2019 Medicare Part D Drug FormularyNational Drug Plan (PDP) Abridged Medication List
This abridged formulary was updated on 12 . This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact EmblemHealth Medicare at 800-585-5786 or, for TTY users, 800-899-2114, 24 hours a day, 7 days a week. Or visit emblemhealth.com/medicare.
i
EmblemHealth National Drug Plan (PDP) Formulary 2019 Abridged Formulary(Partial List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN
9Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Health Plan of New York (HIP)/EmblemHealth and Group Health Incorporated (GHI)/EmblemHealth. When it refers to “plan” or “our plan,” it means EmblemHealth National Drug Plan (PDP) plan.
This document includes a partial list of the drugs (formulary) for our plan, which is current as of 12/1 . For a complete, 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, 2020, and from time to time during the year.
The formulary and pharmacy network may change at any time. You will receive notice when necessary.
ATTENTION: If you speak other languages, language assistance services, free of charge, are available to you. Call 1-877-344-7364 (TTY: 711) ATENCIÓN: Si usted habla español, tiene a su disposición, gratis, servicios de ayuda para idiomas. Llame al, 877-344-7364 (TTY: 711).
Group Health Incorporated (GHI) is a standalone PDP with a Medicare contract. Enrollment in GHI depends on contract renewal. GHI is an EmblemHealth company.
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EmblemHealth National Drug Plan (PDP)
What is the EmblemHealth National Drug Plan (PDP) Abridged Formulary? A formulary is a list of covered drugs selected by our plan 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. Our Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
This document is a partial formulary and includes only some of the drugs covered by our plan. For a complete listing of all prescription drugs covered by, please visit our website or call us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
Can the formulary (drug list) change?Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug:
• New generic drugs. We may immediately remove a brand-name drug on our druglist if we are replacing it with a new generic drug that will appear on the same orlower cost-sharing tier and with the same or fewer restrictions. Also, when addingthe new generic drug, we may decide to keep the brand-name drug on our drug list,but immediately move it to a different cost-sharing tier or add new restrictions. If youare currently taking that brand-name drug, we may not tell you in advance before wemake that change, but we will later provide you with information about the specificchange(s) we have made.– I
• Drugs removed from the market. If the Food and Drug Administration (FDA) deemsa drug on our formulary to be unsafe or the drug’s manufacturer removes the drugfrom the market, we will immediately remove the drug from our formulary andprovide notice to members who take the drug.
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• Other chang es. We may make other changes that affect members currently taking adrug. For instance, we may add a generic drug that is not new to market to replace abrand-name drug currently on the formulary, or add new restrictions to the brand-name drug or move it to a different cost-sharing tier. Or we may make changes basedon new clinical guidelines. If we remove drugs from our formulary, add priorauthorization, quantity limits, and/or step therapy restrictions on a drug or move adrug to a higher cost-sharing tier, we must notify affected members of the change atleast 30 days before the change becomes effective, or at the time the memberrequests a refill of the drug, at which time the member will receive a 30-day supply ofthe drug.
The enclosed formulary is current as of 12 . To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages.
Note: In the event of a mid-year, non-maintenance formulary change, the change is added to a comprehensive list of changes that have been made since the formulary was printed. The list of changes is included with the formulary booklet that is mailed to new members with their welcome kit. Existing members can view the updated formulary by visiting us on the web at www.emblemhealth.com/medicare. The formulary that is posted on our website is updated.
How do I use the formulary? There are two ways to find your drug within the formulary:
Medical ConditionThe formulary begins on page 2. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Hypertensive/Lipids.” If you know what your drug is used for, look for the category name in the list that begins on page 2. Then look under the category name for your drug.
Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page 131. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?Our plan 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.
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EmblemHealth National Drug Plan (PDP)
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: Our plan requires your physician to get prior authorization forcertain drugs. This means that you will need to get approval from our plan before youfill your prescriptions. If you don’t get approval, our plan may not cover the drug.
• Quantity Limits: For certain drugs, our plan limit the amount of the drug that we willcover. For example, our plan provides 30 tablets per prescription for JANUVIA®. Thismay be in addition to a standard one-month or three-month supply.
• Step Therapy: In some cases, our plan requires you to first try certain drugs to treatyour medical condition before we will cover another drug for that condition. Forexample, if Drug A and Drug B both treat your medical condition, our plan may notcover Drug B unless you try Drug A first. If Drug A does not work for you, our plan willthen cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 2. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
You can ask us 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 EmblemHealth National Drug Plan (PDP) Formulary?” on page iv for information about how to request an exception.
What if my drug is not on the formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Services and ask if your drug is covered. This document includes only a partial list of covered drugs, so our plan may cover your drug. For more information, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
If you learn that our plan does not cover your drug, you have two options:
• Y ou can ask Customer Services for a list of similar drugs that are covered by our plan.When you receive the list, show it to your doctor and ask him or her to prescribe asimilar drug that is covered by our plan.
• Y ou can ask our plan to make an exception and cover your drug. See below forinformation about how to request an exception.
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How do I request an exception to the EmblemHealth National Drug Plan (PDP) Formulary?You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
• Y ou can ask us to cover a drug even if it is not on our formulary. If approved, this drugwill be covered at a pre-determined cost-sharing level, and you would not be able toask us to provide the drug at a lower cost-sharing level.
• Y ou can ask us to cover a formulary drug at a lower cost-sharing level if this drug isnot on the specialty tier. If approved, this would lower the amount you must pay foryour drug.
• Y ou can ask us to waive coverage restrictions or limits on your drug. For example, forcertain drugs, our plan limit the amount of the drug that we will cover. If your drughas a quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, utilization restriction exception. When you request a formulary or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
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If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.
If you are a current member in our plan and you experience a change in the level of care, such as an admission or discharge from the long-term care facility, you will be allowed an “early” refill of your medications, as needed, to assist with your transition to your new level of care for more information.
For more informationFor more detailed information about your EmblemHealth Medicare HMO prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/seven days a week. TTY users should call 877-486-2048. Or, visit medicare.gov.
EmblemHealth National Drug Plan (PDP) Formulary The abridged formulary that begins on page 2 provides coverage information about some of the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 131.
Remember: This is only a partial list of drugs covered by our plan. If your prescription is not in this partial formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., SYNTHROID and generic drugs are listed in lower-case italics (e.g., levothyroxine).
The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug.
Below is a list of abbreviations that may appear on the following pages in the Requirements/Limits column that tells you if there are any special requirements for coverage of your drug.
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List of AbbreviationsB/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service.
MO: Mail-Order Drug. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics).
PA: Prior Authorization. The plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug.
QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover.
ST: Step Therapy. In some cases, the plan 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
Please refer to your plan Benefit Summary about how the plan’s cost-sharing relates to the different tier levels listed in this formulary for a one-month supply of a drug. If you are eligible for “Extra Help” or “Low Income Subsidy” (LIS), some of the information in listed in Benefit Summary about the cost of Part D prescription drugs may not apply to you. We will send you a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS rider), which tells you about your drug coverage. If you don’t have this insert, please call Customer Service at the numbers listed on the back cover and ask for the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS rider).
Please Note: Employer Group Waiver Plan (EGWP) please refer to your Cost Sharing Guide or contact Customer Service for benefit details and cost sharing amounts.
(Continued)
Y0026_126476 Accepted 8/29/16Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are
ATTENTION: If you speak other languages, language assistance services, free of charge, are available to you. Call 1-877-411-3625 (TTY/TDD: 711).
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711)
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1-877-411-3625 TTY/TDD: 711).
Kreyòl Ayisyen (Haitian Creole)ATANSYON: Si ou pale Kreyòl Ayisyen, gen sèvis èd nan lang gratis ki disponib pou ou. Rele nimewo 1-877-411-3625 (TTY/TDD: 711).
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Notice of Nondiscrimination Policy EmblemHealth complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. EmblemHealth does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
EmblemHealth: Provides free aids and services to people with disabilities to communicate effectively with us, such as:
Qualified sign language interpretersWritten information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:Qualified interpretersInformation written in other languages
If you need these services, contact 1-877-411-3625.
If you believe that EmblemHealth has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with EmblemHealth Grievance and Appeals Department, PO Box 2844, New York, NY 10116, or call 1-877- 411-3625. (Dial 711 for TTY/TDD services.) You can file a grievance in person, by mail or by phone. If you need help filing a grievance, EmblemHealth’s Grievance and Appeals Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office of Civil Rights electronically through the Office of Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201; 1-800-368-1019, (dial 1-800-537-7697 for TTY services).
Complaint forms are available at hhs.gov/ocr/office/file/index.html.
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Below is a list of abbreviations that may appear on the following pages in the Requirements/Limits column
that tells you if there are any special requirements for coverage of your drug.
List of Abbreviations
B/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the
circumstances. Information may need to be submitted describing the use and setting of the drug to make the
determination.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more
information, please call Customer Service.
MO: Mail-Order Drug. This prescription drug is available through our mail-order service, as well as through
our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such
as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term
prescriptions (such as antibiotics).
PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs.
This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we
may not cover the drug.
QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.
ST: Step Therapy. In some cases, the Plan 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for
you, we will then cover Drug B.
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
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Drug Name Drug Tier Requirements/Limits
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
ABELCET INTRAVENOUS SUSPENSION 4 B/D PA; MO
AMBISOME INTRAVENOUS SUSPENSION
FOR RECONSTITUTION
4 B/D PA; MO
amphotericin b injection recon soln 3 B/D PA; MO
ANCOBON ORAL CAPSULE 4 MO
CANCIDAS INTRAVENOUS RECON SOLN 4 B/D PA; MO
caspofungin intravenous recon soln 4 B/D PA
clotrimazole mucous membrane troche 1 MO
CRESEMBA ORAL CAPSULE 4 MO
DIFLUCAN ORAL SUSPENSION FOR
RECONSTITUTION
3 MO
DIFLUCAN ORAL TABLET 3 MO
ERAXIS(WATER DILUENT) INTRAVENOUS
RECON SOLN 100 MG
4 MO
ERAXIS(WATER DILUENT) INTRAVENOUS
RECON SOLN 50 MG
3 MO
fluconazole in nacl (iso-osm) intravenous
piggyback 200 mg/100 ml
1 MO
fluconazole in nacl (iso-osm) intravenous
piggyback 400 mg/200 ml
1
fluconazole oral suspension for reconstitution 1 MO
fluconazole oral tablet 1 MO
flucytosine oral capsule 4 MO
griseofulvin microsize oral suspension 1 MO
griseofulvin microsize oral tablet 1 MO
griseofulvin ultramicrosize oral tablet 1 MO
itraconazole oral capsule 1 MO
itraconazole oral solution 1 MO
ketoconazole oral tablet 1 MO
MYCAMINE INTRAVENOUS RECON SOLN 4 MO
NOXAFIL ORAL SUSPENSION 4 MO
NOXAFIL ORAL TABLET,DELAYED
RELEASE (DR/EC)
4 MO
nystatin oral suspension 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
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Drug Name Drug Tier Requirements/Limits
nystatin oral tablet 1 MO
ORAVIG MUCO-ADHESIVE BUCCAL
TABLET
3 MO
posaconazole oral tablet,delayed release (dr/ec) 4 MO
SPORANOX ORAL CAPSULE 3 MO
SPORANOX ORAL SOLUTION 2 MO
terbinafine hcl oral tablet 1 MO
TOLSURA ORAL CAPSULE, SOLID
DISPERSION
4 MO
VFEND IV INTRAVENOUS RECON SOLN 3 MO
VFEND ORAL SUSPENSION FOR
RECONSTITUTION
4 MO
VFEND ORAL TABLET 4 MO
voriconazole intravenous recon soln 1 MO
voriconazole oral suspension for reconstitution 4 MO
voriconazole oral tablet 4 MO
ANTIVIRALS
abacavir oral solution 1 MO
abacavir oral tablet 1 MO
abacavir-lamivudine oral tablet 4 MO
abacavir-lamivudine-zidovudine oral tablet 4 MO
acyclovir oral capsule 1 MO
acyclovir oral suspension 200 mg/5 ml 1 MO
acyclovir oral tablet 1 MO
acyclovir sodium intravenous solution 3 B/D PA; MO
adefovir oral tablet 4 MO
amantadine hcl oral capsule 1 MO
amantadine hcl oral solution 1 MO
amantadine hcl oral tablet 1 MO
APTIVUS ORAL CAPSULE 4 MO
APTIVUS ORAL SOLUTION 4
atazanavir oral capsule 150 mg, 200 mg 1 MO
atazanavir oral capsule 300 mg 4 MO
ATRIPLA ORAL TABLET 4 MO
BARACLUDE ORAL SOLUTION 4 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
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Drug Name Drug Tier Requirements/Limits
BARACLUDE ORAL TABLET 4 MO
BIKTARVY ORAL TABLET 4 MO
CIMDUO ORAL TABLET 4 MO
COMBIVIR ORAL TABLET 4 MO
COMPLERA ORAL TABLET 4 MO
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 2 MO
DELSTRIGO ORAL TABLET 4 MO
DESCOVY ORAL TABLET 4 MO
didanosine oral capsule,delayed release(dr/ec)
200 mg
1
didanosine oral capsule,delayed release(dr/ec)
250 mg, 400 mg
1 MO
DOVATO ORAL TABLET 4 MO
EDURANT ORAL TABLET 4 MO
efavirenz oral capsule 200 mg 4 MO
efavirenz oral capsule 50 mg 1 MO
efavirenz oral tablet 4 MO
EMTRIVA ORAL CAPSULE 2 MO
EMTRIVA ORAL SOLUTION 2 MO
entecavir oral tablet 4 MO
EPCLUSA ORAL TABLET 4 PA; MO; QL (28 per 28 days)
EPIVIR HBV ORAL SOLUTION 2 MO
EPIVIR HBV ORAL TABLET 3 MO
EPIVIR ORAL SOLUTION 3 MO
EPIVIR ORAL TABLET 3 MO
EPZICOM ORAL TABLET 4 MO
EVOTAZ ORAL TABLET 4 MO
famciclovir oral tablet 1 MO
FLUMADINE ORAL TABLET 3 MO
fosamprenavir oral tablet 4 MO
FUZEON SUBCUTANEOUS RECON SOLN 4 MO
GENVOYA ORAL TABLET 4 MO
HARVONI ORAL TABLET 90-400 MG 4 PA; MO; QL (28 per 28 days)
HEPSERA ORAL TABLET 4 MO
INTELENCE ORAL TABLET 100 MG, 200 MG 4 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
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Drug Name Drug Tier Requirements/Limits
INTELENCE ORAL TABLET 25 MG 2 MO
INVIRASE ORAL TABLET 4 MO
ISENTRESS HD ORAL TABLET 4 MO
ISENTRESS ORAL POWDER IN PACKET 4 MO
ISENTRESS ORAL TABLET 4 MO
ISENTRESS ORAL TABLET,CHEWABLE 100
MG
4 MO
ISENTRESS ORAL TABLET,CHEWABLE 25
MG
2 MO
JULUCA ORAL TABLET 4 MO
KALETRA ORAL SOLUTION 4 MO
KALETRA ORAL TABLET 100-25 MG 2 MO
KALETRA ORAL TABLET 200-50 MG 4 MO
lamivudine oral solution 1 MO
lamivudine oral tablet 1 MO
lamivudine-zidovudine oral tablet 1 MO
LEDIPASVIR-SOFOSBUVIR ORAL TABLET 4 PA; MO; QL (28 per 28 days)
LEXIVA ORAL SUSPENSION 2 MO
LEXIVA ORAL TABLET 4 MO
lopinavir-ritonavir oral solution 1 MO
MAVYRET ORAL TABLET 4 PA; MO; QL (84 per 28 days)
nevirapine oral suspension 1
nevirapine oral tablet 1 MO
nevirapine oral tablet extended release 24 hr 1 MO
NORVIR ORAL POWDER IN PACKET 2 MO
NORVIR ORAL SOLUTION 2 MO
NORVIR ORAL TABLET 3 MO
ODEFSEY ORAL TABLET 4 MO
oseltamivir oral capsule 1 MO
oseltamivir oral suspension for reconstitution 1 MO
PIFELTRO ORAL TABLET 4 MO
PREVYMIS ORAL TABLET 4 MO; QL (30 per 30 days)
PREZCOBIX ORAL TABLET 4 MO
PREZISTA ORAL SUSPENSION 4 MO
PREZISTA ORAL TABLET 150 MG, 75 MG 2 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
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Drug Name Drug Tier Requirements/Limits
PREZISTA ORAL TABLET 600 MG, 800 MG 4 MO
RELENZA DISKHALER INHALATION
BLISTER WITH DEVICE
2 MO
RESCRIPTOR ORAL TABLET 2 MO
RETROVIR ORAL CAPSULE 3 MO
RETROVIR ORAL SYRUP 3 MO
REYATAZ ORAL CAPSULE 150 MG, 200 MG,
300 MG
4 MO
REYATAZ ORAL POWDER IN PACKET 4 MO
ribavirin oral capsule 1 MO
ribavirin oral tablet 200 mg 1 MO
rimantadine oral tablet 1 MO
ritonavir oral tablet 1 MO
SELZENTRY ORAL SOLUTION 2 MO
SELZENTRY ORAL TABLET 2 MO
SITAVIG MUCO-ADHESIVE BUCCAL
TABLET
3 MO
SOFOSBUVIR-VELPATASVIR ORAL TABLET 4 PA; MO; QL (28 per 28 days)
SOVALDI ORAL TABLET 400 MG 4 PA; MO; QL (28 per 28 days)
stavudine oral capsule 1 MO
STRIBILD ORAL TABLET 4 MO
SUSTIVA ORAL CAPSULE 200 MG 4 MO
SUSTIVA ORAL CAPSULE 50 MG 3 MO
SUSTIVA ORAL TABLET 4 MO
SYMFI LO ORAL TABLET 4 MO
SYMFI ORAL TABLET 4 MO
SYMTUZA ORAL TABLET 4 MO
TAMIFLU ORAL CAPSULE 3 MO
TAMIFLU ORAL SUSPENSION FOR
RECONSTITUTION
3 MO
TEMIXYS ORAL TABLET 4 MO
tenofovir disoproxil fumarate oral tablet 4 MO
TIVICAY ORAL TABLET 10 MG 2 MO
TIVICAY ORAL TABLET 25 MG, 50 MG 4 MO
TRIUMEQ ORAL TABLET 4 MO
TRIZIVIR ORAL TABLET 4 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
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Drug Name Drug Tier Requirements/Limits
TRUVADA ORAL TABLET 4 MO
TYBOST ORAL TABLET 3 MO
valacyclovir oral tablet 1 gram 1 MO; QL (120 per 30 days)
valacyclovir oral tablet 500 mg 1 MO; QL (60 per 30 days)
VALCYTE ORAL RECON SOLN 4 MO
VALCYTE ORAL TABLET 4 MO
valganciclovir oral recon soln 4 MO
valganciclovir oral tablet 4 MO
VALTREX ORAL TABLET 1 GRAM 3 MO; QL (120 per 30 days)
VALTREX ORAL TABLET 500 MG 3 MO; QL (60 per 30 days)
VEMLIDY ORAL TABLET 4 MO
VIDEX 2 GRAM PEDIATRIC ORAL RECON
SOLN
2 MO
VIDEX EC ORAL CAPSULE,DELAYED
RELEASE(DR/EC)
3 MO
VIEKIRA PAK ORAL TABLETS,DOSE PACK 4 PA; MO; QL (112 per 28 days)
VIRACEPT ORAL TABLET 4 MO
VIRAMUNE ORAL SUSPENSION 3 MO
VIRAMUNE ORAL TABLET 3 MO
VIRAMUNE XR ORAL TABLET EXTENDED
RELEASE 24 HR 400 MG
3 MO
VIREAD ORAL POWDER 4 MO
VIREAD ORAL TABLET 4 MO
VOSEVI ORAL TABLET 4 PA; MO; QL (28 per 28 days)
XOFLUZA ORAL TABLET 2 MO
ZEPATIER ORAL TABLET 4 PA; MO; QL (28 per 28 days)
ZIAGEN ORAL SOLUTION 3 MO
ZIAGEN ORAL TABLET 3 MO
zidovudine oral capsule 1 MO
zidovudine oral syrup 1 MO
zidovudine oral tablet 1 MO
ZOVIRAX ORAL CAPSULE 3 MO
ZOVIRAX ORAL SUSPENSION 3 MO
ZOVIRAX ORAL TABLET 800 MG 3 MO
CEPHALOSPORINS
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
8
Drug Name Drug Tier Requirements/Limits
AVYCAZ INTRAVENOUS RECON SOLN 4 MO
cefaclor oral capsule 1 MO
cefaclor oral suspension for reconstitution 125
mg/5 ml
1 MO
cefaclor oral suspension for reconstitution 250
mg/5 ml, 375 mg/5 ml
1
cefaclor oral tablet extended release 12 hr 1 MO
cefadroxil oral capsule 1 MO
cefadroxil oral suspension for reconstitution 250
mg/5 ml, 500 mg/5 ml
1 MO
cefadroxil oral tablet 1 MO
cefazolin injection recon soln 1 gram, 500 mg 1 MO
cefazolin injection recon soln 10 gram 1
cefdinir oral capsule 1 MO
cefdinir oral suspension for reconstitution 1 MO
cefepime injection recon soln 1 MO
cefixime oral capsule 1 MO
cefixime oral suspension for reconstitution 1 MO
cefotaxime injection recon soln 1 gram, 500 mg 1
cefotetan injection recon soln 1
cefoxitin intravenous recon soln 1 gram, 2 gram 1 MO
cefoxitin intravenous recon soln 10 gram 1
cefpodoxime oral suspension for reconstitution 1 MO
cefpodoxime oral tablet 1 MO
cefprozil oral suspension for reconstitution 1 MO
cefprozil oral tablet 1 MO
ceftazidime injection recon soln 1 gram, 2 gram 1 MO
ceftazidime injection recon soln 6 gram 1
ceftriaxone injection recon soln 1 gram, 2 gram,
250 mg, 500 mg
1 MO
ceftriaxone injection recon soln 10 gram 1
cefuroxime axetil oral tablet 1 MO
cefuroxime sodium injection recon soln 750 mg 1 MO
cefuroxime sodium intravenous recon soln 1.5
gram
1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
9
Drug Name Drug Tier Requirements/Limits
cefuroxime sodium intravenous recon soln 7.5
gram
1
cephalexin oral capsule 1 MO
cephalexin oral suspension for reconstitution 1 MO
cephalexin oral tablet 1 MO
MAXIPIME INJECTION RECON SOLN 3 MO
SUPRAX ORAL CAPSULE 3 MO
SUPRAX ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML, 200 MG/5
ML
3 MO
SUPRAX ORAL SUSPENSION FOR
RECONSTITUTION 500 MG/5 ML
3
SUPRAX ORAL TABLET,CHEWABLE 3 MO
tazicef injection recon soln 1 gram 1
tazicef injection recon soln 2 gram, 6 gram 1 MO
TEFLARO INTRAVENOUS RECON SOLN 4 MO
ZERBAXA INTRAVENOUS RECON SOLN 4
ERYTHROMYCINS / OTHER MACROLIDES
azithromycin intravenous recon soln 1 MO
azithromycin oral packet 1 MO
azithromycin oral suspension for reconstitution 1 MO
azithromycin oral tablet 250 mg, 250 mg (6 pack),
500 mg, 600 mg
1 MO
azithromycin oral tablet 500 mg (3 pack) 1
clarithromycin oral suspension for reconstitution 1 MO
clarithromycin oral tablet 1 MO
clarithromycin oral tablet extended release 24 hr 1 MO
DIFICID ORAL TABLET 4 MO
e.e.s. 400 oral tablet 1 MO
E.E.S. GRANULES ORAL SUSPENSION FOR
RECONSTITUTION
3 MO
ERYPED 200 ORAL SUSPENSION FOR
RECONSTITUTION
3 MO
ERYPED 400 ORAL SUSPENSION FOR
RECONSTITUTION
3 MO
ery-tab oral tablet,delayed release (dr/ec) 250 mg,
333 mg
1 MO
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10
Drug Name Drug Tier Requirements/Limits
ERY-TAB ORAL TABLET,DELAYED
RELEASE (DR/EC) 500 MG
2 MO
erythrocin (as stearate) oral tablet 250 mg 1 MO
ERYTHROCIN INTRAVENOUS RECON SOLN
500 MG
2 MO
erythromycin ethylsuccinate oral suspension for
reconstitution
1 MO
erythromycin ethylsuccinate oral tablet 1 MO
erythromycin oral capsule,delayed release(dr/ec) 1 MO
erythromycin oral tablet 1 MO
erythromycin oral tablet,delayed release (dr/ec) 1 MO
ZITHROMAX INTRAVENOUS RECON SOLN 3 MO
ZITHROMAX ORAL PACKET 3 MO
ZITHROMAX ORAL SUSPENSION FOR
RECONSTITUTION
3 MO
ZITHROMAX ORAL TABLET 250 MG, 500
MG
3 MO
ZITHROMAX TRI-PAK ORAL TABLET 3 MO
ZITHROMAX Z-PAK ORAL TABLET 3 MO
MISCELLANEOUS ANTIINFECTIVES
albendazole oral tablet 4 MO
ALBENZA ORAL TABLET 4 MO
ALINIA ORAL SUSPENSION FOR
RECONSTITUTION
2 MO
ALINIA ORAL TABLET 4 MO
amikacin injection solution 500 mg/2 ml 1 MO
ARIKAYCE INHALATION SUSPENSION FOR
NEBULIZATION
4 PA; MO; LA
atovaquone oral suspension 4 MO
atovaquone-proguanil oral tablet 1 MO
AZACTAM INJECTION RECON SOLN 3 MO
aztreonam injection recon soln 1 gram 1 MO
BENZNIDAZOLE ORAL TABLET 2
BETHKIS INHALATION SOLUTION FOR
NEBULIZATION
4 B/D PA; MO; QL (224 per 28 days)
BILTRICIDE ORAL TABLET 4 MO
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11
Drug Name Drug Tier Requirements/Limits
CAYSTON INHALATION SOLUTION FOR
NEBULIZATION
4 MO; LA; QL (84 per 28 days)
chloroquine phosphate oral tablet 1 MO
CLEOCIN HCL ORAL CAPSULE 3 MO
CLEOCIN IN 5 % DEXTROSE INTRAVENOUS
PIGGYBACK 300 MG/50 ML, 900 MG/50 ML
3
CLEOCIN IN 5 % DEXTROSE INTRAVENOUS
PIGGYBACK 600 MG/50 ML
3 MO
CLEOCIN INJECTION SOLUTION 3 MO
CLEOCIN PEDIATRIC ORAL RECON SOLN 3 MO
clindamycin hcl oral capsule 1 MO
clindamycin in 5 % dextrose intravenous
piggyback
1 MO
clindamycin palmitate hcl oral recon soln 1 MO
clindamycin phosphate injection solution 1 MO
clindamycin phosphate intravenous solution 600
mg/4 ml
1 MO
COARTEM ORAL TABLET 2 MO
colistin (colistimethate na) injection recon soln 1 MO
CUBICIN INTRAVENOUS RECON SOLN 4 MO
DALVANCE INTRAVENOUS SOLUTION 3 MO
dapsone oral tablet 1 MO
DAPTOMYCIN INTRAVENOUS RECON
SOLN 350 MG
2 MO
daptomycin intravenous recon soln 500 mg 4 MO
DARAPRIM ORAL TABLET 4 PA
EMVERM ORAL TABLET,CHEWABLE 4 MO
ertapenem injection recon soln 1 MO
ethambutol oral tablet 1 MO
FIRVANQ ORAL RECON SOLN 3 MO
FLAGYL ORAL CAPSULE 3 MO
FLAGYL ORAL TABLET 3 MO
gentamicin in nacl (iso-osm) intravenous
piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/50
ml
1 MO
gentamicin in nacl (iso-osm) intravenous
piggyback 80 mg/100 ml
1
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
12
Drug Name Drug Tier Requirements/Limits
gentamicin injection solution 40 mg/ml 1 MO
hydroxychloroquine oral tablet 1 MO
imipenem-cilastatin intravenous recon soln 1 MO
INVANZ INJECTION RECON SOLN 3 MO
isoniazid oral solution 1 MO
isoniazid oral tablet 1 MO
ivermectin oral tablet 1 MO
KITABIS PAK INHALATION SOLUTION FOR
NEBULIZATION
4 MO
KRINTAFEL ORAL TABLET 3 MO
linezolid in dextrose 5% intravenous piggyback 4
linezolid oral suspension for reconstitution 4 MO
linezolid oral tablet 4 MO
MALARONE ORAL TABLET 3 MO
MALARONE PEDIATRIC ORAL TABLET 3 MO
mefloquine oral tablet 1 MO
MEPRON ORAL SUSPENSION 4 MO
meropenem intravenous recon soln 1 MO
MERREM INTRAVENOUS RECON SOLN 500
MG
3
metronidazole in nacl (iso-osm) intravenous
piggyback
1 MO
metronidazole oral capsule 1 MO
metronidazole oral tablet 1 MO
MYAMBUTOL ORAL TABLET 400 MG 3 MO
MYCOBUTIN ORAL CAPSULE 3 MO
NEBUPENT INHALATION RECON SOLN 2 B/D PA; MO; QL (1 per 28 days)
neomycin oral tablet 1 MO
paromomycin oral capsule 3 MO
PASER ORAL GRANULES DR FOR SUSP IN
PACKET
2 MO
PENTAM INJECTION RECON SOLN 3 MO
PLAQUENIL ORAL TABLET 3 MO
polymyxin b sulfate injection recon soln 1 MO
praziquantel oral tablet 1 MO
PRIFTIN ORAL TABLET 2 MO
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13
Drug Name Drug Tier Requirements/Limits
PRIMAQUINE ORAL TABLET 2 MO
PRIMAXIN IV INTRAVENOUS RECON SOLN
500 MG
3 MO
pyrazinamide oral tablet 1 MO
QUALAQUIN ORAL CAPSULE 3 MO
quinine sulfate oral capsule 1 MO
rifabutin oral capsule 1 MO
RIFADIN ORAL CAPSULE 150 MG 3 MO
RIFAMATE ORAL CAPSULE 3 MO
rifampin intravenous recon soln 1 MO
rifampin oral capsule 1 MO
RIFATER ORAL TABLET 3 MO
SIRTURO ORAL TABLET 4 MO; LA
SIVEXTRO INTRAVENOUS RECON SOLN 4
SIVEXTRO ORAL TABLET 4 MO
SOLOSEC ORAL GRANULES DEL RELEASE
IN PACKET
3 MO
STREPTOMYCIN INTRAMUSCULAR RECON
SOLN
2 MO
STROMECTOL ORAL TABLET 3 MO
tigecycline intravenous recon soln 4
tinidazole oral tablet 1 MO
TOBI INHALATION SOLUTION FOR
NEBULIZATION
4 B/D PA; MO; QL (280 per 28 days)
TOBI PODHALER INHALATION CAPSULE,
W/INHALATION DEVICE
4 MO; QL (224 per 28 days)
tobramycin in 0.225 % nacl inhalation solution for
nebulization
4 B/D PA; MO; QL (280 per 28 days)
tobramycin sulfate injection solution 1 MO
TRECATOR ORAL TABLET 2 MO
TYGACIL INTRAVENOUS RECON SOLN 4 MO
VABOMERE INTRAVENOUS RECON SOLN 3
VANCOCIN ORAL CAPSULE 4 MO
vancomycin intravenous recon soln 1,000 mg, 10
gram, 500 mg, 750 mg
1 MO
VANCOMYCIN INTRAVENOUS RECON
SOLN 250 MG
3
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14
Drug Name Drug Tier Requirements/Limits
vancomycin oral capsule 125 mg 1 MO
vancomycin oral capsule 250 mg 4 MO
vancomycin oral recon soln 1
XENLETA ORAL TABLET 4
XIFAXAN ORAL TABLET 200 MG 4 MO; QL (9 per 30 days)
XIFAXAN ORAL TABLET 550 MG 4 MO; QL (90 per 30 days)
ZYVOX INTRAVENOUS PIGGYBACK 600
MG/300 ML
4 MO
ZYVOX ORAL SUSPENSION FOR
RECONSTITUTION
4 MO
ZYVOX ORAL TABLET 4 MO
PENICILLINS
amoxicillin oral capsule 1 MO
amoxicillin oral suspension for reconstitution 1 MO
amoxicillin oral tablet 1 MO
amoxicillin oral tablet,chewable 125 mg, 250 mg 1 MO
amoxicillin-pot clavulanate oral suspension for
reconstitution
1 MO
amoxicillin-pot clavulanate oral tablet 1 MO
amoxicillin-pot clavulanate oral tablet extended
release 12 hr
1 MO
amoxicillin-pot clavulanate oral tablet,chewable 1 MO
ampicillin oral capsule 500 mg 1 MO
ampicillin sodium injection recon soln 1 gram, 10
gram, 125 mg
1 MO
ampicillin-sulbactam injection recon soln 1.5
gram, 3 gram
1 MO
ampicillin-sulbactam injection recon soln 15 gram 1
AUGMENTIN ORAL SUSPENSION FOR
RECONSTITUTION 125-31.25 MG/5 ML
2 MO
BICILLIN C-R INTRAMUSCULAR SYRINGE 2 MO
BICILLIN L-A INTRAMUSCULAR SYRINGE 2 MO
dicloxacillin oral capsule 1 MO
nafcillin injection recon soln 1 gram, 2 gram 1 MO
nafcillin injection recon soln 10 gram 4 MO
oxacillin in dextrose (iso-osm) intravenous
piggyback 1 gram/50 ml
1
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15
Drug Name Drug Tier Requirements/Limits
oxacillin in dextrose (iso-osm) intravenous
piggyback 2 gram/50 ml
1 MO
oxacillin injection recon soln 1 gram 1
oxacillin injection recon soln 10 gram 4
oxacillin injection recon soln 2 gram 1 MO
PENICILLIN G POT IN DEXTROSE
INTRAVENOUS PIGGYBACK 2 MILLION
UNIT/50 ML
2
PENICILLIN G POT IN DEXTROSE
INTRAVENOUS PIGGYBACK 3 MILLION
UNIT/50 ML
2 MO
penicillin g potassium injection recon soln 20
million unit
1 MO
penicillin g procaine intramuscular syringe 1.2
million unit/2 ml
1 MO
penicillin g sodium injection recon soln 1 MO
penicillin v potassium oral recon soln 1 MO
penicillin v potassium oral tablet 1 MO
piperacillin-tazobactam intravenous recon soln
2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram
1 MO
UNASYN INJECTION RECON SOLN 15
GRAM
3
UNASYN INJECTION RECON SOLN 3 GRAM 3 MO
ZOSYN IN DEXTROSE (ISO-OSM)
INTRAVENOUS PIGGYBACK 2.25 GRAM/50
ML
3
ZOSYN IN DEXTROSE (ISO-OSM)
INTRAVENOUS PIGGYBACK 3.375 GRAM/50
ML
3 MO
ZOSYN INTRAVENOUS RECON SOLN 40.5
GRAM
3 MO
QUINOLONES
BAXDELA INTRAVENOUS RECON SOLN 4
BAXDELA ORAL TABLET 4 MO
CIPRO ORAL SUSPENSION,MICROCAPSULE
RECON
3 MO
CIPRO ORAL TABLET 250 MG, 500 MG 3 MO
ciprofloxacin hcl oral tablet 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
16
Drug Name Drug Tier Requirements/Limits
ciprofloxacin in 5 % dextrose intravenous
piggyback 200 mg/100 ml
1 MO
ciprofloxacin oral suspension,microcapsule recon
500 mg/5 ml
1
LEVAQUIN ORAL TABLET 500 MG, 750 MG 3 MO
levofloxacin in d5w intravenous piggyback 500
mg/100 ml, 750 mg/150 ml
1 MO
levofloxacin intravenous solution 1 MO
levofloxacin oral solution 1 MO
levofloxacin oral tablet 1 MO
moxifloxacin oral tablet 1 MO
moxifloxacin-sod.chloride(iso) intravenous
piggyback
1
ofloxacin oral tablet 300 mg 1
ofloxacin oral tablet 400 mg 1 MO
SULFA'S / RELATED AGENTS
