephrine
BRAND 2 MPL 1 / claim(s)
VENTOLIN HFA AERO SOLN 108 (90 BASE)MCG/ACTalbuterol sulfate
BRAND 2 MPL 2 / 30 days
XOPENEX HFA AEROSOL 45 MCG/ACTlevalbuterol tartrate
BRAND 3PA
MPL 2 / 30 days
CYSTIC FIBROSIS AGENTS
CAYSTON RECON SOLN 75 MGaztreonam lysine
BRAND 4PA
S
KALYDECO TAB 150 MGivacaftor
BRAND 4PA
S
TOBI NEBU SOLN 300 MG/5MLtobramycin
BRAND 4PA
S
tobramycin nebu soln 300 mg/5ml generic 4PA
S
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
aminophylline solution 25 mg/ml generic 1
ELIXOPHYLLIN ELIXIR 80 MG/15MLtheophylline
BRAND 1
LUFYLLIN TAB 200 MGdyphylline
BRAND 3
LUFYLLIN TAB 400 MGdyphylline
BRAND 3
theochron tab er 12h 100 mg generic 1
theochron tab er 12h 200 mg generic 1
theochron tab er 12h 300 mg generic 1
PAGE 323 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
theophylline er tab er 12h 100 mg generic 1
theophylline er tab er 12h 200 mg generic 1
theophylline er tab er 12h 300 mg generic 1
theophylline er tab er 12h 450 mg generic 1
theophylline er tab er 24h 400 mg generic 1
theophylline er tab er 24h 600 mg generic 1
PULMONARY ANTIHYPERTENSIVES
ADCIRCA TAB 20 MGtadalafil (pulmonary hypertension)
BRAND 4PA
S
LETAIRIS TAB 10 MGambrisentan
BRAND 4PA
S
LETAIRIS TAB 5 MGambrisentan
BRAND 4PA
S
REMODULIN SOLUTION 1 MG/MLtreprostinil sodium
BRAND 4PA
S
REMODULIN SOLUTION 10 MG/MLtreprostinil sodium
BRAND 4PA
S
REMODULIN SOLUTION 2.5 MG/MLtreprostinil sodium
BRAND 4PA
S
REMODULIN SOLUTION 5 MG/MLtreprostinil sodium
BRAND 4PA
S
REVATIO SOLUTION 10 MG/12.5MLsildenafil citrate (pulmonary hypertension)
BRAND 4PA
S
REVATIO TAB 20 MGsildenafil citrate (pulmonary hypertension)
BRAND 4PA
S
sildenafil citrate solution 10 mg/12.5ml generic 4PA
S
sildenafil citrate tab 20 mg generic 4PA
S
PAGE 324 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
TRACLEER TAB 125 MGbosentan
BRAND 4
PA
MDD 2 per dayS
TRACLEER TAB 62.5 MGbosentan
BRAND 4
PA
MDD 1 per dayS
VENTAVIS SOLUTION 10 MCG/MLiloprost
BRAND 4PA
S
VENTAVIS SOLUTION 20 MCG/MLiloprost
BRAND 4PA
S
RESPIRATORY TRACT AGENTS, OTHER
acetylcysteine solution 10 % generic 1
acetylcysteine solution 20 % generic 1
ADVAIR DISKUS AER POW BA 100-50MCG/DOSEfluticasone-salmeterol
BRAND 2PA
MPL 1 / 30 days
ADVAIR DISKUS AER POW BA 250-50MCG/DOSEfluticasone-salmeterol
BRAND 2PA
MPL 1 / 30 days
ADVAIR DISKUS AER POW BA 500-50MCG/DOSEfluticasone-salmeterol
BRAND 2PA
MPL 1 / 30 days
ADVAIR HFA AEROSOL 115-21 MCG/ACTfluticasone-salmeterol
BRAND 2PA
MPL 1 / 30 days
ADVAIR HFA AEROSOL 230-21 MCG/ACTfluticasone-salmeterol
BRAND 2PA
MPL 1 / 30 days
ADVAIR HFA AEROSOL 45-21 MCG/ACTfluticasone-salmeterol
BRAND 2PA
MPL 1 / 30 days
ARALAST NP RECON SOLN 1000 MGalpha1-proteinase inhibitor (human)
BRAND 4PA
S
ARALAST NP RECON SOLN 400 MGalpha1-proteinase inhibitor (human)
BRAND 4PA
S
PAGE 325 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ARALAST NP RECON SOLN 800 MGalpha1-proteinase inhibitor (human)
BRAND 4PA
S
ARALAST RECON SOLN 800 MGalpha1-proteinase inhibitor (human)
BRAND 4PA
S
benzonatate cap 100 mg generic 1 MDD 6 per day
benzonatate cap 200 mg generic 1 MDD 3 per day
BREO ELLIPTA AER POW BA 100-25MCG/INHfluticasone furoate-vilanterol
BRAND 2 MPL 1 / 30 days
BREO ELLIPTA AER POW BA 200-25MCG/INHfluticasone furoate-vilanterol
BRAND 2 MPL 1 / 30 days
cromolyn sodium nebu soln 20 mg/2ml generic 1 MDS 240 / 30 days
HYPERSAL NEBU SOLN 3.5 %sodium chloride (inhalant)
BRAND 1
ipratropium-albuterol solution 0.5-2.5 (3)mg/3ml
generic 1 MDS 540 / 30 days
NEBUSAL NEBU SOLN 6 %sodium chloride (inhalant)
BRAND 1
PROLASTIN RECON SUSP 1000 MGalpha1-proteinase inhibitor (human)
BRAND 4PA
S
PROLASTIN-C RECON SOLN 1000 MGalpha1-proteinase inhibitor (human)
BRAND 4PA
S
pulmosal nebu soln 7 % generic 1
PULMOZYME SOLUTION 1 MG/MLdornase alfa
BRAND 4PA
S
sodium chloride nebu soln 7 % generic 1
SYMBICORT AEROSOL 160-4.5 MCG/ACTbudesonide-formoterol fumarate dihydrate
BRAND 2PA
MPL 1 / 30 days
SYMBICORT AEROSOL 80-4.5 MCG/ACTbudesonide-formoterol fumarate dihydrate
BRAND 2PA
MPL 1 / 30 days
PAGE 326 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
TYZINE SOLUTION 0.05 %tetrahydrozoline hcl
BRAND 3
TYZINE SOLUTION 0.1 %tetrahydrozoline hcl
BRAND 3
XOLAIR RECON SOLN 150 MGomalizumab
BRAND 4PA
S
ZEMAIRA RECON SOLN 1000 MGalpha1-proteinase inhibitor (human)
BRAND 4PA
S
SKELETAL MUSCLE RELAXANTS
BOTOX RECON SOLN 100 UNITonabotulinumtoxina
BRAND 3 PA
BOTOX RECON SOLN 200 UNITonabotulinumtoxina
BRAND 3 PA
carisoprodol tab 250 mg generic 1
carisoprodol tab 350 mg generic 1
chlorzoxazone tab 500 mg generic 1
cyclobenzaprine hcl tab 10 mg generic 1 MDD 3 per day
cyclobenzaprine hcl tab 5 mg generic 1 MDD 3 per day
cyclobenzaprine hcl tab 7.5 mg generic 1 MDD 3 per day
DYSPORT (GLABELLAR LINES) RECON SOLN300 UNITabobotulinumtoxina (glabellar lines)
BRAND 3 PA
DYSPORT RECON SOLN 300 UNITabobotulinumtoxina
BRAND 3 PA
DYSPORT RECON SOLN 500 UNITabobotulinumtoxina
BRAND 3 PA
metaxall tab 800 mg generic 1 MDD 4 per day
metaxalone tab 800 mg generic 1 MDD 4 per day
methocarbamol tab 500 mg generic 1
methocarbamol tab 750 mg generic 1
PAGE 327 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
orphenadrine citrate er tab er 12h 100 mg generic 1 MDD 2 per day
XEOMIN RECON SOLN 50 UNITincobotulinumtoxina
BRAND 3 PA
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
estazolam tab 1 mg generic 1
estazolam tab 2 mg generic 1
eszopiclone tab 1 mg generic 1
ST
AL At least 18 yrs oldMDD 1 per day
eszopiclone tab 2 mg generic 1
ST
AL At least 18 yrs oldMDD 1 per day
eszopiclone tab 3 mg generic 1
ST
AL At least 18 yrs oldMDD 1 per day
LUNESTA TAB 1 MGeszopiclone
BRAND 3
ST
AL At least 18 yrs oldMDD 1 per day
LUNESTA TAB 2 MGeszopiclone
BRAND 3
ST
AL At least 18 yrs oldMDD 1 per day
LUNESTA TAB 3 MGeszopiclone
BRAND 3
ST
AL At least 18 yrs oldMDD 1 per day
triazolam tab 0.125 mg generic 1
triazolam tab 0.25 mg generic 1
zaleplon cap 10 mg generic 1AL At least 18 yrs old
MDD 2 per day
PAGE 328 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
zaleplon cap 5 mg generic 1AL At least 18 yrs old
MDD 1 per day
zolpidem tartrate tab 10 mg generic 1AL At least 18 yrs old
MDD 1 per day
zolpidem tartrate tab 5 mg generic 1AL At least 18 yrs old
MDD 1 per day
SLEEP DISORDERS, OTHER
modafinil tab 100 mg generic 1
PA
AL At least 16 yrs oldMDD 1 per day
modafinil tab 200 mg generic 1
PA
AL At least 16 yrs oldMDD 2 per day
NUVIGIL TAB 150 MGarmodafinil
BRAND 2
PA
AL At least 17 yrs oldMDD 1 per day
NUVIGIL TAB 200 MGarmodafinil
BRAND 2
PA
AL At least 17 yrs oldMDD 1 per day
NUVIGIL TAB 250 MGarmodafinil
BRAND 2
PA
AL At least 17 yrs oldMDD 1 per day
NUVIGIL TAB 50 MGarmodafinil
BRAND 2
PA
AL At least 17 yrs oldMDD 1 per day
ROZEREM TAB 8 MGramelteon
BRAND 3
ST
AL At least 18 yrs oldMDD 1 per day
XYREM SOLUTION 500 MG/MLsodium oxybate
BRAND 4
PA
MDS 540 / 30 daysS
PAGE 329 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL MODIFIERS
CHEMET CAP 100 MGsuccimer
BRAND 3
EXJADE TAB SOL 125 MGdeferasirox
BRAND 4PA
S
EXJADE TAB SOL 250 MGdeferasirox
BRAND 4PA
S
EXJADE TAB SOL 500 MGdeferasirox
BRAND 4PA
S
FERRIPROX TAB 500 MGdeferiprone
BRAND 3
JADENU TAB 180 MGdeferasirox
BRAND 4PA
S
JADENU TAB 360 MGdeferasirox
BRAND 4PA
S
JADENU TAB 90 MGdeferasirox
BRAND 4PA
S
kionex powder generic 1
kionex suspension 15 gm/60ml generic 1
SAMSCA TAB 15 MGtolvaptan
BRAND 4PA
S
SAMSCA TAB 30 MGtolvaptan
BRAND 4PA
S
sodium polystyrene sulfonate powder generic 1
sodium polystyrene sulfonate suspension15 gm/60ml
generic 1
sps suspension 15 gm/60ml generic 1
SYPRINE CAP 250 MGtrientine hcl
BRAND 4PA
S
PAGE 330 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ELECTROLYTE/MINERAL REPLACEMENT
AMMONIUM CHLORIDE SOLUTION 5MEQ/MLammonium chloride
BRAND 3
calcium chloride solution 10 % generic 1
calcium gluconate solution 10 % generic 1
delflex-lm/1.5% dextrose solution 346mosm/l
generic 1
DEXTROSE 5%/ELECTROLYTE #48SOLUTIONelectrolyte-48 in dextrose
BRAND 1
dextrose in lactated ringers solution 5 % generic 1
dextrose in ringers solution 5 % generic 1
DIANEAL LOW CALCIUM/1.5% DEXSOLUTION 344 MOSM/Lperitoneal dialysis solutions
BRAND 1
DIANEAL PD-2/1.5% DEXTROSE SOLUTION346 MOSM/Lperitoneal dialysis solutions
BRAND 1
effer-k effer tab 25 meq generic 1
effervescent pot chloride effer tab 25 meq generic 1
epiklor packet 20 meq generic 1
hematinic/folic acid tab 324-1 mg generic 1 MDD 1 per day
hemocyte-f tab 324-1 mg generic 1 MDD 1 per day
inpersol-lm/1.5% dextrose solution 346mosm/l
generic 1
IONOSOL-B IN D5W SOLUTIONelectrolyte-b in dextrose
BRAND 1
IONOSOL-MB IN D5W SOLUTIONelectrolyte-mb in dextrose
BRAND 1
isolyte-m in d5w solution generic 1
PAGE 331 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
ISOLYTE-P IN D5W SOLUTIONelectrolyte-p in dextrose
BRAND 1
ISOLYTE-S SOLUTIONelectrolyte-s
BRAND 1
k-effervescent effer tab 25 meq generic 1
k-prime effer tab 25 meq generic 1
k-sol solution 20 meq/15ml (10%) generic 1
k-vescent effer tab 25 meq generic 1
k-vescent packet 20 meq generic 1
kcl in dextrose-nacl solution 10-5-0.45meq/l-%-%
generic 1
kcl in dextrose-nacl solution 20-5-0.2meq/l-%-%
generic 1
kcl in dextrose-nacl solution 20-5-0.33meq/l-%-%
generic 1
kcl in dextrose-nacl solution 20-5-0.45meq/l-%-%
generic 1
kcl in dextrose-nacl solution 20-5-0.9meq/l-%-%
generic 1
kcl in dextrose-nacl solution 30-5-0.45meq/l-%-%
generic 1
kcl in dextrose-nacl solution 40-5-0.45meq/l-%-%
generic 1
KCL IN DEXTROSE-NACL SOLUTION 40-5-0.9 MEQ/L-%-%potassium chloride in dextrose & sodiumchloride
BRAND 1
KCL-LACTATED RINGERS-D5W SOLUTION20 MEQ/Lpotassium chloride in d5w lactated ringers
BRAND 1
klor-con 10 tab er 10 meq generic 1
klor-con m10 tab er 10 meq generic 1
PAGE 332 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
KLOR-CON M15 TAB ER 15 MEQpotassium chloride microencapsulatedcrystals cr
BRAND 1
klor-con m20 tab er 20 meq generic 1
klor-con packet 20 meq generic 1
klor-con sprinkle cap er 10 meq generic 1
