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MEMBER 2020 PREFERRED DRUG LIST...MEMBER PREFERRED DRUG LIST 2020 For group HMO, PPO and EPO members...

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MEMBER PREFERRED DRUG LIST 2020 For group HMO, PPO and EPO members with an insurance plan that includes a prescription drug benefit Effective January 1, 2020
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Page 1: MEMBER 2020 PREFERRED DRUG LIST...MEMBER PREFERRED DRUG LIST 2020 For group HMO, PPO and EPO members with an insurance plan that includes a prescription drug benefit Effective January

MEMBER

PREFERRED DRUG LIST2020

For group HMO, PPO and EPO members with an insurance plan that includes a prescription drug benefit

Effective January 1, 2020

Page 2: MEMBER 2020 PREFERRED DRUG LIST...MEMBER PREFERRED DRUG LIST 2020 For group HMO, PPO and EPO members with an insurance plan that includes a prescription drug benefit Effective January

Blue Cross and Blue Shield of Kansas City 2020 Preferred Drug List

IntroductionThe Prescription Drug List (PDL) has been developed and is maintained by the Medical and Pharmacy Management Committee of Blue Cross and Blue Shield of Kansas City (Blue KC). The committee is composed of practicing doctors and pharmacists within the Kansas City area. Quarterly meetings are held to evaluate new drug therapies and review drug utilization issues.

Medications are evaluated on the basis of safety, effectiveness, adverse events, proven advantages over existing agents and cost. Tier 1 medications are typically generic drugs that contain the same active ingredients as brand name drugs and have the lowest copay. New drugs will require an exception or prior authorization until they are reviewed by the committee.

While extensive, this is not an exhaustive list of all available medications and this list is subject to change. See the most current PDL by visiting your member portal at MyBlueKC.com. If you require additional information or clarification, contact our Clinical Pharmacy unit at 816-395-2176 or 800-228-1436.

Please be aware that as new products are released and post-marketing information on existing therapies becomes available, changes in the PDL status may occur. The committee may also implement prior authorization or other utilization management processes as deemed necessary. Doctors and pharmacists will be notified of any such changes via direct mailings.

How to use this list:1 Find the page number for your drug by searching the alphabetical index at the end.

2 Locate your drug and identify the Drug Tier. You will also want to note restrictions and preferred alternatives if applicable.

3 Refer to the Drug Tier description tables at the end of this introduction to identify the tier copay for your drug (based on the benefit schedule described in your member certificate or in your Blue KC benefit summary.

Prior Authorization/Drug Utilization ManagementSome drugs have coverage rules or have limits on the amount dispensed. In some cases, the prescriber must do something in order to obtain the drug. For example:

• Prior approval (or prior authorization): For some drugs, the prescriber must get approval from BlueKC before the prescription can be filled. Without that approval, the drug may not be covered.

• Quantity limits: For some drugs, there are limits to the amount of drug that may be obtained.

• Step Therapy: For some drugs, BlueKC requires step therapy. This means that drugs will have to be tried in a certain order for a medical condition. If the doctor feels that the first drugs are not appropriate, the prescriber will have to submit a prior authorization request.

Prescribers may request exceptions to these coverage rules or limits by submitting an electronic prior authorization request form. www.BlueKC.com > Providers > Forms > Prior Authorizations for Medications.

HOW TO REACH USBlue Cross and Blue Shield of Kansas City Pharmacy Services P.O. Box 419169 Kansas City, MO 64141-2735

816-395-2176 or 800-228-1436

www.BlueKC.com

Page 3: MEMBER 2020 PREFERRED DRUG LIST...MEMBER PREFERRED DRUG LIST 2020 For group HMO, PPO and EPO members with an insurance plan that includes a prescription drug benefit Effective January

Frequently asked questionsWhat is the difference between brand name drugs and generic drugs?When a drug company develops a new medication they apply for a patent. This patent protects the drug from being copied by other drug companies for a certain period of time. These drugs are brand name drugs. Once the patent period expires, other manufacturers can produce the same drug as long as they follow strict guidelines established by the Food and Drug Administration's (FDA) guidelines. These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose patents have expired. They are made with the same active ingredients of the brand name drug, but they may have a different color, shape or filler material. The cost of a generic drug is typically less than a brand name drug. All generic medications are approved by the FDA before they are released on the market.

What is the difference between a generic equivalent and a generic alternative?A generic equivalent is a medication that contains the same active ingredient and works the same way as the original brand name drug. A generic alternative is a generic medication that may not have the same active ingredient, but works in the same way as another drug.

What is a maintenance drug?A maintenance drug is a medication used to treat a chronic condition like diabetes or high blood pressure. The FDA must approve maintenance drugs as safe for long-term use. Blue KC uses a national drug information database called Medispan to determine which medications are included on the maintenance drug list. If your prescription is a maintenance drug, you can have it filled for several months instead of just one prescription at a time.

Does Blue KC cover all prescription drugs?Blue KC covers most prescription drugs. However, some drug classes require an additional benefit be added to your health insurance plan in order to be covered. This additional benefit is referred to as a ‘rider.’ Examples of such drug classes are fertility, birth control, impotency, and weight loss.

How is the tier level status determined for medications?The PDL is a list of prescription medications that have been reviewed and recommended by the Blue KC Medical and Pharmacy Management Committee.

The list has a combination of brand name and generic medications. Each of these medications has been reviewed for its safety, effectiveness, clinical outcomes, and cost. Doctors and pharmacists on the committee look at drug utilization issues, the number of adverse events, and any proven advantages over other drugs on the PDL. The most efficient and cost-effective drugs are on Tier 1 of the PDL.

Why does Blue KC require prior authorization for some drugs before they are covered?Blue KC may require prior authorization for some drugs or a class. Medications on the prior authorization list may have safety concerns or have FDA approval, only for a certain use. Some of the prior authorization medications may also have a lower-cost alternative that should be considered first or the drug may not be as effective as something else in the same drug class. Some medications are also on the prior authorization list because they have the potential to be misused. Your doctor and Blue KC will work together to get prior authorization and approval for your prescription when needed.

Do I need to show my member ID card at the pharmacy?Yes, show your member ID card to your pharmacist whenever you have a prescription filled. Your prescription claim is electronically transmitted to Blue KC when you fill your prescription. Please make sure the pharmacy has your most current health insurance information and correct birth date so there won’t be any delays or claim denials when we process your claim.

What do I do if I need to refill my prescription early (i.e., leaving on vacation, the doctor increased my dosage)? To have a prescription refilled early, have your pharmacist call the Pharmacy Customer Service unit at 816-395- 2176 or 800-228-1436, Monday through Friday from 8 a.m. to 5 p.m. Central Time.

What if I am out of town and need to have a prescription filled?Blue KC contracts with most major pharmacy chains and has a network of over 44,000 pharmacies nationwide. If the pharmacy you are using has difficulty in processing your prescription claim, have them contact the Pharmacy Customer Service unit for assistance at 816-395-2176 or 800-228-1436, Monday through Friday from 8 a.m. to 5 p.m. Central Time.

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Why must some drugs be purchased through a Specialty Pharmacy?Specialty drugs are those that require special ordering, handling, clinical monitoring and/or customer service. These drugs are best purchased through a Specialty Pharmacy. Blue KC has a network of Specialty Pharmacies available to provide specialized care for patients with complex chronic health conditions to obtain

their medications and manage their health conditions. Specialty medications are limited to a 34 day supply.

What if I have questions about my prescription drug coverage?For more information on your prescription drug coverage, call the Pharmacy Customer Service unit at 816-395-2176 or 800-228-1436, Monday through Friday from 8 a.m. to 5 p.m. Central Time.

Miscellaneous Information

Specialty PharmacyA Specialty Pharmacy is one that provides specialized care for patients with complex chronic health conditions such as Rheumatoid Arthritis, Multiple Sclerosis or Psoriasis. Specialty drugs may be oral or injectable medications that can either be self-administered or administered by a health care professional. These pharmacies do everything from dispense the specialty medication to help patients manage their health condition. Most specialty medications are covered under the pharmacy benefit. Specialty medications are limited to a 34 day supply. The following is a list of other services provided by the Specialty Pharmacies:

• Assigns a Patient Care Coordinator who serves as a personal advocate and point of contact

• Offers access to a dedicated clinical staff of nurses and pharmacists who are knowledgeable about the medications and conditions

• Provides the necessary supplies to administer the medications — at no additional cost

• Offers care management programs to help patients get the most from their medications

• Provides patients with refill reminder calls

• Allows the medications to be delivered to either the physician’s office or patients home

• Works directly with patients to arrange a convenient shipment date

• Ships all medications overnight

• Coordinates with Blue KC to take care of billing issues

These services are provided to you at no additional cost. Prescriptions for a specialty medication will need to be filled at the Specialty Pharmacy listed below.

Optum Specialty Pharmacy Phone: 1-855-427-4682

Drug Tier DescriptionsTo find out what prescription drug tier is on your plan, please see the benefit schedule in your member certificate or in your Blue KC benefit summary.

2-Tier Benefit Drug Tier

Tier 1 copayG

G-S

Tier 2 copayPB

PB-S

Not CoveredNPB

NPB-S

3-Tier Benefit Drug Tier

Tier 1 copayG

G-S

Tier 2 copayPB

PB-S

Tier 3 copayNPB

NPB-S

3-Tier Retail/Specialty Benefit Drug Tier

Tier 1 copay G

Tier 2 copay PB

Tier 3 copay NPB

Generic Specialty copay G-S

Preferred Brand Specialty copay PB-S

Non-Preferred Brand Specialty copay NPB-S

4-Tier Benefit Drug Tier

Tier 1 copayG

G-S

Tier 2 copay PB

Tier 3 copayPB-S

NPB

Tier 4 copay NPB-S

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List of AbbreviationsG Generic Drug.

G-S Generic Specialty Drug.

NPB Non-preferred Brand Drug.

NPB-S Non-preferred Brand Specialty Drug.

PB Preferred Brand Drug.

PB-S Preferred Brand Specialty Drug.

ACA Affordable Care Act. These preventative drugs may be covered at no cost (check your benefits to confirm).

M Maintenance Drug.

OTC Over the Counter. An OTC drug is a non-prescription drug.

PA Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don’t get approval, your plan may not cover the drug.

QL Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.

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

Page 6: MEMBER 2020 PREFERRED DRUG LIST...MEMBER PREFERRED DRUG LIST 2020 For group HMO, PPO and EPO members with an insurance plan that includes a prescription drug benefit Effective January

Discrimination is Against the LawBlue KC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue KC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Blue KC:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: › Qualified sign language interpreters › Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as: › Qualified interpreters › Information written in other languages

If you need these services, contact Customer Service, 844-395-7126 (Toll free), [email protected].

If you believe that Blue KC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Appeals Department, PO Box 419169, Kansas City, MO 64141-6169, 816-395-3537, TTY: 816-842-5607, [email protected]. You can file a grievance in person or by mail, or email. If you need help filing a grievance, the Appeals Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

If you, or someone you’re helping, has questions about Blue KC, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-844-395-7126.

Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Blue KC, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-844-395-7126.

Chinese: 如果您,或是您正在協助的對象,有關於 Blue KC方面的問題,您 有權利免費以您的母語得到幫 助和訊息。洽詢一位翻譯員,請撥電話1-844-395-7126。

Vietnamese: Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Blue KC, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-844-395-7126.

German: Falls Sie oder jemand, dem Sie helfen, Fragen zum Blue KC haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-844-395-7126 an.

Korean: 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 [Blue KC]에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1-844-395-7126 로 전화하십시오.

Serbo-Croatian: Ukoliko Vi ili neko kome Vi pomažete ima pitanje o Blue KC, imate pravo da besplatno dobijete pomoć i informacije na Vašem jeziku. Da biste razgovarali sa prevodiocem, nazovite 1-844-395-7126.

Page 7: MEMBER 2020 PREFERRED DRUG LIST...MEMBER PREFERRED DRUG LIST 2020 For group HMO, PPO and EPO members with an insurance plan that includes a prescription drug benefit Effective January

M57313-C 9/19

Arabic:إن كان لديك أو لدى شخص تساعده أسئلة بخصوص Blue KC ، .فلديك الحق في الحصول على المساعدة والمعلومات الضرورية بلغتك من دون اية تكلفة

للتحدث مع مترجم اتصل ب. 7126 -1-844-395.

Russian: Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Blue KC, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону1-844-395-7126.

French: Si vous, ou quelqu’un que vous êtes en train d’aider, a des questions à propos de Blue KC, vous avez le droit d’obtenir de l’aide et l’information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-844-395-7126.

Tagalog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Blue KC, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa1-844-395-7126.

Laotian: ຖ້ າທ່ ານ, ືຫຼ ຄົ ນ ່◌ທທ່ ານກໍ າລັ ງຊ່ ວຍເຫືຼ ອ, ມ ໍ◌ຄາຖາມກ່ ຽວກັ ບ Blue KC, ທ່ ານມ ິ◌ສດ ່◌ທຈະໄດ້ ຮັ ບການຊ່ ວຍເຫືຼ ອແລະໍ◌ຂ້ ມູ ນຂ່ າວສານ ່◌ທເປັ ນພາສາຂອງທ່ າໍນ ່◌ບມ ຄ່ າໃຊ້ ຈ່ າຍ. ການໂອ້ ລົ ມກັ ບນາຍພາສາ, ໃຫ້ ໂທຫາ 1-844-395-7126.

Pennsylvanian Dutch: Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut Blue KC, hoscht du es Recht fer Hilf un Information in deinre eegne Schprooch griege, un die Hilf koschtet nix. Wann du mit me Interpreter schwetze witt, kannscht du 1-844-395-7126 uffrufe.

Persian:اگر شما، يا کسی که شما به او کمک ميکنيد ، سوال در مورد Blue KC ، داشته باشيد حق اين را داريد که کمکو اطالعات به زبان خود را به طور

رايگان دريافت مناييد 7126-395-844-1.متاس حاصل مناييد.

Cushite: Isin yookan namni biraa isin deeggartan Blue KC irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabdu. Nama isiniif ibsu argachuuf, lakkoofsa bilbilaa 1-844-395-7126 tiin bilbilaa.

Portuguese: Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Blue KC, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-844-395-7126.

For TTY services, please call 1-816-842-5607.

An Independent Licensee of the Blue Cross and Blue Shield Association

All Optum trademarks and logos are owned by Optum, Inc. All other trademarks are the property of their respective owners.

Page 8: MEMBER 2020 PREFERRED DRUG LIST...MEMBER PREFERRED DRUG LIST 2020 For group HMO, PPO and EPO members with an insurance plan that includes a prescription drug benefit Effective January

Table of Contents

Analgesics - Drugs for Pain...............................................................................................................................10Analgesics - Drugs for Pain and Inflammation.................................................................................................. 13Anesthetics........................................................................................................................................................16Anti-Addiction / Substance Abuse Treatment Agents....................................................................................... 16Antibacterials.....................................................................................................................................................17Anticoagulants...................................................................................................................................................21Anticonvulsants - Drugs for Seizures................................................................................................................ 21Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.............................................................. 23Antidepressants.................................................................................................................................................24Antiemetics - Drugs for Nausea and Vomiting.................................................................................................. 26Antifungals.........................................................................................................................................................27Antigout Agents................................................................................................................................................. 29Anti-inflammatory Agents.................................................................................................................................. 29Antimigraine Agents.......................................................................................................................................... 29Antimyasthenic Agents......................................................................................................................................30Antimycobacterials............................................................................................................................................ 31Antineoplastics - Drugs for Cancer....................................................................................................................31Antiparasitics..................................................................................................................................................... 35Antiparkinson Agents........................................................................................................................................ 36Antiplatelets.......................................................................................................................................................37Antipsychotics - Drugs for Mood Disorders....................................................................................................... 38Antivirals............................................................................................................................................................39Anxiolytics - Drugs for Anxiety...........................................................................................................................42Bipolar Agents - Drugs for Mood Disorders.......................................................................................................43Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders..............................................43Cardiovascular Agents - Drugs for Heart and Circulation Conditions............................................................... 44Central Nervous System Agents - Drugs for Attention Deficit Disorder........................................................... 52Central Nervous System Agents - Drugs for Multiple Sclerosis........................................................................ 54Central Nervous System Agents - Miscellaneous............................................................................................. 55Dental and Oral Agents - Drugs for Mouth and Throat Conditions....................................................................55Dermatological Agents - Drugs for Skin Conditions.......................................................................................... 57Diabetes - Antidiabetic Agents.......................................................................................................................... 65Diabetes - Glucose Monitoring.......................................................................................................................... 67Diabetes - Glycemic Agents.............................................................................................................................. 69Diabetes - Insulins.............................................................................................................................................69Electrolytes / Minerals / Metals / Vitamins.........................................................................................................71Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer................................................................................76Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions.................................................77Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment............................................. 80Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.......................................................80Genitourinary Agents - Drugs for Prostate Conditions...................................................................................... 82Hormonal Agents - Adrenal............................................................................................................................... 82Hormonal Agents - Men's Health.......................................................................................................................84Hormonal Agents - Osteoporosis...................................................................................................................... 85Hormonal Agents - Pituitary.............................................................................................................................. 85Hormonal Agents - Prostaglandins....................................................................................................................87Hormonal Agents - Sex Hormones and Birth Control........................................................................................87Hormonal Agents - Thyroid............................................................................................................................... 94Immunological Agents - Drugs for Immune System Stimulation or Suppression.............................................. 95Immunological Agents - Drugs for Vaccination................................................................................................. 97Inflammatory Bowel Disease Agents.................................................................................................................99

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Metabolic Bone Disease Agents - Drugs for Osteoporosis............................................................................. 100Metabolic Bone Disease Agents - Other......................................................................................................... 100Miscellaneous Therapeutic Agents................................................................................................................. 101Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation.........................................................102Ophthalmic Agents - Drugs for Glaucoma.......................................................................................................104Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions....................................................................... 105Otic Agents - Drugs for Ear Conditions........................................................................................................... 106Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold......................................................107Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions................................. 109Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis.................................................................. 112Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension.................................................. 112Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm.................................................................... 113Sleep Disorder Agents.................................................................................................................................... 114

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Drug Name Drug Tier Restrictions / Limits

Analgesics - Drugs for Pain

ABSTRAL NPB ST; QL

acetaminophen-codeine G

acetaminophen-codeine #2 G

acetaminophen-codeine #3 G

acetaminophen-codeine #4 G

ACTIQ NPB PA; QL

ALLZITAL NPB ST

APADAZ NPB

apap-caff-dihydrocodeine oral capsule G

apap-caff-dihydrocodeine oral tablet NPB

ARYMO ER NPB ST; QL

ascomp-codeine G

BELBUCA PB ST; QL

BENZHYDROCODONE-ACETAMINOPHEN NPB

BUPAP NPB ST

buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr

G ST; QL

BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR

NPB ST; QL

butalbital-acetaminophen capsule 50-300 mg oral

G

BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL

G ST

butalbital-acetaminophen oral tablet G

butalbital-apap-caff-cod G

butalbital-apap-caffeine G

butalbital-asa-caff-codeine G

butalbital-aspirin-caffeine G

butorphanol tartrate nasal G

BUTRANS NPB ST; QL

carisoprodol-aspirin-codeine G

codeine sulfate G

CONZIP NPB ST; QL

DILAUDID ORAL NPB

DOLOPHINE G ST

DSUVIA NPB

DURAGESIC-100 NPB ST; QL

DURAGESIC-12 NPB ST; QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

DURAGESIC-25 NPB ST; QL

DURAGESIC-50 NPB ST; QL

DURAGESIC-75 NPB ST; QL

duraxin G

DVORAH NPB

endocet G

ESGIC NPB ST

fentanyl G ST; QL

fentanyl citrate buccal lozenge on a handle G PA; QL

FENTANYL CITRATE BUCCAL TABLET NPB ST; QL

FENTORA NPB ST; QL

FIORICET NPB ST

FIORICET/CODEINE NPB

FIORINAL NPB ST

FIORINAL/CODEINE #3 NPB

hydrocodone bitartrate er oral capsule er 12 hour abuse-deterrent 10 mg, 15 mg, 30 mg, 40 mg, 50 mg

G ST; QL

hydrocodone bitartrate er oral capsule er 12 hour abuse-deterrent 20 mg

G ST

hydrocodone-acetaminophen G

hydrocodone-ibuprofen G

hydromorphone hcl er G ST; QL

HYDROMORPHONE HCL INJECTION SOLUTION 0.2 MG/ML

NPB

hydromorphone hcl oral G

hydromorphone hcl rectal G

HYSINGLA ER PB ST; QL

KADIAN NPB ST; QL

LAZANDA NPB ST; QL

levorphanol tartrate oral tablet 2 mg G

levorphanol tartrate oral tablet 3 mg NPB

lorcet G

lorcet hd G

lorcet plus G

LORTAB G

MEDROX-RX NPB

meperidine hcl oral G

methadone hcl intensol G ST

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

methadone hcl oral G ST

methadose oral concentrate 10 mg/ml G ST

methadose oral tablet soluble G ST

methadose sugar-free G ST

MORPHABOND ER NPB ST; QL

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml

G

morphine sulfate er G ST; QL

morphine sulfate er beads G ST; QL

morphine sulfate oral G

morphine sulfate rectal G

MS CONTIN NPB ST; QL

NALOCET NPB

NORCO NPB ST

NUCYNTA PB

NUCYNTA ER PB ST; QL

OPANA NPB

OXAYDO NPB

OXYCODONE HCL ER NPB ST; QL

oxycodone hcl oral capsule G

oxycodone hcl oral concentrate 100 mg/5ml G

oxycodone hcl oral solution G

oxycodone hcl oral tablet G

oxycodone-acetaminophen G

oxycodone-aspirin G

oxycodone-ibuprofen G

OXYCONTIN PB ST; QL

oxymorphone hcl G

oxymorphone hcl er G ST; QL

pentazocine-naloxone hcl G

PERCOCET NPB

PRIMLEV NPB

PROLATE NPB

ROXICODONE NPB

SUBSYS NPB PA; QL

SYNAPRYN FUSEPAQ NPB

tencon G

tramadol hcl er (biphasic) G ST; QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG

NPB ST; QL

tramadol hcl er oral capsule extended release 24 hour 150 mg

G ST; QL

tramadol hcl er oral tablet extended release 24 hour

G ST; QL

tramadol hcl oral tablet 100 mg G QL

tramadol hcl oral tablet 50 mg G

tramadol-acetaminophen G

TREZIX NPB

TYLENOL WITH CODEINE #3 NPB

ULTRACET NPB

ULTRAM NPB

VANATOL LQ NPB ST

VANATOL S NPB ST

vicodin hp G

VTOL LQ NPB ST

XTAMPZA ER NPB ST; QL

ZEBUTAL NPB ST

ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 30 MG, 40 MG, 50 MG

NPB ST; QL

ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT 20 MG

NPB ST

Analgesics - Drugs for Pain and Inflammation

ACTIVE INJECTION KET-L NPB

ACTIVE INJECTION KETMARC-L NPB

ACTIVE-KETOPROFEN NPB

ACTIVE-PREP KIT I NPB

ACTIVE-PREP KIT II NPB

ACTIVE-PREP KIT III NPB

AIF #2 DRUG PREPARATION KIT NPB

AIF #3 DRUG PREPARATION KIT NPB

ARTHROTEC NPB ST

CAMBIA NPB ST; QL

CELEBREX NPB ST; QL

celecoxib oral G QL

choline-mag trisalicylate G

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

DAYPRO NPB ST

DICLOFENAC EPOLAMINE NPB ST; QL

diclofenac potassium G

diclofenac sodium er G

diclofenac sodium oral G

diclofenac sodium transdermal gel 1 % G QL

diclofenac sodium transdermal solution G

diclofenac-misoprostol G

diflunisal oral G

DUAL COMPLEX FORMULA 1 KIT NPB

DUEXIS NPB ST; QL

EC-NAPROSYN NPB ST

ec-naproxen G

ENOVARX-DICLOFENAC SODIUM NPB

ENOVARX-IBUPROFEN NPB

ENOVARX-NAPROXEN NPB

etodolac G

etodolac er G

FBL KIT NPB

FELDENE NPB ST

fenoprofen calcium oral capsule NPB ST

fenoprofen calcium oral tablet G ST

fenortho NPB ST

FLECTOR PB ST; QL

flurbiprofen oral G

ibu G

ibuprofen oral tablet 400 mg, 600 mg, 800 mg G

INDOCIN ORAL NPB ST

INDOCIN RECTAL NPB

indomethacin er G

indomethacin oral capsule 25 mg, 50 mg G

K.B.G.L IN TERODERM NPB

KETOPHENE RAPIDPAQ NPB

ketoprofen er G

ketoprofen oral capsule 25 mg G

KETOROCAINE-L NPB

KETOROCAINE-LM NPB

KETOROLAC TROMETHAMINE EXTERNAL NPB

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

KETOROLAC TROMETHAMINE INTRAMUSCULAR

NPB-S

ketorolac tromethamine oral G QL

LIDOPROFEN NPB

LODINE NPB ST

meclofenamate sodium oral G

mefenamic acid oral G

meloxicam oral G QL

MOBIC NPB ST; QL

nabumetone oral G

NALFON NPB ST

NAPRELAN NPB ST

NAPRO NPB

NAPROSYN ORAL SUSPENSION NPB ST

naproxen dr G

naproxen oral G

naproxen sodium er G

naproxen sodium oral tablet 275 mg, 550 mg G

naproxen-esomeprazole G QL

NP #2 DRUG PREPARATION KIT NPB

oxaprozin G

PENNSAID NPB ST; QL

piroxicam oral G

PRASTERA NPB

QMIIZ ODT NPB ST

READYSHARP ANESTH + KETOROLAC NPB

RELAFEN DS NPB

salsalate oral G

SPRIX NPB ST; QL

sulindac oral G

TIVORBEX NPB ST

tolmetin sodium G

TRIPLE COMPLEX FORMULA 3 KIT NPB

VIMOVO NPB ST; QL

VIVLODEX NPB ST

VOLTAREN NPB ST; QL

VOPAC GB NPB

VOPAC KT NPB

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

VP FC KIT NPB

VP GKL KIT NPB

ZIPSOR NPB ST; QL

ZORVOLEX NPB ST; QL

Anesthetics

ACTIVE INJECTION LM-2 NPB

BUPIVACAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 0.125 % (50 ML)

