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2017 Formulary (List of Covered Drugs) - Health … · 2017 Formulary (List of Covered Drugs) ii...

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2017 Formulary (List of Covered Drugs) Blue Cross Medicare Advantage (HMO) SM Blue Cross Medicare Advantage (HMO-POS) SM Blue Cross Medicare Advantage (PPO) SM Y0096_MRK_TX_MAFRMLRY17 Accepted 08272016 728167.1117 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File ID: 00017162, Version 16 This formulary was updated on 11/17/2017. For more recent information or other questions, please contact Blue Cross Medicare Advantage SM Customer Service, at 1-877-774-8592 or, for TTY/TDD users, 711, 8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays, or visit www.getbluetx.com/mapd/druglist.
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2017 Formulary (List of Covered Drugs)Blue Cross Medicare Advantage (HMO)SM

Blue Cross Medicare Advantage (HMO-POS)SM

Blue Cross Medicare Advantage (PPO)SM

Y0096_MRK_TX_MAFRMLRY17 Accepted 08272016 728167.1117

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

HPMS Approved Formulary File ID: 00017162, Version 16

This formulary was updated on 11/17/2017. For more recent information or other questions, please contact Blue Cross Medicare AdvantageSM Customer Service, at 1-877-774-8592 or, for TTY/TDD users, 711, 8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays, or visit www.getbluetx.com/mapd/druglist.

i

This information is available for free in other languages. Please call our Customer Service number at 1-877-774-8592. (TTY/TDD users should call 711). We are open between 8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on the weekends and holidays.Esta información está disponible en otros idiomas de forma gratuita. Comuníquese a nuestro número de Servicio al cliente al 1-877-774-8592 (los usuarios de TTY/TDD deben llamar al 711). Nuestro horario es de 8:00 a.m. a 8:00 p.m., hora local, los 7 días de la semana. Si usted llama del 15 de febrero al 30 de septiembre, durante los fines de semana y feriados, se usarán tecnologías alternas (por ejemplo, correo de voz).

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Note to existing members: This formulary has changed since last year. Please review this document to make sure it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Blue Cross and Blue Shield of Texas. When it refers to “plan” or “our plan,” it means Blue Cross Medicare Advantage.

This document includes a list of the drugs (formulary) for our plan which is current as of November 2017. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year.

Blue Cross Medicare Advantage

2017 Formulary (List of Covered Drugs)

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What is the Blue Cross Medicare Advantage Formulary?A formulary is a list of covered drugs selected by Blue Cross Medicare Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Blue Cross Medicare Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Blue Cross Medicare Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?Generally, if you are taking a drug on our 2017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2017 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of November 17, 2017. To get updated information about the drugs covered by Blue Cross Medicare Advantage, please contact us. Our contact information appears on the front and back cover pages.

How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical ConditionThe formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page 104. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

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What are generic drugs?Blue Cross Medicare Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

Prior Authorization: Blue Cross Medicare Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Blue Cross Medicare Advantage before you fill your prescriptions. If you don’t get approval, Blue Cross Medicare Advantage may not cover the drug.

Quantity Limits: For certain drugs, Blue Cross Medicare Advantage limits the amount of the drug that Blue Cross Medicare Advantage will cover. For example, Blue Cross Medicare Advantage provides 30 tablets per prescription for alfuzosin ER. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, Blue Cross Medicare Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Blue Cross Medicare Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Blue Cross Medicare Advantage will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Blue Cross Medicare Advantage to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Blue Cross Medicare Advantage’s formulary?” on page iv for information about how to request an exception.

What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.

If you learn that Blue Cross Medicare Advantage does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by Blue Cross Medicare Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Blue Cross Medicare Advantage.

• You can ask Blue Cross Medicare Advantage to make an exception and cover your drug. See below for information about how to request an exception.

iv

How do I request an exception to the Blue Cross Medicare Advantage’s Formulary?You can ask Blue Cross Medicare Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Blue Cross Medicare Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Blue Cross Medicare Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

v

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a maximum 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

You may have changes that take you from one treatment setting to another. During this level of care change, drugs may be prescribed that are not covered by your plan. If this happens, you and your doctor must use your plan’s exception and appeals processes. However, when you are admitted to, or discharged from, a long-term care (LTC) setting, you may not have access to the drugs you were previously given. You may get a refill upon admission or discharge to prevent a gap in care.

For more informationFor more detailed information about your Blue Cross Medicare Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Blue Cross Medicare Advantage, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Blue Cross Medicare Advantage’s FormularyThe formulary below provides coverage information about the drugs covered by Blue Cross Medicare Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 104.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LANTUS) and generic drugs are listed in lower-case italics (e.g., metformin).

The information in the Requirements/Limits column tells you if Blue Cross Medicare Advantage has any special requirements for coverage of your drug.

All drugs included in this formulary are available via mail-order benefit. Contact us for details. Our contact information appears on the front and back cover pages.

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KEYUppercase = BRAND-NAME

Lower case italics = generics

Tier 1 = Preferred Generic Drugs

Tier 2 = Generic Drugs

Tier 3 = Preferred Brand Drugs

Tier 4 = Non-Preferred Brand Drugs

Tier 5 = Specialty Drugs

BD = Drugs that may be covered under Medicare Part B or Part D depending on the circumstance. These drugs require prior authorization to determine coverage under Part B or Part D. Information may need to be provided that describes the use or the place where the drug is received to determine coverage.

PA = Prior Authorization

QL = Quantity Limits

ST = Step Therapy

* = Limited Distribution Drug. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at 1-877-774-8592, 8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays. TTY/TDD users should call 711.

# = High Risk Medication (HRM). Medicine that may be unsafe in patients greater than 65 years of age. Our formulary does include coverage for some of these drugs, but alternatives may be found in lower co-pay tiers. Please discuss with your doctor if there are alternatives to these medications that would be appropriate for you to use.

^ = We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.

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Copayment and Coinsurance Amounts:Tier 1 – Preferred Generic Drugs: $0/$9

Tier 2 – Generic Drugs: $9/$20

Tier 3 – Preferred Brand Drugs: $39/$47

Tier 4 – Non-Preferred Brand Drugs: $95/$100

Tier 5 – Specialty Drugs: 33%

You must continue to pay your Medicare Part B premium.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Out-of-network/non-contracted providers are under no obligation to treat Blue Cross Medicare Advantage members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our Customer Service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Below is the key for abbreviations used within the drug list.

KEY

act actuation mcg microgram

ad adsorbed meq milliequivalent

aer, aero aerosol mg milligram

ba, breath activ breath activated ml milliliter

bau bioequivalent allergy units mu million units

cap capsules nebu nebules

chew tab chewable tablets NF non-formulary

conc concentrate odt orally disintegrating tablets

conj conjugate oin, oint ointment

cr controlled-release op, ophth ophthalmic

crys crystals pow, powd powder

dr delayed-release pf preservative-free

deter deterrent pfu plaque forming units

viii

KEY continued

ec enteric coated pref prefilled

elenzyme-linked immunosorbent assay recmb, recomb recombinant

er, extend-release, extended, extended rel, xl, xr

extended-release sl sublingual

g, gm gram sol, soln solution

gu genitourinary suppos suppositories

hr hour sus, susp suspension

ir immediate-release sr sustained-release

inh, inhal inhalation syr syringe

inj injection tab, tabs tablets

im intramuscular td transdermal

iv intravenous tl translingual

l liter unt unit

lf flocculation units va vaginal

liqd liquid vac vaccine

la long acting

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

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Drug Name Drug Tier Requirements/LimitsAnalgesicsABSTRAL - fentanyl citrate sl tab 100 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 200 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 300 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 400 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 600 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 800 mcg 5 PA, QL (120 tablets/30 days)acetaminophen w/ codeine soln 120-12 mg/5ml 4 QL (2700 mls/30 days)acetaminophen w/ codeine tab 300-15 mg 4 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-30 mg 4 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-60 mg 4 QL (180 tablets/30 days)butorphanol tartrate inj 1 mg/ml 4butorphanol tartrate inj 2 mg/ml 4butorphanol tartrate nasal soln 10 mg/ml 4celecoxib cap 50 mg^ 2 QL (60 capsules/30 days)celecoxib cap 100 mg^ 2 QL (60 capsules/30 days)celecoxib cap 200 mg^ 2 QL (60 capsules/30 days)celecoxib cap 400 mg^ 2 QL (30 capsules/30 days)codeine sulfate tab 15 mg 4 QL (180 tablets/30 days)codeine sulfate tab 30 mg 4 QL (180 tablets/30 days)codeine sulfate tab 60 mg 4 QL (180 tablets/30 days)diclofenac potassium tab 50 mg^ 2 QL (120 tablets/30 days)diclofenac sodium gel 1%^ 2 STdiclofenac sodium tab delayed release 25 mg^ 2 QL (240 tablets/30 days)diclofenac sodium tab delayed release 50 mg^ 2 QL (120 tablets/30 days)diclofenac sodium tab delayed release 75 mg^ 2 QL (60 tablets/30 days)diclofenac sodium tab er 24hr 100 mg^ 2 QL (60 tablets/30 days)diclofenac w/ misoprostol tab delayed release 50-0.2 mg^ 2 QL (120 tablets/30 days)diclofenac w/ misoprostol tab delayed release 75-0.2 mg^ 2 QL (90 tablets/30 days)etodolac cap 200 mg^ 2 QL (150 capsules/30 days)etodolac cap 300 mg^ 2 QL (90 capsules/30 days)etodolac tab er 24hr 400 mg^ 2 QL (60 tablets/30 days)etodolac tab er 24hr 500 mg^ 2 QL (60 tablets/30 days)etodolac tab er 24hr 600 mg^ 2 QL (30 tablets/30 days)etodolac tab 400 mg^ 2 QL (60 tablets/30 days)etodolac tab 500 mg^ 2 QL (60 tablets/30 days)fentanyl citrate lozenge on a handle 200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 400 mcg 5 PA, QL (120 lozenges/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.2

Drug Name Drug Tier Requirements/Limitsfentanyl citrate lozenge on a handle 600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 800 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl td patch 72hr 12 mcg/hr 4 QL (15 patches/30 days)fentanyl td patch 72hr 25 mcg/hr 4 QL (15 patches/30 days)fentanyl td patch 72hr 50 mcg/hr 4 QL (15 patches/30 days)fentanyl td patch 72hr 75 mcg/hr 4 QL (15 patches/30 days)fentanyl td patch 72hr 100 mcg/hr 4 QL (15 patches/30 days)flurbiprofen tab 50 mg^ 2 QL (180 tablets/30 days)flurbiprofen tab 100 mg^ 2 QL (90 tablets/30 days)hydrocodone-acetaminophen soln 7.5-325 mg/15ml 4 QL (3600 mls/30 days)hydrocodone-acetaminophen tab 10-325 mg 4 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-300 mg 4 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-300 mg 4 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-325 mg 4 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-325 mg 4 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 10-300 mg 4 QL (180 tablets/30 days)hydrocodone-ibuprofen tab 5-200 mg 4 QL (150 tablets/30 days)hydrocodone-ibuprofen tab 7.5-200 mg 4 QL (150 tablets/30 days)hydrocodone-ibuprofen tab 10-200 mg 4 QL (150 tablets/30 days)hydromorphone hcl liqd 1 mg/ml 4 QL (1440 mls/30 days)hydromorphone hcl preservative free inj 10 mg/ml 4 BDhydromorphone hcl tab 2 mg 4 QL (180 tablets/30 days)hydromorphone hcl tab 4 mg 4 QL (180 tablets/30 days)hydromorphone hcl tab 8 mg 4 QL (180 tablets/30 days)ibuprofen susp 100 mg/5ml^ 2 QL (4800 mls/30 days)ibuprofen tab 400 mg^ 2 QL (240 tablets/30 days)ibuprofen tab 600 mg^ 2 QL (150 tablets/30 days)ibuprofen tab 800 mg^ 2 QL (120 tablets/30 days)ketoprofen cap 50 mg^ 2 QL (180 capsules/30 days)ketoprofen cap 75 mg^ 2 QL (120 capsules/30 days)LAZANDA - fentanyl citrate nasal spray 100 mcg/act 5 PA, QL (30 bottles/30 days)LAZANDA - fentanyl citrate nasal spray 300 mcg/act 5 PA, QL (30 bottles/30 days)LAZANDA - fentanyl citrate nasal spray 400 mcg/act 5 PA, QL (30 bottles/30 days)LEVORPHANOL TARTRATE - levorphanol tartrate tab 2 mg 4 QL (120 tablets/30 days)meloxicam tab 7.5 mg^ 2 QL (60 tablets/30 days)meloxicam tab 15 mg^ 2 QL (30 tablets/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

3

Drug Name Drug Tier Requirements/Limitsmethadone hcl tab 5 mg 3 QL (180 tablets/30 days)methadone hcl tab 10 mg 3 QL (360 tablets/30 days)MORPHINE SULFATE - morphine sulfate tab 15 mg 4 QL (240 tablets/30 days)MORPHINE SULFATE - morphine sulfate tab 30 mg 4 QL (180 tablets/30 days)morphine sulfate inj pf 0.5 mg/ml 4 BDmorphine sulfate inj pf 1 mg/ml 4 BDmorphine sulfate oral soln 10 mg/5ml 4 QL (2700 mls/30 days)morphine sulfate oral soln 20 mg/5ml 4 QL (1350 mls/30 days)morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 4 QL (270 mls/30 days)morphine sulfate tab er 15 mg 4 QL (90 tablets/30 days)morphine sulfate tab er 30 mg 4 QL (90 tablets/30 days)morphine sulfate tab er 60 mg 4 QL (90 tablets/30 days)morphine sulfate tab er 100 mg 4 QL (90 tablets/30 days)morphine sulfate tab er 200 mg 4 QL (90 tablets/30 days)nabumetone tab 500 mg^ 2 QL (120 tablets/30 days)nabumetone tab 750 mg^ 2 QL (60 tablets/30 days)naproxen sodium tab 275 mg^ 2 QL (150 tablets/30 days)naproxen sodium tab 550 mg^ 2 QL (90 tablets/30 days)naproxen susp 125 mg/5ml^ 2 QL (1800 mls/30 days)naproxen tab ec 375 mg^ 2 QL (120 tablets/30 days)naproxen tab ec 500 mg^ 2 QL (90 tablets/30 days)naproxen tab 250 mg^ 2 QL (180 tablets/30 days)naproxen tab 375 mg^ 2 QL (120 tablets/30 days)naproxen tab 500 mg^ 2 QL (90 tablets/30 days)oxaprozin tab 600 mg^ 2 QL (90 tablets/30 days)oxycodone hcl tab 5 mg 4 QL (360 tablets/30 days)oxycodone hcl tab 10 mg 4 QL (180 tablets/30 days)oxycodone hcl tab 15 mg 4 QL (180 tablets/30 days)oxycodone hcl tab 20 mg 4 QL (180 tablets/30 days)oxycodone hcl tab 30 mg 4 QL (180 tablets/30 days)oxycodone w/ acetaminophen tab 2.5-325 mg 4 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 5-325 mg 4 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 7.5-325 mg 4 QL (240 tablets/30 days)oxycodone w/ acetaminophen tab 10-325 mg 4 QL (180 tablets/30 days)oxycodone-aspirin tab 4.8355-325 mg 4 QL (360 tablets/30 days)piroxicam cap 10 mg^ 2 QL (60 capsules/30 days)piroxicam cap 20 mg^ 2 QL (30 capsules/30 days)sulindac tab 150 mg^ 2 QL (60 tablets/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.4

Drug Name Drug Tier Requirements/Limitssulindac tab 200 mg^ 2 QL (60 tablets/30 days)tolmetin sodium cap 400 mg^ 2 QL (120 capsules/30 days)tramadol hcl tab 50 mg^ 2 QL (240 tablets/30 days)tramadol-acetaminophen tab 37.5-325 mg^ 2 QL (240 tablets/30 days)ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-

deterrent 10 mg4 PA, QL (60 capsules/30 days)

ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-deterrent 15 mg

4 PA, QL (60 capsules/30 days)

ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-deterrent 20 mg

4 PA, QL (60 capsules/30 days)

ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-deterrent 30 mg

4 PA, QL (60 capsules/30 days)

ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-deterrent 40 mg

4 PA, QL (60 capsules/30 days)

ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-deterrent 50 mg

4 PA, QL (60 capsules/30 days)

Anestheticslidocaine hcl gel 2%^ 2lidocaine hcl soln 4%^ 2lidocaine hcl viscous soln 2%^ 2lidocaine oint 5%^ 2lidocaine patch 5%^ 2 PA, QL (90 patches/30 days)lidocaine-prilocaine cream 2.5-2.5%^ 2Anti-Addiction/Substance Abuse Treatment Agentsacamprosate calcium tab delayed release 333 mg^ 2buprenorphine hcl sl tab 2 mg^ 2 PAbuprenorphine hcl sl tab 8 mg^ 2 PAbuprenorphine hcl-naloxone hcl sl tab 2-0.5 mg^ 2 PAbuprenorphine hcl-naloxone hcl sl tab 8-2 mg^ 2 PAbupropion hcl (smoking deterrent) tab er 12hr 150 mg^ 2CHANTIX - varenicline tartrate tab 0.5 mg 3CHANTIX - varenicline tartrate tab 1 mg 3CHANTIX CONTINUING MONTH PACK - varenicline tartrate tab

1 mg3

CHANTIX STARTING MONTH PACK - varenicline tartrate tab0.5 mg x 11 & tab 1 mg x 42 pack

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disulfiram tab 250 mg^ 2disulfiram tab 500 mg^ 2NALOXONE HCL - naloxone hcl soln cartridge 0.4 mg/ml^ 2NALOXONE HCL - naloxone hcl soln prefilled syringe 2 mg/2ml 3naloxone hcl inj 0.4 mg/ml^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

5

Drug Name Drug Tier Requirements/Limitsnaloxone hcl inj 4 mg/10ml^ 2naltrexone hcl tab 50 mg^ 2NARCAN - naloxone hcl nasal spray 4 mg/0.1ml 4NICOTROL INHALER - nicotine inhaler system 10 mg (4 mg

delivered)4

NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray) 4SUBOXONE - buprenorphine hcl-naloxone hcl sl film 2-0.5 mg 4 PASUBOXONE - buprenorphine hcl-naloxone hcl sl film 4-1 mg 4 PASUBOXONE - buprenorphine hcl-naloxone hcl sl film 8-2 mg 4 PASUBOXONE - buprenorphine hcl-naloxone hcl sl film 12-3 mg 4 PAVIVITROL - naltrexone for im extended release susp 380 mg 5Antibacterialsamikacin sulfate inj 500 mg/2ml (250 mg/ml) 4amikacin sulfate inj 1 gm/4ml (250 mg/ml) 4amoxicillin (trihydrate) cap 250 mg^ 2amoxicillin (trihydrate) cap 500 mg^ 2amoxicillin (trihydrate) for susp 125 mg/5ml^ 2amoxicillin (trihydrate) for susp 200 mg/5ml^ 2amoxicillin (trihydrate) for susp 250 mg/5ml^ 2amoxicillin (trihydrate) for susp 400 mg/5ml^ 2amoxicillin (trihydrate) tab 500 mg^ 2amoxicillin (trihydrate) tab 875 mg^ 2amoxicillin & k clavulanate for susp 200-28.5 mg/5ml^ 2amoxicillin & k clavulanate for susp 400-57 mg/5ml^ 2amoxicillin & k clavulanate for susp 600-42.9 mg/5ml^ 2amoxicillin & k clavulanate tab 250-125 mg^ 2amoxicillin & k clavulanate tab 500-125 mg^ 2amoxicillin & k clavulanate tab 875-125 mg^ 2AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & k

clavulanate chew tab 200-28.5 mg4

AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & kclavulanate chew tab 400-57 mg

4

ampicillin & sulbactam sodium for inj 3 (2-1) gm 4ampicillin cap 250 mg^ 2ampicillin cap 500 mg^ 2AMPICILLIN SODIUM - ampicillin sodium for iv soln 1 gm 4ampicillin sodium for inj 250 mg 4ampicillin sodium for inj 500 mg 4ampicillin sodium for inj 1 gm 4

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.6

Drug Name Drug Tier Requirements/Limitsampicillin sodium for inj 2 gm 4ampicillin sodium for iv soln 2 gm 4ampicillin sodium for iv soln 10 gm 4AVELOX - moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8%

inj3

AZACTAM IN ISO-OSMOTIC DEXTROSE - aztreonam in dextroseinj 1 gm/50 ml

4

AZACTAM IN ISO-OSMOTIC DEXTROSE - aztreonam in dextroseinj 2 gm/50 ml

4

AZITHROMYCIN - azithromycin powd pack for susp 1 gm 4azithromycin for susp 100 mg/5ml^ 2azithromycin for susp 200 mg/5ml^ 2azithromycin iv for soln 500 mg 4azithromycin tab 250 mg^ 2azithromycin tab 500 mg^ 2azithromycin tab 600 mg^ 2aztreonam for inj 1 gm 4aztreonam for inj 2 gm 4BICILLIN L-A - penicillin g benzathine intramuscular susp 600000

unit/ml4

BICILLIN L-A - penicillin g benzathine intramuscular susp 1200000unit/2ml

4

BICILLIN L-A - penicillin g benzathine intramuscular susp 2400000unit/4ml

4

cefaclor cap 250 mg^ 2cefaclor cap 500 mg^ 2cefadroxil cap 500 mg^ 2cefadroxil for susp 250 mg/5ml^ 2cefadroxil for susp 500 mg/5ml^ 2cefadroxil tab 1 gm^ 2cefazolin sodium for inj 500 mg 4cefazolin sodium for inj 1 gm 4cefazolin sodium for inj 10 gm 4cefazolin sodium for inj 20 gm 4cefdinir cap 300 mg^ 2cefdinir for susp 125 mg/5ml^ 2cefdinir for susp 250 mg/5ml^ 2cefepime hcl for inj 1 gm 4cefepime hcl for inj 2 gm 4cefotaxime sodium for inj 500 mg 4

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

7

Drug Name Drug Tier Requirements/Limitscefotaxime sodium for inj 1 gm 4cefotaxime sodium for inj 2 gm 4cefotaxime sodium for inj 10 gm 4cefoxitin sodium for inj 10 gm 4cefoxitin sodium for iv soln 1 gm 4cefoxitin sodium for iv soln 2 gm 4cefpodoxime proxetil for susp 50 mg/5ml^ 2cefpodoxime proxetil for susp 100 mg/5ml^ 2cefpodoxime proxetil tab 100 mg^ 2cefpodoxime proxetil tab 200 mg^ 2cefprozil for susp 125 mg/5ml^ 2cefprozil for susp 250 mg/5ml^ 2cefprozil tab 250 mg^ 2cefprozil tab 500 mg^ 2ceftazidime for inj 1 gm 4ceftazidime for inj 2 gm 4ceftazidime for inj 6 gm 4ceftazidime for iv soln 1 gm 4ceftazidime for iv soln 2 gm 4CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxone

sodium in dextrose inj 20 mg/ml4

CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxonesodium in dextrose inj 40 mg/ml

4

ceftriaxone sodium for inj 250 mg 3ceftriaxone sodium for inj 500 mg 3ceftriaxone sodium for inj 1 gm 4ceftriaxone sodium for inj 2 gm 4ceftriaxone sodium for inj 10 gm 4ceftriaxone sodium for iv soln 1 gm 4ceftriaxone sodium for iv soln 2 gm 4CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 1 gm

and dextrose 3.74%4

CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 2 gmand dextrose 2.22%

4

cefuroxime axetil tab 250 mg^ 2cefuroxime axetil tab 500 mg^ 2cefuroxime sodium for inj 750 mg 4cefuroxime sodium for inj 1.5 gm 4cefuroxime sodium for inj 7.5 gm 4

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.8

Drug Name Drug Tier Requirements/Limitscefuroxime sodium for iv soln 1.5 gm 4cephalexin cap 250 mg^ 2cephalexin cap 500 mg^ 2cephalexin cap 750 mg^ 2cephalexin for susp 125 mg/5ml^ 2cephalexin for susp 250 mg/5ml^ 2CHLORAMPHENICOL SODIUM SUCCINATE - chloramphenicol

sodium succinate for iv inj 1 gm4

ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml)^ 2ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml)^ 2CIPROFLOXACIN HCL - ciprofloxacin hcl tab 100 mg 4ciprofloxacin hcl tab er 24hr 500 mg^ 2ciprofloxacin hcl tab er 24hr 1000 mg^ 2ciprofloxacin hcl tab 250 mg^ 2ciprofloxacin hcl tab 500 mg^ 2ciprofloxacin hcl tab 750 mg^ 2ciprofloxacin iv soln 200 mg/20ml (1%) 4ciprofloxacin iv soln 400 mg/40ml (1%) 4ciprofloxacin 200 mg/100ml in d5w 4ciprofloxacin 400 mg/200ml in d5w 4clarithromycin for susp 125 mg/5ml^ 2clarithromycin for susp 250 mg/5ml^ 2clarithromycin tab er 24hr 500 mg^ 2clarithromycin tab 250 mg^ 2clarithromycin tab 500 mg^ 2clindamycin hcl cap 75 mg^ 2clindamycin hcl cap 150 mg^ 2clindamycin hcl cap 300 mg^ 2clindamycin phosphate in d5w iv soln 300 mg/50ml 4clindamycin phosphate in d5w iv soln 600 mg/50ml 4clindamycin phosphate in d5w iv soln 900 mg/50ml 4clindamycin phosphate inj 300 mg/2ml 4clindamycin phosphate inj 600 mg/4ml 4clindamycin phosphate inj 900 mg/6ml 4clindamycin phosphate inj 9 gm/60ml 4clindamycin phosphate iv soln 300 mg/2ml 4clindamycin phosphate iv soln 900 mg/6ml 4clindamycin phosphate vaginal cream 2%^ 2colistimethate sodium for inj 150 mg^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

9

Drug Name Drug Tier Requirements/LimitsCUBICIN - daptomycin for iv soln 500 mg 5CUBICIN RF - daptomycin for iv soln 500 mg 5DALVANCE - dalbavancin hcl for iv soln 500 mg 5daptomycin for iv soln 500 mg 5demeclocycline hcl tab 150 mg 4demeclocycline hcl tab 300 mg 4dicloxacillin sodium cap 250 mg^ 2dicloxacillin sodium cap 500 mg^ 2DIFICID - fidaxomicin tab 200 mg 5doxycycline hyclate cap 50 mg^ 2doxycycline hyclate cap 100 mg^ 2doxycycline hyclate for inj 100 mg 4doxycycline hyclate tab 20 mg^ 2doxycycline hyclate tab 100 mg^ 2doxycycline monohydrate cap 50 mg 4doxycycline monohydrate cap 75 mg 4doxycycline monohydrate cap 100 mg 4doxycycline monohydrate cap 150 mg 4doxycycline monohydrate tab 50 mg 4doxycycline monohydrate tab 75 mg 4doxycycline monohydrate tab 100 mg 4doxycycline monohydrate tab 150 mg 4E.E.S. GRANULES - erythromycin ethylsuccinate for susp

200 mg/5ml4

ERY-TAB - erythromycin tab delayed release 250 mg 4ERY-TAB - erythromycin tab delayed release 333 mg 4ERY-TAB - erythromycin tab delayed release 500 mg 4ERYPED 200 - erythromycin ethylsuccinate for susp 200 mg/5ml 4ERYPED 400 - erythromycin ethylsuccinate for susp 400 mg/5ml 4ERYTHROCIN LACTOBIONATE - erythromycin lactobionate for inj

500 mg4

ERYTHROCIN STEARATE - erythromycin stearate tab 250 mg 4ERYTHROMYCIN BASE - erythromycin tab 250 mg 4ERYTHROMYCIN BASE - erythromycin tab 500 mg 4erythromycin ethylsuccinate for susp 200 mg/5ml^ 2gentamicin in saline inj 0.8 mg/ml 3gentamicin in saline inj 1 mg/ml 3gentamicin in saline inj 1.2 mg/ml 3gentamicin in saline inj 1.6 mg/ml 3

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.10

Drug Name Drug Tier Requirements/Limitsgentamicin sulfate inj 10 mg/ml 4gentamicin sulfate inj 40 mg/ml 4gentamicin sulfate iv soln 10 mg/ml 4imipenem-cilastatin intravenous for soln 250 mg 3imipenem-cilastatin intravenous for soln 500 mg 3INVANZ - ertapenem sodium for inj 1 gm 4INVANZ - ertapenem sodium for iv inj 1 gm 4levofloxacin in d5w iv soln 250 mg/50ml 4levofloxacin in d5w iv soln 500 mg/100ml 4levofloxacin in d5w iv soln 750 mg/150ml 4levofloxacin iv soln 25 mg/ml 4levofloxacin oral soln 25 mg/ml^ 2levofloxacin tab 250 mg^ 2levofloxacin tab 500 mg^ 2levofloxacin tab 750 mg^ 2LINEZOLID - linezolid in sodium chloride iv soln

600 mg/300ml-0.9%5

linezolid for susp 100 mg/5ml 5 PAlinezolid iv soln 600 mg/300ml (2 mg/ml) 5linezolid tab 600 mg 5 PAmeropenem iv for soln 500 mg 4meropenem iv for soln 1 gm 4methenamine hippurate tab 1 gm^ 2METRO IV - metronidazole in nacl 0.74% iv soln 500 mg/100ml 4metronidazole cap 375 mg^ 2metronidazole in nacl 0.79% iv soln 500 mg/100ml 4metronidazole tab 250 mg^ 2metronidazole tab 500 mg^ 2metronidazole vaginal gel 0.75%^ 2minocycline hcl cap 50 mg 4minocycline hcl cap 75 mg 4minocycline hcl cap 100 mg 4minocycline hcl tab 50 mg 4minocycline hcl tab 75 mg 4minocycline hcl tab 100 mg 4moxifloxacin hcl tab 400 mg^ 2moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8% inj 3NAFCILLIN SODIUM - nafcillin sodium for iv soln 1 gm 4NAFCILLIN SODIUM - nafcillin sodium for iv soln 2 gm 4

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

11

Drug Name Drug Tier Requirements/Limitsnafcillin sodium for inj 1 gm 4nafcillin sodium for inj 2 gm 4nafcillin sodium for inj 10 gm 5neomycin sulfate tab 500 mg^ 2neomycin-polymyxin b gu irrigation soln^ 2nitrofurantoin macrocrystalline cap 50 mg# 4 PAnitrofurantoin macrocrystalline cap 100 mg# 4 PAnitrofurantoin monohydrate macrocrystalline cap 100 mg# 4 PAnitrofurantoin susp 25 mg/5ml# 4 PAofloxacin tab 400 mg^ 2paromomycin sulfate cap 250 mg^ 2penicillin g potassium for inj 5000000 unit 4penicillin g potassium for inj 20000000 unit 4PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g

potassium inj 20000 unit/ml in dextrose4

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 40000 unit/ml in dextrose

4

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 60000 unit/ml in dextrose

4

PENICILLIN G SODIUM - penicillin g sodium for inj 5000000 unit 4penicillin v potassium for soln 125 mg/5ml^ 2penicillin v potassium for soln 250 mg/5ml^ 2penicillin v potassium tab 250 mg^ 2penicillin v potassium tab 500 mg^ 2piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm) 4piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) 4piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) 4SIVEXTRO - tedizolid phosphate for iv soln 200 mg 5SIVEXTRO - tedizolid phosphate tab 200 mg 5 PASTREPTOMYCIN SULFATE - streptomycin sulfate for inj 1 gm 4SULFADIAZINE - sulfadiazine tab 500 mg 4sulfamethoxazole-trimethoprim susp 200-40 mg/5ml^ 2sulfamethoxazole-trimethoprim tab 400-80 mg^ 2sulfamethoxazole-trimethoprim tab 800-160 mg^ 2SULFAMETHOXAZOLE/TRIMETHOPRIM - sulfamethoxazole-

trimethoprim iv soln 400-80 mg/5ml4

SUPRAX - cefixime cap 400 mg 4SUPRAX - cefixime chew tab 100 mg 4SUPRAX - cefixime chew tab 200 mg 4

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.12

Drug Name Drug Tier Requirements/LimitsSYNERCID - quinupristin-dalfopristin for inj 500 mg (150-350 mg) 5TEFLARO - ceftaroline fosamil for iv soln 400 mg 5TEFLARO - ceftaroline fosamil for iv soln 600 mg 5tetracycline hcl cap 250 mg^ 2tetracycline hcl cap 500 mg^ 2TOBRAMYCIN SULFATE - tobramycin sulfate inj 2 gm/50ml

(40 mg/ml)4

tobramycin sulfate for inj 1.2 gm 4tobramycin sulfate inj 10 mg/ml 4tobramycin sulfate inj 80 mg/2ml (40 mg/ml) 4tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) 4trimethoprim tab 100 mg^ 2TYGACIL - tigecycline for iv soln 50 mg 5vancomycin hcl cap 125 mg 4vancomycin hcl cap 250 mg 5vancomycin hcl for inj 100 gm 4vancomycin hcl for inj 500 mg 4vancomycin hcl for inj 750 mg 4vancomycin hcl for inj 1000 mg 4vancomycin hcl for inj 5000 mg 4vancomycin hcl for inj 10 gm 4VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl in dextrose

5% inj 500 mg/100ml4

VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl in dextrose5% inj 750 mg/150ml

4

VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl in dextrose5% inj 1 gm/200ml

4

XIFAXAN - rifaximin tab 550 mg 5ZOSYN - piperacillin sod-tazobactam sod in dex iv soln

2-0.25gm/50ml4

ZOSYN - piperacillin sod-tazobactam sod in dex iv soln4-0.5gm/100ml

4

ZOSYN - piperacillin sod-tazobactam sod in dex iv sol3-0.375gm/50ml

4

ZYVOX - linezolid for susp 100 mg/5ml 5 PAAnticonvulsantsAPTIOM - eslicarbazepine acetate tab 200 mg 5APTIOM - eslicarbazepine acetate tab 400 mg 5APTIOM - eslicarbazepine acetate tab 600 mg 5APTIOM - eslicarbazepine acetate tab 800 mg 5BANZEL - rufinamide susp 40 mg/ml 5

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

13

Drug Name Drug Tier Requirements/LimitsBANZEL - rufinamide tab 200 mg 4BANZEL - rufinamide tab 400 mg 5BRIVIACT - brivaracetam iv soln 50 mg/5ml 4BRIVIACT - brivaracetam oral soln 10 mg/ml 5BRIVIACT - brivaracetam tab 10 mg 5BRIVIACT - brivaracetam tab 25 mg 5BRIVIACT - brivaracetam tab 50 mg 5BRIVIACT - brivaracetam tab 75 mg 5BRIVIACT - brivaracetam tab 100 mg 5carbamazepine cap er 12hr 100 mg^ 2carbamazepine cap er 12hr 200 mg^ 2carbamazepine cap er 12hr 300 mg^ 2carbamazepine chew tab 100 mg^ 2carbamazepine susp 100 mg/5ml^ 2carbamazepine tab er 12hr 100 mg^ 2carbamazepine tab er 12hr 200 mg^ 2carbamazepine tab er 12hr 400 mg^ 2carbamazepine tab 200 mg^ 2CELONTIN - methsuximide cap 300 mg 4clonazepam orally disintegrating tab 0.125 mg^ 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.25 mg^ 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.5 mg^ 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 1 mg^ 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 2 mg^ 2 PA, QL (300 tablets/30 days)clonazepam tab 0.5 mg^ 2 PA, QL (120 tablets/30 days)clonazepam tab 1 mg^ 2 PA, QL (120 tablets/30 days)clonazepam tab 2 mg^ 2 PA, QL (300 tablets/30 days)clorazepate dipotassium tab 3.75 mg^ 2 PA, QL (120 tablets/30 days)clorazepate dipotassium tab 7.5 mg^ 2 PA, QL (90 tablets/30 days)clorazepate dipotassium tab 15 mg^ 2 PA, QL (180 tablets/30 days)DIASTAT ACUDIAL - diazepam rectal gel delivery system 10 mg 4 QL (5 twin pack(s)/30 days)DIASTAT ACUDIAL - diazepam rectal gel delivery system 20 mg 4 QL (5 twin pack(s)/30 days)DIASTAT PEDIATRIC - diazepam rectal gel delivery system 2.5 mg 4 QL (5 twin pack(s)/30 days)DIAZEPAM - diazepam oral soln 1 mg/ml 4 PA, QL (1200 mls/30 days)diazepam conc 5 mg/ml^ 2 PA, QL (240 mls/30 days)DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system

2.5 mg4 QL (5 twin pack(s)/30 days)

DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system10 mg

4 QL (5 twin pack(s)/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.14

Drug Name Drug Tier Requirements/LimitsDIAZEPAM RECTAL GEL - diazepam rectal gel delivery system

20 mg4 QL (5 twin pack(s)/30 days)

diazepam tab 2 mg^ 2 PA, QL (120 tablets/30 days)diazepam tab 5 mg^ 2 PA, QL (120 tablets/30 days)diazepam tab 10 mg^ 2 PA, QL (120 tablets/30 days)DILANTIN - phenytoin sodium extended cap 30 mg 4divalproex sodium cap delayed release sprinkle 125 mg^ 2divalproex sodium tab delayed release 125 mg^ 2divalproex sodium tab delayed release 250 mg^ 2divalproex sodium tab delayed release 500 mg^ 2divalproex sodium tab er 24 hr 250 mg^ 2divalproex sodium tab er 24 hr 500 mg^ 2ethosuximide cap 250 mg^ 2ethosuximide soln 250 mg/5ml^ 2felbamate susp 600 mg/5ml^ 2felbamate tab 400 mg^ 2felbamate tab 600 mg^ 2fosphenytoin sodium inj 100 mg/2ml 3fosphenytoin sodium inj 500 mg/10ml 3FYCOMPA - perampanel susp 0.5 mg/ml 4FYCOMPA - perampanel tab 2 mg 4FYCOMPA - perampanel tab 4 mg 4FYCOMPA - perampanel tab 6 mg 4FYCOMPA - perampanel tab 8 mg 4FYCOMPA - perampanel tab 10 mg 4FYCOMPA - perampanel tab 12 mg 4gabapentin cap 100 mg^ 2 QL (1080 capsules/30 days)gabapentin cap 300 mg^ 2 QL (360 capsules/30 days)gabapentin cap 400 mg^ 2 QL (270 capsules/30 days)gabapentin oral soln 250 mg/5ml^ 2 QL (2160 mls/30 days)gabapentin tab 600 mg^ 2 QL (180 tablets/30 days)gabapentin tab 800 mg^ 2 QL (135 tablets/30 days)GABITRIL - tiagabine hcl tab 12 mg 4GABITRIL - tiagabine hcl tab 16 mg 4lamotrigine tab chewable dispersible 5 mg^ 2lamotrigine tab chewable dispersible 25 mg^ 2lamotrigine tab 25 mg^ 2lamotrigine tab 100 mg^ 2lamotrigine tab 150 mg^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

15

Drug Name Drug Tier Requirements/Limitslamotrigine tab 200 mg^ 2levetiracetam in sodium chloride iv soln 500 mg/100ml 4levetiracetam in sodium chloride iv soln 1000 mg/100ml 4levetiracetam in sodium chloride iv soln 1500 mg/100ml 4levetiracetam inj 500 mg/5ml (100 mg/ml) 3levetiracetam oral soln 100 mg/ml^ 2levetiracetam tab 250 mg^ 2levetiracetam tab 500 mg^ 2levetiracetam tab 750 mg^ 2levetiracetam tab 1000 mg^ 2LYRICA - pregabalin cap 25 mg 3LYRICA - pregabalin cap 50 mg 3LYRICA - pregabalin cap 75 mg 3LYRICA - pregabalin cap 100 mg 3LYRICA - pregabalin cap 150 mg 3LYRICA - pregabalin cap 200 mg 3LYRICA - pregabalin cap 225 mg 3LYRICA - pregabalin cap 300 mg 3LYRICA - pregabalin soln 20 mg/ml 3ONFI - clobazam suspension 2.5 mg/ml 4 PA, QL (480 mls/30 days)ONFI - clobazam tab 10 mg 4 PA, QL (60 tablets/30 days)ONFI - clobazam tab 20 mg 4 PA, QL (60 tablets/30 days)oxcarbazepine susp 300 mg/5ml (60 mg/ml)^ 2oxcarbazepine tab 150 mg^ 2oxcarbazepine tab 300 mg^ 2oxcarbazepine tab 600 mg^ 2PEGANONE - ethotoin tab 250 mg 4PHENOBARBITAL - phenobarbital tab 15 mg# 4 PAPHENOBARBITAL - phenobarbital tab 30 mg# 4 PAPHENOBARBITAL - phenobarbital tab 60 mg# 4 PAPHENOBARBITAL - phenobarbital tab 100 mg# 4 PAphenobarbital elixir 20 mg/5ml# 4 PAPHENOBARBITAL SODIUM - phenobarbital sodium inj 65 mg/ml# 4 PAPHENOBARBITAL SODIUM - phenobarbital sodium inj 130 mg/ml# 4 PAphenobarbital tab 16.2 mg# 4 PAphenobarbital tab 32.4 mg# 4 PAphenobarbital tab 64.8 mg# 4 PAphenobarbital tab 97.2 mg# 4 PA

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.16

Drug Name Drug Tier Requirements/Limitsphenytoin chew tab 50 mg^ 2phenytoin sodium extended cap 100 mg^ 2phenytoin sodium extended cap 200 mg^ 2phenytoin sodium extended cap 300 mg^ 2phenytoin susp 125 mg/5ml^ 2primidone tab 50 mg^ 2primidone tab 250 mg^ 2SABRIL - vigabatrin powd pack 500 mg* 4SABRIL - vigabatrin tab 500 mg* 5SPRITAM - levetiracetam tab disintegrating soluble 250 mg 4SPRITAM - levetiracetam tab disintegrating soluble 500 mg 4SPRITAM - levetiracetam tab disintegrating soluble 750 mg 4SPRITAM - levetiracetam tab disintegrating soluble 1000 mg 4tiagabine hcl tab 2 mg^ 2tiagabine hcl tab 4 mg^ 2topiramate sprinkle cap 15 mg^ 2topiramate sprinkle cap 25 mg^ 2topiramate tab 25 mg^ 2topiramate tab 50 mg^ 2topiramate tab 100 mg^ 2topiramate tab 200 mg^ 2valproate sodium inj 100 mg/ml 3valproate sodium oral soln 250 mg/5ml^ 2valproic acid cap 250 mg^ 2vigabatrin powd pack 500 mg^* 2VIMPAT - lacosamide iv inj 200 mg/20ml (10 mg/ml) 3VIMPAT - lacosamide oral solution 10 mg/ml 3VIMPAT - lacosamide tab 50 mg 3VIMPAT - lacosamide tab 100 mg 3VIMPAT - lacosamide tab 150 mg 3VIMPAT - lacosamide tab 200 mg 3zonisamide cap 25 mg^ 2zonisamide cap 50 mg^ 2zonisamide cap 100 mg^ 2Antidementia Agentsdonepezil hydrochloride orally disintegrating tab 5 mg^ 2donepezil hydrochloride orally disintegrating tab 10 mg^ 2donepezil hydrochloride tab 5 mg^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

17

Drug Name Drug Tier Requirements/Limitsdonepezil hydrochloride tab 10 mg^ 2donepezil hydrochloride tab 23 mg^ 2ERGOLOID MESYLATES - ergoloid mesylates tab 1 mg# 3 PAGALANTAMINE HYDROBROMIDE - galantamine hydrobromide

oral soln 4 mg/ml4

galantamine hydrobromide cap er 24hr 8 mg^ 2galantamine hydrobromide cap er 24hr 16 mg^ 2galantamine hydrobromide cap er 24hr 24 mg^ 2galantamine hydrobromide tab 4 mg^ 2galantamine hydrobromide tab 8 mg^ 2galantamine hydrobromide tab 12 mg^ 2memantine hcl oral solution 2 mg/ml^ 2 PAmemantine hcl tab 5 mg^ 2 PAmemantine hcl tab 10 mg^ 2 PAmemantine hcl tab 5 mg (28) & 10 mg (21) titration pak^ 2 PArivastigmine tartrate cap 1.5 mg^ 2rivastigmine tartrate cap 3 mg^ 2rivastigmine tartrate cap 4.5 mg^ 2rivastigmine tartrate cap 6 mg^ 2rivastigmine td patch 24hr 4.6 mg/24hr^ 2rivastigmine td patch 24hr 9.5 mg/24hr^ 2rivastigmine td patch 24hr 13.3 mg/24hr^ 2AntidepressantsABILIFY MAINTENA - aripiprazole im for er susp prefilled syringe

300 mg5 PA, QL (1 syringe

or vial/28 days)ABILIFY MAINTENA - aripiprazole im for er susp prefilled syringe

400 mg5 PA, QL (1 syringe

or vial/28 days)ABILIFY MAINTENA - aripiprazole im for extended release susp

300 mg5 PA, QL (1 syringe

or vial/28 days)ABILIFY MAINTENA - aripiprazole im for extended release susp

400 mg5 PA, QL (1 syringe

or vial/28 days)amitriptyline hcl tab 10 mg# 4 PAamitriptyline hcl tab 25 mg# 4 PAamitriptyline hcl tab 50 mg# 4 PAamitriptyline hcl tab 75 mg# 4 PAamitriptyline hcl tab 100 mg# 4 PAamitriptyline hcl tab 150 mg# 4 PAAMOXAPINE - amoxapine tab 25 mg 4AMOXAPINE - amoxapine tab 50 mg 4AMOXAPINE - amoxapine tab 100 mg 4

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.18

Drug Name Drug Tier Requirements/LimitsAMOXAPINE - amoxapine tab 150 mg 4aripiprazole oral solution 1 mg/ml 4 PA, QL (750 mls/30 days)aripiprazole orally disintegrating tab 10 mg 5 PA, QL (60 tablets/30 days)aripiprazole orally disintegrating tab 15 mg 5 PA, QL (60 tablets/30 days)aripiprazole tab 2 mg 4 PA, QL (45 tablets/30 days)aripiprazole tab 5 mg 4 PA, QL (45 tablets/30 days)aripiprazole tab 10 mg 4 PA, QL (30 tablets/30 days)aripiprazole tab 15 mg 4 PA, QL (30 tablets/30 days)aripiprazole tab 20 mg 4 PA, QL (30 tablets/30 days)aripiprazole tab 30 mg 4 PA, QL (30 tablets/30 days)bupropion hcl tab er 12hr 100 mg^ 2 QL (90 tablets/30 days)bupropion hcl tab er 12hr 150 mg^ 2 QL (60 tablets/30 days)bupropion hcl tab er 12hr 200 mg^ 2 QL (60 tablets/30 days)bupropion hcl tab er 24hr 150 mg^ 2 QL (90 tablets/30 days)bupropion hcl tab er 24hr 300 mg^ 2 QL (30 tablets/30 days)bupropion hcl tab 75 mg^ 2 QL (60 tablets/30 days)bupropion hcl tab 100 mg^ 2 QL (120 tablets/30 days)citalopram hydrobromide oral soln 10 mg/5ml^ 2 QL (600 mls/30 days)citalopram hydrobromide tab 10 mg^ 1 QL (45 tablets/30 days)citalopram hydrobromide tab 20 mg^ 1 QL (45 tablets/30 days)citalopram hydrobromide tab 40 mg^ 1 QL (30 tablets/30 days)clomipramine hcl cap 25 mg# 4 PAclomipramine hcl cap 50 mg# 4 PAclomipramine hcl cap 75 mg# 4 PAdesipramine hcl tab 10 mg^ 2desipramine hcl tab 25 mg^ 2desipramine hcl tab 50 mg^ 2desipramine hcl tab 75 mg^ 2desipramine hcl tab 100 mg^ 2desipramine hcl tab 150 mg^ 2desvenlafaxine succinate tab er 24hr 25 mg^ 2 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 50 mg^ 2 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 100 mg^ 2 QL (30 tablets/30 days)doxepin hcl cap 10 mg# 4 PAdoxepin hcl cap 25 mg# 4 PAdoxepin hcl cap 50 mg# 4 PAdoxepin hcl cap 75 mg# 4 PAdoxepin hcl cap 100 mg# 4 PA

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

19

Drug Name Drug Tier Requirements/Limitsdoxepin hcl cap 150 mg# 4 PAdoxepin hcl conc 10 mg/ml# 4 PAduloxetine hcl enteric coated pellets cap 20 mg^ 2 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 30 mg^ 2 QL (90 capsules/30 days)duloxetine hcl enteric coated pellets cap 60 mg^ 2 QL (60 capsules/30 days)EMSAM - selegiline td patch 24hr 6 mg/24hr 5EMSAM - selegiline td patch 24hr 9 mg/24hr 5EMSAM - selegiline td patch 24hr 12 mg/24hr 5escitalopram oxalate soln 5 mg/5ml^ 2 QL (600 mls/30 days)escitalopram oxalate tab 5 mg^ 1 QL (45 tablets/30 days)escitalopram oxalate tab 10 mg^ 1 QL (45 tablets/30 days)escitalopram oxalate tab 20 mg^ 1 QL (30 tablets/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 20 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 40 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 80 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 120 mg 4 QL (30 capsules/30 days)FETZIMA TITRATION PACK - levomilnacipran hcl cap er 24hr 20 &

40 mg therapy pack4 QL (28 capsules/28 days)

fluoxetine hcl cap delayed release 90 mg^ 2 QL (4 capsules/28 days)fluoxetine hcl cap 10 mg^ 2 QL (90 capsules/30 days)fluoxetine hcl cap 20 mg^ 2 QL (120 capsules/30 days)fluoxetine hcl cap 40 mg^ 2 QL (60 capsules/30 days)fluoxetine hcl solution 20 mg/5ml^ 2 QL (600 mls/30 days)fluoxetine hcl tab 10 mg^ 2 QL (90 tablets/30 days)fluoxetine hcl tab 20 mg^ 2 QL (120 tablets/30 days)fluvoxamine maleate tab 25 mg^ 2 QL (30 tablets/30 days)fluvoxamine maleate tab 50 mg^ 2 QL (30 tablets/30 days)fluvoxamine maleate tab 100 mg^ 2 QL (90 tablets/30 days)imipramine hcl tab 10 mg# 4 PAimipramine hcl tab 25 mg# 4 PAimipramine hcl tab 50 mg# 4 PAMAPROTILINE HCL - maprotiline hcl tab 25 mg 4 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 50 mg 4 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 75 mg 4 QL (90 tablets/30 days)MARPLAN - isocarboxazid tab 10 mg 4mirtazapine orally disintegrating tab 15 mg^ 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 30 mg^ 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 45 mg^ 2 QL (30 tablets/30 days)mirtazapine tab 7.5 mg^ 1 QL (30 tablets/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.20

Drug Name Drug Tier Requirements/Limitsmirtazapine tab 15 mg^ 1 QL (45 tablets/30 days)mirtazapine tab 30 mg^ 1 QL (30 tablets/30 days)mirtazapine tab 45 mg^ 1 QL (30 tablets/30 days)NEFAZODONE HCL - nefazodone hcl tab 100 mg 4NEFAZODONE HCL - nefazodone hcl tab 150 mg 4NEFAZODONE HCL - nefazodone hcl tab 200 mg 4nefazodone hcl tab 50 mg^ 2nefazodone hcl tab 250 mg^ 2NORTRIPTYLINE HCL - nortriptyline hcl soln 10 mg/5ml 4nortriptyline hcl cap 10 mg^ 2nortriptyline hcl cap 25 mg^ 2nortriptyline hcl cap 50 mg^ 2nortriptyline hcl cap 75 mg^ 2paroxetine hcl tab 10 mg^ 2 QL (45 tablets/30 days)paroxetine hcl tab 20 mg^ 2 QL (30 tablets/30 days)paroxetine hcl tab 30 mg^ 2 QL (60 tablets/30 days)paroxetine hcl tab 40 mg^ 2 QL (45 tablets/30 days)PAXIL - paroxetine hcl oral susp 10 mg/5ml 4 QL (900 mls/30 days)phenelzine sulfate tab 15 mg^ 2PRISTIQ - desvenlafaxine succinate tab er 24hr 25 mg 4 QL (30 tablets/30 days)PRISTIQ - desvenlafaxine succinate tab er 24hr 50 mg 4 QL (30 tablets/30 days)PRISTIQ - desvenlafaxine succinate tab er 24hr 100 mg 4 QL (30 tablets/30 days)protriptyline hcl tab 5 mg^ 2protriptyline hcl tab 10 mg^ 2quetiapine fumarate tab 25 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 50 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 100 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 200 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 300 mg^ 2 PA, QL (60 tablets/30 days)quetiapine fumarate tab 400 mg^ 2 PA, QL (60 tablets/30 days)REXULTI - brexpiprazole tab 0.25 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 0.5 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 1 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 2 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 3 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 4 mg 5 PA, QL (30 tablets/30 days)sertraline hcl oral conc 20 mg/ml^ 2 QL (300 mls/30 days)sertraline hcl tab 25 mg^ 1 QL (45 tablets/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