BACTRIM DS ORAL TABLET 3 MO
BACTRIM ORAL TABLET 3 MO
sulfadiazine oral tablet 3 MO
sulfamethoxazole-trimethoprim oral suspension 1 MO
sulfamethoxazole-trimethoprim oral tablet 1 MO
TETRACYCLINES
demeclocycline oral tablet 3 MO
DORYX MPC ORAL TABLET,DELAYED
RELEASE (DR/EC)
3 ST; MO
DORYX ORAL TABLET,DELAYED RELEASE
(DR/EC) 200 MG, 50 MG
3 ST; MO
doxy-100 intravenous recon soln 1 MO
doxycycline hyclate oral capsule 1 MO
doxycycline hyclate oral tablet 100 mg, 150 mg, 20
mg, 75 mg
1 MO
doxycycline hyclate oral tablet,delayed release
(dr/ec) 100 mg, 150 mg, 200 mg, 50 mg, 75 mg
1 MO
doxycycline monohydrate oral capsule 1 MO
doxycycline monohydrate oral suspension for
reconstitution
1 MO
doxycycline monohydrate oral tablet 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
17
Drug Name Drug Tier Requirements/Limits
MINOCIN ORAL CAPSULE 50 MG 3 ST; MO
minocycline oral capsule 1 MO
minocycline oral tablet 1 MO
minocycline oral tablet extended release 24 hr 105
mg, 80 mg
4 MO
minocycline oral tablet extended release 24 hr 115
mg, 135 mg, 45 mg, 65 mg, 90 mg
1 MO
MINOCYCLINE ORAL TABLET EXTENDED
RELEASE 24 HR 55 MG
4 ST; MO
MINOLIRA ER ORAL TABLET, IR - ER,
BIPHASIC 24HR
3 ST; MO
mondoxyne nl oral capsule 100 mg, 75 mg 1 MO
morgidox oral capsule 50 mg 1 MO
NUZYRA (7 DAY WITH LOAD DOSE) ORAL
TABLET
4 ST
NUZYRA (7 DAY) ORAL TABLET 4 ST
NUZYRA INTRAVENOUS RECON SOLN 4
NUZYRA ORAL TABLET 4 ST; MO
ORACEA ORAL CAPSULE, IR - DELAYED
RELEASE, BIPHASE
3 ST; MO
SOLODYN ORAL TABLET EXTENDED
RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65
MG, 80 MG
4 ST; MO
TARGADOX ORAL TABLET 3 ST; MO
tetracycline oral capsule 1 MO
VIBRAMYCIN ORAL CAPSULE 100 MG 3 ST; MO
VIBRAMYCIN ORAL SUSPENSION FOR
RECONSTITUTION
3 MO
VIBRAMYCIN ORAL SYRUP 2 MO
XIMINO ORAL CAPSULE,EXTENDED
RELEASE 24HR
3 ST; MO
URINARY TRACT AGENTS
FURADANTIN ORAL SUSPENSION 3
HIPREX ORAL TABLET 3 MO
MACROBID ORAL CAPSULE 3 MO
MACRODANTIN ORAL CAPSULE 3 MO
methenamine hippurate oral tablet 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
18
Drug Name Drug Tier Requirements/Limits
MONUROL ORAL PACKET 3 MO
nitrofurantoin macrocrystal oral capsule 1 MO
nitrofurantoin monohyd/m-cryst oral capsule 1 MO
nitrofurantoin oral suspension 1 MO
trimethoprim oral tablet 1 MO
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
leucovorin calcium oral tablet 1 MO
MESNEX ORAL TABLET 4 MO
XGEVA SUBCUTANEOUS SOLUTION 4 B/D PA; MO
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
abiraterone oral tablet 4 PA; MO; QL (120 per 30 days)
AFINITOR DISPERZ ORAL TABLET FOR
SUSPENSION
4 PA; MO
AFINITOR ORAL TABLET 4 PA; MO; QL (30 per 30 days)
ALECENSA ORAL CAPSULE 4 PA; MO; QL (240 per 30 days)
ALUNBRIG ORAL TABLET 180 MG, 90 MG 4 PA; MO; QL (30 per 30 days)
ALUNBRIG ORAL TABLET 30 MG 4 PA; MO; QL (60 per 30 days)
ALUNBRIG ORAL TABLETS,DOSE PACK 4 PA; MO; QL (30 per 30 days)
anastrozole oral tablet 1 MO
ARIMIDEX ORAL TABLET 3 MO
AROMASIN ORAL TABLET 3 MO
ASTAGRAF XL ORAL CAPSULE,EXTENDED
RELEASE 24HR
3 B/D PA; MO
AZASAN ORAL TABLET 3 B/D PA; MO
azathioprine oral tablet 1 B/D PA; MO
BALVERSA ORAL TABLET 4 PA; MO; LA
bexarotene oral capsule 4 PA; MO
bicalutamide oral tablet 1 MO
BOSULIF ORAL TABLET 100 MG 4 PA; MO; QL (90 per 30 days)
BOSULIF ORAL TABLET 400 MG, 500 MG 4 PA; MO; QL (30 per 30 days)
BRAFTOVI ORAL CAPSULE 75 MG 4 PA; MO; LA; QL (180 per 30 days)
CABOMETYX ORAL TABLET 4 PA; MO; LA
CALQUENCE ORAL CAPSULE 4 PA; MO; LA; QL (60 per 30 days)
CAPRELSA ORAL TABLET 100 MG 4 PA; LA; QL (60 per 30 days)
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19
Drug Name Drug Tier Requirements/Limits
CAPRELSA ORAL TABLET 300 MG 4 PA; MO; LA; QL (30 per 30 days)
CASODEX ORAL TABLET 3 MO
CELLCEPT ORAL CAPSULE 3 B/D PA; MO
CELLCEPT ORAL SUSPENSION FOR
RECONSTITUTION
4 B/D PA; MO
CELLCEPT ORAL TABLET 4 B/D PA; MO
COMETRIQ ORAL CAPSULE 4 PA; MO
COPIKTRA ORAL CAPSULE 4 PA; MO; LA
COTELLIC ORAL TABLET 4 PA; MO; LA; QL (63 per 28 days)
cyclophosphamide oral capsule 1 B/D PA; MO
cyclosporine modified oral capsule 1 B/D PA; MO
cyclosporine modified oral solution 1 B/D PA; MO
cyclosporine oral capsule 1 B/D PA; MO
DAURISMO ORAL TABLET 4 PA; MO
DROXIA ORAL CAPSULE 2 MO
ELIGARD (3 MONTH) SUBCUTANEOUS
SYRINGE
3 PA; MO
ELIGARD (4 MONTH) SUBCUTANEOUS
SYRINGE
3 PA; MO
ELIGARD (6 MONTH) SUBCUTANEOUS
SYRINGE
3 PA; MO
ELIGARD SUBCUTANEOUS SYRINGE 3 PA; MO
EMCYT ORAL CAPSULE 4 MO
ENVARSUS XR ORAL TABLET EXTENDED
RELEASE 24 HR
3 B/D PA; MO
ERIVEDGE ORAL CAPSULE 4 PA; MO; QL (30 per 30 days)
ERLEADA ORAL TABLET 4 PA; MO
erlotinib oral tablet 100 mg, 150 mg 4 PA; MO; QL (30 per 30 days)
erlotinib oral tablet 25 mg 4 PA; MO; QL (60 per 30 days)
exemestane oral tablet 1 MO
FARESTON ORAL TABLET 4 MO
FARYDAK ORAL CAPSULE 10 MG 4 PA; MO; QL (12 per 21 days)
FARYDAK ORAL CAPSULE 15 MG, 20 MG 4 PA; MO; QL (6 per 21 days)
FEMARA ORAL TABLET 3 MO
FIRMAGON KIT W DILUENT SYRINGE
SUBCUTANEOUS RECON SOLN 120 MG
4 B/D PA; MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
20
Drug Name Drug Tier Requirements/Limits
FIRMAGON KIT W DILUENT SYRINGE
SUBCUTANEOUS RECON SOLN 80 MG
2 B/D PA; MO
flutamide oral capsule 1 MO
gengraf oral capsule 100 mg, 25 mg 1 B/D PA; MO
gengraf oral solution 1 B/D PA; MO
GILOTRIF ORAL TABLET 4 PA; MO; QL (30 per 30 days)
GLEEVEC ORAL TABLET 100 MG 4 PA; MO; QL (180 per 30 days)
GLEEVEC ORAL TABLET 400 MG 4 PA; MO; QL (60 per 30 days)
GLEOSTINE ORAL CAPSULE 10 MG, 100 MG,
40 MG
2 MO
HYDREA ORAL CAPSULE 3 MO
hydroxyurea oral capsule 1 MO
IBRANCE ORAL CAPSULE 4 PA; MO; QL (21 per 28 days)
ICLUSIG ORAL TABLET 15 MG 4 PA; MO; QL (60 per 30 days)
ICLUSIG ORAL TABLET 45 MG 4 PA; MO; QL (30 per 30 days)
IDHIFA ORAL TABLET 4 PA; MO; LA; QL (30 per 30 days)
imatinib oral tablet 100 mg 4 PA; MO; QL (180 per 30 days)
imatinib oral tablet 400 mg 4 PA; MO; QL (60 per 30 days)
IMBRUVICA ORAL CAPSULE 140 MG 4 PA; MO; QL (120 per 30 days)
IMBRUVICA ORAL CAPSULE 70 MG 4 PA; MO; QL (30 per 30 days)
IMBRUVICA ORAL TABLET 4 PA; MO; QL (30 per 30 days)
IMURAN ORAL TABLET 3 B/D PA; MO
INLYTA ORAL TABLET 1 MG 4 PA; MO; QL (180 per 30 days)
INLYTA ORAL TABLET 5 MG 4 PA; MO; QL (120 per 30 days)
INREBIC ORAL CAPSULE 4 PA; MO; LA; QL (120 per 30 days)
IRESSA ORAL TABLET 4 PA; MO; QL (30 per 30 days)
JAKAFI ORAL TABLET 4 PA; MO; QL (60 per 30 days)
KISQALI FEMARA CO-PACK ORAL TABLET 4 PA; MO
KISQALI ORAL TABLET 4 PA; MO
LENVIMA ORAL CAPSULE 4 PA; MO
letrozole oral tablet 1 MO
LEUKERAN ORAL TABLET 2 MO
leuprolide subcutaneous kit 4 MO
LONSURF ORAL TABLET 4 PA; MO
LORBRENA ORAL TABLET 4 PA; MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
21
Drug Name Drug Tier Requirements/Limits
LUPRON DEPOT (3 MONTH)
INTRAMUSCULAR SYRINGE KIT
4 PA; MO
LUPRON DEPOT (4 MONTH)
INTRAMUSCULAR SYRINGE KIT
4 PA; MO
LUPRON DEPOT (6 MONTH)
INTRAMUSCULAR SYRINGE KIT
4 PA; MO
LUPRON DEPOT INTRAMUSCULAR
SYRINGE KIT
4 PA; MO
LYNPARZA ORAL TABLET 4 PA; MO; QL (120 per 30 days)
LYSODREN ORAL TABLET 2 MO
MATULANE ORAL CAPSULE 4 MO
megestrol oral suspension 400 mg/10 ml (40
mg/ml), 625 mg/5 ml
1 PA; MO
megestrol oral tablet 1 PA; MO
MEKINIST ORAL TABLET 0.5 MG 4 PA; MO; QL (90 per 30 days)
MEKINIST ORAL TABLET 2 MG 4 PA; MO; QL (30 per 30 days)
MEKTOVI ORAL TABLET 4 PA; MO; LA; QL (180 per 30 days)
mercaptopurine oral tablet 1 MO
methotrexate sodium (pf) injection solution 1 B/D PA; MO
methotrexate sodium injection solution 1 B/D PA; MO
methotrexate sodium oral tablet 1 B/D PA; MO
mycophenolate mofetil oral capsule 1 B/D PA; MO
mycophenolate mofetil oral suspension for
reconstitution
4 B/D PA; MO
mycophenolate mofetil oral tablet 1 B/D PA; MO
mycophenolate sodium oral tablet,delayed release
(dr/ec)
1 B/D PA; MO
MYFORTIC ORAL TABLET,DELAYED
RELEASE (DR/EC)
3 B/D PA; MO
NEORAL ORAL CAPSULE 3 B/D PA; MO
NEORAL ORAL SOLUTION 3 B/D PA; MO
NERLYNX ORAL TABLET 4 PA; MO; LA
NEXAVAR ORAL TABLET 4 PA; MO; LA; QL (120 per 30 days)
NILANDRON ORAL TABLET 4 MO
nilutamide oral tablet 4 MO
NINLARO ORAL CAPSULE 2.3 MG 4 PA; MO; QL (6 per 28 days)
NINLARO ORAL CAPSULE 3 MG 4 PA; MO; QL (4 per 28 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
22
Drug Name Drug Tier Requirements/Limits
NINLARO ORAL CAPSULE 4 MG 4 PA; MO; QL (3 per 28 days)
NUBEQA ORAL TABLET 4 PA; MO; LA
octreotide acetate injection solution 1,000 mcg/ml,
500 mcg/ml
4 MO
octreotide acetate injection solution 100 mcg/ml,
200 mcg/ml, 50 mcg/ml
1 MO
ODOMZO ORAL CAPSULE 4 PA; MO; LA; QL (30 per 30 days)
PIQRAY ORAL TABLET 4 PA; MO
POMALYST ORAL CAPSULE 4 PA; MO; LA
PROGRAF ORAL CAPSULE 0.5 MG, 1 MG 3 B/D PA; MO
PROGRAF ORAL CAPSULE 5 MG 4 B/D PA; MO
PROGRAF ORAL GRANULES IN PACKET 2 B/D PA; MO
PURIXAN ORAL SUSPENSION 4
RAPAMUNE ORAL SOLUTION 4 B/D PA; MO
RAPAMUNE ORAL TABLET 0.5 MG 3 B/D PA; MO
RAPAMUNE ORAL TABLET 1 MG, 2 MG 4 B/D PA; MO
REVLIMID ORAL CAPSULE 4 PA; MO; LA; QL (28 per 28 days)
ROZLYTREK ORAL CAPSULE 4 PA; MO
RUBRACA ORAL TABLET 4 PA; MO; LA; QL (120 per 30 days)
RYDAPT ORAL CAPSULE 4 PA; MO
SANDIMMUNE ORAL CAPSULE 3 B/D PA; MO
SANDIMMUNE ORAL SOLUTION 2 B/D PA; MO
SANDOSTATIN INJECTION SOLUTION 100
MCG/ML
4 MO
SANDOSTATIN INJECTION SOLUTION 50
MCG/ML, 500 MCG/ML
3 MO
SIGNIFOR SUBCUTANEOUS SOLUTION 4 MO
SIKLOS ORAL TABLET 4 MO
sirolimus oral solution 4 B/D PA; MO
sirolimus oral tablet 0.5 mg, 1 mg 1 B/D PA; MO
sirolimus oral tablet 2 mg 4 B/D PA; MO
SOLTAMOX ORAL SOLUTION 2 MO
SOMATULINE DEPOT SUBCUTANEOUS
SYRINGE
4 MO
SPRYCEL ORAL TABLET 100 MG, 140 MG, 50
MG, 80 MG
4 PA; MO; QL (30 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
23
Drug Name Drug Tier Requirements/Limits
SPRYCEL ORAL TABLET 20 MG 4 PA; MO; QL (90 per 30 days)
SPRYCEL ORAL TABLET 70 MG 4 PA; MO; QL (60 per 30 days)
STIVARGA ORAL TABLET 4 PA; MO; QL (84 per 28 days)
SUTENT ORAL CAPSULE 4 PA; MO; QL (30 per 30 days)
SYNRIBO SUBCUTANEOUS RECON SOLN 4 B/D PA; MO
TABLOID ORAL TABLET 2 MO
tacrolimus oral capsule 1 B/D PA; MO
TAFINLAR ORAL CAPSULE 4 PA; MO; QL (120 per 30 days)
TAGRISSO ORAL TABLET 4 PA; MO; LA; QL (30 per 30 days)
TALZENNA ORAL CAPSULE 4 PA; MO
tamoxifen oral tablet 1 MO
TARCEVA ORAL TABLET 100 MG, 150 MG 4 PA; MO; QL (30 per 30 days)
TARCEVA ORAL TABLET 25 MG 4 PA; MO; QL (60 per 30 days)
TARGRETIN ORAL CAPSULE 4 PA; MO
TARGRETIN TOPICAL GEL 4 PA; MO
TASIGNA ORAL CAPSULE 150 MG, 200 MG 4 PA; MO; QL (112 per 28 days)
TASIGNA ORAL CAPSULE 50 MG 4 PA; MO; QL (120 per 30 days)
THALOMID ORAL CAPSULE 4 PA; MO
TIBSOVO ORAL TABLET 4 PA; MO
toremifene oral tablet 4 MO
TRELSTAR INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION
4 B/D PA; MO
tretinoin (chemotherapy) oral capsule 4 MO
TREXALL ORAL TABLET 3 B/D PA; MO
TURALIO ORAL CAPSULE 4 PA; MO; LA
TYKERB ORAL TABLET 4 PA; MO; LA; QL (180 per 30 days)
VENCLEXTA ORAL TABLET 10 MG, 50 MG 2 PA; MO; LA
VENCLEXTA ORAL TABLET 100 MG 4 PA; MO; LA
VENCLEXTA STARTING PACK ORAL
TABLETS,DOSE PACK
4 PA; MO; LA; QL (42 per 180 days)
VERZENIO ORAL TABLET 4 PA; MO; LA; QL (60 per 30 days)
VITRAKVI ORAL CAPSULE 4 PA; MO; LA
VITRAKVI ORAL SOLUTION 4 PA; MO; LA
VIZIMPRO ORAL TABLET 4 PA; MO; QL (30 per 30 days)
VOTRIENT ORAL TABLET 4 PA; MO; QL (120 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
24
Drug Name Drug Tier Requirements/Limits
XALKORI ORAL CAPSULE 4 PA; MO; QL (60 per 30 days)
XATMEP ORAL SOLUTION 4 B/D PA; MO
XERMELO ORAL TABLET 4 PA; MO; LA; QL (90 per 30 days)
XOSPATA ORAL TABLET 4 PA; MO; LA
XPOVIO ORAL TABLET 4 PA; MO; LA
XTANDI ORAL CAPSULE 4 PA; MO; QL (120 per 30 days)
YONSA ORAL TABLET 4 PA; MO; QL (120 per 30 days)
ZEJULA ORAL CAPSULE 4 PA; MO; LA; QL (90 per 30 days)
ZELBORAF ORAL TABLET 4 PA; MO; QL (240 per 30 days)
ZOLINZA ORAL CAPSULE 4 MO
ZORTRESS ORAL TABLET 4 B/D PA; MO
ZYDELIG ORAL TABLET 4 PA; MO; QL (60 per 30 days)
ZYKADIA ORAL CAPSULE 4 PA; MO; QL (150 per 30 days)
ZYKADIA ORAL TABLET 4 PA; MO; QL (150 per 30 days)
ZYTIGA ORAL TABLET 250 MG 4 PA; MO; QL (120 per 30 days)
ZYTIGA ORAL TABLET 500 MG 4 PA; MO; QL (60 per 30 days)
AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
APTIOM ORAL TABLET 200 MG, 400 MG, 800
MG
3 MO
APTIOM ORAL TABLET 600 MG 4 MO
BANZEL ORAL SUSPENSION 4 MO
BANZEL ORAL TABLET 4 MO
BRIVIACT INTRAVENOUS SOLUTION 3
BRIVIACT ORAL SOLUTION 4 MO
BRIVIACT ORAL TABLET 4 MO
carbamazepine oral capsule, er multiphase 12 hr 1 MO
carbamazepine oral suspension 100 mg/5 ml 1 MO
carbamazepine oral tablet 1 MO
carbamazepine oral tablet extended release 12 hr 1 MO
carbamazepine oral tablet,chewable 1 MO
CARBATROL ORAL CAPSULE, ER
MULTIPHASE 12 HR
3 MO
CELONTIN ORAL CAPSULE 300 MG 2 MO
clobazam oral suspension 1 PA; MO; QL (480 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
25
Drug Name Drug Tier Requirements/Limits
clobazam oral tablet 1 PA; MO; QL (60 per 30 days)
clonazepam oral tablet 0.5 mg, 1 mg 1 PA; MO; QL (90 per 30 days)
clonazepam oral tablet 2 mg 1 PA; MO; QL (300 per 30 days)
clonazepam oral tablet,disintegrating 0.125 mg,
0.25 mg, 0.5 mg, 1 mg
1 PA; MO; QL (90 per 30 days)
clonazepam oral tablet,disintegrating 2 mg 1 PA; MO; QL (300 per 30 days)
DEPAKOTE ER ORAL TABLET EXTENDED
RELEASE 24 HR
3 MO
DEPAKOTE ORAL TABLET,DELAYED
RELEASE (DR/EC)
3 MO
DEPAKOTE SPRINKLES ORAL CAPSULE,
DELAYED REL SPRINKLE
3 MO
DIASTAT ACUDIAL RECTAL KIT 3 MO
DIASTAT RECTAL KIT 3 MO
DILANTIN 30 MG ORAL CAPSULE 2 MO
DILANTIN EXTENDED 100 MG ORAL
CAPSULE
3 MO
DILANTIN INFATABS 50 MG ORAL
TABLET,CHEWABLE
3 MO
DILANTIN-125 125 MG/5 ML ORAL
SUSPENSION
3 MO
divalproex oral capsule, delayed release sprinkle 1 MO
divalproex oral tablet extended release 24 hr 1 MO
divalproex oral tablet,delayed release (dr/ec) 1 MO
EPIDIOLEX ORAL SOLUTION 4 PA; MO; LA
epitol oral tablet 1 MO
EQUETRO ORAL CAPSULE, ER
MULTIPHASE 12 HR
3 MO
ethosuximide oral capsule 1 MO
ethosuximide oral solution 1 MO
felbamate oral suspension 4 MO
felbamate oral tablet 1 MO
FELBATOL ORAL SUSPENSION 4 MO
FELBATOL ORAL TABLET 4 MO
FYCOMPA ORAL SUSPENSION 4 MO
FYCOMPA ORAL TABLET 2 MO
gabapentin oral capsule 100 mg 1 PA; MO; QL (1080 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
26
Drug Name Drug Tier Requirements/Limits
gabapentin oral capsule 300 mg 1 PA; MO; QL (360 per 30 days)
gabapentin oral capsule 400 mg 1 PA; MO; QL (270 per 30 days)
gabapentin oral solution 250 mg/5 ml 1 PA; MO; QL (2160 per 30 days)
gabapentin oral tablet 600 mg 1 PA; MO; QL (180 per 30 days)
gabapentin oral tablet 800 mg 1 PA; MO; QL (120 per 30 days)
GABITRIL ORAL TABLET 3 MO
GRALISE 30-DAY STARTER PACK ORAL
TABLET EXTENDED RELEASE 24 HR
2 PA; QL (78 per 180 days)
GRALISE ORAL TABLET EXTENDED
RELEASE 24 HR 300 MG
2 PA; MO; QL (30 per 30 days)
GRALISE ORAL TABLET EXTENDED
RELEASE 24 HR 600 MG
2 PA; MO; QL (90 per 30 days)
KEPPRA ORAL SOLUTION 3 MO
KEPPRA ORAL TABLET 3 MO
KEPPRA XR ORAL TABLET EXTENDED
RELEASE 24 HR
3 MO
KLONOPIN ORAL TABLET 0.5 MG, 1 MG 3 PA; MO; QL (90 per 30 days)
KLONOPIN ORAL TABLET 2 MG 3 PA; MO; QL (300 per 30 days)
LAMICTAL ODT ORAL
TABLET,DISINTEGRATING
3 MO
LAMICTAL ORAL TABLET 3 MO
LAMICTAL ORAL TABLET, CHEWABLE
DISPERSIBLE 25 MG, 5 MG
3 MO
LAMICTAL STARTER (BLUE) KIT ORAL
TABLETS,DOSE PACK
3 MO
LAMICTAL STARTER (GREEN) KIT ORAL
TABLETS,DOSE PACK
3 MO
LAMICTAL STARTER (ORANGE) KIT ORAL
TABLETS,DOSE PACK
3 MO
LAMICTAL XR ORAL TABLET EXTENDED
RELEASE 24HR
3 MO
LAMICTAL XR STARTER (BLUE) ORAL
TABLET EXTENDED REL,DOSE PACK
3 MO
LAMICTAL XR STARTER (GREEN) ORAL
TABLET EXTENDED REL,DOSE PACK
3 MO
LAMICTAL XR STARTER (ORANGE) ORAL
TABLET EXTENDED REL,DOSE PACK
3 MO
lamotrigine oral tablet 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
27
Drug Name Drug Tier Requirements/Limits
lamotrigine oral tablet extended release 24hr 3 MO
lamotrigine oral tablet, chewable dispersible 1 MO
lamotrigine oral tablet,disintegrating 3 MO
lamotrigine oral tablets,dose pack 1 MO
levetiracetam oral solution 100 mg/ml 1 MO
levetiracetam oral tablet 1 MO
levetiracetam oral tablet extended release 24 hr 1 MO
LYRICA CR ORAL TABLET EXTENDED
RELEASE 24 HR 165 MG, 82.5 MG
3 PA; MO; QL (30 per 30 days)
LYRICA CR ORAL TABLET EXTENDED
RELEASE 24 HR 330 MG
3 PA; MO; QL (60 per 30 days)
LYRICA ORAL CAPSULE 100 MG, 150 MG,
200 MG, 25 MG, 50 MG, 75 MG
2 PA; MO; QL (90 per 30 days)
LYRICA ORAL CAPSULE 225 MG, 300 MG 2 PA; MO; QL (60 per 30 days)
LYRICA ORAL SOLUTION 2 PA; MO; QL (900 per 30 days)
MYSOLINE ORAL TABLET 4 MO
NEURONTIN ORAL CAPSULE 100 MG 3 PA; MO; QL (1080 per 30 days)
NEURONTIN ORAL CAPSULE 300 MG 3 PA; MO; QL (360 per 30 days)
NEURONTIN ORAL CAPSULE 400 MG 3 PA; MO; QL (270 per 30 days)
NEURONTIN ORAL SOLUTION 3 PA; MO; QL (2160 per 30 days)
NEURONTIN ORAL TABLET 600 MG 3 PA; MO; QL (180 per 30 days)
NEURONTIN ORAL TABLET 800 MG 3 PA; MO; QL (120 per 30 days)
ONFI ORAL SUSPENSION 4 PA; MO; QL (480 per 30 days)
ONFI ORAL TABLET 10 MG, 20 MG 4 PA; MO; QL (60 per 30 days)
oxcarbazepine oral suspension 1 MO
oxcarbazepine oral tablet 1 MO
OXTELLAR XR ORAL TABLET EXTENDED
RELEASE 24 HR
3 MO
PEGANONE ORAL TABLET 2 MO
phenobarbital oral elixir 1 PA; MO
phenobarbital oral tablet 1 PA; MO
PHENYTEK ORAL CAPSULE 3 MO
phenytoin oral suspension 125 mg/5 ml 1 MO
phenytoin oral tablet,chewable 1 MO
phenytoin sodium extended release oral capsule 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
28
Drug Name Drug Tier Requirements/Limits
pregabalin oral capsule 100 mg, 150 mg, 200 mg,
25 mg, 50 mg, 75 mg
1 PA; MO; QL (90 per 30 days)
pregabalin oral capsule 225 mg, 300 mg 1 PA; MO; QL (60 per 30 days)
pregabalin oral solution 1 PA; MO; QL (900 per 30 days)
primidone oral tablet 1 MO
QUDEXY XR ORAL CAPSULE,SPRINKLE,ER
24HR
3 PA; MO
roweepra oral tablet 1 MO
roweepra xr oral tablet extended release 24 hr 1 MO
SABRIL ORAL POWDER IN PACKET 4 MO; LA
SABRIL ORAL TABLET 4 MO; LA
SPRITAM ORAL TABLET FOR SUSPENSION 3 MO
SYMPAZAN ORAL FILM 10 MG, 20 MG 4 PA; MO; QL (60 per 30 days)
SYMPAZAN ORAL FILM 5 MG 3 PA; MO; QL (60 per 30 days)
TEGRETOL ORAL SUSPENSION 3 MO
TEGRETOL ORAL TABLET 3 MO
TEGRETOL XR ORAL TABLET EXTENDED
RELEASE 12 HR
3 MO
tiagabine oral tablet 3 MO
TOPAMAX ORAL CAPSULE, SPRINKLE 3 PA; MO
TOPAMAX ORAL TABLET 3 PA; MO
topiramate oral capsule, sprinkle 1 PA; MO
TOPIRAMATE ORAL
CAPSULE,SPRINKLE,ER 24HR
3 PA; MO
topiramate oral tablet 1 PA; MO
TRILEPTAL ORAL SUSPENSION 3 MO
TRILEPTAL ORAL TABLET 3 MO
TROKENDI XR ORAL CAPSULE,EXTENDED
RELEASE 24HR 100 MG, 25 MG, 50 MG
3 PA; MO
TROKENDI XR ORAL CAPSULE,EXTENDED
RELEASE 24HR 200 MG
4 PA; MO
valproic acid (as sodium salt) oral solution 250
mg/5 ml
1 MO
valproic acid oral capsule 1 MO
vigabatrin oral powder in packet 4 MO; LA
vigabatrin oral tablet 4 MO; LA
vigadrone oral powder in packet 4 MO; LA
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
29
Drug Name Drug Tier Requirements/Limits
VIMPAT ORAL SOLUTION 2 MO
VIMPAT ORAL TABLET 2 MO
ZARONTIN ORAL CAPSULE 3 MO
ZARONTIN ORAL SOLUTION 3 MO
ZONEGRAN ORAL CAPSULE 100 MG, 25 MG 3 PA; MO
zonisamide oral capsule 1 PA; MO
ANTIPARKINSONISM AGENTS
APOKYN SUBCUTANEOUS CARTRIDGE 4 MO; LA
AZILECT ORAL TABLET 3 MO
benztropine oral tablet 1 PA; MO
bromocriptine oral capsule 3 MO
bromocriptine oral tablet 3 MO
carbidopa oral tablet 1 MO
carbidopa-levodopa oral tablet 1 MO
carbidopa-levodopa oral tablet extended release 1 MO
carbidopa-levodopa oral tablet,disintegrating 1 MO
carbidopa-levodopa-entacapone oral tablet 3 MO
COMTAN ORAL TABLET 3 MO
DUOPA J-TUBE INTESTINAL PUMP
SUSPENSION
3 B/D PA; MO
entacapone oral tablet 1 MO
GOCOVRI ORAL CAPSULE,EXTENDED
RELEASE 24HR 137 MG
4 PA; MO; QL (60 per 30 days)
GOCOVRI ORAL CAPSULE,EXTENDED
RELEASE 24HR 68.5 MG
4 PA; MO; QL (30 per 30 days)
INBRIJA INHALATION CAPSULE,
W/INHALATION DEVICE
4 PA; MO
LODOSYN ORAL TABLET 3 MO
MIRAPEX ER ORAL TABLET EXTENDED
RELEASE 24 HR
3 MO
MIRAPEX ORAL TABLET 3 MO
NEUPRO TRANSDERMAL PATCH 24 HOUR 2 MO
NOURIANZ ORAL TABLET 4 MO; LA
OSMOLEX ER ORAL TABLET, IR - ER,
BIPHASIC 24HR
3 PA; MO
PARLODEL ORAL CAPSULE 3 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
30
Drug Name Drug Tier Requirements/Limits
PARLODEL ORAL TABLET 3 MO
pramipexole oral tablet 1 MO
pramipexole oral tablet extended release 24 hr 1 MO
rasagiline oral tablet 1 MO
REQUIP XL ORAL TABLET EXTENDED
RELEASE 24 HR 12 MG, 4 MG, 6 MG, 8 MG
3 MO
ropinirole oral tablet 1 MO
ropinirole oral tablet extended release 24 hr 1 MO
RYTARY ORAL CAPSULE, EXTENDED
RELEASE
3 MO
selegiline hcl oral capsule 1 MO
selegiline hcl oral tablet 1 MO
SINEMET CR ORAL TABLET EXTENDED
RELEASE
3 MO
SINEMET ORAL TABLET 3 MO
STALEVO 100 ORAL TABLET 3 MO
STALEVO 125 ORAL TABLET 3 MO
STALEVO 150 ORAL TABLET 3 MO
STALEVO 200 ORAL TABLET 3 MO
STALEVO 50 ORAL TABLET 3 MO
STALEVO 75 ORAL TABLET 3 MO
TASMAR ORAL TABLET 100 MG 4 MO
tolcapone oral tablet 4 MO
ZELAPAR ORAL TABLET,DISINTEGRATING 3 MO
MIGRAINE / CLUSTER HEADACHE THERAPY
AIMOVIG AUTOINJECTOR SUBCUTANEOUS
AUTO-INJECTOR 140 MG/ML
2 PA; MO; QL (1 per 30 days)
AIMOVIG AUTOINJECTOR SUBCUTANEOUS
AUTO-INJECTOR 70 MG/ML
2 PA; MO; QL (2 per 30 days)
AJOVY SUBCUTANEOUS SYRINGE 3 PA; MO; QL (1.5 per 30 days)
almotriptan malate oral tablet 12.5 mg 1 MO; QL (24 per 28 days)
almotriptan malate oral tablet 6.25 mg 1 MO; QL (18 per 28 days)
AMERGE ORAL TABLET 3 MO; QL (18 per 28 days)
CAFERGOT ORAL TABLET 3 MO
dihydroergotamine nasal spray,non-aerosol 1 MO; QL (8 per 28 days)
eletriptan oral tablet 1 MO; QL (18 per 28 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
31
Drug Name Drug Tier Requirements/Limits
EMGALITY SUBCUTANEOUS PEN
INJECTOR
2 PA; MO; QL (2 per 30 days)
EMGALITY SUBCUTANEOUS SYRINGE 120
MG/ML
2 PA; MO; QL (2 per 30 days)
EMGALITY SUBCUTANEOUS SYRINGE 300
MG/3 ML (100 MG/ML X 3)
4 PA; MO; QL (3 per 30 days)
ergotamine-caffeine oral tablet 1 MO
FROVA ORAL TABLET 3 MO; QL (27 per 28 days)
frovatriptan oral tablet 1 MO; QL (27 per 28 days)
IMITREX NASAL SPRAY,NON-AEROSOL 20
MG/ACTUATION
3 MO; QL (18 per 28 days)
IMITREX NASAL SPRAY,NON-AEROSOL 5
MG/ACTUATION
3 MO; QL (36 per 28 days)
IMITREX ORAL TABLET 3 MO; QL (18 per 28 days)
IMITREX STATDOSE SUBCUTANEOUS PEN
INJECTOR 4 MG/0.5 ML
3 MO; QL (8 per 28 days)
IMITREX STATDOSE REFILL
SUBCUTANEOUS CARTRIDGE 6 MG/0.5 ML
3 MO; QL (8 per 28 days)
IMITREX SUBCUTANEOUS SOLUTION 3 MO; QL (8 per 28 days)
MAXALT ORAL TABLET 10 MG 3 MO; QL (36 per 28 days)
MAXALT-MLT ORAL
TABLET,DISINTEGRATING 10 MG
3 MO; QL (36 per 28 days)
migergot rectal suppository 1 MO
MIGRANAL NASAL SPRAY,NON-AEROSOL 3 MO; QL (8 per 28 days)
naratriptan oral tablet 1 MO; QL (18 per 28 days)
ONZETRA XSAIL NASAL AEROSOL POWDR
BREATH ACTIVATED
3 MO; QL (32 per 28 days)
RELPAX ORAL TABLET 3 MO; QL (18 per 28 days)
rizatriptan oral tablet 1 MO; QL (36 per 28 days)
rizatriptan oral tablet,disintegrating 1 MO; QL (36 per 28 days)
sumatriptan nasal spray,non-aerosol 20
mg/actuation
1 MO; QL (18 per 28 days)
sumatriptan nasal spray,non-aerosol 5
mg/actuation
1 MO; QL (36 per 28 days)
sumatriptan succinate oral tablet 1 MO; QL (18 per 28 days)
sumatriptan succinate subcutaneous cartridge 1 MO; QL (8 per 28 days)
sumatriptan succinate subcutaneous pen injector 1 MO; QL (8 per 28 days)
sumatriptan succinate subcutaneous solution 1 MO; QL (8 per 28 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
32
Drug Name Drug Tier Requirements/Limits
sumatriptan succinate subcutaneous syringe 6
mg/0.5 ml
1 MO; QL (8 per 28 days)
sumatriptan-naproxen oral tablet 1 MO; QL (18 per 28 days)
TOSYMRA NASAL SPRAY,NON-AEROSOL 3
TREXIMET ORAL TABLET 85-500 MG 3 MO; QL (18 per 28 days)
ZEMBRACE SYMTOUCH SUBCUTANEOUS
PEN INJECTOR
4 MO; QL (8 per 28 days)
zolmitriptan oral tablet 1 MO; QL (18 per 28 days)
zolmitriptan oral tablet,disintegrating 1 MO; QL (18 per 28 days)
ZOMIG NASAL SPRAY,NON-AEROSOL 3 MO; QL (18 per 28 days)
ZOMIG ORAL TABLET 3 MO; QL (18 per 28 days)
ZOMIG ZMT ORAL
TABLET,DISINTEGRATING
3 MO; QL (18 per 28 days)
MISCELLANEOUS NEUROLOGICAL THERAPY
AMPYRA ORAL TABLET EXTENDED
RELEASE 12 HR
4 PA; MO; LA
ARICEPT ORAL TABLET 3 MO
AUBAGIO ORAL TABLET 4 PA; MO
AUSTEDO ORAL TABLET 12 MG, 9 MG 4 PA; MO; LA; QL (120 per 30 days)
AUSTEDO ORAL TABLET 6 MG 4 PA; MO; LA; QL (60 per 30 days)
COPAXONE SUBCUTANEOUS SYRINGE 20
MG/ML
4 PA; MO; QL (30 per 30 days)
COPAXONE SUBCUTANEOUS SYRINGE 40
MG/ML
4 PA; MO; QL (12 per 28 days)
dalfampridine oral tablet extended release 12 hr 4 PA; MO
donepezil oral tablet 10 mg, 5 mg 1 MO
donepezil oral tablet 23 mg 3 MO
donepezil oral tablet,disintegrating 1 MO
EXELON TRANSDERMAL PATCH 24 HOUR 3 MO
FIRDAPSE ORAL TABLET 4 PA; MO; LA
galantamine oral capsule, extended release pellets
24 hr
1 MO
galantamine oral solution 1 MO
galantamine oral tablet 1 MO
GILENYA ORAL CAPSULE 0.5 MG 4 PA; MO
glatiramer subcutaneous syringe 20 mg/ml 4 PA; MO; QL (30 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
33
Drug Name Drug Tier Requirements/Limits
glatiramer subcutaneous syringe 40 mg/ml 4 PA; MO; QL (12 per 28 days)
glatopa subcutaneous syringe 20 mg/ml 4 PA; MO; QL (30 per 30 days)
glatopa subcutaneous syringe 40 mg/ml 4 PA; MO; QL (12 per 28 days)
HORIZANT ORAL TABLET EXTENDED
RELEASE 300 MG
3 PA; MO; QL (30 per 30 days)
HORIZANT ORAL TABLET EXTENDED
RELEASE 600 MG
3 PA; MO; QL (60 per 30 days)
INGREZZA INITIATION PACK ORAL
CAPSULE,DOSE PACK
4 PA; MO; LA; QL (28 per 28 days)
INGREZZA ORAL CAPSULE 4 PA; MO; LA; QL (30 per 30 days)
KEVEYIS ORAL TABLET 4 PA; MO
MAVENCLAD (10 TABLET PACK) ORAL
TABLET
4 PA; MO; LA
MAVENCLAD (4 TABLET PACK) ORAL
TABLET
4 PA; MO; LA
MAVENCLAD (5 TABLET PACK) ORAL
TABLET
4 PA; MO; LA
MAVENCLAD (6 TABLET PACK) ORAL
TABLET
4 PA; MO; LA
MAVENCLAD (7 TABLET PACK) ORAL
TABLET
4 PA; MO; LA
MAVENCLAD (8 TABLET PACK) ORAL
TABLET
4 PA; MO; LA
MAVENCLAD (9 TABLET PACK) ORAL
TABLET
4 PA; MO; LA
MAYZENT ORAL TABLET 4 PA; MO
memantine oral capsule,sprinkle,er 24hr 1 PA; MO
memantine oral solution 1 PA; MO
memantine oral tablet 1 PA; MO
MEMANTINE ORAL TABLETS,DOSE PACK 3 PA; MO
NAMENDA ORAL TABLET 3 PA; MO
NAMENDA TITRATION PAK ORAL
TABLETS,DOSE PACK
3 PA; MO
NAMENDA XR ORAL CAP,SPRINKLE,ER
24HR DOSE PACK
3 PA; MO
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR
3 PA; MO
NAMZARIC ORAL CAP,SPRINKLE,ER 24HR
DOSE PACK
2 PA; MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
34
Drug Name Drug Tier Requirements/Limits
NAMZARIC ORAL CAPSULE,SPRINKLE,ER
24HR
2 PA; MO
NUEDEXTA ORAL CAPSULE 2 PA; MO
RAZADYNE ER ORAL CAPSULE,EXT REL.
PELLETS 24 HR
3 MO
RAZADYNE ORAL TABLET 3 MO
rivastigmine tartrate oral capsule 1 MO
rivastigmine transdermal patch 24 hour 1 MO
RUZURGI ORAL TABLET 4 PA; MO
TECFIDERA ORAL CAPSULE,DELAYED
RELEASE(DR/EC)
4 PA; MO; LA
TEGSEDI SUBCUTANEOUS SYRINGE 4 PA; MO; LA
tetrabenazine oral tablet 12.5 mg 4 PA; MO; QL (240 per 30 days)
tetrabenazine oral tablet 25 mg 4 PA; MO; QL (120 per 30 days)
XENAZINE ORAL TABLET 12.5 MG 4 PA; MO; LA; QL (240 per 30 days)
XENAZINE ORAL TABLET 25 MG 4 PA; MO; LA; QL (120 per 30 days)
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
baclofen oral tablet 10 mg, 20 mg 1 MO
BACLOFEN ORAL TABLET 5 MG 3 MO
cyclobenzaprine oral tablet 3 PA; MO
DANTRIUM ORAL CAPSULE 25 MG, 50 MG 3 MO
dantrolene oral capsule 1 MO
FEXMID ORAL TABLET 3 PA
MESTINON ORAL SYRUP 4 MO
MESTINON ORAL TABLET 4 MO
MESTINON TIMESPAN ORAL TABLET
EXTENDED RELEASE
4 MO
pyridostigmine bromide oral syrup 4 MO
PYRIDOSTIGMINE BROMIDE ORAL TABLET
30 MG
4 MO
pyridostigmine bromide oral tablet 60 mg 1 MO
pyridostigmine bromide oral tablet extended
release
1 MO
tizanidine oral capsule 1 MO
tizanidine oral tablet 1 MO
ZANAFLEX ORAL CAPSULE 3 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
35
Drug Name Drug Tier Requirements/Limits
ZANAFLEX ORAL TABLET 3 MO
NARCOTIC ANALGESICS
ABSTRAL SUBLINGUAL TABLET 4 PA; MO; QL (120 per 30 days)
acetaminophen-codeine oral solution 120-12 mg/5
ml
1 MO; QL (4500 per 30 days)
acetaminophen-codeine oral tablet 300-15 mg,
300-30 mg
1 MO; QL (360 per 30 days)
acetaminophen-codeine oral tablet 300-60 mg 1 MO; QL (180 per 30 days)
ACTIQ BUCCAL LOZENGE ON A HANDLE 4 PA; MO; QL (120 per 30 days)
ARYMO ER ORAL TABLET,ORAL
ONLY,EXTND RELEASE
3 PA; MO; QL (120 per 30 days)
BELBUCA BUCCAL FILM 3 PA; MO; QL (60 per 30 days)
buprenorphine hcl sublingual tablet 1 MO
buprenorphine transdermal patch weekly 10
mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour
1 PA; MO; QL (4 per 28 days)
BUPRENORPHINE TRANSDERMAL PATCH
WEEKLY 7.5 MCG/HOUR
3 PA; MO; QL (4 per 28 days)
BUTRANS TRANSDERMAL PATCH WEEKLY 3 PA; MO; QL (4 per 28 days)
codeine sulfate oral tablet 30 mg, 60 mg 1 MO; QL (180 per 30 days)
DILAUDID ORAL LIQUID 3 MO; QL (2400 per 30 days)
DILAUDID ORAL TABLET 3 MO; QL (180 per 30 days)
DOLOPHINE ORAL TABLET 10 MG 3 PA; MO; QL (120 per 30 days)
DOLOPHINE ORAL TABLET 5 MG 3 PA; MO; QL (240 per 30 days)
DURAGESIC TRANSDERMAL PATCH 72
HOUR 100 MCG/HR, 75 MCG/HR
4 PA; MO; QL (10 per 30 days)
DURAGESIC TRANSDERMAL PATCH 72
HOUR 12 MCG/HR, 25 MCG/HR, 50 MCG/HR
3 PA; MO; QL (10 per 30 days)
duramorph (pf) injection solution 0.5 mg/ml 1 MO; QL (4000 per 30 days)
duramorph (pf) injection solution 1 mg/ml 1 QL (2000 per 30 days)
dvorah oral tablet 1 QL (300 per 30 days)
EMBEDA ORAL CAPSULE,ORAL
ONLY,EXT.REL PELL 100-4 MG, 60-2.4 MG,
80-3.2 MG
4 PA; MO; QL (90 per 30 days)
EMBEDA ORAL CAPSULE,ORAL
ONLY,EXT.REL PELL 20-0.8 MG, 30-1.2 MG,
50-2 MG
3 PA; MO; QL (90 per 30 days)
endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325
mg
1 MO; QL (360 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
36
Drug Name Drug Tier Requirements/Limits
fentanyl citrate buccal lozenge on a handle 4 PA; MO; QL (120 per 30 days)
FENTANYL CITRATE BUCCAL TABLET,
EFFERVESCENT
4 PA; QL (120 per 30 days)
fentanyl transdermal patch 72 hour 100 mcg/hr,
12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr,
62.5 mcg/hour, 75 mcg/hr
1 PA; MO; QL (10 per 30 days)
fentanyl transdermal patch 72 hour 87.5 mcg/hour 4 PA; MO; QL (10 per 30 days)
FENTORA BUCCAL TABLET,
EFFERVESCENT
4 PA; MO; QL (120 per 30 days)
hydrocodone-acetaminophen oral solution 7.5-325
mg/15 ml
1 MO; QL (5550 per 30 days)
hydrocodone-acetaminophen oral tablet 10-300
mg, 5-300 mg, 7.5-300 mg
1 MO; QL (390 per 30 days)
hydrocodone-acetaminophen oral tablet 10-325
mg, 5-325 mg, 7.5-325 mg
1 MO; QL (360 per 30 days)
hydrocodone-ibuprofen oral tablet 10-200 mg, 5-
200 mg, 7.5-200 mg
1 MO; QL (50 per 30 days)
hydromorphone (pf) injection solution 10 (mg/ml)
(5 ml), 10 mg/ml
1 MO; QL (240 per 30 days)
hydromorphone injection syringe 2 mg/ml 1 QL (1200 per 30 days)
hydromorphone oral liquid 1 MO; QL (2400 per 30 days)
hydromorphone oral tablet 1 MO; QL (180 per 30 days)
hydromorphone oral tablet extended release 24 hr
12 mg, 8 mg
1 PA; MO; QL (60 per 30 days)
hydromorphone oral tablet extended release 24 hr
16 mg, 32 mg
4 PA; MO; QL (60 per 30 days)
HYSINGLA ER ORAL TABLET,ORAL
ONLY,EXT.REL.24 HR 100 MG, 120 MG, 80
MG
4 PA; MO; QL (60 per 30 days)
HYSINGLA ER ORAL TABLET,ORAL
ONLY,EXT.REL.24 HR 20 MG, 30 MG, 40 MG,
60 MG
3 PA; MO; QL (60 per 30 days)
ibuprofen-oxycodone oral tablet 1 MO; QL (28 per 30 days)
KADIAN ORAL CAPSULE,EXTEND.RELEASE
PELLETS 10 MG, 100 MG, 20 MG, 30 MG, 40
MG, 50 MG, 60 MG, 80 MG
3 PA; MO; QL (90 per 30 days)
KADIAN ORAL CAPSULE, EXTENDED
RELEASE PELLETS 200 MG
4 PA; MO; QL (90 per 30 days)
LAZANDA NASAL SPRAY,NON-AEROSOL
100 MCG/SPRAY
4 PA; MO; QL (45 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
37
Drug Name Drug Tier Requirements/Limits
LAZANDA NASAL SPRAY,NON-AEROSOL
300 MCG/SPRAY
4 PA; QL (23 per 30 days)
LAZANDA NASAL SPRAY,NON-AEROSOL
400 MCG/SPRAY
4 PA; MO; QL (30 per 30 days)
levorphanol tartrate oral tablet 2 mg 1 MO; QL (120 per 30 days)
LEVORPHANOL TARTRATE ORAL TABLET
3 MG
4 MO; QL (120 per 30 days)
lorcet (hydrocodone) oral tablet 1 MO; QL (360 per 30 days)
lorcet hd oral tablet 1 MO; QL (360 per 30 days)
lorcet plus oral tablet 7.5-325 mg 1 MO; QL (360 per 30 days)
methadone oral solution 10 mg/5 ml 1 PA; MO; QL (600 per 30 days)
methadone oral solution 5 mg/5 ml 1 PA; MO; QL (1200 per 30 days)
methadone oral tablet 10 mg 1 PA; MO; QL (120 per 30 days)
methadone oral tablet 5 mg 1 PA; MO; QL (240 per 30 days)
MORPHABOND ER ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 100 MG, 60 MG
4 PA; MO; QL (120 per 30 days)
MORPHABOND ER ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 15 MG, 30 MG
3 PA; MO; QL (120 per 30 days)
morphine concentrate oral solution 1 MO; QL (900 per 30 days)
morphine oral capsule, er multiphase 24 hr 1 PA; MO; QL (60 per 30 days)