NPB

CETACAINE EXTERNAL AEROSOL NPB

c-topical G

ENOVARX-LIDOCAINE HCL NPB

ethyl chloride G

GEBAUERS PAIN EASE NPB

GEBAUERS SPRAY AND STRETCH NPB

glydo G

L.E.T. NPB

lidocaine external ointment G

lidocaine external patch 5 % G

lidocaine hcl external solution G

lidocaine hcl urethral/mucosal G

lidocaine-prilocaine external cream G

LIDOCAINE-TETRACAINE EXTERNAL CREAM 7-7 %

NPB PA

LIDODERM NPB ST

marlido G

MARLIDO-25 NPB

P-CARE 100MX NPB

PLIAGLIS NPB PA

POINT OF CARE LM-2.2 NPB

POINT OF CARE LM-2.5 NPB

READYSHARP-A NPB

ROPIVACAINE HCL INJECTION SOLUTION 33.4 MG/ML

NPB

SYNERA NPB

VENIPUNCTURE PX1 PHLEBOTOMY NPB

ZTLIDO PB ST

Anti-Addiction / Substance Abuse Treatment Agents

acamprosate calcium G

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

ANTABUSE NPB

BUNAVAIL G QL

buprenorphine hcl sublingual G QL

buprenorphine hcl-naloxone hcl G QL

bupropion hcl er (smoking det) G M; ACA

CHANTIX PB ACA; QL

CHANTIX CONTINUING MONTH PAK PB ACA; QL

CHANTIX STARTING MONTH PAK PB ACA; QL

disulfiram oral G

EVZIO G ST

LUCEMYRA NPB QL

naloxone hcl injection solution G

NALOXONE HCL INJECTION SOLUTION AUTO-INJECTOR

G ST

naloxone hcl injection solution cartridge G

naloxone hcl injection solution prefilled syringe G

naltrexone hcl oral G

NALTREXONE SUBCUTANEOUS NPB

NARCAN G

NICOTROL NPB M; ACA; QL

NICOTROL NS NPB M; ACA; QL

SUBOXONE G QL

ZUBSOLV G QL

Antibacterials

ACTICLATE NPB ST

ALTABAX NPB

amoxicillin G

amoxicillin-potassium clavulanate er G

amoxicillin-potassium clavulanate oral G

ampicillin G

ARIKAYCE PB-S PA

AUGMENTIN ES-600 NPB

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML

PB

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 250-62.5 MG/5ML

NPB

AUGMENTIN ORAL TABLET NPB

avidoxy G

azithromycin oral G

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

BACTRIM NPB

BACTRIM DS NPB

BAXDELA ORAL NPB

cefaclor G

cefaclor er G

cefadroxil G

cefdinir G

cefditoren pivoxil G

cefixime G

cefpodoxime proxetil G

cefprozil G

cefuroxime axetil G

CENTANY NPB

cephalexin G

CIPRO NPB

ciprofloxacin hcl oral G

clarithromycin er G

clarithromycin oral G

CLEOCIN NPB

clindamycin hcl oral G

clindamycin palmitate hcl G

clindamycin phosphate vaginal G

CLINDESSE NPB

colistimethate sodium (cba) G

COLY-MYCIN M NPB

coremino G

demeclocycline hcl G

dicloxacillin sodium G

DIFICID NPB

DORYX NPB ST

DORYX MPC NPB ST

doxycycline hyclate oral G

doxycycline monohydrate oral G

E.E.S. 400 NPB

E.E.S. GRANULES NPB

ERYPED 200 NPB

ERYPED 400 NPB

ERY-TAB G

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

ERYTHROCIN STEARATE G

erythromycin base G

erythromycin ethylsuccinate oral G

erythromycin oral G

FIRST-METRONIDAZOLE NPB

FLAGYL NPB

gentamicin sulfate external G

HIPREX NPB

KEFLEX NPB

LEVAQUIN ORAL TABLET 500 MG, 750 MG NPB

levofloxacin oral G

linezolid oral G QL

MACROBID NPB

MACRODANTIN NPB

mafenide acetate external G

methenamine hippurate G

methenamine mandelate oral G

METRONIDAZOLE BENZO+SYRSPEND NPB

metronidazole oral G

metronidazole vaginal G

MINOCIN ORAL CAPSULE 50 MG NPB ST

minocycline hcl er oral tablet extended release 24 hour

G

minocycline hcl oral G

MINOLIRA NPB ST

mondoxyne nl G

MONUROL NPB

morgidox oral G

moxifloxacin hcl oral G

mupirocin calcium G

mupirocin external G

neomycin sulfate oral G

nitrofurantoin G

nitrofurantoin macrocrystal oral G

nitrofurantoin monohydrate macrocrystals G

NUTRIDOX NPB ST

NUVESSA NPB

NUZYRA ORAL NPB

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

ofloxacin oral G

okebo G

paromomycin sulfate oral G

penicillin v potassium G

PRIMSOL NPB

SEYSARA NPB ST

SILVADENE NPB

silver nitrate external G

silver sulfadiazine external G

SIVEXTRO ORAL NPB QL

SOLODYN NPB ST

SOLOSEC NPB

SPECTRACEF NPB

ssd G

sulfadiazine oral G

sulfamethoxazole-trimethoprim oral G

SULFAMYLON EXTERNAL CREAM PB

SULFAMYLON EXTERNAL PACKET NPB

sulfatrim pediatric G

SUPRAX NPB

TARGADOX NPB ST

tetracycline hcl oral G

tinidazole oral G

trimethoprim oral G

VANCOCIN NPB

VANCOCIN HCL NPB

vancomycin hcl oral capsule G

VANCOMYCIN+SYRSPEND SF NPB

vandazole G

VIBRAMYCIN NPB ST

XENLETA ORAL NPB

XEPI NPB PA

XIFAXAN PB

XIMINO NPB ST

ZITHROMAX ORAL NPB

ZITHROMAX TRI-PAK NPB

ZITHROMAX Z-PAK NPB

ZYVOX ORAL NPB ST; QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

Anticoagulants

ARIXTRA NPB QL

BEVYXXA NPB QL

COUMADIN NPB

ELIQUIS PB M; QL

ELIQUIS DVT/PE STARTER PACK PB M; QL

enoxaparin sodium subcutaneous G

fondaparinux sodium G QL

FRAGMIN PB

heparin sodium (porcine) G

heparin sodium (porcine) pf G

jantoven G

LOVENOX SUBCUTANEOUS NPB ST

PRADAXA NPB M; QL

SAVAYSA NPB M; QL

warfarin sodium oral G

XARELTO PB M; QL

XARELTO STARTER PACK PB M; QL

Anticonvulsants - Drugs for Seizures

APTIOM NPB

BANZEL PB

BRIVIACT ORAL NPB ST

carbamazepine er G

carbamazepine oral G

CARBATROL NPB

CELONTIN PB

clobazam G

DEPAKOTE NPB ST

DEPAKOTE ER NPB ST

DEPAKOTE SPRINKLES NPB ST

DIACOMIT NPB-S PA

DIASTAT ACUDIAL NPB QL

DIASTAT PEDIATRIC NPB QL

diazepam rectal G QL

DILANTIN INFATABS NPB

DILANTIN ORAL CAPSULE 100 MG NPB

DILANTIN ORAL CAPSULE 30 MG PB

DILANTIN ORAL SUSPENSION NPB

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

divalproex sodium er G

divalproex sodium oral G

EPIDIOLEX PB-S PA

epitol G

EQUETRO NPB

ethosuximide oral G

FANATREX FUSEPAQ NPB

felbamate G

FELBATOL NPB

FYCOMPA PB

gabapentin oral G

GABITRIL NPB

KEPPRA ORAL NPB ST

KEPPRA XR NPB ST

LAMICTAL NPB ST

LAMICTAL ODT NPB ST

LAMICTAL STARTER NPB ST

LAMICTAL XR NPB ST

lamotrigine er G

lamotrigine oral G

lamotrigine starter kit-blue G

lamotrigine starter kit-green G

lamotrigine starter kit-orange G

levetiracetam er G

levetiracetam oral G

MYSOLINE NPB

NEURONTIN NPB ST

ONFI NPB

oxcarbazepine G

OXTELLAR XR NPB ST

PEGANONE PB

phenobarbital oral G

PHENYTEK NPB

phenytoin infatabs G

phenytoin oral G

phenytoin sodium extended G

primidone oral G

QUDEXY XR PB ST

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

roweepra G

roweepra xr G

SABRIL NPB-S PA

SPRITAM NPB ST

subvenite G

subvenite starter kit-blue G

subvenite starter kit-green G

subvenite starter kit-orange G

SYMPAZAN NPB ST

TEGRETOL NPB

TEGRETOL-XR NPB

tiagabine hcl G

TOPAMAX NPB ST

TOPAMAX SPRINKLE NPB ST

topiramate er NPB

topiramate oral G

TRILEPTAL NPB ST

TROKENDI XR NPB ST

valproic acid oral G

VALTOCO 10 MG DOSE NPB PA

VALTOCO 15 MG DOSE NPB PA

VALTOCO 20 MG DOSE NPB PA

VALTOCO 5 MG DOSE NPB PA

vigabatrin G-S PA

vigadrone G-S PA

VIMPAT ORAL PB

ZARONTIN NPB

ZONEGRAN NPB ST

zonisamide oral G

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia

ARICEPT NPB ST; M

donepezil hcl G M

EXELON NPB ST; M; QL

galantamine hydrobromide er G M; QL

galantamine hydrobromide oral solution G M; QL

galantamine hydrobromide oral tablet 12 mg G M

galantamine hydrobromide oral tablet 4 mg, 8 mg

G M; QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

memantine hcl er G M; QL

memantine hcl oral solution G M

memantine hcl oral tablet 10 mg, 5 mg G M

memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg

NPB M

NAMENDA NPB ST; M

NAMENDA TITRATION PAK NPB ST; M

NAMENDA XR NPB ST; M; QL

NAMENDA XR TITRATION PACK NPB ST; M; QL

NAMZARIC PB ST; QL

RAZADYNE ER NPB ST; M; QL

RAZADYNE ORAL TABLET 12 MG NPB ST; M

RAZADYNE ORAL TABLET 4 MG, 8 MG NPB ST; M; QL

rivastigmine G M; QL

rivastigmine tartrate G M; QL

Antidepressants

amitriptyline hcl oral G

amoxapine G

ANAFRANIL NPB

APLENZIN NPB ST; M; QL

BRISDELLE NPB ST; M; QL

bupropion hcl er (sr) G M; QL

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

G M; QL

BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG

NPB ST; M; QL

bupropion hcl oral G M

CELEXA NPB ST; M; QL

chlordiazepoxide-amitriptyline G

citalopram hydrobromide oral solution G M

citalopram hydrobromide oral tablet G M; QL

clomipramine hcl oral G

CYMBALTA NPB ST; M; QL

desipramine hcl oral G

DESVENLAFAXINE ER NPB ST; M; QL

desvenlafaxine succinate er G M; QL

doxepin hcl oral capsule G

doxepin hcl oral concentrate G

duloxetine hcl oral G M; QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

EFFEXOR XR NPB ST; M; QL

EMSAM NPB QL

escitalopram oxalate oral solution G M

escitalopram oxalate oral tablet G M; QL

FETZIMA PB ST; M; QL

FETZIMA TITRATION PB ST; M; QL

fluoxetine hcl (pmdd) G M; QL

fluoxetine hcl oral capsule G M; QL

fluoxetine hcl oral capsule delayed release G M; QL

fluoxetine hcl oral solution G M

fluoxetine hcl oral tablet 10 mg, 20 mg G M; QL

fluoxetine hcl oral tablet 60 mg G M

fluvoxamine maleate G M

fluvoxamine maleate er G M; QL

FORFIVO XL NPB ST; M; QL

imipramine hcl oral G

imipramine pamoate G

LEXAPRO NPB ST; M; QL

maprotiline hcl G

MARPLAN NPB

mirtazapine oral G QL

NARDIL NPB

nefazodone hcl G M

NORPRAMIN NPB

nortriptyline hcl oral G

olanzapine-fluoxetine hcl G QL

PAMELOR NPB

PARNATE NPB

paroxetine hcl G M; QL

paroxetine hcl er G M; QL

paroxetine mesylate G M; QL

PAXIL CR NPB ST; M; QL

PAXIL ORAL SUSPENSION NPB ST; M

PAXIL ORAL TABLET NPB ST; M; QL

perphenazine-amitriptyline G

PEXEVA NPB ST; M; QL

phenelzine sulfate oral G

PRISTIQ NPB ST; M; QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

protriptyline hcl G

PROZAC NPB ST; M; QL

REMERON NPB QL

REMERON SOLTAB NPB QL

SARAFEM NPB ST; M; QL

sertraline hcl oral concentrate G M

sertraline hcl oral tablet G M; QL

SPRAVATO (56 MG DOSE) NPB-S PA

SPRAVATO (84 MG DOSE) NPB-S PA

SYMBYAX NPB QL

tranylcypromine sulfate G

trazodone hcl oral G

trimipramine maleate oral G

TRINTELLIX NPB ST; QL

venlafaxine hcl G M; QL

venlafaxine hcl er G M; QL

VIIBRYD PB ST; M; QL

VIIBRYD STARTER PACK PB ST; M; QL

WELLBUTRIN SR NPB ST; M; QL

WELLBUTRIN XL NPB ST; M; QL

ZOLOFT ORAL CONCENTRATE NPB ST; M

ZOLOFT ORAL TABLET NPB ST; M; QL

Antiemetics - Drugs for Nausea and Vomiting

AKYNZEO ORAL PB QL

ANZEMET NPB QL

aprepitant G QL

BONJESTA NPB QL

compro G

DICLEGIS NPB QL

dimenhydrinate injection G

doxylamine-pyridoxine G QL

dronabinol G QL

EMEND ORAL NPB QL

EMEND TRI-PACK NPB QL

granisetron hcl oral G QL

metoclopramide hcl oral G

ONDANSETRON HCL INJECTION SOLUTION 4 MG/2ML

NPB

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

ondansetron hcl oral G QL

ondansetron odt G QL

perphenazine oral G

prochlorperazine G

prochlorperazine maleate oral G

REGLAN NPB

SANCUSO PB QL

scopolamine G

SYNDROS NPB QL

TIGAN ORAL NPB

TRANSDERM SCOP (1.5 MG) NPB

TRANSDERM-SCOP (1.5 MG) NPB

trimethobenzamide hcl oral G

VARUBI ORAL TABLET 90 MG PB QL

ZOFRAN NPB QL

ZUPLENZ NPB QL

Antifungals

ACTIVE-PREP KIT V NPB

ANCOBON NPB

BIO-STATIN ORAL CAPSULE NPB

bio-statin oral powder G

ciclodan G

ciclopirox G

ciclopirox olamine external G

clotrimazole mouth/throat G

clotrimazole-betamethasone G

CRESEMBA ORAL PB

DIFLUCAN ORAL SUSPENSION RECONSTITUTED

NPB

DIFLUCAN ORAL TABLET 100 MG, 200 MG, 50 MG

NPB

DIFLUCAN ORAL TABLET 150 MG NPB QL

econazole nitrate external G

ECOZA NPB

ERTACZO NPB

EXELDERM NPB

exoderm external lotion NPB

EXTINA NPB

fluconazole oral suspension reconstituted G

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

fluconazole oral tablet 100 mg, 200 mg, 50 mg G

fluconazole oral tablet 150 mg G QL

flucytosine oral G

griseofulvin microsize oral G

griseofulvin ultramicrosize G

GYNAZOLE-1 NPB

itraconazole oral capsule G QL

itraconazole oral solution G

JUBLIA NPB ST

KERYDIN NPB ST; QL

ketoconazole external G

ketoconazole oral G

ketodan external foam G

LOPROX EXTERNAL CREAM NPB

LOPROX EXTERNAL KIT 0.77 % (SUSP) NPB

LOPROX EXTERNAL SHAMPOO NPB

LOPROX EXTERNAL SUSPENSION NPB

LOTRISONE NPB

LULICONAZOLE NPB ST; QL

LUZU NPB ST; QL

MENTAX NPB

miconazole 3 vaginal suppository G QL

MICONAZOLE-ZINC OXIDE-PETROLAT NPB

naftifine hcl G

NAFTIN NPB

NIZORAL NPB

NOXAFIL ORAL SUSPENSION PB

NOXAFIL ORAL TABLET DELAYED RELEASE NPB

nyamyc G

nystatin external G

nystatin mouth/throat G

nystatin oral G

nystatin-triamcinolone G

nystop G

ORAVIG NPB

oxiconazole nitrate G

OXISTAT NPB

posaconazole G

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

RECURA NPB

SPORANOX ORAL CAPSULE NPB QL

SPORANOX ORAL SOLUTION NPB

SPORANOX PULSEPAK NPB QL

terbinafine hcl oral G QL

terconazole G QL

TOLSURA NPB ST

VFEND NPB

voriconazole oral G

VUSION NPB

XOLEGEL NPB

XOLEGEL COREPAK NPB

XOLEGEL DUO/HEAD & SHOULDERS NPB

XOLEGEL DUO/XOLEX NPB

Antigout Agents

allopurinol oral G M

COLCHICINE ORAL NPB ST

colchicine-probenecid G

COLCRYS PB

febuxostat G ST; M

MITIGARE PB

probenecid G M

ULORIC PB ST; M

ZYLOPRIM NPB M

Anti-inflammatory Agents

EMFLAZA NPB-S PA

Antimigraine Agents

AIMOVIG PB PA; M

AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

PB PA; M

almotriptan malate G QL

AMERGE NPB ST; QL

CAFERGOT NPB

D.H.E. 45 NPB

dihydroergotamine mesylate injection G

dihydroergotamine mesylate nasal G QL

eletriptan hydrobromide G QL

EMGALITY PB PA; M

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Drug Name Drug Tier Restrictions / Limits

EMGALITY (300 MG DOSE) PB PA; M

ERGOMAR NPB

ergotamine-caffeine G

FROVA NPB ST; QL

frovatriptan succinate G QL

IMITREX NPB ST; QL

IMITREX STATDOSE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE 4 MG/0.5ML

NPB ST; QL

IMITREX STATDOSE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE 6 MG/0.5ML

NPB ST

IMITREX STATDOSE SYSTEM NPB ST; QL

MAXALT NPB ST; QL

MAXALT-MLT NPB ST; QL

MIGERGOT G

MIGRANAL NPB QL

naratriptan hcl G QL

ONZETRA XSAIL NPB ST; QL

RELPAX NPB ST; QL

rizatriptan benzoate G QL

sumatriptan nasal G QL

sumatriptan succinate oral G QL

sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml

G QL

sumatriptan succinate refill subcutaneous solution cartridge 6 mg/0.5ml

G

sumatriptan succinate subcutaneous G QL

sumatriptan-naproxen sodium G QL

TOSYMRA NPB-S ST; QL

TREXIMET NPB ST; QL

ZEMBRACE SYMTOUCH NPB ST; QL

zolmitriptan oral G QL

ZOMIG NASAL PB ST; QL

ZOMIG ORAL NPB ST; QL

ZOMIG ZMT NPB ST; QL

Antimyasthenic Agents

GUANIDINE HCL G

MESTINON ORAL TABLET NPB M

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Drug Name Drug Tier Restrictions / Limits

MESTINON ORAL TABLET EXTENDED RELEASE

NPB M

pyridostigmine bromide er G M

pyridostigmine bromide oral G M

Antimycobacterials

cycloserine oral NPB

dapsone oral G

ethambutol hcl oral G

isoniazid oral G

MYAMBUTOL NPB

MYCOBUTIN NPB

PASER NPB

PRIFTIN PB

pyrazinamide oral G

rifabutin G

RIFADIN ORAL NPB

RIFAMATE NPB

rifampin oral G

RIFAMPIN+SYRSPEND SF NPB

RIFATER NPB

SIRTURO PB-S

TRECATOR NPB

Antineoplastics - Drugs for Cancer

abiraterone acetate G-S QL

AFINITOR DISPERZ PB-S QL

AFINITOR ORAL TABLET 10 MG PB-S QL

AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG

NPB-S QL

ALECENSA PB-S

ALKERAN ORAL NPB

ALUNBRIG NPB-S PA; QL

anastrozole oral G

ARIMIDEX NPB ST

AROMASIN NPB

AYVAKIT NPB-S PA

BALVERSA NPB PA

bexarotene G-S

bicalutamide G

BOSULIF PB-S

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Drug Name Drug Tier Restrictions / Limits

BRAFTOVI NPB-S PA

CABOMETYX PB-S QL

CALQUENCE NPB-S PA

capecitabine G-S

CAPRELSA PB-S QL

CASODEX NPB

COMETRIQ (100 MG DAILY DOSE) NPB-S QL

COMETRIQ (140 MG DAILY DOSE) NPB-S QL

COMETRIQ (60 MG DAILY DOSE) NPB-S QL

COPIKTRA NPB-S PA

COTELLIC PB-S

cyclophosphamide oral G

DAURISMO NPB-S PA

DROXIA PB-S

EMCYT PB-S

ERIVEDGE PB-S

ERLEADA PB-S PA

erlotinib hcl oral tablet 100 mg, 150 mg G-S

erlotinib hcl oral tablet 25 mg G-S QL

etoposide oral G-S

everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg G-S QL

exemestane G

FARESTON NPB-S

FARYDAK NPB-S

FEMARA NPB

flutamide G

GILOTRIF PB-S QL

GLEEVEC NPB-S ST; QL

GLEOSTINE PB-S

HYCAMTIN ORAL PB-S

HYDREA NPB

hydroxyurea oral G

IBRANCE ORAL CAPSULE PB-S

IBRANCE ORAL TABLET NPB

ICLUSIG ORAL TABLET 15 MG PB-S QL

ICLUSIG ORAL TABLET 45 MG PB-S

IDHIFA PB-S PA; QL

imatinib mesylate G-S QL

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Drug Name Drug Tier Restrictions / Limits

IMBRUVICA PB-S

INLYTA PB-S QL

INREBIC NPB-S

IRESSA PB-S

JAKAFI ORAL TABLET 10 MG PB-S QL

JAKAFI ORAL TABLET 15 MG, 20 MG, 25 MG, 5 MG

PB-S

KISQALI (200 MG DOSE) NPB-S PA

KISQALI (400 MG DOSE) NPB-S PA

KISQALI (600 MG DOSE) NPB-S PA

KISQALI FEMARA (400 MG DOSE) NPB-S PA

KISQALI FEMARA (600 MG DOSE) NPB-S PA

KISQALI FEMARA(200 MG DOSE) NPB-S PA

LENVIMA (10 MG DAILY DOSE) PB-S

LENVIMA (12 MG DAILY DOSE) PB-S

LENVIMA (14 MG DAILY DOSE) PB-S

LENVIMA (18 MG DAILY DOSE) PB-S

LENVIMA (20 MG DAILY DOSE) PB-S

LENVIMA (24 MG DAILY DOSE) PB-S

LENVIMA (4 MG DAILY DOSE) PB-S

LENVIMA (8 MG DAILY DOSE) PB-S

letrozole oral G

leucovorin calcium oral G

LEUKERAN PB

LONSURF PB-S

LORBRENA PB-S PA

LYNPARZA PB-S

LYSODREN PB-S

MATULANE PB-S

MEKINIST PB-S

MEKTOVI NPB-S PA

melphalan G

mercaptopurine oral G

MESNEX ORAL PB

MYLERAN PB-S

NERLYNX PB-S PA; QL

NEXAVAR PB-S QL

NILANDRON NPB-S

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

nilutamide G-S

NINLARO PB-S

NUBEQA PB-S

ODOMZO NPB-S

PANRETIN NPB

PIQRAY (200 MG DAILY DOSE) PB-S PA

PIQRAY (250 MG DAILY DOSE) PB-S PA

PIQRAY (300 MG DAILY DOSE) PB-S PA

POMALYST PB-S QL

PURIXAN PB-S

REVLIMID PB-S

ROZLYTREK PB-S

RUBRACA PB-S PA

RYDAPT PB-S PA

SIKLOS NPB-S ST

SOLTAMOX NPB ACA

SPRYCEL PB-S QL

STIVARGA PB-S

SUTENT PB-S QL

TABLOID PB-S

TAFINLAR PB-S

TAGRISSO ORAL TABLET 40 MG PB-S QL

TAGRISSO ORAL TABLET 80 MG PB-S

TALZENNA PB-S PA

tamoxifen citrate oral G ACA

TARCEVA ORAL TABLET 100 MG, 150 MG PB-S

TARCEVA ORAL TABLET 25 MG PB-S QL

TARGRETIN EXTERNAL PB

TARGRETIN ORAL NPB-S

TASIGNA PB-S QL

TEMODAR ORAL NPB-S

temozolomide G-S

THALOMID PB-S

TIBSOVO PB-S PA

toremifene citrate G-S

tretinoin oral G-S

TURALIO NPB

TYKERB PB-S QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

VALCHLOR PB-S

VENCLEXTA PB-S

VENCLEXTA STARTING PACK PB-S

VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG

PB-S

VERZENIO ORAL TABLET 50 MG PB-S PA

VITRAKVI PB-S PA

VIZIMPRO PB-S PA

VOTRIENT PB-S QL

XALKORI ORAL CAPSULE 200 MG PB-S PA; QL

XALKORI ORAL CAPSULE 250 MG PB-S QL

XELODA NPB-S

XOSPATA PB-S PA

XPOVIO (100 MG ONCE WEEKLY) NPB-S PA

XPOVIO (60 MG ONCE WEEKLY) NPB-S PA

XPOVIO (80 MG ONCE WEEKLY) NPB-S PA

XPOVIO (80 MG TWICE WEEKLY) NPB-S PA

XTANDI PB-S QL

YONSA PB-S PA

ZEJULA PB-S PA

ZELBORAF PB-S QL

ZOLINZA PB-S QL

ZYDELIG PB-S

ZYKADIA PB-S

ZYTIGA ORAL TABLET 250 MG NPB-S QL

ZYTIGA ORAL TABLET 500 MG PB-S QL

Antiparasitics

albendazole oral G

ALBENZA NPB

ALINIA PB

ARAKODA NPB

atovaquone oral G

atovaquone-proguanil hcl G

BENZNIDAZOLE PB

BILTRICIDE NPB

chloroquine phosphate oral G

COARTEM PB

crotan G

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

DARAPRIM PB-S PA

EGATEN NPB

ELIMITE NPB

EMVERM PB

hydroxychloroquine sulfate oral G M

IMPAVIDO PB-S

ivermectin oral G

KRINTAFEL NPB

lindane G QL

MALARONE NPB

malathion G

mefloquine hcl G

MEPRON NPB

NATROBA NPB QL

NEBUPENT NPB QL

OVIDE NPB

pentamidine isethionate inhalation G QL

permethrin external G

PLAQUENIL NPB ST; M

praziquantel oral G

primaquine phosphate PB

PYRIMETHAMINE-LEUCOVORIN NPB

QUALAQUIN NPB

quinine sulfate oral G

SKLICE NPB

spinosad G QL

STROMECTOL NPB

sulfurated lime G

ULESFIA NPB

Antiparkinson Agents

amantadine hcl oral G M

APOKYN PB-S QL

AZILECT NPB M

benztropine mesylate oral G

bromocriptine mesylate oral G

carbidopa oral G M

carbidopa-levodopa G M

carbidopa-levodopa er G M

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

carbidopa-levodopa-entacapone G M

COMTAN NPB M

entacapone G M

GOCOVRI NPB-S PA; M

INBRIJA NPB

LODOSYN NPB M

MIRAPEX NPB M

MIRAPEX ER NPB M

NEUPRO NPB M

NOURIANZ NPB-S PA

OSMOLEX ER NPB ST; M

PARLODEL NPB

pramipexole dihydrochloride G M

pramipexole dihydrochloride er G M

rasagiline mesylate oral G M

REQUIP XL NPB M

ropinirole hcl G M

ropinirole hcl er G M

RYTARY NPB M

selegiline hcl oral G M

SINEMET NPB M

SINEMET CR NPB M

STALEVO 100 NPB M

STALEVO 125 NPB M

STALEVO 150 NPB M

STALEVO 200 NPB M

STALEVO 50 NPB M

STALEVO 75 NPB M

TASMAR NPB M

tolcapone G M

trihexyphenidyl hcl G

XADAGO NPB ST; M; QL

ZELAPAR NPB M

Antiplatelets

AGGRENOX NPB M

aspirin-dipyridamole er G M

ASPIRIN-OMEPRAZOLE NPB ST; QL

BRILINTA PB M

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

CABLIVI NPB-S PA; QL

cilostazol G M

clopidogrel bisulfate oral G M

dipyridamole oral G M

DURLAZA NPB ST

EFFIENT NPB ST; M

PLAVIX NPB ST; M

prasugrel hcl G M

YOSPRALA NPB ST; QL

ZONTIVITY PB M

Antipsychotics - Drugs for Mood Disorders

ABILIFY NPB ST; QL

ABILIFY MAINTENA PB

ABILIFY MYCITE NPB-S PA; QL

ADASUVE NPB

aripiprazole G QL

ARISTADA PB

ARISTADA INITIO PB

chlorpromazine hcl injection G

chlorpromazine hcl oral G

clozapine oral tablet G QL

clozapine oral tablet dispersible 100 mg, 12.5 mg, 25 mg

G QL

clozapine oral tablet dispersible 150 mg, 200 mg NPB QL

CLOZARIL NPB QL

FANAPT NPB QL

FANAPT TITRATION PACK NPB QL

fluphenazine hcl G

GEODON INTRAMUSCULAR NPB

GEODON ORAL NPB QL

HALDOL DECANOATE NPB

haloperidol decanoate intramuscular G

haloperidol lactate oral G

haloperidol oral G

INVEGA NPB QL

INVEGA SUSTENNA NPB

INVEGA TRINZA NPB

LATUDA PB QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

loxapine succinate G

molindone hcl G

NUPLAZID NPB

olanzapine oral G QL

paliperidone er G QL

PERSERIS NPB

pimozide G

quetiapine fumarate G QL

quetiapine fumarate er G QL

REXULTI NPB QL

RISPERDAL NPB QL

RISPERDAL CONSTA PB

risperidone G QL

SAPHRIS NPB QL

SEROQUEL NPB ST; QL

SEROQUEL XR NPB ST; QL

thioridazine hcl oral G

thiothixene G

trifluoperazine hcl G

VERSACLOZ NPB QL

VRAYLAR NPB QL

ziprasidone hcl G QL

ziprasidone mesylate G

ZYPREXA ORAL NPB QL

ZYPREXA RELPREVV NPB

ZYPREXA ZYDIS NPB QL

Antivirals

abacavir sulfate G QL

abacavir sulfate-lamivudine G QL

abacavir-lamivudine-zidovudine G QL

acyclovir external G QL

acyclovir oral G

adefovir dipivoxil G

APTIVUS PB QL

atazanavir sulfate G

ATRIPLA PB ST; QL

BARACLUDE ORAL SOLUTION PB QL

BARACLUDE ORAL TABLET NPB ST; QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

BIKTARVY PB

CIMDUO PB

COMBIVIR NPB QL

COMPLERA PB QL

CRIXIVAN PB QL

DELSTRIGO NPB ST

DENAVIR NPB

DESCOVY PB

didanosine G QL

DOVATO NPB

EDURANT PB QL

efavirenz G QL

EMTRIVA PB QL

entecavir G QL

EPCLUSA PB-S PA

EPIVIR NPB QL

EPIVIR HBV ORAL SOLUTION PB

EPIVIR HBV ORAL TABLET NPB QL

EPZICOM NPB QL

EVOTAZ NPB QL

famciclovir G

fosamprenavir calcium G QL

FUZEON PB

GENVOYA PB

HARVONI PB-S PA

HEPSERA NPB

INTELENCE PB QL

INTRON A PB-S

INVIRASE PB QL

ISENTRESS PB QL

ISENTRESS HD PB

JULUCA NPB

KALETRA ORAL SOLUTION NPB QL

KALETRA ORAL TABLET PB QL

lamivudine G QL

lamivudine-zidovudine G QL

LEXIVA ORAL SUSPENSION PB QL

LEXIVA ORAL TABLET NPB QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

lopinavir-ritonavir G QL

MAVYRET NPB-S PA

nevirapine G QL

nevirapine er G QL

NORVIR ORAL PACKET PB

NORVIR ORAL SOLUTION PB QL

NORVIR ORAL TABLET NPB QL

ODEFSEY PB

oseltamivir phosphate oral G QL

PEGASYS PB-S QL

PEGASYS PROCLICK PB-S QL

PEGINTRON NPB-S QL

PIFELTRO NPB ST

PREVYMIS ORAL PB

PREZCOBIX NPB

PREZISTA PB QL

RELENZA DISKHALER PB QL

RETROVIR ORAL NPB QL

REYATAZ ORAL CAPSULE NPB

REYATAZ ORAL PACKET PB

ribavirin inhalation G-S

ribavirin oral G-S

rimantadine hcl G

ritonavir G QL

SELZENTRY ORAL SOLUTION PB

SELZENTRY ORAL TABLET 150 MG, 300 MG PB QL

SELZENTRY ORAL TABLET 25 MG, 75 MG PB

SITAVIG NPB QL

SOVALDI NPB-S PA; QL

stavudine G QL

STRIBILD PB QL

SUSTIVA NPB QL

SYLATRON PB-S QL

SYMFI PB

SYMFI LO PB

SYMTUZA NPB

TAMIFLU NPB QL

TEMIXYS PB

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

tenofovir disoproxil fumarate G QL

TIVICAY ORAL TABLET 10 MG, 25 MG PB

TIVICAY ORAL TABLET 50 MG PB QL

TRIUMEQ PB QL

TRIZIVIR NPB QL

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG

PB

TRUVADA ORAL TABLET 200-300 MG PB QL

TYBOST NPB QL

valacyclovir hcl oral G QL

VALCYTE NPB

valganciclovir hcl G

VALTREX NPB ST; QL

VEMLIDY PB

VIDEX PB QL

VIDEX EC NPB QL

VIEKIRA PAK NPB-S PA; QL

VIRACEPT PB QL

VIRAMUNE NPB QL

VIRAMUNE XR NPB QL

VIRAZOLE NPB-S

VIREAD ORAL POWDER PB QL

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

PB QL

VIREAD ORAL TABLET 300 MG NPB QL

VOSEVI PB-S PA

XERESE NPB ST; QL

XOFLUZA (40 MG DOSE) PB QL

XOFLUZA (80 MG DOSE) PB QL

ZEPATIER PB-S PA

ZIAGEN NPB QL

zidovudine G QL

ZOVIRAX EXTERNAL NPB QL

ZOVIRAX ORAL NPB

Anxiolytics - Drugs for Anxiety

alprazolam er G QL

alprazolam intensol G QL

alprazolam oral G QL

alprazolam xr G QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

ATIVAN ORAL NPB QL

buspirone hcl oral G M

chlordiazepoxide hcl G QL

clonazepam oral G QL

clorazepate dipotassium G QL

diazepam intensol G

diazepam oral G

DORAL NPB QL

estazolam G QL

HALCION NPB QL

hydroxyzine hcl oral G

hydroxyzine pamoate oral G

KLONOPIN NPB QL

lorazepam intensol G QL

lorazepam oral concentrate 2 mg/ml G QL

lorazepam oral tablet G QL

meprobamate G

oxazepam G QL

quazepam G QL

TRANXENE-T NPB QL

triazolam G QL

VALIUM NPB ST

VISTARIL NPB

XANAX NPB ST; QL

XANAX XR NPB ST; QL

Bipolar Agents - Drugs for Mood Disorders

lithium G

lithium carbonate er G

lithium carbonate oral G

LITHOBID NPB

Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders

AGRYLIN NPB M

AMICAR NPB

aminocaproic acid oral G

anagrelide hcl G M

DOPTELET PB-S PA

LYSTEDA NPB

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

MONSELS FERRIC SUBSULFATE PB

MULPLETA PB-S PA

PROMACTA PB PA

REBLOZYL NPB

TAVALISSE NPB-S PA

THROMBIN-JMI NPB

THROMBIN-JMI EPISTAXIS NPB

THROMBOGEN NPB

tranexamic acid oral G

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

ACCUPRIL NPB M

ACCURETIC NPB ST; M

acebutolol hcl oral G M

ADALAT CC NPB ST; M

ALDACTAZIDE NPB M

ALDACTONE NPB M

aliskiren fumarate G M

ALTACE NPB M

ALTOPREV NPB ST; M; QL

amiloride hcl oral G M

amiloride-hydrochlorothiazide G M

amiodarone hcl oral G M

AMLODIPINE BES+SYRSPEND SF NPB ST; M

amlodipine besylate oral G M

amlodipine besylate-benazepril hcl G M

amlodipine besylate-valsartan G M

amlodipine-atorvastatin G M; QL

amlodipine-olmesartan G M

amlodipine-valsartan-hctz G M

ANTARA NPB ST; M; QL

ATACAND NPB ST; M

ATACAND HCT NPB ST; M

atenolol oral G M

ATENOLOL+SYRSPEND SF NPB ST; M

atenolol-chlorthalidone G M

atorvastatin calcium oral tablet 10 mg, 20 mg G M; ACA; QL

atorvastatin calcium oral tablet 40 mg, 80 mg G M; QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