21

Drug Name Drug Tier Requirements/Limitssertraline hcl tab 50 mg^ 1 QL (45 tablets/30 days)sertraline hcl tab 100 mg^ 1 QL (60 tablets/30 days)tranylcypromine sulfate tab 10 mg^ 2trazodone hcl tab 50 mg^ 2trazodone hcl tab 100 mg^ 2trazodone hcl tab 150 mg^ 2trazodone hcl tab 300 mg^ 2trimipramine maleate cap 25 mg# 4 PAtrimipramine maleate cap 50 mg# 4 PAtrimipramine maleate cap 100 mg# 4 PATRINTELLIX - vortioxetine hbr tab 5 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 10 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 20 mg 4 QL (30 tablets/30 days)venlafaxine hcl cap er 24hr 37.5 mg^ 2 QL (60 capsules/30 days)venlafaxine hcl cap er 24hr 75 mg^ 2 QL (90 capsules/30 days)venlafaxine hcl cap er 24hr 150 mg^ 2 QL (30 capsules/30 days)venlafaxine hcl tab er 24hr 37.5 mg^ 2 QL (60 tablets/30 days)venlafaxine hcl tab er 24hr 75 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab er 24hr 150 mg^ 2 QL (30 tablets/30 days)venlafaxine hcl tab 25 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 37.5 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 50 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 75 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 100 mg^ 2 QL (90 tablets/30 days)VIIBRYD - vilazodone hcl tab 10 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 20 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 40 mg 4 QL (30 tablets/30 days)VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 10 (7) &

20 (23) mg4 QL (1 kit/30 days)

AntiemeticsALOXI - palonosetron hcl iv soln 0.25 mg/5ml 4aprepitant capsule therapy pack 80 & 125 mg^ 2 BDaprepitant capsule 40 mg^ 2 BDaprepitant capsule 80 mg^ 2 BDaprepitant capsule 125 mg^ 2 BDCHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/ml 4 PACHLORPROMAZINE HCL - chlorpromazine hcl inj 50 mg/2ml 4 PAchlorpromazine hcl tab 10 mg^ 2 PAchlorpromazine hcl tab 25 mg^ 2 PA

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.22

Drug Name Drug Tier Requirements/Limitschlorpromazine hcl tab 50 mg^ 2 PAchlorpromazine hcl tab 100 mg^ 2 PAchlorpromazine hcl tab 200 mg^ 2 PAdiphenhydramine hcl inj 50 mg/ml 4dronabinol cap 2.5 mg^ 2 BDdronabinol cap 5 mg^ 2 BDdronabinol cap 10 mg^ 2 BDEMEND - aprepitant capsule 40 mg 4 BDEMEND - aprepitant capsule 80 mg 4 BDEMEND - aprepitant capsule 125 mg 4 BDEMEND - fosaprepitant dimeglumine for iv infusion 150 mg 4EMEND TRIPACK - aprepitant capsule therapy pack 80 & 125 mg 4 BDgranisetron hcl tab 1 mg^ 2 BDhydroxyzine hcl syrup 10 mg/5ml# 4 PAhydroxyzine hcl tab 10 mg# 4 PAhydroxyzine hcl tab 25 mg# 4 PAhydroxyzine hcl tab 50 mg# 4 PAmeclizine hcl tab 12.5 mg^ 2metoclopramide hcl inj 5 mg/ml 4metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 4metoclopramide hcl tab 5 mg^ 2metoclopramide hcl tab 10 mg^ 2ondansetron hcl inj 4 mg/2ml (2 mg/ml) 4ondansetron hcl inj 40 mg/20ml (2 mg/ml) 4ondansetron hcl oral soln 4 mg/5ml^ 2 BDondansetron hcl tab 4 mg^ 2 BDondansetron hcl tab 8 mg^ 2 BDondansetron hcl tab 24 mg^ 2 BDondansetron orally disintegrating tab 4 mg^ 2 BDondansetron orally disintegrating tab 8 mg^ 2 BDperphenazine tab 2 mg^ 2 PAperphenazine tab 4 mg^ 2 PAperphenazine tab 8 mg^ 2 PAperphenazine tab 16 mg^ 2 PAprochlorperazine edisylate inj 5 mg/ml 4prochlorperazine maleate tab 5 mg^ 2prochlorperazine maleate tab 10 mg^ 2prochlorperazine suppos 25 mg^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

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Drug Name Drug Tier Requirements/Limitspromethazine hcl suppos 12.5 mg# 4 PApromethazine hcl suppos 25 mg# 4 PApromethazine hcl syrup 6.25 mg/5ml# 4 PApromethazine hcl tab 12.5 mg# 4 PApromethazine hcl tab 25 mg# 4 PApromethazine hcl tab 50 mg# 4 PAAntifungalsAMBISOME - amphotericin b liposome iv for susp 50 mg 5 BDAMPHOTERICIN B - amphotericin b for inj 50 mg 4 BDCANCIDAS - caspofungin acetate for iv soln 50 mg 5CANCIDAS - caspofungin acetate for iv soln 70 mg 5caspofungin acetate for iv soln 50 mg 5clotrimazole troche 10 mg^ 2CRESEMBA - isavuconazonium sulfate cap 186 mg 5 PACRESEMBA - isavuconazonium sulfate for iv soln 372 mg 5 PAfluconazole for susp 10 mg/ml^ 2fluconazole for susp 40 mg/ml^ 2fluconazole in dextrose inj 200 mg/100ml 4fluconazole in dextrose inj 400 mg/200ml 4fluconazole in nacl 0.9% inj 200 mg/100ml 4fluconazole in nacl 0.9% inj 400 mg/200ml 4fluconazole tab 50 mg^ 2fluconazole tab 100 mg^ 2fluconazole tab 150 mg^ 2fluconazole tab 200 mg^ 2flucytosine cap 250 mg 5flucytosine cap 500 mg 5griseofulvin microsize susp 125 mg/5ml^ 2griseofulvin ultramicrosize tab 125 mg^ 2griseofulvin ultramicrosize tab 250 mg^ 2itraconazole cap 100 mg^ 2ketoconazole tab 200 mg^ 2MYCAMINE - micafungin sodium for iv soln 50 mg 5MYCAMINE - micafungin sodium for iv soln 100 mg 5NOXAFIL - posaconazole iv soln 300 mg/16.7ml (18 mg/ml) 4 PANOXAFIL - posaconazole susp 40 mg/ml 5 PANOXAFIL - posaconazole tab delayed release 100 mg 5 PAnystatin susp 100000 unit/ml^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.24

Drug Name Drug Tier Requirements/Limitsnystatin tab 500000 unit^ 2terbinafine hcl tab 250 mg^ 2terconazole vaginal cream 0.4%^ 2terconazole vaginal cream 0.8%^ 2terconazole vaginal suppos 80 mg^ 2voriconazole for inj 200 mg 4 PAvoriconazole for susp 40 mg/ml 5 PAvoriconazole tab 50 mg 5 PAvoriconazole tab 200 mg 5 PAAntigout Agentsallopurinol sodium for inj 500 mg^ 2allopurinol tab 100 mg^ 1allopurinol tab 300 mg^ 1ALOPRIM - allopurinol sodium for inj 500 mg 4colchicine w/ probenecid tab 0.5-500 mg^ 2COLCRYS - colchicine tab 0.6 mg 3probenecid tab 500 mg^ 2ULORIC - febuxostat tab 40 mg 3ULORIC - febuxostat tab 80 mg 3Anti-Inflammatory Agentscelecoxib cap 50 mg^ 2 QL (60 capsules/30 days)celecoxib cap 100 mg^ 2 QL (60 capsules/30 days)celecoxib cap 200 mg^ 2 QL (60 capsules/30 days)celecoxib cap 400 mg^ 2 QL (30 capsules/30 days)diclofenac potassium tab 50 mg^ 2 QL (120 tablets/30 days)diclofenac sodium gel 1%^ 2 STdiclofenac sodium tab delayed release 25 mg^ 2 QL (240 tablets/30 days)diclofenac sodium tab delayed release 50 mg^ 2 QL (120 tablets/30 days)diclofenac sodium tab delayed release 75 mg^ 2 QL (60 tablets/30 days)diclofenac sodium tab er 24hr 100 mg^ 2 QL (60 tablets/30 days)diclofenac w/ misoprostol tab delayed release 50-0.2 mg^ 2 QL (120 tablets/30 days)diclofenac w/ misoprostol tab delayed release 75-0.2 mg^ 2 QL (90 tablets/30 days)etodolac cap 200 mg^ 2 QL (150 capsules/30 days)etodolac cap 300 mg^ 2 QL (90 capsules/30 days)etodolac tab er 24hr 400 mg^ 2 QL (60 tablets/30 days)etodolac tab er 24hr 500 mg^ 2 QL (60 tablets/30 days)etodolac tab er 24hr 600 mg^ 2 QL (30 tablets/30 days)etodolac tab 400 mg^ 2 QL (60 tablets/30 days)etodolac tab 500 mg^ 2 QL (60 tablets/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

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Drug Name Drug Tier Requirements/Limitsflurbiprofen tab 50 mg^ 2 QL (180 tablets/30 days)flurbiprofen tab 100 mg^ 2 QL (90 tablets/30 days)ibuprofen susp 100 mg/5ml^ 2 QL (4800 mls/30 days)ibuprofen tab 400 mg^ 2 QL (240 tablets/30 days)ibuprofen tab 600 mg^ 2 QL (150 tablets/30 days)ibuprofen tab 800 mg^ 2 QL (120 tablets/30 days)ketoprofen cap 50 mg^ 2 QL (180 capsules/30 days)ketoprofen cap 75 mg^ 2 QL (120 capsules/30 days)meloxicam tab 7.5 mg^ 2 QL (60 tablets/30 days)meloxicam tab 15 mg^ 2 QL (30 tablets/30 days)nabumetone tab 500 mg^ 2 QL (120 tablets/30 days)nabumetone tab 750 mg^ 2 QL (60 tablets/30 days)naproxen sodium tab 275 mg^ 2 QL (150 tablets/30 days)naproxen sodium tab 550 mg^ 2 QL (90 tablets/30 days)naproxen susp 125 mg/5ml^ 2 QL (1800 mls/30 days)naproxen tab ec 375 mg^ 2 QL (120 tablets/30 days)naproxen tab ec 500 mg^ 2 QL (90 tablets/30 days)naproxen tab 250 mg^ 2 QL (180 tablets/30 days)naproxen tab 375 mg^ 2 QL (120 tablets/30 days)naproxen tab 500 mg^ 2 QL (90 tablets/30 days)oxaprozin tab 600 mg^ 2 QL (90 tablets/30 days)piroxicam cap 10 mg^ 2 QL (60 capsules/30 days)piroxicam cap 20 mg^ 2 QL (30 capsules/30 days)sulindac tab 150 mg^ 2 QL (60 tablets/30 days)sulindac tab 200 mg^ 2 QL (60 tablets/30 days)tolmetin sodium cap 400 mg^ 2 QL (120 capsules/30 days)Antimigraine Agentsbutalbital-acetaminophen tab 50-325 mg# 4 PA, QL (180 tablets/30 days)butalbital-acetaminophen-caffeine cap 50-300-40 mg# 4 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caffeine cap 50-325-40 mg# 4 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caffeine tab 50-325-40 mg# 4 PA, QL (180 tablets/30 days)butalbital-aspirin-caffeine cap 50-325-40 mg# 4 PA, QL (180 capsules/30 days)divalproex sodium cap delayed release sprinkle 125 mg^ 2divalproex sodium tab delayed release 125 mg^ 2divalproex sodium tab delayed release 250 mg^ 2divalproex sodium tab delayed release 500 mg^ 2divalproex sodium tab er 24 hr 250 mg^ 2divalproex sodium tab er 24 hr 500 mg^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.26

Drug Name Drug Tier Requirements/LimitsMIGERGOT - ergotamine w/ caffeine suppos 2-100 mg 4MIGRANAL - dihydroergotamine mesylate nasal spray 4 mg/ml 3naratriptan hcl tab 1 mg^ 2 QL (18 tablets/30 days)naratriptan hcl tab 2.5 mg^ 2 QL (18 tablets/30 days)propranolol hcl cap er 24hr 60 mg^ 2propranolol hcl cap er 24hr 80 mg^ 2propranolol hcl cap er 24hr 120 mg^ 2propranolol hcl cap er 24hr 160 mg^ 2propranolol hcl inj 1 mg/ml 3propranolol hcl tab 10 mg^ 1propranolol hcl tab 20 mg^ 1propranolol hcl tab 40 mg^ 1propranolol hcl tab 60 mg^ 1propranolol hcl tab 80 mg^ 1rizatriptan benzoate oral disintegrating tab 5 mg^ 2 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 10 mg^ 2 QL (18 tablets/30 days)rizatriptan benzoate tab 5 mg^ 2 QL (18 tablets/30 days)rizatriptan benzoate tab 10 mg^ 2 QL (18 tablets/30 days)sumatriptan nasal spray 5 mg/act^ 2 QL (12 units (2

packages)/30 days)sumatriptan nasal spray 20 mg/act^ 2 QL (12 units (2

packages)/30 days)SUMATRIPTAN SUCCINATE - sumatriptan succinate solution

prefilled syringe 6 mg/0.5ml4

sumatriptan succinate inj 6 mg/0.5ml 4sumatriptan succinate solution auto-injector 4 mg/0.5ml 4sumatriptan succinate solution auto-injector 6 mg/0.5ml 4sumatriptan succinate solution cartridge 4 mg/0.5ml 4sumatriptan succinate solution cartridge 6 mg/0.5ml 4sumatriptan succinate tab 25 mg^ 2 QL (18 tablets/30 days)sumatriptan succinate tab 50 mg^ 2 QL (18 tablets/30 days)sumatriptan succinate tab 100 mg^ 2 QL (18 tablets/30 days)TIMOLOL MALEATE - timolol maleate tab 5 mg 4TIMOLOL MALEATE - timolol maleate tab 10 mg 4TIMOLOL MALEATE - timolol maleate tab 20 mg 4topiramate sprinkle cap 15 mg^ 2topiramate sprinkle cap 25 mg^ 2topiramate tab 25 mg^ 2topiramate tab 50 mg^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

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Drug Name Drug Tier Requirements/Limitstopiramate tab 100 mg^ 2topiramate tab 200 mg^ 2Antimyasthenic AgentsGUANIDINE HCL - guanidine hcl tab 125 mg 4MESTINON - pyridostigmine bromide syrup 60 mg/5ml 4pyridostigmine bromide tab er 180 mg^ 2pyridostigmine bromide tab 60 mg^ 2AntimycobacterialsCAPASTAT SULFATE - capreomycin sulfate for inj 1 gm 4CYCLOSERINE - cycloserine cap 250 mg 5dapsone tab 25 mg^ 2dapsone tab 100 mg^ 2ethambutol hcl tab 100 mg^ 2ethambutol hcl tab 400 mg^ 2ISONIAZID - isoniazid inj 100 mg/ml 4isoniazid tab 100 mg^ 2isoniazid tab 300 mg^ 2PASER - aminosalicylic acid er granules packet 4 gm 4PRIFTIN - rifapentine tab 150 mg 4pyrazinamide tab 500 mg^ 2rifabutin cap 150 mg^ 2rifampin cap 150 mg^ 2rifampin cap 300 mg^ 2rifampin for inj 600 mg 4SIRTURO - bedaquiline fumarate tab 100 mg 5TRECATOR - ethionamide tab 250 mg 4AntineoplasticsABRAXANE - paclitaxel protein-bound particles for iv susp 100 mg 5AFINITOR - everolimus tab 2.5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 7.5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 10 mg 5 PA, QL (30 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 2 mg 5 PA, QL (60 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 3 mg 5 PA, QL (90 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 5 mg 5 PA, QL (60 tablets/30 days)ALECENSA - alectinib hcl cap 150 mg* 5 PA, QL (240 capsules/30 days)ALIMTA - pemetrexed disodium for iv soln 100 mg 5ALIMTA - pemetrexed disodium for iv soln 500 mg 5ALIQOPA - copanlisib hcl for iv soln 60 mg 5

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.28

Drug Name Drug Tier Requirements/LimitsALUNBRIG - brigatinib tab 30 mg 5 PA, QL (180 tablets/30 days)anastrozole tab 1 mg^ 2ARRANON - nelarabine iv soln 5 mg/ml 5ARZERRA - ofatumumab conc for iv infusion 100 mg/5ml* 5ARZERRA - ofatumumab conc for iv infusion 1000 mg/50ml* 5AVASTIN - bevacizumab iv soln 100 mg/4ml (for infusion)* 5AVASTIN - bevacizumab iv soln 400 mg/16ml (for infusion)* 5azacitidine for inj 100 mg 5BAVENCIO - avelumab soln for iv infusion 200 mg/10ml (20 mg/ml) 5BELEODAQ - belinostat for iv inj 500 mg* 5BENDEKA - bendamustine hcl iv soln 100 mg/4ml (25 mg/ml) 5BESPONSA - inotuzumab ozogamicin for iv soln 0.9 mg 5bexarotene cap 75 mg 5 PAbicalutamide tab 50 mg^ 2BICNU - carmustine for inj 100 mg 4BLEO 15K - bleomycin sulf for inj 15 usp unit(15000 international

unit)4 BD

bleomycin sulfate for inj 15 unit 4 BDbleomycin sulfate for inj 30 unit 3 BDBLINCYTO - blinatumomab for iv infusion 35 mcg* 5 BDBOSULIF - bosutinib tab 100 mg 5 PA, QL (120 tablets/30 days)BOSULIF - bosutinib tab 500 mg 5 PA, QL (30 tablets/30 days)busulfan inj 6 mg/ml 5BUSULFEX - busulfan inj 6 mg/ml 5CABOMETYX - cabozantinib s-malate tab 20 mg 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 40 mg 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 60 mg 5 PA, QL (30 tablets/30 days)CAPRELSA - vandetanib tab 100 mg* 5 PA, QL (60 tablets/30 days)CAPRELSA - vandetanib tab 300 mg* 5 PA, QL (30 tablets/30 days)carboplatin iv soln 50 mg/5ml 3carboplatin iv soln 150 mg/15ml 3carboplatin iv soln 450 mg/45ml 3carboplatin iv soln 600 mg/60ml 3CISPLATIN - cisplatin inj 200 mg/200ml (1 mg/ml) 3cisplatin inj 50 mg/50ml (1 mg/ml) 3cisplatin inj 100 mg/100ml (1 mg/ml) 3cladribine iv soln 10 mg/10ml (1 mg/ml) 5 BDclofarabine iv soln 1 mg/ml 5CLOLAR - clofarabine iv soln 1 mg/ml 5

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

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Drug Name Drug Tier Requirements/LimitsCOMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100

dose) kit*5 PA, QL (56 capsules/28 days)

COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140dose) kit*

5 PA, QL (112 capsules/28 days)

COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg dose)kit*

5 PA, QL (84 capsules/28 days)

COSMEGEN - dactinomycin for inj 0.5 mg 5COTELLIC - cobimetinib fumarate tab 20 mg* 5 PA, QL (63 tablets/28 days)CYCLOPHOSPHAMIDE - cyclophosphamide cap 25 mg 4 BDCYCLOPHOSPHAMIDE - cyclophosphamide cap 50 mg 4 BDcyclophosphamide for inj 500 mg 5cyclophosphamide for inj 1 gm 5cyclophosphamide for inj 2 gm 5CYRAMZA - ramucirumab iv soln 100 mg/10ml (for infusion)* 5CYRAMZA - ramucirumab iv soln 500 mg/50ml (for infusion)* 5cytarabine inj pf 20 mg/ml 4 BDcytarabine inj pf 100 mg/ml 3 BDcytarabine inj 20 mg/ml 3 BDDACARBAZINE - dacarbazine for inj 100 mg 4dacarbazine for inj 200 mg 3DARZALEX - daratumumab iv soln 100 mg/5ml* 5DARZALEX - daratumumab iv soln 400 mg/20ml* 5daunorubicin hcl inj 5 mg/ml 3decitabine for inj 50 mg 5dexrazoxane for inj 250 mg 5dexrazoxane for inj 500 mg 5DOCETAXEL - docetaxel for inj conc 20 mg/ml 5DOCETAXEL - docetaxel for inj conc 80 mg/4ml (20 mg/ml) 5DOCETAXEL - docetaxel for inj conc 160 mg/8ml (20 mg/ml) 5DOCETAXEL - docetaxel for inj conc 200 mg/10ml (20 mg/ml) 5DOCETAXEL - docetaxel soln for iv infusion 20 mg/2ml 5DOCETAXEL - docetaxel soln for iv infusion 80 mg/8ml 5DOCETAXEL - docetaxel soln for iv infusion 160 mg/16ml 5DOCETAXEL - docetaxel soln for iv infusion 200 mg/20ml 5docetaxel for inj conc 20 mg/ml 5docetaxel for inj conc 80 mg/4ml (20 mg/ml) 5DOXORUBICIN HCL - doxorubicin hcl for inj 10 mg 4 BDDOXORUBICIN HCL - doxorubicin hcl for inj 50 mg 4 BDdoxorubicin hcl inj 2 mg/ml 3 BD

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.30

Drug Name Drug Tier Requirements/Limitsdoxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml 5 BDELITEK - rasburicase for iv soln 1.5 mg 5ELITEK - rasburicase for iv soln 7.5 mg 5EMCYT - estramustine phosphate sodium cap 140 mg 4EMPLICITI - elotuzumab for iv soln 300 mg 5EMPLICITI - elotuzumab for iv soln 400 mg 5epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) 4epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) 4ERBITUX - cetuximab iv soln 100 mg/50ml (2 mg/ml) 5ERBITUX - cetuximab iv soln 200 mg/100ml (2 mg/ml) 5ERIVEDGE - vismodegib cap 150 mg* 5 PA, QL (30 capsules/30 days)ERWINAZE - asparaginase erwinia chrysanthemi for inj 10000 unit 5ETOPOPHOS - etoposide phosphate iv for inj 100 mg 4etoposide inj 100 mg/5ml (20 mg/ml) 3etoposide inj 500 mg/25ml (20 mg/ml) 3etoposide inj 1 gm/50ml (20 mg/ml) 3EVOMELA - melphalan hcl for inj 50 mg 5exemestane tab 25 mg^ 2FARESTON - toremifene citrate tab 60 mg 5FARYDAK - panobinostat lactate cap 10 mg* 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 15 mg* 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 20 mg* 5 PA, QL (6 capsules/21 days)FASLODEX - fulvestrant inj 250 mg/5ml 5fludarabine phosphate for inj 50 mg 3fludarabine phosphate inj 25 mg/ml 4fluorouracil inj 500 mg/10ml (50 mg/ml)^ 2 BDfluorouracil inj 1 gm/20ml (50 mg/ml)^ 2 BDfluorouracil inj 2.5 gm/50ml (50 mg/ml)^ 2 BDfluorouracil inj 5 gm/100ml (50 mg/ml)^ 2 BDflutamide cap 125 mg^ 2FOLOTYN - pralatrexate iv inj 20 mg/ml 5FOLOTYN - pralatrexate iv inj 40 mg/2ml 5GAZYVA - obinutuzumab soln for iv infusion 1000 mg/40ml (25 mg/

ml)5

gemcitabine hcl for inj 200 mg^ 2gemcitabine hcl for inj 1 gm^ 2gemcitabine hcl for inj 2 gm^ 2gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml)^ 2gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml)^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

31

Drug Name Drug Tier Requirements/Limitsgemcitabine hcl inj 2 gm/52.6ml (38 mg/ml)^ 2GILOTRIF - afatinib dimaleate tab 20 mg 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 30 mg 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 40 mg 5 PA, QL (30 tablets/30 days)GLEEVEC - imatinib mesylate tab 100 mg 5 PA, QL (90 tablets/30 days)GLEEVEC - imatinib mesylate tab 400 mg 5 PA, QL (60 tablets/30 days)GLEOSTINE - lomustine cap 5 mg 4GLEOSTINE - lomustine cap 10 mg 4GLEOSTINE - lomustine cap 40 mg 4GLEOSTINE - lomustine cap 100 mg 4HALAVEN - eribulin mesylate inj 1 mg/2ml (0.5 mg/ml) 5HERCEPTIN - trastuzumab for iv soln 150 mg* 5HERCEPTIN - trastuzumab for iv soln 440 mg* 5HEXALEN - altretamine cap 50 mg 5 PAHYDROXYPROGESTERONE CAPROATE - hydroxyprogesterone

caproate im in oil 1.25 gm/5ml5

hydroxyurea cap 500 mg^ 2IBRANCE - palbociclib cap 75 mg* 5 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 100 mg* 5 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 125 mg* 5 PA, QL (21 capsules/28 days)ICLUSIG - ponatinib hcl tab 15 mg 5 PA, QL (60 tablets/30 days)ICLUSIG - ponatinib hcl tab 45 mg 5 PA, QL (30 tablets/30 days)idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 5idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 5idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 5IDHIFA - enasidenib mesylate tab 50 mg 5 PA, QL (30 tablets/30 days)IDHIFA - enasidenib mesylate tab 100 mg 5 PA, QL (30 tablets/30 days)IFEX - ifosfamide for inj 3 gm 4IFOSFAMIDE - ifosfamide for inj 3 gm 4ifosfamide for inj 1 gm 3ifosfamide iv inj 1 gm/20ml (50 mg/ml) 4ifosfamide iv inj 3 gm/60ml (50 mg/ml) 4imatinib mesylate tab 100 mg 5 PA, QL (90 tablets/30 days)imatinib mesylate tab 400 mg 5 PA, QL (60 tablets/30 days)IMBRUVICA - ibrutinib cap 140 mg 5 PA, QL (120 capsules/30 days)IMFINZI - durvalumab soln for iv infusion 120 mg/2.4ml (50 mg/ml) 5IMFINZI - durvalumab soln for iv infusion 500 mg/10ml (50 mg/ml) 5IMLYGIC - talimogene laherparepvec intralesional inj 1000000 unit/

ml*4

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.32

Drug Name Drug Tier Requirements/LimitsIMLYGIC - talimogene laherparepvec intralesional inj 100000000

unit/ml*5

INLYTA - axitinib tab 1 mg* 5 PA, QL (180 tablets/30 days)INLYTA - axitinib tab 5 mg* 5 PA, QL (120 tablets/30 days)IRESSA - gefitinib tab 250 mg* 5 PA, QL (30 tablets/30 days)IRINOTECAN - irinotecan hcl inj 500 mg/25ml (20 mg/ml)^ 2irinotecan hcl inj 40 mg/2ml (20 mg/ml)^ 2irinotecan hcl inj 100 mg/5ml (20 mg/ml)^ 2ISTODAX - romidepsin for iv inj 10 mg 5ISTODAX (OVERFILL) - romidepsin for iv inj 10 mg 5IXEMPRA KIT - ixabepilone for iv infusion 15 mg 5IXEMPRA KIT - ixabepilone for iv infusion 45 mg 5JAKAFI - ruxolitinib phosphate tab 5 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 10 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 15 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 20 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 25 mg* 5 PA, QL (60 tablets/30 days)JEVTANA - cabazitaxel inj 60 mg/1.5ml (for iv infusion) 5KADCYLA - ado-trastuzumab emtansine for iv soln 100 mg 5KADCYLA - ado-trastuzumab emtansine for iv soln 160 mg 5KEYTRUDA - pembrolizumab for iv soln 50 mg* 5KEYTRUDA - pembrolizumab iv soln 100 mg/4ml (25 mg/ml)* 5KISQALI - ribociclib succinate tab 200 mg 5 PA, QL (63 tablets/28 days)KISQALI FEMARA 200 DOSE - ribociclib tab 200 mg & letrozole

tab 2.5 mg therapy pack5 PA, QL (91 tablets/28 days)

KISQALI FEMARA 400 DOSE - ribociclib tab 200 mg & letrozoletab 2.5 mg therapy pack

5 PA, QL (91 tablets/28 days)

KISQALI FEMARA 600 DOSE - ribociclib tab 200 mg & letrozoletab 2.5 mg therapy pack

5 PA, QL (91 tablets/28 days)

KYPROLIS - carfilzomib for inj 30 mg 5KYPROLIS - carfilzomib for inj 60 mg 5LARTRUVO - olaratumab soln for iv infusion 190 mg/19ml (10 mg/

ml)5

LARTRUVO - olaratumab soln for iv infusion 500 mg/50ml (10 mg/ml)

5

LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy pack10 mg*

5 PA, QL (30 capsules/30 days)

LENVIMA 14 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 mg*

5 PA, QL (60 capsules/30 days)

LENVIMA 18 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 (2) mg*

5 PA, QL (90 capsules/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

33

Drug Name Drug Tier Requirements/LimitsLENVIMA 20 MG DAILY DOSE - lenvatinib cap therapy pack 10

(2) mg*5 PA, QL (60 capsules/30 days)

LENVIMA 24 MG DAILY DOSE - lenvatinib cap therapy pack 10 (2)& 4 mg*

5 PA, QL (90 capsules/30 days)

LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 4(2) mg*

5 PA, QL (60 capsules/30 days)

letrozole tab 2.5 mg^ 2LEUCOVORIN CALCIUM - leucovorin calcium for inj 500 mg 4LEUCOVORIN CALCIUM - leucovorin calcium tab 10 mg 4LEUCOVORIN CALCIUM - leucovorin calcium tab 15 mg 4leucovorin calcium for inj 50 mg 4leucovorin calcium for inj 100 mg 4leucovorin calcium for inj 200 mg 4leucovorin calcium for inj 350 mg 4leucovorin calcium tab 5 mg^ 2leucovorin calcium tab 25 mg^ 2LEUKERAN - chlorambucil tab 2 mg 3LONSURF - trifluridine-tipiracil tab 15-6.14 mg 5 PA, QL (100 tablets/28 days)LONSURF - trifluridine-tipiracil tab 20-8.19 mg 5 PA, QL (80 tablets/28 days)LYNPARZA - olaparib cap 50 mg* 5 PA, QL (480 capsules/30 days)LYNPARZA - olaparib tab 100 mg* 5 PA, QL (120 tablets/30 days)LYNPARZA - olaparib tab 150 mg* 5 PA, QL (120 tablets/30 days)MARQIBO - vincristine sulfate liposome iv susp 5 mg/31ml

(0.16 mg/ml)5

MATULANE - procarbazine hcl cap 50 mg* 5 PAMEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg* 5 PA, QL (90 tablets/30 days)MEKINIST - trametinib dimethyl sulfoxide tab 2 mg* 5 PA, QL (30 tablets/30 days)melphalan hcl for inj 50 mg 5mercaptopurine tab 50 mg^ 2mesna inj 100 mg/ml 3MESNEX - mesna tab 400 mg 4METHOTREXATE SODIUM - methotrexate sodium inj

250 mg/10ml (25 mg/ml)^2

methotrexate sodium for inj 1 gm^ 2methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)^ 2methotrexate sodium inj pf 100 mg/4ml (25 mg/ml)^ 2methotrexate sodium inj pf 200 mg/8ml (25 mg/ml)^ 2methotrexate sodium inj pf 250 mg/10ml (25 mg/ml)^ 2methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml)^ 2methotrexate sodium inj 50 mg/2ml (25 mg/ml)^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.34

Drug Name Drug Tier Requirements/Limitsmethotrexate sodium tab 2.5 mg^ 2MITOMYCIN - mitomycin for iv soln 5 mg 4mitomycin for iv soln 20 mg 3mitomycin for iv soln 40 mg 3mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) 3mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) 3mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) 3MUSTARGEN - mechlorethamine hcl for inj 10 mg 4MYLOTARG - gemtuzumab ozogamicin for iv soln 4.5 mg 5NERLYNX - neratinib maleate tab 40 mg 5 PA, QL (180 tablets/30 days)NEXAVAR - sorafenib tosylate tab 200 mg* 5 PA, QL (120 tablets/30 days)NILANDRON - nilutamide tab 150 mg 5nilutamide tab 150 mg 5NINLARO - ixazomib citrate cap 2.3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 4 mg 5 PA, QL (3 capsules/28 days)NIPENT - pentostatin for inj 10 mg 5ODOMZO - sonidegib phosphate cap 200 mg* 5 PA, QL (30 capsules/30 days)ONCASPAR - pegaspargase inj 750 unit/ml 5ONIVYDE - irinotecan hcl liposome iv inj 43 mg/10ml (4.3 mg/ml) 5OPDIVO - nivolumab iv soln 40 mg/4ml* 5OPDIVO - nivolumab iv soln 100 mg/10ml* 5oxaliplatin for iv inj 50 mg 5oxaliplatin for iv inj 100 mg 5oxaliplatin iv soln 50 mg/10ml 3oxaliplatin iv soln 100 mg/20ml 3paclitaxel iv conc 30 mg/5ml (6 mg/ml)^ 2paclitaxel iv conc 100 mg/16.7ml (6 mg/ml)^ 2paclitaxel iv conc 300 mg/50ml (6 mg/ml)^ 2PANRETIN - alitretinoin gel 0.1% 5PERJETA - pertuzumab soln for iv infusion 420 mg/14ml (30 mg/

ml)*5

POMALYST - pomalidomide cap 1 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 2 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 3 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 4 mg* 5 PA, QL (21 capsules/28 days)PORTRAZZA - necitumumab iv soln 800 mg/50ml (16 mg/ml)* 5PROLEUKIN - aldesleukin for iv soln 22000000 unit 5PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml)* 5

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

35

Drug Name Drug Tier Requirements/LimitsREVLIMID - lenalidomide caps 2.5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 10 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 15 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 20 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 25 mg* 5 PA, QL (21 capsules/28 days)RITUXAN - rituximab iv soln 100 mg/10ml* 5 PARITUXAN - rituximab iv soln 500 mg/50ml* 5 PARITUXAN HYCELA - rituximab-hyaluronidase human inj

1400-23400 mg-unit/11.7ml5 PA

RITUXAN HYCELA - rituximab-hyaluronidase human inj1600-26800 mg-unit/13.4ml

5 PA

RUBRACA - rucaparib camsylate tab 200 mg 5 PA, QL (120 tablets/30 days)RUBRACA - rucaparib camsylate tab 250 mg 5 PA, QL (120 tablets/30 days)RUBRACA - rucaparib camsylate tab 300 mg 5 PA, QL (120 tablets/30 days)RYDAPT - midostaurin cap 25 mg 5 PA, QL (240 capsules/30 days)SOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml 4SPRYCEL - dasatinib tab 20 mg 5 PA, QL (60 tablets/30 days)SPRYCEL - dasatinib tab 50 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 70 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 80 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 100 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 140 mg 5 PA, QL (30 tablets/30 days)STIVARGA - regorafenib tab 40 mg* 5 PA, QL (84 tablets/28 days)SUTENT - sunitinib malate cap 12.5 mg 5 PA, QL (90 capsules/30 days)SUTENT - sunitinib malate cap 25 mg 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 37.5 mg 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 50 mg 5 PA, QL (30 capsules/30 days)SYLATRON - peginterferon alfa-2b for inj kit 200 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 300 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 600 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 4 x 200 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 4 x 300 mcg 5 PASYLVANT - siltuximab for iv infusion 100 mg 5SYLVANT - siltuximab for iv infusion 400 mg 5SYNRIBO - omacetaxine mepesuccinate for inj 3.5 mg 5TABLOID - thioguanine tab 40 mg 4TAFINLAR - dabrafenib mesylate cap 50 mg* 5 PA, QL (120 capsules/30 days)TAFINLAR - dabrafenib mesylate cap 75 mg* 5 PA, QL (120 capsules/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.36

Drug Name Drug Tier Requirements/LimitsTAGRISSO - osimertinib mesylate tab 40 mg* 5 PA, QL (30 tablets/30 days)TAGRISSO - osimertinib mesylate tab 80 mg* 5 PA, QL (30 tablets/30 days)tamoxifen citrate tab 10 mg^ 2tamoxifen citrate tab 20 mg^ 2TARCEVA - erlotinib hcl tab 25 mg 5 PA, QL (60 tablets/30 days)TARCEVA - erlotinib hcl tab 100 mg 5 PA, QL (30 tablets/30 days)TARCEVA - erlotinib hcl tab 150 mg 5 PA, QL (30 tablets/30 days)TARGRETIN - bexarotene cap 75 mg 5 PATARGRETIN - bexarotene gel 1% 5TASIGNA - nilotinib hcl cap 150 mg 5 PA, QL (120 capsules/30 days)TASIGNA - nilotinib hcl cap 200 mg 5 PA, QL (120 capsules/30 days)TAXOTERE - docetaxel for inj conc 20 mg/ml 5TAXOTERE - docetaxel for inj conc 80 mg/4ml (20 mg/ml) 5TECENTRIQ - atezolizumab iv soln 1200 mg/20ml 5TEMODAR - temozolomide for iv soln 100 mg 5THALOMID - thalidomide cap 50 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 100 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 150 mg 5 PA, QL (60 capsules/30 days)THALOMID - thalidomide cap 200 mg 5 PA, QL (60 capsules/30 days)thiotepa for inj 15 mg 5TOPOTECAN HCL - topotecan hcl inj 4 mg/4ml (for infusion) 5topotecan hcl for inj 4 mg 5TORISEL - temsirolimus soln for iv infusion 25 mg/ml 5TREANDA - bendamustine hcl for iv soln 25 mg 5TREANDA - bendamustine hcl for iv soln 100 mg 5tretinoin cap 10 mg 5 PATRISENOX - arsenic trioxide inj 10 mg/10ml (1 mg/ml) 4TYKERB - lapatinib ditosylate tab 250 mg* 5 PA, QL (180 tablets/30 days)UNITUXIN - dinutuximab iv soln 17.5 mg/5ml (3.5 mg/ml)* 5UVADEX - methoxsalen soln 20 mcg/ml 4VECTIBIX - panitumumab iv soln 100 mg/5ml 5VECTIBIX - panitumumab iv soln 400 mg/20ml 5VELCADE - bortezomib for inj 3.5 mg 5VENCLEXTA - venetoclax tab 10 mg 3 PA, QL (60 tablets/30 days)VENCLEXTA - venetoclax tab 50 mg 4 PA, QL (30 tablets/30 days)VENCLEXTA - venetoclax tab 100 mg 5 PA, QL (120 tablets/30 days)VENCLEXTA STARTING PACK - venetoclax tab therapy starter

pack 10 & 50 & 100 mg5 PA, QL (1 pack (42

tablets)/28 days)VINBLASTINE SULFATE - vinblastine sulfate inj 1 mg/ml 4 BD

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

37

Drug Name Drug Tier Requirements/Limitsvincristine sulfate iv soln 1 mg/ml^ 2 BDvinorelbine tartrate inj 10 mg/ml^ 2vinorelbine tartrate inj 50 mg/5ml (10 mg/ml)^ 2VOTRIENT - pazopanib hcl tab 200 mg* 5 PA, QL (120 tablets/30 days)VYXEOS - daunorubicin-cytarabine liposome for iv inj 44-100 mg 5XALKORI - crizotinib cap 200 mg* 5 PA, QL (60 capsules/30 days)XALKORI - crizotinib cap 250 mg* 5 PA, QL (60 capsules/30 days)XTANDI - enzalutamide cap 40 mg* 5 PA, QL (120 capsules/30 days)YERVOY - ipilimumab soln for iv infusion 50 mg/10ml (5 mg/ml)* 5YERVOY - ipilimumab soln for iv infusion 200 mg/40ml (5 mg/ml)* 5YONDELIS - trabectedin for inj 1 mg 5ZALTRAP - ziv-aflibercept iv soln 100 mg/4ml (for infusion) 5ZALTRAP - ziv-aflibercept iv soln 200 mg/8ml (for infusion) 5ZANOSAR - streptozocin for inj 1 gm 4ZEJULA - niraparib tosylate cap 100 mg 5 PA, QL (90 capsules/30 days)ZELBORAF - vemurafenib tab 240 mg* 5 PA, QL (240 tablets/30 days)ZOLINZA - vorinostat cap 100 mg 5 PA, QL (120 capsules/30 days)ZYDELIG - idelalisib tab 100 mg* 5 PA, QL (60 tablets/30 days)ZYDELIG - idelalisib tab 150 mg* 5 PA, QL (60 tablets/30 days)ZYKADIA - ceritinib cap 150 mg* 5 PA, QL (150 capsules/30 days)ZYTIGA - abiraterone acetate tab 250 mg* 5 PA, QL (120 tablets/30 days)ZYTIGA - abiraterone acetate tab 500 mg* 5 PA, QL (60 tablets/30 days)AntiparasiticsALBENZA - albendazole tab 200 mg 4ALINIA - nitazoxanide for susp 100 mg/5ml 4ALINIA - nitazoxanide tab 500 mg 4atovaquone susp 750 mg/5ml 5atovaquone-proguanil hcl tab 62.5-25 mg^ 2atovaquone-proguanil hcl tab 250-100 mg^ 2BILTRICIDE - praziquantel tab 600 mg 4chloroquine phosphate tab 250 mg^ 2chloroquine phosphate tab 500 mg^ 2COARTEM - artemether-lumefantrine tab 20-120 mg 4DARAPRIM - pyrimethamine tab 25 mg 5hydroxychloroquine sulfate tab 200 mg^ 2ivermectin tab 3 mg^ 2lindane shampoo 1%^ 2malathion lotion 0.5%^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.38

Drug Name Drug Tier Requirements/Limitsmefloquine hcl tab 250 mg^ 2NEBUPENT - pentamidine isethionate for nebulization soln 300 mg 4 BDPENTAM 300 - pentamidine isethionate for soln 300 mg 4 BDpermethrin cream 5%^ 2PRIMAQUINE PHOSPHATE - primaquine phosphate tab 26.3 mg 4Antiparkinson Agentsamantadine hcl cap 100 mg^ 2amantadine hcl syrup 50 mg/5ml^ 2amantadine hcl tab 100 mg^ 2APOKYN - apomorphine hcl soln cartridge 30 mg/3ml* 5AZILECT - rasagiline mesylate tab 0.5 mg 3AZILECT - rasagiline mesylate tab 1 mg 3benztropine mesylate tab 0.5 mg# 3 PAbenztropine mesylate tab 1 mg# 3 PAbenztropine mesylate tab 2 mg# 3 PAbromocriptine mesylate cap 5 mg^ 2bromocriptine mesylate tab 2.5 mg^ 2carbidopa & levodopa orally disintegrating tab 10-100 mg^ 2carbidopa & levodopa orally disintegrating tab 25-100 mg^ 2carbidopa & levodopa orally disintegrating tab 25-250 mg^ 2carbidopa & levodopa tab er 25-100 mg^ 2carbidopa & levodopa tab er 50-200 mg^ 2carbidopa & levodopa tab 10-100 mg^ 2carbidopa & levodopa tab 25-100 mg^ 2carbidopa & levodopa tab 25-250 mg^ 2carbidopa tab 25 mg 5CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-

entacapone tabs 12.5-50-200 mg^2

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 18.75-75-200 mg^

2

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 25-100-200 mg^

2

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 31.25-125-200 mg^

2

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 37.5-150-200 mg^

2

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 50-200-200 mg^

2

diphenhydramine hcl inj 50 mg/ml 4entacapone tab 200 mg^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

39

Drug Name Drug Tier Requirements/LimitsNEUPRO - rotigotine td patch 24hr 1 mg/24hr 3NEUPRO - rotigotine td patch 24hr 2 mg/24hr 3NEUPRO - rotigotine td patch 24hr 3 mg/24hr 3NEUPRO - rotigotine td patch 24hr 4 mg/24hr 3NEUPRO - rotigotine td patch 24hr 6 mg/24hr 3NEUPRO - rotigotine td patch 24hr 8 mg/24hr 3NUPLAZID - pimavanserin tartrate tab 17 mg 5 PA, QL (60 tablets/30 days)pramipexole dihydrochloride tab 0.125 mg^ 2pramipexole dihydrochloride tab 0.25 mg^ 2pramipexole dihydrochloride tab 0.5 mg^ 2pramipexole dihydrochloride tab 0.75 mg^ 2pramipexole dihydrochloride tab 1 mg^ 2pramipexole dihydrochloride tab 1.5 mg^ 2rasagiline mesylate tab 0.5 mg^ 2rasagiline mesylate tab 1 mg^ 2ropinirole hydrochloride tab 0.25 mg^ 2ropinirole hydrochloride tab 0.5 mg^ 2ropinirole hydrochloride tab 1 mg^ 2ropinirole hydrochloride tab 2 mg^ 2ropinirole hydrochloride tab 3 mg^ 2ropinirole hydrochloride tab 4 mg^ 2ropinirole hydrochloride tab 5 mg^ 2selegiline hcl cap 5 mg^ 2selegiline hcl tab 5 mg^ 2tolcapone tab 100 mg 5AntipsychoticsABILIFY MAINTENA - aripiprazole im for er susp prefilled syringe

300 mg5 PA, QL (1 syringe

or vial/28 days)ABILIFY MAINTENA - aripiprazole im for er susp prefilled syringe

400 mg5 PA, QL (1 syringe

or vial/28 days)ABILIFY MAINTENA - aripiprazole im for extended release susp

300 mg5 PA, QL (1 syringe

or vial/28 days)ABILIFY MAINTENA - aripiprazole im for extended release susp

400 mg5 PA, QL (1 syringe

or vial/28 days)ADASUVE - loxapine aerosol powder breath activated 10 mg 4 PAaripiprazole oral solution 1 mg/ml 4 PA, QL (750 mls/30 days)aripiprazole orally disintegrating tab 10 mg 5 PA, QL (60 tablets/30 days)aripiprazole orally disintegrating tab 15 mg 5 PA, QL (60 tablets/30 days)aripiprazole tab 2 mg 4 PA, QL (45 tablets/30 days)

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Drug Name Drug Tier Requirements/Limitsaripiprazole tab 5 mg 4 PA, QL (45 tablets/30 days)aripiprazole tab 10 mg 4 PA, QL (30 tablets/30 days)aripiprazole tab 15 mg 4 PA, QL (30 tablets/30 days)aripiprazole tab 20 mg 4 PA, QL (30 tablets/30 days)aripiprazole tab 30 mg 4 PA, QL (30 tablets/30 days)CHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/ml 4 PACHLORPROMAZINE HCL - chlorpromazine hcl inj 50 mg/2ml 4 PAchlorpromazine hcl tab 10 mg^ 2 PAchlorpromazine hcl tab 25 mg^ 2 PAchlorpromazine hcl tab 50 mg^ 2 PAchlorpromazine hcl tab 100 mg^ 2 PAchlorpromazine hcl tab 200 mg^ 2 PAclozapine orally disintegrating tab 25 mg^ 2 PA, QL (270 tablets/30 days)clozapine orally disintegrating tab 100 mg^ 2 PA, QL (270 tablets/30 days)clozapine tab 25 mg^ 2 PA, QL (90 tablets/30 days)clozapine tab 50 mg^ 2 PA, QL (90 tablets/30 days)clozapine tab 100 mg^ 2 PA, QL (270 tablets/30 days)clozapine tab 200 mg^ 2 PA, QL (120 tablets/30 days)FANAPT - iloperidone tab 1 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 2 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 4 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 6 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 8 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 10 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 12 mg 4 PA, QL (60 tablets/30 days)FANAPT TITRATION PACK - iloperidone tab 1 mg & 2 mg & 4 mg

& 6 mg titration pak4 PA, QL (7 packs (56

tablets)/28 days)fluphenazine decanoate inj 25 mg/ml 4 PAFLUPHENAZINE HCL - fluphenazine hcl elixir 2.5 mg/5ml 4 PAFLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml 4 PAFLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml 4 PAfluphenazine hcl tab 1 mg^ 2 PAfluphenazine hcl tab 2.5 mg^ 2 PAfluphenazine hcl tab 5 mg^ 2 PAfluphenazine hcl tab 10 mg^ 2 PAGEODON - ziprasidone mesylate for inj 20 mg 4 PA, QL (60 vials/30 days)haloperidol decanoate im soln 50 mg/ml 4 PAhaloperidol decanoate im soln 100 mg/ml 4 PAhaloperidol lactate inj 5 mg/ml 4 PA

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Drug Name Drug Tier Requirements/Limitshaloperidol lactate oral conc 2 mg/ml^ 2 PAhaloperidol tab 0.5 mg^ 2 PAhaloperidol tab 1 mg^ 2 PAhaloperidol tab 2 mg^ 2 PAhaloperidol tab 5 mg^ 2 PAhaloperidol tab 10 mg^ 2 PAhaloperidol tab 20 mg^ 2 PAINVEGA - paliperidone tab er 24hr 1.5 mg 5 PA, QL (30 tablets/30 days)INVEGA - paliperidone tab er 24hr 3 mg 5 PA, QL (30 tablets/30 days)INVEGA - paliperidone tab er 24hr 6 mg 5 PA, QL (60 tablets/30 days)INVEGA - paliperidone tab er 24hr 9 mg 5 PA, QL (30 tablets/30 days)INVEGA SUSTENNA - paliperidone palmitate im extend-release

susp 117 mg/0.75ml5 PA, QL (1 kit/28 days)

INVEGA SUSTENNA - paliperidone palmitate im extended-releasesusp 39 mg/0.25ml

4 PA, QL (1 kit/28 days)

INVEGA SUSTENNA - paliperidone palmitate im extended-releasesusp 78 mg/0.5ml

5 PA, QL (1 kit/28 days)

INVEGA SUSTENNA - paliperidone palmitate im extended-releasesusp 156 mg/ml

5 PA, QL (1 kit/28 days)

INVEGA SUSTENNA - paliperidone palmitate im extended-releasesusp 234 mg/1.5ml

5 PA, QL (1 kit/28 days)

INVEGA TRINZA - paliperidone palmitate im extend-release susp273 mg/0.875ml

5 PA, QL (1 kit/90 days)

INVEGA TRINZA - paliperidone palmitate im extend-release susp410 mg/1.315ml

5 PA, QL (1 kit/90 days)

INVEGA TRINZA - paliperidone palmitate im extend-release susp546 mg/1.75ml

5 PA, QL (1 kit/90 days)

INVEGA TRINZA - paliperidone palmitate im extend-release susp819 mg/2.625ml

5 PA, QL (1 kit/90 days)

LATUDA - lurasidone hcl tab 20 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 40 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 60 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 80 mg 5 PA, QL (60 tablets/30 days)LATUDA - lurasidone hcl tab 120 mg 5 PA, QL (30 tablets/30 days)loxapine succinate cap 5 mg^ 2 PAloxapine succinate cap 10 mg^ 2 PAloxapine succinate cap 25 mg^ 2 PAloxapine succinate cap 50 mg^ 2 PANUPLAZID - pimavanserin tartrate tab 17 mg 5 PA, QL (60 tablets/30 days)olanzapine for im inj 10 mg 4 PA, QL (90 vials/30 days)olanzapine orally disintegrating tab 5 mg^ 2 PA, QL (30 tablets/30 days)