morphine oral capsule, extended release pellets 1 PA; MO; QL (90 per 30 days)
morphine oral solution 1 MO; QL (900 per 30 days)
morphine oral tablet 1 MO; QL (180 per 30 days)
morphine oral tablet extended release 1 PA; MO; QL (120 per 30 days)
MS CONTIN ORAL TABLET EXTENDED
RELEASE 100 MG, 200 MG, 60 MG
4 PA; MO; QL (120 per 30 days)
MS CONTIN ORAL TABLET EXTENDED
RELEASE 15 MG, 30 MG
3 PA; MO; QL (120 per 30 days)
NORCO ORAL TABLET 3 MO; QL (360 per 30 days)
OPANA ORAL TABLET 10 MG 3 MO; QL (360 per 30 days)
OPANA ORAL TABLET 5 MG 3 MO; QL (180 per 30 days)
OXAYDO ORAL TABLET, ORAL ONLY 4 MO; QL (360 per 30 days)
oxycodone oral capsule 1 MO; QL (360 per 30 days)
oxycodone oral concentrate 1 MO; QL (180 per 30 days)
oxycodone oral solution 1 MO; QL (1200 per 30 days)
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg 1 MO; QL (180 per 30 days)
oxycodone oral tablet 5 mg 1 MO; QL (360 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
38
Drug Name Drug Tier Requirements/Limits
OXYCODONE ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 10 MG, 20 MG, 40 MG
3 PA; MO; QL (90 per 30 days)
OXYCODONE ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 15 MG, 30 MG, 60 MG
3 PA; QL (90 per 30 days)
OXYCODONE ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 80 MG
4 PA; MO; QL (60 per 30 days)
oxycodone-acetaminophen oral tablet 10-325 mg,
2.5-325 mg, 5-325 mg, 7.5-325 mg
1 MO; QL (360 per 30 days)
oxycodone-aspirin oral tablet 1 MO; QL (360 per 30 days)
OXYCONTIN ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG,
30 MG, 40 MG, 60 MG
2 PA; MO; QL (90 per 30 days)
OXYCONTIN ORAL TABLET, EXTENDED
RELEASE 12 HR 80 MG
4 PA; MO; QL (60 per 30 days)
oxymorphone oral tablet 10 mg 1 MO; QL (360 per 30 days)
oxymorphone oral tablet 5 mg 1 MO; QL (180 per 30 days)
oxymorphone oral tablet extended release 12 hr 1 PA; MO; QL (90 per 30 days)
PERCOCET ORAL TABLET 10-325 MG, 2.5-
325 MG, 5-325 MG, 7.5-325 MG
3 MO; QL (360 per 30 days)
PRIMLEV ORAL TABLET 3 MO; QL (390 per 30 days)
ROXICODONE ORAL TABLET 15 MG, 30 MG 3 MO; QL (180 per 30 days)
ROXICODONE ORAL TABLET 5 MG 3 QL (360 per 30 days)
SUBSYS SUBLINGUAL SPRAY,NON-
AEROSOL
4 PA; MO; QL (120 per 30 days)
TREZIX ORAL CAPSULE 320.5-30-16 MG 3 MO; QL (300 per 30 days)
TYLENOL-CODEINE #3 ORAL TABLET 3 MO; QL (360 per 30 days)
TYLENOL-CODEINE #4 ORAL TABLET 3 MO; QL (180 per 30 days)
vicodin es oral tablet 1 MO; QL (390 per 30 days)
vicodin hp oral tablet 1 MO; QL (390 per 30 days)
XTAMPZA ER ORAL
CAP,SPRINKL,ER12HR(DONT CRUSH)
3 PA; MO; QL (90 per 30 days)
ZOHYDRO ER CAPSULE, ORAL ONLY, ER
12HR
3 PA; MO; QL (90 per 30 days)
NON-NARCOTIC ANALGESICS
ARTHROTEC 50 ORAL
TABLET,IR,DELAYED REL,BIPHASIC
3 ST; MO
ARTHROTEC 75 ORAL
TABLET,IR,DELAYED REL,BIPHASIC
3 ST; MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
39
Drug Name Drug Tier Requirements/Limits
BUNAVAIL BUCCAL FILM 2.1-0.3 MG 3 MO; QL (30 per 30 days)
BUNAVAIL BUCCAL FILM 4.2-0.7 MG, 6.3-1
MG
3 MO; QL (60 per 30 days)
buprenorphine-naloxone sublingual film 12-3 mg 1 MO; QL (60 per 30 days)
buprenorphine-naloxone sublingual film 2-0.5 mg 1 MO; QL (360 per 30 days)
buprenorphine-naloxone sublingual film 4-1 mg,
8-2 mg
1 MO; QL (90 per 30 days)
buprenorphine-naloxone sublingual tablet 2-0.5
mg
1 MO; QL (360 per 30 days)
buprenorphine-naloxone sublingual tablet 8-2 mg 1 MO; QL (90 per 30 days)
butorphanol tartrate nasal spray,non-aerosol 1 MO; QL (10 per 28 days)
CAMBIA ORAL POWDER IN PACKET 3 ST; MO; QL (9 per 30 days)
CELEBREX ORAL CAPSULE 3 MO
celecoxib oral capsule 1 MO
CONZIP ORAL CAPSULE,ER BIPHASE 24 HR
17-83
3 PA; MO; QL (30 per 30 days)
CONZIP ORAL CAPSULE,ER BIPHASE 24 HR
25-75
3 PA; MO; QL (30 per 30 days)
DAYPRO ORAL TABLET 3 ST; MO
DICLOFENAC EPOLAMINE TRANSDERMAL
PATCH 12 HOUR
3 PA; MO; QL (60 per 30 days)
diclofenac potassium oral tablet 1 MO
diclofenac sodium oral tablet extended release 24
hr
1 MO
diclofenac sodium oral tablet,delayed release
(dr/ec)
1 MO
diclofenac sodium topical drops 1 MO; QL (300 per 28 days)
diclofenac sodium topical gel 1 % 1 MO; QL (1000 per 28 days)
diclofenac-misoprostol oral tablet, ir, delayed
release, biphasic
1 MO
diflunisal oral tablet 1 MO
DUEXIS ORAL TABLET 3 ST; MO
etodolac oral capsule 1 MO
etodolac oral tablet 1 MO
etodolac oral tablet extended release 24 hr 1 MO
EVZIO INJECTION AUTO-INJECTOR 2
MG/0.4 ML
3 MO; QL (0.8 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
40
Drug Name Drug Tier Requirements/Limits
FELDENE ORAL CAPSULE 3 ST; MO
FENOPROFEN ORAL CAPSULE 400 MG 3 ST; MO
fenoprofen oral tablet 1 MO
FLECTOR TRANSDERMAL PATCH 12 HOUR 3 PA; MO; QL (60 per 30 days)
flurbiprofen oral tablet 1 MO
ibu oral tablet 600 mg, 800 mg 1 MO
ibuprofen oral suspension 1 MO
ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 MO
INDOCIN RECTAL SUPPOSITORY 3 MO
ketoprofen oral capsule 25 mg 1 MO
ketoprofen oral capsule, extended release pellets
24 hr 200 mg
1 MO
LODINE ORAL TABLET 3 ST
LUCEMYRA ORAL TABLET 4 MO
meclofenamate oral capsule 1 MO
mefenamic acid oral capsule 1 MO
meloxicam oral tablet 15 mg 1 MO
meloxicam oral tablet 7.5 mg 1 MO; QL (30 per 30 days)
MOBIC ORAL TABLET 15 MG 3 ST; MO
MOBIC ORAL TABLET 7.5 MG 3 ST; MO; QL (30 per 30 days)
nabumetone oral tablet 1 MO
NALFON ORAL TABLET 3 ST
naloxone injection solution 1 MO
naloxone injection syringe 1 MO
naltrexone oral tablet 1 MO
NAPRELAN CR ORAL TABLET, ER
MULTIPHASE 24 HR
3 ST; MO
naproxen oral suspension 1 MO
naproxen oral tablet 1 MO
naproxen oral tablet,delayed release (dr/ec) 1 MO
naproxen sodium oral tablet 275 mg, 550 mg 1 MO
naproxen sodium oral tablet, er multiphase 24 hr 1 MO
NARCAN NASAL SPRAY,NON-AEROSOL 4
MG/ACTUATION
2 MO
NUCYNTA ER ORAL TABLET EXTENDED
RELEASE 12 HR
3 PA; MO; QL (60 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
41
Drug Name Drug Tier Requirements/Limits
NUCYNTA ORAL TABLET 100 MG 3 MO; QL (181 per 30 days)
NUCYNTA ORAL TABLET 50 MG 3 MO; QL (362 per 30 days)
NUCYNTA ORAL TABLET 75 MG 3 MO; QL (242 per 30 days)
oxaprozin oral tablet 1 MO
PENNSAID TOPICAL SOLUTION IN
METERED-DOSE PUMP
4 ST; MO; QL (224 per 28 days)
piroxicam oral capsule 1 MO
QMIIZ ODT ORAL
TABLET,DISINTEGRATING 15 MG
3 ST; MO
QMIIZ ODT ORAL
TABLET,DISINTEGRATING 7.5 MG
3 ST; MO; QL (30 per 30 days)
SPRIX NASAL SPRAY,NON-AEROSOL 3 ST
SUBOXONE SUBLINGUAL FILM 12-3 MG 2 MO; QL (60 per 30 days)
SUBOXONE SUBLINGUAL FILM 2-0.5 MG 2 MO; QL (360 per 30 days)
SUBOXONE SUBLINGUAL FILM 4-1 MG, 8-2
MG
2 MO; QL (90 per 30 days)
sulindac oral tablet 1 MO
TIVORBEX ORAL CAPSULE 3 ST; MO; QL (90 per 30 days)
tolmetin oral capsule 1 MO
tolmetin oral tablet 600 mg 1 MO
TRAMADOL ORAL CAPSULE,ER BIPHASE
24 HR 17-83
3 PA; MO; QL (30 per 30 days)
TRAMADOL ORAL CAPSULE,ER BIPHASE
24 HR 25-75 100 MG, 200 MG
3 PA; MO; QL (30 per 30 days)
tramadol oral tablet 1 MO; QL (240 per 30 days)
tramadol oral tablet extended release 24 hr 1 PA; MO; QL (30 per 30 days)
tramadol oral tablet, er multiphase 24 hr 1 PA; MO; QL (30 per 30 days)
tramadol-acetaminophen oral tablet 1 MO; QL (240 per 30 days)
ULTRACET ORAL TABLET 3 MO; QL (240 per 30 days)
ULTRAM ORAL TABLET 3 MO; QL (240 per 30 days)
VIMOVO ORAL TABLET,IR,DELAYED
REL,BIPHASIC
4 ST; MO
VIVITROL INTRAMUSCULAR SUSPENSION,
EXTENDED RELEASE RECON
4 MO
VIVLODEX ORAL CAPSULE 10 MG 3 ST; MO
VIVLODEX ORAL CAPSULE 5 MG 3 ST; MO; QL (30 per 30 days)
VOLTAREN TOPICAL GEL 3 ST; MO; QL (1000 per 28 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
42
Drug Name Drug Tier Requirements/Limits
ZIPSOR ORAL CAPSULE 3 ST; MO
ZORVOLEX ORAL CAPSULE 3 ST; MO
ZUBSOLV SUBLINGUAL TABLET 0.7-0.18
MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG,
5.7-1.4 MG
2 MO; QL (30 per 30 days)
ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG 2 MO; QL (60 per 30 days)
PSYCHOTHERAPEUTIC DRUGS
ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION, EXTENDED RELEASE RECON
4 MO
ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION, EXTENDED RELEASE
SYRINGE
4 MO
ABILIFY MYCITE ORAL TABLET WITH
SENSOR AND PATCH
4 MO; QL (30 per 30 days)
ABILIFY ORAL TABLET 4 MO; QL (30 per 30 days)
ADDERALL ORAL TABLET 20 MG, 5 MG, 7.5
MG
3 MO
ADDERALL XR ORAL CAPSULE,EXTENDED
RELEASE 24HR
3 MO
ADZENYS ER ORAL SUSPEN, IR - ER,
BIPHASIC 24HR
3 MO
ADZENYS XR-ODT ORAL
TABLET,DISINTEG ER BIPHASE 24H
3 MO
AMBIEN CR ORAL TABLET,EXT RELEASE
MULTIPHASE
3 ST; MO; QL (30 per 30 days)
AMBIEN ORAL TABLET 3 ST; MO; QL (30 per 30 days)
amitriptyline oral tablet 1 PA; MO
amoxapine oral tablet 1 PA; MO
amphetamine sulfate oral tablet 1 PA; MO
ANAFRANIL ORAL CAPSULE 3 PA; MO
APLENZIN ORAL TABLET EXTENDED
RELEASE 24 HR
3 MO; QL (30 per 30 days)
APTENSIO XR ORAL CAP,ER
SPRINKLE,BIPHASIC 40-60
3 MO
aripiprazole oral solution 4 MO
aripiprazole oral tablet 1 MO; QL (30 per 30 days)
aripiprazole oral tablet,disintegrating 4 MO; QL (60 per 30 days)
ARISTADA INITIO INTRAMUSCULAR
SUSPENSION,EXTENDED REL SYRING
4 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
43
Drug Name Drug Tier Requirements/Limits
ARISTADA INTRAMUSCULAR SUSPENSION,
EXTENDED RELEASE SYRINGE
4 MO
armodafinil oral tablet 3 PA; MO
ATIVAN ORAL TABLET 0.5 MG, 1 MG 3 PA; MO; QL (90 per 30 days)
ATIVAN ORAL TABLET 2 MG 3 PA; MO; QL (150 per 30 days)
atomoxetine oral capsule 1 MO
BELSOMRA ORAL TABLET 3 ST; MO; QL (30 per 30 days)
BRISDELLE ORAL CAPSULE 3 MO; QL (30 per 30 days)
bupropion hcl oral tablet 1 MO
bupropion hcl oral tablet extended release 24 hr
150 mg
1 MO; QL (90 per 30 days)
bupropion hcl oral tablet extended release 24 hr
300 mg
1 MO; QL (30 per 30 days)
BUPROPION HCL ORAL TABLET
EXTENDED RELEASE 24 HR 450 MG
3 MO; QL (30 per 30 days)
bupropion hcl oral tablet sustained-release 12 hr 1 MO; QL (60 per 30 days)
buspirone oral tablet 1 MO
CELEXA ORAL TABLET 3 MO; QL (30 per 30 days)
chlorpromazine oral tablet 1 MO
citalopram oral solution 1 MO
citalopram oral tablet 1 MO; QL (30 per 30 days)
clomipramine oral capsule 3 PA; MO
clonidine hcl oral tablet extended release 12 hr 1 MO
clorazepate dipotassium oral tablet 15 mg 1 PA; MO; QL (180 per 30 days)
clorazepate dipotassium oral tablet 3.75 mg 1 PA; MO; QL (90 per 30 days)
clorazepate dipotassium oral tablet 7.5 mg 1 PA; MO; QL (360 per 30 days)
clozapine oral tablet 1 MO
clozapine oral tablet,disintegrating 100 mg, 12.5
mg, 25 mg
1
CLOZAPINE ORAL
TABLET,DISINTEGRATING 150 MG, 200 MG
3
CLOZARIL ORAL TABLET 3
CONCERTA ORAL TABLET EXTENDED
RELEASE 24HR
3 MO
COTEMPLA XR-ODT ORAL
TABLET,DISINTEG ER BIPHASE 24H
3 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
44
Drug Name Drug Tier Requirements/Limits
CYMBALTA ORAL CAPSULE,DELAYED
RELEASE(DR/EC)
3 MO; QL (60 per 30 days)
DAYTRANA TRANSDERMAL PATCH 24
HOUR
3 MO
desipramine oral tablet 1 PA; MO
DESOXYN ORAL TABLET 3 PA; MO
DESVENLAFAXINE ORAL TABLET
EXTENDED RELEASE 24 HR 100 MG
3 MO; QL (120 per 30 days)
DESVENLAFAXINE ORAL TABLET
EXTENDED RELEASE 24 HR 50 MG
3 MO; QL (30 per 30 days)
desvenlafaxine succinate oral tablet extended
release 24 hr
1 MO; QL (30 per 30 days)
DEXEDRINE SPANSULE ORAL CAPSULE,
EXTENDED RELEASE
3 MO
dexmethylphenidate oral capsule,er biphasic 50-
50
1 MO
dexmethylphenidate oral tablet 1 MO
dextroamphetamine oral capsule, extended release 1 MO
dextroamphetamine oral tablet 1 MO
dextroamphetamine-amphetamine oral
capsule,extended release 24hr
1 MO
dextroamphetamine-amphetamine oral tablet 1 MO
diazepam intensol oral concentrate 1 PA; MO; QL (240 per 30 days)
diazepam oral solution 5 mg/5 ml (1 mg/ml) 1 PA; MO; QL (1200 per 30 days)
diazepam oral tablet 1 PA; MO; QL (120 per 30 days)
doxepin oral capsule 3 PA; MO
doxepin oral concentrate 3 PA; MO
duloxetine oral capsule,delayed release(dr/ec) 20
mg, 30 mg, 60 mg
1 MO; QL (60 per 30 days)
duloxetine oral capsule,delayed release(dr/ec) 40
mg
1 MO; QL (90 per 30 days)
DYANAVEL XR ORAL SUSPEN, IR - ER,
BIPHASIC 24HR
3 MO
EFFEXOR XR ORAL CAPSULE,EXTENDED
RELEASE 24HR 150 MG, 37.5 MG
3 MO; QL (30 per 30 days)
EFFEXOR XR ORAL CAPSULE,EXTENDED
RELEASE 24HR 75 MG
3 MO; QL (90 per 30 days)
EMSAM TRANSDERMAL PATCH 24 HOUR 4 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
45
Drug Name Drug Tier Requirements/Limits
ergoloid oral tablet 3 MO
escitalopram oxalate oral solution 1 MO
escitalopram oxalate oral tablet 1 MO; QL (30 per 30 days)
eszopiclone oral tablet 3 ST; MO; QL (30 per 30 days)
EVEKEO ODT ORAL
TABLET,DISINTEGRATING
3 PA; MO
EVEKEO ORAL TABLET 3 PA; MO
FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG 3 MO; QL (60 per 30 days)
FANAPT ORAL TABLET 10 MG, 12 MG, 6
MG, 8 MG
4 MO; QL (60 per 30 days)
FANAPT ORAL TABLETS,DOSE PACK 3 MO; QL (8 per 28 days)
FAZACLO ORAL TABLET,DISINTEGRATING
100 MG
4
FAZACLO ORAL TABLET,DISINTEGRATING
12.5 MG, 150 MG, 200 MG, 25 MG
3
FETZIMA ORAL CAPSULE, EXTENDED
RELEASE 24HR DOSE PACK
2 MO; QL (28 per 28 days)
FETZIMA ORAL CAPSULE,EXTENDED
RELEASE 24 HR
2 MO; QL (30 per 30 days)
fluoxetine oral capsule 10 mg 1 MO; QL (30 per 30 days)
fluoxetine oral capsule 20 mg 1 MO
fluoxetine oral capsule 40 mg 1 MO; QL (60 per 30 days)
fluoxetine oral capsule,delayed release(dr/ec) 1 MO; QL (4 per 28 days)
fluoxetine oral solution 1 MO
fluoxetine oral tablet 10 mg 1 MO; QL (30 per 30 days)
fluoxetine oral tablet 20 mg, 60 mg 1 MO
fluphenazine decanoate injection solution 1 MO
fluphenazine hcl injection solution 1 MO
fluphenazine hcl oral concentrate 1 MO
fluphenazine hcl oral elixir 1 MO
fluphenazine hcl oral tablet 1 MO
fluvoxamine oral capsule,extended release 24hr 3 MO; QL (60 per 30 days)
fluvoxamine oral tablet 100 mg 1 MO; QL (90 per 30 days)
fluvoxamine oral tablet 25 mg 1 MO; QL (30 per 30 days)
fluvoxamine oral tablet 50 mg 1 MO; QL (60 per 30 days)
FOCALIN ORAL TABLET 3 MO
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46
Drug Name Drug Tier Requirements/Limits
FOCALIN XR ORAL CAPSULE,ER BIPHASIC
50-50
3 MO
FORFIVO XL ORAL TABLET EXTENDED
RELEASE 24 HR
3 MO; QL (30 per 30 days)
GEODON INTRAMUSCULAR RECON SOLN 3 MO
GEODON ORAL CAPSULE 4 MO; QL (60 per 30 days)
guanidine oral tablet 1 MO
HALDOL DECANOATE INTRAMUSCULAR
SOLUTION
3 MO
HALDOL INJECTION SOLUTION 3 MO
haloperidol decanoate intramuscular solution 1 MO
haloperidol lactate injection solution 1 MO
haloperidol lactate intramuscular syringe 1
haloperidol lactate oral concentrate 1 MO
haloperidol oral tablet 1 MO
HETLIOZ ORAL CAPSULE 4 PA; MO; QL (30 per 30 days)
imipramine hcl oral tablet 3 PA; MO
imipramine pamoate oral capsule 3 PA; MO
INVEGA ORAL TABLET EXTENDED
RELEASE 24HR 1.5 MG, 3 MG, 9 MG
4 MO; QL (30 per 30 days)
INVEGA ORAL TABLET EXTENDED
RELEASE 24HR 6 MG
4 MO; QL (60 per 30 days)
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234
MG/1.5 ML, 78 MG/0.5 ML
4 MO
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 39 MG/0.25 ML
3 MO
INVEGA TRINZA INTRAMUSCULAR
SYRINGE
4 MO
KAPVAY ORAL TABLET EXTENDED
RELEASE 12 HR
3 MO
KHEDEZLA ORAL TABLET EXTENDED
RELEASE 24HR 100 MG
3 MO; QL (120 per 30 days)
KHEDEZLA ORAL TABLET EXTENDED
RELEASE 24HR 50 MG
3 MO; QL (30 per 30 days)
LATUDA ORAL TABLET 120 MG, 20 MG, 40
MG, 60 MG
4 MO; QL (30 per 30 days)
LATUDA ORAL TABLET 80 MG 4 MO; QL (60 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
47
Drug Name Drug Tier Requirements/Limits
LEXAPRO ORAL TABLET 3 MO; QL (30 per 30 days)
lithium carbonate oral capsule 1 MO
lithium carbonate oral tablet 1 MO
lithium carbonate oral tablet extended release 1 MO
lithium citrate oral solution 8 meq/5 ml 1 MO
LITHOBID ORAL TABLET EXTENDED
RELEASE
3 MO
lorazepam oral concentrate 1 PA; MO; QL (150 per 30 days)
lorazepam oral tablet 0.5 mg, 1 mg 1 PA; MO; QL (90 per 30 days)
lorazepam oral tablet 2 mg 1 PA; MO; QL (150 per 30 days)
loxapine succinate oral capsule 1 MO
LUNESTA ORAL TABLET 3 ST; MO; QL (30 per 30 days)
maprotiline oral tablet 1 MO
MARPLAN ORAL TABLET 2 MO
metadate oral tablet extended release 1 MO
methamphetamine oral tablet 1 PA; MO
METHYLIN ORAL SOLUTION 3 MO
methylphenidate hcl oral capsule, er biphasic 30-
70
1 MO
methylphenidate hcl oral capsule,er biphasic 50-
50
1 MO
methylphenidate hcl oral solution 1 MO
methylphenidate hcl oral tablet 1 MO
methylphenidate hcl oral tablet extended release 1 MO
methylphenidate hcl oral tablet extended release
24hr 18 mg, 27 mg, 36 mg, 54 mg
1 MO
METHYLPHENIDATE HCL ORAL TABLET
EXTENDED RELEASE 24HR 72 MG
3 MO
methylphenidate hcl oral tablet,chewable 1 MO
mirtazapine oral tablet 1 MO
mirtazapine oral tablet,disintegrating 1 MO
modafinil oral tablet 1 PA; MO
molindone oral tablet 1 MO
MYDAYIS ORAL CAPSULE, ER TRIPHASIC
24 HR
3 MO
NARDIL ORAL TABLET 3 MO
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48
Drug Name Drug Tier Requirements/Limits
nefazodone oral tablet 1 MO
NORPRAMIN ORAL TABLET 10 MG, 25 MG 3 PA; MO
nortriptyline oral capsule 1 PA; MO
nortriptyline oral solution 1 PA; MO
NUPLAZID ORAL CAPSULE 4 PA; MO
NUPLAZID ORAL TABLET 10 MG 4 PA; MO
NUVIGIL ORAL TABLET 3 PA; MO
olanzapine intramuscular recon soln 1 MO
olanzapine oral tablet 1 MO; QL (30 per 30 days)
olanzapine oral tablet,disintegrating 1 MO; QL (30 per 30 days)
olanzapine-fluoxetine oral capsule 1 MO
paliperidone oral tablet extended release 24hr 1.5
mg, 3 mg
1 MO; QL (30 per 30 days)
paliperidone oral tablet extended release 24hr 6
mg
1 MO; QL (60 per 30 days)
paliperidone oral tablet extended release 24hr 9
mg
4 MO; QL (30 per 30 days)
PAMELOR ORAL CAPSULE 3 PA; MO
PARNATE ORAL TABLET 3 MO
paroxetine hcl oral tablet 10 mg, 20 mg, 40 mg 1 MO; QL (30 per 30 days)
paroxetine hcl oral tablet 30 mg 1 MO; QL (60 per 30 days)
paroxetine hcl oral tablet extended release 24 hr 1 MO; QL (60 per 30 days)
paroxetine mesylate(menop.sym) oral capsule 1 MO; QL (30 per 30 days)
PAXIL CR ORAL TABLET EXTENDED
RELEASE 24 HR
3 MO; QL (60 per 30 days)
PAXIL ORAL SUSPENSION 3 MO
PAXIL ORAL TABLET 10 MG, 20 MG, 40 MG 3 MO; QL (30 per 30 days)
PAXIL ORAL TABLET 30 MG 3 MO; QL (60 per 30 days)
perphenazine oral tablet 1 MO
PERSERIS ABDOMINAL SUBCUTANEOUS
SUSPENSION,EXTEND REL SYR KIT
4 MO
PEXEVA ORAL TABLET 10 MG, 20 MG, 40
MG
3 MO; QL (30 per 30 days)
PEXEVA ORAL TABLET 30 MG 3 MO; QL (60 per 30 days)
phenelzine oral tablet 1 MO
pimozide oral tablet 1 MO
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49
Drug Name Drug Tier Requirements/Limits
PRISTIQ ORAL TABLET EXTENDED
RELEASE 24 HR
3 MO; QL (30 per 30 days)
procentra oral solution 1 MO
protriptyline oral tablet 1 MO
PROVIGIL ORAL TABLET 4 PA; MO
PROZAC ORAL CAPSULE 10 MG 3 MO; QL (30 per 30 days)
PROZAC ORAL CAPSULE 20 MG 3 MO
PROZAC ORAL CAPSULE 40 MG 3 MO; QL (60 per 30 days)
quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50
mg
1 MO; QL (90 per 30 days)
quetiapine oral tablet 300 mg, 400 mg 1 MO; QL (60 per 30 days)
quetiapine oral tablet extended release 24 hr 150
mg, 200 mg
1 MO; QL (30 per 30 days)
quetiapine oral tablet extended release 24 hr 300
mg, 400 mg, 50 mg
1 MO; QL (60 per 30 days)
QUILLICHEW ER ORAL TABLET,CHEW,IR-
ER.BIPHASIC24HR
3 MO
QUILLIVANT XR ORAL SUSPENSION,EXT
REL 24HR,RECON
3 MO
ramelteon oral tablet 1 MO; QL (30 per 30 days)
RELEXXII ORAL TABLET EXTENDED
RELEASE 24HR
3
REMERON ORAL TABLET 15 MG, 30 MG 3 MO
REMERON SOLTAB ORAL
TABLET,DISINTEGRATING
3 MO
REXULTI ORAL TABLET 4 MO; QL (30 per 30 days)
RISPERDAL CONSTA INTRAMUSCULAR
SYRINGE 12.5 MG/2 ML, 25 MG/2 ML
2 MO
RISPERDAL CONSTA INTRAMUSCULAR
SYRINGE 37.5 MG/2 ML, 50 MG/2 ML
4 MO
RISPERDAL ORAL SOLUTION 3 MO
RISPERDAL ORAL TABLET 0.5 MG, 1 MG, 2
MG, 3 MG
3 MO; QL (60 per 30 days)
RISPERDAL ORAL TABLET 4 MG 3 MO; QL (120 per 30 days)
risperidone oral solution 1 MO
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2
mg, 3 mg
1 MO; QL (60 per 30 days)
risperidone oral tablet 4 mg 1 MO; QL (120 per 30 days)
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50
Drug Name Drug Tier Requirements/Limits
risperidone oral tablet,disintegrating 0.25 mg, 0.5
mg, 1 mg, 2 mg, 3 mg
1 MO; QL (60 per 30 days)
risperidone oral tablet,disintegrating 4 mg 1 MO; QL (120 per 30 days)
RITALIN LA ORAL CAPSULE,ER BIPHASIC
50-50 10 MG, 20 MG, 30 MG, 40 MG
3 MO
RITALIN ORAL TABLET 3 MO
ROZEREM ORAL TABLET 2 MO; QL (30 per 30 days)
SAPHRIS SUBLINGUAL TABLET 2 MO; QL (60 per 30 days)
SARAFEM ORAL TABLET 10 MG, 20 MG 3 MO
SEROQUEL ORAL TABLET 100 MG, 200 MG,
25 MG, 50 MG
3 MO; QL (90 per 30 days)
SEROQUEL ORAL TABLET 300 MG, 400 MG 3 MO; QL (60 per 30 days)
SEROQUEL XR ORAL TABLET EXTENDED
RELEASE 24 HR 150 MG, 200 MG
3 MO; QL (30 per 30 days)
SEROQUEL XR ORAL TABLET EXTENDED
RELEASE 24 HR 300 MG, 400 MG, 50 MG
3 MO; QL (60 per 30 days)
sertraline oral concentrate 1 MO
sertraline oral tablet 100 mg, 50 mg 1 MO; QL (60 per 30 days)
sertraline oral tablet 25 mg 1 MO; QL (30 per 30 days)
SILENOR ORAL TABLET 3 MO; QL (30 per 30 days)
STRATTERA ORAL CAPSULE 3 MO
SUNOSI ORAL TABLET 3 PA; MO
SYMBYAX ORAL CAPSULE 12-50 MG, 3-25
MG, 6-25 MG, 6-50 MG
3 MO
thioridazine oral tablet 3 MO
thiothixene oral capsule 1 MO
TOFRANIL ORAL TABLET 3 PA; MO
TRANXENE T-TAB ORAL TABLET 7.5 MG 3 PA; MO; QL (360 per 30 days)
tranylcypromine oral tablet 3 MO
trazodone oral tablet 1 MO
trifluoperazine oral tablet 1 MO
trimipramine oral capsule 3 PA; MO
TRINTELLIX ORAL TABLET 2 MO; QL (30 per 30 days)
VALIUM ORAL TABLET 3 PA; MO; QL (120 per 30 days)
venlafaxine oral capsule,extended release 24hr
150 mg, 37.5 mg
1 MO; QL (30 per 30 days)
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51
Drug Name Drug Tier Requirements/Limits
venlafaxine oral capsule,extended release 24hr 75
mg
1 MO; QL (90 per 30 days)
venlafaxine oral tablet 1 MO; QL (90 per 30 days)
VENLAFAXINE ORAL TABLET EXTENDED
RELEASE 24HR
3 MO; QL (30 per 30 days)
VERSACLOZ ORAL SUSPENSION 4
VIIBRYD ORAL TABLET 2 MO; QL (30 per 30 days)
VIIBRYD ORAL TABLETS,DOSE PACK 10
MG (7)- 20 MG (23)
2 MO; QL (30 per 180 days)
VRAYLAR ORAL CAPSULE 4 MO; QL (30 per 30 days)
VRAYLAR ORAL CAPSULE,DOSE PACK 3 MO; QL (7 per 30 days)
VYVANSE ORAL CAPSULE 3 MO
VYVANSE ORAL TABLET,CHEWABLE 3 MO
WELLBUTRIN SR ORAL TABLET
SUSTAINED-RELEASE 12 HR
3 MO; QL (60 per 30 days)
WELLBUTRIN XL ORAL TABLET
EXTENDED RELEASE 24 HR 150 MG
3 MO; QL (90 per 30 days)
WELLBUTRIN XL ORAL TABLET
EXTENDED RELEASE 24 HR 300 MG
3 MO; QL (30 per 30 days)
XYREM ORAL SOLUTION 4 PA; MO; LA
zaleplon oral capsule 10 mg 3 ST; MO; QL (60 per 30 days)
zaleplon oral capsule 5 mg 3 ST; MO; QL (30 per 30 days)
zenzedi oral tablet 10 mg, 5 mg 1 MO
ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20
MG, 30 MG, 7.5 MG
3 MO
ziprasidone hcl oral capsule 1 MO; QL (60 per 30 days)
ZOLOFT ORAL TABLET 100 MG, 50 MG 3 MO; QL (60 per 30 days)
ZOLOFT ORAL TABLET 25 MG 3 MO; QL (30 per 30 days)
zolpidem oral tablet 1 ST; MO; QL (30 per 30 days)
zolpidem oral tablet, extended release multiphase 1 ST; MO; QL (30 per 30 days)
ZYPREXA INTRAMUSCULAR RECON SOLN 3 MO
ZYPREXA ORAL TABLET 10 MG, 2.5 MG, 5
MG, 7.5 MG
3 MO; QL (30 per 30 days)
ZYPREXA ORAL TABLET 15 MG, 20 MG 4 MO; QL (30 per 30 days)
ZYPREXA RELPREVV INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 210
MG
2 MO
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52
Drug Name Drug Tier Requirements/Limits
ZYPREXA ZYDIS ORAL
TABLET,DISINTEGRATING 10 MG, 5 MG
3 MO; QL (30 per 30 days)
ZYPREXA ZYDIS ORAL
TABLET,DISINTEGRATING 15 MG, 20 MG
4 MO; QL (30 per 30 days)
CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone oral tablet 1 MO
BETAPACE AF ORAL TABLET 3 MO
dofetilide oral capsule 1 MO
flecainide oral tablet 1 MO
mexiletine oral capsule 1 MO
MULTAQ ORAL TABLET 3 MO
pacerone oral tablet 100 mg, 200 mg, 400 mg 1 MO
propafenone oral capsule,extended release 12 hr 1 MO
propafenone oral tablet 1 MO
quinidine gluconate oral tablet extended release 1 MO
quinidine sulfate oral tablet 1 MO
RYTHMOL SR ORAL CAPSULE,EXTENDED
RELEASE 12 HR
3 MO
sorine oral tablet 120 mg, 160 mg, 80 mg 1 MO
sorine oral tablet 240 mg 1
sotalol af oral tablet 120 mg 1 MO
sotalol oral tablet 1 MO
SOTYLIZE ORAL SOLUTION 2 MO
TIKOSYN ORAL CAPSULE 3 MO
ANTIHYPERTENSIVE THERAPY
ACCUPRIL ORAL TABLET 3 MO
ACCURETIC ORAL TABLET 3 MO
acebutolol oral capsule 1 MO
ADALAT CC ORAL TABLET EXTENDED
RELEASE
3 MO
ALDACTAZIDE ORAL TABLET 3 MO
ALDACTONE ORAL TABLET 3 MO
aliskiren oral tablet 1 MO
ALTACE ORAL CAPSULE 3 MO
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53
Drug Name Drug Tier Requirements/Limits
amiloride oral tablet 1 MO
amiloride-hydrochlorothiazide oral tablet 1 MO
amlodipine oral tablet 1 MO
amlodipine-benazepril oral capsule 1 MO
amlodipine-olmesartan oral tablet 1 MO
amlodipine-valsartan oral tablet 1 MO
amlodipine-valsartan-hydrochlorothiazide oral
tablet
1 MO
ATACAND HCT ORAL TABLET 3 ST; MO
ATACAND ORAL TABLET 3 ST; MO
atenolol oral tablet 1 MO
atenolol-chlorthalidone oral tablet 1 MO
AVALIDE ORAL TABLET 3 ST; MO
AVAPRO ORAL TABLET 3 ST; MO
AZOR ORAL TABLET 3 ST; MO
benazepril oral tablet 1 MO
benazepril-hydrochlorothiazide oral tablet 1 MO
BENICAR HCT ORAL TABLET 3 ST; MO
BENICAR ORAL TABLET 3 ST; MO
betaxolol oral tablet 1 MO
BIDIL ORAL TABLET 2 MO
bisoprolol fumarate oral tablet 1 MO
bisoprolol-hydrochlorothiazide oral tablet 1 MO
bumetanide injection solution 1 MO
bumetanide oral tablet 1 MO
BYSTOLIC ORAL TABLET 2 MO
CALAN ORAL TABLET 120 MG 3 MO
CALAN SR ORAL TABLET EXTENDED
RELEASE 120 MG, 240 MG
3 MO
candesartan oral tablet 1 MO
candesartan-hydrochlorothiazide oral tablet 1 MO
captopril oral tablet 1 MO
captopril-hydrochlorothiazide oral tablet 1 MO
CARDIZEM CD ORAL CAPSULE,EXTENDED
RELEASE 24HR
3 MO
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54
Drug Name Drug Tier Requirements/Limits
CARDIZEM LA ORAL TABLET EXTENDED
RELEASE 24 HR
3 MO
CARDIZEM ORAL TABLET 120 MG, 30 MG,
60 MG
3 MO
CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG 3 ST; MO; QL (30 per 30 days)
CARDURA ORAL TABLET 8 MG 3 ST; MO; QL (60 per 30 days)
CARDURA XL ORAL TABLET EXTENDED
RELEASE 24HR
3 ST; MO; QL (30 per 30 days)
CAROSPIR ORAL SUSPENSION 3 MO
cartia xt oral capsule,extended release 24hr 1 MO
carvedilol oral tablet 1 MO
carvedilol phosphate oral capsule, er multiphase
24 hr
1 MO
CATAPRES ORAL TABLET 3 MO
CATAPRES-TTS-1 TRANSDERMAL PATCH
WEEKLY
3 MO; QL (4 per 28 days)
CATAPRES-TTS-2 TRANSDERMAL PATCH
WEEKLY
3 MO; QL (4 per 28 days)
CATAPRES-TTS-3 TRANSDERMAL PATCH
WEEKLY
3 MO; QL (4 per 28 days)
chlorothiazide oral tablet 1 MO
chlorthalidone oral tablet 25 mg, 50 mg 1 MO
clonidine hcl oral tablet 1 MO
clonidine transdermal patch weekly 3 MO; QL (4 per 28 days)
COREG CR ORAL CAPSULE, ER
MULTIPHASE 24 HR
3 MO
COREG ORAL TABLET 3 MO
CORGARD ORAL TABLET 3 MO
COZAAR ORAL TABLET 3 ST; MO
DEMSER ORAL CAPSULE 4 PA; MO
DIBENZYLINE ORAL CAPSULE 4 PA; MO
diltiazem hcl oral capsule,extended release 12 hr 1 MO
diltiazem hcl oral capsule,extended release 24 hr
360 mg, 420 mg
1 MO
diltiazem hcl oral capsule,extended release 24hr
120 mg, 180 mg, 240 mg, 300 mg
1 MO
diltiazem hcl oral tablet 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
55
Drug Name Drug Tier Requirements/Limits
dilt-xr oral capsule, extended release 24h
degradable
1 MO
DIOVAN HCT ORAL TABLET 3 ST; MO
DIOVAN ORAL TABLET 3 ST; MO
DIURIL ORAL SUSPENSION 3 MO
doxazosin oral tablet 1 mg, 2 mg, 4 mg 1 MO; QL (30 per 30 days)
doxazosin oral tablet 8 mg 1 MO; QL (60 per 30 days)
DUTOPROL ORAL TABLET EXTENDED
RELEASE 24 HR
3 MO
DYAZIDE ORAL CAPSULE 3 MO
DYRENIUM ORAL CAPSULE 3 MO
EDARBI ORAL TABLET 2 MO
EDARBYCLOR ORAL TABLET 2 MO
EDECRIN ORAL TABLET 4 MO
enalapril maleate oral tablet 1 MO
enalapril-hydrochlorothiazide oral tablet 1 MO
eplerenone oral tablet 1 MO
eprosartan oral tablet 1 MO
ethacrynic acid oral tablet 4 MO
EXFORGE HCT ORAL TABLET 3 ST; MO
EXFORGE ORAL TABLET 3 ST; MO
felodipine oral tablet extended release 24 hr 1 MO
fosinopril oral tablet 1 MO
fosinopril-hydrochlorothiazide oral tablet 1 MO
furosemide injection solution 1 MO
furosemide injection syringe 1 MO
furosemide oral solution 10 mg/ml, 40 mg/5 ml (8
mg/ml)
1 MO
furosemide oral tablet 1 MO
hydralazine oral tablet 1 MO
hydrochlorothiazide oral capsule 1 MO
hydrochlorothiazide oral tablet 1 MO
HYZAAR ORAL TABLET 3 ST; MO
indapamide oral tablet 1 MO
INDERAL LA ORAL CAPSULE,EXTENDED
RELEASE 24 HR
3 MO
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56
Drug Name Drug Tier Requirements/Limits
INNOPRAN XL ORAL CAPSULE,EXTENDED
RELEASE 24HR
3 MO
INSPRA ORAL TABLET 3 MO
irbesartan oral tablet 1 MO
irbesartan-hydrochlorothiazide oral tablet 1 MO
isradipine oral capsule 1 MO
KAPSPARGO SPRINKLE ORAL
CAPSULE,SPRINKLE,ER 24HR
3 MO
labetalol oral tablet 1 MO
LASIX ORAL TABLET 3 MO
lisinopril oral tablet 1 MO
lisinopril-hydrochlorothiazide oral tablet 1 MO
LOPRESSOR HCT ORAL TABLET 3
LOPRESSOR ORAL TABLET 100 MG 3 MO
losartan oral tablet 1 MO
losartan-hydrochlorothiazide oral tablet 1 MO
LOTENSIN ORAL TABLET 10 MG, 20 MG, 40
MG
3 MO
LOTREL ORAL CAPSULE 10-20 MG, 10-40
MG, 5-10 MG, 5-20 MG
3 MO
matzim la oral tablet extended release 24 hr 1 MO
MAXZIDE ORAL TABLET 3 MO
MAXZIDE-25MG ORAL TABLET 3 MO
methyldopa oral tablet 1 MO
metolazone oral tablet 1 MO
metoprolol succinate oral tablet extended release
24 hr
1 MO
metoprolol tartrate oral tablet 100 mg, 25 mg, 50
mg
1 MO
metoprolol tartrate-hydrochlorothiazide oral
tablet
1 MO
MICARDIS HCT ORAL TABLET 3 ST; MO
MICARDIS ORAL TABLET 3 ST; MO
MINIPRESS ORAL CAPSULE 3 MO
minoxidil oral tablet 1 MO
moexipril oral tablet 1 MO
nadolol oral tablet 1 MO
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57
Drug Name Drug Tier Requirements/Limits
nadolol-bendroflumethiazide oral tablet 40-5 mg 1
nicardipine oral capsule 1 MO
nifedipine oral tablet extended release 1 MO
nifedipine oral tablet extended release 24hr 1 MO
nimodipine oral capsule 1 MO
nisoldipine oral tablet extended release 24 hr 1 MO
NORVASC ORAL TABLET 3 MO
NYMALIZE ORAL SOLUTION 30 MG/10 ML 4
olmesartan oral tablet 1 MO
olmesartan-amlodipine-hydrochlorothiazide oral
tablet
1 MO
olmesartan-hydrochlorothiazide oral tablet 1 MO
ORENITRAM ORAL TABLET EXTENDED
RELEASE 0.125 MG
3 PA; MO
ORENITRAM ORAL TABLET EXTENDED
RELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG
4 PA; MO
perindopril erbumine oral tablet 1 MO
phenoxybenzamine oral capsule 4 PA; MO
pindolol oral tablet 1 MO
prazosin oral capsule 1 MO
PRINIVIL ORAL TABLET 10 MG, 20 MG, 5
MG
3 MO
PROCARDIA XL ORAL TABLET EXTENDED
RELEASE 24HR
3 MO
propranolol oral capsule,extended release 24 hr 1 MO
propranolol oral solution 1 MO
propranolol oral tablet 1 MO
propranolol-hydrochlorothiazide oral tablet 1 MO
QBRELIS ORAL SOLUTION 3 MO
quinapril oral tablet 1 MO
quinapril-hydrochlorothiazide oral tablet 1 MO
ramipril oral capsule 1 MO
spironolactone oral tablet 1 MO
spironolactone-hydrochlorothiazide oral tablet 1 MO
SULAR ORAL TABLET EXTENDED
RELEASE 24 HR 17 MG, 34 MG, 8.5 MG
3 MO
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58
Drug Name Drug Tier Requirements/Limits
TARKA ORAL TABLET, IR - ER, BIPHASIC
24HR 2-180 MG, 2-240 MG, 4-240 MG
3 MO
taztia xt oral capsule,extended release 24 hr 1 MO
TEKTURNA HCT ORAL TABLET 2 MO
TEKTURNA ORAL TABLET 2 MO
telmisartan oral tablet 1 MO
telmisartan-amlodipine oral tablet 1 MO
telmisartan-hydrochlorothiazide oral tablet 1 MO
TENORETIC 100 ORAL TABLET 3 MO
TENORETIC 50 ORAL TABLET 3 MO
TENORMIN ORAL TABLET 3 MO
terazosin oral capsule 1 mg, 2 mg, 5 mg 1 MO; QL (30 per 30 days)
terazosin oral capsule 10 mg 1 MO; QL (60 per 30 days)
TIAZAC ORAL CAPSULE,EXTENDED
RELEASE 24 HR
3 MO
timolol maleate oral tablet 1 MO
TOPROL XL ORAL TABLET EXTENDED
RELEASE 24 HR
3 MO
torsemide oral tablet 1 MO
trandolapril oral tablet 1 MO
trandolapril-verapamil oral tablet, ir - er, biphasic
24hr
1 MO
triamterene oral capsule 1 MO
triamterene-hydrochlorothiazide oral capsule
37.5-25 mg
1 MO
triamterene-hydrochlorothiazide oral tablet 1 MO
TRIBENZOR ORAL TABLET 3 ST; MO
TWYNSTA ORAL TABLET 40-10 MG, 40-5
MG, 80-5 MG
3 ST; MO
UPTRAVI ORAL TABLET 4 PA; MO; LA
UPTRAVI ORAL TABLETS,DOSE PACK 4 PA; MO; LA
valsartan oral tablet 1 MO
valsartan-hydrochlorothiazide oral tablet 1 MO
VASERETIC ORAL TABLET 3 MO
VASOTEC ORAL TABLET 3 MO
verapamil oral capsule, 24 hr er pellet ct 1 MO
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59
Drug Name Drug Tier Requirements/Limits
verapamil oral capsule,ext rel. pellets 24 hr 120
mg, 180 mg, 240 mg
1 MO
verapamil oral capsule,ext rel. pellets 24 hr 360
mg
1 MO
verapamil oral tablet 1 MO
verapamil oral tablet extended release 1 MO
VERELAN ORAL CAPSULE,EXT REL.
