2018 Cigna COMPREHENSIVE DRUG LIST (Formulary) · PDF file2018 Cigna COMPREHENSIVE DRUG LIST...

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

2018 Cigna COMPREHENSIVE DRUG LIST (Formulary)

This drug list was updated in May 2018. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-627-7534 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m., hours apply Monday – Friday, February 15 – September 30, or visit www.CignaHealthSpring.com. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Cigna is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna depends on contract renewal.HPMS Approved Formulary File Submission ID 18089, Version 11 Y0036_18_55624a_Final_3e Populated Template 08042017

Plans coveredCigna-HealthSpring Preferred (HMO)Cigna-HealthSpring Achieve Plus (HMO SNP)

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What is the Cigna Comprehensive Drug List?A drug list is a list of covered drugs selected by Cigna 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. Cigna will generally cover the drugs listed in our drug list as long as the drug is medically necessary, the prescription is filled at a Cigna 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 Drug List (formulary) change?Generally, if you are taking a drug on our 2018 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic equivalent of the drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of drug list changes, such as removing a drug from our drug list, will not affect customers who are currently taking the drug. It will remain available at the same cost-sharing for those customers 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 drugs that were available when you chose our plan, except for cases in which you can save additional money on the generic equivalent or we can ensure your safety. If we remove drugs from our drug list, 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 customers of the change at least 60 days before the change becomes effective, or at the time the customer requests a refill of the drug, at which time the customer will receive a 60-day supply of the drug. If the Food and Drug Administration

(FDA) deems a drug on our drug list to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our drug list and provide notice to customers who take the drug. The enclosed drug list is current as of May 2018. To get updated information about the drugs covered by Cigna, please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our website are reviewed and updated on a monthly basis.

How do I use the Drug List? There are two ways to find your drug within the drug list:Medical ConditionThe drug list begins on page 7. The drugs in this drug list 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 7. Then look under the category name for your drug. Covered Drug IndexIf you are not sure what category to look under, you should look for your drug in the Covered Drugs Index section that begins on page 54. The Covered Drugs Index provides a list of all of the drugs included in this document. Both brand name drugs and generic drugs are in the Drug List. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Covered Drug Index and find the name of your drug in the drug name column of the list.

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

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Cigna. When it refers to “plan” or “our plan,” it means Cigna-HealthSpring Preferred (HMO) and Cigna-HealthSpring Achieve Plus (HMO SNP).

This document includes a list of the drugs (formulary) for our plans, which is current as of May 2018. 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, 2019, and from time to time during the year.

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What are generic drugs?Cigna 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: Cigna requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval from Cigna before you fill your prescriptions. If you don’t get approval, Cigna may not cover the drug.

• Quantity Limits: For certain drugs, Cigna limits the amount of the drug that Cigna will cover. For example, Cigna allows for 1 tablet per day for BYSTOLIC 10MG. This applies to a standard one-month supply (for total quantity of 30 per 30 days) or three-month supply (for total quantity of 90 per 90 days).

• Step Therapy: In some cases, Cigna 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, Cigna may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Cigna will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online 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 drug list, appears on the front and back cover pages.You can ask Cigna 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 Cigna Drug List?” on this page for information about how to request an exception.

Options for Maintenance MedicationsTaking the medications prescribed by your doctor (or other prescriber) is important to your health. We are committed to helping you achieve control of chronic conditions by making it easy for you to receive your maintenance medications. As part of our commitment to coordinating your healthcare needs, we have set a goal of

helping you take your medications at least 80% of the time. There are several ways we can work together to accomplish this goal:• Talk with your doctor about whether a 90-day supply of your

ongoing, stable medications may be appropriate. Taking these medications every day as prescribed is important for your overall health, and getting 90-day prescriptions of these medications can help ensure that you do not miss a dose.

• You can receive a 90-day supply at most retail pharmacies or through one of our mail-order pharmacies.

• Talk to your pharmacist if you are experiencing any new challenges with your maintenance medications.

How can I use my prescription drug coverage to save money on my medications?There may be opportunities for you to save money on your medications using your Cigna coverage.• Ask your doctor (or other prescriber) if there are any lower-

cost generic alternatives available for any of your current medications.

• Explore whether the ‘CMS extra help’ program may offer additional financial support for your medications.

• If your medication is not covered on the Cigna drug list, talk with your doctor about alternative medications which are covered in the drug list.

What if my drug is not in the Drug List?If your drug is not included in this drug list, you should first contact Customer Service and ask if your drug is covered. If you learn that Cigna does not cover your drug, you have two options:• You can ask Customer Service for a list of similar drugs that

are covered by Cigna. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Cigna.

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

How do I request an exception to the Cigna Drug List?You can ask Cigna 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 in our drug

list. If approved, this drug will be covered at a pre-determined

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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 waive coverage restrictions or limits on your drug. For example, for certain drugs, Cigna 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.

• You can ask us to provide a tiering exception for a higher cost sharing drug to be covered at a lower cost-sharing tier. If your drug is contained in the Non-Preferred Drugs tier, you can ask us to cover it at the Preferred Brand Drugs tier, and if your drug is contained in the Generic Drugs tier, you can ask us to cover it at the Preferred Generic Drugs tier. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not in our drug list, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.

Generally, Cigna will only approve your request for an exception if the alternative drugs included on the plan’s drug list, 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 drug list, tiering or utilization restriction exception. When you request a drug list, tiering or utilization restriction exception you should submit a statement from your prescriber or doctor supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or existing customer in our plan you may be taking drugs that are not in our drug list. Or, you may be taking a drug that is on our drug list 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 drug list 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 customer of our plan.

For each of your drugs that is not on our drug list 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 without a drug list exception, even if you have been a customer 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 91- to 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 customer of our plan. If you need a drug that is not in our drug list 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 drug list exception. In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-of-care changes due to discharge from a hospital to a nursing facility or to a home, Cigna will allow a one-time 31-day supply (unless the prescription is written for fewer days). Cigna’s Drug ListThe comprehensive drug list provides coverage information about all of the drugs covered by Cigna. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 54. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., BYSTOLIC) and generic drugs are listed in lower-case italics (e.g., simvastatin).The information in the Requirements/Limits column tells you if Cigna has any special requirements for coverage of your drug. We provide quantity limits on certain drugs which are indicated with a QL in the Covered Drugs by Category list on page 7 along with the amount dispensed per the days supplied. (For example: BYSTOLIC 10MG QL 30/30; this means the drug BYSTOLIC 10MG is limited to 30 tablets per 30 days. For 90-day supplies, this quantity limit would be expanded to 90 tablets per 90 days).

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Drug Tier and Cost-Share TableThe following table represents the plan name, plan service area, the drug tier number as it appears in the drug list, and the cost-share amount for that tier number. Tier 1 is for Preferred Generic drugs. Tier 2 is for Generic drugs. Tier 3 is for Preferred Brand drugs. Tier 4 is for Non-Preferred drugs. Tier 5 is for Specialty tier drugs. You may also refer to your Evidence of Coverage document for additional details.Cigna is not always able to keep all generic medications in the Preferred Generic and Generic drug tiers, and some generic medications may be in Tier 3, Tier 4, or Tier 5. Keep in mind that

the name “Tier 3: Preferred Brand Drugs” is just a description of the majority of the drugs in the tier. It does not mean that there are only brand drugs in that tier.For customers receiving Extra Help: Your Low Income Subsidy (LIS) copay level will be based on how the Food and Drug Administration (FDA) classifies certain drugs. Due to this, a generic drug may receive a preferred brand copay, or a preferred brand drug may receive a generic drug copay. Please see your LIS Rider for additional information on these copay levels. Or call Customer Service for further clarification regarding a specific drug.

For more information

For more detailed information about your Cigna prescription drug coverage, please review your Evidence of Coverage and other plan materials.If you have questions about Cigna, please contact us. Our contact information, along with the date we last updated the drug list, 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.

Key:B/D – This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending on circumstances.

PA – This drug requires prior authorization

QL – This drug has quantity limits

ST – This drug has step therapy requirements

Generally all medications in the drug list are available through mail order, except when special circumstances or situations prohibit mailing a particular medication to your home.

What is a preferred network pharmacy?If your plan has preferred network pharmacies, you will typically save money by using these pharmacies. Your prescription drug costs (like a copay or coinsurance) will typically be less at a preferred network pharmacy because it has a preferred

agreement with your plan. You will receive a Pharmacy Directory in your Welcome Kit after you enroll, or you can visit www.CignaHealthSpring.com for the most current Pharmacy Directory.

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To locate your drug cost, please refer to the tables on the following page to find your service area and the Medicare Advantage plan in which you are currently enrolled or would like to enroll.Cigna has pharmacies with preferred cost-shares. See your Pharmacy Directory or visit www.CignaHealthSpring.com for information on which stores with preferred cost-shares are near you.

Service Area: Arizona Cigna-HealthSpring Preferred (HMO)H0354-001Cigna-HealthSpring Achieve Plus (HMO SNP) H0354-027Maricopa and Pinal (Apache Junction and Queen Creek: 85117, 85118, 85119, 85120, 85140, 85143, 85178, 85220), Arizona

Preferred Retail Cost-Sharing

Standard Retail Cost-Sharing

Standard Mail Order Cost-Sharing

30/60/90 Days 30/60/90 Days 30/60/90 DaysTier 1: Preferred Generic Drugs $2 / $4 / $5 $7 / $14 / $21 $7 / $14 / $21

Tier 2: Generic Drugs $10 / $20 / $25 $15 / $30 / $45 $15 / $30 / $45

Tier 3: Preferred Brand Drugs $42 / $84 / $126 $47 / $94 / $141 $47 / $94 / $141

Tier 4: Non-Preferred Drugs $95 / $190 / $285 $100 / $200 / $300 $100 / $200 / $300

Tier 5: Specialty Tier 29% (30-day supply only)

29% (30-day supply only)


Service Area: Arizona Cigna-HealthSpring Preferred (HMO)H0354-024Pima, Arizona

Preferred Retail Cost-Sharing

Standard Retail Cost-Sharing

Standard Mail Order Cost-Sharing

30/60/90 Days 30/60/90 Days 30/60/90 DaysTier 1: Preferred Generic Drugs $2 / $4 / $5 $7 / $14 / $21 $7 / $14 / $21

Tier 2: Generic Drugs $10 / $20 / $25 $15 / $30 / $45 $15 / $30 / $45

Tier 3: Preferred Brand Drugs $42 / $84 / $126 $47 / $94 / $141 $47 / $94 / $141

Tier 4: Non-Preferred Drugs $95 / $190 / $285 $100 / $200 / $300 $100 / $200 / $300

Tier 5: Specialty Tier 33% (30-day supply only)



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My MedicationsIn this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service at 1-800-627-7534, 7 days a week, 8 a.m. – 8 p.m., hours apply Monday – Friday, February 15 – September 30. TTY users can call 711.

My Medications Page Number in the Drug List

Cost-Share through Cigna

Generic Available?

Generic Cost-Share

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Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drugQL = Quantity Limits listed as (qty/days) ST = Step Therapy rules applyPA = Prior Authorization may be required B/D = Drugs covered under Medicare Part B or Part DYou can find more information on the symbols by going to page 4.

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Analgesics

Analgesicsbutalbital/acetaminophen tabs 325mg; 50mg

2 PA QL(180/30)

butalbital/acetaminophen/caffeine caps

2 PA QL(180/30)

butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg

2 PA QL(180/30)

butalbital/aspirin/caffeine caps 2 PA QL(180/30)esgic caps 2 PA QL(180/30)PRIALT 5 B/D PAzebutal caps 325mg; 50mg; 40mg

2 PA QL(180/30)

Nonsteroidal Anti-inflammatory Drugscelecoxib caps 400mg 2 QL(30/30)celecoxib caps 100mg, 200mg, 50mg

2 QL(60/30)

choline magnesium trisalicylate liqd

2

diclofenac potassium 2diclofenac sodium dr 2diclofenac sodium er 2diclofenac sodium/misoprostol 2diflunisal 2etodolac 2etodolac er 2ibuprofen susp 2ibuprofen tabs 400mg, 600mg, 800mg

2

ketoprofen 2ketorolac tromethamine inj 30mg/ml

2 PA QL(20/30)

ketorolac tromethamine inj 15mg/ml, 30mg/ml

2 PA QL(40/30)

ketorolac tromethamine tabs 2 PA QL(20/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

meloxicam 2 QL(30/30)nabumetone 2naproxen 2naproxen dr 2naproxen sodium tabs 275mg, 550mg

2

piroxicam 2salsalate 2sulindac 2tolmetin sodium 2Opioid Analgesics, Long-actingbuprenorphine hcl inj 2 QL(150/30)buprenorphine ptwk 10mcg/hr, 15mcg/hr, 20mcg/hr, 5mcg/hr

3 QL(4/28)

BUTRANS PTWK 7.5MCG/HR 3 QL(4/28)DURAMORPH 4 QL(180/30)fentanyl 3 QL(10/30)INFUMORPH 200 4 QL(200/30)INFUMORPH 500 4 QL(200/30)levorphanol tartrate 5 QL(120/30)morphine sulfate er cp24 4 QL(60/30)morphine sulfate er tbcr 2 QL(90/30)morphine sulfate inj 0.5mg/ml, 1mg/ml

2 QL(180/30)

morphine sulfate supp 2OPANA ER (CRUSH RESISTANT) T12A 40MG

5 QL(120/30)

OPANA ER (CRUSH RESISTANT) T12A 10MG, 15MG, 20MG, 30MG, 5MG, 7.5MG

4 QL(60/30)

XTAMPZA ER 3 QL(60/30)Opioid Analgesics, Short-actingacetaminophen/codeine oral soln

2 QL(2700/30)

acetaminophen/codeine tabs 300mg; 60mg

2 QL(180/30)

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lorcet plus tabs 325mg; 7.5mg 2 QL(180/30)morphine sulfate inj 150mg/30ml, 50mg/ml, 5mg/ml

2

morphine sulfate inj 1mg/ml 2 QL(180/30)morphine sulfate inj 10mg/ml 2 QL(200/30)morphine sulfate inj 8mg/ml 2 QL(250/30)morphine sulfate inj 4mg/ml 2 QL(630/30)morphine sulfate inj 2mg/ml 2 QL(1260/30)morphine sulfate oral soln 100mg/5ml

2 QL(180/30)

morphine sulfate oral soln 20mg/5ml

2 QL(300/30)

morphine sulfate oral soln 10mg/5ml

2 QL(700/30)

morphine sulfate tabs 2 QL(120/30)nalbuphine hcl inj 20mg/ml 2 QL(90/30)nalbuphine hcl inj 10mg/ml 2 QL(180/30)OPIUM 3OPIUM TINCTURE 3oxycodone hcl caps 4 QL(120/30)oxycodone hcl conc 2 QL(120/30)oxycodone hcl oral soln 2 QL(1200/30)oxycodone hcl tabs 30mg 2 QL(90/30)oxycodone hcl tabs 10mg, 15mg, 20mg, 5mg

2 QL(120/30)

oxycodone/acetaminophen oral soln

3 QL(1800/30)

oxycodone/acetaminophen tabs 325mg; 10mg

3 QL(180/30)

oxycodone/acetaminophen tabs 325mg; 7.5mg

3 QL(240/30)

oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg

3 QL(360/30)

oxycodone/aspirin 3 QL(180/30)tramadol hcl 2 QL(240/30)tramadol hydrochloride/acetaminophen

2 QL(240/30)

Anesthetics

Local Anestheticsglydo 2lidocaine hcl external soln 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

acetaminophen/codeine tabs 300mg; 15mg, 300mg; 30mg

2 QL(360/30)

butorphanol tartrate inj 2mg/ml 2 QL(240/30)butorphanol tartrate inj 1mg/ml 2 QL(480/30)butorphanol tartrate nasal soln 2 QL(5/30)codeine sulfate 3 QL(180/30)endocet tabs 325mg; 10mg 3 QL(180/30)endocet tabs 325mg; 7.5mg 3 QL(240/30)endocet tabs 325mg; 2.5mg, 325mg; 5mg

3 QL(360/30)

fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, 2500mcg/50ml, 250mcg/5ml

2 B/D PA

fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, 600mcg

4 PA QL(120/30)

fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg

5 PA QL(120/30)

hydrocodone bitartrate/acetaminophen oral soln

2 QL(2700/30)

hydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mg

2 QL(360/30)

hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg

2 QL(180/30)

hydrocodone/acetaminophen tabs 325mg; 5mg

2 QL(360/30)

hydrocodone/ibuprofen tabs 5mg; 200mg, 7.5mg; 200mg

3 QL(150/30)

hydrocodone/ibuprofen tabs 10mg; 200mg

3 QL(180/30)

hydromorphone hcl dosette 3hydromorphone hcl inj 3hydromorphone hcl liqd 3 QL(1200/30)hydromorphone hcl supp 3hydromorphone hcl tabs 8mg 3 QL(120/30)hydromorphone hcl tabs 2mg, 4mg

3 QL(180/30)

ibudone tabs 5mg; 200mg 3 QL(150/30)lorcet 2 QL(360/30)lorcet hd 2 QL(180/30)

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NICOTROL INHALER 4 QL(1008/90)NICOTROL NS 4 QL(30/30)

Antibacterials

Aminoglycosidesamikacin sulfate 2 HIgentak 2gentamicin sulfate 2gentamicin sulfate pediatric 2gentamicin sulfate/0.9% sodium chloride

2

isotonic gentamicin 2neomycin sulfate 2neomycin/polymyxin b sulfates 2paromomycin sulfate 2streptomycin sulfate 2tobramycin ophthalmic soln 2tobramycin sulfate inj 1.2gm, 1.2gm/30ml, 10mg/ml, 80mg/2ml

2

tobramycin sulfate ophthalmic soln

2

tobramycin sulfate/sodium chloride inj 0.9%; 0.8mg/ml

2

TOBREX OINT 3ZYLET 4Antibacterials, Otheralcohol prep pads 2baciim 2bacitracin inj 2bacitracin ophthalmic oint 2bacitracin/polymyxin b 2chloramphenicol sodium succinate

2

CLEOCIN SUPP 4clindacin-p 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lidocaine hcl gel 2lidocaine hcl inj 2lidocaine hcl jelly 2lidocaine hcl mouth/throat soln 2lidocaine hcl viscous 2lidocaine oint 4 QL(120/30)lidocaine ptch 3 PA QL(90/30)lidocaine viscous 2lidocaine/prilocaine crea 4

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-cravingacamprosate calcium dr 2disulfiram 2VIVITROL 5 PAOpioid Dependence Treatmentsbuprenorphine hcl subl 2 QL(90/30)buprenorphine hcl/naloxone hcl 2 PA QL(90/30)naltrexone hcl 2SUBOXONE 3 PA QL(90/30)ZUBSOLV SUBL 0.7MG; 0.18MG

3 PA QL(30/30)

ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG

3 PA QL(90/30)

Opioid Reversal Agentsnaloxone hcl 2NARCAN 3 QL(4/30)Smoking Cessation Agentsbupropion hcl sr 2 QL(60/30)CHANTIX 3 QL(336/365)CHANTIX CONTINUING MONTH PAK

3 QL(336/365)

CHANTIX STARTING MONTH PAK

3 QL(336/365)

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

neomycin/bacitracin/polymyxin 2neomycin/polymyxin/bacitracin/hydrocortisone

2

neomycin/polymyxin/gramicidin 2neomycin/polymyxin/hydrocortisone

2

nitrofurantoin 3nitrofurantoin macrocrystals 2nitrofurantoin monohydrate 2nitrofurantoin monohydrate/macrocrystals

2

polycin 2polymyxin b sulfate 2polymyxin b sulfate/trimethoprim sulfate

2

RELAGARD 4silver sulfadiazine 2ssd 2SYNERCID 5 HItigecycline 5 HItrimethoprim 2trimethoprim sulfate/polymyxin b sulfate

2

TYGACIL 5 HIvancomycin 2 HIvancomycin hcl caps 125mg 4 QL(40/10)vancomycin hcl caps 250mg 4 QL(80/10)vancomycin hcl in dextrose 2 HIvancomycin hcl inj 0.9%; 1gm/200ml, 1000mg, 10gm, 500mg, 750mg

2 HI

vancomycin hcl inj 5000mg 2 B/D PAvancomycin hydrochloride/sodium chloride inj 0.9%; 750mg/150ml

2 HI

vandazole 2XIFAXAN TABS 550MG 5 PA QL(90/30)XIFAXAN TABS 200MG 4 PA QL(9/30)Beta-lactam, Cephalosporinscefaclor caps 2cefaclor er 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clindamycin 2 HIclindamycin hcl 2clindamycin palmitate hcl 2clindamycin phosphate crea 2clindamycin phosphate external soln

2

clindamycin phosphate foam 2clindamycin phosphate gel 2clindamycin phosphate in d5w 2 HIclindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml

2 HI

clindamycin phosphate lotn 2clindamycin phosphate swab 2clindamycin/sodium chloride 2 HIcolistimethate sodium 2CORTISPORIN CREA 3CORTISPORIN OINT 3daptomycin 5 HIFEM PH 4lincomycin hcl 2linezolid inj 2 HIlinezolid susr 5 QL(1800/30)linezolid tabs 5 QL(60/30)methenamine hippurate 2methenamine mandelate 2METRO IV 3 HImetronidazole caps 2metronidazole crea 2metronidazole gel 2metronidazole in nacl 0.79% 2 HImetronidazole inj 2 HImetronidazole lotn 2metronidazole tabs 2metronidazole vaginal 2MONUROL 4mupirocin crea 4mupirocin oint 2neo-polycin 2neo-polycin hc 2

11



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Beta-lactam, OtherAZACTAM 4 HIAZACTAM IN ISO-OSMOTIC DEXTROSE

4 HI

aztreonam 2 HIcefotetan 2doripenem 4 HIimipenem/cilastatin 2 HIINVANZ 4 HImeropenem 4 HImeropenem/sodium chloride inj 500mg/50ml; 0.9%

4 HI

meropenem/sodium chloride inj 1gm/50ml; 0.9%

5 HI

Beta-lactam, Penicillinsamoxicillin 2amoxicillin/clavulanate potassium

2

ampicillin 2ampicillin sodium inj 125mg, 250mg, 500mg

2

ampicillin sodium inj 10gm, 1gm, 2gm

2 HI

ampicillin-sulbactam 2 HIbactocill in dextrose 2 HIBICILLIN C-R 4BICILLIN L-A 4dicloxacillin sodium 2NAFCILLIN 3 HInafcillin sodium 2 HIoxacillin sodium inj 10gm, 2gm 2 HIpenicillin g potassium 2 HIpenicillin g potassium in iso-osmotic dextrose

2 HI

penicillin g procaine 2penicillin g sodium 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cefaclor susr 3cefadroxil 2cefazolin 2 HIcefazolin sodium inj 100gm, 10gm, 1gm, 1gm/50ml; 4%, 20gm, 300gm, 500mg

2 HI

cefazolin sodium/dextrose inj 1gm; 4%, 2gm; 3%

2 HI

cefdinir 2cefepime 2 HIcefepime/dextrose 2 HIcefixime 3cefotaxime sodium inj 1gm, 2gm, 500mg

2

cefotetan/dextrose 2cefoxitin sodium 2 HIcefpodoxime proxetil 2cefprozil 2ceftazidime 2 HIceftazidime/dextrose 2 HICEFTIN 4ceftriaxone in iso-osmotic dextrose

2

ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg

2

ceftriaxone/dextrose 2cefuroxime axetil 2cefuroxime sodium 2cefuroxime/dextrose 2cephalexin 2SUPRAX CAPS 4SUPRAX CHEW 4SUPRAX SUSR 500MG/5ML 4tazicef inj 1gm, 2gm, 6gm 2 HITEFLARO 5 HI

12


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5%

2 HI

ciprofloxacin inj 2 HIciprofloxacin susr 2gatifloxacin 2 QL(2.5/25)levofloxacin in d5w 2 HIlevofloxacin inj 2 HIlevofloxacin ophthalmic soln 2levofloxacin oral soln 2levofloxacin tabs 2 QL(30/30)moxifloxacinhydrochloride/sodium hydrochloride

4

moxifloxacin hcl inj 2moxifloxacin hcl ophthalmic soln

2

moxifloxacin hcl tabs 2 QL(30/30)moxifloxacin hydrochloride ophthalmic soln

2

ofloxacin 2VIGAMOX 3SulfonamidesBLEPHAMIDE 4BLEPHAMIDE S.O.P. 4sodium sulfacetamide ophthalmic soln

2

sulfacetamide sodium lotn 2sulfacetamide sodium oint 2sulfacetamide sodium/prednisolone sodium phosphate

2

sulfadiazine 2sulfamethoxazole/trimethoprim 2sulfamethoxazole/trimethoprim ds

2

Tetracyclinesdemeclocycline hcl 2doxy 100 2doxycycline hyclate caps 2doxycycline hyclate dr tbec 100mg, 150mg, 75mg

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

penicillin v potassium 2pfizerpen-g 2 HIpiperacillin sodium/tazobactam sodium

2 HI

piperacillin/tazobactam 2 HIMacrolidesAZASITE 3azithromycin inj 2 HIazithromycin pack 2azithromycin susr 200mg/5ml 2 QL(75/30)azithromycin susr 100mg/5ml 2 QL(150/30)azithromycin tabs 250mg, 500mg

2 QL(12/28)

azithromycin tabs 600mg 2 QL(60/30)clarithromycin er 2 QL(60/30)clarithromycin susr 2clarithromycin tabs 2 QL(42/14)DIFICID 5 PA QL(20/10)e.e.s. 400 3ery 2ERY-TAB 3ERYPED 400 5ERYTHROCIN LACTOBIONATE

3

erythrocin stearate 2erythromycin 2erythromycin base 3erythromycin ethylsuccinate 3PCE 3ZMAX 4 QL(60/30)QuinolonesAVELOX INJ 4BAXDELA 4BESIVANCE 4CILOXAN OINT 3CIPRO HC 3CIPRODEX 3ciprofloxacin er tb24 500mg; 0 2 QL(3/3)ciprofloxacin er tb24 1000mg; 0 2 QL(14/14)ciprofloxacin hcl 2

13



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Calcium Channel Modifying AgentsCELONTIN 4ethosuximide 2LYRICA CAPS 225MG, 300MG 3 QL(60/30)LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG

3 QL(90/30)

LYRICA ORAL SOLN 3 QL(900/30)zonisamide 2Gamma-aminobutyric Acid (GABA) Augmenting Agentsclonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg

2 QL(90/30)

clonazepam odt tbdp 1mg 2 QL(120/30)clonazepam odt tbdp 2mg 2 QL(300/30)clonazepam tabs 0.5mg 2 QL(90/30)clonazepam tabs 1mg 2 QL(120/30)clonazepam tabs 2mg 2 QL(300/30)DIASTAT ACUDIAL GEL 10MG 4 QL(20/30)DIASTAT ACUDIAL GEL 20MG 4 QL(40/30)DIASTAT PEDIATRIC 4 QL(5/30)diazepam rectal gel gel 2.5mg 2 QL(5/30)diazepam rectal gel gel 10mg 2 QL(20/30)diazepam rectal gel gel 20mg 2 QL(40/30)divalproex sodium 2divalproex sodium dr 2divalproex sodium er 2gabapentin caps 100mg 2 QL(180/30)gabapentin caps 300mg, 400mg

2 QL(270/30)

gabapentin oral soln 2 QL(2160/30)gabapentin tabs 800mg 2gabapentin tabs 600mg 2 QL(180/30)ONFI SUSP 4 QL(480/30)ONFI TABS 10MG, 5MG 4 QL(60/30)ONFI TABS 20MG 5 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

doxycycline hyclate tabs 100mg, 20mg

2

doxycycline monohydrate caps 150mg

2

doxycycline monohydrate caps 100mg, 50mg

2 QL(60/30)

doxycycline monohydrate tabs 2doxycycline susr 2minocycline hcl 2mondoxyne nl caps 100mg, 50mg

3 QL(60/30)

morgidox 1x50mg 2tetracycline hydrochloride 2

Anticonvulsants

Anticonvulsants, OtherAPTIOM TABS 200MG, 400MG, 800MG

5 QL(30/30)

APTIOM TABS 600MG 5 QL(60/30)BRIVIACT INJ 5 QL(600/30)BRIVIACT ORAL SOLN 5 QL(1200/30)BRIVIACT TABS 10MG, 25MG, 50MG, 75MG

5 QL(60/30)

BRIVIACT TABS 100MG 5 QL(120/30)FYCOMPA SUSP 4 QL(720/30)FYCOMPA TABS 4 QL(30/30)levetiracetam 2levetiracetam er tb24 750mg 2 QL(120/30)levetiracetam er tb24 500mg 2 QL(180/30)magnesium sulfate in d5w inj 5%; 1gm/100ml

2

roweepra 2roweepra xr tb24 750mg 2 QL(120/30)roweepra xr tb24 500mg 2 QL(180/30)SPRITAM TB3D 1000MG, 250MG, 500MG

4 QL(60/30)

SPRITAM TB3D 750MG 4 QL(120/30)

14


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VIMPAT INJ 4 QL(1200/30)VIMPAT ORAL SOLN 4 QL(1200/30)VIMPAT TABS 4 QL(60/30)

Antidementia Agents

Antidementia Agents, Otherergoloid mesylates 2 PACholinesterase Inhibitorsdonepezil hcl tabs 23mg, 5mg 2 QL(30/30)donepezil hcl tabs 10mg 2 QL(60/30)donepezil hcl tbdp 5mg 2 QL(30/30)donepezil hcl tbdp 10mg 2 QL(60/30)donepezil hydrochloride tabs 5mg

2 QL(30/30)

donepezil hydrochloride tabs 10mg

2 QL(60/30)

galantamine hydrobromide er 4 QL(30/30)galantamine hydrobromide oral soln

4 QL(200/30)

galantamine hydrobromide tabs 4 QL(60/30)rivastigmine tartrate 3 QL(60/30)rivastigmine transdermal system

4 QL(30/30)

N-methyl-D-aspartate (NMDA) Receptor Antagonistmemantine hcl tabs 10mg 2 PA QL(60/30)memantine hcl tabs 5mg 2 PA QL(90/30)memantine hcl titration pak 2 PA QL(49/28)memantine hydrochloride 2 PA QL(300/30)memantine hydrochloride er 4 PA QL(30/30)NAMENDA XR 4 PA QL(30/30)NAMENDA XR TITRATION PACK

4 PA QL(56/365)

Antidepressants

Antidepressants, OtherAPLENZIN 4 QL(30/30)bupropion hcl er tb12 150mg, 200mg

2 QL(60/30)

bupropion hcl sr 2 QL(60/30)bupropion hcl tabs 100mg 2 QL(120/30)bupropion hcl tabs 75mg 2 QL(180/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

phenobarbital elix 2 QL(1500/30)phenobarbital tabs 2 QL(120/30)primidone 2SABRIL PACK 5 PA QL(200/30)SABRIL TABS 5 PA QL(180/30)tiagabine hydrochloride tabs 4mg

4

tiagabine hydrochloride tabs 2mg

4 QL(60/30)


4 QL(90/30)


4 QL(120/30)

valproate sodium 2valproic acid 2vigabatrin 5 PA QL(200/30)Glutamate Reducing Agentsfelbamate susp 5felbamate tabs 2lamotrigine 2lamotrigine er 2lamotrigine odt 2topiramate 2Sodium Channel AgentsBANZEL SUSP 5 QL(2400/30)BANZEL TABS 200MG 5 QL(60/30)BANZEL TABS 400MG 5 QL(240/30)carbamazepine 2carbamazepine er 2DILANTIN 4DILANTIN INFATABS 4DILANTIN-125 4epitol 2fosphenytoin sodium inj 100mg pe/2ml

2

oxcarbazepine 2PEGANONE 4phenytoin 2phenytoin sodium 2phenytoin sodium extended 2

15



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluoxetine hcl caps 40mg 2 QL(60/30)fluoxetine hcl caps 20mg 2 QL(120/30)fluoxetine hcl oral soln 2 QL(600/30)fluoxetine hcl tabs 10mg, 60mg 2 QL(30/30)fluoxetine hcl tabs 20mg 2 QL(120/30)fluvoxamine maleate tabs 25mg, 50mg

2 QL(30/30)

fluvoxamine maleate tabs 100mg

2 QL(90/30)

olanzapine/fluoxetine 3 QL(30/30)paroxetine hcl tabs 10mg 2 QL(30/30)paroxetine hcl tabs 30mg, 40mg

2 QL(60/30)

paroxetine hcl tabs 20mg 2 QL(90/30)PAXIL SUSP 4 QL(900/30)PRISTIQ 3 QL(30/30)sertraline hcl conc 2 QL(300/30)sertraline hcl tabs 25mg 2 QL(30/30)sertraline hcl tabs 100mg 2 QL(60/30)sertraline hcl tabs 50mg 2 QL(120/30)venlafaxine hcl 2 QL(90/30)venlafaxine hcl er cp24 37.5mg 2 QL(30/30)venlafaxine hcl er cp24 150mg 2 QL(60/30)venlafaxine hcl er cp24 75mg 2 QL(90/30)venlafaxine hcl er tb24 225mg, 37.5mg, 75mg

4 QL(30/30)

venlafaxine hcl er tb24 150mg 4 QL(60/30)VIIBRYD 3 QL(30/30)VIIBRYD STARTER PACK 3 QL(30/30)Tricyclicsamitriptyline hcl 2 PAamoxapine 2clomipramine hcl 2 PAdesipramine hcl 2imipramine hcl 2 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

bupropion hcl xl 2 QL(30/30)maprotiline hcl 3 QL(90/30)mirtazapine 2 QL(30/30)mirtazapine odt 2 QL(30/30)nefazodone hcl 2 QL(60/30)trazodone hcl 2TRINTELLIX 4 QL(30/30)Monoamine Oxidase InhibitorsEMSAM 5 QL(30/30)MARPLAN 4 QL(180/30)phenelzine sulfate 2tranylcypromine sulfate 2SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitorcitalopram hydrobromide oral soln

2 QL(600/30)

citalopram hydrobromide tabs 10mg

2


2 QL(30/30)


2 QL(60/30)

desvenlafaxine er 3 QL(30/30)duloxetine hcl cpep 20mg, 60mg

2 QL(60/30)

duloxetine hcl cpep 30mg 2 QL(90/30)escitalopram oxalate oral soln 2 QL(600/30)escitalopram oxalate tabs 5mg 2 QL(30/30)escitalopram oxalate tabs 10mg 2 QL(60/30)escitalopram oxalate tabs 20mg 2 QL(90/30)FETZIMA 4 QL(30/30)FETZIMA TITRATION PACK 4 QL(56/365)fluoxetine caps 10mg 2 QL(30/30)fluoxetine caps 20mg 2 QL(120/30)fluoxetine hcl caps 10mg 2 QL(30/30)

16


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

caspofungin acetate 5 HIciclodan 2ciclopirox 2ciclopirox nail lacquer 2ciclopirox olamine 2clotrimazole external crea 2clotrimazole external soln 2clotrimazole lozg 2clotrimazole/betamethasone dipropionate

2

econazole nitrate 2fluconazole 2fluconazole in dextrose 2 HIfluconazole in nacl inj 200mg/100ml; 0.9%, 400mg/200ml; 0.9%

2 HI

flucytosine 5griseofulvin microsize 4griseofulvin ultramicrosize 4GYNAZOLE-1 4itraconazole 3 PA QL(120/30)ketoconazole crea 2ketoconazole sham 2ketoconazole tabs 2miconazole 3 2 QL(6/30)MYCAMINE 5 HInaftifine hcl 2naftifine hydrochloride 2NAFTIN GEL 3NATACYN 4NOXAFIL SUSP 5 PA QL(600/30)NOXAFIL TBEC 5 PA QL(96/30)nyamyc 2nystatin 2nystatin/triamcinolone 2nystop 2SPORANOX ORAL SOLN 5 PAterbinafine hcl tabs 2 QL(90/365)terconazole 2voriconazole inj 5 PA HI

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nortriptyline hcl 2perphenazine/amitriptyline 4 PAprotriptyline hcl 2trimipramine maleate 2 PA

Antiemetics

Antiemetics, Otherdimenhydrinate inj 2droperidol 2meclizine hcl tabs 2phenadoz 2 PAphenergan supp 2 PApromethazine hcl supp 2 PApromethegan 2 PAscopolamine 4 QL(10/30)TRANSDERM-SCOP 4 QL(10/30)Emetogenic Therapy Adjunctsaprepitant caps 40mg 3 B/D PA QL(1/30)aprepitant caps 125mg 3 B/D PA QL(2/28)aprepitant caps 80mg 3 B/D PA QL(4/28)aprepitant caps 3 B/D PA QL(6/28)CESAMET 5 B/D PA QL(60/30)dronabinol 3 B/D PA QL(60/30)EMEND SUSR 3 B/D PA QL(6/28)granisetron hcl inj 2 HIgranisetron hcl tabs 2 B/D PA QL(30/30)ondansetron hcl inj 40mg/20ml, 4mg/2ml

2 B/D PA

ondansetron hcl oral soln 2 B/D PA QL(450/30)ondansetron hcl tabs 24mg 2 B/D PA QL(15/30)ondansetron hcl tabs 4mg, 8mg 2 B/D PA QL(90/30)ondansetron odt 2 B/D PA QL(90/30)SANCUSO 5 PA QL(4/28)

Antifungals

AntifungalsABELCET 5 PAAMBISOME 5 PAamphotericin b 4 PACANCIDAS 5 HI

17



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antimyasthenic Agents

ParasympathomimeticsGUANIDINE HCL 3MESTINON SYRP 3pyridostigmine bromide 2pyridostigmine bromide er 4

Antimycobacterials

Antimycobacterials, Otherdapsone tabs 3rifabutin 3AntitubercularsCAPASTAT SULFATE 3cycloserine 2ethambutol hcl 2isoniazid 2PASER 4PRIFTIN 4pyrazinamide 2rifampin 2RIFATER 4SIRTURO 4 QL(188/365)TRECATOR 3