klor-con sprinkle cap er 8 meq generic 1
klor-con tab er 8 meq generic 1
klor-con/ef effer tab 25 meq generic 1
lactated ringers solution generic 1
MAGNESIUM SULFATE SOLUTION 2GM/50MLmagnesium sulfate
BRAND 1
MAGNESIUM SULFATE SOLUTION 20GM/500MLmagnesium sulfate
BRAND 1
MAGNESIUM SULFATE SOLUTION 4GM/100MLmagnesium sulfate
BRAND 1
MAGNESIUM SULFATE SOLUTION 4GM/50MLmagnesium sulfate
BRAND 1
MAGNESIUM SULFATE SOLUTION 40GM/1000MLmagnesium sulfate
BRAND 1
magnesium sulfate solution 50 % generic 1
NORMOSOL-M IN D5W SOLUTIONelectrolyte-m in dextrose
BRAND 1
NORMOSOL-R PH 7.4 SOLUTIONelectrolyte-r (ph 7.4)
BRAND 1
nutrilyte conc generic 1
nutrilyte ii conc generic 1
PAGE 333 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
physiolyte solution generic 1
physiosol irrigation solution generic 1
PLASMA-LYTE 148 SOLUTIONelectrolyte-148
BRAND 1
PLASMA-LYTE A SOLUTIONelectrolyte-a
BRAND 1
PLASMA-LYTE-56 IN D5W SOLUTIONelectrolyte-56 in dextrose
BRAND 1
pot bicarb-pot chloride effer tab 25 meq generic 1
potassium acetate solution 2 meq/ml generic 1
potassium acetate solution 4 meq/ml generic 1
potassium bicarbonate effer tab 25 meq generic 1
potassium chloride crys er tab er 10 meq generic 1
potassium chloride crys er tab er 20 meq generic 1
potassium chloride er cap er 10 meq generic 1
potassium chloride er cap er 8 meq generic 1
potassium chloride er tab er 10 meq generic 1
potassium chloride er tab er 8 meq generic 1
POTASSIUM CHLORIDE ER TAB ER 8 MEQpotassium chloride
BRAND 1
potassium chloride in dextrose solution 20-5 meq/l-%
generic 1
potassium chloride in dextrose solution 40-5 meq/l-%
generic 1
potassium chloride in nacl solution 20-0.45meq/l-%
generic 1
potassium chloride in nacl solution 20-0.9meq/l-%
generic 1
potassium chloride in nacl solution 40-0.9meq/l-%
generic 1
PAGE 334 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
potassium chloride packet 20 meq generic 1
potassium chloride solution 0.4 meq/ml generic 1
potassium chloride solution 10 meq/100ml generic 1
potassium chloride solution 10 meq/100ml generic 1
POTASSIUM CHLORIDE SOLUTION 10MEQ/50MLpotassium chloride
BRAND 1
potassium chloride solution 2 meq/ml generic 1
potassium chloride solution 20 meq/15ml(10%)
generic 1
potassium chloride solution 20 meq/15ml(10%)
generic 1
potassium chloride solution 20 meq/50ml generic 1
potassium chloride solution 30 meq/100ml generic 1
POTASSIUM CHLORIDE SOLUTION 30MEQ/100MLpotassium chloride
BRAND 1
potassium phosphates solution 15mmole/5ml
generic 1
potassium phosphates solution 150mmole/15ml
generic 1
potassium phosphates solution 150mmole/50ml
generic 1
potassium phosphates solution 45mmole/15ml
generic 1
ringers irrigation solution generic 1
ringers solution generic 1
sodium acetate solution 2 meq/ml generic 1
sodium acetate solution 4 meq/ml generic 1
sodium chloride 0.9 % generic 1
sodium chloride solution 0.45 % generic 1
PAGE 335 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
sodium chloride solution 0.9 % generic 1
sodium chloride solution 2.5 meq/ml generic 1
sodium chloride solution 3 % generic 1
sodium chloride solution 4 meq/ml generic 1
sodium chloride solution 5 % generic 1
sodium phosphate solution 3 mmole/ml generic 1
tis-u-sol solution generic 1
tpn electrolytes conc generic 1
tpn electrolytes solution generic 1
ULTRABAG/DIANEAL PD-2/1.5% DEXSOLUTION 346 MOSM/Lperitoneal dialysis solutions
BRAND 1
ULTRABAG/DIANEAL/1.5% DEXTROSESOLUTION 344 MOSM/Lperitoneal dialysis solutions
BRAND 1
AMINOSYN II IN DEXTROSE 25% SOLUTION4.25 %amino acid infusion in d25w
BRAND 3
CLINIMIX E/DEXTROSE (5/20) SOLUTION 5%amino acid electrolyte w/ calcium infusionin d20w
BRAND 3
CLINIMIX/DEXTROSE (2.75/5) SOLUTION2.75 %amino acid infusion in d5w
BRAND 3
CLINIMIX/DEXTROSE (4.25/10) SOLUTION4.25 %amino acid infusion in d10w
BRAND 3
CLINIMIX/DEXTROSE (4.25/25) SOLUTION4.25 %amino acid infusion in d25w
BRAND 3
CLINIMIX/DEXTROSE (4.25/5) SOLUTION4.25 %amino acid infusion in d5w
BRAND 3
PAGE 336 LAST UPDATED 09/2016
PRODUCT DESCRIPTION BRAND/GE TIER LIMITS & RESTRICTIONS
CLINIMIX/DEXTROSE (5/25) SOLUTION 5 %amino acid infusion in d25w
BRAND 3
DRISDOL CAP 50000 UNITergocalciferol
BRAND 0
ergocalciferol cap 50000 unit generic 0
folic acid 1 mg generic 0GL FemaleAL 12 to 55 yrs old
folic acid tab 1 mg generic 0GL FemaleAL 12 to 55 yrs old
lactated ringers solution generic 1
vitamin d (ergocalciferol) cap 50000 unit generic 0
PAGE 337 LAST UPDATED 09/2016
Index of Covered Drugs
11st Choice Lancets Super Thin 2151st Choice Lancets Thin 2151st Choice Lancets Ultra Thin 2151st Choice Pen Needles 2151st Tier Unifine Pentips 215,2161st Tier Unifine Pentips Plus 2161st Tier Unilet ComforTouch 216
AA-Hydrocort 170Abacavir Sulfate 98,100Abacavir Sulfate-Lamivudine 99Abacavir Sulfate-Lamivudine-Zidovudine 98,99Abacavir-Dolutegravir-Lamivudine 100Abatacept 205Abciximab 119Abelcet 50Abiraterone Acetate 63AbobotulinumtoxinA 327AbobotulinumtoxinA (Glabellar Lines) 327Abraxane 66Acamprosate Calcium 17Acarbose 105Accu-Chek Active Glucose Cont 216Accu-Chek Aviva 216Accu-Chek Comfort Curve 216Accu-Chek Comfort Curve Linear 216Accu-Chek Compact Blue Control 216Accu-Chek Compact Plus Control 216Accu-Chek FastClix Lancets 217Accu-Chek Instant Control 217Accu-Chek Multiclix Lancets 217Accu-Chek Safe-T Pro Lancets 217Accu-Chek SmartView Control 217Accu-Chek Soft Touch Lancets 217Accu-Chek Softclix Lancet Dev 217Accu-Chek Softclix Lancets 217Accusure Insulin Syringe 217Accutrend Glucose Control 217
Acebutolol HCl 125Acetaminophen w/ Codeine 11Acetazolamide 134Acetazolamide Sodium 134Acetic Acid 20Acetic Acid (Otic) 315Acetone (Urine) Test 229,258Acetylcysteine 325Acitretin 151,156Actemra 207,208Acti-Lance 28G 218Acti-Lance Lite Lancets 28G 218Acti-Lance Special Lancets 17G 218Acti-Lance Universal 23G 218Actimmune 208Actonel 212Actoplus Met 105Acura Control 218Acyclovir 103Acyclovir Topical 103Adacel 208Adagen 159Adalimumab 204Adapalene 151,154Adapalene-Benzoyl Peroxide 154Adcetris 78Adcirca 324Adefovir Dipivoxil 93Adjustable Lancing Device 218Adrenaclick 321Advair Diskus 325Advair HFA 325Advance Intuition Control 218Advicor 137Advocate Control Solution 218Advocate Insulin Pen Needles 218Advocate Insulin Syringe 218,219Advocate Lancets 219Advocate Lancets 30G 219Advocate Lancing Device 219Advocate Rapid-Safe Lancing 219
Advocate Redi-Code+ Control 219Advocate Safety Lancets 219Advocate Safety Lancets 26G 219AF Lancets Super Thin 220Afinitor 74Afluria 208Afluria Preservative Free 208Agalsidase beta 160AgaMatrix Control 220AgaMatrix Ultra-Thin Lancets 220Aggrenox 118Agriflu 208Albendazole 79Albenza 79Albuterol Sulfate 321,322,323Alcaftadine 311Alclometasone Dipropionate 170Aldesleukin 71Aldurazyme 159Alemtuzumab 67Alendronate Sodium 212Alendronate Sodium-Cholecalciferol 213Alfuzosin HCl 167Alglucosidase Alfa 160Alimta 64Alinia 79Aliskiren Fumarate 133Alitretinoin 79Alkeran 60Allegra 318Allopurinol 54Almotriptan Malate 55Alocril 312Alomide 312Alora 180Alosetron HCl 164Aloxi 49Alpha1-Proteinase Inhibitor (Human) 325,326,327Alprazolam 104Alrex 312Altabax 20
Alternate Site Lancing Device 220Altoprev 136Altretamine 61Alvesco 316Alvimopan 162Amantadine HCl 81Ambenonium Chloride 58AmBisome 50Ambrisentan 324Amcinonide 170Amikacin Sulfate 19Amiloride & Hydrochlorothiazide 131Amiloride HCl 134Amino Acid Electrolyte w/ Calcium Infusion inD20W 336Amino Acid Infusion in D10W 336Amino Acid Infusion in D25W 336,337Amino Acid Infusion in D5W 336Aminophylline 323Aminosalicylic Acid 59Aminosyn II in Dextrose 25% 336Amiodarone HCl 123,124Amiodarone HCl (Bulk) 220Amitiza 164Amitriptyline HCl 47Amlodipine Besylate 127Amlodipine Besylate-Benazepril HCl 131Ammonium Chloride 331Amoxapine 47Amoxicillin 27Amoxicillin & Pot Clavulanate 27,28Amphetamine-Dextroamphetamine 140,141Amphotec 50Amphotericin B 51Amphotericin B Cholesteryl Sulfate Complex 50Amphotericin B Lipid 50Amphotericin B Liposome 50Ampicillin 28Ampicillin & Sulbactam Sodium 28Ampicillin Sodium 28Ampyra 149
Anadrol-50 179Anagrelide HCl 115Anakinra 204Anastrozole 73Androderm 179,180Androxy 180Anidulafungin 51Anti-Stick Insulin Syringe 220Anti-Thymocyte Globulin (Rabbit), LymphocyteImmune Globulin 207Antipyrine-Benzocaine 315Anzemet 49Apidra 109Apidra SoloStar 109Apixaban 112Apokyn 83Apomorphine Hydrochloride 83Apraclonidine HCl 313,314Aprepitant 50Apriso 211Aptivus 101Aqua Lance Adjustable Lancing 220Aralast 326Aralast NP 325,326Aranesp (Albumin Free) 115,116Arcalyst 208Arcapta Neohaler 321Aredia 212Arestin 150Arformoterol Tartrate 321Arimidex 73Aripiprazole 86,87Armodafinil 329Aromasin 73Arranon 66Arsenic Trioxide 72Artemether-Lumefantrine 80Artificial Tear Insert 311Arzerra 78Asacol 211Asacol HD 211
Ascensia Autodisc Control 220Ascensia Autodisc Controls 220Asenapine Maleate 90Asmanex 120 Metered Doses 316Asmanex 14 Metered Doses 316Asmanex 30 Metered Doses 316Asmanex 60 Metered Doses 316Asmanex 7 Metered Doses 316Asparaginase 68Asparaginase Erwinia Chrysanthemi 69Aspirin-Dipyridamole 118Assure 3 Control 220Assure 4 Control Level 1 & 2 220Assure Comfort Lancets 28G 220Assure Comfort Lancets 30G 220Assure Dose Control 220Assure Dose Norm/High Control 221Assure Haemolance Plus High 221Assure Haemolance Plus Low 221Assure Haemolance Plus Micro 221Assure Haemolance Plus Normal 221Assure Haemolance Plus Ped 221Assure ID Insulin Safety Syr 221Assure Lance Lancets 221Assure Lance Lancets 21G 221Assure Lance Plus Safety 25G 221Assure Lance Plus Safety 30G 221Assure Lancets 221Assure Prism Control Level 1&2 221Assure Pro Control Level 1 & 2 221Astelin 318Astepro 318Atazanavir Sulfate 102Atelvia 212Atenolol 125Atenolol & Chlorthalidone 131Atgam 206Atomoxetine HCl 146,147Atorvastatin Calcium 136Atovaquone 80,222Atovaquone (Bulk) 222