AVALIDE NPB ST; M

AVAPRO NPB ST; M

AZOR NPB ST; M

benazepril hcl oral G M

benazepril-hydrochlorothiazide G M

BENICAR NPB ST; M

BENICAR HCT NPB ST; M

BETAPACE NPB ST; M

BETAPACE AF NPB ST; M

betaxolol hcl oral G M

BIDIL NPB M

bisoprolol fumarate G M

bisoprolol-hydrochlorothiazide G M

bumetanide oral G M

BUMEX NPB M

BYSTOLIC PB ST; M

CADUET NPB ST; M; QL

CALAN SR NPB ST; M

candesartan cilexetil G M

candesartan cilexetil-hctz G M

captopril oral G M

captopril-hydrochlorothiazide G M

CARDIZEM NPB ST; M

CARDIZEM CD NPB ST; M

CARDIZEM LA NPB ST; M

CARDURA NPB ST; M; QL

CAROSPIR NPB ST; M

cartia xt G M

carvedilol G M

carvedilol phosphate er G M

CATAPRES NPB M

CATAPRES-TTS-1 NPB M; QL

CATAPRES-TTS-2 NPB M; QL

CATAPRES-TTS-3 NPB M; QL

chlorothiazide oral G M

chlorthalidone G M

cholestyramine light G M

cholestyramine oral G M

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

clonidine G M; QL

clonidine hcl oral G M

colesevelam hcl G M

COLESTID NPB ST; M

COLESTID FLAVORED NPB ST; M

colestipol hcl G M

COREG NPB ST; M

COREG CR NPB ST; M

CORGARD NPB ST; M

CORLANOR ORAL SOLUTION NPB M; QL

CORLANOR ORAL TABLET PB M; QL

COZAAR NPB ST; M

CRESTOR NPB ST; M; QL

DEMSER PB

DIBENZYLINE NPB

digitek G M

digox G M

digoxin oral G M

DILATRATE-SR PB M

diltiazem hcl er beads G M

diltiazem hcl er coated beads G M

diltiazem hcl er oral capsule extended release 12 hour

G M

diltiazem hcl oral G M

dilt-xr G M

DIOVAN NPB ST; M

DIOVAN HCT NPB ST; M

disopyramide phosphate G M

DIURIL NPB M

dofetilide G

doxazosin mesylate oral G M; QL

DUTOPROL NPB ST; M

DYAZIDE NPB M

DYRENIUM NPB M

EDARBI PB ST; M

EDARBYCLOR PB ST; M

EDECRIN NPB M

enalapril maleate oral G M

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

enalapril-hydrochlorothiazide G M

ENTRESTO PB M; QL

EPANED NPB M

eplerenone G M

eprosartan mesylate G M

ethacrynic acid G M

EXFORGE NPB ST; M

EXFORGE HCT NPB ST; M

EZALLOR SPRINKLE NPB ST; M

ezetimibe G M

ezetimibe-simvastatin G M; QL

felodipine er G M

fenofibrate micronized G M; QL

fenofibrate oral capsule 134 mg, 200 mg, 67 mg G M; QL

fenofibrate oral capsule 150 mg, 50 mg NPB M; QL

fenofibrate oral tablet G M; QL

fenofibric acid G M; QL

FENOGLIDE NPB ST; M; QL

FIBRICOR NPB ST; M; QL

FIRST - METOPROLOL NPB ST; M

FIRST-ATENOLOL NPB ST; M

flecainide acetate G M

FLOLIPID NPB ST; M

fluvastatin sodium G M; ACA; QL

fluvastatin sodium er G M; ACA; QL

fosinopril sodium G M

fosinopril sodium-hctz G M

furosemide oral G M

gemfibrozil oral G M; QL

GONITRO NPB M

guanfacine hcl G M

HEMANGEOL NPB-S M

hydralazine hcl oral G M

hydrochlorothiazide oral G M

HYZAAR NPB ST; M

indapamide G M

INDERAL LA NPB ST; M

INDERAL XL NPB ST; M

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

INNOPRAN XL NPB ST; M

INSPRA NPB M

irbesartan G M

irbesartan-hydrochlorothiazide G M

ISORDIL TITRADOSE NPB M

isosorbide dinitrate G M

isosorbide mononitrate G M

isosorbide mononitrate er G M

isoxsuprine hcl oral G M

isradipine G M

JUXTAPID PB-S PA; QL

KAPSPARGO SPRINKLE NPB ST; M

KATERZIA NPB ST

labetalol hcl oral G M

LANOXIN ORAL NPB M

LASIX NPB M

LESCOL XL NPB ST; M; QL

LIPITOR NPB ST; M; QL

LIPOFEN PB ST; M; QL

lisinopril oral G M

lisinopril-hydrochlorothiazide G M

LIVALO PB ST; M; QL

LOPID NPB ST; M; QL

LOPRESSOR NPB ST; M

LOPRESSOR HCT NPB ST; M

losartan potassium G M

losartan potassium-hctz G M

LOTENSIN NPB M

LOTENSIN HCT NPB ST; M

LOTREL NPB ST; M

lovastatin G M; ACA; QL

LOVAZA NPB M

matzim la G M

MAXZIDE NPB M

MAXZIDE-25 NPB ST; M

methyldopa G M

methyldopa-hydrochlorothiazide G M

metolazone G M

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

metoprolol succinate er G M

metoprolol tartrate oral G M

metoprolol-hydrochlorothiazide G M

mexiletine hcl oral G M

MICARDIS NPB ST; M

MICARDIS HCT NPB ST; M

midodrine hcl G

MINIPRESS NPB M

minitran G M

minoxidil oral G M

moexipril hcl G M

MULTAQ NPB M

nadolol oral G M

niacin (antihyperlipidemic) G M

niacin er (antihyperlipidemic) G M

niacor G M

NIASPAN NPB M

nicardipine hcl oral G M

nifedipine er G M

nifedipine er osmotic release G M

nifedipine oral G M

nimodipine oral G

nisoldipine er G M

NITRO-BID G M

NITRO-DUR NPB M

nitroglycerin sublingual G M

nitroglycerin transdermal G M

nitroglycerin translingual G M

NITROLINGUAL NPB M

NITROMIST NPB M

NITROSTAT NPB M

nitro-time G M

NORPACE NPB M

NORPACE CR NPB M

NORTHERA NPB-S PA

NORVASC NPB ST; M

NYMALIZE NPB ST

olmesartan medoxomil oral G M

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

olmesartan medoxomil-hctz G M

olmesartan-amlodipine-hctz G M

OMEGA-3/D-3 WELLNESS PACK NPB

omega-3-acid ethyl esters G M

PACERONE ORAL TABLET 100 MG, 400 MG NPB M

pacerone oral tablet 200 mg G M

papaverine hcl injection G

pentoxifylline er G M

perindopril erbumine G M

phenoxybenzamine hcl oral G

pindolol G M

PRALUENT PB PA

PRAVACHOL NPB ST; M; QL

pravastatin sodium G M; ACA; QL

prazosin hcl oral G M

PRESTALIA NPB ST; M

prevalite G M

PRINIVIL NPB M

PROCARDIA NPB ST; M

PROCARDIA XL NPB ST; M

propafenone hcl G M

propafenone hcl er G M

propranolol hcl er G M

propranolol hcl oral G M

propranolol-hctz G M

QBRELIS NPB M

QUESTRAN NPB ST; M

QUESTRAN LIGHT NPB ST; M

quinapril hcl G M

quinapril-hydrochlorothiazide G M

quinidine gluconate er G M

quinidine sulfate G M

ramipril G M

RANEXA NPB M

ranolazine er G M

RECTIV PB

REPATHA PB PA

REPATHA PUSHTRONEX SYSTEM PB PA

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

REPATHA SURECLICK PB PA

rosuvastatin calcium oral tablet 10 mg, 5 mg G M; ACA; QL

rosuvastatin calcium oral tablet 20 mg, 40 mg G M; QL

RYTHMOL SR NPB M

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg

G M; ACA; QL

simvastatin oral tablet 80 mg G M; QL

sorine G M

sotalol hcl (af) G M

sotalol hcl oral G M

sotalol hydrochloride oral tablet 120 mg, 160 mg, 80 mg

G M

SOTYLIZE PB ST; M

spironolactone oral G M

spironolactone-hctz G M

SULAR NPB ST; M

SURE RESULT O3D3 SYSTEM NPB

TARKA NPB ST; M

taztia xt G M

TEKTURNA NPB ST; M

TEKTURNA HCT PB ST; M

telmisartan G M

telmisartan-amlodipine G M

telmisartan-hctz G M

TENORETIC 100 NPB ST; M

TENORETIC 50 NPB ST; M

TENORMIN NPB ST; M

tiadylt er G M

TIAZAC NPB ST; M

TIKOSYN NPB ST

timolol maleate oral G M

TOPROL XL NPB ST; M

torsemide G M

trandolapril G M

trandolapril-verapamil hcl er G M

triamterene oral G M

triamterene-hctz G M

TRIBENZOR NPB ST; M

TRICOR NPB ST; M; QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

TRIGLIDE NPB ST; M; QL

TRILIPIX NPB ST; M; QL

TWYNSTA NPB ST; M

valsartan G M

valsartan-hydrochlorothiazide G M

VASCEPA PB M

VASERETIC NPB ST; M

VASOTEC NPB M

VECAMYL NPB-S

verapamil hcl er G M

verapamil hcl oral G M

VERELAN NPB ST; M

VERELAN PM NPB ST; M

VYNDAMAX PB PA; QL

VYNDAQEL NPB-S PA; QL

VYTORIN NPB ST; M; QL

WELCHOL NPB ST; M

ZESTORETIC NPB ST; M

ZESTRIL NPB M

ZETIA NPB ST; M

ZIAC NPB ST; M

ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG

NPB ST; M; QL

ZYPITAMAG NPB ST; M

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 30 MG, 5 MG, 7.5 MG

NPB ST; QL

ADDERALL ORAL TABLET 20 MG NPB ST

ADDERALL XR NPB ST; QL

ADHANSIA XR NPB ST; QL

ADZENYS ER NPB ST; QL

ADZENYS XR-ODT NPB ST; QL

amphetamine sulfate G QL

amphetamine-dextroamphetamine er G QL

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 30 mg, 5 mg, 7.5 mg

G QL

amphetamine-dextroamphetamine oral tablet 20 mg

G

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

APTENSIO XR NPB ST; QL

atomoxetine hcl G QL

clonidine hcl er G QL

CONCERTA NPB ST; QL

COTEMPLA XR-ODT NPB ST; QL

DAYTRANA PB ST; QL

DESOXYN NPB ST; QL

DEXEDRINE NPB ST; QL

dexmethylphenidate hcl G QL

dexmethylphenidate hcl er G QL

dextroamphetamine sulfate G QL

dextroamphetamine sulfate er G QL

DYANAVEL XR NPB ST; QL

EVEKEO NPB ST; QL

EVEKEO ODT NPB ST; QL

FOCALIN NPB ST; QL

FOCALIN XR NPB ST; QL

guanfacine hcl er G QL

INTUNIV NPB ST; QL

JORNAY PM NPB ST; QL

KAPVAY NPB ST; QL

metadate er G QL

methamphetamine hcl G QL

METHYLIN NPB ST; QL

methylphenidate hcl er (cd) G QL

methylphenidate hcl er (la) G QL

methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg

G QL

methylphenidate hcl er oral tablet extended release 24 hour

G QL

methylphenidate hcl er oral tablet extended release 72 mg

NPB QL

methylphenidate hcl oral G QL

MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 12.5 MG

PB QL

MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG, 37.5 MG, 50 MG

PB

PROCENTRA NPB ST; QL

QUILLICHEW ER PB ST; QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED 25 MG/5ML

PB ST; QL

relexxii NPB QL

RITALIN NPB ST; QL

RITALIN LA NPB ST; QL

STRATTERA NPB ST; QL

VYVANSE PB QL

ZENZEDI NPB ST; QL

Central Nervous System Agents - Drugs for Multiple Sclerosis

AMPYRA NPB-S ST; QL

AUBAGIO NPB-S QL

AVONEX PEN PB-S QL

AVONEX PREFILLED PB-S QL

BETASERON PB-S QL

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML

NPB-S ST; QL

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML

PB-S ST; QL

dalfampridine er G-S PA; QL

EXTAVIA NPB-S ST; QL

GILENYA PB-S QL

glatiramer acetate G-S QL

glatopa G-S QL

MAVENCLAD (10 TABS) NPB-S PA

MAVENCLAD (4 TABS) NPB-S PA

MAVENCLAD (5 TABS) NPB-S PA

MAVENCLAD (6 TABS) NPB-S PA

MAVENCLAD (7 TABS) NPB-S PA

MAVENCLAD (8 TABS) NPB-S PA

MAVENCLAD (9 TABS) NPB-S PA

MAYZENT NPB-S PA; QL

MAYZENT STARTER PACK NPB QL

PLEGRIDY PB-S QL

PLEGRIDY STARTER PACK PB-S QL

REBIF PB-S QL

REBIF REBIDOSE PB-S QL

REBIF REBIDOSE TITRATION PACK PB-S QL

REBIF TITRATION PACK PB-S QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

TECFIDERA PB-S QL

Central Nervous System Agents - Miscellaneous

ADDYI NPB PA; QL

ADIPEX-P NPB

AUSTEDO PB-S PA; QL

benzphetamine hcl G

caffeine citrate oral G

CONTRAVE NPB ST

diethylpropion hcl er G

diethylpropion hcl oral G

GRALISE PB ST; QL

GRALISE STARTER PB ST

HORIZANT NPB ST; QL

INGREZZA NPB-S PA; QL

LOMAIRA NPB

LYRICA NPB ST; QL

LYRICA CR NPB ST; QL

NUEDEXTA PB

phendimetrazine tartrate G

phendimetrazine tartrate er G

phentermine hcl oral G

pregabalin oral G QL

QSYMIA NPB ST

RILUTEK NPB

riluzole G

SAVELLA PB M; QL

SAVELLA TITRATION PACK PB M; QL

SAXENDA NPB

TEGSEDI NPB-S PA

tetrabenazine G-S PA

TIGLUTIK NPB

VYLEESI NPB PA; QL

XENAZINE NPB-S ST

XENICAL NPB

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

cavarest G M

cevimeline hcl G M

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

chlorhexidine gluconate mouth/throat G

clinpro 5000 NPB M

DEBACTEROL NPB

denta 5000 plus G M

dentagel G M

easygel G M

EVOXAC NPB M

fluoridex NPB M

fluoridex daily renewal G M

fluoridex enhanced whitening NPB M

fluoridex sensitivity relief G M

lidocaine hcl mouth/throat G

lidocaine viscous hcl G

NAFRINSE DAILY ACIDULATED NPB

NAFRINSE DAILY/NEUTRAL NPB M

NAFRINSE WEEKLY NPB M

neutral sodium fluoride G M

NUMOISYN MOUTH/THROAT LOZENGE NPB

oralone G

paroex G

PERIDEX NPB

periogard G

pilocarpine hcl oral G

PREVIDENT 5000 BOOSTER PLUS NPB M

PREVIDENT 5000 DRY MOUTH NPB M

PREVIDENT 5000 ENAMEL PROTECT NPB M

PREVIDENT 5000 ORTHO DEFENSE NPB M

PREVIDENT 5000 PLUS NPB M

PREVIDENT 5000 SENSITIVE NPB M

PREVIDENT DENTAL NPB M

prevident mouth/throat G M

REMESENSE NPB

SALAGEN NPB

sf G M

sf 5000 plus G M

sodium fluoride 5000 plus G M

sodium fluoride 5000 ppm G M

sodium fluoride dental G M

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

TOPEX TOPICAL ANESTHETIC NPB

triamcinolone acetonide mouth/throat G

Dermatological Agents - Drugs for Skin Conditions

A.A.G.C. KIT IN TERODERM NPB

ABSORICA PB QL

ABSORICA LD NPB

ACANYA NPB ST; QL

acitretin G

ACTIVE-PREP KIT IV NPB

ACTIVE-TRAMADOL NPB

ACZONE NPB ST

adapalene external cream G QL

adapalene external gel 0.3 % G QL

ADAPALENE EXTERNAL PAD NPB ST

ADAPALENE EXTERNAL SOLUTION G ST

adapalene-benzoyl peroxide G QL

ALA SCALP NPB ST

ala-cort external cream 2.5 % G

alclometasone dipropionate G

ALDARA NPB QL

ALTRENO NPB

amcinonide G

ammonium lactate external lotion G

amnesteem G QL

APEXICON E G ST; QL

arzol silver nit applicators G

ATRALIN NPB QL

AVAR LS CLEANSER NPB ST

AVAR-E EMOLLIENT NPB ST

AVAR-E GREEN NPB ST

AVAR-E LS NPB ST

avita external cream G QL

avita external gel NPB

azelaic acid external G

AZELEX NPB ST; QL

BENZAC AC WASH NPB ST

BENZACLIN NPB ST; QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

BENZACLIN WITH PUMP NPB ST; QL

BENZAMYCIN NPB ST

benzepro external foam 5.3 % G

benzepro foaming cloths G

BENZEPRO SHORT CONTACT NPB ST

BENZIQ NPB ST

BENZIQ LS NPB ST

BENZIQ WASH NPB ST

BENZOYL PEROX-HYDROCORTISONE NPB ST

benzoyl peroxide external foam 9.8 % G

BENZOYL PEROXIDE EXTERNAL GEL 6.5 %, 8 %

NPB

BENZOYL PEROXIDE FORTE- HC NPB

benzoyl peroxide-erythromycin G

beser external lotion G

betamethasone dipropionate aug G

betamethasone dipropionate external G

betamethasone valerate external G

bp cleansing wash G

bp wash external liquid 2.5 % NPB

BRYHALI NPB ST

calcipotriene external cream G QL

CALCIPOTRIENE EXTERNAL FOAM NPB QL

calcipotriene external ointment G QL

calcipotriene external solution G QL

calcipotriene-betameth diprop external ointment G QL

CALCITRENE NPB QL

calcitriol external G QL

CANTHARIDIN EXTERNAL NPB

CAPEX NPB ST; QL

CARAC PB QL

claravis G QL

CLEOCIN-T NPB ST

clindacin etz external swab G

clindacin-p G

CLINDAGEL NPB ST

clindamycin phosphate-benzoyl peroxide G QL

clindamycin phosphate external foam G

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

clindamycin phosphate external lotion G

clindamycin phosphate external solution G

clindamycin phosphate external swab G

CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL

NPB ST

clindamycin phosphate gel 1 % external G

clindamycin-tretinoin G

CLINOIN NPB

clobetasol prop emollient base G

clobetasol propionate e G

clobetasol propionate emulsion G

clobetasol propionate external G

CLOBEX NPB ST

CLOBEX SPRAY NPB ST

clocortolone pivalate NPB QL

clodan external shampoo G

CLODERM NPB ST; QL

coal tar external PB

CONDYLOX NPB

CORDRAN EXTERNAL CREAM NPB ST

CORDRAN EXTERNAL LOTION NPB ST

CORDRAN EXTERNAL OINTMENT NPB ST

CORDRAN EXTERNAL TAPE NPB ST; QL

CORTANE-B NPB

CORTISPORIN NPB

CUTIVATE NPB ST

dapsone external G

DERMA-SMOOTHE/FS BODY NPB ST; QL

DERMA-SMOOTHE/FS SCALP NPB ST; QL

DESONATE NPB ST

desonide external G QL

DESOWEN NPB ST; QL

desoximetasone external cream G QL

desoximetasone external gel G QL

desoximetasone external liquid G

desoximetasone external ointment G QL

diclofenac sodium transdermal gel 3 % G QL

DIFFERIN EXTERNAL CREAM NPB ST; QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

DIFFERIN EXTERNAL GEL 0.3 % NPB ST; QL

DIFFERIN EXTERNAL LOTION NPB ST; QL

diflorasone diacetate external cream G QL

diflorasone diacetate external ointment G

DIPROLENE NPB ST

DIPROLENE AF NPB ST

DOVONEX NPB QL

doxepin hcl external G QL

doxycycline NPB ST

DRITHO-CREME HP NPB

DRYSOL NPB

DUOBRII NPB ST

DUPIXENT PB-S PA; QL

EFUDEX NPB

ELIDEL NPB ST; QL

ELOCON NPB ST

ENOVARX-TRAMADOL NPB

ENSTILAR PB QL

ENZOCLEAR NPB ST

EPIDUO NPB ST; QL

EPIDUO FORTE PB ST

EPIFOAM NPB ST

ery G

ERYGEL G

erythromycin external G

EUCRISA NPB ST; QL

EVOCLIN NPB ST

FABIOR NPB PA; QL

FINACEA EXTERNAL FOAM PB ST

FINACEA EXTERNAL GEL NPB ST

fluocinolone acetonide body G QL

fluocinolone acetonide external cream 0.01 % G

fluocinolone acetonide external cream 0.025 % G QL

fluocinolone acetonide external ointment G QL

fluocinolone acetonide external solution G QL

fluocinolone acetonide scalp G QL

fluocinonide emulsified base G

fluocinonide external cream 0.05 % G

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

fluocinonide external cream 0.1 % G QL

fluocinonide external gel G

fluocinonide external ointment G

fluocinonide external solution G

FLUOROPLEX NPB QL

FLUOROURACIL EXTERNAL CREAM 0.5 % NPB QL

fluorouracil external cream 5 % G

fluorouracil external solution G QL

flurandrenolide G

fluticasone propionate external G

GORDOFILM NPB

grafco silver nit applicator G

halcinonide G

halobetasol propionate external cream G QL

HALOBETASOL PROPIONATE EXTERNAL FOAM

NPB ST

halobetasol propionate external ointment G QL

HALOG NPB ST

HYALUCIL-4 NPB

HYDRO 40 NPB

hydrocortisone ace-pramoxine external cream 2.5-1 %

G

hydrocortisone butyr lipo base G

hydrocortisone butyrate G

hydrocortisone external cream 2.5 % G

hydrocortisone external lotion 2.5 % G

hydrocortisone external ointment 2.5 % G

hydrocortisone valerate G

imiquimod external G QL

IMIQUIMOD PUMP NPB ST; QL

IMPOYZ NPB ST

INOVA 4/1 ACNE CONTROL THERAPY NPB ST

INOVA EXTERNAL KIT 4 & 5 % NPB ST

isotretinoin oral G QL

ivermectin external G

KENALOG EXTERNAL NPB ST

KERALYT EXTERNAL GEL 6 % NPB

KLARON NPB ST

lactic acid e G

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

lactic acid external G

latrix xm G

LEXETTE NPB ST

LOCOID NPB ST

LOCOID LIPOCREAM NPB ST

LUXIQ NPB ST

methoxsalen rapid G

methyl salicylate external liquid G

METROCREAM NPB ST

METROGEL NPB ST

METROLOTION NPB ST

metronidazole external G

MIRVASO PB PA

mometasone furoate external G

myorisan G QL

NEO-SYNALAR EXTERNAL CREAM NPB

neuac external gel G QL

nolix G

NORITATE NPB ST

OLUX NPB ST

OLUX-E NPB ST

ONEXTON PB ST; QL

ORACEA PB ST

OVACE PLUS EXTERNAL SHAMPOO NPB

OXSORALEN ULTRA NPB

PANDEL NPB ST

PICATO PB QL

pimecrolimus G QL

PLEXION CLEANSER NPB ST

PLEXION EXTERNAL LOTION NPB ST

podocon NPB

podofilox external G

PRAMOSONE NPB ST

prednicarbate G

PROTOPIC NPB ST; QL

PRUDOXIN G ST; QL

PSORCON NPB ST; QL

PYROGALLIC ACID NPB

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Drug Name Drug Tier Restrictions / Limits

QBREXZA PB QL

REGRANEX PB QL

RETIN-A EXTERNAL CREAM 0.025 % NPB QL

RETIN-A EXTERNAL CREAM 0.05 %, 0.1 % NPB

RETIN-A EXTERNAL GEL NPB

RETIN-A MICRO GEL 0.04 %, 0.1 % NPB

RETIN-A MICRO PUMP NPB

RHOFADE NPB PA

RIAX NPB

rosadan external cream G

rosadan external gel G

SALEX EXTERNAL SHAMPOO NPB

salicylic acid er G

salicylic acid external foam G

salicylic acid external gel G

salicylic acid external lotion G

salicylic acid external shampoo G

salicylic acid-cleanser external kit 6 % (lotion) G

SALVAX G

SALVAX DUO PLUS NPB

SANTYL PB

selenium sulfide external G

SERNIVO NPB ST

sodium hyaluronate external G

sodium sulfacetamide G

SODIUM SULFACETAMIDE WASH G

SOOLANTRA NPB ST

SORIATANE NPB

SORILUX NPB QL

sss 10-5 external foam G

sulfacetamide sodium (acne) G

sulfacetamide sodium external gel G

sulfacetamide sodium-sulfur external cream 10-2 %

G

sulfacetamide sodium-sulfur external liquid 10-2 %, 9-4 %, 9.8-4.8 %

G

sulfacetamide sodium-sulfur external lotion 10-5 %

G

sulfacetamide sodium-sulfur external pad G

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Drug Name Drug Tier Restrictions / Limits

sulfacetamide sodium-sulfur external suspension

G

sulfacetamide-sulfur in urea G

sulfacleanse 8/4 G

SYNALAR NPB ST; QL

TACLONEX EXTERNAL OINTMENT NPB QL

TACLONEX EXTERNAL SUSPENSION PB QL

tacrolimus external ointment G QL

tazarotene external G PA; QL

TAZORAC EXTERNAL CREAM 0.05 % PB PA; QL

TAZORAC EXTERNAL CREAM 0.1 % NPB PA; QL

TAZORAC EXTERNAL GEL PB PA; QL

TEMOVATE NPB ST

TEXACORT NPB ST

TOLAK NPB QL

TOPICORT NPB ST; QL

TOPICORT SPRAY NPB ST

tovet external foam G

tretinoin external cream 0.025 % G QL

tretinoin external cream 0.05 %, 0.1 % G

tretinoin external gel 0.01 %, 0.025 % G

tretinoin external gel 0.05 % G QL

tretinoin microsphere G

tretinoin microsphere pump G

triamcinolone acetonide external G

trianex G

TRI-CHLOR G

triderm G

TRIDESILON NPB ST; QL

turpentine external PB

ULTRAVATE NPB ST

UMECTA MOUSSE NPB

urea external cream 39 %, 45 % G

urea hydrating G

urea nail G

VANOS NPB ST; QL

VANOXIDE-HC NPB ST

VECTICAL NPB QL

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Drug Name Drug Tier Restrictions / Limits

VELTIN NPB ST

VERDESO NPB ST

VEREGEN NPB

VIRASAL NPB

XERAC AC NPB

XEROFORM OIL EMULSION 2"X2" NPB

XEROFORM OIL EMULSION GAUZE NPB

XEROFORM PETROLAT PATCH 2"X2" NPB

XEROFORM PETROLAT PATCH 4"X4" NPB

ZACARE NPB ST

zaclir cleansing G

zenatane G QL

ZIANA NPB ST

ZONALON NPB ST; QL

ZYCLARA NPB ST; QL

ZYCLARA PUMP NPB ST; QL

Diabetes - Antidiabetic Agents

acarbose oral G M

ACTOPLUS MET NPB ST; M; QL

ACTOS NPB M; QL

ADLYXIN NPB ST; M; QL

ADLYXIN STARTER PACK NPB ST; M; QL

ALOGLIPTIN BENZOATE NPB ST; M; QL

ALOGLIPTIN-METFORMIN HCL NPB ST; M; QL

ALOGLIPTIN-PIOGLITAZONE NPB ST; M; QL

AMARYL NPB M

AVANDIA NPB ST; M; QL

BYDUREON PB ST; M; QL

BYDUREON BCISE AUTOINJECTOR PB ST; M; QL

BYETTA 10 MCG PEN PB ST; M; QL

BYETTA 5 MCG PEN PB ST; M; QL

CYCLOSET NPB M; QL

DUETACT NPB ST; M; QL

FARXIGA PB ST; M; QL

FORTAMET NPB ST; M

glimepiride G M

glipizide er G M

glipizide ir G M

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Drug Name Drug Tier Restrictions / Limits

glipizide xl G M

glipizide-metformin hcl G M

GLUCOTROL NPB M

GLUCOTROL XL NPB M

GLUMETZA NPB ST; M; QL

glyburide micronized G M

glyburide oral G M

glyburide-metformin G M

GLYNASE NPB M

GLYSET NPB M

GLYXAMBI PB ST; M

INVOKAMET PB ST; M; QL

INVOKAMET XR PB ST; M; QL

INVOKANA PB ST; M; QL

JANUMET PB ST; M; QL

JANUMET XR PB ST; M; QL

JANUVIA PB ST; M; QL

JARDIANCE PB ST; M; QL

JENTADUETO PB ST; M; QL

JENTADUETO XR PB ST; M

KAZANO NPB ST; M; QL

KOMBIGLYZE XR NPB ST; M; QL

metformin hcl er G M

metformin hcl er (mod) G ST; M; QL

metformin hcl er (osm) G ST; M

METFORMIN HCL ORAL SOLUTION NPB ST; M; QL

metformin hcl oral tablet G M

miglitol G M

nateglinide G M

NESINA NPB ST; M; QL

ONGLYZA NPB ST; M; QL

OSENI NPB ST; M; QL

OZEMPIC PB ST; M; QL

pioglitazone hcl G M; QL

pioglitazone hcl-glimepiride G M; QL

pioglitazone hcl-metformin hcl G M; QL

PRECOSE NPB M

QTERN NPB ST; M

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Drug Name Drug Tier Restrictions / Limits

repaglinide G M

RIOMET NPB ST; M; QL

RYBELSUS PB ST; M; QL

SEGLUROMET PB ST; M

SOLIQUA PB ST; M; QL

STARLIX NPB M

STEGLATRO PB ST; M

STEGLUJAN NPB ST; M

SYMLINPEN 120 PB ST; M; QL

SYMLINPEN 60 PB ST; M; QL

SYNJARDY PB ST; M

SYNJARDY XR PB ST; M

tolbutamide G M

TRADJENTA PB ST; QL

TRULICITY PB ST; M; QL

VICTOZA PB ST; M; QL

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 5-1000 MG, 5-500 MG

PB ST; M; QL

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG

PB ST; M

XULTOPHY PB ST; M; QL

Diabetes - Glucose Monitoring

ACCU-CHEK AVIVA CONNECT KIT W/DEVICE NPB ST; OTC; QL

ACCU-CHEK AVIVA PLUS KIT W/DEVICE NPB ST; OTC; QL

ACCU-CHEK COMPACT PLUS TEST STRIPS NPB ST; OTC; QL

ACCU-CHEK GUIDE KIT W/DEVICE NPB ST; OTC; QL

ACCU-CHEK GUIDE ME NPB ST; OTC; QL

ACCU-CHEK GUIDE STRIP IN VITRO NPB OTC; QL

ACCU-CHEK GUIDE STRIP IN VITRO NPB ST; OTC; QL

ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE

NPB ST; OTC; QL

ACCU-CHEK SMARTVIEW TEST STRIPS NPB ST; OTC; QL

AGAMATRIX PRESTO TEST NPB OTC; QL

ASSURE PLATINUM NPB OTC; QL

BIOTEL CARE BLOOD GLUCOSE SYST NPB ST; OTC; QL

BLOOD GLUCOSE TEST NPB ST; OTC; QL

CONTOUR NEXT MONITOR KIT W/DEVICE NPB OTC; QL

CONTOUR NEXT MONITOR KIT W/DEVICE NPB ST; OTC; QL

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Drug Name Drug Tier Restrictions / Limits

CONTOUR NEXT TEST STRIP IN VITRO NPB OTC; QL

CONTOUR NEXT TEST STRIP IN VITRO NPB ST; OTC; QL

CONTOUR TEST NPB ST; OTC; QL

DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC)

PB ST; QL

DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC) DEVICE

PB ST; QL

DIATHRIVE BLOOD GLUCOSE TEST NPB ST; OTC; QL

DIATHRIVE GLUCOSE TEST NPB ST; OTC; QL

EASYPLUS BLOOD GLUCOSE TEST NPB ST; OTC; QL

EMBRACE TALK GLUCOSE TEST NPB ST; OTC; QL

EMBRACE TALK MONITORING SYSTEM NPB ST; OTC; QL

EVENCARE PROVIEW GLUCOSE TEST NPB OTC; QL

FORA GTEL BLOOD GLUCOSE TEST NPB ST; OTC; QL

FREESTYLE FREEDOM LITE NPB ST; OTC; QL

FREESTYLE INSULINX SYSTEM NPB ST; OTC; QL

FREESTYLE INSULINX TEST NPB ST; OTC; QL

FREESTYLE LIBRE 14 DAY READER PB ST; QL

FREESTYLE LIBRE 14 DAY SENSOR PB ST; QL

FREESTYLE LIBRE READER PB ST; QL

FREESTYLE LIBRE SENSOR SYSTEM PB ST; QL

FREESTYLE LITE TEST NPB ST; OTC; QL

FREESTYLE PRECISION NEO TEST NPB ST; OTC; QL

FREESTYLE TEST NPB ST; OTC; QL

GLUCOCARD 01 SENSOR PLUS NPB ST; OTC; QL

GLUCOCARD EXPRESSION TEST NPB ST; OTC; QL

GLUCOCARD SHINE CONNEX NPB ST; OTC; QL

GLUCOCARD SHINE EXPRESS NPB ST; OTC; QL

GLUCOCARD SHINE TEST NPB ST; OTC; QL

GLUCOCARD VITAL TEST NPB ST; OTC; QL

GOJJI BLOOD GLUCOSE TEST NPB OTC; QL

GOJJI BLOOD TEST STRIP/LANCETS NPB OTC; QL

HARMONY BLOOD GLUCOSE TEST NPB OTC; QL

HW EMBRACE PRO GLUCOSE TEST NPB ST; OTC; QL

HW EMBRACE TALK GLUCOSE TEST NPB ST; OTC; QL

INFINITY BLOOD GLUCOSE TEST NPB ST; OTC; QL

KROGER HEALTHPRO GLUCOSE TEST NPB ST; OTC; QL

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Drug Name Drug Tier Restrictions / Limits

MICRODOT TEST NPB OTC; QL

ONE DROP BLOOD GLUCOSE MONITOR NPB ST; OTC; QL

ONE DROP TEST NPB ST; OTC; QL

ONETOUCH ULTRA 2 KIT W/DEVICE PB OTC; QL

ONETOUCH ULTRA BLUE TEST STRIPS PB OTC; QL

ONETOUCH ULTRA MINI KIT W/DEVICE PB OTC; QL

ONETOUCH VERIO KIT W/DEVICE PB OTC; QL

ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE

PB OTC; QL

ONETOUCH VERIO TEST STRIPS PB OTC; QL

ONETOUCH VERIO IQ SYSTEM PB OTC; QL

ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE

PB OTC; QL

PRECISION LINK NPB ST; OTC; QL

PRECISION PCX PLUS TEST NPB ST; OTC; QL

PRECISION QID TEST NPB ST; OTC; QL

PRECISION SOF-TACT TEST NPB ST; OTC; QL

PRECISION XTRA BLOOD GLUCOSE NPB ST; OTC; QL

PRODIGY NO CODING BLOOD GLUC NPB OTC; QL

RELION BLOOD GLUCOSE TEST NPB ST; OTC; QL

RELION PREMIER TEST NPB ST; OTC; QL

RELION ULTIMA TEST NPB ST; OTC; QL

TRUE METRIX BLOOD GLUCOSE TEST NPB ST; OTC; QL

TRUE METRIX PRO BLOOD GLUCOSE NPB OTC; QL

TRUETRACK TEST NPB ST; OTC; QL

VIVAGUARD INO TEST STRIPS NPB ST; OTC; QL

Diabetes - Glycemic Agents

BAQSIMI ONE PACK NPB

BAQSIMI TWO PACK NPB

GLUCAGEN HYPOKIT PB

GLUCAGON EMERGENCY KIT PB

GLUCAGON EMERGENCY KIT NPB

GVOKE PFS NPB

PROGLYCEM PB M

Diabetes - Insulins

ADMELOG NPB ST; M; QL

ADMELOG SOLOSTAR NPB ST; M; QL

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Drug Name Drug Tier Restrictions / Limits

AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT, 90 X 8 UNIT & 90X12 UNIT

NPB M

AFREZZA INHALATION POWDER 4 UNIT NPB M; QL

APIDRA SOLOSTAR NPB ST; M; QL

APIDRA VIAL NPB ST; M; QL

BASAGLAR KWIKPEN NPB ST; M

DROPLET MICRON PB ST; M; OTC

FIASP NPB ST; M; QL

FIASP FLEXTOUCH NPB ST; M; QL

FIASP PENFILL NPB ST; M; QL

HUMALOG PB M; QL

HUMALOG KWIKPEN PB M; QL

HUMALOG MIX 50/50 KWIKPEN PB M; QL

HUMALOG MIX 50/50 VIAL PB M; QL

HUMALOG MIX 75/25 KWIKPEN PB M; QL

HUMALOG MIX 75/25 VIAL PB M; QL

HUMALOG U-100 JUNIOR KWIKPEN PB M; QL

HUMULIN 70/30 KWIKPEN PB M; OTC; QL

HUMULIN 70/30 VIAL PB M; OTC; QL

HUMULIN N KWIKPEN PB M; OTC

HUMULIN N VIAL PB M; OTC; QL

HUMULIN R U-500 KWIKPEN PB M; QL

HUMULIN R U-500 VIAL (CONCENTRATED) PB M; QL

HUMULIN R VIAL PB M; OTC; QL

INSULIN ASP PROT & ASP FLEXPEN NPB ST; M

INSULIN ASPART NPB ST; M

INSULIN ASPART FLEXPEN NPB ST; M; QL

INSULIN ASPART PENFILL NPB ST; M; QL

INSULIN ASPART PROT & ASPART NPB ST; M

INSULIN LISPRO NPB M; QL

INSULIN LISPRO (1 UNIT DIAL) NPB M; QL

LANTUS SOLOSTAR PB M

LANTUS U-100 VIAL PB M; QL

LEVEMIR U-100 FLEXTOUCH PB M; QL

LEVEMIR U-100 VIAL PB M; QL

NOVOLIN 70/30 FLEXPEN NPB ST; M; OTC; QL

NOVOLIN 70/30 FLEXPEN RELION NPB ST; M; OTC; QL

NOVOLIN 70/30 RELION NPB ST; M; OTC; QL

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Drug Name Drug Tier Restrictions / Limits

