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
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
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.
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
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.
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.
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M57313-C 9/19
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للتحدث مع مترجم اتصل ب. 7126 -1-844-395.
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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
8
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
9
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
10
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
11
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
12
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
13
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
14
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
15
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
16
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
17
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
18
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
19
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
20
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
21
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
22
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
23
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
24
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
25
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
26
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
27
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
28
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
Last Updated 3/20/2020
29
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
Last Updated 3/20/2020
30
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
Last Updated 3/20/2020
31
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
Last Updated 3/20/2020
32
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
33
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
34
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
35
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
36
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
37
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
38
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
39
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
40
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
41
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
42
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
43
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
44
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
45
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
46
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
47
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
48
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
49
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
50
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
51
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
52
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
53
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
54
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
55
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
56
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
57
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
58
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
59
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
60
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
61
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
Last Updated 3/20/2020
62
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
Last Updated 3/20/2020
63
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
Last Updated 3/20/2020
64
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
Last Updated 3/20/2020
65
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
Last Updated 3/20/2020
66
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
Last Updated 3/20/2020
67
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
Last Updated 3/20/2020
68
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
Last Updated 3/20/2020
69
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
Last Updated 3/20/2020
70
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
Last Updated 3/20/2020
71
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
Last Updated 3/20/2020
72
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
Last Updated 3/20/2020
73
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
Last Updated 3/20/2020
74
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
Last Updated 3/20/2020
75
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
Last Updated 3/20/2020
76
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
Last Updated 3/20/2020
77
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
78
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
79
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
Last Updated 3/20/2020
80
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
81
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
82
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
83
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
84
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
85
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
86
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
Last Updated 3/20/2020
87
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
Last Updated 3/20/2020
88
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
Last Updated 3/20/2020
89
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
Last Updated 3/20/2020
90
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
Last Updated 3/20/2020
91
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
Last Updated 3/20/2020
92
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
Last Updated 3/20/2020
93
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
Last Updated 3/20/2020
94
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
Last Updated 3/20/2020
95
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
Last Updated 3/20/2020
96
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
Last Updated 3/20/2020
97
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
Last Updated 3/20/2020
98
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
Last Updated 3/20/2020
99
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
Last Updated 3/20/2020
100
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
Last Updated 3/20/2020
101
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
Last Updated 3/20/2020
102
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
Last Updated 3/20/2020
103
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
Last Updated 3/20/2020
104
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
Last Updated 3/20/2020
105
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
Last Updated 3/20/2020
106
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
Last Updated 3/20/2020
107
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
Last Updated 3/20/2020
108
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
Last Updated 3/20/2020
109
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
Last Updated 3/20/2020
110
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
Last Updated 3/20/2020
111
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
Last Updated 3/20/2020
112
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
Last Updated 3/20/2020
113
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
Last Updated 3/20/2020
114
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
Last Updated 3/20/2020
115
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
116
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
117
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
125
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
127
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
128
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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