Antineoplastics

Alkylating AgentsBENDEKA 5 B/D PA QL(8/21)BICNU 3 B/D PAbusulfan 3 B/D PABUSULFEX 3 B/D PAcyclophosphamide caps 3 B/D PAcyclophosphamide inj 2gm 5 B/D PAcyclophosphamide inj 1gm, 500mg

4 B/D PA

dacarbazine 2 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

voriconazole susr 5 PA QL(300/30)voriconazole tabs 4 PA QL(90/30)zazole 2

Antigout Agents

Antigout Agentsallopurinol 2allopurinol sodium 4colchicine caps 3 QL(60/30)colchicine tabs 2 QL(120/30)MITIGARE 3 QL(60/30)probenecid 2probenecid/colchicine 2ULORIC 3 QL(30/30) ST

Antimigraine Agents

Ergot Alkaloidsdihydroergotamine mesylate inj 4 QL(30/28)ergotamine tartrate/caffeine 2 QL(40/28)migergot 5 QL(20/28)Serotonin (5-HT) 1b/1d Receptor Agonistsnaratriptan hcl 2 QL(9/30) STrizatriptan benzoate 2 QL(12/30)rizatriptan benzoate odt 2 QL(12/30)sumatriptan 2 QL(12/30)sumatriptan succinate inj 6mg/0.5ml

2 QL(4/30)

sumatriptan succinate inj 4mg/0.5ml

2 QL(8/30)

sumatriptan succinate refill inj 6mg/0.5ml

2 QL(4/30)

sumatriptan succinate refill inj 4mg/0.5ml

2 QL(8/30)

sumatriptan succinate tabs 2 QL(9/30)zolmitriptan 2 QL(6/30)zolmitriptan odt 2 QL(6/30)

18


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antimetabolitesadrucil 2 B/D PAALIMTA 5 PAARRANON 5 B/D PAcladribine 5 B/D PAclofarabine 5 B/D PAcytarabine aqueous 2 B/D PAcytarabine inj 100mg/ml 2 B/D PADROXIA 3ELITEK 5 B/D PAfloxuridine 3 B/D PAfluorouracil inj 2 B/D PAFOLOTYN 5 B/D PAgemcitabine hcl inj 1gm, 2gm 5 B/D PAgemcitabine hcl inj 200mg 2 B/D PAgemcitabine hydrochloride inj 1.5gm/15ml, 1gm/10ml, 200mg/2ml, 2gm/20ml

5 B/D PA

gemcitabine inj 1gm/26.3ml, 2gm/52.6ml

5 B/D PA

gemcitabine inj 200mg/5.26ml 2 B/D PAhydroxyurea 2LONSURF TABS 8.19MG; 20MG

5 QL(80/28)

LONSURF TABS 6.14MG; 15MG

5 QL(100/28)

mercaptopurine 2NIPENT 5 B/D PAPURIXAN 5 QL(300/30)TABLOID 4VYXEOS 5 B/D PAAntineoplastics, OtherABRAXANE 5 PAadriamycin 2 B/D PAazacitidine 5 B/D PABELEODAQ 5 B/D PAbleomycin sulfate 2 B/D PABORTEZOMIB 5 PA QL(14/21)carboplatin inj 150mg/15ml, 50mg/5ml

2 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

EVOMELA 5 B/D PAGLEOSTINE 3HEXALEN 5ifosfamide inj 1gm, 3gm 2 B/D PAKISQALI FEMARA 200 DOSE 5 PA QL(49/28)KISQALI FEMARA 400 DOSE 5 PA QL(70/28)KISQALI FEMARA 600 DOSE 5 PA QL(91/28)LEUKERAN 3MATULANE 5melphalan hydrochloride 2 B/D PAMUSTARGEN 3 B/D PAthiotepa 2 B/D PATREANDA INJ 100MG 5 B/D PATREANDA INJ 25MG 5 B/D PA QL(8/21)VALCHLOR 5 QL(60/30)YONDELIS 5 B/D PAZANOSAR 4 B/D PAAntiandrogensbicalutamide 2 QL(30/30)ERLEADA 5 QL(120/30)flutamide 2nilutamide 5 QL(60/30)XTANDI 5 QL(120/30)ZYTIGA TABS 500MG 5 QL(60/30)ZYTIGA TABS 250MG 5 QL(120/30)Antiangiogenic AgentsPOMALYST 5 QL(21/28)REVLIMID CAPS 15MG, 20MG, 25MG

5 QL(21/28)

REVLIMID CAPS 10MG, 2.5MG, 5MG

5 QL(28/28)

THALOMID CAPS 100MG, 150MG, 50MG

5 QL(28/28)

THALOMID CAPS 200MG 5 QL(56/28)Antiestrogens/ModifiersEMCYT 3FARESTON 5 QL(30/30)FASLODEX 5 B/D PA QL(30/30)SOLTAMOX 5tamoxifen citrate 2

19



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

mesna 2 B/D PAMESNEX TABS 5mitomycin inj 40mg 5 B/D PAmitomycin inj 20mg, 5mg 4 B/D PAmitoxantrone hcl 2 B/D PANERLYNX 5 PA QL(180/30)NINLARO 5 QL(3/28)ODOMZO 5 QL(30/30)oxaliplatin inj 100mg, 100mg/20ml, 50mg/10ml

4 B/D PA

paclitaxel 2 B/D PAPORTRAZZA 5 B/D PAPROLEUKIN 5 B/D PAromidepsin 5 B/D PARUBRACA 5 PA QL(120/30)RYDAPT 5 PA QL(224/28)SYLATRON 5 PA QL(4/28)SYNRIBO 5 B/D PA QL(28/28)TICE BCG 3TRISENOX 4 B/D PAVELCADE 5 PA QL(14/21)VENCLEXTA STARTING PACK 5 QL(84/365)VENCLEXTA TABS 50MG 4 QL(30/30)VENCLEXTA TABS 10MG 4 QL(60/30)VENCLEXTA TABS 100MG 5 QL(120/30)VERZENIO 5 PA QL(60/30)vinblastine sulfate 2 B/D PAvincasar pfs 2 B/D PAvincristine sulfate 2 B/D PAvinorelbine tartrate inj 50mg/5ml

2 B/D PA

ZEJULA 5 PA QL(90/30)ZOLINZA 5 QL(120/30)Aromatase Inhibitors, 3rd Generationanastrozole 2 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cisplatin 2 B/D PACOSMEGEN 5 B/D PAdactinomycin 5 B/D PAdaunorubicin hcl 2 B/D PAdecitabine 5 B/D PAdexrazoxane 2 B/D PADOCETAXEL INJ 200MG/10ML 5 B/D PAdocetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml

5 B/D PA

doxorubicin hcl 2 B/D PAdoxorubicin hcl liposome 5 B/D PAepirubicin hcl inj 200mg/100ml 2 B/D PAERWINAZE 5 B/D PA QL(60/28)ETHYOL 5 B/D PAfludarabine phosphate inj 50mg 2 B/D PAHALAVEN 5idarubicin hcl 5 B/D PAirinotecan 2 B/D PAirinotecan hcl 2 B/D PAirinotecan hydrochloride inj 40mg/2ml

2 B/D PA

ISTODAX (OVERFILL) 5 B/D PAIXEMPRA KIT 5 B/D PAJEVTANA 5 PAKISQALI 5 PA QL(63/28)LARTRUVO 5 PAleucovorin calcium 2levoleucovorin calcium 5levoleucovorin inj 175mg/17.5ml, 250mg/25ml, 50mg

5

lipodox 50 5 B/D PALYNPARZA TABS 5 QL(120/30)MARQIBO 5 B/D PA

20


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

IDHIFA 5 PA QL(30/30)imatinib mesylate 5 PA QL(60/30)IMBRUVICA CAPS 70MG 5 QL(30/30)IMBRUVICA CAPS 140MG 5 QL(120/30)IMBRUVICA TABS 5 QL(30/30)INLYTA 5 QL(120/30)IRESSA 5JAKAFI 5 QL(60/30)LENVIMA 10 MG DAILY DOSE 5 QL(30/30)LENVIMA 14 MG DAILY DOSE 5 QL(60/30)LENVIMA 18 MG DAILY DOSE 5 QL(90/30)LENVIMA 20 MG DAILY DOSE 5 QL(60/30)LENVIMA 24 MG DAILY DOSE 5 QL(90/30)LENVIMA 8 MG DAILY DOSE 5 QL(60/30)LYNPARZA CAPS 5 QL(448/28)MEKINIST TABS 2MG 5 QL(30/30)MEKINIST TABS 0.5MG 5 QL(90/30)NEXAVAR 5 QL(120/30)SPRYCEL 5 QL(30/30)STIVARGA 5 QL(84/28)SUTENT 5 QL(28/28)TAFINLAR 5 QL(120/30)TAGRISSO 5 QL(30/30)TARCEVA TABS 100MG, 150MG

5 QL(30/30)

TARCEVA TABS 25MG 5 QL(60/30)TASIGNA CAPS 50MG 5 QL(420/30)TASIGNA CAPS 150MG, 200MG

5 QL(112/28)

TYKERB 5 QL(180/30)VOTRIENT 5 QL(120/30)XALKORI 5 QL(60/30)ZALTRAP 5 B/D PA QL(40/28)ZELBORAF 5 QL(240/30)ZYDELIG 5 QL(60/30)ZYKADIA 5 QL(140/28)Monoclonal Antibody/Antibody-Drug ConjugateAVASTIN 5 PABAVENCIO 5 B/D PABESPONSA 5 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

exemestane 2 QL(60/30)letrozole 2 QL(30/30)Enzyme Inhibitorsetoposide inj 2 B/D PAKYPROLIS 5 B/D PAtoposar 2 B/D PAtopotecan hcl 5 B/D PAMolecular Target InhibitorsAFINITOR DISPERZ TBSO 2MG, 3MG

5 QL(56/28)

AFINITOR DISPERZ TBSO 5MG

5 QL(112/28)

AFINITOR TABS 2.5MG, 5MG, 7.5MG

5 QL(28/28)

AFINITOR TABS 10MG 5 QL(56/28)ALECENSA 5 PA QL(240/30)ALIQOPA 5 PA QL(3/28)ALUNBRIG TABS 180MG, 90MG

5 PA QL(30/30)

ALUNBRIG TABS 30MG 5 PA QL(180/30)ALUNBRIG TBPK 5 PA QL(60/365)BOSULIF TABS 400MG, 500MG

5 QL(30/30)

BOSULIF TABS 100MG 5 QL(120/30)CABOMETYX TABS 20MG, 60MG

5 PA QL(30/30)

CABOMETYX TABS 40MG 5 PA QL(60/30)CALQUENCE 5 PA QL(60/30)CAPRELSA TABS 300MG 5 QL(30/30)CAPRELSA TABS 100MG 5 QL(60/30)COMETRIQ KIT 5 QL(56/28)COMETRIQ KIT 20MG 5 QL(84/28)COMETRIQ KIT 5 QL(112/28)COTELLIC 5 QL(63/28)ERIVEDGE 5 QL(28/28)FARYDAK 5 QL(6/21)GILOTRIF 5 QL(30/30)IBRANCE 5 QL(21/28)ICLUSIG TABS 45MG 5 QL(30/30)ICLUSIG TABS 15MG 5 QL(60/30)

21



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ALINIA TABS 5 QL(20/30)atovaquone 4atovaquone/proguanil hcl 2chloroquine phosphate 2COARTEM 4 QL(24/30)DARAPRIM 5 QL(90/30)hydroxychloroquine sulfate 2mefloquine hcl 2NEBUPENT 4 B/D PA QL(6/28)PENTAM 300 4PRIMAQUINE PHOSPHATE 4quinine sulfate 2 PA QL(42/7)Pediculicides/ScabicidesEURAX 4lindane 2malathion 2permethrin 2SKLICE 4

Antiparkinson Agents

Anticholinergicsbenztropine mesylate inj 2benztropine mesylate tabs 2 PAtrihexyphenidyl hcl 2 PAAntiparkinson Agents, Otheramantadine hcl 2entacapone 2 QL(240/30)tolcapone 5Dopamine AgonistsAPOKYN 5 PA QL(60/30)bromocriptine mesylate 2NEUPRO 4 QL(30/30)pramipexole dihydrochloride 2 QL(90/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CYRAMZA 5 B/D PADARZALEX 5 B/D PAEMPLICITI 5 B/D PAERBITUX 5 PAGAZYVA 5 B/D PAHERCEPTIN INJ 440MG 5 PAHERCEPTIN INJ 150MG 5 B/D PAIMFINZI 5 PAKADCYLA 5 B/D PAKEYTRUDA 5 B/D PAMYLOTARG 5 PAOPDIVO INJ 240MG/24ML 5 B/D PA QL(48/28)OPDIVO INJ 100MG/10ML, 40MG/4ML

5 B/D PA QL(80/28)

PERJETA 5 B/D PARITUXAN 5 PARITUXAN HYCELA 5 PATECENTRIQ 5 PA QL(20/21)UNITUXIN 5 B/D PAVECTIBIX 5 PAYERVOY INJ 50MG/10ML 5 PAYERVOY INJ 200MG/40ML 5 PA QL(80/21)Retinoidsbexarotene 5PANRETIN 5TARGRETIN GEL 5 QL(60/30)tretinoin caps 5

Antiparasitics

AnthelminticsALBENZA 4BILTRICIDE 4ivermectin 2AntiprotozoalsALINIA SUSR 4 QL(150/30)

22


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

prochlorperazine maleate 2thioridazine hcl 2thiothixene 2trifluoperazine hcl 22nd Generation/AtypicalABILIFY MAINTENA 5 QL(1/28)aripiprazole odt 5 QL(60/30)aripiprazole oral soln 3 QL(900/30)aripiprazole tabs 3 QL(30/30)ARISTADA INJ 441MG/1.6ML 5 QL(1.6/30)ARISTADA INJ 662MG/2.4ML 5 QL(2.4/30)ARISTADA INJ 882MG/3.2ML 5 QL(3.2/30)ARISTADA INJ 1064MG/3.9ML 5 QL(3.9/60)FANAPT TABS 10MG, 12MG, 6MG, 8MG

5 QL(60/30) ST

FANAPT TABS 1MG, 2MG, 4MG

4 QL(60/30) ST

FANAPT TITRATION PACK 4 QL(16/365) STGEODON INJ 4 QL(6/30)INVEGA SUSTENNA INJ 39MG/0.25ML

4 QL(0.25/28)

INVEGA SUSTENNA INJ 78MG/0.5ML

5 QL(0.5/28)


5 QL(0.75/28)

INVEGA SUSTENNA INJ 156MG/ML

5 QL(1/28)


5 QL(1.5/28)

INVEGA TRINZA INJ 273MG/0.875ML

5 QL(0.88/90)


5 QL(1.32/90)


5 QL(1.75/90)


5 QL(2.63/90)

LATUDA TABS 120MG, 20MG, 40MG, 60MG

5 QL(30/30) ST

LATUDA TABS 80MG 5 QL(60/30) STNUPLAZID 5 PA QL(60/30)olanzapine inj 2 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg

4 QL(30/30)

pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg

4 QL(90/30)

ropinirole er tb24 2mg, 4mg, 6mg, 8mg

2 QL(30/30)

ropinirole er tb24 12mg 2 QL(60/30)ropinirole hcl 2Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitorscarbidopa 2carbidopa/levodopa 2carbidopa/levodopa er 2carbidopa/levodopa odt 2carbidopa/levodopa/entacapone

2

RYTARY 4 STMonoamine Oxidase B (MAO-B) Inhibitorsrasagiline mesylate 3 QL(30/30)selegiline hcl 2ZELAPAR 5

Antipsychotics

1st Generation/Typicalchlorpromazine hcl 2compro 2fluphenazine decanoate 2fluphenazine hcl 2haloperidol 2haloperidol decanoate 2haloperidol lactate 2loxapine caps 10mg, 5mg 2 QL(120/30)loxapine succinate caps 25mg, 50mg

2

loxapine succinate caps 10mg, 5mg

2 QL(120/30)

perphenazine 2pimozide 2prochlorperazine 2prochlorperazine edisylate 2

23



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clozapine odt tbdp 150mg 4 QL(180/30)clozapine odt tbdp 100mg 4 QL(270/30)clozapine odt tbdp 200mg 5 QL(120/30)clozapine tabs 25mg, 50mg 2clozapine tabs 200mg 2 QL(120/30)clozapine tabs 100mg 2 QL(270/30)VERSACLOZ 4 QL(540/30)

Antispasticity Agents

Antispasticity Agentsbaclofen tabs 2dantrolene sodium 2tizanidine hcl caps 4tizanidine hcl tabs 2

Antivirals

Anti-cytomegalovirus (CMV) Agentscidofovir 5ganciclovir inj 500mg 2 B/D PAvalganciclovir 5valganciclovir hydrochlorde 5ZIRGAN 4Anti-hepatitis B (HBV) Agentsadefovir dipivoxil 4 QL(30/30)BARACLUDE ORAL SOLN 4 QL(630/30)entecavir 4 QL(30/30)EPIVIR HBV ORAL SOLN 4INTRON A INJ 18MU 4INTRON A INJ 10MU, 10MU/ML, 50MU, 6000000UNIT/ML

5

lamivudine tabs 100mg 2Anti-hepatitis C (HCV) Agents, Direct Acting AgentsEPCLUSA 5 PA QL(28/28)HARVONI 5 PA QL(28/28)VOSEVI 5 PA QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

olanzapine odt 3 QL(30/30)olanzapine tabs 2 QL(30/30)paliperidone er tb24 1.5mg, 3mg

2 QL(30/30)

paliperidone er tb24 6mg 2 QL(60/30)paliperidone er tb24 9mg 5 QL(30/30)quetiapine fumarate 2 QL(60/30)quetiapine fumarate er tb24 150mg, 200mg

3 QL(30/30)

quetiapine fumarate er tb24 300mg, 400mg, 50mg

3 QL(60/30)

REXULTI 5 QL(30/30)RISPERDAL CONSTA INJ 50MG

5 QL(2/28)

RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG

4 QL(2/28)

risperidone m-tab 3 QL(60/30)risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg

3 QL(60/30)

risperidone odt tbdp 4mg 3 QL(120/30)risperidone oral soln 2 QL(240/30)risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg

2 QL(60/30)

risperidone tabs 4mg 2 QL(120/30)SAPHRIS 4 QL(60/30)VRAYLAR CAPS 5 QL(30/30) STVRAYLAR CPPK 4 QL(14/365) STziprasidone hcl 3 QL(60/30)ZYPREXA RELPREVV INJ 405MG

5 QL(1/28)

ZYPREXA RELPREVV INJ 300MG

5 QL(2/28)

ZYPREXA RELPREVV INJ 210MG

4 QL(2/28)

Treatment-Resistantclozapine odt tbdp 12.5mg, 25mg

4

24


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)abacavir oral soln 3 QL(960/30)abacavir sulfate/lamivudine/zidovudine

5 QL(60/30)

abacavir tabs 2 QL(60/30)abacavir/lamivudine 5 QL(30/30)CIMDUO 5 QL(30/30)DESCOVY 5 QL(30/30)didanosine 2 QL(30/30)EMTRIVA CAPS 4 QL(30/30)EMTRIVA ORAL SOLN 4 QL(680/28)lamivudine oral soln 2 QL(900/30)lamivudine tabs 300mg 2 QL(30/30)lamivudine tabs 150mg 2 QL(60/30)lamivudine/zidovudine 2 QL(60/30)RETROVIR IV INFUSION 4stavudine 2 QL(60/30)tenofovir disoproxil fumarate 5 QL(30/30)TRIUMEQ 5 QL(30/30)TRUVADA 5 QL(30/30)VIDEX EC CPDR 125MG 4 QL(30/30)VIDEX PEDIATRIC 3 QL(1200/30)VIREAD POWD 5 QL(240/30)VIREAD TABS 5 QL(30/30)ZERIT ORAL SOLN 3 QL(2400/30)ZIAGEN ORAL SOLN 4 QL(960/30)zidovudine caps 2 QL(180/30)zidovudine syrp 2 QL(1680/28)zidovudine tabs 2 QL(60/30)Anti-HIV Agents, OtherATRIPLA 5 QL(30/30)FUZEON 5 QL(60/30)ISENTRESS HD 5 QL(60/30)SELZENTRY ORAL SOLN 5 QL(1610/26)SELZENTRY TABS 150MG, 75MG

5 QL(60/30)

SELZENTRY TABS 300MG 5 QL(120/30)SELZENTRY TABS 25MG 4 QL(240/30)TROGARZO 5 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Anti-hepatitis C (HCV) Agents, OtherPEGASYS INJ 180MCG/0.5ML 5 PA QL(2/28)PEGASYS INJ 180MCG/ML 5 PA QL(4/28)PEGASYS PROCLICK 5 PA QL(2/28)ribavirin caps 3 QL(168/28)ribavirin tabs 3 QL(168/28)Anti-HIV Agents, Integrase Inhibitors (INSTI)BIKTARVY 5 QL(30/30)GENVOYA 5 QL(30/30)ISENTRESS CHEW 100MG 5 QL(180/30)ISENTRESS CHEW 25MG 3 QL(180/30)ISENTRESS PACK 5 QL(180/30)ISENTRESS TABS 5 QL(60/30)JULUCA 5 QL(30/30)TIVICAY TABS 50MG 5 QL(60/30)TIVICAY TABS 10MG, 25MG 4 QL(60/30)Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)COMPLERA 5 QL(30/30)EDURANT 5 QL(30/30)efavirenz caps 200mg 3 QL(60/30)efavirenz caps 50mg 3 QL(90/30)efavirenz tabs 5 QL(30/30)INTELENCE TABS 100MG, 200MG

5 QL(60/30)

INTELENCE TABS 25MG 4 QL(120/30)nevirapine er tb24 400mg 2 QL(30/30)nevirapine er tb24 100mg 2 QL(90/30)nevirapine susp 2 QL(1200/30)nevirapine tabs 2 QL(60/30)ODEFSEY 5 QL(30/30)RESCRIPTOR TABS 200MG 4 QL(180/30)RESCRIPTOR TABS 100MG 4 QL(270/30)STRIBILD 5 QL(30/30)SUSTIVA CAPS 200MG 5 QL(60/30)SUSTIVA CAPS 50MG 3 QL(90/30)SUSTIVA TABS 5 QL(30/30)SYMFI 5 QL(30/30)SYMFI LO 5 QL(30/30)

25



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

REYATAZ CAPS 200MG 5 QL(60/30)REYATAZ PACK 5 QL(180/30)ritonavir 4 QL(360/30)VIRACEPT TABS 625MG 5 QL(120/30)VIRACEPT TABS 250MG 5 QL(270/30)Anti-influenza Agentsoseltamivir phosphate caps 45mg, 75mg

3 QL(56/365)

oseltamivir phosphate caps 30mg

3 QL(112/365)

oseltamivir phosphate susr 3 QL(700/365)rimantadine hcl 2TAMIFLU CAPS 45MG, 75MG 4 QL(56/365)TAMIFLU CAPS 30MG 4 QL(112/365)TAMIFLU SUSR 3 QL(700/365)Antiherpetic Agentsacyclovir caps 2acyclovir oint 4 QL(30/30)acyclovir sodium 2 B/D PAacyclovir susp 2acyclovir tabs 2famciclovir 2 QL(60/30)trifluridine 2valacyclovir hcl 2 QL(30/30)ZOVIRAX CREA 4 QL(5/30)

Anxiolytics

Anxiolytics, Otherbuspirone hcl 2doxepin hcl 2 PABenzodiazepinesalprazolam intensol 2 QL(300/30)alprazolam odt tbdp 0.25mg, 0.5mg, 1mg

2 QL(90/30)

alprazolam odt tbdp 2mg 2 QL(150/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TYBOST 3 QL(30/30)Anti-HIV Agents, Protease InhibitorsAPTIVUS CAPS 5 QL(120/30)APTIVUS ORAL SOLN 5 QL(285/28)atazanavir caps 300mg 5 QL(30/30)atazanavir caps 200mg 5 QL(60/30)atazanavir caps 150mg 4 QL(30/30)atazanavir sulfate caps 150mg 4 QL(30/30)atazanavir sulfate caps 300mg 5 QL(30/30)atazanavir sulfate caps 200mg 5 QL(60/30)CRIXIVAN CAPS 400MG 3 QL(180/30)CRIXIVAN CAPS 200MG 3 QL(270/30)EVOTAZ 5 QL(30/30)fosamprenavir calcium 5 QL(120/30)INVIRASE CAPS 5 QL(300/30)INVIRASE TABS 5 QL(120/30)kaletra oral soln 4 QL(480/30)KALETRA TABS 100MG; 25MG

4 QL(300/30)

KALETRA TABS 200MG; 50MG

5 QL(120/30)

LEXIVA SUSP 4 QL(1575/28)LEXIVA TABS 5 QL(120/30)lopinavir/ritonavir 4 QL(480/30)NORVIR CAPS 4 QL(360/30)NORVIR ORAL SOLN 4 QL(480/30)NORVIR TABS 4 QL(360/30)PREZCOBIX 5 QL(30/30)PREZISTA SUSP 5 QL(400/30)PREZISTA TABS 800MG 5 QL(30/30)PREZISTA TABS 600MG 5 QL(60/30)PREZISTA TABS 150MG 4 QL(180/30)PREZISTA TABS 75MG 4 QL(210/30)REYATAZ CAPS 150MG, 300MG

5 QL(30/30)

26


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

glipizide er tb24 2.5mg 1 QL(240/30)glipizide tabs 5mg 1 QL(60/30)glipizide tabs 10mg 1 QL(120/30)glipizide xl tb24 10mg 1 QL(60/30)glipizide xl tb24 5mg 1 QL(120/30)glipizide xl tb24 2.5mg 1 QL(240/30)glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg

1 QL(120/30)

glipizide/metformin hcl tabs 2.5mg; 250mg

1 QL(240/30)

GLYXAMBI 4 QL(30/30)INVOKAMET 3 QL(60/30)INVOKAMET XR 3 QL(60/30)INVOKANA 3 QL(30/30)JANUMET 3 QL(60/30)JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG

3 QL(30/30)

JANUMET XR TB24 1000MG; 50MG

3 QL(60/30)

JANUVIA 3 QL(30/30)JARDIANCE 4 QL(30/30)JENTADUETO 3 QL(60/30)JENTADUETO XR TB24 5MG; 1000MG

3 QL(30/30)

JENTADUETO XR TB24 2.5MG; 1000MG

3 QL(60/30)

metformin hcl er tb24 750mg (generic Glucophage XR)

1 QL(60/30)

metformin hcl er tb24 500mg (generic for Glucophage XR)

1 QL(120/30)

metformin hcl tabs 1000mg 1 QL(60/30)metformin hcl tabs 850mg 1 QL(90/30)metformin hcl tabs 500mg 1 QL(150/30)miglitol 4 QL(90/30)nateglinide 2 QL(90/30)OZEMPIC 3 QL(3/30)pioglitazone hcl 1 QL(30/30)pioglitazone hcl-glimepiride 3 QL(30/30)pioglitazone hcl/metformin hcl 2 QL(90/30)repaglinide tabs 0.5mg, 1mg 2 QL(120/30)repaglinide tabs 2mg 2 QL(240/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

alprazolam tabs 0.25mg, 0.5mg, 1mg

2 QL(90/30)

alprazolam tabs 2mg 2 QL(150/30)clorazepate dipotassium tabs 3.75mg, 7.5mg

3 QL(90/30)

clorazepate dipotassium tabs 15mg

3 QL(180/30)

diazepam conc 2 QL(240/30)diazepam inj 5mg/ml 2diazepam intensol 2 QL(240/30)diazepam oral soln 2 QL(1200/30)diazepam tabs 2 QL(120/30)lorazepam conc 2 QL(150/30)lorazepam inj 2lorazepam intensol 2 QL(150/30)lorazepam tabs 0.5mg, 1mg 2 QL(90/30)lorazepam tabs 2mg 2 QL(150/30)oxazepam 2 QL(120/30)

Bipolar Agents

Mood Stabilizerslithium 2lithium carbonate 2lithium carbonate er 2

Blood Glucose Regulators

Antidiabetic Agentsacarbose 2 QL(90/30)AVANDIA 4 QL(60/30) STBYDUREON 3 QL(4/28)BYDUREON BCISE 3 QL(4/28)BYDUREON PEN 3 QL(4/28)BYETTA INJ 5MCG/0.02ML 3 QL(1.2/30)BYETTA INJ 10MCG/0.04ML 3 QL(2.4/30)FARXIGA 3 QL(30/30)glimepiride tabs 4mg 1 QL(60/30)glimepiride tabs 2mg 1 QL(120/30)glimepiride tabs 1mg 1 QL(240/30)glipizide er tb24 10mg 1 QL(60/30)glipizide er tb24 5mg 1 QL(120/30)

27



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMULIN R U-500 (CONCENTRATED)

3

HUMULIN R U-500 KWIKPEN 3LANTUS 3LANTUS SOLOSTAR 3LEVEMIR 3LEVEMIR FLEXTOUCH 3NOVOLIN 70/30 4 STNOVOLIN 70/30 RELION 4 STNOVOLIN N 4 STNOVOLIN N RELION 4 STNOVOLIN R 4 STNOVOLIN R INNOLET 4 STNOVOLIN R RELION 4 STNOVOLOG 4 STNOVOLOG FLEXPEN 4 STNOVOLOG MIX 70/30 4 STNOVOLOG MIX 70/30 PREFILLED FLEXPEN

4 ST

NOVOLOG PENFILL 4 STSOLIQUA 100/33 3 QL(18/30) STTOUJEO MAX SOLOSTAR 3TOUJEO SOLOSTAR 3TRESIBA FLEXTOUCH 3XULTOPHY 100/3.6 3 QL(15/30) ST

Blood Products/Modifiers/Volume Expanders

AnticoagulantsCOUMADIN 4ELIQUIS STARTER PACK 3 QL(74/30)ELIQUIS TABS 2.5MG 3 QL(60/30)ELIQUIS TABS 5MG 3 QL(74/30)enoxaparin sodium inj 30mg/0.3ml

3 QL(9/90)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RIOMET 3 QL(750/30)SYMLINPEN 120 4 QL(10.8/28)SYMLINPEN 60 4 QL(6/30)SYNJARDY 4 QL(60/30)SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG

4 QL(30/30)

SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG

4 QL(60/30)

TRADJENTA 3 QL(30/30)TRULICITY 3 QL(2/28)VICTOZA 3 QL(9/30)XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 2.5MG; 1000MG, 5MG; 500MG

3 QL(30/30)

XIGDUO XR TB24 5MG; 1000MG

3 QL(60/30)

Glycemic AgentsGLUCAGEN HYPOKIT 3 QL(4/30)GLUCAGON EMERGENCY KIT

3 QL(4/30)

PROGLYCEM 4InsulinsHUMALOG 3HUMALOG JUNIOR KWIKPEN 3HUMALOG KWIKPEN 3HUMALOG MIX 50/50 3HUMALOG MIX 50/50 KWIKPEN

3

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

3

HUMULIN 70/30 3HUMULIN 70/30 KWIKPEN 3HUMULIN N 3HUMULIN N KWIKPEN 3HUMULIN R 3

28


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

warfarin sodium 2XARELTO STARTER PACK 3 QL(102/365)XARELTO TABS 20MG 3 QL(30/30)XARELTO TABS 15MG 3 QL(60/30)XARELTO TABS 10MG 3 QL(90/90)Blood Formation Modifiersanagrelide hydrochloride 2ARANESP ALBUMIN FREE INJ 60MCG/0.3ML

4 PA QL(1.2/28)

ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML

4 PA QL(1.6/28)

ARANESP ALBUMIN FREE INJ 25MCG/0.42ML

4 PA QL(1.68/28)

ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML

4 PA QL(4/28)

ARANESP ALBUMIN FREE INJ 500MCG/ML

5 PA QL(1/21)


5 PA QL(1.2/28)


5 PA QL(1.6/28)


5 PA QL(2/28)


5 PA QL(2.4/28)

ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML

5 PA QL(4/28)

GRANIX 5LEUKINE INJ 250MCG 5 PAMOZOBIL 5 QL(9.6/30)PROCRIT INJ 40000UNIT/ML 5 PA QL(6/28)PROCRIT INJ 20000UNIT/ML 5 PA QL(12/28)PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

3 PA QL(12/28)

PROMACTA 5 PA QL(30/30)ZARXIO 5Hemostasis Agentsaminocaproic acid 2tranexamic acid inj 2tranexamic acid tabs 2 QL(30/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

enoxaparin sodium inj 40mg/0.4ml

3 QL(12/90)

enoxaparin sodium inj 60mg/0.6ml

3 QL(18/90)

enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml

3 QL(24/90)

enoxaparin sodium inj 100mg/ml, 150mg/ml, 300mg/3ml

3 QL(30/90)

fondaparinux sodium inj 2.5mg/0.5ml

4 QL(15/90)

fondaparinux sodium inj 5mg/0.4ml

5 QL(12/90)

fondaparinux sodium inj 7.5mg/0.6ml

5 QL(18/90)

fondaparinux sodium inj 10mg/0.8ml

5 QL(24/90)

FRAGMIN INJ 7500UNIT/0.3ML

5 QL(9/30) ST


5 QL(15/30) ST


5 QL(18/30) ST

FRAGMIN INJ 18000UNT/0.72ML

5 QL(21.6/30) ST


5 QL(22.8/30) ST

FRAGMIN INJ 10000UNIT/ML 5 QL(30/30) STFRAGMIN INJ 2500UNIT/0.2ML, 5000UNIT/0.2ML

4 QL(6/30) ST

heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml

2

heparin sodium/d5w 2heparin sodium/nacl 0.45% 2heparin sodium/nacl 0.9% 2heparin sodium/sodium chloride 0.9%

2

heparin sodium/sodium chloride 0.9% premix

2

jantoven 2PRADAXA 4 QL(60/30)SAVAYSA 4 QL(30/30)

29



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

losartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg

1 QL(60/30)

olmesartan medoxomil 4 QL(30/30)olmesartan medoxomil/hydrochlorothiazide

4 QL(30/30)

valsartan 1 QL(30/30)valsartan/hydrochlorothiazide 1 QL(30/30)Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl 1 QL(60/30)benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg, 20mg; 25mg, 5mg; 6.25mg

1 QL(30/30)

benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg

1 QL(60/30)

captopril tabs 100mg, 50mg 3captopril tabs 12.5mg, 25mg 3 QL(90/30)enalapril maleate 1 QL(60/30)enalapril maleate/hydrochlorothiazide

1 QL(60/30)

enalaprilat 2fosinopril sodium 1 QL(60/30)fosinopril sodium/hydrochlorothiazide

1 QL(120/30)

lisinopril 1 QL(60/30)lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg, 25mg; 20mg

1 QL(60/30)

lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg

1 QL(120/30)

moexipril hcl 1moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg

1 QL(30/30)

moexipril/hydrochlorothiazide tabs 12.5mg; 15mg, 25mg; 15mg

1 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Platelet Modifying AgentsAGGRENOX 4 QL(60/30) STaspirin/dipyridamole 3 QL(60/30)BRILINTA 3 QL(60/30)cilostazol 2clopidogrel tabs 300mg 2 QL(2/365)clopidogrel tabs 75mg 2 QL(30/30)prasugrel 4 QL(30/30)

Cardiovascular Agents

Alpha-adrenergic Agonistsclonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr

2 QL(4/28)

clonidine hcl ptwk 0.3mg/24hr 2 QL(8/28)clonidine hcl tabs 1midodrine hcl 2Alpha-adrenergic Blocking Agentsphenoxybenzamine hydrochloride

5

prazosin hcl 2Angiotensin II Receptor AntagonistsBENICAR 4 QL(30/30) STBENICAR HCT 4 QL(30/30) STEDARBI 4 STEDARBYCLOR 4 STENTRESTO 3 PA QL(60/30)irbesartan 1 QL(30/30)irbesartan/hydrochlorothiazide 1 QL(30/30)losartan potassium tabs 100mg 1 QL(30/30)losartan potassium tabs 25mg, 50mg

1 QL(60/30)

losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg

1 QL(30/30)

30


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

bisoprolol fumarate/hydrochlorothiazide

2

BYSTOLIC TABS 10MG, 2.5MG, 5MG

3 QL(30/30)

BYSTOLIC TABS 20MG 3 QL(60/30)BYVALSON 3 QL(30/30)carvedilol 2carvedilol phosphate 4 QL(30/30)COREG CR 4 QL(30/30)labetalol hcl 2metoprolol succinate er 2 QL(60/30)metoprolol tartrate inj 2metoprolol tartrate tabs 1metoprolol/hydrochlorothiazide 2nadolol 2nadolol/bendroflumethiazide 3 QL(30/30)pindolol 2propranolol hcl er cp24 160mg 3propranolol hcl er cp24 120mg, 60mg, 80mg

2

propranolol hcl inj 2propranolol hcl oral soln 2propranolol hcl tabs 1propranolol hydrochloride 1propranolol/hydrochlorothiazide 2timolol maleate tabs 4Calcium Channel Blocking Agentsafeditab cr 2 QL(60/30)amlodipine besylate tabs 10mg 1 QL(30/30)amlodipine besylate tabs 5mg 1 QL(60/30)amlodipine besylate tabs 2.5mg 1 QL(120/30)amlodipine besylate/benazepril hydrochloride caps 10mg; 20mg, 10mg; 40mg

2 QL(30/30)

amlodipine besylate/benazepril hydrochloride caps 2.5mg; 10mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg

2 QL(60/30)

amlodipine besylate/valsartan 2 QL(30/30)amlodipine/valsartan/hctz 2 QL(30/30)CARDENE IV 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

perindopril erbumine 2 QL(60/30)quinapril hcl 1 QL(60/30)quinapril/hydrochlorothiazide tabs 12.5mg; 10mg

1 QL(30/30)

quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg

1 QL(60/30)

ramipril 1 QL(60/30)trandolapril tabs 1mg 1 QL(30/30)trandolapril tabs 2mg, 4mg 1 QL(60/30)trandolapril/verapamil hcl er tbcr 1mg; 240mg, 2mg; 180mg, 2mg; 240mg