Atovaquone-Proguanil HCl 80Atripla 97Atropine Sulfate 161Atrovent HFA 320Auranofin 208Aurora Healthcare Lancets 222Aurora Lancet Super Thin 30G 222Aurora Lancet Thin 23G 222Aurora Pen Needles 222Aurora Unifine Pentips 222Auto-Lancet 222Auto-Lancet Mini 222Autolet Impression 222Autolet Lancing Device 222Autolet Mini 222Auvi-Q 321Avanafil 169Avandia 105Avastin 78Avelox 31Avelox ABC Pack 31Avodart 167Avonex 149Avonex Pen 149Avonex Prefilled 149Axert 55Axitinib 75Aygestin 193Azacitidine 66,72Azactam in Dextrose 26Azasan 202,203AzaSite 30Azathioprine 202,203Azathioprine Sodium 203Azelaic Acid 154Azelaic Acid (Acne) 152Azelastine HCl 318Azelastine HCl (Ophth) 312Azelex 152Azilect 84,85Azilsartan Medoxomil 120
Azithromycin 30,31Azithromycin (Ophth) 30Azopt 313Aztreonam 27Aztreonam in Dextrose 26Aztreonam Lysine 323
BBacitracin 20Bacitracin (Ophthalmic) 20Bacitracin-Polymyxin-Neomycin HC 154Baclofen 91,92Balsalazide Disodium 211Banzel 38Baraclude 93Basiliximab 208Bayer Breeze 2 Control 222Bayer Contour 223Bayer Contour Next Control 223Bayer Microlet 2 Lancing Devic 223Bayer Microlet Lancets 223BD AutoShield 223BD Insulin Syr Ultrafine II 223BD Insulin Syringe 224BD Insulin Syringe Half-Unit 223BD Insulin Syringe MicroFine 223,224BD Insulin Syringe Ultrafine 224,225BD Integra Insulin Syringe 225BD Integra Syringe 225BD Lancet Device 225BD Lancet Ultrafine 30G 225BD Lancet Ultrafine 33G 225BD Microtainer Lancets 225BD Pen Needle Mini U/F 225BD Pen Needle Nano U/F 226BD Pen Needle Short U/F 226BD Pen Needle Ultrafine 226BD Safety-Lok Insulin Syringe 226BD SafetyGlide Insulin Syringe 226Becaplermin 156Beclomethasone Dipropionate 318
Belatacept 205Benazepril & Hydrochlorothiazide 131,132Benazepril HCl 121Bendamustine HCl 63Benicar 120Benzonatate 326Benzoyl Peroxide 152,154,155,156Benzoyl Peroxide-Erythromycin 152Benztropine Mesylate 81Benzyl Alcohol (Pediculicide) 81Bepotastine Besilate 312Bepreve 312Besifloxacin HCl 31Besivance 31Betaine 160Betamethasone Dipropionate (Topical) 171Betamethasone Dipropionate Augmented 170,171Betamethasone Valerate 170,171Betaseron 149Betaxolol HCl 125Betaxolol HCl (Ophth) 313Bethanechol Chloride 168Bevacizumab 78Bexarotene 79Bexarotene (Topical) 79Bexxar 78Beyaz 181Bicalutamide 63BiCNU 60BiDil 132Biltricide 79Bimatoprost 314Bisoprolol Fumarate 125Bleomycin Sulfate 66Blood GlucoseCalibration216,217,218,219,220,221,222,223,229,232,233,237,240,241,242,243,245,246,247,249,250,251,256,263,266,267,268,272,273,274,276,278,281,282,284,288,290,291,292,293,297,298,299,305,306,308,311Blood Glucose Monitoring Supplies 226,297,298
Boceprevir 97Boniva 212Boostrix 208Bortezomib 72Bosentan 325Bosulif 74Bosutinib 74Botox 327Brentuximab Vedotin 78Breo Ellipta 326Brevicon (28) 181Brilinta 118Brimonidine Tartrate 313Brimonidine Tartrate-Timolol Maleate 314Brintellix 43,44Brinzolamide 313Bromfenac Sodium (Ophth) 312Bromocriptine Mesylate 83Bromocriptine Mesylate (Diabetes) 105Brovana 321Budesonide 211Budesonide (Inhalation) 316,317Budesonide (Nasal) 316,318Budesonide-Formoterol Fumarate Dihydrate 326Bullseye Mini Safety Lancets 226Bullseye Safety Lancets 226Bumetanide 134Buphenyl 159Buprenorphine 6Buprenorphine HCl 17Buprenorphine HCl-Naloxone HCl Dihydrate 17,18Bupropion HCl 42,43Bupropion HCl (Smoking Deterrent) 18Buspirone HCl 103Busulfan 60,62Busulfex 60Butalbital-Acetaminophen-Caffeine 147,148Butalbital-Acetaminophen-Caffeine w/ Codeine 11Butalbital-Aspirin-Caffeine 147Butalbital-Aspirin-Caffeine w/Cod 11,12Butenafine HCl 52
Butoconazole Nitrate (One Dose) 52Butorphanol Tartrate 12Butrans 6Byetta 10 MCG Pen 105Byetta 5 MCG Pen 105Bystolic 125
CCabazitaxel 70Cabergoline 199Cabozantinib S-Malate 75Cafergot 54Calcipotriene 153Calcipotriene-BetamethasoneDipropionate 153,157Calcitonin (Salmon) 212Calcitriol 212Calcitriol (Topical) 153,158Calcium Acetate (Phosphate Binder) 169,170Calcium Chloride (Dihydrate) 331Calcium Gluconate 331Campath 67Campral 17Camptosar 67Canagliflozin 107Canasa 211Cancidas 51Candesartan Cilexetil 120Cantil 161Capastat Sulfate 59Capecitabine 64,65,66Caprelsa 75Capreomycin Sulfate 59Captopril 121Carafate 165Carbaglu 159Carbamazepine 39,40Carbamazepine (Antipsychotic) 104Carbidopa 84Carbidopa-Levodopa 84Carbidopa-Levodopa-Entacapone 81,82,83
Carbinoxamine Maleate 318Carboplatin 67CardioCom Lancing Device 226CareFine Pen Needles 226,227CareOne Advanced Lancing Dev 227CareOne Insulin Syringe 227CareOne Lancet Thin 23G 227CareOne Lancet Ultra Thin 28G 227CareOne UltiGuard Insulin Syr 227,228CareOne Unifine Pentips 228CareOne Unifine Pentips Plus 228,229CareSens Control A 229Carfilzomib 76Carglumic Acid 159Carimune NF 206Carisoprodol 327Carmustine 60Carteolol HCl (Ophth) 314Carvedilol 125Casodex 63Caspofungin Acetate 51Caya 229Cayston 323Cedax 23CeeNU 60Cefaclor 23Cefaclor Monohydrate 23Cefadroxil 23,24Cefazolin Sodium 24Cefdinir 24Cefditoren Pivoxil 24,26Cefepime HCl 24Cefixime 24,26Cefotaxime Sodium 24Cefotetan Disodium 24Cefoxitin Sodium 24,25Cefpodoxime Proxetil 25Cefprozil 25Ceftaroline Fosamil 26Ceftazidime 25,26Ceftibuten 23,25
Ceftin 25Ceftriaxone Sodium 25Cefuroxime Axetil 25Cefuroxime Sodium 25,26Celecoxib 4CellCept Intravenous 203Celontin 35Cenestin 181Cephalexin 26Cerezyme 159Certolizumab Pegol 203Cerubidine 67Cervical Caps 245,278Cesamet 50Cetirizine HCl 318Cetraxal 31Cetuximab 78Cevimeline HCl 150Chantix 18Chantix Continuing Month Pak 18Chantix Starting Month Pak 18Chek-Stix Control 229Chemet 330Chemstrip K 229Chlorambucil 61Chloramphenicol Sodium Succinate 20Chlordiazepoxide HCl-Clidinium Bromide 162Chlorhexidine Gluconate (Mouth-Throat) 150,151Chloroquine Phosphate 80Chlorothiazide 135Chlorpromazine HCl 85Chlorpropamide 105Chlorthalidone 135Chlorzoxazone 327Cholbam 162Cholestyramine 137,138Cholestyramine Light 137,138Cholic Acid 162Choline & Mag Salicylate 4Chorionic Gonadotropin 176,178Cialis 167
Ciclesonide 316Ciclopirox 51Ciclopirox & Vitamin E 51Ciclopirox Olamine 51Cidofovir 92Cilostazol 118Cimetidine 163Cimetidine HCl 163Cimzia 203Cimzia Prefilled 203Cimzia Starter Kit 203Cinacalcet HCl 199Cipro HC 315Cipro in D5W 32Ciprodex 315Ciprofloxacin 32Ciprofloxacin HCl 32Ciprofloxacin HCl (Ophth) 32Ciprofloxacin HCl (Otic) 31,32Ciprofloxacin in D5W 32Ciprofloxacin-Ciprofloxacin HCl 32Ciprofloxacin-Dexamethasone 315Ciprofloxacin-Hydrocortisone 315Cisplatin 67Citalopram Hydrobromide 44Cladribine 65Clarithromycin 30Cleanlet Lancets 28G 229Clemastine Fumarate 318Clever Chek Lancets 229Clever Choice Glucose Control 229Clickfine Pen Needles 229Climara Pro 182Clindamycin HCl 20Clindamycin Palmitate Hydrochloride 20Clindamycin Phosphate 21,229Clindamycin Phosphate (Bulk) 229Clindamycin Phosphate (Topical) 20,21,153Clindamycin Phosphate Vaginal 20Clindamycin Phosphate-Benzoyl Peroxide 153
Clindamycin Phosphate-Benzoyl Peroxide(Refrigerate) 153,155Clindamycin Phosphate-Tretinoin 158,159Clinimix E/Dextrose (5/20) 336Clinimix/Dextrose (2.75/5) 336Clinimix/Dextrose (4.25/10) 336Clinimix/Dextrose (4.25/25) 336Clinimix/Dextrose (4.25/5) 336Clinimix/Dextrose (5/25) 337Clobazam 36,37Clobetasol Propionate 171,172Clobetasol Propionate Emollient Base 171Clocortolone Pivalate 171Cloderm 171Cloderm Pump 171Clofarabine 65Clolar 65Clomipramine HCl 47Clonazepam 104Clonidine HCl 119Clopidogrel Bisulfate 118Closercare 229Clotrimazole 51Clotrimazole (Topical) 51Clotrimazole w/ Betamethasone 153Clozapine 91CoaguChek Lancets 229Coartem 80Cobicistat 100Codeine Sulfate 12Colchicine 54Colchicine w/ Probenecid 54Colcrys 54Colesevelam HCl 139Colestipol HCl 138Collagenase 156Coly-Mycin S 315Combigan 314Cometriq (100 mg Daily Dose) 75Cometriq (140 mg Daily Dose) 75Cometriq (60 mg Daily Dose) 75
Comfort Assist Insulin Syringe 230Comfort Assured Lancets 28G 230Comfort Assured Lancets 33G 230Comfort EZ Insulin Syringe 230,231Comfort EZ Pen Needles 232Comfort Lancets 232Complera 97Conjugated Estrogens-MedroxyprogesteroneAcetate 190,191Control 232Copaxone 149Copper (IUD) 275Cordran 171Cortisone Acetate 172Cortisporin 154,315Cortisporin-TC 315Cosmegen 67Coumadin 112Creon 159Crestor 136Crixivan 101Crizotinib 77Cromolyn Sodium 326Cromolyn Sodium (Ophth) 312Crotamiton 80Cubicin 21Cuprimine 168CVS Insulin Syringe 232CVS Lancets 21G 233CVS Lancets Micro Thin 33G 233CVS Lancets Original 233CVS Lancets Thin 233CVS Lancets Thin 26G 233CVS Lancets Ultra Thin 30G 233CVS Lancing Device 233CVS Ultra Thin Lancets 233Cyclessa 182Cyclobenzaprine HCl 327Cyclophosphamide 60,61Cycloserine 59,60CycloSERINE 59
Cycloset 105Cyclosporine 203Cyclosporine (Ophth) 311Cyclosporine Modified (ForMicroemulsion) 203,204Cyproheptadine HCl 318Cystadane 160Cystagon 168Cysteamine Bitartrate 168Cytarabine 65Cytarabine Liposome 65
DD.H.E. 45 55Dabigatran Etexilate Mesylate 115Dacarbazine 61Daclizumab (Multiple Sclerosis) 150Dacogen 67Dactinomycin 67Dalfampridine 149Dalteparin Sodium 113,114Danazol 180Dantrolene Sodium 91,92Dapsone 59Daptomycin 21Daraprim 80Darbepoetin Alfa 115,116Darifenacin Hydrobromide 166Darunavir Ethanolate 101,102Dasatinib 76Daunorubicin Citrate Liposome 61Daunorubicin HCl 67DaunoXome 61Decitabine 67Deferasirox 330Deferiprone 330Degarelix Acetate 200Delavirdine Mesylate 98Demeclocycline HCl 34Denavir 103Denileukin Diftitox 71
Denosumab 214Depo-Estradiol 182Depo-Medrol 172Depo-Provera 193Depo-SubQ Provera 104 193DepoCyt 65Descovy 98Desipramine HCl 47,48Desloratadine 319Desmopressin Acetate 177,179Desmopressin Acetate Spray 177Desmopressin Acetate Spray Refrigerated 177Desogen 182Desogestrel & EthinylEstradiol 180,182,183,185,190,191Desogestrel-Ethinyl Estradiol(Biphasic) 181,182,185,188,190,192Desogestrel-Ethinyl Estradiol(Triphasic) 181,182,192Desonide 172,174Desoximetasone 172Desoxyn 141Desvenlafaxine Succinate 45Detrol LA 166Dexamethasone 170,172Dexamethasone (Ophth) 313Dexamethasone Intensol 172Dexamethasone Sodium Phosphate 172Dexamethasone Sodium Phosphate (Ophth) 312Dexchlorpheniramine Maleate 319Dexilant 165Dexlansoprazole 165Dexmethylphenidate HCl 143Dextroamphetamine Sulfate 141,142Dextromethorphan HBr-Quinidine Sulfate 147Dextrose 5%/Electrolyte #48 331Dextrose in Lactated Ringers 331Dextrose in Ringers 331Dianeal Low Calcium/1.5% Dex 331Dianeal PD-2/1.5% Dextrose 331Diaphragm Arc-Spring 229,274
