Formulario Clásico de 2015 - Health Net...Formulario Clásico de 2015 (Lista de Medicamentos...

LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE ALGUNOS DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN

Health Net Healthy Heart (HMO) en el Condado de Fresno, Health Net Gold Select (HMO), Health Net Amber (HMO SNP), Health Net Seniority Plus Amber I (HMO SNP), Health Net Seniority Plus Amber II (HMO SNP), Health Net Seniority Plus Sapphire (HMO SNP), Health Net Seniority Plus Complete (HMO) y Health Net Jade (HMO SNP) en Oregon

Identificación de Presentación del Archivo del Formulario Aprobado por HPMS 15439, Versión Número

Este formulario se actualizó el Si desea obtener información más reciente o si tiene otras preguntas, comuníquese con Health Net al:

Planes de Arizona: 1-800-977-7522

Planes HMO de California: 1-800-275-4737 Planes HMO SNP de California: 1-800-431-9007 Planes PPO de California: 1-800-960-4638

Planes de Oregon/Washington: 1-888-445-8913

o para los usuarios de TTY: 711, de 8:00 a.m. a 8:00 p.m., los siete días de la semana(algunos fines de semana y días feriados se utiliza el servicio telefónico automático), o bien, visite www.healthnet.com/medicare.

N.º de Identificación del Material Y0035_2015_0011_SPN (H0351, H0562, H5439, H5520, H6815, EG) Aceptado por los CMS 07202014

Formulario Clásico de 2015 (Lista de Medicamentos Cubiertos)

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12/01/2015.

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Nota para los afiliados existentes: Se han registrado cambios en este formulario desde el año pasado. Revise este documento para asegurarse de que aún incluya los medicamentos que usted toma.

Cuando esta lista de medicamentos (formulario) dice “nosotros” o “nuestro/a”, se refiere a Health Net. Cuando dice “plan” o “nuestro plan”, se refiere a Health Net Amber (HMO SNP), Health Net Gold Select (HMO), Health Net Healthy Heart (HMO) en el Condado de Fresno, Health Net Jade (HMO SNP) en Oregon, Health Net Seniority Plus Amber I (HMO SNP), Health Net Seniority Plus Amber II (HMO SNP), Health Net Seniority Plus Sapphire (HMO SNP) y Health Net Seniority Plus Complete (HMO).

Este documento incluye una lista de los medicamentos (formulario) correspondientes a nuestro plan, que entra en vigencia a partir de la fecha que figura en la portada y la contraportada. Para obtener un formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha en que actualizamos el formulario por última vez, aparece en la portada y la contraportada.

Generalmente, usted debe usar las farmacias de la red para acceder a su beneficio de medicamentos que requieren receta médica. Los beneficios, el formulario, la red de farmacias y/o los co-pagos/el coseguro pueden cambiar a partir del 1 de enero de 2016 y ocasionalmente durante el año.

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¿Qué es el Formulario Clásico de Health Net Amber (HMO SNP), Health Net Gold Select (HMO), Health Net Healthy Heart (HMO) en el Condado de Fresno, Health Net Jade (HMO SNP) en Oregon, Health Net Seniority Plus Amber I (HMO SNP), Health Net Seniority Plus Amber II (HMO SNP), Health Net Seniority Plus Sapphire (HMO SNP) y Health Net Seniority Plus Complete (HMO)?Un formulario es una lista de medicamentos cubiertos seleccionados por nuestro plan en consulta con un equipo de proveedores de cuidado de la salud, que incluye las terapias con medicamentos que requieren receta médica consideradas como una parte necesaria de un programa de tratamiento de calidad. Generalmente, cubriremos los medicamentos enumerados en nuestro formulario, siempre que el medicamento sea médicamente necesario, que la receta se surta en una farmacia de la red de Health Net y que se cumpla con las demás reglas del plan. Para obtener más información sobre cómo surtir sus recetas, revise su Evidencia de Cobertura.

¿Puede cambiar el Formulario (lista de medicamentos)?Por lo general, si usted está tomando un medicamento de nuestro formulario de 2015 que estaba cubierto al comienzo del año, no interrumpiremos ni reduciremos la cobertura de dicho medicamento durante el año de cobertura 2015, excepto cuando se encuentre disponible un nuevo medicamento genérico menos costoso o cuando se divulgue nueva información adversa sobre la seguridad o la eficacia de un medicamento. Otros tipos de cambios en nuestro formulario, como la eliminación de un medicamento, no afectarán a los

afiliados que actualmente estén tomando el medicamento. Durante el resto del año de cobertura, seguirá estando disponible al mismo costo compartido para aquellos afiliados que lo estén tomando. Creemos que es importante que usted tenga un acceso continuo durante el resto del año de cobertura a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan, excepto en los casos en que pueda ahorrar dinero adicional o cuando podamos garantizar su seguridad. Si eliminamos medicamentos de nuestro formulario, si agregamos requisitos de autorización previa, límites de cantidad y/o restricciones de terapia escalonada a un medicamento, o si pasamos un medicamento a un nivel de costos compartidos más alto, debemos notificar el cambio a los afiliados afectados al menos 60 días antes de que dicho cambio entre en vigencia, o bien, cuando el afiliado solicite que le vuelvan a surtir el medicamento, en cuyo caso el afiliado recibirá un suministro de 60 días del medicamento. Si la Administración de Alimentos y Medicamentos de los Estados Unidos (por sus siglas en inglés, FDA) considera que un medicamento de nuestro formulario no es seguro o si el fabricante del medicamento lo retira del mercado, nosotros eliminaremos de inmediato dicho medicamento de nuestro formulario y enviaremos un aviso a los afiliados que lo toman. El formulario adjunto entra en vigencia a partir de la fecha que figura en la portada y la contraportada. Para obtener información actualizada sobre los medicamentos que cubrimos, comuníquese con nosotros. Nuestra información de contacto aparece en la portada y la contraportada. Si realizamos algún otro cambio negativo en el formulario durante el año, se lo notificaremos por correo, y los cambios se publicarán en nuestro sitio Web.

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¿Cómo utilizo el formulario? Hay dos maneras de buscar su medicamento en el formulario:

Condición MédicaEl formulario comienza en la página 1. Los medicamentos de este formulario se agrupan en categorías según el tipo de condición médica que traten. Por ejemplo, los medicamentos utilizados para tratar una condición cardíaca se enumeran bajo la categoría “AGENTES CARDIOVASCULARES - DISPOSICIONES VARIAS”. Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que comienza en la página 1. Luego busque su medicamento bajo el nombre de la categoría.

Lista AlfabéticaSi no está seguro de la categoría bajo la que se enumera su medicamento, debe buscarlo en el Índice que comienza en la página 1 del Índice. El Índice proporciona una lista alfabética de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los medicamentos genéricos están enumerados en el Índice. Busque allí y encontrará su medicamento. Junto a su medicamento, verá el número de página en la que puede encontrar la información sobre la cobertura. Consulte la página que aparece en el Índice y busque el nombre de su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos?Nuestro plan cubre tanto los medicamentos de marca como los medicamentos genéricos. Un medicamento genérico es aprobado por la FDA por contener los mismos ingredientes activos que el medicamento de marca. Por lo general, los medicamentos genéricos cuestan menos que los de marca.

¿Hay alguna restricción en mi cobertura?Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales en la cobertura. Estos requisitos y límites pueden incluir: • Autorización Previa: Nuestro plan

les exige a usted o a su médico que obtengan una autorización previa para ciertos medicamentos. Esto significa que deberá solicitar la aprobación de parte nuestra antes de surtir sus recetas. Si no obtiene la aprobación, es posible que no cubramos el medicamento.

• Límites de Cantidad: Para ciertos medicamentos, nuestro plan limita la cantidad del medicamento que cubriremos. Por ejemplo, nuestro plan establece un máximo de dos tabletas por día por receta de simvastatina 40 mg. Esto puede sumarse a un suministro estándar de un mes o de tres meses.

• Terapia Escalonada: En algunos casos, nuestro plan exige que usted pruebe primero determinados medicamentos para tratar su condición médica antes de cubrir otro medicamento para esa condición. Por ejemplo, si tanto el Medicamento A como el Medicamento B tratan su condición médica, posiblemente no cubramos el Medicamento B, a menos que usted pruebe primero el Medicamento A. Si el Medicamento A no es eficaz para su caso, entonces cubriremos el Medicamento B.

Para averiguar si su medicamento tiene requisitos o límites adicionales, puede consultar el formulario que comienza en la página 1. También puede obtener más información sobre las restricciones que se aplican a medicamentos cubiertos específicos visitando nuestro sitio Web. Hemos publicado documentos en línea que explican nuestros requisitos de autorización previa y nuestras restricciones de terapia escalonada.

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Además, usted puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha en que actualizamos el formulario por última vez, aparece en la portada y la contraportada.Puede solicitarnos que hagamos una excepción a estas restricciones o límites, o que le proporcionemos una lista de otros medicamentos similares que puedan tratar su condición de salud. Consulte la sección “¿Cómo solicito una excepción al Formulario Clásico de Health Net Amber (HMO SNP), Health Net Gold Select (HMO), Health Net Healthy Heart (HMO) en el Condado de Fresno, Health Net Jade (HMO SNP) en Oregon, Health Net Seniority Plus Amber I (HMO SNP), Health Net Seniority Plus Amber II (HMO SNP), Health Net Seniority Plus Sapphire (HMO SNP) y Health Net Seniority Plus Complete (HMO)?”, que aparece en la página iv, para obtener información sobre cómo solicitar una excepción.

¿Qué sucede si mi medicamento no está en el formulario?Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), usted debe comunicarse primero con el Departamento de Servicios al Afiliado y preguntar si su medicamento está cubierto. Si se entera de que nuestro plan no cubre su medicamento, tiene dos opciones:• Puede solicitar al Departamento

de Servicios al Afiliado una lista de medicamentos similares que cubramos. Cuando reciba la lista, muéstresela a su médico y solicítele que le recete un medicamento similar que esté cubierto por nuestro plan.

• Puede solicitarnos que hagamos una excepción y cubramos su medicamento. Consulte la sección a continuación para obtener información sobre cómo solicitar una excepción.

¿Cómo solicito una excepción al Formulario Clásico de Health Net Amber (HMO SNP), Health Net Gold Select (HMO), Health Net Healthy Heart (HMO) en el Condado de Fresno, Health Net Jade (HMO SNP) en Oregon, Health Net Seniority Plus Amber I (HMO SNP), Health Net Seniority Plus Amber II (HMO SNP), Health Net Seniority Plus Sapphire (HMO SNP) y Health Net Seniority Plus Complete (HMO)?Usted puede solicitarnos que hagamos una excepción a nuestras reglas de cobertura. Existen varios tipos de excepciones que usted puede solicitar.• Puede pedirnos que cubramos un

medicamento aunque éste no se encuentre en nuestro formulario. Si se aprueba, este medicamento estará cubierto a un nivel de costos compartidos predeterminado, y usted no podría solicitarnos que se lo proporcionemos a un nivel de costos compartido más bajo.

• Puede solicitarnos que cubramos un medicamento del formulario a un nivel de costos compartidos más bajo. Si se aprueba, esto reduciría la cantidad que usted debe pagar por su medicamento.

• Puede pedirnos que anulemos las restricciones o límites de cobertura con respecto a su medicamento. Por ejemplo, para determinados medicamentos, nuestro plan limita la cantidad del medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, usted puede solicitarnos que anulemos dicho límite y cubramos una cantidad mayor.

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Generalmente, sólo aprobaremos su solicitud de excepción si los medicamentos alternativos incluidos en el formulario del plan, el medicamento de costos compartidos más bajos o las restricciones de utilización adicionales no fuesen tan eficaces en el tratamiento de su condición y/o le ocasionaran efectos médicos adversos. Debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial para una excepción al formulario, al nivel o a las restricciones de utilización. Si solicita una excepción al formulario, al nivel o a las restricciones de utilización, debe enviar una declaración de parte de su médico o profesional que receta para respaldar su solicitud. Generalmente, debemos tomar nuestra decisión dentro de las 72 horas de haber recibido la declaración de respaldo del profesional que receta. Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que su salud podría verse gravemente perjudicada al esperar las 72 horas para obtener una decisión. Si se otorga su solicitud de excepción acelerada, debemos informarle de la decisión en un lapso de 24 horas como máximo después de haber recibido una declaración de respaldo de su médico u otro profesional que receta.

¿Qué debo hacer antes de poder hablar con mi médico sobre cómo cambiar mis medicamentos o solicitar una excepción?Como afiliado nuevo o que continúa con la cobertura de nuestro plan, es posible que esté tomando medicamentos que no se encuentran en nuestro formulario. O quizás esté tomando un medicamento que se encuentra en nuestro formulario, pero sus posibilidades de obtenerlo son limitadas. Por ejemplo, tal vez necesite que le proporcionemos una autorización previa antes de que pueda surtir su receta. Le recomendamos que hable con su médico para decidir si debe cambiar

el medicamento por uno adecuado que cubramos o si debe solicitar una excepción al formulario para que le cubramos el medicamento que toma. Mientras habla con su médico para determinar la forma de proceder correcta para usted, en ciertos casos, podemos cubrir su medicamento durante los primeros 90 días de haberse afiliado a nuestro plan.Por cada uno de sus medicamentos que no se encuentra en nuestro formulario o si sus posibilidades de obtener sus medicamentos son limitadas, cubriremos un suministro temporal para 30 días (a menos que tenga una receta hecha para menos días) cuando vaya a una farmacia de la red. Después de obtener su primer suministro para 30 días, no pagaremos por estos medicamentos, aunque haya estado afiliado al plan por menos de 90 días. Si es residente de un centro de atención a largo plazo, le permitiremos volver a surtir su receta hasta que le hayamos proporcionado un suministro de transición para 102 días, de acuerdo con el incremento de despacho (a menos que tenga una receta hecha para menos días). Cubriremos más de un resurtido de estos medicamentos para los primeros 90 días de haberse afiliado a nuestro plan. Si necesita un medicamento que no se encuentra en nuestro formulario o si sus posibilidades de obtener sus medicamentos son limitadas, pero ya transcurrieron los primeros 90 días de su afiliación a nuestro plan, cubriremos un suministro de emergencia de ese medicamento para 34 días (a menos que tenga una receta para menos días) mientras solicita una excepción al formulario.

Cambios en el nivel de atenciónSi experimenta un cambio en su nivel de atención, cubriremos un suministro de transición de sus medicamentos. Un cambio en el nivel de atención ocurre cuando se le da de alta de un hospital o se le traslada desde o hacia un centro de atención a largo plazo.

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• Si se traslada de un centro de atención a largo plazo u hospital a su hogar y necesita un suministro de transición, cubriremos un suministro de 30 días. Si su receta está hecha para menos días, permitiremos que se surtan varias recetas hasta alcanzar el total de un suministro de 30 días.

• Si se traslada de su hogar o de un hospital a un centro de atención a largo plazo y necesita un suministro de transición, cubriremos un suministro de 34 días. Si su receta está hecha para menos días, permitiremos que se surtan varias recetas hasta alcanzar el total de un suministro de 34 días.

Entendemos que hay otras circunstancias en las que se puede otorgar un suministro adicional. Estas situaciones se manejan según cada caso mediante la comunicación entre la farmacia que despacha el medicamento y Health Net.

Para obtener más informaciónPara obtener información más detallada sobre la cobertura de medicamentos que requieren receta médica de su plan, revise su Evidencia de Cobertura y demás materiales del plan.Si tiene preguntas sobre nuestro plan, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha en que actualizamos el formulario por última vez, aparece en la portada y la contraportada.Si tiene preguntas generales acerca de la cobertura de medicamentos que requieren receta médica de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O bien, visite http://www.medicare.gov.

Formulario Clásico de Health Net Amber (HMO SNP), Health Net Gold Select (HMO), Health Net Healthy Heart (HMO) en el Condado de Fresno, Health Net Jade (HMO SNP) en Oregon, Health Net Seniority Plus Amber I (HMO SNP), Health Net Seniority Plus Amber II (HMO SNP), Health Net Seniority Plus Sapphire (HMO SNP) y Health Net Seniority Plus Complete (HMO)El formulario que comienza en la página 1 brinda información de cobertura sobre los medicamentos cubiertos por nuestro plan. Si tiene dificultades para encontrar su medicamento en la lista, vaya al Índice que comienza en la página 1 del Índice.La primera columna del cuadro menciona el nombre del medicamento. Los medicamentos de marca aparecen en letra mayúscula (por ejemplo, LIPITOR) y los medicamentos genéricos se enumeran en letra minúscula cursiva (por ejemplo, atorvastatina calcio).La información de la columna Requisitos/Límites le indica si nuestro plan tiene algún requisito especial para la cobertura de su medicamento.

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Descripciones de los niveles del formulario Para determinar cuánto paga usted por un medicamento, consulte las siguientes abreviaturas, que aparecen en la columna Nivel de Medicamentos del formulario. El nivel de co-pago o coseguro se muestra en la columna Co-pago/Coseguro. Para conocer su co-pago o coseguro correspondiente a cada nivel, consulte su Evidencia de Cobertura.

Abreviatura Co-pago/Coseguro Descripción1 Co-pago del Nivel 1 Medicamentos genéricos

preferidos. Estos medicamentos no son elegibles para excepciones de pago en un nivel inferior.

2 Co-pago del Nivel 2 Medicamentos genéricos no preferidos.

3 Co-pago del Nivel 3 Medicamentos de marca preferidos. Estos medicamentos no son elegibles para excepciones de pago en un nivel inferior.

4 Co-pago del Nivel 4 Medicamentos de marca no preferidos.

5 (Medicamentos de

especialidades)

Co-pago o coseguro del Nivel 5

Medicamentos de costo elevado. Estos medicamentos no son elegibles para excepciones de pago en un nivel inferior.

6(Select Care)

$0 de co-pago Algunos medicamentos genéricos y de marca utilizados para tratar condiciones crónicas específicas.

NF Fuera del formulario: Si se aprueba una solicitud de excepción para un medicamento que está fuera del formulario, se aplica el co-pago del nivel de Medicamentos de marca no preferidos (Nivel 4). No podrá solicitarnos que proporcionemos el medicamento a un nivel de costos compartidos más bajo.

Medicamentos que no están cubiertos en el formulario de Medicare Parte D de Health Net. Puede solicitar una excepción a Health Net para que cubra estos medicamentos. Consulte la sección “¿Cómo solicito una excepción al Formulario Clásico de Health Net Medicare Parte D?”

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AbreviaturasLas siguientes abreviaturas pueden aparecer en la columna Requisito/Límites del formulario.

Abreviatura Definición DescripciónAL Límite de Edad Es posible que algunos medicamentos requieran

una autorización previa si su edad no está dentro de las recomendaciones clínicas, del fabricante o de la FDA.

B/D Medicare Parte B frente a Medicare Parte D

Algunos medicamentos requieren autorización previa para determinar la cobertura conforme al beneficio de Medicare Parte B o Parte D, de acuerdo con las pautas de Medicare. Es posible que su médico u otro profesional que receta deban proporcionar información adicional para ayudarnos a tomar la determinación de cobertura.

GL Límite de Género Algunos medicamentos sólo están cubiertos para hombres o mujeres según las recomendaciones clínicas, del fabricante o de la FDA.

LA Acceso Limitado Algunos medicamentos pueden estar sujetos a un acceso limitado o restringido. Esto significa que un medicamento sólo puede estar disponible en una farmacia o en una cantidad limitada de farmacias. El acceso limitado puede deberse a los siguientes motivos:• La FDA ha restringido la distribución de

un medicamento a determinados centros, farmacias o profesionales que recetan; o bien,

• Determinados medicamentos requieren un manejo especial, una coordinación de la atención o una educación del paciente que no pueden proporcionarse en una farmacia de venta minorista; o bien,

Usted debe hablar con su médico u otro profesional que receta, o con su farmacéutico para solicitar detalles sobre cómo obtener medicamentos de acceso limitado.

MO Compra por Correo

Este medicamento está disponible en una farmacia de compra por correo de Health Net, así como en otras farmacias de la red.

PA Autorización Previa

Health Net les exige a usted o a su médico que obtengan una autorización previa para ciertos medicamentos. Esto significa que deberá solicitar la aprobación de parte nuestra antes de surtir sus recetas. Si no obtiene la aprobación, es posible que no cubramos el medicamento.

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Abreviatura Definición DescripciónQL Límite de

CantidadPara ciertos medicamentos, Health Net limita la cantidad del medicamento que cubriremos. Por ejemplo, Health Net cubre un máximo de dos tabletas por día por receta de simvastatina 40 mg. Esto puede sumarse a los límites de un suministro estándar de un mes o de tres meses.

RX/OTC Medicamentos que Requieren Receta Médica y de Venta Libre

Ciertos medicamentos se encuentran disponibles tanto en forma de medicamento que requiere receta médica como en forma de venta libre. Salvo algunos tipos de insulinas y suministros para insulina, los planes Health Net Medicare Parte D sólo cubren los medicamentos que requieren receta médica.

ST Terapia Escalonada

En algunos casos, Health Net requiere que usted pruebe primero determinados medicamentos para tratar su condición médica antes de cubrir otro medicamento para esa condición.

Por ejemplo, si tanto el Medicamento A como el Medicamento B tratan su condición médica, posiblemente no cubramos el Medicamento B, a menos que usted pruebe primero el Medicamento A. Si el Medicamento A no es eficaz para su caso, entonces cubriremos el Medicamento B.

* Cobertura Adicional en la Brecha

Para planes Health Net Gold Select (HMO) únicamente:Proporcionamos cobertura adicional de este medicamento que requiere receta médica en la brecha de cobertura. Si desea más información sobre esta cobertura, consulte su Evidencia de Cobertura.

+ Cobertura Adicional en la Brecha

Para planes Health Net Seniority Plus Complete (HMO) únicamente:Proporcionamos cobertura adicional de este medicamento que requiere receta médica en la brecha de cobertura. Si desea más información sobre esta cobertura, consulte su Evidencia de Cobertura.

Drug Name DrugTier

Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating DisordersAmphetaminesADDERALL XR (UseAmphetamine-Dextroamphetamine)

NFMO

amphetamine sulfate 10mg 2 MO; *; +

amphetamine sulfate 5 mg 2 *; +

amphetamine-dextroamphetamine 2 MO; *; +

DESOXYN (UseMethamphetamine HCl) NF MO

DEXEDRINE 10 MG,15MG,5 MG (UseDextroamphetamineSulfate)

NF

MO

dextroamphetamine sulfatecp24 10 mg, 15 mg, 5 mg 2 MO; *; +

dextroamphetamine sulfatetabs 10 mg, 15 mg, 2.5 mg,20 mg, 30 mg, 5 mg, 7.5mg

2

MO; *; +

methamphetamine hcl 1 MO; *; +

VYVANSE 10 MG 4 QL(7 ea daily);MO; +



VYVANSE 40 MG, 50 MG,60 MG, 70 MG 4 QL(1 ea daily);

MO; +Attention-Deficit/Hyperactivity Disorder (ADHD)clonidine hcl (adhd) 2 MO; *; +

guanfacine hcl (adhd) 2 AL; MO; *; +

INTUNIV (Use GuanfacineHCl (ADHD)) 4 AL; MO; +

KAPVAY (Use ClonidineHCl (ADHD)) NF MO

STRATTERA 10 MG 3 QL(10 eadaily); MO; +

Drug Name DrugTier

Requirements/Limits

STRATTERA 100 MG, 60MG, 80 MG 3 QL(1 ea daily);

MO; +

STRATTERA 18 MG 3 QL(5 ea daily);MO; +



Stimulants - Misc.CONCERTA (UseMethylphenidate HCl) NF MO

DAYTRANA 30 MG/9HR 4 MO; +

dexmethylphenidate hclcp24 10 mg, 15 mg, 20 mg 2 MO; *; +

dexmethylphenidate hcltabs 10 mg, 2.5 mg, 5 mg 1 MO; *; +

FOCALIN (UseDexmethylphenidate HCl) NF MO

FOCALIN XR 10 MG, 20MG (UseDexmethylphenidate HCl)

4MO; +

FOCALIN XR 15 MG (UseDexmethylphenidate HCl) NF MO

METADATE CD (UseMethylphenidate HCl) NF MO

methylphenidate hcl cp24or 20 mg, 30 mg, 40 mg 2 MO; *; +

methylphenidate hcl cpcr or10 mg, 20 mg, 30 mg, 40mg, 50 mg, 60 mg

2MO; *; +

methylphenidate hcl tabs or10 mg, 20 mg, 5 mg 2 MO; *; +

methylphenidate hcl tb24 or18 mg, 27 mg, 36 mg, 54mg

2MO; *; +

methylphenidate hcl tbcr or10 mg, 18 mg, 20 mg, 27mg, 36 mg, 54 mg

2MO; *; +

modafinil 100 mg 2 PA; MO; *; +

modafinil 200 mg 5 PA; MO

NUVIGIL 3 PA; MO; +

PROVIGIL (Use Modafinil) 5 PA; MO

You can find information on what the symbols and abbreviations on this table mean by going topage viii.

Health Net 2015 Classic Formulary

1

Drug Name DrugTier

Requirements/Limits

RITALIN (UseMethylphenidate HCl) NF MO

RITALIN LA 10 MG 4 MO; +

RITALIN LA 20 MG, 30MG, 40 MG (UseMethylphenidate HCl)

NFMO

RITALIN SR (UseMethylphenidate HCl) NF MO

AMINOGLYCOSIDES - Drugs to Treat BacterialInfectionsAminoglycosidesamikacin sulfate soln ij 1gm/4ml, 500 mg/2ml 1 MO; *; +

BETHKIS 5 B/D

gentamicin in saline 0.9%-0.8mg/ml 2 MO; *; +

gentamicin in saline 0.9%-0.9mg/ml, 0.9%-1.4mg/ml,0.9%-1.6mg/ml, 0.9%-1mg/ml, 0.9%-2mg/ml

2

*; +

gentamicin in saline 0.9%-1.2mg/ml 1 *; +

gentamicin sulfate soln ij10 mg/ml, 40 mg/ml 1 MO; *; +

gentamicin sulfate soln iv10 mg/ml 2 *; +

neomycin sulfate tabs or 1 MO; *; +

paromomycin sulfate 1 MO; *; +

streptomycin sulfate solr im 2 MO; *; +

TOBI (Use Tobramycin) 5 B/D

TOBI PODHALER 5

tobramycin nebu in 2 B/D; *; +

tobramycin sulfate in saline 2 *; +

tobramycin sulfate soln ij1.2 gm/30ml, 40 mg/ml, 80mg/2ml

1MO; *; +

tobramycin sulfate soln ij10 mg/ml 2 *; +

Drug Name DrugTier

Requirements/Limits

tobramycin sulfate solr ij1.2 gm 1 *; +

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditionsAnti-TNF-alpha - Monoclonal AntibodiesHUMIRA 5 PA

HUMIRA PEDIATRICCROHNS DISEASESTARTER PACK

5PA

HUMIRA PEN 5 PA

HUMIRA PEN-CROHNSDISEASESTARTER 5 PA

HUMIRA PEN-PSORIASISSTARTER 5 PA

SIMPONI 5 PA

SIMPONI ARIA 5 PA

Antirheumatic - Enzyme InhibitorsXELJANZ 5 PA

Antirheumatic AntimetabolitesOTREXUP 4 PA; +

RASUVO 4 PA; +

RHEUMATREX 3 MO; +

Gold CompoundsRIDAURA 5 MO

Interleukin-1 BlockersARCALYST 5 LA

Interleukin-1 Receptor Antagonist (IL-1Ra)KINERET 5 PA

Interleukin-1beta BlockersILARIS 5 LA

Interleukin-6 Receptor Inhibitors



2

Drug Name DrugTier

Requirements/Limits

ACTEMRA 5 PA

Nonsteroidal Anti-inflammatory Agents (NSAIDs)ANAPROX (Use NaproxenSodium) NF MO

ANAPROX DS (UseNaproxen Sodium) NF MO

ARTHROTEC 50 (UseDiclofenac w/ Misoprostol) NF MO

ARTHROTEC 75 (UseDiclofenac w/ Misoprostol) NF MO

CATAFLAM (UseDiclofenac Potassium) NF MO

CELEBREX (UseCelecoxib) 3 MO; +

celecoxib 2 MO; *; +

DAYPRO (Use Oxaprozin) NF MO

diclofenac potassium 2 MO; *; +

diclofenac sodium tb24 or100 mg 2 MO; *; +

diclofenac sodium tbec or25 mg, 50 mg, 75 mg 2 MO; *; +

diclofenac w/ misoprostol 2 MO; *; +

DUEXIS 4 MO; +

EC-NAPROSYN (UseNaproxen) NF MO

etodolac caps or 200 mg,300 mg 2 MO; *; +

etodolac tabs or 400 mg,500 mg 2 MO; *; +

etodolac tb24 or 400 mg,500 mg, 600 mg 2 MO; *; +

FELDENE (Use Piroxicam) NF MO

fenoprofen calcium tabs600 mg 1 MO; *; +

flurbiprofen tabs or 100 mg,50 mg 1 MO; *; +

ibuprofen susp or 100mg/5ml 2 RX/OTC; MO;

*; +

ibuprofen tabs or 400 mg 1 QL(8 ea daily);MO; *; +

Drug Name DrugTier

Requirements/Limits



INDOCIN 4 AL; MO; +

indomethacin caps or 25mg, 50 mg 2 AL; MO; *; +

indomethacin cpcr or 75mg 2 AL; MO; *; +

indomethacin supp re 50mg 2 MO; *; +

ketoprofen caps or 50 mg,75 mg 2 MO; *; +

ketoprofen cp24 or 200 mg 2 MO; *; +

ketorolac trometh &bupivacaine hcl & lidocainehcl

2*; +

ketorolac tromethamine &lidocaine hcl 2 *; +

ketorolac tromethaminesoln ij 15 mg/ml, 30 mg/ml 2 AL; MO; *; +

ketorolac tromethaminesoln im 30 mg/ml, 60mg/2ml

1AL; MO; *; +

ketorolac tromethaminetabs or 10 mg 2 AL; MO; *; +

meclofenamate sodiumcaps or 100 mg, 50 mg 1 MO; *; +

mefenamic acid caps or 2 MO; *; +

meloxicam tabs or 15 mg,7.5 mg 1 MO; *; +

meloxicam w/ liniment 2 *; +

MOBIC TABS 15 MG, 7.5MG (Use Meloxicam) NF MO

nabumetone 2 MO; *; +

NAPRELAN 375 MG (UseNaproxen Sodium) 4 MO; +

NAPRELAN 375 MG, 750MG 4 MO; +

NAPRELAN 500 MG (UseNaproxen Sodium) NF MO



3

Drug Name DrugTier

Requirements/Limits

NAPROSYN (UseNaproxen) NF MO

naproxen sodium tabs or275 mg, 550 mg 2 MO; *; +

naproxen sodium tb24 or375 mg, 500 mg 2 MO; *; +

naproxen tabs or 250 mg,375 mg, 500 mg 1 MO; *; +

naproxen tbec or 375 mg,500 mg 2 MO; *; +

oxaprozin 1 MO; *; +

piroxicam caps or 10 mg,20 mg 2 MO; *; +

PONSTEL (Use MefenamicAcid) 5 MO

SPRIX 4 AL; MO; +

sulindac tabs or 150 mg,200 mg 2 MO; *; +

tolmetin sodium 1 MO; *; +

VIMOVO 4 MO; +

VOLTAREN-XR (UseDiclofenac Sodium) NF MO

ZIPSOR 4 MO; +

Phosphodiesterase 4 (PDE4) InhibitorsOTEZLA 5 PA

Pyrimidine Synthesis InhibitorsARAVA (Use Leflunomide) NF MO

leflunomide 2 MO; *; +

Selective Costimulation ModulatorsORENCIA 5 PA

Soluble Tumor Necrosis Factor Receptor AgentsENBREL 5 PA

ENBREL SURECLICK 5 PA

ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint Conditions

Drug Name DrugTier

Requirements/Limits

Salicylatesdiflunisal 1 MO; *; +

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint ConditionsOpioid Agonists

ABSTRAL 100 MCG 4 PA; QL(6 eadaily); +

ABSTRAL 200 MCG 5 PA; QL(6 eadaily)

ABSTRAL 300 MCG, 400MCG, 600 MCG, 800 MCG 5 PA; QL(4 ea

daily)ACTIQ 1200 MCG, 1600MCG, 400 MCG, 600 MCG,800 MCG (Use FentanylCitrate)

5

PA; QL(4 eadaily); MO

ACTIQ 200 MCG (UseFentanyl Citrate) 5 PA; QL(6 ea

daily); MOAVINZA (Use MorphineSulfate Beads) 4 QL(5 ea daily);

MO; +

codeine sulfate 15 mg 2 QL(24 eadaily); MO; *; +

CODEINE SULFATE 15MG (Use Codeine Sulfate) 4 QL(24 ea

daily); MO; +

codeine sulfate 30 mg 2 QL(12 eadaily); MO; *; +

codeine sulfate 60 mg 2 QL(6 ea daily);MO; *; +

DEMEROL TABS OR 100MG, 50 MG (UseMeperidine HCl)

NFAL; MO

DILAUDID LIQD OR 1MG/ML (UseHydromorphone HCl)

NFQL(30 mldaily); MO

DILAUDID TABS OR 2 MG(Use Hydromorphone HCl) NF QL(29 ea

daily); MODILAUDID TABS OR 4 MG(Use Hydromorphone HCl) NF QL(14 ea

daily); MODILAUDID TABS OR 8 MG(Use Hydromorphone HCl) NF QL(7 ea daily);

MODILAUDID-HP SOLN 10MG/ML (UseHydromorphone HCl)

NFMO

DOLOPHINE 10 MG (UseMethadone HCl) NF QL(19 ea

daily); MO



4

Drug Name DrugTier

Requirements/Limits

DOLOPHINE 5 MG (UseMethadone HCl) NF QL(38 ea

daily); MODURAGESIC 100 MCG/HR(Use Fentanyl) 5 QL(1 ea daily);

MODURAGESIC 12 MCG/HR(Use Fentanyl) NF QL(1.44 ea

daily); MODURAGESIC 25 MCG/HR(Use Fentanyl) NF QL(0.7 ea

daily); MODURAGESIC 50 MCG/HR(Use Fentanyl) NF QL(0.74 ea

daily); MODURAGESIC 75 MCG/HR(Use Fentanyl) 5 QL(0.61 ea

daily); MOEXALGO 12 MG (UseHydromorphone HCl) 4 QL(4 ea daily);

MO; +EXALGO 16 MG (UseHydromorphone HCl) 4 QL(3.67 ea

daily); MO; +

EXALGO 32 MG 4 QL(2 ea daily);MO; +

EXALGO 8 MG (UseHydromorphone HCl) 4 QL(7 ea daily);

MO; +

fentanyl 100 mcg/hr 2 QL(1 ea daily);MO; *; +

fentanyl 12 mcg/hr 2 QL(1.44 eadaily); MO; *; +


fentanyl 37.5 mcg/hr, 62.5mcg/hr, 87.5 mcg/hr 2 *; +



fentanyl citrate lpop bu1200 mcg, 1600 mcg, 400mcg, 600 mcg, 800 mcg

5PA; QL(4 eadaily); MO

fentanyl citrate lpop bu 200mcg 5 PA; QL(6 ea

daily); MOFENTORA 100 MCG, 200MCG 5 PA; QL(6 ea

daily); MOFENTORA 400 MCG, 600MCG, 800 MCG 5 PA; QL(4 ea

daily); MOHYDROMORPHONE HCLER 4 QL(2 ea daily);

MO; +hydromorphone hcl liqd or1 mg/ml 2 QL(30 ml

daily); MO; *; +

Drug Name DrugTier

Requirements/Limits

hydromorphone hcl soln ij10 mg/ml, 2 mg/ml, 50mg/5ml, 500 mg/50ml

2MO; *; +

hydromorphone hcl t24a or12 mg 2 QL(4 ea daily);

MO; *; +hydromorphone hcl t24a or16 mg 2 QL(3.67 ea

daily); MO; *; +hydromorphone hcl t24a or8 mg 2 QL(7 ea daily);

MO; *; +hydromorphone hcl tabs or2 mg 2 QL(29 ea

daily); MO; *; +hydromorphone hcl tabs or4 mg 2 QL(14 ea

daily); MO; *; +hydromorphone hcl tabs or8 mg 2 QL(7 ea daily);

MO; *; +HYSINGLA ER 100 MG,120 MG 4 PA; QL(2 ea

daily); +HYSINGLA ER 20 MG, 30MG, 40 MG, 60 MG, 80 MG 4 PA; QL(2 ea

daily); MO; +KADIAN 10 MG (UseMorphine Sulfate) NF QL(6 ea daily);

MOKADIAN 100 MG (UseMorphine Sulfate) 5 QL(6 ea daily);

MO

KADIAN 130 MG, 150 MG 4 PA; QL(1 eadaily); +

KADIAN 20 MG, 30 MG, 50MG, 60 MG, 80 MG (UseMorphine Sulfate)

NFQL(5 ea daily);MO

KADIAN 40 MG, 70 MG 4 PA; QL(5 eadaily); MO; +

LAZANDA 100 MCG/ACT 5 PA; QL(6 eadaily); MO

LAZANDA 400 MCG/ACT 5 PA; QL(4 eadaily)

levorphanol tartrate tabs or 1 MO; *; +

meperidine hcl soln or 50mg/5ml 2 AL; MO; *; +

meperidine hcl tabs or 100mg, 50 mg 2 AL; MO; *; +

methadone hcl conc or 10mg/ml 2 QL(4 ml daily);

MO; *; +methadone hcl soln or 10mg/5ml 2 QL(20 ml

daily); MO; *; +methadone hcl soln or 5mg/5ml 2 QL(40 ml

daily); MO; *; +



5

Drug Name DrugTier

Requirements/Limits

methadone hcl tabs or 10mg 2 QL(19 ea

daily); MO; *; +methadone hcl tabs or 5mg 2 QL(38 ea

daily); MO; *; +METHADOSE 10 MG/ML(Use Methadone HCl) NF QL(4 ml daily);

MOMETHADOSE SUGAR-FREE (Use MethadoneHCl)

NFQL(4 ml daily);MO

morphine sulfate beads 2 QL(5 ea daily);MO; *; +

morphine sulfate cp24 or10 mg 2 QL(6 ea daily);

MO; *; +morphine sulfate cp24 or100 mg 5 QL(6 ea daily);

MOmorphine sulfate cp24 or20 mg, 30 mg, 50 mg, 60mg, 80 mg

2QL(5 ea daily);MO; *; +

morphine sulfate soln ij 0.5mg/ml 2 *; +

morphine sulfate soln ij 1mg/ml 2 MO; *; +

morphine sulfate soln or 10mg/5ml 2 QL(60 ml

daily); MO; *; +morphine sulfate soln or100 mg/5ml, 20 mg/ml 2 QL(6 ml daily);

MO; *; +morphine sulfate soln or 20mg/5ml 2 QL(30 ml

daily); MO; *; +morphine sulfate tabs or 15mg 2 QL(8 ea daily);

MO; *; +morphine sulfate tabs or 30mg 2 QL(14 ea

daily); MO; *; +morphine sulfate tbcr or100 mg 2 QL(6 ea daily);

MO; *; +morphine sulfate tbcr or 15mg 2 QL(8 ea daily);

MO; *; +morphine sulfate tbcr or200 mg 2 QL(3 ea daily);

MO; *; +morphine sulfate tbcr or 30mg, 60 mg 2 QL(5 ea daily);

MO; *; +MS CONTIN 100 MG (UseMorphine Sulfate) NF QL(6 ea daily);

MOMS CONTIN 15 MG (UseMorphine Sulfate) NF QL(8 ea daily);

MOMS CONTIN 200 MG (UseMorphine Sulfate) NF QL(3 ea daily);

MO

Drug Name DrugTier

Requirements/Limits

MS CONTIN 30 MG, 60MG (Use Morphine Sulfate) NF QL(5 ea daily);

MO

NUCYNTA 100 MG 4 QL(6 ea daily);MO; +

NUCYNTA 50 MG 4 QL(12 eadaily); MO; +

NUCYNTA 75 MG 4 QL(8 ea daily);MO; +

NUCYNTA ER 100 MG 3 QL(4 ea daily);MO; +

NUCYNTA ER 150 MG,200 MG, 250 MG 3 QL(2 ea daily);

MO; +

NUCYNTA ER 50 MG 3 QL(8 ea daily);MO; +

OPANA TABS OR 10 MG(Use Oxymorphone HCl) NF QL(4 ea daily);

MOOPANA TABS OR 5 MG(Use Oxymorphone HCl) NF QL(8 ea daily);

MO

OXAYDO 5 MG 4 QL(17 eadaily); MO; +

OXAYDO 7.5 MG 4 QL(11 eadaily); +

OXECTA 5 MG 4 QL(17 eadaily); MO; +

OXECTA 7.5 MG 4 QL(11 eadaily); +

oxycodone hcl caps or 5mg 2 QL(17 ea

daily); MO; *; +oxycodone hcl conc or 100mg/5ml, 20 mg/ml 2 QL(4 ml daily);

MO; *; +OXYCODONE HCL ER 10MG, 20 MG, 40 MG 3 QL(2 ea daily);

MO; +OXYCODONE HCL ER 80MG 3 QL(7 ea daily);

MO; +oxycodone hcl tabs or 10mg 2 QL(16 ea

daily); MO; *; +oxycodone hcl tabs or 15mg 2 QL(11 ea

daily); MO; *; +oxycodone hcl tabs or 20mg 2 QL(8 ea daily);

MO; *; +oxycodone hcl tabs or 30mg 2 QL(15 ea

daily); MO; *; +

oxycodone hcl tabs or 5 mg 2 QL(17 eadaily); MO; *; +



6

Drug Name DrugTier

Requirements/Limits

OXYCONTIN 10 MG, 15MG, 20 MG, 30 MG, 40MG, 60 MG

3QL(2 ea daily);MO; +

OXYCONTIN 80 MG 3 QL(7 ea daily);MO; +

oxymorphone hcl tabs 10mg 2 QL(4 ea daily);

MO; *; +oxymorphone hcl tabs 5mg 2 QL(8 ea daily);

MO; *; +oxymorphone hcl tb12 10mg 1 QL(4 ea daily);

MO; *; +oxymorphone hcl tb12 15mg 2 QL(2.67 ea

daily); MO; *; +oxymorphone hcl tb12 20mg 1 QL(2 ea daily);

MO; *; +oxymorphone hcl tb12 30mg, 40 mg 2 QL(2 ea daily);

MO; *; +oxymorphone hcl tb12 5mg 1 QL(8 ea daily);

MO; *; +oxymorphone hcl tb12 7.5mg 2 QL(5 ea daily);

MO; *; +ROXICODONE 15 MG(Use Oxycodone HCl) NF QL(11 ea

daily); MOROXICODONE 30 MG(Use Oxycodone HCl) NF QL(15 ea

daily); MOROXICODONE 5 MG (UseOxycodone HCl) NF QL(17 ea

daily); MOSUBSYS 100 MCG, 200MCG 5 PA; QL(6 ea

daily); MOSUBSYS 1200 MCG, 1600MCG 5 PA; QL(4 ea

daily)SUBSYS 400 MCG, 600MCG, 800 MCG 5 PA; QL(4 ea

daily); MO

tramadol hcl tabs or 50 mg 2 QL(8 ea daily);MO; *; +

tramadol hcl tb24 or 100mg 2 QL(3 ea daily);

MO; *; +tramadol hcl tb24 or 200mg, 300 mg 2 QL(1 ea daily);

MO; *; +ULTRAM (Use TramadolHCl) NF QL(8 ea daily);

MOULTRAM ER 100 MG (UseTramadol HCl) NF QL(3 ea daily);

MOULTRAM ER 200 MG, 300MG (Use Tramadol HCl) NF QL(1 ea daily);

MO

Drug Name DrugTier

Requirements/Limits

ZOHYDRO ER C12A 10MG, 15 MG, 20 MG, 30MG, 40 MG, 50 MG

4PA; QL(2 eadaily); MO; +

ZOHYDRO ER CP12 10MG, 15 MG, 20 MG, 30MG, 40 MG, 50 MG

4PA; QL(2 eadaily); +

Opioid Combinationsacetaminophen w/ codeinesoln 120mg/5ml-12mg/5ml 2 QL(166 ml

daily); MO; *; +acetaminophen w/ codeinesusp 120mg/5ml-12mg/5ml 2 QL(166 ml

daily); MO; *; +acetaminophen w/ codeinetabs 300mg-15mg, 300mg-30mg, 300mg-60mg

2QL(13 eadaily); MO; *; +

acetaminophen-caff-dihydrocod 2 QL(12 ea

daily); *; +butalbital-acetaminophen-caffeine w/ codeine 300mg-50mg-40mg-30mg

2AL; QL(13 eadaily); MO; *; +

butalbital-acetaminophen-caffeine w/ codeine 325mg-50mg-40mg-30mg

2AL; QL(12 eadaily); MO; *; +

butalbital-aspirin-caffeinew/cod 2 AL; MO; *; +

FIORINAL/CODEINE #3(Use Butalbital-Aspirin-Caffeine w/Cod)

NFAL; MO

hydrocodone-acetaminophen elix10mg/15ml-300mg/15ml

2QL(200 mldaily); MO; *; +

hydrocodone-acetaminophen soln2.5mg/5ml-108mg/5ml,5mg/10ml-217mg/10ml,7.5mg/15ml-325mg/15ml

2

QL(184 mldaily); MO; *; +

hydrocodone-acetaminophen tabs 10mg-300mg, 5mg-300mg,7.5mg-300mg

2

QL(13 eadaily); MO; *; +

hydrocodone-acetaminophen tabs 10mg-325mg, 5mg-325mg,7.5mg-325mg

2


hydrocodone-ibuprofen200mg-10mg, 200mg-5mg,200mg-7.5mg

2MO; *; +



7

Drug Name DrugTier

Requirements/Limits

oxycodone w/acetaminophen soln5mg/5ml-325mg/5ml

2QL(61 mldaily); *; +

oxycodone w/acetaminophen tabs 10mg-300mg, 5mg-300mg,7.5mg-300mg

2


oxycodone w/acetaminophen tabs 10mg-325mg, 2.5mg-325mg,5mg-325mg, 7.5mg-325mg

2


oxycodone-aspirin 1 MO; *; +

PERCODAN (UseOxycodone-Aspirin) NF MO

tramadol-acetaminophen 2 QL(8 ea daily);MO; *; +

ULTRACET (UseTramadol-Acetaminophen) NF QL(8 ea daily);

MOVICOPROFEN (UseHydrocodone-Ibuprofen) NF MO

Opioid Partial AgonistsBUNAVAIL 4 PA; +

buprenorphine hcl subl sl 2mg 1 PA; QL(16 ea

daily); MO; *; +buprenorphine hcl subl sl 8mg 1 PA; QL(4 ea

daily); MO; *; +buprenorphine hcl-naloxone hcl dihydrate2mg-0.5mg

2PA; QL(16 eadaily); MO; *; +

buprenorphine hcl-naloxone hcl dihydrate8mg-2mg

2PA; QL(4 eadaily); MO; *; +

butorphanol tartrate soln na10 mg/ml 1 QL(4.2 ml

daily); MO; *; +

BUTRANS 10 MCG/HR 3 QL(0.29 eadaily); MO; +


BUTRANS 20 MCG/HR,7.5 MCG/HR 3 QL(0.15 ea

daily); MO; +


pentazocine w/ naloxone 2 AL; MO; *; +

Drug Name DrugTier

Requirements/Limits

SUBOXONE 4 PA; MO; +

TALWIN 4 AL; +

ZUBSOLV 1.4MG-0.36MG,5.7MG-1.4MG, 8.6MG-2.1MG

4PA; MO; +

ZUBSOLV 11.4MG-2.9MG,2.9MG-0.71MG 4 PA; +

ANDROGENS-ANABOLIC - Drugs to RegulateHormonesAnabolic SteroidsANADROL-50 5 MO

OXANDRIN 10 MG (UseOxandrolone) 5 MO

OXANDRIN 2.5 MG (UseOxandrolone) NF MO

oxandrolone tabs or 10 mg 5 MO

oxandrolone tabs or 2.5 mg 2 MO; *; +

AndrogensANDRODERM 3 GL; MO; +

ANDROGEL 20.25MG/1.25GM,40.5MG/2.5GM

3GL; MO; +

ANDROGEL 25MG/2.5GM,50 MG/5GM(Use Testosterone)