2 QL(30/30)

trandolapril/verapamil hcl er tbcr 4mg; 240mg

2 QL(60/30)

Antiarrhythmicsamiodarone hcl 2dofetilide 4 QL(60/30)flecainide acetate 2lidocaine hcl inj 2mexiletine hcl 2MULTAQ 3 QL(60/30)pacerone 2procainamide hcl 2propafenone hcl 2propafenone hcl er 4quinidine sulfate 2sorine 2sotalol hcl 2sotalol hcl (af) 2sotalol hydrochloride (af) tabs 80mg

2

sotalol hydrochloride tabs 120mg

2

Beta-adrenergic Blocking Agentsacebutolol hcl 2atenolol 1atenolol/chlorthalidone 2betaxolol hcl 2bisoprolol fumarate 2

31



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LANOXIN TABS 62.5MCG 4 QL(30/30)LANOXIN TABS 187.5MCG 4 PA QL(30/30)NORTHERA CAPS 100MG 5 PA QL(90/30)NORTHERA CAPS 200MG, 300MG

5 PA QL(180/30)

pentoxifylline er 2PRALUENT 5 PARANEXA 3 QL(60/30)TEKTURNA 4 QL(30/30)TEKTURNA HCT 4 QL(30/30)Diuretics, Carbonic Anhydrase Inhibitorsacetazolamide 2acetazolamide sodium 2methazolamide 4Diuretics, Loopbumetanide 2ethacrynate sodium 2ethacrynic acid 3furosemide inj 2furosemide oral soln 2furosemide tabs 1torsemide 2Diuretics, Potassium-sparingamiloride hcl 2amiloride/hydrochlorothiazide 2DYRENIUM 4eplerenone 2spironolactone 1spironolactone/hydrochlorothiazide

2

triamterene/hydrochlorothiazide caps

2

triamterene/hydrochlorothiazide tabs

1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cartia xt 2dilt-cd cp24 180mg, 240mg 2dilt-xr 2diltiazem hcl 2diltiazem hcl er cp12 2diltiazem hcl er cp24 120mg, 180mg, 240mg, 300mg, 420mg

2

diltiazem hcl er tb24 2felodipine er 2 QL(60/30)isradipine 2matzim la 2nicardipine hcl 2nifedipine er tb24 90mg 2 QL(30/30)nifedipine er tb24 30mg, 60mg 2 QL(60/30)taztia xt cp24 120mg, 180mg, 240mg, 300mg

2

verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg

2 QL(30/30)

verapamil hcl er cp24 200mg 2 QL(60/30)verapamil hcl er tbcr 2verapamil hcl inj 2verapamil hcl sr cp24 2 QL(30/30)verapamil hcl tabs 1Cardiovascular Agents, Otheratropine sulfate inj 0.5mg/5ml 2CORLANOR 4 PA QL(60/30)DEMSER 3digitek tabs 0.125mg 2 QL(30/30)digitek tabs 0.25mg 2 PAdigox tabs 125mcg 2 QL(30/30)digox tabs 250mcg 2 PAdigoxin inj 2 PAdigoxin oral soln 2 PA QL(150/30)digoxin tabs 125mcg 2 QL(30/30)digoxin tabs 250mcg 2 PA

32


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

prevalite 2REPATHA 5 PA QL(3/30)REPATHA PUSHTRONEX SYSTEM

5 PA QL(3.5/30)

REPATHA SURECLICK 5 PA QL(3/30)VASCEPA CAPS 1GM 4 QL(120/30)VASCEPA CAPS 0.5GM 4 QL(240/30)WELCHOL 3ZETIA 4 QL(30/30) STVasodilators, Direct-acting Arterialhydralazine hcl 2minoxidil 2Vasodilators, Direct-acting Arterial/VenousBIDIL 4 QL(180/30)isosorbide dinitrate er 2isosorbide dinitrate tabs 2isosorbide mononitrate 2isosorbide mononitrate er 2minitran 2 QL(30/30)NITRO-BID 4NITRO-DUR PT24 0.3MG/HR, 0.8MG/HR

4 QL(30/30)

nitroglycerin 2nitroglycerin lingual 3nitroglycerin transdermal 2 QL(30/30)RECTIV 4 QL(30/30)

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetaminesamphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg

3 QL(30/30)

amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg; 1.25mg; 1.25mg, 6.25mg; 6.25mg; 6.25mg; 6.25mg

3 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Diuretics, Thiazidechlorothiazide 2chlorothiazide sodium 2chlorthalidone 2hydrochlorothiazide 1indapamide 2methyclothiazide 2metolazone 2Dyslipidemics, Fibric Acid Derivativesfenofibrate caps 130mg, 150mg 4 QL(30/30)fenofibrate caps 43mg, 50mg 4 QL(60/30)fenofibrate micronized caps 134mg, 200mg

2 QL(30/30)

fenofibrate micronized caps 67mg

2 QL(60/30)

fenofibrate tabs 145mg, 160mg 2 QL(30/30)fenofibrate tabs 48mg, 54mg 2 QL(60/30)fenofibric acid dr cpdr 135mg 4 QL(30/30)fenofibric acid dr cpdr 45mg 4 QL(60/30)gemfibrozil 2 QL(60/30)Dyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium 1 QL(30/30)CRESTOR 4 QL(30/30) STLIVALO 3 QL(30/30) STlovastatin tabs 10mg, 20mg 1 QL(30/30)lovastatin tabs 40mg 1 QL(60/30)pravastatin sodium 1 QL(30/30)rosuvastatin calcium 1 QL(30/30)simvastatin 1 QL(30/30)Dyslipidemics, Othercholestyramine 2cholestyramine light 2colestipol hcl 2ezetimibe 3 QL(30/30)ezetimibe/simvastatin 4 QL(30/30)niacin er tbcr 500mg 2 QL(30/30)niacin er tbcr 1000mg, 750mg 2 QL(60/30)niacor 2omega-3-acid ethyl esters 4 QL(120/30)

33



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

methylphenidate hcl er cp24 4 QL(30/30)methylphenidate hcl er cpcr 20mg, 30mg, 40mg

4 QL(30/30)

methylphenidate hcl er tb24 27mg, 54mg

4 QL(30/30)

methylphenidate hcl er tb24 36mg

4 QL(60/30)

methylphenidate hcl er tb24 18mg

4 QL(120/30)

methylphenidate hcl er tbcr 10mg, 27mg, 54mg

4 QL(30/30)

methylphenidate hcl er tbcr 36mg

4 QL(60/30)


4 QL(90/30)


4 QL(120/30)

methylphenidate hcl tabs 3 QL(90/30)methylphenidate hydrochloride oral soln

3 QL(900/30)

Central Nervous System, OtherHETLIOZ 5 PA QL(30/30)HORIZANT 4NUEDEXTA 3 QL(60/30)riluzole 2tetrabenazine tabs 12.5mg 5 QL(90/30)tetrabenazine tabs 25mg 5 QL(120/30)Fibromyalgia AgentsSAVELLA 4 QL(60/30)SAVELLA TITRATION PACK 4 QL(110/365)Multiple Sclerosis AgentsAMPYRA 5 PA QL(60/30)AVONEX 5 PA QL(4/28)AVONEX PEN 5 PA QL(4/28)COPAXONE INJ 40MG/ML 5 PA QL(12/28)COPAXONE INJ 20MG/ML 5 PA QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg

2 QL(60/30)

amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg

2 QL(90/30)

dextroamphetamine sulfate er cp24 5mg

2 QL(60/30)


2 QL(90/30)


2 QL(120/30)

dextroamphetamine sulfate oral soln

2 QL(1800/30)

dextroamphetamine sulfate tabs 5mg

2 QL(60/30)

dextroamphetamine sulfate tabs 10mg

2 QL(180/30)

Attention Deficit Hyperactivity Disorder Agents, Non-amphetaminesatomoxetine caps 100mg, 60mg, 80mg

4 QL(30/30)

atomoxetine caps 10mg, 18mg, 25mg, 40mg

4 QL(60/30)

clonidine hcl er 4 QL(120/30)dexmethylphenidate hcl 2 QL(60/30)metadate er 4 QL(90/30)methylphenidate hcl cd 4 QL(30/30)methylphenidate hcl chew 2.5mg, 5mg

3 QL(90/30)

methylphenidate hcl chew 10mg

3 QL(180/30)

34


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

diclofenac sodium gel 1% 2 QL(1000/30)diclofenac sodium gel 3% 5 QL(100/30)DIFFERIN LOTN 4DRITHO-CREME HP 3ELIDEL 4 QL(100/90)erythromycin/benzoyl peroxide 2FINACEA 3fluorouracil crea 5% 3fluorouracil crea 0.5% 5fluorouracil external soln 2GORDONS UREA OINT 40% 4imiquimod 2 QL(12/30)isotretinoin 2LEVULAN KERASTICK 3methoxsalen 5myorisan 2neuac 2ORACEA 4podocon 25 in benzoin tincture 2podofilox 2rea lo 40 crea 2REGRANEX 5 PA QL(15/30)SANTYL 3selenium sulfide lotn 2selenium sulfide sham 2.25% 2tazarotene 4 QL(120/30)TAZORAC CREA 4 QL(120/30)TAZORAC GEL 4 QL(100/30)tretinoin crea 2 PA QL(45/30)tretinoin gel 2 PA QL(45/30)tretinoin microsphere 4 PAtretinoin microsphere pump gel 0.1%

4 PA

umecta mousse 2urea crea 39%, 40%, 45%, 50%

2

zenatane 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

EXTAVIA 5 PA QL(15/30)TECFIDERA CPDR 120MG 5 PA QL(14/30)TECFIDERA CPDR 240MG 5 PA QL(60/30)TECFIDERA STARTER PACK 5 PA QL(120/365)TYSABRI 5 PA QL(15/28)

Dental and Oral Agents

Dental and Oral Agentscevimeline hcl 2chlorhexidine gluconate mouth/throat soln

2

KEPIVANCE 5oralone dental paste 2paroex 2periogard 2phos-flur 2pilocarpine hcl 2pilocarpine hydrochloride 2triamcinolone acetonide dental paste

2

Dermatological Agents

Dermatological Agentsacitretin 4adapalene 2ammonium lactate 2amnesteem 2AZELEX 3calcipotriene crea 2 QL(120/30)calcipotriene external soln 2 QL(60/30)calcipotriene oint 2 QL(120/30)calcitrene 2 QL(120/30)claravis 2clindamycin phosphate/tretinoin 4clindamycin/benzoyl peroxide 2CONDYLOX 4curity gauze pads 2”x2” 2

35



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

AMINOSYN II INJ 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 38MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML

4 B/D PA

AMINOSYN INJ 90MEQ/L; 1100MG/100ML; 850MG/100ML; 35MEQ/L; 1100MG/100ML; 260MG/100ML; 620MG/100ML; 810MG/100ML; 624MG/100ML; 340MG/100ML; 380MG/100ML; 5.4MEQ/L; 750MG/100ML; 370MG/100ML; 460MG/100ML; 150MG/100ML; 44MG/100ML; 680MG/100ML

3 B/D PA

AMINOSYN INJ 148MEQ/L; 1280MG/100ML; 980MG/100ML; 1280MG/100ML; 300MG/100ML; 720MG/100ML; 940MG/100ML; 720MG/100ML; 400MG/100ML; 440MG/100ML; 5.4MEQ/L; 860MG/100ML; 420MG/100ML; 520MG/100ML; 160MG/100ML; 44MG/100ML; 800MG/100ML

4 B/D PA

AMINOSYN M 3 B/D PAAMINOSYN-HBC 3 B/D PAAMINOSYN-PF 4 B/D PAAMINOSYN-PF 7% 3 B/D PAAMINOSYN-RF 3 B/D PAcalcium gluconate inj 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral ReplacementAMINOSYN 7%/ELECTROLYTES

3 B/D PA

AMINOSYN 8.5%/ELECTROLYTES

3 B/D PA

AMINOSYN II 8.5%/ELECTROLYTES

3 B/D PA

AMINOSYN II INJ 107.6MEQ/L; 1490MG/100ML; 1527MG/100ML; 1050MG/100ML; 1107MG/100ML; 750MG/100ML; 450MG/100ML; 990MG/100ML; 1500MG/100ML; 1575MG/100ML; 258MG/100ML; 447MG/100ML; 1083MG/100ML; 795MG/100ML; 50MEQ/L; 600MG/100ML; 300MG/100ML; 405MG/100ML; 750MG/100ML, 61.1MEQ/L; 844MG/100ML; 865MG/100ML; 595MG/100ML; 627MG/100ML; 425MG/100ML; 255MG/100ML; 561MG/100ML; 850MG/100ML; 893MG/100ML; 146MG/100ML; 253MG/100ML; 614MG/100ML; 450MG/100ML; 33.3MEQ/L; 340MG/100ML; 170MG/100ML; 230MG/100ML; 425MG/100ML

3 B/D PA

36


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dextrose 2.5%/nacl 0.45% 3 B/D PAdextrose 20% 2 B/D PAdextrose 25% 2 B/D PAdextrose 30% 2 B/D PAdextrose 40% 2 B/D PAdextrose 5% 2DEXTROSE 5%/LACTATED RINGERS

3 B/D PA

DEXTROSE 5%/NACL 0.2% 3DEXTROSE 5%/NACL 0.225% 3 B/D PADEXTROSE 5%/NACL 0.3% 3DEXTROSE 5%/NACL 0.33% 3DEXTROSE 5%/NACL 0.45% 3dextrose 5%/nacl 0.9% 3dextrose 50% 2 B/D PAdextrose 70% 2effer-k tbef 25meq 2effervescent pot chloride 2effervescent potassium 2fluoride chew 0.25mg 2fluoritab chew 0.5mg, 1mg 2fluoritab oral soln 2flura-drops 2FREAMINE HBC 6.9% 3 B/D PAFREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML

4 B/D PA

HEPATAMINE 3 B/D PAhyperlyte-cr 2 B/D PAIONOSOL-MB/DEXTROSE 5% 3ISOLYTE-P/DEXTROSE 5% 3ISOLYTE-S 3 B/D PAISOLYTE-S PH 7.4 3 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CARBAGLU 5 PACLINIMIX 2.75%/DEXTROSE 5%

3 B/D PA

CLINIMIX 4.25%/DEXTROSE 10%

3 B/D PA


3 B/D PA


3 B/D PA


3 B/D PA

CLINIMIX 5%/DEXTROSE 15% 3 B/D PACLINIMIX 5%/DEXTROSE 20% 3 B/D PACLINIMIX 5%/DEXTROSE 25% 3 B/D PACLINIMIX E 2.75%/DEXTROSE 10%

3 B/D PA

CLINIMIX E 2.75%/DEXTROSE 5%

3 B/D PA


3 B/D PA


3 B/D PA


3 B/D PA

CLINIMIX E 5%/DEXTROSE 15%

3 B/D PA


3 B/D PA


3 B/D PA

CLINIMIX N14G30E 3 B/D PACLINIMIX N9G15E 3 B/D PACLINISOL SF 15% 3 B/D PAclinpro 5000 2cytra k crystals 2denta 5000 plus 2dentagel 2DEXTROSE10%/NACL 0.45% 3 B/D PADEXTROSE5% /ELECTROLYTE #48 VIAFLEX

3 B/D PA

dextrose 10% 2 B/D PADEXTROSE 10%/NACL 0.2% 3 B/D PA

37



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

potassium chloride /sodium chloride

3 B/D PA

potassium chloride cr 2potassium chloride er 2potassium chloride inj 0.4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 2meq/ml, 40meq/100ml

2 B/D PA

potassium chloride oral soln 2potassium chloride sr 2POTASSIUM CHLORIDE/DEXTROSE

3 B/D PA

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS

3 B/D PA

POTASSIUM CHLORIDE/DEXTROSE/SODIUM CHLORIDE

3 B/D PA

POTASSIUM CHLORIDE/SODIUM CHLORIDE INJ 20MEQ/L; 0.45%, 20MEQ/L; 0.9%, 40MEQ/L; 0.9%

3 B/D PA

potassium citrate er 2potassium citrate/citric acid 2PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML

4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

k-effervescent 2K-PHOS 3K-PHOS NO 2 3K-TAB 3k-vescent tbef 2KABIVEN 4 B/D PAkcl 0.075%/d5w/nacl 0.45% 3 B/D PAKCL 0.15%/D5W/NACL 0.2% 3 B/D PAKCL 0.15%/D5W/NACL 0.225% 3 B/D PAKCL 0.15%/D5W/NACL 0.45% 3 B/D PAkcl 0.15%/d5w/nacl 0.9% 3 B/D PAkcl 0.3%/d5w/nacl 0.45% 3 B/D PAKCL 0.3%/D5W/NACL 0.9% 3 B/D PAklor-con 2klor-con 10 3klor-con 8 3klor-con m10 2klor-con m15 2klor-con m20 2klor-con sprinkle 2klor-con/ef 2LACTATED RINGERS VIAFLEX

3

ludent 2magnesium sulfate inj 2 B/D PANEPHRAMINE 3 B/D PANORMOSOL -R 3 B/D PANORMOSOL-M IN D5W 3 B/D PANORMOSOL-R 3 B/D PANORMOSOL-R IN D5W 3 B/D PAPERIKABIVEN 4 B/D PAPLASMA-LYTE A 3 B/D PAPLASMA-LYTE-148 3 B/D PAPLENAMINE 3 B/D PA

38


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TROPHAMINE INJ 0; 0.32GM/100ML; 0.73GM/100ML; 0.19GM/100ML; 0.014GM/100ML; 0.22GM/100ML; 0.29GM/100ML; 0.49GM/100ML; 0.3GM/100ML; 0.84GM/100ML; 0.49GM/100ML; 0.2GM/100ML; 0.29GM/100ML; 0.41GM/100ML; 0.23GM/100ML; 0.05GM/100ML; 0.015GM/100ML; 0.25GM/100ML; 0.12GM/100ML; 0.14GM/100ML; 0.47GM/100ML

3 B/D PA

Electrolyte/Mineral/Metal ModifiersCUPRIMINE 5JADENU 5JADENU SPRINKLE 5kionex 2SAMSCA TABS 15MG 5 QL(30/30)SAMSCA TABS 30MG 5 QL(60/30)sodium polystyrene sulfonate powd

2

sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml

2

sps 2SYPRINE 5trientine hydrochloride 5VELTASSA 3Phosphate Binderscalcium acetate caps 2calcium acetate tabs 667mg 2PHOSLYRA 4RENVELA PACK 3 QL(180/30)RENVELA TABS 3 QL(540/30)VELPHORO 4 QL(180/30)Vitaminsmulti-vit/fluoride 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PREMASOL INJ 56MEQ/L; 320MG/100ML; 730MG/100ML; 190MG/100ML; 3MEQ/L; 20MG/100ML; 300MG/100ML; 220MG/100ML; 290MG/100ML; 490MG/100ML; 840MG/100ML; 490MG/100ML; 200MG/100ML; 290MG/100ML; 410MG/100ML; 230MG/100ML; 5MEQ/L; 15MG/100ML; 250MG/100ML; 120MG/100ML; 140MG/100ML; 470MG/100ML

3 B/D PA

PROCALAMINE 3 B/D PAPROSOL 4 B/D PAringers injection 3sf 2sf 5000 plus 2sodium bicarbonate inj 2 B/D PAsodium bicarbonate partial fill 2 B/D PAsodium chloride 0.45% 2sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5%

2

sodium citrate/citric acid 2sodium fluoride chew 0.5mg, 1mg

2

sodium fluoride oral soln 2SODIUM LACTATE INJ 5MEQ/ML

3 B/D PA

TPN ELECTROLYTES 4 B/D PATRAVASOL 4 B/D PATROPHAMINE INJ 97MEQ/L; 0.54GM/100ML; 1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML; 5MEQ/L; 0.025GM/100ML; 0.42GM/100ML; 0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML

4 B/D PA

39



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dicyclomine hcl oral soln 2dicyclomine hcl tabs 2ed-spaz 2glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml

2

glycopyrrolate tabs 2hyoscyamine sulfate elix 2hyoscyamine sulfate odt 2hyoscyamine sulfate subl 2hyoscyamine sulfate tabs 2hyoscyamine sulfate tbdp 2methscopolamine bromide 2nulev 2oscimin 2propantheline bromide 2Gastrointestinal Agents, OtherCHENODAL 5cromolyn sodium conc 4diphenoxylate/atropine 2GATTEX 5 PA QL(30/30)loperamide hcl caps 2metoclopramide hcl 2OSMOPREP 4PAREGORIC 3RELISTOR INJ 8MG/0.4ML 4 PA QL(11.2/28)RELISTOR INJ 12MG/0.6ML 4 PA QL(16.8/28)TRULANCE 4 QL(30/30)ursodiol 2Histamine2 (H2) Receptor Antagonistscimetidine 2cimetidine hcl 2famotidine inj 2famotidine premixed 2famotidine susr 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

multi-vit/iron/fluoride 2multi-vitamin/fluoride drops 2multivitamin with fluoride chew 2multivitamin with fluoride oral soln 35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml, 35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 0.5mg/ml; 1500unit/ml; 5unit/ml

2

multivitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 0.25mg; 1.05mg; 15unit; 2500unit, 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 0.5mg; 1.05mg; 15unit; 2500unit, 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1mg; 1.05mg; 15unit; 2500unit

2

multivitamins/fluoride 2mvc-fluoride 2tl-fluorivite 2tri-vit/fluoride 2tri-vit/fluoride/iron 2tri-vitamin/fluoride 2VP-PNV-DHA 3

Gastrointestinal Agents

Antispasmodics, Gastrointestinalanaspaz 2atropine sulfate inj 0.25mg/5ml, 0.4mg/ml, 1mg/ml

2

belladonna & opium 2belladonna alkaloids & opium 2dicyclomine hcl caps 2

40


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lansoprazole cpdr 3 QL(60/30)omeprazole cpdr 2 QL(60/30)pantoprazole sodium tbec 2 QL(60/30)

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

Genetic or Enzyme Disorder: Replacement, Modifiers, TreatmentADAGEN 5ALDURAZYME 5BUPHENYL TABS 5 PACEREZYME 5 B/D PACREON 3CYSTADANE 5CYSTAGON 3ELAPRASE 5ELELYSO 5FABRAZYME 5 B/D PAKUVAN 5 PALUMIZYME 5NAGLAZYME 5ORFADIN 5RAVICTI 5 PA QL(525/30)sodium phenylbutyrate 5 PAVPRIV 5 B/D PAXIAFLEX 5 PAZAVESCA 5 QL(90/30)ZENPEP CPEP 105000UNIT; 25000UNIT; 79000UNIT, 136000UNIT; 25000UNIT; 85000UNIT, 16000UNIT; 3000UNIT; 10000UNIT, 168000UNIT; 40000UNIT; 126000UNIT, 218000UNIT; 40000UNIT; 136000UNIT, 24000UNIT; 5000UNIT; 17000UNIT, 27000UNIT; 5000UNIT; 17000UNIT, 55000UNIT; 10000UNIT; 34000UNIT, 82000UNIT; 15000UNIT; 51000UNIT, 84000UNIT; 20000UNIT; 63000UNIT

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

famotidine tabs 20mg, 40mg 2nizatidine caps 2ranitidine hcl 2Irritable Bowel Syndrome Agentsalosetron hydrochloride tabs 0.5mg

4 PA QL(60/30)

alosetron hydrochloride tabs 1mg

5 PA QL(60/30)

AMITIZA 3 QL(60/30)LINZESS 3 QL(30/30)VIBERZI 4 PA QL(60/30)Laxativesconstulose 2enulose 2gavilyte-c 2gavilyte-g 2gavilyte-n/flavor pack 2generlac 2GOLYTELY 3KRISTALOSE 4lactulose 2MOVIPREP 3NULYTELY/FLAVOR PACKS 3peg 3350/electrolytes 2peg-3350/electrolytes 2peg-3350/nacl/na bicarbonate/kcl

2

pegylax 2polyethylene glycol 3350 2SUPREP BOWEL PREP KIT 3trilyte 2ProtectantsCARAFATE SUSP 4misoprostol 2sucralfate 2Proton Pump InhibitorsDEXILANT 4 QL(60/30) STesomeprazole magnesium 3 QL(60/30)esomeprazole sodium 3

41



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

finasteride tabs 5mg 2 QL(30/30)tamsulosin hcl 2 QL(60/30)terazosin hcl caps 1mg, 2mg, 5mg

2

terazosin hcl caps 10mg 2 QL(60/30)Genitourinary Agents, Otheracetic acid 0.25% 2bethanechol chloride 2ELMIRON 4LITHOSTAT 4

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)ala-cort crea 1% 2alclometasone dipropionate 2augmented betamethasone dipropionate

2

betamethasone dipropionate 3betamethasone sodium phosphate/betamethasone acetate

2

betamethasone valerate crea 2betamethasone valerate lotn 2betamethasone valerate oint 2clobetasol propionate crea 2clobetasol propionate e 2clobetasol propionate emollient foam

4

clobetasol propionate external soln

2

clobetasol propionate foam 4clobetasol propionate gel 2clobetasol propionate liqd 4clobetasol propionate lotn 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Genitourinary Agents

Antispasmodics, Urinaryflavoxate hcl 2GELNIQUE 4 QL(30/30)MYRBETRIQ 3 QL(30/30)oxybutynin chloride er tb24 10mg, 5mg

2 QL(30/30)

oxybutynin chloride er tb24 15mg

2 QL(60/30)

oxybutynin chloride syrp 2 QL(600/30)oxybutynin chloride tabs 2 QL(120/30)phosphasal 2tolterodine tartrate 3 QL(60/30)tolterodine tartrate er 4 QL(30/30)trospium chloride 2 QL(60/30)trospium chloride er 3 QL(30/30)ur n-c 2URELLE 4uribel 2urin d/s 2URO-458 4uro-mp 2ustell 2utira-c 2VESICARE 4 QL(30/30)Benign Prostatic Hypertrophy Agentsalfuzosin hcl er 2 QL(30/30)doxazosin 2 QL(30/30)doxazosin mesylate tabs 1mg, 2mg

2 QL(30/30)

doxazosin mesylate tabs 8mg 2 QL(60/30)dutasteride 2 QL(30/30)dutasteride/tamsulosin hydrochloride

4 QL(30/30)

42


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

hydrocortisone oint 1%, 2.5% 2hydrocortisone rectal crea 2hydrocortisone tabs 2hydrocortisone valerate 2KENALOG 4MEDROL TABS 2MG 4methylprednisolone acetate 2methylprednisolone dose pack 2methylprednisolone sodiumsuccinate

2

methylprednisolone tabs 2mometasone furoate crea 2mometasone furoate external soln

2

mometasone furoate oint 2PANDEL 3prednicarbate 2prednisolone 2prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml

2

prednisone 2prednisone intensol 2procto-med hc 2procto-pak 2proctosol hc 2proctozone-hc 2SOLU-CORTEF 3SOLU-MEDROL INJ 500MG 3SOLU-MEDROL INJ 2GM 3 HITEXACORT 3triamcinolone acetonide aers 2triamcinolone acetonide crea 2triamcinolone acetonide inj 40mg/ml

2

triamcinolone acetonide lotn 2triamcinolone acetonide oint 2triderm crea 0.1% 2TRIPTODUR 5 PA QL(1/168)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clobetasol propionate oint 2clobetasol propionate sham 4clocortolone pivalate 2clocortolone pivalate pump 2clodan 4CORDRAN TAPE 3CORTIFOAM 4cortisone acetate 2DEPO-MEDROL INJ 20MG/ML 4DESONATE 4desonide 2desoximetasone 4dexamethasone 2dexamethasone intensol 2dexamethasone sodium phosphate inj 100mg/10ml, 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml

2

fludrocortisone acetate 2fluocinolone acetonide 2fluocinolone acetonide body 2fluocinolone acetonide scalp 2fluocinonide crea 0.05% 2fluocinonide crea 0.1% 4fluocinonide external soln 2fluocinonide gel 2fluocinonide oint 2fluticasone propionate crea 2fluticasone propionate lotn 2fluticasone propionate oint 2halobetasol propionate 2hydrocortisone butyrate (lipid) 2hydrocortisone butyrate (lipophilic)

2

hydrocortisone butyrate crea 2hydrocortisone butyrate external soln

2

hydrocortisone butyrate oint 2hydrocortisone external crea 2hydrocortisone lotn 2.5% 2

43



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

altavera 2alyacen 1/35 2amabelz 2 PAamethia 2 QL(91/91)amethia lo 2 QL(91/91)ANGELIQ 4 PAapri 2aranelle 2ashlyna 2 QL(91/91)aubra 2aviane 2balziva 2bekyree 2blisovi 24 fe 2blisovi fe 1.5/30 2blisovi fe 1/20 2briellyn 2camrese 2 QL(91/91)camrese lo 2 QL(91/91)caziant 2cesia 2chateal 2CLIMARA PRO 4 PA QL(4/28)COMBIPATCH 4 PA QL(8/28)cryselle-28 2cyclafem 1/35 2cyclafem 7/7/7 2cyred 2daysee 2 QL(91/91)delyla 2DEPO-ESTRADIOL 3desogestrel/ethinyl estradiol 2DIVIGEL 4 QL(30/30)drospirenone/ethinyl estradiol 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)desmopressin acetate inj 2desmopressin acetate nasal soln

4 QL(15/30)

desmopressin acetate tabs 2EGRIFTA 5 PA QL(60/30)GENOTROPIN 5 PAGENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG

5 PA

GENOTROPIN MINIQUICK INJ 0.2MG

4 PA

H.P. ACTHAR 5 PA QL(1.5/1)INCRELEX 4 PASEROSTIM 5 PAZORBTIVE 5 PA

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

Anabolic SteroidsANADROL-50 5 PAoxandrolone tabs 10mg 3 PA QL(60/30)oxandrolone tabs 2.5mg 3 PA QL(120/30)Androgensdanazol 4testosterone cypionate 2testosterone enanthate 2 QL(5/30)testosterone gel 25mg/2.5gm, 50mg/5gm

3 QL(300/30)

testosterone pump 3 QL(300/30)EstrogensALORA 4 PA QL(8/28)

44


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

larin 24 fe 2larin fe 1.5/30 2larin fe 1/20 2larissia 2layolis fe 2leena 2lessina 2levonest 2levonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg

2

levonorgestrel and ethinyl estradiol tabs 0; 0

2 QL(91/91)

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg

2

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0

2 QL(91/91)

levora 0.15/30-28 2lopreeza 2 PAloryna 2low-ogestrel 2lutera 2marlissa 2MENEST 4 PAMENOSTAR 4 PA QL(4/28)microgestin 1.5/30 2microgestin 1/20 2microgestin fe 2microgestin fe 1.5/30 2mimvey 2 PAmimvey lo 2 PAmono-linyah 2mononessa 2myzilra 2necon 0.5/35-28 2necon 7/7/7 2nikki 2norethindrone & ethinyl estradiol ferrous fumarate

2

norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

emoquette 2enpresse-28 2enskyce 2estarylla 2ESTRACE CREA 4estradiol crea 4estradiol pttw 2 PA QL(8/28)estradiol ptwk 2 PA QL(4/28)estradiol tabs 0.5mg, 1mg, 2mg 2 PAestradiol tabs 10mcg 4 QL(18/28)estradiol/norethindrone acetate 2 PAESTRING 4 QL(1/90)estropipate 2 PAethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg

2

falmina 2FEMRING 4 QL(1/90)femynor 2fyavolv 2 PAgianvi 2gildagia 2introvale 2 QL(91/91)isibloom 2jevantique lo 2 PAjinteli 2 PAjolessa 2 QL(91/91)juleber 2junel 1.5/30 2junel 1/20 2junel fe 1.5/30 2junel fe 1/20 2junel fe 24 2kaitlib fe 2kariva 2kelnor 1/35 2kimidess 2kurvelo 2larin 1.5/30 2larin 1/20 2

45



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tri-linyah 2tri-lo-estarylla 2tri-lo-marzia 2tri-lo-sprintec 2tri-previfem 2tri-sprintec 2trinessa 2trinessa lo 2trivora-28 2tydemy 2velivet 2vestura 2vienva 2viorele 2vyfemla 2wymzya fe 2xulane 2 QL(3/28)yuvafem 4 QL(18/28)zarah 2zenchent 2zovia 1/35e 2zovia 1/50e 2Progesterone Agonists/AntagonistsMAKENA 5 PAProgestinscamila 2deblitane 2DEPO-PROVERA 3 QL(10/28)DEPO-SUBQ PROVERA 104 3 QL(0.65/90)errin 2heather 2hydroxyprogesterone caproate 5 PAjencycla 2jolivette 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg, 5mcg; 1mg

2 PA

norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs

2

norethindrone/ethinyl estradiol/ferrous fumarate

2

norgestimate/ethinyl estradiol 2nortrel 0.5/35 (28) 2nortrel 1/35 2nortrel 7/7/7 2NUVARING 4 QL(1/28)ocella 2ogestrel 2orsythia 2ORTHO TRI-CYCLEN LO 4pimtrea 2pirmella 1/35 2portia-28 2PREFEST 4 PAPREMARIN CREA 3PREMARIN INJ 4PREMARIN TABS 4 PA QL(30/30)PREMPHASE 4 PAPREMPRO 4 PAprevifem 2quasense 2 QL(91/91)reclipsen 2setlakin 2 QL(91/91)sprintec 28 2sronyx 2tarina fe 1/20 2tilia fe 2tri-estarylla 2tri-legest fe 2

46


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ELIGARD INJ 30MG 4 PA QL(1/120)ELIGARD INJ 45MG 4 PA QL(1/180)ELIGARD INJ 7.5MG 4 PA QL(1/30)ELIGARD INJ 22.5MG 4 PA QL(1/90)FIRMAGON INJ 80MG 4 B/D PA QL(1/28)FIRMAGON INJ 120MG 5 B/D PA QL(4/365)leuprolide acetate 2 PALUPRON DEPOT (1-MONTH) 5 PA QL(1/30)LUPRON DEPOT (3-MONTH) 5 PA QL(1/84)LUPRON DEPOT (4-MONTH) 5 PA QL(1/112)LUPRON DEPOT (6-MONTH) 5 PA QL(1/168)LUPRON DEPOT-PED (1-MONTH)

5 PA QL(1/30)

LUPRON DEPOT-PED (3-MONTH)

5 PA QL(1/84)

octreotide acetate inj 500mcg/ml

5

octreotide acetate inj 100mcg/ml, 200mcg/ml, 50mcg/ml

2

octreotide acetate inj 1000mcg/ml

4

SANDOSTATIN LAR DEPOT 5SIGNIFOR 5 QL(60/30)SOMATULINE DEPOT INJ 60MG/0.2ML

5 QL(0.2/28)

SOMATULINE DEPOT INJ 90MG/0.3ML

5 QL(0.3/28)

SOMATULINE DEPOT INJ 120MG/0.5ML

5 QL(0.5/28)

SOMAVERT 5 QL(30/30)SYNAREL 5 PATRELSTAR MIXJECT INJ 22.5MG

5 PA QL(1/168)

TRELSTAR MIXJECT INJ 3.75MG

5 PA QL(1/28)

TRELSTAR MIXJECT INJ 11.25MG

5 PA QL(1/84)

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agentsmethimazole 2propylthiouracil 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lyza 2MAKENA 5 PAmedroxyprogesterone acetate inj

2 QL(1/90)

medroxyprogesterone acetate tabs

2

megestrol acetate susp 40mg/ml

2 PA

megestrol acetate susp 625mg/5ml

4 PA

megestrol acetate tabs 2 PAnora-be 2norethindrone 2norethindrone acetate 2norlyroc 2progesterone 2sharobel 2Selective Estrogen Receptor Modifying Agentsraloxifene hydrochloride 2 QL(30/30)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium inj 5levothyroxine sodium tabs 2LEVOXYL 3liothyronine sodium 2SYNTHROID 4THYROLAR-1 4THYROLAR-1/2 4THYROLAR-1/4 4THYROLAR-2 4THYROLAR-3 4

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)LYSODREN 5

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)cabergoline 2 QL(16/28)

47



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

methotrexate tabs 2mycophenolate mofetil caps 2 PAmycophenolate mofetil inj 4 PAmycophenolate mofetil susr 2 PAmycophenolate mofetil tabs 2 PAmycophenolic acid dr 2 PAMYFORTIC 3 PANEORAL 4 PANULOJIX 5 PA QL(150/30)ORENCIA INJ 250MG 5 PAPROGRAF CAPS 5MG 5 PAPROGRAF CAPS 0.5MG, 1MG 4 PAPROGRAF INJ 4 PARAPAMUNE ORAL SOLN 5 PAREMICADE 5 PARENFLEXIS 5 PASANDIMMUNE 4 PAsirolimus 4 PAtacrolimus caps 2 PATORISEL 5 B/D PA QL(4/28)XATMEP 4 PAZORTRESS TABS 0.25MG, 0.75MG

5 PA QL(60/30)

ZORTRESS TABS 0.5MG 5 PA QL(120/30)Immunizing Agents, PassiveATGAM 5 PAGAMMAKED INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 5GM/50ML

5 B/D PA

GAMMAKED INJ 1GM/10ML 4 B/D PAGAMUNEX-C INJ 1GM/10ML 4 B/D PAGAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML

5 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Immunological Agents

Angioedema AgentsBERINERT 5 PACINRYZE 5 PA QL(100/30)FIRAZYR 5 PA QL(18/30)KALBITOR 5 PAImmune SuppressantsASTAGRAF XL CP24 0.5MG, 1MG

4 PA

ASTAGRAF XL CP24 5MG 5 PAazathioprine 2 PACELLCEPT TABS 5 PAcyclosporine caps 3 PAcyclosporine inj 2 PAcyclosporine modified 3 PAENBREL INJ 25MG/0.5ML 5 PA QL(4.08/28)ENBREL INJ 25MG, 50MG/ML 5 PA QL(8/28)ENBREL MINI 5 PA QL(8/28)ENBREL SURECLICK 5 PA QL(8/28)ENVARSUS XR TB24 4MG 5 PAENVARSUS XR TB24 0.75MG, 1MG