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Drug Name Drug Tier Requirements/Limitsolanzapine orally disintegrating tab 10 mg^ 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 15 mg^ 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 20 mg^ 2 PA, QL (30 tablets/30 days)olanzapine tab 2.5 mg^ 2 PA, QL (45 tablets/30 days)olanzapine tab 5 mg^ 2 PA, QL (45 tablets/30 days)olanzapine tab 7.5 mg^ 2 PA, QL (45 tablets/30 days)olanzapine tab 10 mg^ 2 PA, QL (45 tablets/30 days)olanzapine tab 15 mg^ 2 PA, QL (30 tablets/30 days)olanzapine tab 20 mg^ 2 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 1.5 mg^ 2 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 3 mg^ 2 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 6 mg^ 2 PA, QL (60 tablets/30 days)paliperidone tab er 24hr 9 mg 5 PA, QL (30 tablets/30 days)perphenazine tab 2 mg^ 2 PAperphenazine tab 4 mg^ 2 PAperphenazine tab 8 mg^ 2 PAperphenazine tab 16 mg^ 2 PApimozide tab 1 mg^ 2pimozide tab 2 mg^ 2prochlorperazine edisylate inj 5 mg/ml 4prochlorperazine maleate tab 5 mg^ 2prochlorperazine maleate tab 10 mg^ 2prochlorperazine suppos 25 mg^ 2quetiapine fumarate tab 25 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 50 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 100 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 200 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 300 mg^ 2 PA, QL (60 tablets/30 days)quetiapine fumarate tab 400 mg^ 2 PA, QL (60 tablets/30 days)REXULTI - brexpiprazole tab 0.25 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 0.5 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 1 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 2 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 3 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 4 mg 5 PA, QL (30 tablets/30 days)RISPERDAL CONSTA - risperidone microspheres for inj 12.5 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 25 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 37.5 mg 4 PA, QL (2 vials/28 days)

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Drug Name Drug Tier Requirements/LimitsRISPERDAL CONSTA - risperidone microspheres for inj 50 mg 5 PA, QL (2 vials/28 days)risperidone orally disintegrating tab 0.25 mg^ 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 0.5 mg^ 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 1 mg^ 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 2 mg^ 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 3 mg^ 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 4 mg^ 2 PA, QL (120 tablets/30 days)risperidone soln 1 mg/ml^ 2 PA, QL (480 mls/30 days)risperidone tab 0.25 mg^ 2 PA, QL (60 tablets/30 days)risperidone tab 0.5 mg^ 2 PA, QL (60 tablets/30 days)risperidone tab 1 mg^ 2 PA, QL (60 tablets/30 days)risperidone tab 2 mg^ 2 PA, QL (60 tablets/30 days)risperidone tab 3 mg^ 2 PA, QL (60 tablets/30 days)risperidone tab 4 mg^ 2 PA, QL (120 tablets/30 days)SAPHRIS - asenapine maleate sl tab 2.5 mg 4 PA, QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 5 mg 4 PA, QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 10 mg 4 PA, QL (60 tablets/30 days)thioridazine hcl tab 10 mg# 4 PAthioridazine hcl tab 25 mg# 4 PAthioridazine hcl tab 50 mg# 4 PAthioridazine hcl tab 100 mg# 4 PAthiothixene cap 1 mg^ 2 PAthiothixene cap 2 mg^ 2 PAthiothixene cap 5 mg^ 2 PAthiothixene cap 10 mg^ 2 PAtrifluoperazine hcl tab 1 mg^ 2 PAtrifluoperazine hcl tab 2 mg^ 2 PAtrifluoperazine hcl tab 5 mg^ 2 PAtrifluoperazine hcl tab 10 mg^ 2 PAVERSACLOZ - clozapine susp 50 mg/ml 5 PA, QL (540 mls/30 days)VRAYLAR - cariprazine hcl cap 1.5 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 3 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 4.5 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 6 mg 5 PA, QL (30 capsules/30 days)ziprasidone hcl cap 20 mg^ 2 PA, QL (90 capsules/30 days)ziprasidone hcl cap 40 mg^ 2 PA, QL (90 capsules/30 days)ziprasidone hcl cap 60 mg^ 2 PA, QL (60 capsules/30 days)ziprasidone hcl cap 80 mg^ 2 PA, QL (60 capsules/30 days)

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Drug Name Drug Tier Requirements/LimitsZYPREXA RELPREVV - olanzapine pamoate for extended rel im

susp 210 mg4 PA, QL (2 vials/28 days)

ZYPREXA RELPREVV - olanzapine pamoate for extended rel imsusp 300 mg

5 PA, QL (2 vials/28 days)

ZYPREXA RELPREVV - olanzapine pamoate for extended rel imsusp 405 mg

5 PA, QL (1 vial/28 days)

Antispasticity Agentsbaclofen tab 10 mg^ 1baclofen tab 20 mg^ 1dantrolene sodium cap 25 mg^ 2dantrolene sodium cap 50 mg^ 2dantrolene sodium cap 100 mg^ 2tizanidine hcl cap 2 mg^ 2tizanidine hcl cap 4 mg^ 2tizanidine hcl cap 6 mg^ 2tizanidine hcl tab 2 mg^ 1tizanidine hcl tab 4 mg^ 1Antiviralsabacavir sulfate soln 20 mg/ml 4 QL (960 mls/30 days)abacavir sulfate tab 300 mg^ 2 QL (60 tablets/30 days)abacavir sulfate-lamivudine tab 600-300 mg 5 QL (30 tablets/30 days)abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg 5 QL (60 tablets/30 days)acyclovir cap 200 mg^ 2acyclovir sodium for inj 500 mg 4 BDacyclovir sodium iv soln 50 mg/ml 4 BDacyclovir susp 200 mg/5ml^ 2acyclovir tab 400 mg^ 2acyclovir tab 800 mg^ 2adefovir dipivoxil tab 10 mg 5amantadine hcl cap 100 mg^ 2amantadine hcl syrup 50 mg/5ml^ 2amantadine hcl tab 100 mg^ 2APTIVUS - tipranavir cap 250 mg 5 QL (120 capsules/30 days)APTIVUS - tipranavir oral soln 100 mg/ml 5 QL (380 mls/30 days)ATRIPLA - efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg 5 QL (30 tablets/30 days)BARACLUDE - entecavir oral soln 0.05 mg/ml 4cidofovir iv inj 75 mg/ml 5COMPLERA - emtricitabine-rilpivirine-tenofovir df tab

200-25-300 mg5 QL (30 tablets/30 days)

CRIXIVAN - indinavir sulfate cap 200 mg 3 QL (270 capsules/30 days)

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Drug Name Drug Tier Requirements/LimitsCRIXIVAN - indinavir sulfate cap 400 mg 3 QL (180 capsules/30 days)DAKLINZA - daclatasvir dihydrochloride tab 30 mg 5 PADAKLINZA - daclatasvir dihydrochloride tab 60 mg 5 PADAKLINZA - daclatasvir dihydrochloride tab 90 mg 5 PADESCOVY - emtricitabine-tenofovir alafenamide fumarate tab

200-25 mg5 QL (30 tablets/30 days)

didanosine delayed release capsule 125 mg^ 2 QL (30 capsules/30 days)didanosine delayed release capsule 200 mg^ 2 QL (30 capsules/30 days)didanosine delayed release capsule 250 mg^ 2 QL (30 capsules/30 days)didanosine delayed release capsule 400 mg^ 2 QL (30 capsules/30 days)EDURANT - rilpivirine hcl tab 25 mg 5 QL (30 tablets/30 days)EMTRIVA - emtricitabine caps 200 mg 4 QL (30 capsules/30 days)EMTRIVA - emtricitabine soln 10 mg/ml 4 QL (850 mls/30 days)entecavir tab 0.5 mg 5entecavir tab 1 mg 5EPCLUSA - sofosbuvir-velpatasvir tab 400-100 mg 5 PAEPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv) 3EPZICOM - abacavir sulfate-lamivudine tab 600-300 mg 5 QL (30 tablets/30 days)EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg 5 QL (30 tablets/30 days)famciclovir tab 125 mg^ 2famciclovir tab 250 mg^ 2famciclovir tab 500 mg^ 2fosamprenavir calcium tab 700 mg 5 QL (120 tablets/30 days)FUZEON - enfuvirtide for inj 90 mg 5 QL (60 vials/30 days)ganciclovir sodium for inj 500 mg 3 BDGENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab

150-150-200-10 mg5 QL (30 tablets/30 days)

HARVONI - ledipasvir-sofosbuvir tab 90-400 mg 5 PAINTELENCE - etravirine tab 25 mg 4 QL (120 tablets/30 days)INTELENCE - etravirine tab 100 mg 4 QL (60 tablets/30 days)INTELENCE - etravirine tab 200 mg 5 QL (60 tablets/30 days)INTRON A - interferon alfa-2b inj 6000000 unit/ml 5INTRON A - interferon alfa-2b inj 10000000 unit/ml 5INTRON A - interferon alfa-2b for inj 10000000 unit 5INTRON A - interferon alfa-2b for inj 18000000 unit 5INTRON A - interferon alfa-2b for inj 50000000 unit 5INTRON A W/DILUENT - interferon alfa-2b for inj 10000000 unit 5INTRON A W/DILUENT - interferon alfa-2b for inj 18000000 unit 5INTRON A W/DILUENT - interferon alfa-2b for inj 50000000 unit 5

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Drug Name Drug Tier Requirements/LimitsINVIRASE - saquinavir mesylate cap 200 mg 5 QL (300 capsules/30 days)INVIRASE - saquinavir mesylate tab 500 mg 5 QL (120 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 25 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 100 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium packet for susp 100 mg 4 QL (60 packets/30 days)ISENTRESS - raltegravir potassium tab 400 mg 5 QL (60 tablets/30 days)ISENTRESS HD - raltegravir potassium tab 600 mg 5 QL (60 tablets/30 days)KALETRA - lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 5 QL (480 mls/30 days)KALETRA - lopinavir-ritonavir tab 100-25 mg 4 QL (300 tablets/30 days)KALETRA - lopinavir-ritonavir tab 200-50 mg 5 QL (120 tablets/30 days)lamivudine oral soln 10 mg/ml^ 2 QL (960 mls/30 days)lamivudine tab 100 mg (hbv)^ 2lamivudine tab 150 mg^ 2 QL (60 tablets/30 days)lamivudine tab 300 mg^ 2 QL (30 tablets/30 days)lamivudine-zidovudine tab 150-300 mg 4 QL (60 tablets/30 days)LEXIVA - fosamprenavir calcium susp 50 mg/ml 4 QL (1800 mls/30 days)LEXIVA - fosamprenavir calcium tab 700 mg 5 QL (120 tablets/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 5 QL (480 mls/30 days)MAVYRET - glecaprevir-pibrentasvir tab 100-40 mg 5 PANEVIRAPINE - nevirapine susp 50 mg/5ml 4 QL (1200 mls/30 days)nevirapine tab er 24hr 100 mg^ 2 QL (90 tablets/30 days)nevirapine tab er 24hr 400 mg^ 2 QL (30 tablets/30 days)nevirapine tab 200 mg^ 2 QL (60 tablets/30 days)NORVIR - ritonavir cap 100 mg 4 QL (360 capsules/30 days)NORVIR - ritonavir oral soln 80 mg/ml 4 QL (480 mls/30 days)NORVIR - ritonavir tab 100 mg 4 QL (360 tablets/30 days)ODEFSEY - emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg 5 QL (30 tablets/30 days)OLYSIO - simeprevir sodium cap 150 mg 5 PAoseltamivir phosphate cap 30 mg^ 2oseltamivir phosphate cap 45 mg^ 2oseltamivir phosphate cap 75 mg^ 2PEG-INTRON REDIPEN - peginterferon alfa-2b for inj kit

120 mcg/0.5ml5 PA

PEG-INTRON REDIPEN PAK 4 - peginterferon alfa-2b for inj kit120 mcg/0.5ml

5 PA

PEGASYS - peginterferon alfa-2a inj 180 mcg/ml 5 PAPEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPEGASYS PROCLICK - peginterferon alfa-2a inj 135 mcg/0.5ml 5 PAPEGASYS PROCLICK - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PA

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Drug Name Drug Tier Requirements/LimitsPEGINTRON - peginterferon alfa-2b for inj kit 50 mcg/0.5ml 5 PAPEGINTRON - peginterferon alfa-2b for inj kit 80 mcg/0.5ml 5 PAPEGINTRON - peginterferon alfa-2b for inj kit 120 mcg/0.5ml 5 PAPEGINTRON - peginterferon alfa-2b for inj kit 150 mcg/0.5ml 5 PAPREZCOBIX - darunavir-cobicistat tab 800-150 mg 5 QL (30 tablets/30 days)PREZISTA - darunavir ethanolate susp 100 mg/ml 5 QL (400 mls/30 days)PREZISTA - darunavir ethanolate tab 75 mg 4 QL (300 tablets/30 days)PREZISTA - darunavir ethanolate tab 150 mg 4 QL (180 tablets/30 days)PREZISTA - darunavir ethanolate tab 600 mg 5 QL (60 tablets/30 days)PREZISTA - darunavir ethanolate tab 800 mg 5 QL (30 tablets/30 days)REBETOL - ribavirin soln 40 mg/ml 4RESCRIPTOR - delavirdine mesylate tab 100 mg 4 QL (360 tablets/30 days)RESCRIPTOR - delavirdine mesylate tab 200 mg 4 QL (180 tablets/30 days)RETROVIR IV INFUSION - zidovudine iv soln 10 mg/ml 4REYATAZ - atazanavir sulfate cap 150 mg 5 QL (30 capsules/30 days)REYATAZ - atazanavir sulfate cap 200 mg 5 QL (60 capsules/30 days)REYATAZ - atazanavir sulfate cap 300 mg 5 QL (30 capsules/30 days)REYATAZ - atazanavir sulfate oral powder packet 50 mg 5 QL (240 packets/30 days)RIBASPHERE - ribavirin tab 400 mg 4RIBASPHERE - ribavirin tab 600 mg 5RIBASPHERE RIBAPAK - ribavirin tab 400 mg 5RIBASPHERE RIBAPAK - ribavirin tab 600 mg 5ribavirin cap 200 mg^ 2ribavirin for inhal soln 6 gm 5ribavirin tab 200 mg^ 2rimantadine hydrochloride tab 100 mg^ 2SELZENTRY - maraviroc oral soln 20 mg/ml 5 QL (1840 mls/30 days)SELZENTRY - maraviroc tab 25 mg 4 QL (240 tablets/30 days)SELZENTRY - maraviroc tab 75 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 150 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 300 mg 5 QL (120 tablets/30 days)SOVALDI - sofosbuvir tab 400 mg 5 PAstavudine cap 15 mg^ 2 QL (60 capsules/30 days)stavudine cap 20 mg^ 2 QL (60 capsules/30 days)stavudine cap 30 mg^ 2 QL (60 capsules/30 days)stavudine cap 40 mg^ 2 QL (60 capsules/30 days)STRIBILD - elvitegrav-cobic-emtricitab-tenofovdf tab

150-150-200-300 mg5 QL (30 tablets/30 days)

SUSTIVA - efavirenz cap 50 mg 4 QL (90 capsules/30 days)

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Drug Name Drug Tier Requirements/LimitsSUSTIVA - efavirenz cap 200 mg 5 QL (60 capsules/30 days)SUSTIVA - efavirenz tab 600 mg 5 QL (30 tablets/30 days)SYLATRON - peginterferon alfa-2b for inj kit 200 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 300 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 600 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 4 x 200 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 4 x 300 mcg 5 PATAMIFLU - oseltamivir phosphate cap 30 mg 4TAMIFLU - oseltamivir phosphate cap 45 mg 4TAMIFLU - oseltamivir phosphate cap 75 mg 4TAMIFLU - oseltamivir phosphate for susp 6 mg/ml 4TECHNIVIE - ombitasvir-paritaprevir-ritonavir tab 12.5-75-50 mg 5 PATIVICAY - dolutegravir sodium tab 10 mg 4 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 25 mg 5 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 50 mg 5 QL (60 tablets/30 days)TRIUMEQ - abacavir-dolutegravir-lamivudine tab 600-50-300 mg 5 QL (30 tablets/30 days)TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab

100-150 mg5 QL (30 tablets/30 days)

TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab133-200 mg

5 QL (30 tablets/30 days)

TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab167-250 mg

5 QL (30 tablets/30 days)

TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab200-300 mg

5 QL (30 tablets/30 days)

TYBOST - cobicistat tab 150 mg 3 QL (30 tablets/30 days)valacyclovir hcl tab 500 mg^ 2valacyclovir hcl tab 1 gm^ 2VALCYTE - valganciclovir hcl for soln 50 mg/ml 5valganciclovir hcl for soln 50 mg/ml 5valganciclovir hcl tab 450 mg 5VIDEX - didanosine for soln 2 gm 4 QL (1200 mls/30 days)VIDEX - didanosine for soln 4 gm 4 QL (1200 mls/30 days)VIEKIRA PAK - ombitas-paritapre-riton & dasab tab pak 12.5-75-50

& 250 mg5 PA

VIEKIRA XR - dasab-ombit-paritap-riton tab er 24hr200-8.33-50-33.33 mg

5 PA

VIRACEPT - nelfinavir mesylate tab 250 mg 5 QL (270 tablets/30 days)VIRACEPT - nelfinavir mesylate tab 625 mg 5 QL (120 tablets/30 days)VIRAMUNE - nevirapine susp 50 mg/5ml 4 QL (1200 mls/30 days)VIRAZOLE - ribavirin for inhal soln 6 gm 5

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You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

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Drug Name Drug Tier Requirements/LimitsVIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm 5 QL (240 grams/30 days)VIREAD - tenofovir disoproxil fumarate tab 150 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 200 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 250 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 300 mg 5 QL (30 tablets/30 days)VOSEVI - sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg 5 PAZEPATIER - elbasvir-grazoprevir tab 50-100 mg 5 PAZERIT - stavudine for oral soln 1 mg/ml 4 QL (2400 mls/30 days)ZIAGEN - abacavir sulfate soln 20 mg/ml 4 QL (960 mls/30 days)zidovudine cap 100 mg^ 2 QL (180 capsules/30 days)zidovudine syrup 10 mg/ml^ 2 QL (1920 mls/30 days)zidovudine tab 300 mg^ 2 QL (60 tablets/30 days)Anxiolyticsbuspirone hcl tab 5 mg^ 2buspirone hcl tab 7.5 mg^ 2buspirone hcl tab 10 mg^ 2buspirone hcl tab 15 mg^ 2buspirone hcl tab 30 mg^ 2clonazepam orally disintegrating tab 0.125 mg^ 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.25 mg^ 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.5 mg^ 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 1 mg^ 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 2 mg^ 2 PA, QL (300 tablets/30 days)clonazepam tab 0.5 mg^ 2 PA, QL (120 tablets/30 days)clonazepam tab 1 mg^ 2 PA, QL (120 tablets/30 days)clonazepam tab 2 mg^ 2 PA, QL (300 tablets/30 days)clorazepate dipotassium tab 3.75 mg^ 2 PA, QL (120 tablets/30 days)clorazepate dipotassium tab 7.5 mg^ 2 PA, QL (90 tablets/30 days)clorazepate dipotassium tab 15 mg^ 2 PA, QL (180 tablets/30 days)DIAZEPAM - diazepam oral soln 1 mg/ml 4 PA, QL (1200 mls/30 days)diazepam conc 5 mg/ml^ 2 PA, QL (240 mls/30 days)diazepam tab 2 mg^ 2 PA, QL (120 tablets/30 days)diazepam tab 5 mg^ 2 PA, QL (120 tablets/30 days)diazepam tab 10 mg^ 2 PA, QL (120 tablets/30 days)doxepin hcl cap 10 mg# 4 PAdoxepin hcl cap 25 mg# 4 PAdoxepin hcl cap 50 mg# 4 PAdoxepin hcl cap 75 mg# 4 PA

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.50

Drug Name Drug Tier Requirements/Limitsdoxepin hcl cap 100 mg# 4 PAdoxepin hcl cap 150 mg# 4 PAdoxepin hcl conc 10 mg/ml# 4 PAduloxetine hcl enteric coated pellets cap 20 mg^ 2 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 30 mg^ 2 QL (90 capsules/30 days)duloxetine hcl enteric coated pellets cap 60 mg^ 2 QL (60 capsules/30 days)escitalopram oxalate soln 5 mg/5ml^ 2 QL (600 mls/30 days)escitalopram oxalate tab 5 mg^ 1 QL (45 tablets/30 days)escitalopram oxalate tab 10 mg^ 1 QL (45 tablets/30 days)escitalopram oxalate tab 20 mg^ 1 QL (30 tablets/30 days)hydroxyzine hcl syrup 10 mg/5ml# 4 PAhydroxyzine hcl tab 10 mg# 4 PAhydroxyzine hcl tab 25 mg# 4 PAhydroxyzine hcl tab 50 mg# 4 PAlorazepam tab 0.5 mg^ 2 PA, QL (120 tablets/30 days)lorazepam tab 1 mg^ 2 PA, QL (120 tablets/30 days)lorazepam tab 2 mg^ 2 PA, QL (150 tablets/30 days)paroxetine hcl tab 10 mg^ 2 QL (45 tablets/30 days)paroxetine hcl tab 20 mg^ 2 QL (30 tablets/30 days)paroxetine hcl tab 30 mg^ 2 QL (60 tablets/30 days)paroxetine hcl tab 40 mg^ 2 QL (45 tablets/30 days)PAXIL - paroxetine hcl oral susp 10 mg/5ml 4 QL (900 mls/30 days)sertraline hcl oral conc 20 mg/ml^ 2 QL (300 mls/30 days)sertraline hcl tab 25 mg^ 1 QL (45 tablets/30 days)sertraline hcl tab 50 mg^ 1 QL (45 tablets/30 days)sertraline hcl tab 100 mg^ 1 QL (60 tablets/30 days)venlafaxine hcl cap er 24hr 37.5 mg^ 2 QL (60 capsules/30 days)venlafaxine hcl cap er 24hr 75 mg^ 2 QL (90 capsules/30 days)venlafaxine hcl cap er 24hr 150 mg^ 2 QL (30 capsules/30 days)venlafaxine hcl tab er 24hr 37.5 mg^ 2 QL (60 tablets/30 days)venlafaxine hcl tab er 24hr 75 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab er 24hr 150 mg^ 2 QL (30 tablets/30 days)venlafaxine hcl tab 25 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 37.5 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 50 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 75 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 100 mg^ 2 QL (90 tablets/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

51

Drug Name Drug Tier Requirements/LimitsBipolar AgentsABILIFY MAINTENA - aripiprazole im for er susp prefilled syringe

300 mg5 PA, QL (1 syringe

or vial/28 days)ABILIFY MAINTENA - aripiprazole im for er susp prefilled syringe

400 mg5 PA, QL (1 syringe

or vial/28 days)ABILIFY MAINTENA - aripiprazole im for extended release susp

300 mg5 PA, QL (1 syringe

or vial/28 days)ABILIFY MAINTENA - aripiprazole im for extended release susp

400 mg5 PA, QL (1 syringe

or vial/28 days)aripiprazole oral solution 1 mg/ml 4 PA, QL (750 mls/30 days)aripiprazole orally disintegrating tab 10 mg 5 PA, QL (60 tablets/30 days)aripiprazole orally disintegrating tab 15 mg 5 PA, QL (60 tablets/30 days)aripiprazole tab 2 mg 4 PA, QL (45 tablets/30 days)aripiprazole tab 5 mg 4 PA, QL (45 tablets/30 days)aripiprazole tab 10 mg 4 PA, QL (30 tablets/30 days)aripiprazole tab 15 mg 4 PA, QL (30 tablets/30 days)aripiprazole tab 20 mg 4 PA, QL (30 tablets/30 days)aripiprazole tab 30 mg 4 PA, QL (30 tablets/30 days)divalproex sodium cap delayed release sprinkle 125 mg^ 2divalproex sodium tab delayed release 125 mg^ 2divalproex sodium tab delayed release 250 mg^ 2divalproex sodium tab delayed release 500 mg^ 2divalproex sodium tab er 24 hr 250 mg^ 2divalproex sodium tab er 24 hr 500 mg^ 2lamotrigine tab chewable dispersible 5 mg^ 2lamotrigine tab chewable dispersible 25 mg^ 2lamotrigine tab 25 mg^ 2lamotrigine tab 100 mg^ 2lamotrigine tab 150 mg^ 2lamotrigine tab 200 mg^ 2LITHIUM - lithium oral solution 8 meq/5ml 4lithium carbonate cap 150 mg^ 2lithium carbonate cap 300 mg^ 2lithium carbonate cap 600 mg^ 2lithium carbonate tab er 300 mg^ 2lithium carbonate tab er 450 mg^ 2lithium carbonate tab 300 mg^ 2olanzapine for im inj 10 mg 4 PA, QL (90 vials/30 days)olanzapine orally disintegrating tab 5 mg^ 2 PA, QL (30 tablets/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.52

Drug Name Drug Tier Requirements/Limitsolanzapine orally disintegrating tab 10 mg^ 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 15 mg^ 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 20 mg^ 2 PA, QL (30 tablets/30 days)olanzapine tab 2.5 mg^ 2 PA, QL (45 tablets/30 days)olanzapine tab 5 mg^ 2 PA, QL (45 tablets/30 days)olanzapine tab 7.5 mg^ 2 PA, QL (45 tablets/30 days)olanzapine tab 10 mg^ 2 PA, QL (45 tablets/30 days)olanzapine tab 15 mg^ 2 PA, QL (30 tablets/30 days)olanzapine tab 20 mg^ 2 PA, QL (30 tablets/30 days)quetiapine fumarate tab 25 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 50 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 100 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 200 mg^ 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 300 mg^ 2 PA, QL (60 tablets/30 days)quetiapine fumarate tab 400 mg^ 2 PA, QL (60 tablets/30 days)RISPERDAL CONSTA - risperidone microspheres for inj 12.5 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 25 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 37.5 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 50 mg 5 PA, QL (2 vials/28 days)risperidone orally disintegrating tab 0.25 mg^ 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 0.5 mg^ 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 1 mg^ 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 2 mg^ 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 3 mg^ 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 4 mg^ 2 PA, QL (120 tablets/30 days)risperidone soln 1 mg/ml^ 2 PA, QL (480 mls/30 days)risperidone tab 0.25 mg^ 2 PA, QL (60 tablets/30 days)risperidone tab 0.5 mg^ 2 PA, QL (60 tablets/30 days)risperidone tab 1 mg^ 2 PA, QL (60 tablets/30 days)risperidone tab 2 mg^ 2 PA, QL (60 tablets/30 days)risperidone tab 3 mg^ 2 PA, QL (60 tablets/30 days)risperidone tab 4 mg^ 2 PA, QL (120 tablets/30 days)valproic acid cap 250 mg^ 2VRAYLAR - cariprazine hcl cap 1.5 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 3 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 4.5 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 6 mg 5 PA, QL (30 capsules/30 days)ziprasidone hcl cap 20 mg^ 2 PA, QL (90 capsules/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

53

Drug Name Drug Tier Requirements/Limitsziprasidone hcl cap 40 mg^ 2 PA, QL (90 capsules/30 days)ziprasidone hcl cap 60 mg^ 2 PA, QL (60 capsules/30 days)ziprasidone hcl cap 80 mg^ 2 PA, QL (60 capsules/30 days)Blood Glucose Regulatorsacarbose tab 25 mg^ 2 QL (360 tablets/30 days)acarbose tab 50 mg^ 2 QL (180 tablets/30 days)acarbose tab 100 mg^ 2 QL (90 tablets/30 days)ALCOHOL SWABS 3BYDUREON - exenatide for inj extended release susp 2 mg 3 QL (4 vials/28 days)BYDUREON PEN - exenatide extended release for susp pen-

injector 2 mg3 QL (4 vials/28 days)

CYCLOSET - bromocriptine mesylate tab 0.8 mg 4 QL (180 tablets/30 days)GAUZE PADS 2" X 2" 3glimepiride tab 1 mg^ 1 QL (240 tablets/30 days)glimepiride tab 2 mg^ 1 QL (120 tablets/30 days)glimepiride tab 4 mg^ 1 QL (60 tablets/30 days)glipizide tab er 24hr 2.5 mg^ 1 QL (240 tablets/30 days)glipizide tab er 24hr 5 mg^ 1 QL (120 tablets/30 days)glipizide tab er 24hr 10 mg^ 1 QL (60 tablets/30 days)glipizide tab 5 mg^ 1 QL (240 tablets/30 days)glipizide tab 10 mg^ 1 QL (120 tablets/30 days)glipizide-metformin hcl tab 2.5-250 mg^ 2 QL (240 tablets/30 days)glipizide-metformin hcl tab 2.5-500 mg^ 2 QL (120 tablets/30 days)glipizide-metformin hcl tab 5-500 mg^ 2 QL (120 tablets/30 days)GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg 3GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj kit 1 mg 3HUMALOG - insulin lispro inj 100 unit/ml^ 2HUMALOG - insulin lispro soln cartridge 100 unit/ml^ 2HUMALOG JUNIOR KWIKPEN - insulin lispro soln pen-injector 100

unit/ml^2

HUMALOG KWIKPEN - insulin lispro soln pen-injector 100 unit/ml^ 2HUMALOG KWIKPEN - insulin lispro soln pen-injector 200 unit/ml^ 2HUMALOG MIX 50/50 - insulin lispro protamine & lispro inj 100

unit/ml (50-50)^2

HUMALOG MIX 50/50 KWIKPEN - insulin lispro prot & lispro suspen-inj 100 unit/ml (50-50)^

2

HUMALOG MIX 75/25 - insulin lispro prot & lispro inj 100 unit/ml(75-25)^

2

HUMALOG MIX 75/25 KWIKPEN - insulin lispro prot & lispro suspen-inj 100 unit/ml (75-25)^

2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.54

Drug Name Drug Tier Requirements/LimitsHUMULIN N - insulin nph (human) (isophane) inj 100 unit/ml^ 2HUMULIN N KWIKPEN - insulin nph (human) (isophane) susp pen-

injector 100 unit/ml^2

HUMULIN R - insulin regular (human) inj 100 unit/ml^ 2HUMULIN R U-500 (CONCENTRATE) - insulin regular (human) inj

500 unit/ml^2 BD

HUMULIN R U-500 KWIKPEN - insulin regular (human) soln pen-injector 500 unit/ml^

2

HUMULIN 70/30 - insulin nph isophane & regular human inj 100unit/ml (70-30)^

2

HUMULIN 70/30 KWIKPEN - insulin nph & regular susp pen-inj 100unit/ml (70-30)^

2

INSULIN INJECTION DEVICE 3INSULIN SYRINGE/NEEDLE 3INVOKAMET - canagliflozin-metformin hcl tab 50-500 mg 3 QL (120 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-500 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-1000 mg 3 QL (60 tablets/30 days)INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr

50-500 mg3 QL (120 tablets/30 days)

INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr50-1000 mg

3 QL (60 tablets/30 days)

INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr150-500 mg

3 QL (60 tablets/30 days)

INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr150-1000 mg

3 QL (60 tablets/30 days)

INVOKANA - canagliflozin tab 100 mg 3 QL (90 tablets/30 days)INVOKANA - canagliflozin tab 300 mg 3 QL (30 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-500 mg 3 QL (60 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-500 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 100-1000 mg 3 QL (30 tablets/30 days)JANUVIA - sitagliptin phosphate tab 25 mg 3 QL (120 tablets/30 days)JANUVIA - sitagliptin phosphate tab 50 mg 3 QL (60 tablets/30 days)JANUVIA - sitagliptin phosphate tab 100 mg 3 QL (30 tablets/30 days)JARDIANCE - empagliflozin tab 10 mg 3 QL (60 tablets/30 days)JARDIANCE - empagliflozin tab 25 mg 3 QL (30 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-500 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-850 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-1000 mg 4 QL (60 tablets/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

55

Drug Name Drug Tier Requirements/LimitsJENTADUETO XR - linagliptin-metformin hcl tab er 24hr

2.5-1000 mg4 QL (60 tablets/30 days)

JENTADUETO XR - linagliptin-metformin hcl tab er 24hr 5-1000 mg 4 QL (30 tablets/30 days)KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr

2.5-1000 mg3 QL (60 tablets/30 days)

KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr 5-500 mg 3 QL (30 tablets/30 days)KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr

5-1000 mg3 QL (30 tablets/30 days)

LANTUS - insulin glargine inj 100 unit/ml^ 2LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/

ml^2

LEVEMIR - insulin detemir inj 100 unit/ml^ 2LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector 100 unit/

ml^2

metformin hcl tab er 24hr 500 mg^ 1 QL (120 tablets/30 days)metformin hcl tab er 24hr 750 mg^ 1 QL (60 tablets/30 days)metformin hcl tab 500 mg^ 1 QL (150 tablets/30 days)metformin hcl tab 850 mg^ 1 QL (90 tablets/30 days)metformin hcl tab 1000 mg^ 1 QL (75 tablets/30 days)nateglinide tab 60 mg^ 2 QL (180 tablets/30 days)nateglinide tab 120 mg^ 2 QL (90 tablets/30 days)ONGLYZA - saxagliptin hcl tab 2.5 mg 3 QL (60 tablets/30 days)ONGLYZA - saxagliptin hcl tab 5 mg 3 QL (30 tablets/30 days)pioglitazone hcl tab 15 mg^ 1 QL (90 tablets/30 days)pioglitazone hcl tab 30 mg^ 1 QL (30 tablets/30 days)pioglitazone hcl tab 45 mg^ 1 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-2 mg^ 2 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-4 mg^ 2 QL (30 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-500 mg^ 2 QL (90 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-850 mg^ 2 QL (90 tablets/30 days)PROGLYCEM - diazoxide susp 50 mg/ml 4repaglinide tab 0.5 mg^ 2 QL (960 tablets/30 days)repaglinide tab 1 mg^ 2 QL (480 tablets/30 days)repaglinide tab 2 mg^ 2 QL (240 tablets/30 days)SYMLINPEN 120 - pramlintide acetate pen-inj 2700 mcg/2.7ml

(1000 mcg/ml)3

SYMLINPEN 60 - pramlintide acetate pen-inj 1500 mcg/1.5ml(1000 mcg/ml)

3

SYNJARDY - empagliflozin-metformin hcl tab 5-500 mg 3 QL (120 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 5-1000 mg 3 QL (60 tablets/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.56

Drug Name Drug Tier Requirements/LimitsSYNJARDY - empagliflozin-metformin hcl tab 12.5-500 mg 3 QL (60 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 12.5-1000 mg 3 QL (60 tablets/30 days)SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr

5-1000 mg3 QL (60 tablets/30 days)

SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr10-1000 mg

3 QL (60 tablets/30 days)

SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr12.5-1000 mg

3 QL (60 tablets/30 days)

SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr25-1000 mg

3 QL (30 tablets/30 days)

TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml^

2

TRADJENTA - linagliptin tab 5 mg 4 QL (30 tablets/30 days)TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 100

unit/ml^2

TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 200unit/ml^

2

VICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 3 QL (1 package/30 days)WELCHOL - colesevelam hcl packet for susp 3.75 gm 4WELCHOL - colesevelam hcl tab 625 mg 4Blood Products/Modifiers/Volume ExpandersAGGRENOX - aspirin-dipyridamole cap er 12hr 25-200 mg 4anagrelide hcl cap 0.5 mg^ 2anagrelide hcl cap 1 mg^ 2ARANESP ALBUMIN FREE - darbepoetin alfa soln inj 25 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 40 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 60 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 100 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 200 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 300 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe

10 mcg/0.4ml4 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe25 mcg/0.42ml

4 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe40 mcg/0.4ml

4 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe60 mcg/0.3ml

4 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe100 mcg/0.5ml

5 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe150 mcg/0.3ml

5 PA

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

57

Drug Name Drug Tier Requirements/LimitsARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe

200 mcg/0.4ml5 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe300 mcg/0.6ml

5 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe500 mcg/ml

5 PA

aspirin-dipyridamole cap er 12hr 25-200 mg^ 2BRILINTA - ticagrelor tab 60 mg 3BRILINTA - ticagrelor tab 90 mg 3cilostazol tab 50 mg^ 1cilostazol tab 100 mg^ 1clopidogrel bisulfate tab 75 mg^ 2COUMADIN - warfarin sodium tab 1 mg 4COUMADIN - warfarin sodium tab 2 mg 4COUMADIN - warfarin sodium tab 2.5 mg 4COUMADIN - warfarin sodium tab 3 mg 4COUMADIN - warfarin sodium tab 4 mg 4COUMADIN - warfarin sodium tab 5 mg 4COUMADIN - warfarin sodium tab 6 mg 4COUMADIN - warfarin sodium tab 7.5 mg 4COUMADIN - warfarin sodium tab 10 mg 4dipyridamole tab 25 mg# 4dipyridamole tab 50 mg# 4dipyridamole tab 75 mg# 4EFFIENT - prasugrel hcl tab 5 mg 3EFFIENT - prasugrel hcl tab 10 mg 3ELIQUIS - apixaban tab 2.5 mg 3 QL (60 tablets/30 days)ELIQUIS - apixaban tab 5 mg 3 QL (120 tablets/30 days)enoxaparin sodium inj 30 mg/0.3ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 40 mg/0.4ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 60 mg/0.6ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 80 mg/0.8ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 100 mg/ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 120 mg/0.8ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 150 mg/ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 300 mg/3ml 4 QL (10 vials/90 days)EPOGEN - epoetin alfa inj 2000 unit/ml 4 PAEPOGEN - epoetin alfa inj 3000 unit/ml 4 PAEPOGEN - epoetin alfa inj 4000 unit/ml 4 PA

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.58

Drug Name Drug Tier Requirements/LimitsEPOGEN - epoetin alfa inj 10000 unit/ml 4 PAEPOGEN - epoetin alfa inj 20000 unit/ml 4 PAfondaparinux sodium subcutaneous inj 2.5 mg/0.5ml 4 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 5 mg/0.4ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 10 mg/0.8ml 5 QL (30 syringes/90 days)GRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml 5GRANIX - tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml 5heparin sodium (porcine) inj 1000 unit/ml 3heparin sodium (porcine) inj 5000 unit/ml 3heparin sodium (porcine) inj 10000 unit/ml 3heparin sodium (porcine) inj 20000 unit/ml 4heparin sodium (porcine) pf inj 5000 unit/0.5ml 4heparin sodium (porcine) 40 unit/ml in d5w 4LEUKINE - sargramostim lyophilized for inj 250 mcg 5MOZOBIL - plerixafor subcutaneous inj 24 mg/1.2ml (20 mg/ml) 5NEULASTA - pegfilgrastim soln prefilled syringe 6 mg/0.6ml 5NEULASTA ONPRO KIT - pegfilgrastim soln prefilled syringe kit

6 mg/0.6ml5

NEUPOGEN - filgrastim inj 300 mcg/ml 5NEUPOGEN - filgrastim inj 480 mcg/1.6ml (300 mcg/ml) 5NEUPOGEN - filgrastim soln prefilled syringe 300 mcg/0.5ml 5NEUPOGEN - filgrastim soln prefilled syringe 480 mcg/0.8ml

(600 mcg/ml)5

PRADAXA - dabigatran etexilate mesylate cap 75 mg 4 QL (60 capsules/30 days)PRADAXA - dabigatran etexilate mesylate cap 110 mg 4 QL (71 capsules/90 days)PRADAXA - dabigatran etexilate mesylate cap 150 mg 4 QL (60 capsules/30 days)prasugrel hcl tab 5 mg^ 2prasugrel hcl tab 10 mg^ 2PROCRIT - epoetin alfa inj 2000 unit/ml 4 PAPROCRIT - epoetin alfa inj 3000 unit/ml 4 PAPROCRIT - epoetin alfa inj 4000 unit/ml 4 PAPROCRIT - epoetin alfa inj 10000 unit/ml 4 PAPROCRIT - epoetin alfa inj 20000 unit/ml 5 PAPROCRIT - epoetin alfa inj 40000 unit/ml 5 PAPROMACTA - eltrombopag olamine tab 12.5 mg* 5 PAPROMACTA - eltrombopag olamine tab 25 mg* 5 PAPROMACTA - eltrombopag olamine tab 50 mg* 5 PAPROMACTA - eltrombopag olamine tab 75 mg* 5 PA

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

59

Drug Name Drug Tier Requirements/Limitstranexamic acid iv soln 1000 mg/10ml (100 mg/ml) 4tranexamic acid tab 650 mg^ 2warfarin sodium tab 1 mg^ 2warfarin sodium tab 2 mg^ 2warfarin sodium tab 2.5 mg^ 2warfarin sodium tab 3 mg^ 2warfarin sodium tab 4 mg^ 2warfarin sodium tab 5 mg^ 2warfarin sodium tab 6 mg^ 2warfarin sodium tab 7.5 mg^ 2warfarin sodium tab 10 mg^ 2XARELTO - rivaroxaban tab 10 mg 3 QL (35 tablets/90 days)XARELTO - rivaroxaban tab 15 mg 3 QL (60 tablets/30 days)XARELTO - rivaroxaban tab 20 mg 3 QL (30 tablets/30 days)XARELTO STARTER PACK - rivaroxaban tab starter therapy pack

15 mg & 20 mg3 QL (51 tablets/30 days)

ZONTIVITY - vorapaxar sulfate tab 2.08 mg 4Cardiovascular Agentsacebutolol hcl cap 200 mg^ 2acebutolol hcl cap 400 mg^ 2acetazolamide cap er 12hr 500 mg^ 2acetazolamide tab 125 mg^ 2acetazolamide tab 250 mg^ 2amiloride & hydrochlorothiazide tab 5-50 mg^ 2amiloride hcl tab 5 mg^ 2amiodarone hcl tab 200 mg^ 2amiodarone hcl tab 400 mg^ 2amlodipine besylate tab 2.5 mg^ 1amlodipine besylate tab 5 mg^ 1amlodipine besylate tab 10 mg^ 1amlodipine besylate-atorvastatin calcium tab 2.5-10 mg 4amlodipine besylate-atorvastatin calcium tab 2.5-20 mg 4amlodipine besylate-atorvastatin calcium tab 2.5-40 mg 4amlodipine besylate-atorvastatin calcium tab 5-10 mg 4amlodipine besylate-atorvastatin calcium tab 5-20 mg 4amlodipine besylate-atorvastatin calcium tab 5-40 mg 4amlodipine besylate-atorvastatin calcium tab 5-80 mg 4amlodipine besylate-atorvastatin calcium tab 10-10 mg 4amlodipine besylate-atorvastatin calcium tab 10-20 mg 4

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.60

Drug Name Drug Tier Requirements/Limitsamlodipine besylate-atorvastatin calcium tab 10-40 mg 4amlodipine besylate-atorvastatin calcium tab 10-80 mg 4amlodipine besylate-benazepril hcl cap 2.5-10 mg^ 2amlodipine besylate-benazepril hcl cap 5-10 mg^ 2amlodipine besylate-benazepril hcl cap 5-20 mg^ 2amlodipine besylate-benazepril hcl cap 5-40 mg^ 2amlodipine besylate-benazepril hcl cap 10-20 mg^ 2amlodipine besylate-benazepril hcl cap 10-40 mg^ 2amlodipine besylate-valsartan tab 5-160 mg^ 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 5-320 mg^ 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-160 mg^ 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-320 mg^ 2 QL (30 tablets/30 days)atenolol & chlorthalidone tab 50-25 mg^ 2atenolol & chlorthalidone tab 100-25 mg^ 2atenolol tab 25 mg^ 1atenolol tab 50 mg^ 1atenolol tab 100 mg^ 1atorvastatin calcium tab 10 mg^ 1 QL (45 tablets/30 days)atorvastatin calcium tab 20 mg^ 1 QL (45 tablets/30 days)atorvastatin calcium tab 40 mg^ 1 QL (45 tablets/30 days)atorvastatin calcium tab 80 mg^ 1 QL (30 tablets/30 days)benazepril & hydrochlorothiazide tab 5-6.25 mg^ 2benazepril & hydrochlorothiazide tab 10-12.5 mg^ 2benazepril & hydrochlorothiazide tab 20-12.5 mg^ 2benazepril & hydrochlorothiazide tab 20-25 mg^ 2benazepril hcl tab 5 mg^ 1benazepril hcl tab 10 mg^ 1benazepril hcl tab 20 mg^ 1benazepril hcl tab 40 mg^ 1betaxolol hcl tab 10 mg^ 2betaxolol hcl tab 20 mg^ 2bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg^ 2bisoprolol & hydrochlorothiazide tab 5-6.25 mg^ 2bisoprolol & hydrochlorothiazide tab 10-6.25 mg^ 2bisoprolol fumarate tab 5 mg^ 2bisoprolol fumarate tab 10 mg^ 2bumetanide inj 0.25 mg/ml 4bumetanide tab 0.5 mg^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

61

Drug Name Drug Tier Requirements/Limitsbumetanide tab 1 mg^ 2bumetanide tab 2 mg^ 2candesartan cilexetil tab 4 mg^ 2 QL (60 tablets/30 days)candesartan cilexetil tab 8 mg^ 2 QL (60 tablets/30 days)candesartan cilexetil tab 16 mg^ 2 QL (60 tablets/30 days)candesartan cilexetil tab 32 mg^ 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg^ 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg^ 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-25 mg^ 2 QL (30 tablets/30 days)captopril tab 12.5 mg^ 2captopril tab 25 mg^ 2captopril tab 50 mg^ 2captopril tab 100 mg^ 2carvedilol tab 3.125 mg^ 1carvedilol tab 6.25 mg^ 1carvedilol tab 12.5 mg^ 1carvedilol tab 25 mg^ 1CHLOROTHIAZIDE - chlorothiazide tab 250 mg 4chlorothiazide tab 500 mg^ 2chlorthalidone tab 25 mg^ 2chlorthalidone tab 50 mg^ 2cholestyramine light powder packets 4 gm^ 2cholestyramine light powder 4 gm/dose^ 2cholestyramine powder packets 4 gm^ 2cholestyramine powder 4 gm/dose^ 2choline fenofibrate cap dr 45 mg^ 2 QL (60 capsules/30 days)choline fenofibrate cap dr 135 mg^ 2 QL (30 capsules/30 days)clonidine hcl tab 0.1 mg^ 2clonidine hcl tab 0.2 mg^ 2clonidine hcl tab 0.3 mg^ 2clonidine hcl td patch weekly 0.1 mg/24hr^ 2clonidine hcl td patch weekly 0.2 mg/24hr^ 2clonidine hcl td patch weekly 0.3 mg/24hr^ 2colestipol hcl granule packets 5 gm^ 2colestipol hcl granules 5 gm^ 2colestipol hcl tab 1 gm^ 2CORLANOR - ivabradine hcl tab 5 mg 3 PA, QL (60 tablets/30 days)CORLANOR - ivabradine hcl tab 7.5 mg 3 PA, QL (60 tablets/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.62

Drug Name Drug Tier Requirements/LimitsCRESTOR - rosuvastatin calcium tab 5 mg 3 QL (45 tablets/30 days)CRESTOR - rosuvastatin calcium tab 10 mg 3 QL (45 tablets/30 days)CRESTOR - rosuvastatin calcium tab 20 mg 3 QL (45 tablets/30 days)CRESTOR - rosuvastatin calcium tab 40 mg 3 QL (30 tablets/30 days)DEMSER - metyrosine cap 250 mg 5DIGOXIN - digoxin oral soln 0.05 mg/ml# 4 QL (150 mls/30 days)digoxin tab 125 mcg (0.125 mg)#^ 2 QL (30 tablets/30 days)digoxin tab 250 mcg (0.25 mg)# 4 PA, QL (30 tablets/30 days)diltiazem hcl cap er 12hr 60 mg^ 2diltiazem hcl cap er 12hr 90 mg^ 2diltiazem hcl cap er 12hr 120 mg^ 2diltiazem hcl cap er 24hr 120 mg^ 2diltiazem hcl cap er 24hr 180 mg^ 2diltiazem hcl cap er 24hr 240 mg^ 2diltiazem hcl coated beads cap er 24hr 120 mg^ 2diltiazem hcl coated beads cap er 24hr 180 mg^ 2diltiazem hcl coated beads cap er 24hr 240 mg^ 2diltiazem hcl coated beads cap er 24hr 300 mg^ 2diltiazem hcl coated beads cap er 24hr 360 mg^ 2diltiazem hcl coated beads tab er 24hr 180 mg^ 2diltiazem hcl coated beads tab er 24hr 240 mg^ 2diltiazem hcl coated beads tab er 24hr 300 mg^ 2diltiazem hcl coated beads tab er 24hr 360 mg^ 2diltiazem hcl coated beads tab er 24hr 420 mg^ 2diltiazem hcl extended release beads cap er 24hr 120 mg^ 2diltiazem hcl extended release beads cap er 24hr 180 mg^ 2diltiazem hcl extended release beads cap er 24hr 240 mg^ 2diltiazem hcl extended release beads cap er 24hr 300 mg^ 2diltiazem hcl extended release beads cap er 24hr 360 mg^ 2diltiazem hcl extended release beads cap er 24hr 420 mg^ 2diltiazem hcl tab 30 mg^ 2diltiazem hcl tab 60 mg^ 2diltiazem hcl tab 90 mg^ 2diltiazem hcl tab 120 mg^ 2dofetilide cap 125 mcg (0.125 mg)^ 2dofetilide cap 250 mcg (0.25 mg)^ 2dofetilide cap 500 mcg (0.5 mg)^ 2doxazosin mesylate tab 1 mg^ 2 QL (60 tablets/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

63

Drug Name Drug Tier Requirements/Limitsdoxazosin mesylate tab 2 mg^ 2 QL (60 tablets/30 days)doxazosin mesylate tab 4 mg^ 2 QL (60 tablets/30 days)doxazosin mesylate tab 8 mg^ 2 QL (60 tablets/30 days)enalapril maleate & hydrochlorothiazide tab 5-12.5 mg^ 1enalapril maleate & hydrochlorothiazide tab 10-25 mg^ 1enalapril maleate tab 2.5 mg^ 1enalapril maleate tab 5 mg^ 1enalapril maleate tab 10 mg^ 1enalapril maleate tab 20 mg^ 1ENTRESTO - sacubitril-valsartan tab 24-26 mg 3 PA, QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 49-51 mg 3 PA, QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 97-103 mg 3 PA, QL (60 tablets/30 days)eplerenone tab 25 mg^ 2eplerenone tab 50 mg^ 2ezetimibe tab 10 mg^ 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-10 mg^ 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-20 mg^ 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-40 mg^ 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-80 mg^ 2 QL (30 tablets/30 days)felodipine tab er 24hr 2.5 mg^ 2felodipine tab er 24hr 5 mg^ 2felodipine tab er 24hr 10 mg^ 2fenofibrate micronized cap 67 mg^ 2 QL (30 capsules/30 days)fenofibrate micronized cap 134 mg^ 2 QL (30 capsules/30 days)fenofibrate micronized cap 200 mg^ 2 QL (30 capsules/30 days)fenofibrate tab 48 mg^ 2 QL (60 tablets/30 days)fenofibrate tab 54 mg^ 2 QL (60 tablets/30 days)fenofibrate tab 145 mg^ 2 QL (30 tablets/30 days)fenofibrate tab 160 mg^ 2 QL (30 tablets/30 days)flecainide acetate tab 50 mg^ 2flecainide acetate tab 100 mg^ 2flecainide acetate tab 150 mg^ 2fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg^ 2fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg^ 2fosinopril sodium tab 10 mg^ 1fosinopril sodium tab 20 mg^ 1fosinopril sodium tab 40 mg^ 1furosemide inj 10 mg/ml 4