3GL; MO; +

ANDROGEL PUMP 3 GL; MO; +

AVEED 4 LA; +

AXIRON 4 GL; MO; +

danazol caps or 100 mg,200 mg, 50 mg 1 MO; *; +

fluoxymesterone tabs or 2 *; +

FORTESTA 4 GL; MO; +

methyltestosterone caps or 2 MO; *; +

methyltestosterone tabs or 2 *; +



8

Drug Name DrugTier

Requirements/Limits

NATESTO 4 GL; MO; +

TESTIM 3 GL; MO; +

testosterone cypionate 2 MO; *; +

testosterone enanthatesoln im 1 MO; *; +

TESTOSTERONE GEL TD1 %, 10 MG/ACT, 50MG/5GM

4GL; MO; +

TESTOSTERONE GEL TD25 MG/2.5GM 3 GL; MO; +

testosterone gel td 25mg/2.5gm, 50 mg/5gm 2 GL; MO; *; +

testosterone pllt il 75 mg 2 GL; *; +

TESTOSTERONE PUMP 4 GL; MO; +

VOGELXO 4 GL; MO; +

VOGELXO PUMP 4 GL; MO; +

ANORECTAL AGENTS - Rectal Drugs to TreatPain, Swelling and ItchingIntrarectal SteroidsCORTENEMA (UseHydrocortisone(Intrarectal))

NFMO

CORTIFOAM 4 MO; +

hydrocortisone (intrarectal) 1 MO; *; +

UCERIS FOAM RE 2MG/ACT 4 +

Rectal Combinationshydrocortisone acetate w/pramoxine crea 1%-1% 2 MO; *; +

hydrocortisone acetate w/pramoxine foam 1%-1% 2 MO; *; +

Rectal Steroidshydrocortisone (rectal) 1 MO; *; +

PROCTOCORT CREA 1 %(Use Hydrocortisone(Rectal))

NFMO

Drug Name DrugTier

Requirements/Limits

Vasodilating AgentsRECTIV 4 MO; +

ANTHELMINTICS - Drugs to Treat WormInfectionsAnthelminticsALBENZA 4 MO; +

BILTRICIDE 3 MO; +

ivermectin tabs or 2 MO; *; +

STROMECTOL (UseIvermectin) 4 MO; +

ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial InfectionsAnti-infective Agents - Misc.AZACTAM (UseAztreonam) NF MO

aztreonam 2 MO; *; +

CAYSTON 5

colistimethate sodium solr ij 1 MO; *; +

COLY-MYCIN M (UseColistimethate Sodium) NF MO

FLAGYL CAPS 375 MG(Use Metronidazole) NF QL(10 ea

daily); MO

FLAGYL ER 4 QL(5 ea daily);+

FLAGYL TABS 250 MG(Use Metronidazole) NF QL(16 ea

daily); MOFLAGYL TABS 500 MG(Use Metronidazole) NF QL(8 ea daily);

MOmetronidazole caps or 375mg 2 QL(10 ea

daily); MO; *; +

metronidazole in nacl 1 *; +

metronidazole tabs or 250mg 2 QL(16 ea

daily); MO; *; +metronidazole tabs or 500mg 2 QL(8 ea daily);

MO; *; +

NEBUPENT 3 MO; B/D; +



9

Drug Name DrugTier

Requirements/Limits

PENTAM 300 4 MO; +

PRIMSOL 3 MO; +

TINDAMAX (UseTinidazole) NF MO

tinidazole tabs or 250 mg,500 mg 1 MO; *; +

trimethoprim tabs or 2 MO; *; +

VANCOCIN HCL (UseVancomycin HCl) 5 PA; MO

vancomycin hcl caps or125 mg, 250 mg 5 PA; MO

VANCOMYCIN HCL INDEXTROSE 4 +

vancomycin hcl solr iv 10gm, 1000 mg, 5000 mg,750 mg

2*; +

vancomycin hcl solr iv 500mg 2 MO; *; +

XIFAXAN 5 MO

Anti-infective Misc. - CombinationsBACTRIM (UseSulfamethoxazole-Trimethoprim)

NFMO

BACTRIM DS (UseSulfamethoxazole-Trimethoprim)

NFMO

sulfamethoxazole-trimethoprim soln iv80mg/5ml-400mg/5ml

2MO; *; +

sulfamethoxazole-trimethoprim susp or40mg/5ml-200mg/5ml

2MO; *; +

sulfamethoxazole-trimethoprim tabs or160mg-800mg, 80mg-400mg

1

MO; *; +

Antiprotozoal AgentsALINIA TABS 500 MG 4 MO; +

atovaquone 5 MO

MEPRON (UseAtovaquone) 5 MO

Drug Name DrugTier

Requirements/Limits

CarbapenemsDORIBAX 500 MG 4 +

imipenem-cilastatin 1 MO; *; +

INVANZ IJ 4 MO; +

meropenem 1 gm 5 MO

meropenem 500 mg 1 MO; *; +

MERREM 1 GM (UseMeropenem) 5 MO

MERREM 500 MG (UseMeropenem) NF MO

PRIMAXIN IV (UseImipenem-Cilastatin) NF MO

Chloramphenicolschloramphenicol sodiumsuccinate 2 *; +

Cyclic LipopeptidesCUBICIN 5

GlycylcyclinesTYGACIL 5

KetolidesKETEK 300 MG 4 +

KETEK 400 MG 4 MO; +

Leprostaticsdapsone tabs or 100 mg,25 mg 2 MO; *; +

LincosamidesCLEOCIN CAPS OR 150MG, 300 MG, 75 MG (UseClindamycin HCl)

NFMO

CLEOCIN IN D5W (UseClindamycin Phosphate inD5W)

4+

CLEOCIN PHOSPHATE IJ600 MG/4ML, 900 MG/6ML(Use ClindamycinPhosphate)

NF

MO



10

Drug Name DrugTier

Requirements/Limits

CLEOCIN PHOSPHATE IV300MG/50ML-5%,600MG/50ML-5%,900MG/50ML-5% (UseClindamycin Phosphate inD5W)

4

+

clindamycin hcl caps or150 mg, 300 mg, 75 mg 2 MO; *; +

clindamycin palmitatehydrochloride 1 MO; *; +

clindamycin phosphate ind5w 2 *; +

clindamycin phosphatesoln ij 150 mg/ml, 9000mg/60ml

1*; +

clindamycin phosphatesoln ij 600 mg/4ml, 900mg/6ml

1MO; *; +

clindamycin phosphatesoln iv 150 mg/ml, 600mg/4ml

2*; +

LINCOCIN 4 MO; +

Oxazolidinoneslinezolid soln iv 2 mg/ml 5

linezolid tabs or 600 mg 5 MO

SIVEXTRO SOLR IV 5

SIVEXTRO TABS OR 5 MO

ZYVOX SOLN IV 2 MG/ML(Use Linezolid) 5

ZYVOX SUSR OR 100MG/5ML 5 MO

ZYVOX TABS OR 600 MG(Use Linezolid) 5 MO

Polymyxinspolymyxin b sulfate solr ij 2 *; +

StreptograminsSYNERCID 5

ANTIANGINAL AGENTS - Drugs to Treat ChestPain

Drug Name DrugTier

Requirements/Limits

Antianginals-OtherRANEXA 4 PA; MO; +

NitratesDILATRATE SR 4 MO; +

ISORDIL TITRADOSE 40MG 4 MO; +

ISORDIL TITRADOSE 5MG (Use IsosorbideDinitrate)

NFMO

isosorbide dinitrate subl sl2.5 mg 1 *; +

isosorbide dinitrate tabs or10 mg, 20 mg, 30 mg, 5 mg 1 MO; *; +

isosorbide dinitrate tbcr or40 mg 1 MO; *; +

isosorbide mononitrate tabs10 mg 2 MO; *; +

isosorbide mononitrate tabs20 mg 1 MO; *; +

isosorbide mononitratetb24 120 mg, 30 mg, 60 mg 1 MO; *; +

NITRO-DUR 0.1 MG/HR,0.2 MG/HR, 0.4 MG/HR,0.6 MG/HR (UseNitroglycerin)

NF

MO

NITRO-DUR 0.3 MG/HR,0.8 MG/HR 4 MO; +

NITROGLYCERINLINGUAL 4 MO; +

nitroglycerin oint td 2 % 2 MO; *; +

nitroglycerin pt24 td 0.1mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hr

1MO; *; +

nitroglycerin soln iv 5mg/ml 2 *; +

nitroglycerin soln tl 0.4mg/spray 2 MO; *; +

NITROLINGUALPUMPSPRAY (UseNitroglycerin)

NFMO

NITROMIST 4 MO; +



11

Drug Name DrugTier

Requirements/Limits

NITROSTAT 3 MO; +

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc.buspirone hcl tabs or 10mg, 15 mg, 30 mg, 5 mg,7.5 mg

2MO; *; +

hydroxyzine hcl soln im 25mg/ml, 50 mg/ml 2 AL; MO; *; +

hydroxyzine hcl soln or 10mg/5ml 2 AL; MO; *; +

hydroxyzine hcl syrp or 10mg/5ml 2 AL; MO; *; +

hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg 2 AL; MO; *; +

hydroxyzine pamoate capsor 100 mg, 25 mg, 50 mg 2 AL; MO; *; +

meprobamate 2 AL; MO; *; +

VISTARIL (UseHydroxyzine Pamoate) NF AL; MO

Benzodiazepinesalprazolam conc or 1mg/ml 2 MO; *; +

alprazolam tabs or 0.25mg, 0.5 mg, 1 mg, 2 mg 2 MO; *; +

alprazolam tb24 or 0.5 mg,1 mg, 2 mg, 3 mg 2 MO; *; +

alprazolam tbdp or 0.25mg, 0.5 mg, 1 mg, 2 mg 2 MO; *; +

ATIVAN SOLN IJ 2 MG/ML(Use Lorazepam) NF MO

ATIVAN SOLN IJ 4 MG/ML(Use Lorazepam) NF

ATIVAN TABS OR 0.5 MG,1 MG, 2 MG (UseLorazepam)

NFMO

chlordiazepoxide hcl 1 MO; *; +

clorazepate dipotassium 1 MO; *; +

diazepam conc or 5 mg/ml 2 MO; *; +

diazepam soln ij 5 mg/ml 2 MO; *; +

Drug Name DrugTier

Requirements/Limits

diazepam soln or 1 mg/ml 2 MO; *; +

diazepam tabs or 10 mg, 2mg, 5 mg 2 MO; *; +

lorazepam conc or 2 mg/ml 2 MO; *; +

lorazepam soln ij 2 mg/ml,20 mg/10ml 2 MO; *; +

lorazepam soln ij 4 mg/ml 2 *; +

lorazepam tabs or 0.5 mg,1 mg, 2 mg 2 MO; *; +

NIRAVAM (UseAlprazolam) NF MO

oxazepam 1 MO; *; +

TRANXENE T (UseClorazepate Dipotassium) NF MO

VALIUM (Use Diazepam) NF MO

XANAX (Use Alprazolam) NF MO

XANAX XR (UseAlprazolam) NF MO

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythmsAntiarrhythmics Type I-Adisopyramide phosphate 2 AL; MO; *; +

NORPACE (UseDisopyramide Phosphate) NF AL; MO

NORPACE CR 100 MG 4 AL; MO; +

procainamide hcl soln ij100 mg/ml, 500 mg/ml 2 *; +

quinidine gluconate tbcr or324 mg 1 MO; *; +

quinidine sulfate 1 MO; *; +

Antiarrhythmics Type I-Blidocaine hcl (cardiac) 1 MO; *; +

mexiletine hcl 1 MO; *; +

XYLOCAINE IV 20 MG/ML(Use Lidocaine HCl(Cardiac))

NFMO



12

Drug Name DrugTier

Requirements/Limits

Antiarrhythmics Type I-C

flecainide acetate 100 mg 1 QL(4 ea daily);MO; *; +



propafenone hcl 1 MO; *; +

RYTHMOL (UsePropafenone HCl) NF MO

RYTHMOL SR (UsePropafenone HCl) NF MO

Antiarrhythmics Type IIIamiodarone hcl soln iv 900mg/18ml 2 *; +

amiodarone hcl tabs or 100mg, 200 mg, 400 mg 1 MO; *; +

CORDARONE (UseAmiodarone HCl) NF MO

MULTAQ 3 MO; +

TIKOSYN 4 +

ANTIASTHMATIC AND BRONCHODILATORAGENTS - Drugs to Treat Lung ConditionsAnti-Inflammatory Agentscromolyn sodium nebu in 1 MO; B/D; *; +

Antiasthmatic - Monoclonal AntibodiesXOLAIR 5 PA; LA

Bronchodilators - Anticholinergics

ATROVENT HFA 4 QL(0.86 gmdaily); MO; +

INCRUSE ELLIPTA 3 QL(1 ea daily);MO; +

ipratropium bromide soln in 1 MO; B/D; *; +

SPIRIVA HANDIHALER 3 QL(1 ea daily);MO; +

SPIRIVA RESPIMAT 1.25MCG/ACT 3

60actuations;QL(0.14 gm daily);+

Drug Name DrugTier

Requirements/Limits


28actuations;QL(0.28 gm daily);MO; +


60actuations;QL(0.14 gm daily);MO; +

TUDORZA PRESSAIR 3 QL(0.04 eadaily); MO; +

Leukotriene ModulatorsACCOLATE (UseZafirlukast) NF MO

montelukast sodium chew4 mg, 5 mg 2 QL(1 ea daily);

MO; *; +montelukast sodium tabs10 mg 2 QL(1 ea daily);

MO; *; +SINGULAIR CHEW 4 MG,5 MG (Use MontelukastSodium)

NFQL(1 ea daily);MO

SINGULAIR TABS 10 MG(Use Montelukast Sodium) NF QL(1 ea daily);

MO

zafirlukast 1 MO; *; +

ZYFLO CR 5 QL(4 ea daily);MO

Selective Phosphodiesterase 4 (PDE4) Inhibitors

DALIRESP 4 QL(1 ea daily);MO; +

Steroid Inhalants

AEROSPAN 3 QL(0.6 gmdaily); MO; +

ALVESCO 160 MCG/ACT 4 QL(0.41 gmdaily); MO; +

ALVESCO 80 MCG/ACT 4 QL(0.82 gmdaily); MO; +

ARNUITY ELLIPTA 3 QL(1 ea daily);MO; +

ASMANEX HFA 100MCG/ACT 3 QL(0.87 gm

daily); MO; +ASMANEX HFA 200MCG/ACT 3 QL(0.44 gm

daily); MO; +ASMANEX TWISTHALER120 METERED DOSES 3 QL(0.04 ea


daily); MO; +You can find information on what the symbols and abbreviations on this table mean by going topage viii.


13

Drug Name DrugTier

Requirements/Limits

ASMANEX TWISTHALER30 METERED DOSES 110MCG/INH

3QL(0.04 eadaily); MO; +

ASMANEX TWISTHALER30 METERED DOSES 220MCG/INH

3QL(0.14 eadaily); MO; +

ASMANEX TWISTHALER60 METERED DOSES 3 QL(0.07 ea


daily); MO; +budesonide (inhalation)0.25 mg/2ml 1 QL(8 ml daily);

MO; B/D; *; +budesonide (inhalation) 0.5mg/2ml 1 QL(4 ml daily);

MO; B/D; *; +budesonide (inhalation) 1mg/2ml 2 QL(2 ml daily);

MO; B/D; *; +FLOVENT DISKUS 100MCG/BLIST 3 QL(20 ea

daily); MO; +FLOVENT DISKUS 250MCG/BLIST 3 QL(8 ea daily);

MO; +FLOVENT DISKUS 50MCG/BLIST 3 QL(40 ea

daily); MO; +FLOVENT HFA 110MCG/ACT, 220 MCG/ACT 3 QL(0.8 gm

daily); MO; +FLOVENT HFA 44MCG/ACT 3 QL(0.36 gm

daily); MO; +PULMICORT 0.25 MG/2ML(Use Budesonide(Inhalation))

NFQL(8 ml daily);MO; B/D

PULMICORT 0.5 MG/2ML(Use Budesonide(Inhalation))

NFQL(4 ml daily);MO; B/D

PULMICORT 1 MG/2ML(Use Budesonide(Inhalation))

4QL(2 ml daily);MO; B/D; +

PULMICORT FLEXHALER180 MCG/ACT 4 QL(0.07 ea

daily); MO; +PULMICORT FLEXHALER90 MCG/ACT 4 QL(0.27 ea

daily); MO; +

QVAR 3 QL(0.87 gmdaily); MO; +

Sympathomimetics

ADVAIR DISKUS 3 QL(2 ea daily);MO; +

ADVAIR HFA 3 QL(4 gm daily);MO; +

Drug Name DrugTier

Requirements/Limits

albuterol sulfate nebu in0.083 %, 0.5 %, 0.63mg/3ml, 1.25 mg/3ml

1MO; B/D; *; +

albuterol sulfate syrp or 2mg/5ml 1 MO; *; +

albuterol sulfate tabs or 2mg, 4 mg 1 MO; *; +

albuterol sulfate tb12 or 4mg, 8 mg 1 MO; *; +

ANORO ELLIPTA 3 QL(2 ea daily);MO; +

ARCAPTA NEOHALER 4 QL(1 ea daily);MO; +

BREO ELLIPTA25MCG/INH-100MCG/INH,25MCG/INH-200MCG/INH

3

Limited to 2inhalers permonth(InstitutionalPack);QL(2 eadaily); MO; +

BREO ELLIPTA25MCG/INH-100MCG/INH,25MCG/INH-200MCG/INH

3

Limit 1 inhalerper month;QL(2ea daily); MO;+

BROVANA 4 MO; B/D; +

COMBIVENT RESPIMAT 4 QL(0.2 gmdaily); MO; +

DULERA 3 QL(4 gm daily);MO; +

DUONEB (UseIpratropium-Albuterol) NF MO; B/D

epinephrine hcl sosy 0.1mg/ml 2 MO; *; +

FORADIL AEROLIZER 3 QL(2 ea daily);MO; +

ipratropium-albuterol 1 MO; B/D; *; +

levalbuterol hcl nebu in0.31 mg/3ml, 0.63 mg/3ml,1.25 mg/0.5ml, 1.25mg/3ml

1

MO; B/D; *; +

metaproterenol sulfate 1 MO; *; +

PERFOROMIST 4 QL(4 ml daily);MO; B/D; +

PROAIR HFA 3 MO; +



14

Drug Name DrugTier

Requirements/Limits

PROAIR RESPICLICK 3 MO; +

PROVENTIL HFA 3 MO; +

SEREVENT DISKUS 3 QL(2 ea daily);MO; +

STIOLTO RESPIMAT 3

Limited to 1inhaler permonth;QL(0.14gm daily); MO;+

STRIVERDI RESPIMAT 3

InstitutionalPack;QL(0.28gm daily); MO;+

STRIVERDI RESPIMAT 3 QL(0.14 gmdaily); MO; +

SYMBICORT 4 QL(0.34 gmdaily); MO; +

terbutaline sulfate tabs or2.5 mg, 5 mg 1 MO; *; +

VENTOLIN HFA 4 MO; +

XOPENEX (UseLevalbuterol HCl) NF MO; B/D

XOPENEXCONCENTRATE (UseLevalbuterol HCl)

NFMO; B/D

XOPENEX HFA 4 MO; +

Xanthinesaminophylline 2 MO; *; +

dyphylline tabs or 2 *; +

theophylline cp24 100mg,200 mg, 300 mg, 400 mg 2 MO; *; +

theophylline elix 80mg/15ml 2 MO; *; +

theophylline tb12 100 mg,200 mg, 300 mg, 450 mg 1 MO; *; +

theophylline tb24 400 mg,600 mg 1 MO; *; +

ANTICOAGULANTS - Blood Thinners

Coumarin Anticoagulants

Drug Name DrugTier

Requirements/Limits

COUMADIN TABS OR 1MG, 10 MG, 2 MG, 2.5 MG,3 MG, 4 MG, 5 MG, 6 MG,7.5 MG (Use WarfarinSodium)

4

MO; +

warfarin sodium 1 MO; *; +

Direct Factor Xa InhibitorsELIQUIS 4 MO; +

SAVAYSA 4 MO; +

XARELTO 3 MO; +

XARELTO STARTERPACK 3 MO; +

Heparins And Heparinoid-Like AgentsARIXTRA 10 MG/0.8ML, 5MG/0.4ML, 7.5 MG/0.6ML(Use FondaparinuxSodium)

5

MO

ARIXTRA 2.5 MG/0.5ML(Use FondaparinuxSodium)

NFMO

enoxaparin sodium ij 300mg/3ml 2 MO; *; +

enoxaparin sodium sc 100mg/ml, 60 mg/0.6ml, 80mg/0.8ml

2MO; *; +

enoxaparin sodium sc 120mg/0.8ml, 150 mg/ml 5 MO

enoxaparin sodium sc 30mg/0.3ml, 40 mg/0.4ml 1 MO; *; +

fondaparinux sodium 10mg/0.8ml, 5 mg/0.4ml, 7.5mg/0.6ml

5MO

fondaparinux sodium 2.5mg/0.5ml 1 MO; *; +

FRAGMIN 10000 UNIT/ML,2500 UNIT/0.2ML, 5000UNIT/0.2ML

4MO; +

FRAGMIN 12500UNIT/0.5ML, 15000UNIT/0.6ML, 18000UNT/0.72ML, 25000UNIT/ML, 7500UNIT/0.3ML

5

MO



15

Drug Name DrugTier

Requirements/Limits

FRAGMIN 95000UNIT/3.8ML 5

heparin sodium (porcine)1000 unit/ml 2 MO; *; +

heparin sodium (porcine)10000 unit/ml, 20000unit/ml, 5000 unit/0.5ml,5000 unit/ml

1

MO; *; +

LOVENOX IJ 300 MG/3ML(Use Enoxaparin Sodium) NF MO

LOVENOX SC 100 MG/ML,30 MG/0.3ML, 40MG/0.4ML, 60 MG/0.6ML,80 MG/0.8ML (UseEnoxaparin Sodium)

NF

MO

LOVENOX SC 120MG/0.8ML, 150 MG/ML(Use Enoxaparin Sodium)

4MO; +

Thrombin Inhibitorsargatroban 250 mg/2.5ml 2 MO; *; +

PRADAXA 3 MO; +

ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor Antagonists

FYCOMPA 10 MG 4 QL(1.2 eadaily); MO; +

FYCOMPA 12 MG 4 QL(1 ea daily);MO; +




FYCOMPA 8 MG 4 QL(1.5 eadaily); MO; +

Anticonvulsants - Benzodiazepines

clonazepam tabs or 0.5 mg 2 QL(40 eadaily); MO; *; +

clonazepam tabs or 1 mg 2 QL(20 eadaily); MO; *; +

clonazepam tabs or 2 mg 2 QL(10 eadaily); MO; *; +

Drug Name DrugTier

Requirements/Limits

clonazepam tbdp or 0.125mg, 0.25 mg, 0.5 mg, 1 mg,2 mg

2MO; *; +

DIASTAT ACUDIAL 4 MO; +

DIASTAT PEDIATRIC 4 MO; +

DIAZEPAM GEL RE 10MG, 2.5 MG, 20 MG 4 MO; +

KLONOPIN 0.5 MG (UseClonazepam) 4 QL(40 ea

daily); MO; +KLONOPIN 1 MG (UseClonazepam) 4 QL(20 ea

daily); MO; +KLONOPIN 2 MG (UseClonazepam) 4 QL(10 ea

daily); MO; +

ONFI SUSP 2.5 MG/ML 4 MO; +

ONFI TABS 10 MG, 5 MG 4 MO; +

ONFI TABS 20 MG 5 MO

Anticonvulsants - Misc.

APTIOM 200 MG 4 QL(6 ea daily);MO; +

APTIOM 400 MG 5 QL(3 ea daily);MO



BANZEL SUSP 40 MG/ML 4 MO; +

BANZEL TABS 200 MG 4 MO; +

BANZEL TABS 400 MG 5 MO

carbamazepine chew or100 mg 2 MO; *; +

carbamazepine cp12 or100 mg, 200 mg, 300 mg 2 MO; *; +

carbamazepine susp or100 mg/5ml 2 MO; *; +

carbamazepine tabs or 200mg 2 MO; *; +

carbamazepine tb12 or 200mg, 400 mg 2 MO; *; +



16

Drug Name DrugTier

Requirements/Limits

CARBATROL (UseCarbamazepine) 4 MO; +

gabapentin caps or 100mg, 300 mg, 400 mg 2 MO; *; +

gabapentin soln or 250mg/5ml 2 MO; *; +

gabapentin tabs or 600 mg,800 mg 2 MO; *; +

KEPPRA (UseLevetiracetam) 4 MO; +

KEPPRA XR (UseLevetiracetam) 4 MO; +

LAMICTAL CHEWABLEDISPERSIBLE (UseLamotrigine)

4MO; +

LAMICTAL ODT TBDP 100MG, 200 MG, 25 MG, 50MG (Use Lamotrigine)

4MO; +

LAMICTAL STARTER/NOTTAKINGCARBAMAZEPINE

4MO; +

LAMICTALSTARTER/TAKINGCARBAMAZEPINE/NOTTAKING VALPROATE

4

MO; +

LAMICTALSTARTER/TAKINGVALPROATE

4MO; +

LAMICTAL TABS 100 MG,150 MG, 200 MG, 25 MG(Use Lamotrigine)

4MO; +

LAMICTAL XR 4 MO; +

LAMICTAL XR 100MG,200 MG,25 MG,250MG,300 MG,50 MG (UseLamotrigine)

4

MO; +

lamotrigine chew 25 mg, 5mg 2 MO; *; +

lamotrigine tabs 100 mg,150 mg, 200 mg, 25 mg 2 MO; *; +

lamotrigine tb24 100 mg,200 mg, 25 mg, 250 mg,300 mg, 50 mg

2MO; *; +

lamotrigine tbdp 100 mg,200 mg, 25 mg, 50 mg 2 MO; *; +

Drug Name DrugTier

Requirements/Limits

LEVETIRACETAM SOLNIV 1000MG/100ML-750MG/100ML,1500MG/100ML-540MG/100ML,500MG/100ML-820MG/100ML

4

+

levetiracetam soln iv 500mg/5ml 2 MO; *; +

levetiracetam soln or 100mg/ml, 500 mg/5ml 2 MO; *; +

levetiracetam tabs or 1000mg, 250 mg, 500 mg, 750mg

2MO; *; +

levetiracetam tb24 or 500mg, 750 mg 2 MO; *; +

LYRICA CAPS 100 MG 3 QL(6 ea daily);MO; +



LYRICA CAPS 225 MG,300 MG 3 QL(2 ea daily);

MO; +

LYRICA CAPS 25 MG 3 QL(24 eadaily); MO; +

LYRICA CAPS 50 MG 3 QL(12 eadaily); MO; +


LYRICA SOLN 20 MG/ML 3 QL(30 mldaily); MO; +

MYSOLINE (UsePrimidone) 4 MO; +

NEURONTIN (UseGabapentin) 4 MO; +

oxcarbazepine 2 MO; *; +

POTIGA 200 MG 5 QL(6 ea daily);MO

POTIGA 300 MG 4 QL(4 ea daily);MO; +

POTIGA 400 MG 4 QL(3 ea daily);MO; +

POTIGA 50 MG 5 QL(24 eadaily); MO



17

Drug Name DrugTier

Requirements/Limits

primidone tabs or 250 mg,50 mg 2 MO; *; +

TEGRETOL (UseCarbamazepine) 4 MO; +

TEGRETOL-XR 100 MG 4 MO; +

TEGRETOL-XR 200MG,400 MG (UseCarbamazepine)

4MO; +

TOPAMAX (UseTopiramate) 4 MO; +

TOPAMAX SPRINKLE(Use Topiramate) 4 MO; +

topiramate cpsp or 15 mg,25 mg 2 MO; *; +

topiramate tabs or 100 mg,200 mg, 25 mg, 50 mg 2 MO; *; +

TRILEPTAL (UseOxcarbazepine) 4 MO; +

VIMPAT SOLN IV 200MG/20ML 4 +

VIMPAT SOLN OR 10MG/ML 4 MO; +

VIMPAT TABS OR 100MG, 150 MG, 200 MG, 50MG

4MO; +

ZONEGRAN (UseZonisamide) 4 MO; +

zonisamide 2 MO; *; +

Carbamatesfelbamate susp 600mg/5ml 2 MO; *; +

felbamate tabs 400 mg 2 MO; *; +

felbamate tabs 600 mg 5 MO

FELBATOL SUSP 600MG/5ML (Use Felbamate) 4 MO; +

FELBATOL TABS 400 MG(Use Felbamate) 4 MO; +

FELBATOL TABS 600 MG(Use Felbamate) 5 MO

GABA ModulatorsGABITRIL 12 MG,16 MG 4 MO; +

Drug Name DrugTier

Requirements/Limits

GABITRIL 2 MG,4 MG(Use Tiagabine HCl) 4 MO; +

SABRIL 5 LA

tiagabine hcl 2 mg 2 MO; *; +

tiagabine hcl 4 mg 1 MO; *; +

HydantoinsCEREBYX 100 MGPE/2ML (Use FosphenytoinSodium)

4+

CEREBYX 500 MGPE/10ML (UseFosphenytoin Sodium)

4MO; +

DILANTIN-125 (UsePhenytoin) 4 MO; +

fosphenytoin sodium 100mg pe/2ml 2 *; +

fosphenytoin sodium 500mg pe/10ml 2 MO; *; +

PEGANONE 4 MO; +

phenytoin chew or 50 mg 2 MO; *; +

phenytoin sodium extended 2 MO; *; +

phenytoin sodium soln ij 2 *; +

phenytoin susp or 125mg/5ml 2 MO; *; +

SuccinimidesCELONTIN 4 MO; +

ethosuximide caps or 250mg 1 MO; *; +

ethosuximide soln or 250mg/5ml 2 MO; *; +

ZARONTIN 250 MG (UseEthosuximide) 4 MO; +

Valproic AcidDEPACON (Use ValproateSodium) 4 +

DEPAKENE (UseValproate Sodium) 4 MO; +



18

Drug Name DrugTier

Requirements/Limits

DEPAKENE (Use ValproicAcid) 4 MO; +

DEPAKOTE (UseDivalproex Sodium) 4 MO; +

DEPAKOTE ER (UseDivalproex Sodium) 4 MO; +

DEPAKOTE SPRINKLES(Use Divalproex Sodium) 4 MO; +

divalproex sodium 2 MO; *; +

valproate sodium soln iv100 mg/ml, 500 mg/5ml 2 *; +

valproate sodium soln or250 mg/5ml 2 MO; *; +

valproate sodium syrp or250 mg/5ml 2 MO; *; +

valproic acid caps or 2 MO; *; +

ANTIDEPRESSANTS - Drugs to Treat Depression

Alpha-2 Receptor Antagonists (Tetracyclics)mirtazapine 2 MO; *; +

REMERON (UseMirtazapine) NF MO

REMERON SOLTAB (UseMirtazapine) NF MO

Antidepressants - Misc.

APLENZIN 174 MG 4 ST; QL(3 eadaily); MO; +

APLENZIN 348 MG, 522MG 4 ST; QL(1 ea

daily); MO; +bupropion hcl tabs or 100mg 2 QL(4.5 ea

daily); MO; *; +bupropion hcl tabs or 75mg 2 QL(6 ea daily);

MO; *; +bupropion hcl tb12 or 100mg 2 QL(4 ea daily);

MO; *; +bupropion hcl tb12 or 150mg, 200 mg 2 QL(2 ea daily);



MO; *; +

FORFIVO XL 4 ST; MO; +

Drug Name DrugTier

Requirements/Limits

maprotiline hcl 25 mg, 50mg 1 MO; *; +

maprotiline hcl 75 mg 2 MO; *; +

WELLBUTRIN 100 MG(Use Bupropion HCl) NF QL(4.5 ea

daily); MOWELLBUTRIN 75 MG (UseBupropion HCl) NF QL(6 ea daily);

MOWELLBUTRIN SR 100 MG(Use Bupropion HCl) NF QL(4 ea daily);

MOWELLBUTRIN SR 150 MG,200 MG (Use BupropionHCl)

NFQL(2 ea daily);MO

WELLBUTRIN XL 150 MG(Use Bupropion HCl) NF QL(3 ea daily);

MOWELLBUTRIN XL 300 MG(Use Bupropion HCl) NF QL(1 ea daily);

MOMonoamine Oxidase Inhibitors (MAOIs)EMSAM 5 MO

MARPLAN 4 MO; +

NARDIL (Use PhenelzineSulfate) NF MO

PARNATE (UseTranylcypromine Sulfate) 5 MO

phenelzine sulfate tabs or 2 MO; *; +

tranylcypromine sulfate 2 MO; *; +

Selective Serotonin Reuptake Inhibitors (SSRIs)CELEXA 10 MG (UseCitalopram Hydrobromide) NF QL(4 ea daily);

MOCELEXA 20 MG (UseCitalopram Hydrobromide) NF QL(2 ea daily);

MOCELEXA 40 MG (UseCitalopram Hydrobromide) NF QL(1 ea daily);

MOcitalopram hydrobromidesoln 10 mg/5ml 2 QL(20 ml

daily); MO; *; +citalopram hydrobromidetabs 10 mg 1 QL(4 ea daily);

MO; *; +citalopram hydrobromidetabs 20 mg 1 QL(2 ea daily);

MO; *; +citalopram hydrobromidetabs 40 mg 1 QL(1 ea daily);

MO; *; +



19

Drug Name DrugTier

Requirements/Limits

escitalopram oxalate 2 MO; *; +

fluoxetine hcl caps or 10mg, 20 mg, 40 mg 2 MO; *; +

fluoxetine hcl cpdr or 90mg 2 MO; *; +

fluoxetine hcl soln or 20mg/5ml 2 MO; *; +

fluoxetine hcl tabs or 10mg, 20 mg 2 MO; *; +

FLUOXETINE HCL TABSOR 60 MG 4 MO; +

fluvoxamine maleate 2 MO; *; +

LEXAPRO (UseEscitalopram Oxalate) NF MO

LUVOX CR (UseFluvoxamine Maleate) NF MO

paroxetine hcl 2 MO; *; +

PAXIL CR (Use ParoxetineHCl) NF MO

PAXIL SUSP 10 MG/5ML 4 MO; +

PAXIL TABS 10 MG, 20MG, 30 MG, 40 MG (UseParoxetine HCl)

NFMO

PEXEVA 4 ST; MO; +

PROZAC (Use FluoxetineHCl) NF MO

PROZAC WEEKLY (UseFluoxetine HCl) NF MO

sertraline hcl conc or 20mg/ml 2 MO; *; +

sertraline hcl tabs or 100mg, 25 mg, 50 mg 1 MO; *; +

ZOLOFT (Use SertralineHCl) NF MO

Serotonin Modulators

BRINTELLIX 10 MG 4 ST; QL(2 eadaily); MO; +



Drug Name DrugTier

Requirements/Limits

nefazodone hcl 2 MO; *; +

OLEPTRO 4 MO; +

trazodone hcl tabs or 100mg, 150 mg, 300 mg, 50mg

1MO; *; +

VIIBRYD 4 ST; MO; +

VIIBRYD STARTER PACK 4 ST; +

Serotonin-Norepinephrine Reuptake InhibitorsCYMBALTA (UseDuloxetine HCl) NF MO

DESVENLAFAXINE ER100 MG, 50 MG 4 ST; MO; +

DESVENLAFAXINE ER100 MG, 50 MG 4 ST; Fumarate;

+duloxetine hcl 20 mg, 30mg, 60 mg 2 MO; *; +

EFFEXOR XR 150 MG(Use Venlafaxine HCl) NF QL(1 ea daily);

MOEFFEXOR XR 37.5 MG(Use Venlafaxine HCl) NF QL(6 ea daily);

MOEFFEXOR XR 75 MG (UseVenlafaxine HCl) NF QL(3 ea daily);

MOFETZIMA 120 MG, 40 MG,80 MG 4 ST; QL(1 ea

daily); MO; +

FETZIMA 20 MG 4 ST; QL(2 eadaily); MO; +

FETZIMA TITRATIONPACK 4 ST; MO; +

KHEDEZLA 4 ST; MO; +

PRISTIQ 4 ST; MO; +

venlafaxine hcl cp24 150mg 2 QL(1 ea daily);

MO; *; +venlafaxine hcl cp24 37.5mg 2 QL(6 ea daily);

MO; *; +

venlafaxine hcl cp24 75 mg 2 QL(3 ea daily);MO; *; +

VENLAFAXINE HCL ER 4 ST; QL(1 eadaily); MO; +

venlafaxine hcl tabs 100mg 2 QL(3.5 ea

daily); MO; *; +



20

Drug Name DrugTier

Requirements/Limits

venlafaxine hcl tabs 25 mg 2 QL(15 eadaily); MO; *; +

venlafaxine hcl tabs 37.5mg 2 QL(10 ea

daily); MO; *; +

venlafaxine hcl tabs 50 mg 2 QL(7.5 eadaily); MO; *; +

venlafaxine hcl tabs 75 mg 2 QL(5 ea daily);MO; *; +

venlafaxine hcl tb24 150mg 2 QL(1 ea daily);

MO; *; +venlafaxine hcl tb24 37.5mg 2 QL(6 ea daily);

MO; *; +

venlafaxine hcl tb24 75 mg 2 QL(3 ea daily);MO; *; +

Tricyclic Agentsamitriptyline hcl 2 AL; MO; *; +

amoxapine 100 mg, 25 mg,50 mg 1 MO; *; +

amoxapine 150 mg 2 MO; *; +

ANAFRANIL (UseClomipramine HCl) NF AL; MO

clomipramine hcl caps or25 mg, 50 mg, 75 mg 2 AL; MO; *; +

desipramine hcl tabs or 10mg, 100 mg, 150 mg, 25mg, 50 mg, 75 mg

2MO; *; +

doxepin hcl caps or 10 mg,100 mg, 150 mg, 25 mg, 50mg, 75 mg

2AL; MO; *; +

doxepin hcl conc or 10mg/ml 2 AL; MO; *; +

imipramine hcl tabs or 10mg, 25 mg 2 AL; MO; *; +

imipramine hcl tabs or 50mg 2 MO; *; +

imipramine pamoate 2 AL; MO; *; +

NORPRAMIN (UseDesipramine HCl) NF MO

nortriptyline hcl caps or 10mg, 25 mg, 50 mg, 75 mg 1 MO; *; +

nortriptyline hcl soln or 10mg/5ml 2 MO; *; +

Drug Name DrugTier

Requirements/Limits

PAMELOR (UseNortriptyline HCl) NF MO

protriptyline hcl 1 MO; *; +

SURMONTIL (UseTrimipramine Maleate) 4 AL; MO; +

TOFRANIL-PM (UseImipramine Pamoate) NF AL; MO

trimipramine maleate capsor 100 mg, 25 mg, 50 mg 2 AL; MO; *; +

ANTIDIABETICS - Drugs to Regulate Blood Sugar

Alpha-Glucosidase Inhibitors

acarbose 6 QL(3 ea daily);MO; *; +

GLYSET 6 QL(3 ea daily);MO; *; +

PRECOSE (Use Acarbose) NF QL(3 ea daily);MO

Antidiabetic - Amylin Analogs

SYMLINPEN 120 4 QL(0.4 mldaily); MO; +

SYMLINPEN 60 4 QL(0.4 mldaily); MO; +

Antidiabetic CombinationsACTOPLUS MET (UsePioglitazone HCl-MetforminHCl)

NFQL(3 ea daily);MO

ACTOPLUS MET XR15MG-1000MG 6 QL(2 ea daily);

MO; *; +ACTOPLUS MET XR30MG-1000MG 6 QL(1 ea daily);

MO; *; +AVANDAMET 2MG-1000MG 6 QL(2 ea daily);

LA; MO; *; +

AVANDAMET 2MG-500MG 6 QL(4 ea daily);LA; *; +

AVANDAMET 4MG-1000MG, 4MG-500MG 6 QL(2 ea daily);

LA; *; +AVANDARYL 4MG-1MG,4MG-2MG 6 QL(2 ea daily);

LA; *; +AVANDARYL 4MG-4MG,8MG-4MG 6 QL(1 ea daily);

LA; MO; *; +

AVANDARYL 8MG-2MG 6 QL(1 ea daily);LA; *; +



21

Drug Name DrugTier

Requirements/Limits

DUETACT (UsePioglitazone HCl-Glimepiride)

NFQL(1.5 eadaily); MO

glipizide-metformin hcl2.5mg-250mg 6 QL(8 ea daily);

MO; *; +glipizide-metformin hcl2.5mg-500mg, 5mg-500mg 6 QL(4 ea daily);

MO; *; +GLUCOVANCE 1.25MG-250MG (Use Glyburide-Metformin)

NFAL; QL(8 eadaily); MO

GLUCOVANCE 2.5MG-500MG, 5MG-500MG (UseGlyburide-Metformin)

NFAL; QL(4 eadaily); MO

glyburide-metformin1.25mg-250mg 2 AL; QL(8 ea

daily); MO; *; +glyburide-metformin 2.5mg-500mg, 5mg-500mg 2 AL; QL(4 ea

daily); MO; *; +INVOKAMET 150MG-1000MG, 150MG-500MG,50MG-1000MG


INVOKAMET 50MG-500MG 3 QL(4 ea daily);

MO; +

JANUMET 6 QL(2 ea daily);MO; *; +

JANUMET XR 100MG-1000MG 6 QL(1 ea daily);

MO; *; +JANUMET XR 50MG-1000MG, 50MG-500MG 6 QL(2 ea daily);

MO; *; +

JENTADUETO 6 QL(2 ea daily);MO; *; +

KAZANO 3 QL(2 ea daily);MO; +

KOMBIGLYZE XR 2.5MG-1000MG 3 QL(2 ea daily);

MO; +KOMBIGLYZE XR 5MG-1000MG, 5MG-500MG 3 QL(1 ea daily);

MO; +

OSENI 12.5MG-15MG 3 QL(2 ea daily);MO; +

OSENI 12.5MG-30MG,12.5MG-45MG, 25MG-15MG, 25MG-30MG,25MG-45MG

3

QL(1 ea daily);MO; +

pioglitazone hcl-glimepiride 6 QL(1.5 eadaily); MO; *; +

pioglitazone hcl-metforminhcl 6 QL(3 ea daily);

MO; *; +

Drug Name DrugTier

Requirements/Limits

PRANDIMET 6 QL(5 ea daily);MO; *; +

XIGDUO XR 10MG-1000MG, 10MG-500MG 4 QL(1 ea daily);

MO; +XIGDUO XR 5MG-1000MG, 5MG-500MG 4 QL(2 ea daily);

MO; +BiguanidesFORTAMET 1000 MG (UseMetformin HCl) NF Osmotic;QL(2

ea daily); MOFORTAMET 500 MG (UseMetformin HCl) NF Osmotic;QL(5

ea daily); MOGLUCOPHAGE 1000 MG(Use Metformin HCl) NF QL(2.5 ea

daily); MOGLUCOPHAGE 500 MG(Use Metformin HCl) NF QL(5 ea daily);

MOGLUCOPHAGE 850 MG(Use Metformin HCl) NF QL(3 ea daily);

MOGLUCOPHAGE XR 500MG (Use Metformin HCl) NF QL(4 ea daily);

MOGLUCOPHAGE XR 750MG (Use Metformin HCl) NF QL(2 ea daily);

MO

GLUMETZA 1000 MG 6 QL(2 ea daily);MO; *; +

GLUMETZA 500 MG 6 QL(4 ea daily);MO; *; +

metformin hcl tabs or 1000mg 6 QL(2.5 ea

daily); MO; *; +metformin hcl tabs or 500mg 6 QL(5 ea daily);

MO; *; +metformin hcl tabs or 850mg 6 QL(3 ea daily);

MO; *; +

metformin hcl tb24 or 1000mg 6

Osmotic;QL(2ea daily); MO;*; +

metformin hcl tb24 or 500mg 6

Osmotic;QL(5ea daily); MO;*; +

metformin hcl tb24 or 500mg 6 QL(4 ea daily);

MO; *; +metformin hcl tb24 or 750mg 6 QL(2 ea daily);

MO; *; +

RIOMET 6 QL(25.5 mldaily); MO; *; +

Diabetic Other



22

Drug Name DrugTier

Requirements/Limits

GLUCAGEN HYPOKIT 3 MO; +

glucagon (rdna) 1 MO; *; +

PROGLYCEM 4 MO; +

Dipeptidyl Peptidase-4 (DPP-4) InhibitorsJANUVIA 6 MO; *; +

NESINA 3 MO; +

ONGLYZA 3 MO; +

TRADJENTA 6 MO; *; +

Dopamine Receptor Agonists - Antidiabetic

CYCLOSET 4 QL(6 ea daily);MO; +

Incretin Mimetic Agents (GLP-1 ReceptorBYDUREON 6 ST; MO; *; +

BYETTA 6 ST; MO; *; +

TANZEUM 4 ST; MO; +

TRULICITY 4 ST; MO; +

VICTOZA 6 ST; MO; *; +

Insulin Sensitizing AgentsACTOS 15 MG (UsePioglitazone HCl) NF QL(3 ea daily);

MOACTOS 30 MG, 45 MG(Use Pioglitazone HCl) NF QL(1 ea daily);

MO

AVANDIA 2 MG 6 QL(4 ea daily);LA; MO; *; +



pioglitazone hcl 15 mg 6 QL(3 ea daily);MO; *; +

pioglitazone hcl 30 mg, 45mg 6 QL(1 ea daily);

MO; *; +Insulin

Drug Name DrugTier

Requirements/Limits

AFREZZA 4 QL(3 ea daily);MO; +

APIDRA 4 QL(1.5 mldaily); MO; +

APIDRA SOLOSTAR 4 QL(1.5 mldaily); MO; +

HUMALOG 3 QL(1.5 mldaily); MO; +

HUMALOG KWIKPEN 3 QL(1.5 mldaily); MO; +

HUMALOG MIX 50/50 3 QL(1.5 mldaily); MO; +

HUMALOG MIX 50/50KWIKPEN 3 QL(1.5 ml

daily); MO; +

HUMALOG MIX 75/25 3 QL(1.5 mldaily); MO; +

HUMALOG MIX 75/25KWIKPEN 3 QL(1.5 ml

daily); MO; +

HUMULIN 70/30 3 QL(1.5 mldaily); MO; +

HUMULIN 70/30 KWIKPEN 3 QL(1.5 mldaily); MO; +

HUMULIN 70/30 PEN 3 QL(1.5 mldaily); MO; +

HUMULIN N 3 QL(1.5 mldaily); MO; +

HUMULIN N KWIKPEN 3 QL(1.5 mldaily); MO; +

HUMULIN N U-100 PEN 3 QL(1.5 mldaily); MO; +

HUMULIN R 3 QL(1.5 mldaily); MO; +

HUMULIN R U-500(CONCENTRATED) 3 QL(1.5 ml

daily); MO; +

LANTUS 3 QL(1.5 mldaily); MO; +

LANTUS SOLOSTAR 3 QL(1.5 mldaily); MO; +

LEVEMIR 3 QL(1.5 mldaily); MO; +

LEVEMIR FLEXPEN 3 QL(1.5 mldaily); MO; +

LEVEMIR FLEXTOUCH 3 QL(1.5 mldaily); MO; +

NOVOLIN 70/30 4 QL(1.5 mldaily); MO; +



23

Drug Name DrugTier

Requirements/Limits

NOVOLIN 70/30 RELION 4 QL(1.5 mldaily); MO; +

NOVOLIN N 4 QL(1.5 mldaily); MO; +

NOVOLIN N RELION 4 QL(1.5 mldaily); MO; +

NOVOLIN R 4 QL(1.5 mldaily); MO; +

NOVOLIN R RELION 4 QL(1.5 mldaily); MO; +

NOVOLOG 4 QL(1.5 mldaily); MO; +

NOVOLOG FLEXPEN 4 QL(1.5 mldaily); MO; +

NOVOLOG MIX 70/30 4 QL(1.5 mldaily); MO; +

NOVOLOG MIX 70/30PREFILLED FLEXPEN 4 QL(1.5 ml

daily); MO; +

NOVOLOG PENFILL 4 QL(1.5 mldaily); MO; +

TOUJEO SOLOSTAR 3

Limit 15mL permonth;QL(0.5ml daily); MO;+

Meglitinide Analogues

nateglinide 6 QL(3 ea daily);MO; *; +

PRANDIN 0.5 MG (UseRepaglinide) NF QL(32 ea

daily); MOPRANDIN 1 MG (UseRepaglinide) NF QL(16 ea

daily); MOPRANDIN 2 MG (UseRepaglinide) NF QL(8 ea daily);