4 PA

gengraf 3 PAHUMIRA INJ 10MG/0.2ML, 20MG/0.4ML

5 PA QL(2/28)

HUMIRA INJ 40MG/0.8ML 5 PA QL(4/28)HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK

5 PA QL(6/365)

HUMIRA PEN 5 PA QL(4/28)HUMIRA PEN-CROHNS DISEASESTARTER

5 PA QL(12/365)

HUMIRA PEN-PSORIASIS STARTER

5 PA QL(8/365)

KINERET 5 PA QL(20.1/30)methotrexate sodium 2

48


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PROQUAD 3 QL(2/365)QUADRACEL 3RABAVERT 3 B/D PARECOMBIVAX HB 3 B/D PA QL(3/365)ROTARIX 3ROTATEQ 3SHINGRIX 3 QL(2/999)STAMARIL 3 QL(1/999)TENIVAC 3 QL(0.5/28)TETANUS/DIPHTHERIA TOXOIDS-ADSORBED

3

TRUMENBA 3TWINRIX 3TYPHIM VI 3VAQTA 3VARIVAX 3 QL(1/365)VARIZIG 4 QL(12/30)VAXCHORA 3YF-VAX 3ZOSTAVAX 3 QL(1/999)

Inflammatory Bowel Disease Agents

AminosalicylatesAPRISO 3 QL(120/30)balsalazide disodium 2CANASA 5 QL(30/30)LIALDA 3 QL(120/30)mesalamine enema and kit 2mesalamine dr tbec 1.2gm 3 QL(120/30)Glucocorticoidsbudesonide cpep 4colocort 2hydrocortisone enem 2Sulfonamidessulfasalazine 2

Metabolic Bone Disease Agents

Metabolic Bone Disease Agentsalendronate sodium oral soln 2 QL(330/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

THYMOGLOBULIN 3 B/D PAImmunomodulatorsACTEMRA INJ 162MG/0.9ML 5 PA QL(3.6/28)ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML

5 PA QL(40/28)

ACTIMMUNE 5 PAARCALYST 5 PABENLYSTA INJ 400MG 5 PA QL(9/28)BENLYSTA INJ 120MG 5 PA QL(30/28)ILARIS 5 PA QL(2/28)leflunomide 3 QL(30/30)RIDAURA 4SIMULECT 5 B/D PASYNAGIS 5 PAVaccinesACTHIB 3ADACEL 3 QL(0.5/365)BCG VACCINE 3BEXSERO 3BOOSTRIX 3 QL(0.5/365)DAPTACEL 3DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC

3

ENGERIX-B INJ 10MCG/0.5ML 3 B/D PA QL(3/365)ENGERIX-B INJ 20MCG/ML 3 B/D PA QL(8/365)GARDASIL 9 3 QL(1.5/365)HAVRIX 3HIBERIX 3IMOVAX RABIES (H.D.C.V.) 3 B/D PAINFANRIX 3IPOL INACTIVATED IPV 3IXIARO 3KINRIX 3M-M-R II 3 QL(2/365)MENACTRA 3MENVEO 3PEDIARIX 3PEDVAX HIB 3PENTACEL 3

49



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

bd insulin syringe ultrafine/0.3ml/31g x 5/16”

2 QL(200/30)

bd insulin syringe ultrafine/0.5ml/30g x 1/2”

2 QL(200/30)

bd insulin syringe ultrafine/1ml/31g x 5/16”

2 QL(200/30)

bd pen needle/ultrafine/29g x 12.7mm

2 QL(200/30)

bd safetyglide 27g x 5/8” 2 QL(200/30)BOTOX INJ 200UNIT 4 PA QL(1/90)BOTOX INJ 100UNIT 4 PA QL(4/90)CARNITOR INJ 4 B/D PADYSPORT 4 PAFERRIPROX 5fomepizole 5INTRALIPID 3 B/D PAKORLYM 5 PA QL(120/30)LACTATED RINGERS IRRIGATION

3

levocarnitine 2LIPOSYN III 3 B/D PAmethylergonovine maleate 2NATPARA 5 PA QL(2/28)novofine 30gx8mm 2 QL(200/30)novofine 31 2 QL(200/30)novofine 32gx6mm 2 QL(200/30)novofine autocover 30gx8mm 2 QL(200/30)novotwist 32gx5mm 2 QL(200/30)NUTRILIPID 3 B/D PAPHYSIOLYTE 3PHYSIOSOL IRRIGATION 3RINGERS IRRIGATION 3sodium chloride0.9% 2sodium chloride 0.9% 2sterile water irrigation 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

alendronate sodium tabs 35mg, 70mg

1 QL(4/28)

alendronate sodium tabs 10mg, 40mg, 5mg

1 QL(30/30)

calcitonin-salmon 2 QL(3.7/30)calcitriol caps 2calcitriol inj 2calcitriol oral soln 2doxercalciferol caps 0.5mcg 4 QL(90/30)doxercalciferol caps 1mcg 4 QL(240/30)doxercalciferol caps 2.5mcg 5 QL(120/30)doxercalciferol inj 4etidronate disodium 2FORTEO 5 PA QL(2.4/28)ibandronate sodium inj 3 QL(3/90)ibandronate sodium tabs 3 QL(1/28)pamidronate disodium inj 30mg/10ml, 6mg/ml, 90mg/10ml

4 B/D PA

paricalcitol caps 4mcg 4 QL(60/30)paricalcitol caps 1mcg, 2mcg 4 QL(90/30)paricalcitol inj 4PROLIA 4 QL(1/180)risedronate sodium tabs 150mg 3 QL(1/30)SENSIPAR TABS 30MG 3 QL(60/30)SENSIPAR TABS 60MG 5 QL(60/30)SENSIPAR TABS 90MG 5 QL(120/30)XGEVA 5 PA QL(1.7/28)zoledronic acid inj 4mg/5ml 2 B/D PA QL(15/21)zoledronic acid inj 5mg/100ml 2 B/D PA QL(100/365)

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agentsbd eclipse syringe/1ml/30gx1/2” 2 QL(200/30)bd insulin syringe safetyglide/1ml/29g x 1/2”

2 QL(200/30)

50


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Ophthalmic Anti-allergy AgentsALOCRIL 4azelastine hcl ophthalmic soln 2cromolyn sodium ophthalmic soln

2

olopatadine hcl ophthalmic soln 2 QL(5/30)olopatadine hydrochloride 2 QL(2.5/30)PAZEO 3 QL(2.5/30)Ophthalmic Anti-inflammatoriesdexamethasone sodium phosphate ophthalmic soln

2

diclofenac sodium ophthalmic soln

2

DUREZOL 3FLAREX 4fluorometholone 2flurbiprofen sodium 2FML 4FML FORTE 4ketorolac tromethamine ophthalmic soln

2

LOTEMAX 4MAXIDEX 4neomycin/polymyxin/dexamethasone

2

NEVANAC 4 STPRED MILD 4PRED-G 3PRED-G S.O.P. 3prednisolone acetate 2prednisolone sodium phosphate ophthalmic soln

2

PROLENSA 3TOBRADEX OINT 4tobramycin/dexamethasone 2Ophthalmic Antiglaucoma Agentsacetazolamide er 2ALPHAGAN P OPHTHALMIC SOLN 0.1%

4

apraclonidine 2AZOPT 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sterile water irrigation plastic bottle

2

techlite pen needles/31g x 6 mm

2 QL(200/30)

techlite pen needles/31g x 8mm 2 QL(200/30)techlite pen needles/32g x 4mm 2 QL(200/30)techlite pen needles/32g x 6mm 2 QL(200/30)techlite pen needles/32g x 8mm 2 QL(200/30)TIS-U-SOL 3V-GO 20 3V-GO 30 3V-GO 40 3XEOMIN INJ 200UNIT 5 PAXEOMIN INJ 100UNIT, 50UNIT 4 PA

Ophthalmic Agents

Ophthalmic Prostaglandin and Prostamide Analogsbimatoprost ophthalmic soln 2 QL(5/30)COMBIGAN 4latanoprost 2 QL(5/30)LUMIGAN 4 QL(5/30) STTRAVATAN Z 3 QL(5/30)ZIOPTAN 4 QL(30/30)Ophthalmic Agents, Otheratropine sulfate oint 2atropine sulfate ophthalmic soln 2CYCLOMYDRIL 3cyclopentolate hcl 2cyclopentolate hydrochloride 2CYSTARAN 5 QL(60/28)homatropaire 2homatropine hbr 2LACRISERT 4phenylephrine hcl ophthalmic soln 10%, 2.5%

2

PROCYSBI 5proparacaine hcl 2RESTASIS 3 QL(60/30)tropicamide 2

51



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ASMANEX TWISTHALER 120 METERED DOSES

3 QL(1/30)


3 QL(1/30)


3 QL(1/30)


3 QL(1/30)


3 QL(1/30)

BREO ELLIPTA 3 QL(60/30)budesonide susp 2 B/D PA QL(120/30)FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST

3 QL(60/30)

FLOVENT DISKUS AEPB 250MCG/BLIST

3 QL(240/30)

FLOVENT HFA AERO 44MCG/ACT

3 QL(10.6/30)


3 QL(12/30)


3 QL(24/30)

flunisolide 3 QL(50/30)fluticasone propionate susp 2 QL(16/30)QVAR AERS 40MCG/ACT 3 QL(8.7/30)QVAR AERS 80MCG/ACT 3 QL(17.4/30)QVAR REDIHALER AERB 40MCG/ACT

3 QL(10.6/30)

QVAR REDIHALER AERB 80MCG/ACT

3 QL(21.2/30)

Antihistaminesazelastine hcl nasal soln 2 QL(30/25)desloratadine 2 QL(30/30)diphenhydramine hcl inj 2levocetirizine dihydrochloride oral soln

2 QL(300/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

betaxolol hcl 2BETIMOL 4BETOPTIC-S 3brimonidine tartrate 2carteolol hcl 2dorzolamide hcl 2 QL(10/30)dorzolamide hcl/timolol maleate 2 QL(10/30)IOPIDINE OPHTHALMIC SOLN 1%

4

isopto carpine 2levobunolol hcl 2metipranolol 2PHOSPHOLINE IODIDE 4pilocarpine hcl 2SIMBRINZA 3timolol maleate ophthalmic soln 2

Otic Agents

Otic Agentsacetasol hc 2acetic acid 2aurodex 2COLY-MYCIN S 4fluocinolone acetonide 2fluocinolone acetonide ear drops

2

hydrocortisone/acetic acid 2neomycin/polymyxin/hc 2neomycin/polymyxin/hydrocortisone

2

Respiratory Tract/Pulmonary Agents

Anti-inflammatories, Inhaled CorticosteroidsADVAIR DISKUS 3 QL(60/30)ADVAIR HFA 3 QL(12/30)ASMANEX HFA 3 QL(13/30)

52


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

levalbuterol 2 B/D PA QL(90/30)levalbuterol hcl nebu 1.25mg/3ml

2 B/D PA QL(90/30)

levalbuterol hcl nebu 0.31mg/3ml

2 B/D PA QL(270/30)

levalbuterol hcl nebu 0.63mg/3ml

2 B/D PA QL(540/30)

levalbuterol tartrate hfa 3 QL(30/30)metaproterenol sulfate 2PERFOROMIST 4 B/D PA QL(120/30)PROAIR HFA 3 QL(17/30)PROAIR RESPICLICK 3 QL(2/30)PROVENTIL HFA 4 QL(13.4/30)SEREVENT DISKUS 3 QL(60/30)STRIVERDI RESPIMAT 3 QL(4/30)terbutaline sulfate 3Cystic Fibrosis AgentsCAYSTON 5 QL(84/56)KALYDECO 5 PA QL(60/30)ORKAMBI 5 PA QL(120/30)PULMOZYME 5 B/D PA QL(150/30)TOBI PODHALER 5 QL(1568/365)tobramycin nebu 5 B/D PA QL(280/56)Mast Cell Stabilizerscromolyn sodium nebu 2 B/D PA QL(240/30)Phosphodiesterase Inhibitors, Airways Diseaseaminophylline 2DALIRESP TABS 500MCG 3 PA QL(30/30)DALIRESP TABS 250MCG 3 PA QL(60/365)THEO-24 3theophylline 2theophylline cr 2theophylline er tb12 300mg, 450mg

2

theophylline er tb24 2Pulmonary AntihypertensivesADCIRCA 5 PA QL(60/30)ADEMPAS 5 PA QL(90/30)LETAIRIS 5 PA QL(30/30)OPSUMIT 5 PA QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

levocetirizine dihydrochloride tabs

2 QL(30/30)

promethazine hcl inj 2 PApromethazine hcl plain 2 PApromethazine hcl syrp 2 PApromethazine hcl tabs 2 PAAntileukotrienesmontelukast sodium 2 QL(30/30)zafirlukast 2 QL(60/30)Bronchodilators, AnticholinergicCOMBIVENT RESPIMAT 3 QL(8/30)ipratropium bromide inhalation soln

2 B/D PA QL(300/30)

ipratropium bromide nasal soln 2 QL(30/30)ipratropium bromide/albuterol sulfate

2 B/D PA QL(540/30)

SPIRIVA HANDIHALER 3 QL(30/30)SPIRIVA RESPIMAT 3 QL(4/30)TUDORZA PRESSAIR 4 QL(1/30)Bronchodilators, SympathomimeticADRENALIN INJ 3albuterol sulfate er 2albuterol sulfate nebu 0.5% 2 B/D PA QL(180/30)albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml

2 B/D PA QL(360/30)

albuterol sulfate syrp 2albuterol sulfate tabs 2ANORO ELLIPTA 3 QL(60/30)ARCAPTA NEOHALER 4AUVI-Q 4 QL(2/30)BROVANA 4 B/D PA QL(120/30)epinephrine hcl inj 1mg/ml, 30mg/30ml

2

epinephrine inj 0.15mg/0.3ml 3 QL(2/30)epinephrine inj 0.15mg/0.15ml, 0.3mg/0.3ml

2 QL(2/30)

EPIPEN 2-PAK 3 QL(2/30)EPIPEN-JR 2-PAK 3 QL(2/30)isoproterenol hydrochloride 3ISUPREL 3

53



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Sleep Disorders, Otherarmodafinil 4 PA QL(30/30)modafinil 3 PA QL(30/30)ROZEREM 4 QL(30/30)SILENOR 4 QL(30/30)XYREM 5 QL(540/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

REMODULIN 5 B/D PAsildenafil tabs 3 PA QL(90/30)TRACLEER 5 PA QL(60/30)TYVASO 5 B/D PATYVASO REFILL 5 B/D PATYVASO STARTER 5 B/D PAVENTAVIS 5 PA QL(270/30)Pulmonary Fibrosis AgentsESBRIET CAPS 5 PA QL(270/30)ESBRIET TABS 801MG 5 PA QL(90/30)ESBRIET TABS 267MG 5 PA QL(270/30)OFEV 5 PA QL(60/30)Respiratory Tract Agents, Otheracetylcysteine inhalation soln 2 B/D PAARALAST NP 4 B/D PAGLASSIA 5 B/D PAPROLASTIN-C 5 B/D PApromethazine vc plain 2 PAribavirin inhalation soln 5 B/D PATRELEGY ELLIPTA 3 QL(60/30)XOLAIR 5 PA QL(6/28)ZEMAIRA 5 B/D PA

Skeletal Muscle Relaxants

Skeletal Muscle Relaxantscyclobenzaprine hcl tabs 10mg, 5mg

2 PA QL(90/30)

orphenadrine citrate er 2 PA QL(60/30)

Sleep Disorder Agents

GABA Receptor Modulatorstemazepam 2 QL(60/365)zaleplon 2 QL(30/30)zolpidem tartrate tabs 2 QL(30/30)

54

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

Aabacavir/lamivudine . . . . . . . . . . . . . . . 24abacavir oral soln . . . . . . . . . . . . . . . . . 24abacavir sulfate/ lamivudine/zidovudine . . . . . . . . . . . . . 24abacavir tabs . . . . . . . . . . . . . . . . . . . . . 24ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . 16ABILIFY MAINTENA . . . . . . . . . . . . . . . 22ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . 18acamprosate calcium dr . . . . . . . . . . . . . 9acarbose . . . . . . . . . . . . . . . . . . . . . . . . . . 26acebutolol hcl . . . . . . . . . . . . . . . . . . . . . 30acetaminophen/codeine oral soln . . . . 7acetaminophen/codeine tabs 300mg; 15mg, 300mg; 30mg . . . . . . . . 8acetaminophen/codeine tabs 300mg; 60mg . . . . . . . . . . . . . . . . . . . . . . 7acetasol hc . . . . . . . . . . . . . . . . . . . . . . . . 51acetazolamide . . . . . . . . . . . . . . . . . . . . . 31acetazolamide er . . . . . . . . . . . . . . . . . . 50acetazolamide sodium . . . . . . . . . . . . . 31acetic acid . . . . . . . . . . . . . . . . . . . . . . . . 51acetic acid 0.25% . . . . . . . . . . . . . . . . . . 41acetylcysteine inhalation soln . . . . . . 53acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 34ACTEMRA INJ 162MG/0.9ML . . . . . . 48ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML . . . . . . . . . . 48ACTHIB . . . . . . . . . . . . . . . . . . . . . . . . . . . 48ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . 48acyclovir caps . . . . . . . . . . . . . . . . . . . . 25acyclovir oint . . . . . . . . . . . . . . . . . . . . . 25acyclovir sodium . . . . . . . . . . . . . . . . . . . 25acyclovir susp . . . . . . . . . . . . . . . . . . . . 25acyclovir tabs . . . . . . . . . . . . . . . . . . . . . 25ADACEL . . . . . . . . . . . . . . . . . . . . . . . . . . 48ADAGEN . . . . . . . . . . . . . . . . . . . . . . . . . 40adapalene . . . . . . . . . . . . . . . . . . . . . . . . 34ADCIRCA . . . . . . . . . . . . . . . . . . . . . . . . . 52adefovir dipivoxil . . . . . . . . . . . . . . . . . . . 23

ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . . 52ADRENALIN INJ . . . . . . . . . . . . . . . . . . 52adriamycin . . . . . . . . . . . . . . . . . . . . . . . . 18adrucil . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ADVAIR DISKUS . . . . . . . . . . . . . . . . . . 51ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . 51afeditab cr . . . . . . . . . . . . . . . . . . . . . . . . 30AFINITOR DISPERZ TBSO 2MG, 3MG . . . . . . . . . . . . . . . . . . . . . . . . 20AFINITOR DISPERZ TBSO 5MG . . . 20AFINITOR TABS 2.5MG, 5MG, 7.5MG . . . . . . . . . . . . . . 20AFINITOR TABS 10MG . . . . . . . . . . . . 20AGGRENOX . . . . . . . . . . . . . . . . . . . . . . 29ala-cort crea 1% . . . . . . . . . . . . . . . . . . . 41ALBENZA . . . . . . . . . . . . . . . . . . . . . . . . . 21albuterol sulfate er . . . . . . . . . . . . . . . . . 52albuterol sulfate nebu 0.5% . . . . . . . . 52albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml . . . . . . . . . . . 52albuterol sulfate syrp . . . . . . . . . . . . . . 52albuterol sulfate tabs . . . . . . . . . . . . . . 52alclometasone dipropionate . . . . . . . . 41alcohol prep pads . . . . . . . . . . . . . . . . . . 9ALDURAZYME . . . . . . . . . . . . . . . . . . . . 40ALECENSA . . . . . . . . . . . . . . . . . . . . . . . 20alendronate sodium oral soln . . . . . . 48alendronate sodium tabs 10mg, 40mg, 5mg . . . . . . . . . . . . . . . . . 49alendronate sodium tabs 35mg, 70mg . . . . . . . . . . . . . . . . . . . . . . . 49alfuzosin hcl er . . . . . . . . . . . . . . . . . . . . 41ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ALINIA SUSR . . . . . . . . . . . . . . . . . . . . . 21ALINIA TABS . . . . . . . . . . . . . . . . . . . . . 21ALIQOPA . . . . . . . . . . . . . . . . . . . . . . . . . 20allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . 17allopurinol sodium . . . . . . . . . . . . . . . . . 17ALOCRIL . . . . . . . . . . . . . . . . . . . . . . . . . 50ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

alosetron hydrochloride tabs 0.5mg . . . . . . . . . . . . . . . . . . . . . . . . 40alosetron hydrochloride tabs 1mg . . . 40ALPHAGAN P OPHTHALMIC SOLN 0.1% . . . . . . . . 50alprazolam intensol . . . . . . . . . . . . . . . . 25alprazolam odt tbdp 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 25alprazolam odt tbdp 2mg . . . . . . . . . . . 25alprazolam tabs 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 26alprazolam tabs 2mg . . . . . . . . . . . . . . 26altavera . . . . . . . . . . . . . . . . . . . . . . . . . . . 43ALUNBRIG TABS 30MG . . . . . . . . . . . 20ALUNBRIG TABS 180MG, 90MG . . . 20ALUNBRIG TBPK . . . . . . . . . . . . . . . . . 20alyacen 1/35 . . . . . . . . . . . . . . . . . . . . . . 43amabelz . . . . . . . . . . . . . . . . . . . . . . . . . . 43amantadine hcl . . . . . . . . . . . . . . . . . . . . 21AMBISOME . . . . . . . . . . . . . . . . . . . . . . . 16amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . 43amethia lo . . . . . . . . . . . . . . . . . . . . . . . . . 43amikacin sulfate . . . . . . . . . . . . . . . . . . . . 9amiloride hcl . . . . . . . . . . . . . . . . . . . . . . 31amiloride/hydrochlorothiazide . . . . . . 31aminocaproic acid . . . . . . . . . . . . . . . . . 28aminophylline . . . . . . . . . . . . . . . . . . . . . 52AMINOSYN 7%/ELECTROLYTES . . 35AMINOSYN 8.5%/ ELECTROLYTES . . . . . . . . . . . . . . . . . . 35AMINOSYN-HBC . . . . . . . . . . . . . . . . . . 35AMINOSYN II 8.5%/ ELECTROLYTES . . . . . . . . . . . . . . . . . . 35AMINOSYN II INJ 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 38MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML . . . . . 35

55


Covered Drugs Index

ANADROL-50 . . . . . . . . . . . . . . . . . . . . . 43anagrelide hydrochloride . . . . . . . . . . . 28anaspaz . . . . . . . . . . . . . . . . . . . . . . . . . . 39anastrozole . . . . . . . . . . . . . . . . . . . . . . . 19ANGELIQ . . . . . . . . . . . . . . . . . . . . . . . . . 43ANORO ELLIPTA . . . . . . . . . . . . . . . . . . 52APLENZIN . . . . . . . . . . . . . . . . . . . . . . . . 14APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . 21apraclonidine . . . . . . . . . . . . . . . . . . . . . . 50aprepitant caps . . . . . . . . . . . . . . . . . . . 16aprepitant caps 40mg . . . . . . . . . . . . . . 16aprepitant caps 80mg . . . . . . . . . . . . . . 16aprepitant caps 125mg . . . . . . . . . . . . . 16apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43APRISO . . . . . . . . . . . . . . . . . . . . . . . . . . 48APTIOM TABS 200MG, 400MG, 800MG . . . . . . . . . . . 13APTIOM TABS 600MG . . . . . . . . . . . . . 13APTIVUS CAPS . . . . . . . . . . . . . . . . . . 25APTIVUS ORAL SOLN . . . . . . . . . . . . 25ARALAST NP . . . . . . . . . . . . . . . . . . . . . 53aranelle . . . . . . . . . . . . . . . . . . . . . . . . . . . 43ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML . . . . . 28ARANESP ALBUMIN FREE INJ 25MCG/0.42ML . . . . . . . . . . . . . . . . . . . 28ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML . . . . . . . . . . . 28ARANESP ALBUMIN FREE INJ 60MCG/0.3ML . . . . . . . . . . . . . . . . . . . . 28ARANESP ALBUMIN FREE INJ 100MCG/0.5ML . . . . . . . . . . . . . . . . . . . 28ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML . . . . . . . . . . 28ARANESP ALBUMIN FREE INJ 150MCG/0.3ML . . . . . . . . . . . . . . . . . . . 28ARANESP ALBUMIN FREE INJ 200MCG/0.4ML . . . . . . . . . . . . . . . . . . . 28ARANESP ALBUMIN FREE INJ 300MCG/0.6ML . . . . . . . . . . . . . . . . . . . 28

amlodipine besylate/benazepril hydrochloride caps 2.5mg; 10mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg . . . . . . . . . . . . . . . . . 30amlodipine besylate/benazepril hydrochloride caps 10mg; 20mg, 10mg; 40mg . . . . . . . . . . . . . . . . 30amlodipine besylate tabs 2.5mg . . . . 30amlodipine besylate tabs 5mg . . . . . . 30amlodipine besylate tabs 10mg . . . . . 30amlodipine besylate/valsartan . . . . . . 30amlodipine/valsartan/hctz . . . . . . . . . . 30ammonium lactate . . . . . . . . . . . . . . . . . 34amnesteem . . . . . . . . . . . . . . . . . . . . . . . 34amoxapine . . . . . . . . . . . . . . . . . . . . . . . . 15amoxicillin . . . . . . . . . . . . . . . . . . . . . . . . . 11amoxicillin/clavulanate potassium . . . 11amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg; 1.25mg; 1.25mg, 6.25mg; 6.25mg; 6.25mg; 6.25mg . . . . . . . . . . . . . . . . . . . 32amphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg . . . . . . . 32amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg . . . . . . . 33amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg . . . . . . . . . 33amphotericin b . . . . . . . . . . . . . . . . . . . . 16ampicillin . . . . . . . . . . . . . . . . . . . . . . . . . . 11ampicillin sodium inj 10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 11ampicillin sodium inj 125mg, 250mg, 500mg . . . . . . . . . . . . 11ampicillin-sulbactam . . . . . . . . . . . . . . . 11AMPYRA . . . . . . . . . . . . . . . . . . . . . . . . . 33

AMINOSYN II INJ 107.6MEQ/L; 1490MG/100ML; 1527MG/100ML; 1050MG/100ML; 1107MG/100ML; 750MG/100ML; 450MG/100ML; 990MG/100ML; 1500MG/100ML; 1575MG/100ML; 258MG/100ML; 447MG/100ML; 1083MG/100ML; 795MG/100ML; 50MEQ/L; 600MG/100ML; 300MG/100ML; 405MG/100ML; 750MG/100ML, 61.1MEQ/L; 844MG/100ML; 865MG/100ML; 595MG/100ML; 627MG/100ML; 425MG/100ML; 255MG/100ML; 561MG/100ML; 850MG/100ML; 893MG/100ML; 146MG/100ML; 253MG/100ML; 614MG/100ML; 450MG/100ML; 33.3MEQ/L; 340MG/100ML; 170MG/100ML; 230MG/100ML; 425MG/100ML . . . . . . . . . . . . . . . . . . . . 35AMINOSYN INJ 90MEQ/L; 1100MG/100ML; 850MG/100ML; 35MEQ/L; 1100MG/100ML; 260MG/100ML; 620MG/100ML; 810MG/100ML; 624MG/100ML; 340MG/100ML; 380MG/100ML; 5.4MEQ/L; 750MG/100ML; 370MG/100ML; 460MG/100ML; 150MG/100ML; 44MG/100ML; 680MG/100ML . . . . . . . . . . . . . . . . . . . . 35AMINOSYN INJ 148MEQ/L; 1280MG/100ML; 980MG/100ML; 1280MG/100ML; 300MG/100ML; 720MG/100ML; 940MG/100ML; 720MG/100ML; 400MG/100ML; 440MG/100ML; 5.4MEQ/L; 860MG/100ML; 420MG/100ML; 520MG/100ML; 160MG/100ML; 44MG/100ML; 800MG/100ML . . . . . . 35AMINOSYN M . . . . . . . . . . . . . . . . . . . . . 35AMINOSYN-PF . . . . . . . . . . . . . . . . . . . . 35AMINOSYN-PF 7% . . . . . . . . . . . . . . . . 35AMINOSYN-RF . . . . . . . . . . . . . . . . . . . 35amiodarone hcl . . . . . . . . . . . . . . . . . . . . 30AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . . 40amitriptyline hcl . . . . . . . . . . . . . . . . . . . . 15

56


Covered Drugs Index

bacitracin inj . . . . . . . . . . . . . . . . . . . . . . . 9bacitracin ophthalmic oint . . . . . . . . . . . 9bacitracin/polymyxin b . . . . . . . . . . . . . . 9baclofen tabs . . . . . . . . . . . . . . . . . . . . . 23bactocill in dextrose . . . . . . . . . . . . . . . . 11balsalazide disodium . . . . . . . . . . . . . . 48balziva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43BANZEL SUSP . . . . . . . . . . . . . . . . . . . 14BANZEL TABS 200MG . . . . . . . . . . . . 14BANZEL TABS 400MG . . . . . . . . . . . . 14BARACLUDE ORAL SOLN . . . . . . . . 23BAVENCIO . . . . . . . . . . . . . . . . . . . . . . . . 20BAXDELA . . . . . . . . . . . . . . . . . . . . . . . . . 12BCG VACCINE . . . . . . . . . . . . . . . . . . . . 48bd eclipse syringe/1ml/30gx1/2” . . . . 49bd insulin syringe safetyglide/ 1ml/29g x 1/2” . . . . . . . . . . . . . . . . . . . . . 49bd insulin syringe ultrafine/ 0.3ml/31g x 5/16” . . . . . . . . . . . . . . . . . . 49bd insulin syringe ultrafine/ 0.5ml/30g x 1/2” . . . . . . . . . . . . . . . . . . . 49bd insulin syringe ultrafine/ 1ml/31g x 5/16” . . . . . . . . . . . . . . . . . . . . 49bd pen needle/ultrafine/ 29g x 12.7mm . . . . . . . . . . . . . . . . . . . . . 49bd safetyglide 27g x 5/8” . . . . . . . . . . . 49bekyree . . . . . . . . . . . . . . . . . . . . . . . . . . . 43BELEODAQ . . . . . . . . . . . . . . . . . . . . . . . 18belladonna alkaloids & opium . . . . . . 39belladonna & opium . . . . . . . . . . . . . . . 39benazepril hcl . . . . . . . . . . . . . . . . . . . . . 29benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg, 20mg; 25mg, 5mg; 6.25mg . . . . . . . . . . . . . . . 29benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg . . . . . . . . . . . . . . . . 29BENDEKA . . . . . . . . . . . . . . . . . . . . . . . . 17BENICAR . . . . . . . . . . . . . . . . . . . . . . . . . 29BENICAR HCT . . . . . . . . . . . . . . . . . . . . 29BENLYSTA INJ 120MG . . . . . . . . . . . . 48BENLYSTA INJ 400MG . . . . . . . . . . . . 48

atorvastatin calcium . . . . . . . . . . . . . . . 32atovaquone . . . . . . . . . . . . . . . . . . . . . . . 21atovaquone/proguanil hcl . . . . . . . . . . 21ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . 24atropine sulfate inj 0.5mg/5ml . . . . . . 31atropine sulfate inj 0.25mg/5ml, 0.4mg/ml, 1mg/ml . . . . . . . . . . . . . . . . . 39atropine sulfate oint . . . . . . . . . . . . . . . 50atropine sulfate ophthalmic soln . . . . 50aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43augmented betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . 41aurodex . . . . . . . . . . . . . . . . . . . . . . . . . . . 51AUVI-Q . . . . . . . . . . . . . . . . . . . . . . . . . . . 52AVANDIA . . . . . . . . . . . . . . . . . . . . . . . . . 26AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 20AVELOX INJ . . . . . . . . . . . . . . . . . . . . . . 12aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43AVONEX . . . . . . . . . . . . . . . . . . . . . . . . . . 33AVONEX PEN . . . . . . . . . . . . . . . . . . . . . 33azacitidine . . . . . . . . . . . . . . . . . . . . . . . . 18AZACTAM . . . . . . . . . . . . . . . . . . . . . . . . 11AZACTAM IN ISO-OSMOTIC DEXTROSE . . . . . . . . . . . . . . . . . . . . . . . 11AZASITE . . . . . . . . . . . . . . . . . . . . . . . . . . 12azathioprine . . . . . . . . . . . . . . . . . . . . . . . 47azelastine hcl nasal soln . . . . . . . . . . . 51azelastine hcl ophthalmic soln . . . . . 50AZELEX . . . . . . . . . . . . . . . . . . . . . . . . . . 34azithromycin inj . . . . . . . . . . . . . . . . . . . 12azithromycin pack . . . . . . . . . . . . . . . . . 12azithromycin susr 100mg/5ml . . . . . . 12azithromycin susr 200mg/5ml . . . . . . 12azithromycin tabs 250mg, 500mg . . . 12azithromycin tabs 600mg . . . . . . . . . . . 12AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . 50aztreonam . . . . . . . . . . . . . . . . . . . . . . . . 11

Bbaciim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

ARANESP ALBUMIN FREE INJ 500MCG/ML . . . . . . . . . . . . . . . . . . . . . . 28ARCALYST . . . . . . . . . . . . . . . . . . . . . . . 48ARCAPTA NEOHALER . . . . . . . . . . . . 52aripiprazole odt . . . . . . . . . . . . . . . . . . . . 22aripiprazole oral soln . . . . . . . . . . . . . . 22aripiprazole tabs . . . . . . . . . . . . . . . . . . 22ARISTADA INJ 441MG/1.6ML . . . . . . 22ARISTADA INJ 662MG/2.4ML . . . . . . 22ARISTADA INJ 882MG/3.2ML . . . . . . 22ARISTADA INJ 1064MG/3.9ML . . . . . 22armodafinil . . . . . . . . . . . . . . . . . . . . . . . . 53ARRANON . . . . . . . . . . . . . . . . . . . . . . . . 18ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . . 43ASMANEX HFA . . . . . . . . . . . . . . . . . . . 51ASMANEX TWISTHALER 7 METERED DOSES . . . . . . . . . . . . . . 51ASMANEX TWISTHALER 14 METERED DOSES . . . . . . . . . . . . . 51ASMANEX TWISTHALER 30 METERED DOSES . . . . . . . . . . . . . 51ASMANEX TWISTHALER 60 METERED DOSES . . . . . . . . . . . . . 51ASMANEX TWISTHALER 120 METERED DOSES . . . . . . . . . . . . 51aspirin/dipyridamole . . . . . . . . . . . . . . . 29ASTAGRAF XL CP24 0.5MG, 1MG . . . . . . . . . . . . . . . . . . . . . . 47ASTAGRAF XL CP24 5MG . . . . . . . . . 47atazanavir caps 150mg . . . . . . . . . . . . 25atazanavir caps 200mg . . . . . . . . . . . . 25atazanavir caps 300mg . . . . . . . . . . . . 25atazanavir sulfate caps 150mg . . . . . 25atazanavir sulfate caps 200mg . . . . . 25atazanavir sulfate caps 300mg . . . . . 25atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 30atenolol/chlorthalidone . . . . . . . . . . . . . 30ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 47atomoxetine caps 10mg, 18mg, 25mg, 40mg . . . . . . . . . 33atomoxetine caps 100mg, 60mg, 80mg . . . . . . . . . . . . . . . 33

57


Covered Drugs Index

BUTRANS PTWK 7.5MCG/HR . . . . . . 7BYDUREON . . . . . . . . . . . . . . . . . . . . . . 26BYDUREON BCISE . . . . . . . . . . . . . . . 26BYDUREON PEN . . . . . . . . . . . . . . . . . 26BYETTA INJ 5MCG/0.02ML . . . . . . . . 26BYETTA INJ 10MCG/0.04ML . . . . . . . 26BYSTOLIC TABS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 30BYSTOLIC TABS 20MG . . . . . . . . . . . 30BYVALSON . . . . . . . . . . . . . . . . . . . . . . . 30

Ccabergoline . . . . . . . . . . . . . . . . . . . . . . . 46CABOMETYX TABS 20MG, 60MG . . . . . . . . . . . . . . . . . . . . . . 20CABOMETYX TABS 40MG . . . . . . . . 20calcipotriene crea . . . . . . . . . . . . . . . . . 34calcipotriene external soln . . . . . . . . . 34calcipotriene oint . . . . . . . . . . . . . . . . . . 34calcitonin-salmon . . . . . . . . . . . . . . . . . . 49calcitrene . . . . . . . . . . . . . . . . . . . . . . . . . 34calcitriol caps . . . . . . . . . . . . . . . . . . . . . 49calcitriol inj . . . . . . . . . . . . . . . . . . . . . . . 49calcitriol oral soln . . . . . . . . . . . . . . . . . 49calcium acetate caps . . . . . . . . . . . . . . 38calcium acetate tabs 667mg . . . . . . . . 38calcium gluconate inj . . . . . . . . . . . . . . 35CALQUENCE . . . . . . . . . . . . . . . . . . . . . 20camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45camrese . . . . . . . . . . . . . . . . . . . . . . . . . . 43camrese lo . . . . . . . . . . . . . . . . . . . . . . . . 43CANASA . . . . . . . . . . . . . . . . . . . . . . . . . . 48CANCIDAS . . . . . . . . . . . . . . . . . . . . . . . 16CAPASTAT SULFATE . . . . . . . . . . . . . . 17CAPRELSA TABS 100MG . . . . . . . . . 20CAPRELSA TABS 300MG . . . . . . . . . 20captopril tabs 12.5mg, 25mg . . . . . . . 29captopril tabs 100mg, 50mg . . . . . . . . 29CARAFATE SUSP . . . . . . . . . . . . . . . . 40CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . 36