Diaphragm Coil Spring 274Diaphragm Flat Spring 275Diaphragm Wide Seal 310Diaphragms 273Diastar Easy Test II Lancets 233Diastar Easy Test Lancets 233Diastat AcuDial 36Diastat Pediatric 36DiaTrue Control Level 1 233DiaTrue Control Level 2 233Diazepam 104Diazepam (Anticonvulsant) 36Diazoxide 109Dibenzyline 119Diclofenac Epolamine 4Diclofenac Potassium 4Diclofenac Sodium 4Diclofenac Sodium (Actinic Keratoses) 154,156Diclofenac Sodium (Ophth) 312Diclofenac Sodium (Topical) 154,158Diclofenac w/ Misoprostol 4Dicloxacillin Sodium 28Dicyclomine HCl 162Didanosine 98,99,100Difenoxin w/ Atropine 162Differin 154Dificid 30Diflorasone Diacetate 170,173Diflunisal 4Difluprednate 312Digoxin 132Dihydroergotamine Mesylate 55Dilantin 39Dilantin Infatabs 39Diltiazem HCl 127,128,129Diltiazem HCl Coated Beads 127,128,129Diltiazem HCl Extended ReleaseBeads 127,129,130Dipentum 211Diphenhydramine HCl 319Diphenoxylate w/ Atropine 162
Dipyridamole 118,119Disopyramide Phosphate 123Disulfiram 17Divalproex Sodium 36Divigel 182Docefrez 67Docetaxel 67,68,72DOCEtaxel 68Dofetilide 124Dolasetron Mesylate 49Donepezil Hydrochloride 41Dornase Alfa 326Dorzolamide HCl 314Dorzolamide HCl-Timolol Maleate 314Doxazosin Mesylate 119,120Doxepin HCl 48Doxepin HCl (Antipruritic) 156,159Doxercalciferol 212,213Doxil 68Doxorubicin HCl 66,68DOXOrubicin HCl 68Doxorubicin HCl Liposomal 68,70Doxycycline (Monohydrate) 33,34Doxycycline Hyclate 34Drisdol 337Dronabinol 50Dronedarone HCl 123Droplet Lancets Ultra Thin 30G 233Droplet Lancing Device 233Drospirenone-EthinylEstradiol 182,183,185,187,188,189,191,192,193Drospirenone-Ethinyl Estradiol-LevomefolateCalcium 181,191Droxia 65Drug Mart Lancets Thin 26G 233Drug Mart Lancets Ultra Thin 233Drug Mart Lancing Device 234Drug Mart On-The-Go Lancet 30G 234Drug Mart Ultra Comfort Syr 234Drug Mart Unifine Pentips 234,235Drug Mart Unifine Pentips Plus 235
Drug Mart Unilet Lancets 28G 235Drug Mart Unilet Lancets 30G 235Duane Reade Lancet Altern Site 235Duane Reade Lancet Super Thin 235Duane Reade Lancet Ultra Thin 235Duane Reade Unifine Pentips 235Duloxetine HCl 148Durezol 312Dutasteride 167Dyphylline 323Dyrenium 134,135Dysport 327Dysport (Glabellar Lines) 327
EE-Z Ject Lancet Micro-Thin 33G 235E-Z Ject Lancet Super Thin 30G 235E-Z Ject Lancets 236E-Z Ject Lancets 21G 235E-Z Ject Lancets Thin 26G 236E.E.S. 400 30E.E.S. Granules 30Easy Comfort Insulin Syringe 236Easy Comfort Lancets 236Easy Comfort Pen Needles 236,237Easy Mini Lancing Device 237Easy Plus Control 237Easy Plus II Control 237Easy Step Control 237Easy Talk Control 237Easy Touch Control High & Low 237Easy Touch HealthPro Control 237Easy Touch Insulin Safety Syr 237,238Easy Touch Insulin Syringe 238,239Easy Touch Lancets 21G 239Easy Touch Lancets 23G 239Easy Touch Lancets 26G 239Easy Touch Lancets 26G/Twist 239Easy Touch Lancets 28G 239Easy Touch Lancets 28G/Twist 239Easy Touch Lancets 30G 239
Easy Touch Lancets 30G/Twist 239Easy Touch Lancets 32G 239Easy Touch Lancets 32G/Twist 239Easy Touch Lancets 33G/Twist 239Easy Touch Lancing Device 240Easy Touch Pen Needles 240Easy Touch Safety Lancets 21G 240Easy Touch Safety Lancets 23G 240Easy Touch Safety Lancets 26G 240Easy Touch Safety Lancets 28G 240Easy Trak Control 240Easy Twist & Cap Lancets 241EasyGluco Control 241EasyMax 15 Level 1 Control 241EasyMax 15 Level 2 Control 241EasyMax Control 241Echothiophate Iodide 314Eclipse Control 241Econazole Nitrate 51Edarbi 120Edecrin 134Edurant 97Efavirenz 98Efavirenz-Emtricitabine-Tenofovir DisoproxilFumarate 97Effient 119Elaprase 160Electrolyte-148 334Electrolyte-48 in Dextrose 331Electrolyte-56 in Dextrose 334Electrolyte-A 334Electrolyte-B in Dextrose 331Electrolyte-M in Dextrose 331,333Electrolyte-MB in Dextrose 331Electrolyte-P in Dextrose 332Electrolyte-R (PH 7.4) 333Electrolyte-S 332Elelyso 160Element Compact Control 2 241Element Compact Control 3 241Element Control 241
Element Plus Control 241Elestrin 183Eletriptan Hydrobromide 56Elidel 154Eligard 199Eliquis 112Elixophyllin 323Ella 193Elmiron 168Eloxatin 68Elspar 68Eltrombopag Olamine 118Elvitegravir-Cobicistat-Emtricitabine-Tenofovir 97Elvitegravir-Cobicistat-Emtricitabine-TenofovirAlafenamide 97Emadine 312Embeda 6,7Embrace Control 241Embrace Evo Control Level 1 242Embrace Evo Control Level 2 242Embrace Lancets Ultra Thin 30G 242Embrace Pro Glucose Control 242Emcyt 64Emedastine Difumarate 312Emend 50Emsam 43Emtricitabine 99Emtricitabine-Rilpivirine-Tenofovir AlafenamideFumarate 98Emtricitabine-Rilpivirine-Tenofovir DisoproxilFumarate 97Emtricitabine-Tenofovir Alafenamide Fumarate 98Emtricitabine-Tenofovir Disoproxil Fumarate 99Emtriva 99Enablex 166Enalapril Maleate 121,122Enalapril Maleate & Hydrochlorothiazide 132Enbrel 203Enbrel SureClick 203Enfuvirtide 100Enjuvia 183
Enoxaparin Sodium 113Entacapone 82Entecavir 93Entereg 162Envision Control 242Enzalutamide 63Epclusa 94Epiduo 154Epinastine HCl (Ophth) 312Epinephrine 321,322,323EPINEPHrine 322Epinephrine HCl 321EpiPen 322EpiPen 2-Pak 322EpiPen Jr 322EpiPen Jr 2-Pak 322Epirubicin HCl 69Epivir 99Epivir HBV 93Eplerenone 135Epoetin Alfa 116,117,118Epogen 116Eprosartan Mesylate 120,121Epzicom 99EQL Color Lancets 21G 242EQL Color Lancets Micro 33G 242EQL Insulin Syringe 242,243EQL Short Pen Needle 243EQL Super Thin Lancets 30G 243EQL Thin Lancets 26G 243EQL Ultra Comfort Insulin Syr 243EQL Ultra Short Pen Needle 243Equetro 104Eraxis 51Erbitux 78Ergocalciferol 337Ergoloid Mesylates 41Ergomar 55Ergotamine Tartrate 55Ergotamine w/ Caffeine 54Eribulin Mesylate 69
Erivedge 75Erlotinib HCl 77Ertaczo 51Ertapenem Sodium 27Erwinaze 69Ery-Tab 30EryPed 200 30EryPed 400 31Erythromycin (Acne Aid) 30,31Erythromycin (Ophth) 31Erythromycin Base 30,31Erythromycin Ethylsuccinate 30,31Escitalopram Oxalate 44Esomeprazole Magnesium 165,166Estazolam 328Esterified Estrogens 187Estrace 183Estraderm 183Estradiol 180,182,183,184,187,188,192Estradiol Acetate Vaginal 184,185Estradiol Cypionate 182Estradiol Vaginal 183Estradiol Valerate 184Estradiol Valerate-Dienogest 188Estradiol-Levonorgestrel 182Estramustine Phosphate Sodium 64Estrasorb 184Estrogel 184Estrogens, Conjugated 190Estrogens, Conjugated Synthetic A 181Estrogens, Conjugated Synthetic B 183Estrogens, Conjugated Vaginal 190Estropipate 184Estrostep Fe 184Eszopiclone 328Etanercept 203Ethacrynic Acid 134Ethambutol HCl 59Ethionamide 60Ethosuximide 35Ethotoin 40
Ethynodiol Diacet & Eth Estrad 185,193Etidronate Disodium 213Etodolac 4Etonogestrel 194,195Etonogestrel-Ethinyl Estradiol 189Etopophos 73Etoposide 73,74Etoposide Phosphate 73Etravirine 97Eurax 80Evamist 184EvenCare Control Low/High 243EvenCare G2 Low/High Control 243EvenCare G3 Low/High Control 243Everolimus 74Everolimus (Immunosuppressant) 206Evista 195Evolution Control 243Exalgo 7Exel Comfort Point Insulin Syr 243,244Exel Comfort Point Pen Needle 244Exelderm 51,52Exemestane 73Exenatide 105Exjade 330Extavia 149Ez Smart Blood Glucose Lancets 244EZ-Lets Lancets 21G 244EZ-Lets Lancets 26G 245EZ-Lets Lancets 28G 245EZ-Lets Lancets 30G 245Ezetimibe 139Ezetimibe-Simvastatin 139Ezogabine 35
FFabrazyme 160Factive 32Famciclovir 103Famotidine 163Famotidine in NaCl 163
Famotidine Premixed 163Fanapt 87,88Fanapt Titration Pack 88Fareston 64Faslodex 64Febuxostat 54Felbamate 38Felodipine 129Femara 73FemCap 245Femcon Fe 184Femring 184,185Fenofibrate 136Fenofibrate Micronized 135Fenoprofen Calcium 4Fentanyl 7Fentanyl Citrate 12Ferriprox 330Ferrous Fumarate-Folic Acid 331Fesoterodine Fumarate 167Fexofenadine HCl 318Fidaxomicin 30Fifty50 Control 2.0 245Fifty50 Lancing Device 245Fifty50 Pen Needles 245Fifty50 Safety Seal Lancets 245Fifty50 Superior Comfort Syr 245Filgrastim 117Finacea 154Finasteride 167Finasteride (Alopecia) 154Fine 30 245Fingerstix Lancets 245Fingolimod HCl 150Firmagon 200Flavoxate HCl 166Flecainide Acetate 123Flector 4Flovent Diskus 317Flovent HFA 317Floxuridine 65
Fluarix 209Fluarix Quadrivalent 209Flucelvax 209Fluconazole 52Flucytosine 52Fludara 69Fludarabine Phosphate 69,70Fludrocortisone Acetate 173Flulaval 209Flulaval Quadrivalent 209Flunisolide (Nasal) 317Fluocinolone Acetonide 173Fluocinolone Acetonide (Otic) 315Fluocinonide 173Fluocinonide Emulsified Base 173Fluorometholone (Ophth) 312,313Fluorouracil 64,65Fluorouracil (Topical) 154Fluoxetine HCl 44Fluoxetine HCl (PMDD) 44,46Fluoxymesterone 180Fluphenazine HCl 85Flurandrenolide 171Flurbiprofen 4,5Flurbiprofen Sodium 312Flutamide 63Fluticasone Furoate-Vilanterol 326Fluticasone Propionate 173,246Fluticasone Propionate HFA 317Fluticasone Propionate (Bulk) 246Fluticasone Propionate (Inhalation) 317Fluticasone Propionate (Nasal) 317Fluticasone Propionate HFA 317Fluticasone-Salmeterol 325Fluvastatin Sodium 136Fluvirin 209Fluvirin Preservative Free 209Fluvoxamine Maleate 44Fluzone 210Fluzone High-Dose 209Fluzone Pediatric PF 209
Fluzone Preservative Free 209,210Fluzone Quadrivalent 210FML 313FML Forte 312Folic Acid 337Folotyn 65Fondaparinux Sodium 113FORA Control 246FORA Lancets 246FORA Lancing Device 246ForaCare GDH Control 246Foradil Aerolizer 322Formoterol Fumarate 322Forteo 213FortisCare Control 246Fosamax Plus D 213Fosamprenavir Calcium 101Foscarnet Sodium 92Foscavir 92Fosfomycin Tromethamine 22Fosinopril Sodium 122Fosinopril Sodium & Hydrochlorothiazide 132Fosphenytoin Sodium 39Fosrenol 169,170Fragmin 113,114Freds Pharmacy Autolet Lancing 246Freds Pharmacy Unifine Pentip+ 246Freds Pharmacy Unifine Pentips 246Freds Pharmacy Unilet Lanc 28G 246Freds Pharmacy Unilet Lanc 30G 247FreeStyle Control Solution 247FreeStyle Lancets 247FreeStyle Precision Ins Syr 247FreeStyle Unistick II Lancets 247Frova 55Frovatriptan Succinate 55Fulvestrant 64Furosemide 134Fuzeon 100