MO

repaglinide 0.5 mg 6 QL(32 eadaily); MO; *; +

repaglinide 1 mg 6 QL(16 eadaily); MO; *; +

repaglinide 2 mg 6 QL(8 ea daily);MO; *; +

STARLIX (Use Nateglinide) NF QL(3 ea daily);MO

Sodium-Glucose Co-Transporter 2 (SGLT2)FARXIGA 4 MO; +

INVOKANA 3 MO; +

Drug Name DrugTier

Requirements/Limits

JARDIANCE 10 MG 3 QL(2 ea daily);MO; +

JARDIANCE 25 MG 3 QL(1 ea daily);MO; +

SulfonylureasAMARYL 1 MG (UseGlimepiride) NF QL(8 ea daily);

MOAMARYL 2 MG (UseGlimepiride) NF QL(4 ea daily);

MOAMARYL 4 MG (UseGlimepiride) NF QL(2 ea daily);

MO

chlorpropamide 100 mg 2 AL; QL(7.5 eadaily); MO; *; +

chlorpropamide 250 mg 2 AL; QL(3 eadaily); MO; *; +

DIABETA 1.25 MG (UseGlyburide) 4 AL; QL(16 ea

daily); MO; +DIABETA 2.5 MG (UseGlyburide) 4 AL; QL(8 ea

daily); MO; +DIABETA 5 MG (UseGlyburide) 4 AL; MO; +

glimepiride 1 mg 6 QL(8 ea daily);MO; *; +



glipizide tabs or 10 mg 6 QL(4 ea daily);MO; *; +

glipizide tabs or 5 mg 6 QL(8 ea daily);MO; *; +

glipizide tb24 or 10 mg 6 QL(2 ea daily);MO; *; +

glipizide tb24 or 2.5 mg 6 QL(8 ea daily);MO; *; +

glipizide tb24 or 5 mg 6 QL(4 ea daily);MO; *; +

GLUCOTROL 10 MG (UseGlipizide) NF QL(4 ea daily);

MOGLUCOTROL 5 MG (UseGlipizide) NF QL(8 ea daily);

MOGLUCOTROL XL 10 MG(Use Glipizide) NF QL(2 ea daily);

MOGLUCOTROL XL 2.5 MG(Use Glipizide) NF QL(8 ea daily);

MO



24

Drug Name DrugTier

Requirements/Limits

GLUCOTROL XL 5 MG(Use Glipizide) NF QL(4 ea daily);

MO

glyburide 1.25 mg 2 AL; QL(16 eadaily); MO; *; +

glyburide 2.5 mg 2 AL; QL(8 eadaily); MO; *; +

glyburide 5 mg 2 AL; QL(4 eadaily); MO; *; +

glyburide micronized 1.5mg 2 AL; QL(8 ea

daily); MO; *; +

glyburide micronized 3 mg 2 AL; QL(4 eadaily); MO; *; +

glyburide micronized 6 mg 2 AL; QL(2 eadaily); MO; *; +

GLYNASE 1.5 MG (UseGlyburide Micronized) NF AL; QL(8 ea

daily); MOGLYNASE 3 MG (UseGlyburide Micronized) NF AL; QL(4 ea

daily); MOGLYNASE 6 MG (UseGlyburide Micronized) NF AL; QL(2 ea

daily); MO

tolazamide 250 mg 6 QL(4 ea daily);MO; *; +

TOLAZAMIDE 500 MG 6 QL(2 ea daily);MO; *; +

TOLBUTAMIDE 6 QL(6 ea daily);MO; *; +

ANTIDIARRHEALS - Drugs to Treat Diarrhea

Antidiarrheal - Chloride Channel Antagonists

FULYZAQ 4 PA; QL(2 eadaily); MO; +

Antiperistaltic Agentsdiphenoxylate w/ atropine 2 MO; *; +

LOMOTIL (UseDiphenoxylate w/ Atropine) NF MO

loperamide hcl caps or 2mg 2 RX/OTC; MO;

*; +

MOTOFEN 4 MO; +

opium tincture 5 MO

ANTIDOTES - Drugs to Treat Overdose orToxicityAntidotes - Chelating Agents

Drug Name DrugTier

Requirements/Limits

CHEMET 4 MO; +

EXJADE 5 LA

JADENU 5

Opioid AntagonistsEVZIO 4 PA; MO; +

naloxone hcl soln ij 1 mg/ml 2 MO; *; +

naltrexone hcl tabs or 1 MO; *; +

ANTIEMETICS - Drugs to Treat Nausea andVomiting5-HT3 Receptor Antagonistsgranisetron hcl tabs or 1mg 1 MO; B/D; *; +

ondansetron 2 MO; B/D; *; +

ondansetron hcl soln ij 4mg/2ml, 40 mg/20ml 2 MO; *; +

ondansetron hcl soln or 4mg/5ml 2 MO; B/D; *; +

ondansetron hcl tabs or 24mg, 4 mg, 8 mg 2 MO; B/D; *; +

SANCUSO 5 MO

ZOFRAN ODT (UseOndansetron) NF MO; B/D

ZOFRAN SOLN IJ 40MG/20ML (UseOndansetron HCl)

NFMO

ZOFRAN SOLN OR 4MG/5ML (Use OndansetronHCl)

NFMO; B/D

ZOFRAN TABS OR 4 MG,8 MG (Use OndansetronHCl)

NFMO; B/D

Antiemetics - Anticholinergicdimenhydrinate soln ij 50mg/ml 2 *; +

meclizine hcl tabs 12.5 mg,25 mg 2 RX/OTC; MO;

*; +TIGAN 300 MG (UseTrimethobenzamide HCl) NF AL; MO



25

Drug Name DrugTier

Requirements/Limits

TRANSDERM-SCOP 4 MO; +

trimethobenzamide hclcaps or 300 mg 2 AL; MO; *; +

trimethobenzamide hcl solnim 100 mg/ml 1 AL; MO; *; +

Antiemetics - MiscellaneousAKYNZEO 4 MO; B/D; +

CESAMET 4 MO; B/D; +

dronabinol 10 mg 5 MO; B/D

dronabinol 2.5 mg, 5 mg 2 MO; B/D; *; +

MARINOL 10 MG, 5 MG(Use Dronabinol) 5 MO; B/D

MARINOL 2.5 MG (UseDronabinol) NF MO; B/D

Substance P/Neurokinin 1 (NK1) ReceptorEMEND CAPS OR 125MG, 80 MG 4 MO; B/D; +

EMEND CAPS OR 40 MG 4 PA; MO; +

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungal - Glucan Synthesis InhibitorsERAXIS 100 MG 4 +

MYCAMINE 100 MG 5 MO

AntifungalsABELCET 5

AMBISOME 5

amphotericin b solr ij 50 mg 1 MO; *; +

ANCOBON (UseFlucytosine) NF MO

flucytosine 2 MO; *; +

GRIS-PEG (UseGriseofulvin Ultramicrosize) NF MO

griseofulvin microsize susp125 mg/5ml 2 MO; *; +

Drug Name DrugTier

Requirements/Limits

griseofulvin microsize tabs500 mg 1 MO; *; +

griseofulvin ultramicrosize 1 MO; *; +

LAMISIL PACK 125 MG,187.5 MG 3 PA; MO; +

LAMISIL TABS 250 MG(Use Terbinafine HCl) NF MO

nystatin tabs or 1 MO; *; +

terbinafine hcl tabs or 2 MO; *; +

Imidazole-Related AntifungalsCRESEMBA CAPS OR186 MG 5 MO

CRESEMBA SOLR IV 372MG 5

DIFLUCAN (UseFluconazole) NF MO

fluconazole in dextrose 2 *; +

fluconazole in nacl 1 *; +

fluconazole susr or 10mg/ml, 40 mg/ml 2 MO; *; +

fluconazole tabs or 100 mg,150 mg, 200 mg, 50 mg 1 MO; *; +

itraconazole caps or 1 MO; *; +

ketoconazole tabs or 2 MO; *; +

NOXAFIL SOLN IV 300MG/16.7ML 5

NOXAFIL SUSP OR 40MG/ML 5 MO

NOXAFIL TBEC OR 100MG 5 MO

ONMEL 4 MO; +

SPORANOX CAPS 100MG (Use Itraconazole) NF MO

SPORANOX PULSEPAK(Use Itraconazole) NF MO

SPORANOX SOLN 10MG/ML 5 MO

VFEND IV (UseVoriconazole) NF



26

Drug Name DrugTier

Requirements/Limits

VFEND TABS 200 MG, 50MG (Use Voriconazole) 5 MO

voriconazole solr iv 200 mg 2 *; +

voriconazole tabs or 200mg, 50 mg 5 MO

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Ethanolaminescarbinoxamine maleate 2 AL; MO; *; +

clemastine fumarate syrpor 0.67 mg/5ml 2 AL; *; +

clemastine fumarate tabsor 2.68 mg 2 AL; MO; *; +

diphenhydramine hcl soln ij50 mg/ml 1 AL; MO; *; +

Antihistamines - Non-Sedating

cetirizine hcl soln 1 mg/ml 1 RX/OTC; MO;*; +

cetirizine hcl syrp 1 mg/ml,5 mg/5ml 1 RX/OTC; MO;

*; +CLARINEX REDITABS 5MG (Use Desloratadine) NF MO

CLARINEX TABS 5 MG(Use Desloratadine) NF MO

desloratadine tabs 5 mg 2 MO; *; +

desloratadine tbdp 5 mg 2 MO; *; +

levocetirizinedihydrochloride 2 MO; *; +

XYZAL (Use LevocetirizineDihydrochloride) NF MO

Antihistamines - Phenothiazinespromethazine hcl soln ij 25mg/ml, 50 mg/ml 2 AL; MO; *; +

promethazine hcl soln or6.25 mg/5ml 2 AL; MO; *; +

promethazine hcl supp re12.5 mg, 25 mg, 50 mg 2 AL; MO; *; +

promethazine hcl syrp or6.25 mg/5ml 2 AL; MO; *; +

promethazine hcl tabs or12.5 mg, 25 mg, 50 mg 2 AL; MO; *; +

Drug Name DrugTier

Requirements/Limits

Antihistamines - Piperidinescyproheptadine hcl syrp or2 mg/5ml 2 AL; MO; *; +

cyproheptadine hcl tabs or4 mg 2 AL; MO; *; +

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterolAntihyperlipidemics - CombinationsLIPTRUZET 3 +

VYTORIN 10MG-10MG 3 QL(8 ea daily);MO; +



VYTORIN 80MG-10MG 3 PA; QL(1 eadaily); MO; +

Antihyperlipidemics - Misc.KYNAMRO 5 PA; LA

LOVAZA (Use Omega-3-acid Ethyl Esters) 4 MO; +

omega-3-acid ethyl esters 2 MO; *; +

VASCEPA 4 MO; +

Bile Acid Sequestrantscholestyramine light 1 MO; *; +

cholestyramine pack or 4gm 2 MO; *; +

cholestyramine powd or 4gm/dose 2

PowderCanister;MO; *;+

COLESTID (Use ColestipolHCl) NF MO

COLESTID FLAVOREDGRAN 5 GM (UseColestipol HCl)

NFMO

colestipol hcl gran 5 gm 1 MO; *; +

colestipol hcl pack 5 gm 2 MO; *; +

colestipol hcl tabs 1 gm 1 MO; *; +



27

Drug Name DrugTier

Requirements/Limits

WELCHOL 4 MO; +

Fibric Acid DerivativesANTARA 130 MG (UseFenofibrate Micronized) NF QL(1 ea daily);

MO

ANTARA 30 MG 4 QL(3 ea daily);MO; +

ANTARA 43 MG (UseFenofibrate Micronized) NF QL(3 ea daily);

MO

ANTARA 90 MG 4 QL(1 ea daily);MO; +

choline fenofibrate 2 MO; *; +

FENOFIBRATE CAPS 150MG, 50 MG 4 MO; +

fenofibrate micronized 130mg 2 QL(1 ea daily);

MO; *; +fenofibrate micronized 134mg, 200 mg, 67 mg 1 MO; *; +

fenofibrate micronized 43mg 2 QL(3 ea daily);

MO; *; +FENOFIBRATE TABS 120MG, 40 MG 4 MO; +

fenofibrate tabs 145 mg, 48mg 2 MO; *; +

fenofibrate tabs 160 mg, 54mg 1 MO; *; +

FENOGLIDE 4 MO; +

gemfibrozil tabs or 1 MO; *; +

LIPOFEN 4 MO; +

LOPID (Use Gemfibrozil) NF MO

TRICOR (Use Fenofibrate) NF MO

TRILIPIX (Use CholineFenofibrate) NF MO

HMG CoA Reductase InhibitorsADVICOR 4 MO; +

ALTOPREV 4 MO; +

atorvastatin calcium 6 MO; *; +

Drug Name DrugTier

Requirements/Limits

CRESTOR 4 ST; MO; +

fluvastatin sodium caps 20mg, 40 mg 6 MO; *; +

fluvastatin sodium tb24 80mg 2 MO; *; +

LESCOL (Use FluvastatinSodium) NF MO

LESCOL XL (UseFluvastatin Sodium) 4 MO; +

LIPITOR (Use AtorvastatinCalcium) NF MO

LIVALO 4 MO; +

lovastatin 6 MO; *; +

MEVACOR (UseLovastatin) NF MO

PRAVACHOL (UsePravastatin Sodium) NF MO

pravastatin sodium 6 MO; *; +

SIMCOR 20MG-1000MG,20MG-500MG, 20MG-750MG


SIMCOR 40MG-1000MG,40MG-500MG 4 QL(1 ea daily);

MO; +

simvastatin tabs or 10 mg 6 QL(8 ea daily);MO; *; +



simvastatin tabs or 5 mg 6 QL(16 eadaily); MO; *; +


ZOCOR 10 MG (UseSimvastatin) NF QL(8 ea daily);

MOZOCOR 20 MG (UseSimvastatin) NF QL(4 ea daily);

MOZOCOR 40 MG (UseSimvastatin) NF QL(2 ea daily);

MOZOCOR 5 MG (UseSimvastatin) NF QL(16 ea

daily); MO



28

Drug Name DrugTier

Requirements/Limits

ZOCOR 80 MG (UseSimvastatin) NF QL(1 ea daily);

MOIntestinal Cholesterol Absorption InhibitorsZETIA 3 MO; +

Microsomal Triglyceride Transfer Protein (MTP)

JUXTAPID 10 MG 5 PA; QL(6 eadaily); LA



JUXTAPID 40 MG, 60 MG 5 PA; QL(1 eadaily); LA


Nicotinic Acid Derivativesniacin (antihyperlipidemic)tabs 500 mg 1 MO; *; +

niacin (antihyperlipidemic)tbcr 1000 mg, 500 mg, 750mg

2MO; *; +

NIASPAN (Use Niacin(Antihyperlipidemic)) NF MO

Proprotein Convertase Subtilisin/Kexin Type 9PRALUENT SOPN 150MG/ML 5 PA; QL(0.08 ml

daily); MOPRALUENT SOPN 75MG/ML 5 PA; QL(0.15 ml

daily); MOPRALUENT SOSY 150MG/ML 5 PA; QL(0.08 ml

daily); MOPRALUENT SOSY 75MG/ML 5 PA; QL(0.15 ml

daily); MOANTIHYPERTENSIVES - Drugs to Treat HighBlood PressureACE InhibitorsACCUPRIL (Use QuinaprilHCl) NF MO

ACEON 4 MG (UsePerindopril Erbumine) NF QL(4 ea daily);

MOACEON 8 MG (UsePerindopril Erbumine) NF QL(2 ea daily);

MO

ALTACE (Use Ramipril) NF MO

Drug Name DrugTier

Requirements/Limits

benazepril hcl tabs or 10mg, 20 mg, 40 mg, 5 mg 6 MO; *; +

captopril tabs or 100 mg,12.5 mg, 25 mg, 50 mg 6 MO; *; +

enalapril maleate tabs or10 mg 6 QL(4 ea daily);

MO; *; +enalapril maleate tabs or2.5 mg 6 QL(16 ea

daily); MO; *; +enalapril maleate tabs or20 mg 6 QL(2 ea daily);

MO; *; +enalapril maleate tabs or 5mg 6 QL(8 ea daily);

MO; *; +

enalaprilat 6 *; +

fosinopril sodium 6 MO; *; +

lisinopril tabs or 10 mg, 2.5mg, 20 mg, 30 mg, 40 mg,5 mg

6MO; *; +

LOTENSIN (UseBenazepril HCl) NF MO

MAVIK (Use Trandolapril) NF MO

moexipril hcl 6 MO; *; +

perindopril erbumine 2 mg 6 QL(8 ea daily);MO; *; +



PRINIVIL (Use Lisinopril) NF MO

quinapril hcl 6 MO; *; +

ramipril 6 MO; *; +

trandolapril 6 MO; *; +

UNIVASC (Use MoexiprilHCl) NF MO

VASOTEC 10 MG (UseEnalapril Maleate) NF QL(4 ea daily);

MOVASOTEC 2.5 MG (UseEnalapril Maleate) NF QL(16 ea

daily); MOVASOTEC 20 MG (UseEnalapril Maleate) NF QL(2 ea daily);

MO



29

Drug Name DrugTier

Requirements/Limits

VASOTEC 5 MG (UseEnalapril Maleate) NF QL(8 ea daily);

MO

ZESTRIL (Use Lisinopril) NF MO

Agents for PheochromocytomaDEMSER 5 MO

DIBENZYLINE (UsePhenoxybenzamine HCl) 4 MO; +

phenoxybenzamine hclcaps or 2 MO; *; +

Angiotensin II Receptor AntagonistsATACAND (UseCandesartan Cilexetil) NF MO

AVAPRO (Use Irbesartan) NF MO

BENICAR 3 MO; +

candesartan cilexetil 6 MO; *; +

COZAAR (Use LosartanPotassium) NF MO

DIOVAN (Use Valsartan) 3 MO; +

EDARBI 4 MO; +

EPROSARTANMESYLATE 6 MO; *; +

irbesartan 6 MO; *; +

losartan potassium 6 MO; *; +

MICARDIS (UseTelmisartan) 4 MO; +

telmisartan 2 MO; *; +

valsartan 6 MO; *; +

Antiadrenergic AntihypertensivesCARDURA (UseDoxazosin Mesylate) NF MO

CATAPRES (Use ClonidineHCl) NF MO

CATAPRES-TTS-1 (UseClonidine HCl) NF MO


Drug Name DrugTier

Requirements/Limits


clonidine hcl ptwk td 0.1mg/24hr, 0.2 mg/24hr, 0.3mg/24hr

1MO; *; +

clonidine hcl tabs or 0.1mg, 0.2 mg, 0.3 mg 1 MO; *; +

doxazosin mesylate 1 MO; *; +

guanfacine hcl 2 AL; MO; *; +

methyldopa 2 AL; MO; *; +

MINIPRESS (Use PrazosinHCl) NF MO

prazosin hcl 1 MO; *; +

reserpine tabs or 0.1 mg,0.25 mg 2 MO; *; +

TENEX (Use GuanfacineHCl) NF AL; MO

terazosin hcl 1 MO; *; +

Antihypertensive CombinationsACCURETIC (UseQuinapril-Hydrochlorothiazide)

NFMO

amlodipine besylate-benazepril hcl 6 MO; *; +

amlodipine besylate-valsartan 2 MO; *; +

amlodipine-valsartan-hydrochlorothiazide 2 MO; *; +

AMTURNIDE 300MG-10MG-12.5MG, 300MG-10MG-25MG

3+

AMTURNIDE 300MG-5MG-12.5MG, 300MG-5MG-25MG

3MO; +

ATACAND HCT (UseCandesartan Cilexetil-Hydrochlorothiazide)

NFMO

atenolol & chlorthalidone 1 MO; *; +

AVALIDE (Use Irbesartan-Hydrochlorothiazide) NF MO



30

Drug Name DrugTier

Requirements/Limits

AZOR 3 MO; +

benazepril &hydrochlorothiazide 6 MO; *; +

BENICAR HCT 3 MO; +

bisoprolol &hydrochlorothiazide 1 MO; *; +

candesartan cilexetil-hydrochlorothiazide 6 MO; *; +

CAPTOPRIL/HYDROCHLOROTHIAZIDE 6 MO; *; +

clonidine & chlorthalidone 2 MO; *; +

CORZIDE (Use Nadolol &Bendroflumethiazide) NF MO

DIOVAN HCT (UseValsartan-Hydrochlorothiazide)

NFMO

EDARBYCLOR 4 MO; +

enalapril maleate &hydrochlorothiazide 6 MO; *; +

EXFORGE (UseAmlodipine Besylate-Valsartan)

3MO; +

EXFORGE HCT (UseAmlodipine-Valsartan-Hydrochlorothiazide)

3MO; +

fosinopril sodium &hydrochlorothiazide 6 MO; *; +

HYZAAR (Use LosartanPotassium &Hydrochlorothiazide)

NFMO

irbesartan-hydrochlorothiazide 6 MO; *; +

lisinopril &hydrochlorothiazide 6 MO; *; +

LOPRESSOR HCT (UseMetoprolol &Hydrochlorothiazide)

NFMO

losartan potassium &hydrochlorothiazide 6 MO; *; +

LOTENSIN HCT (UseBenazepril &Hydrochlorothiazide)

NFMO

Drug Name DrugTier

Requirements/Limits

LOTREL (Use AmlodipineBesylate-Benazepril HCl) NF MO

methyldopa &hydrochlorothiazide 2 AL; MO; *; +

metoprolol &hydrochlorothiazide100mg-25mg, 50mg-25mg

1MO; *; +

metoprolol &hydrochlorothiazide100mg-50mg

2MO; *; +

MICARDIS HCT (UseTelmisartan-Hydrochlorothiazide)

4MO; +

moexipril-hydrochlorothiazide 6 MO; *; +

nadolol &bendroflumethiazide 40mg-5mg

1MO; *; +

nadolol &bendroflumethiazide 80mg-5mg

2MO; *; +

propranolol &hydrochlorothiazide 1 MO; *; +

quinapril-hydrochlorothiazide 6 MO; *; +

TARKA 2MG-240MG,4MG-240MG (UseTrandolapril-VerapamilHCl)

NF

MO

TEKAMLO 150MG-10MG 3 MO; +

TEKAMLO 150MG-5MG 3 +

TEKTURNA HCT 3 MO; +

telmisartan-amlodipine 2 MO; *; +

telmisartan-hydrochlorothiazide 2 MO; *; +

TENORETIC 100 (UseAtenolol & Chlorthalidone) NF MO

TENORETIC 50 (UseAtenolol & Chlorthalidone) NF MO

trandolapril-verapamil hcl2mg-240mg, 4mg-240mg 1 MO; *; +

TRIBENZOR 3 MO; +



31

Drug Name DrugTier

Requirements/Limits

TWYNSTA (UseTelmisartan-Amlodipine) 4 MO; +

UNIRETIC (Use Moexipril-Hydrochlorothiazide) NF MO

valsartan-hydrochlorothiazide 6 MO; *; +

VASERETIC (Use EnalaprilMaleate &Hydrochlorothiazide)

NFMO

ZESTORETIC (UseLisinopril &Hydrochlorothiazide)

NFMO

ZIAC (Use Bisoprolol &Hydrochlorothiazide) NF MO

Antihypertensives - Misc.mecamylamine hcl 2 *; +

Direct Renin InhibitorsTEKTURNA 3 MO; +

Selective Aldosterone Receptor Antagonistseplerenone 25 mg 1 MO; *; +

eplerenone 50 mg 2 MO; *; +

INSPRA (Use Eplerenone) NF MO

Vasodilatorshydralazine hcl tabs or 10mg, 100 mg, 25 mg, 50 mg 1 MO; *; +

minoxidil tabs or 10 mg, 2.5mg 1 MO; *; +

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections)Antimalarial Combinationsatovaquone-proguanil hcl 2 MO; *; +

COARTEM 3 MO; +

MALARONE 250MG-100MG (Use Atovaquone-Proguanil HCl)

NFMO

MALARONE 62.5MG-25MG (Use Atovaquone-Proguanil HCl)

4MO; +

Drug Name DrugTier

Requirements/Limits

AntimalarialsARALEN (Use ChloroquinePhosphate) NF MO

chloroquine phosphate tabsor 250 mg, 500 mg 1 MO; *; +

DARAPRIM 4 MO; +

hydroxychloroquine sulfatetabs or 2 MO; *; +

mefloquine hcl 1 MO; *; +

PLAQUENIL (UseHydroxychloroquineSulfate)

NFMO

PRIMAQUINEPHOSPHATE 4 MO; +

primaquine phosphate 2 MO; *; +

QUALAQUIN (Use QuinineSulfate) NF PA; MO

quinine sulfate caps or 1 PA; MO; *; +

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic Agentsguanidine hcl 2 *; +

MESTINON TABS 60 MG(Use PyridostigmineBromide)

NFMO

MESTINON TIMESPAN(Use PyridostigmineBromide)

4MO; +

pyridostigmine bromidetabs or 60 mg 2 MO; *; +

pyridostigmine bromide tbcror 180 mg 2 MO; *; +

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections)Anti TB Combinationsisoniazid & rifampin 2 MO; *; +

RIFATER 4 MO; +

Antimycobacterial Agents



32

Drug Name DrugTier

Requirements/Limits

aminosalicylic acid pack or 2 MO; *; +

CAPASTAT SULFATE 4 +

cycloserine 2 MO; *; +

ethambutol hcl tabs or 100mg, 400 mg 1 MO; *; +

isoniazid soln ij 100 mg/ml 2 *; +

isoniazid syrp or 50 mg/5ml 2 MO; *; +

isoniazid tabs or 100 mg,300 mg 1 MO; *; +

MYAMBUTOL (UseEthambutol HCl) NF MO

MYCOBUTIN (UseRifabutin) 4 MO; +

PRIFTIN 4 MO; +

pyrazinamide 1 MO; *; +

rifabutin 2 MO; *; +

RIFADIN 300 MG,600 MG(Use Rifampin) NF MO

rifampin caps or 150 mg,300 mg 2 MO; *; +

rifampin solr iv 600 mg 2 MO; *; +

SIRTURO 5

TRECATOR 4 MO; +

ANTINEOPLASTICS AND ADJUNCTIVETHERAPIES - Drugs to Treat CancerAlkylating AgentsALKERAN SOLR IV 50 MG(Use Melphalan HCl) 4 +

ALKERAN TABS OR 2 MG 4 MO; B/D; +

BICNU 4 +

BUSULFEX 4 +

carboplatin 150 mg/15ml,600 mg/60ml 1 *; +

Drug Name DrugTier

Requirements/Limits

carboplatin 450 mg/45ml,50 mg/5ml 1 MO; *; +

cisplatin 2 *; +

cyclophosphamide solr ij 1gm, 500 mg 1 MO; *; +

cyclophosphamide tabs or25 mg, 50 mg 1 B/D; *; +

ELOXATIN 100 MG/20ML(Use Oxaliplatin) NF MO

ELOXATIN 50 MG/10ML(Use Oxaliplatin) 5 MO

GLEOSTINE 3 +

HEXALEN 5 MO

IFEX 1 GM (UseIfosfamide) 4 +

IFEX 3 GM 4 +

ifosfamide soln 1 gm/20ml,3 gm/60ml 2 *; +

ifosfamide solr 1 gm 2 *; +

IFOSFAMIDE SOLR 3 GM 4 +

LEUKERAN 4 MO; +

lomustine 2 *; +

melphalan hcl 2 *; +

MUSTARGEN 4 +

oxaliplatin soln 100mg/20ml 2 MO; *; +

oxaliplatin soln 50 mg/10ml 5 MO

oxaliplatin solr 100 mg, 50mg 5

TEMODAR SOLR IV 100MG 5

THIOTEPA SOLR IJ 5

TREANDA 5

YONDELIS 5



33

Drug Name DrugTier

Requirements/Limits

ZANOSAR 4 MO; +

AntimetabolitesALIMTA 100 MG 5

ALIMTA 500 MG 5 MO

ARRANON 5

azacitidine 5

cladribine 2 MO; *; +

CLOLAR 4 +

cytarabine soln 100 mg/ml 1 *; +

cytarabine soln 20 mg/ml 1 PreservativeFree;MO; *; +

cytarabine soln 20 mg/ml 2 MO; *; +

DACOGEN (UseDecitabine) NF

decitabine 2 *; +

FLUDARA (UseFludarabine Phosphate) 4 MO; +

fludarabine phosphate solr50 mg 2 MO; *; +

fluorouracil soln iv 1gm/20ml 2 *; +

fluorouracil soln iv 2.5gm/50ml, 5 gm/100ml, 500mg/10ml

2MO; *; +

FOLOTYN 5

GEMCITABINE 5

gemcitabine hcl 1 gm 1 MO; *; +

gemcitabine hcl 2 gm 5

gemcitabine hcl 200 mg 5 MO

GEMZAR 1 GM (UseGemcitabine HCl) NF MO

GEMZAR 200 MG (UseGemcitabine HCl) 5 MO

Drug Name DrugTier

Requirements/Limits

mercaptopurine tabs or 2 MO; *; +

methotrexate sodium soln ij1 gm/40ml, 100 mg/4ml,200 mg/8ml, 25 mg/ml, 250mg/10ml, 50 mg/2ml

1

*; +

methotrexate sodium soln ij25 mg/ml 2 *; +

methotrexate sodium solr ij1 gm 2 *; +

methotrexate sodium tabsor 10 mg, 15 mg, 2.5 mg 1 MO; *; +

methotrexate sodium tabsor 5 mg, 7.5 mg 2 MO; *; +

PURINETHOL (UseMercaptopurine) NF MO

PURIXAN 5

TABLOID 3 MO; +

VIDAZA (Use Azacitidine) 5

Antineoplastic - Angiogenesis InhibitorsAVASTIN 5

CYRAMZA 5 LA

ZALTRAP 5

Antineoplastic - AntibodiesARZERRA 5

BLINCYTO 5 PA

ERBITUX 5

GAZYVA 5 LA

HERCEPTIN 5

KADCYLA 5

KEYTRUDA 5

OPDIVO 5

PERJETA 5



34

Drug Name DrugTier

Requirements/Limits

RITUXAN 5

VECTIBIX 5

YERVOY 5

Antineoplastic - Hedgehog Pathway InhibitorsERIVEDGE 5 LA

ODOMZO 5 PA

Antineoplastic - Hormonal and Related Agentsanastrozole tabs or 2 MO; *; +

ARIMIDEX (UseAnastrozole) NF MO

AROMASIN (UseExemestane) NF MO

bicalutamide 2 MO; *; +

CASODEX (UseBicalutamide) NF MO

DEPO-PROVERA 4 MO; +

ELIGARD 4 +

EMCYT 4 MO; +

exemestane 2 MO; *; +

FARESTON 5 MO

FASLODEX 5 MO

FEMARA (Use Letrozole) NF MO

FIRMAGON 120 MG 5

FIRMAGON 80 MG 4 +

flutamide 1 MO; *; +

letrozole 2 MO; *; +

leuprolide acetate kit ij 1 *; +

LUPRON DEPOT 5

Drug Name DrugTier

Requirements/Limits

LYSODREN 3 MO; +

MEGACE ORAL (UseMegestrol Acetate) NF AL; MO

megestrol acetate susp or40 mg/ml, 400 mg/10ml 2 AL; MO; *; +

megestrol acetate tabs or20 mg, 40 mg 2 AL; MO; *; +

NILANDRON 5 MO

SOLTAMOX 4 MO; +

tamoxifen citrate tabs or 10mg, 20 mg 2 MO; *; +

TRELSTAR 5

TRELSTAR MIXJECT 5

VANTAS 5

XTANDI 5 PA; LA

ZOLADEX 4 +

ZYTIGA 5

Antineoplastic - ImmunomodulatorsPOMALYST 5 LA

Antineoplastic Antibioticsbleomycin sulfate 15 unit 2 MO; *; +

bleomycin sulfate 30 unit 2 *; +

COSMEGEN 4 MO; +

daunorubicin hcl 2 *; +

DAUNOXOME 4 +

DOXIL (Use DoxorubicinHCl Liposomal) NF

doxorubicin hcl liposomal 2 *; +

doxorubicin hcl soln 2mg/ml 1 MO; *; +

doxorubicin hcl solr 10 mg 1 *; +



35

Drug Name DrugTier

Requirements/Limits

doxorubicin hcl solr 50 mg 1 MO; *; +

ELLENCE (Use EpirubicinHCl) 4 MO; +

epirubicin hcl soln 200mg/100ml, 50 mg/25ml 2 MO; *; +

IDAMYCIN PFS (UseIdarubicin HCl) 4 +

idarubicin hcl 2 *; +

mitomycin solr iv 20 mg, 40mg, 5 mg 2 MO; *; +

mitoxantrone hcl 2 *; +

VALSTAR 5

Antineoplastic Enzyme InhibitorsAFINITOR 5

AFINITOR DISPERZ 5

BELEODAQ 5

BOSULIF 5 PA

CAPRELSA 5 LA

COMETRIQ 5

COMETRIQ 5 140 MG DoseKit;MO

FARYDAK 5 PA; LA

GILOTRIF 5 LA

GLEEVEC 5

IBRANCE 5 LA

ICLUSIG 5 LA

IMBRUVICA 5 PA

INLYTA 5 PA; LA

IRESSA 5 LA

ISTODAX 5

Drug Name DrugTier

Requirements/Limits

JAKAFI 5 LA

LENVIMA 10MG DAILYDOSE 5 PA




LYNPARZA 5 PA; LA

MEKINIST 5

NEXAVAR 5 LA

SPRYCEL 5

STIVARGA 5 PA; LA

SUTENT 5

TAFINLAR 5

TARCEVA 5

TASIGNA 5

TORISEL 5

TYKERB 5

VELCADE 5

VOTRIENT 5

XALKORI 5

ZELBORAF 5 LA

ZOLINZA 5

ZYDELIG 5 PA

ZYKADIA 5 PA; LA

Antineoplastic EnzymesERWINAZE 5



36

Drug Name DrugTier

Requirements/Limits

ONCASPAR 5

Antineoplastics Misc.ACTIMMUNE 5 LA

bexarotene 5

dacarbazine 100 mg 2 *; +

dacarbazine 200 mg 2 MO; *; +

HYDREA (UseHydroxyurea) NF MO

hydroxyurea caps or 2 MO; *; +

INTRON A SOLN 10MU/ML 5

INTRON A SOLN 6000000UNIT/ML 4 +

INTRON A SOLR 10 MU,18 MU, 50 MU 5

INTRON A W/DILUENT 5

MATULANE 5 LA

NIPENT 4 +

PROLEUKIN 5

SYLATRON 5

SYNRIBO 5

TARGRETIN 1 %,75 MG 5

TARGRETIN 75 MG (UseBexarotene) 5

THERACYS 5 MO

TICE BCG 5 MO

tretinoin (chemotherapy) 5 MO

TRISENOX 4 MO; +

UVADEX 4 +

Chemotherapy Adjuncts

Drug Name DrugTier

Requirements/Limits

ELITEK 5

KEPIVANCE 5 MO

Chemotherapy Rescue/Antidote Agentsamifostine crystalline 2 MO; *; +

dexrazoxane 2 *; +

ETHYOL (Use AmifostineCrystalline) 4 MO; +

FUSILEV 4 +

leucovorin calcium solr ij100 mg, 200 mg, 350 mg 2 MO; *; +

leucovorin calcium solr ij 50mg, 500 mg 2 *; +

leucovorin calcium tabs or10 mg, 15 mg, 25 mg, 5 mg 2 MO; *; +

LEVOLEUCOVORIN 5

levoleucovorin calcium 5

mesna 2 MO; *; +

MESNEX SOLN IV 100MG/ML (Use Mesna) 4 MO; +

MESNEX TABS OR 400MG 5 MO

TOTECT 4 +

ZINECARD (UseDexrazoxane) 4 +

Mitotic InhibitorsABRAXANE 5 MO

DOCEFREZ 5

DOCETAXEL CONC 140MG/7ML, 20 MG/0.5ML, 20MG/ML, 80 MG/2ML, 80MG/4ML

5

docetaxel conc 20 mg/ml,80 mg/4ml 5

DOCETAXEL SOLN 160MG/16ML, 20 MG/2ML,200 MG/20ML, 80 MG/8ML

5



37

Drug Name DrugTier

Requirements/Limits

ETOPOPHOS 4 MO; +

etoposide soln iv 1gm/50ml, 100 mg/5ml 2 MO; *; +

etoposide soln iv 500mg/25ml 2 *; +

HALAVEN 5

IXEMPRA KIT 5

JEVTANA 5

NAVELBINE (UseVinorelbine Tartrate) NF MO

paclitaxel 100 mg/16.7ml,30 mg/5ml, 300 mg/50ml 2 MO; *; +

paclitaxel 150 mg/25ml 2 *; +

TAXOL (Use Paclitaxel) 4 MO; +

TAXOTERE (UseDocetaxel) 5

vinblastine sulfate soln 1mg/ml 2 MO; *; +

vinblastine sulfate solr 10mg 2 *; +

vincristine sulfate 1 MO; *; +

vinorelbine tartrate 2 MO; *; +

Topoisomerase I InhibitorsCAMPTOSAR 100MG/5ML, 40 MG/2ML (UseIrinotecan HCl)

4MO; +

CAMPTOSAR 300MG/15ML 4 +

HYCAMTIN SOLR IV 4 MG(Use Topotecan HCl) 4 MO; +

irinotecan hcl 100 mg/5ml,40 mg/2ml 2 MO; *; +

irinotecan hcl 500 mg/25ml 2 *; +

topotecan hcl solr 4 mg 2 MO; *; +

ANTIPARKINSON AGENTS - Drugs to TreatParkinson's DiseaseAntiparkinson Adjuvants

Drug Name DrugTier

Requirements/Limits

carbidopa tabs or 2 MO; *; +

LODOSYN (UseCarbidopa) 4 MO; +

Antiparkinson Anticholinergicsbenztropine mesylate solnij 1 mg/ml 2 MO; *; +

benztropine mesylate tabsor 0.5 mg, 1 mg, 2 mg 2 AL; MO; *; +

COGENTIN (UseBenztropine Mesylate) 4 MO; +

trihexyphenidyl hcl 2 AL; MO; *; +

Antiparkinson COMT InhibitorsCOMTAN (UseEntacapone) NF QL(8 ea daily);

MO

entacapone 2 QL(8 ea daily);MO; *; +

TASMAR (Use Tolcapone) 4 MO; +

tolcapone 2 MO; *; +

Antiparkinson Dopaminergicsamantadine hcl caps or 100mg 2 MO; *; +

amantadine hcl syrp or 50mg/5ml 2 MO; *; +

amantadine hcl tabs or 100mg 2 MO; *; +

APOKYN 5 LA

bromocriptine mesylatecaps or 5 mg 1 MO; *; +

bromocriptine mesylatetabs or 2.5 mg 1 MO; *; +

carbidopa-levodopa 2 MO; *; +

carbidopa-levodopa-entacapone 2 MO; *; +

DUOPA 5 B/D

MIRAPEX (UsePramipexoleDihydrochloride)

NFMO



38

Drug Name DrugTier

Requirements/Limits

MIRAPEX ER 0.375MG,0.75 MG,1.5 MG,3MG,4.5 MG (UsePramipexoleDihydrochloride)

4

MO; +

MIRAPEX ER 2.25MG,3.75 MG 4 MO; +

NEUPRO 4 MO; +

PARLODEL (UseBromocriptine Mesylate) NF MO

pramipexoledihydrochloride 2 MO; *; +

REQUIP (Use RopiniroleHydrochloride) NF MO

REQUIP XL (UseRopinirole Hydrochloride) NF MO

ropinirole hydrochloride 2 MO; *; +

RYTARY 4 MO; +

SINEMET (Use Carbidopa-Levodopa) NF MO

SINEMET CR (UseCarbidopa-Levodopa) NF MO

STALEVO 100 (UseCarbidopa-Levodopa-Entacapone)

NFMO


NFMO


NFMO


NFMO


NFMO


NFMO

Antiparkinson Monoamine Oxidase InhibitorsAZILECT 3 MO; +

Drug Name DrugTier

Requirements/Limits

ELDEPRYL (Use SelegilineHCl) 4 MO; +

selegiline hcl caps or 2 MO; *; +

selegiline hcl tabs or 2 MO; *; +

ZELAPAR 4 MO; +

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood DisordersAntimanic Agentslithium 1 MO; *; +

lithium carbonate caps or150 mg, 300 mg, 600 mg 2 MO; *; +

lithium carbonate tabs or300 mg 2 MO; *; +

lithium carbonate tbcr or300 mg, 450 mg 2 MO; *; +

LITHOBID (Use LithiumCarbonate) NF MO

Antipsychotics - Misc.EQUETRO 4 MO; +

GEODON CAPS OR 20MG, 40 MG, 60 MG, 80 MG(Use Ziprasidone HCl)

NFMO

GEODON SOLR IM 20 MG 4 MO; +

LATUDA 120 MG 5 QL(1 ea daily);MO



LATUDA 60 MG 4 QL(2.67 eadaily); MO; +


ziprasidone hcl 2 MO; *; +

BenzisoxazolesFANAPT 1 MG, 10 MG, 12MG, 2 MG, 4 MG 4 MO; +

FANAPT 6 MG, 8 MG 5 MO



39

Drug Name DrugTier

Requirements/Limits

FANAPT TITRATIONPACK 4 +

INVEGA 1.5 MG (UsePaliperidone) 5 QL(8 ea daily);

MOINVEGA 3 MG (UsePaliperidone) 5 QL(4 ea daily);



MOINVEGA SUSTENNA 117MG/0.75ML, 156 MG/ML,234 MG/1.5ML

5MO

INVEGA SUSTENNA 39MG/0.25ML, 78 MG/0.5ML 4 MO; +

INVEGA TRINZA 5

paliperidone 1.5 mg 2 QL(8 ea daily);MO; *; +

paliperidone 3 mg 2 QL(4 ea daily);MO; *; +

paliperidone 6 mg 2 QL(2 ea daily);MO; *; +

paliperidone 9 mg 5 QL(1 ea daily);MO

RISPERDAL (UseRisperidone) NF MO

RISPERDAL CONSTA12.5 MG 4 QL(0.29 ea

daily); MO; +RISPERDAL CONSTA 25MG 4 QL(0.15 ea

daily); MO; +RISPERDAL CONSTA37.5 MG, 50 MG 5 QL(0.08 ea

daily); MORISPERDAL M-TAB (UseRisperidone) NF MO

risperidone 2 MO; *; +

ButyrophenonesHALDOL (Use HaloperidolLactate) NF MO

HALDOL DECANOATE100 (Use HaloperidolDecanoate)

NFMO

HALDOL DECANOATE 50(Use HaloperidolDecanoate)

NFMO

Drug Name DrugTier

Requirements/Limits

haloperidol 2 MO; *; +

haloperidol decanoate 2 MO; *; +

haloperidol lactate 1 MO; *; +

DibenzapinesADASUVE 4 +

clozapine 2 *; +

CLOZAPINE ODT 4 +

CLOZARIL (UseClozapine) NF

FAZACLO 100 MG,25 MG(Use Clozapine) 4 +

FAZACLO 12.5 MG,150MG,200 MG 4 +

loxapine succinate 10 mg,25 mg, 5 mg, 50 mg 2 MO; *; +

olanzapine 2 MO; *; +

quetiapine fumarate 2 MO; *; +

SAPHRIS 10 MG 4 QL(2 ea daily);MO; +

SAPHRIS 2.5 MG 4 QL(8 ea daily);MO; +

SAPHRIS 5 MG 4 QL(4 ea daily);MO; +

SEROQUEL 100 MG, 200MG, 25 MG, 50 MG (UseQuetiapine Fumarate)

NFMO

SEROQUEL 300 MG, 400MG (Use QuetiapineFumarate)

5MO

SEROQUEL XR 150 MG,200 MG, 300 MG, 50 MG 4 PA; MO; +

SEROQUEL XR 400 MG 5 PA; MO

VERSACLOZ 5 PA; QL(18 mldaily)

ZYPREXA SOLR IM 10MG (Use Olanzapine) NF MO



40

Drug Name DrugTier

Requirements/Limits

ZYPREXA TABS OR 10MG, 2.5 MG, 5 MG, 7.5 MG(Use Olanzapine)

NFMO

ZYPREXA TABS OR 15MG, 20 MG (UseOlanzapine)

5MO

ZYPREXA ZYDIS (UseOlanzapine) NF MO

Phenothiazineschlorpromazine hcl soln ij25 mg/ml 2 MO; *; +

chlorpromazine hcl soln ij50 mg/2ml 2 *; +

chlorpromazine hcl tabs or10 mg, 100 mg, 200 mg, 25mg, 50 mg

2MO; *; +

fluphenazine decanoatesoln ij 2 MO; *; +

fluphenazine hcl 2 MO; *; +

perphenazine tabs or 16mg, 2 mg, 4 mg, 8 mg 2 MO; *; +

prochlorperazine 2 MO; *; +

prochlorperazine edisylatesoln ij 2 MO; *; +

prochlorperazine maleatetabs or 10 mg, 5 mg 2 MO; *; +

thioridazine hcl tabs or 10mg, 100 mg, 25 mg, 50 mg 2 AL; MO; *; +

trifluoperazine hcl 1 MO; *; +

Quinolinone DerivativesABILIFY DISCMELT 10MG 5 QL(3 ea daily)

ABILIFY DISCMELT 15MG 5 QL(2 ea daily)

ABILIFY MAINTENA 5 MO

ABILIFY SOLN IM 9.75MG/1.3ML 4 QL(4 ml daily);

MO; +ABILIFY SOLN OR 1MG/ML 5 QL(30 ml

daily); MOABILIFY TABS OR 10 MG(Use Aripiprazole) 5 QL(3 ea daily);

MO

Drug Name DrugTier

Requirements/Limits

ABILIFY TABS OR 15 MG(Use Aripiprazole) 5 QL(2 ea daily);

MOABILIFY TABS OR 2 MG(Use Aripiprazole) 5 QL(15 ea

daily); MOABILIFY TABS OR 20 MG,30 MG (Use Aripiprazole) 5 QL(1 ea daily);

MOABILIFY TABS OR 5 MG(Use Aripiprazole) 5 QL(6 ea daily);

MOARIPIPRAZOLE ODT 10MG 5 QL(3 ea daily)

ARIPIPRAZOLE ODT 15MG 5 QL(2 ea daily)

aripiprazole soln 1 mg/ml 2 QL(30 mldaily); MO; *; +

aripiprazole tabs 10 mg 2 QL(3 ea daily);MO; *; +


aripiprazole tabs 2 mg 2 QL(15 eadaily); MO; *; +

aripiprazole tabs 20 mg, 30mg 5 QL(1 ea daily);

MO


REXULTI 0.25 MG 5 PA; QL(16 eadaily); MO

REXULTI 0.5 MG 5 PA; QL(8 eadaily); MO

REXULTI 1 MG 5 PA; QL(4 eadaily); MO

REXULTI 2 MG 5 PA; QL(2 eadaily); MO

REXULTI 3 MG, 4 MG 5 PA; QL(1 eadaily); MO

Thioxanthenesthiothixene 2 MO; *; +

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretroviralsabacavir sulfate 1 MO; *; +

abacavir sulfate-lamivudine-zidovudine 5 MO

APTIVUS CAPS 250 MG 5 MO



41

Drug Name DrugTier

Requirements/Limits

APTIVUS SOLN 100MG/ML 3 +

ATRIPLA 5 MO

COMBIVIR (UseLamivudine-Zidovudine) 5 MO

COMPLERA 5 MO

CRIXIVAN 4 MO; +

didanosine 125 mg 2 MO; *; +

didanosine 200 mg, 250mg, 400 mg 1 MO; *; +

EDURANT 5 MO

EMTRIVA 4 MO; +

EPIVIR SOLN 10 MG/ML(Use Lamivudine) 3 MO; +

EPIVIR TABS 150 MG, 300MG (Use Lamivudine) NF MO

EPZICOM 5 MO

EVOTAZ 5 MO

FUZEON 5

INTELENCE 100 MG, 200MG 5 MO

INTELENCE 25 MG 4 +

INVIRASE 5 MO

ISENTRESS CHEW 100MG 4 QL(6 ea daily);