BOTOX INJ 200UNIT . . . . . . . . . . . . . . 49BREO ELLIPTA . . . . . . . . . . . . . . . . . . . 51briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . 29brimonidine tartrate . . . . . . . . . . . . . . . . 51BRIVIACT INJ . . . . . . . . . . . . . . . . . . . . 13BRIVIACT ORAL SOLN . . . . . . . . . . . 13BRIVIACT TABS 10MG, 25MG, 50MG, 75MG . . . . . . . 13BRIVIACT TABS 100MG . . . . . . . . . . . 13bromocriptine mesylate . . . . . . . . . . . . 21BROVANA . . . . . . . . . . . . . . . . . . . . . . . . 52budesonide cpep . . . . . . . . . . . . . . . . . 48budesonide susp . . . . . . . . . . . . . . . . . . 51bumetanide . . . . . . . . . . . . . . . . . . . . . . . 31BUPHENYL TABS . . . . . . . . . . . . . . . . 40buprenorphine hcl inj . . . . . . . . . . . . . . . 7buprenorphine hcl/naloxone hcl . . . . . . 9buprenorphine hcl subl . . . . . . . . . . . . . 9buprenorphine ptwk 10mcg/hr, 15mcg/hr, 20mcg/hr, 5mcg/hr . . . . . . . . 7bupropion hcl er tb12 150mg, 200mg . . . . . . . . . . . . . . . . . . . . 14bupropion hcl sr . . . . . . . . . . . . . . . . . . . . 9bupropion hcl sr . . . . . . . . . . . . . . . . . . . 14bupropion hcl tabs 75mg . . . . . . . . . . . 14bupropion hcl tabs 100mg . . . . . . . . . . 14bupropion hcl xl . . . . . . . . . . . . . . . . . . . 15buspirone hcl . . . . . . . . . . . . . . . . . . . . . . 25busulfan . . . . . . . . . . . . . . . . . . . . . . . . . . 17BUSULFEX . . . . . . . . . . . . . . . . . . . . . . . 17butalbital/acetaminophen/ caffeine caps . . . . . . . . . . . . . . . . . . . . . . 7butalbital/acetaminophen/ caffeine tabs 325mg; 50mg; 40mg . . . 7butalbital/acetaminophen tabs 325mg; 50mg . . . . . . . . . . . . . . . . . . 7butalbital/aspirin/caffeine caps . . . . . . 7butorphanol tartrate inj 1mg/ml . . . . . . 8butorphanol tartrate inj 2mg/ml . . . . . . 8butorphanol tartrate nasal soln . . . . . . 8

benztropine mesylate inj . . . . . . . . . . . 21benztropine mesylate tabs . . . . . . . . . 21BERINERT . . . . . . . . . . . . . . . . . . . . . . . . 47BESIVANCE . . . . . . . . . . . . . . . . . . . . . . 12BESPONSA . . . . . . . . . . . . . . . . . . . . . . . 20betamethasone dipropionate . . . . . . . 41betamethasone sodium phosphate/betamethasone acetate . . . . . . . . . . . . 41betamethasone valerate crea . . . . . . 41betamethasone valerate lotn . . . . . . . 41betamethasone valerate oint . . . . . . . 41betaxolol hcl . . . . . . . . . . . . . . . . . . . . . . . 30betaxolol hcl . . . . . . . . . . . . . . . . . . . . . . . 51bethanechol chloride . . . . . . . . . . . . . . . 41BETIMOL . . . . . . . . . . . . . . . . . . . . . . . . . 51BETOPTIC-S . . . . . . . . . . . . . . . . . . . . . . 51bexarotene . . . . . . . . . . . . . . . . . . . . . . . . 21BEXSERO . . . . . . . . . . . . . . . . . . . . . . . . 48bicalutamide . . . . . . . . . . . . . . . . . . . . . . 18BICILLIN C-R . . . . . . . . . . . . . . . . . . . . . 11BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . 11BICNU . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32BIKTARVY . . . . . . . . . . . . . . . . . . . . . . . . 24BILTRICIDE . . . . . . . . . . . . . . . . . . . . . . . 21bimatoprost ophthalmic soln . . . . . . . 50bisoprolol fumarate . . . . . . . . . . . . . . . . 30bisoprolol fumarate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 30bleomycin sulfate . . . . . . . . . . . . . . . . . . 18BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . 12BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . 12blisovi 24 fe . . . . . . . . . . . . . . . . . . . . . . . 43blisovi fe 1.5/30 . . . . . . . . . . . . . . . . . . . . 43blisovi fe 1/20 . . . . . . . . . . . . . . . . . . . . . 43BOOSTRIX . . . . . . . . . . . . . . . . . . . . . . . 48BORTEZOMIB . . . . . . . . . . . . . . . . . . . . 18BOSULIF TABS 100MG . . . . . . . . . . . . 20BOSULIF TABS 400MG, 500MG . . . 20BOTOX INJ 100UNIT . . . . . . . . . . . . . . 49

58


Covered Drugs Index

cidofovir . . . . . . . . . . . . . . . . . . . . . . . . . . 23cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . 29CILOXAN OINT . . . . . . . . . . . . . . . . . . . 12CIMDUO . . . . . . . . . . . . . . . . . . . . . . . . . . 24cimetidine . . . . . . . . . . . . . . . . . . . . . . . . . 39cimetidine hcl . . . . . . . . . . . . . . . . . . . . . 39CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . . 47CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . 12ciprofloxacin er tb24 500mg; 0 . . . . . . 12ciprofloxacin er tb24 1000mg; 0 . . . . 12ciprofloxacin hcl . . . . . . . . . . . . . . . . . . . 12ciprofloxacin inj . . . . . . . . . . . . . . . . . . . 12ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5% . . . . . . . . . . . . . . . . . 12ciprofloxacin susr . . . . . . . . . . . . . . . . . 12CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . . 12cisplatin . . . . . . . . . . . . . . . . . . . . . . . . . . . 19citalopram hydrobromide oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 15citalopram hydrobromide tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 15citalopram hydrobromide tabs 20mg . . . . . . . . . . . . . . . . . . . . . . . . 15citalopram hydrobromide tabs 40mg . . . . . . . . . . . . . . . . . . . . . . . . 15cladribine . . . . . . . . . . . . . . . . . . . . . . . . . 18claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . 34clarithromycin er . . . . . . . . . . . . . . . . . . . 12clarithromycin susr . . . . . . . . . . . . . . . . 12clarithromycin tabs . . . . . . . . . . . . . . . . 12CLEOCIN SUPP . . . . . . . . . . . . . . . . . . . 9CLIMARA PRO . . . . . . . . . . . . . . . . . . . . 43clindacin-p . . . . . . . . . . . . . . . . . . . . . . . . . 9clindamycin . . . . . . . . . . . . . . . . . . . . . . . 10clindamycin/benzoyl peroxide . . . . . . 34clindamycin hcl . . . . . . . . . . . . . . . . . . . . 10clindamycin palmitate hcl . . . . . . . . . . . 10clindamycin phosphate crea . . . . . . . 10clindamycin phosphate external soln . . . . . . . . . . . . . . . . . . . . . . 10clindamycin phosphate foam . . . . . . . 10

CEFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . 11ceftriaxone/dextrose . . . . . . . . . . . . . . . 11ceftriaxone in iso-osmotic dextrose . . 11ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg . . . . . . . . . 11cefuroxime axetil . . . . . . . . . . . . . . . . . . 11cefuroxime/dextrose . . . . . . . . . . . . . . . 11cefuroxime sodium . . . . . . . . . . . . . . . . 11celecoxib caps 100mg, 200mg, 50mg . . . . . . . . . . . . . . . 7celecoxib caps 400mg . . . . . . . . . . . . . . 7CELLCEPT TABS . . . . . . . . . . . . . . . . . 47CELONTIN . . . . . . . . . . . . . . . . . . . . . . . . 13cephalexin . . . . . . . . . . . . . . . . . . . . . . . . 11CEREZYME . . . . . . . . . . . . . . . . . . . . . . . 40CESAMET . . . . . . . . . . . . . . . . . . . . . . . . 16cesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43cevimeline hcl . . . . . . . . . . . . . . . . . . . . . 34CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . . 9CHANTIX CONTINUING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . . 9CHANTIX STARTING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . . 9chateal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43CHENODAL . . . . . . . . . . . . . . . . . . . . . . . 39chloramphenicol sodium succinate . . . 9chlorhexidine gluconate mouth/throat soln . . . . . . . . . . . . . . . . . 34chloroquine phosphate . . . . . . . . . . . . . 21chlorothiazide . . . . . . . . . . . . . . . . . . . . . 32chlorothiazide sodium . . . . . . . . . . . . . . 32chlorpromazine hcl . . . . . . . . . . . . . . . . 22chlorthalidone . . . . . . . . . . . . . . . . . . . . . 32cholestyramine . . . . . . . . . . . . . . . . . . . . 32cholestyramine light . . . . . . . . . . . . . . . 32choline magnesium trisalicylate liqd . . . . . . . . . . . . . . . . . . . . 7ciclodan . . . . . . . . . . . . . . . . . . . . . . . . . . . 16ciclopirox . . . . . . . . . . . . . . . . . . . . . . . . . . 16ciclopirox nail lacquer . . . . . . . . . . . . . . 16ciclopirox olamine . . . . . . . . . . . . . . . . . 16

carbamazepine . . . . . . . . . . . . . . . . . . . . 14carbamazepine er . . . . . . . . . . . . . . . . . 14carbidopa . . . . . . . . . . . . . . . . . . . . . . . . . 22carbidopa/levodopa . . . . . . . . . . . . . . . . 22carbidopa/levodopa/entacapone . . . . 22carbidopa/levodopa er . . . . . . . . . . . . . 22carbidopa/levodopa odt . . . . . . . . . . . . 22carboplatin inj 150mg/15ml, 50mg/5ml . . . . . . . . . . . . 18CARDENE IV . . . . . . . . . . . . . . . . . . . . . 30CARNITOR INJ . . . . . . . . . . . . . . . . . . . 49carteolol hcl . . . . . . . . . . . . . . . . . . . . . . . 51cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . 31carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . 30carvedilol phosphate . . . . . . . . . . . . . . . 30caspofungin acetate . . . . . . . . . . . . . . . 16CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . 52caziant . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43cefaclor caps . . . . . . . . . . . . . . . . . . . . . 10cefaclor er . . . . . . . . . . . . . . . . . . . . . . . . 10cefaclor susr . . . . . . . . . . . . . . . . . . . . . . 11cefadroxil . . . . . . . . . . . . . . . . . . . . . . . . . 11cefazolin . . . . . . . . . . . . . . . . . . . . . . . . . . 11cefazolin sodium/dextrose inj 1gm; 4%, 2gm; 3% . . . . . . . . . . . . . . . . 11cefazolin sodium inj 100gm, 10gm, 1gm, 1gm/50ml; 4%, 20gm, 300gm, 500mg . . . . . . . . . 11cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11cefepime . . . . . . . . . . . . . . . . . . . . . . . . . . 11cefepime/dextrose . . . . . . . . . . . . . . . . . 11cefixime . . . . . . . . . . . . . . . . . . . . . . . . . . . 11cefotaxime sodium inj 1gm, 2gm, 500mg . . . . . . . . . . . . . . . . . 11cefotetan . . . . . . . . . . . . . . . . . . . . . . . . . . 11cefotetan/dextrose . . . . . . . . . . . . . . . . . 11cefoxitin sodium . . . . . . . . . . . . . . . . . . . 11cefpodoxime proxetil . . . . . . . . . . . . . . . 11cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . 11ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . 11ceftazidime/dextrose . . . . . . . . . . . . . . . 11

59


Covered Drugs Index

colchicine caps . . . . . . . . . . . . . . . . . . . 17colchicine tabs . . . . . . . . . . . . . . . . . . . . 17colestipol hcl . . . . . . . . . . . . . . . . . . . . . . 32colistimethate sodium . . . . . . . . . . . . . . 10colocort . . . . . . . . . . . . . . . . . . . . . . . . . . . 48COLY-MYCIN S . . . . . . . . . . . . . . . . . . . 51COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . 50COMBIPATCH . . . . . . . . . . . . . . . . . . . . 43COMBIVENT RESPIMAT . . . . . . . . . . 52COMETRIQ KIT . . . . . . . . . . . . . . . . . . 20COMETRIQ KIT . . . . . . . . . . . . . . . . . . 20COMETRIQ KIT 20MG . . . . . . . . . . . . 20COMPLERA . . . . . . . . . . . . . . . . . . . . . . 24compro . . . . . . . . . . . . . . . . . . . . . . . . . . . 22CONDYLOX . . . . . . . . . . . . . . . . . . . . . . 34constulose . . . . . . . . . . . . . . . . . . . . . . . . 40COPAXONE INJ 20MG/ML . . . . . . . . . 33COPAXONE INJ 40MG/ML . . . . . . . . . 33CORDRAN TAPE . . . . . . . . . . . . . . . . . 42COREG CR . . . . . . . . . . . . . . . . . . . . . . . 30CORLANOR . . . . . . . . . . . . . . . . . . . . . . 31CORTIFOAM . . . . . . . . . . . . . . . . . . . . . . 42cortisone acetate . . . . . . . . . . . . . . . . . . 42CORTISPORIN CREA . . . . . . . . . . . . . 10CORTISPORIN OINT . . . . . . . . . . . . . 10COSMEGEN . . . . . . . . . . . . . . . . . . . . . . 19COTELLIC . . . . . . . . . . . . . . . . . . . . . . . . 20COUMADIN . . . . . . . . . . . . . . . . . . . . . . . 27CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . 40CRESTOR . . . . . . . . . . . . . . . . . . . . . . . . 32CRIXIVAN CAPS 200MG . . . . . . . . . . 25CRIXIVAN CAPS 400MG . . . . . . . . . . 25cromolyn sodium conc . . . . . . . . . . . . 39cromolyn sodium nebu . . . . . . . . . . . . 52cromolyn sodium ophthalmic soln . . . 50cryselle-28 . . . . . . . . . . . . . . . . . . . . . . . . 43CUPRIMINE . . . . . . . . . . . . . . . . . . . . . . 38curity gauze pads 2”x2” . . . . . . . . . . . . 34cyclafem 1/35 . . . . . . . . . . . . . . . . . . . . . 43cyclafem 7/7/7 . . . . . . . . . . . . . . . . . . . . . 43

clobetasol propionate liqd . . . . . . . . . 41clobetasol propionate lotn . . . . . . . . . 41clobetasol propionate oint . . . . . . . . . 42clobetasol propionate sham . . . . . . . . 42clocortolone pivalate . . . . . . . . . . . . . . . 42clocortolone pivalate pump . . . . . . . . . 42clodan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42clofarabine . . . . . . . . . . . . . . . . . . . . . . . . 18clomipramine hcl . . . . . . . . . . . . . . . . . . 15clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg . . . . . . . . . . . 13clonazepam odt tbdp 1mg . . . . . . . . . . 13clonazepam odt tbdp 2mg . . . . . . . . . . 13clonazepam tabs 0.5mg . . . . . . . . . . . . 13clonazepam tabs 1mg . . . . . . . . . . . . . 13clonazepam tabs 2mg . . . . . . . . . . . . . 13clonidine hcl er . . . . . . . . . . . . . . . . . . . . 33clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr . . . . . . . . . . . . 29clonidine hcl ptwk 0.3mg/24hr . . . . . . 29clonidine hcl tabs . . . . . . . . . . . . . . . . . 29clopidogrel tabs 75mg . . . . . . . . . . . . . 29clopidogrel tabs 300mg . . . . . . . . . . . . 29clorazepate dipotassium tabs 3.75mg, 7.5mg . . . . . . . . . . . . . . . 26clorazepate dipotassium tabs 15mg . . . . . . . . . . . . . . . . . . . . . . . . 26clotrimazole/ betamethasone dipropionate . . . . . . . 16clotrimazole external crea . . . . . . . . . 16clotrimazole external soln . . . . . . . . . . 16clotrimazole lozg . . . . . . . . . . . . . . . . . . 16clozapine odt tbdp 12.5mg, 25mg . . . 23clozapine odt tbdp 100mg . . . . . . . . . . 23clozapine odt tbdp 150mg . . . . . . . . . . 23clozapine odt tbdp 200mg . . . . . . . . . . 23clozapine tabs 25mg, 50mg . . . . . . . . 23clozapine tabs 100mg . . . . . . . . . . . . . . 23clozapine tabs 200mg . . . . . . . . . . . . . . 23COARTEM . . . . . . . . . . . . . . . . . . . . . . . . 21codeine sulfate . . . . . . . . . . . . . . . . . . . . . 8

clindamycin phosphate gel . . . . . . . . 10clindamycin phosphate in d5w . . . . . . 10clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml . . . . . . . . . . . . 10clindamycin phosphate lotn . . . . . . . . 10clindamycin phosphate swab . . . . . . 10clindamycin phosphate/tretinoin . . . . 34clindamycin/sodium chloride . . . . . . . . 10CLINIMIX 2.75%/DEXTROSE 5% . . . 36CLINIMIX 4.25%/DEXTROSE 5% . . . 36CLINIMIX 4.25%/DEXTROSE 10% . . 36CLINIMIX 4.25%/DEXTROSE 20% . . 36CLINIMIX 4.25%/DEXTROSE 25% . . 36CLINIMIX 5%/DEXTROSE 15% . . . . 36CLINIMIX 5%/DEXTROSE 20% . . . . 36CLINIMIX 5%/DEXTROSE 25% . . . . 36CLINIMIX E 2.75%/ DEXTROSE 5% . . . . . . . . . . . . . . . . . . . 36CLINIMIX E 2.75%/ DEXTROSE 10% . . . . . . . . . . . . . . . . . . 36CLINIMIX E 4.25%/ DEXTROSE 5% . . . . . . . . . . . . . . . . . . . 36CLINIMIX E 4.25%/ DEXTROSE 10% . . . . . . . . . . . . . . . . . . 36CLINIMIX E 4.25%/ DEXTROSE 25% . . . . . . . . . . . . . . . . . . 36CLINIMIX E 5%/DEXTROSE 15% . . . 36CLINIMIX E 5%/DEXTROSE 20% . . . 36CLINIMIX E 5%/DEXTROSE 25% . . . 36CLINIMIX N9G15E . . . . . . . . . . . . . . . . 36CLINIMIX N14G30E . . . . . . . . . . . . . . . 36CLINISOL SF 15% . . . . . . . . . . . . . . . . 36clinpro 5000 . . . . . . . . . . . . . . . . . . . . . . . 36clobetasol propionate crea . . . . . . . . . 41clobetasol propionate e . . . . . . . . . . . . 41clobetasol propionate emollient foam . . . . . . . . . . . . . . . . . . . . 41clobetasol propionate external soln . . . . . . . . . . . . . . . . . . . . . . 41clobetasol propionate foam . . . . . . . . 41clobetasol propionate gel . . . . . . . . . . 41

60


Covered Drugs Index

DEXTROSE5% / ELECTROLYTE #48 VIAFLEX . . . . . 36DEXTROSE 5%/ LACTATED RINGERS . . . . . . . . . . . . . 36DEXTROSE 5%/NACL 0.2% . . . . . . . 36DEXTROSE 5%/NACL 0.3% . . . . . . . 36dextrose 5%/nacl 0.9% . . . . . . . . . . . . 36DEXTROSE 5%/NACL 0.33% . . . . . . 36DEXTROSE 5%/NACL 0.45% . . . . . . 36DEXTROSE 5%/NACL 0.225% . . . . . 36dextrose 10% . . . . . . . . . . . . . . . . . . . . . 36DEXTROSE 10%/NACL 0.2% . . . . . . 36DEXTROSE10%/NACL 0.45% . . . . . 36dextrose 20% . . . . . . . . . . . . . . . . . . . . . 36dextrose 25% . . . . . . . . . . . . . . . . . . . . . 36dextrose 30% . . . . . . . . . . . . . . . . . . . . . 36dextrose 40% . . . . . . . . . . . . . . . . . . . . . 36dextrose 50% . . . . . . . . . . . . . . . . . . . . . 36dextrose 70% . . . . . . . . . . . . . . . . . . . . . 36DIASTAT ACUDIAL GEL 10MG . . . . . 13DIASTAT ACUDIAL GEL 20MG . . . . . 13DIASTAT PEDIATRIC . . . . . . . . . . . . . . 13diazepam conc . . . . . . . . . . . . . . . . . . . 26diazepam inj 5mg/ml . . . . . . . . . . . . . . . 26diazepam intensol . . . . . . . . . . . . . . . . . 26diazepam oral soln . . . . . . . . . . . . . . . . 26diazepam rectal gel gel 2.5mg . . . . . . 13diazepam rectal gel gel 10mg . . . . . . 13diazepam rectal gel gel 20mg . . . . . . 13diazepam tabs . . . . . . . . . . . . . . . . . . . . 26diclofenac potassium . . . . . . . . . . . . . . . 7diclofenac sodium dr . . . . . . . . . . . . . . . . 7diclofenac sodium er . . . . . . . . . . . . . . . . 7diclofenac sodium gel 1% . . . . . . . . . . 34diclofenac sodium gel 3% . . . . . . . . . . 34diclofenac sodium/misoprostol . . . . . . . 7diclofenac sodium ophthalmic soln . . . 50dicloxacillin sodium . . . . . . . . . . . . . . . . 11dicyclomine hcl caps . . . . . . . . . . . . . . 39dicyclomine hcl oral soln . . . . . . . . . . . 39

DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . 31denta 5000 plus . . . . . . . . . . . . . . . . . . . 36dentagel . . . . . . . . . . . . . . . . . . . . . . . . . . 36DEPO-ESTRADIOL . . . . . . . . . . . . . . . 43DEPO-MEDROL INJ 20MG/ML . . . . . 42DEPO-PROVERA . . . . . . . . . . . . . . . . . 45DEPO-SUBQ PROVERA 104 . . . . . . 45DESCOVY . . . . . . . . . . . . . . . . . . . . . . . . 24desipramine hcl . . . . . . . . . . . . . . . . . . . 15desloratadine . . . . . . . . . . . . . . . . . . . . . . 51desmopressin acetate inj . . . . . . . . . . 43desmopressin acetate nasal soln . . 43desmopressin acetate tabs . . . . . . . . 43desogestrel/ethinyl estradiol . . . . . . . . 43DESONATE . . . . . . . . . . . . . . . . . . . . . . . 42desonide . . . . . . . . . . . . . . . . . . . . . . . . . . 42desoximetasone . . . . . . . . . . . . . . . . . . . 42desvenlafaxine er . . . . . . . . . . . . . . . . . . 15dexamethasone . . . . . . . . . . . . . . . . . . . 42dexamethasone intensol . . . . . . . . . . . 42dexamethasone sodium phosphate inj 100mg/10ml, 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml . . . . 42dexamethasone sodium phosphate ophthalmic soln . . . . . . . . 50DEXILANT . . . . . . . . . . . . . . . . . . . . . . . . 40dexmethylphenidate hcl . . . . . . . . . . . . 33dexrazoxane . . . . . . . . . . . . . . . . . . . . . . 19dextroamphetamine sulfate er cp24 5mg . . . . . . . . . . . . . . . . . . . . . . . . . 33dextroamphetamine sulfate er cp24 10mg . . . . . . . . . . . . . . . . . . . . . . . . 33dextroamphetamine sulfate er cp24 15mg . . . . . . . . . . . . . . . . . . . . . . . . 33dextroamphetamine sulfate oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 33dextroamphetamine sulfate tabs 5mg . . . . . . . . . . . . . . . . . . . . . . . . . . 33dextroamphetamine sulfate tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 33dextrose 2.5%/nacl 0.45% . . . . . . . . . 36dextrose 5% . . . . . . . . . . . . . . . . . . . . . . . 36

cyclobenzaprine hcl tabs 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 53CYCLOMYDRIL . . . . . . . . . . . . . . . . . . . 50cyclopentolate hcl . . . . . . . . . . . . . . . . . 50cyclopentolate hydrochloride . . . . . . . 50cyclophosphamide caps . . . . . . . . . . . 17cyclophosphamide inj 1gm, 500mg . . . . . . . . . . . . . . . . . . . . . . . 17cyclophosphamide inj 2gm . . . . . . . . . 17cycloserine . . . . . . . . . . . . . . . . . . . . . . . . 17cyclosporine caps . . . . . . . . . . . . . . . . . 47cyclosporine inj . . . . . . . . . . . . . . . . . . . 47cyclosporine modified . . . . . . . . . . . . . . 47CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . . 21cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43CYSTADANE . . . . . . . . . . . . . . . . . . . . . 40CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . 40CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . 50cytarabine aqueous . . . . . . . . . . . . . . . . 18cytarabine inj 100mg/ml . . . . . . . . . . . . 18cytra k crystals . . . . . . . . . . . . . . . . . . . . 36

Ddacarbazine . . . . . . . . . . . . . . . . . . . . . . . 17dactinomycin . . . . . . . . . . . . . . . . . . . . . . 19DALIRESP TABS 250MCG . . . . . . . . . 52DALIRESP TABS 500MCG . . . . . . . . . 52danazol . . . . . . . . . . . . . . . . . . . . . . . . . . . 43dantrolene sodium . . . . . . . . . . . . . . . . . 23dapsone tabs . . . . . . . . . . . . . . . . . . . . . 17DAPTACEL . . . . . . . . . . . . . . . . . . . . . . . 48daptomycin . . . . . . . . . . . . . . . . . . . . . . . 10DARAPRIM . . . . . . . . . . . . . . . . . . . . . . . 21DARZALEX . . . . . . . . . . . . . . . . . . . . . . . 21daunorubicin hcl . . . . . . . . . . . . . . . . . . . 19daysee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43deblitane . . . . . . . . . . . . . . . . . . . . . . . . . . 45decitabine . . . . . . . . . . . . . . . . . . . . . . . . . 19delyla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43demeclocycline hcl . . . . . . . . . . . . . . . . 12

61


Covered Drugs Index

dutasteride/ tamsulosin hydrochloride . . . . . . . . . . . 41DYRENIUM . . . . . . . . . . . . . . . . . . . . . . . 31DYSPORT . . . . . . . . . . . . . . . . . . . . . . . . 49

Eeconazole nitrate . . . . . . . . . . . . . . . . . . 16EDARBI . . . . . . . . . . . . . . . . . . . . . . . . . . 29EDARBYCLOR . . . . . . . . . . . . . . . . . . . . 29ed-spaz . . . . . . . . . . . . . . . . . . . . . . . . . . . 39EDURANT . . . . . . . . . . . . . . . . . . . . . . . . 24e.e.s. 400 . . . . . . . . . . . . . . . . . . . . . . . . . 12efavirenz caps 50mg . . . . . . . . . . . . . . . 24efavirenz caps 200mg . . . . . . . . . . . . . 24efavirenz tabs . . . . . . . . . . . . . . . . . . . . 24effer-k tbef 25meq . . . . . . . . . . . . . . . . . 36effervescent potassium . . . . . . . . . . . . 36effervescent pot chloride . . . . . . . . . . . 36EGRIFTA . . . . . . . . . . . . . . . . . . . . . . . . . 43ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . 40ELELYSO . . . . . . . . . . . . . . . . . . . . . . . . . 40ELIDEL . . . . . . . . . . . . . . . . . . . . . . . . . . . 34ELIGARD INJ 7.5MG . . . . . . . . . . . . . . 46ELIGARD INJ 22.5MG . . . . . . . . . . . . . 46ELIGARD INJ 30MG . . . . . . . . . . . . . . . 46ELIGARD INJ 45MG . . . . . . . . . . . . . . . 46ELIQUIS STARTER PACK . . . . . . . . . 27ELIQUIS TABS 2.5MG . . . . . . . . . . . . . 27ELIQUIS TABS 5MG . . . . . . . . . . . . . . . 27ELITEK . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . 41EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . 18EMEND SUSR . . . . . . . . . . . . . . . . . . . . 16emoquette . . . . . . . . . . . . . . . . . . . . . . . . 44EMPLICITI . . . . . . . . . . . . . . . . . . . . . . . . 21EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 15EMTRIVA CAPS . . . . . . . . . . . . . . . . . . 24EMTRIVA ORAL SOLN . . . . . . . . . . . . 24enalaprilat . . . . . . . . . . . . . . . . . . . . . . . . . 29

donepezil hcl tabs 23mg, 5mg . . . . . . 14donepezil hcl tbdp 5mg . . . . . . . . . . . . 14donepezil hcl tbdp 10mg . . . . . . . . . . . 14donepezil hydrochloride tabs 5mg . . 14donepezil hydrochloride tabs 10mg . . 14doripenem . . . . . . . . . . . . . . . . . . . . . . . . 11dorzolamide hcl . . . . . . . . . . . . . . . . . . . 51dorzolamide hcl/timolol maleate . . . . 51doxazosin . . . . . . . . . . . . . . . . . . . . . . . . . 41doxazosin mesylate tabs 1mg, 2mg . . . . . . . . . . . . . . . . . . . . . . . . . 41doxazosin mesylate tabs 8mg . . . . . . 41doxepin hcl . . . . . . . . . . . . . . . . . . . . . . . . 25doxercalciferol caps 0.5mcg . . . . . . . . 49doxercalciferol caps 1mcg . . . . . . . . . . 49doxercalciferol caps 2.5mcg . . . . . . . . 49doxercalciferol inj . . . . . . . . . . . . . . . . . 49doxorubicin hcl . . . . . . . . . . . . . . . . . . . . 19doxorubicin hcl liposome . . . . . . . . . . . 19doxy 100 . . . . . . . . . . . . . . . . . . . . . . . . . . 12doxycycline hyclate caps . . . . . . . . . . 12doxycycline hyclate dr tbec 100mg, 150mg, 75mg . . . . . . . . . . . . . . 12doxycycline hyclate tabs 100mg, 20mg . . . . . . . . . . . . . . . . . . . . . 13doxycycline monohydrate caps 100mg, 50mg . . . . . . . . . . . . . . . . 13doxycycline monohydrate caps 150mg . . . . . . . . . . . . . . . . . . . . . . . 13doxycycline monohydrate tabs . . . . . 13doxycycline susr . . . . . . . . . . . . . . . . . . 13DRITHO-CREME HP . . . . . . . . . . . . . . 34dronabinol . . . . . . . . . . . . . . . . . . . . . . . . 16droperidol . . . . . . . . . . . . . . . . . . . . . . . . . 16drospirenone/ethinyl estradiol . . . . . . 43DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . 18duloxetine hcl cpep 20mg, 60mg . . . 15duloxetine hcl cpep 30mg . . . . . . . . . . 15DURAMORPH . . . . . . . . . . . . . . . . . . . . . 7DUREZOL . . . . . . . . . . . . . . . . . . . . . . . . 50dutasteride . . . . . . . . . . . . . . . . . . . . . . . . 41

dicyclomine hcl tabs . . . . . . . . . . . . . . . 39didanosine . . . . . . . . . . . . . . . . . . . . . . . . 24DIFFERIN LOTN . . . . . . . . . . . . . . . . . . 34DIFICID . . . . . . . . . . . . . . . . . . . . . . . . . . . 12diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . . 7digitek tabs 0.25mg . . . . . . . . . . . . . . . . 31digitek tabs 0.125mg . . . . . . . . . . . . . . . 31digoxin inj . . . . . . . . . . . . . . . . . . . . . . . . 31digoxin oral soln . . . . . . . . . . . . . . . . . . 31digoxin tabs 125mcg . . . . . . . . . . . . . . . 31digoxin tabs 250mcg . . . . . . . . . . . . . . . 31digox tabs 125mcg . . . . . . . . . . . . . . . . 31digox tabs 250mcg . . . . . . . . . . . . . . . . 31dihydroergotamine mesylate inj . . . . 17DILANTIN . . . . . . . . . . . . . . . . . . . . . . . . . 14DILANTIN-125 . . . . . . . . . . . . . . . . . . . . 14DILANTIN INFATABS . . . . . . . . . . . . . . 14dilt-cd cp24 180mg, 240mg . . . . . . . . 31diltiazem hcl . . . . . . . . . . . . . . . . . . . . . . . 31diltiazem hcl er cp12 . . . . . . . . . . . . . . 31diltiazem hcl er cp24 120mg, 180mg, 240mg, 300mg, 420mg . . . . . 31diltiazem hcl er tb24 . . . . . . . . . . . . . . . 31dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31dimenhydrinate inj . . . . . . . . . . . . . . . . 16diphenhydramine hcl inj . . . . . . . . . . . 51diphenoxylate/atropine . . . . . . . . . . . . . 39DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC . . . . . . . . . . 48disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . . 9divalproex sodium . . . . . . . . . . . . . . . . . 13divalproex sodium dr . . . . . . . . . . . . . . . 13divalproex sodium er . . . . . . . . . . . . . . . 13DIVIGEL . . . . . . . . . . . . . . . . . . . . . . . . . . 43docetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml . . . . . . . . . . . . . . 19DOCETAXEL INJ 200MG/10ML . . . . 19dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . . 30donepezil hcl tabs 10mg . . . . . . . . . . . 14

62


Covered Drugs Index

ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg . . . . . . . . . 44ETHYOL . . . . . . . . . . . . . . . . . . . . . . . . . . 19etidronate disodium . . . . . . . . . . . . . . . . 49etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . . 7etodolac er . . . . . . . . . . . . . . . . . . . . . . . . . 7etoposide inj . . . . . . . . . . . . . . . . . . . . . . 20EURAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 21EVOMELA . . . . . . . . . . . . . . . . . . . . . . . . 18EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . 25exemestane . . . . . . . . . . . . . . . . . . . . . . . 20EXTAVIA . . . . . . . . . . . . . . . . . . . . . . . . . . 34ezetimibe . . . . . . . . . . . . . . . . . . . . . . . . . 32ezetimibe/simvastatin . . . . . . . . . . . . . . 32

FFABRAZYME . . . . . . . . . . . . . . . . . . . . . 40falmina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44famciclovir . . . . . . . . . . . . . . . . . . . . . . . . 25famotidine inj . . . . . . . . . . . . . . . . . . . . . 39famotidine premixed . . . . . . . . . . . . . . . 39famotidine susr . . . . . . . . . . . . . . . . . . . 39famotidine tabs 20mg, 40mg . . . . . . . 40FANAPT TABS 1MG, 2MG, 4MG . . . 22FANAPT TABS 10MG, 12MG, 6MG, 8MG . . . . . . . . . . 22FANAPT TITRATION PACK . . . . . . . . 22FARESTON . . . . . . . . . . . . . . . . . . . . . . . 18FARXIGA . . . . . . . . . . . . . . . . . . . . . . . . . 26FARYDAK . . . . . . . . . . . . . . . . . . . . . . . . 20FASLODEX . . . . . . . . . . . . . . . . . . . . . . . 18felbamate susp . . . . . . . . . . . . . . . . . . . 14felbamate tabs . . . . . . . . . . . . . . . . . . . . 14felodipine er . . . . . . . . . . . . . . . . . . . . . . . 31FEM PH . . . . . . . . . . . . . . . . . . . . . . . . . . 10FEMRING . . . . . . . . . . . . . . . . . . . . . . . . . 44femynor . . . . . . . . . . . . . . . . . . . . . . . . . . . 44fenofibrate caps 43mg, 50mg . . . . . . . 32fenofibrate caps 130mg, 150mg . . . . 32fenofibrate micronized caps 67mg . . . 32

ERBITUX . . . . . . . . . . . . . . . . . . . . . . . . . 21ergoloid mesylates . . . . . . . . . . . . . . . . . 14ergotamine tartrate/caffeine . . . . . . . . 17ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . 20ERLEADA . . . . . . . . . . . . . . . . . . . . . . . . 18errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45ERWINAZE . . . . . . . . . . . . . . . . . . . . . . . 19ery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12ERYPED 400 . . . . . . . . . . . . . . . . . . . . . 12ERY-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . 12ERYTHROCIN LACTOBIONATE . . . 12erythrocin stearate . . . . . . . . . . . . . . . . . 12erythromycin . . . . . . . . . . . . . . . . . . . . . . 12erythromycin base . . . . . . . . . . . . . . . . . 12erythromycin/benzoyl peroxide . . . . . 34erythromycin ethylsuccinate . . . . . . . . 12ESBRIET CAPS . . . . . . . . . . . . . . . . . . 53ESBRIET TABS 267MG . . . . . . . . . . . . 53ESBRIET TABS 801MG . . . . . . . . . . . . 53escitalopram oxalate oral soln . . . . . 15escitalopram oxalate tabs 5mg . . . . . 15escitalopram oxalate tabs 10mg . . . . 15escitalopram oxalate tabs 20mg . . . . 15esgic caps . . . . . . . . . . . . . . . . . . . . . . . . . 7esomeprazole magnesium . . . . . . . . . 40esomeprazole sodium . . . . . . . . . . . . . 40estarylla . . . . . . . . . . . . . . . . . . . . . . . . . . 44ESTRACE CREA . . . . . . . . . . . . . . . . . 44estradiol crea . . . . . . . . . . . . . . . . . . . . . 44estradiol/norethindrone acetate . . . . . 44estradiol pttw . . . . . . . . . . . . . . . . . . . . . 44estradiol ptwk . . . . . . . . . . . . . . . . . . . . . 44estradiol tabs 0.5mg, 1mg, 2mg . . . . 44estradiol tabs 10mcg . . . . . . . . . . . . . . . 44ESTRING . . . . . . . . . . . . . . . . . . . . . . . . . 44estropipate . . . . . . . . . . . . . . . . . . . . . . . . 44ethacrynate sodium . . . . . . . . . . . . . . . . 31ethacrynic acid . . . . . . . . . . . . . . . . . . . . 31ethambutol hcl . . . . . . . . . . . . . . . . . . . . 17ethosuximide . . . . . . . . . . . . . . . . . . . . . . 13

enalapril maleate . . . . . . . . . . . . . . . . . . 29enalapril maleate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 29ENBREL INJ 25MG/0.5ML . . . . . . . . . 47ENBREL INJ 25MG, 50MG/ML . . . . . 47ENBREL MINI . . . . . . . . . . . . . . . . . . . . . 47ENBREL SURECLICK . . . . . . . . . . . . . 47endocet tabs 325mg; 2.5mg, 325mg; 5mg . . . . . . . . . 8endocet tabs 325mg; 7.5mg . . . . . . . . . 8endocet tabs 325mg; 10mg . . . . . . . . . 8ENGERIX-B INJ 10MCG/0.5ML . . . . 48ENGERIX-B INJ 20MCG/ML . . . . . . . 48enoxaparin sodium inj 30mg/0.3ml . . 27enoxaparin sodium inj 40mg/0.4ml . . 28enoxaparin sodium inj 60mg/0.6ml . . 28enoxaparin sodium inj 100mg/ml, 150mg/ml, 300mg/3ml . . 28enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml . . . . . . . . . . 28enpresse-28 . . . . . . . . . . . . . . . . . . . . . . . 44enskyce . . . . . . . . . . . . . . . . . . . . . . . . . . . 44entacapone . . . . . . . . . . . . . . . . . . . . . . . 21entecavir . . . . . . . . . . . . . . . . . . . . . . . . . . 23ENTRESTO . . . . . . . . . . . . . . . . . . . . . . . 29enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . 40ENVARSUS XR TB24 0.75MG, 1MG . . . . . . . . . . . . . . . . . . . . . 47ENVARSUS XR TB24 4MG . . . . . . . . 47EPCLUSA . . . . . . . . . . . . . . . . . . . . . . . . 23epinephrine hcl inj 1mg/ml, 30mg/30ml . . . . . . . . . . . . . . . . 52epinephrine inj 0.15mg/0.3ml . . . . . . . 52epinephrine inj 0.15mg/0.15ml, 0.3mg/0.3ml . . . . . . . 52EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . . . 52EPIPEN-JR 2-PAK . . . . . . . . . . . . . . . . . 52epirubicin hcl inj 200mg/100ml . . . . . 19epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14EPIVIR HBV ORAL SOLN . . . . . . . . . 23eplerenone . . . . . . . . . . . . . . . . . . . . . . . . 31