GGabapentin 36Gabapentin Enacarbil 147Galantamine Hydrobromide 41Galsulfase 160Gammagard 207Gammagard S/D 207Gammagard S/D Less IgA 206,207Gammaked 207Gamunex-C 207Ganciclovir Ophthalmic 93Ganciclovir Sodium 92Gatifloxacin (Ophth) 32,33GE100 Control 247Gel-Kam Oral Care Rinse 150Gemcitabine HCl 65,66Gemfibrozil 136Gemifloxacin Mesylate 32Gemzar 66Generess FE 185Genotropin 177Genotropin MiniQuick 177Gentamicin in Saline 19Gentamicin Sulfate 19Gentamicin Sulfate (Ophth) 19Genvoya 97Gilenya 150Glatiramer Acetate 149,150Gleevec 75Glimepiride 105,106Glipizide 106Glipizide-Metformin HCl 106Global Ease Inject Pen Needles 247Global Inject Ease Insulin Syr 248,249Global Inject Ease Lancets 28G 249Global Inject Ease Lancets 30G 249Global Lancing Device 249GlucaGen Diagnostic 109GlucaGen HypoKit 109Glucagon (rDNA) 109
Glucagon Emergency 109Glucagon HCl (rDNA) 109Glucagon HCl rDNA (Diagnostic) 109Glucarpidase 73Glucocard 01 Control 249Glucocard Expression Control 249Glucocard Shine Control 249Glucocard X-Sensor Control 249GlucoCom Control 249GlucoCom Lancets 28G 249GlucoCom Lancets 30G 249GlucoCom Lancets 33G 249GlucoLab Control 249,250Glucolet 2 Automatic Lancing 250GlucoPro Insulin Syringe 250Glucose Blood 226,247,297,299Glucose Control 250Glucosource Lancet Device 251Glucosource Lancets 251Glyburide 106GlyBURIDE 106Glyburide Micronized 106Glyburide-Metformin 106Glycine (GU Irrigant) 168Glycopyrrolate 162Glyset 106,107Gmate Control Level 2 251GNP Clickfine Pen Needles 251GNP Insulin Syringe 251,252GNP Lancets 252GNP Lancets 21G 252GNP Lancets Micro Thin 33G 252GNP Lancets Super Thin 30G 252GNP Lancets Thin 252GNP Lancets Thin 26G 252GNP Micro Thin Lancets 33G 252GNP Super Thin Lancets 30G 252GNP Ultra Com Insulin Syringe 252,253Golimumab 205Golytely 164Goserelin Acetate 202
Granisetron HCl 50Griseofulvin Microsize 52Griseofulvin Ultramicrosize 52Guanabenz Acetate 119Guanfacine HCl 119Guanfacine HCl (ADHD) 143Guanidine HCl 58Gynazole-1 52
HH&H Thinlet Lancets 26G 253H&H Thinlet Lancets 30G 253H-E-B inControl Adv Lancing 253H-E-B inControl Lancets 28G 253H-E-B inControl Lancets 30G 253H-E-B inControl Pen Needles 253,254Haemolance 254Haemolance Low Flow Lancets 254Haemolance Plus 254Haemolance Plus High Flow 254Haemolance Plus Low Flow 254Haemolance Plus Max Flow 254Haemolance Plus Pediatric Flow 254Halaven 69Halcinonide 173Halobetasol Propionate 173Halog 173Haloperidol 85,86Haloperidol Decanoate 85Haloperidol Lactate 85Harvoni 94Health Care Lancing Device 254HealthWise Lancets 30G 254HealthWise Lancing Pen 254HealthWise Mini Pen Needles 254HealthWise Pen Needles 255HealthWise Short Pen Needles 255HealthWise Unifine Pentips 255Healthy Accents Lancing Device 255Healthy Accents Unifine Pentip 255Healthy Accents Unilet Lancets 255
Heparin (Porcine) in NaCl 114Heparin (Porcine) in Sodium Chloride 114Heparin Sod (Porcine) in D5W 114Heparin Sodium (Porcine) 114Hepsera 93Herceptin 78Hexachlorophene 276Hexalen 61Hizentra 207Hizentra 20% 207HM Lancets Micro Thin 33G 255HM Lancets Ultra Thin 30G 255Horizant 147HumaLOG 110HumaLOG KwikPen 109HumaLOG Mix 50/50 109HumaLOG Mix 50/50 KwikPen 109HumaLOG Mix 50/50 Pen 109HumaLOG Mix 75/25 109HumaLOG Mix 75/25 KwikPen 109HumaLOG Mix 75/25 Pen 109HumaLOG Pen 110Humatrope 177Humira 204Humira Pediatric Crohns Start 204Humira Pen 204Humira Pen-Crohns Starter 204Humira Pen-Psoriasis Starter 204HumuLIN 70/30 110HumuLIN 70/30 KwikPen 110HumuLIN 70/30 Pen 110HumuLIN N 110HumuLIN N KwikPen 110HumuLIN N Pen 110HumuLIN R 110HumuLIN R U-500 (CONCENTRATED) 110Hy-Vee Insulin Syringe 255,256Hycamtin 74Hydralazine HCl 139Hydrea 66Hydrochlorothiazide 135
Hydrocodone Bitartrate 10,11Hydrocodone-Acetaminophen 12,13,14,16Hydrocodone-Ibuprofen 14,16Hydrocortisone 174Hydrocortisone (Intrarectal) 211Hydrocortisone (Rectal) 211Hydrocortisone (Topical) 151,154,211Hydrocortisone Acetate (Rectal) 170,173,174,176Hydrocortisone Butyrate 174Hydrocortisone Sod Succinate 170,176Hydrocortisone Valerate 174Hydrocortisone w/Acetic Acid 315Hydromorphone HCl 7,14Hydroxychloroquine Sulfate 80Hydroxyurea 66Hydroxyurea (Sickle Cell Anemia) 65Hydroxyzine HCl 319Hydroxyzine Pamoate 319HyperSal 326
IIbandronate Sodium 212,213Ibuprofen 5Idamycin PFS 69Idarubicin HCl 69Idursulfase 160Ifex 61Ifosfamide 61Ifosfamide & Mesna 61Ilevro 313Iloperidone 87,88Iloprost 325Imatinib Mesylate 75Imiglucerase 159Imipenem-Cilastatin 27Imipramine HCl 48Imipramine Pamoate 48Imiquimod 154Imitrex 55Immune Globulin (Human) IV 206,207
Immune Globulin (Human) IV orSubcutaneous 207Immune Globulin (Human) Subcutaneous 207Implanon 194In Touch Glucose Control 256In Touch Lancing Device 256In Touch Sterile Lancets 30G 256Incivek 94IncobotulinumtoxinA 328Increlex 177Incruse Ellipta 320Indacaterol Maleate 321Indapamide 135Indinavir Sulfate 101Indomethacin 5Infergen 94Infinity Control 256Infliximab 205Influenza Virus Vaccine Split 208,209,210Influenza Virus Vaccine Split High-DosePreservative Free 209Influenza Virus Vaccine Split PreservativeFree 208,209,210Influenza Virus Vaccine Split Quadrivalent 209,210Influenza Virus Vaccine Tissue-CulturedSubunit 209Influenza Virus Vaccine Types A & B PreservativeFree 208,209Influenza Virus Vaccine Types A & B SurfaceAntigen 209Ingenol Mebutate 155Inlyta 75Insulin Aspart 111Insulin Aspart Protamine & Aspart (Human) 111Insulin Detemir 110,111Insulin Glargine 110Insulin Glulisine 109Insulin Isophane & Reg (Human) 110,111,112Insulin Isophane (Human) 110,111,112Insulin Lispro (Human) 109,110Insulin Lispro Protamine & Lispro (Human) 109
Insulin NPH (Human) (Isophane) 111Insulin NPH Isophane & Reg (Human) 110Insulin PenNeedle215,216,218,222,223,225,226,227,228,229,232,234,235,236,237,240,243,244,245,246,247,251,253,254,255,258,260,262,263,264,265,267,268,272,273,275,276,278,279,280,281,282,283,286,290,291,295,296,300,301,302,304,305,307,308,310Insulin Regular (Human) 110,111,112Insulin Syringe 256,257Insulin Syringe/Needle 257,258Insulin Syringe/Needle U-100 217,218,219,220,221,223,224,225,226,227,228,230,231,232,234,236,237,238,239,242,243,244,245,247,248,249,250,251,252,253,255,256,257,258,259,260,261,262,263,264,265,266,269,270,271,272,274,276,277,278,279,280,281,282,283,284,285,286,287,289,290,291,292,293,294,295,296,297,298,299,300,301,302,303,304,306,307,308,309Insulin Syringes (Disposable) 224,259,270Insupen Pen Needles 258Insupen Sensitive 258Insupen Ultrafin 258Intelence 97Interferon Alfa-2B 94Interferon alfacon-1 94Interferon Beta-1a 149,150Interferon Beta-1b 149Interferon Gamma-1B 208Intron A 94Intuniv 143INVanz 27Invega 88Invirase 101Invokana 107Ionosol-B in D5W 331Ionosol-MB in D5W 331Iopidine 314Ipilimumab 78,79
Ipratropium Bromide 320Ipratropium Bromide (Nasal) 320Ipratropium Bromide HFA 320Ipratropium-Albuterol 326Irbesartan 120Irinotecan HCl 67,69Irrigation Solutions, Physiological 334Isentress 97Isocarboxazid 43Isolyte-P in D5W 332Isolyte-S 332Isoniazid 59Isoniazid & Rifampin 59Isoniazid-Rifampin w/ Pyrazinamide 60Isosorbide Dinitrate 139,140Isosorbide Dinitrate-Hydralazine HCl 132Isosorbide Mononitrate 140Isotretinoin 151,153,155,156,158,159Isradipine 129Istodax 69Itraconazole 52,53Ivacaftor 323Ivermectin 79Ivermectin (Pediculicide) 79Ixabepilone 69Ixazomib Citrate 76Ixempra Kit 69
JJadenu 330Jakafi 75,76Januvia 107Jevtana 70
KKaletra 101Kalydeco 323Kanamycin Sulfate 19KCl in Dextrose-NaCl 332KCl-Lactated Ringers-D5W 332Kenalog 174
Kepivance 150Ketek 31KetoCare 258Ketoconazole 52Ketoconazole (Topical) 52Ketoprofen 5Ketorolac Tromethamine 5Ketorolac Tromethamine (Ophth) 313Ketostix 258Kineret 204Kinney Lancets 258Kinney Thin Lancets 258Kinray Insulin Syringe 259Klor-Con M15 333Kmart Valu Insulin Syringe 29G 259Kmart Valu Insulin Syringe 30G 259Kroger Insulin Syringe 259,260Kroger Lancets 21G 260Kroger Lancets Micro Thin 33G 260Kroger Lancets Super Thin 260Kroger Lancets Thin 26G 260Kroger Lancets UltraThin 30G 260Kroger Lancing Device 260Kroger Pen Needles 260Kuvan 160Kyprolis 76
LLabetalol HCl 125Lacosamide 40Lacrisert 311Lactated Ringer's 333Lactated Ringer's (Irrigation) 337Lactic Acid (Ammonium Lactate) 151,154Lactulose 164Lactulose (Encephalopathy) 164Lady Lite Lancets 260Lamivudine 99Lamivudine (HBV) 93Lamivudine-Zidovudine 99Lamotrigine 38
Lancet Device 260Lancet Device with Ejector 261LancetDevices 217,218,219,220,222,223,225,226,227,229,233,234,237,240,245,246,249,250,251,253,254,255,256,260,261,263,265,269,272,273,279,280,282,283,284,286,288,290,292,294,295,297,299,307,308,309Lancets 215,216,217,218,219,220,221,222,223,225,226,227,229,230,232,233,234,235,236,239,240,241,242,243,244,245,246,247,249,251,252,253,254,255,256,258,260,261,263,264,265,266,267,268,269,270,272,273,274,275,276,278,279,280,281,283,284,285,286,287,288,289,290,292,293,294,295,296,297,298,301,302,303,304,305,306,307,308,309Lancets 28G 261Lancets 30G 261Lancets Micro Thin 33G 261Lancets Super Thin 28G 261Lancets Thin 261Lancets Ultra Fine 261Lancets Ultra Thin 261Lancets Ultra Thin 30G 261Lancing Device 261Lanoxin 132Lanreotide Acetate 201Lansoprazole 165,166Lanthanum Carbonate 169,170Lantus 110Lantus SoloStar 110LANZO 261Lapatinib Ditosylate 77Laronidase 159Lastacaft 311Latanoprost 314Latuda 88Leader Advanced Lancing Device 261Leader Insulin Syringe 261,262Leader Unifine Pentips 262Leader Unifine Pentips Plus 263
Ledipasvir-Sofosbuvir 94Leflunomide 208Lenalidomide 63,64Letairis 324Letrozole 73Leucovorin Calcium 70Leukeran 61Leukine 116,117Leuprolide Acetate 199,200Leuprolide Acetate (3 Month) 199,200Leuprolide Acetate (4 Month) 199,200Leuprolide Acetate (6 Month) 199,200Leuprolide Acetate (CPP) 200Leuprolide Acetate (CPP) (3 Month) 200Levalbuterol HCl 322Levalbuterol Tartrate 323Levatol 125Levemir 111Levemir FlexPen 110Levemir FlexTouch 111Levetiracetam 35Levobunolol HCl 314Levocetirizine Dihydrochloride 319Levofloxacin 32Levofloxacin (Ophth) 32Levofloxacin in D5W 32Levonorgestrel & EthEstradiol 180,181,182,184,185,186,187,188,189,190,191Levonorgestrel (Emergency OC) 194,195Levonorgestrel (IUD) 194,195Levonorgestrel-Eth Estradiol(Triphasic) 183,186,188,192Levonorgestrel-Ethinyl Estradiol (91-Day) 180,181,182,185,186,187,191Levonorgestrel-Ethinyl Estradiol(Continuous) 180,186Levorphanol Tartrate 7Levothyroxine Sodium 196,197,198,199Lexiva 101Lialda 211