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.64

Drug Name Drug Tier Requirements/Limitsfurosemide oral soln 10 mg/ml^ 2furosemide tab 20 mg^ 2furosemide tab 40 mg^ 2furosemide tab 80 mg^ 2gemfibrozil tab 600 mg^ 2 QL (60 tablets/30 days)hydralazine hcl tab 10 mg^ 2hydralazine hcl tab 25 mg^ 2hydralazine hcl tab 50 mg^ 2hydralazine hcl tab 100 mg^ 2hydrochlorothiazide cap 12.5 mg^ 2hydrochlorothiazide tab 12.5 mg^ 2hydrochlorothiazide tab 25 mg^ 2hydrochlorothiazide tab 50 mg^ 2indapamide tab 1.25 mg^ 2indapamide tab 2.5 mg^ 2irbesartan tab 75 mg^ 1 QL (30 tablets/30 days)irbesartan tab 150 mg^ 1 QL (30 tablets/30 days)irbesartan tab 300 mg^ 1 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 150-12.5 mg^ 1 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 300-12.5 mg^ 1 QL (30 tablets/30 days)isosorbide dinitrate tab 5 mg^ 2isosorbide dinitrate tab 10 mg^ 2isosorbide dinitrate tab 20 mg^ 2isosorbide dinitrate tab 30 mg^ 2isosorbide mononitrate tab er 24hr 30 mg^ 2isosorbide mononitrate tab er 24hr 60 mg^ 2isosorbide mononitrate tab er 24hr 120 mg^ 2isosorbide mononitrate tab 10 mg^ 2isosorbide mononitrate tab 20 mg^ 2isradipine cap 2.5 mg^ 2isradipine cap 5 mg^ 2JUXTAPID - lomitapide mesylate cap 5 mg* 5 PAJUXTAPID - lomitapide mesylate cap 10 mg* 5 PAJUXTAPID - lomitapide mesylate cap 20 mg* 5 PAJUXTAPID - lomitapide mesylate cap 30 mg* 5 PAJUXTAPID - lomitapide mesylate cap 40 mg* 5 PAJUXTAPID - lomitapide mesylate cap 60 mg* 5 PAKYNAMRO - mipomersen sodium soln prefilled syringe 200 mg/ml* 5 PA

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

65

Drug Name Drug Tier Requirements/Limitslabetalol hcl tab 100 mg^ 2labetalol hcl tab 200 mg^ 2labetalol hcl tab 300 mg^ 2LIDOCAINE HCL - lidocaine hcl iv inj 10 mg/ml 4lisinopril & hydrochlorothiazide tab 10-12.5 mg^ 1lisinopril & hydrochlorothiazide tab 20-12.5 mg^ 1lisinopril & hydrochlorothiazide tab 20-25 mg^ 1lisinopril tab 2.5 mg^ 1lisinopril tab 5 mg^ 1lisinopril tab 10 mg^ 1lisinopril tab 20 mg^ 1lisinopril tab 30 mg^ 1lisinopril tab 40 mg^ 1losartan potassium & hydrochlorothiazide tab 50-12.5 mg^ 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-12.5 mg^ 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-25 mg^ 1 QL (30 tablets/30 days)losartan potassium tab 25 mg^ 1 QL (60 tablets/30 days)losartan potassium tab 50 mg^ 1 QL (60 tablets/30 days)losartan potassium tab 100 mg^ 1 QL (30 tablets/30 days)lovastatin tab 10 mg^ 1 QL (60 tablets/30 days)lovastatin tab 20 mg^ 1 QL (60 tablets/30 days)lovastatin tab 40 mg^ 1 QL (60 tablets/30 days)methazolamide tab 25 mg^ 2methazolamide tab 50 mg^ 2metolazone tab 2.5 mg^ 2metolazone tab 5 mg^ 2metolazone tab 10 mg^ 2metoprolol & hydrochlorothiazide tab 50-25 mg^ 2metoprolol & hydrochlorothiazide tab 100-25 mg^ 2metoprolol succinate tab er 24hr 25 mg^ 2metoprolol succinate tab er 24hr 50 mg^ 2metoprolol succinate tab er 24hr 100 mg^ 2metoprolol succinate tab er 24hr 200 mg^ 2metoprolol tartrate tab 25 mg^ 1metoprolol tartrate tab 50 mg^ 1metoprolol tartrate tab 100 mg^ 1mexiletine hcl cap 150 mg^ 2mexiletine hcl cap 200 mg^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.66

Drug Name Drug Tier Requirements/Limitsmexiletine hcl cap 250 mg^ 2midodrine hcl tab 2.5 mg^ 2midodrine hcl tab 5 mg^ 2midodrine hcl tab 10 mg^ 2minoxidil tab 2.5 mg^ 2minoxidil tab 10 mg^ 2moexipril hcl tab 7.5 mg^ 2moexipril hcl tab 15 mg^ 2moexipril-hydrochlorothiazide tab 7.5-12.5 mg^ 2moexipril-hydrochlorothiazide tab 15-12.5 mg^ 2moexipril-hydrochlorothiazide tab 15-25 mg^ 2MULTAQ - dronedarone hcl tab 400 mg 3nadolol tab 20 mg^ 2nadolol tab 40 mg^ 2nadolol tab 80 mg^ 2niacin tab er 500 mg^ 2 QL (30 tablets/30 days)niacin tab er 750 mg^ 2 QL (60 tablets/30 days)niacin tab er 1000 mg^ 2 QL (60 tablets/30 days)nicardipine hcl cap 20 mg^ 2nicardipine hcl cap 30 mg^ 2nifedipine tab er 24hr 30 mg^ 2nifedipine tab er 24hr 60 mg^ 2nifedipine tab er 24hr 90 mg^ 2nifedipine tab er 24hr osmotic release 30 mg^ 2nifedipine tab er 24hr osmotic release 60 mg^ 2nifedipine tab er 24hr osmotic release 90 mg^ 2NISOLDIPINE ER - nisoldipine tab er 24hr 25.5 mg 4nisoldipine tab er 24hr 8.5 mg^ 2nisoldipine tab er 24hr 17 mg^ 2nisoldipine tab er 24hr 34 mg^ 2NITRO-BID - nitroglycerin oint 2% 4nitroglycerin sl tab 0.3 mg^ 2nitroglycerin sl tab 0.4 mg^ 2nitroglycerin sl tab 0.6 mg^ 2nitroglycerin td patch 24hr 0.1 mg/hr^ 2nitroglycerin td patch 24hr 0.2 mg/hr^ 2nitroglycerin td patch 24hr 0.4 mg/hr^ 2nitroglycerin td patch 24hr 0.6 mg/hr^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

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Drug Name Drug Tier Requirements/Limitsnitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) 4NITROSTAT - nitroglycerin sl tab 0.3 mg 3NITROSTAT - nitroglycerin sl tab 0.4 mg 3NITROSTAT - nitroglycerin sl tab 0.6 mg 3NORTHERA - droxidopa cap 100 mg* 5 PANORTHERA - droxidopa cap 200 mg* 5 PANORTHERA - droxidopa cap 300 mg* 5 PAomega-3-acid ethyl esters cap 1 gm^ 2pentoxifylline tab er 400 mg^ 2perindopril erbumine tab 2 mg^ 2perindopril erbumine tab 4 mg^ 2perindopril erbumine tab 8 mg^ 2phenoxybenzamine hcl cap 10 mg 5pindolol tab 5 mg^ 2pindolol tab 10 mg^ 2PRALUENT - alirocumab subcutaneous soln pen-injector 75 mg/ml 5 PA, QL (2 pens/28 days)PRALUENT - alirocumab subcutaneous soln pen-injector 150 mg/

ml5 PA, QL (2 pens/28 days)

pravastatin sodium tab 10 mg^ 1 QL (45 tablets/30 days)pravastatin sodium tab 20 mg^ 1 QL (45 tablets/30 days)pravastatin sodium tab 40 mg^ 1 QL (45 tablets/30 days)pravastatin sodium tab 80 mg^ 1 QL (30 tablets/30 days)prazosin hcl cap 1 mg^ 2prazosin hcl cap 2 mg^ 2prazosin hcl cap 5 mg^ 2propafenone hcl cap er 12hr 225 mg^ 2propafenone hcl cap er 12hr 325 mg^ 2propafenone hcl cap er 12hr 425 mg^ 2propafenone hcl tab 150 mg^ 2propafenone hcl tab 225 mg^ 2propafenone hcl tab 300 mg^ 2propranolol hcl cap er 24hr 60 mg^ 2propranolol hcl cap er 24hr 80 mg^ 2propranolol hcl cap er 24hr 120 mg^ 2propranolol hcl cap er 24hr 160 mg^ 2propranolol hcl inj 1 mg/ml 3propranolol hcl tab 10 mg^ 1propranolol hcl tab 20 mg^ 1propranolol hcl tab 40 mg^ 1

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.68

Drug Name Drug Tier Requirements/Limitspropranolol hcl tab 60 mg^ 1propranolol hcl tab 80 mg^ 1quinapril hcl tab 5 mg^ 1quinapril hcl tab 10 mg^ 1quinapril hcl tab 20 mg^ 1quinapril hcl tab 40 mg^ 1quinapril-hydrochlorothiazide tab 10-12.5 mg^ 2quinapril-hydrochlorothiazide tab 20-12.5 mg^ 2quinapril-hydrochlorothiazide tab 20-25 mg^ 2quinidine gluconate tab er 324 mg^ 2QUINIDINE SULFATE - quinidine sulfate tab 200 mg 4QUINIDINE SULFATE - quinidine sulfate tab 300 mg 4ramipril cap 1.25 mg^ 1ramipril cap 2.5 mg^ 1ramipril cap 5 mg^ 1ramipril cap 10 mg^ 1RANEXA - ranolazine tab er 12hr 500 mg 3RANEXA - ranolazine tab er 12hr 1000 mg 3REPATHA - evolocumab subcutaneous soln prefilled syringe

140 mg/ml5 PA, QL (3 syringes/30 days)

REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneoussoln cartridge/infusor 420 mg/3.5ml

5 PA, QL (1 system/30 days)

REPATHA SURECLICK - evolocumab subcutaneous soln auto-injector 140 mg/ml

5 PA, QL (3 pens/30 days)

rosuvastatin calcium tab 5 mg^ 2 QL (45 tablets/30 days)rosuvastatin calcium tab 10 mg^ 2 QL (45 tablets/30 days)rosuvastatin calcium tab 20 mg^ 2 QL (45 tablets/30 days)rosuvastatin calcium tab 40 mg^ 2 QL (30 tablets/30 days)simvastatin tab 5 mg^ 1 QL (45 tablets/30 days)simvastatin tab 10 mg^ 1 QL (45 tablets/30 days)simvastatin tab 20 mg^ 1 QL (60 tablets/30 days)simvastatin tab 40 mg^ 1 QL (45 tablets/30 days)simvastatin tab 80 mg^ 1 QL (30 tablets/30 days)sotalol hcl tab 80 mg^ 2sotalol hcl tab 120 mg^ 2sotalol hcl tab 160 mg^ 2sotalol hcl tab 240 mg^ 2spironolactone & hydrochlorothiazide tab 25-25 mg^ 2spironolactone tab 25 mg^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

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Drug Name Drug Tier Requirements/Limitsspironolactone tab 50 mg^ 2spironolactone tab 100 mg^ 2TEKTURNA - aliskiren fumarate tab 150 mg 3 QL (30 tablets/30 days)TEKTURNA - aliskiren fumarate tab 300 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-25 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-25 mg 3 QL (30 tablets/30 days)telmisartan tab 20 mg^ 2 QL (30 tablets/30 days)telmisartan tab 40 mg^ 2 QL (30 tablets/30 days)telmisartan tab 80 mg^ 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 40-12.5 mg^ 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-12.5 mg^ 2 QL (60 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-25 mg^ 2 QL (30 tablets/30 days)terazosin hcl cap 1 mg^ 2 QL (90 capsules/30 days)terazosin hcl cap 2 mg^ 2 QL (60 capsules/30 days)terazosin hcl cap 5 mg^ 2 QL (60 capsules/30 days)terazosin hcl cap 10 mg^ 2 QL (60 capsules/30 days)TIMOLOL MALEATE - timolol maleate tab 5 mg 4TIMOLOL MALEATE - timolol maleate tab 10 mg 4TIMOLOL MALEATE - timolol maleate tab 20 mg 4torsemide tab 5 mg^ 2torsemide tab 10 mg^ 2torsemide tab 20 mg^ 2torsemide tab 100 mg^ 2trandolapril tab 1 mg^ 1trandolapril tab 2 mg^ 1trandolapril tab 4 mg^ 1triamterene & hydrochlorothiazide cap 37.5-25 mg^ 2triamterene & hydrochlorothiazide tab 37.5-25 mg^ 2triamterene & hydrochlorothiazide tab 75-50 mg^ 2valsartan tab 40 mg^ 2 QL (60 tablets/30 days)valsartan tab 80 mg^ 2 QL (60 tablets/30 days)valsartan tab 160 mg^ 2 QL (60 tablets/30 days)valsartan tab 320 mg^ 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 80-12.5 mg^ 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-12.5 mg^ 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-25 mg^ 2 QL (30 tablets/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.70

Drug Name Drug Tier Requirements/Limitsvalsartan-hydrochlorothiazide tab 320-12.5 mg^ 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 320-25 mg^ 2 QL (30 tablets/30 days)VASCEPA - icosapent ethyl cap 0.5 gm 3VASCEPA - icosapent ethyl cap 1 gm 3verapamil hcl cap er 24hr 100 mg^ 2verapamil hcl cap er 24hr 120 mg^ 2verapamil hcl cap er 24hr 180 mg^ 2verapamil hcl cap er 24hr 200 mg^ 2verapamil hcl cap er 24hr 240 mg^ 2verapamil hcl cap er 24hr 300 mg^ 2verapamil hcl cap er 24hr 360 mg^ 2verapamil hcl tab er 120 mg^ 2verapamil hcl tab er 180 mg^ 2verapamil hcl tab er 240 mg^ 2verapamil hcl tab 40 mg^ 2verapamil hcl tab 80 mg^ 2verapamil hcl tab 120 mg^ 2VYTORIN - ezetimibe-simvastatin tab 10-10 mg 3 QL (30 tablets/30 days)VYTORIN - ezetimibe-simvastatin tab 10-20 mg 3 QL (30 tablets/30 days)VYTORIN - ezetimibe-simvastatin tab 10-40 mg 3 QL (30 tablets/30 days)VYTORIN - ezetimibe-simvastatin tab 10-80 mg 3 QL (30 tablets/30 days)WELCHOL - colesevelam hcl packet for susp 3.75 gm 4WELCHOL - colesevelam hcl tab 625 mg 4ZETIA - ezetimibe tab 10 mg 3 QL (30 tablets/30 days)Central Nervous System Agentsamphetamine-dextroamphetamine cap er 24hr 5 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 10 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 15 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 20 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 25 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 30 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine tab 5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 7.5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 10 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 12.5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 15 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 20 mg 3 QL (90 tablets/30 days)amphetamine-dextroamphetamine tab 30 mg 3 QL (60 tablets/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

71

Drug Name Drug Tier Requirements/LimitsAMPYRA - dalfampridine tab er 12hr 10 mg* 5 PAatomoxetine hcl cap 10 mg^ 2 QL (60 capsules/30 days)atomoxetine hcl cap 18 mg^ 2 QL (60 capsules/30 days)atomoxetine hcl cap 25 mg^ 2 QL (60 capsules/30 days)atomoxetine hcl cap 40 mg^ 2 QL (60 capsules/30 days)atomoxetine hcl cap 60 mg^ 2 QL (30 capsules/30 days)atomoxetine hcl cap 80 mg^ 2 QL (30 capsules/30 days)atomoxetine hcl cap 100 mg^ 2 QL (30 capsules/30 days)AVONEX - interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/

vial)5 PA, QL (1 kit/28 days)

AVONEX - interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)AVONEX PEN - interferon beta-1a im auto-injector kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)BETASERON - interferon beta-1b for inj kit 0.3 mg 5 PA, QL (15 vials/

syringes/30 days)clonidine hcl tab er 12hr 0.1 mg^ 2 QL (120 tablets/30 days)COPAXONE - glatiramer acetate soln prefilled syringe 20 mg/ml 5 PA, QL (30 syringes/30 days)COPAXONE - glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)dexmethylphenidate hcl tab 2.5 mg 4 QL (60 tablets/30 days)dexmethylphenidate hcl tab 5 mg 4 QL (60 tablets/30 days)dexmethylphenidate hcl tab 10 mg 4 QL (60 tablets/30 days)dextroamphetamine sulfate cap er 24hr 5 mg 4 QL (90 capsules/30 days)dextroamphetamine sulfate cap er 24hr 10 mg 4 QL (120 capsules/30 days)dextroamphetamine sulfate cap er 24hr 15 mg 4 QL (120 capsules/30 days)dextroamphetamine sulfate tab 5 mg 4 QL (90 tablets/30 days)dextroamphetamine sulfate tab 10 mg 4 QL (180 tablets/30 days)duloxetine hcl enteric coated pellets cap 20 mg^ 2 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 30 mg^ 2 QL (90 capsules/30 days)duloxetine hcl enteric coated pellets cap 60 mg^ 2 QL (60 capsules/30 days)glatiramer acetate soln prefilled syringe 20 mg/ml 5 PA, QL (30 syringes/30 days)glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)LYRICA - pregabalin cap 25 mg 3LYRICA - pregabalin cap 50 mg 3LYRICA - pregabalin cap 75 mg 3LYRICA - pregabalin cap 100 mg 3LYRICA - pregabalin cap 150 mg 3LYRICA - pregabalin cap 200 mg 3LYRICA - pregabalin cap 225 mg 3LYRICA - pregabalin cap 300 mg 3LYRICA - pregabalin soln 20 mg/ml 3

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.72

Drug Name Drug Tier Requirements/Limitsmethylphenidate hcl tab er 20 mg 4 QL (90 tablets/30 days)methylphenidate hcl tab 5 mg 4 QL (90 tablets/30 days)methylphenidate hcl tab 10 mg 4 QL (90 tablets/30 days)methylphenidate hcl tab 20 mg 4 QL (90 tablets/30 days)mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) 3mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) 3mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) 3NUEDEXTA - dextromethorphan hbr-quinidine sulfate cap

20-10 mg3

PLEGRIDY - peginterferon beta-1a soln pen-injector 125 mcg/0.5ml 5 PA, QL (2 syringes/28 days)PLEGRIDY - peginterferon beta-1a soln prefilled syringe

125 mcg/0.5ml5 PA, QL (2 syringes/28 days)

PLEGRIDY STARTER PACK - peginterferon beta-1a soln pen-inj63 & 94 mcg/0.5ml pack

5 PA, QL (2 syringes/28 days)

PLEGRIDY STARTER PACK - peginterferon beta-1a soln pref syr63 & 94 mcg/0.5ml pack

5 PA, QL (2 syringes/28 days)

riluzole tab 50 mg^ 2STRATTERA - atomoxetine hcl cap 10 mg 4 QL (60 capsules/30 days)STRATTERA - atomoxetine hcl cap 18 mg 4 QL (60 capsules/30 days)STRATTERA - atomoxetine hcl cap 25 mg 4 QL (60 capsules/30 days)STRATTERA - atomoxetine hcl cap 40 mg 4 QL (60 capsules/30 days)STRATTERA - atomoxetine hcl cap 60 mg 4 QL (30 capsules/30 days)STRATTERA - atomoxetine hcl cap 80 mg 4 QL (30 capsules/30 days)STRATTERA - atomoxetine hcl cap 100 mg 4 QL (30 capsules/30 days)TECFIDERA - dimethyl fumarate capsule delayed release 120 mg 5 PA, QL (60 capsules/30 days)TECFIDERA - dimethyl fumarate capsule delayed release 240 mg 5 PA, QL (60 capsules/30 days)TECFIDERA STARTER PACK - dimethyl fumarate capsule dr

starter pack 120 mg & 240 mg5 PA, QL (60 capsules/30 days)

tetrabenazine tab 12.5 mg* 5 PA, QL (240 tablets/30 days)tetrabenazine tab 25 mg* 5 PA, QL (120 tablets/30 days)TYSABRI - natalizumab for iv inj conc 300 mg/15ml* 5 PAXENAZINE - tetrabenazine tab 12.5 mg* 5 PA, QL (240 tablets/30 days)XENAZINE - tetrabenazine tab 25 mg* 5 PA, QL (120 tablets/30 days)Dental and Oral Agentschlorhexidine gluconate soln 0.12%^ 2doxycycline hyclate cap 50 mg^ 2doxycycline hyclate cap 100 mg^ 2doxycycline hyclate for inj 100 mg 4doxycycline hyclate tab 20 mg^ 2doxycycline hyclate tab 100 mg^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

73

Drug Name Drug Tier Requirements/LimitsKEPIVANCE - palifermin for iv inj 6.25 mg 5pilocarpine hcl tab 5 mg^ 2pilocarpine hcl tab 7.5 mg^ 2triamcinolone acetonide dental paste 0.1%^ 2Dermatological Agentsacitretin cap 10 mg 5acitretin cap 17.5 mg 5acitretin cap 25 mg 5acyclovir oint 5% 4alclometasone dipropionate cream 0.05%^ 2alclometasone dipropionate oint 0.05%^ 2AZELEX - azelaic acid cream 20% 4benzoyl peroxide-erythromycin gel 5-3%^ 2betamethasone dipropionate augmented cream 0.05%^ 2betamethasone dipropionate augmented gel 0.05%^ 2betamethasone dipropionate augmented lotion 0.05%^ 2betamethasone dipropionate augmented oint 0.05%^ 2betamethasone dipropionate cream 0.05%^ 2betamethasone dipropionate lotion 0.05%^ 2betamethasone dipropionate oint 0.05%^ 2betamethasone valerate cream 0.1%^ 2betamethasone valerate lotion 0.1%^ 2betamethasone valerate oint 0.1%^ 2calcipotriene cream 0.005%^ 2calcipotriene oint 0.005%^ 2calcipotriene soln 0.005% (50 mcg/ml)^ 2CARAC - fluorouracil cream 0.5% 5ciclopirox gel 0.77%^ 2ciclopirox olamine cream 0.77%^ 2ciclopirox olamine susp 0.77%^ 2ciclopirox shampoo 1%^ 2ciclopirox solution 8%^ 2clindamycin phosphate gel 1%^ 2clindamycin phosphate lotion 1%^ 2clindamycin phosphate soln 1%^ 2clindamycin phosphate swab 1%^ 2clindamycin phosphate-benzoyl peroxide gel 1-5%^ 2clobetasol propionate cream 0.05%^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.74

Drug Name Drug Tier Requirements/Limitsclobetasol propionate emollient base cream 0.05%^ 2clobetasol propionate gel 0.05%^ 2clobetasol propionate oint 0.05%^ 2clobetasol propionate soln 0.05%^ 2clotrimazole cream 1%^ 2clotrimazole w/ betamethasone cream 1-0.05%^ 2clotrimazole w/ betamethasone lotion 1-0.05%^ 2DENAVIR - penciclovir cream 1% 5desonide cream 0.05%^ 2desonide lotion 0.05%^ 2desonide oint 0.05%^ 2desoximetasone cream 0.05%^ 2desoximetasone cream 0.25%^ 2desoximetasone gel 0.05%^ 2desoximetasone oint 0.25%^ 2diclofenac sodium gel 1%^ 2 STdiclofenac sodium gel 3% 5DIFLORASONE DIACETATE - diflorasone diacetate oint 0.05% 4econazole nitrate cream 1%^ 2ELIDEL - pimecrolimus cream 1% 4 PAerythromycin pads 2%^ 2erythromycin soln 2%^ 2FINACEA - azelaic acid foam 15% 4FINACEA - azelaic acid gel 15% 4fluocinolone acetonide cream 0.01%^ 2fluocinonide cream 0.05%^ 2fluocinonide emulsified base cream 0.05%^ 2fluocinonide gel 0.05%^ 2fluocinonide oint 0.05%^ 2fluocinonide soln 0.05%^ 2fluorouracil cream 5%^ 2fluorouracil soln 2%^ 2fluorouracil soln 5%^ 2fluticasone propionate cream 0.05%^ 2fluticasone propionate oint 0.005%^ 2GENTAMICIN SULFATE - gentamicin sulfate oint 0.1% 4gentamicin sulfate cream 0.1%^ 2halobetasol propionate cream 0.05%^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

75

Drug Name Drug Tier Requirements/Limitshalobetasol propionate oint 0.05%^ 2hydrocortisone butyrate cream 0.1%^ 2hydrocortisone butyrate oint 0.1%^ 2hydrocortisone butyrate soln 0.1%^ 2hydrocortisone cream 1%^ 2hydrocortisone cream 2.5%^ 2hydrocortisone lotion 2.5%^ 2hydrocortisone oint 1%^ 2hydrocortisone oint 2.5%^ 2hydrocortisone valerate cream 0.2%^ 2hydrocortisone valerate oint 0.2%^ 2imiquimod cream 5%^ 2 PAisotretinoin cap 10 mg^ 2isotretinoin cap 20 mg^ 2isotretinoin cap 30 mg^ 2isotretinoin cap 40 mg^ 2ketoconazole cream 2%^ 2ketoconazole shampoo 2%^ 2lactic acid (ammonium lactate) cream 12%^ 2lactic acid (ammonium lactate) lotion 12%^ 2methoxsalen rapid cap 10 mg 5metronidazole cream 0.75%^ 2metronidazole gel 0.75%^ 2metronidazole gel 1%^ 2metronidazole lotion 0.75%^ 2mometasone furoate cream 0.1%^ 2mometasone furoate oint 0.1%^ 2mometasone furoate solution 0.1% (lotion)^ 2mupirocin oint 2%^ 2nystatin cream 100000 unit/gm^ 2nystatin oint 100000 unit/gm^ 2nystatin topical powder 100000 unit/gm^ 2nystatin-triamcinolone cream 100000-0.1 unit/gm-%^ 2nystatin-triamcinolone oint 100000-0.1 unit/gm-%^ 2ORACEA - doxycycline cap delayed release 40 mg 4PICATO - ingenol mebutate gel 0.015% 3 QL (3 tubes/30 days)PICATO - ingenol mebutate gel 0.05% 3 QL (2 tubes/30 days)podofilox soln 0.5%^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.76

Drug Name Drug Tier Requirements/Limitsprednicarbate cream 0.1%^ 2prednicarbate oint 0.1%^ 2REGRANEX - becaplermin gel 0.01% 5 PA, QL (15 grams/30 days)SANTYL - collagenase oint 250 unit/gm 3selenium sulfide lotion 2.5%^ 2silver sulfadiazine cream 1%^ 2SOOLANTRA - ivermectin cream 1% 3STELARA - ustekinumab inj 45 mg/0.5ml 5 PASTELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml 5 PASTELARA - ustekinumab soln prefilled syringe 90 mg/ml 5 PAsulfacetamide sodium lotion 10%^ 2tacrolimus oint 0.03%^ 2 PAtacrolimus oint 0.1%^ 2 PAtazarotene cream 0.1% 4TAZORAC - tazarotene cream 0.05% 4TAZORAC - tazarotene cream 0.1% 4TAZORAC - tazarotene gel 0.05% 4TAZORAC - tazarotene gel 0.1% 4tretinoin cream 0.025%^ 2tretinoin cream 0.05%^ 2tretinoin cream 0.1%^ 2tretinoin gel 0.01%^ 2tretinoin gel 0.025%^ 2triamcinolone acetonide cream 0.025%^ 2triamcinolone acetonide cream 0.1%^ 2triamcinolone acetonide cream 0.5%^ 2triamcinolone acetonide lotion 0.025%^ 2triamcinolone acetonide lotion 0.1%^ 2triamcinolone acetonide oint 0.025%^ 2triamcinolone acetonide oint 0.1%^ 2triamcinolone acetonide oint 0.5%^ 2UVADEX - methoxsalen soln 20 mcg/ml 4VALCHLOR - mechlorethamine hcl gel 0.016%* 5Enzyme Replacements/ModifiersADAGEN - pegademase bovine inj 250 unit/ml* 5ALDURAZYME - laronidase soln for iv infusion 2.9 mg/5ml (500

unit/5ml)*5

BUPHENYL - sodium phenylbutyrate tab 500 mg 5CEREZYME - imiglucerase for inj 400 unit* 5

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

77

Drug Name Drug Tier Requirements/LimitsCREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit 3CREON - pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000

unit3

CREON - pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit

3

CYSTADANE - betaine powder for oral solution 5CYSTAGON - cysteamine bitartrate cap 50 mg* 4CYSTAGON - cysteamine bitartrate cap 150 mg* 4ELAPRASE - idursulfase soln for iv infusion 6 mg/3ml (2 mg/ml)* 5ELELYSO - taliglucerase alfa for inj 200 unit* 5FABRAZYME - agalsidase beta for iv soln 5 mg* 5FABRAZYME - agalsidase beta for iv soln 35 mg* 5KUVAN - sapropterin dihydrochloride powder packet 100 mg* 5 PAKUVAN - sapropterin dihydrochloride powder packet 500 mg* 5 PAKUVAN - sapropterin dihydrochloride soluble tab 100 mg* 5 PANAGLAZYME - galsulfase soln for iv infusion 1 mg/ml* 5ORFADIN - nitisinone cap 2 mg* 5ORFADIN - nitisinone cap 5 mg* 5ORFADIN - nitisinone cap 10 mg* 5ORFADIN - nitisinone cap 20 mg* 5ORFADIN - nitisinone susp 4 mg/ml* 5sodium phenylbutyrate oral powder 3 gm/teaspoonful 5sodium phenylbutyrate tab 500 mg 5STRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml* 5STRENSIQ - asfotase alfa subcutaneous inj 28 mg/0.7ml* 5STRENSIQ - asfotase alfa subcutaneous inj 40 mg/ml* 5STRENSIQ - asfotase alfa subcutaneous inj 80 mg/0.8ml* 5VIOKACE - pancrelipase (lip-prot-amyl) tab 10440-39150-39150

unit4

VIOKACE - pancrelipase (lip-prot-amyl) tab 20880-78300-78300unit

4

VPRIV - velaglucerase alfa for inj 400 unit 5ZAVESCA - miglustat cap 100 mg* 5ZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000

unit3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000unit

3

2017

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Drug Name Drug Tier Requirements/LimitsZENPEP - pancrelipase (lip-prot-amyl) dr cap 10000-34000-55000

unit3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 15000-51000-82000unit

3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 20000-68000-109000unit

3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 25000-85000-136000unit

3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap40000-136000-218000 unit

3

Gastrointestinal Agentsalosetron hcl tab 0.5 mg 4alosetron hcl tab 1 mg 5AMITIZA - lubiprostone cap 8 mcg 3 PAAMITIZA - lubiprostone cap 24 mcg 3 PACHENODAL - chenodiol tab 250 mg* 5cimetidine hcl soln 300 mg/5ml^ 2cimetidine tab 200 mg^ 2cimetidine tab 300 mg^ 2cimetidine tab 400 mg^ 2cimetidine tab 800 mg^ 2cromolyn sodium oral conc 100 mg/5ml^ 2dicyclomine hcl tab 20 mg 4esomeprazole magnesium cap delayed release 20 mg^ 2 QL (30 capsules/30 days)esomeprazole magnesium cap delayed release 40 mg^ 2 QL (30 capsules/30 days)ESOMEPRAZOLE SODIUM - esomeprazole sodium for

intravenous soln 20 mg4

esomeprazole sodium for intravenous soln 40 mg 4famotidine inj 20 mg/2ml 4famotidine inj 40 mg/4ml 4famotidine inj 200 mg/20ml 4famotidine tab 20 mg^ 2famotidine tab 40 mg^ 2GATTEX - teduglutide (rdna) for inj kit 5 mg* 5 PAglycopyrrolate tab 1 mg^ 2glycopyrrolate tab 2 mg^ 2lactulose (encephalopathy) solution 10 gm/15ml^ 2lactulose solution 10 gm/15ml^ 2lansoprazole cap delayed release 15 mg^ 2 QL (30 capsules/30 days)lansoprazole cap delayed release 30 mg^ 2 QL (30 capsules/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

79

Drug Name Drug Tier Requirements/LimitsLINZESS - linaclotide cap 72 mcg 3 PALINZESS - linaclotide cap 145 mcg 3 PALINZESS - linaclotide cap 290 mcg 3 PAloperamide hcl cap 2 mg^ 2methscopolamine bromide tab 2.5 mg^ 2methscopolamine bromide tab 5 mg^ 2metoclopramide hcl inj 5 mg/ml 4metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 4metoclopramide hcl tab 5 mg^ 2metoclopramide hcl tab 10 mg^ 2misoprostol tab 100 mcg^ 2misoprostol tab 200 mcg^ 2MOVIPREP - peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln

100 gm4

NEXIUM - esomeprazole magnesium for delayed release susppacket 5 mg

4 QL (30 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susppacket 10 mg

4 QL (30 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susppacket 20 mg

4 QL (30 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susppacket 40 mg

4 QL (30 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susppacket 2.5 mg

4 QL (30 packets/30 days)

nizatidine cap 150 mg^ 2nizatidine cap 300 mg^ 2OCALIVA - obeticholic acid tab 5 mg 5 PA, QL (30 tablets/30 days)OCALIVA - obeticholic acid tab 10 mg 5 PA, QL (30 tablets/30 days)omeprazole cap delayed release 10 mg^ 2 QL (30 capsules/30 days)omeprazole cap delayed release 20 mg^ 2 QL (60 capsules/30 days)omeprazole cap delayed release 40 mg^ 2 QL (60 capsules/30 days)pantoprazole sodium ec tab 20 mg^ 2 QL (30 tablets/30 days)pantoprazole sodium ec tab 40 mg^ 2 QL (60 tablets/30 days)pantoprazole sodium for iv soln 40 mg^ 2peg 3350-kcl-sod bicarb-nacl for soln 420 gm^ 2peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm^ 2peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm^ 2polyethylene glycol 3350 oral packet^ 2polyethylene glycol 3350 oral powder^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.80

Drug Name Drug Tier Requirements/LimitsPYLERA - bismuth subcit-metronidazole-tetracycline cap

140-125-125 mg3

ranitidine hcl cap 150 mg^ 2ranitidine hcl cap 300 mg^ 2ranitidine hcl syrup 15 mg/ml (75 mg/5ml)^ 2ranitidine hcl tab 150 mg^ 2ranitidine hcl tab 300 mg^ 2RELISTOR - methylnaltrexone bromide inj 8 mg/0.4ml (20 mg/ml) 4 PARELISTOR - methylnaltrexone bromide inj 12 mg/0.6ml (20 mg/ml) 4 PARELISTOR - methylnaltrexone bromide tab 150 mg 5 PAsucralfate tab 1 gm^ 2SUPREP BOWEL PREP KIT - sod sulfate-pot sulf-mg sulf oral sol

17.5-3.13-1.6 gm/180ml4

ursodiol cap 300 mg^ 2ursodiol tab 250 mg^ 2ursodiol tab 500 mg^ 2XIFAXAN - rifaximin tab 550 mg 5Genitourinary Agentsalfuzosin hcl tab er 24hr 10 mg^ 2 QL (30 tablets/30 days)bethanechol chloride tab 5 mg^ 2bethanechol chloride tab 10 mg^ 2bethanechol chloride tab 25 mg^ 2bethanechol chloride tab 50 mg^ 2calcium acetate cap 667 mg^ 2calcium acetate tab 667 mg^ 2DEPEN TITRATABS - penicillamine tab 250 mg 5doxazosin mesylate tab 1 mg^ 2 QL (60 tablets/30 days)doxazosin mesylate tab 2 mg^ 2 QL (60 tablets/30 days)doxazosin mesylate tab 4 mg^ 2 QL (60 tablets/30 days)doxazosin mesylate tab 8 mg^ 2 QL (60 tablets/30 days)dutasteride cap 0.5 mg^ 2 QL (30 capsules/30 days)dutasteride-tamsulosin hcl cap 0.5-0.4 mg^ 2 QL (30 capsules/30 days)finasteride tab 5 mg^ 2 QL (30 tablets/30 days)FOSRENOL - lanthanum carbonate chew tab 500 mg 5FOSRENOL - lanthanum carbonate chew tab 750 mg 5FOSRENOL - lanthanum carbonate chew tab 1000 mg 5FOSRENOL - lanthanum carbonate oral powder pack 750 mg 5FOSRENOL - lanthanum carbonate oral powder pack 1000 mg 5lanthanum carbonate chew tab 500 mg 5

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

81

Drug Name Drug Tier Requirements/Limitslanthanum carbonate chew tab 750 mg 5lanthanum carbonate chew tab 1000 mg 5methylergonovine maleate tab 0.2 mg 5neomycin-polymyxin b gu irrigation soln^ 2oxybutynin chloride syrup 5 mg/5ml^ 2 QL (600 mls/30 days)oxybutynin chloride tab er 24hr 5 mg^ 2 QL (30 tablets/30 days)oxybutynin chloride tab er 24hr 10 mg^ 2 QL (60 tablets/30 days)oxybutynin chloride tab er 24hr 15 mg^ 2 QL (60 tablets/30 days)oxybutynin chloride tab 5 mg^ 2 QL (120 tablets/30 days)PHOSLYRA - calcium acetate oral soln 667 mg/5ml 3prazosin hcl cap 1 mg^ 2prazosin hcl cap 2 mg^ 2prazosin hcl cap 5 mg^ 2RAPAFLO - silodosin cap 4 mg 3 QL (30 capsules/30 days)RAPAFLO - silodosin cap 8 mg 3 QL (30 capsules/30 days)RENVELA - sevelamer carbonate packet 0.8 gm 5RENVELA - sevelamer carbonate packet 2.4 gm 5RENVELA - sevelamer carbonate tab 800 mg 5sevelamer carbonate packet 0.8 gm 5sevelamer carbonate packet 2.4 gm 5sevelamer carbonate tab 800 mg 5tamsulosin hcl cap 0.4 mg^ 2 QL (60 capsules/30 days)terazosin hcl cap 1 mg^ 2 QL (90 capsules/30 days)terazosin hcl cap 2 mg^ 2 QL (60 capsules/30 days)terazosin hcl cap 5 mg^ 2 QL (60 capsules/30 days)terazosin hcl cap 10 mg^ 2 QL (60 capsules/30 days)tolterodine tartrate cap er 24hr 2 mg^ 2 QL (30 capsules/30 days)tolterodine tartrate cap er 24hr 4 mg^ 2 QL (30 capsules/30 days)tolterodine tartrate tab 1 mg^ 2 QL (60 tablets/30 days)tolterodine tartrate tab 2 mg^ 2 QL (60 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 4 mg 3 QL (30 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 8 mg 3 QL (30 tablets/30 days)trospium chloride cap er 24hr 60 mg^ 2 QL (30 capsules/30 days)trospium chloride tab 20 mg^ 2 QL (60 tablets/30 days)Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)CORTISONE ACETATE - cortisone acetate tab 25 mg 4DEXAMETHASONE - dexamethasone tab 1 mg 4DEXAMETHASONE - dexamethasone tab 2 mg 4

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.82

Drug Name Drug Tier Requirements/Limitsdexamethasone elixir 0.5 mg/5ml^ 2dexamethasone sodium phosphate inj 4 mg/ml 4dexamethasone sodium phosphate inj 20 mg/5ml 4dexamethasone sodium phosphate inj 120 mg/30ml 4dexamethasone tab 0.5 mg^ 2dexamethasone tab 0.75 mg^ 2dexamethasone tab 1.5 mg^ 2dexamethasone tab 4 mg^ 2dexamethasone tab 6 mg^ 2fludrocortisone acetate tab 0.1 mg^ 2H.P. ACTHAR - corticotropin inj gel 80 unit/ml* 5 PAhydrocortisone tab 5 mg^ 2hydrocortisone tab 10 mg^ 2hydrocortisone tab 20 mg^ 2methylprednisolone sod succ for inj 40 mg 3methylprednisolone sod succ for inj 125 mg 3methylprednisolone sod succ for inj 1000 mg 3methylprednisolone tab therapy pack 4 mg (21)^ 2methylprednisolone tab 4 mg^ 2 BDmethylprednisolone tab 8 mg^ 2 BDmethylprednisolone tab 16 mg^ 2 BDmethylprednisolone tab 32 mg^ 2 BDMYALEPT - metreleptin for subcutaneous inj 11.3 mg* 5 PAprednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)^ 2 BDprednisolone sod phosphate oral soln 15 mg/5ml^ 2 BDprednisolone syrup 15 mg/5ml^ 2 BDPREDNISONE - prednisone oral soln 5 mg/5ml 4 BDPREDNISONE - prednisone tab therapy pack 5 mg (21)^ 2PREDNISONE - prednisone tab therapy pack 5 mg (48)^ 2PREDNISONE - prednisone tab therapy pack 10 mg (21)^ 2PREDNISONE - prednisone tab therapy pack 10 mg (48)^ 2PREDNISONE - prednisone tab 50 mg 4 BDprednisone tab 1 mg^ 2 BDprednisone tab 2.5 mg^ 2 BDprednisone tab 5 mg^ 2 BDprednisone tab 10 mg^ 2 BDprednisone tab 20 mg^ 2 BD

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

83

Drug Name Drug Tier Requirements/LimitsHormonal Agents, Stimulant/Replacement/Modifying (Pituitary)chorionic gonadotropin for im inj 10000 unit

(chorionic gonadotropin, pregnyl)4 PA

desmopressin acetate inj 4 mcg/ml 4desmopressin acetate nasal soln 0.01% (refrigerated)^ 2desmopressin acetate tab 0.1 mg^ 2desmopressin acetate tab 0.2 mg^ 2EGRIFTA - tesamorelin acetate for inj 1 mg* 5 PAEGRIFTA - tesamorelin acetate for inj 2 mg* 5 PAINCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)* 5OMNITROPE - somatropin for inj 5.8 mg* 4 PAOMNITROPE - somatropin inj 5 mg/1.5ml* 5 PAOMNITROPE - somatropin inj 10 mg/1.5ml* 5 PASTIMATE - desmopressin acetate nasal soln 1.5 mg/ml 4Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)ANADROL-50 - oxymetholone tab 50 mg 5 PAANDRODERM - testosterone td patch 24hr 2 mg/24hr 3 PA, QL (30 patches/30 days)ANDRODERM - testosterone td patch 24hr 4 mg/24hr 3 PA, QL (30 patches/30 days)ANDROGEL - testosterone td gel 20.25 mg/1.25gm (1.62%) 3 PA, QL (30 packets/30 days)ANDROGEL - testosterone td gel 40.5 mg/2.5gm (1.62%) 3 PA, QL (60 packets/30 days)ANDROGEL PUMP - testosterone td gel 20.25 mg/act (1.62%) 3 PA, QL (2 pump bottles/30 days)AXIRON - testosterone td soln 30 mg/act 4 PA, QL (2 pump bottles/30 days)danazol cap 50 mg^ 2 PAdanazol cap 100 mg^ 2 PAdanazol cap 200 mg^ 2 PADEPO-PROVERA - medroxyprogesterone acetate im susp 400 mg/

ml4

desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)^ 2desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg^ 2desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg^ 2drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg^ 2drospirenone-ethinyl estradiol tab 3-0.02 mg^ 2drospirenone-ethinyl estradiol tab 3-0.03 mg^ 2ELLA - ulipristal acetate tab 30 mg 3ESTRACE - estradiol vaginal cream 0.1 mg/gm 4estradiol & norethindrone acetate tab 0.5-0.1 mg# 4 PAestradiol & norethindrone acetate tab 1-0.5 mg# 4 PAestradiol tab 0.5 mg# 4 PAestradiol tab 1 mg# 4 PA

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.84

Drug Name Drug Tier Requirements/Limitsestradiol tab 2 mg# 4 PAestradiol vaginal tab 10 mcg^ 2ESTROPIPATE - estropipate tab 0.75 mg# 4 PAESTROPIPATE - estropipate tab 1.5 mg# 4 PAESTROPIPATE - estropipate tab 3 mg# 4 PAethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg^ 2ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg^ 2levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)^ 2levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7)^ 2levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg^ 2levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg^ 2levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg^ 2levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg^ 2levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg^ 2medroxyprogesterone acetate im susp prefilled syr 150 mg/ml 4medroxyprogesterone acetate im susp 150 mg/ml 4medroxyprogesterone acetate tab 2.5 mg^ 2medroxyprogesterone acetate tab 5 mg^ 2medroxyprogesterone acetate tab 10 mg^ 2megestrol acetate susp 40 mg/ml# 4 PAmegestrol acetate tab 20 mg# 4 PAmegestrol acetate tab 40 mg# 4 PAmethyltestosterone cap 10 mg^ 2 PAnorethindrone & ethinyl estradiol tab 0.4 mg-35 mcg^ 2norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg^ 2norethindrone & ethinyl estradiol tab 1 mg-35 mcg^ 2norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg^ 2norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg^ 2norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg^ 2norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg^ 2norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg^ 2norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg^ 2norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg^ 2norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24)^ 2norethindrone acetate tab 5 mg^ 2norethindrone tab 0.35 mg^ 2norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg^ 2norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg^ 2

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You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

85

Drug Name Drug Tier Requirements/Limitsnorgestimate & ethinyl estradiol tab 0.25 mg-35 mcg^ 2norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg^ 2norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg^ 2norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg^ 2oxandrolone tab 2.5 mg^ 2 PAoxandrolone tab 10 mg 5 PAPREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm 3PREMPHASE - conj est 0.625(14)/conj est-medroxypro ac tab

0.625-5mg(14)#4 PA

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.3-1.5 mg#

4 PA

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.45-1.5 mg#

4 PA

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.625-2.5 mg#

4 PA

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.625-5 mg#

4 PA

raloxifene hcl tab 60 mg^ 2testosterone cypionate im inj in oil 100 mg/ml 4 PAtestosterone cypionate im inj in oil 200 mg/ml 4 PAtestosterone enanthate im inj in oil 200 mg/ml 4 PAtestosterone td gel 25 mg/2.5gm (1%)^ 2 PA, QL (90 packets/30 days)testosterone td gel 50 mg/5gm (1%)^ 2 PA, QL (60 packets/30 days)testosterone td gel 12.5 mg/act (1%)^ 2 PA, QL (4 pump bottles/30 days)testosterone td soln 30 mg/act^ 2 PA, QL (2 pump bottles/30 days)VAGIFEM - estradiol vaginal tab 10 mcg 3Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tab 25 mcg^ 2levothyroxine sodium tab 50 mcg^ 2levothyroxine sodium tab 75 mcg^ 2levothyroxine sodium tab 88 mcg^ 2levothyroxine sodium tab 100 mcg^ 2levothyroxine sodium tab 112 mcg^ 2levothyroxine sodium tab 125 mcg^ 2levothyroxine sodium tab 137 mcg^ 2levothyroxine sodium tab 150 mcg^ 2levothyroxine sodium tab 175 mcg^ 2levothyroxine sodium tab 200 mcg^ 2levothyroxine sodium tab 300 mcg^ 2liothyronine sodium tab 5 mcg^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.86

Drug Name Drug Tier Requirements/Limitsliothyronine sodium tab 25 mcg^ 2liothyronine sodium tab 50 mcg^ 2NATPARA - parathyroid hormone (recombinant) for inj cartridge

25 mcg*5 PA, QL (2 cartridges/28 days)

NATPARA - parathyroid hormone (recombinant) for inj cartridge50 mcg*

5 PA, QL (2 cartridges/28 days)

NATPARA - parathyroid hormone (recombinant) for inj cartridge75 mcg*

5 PA, QL (2 cartridges/28 days)

NATPARA - parathyroid hormone (recombinant) for inj cartridge100 mcg*

5 PA, QL (2 cartridges/28 days)

SYNTHROID - levothyroxine sodium tab 25 mcg 4SYNTHROID - levothyroxine sodium tab 50 mcg 4SYNTHROID - levothyroxine sodium tab 75 mcg 4SYNTHROID - levothyroxine sodium tab 88 mcg 4SYNTHROID - levothyroxine sodium tab 100 mcg 4SYNTHROID - levothyroxine sodium tab 112 mcg 4SYNTHROID - levothyroxine sodium tab 125 mcg 4SYNTHROID - levothyroxine sodium tab 137 mcg 4SYNTHROID - levothyroxine sodium tab 150 mcg 4SYNTHROID - levothyroxine sodium tab 175 mcg 4SYNTHROID - levothyroxine sodium tab 200 mcg 4SYNTHROID - levothyroxine sodium tab 300 mcg 4Hormonal Agents, Suppressant (Adrenal)KORLYM - mifepristone tab 300 mg* 5 PA, QL (120 tablets/30 days)LYSODREN - mitotane tab 500 mg 3Hormonal Agents, Suppressant (Parathyroid)SENSIPAR - cinacalcet hcl tab 30 mg 3 PASENSIPAR - cinacalcet hcl tab 60 mg 3 PASENSIPAR - cinacalcet hcl tab 90 mg 3 PAHormonal Agents, Suppressant (Pituitary)bromocriptine mesylate cap 5 mg^ 2bromocriptine mesylate tab 2.5 mg^ 2cabergoline tab 0.5 mg^ 2ELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit

22.5mg4

ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit30 mg

4

ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit45 mg

4

ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg 4FIRMAGON - degarelix acetate for inj 80 mg 4

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

87

Drug Name Drug Tier Requirements/LimitsFIRMAGON - degarelix acetate for inj 120 mg 5leuprolide acetate inj kit 5 mg/ml 3LUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit

3.75 mg5

LUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit 7.5 mg 5LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for inj

kit 11.25 mg5

LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for injkit 22.5 mg

5

LUPRON DEPOT (4-MONTH) - leuprolide acetate (4 month) for injkit 30 mg

5

LUPRON DEPOT (6-MONTH) - leuprolide acetate (6 month) for injkit 45 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 7.5 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 11.25 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 15 mg

5

LUPRON DEPOT-PED (3-MONTH) - leuprolide acetate (3 month)for inj pediatric kit 11.25 mg

5

LUPRON DEPOT-PED (3-MONTH) - leuprolide acetate (3 month)for inj pediatric kit 30 mg

5

octreotide acetate inj 50 mcg/ml (0.05 mg/ml) 4 PAoctreotide acetate inj 100 mcg/ml (0.1 mg/ml) 4 PAoctreotide acetate inj 200 mcg/ml (0.2 mg/ml) 4 PAoctreotide acetate inj 500 mcg/ml (0.5 mg/ml) 5 PAoctreotide acetate inj 1000 mcg/ml (1 mg/ml) 5 PASIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.6 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.9 mg/ml* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 20 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 40 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 60 mg* 5 PASOMATULINE DEPOT - lanreotide acetate extended release inj

60 mg/0.2ml5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj90 mg/0.3ml

5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj120 mg/0.5ml

5 PA

SOMAVERT - pegvisomant for inj 10 mg* 5 PASOMAVERT - pegvisomant for inj 15 mg* 5 PA

2017

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Drug Name Drug Tier Requirements/LimitsSOMAVERT - pegvisomant for inj 20 mg* 5 PASOMAVERT - pegvisomant for inj 25 mg* 5 PASOMAVERT - pegvisomant for inj 30 mg* 5 PASYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) 5TRELSTAR - triptorelin pamoate for im susp 3.75 mg 5TRELSTAR - triptorelin pamoate for im susp 11.25 mg 5TRELSTAR MIXJECT - triptorelin pamoate for im susp 3.75 mg 5TRELSTAR MIXJECT - triptorelin pamoate for im susp 11.25 mg 5TRELSTAR MIXJECT - triptorelin pamoate for im susp 22.5 mg 5Hormonal Agents, Suppressant (Thyroid)methimazole tab 5 mg^ 2methimazole tab 10 mg^ 2propylthiouracil tab 50 mg^ 2Immunological AgentsACTHIB - haemophilus b polysaccharide conjugate vaccine for inj 4ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000

unit/0.5ml)*5

ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml 4ARCALYST - rilonacept for inj 220 mg* 5 PAATGAM - lymphocyte immune globulin anti-thymocyte g inj 50 mg/

ml(eq)5 BD

AZASAN - azathioprine tab 75 mg 4 BDAZASAN - azathioprine tab 100 mg 4 BDAZATHIOPRINE - azathioprine sodium for inj 100 mg 4 BDazathioprine tab 50 mg^ 2 BDBCG VACCINE - bcg vaccine inj 4BENLYSTA - belimumab for iv soln 120 mg 5 PABENLYSTA - belimumab for iv soln 400 mg 5 PABENLYSTA - belimumab subcutaneous solution auto-injector