NOVOLIN 70/30 VIAL NPB ST; M; OTC; QL

NOVOLIN N FLEXPEN NPB ST; M; OTC

NOVOLIN N FLEXPEN RELION NPB ST; M; OTC

NOVOLIN N RELION NPB ST; M; OTC; QL

NOVOLIN N VIAL NPB ST; M; OTC; QL

NOVOLIN R FLEXPEN NPB ST; M; OTC

NOVOLIN R FLEXPEN RELION NPB ST; M; OTC

NOVOLIN R RELION NPB ST; M; OTC; QL

NOVOLIN R VIAL NPB ST; M; OTC; QL

NOVOLOG FLEXPEN NPB ST; M; QL

NOVOLOG MIX 70/30 FLEXPEN NPB ST; M

NOVOLOG MIX 70/30 VIAL NPB ST; M

NOVOLOG PENFILL NPB ST; M; QL

NOVOLOG U-100 VIAL NPB ST; M

TOUJEO MAX SOLOSTAR PB M; QL

TOUJEO SOLOSTAR PB M

TRESIBA PB M; QL

TRESIBA FLEXTOUCH PB M; QL

Electrolytes / Minerals / Metals / Vitamins

adc/f (0.5mg/ml) G ACA

aminobenzoate potassium G M

ARGININE HCL INJECTION NPB

ASCORBIC ACID INJECTION NPB

ATABEX OB NPB

BCAA INJECTION NPB

CALCIFOL NPB

calcium-folic acid plus d G

CARBAGLU PB-S PA

CARNITOR ORAL SOLUTION NPB M

CARNITOR SF NPB M

CHEMET PB

CHOLECAL DF NPB

CITRANATAL BLOOM NPB

CITRANATAL MEDLEY NPB

clovique G PA

cyanocobalamin injection solution 1000 mcg/ml G M

CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML

PB M

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Drug Name Drug Tier Restrictions / Limits

cytra k crystals G

deferasirox G-S

DEXPANTHENOL INJECTION NPB

DRISDOL NPB

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ

NPB M

effer-k oral tablet effervescent 25 meq G M

ELITE-OB NPB

ENBRACE HR NPB

ERGOCAL NPB

ergocalciferol oral capsule G

EXJADE PB-S

FERIVA 21/7 NPB

ferotrinsic G

FERRALET 90 NPB

ferraplus 90 G

FERRIPROX PB-S

FERRO-PLEX HEMATINIC NPB

FERROTRIN NPB

FLORIVA ORAL LIQUID NPB M; ACA

FLORIVA ORAL TABLET CHEWABLE NPB

FLORIVA PLUS NPB ACA

FLUORABON NPB M; ACA

fluoritab oral solution G M; ACA

fluoritab oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg

G M; ACA

fluoritab oral tablet chewable 2.2 (1 f) mg G M

FLURA-DROPS NPB M; ACA

folic acid oral tablet 1 mg G M

FOLI-D NPB

FOLITE NPB

foltrin G

FOLVITE-D NPB

FOLVITE-FE NPB

GALZIN NPB

GENICIN VITA-D NPB

GLUTATHIONE INJECTION NPB

GLYCINE INJECTION NPB

HEMATRON-AF NPB

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Drug Name Drug Tier Restrictions / Limits

hemocyte-plus G

hydroxocobalamin acetate G

iodine strong oral G

IS 24/6 NPB

JADENU NPB-S

JADENU SPRINKLE PB-S

JYNARQUE ORAL TABLET PB-S PA; QL

JYNARQUE ORAL TABLET THERAPY PACK NPB-S PA; QL

kionex G

klor-con G M

klor-con 10 G M

klor-con m10 G M

KLOR-CON M15 G M

klor-con m20 G M

klor-con sprinkle G M

klor-con/ef G M

K-PHOS PB

K-PHOS NO 2 NPB

k-prime G M

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 8 MEQ

G M

K-TAB ORAL TABLET EXTENDED RELEASE 20 MEQ

NPB ST; M

k-tan plus G

levocarnitine oral solution G M

levocarnitine oral tablet G M

levocarnitine sf G M

LIPO NPB

LIPO-C NPB

LOKELMA PB

ludent oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg

G M; ACA

ludent oral tablet chewable 2.2 (1 f) mg G M

LYSINE HCL INJECTION NPB

MAGNESIUM SULFATE INJECTION NPB

MEPHYTON NPB

METHYLCOBALAMIN INJECTION NPB

MIC-L-CARNITINE NPB

multigen G

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Drug Name Drug Tier Restrictions / Limits

multi-vit/iron/fluoride G ACA

multi-vitamin/fluoride G ACA

multivitamin/fluoride oral solution G ACA

multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg

G ACA

MULTIVITAMIN/FLUORIDE ORAL TABLET CHEWABLE 0.25-0.3 MG, 0.5-0.3 MG, 1-0.3 MG

NPB

multivitamin/fluoride oral tablet chewable 1 mg G

multivitamin/fluoride/iron G ACA

multi-vitamin/fluoride/iron G ACA

multivitamins/fluoride G ACA

mvc-fluoride oral tablet chewable 0.25 mg, 0.5 mg

G ACA

mvc-fluoride oral tablet chewable 1 mg G

nafrinse G M

nafrinse drops G M; ACA

NASCOBAL PB M

NEPHRON FA NPB

NESTABS NPB

NESTABS ONE NPB

NIFEREX NPB

NUTRIVIT PB

ORACIT NPB

phospho-trin 250 neutral G

phytonadione oral G

pnv prenatal plus multivit+dha NPB

polysaccharide iron forte G

POLY-VI-FLOR NPB

POLY-VI-FLOR FS NPB

POLY-VI-FLOR/IRON NPB

pot bicarb-pot chloride G M

POTABA NPB M

potassium bicarbonate oral G M

potassium chloride crys er G M

potassium chloride er G M

potassium chloride oral G M

potassium citrate er G M

potassium citrate-citric acid G

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Drug Name Drug Tier Restrictions / Limits

PRENAISSANCE NPB

PRENATA NPB

prenatal plus iron G

PRENATE DHA NPB

PRENATE ELITE NPB

PRENATE ENHANCE G

PRENATE ESSENTIAL NPB

PRENATE MINI NPB

PRENATE PIXIE NPB

PRENATE RESTORE G

PRENATVITE PLUS NPB

PRENATVITE RX NPB

PRIMACARE NPB

PYRIDOXAL-5 PHOSPHATE INJECTION NPB

QUFLORA FE NPB

QUFLORA FE PEDIATRIC NPB ACA

QUFLORA GUMMIES NPB

QUFLORA PEDIATRIC ORAL SOLUTION NPB ACA

QUFLORA PEDIATRIC ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG

NPB ACA

QUFLORA PEDIATRIC ORAL TABLET CHEWABLE 1 MG

NPB

RELNATE DHA NPB

RENATABS WITH IRON NPB

SALINE-PHENOL NPB

SAMSCA PB-S PA; QL

SELECT-OB ORAL TABLET CHEWABLE 29-1 MG

NPB

sodium fluoride oral solution G M; ACA

sodium fluoride oral tablet 1.1 (0.5 f) mg G M; ACA

sodium fluoride oral tablet 2.2 (1 f) mg G M

sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg

G M; ACA

sodium fluoride oral tablet chewable 2.2 (1 f) mg G M

sodium polystyrene sulfonate oral G

sodium polystyrene sulfonate rectal suspension 30 gm/120ml

G

sodium polystyrene sulfonate rectal suspension 50 gm/200ml

NPB

sps G

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Drug Name Drug Tier Restrictions / Limits

SYPRINE NPB PA

taron-crystals G

TAURINE INJECTION NPB

TRI-AMINO NPB

TRICARE PRENATAL DHA ONE NPB

trientine hcl G PA

trinate G

TRISTART ONE NPB

TRI-VI-FLOR NPB

TRI-VI-FLORO NPB

tri-vitamin/fluoride G ACA

tri-vite/fluoride G ACA

tryptophan oral G

UROCIT-K 10 NPB M

UROCIT-K 15 NPB M

UROCIT-K 5 NPB M

VELTASSA PB

VITAFOL-OB+DHA NPB

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

G

vitamins acd-fluoride G ACA

vp-pnv-dha NPB

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

ACIPHEX NPB ST; M; QL

ACIPHEX SPRINKLE NPB ST; M; QL

CARAFATE NPB M

cimetidine hcl G M

cimetidine oral tablet 300 mg, 400 mg, 800 mg G M

CYTOTEC NPB M

DEPRIZINE FUSEPAQ NPB M

DEXILANT NPB ST; M; QL

esomeprazole magnesium oral capsule delayed release

PB M; QL

famotidine oral suspension reconstituted G M

famotidine oral tablet 40 mg G M

lansoprazole oral PB M; QL

misoprostol oral G M

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Drug Name Drug Tier Restrictions / Limits

NEXIUM ORAL CAPSULE DELAYED RELEASE 40 MG

NPB ST; M; QL

NEXIUM ORAL PACKET PB ST; M; QL

nizatidine G M

omeprazole oral capsule delayed release PB M; QL

omeprazole-sodium bicarbonate PB M; QL

pantoprazole sodium oral PB M; QL

PEPCID ORAL TABLET 40 MG NPB M

PREVACID ORAL CAPSULE DELAYED RELEASE 30 MG

NPB ST; M; QL

PREVACID SOLUTAB NPB ST; M; QL

PRILOSEC NPB ST; M; QL

PROTONIX ORAL NPB ST; M; QL

RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE

NPB ST; M; QL

rabeprazole sodium oral tablet delayed release PB M; QL

ranitidine hcl oral capsule G M

ranitidine hcl oral syrup G M

ranitidine hcl oral tablet 300 mg G M

ranitidine hcl tablet 150 mg oral (rx) G M

sucralfate oral G M

ZEGERID NPB ST; M; QL

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

ACTIGALL NPB M

alosetron hcl G

AMITIZA PB QL

amoxicill-clarithro-lansopraz G QL

ANASPAZ G

ATROPEN NPB

belladonna alkaloids-opium G

cascara sagrada oral fluid extract NPB

CHENODAL PB-S PA

chlordiazepoxide-clidinium G

CLENPIQ PB ACA

constulose G

cromolyn sodium oral G

CUVPOSA NPB

dicyclomine hcl oral G

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Drug Name Drug Tier Restrictions / Limits

diphenoxylate-atropine G

DONNATAL NPB

ENTEREG NPB

enulose G

GASTROCROM NPB

GATTEX NPB-S

gavilyte-c G ACA

gavilyte-g G ACA

gavilyte-n with flavor pack G ACA

generlac G

GIALAX NPB ACA

GLYCATE NPB

glycopyrrolate oral tablet 1 mg, 2 mg G

GLYCOPYRROLATE ORAL TABLET 1.5 MG G

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM

NPB ACA

GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM

NPB

hyoscyamine sulfate er G

hyoscyamine sulfate injection G

hyoscyamine sulfate oral elixir G

hyoscyamine sulfate oral solution G

hyoscyamine sulfate oral tablet G

hyoscyamine sulfate sl G

hyoscyamine sulfate sublingual G

hyosyne G

KRISTALOSE NPB

lactulose G

lactulose encephalopathy G

LEVBID NPB

LEVSIN ORAL NPB

LEVSIN/SL NPB

LIBRAX NPB ST

LINZESS PB QL

LOMOTIL NPB

LOTRONEX NPB

methscopolamine bromide oral G

mineral oil heavy oral PB

MOTEGRITY NPB QL

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

MOTOFEN NPB

MOVANTIK PB QL

MOVIPREP NPB ACA

MYTESI NPB QL

NULYTELY WITH FLAVOR PACKS NPB

OMECLAMOX-PAK NPB QL

opium G

oscimin G

oscimin sr G

OSMOPREP NPB ACA

paregoric G

PCP 100 NPB

peg 3350-kcl-na bicarb-nacl G ACA

peg-3350/electrolytes G ACA

phenobarbital-belladonna alk G

phenohytro G

PLENVU NPB ACA

PREPOPIK PB ACA

propantheline bromide oral G

PYLERA PB

RELISTOR ORAL NPB QL

RELISTOR SUBCUTANEOUS PB QL

SEROSTIM PB-S PA

SUPREP BOWEL PREP KIT PB ACA

SYMAX DUOTAB NPB

symax-sl G

symax-sr G

SYMPROIC PB QL

trilyte G ACA

TRULANCE PB QL

URSO 250 NPB M

URSO FORTE NPB M

ursodiol oral G M

VIBERZI PB QL

XERMELO PB-S PA; QL

ZELNORM NPB QL

ZORBTIVE NPB-S PA

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment

BUPHENYL ORAL TABLET NPB

CERDELGA PB-S

CHOLBAM PB-S

CREON PB

CYSTAGON PB-S PA

GALAFOLD NPB-S PA; QL

KUVAN PB-S PA

miglustat G-S

MYALEPT PB-S PA

nitisinone G-S

NITYR PB-S

OCALIVA PB-S PA; QL

ORFADIN PB-S

PALYNZIQ PB-S PA; QL

PANCREAZE NPB ST

PERTZYE NPB ST

PROCYSBI ORAL CAPSULE DELAYED RELEASE

NPB-S ST

RAVICTI PB-S

sodium phenylbutyrate oral tablet G

STRENSIQ PB-S PA

SUCRAID PB-S

VIOKACE PB

XURIDEN PB-S QL

ZAVESCA NPB-S ST

ZENPEP PB

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions

AURYXIA NPB

bethanechol chloride oral G

calcium acetate (phos binder) G

calcium acetate oral tablet 667 mg G

CUPRIMINE NPB ST; M

darifenacin hydrobromide er G M

DEPEN TITRATABS NPB M

DETROL NPB ST; M

DETROL LA NPB ST; M

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Drug Name Drug Tier Restrictions / Limits

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG

NPB ST; M

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 5 MG

NPB ST; M; QL

ELMIRON PB

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 7.5 MG

NPB ST; M

FEM PH G

flavoxate hcl G M

FOSRENOL NPB ST

GELNIQUE PB ST; M; QL

hyophen G

INTRAROSA NPB

lanthanum carbonate G

LITHOSTAT NPB

me/naphos/mb/hyo1 G

MYRBETRIQ PB ST

oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg

G M

oxybutynin chloride er oral tablet extended release 24 hour 5 mg

G M; QL

oxybutynin chloride oral G M

OXYTROL NPB ST; M; QL

penicillamine oral G M

PENTOSAN POLYSULFATE SODIUM ORAL NPB

phenazo oral tablet 200 mg G

phenazopyridine hcl oral tablet 100 mg, 200 mg G

PHOSLYRA PB

phosphasal G

PYRIDIUM NPB

RENAGEL NPB ST

RENVELA NPB

RIMSO-50 NPB

sevelamer carbonate G

sevelamer hcl G

solifenacin succinate G M

THIOLA NPB-S

THIOLA EC NPB-S

tolterodine tartrate G M

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

tolterodine tartrate er G M

TOVIAZ PB ST

trospium chloride G M

trospium chloride er G M

URECHOLINE NPB

URELLE NPB

uretron d/s G

URIMAR-T NPB

urin ds G

URO-458 NPB

UROGESIC-BLUE G

URYL G

ustell G

uticap G

utira-c G

utrona-c G

VELPHORO PB

VESICARE PB ST; M

VILEVEV MB NPB

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er G M

AVODART NPB ST; M

CARDURA XL NPB M; QL

dutasteride oral G M

dutasteride-tamsulosin hcl G M

finasteride oral tablet 5 mg G M

FLOMAX NPB ST; M

JALYN NPB ST; M

PROSCAR NPB ST; M

RAPAFLO NPB ST; M

silodosin G M

tamsulosin hcl G M

terazosin hcl G M; QL

UROXATRAL NPB ST; M

Hormonal Agents - Adrenal

ACTIVE INJECTION BLM-1 NPB

ACTIVE INJECTION BM NPB

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

ACTIVE INJECTION DL NPB

ACTIVE INJECTION DLM NPB

ACTIVE INJECTION KIT L NPB

ACTIVE INJECTION KM NPB

ACTIVE INJECTION LM-DEP-2 NPB

ACTIVE INJECTION M-1 NPB

BETALIDO NPB

BUPIVILOG NPB

CONTRAST ALLERGY PREMED PACK NPB

CORTEF NPB

cortisone acetate oral G

DECADRON G

DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML

NPB

dexamethasone intensol G

dexamethasone oral elixir G

dexamethasone oral solution G

dexamethasone oral tablet G

dexamethasone oral tablet therapy pack G ST

DEXLIDO NPB

DEXLIDO-M NPB

DEXOPIN NPB

DEXPAK 10 DAY NPB ST

DEXPAK 13 DAY NPB ST

DEXPAK 6 DAY NPB ST

DXEVO 11-DAY NPB ST

DYURAL-40 NPB

DYURAL-80 NPB

DYURAL-L NPB

DYURAL-LM NPB

fludrocortisone acetate oral G M

HIDEX 6-DAY PB ST

hydrocortisone oral G

lidolog G

LT INJECTION KIT NPB

MARBETA-25 NPB

MARBETA-L NPB

MARDEX-25 NPB

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

MEDROL NPB

METHYLPREDNISOLONE ACE-LIDO NPB

methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml

G

methylprednisolone oral G

MILLIPRED G

MILLIPRED DP G

MILLIPRED DP 12-DAY G

MULTI-SPECIALTY NPB

ORAPRED ODT NPB

P-CARE D40MX NPB

P-CARE D80MX NPB

P-CARE K40MX NPB

P-CARE K80MX NPB

PEDIAPRED NPB

POINT OF CARE KM NPB

POINT OF CARE L.2 NPB

POINT OF CARE L.5 NPB

POINT OF CARE LM DEP 2 NPB

prednisolone oral solution G

prednisolone sodium phosphate oral G

prednisone intensol G

prednisone oral G

RAYOS NPB ST

READYSHARP ANESTH + BETAMETH NPB

READYSHARP ANESTH + DEXAMETH NPB

READYSHARP ANESTH + METHYLPRED NPB

ROPIDEX NPB

SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 1000 MG, 250 MG, 500 MG

PB

TAPERDEX 12-DAY NPB ST

TAPERDEX 6-DAY NPB ST

TAPERDEX 7-DAY NPB ST

Hormonal Agents - Men's Health

ANDRODERM PB PA

ANDROGEL PUMP NPB

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)

NPB

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%), 50 MG/5GM (1%)

NPB ST

danazol oral G

DEPO-TESTOSTERONE NPB

FORTESTA NPB ST

METHITEST PB

methyltestosterone oral G

NANDROLONE-TESTOSTERONE CYP NPB

NATESTO NPB ST

STRIANT NPB

TESTIM NPB ST

TESTOSTERONE CYPIONATE INJECTION G

testosterone cypionate intramuscular G

testosterone enanthate intramuscular G PA

testosterone transdermal G

VOGELXO NPB ST

VOGELXO PUMP NPB ST

XYOSTED NPB PA

Hormonal Agents - Osteoporosis

EVISTA NPB PA; M

OSPHENA NPB

raloxifene hcl G PA; M

Hormonal Agents - Pituitary

cabergoline G M; QL

CETROTIDE PB

chorionic gonadotropin intramuscular G ST; QL

clomiphene citrate oral G

DDAVP NASAL NPB M

DDAVP ORAL NPB M

DDAVP RHINAL TUBE NPB M

desmopressin ace spray refrig G M

desmopressin acetate oral G M

desmopressin acetate spray G M

EGRIFTA PB-S PA; QL

EGRIFTA SV PB-S PA; QL

ELIGARD PB-S QL

FIRMAGON PB-S QL

FOLLISTIM AQ NPB ST

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

ganirelix acetate G-S ST

GENOTROPIN PB-S PA

GENOTROPIN MINIQUICK PB-S PA

GONAL-F PB ST

GONAL-F RFF PB ST

GONAL-F RFF REDIJECT PB ST

HUMATROPE NPB-S PA

INCRELEX PB-S PA

leuprolide acetate injection G-S

LEUPROLIDE ACETATE-BUPIVACAINE NPB

LUPANETA PACK PB QL

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG

PB-S

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG

NPB-S

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG

PB-S

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG

NPB-S

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

NPB-S

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

NPB-S

LUPRON DEPOT-PED (1-MONTH) PB-S PA

LUPRON DEPOT-PED (3-MONTH) PB PA

MENOPUR PB

NOCDURNA NPB M

NOCTIVA NPB ST; M

NORDITROPIN FLEXPRO PB-S PA

novarel intramuscular solution reconstituted 10000 unit

NPB QL

NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT

PB

NUTROPIN AQ NUSPIN 10 NPB-S PA

NUTROPIN AQ NUSPIN 20 NPB-S PA

NUTROPIN AQ NUSPIN 5 NPB-S PA

octreotide acetate G-S

OMNITROPE SUBCUTANEOUS SOLUTION PB-S PA

OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED

NPB-S PA

Last Updated 3/20/2020

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Drug Name Drug Tier Restrictions / Limits

ORILISSA PB PA; QL

OVIDREL PB

pregnyl NPB ST; QL

SAIZEN NPB-S PA

SAIZENPREP NPB-S PA

SANDOSTATIN NPB-S

SOMATULINE DEPOT PB-S

SOMAVERT PB-S

STIMATE PB M

SYNAREL PB

ZOMACTON NPB-S PA

Hormonal Agents - Prostaglandins

KORLYM NPB-S PA; QL

Hormonal Agents - Sex Hormones and Birth Control

ACTIVELLA NPB M

afirmelle G M; ACA

ALORA NPB M; QL

altavera G M; ACA

alyacen 1/35 G M; ACA

alyacen 7/7/7 G M; ACA

amabelz G M

amethia G M; ACA; QL

amethia lo G M; ACA; QL

amethyst G M; ACA

ANGELIQ NPB M

ANNOVERA NPB ACA

apri G M; ACA

aranelle G M; ACA

ashlyna G M; ACA; QL

aubra G M; ACA

aubra eq G M; ACA

aurovela 1.5/30 G M; ACA

aurovela 1/20 G M; ACA

aurovela 24 fe G M; ACA

aurovela fe 1.5/30 G M; ACA

aurovela fe 1/20 G M; ACA

aviane G M; ACA

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Drug Name Drug Tier Restrictions / Limits

AYGESTIN NPB M

ayuna G M; ACA

azurette G M; ACA

BALCOLTRA NPB ST; M; ACA

balziva G M; ACA

bekyree G M; ACA

BEYAZ NPB ST; M

BI-EST 80:20 PROGESTERONE NPB

BIEST/PROGESTERONE NPB

BIJUVA NPB

blisovi 24 fe G M; ACA

blisovi fe 1.5/30 G M; ACA

blisovi fe 1/20 G M; ACA

briellyn G M; ACA

camila G M; ACA

camrese G M; ACA; QL

camrese lo G M; ACA; QL

caziant G M; ACA

chateal G M; ACA

chateal eq G M; ACA

CLIMARA NPB M; QL

CLIMARA PRO NPB ST; M; QL

COMBIPATCH PB M

covaryx G

covaryx hs G

CRINONE PB QL

cryselle-28 G M; ACA

cyclafem 1/35 G M; ACA

cyclafem 7/7/7 G M; ACA

cyred G M; ACA

cyred eq G M; ACA

dasetta 1/35 G M; ACA

dasetta 7/7/7 G M; ACA

daysee G M; ACA; QL

deblitane G M; ACA

DELESTROGEN NPB

delyla G M; ACA

DEPO-ESTRADIOL PB

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Drug Name Drug Tier Restrictions / Limits

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML

NPB QL

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML

PB

DEPO-SUBQ PROVERA 104 NPB ACA; QL

desogestrel-ethinyl estradiol G M; ACA

DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 1 MG/GM

PB M; QL

DIVIGEL TRANSDERMAL GEL 0.75 MG/0.75GM, 1.25 MG/1.25GM

PB M

dotti G M; QL

drospiren-eth estrad-levomefol G M; ACA

drospirenone-ethinyl estradiol G M; ACA

DUAVEE PB

eemt G

eemt hs G

ELESTRIN NPB M; QL

elinest G M; ACA

ELLA NPB ACA; QL

eluryng G M; ACA; QL

emoquette G M; ACA

ENDOMETRIN NPB ST

enpresse-28 G M; ACA

enskyce G M; ACA

errin G M; ACA

est estrogens-methyltest G

est estrogens-methyltest ds G

est estrogens-methyltest hs G

estarylla G M; ACA

ESTRACE NPB M

estradiol oral G M

estradiol transdermal G M; QL

estradiol vaginal G M

estradiol valerate intramuscular G

estradiol-norethindrone acet G M

ESTRING PB M; QL

ESTROGEL NPB M; QL

ESTROSTEP FE NPB ST; M

ethynodiol diac-eth estradiol G M; ACA

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Drug Name Drug Tier Restrictions / Limits

etonogestrel-ethinyl estradiol NPB M; ACA; QL

EVAMIST NPB M; QL

FALESSA NPB ST; ACA

falmina G M; ACA

fayosim G M; ACA; QL

FEMHRT LOW DOSE NPB M

FEMRING NPB ST; M; QL

femynor G M; ACA

fyavolv G M

GENERESS FE NPB ST; M

gianvi G M; ACA

hailey 1.5/30 G M; ACA

hailey 24 fe G M; ACA

heather G M; ACA

IMVEXXY MAINTENANCE PACK NPB M

IMVEXXY STARTER PACK NPB M

incassia G M; ACA

introvale G M; ACA; QL

isibloom G M; ACA

jaimiess G M; ACA; QL

jasmiel G M; ACA

jencycla G M; ACA

jinteli G M

jolessa G M; ACA; QL

juleber G M; ACA

junel 1.5/30 G M; ACA

junel 1/20 G M; ACA

junel fe 1.5/30 G M; ACA

junel fe 1/20 G M; ACA

junel fe 24 G M; ACA

kaitlib fe G M; ACA

kalliga G M; ACA

kariva G M; ACA

kelnor 1/35 G M; ACA

kelnor 1/50 G M; ACA

kurvelo G M; ACA

larin 1.5/30 G M; ACA

larin 1/20 G M; ACA

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Drug Name Drug Tier Restrictions / Limits

larin 24 fe G M; ACA

larin fe 1.5/30 G M; ACA

larin fe 1/20 G M; ACA

larissia G M; ACA

layolis fe G M; ACA

leena G M; ACA

lessina G M; ACA

levonest G M; ACA

levonorgest-eth est & eth est G M; ACA; QL

levonorgest-eth estrad 91-day G M; ACA; QL

levonorgestrel-ethinyl estrad G M; ACA

levonorg-eth estrad triphasic G M; ACA

levora 0.15/30 (28) G M; ACA

lillow G M; ACA

LO LOESTRIN FE PB ST; M; ACA

LOESTRIN 1.5/30 (21) NPB ST; M

LOESTRIN 1/20 (21) NPB ST; M

LOESTRIN FE 1.5/30 NPB ST; M

LOESTRIN FE 1/20 NPB ST; M

lojaimiess G M; ACA; QL

lopreeza G M

loryna G M; ACA

LOSEASONIQUE NPB ST; M; QL

low-ogestrel G M; ACA

lo-zumandimine G M; ACA

lutera G M; ACA

lyza G M; ACA

marlissa G M; ACA

medroxyprogesterone acetate intramuscular suspension

G ACA; QL

medroxyprogesterone acetate oral G M

MEGACE ES NPB

megestrol acetate oral suspension G

megestrol acetate oral tablet G-S

melodetta 24 fe G M; ACA

MENEST NPB M

MENOSTAR NPB M; QL

mibelas 24 fe G M; ACA

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Drug Name Drug Tier Restrictions / Limits

microgestin 1.5/30 G M; ACA

microgestin 1/20 G M; ACA

microgestin fe 1.5/30 G M; ACA

microgestin fe 1/20 G M; ACA

mili G M; ACA

mimvey G M

MINASTRIN 24 FE NPB ST; M

MINIVELLE NPB ST; M; QL

MIRCETTE NPB ST; M

mono-linyah G M; ACA

NATAZIA NPB ST; M; ACA

necon 0.5/35 (28) G M; ACA

nikki G M; ACA

nora-be G M; ACA

norethin ace-eth estrad-fe G M; ACA

norethindrone acetate oral G M

norethindrone acet-ethinyl est G M; ACA

norethindrone oral G M; ACA

norethindrone-eth estradiol G M

norethin-eth estradiol-fe G M; ACA

norgestimate-eth estradiol G M; ACA

norgestimate-ethinyl estradiol triphasic G M; ACA

norlyda G M; ACA

norlyroc G M; ACA

nortrel 0.5/35 (28) G M; ACA

nortrel 1/35 (21) G M; ACA

nortrel 1/35 (28) G M; ACA

nortrel 7/7/7 G M; ACA

NUVARING NPB M; QL

ocella G M; ACA

ogestrel G M; ACA

orsythia G M; ACA

ORTHO MICRONOR NPB ST; M

ORTHO TRI-CYCLEN LO NPB ST; M

ORTHO-NOVUM 1/35 (28) NPB ST; M

ORTHO-NOVUM 7/7/7 (28) NPB ST; M

philith G M; ACA

pimtrea G M; ACA

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Drug Name Drug Tier Restrictions / Limits

pirmella 1/35 G M; ACA

pirmella 7/7/7 G M; ACA

portia-28 G M; ACA

PREFEST NPB M

PREMARIN ORAL PB M

PREMARIN VAGINAL PB M

PREMPHASE PB M

PREMPRO PB M

previfem G M; ACA

progesterone intramuscular G

progesterone micronized oral G

PROMETRIUM NPB

PROVERA NPB M

QUARTETTE NPB ST; M; QL

reclipsen G M; ACA

rivelsa G M; ACA; QL

SAFYRAL NPB ST; M

SEASONIQUE NPB ST; M; QL

setlakin G M; ACA; QL

sharobel G M; ACA

simliya G M; ACA

simpesse G M; ACA; QL

SLYND NPB ACA

sprintec 28 G M; ACA

sronyx G M; ACA

syeda G M; ACA

tarina 24 fe G M; ACA

tarina fe 1/20 G M; ACA

tarina fe 1/20 eq G M; ACA

TAYTULLA PB ST; M; ACA

tilia fe G M; ACA

tri femynor G M; ACA

tri-estarylla G M; ACA

tri-legest fe G M; ACA

tri-linyah G M; ACA

tri-lo-estarylla G M; ACA

tri-lo-marzia G M; ACA

tri-lo-mili G M; ACA

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Drug Name Drug Tier Restrictions / Limits

tri-lo-sprintec G M; ACA

tri-mili G M; ACA

tri-previfem G M; ACA

tri-sprintec G M; ACA

trivora (28) G M; ACA

tri-vylibra G M; ACA

tri-vylibra lo G M; ACA

tulana G M; ACA

tydemy G M; ACA

VAGIFEM NPB ST; M

velivet G M; ACA

vienva G M; ACA

viorele G M; ACA

VIVELLE-DOT NPB ST; M; QL

volnea G M; ACA

vyfemla G M; ACA

vylibra G M; ACA

wera G M; ACA

wymzya fe G M; ACA

xulane G M; ACA

YASMIN 28 NPB ST; M

YAZ NPB ST; M

yuvafem G M

zarah G M; ACA

zovia 1/35e (28) G M; ACA

zumandimine G M; ACA

Hormonal Agents - Thyroid

ARMOUR THYROID G M

CYTOMEL NPB ST; M

euthyrox oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 88 mcg

NPB M

levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 88 mcg

NPB M

levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 88 mcg

G M

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Drug Name Drug Tier Restrictions / Limits

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 88 mcg

G M

liothyronine sodium oral G M

methimazole oral G M

NATURE-THROID G M

np thyroid G M

propylthiouracil oral G M

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 88 MCG

NPB M

TAPAZOLE NPB M

thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg

G M

TIROSINT NPB M

TIROSINT-SOL NPB M

unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 88 mcg

G M

WESTHROID G M

WP THYROID G M

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ACTEMRA ACTPEN NPB-S PA

ACTEMRA SUBCUTANEOUS NPB-S PA; QL

ARAVA NPB M; QL

ARCALYST NPB-S PA

ASTAGRAF XL NPB ST

AZASAN NPB

azathioprine oral G

BENLYSTA SUBCUTANEOUS PB-S PA

CELLCEPT NPB

CIMZIA PB-S PA

CIMZIA PREFILLED KIT PB-S PA

CIMZIA STARTER KIT PB-S PA

COSENTYX (300 MG DOSE) NPB-S PA; QL

COSENTYX 150 MG/ML NPB-S PA; QL

COSENTYX SENSOREADY (300 MG) NPB-S PA; QL

COSENTYX SENSOREADY PEN NPB-S PA; QL

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Drug Name Drug Tier Restrictions / Limits