Liberty Glucose Control 263Liberty Glucose Control Mid 263Liberty Medical Lancets 263Liberty Mini Lancing Device 263Lidocaine 107,155,156Lidocaine HCl 16,17,154Lidocaine HCl (Local Anesth.) 16,17Lidocaine HCl (Mouth-Throat) 17Lidocaine-Prilocaine 17Lidocaine-Tetracaine 157Lidoderm 155Liletta (52 MG) 194Linagliptin 108Lincocin 21Lincomycin HCl 21Lindane 81Linezolid 21,23Linezolid in Sodium Chloride 21Liothyronine Sodium 198Liotrix (T3-T4) 198Liraglutide 108Lisdexamfetamine Dimesylate 142Lisinopril 122Lisinopril & Hydrochlorothiazide 132,133Lite Touch Lancets 263Lite Touch Lancing Device 263Lite Touch Lancing Pen 263Lite Touch Pen Needles 263Litetouch Insulin Syringe 263,264Litetouch Lancets 264Litetouch Pen Needles 264,265Lithium 105Lithium Carbonate 104,105Livalo 136,137Live Better Adv Lancing Device 265Live Better Lancet Super Thin 265Live Better Lancet Ultra Thin 265Live Better Pen Needles 265Lo Loestrin Fe 186Lo/Ovral (28) 186Lodosyn 84
Lodoxamide Tromethamine 312Loestrin 1.5/30 (21) 186Loestrin 1/20 (21) 186Loestrin 24 Fe 186Loestrin Fe 1.5/30 187Loestrin Fe 1/20 187Lomustine 60,61Longs Insulin Syringe 265Longs Lancets Standard 265Longs Lancets Thin 265Longs Lancets Ultra Thin 265Loperamide HCl 162Lopinavir-Ritonavir 101Lorazepam 104Losartan Potassium 120,121Losartan Potassium & Hydrochlorothiazide 133LoSeasonique 187Lotemax 313Loteprednol Etabonate 312,313Lotronex 164Lovastatin 136,137Loxapine Succinate 86Lubiprostone 164Lufyllin 323Lumigan 314Lumizyme 160Lunesta 328Lupron Depot 200Lupron Depot-Ped 200Lurasidone HCl 88Lymphocyte Immune Globulin,Anti-ThymocyteGlobulin (Equine) 206Lyrica 148Lysodren 70
MMafenide Acetate 21,22Magellan Insulin Safety Syr 265,266Magnesium Sulfate 333Major Comfort Lancets 266Malarone 80
Malathion 81Mannitol (GU Irrigant) 169Maprotiline HCl 44Maraviroc 100Marplan 43Matulane 61Maxair Autohaler 322Maxi-Comfort Insulin Syringe 266Maxidex 313Maxima Control 266Mebendazole 79Mecasermin 177Mechlorethamine HCl 62Meclizine HCl 49Meclofenamate Sodium 5Medi-Lance Lancets 266Medic Insulin Syringe 266MediChoice Safety Lancet 266MediChoice Safety Lancet Extra 266MediChoice Safety Lancet Norm 267Medicine Shoppe Lancets 267Medicine Shoppe Lancets Thin 267Medicine Shoppe Pen Needles 267MediSense Glucose Ketone Contr 267Medisense Hi/Mid/Low Control 267Medisense High/Low Control 267Medisense Mid Control 267MediSense Thin Lancets 267Medlance Extra 21G 267Medlance Lite 25G 267Medlance Plus Extra 21G 267Medlance Plus Lancets 267Medlance Plus Lite 25G 268Medlance Plus Special 0.8mm 268Medlance Plus SuperLite 30G 268Medlance Plus Universal 21G 268Medlance Universal 21G 268Medrol 174Medroxyprogesterone Acetate 194Medroxyprogesterone Acetate(Contraceptive) 193,194
Mefenamic Acid 5Mefloquine HCl 80Megace ES 194Megace Oral 194Megestrol Acetate 194Megestrol Acetate (Appetite) 194Meijer Lancets 268Meijer Lancets Thin 268Meijer Lancets Universal 30G 268Meijer Lancets Universal 33G 268Meijer Pen Needles 268Meijer Super Thin Lancets 268Meloxicam 5Melphalan 60Melphalan HCl 62Memantine HCl 41,42Menactra 210Menest 187Meningococcal (A,C,Y&W-135) OligosaccharideConjugate Vac 210Meningococcal (A,C,Y&W-135) PolysaccharideConjugate Vaccine 210Meningococcal Vac A,C,Y&W-135 210Menomune 210Menostar 187Mentax 52Menveo 210Mepenzolate Bromide 161Meperidine HCl 14,15Meprobamate 103,104Mepron 80Mercaptopurine 66Meropenem 27Mesalamine 211Mestinon 58Metaproterenol Sulfate 268,322Metaxalone 327Metformin HCl 107Methadone HCl 8Methadose 8Methadose Sugar-Free 8
Methamphetamine HCl 141,142Methazolamide 314Methenamine Hippurate 21Methimazole 202Methitest 180Methocarbamol 327Methotrexate Sodium 204,205,206Methotrexate Sodium (Antirheumatic) 205Methoxsalen (Photopheresis) 72Methoxsalen (Topical) 155Methoxsalen Rapid 155Methscopolamine Bromide 162Methsuximide 35Methyclothiazide 135Methyldopa 119Methyldopate HCl 119Methylnaltrexone Bromide 162Methylphenidate HCl 144,145,146Methylphenidate HCl ER 145Methylprednisolone 174,175Methylprednisolone Acetate 172,174Methylprednisolone Sod Succ 170,174,176Methyltestosterone 180Metipranolol 314Metoclopramide HCl 49Metolazone 135Metoprolol Succinate 125,126Metoprolol Tartrate 126Metronidazole 22Metronidazole (Topical) 22,23Metronidazole Vaginal 22,23Mexiletine HCl 123Micafungin Sodium 52Micardis 121Miconazole 3 52Miconazole Nitrate Vaginal 52Microdot Control 268Microdot Control High/Low 268Microlet Lancets 268Microtainer Safety Flow Lancet 269Midodrine HCl 119
Miglitol 106,107Miglustat 161Migranal 55Millipred 175Millipred DP 175Millipred DP 12-Day 175Milnacipran HCl 148,149Minastrin 24 Fe 187Mini Lancing Device 269Minivelle 187,188Minocycline HCl 34Minocycline HCl (Subgingival) 150Minoxidil 139Mirabegron 166Mircette 188Mirena 194Mirtazapine 42Misoprostol 165Mitomycin 70Mitotane 70Mitoxantrone HCl 70Mobic 5Modafinil 329Modicon (28) 188Moexipril HCl 122Mometasone Furoate 175Mometasone Furoate (Inhalation) 316Mometasone Furoate (Nasal) 317Monoject Insulin Syringe 269,270Monoject Ultra Comfort Syringe 270Monoket 140Monolet Lancets 270Monolet OPD Lancets 270Monolettor Safety Lancets 270Montelukast Sodium 320Monurol 22Moore Mono Insulin Syringe 271Morphine Sulfate 8,9,11,12,15Morphine-Naltrexone 6,7Motofen 162MoviPrep 164
Moxifloxacin HCl 31,32Moxifloxacin HCl in Sodium Chloride 31Mozobil 117MS Insulin Syringe 271,272Multaq 123Mupirocin 22Mupirocin Calcium (Topical) 22Mustargen 62Mycamine 52Mycobutin 59Mycophenolate Mofetil 205Mycophenolate Mofetil HCl 203Mycophenolate Sodium 205Myfortic 205MyGlucoHealth Control 272MyGlucoHealth Lancets 30G 272Myleran 62Myozyme 160Myrbetriq 166Mytelase 58
NNabilone 50Nabumetone 5Nadolol 126Nafarelin Acetate 202Nafcillin Sodium 28Naftifine HCl 53Naftin 53Naglazyme 160Nalbuphine HCl 15Naloxone HCl 18Naltrexone HCl 17Namenda 42Namenda Titration Pak 42Naproxen 5,6Naproxen Sodium 5Naratriptan HCl 55,56Nasonex 317Natacyn 53Natalizumab 150
Natamycin 53Natazia 188Nateglinide 107Natroba 81Navelbine 70Nebivolol HCl 125Nebupent 80Nebusal 326Necon 1/50 (28) 188Necon 10/11 (28) 188Nedocromil Sodium (Ophth) 312Nefazodone HCl 45Nelarabine 66Nelfinavir Mesylate 102Neomycin Sulfate 19Neomycin-Bacitracin Zn-Polymyxin 311Neomycin-Colistin-HC-Thonzonium 315Neomycin-Polymy-Dexameth 311Neomycin-Polymyxin-HC 154Neomycin-Polymyxin-HC (Ophth) 311Neomycin-Polymyxin-HC (Otic) 315Nepafenac 313NetGroup Lancets 272Neulasta 117Neulasta Onpro 117Neupogen 117Neupro 83Neutek 2Tek Control 272Nevanac 313Nevirapine 97,98NexAVAR 76NexIUM 166Nexplanon 195Niacin (Antihyperlipidemic) 138Niacin-Lovastatin 137Niacin-Simvastatin 138Niaspan 138Nicardipine HCl 129Nicotine 18Nicotrol 18Nicotrol NS 18
Nifedipine 127,129,130Nilandron 63Nilotinib HCl 77Nilutamide 63Nimodipine 130Ninlaro 76Nipent 66Nisoldipine 130Nitazoxanide 79Nitisinone 160Nitro-Bid 140Nitrofurantoin 22Nitrofurantoin Macrocrystal 22Nitrofurantoin Monohyd Macro 22Nitroglycerin 140Nitroglycerin (Intra-Anal) 156Nitrostat 140Nizatidine 163Nor-QD 195Nordette (28) 188Norditropin 178Norditropin FlexPro 177Norditropin NordiFlex Pen 178Norelgestromin-Ethinyl Estradiol 189,193Norethin Acet & Estrad-Fe 181,185,186,187,188,191Norethindrone & EthEstradiol 180,181,182,185,188,189,190,193Norethindrone & Ethinyl Estradiol-Fe 184,185,186,188,193Norethindrone & Mestranol 188,189Norethindrone (Contraceptive) 193,194,195Norethindrone Acet & Eth Estra 185,186,187,189Norethindrone Acetate 193,195Norethindrone Acetate-Ethinyl Estradiol-Fe 184,191,192Norethindrone Acetate-Ethinyl Estradiol-Fe Fum(Biphasic) 186Norethindrone-Eth Estradiol (Biphasic) 188Norethindrone-Eth Estradiol(Triphasic) 180,181,182,186,188,189,190,192
Norfloxacin 32Norgestimate-EthinylEstradiol 183,188,189,190,191Norgestimate-Ethinyl Estradiol(Triphasic) 189,191,192Norgestrel & EthinylEstradiol 182,183,186,187,189Norinyl 1+35 (28) 189Norinyl 1+50 (28) 189Normosol-M in D5W 333Normosol-R pH 7.4 333Noroxin 32Nortriptyline HCl 48Norvir 101Nova Max Plus Glu/Ket Control 272Nova Safety Lancets 23G 272Nova Safety Lancets 28G 272Nova Sureflex Lancets 272Nova Sureflex Lancing Device 272NovoFine 272NovoFine Autocover 272NovoFine Plus 272NovoLIN 70/30 111NovoLIN 70/30 ReliOn 111NovoLIN N 111NovoLIN N ReliOn 111NovoLIN R 111NovoLIN R ReliOn 111NovoLOG 111NovoLOG FlexPen 111NovoLOG Mix 70/30 111NovoLOG Mix 70/30 FlexPen 111NovoLOG PenFill 111NovoTwist 272,273Noxafil 53Nplate 117Nucynta 15Nucynta ER 9Nuedexta 147Nulojix 205Nutropin 178
Nutropin AQ 178Nutropin AQ NuSpin 10 178Nutropin AQ Pen 178NuvaRing 189Nuvigil 329Nystatin 53Nystatin (Mouth-Throat) 53Nystatin (Topical) 53,273Nystatin-Triamcinolone 53
OOctreotide Acetate 200,201Odefsey 98Ofatumumab 78Ofloxacin 33Ofloxacin (Ophth) 33Ofloxacin (Otic) 33Oforta 70Ogestrel 189Olanzapine 88,89Oleptro 45Olmesartan Medoxomil 120Olopatadine HCl 312Olopatadine HCl (Nasal) 319Olsalazine Sodium 211Omacetaxine Mepesuccinate 72Omalizumab 327Omega-3-acid Ethyl Esters 138Omeprazole 166Omeprazole-Sodium Bicarbonate 166Omniflex Diaphragm 273Omnitrope 178Omontys 117On Call Express Glucose Contr 273On Call Lancets 273On Call Lancing Device 273On Call Plus Glucose Control 273On Call Plus Lancets 273On Call Plus Lancing Device 273On Call Vivid Glucose Control 273OnabotulinumtoxinA 327
Oncaspar 71Ondansetron 50Ondansetron HCl 50OneTouch Delica Lancets 33G 273OneTouch Delica Lancets Fine 273OneTouch Delica Lancing Dev 273OneTouch FinePoint Lancets 273OneTouch Lancets 273OneTouch Ultra Control 274OneTouch UltraSoft Lancets 274OneTouch Verio 274Onfi 36,37Onglyza 107Ontak 71OptumRx Glucose Control 274Orap 86Orapred ODT 175Orbivan 147Orencia 205Orfadin 160Orphenadrine Citrate 328Orsini Insulin Syringe 274Ortho Diaphragm All-Flex 274Ortho Diaphragm Coil 274Ortho Diaphragm Flat 275Ortho Evra 189Ortho Micronor 195Ortho Tri-Cyclen (28) 189Ortho Tri-Cyclen Lo 189Ortho-Cept (28) 190Ortho-Cyclen (28) 190Ortho-Novum 1/35 (28) 190Ortho-Novum 7/7/7 (28) 190Oseltamivir Phosphate 102OsmoPrep 165Ovcon-35 (28) 190Oxacillin Sodium 28Oxaliplatin 68,71Oxandrolone 179Oxaprozin 6Oxcarbazepine 39