PELLETS 24 HR
3 MO
VERELAN PM ORAL CAPSULE, 24 HR ER
PELLET CT
3 MO
ZESTORETIC ORAL TABLET 3 MO
ZESTRIL ORAL TABLET 3 MO
ZIAC ORAL TABLET 3 MO
COAGULATION THERAPY
AGGRENOX ORAL CAPSULE, ER
MULTIPHASE 12 HR
3 MO
ARIXTRA SUBCUTANEOUS SYRINGE 10
MG/0.8 ML, 5 MG/0.4 ML, 7.5 MG/0.6 ML
4 MO
ARIXTRA SUBCUTANEOUS SYRINGE 2.5
MG/0.5 ML
3 MO
aspirin-dipyridamole oral capsule, er multiphase
12 hr
1 MO
BEVYXXA ORAL CAPSULE 3 MO
BRILINTA ORAL TABLET 2 MO
CABLIVI INJECTION KIT 4 PA; MO; LA
cilostazol oral tablet 1 MO
clopidogrel oral tablet 75 mg 1 MO
COUMADIN ORAL TABLET 3 MO
dipyridamole oral tablet 1 MO
DOPTELET (10 TAB PACK) ORAL TABLET 4 PA; MO; LA
DOPTELET (15 TAB PACK) ORAL TABLET 4 PA; MO; LA
DOPTELET (30 TAB PACK) ORAL TABLET 4 PA; MO; LA
EFFIENT ORAL TABLET 3 MO
ELIQUIS ORAL TABLET 2 MO
ELIQUIS ORAL TABLETS,DOSE PACK 2 MO
enoxaparin subcutaneous syringe 1 MO
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60
Drug Name Drug Tier Requirements/Limits
fondaparinux subcutaneous syringe 10 mg/0.8 ml,
5 mg/0.4 ml, 7.5 mg/0.6 ml
4 MO
fondaparinux subcutaneous syringe 2.5 mg/0.5 ml 1 MO
FRAGMIN SUBCUTANEOUS SOLUTION 4 MO
FRAGMIN SUBCUTANEOUS SYRINGE 10,000
ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5
ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000
ANTI-XA UNIT/0.72 ML, 7,500 ANTI-XA
UNIT/0.3 ML
4 MO
FRAGMIN SUBCUTANEOUS SYRINGE 2,500
ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA
UNIT/0.2 ML
3 MO
heparin (porcine) injection solution 1 MO
jantoven oral tablet 1 MO
LOVENOX SUBCUTANEOUS SYRINGE 3 MO
MULPLETA ORAL TABLET 4 PA; MO
pentoxifylline oral tablet extended release 1 MO
PLAVIX ORAL TABLET 75 MG 3 MO
PRADAXA ORAL CAPSULE 3 MO
prasugrel oral tablet 1 MO
PROMACTA ORAL POWDER IN PACKET 4 PA; MO; LA
PROMACTA ORAL TABLET 4 PA; MO; LA
SAVAYSA ORAL TABLET 3 MO
TAVALISSE ORAL TABLET 4 PA; MO; LA; QL (60 per 30 days)
warfarin oral tablet 1 MO
XARELTO ORAL TABLET 2 MO
XARELTO ORAL TABLETS,DOSE PACK 2 MO
YOSPRALA ORAL TABLET,IR,DELAYED
REL,BIPHASIC
3 MO
ZONTIVITY ORAL TABLET 2 MO
LIPID/CHOLESTEROL LOWERING AGENTS
ALTOPREV ORAL TABLET EXTENDED
RELEASE 24 HR
3 ST; MO; QL (30 per 30 days)
amlodipine-atorvastatin oral tablet 1 MO; QL (30 per 30 days)
ANTARA ORAL CAPSULE 30 MG, 90 MG 3 MO
atorvastatin oral tablet 1 MO; QL (30 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
61
Drug Name Drug Tier Requirements/Limits
CADUET ORAL TABLET 10-10 MG, 10-20 MG,
10-40 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40
MG, 5-80 MG
3 ST; MO; QL (30 per 30 days)
cholestyramine (with sugar) oral powder in packet 1 MO
cholestyramine light oral powder 1 MO
colesevelam oral powder in packet 1 MO
colesevelam oral tablet 1 MO
COLESTID ORAL PACKET 3 MO
COLESTID ORAL TABLET 3 MO
colestipol oral packet 1 MO
colestipol oral tablet 1 MO
CRESTOR ORAL TABLET 3 ST; MO; QL (30 per 30 days)
EZALLOR SPRINKLE ORAL CAPSULE 3 ST; MO; QL (30 per 30 days)
ezetimibe oral tablet 1 MO
ezetimibe-simvastatin oral tablet 1 MO; QL (30 per 30 days)
fenofibrate micronized oral capsule 1 MO
fenofibrate nanocrystallized oral tablet 145 mg, 48
mg
1 MO
FENOFIBRATE ORAL CAPSULE 3 MO
fenofibrate oral tablet 1 MO
fenofibric acid (choline) oral capsule,delayed
release(dr/ec)
1 MO
fenofibric acid oral tablet 1 MO
FENOGLIDE ORAL TABLET 3 MO
FIBRICOR ORAL TABLET 3 MO
FLOLIPID ORAL SUSPENSION 3 ST; MO; QL (300 per 30 days)
fluvastatin oral capsule 20 mg 1 MO; QL (30 per 30 days)
fluvastatin oral capsule 40 mg 1 MO; QL (60 per 30 days)
fluvastatin oral tablet extended release 24 hr 1 MO; QL (30 per 30 days)
gemfibrozil oral tablet 1 MO
JUXTAPID ORAL CAPSULE 4 PA; MO; LA
LESCOL XL ORAL TABLET EXTENDED
RELEASE 24 HR
3 ST; MO; QL (30 per 30 days)
LIPITOR ORAL TABLET 3 ST; MO; QL (30 per 30 days)
LIPOFEN ORAL CAPSULE 3 MO
LIVALO ORAL TABLET 2 MO; QL (30 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
62
Drug Name Drug Tier Requirements/Limits
LOPID ORAL TABLET 3 MO
lovastatin oral tablet 10 mg 1 MO; QL (30 per 30 days)
lovastatin oral tablet 20 mg, 40 mg 1 MO; QL (60 per 30 days)
LOVAZA ORAL CAPSULE 3 ST; MO
niacin oral tablet extended release 24 hr 1 MO
NIACOR ORAL TABLET 3 MO
NIASPAN EXTENDED-RELEASE ORAL
TABLET EXTENDED RELEASE 24 HR
3 MO
omega-3 acid ethyl esters oral capsule 3 ST; MO
PRALUENT SUBCUTANEOUS PEN
INJECTOR 150 MG/ML
4 PA; MO; QL (2 per 28 days)
PRALUENT SUBCUTANEOUS PEN
INJECTOR 75 MG/ML
4 PA; MO; QL (4 per 28 days)
PRAVACHOL ORAL TABLET 20 MG, 40 MG,
80 MG
3 ST; MO; QL (30 per 30 days)
pravastatin oral tablet 1 MO; QL (30 per 30 days)
prevalite oral powder in packet 1 MO
QUESTRAN LIGHT ORAL POWDER 3 MO
QUESTRAN ORAL POWDER IN PACKET 3 MO
REPATHA PUSHTRONEX SUBCUTANEOUS
WEARABLE INJECTOR
4 PA; MO; QL (3.5 per 28 days)
REPATHA SUBCUTANEOUS SYRINGE 4 PA; MO; QL (3 per 28 days)
REPATHA SURECLICK SUBCUTANEOUS
PEN INJECTOR
4 PA; MO; QL (3 per 28 days)
rosuvastatin oral tablet 1 MO; QL (30 per 30 days)
simvastatin oral tablet 1 MO; QL (30 per 30 days)
TRICOR ORAL TABLET 3 MO
TRIGLIDE ORAL TABLET 160 MG 3 MO
TRILIPIX ORAL CAPSULE,DELAYED
RELEASE(DR/EC)
3 MO
VASCEPA ORAL CAPSULE 2 MO
VYTORIN 10-10 ORAL TABLET 3 ST; MO; QL (30 per 30 days)
VYTORIN 10-20 ORAL TABLET 3 ST; MO; QL (30 per 30 days)
VYTORIN 10-40 ORAL TABLET 3 ST; MO; QL (30 per 30 days)
VYTORIN 10-80 ORAL TABLET 3 ST; MO; QL (30 per 30 days)
WELCHOL ORAL POWDER IN PACKET 3 MO
WELCHOL ORAL TABLET 3 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
63
Drug Name Drug Tier Requirements/Limits
ZETIA ORAL TABLET 3 MO
ZOCOR ORAL TABLET 10 MG, 20 MG, 40
MG, 80 MG
3 ST; MO; QL (30 per 30 days)
ZYPITAMAG ORAL TABLET 3 ST; MO; QL (30 per 30 days)
MISCELLANEOUS CARDIOVASCULAR AGENTS
CORLANOR ORAL SOLUTION 2 PA
CORLANOR ORAL TABLET 2 PA; MO
digitek oral tablet 1 MO
digox oral tablet 1 MO
digoxin oral solution 50 mcg/ml (0.05 mg/ml) 1 MO
digoxin oral tablet 1 MO
ENTRESTO ORAL TABLET 2 MO; QL (60 per 30 days)
LANOXIN ORAL TABLET 125 MCG (0.125
MG), 250 MCG (0.25 MG)
3 MO
LANOXIN ORAL TABLET 62.5 MCG (0.0625
MG)
2 MO
RANEXA ORAL TABLET EXTENDED
RELEASE 12 HR
2 MO
ranolazine oral tablet extended release 12 hr 1 MO
VECAMYL ORAL TABLET 4
VYNDAQEL ORAL CAPSULE 4 PA; MO
NITRATES
ISORDIL ORAL TABLET 3 MO
ISORDIL TITRADOSE ORAL TABLET 5 MG 3 MO
isosorbide dinitrate oral tablet 1 MO
isosorbide dinitrate oral tablet extended release 1
isosorbide mononitrate oral tablet 1 MO
isosorbide mononitrate oral tablet extended
release 24 hr
1 MO
MINITRAN TRANSDERMAL PATCH 24
HOUR
3 MO
nitro-bid transdermal ointment 1 MO
NITRO-DUR TRANSDERMAL PATCH 24
HOUR
3 MO
nitroglycerin sublingual tablet 1 MO
nitroglycerin transdermal patch 24 hour 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
64
Drug Name Drug Tier Requirements/Limits
nitroglycerin translingual spray,non-aerosol 1 MO
NITROSTAT SUBLINGUAL TABLET 3 MO
DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
acitretin oral capsule 10 mg 1 MO
acitretin oral capsule 17.5 mg, 25 mg 4 MO
calcipotriene scalp solution 1 MO; QL (120 per 30 days)
calcipotriene topical cream 3 MO; QL (120 per 30 days)
calcipotriene topical ointment 1 MO; QL (120 per 30 days)
calcipotriene-betamethasone topical ointment 1 MO; QL (400 per 30 days)
calcitriol topical ointment 3 MO
COSENTYX (2 SYRINGES) SUBCUTANEOUS
SYRINGE
4 PA; MO
COSENTYX (2 PENS) SUBCUTANEOUS PEN
INJECTOR
4 PA; MO
DOVONEX TOPICAL CREAM 3 MO; QL (120 per 30 days)
ENSTILAR TOPICAL FOAM 4 MO; QL (400 per 30 days)
ILUMYA SUBCUTANEOUS SYRINGE 4 PA; MO
selenium sulfide topical lotion 1 MO
SILIQ SUBCUTANEOUS SYRINGE 4 PA; MO
SKYRIZI SUBCUTANEOUS SYRINGE KIT 4 PA; MO; QL (1 per 28 days)
SORIATANE ORAL CAPSULE 10 MG, 25 MG 4 MO
SORILUX TOPICAL FOAM 3 MO; QL (120 per 30 days)
STELARA INTRAVENOUS SOLUTION 4 PA; MO
STELARA SUBCUTANEOUS SOLUTION 4 PA; MO
STELARA SUBCUTANEOUS SYRINGE 4 PA; MO
TACLONEX TOPICAL OINTMENT 3 MO; QL (400 per 30 days)
TACLONEX TOPICAL SUSPENSION 3 MO; QL (400 per 30 days)
TALTZ AUTOINJECTOR SUBCUTANEOUS
AUTO-INJECTOR
4 PA; MO
TALTZ SUBCUTANEOUS SYRINGE 4 PA; MO
TREMFYA SUBCUTANEOUS AUTO-
INJECTOR
4 PA; MO
TREMFYA SUBCUTANEOUS SYRINGE 4 PA; MO
VECTICAL TOPICAL OINTMENT 3 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
65
Drug Name Drug Tier Requirements/Limits
MISCELLANEOUS DERMATOLOGICALS
ALDARA TOPICAL CREAM IN PACKET 3 ST; MO
ammonium lactate topical cream 1 MO
ammonium lactate topical lotion 1 MO
CARAC TOPICAL CREAM 4 MO
CONDYLOX TOPICAL GEL 2 MO
diclofenac sodium topical gel 3 % 4 PA; MO; QL (100 per 28 days)
doxepin topical cream 4 MO; QL (45 per 30 days)
DUPIXENT SUBCUTANEOUS SYRINGE 4 PA; MO
EFUDEX TOPICAL CREAM 3 ST; MO
ELIDEL TOPICAL CREAM 3 PA; MO; QL (100 per 30 days)
EUCRISA TOPICAL OINTMENT 3 PA; MO; QL (120 per 30 days)
FLUOROURACIL TOPICAL CREAM 0.5 % 4 ST; MO
fluorouracil topical cream 5 % 1 MO
fluorouracil topical solution 1 MO
IMIQUIMOD TOPICAL CREAM IN
METERED-DOSE PUMP
4 ST; MO
imiquimod topical cream in packet 1 MO
lidocaine hcl mucous membrane jelly 1 MO; QL (60 per 30 days)
lidocaine hcl mucous membrane solution 4 % (40
mg/ml)
1 MO
lidocaine topical adhesive patch,medicated 1 PA; MO; QL (90 per 30 days)
lidocaine topical ointment 3 MO; QL (36 per 30 days)
lidocaine viscous mucous membrane solution 1 MO
lidocaine-prilocaine topical cream 1 MO; QL (30 per 30 days)
LIDODERM TOPICAL ADHESIVE
PATCH,MEDICATED
3 PA; MO; QL (90 per 30 days)
methoxsalen oral capsule, liquid-filled, rapid
release
4 MO
OXSORALEN ULTRA ORAL CAPSULE,LIQD-
FILLED,RAPID REL
4 MO
PANRETIN TOPICAL GEL 4 MO
PICATO TOPICAL GEL 4 MO
pimecrolimus topical cream 1 PA; MO; QL (100 per 30 days)
PLIAGLIS TOPICAL CREAM 3 MO
podofilox topical solution 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
66
Drug Name Drug Tier Requirements/Limits
PROTOPIC TOPICAL OINTMENT 3 PA; MO; QL (100 per 30 days)
prudoxin topical cream 1 MO; QL (45 per 30 days)
QBREXZA TOPICAL TOWELETTE 3 MO
REGRANEX TOPICAL GEL 4 MO
SANTYL TOPICAL OINTMENT 2 MO
SILVADENE TOPICAL CREAM 3 MO
silver sulfadiazine topical cream 1 MO
ssd topical cream 1 MO
tacrolimus topical ointment 1 PA; MO; QL (100 per 30 days)
TOLAK TOPICAL CREAM 3 MO
VALCHLOR TOPICAL GEL 4 MO
VEREGEN TOPICAL OINTMENT 3 MO
ZONALON TOPICAL CREAM 3 MO; QL (45 per 30 days)
ZTLIDO TOPICAL ADHESIVE
PATCH,MEDICATED
3 PA; MO; QL (90 per 30 days)
ZYCLARA TOPICAL CREAM IN METERED-
DOSE PUMP
4 ST; MO
ZYCLARA TOPICAL CREAM IN PACKET 4 ST; MO
THERAPY FOR ACNE
ABSORICA ORAL CAPSULE 4 MO
ACANYA TOPICAL GEL WITH PUMP 3 MO
ACZONE TOPICAL GEL 3 MO
adapalene topical cream 1 PA; MO
adapalene topical gel 1 PA; MO
adapalene topical solution 1 PA
adapalene topical swab 1 PA
adapalene-benzoyl peroxide topical gel with pump 1 PA; MO
AKTIPAK TOPICAL GEL 3 MO
ALTRENO TOPICAL LOTION 3 PA; MO
amnesteem oral capsule 1 MO
ATRALIN TOPICAL GEL 3 PA; MO
avita topical cream 1 PA; MO
AVITA TOPICAL GEL 3 PA; MO
azelaic acid topical gel 1 MO
AZELEX TOPICAL CREAM 3 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
67
Drug Name Drug Tier Requirements/Limits
BENZACLIN TOPICAL GEL WITH PUMP 3 MO
BENZAMYCIN TOPICAL GEL 3 MO
claravis oral capsule 3 MO
CLEOCIN T TOPICAL GEL 3 MO
CLEOCIN T TOPICAL LOTION 3 MO
CLEOCIN T TOPICAL SWAB 3 MO
clindacin p topical swab 1 MO
CLINDAGEL TOPICAL GEL, ONCE DAILY 3 MO
clindamycin phosphate topical foam 1 MO
clindamycin phosphate topical gel 1 MO
clindamycin phosphate topical lotion 1 MO
clindamycin phosphate topical solution 1 MO
clindamycin phosphate topical swab 1 MO
clindamycin-benzoyl peroxide topical gel 1 MO
clindamycin-benzoyl peroxide topical gel with
pump 1.2-2.5 %
1 MO
clindamycin-tretinoin topical gel 1 PA; MO
dapsone topical gel 1 MO
DIFFERIN TOPICAL CREAM 3 PA; MO
DIFFERIN TOPICAL GEL 0.1 % 3 PA; MO
DIFFERIN TOPICAL GEL WITH PUMP 3 PA; MO
DIFFERIN TOPICAL LOTION 3 PA; MO
DUAC TOPICAL GEL 3 MO
EPIDUO FORTE TOPICAL GEL WITH PUMP 3 PA; MO
EPIDUO TOPICAL GEL WITH PUMP 3 PA; MO
ery pads topical swab 1 MO
erygel topical gel 1 MO
erythromycin with ethanol topical gel 1 MO
erythromycin with ethanol topical solution 1 MO
erythromycin-benzoyl peroxide topical gel 1 MO
EVOCLIN TOPICAL FOAM 3 MO
FABIOR TOPICAL FOAM 3 MO
FINACEA TOPICAL FOAM 3 ST; MO
FINACEA TOPICAL GEL 3 ST; MO
isotretinoin oral capsule 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
68
Drug Name Drug Tier Requirements/Limits
METROCREAM TOPICAL CREAM 3 ST; MO
METROGEL TOPICAL GEL 1 % 3 ST; MO
METROLOTION TOPICAL LOTION 3 ST; MO
metronidazole topical cream 1 MO
metronidazole topical gel 1 MO
metronidazole topical lotion 1 MO
MIRVASO TOPICAL GEL WITH PUMP 3 PA; MO
myorisan oral capsule 1 MO
neuac topical gel 1 MO
NORITATE TOPICAL CREAM 4 ST; MO
ONEXTON TOPICAL GEL WITH PUMP 3 MO
RETIN-A MICRO TOPICAL GEL 0.04 %, 0.1 % 3 PA; MO
RETIN-A MICRO TOPICAL GEL WITH PUMP
0.06 %, 0.08 %
3 PA; MO
RETIN-A TOPICAL CREAM 3 PA; MO
RETIN-A TOPICAL GEL 3 PA; MO
RHOFADE TOPICAL CREAM 3 PA; MO
SOOLANTRA TOPICAL CREAM 3 ST; MO
tazarotene topical cream 1 PA; MO
TAZORAC TOPICAL CREAM 0.05 % 2 PA; MO
TAZORAC TOPICAL CREAM 0.1 % 3 PA; MO
TAZORAC TOPICAL GEL 2 PA; MO
tretinoin microspheres topical gel 1 PA; MO
tretinoin topical cream 1 PA; MO
tretinoin topical gel 1 PA; MO
zenatane oral capsule 3 MO
ZIANA TOPICAL GEL 3 PA; MO
TOPICAL ANTIBACTERIALS
CORTISPORIN TOPICAL CREAM 3 MO
CORTISPORIN TOPICAL OINTMENT 3 MO
gentamicin topical cream 1 MO
gentamicin topical ointment 1 MO
KLARON TOPICAL SUSPENSION 3 MO
mafenide acetate topical packet 1 MO
mupirocin calcium topical cream 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
69
Drug Name Drug Tier Requirements/Limits
mupirocin topical ointment 1 MO
NEO-SYNALAR TOPICAL CREAM 3 MO
sulfacetamide sodium (acne) topical suspension 1 MO
SULFAMYLON TOPICAL CREAM 2 MO
SULFAMYLON TOPICAL PACKET 4 MO
XEPI TOPICAL CREAM 3 MO
TOPICAL ANTIFUNGALS
ciclopirox topical cream 1 MO; QL (90 per 28 days)
ciclopirox topical gel 1 MO; QL (45 per 28 days)
ciclopirox topical shampoo 1 MO; QL (120 per 28 days)
ciclopirox topical solution 1 MO
ciclopirox topical suspension 1 MO; QL (60 per 28 days)
clotrimazole topical cream 1 MO; QL (45 per 28 days)
clotrimazole topical solution 1 MO; QL (30 per 28 days)
clotrimazole-betamethasone topical cream 1 MO; QL (45 per 28 days)
clotrimazole-betamethasone topical lotion 1 MO; QL (60 per 28 days)
econazole topical cream 1 MO; QL (85 per 28 days)
ERTACZO TOPICAL CREAM 3 MO; QL (60 per 28 days)
EXELDERM TOPICAL CREAM 3 MO
EXELDERM TOPICAL SOLUTION 3 MO
EXTINA TOPICAL FOAM 3 MO; QL (100 per 28 days)
JUBLIA TOPICAL SOLUTION WITH
APPLICATOR
3 MO
KERYDIN TOPICAL SOLUTION WITH
APPLICATOR
3 MO
ketoconazole topical cream 1 MO; QL (60 per 28 days)
ketoconazole topical foam 1 MO; QL (100 per 28 days)
ketoconazole topical shampoo 1 MO; QL (120 per 28 days)
LOPROX (AS OLAMINE) TOPICAL CREAM 3 MO; QL (90 per 28 days)
LOPROX TOPICAL SHAMPOO 3 MO; QL (120 per 28 days)
LOTRISONE TOPICAL CREAM 3 MO; QL (45 per 28 days)
LULICONAZOLE TOPICAL CREAM 3 MO; QL (60 per 28 days)
LUZU TOPICAL CREAM 3 MO; QL (60 per 28 days)
MENTAX TOPICAL CREAM 3 MO
naftifine topical cream 1 MO; QL (60 per 28 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
70
Drug Name Drug Tier Requirements/Limits
NAFTIN TOPICAL CREAM 2 % 3 MO; QL (60 per 28 days)
NAFTIN TOPICAL GEL 2 MO; QL (60 per 28 days)
NIZORAL TOPICAL SHAMPOO 3 MO; QL (120 per 28 days)
nyamyc topical powder 1 MO
nystatin topical cream 1 MO; QL (30 per 28 days)
nystatin topical ointment 1 MO; QL (30 per 28 days)
nystatin topical powder 1 MO
nystatin-triamcinolone topical cream 1 MO; QL (60 per 28 days)
nystatin-triamcinolone topical ointment 1 MO; QL (60 per 28 days)
nystop topical powder 1 MO
oxiconazole topical cream 1 MO
OXISTAT TOPICAL CREAM 3 MO
OXISTAT TOPICAL LOTION 3 MO
TOPICAL ANTIVIRALS
acyclovir topical cream 1 PA; MO; QL (5 per 30 days)
acyclovir topical ointment 3 PA; MO; QL (30 per 30 days)
DENAVIR TOPICAL CREAM 2 MO
XERESE TOPICAL CREAM 3 MO
ZOVIRAX TOPICAL CREAM 4 PA; MO; QL (5 per 30 days)
ZOVIRAX TOPICAL OINTMENT 4 PA; MO; QL (30 per 30 days)
TOPICAL CORTICOSTEROIDS
ala-cort topical cream 1 MO
ALA-SCALP TOPICAL LOTION 3 MO
alclometasone topical cream 1 MO
alclometasone topical ointment 1 MO
amcinonide topical cream 1 MO
amcinonide topical lotion 1 MO
amcinonide topical ointment 1
apexicon e topical cream 1 MO
beser topical lotion 1
betamethasone dipropionate topical cream 1 MO
betamethasone dipropionate topical lotion 1 MO
betamethasone dipropionate topical ointment 1 MO
betamethasone valerate topical cream 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
71
Drug Name Drug Tier Requirements/Limits
betamethasone valerate topical foam 1 MO
betamethasone valerate topical lotion 1 MO
betamethasone valerate topical ointment 1 MO
betamethasone, augmented topical cream 1 MO
betamethasone, augmented topical gel 1 MO
betamethasone, augmented topical lotion 1 MO
betamethasone, augmented topical ointment 1 MO
BRYHALI TOPICAL LOTION 3 MO
CAPEX TOPICAL SHAMPOO 2 MO
clobetasol scalp solution 1 MO; QL (100 per 28 days)
clobetasol topical cream 1 MO; QL (120 per 28 days)
clobetasol topical foam 1 MO; QL (100 per 28 days)
clobetasol topical gel 1 MO; QL (120 per 28 days)
clobetasol topical lotion 1 MO; QL (118 per 28 days)
clobetasol topical ointment 1 MO; QL (120 per 28 days)
clobetasol topical shampoo 1 MO; QL (236 per 28 days)
clobetasol topical spray,non-aerosol 1 MO; QL (125 per 28 days)
clobetasol-emollient topical cream 1 MO; QL (120 per 28 days)
clobetasol-emollient topical foam 1 MO; QL (100 per 28 days)
CLOBEX TOPICAL LOTION 3 MO; QL (118 per 28 days)
CLOBEX TOPICAL SHAMPOO 3 MO; QL (236 per 28 days)
CLOBEX TOPICAL SPRAY,NON-AEROSOL 3 MO; QL (125 per 28 days)
CLOCORTOLONE PIVALATE TOPICAL
CREAM
3 MO
clodan topical shampoo 1 MO; QL (236 per 28 days)
CLODERM TOPICAL CREAM 3 MO
CORDRAN LARGE ROLL TOPICAL TAPE 3 MO
CUTIVATE TOPICAL LOTION 3 MO
DESONATE TOPICAL GEL 3 MO
desonide topical cream 3 MO
desonide topical lotion 3 MO
desonide topical ointment 3 MO
DESOWEN TOPICAL CREAM 3 MO
DESOWEN TOPICAL LOTION 3 MO
desoximetasone topical cream 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
72
Drug Name Drug Tier Requirements/Limits
desoximetasone topical gel 1 MO
desoximetasone topical ointment 1 MO
desoximetasone topical spray,non-aerosol 1 MO
diflorasone topical cream 1 MO
diflorasone topical ointment 1 MO
DIPROLENE TOPICAL OINTMENT 3 MO
DUOBRII TOPICAL LOTION 4 MO
ELOCON TOPICAL CREAM 3 MO
fluocinolone and shower cap scalp oil 1 MO
fluocinolone topical cream 1 MO
fluocinolone topical ointment 1 MO
fluocinolone topical solution 1 MO
fluocinonide topical cream 0.1 % 1 MO; QL (120 per 30 days)
fluocinonide topical gel 1 MO; QL (120 per 30 days)
fluocinonide topical ointment 1 MO; QL (120 per 30 days)
fluocinonide topical solution 1 MO; QL (120 per 30 days)
fluocinonide-e topical cream 1 MO; QL (120 per 30 days)
flurandrenolide topical cream 1 MO
flurandrenolide topical lotion 1 MO
flurandrenolide topical ointment 1 MO
fluticasone propionate topical cream 1 MO
fluticasone propionate topical lotion 1 MO
fluticasone propionate topical ointment 1 MO
halcinonide topical cream 1 MO
halobetasol propionate topical cream 1 MO
HALOBETASOL PROPIONATE TOPICAL
FOAM
3 MO
halobetasol propionate topical ointment 1 MO
HALOG TOPICAL CREAM 3 MO
HALOG TOPICAL OINTMENT 3 MO
hydrocortisone butyrate topical cream 1 MO
hydrocortisone butyrate topical lotion 1 MO
hydrocortisone butyrate topical ointment 1 MO
hydrocortisone butyrate topical solution 1 MO
hydrocortisone topical cream 1 %, 2.5 % 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
73
Drug Name Drug Tier Requirements/Limits
hydrocortisone topical lotion 2.5 % 1 MO
hydrocortisone topical ointment 1 %, 2.5 % 1 MO
hydrocortisone valerate topical cream 1 MO
hydrocortisone valerate topical ointment 1 MO
IMPOYZ TOPICAL CREAM 3 MO; QL (120 per 28 days)
KENALOG TOPICAL AEROSOL 3 MO
LEXETTE TOPICAL FOAM 3 MO
LOCOID LIPOCREAM TOPICAL CREAM 3 MO
LOCOID TOPICAL LOTION 3 MO
LOCOID TOPICAL SOLUTION 3 MO
LUXIQ TOPICAL FOAM 3 MO
mometasone topical cream 1 MO
mometasone topical ointment 1 MO
mometasone topical solution 1 MO
nolix topical cream 1
nolix topical lotion 1 MO
OLUX TOPICAL FOAM 3 MO; QL (100 per 28 days)
OLUX-E TOPICAL FOAM 3 MO; QL (100 per 28 days)
PANDEL TOPICAL CREAM 3 MO
prednicarbate topical cream 1 MO
prednicarbate topical ointment 1 MO
PSORCON TOPICAL CREAM 3
SERNIVO TOPICAL SPRAY WITH PUMP 4 MO
SYNALAR TOPICAL CREAM 3 MO
TEXACORT TOPICAL SOLUTION 3 MO
TOPICORT TOPICAL CREAM 3 MO
TOPICORT TOPICAL GEL 3 MO
TOPICORT TOPICAL OINTMENT 3 MO
TOPICORT TOPICAL SPRAY,NON-AEROSOL 3 MO
triamcinolone acetonide topical aerosol 1 MO
triamcinolone acetonide topical cream 1 MO
triamcinolone acetonide topical lotion 1 MO
triamcinolone acetonide topical ointment 0.025 %,
0.1 %, 0.5 %
1 MO
trianex topical ointment 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
74
Drug Name Drug Tier Requirements/Limits
triderm topical cream 0.1 % 1 MO
TRIDESILON TOPICAL CREAM 3 MO
ULTRAVATE TOPICAL LOTION 4 MO
ULTRAVATE TOPICAL OINTMENT 3 MO
VANOS TOPICAL CREAM 4 MO; QL (120 per 30 days)
TOPICAL SCABICIDES / PEDICULICIDES
ELIMITE TOPICAL CREAM 3
EURAX TOPICAL CREAM 3 MO
EURAX TOPICAL LOTION 3 MO
lindane topical shampoo 1 MO
malathion topical lotion 1 MO
NATROBA TOPICAL SUSPENSION 3 MO
OVIDE TOPICAL LOTION 3 MO
permethrin topical cream 1 MO
SKLICE TOPICAL LOTION 2 MO
DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
acamprosate oral tablet,delayed release (dr/ec) 3 MO
AGRYLIN ORAL CAPSULE 3 MO
alendronate oral tablet 40 mg 1 MO; QL (30 per 30 days)
anagrelide oral capsule 1 MO
ANTABUSE ORAL TABLET 3 MO
ARALAST NP INTRAVENOUS RECON SOLN
1,000 MG
4 MO; LA
AURYXIA ORAL TABLET 4 PA; MO
BUPHENYL ORAL POWDER 4 MO
BUPHENYL ORAL TABLET 4 MO
CARBAGLU ORAL TABLET, DISPERSIBLE 4 MO; LA
CARNITOR ORAL SOLUTION 3 MO
CARNITOR ORAL TABLET 3 MO
cevimeline oral capsule 1 MO
CHEMET ORAL CAPSULE 2 PA; MO
CLINIMIX 4.25%/D5W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
2 B/D PA
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75
Drug Name Drug Tier Requirements/Limits
CLINIMIX E 2.75%/D5W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
3 B/D PA
d10 %-0.45 % sodium chloride intravenous
parenteral solution
1
d2.5 %-0.45 % sodium chloride intravenous
parenteral solution
1
d5 % and 0.9 % sodium chloride intravenous
parenteral solution
1 MO
d5 %-0.45 % sodium chloride intravenous
parenteral solution
1 MO
deferasirox oral tablet, dispersible 4 PA; MO
dextrose 10 % and 0.2 % nacl intravenous
parenteral solution
1
dextrose 10 % in water (d10w) intravenous
parenteral solution
1 MO
dextrose 5 % in water (d5w) intravenous
parenteral solution
1 MO
dextrose 5%-0.2 % sod chloride intravenous
parenteral solution
1
dextrose 5%-0.3 % sod.chloride intravenous
parenteral solution
1
dextrose with sodium chloride intravenous
parenteral solution
1
disulfiram oral tablet 1 MO
ENDARI ORAL POWDER IN PACKET 4 PA; MO
etidronate disodium oral tablet 1 MO
EVOXAC ORAL CAPSULE 3 MO
EXJADE ORAL TABLET, DISPERSIBLE 4 PA; MO; LA
FERRIPROX ORAL SOLUTION 4 PA; MO
ferriprox oral tablet 1,000 mg 4 PA; MO
FERRIPROX ORAL TABLET 500 MG 4 PA; MO
FOSRENOL ORAL POWDER IN PACKET 3 MO
FOSRENOL ORAL TABLET,CHEWABLE 3 MO
GLASSIA INTRAVENOUS SOLUTION 4 MO; LA
INCRELEX SUBCUTANEOUS SOLUTION 4 MO; LA
JADENU ORAL TABLET 4 PA; MO
JADENU SPRINKLE ORAL GRANULES IN
PACKET
4 PA; MO
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76
Drug Name Drug Tier Requirements/Limits
kionex (with sorbitol) oral suspension 1 MO
lanthanum oral tablet,chewable 1 MO
levocarnitine (with sugar) oral solution 1 MO
levocarnitine oral tablet 1 MO
LITHOSTAT ORAL TABLET 3 MO
LOKELMA ORAL POWDER IN PACKET 2 MO
midodrine oral tablet 1 MO
NITYR ORAL TABLET 3 MO; LA
NORTHERA ORAL CAPSULE 4 PA; MO
ORFADIN ORAL CAPSULE 4 MO; LA
ORFADIN ORAL SUSPENSION 4 MO; LA
pilocarpine hcl oral tablet 1 MO
PROLASTIN-C INTRAVENOUS RECON SOLN 4 LA
PROLASTIN-C INTRAVENOUS SOLUTION 4 MO; LA
RAVICTI ORAL LIQUID 4 MO
RENAGEL ORAL TABLET 800 MG 3 MO
RENVELA ORAL POWDER IN PACKET 4 MO
RENVELA ORAL TABLET 4 MO
RILUTEK ORAL TABLET 4 MO
riluzole oral tablet 1 MO
risedronate oral tablet 30 mg 1 MO; QL (30 per 30 days)
SALAGEN (PILOCARPINE) ORAL TABLET 3 MO
sevelamer carbonate oral powder in packet 4 MO
sevelamer carbonate oral tablet 1 MO
sevelamer hcl oral tablet 1 MO
sodium chloride 0.9 % intravenous parenteral
solution
1 MO
sodium chloride irrigation solution 1 MO
sodium phenylbutyrate oral powder 4 MO
sodium phenylbutyrate oral tablet 4 MO
sodium polystyrene sulfonate oral powder 1 MO
sps (with sorbitol) oral suspension 1 MO
SYPRINE ORAL CAPSULE 4 PA; MO
THIOLA EC ORAL TABLET,DELAYED
RELEASE (DR/EC)
4 MO
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77
Drug Name Drug Tier Requirements/Limits
THIOLA ORAL TABLET 4 MO
TIGLUTIK ORAL SUSPENSION 4 MO
trientine oral capsule 4 PA; MO
VELPHORO ORAL TABLET,CHEWABLE 4 MO
VELTASSA ORAL POWDER IN PACKET 2 MO
XURIDEN ORAL GRANULES IN PACKET 4 MO
ZEMAIRA INTRAVENOUS RECON SOLN 4 MO; LA
SMOKING DETERRENTS
bupropion hcl (smoking deter) oral tablet extended
release 12 hr
1 MO
CHANTIX CONTINUING MONTH BOX ORAL
TABLET
2 MO
CHANTIX ORAL TABLET 2 MO
CHANTIX STARTING MONTH BOX ORAL
TABLETS,DOSE PACK
2 MO
NICOTROL INHALATION CARTRIDGE 3 MO
NICOTROL NS NASAL SPRAY,NON-
AEROSOL
3 MO
EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS AGENTS
ASTEPRO NASAL SPRAY,NON-AEROSOL 3 MO; QL (60 per 30 days)
azelastine nasal spray, aerosol 1 MO; QL (60 per 30 days)
azelastine nasal spray,non-aerosol 1 MO; QL (60 per 30 days)
chlorhexidine gluconate mucous membrane
mouthwash
1 MO
ipratropium bromide nasal spray,non-aerosol 1 MO; QL (30 per 30 days)
olopatadine nasal spray,non-aerosol 1 MO; QL (30.5 per 30 days)
PATANASE NASAL SPRAY,NON-AEROSOL 3 MO; QL (30.5 per 30 days)
triamcinolone acetonide dental paste 1 MO
MISCELLANEOUS OTIC PREPARATIONS
acetic acid otic (ear) solution 1 MO
CETRAXAL OTIC (EAR) DROPPERETTE 3 MO
ciprofloxacin hcl otic (ear) dropperette 1 MO
flac oil otic (ear) drops 1
fluocinolone acetonide oil otic (ear) drops 1 MO
hydrocortisone-acetic acid otic (ear) drops 1 MO
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78
Drug Name Drug Tier Requirements/Limits
ofloxacin otic (ear) drops 1 MO
OTIC STEROID / ANTIBIOTIC
CIPRO HC OTIC (EAR) DROPS,SUSPENSION 3 MO
CIPRODEX OTIC (EAR) DROPS,SUSPENSION 2 MO
COLY-MYCIN S OTIC (EAR)
DROPS,SUSPENSION
3 MO
neomycin-polymyxin-hc otic (ear)
drops,suspension
1 MO
neomycin-polymyxin-hc otic (ear) solution 1 MO
OTOVEL OTIC (EAR) SOLUTION 2 MO
ENDOCRINE/DIABETES
ADRENAL HORMONES
ACTHAR INJECTION GEL 4 PA; MO
CORTEF ORAL TABLET 3 MO
cortisone oral tablet 1 MO
dexamethasone intensol oral drops 1 MO
dexamethasone oral elixir 1 MO
dexamethasone oral tablet 1 MO
dexamethasone oral tablets,dose pack 1 MO
DEXPAK 13 DAY ORAL TABLETS,DOSE
PACK
3 MO
EMFLAZA ORAL SUSPENSION 4 PA; MO; LA
EMFLAZA ORAL TABLET 4 PA; MO; LA
fludrocortisone oral tablet 1 MO
hydrocortisone oral tablet 1 MO
MEDROL (PAK) ORAL TABLETS,DOSE
PACK
3 MO
MEDROL ORAL TABLET 3 B/D PA; MO
methylprednisolone oral tablet 1 B/D PA; MO
methylprednisolone oral tablets,dose pack 1 MO
millipred oral tablet 3 B/D PA; MO
ORAPRED ODT ORAL
TABLET,DISINTEGRATING
3 B/D PA; MO
prednisolone oral solution 15 mg/5 ml 1 MO
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79
Drug Name Drug Tier Requirements/Limits
prednisolone sodium phosphate oral solution 10
mg/5 ml, 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5
mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)
1 MO
prednisolone sodium phosphate oral
tablet,disintegrating
1 B/D PA; MO
prednisone intensol oral concentrate 1 B/D PA; MO
prednisone oral solution 1 MO
prednisone oral tablet 1 B/D PA; MO
prednisone oral tablets,dose pack 1 MO
RAYOS ORAL TABLET,DELAYED RELEASE
(DR/EC)
4 B/D PA; MO
TAPERDEX ORAL TABLETS,DOSE PACK 1.5
MG (21 TABS)
3 MO
TAPERDEX ORAL TABLETS,DOSE PACK 1.5
MG (27 TABS), 1.5 MG (49 TABS)
3
ANTITHYROID AGENTS
methimazole oral tablet 10 mg, 5 mg 1 MO
propylthiouracil oral tablet 1 MO
TAPAZOLE ORAL TABLET 3 MO
DIABETES THERAPY
acarbose oral tablet 100 mg 1 MO; QL (90 per 30 days)
acarbose oral tablet 25 mg 1 MO; QL (360 per 30 days)
acarbose oral tablet 50 mg 1 MO; QL (180 per 30 days)
ACTOPLUS MET ORAL TABLET 3 MO; QL (90 per 30 days)
ACTOS ORAL TABLET 3 MO; QL (30 per 30 days)
ADLYXIN SUBCUTANEOUS PEN INJECTOR
10 MCG/0.2 ML- 20 MCG/0.2 ML
3 PA; MO; QL (6 per 180 days)
ADLYXIN SUBCUTANEOUS PEN INJECTOR
20 MCG/0.2 ML
3 PA; MO; QL (6 per 30 days)
ADMELOG SOLOSTAR U-100 INSULIN
SUBCUTANEOUS PEN
3 ST; MO
ADMELOG U-100 INSULIN LISPRO
SUBCUTANEOUS SOLUTION
3 ST; MO
AFREZZA INHALATION CARTRIDGE WITH
INHALER 12 UNIT, 4 UNIT, 4 UNIT (90)/ 8
UNIT (90), 4 UNIT/8 UNIT/ 12 UNIT (60), 8
UNIT, 8 UNIT (90)/ 12 UNIT (90)
3 MO
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80
Drug Name Drug Tier Requirements/Limits
ALCOHOL PADS TOPICAL PADS,
MEDICATED
2 MO
ALOGLIPTIN ORAL TABLET 3 ST; MO; QL (30 per 30 days)
ALOGLIPTIN-METFORMIN ORAL TABLET 3 ST; MO; QL (60 per 30 days)
ALOGLIPTIN-PIOGLITAZONE ORAL
TABLET
3 MO; QL (30 per 30 days)
AMARYL ORAL TABLET 1 MG 3 MO; QL (240 per 30 days)
AMARYL ORAL TABLET 2 MG 3 MO; QL (120 per 30 days)
AMARYL ORAL TABLET 4 MG 3 MO; QL (60 per 30 days)
APIDRA SOLOSTAR U-100 INSULIN
SUBCUTANEOUS PEN
3 ST; MO
APIDRA U-100 INSULIN SUBCUTANEOUS
SOLUTION
3 ST; MO
AVANDIA ORAL TABLET 2 MG, 4 MG 3 MO; QL (60 per 30 days)
BAQSIMI NASAL SPRAY,NON-AEROSOL 2 MO
BASAGLAR KWIKPEN U-100 INSULIN
SUBCUTANEOUS PEN
3 ST; MO
BYDUREON BCISE SUBCUTANEOUS AUTO-
INJECTOR
2 PA; MO; QL (4 per 28 days)
BYDUREON SUBCUTANEOUS PEN
INJECTOR
2 PA; MO; QL (4 per 28 days)
BYETTA SUBCUTANEOUS PEN INJECTOR
10 MCG/DOSE(250 MCG/ML) 2.4 ML
2 PA; MO; QL (2.4 per 30 days)
BYETTA SUBCUTANEOUS PEN INJECTOR 5
MCG/DOSE (250 MCG/ML) 1.2 ML
2 PA; MO; QL (1.2 per 30 days)
CYCLOSET ORAL TABLET 3 MO; QL (180 per 30 days)
DUETACT ORAL TABLET 3 MO; QL (30 per 30 days)
FARXIGA ORAL TABLET 10 MG 2 MO; QL (30 per 30 days)
FARXIGA ORAL TABLET 5 MG 2 MO; QL (60 per 30 days)
FIASP FLEXTOUCH U-100 INSULIN
SUBCUTANEOUS PEN
3 ST; MO
FIASP U-100 INSULIN SUBCUTANEOUS
SOLUTION
3 ST; MO
FORTAMET ORAL TABLET EXTENDED
RELEASE 24HR 1,000 MG
4 MO; QL (75 per 30 days)
FORTAMET ORAL TABLET EXTENDED
RELEASE 24HR 500 MG
4 MO; QL (150 per 30 days)
GAUZE PADS 2 X 2 2 MO
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81
Drug Name Drug Tier Requirements/Limits
glimepiride oral tablet 1 mg 1 MO; QL (240 per 30 days)
glimepiride oral tablet 2 mg 1 MO; QL (120 per 30 days)
glimepiride oral tablet 4 mg 1 MO; QL (60 per 30 days)
glipizide oral tablet 10 mg 1 MO; QL (120 per 30 days)
glipizide oral tablet 5 mg 1 MO; QL (240 per 30 days)
glipizide oral tablet extended release 24hr 10 mg 1 MO; QL (60 per 30 days)
glipizide oral tablet extended release 24hr 2.5 mg 1 MO; QL (240 per 30 days)
glipizide oral tablet extended release 24hr 5 mg 1 MO; QL (120 per 30 days)
glipizide-metformin oral tablet 2.5-250 mg 1 MO; QL (240 per 30 days)
glipizide-metformin oral tablet 2.5-500 mg, 5-500
mg
1 MO; QL (120 per 30 days)
GLUCAGEN HYPOKIT INJECTION RECON
SOLN
2 MO
GLUCAGON EMERGENCY KIT (HUMAN)
INJECTION RECON SOLN
2 MO
GLUCOPHAGE ORAL TABLET 1,000 MG 3 MO; QL (75 per 30 days)
GLUCOPHAGE ORAL TABLET 500 MG 3 MO; QL (150 per 30 days)
GLUCOPHAGE ORAL TABLET 850 MG 3 MO; QL (90 per 30 days)
GLUCOPHAGE XR ORAL TABLET
EXTENDED RELEASE 24 HR 500 MG
3 MO; QL (120 per 30 days)
GLUCOPHAGE XR ORAL TABLET
EXTENDED RELEASE 24 HR 750 MG
3 MO; QL (75 per 30 days)
GLUCOTROL ORAL TABLET 10 MG 3 MO; QL (120 per 30 days)
GLUCOTROL ORAL TABLET 5 MG 3 MO; QL (240 per 30 days)
GLUCOTROL XL ORAL TABLET EXTENDED
RELEASE 24HR 10 MG
3 MO; QL (60 per 30 days)
GLUCOTROL XL ORAL TABLET EXTENDED
RELEASE 24HR 2.5 MG
3 MO; QL (240 per 30 days)
GLUCOTROL XL ORAL TABLET EXTENDED
RELEASE 24HR 5 MG
3 MO; QL (120 per 30 days)
GLUMETZA ORAL TABLET,ER
GAST.RETENTION 24 HR 1,000 MG
4 MO; QL (60 per 30 days)
GLUMETZA ORAL TABLET,ER
GAST.RETENTION 24 HR 500 MG
4 MO; QL (120 per 30 days)
GLYSET ORAL TABLET 100 MG 3 MO; QL (90 per 30 days)
GLYSET ORAL TABLET 25 MG 3 MO; QL (360 per 30 days)
GLYSET ORAL TABLET 50 MG 3 MO; QL (180 per 30 days)
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82
Drug Name Drug Tier Requirements/Limits
GLYXAMBI ORAL TABLET 2 MO; QL (30 per 30 days)
GVOKE SUBCUTANEOUS SYRINGE 3 MO
HUMALOG JUNIOR KWIKPEN U-100
SUBCUTANEOUS INSULIN PEN, HALF-UNIT
2 MO
HUMALOG KWIKPEN INSULIN
SUBCUTANEOUS PEN
2 MO
HUMALOG MIX 50-50 INSULN U-100
SUBCUTANEOUS SUSPENSION
2 MO
HUMALOG MIX 50-50 KWIKPEN
SUBCUTANEOUS INSULIN PEN
2 MO
HUMALOG MIX 75-25 KWIKPEN
SUBCUTANEOUS INSULIN PEN
2 MO
HUMALOG MIX 75-25(U-100)INSULN
SUBCUTANEOUS SUSPENSION
2 MO
HUMALOG U-100 INSULIN SUBCUTANEOUS
CARTRIDGE
2 MO
HUMALOG U-100 INSULIN SUBCUTANEOUS
SOLUTION
2 MO
HUMULIN 70/30 U-100 INSULIN
SUBCUTANEOUS SUSPENSION
2 MO
HUMULIN 70/30 U-100 KWIKPEN
SUBCUTANEOUS INSULIN PEN
2 MO
HUMULIN N NPH INSULIN KWIKPEN
SUBCUTANEOUS PEN
2 MO
HUMULIN N NPH U-100 INSULIN
SUBCUTANEOUS SUSPENSION
2 MO
HUMULIN R REGULAR U-100 INSULN
INJECTION SOLUTION
2 MO
HUMULIN R U-500 (CONC) INSULIN
SUBCUTANEOUS SOLUTION
2 MO
HUMULIN R U-500 (CONC) KWIKPEN
SUBCUTANEOUS INSULIN PEN
2 MO
INSULIN LISPRO SUBCUTANEOUS PEN 3 ST; MO
INSULIN LISPRO SUBCUTANEOUS
SOLUTION
3 ST; MO
INSULIN PEN NEEDLE 2 MO
INSULIN SYRINGE (DISP) U-100 0.3 ML, 1
ML, 1/2 ML
2 MO
INVOKAMET ORAL TABLET 150-1,000 MG,
150-500 MG, 50-1,000 MG
2 MO; QL (60 per 30 days)
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83
Drug Name Drug Tier Requirements/Limits
INVOKAMET ORAL TABLET 50-500 MG 2 MO; QL (120 per 30 days)
INVOKAMET XR ORAL TABLET, IR - ER,
BIPHASIC 24HR 150-1,000 MG, 150-500 MG,
50-1,000 MG
2 MO; QL (60 per 30 days)
INVOKAMET XR ORAL TABLET, IR - ER,
BIPHASIC 24HR 50-500 MG
2 MO; QL (120 per 30 days)
INVOKANA ORAL TABLET 100 MG 2 MO; QL (90 per 30 days)
INVOKANA ORAL TABLET 300 MG 2 MO; QL (30 per 30 days)
JANUMET ORAL TABLET 2 MO; QL (60 per 30 days)
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 100-1,000 MG
2 MO; QL (30 per 30 days)
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG
2 MO; QL (60 per 30 days)
JANUVIA ORAL TABLET 2 MO; QL (30 per 30 days)
JARDIANCE ORAL TABLET 2 MO; QL (30 per 30 days)
JENTADUETO ORAL TABLET 3 ST; MO; QL (60 per 30 days)
JENTADUETO XR ORAL TABLET, IR - ER,
BIPHASIC 24HR 2.5-1,000 MG
3 ST; MO; QL (60 per 30 days)
JENTADUETO XR ORAL TABLET, IR - ER,
BIPHASIC 24HR 5-1,000 MG
3 ST; MO; QL (30 per 30 days)
KAZANO ORAL TABLET 3 ST; MO; QL (60 per 30 days)
KOMBIGLYZE XR ORAL TABLET, ER
MULTIPHASE 24 HR 2.5-1,000 MG
2 MO; QL (60 per 30 days)
KOMBIGLYZE XR ORAL TABLET, ER
MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG
2 MO; QL (30 per 30 days)
LANTUS SOLOSTAR U-100 INSULIN
SUBCUTANEOUS PEN
2 MO
LANTUS U-100 INSULIN SUBCUTANEOUS
SOLUTION
2 MO
LEVEMIR FLEXTOUCH U-100 INSULN
SUBCUTANEOUS INSULIN PEN
3 ST; MO
LEVEMIR U-100 INSULIN SUBCUTANEOUS
SOLUTION
3 ST; MO
metformin oral tablet 1,000 mg 1 MO; QL (75 per 30 days)
metformin oral tablet 500 mg 1 MO; QL (150 per 30 days)
metformin oral tablet 850 mg 1 MO; QL (90 per 30 days)
metformin oral tablet extended release 24 hr 500
mg
1 MO; QL (120 per 30 days)
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84
Drug Name Drug Tier Requirements/Limits
metformin oral tablet extended release 24 hr 750
mg
1 MO; QL (75 per 30 days)
metformin oral tablet extended release (osm) 24 hr
1,000 mg
4 MO; QL (75 per 30 days)
metformin oral tablet extended release (osm) 24 hr
500 mg
1 MO; QL (150 per 30 days)
metformin oral tablet,er gast.retention 24 hr 1,000
mg
4 MO; QL (60 per 30 days)
metformin oral tablet,er gast.retention 24 hr 500
mg
4 MO; QL (120 per 30 days)
miglitol oral tablet 100 mg 1 MO; QL (90 per 30 days)
miglitol oral tablet 25 mg 1 MO; QL (360 per 30 days)
miglitol oral tablet 50 mg 1 MO; QL (180 per 30 days)
nateglinide oral tablet 120 mg 1 MO; QL (90 per 30 days)
nateglinide oral tablet 60 mg 1 MO; QL (180 per 30 days)
NEEDLES, INSULIN DISP., SAFETY 2 MO
NESINA ORAL TABLET 3 ST; MO; QL (30 per 30 days)
NOVOFINE 32 NEEDLE 2 MO
NOVOLIN 70/30 U-100 INSULIN
SUBCUTANEOUS SUSPENSION
3 ST; MO
NOVOLIN N NPH U-100 INSULIN
SUBCUTANEOUS SUSPENSION
3 ST; MO
NOVOLIN R REGULAR U-100 INSULN
INJECTION SOLUTION
3 ST; MO
NOVOLOG FLEXPEN U-100 INSULIN
SUBCUTANEOUS PEN
3 ST; MO
NOVOLOG MIX 70-30 U-100 INSULN
SUBCUTANEOUS SOLUTION
3 ST; MO
NOVOLOG MIX 70-30FLEXPEN U-100
SUBCUTANEOUS INSULIN PEN
3 ST; MO
NOVOLOG PENFILL U-100 INSULIN
SUBCUTANEOUS CARTRIDGE
3 ST; MO
NOVOLOG U-100 INSULIN ASPART
SUBCUTANEOUS SOLUTION
3 ST; MO
OMNIPOD DASH INSULIN POD
SUBCUTANEOUS CARTRIDGE
2 MO
OMNIPOD INSULIN MANAGEMENT 2 MO
OMNIPOD INSULIN REFILL
SUBCUTANEOUS CARTRIDGE
2 MO
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85
Drug Name Drug Tier Requirements/Limits
ONGLYZA ORAL TABLET 2 MO; QL (30 per 30 days)
OSENI ORAL TABLET 3 MO; QL (30 per 30 days)
OZEMPIC SUBCUTANEOUS PEN INJECTOR
0.25 MG OR 0.5 MG(2 MG/1.5 ML)
2 PA; MO; QL (1.5 per 28 days)
OZEMPIC SUBCUTANEOUS PEN INJECTOR 1
MG/DOSE (2 MG/1.5 ML)
2 PA; MO; QL (3 per 28 days)
pioglitazone oral tablet 1 MO; QL (30 per 30 days)
pioglitazone-glimepiride oral tablet 1 MO; QL (30 per 30 days)
pioglitazone-metformin oral tablet 1 MO; QL (90 per 30 days)
PRANDIN ORAL TABLET 1 MG 3 MO; QL (480 per 30 days)
PRANDIN ORAL TABLET 2 MG 3 MO; QL (240 per 30 days)
PRECOSE ORAL TABLET 100 MG 3 MO; QL (90 per 30 days)
PRECOSE ORAL TABLET 25 MG 3 MO; QL (360 per 30 days)
PRECOSE ORAL TABLET 50 MG 3 MO; QL (180 per 30 days)
PROGLYCEM ORAL SUSPENSION 2 MO
QTERN ORAL TABLET 10-5 MG 3 MO; QL (30 per 30 days)
QTERN ORAL TABLET 5-5 MG 3
repaglinide oral tablet 0.5 mg 1 MO; QL (960 per 30 days)
repaglinide oral tablet 1 mg 1 MO; QL (480 per 30 days)
repaglinide oral tablet 2 mg 1 MO; QL (240 per 30 days)
repaglinide-metformin oral tablet 1 MO; QL (150 per 30 days)
RIOMET ORAL SOLUTION 2 MO; QL (765 per 30 days)
SEGLUROMET ORAL TABLET 2.5-1,000 MG,
7.5-1,000 MG, 7.5-500 MG
2 MO; QL (60 per 30 days)
SEGLUROMET ORAL TABLET 2.5-500 MG 2 MO; QL (120 per 30 days)
SOLIQUA 100/33 SUBCUTANEOUS INSULIN
PEN
2 MO
STARLIX ORAL TABLET 120 MG 3 MO; QL (90 per 30 days)
STARLIX ORAL TABLET 60 MG 3 MO; QL (180 per 30 days)
STEGLATRO ORAL TABLET 2 MO; QL (30 per 30 days)
STEGLUJAN ORAL TABLET 3 MO; QL (30 per 30 days)
SYMLINPEN 120 SUBCUTANEOUS PEN
INJECTOR
4 PA; MO; QL (10.8 per 30 days)
SYMLINPEN 60 SUBCUTANEOUS PEN
INJECTOR
4 PA; MO; QL (6 per 30 days)
SYNJARDY ORAL TABLET 12.5-1,000 MG,
12.5-500 MG, 5-1,000 MG
2 MO; QL (60 per 30 days)
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86
Drug Name Drug Tier Requirements/Limits
SYNJARDY ORAL TABLET 5-500 MG 2 MO; QL (120 per 30 days)
SYNJARDY XR ORAL TABLET, IR - ER,
BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG,
5-1,000 MG
2 MO; QL (60 per 30 days)
SYNJARDY XR ORAL TABLET, IR - ER,
BIPHASIC 24HR 25-1,000 MG
2 MO; QL (30 per 30 days)
TECHLITE INSULIN SYR HALF UNIT
SYRINGE
2
TECHLITE INSULIN SYRINGE 2
tolbutamide oral tablet 1 MO; QL (180 per 30 days)
TOUJEO MAX U-300 SOLOSTAR
SUBCUTANEOUS INSULIN PEN
2 MO
TOUJEO SOLOSTAR U-300 INSULIN
SUBCUTANEOUS PEN
2 MO
TRADJENTA ORAL TABLET 3 ST; MO; QL (30 per 30 days)
TRESIBA FLEXTOUCH U-100
SUBCUTANEOUS INSULIN PEN
3 ST; MO
TRESIBA FLEXTOUCH U-200
SUBCUTANEOUS INSULIN PEN
3 ST; MO
TRESIBA U-100 INSULIN SUBCUTANEOUS
SOLUTION
3 ST; MO
TRULICITY SUBCUTANEOUS PEN
INJECTOR
2 PA; MO; QL (2 per 28 days)
V-GO 20 DEVICE 2 MO
V-GO 30 DEVICE 2 MO
V-GO 40 DEVICE 2 MO
VICTOZA 3-PAK SUBCUTANEOUS PEN
INJECTOR
2 PA; MO; QL (9 per 30 days)
XIGDUO XR ORAL TABLET, IR - ER,
BIPHASIC 24HR 10-1,000 MG
2 MO; QL (30 per 30 days)
XIGDUO XR ORAL TABLET, IR - ER,
BIPHASIC 24HR 10-500 MG, 2.5-1,000 MG, 5-
1,000 MG, 5-500 MG
2 MO; QL (60 per 30 days)
XULTOPHY 100/3.6 SUBCUTANEOUS
INSULIN PEN
4 MO; QL (15 per 30 days)
MISCELLANEOUS HORMONES
ANADROL-50 ORAL TABLET 4 PA; MO
ANDRODERM TRANSDERMAL PATCH 24
HOUR
2 PA; MO; QL (30 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
87
Drug Name Drug Tier Requirements/Limits
ANDROGEL TRANSDERMAL GEL IN
METERED-DOSE PUMP 20.25 MG/1.25 GRAM
(1.62 %)
2 PA; MO; QL (150 per 30 days)
ANDROGEL TRANSDERMAL GEL IN
PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5
GRAM)
3 PA; MO; QL (300 per 30 days)
ANDROGEL TRANSDERMAL GEL IN
PACKET 1.62 % (20.25 MG/1.25 GRAM)
2 PA; MO; QL (37.5 per 30 days)
ANDROGEL TRANSDERMAL GEL IN
PACKET 1.62 % (40.5 MG/2.5 GRAM)
2 PA; MO; QL (150 per 30 days)
AVEED INTRAMUSCULAR SOLUTION 3 PA; MO; LA
cabergoline oral tablet 1 MO
calcitonin (salmon) nasal spray,non-aerosol 1 MO
calcitriol oral capsule 1 MO
calcitriol oral solution 1 MO
CERDELGA ORAL CAPSULE 4 MO
cinacalcet oral tablet 30 mg 1 MO
cinacalcet oral tablet 60 mg, 90 mg 4 MO
danazol oral capsule 3 MO
DDAVP NASAL SOLUTION 2 MO
DDAVP NASAL SPRAY WITH PUMP 3 MO
DDAVP ORAL TABLET 3 MO
DEPO-TESTOSTERONE INTRAMUSCULAR
OIL
3 PA; MO
desmopressin nasal spray,non-aerosol 1 MO
desmopressin oral tablet 1 MO
doxercalciferol oral capsule 1 MO
FORTESTA TRANSDERMAL GEL IN
METERED-DOSE PUMP
3 PA; MO; QL (120 per 30 days)
GALAFOLD ORAL CAPSULE 4 PA; MO; LA; QL (15 per 30 days)
JYNARQUE ORAL TABLET 4 PA; LA
JYNARQUE ORAL TABLETS, SEQUENTIAL 4 PA; MO; LA
KORLYM ORAL TABLET 4 PA; MO
KUVAN ORAL POWDER IN PACKET 4 PA; MO
KUVAN ORAL TABLET,SOLUBLE 4 PA; MO
METHITEST ORAL TABLET 3 MO
methyltestosterone oral capsule 4 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
88
Drug Name Drug Tier Requirements/Limits
miglustat oral capsule 4 MO; LA
MYALEPT SUBCUTANEOUS RECON SOLN 4 PA; MO; LA
NATPARA SUBCUTANEOUS CARTRIDGE 4 PA; MO; LA
NOCDURNA (MEN) SUBLINGUAL
TABLET,DISINTEGRATING
3 PA; MO; QL (30 per 30 days)
NOCDURNA (WOMEN) SUBLINGUAL
TABLET,DISINTEGRATING
3 PA; MO; QL (30 per 30 days)
NOCTIVA NASAL SPRAY,NON-AEROSOL 3 PA; MO; QL (3.8 per 30 days)
ORILISSA ORAL TABLET 4 MO
oxandrolone oral tablet 10 mg 4 PA; MO
oxandrolone oral tablet 2.5 mg 1 PA; MO
PALYNZIQ SUBCUTANEOUS SYRINGE 10
MG/0.5 ML
4 PA; MO; LA; QL (15 per 30 days)
PALYNZIQ SUBCUTANEOUS SYRINGE 2.5
MG/0.5 ML
4 PA; MO; LA; QL (4 per 30 days)
PALYNZIQ SUBCUTANEOUS SYRINGE 20