CUTAQUIG NPB

cyclosporine modified G

cyclosporine oral G

ENBREL NPB-S PA; QL

ENBREL MINI NPB-S PA; QL

ENBREL SURECLICK NPB-S PA; QL

ENVARSUS XR NPB ST

everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg G

FIRAZYR PB-S PA

gengraf G

HUMIRA PB-S PA; QL

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML

PB-S PA

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML

PB-S PA; QL

HUMIRA PEN PB-S PA; QL

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

PB-S PA; QL

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML

PB-S PA

HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

PB-S PA; QL

HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML

PB-S PA

HYPERRAB INJECTION SOLUTION 900 UNIT/3ML

NPB

icatibant acetate G-S PA

IMURAN NPB

KEVZARA NPB-S PA

KINERET NPB-S PA; QL

leflunomide oral G M; QL

methotrexate oral G

methotrexate sodium G

methotrexate sodium (pf) G

mycophenolate mofetil G

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Drug Name Drug Tier Restrictions / Limits

mycophenolate sodium G

MYFORTIC NPB

NEORAL NPB

OLUMIANT NPB-S PA

ORENCIA CLICKJECT NPB-S PA

ORENCIA SUBCUTANEOUS NPB-S PA

OTEZLA PB-S PA; QL

OTREXUP PB-S QL

PROGRAF ORAL NPB

RAPAMUNE NPB

RASUVO PB-S QL

RIDAURA PB M

RINVOQ PB-S

SANDIMMUNE ORAL CAPSULE NPB

SANDIMMUNE ORAL SOLUTION PB

SILIQ NPB-S PA

SIMPONI PB-S PA; QL

sirolimus oral G

SKYRIZI (150 MG DOSE) PB-S PA

STELARA SUBCUTANEOUS PB-S PA

tacrolimus oral G

TAKHZYRO NPB-S PA

TALTZ NPB-S PA

TREMFYA PB-S PA

TREXALL NPB

XATMEP NPB-S PA

XELJANZ PB-S PA; QL

XELJANZ XR PB-S PA; QL

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG

NPB

ZORTRESS ORAL TABLET 1 MG PB

Immunological Agents - Drugs for Vaccination

ACTHIB PB ACA

ADACEL PB ACA

AFLURIA QUADRIVALENT PB ACA

BEXSERO PB ACA

BOOSTRIX PB ACA

DAPTACEL PB ACA

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Drug Name Drug Tier Restrictions / Limits

DIPHTHERIA-TETANUS TOXOIDS DT PB ACA

ENGERIX-B INJECTION PB ACA

ENGERIX-B INTRAMUSCULAR NPB ACA

FLUAD PB ACA

FLUARIX QUADRIVALENT PB ACA

FLUBLOK QUADRIVALENT PB ACA

FLUCELVAX QUADRIVALENT PB ACA

FLULAVAL QUADRIVALENT PB ACA

FLUZONE HIGH-DOSE PB ACA

FLUZONE QUADRIVALENT PB ACA

GARDASIL 9 PB ACA

HAVRIX NPB ACA

HEPLISAV-B NPB ACA

HIBERIX PB ACA

INFANRIX PB ACA

IPOL PB ACA

KINRIX NPB ACA

MENACTRA PB ACA

MENVEO NPB ACA

M-M-R II PB ACA

PEDIARIX PB ACA

PEDVAX HIB PB ACA

PENTACEL PB ACA

PNEUMOVAX 23 PB ACA

PREVNAR 13 PB ACA

PROQUAD PB ACA

QUADRACEL PB ACA

RECOMBIVAX HB PB ACA

ROTARIX NPB ACA

ROTATEQ PB ACA

SHINGRIX PB ACA

TDVAX PB ACA

TENIVAC NPB ACA

TRUMENBA PB ACA

TWINRIX PB ACA

VAQTA NPB ACA

VARIVAX PB ACA

ZOSTAVAX NPB ACA

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Drug Name Drug Tier Restrictions / Limits

Inflammatory Bowel Disease Agents

ANALPRAM HC RECTAL CREAM 2.5-1 % NPB

ANALPRAM HC SINGLES RECTAL CREAM 2.5-1 %

NPB

ANALPRAM-HC RECTAL CREAM 1-1 % NPB

ANALPRAM-HC RECTAL LOTION 2.5-1 % NPB

anucort-hc G

ANUSOL-HC RECTAL CREAM 2.5 % NPB ST

anusol-hc rectal suppository NPB

APRISO NPB M

ASACOL HD NPB ST; M

AZULFIDINE NPB M

AZULFIDINE EN-TABS NPB M

balsalazide disodium G

budesonide er G

budesonide oral G

CANASA NPB M

COLAZAL NPB

colocort G

CORTENEMA NPB

CORTIFOAM RECTAL FOAM 10 % NPB ST

DELZICOL NPB ST; M

DIPENTUM NPB ST; M

ENTOCORT EC NPB

hemmorex-hc G

hydrocortisone ace-pramoxine rectal cream 1-1 %, 2.5-1 %

G

hydrocortisone acetate rectal G

hydrocortisone rectal G

hydrocortisone rectal cream 1 %, 2.5 % G

LIALDA NPB M

LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL

NPB

mesalamine er G M

mesalamine oral G M

mesalamine rectal G M

mesalamine-cleanser G

PENTASA PB M

PROCORT RECTAL CREAM 1.85-1.15 % NPB

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Drug Name Drug Tier Restrictions / Limits

PROCTOCORT RECTAL CREAM 1 % NPB ST

PROCTOCORT RECTAL SUPPOSITORY NPB

PROCTOFOAM HC RECTAL FOAM 1-1 % NPB

procto-med hc rectal cream 2.5 % G

procto-pak rectal cream 1 % G

proctosol hc rectal cream 2.5 % G

proctozone-hc rectal cream 2.5 % G

ROWASA NPB

SFROWASA NPB M

sulfasalazine oral G M

UCERIS ORAL NPB

UCERIS RECTAL PB

Metabolic Bone Disease Agents - Drugs for Osteoporosis

ACTONEL ORAL TABLET 150 MG, 35 MG, 5 MG

NPB ST; M; QL

ACTONEL ORAL TABLET 30 MG NPB ST; M

alendronate sodium G M; QL

ATELVIA NPB ST; M; QL

BINOSTO NPB ST; M; QL

BONIVA ORAL NPB ST; M; QL

calcitonin (salmon) G M; QL

FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML

PB-S ST; QL

FOSAMAX NPB ST; M; QL

FOSAMAX PLUS D NPB ST; QL

ibandronate sodium oral G M; QL

RAYALDEE NPB M

risedronate sodium oral tablet 150 mg, 35 mg, 5 mg

G M; QL

risedronate sodium oral tablet 30 mg G M

risedronate sodium oral tablet delayed release G M; QL

TYMLOS PB-S PA

Metabolic Bone Disease Agents - Other

calcitriol oral G M

cinacalcet hcl G

doxercalciferol oral G M

NATPARA PB-S PA; QL

paricalcitol oral G M

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Drug Name Drug Tier Restrictions / Limits

ROCALTROL NPB M

SENSIPAR NPB

ZEMPLAR ORAL NPB M

Miscellaneous Therapeutic Agents

ALPHA-LIPOIC ACID INJECTION NPB

AMINOPMRMS NPB

APP SLIM RMS NPB

asilnasalrms G

BACTERIOSTATIC WATER(BENZ ALC) NPB

COENZYME Q-10 INJECTION NPB

DANDELION NPB

DIMERCAPTOPROPANE-SULFONATE NPB

ENDARI NPB-S PA

ergoloid mesylates oral G M

FIRDAPSE NPB-S PA

GRASTEK PB

HONEY BEE VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 1300 MCG

NPB

INSPIREASE RESERVOIR BAGS NPB

LENSCALE NPB

methergine G

methylergonovine maleate oral G

mlk f1 G

mlk f2 G

mlk f3 G

MLK F4 NPB

ODACTRA PB

ORAFATE NPB-S

ORALAIR NPB

ORALAIR ADULT SAMPLE KIT NPB

ORALAIR ADULT STARTER PACK NPB

ORALAIR CHILDRENS SAMPLE KIT NPB

ORALAIR CHILDRENS STARTER PACK NPB

PHENOL INJECTION NPB

PROTHELIAL NPB-S

RAGWITEK PB

RUZURGI NPB-S PA

STEMPHYLIUM NPB

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Drug Name Drug Tier Restrictions / Limits

VENOMIL HONEY BEE VENOM NPB

VENOMIL WASP VENOM NPB

VENOMIL WHITE FACED HORNET NPB

VENOMIL YELLOW HORNET VENOM NPB

VENOMIL YELLOW JACKET VENOM NPB

VISTOGARD PB-S

WASP VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 1300 MCG

NPB

WHITE-FACED HORNET VENOM INJECTION SOLUTION RECONSTITUTED 1300 MCG

NPB

YELLOW JACKET VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 1300 MCG

NPB

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation

ACULAR NPB

ACULAR LS NPB

ACUVAIL NPB ST

ALOCRIL NPB ST

ALOMIDE NPB ST

ALREX PB ST

AZASITE PB

azelastine hcl ophthalmic G

bacitracin ophthalmic G

BEPREVE PB ST

BESIVANCE NPB

BETADINE OPHTHALMIC PREP NPB

BLEPH-10 NPB

bromfenac sodium (once-daily) G QL

BROMSITE NPB QL

CILOXAN NPB

ciprofloxacin hcl ophthalmic G

cromolyn sodium ophthalmic G

dexamethasone sodium phosphate ophthalmic G

diclofenac sodium ophthalmic G

DUREZOL NPB

epinastine hcl G

erythromycin ophthalmic G

FLAREX NPB ST

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Drug Name Drug Tier Restrictions / Limits

fluorometholone G

flurbiprofen sodium G

FML NPB ST

FML FORTE NPB ST

FML LIQUIFILM NPB ST

gatifloxacin ophthalmic G

gentak G

gentamicin sulfate ophthalmic G

ILEVRO PB QL

INVELTYS PB ST

ketorolac tromethamine ophthalmic G

KLARITY-A NPB

KLARITY-B NPB

KLARITY-L NPB

levofloxacin ophthalmic G

LOTEMAX OPHTHALMIC GEL PB QL

LOTEMAX OPHTHALMIC OINTMENT PB QL

LOTEMAX OPHTHALMIC SUSPENSION PB

LOTEMAX SM PB

loteprednol etabonate G

MAXIDEX NPB ST

MITOSOL NPB

MOXEZA NPB

moxifloxacin hcl (2x day) G

moxifloxacin hcl ophthalmic G

NATACYN PB

NEVANAC NPB ST; QL

OCUFLOX NPB

ofloxacin ophthalmic G

olopatadine hcl ophthalmic G

PAZEO PB ST

POVIDONE-IODINE OPHTHALMIC NPB

PRED FORTE NPB ST

PRED MILD NPB ST

prednisolone acetate ophthalmic G

prednisolone acetate p-f G

prednisolone sodium phosphate ophthalmic G

PREDNISOLON-MOXIFLOX-NEPAFENAC NPB

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Drug Name Drug Tier Restrictions / Limits

PROLENSA PB QL

sulfacetamide sodium ophthalmic G

tobramycin ophthalmic G

TOBREX NPB

trifluridine G

TRIPLE PMB NPB

TRIPLE PMK NPB

VIGAMOX NPB

ZIRGAN NPB

ZYMAXID NPB

Ophthalmic Agents - Drugs for Glaucoma

acetazolamide er G M

acetazolamide oral G M

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % PB M

ALPHAGAN P OPHTHALMIC SOLUTION 0.15 %

NPB M

apraclonidine hcl G

AZOPT NPB M

betaxolol hcl ophthalmic G M

BETIMOL NPB M

BETOPTIC-S NPB M

bimatoprost ophthalmic G M; QL

brimonidine tartrate ophthalmic G M

carteolol hcl G M

COMBIGAN PB M

COSOPT NPB ST; M

COSOPT PF NPB ST; M

dorzolamide hcl ophthalmic G M

dorzolamide hcl-timolol mal pf G M

DORZOLAMIDE HCL-TIMOLOL MAL SOLUTION 22.3-6.8 MG/ML OPHTHALMIC

NPB ST; M

dorzolamide hcl-timolol mal solution 22.3-6.8 mg/ml ophthalmic

G M

IOPIDINE NPB

ISOPTO CARPINE NPB M

ISTALOL NPB ST; M

KEVEYIS NPB-S PA; QL

LATANOPROST SOLUTION 0.005 % OPHTHALMIC

NPB ST; M

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Drug Name Drug Tier Restrictions / Limits

latanoprost solution 0.005 % ophthalmic G M

levobunolol hcl G M

LUMIGAN PB M; QL

methazolamide oral G M

PHOSPHOLINE IODIDE PB M

pilocarpine hcl ophthalmic G M

RHOPRESSA PB M

ROCKLATAN NPB ST; M; QL

SIMBRINZA NPB M

timolol maleate ophthalmic G M

TIMOPTIC NPB M

TIMOPTIC OCUDOSE NPB ST; M

TIMOPTIC-XE NPB M

TRAVATAN Z NPB M; QL

travoprost (bak free) G M; QL

VYZULTA NPB M; QL

XALATAN NPB ST; M

XELPROS NPB ST; M; QL

ZIOPTAN NPB ST; M; QL

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

ak-poly-bac G

AKTEN NPB

ALCAINE NPB

altafrin G

atropine sulfate ophthalmic ointment G M

bacitracin-polymyxin b ophthalmic G

bacitra-neomycin-polymyxin-hc G

BLEPHAMIDE NPB

BLEPHAMIDE S.O.P. NPB

CYCLOGYL NPB M

CYCLOMYDRIL NPB M

cyclopentolate hcl ophthalmic G M

CYSTARAN PB-S PA; QL

DOUBLE PM NPB

GELFILM OPHTHALMIC NPB

homatropaire G M

homatropine hbr G M

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Drug Name Drug Tier Restrictions / Limits

LACRISERT NPB

LASTACAFT NPB ST

MAXITROL NPB

neomycin-bacitracin zn-polymyx G

neomycin-polymyxin-dexameth ophthalmic ointment

G

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

G

neomycin-polymyxin-gramicidin G

neomycin-polymyxin-hc ophthalmic G

neo-polycin G

neo-polycin hc G

OXERVATE PB-S PA; QL

phenylephrine hcl ophthalmic G

polycin G

polymyxin b-trimethoprim G

POLYTRIM NPB

PRED-G NPB

PRED-G S.O.P. NPB

PREDNISOLONE ACET-MOXIFLOXACIN NPB

proparacaine hcl ophthalmic G

RESTASIS PB M; QL

RESTASIS MULTIDOSE PB M; QL

sulfacetamide-prednisolone ophthalmic solution G

TOBRADEX OPHTHALMIC OINTMENT PB

TOBRADEX OPHTHALMIC SUSPENSION NPB

TOBRADEX ST PB

tobramycin-dexamethasone G

TROPICAMIDE-PHENYLEPHRINE NPB

XIIDRA PB M

ZYLET PB

Otic Agents - Drugs for Ear Conditions

acetic acid otic G

CETRAXAL NPB ST

CIPRO HC NPB

CIPRODEX PB

ciprofloxacin hcl otic G

COLY-MYCIN S NPB

cortic-nd G

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Drug Name Drug Tier Restrictions / Limits

DERMOTIC NPB

exotic-hc G

flac G

fluocinolone acetonide otic G

hydrocortisone-acetic acid G

neomycin-polymyxin-hc otic G

ofloxacin otic G

OTICIN HC NR NPB

OTIPRIO NPB

OTOVEL PB

PRAMOTIC NPB

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold

ADRENALIN NASAL NPB

ASTEPRO NPB QL

azelastine hcl nasal G QL

azelastine-fluticasone G QL

BECONASE AQ NPB ST; QL

benzonatate G

bromfed dm G

BROMPHENIRAMINE MALEATE INTRAMUSCULAR

NPB

brompheniramine tannate G

carbinoxamine maleate G

CLARINEX NPB QL

CLARINEX-D 12 HOUR NPB QL

clemastine fumarate oral tablet 2.68 mg G

cyproheptadine hcl oral G

desloratadine PB QL

dexchlorpheniramine maleate oral G

DICOPANOL FUSEPAQ NPB

DICOPANOL RAPIDPAQ NPB

diphen oral elixir G

diphenhydramine hcl oral elixir G

DYMISTA NPB ST; QL

flunisolide nasal PB QL

fluticasone propionate nasal PB

GILPHEX TR NPB

GILTUSS TR NPB

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Drug Name Drug Tier Restrictions / Limits

guaiatussin ac G OTC

guaifenesin ac G OTC

hydrocodone polst-cpm polst er G

hydrocodone-homatropine G

hydromet G

HYPERSAL NPB

ipratropium bromide nasal G

KARBINAL ER NPB

mometasone furoate nasal PB QL

NASONEX NPB ST; QL

nebusal inhalation nebulization solution 3 % G

NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %

NPB

NEOTUSS PLUS PB

NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR

PB-S PA; QL

NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

PB-S PA; QL

NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED

NPB QL

olopatadine hcl nasal G QL

OMNARIS NPB ST; QL

PATANASE NPB QL

phenadoz G

promethazine hcl oral G

promethazine hcl rectal G

promethazine-codeine G

promethazine-dm G

promethazine-dm oral solution 6.25-15 mg/5ml G

promethazine-phenyleph-codeine G

promethazine-phenylephrine G

promethegan G

pseudoephedrine-bromphen-dm G

pulmosal G

QNASL PB ST; QL

QNASL CHILDRENS PB ST; QL

RYCLORA NPB

ryvent NPB

SEMPREX-D NPB

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Drug Name Drug Tier Restrictions / Limits

sodium chloride inhalation G

SSKI NPB

TESSALON PERLES NPB

TUSSICAPS NPB

TUXARIN ER NPB

TUZISTRA XR NPB

virtussin ac w/alc G OTC

XHANCE NPB ST; QL

ZETONNA NPB ST; QL

Z-TUSS AC NPB OTC

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ACCOLATE NPB ST; M; QL

acetylcysteine inhalation G

ADVAIR DISKUS NPB M; QL

ADVAIR HFA PB M; QL

AIRDUO RESPICLICK 113/14 PB M; QL

AIRDUO RESPICLICK 232/14 PB M; QL

AIRDUO RESPICLICK 55/14 PB M; QL

albuterol sulfate er G M

albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation

G M; QL

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION

NPB M; QL

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION

PB M; QL

albuterol sulfate inhalation G M; QL

albuterol sulfate oral G M

ALVESCO NPB ST; M; QL

ANORO ELLIPTA PB M; QL

ARCAPTA NEOHALER PB M; QL

ARNUITY ELLIPTA PB M; QL

ASMANEX (120 METERED DOSES) PB M

ASMANEX (14 METERED DOSES) PB M

ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH

PB M; QL

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Drug Name Drug Tier Restrictions / Limits

ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH

PB M

ASMANEX (60 METERED DOSES) PB M

ASMANEX (7 METERED DOSES) PB M; QL

ASMANEX HFA PB M; QL

ATROVENT HFA PB M; QL

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 MG/0.1ML

NPB ST; QL

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.15ML, 0.3 MG/0.3ML

NPB ST

BEVESPI AEROSPHERE PB M; QL

BREO ELLIPTA PB M; QL

BROVANA NPB ST; M; QL

budesonide inhalation suspension 0.25 mg/2ml, 1 mg/2ml

G M

budesonide inhalation suspension 0.5 mg/2ml G M; QL

BUDESONIDE-FORMOTEROL FUMARATE NPB M; QL

COMBIVENT RESPIMAT PB QL

cromolyn sodium inhalation G M

DALIRESP ORAL TABLET 250 MCG PB PA

DALIRESP ORAL TABLET 500 MCG PB PA; QL

difil-g forte G

DUAKLIR PRESSAIR NPB QL

DULERA INHALATION AEROSOL 100-5 MCG/ACT, 50-5 MCG/ACT

PB M; QL

DULERA INHALATION AEROSOL 200-5 MCG/ACT

PB M

ELIXOPHYLLIN NPB M

epinephrine injection solution auto-injector 0.15 mg/0.15ml

NPB

epinephrine injection solution auto-injector 0.15 mg/0.3ml

PB QL

epinephrine solution auto-injector 0.3 mg/0.3ml injection

NPB

epinephrine solution auto-injector 0.3 mg/0.3ml injection

G

EPIPEN 2-PAK NPB

EPIPEN JR 2-PAK PB QL

ESBRIET PB-S PA

FLOVENT DISKUS PB M; QL

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Drug Name Drug Tier Restrictions / Limits

FLOVENT HFA PB M; QL

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

G M; QL

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT

PB M; QL

INCRUSE ELLIPTA PB M; QL

ipratropium bromide inhalation G M; QL

ipratropium-albuterol G QL

levalbuterol hcl inhalation G QL

LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT

NPB ST; QL

LONHALA MAGNAIR REFILL KIT NPB M; QL

LONHALA MAGNAIR STARTER KIT NPB M; QL

metaproterenol sulfate oral G M

montelukast sodium oral packet G M

montelukast sodium oral tablet G M; QL

montelukast sodium oral tablet chewable G M; QL

OFEV PB-S PA

PERFOROMIST PB M; QL

PROAIR DIGIHALER NPB M; QL

PROAIR HFA G M; QL

PROAIR RESPICLICK G M; QL

PROVENTIL HFA NPB ST; M; QL

PULMICORT FLEXHALER PB M; QL

PULMICORT SUSPENSION INHALATION SUSPENSION 0.25 MG/2ML, 1 MG/2ML

NPB ST; M

PULMICORT SUSPENSION INHALATION SUSPENSION 0.5 MG/2ML

NPB ST; M; QL

QVAR REDIHALER PB M; QL

SEEBRI NEOHALER NPB M; QL

SEREVENT DISKUS PB M; QL

SINGULAIR ORAL PACKET NPB ST; M

SINGULAIR ORAL TABLET NPB ST; M; QL

SINGULAIR ORAL TABLET CHEWABLE NPB ST; M; QL

SPIRIVA HANDIHALER PB ST; M; QL

SPIRIVA RESPIMAT PB M; QL

STIOLTO RESPIMAT PB M; QL

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Drug Name Drug Tier Restrictions / Limits

STRIVERDI RESPIMAT PB M; QL

SYMBICORT PB M; QL

SYMJEPI NPB

terbutaline sulfate oral G M

THEO-24 NPB M

theophylline G M

theophylline er G M

TRELEGY ELLIPTA PB M; QL

TUDORZA PRESSAIR PB QL

UTIBRON NEOHALER NPB M; QL

VENTOLIN HFA PB M; QL

wixela inhub G M; QL

XOPENEX NPB QL

XOPENEX CONCENTRATE NPB QL

XOPENEX HFA NPB ST; QL

YUPELRI PB M; QL

zafirlukast G M; QL

zileuton er G ST; M; QL

ZYFLO NPB ST; M

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis

BETHKIS PB-S QL

CAYSTON PB-S

KALYDECO PB-S PA

KITABIS PAK PB-S QL

ORKAMBI PB-S PA; QL

PULMOZYME PB

SYMDEKO PB-S PA; QL

TOBI NEBULIZER NPB QL

TOBI PODHALER PB QL

tobramycin nebulization solution 300 mg/5ml inhalation

G QL

TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION

PB-S QL

TRIKAFTA PB-S PA; QL

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension

ADCIRCA NPB-S PA; QL

ADEMPAS PB-S PA; QL

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Drug Name Drug Tier Restrictions / Limits

alyq G-S PA; QL

ambrisentan G-S PA; QL

bosentan G-S PA; QL

LETAIRIS PB-S PA; QL

OPSUMIT PB-S PA; QL

ORENITRAM NPB-S PA

REVATIO ORAL NPB-S PA; QL

sildenafil citrate oral suspension reconstituted G PA; QL

sildenafil citrate oral tablet 20 mg G-S PA; QL

tadalafil (pah) G-S PA; QL

TRACLEER PB-S PA; QL

UPTRAVI PB-S PA; QL

VENTAVIS NPB-S PA; QL

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

ACTIVE-CYCLOBENZAPRINE NPB

AMRIX NPB ST

baclofen external G

baclofen oral tablet 10 mg, 20 mg G

baclofen oral tablet 5 mg NPB

carisoprodol oral G

carisoprodol-aspirin G

chlorzoxazone oral tablet 250 mg G ST

chlorzoxazone oral tablet 375 mg, 500 mg, 750 mg

G

cyclobenzaprine hcl er G

cyclobenzaprine hcl oral G

CYCLOPHENE RAPIDPAQ NPB

DANTRIUM ORAL NPB ST

dantrolene sodium oral G

ENOVARX-BACLOFEN NPB

enovarx-cyclobenzaprine hcl cream 20 mg/gm transdermal

G

ENOVARX-CYCLOBENZAPRINE HCL CREAM 20 MG/GM TRANSDERMAL

NPB

FEXMID NPB ST

FIRST-BACLOFEN NPB

LORZONE NPB ST

METAXALL CP NPB

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Drug Name Drug Tier Restrictions / Limits

metaxalone G

methocarbamol oral G

NORGESIC FORTE NPB ST

orphenadrine citrate er G

orphenadrine-aspirin-caffeine G ST

ORPHENGESIC FORTE G ST

OZOBAX NPB

ROBAXIN-750 NPB ST

SKELAXIN NPB ST

SOMA NPB ST

TABRADOL FUSEPAQ NPB

TABRADOL RAPIDPAQ NPB

tizanidine hcl oral G

ZANAFLEX NPB ST

Sleep Disorder Agents

AMBIEN NPB ST; QL

AMBIEN CR NPB ST; QL

armodafinil G PA; QL

BELSOMRA NPB ST; QL

doxepin hcl oral tablet G QL

EDLUAR NPB ST; QL

eszopiclone G QL

flurazepam hcl G QL

HETLIOZ NPB-S ST; QL

INTERMEZZO NPB ST; QL

LUNESTA NPB ST; QL

modafinil G PA; QL

NUVIGIL NPB PA; QL

PROVIGIL NPB PA; QL

ramelteon G QL

RESTORIL ORAL CAPSULE 15 MG, 30 MG, 7.5 MG

NPB QL

RESTORIL ORAL CAPSULE 22.5 MG NPB

ROZEREM NPB ST; QL

SECONAL G

SILENOR NPB ST; QL

SUNOSI PB PA; QL

temazepam oral capsule 15 mg, 30 mg, 7.5 mg G QL

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Drug Name Drug Tier Restrictions / Limits

temazepam oral capsule 22.5 mg G

WAKIX NPB-S PA; QL

XYREM PB-S PA; QL

zaleplon G QL

zolpidem tartrate G QL

zolpidem tartrate er G QL

ZOLPIMIST NPB ST; QL

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Index of Drugs

A.A.G.C. KIT IN TERODERM... 57abacavir sulfate.........................39abacavir sulfate-lamivudine...... 39abacavir-lamivudine-zidovudine.................................39ABILIFY.....................................38ABILIFY MAINTENA................. 38ABILIFY MYCITE...................... 38abiraterone acetate................... 31ABSORICA............................... 57ABSORICA LD..........................57ABSTRAL..................................10acamprosate calcium................ 16ACANYA................................... 57acarbose................................... 65ACCOLATE.............................109ACCU-CHEK AVIVA CONNECT KIT W/DEVICE.......67ACCU-CHEK AVIVA PLUS KIT W/DEVICE..........................67ACCU-CHEK COMPACT PLUS TEST STRIPS................ 67ACCU-CHEK GUIDE KIT W/DEVICE................................ 67ACCU-CHEK GUIDE ME..........67ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE...67ACCU-CHEK SMARTVIEW TEST STRIPS...........................67ACCUPRIL................................44ACCURETIC............................. 44acebutolol hcl............................ 44acetaminophen-codeine............10acetaminophen-codeine #2.......10acetaminophen-codeine #3.......10acetaminophen-codeine #4.......10acetazolamide.........................104acetazolamide er.....................104acetic acid............................... 106acetylcysteine......................... 109ACIPHEX.................................. 76ACIPHEX SPRINKLE............... 76acitretin..................................... 57ACTEMRA................................ 95ACTEMRA ACTPEN.................95ACTHIB.....................................97ACTICLATE.............................. 17ACTIGALL.................................77ACTIQ....................................... 10ACTIVE INJECTION BLM-1..... 82ACTIVE INJECTION BM...........82ACTIVE INJECTION DL........... 83

ACTIVE INJECTION DLM........ 83ACTIVE INJECTION KET-L......13ACTIVE INJECTION KETMARC-L............................. 13ACTIVE INJECTION KIT L....... 83ACTIVE INJECTION KM...........83ACTIVE INJECTION LM-2........16ACTIVE INJECTION LM-DEP-2................................................ 83ACTIVE INJECTION M-1..........83ACTIVE-CYCLOBENZAPRINE................................................ 113ACTIVE-KETOPROFEN........... 13ACTIVELLA...............................87ACTIVE-PREP KIT I................. 13ACTIVE-PREP KIT II ................ 13ACTIVE-PREP KIT III ............... 13ACTIVE-PREP KIT IV............... 57ACTIVE-PREP KIT V................ 27ACTIVE-TRAMADOL................57ACTONEL............................... 100ACTOPLUS MET...................... 65ACTOS......................................65ACULAR................................. 102ACULAR LS............................ 102ACUVAIL.................................102acyclovir.................................... 39ACZONE................................... 57ADACEL....................................97ADALAT CC..............................44adapalene................................. 57ADAPALENE............................ 57adapalene-benzoyl peroxide.....57ADASUVE.................................38adc/f (0.5mg/ml)........................ 71ADCIRCA................................112ADDERALL............................... 52ADDERALL XR......................... 52ADDYI....................................... 55adefovir dipivoxil ....................... 39ADEMPAS.............................. 112ADHANSIA XR..........................52ADIPEX-P................................. 55ADLYXIN...................................65ADLYXIN STARTER PACK...... 65ADMELOG................................ 69ADMELOG SOLOSTAR........... 69ADRENALIN........................... 107ADVAIR DISKUS.................... 109ADVAIR HFA.......................... 109ADZENYS ER........................... 52ADZENYS XR-ODT.................. 52

AFINITOR................................. 31AFINITOR DISPERZ.................31afirmelle.................................... 87AFLURIA QUADRIVALENT......97AFREZZA..................................70AGAMATRIX PRESTO TEST...67AGGRENOX............................. 37AGRYLIN.................................. 43AIF #2 DRUG PREPARATION KIT............................................ 13AIF #3 DRUG PREPARATION KIT............................................ 13AIMOVIG...................................29AIRDUO RESPICLICK 113/14109AIRDUO RESPICLICK 232/14109AIRDUO RESPICLICK 55/14..109AJOVY...................................... 29ak-poly-bac............................. 105AKTEN.................................... 105AKYNZEO.................................26ALA SCALP.............................. 57ala-cort...................................... 57albendazole...............................35ALBENZA..................................35albuterol sulfate.......................109albuterol sulfate er.................. 109albuterol sulfate hfa.................109ALBUTEROL SULFATE HFA. 109ALCAINE.................................105alclometasone dipropionate...... 57ALDACTAZIDE......................... 44ALDACTONE............................ 44ALDARA....................................57ALECENSA...............................31alendronate sodium................ 100alfuzosin hcl er.......................... 82ALINIA.......................................35aliskiren fumarate......................44ALKERAN................................. 31allopurinol..................................29ALLZITAL..................................10almotriptan malate.................... 29ALOCRIL.................................102ALOGLIPTIN BENZOATE........ 65ALOGLIPTIN-METFORMIN HCL...........................................65ALOGLIPTIN-PIOGLITAZONE. 65ALOMIDE................................102ALORA......................................87alosetron hcl..............................77ALPHAGAN P......................... 104ALPHA-LIPOIC ACID..............101

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alprazolam................................ 42alprazolam er............................ 42alprazolam intensol................... 42alprazolam xr............................ 42ALREX.................................... 102ALTABAX..................................17ALTACE.................................... 44altafrin..................................... 105altavera..................................... 87ALTOPREV...............................44ALTRENO................................. 57ALUNBRIG................................31ALVESCO............................... 109alyacen 1/35..............................87alyacen 7/7/7.............................87alyq......................................... 113amabelz.................................... 87amantadine hcl..........................36AMARYL................................... 65AMBIEN.................................. 114AMBIEN CR............................ 114ambrisentan............................ 113amcinonide................................57AMERGE.................................. 29amethia..................................... 87amethia lo................................. 87amethyst................................... 87AMICAR.................................... 43amiloride hcl..............................44amiloride-hydrochlorothiazide... 44aminobenzoate potassium........ 71aminocaproic acid..................... 43AMINOPMRMS.......................101amiodarone hcl......................... 44AMITIZA....................................77amitriptyline hcl......................... 24AMLODIPINE BES+SYRSPEND SF............... 44amlodipine besylate.................. 44amlodipine besylate-benazepril hcl............................................. 44amlodipine besylate-valsartan.. 44amlodipine-atorvastatin.............44amlodipine-olmesartan..............44amlodipine-valsartan-hctz......... 44ammonium lactate.....................57amnesteem............................... 57amoxapine................................ 24amoxicill-clarithro-lansopraz..... 77amoxicillin................................. 17amoxicillin-potassium clavulanate................................17

amoxicillin-potassium clavulanate er............................17amphetamine sulfate.................52amphetamine-dextroamphetamine.................. 52amphetamine-dextroamphetamine er.............. 52ampicillin................................... 17AMPYRA...................................54AMRIX.....................................113ANAFRANIL..............................24anagrelide hcl............................43ANALPRAM HC........................ 99ANALPRAM HC SINGLES....... 99ANALPRAM-HC........................99ANASPAZ................................. 77anastrozole............................... 31ANCOBON................................27ANDRODERM.......................... 84ANDROGEL........................84, 85ANDROGEL PUMP.................. 84ANGELIQ.................................. 87ANNOVERA..............................87ANORO ELLIPTA................... 109ANTABUSE...............................17ANTARA................................... 44anucort-hc................................. 99ANUSOL-HC.............................99anusol-hc.................................. 99ANZEMET.................................26APADAZ....................................10apap-caff-dihydrocodeine......... 10APEXICON E............................ 57APIDRA SOLOSTAR................ 70APIDRA VIAL............................70APLENZIN................................ 24APOKYN................................... 36APP SLIM RMS...................... 101apraclonidine hcl..................... 104aprepitant.................................. 26apri............................................ 87APRISO.................................... 99APTENSIO XR..........................53APTIOM.................................... 21APTIVUS...................................39ARAKODA................................ 35aranelle..................................... 87ARAVA......................................95ARCALYST............................... 95ARCAPTA NEOHALER.......... 109ARGININE HCL........................ 71ARICEPT.................................. 23ARIKAYCE................................17