Oxiconazole Nitrate 53Oxistat 53Oxsoralen 155Oxsoralen Ultra 155Oxybutynin Chloride 166,167Oxycodone HCl 9,10,15Oxycodone w/ Acetaminophen 12,15,16Oxycodone-Ibuprofen 16OxyCONTIN 9,10Oxymetholone 179Oxymorphone HCl 10,16
PPaclitaxel 71Paclitaxel Protein-Bound Particles 66Palifermin 150Paliperidone 88Palonosetron HCl 49Pamidronate Disodium 212,213Pancreaze 160Pancrelipase (Lipase-Protease-Amylase) 159,160,161Panitumumab 78Panretin 79Pantoprazole Sodium 166Paragard Intrauterine Copper 275Parenteral Electrolytes 333,336Paricalcitol 213,214Paromomycin Sulfate 19Paroxetine HCl 45Paser 59Pataday 312Patanol 312Paxil 45Pazopanib HCl 77PC Lancets Super Thin 30G 275PC Unifine Pentips 275PEG 3350-KCl-NaCl-Na Sulfate-Na Ascorbate-Ascorbic Acid 164PEG 3350-KCl-Sod Bicarb-Sod Chloride-SodSulfate 164,165
Peg-Intron 94Peg-Intron Redipen 95Peg-Intron Redipen Pak 4 95Pegademase Bovine 159Peganone 40Pegaspargase 71Pegasys 95,96Pegasys ProClick 95,96Pegfilgrastim 117Peginesatide Acetate 117Peginterferon alfa-2a 95,96Peginterferon alfa-2b 94,95,96Peginterferon alfa-2b (Antineoplastic) 71,72PegIntron 96Pegvisomant 201,202Pemetrexed Disodium 64Pen Needles 276Pen Needles 3/16" 275Pen Needles 5/16" 276Penbutolol Sulfate 125Penciclovir 103Penicillamine 168Penicillin G Pot in Dextrose 28,29Penicillin G Potassium 29Penicillin G Procaine 29Penicillin G Sodium 29Penicillin V Potassium 29Pentam 80Pentamidine Isethionate 80Pentasa 211Pentazocine Lactate 16Pentazocine w/ Naloxone 16PenTips 276Pentosan Polysulfate Sodium 168Pentostatin 66Pentoxifylline 133Perfect Lancets 28G 276Perfect Lancets 30G 276Perindopril Erbumine 122Peritoneal Dialysis Solutions 331,336Perjeta 78
Permethrin 80,81Perphenazine 49Perphenazine-Amitriptyline 43Pertuzumab 78Pharmacist Choice Lancets 276Pharmacy Counter Lancets 276Phenazopyridine HCl 169Phenelzine Sulfate 43Phenobarbital 37Phenoxybenzamine HCl 119,120Phenytek 40Phenytoin 39,40Phenytoin Sodium 40Phenytoin Sodium Extended 39,40Phisohex 276Phoslyra 170Phospholine Iodide 314Photofrin 71Picato 155Pilocarpine HCl 314Pilocarpine HCl (Oral) 151Pimecrolimus 154Pimozide 86Pindolol 126Pioglitazone HCl 107Pioglitazone HCl-Metformin HCl 105,108Piperacillin Sodium-Tazobactam Sodium 29Pirbuterol Acetate 322Piroxicam 6Pitavastatin Calcium 136,137Plan B 195Plan B One-Step 195Plasma-Lyte 148 334Plasma-Lyte A 334Plasma-Lyte-56 in D5W 334Plerixafor 117Pneumococcal 13-Valent Conjugate Vaccine 210Pneumococcal Vac Polyvalent 210Pneumovax 23 210PocketChem EZ Control 276Podofilox 155
Polymyxin B Sulfate 22Polymyxin B-Trimethoprim 311Porfimer Sodium 71Posaconazole 53Potassium Acetate 334Potassium Bicarb & Chloride 331,334Potassium Bicarbonate 331,332,333,334Potassium Chloride 331,332,333,334,335Potassium Chloride ER 334Potassium Chloride in D5W Lactated Ringers 332Potassium Chloride in Dextrose 334Potassium Chloride in Dextrose & SodiumChloride 332Potassium Chloride in NaCl 334Potassium Chloride Microencapsulated CrystalsCR 332,333,334Potassium Citrate (Alkalinizer) 169Potassium Phosphates 335Potiga 35Pradaxa 115Pralatrexate 65Pramipexole Dihydrochloride 83Pramlintide Acetate 108PrandiMet 108Prandin 108Prasugrel HCl 119Pravastatin Sodium 137Praziquantel 79Prazosin HCl 120Precision Glucose Ketone Contr 276Precision Sure-Dose Syringe 276,277Precision SureDose Plus Syr 277Pred Mild 313Prednicarbate 175Prednisolone 175,176Prednisolone Acetate (Ophth) 313Prednisolone Sodium Phosphate 170,175,176PrednisoLONE Sodium Phosphate 175,313Prednisolone Sodium Phosphate (Ophth) 313Prednisone 172,176Preferred Plus Insulin Syringe 277,278
Preferred Plus Lancets Colored 278Preferred Plus Lancets Thin 278Preferred Plus Unifine Pentips 278Pregabalin 148Premarin 190Premphase 190Prempro 191Prentif Fitting Set 278Prepopik 165Prestige Glucose Control 278Prevnar 13 210Prezista 101,102Priftin 59Primaquine Phosphate 80Primidone 37Pristiq 45ProAir HFA 322Probenecid 54Procainamide HCl 124Procarbazine HCl 61Prochlorperazine 48,49Prochlorperazine Maleate 49Procrit 117,118Prodigy Control Solution 278Prodigy Insulin Syringe 278,279Prodigy Lancets 21G 279Prodigy Lancets 26G 279Prodigy Lancets 28G 279Prodigy Lancing Device 279Prodigy Mini Pen Needles 279Prodigy Safety Lancets 26G 279Prodigy Short Pen Needles 279Prodigy Twist Top Lancets 28G 279Progesterone Micronized 195Proglycem 109Prograf 205Prolastin 326Prolastin-C 326Proleukin 71Prolia 214Promacta 118
Promethazine HCl 319,320Propafenone HCl 124Proparacaine HCl 311Propranolol HCl 126Propylthiouracil 202Protriptyline HCl 48Proventil HFA 322Prudoxin 156Pulmicort 317Pulmicort Flexhaler 317Pulmozyme 326Purinethol 66PX Advanced Lancing Device 279PX Extra Short Pen Needles 279PX Insulin Syringe 279,280PX Lancet Auto Injector 280PX Lancets 280PX Lancets Ultra Thin 280PX Mini Pen Needles 280PX Pen Needle 280Pyrazinamide 59Pyridostigmine Bromide 58,59Pyrimethamine 80
QQC Advanced Lancing Device 280QC Insulin Syringe 280,281QC Lancets Super Thin 30G 281QC Lancets Ultra Thin 281QC Pen Needles 281QC Unifine Pentips 281Quetiapine Fumarate 89,90,91QuickTek Control Solution 281Quinapril HCl 122,123Quinidine Sulfate 124Quinine Sulfate 80Quintet Control High/Normal 281Qvar 318
RRA E-Zject Color Lancets 33G 281
RA E-Zject Lancets 28G 281RA E-Zject Lancets Thin 26G 281RA E-Zject Lancets Thin 28G 281RA E-Zject Lancets Ultra Thin 281RA Insulin Syringe 281,282RA Lancing Device 282RA Pen Needles 282Rabeprazole Sodium 166Raloxifene HCl 195Raltegravir Potassium 97Ramelteon 329Ramipril 123Ranexa 133Ranitidine HCl 163,164Ranolazine 133Rapaflo 167,168Rapamune 205Rasagiline Mesylate 84,85Rebetol 96Rebif 150Rebif Rebidose 150Rebif Rebidose Titration Pack 150Rebif Titration Pack 150Reclast 214Rectiv 156RefuAH Plus Glucose Control 282Regorafenib 76Regranex 156Relenza Diskhaler 102Reli-On Insulin Syringe 282ReliOn 70/30 112ReliOn Insulin Syringe 282,283ReliOn Lancets Micro-Thin 33G 283ReliOn Lancets Standard 21G 283ReliOn Lancets Thin 26G 283ReliOn Lancets Ultra-Thin 30G 283ReliOn Lancing Device 283ReliOn Mini Pen Needles 283ReliOn N 112ReliOn Pen Needles 283ReliOn R 112
ReliOn Short Pen Needles 283ReliOn Ultra Thin Lancets 30G 284ReliOn Ultra Thin Plus Lancets 284Relistor 162Relpax 56Remicade 205Remodulin 324Renagel 170Renew Adv Cartridge Refills 284Renew Advanced Lancing Device 284ReoPro 119Repaglinide 108Repaglinide-Metformin HCl 108Rescriptor 98Resectisol 169Restasis 311Retapamulin 20Retrovir 99Revatio 324Revlimid 63,64Rexall Lancets Ultra Thin 30G 284Reyataz 102Rheumatrex 205Rhinocort Aqua 318Ribavirin (Hepatitis C) 94,96Ridaura 208Rifabutin 59Rifamate 59Rifampin 59,60Rifapentine 59Rifater 60Rifaximin 23Rightest GC300 Control 284Rightest GD500 Lancing Device 284Rightest GL300 Lancets 284Rilonacept 208Rilpivirine HCl 97Rilutek 147Riluzole 147Rimantadine Hydrochloride 102Rimexolone 313
Ringer's 335Ringer's Irrigation 335,336Risedronate Sodium 212,214RisperDAL Consta 89Risperidone 89,90Risperidone Microspheres 89Ritonavir 101Rituxan 78Rituximab 78Rivaroxaban 115Rivastigmine Tartrate 41Rizatriptan Benzoate 56Romidepsin 69Romiplostim 117Ropinirole Hydrochloride 83,84Rosiglitazone Maleate 105Rosuvastatin Calcium 136Rotigotine 83Rozerem 329Rufinamide 38Ruxolitinib Phosphate 75,76
SSabril 37Sacrosidase 161SafeSnap Insulin Syringe 284Safety Lancet 21G/Pressure Act 284Safety Lancet 28G/Pressure Act 285Safety Lancet 2MM 285Safety Lancets 285Safety Lancets 21G 285Safety Lancets 28G 285Safety Let Lancets 285Safety Seal Lancets 285Safety-Glide Syringe 285Safyral 191Saizen 179Saizen Click.Easy 178Salmeterol Xinafoate 322Salsalate 6Samsca 330
SandoSTATIN 201Santyl 156Saphris 90Sapropterin Dihydrochloride 160SAPScare Twist Top Lancets 285Saquinavir Mesylate 101Sargramostim 116,117Savella 148,149Savella Titration Pack 149Saxagliptin HCl 107SB Insulin Syringe 285SB Lancets Thin 285SB Lancets Ultra Thin 286Schnucks Insulin Syringe 286Scopolamine 49Seasonale 191Seasonique 191Selegiline 43Selegiline HCl 85Selenium Sulfide 156Selzentry 100Sensipar 199Serevent Diskus 322Seromycin 60SEROquel XR 90,91Serostim 179Sertaconazole Nitrate 51Sertraline HCl 46Sevelamer HCl 170Shopko Autolet Lancing Device 286Shopko On-the-Go Lancets 30G 286Shopko Unifine Pentips 286Shopko Unilet Lancets 28G 286Shopko Unilet Lancets 30G 286Sildenafil Citrate (Pulmonary Hypertension) 324Silodosin 167,168Silver Sulfadiazine 33Simcor 138Simple Diagnostics Lancing Dev 286Simponi 205Simulect 208
Simvastatin 137Sinecatechins 158Sirolimus 205,206Sitagliptin Phosphate 107Skelid 214Sklice 79Skyla 195SM Insulin Syringe 286,287SM Lancets 21G 287SM Lancets 33G 287SM Super Thin Lancets 30G 287SM Thin Lancets 26G 288Smart Diabetes Vantage Lancets 288Smart Diabetes Vantage Lancing 288Smart Sense Color Lancets 33G 288Smart Sense Standard Lancets 288Smart Sense Super Thin Lancets 288Smart Sense Thin Lancets 26G 288Smartest Control Medium 288Smartest Lancets 28G 288Sodium Acetate 335Sodium Chloride 335,336Sodium Chloride (GU Irrigant) 168,169Sodium Chloride (Inhalant) 326Sodium Citrate & Citric Acid 168,169Sodium Oxybate 329Sodium Phenylbutyrate 159,161Sodium Phosphate 336Sodium Phosphate Monobasic-Sodium PhosphateDibasic 165Sodium Phosphate Monobasic-Sodium PhosphateDibasic-MCC 165Sodium Picosulfate-Magnesium Oxide-AnhydrousCitric Acid 165Sodium Polystyrene Sulfonate 330Sodium Polystyrene Sulfonate (Bulk) 288Sodium Sulfate-Potassium Sulfate-MagnesiumSulfate 165Sofosbuvir 96Sofosbuvir-Velpatasvir 94Solaraze 156