200 mg/ml5 PA

BENLYSTA - belimumab subcutaneous solution prefilled syringe200 mg/ml

5 PA

BEXSERO - meningococcal vac b (recomb omv adjuv) inj prefilledsyringe

4

BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml

4

CELLCEPT INTRAVENOUS - mycophenolate mofetil hcl for iv soln500 mg

4 BD

CINRYZE - c1 esterase inhibitor (human) for iv inj 500 unit* 5 PA, QL (20 vials/30 days)cyclosporine cap 25 mg^ 2 BDcyclosporine cap 100 mg^ 2 BD

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

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Drug Name Drug Tier Requirements/Limitscyclosporine iv soln 50 mg/ml 4 BDcyclosporine modified cap 25 mg^ 2 BDcyclosporine modified cap 50 mg^ 2 BDcyclosporine modified cap 100 mg^ 2 BDcyclosporine modified oral soln 100 mg/ml^ 2 BDDAPTACEL - diph, acellular pert & tet tox inj 15 lf-23 mcg-5 lf/0.5ml 4DEPEN TITRATABS - penicillamine tab 250 mg 5DIPHTHERIA/TETANUS TOXOIDS ADSORBED - diphtheria-

tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml4

ELIDEL - pimecrolimus cream 1% 4 PAENBREL - etanercept for subcutaneous inj 25 mg 5 PAENBREL - etanercept subcutaneous soln prefilled syringe

25 mg/0.5ml5 PA

ENBREL - etanercept subcutaneous soln prefilled syringe 50 mg/ml 5 PAENBREL MINI - etanercept subcutaneous solution cartridge 50 mg/

ml5 PA

ENBREL SURECLICK - etanercept subcutaneous solution auto-injector 50 mg/ml

5 PA

ENGERIX-B - hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml 4 BDENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml 4 BDFIRAZYR - icatibant acetate inj 30 mg/3ml* 5 PA, QL (6 syringes/30 days)GAMMAPLEX - immune globulin (human) iv soln 2.5 gm/50ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 5 gm/100ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 10 gm/200ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 20 gm/400ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 5 gm/50ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 10 gm/100ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 20 gm/200ml 5 BD, PAGAMUNEX-C - immune globulin (human) iv or subcutaneous soln

1 gm/10ml5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln2.5 gm/25ml

5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln5 gm/50ml

5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln10 gm/100ml

5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln20 gm/200ml

5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln40 gm/400ml

5 BD, PA

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.90

Drug Name Drug Tier Requirements/LimitsGARDASIL - human papillomavirus (hpv) quadrivalent recombinant

vac inj4

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac imsusp

4

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vacsusp pref syr

4

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj2000 unit

5 PA, QL (24 vials/30 days)

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj3000 unit

5 PA, QL (16 vials/30 days)

HAVRIX - hepatitis a vaccine inj susp 720 el unit/0.5ml 4HAVRIX - hepatitis a vaccine inj susp 1440 el unit/ml 4HIBERIX - haemophilus b polysaccharide conjugate vac for inj

10 mcg4

HUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml 5 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.4ml 5 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.8ml 5 PAHUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -

adalimumab prefilled syringe kit 40 mg/0.8ml5 PA

HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml 5 PAHUMIRA PEN-CROHNS DISEASE STARTER - adalimumab pen-

injector kit 40 mg/0.8ml5 PA

HUMIRA PEN-PSORIASIS STARTER - adalimumab pen-injector kit40 mg/0.8ml

5 PA

ILARIS - canakinumab for inj 180 mg* 5 PAILARIS - canakinumab subcutaneous inj 150 mg/ml* 5 PAIMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj 3 BDINFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml 4IPOL INACTIVATED IPV - poliovirus vaccine, ipv injection 4IXIARO - japanese encephalitis vaccine inactivated adsorbed inj 4KINERET - anakinra subcutaneous soln prefilled syringe

100 mg/0.67ml5 PA

KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj 4leflunomide tab 10 mg^ 2leflunomide tab 20 mg^ 2M-M-R II - measles, mumps & rubella virus vaccines for inj 4MENACTRA - meningococcal (a, c, y, and w-135) conjugate

vaccine inj4

MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac for inj 4METHOTREXATE SODIUM - methotrexate sodium inj

250 mg/10ml (25 mg/ml)^2

methotrexate sodium for inj 1 gm^ 2

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Drug Name Drug Tier Requirements/Limitsmethotrexate sodium inj pf 50 mg/2ml (25 mg/ml)^ 2methotrexate sodium inj pf 100 mg/4ml (25 mg/ml)^ 2methotrexate sodium inj pf 200 mg/8ml (25 mg/ml)^ 2methotrexate sodium inj pf 250 mg/10ml (25 mg/ml)^ 2methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml)^ 2methotrexate sodium inj 50 mg/2ml (25 mg/ml)^ 2methotrexate sodium tab 2.5 mg^ 2mycophenolate mofetil cap 250 mg^ 2 BDmycophenolate mofetil for oral susp 200 mg/ml 5 BDmycophenolate mofetil hcl for iv soln 500 mg^ 2 BDmycophenolate mofetil tab 500 mg^ 2 BDmycophenolate sodium tab dr 180 mg^ 2 BDmycophenolate sodium tab dr 360 mg^ 2 BDNULOJIX - belatacept for iv infusion 250 mg 5 BDORENCIA - abatacept for iv soln 250 mg 5 PAORENCIA - abatacept subcutaneous soln prefilled syringe

50 mg/0.4ml5 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe87.5 mg/0.7ml

5 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe 125 mg/ml

5 PA

ORENCIA CLICKJECT - abatacept subcutaneous soln auto-injector125 mg/ml

5 PA

PEDVAX HIB - haemophilus b polysaccharide conj vac im susp7.5 mcg/0.5 ml

4

PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac forim susp

4

PROGRAF - tacrolimus inj 5 mg/ml 4 BDPROQUAD - measles-mumps-rubella-varicella virus vaccines for inj 4QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vac

inj4

RABAVERT - rabies vaccine, pcec for inj 4 BDRAPAMUNE - sirolimus oral soln 1 mg/ml 5 BDRECOMBIVAX HB - hepatitis b vaccine (recombinant) susp

5 mcg/0.5ml4 BD

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp10 mcg/ml

4 BD

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp40 mcg/ml

4 BD

REMICADE - infliximab for iv inj 100 mg 5 PARIDAURA - auranofin cap 3 mg 5

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.92

Drug Name Drug Tier Requirements/LimitsROTARIX - rotavirus vaccine, live for oral susp 4ROTATEQ - rotavirus vaccine, live oral pentavalent soln 4SANDIMMUNE - cyclosporine oral soln 100 mg/ml 4 BDSIMULECT - basiliximab for iv soln 10 mg 5 BDSIMULECT - basiliximab for iv soln 20 mg 5 BDsirolimus tab 0.5 mg^ 2 BDsirolimus tab 1 mg^ 2 BDsirolimus tab 2 mg 5 BDSTAMARIL - yellow fever vaccine for inj suspension 4STELARA - ustekinumab iv soln 130 mg/26ml (5 mg/ml) (for iv

infusion)5 PA

STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml 5 PASTELARA - ustekinumab soln prefilled syringe 90 mg/ml 5 PASYNAGIS - palivizumab im soln 50 mg/0.5ml* 5SYNAGIS - palivizumab im soln 100 mg/ml* 5tacrolimus cap 0.5 mg^ 2 BDtacrolimus cap 1 mg^ 2 BDtacrolimus cap 5 mg^ 2 BDTENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu 3TETANUS/DIPHTHERIA TOXOIDS ADSORBED - tetanus-

diphtheria toxoids (td) inj 2-2 lf/0.5ml3

THALOMID - thalidomide cap 50 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 100 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 150 mg 5 PA, QL (60 capsules/30 days)THALOMID - thalidomide cap 200 mg 5 PA, QL (60 capsules/30 days)THYMOGLOBULIN - anti-thymocyte globulin for iv soln 25 mg

(lymphocyte ig)5 BD

TRUMENBA - meningococcal group b vac (recomb) im suspprefilled syr

4

TWINRIX - hepatitis a (inact)-hep b (recomb) vac inj 720-20 elu-mcg/ml

4

TYPHIM VI - typhoid vi polysaccharide intramuscular vac inj25 mcg/0.5ml

4

TYSABRI - natalizumab for iv inj conc 300 mg/15ml* 5 PAVAQTA - hepatitis a vaccine inj susp 25 unit/0.5ml 4VAQTA - hepatitis a vaccine inj susp 50 unit/ml 4VARIVAX - varicella virus vac live for subcutaneous inj 1350

pfu/0.5ml4

XATMEP - methotrexate oral soln 2.5 mg/ml 5 BDYF-VAX - yellow fever vaccine subcutaneous inj 4

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Drug Name Drug Tier Requirements/LimitsZORTRESS - everolimus tab 0.25 mg 4 BDZORTRESS - everolimus tab 0.5 mg 5 BDZORTRESS - everolimus tab 0.75 mg 5 BDZOSTAVAX - zoster vaccine live for subcutaneous susp 19400

unit/0.65ml4 QL (1 vaccine/lifetime)

Inflammatory Bowel Disease AgentsAPRISO - mesalamine cap er 24hr 0.375 gm 4ASACOL HD - mesalamine tab delayed release 800 mg 3balsalazide disodium cap 750 mg^ 2budesonide delayed release particles cap 3 mg 5CANASA - mesalamine suppos 1000 mg 3DELZICOL - mesalamine cap dr 400 mg 3DIPENTUM - olsalazine sodium cap 250 mg 5hydrocortisone enema 100 mg/60ml^ 2hydrocortisone rectal cream 1%^ 2hydrocortisone rectal cream 2.5%^ 2LIALDA - mesalamine tab delayed release 1.2 gm 4mesalamine enema 4 gm^ 2mesalamine tab delayed release 1.2 gm 3PENTASA - mesalamine cap er 250 mg 4PENTASA - mesalamine cap er 500 mg 4sulfasalazine tab delayed release 500 mg^ 2sulfasalazine tab 500 mg^ 2Metabolic Bone Disease Agentsalendronate sodium tab 5 mg^ 1 QL (30 tablets/30 days)alendronate sodium tab 10 mg^ 1 QL (120 tablets/30 days)alendronate sodium tab 35 mg^ 1 QL (4 tablets/28 days)alendronate sodium tab 70 mg^ 1 QL (4 tablets/28 days)calcitonin (salmon) nasal soln 200 unit/act^ 2calcitriol cap 0.25 mcg^ 2calcitriol cap 0.5 mcg^ 2calcitriol inj 1 mcg/ml 4calcitriol oral soln 1 mcg/ml^ 2ETIDRONATE DISODIUM - etidronate disodium tab 200 mg 4ETIDRONATE DISODIUM - etidronate disodium tab 400 mg 4FORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml 5 PAibandronate sodium iv soln 3 mg/3ml 4ibandronate sodium tab 150 mg^ 2 QL (1 tablet/28 days)MIACALCIN - calcitonin (salmon) inj 200 unit/ml 4

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.94

Drug Name Drug Tier Requirements/Limitsparicalcitol cap 1 mcg^ 2paricalcitol cap 2 mcg^ 2paricalcitol cap 4 mcg^ 2paricalcitol iv soln 2 mcg/ml 4paricalcitol iv soln 5 mcg/ml 4PROLIA - denosumab inj 60 mg/ml 4 PArisedronate sodium tab delayed release 35 mg^ 2 QL (4 tablets/28 days)risedronate sodium tab 5 mg^ 2 QL (30 tablets/30 days)risedronate sodium tab 30 mg^ 2 QL (30 tablets/30 days)risedronate sodium tab 35 mg^ 2 QL (4 tablets/28 days)risedronate sodium tab 150 mg^ 2 QL (1 tablet/28 days)XGEVA - denosumab inj 120 mg/1.7ml 5zoledronic acid inj conc for iv infusion 4 mg/5ml 4zoledronic acid iv soln 5 mg/100ml 4ZOMETA - zoledronic acid iv soln 4 mg/100ml 5Ophthalmic AgentsALPHAGAN P - brimonidine tartrate ophth soln 0.1% 4azelastine hcl ophth soln 0.05%^ 2AZOPT - brinzolamide ophth susp 1% 4BACITRACIN - bacitracin ophth oint 500 unit/gm 4bacitracin-polymyxin b ophth oint^ 2bacitracin-polymyxin-neomycin-hc ophth oint 1%^ 2BESIVANCE - besifloxacin hcl ophth susp 0.6% 4betaxolol hcl ophth soln 0.5%^ 2BETOPTIC-S - betaxolol hcl ophth susp 0.25% 4brimonidine tartrate ophth soln 0.15%^ 2brimonidine tartrate ophth soln 0.2%^ 2bromfenac sodium ophth soln 0.09% (once-daily)^ 2carteolol hcl ophth soln 1%^ 2ciprofloxacin hcl ophth soln 0.3%^ 2COMBIGAN - brimonidine tartrate-timolol maleate ophth soln

0.2-0.5%3

cromolyn sodium ophth soln 4%^ 2CYSTARAN - cysteamine hcl ophth soln 0.44% 5DEXAMETHASONE SODIUM PHOSPHATE - dexamethasone

sodium phosphate ophth soln 0.1%4

diclofenac sodium ophth soln 0.1%^ 2dorzolamide hcl ophth soln 2%^ 2dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml^ 2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

95

Drug Name Drug Tier Requirements/LimitsDUREZOL - difluprednate ophth emulsion 0.05% 3epinastine hcl ophth soln 0.05%^ 2erythromycin ophth oint 5 mg/gm^ 2fluorometholone ophth susp 0.1%^ 2flurbiprofen sodium ophth soln 0.03%^ 2gentamicin sulfate ophth oint 0.3%^ 2gentamicin sulfate ophth soln 0.3%^ 2ILEVRO - nepafenac ophth susp 0.3% 3ISTALOL - timolol maleate ophth soln 0.5% (once-daily) 4ketorolac tromethamine ophth soln 0.4%^ 2ketorolac tromethamine ophth soln 0.5%^ 2LACRISERT - artificial tear ophth insert 4latanoprost ophth soln 0.005%^ 2levobunolol hcl ophth soln 0.5%^ 2LOTEMAX - loteprednol etabonate ophth gel 0.5% 3LOTEMAX - loteprednol etabonate ophth oint 0.5% 3LOTEMAX - loteprednol etabonate ophth susp 0.5% 3LUMIGAN - bimatoprost ophth soln 0.01% 3MOXEZA - moxifloxacin hcl ophth soln 0.5% (2 times daily) 4moxifloxacin hcl ophth soln 0.5%^ 2NATACYN - natamycin ophth susp 5% 4neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin^ 2neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml^ 2neomycin-polymyxin-dexamethasone ophth oint 0.1%^ 2neomycin-polymyxin-dexamethasone ophth susp 0.1%^ 2ofloxacin ophth soln 0.3%^ 2olopatadine hcl ophth soln 0.1%^ 2olopatadine hcl ophth soln 0.2%^ 2PATADAY - olopatadine hcl ophth soln 0.2% 3PAZEO - olopatadine hcl ophth soln 0.7% 3PHOSPHOLINE IODIDE - echothiophate iodide ophth for soln

0.125%4

pilocarpine hcl ophth soln 1%^ 2pilocarpine hcl ophth soln 2%^ 2pilocarpine hcl ophth soln 4%^ 2polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%^ 2prednisolone acetate ophth susp 1%^ 2PROLENSA - bromfenac sodium ophth soln 0.07% 4RESTASIS - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (60 vials/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.96

Drug Name Drug Tier Requirements/LimitsRESTASIS MULTIDOSE - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (2 bottles/30 days)SIMBRINZA - brinzolamide-brimonidine tartrate ophth susp 1-0.2% 3sulfacetamide sodium ophth soln 10%^ 2sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%^ 2timolol maleate ophth gel forming soln 0.25%^ 2timolol maleate ophth gel forming soln 0.5%^ 2timolol maleate ophth soln 0.25%^ 2timolol maleate ophth soln 0.5%^ 2TOBRADEX - tobramycin-dexamethasone ophth oint 0.3-0.1% 4tobramycin ophth soln 0.3%^ 2tobramycin-dexamethasone ophth susp 0.3-0.1%^ 2TRAVATAN Z - travoprost ophth soln 0.004% 3trifluridine ophth soln 1%^ 2VIGAMOX - moxifloxacin hcl ophth soln 0.5% 3Otic Agentsacetic acid otic soln 2%^ 2ACETIC ACID/ALUMINUM ACETATE - acetic acid 2% in aluminum

acetate otic soln4

CIPRODEX - ciprofloxacin-dexamethasone otic susp 0.3-0.1% 4fluocinolone acetonide (otic) oil 0.01%^ 2hydrocortisone w/ acetic acid otic soln 1-2%^ 2neomycin-polymyxin-hc otic soln 1%^ 2neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%^ 2ofloxacin otic soln 0.3%^ 2Respiratory Tract/Pulmonary Agentsacetylcysteine inhal soln 10%^ 2 BDacetylcysteine inhal soln 20%^ 2 BDADCIRCA - tadalafil tab 20 mg 5 PA, QL (60 tablets/30 days)ADEMPAS - riociguat tab 0.5 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1.5 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2.5 mg 5 PA, QL (90 tablets/30 days)ADVAIR DISKUS - fluticasone-salmeterol aer powder ba

100-50 mcg/dose3 QL (1 inhaler/30 days)

ADVAIR DISKUS - fluticasone-salmeterol aer powder ba250-50 mcg/dose

3 QL (1 inhaler/30 days)

ADVAIR DISKUS - fluticasone-salmeterol aer powder ba500-50 mcg/dose

3 QL (1 inhaler/30 days)

ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act 3 QL (1 canister/30 days)

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Drug Name Drug Tier Requirements/LimitsADVAIR HFA - fluticasone-salmeterol inhal aerosol 115-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 230-21 mcg/act 3 QL (1 canister/30 days)albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)^ 2 BDalbuterol sulfate soln nebu 0.5% (5 mg/ml)^ 2 BDalbuterol sulfate soln nebu 0.63 mg/3ml^ 2 BDalbuterol sulfate soln nebu 1.25 mg/3ml^ 2 BDalbuterol sulfate syrup 2 mg/5ml^ 2albuterol sulfate tab er 12hr 4 mg 4albuterol sulfate tab er 12hr 8 mg 4albuterol sulfate tab 2 mg 4albuterol sulfate tab 4 mg 4ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba

62.5-25 mcg/inh3 QL (1 package/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powder breathactiv 100 mcg/act

3 QL (30 blisters/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powder breathactiv 200 mcg/act

3 QL (30 blisters/30 days)

ASMANEX HFA - mometasone furoate inhal aerosol suspension100 mcg/act

3 QL (1 canister/30 days)

ASMANEX HFA - mometasone furoate inhal aerosol suspension200 mcg/act

3 QL (1 canister/30 days)

ASMANEX TWISTHALER 120 METERED DOSES - mometasonefuroate inhal powd 220 mcg/inh

3 QL (1 canister/30 days)

ASMANEX TWISTHALER 14 METERED DOSES - mometasonefuroate inhal powd 220 mcg/inh

3 QL (1 canister/30 days)

ASMANEX TWISTHALER 30 METERED DOSES - mometasonefuroate inhal powd 110 mcg/inh

3 QL (1 canister/30 days)

ASMANEX TWISTHALER 30 METERED DOSES - mometasonefuroate inhal powd 220 mcg/inh

3 QL (1 canister/30 days)

ASMANEX TWISTHALER 60 METERED DOSES - mometasonefuroate inhal powd 220 mcg/inh

3 QL (1 canister/30 days)

ASMANEX TWISTHALER 7 METERED DOSES - mometasonefuroate inhal powd 110 mcg/inh

3 QL (1 canister/30 days)

ATROVENT HFA - ipratropium bromide hfa inhal aerosol 17 mcg/act

4 QL (2 canisters/30 days)

azelastine hcl nasal spray 0.1% (137 mcg/spray)^ 2 QL (2 bottles/30 days)azelastine hcl nasal spray 0.15% (205.5 mcg/spray)^ 2 QL (2 bottles/30 days)BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba

100-25 mcg/inh3 QL (1 package/30 days)

BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba200-25 mcg/inh

3 QL (1 package/30 days)

budesonide inhalation susp 0.25 mg/2ml^ 2 BD

2017

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Drug Name Drug Tier Requirements/Limitsbudesonide inhalation susp 0.5 mg/2ml^ 2 BDbudesonide inhalation susp 1 mg/2ml^ 2 BDcaffeine citrate oral soln 60 mg/3ml^ 2clemastine fumarate tab 2.68 mg# 4 PACOMBIVENT RESPIMAT - ipratropium-albuterol inhal aerosol soln

20-100 mcg/act4 QL (2 canisters/30 days)

cromolyn sodium soln nebu 20 mg/2ml 3 BDDALIRESP - roflumilast tab 500 mcg 4DULERA - mometasone furoate-formoterol fumarate aerosol

100-5 mcg/act4 QL (1 canister/30 days)

DULERA - mometasone furoate-formoterol fumarate aerosol200-5 mcg/act

4 QL (1 canister/30 days)

EPINEPHRINE - epinephrine solution auto-injector 0.15 mg/0.3ml(1:2000)

3

EPINEPHRINE- epinephrine solution auto-injector 0.3 mg/0.3ml(1:1000)(authorized generic for EpiPen 2-Pak)

3

EPIPEN 2-PAK - epinephrine solution auto-injector 0.3 mg/0.3ml(1:1000)

3

EPIPEN-JR 2-PAK - epinephrine solution auto-injector0.15 mg/0.3ml (1:2000)

3

ESBRIET - pirfenidone cap 267 mg* 5 PA, QL (270 capsules/30 days)ESBRIET - pirfenidone tab 267 mg* 5 PA, QL (270 tablets/30 days)ESBRIET - pirfenidone tab 801 mg* 5 PA, QL (90 tablets/30 days)FLOVENT DISKUS - fluticasone propionate aer pow ba 50 mcg/

blister3 QL (1 inhaler/30 days)

FLOVENT DISKUS - fluticasone propionate aer pow ba 100 mcg/blister

3 QL (1 inhaler/30 days)

FLOVENT DISKUS - fluticasone propionate aer pow ba 250 mcg/blister

3 QL (4 inhalers/30 days)

FLOVENT HFA - fluticasone propionate hfa inhal aero 44 mcg/act(50/valve)

3 QL (1 canister/30 days)

FLOVENT HFA - fluticasone propionate hfa inhal aer 110 mcg/act(125/valve)

3 QL (1 canister/30 days)

FLOVENT HFA - fluticasone propionate hfa inhal aer 220 mcg/act(250/valve)

3 QL (2 canisters/30 days)

fluticasone propionate nasal susp 50 mcg/act^ 2 QL (1 bottle/30 days)FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-

salmeterol aer powder ba 55-14 mcg/act^2 QL (1 inhaler/30 days)

FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-salmeterol aer powder ba 113-14 mcg/act^

2 QL (1 inhaler/30 days)

FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-salmeterol aer powder ba 232-14 mcg/act^

2 QL (1 inhaler/30 days)

GRASTEK - timothy grass pollen allergen ext tab sl 2800 bau 4 PA, QL (30 tablets/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

99

Drug Name Drug Tier Requirements/Limitshydroxyzine hcl syrup 10 mg/5ml# 4 PAhydroxyzine hcl tab 10 mg# 4 PAhydroxyzine hcl tab 25 mg# 4 PAhydroxyzine hcl tab 50 mg# 4 PAINCRUSE ELLIPTA - umeclidinium br aero powd breath act

62.5 mcg/inh3 QL (30 blisters/30 days)

ipratropium bromide inhal soln 0.02%^ 2 BDipratropium bromide nasal soln 0.03% (21 mcg/spray)^ 2 QL (2 bottles/30 days)ipratropium bromide nasal soln 0.06% (42 mcg/spray)^ 2 QL (3 bottles/30 days)KALYDECO - ivacaftor packet 50 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor packet 75 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor tab 150 mg 5 PA, QL (60 tablets/30 days)LETAIRIS - ambrisentan tab 5 mg* 5 PA, QL (30 tablets/30 days)LETAIRIS - ambrisentan tab 10 mg* 5 PA, QL (30 tablets/30 days)levocetirizine dihydrochloride tab 5 mg^ 1mometasone furoate nasal susp 50 mcg/act^ 2 QL (2 bottles/30 days)montelukast sodium chew tab 4 mg^ 2montelukast sodium chew tab 5 mg^ 2montelukast sodium oral granules packet 4 mg^ 2montelukast sodium tab 10 mg^ 2OFEV - nintedanib esylate cap 100 mg* 5 PA, QL (60 capsules/30 days)OFEV - nintedanib esylate cap 150 mg* 5 PA, QL (60 capsules/30 days)olopatadine hcl nasal soln 0.6%^ 2 QL (1 bottle/30 days)OPSUMIT - macitentan tab 10 mg* 5 PA, QL (30 tablets/30 days)ORALAIR - grass mixed pollen ext tab sl 300 ir 4 PA, QL (30 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 100-125 mg* 5 PA, QL (120 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 200-125 mg* 5 PA, QL (120 tablets/30 days)PROAIR HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (2 canisters/30 days)PROAIR RESPICLICK - albuterol sulfate aer pow ba 108 mcg/act 3 QL (2 canisters/30 days)PROLASTIN-C - alpha1-proteinase inhibitor (human) for iv soln

1000 mg*5 PA

promethazine hcl suppos 12.5 mg# 4 PApromethazine hcl suppos 25 mg# 4 PApromethazine hcl syrup 6.25 mg/5ml# 4 PApromethazine hcl tab 12.5 mg# 4 PApromethazine hcl tab 25 mg# 4 PApromethazine hcl tab 50 mg# 4 PAPULMOZYME - dornase alfa inhal soln 1 mg/ml 5 BD

2017

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Drug Name Drug Tier Requirements/LimitsQVAR - beclomethasone diprop inhal aero soln 40 mcg/act (50/

valve)3 QL (1 canister/30 days)

QVAR - beclomethasone diprop inhal aero soln 80 mcg/act (100/valve)

3 QL (2 canisters/30 days)

RAGWITEK - short ragweed pollen allergen extract tab sl 12 amb a1-u

4 PA, QL (30 tablets/30 days)

REMODULIN - treprostinil sodium inj 1 mg/ml* 5 BDREMODULIN - treprostinil sodium inj 2.5 mg/ml* 5 BDREMODULIN - treprostinil sodium inj 5 mg/ml* 5 BDREMODULIN - treprostinil sodium inj 10 mg/ml* 5 BDSEREVENT DISKUS - salmeterol xinafoate aer pow ba 50 mcg/

dose3 QL (1 inhaler/30 days)

sildenafil citrate tab 20 mg^ 2 PA, QL (90 tablets/30 days)SPIRIVA HANDIHALER - tiotropium bromide monohydrate inhal

cap 18 mcg3 QL (30 capsules/30 days)

SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 1.25 mcg/act

3 QL (1 inhaler/30 days)

SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 2.5 mcg/act

3 QL (1 inhaler/30 days)

STIOLTO RESPIMAT - tiotropium br-olodaterol inhal aero soln2.5-2.5 mcg/act

3 QL (1 canister/30 days)

SYMBICORT - budesonide-formoterol fumarate dihyd aerosol80-4.5 mcg/act

3 QL (1 canister/30 days)

SYMBICORT - budesonide-formoterol fumarate dihyd aerosol160-4.5 mcg/act

3 QL (1 canister/30 days)

terbutaline sulfate tab 2.5 mg^ 2terbutaline sulfate tab 5 mg^ 2theophylline tab er 12hr 100 mg^ 2theophylline tab er 12hr 200 mg^ 2theophylline tab er 12hr 300 mg^ 2theophylline tab er 12hr 450 mg^ 2theophylline tab er 24hr 400 mg^ 2theophylline tab er 24hr 600 mg^ 2tobramycin nebu soln 300 mg/5ml 5 BDTRACLEER - bosentan tab 62.5 mg* 5 PA, QL (60 tablets/30 days)TRACLEER - bosentan tab 125 mg* 5 PA, QL (60 tablets/30 days)triamcinolone acetonide nasal aerosol suspension 55 mcg/act^ 2 QL (1 bottle/30 days)UPTRAVI - selexipag tab therapy pack 200 mcg (140) & 800 mcg

(60)*5 PA, QL (1 pack (200

tablets)/28 days)UPTRAVI - selexipag tab 200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 400 mcg* 5 PA, QL (60 tablets/30 days)

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

101

Drug Name Drug Tier Requirements/LimitsUPTRAVI - selexipag tab 600 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 800 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1000 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1600 mcg* 5 PA, QL (60 tablets/30 days)VENTAVIS - iloprost inhalation solution 10 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTAVIS - iloprost inhalation solution 20 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (2 canisters/30 days)XOLAIR - omalizumab for inj 150 mg* 5 PAXOPENEX HFA - levalbuterol tartrate inhal aerosol 45 mcg/act 4 QL (2 canisters/30 days)zafirlukast tab 10 mg^ 2zafirlukast tab 20 mg^ 2Skeletal Muscle Relaxantscyclobenzaprine hcl tab 5 mg# 4 PAcyclobenzaprine hcl tab 7.5 mg# 4 PAcyclobenzaprine hcl tab 10 mg# 4 PAmethocarbamol tab 500 mg# 4 PAmethocarbamol tab 750 mg# 4 PASleep Disorder Agentsarmodafinil tab 50 mg^ 2 PA, QL (30 tablets/30 days)armodafinil tab 150 mg^ 2 PA, QL (30 tablets/30 days)armodafinil tab 200 mg^ 2 PA, QL (30 tablets/30 days)armodafinil tab 250 mg^ 2 PA, QL (30 tablets/30 days)HETLIOZ - tasimelteon capsule 20 mg* 5 PA, QL (30 capsules/30 days)modafinil tab 100 mg^ 2 PA, QL (30 tablets/30 days)modafinil tab 200 mg^ 2 PA, QL (30 tablets/30 days)SILENOR - doxepin hcl tab 3 mg 3 QL (30 tablets/30 days)SILENOR - doxepin hcl tab 6 mg 3 QL (30 tablets/30 days)XYREM - sodium oxybate oral solution 500 mg/ml* 5 PA, QL (540 mls/30 days)zaleplon cap 5 mg# 3 PAzaleplon cap 10 mg# 3 PAzolpidem tartrate tab 5 mg# 4 PAzolpidem tartrate tab 10 mg# 4 PATherapeutic Nutrients/Minerals/Electrolytesamino acid infusion 6% 3 BDamino acid infusion 15% 3 BDCARBAGLU - carglumic acid tab 200 mg 5CHEMET - succimer cap 100 mg 4

2017

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Drug Name Drug Tier Requirements/LimitsDEPEN TITRATABS - penicillamine tab 250 mg 5dextrose inj 5% 4dextrose inj 10% 4dextrose 5% in lactated ringers 4dextrose 2.5% w/ sodium chloride 0.45% 4dextrose 5% w/ sodium chloride 0.2% 4dextrose 5% w/ sodium chloride 0.33% 4dextrose 5% w/ sodium chloride 0.45% 4dextrose 5% w/ sodium chloride 0.9% 4EXJADE - deferasirox tab for oral susp 125 mg* 5EXJADE - deferasirox tab for oral susp 250 mg* 5EXJADE - deferasirox tab for oral susp 500 mg* 5fat emulsion iv soln 20% 4 BDfomepizole inj 1 gm/ml (for iv infusion) 5HEPATAMINE - amino acid infusion 8% 4 BDJADENU - deferasirox tab 90 mg 5JADENU - deferasirox tab 180 mg 5JADENU - deferasirox tab 360 mg 5JADENU SPRINKLE - deferasirox granules packet 90 mg 5JADENU SPRINKLE - deferasirox granules packet 180 mg 5JADENU SPRINKLE - deferasirox granules packet 360 mg 5kcl 20 meq/l (0.15%) in nacl 0.45% inj 3kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj 4kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj 4kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj 4kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj 4kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj 4kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj 4lactated ringer's solution 4levocarnitine oral soln 1 gm/10ml (10%)^ 2levocarnitine tab 330 mg^ 2magnesium sulfate inj 50% 3NORMOSOL-M IN D5W - electrolyte-m in d5w soln 4potassium chloride cap er 8 meq^ 2potassium chloride cap er 10 meq^ 2POTASSIUM CHLORIDE ER - potassium chloride tab er 8 meq

(600 mg)^2

POTASSIUM CHLORIDE ER - potassium chloride tab er 20 meq(1500 mg)^

2

2017

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

103

Drug Name Drug Tier Requirements/Limitspotassium chloride inj 2 meq/ml 3potassium chloride microencapsulated crys er tab 10 meq^ 2potassium chloride microencapsulated crys er tab 20 meq^ 2potassium chloride oral soln 10% (20 meq/15ml)^ 2potassium chloride tab er 8 meq (600 mg)^ 2potassium chloride tab er 10 meq^ 2POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS -

potassium chloride 20 meq/l (0.15%) in d5w lactated ringers4

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS -potassium chloride 40 meq/l (0.3%) in d5w lactated ringers

4

potassium chloride 20 meq/l (0.15%) in dextrose 5% inj 4potassium chloride 40 meq/l (0.3%) in dextrose 5% inj 4potassium citrate tab er 5 meq (540 mg)^ 2potassium citrate tab er 10 meq (1080 mg)^ 2potassium citrate tab er 15 meq (1620 mg)^ 2SAMSCA - tolvaptan tab 15 mg 5 PASAMSCA - tolvaptan tab 30 mg 5 PAsodium chloride inj 0.45% 4sodium chloride irrigation soln 0.9%^ 2sodium chloride iv soln 0.9% 4sodium polystyrene sulfonate oral susp 15 gm/60ml^ 2sodium polystyrene sulfonate powder^ 2sodium polystyrene sulfonate rectal susp 30 gm/120ml^ 2SYPRINE - trientine hcl cap 250 mg 5water for irrigation, sterile irrigation soln 4

2017

104

INDEX

Aabacavir sulfate-lamivudine tab 600-300

mg................................................................................44abacavir sulfate-lamivudine-zidovudine tab

300-150-300 mg........................................................44abacavir sulfate soln 20 mg/ml.................................. 44abacavir sulfate tab 300 mg.......................................44ABILIFY MAINTENA....................................................17ABILIFY MAINTENA....................................................17ABILIFY MAINTENA....................................................17ABILIFY MAINTENA....................................................17ABILIFY MAINTENA....................................................39ABILIFY MAINTENA....................................................39ABILIFY MAINTENA....................................................39ABILIFY MAINTENA....................................................39ABILIFY MAINTENA....................................................51ABILIFY MAINTENA....................................................51ABILIFY MAINTENA....................................................51ABILIFY MAINTENA....................................................51ABRAXANE...................................................................27ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1acamprosate calcium tab delayed release 333

mg..................................................................................4acarbose tab 100 mg.................................................. 53acarbose tab 25 mg.................................................... 53acarbose tab 50 mg.................................................... 53acebutolol hcl cap 200 mg..........................................59acebutolol hcl cap 400 mg..........................................59acetaminophen w/ codeine soln 120-12

mg/5ml.......................................................................... 1acetaminophen w/ codeine tab 300-15

mg..................................................................................1acetaminophen w/ codeine tab 300-30

mg..................................................................................1acetaminophen w/ codeine tab 300-60

mg..................................................................................1acetazolamide cap er 12hr 500 mg...........................59acetazolamide tab 125 mg......................................... 59acetazolamide tab 250 mg......................................... 59ACETIC ACID/ALUMINUM ACETATE...................... 96acetic acid otic soln 2%.............................................. 96acetylcysteine inhal soln 10%.................................... 96acetylcysteine inhal soln 20%.................................... 96acitretin cap 10 mg......................................................73

acitretin cap 17.5 mg...................................................73acitretin cap 25 mg......................................................73ACTHIB..........................................................................88ACTIMMUNE................................................................ 88acyclovir cap 200 mg.................................................. 44acyclovir oint 5%..........................................................73acyclovir sodium for inj 500 mg................................. 44acyclovir sodium iv soln 50 mg/ml.............................44acyclovir susp 200 mg/5ml......................................... 44acyclovir tab 400 mg................................................... 44acyclovir tab 800 mg................................................... 44ADACEL........................................................................ 88ADAGEN........................................................................76ADASUVE..................................................................... 39ADCIRCA...................................................................... 96adefovir dipivoxil tab 10 mg........................................44ADEMPAS..................................................................... 96ADEMPAS..................................................................... 96ADEMPAS..................................................................... 96ADEMPAS..................................................................... 96ADEMPAS..................................................................... 96ADVAIR DISKUS..........................................................96ADVAIR DISKUS..........................................................96ADVAIR DISKUS..........................................................96ADVAIR HFA.................................................................96ADVAIR HFA.................................................................97ADVAIR HFA.................................................................97AFINITOR......................................................................27AFINITOR......................................................................27AFINITOR......................................................................27AFINITOR......................................................................27AFINITOR DISPERZ................................................... 27AFINITOR DISPERZ................................................... 27AFINITOR DISPERZ................................................... 27AGGRENOX................................................................. 56ALBENZA...................................................................... 37albuterol sulfate soln nebu 0.083% (2.5

mg/3ml).......................................................................97albuterol sulfate soln nebu 0.5% (5 mg/

ml)................................................................................97albuterol sulfate soln nebu 0.63

mg/3ml........................................................................ 97albuterol sulfate soln nebu 1.25

mg/3ml........................................................................ 97albuterol sulfate syrup 2 mg/5ml................................97albuterol sulfate tab 2 mg...........................................97albuterol sulfate tab 4 mg...........................................97albuterol sulfate tab er 12hr 4 mg..............................97albuterol sulfate tab er 12hr 8 mg..............................97alclometasone dipropionate cream

0.05%..........................................................................73

2017

105

alclometasone dipropionate oint0.05%..........................................................................73

ALCOHOL SWABS......................................................53ALDURAZYME............................................................. 76ALECENSA................................................................... 27alendronate sodium tab 10 mg.................................. 93alendronate sodium tab 35 mg.................................. 93alendronate sodium tab 5 mg.................................... 93alendronate sodium tab 70 mg.................................. 93alfuzosin hcl tab er 24hr 10 mg................................. 80ALIMTA.......................................................................... 27ALIMTA.......................................................................... 27ALINIA............................................................................37ALINIA............................................................................37ALIQOPA....................................................................... 27allopurinol sodium for inj 500 mg...............................24allopurinol tab 100 mg.................................................24allopurinol tab 300 mg.................................................24ALOPRIM...................................................................... 24alosetron hcl tab 0.5 mg............................................. 78alosetron hcl tab 1 mg................................................ 78ALOXI.............................................................................21ALPHAGAN P...............................................................94ALUNBRIG....................................................................28amantadine hcl cap 100 mg.......................................38amantadine hcl cap 100 mg.......................................44amantadine hcl syrup 50 mg/5ml...............................38amantadine hcl syrup 50 mg/5ml...............................44amantadine hcl tab 100 mg........................................38amantadine hcl tab 100 mg........................................44AMBISOME...................................................................23amikacin sulfate inj 1 gm/4ml (250 mg/

ml)..................................................................................5amikacin sulfate inj 500 mg/2ml (250 mg/

ml)..................................................................................5amiloride & hydrochlorothiazide tab 5-50

mg................................................................................59amiloride hcl tab 5 mg.................................................59amino acid infusion 15%...........................................101amino acid infusion 6%.............................................101amiodarone hcl tab 200 mg........................................59amiodarone hcl tab 400 mg........................................59AMITIZA.........................................................................78AMITIZA.........................................................................78amitriptyline hcl tab 100 mg....................................... 17amitriptyline hcl tab 10 mg..........................................17amitriptyline hcl tab 150 mg....................................... 17amitriptyline hcl tab 25 mg..........................................17amitriptyline hcl tab 50 mg..........................................17amitriptyline hcl tab 75 mg..........................................17amlodipine besylate-atorvastatin calcium tab 10-10

mg................................................................................59

amlodipine besylate-atorvastatin calcium tab 10-20mg................................................................................59

amlodipine besylate-atorvastatin calcium tab 10-40mg................................................................................60

amlodipine besylate-atorvastatin calcium tab 10-80mg................................................................................60

amlodipine besylate-atorvastatin calcium tab 2.5-10mg................................................................................59

amlodipine besylate-atorvastatin calcium tab 2.5-20mg................................................................................59

amlodipine besylate-atorvastatin calcium tab 2.5-40mg................................................................................59

amlodipine besylate-atorvastatin calcium tab 5-10mg................................................................................59

amlodipine besylate-atorvastatin calcium tab 5-20mg................................................................................59

amlodipine besylate-atorvastatin calcium tab 5-40mg................................................................................59

amlodipine besylate-atorvastatin calcium tab 5-80mg................................................................................59

amlodipine besylate-benazepril hcl cap 10-20mg................................................................................60

amlodipine besylate-benazepril hcl cap 10-40mg................................................................................60

amlodipine besylate-benazepril hcl cap 2.5-10mg................................................................................60

amlodipine besylate-benazepril hcl cap 5-10mg................................................................................60

amlodipine besylate-benazepril hcl cap 5-20mg................................................................................60

amlodipine besylate-benazepril hcl cap 5-40mg................................................................................60

amlodipine besylate tab 10 mg..................................59amlodipine besylate tab 2.5 mg.................................59amlodipine besylate tab 5 mg.................................... 59amlodipine besylate-valsartan tab 10-160

mg................................................................................60amlodipine besylate-valsartan tab 10-320

mg................................................................................60amlodipine besylate-valsartan tab 5-160

mg................................................................................60amlodipine besylate-valsartan tab 5-320

mg................................................................................60AMOXAPINE.................................................................17AMOXAPINE.................................................................17AMOXAPINE.................................................................17AMOXAPINE.................................................................18AMOXICILLIN/CLAVULANATE

POTASSIUM................................................................ 5AMOXICILLIN/CLAVULANATE

POTASSIUM................................................................ 5amoxicillin (trihydrate) cap 250 mg..............................5

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106

amoxicillin (trihydrate) cap 500 mg..............................5amoxicillin (trihydrate) for susp 125

mg/5ml.......................................................................... 5amoxicillin (trihydrate) for susp 200

mg/5ml.......................................................................... 5amoxicillin (trihydrate) for susp 250

mg/5ml.......................................................................... 5amoxicillin (trihydrate) for susp 400

mg/5ml.......................................................................... 5amoxicillin (trihydrate) tab 500 mg...............................5amoxicillin (trihydrate) tab 875 mg...............................5amoxicillin & k clavulanate for susp 200-28.5

mg/5ml.......................................................................... 5amoxicillin & k clavulanate for susp 400-57

mg/5ml.......................................................................... 5amoxicillin & k clavulanate for susp 600-42.9

mg/5ml.......................................................................... 5amoxicillin & k clavulanate tab 250-125

mg..................................................................................5amoxicillin & k clavulanate tab 500-125

mg..................................................................................5amoxicillin & k clavulanate tab 875-125

mg..................................................................................5amphetamine-dextroamphetamine cap er 24hr 10

mg................................................................................70amphetamine-dextroamphetamine cap er 24hr 15

mg................................................................................70amphetamine-dextroamphetamine cap er 24hr 20

mg................................................................................70amphetamine-dextroamphetamine cap er 24hr 25

mg................................................................................70amphetamine-dextroamphetamine cap er 24hr 30

mg................................................................................70amphetamine-dextroamphetamine cap er 24hr 5

mg................................................................................70amphetamine-dextroamphetamine tab 10

mg................................................................................70amphetamine-dextroamphetamine tab 12.5

mg................................................................................70amphetamine-dextroamphetamine tab 15

mg................................................................................70amphetamine-dextroamphetamine tab 20

mg................................................................................70amphetamine-dextroamphetamine tab 30

mg................................................................................70amphetamine-dextroamphetamine tab 5

mg................................................................................70amphetamine-dextroamphetamine tab 7.5

mg................................................................................70AMPHOTERICIN B......................................................23ampicillin & sulbactam sodium for inj 3 (2-1)

gm..................................................................................5

ampicillin cap 250 mg....................................................5ampicillin cap 500 mg....................................................5AMPICILLIN SODIUM................................................... 5ampicillin sodium for inj 1 gm.......................................5ampicillin sodium for inj 250 mg...................................5ampicillin sodium for inj 2 gm.......................................6ampicillin sodium for inj 500 mg...................................5ampicillin sodium for iv soln 10 gm..............................6ampicillin sodium for iv soln 2 gm................................6AMPYRA........................................................................71ANADROL-50............................................................... 83anagrelide hcl cap 0.5 mg.......................................... 56anagrelide hcl cap 1 mg............................................. 56anastrozole tab 1 mg...................................................28ANDRODERM.............................................................. 83ANDRODERM.............................................................. 83ANDROGEL.................................................................. 83ANDROGEL.................................................................. 83ANDROGEL PUMP..................................................... 83ANORO ELLIPTA.........................................................97APOKYN........................................................................38aprepitant capsule 125 mg.........................................21aprepitant capsule 40 mg........................................... 21aprepitant capsule 80 mg........................................... 21aprepitant capsule therapy pack 80 & 125

mg................................................................................21APRISO......................................................................... 93APTIOM......................................................................... 12APTIOM......................................................................... 12APTIOM......................................................................... 12APTIOM......................................................................... 12APTIVUS....................................................................... 44APTIVUS....................................................................... 44ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................56ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARCALYST....................................................................88aripiprazole orally disintegrating tab 10

mg................................................................................18

2017

107

aripiprazole orally disintegrating tab 10mg................................................................................39

aripiprazole orally disintegrating tab 10mg................................................................................51

aripiprazole orally disintegrating tab 15mg................................................................................18

aripiprazole orally disintegrating tab 15mg................................................................................39

aripiprazole orally disintegrating tab 15mg................................................................................51

aripiprazole oral solution 1 mg/ml..............................18aripiprazole oral solution 1 mg/ml..............................39aripiprazole oral solution 1 mg/ml..............................51aripiprazole tab 10 mg................................................ 18aripiprazole tab 10 mg................................................ 40aripiprazole tab 10 mg................................................ 51aripiprazole tab 15 mg................................................ 18aripiprazole tab 15 mg................................................ 40aripiprazole tab 15 mg................................................ 51aripiprazole tab 20 mg................................................ 18aripiprazole tab 20 mg................................................ 40aripiprazole tab 20 mg................................................ 51aripiprazole tab 2 mg...................................................18aripiprazole tab 2 mg...................................................39aripiprazole tab 2 mg...................................................51aripiprazole tab 30 mg................................................ 18aripiprazole tab 30 mg................................................ 40aripiprazole tab 30 mg................................................ 51aripiprazole tab 5 mg...................................................18aripiprazole tab 5 mg...................................................40aripiprazole tab 5 mg...................................................51armodafinil tab 150 mg............................................. 101armodafinil tab 200 mg............................................. 101armodafinil tab 250 mg............................................. 101armodafinil tab 50 mg............................................... 101ARNUITY ELLIPTA......................................................97ARNUITY ELLIPTA......................................................97ARRANON.................................................................... 28ARZERRA..................................................................... 28ARZERRA..................................................................... 28ASACOL HD.................................................................93ASMANEX HFA............................................................97ASMANEX HFA............................................................97ASMANEX TWISTHALER 120 METERED

DOSES....................................................................... 97ASMANEX TWISTHALER 14 METERED

DOSES....................................................................... 97ASMANEX TWISTHALER 30 METERED

DOSES....................................................................... 97ASMANEX TWISTHALER 30 METERED

DOSES....................................................................... 97

ASMANEX TWISTHALER 60 METEREDDOSES....................................................................... 97

ASMANEX TWISTHALER 7 METEREDDOSES....................................................................... 97

aspirin-dipyridamole cap er 12hr 25-200mg................................................................................57

atenolol & chlorthalidone tab 100-25mg................................................................................60

atenolol & chlorthalidone tab 50-25 mg.................... 60atenolol tab 100 mg.....................................................60atenolol tab 25 mg.......................................................60atenolol tab 50 mg.......................................................60ATGAM.......................................................................... 88atomoxetine hcl cap 100 mg...................................... 71atomoxetine hcl cap 10 mg........................................ 71atomoxetine hcl cap 18 mg........................................ 71atomoxetine hcl cap 25 mg........................................ 71atomoxetine hcl cap 40 mg........................................ 71atomoxetine hcl cap 60 mg........................................ 71atomoxetine hcl cap 80 mg........................................ 71atorvastatin calcium tab 10 mg.................................. 60atorvastatin calcium tab 20 mg.................................. 60atorvastatin calcium tab 40 mg.................................. 60atorvastatin calcium tab 80 mg.................................. 60atovaquone-proguanil hcl tab 250-100

mg................................................................................37atovaquone-proguanil hcl tab 62.5-25

mg................................................................................37atovaquone susp 750 mg/5ml....................................37ATRIPLA........................................................................ 44ATROVENT HFA..........................................................97AVASTIN........................................................................28AVASTIN........................................................................28AVELOX...........................................................................6AVONEX........................................................................ 71AVONEX........................................................................ 71AVONEX PEN.............................................................. 71AXIRON......................................................................... 83azacitidine for inj 100 mg............................................28AZACTAM IN ISO-OSMOTIC

DEXTROSE................................................................. 6AZACTAM IN ISO-OSMOTIC

DEXTROSE................................................................. 6AZASAN........................................................................ 88AZASAN........................................................................ 88AZATHIOPRINE........................................................... 88azathioprine tab 50 mg............................................... 88azelastine hcl nasal spray 0.1% (137 mcg/

spray)..........................................................................97azelastine hcl nasal spray 0.15% (205.5 mcg/

spray)..........................................................................97azelastine hcl ophth soln 0.05%................................ 94

2017

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AZELEX......................................................................... 73AZILECT........................................................................38AZILECT........................................................................38AZITHROMYCIN............................................................ 6azithromycin for susp 100 mg/5ml...............................6azithromycin for susp 200 mg/5ml...............................6azithromycin iv for soln 500 mg................................... 6azithromycin tab 250 mg...............................................6azithromycin tab 500 mg...............................................6azithromycin tab 600 mg...............................................6AZOPT........................................................................... 94aztreonam for inj 1 gm.................................................. 6aztreonam for inj 2 gm.................................................. 6BBACITRACIN................................................................ 94bacitracin-polymyxin b ophth oint.............................. 94bacitracin-polymyxin-neomycin-hc ophth oint

1%............................................................................... 94baclofen tab 10 mg......................................................44baclofen tab 20 mg......................................................44balsalazide disodium cap 750 mg............................. 93BANZEL.........................................................................12BANZEL.........................................................................13BANZEL.........................................................................13BARACLUDE................................................................ 44BAVENCIO.................................................................... 28BCG VACCINE.............................................................88BELEODAQ.................................................................. 28benazepril & hydrochlorothiazide tab 10-12.5

mg................................................................................60benazepril & hydrochlorothiazide tab 20-12.5

mg................................................................................60benazepril & hydrochlorothiazide tab 20-25

mg................................................................................60benazepril & hydrochlorothiazide tab 5-6.25

mg................................................................................60benazepril hcl tab 10 mg............................................ 60benazepril hcl tab 20 mg............................................ 60benazepril hcl tab 40 mg............................................ 60benazepril hcl tab 5 mg.............................................. 60BENDEKA..................................................................... 28BENLYSTA.................................................................... 88BENLYSTA.................................................................... 88BENLYSTA.................................................................... 88BENLYSTA.................................................................... 88benzoyl peroxide-erythromycin gel