ARIMIDEX.................................31aripiprazole............................... 38ARISTADA................................ 38ARISTADA INITIO.................... 38ARIXTRA.................................. 21armodafinil .............................. 114ARMOUR THYROID.................94ARNUITY ELLIPTA.................109AROMASIN...............................31ARTHROTEC............................13ARYMO ER...............................10arzol silver nit applicators..........57ASACOL HD............................. 99ascomp-codeine........................10ASCORBIC ACID......................71ashlyna......................................87asilnasalrms............................ 101ASMANEX (120 METERED DOSES).................................. 109ASMANEX (14 METERED DOSES).................................. 109ASMANEX (30 METERED DOSES).......................... 109, 110ASMANEX (60 METERED DOSES).................................. 110ASMANEX (7 METERED DOSES).................................. 110ASMANEX HFA...................... 110aspirin-dipyridamole er..............37ASPIRIN-OMEPRAZOLE......... 37ASSURE PLATINUM................ 67ASTAGRAF XL......................... 95ASTEPRO...............................107ATABEX OB..............................71ATACAND.................................44ATACAND HCT........................ 44atazanavir sulfate......................39ATELVIA................................. 100atenolol..................................... 44ATENOLOL+SYRSPEND SF... 44atenolol-chlorthalidone..............44ATIVAN..................................... 43atomoxetine hcl.........................53atorvastatin calcium.................. 44atovaquone............................... 35atovaquone-proguanil hcl..........35ATRALIN...................................57ATRIPLA................................... 39ATROPEN.................................77atropine sulfate....................... 105ATROVENT HFA.................... 110AUBAGIO..................................54aubra.........................................87

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aubra eq....................................87AUGMENTIN............................ 17AUGMENTIN ES-600............... 17aurovela 1.5/30......................... 87aurovela 1/20............................ 87aurovela 24 fe........................... 87aurovela fe 1.5/30..................... 87aurovela fe 1/20........................ 87AURYXIA.................................. 80AUSTEDO.................................55AUVI-Q....................................110AVALIDE...................................45AVANDIA.................................. 65AVAPRO................................... 45AVAR LS CLEANSER.............. 57AVAR-E EMOLLIENT............... 57AVAR-E GREEN.......................57AVAR-E LS............................... 57aviane....................................... 87avidoxy......................................17avita.......................................... 57AVODART.................................82AVONEX PEN...........................54AVONEX PREFILLED.............. 54AYGESTIN................................88ayuna........................................ 88AYVAKIT...................................31AZASAN....................................95AZASITE................................. 102azathioprine.............................. 95azelaic acid............................... 57azelastine hcl.................. 102, 107azelastine-fluticasone............. 107AZELEX.................................... 57AZILECT................................... 36azithromycin..............................17AZOPT.................................... 104AZOR........................................ 45AZULFIDINE............................. 99AZULFIDINE EN-TABS............ 99azurette..................................... 88bacitracin.................................102bacitracin-polymyxin b............ 105bacitra-neomycin-polymyxin-hc................................................ 105baclofen.................................. 113BACTERIOSTATIC WATER(BENZ ALC)............... 101BACTRIM..................................18BACTRIM DS............................18BALCOLTRA.............................88balsalazide disodium.................99BALVERSA............................... 31

balziva.......................................88BANZEL.................................... 21BAQSIMI ONE PACK............... 69BAQSIMI TWO PACK...............69BARACLUDE............................ 39BASAGLAR KWIKPEN............. 70BAXDELA................................. 18BCAA........................................ 71BECONASE AQ......................107bekyree..................................... 88BELBUCA................................. 10belladonna alkaloids-opium...... 77BELSOMRA............................ 114benazepril hcl............................45benazepril-hydrochlorothiazide. 45BENICAR.................................. 45BENICAR HCT..........................45BENLYSTA............................... 95BENZAC AC WASH..................57BENZACLIN..............................57BENZACLIN WITH PUMP........ 58BENZAMYCIN.......................... 58benzepro................................... 58benzepro foaming cloths...........58BENZEPRO SHORT CONTACT.................................58BENZHYDROCODONE-ACETAMINOPHEN...................10BENZIQ.....................................58BENZIQ LS............................... 58BENZIQ WASH.........................58BENZNIDAZOLE...................... 35benzonatate............................ 107BENZOYL PEROX-HYDROCORTISONE................58benzoyl peroxide.......................58BENZOYL PEROXIDE..............58BENZOYL PEROXIDE FORTE- HC.............................. 58benzoyl peroxide-erythromycin. 58benzphetamine hcl....................55benztropine mesylate................36BEPREVE............................... 102beser......................................... 58BESIVANCE........................... 102BETADINE OPHTHALMIC PREP...................................... 102BETALIDO................................ 83betamethasone dipropionate.... 58betamethasone dipropionate aug............................................ 58betamethasone valerate........... 58BETAPACE...............................45

BETAPACE AF......................... 45BETASERON............................54betaxolol hcl...................... 45, 104bethanechol chloride.................80BETHKIS.................................112BETIMOL................................ 104BETOPTIC-S.......................... 104BEVESPI AEROSPHERE.......110BEVYXXA................................. 21bexarotene................................ 31BEXSERO.................................97BEYAZ...................................... 88bicalutamide..............................31BIDIL......................................... 45BI-EST 80:20 PROGESTERONE....................88BIEST/PROGESTERONE........ 88BIJUVA..................................... 88BIKTARVY................................ 40BILTRICIDE.............................. 35bimatoprost............................. 104BINOSTO................................100BIO-STATIN..............................27bio-statin................................... 27BIOTEL CARE BLOOD GLUCOSE SYST...................... 67bisoprolol fumarate................... 45bisoprolol-hydrochlorothiazide.. 45BLEPH-10............................... 102BLEPHAMIDE.........................105BLEPHAMIDE S.O.P.............. 105blisovi 24 fe............................... 88blisovi fe 1.5/30......................... 88blisovi fe 1/20............................ 88BLOOD GLUCOSE TEST.........67BONIVA.................................. 100BONJESTA............................... 26BOOSTRIX............................... 97bosentan................................. 113BOSULIF...................................31bp cleansing wash.................... 58bp wash.....................................58BRAFTOVI................................ 32BREO ELLIPTA...................... 110briellyn.......................................88BRILINTA..................................37brimonidine tartrate................. 104BRISDELLE.............................. 24BRIVIACT................................. 21bromfed dm.............................107bromfenac sodium (once-daily)................................................ 102bromocriptine mesylate.............36

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BROMPHENIRAMINE MALEATE............................... 107brompheniramine tannate....... 107BROMSITE............................. 102BROVANA.............................. 110BRYHALI...................................58budesonide....................... 99, 110budesonide er........................... 99BUDESONIDE-FORMOTEROL FUMARATE..110bumetanide............................... 45BUMEX..................................... 45BUNAVAIL................................ 17BUPAP......................................10BUPHENYL...............................80BUPIVACAINE HCL..................16BUPIVILOG...............................83buprenorphine...........................10BUPRENORPHINE...................10buprenorphine hcl..................... 17buprenorphine hcl-naloxone hcl............................................. 17bupropion hcl............................ 24bupropion hcl er (smoking det). 17bupropion hcl er (sr)..................24bupropion hcl er (xl).................. 24BUPROPION HCL ER (XL)...... 24buspirone hcl.............................43butalbital-acetaminophen..........10BUTALBITAL-ACETAMINOPHEN...................10butalbital-apap-caff-cod............ 10butalbital-apap-caffeine.............10butalbital-asa-caff-codeine........10butalbital-aspirin-caffeine.......... 10butorphanol tartrate...................10BUTRANS.................................10BYDUREON..............................65BYDUREON BCISE AUTOINJECTOR...................... 65BYETTA 10 MCG PEN............. 65BYETTA 5 MCG PEN............... 65BYSTOLIC................................ 45cabergoline............................... 85CABLIVI.................................... 38CABOMETYX........................... 32CADUET................................... 45CAFERGOT.............................. 29caffeine citrate...........................55CALAN SR................................ 45CALCIFOL................................ 71calcipotriene..............................58CALCIPOTRIENE..................... 58

calcipotriene-betameth diprop...58calcitonin (salmon).................. 100CALCITRENE........................... 58calcitriol ............................. 58, 100calcium acetate......................... 80calcium acetate (phos binder)...80calcium-folic acid plus d............ 71CALQUENCE............................32CAMBIA.................................... 13camila........................................88camrese.................................... 88camrese lo................................ 88CANASA................................... 99candesartan cilexetil ................. 45candesartan cilexetil-hctz..........45CANTHARIDIN......................... 58capecitabine..............................32CAPEX......................................58CAPRELSA...............................32captopril .................................... 45captopril-hydrochlorothiazide.... 45CARAC..................................... 58CARAFATE...............................76CARBAGLU.............................. 71carbamazepine......................... 21carbamazepine er..................... 21CARBATROL............................ 21carbidopa.................................. 36carbidopa-levodopa.................. 36carbidopa-levodopa er.............. 36carbidopa-levodopa-entacapone............................... 37carbinoxamine maleate...........107CARDIZEM............................... 45CARDIZEM CD......................... 45CARDIZEM LA..........................45CARDURA................................ 45CARDURA XL...........................82carisoprodol............................ 113carisoprodol-aspirin.................113carisoprodol-aspirin-codeine.....10CARNITOR............................... 71CARNITOR SF..........................71CAROSPIR............................... 45carteolol hcl.............................104cartia xt..................................... 45carvedilol...................................45carvedilol phosphate er.............45cascara sagrada....................... 77CASODEX................................ 32CATAPRES...............................45CATAPRES-TTS-1................... 45CATAPRES-TTS-2................... 45

CATAPRES-TTS-3................... 45cavarest.................................... 55CAYSTON...............................112caziant.......................................88cefaclor..................................... 18cefaclor er................................. 18cefadroxil ...................................18cefdinir...................................... 18cefditoren pivoxil ....................... 18cefixime.....................................18cefpodoxime proxetil ................. 18cefprozil .....................................18cefuroxime axetil ....................... 18CELEBREX...............................13celecoxib................................... 13CELEXA....................................24CELLCEPT............................... 95CELONTIN................................21CENTANY.................................18cephalexin.................................18CERDELGA.............................. 80CETACAINE............................. 16CETRAXAL............................. 106CETROTIDE............................. 85cevimeline hcl........................... 55CHANTIX.................................. 17CHANTIX CONTINUING MONTH PAK.............................17CHANTIX STARTING MONTH PAK...........................................17chateal...................................... 88chateal eq................................. 88CHEMET...................................71CHENODAL.............................. 77chlordiazepoxide hcl................. 43chlordiazepoxide-amitriptyline...24chlordiazepoxide-clidinium........77chlorhexidine gluconate............ 56chloroquine phosphate..............35chlorothiazide............................45chlorpromazine hcl....................38chlorthalidone............................45chlorzoxazone.........................113CHOLBAM................................ 80CHOLECAL DF.........................71cholestyramine..........................45cholestyramine light.................. 45choline-mag trisalicylate............13chorionic gonadotropin..............85ciclodan.....................................27ciclopirox................................... 27ciclopirox olamine..................... 27cilostazol................................... 38

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CILOXAN................................ 102CIMDUO................................... 40cimetidine..................................76cimetidine hcl............................ 76CIMZIA......................................95CIMZIA PREFILLED KIT...........95CIMZIA STARTER KIT............. 95cinacalcet hcl.......................... 100CIPRO.......................................18CIPRO HC.............................. 106CIPRODEX............................. 106ciprofloxacin hcl........ 18, 102, 106citalopram hydrobromide.......... 24CITRANATAL BLOOM..............71CITRANATAL MEDLEY............71claravis......................................58CLARINEX.............................. 107CLARINEX-D 12 HOUR..........107clarithromycin............................18clarithromycin er........................18clemastine fumarate................107CLENPIQ.................................. 77CLEOCIN.................................. 18CLEOCIN-T...............................58CLIMARA.................................. 88CLIMARA PRO......................... 88clindacin etz.............................. 58clindacin-p.................................58CLINDAGEL..............................58clindamycin hcl..........................18clindamycin palmitate hcl.......... 18clindamycin phosphate. 18, 58, 59CLINDAMYCIN PHOSPHATE.. 59clindamycin phosphate-benzoyl peroxide.......................58clindamycin-tretinoin................. 59CLINDESSE..............................18CLINOIN................................... 59clinpro 5000.............................. 56clobazam...................................21clobetasol prop emollient base. 59clobetasol propionate................59clobetasol propionate e.............59clobetasol propionate emulsion 59CLOBEX................................... 59CLOBEX SPRAY...................... 59clocortolone pivalate................. 59clodan....................................... 59CLODERM................................ 59clomiphene citrate.....................85clomipramine hcl....................... 24clonazepam...............................43clonidine....................................46

clonidine hcl.............................. 46clonidine hcl er.......................... 53clopidogrel bisulfate.................. 38clorazepate dipotassium........... 43clotrimazole...............................27clotrimazole-betamethasone.....27clovique.....................................71clozapine...................................38CLOZARIL................................ 38coal tar...................................... 59COARTEM................................ 35codeine sulfate..........................10COENZYME Q-10...................101COLAZAL..................................99COLCHICINE............................29colchicine-probenecid............... 29COLCRYS.................................29colesevelam hcl........................ 46COLESTID................................ 46COLESTID FLAVORED............46colestipol hcl............................. 46colistimethate sodium (cba)...... 18colocort..................................... 99COLY-MYCIN M....................... 18COLY-MYCIN S...................... 106COMBIGAN............................ 104COMBIPATCH.......................... 88COMBIVENT RESPIMAT....... 110COMBIVIR................................ 40COMETRIQ (100 MG DAILY DOSE).......................................32COMETRIQ (140 MG DAILY DOSE).......................................32COMETRIQ (60 MG DAILY DOSE).......................................32COMPLERA..............................40compro...................................... 26COMTAN.................................. 37CONCERTA..............................53CONDYLOX..............................59constulose.................................77CONTOUR NEXT MONITOR... 67CONTOUR NEXT TEST........... 68CONTOUR TEST......................68CONTRAST ALLERGY PREMED PACK........................83CONTRAVE.............................. 55CONZIP.................................... 10COPAXONE..............................54COPIKTRA................................32CORDRAN................................59COREG.....................................46COREG CR...............................46

coremino................................... 18CORGARD................................46CORLANOR..............................46CORTANE-B.............................59CORTEF................................... 83CORTENEMA........................... 99cortic-nd.................................. 106CORTIFOAM............................ 99cortisone acetate.......................83CORTISPORIN......................... 59COSENTYX (300 MG DOSE)...95COSENTYX 150 MG/ML.......... 95COSENTYX SENSOREADY (300 MG)...................................95COSENTYX SENSOREADY PEN...........................................95COSOPT.................................104COSOPT PF........................... 104COTELLIC................................ 32COTEMPLA XR-ODT............... 53COUMADIN.............................. 21covaryx......................................88covaryx hs.................................88COZAAR................................... 46CREON..................................... 80CRESEMBA..............................27CRESTOR................................ 46CRINONE................................. 88CRIXIVAN................................. 40cromolyn sodium.......77, 102, 110crotan........................................ 35cryselle-28.................................88c-topical.....................................16CUPRIMINE..............................80CUTAQUIG............................... 96CUTIVATE................................ 59CUVPOSA................................ 77cyanocobalamin........................ 71CYANOCOBALAMIN................ 71cyclafem 1/35............................88cyclafem 7/7/7...........................88cyclobenzaprine hcl................ 113cyclobenzaprine hcl er............ 113CYCLOGYL............................ 105CYCLOMYDRIL...................... 105cyclopentolate hcl................... 105CYCLOPHENE RAPIDPAQ....113cyclophosphamide.................... 32cycloserine................................ 31CYCLOSET...............................65cyclosporine.............................. 96cyclosporine modified............... 96CYMBALTA...............................24

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cyproheptadine hcl..................107cyred......................................... 88cyred eq.................................... 88CYSTAGON..............................80CYSTARAN............................ 105CYTOMEL.................................94CYTOTEC.................................76cytra k crystals.......................... 72D.H.E. 45.................................. 29dalfampridine er........................ 54DALIRESP.............................. 110danazol..................................... 85DANDELION........................... 101DANTRIUM............................. 113dantrolene sodium.................. 113dapsone.............................. 31, 59DAPTACEL............................... 97DARAPRIM............................... 36darifenacin hydrobromide er..... 80dasetta 1/35.............................. 88dasetta 7/7/7............................. 88DAURISMO...............................32DAYPRO...................................14daysee...................................... 88DAYTRANA.............................. 53DDAVP......................................85DDAVP RHINAL TUBE.............85DEBACTEROL..........................56deblitane................................... 88DECADRON............................. 83deferasirox................................ 72DELESTROGEN.......................88DELSTRIGO............................. 40delyla.........................................88DELZICOL................................ 99demeclocycline hcl....................18DEMSER...................................46DENAVIR.................................. 40denta 5000 plus........................ 56dentagel.................................... 56DEPAKOTE.............................. 21DEPAKOTE ER........................ 21DEPAKOTE SPRINKLES......... 21DEPEN TITRATABS.................80DEPO-ESTRADIOL.................. 88DEPO-MEDROL....................... 83DEPO-PROVERA..................... 89DEPO-SUBQ PROVERA 104...89DEPO-TESTOSTERONE......... 85DEPRIZINE FUSEPAQ.............76DERMA-SMOOTHE/FS BODY.59DERMA-SMOOTHE/FS SCALP...................................... 59

DERMOTIC.............................107DESCOVY................................ 40desipramine hcl.........................24desloratadine.......................... 107desmopressin ace spray refrig..85desmopressin acetate...............85desmopressin acetate spray..... 85desogestrel-ethinyl estradiol..... 89DESONATE.............................. 59desonide................................... 59DESOWEN............................... 59desoximetasone........................59DESOXYN................................ 53DESVENLAFAXINE ER............24desvenlafaxine succinate er......24DETROL................................... 80DETROL LA.............................. 80dexamethasone........................ 83dexamethasone intensol........... 83dexamethasone sodium phosphate............................... 102dexchlorpheniramine maleate.107DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC)..............................68DEXEDRINE............................. 53DEXILANT................................ 76DEXLIDO.................................. 83DEXLIDO-M.............................. 83dexmethylphenidate hcl............ 53dexmethylphenidate hcl er........ 53DEXOPIN..................................83DEXPAK 10 DAY...................... 83DEXPAK 13 DAY...................... 83DEXPAK 6 DAY........................ 83DEXPANTHENOL.....................72dextroamphetamine sulfate.......53dextroamphetamine sulfate er.. 53DIACOMIT................................ 21DIASTAT ACUDIAL.................. 21DIASTAT PEDIATRIC...............21DIATHRIVE BLOOD GLUCOSE TEST...................... 68DIATHRIVE GLUCOSE TEST.. 68diazepam............................ 21, 43diazepam intensol..................... 43DIBENZYLINE.......................... 46DICLEGIS................................. 26DICLOFENAC EPOLAMINE.....14diclofenac potassium................ 14diclofenac sodium....... 14, 59, 102

diclofenac sodium er................. 14diclofenac-misoprostol.............. 14dicloxacillin sodium................... 18DICOPANOL FUSEPAQ.........107DICOPANOL RAPIDPAQ....... 107dicyclomine hcl..........................77didanosine.................................40diethylpropion hcl...................... 55diethylpropion hcl er..................55DIFFERIN........................... 59, 60DIFICID..................................... 18difil-g forte............................... 110diflorasone diacetate.................60DIFLUCAN................................ 27diflunisal.................................... 14digitek........................................46digox......................................... 46digoxin.......................................46dihydroergotamine mesylate.....29DILANTIN..................................21DILANTIN INFATABS............... 21DILATRATE-SR........................ 46DILAUDID................................. 10diltiazem hcl.............................. 46diltiazem hcl er.......................... 46diltiazem hcl er beads............... 46diltiazem hcl er coated beads... 46dilt-xr......................................... 46dimenhydrinate......................... 26DIMERCAPTOPROPANE-SULFONATE.......................... 101DIOVAN.................................... 46DIOVAN HCT............................46DIPENTUM............................... 99diphen..................................... 107diphenhydramine hcl...............107diphenoxylate-atropine..............78DIPHTHERIA-TETANUS TOXOIDS DT............................ 98DIPROLENE............................. 60DIPROLENE AF........................60dipyridamole..............................38disopyramide phosphate...........46disulfiram...................................17DITROPAN XL.......................... 81DIURIL...................................... 46divalproex sodium..................... 22divalproex sodium er.................22DIVIGEL....................................89dofetilide....................................46DOLOPHINE.............................10donepezil hcl............................. 23DONNATAL.............................. 78

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DOPTELET............................... 43DORAL......................................43DORYX..................................... 18DORYX MPC............................ 18dorzolamide hcl.......................104DORZOLAMIDE HCL-TIMOLOL MAL........................104dorzolamide hcl-timolol mal.... 104dorzolamide hcl-timolol mal pf 104dotti ........................................... 89DOUBLE PM...........................105DOVATO...................................40DOVONEX................................ 60doxazosin mesylate.................. 46doxepin hcl..................24, 60, 114doxercalciferol.........................100doxycycline............................... 60doxycycline hyclate................... 18doxycycline monohydrate......... 18doxylamine-pyridoxine.............. 26DRISDOL.................................. 72DRITHO-CREME HP................ 60dronabinol................................. 26DROPLET MICRON................. 70drospiren-eth estrad-levomefol. 89drospirenone-ethinyl estradiol...89DROXIA.................................... 32DRYSOL................................... 60DSUVIA.....................................10DUAKLIR PRESSAIR............. 110DUAL COMPLEX FORMULA 1 KIT............................................ 14DUAVEE................................... 89DUETACT................................. 65DUEXIS.....................................14DULERA................................. 110duloxetine hcl............................ 24DUOBRII................................... 60DUPIXENT................................60DURAGESIC-100..................... 10DURAGESIC-12....................... 10DURAGESIC-25....................... 11DURAGESIC-50....................... 11DURAGESIC-75....................... 11duraxin...................................... 11DUREZOL...............................102DURLAZA................................. 38dutasteride................................ 82dutasteride-tamsulosin hcl........ 82DUTOPROL.............................. 46DVORAH...................................11DXEVO 11-DAY........................83DYANAVEL XR.........................53

DYAZIDE.................................. 46DYMISTA................................ 107DYRENIUM...............................46DYURAL-40.............................. 83DYURAL-80.............................. 83DYURAL-L................................ 83DYURAL-LM............................. 83E.E.S. 400.................................18E.E.S. GRANULES................... 18easygel......................................56EASYPLUS BLOOD GLUCOSE TEST...................... 68EC-NAPROSYN........................14ec-naproxen.............................. 14econazole nitrate.......................27ECOZA......................................27EDARBI.....................................46EDARBYCLOR......................... 46EDECRIN..................................46EDLUAR................................. 114EDURANT.................................40eemt.......................................... 89eemt hs..................................... 89efavirenz................................... 40EFFER-K...................................72effer-k........................................72EFFEXOR XR........................... 25EFFIENT................................... 38EFUDEX................................... 60EGATEN................................... 36EGRIFTA.................................. 85EGRIFTA SV.............................85ELESTRIN................................ 89eletriptan hydrobromide............ 29ELIDEL......................................60ELIGARD.................................. 85ELIMITE.................................... 36elinest........................................89ELIQUIS....................................21ELIQUIS DVT/PE STARTER PACK........................................ 21ELITE-OB..................................72ELIXOPHYLLIN...................... 110ELLA......................................... 89ELMIRON..................................81ELOCON...................................60eluryng...................................... 89EMBRACE TALK GLUCOSE TEST.........................................68EMBRACE TALK MONITORING SYSTEM...........68EMCYT..................................... 32EMEND..................................... 26

EMEND TRI-PACK................... 26EMFLAZA................................. 29EMGALITY................................29EMGALITY (300 MG DOSE).... 30emoquette................................. 89EMSAM.....................................25EMTRIVA.................................. 40EMVERM.................................. 36ENABLEX................................. 81enalapril maleate.......................46enalapril-hydrochlorothiazide.... 47ENBRACE HR.......................... 72ENBREL....................................96ENBREL MINI........................... 96ENBREL SURECLICK.............. 96ENDARI.................................. 101endocet..................................... 11ENDOMETRIN..........................89ENGERIX-B.............................. 98ENOVARX-BACLOFEN..........113enovarx-cyclobenzaprine hcl.. 113ENOVARX-CYCLOBENZAPRINE HCL.... 113ENOVARX-DICLOFENAC SODIUM....................................14ENOVARX-IBUPROFEN.......... 14ENOVARX-LIDOCAINE HCL....16ENOVARX-NAPROXEN........... 14ENOVARX-TRAMADOL........... 60enoxaparin sodium....................21enpresse-28.............................. 89enskyce.....................................89ENSTILAR................................ 60entacapone............................... 37entecavir................................... 40ENTEREG.................................78ENTOCORT EC........................99ENTRESTO.............................. 47enulose..................................... 78ENVARSUS XR........................ 96ENZOCLEAR............................ 60EPANED................................... 47EPCLUSA................................. 40EPIDIOLEX............................... 22EPIDUO.................................... 60EPIDUO FORTE....................... 60EPIFOAM..................................60epinastine hcl.......................... 102epinephrine............................. 110EPIPEN 2-PAK....................... 110EPIPEN JR 2-PAK.................. 110epitol......................................... 22EPIVIR...................................... 40

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EPIVIR HBV..............................40eplerenone................................ 47eprosartan mesylate................. 47EPZICOM..................................40EQUETRO................................ 22ERGOCAL................................ 72ergocalciferol.............................72ergoloid mesylates.................. 101ERGOMAR............................... 30ergotamine-caffeine.................. 30ERIVEDGE............................... 32ERLEADA................................. 32erlotinib hcl................................32errin...........................................89ERTACZO.................................27ery............................................. 60ERYGEL................................... 60ERYPED 200............................ 18ERYPED 400............................ 18ERY-TAB.................................. 18ERYTHROCIN STEARATE...... 19erythromycin............... 19, 60, 102erythromycin base.....................19erythromycin ethylsuccinate......19ESBRIET.................................110escitalopram oxalate................. 25ESGIC.......................................11esomeprazole magnesium........76est estrogens-methyltest...........89est estrogens-methyltest ds...... 89est estrogens-methyltest hs...... 89estarylla.....................................89estazolam..................................43ESTRACE................................. 89estradiol.................................... 89estradiol valerate.......................89estradiol-norethindrone acet..... 89ESTRING.................................. 89ESTROGEL.............................. 89ESTROSTEP FE.......................89eszopiclone............................. 114ethacrynic acid.......................... 47ethambutol hcl...........................31ethosuximide.............................22ethyl chloride.............................16ethynodiol diac-eth estradiol..... 89etodolac.................................... 14etodolac er................................ 14etonogestrel-ethinyl estradiol.... 90etoposide.................................. 32EUCRISA.................................. 60euthyrox.................................... 94EVAMIST.................................. 90

EVEKEO................................... 53EVEKEO ODT...........................53EVENCARE PROVIEW GLUCOSE TEST...................... 68everolimus...........................32, 96EVISTA..................................... 85EVOCLIN.................................. 60EVOTAZ....................................40EVOXAC................................... 56EVZIO....................................... 17EXELDERM.............................. 27EXELON................................... 23exemestane.............................. 32EXFORGE................................ 47EXFORGE HCT........................ 47EXJADE.................................... 72exoderm.................................... 27exotic-hc..................................107EXTAVIA...................................54EXTINA..................................... 27EZALLOR SPRINKLE...............47ezetimibe...................................47ezetimibe-simvastatin............... 47FABIOR.....................................60FALESSA..................................90falmina...................................... 90famciclovir................................. 40famotidine................................. 76FANAPT....................................38FANAPT TITRATION PACK..... 38FANATREX FUSEPAQ.............22FARESTON.............................. 32FARXIGA.................................. 65FARYDAK................................. 32fayosim......................................90FBL KIT.....................................14febuxostat................................. 29felbamate.................................. 22FELBATOL................................22FELDENE................................. 14felodipine er.............................. 47FEM PH.................................... 81FEMARA................................... 32FEMHRT LOW DOSE...............90FEMRING................................. 90femynor..................................... 90fenofibrate................................. 47fenofibrate micronized...............47fenofibric acid............................47FENOGLIDE............................. 47fenoprofen calcium....................14fenortho.....................................14fentanyl..................................... 11

fentanyl citrate...........................11FENTANYL CITRATE...............11FENTORA.................................11FERIVA 21/7............................. 72ferotrinsic.................................. 72FERRALET 90.......................... 72ferraplus 90............................... 72FERRIPROX............................. 72FERRO-PLEX HEMATINIC...... 72FERROTRIN............................. 72FETZIMA...................................25FETZIMA TITRATION...............25FEXMID.................................. 113FIASP........................................70FIASP FLEXTOUCH.................70FIASP PENFILL........................ 70FIBRICOR.................................47FINACEA.................................. 60finasteride................................. 82FIORICET................................. 11FIORICET/CODEINE................11FIORINAL................................. 11FIORINAL/CODEINE #3........... 11FIRAZYR...................................96FIRDAPSE.............................. 101FIRMAGON...............................85FIRST - METOPROLOL........... 47FIRST-ATENOLOL................... 47FIRST-BACLOFEN................. 113FIRST-METRONIDAZOLE....... 19flac.......................................... 107FLAGYL.................................... 19FLAREX.................................. 102flavoxate hcl.............................. 81flecainide acetate...................... 47FLECTOR................................. 14FLOLIPID.................................. 47FLOMAX................................... 82FLORIVA...................................72FLORIVA PLUS........................ 72FLOVENT DISKUS................. 110FLOVENT HFA....................... 111FLUAD...................................... 98FLUARIX QUADRIVALENT......98FLUBLOK QUADRIVALENT.....98FLUCELVAX QUADRIVALENT...................... 98fluconazole..........................27, 28flucytosine................................. 28fludrocortisone acetate..............83FLULAVAL QUADRIVALENT... 98flunisolide................................ 107fluocinolone acetonide...... 60, 107

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fluocinolone acetonide body..... 60fluocinolone acetonide scalp.....60fluocinonide.........................60, 61fluocinonide emulsified base.....60FLUORABON............................72fluoridex.................................... 56fluoridex daily renewal.............. 56fluoridex enhanced whitening... 56fluoridex sensitivity relief........... 56fluoritab..................................... 72fluorometholone...................... 103FLUOROPLEX..........................61FLUOROURACIL......................61fluorouracil ................................ 61fluoxetine hcl............................. 25fluoxetine hcl (pmdd).................25fluphenazine hcl........................ 38FLURA-DROPS........................ 72flurandrenolide.......................... 61flurazepam hcl.........................114flurbiprofen................................ 14flurbiprofen sodium................. 103flutamide................................... 32fluticasone propionate.......61, 107fluticasone-salmeterol............. 111FLUTICASONE-SALMETEROL........................111fluvastatin sodium..................... 47fluvastatin sodium er................. 47fluvoxamine maleate................. 25fluvoxamine maleate er.............25FLUZONE HIGH-DOSE............98FLUZONE QUADRIVALENT.... 98FML.........................................103FML FORTE............................103FML LIQUIFILM...................... 103FOCALIN.................................. 53FOCALIN XR............................ 53folic acid.................................... 72FOLI-D...................................... 72FOLITE..................................... 72FOLLISTIM AQ......................... 85foltrin......................................... 72FOLVITE-D............................... 72FOLVITE-FE............................. 72fondaparinux sodium.................21FORA GTEL BLOOD GLUCOSE TEST...................... 68FORFIVO XL.............................25FORTAMET.............................. 65FORTEO................................. 100FORTESTA...............................85FOSAMAX.............................. 100

FOSAMAX PLUS D................ 100fosamprenavir calcium.............. 40fosinopril sodium....................... 47fosinopril sodium-hctz............... 47FOSRENOL.............................. 81FRAGMIN................................. 21FREESTYLE FREEDOM LITE. 68FREESTYLE INSULINX SYSTEM................................... 68FREESTYLE INSULINX TEST. 68FREESTYLE LIBRE 14 DAY READER................................... 68FREESTYLE LIBRE 14 DAY SENSOR...................................68FREESTYLE LIBRE READER..68FREESTYLE LIBRE SENSOR SYSTEM................................... 68FREESTYLE LITE TEST.......... 68FREESTYLE PRECISION NEO TEST................................ 68FREESTYLE TEST...................68FROVA......................................30frovatriptan succinate................30furosemide................................ 47FUZEON................................... 40fyavolv.......................................90FYCOMPA................................ 22gabapentin................................ 22GABITRIL..................................22GALAFOLD...............................80galantamine hydrobromide....... 23galantamine hydrobromide er... 23GALZIN..................................... 72ganirelix acetate........................86GARDASIL 9.............................98GASTROCROM........................78gatifloxacin.............................. 103GATTEX....................................78gavilyte-c...................................78gavilyte-g...................................78gavilyte-n with flavor pack.........78GEBAUERS PAIN EASE.......... 16GEBAUERS SPRAY AND STRETCH................................. 16GELFILM.................................105GELNIQUE............................... 81gemfibrozil .................................47GENERESS FE........................ 90generlac.................................... 78gengraf......................................96GENICIN VITA-D...................... 72GENOTROPIN..........................86GENOTROPIN MINIQUICK......86

gentak..................................... 103gentamicin sulfate............. 19, 103GENVOYA................................ 40GEODON.................................. 38GIALAX..................................... 78gianvi.........................................90GILENYA.................................. 54GILOTRIF................................. 32GILPHEX TR...........................107GILTUSS TR...........................107glatiramer acetate..................... 54glatopa...................................... 54GLEEVEC................................. 32GLEOSTINE............................. 32glimepiride.................................65glipizide er.................................65glipizide ir.................................. 65glipizide xl................................. 66glipizide-metformin hcl.............. 66GLUCAGEN HYPOKIT............. 69GLUCAGON EMERGENCY KIT............................................ 69GLUCOCARD 01 SENSOR PLUS.........................................68GLUCOCARD EXPRESSION TEST.........................................68GLUCOCARD SHINE CONNEX...................................68GLUCOCARD SHINE EXPRESS................................. 68GLUCOCARD SHINE TEST.....68GLUCOCARD VITAL TEST......68GLUCOTROL............................66GLUCOTROL XL...................... 66GLUMETZA.............................. 66GLUTATHIONE........................ 72glyburide................................... 66glyburide micronized................. 66glyburide-metformin.................. 66GLYCATE................................. 78GLYCINE.................................. 72glycopyrrolate............................78GLYCOPYRROLATE................78glydo......................................... 16GLYNASE................................. 66GLYSET....................................66GLYXAMBI................................66GOCOVRI................................. 37GOJJI BLOOD GLUCOSE TEST.........................................68GOJJI BLOOD TEST STRIP/LANCETS......................68GOLYTELY............................... 78