63


Covered Drugs Index

fluvoxamine maleate tabs 100mg . . . 15FML . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50FML FORTE . . . . . . . . . . . . . . . . . . . . . . 50FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . 18fomepizole . . . . . . . . . . . . . . . . . . . . . . . . 49fondaparinux sodium inj 2.5mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . 28fondaparinux sodium inj 5mg/0.4ml . . . . . . . . . . . . . . . . . . . . . . . . 28fondaparinux sodium inj 7.5mg/0.6ml . . . . . . . . . . . . . . . . . . . . . . . 28fondaparinux sodium inj 10mg/0.8ml . . . . . . . . . . . . . . . . . . . . . . . 28FORTEO . . . . . . . . . . . . . . . . . . . . . . . . . . 49fosamprenavir calcium . . . . . . . . . . . . . 25fosinopril sodium . . . . . . . . . . . . . . . . . . 29fosinopril sodium/ hydrochlorothiazide . . . . . . . . . . . . . . . . 29fosphenytoin sodium inj 100mg pe/2ml . . . . . . . . . . . . . . . . . . . . . 14FRAGMIN INJ 2500UNIT/0.2ML, 5000UNIT/0.2ML . . . . . . . . . . . . . . . . . . 28FRAGMIN INJ 7500UNIT/0.3ML . . . . 28FRAGMIN INJ 10000UNIT/ML. . . . . . 28FRAGMIN INJ 12500UNIT/0.5ML. . . 28FRAGMIN INJ 15000UNIT/0.6ML. . . 28FRAGMIN INJ 18000UNT/0.72ML . . 28FRAGMIN INJ 95000UNIT/3.8ML. . . 28FREAMINE HBC 6.9% . . . . . . . . . . . . . 36FREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML . . . . . 36furosemide inj . . . . . . . . . . . . . . . . . . . . 31furosemide oral soln . . . . . . . . . . . . . . 31furosemide tabs . . . . . . . . . . . . . . . . . . . 31

fludarabine phosphate inj 50mg . . . . 19fludrocortisone acetate . . . . . . . . . . . . . 42flunisolide . . . . . . . . . . . . . . . . . . . . . . . . . 51fluocinolone acetonide . . . . . . . . . . . . . 42fluocinolone acetonide . . . . . . . . . . . . . 51fluocinolone acetonide body . . . . . . . . 42fluocinolone acetonide ear drops . . . 51fluocinolone acetonide scalp . . . . . . . 42fluocinonide crea 0.1% . . . . . . . . . . . . . 42fluocinonide crea 0.05% . . . . . . . . . . . 42fluocinonide external soln . . . . . . . . . . 42fluocinonide gel . . . . . . . . . . . . . . . . . . . 42fluocinonide oint . . . . . . . . . . . . . . . . . . 42fluoride chew 0.25mg . . . . . . . . . . . . . . 36fluoritab chew 0.5mg, 1mg . . . . . . . . . 36fluoritab oral soln . . . . . . . . . . . . . . . . . 36fluorometholone . . . . . . . . . . . . . . . . . . . 50fluorouracil crea 0.5% . . . . . . . . . . . . . . 34fluorouracil crea 5% . . . . . . . . . . . . . . . 34fluorouracil external soln . . . . . . . . . . . 34fluorouracil inj . . . . . . . . . . . . . . . . . . . . . 18fluoxetine caps 10mg . . . . . . . . . . . . . . 15fluoxetine caps 20mg . . . . . . . . . . . . . . 15fluoxetine hcl caps 10mg . . . . . . . . . . . 15fluoxetine hcl caps 20mg . . . . . . . . . . . 15fluoxetine hcl caps 40mg . . . . . . . . . . . 15fluoxetine hcl oral soln . . . . . . . . . . . . . 15fluoxetine hcl tabs 10mg, 60mg . . . . . 15fluoxetine hcl tabs 20mg . . . . . . . . . . . 15fluphenazine decanoate . . . . . . . . . . . . 22fluphenazine hcl . . . . . . . . . . . . . . . . . . . 22flura-drops . . . . . . . . . . . . . . . . . . . . . . . . 36flurbiprofen sodium . . . . . . . . . . . . . . . . 50flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . 18fluticasone propionate crea . . . . . . . . 42fluticasone propionate lotn . . . . . . . . . 42fluticasone propionate oint . . . . . . . . . 42fluticasone propionate susp . . . . . . . . 51fluvoxamine maleate tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 15

fenofibrate micronized caps 134mg, 200mg . . . . . . . . . . . . . . . . . . . . 32fenofibrate tabs 48mg, 54mg . . . . . . . 32fenofibrate tabs 145mg, 160mg . . . . . 32fenofibric acid dr cpdr 45mg . . . . . . . . 32fenofibric acid dr cpdr 135mg . . . . . . . 32fentanyl . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, 2500mcg/50ml, 250mcg/5ml . . . . . . . . 8fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, 600mcg . . . . . 8fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg . . . 8FERRIPROX . . . . . . . . . . . . . . . . . . . . . . 49FETZIMA . . . . . . . . . . . . . . . . . . . . . . . . . 15FETZIMA TITRATION PACK . . . . . . . 15FINACEA . . . . . . . . . . . . . . . . . . . . . . . . . 34finasteride tabs 5mg . . . . . . . . . . . . . . . 41FIRAZYR . . . . . . . . . . . . . . . . . . . . . . . . . 47FIRMAGON INJ 80MG . . . . . . . . . . . . . 46FIRMAGON INJ 120MG . . . . . . . . . . . 46FLAREX . . . . . . . . . . . . . . . . . . . . . . . . . . 50flavoxate hcl . . . . . . . . . . . . . . . . . . . . . . . 41flecainide acetate . . . . . . . . . . . . . . . . . . 30FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST . . . . 51FLOVENT DISKUS AEPB 250MCG/BLIST . . . . . . . . . . . . . . . . . . . 51FLOVENT HFA AERO 44MCG/ACT . . . . . . . . . . . . . . . . . . . . . . 51FLOVENT HFA AERO 110MCG/ACT . . . . . . . . . . . . . . . . . . . . . 51FLOVENT HFA AERO 220MCG/ACT . . . . . . . . . . . . . . . . . . . . . 51floxuridine . . . . . . . . . . . . . . . . . . . . . . . . . 18fluconazole . . . . . . . . . . . . . . . . . . . . . . . . 16fluconazole in dextrose . . . . . . . . . . . . 16fluconazole in nacl inj 200mg/100ml; 0.9%, 400mg/200ml; 0.9% . . . . . . . . . . . . . . . 16flucytosine . . . . . . . . . . . . . . . . . . . . . . . . 16

64


Covered Drugs Index

GLYXAMBI . . . . . . . . . . . . . . . . . . . . . . . . 26GOLYTELY . . . . . . . . . . . . . . . . . . . . . . . 40GORDONS UREA OINT 40% . . . . . . 34granisetron hcl inj . . . . . . . . . . . . . . . . . 16granisetron hcl tabs . . . . . . . . . . . . . . . 16GRANIX . . . . . . . . . . . . . . . . . . . . . . . . . . 28griseofulvin microsize . . . . . . . . . . . . . . 16griseofulvin ultramicrosize . . . . . . . . . . 16GUANIDINE HCL . . . . . . . . . . . . . . . . . . 17GYNAZOLE-1 . . . . . . . . . . . . . . . . . . . . . 16

HHALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . 19halobetasol propionate . . . . . . . . . . . . . 42haloperidol . . . . . . . . . . . . . . . . . . . . . . . . 22haloperidol decanoate . . . . . . . . . . . . . 22haloperidol lactate . . . . . . . . . . . . . . . . . 22HARVONI . . . . . . . . . . . . . . . . . . . . . . . . . 23HAVRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 48heather . . . . . . . . . . . . . . . . . . . . . . . . . . . 45heparin sodium/d5w . . . . . . . . . . . . . . . 28heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml . . . . . . . . 28heparin sodium/nacl 0.9% . . . . . . . . . . 28heparin sodium/nacl 0.45% . . . . . . . . 28heparin sodium/ sodium chloride 0.9% . . . . . . . . . . . . . . 28heparin sodium/ sodium chloride 0.9% premix . . . . . . . 28HEPATAMINE . . . . . . . . . . . . . . . . . . . . . 36HERCEPTIN INJ 150MG . . . . . . . . . . . 21HERCEPTIN INJ 440MG . . . . . . . . . . . 21HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . . 33HEXALEN . . . . . . . . . . . . . . . . . . . . . . . . 18HIBERIX . . . . . . . . . . . . . . . . . . . . . . . . . . 48homatropaire . . . . . . . . . . . . . . . . . . . . . . 50homatropine hbr . . . . . . . . . . . . . . . . . . . 50HORIZANT . . . . . . . . . . . . . . . . . . . . . . . 33H.P. ACTHAR . . . . . . . . . . . . . . . . . . . . . 43

generlac . . . . . . . . . . . . . . . . . . . . . . . . . . 40gengraf . . . . . . . . . . . . . . . . . . . . . . . . . . . 47GENOTROPIN . . . . . . . . . . . . . . . . . . . . 43GENOTROPIN MINIQUICK INJ 0.2MG . . . . . . . . . . . . . . . . . . . . . . . . 43GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG . . 43gentak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9gentamicin sulfate . . . . . . . . . . . . . . . . . . 9gentamicin sulfate/ 0.9% sodium chloride . . . . . . . . . . . . . . . 9gentamicin sulfate pediatric . . . . . . . . . 9GENVOYA . . . . . . . . . . . . . . . . . . . . . . . . 24GEODON INJ . . . . . . . . . . . . . . . . . . . . 22gianvi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44gildagia . . . . . . . . . . . . . . . . . . . . . . . . . . . 44GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . . . 20GLASSIA . . . . . . . . . . . . . . . . . . . . . . . . . 53GLEOSTINE . . . . . . . . . . . . . . . . . . . . . . 18glimepiride tabs 1mg . . . . . . . . . . . . . . . 26glimepiride tabs 2mg . . . . . . . . . . . . . . . 26glimepiride tabs 4mg . . . . . . . . . . . . . . . 26glipizide er tb24 2.5mg . . . . . . . . . . . . . 26glipizide er tb24 5mg . . . . . . . . . . . . . . . 26glipizide er tb24 10mg . . . . . . . . . . . . . 26glipizide/metformin hcl tabs 2.5mg; 250mg . . . . . . . . . . . . . . . . . . . . . 26glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg . . . . . . . . 26glipizide tabs 5mg . . . . . . . . . . . . . . . . . 26glipizide tabs 10mg . . . . . . . . . . . . . . . . 26glipizide xl tb24 2.5mg . . . . . . . . . . . . . 26glipizide xl tb24 5mg . . . . . . . . . . . . . . . 26glipizide xl tb24 10mg . . . . . . . . . . . . . . 26GLUCAGEN HYPOKIT . . . . . . . . . . . . 27GLUCAGON EMERGENCY KIT . . . . 27glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml . . . . 39glycopyrrolate tabs . . . . . . . . . . . . . . . . 39glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

FUZEON . . . . . . . . . . . . . . . . . . . . . . . . . . 24fyavolv . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44FYCOMPA SUSP . . . . . . . . . . . . . . . . . 13FYCOMPA TABS . . . . . . . . . . . . . . . . . 13

Ggabapentin caps 100mg . . . . . . . . . . . 13gabapentin caps 300mg, 400mg . . . . 13gabapentin oral soln . . . . . . . . . . . . . . 13gabapentin tabs 600mg . . . . . . . . . . . . 13gabapentin tabs 800mg . . . . . . . . . . . . 13galantamine hydrobromide er . . . . . . 14galantamine hydrobromide oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 14galantamine hydrobromide tabs . . . . 14GAMMAKED INJ 1GM/10ML . . . . . . . 47GAMMAKED INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 5GM/50ML . . . . . . . . . . 47GAMUNEX-C INJ 1GM/10ML . . . . . . 47GAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML . . . . . . . . . . 47ganciclovir inj 500mg . . . . . . . . . . . . . . 23GARDASIL 9 . . . . . . . . . . . . . . . . . . . . . . 48gatifloxacin . . . . . . . . . . . . . . . . . . . . . . . . 12GATTEX . . . . . . . . . . . . . . . . . . . . . . . . . . 39gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . 40gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . . 40gavilyte-n/flavor pack . . . . . . . . . . . . . . 40GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . . 21GELNIQUE . . . . . . . . . . . . . . . . . . . . . . . 41gemcitabine hcl inj 1gm, 2gm . . . . . . . 18gemcitabine hcl inj 200mg . . . . . . . . . . 18gemcitabine hydrochloride inj 1.5gm/15ml, 1gm/10ml, 200mg/2ml, 2gm/20ml . . . . . . . . . . . . . 18gemcitabine inj 1gm/26.3ml, 2gm/52.6ml . . . . . . . . . . . 18gemcitabine inj 200mg/5.26ml . . . . . . 18gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . 32

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Covered Drugs Index

ifosfamide inj 1gm, 3gm . . . . . . . . . . . . 18ILARIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48imatinib mesylate . . . . . . . . . . . . . . . . . . 20IMBRUVICA CAPS 70MG . . . . . . . . . . 20IMBRUVICA CAPS 140MG. . . . . . . . . 20IMBRUVICA TABS . . . . . . . . . . . . . . . . 20IMFINZI . . . . . . . . . . . . . . . . . . . . . . . . . . . 21imipenem/cilastatin . . . . . . . . . . . . . . . . 11imipramine hcl . . . . . . . . . . . . . . . . . . . . . 15imiquimod . . . . . . . . . . . . . . . . . . . . . . . . . 34IMOVAX RABIES (H.D.C.V.) . . . . . . . 48INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . 43indapamide . . . . . . . . . . . . . . . . . . . . . . . 32INFANRIX . . . . . . . . . . . . . . . . . . . . . . . . . 48INFUMORPH 200 . . . . . . . . . . . . . . . . . . 7INFUMORPH 500 . . . . . . . . . . . . . . . . . . 7INLYTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 20INTELENCE TABS 25MG . . . . . . . . . . 24INTELENCE TABS 100MG, 200MG . . . . . . . . . . . . . . . . . . . 24INTRALIPID . . . . . . . . . . . . . . . . . . . . . . . 49INTRON A INJ 10MU, 10MU/ML, 50MU, 6000000UNIT/ML . . . . . . . . . . . 23INTRON A INJ 18MU . . . . . . . . . . . . . . 23introvale . . . . . . . . . . . . . . . . . . . . . . . . . . 44INVANZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 11INVEGA SUSTENNA INJ 39MG/0.25ML . . . . . . . . . . . . . . . . . . . . . 22INVEGA SUSTENNA INJ 78MG/0.5ML . . . . . . . . . . . . . . . . . . . . . . 22INVEGA SUSTENNA INJ 117MG/0.75ML . . . . . . . . . . . . . . . . . . . . 22INVEGA SUSTENNA INJ 156MG/ML . . . . . . . . . . . . . . . . . . . . . . . . 22INVEGA SUSTENNA INJ 234MG/1.5ML . . . . . . . . . . . . . . . . . . . . . 22INVEGA TRINZA INJ 273MG/0.875ML . . . . . . . . . . . . . . . . . . 22INVEGA TRINZA INJ 410MG/1.315ML . . . . . . . . . . . . . . . . . . 22INVEGA TRINZA INJ 546MG/1.75ML . . . . . . . . . . . . . . . . . . . . 22

hydrocortisone butyrate external soln . . . . . . . . . . . . . . . . . . . . . . 42hydrocortisone butyrate (lipid) . . . . . . 42hydrocortisone butyrate (lipophilic) . . . 42hydrocortisone butyrate oint . . . . . . . 42hydrocortisone enem . . . . . . . . . . . . . . 48hydrocortisone external crea . . . . . . . 42hydrocortisone lotn 2.5% . . . . . . . . . . . 42hydrocortisone oint 1%, 2.5% . . . . . . 42hydrocortisone rectal crea . . . . . . . . . 42hydrocortisone tabs . . . . . . . . . . . . . . . 42hydrocortisone valerate . . . . . . . . . . . . 42hydromorphone hcl dosette . . . . . . . . . 8hydromorphone hcl inj . . . . . . . . . . . . . . 8hydromorphone hcl liqd . . . . . . . . . . . . 8hydromorphone hcl supp . . . . . . . . . . . 8hydromorphone hcl tabs 2mg, 4mg . . 8hydromorphone hcl tabs 8mg . . . . . . . . 8hydroxychloroquine sulfate . . . . . . . . . 21hydroxyprogesterone caproate . . . . . 45hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 18hyoscyamine sulfate elix . . . . . . . . . . . 39hyoscyamine sulfate odt . . . . . . . . . . . 39hyoscyamine sulfate subl . . . . . . . . . . 39hyoscyamine sulfate tabs . . . . . . . . . . 39hyoscyamine sulfate tbdp . . . . . . . . . . 39hyperlyte-cr . . . . . . . . . . . . . . . . . . . . . . . 36

Iibandronate sodium inj . . . . . . . . . . . . 49ibandronate sodium tabs . . . . . . . . . . 49IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . . 20ibudone tabs 5mg; 200mg . . . . . . . . . . . 8ibuprofen susp . . . . . . . . . . . . . . . . . . . . . 7ibuprofen tabs 400mg, 600mg, 800mg . . . . . . . . . . . . . 7ICLUSIG TABS 15MG . . . . . . . . . . . . . 20ICLUSIG TABS 45MG . . . . . . . . . . . . . 20idarubicin hcl . . . . . . . . . . . . . . . . . . . . . . 19IDHIFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

HUMALOG . . . . . . . . . . . . . . . . . . . . . . . . 27HUMALOG JUNIOR KWIKPEN . . . . 27HUMALOG KWIKPEN . . . . . . . . . . . . . 27HUMALOG MIX 50/50 . . . . . . . . . . . . . 27HUMALOG MIX 50/50 KWIKPEN . . . 27HUMALOG MIX 75/25 . . . . . . . . . . . . . 27HUMALOG MIX 75/25 KWIKPEN . . . 27HUMIRA INJ 10MG/0.2ML, 20MG/0.4ML . . . . . . . . 47HUMIRA INJ 40MG/0.8ML . . . . . . . . . 47HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK . . . . . . . . 47HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . 47HUMIRA PEN-CROHNS DISEASESTARTER . . . . . . . . . . . . . . . 47HUMIRA PEN-PSORIASIS STARTER . . . . . . . . . . . . . . . . . . . . . . . . . 47HUMULIN 70/30 . . . . . . . . . . . . . . . . . . . 27HUMULIN 70/30 KWIKPEN . . . . . . . . 27HUMULIN N . . . . . . . . . . . . . . . . . . . . . . . 27HUMULIN N KWIKPEN . . . . . . . . . . . . 27HUMULIN R . . . . . . . . . . . . . . . . . . . . . . . 27HUMULIN R U-500 (CONCENTRATED) . . . . . . . . . . . . . . . 27HUMULIN R U-500 KWIKPEN. . . . . . 27hydralazine hcl . . . . . . . . . . . . . . . . . . . . 32hydrochlorothiazide . . . . . . . . . . . . . . . . 32hydrocodone/acetaminophen tabs 325mg; 5mg . . . . . . . . . . . . . . . . . . . . . . . . 8hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg . . . . . . . 8hydrocodone bitartrate/ acetaminophen oral soln . . . . . . . . . . . 8hydrocodone bitartrate/ acetaminophen tabs 325mg; 2.5mg . . 8hydrocodone/ibuprofen tabs 5mg; 200mg, 7.5mg; 200mg . . . . . . . . . 8hydrocodone/ibuprofen tabs 10mg; 200mg . . . . . . . . . . . . . . . . . . . . . . 8hydrocortisone/acetic acid . . . . . . . . . . 51hydrocortisone butyrate crea . . . . . . . 42

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Covered Drugs Index

KKABIVEN . . . . . . . . . . . . . . . . . . . . . . . . . 37KADCYLA . . . . . . . . . . . . . . . . . . . . . . . . 21kaitlib fe . . . . . . . . . . . . . . . . . . . . . . . . . . . 44KALBITOR . . . . . . . . . . . . . . . . . . . . . . . . 47kaletra oral soln . . . . . . . . . . . . . . . . . . . 25KALETRA TABS 100MG; 25MG . . . . 25KALETRA TABS 200MG; 50MG . . . . 25KALYDECO . . . . . . . . . . . . . . . . . . . . . . . 52kariva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44KCL 0.3%/D5W/NACL 0.9% . . . . . . . . 37kcl 0.3%/d5w/nacl 0.45% . . . . . . . . . . . 37KCL 0.15%/D5W/NACL 0.2% . . . . . . 37kcl 0.15%/d5w/nacl 0.9% . . . . . . . . . . . 37KCL 0.15%/D5W/NACL 0.45% . . . . . 37KCL 0.15%/D5W/NACL 0.225% . . . . 37kcl 0.075%/d5w/nacl 0.45% . . . . . . . . 37k-effervescent . . . . . . . . . . . . . . . . . . . . . 37kelnor 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 44KENALOG . . . . . . . . . . . . . . . . . . . . . . . . 42KEPIVANCE . . . . . . . . . . . . . . . . . . . . . . 34ketoconazole crea . . . . . . . . . . . . . . . . 16ketoconazole sham . . . . . . . . . . . . . . . 16ketoconazole tabs . . . . . . . . . . . . . . . . . 16ketoprofen . . . . . . . . . . . . . . . . . . . . . . . . . 7ketorolac tromethamine inj 15mg/ml, 30mg/ml . . . . . . . . . . . . . . . . . . 7ketorolac tromethamine inj 30mg/ml . . . . . . . . . . . . . . . . . . . . . . . . . . . 7ketorolac tromethamine ophthalmic soln . . . . . . . . . . . . . . . . . . . 50ketorolac tromethamine tabs . . . . . . . . 7KEYTRUDA . . . . . . . . . . . . . . . . . . . . . . . 21kimidess . . . . . . . . . . . . . . . . . . . . . . . . . . 44KINERET . . . . . . . . . . . . . . . . . . . . . . . . . 47KINRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 48kionex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38KISQALI . . . . . . . . . . . . . . . . . . . . . . . . . . 19KISQALI FEMARA 200 DOSE . . . . . . 18

isradipine . . . . . . . . . . . . . . . . . . . . . . . . . 31ISTODAX (OVERFILL) . . . . . . . . . . . . . 19ISUPREL . . . . . . . . . . . . . . . . . . . . . . . . . 52itraconazole . . . . . . . . . . . . . . . . . . . . . . . 16ivermectin . . . . . . . . . . . . . . . . . . . . . . . . . 21IXEMPRA KIT . . . . . . . . . . . . . . . . . . . . . 19IXIARO . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

JJADENU . . . . . . . . . . . . . . . . . . . . . . . . . . 38JADENU SPRINKLE . . . . . . . . . . . . . . . 38JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 20jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . 28JANUMET . . . . . . . . . . . . . . . . . . . . . . . . 26JANUMET XR TB24 1000MG; 50MG . . . . . . . . . . . . . . . . . . . 26JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG . . . 26JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . 26JARDIANCE . . . . . . . . . . . . . . . . . . . . . . 26jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . . 45JENTADUETO . . . . . . . . . . . . . . . . . . . . 26JENTADUETO XR TB24 2.5MG; 1000MG . . . . . . . . . . . . . . . . . . . 26JENTADUETO XR TB24 5MG; 1000MG . . . . . . . . . . . . . . . . . . . . 26jevantique lo . . . . . . . . . . . . . . . . . . . . . . 44JEVTANA . . . . . . . . . . . . . . . . . . . . . . . . . 19jinteli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44jolivette . . . . . . . . . . . . . . . . . . . . . . . . . . . 45juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44JULUCA . . . . . . . . . . . . . . . . . . . . . . . . . . 24junel 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . 44junel 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . 44junel fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 44junel fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 44junel fe 24 . . . . . . . . . . . . . . . . . . . . . . . . . 44

INVEGA TRINZA INJ 819MG/2.625ML . . . . . . . . . . . . . . . . . . 22INVIRASE CAPS . . . . . . . . . . . . . . . . . 25INVIRASE TABS . . . . . . . . . . . . . . . . . . 25INVOKAMET . . . . . . . . . . . . . . . . . . . . . . 26INVOKAMET XR . . . . . . . . . . . . . . . . . . 26INVOKANA . . . . . . . . . . . . . . . . . . . . . . . 26IONOSOL-MB/DEXTROSE 5% . . . . . 36IOPIDINE OPHTHALMIC SOLN 1% . . . . . . . . . . 51IPOL INACTIVATED IPV . . . . . . . . . . . 48ipratropium bromide/ albuterol sulfate . . . . . . . . . . . . . . . . . . . 52ipratropium bromide inhalation soln . . . . . . . . . . . . . . . . . . . . 52ipratropium bromide nasal soln . . . . . 52irbesartan . . . . . . . . . . . . . . . . . . . . . . . . . 29irbesartan/hydrochlorothiazide . . . . . . 29IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 20irinotecan . . . . . . . . . . . . . . . . . . . . . . . . . 19irinotecan hcl . . . . . . . . . . . . . . . . . . . . . . 19irinotecan hydrochloride inj 40mg/2ml . . . . . . . . . . . . . . . . . . . . . . . . . 19ISENTRESS CHEW 25MG . . . . . . . . . 24ISENTRESS CHEW 100MG . . . . . . . 24ISENTRESS HD . . . . . . . . . . . . . . . . . . . 24ISENTRESS PACK . . . . . . . . . . . . . . . 24ISENTRESS TABS . . . . . . . . . . . . . . . . 24isibloom . . . . . . . . . . . . . . . . . . . . . . . . . . . 44ISOLYTE-P/DEXTROSE 5% . . . . . . . 36ISOLYTE-S . . . . . . . . . . . . . . . . . . . . . . . 36ISOLYTE-S PH 7.4 . . . . . . . . . . . . . . . . 36isoniazid . . . . . . . . . . . . . . . . . . . . . . . . . . 17isoproterenol hydrochloride . . . . . . . . 52isopto carpine . . . . . . . . . . . . . . . . . . . . . 51isosorbide dinitrate er . . . . . . . . . . . . . . 32isosorbide dinitrate tabs . . . . . . . . . . . 32isosorbide mononitrate . . . . . . . . . . . . . 32isosorbide mononitrate er . . . . . . . . . . 32isotonic gentamicin . . . . . . . . . . . . . . . . . 9isotretinoin . . . . . . . . . . . . . . . . . . . . . . . . 34

67


Covered Drugs Index

levocetirizine dihydrochloride oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 51levocetirizine dihydrochloride tabs . . 52levofloxacin in d5w . . . . . . . . . . . . . . . . 12levofloxacin inj . . . . . . . . . . . . . . . . . . . . 12levofloxacin ophthalmic soln . . . . . . . 12levofloxacin oral soln . . . . . . . . . . . . . . 12levofloxacin tabs . . . . . . . . . . . . . . . . . . 12levoleucovorin calcium . . . . . . . . . . . . . 19levoleucovorin inj 175mg/17.5ml, 250mg/25ml, 50mg . . . . . . . . . . . . . . . . 19levonest . . . . . . . . . . . . . . . . . . . . . . . . . . 44levonorgestrel and ethinyl estradiol tabs 0; 0 . . . . . . . . . . . . . . . . . 44levonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg . . . . . . . 44levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0 . . . . . . . . . 44levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg . . . . . . . . . . . . . . . . . . 44levora 0.15/30-28 . . . . . . . . . . . . . . . . . . 44levorphanol tartrate . . . . . . . . . . . . . . . . . 7levothyroxine sodium inj . . . . . . . . . . . 46levothyroxine sodium tabs . . . . . . . . . 46LEVOXYL . . . . . . . . . . . . . . . . . . . . . . . . . 46LEVULAN KERASTICK . . . . . . . . . . . . 34LEXIVA SUSP . . . . . . . . . . . . . . . . . . . . 25LEXIVA TABS . . . . . . . . . . . . . . . . . . . . . 25LIALDA . . . . . . . . . . . . . . . . . . . . . . . . . . . 48lidocaine hcl external soln . . . . . . . . . . 8lidocaine hcl gel . . . . . . . . . . . . . . . . . . . . 9lidocaine hcl inj . . . . . . . . . . . . . . . . . . . . 9lidocaine hcl inj . . . . . . . . . . . . . . . . . . . 30lidocaine hcl jelly . . . . . . . . . . . . . . . . . . . 9lidocaine hcl mouth/throat soln . . . . . . 9lidocaine hcl viscous . . . . . . . . . . . . . . . . 9lidocaine oint . . . . . . . . . . . . . . . . . . . . . . 9lidocaine/prilocaine crea . . . . . . . . . . . . 9lidocaine ptch . . . . . . . . . . . . . . . . . . . . . . 9lidocaine viscous . . . . . . . . . . . . . . . . . . . 9

LANTUS SOLOSTAR . . . . . . . . . . . . . . 27larin 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . . 44larin 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . . 44larin 24 fe . . . . . . . . . . . . . . . . . . . . . . . . . 44larin fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 44larin fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 44larissia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44LARTRUVO . . . . . . . . . . . . . . . . . . . . . . . 19latanoprost . . . . . . . . . . . . . . . . . . . . . . . . 50LATUDA TABS 80MG . . . . . . . . . . . . . . 22LATUDA TABS 120MG, 20MG, 40MG, 60MG . . . . . . 22layolis fe . . . . . . . . . . . . . . . . . . . . . . . . . . 44leena . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44leflunomide . . . . . . . . . . . . . . . . . . . . . . . 48LENVIMA 8 MG DAILY DOSE . . . . . . 20LENVIMA 10 MG DAILY DOSE . . . . . 20LENVIMA 14 MG DAILY DOSE . . . . . 20LENVIMA 18 MG DAILY DOSE . . . . . 20LENVIMA 20 MG DAILY DOSE . . . . . 20LENVIMA 24 MG DAILY DOSE . . . . . 20lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44LETAIRIS . . . . . . . . . . . . . . . . . . . . . . . . . 52letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . 20leucovorin calcium . . . . . . . . . . . . . . . . . 19LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . 18LEUKINE INJ 250MCG . . . . . . . . . . . . 28leuprolide acetate . . . . . . . . . . . . . . . . . 46levalbuterol . . . . . . . . . . . . . . . . . . . . . . . 52levalbuterol hcl nebu 0.31mg/3ml . . . 52levalbuterol hcl nebu 0.63mg/3ml . . . 52levalbuterol hcl nebu 1.25mg/3ml . . . 52levalbuterol tartrate hfa . . . . . . . . . . . . 52LEVEMIR . . . . . . . . . . . . . . . . . . . . . . . . . 27LEVEMIR FLEXTOUCH . . . . . . . . . . . 27levetiracetam . . . . . . . . . . . . . . . . . . . . . . 13levetiracetam er tb24 500mg . . . . . . . 13levetiracetam er tb24 750mg . . . . . . . 13levobunolol hcl . . . . . . . . . . . . . . . . . . . . 51levocarnitine . . . . . . . . . . . . . . . . . . . . . . 49

KISQALI FEMARA 400 DOSE . . . . . . 18KISQALI FEMARA 600 DOSE . . . . . . 18klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . . 37klor-con 8 . . . . . . . . . . . . . . . . . . . . . . . . . 37klor-con 10 . . . . . . . . . . . . . . . . . . . . . . . . 37klor-con/ef . . . . . . . . . . . . . . . . . . . . . . . . 37klor-con m10 . . . . . . . . . . . . . . . . . . . . . . 37klor-con m15 . . . . . . . . . . . . . . . . . . . . . . 37klor-con m20 . . . . . . . . . . . . . . . . . . . . . . 37klor-con sprinkle . . . . . . . . . . . . . . . . . . . 37KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . 49K-PHOS . . . . . . . . . . . . . . . . . . . . . . . . . . 37K-PHOS NO 2 . . . . . . . . . . . . . . . . . . . . . 37KRISTALOSE . . . . . . . . . . . . . . . . . . . . . 40K-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37kurvelo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . 40k-vescent tbef . . . . . . . . . . . . . . . . . . . . 37KYPROLIS . . . . . . . . . . . . . . . . . . . . . . . . 20

Llabetalol hcl . . . . . . . . . . . . . . . . . . . . . . . 30LACRISERT . . . . . . . . . . . . . . . . . . . . . . 50LACTATED RINGERS IRRIGATION . . . . . . . . . . . . . . . . . . . . . . 49LACTATED RINGERS VIAFLEX . . . . 37lactulose . . . . . . . . . . . . . . . . . . . . . . . . . . 40lamivudine oral soln . . . . . . . . . . . . . . . 24lamivudine tabs 100mg . . . . . . . . . . . . 23lamivudine tabs 150mg . . . . . . . . . . . . 24lamivudine tabs 300mg . . . . . . . . . . . . 24lamivudine/zidovudine . . . . . . . . . . . . . 24lamotrigine . . . . . . . . . . . . . . . . . . . . . . . . 14lamotrigine er . . . . . . . . . . . . . . . . . . . . . 14lamotrigine odt . . . . . . . . . . . . . . . . . . . . 14LANOXIN TABS 62.5MCG . . . . . . . . . 31LANOXIN TABS 187.5MCG . . . . . . . . 31lansoprazole cpdr . . . . . . . . . . . . . . . . . 40LANTUS . . . . . . . . . . . . . . . . . . . . . . . . . . 27

68


Covered Drugs Index

MARQIBO . . . . . . . . . . . . . . . . . . . . . . . . 19MATULANE . . . . . . . . . . . . . . . . . . . . . . . 18matzim la . . . . . . . . . . . . . . . . . . . . . . . . . 31MAXIDEX . . . . . . . . . . . . . . . . . . . . . . . . . 50meclizine hcl tabs . . . . . . . . . . . . . . . . . 16MEDROL TABS 2MG . . . . . . . . . . . . . . 42medroxyprogesterone acetate inj . . . 46medroxyprogesterone acetate tabs . . 46mefloquine hcl . . . . . . . . . . . . . . . . . . . . . 21megestrol acetate susp 40mg/ml . . . 46megestrol acetate susp 625mg/5ml . . . . . . . . . . . . . . . . . . . . . . . . 46megestrol acetate tabs . . . . . . . . . . . . 46MEKINIST TABS 0.5MG . . . . . . . . . . . 20MEKINIST TABS 2MG . . . . . . . . . . . . . 20meloxicam . . . . . . . . . . . . . . . . . . . . . . . . . 7melphalan hydrochloride . . . . . . . . . . . 18memantine hcl tabs 5mg . . . . . . . . . . . 14memantine hcl tabs 10mg . . . . . . . . . . 14memantine hcl titration pak . . . . . . . . . 14memantine hydrochloride . . . . . . . . . . 14memantine hydrochloride er . . . . . . . . 14MENACTRA . . . . . . . . . . . . . . . . . . . . . . 48MENEST . . . . . . . . . . . . . . . . . . . . . . . . . . 44MENOSTAR . . . . . . . . . . . . . . . . . . . . . . 44MENVEO . . . . . . . . . . . . . . . . . . . . . . . . . 48mercaptopurine . . . . . . . . . . . . . . . . . . . . 18meropenem . . . . . . . . . . . . . . . . . . . . . . . 11meropenem/sodium chloride inj 1gm/50ml; 0.9% . . . . . . . . . . . . . . . . . . . 11meropenem/sodium chloride inj 500mg/50ml; 0.9% . . . . . . . . . . . . . . . . . 11mesalamine dr tbec 1.2gm . . . . . . . . . 48mesalamine enema and kit . . . . . . . . 48mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19MESNEX TABS . . . . . . . . . . . . . . . . . . . 19MESTINON SYRP . . . . . . . . . . . . . . . . 17metadate er . . . . . . . . . . . . . . . . . . . . . . . 33metaproterenol sulfate . . . . . . . . . . . . . 52

losartan potassium tabs 100mg . . . . . 29LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . 50lovastatin tabs 10mg, 20mg . . . . . . . . 32lovastatin tabs 40mg . . . . . . . . . . . . . . . 32low-ogestrel . . . . . . . . . . . . . . . . . . . . . . . 44loxapine caps 10mg, 5mg . . . . . . . . . . 22loxapine succinate caps 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 22loxapine succinate caps 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 22ludent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37LUMIGAN . . . . . . . . . . . . . . . . . . . . . . . . . 50LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . 40LUPRON DEPOT (1-MONTH) . . . . . . 46LUPRON DEPOT (3-MONTH) . . . . . . 46LUPRON DEPOT (4-MONTH) . . . . . . 46LUPRON DEPOT (6-MONTH) . . . . . . 46LUPRON DEPOT-PED (1-MONTH) . . . . . . . . . . . . . . . . . . . . . . . 46LUPRON DEPOT-PED (3-MONTH) . . . . . . . . . . . . . . . . . . . . . . . 46lutera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44LYNPARZA CAPS . . . . . . . . . . . . . . . . 20LYNPARZA TABS . . . . . . . . . . . . . . . . . 19LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG . . . . . . 13LYRICA CAPS 225MG, 300MG . . . . . 13LYRICA ORAL SOLN . . . . . . . . . . . . . . 13LYSODREN . . . . . . . . . . . . . . . . . . . . . . . 46lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Mmagnesium sulfate in d5w inj 5%; 1gm/100ml . . . . . . . . . . . . . . . . . . . . 13magnesium sulfate inj . . . . . . . . . . . . . 37MAKENA . . . . . . . . . . . . . . . . . . . . . . . . . 45MAKENA . . . . . . . . . . . . . . . . . . . . . . . . . 46malathion . . . . . . . . . . . . . . . . . . . . . . . . . 21maprotiline hcl . . . . . . . . . . . . . . . . . . . . . 15marlissa . . . . . . . . . . . . . . . . . . . . . . . . . . 44MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . 15

lincomycin hcl . . . . . . . . . . . . . . . . . . . . . 10lindane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21linezolid inj . . . . . . . . . . . . . . . . . . . . . . . 10linezolid susr . . . . . . . . . . . . . . . . . . . . . 10linezolid tabs . . . . . . . . . . . . . . . . . . . . . 10LINZESS . . . . . . . . . . . . . . . . . . . . . . . . . . 40liothyronine sodium . . . . . . . . . . . . . . . . 46lipodox 50 . . . . . . . . . . . . . . . . . . . . . . . . . 19LIPOSYN III . . . . . . . . . . . . . . . . . . . . . . . 49lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . 29lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg, 25mg; 20mg . . . . . . . . 29lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg . . . . . . . . . . . . . . . . . . . . . 29lithium . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26lithium carbonate . . . . . . . . . . . . . . . . . . 26lithium carbonate er . . . . . . . . . . . . . . . . 26LITHOSTAT . . . . . . . . . . . . . . . . . . . . . . . 41LIVALO . . . . . . . . . . . . . . . . . . . . . . . . . . . 32LONSURF TABS 6.14MG; 15MG . . . 18LONSURF TABS 8.19MG; 20MG . . . 18loperamide hcl caps . . . . . . . . . . . . . . . 39lopinavir/ritonavir . . . . . . . . . . . . . . . . . . 25lopreeza . . . . . . . . . . . . . . . . . . . . . . . . . . 44lorazepam conc . . . . . . . . . . . . . . . . . . . 26lorazepam inj . . . . . . . . . . . . . . . . . . . . . 26lorazepam intensol . . . . . . . . . . . . . . . . 26lorazepam tabs 0.5mg, 1mg . . . . . . . . 26lorazepam tabs 2mg . . . . . . . . . . . . . . . 26lorcet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8lorcet hd . . . . . . . . . . . . . . . . . . . . . . . . . . . 8lorcet plus tabs 325mg; 7.5mg . . . . . . . 8loryna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44losartan potassium/ hydrochlorothiazide tabs 12.5mg; 50mg . . . . . . . . . . . . . . . . . . . . . 29losartan potassium/ hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg . . . . . 29losartan potassium tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 29