MO; +

ISENTRESS CHEW 25 MG 3 QL(24 eadaily); MO; +

ISENTRESS PACK 100MG 4 QL(2 ea daily);

+ISENTRESS TABS 400MG 5 MO

KALETRA SOLN400MG/5ML-100MG/5ML 5 MO

KALETRA TABS 100MG-25MG 4 MO; +

KALETRA TABS 200MG-50MG 5 MO

Drug Name DrugTier

Requirements/Limits

lamivudine 2 MO; *; +

lamivudine-zidovudine 5 MO

LEXIVA SUSP 50 MG/ML 3 MO; +

LEXIVA TABS 700 MG 5 MO

NEVIRAPINE SUSP 50MG/5ML 4 MO; +

nevirapine tabs 200 mg 2 MO; *; +

nevirapine tb24 100 mg 2 *; +

nevirapine tb24 400 mg 2 MO; *; +

NORVIR 4 MO; +

PREZCOBIX 5 MO

PREZISTA SUSP 100MG/ML 5 MO

PREZISTA TABS 150 MG 4 MO; +

PREZISTA TABS 400 MG 5

PREZISTA TABS 600 MG,800 MG 5 MO

PREZISTA TABS 75 MG 4 +

RESCRIPTOR 100 MG 3 MO; +

RESCRIPTOR 200 MG 4 MO; +

RETROVIR (UseZidovudine) NF MO

RETROVIR IV INFUSION 4 +

REYATAZ CAPS 150 MG,200 MG, 300 MG 5 MO

REYATAZ PACK 50 MG 5

SELZENTRY 5 MO

stavudine caps 15 mg 2 MO; *; +

stavudine caps 20 mg, 30mg, 40 mg 1 MO; *; +



42

Drug Name DrugTier

Requirements/Limits

stavudine solr 1 mg/ml 2 MO; *; +

STRIBILD 5 MO

SUSTIVA CAPS 200 MG,50 MG 4 MO; +

SUSTIVA TABS 600 MG 5 MO

TIVICAY 5 MO

TRIUMEQ 5 MO

TRIZIVIR (Use AbacavirSulfate-Lamivudine-Zidovudine)

5MO

TRUVADA 5 MO

TYBOST 4 MO; +

VIDEX EC (UseDidanosine) NF MO

VIDEXPEDIATRIC 4 MO; +

VIRACEPT 5 MO

VIRAMUNE SUSP 50MG/5ML 4 MO; +

VIRAMUNE TABS 200 MG(Use Nevirapine) NF MO

VIRAMUNE XR 100 MG 4 +

VIRAMUNE XR 400 MG(Use Nevirapine) 5 MO

VIREAD POWD 40 MG/GM 5 MO

VIREAD TABS 150 MG,200 MG, 300 MG 5 MO

VIREAD TABS 250 MG 5

VITEKTA 5

ZERIT (Use Stavudine) NF MO

ZIAGEN SOLN 20 MG/ML 3 MO; +

ZIAGEN TABS 300 MG(Use Abacavir Sulfate) NF MO

Drug Name DrugTier

Requirements/Limits

zidovudine caps 100 mg 1 MO; *; +

zidovudine syrp 50 mg/5ml 2 MO; *; +

zidovudine tabs 300 mg 1 MO; *; +

CMV Agentscidofovir 5

CYTOVENE (UseGanciclovir Sodium) NF MO

ganciclovir sodium 2 MO; *; +

VALCYTE 450 MG (UseValganciclovir HCl) 5 MO

VALCYTE 50 MG/ML 5 MO

valganciclovir hcl 5 MO

VISTIDE (Use Cidofovir) 5

Hepatitis Agentsadefovir dipivoxil 5 MO

BARACLUDE SOLN 0.05MG/ML 4 MO; +

BARACLUDE TABS 0.5MG, 1 MG (Use Entecavir) 5 MO

COPEGUS (Use Ribavirin(Hepatitis C)) NF

entecavir 5 MO

EPIVIR HBV 100 MG (UseLamivudine (HBV)) 3 MO; +

EPIVIR HBV 5 MG/ML 3 MO; +

HARVONI 5 PA

HEPSERA (Use AdefovirDipivoxil) 5 MO

INCIVEK 5 PA

lamivudine (hbv) 2 MO; *; +

OLYSIO 5 PA

PEG-INTRON 5



43

Drug Name DrugTier

Requirements/Limits

PEG-INTRON REDIPEN 5

PEG-INTRON REDIPENPAK 4 5

PEGASYS 5

PEGASYS PROCLICK 5

PEGINTRON 5

REBETOL CAPS 200 MG(Use Ribavirin (HepatitisC))

NF

REBETOL SOLN 40MG/ML 3 +

ribavirin (hepatitis c) caps200 mg 1 *; +

ribavirin (hepatitis c) misc 2 *; +

ribavirin (hepatitis c) tabs200 mg 1 *; +

ribavirin (hepatitis c) tabs400 mg, 600 mg 2 *; +

SOVALDI 5 PA

TYZEKA 5 MO

VICTRELIS 5 PA

VIEKIRA PAK 5 PA

Herpes Agentsacyclovir caps or 200 mg 2 MO; *; +

acyclovir sodium soln 50mg/ml 2 *; +

acyclovir sodium solr 500mg 2 MO; *; +

acyclovir susp or 200mg/5ml 2 MO; *; +

acyclovir tabs or 400 mg,800 mg 2 MO; *; +

famciclovir 2 MO; *; +

FAMVIR (Use Famciclovir) NF MO

Drug Name DrugTier

Requirements/Limits

valacyclovir hcl tabs or 1gm, 1000 mg, 500 mg 2 MO; *; +

VALTREX (UseValacyclovir HCl) NF MO

ZOVIRAX CAPS OR 200MG (Use Acyclovir) NF MO

ZOVIRAX SUSP OR 200MG/5ML (Use Acyclovir) NF MO

ZOVIRAX TABS OR 400MG, 800 MG (UseAcyclovir)

NFMO

Influenza AgentsFLUMADINE (UseRimantadineHydrochloride)

NFMO

RELENZA DISKHALER 4 MO; +

rimantadine hydrochloride 1 MO; *; +

TAMIFLU 4 MO; +

Respiratory Syncytial Virus (RSV) AgentsVIRAZOLE 4 +

ASSORTED CLASSES - Miscellaneous Drugs

Chelating AgentsDEPEN TITRATABS 3 MO; +

SYPRINE 5 MO

EnzymesXIAFLEX 5

ImmunomodulatorsREVLIMID 5 LA

THALOMID 5

Immunosuppressive AgentsASTAGRAF XL 4 MO; B/D; +

ATGAM 4 B/D; +

azathioprine tabs or 100mg, 50 mg, 75 mg 2 MO; B/D; *; +



44

Drug Name DrugTier

Requirements/Limits

CELLCEPT (UseMycophenolate Mofetil) 5 MO; B/D

CELLCEPTINTRAVENOUS 4 B/D; +

cyclosporine caps or 100mg, 25 mg 1 MO; B/D; *; +

cyclosporine modified (formicroemulsion) caps 100mg, 25 mg, 50 mg

2MO; B/D; *; +

cyclosporine soln iv 50mg/ml 2 B/D; *; +

IMURAN (UseAzathioprine) 4 MO; B/D; +

mycophenolate mofetilcaps 250 mg 2 MO; B/D; *; +

mycophenolate mofetil susr200 mg/ml 5 MO; B/D

mycophenolate mofetil tabs500 mg 2 MO; B/D; *; +

mycophenolate sodium 180mg 2 MO; B/D; *; +

mycophenolate sodium 360mg 5 MO; B/D

MYFORTIC 180 MG (UseMycophenolate Sodium) 4 MO; B/D; +

MYFORTIC 360 MG (UseMycophenolate Sodium) 5 MO; B/D

NEORAL CAPS 100 MG,25 MG (Use CyclosporineModified (ForMicroemulsion))

4

MO; B/D; +

NULOJIX 5 B/D

PROGRAF CAPS OR 0.5MG, 1 MG, 5 MG (UseTacrolimus)

4MO; B/D; +

PROGRAF SOLN IV 5MG/ML 4 B/D; +

RAPAMUNE SOLN 1MG/ML 3 MO; B/D; +

RAPAMUNE TABS 0.5 MG(Use Sirolimus) 3 MO; B/D; +

RAPAMUNE TABS 1 MG,2 MG (Use Sirolimus) 5 MO; B/D

Drug Name DrugTier

Requirements/Limits

SANDIMMUNE CAPS OR100 MG, 25 MG (UseCyclosporine)

4MO; B/D; +

SANDIMMUNE SOLN IV50 MG/ML (UseCyclosporine)

4B/D; +

SANDIMMUNE SOLN OR100 MG/ML 4 MO; B/D; +

SIMULECT 5 B/D

sirolimus 0.5 mg, 1 mg 2 MO; B/D; *; +

sirolimus 2 mg 5 MO; B/D

tacrolimus caps or 0.5 mg,1 mg, 5 mg 2 MO; B/D; *; +

THYMOGLOBULIN 3 B/D; +

ZORTRESS 0.25 MG 3 MO; B/D; +

ZORTRESS 0.5 MG, 0.75MG 5 MO; B/D

Irrigation Solutionsirrigation solutions,physiological 2 *; +

water for irrigation, sterile 1 MO; *; +

Potassium Removing ResinsKAYEXALATE (UseSodium PolystyreneSulfonate)

NFMO

sodium polystyrenesulfonate powd or 2 MO; *; +

sodium polystyrenesulfonate susp or 15gm/60ml

2MO; *; +

Systemic Lupus Erythematosus AgentsBENLYSTA 5

BETA BLOCKERS - Drugs to Treat High BloodPressureAlpha-Beta Blockers

carvedilol 12.5 mg 1 QL(8 ea daily);MO; *; +

carvedilol 25 mg 1 QL(4 ea daily);MO; *; +



45

Drug Name DrugTier

Requirements/Limits

carvedilol 3.125 mg 1 QL(32 eadaily); MO; *; +

carvedilol 6.25 mg 1 QL(16 eadaily); MO; *; +

COREG 12.5 MG (UseCarvedilol) NF QL(8 ea daily);

MOCOREG 25 MG (UseCarvedilol) NF QL(4 ea daily);

MOCOREG 3.125 MG (UseCarvedilol) NF QL(32 ea

daily); MOCOREG 6.25 MG (UseCarvedilol) NF QL(16 ea

daily); MO

COREG CR 4 MO; +

labetalol hcl tabs or 100mg, 200 mg, 300 mg 1 MO; *; +

TRANDATE (Use LabetalolHCl) NF MO

Beta Blockers Cardio-Selectiveacebutolol hcl caps or 200mg, 400 mg 1 MO; *; +

atenolol tabs or 100 mg, 25mg, 50 mg 1 MO; *; +

betaxolol hcl 10 mg 1 MO; *; +

betaxolol hcl 20 mg 2 MO; *; +

bisoprolol fumarate 1 MO; *; +

BYSTOLIC 4 MO; +

KERLONE (Use BetaxololHCl) NF MO

LOPRESSOR TABS OR100 MG, 50 MG (UseMetoprolol Tartrate)

NFMO

metoprolol succinate 1 MO; *; +

metoprolol tartrate tabs or100 mg, 25 mg, 50 mg 1 MO; *; +

SECTRAL (Use AcebutololHCl) NF MO

TENORMIN (Use Atenolol) NF MO

TOPROL XL (UseMetoprolol Succinate) NF MO

Drug Name DrugTier

Requirements/Limits

ZEBETA (Use BisoprololFumarate) NF MO

Beta Blockers Non-SelectiveBETAPACE (Use SotalolHCl) NF tabs;MO

BETAPACE AF (UseSotalol HCl (AFIB/AFL)) NF MO

CORGARD (Use Nadolol) NF MO

INDERAL LA (UsePropranolol HCl) NF MO

INDERAL XL 4 MO; +

INNOPRAN XL 4 MO; +

LEVATOL 4 MO; +

nadolol tabs or 20 mg, 40mg, 80 mg 1 MO; *; +

pindolol 1 MO; *; +

propranolol hcl cp24 or 120mg, 160 mg, 60 mg, 80 mg 1 MO; *; +

propranolol hcl soln or 20mg/5ml 1 MO; *; +

propranolol hcl soln or 40mg/5ml 2 MO; *; +

propranolol hcl tabs or 10mg, 20 mg, 40 mg, 60 mg,80 mg

1MO; *; +

sotalol hcl 1 tabs;MO; *; +

sotalol hcl (afib/afl) 2 MO; *; +

Sotalol Hcl IV Soln NF

SOTYLIZE 4 +

timolol maleate tabs or 10mg 1 QL(6 ea daily);

MO; *; +timolol maleate tabs or 20mg 1 QL(3 ea daily);

MO; *; +timolol maleate tabs or 5mg 1 QL(12 ea

daily); MO; *; +BIOLOGICALS MISC - Drugs to Treat LowEnzymes



46

Drug Name DrugTier

Requirements/Limits

Allergenic ExtractsGRASTEK 4 PA; MO; +

RAGWITEK 4 PA; MO; +

Biologicals MiscADAGEN 5 LA

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood PressureCalcium Channel BlockersADALAT CC (UseNifedipine) NF MO

amlodipine besylate tabs or10 mg 1 QL(1 ea daily);

MO; *; +amlodipine besylate tabs or2.5 mg 1 QL(4 ea daily);

MO; *; +amlodipine besylate tabs or5 mg 1 QL(2 ea daily);

MO; *; +CALAN (Use VerapamilHCl) NF MO

CALAN SR (Use VerapamilHCl) NF MO

CARDIZEM (Use DiltiazemHCl) NF MO

CARDIZEM CD (UseDiltiazem HCl CoatedBeads)

NFMO

CARDIZEM LA 120 MG 4 MO; +

CARDIZEM LA 180 MG,240 MG, 300 MG, 360 MG,420 MG (Use DiltiazemHCl Coated Beads)

NF

MO

diltiazem hcl coated beads 1 MO; *; +

diltiazem hcl cp12 or 120mg, 60 mg, 90 mg 1 MO; *; +

diltiazem hcl cp24 or 120mg, 180 mg, 240 mg 1 MO; *; +

diltiazem hcl extendedrelease beads 1 MO; *; +

diltiazem hcl solr iv 100 mg 2 *; +

diltiazem hcl tabs or 120mg, 30 mg, 60 mg, 90 mg 1 MO; *; +

Drug Name DrugTier

Requirements/Limits

felodipine 1 MO; *; +

nicardipine hcl caps or 20mg, 30 mg 1 MO; *; +

nifedipine caps or 10 mg,20 mg 2 AL; MO; *; +

nifedipine tb24 or 30 mg,60 mg, 90 mg 1 MO; *; +

nimodipine caps or 2 MO; *; +

nisoldipine 17 mg, 25.5 mg,34 mg, 8.5 mg 1 MO; *; +

nisoldipine 20 mg, 30 mg,40 mg 2 MO; *; +

NORVASC 10 MG (UseAmlodipine Besylate) NF QL(1 ea daily);

MONORVASC 2.5 MG (UseAmlodipine Besylate) NF QL(4 ea daily);

MONORVASC 5 MG (UseAmlodipine Besylate) NF QL(2 ea daily);

MO

NYMALIZE 5

PROCARDIA (UseNifedipine) NF AL; MO

PROCARDIA XL (UseNifedipine) NF MO

SULAR (Use Nisoldipine) NF MO

TIAZAC (Use Diltiazem HClExtended Release Beads) NF MO

verapamil hcl cp24 or 100mg, 120 mg, 180 mg, 200mg, 240 mg, 300 mg, 360mg

1

MO; *; +

verapamil hcl tabs or 120mg, 40 mg, 80 mg 1 MO; *; +

verapamil hcl tbcr or 120mg, 180 mg, 240 mg 1 MO; *; +

VERELAN (Use VerapamilHCl) NF MO

VERELAN PM (UseVerapamil HCl) NF MO

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart RhythmCardiac Glycosides



47

Drug Name DrugTier

Requirements/Limits

DIGOXIN SOLN OR 0.05MG/ML 4 MO; +

digoxin tabs or 0.125 mg,0.25 mg, 125 mcg, 250mcg

2MO; *; +

LANOXIN PEDIATRIC 4 +

LANOXIN TABS OR 125MCG, 250 MCG (UseDigoxin)

4MO; +

LANOXIN TABS OR 187.5MCG, 62.5 MCG 4 MO; +

CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation ConditionsCardiovascular Agents Misc. - Combinationsamlodipine besylate-atorvastatin calcium 2 MO; *; +

BIDIL 4 MO; +

CADUET (Use AmlodipineBesylate-AtorvastatinCalcium)

4MO; +

ENTRESTO 4 PA; MO; +

Prostaglandin VasodilatorsORENITRAM 0.125 MG 4 PA; +

ORENITRAM 0.25 MG, 1MG, 2.5 MG 5 PA

REMODULIN 5 LA; B/D

TYVASO 5 LA; B/D

TYVASO REFILL 5 LA; B/D

TYVASO STARTER 5 LA; B/D

VENTAVIS 10 MCG/ML 3 LA; B/D; +

VENTAVIS 20 MCG/ML 5 LA; B/D

Pulmonary Hypertension - Endothelin ReceptorLETAIRIS 5 LA

OPSUMIT 5

Drug Name DrugTier

Requirements/Limits

TRACLEER 5 LA

Pulmonary Hypertension - PhosphodiesteraseADCIRCA 5 PA

REVATIO SOLN IV 10MG/12.5ML (Use SildenafilCitrate (PulmonaryHypertension))

5

PA

REVATIO TABS OR 20MG (Use Sildenafil Citrate(Pulmonary Hypertension))

5PA

sildenafil citrate (pulmonaryhypertension) 5 PA

Pulmonary Hypertension - Sol Guanylate Cyclase

ADEMPAS 0.5 MG 5 PA; QL(15 eadaily)

ADEMPAS 1 MG 5 PA; QL(7.5 eadaily)


ADEMPAS 2 MG 5 PA; QL(3.75 eadaily)


Sinus Node Inhibitors

CORLANOR 4 QL(2 ea daily);MO; +

CEPHALOSPORINS - Drugs to Treat BacterialInfectionsCephalosporins - 1st Generationcefadroxil caps 500 mg 1 MO; *; +

cefadroxil susr 250 mg/5ml 2 MO; *; +

cefadroxil susr 500 mg/5ml 1 MO; *; +

cefadroxil tabs 1 gm 1 MO; *; +

cefazolin in d5w 1 *; +

cefazolin sodium ij 1 gm,10 gm 1 MO; *; +

cefazolin sodium ij 500 mg 2 MO; *; +



48

Drug Name DrugTier

Requirements/Limits

cefazolin sodium iv 1 gm 2 *; +

cephalexin caps 250 mg,500 mg 1 MO; *; +

cephalexin caps 750 mg 2 MO; *; +

cephalexin susr 125mg/5ml, 250 mg/5ml 2 MO; *; +

cephalexin tabs 250 mg,500 mg 2 MO; *; +

KEFLEX 250 MG, 500 MG(Use Cephalexin) NF MO

KEFLEX 750 MG (UseCephalexin) 4 MO; +

Cephalosporins - 2nd Generationcefaclor caps 250 mg, 500mg 1 MO; *; +

cefaclor monohydrate 1 MO; *; +

cefaclor susr 125 mg/5ml,250 mg/5ml, 375 mg/5ml 2 MO; *; +

cefotetan disodium 1 gm,10 gm 2 *; +

cefotetan disodium 2 gm 1 *; +

cefoxitin sodium indextrose 2 *; +

cefprozil susr 125 mg/5ml 2 MO; *; +

cefprozil susr 250 mg/5ml 1 MO; *; +

cefprozil tabs 250 mg, 500mg 1 MO; *; +

CEFTIN TABS 250 MG,500 MG (Use CefuroximeAxetil)

NFMO

cefuroxime axetil 2 MO; *; +

cefuroxime sodium ij 1.5gm 1 *; +

cefuroxime sodium ij 7.5gm 2 *; +

cefuroxime sodium ij 750mg 1 MO; *; +

cefuroxime sodium iv 7.5gm 2 *; +

Drug Name DrugTier

Requirements/Limits

ZINACEF SOLR IJ 1.5 GM,7.5 GM (Use CefuroximeSodium)

NF

ZINACEF SOLR IJ 750 MG(Use Cefuroxime Sodium) NF MO

Cephalosporins - 3rd Generation

CEDAX CAPS 400 MG 4 QL(1 ea daily);MO; +

cefdinir 2 MO; *; +

cefixime chew 100 mg 2 *; +

cefixime chew 200 mg 2 MO; *; +

cefixime susr 100 mg/5ml,200 mg/5ml 1 MO; *; +

cefixime tabs 400 mg 1 *; +

cefotaxime sodium ij 1 gm 1 MO; *; +

cefotaxime sodium ij 10 gm 2 MO; *; +

cefotaxime sodium ij 2 gm,500 mg 2 *; +

cefotaxime sodium iv 1 gm,2 gm 2 *; +

cefpodoxime proxetil 2 MO; *; +

ceftazidime ij 1 gm, 2 gm 1 MO; *; +

ceftazidime ij 6 gm 1 *; +

CEFTIBUTEN CAPS 400MG 4 QL(1 ea daily);

MO; +ceftriaxone sodium indextrose 20mg/ml 2 QL(200 ml

daily); *; +ceftriaxone sodium indextrose 40mg/ml 2 QL(100 ml

daily); *; +ceftriaxone sodium solr ij 1gm 1 QL(4 ea daily);

MO; *; +ceftriaxone sodium solr ij 2gm 1 QL(2 ea daily);

MO; *; +ceftriaxone sodium solr ij250 mg 1 QL(16 ea

daily); MO; *; +ceftriaxone sodium solr ij500 mg 1 QL(8 ea daily);

MO; *; +



49

Drug Name DrugTier

Requirements/Limits

ceftriaxone sodium solr iv 1gm 1 QL(4 ea daily);

*; +ceftriaxone sodium solr iv10 gm 1 MO; *; +

ceftriaxone sodium solr iv 2gm 2 QL(2 ea daily);

MO; *; +CLAFORAN IJ 1 GM, 10GM (Use CefotaximeSodium)

NFMO

CLAFORAN IJ 2 GM, 500MG (Use CefotaximeSodium)

NF

FORTAZ SOLR IJ 1 GM, 2GM (Use Ceftazidime) NF MO

FORTAZ SOLR IJ 6 GM(Use Ceftazidime) NF

SUPRAX CAPS 400 MG 4 MO; +

SUPRAX SUSR 500MG/5ML 4 +

Cephalosporins - 4th Generationcefepime hcl 1 MO; *; +

CEFEPIME SOLN 1GM/50ML, 2 GM/100ML 4 +

MAXIPIME IJ 1 GM, 2 GM(Use Cefepime HCl) 4 MO; +

Cephalosporins - 5th GenerationTEFLARO 4 +

CONTRACEPTIVES - Drugs to PreventPregnancyCombination Contraceptives - OralBEYAZ 4 MO; +

BREVICON-28 (UseNorethindrone & EthEstradiol)

NFMO

DESOGEN (UseDesogestrel & EthinylEstradiol)

NFMO

desogestrel & ethinylestradiol 1 MO; *; +

desogestrel-ethinylestradiol (biphasic) 1 MO; *; +

Drug Name DrugTier

Requirements/Limits

drospirenone-ethinylestradiol 1 MO; *; +

ethynodiol diacet & ethestrad 1 MO; *; +

FEMCON FE (UseNorethindrone & EthinylEstradiol-Fe)

NFMO

GENERESS FE (UseNorethindrone & EthinylEstradiol-Fe)

4MO; +

levonorgestrel & ethestradiol 1 MO; *; +

levonorgestrel-eth estradiol(triphasic) 1 MO; *; +

levonorgestrel-ethinylestradiol (91-day) 1 MO; *; +

levonorgestrel-ethinylestradiol (continuous) 2 MO; *; +

LO LOESTRIN FE 4 MO; +

LO MINASTRIN FE 4 +

LOSEASONIQUE (UseLevonorgestrel-EthinylEstradiol (91-Day))

NF MO

MINASTRIN 24 FE 4 MO; +

MODICON (UseNorethindrone & EthEstradiol)

NFMO

norethin acet & estrad-fe75mg-20mcg-1mg, 75mg-30mcg-1.5mg

1MO; *; +

norethindrone & ethestradiol 0.4mg-35mcg,1mg-35mcg

1MO; *; +

norethindrone & ethestradiol 0.5mg-35mcg 2 MO; *; +

norethindrone & ethinylestradiol-fe 2 MO; *; +

norethindrone acet & ethestra 1 MO; *; +

norethindrone-eth estradiol(biphasic) 2 MO; *; +

norethindrone-eth estradiol(triphasic) 2 MO; *; +



50

Drug Name DrugTier

Requirements/Limits

norgestimate-ethinylestradiol 1 MO; *; +

norgestimate-ethinylestradiol (triphasic) 1 MO; *; +

norgestrel & ethinylestradiol 0.3mg-30mcg 1 MO; *; +

norgestrel & ethinylestradiol 0.5mg-50mcg 2 MO; *; +

NORINYL 1+35 (UseNorethindrone & EthEstradiol)

NFMO

ORTHO TRI-CYCLEN (UseNorgestimate-EthinylEstradiol (Triphasic))

NFMO

ORTHO-CEPT (UseDesogestrel & EthinylEstradiol)

NFMO

ORTHO-CYCLEN (UseNorgestimate-EthinylEstradiol)

NFMO

ORTHO-NOVUM 1/35(Use Norethindrone & EthEstradiol)

NFMO

ORTHO-NOVUM 7/7/7(Use Norethindrone-EthEstradiol (Triphasic))

NFMO

QUARTETTE 4 MO; +

SAFYRAL 4 MO; +

SEASONIQUE (UseLevonorgestrel-EthinylEstradiol (91-Day))

NF MO

YASMIN 28 (UseDrospirenone-EthinylEstradiol)

NFMO

YAZ (Use Drospirenone-Ethinyl Estradiol) NF MO

Combination Contraceptives - Transdermalnorelgestromin-ethinylestradiol 2 MO; *; +

ORTHO EVRA (UseNorelgestromin-EthinylEstradiol)

3MO; +

Combination Contraceptives - VaginalNUVARING 3 MO; +

Drug Name DrugTier

Requirements/Limits

Emergency ContraceptivesELLA 3 +

levonorgestrel (emergencyoc) 0.75 mg 1 *; +

levonorgestrel (emergencyoc) 1.5 mg 1 RX/OTC; *; +

PLAN B ONE-STEP (UseLevonorgestrel (EmergencyOC))

4RX/OTC; +

Progestin Contraceptives - InjectableDEPO-PROVERACONTRACEPTIVE (UseMedroxyprogesteroneAcetate (Contraceptive))

NF

MO

DEPO-SUBQ PROVERA104 4 MO; +

medroxyprogesteroneacetate (contraceptive) 1 MO; *; +

Progestin Contraceptives - OralNOR-QD (UseNorethindrone(Contraceptive))

NFMO

norethindrone(contraceptive) 1 MO; *; +

ORTHO MICRONOR (UseNorethindrone(Contraceptive))

NFMO

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling ConditionsGlucocorticosteroidsbetamethasone sodphosphate & ace &bupivacaine & lidocaine

2*; +

betamethasone sodphosphate & acetate 1 MO; *; +

betamethasone sodphosphate & acetate &bupivacaine hcl

2*; +

betamethasone sodphosphate & acetate &lidocaine hcl

2*; +

budesonide cp24 or 5 MO



51

Drug Name DrugTier

Requirements/Limits

CELESTONE-SOLUSPAN(Use Betamethasone SodPhosphate & Acetate)

4MO; +

CORTEF (UseHydrocortisone) NF MO

cortisone acetate tabs or 1 MO; *; +

DEPO-MEDROL 20MG/ML 4 MO; +

DEPO-MEDROL 40MG/ML, 80 MG/ML (UseMethylprednisoloneAcetate)

NF

MO

dexamethasone conc or 1mg/ml 2 MO; *; +

dexamethasone elix or 0.5mg/5ml 2 MO; *; +

dexamethasone sod phos& bupivacaine hcl &lidocaine hcl

2*; +

dexamethasone sodiumphosphate & bupivacainehcl

2*; +

dexamethasone sodiumphosphate & lidocaine hcl 2 *; +

dexamethasone sodiumphosphate kit ij 10 mg/ml 2 *; +

dexamethasone sodiumphosphate soln ij 10 mg/ml 1 Preservative

Free;MO; *; +dexamethasone sodiumphosphate soln ij 10 mg/ml,120 mg/30ml

1*; +

dexamethasone sodiumphosphate soln ij 100mg/10ml, 20 mg/5ml, 4mg/ml

1

MO; *; +

dexamethasone soln or 0.5mg/5ml 2 MO; *; +

dexamethasone tabs or 0.5mg, 0.75 mg, 1 mg, 1.5 mg,2 mg, 4 mg, 6 mg

1MO; *; +

dexamethasone tabs or 1.5mg 2 MO; *; +

ENTOCORT EC (UseBudesonide) 5 MO

FLO-PRED 4 MO; +

Drug Name DrugTier

Requirements/Limits

hydrocortisone sodsuccinate 1 MO; *; +

hydrocortisone tabs or 10mg, 20 mg, 5 mg 2 MO; *; +

KENALOG-10 4 MO; +

KENALOG-40 4 MO; +

MEDROL 16 MG, 32 MG, 4MG, 8 MG (UseMethylprednisolone)

NFMO

MEDROL 2 MG 3 MO; +

MEDROL DOSEPAK (UseMethylprednisolone) NF MO

methylprednisolone acetatesusp ij 40 mg/ml, 80 mg/ml 1 MO; *; +

methylprednisolone sodsucc 1 MO; *; +

methylprednisolone tabs or16 mg, 32 mg, 4 mg, 8 mg 2 MO; *; +

ORAPRED ODT 10 MG,15MG,30 MG 4 MO; +

ORAPRED ODT 10 MG,15MG,30 MG (UsePrednisolone SodiumPhosphate)

4

MO; +

prednisolone 1 MO; *; +

prednisolone sodiumphosphate soln or 10mg/5ml, 20 mg/5ml, 25mg/5ml

2

MO; *; +

prednisolone sodiumphosphate soln or 15mg/5ml, 5 mg/5ml, 6.7mg/5ml

1

MO; *; +

prednisolone sodiumphosphate tbdp or 10 mg,15 mg, 30 mg

2MO; *; +

prednisone conc or 5mg/ml 2 MO; *; +

prednisone soln or 5mg/5ml 2 MO; *; +

prednisone tabs or 1 mg,10 mg, 2.5 mg, 20 mg, 5mg, 50 mg

1MO; *; +



52

Drug Name DrugTier

Requirements/Limits

prednisone tabs or 10 mg,5 mg 2 Dose Pack;MO;

*; +

RAYOS 2 MG, 5 MG 4 MO; +

SOLU-CORTEF 100 MG,250 MG 4 MO; +

SOLU-MEDROL 1000 MG,125 MG, 40 MG (UseMethylprednisolone SodSucc)

NF

MO

SOLU-MEDROL 2 GM 4 +

UCERIS TB24 OR 9 MG 5 MO

Mineralocorticoidsfludrocortisone acetatetabs or 2 MO; *; +

COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy SymptomsCough/Cold/Allergy CombinationsCLARINEX-D 12 HOUR 4 MO; +

CLARINEX-D 24 HOUR 4 MO; +

promethazine &phenylephrine 2 AL; MO; *; +

SEMPREX-D 4 MO; +

Mucolyticsacetylcysteine soln in 10%, 20 % 1 MO; B/D; *; +

DERMATOLOGICALS - Drugs to Treat SkinConditionsAcne ProductsABSORICA 30 MG (UseIsotretinoin) NF

ACANYA 4 MO; +

adapalene crea 0.1 % 1 MO; *; +

adapalene gel 0.1 % 1 MO; *; +

adapalene gel 0.3 % 2 MO; *; +

ATRALIN (Use Tretinoin) 4 MO; +

Drug Name DrugTier

Requirements/Limits

AZELEX 4 MO; +

BENZACLIN (UseClindamycin Phosphate-Benzoyl Peroxide)

NFMO

BENZACLIN WITH PUMP(Use ClindamycinPhosphate-BenzoylPeroxide)

NF

MO

BENZAMYCIN (UseBenzoyl Peroxide-Erythromycin)

NFMO

benzoyl peroxide-erythromycin 1 MO; *; +

CLEOCIN-T (UseClindamycin Phosphate(Topical))

NFMO

clindamycin phosphate &cleanser 2 MO; *; +

clindamycin phosphate(topical) 2 MO; *; +

clindamycin phosphate-benzoyl peroxide 1 MO; *; +

clindamycin phosphate-benzoyl peroxide &moisturizer

2MO; *; +

clindamycin phosphate-benzoyl peroxide(refrigerate)

1MO; *; +

DIFFERIN CREA 0.1 %(Use Adapalene) NF MO

DIFFERIN GEL 0.1 % (UseAdapalene) NF MO

DIFFERIN GEL 0.3 % (UseAdapalene) 4 MO; +

DUAC (Use ClindamycinPhosphate-BenzoylPeroxide (Refrigerate))

4MO; +

EPIDUO 4 MO; +

erythromycin (acne aid) gel 1 MO; *; +

erythromycin (acne aid)soln 1 MO; *; +

EVOCLIN (UseClindamycin Phosphate(Topical))

NFMO



53

Drug Name DrugTier

Requirements/Limits

FABIOR 4 QL(3.34 gmdaily); MO; +

isotretinoin caps or 10 mg 2 *; +

isotretinoin caps or 20 mg,30 mg, 40 mg 1 *; +

KLARON (UseSulfacetamide Sodium(Acne))

NFMO

RETIN-A (Use Tretinoin) NF MO

RETIN-A MICRO (UseTretinoin Microsphere) NF MO

RETIN-A MICRO PUMP0.04 %, 0.1 % (UseTretinoin Microsphere)

NFMO

RETIN-A MICRO PUMP0.08 % 4 MO; +

sulfacetamide sodium(acne) 1 MO; *; +

tretinoin crea ex 0.025 %,0.05 %, 0.075 %, 0.1 % 2 MO; *; +

tretinoin crea ex 0.038 % 2 *; +

tretinoin gel ex 0.01 %,0.025 %, 0.05 % 2 MO; *; +

tretinoin microsphere 2 MO; *; +

tretinoin w/ cleanser &moisturizer 0.025%, 0.1% 2 MO; *; +

tretinoin w/ cleanser &moisturizer 0.05% 2 *; +

VELTIN 4 MO; +

ZIANA 4 MO; +

Agents for External Genital and Perianal WartsVEREGEN 4 MO; +

Anti-inflammatory Agents - Topicaldiclofenac sodium (topical) 2 MO; *; +

FLECTOR 4 PA; MO; +

PENNSAID 1.5 % (UseDiclofenac Sodium(Topical))

4MO; +

Drug Name DrugTier

Requirements/Limits

PENNSAID 2 % 4 MO; +

VOLTAREN 4 MO; +

Antibiotics - TopicalALTABAX 4 MO; +

BACTROBAN (UseMupirocin Calcium(Topical))

NFMO

BACTROBAN (UseMupirocin) NF MO

CORTISPORIN CREA EX10000UNIT/GM-0.5%-0.5% 3 MO; +

CORTISPORIN OINT EX400UNIT/GM-5000UNIT/GM-0.5%-1%

3MO; +

gentamicin sulfate (topical) 1 MO; *; +

mupirocin calcium (topical) 2 MO; *; +

mupirocin oint ex 2 MO; *; +

neomycin-fluocinolone 2 MO; *; +

Antifungals - Topicalciclopirox gel 0.77 % 2 MO; *; +

ciclopirox kit 8 % 2 MO; *; +

ciclopirox olamine &cleanser 2 MO; *; +

ciclopirox olamine crea ex 2 MO; *; +

ciclopirox olamine susp ex 2 MO; *; +

ciclopirox sham 1 % 2 MO; *; +

ciclopirox soln 8 % 2 MO; *; +

clotrimazole (topical) 2 RX/OTC; MO;*; +

clotrimazole w/betamethasone 2 MO; *; +

econazole nitrate 2 MO; *; +

EXELDERM SOLN 4 MO; +



54

Drug Name DrugTier

Requirements/Limits

EXTINA (UseKetoconazole (Topical)) NF MO

JUBLIA 4 PA; MO; +

KERYDIN 4 PA; MO; +

ketoconazole & cleanser 2 MO; *; +

ketoconazole (topical) 2 MO; *; +

LOPROX (Use Ciclopirox) NF MO

LOPROX SHAMPOO (UseCiclopirox) NF MO

LOTRISONE (UseClotrimazole w/Betamethasone)

NFMO

LUZU 4 MO; +

naftifine hcl 2 MO; *; +

NAFTIN 1 % (Use NaftifineHCl) 4 MO; +

NAFTIN 1 %,2 % 4 MO; +

NIZORAL (UseKetoconazole (Topical)) NF MO

nystatin & diaper rashproduct 2 MO; *; +

nystatin (topical) 2 MO; *; +

nystatin-triamcinolone 2 MO; *; +

OXISTAT 4 MO; +

PENLAC NAIL LACQUER(Use Ciclopirox) NF MO

Antineoplastic or Premalignant Lesion Agents -CARAC 3 MO; +

diclofenac sodium (actinickeratoses) 5 MO

EFUDEX (Use Fluorouracil(Topical)) NF MO

fluorouracil (topical) 2 MO; *; +

FLUOROURACIL CREAEX 0.5 % 3 MO; +

Drug Name DrugTier

Requirements/Limits

PANRETIN 5 MO

PICATO 5 MO

SOLARAZE (UseDiclofenac Sodium (ActinicKeratoses))

5MO

TARGRETIN 1 %,75 MG 5

VALCHLOR 5 PA

Antipsoriaticsacitretin 5 MO

calcipotriene 2 MO; *; +

CALCITRIOL OINT EX 3MCG/GM 4 MO; +

COSENTYX 5 PA; LA

COSENTYXSENSOREADY PEN 5 PA; LA

DOVONEX (UseCalcipotriene) NF MO

methoxsalen rapid 5 MO

OXSORALEN ULTRA (UseMethoxsalen Rapid) 5 MO

SORIATANE (UseAcitretin) 5 MO

SORILUX 4 MO; +

STELARA 5 PA;

TAZORAC 3 MO; +

VECTICAL 4 MO; +

Antiseborrheic Productsselenium sulfide lotn ex 2.5% 2 MO; *; +

Antivirals - Topicalacyclovir topical 2 MO; *; +

DENAVIR 4 MO; +



55

Drug Name DrugTier

Requirements/Limits

XERESE 4 MO; +

ZOVIRAX CREA EX 5 % 4 MO; +

ZOVIRAX OINT EX 5 %(Use Acyclovir Topical) NF MO

Burn ProductsSILVADENE (Use SilverSulfadiazine) NF MO

silver sulfadiazine crea ex 2 MO; *; +

SULFAMYLON CREA 85MG/GM 4 MO; +

Corticosteroids - Topicalalclometasone dipropionate 1 MO; *; +

amcinonide crea 1 MO; *; +

amcinonide lotn 2 MO; *; +

amcinonide oint 1 MO; *; +

betamethasonedipropionate (topical) 2 MO; *; +

betamethasonedipropionate augmented 2 MO; *; +

betamethasone valeratecrea ex 0.1 % 2 MO; *; +

betamethasone valeratefoam ex 0.12 % 2 MO; *; +

betamethasone valeratelotn ex 0.1 % 2 MO; *; +

betamethasone valerateoint ex 0.1 % 2 MO; *; +

calcipotriene-betamethasonedipropionate

2MO; *; +

CAPEX 4 MO; +

clobetasol propionate &cleanser 2 MO; *; +

clobetasol propionate creaex 2 MO; *; +

clobetasol propionateemollient base 2 MO; *; +

clobetasol propionateemulsion 2 MO; *; +

Drug Name DrugTier

Requirements/Limits

clobetasol propionate foamex 2 MO; *; +

clobetasol propionate gelex 2 MO; *; +

clobetasol propionate liqdex 2 MO; *; +

clobetasol propionate lotnex 2 MO; *; +

clobetasol propionate ointex 2 MO; *; +

clobetasol propionate shamex 2 MO; *; +

clobetasol propionate solnex 2 MO; *; +

CLOBEX LIQD (UseClobetasol Propionate) 4 MO; +

CLOBEX LOTN (UseClobetasol Propionate) NF MO

CLOBEX SHAM (UseClobetasol Propionate) NF MO

CLOCORTOLONEPIVALATE 4 MO; +

CLOCORTOLONEPIVALATE PUMP 4 MO; +

CLODERM 4 MO; +

CLODERM PUMP 4 MO; +

CORDRAN TAPE 4 MO; +

CUTIVATE (UseFluticasone Propionate) NF MO

DERMA-SMOOTHE/FSBODY (Use FluocinoloneAcetonide)

NFMO

DERMA-SMOOTHE/FSSCALP (Use FluocinoloneAcetonide)

NFMO

DERMATOP CREA (UsePrednicarbate) NF MO

DESONATE 4 MO; +

desonide crea ex 2 MO; *; +

desonide lotn ex 2 MO; *; +



56

Drug Name DrugTier

Requirements/Limits

desonide oint ex 2 MO; *; +

DESOWEN 0.05 % (UseDesonide) NF MO

desoximetasone crea ex0.05 %, 0.25 % 2 MO; *; +

desoximetasone gel ex0.05 % 2 MO; *; +

DESOXIMETASONE OINTEX 0.05 % 4 MO; +

desoximetasone oint ex0.25 % 2 MO; *; +

diflorasone diacetate 1 MO; *; +

diflorasone diacetateemollient base 2 MO; *; +

DIPROLENE (UseBetamethasoneDipropionate Augmented)

NFMO

DIPROLENE AF (UseBetamethasoneDipropionate Augmented)

NFMO

ELOCON CREA (UseMometasone Furoate) NF MO

ELOCON OINT (UseMometasone Furoate) NF MO

fluocinolone acetonide creaex 0.01 %, 0.025 % 2 MO; *; +

fluocinolone acetonide oilex 0.01 % 2 MO; *; +

fluocinolone acetonide ointex 0.025 % 2 MO; *; +

fluocinolone acetonide solnex 0.01 % 2 MO; *; +

fluocinonide crea ex 0.05%, 0.1 % 2 MO; *; +

fluocinonide emulsifiedbase 1 MO; *; +

fluocinonide gel ex 0.05 % 2 MO; *; +

fluocinonide oint ex 0.05 % 2 MO; *; +

fluocinonide soln ex 0.05 % 2 MO; *; +

fluticasone propionate creaex 0.05 % 1 MO; *; +

Drug Name DrugTier

Requirements/Limits

fluticasone propionate lotnex 0.05 % 1 MO; *; +

fluticasone propionate ointex 0.005 % 1 MO; *; +

halobetasol propionate 2 MO; *; +

HALOG CREA 4 MO; +

hydrocortisone & cleanser 2 MO; *; +

hydrocortisone & emollient 2 MO; *; +

hydrocortisone (topical)crea 1 % 1 RX/OTC; MO;

*; +hydrocortisone (topical)crea 2.5 % 1 MO; *; +

hydrocortisone (topical) lotn2.5 % 2 MO; *; +

hydrocortisone (topical) oint1 % 1 RX/OTC; MO;

*; +hydrocortisone (topical) oint2.5 % 1 MO; *; +

hydrocortisone (topical)soln 2.5 % 2 MO; *; +

hydrocortisone butyrate 1 MO; *; +

hydrocortisone butyratehydrophilic lipo base 2 MO; *; +

hydrocortisone valerate 2 MO; *; +

KENALOG (UseTriamcinolone Acetonide(Topical))

3MO; +

LOCOID CREA (UseHydrocortisone Butyrate) NF MO

LOCOID LIPOCREAM(Use HydrocortisoneButyrate Hydrophilic LipoBase)

NF

MO

LOCOID LOTN 4 MO; +

LOCOID OINT (UseHydrocortisone Butyrate) NF MO

LOCOID SOLN (UseHydrocortisone Butyrate) NF MO

LUXIQ (UseBetamethasone Valerate) NF MO



57

Drug Name DrugTier

Requirements/Limits

mometasone furoate creaex 2 MO; *; +

mometasone furoate ointex 2 MO; *; +

mometasone furoate solnex 2 MO; *; +

OLUX (Use ClobetasolPropionate) NF MO

OLUX-E (Use ClobetasolPropionate Emulsion) NF MO

pramoxine-hc crea 1%-1% 1 MO; *; +

pramoxine-hc foam 1%-1% 2 MO; *; +

pramoxine-hc lotn 1%-1%,1%-2.5% 2 MO; *; +

prednicarbate crea 1 MO; *; +

SYNALAR (UseFluocinolone Acetonide) NF MO

TACLONEX OINT (UseCalcipotriene-BetamethasoneDipropionate)

4

MO; +

TACLONEX SUSP 5 MO

TEMOVATE (UseClobetasol Propionate) NF MO

TEMOVATE E (UseClobetasol PropionateEmollient Base)

NFMO

TOPICORT 4 MO; +

triamcinolone acetonide &emollient 2 MO; *; +

triamcinolone acetonide(topical) 2 MO; *; +

ULTRAVATE (UseHalobetasol Propionate) NF MO

VANOS (Use Fluocinonide) 4 MO; +

WESTCORT (UseHydrocortisone Valerate) NF MO

EmollientsLAC-HYDRIN (Use LacticAcid (Ammonium Lactate)) NF RX/OTC; MO

Drug Name DrugTier

Requirements/Limits

lactic acid (ammoniumlactate) crea 12 % 2 RX/OTC; MO;

*; +lactic acid (ammoniumlactate) lotn 12 % 2 RX/OTC; MO;

*; +Enzymes - TopicalSANTYL 3 MO; +

Immunomodulating Agents - TopicalALDARA (Use Imiquimod) 4 MO; +

imiquimod crea ex 2 MO; *; +

ZYCLARA 5 MO

ZYCLARA PUMP 5 MO

Immunosuppressive Agents - TopicalELIDEL 4 MO; +

PROTOPIC (UseTacrolimus (Topical)) 4 MO; +

tacrolimus (topical) 2 MO; *; +

Keratolytic/Antimitotic AgentsCONDYLOX GEL 4 MO; +

CONDYLOX SOLN (UsePodofilox) NF MO

podofilox soln ex 1 MO; *; +

Local Anesthetics - TopicalEMLA (Use Lidocaine-Prilocaine) NF MO

lidocaine hcl gel 2 % 2 RX/OTC; MO;*; +

lidocaine hcl soln 4 % 2 MO; *; +

lidocaine oint ex 5 % 2 MO; *; +

lidocaine ptch ex 5 % 2 PA; MO; *; +

lidocaine-prilocaine crea 2 MO; *; +

lidocaine-prilocaine kit 2 *; +



58

Drug Name DrugTier

Requirements/Limits

LIDODERM (UseLidocaine) NF PA; MO

XYLOCAINE EX 4 % (UseLidocaine HCl) NF MO

Pigmenting-Depigmenting AgentsOXSORALEN 4 MO; +

Rosacea AgentsDOXYCYCLINE 4 MO; +

FINACEA GEL 4 MO; +

METROCREAM (UseMetronidazole (Topical)) NF MO

METROGEL (UseMetronidazole (Topical)) NF MO

METROLOTION (UseMetronidazole (Topical)) NF MO

metronidazole (topical) 2 MO; *; +

metronidazole w/ cleanser(topical) 2 Gel; *; +

metronidazole w/ cleanser(topical) 2 MO; *; +

MIRVASO 4 PA; MO; +

NORITATE 4 MO; +

ORACEA 4 MO; +

SOOLANTRA 4 MO; +

Scabicides & PediculicidesEURAX 4 MO; +

lindane lotn 1 MO; *; +

malathion 1 MO; *; +

OVIDE 0.5 % (UseMalathion) NF MO

permethrin crea ex 5 % 2 MO; *; +

Wound Care ProductsREGRANEX 5 MO

Drug Name DrugTier

Requirements/Limits

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymesDigestive EnzymesCREON 3 MO; +