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GONAL-F.................................. 86GONAL-F RFF.......................... 86GONAL-F RFF REDIJECT....... 86GONITRO................................. 47GORDOFILM............................ 61grafco silver nit applicator......... 61GRALISE.................................. 55GRALISE STARTER.................55granisetron hcl.......................... 26GRASTEK...............................101griseofulvin microsize................28griseofulvin ultramicrosize.........28guaiatussin ac......................... 108guaifenesin ac.........................108guanfacine hcl...........................47guanfacine hcl er.......................53GUANIDINE HCL......................30GVOKE PFS............................. 69GYNAZOLE-1........................... 28hailey 1.5/30..............................90hailey 24 fe................................90halcinonide................................61HALCION.................................. 43HALDOL DECANOATE............ 38halobetasol propionate..............61HALOBETASOL PROPIONATE.......................... 61HALOG..................................... 61haloperidol................................ 38haloperidol decanoate...............38haloperidol lactate.....................38HARMONY BLOOD GLUCOSE TEST...................... 68HARVONI..................................40HAVRIX.....................................98heather......................................90HEMANGEOL........................... 47HEMATRON-AF........................72hemmorex-hc............................ 99hemocyte-plus...........................73heparin sodium (porcine).......... 21heparin sodium (porcine) pf...... 21HEPLISAV-B.............................98HEPSERA.................................40HETLIOZ.................................114HIBERIX....................................98HIDEX 6-DAY........................... 83HIPREX.....................................19homatropaire...........................105homatropine hbr......................105HONEY BEE VENOM PROTEIN................................ 101HORIZANT................................55

HUMALOG................................70HUMALOG KWIKPEN.............. 70HUMALOG MIX 50/50 KWIKPEN................................. 70HUMALOG MIX 50/50 VIAL......70HUMALOG MIX 75/25 KWIKPEN................................. 70HUMALOG MIX 75/25 VIAL......70HUMALOG U-100 JUNIOR KWIKPEN................................. 70HUMATROPE........................... 86HUMIRA....................................96HUMIRA PEDIATRIC CROHNS START......................96HUMIRA PEN........................... 96HUMIRA PEN-CD/UC/HS STARTER................................. 96HUMIRA PEN-PS/UV/ADOL HS START................................ 96HUMULIN 70/30 KWIKPEN...... 70HUMULIN 70/30 VIAL...............70HUMULIN N KWIKPEN............ 70HUMULIN N VIAL..................... 70HUMULIN R U-500 KWIKPEN..70HUMULIN R U-500 VIAL (CONCENTRATED)..................70HUMULIN R VIAL..................... 70HW EMBRACE PRO GLUCOSE TEST...................... 68HW EMBRACE TALK GLUCOSE TEST...................... 68HYALUCIL-4............................. 61HYCAMTIN............................... 32hydralazine hcl.......................... 47HYDREA................................... 32HYDRO 40................................ 61hydrochlorothiazide...................47hydrocodone bitartrate er..........11hydrocodone polst-cpm polst er.............................................108hydrocodone-acetaminophen... 11hydrocodone-homatropine...... 108hydrocodone-ibuprofen............. 11hydrocortisone.............. 61, 83, 99hydrocortisone ace-pramoxine............................................ 61, 99hydrocortisone acetate..............99hydrocortisone butyr lipo base.. 61hydrocortisone butyrate............ 61hydrocortisone valerate.............61hydrocortisone-acetic acid...... 107hydromet................................. 108HYDROMORPHONE HCL........11

hydromorphone hcl................... 11hydromorphone hcl er............... 11hydroxocobalamin acetate........ 73hydroxychloroquine sulfate....... 36hydroxyurea.............................. 32hydroxyzine hcl......................... 43hydroxyzine pamoate................43hyophen.................................... 81hyoscyamine sulfate................. 78hyoscyamine sulfate er............. 78hyoscyamine sulfate sl..............78hyosyne.....................................78HYPERRAB.............................. 96HYPERSAL.............................108HYSINGLA ER..........................11HYZAAR................................... 47ibandronate sodium................ 100IBRANCE.................................. 32ibu............................................. 14ibuprofen................................... 14icatibant acetate........................96ICLUSIG....................................32IDHIFA...................................... 32ILEVRO...................................103imatinib mesylate...................... 32IMBRUVICA.............................. 33imipramine hcl...........................25imipramine pamoate................. 25imiquimod..................................61IMIQUIMOD PUMP...................61IMITREX................................... 30IMITREX STATDOSE REFILL..30IMITREX STATDOSE SYSTEM................................... 30IMPAVIDO................................ 36IMPOYZ.................................... 61IMURAN....................................96IMVEXXY MAINTENANCE PACK........................................ 90IMVEXXY STARTER PACK..... 90INBRIJA.................................... 37incassia..................................... 90INCRELEX................................ 86INCRUSE ELLIPTA................ 111indapamide............................... 47INDERAL LA............................. 47INDERAL XL............................. 47INDOCIN...................................14indomethacin.............................14indomethacin er........................ 14INFANRIX................................. 98INFINITY BLOOD GLUCOSE TEST.........................................68

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INGREZZA................................55INLYTA..................................... 33INNOPRAN XL..........................48INOVA.......................................61INOVA 4/1 ACNE CONTROL THERAPY................................. 61INREBIC................................... 33INSPIREASE RESERVOIR BAGS...................................... 101INSPRA.....................................48INSULIN ASP PROT & ASP FLEXPEN..................................70INSULIN ASPART.................... 70INSULIN ASPART FLEXPEN... 70INSULIN ASPART PENFILL.....70INSULIN ASPART PROT & ASPART....................................70INSULIN LISPRO......................70INSULIN LISPRO (1 UNIT DIAL).........................................70INTELENCE..............................40INTERMEZZO.........................114INTRAROSA............................. 81INTRON A.................................40introvale.................................... 90INTUNIV....................................53INVEGA.................................... 38INVEGA SUSTENNA................38INVEGA TRINZA...................... 38INVELTYS...............................103INVIRASE................................. 40INVOKAMET.............................66INVOKAMET XR.......................66INVOKANA............................... 66iodine strong............................. 73IOPIDINE................................ 104IPOL..........................................98ipratropium bromide........ 108, 111ipratropium-albuterol............... 111irbesartan.................................. 48irbesartan-hydrochlorothiazide..48IRESSA.....................................33IS 24/6.......................................73ISENTRESS..............................40ISENTRESS HD....................... 40isibloom.....................................90isoniazid.................................... 31ISOPTO CARPINE................. 104ISORDIL TITRADOSE.............. 48isosorbide dinitrate....................48isosorbide mononitrate..............48isosorbide mononitrate er......... 48isotretinoin.................................61

isoxsuprine hcl.......................... 48isradipine...................................48ISTALOL................................. 104itraconazole...............................28ivermectin............................36, 61JADENU....................................73JADENU SPRINKLE.................73jaimiess..................................... 90JAKAFI......................................33JALYN.......................................82jantoven.................................... 21JANUMET................................. 66JANUMET XR........................... 66JANUVIA...................................66JARDIANCE..............................66jasmiel.......................................90jencycla..................................... 90JENTADUETO.......................... 66JENTADUETO XR.................... 66jinteli ..........................................90jolessa.......................................90JORNAY PM............................. 53JUBLIA......................................28juleber....................................... 90JULUCA.................................... 40junel 1.5/30............................... 90junel 1/20.................................. 90junel fe 1.5/30........................... 90junel fe 1/20.............................. 90junel fe 24................................. 90JUXTAPID.................................48JYNARQUE.............................. 73K.B.G.L IN TERODERM........... 14KADIAN.....................................11kaitlib fe.....................................90KALETRA..................................40kalliga........................................90KALYDECO............................ 112KAPSPARGO SPRINKLE.........48KAPVAY....................................53KARBINAL ER........................ 108kariva........................................ 90KATERZIA................................ 48KAZANO................................... 66KEFLEX.................................... 19kelnor 1/35................................ 90kelnor 1/50................................ 90KENALOG.................................61KEPPRA................................... 22KEPPRA XR............................. 22KERALYT..................................61KERYDIN.................................. 28ketoconazole.............................28

ketodan..................................... 28KETOPHENE RAPIDPAQ........ 14ketoprofen................................. 14ketoprofen er.............................14KETOROCAINE-L.....................14KETOROCAINE-LM..................14KETOROLAC TROMETHAMINE...............14, 15ketorolac tromethamine.... 15, 103KEVEYIS.................................104KEVZARA................................. 96KINERET.................................. 96KINRIX...................................... 98kionex........................................73KISQALI (200 MG DOSE).........33KISQALI (400 MG DOSE).........33KISQALI (600 MG DOSE).........33KISQALI FEMARA (400 MG DOSE).......................................33KISQALI FEMARA (600 MG DOSE).......................................33KISQALI FEMARA(200 MG DOSE).......................................33KITABIS PAK.......................... 112KLARITY-A............................. 103KLARITY-B............................. 103KLARITY-L..............................103KLARON................................... 61KLONOPIN............................... 43klor-con..................................... 73klor-con 10................................ 73klor-con m10............................. 73KLOR-CON M15....................... 73klor-con m20............................. 73klor-con sprinkle........................73klor-con/ef................................. 73KOMBIGLYZE XR.....................66KORLYM...................................87K-PHOS.................................... 73K-PHOS NO 2...........................73k-prime...................................... 73KRINTAFEL.............................. 36KRISTALOSE........................... 78KROGER HEALTHPRO GLUCOSE TEST...................... 68K-TAB....................................... 73k-tan plus.................................. 73kurvelo...................................... 90KUVAN......................................80L.E.T......................................... 16labetalol hcl............................... 48LACRISERT............................106lactic acid.................................. 62

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lactic acid e............................... 61lactulose....................................78lactulose encephalopathy......... 78LAMICTAL................................ 22LAMICTAL ODT........................22LAMICTAL STARTER...............22LAMICTAL XR.......................... 22lamivudine.................................40lamivudine-zidovudine.............. 40lamotrigine................................ 22lamotrigine er............................ 22lamotrigine starter kit-blue.........22lamotrigine starter kit-green...... 22lamotrigine starter kit-orange.... 22LANOXIN.................................. 48lansoprazole..............................76lanthanum carbonate................ 81LANTUS SOLOSTAR............... 70LANTUS U-100 VIAL................ 70larin 1.5/30................................ 90larin 1/20................................... 90larin 24 fe.................................. 91larin fe 1.5/30............................ 91larin fe 1/20............................... 91larissia.......................................91LASIX........................................48LASTACAFT........................... 106LATANOPROST..................... 104latanoprost.............................. 105latrix xm.....................................62LATUDA....................................38layolis fe.................................... 91LAZANDA................................. 11leena......................................... 91leflunomide................................96LENSCALE............................. 101LENVIMA (10 MG DAILY DOSE).......................................33LENVIMA (12 MG DAILY DOSE).......................................33LENVIMA (14 MG DAILY DOSE).......................................33LENVIMA (18 MG DAILY DOSE).......................................33LENVIMA (20 MG DAILY DOSE).......................................33LENVIMA (24 MG DAILY DOSE).......................................33LENVIMA (4 MG DAILY DOSE).......................................33LENVIMA (8 MG DAILY DOSE).......................................33LESCOL XL.............................. 48

lessina.......................................91LETAIRIS................................ 113letrozole.................................... 33leucovorin calcium.................... 33LEUKERAN...............................33leuprolide acetate......................86LEUPROLIDE ACETATE-BUPIVACAINE..........................86levalbuterol hcl........................ 111LEVALBUTEROL HFA............111LEVAQUIN................................19LEVBID..................................... 78LEVEMIR U-100 FLEXTOUCH.70LEVEMIR U-100 VIAL...............70levetiracetam.............................22levetiracetam er........................ 22levobunolol hcl........................ 105levocarnitine..............................73levocarnitine sf.......................... 73levofloxacin....................... 19, 103levonest.....................................91levonorgest-eth est & eth est.... 91levonorgest-eth estrad 91-day.. 91levonorgestrel-ethinyl estrad.....91levonorg-eth estrad triphasic.....91levora 0.15/30 (28)....................91levorphanol tartrate................... 11levo-t......................................... 94levothyroxine sodium................ 94levoxyl....................................... 95LEVSIN..................................... 78LEVSIN/SL................................78LEXAPRO................................. 25LEXETTE.................................. 62LEXIVA..................................... 40LIALDA......................................99LIBRAX..................................... 78lidocaine....................................16lidocaine hcl........................ 16, 56lidocaine hcl urethral/mucosal...16lidocaine viscous hcl................. 56LIDOCAINE-HYDROCORTISONE ACE....... 99lidocaine-prilocaine................... 16LIDOCAINE-TETRACAINE.......16LIDODERM............................... 16lidolog........................................83LIDOPROFEN...........................15lillow.......................................... 91lindane...................................... 36linezolid..................................... 19LINZESS................................... 78liothyronine sodium................... 95

LIPITOR.................................... 48LIPO..........................................73LIPO-C...................................... 73LIPOFEN...................................48lisinopril ..................................... 48lisinopril-hydrochlorothiazide.....48lithium........................................43lithium carbonate.......................43lithium carbonate er.................. 43LITHOBID................................. 43LITHOSTAT.............................. 81LIVALO..................................... 48LO LOESTRIN FE.....................91LOCOID.................................... 62LOCOID LIPOCREAM.............. 62LODINE.....................................15LODOSYN................................ 37LOESTRIN 1.5/30 (21)..............91LOESTRIN 1/20 (21).................91LOESTRIN FE 1.5/30............... 91LOESTRIN FE 1/20.................. 91lojaimiess.................................. 91LOKELMA................................. 73LOMAIRA..................................55LOMOTIL.................................. 78LONHALA MAGNAIR REFILL KIT.......................................... 111LONHALA MAGNAIR STARTER KIT.........................111LONSURF.................................33LOPID....................................... 48lopinavir-ritonavir.......................41lopreeza.................................... 91LOPRESSOR............................48LOPRESSOR HCT................... 48LOPROX................................... 28lorazepam................................. 43lorazepam intensol....................43LORBRENA.............................. 33lorcet......................................... 11lorcet hd.................................... 11lorcet plus..................................11LORTAB....................................11loryna........................................ 91LORZONE...............................113losartan potassium....................48losartan potassium-hctz............ 48LOSEASONIQUE..................... 91LOTEMAX...............................103LOTEMAX SM........................ 103LOTENSIN................................ 48LOTENSIN HCT........................48loteprednol etabonate............. 103

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LOTREL.................................... 48LOTRISONE............................. 28LOTRONEX.............................. 78lovastatin...................................48LOVAZA....................................48LOVENOX.................................21low-ogestrel...............................91loxapine succinate.................... 39lo-zumandimine.........................91LT INJECTION KIT................... 83LUCEMYRA.............................. 17ludent........................................ 73LULICONAZOLE.......................28LUMIGAN................................105LUNESTA............................... 114LUPANETA PACK.................... 86LUPRON DEPOT (1-MONTH)..86LUPRON DEPOT (3-MONTH)..86LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG..86LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG..86LUPRON DEPOT-PED (1-MONTH)....................................86LUPRON DEPOT-PED (3-MONTH)....................................86lutera......................................... 91LUXIQ....................................... 62LUZU.........................................28LYNPARZA............................... 33LYRICA..................................... 55LYRICA CR...............................55LYSINE HCL............................. 73LYSODREN.............................. 33LYSTEDA..................................43lyza............................................91MACROBID...............................19MACRODANTIN....................... 19mafenide acetate...................... 19MAGNESIUM SULFATE...........73MALARONE..............................36malathion.................................. 36maprotiline hcl...........................25MARBETA-25........................... 83MARBETA-L............................. 83MARDEX-25............................. 83marlido...................................... 16MARLIDO-25............................ 16marlissa.....................................91MARPLAN.................................25MATULANE.............................. 33matzim la...................................48MAVENCLAD (10 TABS)..........54

MAVENCLAD (4 TABS)............54MAVENCLAD (5 TABS)............54MAVENCLAD (6 TABS)............54MAVENCLAD (7 TABS)............54MAVENCLAD (8 TABS)............54MAVENCLAD (9 TABS)............54MAVYRET.................................41MAXALT....................................30MAXALT-MLT........................... 30MAXIDEX................................103MAXITROL..............................106MAXZIDE.................................. 48MAXZIDE-25.............................48MAYZENT.................................54MAYZENT STARTER PACK.... 54me/naphos/mb/hyo1................. 81meclofenamate sodium.............15MEDROL...................................84MEDROX-RX............................ 11medroxyprogesterone acetate.. 91mefenamic acid.........................15mefloquine hcl...........................36MEGACE ES.............................91megestrol acetate..................... 91MEKINIST................................. 33MEKTOVI..................................33melodetta 24 fe......................... 91meloxicam.................................15melphalan................................. 33memantine hcl...........................24memantine hcl er...................... 24MENACTRA..............................98MENEST................................... 91MENOPUR................................86MENOSTAR..............................91MENTAX................................... 28MENVEO.................................. 98meperidine hcl...........................11MEPHYTON..............................73meprobamate............................43MEPRON.................................. 36mercaptopurine......................... 33mesalamine...............................99mesalamine er.......................... 99mesalamine-cleanser................99MESNEX...................................33MESTINON......................... 30, 31metadate er...............................53metaproterenol sulfate............ 111METAXALL CP....................... 113metaxalone............................. 114metformin hcl er........................ 66metformin hcl er (mod)..............66

metformin hcl er (osm).............. 66METFORMIN HCL IR............... 66metformin hcl ir ......................... 66methadone hcl.......................... 12methadone hcl intensol............. 11methadose................................ 12methadose sugar-free...............12methamphetamine hcl...............53methazolamide........................105methenamine hippurate............ 19methenamine mandelate.......... 19methergine.............................. 101methimazole..............................95METHITEST..............................85methocarbamol....................... 114methotrexate............................. 96methotrexate sodium................ 96methotrexate sodium (pf).......... 96methoxsalen rapid.....................62methscopolamine bromide........78methyl salicylate........................62METHYLCOBALAMIN.............. 73methyldopa............................... 48methyldopa-hydrochlorothiazide...................48methylergonovine maleate......101METHYLIN................................53methylphenidate hcl.................. 53methylphenidate hcl er..............53methylphenidate hcl er (cd).......53methylphenidate hcl er (la)........53methylprednisolone...................84METHYLPREDNISOLONE ACE-LIDO................................. 84methylprednisolone acetate...... 84methyltestosterone....................85metoclopramide hcl...................26metolazone............................... 48metoprolol succinate er.............49metoprolol tartrate.....................49metoprolol-hydrochlorothiazide.49METROCREAM........................ 62METROGEL..............................62METROLOTION........................62metronidazole..................... 19, 62METRONIDAZOLE BENZO+SYRSPEND................19mexiletine hcl............................ 49mibelas 24 fe.............................91MICARDIS................................ 49MICARDIS HCT........................ 49MIC-L-CARNITINE....................73miconazole 3.............................28

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MICONAZOLE-ZINC OXIDE-PETROLAT............................... 28MICRODOT TEST.................... 69microgestin 1.5/30.....................92microgestin 1/20........................92microgestin fe 1.5/30.................92microgestin fe 1/20....................92midodrine hcl.............................49MIGERGOT.............................. 30miglitol.......................................66miglustat....................................80MIGRANAL............................... 30mili .............................................92MILLIPRED............................... 84MILLIPRED DP......................... 84MILLIPRED DP 12-DAY........... 84mimvey......................................92MINASTRIN 24 FE....................92mineral oil heavy....................... 78MINIPRESS.............................. 49minitran..................................... 49MINIVELLE............................... 92MINOCIN.................................. 19minocycline hcl..........................19minocycline hcl er..................... 19MINOLIRA.................................19minoxidil .................................... 49MIRAPEX..................................37MIRAPEX ER............................37MIRCETTE................................92mirtazapine............................... 25MIRVASO................................. 62misoprostol................................76MITIGARE.................................29MITOSOL................................103mlk f1...................................... 101mlk f2...................................... 101mlk f3...................................... 101MLK F4................................... 101M-M-R II.................................... 98MOBIC...................................... 15modafinil ..................................114moexipril hcl.............................. 49molindone hcl............................39mometasone furoate......... 62, 108mondoxyne nl............................19mono-linyah.............................. 92MONSELS FERRIC SUBSULFATE.......................... 44montelukast sodium................ 111MONUROL................................19morgidox................................... 19MORPHABOND ER..................12

morphine sulfate....................... 12morphine sulfate (concentrate). 12morphine sulfate er................... 12morphine sulfate er beads........ 12MOTEGRITY.............................78MOTOFEN................................ 79MOVANTIK............................... 79MOVIPREP............................... 79MOXEZA.................................103moxifloxacin hcl.................19, 103moxifloxacin hcl (2x day).........103MS CONTIN..............................12MULPLETA............................... 44MULTAQ................................... 49multigen.................................... 73MULTI-SPECIALTY.................. 84multi-vit/iron/fluoride..................74multivitamin/fluoride.................. 74MULTIVITAMIN/FLUORIDE..... 74multi-vitamin/fluoride................. 74multivitamin/fluoride/iron........... 74multi-vitamin/fluoride/iron.......... 74multivitamins/fluoride................ 74mupirocin.................................. 19mupirocin calcium..................... 19mvc-fluoride.............................. 74MYALEPT................................. 80MYAMBUTOL........................... 31MYCOBUTIN............................ 31mycophenolate mofetil .............. 96mycophenolate sodium............. 97MYDAYIS..................................53MYFORTIC............................... 97MYLERAN.................................33myorisan................................... 62MYRBETRIQ.............................81MYSOLINE............................... 22MYTESI.....................................79nabumetone.............................. 15nadolol...................................... 49nafrinse..................................... 74NAFRINSE DAILY ACIDULATED........................... 56NAFRINSE DAILY/NEUTRAL...56nafrinse drops........................... 74NAFRINSE WEEKLY................56naftifine hcl................................28NAFTIN..................................... 28NALFON................................... 15NALOCET................................. 12naloxone hcl..............................17NALOXONE HCL......................17NALTREXONE..........................17

naltrexone hcl............................17NAMENDA................................ 24NAMENDA TITRATION PAK....24NAMENDA XR.......................... 24NAMENDA XR TITRATION PACK........................................ 24NAMZARIC............................... 24NANDROLONE-TESTOSTERONE CYP .....85NAPRELAN...............................15NAPRO..................................... 15NAPROSYN..............................15naproxen................................... 15naproxen dr...............................15naproxen sodium...................... 15naproxen sodium er.................. 15naproxen-esomeprazole........... 15naratriptan hcl........................... 30NARCAN...................................17NARDIL.....................................25NASCOBAL.............................. 74NASONEX.............................. 108NATACYN...............................103NATAZIA...................................92nateglinide.................................66NATESTO................................. 85NATPARA............................... 100NATROBA.................................36NATURE-THROID.................... 95NEBUPENT.............................. 36nebusal................................... 108NEBUSAL............................... 108necon 0.5/35 (28)......................92nefazodone hcl..........................25neomycin sulfate....................... 19neomycin-bacitracin zn-polymyx...................................106neomycin-polymyxin-dexameth................................................ 106neomycin-polymyxin-gramicidin................................106neomycin-polymyxin-hc.. 106, 107neo-polycin..............................106neo-polycin hc.........................106NEORAL................................... 97NEO-SYNALAR........................ 62NEOTUSS PLUS.................... 108NEPHRON FA.......................... 74NERLYNX................................. 33NESINA.....................................66NESTABS................................. 74NESTABS ONE........................ 74neuac........................................ 62

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NEUPRO...................................37NEURONTIN.............................22neutral sodium fluoride..............56NEVANAC...............................103nevirapine................................. 41nevirapine er............................. 41NEXAVAR.................................33NEXIUM.................................... 77niacin (antihyperlipidemic)........ 49niacin er (antihyperlipidemic).... 49niacor........................................ 49NIASPAN.................................. 49nicardipine hcl........................... 49NICOTROL............................... 17NICOTROL NS......................... 17nifedipine...................................49nifedipine er.............................. 49nifedipine er osmotic release.... 49NIFEREX.................................. 74nikki...........................................92NILANDRON.............................33nilutamide..................................34nimodipine.................................49NINLARO.................................. 34nisoldipine er.............................49nitisinone...................................80NITRO-BID................................49NITRO-DUR..............................49nitrofurantoin............................. 19nitrofurantoin macrocrystal........19nitrofurantoin monohydrate macrocrystals............................19nitroglycerin...............................49NITROLINGUAL....................... 49NITROMIST.............................. 49NITROSTAT..............................49nitro-time................................... 49NITYR....................................... 80nizatidine...................................77NIZORAL.................................. 28NOCDURNA............................. 86NOCTIVA.................................. 86nolix...........................................62nora-be......................................92NORCO.....................................12NORDITROPIN FLEXPRO....... 86norethin ace-eth estrad-fe.........92norethindrone............................92norethindrone acetate............... 92norethindrone acet-ethinyl est...92norethindrone-eth estradiol....... 92norethin-eth estradiol-fe............ 92NORGESIC FORTE................114

norgestimate-eth estradiol........ 92norgestimate-ethinyl estradiol triphasic.....................................92NORITATE................................62norlyda...................................... 92norlyroc..................................... 92NORPACE................................ 49NORPACE CR.......................... 49NORPRAMIN............................ 25NORTHERA..............................49nortrel 0.5/35 (28)..................... 92nortrel 1/35 (21)........................ 92nortrel 1/35 (28)........................ 92nortrel 7/7/7...............................92nortriptyline hcl..........................25NORVASC................................ 49NORVIR.................................... 41NOURIANZ............................... 37novarel...................................... 86NOVAREL.................................86NOVOLIN 70/30 FLEXPEN...... 70NOVOLIN 70/30 FLEXPEN RELION.....................................70NOVOLIN 70/30 RELION......... 70NOVOLIN 70/30 VIAL............... 71NOVOLIN N FLEXPEN.............71NOVOLIN N FLEXPEN RELION.....................................71NOVOLIN N RELION................71NOVOLIN N VIAL..................... 71NOVOLIN R FLEXPEN.............71NOVOLIN R FLEXPEN RELION.....................................71NOVOLIN R RELION................71NOVOLIN R VIAL..................... 71NOVOLOG FLEXPEN.............. 71NOVOLOG MIX 70/30 FLEXPEN..................................71NOVOLOG MIX 70/30 VIAL......71NOVOLOG PENFILL................ 71NOVOLOG U-100 VIAL............ 71NOXAFIL...................................28NP #2 DRUG PREPARATION KIT............................................ 15np thyroid.................................. 95NUBEQA...................................34NUCALA................................. 108NUCYNTA.................................12NUCYNTA ER...........................12NUEDEXTA.............................. 55NULYTELY WITH FLAVOR PACKS......................................79NUMOISYN...............................56

NUPLAZID................................ 39NUTRIDOX............................... 19NUTRIVIT................................. 74NUTROPIN AQ NUSPIN 10..... 86NUTROPIN AQ NUSPIN 20..... 86NUTROPIN AQ NUSPIN 5....... 86NUVARING............................... 92NUVESSA.................................19NUVIGIL..................................114NUZYRA................................... 19nyamyc......................................28NYMALIZE................................ 49nystatin......................................28nystatin-triamcinolone............... 28nystop....................................... 28OCALIVA.................................. 80ocella.........................................92octreotide acetate..................... 86OCUFLOX...............................103ODACTRA.............................. 101ODEFSEY.................................41ODOMZO..................................34OFEV...................................... 111ofloxacin....................20, 103, 107ogestrel..................................... 92okebo........................................ 20olanzapine.................................39olanzapine-fluoxetine hcl.......... 25olmesartan medoxomil..............49olmesartan medoxomil-hctz...... 50olmesartan-amlodipine-hctz......50olopatadine hcl................103, 108OLUMIANT............................... 97OLUX........................................ 62OLUX-E.....................................62OMECLAMOX-PAK.................. 79OMEGA-3/D-3 WELLNESS PACK........................................ 50omega-3-acid ethyl esters.........50omeprazole............................... 77omeprazole-sodium bicarbonate............................... 77OMNARIS............................... 108OMNITROPE............................ 86ONDANSETRON HCL..............26ondansetron hcl........................ 27ondansetron odt........................ 27ONE DROP BLOOD GLUCOSE MONITOR.............. 69ONE DROP TEST.....................69ONETOUCH ULTRA 2 KIT W/DEVICE................................ 69

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ONETOUCH ULTRA BLUE TEST STRIPS...........................69ONETOUCH ULTRA MINI KIT W/DEVICE................................ 69ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE..........69ONETOUCH VERIO IQ SYSTEM................................... 69ONETOUCH VERIO KIT W/DEVICE................................ 69ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE..........69ONEXTON................................ 62ONFI......................................... 22ONGLYZA.................................66ONZETRA XSAIL......................30OPANA..................................... 12opium........................................ 79OPSUMIT................................113ORACEA...................................62ORACIT.................................... 74ORAFATE............................... 101ORALAIR................................ 101ORALAIR ADULT SAMPLE KIT.......................................... 101ORALAIR ADULT STARTER PACK...................................... 101ORALAIR CHILDRENS SAMPLE KIT...........................101ORALAIR CHILDRENS STARTER PACK.................... 101oralone...................................... 56ORAPRED ODT........................84ORAVIG.................................... 28ORENCIA..................................97ORENCIA CLICKJECT............. 97ORENITRAM.......................... 113ORFADIN..................................80ORILISSA................................. 87ORKAMBI............................... 112orphenadrine citrate er............114orphenadrine-aspirin-caffeine. 114ORPHENGESIC FORTE........ 114orsythia..................................... 92ORTHO MICRONOR................ 92ORTHO TRI-CYCLEN LO.........92ORTHO-NOVUM 1/35 (28)....... 92ORTHO-NOVUM 7/7/7 (28)...... 92oscimin......................................79oscimin sr..................................79oseltamivir phosphate............... 41OSENI.......................................66OSMOLEX ER.......................... 37

OSMOPREP............................. 79OSPHENA................................ 85OTEZLA.................................... 97OTICIN HC NR....................... 107OTIPRIO................................. 107OTOVEL................................. 107OTREXUP.................................97OVACE PLUS........................... 62OVIDE.......................................36OVIDREL.................................. 87oxaprozin.................................. 15OXAYDO...................................12oxazepam................................. 43oxcarbazepine...........................22OXERVATE............................ 106oxiconazole nitrate.................... 28OXISTAT...................................28OXSORALEN ULTRA...............62OXTELLAR XR......................... 22oxybutynin chloride................... 81oxybutynin chloride er............... 81oxycodone hcl........................... 12OXYCODONE HCL ER............ 12oxycodone-acetaminophen.......12oxycodone-aspirin.....................12oxycodone-ibuprofen................ 12OXYCONTIN.............................12oxymorphone hcl.......................12oxymorphone hcl er.................. 12OXYTROL.................................81OZEMPIC..................................66OZOBAX................................. 114PACERONE..............................50pacerone................................... 50paliperidone er.......................... 39PALYNZIQ................................ 80PAMELOR................................ 25PANCREAZE............................ 80PANDEL....................................62PANRETIN................................34pantoprazole sodium.................77papaverine hcl...........................50paregoric................................... 79paricalcitol............................... 100PARLODEL...............................37PARNATE................................. 25paroex....................................... 56paromomycin sulfate.................20paroxetine hcl............................25paroxetine hcl er....................... 25paroxetine mesylate..................25PASER......................................31PATANASE.............................108

PAXIL........................................25PAXIL CR..................................25PAZEO....................................103P-CARE 100MX........................ 16P-CARE D40MX....................... 84P-CARE D80MX....................... 84P-CARE K40MX........................84P-CARE K80MX........................84PCP 100....................................79PEDIAPRED............................. 84PEDIARIX................................. 98PEDVAX HIB............................ 98peg 3350-kcl-na bicarb-nacl......79peg-3350/electrolytes................79PEGANONE..............................22PEGASYS.................................41PEGASYS PROCLICK............. 41PEGINTRON.............................41penicillamine............................. 81penicillin v potassium................ 20PENNSAID................................15PENTACEL............................... 98pentamidine isethionate............ 36PENTASA................................. 99pentazocine-naloxone hcl......... 12PENTOSAN POLYSULFATE SODIUM....................................81pentoxifylline er......................... 50PEPCID.....................................77PERCOCET.............................. 12PERFOROMIST......................111PERIDEX.................................. 56perindopril erbumine................. 50periogard...................................56permethrin.................................36perphenazine............................ 27perphenazine-amitriptyline........25PERSERIS................................39PERTZYE................................. 80PEXEVA....................................25phenadoz................................ 108phenazo.................................... 81phenazopyridine hcl.................. 81phendimetrazine tartrate........... 55phendimetrazine tartrate er.......55phenelzine sulfate..................... 25phenobarbital............................ 22phenobarbital-belladonna alk....79phenohytro................................ 79PHENOL................................. 101phenoxybenzamine hcl............. 50phentermine hcl........................ 55phenylephrine hcl....................106