MG/ML
4 PA; MO; LA; QL (60 per 30 days)
paricalcitol oral capsule 3 MO
RAYALDEE ORAL CAPSULE,EXTENDED
RELEASE 24 HR
4 MO
ROCALTROL ORAL CAPSULE 3 MO
ROCALTROL ORAL SOLUTION 3 MO
SAMSCA ORAL TABLET 4 PA; MO
SENSIPAR ORAL TABLET 30 MG 2 MO
SENSIPAR ORAL TABLET 60 MG, 90 MG 4 MO
SOMAVERT SUBCUTANEOUS RECON SOLN 4 MO
STIMATE NASAL SPRAY,NON-AEROSOL 2 MO
STRIANT BUCCAL MUCOADHESIVE
SYSTEM ER 12 HR
3 PA; MO; QL (60 per 30 days)
SYNAREL NASAL SPRAY,NON-AEROSOL 4 MO
TESTIM TRANSDERMAL GEL 3 PA; MO; QL (300 per 30 days)
testosterone cypionate intramuscular oil 1 PA; MO
testosterone enanthate intramuscular oil 1 PA; MO
testosterone transdermal gel in metered-dose
pump 10 mg/0.5 gram /actuation
1 PA; MO; QL (120 per 30 days)
testosterone transdermal gel in metered-dose
pump 12.5 mg/ 1.25 gram (1 %)
1 PA; MO; QL (300 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
89
Drug Name Drug Tier Requirements/Limits
testosterone transdermal gel in metered-dose
pump 20.25 mg/1.25 gram (1.62 %)
1 PA; MO; QL (150 per 30 days)
testosterone transdermal gel in packet 1 % (25
mg/2.5gram), 1 % (50 mg/5 gram)
1 PA; MO; QL (300 per 30 days)
testosterone transdermal gel in packet 1.62 %
(20.25 mg/1.25 gram)
1 PA; MO; QL (37.5 per 30 days)
testosterone transdermal gel in packet 1.62 %
(40.5 mg/2.5 gram)
1 PA; MO; QL (150 per 30 days)
testosterone transdermal solution in metered pump
w/app
1 PA; MO; QL (180 per 30 days)
VOGELXO TRANSDERMAL GEL IN
METERED-DOSE PUMP
3 PA; MO; QL (300 per 30 days)
VOGELXO TRANSDERMAL GEL IN PACKET 3 PA; MO; QL (300 per 30 days)
XYOSTED SUBCUTANEOUS AUTO-
INJECTOR
3 PA; MO
ZAVESCA ORAL CAPSULE 4 MO; LA
ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG 3 MO
THYROID HORMONES
CYTOMEL ORAL TABLET 3 MO
LEVO-T ORAL TABLET 3
levothyroxine oral tablet 1 MO
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,
137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50
mcg, 75 mcg, 88 mcg
1 MO
liothyronine oral tablet 1 MO
SYNTHROID ORAL TABLET 3 MO
TIROSINT ORAL CAPSULE 3 MO
TIROSINT-SOL ORAL SOLUTION 3 MO
unithroid oral tablet 100 mcg, 112 mcg, 125 mcg,
150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50
mcg, 75 mcg, 88 mcg
1 MO
GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
CUVPOSA ORAL SOLUTION 3 MO
dicyclomine oral capsule 1 MO
dicyclomine oral solution 1 MO
dicyclomine oral tablet 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
90
Drug Name Drug Tier Requirements/Limits
diphenoxylate-atropine oral liquid 1 MO
diphenoxylate-atropine oral tablet 1 MO
glycopyrrolate oral tablet 1 mg, 2 mg 1 MO
LOMOTIL ORAL TABLET 3 MO
loperamide oral capsule 1 MO
methscopolamine oral tablet 1 MO
MYTESI ORAL TABLET,DELAYED RELEASE
(DR/EC)
3 MO
MISCELLANEOUS GASTROINTESTINAL AGENTS
ACTIGALL ORAL CAPSULE 3 MO
AKYNZEO (FOSNETUPITANT)
INTRAVENOUS RECON SOLN
3 MO
alosetron oral tablet 4 MO
AMITIZA ORAL CAPSULE 2 MO
ANUSOL-HC TOPICAL CREAM WITH
PERINEAL APPLICATOR
3 MO
aprepitant oral capsule 1 B/D PA; MO
aprepitant oral capsule,dose pack 1 B/D PA; MO
APRISO ORAL CAPSULE,EXTENDED
RELEASE 24HR
3 MO
ASACOL HD ORAL TABLET,DELAYED
RELEASE (DR/EC)
2 MO
AZULFIDINE EN-TABS ORAL
TABLET,DELAYED RELEASE (DR/EC)
3 MO
AZULFIDINE ORAL TABLET 3 MO
balsalazide oral capsule 1 MO
BONJESTA ORAL TABLET,IR,DELAYED
REL,BIPHASIC
3 MO
budesonide oral capsule, delayed, extended
release
4 MO
budesonide oral tablet,delayed and ext.release 4 MO
CANASA RECTAL SUPPOSITORY 3 MO
CESAMET ORAL CAPSULE 4 B/D PA; MO
CHENODAL ORAL TABLET 4 PA; MO; LA
CHOLBAM ORAL CAPSULE 250 MG 4 PA; MO
CHOLBAM ORAL CAPSULE 50 MG 4 PA; MO; QL (120 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
91
Drug Name Drug Tier Requirements/Limits
CIMZIA POWDER FOR RECONST
SUBCUTANEOUS KIT
4 PA; MO
CIMZIA SUBCUTANEOUS SYRINGE KIT 4 PA; MO
CLENPIQ ORAL SOLUTION 3 ST; MO
COLAZAL ORAL CAPSULE 4 MO
colocort rectal enema 1 MO
COLYTE WITH FLAVOR PACKS ORAL
RECON SOLN 240-22.72-6.72 -5.84 GRAM
3 ST; MO
compro rectal suppository 1 MO
constulose oral solution 1 MO
CORTIFOAM RECTAL FOAM 2 MO
CREON ORAL CAPSULE,DELAYED
RELEASE(DR/EC)
2 MO
cromolyn oral concentrate 1 MO
CYSTADANE ORAL POWDER 4 MO
DELZICOL ORAL CAPSULE (WITH
DELAYED RELEASE TABLETS)
2 MO
DICLEGIS ORAL TABLET,DELAYED
RELEASE (DR/EC)
3 MO
DIPENTUM ORAL CAPSULE 4 MO
doxylamine-pyridoxine (vit b6) oral tablet,delayed
release (dr/ec)
1 MO
dronabinol oral capsule 10 mg 4 B/D PA; MO
dronabinol oral capsule 2.5 mg, 5 mg 3 B/D PA; MO
EMEND ORAL CAPSULE 3 B/D PA; MO
EMEND ORAL CAPSULE,DOSE PACK 3 B/D PA; MO
EMEND ORAL SUSPENSION FOR
RECONSTITUTION
2 B/D PA; MO
ENTOCORT EC ORAL
CAPSULE,DELAYED,EXTEND.RELEASE
4 MO
enulose oral solution 1 MO
GASTROCROM ORAL CONCENTRATE 3 MO
GATTEX 30-VIAL SUBCUTANEOUS KIT 4 PA; MO
gavilyte-c oral recon soln 1 MO
gavilyte-g oral recon soln 1 MO
gavilyte-n oral recon soln 1 MO
generlac oral solution 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
92
Drug Name Drug Tier Requirements/Limits
GOLYTELY ORAL POWDER IN PACKET 3 ST; MO
GOLYTELY ORAL RECON SOLN 3 ST; MO
granisetron hcl oral tablet 1 B/D PA; MO
hydrocortisone rectal enema 1 MO
hydrocortisone-pramoxine rectal cream 1-1 % 1 MO
INFLECTRA INTRAVENOUS RECON SOLN 4 PA; MO
KRISTALOSE ORAL PACKET 3 MO
lactulose oral packet 1
lactulose oral solution 10 gram/15 ml 1 MO
LIALDA ORAL TABLET,DELAYED RELEASE
(DR/EC)
3 MO
LINZESS ORAL CAPSULE 2 MO
LOTRONEX ORAL TABLET 4 MO
MARINOL ORAL CAPSULE 10 MG, 5 MG 4 B/D PA; MO
MARINOL ORAL CAPSULE 2.5 MG 3 B/D PA; MO
meclizine oral tablet 12.5 mg, 25 mg 1 MO
mesalamine oral capsule (with del rel tablets) 1 MO
mesalamine oral tablet,delayed release (dr/ec) 1 MO
mesalamine rectal enema 1 MO
mesalamine rectal suppository 1 MO
metoclopramide hcl oral solution 1 MO
metoclopramide hcl oral tablet 1 MO
metoclopramide hcl oral tablet,disintegrating 1 MO
MICORT-HC TOPICAL CREAM WITH
PERINEAL APPLICATOR 2.5 %
3 MO
MOTEGRITY ORAL TABLET 3 MO
MOVANTIK ORAL TABLET 2 MO
MOVIPREP ORAL POWDER IN PACKET 3 MO
NULYTELY WITH FLAVOR PACKS ORAL
RECON SOLN
3 ST; MO
OCALIVA ORAL TABLET 4 PA; MO; LA; QL (30 per 30 days)
ondansetron hcl oral solution 1 B/D PA; MO
ondansetron hcl oral tablet 24 mg 1 B/D PA
ondansetron hcl oral tablet 4 mg, 8 mg 1 B/D PA; MO
ondansetron oral tablet,disintegrating 1 B/D PA; MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
93
Drug Name Drug Tier Requirements/Limits
OSMOPREP ORAL TABLET 3 MO
PANCREAZE ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT,
16,800-56,800- 98,400 UNIT, 2,600-6,200- 10,850
UNIT, 21,000-54,700- 83,900 UNIT, 4,200-
14,200- 24,600 UNIT
3 ST; MO
peg 3350-electrolytes oral recon soln 236-22.74-
6.74 -5.86 gram
1 MO
peg 3350-electrolytes oral recon soln 240-22.72-
6.72 -5.84 gram
1
peg-electrolyte oral recon soln 1
PENTASA ORAL CAPSULE, EXTENDED
RELEASE 250 MG
2 MO
PENTASA ORAL CAPSULE, EXTENDED
RELEASE 500 MG
4 MO
PERTZYE ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 16,000-57,500- 60,500 UNIT
4 ST; MO
PERTZYE ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 4,000-14,375- 15,125 UNIT,
8,000-28,750- 30,250 UNIT
3 ST; MO
PLENVU ORAL POWDER IN PACKET,
SEQUENTIAL
3 ST; MO
PREPOPIK ORAL POWDER IN PACKET 3 ST; MO
prochlorperazine maleate oral tablet 1 MO
prochlorperazine rectal suppository 1 MO
procto-med hc topical cream with perineal
applicator
1 MO
procto-pak topical cream with perineal applicator 1 MO
proctosol hc topical cream with perineal
applicator
1 MO
proctozone-hc topical cream with perineal
applicator
1 MO
RECTIV RECTAL OINTMENT 2 MO
REGLAN ORAL TABLET 3 MO
RELISTOR ORAL TABLET 4 MO
RELISTOR SUBCUTANEOUS SOLUTION 4 MO
RELISTOR SUBCUTANEOUS SYRINGE 4 MO
REMICADE INTRAVENOUS RECON SOLN 4 PA; MO
ROWASA RECTAL ENEMA KIT 3 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
94
Drug Name Drug Tier Requirements/Limits
SANCUSO TRANSDERMAL PATCH WEEKLY 4 MO
scopolamine base transdermal patch 3 day 1 MO
SUCRAID ORAL SOLUTION 4 MO
sulfasalazine oral tablet 1 MO
sulfasalazine oral tablet,delayed release (dr/ec) 1 MO
SUPREP BOWEL PREP KIT ORAL RECON
SOLN
2 MO
SYMPROIC ORAL TABLET 2 MO
SYNDROS ORAL SOLUTION 4 B/D PA; MO
TRANSDERM-SCOP TRANSDERMAL PATCH
3 DAY
3 MO
trilyte with flavor packets oral recon soln 1 MO
TRULANCE ORAL TABLET 3 MO
UCERIS ORAL TABLET, DELAYED AND
EXTENDED RELEASE
4 MO
UCERIS RECTAL FOAM 3 MO
URSO 250 ORAL TABLET 3 MO
URSO FORTE ORAL TABLET 3 MO
ursodiol oral capsule 1 MO
ursodiol oral tablet 1 MO
VARUBI INTRAVENOUS EMULSION 2
VARUBI ORAL TABLET 2 B/D PA; MO
VIBERZI ORAL TABLET 4 MO
VIOKACE ORAL TABLET 2 MO
ZELNORM ORAL TABLET 3 MO
ZENPEP ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT,
15,000-47,000 -63,000 UNIT, 20,000-63,000-
84,000 UNIT, 25,000-79,000- 105,000 UNIT,
3,000-10,000 -14,000-UNIT, 40,000-126,000-
168,000 UNIT, 5,000-17,000- 24,000 UNIT
2 MO
ZOFRAN ORAL TABLET 8 MG 3 B/D PA; MO
ZUPLENZ ORAL FILM 3 B/D PA; MO
ULCER THERAPY
ACIPHEX ORAL TABLET,DELAYED
RELEASE (DR/EC)
3 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
95
Drug Name Drug Tier Requirements/Limits
amoxicillin-clarithromycin-lansoprazole oral
combo pack
1 MO; QL (112 per 30 days)
CARAFATE ORAL SUSPENSION 3 MO
CARAFATE ORAL TABLET 3 MO
cimetidine hcl oral solution 1 MO
cimetidine oral tablet 1 MO
CYTOTEC ORAL TABLET 3 MO
DEXILANT ORAL CAPSULE, BIPHASE
DELAYED RELEASE 30 MG
3 MO; QL (30 per 30 days)
DEXILANT ORAL CAPSULE, BIPHASE
DELAYED RELEASE 60 MG
3 MO
esomeprazole magnesium oral capsule,delayed
release(dr/ec) 20 mg
1 MO; QL (30 per 30 days)
esomeprazole magnesium oral capsule,delayed
release(dr/ec) 40 mg
1 MO
ESOMEPRAZOLE STRONTIUM ORAL
CAPSULE,DELAYED RELEASE(DR/EC) 49.3
MG
3 MO
famotidine oral suspension 1 MO
famotidine oral tablet 20 mg, 40 mg 1 MO
lansoprazole oral capsule,delayed release(dr/ec)
15 mg
1 MO; QL (30 per 30 days)
lansoprazole oral capsule,delayed release(dr/ec)
30 mg
1 MO
lansoprazole oral tablet,disintegrat, delay rel 15
mg
1 MO; QL (30 per 30 days)
lansoprazole oral tablet,disintegrat, delay rel 30
mg
1 MO
misoprostol oral tablet 1 MO
NEXIUM ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 20 MG
3 MO; QL (30 per 30 days)
NEXIUM ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 40 MG
3 MO
NEXIUM ORAL GRANULES DR FOR SUSP IN
PACKET 10 MG, 2.5 MG, 20 MG, 5 MG
2 MO; QL (30 per 30 days)
NEXIUM ORAL GRANULES DR FOR SUSP IN
PACKET 40 MG
2 MO
nizatidine oral capsule 1 MO
nizatidine oral solution 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
96
Drug Name Drug Tier Requirements/Limits
OMECLAMOX-PAK ORAL COMBO PACK 3 MO; QL (80 per 28 days)
omeprazole oral capsule,delayed release(dr/ec) 10
mg, 20 mg
1 MO; QL (30 per 30 days)
omeprazole oral capsule,delayed release(dr/ec) 40
mg
1 MO
omeprazole-sodium bicarbonate oral capsule 20-
1.1 mg-gram
4 MO; QL (30 per 30 days)
omeprazole-sodium bicarbonate oral capsule 40-
1.1 mg-gram
4 MO
omeprazole-sodium bicarbonate oral packet 20-
1,680 mg
4 MO; QL (30 per 30 days)
omeprazole-sodium bicarbonate oral packet 40-
1,680 mg
4 MO
pantoprazole oral tablet,delayed release (dr/ec) 20
mg
1 MO; QL (30 per 30 days)
pantoprazole oral tablet,delayed release (dr/ec) 40
mg
1 MO
PEPCID ORAL TABLET 3 MO
PREVACID ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 15 MG
3 MO; QL (30 per 30 days)
PREVACID ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 30 MG
3 MO
PREVACID SOLUTAB ORAL
TABLET,DISINTEGRAT, DELAY REL 15 MG
3 MO; QL (30 per 30 days)
PREVACID SOLUTAB ORAL
TABLET,DISINTEGRAT, DELAY REL 30 MG
3 MO
PRILOSEC ORAL SUSP,DELAYED RELEASE
FOR RECON
3 MO
PROTONIX ORAL GRANULES DR FOR SUSP
IN PACKET
3 MO
PROTONIX ORAL TABLET,DELAYED
RELEASE (DR/EC) 20 MG
3 MO; QL (30 per 30 days)
PROTONIX ORAL TABLET,DELAYED
RELEASE (DR/EC) 40 MG
3 MO
PYLERA ORAL CAPSULE 2 MO
rabeprazole oral tablet,delayed release (dr/ec) 1 MO
ranitidine hcl oral capsule 1 MO
ranitidine hcl oral syrup 1 MO
ranitidine hcl oral tablet 150 mg, 300 mg 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
97
Drug Name Drug Tier Requirements/Limits
sucralfate oral tablet 1 MO
ZEGERID ORAL CAPSULE 20-1.1 MG-GRAM 4 MO; QL (30 per 30 days)
ZEGERID ORAL CAPSULE 40-1.1 MG-GRAM 4 MO
ZEGERID ORAL PACKET 20-1,680 MG 4 MO; QL (30 per 30 days)
ZEGERID ORAL PACKET 40-1,680 MG 4 MO
IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ACTIMMUNE SUBCUTANEOUS SOLUTION 4 B/D PA; MO
ARANESP (IN POLYSORBATE) INJECTION
SOLUTION 100 MCG/ML, 200 MCG/ML, 300
MCG/ML, 60 MCG/ML
4 PA; MO
ARANESP (IN POLYSORBATE) INJECTION
SOLUTION 150 MCG/0.75 ML
4 PA
ARANESP (IN POLYSORBATE) INJECTION
SOLUTION 25 MCG/ML, 40 MCG/ML
3 PA; MO
ARANESP (IN POLYSORBATE) INJECTION
SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML,
40 MCG/0.4 ML
3 PA; MO
ARANESP (IN POLYSORBATE) INJECTION
SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML,
200 MCG/0.4 ML, 300 MCG/0.6 ML, 500
MCG/ML, 60 MCG/0.3 ML
4 PA; MO
ARCALYST SUBCUTANEOUS RECON SOLN 4 PA; MO
AVONEX (WITH ALBUMIN)
INTRAMUSCULAR KIT
4 PA; MO; QL (4 per 28 days)
AVONEX INTRAMUSCULAR PEN INJECTOR
KIT
4 PA; MO; QL (4 per 28 days)
AVONEX INTRAMUSCULAR SYRINGE KIT 4 PA; MO; QL (4 per 28 days)
BETASERON SUBCUTANEOUS KIT 4 PA; MO; QL (15 per 28 days)
EGRIFTA SUBCUTANEOUS RECON SOLN 1
MG
4 PA; MO
EPOGEN INJECTION SOLUTION 2,000
UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML,
4,000 UNIT/ML
3 PA; MO
EPOGEN INJECTION SOLUTION 20,000
UNIT/ML
4 PA; MO
EXTAVIA SUBCUTANEOUS KIT 4 PA; MO; QL (15 per 28 days)
FULPHILA SUBCUTANEOUS SYRINGE 4 PA; MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
98
Drug Name Drug Tier Requirements/Limits
GENOTROPIN MINIQUICK SUBCUTANEOUS
SYRINGE 0.2 MG/0.25 ML
3 PA; MO
GENOTROPIN MINIQUICK SUBCUTANEOUS
SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML,
0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25
ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8
MG/0.25 ML, 2 MG/0.25 ML
4 PA; MO
GENOTROPIN SUBCUTANEOUS
CARTRIDGE
4 PA; MO
GRANIX SUBCUTANEOUS SOLUTION 4 PA; MO
GRANIX SUBCUTANEOUS SYRINGE 4 PA; MO
HUMATROPE INJECTION CARTRIDGE 4 PA; MO
HUMATROPE INJECTION RECON SOLN 4 PA; MO
INTRON A INJECTION RECON SOLN 4 B/D PA; MO
INTRON A INJECTION SOLUTION 10
MILLION UNIT/ML
2 B/D PA; MO
INTRON A INJECTION SOLUTION 6
MILLION UNIT/ML
4 B/D PA; MO
LEUKINE INJECTION RECON SOLN 4 MO
NEULASTA SUBCUTANEOUS SYRINGE 4 PA; MO
NEUPOGEN INJECTION SOLUTION 4 PA; MO
NEUPOGEN INJECTION SYRINGE 4 PA; MO
NIVESTYM INJECTION SOLUTION 4 PA; MO
NIVESTYM SUBCUTANEOUS SYRINGE 4 PA; MO
NORDITROPIN FLEXPRO SUBCUTANEOUS
PEN INJECTOR
4 PA; MO
NUTROPIN AQ NUSPIN SUBCUTANEOUS
PEN INJECTOR
4 PA; MO
OMNITROPE SUBCUTANEOUS CARTRIDGE 4 PA; MO
OMNITROPE SUBCUTANEOUS RECON
SOLN
4 PA; MO
PEGASYS PROCLICK SUBCUTANEOUS PEN
INJECTOR 180 MCG/0.5 ML
4 MO; QL (2 per 28 days)
PEGASYS SUBCUTANEOUS SOLUTION 4 MO; QL (4 per 28 days)
PEGASYS SUBCUTANEOUS SYRINGE 4 MO; QL (2 per 28 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR
125 MCG/0.5 ML
4 PA; MO; QL (1 per 28 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR
63 MCG/0.5 ML- 94 MCG/0.5 ML
4 PA; MO; QL (1 per 180 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
99
Drug Name Drug Tier Requirements/Limits
PLEGRIDY SUBCUTANEOUS SYRINGE 125
MCG/0.5 ML
4 PA; MO; QL (1 per 28 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 63
MCG/0.5 ML- 94 MCG/0.5 ML
4 PA; MO; QL (1 per 180 days)
PROCRIT INJECTION SOLUTION 10,000
UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML,
4,000 UNIT/ML
2 PA; MO
PROCRIT INJECTION SOLUTION 20,000
UNIT/ML, 40,000 UNIT/ML
4 PA; MO
REBIF (WITH ALBUMIN) SUBCUTANEOUS
SYRINGE
4 PA; MO; QL (6 per 28 days)
REBIF REBIDOSE SUBCUTANEOUS PEN
INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML
4 PA; MO; QL (6 per 28 days)
REBIF REBIDOSE SUBCUTANEOUS PEN
INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)
4 PA; MO; QL (4.2 per 180 days)
REBIF TITRATION PACK SUBCUTANEOUS
SYRINGE
4 PA; MO; QL (4.2 per 180 days)
RETACRIT INJECTION SOLUTION 10,000
UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML,
4,000 UNIT/ML
2 PA; MO
RETACRIT INJECTION SOLUTION 40,000
UNIT/ML
4 PA; MO
SAIZEN SAIZENPREP SUBCUTANEOUS
CARTRIDGE
4 PA; MO
SAIZEN SUBCUTANEOUS RECON SOLN 4 PA; MO
SEROSTIM SUBCUTANEOUS RECON SOLN 4
MG, 5 MG, 6 MG
4 PA; MO
SYLATRON SUBCUTANEOUS KIT 4 MO
UDENYCA SUBCUTANEOUS SYRINGE 4 PA; MO
ZARXIO INJECTION SYRINGE 4 PA; MO
ZOMACTON SUBCUTANEOUS RECON SOLN
10 MG
4 PA; MO
ZOMACTON SUBCUTANEOUS RECON SOLN
5 MG
3 PA; MO
ZORBTIVE SUBCUTANEOUS RECON SOLN 4 PA; MO
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON
SOLN
2 MO
ADACEL(TDAP ADOLESN/ADULT)(PF)
INTRAMUSCULAR SUSPENSION
2 MO
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100
Drug Name Drug Tier Requirements/Limits
ADACEL(TDAP ADOLESN/ADULT)(PF)
INTRAMUSCULAR SYRINGE
2 MO
BCG VACCINE, LIVE (PF) PERCUTANEOUS
SUSPENSION FOR RECONSTITUTION
2 MO
BEXSERO INTRAMUSCULAR SYRINGE 2 MO
BOOSTRIX TDAP INTRAMUSCULAR
SUSPENSION
2 MO
BOOSTRIX TDAP INTRAMUSCULAR
SYRINGE
2 MO
DAPTACEL (DTAP PEDIATRIC) (PF)
INTRAMUSCULAR SUSPENSION
2 MO
ENGERIX-B (PF) INTRAMUSCULAR
SYRINGE
2 B/D PA; MO
ENGERIX-B PEDIATRIC (PF)
INTRAMUSCULAR SYRINGE
2 B/D PA; MO
FLEBOGAMMA DIF INTRAVENOUS
SOLUTION 10 %
4 PA; MO
GAMMAGARD LIQUID INJECTION
SOLUTION
4 PA; MO
GAMMAGARD S-D (IGA < 1 MCG/ML)
INTRAVENOUS RECON SOLN
4 PA; MO
GAMMAKED INJECTION SOLUTION 1
GRAM/10 ML (10 %)
4 PA; MO
GAMMAPLEX (WITH SORBITOL)
INTRAVENOUS SOLUTION
4 PA; MO
GAMMAPLEX INTRAVENOUS SOLUTION 4 PA; MO
GAMUNEX-C INJECTION SOLUTION 1
GRAM/10 ML (10 %)
4 PA; MO
GARDASIL 9 (PF) INTRAMUSCULAR
SUSPENSION
2 MO
GARDASIL 9 (PF) INTRAMUSCULAR
SYRINGE
2 MO
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION
2 MO
HAVRIX (PF) INTRAMUSCULAR SYRINGE
1,440 ELISA UNIT/ML
2 MO
HAVRIX (PF) INTRAMUSCULAR SYRINGE
720 ELISA UNIT/0.5 ML
2
HIBERIX (PF) INTRAMUSCULAR RECON
SOLN
2 MO
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101
Drug Name Drug Tier Requirements/Limits
IMOVAX RABIES VACCINE (PF)
INTRAMUSCULAR RECON SOLN
2 MO
INFANRIX (DTAP) (PF) INTRAMUSCULAR
SUSPENSION
2 MO
IPOL INJECTION SUSPENSION 2 MO
IXIARO (PF) INTRAMUSCULAR SYRINGE 2 MO
KINRIX (PF) INTRAMUSCULAR
SUSPENSION
2
KINRIX (PF) INTRAMUSCULAR SYRINGE 2 MO
MENACTRA (PF) INTRAMUSCULAR
SOLUTION
2 MO
MENVEO A-C-Y-W-135-DIP (PF)
INTRAMUSCULAR KIT
2 MO
M-M-R II (PF) SUBCUTANEOUS RECON
SOLN
2 MO
OCTAGAM INTRAVENOUS SOLUTION 4 PA; MO
ORALAIR SUBLINGUAL TABLET 300 INDX
REACTIVITY
3 PA; MO
PANZYGA INTRAVENOUS SOLUTION 10 % 4 PA; MO
PANZYGA INTRAVENOUS SOLUTION 10 %
(100 ML), 10 % (200 ML), 10 % (25 ML), 10 %
(300 ML), 10 % (50 ML)
4 PA
PEDIARIX (PF) INTRAMUSCULAR SYRINGE 2 MO
PEDVAX HIB (PF) INTRAMUSCULAR
SOLUTION
2 MO
PRIVIGEN INTRAVENOUS SOLUTION 4 PA; MO
PROQUAD (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION
2 MO
QUADRACEL (PF) INTRAMUSCULAR
SUSPENSION
2 MO
RABAVERT (PF) INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION
2 MO
RAGWITEK SUBLINGUAL TABLET 2 MO
RECOMBIVAX HB (PF) INTRAMUSCULAR
SUSPENSION 10 MCG/ML, 40 MCG/ML
2 B/D PA; MO
RECOMBIVAX HB (PF) INTRAMUSCULAR
SYRINGE 10 MCG/ML
2 B/D PA; MO
RECOMBIVAX HB (PF) INTRAMUSCULAR
SYRINGE 5 MCG/0.5 ML
2 B/D PA
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102
Drug Name Drug Tier Requirements/Limits
ROTARIX ORAL SUSPENSION FOR
RECONSTITUTION
2
ROTATEQ VACCINE ORAL SOLUTION 2 MO
SHINGRIX (PF) INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION
2 MO
TDVAX INTRAMUSCULAR SUSPENSION 2 MO
TENIVAC (PF) INTRAMUSCULAR SYRINGE 2 MO
TETANUS,DIPHTHERIA TOX PED(PF)
INTRAMUSCULAR SUSPENSION
2 MO
TRUMENBA INTRAMUSCULAR SYRINGE 2 MO
TWINRIX (PF) INTRAMUSCULAR SYRINGE 2 MO
TYPHIM VI INTRAMUSCULAR SOLUTION 2
TYPHIM VI INTRAMUSCULAR SYRINGE 2 MO
VAQTA (PF) INTRAMUSCULAR
SUSPENSION
2 MO
VAQTA (PF) INTRAMUSCULAR SYRINGE 2 MO
VARIVAX (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION
2 MO
VARIZIG INTRAMUSCULAR SOLUTION 2 MO
YF-VAX (PF) SUBCUTANEOUS SUSPENSION
FOR RECONSTITUTION
2 MO
ZOSTAVAX (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION
2 MO
MUSCULOSKELETAL / RHEUMATOLOGY
GOUT THERAPY
allopurinol oral tablet 1 MO
COLCHICINE ORAL CAPSULE 3 ST; MO
COLCHICINE ORAL TABLET 3 ST; MO
COLCRYS ORAL TABLET 2 MO
DUZALLO ORAL TABLET 200-200 MG 3 MO
febuxostat oral tablet 1 MO
MITIGARE ORAL CAPSULE 2 MO
probenecid oral tablet 1 MO
probenecid-colchicine oral tablet 1 MO
ULORIC ORAL TABLET 2 MO
ZYLOPRIM ORAL TABLET 3 MO
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103
Drug Name Drug Tier Requirements/Limits
OSTEOPOROSIS THERAPY
ACTONEL ORAL TABLET 150 MG 3 ST; MO; QL (1 per 30 days)
ACTONEL ORAL TABLET 35 MG 3 ST; MO; QL (4 per 28 days)
ACTONEL ORAL TABLET 5 MG 3 ST; MO; QL (30 per 30 days)
alendronate oral solution 1 MO; QL (1286 per 30 days)
alendronate oral tablet 10 mg, 5 mg 1 MO; QL (30 per 30 days)
alendronate oral tablet 35 mg, 70 mg 1 MO; QL (4 per 28 days)
ATELVIA ORAL TABLET,DELAYED
RELEASE (DR/EC)
3 ST; MO; QL (4 per 28 days)
BINOSTO ORAL TABLET, EFFERVESCENT 3 ST; MO; QL (4 per 28 days)
BONIVA ORAL TABLET 3 ST; MO; QL (1 per 30 days)
EVENITY SUBCUTANEOUS SYRINGE
210MG/2.34ML ( 105MG/1.17MLX2)
4 PA; MO; QL (2.34 per 30 days)
EVISTA ORAL TABLET 3 MO
FORTEO SUBCUTANEOUS PEN INJECTOR 4 PA; MO; QL (2.4 per 28 days)
FOSAMAX ORAL TABLET 70 MG 3 ST; MO; QL (4 per 28 days)
FOSAMAX PLUS D ORAL TABLET 3 ST; MO; QL (4 per 28 days)
ibandronate oral tablet 1 MO; QL (1 per 30 days)
PROLIA SUBCUTANEOUS SYRINGE 2 PA; MO
raloxifene oral tablet 1 MO
risedronate oral tablet 150 mg 1 MO; QL (1 per 30 days)
risedronate oral tablet 35 mg, 35 mg (12 pack), 35
mg (4 pack)
1 MO; QL (4 per 28 days)
risedronate oral tablet 5 mg 1 MO; QL (30 per 30 days)
risedronate oral tablet,delayed release (dr/ec) 1 MO; QL (4 per 28 days)
TYMLOS SUBCUTANEOUS PEN INJECTOR 4 PA; MO; QL (1.56 per 30 days)
OTHER RHEUMATOLOGICALS
ACTEMRA ACTPEN SUBCUTANEOUS PEN
INJECTOR
4 PA; MO; QL (4 per 28 days)
ACTEMRA INTRAVENOUS SOLUTION 4 PA; MO
ACTEMRA SUBCUTANEOUS SYRINGE 4 PA; MO
ARAVA ORAL TABLET 4 MO; QL (30 per 30 days)
BENLYSTA SUBCUTANEOUS AUTO-
INJECTOR
4 PA; MO
BENLYSTA SUBCUTANEOUS SYRINGE 4 PA; MO
CUPRIMINE ORAL CAPSULE 4 MO
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104
Drug Name Drug Tier Requirements/Limits
DEPEN TITRATABS ORAL TABLET 4 MO
ENBREL MINI SUBCUTANEOUS
CARTRIDGE
4 PA; MO; QL (8 per 28 days)
ENBREL SUBCUTANEOUS RECON SOLN 4 PA; MO; QL (16 per 28 days)
ENBREL SUBCUTANEOUS SYRINGE 4 PA; MO; QL (8 per 28 days)
ENBREL SURECLICK SUBCUTANEOUS PEN
INJECTOR
4 PA; MO; QL (8 per 28 days)
HUMIRA PEDIATRIC CROHNS START
SUBCUTANEOUS SYRINGE KIT 40 MG/0.8
ML
4 PA; MO; QL (3 per 180 days)
HUMIRA PEDIATRIC CROHNS START
SUBCUTANEOUS SYRINGE KIT 40 MG/0.8
ML (6 PACK)
4 PA; MO; QL (6 per 180 days)
HUMIRA PEN CROHNS-UC-HS START
SUBCUTANEOUS INJECTOR KIT
4 PA; MO; QL (6 per 180 days)
HUMIRA PEN PSOR-UVEITS-ADOL HS
SUBCUTANEOUS INJECTOR KIT
4 PA; MO; QL (4 per 180 days)
HUMIRA PEN SUBCUTANEOUS INJECTOR
KIT
4 PA; MO; QL (4 per 28 days)
HUMIRA SUBCUTANEOUS SYRINGE KIT 10
MG/0.2 ML, 20 MG/0.4 ML
4 PA; MO; QL (2 per 28 days)
HUMIRA SUBCUTANEOUS SYRINGE KIT 40
MG/0.8 ML
4 PA; MO; QL (4 per 28 days)
HUMIRA(CF) PEDI CROHNS STARTER
SUBCUTANEOUS SYRINGE KIT 80 MG/0.8
ML
4 PA; MO; QL (3 per 180 days)
HUMIRA(CF) PEDI CROHNS STARTER
SUBCUTANEOUS SYRINGE KIT 80 MG/0.8
ML-40 MG/0.4 ML
4 PA; MO; QL (2 per 180 days)
HUMIRA(CF) PEN CROHNS-UC-HS
SUBCUTANEOUS INJECTOR KIT
4 PA; MO; QL (3 per 180 days)
HUMIRA(CF) PEN PSOR-UV-ADOL HS
SUBCUTANEOUS INJECTOR KIT
4 PA; MO; QL (3 per 180 days)
HUMIRA(CF) SUBCUTANEOUS PEN
INJECTOR KIT 40 MG/0.4 ML
4 PA; MO; QL (4 per 28 days)
HUMIRA(CF) SUBCUTANEOUS SYRINGE
KIT 10 MG/0.1 ML, 20 MG/0.2 ML
4 PA; MO; QL (2 per 28 days)
HUMIRA(CF) SUBCUTANEOUS SYRINGE
KIT 40 MG/0.4 ML
4 PA; MO; QL (4 per 28 days)
KEVZARA SUBCUTANEOUS PEN INJECTOR 4 PA; MO; QL (2.28 per 28 days)
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105
Drug Name Drug Tier Requirements/Limits
KEVZARA SUBCUTANEOUS SYRINGE 4 PA; MO; QL (2.28 per 28 days)
KINERET SUBCUTANEOUS SYRINGE 4 PA; MO
leflunomide oral tablet 1 MO; QL (30 per 30 days)
OLUMIANT ORAL TABLET 4 PA; MO; QL (30 per 30 days)
ORENCIA (WITH MALTOSE) INTRAVENOUS
RECON SOLN
4 PA; MO
ORENCIA CLICKJECT SUBCUTANEOUS
AUTO-INJECTOR
4 PA; MO
ORENCIA SUBCUTANEOUS SYRINGE 4 PA; MO
OTEZLA ORAL TABLET 4 PA; MO
OTEZLA STARTER ORAL TABLETS,DOSE
PACK 10 MG (4)-20 MG (4)-30 MG (47)
4 PA; MO
OTEZLA STARTER ORAL TABLETS,DOSE
PACK 10 MG (4)-20 MG (4)-30 MG(19)
4 PA
OTREXUP (PF) SUBCUTANEOUS AUTO-
INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15
MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML,
22.5 MG/0.4 ML, 25 MG/0.4 ML
3 MO
penicillamine oral capsule 4 MO
RASUVO (PF) SUBCUTANEOUS AUTO-
INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15
MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML,
22.5 MG/0.45 ML, 25 MG/0.5 ML, 30 MG/0.6
ML, 7.5 MG/0.15 ML
2 MO
RIDAURA ORAL CAPSULE 4 MO
RINVOQ ER ORAL TABLET EXTENDED
RELEASE 24 HR
4 PA; MO; QL (30 per 30 days)
SAVELLA ORAL TABLET 2 MO; QL (60 per 30 days)
SAVELLA ORAL TABLETS,DOSE PACK 2 MO; QL (55 per 30 days)
SIMPONI SUBCUTANEOUS PEN INJECTOR 4 PA; MO
SIMPONI SUBCUTANEOUS SYRINGE 4 PA; MO
XELJANZ ORAL TABLET 4 PA; MO
XELJANZ XR ORAL TABLET EXTENDED
RELEASE 24 HR
4 PA; MO
OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
ACTIVELLA ORAL TABLET 1-0.5 MG 3 PA; MO
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106
Drug Name Drug Tier Requirements/Limits
ALORA TRANSDERMAL PATCH
SEMIWEEKLY
3 PA; MO; QL (8 per 28 days)
amabelz oral tablet 1 PA; MO
ANGELIQ ORAL TABLET 3 PA; MO
AYGESTIN ORAL TABLET 3 MO
BIJUVA ORAL CAPSULE 3 PA; MO
camila oral tablet 1 MO
CLIMARA PRO TRANSDERMAL PATCH
WEEKLY
3 PA; MO
CLIMARA TRANSDERMAL PATCH WEEKLY 3 PA; MO; QL (4 per 28 days)
COMBIPATCH TRANSDERMAL PATCH
SEMIWEEKLY
3 PA; MO
CRINONE VAGINAL GEL 4 % 3 MO
CRINONE VAGINAL GEL 8 % 3 PA; MO
deblitane oral tablet 1 MO
DELESTROGEN INTRAMUSCULAR OIL 3 MO
DEPO-ESTRADIOL INTRAMUSCULAR OIL 3 MO
DEPO-PROVERA INTRAMUSCULAR
SUSPENSION 150 MG/ML
3 MO
DEPO-PROVERA INTRAMUSCULAR
SUSPENSION 400 MG/ML
2 MO
DEPO-SUBQ PROVERA 104
SUBCUTANEOUS SYRINGE
3 MO
DIVIGEL TRANSDERMAL GEL IN PACKET 1
MG/GRAM (0.1 %)
3 PA; MO; QL (30 per 30 days)
dotti transdermal patch semiweekly 1 PA; MO; QL (8 per 28 days)
DUAVEE ORAL TABLET 2 MO
ELESTRIN TRANSDERMAL GEL IN
METERED-DOSE PUMP
3 PA; MO
errin oral tablet 1 MO
ESTRACE ORAL TABLET 3 PA; MO
ESTRACE VAGINAL CREAM 3 MO
estradiol oral tablet 3 PA; MO
estradiol transdermal patch semiweekly 1 PA; MO; QL (8 per 28 days)
estradiol transdermal patch weekly 1 PA; MO; QL (4 per 28 days)
estradiol vaginal cream 1 MO
estradiol vaginal tablet 1 MO
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107
Drug Name Drug Tier Requirements/Limits
estradiol valerate intramuscular oil 20 mg/ml, 40
mg/ml
1 MO
estradiol-norethindrone acet oral tablet 1 PA; MO
ESTRING VAGINAL RING 2 MO
EVAMIST TRANSDERMAL SPRAY,NON-
AEROSOL
3 PA; MO; QL (16.2 per 30 days)
FEMHRT LOW DOSE ORAL TABLET 3 PA; MO
FEMRING VAGINAL RING 3 MO
fyavolv oral tablet 1 PA; MO
IMVEXXY MAINTENANCE PACK VAGINAL
INSERT
3 MO
IMVEXXY STARTER PACK VAGINAL
INSERT, DOSE PACK
3 MO
incassia oral tablet 1 MO
jinteli oral tablet 1 PA; MO
lopreeza oral tablet 1-0.5 mg 1 PA; MO
lyza oral tablet 1 MO
medroxyprogesterone intramuscular suspension 1 MO
medroxyprogesterone intramuscular syringe 1 MO
medroxyprogesterone oral tablet 1 MO
MENEST ORAL TABLET 0.3 MG, 0.625 MG,
1.25 MG
2 PA; MO
MENOSTAR TRANSDERMAL PATCH
WEEKLY
3 PA; MO; QL (4 per 28 days)
mimvey lo oral tablet 1 PA; MO
mimvey oral tablet 1 PA; MO
MINIVELLE TRANSDERMAL PATCH
SEMIWEEKLY
3 PA; MO; QL (8 per 28 days)
nora-be oral tablet 1 MO
norethindrone (contraceptive) oral tablet 1 MO
norethindrone acetate oral tablet 1 MO
norethindrone ac-eth estradiol oral tablet 0.5-2.5
mg-mcg, 1-5 mg-mcg
3 PA; MO
norlyroc oral tablet 1
ORTHO MICRONOR ORAL TABLET 3 MO
PREFEST ORAL TABLET 3 PA; MO
PREMARIN ORAL TABLET 2 MO
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108
Drug Name Drug Tier Requirements/Limits
PREMARIN VAGINAL CREAM 2 MO
PREMPHASE ORAL TABLET 3 PA; MO
PREMPRO ORAL TABLET 3 PA; MO
progesterone micronized oral capsule 1 MO
PROMETRIUM ORAL CAPSULE 3 MO
PROVERA ORAL TABLET 3 MO
sharobel oral tablet 1 MO
VAGIFEM VAGINAL TABLET 3 MO
VIVELLE-DOT TRANSDERMAL PATCH
SEMIWEEKLY
3 PA; MO; QL (8 per 28 days)
yuvafem vaginal tablet 1 MO
MISCELLANEOUS OB/GYN
AVC VAGINAL CREAM 3 MO
CLEOCIN VAGINAL CREAM 3 MO
CLEOCIN VAGINAL SUPPOSITORY 2 MO
clindamycin phosphate vaginal cream 1 MO
CLINDESSE VAGINAL CREAM,EXTENDED
RELEASE
3 MO
GYNAZOLE-1 VAGINAL CREAM 3 MO
INTRAROSA VAGINAL INSERT 3 MO
LUPANETA PACK (1 MONTH) KIT. SYRINGE
AND TABLET
4 MO
LUPANETA PACK (3 MONTH) KIT. SYRINGE
AND TABLET
4 MO
LYSTEDA ORAL TABLET 3 MO
metronidazole vaginal gel 1 MO
miconazole-3 vaginal suppository 1 MO
NUVARING VAGINAL RING 3 MO
OSPHENA ORAL TABLET 3 MO
terconazole vaginal cream 1 MO
terconazole vaginal suppository 1 MO
tranexamic acid oral tablet 1 MO
vandazole vaginal gel 1 MO
xulane transdermal patch weekly 1 MO
ORAL CONTRACEPTIVES / RELATED AGENTS
altavera (28) oral tablet 1 MO
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109
Drug Name Drug Tier Requirements/Limits
alyacen 1/35 (28) oral tablet 1 MO
amethia lo oral tablets,dose pack,3 month 1 MO
amethia oral tablets,dose pack,3 month 1 MO
apri oral tablet 1 MO
aranelle (28) oral tablet 1 MO
ashlyna oral tablets,dose pack,3 month 1 MO
aubra oral tablet 1 MO
aviane oral tablet 1 MO
BALCOLTRA ORAL TABLET 3 MO
balziva (28) oral tablet 1 MO
BEYAZ ORAL TABLET 3 MO
blisovi 24 fe oral tablet 1 MO
blisovi fe 1.5/30 (28) oral tablet 1 MO
briellyn oral tablet 1 MO
camrese lo oral tablets,dose pack,3 month 1 MO
caziant (28) oral tablet 1 MO
cryselle (28) oral tablet 1 MO
cyclafem 1/35 (28) oral tablet 1 MO
cyclafem 7/7/7 (28) oral tablet 1 MO
cyred eq oral tablet 1 MO
delyla (28) oral tablet 1
desog-e.estradiol/e.estradiol oral tablet 1 MO
desogestrel-ethinyl estradiol oral tablet 1 MO
drospirenone-e.estradiol-lm.fa oral tablet 3-0.02-
0.451 mg (24) (4)
1 MO
drospirenone-ethinyl estradiol oral tablet 1 MO
emoquette oral tablet 1 MO
enpresse oral tablet 1 MO
enskyce oral tablet 1 MO
estarylla oral tablet 1 MO
ethynodiol diac-eth estradiol oral tablet 1
falmina (28) oral tablet 1 MO
fayosim oral tablets,dose pack,3 month 1 MO
femynor oral tablet 1 MO
GENERESS FE ORAL TABLET,CHEWABLE 3 MO
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110
Drug Name Drug Tier Requirements/Limits
gianvi (28) oral tablet 1 MO
hailey 24 fe oral tablet 1 MO
introvale oral tablets,dose pack,3 month 1 MO
isibloom oral tablet 1 MO
jasmiel (28) oral tablet 1 MO
juleber oral tablet 1 MO
junel 1.5/30 (21) oral tablet 1 MO
junel 1/20 (21) oral tablet 1 MO
junel fe 1.5/30 (28) oral tablet 1 MO
junel fe 1/20 (28) oral tablet 1 MO
junel fe 24 oral tablet 1 MO
kaitlib fe oral tablet,chewable 1 MO
kariva (28) oral tablet 1 MO
kelnor 1/35 (28) oral tablet 1 MO
kelnor 1-50 oral tablet 1 MO
kurvelo (28) oral tablet 1 MO
l norgest/e.estradiol-e.estrad oral tablets,dose
pack,3 month
1 MO
larin 1.5/30 (21) oral tablet 1 MO
larin 1/20 (21) oral tablet 1 MO
larin fe 1.5/30 (28) oral tablet 1 MO
larin fe 1/20 (28) oral tablet 1 MO
larissia oral tablet 1 MO
layolis fe oral tablet,chewable 1 MO
leena 28 oral tablet 1 MO
lessina oral tablet 1 MO
levonest (28) oral tablet 1 MO
levonorgestrel-ethinyl estrad oral tablet 1 MO
levonorgestrel-ethinyl estrad oral tablets,dose
pack,3 month
1 MO
levonorg-eth estrad triphasic oral tablet 1 MO
levora-28 oral tablet 1 MO
LO LOESTRIN FE ORAL TABLET 3 MO
LOESTRIN 1.5/30 (21) ORAL TABLET 3 MO
LOESTRIN 1/20 (21) ORAL TABLET 3 MO
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111
Drug Name Drug Tier Requirements/Limits
LOESTRIN FE 1.5/30 (28-DAY) ORAL TABLET 3 MO
LOESTRIN FE 1/20 (28-DAY) ORAL TABLET 3 MO
loryna (28) oral tablet 1 MO
LOSEASONIQUE ORAL TABLETS,DOSE
PACK,3 MONTH
3 MO
low-ogestrel (28) oral tablet 1 MO
lutera (28) oral tablet 1 MO
marlissa (28) oral tablet 1 MO
melodetta 24 fe oral tablet,chewable 1 MO
mibelas 24 fe oral tablet,chewable 1 MO
microgestin 1.5/30 (21) oral tablet 1 MO
microgestin 1/20 (21) oral tablet 1 MO
microgestin fe 1.5/30 (28) oral tablet 1 MO
microgestin fe 1/20 (28) oral tablet 1 MO
mili oral tablet 1 MO
MINASTRIN 24 FE ORAL
TABLET,CHEWABLE
3 MO
NATAZIA ORAL TABLET 3 MO
necon 0.5/35 (28) oral tablet 1 MO
nikki (28) oral tablet 1 MO
noreth-ethinyl estradiol-iron oral tablet,chewable 1 MO
norethindrone ac-eth estradiol oral tablet 1-20
mg-mcg
1 MO
norethindrone-e.estradiol-iron oral tablet 1 mg-20
mcg (24)/75 mg (4)
1 MO
norethindrone-e.estradiol-iron oral
tablet,chewable
1 MO
norgestimate-ethinyl estradiol oral tablet 1 MO
nortrel 0.5/35 (28) oral tablet 1 MO
nortrel 1/35 (21) oral tablet 1 MO
nortrel 1/35 (28) oral tablet 1 MO
nortrel 7/7/7 (28) oral tablet 1 MO
ocella oral tablet 1 MO
ogestrel (28) oral tablet 1 MO
orsythia oral tablet 1 MO
ORTHO TRI-CYCLEN LO (28) ORAL TABLET 3 MO
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112
Drug Name Drug Tier Requirements/Limits
ORTHO-NOVUM 1/35 (28) ORAL TABLET 3 MO
ORTHO-NOVUM 7/7/7 (28) ORAL TABLET 3 MO
pimtrea (28) oral tablet 1 MO
pirmella oral tablet 1-35 mg-mcg 1 MO
portia 28 oral tablet 1 MO
previfem oral tablet 1 MO
QUARTETTE ORAL TABLETS,DOSE PACK,3
MONTH
3 MO
reclipsen (28) oral tablet 1 MO
rivelsa oral tablets,dose pack,3 month 1 MO
SAFYRAL ORAL TABLET 3 MO
SEASONIQUE ORAL TABLETS,DOSE PACK,3
MONTH
3 MO
setlakin oral tablets,dose pack,3 month 1 MO
SLYND ORAL TABLET 3 MO
sprintec (28) oral tablet 1 MO
sronyx oral tablet 1 MO
syeda oral tablet 1 MO
tarina 24 fe oral tablet 1
tarina fe 1/20 (28) oral tablet 1 MO
tri-estarylla oral tablet 1 MO
tri-legest fe oral tablet 1 MO
tri-lo-estarylla oral tablet 1 MO
tri-lo-sprintec oral tablet 1 MO
tri-mili oral tablet 1 MO
tri-previfem (28) oral tablet 1 MO
tri-sprintec (28) oral tablet 1 MO
trivora (28) oral tablet 1 MO
tri-vylibra lo oral tablet 1 MO
tri-vylibra oral tablet 1 MO
tydemy oral tablet 1 MO
velivet triphasic regimen (28) oral tablet 1 MO
vienva oral tablet 1 MO
vyfemla (28) oral tablet 1 MO
vylibra oral tablet 1 MO
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113
Drug Name Drug Tier Requirements/Limits
wymzya fe oral tablet,chewable 1 MO
YASMIN (28) ORAL TABLET 3 MO
YAZ (28) ORAL TABLET 3 MO
zarah oral tablet 1 MO
zovia 1/35e (28) oral tablet 1 MO
OPHTHALMOLOGY
ANTIBIOTICS
AZASITE OPHTHALMIC (EYE) DROPS 2 MO
bacitracin ophthalmic (eye) ointment 1 MO
bacitracin-polymyxin b ophthalmic (eye) ointment 1 MO
BESIVANCE OPHTHALMIC (EYE)
DROPS,SUSPENSION
2 MO
CILOXAN OPHTHALMIC (EYE) DROPS 3 MO
CILOXAN OPHTHALMIC (EYE) OINTMENT 3 MO
ciprofloxacin hcl ophthalmic (eye) drops 1 MO
erythromycin ophthalmic (eye) ointment 1 MO
gatifloxacin ophthalmic (eye) drops 1 MO
gentak ophthalmic (eye) ointment 1 MO
gentamicin ophthalmic (eye) drops 1 MO
levofloxacin ophthalmic (eye) drops 1 MO
MOXEZA OPHTHALMIC (EYE) DROPS,
VISCOUS
3 MO
moxifloxacin ophthalmic (eye) drops 1 MO
NATACYN OPHTHALMIC (EYE)
DROPS,SUSPENSION
2 MO
neomycin-bacitracin-polymyxin ophthalmic (eye)
ointment
1 MO
neomycin-polymyxin-gramicidin ophthalmic (eye)
drops
1 MO
OCUFLOX OPHTHALMIC (EYE) DROPS 3 MO
ofloxacin ophthalmic (eye) drops 1 MO
polymyxin b sulf-trimethoprim ophthalmic (eye)
drops
1 MO
POLYTRIM OPHTHALMIC (EYE) DROPS 3 MO
tobramycin ophthalmic (eye) drops 1 MO
TOBREX OPHTHALMIC (EYE) DROPS 3 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
114
Drug Name Drug Tier Requirements/Limits
TOBREX OPHTHALMIC (EYE) OINTMENT 3 MO
VIGAMOX OPHTHALMIC (EYE) DROPS 3 MO
ZYMAXID OPHTHALMIC (EYE) DROPS 3 MO
ANTIVIRALS
trifluridine ophthalmic (eye) drops 1 MO
ZIRGAN OPHTHALMIC (EYE) GEL 3 MO
BETA-BLOCKERS
betaxolol ophthalmic (eye) drops 1 MO
BETIMOL OPHTHALMIC (EYE) DROPS 3 MO
BETOPTIC S OPHTHALMIC (EYE)
DROPS,SUSPENSION
3 MO
carteolol ophthalmic (eye) drops 1 MO
ISTALOL OPHTHALMIC (EYE) DROPS,
ONCE DAILY
3 MO
levobunolol ophthalmic (eye) drops 0.5 % 1 MO
timolol maleate ophthalmic (eye) drops 1 MO
timolol maleate ophthalmic (eye) drops, once daily 1 MO
timolol maleate ophthalmic (eye) gel forming
solution
1 MO
TIMOPTIC OCUDOSE (PF) OPHTHALMIC
(EYE) DROPPERETTE
3 MO
TIMOPTIC-XE OPHTHALMIC (EYE) GEL
FORMING SOLUTION
3 MO
MISCELLANEOUS OPHTHALMOLOGICS
ALOCRIL OPHTHALMIC (EYE) DROPS 3 MO
ALOMIDE OPHTHALMIC (EYE) DROPS 3 MO
atropine ophthalmic (eye) drops 1 MO
azelastine ophthalmic (eye) drops 1 MO
BEPREVE OPHTHALMIC (EYE) DROPS 3 MO
BLEPH-10 OPHTHALMIC (EYE) DROPS 3 MO
BLEPHAMIDE OPHTHALMIC (EYE)
DROPS,SUSPENSION
3 MO
BLEPHAMIDE S.O.P. OPHTHALMIC (EYE)
OINTMENT
3 MO
CEQUA OPHTHALMIC (EYE) DROPPERETTE 3 MO; QL (60 per 30 days)
cromolyn ophthalmic (eye) drops 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
115
Drug Name Drug Tier Requirements/Limits
CYSTARAN OPHTHALMIC (EYE) DROPS 4 MO
epinastine ophthalmic (eye) drops 1 MO
ISOPTO CARPINE OPHTHALMIC (EYE)
DROPS
3 MO
LACRISERT OPHTHALMIC (EYE) INSERT 3 MO
LASTACAFT OPHTHALMIC (EYE) DROPS 3 MO
olopatadine ophthalmic (eye) drops 1 MO
OXERVATE OPHTHALMIC (EYE) DROPS 4 PA; MO
PATADAY OPHTHALMIC (EYE) DROPS 3 MO
PATANOL OPHTHALMIC (EYE) DROPS 3 MO
PAZEO OPHTHALMIC (EYE) DROPS 2 MO
PHOSPHOLINE IODIDE OPHTHALMIC (EYE)
DROPS
2 MO
pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %,
4 %
1 MO
RESTASIS MULTIDOSE OPHTHALMIC (EYE)
DROPS
2 MO; QL (5.5 per 30 days)
RESTASIS OPHTHALMIC (EYE)
DROPPERETTE
2 MO; QL (60 per 30 days)
sulfacetamide sodium ophthalmic (eye) drops 1 MO
sulfacetamide sodium ophthalmic (eye) ointment 1 MO
sulfacetamide-prednisolone ophthalmic (eye)
drops
1 MO
XIIDRA OPHTHALMIC (EYE) DROPPERETTE 3 MO; QL (60 per 30 days)
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
ACULAR LS OPHTHALMIC (EYE) DROPS 3 MO
ACULAR OPHTHALMIC (EYE) DROPS 3 MO
ACUVAIL (PF) OPHTHALMIC (EYE)
DROPPERETTE
3 MO
bromfenac ophthalmic (eye) drops 1 MO
BROMSITE OPHTHALMIC (EYE) DROPS 2 MO
diclofenac sodium ophthalmic (eye) drops 1 MO
flurbiprofen sodium ophthalmic (eye) drops 1 MO
ILEVRO OPHTHALMIC (EYE)
DROPS,SUSPENSION
2 MO
ketorolac ophthalmic (eye) drops 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
116
Drug Name Drug Tier Requirements/Limits
NEVANAC OPHTHALMIC (EYE)
DROPS,SUSPENSION
3 MO
PROLENSA OPHTHALMIC (EYE) DROPS 2 MO
ORAL DRUGS FOR GLAUCOMA
acetazolamide oral capsule, extended release 1 MO
acetazolamide oral tablet 1 MO
methazolamide oral tablet 1 MO
OTHER GLAUCOMA DRUGS
AZOPT OPHTHALMIC (EYE)
DROPS,SUSPENSION
3 MO
bimatoprost ophthalmic (eye) drops 1 MO
COMBIGAN OPHTHALMIC (EYE) DROPS 2 MO
COSOPT (PF) OPHTHALMIC (EYE)
DROPPERETTE
3 MO
COSOPT OPHTHALMIC (EYE) DROPS 3 MO
dorzolamide ophthalmic (eye) drops 1 MO
dorzolamide-timolol (pf) ophthalmic (eye)
dropperette
1 MO
dorzolamide-timolol ophthalmic (eye) drops 1 MO
latanoprost ophthalmic (eye) drops 1 MO
LUMIGAN OPHTHALMIC (EYE) DROPS 0.01
%
2 MO
RHOPRESSA OPHTHALMIC (EYE) DROPS 2 MO
ROCKLATAN OPHTHALMIC (EYE) DROPS 2 MO
SIMBRINZA OPHTHALMIC (EYE)
DROPS,SUSPENSION
3 MO
TRAVATAN Z OPHTHALMIC (EYE) DROPS 2 MO
TRUSOPT OPHTHALMIC (EYE) DROPS 3 MO
VYZULTA OPHTHALMIC (EYE) DROPS 3 MO
XALATAN OPHTHALMIC (EYE) DROPS 3 ST; MO
XELPROS OPHTHALMIC (EYE) DROPS,
EMULSION
3 ST; MO
ZIOPTAN (PF) OPHTHALMIC (EYE)
DROPPERETTE
3 ST; MO
STEROID-ANTIBIOTIC COMBINATIONS
MAXITROL OPHTHALMIC (EYE)
DROPS,SUSPENSION
3 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
117
Drug Name Drug Tier Requirements/Limits
MAXITROL OPHTHALMIC (EYE) OINTMENT 3 MO
neomycin-bacitracin-poly-hc ophthalmic (eye)
ointment
1 MO
neomycin-polymyxin b-dexameth ophthalmic (eye)
drops,suspension
1 MO
neomycin-polymyxin b-dexameth ophthalmic (eye)
ointment
1 MO
neomycin-polymyxin-hc ophthalmic (eye)
drops,suspension
1 MO
PRED-G OPHTHALMIC (EYE)
DROPS,SUSPENSION
3 MO
PRED-G S.O.P. OPHTHALMIC (EYE)
OINTMENT
3 MO
TOBRADEX OPHTHALMIC (EYE)
DROPS,SUSPENSION
3 MO
TOBRADEX OPHTHALMIC (EYE)
OINTMENT
3 MO
TOBRADEX ST OPHTHALMIC (EYE)
DROPS,SUSPENSION
3 MO
tobramycin-dexamethasone ophthalmic (eye)
drops,suspension
1 MO
ZYLET OPHTHALMIC (EYE)
DROPS,SUSPENSION
2 MO
STEROIDS
ALREX OPHTHALMIC (EYE)
DROPS,SUSPENSION
3 MO
dexamethasone sodium phosphate ophthalmic
(eye) drops
1 MO
DUREZOL OPHTHALMIC (EYE) DROPS 3 MO
FLAREX OPHTHALMIC (EYE)
DROPS,SUSPENSION
3 MO
fluorometholone ophthalmic (eye)
drops,suspension
1 MO
FML FORTE OPHTHALMIC (EYE)
DROPS,SUSPENSION
3 MO
FML LIQUIFILM OPHTHALMIC (EYE)
DROPS,SUSPENSION
3 MO
FML S.O.P. OPHTHALMIC (EYE) OINTMENT 3 MO
INVELTYS OPHTHALMIC (EYE)
DROPS,SUSPENSION
3 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
118
Drug Name Drug Tier Requirements/Limits
LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 2 MO
LOTEMAX OPHTHALMIC (EYE)
DROPS,SUSPENSION
2 MO
LOTEMAX OPHTHALMIC (EYE) OINTMENT 2 MO
LOTEMAX SM OPHTHALMIC (EYE)
DROPS,GEL
2 MO
loteprednol etabonate ophthalmic (eye)
drops,suspension
1 MO
MAXIDEX OPHTHALMIC (EYE)
DROPS,SUSPENSION
3 MO
PRED FORTE OPHTHALMIC (EYE)
DROPS,SUSPENSION
3 MO
PRED MILD OPHTHALMIC (EYE)
DROPS,SUSPENSION
3 MO
prednisolone acetate ophthalmic (eye)
drops,suspension
1 MO
prednisolone sodium phosphate ophthalmic (eye)
drops
1 MO
SYMPATHOMIMETICS
ALPHAGAN P OPHTHALMIC (EYE) DROPS
0.1 %
2 MO
ALPHAGAN P OPHTHALMIC (EYE) DROPS
0.15 %
3 MO
apraclonidine ophthalmic (eye) drops 1 MO
brimonidine ophthalmic (eye) drops 1 MO
IOPIDINE OPHTHALMIC (EYE)
DROPPERETTE
3 MO
RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
AUVI-Q INJECTION AUTO-INJECTOR 4 ST; MO; QL (4 per 30 days)
cetirizine oral solution 1 mg/ml 1 MO
CLARINEX ORAL SYRUP 3
CLARINEX ORAL TABLET 3 MO; QL (30 per 30 days)
CLARINEX-D 12 HOUR ORAL TABLET, ER
MULTIPHASE 12 HR
3 MO; QL (60 per 30 days)
desloratadine oral tablet 1 MO; QL (30 per 30 days)
desloratadine oral tablet,disintegrating 1 MO; QL (30 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
119
Drug Name Drug Tier Requirements/Limits
EPINEPHRINE INJECTION AUTO-INJECTOR
0.15 MG/0.15 ML, 0.3 MG/0.3 ML NOT MADE
BY MYLAN
3 ST; MO; QL (4 per 30 days)
epinephrine injection auto-injector 0.15 mg/0.3 ml,
0.3 mg/0.3 ml (manufactured by mylan specialty)
1 MO; QL (4 per 30 days)
EPIPEN 2-PAK INJECTION AUTO-INJECTOR 2 MO; QL (4 per 30 days)
EPIPEN JR 2-PAK INJECTION AUTO-
INJECTOR