PANCREAZE 3 MO; +

PANCRELIPASE 4 MO; +

PERTZYE 4 MO; +

VIOKACE 4 MO; +

ZENPEP 10000UNIT-3000UNIT-16000UNIT,17000UNIT-5000UNIT-27000UNIT, 34000UNIT-10000UNIT-55000UNIT,51000UNIT-15000UNIT-82000UNIT, 68000UNIT-20000UNIT-109000UNIT,85000UNIT-25000UNIT-136000UNIT

4

MO; +

ZENPEP 136000UNIT-40000UNIT-218000UNIT 5 MO

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood PressureCarbonic Anhydrase Inhibitorsacetazolamide cp12 or 500mg 1 MO; *; +

acetazolamide tabs or 125mg, 250 mg 1 MO; *; +

DIAMOX (UseAcetazolamide) NF MO

methazolamide tabs or 25mg, 50 mg 1 MO; *; +

Diuretic CombinationsALDACTAZIDE 25MG-25MG (Use Spironolactone& Hydrochlorothiazide)

NFMO

ALDACTAZIDE 50MG-50MG 3 MO; +

amiloride &hydrochlorothiazide 1 MO; *; +



59

Drug Name DrugTier

Requirements/Limits

DYAZIDE (UseTriamterene &Hydrochlorothiazide)

NFMO

MAXZIDE (UseTriamterene &Hydrochlorothiazide)

NFMO

MAXZIDE-25 (UseTriamterene &Hydrochlorothiazide)

NFMO

spironolactone &hydrochlorothiazide 1 MO; *; +

triamterene &hydrochlorothiazide 1 MO; *; +

Loop Diureticsbumetanide tabs or 0.5 mg,1 mg, 2 mg 1 MO; *; +

BUMEX (Use Bumetanide) NF MO

DEMADEX (UseTorsemide) NF MO

EDECRIN 4 MO; +

furosemide soln ij 10 mg/ml 1 MO; *; +

furosemide soln or 10mg/ml 1 MO; *; +

furosemide soln or 8 mg/ml 2 MO; *; +

furosemide tabs or 20 mg,40 mg, 80 mg 1 MO; *; +

LASIX (Use Furosemide) NF MO

torsemide soln iv 20mg/2ml, 50 mg/5ml 2 *; +

torsemide tabs or 10 mg,100 mg, 20 mg, 5 mg 1 MO; *; +

Potassium Sparing DiureticsALDACTONE (UseSpironolactone) NF MO

amiloride hcl 1 MO; *; +

DYRENIUM 4 MO; +

spironolactone tabs or 100mg, 25 mg, 50 mg 1 MO; *; +

Thiazides and Thiazide-Like Diuretics

Drug Name DrugTier

Requirements/Limits

chlorothiazide 1 MO; *; +

chlorthalidone 25 mg, 50mg 1 MO; *; +

hydrochlorothiazide caps or12.5 mg 1 MO; *; +

hydrochlorothiazide tabs or12.5 mg, 25 mg, 50 mg 1 MO; *; +

indapamide 1 MO; *; +

methyclothiazide 1 MO; *; +

metolazone 1 MO; *; +

MICROZIDE (UseHydrochlorothiazide) NF MO

ZAROXOLYN (UseMetolazone) NF MO

ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate HormonesBone Density RegulatorsACTONEL 150 MG (UseRisedronate Sodium) 3 QL(0.04 ea

daily); MO; +ACTONEL 30 MG, 5 MG(Use Risedronate Sodium) 3 QL(1 ea daily);

MO; +ACTONEL 35 MG (UseRisedronate Sodium) 3 QL(0.15 ea

daily); MO; +alendronate sodium soln 70mg/75ml 2 MO; *; +

alendronate sodium tabs10 mg, 40 mg, 5 mg 1 MO; *; +

alendronate sodium tabs35 mg, 70 mg 1 QL(0.15 ea

daily); MO; *; +ATELVIA (Use RisedronateSodium) 3 QL(0.15 ea

daily); MO; +BONIVA SOLN IV 3MG/3ML (Use IbandronateSodium)

4QL(0.04 mldaily); MO; +

BONIVA TABS OR 150 MG(Use Ibandronate Sodium) NF QL(0.036 ea

daily); MO

calcitonin (salmon) 2 MO; *; +

etidronate disodium 200mg 2 MO; *; +



60

Drug Name DrugTier

Requirements/Limits

etidronate disodium 400mg 1 MO; *; +

FORTEO 3 QL(0.09 mldaily); +

FOSAMAX (UseAlendronate Sodium) NF QL(0.15 ea

daily); MO

FOSAMAX PLUS D 4 QL(0.15 eadaily); MO; +

ibandronate sodium soln iv3 mg/3ml 2 QL(0.04 ml

daily); MO; *; +ibandronate sodium tabs or150 mg 2 QL(0.036 ea

daily); MO; *; +MIACALCIN IJ 200UNIT/ML 4 MO; +

MIACALCIN NA 200UNIT/ACT (Use Calcitonin(Salmon))

NFMO

NATPARA 5 PA; LA

pamidronate disodium soln6 mg/ml 2 *; +

PROLIA 3 QL(0.01 mldaily); +

RECLAST (Use ZoledronicAcid) NF QL(0.28 ml

daily)risedronate sodium tabs150 mg 2 QL(0.04 ea

daily); MO; *; +risedronate sodium tabs 30mg, 5 mg 2 QL(1 ea daily);

MO; *; +risedronate sodium tabs 35mg 2 QL(0.15 ea

daily); MO; *; +risedronate sodium tbec 35mg 2 QL(0.15 ea

daily); MO; *; +

XGEVA 5 QL(0.243 mldaily)

zoledronic acid conc 4mg/5ml 5

zoledronic acid soln 5mg/100ml 2 QL(0.28 ml

daily); *; +ZOLEDRONIC ACID SOLR4 MG 5

ZOMETA CONC 4MG/5ML (Use ZoledronicAcid)

5

Corticotropin

Drug Name DrugTier

Requirements/Limits

H.P. ACTHAR 5 PA; LA

Fertility Regulatorschorionic gonadotropin solrim 1 *; +

Growth Hormone Receptor AntagonistsSOMAVERT 5 LA

Growth Hormone Releasing Hormones (GHRH)EGRIFTA 5

Growth HormonesGENOTROPIN 5 MG 5 PA

GENOTROPIN MINIQUICK0.4 MG 5 PA

HUMATROPE 5 PA

HUMATROPE COMBOPACK 5 PA

NORDITROPIN FLEXPRO10 MG/1.5ML, 5 MG/1.5ML 5 PA

NUTROPIN AQ NUSPIN20 5 PA

NUTROPIN AQ PEN 20MG/2ML 5 PA

OMNITROPE SOLN 10MG/1.5ML, 5 MG/1.5ML 5 PA

SEROSTIM 4 MG, 6 MG 5 PA

TEV-TROPIN 5 PA

ZOMACTON 5 MG 5 PA

Hormone Receptor ModulatorsEVISTA (Use RaloxifeneHCl) NF QL(1 ea daily);

MO

raloxifene hcl 2 QL(1 ea daily);MO; *; +

Insulin-Like Growth Factors (Somatomedins)INCRELEX 4 LA; +

LHRH/GnRH Agonist Analog PituitaryLUPRON DEPOT-PED11.25 MG 5 3 Month Kit;



61

Drug Name DrugTier

Requirements/Limits

LUPRON DEPOT-PED11.25 MG, 7.5 MG 5

LUPRON DEPOT-PED 15MG 4 +

LUPRON DEPOT-PED 30MG 5

SYNAREL 5 MO

Metabolic Modifierscalcitriol caps or 0.25 mcg,0.5 mcg 2 MO; *; +

calcitriol soln or 1 mcg/ml 2 MO; *; +

CARNITOR TABS OR 330MG (Use Levocarnitine(Metabolic Modifiers))

NFMO

CYSTADANE 4 LA; +

doxercalciferol caps or 0.5mcg, 1 mcg, 2.5 mcg 2 MO; *; +

FABRAZYME 35 MG 5 LA

HECTOROL CAPS OR 0.5MCG, 2.5 MCG (UseDoxercalciferol)

4MO; +

HECTOROL CAPS OR 1MCG (Use Doxercalciferol) 5 MO

KUVAN TBSO 100 MG 5 LA

levocarnitine (metabolicmodifiers) tabs or 330 mg 1 MO; *; +

LUMIZYME 5 LA

MYALEPT 5 LA

MYOZYME 5 LA

NAGLAZYME 5 LA

ORFADIN 3 LA; +

paricalcitol caps or 1 mcg,2 mcg, 4 mcg 2 MO; *; +

ROCALTROL (UseCalcitriol) NF MO

SENSIPAR 30 MG 3 +

Drug Name DrugTier

Requirements/Limits

SENSIPAR 60 MG, 90 MG 5

VIMIZIM 5

ZEMPLAR CAPS OR 1MCG, 2 MCG, 4 MCG (UseParicalcitol)

NFMO

Posterior Pituitary HormonesDDAVP (UseDesmopressin AcetateRefrigerated)

NFMO

DDAVP (UseDesmopressin AcetateSpray)

NFMO

DDAVP (UseDesmopressin Acetate) NF MO

desmopressin acetaterefrigerated 1 MO; *; +

desmopressin acetate solnij 4 mcg/ml 2 MO; *; +

desmopressin acetatespray 1 MO; *; +

desmopressin acetatespray refrigerated 1 MO; *; +

desmopressin acetate tabsor 0.1 mg, 0.2 mg 2 MO; *; +

STIMATE 4 +

Prolactin Inhibitorscabergoline 2 MO; *; +

Somatostatic Agentsoctreotide acetate 100mcg/ml 2 *; +

octreotide acetate 1000mcg/5ml, 200 mcg/ml, 50mcg/ml

1*; +

SANDOSTATIN 100MCG/ML (Use OctreotideAcetate)

5

SANDOSTATIN 200MCG/ML, 50 MCG/ML(Use Octreotide Acetate)

NF

SANDOSTATIN LARDEPOT 20 MG, 30 MG 5



62

Drug Name DrugTier

Requirements/Limits

SIGNIFOR 5 LA

SIGNIFOR LAR 20 MG 5 QL(0.11 eadaily)

SIGNIFOR LAR 40 MG, 60MG 5 QL(0.036 ea

daily)

SOMATULINE DEPOT 5

Vasopressin Receptor AntagonistsSAMSCA 5

ESTROGENS - Hormone Replacement/ModifyingDrugsEstrogen CombinationsACTIVELLA (Use Estradiol& Norethindrone Acetate) NF AL; MO

ANGELIQ 0.5MG-1MG 4 AL; MO; +

CLIMARA PRO 4 AL; MO; +

COMBIPATCH 4 AL; MO; +

DUAVEE 4 MO; +

estradiol & norethindroneacetate 2 AL; MO; *; +

estradiol-norgestimate 2 AL; MO; *; +

FEMHRT LOW DOSE (UseNorethindrone Acetate-Ethinyl Estradiol)

4AL; MO; +

norethindrone acetate-ethinyl estradiol 2.5mcg-0.5mg

2AL; MO; *; +

norethindrone acetate-ethinyl estradiol 5mcg-1mg 1 AL; MO; *; +

PREMPHASE 4 AL; MO; +

PREMPRO 4 AL; MO; +

EstrogensALORA 4 AL; MO; +

CENESTIN 4 AL; +

CLIMARA (Use Estradiol) NF AL; MO

Drug Name DrugTier

Requirements/Limits

DELESTROGEN 20MG/ML,40 MG/ML (UseEstradiol Valerate)

NFMO

DIVIGEL 4 MO; +

ELESTRIN 4 AL; MO; +

ENJUVIA 0.3 MG, 0.45MG, 0.9 MG, 1.25 MG 4 AL; MO; +

ENJUVIA 0.625 MG 4 AL; +

estradiol cypionate oil im 2 MO; *; +

estradiol pttw td 0.025mg/24hr, 0.0375 mg/24hr,0.05 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr

2

AL; MO; *; +

estradiol ptwk td 0.025mg/24hr, 0.05 mg/24hr,0.06 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr

2

AL; MO; *; +

estradiol tabs or 0.5 mg, 1mg, 2 mg 2 AL; MO; *; +

estradiol valerate oil im 10mg/ml, 20 mg/ml, 40 mg/ml 1 MO; *; +

estropipate 2 AL; MO; *; +

EVAMIST 4 AL; MO; +

MENOSTAR 4 AL; MO; +

MINIVELLE 4 AL; MO; +

PREMARIN TABS OR 0.3MG, 0.45 MG, 0.625 MG,0.9 MG, 1.25 MG

4AL; MO; +

VIVELLE-DOT (UseEstradiol) 4 AL; MO; +

FLUOROQUINOLONES - Drugs to Treat BacterialInfectionsFluoroquinolonesAVELOX ABC PACK (UseMoxifloxacin HCl) 4 MO; +

AVELOX TABS OR 400MG (Use Moxifloxacin HCl) 4 MO; +



63

Drug Name DrugTier

Requirements/Limits

CIPRO I.V.-IN D5W200MG/100ML-5% (UseCiprofloxacin in D5W)

NF

CIPRO I.V.-IN D5W400MG/200ML-5% (UseCiprofloxacin in D5W)

NFMO

CIPRO SUSR 5GM/100ML, 500 MG/5ML(Use Ciprofloxacin)

3MO; +

CIPRO TABS 250 MG, 500MG (Use CiprofloxacinHCl)

NFMO

CIPRO XR (UseCiprofloxacin-CiprofloxacinHCl)

NFMO

ciprofloxacin hcl tabs or100 mg, 250 mg, 500 mg,750 mg

1MO; *; +

ciprofloxacin in d5w200mg/100ml-5% 2 *; +

ciprofloxacin in d5w400mg/200ml-5% 1 MO; *; +

ciprofloxacin susr or 250mg/5ml, 500 mg/5ml 2 MO; *; +

ciprofloxacin-ciprofloxacinhcl 1 MO; *; +

LEVAQUIN SOLN IV250MG/50ML-5%,500MG/100ML-5% (UseLevofloxacin in D5W)

NF

LEVAQUIN SOLN IV750MG/150ML-5% (UseLevofloxacin in D5W)

NFMO

LEVAQUIN SOLN OR 25MG/ML (Use Levofloxacin) NF MO

LEVAQUIN TABS OR 250MG, 500 MG, 750 MG (UseLevofloxacin)

NFMO

levofloxacin in d5w250mg/50ml-5%,500mg/100ml-5%

1*; +

levofloxacin in d5w750mg/150ml-5% 1 MO; *; +

levofloxacin soln iv 25mg/ml 2 *; +

levofloxacin soln or 25mg/ml 2 MO; *; +

Drug Name DrugTier

Requirements/Limits

levofloxacin tabs or 250mg, 500 mg, 750 mg 2 MO; *; +

moxifloxacin hcl tabs or400 mg 2 MO; *; +

NOROXIN 4 +

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal DrugsGallstone Solubilizing AgentsACTIGALL (Use Ursodiol) NF MO

CHENODAL 5 LA

URSO 250 (Use Ursodiol) NF MO

URSO FORTE (UseUrsodiol) NF MO

ursodiol caps or 300 mg 2 MO; *; +

ursodiol tabs or 250 mg,500 mg 2 MO; *; +

Gastrointestinal Antiallergy Agentscromolyn sodium(mastocytosis) 1 MO; *; +

GASTROCROM (UseCromolyn Sodium(Mastocytosis))

NFMO

Gastrointestinal Chloride Channel ActivatorsAMITIZA 3 MO; +

Gastrointestinal Stimulantsmetoclopramide hcl soln ij5 mg/ml 2 MO; *; +

metoclopramide hcl soln or10 mg/10ml, 5 mg/5ml 2 MO; *; +

metoclopramide hcl tabs or10 mg, 5 mg 1 MO; *; +

REGLAN (UseMetoclopramide HCl) NF MO

Inflammatory Bowel AgentsAPRISO 3 MO; +

ASACOL HD 3 MO; +



64

Drug Name DrugTier

Requirements/Limits

AZULFIDINE (UseSulfasalazine) NF MO

AZULFIDINE EN-TABS(Use Sulfasalazine) NF MO

balsalazide disodium 2 MO; *; +

CANASA 3 MO; +

CIMZIA 5 PA

CIMZIA STARTER KIT 5 PA

COLAZAL (UseBalsalazide Disodium) NF MO

DELZICOL 3 MO; +

DIPENTUM 5 MO

ENTYVIO 5 PA

LIALDA 3 MO; +

mesalamine enem re 1 MO; *; +

mesalamine w/ cleanser 2 MO; *; +

PENTASA 4 MO; +

REMICADE 5 PA

ROWASA (UseMesalamine w/ Cleanser) 5 MO

sulfasalazine tabs or 2 MO; *; +

sulfasalazine tbec or 2 MO; *; +

Intestinal Acidifierslactulose (encephalopathy) 2 MO; *; +

Irritable Bowel Syndrome (IBS) Agentsalosetron hcl 5 MO

LINZESS 3 MO; +

LOTRONEX (UseAlosetron HCl) 5 MO

Peripheral Opioid Receptor Antagonists

Drug Name DrugTier

Requirements/Limits

MOVANTIK 4 MO; +

RELISTOR KIT 12MG/0.6ML 4 +

RELISTOR SOLN 12MG/0.6ML 4 MO; +

RELISTOR SOLN 8MG/0.4ML 5 MO

Phosphate Binder AgentsAURYXIA 5 MO

calcium acetate (phosphatebinder) 2 MO; *; +

FOSRENOL 3 MO; +

PHOSLO (Use CalciumAcetate (PhosphateBinder))

NFMO

PHOSLYRA 4 MO; +

RENAGEL 800 MG 4 MO; +

RENVELA 3 MO; +

SEVELAMERCARBONATE 3 MO; +

VELPHORO 5 MO

Short Bowel Syndrome (SBS) AgentsGATTEX 5 PA; LA

GENITOURINARY AGENTS - MISCELLANEOUS- Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary SystemAlkalinizerspotassium citrate(alkalinizer) 1080 mg 2 MO; *; +

potassium citrate(alkalinizer) 540 mg 1 MO; *; +

UROCIT-K 10 (UsePotassium Citrate(Alkalinizer))

NFMO

UROCIT-K 5 (UsePotassium Citrate(Alkalinizer))

NFMO

Cystinosis Agents



65

Drug Name DrugTier

Requirements/Limits

CYSTAGON 4 +

PROCYSBI 4 LA; +

Genitourinary Irrigantsacetic acid ir 0.25 % 1 MO; *; +

neomycin/polymyxin b gu 1 MO; *; +

sodium chloride (guirrigant) 2 MO; *; +

Interstitial Cystitis AgentsELMIRON 4 MO; +

Prostatic Hypertrophy Agentsalfuzosin hcl 2 MO; *; +

AVODART (UseDutasteride) 3 GL; MO; +

CARDURA XL 4 MO; +

dutasteride 2 GL; MO; *; +

finasteride tabs or 2 GL; MO; *; +

FLOMAX (Use TamsulosinHCl) NF MO

JALYN 3 GL; MO; +

PROSCAR (UseFinasteride) NF GL; MO

RAPAFLO 4 MO; +

tamsulosin hcl 2 MO; *; +

UROXATRAL (UseAlfuzosin HCl) NF MO

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinationscolchicine w/ probenecid 1 MO; *; +

Gout Agents

allopurinol tabs or 100 mg 1 QL(8 ea daily);MO; *; +

Drug Name DrugTier

Requirements/Limits

allopurinol tabs or 300 mg 1 QL(2 ea daily);MO; *; +

COLCHICINE TABS OR 3 MO; +

COLCRYS 3 MO; +

ULORIC 3 MO; +

ZYLOPRIM 100 MG (UseAllopurinol) NF QL(8 ea daily);

MOZYLOPRIM 300 MG (UseAllopurinol) NF QL(2 ea daily);

MOUricosuricsprobenecid 2 MO; *; +

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood DisordersBradykinin B2 Receptor AntagonistsFIRAZYR 5

Complement InhibitorsBERINERT 5

CINRYZE 5 LA

RUCONEST 5

Hematorheologic Agentspentoxifylline tbcr or 2 MO; *; +

Plasma Kallikrein InhibitorsKALBITOR 5

Platelet Aggregation InhibitorsAGGRENOX 3 MO; +

AGRYLIN (Use AnagrelideHCl) NF MO

anagrelide hcl 1 MO; *; +

ASPIRIN/DIPYRIDAMOLE 3 MO; +

BRILINTA 3 MO; +

cilostazol 1 MO; *; +



66

Drug Name DrugTier

Requirements/Limits

clopidogrel bisulfate 300mg 2 *; +

clopidogrel bisulfate 75 mg 2 MO; *; +

dipyridamole tabs or 25mg, 50 mg, 75 mg 2 AL; MO; *; +

EFFIENT 3 MO; +

PERSANTINE (UseDipyridamole) NF AL; MO

PLAVIX 300 MG (UseClopidogrel Bisulfate) NF

PLAVIX 75 MG (UseClopidogrel Bisulfate) NF MO

PLETAL (Use Cilostazol) NF MO

ticlopidine hcl 2 AL; *; +

ZONTIVITY 3 MO; +

Protamineprotamine sulfate soln iv 2 MO; *; +

HEMATOPOIETIC AGENTS - Drugs to TreatBlood DisordersAgents for Gaucher DiseaseCERDELGA 5 PA

CEREZYME 5 LA

ELELYSO 5

VPRIV 5

ZAVESCA 5 LA

Agents for Sickle Cell AnemiaDROXIA 4 MO; +

Hematopoietic Growth FactorsARANESP ALBUMINFREE SOLN 10MCG/0.4ML, 25 MCG/ML,40 MCG/ML, 60 MCG/ML

4

PA; +

Drug Name DrugTier

Requirements/Limits

ARANESP ALBUMINFREE SOLN 100 MCG/ML,150 MCG/0.75ML, 200MCG/ML, 300 MCG/ML

5

PA

ARANESP ALBUMINFREE SOSY 100MCG/0.5ML, 150MCG/0.3ML, 200MCG/0.4ML, 300MCG/0.6ML, 500 MCG/ML

5

PA

ARANESP ALBUMINFREE SOSY 25MCG/0.42ML, 40MCG/0.4ML, 60MCG/0.3ML

4

PA; +

EPOGEN 4 PA; +

GRANIX 5 PA

LEUKINE 5 PA

MIRCERA 100MCG/0.3ML, 50MCG/0.3ML, 75MCG/0.3ML

4

PA; +

MIRCERA 200 MCG/0.3ML 5 PA

NEULASTA 5 PA

NEULASTA DELIVERYKIT 5 PA

NEUMEGA 3 PA; +

NEUPOGEN 5 PA

PROCRIT 10000 UNIT/ML,2000 UNIT/ML, 3000UNIT/ML, 4000 UNIT/ML

3PA; +

PROCRIT 20000 UNIT/ML,40000 UNIT/ML 5 PA

PROMACTA 12.5 MG 5 QL(12 eadaily); LA

PROMACTA 25 MG 5 QL(6 ea daily);LA





67

Drug Name DrugTier

Requirements/Limits

ZARXIO 5 PA

Stem Cell MobilizersMOZOBIL 5

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood DisordersHemostatics - SystemicAMICAR TABS 1000 MG 5 MO

AMINOCAPROIC ACIDTABS OR 1000 MG 5 MO

aminocaproic acid tabs or500 mg 1 MO; *; +

CYKLOKAPRON (UseTranexamic Acid) NF

LYSTEDA (UseTranexamic Acid) NF MO

tranexamic acid soln iv 100mg/ml 1 *; +

tranexamic acid tabs or650 mg 1 MO; *; +

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTSBarbiturate HypnoticsBUTISOL SODIUM 4 AL; MO; +

phenobarbital elix or 20mg/5ml 2 AL; MO; *; +

phenobarbital soln or 20mg/5ml 2 AL; MO; *; +

phenobarbital tabs or 100mg, 15 mg, 16.2 mg, 30mg, 32.4 mg, 60 mg, 64.8mg, 97.2 mg

2

AL; MO; *; +

Hypnotics - Tricyclic AgentsSILENOR 4 MO; +

Non-Barbiturate HypnoticsAMBIEN 10 MG (UseZolpidem Tartrate) NF AL; QL(1 ea

daily); MOAMBIEN 5 MG (UseZolpidem Tartrate) NF AL; QL(2 ea

daily); MOAMBIEN CR 12.5 MG (UseZolpidem Tartrate) NF AL; QL(1 ea

daily); MO

Drug Name DrugTier

Requirements/Limits

AMBIEN CR 6.25 MG (UseZolpidem Tartrate) NF AL; QL(2 ea

daily); MO

EDLUAR 4 AL; MO; +

eszopiclone 2 AL; MO; *; +

flurazepam hcl 1 MO; *; +

HALCION (Use Triazolam) NF MO

INTERMEZZO 4 AL; MO; +

LUNESTA (UseEszopiclone) 4 AL; MO; +

RESTORIL (UseTemazepam) NF MO

SONATA (Use Zaleplon) NF AL; MO

temazepam 2 MO; *; +

triazolam 2 MO; *; +

zaleplon 2 AL; MO; *; +

zolpidem tartrate tabs 10mg 2 AL; QL(1 ea

daily); MO; *; +

zolpidem tartrate tabs 5 mg 2 AL; QL(2 eadaily); MO; *; +

zolpidem tartrate tbcr 12.5mg 2 AL; QL(1 ea

daily); MO; *; +zolpidem tartrate tbcr 6.25mg 2 AL; QL(2 ea

daily); MO; *; +

ZOLPIMIST 4 AL; MO; +

Orexin Receptor Antagonists

BELSOMRA 10 MG 4 PA; QL(2 eadaily); MO; +

BELSOMRA 15 MG, 20MG 4 PA; QL(1 ea

daily); MO; +

BELSOMRA 5 MG 4 PA; QL(4 eadaily); MO; +

Selective Melatonin Receptor AgonistsHETLIOZ 5 PA

ROZEREM 4 MO; +



68

Drug Name DrugTier

Requirements/Limits

LAXATIVES - Bowel Treatment Drugs

Laxative Combinationsbisacodyl-peg 3350-potchloride-sod bicarb-sodchloride

2MO; *; +

COLYTE-FLAVOR PACKS227.1GM-21.5GM-5.53GM-2.82GM-6.36GM

4+

COLYTE-FLAVOR PACKS240GM-22.72GM-5.84GM-2.98GM-6.72GM (Use PEG3350-KCl-Sod Bicarb-SodChloride-Sod Sulfate)

NF

MO

GOLYTELY 227.1GM-21.5GM-5.53GM-2.82GM-6.36GM

4MO; +

GOLYTELY 236GM-22.74GM-5.86GM-2.97GM-6.74GM (Use PEG 3350-KCl-Sod Bicarb-SodChloride-Sod Sulfate)

NF

MO

mag cit-bisacodyl-petrolat-peg 3350-metoclopramide-electrol

2*; +

MOVIPREP 4 MO; +

NULYTELY/FLAVORPACKS (Use PEG 3350-Potassium Chloride-SodBicarbonate-Sod Chloride)

NF

MO

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 2 MO; *; +

peg 3350-potassiumchloride-sod bicarbonate-sod chloride

2MO; *; +

PREPOPIK 4 MO; +

SUPREP BOWEL PREP 4 MO; +

Laxatives - Miscellaneouslactulose 2 MO; *; +

polyethylene glycol 3350pack or 2 RX/OTC; MO;

*; +polyethylene glycol 3350powd or 2 RX/OTC; MO;

*; +

Drug Name DrugTier

Requirements/Limits

Saline LaxativesOSMOPREP 4 MO; +

LOCAL ANESTHETICS-Parenteral - Drugs forNumbingLocal Anesthetics - Amideslidocaine hcl (local anesth.)1 %, 2 % 1 MO; *; +

prilocaine hcl 2 *; +

XYLOCAINE IJ 1 %, 2 %(Use Lidocaine HCl (LocalAnesth.))

NFMO

XYLOCAINE-MPF 1 %(Use Lidocaine HCl (LocalAnesth.))

NFMO

MACROLIDES - Drugs to Treat BacterialInfectionsAzithromycinazithromycin solr iv 500 mg 2 MO; *; +

azithromycin susr or 100mg/5ml, 200 mg/5ml 2 MO; *; +

azithromycin tabs or 250mg, 500 mg, 600 mg 2 MO; *; +

ZITHROMAX SOLR IV 500MG (Use Azithromycin) NF MO

ZITHROMAX SUSR OR100 MG/5ML, 200 MG/5ML(Use Azithromycin)

NFMO

ZITHROMAX TABS OR250 MG, 500 MG, 600 MG(Use Azithromycin)

NFMO

ZITHROMAX TRI-PAK(Use Azithromycin) NF MO

ZITHROMAX Z-PAK (UseAzithromycin) NF MO

ZMAX 4 MO; +

ClarithromycinBIAXIN (UseClarithromycin) NF MO

BIAXIN XL (UseClarithromycin) NF MO



69

Drug Name DrugTier

Requirements/Limits

BIAXIN XL PAC (UseClarithromycin) NF MO

clarithromycin susr or 125mg/5ml, 250 mg/5ml 2 MO; *; +

clarithromycin tabs or 250mg, 500 mg 2 MO; *; +

clarithromycin tb24 or 500mg 2 MO; *; +

Erythromycins

E.E.S. GRANULES 4 QL(100 mldaily); MO; +

ERYPED 200 4 QL(100 mldaily); MO; +

ERYPED 400 4 QL(50 mldaily); MO; +

erythromycin base cpep250 mg 2 QL(16 ea

daily); MO; *; +erythromycin base tabs250 mg 2 QL(16 ea

daily); MO; *; +erythromycin base tabs500 mg 2 QL(8 ea daily);

MO; *; +erythromycin base tbec250 mg 2 QL(16 ea

daily); MO; *; +erythromycin base tbec333 mg 2 QL(12 ea

daily); MO; *; +erythromycin base tbec500 mg 2 QL(8 ea daily);

MO; *; +erythromycinethylsuccinate tabs or 1 QL(10 ea

daily); MO; *; +

erythromycin lactobionate 2 500 MG;QL(8ea daily); *; +

erythromycin stearate 1 QL(16 eadaily); MO; *; +

PCE 333 MG 4 QL(12 eadaily); MO; +

PCE 500 MG 4 QL(8 ea daily);MO; +

FidaxomicinDIFICID 5 MO

MEDICAL DEVICES

Bandages-Dressings-Tapegauze pads 2" x 2" 1 RX/OTC; MO

Drug Name DrugTier

Requirements/Limits

Misc. DevicesALCOHOL PADS 3 RX/OTC; MO

Parenteral Therapy SuppliesINSULIN SYRINGES ANDPEN NEEDLES 3 MO

MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadachesMigraine Combinationsergotamine w/ caffeine 2 MO; *; +

TREXIMET 4 MO; +

Migraine Products - NSAIDsCAMBIA 4 MO; +

Migraine ProductsD.H.E. 45 (UseDihydroergotamineMesylate)

NFMO

dihydroergotaminemesylate soln ij 1 mg/ml 1 MO; *; +

DIHYDROERGOTAMINEMESYLATE SOLN NA 4MG/ML

5MO

ergotamine tartrate subl sl 2 *; +

MIGRANAL 5 MO

Serotonin Agonists

almotriptan malate 2 QL(0.4 eadaily); MO; *; +

AMERGE (Use NaratriptanHCl) NF QL(0.3 ea

daily); MOAXERT (Use AlmotriptanMalate) 4 QL(0.4 ea

daily); MO; +

FROVA 4 QL(0.6 eadaily); MO; +

IMITREX SOLN SC 6MG/0.5ML (UseSumatriptan Succinate)

NFQL(0.27 mldaily); MO

IMITREX STATDOSEREFILL 4 MG/0.5ML (UseSumatriptan Succinate)




70

Drug Name DrugTier

Requirements/Limits

IMITREX STATDOSEREFILL 6 MG/0.5ML (UseSumatriptan Succinate)


IMITREX STATDOSESYSTEM 4 MG/0.5ML (UseSumatriptan Succinate)


IMITREX STATDOSESYSTEM 6 MG/0.5ML (UseSumatriptan Succinate)


IMITREX TABS OR 100MG (Use SumatriptanSuccinate)


IMITREX TABS OR 25 MG(Use SumatriptanSuccinate)


IMITREX TABS OR 50 MG(Use SumatriptanSuccinate)


MAXALT 10 MG (UseRizatriptan Benzoate) NF QL(0.4 ea

daily); MOMAXALT 5 MG (UseRizatriptan Benzoate) NF QL(0.8 ea

daily); MOMAXALT-MLT 10 MG (UseRizatriptan Benzoate) NF QL(0.4 ea

daily); MOMAXALT-MLT 5 MG (UseRizatriptan Benzoate) NF QL(0.8 ea

daily); MO

naratriptan hcl 1 QL(0.3 eadaily); MO; *; +

RELPAX 4 QL(0.2 eadaily); MO; +

rizatriptan benzoate tabs10 mg 2 QL(0.4 ea

daily); MO; *; +rizatriptan benzoate tabs 5mg 2 QL(0.8 ea

daily); MO; *; +rizatriptan benzoate tbdp10 mg 2 QL(0.4 ea

daily); MO; *; +rizatriptan benzoate tbdp 5mg 2 QL(0.8 ea

daily); MO; *; +sumatriptan succinate soajsc 4 mg/0.5ml 2 QL(0.14 ml

daily); MO; *; +sumatriptan succinate soajsc 6 mg/0.5ml 2 QL(0.27 ml

daily); MO; *; +sumatriptan succinate soctsc 4 mg/0.5ml 2 QL(0.14 ml

daily); MO; *; +sumatriptan succinate soctsc 6 mg/0.5ml 2 QL(0.27 ml

daily); MO; *; +

Drug Name DrugTier

Requirements/Limits

sumatriptan succinate solnsc 6 mg/0.5ml 2 QL(0.27 ml

daily); MO; *; +sumatriptan succinate sosysc 6 mg/0.5ml 2 QL(0.27 ml

daily); *; +sumatriptan succinate tabsor 100 mg 2 QL(0.3 ea

daily); MO; *; +sumatriptan succinate tabsor 25 mg 2 QL(0.9 ea

daily); MO; *; +sumatriptan succinate tabsor 50 mg 2 QL(0.6 ea

daily); MO; *; +SUMAVEL DOSEPRO 4MG/0.5ML 4 QL(0.14 ml

daily); +SUMAVEL DOSEPRO 6MG/0.5ML 4 QL(0.14 ml

daily); MO; +

zolmitriptan tabs 2.5 mg 2 QL(4 ea daily);MO; *; +

zolmitriptan tabs 5 mg 2 QL(2 ea daily);MO; *; +

zolmitriptan tbdp 2.5 mg 2 QL(4 ea daily);MO; *; +

zolmitriptan tbdp 5 mg 2 QL(2 ea daily);MO; *; +

ZOMIG NASAL SPRAY 4 QL(2 ea daily);MO; +

ZOMIG SOLN NA 2.5 MG 4 QL(4 ea daily);MO; +

ZOMIG TABS OR 2.5 MG(Use Zolmitriptan) NF QL(4 ea daily);

MOZOMIG TABS OR 5 MG(Use Zolmitriptan) NF QL(2 ea daily);

MOZOMIG ZMT 2.5 MG (UseZolmitriptan) NF QL(4 ea daily);

MOZOMIG ZMT 5 MG (UseZolmitriptan) NF QL(2 ea daily);

MO

MINERALS & ELECTROLYTES

Chlorideammonium chloride soln iv 2 MO; *; +

Electrolyte Mixturesdextrose in lactated ringers 1 *; +

dextrose w/ sodiumchloride 0.45%-2.5% 2 *; +

dextrose w/ sodiumchloride 0.45%-5% 1 *; +



71

Drug Name DrugTier

Requirements/Limits

dextrose w/ sodiumchloride 0.9%-5% 1 MO; *; +

lactated ringer's 1 *; +

parenteral electrolytes 2 B/D; *; +

potassium chloride indextrose & sodium chloride0.45%-20meq/l-5%

1*; +

Fluoridesodium fluoride tabs or 1mg 1 *; +

Magnesiummagnesium sulfate soln ij50 % 1 MO; *; +

PotassiumK-TAB 10 MEQ (UsePotassium Chloride) NF MO

MICRO-K (Use PotassiumChloride) NF MO

potassium chloride cpcr or10 meq, 8 meq 2 MO; *; +

POTASSIUM CHLORIDEER 2 MO; *; +

potassium chloridemicroencapsulated crystalscr

2MO; *; +

potassium chloride soln iv2 meq/ml 1 MO; *; +

potassium chloride soln or10 %, 20 % 2 *; +

potassium chloride tbcr or10 meq, 8 meq 2 MO; *; +

Sodiumsodium chloride soln iv0.45 % 2 *; +

sodium chloride soln iv 0.9% 2 MO; *; +

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical Orallidocaine hcl (mouth-throat)2 % 2 MO; *; +

Anti-infectives - Throat

Drug Name DrugTier

Requirements/Limits

clotrimazole lozg mt 2 MO; *; +

clotrimazole troc mt 2 MO; *; +

nystatin (mouth-throat) 2 MO; *; +

Antiseptics - Mouth/Throatchlorhexidine gluconate(mouth-throat) 1 MO; *; +

PERIDEX (UseChlorhexidine Gluconate(Mouth-Throat))

NFMO

Steroids - Mouth/Throattriamcinolone acetonide(mouth) 2 MO; *; +

Throat Products - Misc.cevimeline hcl 2 MO; *; +

EVOXAC (Use CevimelineHCl) NF MO

pilocarpine hcl (oral) 2 MO; *; +

SALAGEN (UsePilocarpine HCl (Oral)) NF MO

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat SpasmsCentral Muscle Relaxants

baclofen tabs or 10 mg 2 QL(8 ea daily);MO; *; +

baclofen tabs or 20 mg 2 QL(4 ea daily);MO; *; +

carisoprodol tabs or 250mg, 350 mg 2 AL; MO; *; +

chlorzoxazone 2 AL; MO; *; +

cyclobenzaprine hcl tabs or10 mg, 5 mg, 7.5 mg 2 AL; MO; *; +

metaxalone 2 AL; MO; *; +

methocarbamol tabs or 500mg, 750 mg 2 AL; MO; *; +

NORFLEX (UseOrphenadrine Citrate) NF AL; MO

orphenadrine citrate soln ij30 mg/ml 2 AL; MO; *; +



72

Drug Name DrugTier

Requirements/Limits

orphenadrine citrate tb12or 100 mg 2 AL; MO; *; +

PARAFON FORTE DSC(Use Chlorzoxazone) NF AL; MO

ROBAXIN TABS OR 500MG (Use Methocarbamol) NF AL; MO

ROBAXIN-750 (UseMethocarbamol) NF AL; MO

SKELAXIN (UseMetaxalone) NF AL; MO

SOMA 350 MG (UseCarisoprodol) NF AL; MO

tizanidine hcl caps or 2 mg 2 QL(18 eadaily); MO; *; +

tizanidine hcl caps or 4 mg 2 QL(9 ea daily);MO; *; +

tizanidine hcl caps or 6 mg 2 QL(6 ea daily);MO; *; +

tizanidine hcl tabs or 2 mg 2 QL(18 eadaily); MO; *; +

tizanidine hcl tabs or 4 mg 2 QL(9 ea daily);MO; *; +

ZANAFLEX CAPS 2 MG(Use Tizanidine HCl) NF QL(18 ea

daily); MOZANAFLEX CAPS 4 MG(Use Tizanidine HCl) NF QL(9 ea daily);

MOZANAFLEX CAPS 6 MG(Use Tizanidine HCl) NF QL(6 ea daily);

MOZANAFLEX TABS 4 MG(Use Tizanidine HCl) NF QL(9 ea daily);

MODirect Muscle RelaxantsDANTRIUM (UseDantrolene Sodium) NF MO

dantrolene sodium caps or100 mg, 25 mg, 50 mg 1 MO; *; +

Muscle Relaxant Combinationscarisoprodol w/ aspirin 2 AL; MO; *; +

carisoprodol w/ aspirin &codeine 2 AL; MO; *; +

orphenadrine w/ aspirin &caff 2 AL; *; +

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or SinusNasal Agent Combinations

Drug Name DrugTier

Requirements/Limits

DYMISTA 4 MO; +

Nasal Anti-infectivesBACTROBAN NASAL 4 MO; +

Nasal AntiallergyASTEPRO (Use AzelastineHCl) 3 MO; +

azelastine hcl 2 MO; *; +

olopatadine hcl (nasal) 2 MO; *; +

PATANASE (UseOlopatadine HCl (Nasal)) 4 MO; +

Nasal AnticholinergicsATROVENT (UseIpratropium Bromide(Nasal))

NFMO

ipratropium bromide (nasal) 2 MO; *; +

Nasal SteroidsBECONASE AQ 4 MO; +

budesonide (nasal) 2 MO; *; +

FLONASE (UseFluticasone Propionate(Nasal))

NFRX/OTC; MO

flunisolide (nasal) 2 MO; *; +

fluticasone propionate(nasal) 2 RX/OTC; MO;

*; +

NASONEX 3 MO; +

OMNARIS 4 MO; +

QNASL 4 MO; +

QNASL CHILDRENS 4 MO; +

RHINOCORT AQUA (UseBudesonide (Nasal)) 4 MO; +

triamcinolone acetonide(nasal) 2 RX/OTC; MO;

*; +

VERAMYST 4 MO; +



73

Drug Name DrugTier

Requirements/Limits

ZETONNA 4 MO; +

Sympathomimetic Decongestantstetrahydrozoline hcl soln na 2 *; +

NEUROMUSCULAR AGENTS - Drugs toRelax/Paralyze MusclesALS AgentsRILUTEK (Use Riluzole) 5 MO

riluzole 2 MO; *; +

Neuromuscular Blocking Agent - NeurotoxinsBOTOX 4 PA; +

XEOMIN 4 PA; +

NUTRIENTS

Carbohydratesdextrose soln iv 10 % 2 B/D; *; +

dextrose soln iv 5 % 1 MO; B/D; *; +

Lipidsfat emulsion 20 gm/100ml 2 B/D; *; +

LIPOSYN III1.2GM/100ML-20GM/100ML-2.5GM/100ML (Use FatEmulsion)

4

B/D; +

Proteinsamino acid infusion 15% 2 B/D

Drug Name DrugTier

Requirements/Limits

amino acid infusion34meq/l-356mg/100ml-880mg/100ml-406mg/100ml-390mg/100ml-356mg/100ml-152mg/100ml-52meq/l-372mg/100ml-526mg/100ml-492mg/100ml-526mg/100ml-34mg/100ml-492mg/100ml-1760mg/100ml-1760mg/100ml

2

B/D; *; +

AMINOSYN II 15% (Useamino acid infusion) 4 B/D

CLINIMIX2.75%/DEXTROSE 5% 4 B/D; +

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Beta-blockers - OphthalmicBETAGAN (UseLevobunolol HCl) NF MO

betaxolol hcl (ophth) 1 MO; *; +

BETIMOL 4 MO; +

BETOPTIC-S 3 MO; +

carteolol hcl (ophth) 1 MO; *; +

COMBIGAN 4 MO; +

COSOPT (UseDorzolamide HCl-TimololMaleate)

NFMO

COSOPT PF 4 MO; +

dorzolamide hcl-timololmaleate 2 MO; *; +

ISTALOL 3 MO; +

LEVOBUNOLOL HCL 0.25% 4 MO; +

levobunolol hcl 0.5 % 2 MO; *; +

metipranolol 1 MO; *; +



74

Drug Name DrugTier

Requirements/Limits

timolol maleate (ophth)solg 0.25 %, 0.5 % 2 MO; *; +

timolol maleate (ophth)soln 0.25 %, 0.5 % 1 MO; *; +

TIMOPTIC (Use TimololMaleate (Ophth)) NF MO

TIMOPTIC-XE (UseTimolol Maleate (Ophth)) NF MO

Cycloplegic Mydriaticscyclopentolate hcl soln op0.5 %, 1 %, 2 % 1 MO; *; +

MioticsISOPTO CARPINE (UsePilocarpine HCl) 4 MO; +

PHOSPHOLINE IODIDE 4 +

pilocarpine hcl soln op 1 %,2 %, 4 % 2 MO; *; +

Ophthalmic - Angiogenesis InhibitorsEYLEA 5 LA

Ophthalmic Adrenergic AgentsALPHAGAN P 0.1 % 3 MO; +

ALPHAGAN P 0.15 % (UseBrimonidine Tartrate) NF MO

apraclonidine hcl 1 MO; *; +

brimonidine tartrate 2 MO; *; +

IOPIDINE 0.5 % (UseApraclonidine HCl) NF MO

IOPIDINE 1 % 4 MO; +

SIMBRINZA 4 MO; +

Ophthalmic Anti-infectivesAZASITE 4 MO; +

bacitracin (ophthalmic) 2 MO; *; +

bacitracin-polymyxin b(ophth) 1 MO; *; +

BESIVANCE 4 MO; +

Drug Name DrugTier

Requirements/Limits

BLEPH-10 (UseSulfacetamide Sodium(Ophth))

NFMO

CILOXAN OINT 4 MO; +

CILOXAN SOLN (UseCiprofloxacin HCl (Ophth)) NF MO

ciprofloxacin hcl (ophth) 2 MO; *; +

erythromycin (ophth) 2 MO; *; +

gatifloxacin (ophth) 2 MO; *; +

gentamicin sulfate (ophth) 2 MO; *; +

levofloxacin (ophth) 1 MO; *; +

MOXEZA 3 MO; +

NATACYN 3 MO; +

neomycin-bacitracin zn-polymyxin 1 MO; *; +

neomycin-polymyxin-gramicidin 1 MO; *; +

OCUFLOX (Use Ofloxacin(Ophth)) NF MO

ofloxacin (ophth) 2 MO; *; +

polymyxin b-trimethoprim 2 MO; *; +

POLYTRIM (UsePolymyxin B-Trimethoprim) NF MO

sulfacetamide sodium(ophth) 2 MO; *; +

tobramycin (ophth) 2 MO; *; +

TOBREX OINT 4 MO; +

TOBREX SOLN (UseTobramycin (Ophth)) NF MO

trifluridine soln op 1 MO; *; +

VIGAMOX 3 MO; +

VIROPTIC (UseTrifluridine) NF MO



75

Drug Name DrugTier

Requirements/Limits

ZIRGAN 4 MO; +

ZYMAXID (UseGatifloxacin (Ophth)) NF MO

Ophthalmic Decongestantsnaphazoline hcl 1 MO; *; +

Ophthalmic ImmunomodulatorsRESTASIS 3 MO; +

Ophthalmic Local Anestheticsproparacaine hcl soln op 1 MO; *; +

Ophthalmic SteroidsALREX 4 MO; +

bacitracin-poly-neomycin-hc 1 MO; *; +

BLEPHAMIDE 4 MO; +

dexamethasone sodiumphosphate (ophth) 1 MO; *; +

DUREZOL 3 MO; +

FLAREX 3 MO; +

fluorometholone (ophth) 2 MO; *; +

FML 3 MO; +

FML FORTE 3 MO; +

FML LIQUIFILM (UseFluorometholone (Ophth)) NF MO

LOTEMAX 4 MO; +

MAXIDEX 4 MO; +

MAXITROL (UseNeomycin-Polymy-Dexameth)

NFMO

neomycin-polymy-dexameth 2 MO; *; +

neomycin-polymyxin-hc(ophth) 1 MO; *; +

Drug Name DrugTier

Requirements/Limits

OMNIPRED (UsePrednisolone Acetate(Ophth))

NFMO

PRED FORTE (UsePrednisolone Acetate(Ophth))

NFMO

PRED MILD 3 MO; +

prednisolone acetate(ophth) 2 MO; *; +

prednisolone sodiumphosphate (ophth) 1 MO; *; +

sulfacetamide sod-prednisolone 1 MO; *; +

TOBRADEX OINT 4 MO; +

TOBRADEX ST 4 MO; +

TOBRADEX SUSP (UseTobramycin-Dexamethasone)