Solartek Glucose Control 288Solifenacin Succinate 167Soltamox 64Solu-CORTEF 176Solu-MEDROL 176Solus V2 Control 288Solus V2 Lancets 28G 288Solus V2 Lancing Device 288Solus V2 Twist Lancets 30G 288Somatropin 177,178,179Somatropin (Non-Refrigerated) 178,179Somatuline Depot 201Somavert 201,202Sorafenib Tosylate 76Sorbitol 169Sorbitol Irrigation 169Sorbitol-Mannitol 169Soriatane 156Sotalol HCl 124Sovaldi 96Spectracef 26Spinosad 81Spiriva HandiHaler 321Spiriva Respimat 321Spironolactone 135Spironolactone & Hydrochlorothiazide 133Sporanox 53Sprycel 76Stalevo 100 82Stalevo 125 82Stalevo 150 82Stalevo 200 82Stalevo 50 82Stalevo 75 83Stannous Fluoride 150,151Stannous Fluoride (Bulk) 288Stavudine 99Stelara 156,157Stendra 169SteriLance TL 288Stimate 179
Stivarga 76Strattera 146,147Streptomycin Sulfate 19Streptozocin 63Stribild 97Stromectol 79Suboxone 18Succimer 330Sucraid 161Sucralfate 165Sulconazole Nitrate 51,52Sulfacetamide Sodium (Acne) 157Sulfacetamide Sodium (Ophth) 33Sulfacetamide Sodium w/Sulfur 151,152,153,156,157,158Sulfadiazine 33Sulfamethoxazole-Trimethoprim 33Sulfamylon 22Sulfasalazine 212Sulindac 6Sumatriptan 55,56Sumatriptan Succinate 57Sunitinib Malate 77Super Thin Lancets 289Suprax 26Suprep Bowel Prep 165Sure Comfort Insulin Syringe 289,290Sure Comfort Lancets 28G 290Sure Comfort Lancets 30G 290Sure Comfort Lancing Pen 290Sure Comfort Pen Needles 290Sure Edge Glucose Control 290,291Sure-Fine Pen Needles 291Sure-Ject Insulin Syringe 291,292Sure-Lance Flat Lancets 292Sure-Lance Lancets 26G 292Sure-Lance Thin Lancets 28G 292Sure-Lance Ultra Thin Lancets 292Sure-Pen 292Sure-Test EasyPlus Control 292Sure-Touch Lancets Universal 292
SureChek Control Solution 292Surelite Lancets 292SureStep Glucose Control 292SureStep Pro Low Glucose 292SureStep Pro Normal Glucose 293Sustiva 98Sutent 77Sylatron 71,72Symbicort 326SymlinPen 120 108SymlinPen 60 108Synarel 202Synera 157Synribo 72Syprine 330
TTabloid 66Taclonex 157Tacrolimus 204,205,206Tacrolimus (Topical) 157Tadalafil 167Tadalafil (Pulmonary Hypertension) 324Tafluprost 315Tai Doc Control 293Taliglucerase Alfa 160Talwin 16Tamiflu 102Tamoxifen Citrate 64Tamsulosin HCl 168Tapentadol HCl 9,15Tarceva 77Targretin 79Tasigna 77Tasmar 83Taxotere 72Tazarotene 157,158Tazorac 157,158TechLite AST Lancets 293TechLite Lancets 293TechLite Lancets 30G 293
Teflaro 26TEGretol 40Tekturna 133Telaprevir 94Telavancin HCl 23Telbivudine 94Telcare Glucose Control 293Telithromycin 31Telmisartan 121Temodar 62Temozolomide 62,63Temsirolimus 77Teniposide 72,73Tenofovir Disoproxil Fumarate 100Terazosin HCl 168Terbinafine HCl 54Terbutaline Sulfate 323Terconazole Vaginal 54Teriparatide (Recombinant) 213Terumo Insulin Syringe 293,294Terumo SurGuard Insulin Syr 294Testosterone 179,180Testosterone Cypionate 180Testosterone Enanthate 180Tetanus Toxoid-Diphtheria-Acellular PertussisAdsorb (Tdap) 208Tetrabenazine 147,148Tetracycline HCl 34Tetrahydrozoline HCl 327Tev-Tropin 179Teveten 121TGT Advanced Lancing Device 294TGT Lancet Alternate Site 294TGT Lancet Micro Thin 33G 294TGT Lancet Super Thin 30G 294TGT Lancet Thin 23G 294TGT Lancet Thin 26G 294TGT Lancet Ultra Thin 28G 294TGT Lancet Ultra Thin 30G 294TGT Lancing Device 295Thalidomide 64
Thalomid 64Theophylline 323,324Thinpro Insulin Syringe 295Thioguanine 66Thioridazine HCl 86Thiotepa 72Thiothixene 86Thymoglobulin 207Thyrolar-1 198Thyrolar-1/2 198Thyrolar-1/4 198Thyrolar-2 198Thyrolar-3 198Tiagabine HCl 37Ticagrelor 118Ticarcillin & Pot Clavulanate 29Ticlopidine HCl 119Tigecycline 22Tikosyn 124Tiludronate Disodium 214Timentin 29Timolol Maleate 126,127Timolol Maleate (Ophth) 314Tiotropium Bromide Monohydrate 321Tipranavir 101Tizanidine HCl 92Tobi 323TobraDex 19Tobramycin 323Tobramycin (Ophth) 20Tobramycin Sulfate 20Tobramycin Sulfate in Saline 20Tobramycin-Dexamethasone 19,311Tocilizumab 207,208Todays Health Lancing Device 295Todays Health Mini Pen Needles 295Todays Health Pen Needles 295Todays Health Short Pen Needle 295Todays Health Thin Lancets 28G 295Todays Health Thin Lancets 30G 296Tofacitinib Citrate 206
Tolazamide 108Tolbutamide 108Tolcapone 83Tolmetin Sodium 6Tolterodine Tartrate 166,167Tolvaptan 330TopCare Clickfine Pen Needles 296TopCare Ultra Comfort Ins Syr 296Topiramate 38Topotecan HCl 74Toremifene Citrate 64Torisel 77Torsemide 134Tositumomab 78Toviaz 167Tracleer 325Tradjenta 108Tramadol HCl 10,16Tramadol-Acetaminophen 16Trandolapril 123Tranexamic Acid 118Transderm-Scop 49Tranylcypromine Sulfate 43Trastuzumab 78Travatan Z 314Travel Lancets 297Travoprost 314Trazodone HCl 45,46Treanda 63Trecator 60Trelstar 202Trelstar Depot Mixject 202Trelstar LA Mixject 202Trelstar Mixject 202Treprostinil Sodium 324Tretinoin 152,158Tretinoin (Chemotherapy) 79Tretinoin Microsphere 158Trexall 206Tri-Norinyl (28) 192Triamcinolone Acetonide 174
Triamcinolone Acetonide (Mouth) 175,176Triamcinolone Acetonide (Topical) 176Triamterene 134,135Triamterene & Hydrochlorothiazide 133Triazolam 328Trientine HCl 330Trifluoperazine HCl 86Trifluridine 103Trihexyphenidyl HCl 81Trimethobenzamide HCl 49Trimethoprim 22Trimipramine Maleate 48Triptorelin Pamoate 202Trisenox 72Triumeq 100Trizivir 99Tropicamide 311Trospium Chloride 167True Metrix Air 297True Metrix Air Glucose Meter 297True Metrix Blood Glucose Test 297True Metrix Level 1 297True Metrix Level 2 297True Metrix Meter 297TrueControl Glucose Cont Lev 0 297TrueControl Glucose Cont Lev 1 297TRUEdraw Lancing Device 297TRUEplus Insulin Syringe 297,298TRUEplus Lancets 26G 298TRUEplus Lancets 28G 298TRUEplus Lancets 30G 298TRUEplus Lancets 33G 298TRUEplus Safety Lancets 28G 298TRUEresult Blood Glucose 298TRUEtest Control Level 1 298TRUEtest Control Level 2 299TRUEtest Control Level 3 299TRUEtest Test 299TrueTrack Glucose Control 299TrueTrack Test 299Truvada 99
Twinject 323Tybost 100Tygacil 22Tykerb 77Tysabri 150Tyzeka 94Tyzine 327
UUlesfia 81Ulipristal Acetate 193Uloric 54Ulti-Lance Auto-Adjust Device 299Ulti-Lance Automatic 299Ulti-Lance Mini Adjustable 299UltiCare Insulin Safety Syr 299UltiCare Insulin Syringe 299,300UltiCare Micro Pen Needles 300UltiCare Mini Pen Needles 301UltiCare Pen Needles 301UltiCare Short Pen Needles 301UltiCare Thin Lancets 30G 301Ultilet Basic Lancets 30G 301Ultilet Classic Lancets 301Ultilet Insulin Syringe 301Ultilet Insulin Syringe Short 301,302Ultilet Lancets 302Ultilet Pen Needle 302Ultilet Safety Lancets 23G 302Ultra Comfort Insulin Syringe 302Ultra Thin Lancets 28G 303Ultra Thin Lancets 30G 303Ultra-Comfort Insulin Syringe 303Ultra-Thin II Auto Lancet 304Ultra-Thin II Ins Syr Short 304Ultra-Thin II Insulin Syringe 304Ultra-Thin II Lancets 304Ultra-Thin II Mini Pen Needle 304Ultra-Thin II Pen Needle Short 304Ultra-Thin II Pen Needles 305UltraBag/Dianeal PD-2/1.5% Dex 336
UltraBag/Dianeal/1.5% Dextrose 336UltraTRAK PRO Control 305UltraTRAK Ultimate Control 305Umeclidinium Bromide 320Unifine Pentips 305Unifine Pentips Plus 305Unilet ComforTouch Lancet 305Unilet ExceLite 306Unilet ExceLite II 305Unilet G.P. Lancet 306Unilet G.P. Superlite Lancet 306Unilet GP 28 Ultra Thin 306Unilet Lancet 306Unilet Micro-Thin 33G 306Unilet Super-Thin 30G 306Unilet Superlite Lancet 306Unilet Ultra-Thin 28G 306Unistik 3 Gentle 306Unistik Safety Lancets 28G 306Unistik Safety Lancets 30G 306Unistrip Control 306Universal 1 Lancets Thin 26G 306Universal 1 Lancets Ultra Thin 306Uridine Triacetate (Emergency Treatment) 308Ursodiol 163Ustekinumab 156,157Uvadex 72
VV-R Mono Insulin Syringe 306,307Valacyclovir HCl 103Valcyte 92Valganciclovir HCl 92Valproate Sodium 37Valproic Acid 37Valrubicin 72Valsartan 121Valsartan-Hydrochlorothiazide 133Valstar 72Value Health Insulin Syringe 307Value Plus Lancet Standard 21G 307
Value Plus Lancets Super Thin 307Value Plus Lancets Thin 26G 307Value Plus Lancing Device 307ValuMark Lancet Super Thin 30G 307ValuMark Lancet Ultra Thin 28G 307ValuMark Pen Needles 307,308Vancomycin HCl 22,23Vandetanib 75,77VanishPoint Insulin Syringe 308Varenicline Tartrate 18Vectibix 78Vectical 158Velaglucerase Alfa 161Velcade 72Veltin 158Vemurafenib 78Venlafaxine HCl 46,47Venlafaxine HCl ER 46Ventavis 325Ventolin HFA 323Verapamil HCl 130,131Veregen 158Veripred 20 176VESIcare 167Vexol 313Vibativ 23Victory Control Level 1/2 308Victoza 108Victrelis 97Vida Mia Autolet Lancing Dev 308Vida Mia Unifine Pentips 308Vida Mia Unilet Lancets 28G 308Vida Mia Unilet Lancets 30G 308Vidaza 72Videx 99,100Vigabatrin 37Viibryd 47Vilazodone HCl 47Vimpat 40Vinblastine Sulfate 72Vincristine Sulfate 72
Vinorelbine Tartrate 70,72,73Viracept 102Viramune 98Viramune XR 98Viread 100Visicol 165Vismodegib 75Vistide 92Vistogard 308Vivelle-Dot 192Vocal Point Control 308Voltaren 158Voraxaze 73Voriconazole 54Vorinostat 73Vortioxetine HBr 43,44Votrient 77VP Insulin Syringe 308Vpriv 161Vumon 73Vytorin 139Vyvanse 142
WW&F Lancets 26G 309W&F Lancets Colored 21G 309Walgreens Adv Travel Lancets 309Walgreens Lancets 309Walgreens Lancets Micro Thin 309Walgreens Lancets Super Thin 309Walgreens Lancing Device 309Walgreens Thin Lancets 309Walgreens Ultra Thin Lancets 309Warfarin Sodium 112,114,115Water For Irrigation, Sterile 220,288WD Medic Insulin Syringe 309Wegmans Unifine Pentips Plus 310Welchol 139Wellbutrin 43Wellbutrin SR 43Wide-Seal Diaphragm 60 310
Wide-Seal Diaphragm 65 310Wide-Seal Diaphragm 70 310Wide-Seal Diaphragm 75 310Wide-Seal Diaphragm 80 310Wide-Seal Diaphragm 85 310Wide-Seal Diaphragm 90 310Wide-Seal Diaphragm 95 310
XXalkori 77Xarelto 115Xeljanz 206Xeloda 66Xenazine 147,148Xeomin 328Xgeva 214Xifaxan 23Xolair 327Xopenex HFA 323Xpres Control 311Xtandi 63Xulane 193Xylocaine 17Xyrem 329
YYasmin 28 193YAZ 193Yervoy 78,79
ZZafirlukast 320Zaleplon 328,329Zaltrap 73Zanamivir 102Zanosar 63Zarontin 35Zavesca 161Zelboraf 78Zemaira 327Zemplar 214
Zenpep 161Zetia 139Ziagen 100Ziana 159Zidovudine 99,100Zileuton 320Zinbryta 150Zioptan 315Ziprasidone HCl 91Zirgan 93Zithromax 31Ziv-Aflibercept 73Zohydro ER 10,11Zoladex 202Zoledronic Acid 214,215Zolinza 73Zolmitriptan 57,58Zolpidem Tartrate 329Zolvit 16Zomacton 179Zometa 215Zomig 58Zomig ZMT 58Zonalon 159Zonisamide 35,36Zorbtive 179Zortress 206Zostavax 210Zoster Vaccine Live 210Zovia 1/50E (28) 193Zovirax 103Zyban 18Zyflo CR 320Zymaxid 33Zytiga 63Zyvox 23
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