5-3%............................................................................73benztropine mesylate tab 0.5 mg.............................. 38benztropine mesylate tab 1 mg..................................38benztropine mesylate tab 2 mg..................................38BESIVANCE..................................................................94

BESPONSA.................................................................. 28betamethasone dipropionate augmented cream

0.05%..........................................................................73betamethasone dipropionate augmented gel

0.05%..........................................................................73betamethasone dipropionate augmented lotion

0.05%..........................................................................73betamethasone dipropionate augmented oint

0.05%..........................................................................73betamethasone dipropionate cream

0.05%..........................................................................73betamethasone dipropionate lotion

0.05%..........................................................................73betamethasone dipropionate oint

0.05%..........................................................................73betamethasone valerate cream 0.1%....................... 73betamethasone valerate lotion 0.1%.........................73betamethasone valerate oint 0.1%............................73BETASERON................................................................ 71betaxolol hcl ophth soln 0.5%.................................... 94betaxolol hcl tab 10 mg...............................................60betaxolol hcl tab 20 mg...............................................60bethanechol chloride tab 10 mg.................................80bethanechol chloride tab 25 mg.................................80bethanechol chloride tab 50 mg.................................80bethanechol chloride tab 5 mg...................................80BETOPTIC-S.................................................................94bexarotene cap 75 mg................................................ 28BEXSERO..................................................................... 88bicalutamide tab 50 mg...............................................28BICILLIN L-A...................................................................6BICILLIN L-A...................................................................6BICILLIN L-A...................................................................6BICNU............................................................................28BILTRICIDE...................................................................37bisoprolol & hydrochlorothiazide tab 10-6.25

mg................................................................................60bisoprolol & hydrochlorothiazide tab 2.5-6.25

mg................................................................................60bisoprolol & hydrochlorothiazide tab 5-6.25

mg................................................................................60bisoprolol fumarate tab 10 mg................................... 60bisoprolol fumarate tab 5 mg..................................... 60BLEO 15K..................................................................... 28bleomycin sulfate for inj 15 unit................................. 28bleomycin sulfate for inj 30 unit................................. 28BLINCYTO.....................................................................28BOOSTRIX....................................................................88BOSULIF....................................................................... 28BOSULIF....................................................................... 28BREO ELLIPTA............................................................ 97BREO ELLIPTA............................................................ 97

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BRILINTA.......................................................................57BRILINTA.......................................................................57brimonidine tartrate ophth soln 0.15%...................... 94brimonidine tartrate ophth soln 0.2%........................ 94BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13bromfenac sodium ophth soln 0.09% (once-

daily)............................................................................94bromocriptine mesylate cap 5 mg..............................38bromocriptine mesylate cap 5 mg..............................86bromocriptine mesylate tab 2.5 mg........................... 38bromocriptine mesylate tab 2.5 mg........................... 86budesonide delayed release particles cap 3

mg................................................................................93budesonide inhalation susp 0.25

mg/2ml........................................................................ 97budesonide inhalation susp 0.5

mg/2ml........................................................................ 98budesonide inhalation susp 1 mg/2ml.......................98bumetanide inj 0.25 mg/ml......................................... 60bumetanide tab 0.5 mg............................................... 60bumetanide tab 1 mg.................................................. 61bumetanide tab 2 mg.................................................. 61BUPHENYL...................................................................76buprenorphine hcl-naloxone hcl sl tab 2-0.5

mg..................................................................................4buprenorphine hcl-naloxone hcl sl tab 8-2

mg..................................................................................4buprenorphine hcl sl tab 2 mg......................................4buprenorphine hcl sl tab 8 mg......................................4bupropion hcl (smoking deterrent) tab er 12hr 150

mg..................................................................................4bupropion hcl tab 100 mg...........................................18bupropion hcl tab 75 mg.............................................18bupropion hcl tab er 12hr 100 mg............................. 18bupropion hcl tab er 12hr 150 mg............................. 18bupropion hcl tab er 12hr 200 mg............................. 18bupropion hcl tab er 24hr 150 mg............................. 18bupropion hcl tab er 24hr 300 mg............................. 18buspirone hcl tab 10 mg............................................. 49buspirone hcl tab 15 mg............................................. 49buspirone hcl tab 30 mg............................................. 49buspirone hcl tab 5 mg............................................... 49buspirone hcl tab 7.5 mg............................................ 49busulfan inj 6 mg/ml.................................................... 28BUSULFEX................................................................... 28

butalbital-acetaminophen-caffeine cap 50-300-40mg................................................................................25

butalbital-acetaminophen-caffeine cap 50-325-40mg................................................................................25

butalbital-acetaminophen-caffeine tab 50-325-40mg................................................................................25

butalbital-acetaminophen tab 50-325mg................................................................................25

butalbital-aspirin-caffeine cap 50-325-40mg................................................................................25

butorphanol tartrate inj 1 mg/ml................................... 1butorphanol tartrate inj 2 mg/ml................................... 1butorphanol tartrate nasal soln 10 mg/

ml................................................................................... 1BYDUREON..................................................................53BYDUREON PEN........................................................ 53Ccabergoline tab 0.5 mg............................................... 86CABOMETYX............................................................... 28CABOMETYX............................................................... 28CABOMETYX............................................................... 28caffeine citrate oral soln 60 mg/3ml...........................98calcipotriene cream 0.005%.......................................73calcipotriene oint 0.005%............................................73calcipotriene soln 0.005% (50 mcg/ml).....................73calcitonin (salmon) nasal soln 200 unit/

act................................................................................93calcitriol cap 0.25 mcg................................................ 93calcitriol cap 0.5 mcg...................................................93calcitriol inj 1 mcg/ml...................................................93calcitriol oral soln 1 mcg/ml........................................93calcium acetate cap 667 mg...................................... 80calcium acetate tab 667 mg....................................... 80CANASA........................................................................93CANCIDAS....................................................................23CANCIDAS....................................................................23candesartan cilexetil-hydrochlorothiazide tab 16-12.5

mg................................................................................61candesartan cilexetil-hydrochlorothiazide tab 32-12.5

mg................................................................................61candesartan cilexetil-hydrochlorothiazide tab 32-25

mg................................................................................61candesartan cilexetil tab 16 mg................................. 61candesartan cilexetil tab 32 mg................................. 61candesartan cilexetil tab 4 mg................................... 61candesartan cilexetil tab 8 mg................................... 61CAPASTAT SULFATE..................................................27CAPRELSA................................................................... 28CAPRELSA................................................................... 28captopril tab 100 mg....................................................61captopril tab 12.5 mg...................................................61

2017

110

captopril tab 25 mg......................................................61captopril tab 50 mg......................................................61CARAC.......................................................................... 73CARBAGLU................................................................ 101carbamazepine cap er 12hr 100 mg......................... 13carbamazepine cap er 12hr 200 mg......................... 13carbamazepine cap er 12hr 300 mg......................... 13carbamazepine chew tab 100 mg..............................13carbamazepine susp 100 mg/5ml..............................13carbamazepine tab 200 mg........................................13carbamazepine tab er 12hr 100 mg.......................... 13carbamazepine tab er 12hr 200 mg.......................... 13carbamazepine tab er 12hr 400 mg.......................... 13CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................38CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................38CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................38CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................38CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................38CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................38carbidopa & levodopa orally disintegrating tab

10-100 mg..................................................................38carbidopa & levodopa orally disintegrating tab

25-100 mg..................................................................38carbidopa & levodopa orally disintegrating tab

25-250 mg..................................................................38carbidopa & levodopa tab 10-100 mg....................... 38carbidopa & levodopa tab 25-100 mg....................... 38carbidopa & levodopa tab 25-250 mg....................... 38carbidopa & levodopa tab er 25-100

mg................................................................................38carbidopa & levodopa tab er 50-200

mg................................................................................38carbidopa tab 25 mg................................................... 38carboplatin iv soln 150 mg/15ml................................ 28carboplatin iv soln 450 mg/45ml................................ 28carboplatin iv soln 50 mg/5ml.................................... 28carboplatin iv soln 600 mg/60ml................................ 28carteolol hcl ophth soln 1%........................................ 94carvedilol tab 12.5 mg.................................................61carvedilol tab 25 mg....................................................61carvedilol tab 3.125 mg...............................................61carvedilol tab 6.25 mg.................................................61caspofungin acetate for iv soln 50 mg...................... 23cefaclor cap 250 mg......................................................6cefaclor cap 500 mg......................................................6cefadroxil cap 500 mg...................................................6

cefadroxil for susp 250 mg/5ml....................................6cefadroxil for susp 500 mg/5ml....................................6cefadroxil tab 1 gm........................................................ 6cefazolin sodium for inj 10 gm..................................... 6cefazolin sodium for inj 1 gm....................................... 6cefazolin sodium for inj 20 gm..................................... 6cefazolin sodium for inj 500 mg................................... 6cefdinir cap 300 mg....................................................... 6cefdinir for susp 125 mg/5ml........................................6cefdinir for susp 250 mg/5ml........................................6cefepime hcl for inj 1 gm.............................................. 6cefepime hcl for inj 2 gm.............................................. 6cefotaxime sodium for inj 10 gm..................................7cefotaxime sodium for inj 1 gm.................................... 7cefotaxime sodium for inj 2 gm.................................... 7cefotaxime sodium for inj 500 mg................................6cefoxitin sodium for inj 10 gm...................................... 7cefoxitin sodium for iv soln 1 gm................................. 7cefoxitin sodium for iv soln 2 gm................................. 7cefpodoxime proxetil for susp 100

mg/5ml.......................................................................... 7cefpodoxime proxetil for susp 50

mg/5ml.......................................................................... 7cefpodoxime proxetil tab 100 mg.................................7cefpodoxime proxetil tab 200 mg.................................7cefprozil for susp 125 mg/5ml...................................... 7cefprozil for susp 250 mg/5ml...................................... 7cefprozil tab 250 mg......................................................7cefprozil tab 500 mg......................................................7ceftazidime for inj 1 gm.................................................7ceftazidime for inj 2 gm.................................................7ceftazidime for inj 6 gm.................................................7ceftazidime for iv soln 1 gm..........................................7ceftazidime for iv soln 2 gm..........................................7CEFTRIAXONE/DEXTROSE....................................... 7CEFTRIAXONE/DEXTROSE....................................... 7CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 7CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 7ceftriaxone sodium for inj 10 gm..................................7ceftriaxone sodium for inj 1 gm....................................7ceftriaxone sodium for inj 250 mg................................7ceftriaxone sodium for inj 2 gm....................................7ceftriaxone sodium for inj 500 mg................................7ceftriaxone sodium for iv soln 1 gm.............................7ceftriaxone sodium for iv soln 2 gm.............................7cefuroxime axetil tab 250 mg....................................... 7cefuroxime axetil tab 500 mg....................................... 7cefuroxime sodium for inj 1.5 gm.................................7cefuroxime sodium for inj 7.5 gm.................................7cefuroxime sodium for inj 750 mg................................7

2017

111

cefuroxime sodium for iv soln 1.5 gm..........................8celecoxib cap 100 mg................................................... 1celecoxib cap 100 mg................................................. 24celecoxib cap 200 mg................................................... 1celecoxib cap 200 mg................................................. 24celecoxib cap 400 mg................................................... 1celecoxib cap 400 mg................................................. 24celecoxib cap 50 mg......................................................1celecoxib cap 50 mg................................................... 24CELLCEPT INTRAVENOUS...................................... 88CELONTIN.................................................................... 13cephalexin cap 250 mg.................................................8cephalexin cap 500 mg.................................................8cephalexin cap 750 mg.................................................8cephalexin for susp 125 mg/5ml..................................8cephalexin for susp 250 mg/5ml..................................8CEREZYME.................................................................. 76CHANTIX......................................................................... 4CHANTIX......................................................................... 4CHANTIX CONTINUING MONTH

PACK.............................................................................4CHANTIX STARTING MONTH PACK.........................4CHEMET..................................................................... 101CHENODAL.................................................................. 78CHLORAMPHENICOL SODIUM

SUCCINATE.................................................................8chlorhexidine gluconate soln 0.12%..........................72chloroquine phosphate tab 250 mg...........................37chloroquine phosphate tab 500 mg...........................37CHLOROTHIAZIDE..................................................... 61chlorothiazide tab 500 mg.......................................... 61CHLORPROMAZINE HCL..........................................21CHLORPROMAZINE HCL..........................................21CHLORPROMAZINE HCL..........................................40CHLORPROMAZINE HCL..........................................40chlorpromazine hcl tab 100 mg..................................22chlorpromazine hcl tab 100 mg..................................40chlorpromazine hcl tab 10 mg....................................21chlorpromazine hcl tab 10 mg....................................40chlorpromazine hcl tab 200 mg..................................22chlorpromazine hcl tab 200 mg..................................40chlorpromazine hcl tab 25 mg....................................21chlorpromazine hcl tab 25 mg....................................40chlorpromazine hcl tab 50 mg....................................22chlorpromazine hcl tab 50 mg....................................40chlorthalidone tab 25 mg............................................ 61chlorthalidone tab 50 mg............................................ 61cholestyramine light powder 4 gm/

dose............................................................................ 61cholestyramine light powder packets 4

gm................................................................................61cholestyramine powder 4 gm/dose............................61

cholestyramine powder packets 4 gm.......................61choline fenofibrate cap dr 135 mg............................. 61choline fenofibrate cap dr 45 mg............................... 61chorionic gonadotropin for im inj 10000 unit

(chorionic gonadotropin, pregnyl)...........................83ciclopirox gel 0.77%.................................................... 73ciclopirox olamine cream 0.77%................................73ciclopirox olamine susp 0.77%...................................73ciclopirox shampoo 1%............................................... 73ciclopirox solution 8%..................................................73cidofovir iv inj 75 mg/ml.............................................. 44cilostazol tab 100 mg.................................................. 57cilostazol tab 50 mg.................................................... 57cimetidine hcl soln 300 mg/5ml..................................78cimetidine tab 200 mg.................................................78cimetidine tab 300 mg.................................................78cimetidine tab 400 mg.................................................78cimetidine tab 800 mg.................................................78CINRYZE.......................................................................88CIPRODEX....................................................................96ciprofloxacin 200 mg/100ml in d5w............................. 8ciprofloxacin 400 mg/200ml in d5w............................. 8ciprofloxacin for oral susp 250 mg/5ml (5%) (5

gm/100ml).....................................................................8ciprofloxacin for oral susp 500 mg/5ml (10%) (10

gm/100ml).....................................................................8CIPROFLOXACIN HCL.................................................8ciprofloxacin hcl ophth soln 0.3%.............................. 94ciprofloxacin hcl tab 250 mg.........................................8ciprofloxacin hcl tab 500 mg.........................................8ciprofloxacin hcl tab 750 mg.........................................8ciprofloxacin hcl tab er 24hr 1000 mg......................... 8ciprofloxacin hcl tab er 24hr 500 mg........................... 8ciprofloxacin iv soln 200 mg/20ml (1%)...................... 8ciprofloxacin iv soln 400 mg/40ml (1%)...................... 8CISPLATIN.................................................................... 28cisplatin inj 100 mg/100ml (1 mg/ml).........................28cisplatin inj 50 mg/50ml (1 mg/ml).............................28citalopram hydrobromide oral soln 10

mg/5ml........................................................................ 18citalopram hydrobromide tab 10 mg..........................18citalopram hydrobromide tab 20 mg..........................18citalopram hydrobromide tab 40 mg..........................18cladribine iv soln 10 mg/10ml (1 mg/

ml)................................................................................28clarithromycin for susp 125 mg/5ml.............................8clarithromycin for susp 250 mg/5ml.............................8clarithromycin tab 250 mg............................................ 8clarithromycin tab 500 mg............................................ 8clarithromycin tab er 24hr 500 mg...............................8clemastine fumarate tab 2.68 mg.............................. 98clindamycin hcl cap 150 mg......................................... 8

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clindamycin hcl cap 300 mg......................................... 8clindamycin hcl cap 75 mg........................................... 8clindamycin phosphate-benzoyl peroxide gel

1-5%............................................................................73clindamycin phosphate gel 1%.................................. 73clindamycin phosphate in d5w iv soln 300

mg/50ml........................................................................ 8clindamycin phosphate in d5w iv soln 600

mg/50ml........................................................................ 8clindamycin phosphate in d5w iv soln 900

mg/50ml........................................................................ 8clindamycin phosphate inj 300 mg/2ml....................... 8clindamycin phosphate inj 600 mg/4ml....................... 8clindamycin phosphate inj 900 mg/6ml....................... 8clindamycin phosphate inj 9 gm/60ml......................... 8clindamycin phosphate iv soln 300

mg/2ml.......................................................................... 8clindamycin phosphate iv soln 900

mg/6ml.......................................................................... 8clindamycin phosphate lotion 1%.............................. 73clindamycin phosphate soln 1%................................ 73clindamycin phosphate swab 1%.............................. 73clindamycin phosphate vaginal cream

2%..................................................................................8clobetasol propionate cream 0.05%..........................73clobetasol propionate emollient base cream

0.05%..........................................................................74clobetasol propionate gel 0.05%................................74clobetasol propionate oint 0.05%.............................. 74clobetasol propionate soln 0.05%..............................74clofarabine iv soln 1 mg/ml.........................................28CLOLAR........................................................................ 28clomipramine hcl cap 25 mg...................................... 18clomipramine hcl cap 50 mg...................................... 18clomipramine hcl cap 75 mg...................................... 18clonazepam orally disintegrating tab 0.125

mg................................................................................13clonazepam orally disintegrating tab 0.125

mg................................................................................49clonazepam orally disintegrating tab 0.25

mg................................................................................13clonazepam orally disintegrating tab 0.25

mg................................................................................49clonazepam orally disintegrating tab 0.5

mg................................................................................13clonazepam orally disintegrating tab 0.5

mg................................................................................49clonazepam orally disintegrating tab 1

mg................................................................................13clonazepam orally disintegrating tab 1

mg................................................................................49

clonazepam orally disintegrating tab 2mg................................................................................13

clonazepam orally disintegrating tab 2mg................................................................................49

clonazepam tab 0.5 mg.............................................. 13clonazepam tab 0.5 mg.............................................. 49clonazepam tab 1 mg..................................................13clonazepam tab 1 mg..................................................49clonazepam tab 2 mg..................................................13clonazepam tab 2 mg..................................................49clonidine hcl tab 0.1 mg..............................................61clonidine hcl tab 0.2 mg..............................................61clonidine hcl tab 0.3 mg..............................................61clonidine hcl tab er 12hr 0.1 mg................................ 71clonidine hcl td patch weekly 0.1

mg/24hr...................................................................... 61clonidine hcl td patch weekly 0.2

mg/24hr...................................................................... 61clonidine hcl td patch weekly 0.3

mg/24hr...................................................................... 61clopidogrel bisulfate tab 75 mg..................................57clorazepate dipotassium tab 15 mg...........................13clorazepate dipotassium tab 15 mg...........................49clorazepate dipotassium tab 3.75 mg....................... 13clorazepate dipotassium tab 3.75 mg....................... 49clorazepate dipotassium tab 7.5 mg......................... 13clorazepate dipotassium tab 7.5 mg......................... 49clotrimazole cream 1%................................................74clotrimazole troche 10 mg.......................................... 23clotrimazole w/ betamethasone cream

1-0.05%...................................................................... 74clotrimazole w/ betamethasone lotion

1-0.05%...................................................................... 74clozapine orally disintegrating tab 100

mg................................................................................40clozapine orally disintegrating tab 25

mg................................................................................40clozapine tab 100 mg..................................................40clozapine tab 200 mg..................................................40clozapine tab 25 mg....................................................40clozapine tab 50 mg....................................................40COARTEM.....................................................................37codeine sulfate tab 15 mg............................................ 1codeine sulfate tab 30 mg............................................ 1codeine sulfate tab 60 mg............................................ 1colchicine w/ probenecid tab 0.5-500

mg................................................................................24COLCRYS..................................................................... 24colestipol hcl granule packets 5 gm.......................... 61colestipol hcl granules 5 gm.......................................61colestipol hcl tab 1 gm................................................ 61colistimethate sodium for inj 150 mg...........................8

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COMBIGAN...................................................................94COMBIVENT RESPIMAT........................................... 98COMETRIQ...................................................................29COMETRIQ...................................................................29COMETRIQ...................................................................29COMPLERA.................................................................. 44COPAXONE.................................................................. 71COPAXONE.................................................................. 71CORLANOR..................................................................61CORLANOR..................................................................61CORTISONE ACETATE..............................................81COSMEGEN................................................................. 29COTELLIC.....................................................................29COUMADIN...................................................................57COUMADIN...................................................................57COUMADIN...................................................................57COUMADIN...................................................................57COUMADIN...................................................................57COUMADIN...................................................................57COUMADIN...................................................................57COUMADIN...................................................................57COUMADIN...................................................................57CREON..........................................................................77CREON..........................................................................77CREON..........................................................................77CREON..........................................................................77CREON..........................................................................77CRESEMBA.................................................................. 23CRESEMBA.................................................................. 23CRESTOR.....................................................................62CRESTOR.....................................................................62CRESTOR.....................................................................62CRESTOR.....................................................................62CRIXIVAN......................................................................44CRIXIVAN......................................................................45cromolyn sodium ophth soln 4%................................94cromolyn sodium oral conc 100

mg/5ml........................................................................ 78cromolyn sodium soln nebu 20 mg/2ml.................... 98CUBICIN.......................................................................... 9CUBICIN RF................................................................... 9cyclobenzaprine hcl tab 10 mg................................ 101cyclobenzaprine hcl tab 5 mg.................................. 101cyclobenzaprine hcl tab 7.5 mg...............................101CYCLOPHOSPHAMIDE............................................. 29CYCLOPHOSPHAMIDE............................................. 29cyclophosphamide for inj 1 gm.................................. 29cyclophosphamide for inj 2 gm.................................. 29cyclophosphamide for inj 500 mg..............................29CYCLOSERINE............................................................27CYCLOSET...................................................................53cyclosporine cap 100 mg............................................88

cyclosporine cap 25 mg..............................................88cyclosporine iv soln 50 mg/ml....................................89cyclosporine modified cap 100 mg............................ 89cyclosporine modified cap 25 mg.............................. 89cyclosporine modified cap 50 mg.............................. 89cyclosporine modified oral soln 100 mg/

ml.................................................................................89CYRAMZA.....................................................................29CYRAMZA.....................................................................29CYSTADANE................................................................ 77CYSTAGON.................................................................. 77CYSTAGON.................................................................. 77CYSTARAN...................................................................94cytarabine inj 20 mg/ml...............................................29cytarabine inj pf 100 mg/ml........................................ 29cytarabine inj pf 20 mg/ml.......................................... 29DDACARBAZINE............................................................ 29dacarbazine for inj 200 mg.........................................29DAKLINZA.....................................................................45DAKLINZA.....................................................................45DAKLINZA.....................................................................45DALIRESP.....................................................................98DALVANCE......................................................................9danazol cap 100 mg....................................................83danazol cap 200 mg....................................................83danazol cap 50 mg......................................................83dantrolene sodium cap 100 mg................................. 44dantrolene sodium cap 25 mg....................................44dantrolene sodium cap 50 mg....................................44dapsone tab 100 mg................................................... 27dapsone tab 25 mg......................................................27DAPTACEL....................................................................89daptomycin for iv soln 500 mg..................................... 9DARAPRIM................................................................... 37DARZALEX................................................................... 29DARZALEX................................................................... 29daunorubicin hcl inj 5 mg/ml.......................................29decitabine for inj 50 mg.............................................. 29DELZICOL.....................................................................93demeclocycline hcl tab 150 mg....................................9demeclocycline hcl tab 300 mg....................................9DEMSER....................................................................... 62DENAVIR.......................................................................74DEPEN TITRATABS.................................................... 80DEPEN TITRATABS.................................................... 89DEPEN TITRATABS..................................................102DEPO-PROVERA........................................................ 83DESCOVY.....................................................................45desipramine hcl tab 100 mg.......................................18desipramine hcl tab 10 mg......................................... 18

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desipramine hcl tab 150 mg.......................................18desipramine hcl tab 25 mg......................................... 18desipramine hcl tab 50 mg......................................... 18desipramine hcl tab 75 mg......................................... 18desmopressin acetate inj 4 mcg/ml...........................83desmopressin acetate nasal soln 0.01%

(refrigerated).............................................................. 83desmopressin acetate tab 0.1 mg............................. 83desmopressin acetate tab 0.2 mg............................. 83desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5)..................................................................... 83desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg................................................................................83

desogestrel & ethinyl estradiol tab 0.15 mg-30mcg..............................................................................83

desonide cream 0.05%............................................... 74desonide lotion 0.05%.................................................74desonide oint 0.05%....................................................74desoximetasone cream 0.05%...................................74desoximetasone cream 0.25%...................................74desoximetasone gel 0.05%........................................ 74desoximetasone oint 0.25%....................................... 74desvenlafaxine succinate tab er 24hr 100

mg................................................................................18desvenlafaxine succinate tab er 24hr 25

mg................................................................................18desvenlafaxine succinate tab er 24hr 50

mg................................................................................18DEXAMETHASONE.................................................... 81DEXAMETHASONE.................................................... 81dexamethasone elixir 0.5 mg/5ml..............................82DEXAMETHASONE SODIUM

PHOSPHATE.............................................................94dexamethasone sodium phosphate inj 120

mg/30ml......................................................................82dexamethasone sodium phosphate inj 20

mg/5ml........................................................................ 82dexamethasone sodium phosphate inj 4 mg/

ml.................................................................................82dexamethasone tab 0.5 mg........................................82dexamethasone tab 0.75 mg......................................82dexamethasone tab 1.5 mg........................................82dexamethasone tab 4 mg...........................................82dexamethasone tab 6 mg...........................................82dexmethylphenidate hcl tab 10 mg............................71dexmethylphenidate hcl tab 2.5 mg...........................71dexmethylphenidate hcl tab 5 mg..............................71dexrazoxane for inj 250 mg........................................29dexrazoxane for inj 500 mg........................................29dextroamphetamine sulfate cap er 24hr 10

mg................................................................................71

dextroamphetamine sulfate cap er 24hr 15mg................................................................................71

dextroamphetamine sulfate cap er 24hr 5mg................................................................................71

dextroamphetamine sulfate tab 10 mg......................71dextroamphetamine sulfate tab 5 mg........................71dextrose 2.5% w/ sodium chloride

0.45%........................................................................102dextrose 5% in lactated ringers............................... 102dextrose 5% w/ sodium chloride

0.2%..........................................................................102dextrose 5% w/ sodium chloride

0.33%........................................................................102dextrose 5% w/ sodium chloride

0.45%........................................................................102dextrose 5% w/ sodium chloride

0.9%..........................................................................102dextrose inj 10%........................................................ 102dextrose inj 5%.......................................................... 102DIASTAT ACUDIAL......................................................13DIASTAT ACUDIAL......................................................13DIASTAT PEDIATRIC..................................................13DIAZEPAM.................................................................... 13DIAZEPAM.................................................................... 49diazepam conc 5 mg/ml..............................................13diazepam conc 5 mg/ml..............................................49DIAZEPAM RECTAL GEL.......................................... 13DIAZEPAM RECTAL GEL.......................................... 13DIAZEPAM RECTAL GEL.......................................... 14diazepam tab 10 mg....................................................14diazepam tab 10 mg....................................................49diazepam tab 2 mg......................................................14diazepam tab 2 mg......................................................49diazepam tab 5 mg......................................................14diazepam tab 5 mg......................................................49diclofenac potassium tab 50 mg.................................. 1diclofenac potassium tab 50 mg................................ 24diclofenac sodium gel 1%.............................................1diclofenac sodium gel 1%...........................................24diclofenac sodium gel 1%...........................................74diclofenac sodium gel 3%...........................................74diclofenac sodium ophth soln 0.1%...........................94diclofenac sodium tab delayed release 25

mg..................................................................................1diclofenac sodium tab delayed release 25

mg................................................................................24diclofenac sodium tab delayed release 50

mg..................................................................................1diclofenac sodium tab delayed release 50

mg................................................................................24diclofenac sodium tab delayed release 75

mg..................................................................................1

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115

diclofenac sodium tab delayed release 75mg................................................................................24

diclofenac sodium tab er 24hr 100 mg........................1diclofenac sodium tab er 24hr 100 mg......................24diclofenac w/ misoprostol tab delayed release 50-0.2

mg..................................................................................1diclofenac w/ misoprostol tab delayed release 50-0.2

mg................................................................................24diclofenac w/ misoprostol tab delayed release 75-0.2

mg..................................................................................1diclofenac w/ misoprostol tab delayed release 75-0.2

mg................................................................................24dicloxacillin sodium cap 250 mg.................................. 9dicloxacillin sodium cap 500 mg.................................. 9dicyclomine hcl tab 20 mg..........................................78didanosine delayed release capsule 125

mg................................................................................45didanosine delayed release capsule 200

mg................................................................................45didanosine delayed release capsule 250

mg................................................................................45didanosine delayed release capsule 400

mg................................................................................45DIFICID............................................................................ 9DIFLORASONE DIACETATE.....................................74DIGOXIN........................................................................62digoxin tab 125 mcg (0.125 mg)................................62digoxin tab 250 mcg (0.25 mg).................................. 62DILANTIN...................................................................... 14diltiazem hcl cap er 12hr 120 mg.............................. 62diltiazem hcl cap er 12hr 60 mg.................................62diltiazem hcl cap er 12hr 90 mg.................................62diltiazem hcl cap er 24hr 120 mg.............................. 62diltiazem hcl cap er 24hr 180 mg.............................. 62diltiazem hcl cap er 24hr 240 mg.............................. 62diltiazem hcl coated beads cap er 24hr 120

mg................................................................................62diltiazem hcl coated beads cap er 24hr 180

mg................................................................................62diltiazem hcl coated beads cap er 24hr 240

mg................................................................................62diltiazem hcl coated beads cap er 24hr 300

mg................................................................................62diltiazem hcl coated beads cap er 24hr 360

mg................................................................................62diltiazem hcl coated beads tab er 24hr 180

mg................................................................................62diltiazem hcl coated beads tab er 24hr 240

mg................................................................................62diltiazem hcl coated beads tab er 24hr 300

mg................................................................................62

diltiazem hcl coated beads tab er 24hr 360mg................................................................................62

diltiazem hcl coated beads tab er 24hr 420mg................................................................................62

diltiazem hcl extended release beads cap er 24hr120 mg....................................................................... 62

diltiazem hcl extended release beads cap er 24hr180 mg....................................................................... 62

diltiazem hcl extended release beads cap er 24hr240 mg....................................................................... 62

diltiazem hcl extended release beads cap er 24hr300 mg....................................................................... 62

diltiazem hcl extended release beads cap er 24hr360 mg....................................................................... 62

diltiazem hcl extended release beads cap er 24hr420 mg....................................................................... 62

diltiazem hcl tab 120 mg.............................................62diltiazem hcl tab 30 mg...............................................62diltiazem hcl tab 60 mg...............................................62diltiazem hcl tab 90 mg...............................................62DIPENTUM....................................................................93diphenhydramine hcl inj 50 mg/ml.............................22diphenhydramine hcl inj 50 mg/ml.............................38DIPHTHERIA/TETANUS TOXOIDS

ADSORBED...............................................................89dipyridamole tab 25 mg.............................................. 57dipyridamole tab 50 mg.............................................. 57dipyridamole tab 75 mg.............................................. 57disulfiram tab 250 mg....................................................4disulfiram tab 500 mg....................................................4divalproex sodium cap delayed release sprinkle 125

mg................................................................................14divalproex sodium cap delayed release sprinkle 125

mg................................................................................25divalproex sodium cap delayed release sprinkle 125

mg................................................................................51divalproex sodium tab delayed release 125

mg................................................................................14divalproex sodium tab delayed release 125

mg................................................................................25divalproex sodium tab delayed release 125

mg................................................................................51divalproex sodium tab delayed release 250

mg................................................................................14divalproex sodium tab delayed release 250

mg................................................................................25divalproex sodium tab delayed release 250

mg................................................................................51divalproex sodium tab delayed release 500

mg................................................................................14divalproex sodium tab delayed release 500

mg................................................................................25

2017

116

divalproex sodium tab delayed release 500mg................................................................................51

divalproex sodium tab er 24 hr 250 mg.....................14divalproex sodium tab er 24 hr 250 mg.....................25divalproex sodium tab er 24 hr 250 mg.....................51divalproex sodium tab er 24 hr 500 mg.....................14divalproex sodium tab er 24 hr 500 mg.....................25divalproex sodium tab er 24 hr 500 mg.....................51DOCETAXEL.................................................................29DOCETAXEL.................................................................29DOCETAXEL.................................................................29DOCETAXEL.................................................................29DOCETAXEL.................................................................29DOCETAXEL.................................................................29DOCETAXEL.................................................................29DOCETAXEL.................................................................29docetaxel for inj conc 20 mg/ml................................. 29docetaxel for inj conc 80 mg/4ml (20 mg/

ml)................................................................................29dofetilide cap 125 mcg (0.125 mg)............................62dofetilide cap 250 mcg (0.25 mg).............................. 62dofetilide cap 500 mcg (0.5 mg)................................ 62donepezil hydrochloride orally disintegrating tab 10

mg................................................................................16donepezil hydrochloride orally disintegrating tab 5

mg................................................................................16donepezil hydrochloride tab 10 mg........................... 17donepezil hydrochloride tab 23 mg........................... 17donepezil hydrochloride tab 5 mg..............................16dorzolamide hcl ophth soln 2%..................................94dorzolamide hcl-timolol maleate ophth soln 22.3-6.8

mg/ml.......................................................................... 94doxazosin mesylate tab 1 mg.................................... 62doxazosin mesylate tab 1 mg.................................... 80doxazosin mesylate tab 2 mg.................................... 63doxazosin mesylate tab 2 mg.................................... 80doxazosin mesylate tab 4 mg.................................... 63doxazosin mesylate tab 4 mg.................................... 80doxazosin mesylate tab 8 mg.................................... 63doxazosin mesylate tab 8 mg.................................... 80doxepin hcl cap 100 mg..............................................18doxepin hcl cap 100 mg..............................................50doxepin hcl cap 10 mg................................................18doxepin hcl cap 10 mg................................................49doxepin hcl cap 150 mg..............................................19doxepin hcl cap 150 mg..............................................50doxepin hcl cap 25 mg................................................18doxepin hcl cap 25 mg................................................49doxepin hcl cap 50 mg................................................18doxepin hcl cap 50 mg................................................49doxepin hcl cap 75 mg................................................18doxepin hcl cap 75 mg................................................49

doxepin hcl conc 10 mg/ml.........................................19doxepin hcl conc 10 mg/ml.........................................50DOXORUBICIN HCL...................................................29DOXORUBICIN HCL...................................................29doxorubicin hcl inj 2 mg/ml.........................................29doxorubicin hcl liposomal inj (for iv infusion) 2 mg/

ml.................................................................................30doxycycline hyclate cap 100 mg..................................9doxycycline hyclate cap 100 mg................................72doxycycline hyclate cap 50 mg.................................... 9doxycycline hyclate cap 50 mg..................................72doxycycline hyclate for inj 100 mg...............................9doxycycline hyclate for inj 100 mg.............................72doxycycline hyclate tab 100 mg...................................9doxycycline hyclate tab 100 mg.................................72doxycycline hyclate tab 20 mg.....................................9doxycycline hyclate tab 20 mg...................................72doxycycline monohydrate cap 100 mg........................9doxycycline monohydrate cap 150 mg........................9doxycycline monohydrate cap 50 mg..........................9doxycycline monohydrate cap 75 mg..........................9doxycycline monohydrate tab 100 mg.........................9doxycycline monohydrate tab 150 mg.........................9doxycycline monohydrate tab 50 mg...........................9doxycycline monohydrate tab 75 mg...........................9dronabinol cap 10 mg................................................. 22dronabinol cap 2.5 mg................................................ 22dronabinol cap 5 mg....................................................22drospirenone-ethinyl estradiol tab 3-0.02

mg................................................................................83drospirenone-ethinyl estradiol tab 3-0.03

mg................................................................................83drospirenone-ethinyl estrad-levomefolate tab

3-0.02-0.451 mg........................................................83DULERA........................................................................ 98DULERA........................................................................ 98duloxetine hcl enteric coated pellets cap 20

mg................................................................................19duloxetine hcl enteric coated pellets cap 20

mg................................................................................50duloxetine hcl enteric coated pellets cap 20

mg................................................................................71duloxetine hcl enteric coated pellets cap 30

mg................................................................................19duloxetine hcl enteric coated pellets cap 30

mg................................................................................50duloxetine hcl enteric coated pellets cap 30

mg................................................................................71duloxetine hcl enteric coated pellets cap 60

mg................................................................................19duloxetine hcl enteric coated pellets cap 60

mg................................................................................50

2017

117

duloxetine hcl enteric coated pellets cap 60mg................................................................................71

DUREZOL..................................................................... 95dutasteride cap 0.5 mg............................................... 80dutasteride-tamsulosin hcl cap 0.5-0.4

mg................................................................................80EE.E.S. GRANULES........................................................ 9econazole nitrate cream 1%.......................................74EDURANT..................................................................... 45EFFIENT........................................................................57EFFIENT........................................................................57EGRIFTA....................................................................... 83EGRIFTA....................................................................... 83ELAPRASE................................................................... 77ELELYSO.......................................................................77ELIDEL...........................................................................74ELIDEL...........................................................................89ELIGARD.......................................................................86ELIGARD.......................................................................86ELIGARD.......................................................................86ELIGARD.......................................................................86ELIQUIS.........................................................................57ELIQUIS.........................................................................57ELITEK...........................................................................30ELITEK...........................................................................30ELLA...............................................................................83EMCYT.......................................................................... 30EMEND..........................................................................22EMEND..........................................................................22EMEND..........................................................................22EMEND..........................................................................22EMEND TRIPACK........................................................22EMPLICITI.....................................................................30EMPLICITI.....................................................................30EMSAM..........................................................................19EMSAM..........................................................................19EMSAM..........................................................................19EMTRIVA.......................................................................45EMTRIVA.......................................................................45enalapril maleate & hydrochlorothiazide tab 10-25

mg................................................................................63enalapril maleate & hydrochlorothiazide tab 5-12.5

mg................................................................................63enalapril maleate tab 10 mg.......................................63enalapril maleate tab 2.5 mg......................................63enalapril maleate tab 20 mg.......................................63enalapril maleate tab 5 mg.........................................63ENBREL........................................................................ 89ENBREL........................................................................ 89ENBREL........................................................................ 89ENBREL MINI...............................................................89

ENBREL SURECLICK................................................ 89ENGERIX-B.................................................................. 89ENGERIX-B.................................................................. 89enoxaparin sodium inj 100 mg/ml..............................57enoxaparin sodium inj 120 mg/0.8ml........................ 57enoxaparin sodium inj 150 mg/ml..............................57enoxaparin sodium inj 300 mg/3ml............................57enoxaparin sodium inj 30 mg/0.3ml...........................57enoxaparin sodium inj 40 mg/0.4ml...........................57enoxaparin sodium inj 60 mg/0.6ml...........................57enoxaparin sodium inj 80 mg/0.8ml...........................57entacapone tab 200 mg..............................................38entecavir tab 0.5 mg....................................................45entecavir tab 1 mg.......................................................45ENTRESTO...................................................................63ENTRESTO...................................................................63ENTRESTO...................................................................63EPCLUSA......................................................................45epinastine hcl ophth soln 0.05%................................95EPINEPHRINE............................................................. 98EPINEPHRINE............................................................. 98EPIPEN 2-PAK............................................................. 98EPIPEN-JR 2-PAK....................................................... 98epirubicin hcl iv soln 200 mg/100ml (2 mg/

ml)................................................................................30epirubicin hcl iv soln 50 mg/25ml (2 mg/

ml)................................................................................30EPIVIR HBV..................................................................45eplerenone tab 25 mg.................................................63eplerenone tab 50 mg.................................................63EPOGEN....................................................................... 57EPOGEN....................................................................... 57EPOGEN....................................................................... 57EPOGEN....................................................................... 58EPOGEN....................................................................... 58EPZICOM...................................................................... 45ERBITUX....................................................................... 30ERBITUX....................................................................... 30ERGOLOID MESYLATES...........................................17ERIVEDGE....................................................................30ERWINAZE................................................................... 30ERYPED 200.................................................................. 9ERYPED 400.................................................................. 9ERY-TAB..........................................................................9ERY-TAB..........................................................................9ERY-TAB..........................................................................9ERYTHROCIN LACTOBIONATE.................................9ERYTHROCIN STEARATE.......................................... 9ERYTHROMYCIN BASE...............................................9ERYTHROMYCIN BASE...............................................9erythromycin ethylsuccinate for susp 200

mg/5ml.......................................................................... 9

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erythromycin ophth oint 5 mg/gm.............................. 95erythromycin pads 2%.................................................74erythromycin soln 2%..................................................74ESBRIET....................................................................... 98ESBRIET....................................................................... 98ESBRIET....................................................................... 98escitalopram oxalate soln 5 mg/5ml..........................19escitalopram oxalate soln 5 mg/5ml..........................50escitalopram oxalate tab 10 mg.................................19escitalopram oxalate tab 10 mg.................................50escitalopram oxalate tab 20 mg.................................19escitalopram oxalate tab 20 mg.................................50escitalopram oxalate tab 5 mg...................................19escitalopram oxalate tab 5 mg...................................50esomeprazole magnesium cap delayed release 20

mg................................................................................78esomeprazole magnesium cap delayed release 40

mg................................................................................78ESOMEPRAZOLE SODIUM...................................... 78esomeprazole sodium for intravenous soln 40

mg................................................................................78ESTRACE......................................................................83estradiol & norethindrone acetate tab 0.5-0.1

mg................................................................................83estradiol & norethindrone acetate tab 1-0.5

mg................................................................................83estradiol tab 0.5 mg.....................................................83estradiol tab 1 mg........................................................83estradiol tab 2 mg........................................................84estradiol vaginal tab 10 mcg...................................... 84ESTROPIPATE............................................................. 84ESTROPIPATE............................................................. 84ESTROPIPATE............................................................. 84ethambutol hcl tab 100 mg.........................................27ethambutol hcl tab 400 mg.........................................27ethosuximide cap 250 mg...........................................14ethosuximide soln 250 mg/5ml.................................. 14ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg..............................................................................84ethynodiol diacetate & ethinyl estradiol tab 1 mg-50

mcg..............................................................................84ETIDRONATE DISODIUM..........................................93ETIDRONATE DISODIUM..........................................93etodolac cap 200 mg.....................................................1etodolac cap 200 mg...................................................24etodolac cap 300 mg.....................................................1etodolac cap 300 mg...................................................24etodolac tab 400 mg......................................................1etodolac tab 400 mg....................................................24etodolac tab 500 mg......................................................1etodolac tab 500 mg....................................................24etodolac tab er 24hr 400 mg........................................ 1

etodolac tab er 24hr 400 mg......................................24etodolac tab er 24hr 500 mg........................................ 1etodolac tab er 24hr 500 mg......................................24etodolac tab er 24hr 600 mg........................................ 1etodolac tab er 24hr 600 mg......................................24ETOPOPHOS............................................................... 30etoposide inj 100 mg/5ml (20 mg/ml)........................30etoposide inj 1 gm/50ml (20 mg/ml).......................... 30etoposide inj 500 mg/25ml (20 mg/ml)......................30EVOMELA..................................................................... 30EVOTAZ.........................................................................45exemestane tab 25 mg............................................... 30EXJADE.......................................................................102EXJADE.......................................................................102EXJADE.......................................................................102ezetimibe-simvastatin tab 10-10 mg..........................63ezetimibe-simvastatin tab 10-20 mg..........................63ezetimibe-simvastatin tab 10-40 mg..........................63ezetimibe-simvastatin tab 10-80 mg..........................63ezetimibe tab 10 mg....................................................63FFABRAZYME................................................................ 77FABRAZYME................................................................ 77famciclovir tab 125 mg................................................45famciclovir tab 250 mg................................................45famciclovir tab 500 mg................................................45famotidine inj 200 mg/20ml........................................ 78famotidine inj 20 mg/2ml.............................................78famotidine inj 40 mg/4ml.............................................78famotidine tab 20 mg...................................................78famotidine tab 40 mg...................................................78FANAPT.........................................................................40FANAPT.........................................................................40FANAPT.........................................................................40FANAPT.........................................................................40FANAPT.........................................................................40FANAPT.........................................................................40FANAPT.........................................................................40FANAPT TITRATION PACK....................................... 40FARESTON...................................................................30FARYDAK......................................................................30FARYDAK......................................................................30FARYDAK......................................................................30FASLODEX................................................................... 30fat emulsion iv soln 20%...........................................102felbamate susp 600 mg/5ml....................................... 14felbamate tab 400 mg................................................. 14felbamate tab 600 mg................................................. 14felodipine tab er 24hr 10 mg...................................... 63felodipine tab er 24hr 2.5 mg..................................... 63felodipine tab er 24hr 5 mg........................................ 63

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fenofibrate micronized cap 134 mg........................... 63fenofibrate micronized cap 200 mg........................... 63fenofibrate micronized cap 67 mg............................. 63fenofibrate tab 145 mg................................................63fenofibrate tab 160 mg................................................63fenofibrate tab 48 mg.................................................. 63fenofibrate tab 54 mg.................................................. 63fentanyl citrate lozenge on a handle 1200

mcg................................................................................2fentanyl citrate lozenge on a handle 1600

mcg................................................................................2fentanyl citrate lozenge on a handle 200

mcg................................................................................1fentanyl citrate lozenge on a handle 400

mcg................................................................................1fentanyl citrate lozenge on a handle 600

mcg................................................................................2fentanyl citrate lozenge on a handle 800

mcg................................................................................2fentanyl td patch 72hr 100 mcg/hr...............................2fentanyl td patch 72hr 12 mcg/hr................................. 2fentanyl td patch 72hr 25 mcg/hr................................. 2fentanyl td patch 72hr 50 mcg/hr................................. 2fentanyl td patch 72hr 75 mcg/hr................................. 2FETZIMA....................................................................... 19FETZIMA....................................................................... 19FETZIMA....................................................................... 19FETZIMA....................................................................... 19FETZIMA TITRATION PACK......................................19FINACEA....................................................................... 74FINACEA....................................................................... 74finasteride tab 5 mg.....................................................80FIRAZYR....................................................................... 89FIRMAGON...................................................................86FIRMAGON...................................................................87flecainide acetate tab 100 mg....................................63flecainide acetate tab 150 mg....................................63flecainide acetate tab 50 mg...................................... 63FLOVENT DISKUS......................................................98FLOVENT DISKUS......................................................98FLOVENT DISKUS......................................................98FLOVENT HFA.............................................................98FLOVENT HFA.............................................................98FLOVENT HFA.............................................................98fluconazole for susp 10 mg/ml................................... 23fluconazole for susp 40 mg/ml................................... 23fluconazole in dextrose inj 200

mg/100ml....................................................................23fluconazole in dextrose inj 400

mg/200ml....................................................................23fluconazole in nacl 0.9% inj 200

mg/100ml....................................................................23

fluconazole in nacl 0.9% inj 400mg/200ml....................................................................23

fluconazole tab 100 mg...............................................23fluconazole tab 150 mg...............................................23fluconazole tab 200 mg...............................................23fluconazole tab 50 mg.................................................23flucytosine cap 250 mg............................................... 23flucytosine cap 500 mg............................................... 23fludarabine phosphate for inj 50 mg..........................30fludarabine phosphate inj 25 mg/ml.......................... 30fludrocortisone acetate tab 0.1 mg............................ 82fluocinolone acetonide (otic) oil 0.01%..................... 96fluocinolone acetonide cream 0.01%........................ 74fluocinonide cream 0.05%.......................................... 74fluocinonide emulsified base cream

0.05%..........................................................................74fluocinonide gel 0.05%................................................74fluocinonide oint 0.05%...............................................74fluocinonide soln 0.05%..............................................74fluorometholone ophth susp 0.1%.............................95fluorouracil cream 5%................................................. 74fluorouracil inj 1 gm/20ml (50 mg/ml)........................30fluorouracil inj 2.5 gm/50ml (50 mg/ml).....................30fluorouracil inj 500 mg/10ml (50 mg/

ml)................................................................................30fluorouracil inj 5 gm/100ml (50 mg/ml)......................30fluorouracil soln 2%..................................................... 74fluorouracil soln 5%..................................................... 74fluoxetine hcl cap 10 mg.............................................19fluoxetine hcl cap 20 mg.............................................19fluoxetine hcl cap 40 mg.............................................19fluoxetine hcl cap delayed release 90

mg................................................................................19fluoxetine hcl solution 20 mg/5ml.............................. 19fluoxetine hcl tab 10 mg..............................................19fluoxetine hcl tab 20 mg..............................................19fluphenazine decanoate inj 25 mg/ml........................40FLUPHENAZINE HCL.................................................40FLUPHENAZINE HCL.................................................40FLUPHENAZINE HCL.................................................40fluphenazine hcl tab 10 mg........................................ 40fluphenazine hcl tab 1 mg.......................................... 40fluphenazine hcl tab 2.5 mg....................................... 40fluphenazine hcl tab 5 mg.......................................... 40flurbiprofen sodium ophth soln 0.03%.......................95flurbiprofen tab 100 mg.................................................2flurbiprofen tab 100 mg...............................................25flurbiprofen tab 50 mg................................................... 2flurbiprofen tab 50 mg.................................................25flutamide cap 125 mg..................................................30FLUTICASONE PROPIONATE/

SALMETEROL.......................................................... 98

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FLUTICASONE PROPIONATE/SALMETEROL.......................................................... 98

FLUTICASONE PROPIONATE/SALMETEROL.......................................................... 98

fluticasone propionate cream 0.05%.........................74fluticasone propionate nasal susp 50 mcg/

act................................................................................98fluticasone propionate oint 0.005%........................... 74fluvoxamine maleate tab 100 mg...............................19fluvoxamine maleate tab 25 mg.................................19fluvoxamine maleate tab 50 mg.................................19FOLOTYN......................................................................30FOLOTYN......................................................................30fomepizole inj 1 gm/ml (for iv

infusion)....................................................................102fondaparinux sodium subcutaneous inj 10

mg/0.8ml.....................................................................58fondaparinux sodium subcutaneous inj 2.5

mg/0.5ml.....................................................................58fondaparinux sodium subcutaneous inj 5

mg/0.4ml.....................................................................58fondaparinux sodium subcutaneous inj 7.5

mg/0.6ml.....................................................................58FORTEO........................................................................93fosamprenavir calcium tab 700 mg........................... 45fosinopril sodium & hydrochlorothiazide tab 10-12.5

mg................................................................................63fosinopril sodium & hydrochlorothiazide tab 20-12.5

mg................................................................................63fosinopril sodium tab 10 mg....................................... 63fosinopril sodium tab 20 mg....................................... 63fosinopril sodium tab 40 mg....................................... 63fosphenytoin sodium inj 100 mg/2ml.........................14fosphenytoin sodium inj 500 mg/10ml.......................14FOSRENOL.................................................................. 80FOSRENOL.................................................................. 80FOSRENOL.................................................................. 80FOSRENOL.................................................................. 80FOSRENOL.................................................................. 80furosemide inj 10 mg/ml..............................................63furosemide oral soln 10 mg/ml...................................64furosemide tab 20 mg................................................. 64furosemide tab 40 mg................................................. 64furosemide tab 80 mg................................................. 64FUZEON........................................................................45FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14