2 MO; QL (4 per 30 days)
hydroxyzine hcl oral tablet 1 PA; MO
levocetirizine oral solution 1 MO
levocetirizine oral tablet 1 MO; QL (30 per 30 days)
promethazine oral syrup 3 PA; MO
promethazine oral tablet 3 PA; MO
SEMPREX-D ORAL CAPSULE 3 MO
SYMJEPI INJECTION SYRINGE 3 MO
PULMONARY AGENTS
ACCOLATE ORAL TABLET 3 MO
acetylcysteine solution 1 B/D PA; MO
ADCIRCA ORAL TABLET 4 PA; MO; QL (60 per 30 days)
ADEMPAS ORAL TABLET 4 PA; MO; LA
ADVAIR DISKUS INHALATION BLISTER
WITH DEVICE
2 MO; QL (60 per 30 days)
ADVAIR HFA AEROSOL INHALER 2 MO; QL (12 per 30 days)
AIRDUO RESPICLICK INHALATION
AEROSOL POWDR BREATH ACTIVATED
3 MO; QL (60 per 30 days)
ALBUTEROL SULFATE INHALATION HFA
AEROSOL INHALER 90 MCG/ACTUATION
3 ST; MO; QL (17 per 30 days)
ALBUTEROL SULFATE INHALATION HFA
AEROSOL INHALER 90 MCG/ACTUATION
(NDA020503)
3 ST; MO; QL (13.4 per 30 days)
ALBUTEROL SULFATE INHALATION HFA
AEROSOL INHALER 90 MCG/ACTUATION
(NDA020983)
3 ST; MO; QL (36 per 30 days)
albuterol sulfate inhalation solution for
nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3
ml (0.083 %), 5 mg/ml
1 B/D PA; MO
albuterol sulfate oral syrup 1 MO
albuterol sulfate oral tablet 3 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
120
Drug Name Drug Tier Requirements/Limits
albuterol sulfate oral tablet extended release 12 hr 3 MO
ALVESCO INHALATION HFA AEROSOL
INHALER 160 MCG/ACTUATION
3 MO; QL (12.2 per 30 days)
ALVESCO INHALATION HFA AEROSOL
INHALER 80 MCG/ACTUATION
3 MO; QL (6.1 per 30 days)
alyq oral tablet 4 PA; MO; QL (60 per 30 days)
ambrisentan oral tablet 4 PA; MO; LA
ANORO ELLIPTA INHALATION BLISTER
WITH DEVICE
2 MO; QL (60 per 30 days)
ARCAPTA NEOHALER INHALATION
CAPSULE, W/INHALATION DEVICE
2 MO; QL (30 per 30 days)
ARMONAIR RESPICLICK INHALATION
AEROSOL POWDR BREATH ACTIVATED 232
MCG/ACTUATION, 55 MCG/ACTUATION
3 QL (60 per 30 days)
ARNUITY ELLIPTA INHALATION BLISTER
WITH DEVICE
2 MO; QL (30 per 30 days)
ASMANEX HFA AEROSOL INHALER 2 MO; QL (13 per 30 days)
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 110
MCG/ ACTUATION (30), 220 MCG/
ACTUATION (30), 220 MCG/ ACTUATION
(60)
2 MO; QL (1 per 30 days)
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 220
MCG/ ACTUATION (120)
2 MO; QL (2 per 30 days)
ATROVENT HFA AEROSOL INHALER 2 MO; QL (25.8 per 30 days)
BECONASE AQ NASAL SPRAY,NON-
AEROSOL
3 MO; QL (50 per 30 days)
BERINERT INTRAVENOUS KIT 4 PA; MO
BEVESPI AEROSPHERE HFA AEROSOL
INHALER
2 MO; QL (10.7 per 30 days)
bosentan oral tablet 4 PA; MO; LA
BREO ELLIPTA INHALATION BLISTER
WITH DEVICE
2 MO; QL (60 per 30 days)
BROVANA INHALATION SOLUTION FOR
NEBULIZATION
3 B/D PA; MO
budesonide inhalation suspension for nebulization 1 B/D PA; MO
CINRYZE INTRAVENOUS RECON SOLN 4 PA; MO
COMBIVENT RESPIMAT INHALATION MIST 2 MO; QL (8 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
121
Drug Name Drug Tier Requirements/Limits
cromolyn inhalation solution for nebulization 1 B/D PA; MO
DALIRESP ORAL TABLET 3 PA; MO
DULERA INHALATION HFA AEROSOL
INHALER
2 MO; QL (13 per 30 days)
DYMISTA NASAL SPRAY,NON-AEROSOL 2 MO; QL (23 per 30 days)
ESBRIET ORAL CAPSULE 4 PA; MO; QL (270 per 30 days)
ESBRIET ORAL TABLET 267 MG 4 PA; MO; QL (270 per 30 days)
ESBRIET ORAL TABLET 801 MG 4 PA; MO; QL (90 per 30 days)
FASENRA SUBCUTANEOUS SYRINGE 4 PA; MO
FIRAZYR SUBCUTANEOUS SYRINGE 4 PA; MO
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION, 50
MCG/ACTUATION
2 MO; QL (60 per 30 days)
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 250 MCG/ACTUATION
2 MO; QL (240 per 30 days)
FLOVENT HFA AEROSOL INHALER 110
MCG/ACTUATION
2 MO; QL (12 per 30 days)
FLOVENT HFA AEROSOL INHALER 220
MCG/ACTUATION
2 MO; QL (24 per 30 days)
FLOVENT HFA AEROSOL INHALER 44
MCG/ACTUATION
2 MO; QL (10.6 per 30 days)
flunisolide nasal spray,non-aerosol 25 mcg (0.025
%)
1 MO; QL (50 per 30 days)
fluticasone propionate nasal spray,suspension 1 MO; QL (16 per 30 days)
FLUTICASONE PROPION-SALMETEROL
INHALATION AEROSOL POWDR BREATH
ACTIVATED
3 MO; QL (60 per 30 days)
FLUTICASONE PROPION-SALMETEROL
INHALATION BLISTER WITH DEVICE
3 ST; MO; QL (60 per 30 days)
HAEGARDA SUBCUTANEOUS RECON SOLN 4 PA; MO; LA
icatibant subcutaneous syringe 4 PA; MO
INCRUSE ELLIPTA INHALATION BLISTER
WITH DEVICE
3 ST; MO; QL (30 per 30 days)
ipratropium bromide inhalation solution 1 B/D PA; MO
ipratropium-albuterol inhalation solution for
nebulization
1 B/D PA; MO
KALBITOR SUBCUTANEOUS SOLUTION 4 MO
KALYDECO ORAL GRANULES IN PACKET
25 MG
4 PA; MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
122
Drug Name Drug Tier Requirements/Limits
KALYDECO ORAL GRANULES IN PACKET
50 MG, 75 MG
4 PA; MO; QL (56 per 28 days)
KALYDECO ORAL TABLET 4 PA; MO; QL (60 per 30 days)
LETAIRIS ORAL TABLET 4 PA; MO; LA
levalbuterol hcl inhalation solution for
nebulization
1 B/D PA; MO
LEVALBUTEROL TARTRATE INHALATION
HFA AEROSOL INHALER
3 ST; MO; QL (30 per 30 days)
LONHALA MAGNAIR REFILL INHALATION
SOLUTION FOR NEBULIZATION
4 MO; QL (60 per 30 days)
LONHALA MAGNAIR STARTER
INHALATION SOLUTION FOR
NEBULIZATION
4 MO; QL (60 per 30 days)
metaproterenol oral syrup 1 MO
mometasone nasal spray,non-aerosol 1 MO; QL (34 per 30 days)
montelukast oral granules in packet 1 MO
montelukast oral tablet 1 MO
montelukast oral tablet,chewable 1 MO
NASONEX NASAL SPRAY,NON-AEROSOL 3 MO; QL (34 per 30 days)
NUCALA SUBCUTANEOUS AUTO-INJECTOR 4 PA; MO; LA; QL (3 per 28 days)
NUCALA SUBCUTANEOUS RECON SOLN 4 PA; MO; LA; QL (3 per 28 days)
NUCALA SUBCUTANEOUS SYRINGE 4 PA; MO; LA; QL (3 per 28 days)
OFEV ORAL CAPSULE 4 PA; MO; QL (60 per 30 days)
OMNARIS NASAL SPRAY,NON-AEROSOL 3 MO; QL (12.5 per 30 days)
OPSUMIT ORAL TABLET 4 PA; MO; LA
ORKAMBI ORAL GRANULES IN PACKET 4 PA; MO; QL (56 per 28 days)
ORKAMBI ORAL TABLET 4 PA; MO; QL (112 per 28 days)
PERFOROMIST INHALATION SOLUTION
FOR NEBULIZATION
2 B/D PA; MO
PROAIR HFA AEROSOL INHALER 3 ST; MO; QL (17 per 30 days)
PROAIR RESPICLICK INHALATION
AEROSOL POWDR BREATH ACTIVATED
3 ST; MO; QL (2 per 30 days)
PROVENTIL HFA INHALATION AEROSOL
INHALER
3 ST; MO; QL (13.4 per 30 days)
PULMICORT FLEXHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 180
MCG/ACTUATION
2 MO; QL (2 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
123
Drug Name Drug Tier Requirements/Limits
PULMICORT FLEXHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 90
MCG/ACTUATION
2 MO; QL (1 per 30 days)
PULMICORT INHALATION SUSPENSION
FOR NEBULIZATION
3 B/D PA; MO
PULMOZYME INHALATION SOLUTION 4 B/D PA; MO
QNASL NASAL HFA AEROSOL INHALER 40
MCG/ACTUATION
2 MO; QL (4.9 per 30 days)
QNASL NASAL HFA AEROSOL INHALER 80
MCG/ACTUATION
2 MO; QL (8.7 per 30 days)
QVAR REDIHALER INHALATION HFA
AEROSOL BREATH ACTIVATED 40
MCG/ACTUATION
2 MO; QL (10.6 per 30 days)
QVAR REDIHALER INHALATION HFA
AEROSOL BREATH ACTIVATED 80
MCG/ACTUATION
2 MO; QL (21.2 per 30 days)
REVATIO ORAL SUSPENSION FOR
RECONSTITUTION
4 PA; MO; QL (224 per 30 days)
REVATIO ORAL TABLET 4 PA; MO; QL (90 per 30 days)
RUCONEST INTRAVENOUS RECON SOLN 4 PA; MO
SEEBRI NEOHALER INHALATION CAPSULE,
W/INHALATION DEVICE
3 ST; MO; QL (60 per 30 days)
SEREVENT DISKUS INHALATION BLISTER
WITH DEVICE
2 MO; QL (60 per 30 days)
sildenafil (pulmonary arterial hypertension) oral
suspension for reconstitution 10 mg/ml
4 PA; MO; QL (224 per 30 days)
sildenafil (pulmonary arterial hypertension) oral
tablet 20 mg
1 PA; MO; QL (90 per 30 days)
SINGULAIR ORAL GRANULES IN PACKET 3 MO
SINGULAIR ORAL TABLET 3 MO
SINGULAIR ORAL TABLET,CHEWABLE 3 MO
SPIRIVA RESPIMAT INHALATION MIST 2 MO; QL (4 per 30 days)
SPIRIVA WITH HANDIHALER INHALATION
CAPSULE, W/INHALATION DEVICE
2 MO; QL (90 per 90 days)
STIOLTO RESPIMAT INHALATION MIST 2 MO; QL (4 per 30 days)
STRIVERDI RESPIMAT INHALATION MIST 2 MO; QL (4 per 30 days)
SYMBICORT HFA AEROSOL INHALER 2 MO; QL (10.2 per 30 days)
SYMDEKO ORAL TABLETS, SEQUENTIAL 4 PA; MO; QL (56 per 28 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
124
Drug Name Drug Tier Requirements/Limits
tadalafil (pulmonary arterial hypertension) oral
tablet 20 mg
4 PA; MO; QL (60 per 30 days)
TAKHZYRO SUBCUTANEOUS SOLUTION 4 PA; MO; LA
terbutaline oral tablet 1 MO
THEO-24 ORAL CAPSULE,EXTENDED
RELEASE 24HR
2 MO
theophylline oral solution 1 MO
theophylline oral tablet extended release 12 hr 300
mg
1 MO
theophylline oral tablet extended release 24 hr 1 MO
TRACLEER ORAL TABLET 4 PA; MO; LA
TRACLEER ORAL TABLET FOR
SUSPENSION
4 PA; MO; LA
TRELEGY ELLIPTA INHALATION BLISTER
WITH DEVICE
3 PA; MO; QL (60 per 30 days)
TUDORZA PRESSAIR INHALATION
AEROSOL POWDR BREATH ACTIVATED
2 MO; QL (1 per 30 days)
UTIBRON NEOHALER INHALATION
CAPSULE, W/INHALATION DEVICE
3 MO; QL (60 per 30 days)
VENTAVIS INHALATION SOLUTION FOR
NEBULIZATION
4 B/D PA; MO
VENTOLIN HFA AEROSOL INHALER 2 MO; QL (36 per 30 days)
WIXELA INHUB INHALATION BLISTER
WITH DEVICE
3 ST; MO; QL (60 per 30 days)
XHANCE NASAL AEROSOL BREATH
ACTIVATED
3 MO; QL (32 per 30 days)
XOLAIR SUBCUTANEOUS RECON SOLN 4 PA; MO; LA; QL (6 per 28 days)
XOLAIR SUBCUTANEOUS SYRINGE 150
MG/ML
4 PA; MO; LA; QL (6 per 28 days)
XOLAIR SUBCUTANEOUS SYRINGE 75
MG/0.5 ML
4 PA; MO; LA; QL (5 per 28 days)
XOPENEX CONCENTRATE INHALATION
SOLUTION FOR NEBULIZATION
3 B/D PA; MO
XOPENEX HFA INHALATION AEROSOL
INHALER
3 ST; MO; QL (30 per 30 days)
XOPENEX INHALATION SOLUTION FOR
NEBULIZATION
3 B/D PA; MO
YUPELRI INHALATION SOLUTION FOR
NEBULIZATION
4 B/D PA; MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
125
Drug Name Drug Tier Requirements/Limits
zafirlukast oral tablet 1 MO
ZETONNA NASAL HFA AEROSOL INHALER 3 MO; QL (6.1 per 30 days)
zileuton oral tablet, er multiphase 12 hr 4 MO
ZYFLO ORAL TABLET 4 MO
UROLOGICALS
ANTICHOLINERGICS / ANTISPASMODICS
darifenacin oral tablet extended release 24 hr 1 MO
DETROL LA ORAL CAPSULE,EXTENDED
RELEASE 24HR
3 MO
DETROL ORAL TABLET 3 MO
DITROPAN XL ORAL TABLET EXTENDED
RELEASE 24HR 10 MG, 5 MG
3 MO
ENABLEX ORAL TABLET EXTENDED
RELEASE 24 HR
3 MO
flavoxate oral tablet 1 MO
GELNIQUE TRANSDERMAL GEL IN
METERED-DOSE PUMP 100 MG/GRAM (10
%)
3 MO; QL (30 per 30 days)
MYRBETRIQ ORAL TABLET EXTENDED
RELEASE 24 HR
2 MO
oxybutynin chloride oral syrup 1 MO
oxybutynin chloride oral tablet 1 MO
oxybutynin chloride oral tablet extended release
24hr
1 MO
OXYTROL TRANSDERMAL PATCH
SEMIWEEKLY
3 MO; QL (8 per 28 days)
solifenacin oral tablet 1 MO
tolterodine oral capsule,extended release 24hr 1 MO
tolterodine oral tablet 1 MO
TOVIAZ ORAL TABLET EXTENDED
RELEASE 24 HR
2 MO
trospium oral capsule,extended release 24hr 1 MO
trospium oral tablet 1 MO
VESICARE ORAL TABLET 2 MO
BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY
alfuzosin oral tablet extended release 24 hr 1 MO
AVODART ORAL CAPSULE 3 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
126
Drug Name Drug Tier Requirements/Limits
dutasteride oral capsule 1 MO
dutasteride-tamsulosin oral capsule, er multiphase
24 hr
1 MO
finasteride oral tablet 5 mg 1 MO
FLOMAX ORAL CAPSULE 3 ST; MO
JALYN ORAL CAPSULE, ER MULTIPHASE 24
HR
3 MO
PROSCAR ORAL TABLET 3 MO
RAPAFLO ORAL CAPSULE 2 ST; MO
silodosin oral capsule 1 MO
tamsulosin oral capsule 1 MO
UROXATRAL ORAL TABLET EXTENDED
RELEASE 24 HR
3 ST; MO
MISCELLANEOUS UROLOGICALS
bethanechol chloride oral tablet 1 MO
CIALIS ORAL TABLET 2.5 MG, 5 MG 3 PA; MO; QL (30 per 30 days)
CYSTAGON ORAL CAPSULE 2 MO; LA
ELMIRON ORAL CAPSULE 2 MO
potassium citrate oral tablet extended release 1 MO
tadalafil oral tablet 2.5 mg, 5 mg 1 PA; MO; QL (30 per 30 days)
URECHOLINE ORAL TABLET 3 MO
UROCIT-K 10 ORAL TABLET EXTENDED
RELEASE
3 MO
UROCIT-K 15 ORAL TABLET EXTENDED
RELEASE
3 MO
UROCIT-K 5 ORAL TABLET EXTENDED
RELEASE
3 MO
VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
calcium acetate oral capsule 1 MO
calcium acetate oral tablet 667 mg 1 MO
klor-con 10 oral tablet extended release 1 MO
klor-con 8 oral tablet extended release 1 MO
klor-con m10 oral tablet,er particles/crystals 1 MO
klor-con m15 oral tablet,er particles/crystals 1 MO
klor-con m20 oral tablet,er particles/crystals 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
127
Drug Name Drug Tier Requirements/Limits
klor-con oral packet 1 MO
klor-con sprinkle oral capsule, extended release 8
meq
1 MO
K-TAB ORAL TABLET EXTENDED RELEASE
10 MEQ, 20 MEQ
3 MO
k-tab oral tablet extended release 8 meq 1 MO
magnesium sulfate injection solution 1 MO
magnesium sulfate injection syringe 1
NORMOSOL-R IN 5 % DEXTROSE
INTRAVENOUS PARENTERAL SOLUTION
2
PHOSLYRA ORAL SOLUTION 3 MO
potassium chlorid-d5-0.45%nacl intravenous
parenteral solution 10 meq/l, 30 meq/l, 40 meq/l
1
potassium chlorid-d5-0.45%nacl intravenous
parenteral solution 20 meq/l
1 MO
potassium chloride in 0.9%nacl intravenous
parenteral solution 20 meq/l, 40 meq/l
1
potassium chloride in 5 % dex intravenous
parenteral solution 20 meq/l, 40 meq/l
1
potassium chloride in lr-d5 intravenous parenteral
solution 20 meq/l
1 MO
potassium chloride in water intravenous
piggyback 10 meq/100 ml
1 MO
potassium chloride in water intravenous
piggyback 20 meq/100 ml, 40 meq/100 ml
1
potassium chloride intravenous solution 1 MO
potassium chloride oral capsule, extended release 1 MO
potassium chloride oral liquid 1 MO
potassium chloride oral packet 1 MO
potassium chloride oral tablet extended release 1 MO
potassium chloride oral tablet,er particles/crystals 1 MO
potassium chloride-0.45 % nacl intravenous
parenteral solution
1
potassium chloride-d5-0.2%nacl intravenous
parenteral solution 20 meq/l
1 MO
potassium chloride-d5-0.3%nacl intravenous
parenteral solution 20 meq/l
1
potassium chloride-d5-0.9%nacl intravenous
parenteral solution 20 meq/l
1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
128
Drug Name Drug Tier Requirements/Limits
potassium chloride-d5-0.9%nacl intravenous
parenteral solution 40 meq/l
1
sodium chloride 0.45 % intravenous parenteral
solution
1 MO
sodium chloride 3 % intravenous parenteral
solution
1 MO
sodium chloride 5 % intravenous parenteral
solution
1 MO
sodium lactate intravenous solution 1
TPN ELECTROLYTES INTRAVENOUS
SOLUTION
3
MISCELLANEOUS NUTRITION PRODUCTS
AMINOSYN II 10 % INTRAVENOUS
PARENTERAL SOLUTION
2 B/D PA
AMINOSYN II 15 % INTRAVENOUS
PARENTERAL SOLUTION
2 B/D PA
AMINOSYN-PF 10 % INTRAVENOUS
PARENTERAL SOLUTION
2 B/D PA
AMINOSYN-PF 7 % SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
2 B/D PA
CLINIMIX 5%/D15W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
2 B/D PA
CLINIMIX 5%/D25W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
2 B/D PA
CLINIMIX 4.25%/D10W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
2 B/D PA
CLINIMIX 4.25%-D25W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
2 B/D PA
CLINIMIX 5%-D20W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
2 B/D PA
CLINIMIX E 4.25%/D10W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
3 B/D PA
CLINIMIX E 4.25%/D5W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
3 B/D PA
CLINIMIX E 5%/D15W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
3 B/D PA
CLINIMIX E 5%/D20W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION
3 B/D PA
CLINISOL SF 15 % INTRAVENOUS
PARENTERAL SOLUTION
3 B/D PA; MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
129
Drug Name Drug Tier Requirements/Limits
FREAMINE HBC 6.9 % INTRAVENOUS
PARENTERAL SOLUTION
3 B/D PA
HEPATAMINE 8% INTRAVENOUS
PARENTERAL SOLUTION
2 B/D PA
intralipid intravenous emulsion 20 % 1 B/D PA
INTRALIPID INTRAVENOUS EMULSION 30
%
3 B/D PA
IONOSOL-MB IN D5W INTRAVENOUS
PARENTERAL SOLUTION
2
ISOLYTE-P IN 5 % DEXTROSE
INTRAVENOUS PARENTERAL SOLUTION
2
ISOLYTE-S INTRAVENOUS PARENTERAL
SOLUTION
2
NEPHRAMINE 5.4 % INTRAVENOUS
PARENTERAL SOLUTION
2 B/D PA
NORMOSOL-M IN 5 % DEXTROSE
INTRAVENOUS PARENTERAL SOLUTION
3
NORMOSOL-R PH 7.4 INTRAVENOUS
PARENTERAL SOLUTION
2
NUTRILIPID INTRAVENOUS EMULSION 3 B/D PA
PLASMA-LYTE 148 INTRAVENOUS
PARENTERAL SOLUTION
2
PLASMA-LYTE A INTRAVENOUS
PARENTERAL SOLUTION
2
plenamine intravenous parenteral solution 1 B/D PA
premasol 10 % intravenous parenteral solution 1 B/D PA; MO
PREMASOL 6 % INTRAVENOUS
PARENTERAL SOLUTION
2 B/D PA
PROCALAMINE 3% INTRAVENOUS
PARENTERAL SOLUTION
3 B/D PA
PROSOL 20 % INTRAVENOUS PARENTERAL
SOLUTION
3 B/D PA; MO
travasol 10 % intravenous parenteral solution 3 B/D PA; MO
TROPHAMINE 10 % INTRAVENOUS
PARENTERAL SOLUTION
2 B/D PA; MO
TROPHAMINE 6% INTRAVENOUS
PARENTERAL SOLUTION
2 B/D PA
VITAMINS / HEMATINICS
fluoride (sodium) oral tablet 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
130
Drug Name Drug Tier Requirements/Limits
prenatal vitamin oral tablet 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
131
Index
A abacavir .................................. 3
abacavir-lamivudine ............... 3
abacavir-lamivudine-
zidovudine .......................... 3
ABELCET .............................. 2
ABILIFY .............................. 42
ABILIFY MAINTENA ........ 42
ABILIFY MYCITE .............. 42
abiraterone ............................ 18
ABSORICA .......................... 66
ABSTRAL ............................ 35
acamprosate .......................... 74
ACANYA ............................. 66
acarbose ................................ 79
ACCOLATE....................... 119
ACCUPRIL .......................... 52
ACCURETIC ....................... 52
acebutolol ............................. 52
acetaminophen-codeine ........ 35
acetazolamide ..................... 116
acetic acid ............................. 77
acetylcysteine ..................... 119
ACIPHEX............................. 94
acitretin ................................. 64
ACTEMRA ........................ 103
ACTEMRA ACTPEN ........ 103
ACTHAR ............................. 78
ACTHIB (PF) ....................... 99
ACTIGALL .......................... 90
ACTIMMUNE ..................... 97
ACTIQ .................................. 35
ACTIVELLA ..................... 105
ACTONEL ......................... 103
ACTOPLUS MET ................ 79
ACTOS ................................. 79
ACULAR ........................... 115
ACULAR LS ...................... 115
ACUVAIL (PF) .................. 115
acyclovir ........................... 3, 70
acyclovir sodium .................... 3
ACZONE .............................. 66
ADACEL(TDAP
ADOLESN/ADULT)(PF)99,
100
ADALAT CC ....................... 52
adapalene .............................. 66
adapalene-benzoyl peroxide . 66
ADCIRCA .......................... 119
ADDERALL ........................ 42
ADDERALL XR .................. 42
adefovir ................................... 3
ADEMPAS ......................... 119
ADLYXIN ............................ 79
ADMELOG SOLOSTAR U-
100 INSULIN ................... 79
ADMELOG U-100 INSULIN
LISPRO ............................ 79
ADVAIR DISKUS ............. 119
ADVAIR HFA ................... 119
ADZENYS ER ..................... 42
ADZENYS XR-ODT ........... 42
AFINITOR ........................... 18
AFINITOR DISPERZ .......... 18
AFREZZA ............................ 79
AGGRENOX........................ 59
AGRYLIN ............................ 74
AIMOVIG AUTOINJECTOR
.......................................... 30
AIRDUO RESPICLICK..... 119
AJOVY ................................. 30
AKTIPAK ............................ 66
AKYNZEO
(FOSNETUPITANT) ....... 90
ala-cort .................................. 70
ALA-SCALP ........................ 70
albendazole ........................... 10
ALBENZA ........................... 10
albuterol sulfate .......... 119, 120
ALBUTEROL SULFATE .. 119
alclometasone ....................... 70
ALCOHOL PADS ................ 80
ALDACTAZIDE .................. 52
ALDACTONE...................... 52
ALDARA ............................. 65
ALECENSA ......................... 18
alendronate ................... 74, 103
alfuzosin ............................. 125
ALINIA ................................ 10
aliskiren ................................ 52
allopurinol .......................... 102
almotriptan malate ................ 30
ALOCRIL ........................... 114
ALOGLIPTIN ...................... 80
ALOGLIPTIN-METFORMIN
.......................................... 80
ALOGLIPTIN-
PIOGLITAZONE ............. 80
ALOMIDE .......................... 114
ALORA .............................. 106
alosetron ............................... 90
ALPHAGAN P ................... 118
ALREX ............................... 117
ALTACE .............................. 52
altavera (28) ........................ 108
ALTOPREV ......................... 60
ALTRENO ........................... 66
ALUNBRIG ......................... 18
ALVESCO .......................... 120
alyacen 1/35 (28) ................ 109
alyq ..................................... 120
amabelz ............................... 106
amantadine hcl ........................ 3
AMARYL ............................. 80
AMBIEN .............................. 42
AMBIEN CR ........................ 42
AMBISOME ........................... 2
ambrisentan ......................... 120
amcinonide ........................... 70
AMERGE ............................. 30
amethia ............................... 109
amethia lo ........................... 109
amikacin ............................... 10
amiloride ............................... 53
amiloride-hydrochlorothiazide
.......................................... 53
AMINOSYN II 10 % .......... 128
AMINOSYN II 15 % .......... 128
AMINOSYN-PF 10 % ....... 128
AMINOSYN-PF 7 %
SULFITE FREE ............. 128
amiodarone ........................... 52
AMITIZA ............................. 90
amitriptyline ......................... 42
amlodipine ............................ 53
amlodipine-atorvastatin ........ 60
amlodipine-benazepril .......... 53
amlodipine-olmesartan ......... 53
amlodipine-valsartan ............ 53
amlodipine-valsartan-
hydrochlorothiazide .......... 53
ammonium lactate ................ 65
amnesteem ............................ 66
amoxapine ............................. 42
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
132
amoxicil-clarithromy-lansopraz
.......................................... 95
amoxicillin ............................ 14
amoxicillin-pot clavulanate .. 14
amphetamine sulfate ............. 42
amphotericin b ........................ 2
ampicillin .............................. 14
ampicillin sodium ................. 14
ampicillin-sulbactam ............ 14
AMPYRA ............................. 32
ANADROL-50 ..................... 86
ANAFRANIL ....................... 42
anagrelide ............................. 74
anastrozole ............................ 18
ANCOBON ............................ 2
ANDRODERM .................... 86
ANDROGEL ........................ 87
ANGELIQ .......................... 106
ANORO ELLIPTA ............ 120
ANTABUSE......................... 74
ANTARA ............................. 60
ANUSOL-HC ....................... 90
apexicon e ............................. 70
APIDRA SOLOSTAR U-100
INSULIN .......................... 80
APIDRA U-100 INSULIN ... 80
APLENZIN .......................... 42
APOKYN ............................. 29
apraclonidine ...................... 118
aprepitant .............................. 90
apri ...................................... 109
APRISO ................................ 90
APTENSIO XR .................... 42
APTIOM............................... 24
APTIVUS ............................... 3
ARALAST NP ..................... 74
aranelle (28)........................ 109
ARANESP (IN
POLYSORBATE) ............ 97
ARAVA .............................. 103
ARCALYST ......................... 97
ARCAPTA NEOHALER ... 120
ARICEPT ............................. 32
ARIKAYCE ......................... 10
ARIMIDEX .......................... 18
aripiprazole ........................... 42
ARISTADA .......................... 43
ARISTADA INITIO ............ 42
ARIXTRA ............................ 59
armodafinil ........................... 43
ARMONAIR RESPICLICK
........................................ 120
ARNUITY ELLIPTA ......... 120
AROMASIN ......................... 18
ARTHROTEC 50 ................. 38
ARTHROTEC 75 ................. 38
ARYMO ER ......................... 35
ASACOL HD ....................... 90
ashlyna ................................ 109
ASMANEX HFA ............... 120
ASMANEX TWISTHALER
........................................ 120
aspirin-dipyridamole ............ 59
ASTAGRAF XL................... 18
ASTEPRO ............................ 77
ATACAND .......................... 53
ATACAND HCT ................. 53
atazanavir................................ 3
ATELVIA ........................... 103
atenolol ................................. 53
atenolol-chlorthalidone ......... 53
ATIVAN ............................... 43
atomoxetine .......................... 43
atorvastatin ........................... 60
atovaquone............................ 10
atovaquone-proguanil ........... 10
ATRALIN ............................ 66
ATRIPLA ............................... 3
atropine ............................... 114
ATROVENT HFA ............. 120
AUBAGIO............................ 32
aubra ................................... 109
AUGMENTIN ...................... 14
AURYXIA............................ 74
AUSTEDO ........................... 32
AUVI-Q .............................. 118
AVALIDE ............................ 53
AVANDIA ........................... 80
AVAPRO.............................. 53
AVC.................................... 108
AVEED ................................ 87
aviane.................................. 109
avita ...................................... 66
AVITA.................................. 66
AVODART ........................ 125
AVONEX ............................. 97
AVONEX (WITH ALBUMIN)
.......................................... 97
AVYCAZ ............................... 8
AYGESTIN ........................ 106
AZACTAM .......................... 10
AZASAN .............................. 18
AZASITE ........................... 113
azathioprine .......................... 18
azelaic acid ........................... 66
azelastine ...................... 77, 114
AZELEX ............................... 66
AZILECT ............................. 29
azithromycin ........................... 9
AZOPT ............................... 116
AZOR ................................... 53
aztreonam ............................. 10
AZULFIDINE ...................... 90
AZULFIDINE EN-TABS .... 90
B bacitracin ............................ 113
bacitracin-polymyxin b ....... 113
baclofen ................................ 34
BACLOFEN ......................... 34
BACTRIM ............................ 16
BACTRIM DS ...................... 16
BALCOLTRA .................... 109
balsalazide ............................ 90
BALVERSA ......................... 18
balziva (28) ......................... 109
BANZEL .............................. 24
BAQSIMI ............................. 80
BARACLUDE .................... 3, 4
BASAGLAR KWIKPEN U-
100 INSULIN ................... 80
BAXDELA ........................... 15
BCG VACCINE, LIVE (PF)
........................................ 100
BECONASE AQ ................ 120
BELBUCA ........................... 35
BELSOMRA ........................ 43
benazepril ............................. 53
benazepril-hydrochlorothiazide
.......................................... 53
BENICAR ............................. 53
BENICAR HCT .................... 53
BENLYSTA ....................... 103
BENZACLIN PUMP ............ 67
BENZAMYCIN ................... 67
BENZNIDAZOLE ............... 10
benztropine ........................... 29
BEPREVE .......................... 114
BERINERT ......................... 120
beser ...................................... 70
BESIVANCE ...................... 113
betamethasone dipropionate . 70
betamethasone valerate ... 70, 71
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
133
betamethasone, augmented... 71
BETAPACE AF ................... 52
BETASERON ...................... 97
betaxolol ....................... 53, 114
bethanechol chloride .......... 126
BETHKIS ............................. 10
BETIMOL .......................... 114
BETOPTIC S...................... 114
BEVESPI AEROSPHERE . 120
BEVYXXA .......................... 59
bexarotene ............................ 18
BEXSERO .......................... 100
BEYAZ............................... 109
bicalutamide ......................... 18
BICILLIN C-R ..................... 14
BICILLIN L-A ..................... 14
BIDIL ................................... 53
BIJUVA .............................. 106
BIKTARVY ........................... 4
BILTRICIDE ........................ 10
bimatoprost ......................... 116
BINOSTO........................... 103
bisoprolol fumarate .............. 53
bisoprolol-hydrochlorothiazide
.......................................... 53
BLEPH-10 .......................... 114
BLEPHAMIDE .................. 114
BLEPHAMIDE S.O.P. ....... 114
blisovi 24 fe ........................ 109
blisovi fe 1.5/30 (28) .......... 109
BONIVA ............................ 103
BONJESTA .......................... 90
BOOSTRIX TDAP ............ 100
bosentan .............................. 120
BOSULIF ............................. 18
BRAFTOVI .......................... 18
BREO ELLIPTA ................ 120
briellyn ............................... 109
BRILINTA ........................... 59
brimonidine ........................ 118
BRISDELLE ........................ 43
BRIVIACT ........................... 24
bromfenac ........................... 115
bromocriptine ....................... 29
BROMSITE ........................ 115
BROVANA ........................ 120
BRYHALI ............................ 71
budesonide .................... 90, 120
bumetanide ........................... 53
BUNAVAIL ......................... 39
BUPHENYL......................... 74
buprenorphine ....................... 35
BUPRENORPHINE ............. 35
buprenorphine hcl ................. 35
buprenorphine-naloxone ....... 39
bupropion hcl ........................ 43
BUPROPION HCL .............. 43
bupropion hcl (smoking deter)
.......................................... 77
buspirone .............................. 43
butorphanol tartrate .............. 39
BUTRANS ........................... 35
BYDUREON ........................ 80
BYDUREON BCISE ........... 80
BYETTA .............................. 80
BYSTOLIC .......................... 53
C cabergoline ........................... 87
CABLIVI .............................. 59
CABOMETYX ..................... 18
CADUET .............................. 61
CAFERGOT ......................... 30
CALAN ................................ 53
CALAN SR .......................... 53
calcipotriene ......................... 64
calcipotriene-betamethasone 64
calcitonin (salmon) ............... 87
calcitriol .......................... 64, 87
calcium acetate ................... 126
CALQUENCE ...................... 18
CAMBIA .............................. 39
camila ................................. 106
camrese lo ........................... 109
CANASA.............................. 90
CANCIDAS............................ 2
candesartan ........................... 53
candesartan-
hydrochlorothiazide .......... 53
CAPEX ................................. 71
CAPRELSA.................... 18, 19
captopril ................................ 53
captopril-hydrochlorothiazide
.......................................... 53
CARAC ................................ 65
CARAFATE ......................... 95
CARBAGLU ........................ 74
carbamazepine ...................... 24
CARBATROL ...................... 24
carbidopa .............................. 29
carbidopa-levodopa .............. 29
carbidopa-levodopa-
entacapone ........................ 29
CARDIZEM ......................... 54
CARDIZEM CD ................... 53
CARDIZEM LA ................... 54
CARDURA ........................... 54
CARDURA XL .................... 54
CARNITOR .......................... 74
CAROSPIR ........................... 54
carteolol .............................. 114
cartia xt ................................. 54
carvedilol .............................. 54
carvedilol phosphate ............. 54
CASODEX ........................... 19
caspofungin ............................. 2
CATAPRES .......................... 54
CATAPRES-TTS-1 .............. 54
CATAPRES-TTS-2 .............. 54
CATAPRES-TTS-3 .............. 54
CAYSTON ........................... 11
caziant (28) ......................... 109
cefaclor ................................... 8
cefadroxil ................................ 8
cefazolin ................................. 8
cefdinir .................................... 8
cefepime ................................. 8
cefixime .................................. 8
cefotaxime .............................. 8
cefotetan ................................. 8
cefoxitin .................................. 8
cefpodoxime ........................... 8
cefprozil .................................. 8
ceftazidime ............................. 8
ceftriaxone .............................. 8
cefuroxime axetil .................... 8
cefuroxime sodium ............. 8, 9
CELEBREX ......................... 39
celecoxib ............................... 39
CELEXA .............................. 43
CELLCEPT .......................... 19
CELONTIN .......................... 24
cephalexin ............................... 9
CEQUA .............................. 114
CERDELGA ......................... 87
CESAMET ........................... 90
cetirizine ............................. 118
CETRAXAL ......................... 77
cevimeline ............................. 74
CHANTIX ............................ 77
CHANTIX CONTINUING
MONTH BOX .................. 77
CHANTIX STARTING
MONTH BOX .................. 77
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
134
CHEMET ............................. 74
CHENODAL ........................ 90
chlorhexidine gluconate ....... 77
chloroquine phosphate.......... 11
chlorothiazide ....................... 54
chlorpromazine ..................... 43
chlorthalidone ....................... 54
CHOLBAM .......................... 90
cholestyramine (with sugar) . 61
cholestyramine light ............. 61
CIALIS ............................... 126
ciclopirox .............................. 69
cilostazol............................... 59
CILOXAN .......................... 113
CIMDUO ................................ 4
cimetidine ............................. 95
cimetidine hcl ....................... 95
CIMZIA ................................ 91
CIMZIA POWDER FOR
RECONST ........................ 91
cinacalcet .............................. 87
CINRYZE........................... 120
CIPRO .................................. 15
CIPRO HC............................ 78
CIPRODEX .......................... 78
ciprofloxacin......................... 16
ciprofloxacin hcl ..... 15, 77, 113
ciprofloxacin in 5 % dextrose
.......................................... 16
citalopram ............................. 43
claravis ................................. 67
CLARINEX ........................ 118
CLARINEX-D 12 HOUR .. 118
clarithromycin ........................ 9
CLENPIQ ............................. 91
CLEOCIN..................... 11, 108
CLEOCIN HCL.................... 11
CLEOCIN IN 5 %
DEXTROSE ..................... 11
CLEOCIN PEDIATRIC ....... 11
CLEOCIN T ......................... 67
CLIMARA ......................... 106
CLIMARA PRO ................. 106
clindacin p ............................ 67
CLINDAGEL ....................... 67
clindamycin hcl .................... 11
clindamycin in 5 % dextrose 11
clindamycin palmitate hcl .... 11
clindamycin phosphate .. 11, 67,
108
clindamycin-benzoyl peroxide
.......................................... 67
clindamycin-tretinoin ........... 67
CLINDESSE ...................... 108
CLINIMIX 5%/D15W
SULFITE FREE ............. 128
CLINIMIX 5%/D25W
SULFITE FREE ............. 128
CLINIMIX 4.25%/D10W
SULFITE FREE ............. 128
CLINIMIX 4.25%/D5W
SULFITE FREE ............... 74
CLINIMIX 4.25%-D25W
SULFITE FREE ............. 128
CLINIMIX 5%-D20W
SULFITE FREE ............. 128
CLINIMIX E 2.75%/D5W
SULFITE FREE ............... 75
CLINIMIX E 4.25%/D10W
SULFITE FREE ............. 128
CLINIMIX E 4.25%/D5W
SULFITE FREE ............. 128
CLINIMIX E 5%/D15W
SULFITE FREE ............. 128
CLINIMIX E 5%/D20W
SULFITE FREE ............. 128
CLINISOL SF 15 % ........... 128
clobazam ......................... 24, 25
clobetasol .............................. 71
clobetasol-emollient ............. 71
CLOBEX .............................. 71
CLOCORTOLONE
PIVALATE ...................... 71
clodan ................................... 71
CLODERM .......................... 71
clomipramine ........................ 43
clonazepam ........................... 25
clonidine ............................... 54
clonidine hcl ................... 43, 54
clopidogrel ............................ 59
clorazepate dipotassium ....... 43
clotrimazole ...................... 2, 69
clotrimazole-betamethasone . 69
clozapine ............................... 43
CLOZAPINE ........................ 43
CLOZARIL .......................... 43
COARTEM .......................... 11
codeine sulfate ...................... 35
COLAZAL ........................... 91
COLCHICINE .................... 102
COLCRYS.......................... 102
colesevelam .......................... 61
COLESTID ........................... 61
colestipol ............................... 61
colistin (colistimethate na) ... 11
colocort ................................. 91
COLY-MYCIN S ................. 78
COLYTE WITH FLAVOR
PACKS ............................. 91
COMBIGAN ...................... 116
COMBIPATCH .................. 106
COMBIVENT RESPIMAT 120
COMBIVIR ............................ 4
COMETRIQ ......................... 19
COMPLERA .......................... 4
compro .................................. 91
COMTAN ............................. 29
CONCERTA ......................... 43
CONDYLOX ........................ 65
constulose ............................. 91
CONZIP ................................ 39
COPAXONE ........................ 32
COPIKTRA .......................... 19
CORDRAN TAPE LARGE
ROLL ................................ 71
COREG ................................. 54
COREG CR .......................... 54
CORGARD ........................... 54
CORLANOR ........................ 63
CORTEF ............................... 78
CORTIFOAM ....................... 91
cortisone ............................... 78
CORTISPORIN .................... 68
COSENTYX (2 SYRINGES)
.......................................... 64
COSENTYX PEN (2 PENS) 64
COSOPT ............................. 116
COSOPT (PF) ..................... 116
COTELLIC ........................... 19
COTEMPLA XR-ODT ........ 43
COUMADIN ........................ 59
COZAAR .............................. 54
CREON ................................. 91
CRESEMBA ........................... 2
CRESTOR ............................ 61
CRINONE .......................... 106
CRIXIVAN ............................. 4
cromolyn ............... 91, 114, 121
cryselle (28) ........................ 109
CUBICIN .............................. 11
CUPRIMINE ...................... 103
CUTIVATE .......................... 71
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
135
CUVPOSA ........................... 89
cyclafem 1/35 (28) ............. 109
cyclafem 7/7/7 (28) ............ 109
cyclobenzaprine .................... 34
cyclophosphamide ................ 19
CYCLOSET ......................... 80
cyclosporine ......................... 19
cyclosporine modified .......... 19
CYMBALTA ....................... 44
cyred eq .............................. 109
CYSTADANE ...................... 91
CYSTAGON ...................... 126
CYSTARAN ...................... 115
CYTOMEL........................... 89
CYTOTEC ........................... 95
D d10 %-0.45 % sodium chloride
.......................................... 75
d2.5 %-0.45 % sodium
chloride ............................. 75
d5 % and 0.9 % sodium
chloride ............................. 75
d5 %-0.45 % sodium chloride
.......................................... 75
dalfampridine ....................... 32
DALIRESP ......................... 121
DALVANCE ........................ 11
danazol ................................. 87
DANTRIUM ........................ 34
dantrolene ............................. 34
dapsone ........................... 11, 67
DAPTACEL (DTAP
PEDIATRIC) (PF).......... 100
daptomycin ........................... 11
DAPTOMYCIN ................... 11
DARAPRIM ......................... 11
darifenacin .......................... 125
DAURISMO......................... 19
DAYPRO ............................. 39
DAYTRANA ....................... 44
DDAVP ................................ 87
deblitane ............................. 106
deferasirox ............................ 75
DELESTROGEN ............... 106
DELSTRIGO .......................... 4
delyla (28) .......................... 109
DELZICOL .......................... 91
demeclocycline ..................... 16
DEMSER .............................. 54
DENAVIR ............................ 70
DEPAKOTE ......................... 25
DEPAKOTE ER ................... 25
DEPAKOTE SPRINKLES .. 25
DEPEN TITRATABS ........ 104
DEPO-ESTRADIOL .......... 106
DEPO-PROVERA.............. 106
DEPO-SUBQ PROVERA 104
........................................ 106
DEPO-TESTOSTERONE .... 87
DESCOVY ............................. 4
desipramine .......................... 44
desloratadine ....................... 118
desmopressin ........................ 87
desog-e.estradiol/e.estradiol
........................................ 109
desogestrel-ethinyl estradiol
........................................ 109
DESONATE ......................... 71
desonide ................................ 71
DESOWEN .......................... 71
desoximetasone .............. 71, 72
DESOXYN ........................... 44