69


Covered Drugs Index

moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg . . . . . . . . . . . . . . . . . . . . 29moexipril/hydrochlorothiazide tabs 12.5mg; 15mg, 25mg; 15mg . . . . . . . . 29mometasone furoate crea . . . . . . . . . 42mometasone furoate external soln . . . . . . . . . . . . . . . . . . . . . . 42mometasone furoate oint . . . . . . . . . . 42mondoxyne nl caps 100mg, 50mg . . 13mono-linyah . . . . . . . . . . . . . . . . . . . . . . . 44mononessa . . . . . . . . . . . . . . . . . . . . . . . 44montelukast sodium . . . . . . . . . . . . . . . 52MONUROL . . . . . . . . . . . . . . . . . . . . . . . 10morgidox 1x50mg . . . . . . . . . . . . . . . . . 13morphine sulfate er cp24 . . . . . . . . . . . 7morphine sulfate er tbcr . . . . . . . . . . . . 7morphine sulfate inj 0.5mg/ml, 1mg/ml . . . . . . . . . . . . . . . . . . 7morphine sulfate inj 1mg/ml . . . . . . . . . 8morphine sulfate inj 2mg/ml . . . . . . . . . 8morphine sulfate inj 4mg/ml . . . . . . . . . 8morphine sulfate inj 8mg/ml . . . . . . . . . 8morphine sulfate inj 10mg/ml . . . . . . . . 8morphine sulfate inj 150mg/30ml, 50mg/ml, 5mg/ml . . . . . . 8morphine sulfate oral soln 10mg/5ml . . . . . . . . . . . . . . . . . 8morphine sulfate oral soln 20mg/5ml . . . . . . . . . . . . . . . . . 8morphine sulfate oral soln 100mg/5ml . . . . . . . . . . . . . . . . 8morphine sulfate supp . . . . . . . . . . . . . . 7morphine sulfate tabs . . . . . . . . . . . . . . 8MOVIPREP . . . . . . . . . . . . . . . . . . . . . . . 40moxifloxacin hcl inj . . . . . . . . . . . . . . . . 12moxifloxacin hcl ophthalmic soln . . . . 12moxifloxacin hcl tabs . . . . . . . . . . . . . . 12moxifloxacin hydrochloride ophthalmic soln . . . . . . . . . . . . . . . . . . . 12moxifloxacinhydrochloride/ sodium hydrochloride . . . . . . . . . . . . . . 12MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . 28

metipranolol . . . . . . . . . . . . . . . . . . . . . . . 51metoclopramide hcl . . . . . . . . . . . . . . . . 39metolazone . . . . . . . . . . . . . . . . . . . . . . . 32metoprolol/hydrochlorothiazide . . . . . 30metoprolol succinate er . . . . . . . . . . . . 30metoprolol tartrate inj . . . . . . . . . . . . . . 30metoprolol tartrate tabs . . . . . . . . . . . . 30METRO IV . . . . . . . . . . . . . . . . . . . . . . . . 10metronidazole caps . . . . . . . . . . . . . . . 10metronidazole crea . . . . . . . . . . . . . . . . 10metronidazole gel . . . . . . . . . . . . . . . . . 10metronidazole inj . . . . . . . . . . . . . . . . . . 10metronidazole in nacl 0.79% . . . . . . . 10metronidazole lotn . . . . . . . . . . . . . . . . 10metronidazole tabs . . . . . . . . . . . . . . . . 10metronidazole vaginal . . . . . . . . . . . . . . 10mexiletine hcl . . . . . . . . . . . . . . . . . . . . . 30miconazole 3 . . . . . . . . . . . . . . . . . . . . . . 16microgestin 1.5/30 . . . . . . . . . . . . . . . . . 44microgestin 1/20 . . . . . . . . . . . . . . . . . . . 44microgestin fe . . . . . . . . . . . . . . . . . . . . . 44microgestin fe 1.5/30 . . . . . . . . . . . . . . 44midodrine hcl . . . . . . . . . . . . . . . . . . . . . . 29migergot . . . . . . . . . . . . . . . . . . . . . . . . . . 17miglitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26mimvey . . . . . . . . . . . . . . . . . . . . . . . . . . . 44mimvey lo . . . . . . . . . . . . . . . . . . . . . . . . . 44minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . 32minocycline hcl . . . . . . . . . . . . . . . . . . . . 13minoxidil . . . . . . . . . . . . . . . . . . . . . . . . . . 32mirtazapine . . . . . . . . . . . . . . . . . . . . . . . 15mirtazapine odt . . . . . . . . . . . . . . . . . . . . 15misoprostol . . . . . . . . . . . . . . . . . . . . . . . 40MITIGARE . . . . . . . . . . . . . . . . . . . . . . . . 17mitomycin inj 20mg, 5mg . . . . . . . . . . . 19mitomycin inj 40mg . . . . . . . . . . . . . . . . 19mitoxantrone hcl . . . . . . . . . . . . . . . . . . . 19M-M-R II . . . . . . . . . . . . . . . . . . . . . . . . . . 48modafinil . . . . . . . . . . . . . . . . . . . . . . . . . . 53moexipril hcl . . . . . . . . . . . . . . . . . . . . . . . 29

metformin hcl er tb24 500mg (generic for Glucophage XR) . . . . . . . 26metformin hcl er tb24 750mg (generic Glucophage XR) . . . . . . . . . . 26metformin hcl tabs 500mg . . . . . . . . . . 26metformin hcl tabs 850mg . . . . . . . . . . 26metformin hcl tabs 1000mg . . . . . . . . 26methazolamide . . . . . . . . . . . . . . . . . . . . 31methenamine hippurate . . . . . . . . . . . . 10methenamine mandelate . . . . . . . . . . . 10methimazole . . . . . . . . . . . . . . . . . . . . . . 46methotrexate sodium . . . . . . . . . . . . . . 47methotrexate tabs . . . . . . . . . . . . . . . . . 47methoxsalen . . . . . . . . . . . . . . . . . . . . . . 34methscopolamine bromide . . . . . . . . . 39methyclothiazide . . . . . . . . . . . . . . . . . . 32methylergonovine maleate . . . . . . . . . 49methylphenidate hcl cd . . . . . . . . . . . . 33methylphenidate hcl chew 2.5mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . 33methylphenidate hcl chew 10mg . . . . 33methylphenidate hcl er cp24 . . . . . . . 33methylphenidate hcl er cpcr 20mg, 30mg, 40mg . . . . . . . . . . . . . . . . 33methylphenidate hcl er tb24 18mg . . 33methylphenidate hcl er tb24 27mg, 54mg . . . . . . . . . . . . . . . . . . . . . . . 33methylphenidate hcl er tb24 36mg . . 33methylphenidate hcl er tbcr 10mg, 27mg, 54mg . . . . . . . . . . . . . . . . 33methylphenidate hcl er tbcr 18mg . . . 33methylphenidate hcl er tbcr 20mg . . . 33methylphenidate hcl er tbcr 36mg . . . 33methylphenidate hcl tabs . . . . . . . . . . 33methylphenidate hydrochloride oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 33methylprednisolone acetate . . . . . . . . 42methylprednisolone dose pack . . . . . 42methylprednisolone sodiumsuccinate . . . . . . . . . . . . . . . . . . 42methylprednisolone tabs . . . . . . . . . . . 42

70


Covered Drugs Index

NEORAL . . . . . . . . . . . . . . . . . . . . . . . . . . 47NEPHRAMINE . . . . . . . . . . . . . . . . . . . . 37NERLYNX . . . . . . . . . . . . . . . . . . . . . . . . 19neuac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . 21NEVANAC . . . . . . . . . . . . . . . . . . . . . . . . 50nevirapine er tb24 100mg . . . . . . . . . . 24nevirapine er tb24 400mg . . . . . . . . . . 24nevirapine susp . . . . . . . . . . . . . . . . . . . 24nevirapine tabs . . . . . . . . . . . . . . . . . . . 24NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . 20niacin er tbcr 500mg . . . . . . . . . . . . . . . 32niacin er tbcr 1000mg, 750mg . . . . . . 32niacor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32nicardipine hcl . . . . . . . . . . . . . . . . . . . . . 31NICOTROL INHALER. . . . . . . . . . . . . . . 9NICOTROL NS . . . . . . . . . . . . . . . . . . . . . 9nifedipine er tb24 30mg, 60mg . . . . . 31nifedipine er tb24 90mg . . . . . . . . . . . . 31nikki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44nilutamide . . . . . . . . . . . . . . . . . . . . . . . . . 18NINLARO . . . . . . . . . . . . . . . . . . . . . . . . . 19NIPENT . . . . . . . . . . . . . . . . . . . . . . . . . . . 18NITRO-BID . . . . . . . . . . . . . . . . . . . . . . . 32NITRO-DUR PT24 0.3MG/HR, 0.8MG/HR . . . . . . . . . . . . . 32nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 10nitrofurantoin macrocrystals . . . . . . . . 10nitrofurantoin monohydrate . . . . . . . . . 10nitrofurantoin monohydrate/macrocrystals . . . . . . . . . . . . . . . . . . . . . 10nitroglycerin . . . . . . . . . . . . . . . . . . . . . . . 32nitroglycerin lingual . . . . . . . . . . . . . . . . 32nitroglycerin transdermal . . . . . . . . . . . 32nizatidine caps . . . . . . . . . . . . . . . . . . . . 40nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . 46norethindrone . . . . . . . . . . . . . . . . . . . . . 46norethindrone acetate . . . . . . . . . . . . . . 46norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs . . . . . 45

nadolol/bendroflumethiazide . . . . . . . . 30NAFCILLIN . . . . . . . . . . . . . . . . . . . . . . . 11nafcillin sodium . . . . . . . . . . . . . . . . . . . . 11naftifine hcl . . . . . . . . . . . . . . . . . . . . . . . . 16naftifine hydrochloride . . . . . . . . . . . . . 16NAFTIN GEL . . . . . . . . . . . . . . . . . . . . . 16NAGLAZYME . . . . . . . . . . . . . . . . . . . . . 40nalbuphine hcl inj 10mg/ml . . . . . . . . . . 8nalbuphine hcl inj 20mg/ml . . . . . . . . . . 8naloxone hcl . . . . . . . . . . . . . . . . . . . . . . . 9naltrexone hcl . . . . . . . . . . . . . . . . . . . . . . 9NAMENDA XR . . . . . . . . . . . . . . . . . . . . 14NAMENDA XR TITRATION PACK . . 14naproxen . . . . . . . . . . . . . . . . . . . . . . . . . . . 7naproxen dr . . . . . . . . . . . . . . . . . . . . . . . . 7naproxen sodium tabs 275mg, 550mg . . . . . . . . . . . . . . . . . . . . . 7naratriptan hcl . . . . . . . . . . . . . . . . . . . . . 17NARCAN . . . . . . . . . . . . . . . . . . . . . . . . . . 9NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . 16nateglinide . . . . . . . . . . . . . . . . . . . . . . . . 26NATPARA . . . . . . . . . . . . . . . . . . . . . . . . . 49NEBUPENT . . . . . . . . . . . . . . . . . . . . . . . 21necon 0.5/35-28 . . . . . . . . . . . . . . . . . . . 44necon 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 44nefazodone hcl . . . . . . . . . . . . . . . . . . . . 15neomycin/bacitracin/polymyxin . . . . . 10neomycin/polymyxin/ bacitracin/hydrocortisone . . . . . . . . . . . 10neomycin/polymyxin b sulfates . . . . . . 9neomycin/polymyxin/ dexamethasone . . . . . . . . . . . . . . . . . . . 50neomycin/polymyxin/gramicidin . . . . . 10neomycin/polymyxin/hc . . . . . . . . . . . . 51neomycin/polymyxin/ hydrocortisone . . . . . . . . . . . . . . . . . . . . 10neomycin/polymyxin/ hydrocortisone . . . . . . . . . . . . . . . . . . . . 51neomycin sulfate . . . . . . . . . . . . . . . . . . . 9neo-polycin . . . . . . . . . . . . . . . . . . . . . . . 10neo-polycin hc . . . . . . . . . . . . . . . . . . . . . 10

MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . . 30multivitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 0.25mg; 1.05mg; 15unit; 2500unit, 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 0.5mg; 1.05mg; 15unit; 2500unit, 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1mg; 1.05mg; 15unit; 2500unit . . . . . . . . . . . 39multi-vitamin/fluoride drops . . . . . . . . . 39multivitamins/fluoride . . . . . . . . . . . . . . 39multivitamin with fluoride chew . . . . . 39multivitamin with fluoride oral soln 35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml, 35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 0.5mg/ml; 1500unit/ml; 5unit/ml . . . . . . . . . . . . . . . 39multi-vit/fluoride . . . . . . . . . . . . . . . . . . . 38multi-vit/iron/fluoride . . . . . . . . . . . . . . . 39mupirocin crea . . . . . . . . . . . . . . . . . . . . 10mupirocin oint . . . . . . . . . . . . . . . . . . . . 10MUSTARGEN . . . . . . . . . . . . . . . . . . . . . 18mvc-fluoride . . . . . . . . . . . . . . . . . . . . . . . 39MYCAMINE . . . . . . . . . . . . . . . . . . . . . . . 16mycophenolate mofetil caps . . . . . . . 47mycophenolate mofetil inj . . . . . . . . . . 47mycophenolate mofetil susr . . . . . . . . 47mycophenolate mofetil tabs . . . . . . . . 47mycophenolic acid dr . . . . . . . . . . . . . . 47MYFORTIC . . . . . . . . . . . . . . . . . . . . . . . 47MYLOTARG . . . . . . . . . . . . . . . . . . . . . . . 21myorisan . . . . . . . . . . . . . . . . . . . . . . . . . . 34MYRBETRIQ . . . . . . . . . . . . . . . . . . . . . . 41myzilra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . . 7nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

71


Covered Drugs Index

ondansetron hcl oral soln . . . . . . . . . . 16ondansetron hcl tabs 4mg, 8mg . . . . 16ondansetron hcl tabs 24mg . . . . . . . . 16ondansetron odt . . . . . . . . . . . . . . . . . . . 16ONFI SUSP . . . . . . . . . . . . . . . . . . . . . . 13ONFI TABS 10MG, 5MG . . . . . . . . . . . 13ONFI TABS 20MG . . . . . . . . . . . . . . . . . 13OPANA ER (CRUSH RESISTANT) T12A 10MG, 15MG, 20MG, 30MG, 5MG, 7.5MG . . . . . . . . . . . . . . . . 7OPANA ER (CRUSH RESISTANT) T12A 40MG . . . . . . . . . . . . . . . . . . . . . . . . 7OPDIVO INJ 100MG/10ML, 40MG/4ML . . . . . . . . . . 21OPDIVO INJ 240MG/24ML . . . . . . . . . 21OPIUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8OPIUM TINCTURE . . . . . . . . . . . . . . . . . 8OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . . . 52ORACEA . . . . . . . . . . . . . . . . . . . . . . . . . 34oralone dental paste . . . . . . . . . . . . . . . 34ORENCIA INJ 250MG . . . . . . . . . . . . . 47ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . . 40ORKAMBI . . . . . . . . . . . . . . . . . . . . . . . . . 52orphenadrine citrate er . . . . . . . . . . . . . 53orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . 45ORTHO TRI-CYCLEN LO . . . . . . . . . . 45oscimin . . . . . . . . . . . . . . . . . . . . . . . . . . . 39oseltamivir phosphate caps 30mg . . 25oseltamivir phosphate caps 45mg, 75mg . . . . . . . . . . . . . . . . . . . . . . . 25oseltamivir phosphate susr . . . . . . . . 25OSMOPREP . . . . . . . . . . . . . . . . . . . . . . 39oxacillin sodium inj 10gm, 2gm . . . . . 11oxaliplatin inj 100mg, 100mg/20ml, 50mg/10ml . . . . . . . . . . . 19oxandrolone tabs 2.5mg . . . . . . . . . . . 43oxandrolone tabs 10mg . . . . . . . . . . . . 43oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . 26oxcarbazepine . . . . . . . . . . . . . . . . . . . . 14oxybutynin chloride er tb24 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 41

NOVOLOG PENFILL . . . . . . . . . . . . . . 27novotwist 32gx5mm . . . . . . . . . . . . . . . 49NOXAFIL SUSP . . . . . . . . . . . . . . . . . . 16NOXAFIL TBEC . . . . . . . . . . . . . . . . . . 16NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . 33nulev . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . 47NULYTELY/FLAVOR PACKS . . . . . . . 40NUPLAZID . . . . . . . . . . . . . . . . . . . . . . . . 22NUTRILIPID . . . . . . . . . . . . . . . . . . . . . . . 49NUVARING . . . . . . . . . . . . . . . . . . . . . . . 45nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . 16nystatin . . . . . . . . . . . . . . . . . . . . . . . . . . . 16nystatin/triamcinolone . . . . . . . . . . . . . . 16nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Oocella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45octreotide acetate inj 100mcg/ml, 200mcg/ml, 50mcg/ml . . . . . . . . . . . . . 46octreotide acetate inj 500mcg/ml . . . 46octreotide acetate inj 1000mcg/ml . . . 46ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . . 24ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . . 19OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53ofloxacin . . . . . . . . . . . . . . . . . . . . . . . . . . 12ogestrel . . . . . . . . . . . . . . . . . . . . . . . . . . . 45olanzapine/fluoxetine . . . . . . . . . . . . . . 15olanzapine inj . . . . . . . . . . . . . . . . . . . . . 22olanzapine odt . . . . . . . . . . . . . . . . . . . . 23olanzapine tabs . . . . . . . . . . . . . . . . . . . 23olmesartan medoxomil . . . . . . . . . . . . . 29olmesartan medoxomil/hydrochlorothiazide . . . . . . . . . . . . . . . . 29olopatadine hcl ophthalmic soln . . . . 50olopatadine hydrochloride . . . . . . . . . . 50omega-3-acid ethyl esters . . . . . . . . . . 32omeprazole cpdr . . . . . . . . . . . . . . . . . . 40ondansetron hcl inj 40mg/20ml, 4mg/2ml . . . . . . . . . . . . . . 16

norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg, 5mcg; 1mg . . . . . . . . . . . . . . . . . 45norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg . . . . . . . . . 44norethindrone & ethinyl estradiol ferrous fumarate . . . . . . . . . . 44norethindrone/ethinyl estradiol/ferrous fumarate . . . . . . . . . . 45norgestimate/ethinyl estradiol . . . . . . 45norlyroc . . . . . . . . . . . . . . . . . . . . . . . . . . . 46NORMOSOL-M IN D5W . . . . . . . . . . . 37NORMOSOL -R . . . . . . . . . . . . . . . . . . . 37NORMOSOL-R . . . . . . . . . . . . . . . . . . . . 37NORMOSOL-R IN D5W. . . . . . . . . . . . 37NORTHERA CAPS 100MG . . . . . . . . 31NORTHERA CAPS 200MG, 300MG . . . . . . . . . . . . . . . . . . . 31nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . . 45nortrel 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 45nortrel 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 45nortriptyline hcl . . . . . . . . . . . . . . . . . . . . 16NORVIR CAPS . . . . . . . . . . . . . . . . . . . 25NORVIR ORAL SOLN . . . . . . . . . . . . . 25NORVIR TABS . . . . . . . . . . . . . . . . . . . . 25novofine 30gx8mm . . . . . . . . . . . . . . . . 49novofine 31 . . . . . . . . . . . . . . . . . . . . . . . 49novofine 32gx6mm . . . . . . . . . . . . . . . . 49novofine autocover 30gx8mm . . . . . . 49NOVOLIN 70/30 . . . . . . . . . . . . . . . . . . . 27NOVOLIN 70/30 RELION . . . . . . . . . . 27NOVOLIN N . . . . . . . . . . . . . . . . . . . . . . . 27NOVOLIN N RELION . . . . . . . . . . . . . . 27NOVOLIN R . . . . . . . . . . . . . . . . . . . . . . . 27NOVOLIN R INNOLET . . . . . . . . . . . . . 27NOVOLIN R RELION . . . . . . . . . . . . . . 27NOVOLOG . . . . . . . . . . . . . . . . . . . . . . . . 27NOVOLOG FLEXPEN . . . . . . . . . . . . . 27NOVOLOG MIX 70/30 . . . . . . . . . . . . . 27NOVOLOG MIX 70/30 PREFILLED FLEXPEN . . . . . . . . . . . . 27

72


Covered Drugs Index

phenytoin sodium . . . . . . . . . . . . . . . . . . 14phenytoin sodium extended . . . . . . . . 14phos-flur . . . . . . . . . . . . . . . . . . . . . . . . . . 34PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . . 38phosphasal . . . . . . . . . . . . . . . . . . . . . . . 41PHOSPHOLINE IODIDE . . . . . . . . . . . 51PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . . 49PHYSIOSOL IRRIGATION . . . . . . . . . 49pilocarpine hcl . . . . . . . . . . . . . . . . . . . . . 34pilocarpine hcl . . . . . . . . . . . . . . . . . . . . . 51pilocarpine hydrochloride . . . . . . . . . . . 34pimozide . . . . . . . . . . . . . . . . . . . . . . . . . . 22pimtrea . . . . . . . . . . . . . . . . . . . . . . . . . . . 45pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 30pioglitazone hcl . . . . . . . . . . . . . . . . . . . . 26pioglitazone hcl-glimepiride . . . . . . . . 26pioglitazone hcl/metformin hcl . . . . . . 26piperacillin sodium/ tazobactam sodium . . . . . . . . . . . . . . . . 12piperacillin/tazobactam . . . . . . . . . . . . . 12pirmella 1/35 . . . . . . . . . . . . . . . . . . . . . . 45piroxicam . . . . . . . . . . . . . . . . . . . . . . . . . . 7PLASMA-LYTE-148 . . . . . . . . . . . . . . . 37PLASMA-LYTE A . . . . . . . . . . . . . . . . . . 37PLENAMINE . . . . . . . . . . . . . . . . . . . . . . 37podocon 25 in benzoin tincture . . . . . 34podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . 34polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10polyethylene glycol 3350 . . . . . . . . . . . 40polymyxin b sulfate . . . . . . . . . . . . . . . . 10polymyxin b sulfate/ trimethoprim sulfate . . . . . . . . . . . . . . . . 10POMALYST . . . . . . . . . . . . . . . . . . . . . . . 18portia-28 . . . . . . . . . . . . . . . . . . . . . . . . . . 45PORTRAZZA . . . . . . . . . . . . . . . . . . . . . 19potassium chloride cr . . . . . . . . . . . . . . 37POTASSIUM CHLORIDE/ DEXTROSE . . . . . . . . . . . . . . . . . . . . . . . 37POTASSIUM CHLORIDE/ DEXTROSE/LACTATED RINGERS . . 37

PAXIL SUSP . . . . . . . . . . . . . . . . . . . . . . 15PAZEO . . . . . . . . . . . . . . . . . . . . . . . . . . . 50PCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12PEDIARIX . . . . . . . . . . . . . . . . . . . . . . . . 48PEDVAX HIB . . . . . . . . . . . . . . . . . . . . . . 48peg 3350/electrolytes . . . . . . . . . . . . . . 40peg-3350/electrolytes . . . . . . . . . . . . . . 40peg-3350/nacl/na bicarbonate/kcl . . . 40PEGANONE . . . . . . . . . . . . . . . . . . . . . . 14PEGASYS INJ 180MCG/0.5ML . . . . . 24PEGASYS INJ 180MCG/ML . . . . . . . . 24PEGASYS PROCLICK . . . . . . . . . . . . . 24pegylax . . . . . . . . . . . . . . . . . . . . . . . . . . . 40penicillin g potassium . . . . . . . . . . . . . . 11penicillin g potassium in iso-osmotic dextrose . . . . . . . . . . . . 11penicillin g procaine . . . . . . . . . . . . . . . . 11penicillin g sodium . . . . . . . . . . . . . . . . . 11penicillin v potassium . . . . . . . . . . . . . . 12PENTACEL . . . . . . . . . . . . . . . . . . . . . . . 48PENTAM 300 . . . . . . . . . . . . . . . . . . . . . 21pentoxifylline er . . . . . . . . . . . . . . . . . . . . 31PERFOROMIST . . . . . . . . . . . . . . . . . . . 52PERIKABIVEN . . . . . . . . . . . . . . . . . . . . 37perindopril erbumine . . . . . . . . . . . . . . . 30periogard . . . . . . . . . . . . . . . . . . . . . . . . . 34PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . 21permethrin . . . . . . . . . . . . . . . . . . . . . . . . 21perphenazine . . . . . . . . . . . . . . . . . . . . . 22perphenazine/amitriptyline . . . . . . . . . 16pfizerpen-g . . . . . . . . . . . . . . . . . . . . . . . . 12phenadoz . . . . . . . . . . . . . . . . . . . . . . . . . 16phenelzine sulfate . . . . . . . . . . . . . . . . . 15phenergan supp . . . . . . . . . . . . . . . . . . 16phenobarbital elix . . . . . . . . . . . . . . . . . 14phenobarbital tabs . . . . . . . . . . . . . . . . 14phenoxybenzamine hydrochloride . . 29phenylephrine hcl ophthalmic soln 10%, 2.5% . . . . . . . . 50phenytoin . . . . . . . . . . . . . . . . . . . . . . . . . 14

oxybutynin chloride er tb24 15mg . . . 41oxybutynin chloride syrp . . . . . . . . . . . 41oxybutynin chloride tabs . . . . . . . . . . . 41oxycodone/acetaminophen oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . . 8oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg . . . . 8oxycodone/acetaminophen tabs 325mg; 7.5mg . . . . . . . . . . . . . . . . . 8oxycodone/acetaminophen tabs 325mg; 10mg . . . . . . . . . . . . . . . . . . 8oxycodone/aspirin . . . . . . . . . . . . . . . . . . 8oxycodone hcl caps . . . . . . . . . . . . . . . . 8oxycodone hcl conc . . . . . . . . . . . . . . . . 8oxycodone hcl oral soln . . . . . . . . . . . . 8oxycodone hcl tabs 10mg, 15mg, 20mg, 5mg . . . . . . . . . . . . 8oxycodone hcl tabs 30mg . . . . . . . . . . . 8OZEMPIC . . . . . . . . . . . . . . . . . . . . . . . . . 26

Ppacerone . . . . . . . . . . . . . . . . . . . . . . . . . . 30paclitaxel . . . . . . . . . . . . . . . . . . . . . . . . . . 19paliperidone er tb24 1.5mg, 3mg . . . 23paliperidone er tb24 6mg . . . . . . . . . . . 23paliperidone er tb24 9mg . . . . . . . . . . . 23pamidronate disodium inj 30mg/10ml, 6mg/ml, 90mg/10ml . . . . 49PANDEL . . . . . . . . . . . . . . . . . . . . . . . . . . 42PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . 21pantoprazole sodium tbec . . . . . . . . . 40PAREGORIC . . . . . . . . . . . . . . . . . . . . . . 39paricalcitol caps 1mcg, 2mcg . . . . . . . 49paricalcitol caps 4mcg . . . . . . . . . . . . . 49paricalcitol inj . . . . . . . . . . . . . . . . . . . . . 49paroex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34paromomycin sulfate . . . . . . . . . . . . . . . . 9paroxetine hcl tabs 10mg . . . . . . . . . . 15paroxetine hcl tabs 20mg . . . . . . . . . . 15paroxetine hcl tabs 30mg, 40mg . . . . 15PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

73


Covered Drugs Index

prochlorperazine edisylate . . . . . . . . . 22prochlorperazine maleate . . . . . . . . . . 22PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML . . . . . . 28PROCRIT INJ 20000UNIT/ML . . . . . . 28PROCRIT INJ 40000UNIT/ML . . . . . . 28procto-med hc . . . . . . . . . . . . . . . . . . . . . 42procto-pak . . . . . . . . . . . . . . . . . . . . . . . . 42proctosol hc . . . . . . . . . . . . . . . . . . . . . . . 42proctozone-hc . . . . . . . . . . . . . . . . . . . . . 42PROCYSBI . . . . . . . . . . . . . . . . . . . . . . . 50progesterone . . . . . . . . . . . . . . . . . . . . . . 46PROGLYCEM . . . . . . . . . . . . . . . . . . . . . 27PROGRAF CAPS 0.5MG, 1MG . . . . 47PROGRAF CAPS 5MG . . . . . . . . . . . . 47PROGRAF INJ . . . . . . . . . . . . . . . . . . . 47PROLASTIN-C . . . . . . . . . . . . . . . . . . . . 53PROLENSA . . . . . . . . . . . . . . . . . . . . . . . 50PROLEUKIN . . . . . . . . . . . . . . . . . . . . . . 19PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 49PROMACTA . . . . . . . . . . . . . . . . . . . . . . 28promethazine hcl inj . . . . . . . . . . . . . . . 52promethazine hcl plain . . . . . . . . . . . . . 52promethazine hcl supp . . . . . . . . . . . . 16promethazine hcl syrp . . . . . . . . . . . . . 52promethazine hcl tabs . . . . . . . . . . . . . 52promethazine vc plain . . . . . . . . . . . . . . 53promethegan . . . . . . . . . . . . . . . . . . . . . . 16propafenone hcl . . . . . . . . . . . . . . . . . . . 30propafenone hcl er . . . . . . . . . . . . . . . . . 30propantheline bromide . . . . . . . . . . . . . 39proparacaine hcl . . . . . . . . . . . . . . . . . . . 50propranolol hcl er cp24 120mg, 60mg, 80mg . . . . . . . . . . . . . . . 30propranolol hcl er cp24 160mg . . . . . 30propranolol hcl inj . . . . . . . . . . . . . . . . . 30propranolol hcl oral soln . . . . . . . . . . . 30propranolol hcl tabs . . . . . . . . . . . . . . . 30propranolol hydrochloride . . . . . . . . . . 30

PREMARIN TABS . . . . . . . . . . . . . . . . 45PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML . . . . . . . . . . . . . . . . . . . . 37PREMASOL INJ 56MEQ/L; 320MG/100ML; 730MG/100ML; 190MG/100ML; 3MEQ/L; 20MG/100ML; 300MG/100ML; 220MG/100ML; 290MG/100ML; 490MG/100ML; 840MG/100ML; 490MG/100ML; 200MG/100ML; 290MG/100ML; 410MG/100ML; 230MG/100ML; 5MEQ/L; 15MG/100ML; 250MG/100ML; 120MG/100ML; 140MG/100ML; 470MG/100ML . . . . . 38PREMPHASE . . . . . . . . . . . . . . . . . . . . . 45PREMPRO . . . . . . . . . . . . . . . . . . . . . . . . 45prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . 32previfem . . . . . . . . . . . . . . . . . . . . . . . . . . 45PREZCOBIX . . . . . . . . . . . . . . . . . . . . . . 25PREZISTA SUSP . . . . . . . . . . . . . . . . . 25PREZISTA TABS 75MG . . . . . . . . . . . . 25PREZISTA TABS 150MG . . . . . . . . . . . 25PREZISTA TABS 600MG . . . . . . . . . . . 25PREZISTA TABS 800MG . . . . . . . . . . . 25PRIALT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 17PRIMAQUINE PHOSPHATE . . . . . . . 21primidone . . . . . . . . . . . . . . . . . . . . . . . . . 14PRISTIQ . . . . . . . . . . . . . . . . . . . . . . . . . . 15PROAIR HFA . . . . . . . . . . . . . . . . . . . . . 52PROAIR RESPICLICK . . . . . . . . . . . . . 52probenecid . . . . . . . . . . . . . . . . . . . . . . . . 17probenecid/colchicine . . . . . . . . . . . . . . 17procainamide hcl . . . . . . . . . . . . . . . . . . 30PROCALAMINE . . . . . . . . . . . . . . . . . . . 38prochlorperazine . . . . . . . . . . . . . . . . . . 22

POTASSIUM CHLORIDE/ DEXTROSE/SODIUM CHLORIDE . . 37potassium chloride er . . . . . . . . . . . . . . 37potassium chloride inj 0.4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 2meq/ml, 40meq/100ml . . . . . . . . . . . . 37potassium chloride oral soln . . . . . . . 37potassium chloride / sodium chloride . . . . . . . . . . . . . . . . . . . 37POTASSIUM CHLORIDE/SODIUM CHLORIDE INJ 20MEQ/L; 0.45%, 20MEQ/L; 0.9%, 40MEQ/L; 0.9% . . . 37potassium chloride sr . . . . . . . . . . . . . . 37potassium citrate/citric acid . . . . . . . . . 37potassium citrate er . . . . . . . . . . . . . . . . 37PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . 28PRALUENT . . . . . . . . . . . . . . . . . . . . . . . 31pramipexole dihydrochloride . . . . . . . . 21pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg . . . . . . 22pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg . . 22prasugrel . . . . . . . . . . . . . . . . . . . . . . . . . . 29pravastatin sodium . . . . . . . . . . . . . . . . 32prazosin hcl . . . . . . . . . . . . . . . . . . . . . . . 29PRED-G . . . . . . . . . . . . . . . . . . . . . . . . . . 50PRED-G S.O.P. . . . . . . . . . . . . . . . . . . . 50PRED MILD . . . . . . . . . . . . . . . . . . . . . . . 50prednicarbate . . . . . . . . . . . . . . . . . . . . . 42prednisolone . . . . . . . . . . . . . . . . . . . . . . 42prednisolone acetate . . . . . . . . . . . . . . 50prednisolone sodium phosphate ophthalmic soln . . . . . . . . . . . . . . . . . . . 50prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml . . . . . . . . . . . . . . . . 42prednisone . . . . . . . . . . . . . . . . . . . . . . . . 42prednisone intensol . . . . . . . . . . . . . . . . 42PREFEST . . . . . . . . . . . . . . . . . . . . . . . . . 45PREMARIN CREA . . . . . . . . . . . . . . . . 45PREMARIN INJ . . . . . . . . . . . . . . . . . . . 45

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Covered Drugs Index

RIFATER . . . . . . . . . . . . . . . . . . . . . . . . . . 17riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33rimantadine hcl . . . . . . . . . . . . . . . . . . . . 25ringers injection . . . . . . . . . . . . . . . . . . . 38RINGERS IRRIGATION . . . . . . . . . . . . 49RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . . 27risedronate sodium tabs 150mg . . . . 49RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG . . . . . . . . . . . 23RISPERDAL CONSTA INJ 50MG . . . 23risperidone m-tab . . . . . . . . . . . . . . . . . . 23risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 23risperidone odt tbdp 4mg . . . . . . . . . . . 23risperidone oral soln . . . . . . . . . . . . . . 23risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 23risperidone tabs 4mg . . . . . . . . . . . . . . 23ritonavir . . . . . . . . . . . . . . . . . . . . . . . . . . . 25RITUXAN . . . . . . . . . . . . . . . . . . . . . . . . . 21RITUXAN HYCELA . . . . . . . . . . . . . . . . 21rivastigmine tartrate . . . . . . . . . . . . . . . . 14rivastigmine transdermal system . . . . 14rizatriptan benzoate . . . . . . . . . . . . . . . . 17rizatriptan benzoate odt . . . . . . . . . . . . 17romidepsin . . . . . . . . . . . . . . . . . . . . . . . . 19ropinirole er tb24 2mg, 4mg, 6mg, 8mg . . . . . . . . . . . . . . 22ropinirole er tb24 12mg . . . . . . . . . . . . 22ropinirole hcl . . . . . . . . . . . . . . . . . . . . . . 22rosuvastatin calcium . . . . . . . . . . . . . . . 32ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . 48ROTATEQ . . . . . . . . . . . . . . . . . . . . . . . . 48roweepra . . . . . . . . . . . . . . . . . . . . . . . . . . 13roweepra xr tb24 500mg . . . . . . . . . . . 13roweepra xr tb24 750mg . . . . . . . . . . . 13ROZEREM . . . . . . . . . . . . . . . . . . . . . . . . 53RUBRACA . . . . . . . . . . . . . . . . . . . . . . . . 19RYDAPT . . . . . . . . . . . . . . . . . . . . . . . . . . 19RYTARY . . . . . . . . . . . . . . . . . . . . . . . . . . 22