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PHENYTEK...............................22phenytoin.................................. 22phenytoin infatabs.....................22phenytoin sodium extended...... 22philith.........................................92PHOSLYRA.............................. 81phosphasal................................81PHOSPHOLINE IODIDE.........105phospho-trin 250 neutral........... 74phytonadione............................ 74PICATO.....................................62PIFELTRO................................ 41pilocarpine hcl................... 56, 105pimecrolimus.............................62pimozide....................................39pimtrea...................................... 92pindolol......................................50pioglitazone hcl......................... 66pioglitazone hcl-glimepiride.......66pioglitazone hcl-metformin hcl.. 66PIQRAY (200 MG DAILY DOSE).......................................34PIQRAY (250 MG DAILY DOSE).......................................34PIQRAY (300 MG DAILY DOSE).......................................34pirmella 1/35............................. 93pirmella 7/7/7............................ 93piroxicam...................................15PLAQUENIL..............................36PLAVIX..................................... 38PLEGRIDY................................54PLEGRIDY STARTER PACK... 54PLENVU....................................79PLEXION.................................. 62PLEXION CLEANSER.............. 62PLIAGLIS.................................. 16PNEUMOVAX 23...................... 98pnv prenatal plus multivit+dha.. 74podocon.................................... 62podofilox....................................62POINT OF CARE KM................84POINT OF CARE L.2................ 84POINT OF CARE L.5................ 84POINT OF CARE LM DEP 2.....84POINT OF CARE LM-2.2..........16POINT OF CARE LM-2.5..........16polycin.....................................106polymyxin b-trimethoprim........106polysaccharide iron forte...........74POLYTRIM..............................106POLY-VI-FLOR......................... 74POLY-VI-FLOR FS................... 74

POLY-VI-FLOR/IRON............... 74POMALYST.............................. 34portia-28....................................93posaconazole............................28pot bicarb-pot chloride.............. 74POTABA................................... 74potassium bicarbonate..............74potassium chloride.................... 74potassium chloride crys er........ 74potassium chloride er................74potassium citrate er...................74potassium citrate-citric acid.......74POVIDONE-IODINE............... 103PRADAXA.................................21PRALUENT...............................50pramipexole dihydrochloride..... 37pramipexole dihydrochloride er.37PRAMOSONE...........................62PRAMOTIC............................. 107PRASTERA...............................15prasugrel hcl............................. 38PRAVACHOL............................50pravastatin sodium....................50praziquantel.............................. 36prazosin hcl...............................50PRECISION LINK..................... 69PRECISION PCX PLUS TEST. 69PRECISION QID TEST.............69PRECISION SOF-TACT TEST. 69PRECISION XTRA BLOOD GLUCOSE................................ 69PRECOSE................................ 66PRED FORTE.........................103PRED MILD............................ 103PRED-G.................................. 106PRED-G S.O.P....................... 106prednicarbate............................ 62prednisolone............................. 84prednisolone acetate...............103prednisolone acetate p-f......... 103PREDNISOLONE ACET-MOXIFLOXACIN.....................106prednisolone sodium phosphate......................... 84, 103PREDNISOLON-MOXIFLOX-NEPAFENAC.......................... 103prednisone................................ 84prednisone intensol...................84PREFEST................................. 93pregabalin................................. 55pregnyl...................................... 87PREMARIN............................... 93PREMPHASE........................... 93

PREMPRO................................93PRENAISSANCE......................75PRENATA................................. 75prenatal plus iron...................... 75PRENATE DHA........................ 75PRENATE ELITE...................... 75PRENATE ENHANCE.............. 75PRENATE ESSENTIAL............ 75PRENATE MINI........................ 75PRENATE PIXIE.......................75PRENATE RESTORE...............75PRENATVITE PLUS................. 75PRENATVITE RX..................... 75PREPOPIK................................79PRESTALIA.............................. 50PREVACID................................77PREVACID SOLUTAB..............77prevalite.................................... 50PREVIDENT............................. 56prevident................................... 56PREVIDENT 5000 BOOSTER PLUS.........................................56PREVIDENT 5000 DRY MOUTH.....................................56PREVIDENT 5000 ENAMEL PROTECT.................................56PREVIDENT 5000 ORTHO DEFENSE................................. 56PREVIDENT 5000 PLUS.......... 56PREVIDENT 5000 SENSITIVE.56previfem.................................... 93PREVNAR 13............................98PREVYMIS............................... 41PREZCOBIX............................. 41PREZISTA................................ 41PRIFTIN.................................... 31PRILOSEC................................77PRIMACARE.............................75primaquine phosphate.............. 36primidone.................................. 22PRIMLEV.................................. 12PRIMSOL..................................20PRINIVIL................................... 50PRISTIQ....................................25PROAIR DIGIHALER..............111PROAIR HFA.......................... 111PROAIR RESPICLICK............111probenecid................................ 29PROCARDIA.............................50PROCARDIA XL....................... 50PROCENTRA........................... 53prochlorperazine....................... 27prochlorperazine maleate......... 27

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PROCORT................................ 99PROCTOCORT...................... 100PROCTOFOAM HC................ 100procto-med hc......................... 100procto-pak............................... 100proctosol hc.............................100proctozone-hc......................... 100PROCYSBI............................... 80PRODIGY NO CODING BLOOD GLUC.......................... 69progesterone.............................93progesterone micronized.......... 93PROGLYCEM........................... 69PROGRAF................................ 97PROLATE................................. 12PROLENSA............................ 104PROMACTA..............................44promethazine hcl.....................108promethazine-codeine............ 108promethazine-dm.................... 108promethazine-phenyleph-codeine................................... 108promethazine-phenylephrine.. 108promethegan...........................108PROMETRIUM......................... 93propafenone hcl........................ 50propafenone hcl er.................... 50propantheline bromide.............. 79proparacaine hcl..................... 106propranolol hcl.......................... 50propranolol hcl er...................... 50propranolol-hctz........................ 50propylthiouracil ..........................95PROQUAD................................98PROSCAR................................ 82PROTHELIAL..........................101PROTONIX............................... 77PROTOPIC............................... 62protriptyline hcl..........................26PROVENTIL HFA................... 111PROVERA................................ 93PROVIGIL............................... 114PROZAC................................... 26PRUDOXIN............................... 62pseudoephedrine-bromphen-dm........................................... 108PSORCON................................62PULMICORT FLEXHALER.....111PULMICORT SUSPENSION.. 111pulmosal..................................108PULMOZYME......................... 112PURIXAN.................................. 34PYLERA....................................79

pyrazinamide.............................31PYRIDIUM................................ 81pyridostigmine bromide.............31pyridostigmine bromide er.........31PYRIDOXAL-5 PHOSPHATE... 75PYRIMETHAMINE-LEUCOVORIN.......................... 36PYROGALLIC ACID................. 62QBRELIS.................................. 50QBREXZA.................................63QMIIZ ODT............................... 15QNASL....................................108QNASL CHILDRENS.............. 108QSYMIA.................................... 55QTERN..................................... 66QUADRACEL............................98QUALAQUIN.............................36QUARTETTE............................ 93quazepam................................. 43QUDEXY XR.............................22QUESTRAN.............................. 50QUESTRAN LIGHT.................. 50quetiapine fumarate.................. 39quetiapine fumarate er.............. 39QUFLORA FE........................... 75QUFLORA FE PEDIATRIC.......75QUFLORA GUMMIES.............. 75QUFLORA PEDIATRIC............ 75QUILLICHEW ER......................53QUILLIVANT XR....................... 54quinapril hcl...............................50quinapril-hydrochlorothiazide.... 50quinidine gluconate er...............50quinidine sulfate........................ 50quinine sulfate...........................36QVAR REDIHALER................ 111RABEPRAZOLE SODIUM........ 77rabeprazole sodium.................. 77RAGWITEK.............................101raloxifene hcl.............................85ramelteon................................ 114ramipril ...................................... 50RANEXA................................... 50ranitidine hcl..............................77ranolazine er............................. 50RAPAFLO................................. 82RAPAMUNE..............................97rasagiline mesylate................... 37RASUVO...................................97RAVICTI....................................80RAYALDEE.............................100RAYOS..................................... 84RAZADYNE.............................. 24

RAZADYNE ER........................ 24READYSHARP ANESTH + BETAMETH.............................. 84READYSHARP ANESTH + DEXAMETH.............................. 84READYSHARP ANESTH + KETOROLAC............................15READYSHARP ANESTH + METHYLPRED......................... 84READYSHARP-A......................16REBIF....................................... 54REBIF REBIDOSE....................54REBIF REBIDOSE TITRATION PACK.................... 54REBIF TITRATION PACK.........54REBLOZYL............................... 44reclipsen....................................93RECOMBIVAX HB.................... 98RECTIV.....................................50RECURA...................................29REGLAN................................... 27REGRANEX..............................63RELAFEN DS........................... 15RELENZA DISKHALER............ 41relexxii .......................................54RELION BLOOD GLUCOSE TEST.........................................69RELION PREMIER TEST......... 69RELION ULTIMA TEST............ 69RELISTOR................................ 79RELNATE DHA.........................75RELPAX....................................30REMERON................................26REMERON SOLTAB................ 26REMESENSE........................... 56RENAGEL.................................81RENATABS WITH IRON.......... 75RENVELA................................. 81repaglinide................................ 67REPATHA................................. 50REPATHA PUSHTRONEX SYSTEM................................... 50REPATHA SURECLICK........... 51REQUIP XL...............................37RESTASIS.............................. 106RESTASIS MULTIDOSE........ 106RESTORIL.............................. 114RETIN-A....................................63RETIN-A MICRO GEL 0.04 %, 0.1 %.........................................63RETIN-A MICRO PUMP........... 63RETROVIR............................... 41REVATIO................................ 113

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REVLIMID................................. 34REXULTI...................................39REYATAZ................................. 41RHOFADE................................ 63RHOPRESSA......................... 105RIAX..........................................63ribavirin..................................... 41RIDAURA..................................97rifabutin..................................... 31RIFADIN....................................31RIFAMATE................................31rifampin..................................... 31RIFAMPIN+SYRSPEND SF..... 31RIFATER...................................31RILUTEK...................................55riluzole.......................................55rimantadine hcl..........................41RIMSO-50................................. 81RINVOQ....................................97RIOMET.................................... 67risedronate sodium................. 100RISPERDAL..............................39RISPERDAL CONSTA..............39risperidone................................ 39RITALIN.................................... 54RITALIN LA...............................54ritonavir..................................... 41rivastigmine...............................24rivastigmine tartrate.................. 24rivelsa........................................93rizatriptan benzoate.................. 30ROBAXIN-750.........................114ROCALTROL.......................... 101ROCKLATAN.......................... 105ROPIDEX..................................84ropinirole hcl..............................37ropinirole hcl er......................... 37ROPIVACAINE HCL................. 16rosadan..................................... 63rosuvastatin calcium................. 51ROTARIX.................................. 98ROTATEQ.................................98ROWASA................................ 100roweepra................................... 23roweepra xr............................... 23ROXICODONE......................... 12ROZEREM.............................. 114ROZLYTREK............................ 34RUBRACA................................ 34RUZURGI................................101RYBELSUS...............................67RYCLORA...............................108RYDAPT................................... 34

RYTARY................................... 37RYTHMOL SR.......................... 51ryvent...................................... 108SABRIL..................................... 23SAFYRAL..................................93SAIZEN..................................... 87SAIZENPREP........................... 87SALAGEN................................. 56SALEX...................................... 63salicylic acid.............................. 63salicylic acid er..........................63salicylic acid-cleanser............... 63SALINE-PHENOL..................... 75salsalate....................................15SALVAX.................................... 63SALVAX DUO PLUS.................63SAMSCA...................................75SANCUSO................................ 27SANDIMMUNE......................... 97SANDOSTATIN........................ 87SANTYL.................................... 63SAPHRIS.................................. 39SARAFEM.................................26SAVAYSA................................. 21SAVELLA.................................. 55SAVELLA TITRATION PACK... 55SAXENDA.................................55scopolamine..............................27SEASONIQUE.......................... 93SECONAL...............................114SEEBRI NEOHALER.............. 111SEGLUROMET.........................67SELECT-OB..............................75selegiline hcl............................. 37selenium sulfide........................ 63SELZENTRY.............................41SEMPREX-D...........................108SENSIPAR..............................101SEREVENT DISKUS.............. 111SERNIVO..................................63SEROQUEL.............................. 39SEROQUEL XR........................ 39SEROSTIM............................... 79sertraline hcl..............................26setlakin......................................93sevelamer carbonate................ 81sevelamer hcl............................81SEYSARA................................. 20sf............................................... 56sf 5000 plus...............................56SFROWASA........................... 100sharobel.................................... 93SHINGRIX.................................98

SIKLOS..................................... 34sildenafil citrate....................... 113SILENOR................................ 114SILIQ.........................................97silodosin.................................... 82SILVADENE..............................20silver nitrate...............................20silver sulfadiazine......................20SIMBRINZA............................ 105simliya....................................... 93simpesse...................................93SIMPONI...................................97simvastatin................................ 51SINEMET.................................. 37SINEMET CR............................37SINGULAIR.............................111sirolimus....................................97SIRTURO..................................31SITAVIG....................................41SIVEXTRO................................20SKELAXIN.............................. 114SKLICE..................................... 36SKYRIZI (150 MG DOSE).........97SLYND...................................... 93sodium chloride.......................109sodium fluoride....................56, 75sodium fluoride 5000 plus......... 56sodium fluoride 5000 ppm.........56sodium hyaluronate...................63sodium phenylbutyrate..............80sodium polystyrene sulfonate... 75sodium sulfacetamide............... 63SODIUM SULFACETAMIDE WASH....................................... 63solifenacin succinate.................81SOLIQUA.................................. 67SOLODYN................................ 20SOLOSEC.................................20SOLTAMOX.............................. 34SOLU-CORTEF........................ 84SOMA..................................... 114SOMATULINE DEPOT............. 87SOMAVERT..............................87SOOLANTRA............................63SORIATANE............................. 63SORILUX.................................. 63sorine........................................ 51sotalol hcl.................................. 51sotalol hcl (af)............................51sotalol hydrochloride................. 51SOTYLIZE.................................51SOVALDI.................................. 41SPECTRACEF..........................20

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spinosad....................................36SPIRIVA HANDIHALER..........111SPIRIVA RESPIMAT.............. 111spironolactone...........................51spironolactone-hctz...................51SPORANOX..............................29SPORANOX PULSEPAK..........29SPRAVATO (56 MG DOSE)..... 26SPRAVATO (84 MG DOSE)..... 26sprintec 28................................ 93SPRITAM.................................. 23SPRIX....................................... 15SPRYCEL................................. 34sps............................................ 75sronyx....................................... 93ssd............................................ 20SSKI........................................109sss 10-5.................................... 63STALEVO 100.......................... 37STALEVO 125.......................... 37STALEVO 150.......................... 37STALEVO 200.......................... 37STALEVO 50............................ 37STALEVO 75............................ 37STARLIX................................... 67stavudine...................................41STEGLATRO............................ 67STEGLUJAN.............................67STELARA..................................97STEMPHYLIUM...................... 101STIMATE.................................. 87STIOLTO RESPIMAT............. 111STIVARGA................................34STRATTERA.............................54STRENSIQ................................80STRIANT...................................85STRIBILD..................................41STRIVERDI RESPIMAT......... 112STROMECTOL......................... 36SUBOXONE..............................17SUBSYS................................... 12subvenite...................................23subvenite starter kit-blue...........23subvenite starter kit-green........ 23subvenite starter kit-orange...... 23SUCRAID..................................80sucralfate.................................. 77SULAR...................................... 51sulfacetamide sodium....... 63, 104sulfacetamide sodium (acne).... 63sulfacetamide sodium-sulfur63, 64sulfacetamide-prednisolone.... 106sulfacetamide-sulfur in urea......64

sulfacleanse 8/4........................ 64sulfadiazine............................... 20sulfamethoxazole-trimethoprim.20SULFAMYLON..........................20sulfasalazine........................... 100sulfatrim pediatric......................20sulfurated lime...........................36sulindac.....................................15sumatriptan............................... 30sumatriptan succinate............... 30sumatriptan succinate refill ....... 30sumatriptan-naproxen sodium.. 30SUNOSI.................................. 114SUPRAX................................... 20SUPREP BOWEL PREP KIT....79SURE RESULT O3D3 SYSTEM................................... 51SUSTIVA...................................41SUTENT....................................34syeda........................................ 93SYLATRON...............................41SYMAX DUOTAB..................... 79symax-sl....................................79symax-sr................................... 79SYMBICORT...........................112SYMBYAX.................................26SYMDEKO.............................. 112SYMFI....................................... 41SYMFI LO................................. 41SYMJEPI.................................112SYMLINPEN 120...................... 67SYMLINPEN 60........................ 67SYMPAZAN.............................. 23SYMPROIC...............................79SYMTUZA.................................41SYNALAR................................. 64SYNAPRYN FUSEPAQ............ 12SYNAREL................................. 87SYNDROS................................ 27SYNERA................................... 16SYNJARDY...............................67SYNJARDY XR.........................67SYNTHROID.............................95SYPRINE.................................. 76TABLOID...................................34TABRADOL FUSEPAQ.......... 114TABRADOL RAPIDPAQ......... 114TACLONEX...............................64tacrolimus............................64, 97tadalafil (pah).......................... 113TAFINLAR.................................34TAGRISSO............................... 34TAKHZYRO.............................. 97

TALTZ....................................... 97TALZENNA............................... 34TAMIFLU...................................41tamoxifen citrate........................34tamsulosin hcl........................... 82TAPAZOLE............................... 95TAPERDEX 12-DAY................. 84TAPERDEX 6-DAY................... 84TAPERDEX 7-DAY................... 84TARCEVA................................. 34TARGADOX..............................20TARGRETIN............................. 34tarina 24 fe................................ 93tarina fe 1/20............................. 93tarina fe 1/20 eq........................ 93TARKA...................................... 51taron-crystals............................ 76TASIGNA.................................. 34TASMAR................................... 37TAURINE.................................. 76TAVALISSE.............................. 44TAYTULLA................................93tazarotene................................. 64TAZORAC.................................64taztia xt......................................51TDVAX...................................... 98TECFIDERA..............................55TEGRETOL...............................23TEGRETOL-XR........................ 23TEGSEDI.................................. 55TEKTURNA...............................51TEKTURNA HCT...................... 51telmisartan................................ 51telmisartan-amlodipine..............51telmisartan-hctz.........................51temazepam..................... 114, 115TEMIXYS.................................. 41TEMODAR................................ 34TEMOVATE.............................. 64temozolomide............................34tencon....................................... 12TENIVAC.................................. 98tenofovir disoproxil fumarate.....42TENORETIC 100...................... 51TENORETIC 50........................ 51TENORMIN...............................51terazosin hcl..............................82terbinafine hcl............................29terbutaline sulfate....................112terconazole............................... 29TESSALON PERLES..............109TESTIM.....................................85testosterone.............................. 85

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TESTOSTERONE CYPIONATE............................. 85testosterone cypionate..............85testosterone enanthate............. 85tetrabenazine............................ 55tetracycline hcl.......................... 20TEXACORT.............................. 64THALOMID............................... 34THEO-24.................................112theophylline.............................112theophylline er.........................112THIOLA..................................... 81THIOLA EC............................... 81thioridazine hcl.......................... 39thiothixene.................................39THROMBIN-JMI........................44THROMBIN-JMI EPISTAXIS.... 44THROMBOGEN........................44thyroid....................................... 95tiadylt er.................................... 51tiagabine hcl..............................23TIAZAC..................................... 51TIBSOVO.................................. 34TIGAN....................................... 27TIGLUTIK..................................55TIKOSYN.................................. 51tilia fe.........................................93timolol maleate..................51, 105TIMOPTIC...............................105TIMOPTIC OCUDOSE............105TIMOPTIC-XE.........................105tinidazole...................................20TIROSINT................................. 95TIROSINT-SOL.........................95TIVICAY.................................... 42TIVORBEX................................15tizanidine hcl........................... 114TOBI NEBULIZER.................. 112TOBI PODHALER...................112TOBRADEX............................ 106TOBRADEX ST.......................106tobramycin...................... 104, 112TOBRAMYCIN........................ 112tobramycin-dexamethasone....106TOBREX................................. 104TOLAK...................................... 64tolbutamide............................... 67tolcapone.................................. 37tolmetin sodium.........................15TOLSURA................................. 29tolterodine tartrate.....................81tolterodine tartrate er.................82TOPAMAX................................ 23

TOPAMAX SPRINKLE..............23TOPEX TOPICAL ANESTHETIC........................... 57TOPICORT............................... 64TOPICORT SPRAY.................. 64topiramate................................. 23topiramate er.............................23TOPROL XL..............................51toremifene citrate...................... 34torsemide.................................. 51TOSYMRA................................ 30TOUJEO MAX SOLOSTAR...... 71TOUJEO SOLOSTAR...............71tovet.......................................... 64TOVIAZ..................................... 82TRACLEER.............................113TRADJENTA.............................67TRAMADOL HCL ER................13tramadol hcl er.......................... 13tramadol hcl er (biphasic)..........12tramadol hcl ir ........................... 13tramadol-acetaminophen.......... 13trandolapril ................................ 51trandolapril-verapamil hcl er......51tranexamic acid.........................44TRANSDERM SCOP (1.5 MG).27TRANSDERM-SCOP (1.5 MG).27TRANXENE-T........................... 43tranylcypromine sulfate............. 26TRAVATAN Z..........................105travoprost (bak free)................105trazodone hcl............................ 26TRECATOR.............................. 31TRELEGY ELLIPTA................112TREMFYA.................................97TRESIBA...................................71TRESIBA FLEXTOUCH............71tretinoin............................... 34, 64tretinoin microsphere................ 64tretinoin microsphere pump...... 64TREXALL.................................. 97TREXIMET................................30TREZIX..................................... 13tri femynor................................. 93triamcinolone acetonide...... 57, 64TRI-AMINO............................... 76triamterene................................51triamterene-hctz........................ 51trianex....................................... 64triazolam................................... 43TRIBENZOR............................. 51TRICARE PRENATAL DHA ONE.......................................... 76

TRI-CHLOR.............................. 64TRICOR.................................... 51triderm.......................................64TRIDESILON............................ 64trientine hcl................................76tri-estarylla................................ 93trifluoperazine hcl......................39trifluridine................................ 104TRIGLIDE................................. 52trihexyphenidyl hcl.................... 37TRIKAFTA...............................112tri-legest fe................................ 93TRILEPTAL...............................23tri-linyah.................................... 93TRILIPIX................................... 52tri-lo-estarylla............................ 93tri-lo-marzia............................... 93tri-lo-mili .................................... 93tri-lo-sprintec............................. 94trilyte......................................... 79trimethobenzamide hcl..............27trimethoprim.............................. 20tri-mili ........................................ 94trimipramine maleate................ 26trinate........................................ 76TRINTELLIX..............................26TRIPLE COMPLEX FORMULA 3 KIT......................................... 15TRIPLE PMB...........................104TRIPLE PMK...........................104tri-previfem................................ 94tri-sprintec................................. 94TRISTART ONE........................76TRIUMEQ................................. 42TRI-VI-FLOR.............................76TRI-VI-FLORO.......................... 76tri-vitamin/fluoride......................76tri-vite/fluoride........................... 76trivora (28).................................94tri-vylibra................................... 94tri-vylibra lo................................94TRIZIVIR................................... 42TROKENDI XR......................... 23TROPICAMIDE-PHENYLEPHRINE..................106trospium chloride.......................82trospium chloride er.................. 82TRUE METRIX BLOOD GLUCOSE TEST...................... 69TRUE METRIX PRO BLOOD GLUCOSE................................ 69TRUETRACK TEST..................69TRULANCE...............................79

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TRULICITY............................... 67TRUMENBA..............................98TRUVADA.................................42tryptophan................................. 76TUDORZA PRESSAIR........... 112tulana........................................ 94TURALIO.................................. 34turpentine.................................. 64TUSSICAPS............................109TUXARIN ER.......................... 109TUZISTRA XR........................ 109TWINRIX...................................98TWYNSTA................................ 52TYBOST....................................42tydemy...................................... 94TYKERB....................................34TYLENOL WITH CODEINE #3. 13TYMLOS................................. 100UCERIS.................................. 100ULESFIA................................... 36ULORIC.................................... 29ULTRACET............................... 13ULTRAM................................... 13ULTRAVATE.............................64UMECTA MOUSSE.................. 64unithroid.................................... 95UPTRAVI................................ 113urea...........................................64urea hydrating........................... 64urea nail .................................... 64URECHOLINE.......................... 82URELLE.................................... 82uretron d/s.................................82URIMAR-T................................ 82urin ds....................................... 82URO-458...................................82UROCIT-K 10............................76UROCIT-K 15............................76UROCIT-K 5..............................76UROGESIC-BLUE.................... 82UROXATRAL............................ 82URSO 250.................................79URSO FORTE.......................... 79ursodiol..................................... 79URYL........................................ 82ustell ..........................................82UTIBRON NEOHALER........... 112uticap........................................ 82utira-c........................................ 82utrona-c.....................................82VAGIFEM..................................94valacyclovir hcl..........................42VALCHLOR...............................35

VALCYTE..................................42valganciclovir hcl.......................42VALIUM.....................................43valproic acid.............................. 23valsartan................................... 52valsartan-hydrochlorothiazide... 52VALTOCO 10 MG DOSE..........23VALTOCO 15 MG DOSE..........23VALTOCO 20 MG DOSE..........23VALTOCO 5 MG DOSE............23VALTREX..................................42VANATOL LQ........................... 13VANATOL S..............................13VANCOCIN............................... 20VANCOCIN HCL.......................20vancomycin hcl......................... 20VANCOMYCIN+SYRSPEND SF............................................. 20vandazole..................................20VANOS..................................... 64VANOXIDE-HC......................... 64VAQTA......................................98VARIVAX.................................. 98VARUBI.....................................27VASCEPA................................. 52VASERETIC..............................52VASOTEC.................................52VECAMYL.................................52VECTICAL................................ 64velivet........................................94VELPHORO.............................. 82VELTASSA............................... 76VELTIN..................................... 65VEMLIDY.................................. 42VENCLEXTA.............................35VENCLEXTA STARTING PACK........................................ 35VENIPUNCTURE PX1 PHLEBOTOMY......................... 16venlafaxine hcl.......................... 26venlafaxine hcl er...................... 26VENOMIL HONEY BEE VENOM...................................102VENOMIL WASP VENOM...... 102VENOMIL WHITE FACED HORNET.................................102VENOMIL YELLOW HORNET VENOM...................................102VENOMIL YELLOW JACKET VENOM...................................102VENTAVIS.............................. 113VENTOLIN HFA......................112verapamil hcl.............................52

verapamil hcl er.........................52VERDESO................................ 65VEREGEN................................ 65VERELAN................................. 52VERELAN PM...........................52VERSACLOZ............................ 39VERZENIO................................35VESICARE................................82VFEND......................................29VIBERZI.................................... 79VIBRAMYCIN............................20vicodin hp..................................13VICTOZA.................................. 67VIDEX....................................... 42VIDEX EC................................. 42VIEKIRA PAK............................42vienva........................................94vigabatrin.................................. 23vigadrone.................................. 23VIGAMOX............................... 104VIIBRYD....................................26VIIBRYD STARTER PACK....... 26VILEVEV MB.............................82VIMOVO....................................15VIMPAT.....................................23VIOKACE.................................. 80viorele....................................... 94VIRACEPT................................ 42VIRAMUNE............................... 42VIRAMUNE XR......................... 42VIRASAL...................................65VIRAZOLE................................ 42VIREAD.....................................42virtussin ac w/alc.....................109VISTARIL.................................. 43VISTOGARD...........................102VITAFOL-OB+DHA...................76vitamin d (ergocalciferol)...........76vitamins acd-fluoride................. 76VITRAKVI..................................35VIVAGUARD INO TEST STRIPS..................................... 69VIVELLE-DOT...........................94VIVLODEX................................ 15VIZIMPRO.................................35VOGELXO................................ 85VOGELXO PUMP..................... 85volnea....................................... 94VOLTAREN...............................15VOPAC GB............................... 15VOPAC KT................................15voriconazole..............................29VOSEVI.....................................42

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VOTRIENT................................35VP FC KIT.................................16VP GKL KIT.............................. 16vp-pnv-dha................................ 76VRAYLAR................................. 39VTOL LQ...................................13VUSION.................................... 29vyfemla......................................94VYLEESI................................... 55vylibra........................................94VYNDAMAX..............................52VYNDAQEL.............................. 52VYTORIN.................................. 52VYVANSE................................. 54VYZULTA................................105WAKIX.................................... 115warfarin sodium.........................21WASP VENOM PROTEIN...... 102WELCHOL................................ 52WELLBUTRIN SR.....................26WELLBUTRIN XL..................... 26wera.......................................... 94WESTHROID............................ 95WHITE-FACED HORNET VENOM...................................102wixela inhub............................ 112WP THYROID........................... 95wymzya fe................................. 94XADAGO...................................37XALATAN................................105XALKORI.................................. 35XANAX......................................43XANAX XR................................43XARELTO................................. 21XARELTO STARTER PACK.....21XATMEP................................... 97XELJANZ.................................. 97XELJANZ XR............................ 97XELODA................................... 35XELPROS............................... 105XENAZINE................................ 55XENICAL...................................55XENLETA..................................20XEPI..........................................20XERAC AC................................65XERESE................................... 42XERMELO................................ 79XEROFORM OIL EMULSION 2"X2"......................................... 65XEROFORM OIL EMULSION GAUZE......................................65XEROFORM PETROLAT PATCH 2"X2"............................65

XEROFORM PETROLAT PATCH 4"X4"............................65XHANCE................................. 109XIFAXAN...................................20XIGDUO XR..............................67XIIDRA.................................... 106XIMINO..................................... 20XOFLUZA (40 MG DOSE)........ 42XOFLUZA (80 MG DOSE)........ 42XOLEGEL................................. 29XOLEGEL COREPAK...............29XOLEGEL DUO/HEAD & SHOULDERS............................29XOLEGEL DUO/XOLEX........... 29XOPENEX...............................112XOPENEX CONCENTRATE.. 112XOPENEX HFA...................... 112XOSPATA................................. 35XPOVIO (100 MG ONCE WEEKLY)..................................35XPOVIO (60 MG ONCE WEEKLY)..................................35XPOVIO (80 MG ONCE WEEKLY)..................................35XPOVIO (80 MG TWICE WEEKLY)..................................35XTAMPZA ER........................... 13XTANDI.....................................35xulane....................................... 94XULTOPHY...............................67XURIDEN..................................80XYOSTED.................................85XYREM................................... 115YASMIN 28............................... 94YAZ........................................... 94YELLOW JACKET VENOM PROTEIN................................ 102YONSA..................................... 35YOSPRALA...............................38YUPELRI.................................112yuvafem.................................... 94ZACARE................................... 65zaclir cleansing......................... 65zafirlukast................................112zaleplon...................................115ZANAFLEX............................. 114zarah......................................... 94ZARONTIN................................23ZAVESCA................................. 80ZEBUTAL..................................13ZEGERID.................................. 77ZEJULA.....................................35ZELAPAR..................................37

ZELBORAF............................... 35ZELNORM................................ 79ZEMBRACE SYMTOUCH........ 30ZEMPLAR............................... 101zenatane................................... 65ZENPEP....................................80ZENZEDI...................................54ZEPATIER................................ 42ZESTORETIC........................... 52ZESTRIL................................... 52ZETIA........................................52ZETONNA...............................109ZIAC..........................................52ZIAGEN.....................................42ZIANA....................................... 65zidovudine.................................42zileuton er............................... 112ZIOPTAN................................ 105ziprasidone hcl.......................... 39ziprasidone mesylate................ 39ZIPSOR.....................................16ZIRGAN.................................. 104ZITHROMAX.............................20ZITHROMAX TRI-PAK..............20ZITHROMAX Z-PAK................. 20ZOCOR..................................... 52ZOFRAN................................... 27ZOHYDRO ER.......................... 13ZOLINZA...................................35zolmitriptan................................30ZOLOFT....................................26zolpidem tartrate..................... 115zolpidem tartrate er................. 115ZOLPIMIST............................. 115ZOMACTON............................. 87ZOMIG...................................... 30ZOMIG ZMT..............................30ZONALON.................................65ZONEGRAN..............................23zonisamide................................23ZONTIVITY............................... 38ZORBTIVE................................ 79ZORTRESS.............................. 97ZORVOLEX.............................. 16ZOSTAVAX...............................98zovia 1/35e (28)........................ 94ZOVIRAX.................................. 42ZTLIDO..................................... 16Z-TUSS AC............................. 109ZUBSOLV................................. 17zumandimine.............................94ZUPLENZ..................................27ZYCLARA................................. 65

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ZYCLARA PUMP...................... 65ZYDELIG...................................35ZYFLO.................................... 112ZYKADIA...................................35ZYLET.....................................106ZYLOPRIM................................29ZYMAXID................................ 104ZYPITAMAG............................. 52ZYPREXA................................. 39ZYPREXA RELPREVV............. 39ZYPREXA ZYDIS......................39ZYTIGA..................................... 35ZYVOX......................................20

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