DESVENLAFAXINE .......... 44
desvenlafaxine succinate ...... 44
DETROL ............................ 125
DETROL LA ...................... 125
dexamethasone ..................... 78
dexamethasone intensol ........ 78
dexamethasone sodium
phosphate ........................ 117
DEXEDRINE SPANSULE .. 44
DEXILANT .......................... 95
dexmethylphenidate.............. 44
DEXPAK 13 DAY ............... 78
dextroamphetamine .............. 44
dextroamphetamine-
amphetamine .................... 44
dextrose 10 % and 0.2 % nacl
.......................................... 75
dextrose 10 % in water (d10w)
.......................................... 75
dextrose 5 % in water (d5w). 75
dextrose 5%-0.2 % sod
chloride ............................. 75
dextrose 5%-0.3 %
sod.chloride ...................... 75
dextrose with sodium chloride
.......................................... 75
DIASTAT ............................. 25
DIASTAT ACUDIAL .......... 25
diazepam ............................... 44
diazepam intensol ................. 44
DIBENZYLINE ................... 54
DICLEGIS ............................ 91
DICLOFENAC EPOLAMINE
.......................................... 39
diclofenac potassium ............ 39
diclofenac sodium ... 39, 65, 115
diclofenac-misoprostol ......... 39
dicloxacillin .......................... 14
dicyclomine .......................... 89
didanosine ............................... 4
DIFFERIN ............................ 67
DIFICID ................................. 9
diflorasone ............................ 72
DIFLUCAN ............................ 2
diflunisal ............................... 39
digitek ................................... 63
digox ..................................... 63
digoxin .................................. 63
dihydroergotamine ................ 30
DILANTIN 30 MG ............... 25
DILANTIN EXTENDED 100
MG .................................... 25
DILANTIN INFATABS 50
MG .................................... 25
DILANTIN-125 125 MG/5
ML .................................... 25
DILAUDID ........................... 35
diltiazem hcl ......................... 54
dilt-xr .................................... 55
DIOVAN .............................. 55
DIOVAN HCT ..................... 55
DIPENTUM ......................... 91
diphenoxylate-atropine ......... 90
DIPROLENE ........................ 72
dipyridamole ......................... 59
disulfiram .............................. 75
DITROPAN XL .................. 125
DIURIL ................................. 55
divalproex ............................. 25
DIVIGEL ............................ 106
dofetilide ............................... 52
DOLOPHINE ....................... 35
donepezil ............................... 32
DOPTELET (10 TAB PACK)
.......................................... 59
DOPTELET (15 TAB PACK)
.......................................... 59
DOPTELET (30 TAB PACK)
.......................................... 59
DORYX ................................ 16
DORYX MPC ...................... 16
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
136
dorzolamide ........................ 116
dorzolamide-timolol ........... 116
dorzolamide-timolol (pf) .... 116
dotti..................................... 106
DOVATO ............................... 4
DOVONEX .......................... 64
doxazosin .............................. 55
doxepin ........................... 44, 65
doxercalciferol ...................... 87
doxy-100............................... 16
doxycycline hyclate .............. 16
doxycycline monohydrate .... 16
doxylamine-pyridoxine (vit b6)
.......................................... 91
dronabinol............................. 91
drospirenone-e.estradiol-lm.fa
........................................ 109
drospirenone-ethinyl estradiol
........................................ 109
DROXIA .............................. 19
DUAC................................... 67
DUAVEE ........................... 106
DUETACT ........................... 80
DUEXIS ............................... 39
DULERA ............................ 121
duloxetine ............................. 44
DUOBRII ............................. 72
DUOPA ................................ 29
DUPIXENT .......................... 65
DURAGESIC ....................... 35
duramorph (pf) ..................... 35
DUREZOL ......................... 117
dutasteride .......................... 126
dutasteride-tamsulosin ........ 126
DUTOPROL......................... 55
DUZALLO ......................... 102
dvorah ................................... 35
DYANAVEL XR ................. 44
DYAZIDE ............................ 55
DYMISTA .......................... 121
DYRENIUM ........................ 55
E e.e.s. 400 ................................. 9
E.E.S. GRANULES ............... 9
econazole .............................. 69
EDARBI ............................... 55
EDARBYCLOR ................... 55
EDECRIN............................. 55
EDURANT ............................. 4
efavirenz ................................. 4
EFFEXOR XR...................... 44
EFFIENT .............................. 59
EFUDEX .............................. 65
EGRIFTA ............................. 97
ELESTRIN ......................... 106
eletriptan ............................... 30
ELIDEL ................................ 65
ELIGARD ............................ 19
ELIGARD (3 MONTH) ....... 19
ELIGARD (4 MONTH) ....... 19
ELIGARD (6 MONTH) ....... 19
ELIMITE .............................. 74
ELIQUIS .............................. 59
ELMIRON .......................... 126
ELOCON .............................. 72
EMBEDA ............................. 35
EMCYT ................................ 19
EMEND ................................ 91
EMFLAZA ........................... 78
EMGALITY PEN................. 31
EMGALITY SYRINGE ....... 31
emoquette ........................... 109
EMSAM ............................... 44
EMTRIVA .............................. 4
EMVERM ............................ 11
ENABLEX ......................... 125
enalapril maleate................... 55
enalapril-hydrochlorothiazide
.......................................... 55
ENBREL ............................ 104
ENBREL MINI .................. 104
ENBREL SURECLICK ..... 104
ENDARI ............................... 75
endocet.................................. 35
ENGERIX-B (PF) .............. 100
ENGERIX-B PEDIATRIC
(PF) ................................. 100
enoxaparin ............................ 59
enpresse .............................. 109
enskyce ............................... 109
ENSTILAR ........................... 64
entacapone ............................ 29
entecavir ................................. 4
ENTOCORT EC................... 91
ENTRESTO.......................... 63
enulose .................................. 91
ENVARSUS XR .................. 19
EPCLUSA .............................. 4
EPIDIOLEX ......................... 25
EPIDUO ............................... 67
EPIDUO FORTE .................. 67
epinastine ............................ 115
epinephrine ......................... 119
EPINEPHRINE .................. 119
EPIPEN 2-PAK .................. 119
EPIPEN JR 2-PAK ............. 119
epitol ..................................... 25
EPIVIR ................................... 4
EPIVIR HBV .......................... 4
eplerenone ............................. 55
EPOGEN .............................. 97
eprosartan ............................. 55
EPZICOM ............................... 4
EQUETRO ........................... 25
ERAXIS(WATER DILUENT)
............................................ 2
ergoloid ................................. 45
ergotamine-caffeine .............. 31
ERIVEDGE .......................... 19
ERLEADA ........................... 19
erlotinib ................................. 19
errin ..................................... 106
ERTACZO ............................ 69
ertapenem ............................. 11
ery pads ................................. 67
erygel .................................... 67
ERYPED 200 .......................... 9
ERYPED 400 .......................... 9
ery-tab ..................................... 9
ERY-TAB ............................. 10
ERYTHROCIN .................... 10
erythrocin (as stearate) ......... 10
erythromycin ................. 10, 113
erythromycin ethylsuccinate . 10
erythromycin with ethanol .... 67
erythromycin-benzoyl peroxide
.......................................... 67
ESBRIET ............................ 121
escitalopram oxalate ............. 45
esomeprazole magnesium ..... 95
ESOMEPRAZOLE
STRONTIUM ................... 95
estarylla ............................... 109
ESTRACE .......................... 106
estradiol .............................. 106
estradiol valerate ................. 107
estradiol-norethindrone acet
........................................ 107
ESTRING ........................... 107
eszopiclone ........................... 45
ethacrynic acid ...................... 55
ethambutol ............................ 11
ethosuximide ......................... 25
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
137
ethynodiol diac-eth estradiol
........................................ 109
etidronate disodium .............. 75
etodolac ................................ 39
EUCRISA ............................. 65
EURAX ................................ 74
EVAMIST .......................... 107
EVEKEO .............................. 45
EVEKEO ODT ..................... 45
EVENITY........................... 103
EVISTA .............................. 103
EVOCLIN ............................ 67
EVOTAZ ................................ 4
EVOXAC ............................. 75
EVZIO .................................. 39
EXELDERM ........................ 69
EXELON .............................. 32
exemestane ........................... 19
EXFORGE ........................... 55
EXFORGE HCT .................. 55
EXJADE ............................... 75
EXTAVIA ............................ 97
EXTINA ............................... 69
EZALLOR SPRINKLE........ 61
ezetimibe .............................. 61
ezetimibe-simvastatin ........... 61
F FABIOR ............................... 67
falmina (28) ........................ 109
famciclovir ............................. 4
famotidine............................. 95
FANAPT .............................. 45
FARESTON ......................... 19
FARXIGA ............................ 80
FARYDAK........................... 19
FASENRA .......................... 121
fayosim ............................... 109
FAZACLO ........................... 45
febuxostat ........................... 102
felbamate .............................. 25
FELBATOL ......................... 25
FELDENE ............................ 40
felodipine .............................. 55
FEMARA ............................. 19
FEMHRT LOW DOSE ...... 107
FEMRING .......................... 107
femynor .............................. 109
fenofibrate ............................ 61
FENOFIBRATE ................... 61
fenofibrate micronized ......... 61
fenofibrate nanocrystallized . 61
fenofibric acid....................... 61
fenofibric acid (choline) ....... 61
FENOGLIDE........................ 61
fenoprofen ............................ 40
FENOPROFEN .................... 40
fentanyl ................................. 36
fentanyl citrate ...................... 36
FENTANYL CITRATE ....... 36
FENTORA............................ 36
ferriprox ................................ 75
FERRIPROX ........................ 75
FETZIMA ............................. 45
FEXMID ............................... 34
FIASP FLEXTOUCH U-100
INSULIN .......................... 80
FIASP U-100 INSULIN ....... 80
FIBRICOR............................ 61
FINACEA ............................. 67
finasteride ........................... 126
FIRAZYR ........................... 121
FIRDAPSE ........................... 32
FIRMAGON KIT W
DILUENT SYRINGE 19, 20
FIRVANQ ............................ 11
flac otic oil ............................ 77
FLAGYL .............................. 11
FLAREX ............................ 117
flavoxate ............................. 125
FLEBOGAMMA DIF ........ 100
flecainide .............................. 52
FLECTOR ............................ 40
FLOLIPID ............................ 61
FLOMAX ........................... 126
FLOVENT DISKUS .......... 121
FLOVENT HFA ................. 121
fluconazole ............................. 2
fluconazole in nacl (iso-osm) . 2
flucytosine .............................. 2
fludrocortisone...................... 78
FLUMADINE ........................ 4
flunisolide ........................... 121
fluocinolone .......................... 72
fluocinolone acetonide oil .... 77
fluocinolone and shower cap 72
fluocinonide .......................... 72
fluocinonide-e ....................... 72
fluoride (sodium) ................ 129
fluorometholone ................. 117
fluorouracil ........................... 65
FLUOROURACIL ............... 65
fluoxetine .............................. 45
fluphenazine decanoate ........ 45
fluphenazine hcl .................... 45
flurandrenolide ..................... 72
flurbiprofen ........................... 40
flurbiprofen sodium ............ 115
flutamide ............................... 20
fluticasone propionate .. 72, 121
FLUTICASONE PROPION-
SALMETEROL .............. 121
fluvastatin ............................. 61
fluvoxamine .......................... 45
FML FORTE ...................... 117
FML LIQUIFILM .............. 117
FML S.O.P. ......................... 117
FOCALIN ............................. 45
FOCALIN XR ...................... 46
fondaparinux ......................... 60
FORFIVO XL ....................... 46
FORTAMET ......................... 80
FORTEO ............................. 103
FORTESTA .......................... 87
FOSAMAX ......................... 103
FOSAMAX PLUS D .......... 103
fosamprenavir ......................... 4
fosinopril ............................... 55
fosinopril-hydrochlorothiazide
.......................................... 55
FOSRENOL ......................... 75
FRAGMIN ............................ 60
FREAMINE HBC 6.9 % .... 129
FROVA ................................. 31
frovatriptan ........................... 31
FULPHILA ........................... 97
FURADANTIN .................... 17
furosemide ............................ 55
FUZEON ................................ 4
fyavolv ................................ 107
FYCOMPA ........................... 25
G gabapentin ....................... 25, 26
GABITRIL ........................... 26
GALAFOLD ......................... 87
galantamine ........................... 32
GAMMAGARD LIQUID .. 100
GAMMAGARD S-D (IGA < 1
MCG/ML) ....................... 100
GAMMAKED .................... 100
GAMMAPLEX .................. 100
GAMMAPLEX (WITH
SORBITOL) ................... 100
GAMUNEX-C .................... 100
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
138
GARDASIL 9 (PF)............. 100
GASTROCROM .................. 91
gatifloxacin ......................... 113
GATTEX 30-VIAL .............. 91
GAUZE PAD ....................... 80
gavilyte-c .............................. 91
gavilyte-g .............................. 91
gavilyte-n .............................. 91
GELNIQUE ........................ 125
gemfibrozil ........................... 61
GENERESS FE .................. 109
generlac ................................ 91
gengraf .................................. 20
GENOTROPIN .................... 98
GENOTROPIN MINIQUICK
.......................................... 98
gentak ................................. 113
gentamicin .............. 12, 68, 113
gentamicin in nacl (iso-osm) 11
GENVOYA ............................ 4
GEODON ............................. 46
gianvi (28) .......................... 110
GILENYA ............................ 32
GILOTRIF ............................ 20
GLASSIA ............................. 75
glatiramer ....................... 32, 33
glatopa .................................. 33
GLEEVEC ............................ 20
GLEOSTINE ........................ 20
glimepiride ........................... 81
glipizide ................................ 81
glipizide-metformin .............. 81
GLUCAGEN HYPOKIT ..... 81
GLUCAGON EMERGENCY
KIT (HUMAN) ................ 81
GLUCOPHAGE ................... 81
GLUCOPHAGE XR ............ 81
GLUCOTROL ...................... 81
GLUCOTROL XL ............... 81
GLUMETZA ........................ 81
glycopyrrolate....................... 90
GLYSET............................... 81
GLYXAMBI ........................ 82
GOCOVRI ............................ 29
GOLYTELY......................... 92
GRALISE ............................. 26
GRALISE 30-DAY STARTER
PACK ............................... 26
granisetron hcl ...................... 92
GRANIX .............................. 98
griseofulvin microsize ............ 2
griseofulvin ultramicrosize ..... 2
guanidine .............................. 46
GVOKE SYRINGE .............. 82
GYNAZOLE-1 ................... 108
H HAEGARDA...................... 121
hailey 24 fe ......................... 110
halcinonide ........................... 72
HALDOL.............................. 46
HALDOL DECANOATE .... 46
halobetasol propionate .......... 72
HALOBETASOL
PROPIONATE ................. 72
HALOG ................................ 72
haloperidol ............................ 46
haloperidol decanoate ........... 46
haloperidol lactate ................ 46
HARVONI.............................. 4
HAVRIX (PF) .................... 100
heparin (porcine) .................. 60
HEPATAMINE 8% ............ 129
HEPSERA .............................. 4
HETLIOZ ............................. 46
HIBERIX (PF) .................... 100
HIPREX................................ 17
HORIZANT.......................... 33
HUMALOG JUNIOR
KWIKPEN U-100 ............ 82
HUMALOG KWIKPEN
INSULIN .......................... 82
HUMALOG MIX 50-50
INSULN U-100 ................ 82
HUMALOG MIX 50-50
KWIKPEN........................ 82
HUMALOG MIX 75-25
KWIKPEN........................ 82
HUMALOG MIX 75-25(U-
100)INSULN .................... 82
HUMALOG U-100 INSULIN
.......................................... 82
HUMATROPE ..................... 98
HUMIRA ............................ 104
HUMIRA PEDIATRIC
CROHNS START .......... 104
HUMIRA PEN ................... 104
HUMIRA PEN CROHNS-UC-
HS START ..................... 104
HUMIRA PEN PSOR-
UVEITS-ADOL HS ....... 104
HUMIRA(CF) .................... 104
HUMIRA(CF) PEDI
CROHNS STARTER ..... 104
HUMIRA(CF) PEN ............ 104
HUMIRA(CF) PEN
CROHNS-UC-HS ........... 104
HUMIRA(CF) PEN PSOR-
UV-ADOL HS ................ 104
HUMULIN 70/30 U-100
INSULIN .......................... 82
HUMULIN 70/30 U-100
KWIKPEN ........................ 82
HUMULIN N NPH INSULIN
KWIKPEN ........................ 82
HUMULIN N NPH U-100
INSULIN .......................... 82
HUMULIN R REGULAR U-
100 INSULN .................... 82
HUMULIN R U-500 (CONC)
INSULIN .......................... 82
HUMULIN R U-500 (CONC)
KWIKPEN ........................ 82
hydralazine ........................... 55
HYDREA ............................. 20
hydrochlorothiazide .............. 55
hydrocodone-acetaminophen 36
hydrocodone-ibuprofen ........ 36
hydrocortisone .... 72, 73, 78, 92
hydrocortisone butyrate ........ 72
hydrocortisone valerate ........ 73
hydrocortisone-acetic acid .... 77
hydrocortisone-pramoxine .... 92
hydromorphone ..................... 36
hydromorphone (pf) .............. 36
hydroxychloroquine .............. 12
hydroxyurea .......................... 20
hydroxyzine hcl .................. 119
HYSINGLA ER .................... 36
HYZAAR ............................. 55
I ibandronate ......................... 103
IBRANCE ............................. 20
ibu ......................................... 40
ibuprofen ............................... 40
ibuprofen-oxycodone ............ 36
icatibant .............................. 121
ICLUSIG .............................. 20
IDHIFA ................................. 20
ILEVRO ............................. 115
ILUMYA .............................. 64
imatinib ................................. 20
IMBRUVICA ....................... 20
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
139
imipenem-cilastatin .............. 12
imipramine hcl...................... 46
imipramine pamoate ............. 46
imiquimod ............................ 65
IMIQUIMOD ....................... 65
IMITREX ............................. 31
IMITREX STATDOSE PEN 31
IMITREX STATDOSE
REFILL ............................ 31
IMOVAX RABIES VACCINE
(PF) ................................. 101
IMPOYZ............................... 73
IMURAN .............................. 20
IMVEXXY MAINTENANCE
PACK ............................. 107
IMVEXXY STARTER PACK
........................................ 107
INBRIJA............................... 29
incassia ............................... 107
INCRELEX .......................... 75
INCRUSE ELLIPTA.......... 121
indapamide ........................... 55
INDERAL LA ...................... 55
INDOCIN ............................. 40
INFANRIX (DTAP) (PF)... 101
INFLECTRA ........................ 92
INGREZZA .......................... 33
INGREZZA INITIATION
PACK ............................... 33
INLYTA ............................... 20
INNOPRAN XL ................... 56
INREBIC .............................. 20
INSPRA ................................ 56
INSULIN LISPRO ............... 82
INSULIN PEN NEEDLE ..... 82
INSULIN SYRINGE (DISP)
U-100 ................................ 82
INTELENCE ...................... 4, 5
intralipid ............................. 129
INTRALIPID ..................... 129
INTRAROSA ..................... 108
INTRON A ........................... 98
introvale .............................. 110
INVANZ............................... 12
INVEGA............................... 46
INVEGA SUSTENNA ......... 46
INVEGA TRINZA ............... 46
INVELTYS ........................ 117
INVIRASE ............................. 5
INVOKAMET ................ 82, 83
INVOKAMET XR ............... 83
INVOKANA ........................ 83
IONOSOL-MB IN D5W .... 129
IOPIDINE ........................... 118
IPOL ................................... 101
ipratropium bromide ..... 77, 121
ipratropium-albuterol.......... 121
irbesartan .............................. 56
irbesartan-hydrochlorothiazide
.......................................... 56
IRESSA ................................ 20
ISENTRESS ........................... 5
ISENTRESS HD .................... 5
isibloom .............................. 110
ISOLYTE-P IN 5 %
DEXTROSE ................... 129
ISOLYTE-S ........................ 129
isoniazid................................ 12
ISOPTO CARPINE ............ 115
ISORDIL .............................. 63
ISORDIL TITRADOSE ....... 63
isosorbide dinitrate ............... 63
isosorbide mononitrate ......... 63
isotretinoin ............................ 67
isradipine .............................. 56
ISTALOL ........................... 114
itraconazole ............................ 2
ivermectin ............................. 12
IXIARO (PF) ...................... 101
J JADENU .............................. 75
JADENU SPRINKLE .......... 75
JAKAFI ................................ 20
JALYN ............................... 126
jantoven ................................ 60
JANUMET ........................... 83
JANUMET XR ..................... 83
JANUVIA ............................. 83
JARDIANCE ........................ 83
jasmiel (28) ......................... 110
JENTADUETO .................... 83
JENTADUETO XR .............. 83
jinteli ................................... 107
JUBLIA ................................ 69
juleber ................................. 110
JULUCA ................................. 5
junel 1.5/30 (21) ................. 110
junel 1/20 (21) .................... 110
junel fe 1.5/30 (28) ............. 110
junel fe 1/20 (28) ................ 110
junel fe 24 ........................... 110
JUXTAPID ........................... 61
JYNARQUE ......................... 87
K KADIAN .............................. 36
kaitlib fe .............................. 110
KALBITOR ........................ 121
KALETRA ............................. 5
KALYDECO .............. 121, 122
KAPSPARGO SPRINKLE .. 56
KAPVAY ............................. 46
kariva (28) .......................... 110
KAZANO ............................. 83
kelnor 1/35 (28) .................. 110
kelnor 1-50 .......................... 110
KENALOG ........................... 73
KEPPRA ............................... 26
KEPPRA XR ........................ 26
KERYDIN ............................ 69
ketoconazole ..................... 2, 69
ketoprofen ............................. 40
ketorolac ............................. 115
KEVEYIS ............................. 33
KEVZARA ................. 104, 105
KHEDEZLA ......................... 46
KINERET ........................... 105
KINRIX (PF) ...................... 101
kionex (with sorbitol) ........... 76
KISQALI .............................. 20
KISQALI FEMARA CO-
PACK ............................... 20
KITABIS PAK ..................... 12
KLARON ............................. 68
KLONOPIN .......................... 26
klor-con ............................... 127
klor-con 10 .......................... 126
klor-con 8 ............................ 126
klor-con m10 ...................... 126
klor-con m15 ...................... 126
klor-con m20 ...................... 126
klor-con sprinkle ................. 127
KOMBIGLYZE XR ............. 83
KORLYM ............................. 87
KRINTAFEL ........................ 12
KRISTALOSE ...................... 92
k-tab .................................... 127
K-TAB ................................ 127
kurvelo (28) ........................ 110
KUVAN ................................ 87
L l norgest/e.estradiol-e.estrad
........................................ 110
labetalol ................................ 56
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
140
LACRISERT ...................... 115
lactulose ................................ 92
LAMICTAL ......................... 26
LAMICTAL ODT ................ 26
LAMICTAL STARTER
(BLUE) KIT ..................... 26
LAMICTAL STARTER
(GREEN) KIT .................. 26
LAMICTAL STARTER
(ORANGE) KIT ............... 26
LAMICTAL XR ................... 26
LAMICTAL XR STARTER
(BLUE) ............................. 26
LAMICTAL XR STARTER
(GREEN) .......................... 26
LAMICTAL XR STARTER
(ORANGE)....................... 26
lamivudine .............................. 5
lamivudine-zidovudine ........... 5
lamotrigine ..................... 26, 27
LANOXIN ............................ 63
lansoprazole .......................... 95
lanthanum ............................. 76
LANTUS SOLOSTAR U-100
INSULIN .......................... 83
LANTUS U-100 INSULIN .. 83
larin 1.5/30 (21) .................. 110
larin 1/20 (21) ..................... 110
larin fe 1.5/30 (28) .............. 110
larin fe 1/20 (28) ................. 110
larissia................................. 110
LASIX .................................. 56
LASTACAFT ..................... 115
latanoprost .......................... 116
LATUDA ............................. 46
layolis fe ............................. 110
LAZANDA..................... 36, 37
LEDIPASVIR-SOFOSBUVIR
............................................ 5
leena 28 .............................. 110
leflunomide......................... 105
LENVIMA ........................... 20
LESCOL XL ........................ 61
lessina ................................. 110
LETAIRIS .......................... 122
letrozole ................................ 20
leucovorin calcium ............... 18
LEUKERAN ........................ 20
LEUKINE............................. 98
leuprolide .............................. 20
levalbuterol hcl ................... 122
LEVALBUTEROL
TARTRATE ................... 122
LEVAQUIN ......................... 16
LEVEMIR FLEXTOUCH U-
100 INSULN .................... 83
LEVEMIR U-100 INSULIN 83
levetiracetam ........................ 27
levobunolol ......................... 114
levocarnitine ......................... 76
levocarnitine (with sugar) ..... 76
levocetirizine ...................... 119
levofloxacin .................. 16, 113
levofloxacin in d5w .............. 16
levonest (28) ....................... 110
levonorgestrel-ethinyl estrad
........................................ 110
levonorg-eth estrad triphasic
........................................ 110
levora-28 ............................. 110
levorphanol tartrate............... 37
LEVORPHANOL
TARTRATE ..................... 37
LEVO-T................................ 89
levothyroxine ........................ 89
levoxyl .................................. 89
LEXAPRO............................ 47
LEXETTE ............................ 73
LEXIVA ................................. 5
LIALDA ............................... 92
lidocaine ............................... 65
lidocaine hcl ......................... 65
lidocaine viscous .................. 65
lidocaine-prilocaine .............. 65
LIDODERM ......................... 65
lindane .................................. 74
linezolid ................................ 12
linezolid in dextrose 5% ....... 12
LINZESS .............................. 92
liothyronine .......................... 89
LIPITOR ............................... 61
LIPOFEN.............................. 61
lisinopril................................ 56
lisinopril-hydrochlorothiazide
.......................................... 56
lithium carbonate .................. 47
lithium citrate ....................... 47
LITHOBID ........................... 47
LITHOSTAT ........................ 76
LIVALO ............................... 61
LO LOESTRIN FE ............. 110
LOCOID ............................... 73
LOCOID LIPOCREAM ....... 73
LODINE ............................... 40
LODOSYN ........................... 29
LOESTRIN 1.5/30 (21) ...... 110
LOESTRIN 1/20 (21) ......... 110
LOESTRIN FE 1.5/30 (28-
DAY) .............................. 111
LOESTRIN FE 1/20 (28-DAY)
........................................ 111
LOKELMA ........................... 76
LOMOTIL ............................ 90
LONHALA MAGNAIR
REFILL ........................... 122
LONHALA MAGNAIR
STARTER ...................... 122
LONSURF ............................ 20
loperamide ............................ 90
LOPID .................................. 62
lopinavir-ritonavir ................... 5
lopreeza ............................... 107
LOPRESSOR ....................... 56
LOPRESSOR HCT .............. 56
LOPROX .............................. 69
LOPROX (AS OLAMINE) .. 69
lorazepam ............................. 47
LORBRENA ......................... 20
lorcet (hydrocodone) ............ 37
lorcet hd ................................ 37
lorcet plus ............................. 37
loryna (28) .......................... 111
losartan ................................. 56
losartan-hydrochlorothiazide 56
LOSEASONIQUE .............. 111
LOTEMAX ......................... 118
LOTEMAX SM .................. 118
LOTENSIN ........................... 56
loteprednol etabonate .......... 118
LOTREL ............................... 56
LOTRISONE ........................ 69
LOTRONEX ......................... 92
lovastatin ............................... 62
LOVAZA .............................. 62
LOVENOX ........................... 60
low-ogestrel (28) ................ 111
loxapine succinate ................ 47
LUCEMYRA ........................ 40
LULICONAZOLE ............... 69
LUMIGAN ......................... 116
LUNESTA ............................ 47
LUPANETA PACK (1
MONTH) ........................ 108
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
141
LUPANETA PACK (3
MONTH) ........................ 108
LUPRON DEPOT ................ 21
LUPRON DEPOT (3
MONTH) .......................... 21
LUPRON DEPOT (4
MONTH) .......................... 21
LUPRON DEPOT (6
MONTH) .......................... 21
lutera (28) ........................... 111
LUXIQ ................................. 73
LUZU ................................... 69
LYNPARZA......................... 21
LYRICA ............................... 27
LYRICA CR ......................... 27
LYSODREN......................... 21
LYSTEDA .......................... 108
lyza ..................................... 107
M MACROBID ........................ 17
MACRODANTIN ................ 17
mafenide acetate ................... 68
magnesium sulfate .............. 127
MALARONE ....................... 12
MALARONE PEDIATRIC . 12
malathion .............................. 74
maprotiline ........................... 47
MARINOL ........................... 92
marlissa (28) ....................... 111
MARPLAN .......................... 47
MATULANE ....................... 21
matzim la .............................. 56
MAVENCLAD (10 TABLET
PACK) .............................. 33
MAVENCLAD (4 TABLET
PACK) .............................. 33
MAVENCLAD (5 TABLET
PACK) .............................. 33
MAVENCLAD (6 TABLET
PACK) .............................. 33
MAVENCLAD (7 TABLET
PACK) .............................. 33
MAVENCLAD (8 TABLET
PACK) .............................. 33
MAVENCLAD (9 TABLET
PACK) .............................. 33
MAVYRET ............................ 5
MAXALT ............................. 31
MAXALT-MLT ................... 31
MAXIDEX ......................... 118
MAXIPIME ............................ 9
MAXITROL ............... 116, 117
MAXZIDE............................ 56
MAXZIDE-25MG ................ 56
MAYZENT .......................... 33
meclizine .............................. 92
meclofenamate...................... 40
MEDROL ............................. 78
MEDROL (PAK) ................. 78
medroxyprogesterone ......... 107
mefenamic acid..................... 40
mefloquine ............................ 12
megestrol .............................. 21
MEKINIST ........................... 21
MEKTOVI............................ 21
melodetta 24 fe ................... 111
meloxicam ............................ 40
memantine ............................ 33
MEMANTINE...................... 33
MENACTRA (PF) ............. 101
MENEST ............................ 107
MENOSTAR ...................... 107
MENTAX ............................. 69
MENVEO A-C-Y-W-135-DIP
(PF) ................................. 101
MEPRON ............................. 12
mercaptopurine ..................... 21
meropenem ........................... 12
MERREM ............................. 12
mesalamine ........................... 92
MESNEX.............................. 18
MESTINON ......................... 34
MESTINON TIMESPAN .... 34
metadate er ........................... 47
metaproterenol .................... 122
metformin ....................... 83, 84
methadone ............................ 37
methamphetamine ................ 47
methazolamide.................... 116
methenamine hippurate ........ 17
methimazole ......................... 79
METHITEST ........................ 87
methotrexate sodium ............ 21
methotrexate sodium (pf) ..... 21
methoxsalen .......................... 65
methscopolamine .................. 90
methyldopa ........................... 56
METHYLIN ......................... 47
methylphenidate hcl ............. 47
METHYLPHENIDATE HCL
.......................................... 47
methylprednisolone .............. 78
methyltestosterone ................ 87
metoclopramide hcl .............. 92
metolazone ............................ 56
metoprolol succinate ............. 56
metoprolol tartrate ................ 56
metoprolol tartrate-
hydrochlorothiazide .......... 56
METROCREAM .................. 68
METROGEL ........................ 68
METROLOTION ................. 68
metronidazole ......... 12, 68, 108
metronidazole in nacl (iso-
osm) .................................. 12
mexiletine ............................. 52
mibelas 24 fe ....................... 111
MICARDIS ........................... 56
MICARDIS HCT .................. 56
miconazole-3 ...................... 108
MICORT-HC ........................ 92
microgestin 1.5/30 (21) ...... 111
microgestin 1/20 (21) ......... 111
microgestin fe 1.5/30 (28) .. 111
microgestin fe 1/20 (28) ..... 111
midodrine .............................. 76
migergot ................................ 31
miglitol ................................. 84
miglustat ............................... 88
MIGRANAL ......................... 31
mili ...................................... 111
millipred ............................... 78
mimvey ............................... 107
mimvey lo ........................... 107
MINASTRIN 24 FE ........... 111
MINIPRESS ......................... 56
MINITRAN .......................... 63
MINIVELLE ...................... 107
MINOCIN ............................. 17
minocycline .......................... 17
MINOCYCLINE .................. 17
MINOLIRA ER .................... 17
minoxidil ............................... 56
MIRAPEX ............................ 29
MIRAPEX ER ...................... 29
mirtazapine ........................... 47
MIRVASO ............................ 68
misoprostol ........................... 95
MITIGARE ......................... 102
M-M-R II (PF) .................... 101
MOBIC ................................. 40
modafinil ............................... 47
moexipril ............................... 56
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
142
molindone ............................. 47
mometasone .................. 73, 122
mondoxyne nl ....................... 17
montelukast ........................ 122
MONUROL .......................... 18
morgidox .............................. 17
MORPHABOND ER ........... 37
morphine............................... 37
morphine concentrate ........... 37
MOTEGRITY ...................... 92
MOVANTIK ........................ 92
MOVIPREP .......................... 92
MOXEZA ........................... 113
moxifloxacin................. 16, 113
moxifloxacin-sod.chloride(iso)
.......................................... 16
MS CONTIN ........................ 37
MULPLETA......................... 60
MULTAQ ............................. 52
mupirocin ............................. 69
mupirocin calcium ................ 68
MYALEPT ........................... 88
MYAMBUTOL .................... 12
MYCAMINE .......................... 2
MYCOBUTIN ...................... 12
mycophenolate mofetil ......... 21
mycophenolate sodium ......... 21
MYDAYIS ........................... 47
MYFORTIC ......................... 21
myorisan ............................... 68
MYRBETRIQ .................... 125
MYSOLINE ......................... 27
MYTESI ............................... 90
N nabumetone .......................... 40
nadolol .................................. 56
nadolol-bendroflumethiazide 57
nafcillin................................. 14
naftifine ................................ 69
NAFTIN ............................... 70
NALFON .............................. 40
naloxone ............................... 40
naltrexone ............................. 40
NAMENDA ......................... 33
NAMENDA TITRATION
PAK .................................. 33
NAMENDA XR ................... 33
NAMZARIC................... 33, 34
NAPRELAN CR .................. 40
naproxen ............................... 40
naproxen sodium .................. 40
naratriptan ............................. 31
NARCAN ............................. 40
NARDIL ............................... 47
NASONEX ......................... 122
NATACYN ........................ 113
NATAZIA .......................... 111
nateglinide ............................ 84
NATPARA ........................... 88
NATROBA ........................... 74
NEBUPENT ......................... 12
necon 0.5/35 (28) ................ 111
NEEDLES, INSULIN
DISP.,SAFETY ................ 84
nefazodone............................ 48
neomycin .............................. 12
neomycin-bacitracin-poly-hc
........................................ 117
neomycin-bacitracin-
polymyxin ....................... 113
neomycin-polymyxin b-
dexameth ........................ 117
neomycin-polymyxin-
gramicidin ....................... 113
neomycin-polymyxin-hc ..... 78,
117
NEORAL .............................. 21
NEO-SYNALAR.................. 69
NEPHRAMINE 5.4 % ....... 129
NERLYNX ........................... 21
NESINA ............................... 84
neuac ..................................... 68
NEULASTA ......................... 98
NEUPOGEN ........................ 98
NEUPRO .............................. 29
NEURONTIN ....................... 27
NEVANAC ........................ 116
nevirapine ............................... 5
NEXAVAR .......................... 21
NEXIUM .............................. 95
NEXIUM PACKET ............. 95
niacin .................................... 62
NIACOR ............................... 62
NIASPAN EXTENDED-
RELEASE ........................ 62
nicardipine ............................ 57
NICOTROL .......................... 77
NICOTROL NS .................... 77
nifedipine .............................. 57
nikki (28) ............................ 111
NILANDRON ...................... 21
nilutamide ............................. 21
nimodipine ............................ 57
NINLARO ...................... 21, 22
nisoldipine ............................ 57
nitro-bid ................................ 63
NITRO-DUR ........................ 63
nitrofurantoin ........................ 18
nitrofurantoin macrocrystal .. 18
nitrofurantoin monohyd/m-
cryst .................................. 18