RAPAMUNE ORAL SOLN . . . . . . . . . 47rasagiline mesylate . . . . . . . . . . . . . . . . 22RAVICTI . . . . . . . . . . . . . . . . . . . . . . . . . . 40rea lo 40 crea . . . . . . . . . . . . . . . . . . . . . 34reclipsen . . . . . . . . . . . . . . . . . . . . . . . . . . 45RECOMBIVAX HB . . . . . . . . . . . . . . . . . 48RECTIV . . . . . . . . . . . . . . . . . . . . . . . . . . . 32REGRANEX . . . . . . . . . . . . . . . . . . . . . . 34RELAGARD . . . . . . . . . . . . . . . . . . . . . . . 10RELISTOR INJ 8MG/0.4ML . . . . . . . . 39RELISTOR INJ 12MG/0.6ML . . . . . . . 39REMICADE . . . . . . . . . . . . . . . . . . . . . . . 47REMODULIN . . . . . . . . . . . . . . . . . . . . . . 53RENFLEXIS . . . . . . . . . . . . . . . . . . . . . . . 47RENVELA PACK . . . . . . . . . . . . . . . . . . 38RENVELA TABS . . . . . . . . . . . . . . . . . . 38repaglinide tabs 0.5mg, 1mg . . . . . . . 26repaglinide tabs 2mg . . . . . . . . . . . . . . 26REPATHA . . . . . . . . . . . . . . . . . . . . . . . . . 32REPATHA PUSHTRONEX SYSTEM . . . . . . . . . . 32REPATHA SURECLICK . . . . . . . . . . . . 32RESCRIPTOR TABS 100MG . . . . . . . 24RESCRIPTOR TABS 200MG . . . . . . . 24RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . 50RETROVIR IV INFUSION . . . . . . . . . . 24REVLIMID CAPS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 18REVLIMID CAPS 15MG, 20MG, 25MG . . . . . . . . . . . . . . 18REXULTI . . . . . . . . . . . . . . . . . . . . . . . . . . 23REYATAZ CAPS 150MG, 300MG . . . 25REYATAZ CAPS 200MG . . . . . . . . . . . 25REYATAZ PACK . . . . . . . . . . . . . . . . . . 25ribavirin caps . . . . . . . . . . . . . . . . . . . . . 24ribavirin inhalation soln . . . . . . . . . . . . 53ribavirin tabs . . . . . . . . . . . . . . . . . . . . . . 24RIDAURA . . . . . . . . . . . . . . . . . . . . . . . . . 48rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . . 17rifampin . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

propranolol/hydrochlorothiazide . . . . 30propylthiouracil . . . . . . . . . . . . . . . . . . . . 46PROQUAD . . . . . . . . . . . . . . . . . . . . . . . . 48PROSOL . . . . . . . . . . . . . . . . . . . . . . . . . . 38protriptyline hcl . . . . . . . . . . . . . . . . . . . . 16PROVENTIL HFA . . . . . . . . . . . . . . . . . . 52PULMOZYME . . . . . . . . . . . . . . . . . . . . . 52PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . . 18pyrazinamide . . . . . . . . . . . . . . . . . . . . . . 17pyridostigmine bromide . . . . . . . . . . . . 17pyridostigmine bromide er . . . . . . . . . . 17

QQUADRACEL . . . . . . . . . . . . . . . . . . . . . 48quasense . . . . . . . . . . . . . . . . . . . . . . . . . 45quetiapine fumarate . . . . . . . . . . . . . . . 23quetiapine fumarate er tb24 150mg, 200mg . . . . . . . . . . . . . . . 23quetiapine fumarate er tb24 300mg, 400mg, 50mg . . . . . . . . . 23quinapril hcl . . . . . . . . . . . . . . . . . . . . . . . 30quinapril/hydrochlorothiazide tabs 12.5mg; 10mg . . . . . . . . . . . . . . . . . . . . . 30quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg . . . . . . . . 30quinidine sulfate . . . . . . . . . . . . . . . . . . . 30quinine sulfate . . . . . . . . . . . . . . . . . . . . . 21QVAR AERS 40MCG/ACT . . . . . . . . . 51QVAR AERS 80MCG/ACT . . . . . . . . . 51QVAR REDIHALER AERB 40MCG/ACT . . . . . . . . . . . . . . . . 51QVAR REDIHALER AERB 80MCG/ACT . . . . . . . . . . . . . . . . 51

RRABAVERT . . . . . . . . . . . . . . . . . . . . . . . 48raloxifene hydrochloride . . . . . . . . . . . . 46ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . 30RANEXA . . . . . . . . . . . . . . . . . . . . . . . . . . 31ranitidine hcl . . . . . . . . . . . . . . . . . . . . . . 40

75


Covered Drugs Index

sotalol hydrochloride (af) tabs 80mg . . . . . . . . . . . . . . . . . . . . . 30sotalol hydrochloride tabs 120mg . . . 30SPIRIVA HANDIHALER . . . . . . . . . . . . 52SPIRIVA RESPIMAT . . . . . . . . . . . . . . . 52spironolactone . . . . . . . . . . . . . . . . . . . . 31spironolactone/ hydrochlorothiazide . . . . . . . . . . . . . . . . 31SPORANOX ORAL SOLN . . . . . . . . . 16sprintec 28 . . . . . . . . . . . . . . . . . . . . . . . . 45SPRITAM TB3D 750MG . . . . . . . . . . . 13SPRITAM TB3D 1000MG, 250MG, 500MG . . . . . . . . . . 13SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . . 20sps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45ssd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10STAMARIL . . . . . . . . . . . . . . . . . . . . . . . . 48stavudine . . . . . . . . . . . . . . . . . . . . . . . . . 24sterile water irrigation . . . . . . . . . . . . . . 49sterile water irrigation plastic bottle . . . . . . . . . . . . . . . . . . . . . . . 50STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . 20streptomycin sulfate . . . . . . . . . . . . . . . . 9STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . 24STRIVERDI RESPIMAT . . . . . . . . . . . . 52SUBOXONE . . . . . . . . . . . . . . . . . . . . . . . 9sucralfate . . . . . . . . . . . . . . . . . . . . . . . . . 40sulfacetamide sodium lotn . . . . . . . . . 12sulfacetamide sodium oint . . . . . . . . . 12sulfacetamide sodium/ prednisolone sodium phosphate . . . . 12sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . 12sulfamethoxazole/trimethoprim . . . . . 12sulfamethoxazole/trimethoprim ds . . 12sulfasalazine . . . . . . . . . . . . . . . . . . . . . . 48sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7sumatriptan . . . . . . . . . . . . . . . . . . . . . . . 17sumatriptan succinate inj 4mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . . 17

silver sulfadiazine . . . . . . . . . . . . . . . . . 10SIMBRINZA . . . . . . . . . . . . . . . . . . . . . . . 51SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . 48simvastatin . . . . . . . . . . . . . . . . . . . . . . . . 32sirolimus . . . . . . . . . . . . . . . . . . . . . . . . . . 47SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . 17SKLICE . . . . . . . . . . . . . . . . . . . . . . . . . . . 21sodium bicarbonate inj . . . . . . . . . . . . 38sodium bicarbonate partial fill . . . . . . . 38sodium chloride 0.9% . . . . . . . . . . . . . . 49sodium chloride0.9% . . . . . . . . . . . . . . 49sodium chloride 0.45% . . . . . . . . . . . . . 38sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5% . . . . . . . . . . 38sodium citrate/citric acid . . . . . . . . . . . 38sodium fluoride chew 0.5mg, 1mg . . 38sodium fluoride oral soln . . . . . . . . . . . 38SODIUM LACTATE INJ 5MEQ/ML . . 38sodium phenylbutyrate . . . . . . . . . . . . . 40sodium polystyrene sulfonate powd . . . . . . . . . . . . . . . . . . . 38sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml . . . . . . 38sodium sulfacetamide ophthalmic soln . . . . . . . . . . . . . . . . . . . 12SOLIQUA 100/33 . . . . . . . . . . . . . . . . . . 27SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . 18SOLU-CORTEF . . . . . . . . . . . . . . . . . . . 42SOLU-MEDROL INJ 2GM . . . . . . . . . . 42SOLU-MEDROL INJ 500MG . . . . . . . 42SOMATULINE DEPOT INJ 60MG/0.2ML . . . . . . . . . . . . . . . . . . . . . . 46SOMATULINE DEPOT INJ 90MG/0.3ML . . . . . . . . . . . . . . . . . . . . . . 46SOMATULINE DEPOT INJ 120MG/0.5ML . . . . . . . . . . . . . . . . . . . . . 46SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . 46sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30sotalol hcl . . . . . . . . . . . . . . . . . . . . . . . . . 30sotalol hcl (af) . . . . . . . . . . . . . . . . . . . . . 30

SSABRIL PACK . . . . . . . . . . . . . . . . . . . . 14SABRIL TABS . . . . . . . . . . . . . . . . . . . . 14salsalate . . . . . . . . . . . . . . . . . . . . . . . . . . . 7SAMSCA TABS 15MG . . . . . . . . . . . . . 38SAMSCA TABS 30MG . . . . . . . . . . . . . 38SANCUSO . . . . . . . . . . . . . . . . . . . . . . . . 16SANDIMMUNE . . . . . . . . . . . . . . . . . . . . 47SANDOSTATIN LAR DEPOT . . . . . . . 46SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . 34SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . 23SAVAYSA . . . . . . . . . . . . . . . . . . . . . . . . . 28SAVELLA . . . . . . . . . . . . . . . . . . . . . . . . . 33SAVELLA TITRATION PACK . . . . . . . 33scopolamine . . . . . . . . . . . . . . . . . . . . . . 16selegiline hcl . . . . . . . . . . . . . . . . . . . . . . 22selenium sulfide lotn . . . . . . . . . . . . . . 34selenium sulfide sham 2.25% . . . . . . 34SELZENTRY ORAL SOLN . . . . . . . . 24SELZENTRY TABS 25MG . . . . . . . . . 24SELZENTRY TABS 150MG, 75MG . . 24SELZENTRY TABS 300MG . . . . . . . . 24SENSIPAR TABS 30MG . . . . . . . . . . . 49SENSIPAR TABS 60MG . . . . . . . . . . . 49SENSIPAR TABS 90MG . . . . . . . . . . . 49SEREVENT DISKUS . . . . . . . . . . . . . . 52SEROSTIM . . . . . . . . . . . . . . . . . . . . . . . 43sertraline hcl conc . . . . . . . . . . . . . . . . . 15sertraline hcl tabs 25mg . . . . . . . . . . . . 15sertraline hcl tabs 50mg . . . . . . . . . . . . 15sertraline hcl tabs 100mg . . . . . . . . . . 15setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . . 45sf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38sf 5000 plus . . . . . . . . . . . . . . . . . . . . . . . 38sharobel . . . . . . . . . . . . . . . . . . . . . . . . . . 46SHINGRIX . . . . . . . . . . . . . . . . . . . . . . . . 48SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . 46sildenafil tabs . . . . . . . . . . . . . . . . . . . . . 53SILENOR . . . . . . . . . . . . . . . . . . . . . . . . . 53

76


Covered Drugs Index

TETANUS/DIPHTHERIA TOXOIDS-ADSORBED . . . . . . . . . . . . 48tetrabenazine tabs 12.5mg . . . . . . . . . 33tetrabenazine tabs 25mg . . . . . . . . . . . 33tetracycline hydrochloride . . . . . . . . . . 13TEXACORT . . . . . . . . . . . . . . . . . . . . . . . 42THALOMID CAPS 100MG, 150MG, 50MG . . . . . . . . . . . . 18THALOMID CAPS 200MG . . . . . . . . . 18THEO-24 . . . . . . . . . . . . . . . . . . . . . . . . . 52theophylline . . . . . . . . . . . . . . . . . . . . . . . 52theophylline cr . . . . . . . . . . . . . . . . . . . . . 52theophylline er tb12 300mg, 450mg . . . . . . . . . . . . . . . . . . . . 52theophylline er tb24 . . . . . . . . . . . . . . . 52thioridazine hcl . . . . . . . . . . . . . . . . . . . . 22thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . 18thiothixene . . . . . . . . . . . . . . . . . . . . . . . . 22THYMOGLOBULIN . . . . . . . . . . . . . . . . 48THYROLAR-1 . . . . . . . . . . . . . . . . . . . . . 46THYROLAR-1/2 . . . . . . . . . . . . . . . . . . . 46THYROLAR-1/4 . . . . . . . . . . . . . . . . . . . 46THYROLAR-2 . . . . . . . . . . . . . . . . . . . . . 46THYROLAR-3 . . . . . . . . . . . . . . . . . . . . . 46tiagabine hydrochloride tabs 2mg . . . 14tiagabine hydrochloride tabs 4mg . . . 14tiagabine hydrochloride tabs 12mg . . 14tiagabine hydrochloride tabs 16mg . . 14TICE BCG . . . . . . . . . . . . . . . . . . . . . . . . 19tigecycline . . . . . . . . . . . . . . . . . . . . . . . . 10tilia fe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45timolol maleate ophthalmic soln . . . . 51timolol maleate tabs . . . . . . . . . . . . . . . 30TIS-U-SOL . . . . . . . . . . . . . . . . . . . . . . . . 50TIVICAY TABS 10MG, 25MG . . . . . . . 24TIVICAY TABS 50MG . . . . . . . . . . . . . . 24tizanidine hcl caps . . . . . . . . . . . . . . . . 23tizanidine hcl tabs . . . . . . . . . . . . . . . . . 23tl-fluorivite . . . . . . . . . . . . . . . . . . . . . . . . . 39TOBI PODHALER . . . . . . . . . . . . . . . . . 52

tamoxifen citrate . . . . . . . . . . . . . . . . . . . 18tamsulosin hcl . . . . . . . . . . . . . . . . . . . . . 41TARCEVA TABS 25MG . . . . . . . . . . . . 20TARCEVA TABS 100MG, 150MG . . . 20TARGRETIN GEL . . . . . . . . . . . . . . . . . 21tarina fe 1/20 . . . . . . . . . . . . . . . . . . . . . . 45TASIGNA CAPS 50MG . . . . . . . . . . . . 20TASIGNA CAPS 150MG, 200MG . . . 20tazarotene . . . . . . . . . . . . . . . . . . . . . . . . 34tazicef inj 1gm, 2gm, 6gm . . . . . . . . . . 11TAZORAC CREA . . . . . . . . . . . . . . . . . 34TAZORAC GEL . . . . . . . . . . . . . . . . . . . 34taztia xt cp24 120mg, 180mg, 240mg, 300mg . . . . . 31TECENTRIQ . . . . . . . . . . . . . . . . . . . . . . 21TECFIDERA CPDR 120MG . . . . . . . . 34TECFIDERA CPDR 240MG . . . . . . . . 34TECFIDERA STARTER PACK . . . . . . 34techlite pen needles/31g x 6 mm . . . 50techlite pen needles/31g x 8mm . . . . 50techlite pen needles/32g x 4mm . . . . 50techlite pen needles/32g x 6mm . . . . 50techlite pen needles/32g x 8mm . . . . 50TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . 11TEKTURNA . . . . . . . . . . . . . . . . . . . . . . . 31TEKTURNA HCT . . . . . . . . . . . . . . . . . . 31temazepam . . . . . . . . . . . . . . . . . . . . . . . 53TENIVAC . . . . . . . . . . . . . . . . . . . . . . . . . 48tenofovir disoproxil fumarate . . . . . . . 24terazosin hcl caps 1mg, 2mg, 5mg . . 41terazosin hcl caps 10mg . . . . . . . . . . . 41terbinafine hcl tabs . . . . . . . . . . . . . . . . 16terbutaline sulfate . . . . . . . . . . . . . . . . . 52terconazole . . . . . . . . . . . . . . . . . . . . . . . 16testosterone cypionate . . . . . . . . . . . . . 43testosterone enanthate . . . . . . . . . . . . 43testosterone gel 25mg/2.5gm, 50mg/5gm . . . . . . . . . . . 43testosterone pump . . . . . . . . . . . . . . . . . 43

sumatriptan succinate inj 6mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . . 17sumatriptan succinate refill inj 4mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . . 17sumatriptan succinate refill inj 6mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . . 17sumatriptan succinate tabs . . . . . . . . 17SUPRAX CAPS . . . . . . . . . . . . . . . . . . . 11SUPRAX CHEW . . . . . . . . . . . . . . . . . . 11SUPRAX SUSR 500MG/5ML . . . . . . . 11SUPREP BOWEL PREP KIT . . . . . . . 40SUSTIVA CAPS 50MG . . . . . . . . . . . . . 24SUSTIVA CAPS 200MG . . . . . . . . . . . 24SUSTIVA TABS . . . . . . . . . . . . . . . . . . . 24SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . 20SYLATRON . . . . . . . . . . . . . . . . . . . . . . . 19SYMFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 24SYMFI LO . . . . . . . . . . . . . . . . . . . . . . . . 24SYMLINPEN 60 . . . . . . . . . . . . . . . . . . . 27SYMLINPEN 120 . . . . . . . . . . . . . . . . . . 27SYNAGIS . . . . . . . . . . . . . . . . . . . . . . . . . 48SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . 46SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 10SYNJARDY . . . . . . . . . . . . . . . . . . . . . . . 27SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG . . . 27SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG . . 27SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . 19SYNTHROID . . . . . . . . . . . . . . . . . . . . . . 46SYPRINE . . . . . . . . . . . . . . . . . . . . . . . . . 38

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . 18tacrolimus caps . . . . . . . . . . . . . . . . . . . 47TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . 20TAGRISSO . . . . . . . . . . . . . . . . . . . . . . . . 20TAMIFLU CAPS 30MG . . . . . . . . . . . . 25TAMIFLU CAPS 45MG, 75MG . . . . . 25TAMIFLU SUSR . . . . . . . . . . . . . . . . . . 25

77


Covered Drugs Index

trimipramine maleate . . . . . . . . . . . . . . 16trinessa . . . . . . . . . . . . . . . . . . . . . . . . . . . 45trinessa lo . . . . . . . . . . . . . . . . . . . . . . . . . 45TRINTELLIX . . . . . . . . . . . . . . . . . . . . . . 15tri-previfem . . . . . . . . . . . . . . . . . . . . . . . . 45TRIPTODUR . . . . . . . . . . . . . . . . . . . . . . 42TRISENOX . . . . . . . . . . . . . . . . . . . . . . . 19tri-sprintec . . . . . . . . . . . . . . . . . . . . . . . . 45TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . . . 24tri-vitamin/fluoride . . . . . . . . . . . . . . . . . 39tri-vit/fluoride . . . . . . . . . . . . . . . . . . . . . . 39tri-vit/fluoride/iron . . . . . . . . . . . . . . . . . . 39trivora-28 . . . . . . . . . . . . . . . . . . . . . . . . . 45TROGARZO . . . . . . . . . . . . . . . . . . . . . . 24TROPHAMINE INJ 0; 0.32GM/100ML; 0.73GM/100ML; 0.19GM/100ML; 0.014GM/100ML; 0.22GM/100ML; 0.29GM/100ML; 0.49GM/100ML; 0.3GM/100ML; 0.84GM/100ML; 0.49GM/100ML; 0.2GM/100ML; 0.29GM/100ML; 0.41GM/100ML; 0.23GM/100ML; 0.05GM/100ML; 0.015GM/100ML; 0.25GM/100ML; 0.12GM/100ML; 0.14GM/100ML; 0.47GM/100ML . . . . 38TROPHAMINE INJ 97MEQ/L; 0.54GM/100ML; 1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML; 5MEQ/L; 0.025GM/100ML; 0.42GM/100ML; 0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML . . . . 38tropicamide . . . . . . . . . . . . . . . . . . . . . . . 50trospium chloride . . . . . . . . . . . . . . . . . . 41trospium chloride er . . . . . . . . . . . . . . . . 41TRULANCE . . . . . . . . . . . . . . . . . . . . . . . 39TRULICITY . . . . . . . . . . . . . . . . . . . . . . . 27TRUMENBA . . . . . . . . . . . . . . . . . . . . . . 48TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . 24TUDORZA PRESSAIR . . . . . . . . . . . . . 52

TREANDA INJ 25MG . . . . . . . . . . . . . . 18TREANDA INJ 100MG . . . . . . . . . . . . . 18TRECATOR . . . . . . . . . . . . . . . . . . . . . . . 17TRELEGY ELLIPTA . . . . . . . . . . . . . . . 53TRELSTAR MIXJECT INJ 3.75MG . . 46TRELSTAR MIXJECT INJ 11.25MG . . 46TRELSTAR MIXJECT INJ 22.5MG . . 46TRESIBA FLEXTOUCH . . . . . . . . . . . . 27tretinoin caps . . . . . . . . . . . . . . . . . . . . . 21tretinoin crea . . . . . . . . . . . . . . . . . . . . . 34tretinoin gel . . . . . . . . . . . . . . . . . . . . . . . 34tretinoin microsphere . . . . . . . . . . . . . . 34tretinoin microsphere pump gel 0.1% . . . . . . . . . . . . . . . . . . . . 34triamcinolone acetonide aers . . . . . . 42triamcinolone acetonide crea . . . . . . 42triamcinolone acetonide dental paste . . . . . . . . . . . . . . . . . . . . . . . 34triamcinolone acetonide inj 40mg/ml . . . . . . . . . . . . . . . . . . . . . . . . . . 42triamcinolone acetonide lotn . . . . . . . 42triamcinolone acetonide oint . . . . . . . 42triamterene/ hydrochlorothiazide caps . . . . . . . . . . 31triamterene/ hydrochlorothiazide tabs . . . . . . . . . . . 31triderm crea 0.1% . . . . . . . . . . . . . . . . . 42trientine hydrochloride . . . . . . . . . . . . . 38tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . . 45trifluoperazine hcl . . . . . . . . . . . . . . . . . . 22trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . 25trihexyphenidyl hcl . . . . . . . . . . . . . . . . . 21tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . 45tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . . 45tri-lo-estarylla . . . . . . . . . . . . . . . . . . . . . . 45tri-lo-marzia . . . . . . . . . . . . . . . . . . . . . . . 45tri-lo-sprintec . . . . . . . . . . . . . . . . . . . . . . 45trilyte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40trimethoprim . . . . . . . . . . . . . . . . . . . . . . . 10trimethoprim sulfate/ polymyxin b sulfate . . . . . . . . . . . . . . . . 10

TOBRADEX OINT . . . . . . . . . . . . . . . . 50tobramycin/dexamethasone . . . . . . . . 50tobramycin nebu . . . . . . . . . . . . . . . . . . 52tobramycin ophthalmic soln . . . . . . . . . 9tobramycin sulfate inj 1.2gm, 1.2gm/30ml, 10mg/ml, 80mg/2ml . . . . 9tobramycin sulfate ophthalmic soln . . 9tobramycin sulfate/sodium chloride inj 0.9%; 0.8mg/ml . . . . . . . . . . 9TOBREX OINT . . . . . . . . . . . . . . . . . . . . 9tolcapone . . . . . . . . . . . . . . . . . . . . . . . . . 21tolmetin sodium . . . . . . . . . . . . . . . . . . . . 7tolterodine tartrate . . . . . . . . . . . . . . . . . 41tolterodine tartrate er . . . . . . . . . . . . . . 41topiramate . . . . . . . . . . . . . . . . . . . . . . . . 14toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . 20topotecan hcl . . . . . . . . . . . . . . . . . . . . . . 20TORISEL . . . . . . . . . . . . . . . . . . . . . . . . . 47torsemide . . . . . . . . . . . . . . . . . . . . . . . . . 31TOUJEO MAX SOLOSTAR . . . . . . . . 27TOUJEO SOLOSTAR . . . . . . . . . . . . . . 27TPN ELECTROLYTES . . . . . . . . . . . . . 38TRACLEER . . . . . . . . . . . . . . . . . . . . . . . 53TRADJENTA . . . . . . . . . . . . . . . . . . . . . . 27tramadol hcl . . . . . . . . . . . . . . . . . . . . . . . . 8tramadol hydrochloride/ acetaminophen . . . . . . . . . . . . . . . . . . . . . 8trandolapril tabs 1mg . . . . . . . . . . . . . . 30trandolapril tabs 2mg, 4mg . . . . . . . . . 30trandolapril/verapamil hcl er tbcr 1mg; 240mg, 2mg; 180mg, 2mg; 240mg . . . . . . . . . . . . . . . 30trandolapril/verapamil hcl er tbcr 4mg; 240mg . . . . . . . . . . . . . . . . . . 30tranexamic acid inj . . . . . . . . . . . . . . . . 28tranexamic acid tabs . . . . . . . . . . . . . . 28TRANSDERM-SCOP . . . . . . . . . . . . . . 16tranylcypromine sulfate . . . . . . . . . . . . 15TRAVASOL . . . . . . . . . . . . . . . . . . . . . . . 38TRAVATAN Z . . . . . . . . . . . . . . . . . . . . . . 50trazodone hcl . . . . . . . . . . . . . . . . . . . . . . 15

78


Covered Drugs Index

vestura . . . . . . . . . . . . . . . . . . . . . . . . . . . 45V-GO 20 . . . . . . . . . . . . . . . . . . . . . . . . . . 50V-GO 30 . . . . . . . . . . . . . . . . . . . . . . . . . . 50V-GO 40 . . . . . . . . . . . . . . . . . . . . . . . . . . 50VIBERZI . . . . . . . . . . . . . . . . . . . . . . . . . . 40VICTOZA . . . . . . . . . . . . . . . . . . . . . . . . . 27VIDEX EC CPDR 125MG . . . . . . . . . . 24VIDEX PEDIATRIC . . . . . . . . . . . . . . . . 24vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45vigabatrin . . . . . . . . . . . . . . . . . . . . . . . . . 14VIGAMOX . . . . . . . . . . . . . . . . . . . . . . . . 12VIIBRYD . . . . . . . . . . . . . . . . . . . . . . . . . . 15VIIBRYD STARTER PACK . . . . . . . . . 15VIMPAT INJ . . . . . . . . . . . . . . . . . . . . . . 14VIMPAT ORAL SOLN . . . . . . . . . . . . . 14VIMPAT TABS . . . . . . . . . . . . . . . . . . . . 14vinblastine sulfate . . . . . . . . . . . . . . . . . 19vincasar pfs . . . . . . . . . . . . . . . . . . . . . . . 19vincristine sulfate . . . . . . . . . . . . . . . . . . 19vinorelbine tartrate inj 50mg/5ml . . . . 19viorele . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45VIRACEPT TABS 250MG . . . . . . . . . . 25VIRACEPT TABS 625MG . . . . . . . . . . 25VIREAD POWD . . . . . . . . . . . . . . . . . . . 24VIREAD TABS . . . . . . . . . . . . . . . . . . . . 24VIVITROL . . . . . . . . . . . . . . . . . . . . . . . . . . 9voriconazole inj . . . . . . . . . . . . . . . . . . . 16voriconazole susr . . . . . . . . . . . . . . . . . 17voriconazole tabs . . . . . . . . . . . . . . . . . 17VOSEVI . . . . . . . . . . . . . . . . . . . . . . . . . . 23VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . 20VP-PNV-DHA . . . . . . . . . . . . . . . . . . . . . 39VPRIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40VRAYLAR CAPS . . . . . . . . . . . . . . . . . . 23VRAYLAR CPPK . . . . . . . . . . . . . . . . . . 23vyfemla . . . . . . . . . . . . . . . . . . . . . . . . . . . 45VYXEOS . . . . . . . . . . . . . . . . . . . . . . . . . . 18

vancomycin hcl inj 0.9%; 1gm/200ml, 1000mg, 10gm, 500mg, 750mg . . . . . . . . . . . . . . 10vancomycin hcl inj 5000mg . . . . . . . . . 10vancomycin hydrochloride/sodium chloride inj 0.9%; 750mg/150ml . . . . 10vandazole . . . . . . . . . . . . . . . . . . . . . . . . . 10VAQTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48VARIVAX . . . . . . . . . . . . . . . . . . . . . . . . . 48VARIZIG . . . . . . . . . . . . . . . . . . . . . . . . . . 48VASCEPA CAPS 0.5GM . . . . . . . . . . . 32VASCEPA CAPS 1GM . . . . . . . . . . . . . 32VAXCHORA . . . . . . . . . . . . . . . . . . . . . . . 48VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . 21VELCADE . . . . . . . . . . . . . . . . . . . . . . . . 19velivet . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45VELPHORO . . . . . . . . . . . . . . . . . . . . . . . 38VELTASSA . . . . . . . . . . . . . . . . . . . . . . . . 38VENCLEXTA STARTING PACK . . . . 19VENCLEXTA TABS 10MG . . . . . . . . . 19VENCLEXTA TABS 50MG . . . . . . . . . 19VENCLEXTA TABS 100MG . . . . . . . . 19venlafaxine hcl . . . . . . . . . . . . . . . . . . . . 15venlafaxine hcl er cp24 37.5mg . . . . . 15venlafaxine hcl er cp24 75mg . . . . . . 15venlafaxine hcl er cp24 150mg . . . . . 15venlafaxine hcl er tb24 150mg . . . . . . 15venlafaxine hcl er tb24 225mg, 37.5mg, 75mg . . . . . . . . . . . . . 15VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . 53verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg . . . . . . . . . . . . . . . . . . . . 31verapamil hcl er cp24 200mg . . . . . . . 31verapamil hcl er tbcr . . . . . . . . . . . . . . 31verapamil hcl inj . . . . . . . . . . . . . . . . . . 31verapamil hcl sr cp24 . . . . . . . . . . . . . . 31verapamil hcl tabs . . . . . . . . . . . . . . . . . 31VERSACLOZ . . . . . . . . . . . . . . . . . . . . . 23VERZENIO . . . . . . . . . . . . . . . . . . . . . . . 19VESICARE . . . . . . . . . . . . . . . . . . . . . . . . 41

TWINRIX . . . . . . . . . . . . . . . . . . . . . . . . . 48TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . . 25tydemy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45TYGACIL . . . . . . . . . . . . . . . . . . . . . . . . . 10TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . 20TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . 48TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . 34TYVASO . . . . . . . . . . . . . . . . . . . . . . . . . . 53TYVASO REFILL . . . . . . . . . . . . . . . . . . 53TYVASO STARTER . . . . . . . . . . . . . . . 53

UULORIC . . . . . . . . . . . . . . . . . . . . . . . . . . 17umecta mousse . . . . . . . . . . . . . . . . . . . 34UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . . 21urea crea 39%, 40%, 45%, 50% . . . . 34URELLE . . . . . . . . . . . . . . . . . . . . . . . . . . 41uribel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41urin d/s . . . . . . . . . . . . . . . . . . . . . . . . . . . 41ur n-c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41URO-458 . . . . . . . . . . . . . . . . . . . . . . . . . 41uro-mp . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41ursodiol . . . . . . . . . . . . . . . . . . . . . . . . . . . 39ustell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41utira-c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Vvalacyclovir hcl . . . . . . . . . . . . . . . . . . . . 25VALCHLOR . . . . . . . . . . . . . . . . . . . . . . . 18valganciclovir . . . . . . . . . . . . . . . . . . . . . . 23valganciclovir hydrochlorde . . . . . . . . 23valproate sodium . . . . . . . . . . . . . . . . . . 14valproic acid . . . . . . . . . . . . . . . . . . . . . . . 14valsartan . . . . . . . . . . . . . . . . . . . . . . . . . . 29valsartan/hydrochlorothiazide . . . . . . 29vancomycin . . . . . . . . . . . . . . . . . . . . . . . 10vancomycin hcl caps 125mg . . . . . . . 10vancomycin hcl caps 250mg . . . . . . . 10vancomycin hcl in dextrose . . . . . . . . . 10

79


Covered Drugs Index

zolmitriptan . . . . . . . . . . . . . . . . . . . . . . . 17zolmitriptan odt . . . . . . . . . . . . . . . . . . . . 17zolpidem tartrate tabs . . . . . . . . . . . . . 53zonisamide . . . . . . . . . . . . . . . . . . . . . . . . 13ZORBTIVE . . . . . . . . . . . . . . . . . . . . . . . . 43ZORTRESS TABS 0.5MG . . . . . . . . . . 47ZORTRESS TABS 0.25MG, 0.75MG . . . . . . . . . . . . . . . . . . 47ZOSTAVAX . . . . . . . . . . . . . . . . . . . . . . . 48zovia 1/35e . . . . . . . . . . . . . . . . . . . . . . . 45zovia 1/50e . . . . . . . . . . . . . . . . . . . . . . . 45ZOVIRAX CREA . . . . . . . . . . . . . . . . . . 25ZUBSOLV SUBL 0.7MG; 0.18MG . . . 9ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG . . . . . . 9ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . . 20ZYKADIA . . . . . . . . . . . . . . . . . . . . . . . . . 20ZYLET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9ZYPREXA RELPREVV INJ 210MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 23ZYPREXA RELPREVV INJ 300MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 23ZYPREXA RELPREVV INJ 405MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 23ZYTIGA TABS 250MG . . . . . . . . . . . . . 18ZYTIGA TABS 500MG . . . . . . . . . . . . . 18

zaleplon . . . . . . . . . . . . . . . . . . . . . . . . . . 53ZALTRAP . . . . . . . . . . . . . . . . . . . . . . . . . 20ZANOSAR . . . . . . . . . . . . . . . . . . . . . . . . 18zarah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . . . 28ZAVESCA . . . . . . . . . . . . . . . . . . . . . . . . . 40zazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17zebutal caps 325mg; 50mg; 40mg . . . 7ZEJULA . . . . . . . . . . . . . . . . . . . . . . . . . . 19ZELAPAR . . . . . . . . . . . . . . . . . . . . . . . . . 22ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . 20ZEMAIRA . . . . . . . . . . . . . . . . . . . . . . . . . 53zenatane . . . . . . . . . . . . . . . . . . . . . . . . . . 34zenchent . . . . . . . . . . . . . . . . . . . . . . . . . . 45ZENPEP CPEP 105000UNIT; 25000UNIT; 79000UNIT, 136000UNIT; 25000UNIT; 85000UNIT, 16000UNIT; 3000UNIT; 10000UNIT, 168000UNIT; 40000UNIT; 126000UNIT, 218000UNIT; 40000UNIT; 136000UNIT, 24000UNIT; 5000UNIT; 17000UNIT, 27000UNIT; 5000UNIT; 17000UNIT, 55000UNIT; 10000UNIT; 34000UNIT, 82000UNIT; 15000UNIT; 51000UNIT, 84000UNIT; 20000UNIT; 63000UNIT . . . . . . . . . . . 40ZERIT ORAL SOLN . . . . . . . . . . . . . . . 24ZETIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32ZIAGEN ORAL SOLN . . . . . . . . . . . . . 24zidovudine caps . . . . . . . . . . . . . . . . . . 24zidovudine syrp . . . . . . . . . . . . . . . . . . . 24zidovudine tabs . . . . . . . . . . . . . . . . . . . 24ZIOPTAN . . . . . . . . . . . . . . . . . . . . . . . . . 50ziprasidone hcl . . . . . . . . . . . . . . . . . . . . 23ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . 23ZMAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12zoledronic acid inj 4mg/5ml . . . . . . . . 49zoledronic acid inj 5mg/100ml . . . . . . 49ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . 19

Wwarfarin sodium . . . . . . . . . . . . . . . . . . . 28WELCHOL . . . . . . . . . . . . . . . . . . . . . . . . 32wymzya fe . . . . . . . . . . . . . . . . . . . . . . . . 45

XXALKORI . . . . . . . . . . . . . . . . . . . . . . . . . 20XARELTO STARTER PACK . . . . . . . . 28XARELTO TABS 10MG . . . . . . . . . . . . 28XARELTO TABS 15MG . . . . . . . . . . . . 28XARELTO TABS 20MG . . . . . . . . . . . . 28XATMEP . . . . . . . . . . . . . . . . . . . . . . . . . . 47XEOMIN INJ 100UNIT, 50UNIT . . . . . 50XEOMIN INJ 200UNIT . . . . . . . . . . . . . 50XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 49XIAFLEX . . . . . . . . . . . . . . . . . . . . . . . . . . 40XIFAXAN TABS 200MG . . . . . . . . . . . . 10XIFAXAN TABS 550MG . . . . . . . . . . . . 10XIGDUO XR TB24 5MG; 1000MG . . 27XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 2.5MG; 1000MG, 5MG; 500MG . . . . 27XOLAIR . . . . . . . . . . . . . . . . . . . . . . . . . . . 53XTAMPZA ER . . . . . . . . . . . . . . . . . . . . . . 7XTANDI . . . . . . . . . . . . . . . . . . . . . . . . . . . 18xulane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45XULTOPHY 100/3.6 . . . . . . . . . . . . . . . 27XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

YYERVOY INJ 50MG/10ML . . . . . . . . . 21YERVOY INJ 200MG/40ML . . . . . . . . 21YF-VAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 48YONDELIS . . . . . . . . . . . . . . . . . . . . . . . . 18yuvafem . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . 52

80

Notes

This drug list was updated in May 2018. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-627-7534 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m., hours apply Monday – Friday, February 15 – September 30, or visit www.CignaHealthSpring.com. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-627-7534 (TTY 711), 7 days a week, 8 a.m. – 8 p.m., hours apply Monday – Friday, February 15 – September 30. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-627-7534 (TTY 711). 注意：如果您使用繁體/中文，您可以免費獲得語言援助服務請致電 1-800-627-7534 (TTY 711). Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2017 Cigna

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