NFMO

tobramycin-dexamethasone 2 MO; *; +

VEXOL 4 MO; +

ZYLET 3 MO; +

Ophthalmics - Misc.ACULAR (Use KetorolacTromethamine (Ophth)) NF MO

ACULAR LS (UseKetorolac Tromethamine(Ophth))

NFMO

ACUVAIL 4 MO; +

ALOCRIL 4 MO; +

ALOMIDE 4 MO; +

azelastine hcl (ophth) 2 MO; *; +

AZOPT 3 MO; +

BEPREVE 4 MO; +

bromfenac sodium (ophth) 2 Once dailydosing;MO; *; +



76

Drug Name DrugTier

Requirements/Limits

cromolyn sodium (ophth) 2 MO; *; +

CYSTARAN 4

Limited to 60ml per 28days;QL(2.15ml daily); LA; +

diclofenac sodium (ophth) 2 MO; *; +

dorzolamide hcl 2 MO; *; +

ELESTAT (Use EpinastineHCl (Ophth)) NF MO

epinastine hcl (ophth) 1 MO; *; +

flurbiprofen sodium 1 MO; *; +

ILEVRO 3 MO; +

ketorolac tromethamine(ophth) 2 MO; *; +

LASTACAFT 4 MO; +

NEVANAC 3 MO; +

OCUFEN (Use FlurbiprofenSodium) NF MO

OPTIVAR (Use AzelastineHCl (Ophth)) NF MO

PATADAY 3 MO; +

PATANOL 4 MO; +

PROLENSA 4 MO; +

TRUSOPT (UseDorzolamide HCl) NF MO

Prostaglandins - OphthalmicBIMATOPROST 3 MO; +

latanoprost 2 MO; *; +

LUMIGAN 3 MO; +

RESCULA 4 +

TRAVATAN Z 3 MO; +

Drug Name DrugTier

Requirements/Limits

travoprost 2 MO; *; +

XALATAN (UseLatanoprost) NF MO

ZIOPTAN 4 MO; +

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneousacetic acid (otic) 1 MO; *; +

acetic acid-aluminumacetate 1 MO; *; +

Otic Anti-infectivesofloxacin (otic) 2 MO; *; +

Otic CombinationsCIPRO HC 4 MO; +

CIPRODEX 3 MO; +

COLY-MYCIN S 4 MO; +

CORTISPORIN SOLN OT10000UNIT/ML-3.5MG/ML-1% (Use Neomycin-Polymyxin-HC (Otic))

NF

MO

CORTISPORIN-TC 4 MO; +

neomycin-polymyxin-hc(otic) 2 MO; *; +

Otic SteroidsDERMOTIC (UseFluocinolone Acetonide(Otic))

NFMO

fluocinolone acetonide(otic) 2 MO; *; +

hydrocortisone w/aceticacid 2 MO; *; +

VOSOL HC (UseHydrocortisone w/AceticAcid)

NFMO

OXYTOCICS - Drugs to Prevent/Control UterineBleedingOxytocics



77

Drug Name DrugTier

Requirements/Limits

methylergonovine maleatetabs or 0.2 mg 1 MO; *; +

PASSIVE IMMUNIZING AGENTS - AntibodyDrugs to Treat Low Immune SystemImmune SerumsBIVIGAM 5 B/D

FLEBOGAMMA DIF 10 % 5 B/D

GAMASTAN S/D 4 B/D; +

GAMMAGARD LIQUID 5 B/D

GAMMAKED 5 B/D

GAMUNEX-C 5 B/D

HIZENTRA 1 GM/5ML 4 B/D; +

HIZENTRA 10 GM/50ML, 2GM/10ML, 4 GM/20ML 5 B/D

OCTAGAM 10 GM/100ML,2 GM/20ML, 20GM/200ML, 5 GM/50ML

5B/D

PRIVIGEN 5 B/D

VARIZIG 5

Monoclonal AntibodiesSYNAGIS 5

Passive Immunizing Agents - CombinationsHYQVIA 5 B/D

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillinsamoxicillin caps 250 mg,500 mg 1 MO; *; +

amoxicillin chew 125 mg,250 mg 2 MO; *; +

amoxicillin susr 125mg/5ml, 200 mg/5ml, 250mg/5ml, 400 mg/5ml

2MO; *; +

amoxicillin tabs 500 mg,875 mg 2 MO; *; +

Drug Name DrugTier

Requirements/Limits

ampicillin caps 250 mg,500 mg 2 MO; *; +

ampicillin sodium ij 1 gm 2 MO; *; +

ampicillin sodium ij 125 mg 2 *; +

ampicillin sodium ij 2 gm 1 MO; *; +

ampicillin sodium iv 1 gm,10 gm, 2 gm 2 *; +

ampicillin susr 125 mg/5ml 2 *; +

ampicillin susr 250 mg/5ml 2 MO; *; +

Natural PenicillinsBICILLIN L-A 1200000UNIT/2ML, 2400000UNIT/4ML

4MO; +

penicillin g potassium 20mu, 20000000 unit,5000000 unit

1MO; *; +

penicillin g procaine 2 MO; *; +

penicillin g sodium 2 *; +

penicillin v potassium 2 MO; *; +

Penicillin Combinationsamoxicillin & potclavulanate 2 MO; *; +

ampicillin & sulbactamsodium ij 1gm-2gm 1 MO; *; +

ampicillin & sulbactamsodium iv 1gm-2gm, 5gm-10gm

2*; +

AUGMENTIN ES-600 (UseAmoxicillin & PotClavulanate)

NFMO

AUGMENTIN SUSR250MG/5ML-62.5MG/5ML(Use Amoxicillin & PotClavulanate)

NF

MO

AUGMENTIN TABS500MG-125MG, 875MG-125MG (Use Amoxicillin &Pot Clavulanate)

NF

MO



78

Drug Name DrugTier

Requirements/Limits

AUGMENTIN XR (UseAmoxicillin & PotClavulanate)

NFMO

piperacillin sodium-tazobactam sodium 1 *; +

UNASYN 1GM-2GM (UseAmpicillin & SulbactamSodium)

NFMO

ZOSYN SOLN0.25GM/50ML-2GM/50ML-5%, 0.375GM/50ML-3GM/50ML-5%,0.5GM/100ML-4GM/100ML-5%

4

+

ZOSYN SOLR 0.25GM-2GM, 0.375GM-3GM,0.5GM-4GM, 4.5GM-36GM(Use Piperacillin Sodium-Tazobactam Sodium)

NF

Penicillinase-Resistant Penicillinsdicloxacillin sodium 2 MO; *; +

nafcillin sodium ij 1 gm 2 *; +

nafcillin sodium ij 10 gm 5

nafcillin sodium ij 2 gm 5 MO

nafcillin sodium iv 1 gm, 2gm 2 *; +

PROGESTINS - Hormone Replacement/ModifyingDrugsProgestinsmedroxyprogesteroneacetate 1 MO; *; +

MEGACE ES (UseMegestrol Acetate(Appetite))

4AL; MO; +

megestrol acetate(appetite) 2 AL; MO; *; +

norethindrone acetate tabsor 1 MO; *; +

progesterone micronizedcaps or 100 mg, 200 mg 2 MO; *; +

PROMETRIUM (UseProgesterone Micronized) NF MO

Drug Name DrugTier

Requirements/Limits

PROVERA (UseMedroxyprogesteroneAcetate)

NFMO

PSYCHOTHERAPEUTIC AND NEUROLOGICALAGENTS - MISC. - Drugs to Treat Mental andEmotional ConditionsAgents for Chemical Dependencyacamprosate calcium 2 MO; *; +

CAMPRAL (UseAcamprosate Calcium) NF MO

disulfiram tabs or 250 mg,500 mg 1 MO; *; +

Anti-Cataplectic AgentsXYREM 5 LA

Antidementia AgentsARICEPT (Use DonepezilHydrochloride) NF MO

ARICEPT ODT (UseDonepezil Hydrochloride) NF MO

donepezil hydrochloride 2 MO; *; +

EXELON CAPS OR 1.5MG, 3 MG, 4.5 MG, 6 MG(Use Rivastigmine Tartrate)

NFMO

EXELON PT24 TD 13.3MG/24HR, 4.6 MG/24HR,9.5 MG/24HR (UseRivastigmine)

3

MO; +

galantamine hydrobromide 2 MO; *; +

memantine hcl soln 2mg/ml 2 AL; MO; *; +

memantine hcl tabs 10 mg,5 mg 2 MO; *; +

NAMENDA SOLN 10MG/5ML (Use MemantineHCl)

4AL; MO; +

NAMENDA TABS 10 MG, 5MG (Use Memantine HCl) 4 MO; +

NAMENDA TITRATIONPAK (Use Memantine HCl) 4 MO; +

NAMENDA XR 14 MG 4 AL; QL(2 eadaily); MO; +



79

Drug Name DrugTier

Requirements/Limits

NAMENDA XR 21 MG, 28MG 4 AL; QL(1 ea

daily); MO; +

NAMENDA XR 7 MG 4 AL; QL(4 eadaily); MO; +

NAMENDA XR TITRATIONPACK 4 AL; MO; +

RAZADYNE (UseGalantamineHydrobromide)

NFMO

RAZADYNE ER (UseGalantamineHydrobromide)

NFMO

rivastigmine 2 MO; *; +

rivastigmine tartrate 2 MO; *; +

Combination Psychotherapeuticschlordiazepoxide-amitriptyline 2 AL; MO; *; +

olanzapine-fluoxetine hcl 2 MO; *; +

perphenazine-amitriptyline 2 AL; MO; *; +

SYMBYAX (UseOlanzapine-FluoxetineHCl)

NFMO

Fibromyalgia AgentsSAVELLA 4 PA; MO; +

SAVELLA TITRATIONPACK 4 PA; MO; +

Movement Disorder Drug Therapytetrabenazine 5

XENAZINE (UseTetrabenazine) 5 LA

Multiple Sclerosis AgentsAMPYRA 5

AUBAGIO 5 PA

AVONEX 5 PA

AVONEX PEN 5 PA

BETASERON 5 PA

Drug Name DrugTier

Requirements/Limits

COPAXONE 20 MG/ML(Use Glatiramer Acetate) 5 PA

COPAXONE 40 MG/ML 5 PA

EXTAVIA 5 PA

GILENYA 5 PA

glatiramer acetate 5 PA

LEMTRADA 5 PA; LA

PLEGRIDY 5 PA

PLEGRIDY STARTERPACK 5 PA

REBIF 5 PA

REBIF REBIDOSE 5 PA

REBIF REBIDOSETITRATIONPACK 5 PA

REBIF TITRATION PACK 5 PA

TECFIDERA 5 PA

TECFIDERA STARTERPACK 5 PA

TYSABRI 5 PA

Postherpetic Neuralgia (PHN) Agentsgabapentin & lidocaine-menthol 2 *; +

GRALISE 4 MO; +

GRALISE STARTER 4 MO; +

Premenstrual Dysphoric Disorder (PMDD) Agentsfluoxetine hcl (pmdd) cap10 mg, 20 mg NF

Pseudobulbar Affect (PBA) AgentsNUEDEXTA 3 MO; +

Psychotherapeutic and Neurological Agents -ergoloid mesylates tabs or 2 AL; MO; *; +



80

Drug Name DrugTier

Requirements/Limits

ORAP (Use Pimozide) 4 MO; +

pimozide 2 MO; *; +

Restless Leg Syndrome (RLS) AgentsHORIZANT 4 MO; +

Smoking Deterrentsbupropion hcl (smokingdeterrent) 1 QL(2 ea daily);

MO; *; +

CHANTIX 4 PA; MO; +

CHANTIX CONTINUINGMONTHPAK 4 PA; MO; +

CHANTIX STARTINGMONTH PAK 4 PA; MO; +

NICOTROL INHALER 4 QL(17 eadaily); MO; +

NICOTROL NS 4 MO; +

ZYBAN (Use BupropionHCl (Smoking Deterrent)) NF QL(2 ea daily);

MOVasomotor Symptom AgentsBRISDELLE 4 MO; +

RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung ConditionsAlpha-Proteinase Inhibitor (Human)ARALAST NP 1000 MG 5 LA

GLASSIA 4 LA; +

PROLASTIN-C 5 LA

ZEMAIRA 5 LA

Cystic Fibrosis AgentsKALYDECO PACK 50 MG,75 MG 5 PA

KALYDECO TABS 150 MG 5 PA; LA

ORKAMBI 5 PA

PULMOZYME 5 B/D

Pulmonary Fibrosis Agents

Drug Name DrugTier

Requirements/Limits

ESBRIET 5 PA; LA

OFEV 5 PA; QL(2 eadaily); LA

SULFONAMIDES - Drugs to Treat BacterialInfectionsSulfonamidessulfadiazine tabs or 2 MO; *; +

TETRACYCLINES - Drugs to Treat BacterialInfectionsTetracyclinesADOXA PAK 1/100 (UseDoxycycline(Monohydrate))

NFMO

ADOXA PAK 2/100 (UseDoxycycline(Monohydrate))

NFMO

ADOXA TABS 100 MG(Use Doxycycline(Monohydrate))

NFMO

demeclocycline hcl 1 MO; *; +

DORYX 150 MG (UseDoxycycline Hyclate) NF MO

DORYX 200 MG 4 PA; MO; +

doxycycline (monohydrate)caps 100 mg, 50 mg, 75mg

2MO; *; +

doxycycline (monohydrate)susr 25 mg/5ml 2 MO; *; +

doxycycline (monohydrate)tabs 100 mg, 150 mg, 50mg, 75 mg

2MO; *; +

doxycycline hyclate caps or100 mg, 50 mg 1 MO; *; +

doxycycline hyclate solr iv100 mg 2 MO; *; +

doxycycline hyclate tabs or100 mg, 20 mg 1 MO; *; +

doxycycline hyclate tbec or100 mg, 150 mg, 75 mg 2 MO; *; +

doxycycline hyclate w/cleanser 2 MO; *; +



81

Drug Name DrugTier

Requirements/Limits

doxycycline hyclate w/eyelid cleanser & spray 2 *; +

MINOCIN CAPS OR 100MG, 50 MG, 75 MG (UseMinocycline HCl)

NFMO

minocycline hcl caps or100 mg, 50 mg, 75 mg 2 MO; *; +

minocycline hcl tabs or 100mg, 50 mg 2 MO; *; +

MONODOX (UseDoxycycline(Monohydrate))

NFMO

tetracycline hcl caps or 250mg, 500 mg 1 MO; *; +

VIBRAMYCIN CAPS 100MG (Use DoxycyclineHyclate)

NFMO

VIBRAMYCIN SUSR 25MG/5ML (Use Doxycycline(Monohydrate))

4MO; +

VIBRAMYCIN SYRP 50MG/5ML 4 MO; +

THYROID AGENTS - Drugs to Regulate ThyroidHormonesAntithyroid Agentsmethimazole tabs or 10mg, 5 mg 2 MO; *; +

propylthiouracil tabs or 2 MO; *; +

Thyroid HormonesCYTOMEL (UseLiothyronine Sodium) NF MO

levothyroxine sodium tabsor 100 mcg, 112 mcg, 125mcg, 137 mcg, 150 mcg,175 mcg, 200 mcg, 25mcg, 300 mcg, 50 mcg, 75mcg, 88 mcg

2

MO; *; +

liothyronine sodium tabs or25 mcg, 5 mcg, 50 mcg 2 MO; *; +

SYNTHROID (UseLevothyroxine Sodium) 4 MO; +

TOXOIDS

Toxoid Combinations

Drug Name DrugTier

Requirements/Limits

ADACEL 4 +

BOOSTRIX 4 +

DAPTACEL 4 +

DIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC

4+

INFANRIX 4 +

TENIVAC 4 B/D; +

TETANUS/DIPHTHERIATOXOIDS-ADSORBED 4 B/D; +

TETANUS/DIPHTHERIATOXOIDS-ADSORBEDADULT

4B/D; +

ToxoidsTETANUS TOXOIDADSORBED 4 B/D; +

ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach ConditionsAntispasmodicsBENTYL CAPS OR 10 MG(Use Dicyclomine HCl) NF MO

BENTYL TABS OR 20 MG(Use Dicyclomine HCl) NF MO

CANTIL 4 MO; +

dicyclomine hcl 2 MO; *; +

glycopyrrolate soln ij 0.2mg/ml 2 MO; *; +

glycopyrrolate tabs or 1 mg 1 QL(8 ea daily);MO; *; +

glycopyrrolate tabs or 1.5mg 2 QL(5.34 ea

daily); *; +

glycopyrrolate tabs or 2 mg 1 QL(4 ea daily);MO; *; +

methscopolamine bromidetabs or 2.5 mg, 5 mg 1 MO; *; +

PAMINE (UseMethscopolamine Bromide) NF MO

PAMINE FORTE (UseMethscopolamine Bromide) NF MO



82

Drug Name DrugTier

Requirements/Limits

propantheline bromide tabsor 2 MO; *; +

ROBINUL FORTE (UseGlycopyrrolate) NF QL(4 ea daily);

MOROBINUL SOLN IJ 0.2MG/ML (UseGlycopyrrolate)

NFMO

ROBINUL TABS OR 1 MG(Use Glycopyrrolate) NF QL(8 ea daily);

MOH-2 Antagonists

cimetidine tabs or 200 mg 1 RX/OTC; MO;*; +

cimetidine tabs or 300 mg,400 mg, 800 mg 1 MO; *; +

famotidine in nacl 2 *; +

famotidine soln iv 20mg/2ml, 200 mg/20ml, 40mg/4ml

1*; +

famotidine susr or 40mg/5ml 2 MO; *; +

famotidine tabs or 20 mg 1 RX/OTC; MO;*; +

famotidine tabs or 40 mg 1 MO; *; +

nizatidine caps 150 mg,300 mg 1 MO; *; +

PEPCID 20 MG,40MG/5ML (Use Famotidine) NF MO

ranitidine hcl caps or 150mg, 300 mg 2 MO; *; +

ranitidine hcl syrp or 15mg/ml, 150 mg/10ml, 75mg/5ml

2MO; *; +

ranitidine hcl tabs or 150mg 1 RX/OTC; MO;

*; +ranitidine hcl tabs or 300mg 1 MO; *; +

ZANTAC SYRP OR 15MG/ML (Use RanitidineHCl)

NFMO

ZANTAC TABS OR 150MG (Use Ranitidine HCl) NF RX/OTC; MO

ZANTAC TABS OR 300MG (Use Ranitidine HCl) NF MO

Misc. Anti-Ulcer

Drug Name DrugTier

Requirements/Limits

CARAFATE SUSP 1GM/10ML 4 MO; +

CARAFATE TABS 1 GM(Use Sucralfate) NF MO

sucralfate tabs or 2 MO; *; +

Proton Pump InhibitorsDEXILANT 3 ST; MO; +

esomeprazole magnesium20 mg 2 ST; RX/OTC;

MO; *; +esomeprazole magnesium40 mg 2 ST; MO; *; +

esomeprazole sodium 20mg 2 *; +

ESOMEPRAZOLESTRONTIUM 4 ST; +

lansoprazole cpdr or 15 mg 2 RX/OTC; MO;*; +

lansoprazole cpdr or 30 mg 2 MO; *; +

NEXIUM CPDR 20 MG 4 ST; RX/OTC;MO; +

NEXIUM CPDR 20 MG(Use EsomeprazoleMagnesium)

4ST; RX/OTC;MO; +

NEXIUM CPDR 40 MG 4 ST; MO; +

NEXIUM CPDR 40 MG(Use EsomeprazoleMagnesium)

4ST; MO; +

NEXIUM I.V. 20 MG (UseEsomeprazole Sodium) NF

NEXIUM PACK 10 MG, 2.5MG, 20 MG, 40 MG, 5 MG 4 ST; MO; +

omeprazole cpdr or 10 mg,20 mg, 40 mg 2 MO; *; +

pantoprazole sodium solr iv40 mg 2 *; +

pantoprazole sodium tbecor 20 mg, 40 mg 1 MO; *; +

PREVACID 15 MG (UseLansoprazole) NF RX/OTC; MO

PREVACID 30 MG (UseLansoprazole) NF MO



83

Drug Name DrugTier

Requirements/Limits

PRILOSEC CPDR 10 MG,20 MG, 40 MG (UseOmeprazole)

NFMO

PROTONIX PACK OR 40MG 4 QL(1 ea daily);

MO; +PROTONIX SOLR IV 40MG (Use PantoprazoleSodium)

NF

PROTONIX TBEC OR 20MG, 40 MG (UsePantoprazole Sodium)

NFMO

Ulcer Drugs - ProstaglandinsCYTOTEC (UseMisoprostol) NF MO

misoprostol tabs or 100mcg, 200 mcg 2 MO; *; +

Ulcer Therapy Combinationsamoxicillin-clarithromycinw/ lansoprazole 2 MO; *; +

omeprazole-sodiumbicarbonate 20mg-1100mg 2 RX/OTC; MO;

*; +omeprazole-sodiumbicarbonate 40mg-1100mg 2 MO; *; +

PREVPAC (UseAmoxicillin-Clarithromycinw/ Lansoprazole)

NFMO

PYLERA 4 MO; +

ZEGERID CAPS 20MG-1100MG (UseOmeprazole-SodiumBicarbonate)

NF

RX/OTC; MO

ZEGERID CAPS 40MG-1100MG (UseOmeprazole-SodiumBicarbonate)

NF

MO

ZEGERID PACK 20MG-1680MG 4 ST; MO; +

ZEGERID PACK 40MG-1680MG 4 MO; +

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney InfectionsUrinary Anti-infectivesFURADANTIN (UseNitrofurantoin) 5 AL; MO

Drug Name DrugTier

Requirements/Limits

HIPREX (UseMethenamine Hippurate) NF MO

MACROBID (UseNitrofurantoin MonohydMacro)

NFMO

MACRODANTIN 100 MG,50 MG (Use NitrofurantoinMacrocrystal)

NFAL; MO

MACRODANTIN 25 MG(Use NitrofurantoinMacrocrystal)

4AL; MO; +

methenamine hippurate 2 MO; *; +

MONUROL 4 MO; +

nitrofurantoin macrocrystalcaps or 100 mg, 25 mg, 50mg

2AL; MO; *; +

nitrofurantoin monohydmacro 2 MO; *; +

nitrofurantoin susp or 2 AL; MO; *; +

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder SpasmsUrinary Antispasmodic - AntimuscarinicsDETROL (Use TolterodineTartrate) NF MO

DETROL LA (UseTolterodine Tartrate) NF MO

DITROPAN XL (UseOxybutynin Chloride) NF MO

ENABLEX 3 MO; +

GELNIQUE 4 MO; +

oxybutynin chloride syrp 5mg/5ml 2 MO; *; +

oxybutynin chloride tabs 5mg 1 MO; *; +

oxybutynin chloride tb24 10mg, 15 mg, 5 mg 2 MO; *; +

OXYTROL 4 RX/OTC; MO;+

SANCTURA (UseTrospium Chloride) NF MO



84

Drug Name DrugTier

Requirements/Limits

SANCTURA XR (UseTrospium Chloride) NF MO

tolterodine tartrate 2 MO; *; +

TOVIAZ 3 MO; +

trospium chloride 2 MO; *; +

VESICARE 3 MO; +

Urinary Antispasmodics - Beta-3 AdrenergicMYRBETRIQ 4 MO; +

Urinary Antispasmodics - Cholinergic Agonistsbethanechol chloride 10mg, 25 mg, 5 mg, 50 mg 2 MO; *; +

Urinary Antispasmodics - Direct Muscle Relaxantsflavoxate hcl 1 MO; *; +

VACCINES

Bacterial VaccinesACTHIB 4 +

MENACTRA 4 +

MENOMUNE-A/C/Y/W-135 4 +

MENVEO 4 +

PEDVAX HIB 4 +

TYPHIM VI 4 +

Mixed Vaccine CombinationsCOMVAX 4 +

Viral VaccinesCERVARIX 4 +

ENGERIX-B SUSP IJ 10MCG/0.5ML, 20 MCG/ML 4 B/D; +

GARDASIL 4 +

HAVRIX 4 +

Drug Name DrugTier

Requirements/Limits

IMOVAX RABIES(H.D.C.V.) 4 B/D; +

IPOL INACTIVATED IPV 4 +

IXIARO 4 +

M-M-R II 4 +

PROQUAD 4 +

RABAVERT 4 B/D; +

RECOMBIVAX HB 4 B/D; +

ROTARIX 4 +

ROTATEQ 3 +

TWINRIX 4 +

VAQTA 4 +

VARIVAX 4 +

YF-VAX 4 +

ZOSTAVAX 4 +

VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low HormonesVaginal Anti-infectivesbutoconazole nitrate (onedose) 2 MO; *; +

CLEOCIN CREA VA 2 %(Use ClindamycinPhosphate Vaginal)

NFMO

CLEOCIN SUPP VA 100MG 4 MO; +

clindamycin phosphatevaginal 1 MO; *; +

METROGEL-VAGINAL(Use MetronidazoleVaginal)

NFMO

metronidazole vaginal 2 MO; *; +

miconazole nitrate vaginalsupp 200 mg 1 MO; *; +



85

Drug Name DrugTier

Requirements/Limits

TERAZOL 3 (UseTerconazole Vaginal) NF MO

TERAZOL 7 (UseTerconazole Vaginal) NF MO

terconazole vaginal 2 MO; *; +

Vaginal Estrogensestradiol vaginal 1 MO; *; +

ESTRING 4 MO; +

FEMRING 4 MO; +

PREMARIN CREA VA0.625 MG/GM 3 MO; +

VAGIFEM 4 MO; +

Vaginal ProgestinsCRINONE 4 MO; +

ENDOMETRIN 4 MO; +

VASOPRESSORS - Drugs to Treat Heart andCirculation ConditionsAnaphylaxis Therapy AgentsADRENACLICK 3 MO; +

AUVI-Q 3 MO; +

EPINEPHRINE SOAJ IJ0.15 MG/0.15ML, 0.3MG/0.3ML

3MO; +

EPIPEN 2-PAK 3 MO; +

EPIPEN-JR 2-PAK 3 MO; +

Neurogenic Orthostatic Hypotension (NOH) -

NORTHERA 100 MG 5 PA; QL(18 eadaily)



Vasopressorsdobutamine hcl 1 *; +

Drug Name DrugTier

Requirements/Limits

dopamine hcl 160 mg/ml,80 mg/ml 2 *; +

midodrine hcl 1 MO; *; +



86

Indexabacavir sulfate 41abacavir sulfate-lamivudine-zidovudine 41ABELCET 26ABILIFY 1 MG/ML 41ABILIFY 10 MG 41ABILIFY 15 MG 41ABILIFY 2 MG 41ABILIFY 20 MG, 30 MG 41ABILIFY 5 MG 41ABILIFY 9.75 MG/1.3ML 41ABILIFY DISCMELT 10 MG 41ABILIFY DISCMELT 15 MG 41ABILIFY MAINTENA 41ABRAXANE 37ABSORICA 30 MG 53ABSTRAL 100 MCG 4ABSTRAL 200 MCG 4ABSTRAL 300 MCG, 400 MCG,600 MCG, 800 MCG 4acamprosate calcium 79ACANYA 53acarbose 21ACCOLATE 13ACCUPRIL 29ACCURETIC 30acebutolol hcl 200 mg, 400mg 46ACEON 4 MG 29ACEON 8 MG 29acetaminophen w/ codeine120mg/5ml-12mg/5ml 7acetaminophen w/ codeine300mg-15mg, 300mg-30mg,300mg-60mg 7acetaminophen-caff-dihydrocod 7acetazolamide 125 mg, 250mg 59acetazolamide 500 mg 59acetic acid (otic) 77acetic acid 0.25 % 66acetic acid-aluminumacetate 77acetylcysteine 10 %, 20 % 53acitretin 55ACTEMRA 3ACTHIB 85ACTIGALL 64ACTIMMUNE 37

ACTIQ 1200 MCG, 1600 MCG,400 MCG, 600 MCG, 800MCG 4ACTIQ 200 MCG 4ACTIVELLA 63ACTONEL 150 MG 60ACTONEL 30 MG, 5 MG 60ACTONEL 35 MG 60ACTOPLUS MET 21ACTOPLUS MET XR 15MG-1000MG 21ACTOPLUS MET XR 30MG-1000MG 21ACTOS 15 MG 23ACTOS 30 MG, 45 MG 23ACULAR 76ACULAR LS 76ACUVAIL 76acyclovir 200 mg 44acyclovir 200 mg/5ml 44acyclovir 400 mg, 800 mg 44acyclovir sodium 50 mg/ml 44acyclovir sodium 500 mg 44acyclovir topical 55ADACEL 82ADAGEN 47ADALAT CC 47adapalene 0.1 % 53adapalene 0.3 % 53ADASUVE 40ADCIRCA 48ADDERALL XR 1adefovir dipivoxil 43ADEMPAS 0.5 MG 48ADEMPAS 1 MG 48ADEMPAS 1.5 MG 48ADEMPAS 2 MG 48ADEMPAS 2.5 MG 48ADOXA 100 MG 81ADOXA PAK 1/100 81ADOXA PAK 2/100 81ADRENACLICK 86ADVAIR DISKUS 14ADVAIR HFA 14ADVICOR 28AEROSPAN 13AFINITOR 36AFINITOR DISPERZ 36

AFREZZA 23AGGRENOX 66AGRYLIN 66AKYNZEO 26ALBENZA 9albuterol sulfate 0.083 %, 0.5 %,0.63 mg/3ml, 1.25 mg/3ml 14albuterol sulfate 2 mg, 4 mg 14albuterol sulfate 2 mg/5ml 14albuterol sulfate 4 mg, 8 mg 14alclometasone dipropionate 56ALCOHOL PADS 70ALDACTAZIDE 25MG-25MG 59ALDACTAZIDE 50MG-50MG 59ALDACTONE 60ALDARA 58alendronate sodium 10 mg, 40mg, 5 mg 60alendronate sodium 35 mg, 70mg 60alendronate sodium 70mg/75ml 60alfuzosin hcl 66ALIMTA 100 MG 34ALIMTA 500 MG 34ALINIA 500 MG 10ALKERAN 2 MG 33ALKERAN 50 MG 33allopurinol 100 mg 66allopurinol 300 mg 66almotriptan malate 70ALOCRIL 76ALOMIDE 76ALORA 63alosetron hcl 65ALPHAGAN P 0.1 % 75ALPHAGAN P 0.15 % 75alprazolam 0.25 mg, 0.5 mg, 1mg, 2 mg 12alprazolam 0.5 mg, 1 mg, 2 mg, 3mg 12alprazolam 1 mg/ml 12ALREX 76ALTABAX 54ALTACE 29ALTOPREV 28ALVESCO 160 MCG/ACT 13ALVESCO 80 MCG/ACT 13

Index 1

amantadine hcl 100 mg 38amantadine hcl 50 mg/5ml 38AMARYL 1 MG 24AMARYL 2 MG 24AMARYL 4 MG 24AMBIEN 10 MG 68AMBIEN 5 MG 68AMBIEN CR 12.5 MG 68AMBIEN CR 6.25 MG 68AMBISOME 26amcinonide 56AMERGE 70AMICAR 1000 MG 68amifostine crystalline 37amikacin sulfate 1 gm/4ml, 500mg/2ml 2amiloride &hydrochlorothiazide 59amiloride hcl 60amino acid infusion 15% 74amino acid infusion 34meq/l-356mg/100ml-880mg/100ml-406mg/100ml-390mg/100ml-356mg/100ml-152mg/100ml-52meq/l-372mg/100ml-526mg/100ml-492mg/100ml-526mg/100ml-34mg/100ml-492mg/100ml-1760mg/100ml-1760mg/100ml 74AMINOCAPROIC ACID 1000MG 68aminocaproic acid 500 mg 68aminophylline 15aminosalicylic acid 33AMINOSYN II 15% (Use aminoacid infusion) 74amiodarone hcl 100 mg, 200 mg,400 mg 13amiodarone hcl 900mg/18ml 13AMITIZA 64amitriptyline hcl 21amlodipine besylate 10 mg 47amlodipine besylate 2.5 mg 47amlodipine besylate 5 mg 47amlodipine besylate-atorvastatincalcium 48amlodipine besylate-benazeprilhcl 30amlodipine besylate-valsartan 30

amlodipine-valsartan-hydrochlorothiazide 30ammonium chloride 71amoxapine 100 mg, 25 mg, 50mg 21amoxapine 150 mg 21amoxicillin & potclavulanate 78amoxicillin 125 mg, 250mg 78amoxicillin 125 mg/5ml, 200mg/5ml, 250 mg/5ml, 400mg/5ml 78amoxicillin 250 mg, 500mg 78amoxicillin 500 mg, 875mg 78amoxicillin-clarithromycin w/lansoprazole 84amphetamine sulfate 10 mg 1amphetamine sulfate 5 mg 1amphetamine-dextroamphetamine 1amphotericin b 50 mg 26ampicillin & sulbactam sodium1gm-2gm 78ampicillin & sulbactam sodium1gm-2gm, 5gm-10gm 78ampicillin 125 mg/5ml 78ampicillin 250 mg, 500 mg 78ampicillin 250 mg/5ml 78ampicillin sodium 1 gm 78ampicillin sodium 1 gm, 10 gm,2 gm 78ampicillin sodium 125 mg 78ampicillin sodium 2 gm 78AMPYRA 80AMTURNIDE 300MG-10MG-12.5MG, 300MG-10MG-25MG 30AMTURNIDE 300MG-5MG-12.5MG, 300MG-5MG-25MG 30ANADROL-50 8ANAFRANIL 21anagrelide hcl 66ANAPROX 3ANAPROX DS 3anastrozole 35ANCOBON 26ANDRODERM 8ANDROGEL 8ANDROGEL PUMP 8

ANGELIQ 0.5MG-1MG 63ANORO ELLIPTA 14ANTARA 130 MG 28ANTARA 30 MG 28ANTARA 43 MG 28ANTARA 90 MG 28APIDRA 23APIDRA SOLOSTAR 23APLENZIN 174 MG 19APLENZIN 348 MG, 522 MG19APOKYN 38apraclonidine hcl 75APRISO 64APTIOM 200 MG 16APTIOM 400 MG 16APTIOM 600 MG 16APTIOM 800 MG 16APTIVUS 100 MG/ML 42APTIVUS 250 MG 41ARALAST NP 1000 MG 81ARALEN 32ARANESP ALBUMIN FREE 10MCG/0.4ML, 25 MCG/ML, 40MCG/ML, 60 MCG/ML 67ARANESP ALBUMIN FREE 100MCG/0.5ML, 150 MCG/0.3ML,200 MCG/0.4ML, 300MCG/0.6ML, 500 MCG/ML 67ARANESP ALBUMIN FREE 100MCG/ML, 150 MCG/0.75ML, 200MCG/ML, 300 MCG/ML 67ARANESP ALBUMIN FREE 25MCG/0.42ML, 40 MCG/0.4ML, 60MCG/0.3ML 67ARAVA 4ARCALYST 2ARCAPTA NEOHALER 14argatroban 250 mg/2.5ml 16ARICEPT 79ARICEPT ODT 79ARIMIDEX 35aripiprazole 1 mg/ml 41aripiprazole 10 mg 41aripiprazole 15 mg 41aripiprazole 2 mg 41aripiprazole 20 mg, 30 mg 41aripiprazole 5 mg 41ARIPIPRAZOLE ODT 10MG 41

Index 2

ARIPIPRAZOLE ODT 15MG 41ARIXTRA 10 MG/0.8ML, 5MG/0.4ML, 7.5 MG/0.6ML 15ARIXTRA 2.5 MG/0.5ML 15ARNUITY ELLIPTA 13AROMASIN 35ARRANON 34ARTHROTEC 50 3ARTHROTEC 75 3ARZERRA 34ASACOL HD 64ASMANEX HFA 100MCG/ACT 13ASMANEX HFA 200MCG/ACT 13ASMANEX TWISTHALER 120METERED DOSES 13ASMANEX TWISTHALER 14METERED DOSES 13ASMANEX TWISTHALER 30METERED DOSES 110MCG/INH 14ASMANEX TWISTHALER 30METERED DOSES 220MCG/INH 14ASMANEX TWISTHALER 60METERED DOSES 14ASMANEX TWISTHALER 7METERED DOSES 14ASPIRIN/DIPYRIDAMOLE 66ASTAGRAF XL 44ASTEPRO 73ATACAND 30ATACAND HCT 30ATELVIA 60atenolol & chlorthalidone 30atenolol 100 mg, 25 mg, 50mg 46ATGAM 44ATIVAN 0.5 MG, 1 MG, 2MG 12ATIVAN 2 MG/ML 12ATIVAN 4 MG/ML 12atorvastatin calcium 28atovaquone 10atovaquone-proguanil hcl 32ATRALIN 53ATRIPLA 42ATROVENT 73ATROVENT HFA 13AUBAGIO 80

AUGMENTIN 250MG/5ML-62.5MG/5ML 78AUGMENTIN 500MG-125MG,875MG-125MG 78AUGMENTIN ES-600 78AUGMENTIN XR 79AURYXIA 65AUVI-Q 86AVALIDE 30AVANDAMET 2MG-1000MG 21AVANDAMET 2MG-500MG 21AVANDAMET 4MG-1000MG,4MG-500MG 21AVANDARYL 4MG-1MG, 4MG-2MG 21AVANDARYL 4MG-4MG, 8MG-4MG 21AVANDARYL 8MG-2MG 21AVANDIA 2 MG 23AVANDIA 4 MG 23AVANDIA 8 MG 23AVAPRO 30AVASTIN 34AVEED 8AVELOX 400 MG 63AVELOX ABC PACK 63AVINZA 4AVODART 66AVONEX 80AVONEX PEN 80AXERT 70AXIRON 8azacitidine 34AZACTAM 9AZASITE 75azathioprine 100 mg, 50 mg, 75mg 44azelastine hcl 73azelastine hcl (ophth) 76AZELEX 53AZILECT 39azithromycin 100 mg/5ml, 200mg/5ml 69azithromycin 250 mg, 500 mg,600 mg 69azithromycin 500 mg 69AZOPT 76AZOR 31

aztreonam 9AZULFIDINE 65AZULFIDINE EN-TABS 65bacitracin (ophthalmic) 75bacitracin-poly-neomycin-hc 76bacitracin-polymyxin b(ophth) 75baclofen 10 mg 72baclofen 20 mg 72BACTRIM 10BACTRIM DS 10BACTROBAN 54BACTROBAN NASAL 73balsalazide disodium 65BANZEL 200 MG 16BANZEL 40 MG/ML 16BANZEL 400 MG 16BARACLUDE 0.05 MG/ML 43BARACLUDE 0.5 MG, 1 MG 43BECONASE AQ 73BELEODAQ 36BELSOMRA 10 MG 68BELSOMRA 15 MG, 20 MG 68BELSOMRA 5 MG 68benazepril &hydrochlorothiazide 31benazepril hcl 10 mg, 20 mg, 40mg, 5 mg 29BENICAR 30BENICAR HCT 31BENLYSTA 45BENTYL 10 MG 82BENTYL 20 MG 82BENZACLIN 53BENZACLIN WITH PUMP 53BENZAMYCIN 53benzoyl peroxide-erythromycin 53benztropine mesylate 0.5 mg, 1mg, 2 mg 38benztropine mesylate 1mg/ml 38BEPREVE 76BERINERT 66BESIVANCE 75BETAGAN 74betamethasone dipropionate(topical) 56betamethasone dipropionateaugmented 56

Index 3

betamethasone sod phosphate &ace & bupivacaine &lidocaine 51betamethasone sod phosphate &acetate 51betamethasone sod phosphate &acetate & bupivacaine hcl 51betamethasone sod phosphate &acetate & lidocaine hcl 51betamethasone valerate 0.1% 56betamethasone valerate 0.12% 56BETAPACE 46BETAPACE AF 46BETASERON 80betaxolol hcl (ophth) 74betaxolol hcl 10 mg 46betaxolol hcl 20 mg 46bethanechol chloride 10 mg, 25mg, 5 mg, 50 mg 85BETHKIS 2BETIMOL 74BETOPTIC-S 74bexarotene 37BEYAZ 50BIAXIN 69BIAXIN XL 69BIAXIN XL PAC 70bicalutamide 35BICILLIN L-A 1200000UNIT/2ML, 2400000UNIT/4ML 78BICNU 33BIDIL 48BILTRICIDE 9BIMATOPROST 77bisacodyl-peg 3350-pot chloride-sod bicarb-sod chloride 69bisoprolol &hydrochlorothiazide 31bisoprolol fumarate 46BIVIGAM 78bleomycin sulfate 15 unit 35bleomycin sulfate 30 unit 35BLEPH-10 75BLEPHAMIDE 76BLINCYTO 34BONIVA 150 MG 60BONIVA 3 MG/3ML 60BOOSTRIX 82

BOSULIF 36BOTOX 74BREO ELLIPTA 25MCG/INH-100MCG/INH, 25MCG/INH-200MCG/INH 14BREVICON-28 50BRILINTA 66brimonidine tartrate 75BRINTELLIX 10 MG 20BRINTELLIX 20 MG 20BRINTELLIX 5 MG 20BRISDELLE 81bromfenac sodium (ophth) 76bromocriptine mesylate 2.5mg 38bromocriptine mesylate 5mg 38BROVANA 14budesonide 51budesonide (inhalation) 0.25mg/2ml 14budesonide (inhalation) 0.5mg/2ml 14budesonide (inhalation) 1mg/2ml 14budesonide (nasal) 73bumetanide 0.5 mg, 1 mg, 2mg 60BUMEX 60BUNAVAIL 8buprenorphine hcl 2 mg 8buprenorphine hcl 8 mg 8buprenorphine hcl-naloxone hcldihydrate 2mg-0.5mg 8buprenorphine hcl-naloxone hcldihydrate 8mg-2mg 8bupropion hcl (smokingdeterrent) 81bupropion hcl 100 mg 19bupropion hcl 150 mg 19bupropion hcl 150 mg, 200mg 19bupropion hcl 300 mg 19bupropion hcl 75 mg 19buspirone hcl 10 mg, 15 mg, 30mg, 5 mg, 7.5 mg 12BUSULFEX 33butalbital-acetaminophen-caffeine w/ codeine 300mg-50mg-40mg-30mg 7butalbital-acetaminophen-caffeine w/ codeine 325mg-50mg-40mg-30mg 7

butalbital-aspirin-caffeinew/cod 7BUTISOL SODIUM 68butoconazole nitrate (onedose) 85butorphanol tartrate 10 mg/ml 8BUTRANS 10 MCG/HR 8BUTRANS 15 MCG/HR 8BUTRANS 20 MCG/HR, 7.5MCG/HR 8BUTRANS 5 MCG/HR 8BYDUREON 23BYETTA 23BYSTOLIC 46cabergoline 62CADUET 48CALAN 47CALAN SR 47calcipotriene 55calcipotriene-betamethasonedipropionate 56calcitonin (salmon) 60calcitriol 0.25 mcg, 0.5 mcg 62calcitriol 1 mcg/ml 62CALCITRIOL 3 MCG/GM 55calcium acetate (phosphatebinder) 65CAMBIA 70CAMPRAL 79CAMPTOSAR 100 MG/5ML, 40MG/2ML 38CAMPTOSAR 300MG/15ML 38CANASA 65candesartan cilexetil 30candesartan cilexetil-hydrochlorothiazide 31CANTIL 82CAPASTAT SULFATE 33CAPEX 56CAPRELSA 36captopril 100 mg, 12.5 mg, 25mg, 50 mg 29CAPTOPRIL/HYDROCHLOROTHIAZIDE 31CARAC 55CARAFATE 1 GM 83CARAFATE 1 GM/10ML 83carbamazepine 100 mg 16carbamazepine 100 mg, 200 mg,300 mg 16

Index 4

carbamazepine 100 mg/5ml 16carbamazepine 200 mg 16carbamazepine 200 mg, 400mg 16CARBATROL 17carbidopa 38carbidopa-levodopa 38carbidopa-levodopa-entacapone

38carbinoxamine maleate 27carboplatin 150 mg/15ml, 600mg/60ml 33carboplatin 450 mg/45ml, 50mg/5ml 33CARDIZEM 47CARDIZEM CD 47CARDIZEM LA 120 MG 47CARDIZEM LA 180 MG, 240 MG,300 MG, 360 MG, 420 MG 47CARDURA 30CARDURA XL 66carisoprodol 250 mg, 350mg 72carisoprodol w/ aspirin 73carisoprodol w/ aspirin &codeine 73CARNITOR 330 MG 62carteolol hcl (ophth) 74carvedilol 12.5 mg 45carvedilol 25 mg 45carvedilol 3.125 mg 46carvedilol 6.25 mg 46CASODEX 35CATAFLAM 3CATAPRES 30CATAPRES-TTS-1 30CATAPRES-TTS-2 30CATAPRES-TTS-3 30CAYSTON 9CEDAX 400 MG 49cefaclor 125 mg/5ml, 250mg/5ml, 375 mg/5ml 49cefaclor 250 mg, 500 mg 49cefaclor monohydrate 49cefadroxil 1 gm 48cefadroxil 250 mg/5ml 48cefadroxil 500 mg 48cefadroxil 500 mg/5ml 48cefazolin in d5w 48cefazolin sodium 1 gm 49

cefazolin sodium 1 gm, 10gm 48cefazolin sodium 500 mg 48cefdinir 49CEFEPIME 1 GM/50ML, 2GM/100ML 50cefepime hcl 50cefixime 100 mg 49cefixime 100 mg/5ml, 200mg/5ml 49cefixime 200 mg 49cefixime 400 mg 49cefotaxime sodium 1 gm 49cefotaxime sodium 1 gm, 2gm 49cefotaxime sodium 10 gm 49cefotaxime sodium 2 gm, 500mg 49cefotetan disodium 1 gm, 10gm 49cefotetan disodium 2 gm 49cefoxitin sodium indextrose 49cefpodoxime proxetil 49cefprozil 125 mg/5ml 49cefprozil 250 mg, 500 mg 49cefprozil 250 mg/5ml 49ceftazidime 1 gm, 2 gm 49ceftazidime 6 gm 49CEFTIBUTEN 400 MG 49CEFTIN 250 MG, 500 MG 49ceftriaxone sodium 1 gm 49ceftriaxone sodium 10 gm 50ceftriaxone sodium 2 gm 49ceftriaxone sodium 250 mg49ceftriaxone sodium 500 mg49ceftriaxone sodium in dextrose20mg/ml 49ceftriaxone sodium in dextrose40mg/ml 49cefuroxime axetil 49cefuroxime sodium 1.5 gm 49cefuroxime sodium 7.5 gm 49cefuroxime sodium 750 mg49CELEBREX 3celecoxib 3CELESTONE-SOLUSPAN 52CELEXA 10 MG 19CELEXA 20 MG 19CELEXA 40 MG 19

CELLCEPT 45CELLCEPT INTRAVENOUS 45CELONTIN 18CENESTIN 63cephalexin 125 mg/5ml, 250mg/5ml 49cephalexin 250 mg, 500 mg 49cephalexin 750 mg 49CERDELGA 67CEREBYX 100 MG PE/2ML 18CEREBYX 500 MGPE/10ML 18CEREZYME 67CERVARIX 85CESAMET 26cetirizine hcl 1 mg/ml 27cetirizine hcl 1 mg/ml, 5mg/5ml 27cevimeline hcl 72CHANTIX 81CHANTIX CONTINUINGMONTHPAK 81CHANTIX STARTING MONTHPAK 81CHEMET 25CHENODAL 64chloramphenicol sodiumsuccinate 10chlordiazepoxide hcl 12chlordiazepoxide-amitriptyline

80chlorhexidine gluconate (mouth-throat) 72chloroquine phosphate 250 mg,500 mg 32chlorothiazide 60chlorpromazine hcl 10 mg, 100mg, 200 mg, 25 mg, 50 mg 41chlorpromazine hcl 25 mg/ml41chlorpromazine hcl 50mg/2ml 41chlorpropamide 100 mg 24chlorpropamide 250 mg 24chlorthalidone 25 mg, 50 mg 60chlorzoxazone 72cholestyramine 4 gm 27cholestyramine 4 gm/dose 27cholestyramine light 27choline fenofibrate 28chorionic gonadotropin 61ciclopirox 0.77 % 54