Ggabapentin cap 100 mg.............................................. 14gabapentin cap 300 mg.............................................. 14gabapentin cap 400 mg.............................................. 14gabapentin oral soln 250 mg/5ml.............................. 14gabapentin tab 600 mg............................................... 14gabapentin tab 800 mg............................................... 14GABITRIL...................................................................... 14GABITRIL...................................................................... 14GALANTAMINE HYDROBROMIDE.......................... 17galantamine hydrobromide cap er 24hr 16

mg................................................................................17galantamine hydrobromide cap er 24hr 24

mg................................................................................17galantamine hydrobromide cap er 24hr 8

mg................................................................................17galantamine hydrobromide tab 12 mg...................... 17galantamine hydrobromide tab 4 mg.........................17galantamine hydrobromide tab 8 mg.........................17GAMMAPLEX............................................................... 89GAMMAPLEX............................................................... 89GAMMAPLEX............................................................... 89GAMMAPLEX............................................................... 89GAMMAPLEX............................................................... 89GAMMAPLEX............................................................... 89GAMMAPLEX............................................................... 89GAMUNEX-C................................................................ 89GAMUNEX-C................................................................ 89GAMUNEX-C................................................................ 89GAMUNEX-C................................................................ 89GAMUNEX-C................................................................ 89GAMUNEX-C................................................................ 89ganciclovir sodium for inj 500 mg.............................. 45GARDASIL.................................................................... 90GARDASIL 9.................................................................90GARDASIL 9.................................................................90GATTEX.........................................................................78GAUZE PADS 2" X 2".................................................53GAZYVA.........................................................................30gemcitabine hcl for inj 1 gm....................................... 30gemcitabine hcl for inj 200 mg...................................30gemcitabine hcl for inj 2 gm....................................... 30gemcitabine hcl inj 1 gm/26.3ml (38 mg/

ml)................................................................................30gemcitabine hcl inj 200 mg/5.26ml (38 mg/

ml)................................................................................30gemcitabine hcl inj 2 gm/52.6ml (38 mg/

ml)................................................................................31gemfibrozil tab 600 mg............................................... 64gentamicin in saline inj 0.8 mg/ml................................9gentamicin in saline inj 1.2 mg/ml................................9

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gentamicin in saline inj 1.6 mg/ml................................9gentamicin in saline inj 1 mg/ml...................................9GENTAMICIN SULFATE............................................. 74gentamicin sulfate cream 0.1%..................................74gentamicin sulfate inj 10 mg/ml................................. 10gentamicin sulfate inj 40 mg/ml................................. 10gentamicin sulfate iv soln 10 mg/ml.......................... 10gentamicin sulfate ophth oint 0.3%........................... 95gentamicin sulfate ophth soln 0.3%...........................95GENVOYA.....................................................................45GEODON.......................................................................40GILOTRIF......................................................................31GILOTRIF......................................................................31GILOTRIF......................................................................31glatiramer acetate soln prefilled syringe 20 mg/

ml.................................................................................71glatiramer acetate soln prefilled syringe 40 mg/

ml.................................................................................71GLEEVEC......................................................................31GLEEVEC......................................................................31GLEOSTINE..................................................................31GLEOSTINE..................................................................31GLEOSTINE..................................................................31GLEOSTINE..................................................................31glimepiride tab 1 mg....................................................53glimepiride tab 2 mg....................................................53glimepiride tab 4 mg....................................................53glipizide-metformin hcl tab 2.5-250 mg.....................53glipizide-metformin hcl tab 2.5-500 mg.....................53glipizide-metformin hcl tab 5-500 mg........................ 53glipizide tab 10 mg...................................................... 53glipizide tab 5 mg.........................................................53glipizide tab er 24hr 10 mg.........................................53glipizide tab er 24hr 2.5 mg........................................53glipizide tab er 24hr 5 mg...........................................53GLUCAGEN HYPOKIT............................................... 53GLUCAGON EMERGENCY KIT............................... 53glycopyrrolate tab 1 mg.............................................. 78glycopyrrolate tab 2 mg.............................................. 78granisetron hcl tab 1 mg.............................................22GRANIX......................................................................... 58GRANIX......................................................................... 58GRASTEK..................................................................... 98griseofulvin microsize susp 125

mg/5ml........................................................................ 23griseofulvin ultramicrosize tab 125 mg......................23griseofulvin ultramicrosize tab 250 mg......................23GUANIDINE HCL.........................................................27HH.P. ACTHAR............................................................... 82HAEGARDA.................................................................. 90

HAEGARDA.................................................................. 90HALAVEN...................................................................... 31halobetasol propionate cream 0.05%........................74halobetasol propionate oint 0.05%............................ 75haloperidol decanoate im soln 100 mg/

ml.................................................................................40haloperidol decanoate im soln 50 mg/

ml.................................................................................40haloperidol lactate inj 5 mg/ml................................... 40haloperidol lactate oral conc 2 mg/ml........................41haloperidol tab 0.5 mg................................................ 41haloperidol tab 10 mg................................................. 41haloperidol tab 1 mg....................................................41haloperidol tab 20 mg................................................. 41haloperidol tab 2 mg....................................................41haloperidol tab 5 mg....................................................41HARVONI...................................................................... 45HAVRIX..........................................................................90HAVRIX..........................................................................90heparin sodium (porcine) 40 unit/ml in

d5w..............................................................................58heparin sodium (porcine) inj 10000 unit/

ml.................................................................................58heparin sodium (porcine) inj 1000 unit/

ml.................................................................................58heparin sodium (porcine) inj 20000 unit/

ml.................................................................................58heparin sodium (porcine) inj 5000 unit/

ml.................................................................................58heparin sodium (porcine) pf inj 5000

unit/0.5ml....................................................................58HEPATAMINE............................................................. 102HERCEPTIN................................................................. 31HERCEPTIN................................................................. 31HETLIOZ..................................................................... 101HEXALEN......................................................................31HIBERIX........................................................................ 90HUMALOG.................................................................... 53HUMALOG.................................................................... 53HUMALOG JUNIOR KWIKPEN.................................53HUMALOG KWIKPEN.................................................53HUMALOG KWIKPEN.................................................53HUMALOG MIX 50/50.................................................53HUMALOG MIX 50/50 KWIKPEN............................. 53HUMALOG MIX 75/25.................................................53HUMALOG MIX 75/25 KWIKPEN............................. 53HUMIRA.........................................................................90HUMIRA.........................................................................90HUMIRA.........................................................................90HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.......................................................90HUMIRA PEN............................................................... 90

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HUMIRA PEN-CROHNS DISEASESTARTER...................................................................90

HUMIRA PEN-PSORIASIS STARTER..................... 90HUMULIN 70/30...........................................................54HUMULIN 70/30 KWIKPEN....................................... 54HUMULIN N..................................................................54HUMULIN N KWIKPEN.............................................. 54HUMULIN R..................................................................54HUMULIN R U-500 (CONCENTRATE).....................54HUMULIN R U-500 KWIKPEN...................................54hydralazine hcl tab 100 mg........................................ 64hydralazine hcl tab 10 mg.......................................... 64hydralazine hcl tab 25 mg.......................................... 64hydralazine hcl tab 50 mg.......................................... 64hydrochlorothiazide cap 12.5 mg...............................64hydrochlorothiazide tab 12.5 mg................................64hydrochlorothiazide tab 25 mg...................................64hydrochlorothiazide tab 50 mg...................................64hydrocodone-acetaminophen soln 7.5-325

mg/15ml........................................................................ 2hydrocodone-acetaminophen tab 10-300

mg..................................................................................2hydrocodone-acetaminophen tab 10-325

mg..................................................................................2hydrocodone-acetaminophen tab 5-300

mg..................................................................................2hydrocodone-acetaminophen tab 5-325

mg..................................................................................2hydrocodone-acetaminophen tab 7.5-300

mg..................................................................................2hydrocodone-acetaminophen tab 7.5-325

mg..................................................................................2hydrocodone-ibuprofen tab 10-200 mg.......................2hydrocodone-ibuprofen tab 5-200 mg......................... 2hydrocodone-ibuprofen tab 7.5-200 mg......................2hydrocortisone butyrate cream 0.1%........................ 75hydrocortisone butyrate oint 0.1%.............................75hydrocortisone butyrate soln 0.1%............................ 75hydrocortisone cream 1%...........................................75hydrocortisone cream 2.5%........................................75hydrocortisone enema 100 mg/60ml.........................93hydrocortisone lotion 2.5%......................................... 75hydrocortisone oint 1%............................................... 75hydrocortisone oint 2.5%............................................ 75hydrocortisone rectal cream 1%................................ 93hydrocortisone rectal cream 2.5%.............................93hydrocortisone tab 10 mg...........................................82hydrocortisone tab 20 mg...........................................82hydrocortisone tab 5 mg............................................. 82hydrocortisone valerate cream 0.2%.........................75hydrocortisone valerate oint 0.2%............................. 75

hydrocortisone w/ acetic acid otic soln1-2%............................................................................96

hydromorphone hcl liqd 1 mg/ml..................................2hydromorphone hcl preservative free inj 10 mg/

ml................................................................................... 2hydromorphone hcl tab 2 mg....................................... 2hydromorphone hcl tab 4 mg....................................... 2hydromorphone hcl tab 8 mg....................................... 2hydroxychloroquine sulfate tab 200 mg.................... 37HYDROXYPROGESTERONE

CAPROATE................................................................31hydroxyurea cap 500 mg............................................ 31hydroxyzine hcl syrup 10 mg/5ml.............................. 22hydroxyzine hcl syrup 10 mg/5ml.............................. 50hydroxyzine hcl syrup 10 mg/5ml.............................. 99hydroxyzine hcl tab 10 mg..........................................22hydroxyzine hcl tab 10 mg..........................................50hydroxyzine hcl tab 10 mg..........................................99hydroxyzine hcl tab 25 mg..........................................22hydroxyzine hcl tab 25 mg..........................................50hydroxyzine hcl tab 25 mg..........................................99hydroxyzine hcl tab 50 mg..........................................22hydroxyzine hcl tab 50 mg..........................................50hydroxyzine hcl tab 50 mg..........................................99Iibandronate sodium iv soln 3 mg/3ml........................93ibandronate sodium tab 150 mg................................ 93IBRANCE.......................................................................31IBRANCE.......................................................................31IBRANCE.......................................................................31ibuprofen susp 100 mg/5ml.......................................... 2ibuprofen susp 100 mg/5ml........................................25ibuprofen tab 400 mg.................................................... 2ibuprofen tab 400 mg.................................................. 25ibuprofen tab 600 mg.................................................... 2ibuprofen tab 600 mg.................................................. 25ibuprofen tab 800 mg.................................................... 2ibuprofen tab 800 mg.................................................. 25ICLUSIG........................................................................ 31ICLUSIG........................................................................ 31idarubicin hcl iv inj 10 mg/10ml (1 mg/

ml)................................................................................31idarubicin hcl iv inj 20 mg/20ml (1 mg/

ml)................................................................................31idarubicin hcl iv inj 5 mg/5ml (1 mg/ml).....................31IDHIFA............................................................................31IDHIFA............................................................................31IFEX............................................................................... 31IFOSFAMIDE................................................................ 31ifosfamide for inj 1 gm.................................................31ifosfamide iv inj 1 gm/20ml (50 mg/ml)..................... 31

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ifosfamide iv inj 3 gm/60ml (50 mg/ml)..................... 31ILARIS............................................................................90ILARIS............................................................................90ILEVRO..........................................................................95imatinib mesylate tab 100 mg.................................... 31imatinib mesylate tab 400 mg.................................... 31IMBRUVICA.................................................................. 31IMFINZI..........................................................................31IMFINZI..........................................................................31imipenem-cilastatin intravenous for soln 250

mg................................................................................10imipenem-cilastatin intravenous for soln 500

mg................................................................................10imipramine hcl tab 10 mg........................................... 19imipramine hcl tab 25 mg........................................... 19imipramine hcl tab 50 mg........................................... 19imiquimod cream 5%...................................................75IMLYGIC........................................................................ 31IMLYGIC........................................................................ 32IMOVAX RABIES (H.D.C.V.)...................................... 90INCRELEX.................................................................... 83INCRUSE ELLIPTA..................................................... 99indapamide tab 1.25 mg............................................. 64indapamide tab 2.5 mg............................................... 64INFANRIX......................................................................90INLYTA...........................................................................32INLYTA...........................................................................32INSULIN INJECTION DEVICE...................................54INSULIN SYRINGE/NEEDLE.....................................54INTELENCE.................................................................. 45INTELENCE.................................................................. 45INTELENCE.................................................................. 45INTRON A.....................................................................45INTRON A.....................................................................45INTRON A.....................................................................45INTRON A.....................................................................45INTRON A.....................................................................45INTRON A W/DILUENT..............................................45INTRON A W/DILUENT..............................................45INTRON A W/DILUENT..............................................45INVANZ.......................................................................... 10INVANZ.......................................................................... 10INVEGA......................................................................... 41INVEGA......................................................................... 41INVEGA......................................................................... 41INVEGA......................................................................... 41INVEGA SUSTENNA.................................................. 41INVEGA SUSTENNA.................................................. 41INVEGA SUSTENNA.................................................. 41INVEGA SUSTENNA.................................................. 41INVEGA SUSTENNA.................................................. 41INVEGA TRINZA..........................................................41

INVEGA TRINZA..........................................................41INVEGA TRINZA..........................................................41INVEGA TRINZA..........................................................41INVIRASE......................................................................46INVIRASE......................................................................46INVOKAMET.................................................................54INVOKAMET.................................................................54INVOKAMET.................................................................54INVOKAMET.................................................................54INVOKAMET XR..........................................................54INVOKAMET XR..........................................................54INVOKAMET XR..........................................................54INVOKAMET XR..........................................................54INVOKANA....................................................................54INVOKANA....................................................................54IPOL INACTIVATED IPV.............................................90ipratropium bromide inhal soln 0.02%.......................99ipratropium bromide nasal soln 0.03% (21 mcg/

spray)..........................................................................99ipratropium bromide nasal soln 0.06% (42 mcg/

spray)..........................................................................99irbesartan-hydrochlorothiazide tab 150-12.5

mg................................................................................64irbesartan-hydrochlorothiazide tab 300-12.5

mg................................................................................64irbesartan tab 150 mg.................................................64irbesartan tab 300 mg.................................................64irbesartan tab 75 mg................................................... 64IRESSA..........................................................................32IRINOTECAN................................................................32irinotecan hcl inj 100 mg/5ml (20 mg/

ml)................................................................................32irinotecan hcl inj 40 mg/2ml (20 mg/ml).................... 32ISENTRESS..................................................................46ISENTRESS..................................................................46ISENTRESS..................................................................46ISENTRESS..................................................................46ISENTRESS HD...........................................................46ISONIAZID.................................................................... 27isoniazid tab 100 mg................................................... 27isoniazid tab 300 mg................................................... 27isosorbide dinitrate tab 10 mg....................................64isosorbide dinitrate tab 20 mg....................................64isosorbide dinitrate tab 30 mg....................................64isosorbide dinitrate tab 5 mg......................................64isosorbide mononitrate tab 10 mg............................. 64isosorbide mononitrate tab 20 mg............................. 64isosorbide mononitrate tab er 24hr 120

mg................................................................................64isosorbide mononitrate tab er 24hr 30

mg................................................................................64

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isosorbide mononitrate tab er 24hr 60mg................................................................................64

isotretinoin cap 10 mg.................................................75isotretinoin cap 20 mg.................................................75isotretinoin cap 30 mg.................................................75isotretinoin cap 40 mg.................................................75isradipine cap 2.5 mg..................................................64isradipine cap 5 mg..................................................... 64ISTALOL........................................................................ 95ISTODAX.......................................................................32ISTODAX (OVERFILL)................................................32itraconazole cap 100 mg............................................ 23ivermectin tab 3 mg.....................................................37IXEMPRA KIT...............................................................32IXEMPRA KIT...............................................................32IXIARO...........................................................................90JJADENU...................................................................... 102JADENU...................................................................... 102JADENU...................................................................... 102JADENU SPRINKLE................................................. 102JADENU SPRINKLE................................................. 102JADENU SPRINKLE................................................. 102JAKAFI...........................................................................32JAKAFI...........................................................................32JAKAFI...........................................................................32JAKAFI...........................................................................32JAKAFI...........................................................................32JANUMET......................................................................54JANUMET......................................................................54JANUMET XR...............................................................54JANUMET XR...............................................................54JANUMET XR...............................................................54JANUVIA........................................................................54JANUVIA........................................................................54JANUVIA........................................................................54JARDIANCE..................................................................54JARDIANCE..................................................................54JENTADUETO.............................................................. 54JENTADUETO.............................................................. 54JENTADUETO.............................................................. 54JENTADUETO XR....................................................... 55JENTADUETO XR....................................................... 55JEVTANA.......................................................................32JUXTAPID..................................................................... 64JUXTAPID..................................................................... 64JUXTAPID..................................................................... 64JUXTAPID..................................................................... 64JUXTAPID..................................................................... 64JUXTAPID..................................................................... 64

KKADCYLA......................................................................32KADCYLA......................................................................32KALETRA...................................................................... 46KALETRA...................................................................... 46KALETRA...................................................................... 46KALYDECO...................................................................99KALYDECO...................................................................99KALYDECO...................................................................99kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45%

inj...............................................................................102kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2%

inj...............................................................................102kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33%

inj...............................................................................102kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45%

inj...............................................................................102kcl 20 meq/l (0.15%) in nacl 0.45%

inj...............................................................................102kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45%

inj...............................................................................102kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45%

inj...............................................................................102KEPIVANCE..................................................................73ketoconazole cream 2%..............................................75ketoconazole shampoo 2%........................................ 75ketoconazole tab 200 mg........................................... 23ketoprofen cap 50 mg................................................... 2ketoprofen cap 50 mg................................................. 25ketoprofen cap 75 mg................................................... 2ketoprofen cap 75 mg................................................. 25ketorolac tromethamine ophth soln

0.4%............................................................................95ketorolac tromethamine ophth soln

0.5%............................................................................95KEYTRUDA...................................................................32KEYTRUDA...................................................................32KINERET....................................................................... 90KINRIX........................................................................... 90KISQALI.........................................................................32KISQALI FEMARA 200 DOSE...................................32KISQALI FEMARA 400 DOSE...................................32KISQALI FEMARA 600 DOSE...................................32KOMBIGLYZE XR........................................................55KOMBIGLYZE XR........................................................55KOMBIGLYZE XR........................................................55KORLYM........................................................................86KUVAN...........................................................................77KUVAN...........................................................................77KUVAN...........................................................................77KYNAMRO.................................................................... 64KYPROLIS.................................................................... 32

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KYPROLIS.................................................................... 32Llabetalol hcl tab 100 mg..............................................65labetalol hcl tab 200 mg..............................................65labetalol hcl tab 300 mg..............................................65LACRISERT.................................................................. 95lactated ringer's solution........................................... 102lactic acid (ammonium lactate) cream

12%............................................................................. 75lactic acid (ammonium lactate) lotion

12%............................................................................. 75lactulose (encephalopathy) solution 10

gm/15ml......................................................................78lactulose solution 10 gm/15ml....................................78lamivudine oral soln 10 mg/ml................................... 46lamivudine tab 100 mg (hbv)......................................46lamivudine tab 150 mg................................................46lamivudine tab 300 mg................................................46lamivudine-zidovudine tab 150-300 mg.................... 46lamotrigine tab 100 mg............................................... 14lamotrigine tab 100 mg............................................... 51lamotrigine tab 150 mg............................................... 14lamotrigine tab 150 mg............................................... 51lamotrigine tab 200 mg............................................... 15lamotrigine tab 200 mg............................................... 51lamotrigine tab 25 mg................................................. 14lamotrigine tab 25 mg................................................. 51lamotrigine tab chewable dispersible 25

mg................................................................................14lamotrigine tab chewable dispersible 25

mg................................................................................51lamotrigine tab chewable dispersible 5

mg................................................................................14lamotrigine tab chewable dispersible 5

mg................................................................................51lansoprazole cap delayed release 15

mg................................................................................78lansoprazole cap delayed release 30

mg................................................................................78lanthanum carbonate chew tab 1000

mg................................................................................81lanthanum carbonate chew tab 500

mg................................................................................80lanthanum carbonate chew tab 750

mg................................................................................81LANTUS.........................................................................55LANTUS SOLOSTAR..................................................55LARTRUVO...................................................................32LARTRUVO...................................................................32latanoprost ophth soln 0.005%.................................. 95LATUDA.........................................................................41

LATUDA.........................................................................41LATUDA.........................................................................41LATUDA.........................................................................41LATUDA.........................................................................41LAZANDA........................................................................ 2LAZANDA........................................................................ 2LAZANDA........................................................................ 2leflunomide tab 10 mg.................................................90leflunomide tab 20 mg.................................................90LENVIMA 10 MG DAILY DOSE.................................32LENVIMA 14 MG DAILY DOSE.................................32LENVIMA 18 MG DAILY DOSE.................................32LENVIMA 20 MG DAILY DOSE.................................33LENVIMA 24 MG DAILY DOSE.................................33LENVIMA 8 MG DAILY DOSE...................................33LETAIRIS.......................................................................99LETAIRIS.......................................................................99letrozole tab 2.5 mg.....................................................33LEUCOVORIN CALCIUM...........................................33LEUCOVORIN CALCIUM...........................................33LEUCOVORIN CALCIUM...........................................33leucovorin calcium for inj 100 mg.............................. 33leucovorin calcium for inj 200 mg.............................. 33leucovorin calcium for inj 350 mg.............................. 33leucovorin calcium for inj 50 mg................................ 33leucovorin calcium tab 25 mg.................................... 33leucovorin calcium tab 5 mg.......................................33LEUKERAN...................................................................33LEUKINE....................................................................... 58leuprolide acetate inj kit 5 mg/ml............................... 87LEVEMIR.......................................................................55LEVEMIR FLEXTOUCH..............................................55levetiracetam inj 500 mg/5ml (100 mg/

ml)................................................................................15levetiracetam in sodium chloride iv soln 1000

mg/100ml....................................................................15levetiracetam in sodium chloride iv soln 1500

mg/100ml....................................................................15levetiracetam in sodium chloride iv soln 500

mg/100ml....................................................................15levetiracetam oral soln 100 mg/ml.............................15levetiracetam tab 1000 mg......................................... 15levetiracetam tab 250 mg........................................... 15levetiracetam tab 500 mg........................................... 15levetiracetam tab 750 mg........................................... 15levobunolol hcl ophth soln 0.5%................................ 95levocarnitine oral soln 1 gm/10ml

(10%)........................................................................ 102levocarnitine tab 330 mg.......................................... 102levocetirizine dihydrochloride tab 5 mg.....................99levofloxacin in d5w iv soln 250

mg/50ml......................................................................10

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levofloxacin in d5w iv soln 500mg/100ml....................................................................10

levofloxacin in d5w iv soln 750mg/150ml....................................................................10

levofloxacin iv soln 25 mg/ml..................................... 10levofloxacin oral soln 25 mg/ml..................................10levofloxacin tab 250 mg..............................................10levofloxacin tab 500 mg..............................................10levofloxacin tab 750 mg..............................................10levonorgestrel & ethinyl estradiol (91-day) tab

0.15-0.03 mg............................................................. 84levonorgestrel & ethinyl estradiol tab 0.15 mg-30

mcg..............................................................................84levonorgestrel & ethinyl estradiol tab 0.1 mg-20

mcg..............................................................................84levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg........................84levonorgestrel-ethinyl estradiol (continuous) tab

90-20 mcg..................................................................84levonorg-eth est tab 0.1-0.02mg(84) & eth est tab

0.01mg(7)...................................................................84levonorg-eth est tab 0.15-0.03mg(84) & eth est tab

0.01mg(7)...................................................................84LEVORPHANOL TARTRATE....................................... 2levothyroxine sodium tab 100 mcg............................85levothyroxine sodium tab 112 mcg............................ 85levothyroxine sodium tab 125 mcg............................85levothyroxine sodium tab 137 mcg............................85levothyroxine sodium tab 150 mcg............................85levothyroxine sodium tab 175 mcg............................85levothyroxine sodium tab 200 mcg............................85levothyroxine sodium tab 25 mcg..............................85levothyroxine sodium tab 300 mcg............................85levothyroxine sodium tab 50 mcg..............................85levothyroxine sodium tab 75 mcg..............................85levothyroxine sodium tab 88 mcg..............................85LEXIVA...........................................................................46LEXIVA...........................................................................46LIALDA...........................................................................93LIDOCAINE HCL..........................................................65lidocaine hcl gel 2%.......................................................4lidocaine hcl soln 4%.....................................................4lidocaine hcl viscous soln 2%.......................................4lidocaine oint 5%............................................................4lidocaine patch 5%.........................................................4lidocaine-prilocaine cream 2.5-2.5%........................... 4lindane shampoo 1%...................................................37LINEZOLID....................................................................10linezolid for susp 100 mg/5ml.................................... 10linezolid iv soln 600 mg/300ml (2 mg/

ml)................................................................................10linezolid tab 600 mg.................................................... 10

LINZESS........................................................................79LINZESS........................................................................79LINZESS........................................................................79liothyronine sodium tab 25 mcg.................................86liothyronine sodium tab 50 mcg.................................86liothyronine sodium tab 5 mcg................................... 85lisinopril & hydrochlorothiazide tab 10-12.5

mg................................................................................65lisinopril & hydrochlorothiazide tab 20-12.5

mg................................................................................65lisinopril & hydrochlorothiazide tab 20-25

mg................................................................................65lisinopril tab 10 mg...................................................... 65lisinopril tab 2.5 mg..................................................... 65lisinopril tab 20 mg...................................................... 65lisinopril tab 30 mg...................................................... 65lisinopril tab 40 mg...................................................... 65lisinopril tab 5 mg.........................................................65LITHIUM........................................................................ 51lithium carbonate cap 150 mg....................................51lithium carbonate cap 300 mg....................................51lithium carbonate cap 600 mg....................................51lithium carbonate tab 300 mg.....................................51lithium carbonate tab er 300 mg................................51lithium carbonate tab er 450 mg................................51LONSURF..................................................................... 33LONSURF..................................................................... 33loperamide hcl cap 2 mg............................................ 79lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/

ml)................................................................................46lorazepam tab 0.5 mg................................................. 50lorazepam tab 1 mg.................................................... 50lorazepam tab 2 mg.................................................... 50losartan potassium & hydrochlorothiazide tab

100-12.5 mg.............................................................. 65losartan potassium & hydrochlorothiazide tab 100-25

mg................................................................................65losartan potassium & hydrochlorothiazide tab

50-12.5 mg.................................................................65losartan potassium tab 100 mg..................................65losartan potassium tab 25 mg....................................65losartan potassium tab 50 mg....................................65LOTEMAX..................................................................... 95LOTEMAX..................................................................... 95LOTEMAX..................................................................... 95lovastatin tab 10 mg....................................................65lovastatin tab 20 mg....................................................65lovastatin tab 40 mg....................................................65loxapine succinate cap 10 mg....................................41loxapine succinate cap 25 mg....................................41loxapine succinate cap 50 mg....................................41loxapine succinate cap 5 mg......................................41

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LUMIGAN...................................................................... 95LUPRON DEPOT (1-MONTH)...................................87LUPRON DEPOT (1-MONTH)...................................87LUPRON DEPOT (3-MONTH)...................................87LUPRON DEPOT (3-MONTH)...................................87LUPRON DEPOT (4-MONTH)...................................87LUPRON DEPOT (6-MONTH)...................................87LUPRON DEPOT-PED (1-MONTH)..........................87LUPRON DEPOT-PED (1-MONTH)..........................87LUPRON DEPOT-PED (1-MONTH)..........................87LUPRON DEPOT-PED (3-MONTH)..........................87LUPRON DEPOT-PED (3-MONTH)..........................87LYNPARZA....................................................................33LYNPARZA....................................................................33LYNPARZA....................................................................33LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 71LYRICA.......................................................................... 71LYRICA.......................................................................... 71LYRICA.......................................................................... 71LYRICA.......................................................................... 71LYRICA.......................................................................... 71LYRICA.......................................................................... 71LYRICA.......................................................................... 71LYRICA.......................................................................... 71LYSODREN...................................................................86Mmagnesium sulfate inj 50%...................................... 102malathion lotion 0.5%..................................................37MAPROTILINE HCL.................................................... 19MAPROTILINE HCL.................................................... 19MAPROTILINE HCL.................................................... 19MARPLAN..................................................................... 19MARQIBO......................................................................33MATULANE...................................................................33MAVYRET..................................................................... 46meclizine hcl tab 12.5 mg...........................................22medroxyprogesterone acetate im susp 150 mg/

ml.................................................................................84medroxyprogesterone acetate im susp prefilled syr

150 mg/ml.................................................................. 84medroxyprogesterone acetate tab 10

mg................................................................................84

medroxyprogesterone acetate tab 2.5mg................................................................................84

medroxyprogesterone acetate tab 5mg................................................................................84

mefloquine hcl tab 250 mg......................................... 38megestrol acetate susp 40 mg/ml..............................84megestrol acetate tab 20 mg..................................... 84megestrol acetate tab 40 mg..................................... 84MEKINIST......................................................................33MEKINIST......................................................................33meloxicam tab 15 mg....................................................2meloxicam tab 15 mg..................................................25meloxicam tab 7.5 mg...................................................2meloxicam tab 7.5 mg.................................................25melphalan hcl for inj 50 mg........................................ 33memantine hcl oral solution 2 mg/ml.........................17memantine hcl tab 10 mg...........................................17memantine hcl tab 5 mg............................................. 17memantine hcl tab 5 mg (28) & 10 mg (21) titration

pak...............................................................................17MENACTRA.................................................................. 90MENVEO....................................................................... 90mercaptopurine tab 50 mg......................................... 33meropenem iv for soln 1 gm...................................... 10meropenem iv for soln 500 mg.................................. 10mesalamine enema 4 gm........................................... 93mesalamine tab delayed release 1.2

gm................................................................................93mesna inj 100 mg/ml...................................................33MESNEX........................................................................33MESTINON................................................................... 27metformin hcl tab 1000 mg.........................................55metformin hcl tab 500 mg...........................................55metformin hcl tab 850 mg...........................................55metformin hcl tab er 24hr 500 mg............................. 55metformin hcl tab er 24hr 750 mg............................. 55methadone hcl tab 10 mg.............................................3methadone hcl tab 5 mg............................................... 3methazolamide tab 25 mg.......................................... 65methazolamide tab 50 mg.......................................... 65methenamine hippurate tab 1 gm..............................10methimazole tab 10 mg.............................................. 88methimazole tab 5 mg.................................................88methocarbamol tab 500 mg..................................... 101methocarbamol tab 750 mg..................................... 101METHOTREXATE SODIUM.......................................33METHOTREXATE SODIUM.......................................90methotrexate sodium for inj 1 gm.............................. 33methotrexate sodium for inj 1 gm.............................. 90methotrexate sodium inj 50 mg/2ml (25 mg/

ml)................................................................................33

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methotrexate sodium inj 50 mg/2ml (25 mg/ml)................................................................................91

methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml)................................................................................33

methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml)................................................................................91

methotrexate sodium inj pf 100 mg/4ml (25 mg/ml)................................................................................33

methotrexate sodium inj pf 100 mg/4ml (25 mg/ml)................................................................................91

methotrexate sodium inj pf 200 mg/8ml (25 mg/ml)................................................................................33

methotrexate sodium inj pf 200 mg/8ml (25 mg/ml)................................................................................91

methotrexate sodium inj pf 250 mg/10ml (25 mg/ml)................................................................................33

methotrexate sodium inj pf 250 mg/10ml (25 mg/ml)................................................................................91

methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)................................................................................33

methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)................................................................................91

methotrexate sodium tab 2.5 mg............................... 34methotrexate sodium tab 2.5 mg............................... 91methoxsalen rapid cap 10 mg....................................75methscopolamine bromide tab 2.5 mg......................79methscopolamine bromide tab 5 mg......................... 79methylergonovine maleate tab 0.2 mg......................81methylphenidate hcl tab 10 mg..................................72methylphenidate hcl tab 20 mg..................................72methylphenidate hcl tab 5 mg....................................72methylphenidate hcl tab er 20 mg............................. 72methylprednisolone sod succ for inj 1000

mg................................................................................82methylprednisolone sod succ for inj 125

mg................................................................................82methylprednisolone sod succ for inj 40

mg................................................................................82methylprednisolone tab 16 mg...................................82methylprednisolone tab 32 mg...................................82methylprednisolone tab 4 mg.....................................82methylprednisolone tab 8 mg.....................................82methylprednisolone tab therapy pack 4 mg

(21)..............................................................................82methyltestosterone cap 10 mg...................................84metoclopramide hcl inj 5 mg/ml................................. 22metoclopramide hcl inj 5 mg/ml................................. 79metoclopramide hcl soln 5 mg/5ml (10

mg/10ml).....................................................................22metoclopramide hcl soln 5 mg/5ml (10

mg/10ml).....................................................................79metoclopramide hcl tab 10 mg...................................22

metoclopramide hcl tab 10 mg...................................79metoclopramide hcl tab 5 mg.....................................22metoclopramide hcl tab 5 mg.....................................79metolazone tab 10 mg................................................ 65metolazone tab 2.5 mg............................................... 65metolazone tab 5 mg...................................................65metoprolol & hydrochlorothiazide tab 100-25

mg................................................................................65metoprolol & hydrochlorothiazide tab 50-25

mg................................................................................65metoprolol succinate tab er 24hr 100

mg................................................................................65metoprolol succinate tab er 24hr 200

mg................................................................................65metoprolol succinate tab er 24hr 25

mg................................................................................65metoprolol succinate tab er 24hr 50

mg................................................................................65metoprolol tartrate tab 100 mg...................................65metoprolol tartrate tab 25 mg.....................................65metoprolol tartrate tab 50 mg.....................................65METRO IV.....................................................................10metronidazole cap 375 mg.........................................10metronidazole cream 0.75%.......................................75metronidazole gel 0.75%............................................ 75metronidazole gel 1%..................................................75metronidazole in nacl 0.79% iv soln 500

mg/100ml....................................................................10metronidazole lotion 0.75%........................................ 75metronidazole tab 250 mg..........................................10metronidazole tab 500 mg..........................................10metronidazole vaginal gel 0.75%...............................10mexiletine hcl cap 150 mg..........................................65mexiletine hcl cap 200 mg..........................................65mexiletine hcl cap 250 mg..........................................66MIACALCIN...................................................................93midodrine hcl tab 10 mg............................................. 66midodrine hcl tab 2.5 mg............................................ 66midodrine hcl tab 5 mg............................................... 66MIGERGOT...................................................................26MIGRANAL....................................................................26minocycline hcl cap 100 mg.......................................10minocycline hcl cap 50 mg......................................... 10minocycline hcl cap 75 mg......................................... 10minocycline hcl tab 100 mg........................................10minocycline hcl tab 50 mg..........................................10minocycline hcl tab 75 mg..........................................10minoxidil tab 10 mg..................................................... 66minoxidil tab 2.5 mg.................................................... 66mirtazapine orally disintegrating tab 15

mg................................................................................19

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mirtazapine orally disintegrating tab 30mg................................................................................19

mirtazapine orally disintegrating tab 45mg................................................................................19

mirtazapine tab 15 mg................................................ 20mirtazapine tab 30 mg................................................ 20mirtazapine tab 45 mg................................................ 20mirtazapine tab 7.5 mg............................................... 19misoprostol tab 100 mcg............................................ 79misoprostol tab 200 mcg............................................ 79MITOMYCIN..................................................................34mitomycin for iv soln 20 mg....................................... 34mitomycin for iv soln 40 mg....................................... 34mitoxantrone hcl inj conc 20 mg/10ml (2 mg/

ml)................................................................................34mitoxantrone hcl inj conc 20 mg/10ml (2 mg/

ml)................................................................................72mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/

ml)................................................................................34mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/

ml)................................................................................72mitoxantrone hcl inj conc 30 mg/15ml (2 mg/

ml)................................................................................34mitoxantrone hcl inj conc 30 mg/15ml (2 mg/

ml)................................................................................72M-M-R II........................................................................ 90modafinil tab 100 mg.................................................101modafinil tab 200 mg.................................................101moexipril hcl tab 15 mg...............................................66moexipril hcl tab 7.5 mg..............................................66moexipril-hydrochlorothiazide tab 15-12.5

mg................................................................................66moexipril-hydrochlorothiazide tab 15-25

mg................................................................................66moexipril-hydrochlorothiazide tab 7.5-12.5

mg................................................................................66mometasone furoate cream 0.1%............................. 75mometasone furoate nasal susp 50 mcg/

act................................................................................99mometasone furoate oint 0.1%..................................75mometasone furoate solution 0.1%

(lotion).........................................................................75montelukast sodium chew tab 4 mg..........................99montelukast sodium chew tab 5 mg..........................99montelukast sodium oral granules packet 4

mg................................................................................99montelukast sodium tab 10 mg..................................99MORPHINE SULFATE.................................................. 3MORPHINE SULFATE.................................................. 3morphine sulfate inj pf 0.5 mg/ml.................................3morphine sulfate inj pf 1 mg/ml....................................3

morphine sulfate oral soln 100 mg/5ml (20 mg/ml)..................................................................................3

morphine sulfate oral soln 10 mg/5ml......................... 3morphine sulfate oral soln 20 mg/5ml......................... 3morphine sulfate tab er 100 mg...................................3morphine sulfate tab er 15 mg..................................... 3morphine sulfate tab er 200 mg...................................3morphine sulfate tab er 30 mg..................................... 3morphine sulfate tab er 60 mg..................................... 3MOVIPREP................................................................... 79MOXEZA........................................................................95moxifloxacin hcl 400 mg/250ml in sodium chloride

0.8% inj.......................................................................10moxifloxacin hcl ophth soln 0.5%.............................. 95moxifloxacin hcl tab 400 mg.......................................10MOZOBIL...................................................................... 58MULTAQ........................................................................ 66mupirocin oint 2%........................................................ 75MUSTARGEN............................................................... 34MYALEPT...................................................................... 82MYCAMINE...................................................................23MYCAMINE...................................................................23mycophenolate mofetil cap 250 mg...........................91mycophenolate mofetil for oral susp 200 mg/

ml.................................................................................91mycophenolate mofetil hcl for iv soln 500

mg................................................................................91mycophenolate mofetil tab 500 mg........................... 91mycophenolate sodium tab dr 180 mg......................91mycophenolate sodium tab dr 360 mg......................91MYLOTARG.................................................................. 34Nnabumetone tab 500 mg...............................................3nabumetone tab 500 mg.............................................25nabumetone tab 750 mg...............................................3nabumetone tab 750 mg.............................................25nadolol tab 20 mg........................................................66nadolol tab 40 mg........................................................66nadolol tab 80 mg........................................................66NAFCILLIN SODIUM...................................................10NAFCILLIN SODIUM...................................................10nafcillin sodium for inj 10 gm......................................11nafcillin sodium for inj 1 gm........................................11nafcillin sodium for inj 2 gm........................................11NAGLAZYME................................................................77NALOXONE HCL........................................................... 4NALOXONE HCL........................................................... 4naloxone hcl inj 0.4 mg/ml............................................4naloxone hcl inj 4 mg/10ml...........................................5naltrexone hcl tab 50 mg.............................................. 5naproxen sodium tab 275 mg.......................................3

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naproxen sodium tab 275 mg.................................... 25naproxen sodium tab 550 mg.......................................3naproxen sodium tab 550 mg.................................... 25naproxen susp 125 mg/5ml.......................................... 3naproxen susp 125 mg/5ml........................................25naproxen tab 250 mg.................................................... 3naproxen tab 250 mg.................................................. 25naproxen tab 375 mg.................................................... 3naproxen tab 375 mg.................................................. 25naproxen tab 500 mg.................................................... 3naproxen tab 500 mg.................................................. 25naproxen tab ec 375 mg...............................................3naproxen tab ec 375 mg.............................................25naproxen tab ec 500 mg...............................................3naproxen tab ec 500 mg.............................................25naratriptan hcl tab 1 mg..............................................26naratriptan hcl tab 2.5 mg...........................................26NARCAN..........................................................................5NATACYN......................................................................95nateglinide tab 120 mg............................................... 55nateglinide tab 60 mg..................................................55NATPARA...................................................................... 86NATPARA...................................................................... 86NATPARA...................................................................... 86NATPARA...................................................................... 86NEBUPENT...................................................................38NEFAZODONE HCL....................................................20NEFAZODONE HCL....................................................20NEFAZODONE HCL....................................................20nefazodone hcl tab 250 mg........................................20nefazodone hcl tab 50 mg..........................................20neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oin..........................95neomycin-polymy-gramicid op sol

1.75-10000-0.025mg-unt-mg/ml............................. 95neomycin-polymyxin b gu irrigation

soln..............................................................................11neomycin-polymyxin b gu irrigation

soln..............................................................................81neomycin-polymyxin-dexamethasone ophth oint

0.1%............................................................................95neomycin-polymyxin-dexamethasone ophth susp

0.1%............................................................................95neomycin-polymyxin-hc otic soln 1%........................ 96neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000

unit/ml-1%.................................................................. 96neomycin sulfate tab 500 mg.....................................11NERLYNX......................................................................34NEULASTA....................................................................58NEULASTA ONPRO KIT............................................ 58NEUPOGEN..................................................................58NEUPOGEN..................................................................58

NEUPOGEN..................................................................58NEUPOGEN..................................................................58NEUPRO....................................................................... 39NEUPRO....................................................................... 39NEUPRO....................................................................... 39NEUPRO....................................................................... 39NEUPRO....................................................................... 39NEUPRO....................................................................... 39NEVIRAPINE................................................................ 46nevirapine tab 200 mg................................................ 46nevirapine tab er 24hr 100 mg...................................46nevirapine tab er 24hr 400 mg...................................46NEXAVAR......................................................................34NEXIUM.........................................................................79NEXIUM.........................................................................79NEXIUM.........................................................................79NEXIUM.........................................................................79NEXIUM.........................................................................79niacin tab er 1000 mg................................................. 66niacin tab er 500 mg................................................... 66niacin tab er 750 mg................................................... 66nicardipine hcl cap 20 mg...........................................66nicardipine hcl cap 30 mg...........................................66NICOTROL INHALER................................................... 5NICOTROL NS............................................................... 5nifedipine tab er 24hr 30 mg...................................... 66nifedipine tab er 24hr 60 mg...................................... 66nifedipine tab er 24hr 90 mg...................................... 66nifedipine tab er 24hr osmotic release 30

mg................................................................................66nifedipine tab er 24hr osmotic release 60

mg................................................................................66nifedipine tab er 24hr osmotic release 90

mg................................................................................66NILANDRON.................................................................34nilutamide tab 150 mg.................................................34NINLARO.......................................................................34NINLARO.......................................................................34NINLARO.......................................................................34NIPENT..........................................................................34NISOLDIPINE ER........................................................ 66nisoldipine tab er 24hr 17 mg.................................... 66nisoldipine tab er 24hr 34 mg.................................... 66nisoldipine tab er 24hr 8.5 mg................................... 66NITRO-BID....................................................................66nitrofurantoin macrocrystalline cap 100

mg................................................................................11nitrofurantoin macrocrystalline cap 50

mg................................................................................11nitrofurantoin monohydrate macrocrystalline cap 100

mg................................................................................11nitrofurantoin susp 25 mg/5ml....................................11

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nitroglycerin sl tab 0.3 mg.......................................... 66nitroglycerin sl tab 0.4 mg.......................................... 66nitroglycerin sl tab 0.6 mg.......................................... 66nitroglycerin td patch 24hr 0.1 mg/hr.........................66nitroglycerin td patch 24hr 0.2 mg/hr.........................66nitroglycerin td patch 24hr 0.4 mg/hr.........................66nitroglycerin td patch 24hr 0.6 mg/hr.........................66nitroglycerin tl soln 0.4 mg/spray (400 mcg/

spray)..........................................................................67NITROSTAT.................................................................. 67NITROSTAT.................................................................. 67NITROSTAT.................................................................. 67nizatidine cap 150 mg.................................................79nizatidine cap 300 mg.................................................79norethindrone & ethinyl estradiol-fe chew tab 0.4

mg-35 mcg.................................................................84norethindrone & ethinyl estradiol-fe chew tab 0.8

mg-25 mcg.................................................................84norethindrone & ethinyl estradiol tab 0.4 mg-35

mcg..............................................................................84norethindrone & ethinyl estradiol tab 0.5 mg-35

mcg..............................................................................84norethindrone & ethinyl estradiol tab 1 mg-35

mcg..............................................................................84norethindrone ace & ethinyl estradiol-fe tab 1.5

mg-30 mcg.................................................................84norethindrone ace & ethinyl estradiol-fe tab 1 mg-20

mcg..............................................................................84norethindrone ace & ethinyl estradiol tab 1.5 mg-30

mcg..............................................................................84norethindrone ace & ethinyl estradiol tab 1 mg-20

mcg..............................................................................84norethindrone ace-ethinyl estradiol-fe tab 1 mg-20

mcg (24).....................................................................84norethindrone acetate tab 5 mg.................................84norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35

mg-mcg.......................................................................84norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35

mg-mcg.......................................................................84norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35

mg-mcg.......................................................................84norethindrone tab 0.35 mg......................................... 84norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg..............................................................................85norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg.........................85norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg.........................85norgestrel & ethinyl estradiol tab 0.3 mg-30

mcg..............................................................................85NORMOSOL-M IN D5W...........................................102NORTHERA.................................................................. 67

NORTHERA.................................................................. 67NORTHERA.................................................................. 67NORTRIPTYLINE HCL............................................... 20nortriptyline hcl cap 10 mg......................................... 20nortriptyline hcl cap 25 mg......................................... 20nortriptyline hcl cap 50 mg......................................... 20nortriptyline hcl cap 75 mg......................................... 20NORVIR.........................................................................46NORVIR.........................................................................46NORVIR.........................................................................46NOXAFIL....................................................................... 23NOXAFIL....................................................................... 23NOXAFIL....................................................................... 23NUEDEXTA...................................................................72NULOJIX........................................................................91NUPLAZID.....................................................................39NUPLAZID.....................................................................41nystatin cream 100000 unit/gm..................................75nystatin oint 100000 unit/gm...................................... 75nystatin susp 100000 unit/ml......................................23nystatin tab 500000 unit..............................................24nystatin topical powder 100000 unit/

gm................................................................................75nystatin-triamcinolone cream 100000-0.1 unit/gm-

%..................................................................................75nystatin-triamcinolone oint 100000-0.1 unit/gm-

%..................................................................................75OOCALIVA....................................................................... 79OCALIVA....................................................................... 79octreotide acetate inj 1000 mcg/ml (1 mg/

ml)................................................................................87octreotide acetate inj 100 mcg/ml (0.1 mg/

ml)................................................................................87octreotide acetate inj 200 mcg/ml (0.2 mg/

ml)................................................................................87octreotide acetate inj 500 mcg/ml (0.5 mg/

ml)................................................................................87octreotide acetate inj 50 mcg/ml (0.05 mg/

ml)................................................................................87ODEFSEY..................................................................... 46ODOMZO...................................................................... 34OFEV............................................................................. 99OFEV............................................................................. 99ofloxacin ophth soln 0.3%...........................................95ofloxacin otic soln 0.3%.............................................. 96ofloxacin tab 400 mg...................................................11olanzapine for im inj 10 mg........................................ 41olanzapine for im inj 10 mg........................................ 51olanzapine orally disintegrating tab 10

mg................................................................................42

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olanzapine orally disintegrating tab 10mg................................................................................52

olanzapine orally disintegrating tab 15mg................................................................................42

olanzapine orally disintegrating tab 15mg................................................................................52

olanzapine orally disintegrating tab 20mg................................................................................42

olanzapine orally disintegrating tab 20mg................................................................................52

olanzapine orally disintegrating tab 5mg................................................................................41

olanzapine orally disintegrating tab 5mg................................................................................51

olanzapine tab 10 mg..................................................42olanzapine tab 10 mg..................................................52olanzapine tab 15 mg..................................................42olanzapine tab 15 mg..................................................52olanzapine tab 2.5 mg.................................................42olanzapine tab 2.5 mg.................................................52olanzapine tab 20 mg..................................................42olanzapine tab 20 mg..................................................52olanzapine tab 5 mg....................................................42olanzapine tab 5 mg....................................................52olanzapine tab 7.5 mg.................................................42olanzapine tab 7.5 mg.................................................52olopatadine hcl nasal soln 0.6%................................ 99olopatadine hcl ophth soln 0.1%................................95olopatadine hcl ophth soln 0.2%................................95OLYSIO..........................................................................46omega-3-acid ethyl esters cap 1 gm.........................67omeprazole cap delayed release 10

mg................................................................................79omeprazole cap delayed release 20

mg................................................................................79omeprazole cap delayed release 40

mg................................................................................79OMNITROPE................................................................ 83OMNITROPE................................................................ 83OMNITROPE................................................................ 83ONCASPAR.................................................................. 34ondansetron hcl inj 40 mg/20ml (2 mg/

ml)................................................................................22ondansetron hcl inj 4 mg/2ml (2 mg/

ml)................................................................................22ondansetron hcl oral soln 4 mg/5ml.......................... 22ondansetron hcl tab 24 mg.........................................22ondansetron hcl tab 4 mg...........................................22ondansetron hcl tab 8 mg...........................................22ondansetron orally disintegrating tab 4

mg................................................................................22

ondansetron orally disintegrating tab 8mg................................................................................22

ONFI...............................................................................15ONFI...............................................................................15ONFI...............................................................................15ONGLYZA......................................................................55ONGLYZA......................................................................55ONIVYDE...................................................................... 34OPDIVO.........................................................................34OPDIVO.........................................................................34OPSUMIT...................................................................... 99ORACEA........................................................................75ORALAIR.......................................................................99ORENCIA...................................................................... 91ORENCIA...................................................................... 91ORENCIA...................................................................... 91ORENCIA...................................................................... 91ORENCIA CLICKJECT............................................... 91ORFADIN.......................................................................77ORFADIN.......................................................................77ORFADIN.......................................................................77ORFADIN.......................................................................77ORFADIN.......................................................................77ORKAMBI......................................................................99ORKAMBI......................................................................99oseltamivir phosphate cap 30 mg..............................46oseltamivir phosphate cap 45 mg..............................46oseltamivir phosphate cap 75 mg..............................46oxaliplatin for iv inj 100 mg.........................................34oxaliplatin for iv inj 50 mg...........................................34oxaliplatin iv soln 100 mg/20ml..................................34oxaliplatin iv soln 50 mg/10ml....................................34oxandrolone tab 10 mg............................................... 85oxandrolone tab 2.5 mg..............................................85oxaprozin tab 600 mg....................................................3oxaprozin tab 600 mg................................................. 25oxcarbazepine susp 300 mg/5ml (60 mg/

ml)................................................................................15oxcarbazepine tab 150 mg.........................................15oxcarbazepine tab 300 mg.........................................15oxcarbazepine tab 600 mg.........................................15oxybutynin chloride syrup 5 mg/5ml..........................81oxybutynin chloride tab 5 mg..................................... 81oxybutynin chloride tab er 24hr 10 mg......................81oxybutynin chloride tab er 24hr 15 mg......................81oxybutynin chloride tab er 24hr 5 mg........................81oxycodone-aspirin tab 4.8355-325 mg........................3oxycodone hcl tab 10 mg..............................................3oxycodone hcl tab 15 mg..............................................3oxycodone hcl tab 20 mg..............................................3oxycodone hcl tab 30 mg..............................................3oxycodone hcl tab 5 mg................................................3

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oxycodone w/ acetaminophen tab 10-325mg..................................................................................3

oxycodone w/ acetaminophen tab 2.5-325mg..................................................................................3

oxycodone w/ acetaminophen tab 5-325mg..................................................................................3

oxycodone w/ acetaminophen tab 7.5-325mg..................................................................................3