nitroglycerin ................... 63, 64
NITROSTAT ........................ 64
NITYR .................................. 76
NIVESTYM ......................... 98
nizatidine .............................. 95
NIZORAL ............................. 70
NOCDURNA (MEN) ........... 88
NOCDURNA (WOMEN) .... 88
NOCTIVA ............................ 88
nolix ...................................... 73
nora-be ................................ 107
NORCO ................................ 37
NORDITROPIN FLEXPRO 98
noreth-ethinyl estradiol-iron
........................................ 111
norethindrone (contraceptive)
........................................ 107
norethindrone acetate .......... 107
norethindrone ac-eth estradiol
................................ 107, 111
norethindrone-e.estradiol-iron
........................................ 111
norgestimate-ethinyl estradiol
........................................ 111
NORITATE .......................... 68
norlyroc ............................... 107
NORMOSOL-M IN 5 %
DEXTROSE ................... 129
NORMOSOL-R IN 5 %
DEXTROSE ................... 127
NORMOSOL-R PH 7.4 ...... 129
NORPRAMIN ...................... 48
NORTHERA ........................ 76
nortrel 0.5/35 (28) ............... 111
nortrel 1/35 (21) .................. 111
nortrel 1/35 (28) .................. 111
nortrel 7/7/7 (28) ................. 111
nortriptyline .......................... 48
NORVASC ........................... 57
NORVIR ................................. 5
NOURIANZ ......................... 29
NOVOFINE 32 ..................... 84
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
143
NOVOLIN 70/30 U-100
INSULIN .......................... 84
NOVOLIN N NPH U-100
INSULIN .......................... 84
NOVOLIN R REGULAR U-
100 INSULN .................... 84
NOVOLOG FLEXPEN U-100
INSULIN .......................... 84
NOVOLOG MIX 70-30 U-100
INSULN ........................... 84
NOVOLOG MIX 70-
30FLEXPEN U-100 ......... 84
NOVOLOG PENFILL U-100
INSULIN .......................... 84
NOVOLOG U-100 INSULIN
ASPART........................... 84
NOXAFIL .............................. 2
NUBEQA ............................. 22
NUCALA ........................... 122
NUCYNTA .......................... 41
NUCYNTA ER .................... 40
NUEDEXTA ........................ 34
NULYTELY WITH FLAVOR
PACKS ............................. 92
NUPLAZID .......................... 48
NUTRILIPID ..................... 129
NUTROPIN AQ NUSPIN ... 98
NUVARING....................... 108
NUVIGIL ............................. 48
NUZYRA ............................. 17
NUZYRA (7 DAY WITH
LOAD DOSE) .................. 17
NUZYRA (7 DAY) .............. 17
nyamyc ................................. 70
NYMALIZE ......................... 57
nystatin ......................... 2, 3, 70
nystatin-triamcinolone .......... 70
nystop ................................... 70
O OCALIVA ............................ 92
ocella .................................. 111
OCTAGAM ........................ 101
octreotide acetate .................. 22
OCUFLOX ......................... 113
ODEFSEY .............................. 5
ODOMZO ............................ 22
OFEV ................................. 122
ofloxacin ................. 16, 78, 113
ogestrel (28)........................ 111
olanzapine............................. 48
olanzapine-fluoxetine ........... 48
olmesartan ............................ 57
olmesartan-amlodipine-
hydrochlorothiazide .......... 57
olmesartan-
hydrochlorothiazide .......... 57
olopatadine ................... 77, 115
OLUMIANT ....................... 105
OLUX ................................... 73
OLUX-E ............................... 73
OMECLAMOX-PAK .......... 96
omega-3 acid ethyl esters ..... 62
omeprazole ........................... 96
omeprazole-sodium
bicarbonate ....................... 96
OMNARIS.......................... 122
OMNIPOD DASH INSULIN
POD .................................. 84
OMNIPOD INSULIN
MANAGEMENT ............. 84
OMNIPOD INSULIN REFILL
.......................................... 84
OMNITROPE ....................... 98
ondansetron .......................... 92
ondansetron hcl..................... 92
ONEXTON ........................... 68
ONFI ..................................... 27
ONGLYZA ........................... 85
ONZETRA XSAIL............... 31
OPANA ................................ 37
OPSUMIT .......................... 122
ORACEA.............................. 17
ORALAIR .......................... 101
ORAPRED ODT .................. 78
ORAVIG ................................ 3
ORENCIA .......................... 105
ORENCIA (WITH
MALTOSE) .................... 105
ORENCIA CLICKJECT .... 105
ORENITRAM ...................... 57
ORFADIN ............................ 76
ORILISSA ............................ 88
ORKAMBI ......................... 122
orsythia ............................... 111
ORTHO MICRONOR ........ 107
ORTHO TRI-CYCLEN LO
(28) ................................. 111
ORTHO-NOVUM 1/35 (28)
........................................ 112
ORTHO-NOVUM 7/7/7 (28)
........................................ 112
oseltamivir .............................. 5
OSENI .................................. 85
OSMOLEX ER ..................... 29
OSMOPREP ......................... 93
OSPHENA .......................... 108
OTEZLA ............................. 105
OTEZLA STARTER .......... 105
OTOVEL .............................. 78
OTREXUP (PF) .................. 105
OVIDE .................................. 74
oxacillin ................................ 15
oxacillin in dextrose(iso-osm)
.................................... 14, 15
oxandrolone .......................... 88
oxaprozin .............................. 41
OXAYDO ............................. 37
oxcarbazepine ....................... 27
OXERVATE ....................... 115
oxiconazole ........................... 70
OXISTAT ............................. 70
OXSORALEN ULTRA ........ 65
OXTELLAR XR .................. 27
oxybutynin chloride ............ 125
oxycodone ............................. 37
OXYCODONE ..................... 38
oxycodone-acetaminophen ... 38
oxycodone-aspirin ................ 38
OXYCONTIN ...................... 38
oxymorphone ........................ 38
OXYTROL ......................... 125
OZEMPIC ............................. 85
P pacerone ................................ 52
paliperidone .......................... 48
PALYNZIQ .......................... 88
PAMELOR ........................... 48
PANCREAZE ....................... 93
PANDEL .............................. 73
PANRETIN .......................... 65
pantoprazole ......................... 96
PANZYGA ......................... 101
paricalcitol ............................ 88
PARLODEL ................... 29, 30
PARNATE ............................ 48
paromomycin ........................ 12
paroxetine hcl ....................... 48
paroxetine
mesylate(menop.sym) ....... 48
PASER .................................. 12
PATADAY ......................... 115
PATANASE ......................... 77
PATANOL ......................... 115
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
144
PAXIL .................................. 48
PAXIL CR ............................ 48
PAZEO ............................... 115
PEDIARIX (PF) ................. 101
PEDVAX HIB (PF) ............ 101
peg 3350-electrolytes ........... 93
PEGANONE ........................ 27
PEGASYS ............................ 98
PEGASYS PROCLICK ....... 98
peg-electrolyte ...................... 93
penicillamine ...................... 105
PENICILLIN G POT IN
DEXTROSE ..................... 15
penicillin g potassium........... 15
penicillin g procaine ............. 15
penicillin g sodium ............... 15
penicillin v potassium........... 15
PENNSAID .......................... 41
PENTAM ............................. 12
PENTASA ............................ 93
pentoxifylline ....................... 60
PEPCID ................................ 96
PERCOCET ......................... 38
PERFOROMIST ................ 122
perindopril erbumine ............ 57
permethrin ............................ 74
perphenazine......................... 48
PERSERIS ............................ 48
PERTZYE ............................ 93
PEXEVA .............................. 48
phenelzine............................. 48
phenobarbital ........................ 27
phenoxybenzamine ............... 57
PHENYTEK ......................... 27
phenytoin .............................. 27
phenytoin sodium extended .. 27
PHOSLYRA ....................... 127
PHOSPHOLINE IODIDE .. 115
PICATO ............................... 65
PIFELTRO ............................. 5
pilocarpine hcl .............. 76, 115
pimecrolimus ........................ 65
pimozide ............................... 48
pimtrea (28) ........................ 112
pindolol................................. 57
pioglitazone .......................... 85
pioglitazone-glimepiride ...... 85
pioglitazone-metformin ........ 85
piperacillin-tazobactam ........ 15
PIQRAY ............................... 22
pirmella............................... 112
piroxicam .............................. 41
PLAQUENIL........................ 12
PLASMA-LYTE 148 ......... 129
PLASMA-LYTE A ............ 129
PLAVIX ............................... 60
PLEGRIDY .................... 98, 99
plenamine ........................... 129
PLENVU .............................. 93
PLIAGLIS ............................ 65
podofilox .............................. 65
polymyxin b sulfate .............. 12
polymyxin b sulf-trimethoprim
........................................ 113
POLYTRIM........................ 113
POMALYST ........................ 22
portia 28 .............................. 112
posaconazole .......................... 3
potassium chlorid-d5-
0.45%nacl ....................... 127
potassium chloride .............. 127
potassium chloride in 0.9%nacl
........................................ 127
potassium chloride in 5 % dex
........................................ 127
potassium chloride in lr-d5 . 127
potassium chloride in water 127
potassium chloride-0.45 % nacl
........................................ 127
potassium chloride-d5-
0.2%nacl ......................... 127
potassium chloride-d5-
0.3%nacl ......................... 127
potassium chloride-d5-
0.9%nacl ................. 127, 128
potassium citrate ................. 126
PRADAXA ........................... 60
PRALUENT PEN................. 62
pramipexole .......................... 30
PRANDIN ............................ 85
prasugrel ............................... 60
PRAVACHOL...................... 62
pravastatin ............................ 62
praziquantel .......................... 12
prazosin ................................ 57
PRECOSE ............................ 85
PRED FORTE .................... 118
PRED MILD....................... 118
PRED-G.............................. 117
PRED-G S.O.P. .................. 117
prednicarbate ........................ 73
prednisolone ......................... 78
prednisolone acetate ........... 118
prednisolone sodium phosphate
.................................. 79, 118
prednisone ............................. 79
prednisone intensol ............... 79
PREFEST ........................... 107
pregabalin ............................. 28
PREMARIN ............... 107, 108
premasol 10 % .................... 129
PREMASOL 6 % ............... 129
PREMPHASE ..................... 108
PREMPRO ......................... 108
prenatal vitamin oral tablet . 130
PREPOPIK ........................... 93
PREVACID .......................... 96
PREVACID SOLUTAB ....... 96
prevalite ................................ 62
previfem .............................. 112
PREVYMIS ............................ 5
PREZCOBIX .......................... 5
PREZISTA ......................... 5, 6
PRIFTIN ............................... 12
PRILOSEC ........................... 96
PRIMAQUINE ..................... 13
PRIMAXIN IV ..................... 13
primidone .............................. 28
PRIMLEV ............................. 38
PRINIVIL ............................. 57
PRISTIQ ............................... 49
PRIVIGEN ......................... 101
PROAIR HFA .................... 122
PROAIR RESPICLICK ...... 122
probenecid .......................... 102
probenecid-colchicine ......... 102
PROCALAMINE 3% ......... 129
PROCARDIA XL ................. 57
procentra ............................... 49
prochlorperazine ................... 93
prochlorperazine maleate oral
.......................................... 93
PROCRIT ............................. 99
procto-med hc ....................... 93
procto-pak ............................. 93
proctosol hc .......................... 93
proctozone-hc ....................... 93
progesterone micronized .... 108
PROGLYCEM ..................... 85
PROGRAF ............................ 22
PROLASTIN-C .................... 76
PROLENSA ....................... 116
PROLIA .............................. 103
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
145
PROMACTA ........................ 60
promethazine ...................... 119
PROMETRIUM ................. 108
propafenone .......................... 52
propranolol ........................... 57
propranolol-
hydrochlorothiazide .......... 57
propylthiouracil .................... 79
PROQUAD (PF) ................ 101
PROSCAR .......................... 126
PROSOL 20 % ................... 129
PROTONIX .......................... 96
PROTOPIC........................... 66
protriptyline .......................... 49
PROVENTIL HFA ............. 122
PROVERA ......................... 108
PROVIGIL ........................... 49
PROZAC .............................. 49
prudoxin ............................... 66
PSORCON ........................... 73
PULMICORT ..................... 123
PULMICORT FLEXHALER
................................ 122, 123
PULMOZYME................... 123
PURIXAN ............................ 22
PYLERA .............................. 96
pyrazinamide ........................ 13
pyridostigmine bromide ....... 34
PYRIDOSTIGMINE
BROMIDE ....................... 34
Q QBRELIS ............................. 57
QBREXZA ........................... 66
QMIIZ ODT ......................... 41
QNASL............................... 123
QTERN................................. 85
QUADRACEL (PF) ........... 101
QUALAQUIN ...................... 13
QUARTETTE .................... 112
QUDEXY XR ...................... 28
QUESTRAN......................... 62
QUESTRAN LIGHT............ 62
quetiapine ............................. 49
QUILLICHEW ER ............... 49
QUILLIVANT XR ............... 49
quinapril ............................... 57
quinapril-hydrochlorothiazide
.......................................... 57
quinidine gluconate .............. 52
quinidine sulfate ................... 52
quinine sulfate ...................... 13
QVAR REDIHALER ......... 123
R RABAVERT (PF) .............. 101
rabeprazole ........................... 96
RAGWITEK ....................... 101
raloxifene ............................ 103
ramelteon .............................. 49
ramipril ................................. 57
RANEXA ............................. 63
ranitidine hcl ......................... 96
ranolazine ............................. 63
RAPAFLO .......................... 126
RAPAMUNE........................ 22
rasagiline .............................. 30
RASUVO (PF) ................... 105
RAVICTI .............................. 76
RAYALDEE ........................ 88
RAYOS ................................ 79
RAZADYNE ........................ 34
RAZADYNE ER .................. 34
REBIF (WITH ALBUMIN) . 99
REBIF REBIDOSE .............. 99
REBIF TITRATION PACK . 99
reclipsen (28) ...................... 112
RECOMBIVAX HB (PF) .. 101
RECTIV................................ 93
REGLAN .............................. 93
REGRANEX ........................ 66
RELENZA DISKHALER ...... 6
RELEXXII............................ 49
RELISTOR ........................... 93
RELPAX .............................. 31
REMERON .......................... 49
REMERON SOLTAB .......... 49
REMICADE ......................... 93
RENAGEL ........................... 76
RENVELA ........................... 76
repaglinide ............................ 85
repaglinide-metformin .......... 85
REPATHA............................ 62
REPATHA PUSHTRONEX 62
REPATHA SURECLICK .... 62
REQUIP XL ......................... 30
RESCRIPTOR ........................ 6
RESTASIS.......................... 115
RESTASIS MULTIDOSE . 115
RETACRIT .......................... 99
RETIN-A .............................. 68
RETIN-A MICRO ................ 68
RETROVIR ............................ 6
REVATIO .......................... 123
REVLIMID ........................... 22
REXULTI ............................. 49
REYATAZ ............................. 6
RHOFADE ........................... 68
RHOPRESSA ..................... 116
ribavirin .................................. 6
RIDAURA .......................... 105
rifabutin ................................ 13
RIFADIN .............................. 13
RIFAMATE .......................... 13
rifampin ................................ 13
RIFATER ............................. 13
RILUTEK ............................. 76
riluzole .................................. 76
rimantadine ............................. 6
RINVOQ ER ...................... 105
RIOMET ............................... 85
risedronate .................... 76, 103
RISPERDAL ........................ 49
RISPERDAL CONSTA ....... 49
risperidone ...................... 49, 50
RITALIN .............................. 50
RITALIN LA ........................ 50
ritonavir .................................. 6
rivastigmine .......................... 34
rivastigmine tartrate .............. 34
rivelsa ................................. 112
rizatriptan .............................. 31
ROCALTROL ...................... 88
ROCKLATAN ................... 116
ropinirole .............................. 30
rosuvastatin ........................... 62
ROTARIX .......................... 102
ROTATEQ VACCINE ....... 102
ROWASA ............................. 93
roweepra ............................... 28
roweepra xr ........................... 28
ROXICODONE .................... 38
ROZEREM ........................... 50
ROZLYTREK ...................... 22
RUBRACA ........................... 22
RUCONEST ....................... 123
RUZURGI ............................ 34
RYDAPT .............................. 22
RYTARY .............................. 30
RYTHMOL SR .................... 52
S SABRIL ................................ 28
SAFYRAL .......................... 112
SAIZEN ................................ 99
SAIZEN SAIZENPREP ....... 99
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
146
SALAGEN (PILOCARPINE)
.......................................... 76
SAMSCA ............................. 88
SANCUSO ........................... 94
SANDIMMUNE .................. 22
SANDOSTATIN .................. 22
SANTYL .............................. 66
SAPHRIS ............................. 50
SARAFEM ........................... 50
SAVAYSA ........................... 60
SAVELLA .......................... 105
scopolamine base.................. 94
SEASONIQUE ................... 112
SEEBRI NEOHALER........ 123
SEGLUROMET ................... 85
selegiline hcl ......................... 30
selenium sulfide.................... 64
SELZENTRY ......................... 6
SEMPREX-D ..................... 119
SENSIPAR ........................... 88
SEREVENT DISKUS ........ 123
SERNIVO............................. 73
SEROQUEL ......................... 50
SEROQUEL XR .................. 50
SEROSTIM .......................... 99
sertraline ............................... 50
setlakin ............................... 112
sevelamer carbonate ............. 76
sevelamer hcl ........................ 76
sharobel .............................. 108
SHINGRIX (PF) ................. 102
SIGNIFOR ........................... 22
SIKLOS ................................ 22
sildenafil (pulmonary arterial
hypertension) .................. 123
SILENOR ............................. 50
SILIQ .................................... 64
silodosin ............................. 126
SILVADENE ....................... 66
silver sulfadiazine ................. 66
SIMBRINZA ...................... 116
SIMPONI ........................... 105
simvastatin ............................ 62
SINEMET............................. 30
SINEMET CR ...................... 30
SINGULAIR ...................... 123
sirolimus ............................... 22
SIRTURO ............................. 13
SITAVIG ................................ 6
SIVEXTRO .......................... 13
SKLICE ................................ 74
SKYRIZI .............................. 64
SLYND ............................... 112
sodium chloride .................... 76
sodium chloride 0.45 % ...... 128
sodium chloride 0.9 % .......... 76
sodium chloride 3 % ........... 128
sodium chloride 5 % ........... 128
sodium lactate intravenous . 128
sodium phenylbutyrate ......... 76
sodium polystyrene sulfonate
.......................................... 76
SOFOSBUVIR-
VELPATASVIR ................. 6
solifenacin .......................... 125
SOLIQUA 100/33 ................ 85
SOLODYN ........................... 17
SOLOSEC ............................ 13
SOLTAMOX ........................ 22
SOMATULINE DEPOT ...... 22
SOMAVERT ........................ 88
SOOLANTRA ...................... 68
SORIATANE ....................... 64
SORILUX ............................. 64
sorine .................................... 52
sotalol ................................... 52
sotalol af ............................... 52
SOTYLIZE ........................... 52
SOVALDI .............................. 6
SPIRIVA RESPIMAT ........ 123
SPIRIVA WITH
HANDIHALER .............. 123
spironolactone ...................... 57
spironolactone-
hydrochlorothiazide .......... 57
SPORANOX .......................... 3
sprintec (28) ........................ 112
SPRITAM ............................. 28
SPRIX ................................... 41
SPRYCEL ...................... 22, 23
sps (with sorbitol) ................. 76
sronyx ................................. 112
ssd ......................................... 66
STALEVO 100 ..................... 30
STALEVO 125 ..................... 30
STALEVO 150 ..................... 30
STALEVO 200 ..................... 30
STALEVO 50 ....................... 30
STALEVO 75 ....................... 30
STARLIX ............................. 85
stavudine ................................. 6
STEGLATRO ....................... 85
STEGLUJAN ....................... 85
STELARA ............................ 64
STIMATE ............................. 88
STIOLTO RESPIMAT ....... 123
STIVARGA .......................... 23
STRATTERA ....................... 50
STREPTOMYCIN ............... 13
STRIANT ............................. 88
STRIBILD .............................. 6
STRIVERDI RESPIMAT .. 123
STROMECTOL ................... 13
SUBOXONE ........................ 41
SUBSYS ............................... 38
SUCRAID ............................. 94
sucralfate ............................... 97
SULAR ................................. 57
sulfacetamide sodium ......... 115
sulfacetamide sodium (acne) 69
sulfacetamide-prednisolone 115
sulfadiazine ........................... 16
sulfamethoxazole-trimethoprim
.......................................... 16
SULFAMYLON ................... 69
sulfasalazine ......................... 94
sulindac ................................. 41
sumatriptan ........................... 31
sumatriptan succinate ..... 31, 32
sumatriptan-naproxen ........... 32
SUNOSI ................................ 50
SUPRAX ................................ 9
SUPREP BOWEL PREP KIT
.......................................... 94
SUSTIVA ............................... 6
SUTENT ............................... 23
syeda ................................... 112
SYLATRON ......................... 99
SYMBICORT ..................... 123
SYMBYAX .......................... 50
SYMDEKO ........................ 123
SYMFI .................................... 6
SYMFI LO .............................. 6
SYMJEPI ............................ 119
SYMLINPEN 120 ................ 85
SYMLINPEN 60 .................. 85
SYMPAZAN ........................ 28
SYMPROIC .......................... 94
SYMTUZA ............................. 6
SYNALAR ........................... 73
SYNAREL ............................ 88
SYNDROS ........................... 94
SYNJARDY ................... 85, 86
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
147
SYNJARDY XR .................. 86
SYNRIBO ............................ 23
SYNTHROID ....................... 89
SYPRINE ............................. 76
T TABLOID ............................ 23
TACLONEX ........................ 64
tacrolimus ....................... 23, 66
tadalafil ............................... 126
tadalafil (pulm. hypertension)
........................................ 124
TAFINLAR .......................... 23
TAGRISSO .......................... 23
TAKHZYRO ...................... 124
TALTZ AUTOINJECTOR .. 64
TALTZ SYRINGE ............... 64
TALZENNA......................... 23
TAMIFLU .............................. 6
tamoxifen .............................. 23
tamsulosin........................... 126
TAPAZOLE ......................... 79
TAPERDEX ......................... 79
TARCEVA ........................... 23
TARGADOX ....................... 17
TARGRETIN ....................... 23
tarina 24 fe .......................... 112
tarina fe 1/20 (28) ............... 112
TARKA ................................ 58
TASIGNA ............................ 23
TASMAR ............................. 30
TAVALISSE ........................ 60
tazarotene ............................. 68
tazicef ..................................... 9
TAZORAC ........................... 68
taztia xt ................................. 58
TDVAX .............................. 102
TECFIDERA ........................ 34
TECHLITE INSULIN SYR
HALF UNIT ..................... 86
TECHLITE INSULIN
SYRINGE......................... 86
TEFLARO .............................. 9
TEGRETOL ......................... 28
TEGRETOL XR ................... 28
TEGSEDI ............................. 34
TEKTURNA ........................ 58
TEKTURNA HCT ............... 58
telmisartan ............................ 58
telmisartan-amlodipine ......... 58
telmisartan-
hydrochlorothiazide .......... 58
TEMIXYS .............................. 6
TENIVAC (PF) .................. 102
tenofovir disoproxil fumarate . 6
TENORETIC 100 ................. 58
TENORETIC 50 ................... 58
TENORMIN ......................... 58
terazosin................................ 58
terbinafine hcl ......................... 3
terbutaline ........................... 124
terconazole.......................... 108
TESTIM................................ 88
testosterone ..................... 88, 89
testosterone cypionate .......... 88
testosterone enanthate........... 88
TETANUS,DIPHTHERIA
TOX PED(PF) ................ 102
tetrabenazine ......................... 34
tetracycline ........................... 17
TEXACORT ......................... 73
THALOMID ......................... 23
THEO-24 ............................ 124
theophylline ........................ 124
THIOLA ............................... 77
THIOLA EC ......................... 76
thioridazine ........................... 50
thiothixene ............................ 50
tiagabine ............................... 28
TIAZAC ............................... 58
TIBSOVO ............................. 23
tigecycline ............................ 13
TIGLUTIK ........................... 77
TIKOSYN ............................ 52
timolol maleate ............. 58, 114
TIMOPTIC OCUDOSE (PF)
........................................ 114
TIMOPTIC-XE .................. 114
tinidazole .............................. 13
TIROSINT ............................ 89
TIROSINT-SOL ................... 89
TIVICAY................................ 6
TIVORBEX .......................... 41
tizanidine .............................. 34
TOBI ..................................... 13
TOBI PODHALER .............. 13
TOBRADEX ...................... 117
TOBRADEX ST................. 117
tobramycin .......................... 113
tobramycin in 0.225 % nacl .. 13
tobramycin sulfate ................ 13
tobramycin-dexamethasone 117
TOBREX .................... 113, 114
TOFRANIL .......................... 50
TOLAK ................................. 66
tolbutamide ........................... 86
tolcapone ............................... 30
tolmetin ................................. 41
TOLSURA .............................. 3
tolterodine ........................... 125
TOPAMAX .......................... 28
TOPICORT ........................... 73
topiramate ............................. 28
TOPIRAMATE .................... 28
TOPROL XL ........................ 58
toremifene ............................. 23
torsemide .............................. 58
TOSYMRA ........................... 32
TOUJEO MAX U-300
SOLOSTAR ..................... 86
TOUJEO SOLOSTAR U-300
INSULIN .......................... 86
TOVIAZ ............................. 125
TPN ELECTROLYTES ..... 128
TRACLEER ....................... 124
TRADJENTA ....................... 86
tramadol ................................ 41
TRAMADOL ....................... 41
tramadol-acetaminophen ...... 41
trandolapril ........................... 58
trandolapril-verapamil .......... 58
tranexamic acid ................... 108
TRANSDERM-SCOP .......... 94
TRANXENE T-TAB ............ 50
tranylcypromine .................... 50
travasol 10 % ...................... 129
TRAVATAN Z ................... 116
trazodone .............................. 50
TRECATOR ......................... 13
TRELEGY ELLIPTA ......... 124
TRELSTAR .......................... 23
TREMFYA ........................... 64
TRESIBA FLEXTOUCH U-
100 .................................... 86
TRESIBA FLEXTOUCH U-
200 .................................... 86
TRESIBA U-100 INSULIN . 86
tretinoin (chemotherapy) ...... 23
tretinoin microspheres .......... 68
tretinoin topical ..................... 68
TREXALL ............................ 23
TREXIMET .......................... 32
TREZIX ................................ 38
triamcinolone acetonide .. 73, 77
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
148
triamterene ............................ 58
triamterene-
hydrochlorothiazide .......... 58
trianex ................................... 73
TRIBENZOR ....................... 58
TRICOR ............................... 62
triderm .................................. 74
TRIDESILON ...................... 74
trientine................................. 77
tri-estarylla ......................... 112
trifluoperazine ...................... 50
trifluridine........................... 114
TRIGLIDE ........................... 62
tri-legest fe.......................... 112
TRILEPTAL......................... 28
TRILIPIX ............................. 62
tri-lo-estarylla ..................... 112
tri-lo-sprintec ...................... 112
trilyte with flavor packets ..... 94
trimethoprim ......................... 18
tri-mili................................. 112
trimipramine ......................... 50
TRINTELLIX....................... 50
tri-previfem (28) ................. 112
tri-sprintec (28) ................... 112
TRIUMEQ .............................. 6
trivora (28).......................... 112
tri-vylibra ............................ 112
tri-vylibra lo........................ 112
TRIZIVIR ............................... 6
TROKENDI XR ................... 28
TROPHAMINE 10 % ........ 129
TROPHAMINE 6% ........... 129
trospium .............................. 125
TRULANCE......................... 94
TRULICITY ......................... 86
TRUMENBA ..................... 102
TRUSOPT .......................... 116
TRUVADA ............................ 7
TUDORZA PRESSAIR ..... 124
TURALIO ............................ 23
TWINRIX (PF) .................. 102
TWYNSTA .......................... 58
TYBOST ................................ 7
tydemy ................................ 112
TYGACIL ............................ 13
TYKERB .............................. 23
TYLENOL-CODEINE #3.... 38
TYLENOL-CODEINE #4.... 38
TYMLOS ........................... 103
TYPHIM VI ....................... 102
U UCERIS ................................ 94
UDENYCA .......................... 99
ULORIC ............................. 102
ULTRACET ......................... 41
ULTRAM ............................. 41
ULTRAVATE ...................... 74
UNASYN ............................. 15
unithroid ............................... 89
UPTRAVI ............................. 58
URECHOLINE .................. 126
UROCIT-K 10 .................... 126
UROCIT-K 15 .................... 126
UROCIT-K 5 ...................... 126
UROXATRAL ................... 126
URSO 250 ............................ 94
URSO FORTE ...................... 94
ursodiol ................................. 94
UTIBRON NEOHALER .... 124
V VABOMERE........................ 13
VAGIFEM .......................... 108
valacyclovir ............................ 7
VALCHLOR ........................ 66
VALCYTE ............................. 7
valganciclovir ......................... 7
VALIUM .............................. 50
valproic acid ......................... 28
valproic acid (as sodium salt)
.......................................... 28
valsartan................................ 58
valsartan-hydrochlorothiazide
.......................................... 58
VALTREX ............................. 7
VANCOCIN ......................... 13
vancomycin .................... 13, 14
VANCOMYCIN .................. 13
vandazole ............................ 108
VANOS ................................ 74
VAQTA (PF) ...................... 102
VARIVAX (PF) ................. 102
VARIZIG............................ 102
VARUBI ............................... 94
VASCEPA ............................ 62
VASERETIC ........................ 58
VASOTEC............................ 58
VECAMYL .......................... 63
VECTICAL .......................... 64
velivet triphasic regimen (28)
........................................ 112
VELPHORO ......................... 77
VELTASSA .......................... 77
VEMLIDY .............................. 7
VENCLEXTA ...................... 23
VENCLEXTA STARTING
PACK ............................... 23
venlafaxine ..................... 50, 51
VENLAFAXINE .................. 51
VENTAVIS ........................ 124
VENTOLIN HFA ............... 124
verapamil ........................ 58, 59
VEREGEN ........................... 66
VERELAN ........................... 59
VERELAN PM ..................... 59
VERSACLOZ ....................... 51
VERZENIO .......................... 23
VESICARE ......................... 125
VFEND ................................... 3
VFEND IV .............................. 3
V-GO 20 ............................... 86
V-GO 30 ............................... 86
V-GO 40 ............................... 86
VIBERZI .............................. 94
VIBRAMYCIN .................... 17
vicodin es .............................. 38
vicodin hp ............................. 38
VICTOZA 3-PAK ................ 86
VIDEX 2 GRAM PEDIATRIC
............................................ 7
VIDEX EC .............................. 7
VIEKIRA PAK ....................... 7
vienva ................................. 112
vigabatrin .............................. 28
vigadrone .............................. 28
VIGAMOX ......................... 114
VIIBRYD ............................. 51
VIMOVO .............................. 41
VIMPAT ............................... 29
VIOKACE ............................ 94
VIRACEPT ............................. 7
VIRAMUNE ........................... 7
VIRAMUNE XR .................... 7
VIREAD ................................. 7
VITRAKVI ........................... 23
VIVELLE-DOT .................. 108
VIVITROL ........................... 41
VIVLODEX ......................... 41
VIZIMPRO ........................... 23
VOGELXO ........................... 89
VOLTAREN ......................... 41
voriconazole ........................... 3
VOSEVI ................................. 7
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
149
VOTRIENT .......................... 23
VRAYLAR........................... 51
vyfemla (28) ....................... 112
vylibra................................. 112
VYNDAQEL ........................ 63
VYTORIN 10-10.................. 62
VYTORIN 10-20.................. 62
VYTORIN 10-40.................. 62
VYTORIN 10-80.................. 62
VYVANSE ........................... 51
VYZULTA ......................... 116
W warfarin ................................ 60
WELCHOL .......................... 62
WELLBUTRIN SR .............. 51
WELLBUTRIN XL.............. 51
WIXELA INHUB .............. 124
wymzya fe .......................... 113
X XALATAN......................... 116
XALKORI ............................ 24
XARELTO ........................... 60
XATMEP ............................. 24
XELJANZ .......................... 105
XELJANZ XR .................... 105
XELPROS .......................... 116
XENAZINE .......................... 34
XENLETA ........................... 14
XEPI ..................................... 69
XERESE ............................... 70
XERMELO........................... 24
XGEVA ................................ 18
XHANCE ........................... 124
XIFAXAN ............................ 14
XIGDUO XR........................ 86
XIIDRA .............................. 115
XIMINO ............................... 17
XOFLUZA ............................. 7
XOLAIR ............................. 124
XOPENEX ......................... 124
XOPENEX CONCENTRATE
........................................ 124
XOPENEX HFA ................ 124
XOSPATA ........................... 24
XPOVIO ............................... 24
XTAMPZA ER .................... 38
XTANDI ............................... 24
xulane ................................. 108
XULTOPHY 100/3.6 ........... 86
XURIDEN ............................ 77
XYOSTED ........................... 89
XYREM................................ 51
Y YASMIN (28)..................... 113
YAZ (28) ............................ 113
YF-VAX (PF) ..................... 102
YONSA ................................ 24
YOSPRALA ......................... 60
YUPELRI ........................... 124
yuvafem .............................. 108
Z zafirlukast ........................... 125
zaleplon ................................ 51
ZANAFLEX ................... 34, 35
zarah ................................... 113
ZARONTIN.......................... 29
ZARXIO ............................... 99
ZAVESCA............................ 89
ZEGERID ............................. 97
ZEJULA ............................... 24
ZELAPAR ............................ 30
ZELBORAF ......................... 24
ZELNORM ........................... 94
ZEMAIRA ............................ 77
ZEMBRACE SYMTOUCH . 32
ZEMPLAR ........................... 89
zenatane ................................ 68
ZENPEP ............................... 94
zenzedi .................................. 51
ZENZEDI ............................. 51
ZEPATIER ............................. 7
ZERBAXA ............................. 9
ZESTORETIC ...................... 59
ZESTRIL .............................. 59
ZETIA .................................. 63
ZETONNA ......................... 125
ZIAC ..................................... 59
ZIAGEN ................................. 7
ZIANA.................................. 68
zidovudine .............................. 7
zileuton ............................... 125
ZIOPTAN (PF) ................... 116
ziprasidone hcl ...................... 51
ZIPSOR ................................ 42
ZIRGAN ............................. 114
ZITHROMAX ...................... 10
ZITHROMAX TRI-PAK ..... 10
ZITHROMAX Z-PAK ......... 10
ZOCOR ................................. 63
ZOFRAN .............................. 94
ZOHYDRO ER .................... 38
ZOLINZA ............................. 24
zolmitriptan ........................... 32
ZOLOFT ............................... 51
zolpidem ............................... 51
ZOMACTON ....................... 99
ZOMIG ................................. 32
ZOMIG ZMT ........................ 32
ZONALON ........................... 66
ZONEGRAN ........................ 29
zonisamide ............................ 29
ZONTIVITY ......................... 60
ZORBTIVE .......................... 99
ZORTRESS .......................... 24
ZORVOLEX ......................... 42
ZOSTAVAX (PF) .............. 102
ZOSYN ................................. 15
ZOSYN IN DEXTROSE (ISO-
OSM) ................................ 15
zovia 1/35e (28) .................. 113
ZOVIRAX ........................ 7, 70
ZTLIDO ................................ 66
ZUBSOLV ............................ 42
ZUPLENZ ............................ 94
ZYCLARA ........................... 66
ZYDELIG ............................. 24
ZYFLO ............................... 125
ZYKADIA ............................ 24
ZYLET ............................... 117
ZYLOPRIM ........................ 102
ZYMAXID ......................... 114
ZYPITAMAG ....................... 63
ZYPREXA ............................ 51
ZYPREXA RELPREVV ...... 51
ZYPREXA ZYDIS ............... 52
ZYTIGA ............................... 24
ZYVOX ................................ 14
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