Index 5

ciclopirox 1 % 54ciclopirox 8 % 54ciclopirox olamine 54ciclopirox olamine &cleanser 54cidofovir 43cilostazol 66CILOXAN 75cimetidine 200 mg 83cimetidine 300 mg, 400 mg, 800mg 83CIMZIA 65CIMZIA STARTER KIT 65CINRYZE 66CIPRO 250 MG, 500 MG 64CIPRO 5 GM/100ML, 500MG/5ML 64CIPRO HC 77CIPRO I.V.-IN D5W200MG/100ML-5% 64CIPRO I.V.-IN D5W400MG/200ML-5% 64CIPRO XR 64CIPRODEX 77ciprofloxacin 250 mg/5ml, 500mg/5ml 64ciprofloxacin hcl (ophth) 75ciprofloxacin hcl 100 mg, 250 mg,500 mg, 750 mg 64ciprofloxacin in d5w200mg/100ml-5% 64ciprofloxacin in d5w400mg/200ml-5% 64ciprofloxacin-ciprofloxacinhcl 64cisplatin 33citalopram hydrobromide 10mg 19citalopram hydrobromide 10mg/5ml 19citalopram hydrobromide 20mg 19citalopram hydrobromide 40mg 19cladribine 34CLAFORAN 1 GM, 10 GM 50CLAFORAN 2 GM, 500 MG 50CLARINEX 5 MG 27CLARINEX REDITABS 5MG 27CLARINEX-D 12 HOUR 53CLARINEX-D 24 HOUR 53

clarithromycin 125 mg/5ml, 250mg/5ml 70clarithromycin 250 mg, 500mg 70clarithromycin 500 mg 70clemastine fumarate 0.67mg/5ml 27clemastine fumarate 2.68mg 27CLEOCIN 100 MG 85CLEOCIN 150 MG, 300 MG, 75MG 10CLEOCIN 2 % 85CLEOCIN IN D5W 10CLEOCIN PHOSPHATE300MG/50ML-5%,600MG/50ML-5%,900MG/50ML-5% 11CLEOCIN PHOSPHATE 600MG/4ML, 900 MG/6ML 10CLEOCIN-T 53CLIMARA 63CLIMARA PRO 63clindamycin hcl 150 mg, 300mg, 75 mg 11clindamycin palmitatehydrochloride 11clindamycin phosphate &cleanser 53clindamycin phosphate(topical) 53clindamycin phosphate 150mg/ml, 600 mg/4ml 11clindamycin phosphate 150mg/ml, 9000 mg/60ml 11clindamycin phosphate 600mg/4ml, 900 mg/6ml 11clindamycin phosphate ind5w 11clindamycin phosphatevaginal 85clindamycin phosphate-benzoylperoxide 53clindamycin phosphate-benzoylperoxide & moisturizer 53clindamycin phosphate-benzoylperoxide (refrigerate) 53CLINIMIX 2.75%/DEXTROSE5% 74clobetasol propionate 56clobetasol propionate &cleanser 56clobetasol propionate emollientbase 56clobetasol propionateemulsion 56CLOBEX 56

CLOCORTOLONEPIVALATE 56CLOCORTOLONE PIVALATEPUMP 56CLODERM 56CLODERM PUMP 56CLOLAR 34clomipramine hcl 25 mg, 50 mg,75 mg 21clonazepam 0.125 mg, 0.25 mg,0.5 mg, 1 mg, 2 mg 16clonazepam 0.5 mg 16clonazepam 1 mg 16clonazepam 2 mg 16clonidine & chlorthalidone 31clonidine hcl (adhd) 1clonidine hcl 0.1 mg, 0.2 mg, 0.3mg 30clonidine hcl 0.1 mg/24hr, 0.2mg/24hr, 0.3 mg/24hr 30clopidogrel bisulfate 300 mg 67clopidogrel bisulfate 75 mg 67clorazepate dipotassium 12clotrimazole 72clotrimazole (topical) 54clotrimazole w/betamethasone 54clozapine 40CLOZAPINE ODT 40CLOZARIL 40COARTEM 32codeine sulfate 15 mg 4CODEINE SULFATE 15 MG 4codeine sulfate 30 mg 4codeine sulfate 60 mg 4COGENTIN 38COLAZAL 65COLCHICINE 66colchicine w/ probenecid 66COLCRYS 66COLESTID 27COLESTID FLAVORED 5GM 27colestipol hcl 1 gm 27colestipol hcl 5 gm 27colistimethate sodium 9COLY-MYCIN M 9COLY-MYCIN S 77

Index 6

COLYTE-FLAVOR PACKS227.1GM-21.5GM-5.53GM-2.82GM-6.36GM 69COLYTE-FLAVOR PACKS240GM-22.72GM-5.84GM-2.98GM-6.72GM 69COMBIGAN 74COMBIPATCH 63COMBIVENT RESPIMAT 14COMBIVIR 42COMETRIQ 36COMPLERA 42COMTAN 38COMVAX 85CONCERTA 1CONDYLOX 58COPAXONE 80COPEGUS 43CORDARONE 13CORDRAN TAPE 56COREG 12.5 MG 46COREG 25 MG 46COREG 3.125 MG 46COREG 6.25 MG 46COREG CR 46CORGARD 46CORLANOR 48CORTEF 52CORTENEMA 9CORTIFOAM 9cortisone acetate 52CORTISPORIN 10000UNIT/GM-0.5%-0.5% 54CORTISPORIN 10000UNIT/ML-3.5MG/ML-1% 77CORTISPORIN 400UNIT/GM-5000UNIT/GM-0.5%-1% 54CORTISPORIN-TC 77CORZIDE 31COSENTYX 55COSENTYX SENSOREADYPEN 55COSMEGEN 35COSOPT 74COSOPT PF 74COUMADIN 1 MG, 10 MG, 2 MG,2.5 MG, 3 MG, 4 MG, 5 MG, 6MG, 7.5 MG 15COZAAR 30CREON 59

CRESEMBA 186 MG 26CRESEMBA 372 MG 26CRESTOR 28CRINONE 86CRIXIVAN 42cromolyn sodium 13cromolyn sodium(mastocytosis) 64cromolyn sodium (ophth) 77CUBICIN 10CUTIVATE 56cyclobenzaprine hcl 10 mg, 5mg, 7.5 mg 72cyclopentolate hcl 0.5 %, 1 %, 2% 75cyclophosphamide 1 gm, 500mg 33cyclophosphamide 25 mg, 50mg 33cycloserine 33CYCLOSET 23cyclosporine 100 mg, 25mg 45cyclosporine 50 mg/ml 45cyclosporine modified (formicroemulsion) 100 mg, 25 mg,50 mg 45CYKLOKAPRON 68CYMBALTA 20cyproheptadine hcl 2mg/5ml 27cyproheptadine hcl 4 mg 27CYRAMZA 34CYSTADANE 62CYSTAGON 66CYSTARAN 77cytarabine 100 mg/ml 34cytarabine 20 mg/ml 34CYTOMEL 82CYTOTEC 84CYTOVENE 43D.H.E. 45 70dacarbazine 100 mg 37dacarbazine 200 mg 37DACOGEN 34DALIRESP 13danazol 100 mg, 200 mg, 50mg 8DANTRIUM 73dantrolene sodium 100 mg, 25mg, 50 mg 73

dapsone 100 mg, 25 mg 10DAPTACEL 82DARAPRIM 32daunorubicin hcl 35DAUNOXOME 35DAYPRO 3DAYTRANA 30 MG/9HR 1DDAVP 62decitabine 34DELESTROGEN 63DELZICOL 65DEMADEX 60demeclocycline hcl 81DEMEROL 100 MG, 50 MG 4DEMSER 30DENAVIR 55DEPACON 18DEPAKENE 18DEPAKOTE 19DEPAKOTE ER 19DEPAKOTE SPRINKLES 19DEPEN TITRATABS 44DEPO-MEDROL 20 MG/ML 52DEPO-MEDROL 40 MG/ML, 80MG/ML 52DEPO-PROVERA 35DEPO-PROVERACONTRACEPTIVE 51DEPO-SUBQ PROVERA104 51DERMA-SMOOTHE/FSBODY 56DERMA-SMOOTHE/FSSCALP 56DERMATOP 56DERMOTIC 77desipramine hcl 10 mg, 100 mg,150 mg, 25 mg, 50 mg, 75mg 21desloratadine 5 mg 27desmopressin acetate 0.1 mg,0.2 mg 62desmopressin acetate 4mcg/ml 62desmopressin acetaterefrigerated 62desmopressin acetate spray 62desmopressin acetate sprayrefrigerated 62DESOGEN 50

Index 7

desogestrel & ethinylestradiol 50desogestrel-ethinyl estradiol(biphasic) 50DESONATE 56desonide 56DESOWEN 57desoximetasone 0.05 % 57DESOXIMETASONE 0.05 %57desoximetasone 0.05 %, 0.25% 57desoximetasone 0.25 % 57DESOXYN 1DESVENLAFAXINE ER 100 MG,50 MG 20DETROL 84DETROL LA 84dexamethasone 0.5 mg, 0.75 mg,1 mg, 1.5 mg, 2 mg, 4 mg, 6mg 52dexamethasone 0.5 mg/5ml 52dexamethasone 1 mg/ml 52dexamethasone 1.5 mg 52dexamethasone sod phos &bupivacaine hcl & lidocainehcl 52dexamethasone sodiumphosphate & bupivacaine hcl52dexamethasone sodiumphosphate & lidocaine hcl 52dexamethasone sodiumphosphate (ophth) 76dexamethasone sodiumphosphate 10 mg/ml 52dexamethasone sodiumphosphate 10 mg/ml, 120mg/30ml 52dexamethasone sodiumphosphate 100 mg/10ml, 20mg/5ml, 4 mg/ml 52DEXEDRINE 1DEXILANT 83dexmethylphenidate hcl 10 mg,15 mg, 20 mg 1dexmethylphenidate hcl 10 mg,2.5 mg, 5 mg 1dexrazoxane 37dextroamphetamine sulfate 10mg, 15 mg, 2.5 mg, 20 mg, 30mg, 5 mg, 7.5 mg 1dextroamphetamine sulfate 10mg, 15 mg, 5 mg 1dextrose 10 % 74dextrose 5 % 74

dextrose in lactated ringers71dextrose w/ sodium chloride0.45%-2.5% 71dextrose w/ sodium chloride0.45%-5% 71dextrose w/ sodium chloride0.9%-5% 72DIABETA 1.25 MG 24DIABETA 2.5 MG 24DIABETA 5 MG 24DIAMOX 59DIASTAT ACUDIAL 16DIASTAT PEDIATRIC 16diazepam 1 mg/ml 12diazepam 10 mg, 2 mg, 5mg 12DIAZEPAM 10 MG, 2.5 MG, 20MG 16diazepam 5 mg/ml 12DIBENZYLINE 30diclofenac potassium 3diclofenac sodium (actinickeratoses) 55diclofenac sodium (ophth) 77diclofenac sodium (topical) 54diclofenac sodium 100 mg 3diclofenac sodium 25 mg, 50mg, 75 mg 3diclofenac w/ misoprostol 3dicloxacillin sodium 79dicyclomine hcl 82didanosine 125 mg 42didanosine 200 mg, 250 mg,400 mg 42DIFFERIN 0.1 % 53DIFFERIN 0.3 % 53DIFICID 70diflorasone diacetate 57diflorasone diacetate emollientbase 57DIFLUCAN 26diflunisal 4DIGOXIN 0.05 MG/ML 48digoxin 0.125 mg, 0.25 mg, 125mcg, 250 mcg 48dihydroergotamine mesylate 1mg/ml 70DIHYDROERGOTAMINEMESYLATE 4 MG/ML 70DILANTIN-125 18DILATRATE SR 11

DILAUDID 1 MG/ML 4DILAUDID 2 MG 4DILAUDID 4 MG 4DILAUDID 8 MG 4DILAUDID-HP 10 MG/ML 4diltiazem hcl 100 mg 47diltiazem hcl 120 mg, 180 mg,240 mg 47diltiazem hcl 120 mg, 30 mg, 60mg, 90 mg 47diltiazem hcl 120 mg, 60 mg, 90mg 47diltiazem hcl coated beads 47diltiazem hcl extended releasebeads 47dimenhydrinate 50 mg/ml 25DIOVAN 30DIOVAN HCT 31DIPENTUM 65diphenhydramine hcl 50mg/ml 27diphenoxylate w/ atropine 25DIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC 82DIPROLENE 57DIPROLENE AF 57dipyridamole 25 mg, 50 mg, 75mg 67disopyramide phosphate 12disulfiram 250 mg, 500 mg 79DITROPAN XL 84divalproex sodium 19DIVIGEL 63dobutamine hcl 86DOCEFREZ 37DOCETAXEL 140 MG/7ML, 20MG/0.5ML, 20 MG/ML, 80MG/2ML, 80 MG/4ML 37DOCETAXEL 160 MG/16ML, 20MG/2ML, 200 MG/20ML, 80MG/8ML 37docetaxel 20 mg/ml, 80mg/4ml 37DOLOPHINE 10 MG 4DOLOPHINE 5 MG 5donepezil hydrochloride 79dopamine hcl 160 mg/ml, 80mg/ml 86DORIBAX 500 MG 10DORYX 150 MG 81DORYX 200 MG 81

Index 8

dorzolamide hcl 77dorzolamide hcl-timololmaleate 74DOVONEX 55doxazosin mesylate 30doxepin hcl 10 mg, 100 mg, 150mg, 25 mg, 50 mg, 75 mg 21doxepin hcl 10 mg/ml 21doxercalciferol 0.5 mcg, 1 mcg,2.5 mcg 62DOXIL 35doxorubicin hcl 10 mg 35doxorubicin hcl 2 mg/ml 35doxorubicin hcl 50 mg 36doxorubicin hcl liposomal 35DOXYCYCLINE 59doxycycline (monohydrate) 100mg, 150 mg, 50 mg, 75 mg 81doxycycline (monohydrate) 100mg, 50 mg, 75 mg 81doxycycline (monohydrate) 25mg/5ml 81doxycycline hyclate 100 mg 81doxycycline hyclate 100 mg, 150mg, 75 mg 81doxycycline hyclate 100 mg, 20mg 81doxycycline hyclate 100 mg, 50mg 81doxycycline hyclate w/cleanser 81doxycycline hyclate w/ eyelidcleanser & spray 82dronabinol 10 mg 26dronabinol 2.5 mg, 5 mg 26drospirenone-ethinylestradiol 50DROXIA 67DUAC 53DUAVEE 63DUETACT 22DUEXIS 3DULERA 14duloxetine hcl 20 mg, 30 mg, 60mg 20DUONEB 14DUOPA 38DURAGESIC 100 MCG/HR 5DURAGESIC 12 MCG/HR 5DURAGESIC 25 MCG/HR 5DURAGESIC 50 MCG/HR 5DURAGESIC 75 MCG/HR 5

DUREZOL 76dutasteride 66DYAZIDE 60DYMISTA 73dyphylline 15DYRENIUM 60E.E.S. GRANULES 70EC-NAPROSYN 3econazole nitrate 54EDARBI 30EDARBYCLOR 31EDECRIN 60EDLUAR 68EDURANT 42EFFEXOR XR 150 MG 20EFFEXOR XR 37.5 MG 20EFFEXOR XR 75 MG 20EFFIENT 67EFUDEX 55EGRIFTA 61ELDEPRYL 39ELELYSO 67ELESTAT 77ELESTRIN 63ELIDEL 58ELIGARD 35ELIQUIS 15ELITEK 37ELLA 51ELLENCE 36ELMIRON 66ELOCON 57ELOXATIN 100 MG/20ML 33ELOXATIN 50 MG/10ML 33EMCYT 35EMEND 125 MG, 80 MG 26EMEND 40 MG 26EMLA 58EMSAM 19EMTRIVA 42ENABLEX 84enalapril maleate &hydrochlorothiazide 31enalapril maleate 10 mg 29enalapril maleate 2.5 mg 29enalapril maleate 20 mg 29

enalapril maleate 5 mg 29enalaprilat 29ENBREL 4ENBREL SURECLICK 4ENDOMETRIN 86ENGERIX-B 10 MCG/0.5ML, 20MCG/ML 85ENJUVIA 0.3 MG, 0.45 MG, 0.9MG, 1.25 MG 63ENJUVIA 0.625 MG 63enoxaparin sodium 100 mg/ml,60 mg/0.6ml, 80 mg/0.8ml 15enoxaparin sodium 120mg/0.8ml, 150 mg/ml 15enoxaparin sodium 30 mg/0.3ml,40 mg/0.4ml 15enoxaparin sodium 300mg/3ml 15entacapone 38entecavir 43ENTOCORT EC 52ENTRESTO 48ENTYVIO 65EPIDUO 53epinastine hcl (ophth) 77EPINEPHRINE 0.15 MG/0.15ML,0.3 MG/0.3ML 86epinephrine hcl 0.1 mg/ml 14EPIPEN 2-PAK 86EPIPEN-JR 2-PAK 86epirubicin hcl 200 mg/100ml, 50mg/25ml 36EPIVIR 10 MG/ML 42EPIVIR 150 MG, 300 MG 42EPIVIR HBV 43eplerenone 25 mg 32eplerenone 50 mg 32EPOGEN 67EPROSARTAN MESYLATE 30EPZICOM 42EQUETRO 39ERAXIS 100 MG 26ERBITUX 34ergoloid mesylates 80ergotamine tartrate 70ergotamine w/ caffeine 70ERIVEDGE 35ERWINAZE 36ERYPED 200 70ERYPED 400 70

Index 9

erythromycin (acne aid) 53erythromycin (ophth) 75erythromycin base 250 mg 70erythromycin base 333 mg 70erythromycin base 500 mg 70erythromycin ethylsuccinate 70erythromycin lactobionate 70erythromycin stearate 70ESBRIET 81escitalopram oxalate 20esomeprazole magnesium 20mg 83esomeprazole magnesium 40mg 83esomeprazole sodium 20 mg83ESOMEPRAZOLESTRONTIUM 83estradiol & norethindroneacetate 63estradiol 0.025 mg/24hr, 0.0375mg/24hr, 0.05 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr 63estradiol 0.025 mg/24hr, 0.05mg/24hr, 0.06 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr 63estradiol 0.5 mg, 1 mg, 2 mg 63estradiol cypionate 63estradiol vaginal 86estradiol valerate 10 mg/ml, 20mg/ml, 40 mg/ml 63estradiol-norgestimate 63ESTRING 86estropipate 63eszopiclone 68ethambutol hcl 100 mg, 400mg 33ethosuximide 250 mg 18ethosuximide 250 mg/5ml 18ethynodiol diacet & ethestrad 50ETHYOL 37etidronate disodium 200 mg 60etidronate disodium 400 mg 61etodolac 200 mg, 300 mg 3etodolac 400 mg, 500 mg 3etodolac 400 mg, 500 mg, 600mg 3ETOPOPHOS 38etoposide 1 gm/50ml, 100mg/5ml 38etoposide 500 mg/25ml 38

EURAX 59EVAMIST 63EVISTA 61EVOCLIN 53EVOTAZ 42EVOXAC 72EVZIO 25EXALGO 12 MG 5EXALGO 16 MG 5EXALGO 32 MG 5EXALGO 8 MG 5EXELDERM 54EXELON 1.5 MG, 3 MG, 4.5MG, 6 MG 79EXELON 13.3 MG/24HR, 4.6MG/24HR, 9.5 MG/24HR 79exemestane 35EXFORGE 31EXFORGE HCT 31EXJADE 25EXTAVIA 80EXTINA 55EYLEA 75FABIOR 54FABRAZYME 35 MG 62famciclovir 44famotidine 20 mg 83famotidine 20 mg/2ml, 200mg/20ml, 40 mg/4ml 83famotidine 40 mg 83famotidine 40 mg/5ml 83famotidine in nacl 83FAMVIR 44FANAPT 1 MG, 10 MG, 12 MG,2 MG, 4 MG 39FANAPT 6 MG, 8 MG 39FANAPT TITRATIONPACK 40FARESTON 35FARXIGA 24FARYDAK 36FASLODEX 35fat emulsion 20 gm/100ml 74FAZACLO 40felbamate 400 mg 18felbamate 600 mg 18felbamate 600 mg/5ml 18FELBATOL 400 MG 18

FELBATOL 600 MG 18FELBATOL 600 MG/5ML 18FELDENE 3felodipine 47FEMARA 35FEMCON FE 50FEMHRT LOW DOSE 63FEMRING 86FENOFIBRATE 120 MG, 40MG 28fenofibrate 145 mg, 48 mg 28FENOFIBRATE 150 MG, 50MG 28fenofibrate 160 mg, 54 mg 28fenofibrate micronized 130mg 28fenofibrate micronized 134 mg,200 mg, 67 mg 28fenofibrate micronized 43mg 28FENOGLIDE 28fenoprofen calcium 600 mg 3fentanyl 100 mcg/hr 5fentanyl 12 mcg/hr 5fentanyl 25 mcg/hr 5fentanyl 37.5 mcg/hr, 62.5mcg/hr, 87.5 mcg/hr 5fentanyl 50 mcg/hr 5fentanyl 75 mcg/hr 5fentanyl citrate 1200 mcg, 1600mcg, 400 mcg, 600 mcg, 800mcg 5fentanyl citrate 200 mcg 5FENTORA 100 MCG, 200MCG 5FENTORA 400 MCG, 600 MCG,800 MCG 5FETZIMA 120 MG, 40 MG, 80MG 20FETZIMA 20 MG 20FETZIMA TITRATION PACK20FINACEA 59finasteride 66FIORINAL/CODEINE #3 7FIRAZYR 66FIRMAGON 120 MG 35FIRMAGON 80 MG 35FLAGYL 250 MG 9FLAGYL 375 MG 9FLAGYL 500 MG 9FLAGYL ER 9

Index 10

FLAREX 76flavoxate hcl 85FLEBOGAMMA DIF 10 % 78flecainide acetate 100 mg 13flecainide acetate 150 mg 13flecainide acetate 50 mg 13FLECTOR 54FLO-PRED 52FLOMAX 66FLONASE 73FLOVENT DISKUS 100MCG/BLIST 14FLOVENT DISKUS 250MCG/BLIST 14FLOVENT DISKUS 50MCG/BLIST 14FLOVENT HFA 110 MCG/ACT,220 MCG/ACT 14FLOVENT HFA 44MCG/ACT 14fluconazole 10 mg/ml, 40mg/ml 26fluconazole 100 mg, 150 mg, 200mg, 50 mg 26fluconazole in dextrose 26fluconazole in nacl 26flucytosine 26FLUDARA 34fludarabine phosphate 50mg 34fludrocortisone acetate 53FLUMADINE 44flunisolide (nasal) 73fluocinolone acetonide (otic) 77fluocinolone acetonide 0.01% 57fluocinolone acetonide 0.01 %,0.025 % 57fluocinolone acetonide 0.025% 57fluocinonide 0.05 % 57fluocinonide 0.05 %, 0.1 % 57fluocinonide emulsified base 57fluorometholone (ophth) 76fluorouracil (topical) 55FLUOROURACIL 0.5 % 55fluorouracil 1 gm/20ml 34fluorouracil 2.5 gm/50ml, 5gm/100ml, 500 mg/10ml 34fluoxetine hcl (PMDD) cap 10 mg,20 mg 80fluoxetine hcl 10 mg, 20 mg 20

fluoxetine hcl 10 mg, 20 mg, 40mg 20fluoxetine hcl 20 mg/5ml 20FLUOXETINE HCL 60 MG 20fluoxetine hcl 90 mg 20fluoxymesterone 8fluphenazine decanoate 41fluphenazine hcl 41flurazepam hcl 68flurbiprofen 100 mg, 50 mg 3flurbiprofen sodium 77flutamide 35fluticasone propionate(nasal) 73fluticasone propionate 0.005% 57fluticasone propionate 0.05% 57fluvastatin sodium 20 mg, 40mg 28fluvastatin sodium 80 mg 28fluvoxamine maleate 20FML 76FML FORTE 76FML LIQUIFILM 76FOCALIN 1FOCALIN XR 10 MG, 20MG 1FOCALIN XR 15 MG 1FOLOTYN 34fondaparinux sodium 10mg/0.8ml, 5 mg/0.4ml, 7.5mg/0.6ml 15fondaparinux sodium 2.5mg/0.5ml 15FORADIL AEROLIZER 14FORFIVO XL 19FORTAMET 1000 MG 22FORTAMET 500 MG 22FORTAZ 1 GM, 2 GM 50FORTAZ 6 GM 50FORTEO 61FORTESTA 8FOSAMAX 61FOSAMAX PLUS D 61fosinopril sodium 29fosinopril sodium &hydrochlorothiazide 31fosphenytoin sodium 100 mgpe/2ml 18

fosphenytoin sodium 500 mgpe/10ml 18FOSRENOL 65FRAGMIN 10000 UNIT/ML, 2500UNIT/0.2ML, 5000UNIT/0.2ML 15FRAGMIN 12500 UNIT/0.5ML,15000 UNIT/0.6ML, 18000UNT/0.72ML, 25000 UNIT/ML,7500 UNIT/0.3ML 15FRAGMIN 95000UNIT/3.8ML 16FROVA 70FULYZAQ 25FURADANTIN 84furosemide 10 mg/ml 60furosemide 20 mg, 40 mg, 80mg 60furosemide 8 mg/ml 60FUSILEV 37FUZEON 42FYCOMPA 10 MG 16FYCOMPA 12 MG 16FYCOMPA 2 MG 16FYCOMPA 4 MG 16FYCOMPA 6 MG 16FYCOMPA 8 MG 16gabapentin & lidocaine-menthol 80gabapentin 100 mg, 300 mg, 400mg 17gabapentin 250 mg/5ml 17gabapentin 600 mg, 800 mg 17GABITRIL 18galantamine hydrobromide 79GAMASTAN S/D 78GAMMAGARD LIQUID 78GAMMAKED 78GAMUNEX-C 78ganciclovir sodium 43GARDASIL 85GASTROCROM 64gatifloxacin (ophth) 75GATTEX 65gauze pads 2" X 2" 70GAZYVA 34GELNIQUE 84GEMCITABINE 34gemcitabine hcl 1 gm 34gemcitabine hcl 2 gm 34

Index 11

gemcitabine hcl 200 mg 34gemfibrozil 28GEMZAR 1 GM 34GEMZAR 200 MG 34GENERESS FE 50GENOTROPIN 5 MG 61GENOTROPIN MINIQUICK 0.4MG 61gentamicin in saline 0.9%-0.8mg/ml 2gentamicin in saline 0.9%-0.9mg/ml, 0.9%-1.4mg/ml, 0.9%-1.6mg/ml, 0.9%-1mg/ml, 0.9%-2mg/ml 2gentamicin in saline 0.9%-1.2mg/ml 2gentamicin sulfate (ophth) 75gentamicin sulfate (topical) 54gentamicin sulfate 10 mg/ml 2gentamicin sulfate 10 mg/ml, 40mg/ml 2GEODON 20 MG 39GEODON 20 MG, 40 MG, 60MG, 80 MG 39GILENYA 80GILOTRIF 36GLASSIA 81glatiramer acetate 80GLEEVEC 36GLEOSTINE 33glimepiride 1 mg 24glimepiride 2 mg 24glimepiride 4 mg 24glipizide 10 mg 24glipizide 2.5 mg 24glipizide 5 mg 24glipizide-metformin hcl 2.5mg-250mg 22glipizide-metformin hcl 2.5mg-500mg, 5mg-500mg 22GLUCAGEN HYPOKIT 23glucagon (rdna) 23GLUCOPHAGE 1000 MG 22GLUCOPHAGE 500 MG 22GLUCOPHAGE 850 MG 22GLUCOPHAGE XR 500 MG 22GLUCOPHAGE XR 750 MG 22GLUCOTROL 10 MG 24GLUCOTROL 5 MG 24GLUCOTROL XL 10 MG 24

GLUCOTROL XL 2.5 MG 24GLUCOTROL XL 5 MG 25GLUCOVANCE 1.25MG-250MG 22GLUCOVANCE 2.5MG-500MG,5MG-500MG 22GLUMETZA 1000 MG 22GLUMETZA 500 MG 22glyburide 1.25 mg 25glyburide 2.5 mg 25glyburide 5 mg 25glyburide micronized 1.5mg 25glyburide micronized 3 mg 25glyburide micronized 6 mg 25glyburide-metformin 1.25mg-250mg 22glyburide-metformin 2.5mg-500mg, 5mg-500mg 22glycopyrrolate 0.2 mg/ml 82glycopyrrolate 1 mg 82glycopyrrolate 1.5 mg 82glycopyrrolate 2 mg 82GLYNASE 1.5 MG 25GLYNASE 3 MG 25GLYNASE 6 MG 25GLYSET 21GOLYTELY 227.1GM-21.5GM-5.53GM-2.82GM-6.36GM 69GOLYTELY 236GM-22.74GM-5.86GM-2.97GM-6.74GM 69GRALISE 80GRALISE STARTER 80granisetron hcl 1 mg 25GRANIX 67GRASTEK 47GRIS-PEG 26griseofulvin microsize 125mg/5ml 26griseofulvin microsize 500mg 26griseofulvin ultramicrosize 26guanfacine hcl 30guanfacine hcl (adhd) 1guanidine hcl 32H.P. ACTHAR 61HALAVEN 38HALCION 68HALDOL 40

HALDOL DECANOATE 100 40HALDOL DECANOATE 50 40halobetasol propionate 57HALOG 57haloperidol 40haloperidol decanoate 40haloperidol lactate 40HARVONI 43HAVRIX 85HECTOROL 0.5 MCG, 2.5MCG 62HECTOROL 1 MCG 62heparin sodium (porcine) 1000unit/ml 16heparin sodium (porcine) 10000unit/ml, 20000 unit/ml, 5000unit/0.5ml, 5000 unit/ml 16HEPSERA 43HERCEPTIN 34HETLIOZ 68HEXALEN 33HIPREX 84HIZENTRA 1 GM/5ML 78HIZENTRA 10 GM/50ML, 2GM/10ML, 4 GM/20ML 78HORIZANT 81HUMALOG 23HUMALOG KWIKPEN 23HUMALOG MIX 50/50 23HUMALOG MIX 50/50KWIKPEN 23HUMALOG MIX 75/25 23HUMALOG MIX 75/25KWIKPEN 23HUMATROPE 61HUMATROPE COMBOPACK 61HUMIRA 2HUMIRA PEDIATRIC CROHNSDISEASE STARTER PACK 2HUMIRA PEN 2HUMIRA PEN-CROHNSDISEASESTARTER 2HUMIRA PEN-PSORIASISSTARTER 2HUMULIN 70/30 23HUMULIN 70/30 KWIKPEN 23HUMULIN 70/30 PEN 23HUMULIN N 23HUMULIN N KWIKPEN 23HUMULIN N U-100 PEN 23

Index 12

HUMULIN R 23HUMULIN R U-500(CONCENTRATED) 23HYCAMTIN 4 MG 38hydralazine hcl 10 mg, 100 mg,25 mg, 50 mg 32HYDREA 37hydrochlorothiazide 12.5 mg 60hydrochlorothiazide 12.5 mg, 25mg, 50 mg 60hydrocodone-acetaminophen10mg-300mg, 5mg-300mg,7.5mg-300mg 7hydrocodone-acetaminophen10mg-325mg, 5mg-325mg,7.5mg-325mg 7hydrocodone-acetaminophen10mg/15ml-300mg/15ml 7hydrocodone-acetaminophen2.5mg/5ml-108mg/5ml,5mg/10ml-217mg/10ml,7.5mg/15ml-325mg/15ml 7hydrocodone-ibuprofen 200mg-10mg, 200mg-5mg, 200mg-7.5mg 7hydrocortisone & cleanser 57hydrocortisone & emollient 57hydrocortisone (intrarectal) 9hydrocortisone (rectal) 9hydrocortisone (topical) 1 % 57hydrocortisone (topical) 2.5% 57hydrocortisone 10 mg, 20 mg, 5mg 52hydrocortisone acetate w/pramoxine 1%-1% 9hydrocortisone butyrate 57hydrocortisone butyratehydrophilic lipo base 57hydrocortisone sodsuccinate 52hydrocortisone valerate 57hydrocortisone w/acetic acid 77hydromorphone hcl 1 mg/ml 5hydromorphone hcl 10 mg/ml, 2mg/ml, 50 mg/5ml, 500mg/50ml 5hydromorphone hcl 12 mg 5hydromorphone hcl 16 mg 5hydromorphone hcl 2 mg 5hydromorphone hcl 4 mg 5hydromorphone hcl 8 mg 5HYDROMORPHONE HCL ER5

hydroxychloroquine sulfate 32hydroxyurea 37hydroxyzine hcl 10 mg, 25 mg,50 mg 12hydroxyzine hcl 10 mg/5ml 12hydroxyzine hcl 25 mg/ml, 50mg/ml 12hydroxyzine pamoate 100 mg,25 mg, 50 mg 12HYQVIA 78HYSINGLA ER 100 MG, 120MG 5HYSINGLA ER 20 MG, 30 MG,40 MG, 60 MG, 80 MG 5HYZAAR 31ibandronate sodium 150mg 61ibandronate sodium 3mg/3ml 61IBRANCE 36ibuprofen 100 mg/5ml 3ibuprofen 400 mg 3ibuprofen 600 mg 3ibuprofen 800 mg 3ICLUSIG 36IDAMYCIN PFS 36idarubicin hcl 36IFEX 33ifosfamide 1 gm 33ifosfamide 1 gm/20ml, 3gm/60ml 33IFOSFAMIDE 3 GM 33ILARIS 2ILEVRO 77IMBRUVICA 36imipenem-cilastatin 10imipramine hcl 10 mg, 25mg 21imipramine hcl 50 mg 21imipramine pamoate 21imiquimod 58IMITREX 100 MG 71IMITREX 25 MG 71IMITREX 50 MG 71IMITREX 6 MG/0.5ML 70IMITREX STATDOSE REFILL4 MG/0.5ML 70IMITREX STATDOSE REFILL6 MG/0.5ML 71IMITREX STATDOSE SYSTEM4 MG/0.5ML 71

IMITREX STATDOSE SYSTEM 6MG/0.5ML 71IMOVAX RABIES (H.D.C.V.) 85IMURAN 45INCIVEK 43INCRELEX 61INCRUSE ELLIPTA 13indapamide 60INDERAL LA 46INDERAL XL 46INDOCIN 3indomethacin 25 mg, 50 mg 3indomethacin 50 mg 3indomethacin 75 mg 3INFANRIX 82INLYTA 36INNOPRAN XL 46INSPRA 32INSULIN SYRINGES AND PENNEEDLES 70INTELENCE 100 MG, 200MG 42INTELENCE 25 MG 42INTERMEZZO 68INTRON A 10 MU, 18 MU, 50MU 37INTRON A 10 MU/ML 37INTRON A 6000000UNIT/ML 37INTRON A W/DILUENT 37INTUNIV 1INVANZ 10INVEGA 1.5 MG 40INVEGA 3 MG 40INVEGA 6 MG 40INVEGA 9 MG 40INVEGA SUSTENNA 117MG/0.75ML, 156 MG/ML, 234MG/1.5ML 40INVEGA SUSTENNA 39MG/0.25ML, 78 MG/0.5ML 40INVEGA TRINZA 40INVIRASE 42INVOKAMET 150MG-1000MG,150MG-500MG, 50MG-1000MG 22INVOKAMET 50MG-500MG 22INVOKANA 24IOPIDINE 0.5 % 75IOPIDINE 1 % 75

Index 13

IPOL INACTIVATED IPV 85ipratropium bromide 13ipratropium bromide (nasal) 73ipratropium-albuterol 14irbesartan 30irbesartan-hydrochlorothiazide

31IRESSA 36irinotecan hcl 100 mg/5ml, 40mg/2ml 38irinotecan hcl 500 mg/25ml 38irrigation solutions,physiological 45ISENTRESS 100 MG 42ISENTRESS 25 MG 42ISENTRESS 400 MG 42isoniazid & rifampin 32isoniazid 100 mg, 300 mg 33isoniazid 100 mg/ml 33isoniazid 50 mg/5ml 33ISOPTO CARPINE 75ISORDIL TITRADOSE 40MG 11ISORDIL TITRADOSE 5 MG 11isosorbide dinitrate 10 mg, 20mg, 30 mg, 5 mg 11isosorbide dinitrate 2.5 mg 11isosorbide dinitrate 40 mg 11isosorbide mononitrate 10mg 11isosorbide mononitrate 120 mg,30 mg, 60 mg 11isosorbide mononitrate 20mg 11isotretinoin 10 mg 54isotretinoin 20 mg, 30 mg, 40mg 54ISTALOL 74ISTODAX 36itraconazole 26ivermectin 9IXEMPRA KIT 38IXIARO 85JADENU 25JAKAFI 36JALYN 66JANUMET 22JANUMET XR 100MG-1000MG 22JANUMET XR 50MG-1000MG,50MG-500MG 22

JANUVIA 23JARDIANCE 10 MG 24JARDIANCE 25 MG 24JENTADUETO 22JEVTANA 38JUBLIA 55JUXTAPID 10 MG 29JUXTAPID 20 MG 29JUXTAPID 30 MG 29JUXTAPID 40 MG, 60 MG 29JUXTAPID 5 MG 29K-TAB 10 MEQ 72KADCYLA 34KADIAN 10 MG 5KADIAN 100 MG 5KADIAN 130 MG, 150 MG 5KADIAN 20 MG, 30 MG, 50MG, 60 MG, 80 MG 5KADIAN 40 MG, 70 MG 5KALBITOR 66KALETRA 100MG-25MG 42KALETRA 200MG-50MG 42KALETRA 400MG/5ML-100MG/5ML 42KALYDECO 150 MG 81KALYDECO 50 MG, 75MG 81KAPVAY 1KAYEXALATE 45KAZANO 22KEFLEX 250 MG, 500 MG 49KEFLEX 750 MG 49KENALOG 57KENALOG-10 52KENALOG-40 52KEPIVANCE 37KEPPRA 17KEPPRA XR 17KERLONE 46KERYDIN 55KETEK 300 MG 10KETEK 400 MG 10ketoconazole 26ketoconazole & cleanser 55ketoconazole (topical) 55ketoprofen 200 mg 3ketoprofen 50 mg, 75 mg 3

ketorolac trometh & bupivacainehcl & lidocaine hcl 3ketorolac tromethamine &lidocaine hcl 3ketorolac tromethamine(ophth) 77ketorolac tromethamine 10mg 3ketorolac tromethamine 15mg/ml, 30 mg/ml 3ketorolac tromethamine 30mg/ml, 60 mg/2ml 3KEYTRUDA 34KHEDEZLA 20KINERET 2KLARON 54KLONOPIN 0.5 MG 16KLONOPIN 1 MG 16KLONOPIN 2 MG 16KOMBIGLYZE XR 2.5MG-1000MG 22KOMBIGLYZE XR 5MG-1000MG, 5MG-500MG 22KUVAN 100 MG 62KYNAMRO 27labetalol hcl 100 mg, 200 mg, 300mg 46LAC-HYDRIN 58lactated ringer's 72lactic acid (ammonium lactate) 12% 58lactulose 69lactulose (encephalopathy) 65LAMICTAL 100 MG, 150 MG,200 MG, 25 MG 17LAMICTAL CHEWABLEDISPERSIBLE 17LAMICTAL ODT 100 MG, 200MG, 25 MG, 50 MG 17LAMICTAL STARTER/NOTTAKING CARBAMAZEPINE 17LAMICTAL STARTER/TAKINGCARBAMAZEPINE/NOT TAKINGVALPROATE 17LAMICTAL STARTER/TAKINGVALPROATE 17LAMICTAL XR 17LAMISIL 125 MG, 187.5 MG 26LAMISIL 250 MG 26lamivudine 42lamivudine (hbv) 43lamivudine-zidovudine 42lamotrigine 100 mg, 150 mg, 200mg, 25 mg 17

Index 14

lamotrigine 100 mg, 200 mg, 25mg, 250 mg, 300 mg, 50 mg 17lamotrigine 100 mg, 200 mg, 25mg, 50 mg 17lamotrigine 25 mg, 5 mg 17LANOXIN 125 MCG, 250MCG 48LANOXIN 187.5 MCG, 62.5MCG 48LANOXIN PEDIATRIC 48lansoprazole 15 mg 83lansoprazole 30 mg 83LANTUS 23LANTUS SOLOSTAR 23LASIX 60LASTACAFT 77latanoprost 77LATUDA 120 MG 39LATUDA 20 MG 39LATUDA 40 MG 39LATUDA 60 MG 39LATUDA 80 MG 39LAZANDA 100 MCG/ACT 5LAZANDA 400 MCG/ACT 5leflunomide 4LEMTRADA 80LENVIMA 10MG DAILYDOSE 36LENVIMA 14MG DAILYDOSE 36LENVIMA 20MG DAILYDOSE 36LENVIMA 24MG DAILYDOSE 36LESCOL 28LESCOL XL 28LETAIRIS 48letrozole 35leucovorin calcium 10 mg, 15 mg,25 mg, 5 mg 37leucovorin calcium 100 mg, 200mg, 350 mg 37leucovorin calcium 50 mg, 500mg 37LEUKERAN 33LEUKINE 67leuprolide acetate 35levalbuterol hcl 0.31 mg/3ml, 0.63mg/3ml, 1.25 mg/0.5ml, 1.25mg/3ml 14LEVAQUIN 25 MG/ML 64

LEVAQUIN 250 MG, 500 MG,750 MG 64LEVAQUIN 250MG/50ML-5%,500MG/100ML-5% 64LEVAQUIN 750MG/150ML-5% 64LEVATOL 46LEVEMIR 23LEVEMIR FLEXPEN 23LEVEMIR FLEXTOUCH 23levetiracetam 100 mg/ml, 500mg/5ml 17levetiracetam 1000 mg, 250mg, 500 mg, 750 mg 17LEVETIRACETAM1000MG/100ML-750MG/100ML,1500MG/100ML-540MG/100ML, 500MG/100ML-820MG/100ML 17levetiracetam 500 mg, 750mg 17levetiracetam 500 mg/5ml 17LEVOBUNOLOL HCL 0.25% 74levobunolol hcl 0.5 % 74levocarnitine (metabolicmodifiers) 330 mg 62levocetirizinedihydrochloride 27levofloxacin (ophth) 75levofloxacin 25 mg/ml 64levofloxacin 250 mg, 500 mg,750 mg 64levofloxacin in d5w250mg/50ml-5%,500mg/100ml-5% 64levofloxacin in d5w750mg/150ml-5% 64LEVOLEUCOVORIN 37levoleucovorin calcium 37levonorgestrel & ethestradiol 50levonorgestrel (emergency oc)0.75 mg 51levonorgestrel (emergency oc)1.5 mg 51levonorgestrel-eth estradiol(triphasic) 50levonorgestrel-ethinyl estradiol(91-day) 50levonorgestrel-ethinyl estradiol(continuous) 50levorphanol tartrate 5

levothyroxine sodium 100 mcg,112 mcg, 125 mcg, 137 mcg, 150mcg, 175 mcg, 200 mcg, 25 mcg,300 mcg, 50 mcg, 75 mcg, 88mcg 82LEXAPRO 20LEXIVA 50 MG/ML 42LEXIVA 700 MG 42LIALDA 65lidocaine 5 % 58lidocaine hcl (cardiac) 12lidocaine hcl (local anesth.) 1 %,2 % 69lidocaine hcl (mouth-throat) 2% 72lidocaine hcl 2 % 58lidocaine hcl 4 % 58lidocaine-prilocaine 58LIDODERM 59LINCOCIN 11lindane 59linezolid 2 mg/ml 11linezolid 600 mg 11LINZESS 65liothyronine sodium 25 mcg, 5mcg, 50 mcg 82LIPITOR 28LIPOFEN 28LIPOSYN III 1.2GM/100ML-20GM/100ML-2.5GM/100ML

74LIPTRUZET 27lisinopril &hydrochlorothiazide 31lisinopril 10 mg, 2.5 mg, 20 mg,30 mg, 40 mg, 5 mg 29lithium 39lithium carbonate 150 mg, 300mg, 600 mg 39lithium carbonate 300 mg 39lithium carbonate 300 mg, 450mg 39LITHOBID 39LIVALO 28LO LOESTRIN FE 50LO MINASTRIN FE 50LOCOID 57LOCOID LIPOCREAM 57LODOSYN 38LOMOTIL 25lomustine 33

Index 15

loperamide hcl 2 mg 25LOPID 28LOPRESSOR 100 MG, 50MG 46LOPRESSOR HCT 31LOPROX 55LOPROX SHAMPOO 55lorazepam 0.5 mg, 1 mg, 2mg 12lorazepam 2 mg/ml 12lorazepam 2 mg/ml, 20mg/10ml 12lorazepam 4 mg/ml 12losartan potassium 30losartan potassium &hydrochlorothiazide 31LOSEASONIQUE 50LOTEMAX 76LOTENSIN 29LOTENSIN HCT 31LOTREL 31LOTRISONE 55LOTRONEX 65lovastatin 28LOVAZA 27LOVENOX 100 MG/ML, 30MG/0.3ML, 40 MG/0.4ML, 60MG/0.6ML, 80 MG/0.8ML 16LOVENOX 120 MG/0.8ML, 150MG/ML 16LOVENOX 300 MG/3ML 16loxapine succinate 10 mg, 25 mg,5 mg, 50 mg 40LUMIGAN 77LUMIZYME 62LUNESTA 68LUPRON DEPOT 35LUPRON DEPOT-PED 11.25MG 61LUPRON DEPOT-PED 11.25MG, 7.5 MG 62LUPRON DEPOT-PED 15MG 62LUPRON DEPOT-PED 30MG 62LUVOX CR 20LUXIQ 57LUZU 55LYNPARZA 36LYRICA 100 MG 17LYRICA 150 MG 17

LYRICA 20 MG/ML 17LYRICA 200 MG 17LYRICA 225 MG, 300 MG 17LYRICA 25 MG 17LYRICA 50 MG 17LYRICA 75 MG 17LYSODREN 35LYSTEDA 68M-M-R II 85MACROBID 84MACRODANTIN 100 MG, 50MG 84MACRODANTIN 25 MG 84mag cit-bisacodyl-petrolat-peg3350-metoclopramide-electrol

69magnesium sulfate 50 % 72MALARONE 250MG-100MG 32MALARONE 62.5MG-25MG 32malathion 59maprotiline hcl 25 mg, 50mg 19maprotiline hcl 75 mg 19MARINOL 10 MG, 5 MG 26MARINOL 2.5 MG 26MARPLAN 19MATULANE 37MAVIK 29MAXALT 10 MG 71MAXALT 5 MG 71MAXALT-MLT 10 MG 71MAXALT-MLT 5 MG 71MAXIDEX 76MAXIPIME 1 GM, 2 GM 50MAXITROL 76MAXZIDE 60MAXZIDE-25 60mecamylamine hcl 32meclizine hcl 12.5 mg, 25mg 25meclofenamate sodium 100mg, 50 mg 3MEDROL 16 MG, 32 MG, 4MG, 8 MG 52MEDROL 2 MG 52MEDROL DOSEPAK 52medroxyprogesteroneacetate 79

medroxyprogesterone acetate(contraceptive) 51mefenamic acid 3mefloquine hcl 32MEGACE ES 79MEGACE ORAL 35megestrol acetate (appetite) 79megestrol acetate 20 mg, 40mg 35megestrol acetate 40 mg/ml, 400mg/10ml 35MEKINIST 36meloxicam 15 mg, 7.5 mg 3meloxicam w/ liniment 3melphalan hcl 33memantine hcl 10 mg, 5 mg 79memantine hcl 2 mg/ml 79MENACTRA 85MENOMUNE-A/C/Y/W-135 85MENOSTAR 63MENVEO 85meperidine hcl 100 mg, 50 mg5meperidine hcl 50 mg/5ml 5meprobamate 12MEPRON 10mercaptopurine 34meropenem 1 gm 10meropenem 500 mg 10MERREM 1 GM 10MERREM 500 MG 10mesalamine 65mesalamine w/ cleanser 65mesna 37MESNEX 100 MG/ML 37MESNEX 400 MG 37MESTINON 60 MG 32MESTINON TIMESPAN 32METADATE CD 1metaproterenol sulfate 14metaxalone 72metformin hcl 1000 mg 22metformin hcl 500 mg 22metformin hcl 750 mg 22metformin hcl 850 mg 22methadone hcl 10 mg 6methadone hcl 10 mg/5ml 5methadone hcl 10 mg/ml 5