Ppaclitaxel iv conc 100 mg/16.7ml (6 mg/

ml)................................................................................34paclitaxel iv conc 300 mg/50ml (6 mg/

ml)................................................................................34paclitaxel iv conc 30 mg/5ml (6 mg/ml).....................34paliperidone tab er 24hr 1.5 mg.................................42paliperidone tab er 24hr 3 mg....................................42paliperidone tab er 24hr 6 mg....................................42paliperidone tab er 24hr 9 mg....................................42PANRETIN.....................................................................34pantoprazole sodium ec tab 20 mg........................... 79pantoprazole sodium ec tab 40 mg........................... 79pantoprazole sodium for iv soln 40 mg..................... 79paricalcitol cap 1 mcg................................................. 94paricalcitol cap 2 mcg................................................. 94paricalcitol cap 4 mcg................................................. 94paricalcitol iv soln 2 mcg/ml....................................... 94paricalcitol iv soln 5 mcg/ml....................................... 94paromomycin sulfate cap 250 mg..............................11paroxetine hcl tab 10 mg............................................ 20paroxetine hcl tab 10 mg............................................ 50paroxetine hcl tab 20 mg............................................ 20paroxetine hcl tab 20 mg............................................ 50paroxetine hcl tab 30 mg............................................ 20paroxetine hcl tab 30 mg............................................ 50paroxetine hcl tab 40 mg............................................ 20paroxetine hcl tab 40 mg............................................ 50PASER........................................................................... 27PATADAY.......................................................................95PAXIL............................................................................. 20PAXIL............................................................................. 50PAZEO........................................................................... 95PEDVAX HIB................................................................ 91peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236

gm................................................................................79peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240

gm................................................................................79peg 3350-kcl-sod bicarb-nacl for soln 420

gm................................................................................79PEGANONE..................................................................15PEGASYS..................................................................... 46PEGASYS..................................................................... 46

PEGASYS PROCLICK................................................46PEGASYS PROCLICK................................................46PEGINTRON.................................................................47PEGINTRON.................................................................47PEGINTRON.................................................................47PEGINTRON.................................................................47PEG-INTRON REDIPEN............................................ 46PEG-INTRON REDIPEN PAK 4................................ 46penicillin g potassium for inj 20000000

unit...............................................................................11penicillin g potassium for inj 5000000

unit...............................................................................11PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 11PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 11PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 11PENICILLIN G SODIUM............................................. 11penicillin v potassium for soln 125

mg/5ml........................................................................ 11penicillin v potassium for soln 250

mg/5ml........................................................................ 11penicillin v potassium tab 250 mg............................. 11penicillin v potassium tab 500 mg............................. 11PENTACEL....................................................................91PENTAM 300................................................................38PENTASA...................................................................... 93PENTASA...................................................................... 93pentoxifylline tab er 400 mg....................................... 67perindopril erbumine tab 2 mg................................... 67perindopril erbumine tab 4 mg................................... 67perindopril erbumine tab 8 mg................................... 67PERJETA.......................................................................34permethrin cream 5%..................................................38perphenazine tab 16 mg.............................................22perphenazine tab 16 mg.............................................42perphenazine tab 2 mg............................................... 22perphenazine tab 2 mg............................................... 42perphenazine tab 4 mg............................................... 22perphenazine tab 4 mg............................................... 42perphenazine tab 8 mg............................................... 22perphenazine tab 8 mg............................................... 42phenelzine sulfate tab 15 mg.....................................20PHENOBARBITAL....................................................... 15PHENOBARBITAL....................................................... 15PHENOBARBITAL....................................................... 15PHENOBARBITAL....................................................... 15phenobarbital elixir 20 mg/5ml...................................15PHENOBARBITAL SODIUM...................................... 15PHENOBARBITAL SODIUM...................................... 15phenobarbital tab 16.2 mg..........................................15

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phenobarbital tab 32.4 mg..........................................15phenobarbital tab 64.8 mg..........................................15phenobarbital tab 97.2 mg..........................................15phenoxybenzamine hcl cap 10 mg............................67phenytoin chew tab 50 mg......................................... 16phenytoin sodium extended cap 100

mg................................................................................16phenytoin sodium extended cap 200

mg................................................................................16phenytoin sodium extended cap 300

mg................................................................................16phenytoin susp 125 mg/5ml....................................... 16PHOSLYRA...................................................................81PHOSPHOLINE IODIDE.............................................95PICATO..........................................................................75PICATO..........................................................................75pilocarpine hcl ophth soln 1%.................................... 95pilocarpine hcl ophth soln 2%.................................... 95pilocarpine hcl ophth soln 4%.................................... 95pilocarpine hcl tab 5 mg..............................................73pilocarpine hcl tab 7.5 mg.......................................... 73pimozide tab 1 mg....................................................... 42pimozide tab 2 mg....................................................... 42pindolol tab 10 mg....................................................... 67pindolol tab 5 mg......................................................... 67pioglitazone hcl-glimepiride tab 30-2

mg................................................................................55pioglitazone hcl-glimepiride tab 30-4

mg................................................................................55pioglitazone hcl-metformin hcl tab 15-500

mg................................................................................55pioglitazone hcl-metformin hcl tab 15-850

mg................................................................................55pioglitazone hcl tab 15 mg..........................................55pioglitazone hcl tab 30 mg..........................................55pioglitazone hcl tab 45 mg..........................................55piperacillin sod-tazobactam na for inj 3.375 gm

(3-0.375 gm)..............................................................11piperacillin sod-tazobactam sod for inj 2.25 gm

(2-0.25 gm)................................................................ 11piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5

gm).............................................................................. 11piroxicam cap 10 mg..................................................... 3piroxicam cap 10 mg...................................................25piroxicam cap 20 mg..................................................... 3piroxicam cap 20 mg...................................................25PLEGRIDY.................................................................... 72PLEGRIDY.................................................................... 72PLEGRIDY STARTER PACK..................................... 72PLEGRIDY STARTER PACK..................................... 72podofilox soln 0.5%..................................................... 75polyethylene glycol 3350 oral packet........................ 79

polyethylene glycol 3350 oral powder.......................79polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%...................................................................... 95POMALYST...................................................................34POMALYST...................................................................34POMALYST...................................................................34POMALYST...................................................................34PORTRAZZA................................................................ 34POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS.................................................................103POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS.................................................................103potassium chloride 20 meq/l (0.15%) in dextrose 5%

inj...............................................................................103potassium chloride 40 meq/l (0.3%) in dextrose 5%

inj...............................................................................103potassium chloride cap er 10 meq.......................... 102potassium chloride cap er 8 meq............................ 102POTASSIUM CHLORIDE ER...................................102POTASSIUM CHLORIDE ER...................................102potassium chloride inj 2 meq/ml.............................. 103potassium chloride microencapsulated crys er tab 10

meq........................................................................... 103potassium chloride microencapsulated crys er tab 20

meq........................................................................... 103potassium chloride oral soln 10% (20

meq/15ml)................................................................ 103potassium chloride tab er 10 meq........................... 103potassium chloride tab er 8 meq (600

mg)............................................................................103potassium citrate tab er 10 meq (1080

mg)............................................................................103potassium citrate tab er 15 meq (1620

mg)............................................................................103potassium citrate tab er 5 meq (540

mg)............................................................................103PRADAXA..................................................................... 58PRADAXA..................................................................... 58PRADAXA..................................................................... 58PRALUENT................................................................... 67PRALUENT................................................................... 67pramipexole dihydrochloride tab 0.125

mg................................................................................39pramipexole dihydrochloride tab 0.25

mg................................................................................39pramipexole dihydrochloride tab 0.5

mg................................................................................39pramipexole dihydrochloride tab 0.75

mg................................................................................39pramipexole dihydrochloride tab 1.5

mg................................................................................39pramipexole dihydrochloride tab 1 mg...................... 39

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prasugrel hcl tab 10 mg..............................................58prasugrel hcl tab 5 mg................................................ 58pravastatin sodium tab 10 mg....................................67pravastatin sodium tab 20 mg....................................67pravastatin sodium tab 40 mg....................................67pravastatin sodium tab 80 mg....................................67prazosin hcl cap 1 mg.................................................67prazosin hcl cap 1 mg.................................................81prazosin hcl cap 2 mg.................................................67prazosin hcl cap 2 mg.................................................81prazosin hcl cap 5 mg.................................................67prazosin hcl cap 5 mg.................................................81prednicarbate cream 0.1%......................................... 76prednicarbate oint 0.1%..............................................76prednisolone acetate ophth susp 1%........................95prednisolone sod phosphate oral soln 15

mg/5ml........................................................................ 82prednisolone sod phosph oral soln 6.7 mg/5ml (5

mg/5ml base).............................................................82prednisolone syrup 15 mg/5ml...................................82PREDNISONE.............................................................. 82PREDNISONE.............................................................. 82PREDNISONE.............................................................. 82PREDNISONE.............................................................. 82PREDNISONE.............................................................. 82PREDNISONE.............................................................. 82prednisone tab 10 mg................................................. 82prednisone tab 1 mg................................................... 82prednisone tab 2.5 mg................................................ 82prednisone tab 20 mg................................................. 82prednisone tab 5 mg................................................... 82PREMARIN................................................................... 85PREMPHASE............................................................... 85PREMPRO.................................................................... 85PREMPRO.................................................................... 85PREMPRO.................................................................... 85PREMPRO.................................................................... 85PREZCOBIX................................................................. 47PREZISTA..................................................................... 47PREZISTA..................................................................... 47PREZISTA..................................................................... 47PREZISTA..................................................................... 47PREZISTA..................................................................... 47PRIFTIN.........................................................................27PRIMAQUINE PHOSPHATE......................................38primidone tab 250 mg................................................. 16primidone tab 50 mg................................................... 16PRISTIQ........................................................................ 20PRISTIQ........................................................................ 20PRISTIQ........................................................................ 20PROAIR HFA................................................................99PROAIR RESPICLICK................................................ 99

probenecid tab 500 mg............................................... 24prochlorperazine edisylate inj 5 mg/ml......................22prochlorperazine edisylate inj 5 mg/ml......................42prochlorperazine maleate tab 10 mg.........................22prochlorperazine maleate tab 10 mg.........................42prochlorperazine maleate tab 5 mg...........................22prochlorperazine maleate tab 5 mg...........................42prochlorperazine suppos 25 mg................................ 22prochlorperazine suppos 25 mg................................ 42PROCRIT...................................................................... 58PROCRIT...................................................................... 58PROCRIT...................................................................... 58PROCRIT...................................................................... 58PROCRIT...................................................................... 58PROCRIT...................................................................... 58PROGLYCEM............................................................... 55PROGRAF.....................................................................91PROLASTIN-C..............................................................99PROLENSA...................................................................95PROLEUKIN................................................................. 34PROLIA..........................................................................94PROMACTA.................................................................. 58PROMACTA.................................................................. 58PROMACTA.................................................................. 58PROMACTA.................................................................. 58promethazine hcl suppos 12.5 mg............................ 23promethazine hcl suppos 12.5 mg............................ 99promethazine hcl suppos 25 mg................................23promethazine hcl suppos 25 mg................................99promethazine hcl syrup 6.25 mg/5ml........................ 23promethazine hcl syrup 6.25 mg/5ml........................ 99promethazine hcl tab 12.5 mg....................................23promethazine hcl tab 12.5 mg....................................99promethazine hcl tab 25 mg.......................................23promethazine hcl tab 25 mg.......................................99promethazine hcl tab 50 mg.......................................23promethazine hcl tab 50 mg.......................................99propafenone hcl cap er 12hr 225 mg........................ 67propafenone hcl cap er 12hr 325 mg........................ 67propafenone hcl cap er 12hr 425 mg........................ 67propafenone hcl tab 150 mg...................................... 67propafenone hcl tab 225 mg...................................... 67propafenone hcl tab 300 mg...................................... 67propranolol hcl cap er 24hr 120 mg.......................... 26propranolol hcl cap er 24hr 120 mg.......................... 67propranolol hcl cap er 24hr 160 mg.......................... 26propranolol hcl cap er 24hr 160 mg.......................... 67propranolol hcl cap er 24hr 60 mg.............................26propranolol hcl cap er 24hr 60 mg.............................67propranolol hcl cap er 24hr 80 mg.............................26propranolol hcl cap er 24hr 80 mg.............................67propranolol hcl inj 1 mg/ml......................................... 26

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propranolol hcl inj 1 mg/ml......................................... 67propranolol hcl tab 10 mg...........................................26propranolol hcl tab 10 mg...........................................67propranolol hcl tab 20 mg...........................................26propranolol hcl tab 20 mg...........................................67propranolol hcl tab 40 mg...........................................26propranolol hcl tab 40 mg...........................................67propranolol hcl tab 60 mg...........................................26propranolol hcl tab 60 mg...........................................68propranolol hcl tab 80 mg...........................................26propranolol hcl tab 80 mg...........................................68propylthiouracil tab 50 mg.......................................... 88PROQUAD.................................................................... 91protriptyline hcl tab 10 mg.......................................... 20protriptyline hcl tab 5 mg............................................ 20PULMOZYME............................................................... 99PURIXAN.......................................................................34PYLERA.........................................................................80pyrazinamide tab 500 mg........................................... 27pyridostigmine bromide tab 60 mg............................ 27pyridostigmine bromide tab er 180 mg......................27QQUADRACEL................................................................91quetiapine fumarate tab 100 mg................................20quetiapine fumarate tab 100 mg................................42quetiapine fumarate tab 100 mg................................52quetiapine fumarate tab 200 mg................................20quetiapine fumarate tab 200 mg................................42quetiapine fumarate tab 200 mg................................52quetiapine fumarate tab 25 mg..................................20quetiapine fumarate tab 25 mg..................................42quetiapine fumarate tab 25 mg..................................52quetiapine fumarate tab 300 mg................................20quetiapine fumarate tab 300 mg................................42quetiapine fumarate tab 300 mg................................52quetiapine fumarate tab 400 mg................................20quetiapine fumarate tab 400 mg................................42quetiapine fumarate tab 400 mg................................52quetiapine fumarate tab 50 mg..................................20quetiapine fumarate tab 50 mg..................................42quetiapine fumarate tab 50 mg..................................52quinapril hcl tab 10 mg............................................... 68quinapril hcl tab 20 mg............................................... 68quinapril hcl tab 40 mg............................................... 68quinapril hcl tab 5 mg..................................................68quinapril-hydrochlorothiazide tab 10-12.5

mg................................................................................68quinapril-hydrochlorothiazide tab 20-12.5

mg................................................................................68quinapril-hydrochlorothiazide tab 20-25

mg................................................................................68

quinidine gluconate tab er 324 mg............................ 68QUINIDINE SULFATE................................................. 68QUINIDINE SULFATE................................................. 68QVAR........................................................................... 100QVAR........................................................................... 100RRABAVERT................................................................... 91RAGWITEK.................................................................100raloxifene hcl tab 60 mg............................................. 85ramipril cap 1.25 mg....................................................68ramipril cap 10 mg.......................................................68ramipril cap 2.5 mg......................................................68ramipril cap 5 mg.........................................................68RANEXA........................................................................68RANEXA........................................................................68ranitidine hcl cap 150 mg........................................... 80ranitidine hcl cap 300 mg........................................... 80ranitidine hcl syrup 15 mg/ml (75

mg/5ml).......................................................................80ranitidine hcl tab 150 mg............................................ 80ranitidine hcl tab 300 mg............................................ 80RAPAFLO...................................................................... 81RAPAFLO...................................................................... 81RAPAMUNE.................................................................. 91rasagiline mesylate tab 0.5 mg.................................. 39rasagiline mesylate tab 1 mg..................................... 39REBETOL......................................................................47RECOMBIVAX HB....................................................... 91RECOMBIVAX HB....................................................... 91RECOMBIVAX HB....................................................... 91REGRANEX.................................................................. 76RELISTOR.....................................................................80RELISTOR.....................................................................80RELISTOR.....................................................................80REMICADE................................................................... 91REMODULIN.............................................................. 100REMODULIN.............................................................. 100REMODULIN.............................................................. 100REMODULIN.............................................................. 100RENVELA......................................................................81RENVELA......................................................................81RENVELA......................................................................81repaglinide tab 0.5 mg................................................ 55repaglinide tab 1 mg....................................................55repaglinide tab 2 mg....................................................55REPATHA...................................................................... 68REPATHA PUSHTRONEX SYSTEM........................68REPATHA SURECLICK.............................................. 68RESCRIPTOR.............................................................. 47RESCRIPTOR.............................................................. 47RESTASIS.....................................................................95RESTASIS MULTIDOSE.............................................96

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RETROVIR IV INFUSION...........................................47REVLIMID......................................................................35REVLIMID......................................................................35REVLIMID......................................................................35REVLIMID......................................................................35REVLIMID......................................................................35REVLIMID......................................................................35REXULTI........................................................................20REXULTI........................................................................20REXULTI........................................................................20REXULTI........................................................................20REXULTI........................................................................20REXULTI........................................................................20REXULTI........................................................................42REXULTI........................................................................42REXULTI........................................................................42REXULTI........................................................................42REXULTI........................................................................42REXULTI........................................................................42REYATAZ.......................................................................47REYATAZ.......................................................................47REYATAZ.......................................................................47REYATAZ.......................................................................47RIBASPHERE...............................................................47RIBASPHERE...............................................................47RIBASPHERE RIBAPAK.............................................47RIBASPHERE RIBAPAK.............................................47ribavirin cap 200 mg....................................................47ribavirin for inhal soln 6 gm........................................ 47ribavirin tab 200 mg.....................................................47RIDAURA...................................................................... 91rifabutin cap 150 mg....................................................27rifampin cap 150 mg....................................................27rifampin cap 300 mg....................................................27rifampin for inj 600 mg................................................ 27riluzole tab 50 mg........................................................ 72rimantadine hydrochloride tab 100 mg......................47risedronate sodium tab 150 mg................................. 94risedronate sodium tab 30 mg................................... 94risedronate sodium tab 35 mg................................... 94risedronate sodium tab 5 mg..................................... 94risedronate sodium tab delayed release 35

mg................................................................................94RISPERDAL CONSTA................................................ 42RISPERDAL CONSTA................................................ 42RISPERDAL CONSTA................................................ 42RISPERDAL CONSTA................................................ 43RISPERDAL CONSTA................................................ 52RISPERDAL CONSTA................................................ 52RISPERDAL CONSTA................................................ 52RISPERDAL CONSTA................................................ 52

risperidone orally disintegrating tab 0.25mg................................................................................43

risperidone orally disintegrating tab 0.25mg................................................................................52

risperidone orally disintegrating tab 0.5mg................................................................................43

risperidone orally disintegrating tab 0.5mg................................................................................52

risperidone orally disintegrating tab 1mg................................................................................43

risperidone orally disintegrating tab 1mg................................................................................52

risperidone orally disintegrating tab 2mg................................................................................43

risperidone orally disintegrating tab 2mg................................................................................52

risperidone orally disintegrating tab 3mg................................................................................43

risperidone orally disintegrating tab 3mg................................................................................52

risperidone orally disintegrating tab 4mg................................................................................43

risperidone orally disintegrating tab 4mg................................................................................52

risperidone soln 1 mg/ml............................................ 43risperidone soln 1 mg/ml............................................ 52risperidone tab 0.25 mg..............................................43risperidone tab 0.25 mg..............................................52risperidone tab 0.5 mg................................................ 43risperidone tab 0.5 mg................................................ 52risperidone tab 1 mg................................................... 43risperidone tab 1 mg................................................... 52risperidone tab 2 mg................................................... 43risperidone tab 2 mg................................................... 52risperidone tab 3 mg................................................... 43risperidone tab 3 mg................................................... 52risperidone tab 4 mg................................................... 43risperidone tab 4 mg................................................... 52RITUXAN.......................................................................35RITUXAN.......................................................................35RITUXAN HYCELA......................................................35RITUXAN HYCELA......................................................35rivastigmine tartrate cap 1.5 mg................................ 17rivastigmine tartrate cap 3 mg....................................17rivastigmine tartrate cap 4.5 mg................................ 17rivastigmine tartrate cap 6 mg....................................17rivastigmine td patch 24hr 13.3

mg/24hr...................................................................... 17rivastigmine td patch 24hr 4.6 mg/24hr.....................17rivastigmine td patch 24hr 9.5 mg/24hr.....................17rizatriptan benzoate oral disintegrating tab 10

mg................................................................................26

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rizatriptan benzoate oral disintegrating tab 5mg................................................................................26

rizatriptan benzoate tab 10 mg.................................. 26rizatriptan benzoate tab 5 mg.................................... 26ropinirole hydrochloride tab 0.25 mg.........................39ropinirole hydrochloride tab 0.5 mg...........................39ropinirole hydrochloride tab 1 mg.............................. 39ropinirole hydrochloride tab 2 mg.............................. 39ropinirole hydrochloride tab 3 mg.............................. 39ropinirole hydrochloride tab 4 mg.............................. 39ropinirole hydrochloride tab 5 mg.............................. 39rosuvastatin calcium tab 10 mg................................. 68rosuvastatin calcium tab 20 mg................................. 68rosuvastatin calcium tab 40 mg................................. 68rosuvastatin calcium tab 5 mg................................... 68ROTARIX.......................................................................92ROTATEQ......................................................................92RUBRACA.....................................................................35RUBRACA.....................................................................35RUBRACA.....................................................................35RYDAPT........................................................................ 35SSABRIL.......................................................................... 16SABRIL.......................................................................... 16SAMSCA..................................................................... 103SAMSCA..................................................................... 103SANDIMMUNE............................................................. 92SANTYL.........................................................................76SAPHRIS.......................................................................43SAPHRIS.......................................................................43SAPHRIS.......................................................................43selegiline hcl cap 5 mg............................................... 39selegiline hcl tab 5 mg................................................ 39selenium sulfide lotion 2.5%.......................................76SELZENTRY.................................................................47SELZENTRY.................................................................47SELZENTRY.................................................................47SELZENTRY.................................................................47SELZENTRY.................................................................47SENSIPAR.....................................................................86SENSIPAR.....................................................................86SENSIPAR.....................................................................86SEREVENT DISKUS.................................................100sertraline hcl oral conc 20 mg/ml...............................20sertraline hcl oral conc 20 mg/ml...............................50sertraline hcl tab 100 mg............................................ 21sertraline hcl tab 100 mg............................................ 50sertraline hcl tab 25 mg.............................................. 20sertraline hcl tab 25 mg.............................................. 50sertraline hcl tab 50 mg.............................................. 21sertraline hcl tab 50 mg.............................................. 50

sevelamer carbonate packet 0.8 gm......................... 81sevelamer carbonate packet 2.4 gm......................... 81sevelamer carbonate tab 800 mg..............................81SIGNIFOR..................................................................... 87SIGNIFOR..................................................................... 87SIGNIFOR..................................................................... 87SIGNIFOR LAR............................................................87SIGNIFOR LAR............................................................87SIGNIFOR LAR............................................................87sildenafil citrate tab 20 mg....................................... 100SILENOR.....................................................................101SILENOR.....................................................................101silver sulfadiazine cream 1%......................................76SIMBRINZA...................................................................96SIMULECT.................................................................... 92SIMULECT.................................................................... 92simvastatin tab 10 mg.................................................68simvastatin tab 20 mg.................................................68simvastatin tab 40 mg.................................................68simvastatin tab 5 mg................................................... 68simvastatin tab 80 mg.................................................68sirolimus tab 0.5 mg.................................................... 92sirolimus tab 1 mg....................................................... 92sirolimus tab 2 mg....................................................... 92SIRTURO.......................................................................27SIVEXTRO.................................................................... 11SIVEXTRO.................................................................... 11sodium chloride inj 0.45%........................................ 103sodium chloride irrigation soln 0.9%....................... 103sodium chloride iv soln 0.9%................................... 103sodium phenylbutyrate oral powder 3 gm/

teaspoonful.................................................................77sodium phenylbutyrate tab 500 mg........................... 77sodium polystyrene sulfonate oral susp 15

gm/60ml....................................................................103sodium polystyrene sulfonate powder.....................103sodium polystyrene sulfonate rectal susp 30

gm/120ml................................................................. 103SOLTAMOX...................................................................35SOMATULINE DEPOT................................................87SOMATULINE DEPOT................................................87SOMATULINE DEPOT................................................87SOMAVERT.................................................................. 87SOMAVERT.................................................................. 87SOMAVERT.................................................................. 88SOMAVERT.................................................................. 88SOMAVERT.................................................................. 88SOOLANTRA................................................................76sotalol hcl tab 120 mg.................................................68sotalol hcl tab 160 mg.................................................68sotalol hcl tab 240 mg.................................................68sotalol hcl tab 80 mg...................................................68

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139

SOVALDI....................................................................... 47SPIRIVA HANDIHALER............................................100SPIRIVA RESPIMAT................................................. 100SPIRIVA RESPIMAT................................................. 100spironolactone & hydrochlorothiazide tab 25-25

mg................................................................................68spironolactone tab 100 mg.........................................69spironolactone tab 25 mg........................................... 68spironolactone tab 50 mg........................................... 69SPRITAM.......................................................................16SPRITAM.......................................................................16SPRITAM.......................................................................16SPRITAM.......................................................................16SPRYCEL......................................................................35SPRYCEL......................................................................35SPRYCEL......................................................................35SPRYCEL......................................................................35SPRYCEL......................................................................35SPRYCEL......................................................................35STAMARIL.....................................................................92stavudine cap 15 mg...................................................47stavudine cap 20 mg...................................................47stavudine cap 30 mg...................................................47stavudine cap 40 mg...................................................47STELARA...................................................................... 76STELARA...................................................................... 76STELARA...................................................................... 76STELARA...................................................................... 92STELARA...................................................................... 92STELARA...................................................................... 92STIMATE....................................................................... 83STIOLTO RESPIMAT................................................ 100STIVARGA.....................................................................35STRATTERA.................................................................72STRATTERA.................................................................72STRATTERA.................................................................72STRATTERA.................................................................72STRATTERA.................................................................72STRATTERA.................................................................72STRATTERA.................................................................72STRENSIQ....................................................................77STRENSIQ....................................................................77STRENSIQ....................................................................77STRENSIQ....................................................................77STREPTOMYCIN SULFATE...................................... 11STRIBILD...................................................................... 47SUBOXONE....................................................................5SUBOXONE....................................................................5SUBOXONE....................................................................5SUBOXONE....................................................................5sucralfate tab 1 gm......................................................80sulfacetamide sodium lotion 10%.............................. 76

sulfacetamide sodium ophth soln 10%..................... 96sulfacetamide sodium-prednisolone ophth soln

10-0.23(0.25)%..........................................................96SULFADIAZINE............................................................ 11SULFAMETHOXAZOLE/

TRIMETHOPRIM...................................................... 11sulfamethoxazole-trimethoprim susp 200-40

mg/5ml........................................................................ 11sulfamethoxazole-trimethoprim tab 400-80

mg................................................................................11sulfamethoxazole-trimethoprim tab 800-160

mg................................................................................11sulfasalazine tab 500 mg............................................93sulfasalazine tab delayed release 500

mg................................................................................93sulindac tab 150 mg...................................................... 3sulindac tab 150 mg....................................................25sulindac tab 200 mg...................................................... 4sulindac tab 200 mg....................................................25sumatriptan nasal spray 20 mg/act........................... 26sumatriptan nasal spray 5 mg/act..............................26SUMATRIPTAN SUCCINATE.....................................26sumatriptan succinate inj 6 mg/0.5ml........................26sumatriptan succinate solution auto-injector 4

mg/0.5ml.....................................................................26sumatriptan succinate solution auto-injector 6

mg/0.5ml.....................................................................26sumatriptan succinate solution cartridge 4

mg/0.5ml.....................................................................26sumatriptan succinate solution cartridge 6

mg/0.5ml.....................................................................26sumatriptan succinate tab 100 mg............................ 26sumatriptan succinate tab 25 mg...............................26sumatriptan succinate tab 50 mg...............................26SUPRAX........................................................................11SUPRAX........................................................................11SUPRAX........................................................................11SUPREP BOWEL PREP KIT.....................................80SUSTIVA........................................................................47SUSTIVA........................................................................48SUSTIVA........................................................................48SUTENT........................................................................ 35SUTENT........................................................................ 35SUTENT........................................................................ 35SUTENT........................................................................ 35SYLATRON................................................................... 35SYLATRON................................................................... 35SYLATRON................................................................... 35SYLATRON................................................................... 35SYLATRON................................................................... 35SYLATRON................................................................... 48SYLATRON................................................................... 48

2017

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SYLATRON................................................................... 48SYLATRON................................................................... 48SYLATRON................................................................... 48SYLVANT.......................................................................35SYLVANT.......................................................................35SYMBICORT...............................................................100SYMBICORT...............................................................100SYMLINPEN 120......................................................... 55SYMLINPEN 60............................................................55SYNAGIS.......................................................................92SYNAGIS.......................................................................92SYNAREL......................................................................88SYNERCID....................................................................12SYNJARDY................................................................... 55SYNJARDY................................................................... 55SYNJARDY................................................................... 56SYNJARDY................................................................... 56SYNJARDY XR............................................................ 56SYNJARDY XR............................................................ 56SYNJARDY XR............................................................ 56SYNJARDY XR............................................................ 56SYNRIBO...................................................................... 35SYNTHROID.................................................................86SYNTHROID.................................................................86SYNTHROID.................................................................86SYNTHROID.................................................................86SYNTHROID.................................................................86SYNTHROID.................................................................86SYNTHROID.................................................................86SYNTHROID.................................................................86SYNTHROID.................................................................86SYNTHROID.................................................................86SYNTHROID.................................................................86SYNTHROID.................................................................86SYPRINE.....................................................................103TTABLOID........................................................................35tacrolimus cap 0.5 mg.................................................92tacrolimus cap 1 mg....................................................92tacrolimus cap 5 mg....................................................92tacrolimus oint 0.03%..................................................76tacrolimus oint 0.1%.................................................... 76TAFINLAR..................................................................... 35TAFINLAR..................................................................... 35TAGRISSO.................................................................... 36TAGRISSO.................................................................... 36TAMIFLU........................................................................48TAMIFLU........................................................................48TAMIFLU........................................................................48TAMIFLU........................................................................48tamoxifen citrate tab 10 mg........................................36tamoxifen citrate tab 20 mg........................................36

tamsulosin hcl cap 0.4 mg..........................................81TARCEVA...................................................................... 36TARCEVA...................................................................... 36TARCEVA...................................................................... 36TARGRETIN..................................................................36TARGRETIN..................................................................36TASIGNA....................................................................... 36TASIGNA....................................................................... 36TAXOTERE................................................................... 36TAXOTERE................................................................... 36tazarotene cream 0.1%...............................................76TAZORAC......................................................................76TAZORAC......................................................................76TAZORAC......................................................................76TAZORAC......................................................................76TECENTRIQ................................................................. 36TECFIDERA..................................................................72TECFIDERA..................................................................72TECFIDERA STARTER PACK...................................72TECHNIVIE................................................................... 48TEFLARO......................................................................12TEFLARO......................................................................12TEKTURNA...................................................................69TEKTURNA...................................................................69TEKTURNA HCT......................................................... 69TEKTURNA HCT......................................................... 69TEKTURNA HCT......................................................... 69TEKTURNA HCT......................................................... 69telmisartan-hydrochlorothiazide tab 40-12.5

mg................................................................................69telmisartan-hydrochlorothiazide tab 80-12.5

mg................................................................................69telmisartan-hydrochlorothiazide tab 80-25

mg................................................................................69telmisartan tab 20 mg................................................. 69telmisartan tab 40 mg................................................. 69telmisartan tab 80 mg................................................. 69TEMODAR.................................................................... 36TENIVAC....................................................................... 92terazosin hcl cap 10 mg..............................................69terazosin hcl cap 10 mg..............................................81terazosin hcl cap 1 mg................................................69terazosin hcl cap 1 mg................................................81terazosin hcl cap 2 mg................................................69terazosin hcl cap 2 mg................................................81terazosin hcl cap 5 mg................................................69terazosin hcl cap 5 mg................................................81terbinafine hcl tab 250 mg..........................................24terbutaline sulfate tab 2.5 mg.................................. 100terbutaline sulfate tab 5 mg......................................100terconazole vaginal cream 0.4%................................24terconazole vaginal cream 0.8%................................24

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terconazole vaginal suppos 80 mg............................24testosterone cypionate im inj in oil 100 mg/

ml.................................................................................85testosterone cypionate im inj in oil 200 mg/

ml.................................................................................85testosterone enanthate im inj in oil 200 mg/

ml.................................................................................85testosterone td gel 12.5 mg/act (1%)........................ 85testosterone td gel 25 mg/2.5gm (1%)......................85testosterone td gel 50 mg/5gm (1%).........................85testosterone td soln 30 mg/act...................................85TETANUS/DIPHTHERIA TOXOIDS

ADSORBED...............................................................92tetrabenazine tab 12.5 mg..........................................72tetrabenazine tab 25 mg.............................................72tetracycline hcl cap 250 mg........................................12tetracycline hcl cap 500 mg........................................12THALOMID....................................................................36THALOMID....................................................................36THALOMID....................................................................36THALOMID....................................................................36THALOMID....................................................................92THALOMID....................................................................92THALOMID....................................................................92THALOMID....................................................................92theophylline tab er 12hr 100 mg..............................100theophylline tab er 12hr 200 mg..............................100theophylline tab er 12hr 300 mg..............................100theophylline tab er 12hr 450 mg..............................100theophylline tab er 24hr 400 mg..............................100theophylline tab er 24hr 600 mg..............................100thioridazine hcl tab 100 mg........................................ 43thioridazine hcl tab 10 mg.......................................... 43thioridazine hcl tab 25 mg.......................................... 43thioridazine hcl tab 50 mg.......................................... 43thiotepa for inj 15 mg.................................................. 36thiothixene cap 10 mg.................................................43thiothixene cap 1 mg...................................................43thiothixene cap 2 mg...................................................43thiothixene cap 5 mg...................................................43THYMOGLOBULIN......................................................92tiagabine hcl tab 2 mg.................................................16tiagabine hcl tab 4 mg.................................................16TIMOLOL MALEATE................................................... 26TIMOLOL MALEATE................................................... 26TIMOLOL MALEATE................................................... 26TIMOLOL MALEATE................................................... 69TIMOLOL MALEATE................................................... 69TIMOLOL MALEATE................................................... 69timolol maleate ophth gel forming soln

0.25%..........................................................................96

timolol maleate ophth gel forming soln0.5%............................................................................96

timolol maleate ophth soln 0.25%..............................96timolol maleate ophth soln 0.5%................................96TIVICAY......................................................................... 48TIVICAY......................................................................... 48TIVICAY......................................................................... 48tizanidine hcl cap 2 mg............................................... 44tizanidine hcl cap 4 mg............................................... 44tizanidine hcl cap 6 mg............................................... 44tizanidine hcl tab 2 mg................................................44tizanidine hcl tab 4 mg................................................44TOBRADEX...................................................................96tobramycin-dexamethasone ophth susp

0.3-0.1%..................................................................... 96tobramycin nebu soln 300 mg/5ml.......................... 100tobramycin ophth soln 0.3%.......................................96TOBRAMYCIN SULFATE........................................... 12tobramycin sulfate for inj 1.2 gm................................12tobramycin sulfate inj 1.2 gm/30ml (40 mg/

ml)................................................................................12tobramycin sulfate inj 10 mg/ml................................. 12tobramycin sulfate inj 80 mg/2ml (40 mg/

ml)................................................................................12tolcapone tab 100 mg................................................. 39tolmetin sodium cap 400 mg........................................ 4tolmetin sodium cap 400 mg...................................... 25tolterodine tartrate cap er 24hr 2 mg.........................81tolterodine tartrate cap er 24hr 4 mg.........................81tolterodine tartrate tab 1 mg.......................................81tolterodine tartrate tab 2 mg.......................................81topiramate sprinkle cap 15 mg...................................16topiramate sprinkle cap 15 mg...................................26topiramate sprinkle cap 25 mg...................................16topiramate sprinkle cap 25 mg...................................26topiramate tab 100 mg................................................16topiramate tab 100 mg................................................27topiramate tab 200 mg................................................16topiramate tab 200 mg................................................27topiramate tab 25 mg.................................................. 16topiramate tab 25 mg.................................................. 26topiramate tab 50 mg.................................................. 16topiramate tab 50 mg.................................................. 26TOPOTECAN HCL...................................................... 36topotecan hcl for inj 4 mg........................................... 36TORISEL....................................................................... 36torsemide tab 100 mg................................................. 69torsemide tab 10 mg................................................... 69torsemide tab 20 mg................................................... 69torsemide tab 5 mg......................................................69TOUJEO SOLOSTAR..................................................56TOVIAZ.......................................................................... 81

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TOVIAZ.......................................................................... 81TRACLEER.................................................................100TRACLEER.................................................................100TRADJENTA................................................................. 56tramadol-acetaminophen tab 37.5-325

mg..................................................................................4tramadol hcl tab 50 mg................................................. 4trandolapril tab 1 mg................................................... 69trandolapril tab 2 mg................................................... 69trandolapril tab 4 mg................................................... 69tranexamic acid iv soln 1000 mg/10ml (100 mg/

ml)................................................................................59tranexamic acid tab 650 mg.......................................59tranylcypromine sulfate tab 10 mg............................ 21TRAVATAN Z................................................................ 96trazodone hcl tab 100 mg...........................................21trazodone hcl tab 150 mg...........................................21trazodone hcl tab 300 mg...........................................21trazodone hcl tab 50 mg.............................................21TREANDA..................................................................... 36TREANDA..................................................................... 36TRECATOR...................................................................27TRELSTAR....................................................................88TRELSTAR....................................................................88TRELSTAR MIXJECT..................................................88TRELSTAR MIXJECT..................................................88TRELSTAR MIXJECT..................................................88TRESIBA FLEXTOUCH.............................................. 56TRESIBA FLEXTOUCH.............................................. 56tretinoin cap 10 mg......................................................36tretinoin cream 0.025%............................................... 76tretinoin cream 0.05%................................................. 76tretinoin cream 0.1%................................................... 76tretinoin gel 0.01%.......................................................76tretinoin gel 0.025%.....................................................76triamcinolone acetonide cream

0.025%........................................................................76triamcinolone acetonide cream 0.1%........................76triamcinolone acetonide cream 0.5%........................76triamcinolone acetonide dental paste

0.1%............................................................................73triamcinolone acetonide lotion 0.025%..................... 76triamcinolone acetonide lotion 0.1%..........................76triamcinolone acetonide nasal aerosol suspension

55 mcg/act............................................................... 100triamcinolone acetonide oint 0.025%........................ 76triamcinolone acetonide oint 0.1%.............................76triamcinolone acetonide oint 0.5%.............................76triamterene & hydrochlorothiazide cap 37.5-25

mg................................................................................69triamterene & hydrochlorothiazide tab 37.5-25

mg................................................................................69

triamterene & hydrochlorothiazide tab 75-50mg................................................................................69

trifluoperazine hcl tab 10 mg......................................43trifluoperazine hcl tab 1 mg........................................43trifluoperazine hcl tab 2 mg........................................43trifluoperazine hcl tab 5 mg........................................43trifluridine ophth soln 1%............................................ 96trimethoprim tab 100 mg.............................................12trimipramine maleate cap 100 mg............................. 21trimipramine maleate cap 25 mg............................... 21trimipramine maleate cap 50 mg............................... 21TRINTELLIX..................................................................21TRINTELLIX..................................................................21TRINTELLIX..................................................................21TRISENOX....................................................................36TRIUMEQ......................................................................48trospium chloride cap er 24hr 60 mg.........................81trospium chloride tab 20 mg.......................................81TRUMENBA.................................................................. 92TRUVADA......................................................................48TRUVADA......................................................................48TRUVADA......................................................................48TRUVADA......................................................................48TWINRIX........................................................................92TYBOST........................................................................ 48TYGACIL....................................................................... 12TYKERB........................................................................ 36TYPHIM VI.................................................................... 92TYSABRI....................................................................... 72TYSABRI....................................................................... 92UULORIC......................................................................... 24ULORIC......................................................................... 24UNITUXIN......................................................................36UPTRAVI..................................................................... 100UPTRAVI..................................................................... 100UPTRAVI..................................................................... 100UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101ursodiol cap 300 mg....................................................80ursodiol tab 250 mg.....................................................80ursodiol tab 500 mg.....................................................80UVADEX........................................................................ 36UVADEX........................................................................ 76VVAGIFEM.......................................................................85valacyclovir hcl tab 1 gm............................................ 48

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valacyclovir hcl tab 500 mg........................................48VALCHLOR................................................................... 76VALCYTE.......................................................................48valganciclovir hcl for soln 50 mg/ml.......................... 48valganciclovir hcl tab 450 mg.....................................48valproate sodium inj 100 mg/ml.................................16valproate sodium oral soln 250 mg/5ml.................... 16valproic acid cap 250 mg............................................16valproic acid cap 250 mg............................................52valsartan-hydrochlorothiazide tab 160-12.5

mg................................................................................69valsartan-hydrochlorothiazide tab 160-25

mg................................................................................69valsartan-hydrochlorothiazide tab 320-12.5

mg................................................................................70valsartan-hydrochlorothiazide tab 320-25

mg................................................................................70valsartan-hydrochlorothiazide tab 80-12.5

mg................................................................................69valsartan tab 160 mg...................................................69valsartan tab 320 mg...................................................69valsartan tab 40 mg.....................................................69valsartan tab 80 mg.....................................................69vancomycin hcl cap 125 mg.......................................12vancomycin hcl cap 250 mg.......................................12vancomycin hcl for inj 1000 mg................................. 12vancomycin hcl for inj 100 gm................................... 12vancomycin hcl for inj 10 gm......................................12vancomycin hcl for inj 5000 mg................................. 12vancomycin hcl for inj 500 mg................................... 12vancomycin hcl for inj 750 mg................................... 12VANCOMYCIN HCL IN DEXTROSE.........................12VANCOMYCIN HCL IN DEXTROSE.........................12VANCOMYCIN HCL IN DEXTROSE.........................12VAQTA........................................................................... 92VAQTA........................................................................... 92VARIVAX........................................................................92VASCEPA...................................................................... 70VASCEPA...................................................................... 70VECTIBIX...................................................................... 36VECTIBIX...................................................................... 36VELCADE......................................................................36VENCLEXTA.................................................................36VENCLEXTA.................................................................36VENCLEXTA.................................................................36VENCLEXTA STARTING PACK................................ 36venlafaxine hcl cap er 24hr 150 mg.......................... 21venlafaxine hcl cap er 24hr 150 mg.......................... 50venlafaxine hcl cap er 24hr 37.5 mg......................... 21venlafaxine hcl cap er 24hr 37.5 mg......................... 50venlafaxine hcl cap er 24hr 75 mg............................ 21venlafaxine hcl cap er 24hr 75 mg............................ 50

venlafaxine hcl tab 100 mg........................................ 21venlafaxine hcl tab 100 mg........................................ 50venlafaxine hcl tab 25 mg...........................................21venlafaxine hcl tab 25 mg...........................................50venlafaxine hcl tab 37.5 mg....................................... 21venlafaxine hcl tab 37.5 mg....................................... 50venlafaxine hcl tab 50 mg...........................................21venlafaxine hcl tab 50 mg...........................................50venlafaxine hcl tab 75 mg...........................................21venlafaxine hcl tab 75 mg...........................................50venlafaxine hcl tab er 24hr 150 mg........................... 21venlafaxine hcl tab er 24hr 150 mg........................... 50venlafaxine hcl tab er 24hr 37.5 mg..........................21venlafaxine hcl tab er 24hr 37.5 mg..........................50venlafaxine hcl tab er 24hr 75 mg............................. 21venlafaxine hcl tab er 24hr 75 mg............................. 50VENTAVIS................................................................... 101VENTAVIS................................................................... 101VENTOLIN HFA......................................................... 101verapamil hcl cap er 24hr 100 mg.............................70verapamil hcl cap er 24hr 120 mg.............................70verapamil hcl cap er 24hr 180 mg.............................70verapamil hcl cap er 24hr 200 mg.............................70verapamil hcl cap er 24hr 240 mg.............................70verapamil hcl cap er 24hr 300 mg.............................70verapamil hcl cap er 24hr 360 mg.............................70verapamil hcl tab 120 mg........................................... 70verapamil hcl tab 40 mg............................................. 70verapamil hcl tab 80 mg............................................. 70verapamil hcl tab er 120 mg.......................................70verapamil hcl tab er 180 mg.......................................70verapamil hcl tab er 240 mg.......................................70VERSACLOZ................................................................ 43VICTOZA....................................................................... 56VIDEX............................................................................ 48VIDEX............................................................................ 48VIEKIRA PAK................................................................48VIEKIRA XR..................................................................48vigabatrin powd pack 500 mg.................................... 16VIGAMOX......................................................................96VIIBRYD.........................................................................21VIIBRYD.........................................................................21VIIBRYD.........................................................................21VIIBRYD STARTER PACK......................................... 21VIMPAT.......................................................................... 16VIMPAT.......................................................................... 16VIMPAT.......................................................................... 16VIMPAT.......................................................................... 16VIMPAT.......................................................................... 16VIMPAT.......................................................................... 16VINBLASTINE SULFATE............................................36vincristine sulfate iv soln 1 mg/ml..............................37

2017

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vinorelbine tartrate inj 10 mg/ml.................................37vinorelbine tartrate inj 50 mg/5ml (10 mg/

ml)................................................................................37VIOKACE.......................................................................77VIOKACE.......................................................................77VIRACEPT.................................................................... 48VIRACEPT.................................................................... 48VIRAMUNE................................................................... 48VIRAZOLE.....................................................................48VIREAD..........................................................................49VIREAD..........................................................................49VIREAD..........................................................................49VIREAD..........................................................................49VIREAD..........................................................................49VIVITROL........................................................................ 5voriconazole for inj 200 mg........................................ 24voriconazole for susp 40 mg/ml.................................24voriconazole tab 200 mg............................................ 24voriconazole tab 50 mg...............................................24VOSEVI..........................................................................49VOTRIENT.................................................................... 37VPRIV............................................................................ 77VRAYLAR...................................................................... 43VRAYLAR...................................................................... 43VRAYLAR...................................................................... 43VRAYLAR...................................................................... 43VRAYLAR...................................................................... 52VRAYLAR...................................................................... 52VRAYLAR...................................................................... 52VRAYLAR...................................................................... 52VYTORIN.......................................................................70VYTORIN.......................................................................70VYTORIN.......................................................................70VYTORIN.......................................................................70VYXEOS........................................................................37Wwarfarin sodium tab 10 mg.........................................59warfarin sodium tab 1 mg...........................................59warfarin sodium tab 2.5 mg........................................59warfarin sodium tab 2 mg...........................................59warfarin sodium tab 3 mg...........................................59warfarin sodium tab 4 mg...........................................59warfarin sodium tab 5 mg...........................................59warfarin sodium tab 6 mg...........................................59warfarin sodium tab 7.5 mg........................................59water for irrigation, sterile irrigation

soln............................................................................103WELCHOL.....................................................................56WELCHOL.....................................................................56WELCHOL.....................................................................70WELCHOL.....................................................................70

XXALKORI....................................................................... 37XALKORI....................................................................... 37XARELTO...................................................................... 59XARELTO...................................................................... 59XARELTO...................................................................... 59XARELTO STARTER PACK.......................................59XATMEP........................................................................ 92XENAZINE.................................................................... 72XENAZINE.................................................................... 72XGEVA...........................................................................94XIFAXAN........................................................................12XIFAXAN........................................................................80XOLAIR........................................................................101XOPENEX HFA..........................................................101XTANDI.......................................................................... 37XYREM........................................................................101YYERVOY........................................................................37YERVOY........................................................................37YF-VAX.......................................................................... 92YONDELIS.................................................................... 37Zzafirlukast tab 10 mg.................................................101zafirlukast tab 20 mg.................................................101zaleplon cap 10 mg...................................................101zaleplon cap 5 mg..................................................... 101ZALTRAP.......................................................................37ZALTRAP.......................................................................37ZANOSAR..................................................................... 37ZAVESCA...................................................................... 77ZEJULA..........................................................................37ZELBORAF................................................................... 37ZENPEP........................................................................ 77ZENPEP........................................................................ 77ZENPEP........................................................................ 78ZENPEP........................................................................ 78ZENPEP........................................................................ 78ZENPEP........................................................................ 78ZENPEP........................................................................ 78ZEPATIER..................................................................... 49ZERIT.............................................................................49ZETIA............................................................................. 70ZIAGEN..........................................................................49zidovudine cap 100 mg...............................................49zidovudine syrup 10 mg/ml.........................................49zidovudine tab 300 mg................................................49ziprasidone hcl cap 20 mg..........................................43ziprasidone hcl cap 20 mg..........................................52ziprasidone hcl cap 40 mg..........................................43

2017

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ziprasidone hcl cap 40 mg..........................................53ziprasidone hcl cap 60 mg..........................................43ziprasidone hcl cap 60 mg..........................................53ziprasidone hcl cap 80 mg..........................................43ziprasidone hcl cap 80 mg..........................................53ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4zoledronic acid inj conc for iv infusion 4

mg/5ml........................................................................ 94zoledronic acid iv soln 5 mg/100ml........................... 94ZOLINZA........................................................................37zolpidem tartrate tab 10 mg..................................... 101zolpidem tartrate tab 5 mg....................................... 101ZOMETA........................................................................ 94zonisamide cap 100 mg..............................................16zonisamide cap 25 mg................................................16zonisamide cap 50 mg................................................16ZONTIVITY....................................................................59ZORTRESS...................................................................93ZORTRESS...................................................................93ZORTRESS...................................................................93ZOSTAVAX....................................................................93ZOSYN...........................................................................12ZOSYN...........................................................................12ZOSYN...........................................................................12ZYDELIG....................................................................... 37ZYDELIG....................................................................... 37ZYKADIA....................................................................... 37ZYPREXA RELPREVV............................................... 44ZYPREXA RELPREVV............................................... 44ZYPREXA RELPREVV............................................... 44ZYTIGA..........................................................................37ZYTIGA..........................................................................37ZYVOX...........................................................................12

Y0096_MRK_TX_NDNOTICE17 Accepted 09042016

Blue Cross and Blue Shield of Texas complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of Texas does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Blue Cross and Blue Shield of Texas:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

○ Qualified sign language interpreters

○ Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

○ Qualified interpreters

○ Information written in other languages

If you need these services, contact Civil Rights Coordinator

If you believe that Blue Cross and Blue Shield of Texas has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35th floor, Chicago, Illinois 60601, 1-855-664-7270, TTY/TDD: 1-855-661-6965, Fax: 1-855-661-6960, [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW

Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

732356.0816

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call ATT NTION If you peak Engli h, language a i tance ervice , free of charge, are avai able to you Call

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số <

注意:如果您使用繁體中文, 您可以免費獲得語言援助服務。請致電 。

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اتصل رقم . إذا كنت تتحدث اللغة العربية، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان: ملحوظ : رقم هاتف الصم والبكم)

کريں لکا ۔ ںہی بدستيا ںمی تمف تخدما یک دمد یک نزبا وک پآ وت ،ہيں ےبولت وارد پآ راگ: خبردار

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa

ATTENTION Si vous parlez français des services d’aide linguistique vous sont proposés gratuitement. Appelez le

ध्यान दें: यदद आप दहिंदी बोलत ेहैं तो आपके ललए मफु्त में भाषा सहायता सेवाएिं उपलब्ध हैं।

पर कॉल करें।

با . اگر به زبان فارسی گفتگو می کنيد، تسهيالت زبانی به صورت رايگان برای شما فراهم می باشد: توجه .تماس بگيريد

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer:

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注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。 まで、お電話にてご連絡ください。

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບ່ໍເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ

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Plans provided by Blue Cross and Blue Shield of Texas, which refers to HCSC Insurance Services Company (HISC) (PPO plans), and GHS Insurance Company (GHS) (HMO and HMO-POS plans). HISC and GHS are Independent Licensees of the Blue Cross and Blue Shield Association. HISC and GHS are Medicare Advantage organizations with a Medicare contract. Enrollment in HISC’s and GHS’ plans depends on contract renewal.

This formulary was updated on 11/17/2017. For more recent information or other questions, please contact Blue Cross Medicare Advantage Customer Service, at 1-877-774-8592 or, for TTY/TDD users, 711, 8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays, or visit www.getbluetx.com/mapd/druglist.


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