Index 16

methadone hcl 5 mg 6methadone hcl 5 mg/5ml 5METHADOSE 6METHADOSE SUGAR-FREE 6methamphetamine hcl 1methazolamide 25 mg, 50mg 59methenamine hippurate 84methimazole 10 mg, 5 mg 82methocarbamol 500 mg, 750mg 72methotrexate sodium 1 gm 34methotrexate sodium 1 gm/40ml,100 mg/4ml, 200 mg/8ml, 25mg/ml, 250 mg/10ml, 50mg/2ml 34methotrexate sodium 10 mg, 15mg, 2.5 mg 34methotrexate sodium 25mg/ml 34methotrexate sodium 5 mg, 7.5mg 34methoxsalen rapid 55methscopolamine bromide 2.5mg, 5 mg 82methyclothiazide 60methyldopa 30methyldopa &hydrochlorothiazide 31methylergonovine maleate 0.2mg 78methylphenidate hcl 10 mg, 18mg, 20 mg, 27 mg, 36 mg, 54mg 1methylphenidate hcl 10 mg, 20mg, 30 mg, 40 mg, 50 mg, 60mg 1methylphenidate hcl 10 mg, 20mg, 5 mg 1methylphenidate hcl 18 mg, 27mg, 36 mg, 54 mg 1methylphenidate hcl 20 mg, 30mg, 40 mg 1methylprednisolone 16 mg, 32mg, 4 mg, 8 mg 52methylprednisolone acetate 40mg/ml, 80 mg/ml 52methylprednisolone sodsucc 52methyltestosterone 8metipranolol 74metoclopramide hcl 10 mg, 5mg 64metoclopramide hcl 10 mg/10ml,5 mg/5ml 64

metoclopramide hcl 5mg/ml 64metolazone 60metoprolol &hydrochlorothiazide 100mg-25mg, 50mg-25mg 31metoprolol &hydrochlorothiazide 100mg-50mg 31metoprolol succinate 46metoprolol tartrate 100 mg, 25mg, 50 mg 46METROCREAM 59METROGEL 59METROGEL-VAGINAL 85METROLOTION 59metronidazole (topical) 59metronidazole 250 mg 9metronidazole 375 mg 9metronidazole 500 mg 9metronidazole in nacl 9metronidazole vaginal 85metronidazole w/ cleanser(topical) 59MEVACOR 28mexiletine hcl 12MIACALCIN 200UNIT/ACT 61MIACALCIN 200 UNIT/ML 61MICARDIS 30MICARDIS HCT 31miconazole nitrate vaginal 200mg 85MICRO-K 72MICROZIDE 60midodrine hcl 86MIGRANAL 70MINASTRIN 24 FE 50MINIPRESS 30MINIVELLE 63MINOCIN 100 MG, 50 MG, 75MG 82minocycline hcl 100 mg, 50mg 82minocycline hcl 100 mg, 50 mg,75 mg 82minoxidil 10 mg, 2.5 mg 32MIRAPEX 38MIRAPEX ER 39MIRCERA 100 MCG/0.3ML, 50MCG/0.3ML, 75MCG/0.3ML 67

MIRCERA 200 MCG/0.3ML 67mirtazapine 19MIRVASO 59misoprostol 100 mcg, 200mcg 84mitomycin 20 mg, 40 mg, 5mg 36mitoxantrone hcl 36MOBIC 15 MG, 7.5 MG 3modafinil 100 mg 1modafinil 200 mg 1MODICON 50moexipril hcl 29moexipril-hydrochlorothiazide

31mometasone furoate 58MONODOX 82montelukast sodium 10 mg 13montelukast sodium 4 mg, 5mg 13MONUROL 84morphine sulfate 0.5 mg/ml 6morphine sulfate 1 mg/ml 6morphine sulfate 10 mg 6morphine sulfate 10 mg/5ml 6morphine sulfate 100 mg 6morphine sulfate 100 mg/5ml, 20mg/ml 6morphine sulfate 15 mg 6morphine sulfate 20 mg, 30 mg,50 mg, 60 mg, 80 mg 6morphine sulfate 20 mg/5ml 6morphine sulfate 200 mg 6morphine sulfate 30 mg 6morphine sulfate 30 mg, 60mg 6morphine sulfate beads 6MOTOFEN 25MOVANTIK 65MOVIPREP 69MOXEZA 75moxifloxacin hcl 400 mg 64MOZOBIL 68MS CONTIN 100 MG 6MS CONTIN 15 MG 6MS CONTIN 200 MG 6MS CONTIN 30 MG, 60 MG 6MULTAQ 13mupirocin 54

Index 17

mupirocin calcium (topical) 54MUSTARGEN 33MYALEPT 62MYAMBUTOL 33MYCAMINE 100 MG 26MYCOBUTIN 33mycophenolate mofetil 200mg/ml 45mycophenolate mofetil 250mg 45mycophenolate mofetil 500mg 45mycophenolate sodium 180mg 45mycophenolate sodium 360mg 45MYFORTIC 180 MG 45MYFORTIC 360 MG 45MYOZYME 62MYRBETRIQ 85MYSOLINE 17nabumetone 3nadolol & bendroflumethiazide40mg-5mg 31nadolol & bendroflumethiazide80mg-5mg 31nadolol 20 mg, 40 mg, 80mg 46nafcillin sodium 1 gm 79nafcillin sodium 1 gm, 2 gm 79nafcillin sodium 10 gm 79nafcillin sodium 2 gm 79naftifine hcl 55NAFTIN 55NAGLAZYME 62naloxone hcl 1 mg/ml 25naltrexone hcl 25NAMENDA 10 MG, 5 MG 79NAMENDA 10 MG/5ML 79NAMENDA TITRATION PAK79NAMENDA XR 14 MG 79NAMENDA XR 21 MG, 28MG 80NAMENDA XR 7 MG 80NAMENDA XR TITRATIONPACK 80naphazoline hcl 76NAPRELAN 375 MG 3NAPRELAN 375 MG, 750 MG3NAPRELAN 500 MG 3

NAPROSYN 4naproxen 250 mg, 375 mg, 500mg 4naproxen 375 mg, 500 mg 4naproxen sodium 275 mg, 550mg 4naproxen sodium 375 mg, 500mg 4naratriptan hcl 71NARDIL 19NASONEX 73NATACYN 75nateglinide 24NATESTO 9NATPARA 61NAVELBINE 38NEBUPENT 9nefazodone hcl 20neomycin sulfate 2neomycin-bacitracin zn-polymyxin 75neomycin-fluocinolone 54neomycin-polymy-dexameth 76neomycin-polymyxin-gramicidin

75neomycin-polymyxin-hc(ophth) 76neomycin-polymyxin-hc(otic) 77neomycin/polymyxin b gu 66NEORAL 100 MG, 25 MG 45NESINA 23NEULASTA 67NEULASTA DELIVERYKIT 67NEUMEGA 67NEUPOGEN 67NEUPRO 39NEURONTIN 17NEVANAC 77nevirapine 100 mg 42nevirapine 200 mg 42nevirapine 400 mg 42NEVIRAPINE 50 MG/5ML 42NEXAVAR 36NEXIUM 10 MG, 2.5 MG, 20MG, 40 MG, 5 MG 83NEXIUM 20 MG 83NEXIUM 40 MG 83

NEXIUM I.V. 20 MG 83niacin (antihyperlipidemic) 1000mg, 500 mg, 750 mg 29niacin (antihyperlipidemic) 500mg 29NIASPAN 29nicardipine hcl 20 mg, 30 mg47NICOTROL INHALER 81NICOTROL NS 81nifedipine 10 mg, 20 mg 47nifedipine 30 mg, 60 mg, 90mg 47NILANDRON 35nimodipine 47NIPENT 37NIRAVAM 12nisoldipine 17 mg, 25.5 mg, 34mg, 8.5 mg 47nisoldipine 20 mg, 30 mg, 40mg 47NITRO-DUR 0.1 MG/HR, 0.2MG/HR, 0.4 MG/HR, 0.6MG/HR 11NITRO-DUR 0.3 MG/HR, 0.8MG/HR 11nitrofurantoin 84nitrofurantoin macrocrystal 100mg, 25 mg, 50 mg 84nitrofurantoin monohydmacro 84nitroglycerin 0.1 mg/hr, 0.2 mg/hr,0.4 mg/hr, 0.6 mg/hr 11nitroglycerin 0.4 mg/spray 11nitroglycerin 2 % 11nitroglycerin 5 mg/ml 11NITROGLYCERIN LINGUAL11NITROLINGUALPUMPSPRAY 11NITROMIST 11NITROSTAT 12nizatidine 150 mg, 300 mg 83NIZORAL 55NOR-QD 51NORDITROPIN FLEXPRO 10MG/1.5ML, 5 MG/1.5ML 61norelgestromin-ethinylestradiol 51norethin acet & estrad-fe 75mg-20mcg-1mg, 75mg-30mcg-1.5mg 50norethindrone & eth estradiol0.4mg-35mcg, 1mg-35mcg 50norethindrone & eth estradiol0.5mg-35mcg 50

Index 18

norethindrone & ethinyl estradiol-fe 50norethindrone(contraceptive) 51norethindrone acet & ethestra 50norethindrone acetate 79norethindrone acetate-ethinylestradiol 2.5mcg-0.5mg 63norethindrone acetate-ethinylestradiol 5mcg-1mg 63norethindrone-eth estradiol(biphasic) 50norethindrone-eth estradiol(triphasic) 50NORFLEX 72norgestimate-ethinylestradiol 51norgestimate-ethinyl estradiol(triphasic) 51norgestrel & ethinyl estradiol0.3mg-30mcg 51norgestrel & ethinyl estradiol0.5mg-50mcg 51NORINYL 1+35 51NORITATE 59NOROXIN 64NORPACE 12NORPACE CR 100 MG 12NORPRAMIN 21NORTHERA 100 MG 86NORTHERA 200 MG 86NORTHERA 300 MG 86nortriptyline hcl 10 mg, 25 mg, 50mg, 75 mg 21nortriptyline hcl 10 mg/5ml 21NORVASC 10 MG 47NORVASC 2.5 MG 47NORVASC 5 MG 47NORVIR 42NOVOLIN 70/30 23NOVOLIN 70/30 RELION 24NOVOLIN N 24NOVOLIN N RELION 24NOVOLIN R 24NOVOLIN R RELION 24NOVOLOG 24NOVOLOG FLEXPEN 24NOVOLOG MIX 70/30 24NOVOLOG MIX 70/30PREFILLED FLEXPEN 24NOVOLOG PENFILL 24

NOXAFIL 100 MG 26NOXAFIL 300 MG/16.7ML 26NOXAFIL 40 MG/ML 26NUCYNTA 100 MG 6NUCYNTA 50 MG 6NUCYNTA 75 MG 6NUCYNTA ER 100 MG 6NUCYNTA ER 150 MG, 200MG, 250 MG 6NUCYNTA ER 50 MG 6NUEDEXTA 80NULOJIX 45NULYTELY/FLAVORPACKS 69NUTROPIN AQ NUSPIN20 61NUTROPIN AQ PEN 20MG/2ML 61NUVARING 51NUVIGIL 1NYMALIZE 47nystatin 26nystatin & diaper rashproduct 55nystatin (mouth-throat) 72nystatin (topical) 55nystatin-triamcinolone 55OCTAGAM 10 GM/100ML, 2GM/20ML, 20 GM/200ML, 5GM/50ML 78octreotide acetate 100mcg/ml 62octreotide acetate 1000mcg/5ml, 200 mcg/ml, 50mcg/ml 62OCUFEN 77OCUFLOX 75ODOMZO 35OFEV 81ofloxacin (ophth) 75ofloxacin (otic) 77olanzapine 40olanzapine-fluoxetine hcl 80OLEPTRO 20olopatadine hcl (nasal) 73OLUX 58OLUX-E 58OLYSIO 43omega-3-acid ethyl esters 27

omeprazole 10 mg, 20 mg, 40mg 83omeprazole-sodium bicarbonate20mg-1100mg 84omeprazole-sodium bicarbonate40mg-1100mg 84OMNARIS 73OMNIPRED 76OMNITROPE 10 MG/1.5ML, 5MG/1.5ML 61ONCASPAR 37ondansetron 25ondansetron hcl 24 mg, 4 mg, 8mg 25ondansetron hcl 4 mg/2ml, 40mg/20ml 25ondansetron hcl 4 mg/5ml 25ONFI 10 MG, 5 MG 16ONFI 2.5 MG/ML 16ONFI 20 MG 16ONGLYZA 23ONMEL 26OPANA 10 MG 6OPANA 5 MG 6OPDIVO 34opium tincture 25OPSUMIT 48OPTIVAR 77ORACEA 59ORAP 81ORAPRED ODT 52ORENCIA 4ORENITRAM 0.125 MG 48ORENITRAM 0.25 MG, 1 MG,2.5 MG 48ORFADIN 62ORKAMBI 81orphenadrine citrate 100 mg 73orphenadrine citrate 30mg/ml 72orphenadrine w/ aspirin &caff 73ORTHO EVRA 51ORTHO MICRONOR 51ORTHO TRI-CYCLEN 51ORTHO-CEPT 51ORTHO-CYCLEN 51ORTHO-NOVUM 1/35 51ORTHO-NOVUM 7/7/7 51OSENI 12.5MG-15MG 22

Index 19

OSENI 12.5MG-30MG, 12.5MG-45MG, 25MG-15MG, 25MG-30MG, 25MG-45MG 22OSMOPREP 69OTEZLA 4OTREXUP 2OVIDE 59oxaliplatin 100 mg, 50 mg 33oxaliplatin 100 mg/20ml 33oxaliplatin 50 mg/10ml 33OXANDRIN 10 MG 8OXANDRIN 2.5 MG 8oxandrolone 10 mg 8oxandrolone 2.5 mg 8oxaprozin 4OXAYDO 5 MG 6OXAYDO 7.5 MG 6oxazepam 12oxcarbazepine 17OXECTA 5 MG 6OXECTA 7.5 MG 6OXISTAT 55OXSORALEN 59OXSORALEN ULTRA 55oxybutynin chloride 10 mg, 15mg, 5 mg 84oxybutynin chloride 5 mg 84oxybutynin chloride 5mg/5ml 84oxycodone hcl 10 mg 6oxycodone hcl 100 mg/5ml, 20mg/ml 6oxycodone hcl 15 mg 6oxycodone hcl 20 mg 6oxycodone hcl 30 mg 6oxycodone hcl 5 mg 6OXYCODONE HCL ER 10 MG,20 MG, 40 MG 6OXYCODONE HCL ER 80MG 6oxycodone w/ acetaminophen10mg-300mg, 5mg-300mg,7.5mg-300mg 8oxycodone w/ acetaminophen10mg-325mg, 2.5mg-325mg,5mg-325mg, 7.5mg-325mg 8oxycodone w/ acetaminophen5mg/5ml-325mg/5ml 8oxycodone-aspirin 8OXYCONTIN 10 MG, 15 MG, 20MG, 30 MG, 40 MG, 60 MG 7

OXYCONTIN 80 MG 7oxymorphone hcl 10 mg 7oxymorphone hcl 15 mg 7oxymorphone hcl 20 mg 7oxymorphone hcl 30 mg, 40mg 7oxymorphone hcl 5 mg 7oxymorphone hcl 7.5 mg 7OXYTROL 84paclitaxel 100 mg/16.7ml, 30mg/5ml, 300 mg/50ml 38paclitaxel 150 mg/25ml 38paliperidone 1.5 mg 40paliperidone 3 mg 40paliperidone 6 mg 40paliperidone 9 mg 40PAMELOR 21pamidronate disodium 6mg/ml 61PAMINE 82PAMINE FORTE 82PANCREAZE 59PANCRELIPASE 59PANRETIN 55pantoprazole sodium 20 mg, 40mg 83pantoprazole sodium 40mg 83PARAFON FORTE DSC 73parenteral electrolytes 72paricalcitol 1 mcg, 2 mcg, 4mcg 62PARLODEL 39PARNATE 19paromomycin sulfate 2paroxetine hcl 20PATADAY 77PATANASE 73PATANOL 77PAXIL 10 MG, 20 MG, 30 MG,40 MG 20PAXIL 10 MG/5ML 20PAXIL CR 20PCE 333 MG 70PCE 500 MG 70PEDVAX HIB 85peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 69

peg 3350-potassium chloride-sodbicarbonate-sod chloride 69PEG-INTRON 43PEG-INTRON REDIPEN 44PEG-INTRON REDIPEN PAK4 44PEGANONE 18PEGASYS 44PEGASYS PROCLICK 44PEGINTRON 44penicillin g potassium 20 mu,20000000 unit, 5000000 unit 78penicillin g procaine 78penicillin g sodium 78penicillin v potassium 78PENLAC NAIL LACQUER 55PENNSAID 54PENTAM 300 10PENTASA 65pentazocine w/ naloxone 8pentoxifylline 66PEPCID 83PERCODAN 8PERFOROMIST 14PERIDEX 72perindopril erbumine 2 mg 29perindopril erbumine 4 mg 29perindopril erbumine 8 mg 29PERJETA 34permethrin 5 % 59perphenazine 16 mg, 2 mg, 4 mg,8 mg 41perphenazine-amitriptyline 80PERSANTINE 67PERTZYE 59PEXEVA 20phenelzine sulfate 19phenobarbital 100 mg, 15 mg,16.2 mg, 30 mg, 32.4 mg, 60 mg,64.8 mg, 97.2 mg 68phenobarbital 20 mg/5ml 68phenoxybenzamine hcl 30phenytoin 125 mg/5ml 18phenytoin 50 mg 18phenytoin sodium 18phenytoin sodium extended 18PHOSLO 65PHOSLYRA 65

Index 20

PHOSPHOLINE IODIDE 75PICATO 55pilocarpine hcl (oral) 72pilocarpine hcl 1 %, 2 %, 4% 75pimozide 81pindolol 46pioglitazone hcl 15 mg 23pioglitazone hcl 30 mg, 45mg 23pioglitazone hcl-glimepiride 22pioglitazone hcl-metforminhcl 22piperacillin sodium-tazobactamsodium 79piroxicam 10 mg, 20 mg 4PLAN B ONE-STEP 51PLAQUENIL 32PLAVIX 300 MG 67PLAVIX 75 MG 67PLEGRIDY 80PLEGRIDY STARTERPACK 80PLETAL 67podofilox 58polyethylene glycol 3350 69polymyxin b sulfate 11polymyxin b-trimethoprim 75POLYTRIM 75POMALYST 35PONSTEL 4potassium chloride 10 %, 20% 72potassium chloride 10 meq, 8meq 72potassium chloride 2 meq/ml 72POTASSIUM CHLORIDEER 72potassium chloride in dextrose &sodium chloride 0.45%-20meq/l-5% 72potassium chloridemicroencapsulated crystalscr 72potassium citrate (alkalinizer)1080 mg 65potassium citrate (alkalinizer) 540mg 65POTIGA 200 MG 17POTIGA 300 MG 17POTIGA 400 MG 17POTIGA 50 MG 17

PRADAXA 16PRALUENT 150 MG/ML 29PRALUENT 75 MG/ML 29pramipexoledihydrochloride 39pramoxine-hc 1%-1% 58pramoxine-hc 1%-1%, 1%-2.5% 58PRANDIMET 22PRANDIN 0.5 MG 24PRANDIN 1 MG 24PRANDIN 2 MG 24PRAVACHOL 28pravastatin sodium 28prazosin hcl 30PRECOSE 21PRED FORTE 76PRED MILD 76prednicarbate 58prednisolone 52prednisolone acetate(ophth) 76prednisolone sodiumphosphate (ophth) 76prednisolone sodiumphosphate 10 mg, 15 mg, 30mg 52prednisolone sodiumphosphate 10 mg/5ml, 20mg/5ml, 25 mg/5ml 52prednisolone sodiumphosphate 15 mg/5ml, 5mg/5ml, 6.7 mg/5ml 52prednisone 1 mg, 10 mg, 2.5mg, 20 mg, 5 mg, 50 mg 52prednisone 10 mg, 5 mg 53prednisone 5 mg/5ml 52prednisone 5 mg/ml 52PREMARIN 0.3 MG, 0.45 MG,0.625 MG, 0.9 MG, 1.25MG 63PREMARIN 0.625 MG/GM 86PREMPHASE 63PREMPRO 63PREPOPIK 69PREVACID 15 MG 83PREVACID 30 MG 83PREVPAC 84PREZCOBIX 42PREZISTA 100 MG/ML 42PREZISTA 150 MG 42

PREZISTA 400 MG 42PREZISTA 600 MG, 800 MG42PREZISTA 75 MG 42PRIFTIN 33prilocaine hcl 69PRILOSEC 10 MG, 20 MG, 40MG 84PRIMAQUINE PHOSPHATE32primaquine phosphate 32PRIMAXIN IV 10primidone 250 mg, 50 mg 18PRIMSOL 10PRINIVIL 29PRISTIQ 20PRIVIGEN 78PROAIR HFA 14PROAIR RESPICLICK 15probenecid 66procainamide hcl 100 mg/ml, 500mg/ml 12PROCARDIA 47PROCARDIA XL 47prochlorperazine 41prochlorperazine edisylate 41prochlorperazine maleate 10 mg,5 mg 41PROCRIT 10000 UNIT/ML, 2000UNIT/ML, 3000 UNIT/ML, 4000UNIT/ML 67PROCRIT 20000 UNIT/ML,40000 UNIT/ML 67PROCTOCORT 1 % 9PROCYSBI 66progesterone micronized 100 mg,200 mg 79PROGLYCEM 23PROGRAF 0.5 MG, 1 MG, 5MG 45PROGRAF 5 MG/ML 45PROLASTIN-C 81PROLENSA 77PROLEUKIN 37PROLIA 61PROMACTA 12.5 MG 67PROMACTA 25 MG 67PROMACTA 50 MG 67PROMACTA 75 MG 67promethazine &phenylephrine 53

Index 21

promethazine hcl 12.5 mg, 25mg, 50 mg 27promethazine hcl 25 mg/ml, 50mg/ml 27promethazine hcl 6.25mg/5ml 27PROMETRIUM 79propafenone hcl 13propantheline bromide 83proparacaine hcl 76propranolol &hydrochlorothiazide 31propranolol hcl 10 mg, 20 mg, 40mg, 60 mg, 80 mg 46propranolol hcl 120 mg, 160 mg,60 mg, 80 mg 46propranolol hcl 20 mg/5ml 46propranolol hcl 40 mg/5ml 46propylthiouracil 82PROQUAD 85PROSCAR 66protamine sulfate 67PROTONIX 20 MG, 40 MG 84PROTONIX 40 MG 84PROTOPIC 58protriptyline hcl 21PROVENTIL HFA 15PROVERA 79PROVIGIL 1PROZAC 20PROZAC WEEKLY 20PULMICORT 0.25 MG/2ML 14PULMICORT 0.5 MG/2ML 14PULMICORT 1 MG/2ML 14PULMICORT FLEXHALER 180MCG/ACT 14PULMICORT FLEXHALER 90MCG/ACT 14PULMOZYME 81PURINETHOL 34PURIXAN 34PYLERA 84pyrazinamide 33pyridostigmine bromide 180mg 32pyridostigmine bromide 60mg 32QNASL 73QNASL CHILDRENS 73QUALAQUIN 32

QUARTETTE 51quetiapine fumarate 40quinapril hcl 29quinapril-hydrochlorothiazide

31quinidine gluconate 324mg 12quinidine sulfate 12quinine sulfate 32QVAR 14RABAVERT 85RAGWITEK 47raloxifene hcl 61ramipril 29RANEXA 11ranitidine hcl 15 mg/ml, 150mg/10ml, 75 mg/5ml 83ranitidine hcl 150 mg 83ranitidine hcl 150 mg, 300mg 83ranitidine hcl 300 mg 83RAPAFLO 66RAPAMUNE 0.5 MG 45RAPAMUNE 1 MG, 2 MG 45RAPAMUNE 1 MG/ML 45RASUVO 2RAYOS 2 MG, 5 MG 53RAZADYNE 80RAZADYNE ER 80REBETOL 200 MG 44REBETOL 40 MG/ML 44REBIF 80REBIF REBIDOSE 80REBIF REBIDOSETITRATIONPACK 80REBIF TITRATION PACK 80RECLAST 61RECOMBIVAX HB 85RECTIV 9REGLAN 64REGRANEX 59RELENZA DISKHALER 44RELISTOR 12 MG/0.6ML 65RELISTOR 8 MG/0.4ML 65RELPAX 71REMERON 19REMERON SOLTAB 19REMICADE 65

REMODULIN 48RENAGEL 800 MG 65RENVELA 65repaglinide 0.5 mg 24repaglinide 1 mg 24repaglinide 2 mg 24REQUIP 39REQUIP XL 39RESCRIPTOR 100 MG 42RESCRIPTOR 200 MG 42RESCULA 77reserpine 0.1 mg, 0.25 mg 30RESTASIS 76RESTORIL 68RETIN-A 54RETIN-A MICRO 54RETIN-A MICRO PUMP 0.04 %,0.1 % 54RETIN-A MICRO PUMP 0.08% 54RETROVIR 42RETROVIR IV INFUSION 42REVATIO 10 MG/12.5ML 48REVATIO 20 MG 48REVLIMID 44REXULTI 0.25 MG 41REXULTI 0.5 MG 41REXULTI 1 MG 41REXULTI 2 MG 41REXULTI 3 MG, 4 MG 41REYATAZ 150 MG, 200 MG, 300MG 42REYATAZ 50 MG 42RHEUMATREX 2RHINOCORT AQUA 73ribavirin (hepatitis c) 44ribavirin (hepatitis c) 200 mg 44ribavirin (hepatitis c) 400 mg, 600mg 44RIDAURA 2rifabutin 33RIFADIN 33rifampin 150 mg, 300 mg 33rifampin 600 mg 33RIFATER 32RILUTEK 74riluzole 74rimantadine hydrochloride 44

Index 22

RIOMET 22risedronate sodium 150 mg 61risedronate sodium 30 mg, 5mg 61risedronate sodium 35 mg 61RISPERDAL 40RISPERDAL CONSTA 12.5MG 40RISPERDAL CONSTA 25MG 40RISPERDAL CONSTA 37.5 MG,50 MG 40RISPERDAL M-TAB 40risperidone 40RITALIN 2RITALIN LA 10 MG 2RITALIN LA 20 MG, 30 MG, 40MG 2RITALIN SR 2RITUXAN 35rivastigmine 80rivastigmine tartrate 80rizatriptan benzoate 10 mg 71rizatriptan benzoate 5 mg 71ROBAXIN 500 MG 73ROBAXIN-750 73ROBINUL 0.2 MG/ML 83ROBINUL 1 MG 83ROBINUL FORTE 83ROCALTROL 62ropinirole hydrochloride 39ROTARIX 85ROTATEQ 85ROWASA 65ROXICODONE 15 MG 7ROXICODONE 30 MG 7ROXICODONE 5 MG 7ROZEREM 68RUCONEST 66RYTARY 39RYTHMOL 13RYTHMOL SR 13SABRIL 18SAFYRAL 51SALAGEN 72SAMSCA 63SANCTURA 84SANCTURA XR 85

SANCUSO 25SANDIMMUNE 100 MG, 25MG 45SANDIMMUNE 100MG/ML 45SANDIMMUNE 50 MG/ML 45SANDOSTATIN 100MCG/ML 62SANDOSTATIN 200 MCG/ML,50 MCG/ML 62SANDOSTATIN LAR DEPOT20 MG, 30 MG 62SANTYL 58SAPHRIS 10 MG 40SAPHRIS 2.5 MG 40SAPHRIS 5 MG 40SAVAYSA 15SAVELLA 80SAVELLA TITRATIONPACK 80SEASONIQUE 51SECTRAL 46selegiline hcl 39selenium sulfide 2.5 % 55SELZENTRY 42SEMPREX-D 53SENSIPAR 30 MG 62SENSIPAR 60 MG, 90 MG 62SEREVENT DISKUS 15SEROQUEL 100 MG, 200 MG,25 MG, 50 MG 40SEROQUEL 300 MG, 400MG 40SEROQUEL XR 150 MG, 200MG, 300 MG, 50 MG 40SEROQUEL XR 400 MG 40SEROSTIM 4 MG, 6 MG 61sertraline hcl 100 mg, 25 mg,50 mg 20sertraline hcl 20 mg/ml 20SEVELAMERCARBONATE 65SIGNIFOR 63SIGNIFOR LAR 20 MG 63SIGNIFOR LAR 40 MG, 60MG 63sildenafil citrate (pulmonaryhypertension) 48SILENOR 68SILVADENE 56silver sulfadiazine 56SIMBRINZA 75

SIMCOR 20MG-1000MG, 20MG-500MG, 20MG-750MG 28SIMCOR 40MG-1000MG, 40MG-500MG 28SIMPONI 2SIMPONI ARIA 2SIMULECT 45simvastatin 10 mg 28simvastatin 20 mg 28simvastatin 40 mg 28simvastatin 5 mg 28simvastatin 80 mg 28SINEMET 39SINEMET CR 39SINGULAIR 10 MG 13SINGULAIR 4 MG, 5 MG 13sirolimus 0.5 mg, 1 mg 45sirolimus 2 mg 45SIRTURO 33SIVEXTRO 11SKELAXIN 73sodium chloride (gu irrigant) 66sodium chloride 0.45 % 72sodium chloride 0.9 % 72sodium fluoride 1 mg 72sodium polystyrenesulfonate 45sodium polystyrene sulfonate 15gm/60ml 45SOLARAZE 55SOLTAMOX 35SOLU-CORTEF 100 MG, 250MG 53SOLU-MEDROL 1000 MG, 125MG, 40 MG 53SOLU-MEDROL 2 GM 53SOMA 350 MG 73SOMATULINE DEPOT 63SOMAVERT 61SONATA 68SOOLANTRA 59SORIATANE 55SORILUX 55sotalol hcl 46sotalol hcl (afib/afl) 46Sotalol Hcl IV Soln 46SOTYLIZE 46SOVALDI 44SPIRIVA HANDIHALER 13

Index 23

SPIRIVA RESPIMAT 1.25MCG/ACT 13SPIRIVA RESPIMAT 2.5MCG/ACT 13spironolactone &hydrochlorothiazide 60spironolactone 100 mg, 25 mg,50 mg 60SPORANOX 10 MG/ML 26SPORANOX 100 MG 26SPORANOX PULSEPAK 26SPRIX 4SPRYCEL 36STALEVO 100 39STALEVO 125 39STALEVO 150 39STALEVO 200 39STALEVO 50 39STALEVO 75 39STARLIX 24stavudine 1 mg/ml 43stavudine 15 mg 42stavudine 20 mg, 30 mg, 40mg 42STELARA 55STIMATE 62STIOLTO RESPIMAT 15STIVARGA 36STRATTERA 10 MG 1STRATTERA 100 MG, 60 MG, 80MG 1STRATTERA 18 MG 1STRATTERA 25 MG 1STRATTERA 40 MG 1streptomycin sulfate 2STRIBILD 43STRIVERDI RESPIMAT 15STROMECTOL 9SUBOXONE 8SUBSYS 100 MCG, 200 MCG7SUBSYS 1200 MCG, 1600MCG 7SUBSYS 400 MCG, 600 MCG,800 MCG 7sucralfate 83SULAR 47sulfacetamide sod-prednisolone 76sulfacetamide sodium (acne)54

sulfacetamide sodium(ophth) 75sulfadiazine 81sulfamethoxazole-trimethoprim160mg-800mg, 80mg-400mg 10sulfamethoxazole-trimethoprim40mg/5ml-200mg/5ml 10sulfamethoxazole-trimethoprim80mg/5ml-400mg/5ml 10SULFAMYLON 85 MG/GM56sulfasalazine 65sulindac 150 mg, 200 mg 4sumatriptan succinate 100mg 71sumatriptan succinate 25mg 71sumatriptan succinate 4mg/0.5ml 71sumatriptan succinate 50mg 71sumatriptan succinate 6mg/0.5ml 71SUMAVEL DOSEPRO 4MG/0.5ML 71SUMAVEL DOSEPRO 6MG/0.5ML 71SUPRAX 400 MG 50SUPRAX 500 MG/5ML 50SUPREP BOWEL PREP 69SURMONTIL 21SUSTIVA 200 MG, 50 MG 43SUSTIVA 600 MG 43SUTENT 36SYLATRON 37SYMBICORT 15SYMBYAX 80SYMLINPEN 120 21SYMLINPEN 60 21SYNAGIS 78SYNALAR 58SYNAREL 62SYNERCID 11SYNRIBO 37SYNTHROID 82SYPRINE 44TABLOID 34TACLONEX 58tacrolimus (topical) 58tacrolimus 0.5 mg, 1 mg, 5mg 45TAFINLAR 36

TALWIN 8TAMIFLU 44tamoxifen citrate 10 mg, 20mg 35tamsulosin hcl 66TANZEUM 23TARCEVA 36TARGRETIN 37TARKA 2MG-240MG, 4MG-240MG 31TASIGNA 36TASMAR 38TAXOL 38TAXOTERE 38TAZORAC 55TECFIDERA 80TECFIDERA STARTERPACK 80TEFLARO 50TEGRETOL 18TEGRETOL-XR 18TEKAMLO 150MG-10MG 31TEKAMLO 150MG-5MG 31TEKTURNA 32TEKTURNA HCT 31telmisartan 30telmisartan-amlodipine 31telmisartan-hydrochlorothiazide

31temazepam 68TEMODAR 100 MG 33TEMOVATE 58TEMOVATE E 58TENEX 30TENIVAC 82TENORETIC 100 31TENORETIC 50 31TENORMIN 46TERAZOL 3 86TERAZOL 7 86terazosin hcl 30terbinafine hcl 26terbutaline sulfate 2.5 mg, 5mg 15terconazole vaginal 86TESTIM 9TESTOSTERONE 1 %, 10MG/ACT, 50 MG/5GM 9

Index 24

TESTOSTERONE 25MG/2.5GM 9testosterone 25 mg/2.5gm, 50mg/5gm 9testosterone 75 mg 9testosterone cypionate 9testosterone enanthate 9TESTOSTERONE PUMP 9TETANUS TOXOIDADSORBED 82TETANUS/DIPHTHERIATOXOIDS-ADSORBED 82TETANUS/DIPHTHERIATOXOIDS-ADSORBEDADULT 82tetrabenazine 80tetracycline hcl 250 mg, 500mg 82tetrahydrozoline hcl 74TEV-TROPIN 61THALOMID 44theophylline 100 mg, 200 mg,300 mg, 450 mg 15theophylline 100mg, 200 mg, 300mg, 400 mg 15theophylline 400 mg, 600 mg15theophylline 80 mg/15ml 15THERACYS 37thioridazine hcl 10 mg, 100 mg,25 mg, 50 mg 41THIOTEPA 33thiothixene 41THYMOGLOBULIN 45tiagabine hcl 2 mg 18tiagabine hcl 4 mg 18TIAZAC 47TICE BCG 37ticlopidine hcl 67TIGAN 25TIKOSYN 13timolol maleate (ophth) 0.25 %,0.5 % 75timolol maleate 10 mg 46timolol maleate 20 mg 46timolol maleate 5 mg 46TIMOPTIC 75TIMOPTIC-XE 75TINDAMAX 10tinidazole 250 mg, 500 mg 10TIVICAY 43tizanidine hcl 2 mg 73

tizanidine hcl 4 mg 73tizanidine hcl 6 mg 73TOBI 2TOBI PODHALER 2TOBRADEX 76TOBRADEX ST 76tobramycin 2tobramycin (ophth) 75tobramycin sulfate 1.2 gm 2tobramycin sulfate 1.2 gm/30ml,40 mg/ml, 80 mg/2ml 2tobramycin sulfate 10 mg/ml2tobramycin sulfate in saline 2tobramycin-dexamethasone 76TOBREX 75TOFRANIL-PM 21tolazamide 250 mg 25TOLAZAMIDE 500 MG 25TOLBUTAMIDE 25tolcapone 38tolmetin sodium 4tolterodine tartrate 85TOPAMAX 18TOPAMAX SPRINKLE 18TOPICORT 58topiramate 100 mg, 200 mg, 25mg, 50 mg 18topiramate 15 mg, 25 mg 18topotecan hcl 4 mg 38TOPROL XL 46TORISEL 36torsemide 10 mg, 100 mg, 20mg, 5 mg 60torsemide 20 mg/2ml, 50mg/5ml 60TOTECT 37TOUJEO SOLOSTAR 24TOVIAZ 85TRACLEER 48TRADJENTA 23tramadol hcl 100 mg 7tramadol hcl 200 mg, 300mg 7tramadol hcl 50 mg 7tramadol-acetaminophen 8TRANDATE 46trandolapril 29

trandolapril-verapamil hcl 2mg-240mg, 4mg-240mg 31tranexamic acid 100 mg/ml 68tranexamic acid 650 mg 68TRANSDERM-SCOP 26TRANXENE T 12tranylcypromine sulfate 19TRAVATAN Z 77travoprost 77trazodone hcl 100 mg, 150 mg,300 mg, 50 mg 20TREANDA 33TRECATOR 33TRELSTAR 35TRELSTAR MIXJECT 35tretinoin (chemotherapy) 37tretinoin 0.01 %, 0.025 %, 0.05% 54tretinoin 0.025 %, 0.05 %, 0.075%, 0.1 % 54tretinoin 0.038 % 54tretinoin microsphere 54tretinoin w/ cleanser & moisturizer0.025%, 0.1% 54tretinoin w/ cleanser & moisturizer0.05% 54TREXIMET 70triamcinolone acetonide &emollient 58triamcinolone acetonide(mouth) 72triamcinolone acetonide(nasal) 73triamcinolone acetonide(topical) 58triamterene &hydrochlorothiazide 60triazolam 68TRIBENZOR 31TRICOR 28trifluoperazine hcl 41trifluridine 75trihexyphenidyl hcl 38TRILEPTAL 18TRILIPIX 28trimethobenzamide hcl 100mg/ml 26trimethobenzamide hcl 300mg 26trimethoprim 10trimipramine maleate 100 mg, 25mg, 50 mg 21

Index 25

TRISENOX 37TRIUMEQ 43TRIZIVIR 43trospium chloride 85TRULICITY 23TRUSOPT 77TRUVADA 43TUDORZA PRESSAIR 13TWINRIX 85TWYNSTA 32TYBOST 43TYGACIL 10TYKERB 36TYPHIM VI 85TYSABRI 80TYVASO 48TYVASO REFILL 48TYVASO STARTER 48TYZEKA 44UCERIS 2 MG/ACT 9UCERIS 9 MG 53ULORIC 66ULTRACET 8ULTRAM 7ULTRAM ER 100 MG 7ULTRAM ER 200 MG, 300MG 7ULTRAVATE 58UNASYN 1GM-2GM 79UNIRETIC 32UNIVASC 29UROCIT-K 10 65UROCIT-K 5 65UROXATRAL 66URSO 250 64URSO FORTE 64ursodiol 250 mg, 500 mg 64ursodiol 300 mg 64UVADEX 37VAGIFEM 86valacyclovir hcl 1 gm, 1000 mg,500 mg 44VALCHLOR 55VALCYTE 43valganciclovir hcl 43VALIUM 12

valproate sodium 100 mg/ml,500 mg/5ml 19valproate sodium 250mg/5ml 19valproic acid 19valsartan 30valsartan-hydrochlorothiazide

32VALSTAR 36VALTREX 44VANCOCIN HCL 10vancomycin hcl 10 gm, 1000mg, 5000 mg, 750 mg 10vancomycin hcl 125 mg, 250mg 10vancomycin hcl 500 mg 10VANCOMYCIN HCL INDEXTROSE 10VANOS 58VANTAS 35VAQTA 85VARIVAX 85VARIZIG 78VASCEPA 27VASERETIC 32VASOTEC 10 MG 29VASOTEC 2.5 MG 29VASOTEC 20 MG 29VASOTEC 5 MG 30VECTIBIX 35VECTICAL 55VELCADE 36VELPHORO 65VELTIN 54venlafaxine hcl 100 mg 20venlafaxine hcl 150 mg 20venlafaxine hcl 25 mg 21venlafaxine hcl 37.5 mg 20venlafaxine hcl 50 mg 21venlafaxine hcl 75 mg 20VENLAFAXINE HCL ER 20VENTAVIS 10 MCG/ML 48VENTAVIS 20 MCG/ML 48VENTOLIN HFA 15VERAMYST 73verapamil hcl 100 mg, 120 mg,180 mg, 200 mg, 240 mg, 300mg, 360 mg 47verapamil hcl 120 mg, 180 mg,240 mg 47

verapamil hcl 120 mg, 40 mg, 80mg 47VEREGEN 54VERELAN 47VERELAN PM 47VERSACLOZ 40VESICARE 85VEXOL 76VFEND 200 MG, 50 MG 27VFEND IV 26VIBRAMYCIN 100 MG 82VIBRAMYCIN 25 MG/5ML 82VIBRAMYCIN 50 MG/5ML 82VICOPROFEN 8VICTOZA 23VICTRELIS 44VIDAZA 34VIDEX EC 43VIDEXPEDIATRIC 43VIEKIRA PAK 44VIGAMOX 75VIIBRYD 20VIIBRYD STARTER PACK 20VIMIZIM 62VIMOVO 4VIMPAT 10 MG/ML 18VIMPAT 100 MG, 150 MG, 200MG, 50 MG 18VIMPAT 200 MG/20ML 18vinblastine sulfate 1 mg/ml 38vinblastine sulfate 10 mg 38vincristine sulfate 38vinorelbine tartrate 38VIOKACE 59VIRACEPT 43VIRAMUNE 200 MG 43VIRAMUNE 50 MG/5ML 43VIRAMUNE XR 100 MG 43VIRAMUNE XR 400 MG 43VIRAZOLE 44VIREAD 150 MG, 200 MG, 300MG 43VIREAD 250 MG 43VIREAD 40 MG/GM 43VIROPTIC 75VISTARIL 12VISTIDE 43

Index 26

VITEKTA 43VIVELLE-DOT 63VOGELXO 9VOGELXO PUMP 9VOLTAREN 54VOLTAREN-XR 4voriconazole 200 mg 27voriconazole 200 mg, 50 mg 27VOSOL HC 77VOTRIENT 36VPRIV 67VYTORIN 10MG-10MG 27VYTORIN 10MG-20MG 27VYTORIN 40MG-10MG 27VYTORIN 80MG-10MG 27VYVANSE 10 MG 1VYVANSE 20 MG 1VYVANSE 30 MG 1VYVANSE 40 MG, 50 MG, 60MG, 70 MG 1warfarin sodium 15water for irrigation, sterile 45WELCHOL 28WELLBUTRIN 100 MG 19WELLBUTRIN 75 MG 19WELLBUTRIN SR 100 MG 19WELLBUTRIN SR 150 MG, 200MG 19WELLBUTRIN XL 150 MG 19WELLBUTRIN XL 300 MG 19WESTCORT 58XALATAN 77XALKORI 36XANAX 12XANAX XR 12XARELTO 15XARELTO STARTER PACK 15XELJANZ 2XENAZINE 80XEOMIN 74XERESE 56XGEVA 61XIAFLEX 44XIFAXAN 10XIGDUO XR 10MG-1000MG,10MG-500MG 22XIGDUO XR 5MG-1000MG,5MG-500MG 22

XOLAIR 13XOPENEX 15XOPENEXCONCENTRATE 15XOPENEX HFA 15XTANDI 35XYLOCAINE 1 %, 2 % 69XYLOCAINE 20 MG/ML 12XYLOCAINE 4 % 59XYLOCAINE-MPF 1 % 69XYREM 79XYZAL 27YASMIN 28 51YAZ 51YERVOY 35YF-VAX 85YONDELIS 33zafirlukast 13zaleplon 68ZALTRAP 34ZANAFLEX 2 MG 73ZANAFLEX 4 MG 73ZANAFLEX 6 MG 73ZANOSAR 34ZANTAC 15 MG/ML 83ZANTAC 150 MG 83ZANTAC 300 MG 83ZARONTIN 18ZAROXOLYN 60ZARXIO 68ZAVESCA 67ZEBETA 46ZEGERID 20MG-1100MG 84ZEGERID 20MG-1680MG 84ZEGERID 40MG-1100MG 84ZEGERID 40MG-1680MG 84ZELAPAR 39ZELBORAF 36ZEMAIRA 81ZEMPLAR 1 MCG, 2 MCG, 4MCG 62

ZENPEP 10000UNIT-3000UNIT-16000UNIT, 17000UNIT-5000UNIT-27000UNIT,34000UNIT-10000UNIT-55000UNIT, 51000UNIT-15000UNIT-82000UNIT,68000UNIT-20000UNIT-109000UNIT, 85000UNIT-25000UNIT-136000UNIT 59ZENPEP 136000UNIT-40000UNIT-218000UNIT 59ZERIT 43ZESTORETIC 32ZESTRIL 30ZETIA 29ZETONNA 74ZIAC 32ZIAGEN 20 MG/ML 43ZIAGEN 300 MG 43ZIANA 54zidovudine 100 mg 43zidovudine 300 mg 43zidovudine 50 mg/5ml 43ZINACEF 1.5 GM, 7.5 GM 49ZINACEF 750 MG 49ZINECARD 37ZIOPTAN 77ziprasidone hcl 39ZIPSOR 4ZIRGAN 76ZITHROMAX 100 MG/5ML, 200MG/5ML 69ZITHROMAX 250 MG, 500 MG,600 MG 69ZITHROMAX 500 MG 69ZITHROMAX TRI-PAK 69ZITHROMAX Z-PAK 69ZMAX 69ZOCOR 10 MG 28ZOCOR 20 MG 28ZOCOR 40 MG 28ZOCOR 5 MG 28ZOCOR 80 MG 29ZOFRAN 4 MG, 8 MG 25ZOFRAN 4 MG/5ML 25ZOFRAN 40 MG/20ML 25ZOFRAN ODT 25ZOHYDRO ER 10 MG, 15 MG,20 MG, 30 MG, 40 MG, 50MG 7

Index 27

ZOLADEX 35ZOLEDRONIC ACID 4 MG 61zoledronic acid 4 mg/5ml 61zoledronic acid 5 mg/100ml 61ZOLINZA 36zolmitriptan 2.5 mg 71zolmitriptan 5 mg 71ZOLOFT 20zolpidem tartrate 10 mg 68zolpidem tartrate 12.5 mg 68zolpidem tartrate 5 mg 68zolpidem tartrate 6.25 mg 68ZOLPIMIST 68ZOMACTON 5 MG 61ZOMETA 4 MG/5ML 61ZOMIG 2.5 MG 71ZOMIG 5 MG 71ZOMIG NASAL SPRAY 71ZOMIG ZMT 2.5 MG 71ZOMIG ZMT 5 MG 71ZONEGRAN 18zonisamide 18ZONTIVITY 67ZORTRESS 0.25 MG 45ZORTRESS 0.5 MG, 0.75MG 45ZOSTAVAX 85ZOSYN 0.25GM-2GM, 0.375GM-3GM, 0.5GM-4GM, 4.5GM-36GM 79ZOSYN 0.25GM/50ML-2GM/50ML-5%, 0.375GM/50ML-3GM/50ML-5%, 0.5GM/100ML-4GM/100ML-5% 79ZOVIRAX 200 MG 44ZOVIRAX 200 MG/5ML 44ZOVIRAX 400 MG, 800 MG 44ZOVIRAX 5 % 56ZUBSOLV 1.4MG-0.36MG,5.7MG-1.4MG, 8.6MG-2.1MG 8ZUBSOLV 11.4MG-2.9MG,2.9MG-0.71MG 8ZYBAN 81ZYCLARA 58ZYCLARA PUMP 58ZYDELIG 36ZYFLO CR 13ZYKADIA 36ZYLET 76

ZYLOPRIM 100 MG 66ZYLOPRIM 300 MG 66ZYMAXID 76ZYPREXA 10 MG 40ZYPREXA 10 MG, 2.5 MG, 5MG, 7.5 MG 41ZYPREXA 15 MG, 20 MG 41ZYPREXA ZYDIS 41ZYTIGA 35ZYVOX 100 MG/5ML 11ZYVOX 2 MG/ML 11ZYVOX 600 MG 11

Index 28

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12/01/2015.

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