UUHP Exchange Formulary Table of Contents 3 7sulfasalazine oral tablet 500 mg. 2: sulfasalazine oral...

UUHP Exchange Formulary

Table of Contents

Analgesic, Anti-Inflammatory Or Antipyretic ............................................................................................................................................... 3Anesthetics ......................................................................................................................................................................................................7Anorectal Preparations....................................................................................................................................................................................7Antidotes And Other Reversal Agents ........................................................................................................................................................... 7Anti-Infective Agents ..................................................................................................................................................................................... 8Antineoplastics ............................................................................................................................................................................................. 14Biologicals .................................................................................................................................................................................................... 16Cardiovascular Therapy Agents ................................................................................................................................................................... 17Central Nervous System Agents ...................................................................................................................................................................22Chemical Dependency, Agents To Treat ......................................................................................................................................................30Chemicals-Pharmaceutical Adjuvants .......................................................................................................................................................... 30Cognitive Disorder Therapy......................................................................................................................................................................... 30Contraceptives .............................................................................................................................................................................................. 31Dermatological ............................................................................................................................................................................................. 35Diagnostic Agents .........................................................................................................................................................................................41Eating Disorder Therapy...............................................................................................................................................................................41Electrolyte Balance-Nutritional Products ..................................................................................................................................................... 42Endocrine......................................................................................................................................................................................................43Gastrointestinal Therapy Agents .................................................................................................................................................................. 49Genitourinary Therapy..................................................................................................................................................................................52Gout And Hyperuricemia Therapy............................................................................................................................................................... 53Hematological Agents .................................................................................................................................................................................. 53Immunosuppressive Agents ..........................................................................................................................................................................55Locomotor System........................................................................................................................................................................................55Medical Supplies And Durable Medical Equipment (Dme).........................................................................................................................56Medical Supply, Fdb Superset ......................................................................................................................................................................56Metabolic Modifiers ..................................................................................................................................................................................... 57Mouth-Throat-Dental - Preparations............................................................................................................................................................ 57Multiple Sclerosis Agents .............................................................................................................................................................................58Ophthalmic Agents ....................................................................................................................................................................................... 58Otic ............................................................................................................................................................................................................... 61Respiratory Therapy Agents ......................................................................................................................................................................... 61Vaginal Products ...........................................................................................................................................................................................64

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2

UUHP Exchange Formulary

lowercase italics = Generic drugsUPPERCASE BOLD = Brand name drugs

Tier0 = Zero Cost Share Preventive Drugs1 = Preferred Generic2 = Non-Preferred Generic, Preferred Brand3 = Non-Preferred Brand4 = Specialty Drugs Notes

Drug Tier Notes

Analgesic, Anti-Inflammatory Or AntipyreticABSTRAL SUBLINGUAL TABLET 100 MCG, 200 MCG, 300 MCG, 400 MCG, 600 MCG, 800 MCG 4 PA; QL

acetaminophen-codeine oral tablet 300-30 mg, 300-60 mg 1 QL

ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML 4 PA

aspirin oral tablet 325 mg 1 QL

aspirin oral tablet,delayed release (dr/ec) 81 mg 1

AZASAN ORAL TABLET 100 MG, 75 MG 3 PA

azathioprine oral tablet 50 mg 1

buprenorphine hcl injection syringe 0.3 mg/ml 2

BUTALBITAL COMPOUND W/CODEINE ORAL CAPSULE 30-50-325-40 MG 2

BUTALBITAL COMPOUND-CODEINE ORAL CAPSULE 30-50-325-40 MG 2

butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg, 50-325-40-30 mg

2

butalbital-acetaminophen-caff oral tablet 50-325-40 mg 2

butalbital-aspirin-caffeine oral tablet 50-325-40 mg 1

butorphanol tartrate nasal spray,non-aerosol 10 mg/ml 2 QL

BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR

2 QL

CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, 50 MG 3 PA; QL

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg 1

CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) 4 PA

CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) 4 PA

CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) 4 PA

codeine sulfate oral tablet 15 mg, 30 mg, 60 mg 2

COMFORT PAC-IBUPROFEN KIT 800 MG 1

COMFORT PAC-MELOXICAM KIT 15 MG 1

COMFORT PAC-NAPROXEN KIT 500 MG 1

CUPRIMINE ORAL CAPSULE 250 MG 4 PA

cyclophosphamide oral capsule 25 mg, 50 mg 4 PA

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 1

cyclosporine modified oral solution 100 mg/ml 2

PA = Prior Authorization; ST = Step Therapy; QL = Quantity Limits

3

Drug Tier Notescyclosporine oral capsule 100 mg 2

cyclosporine oral capsule 25 mg 1

diclofenac potassium oral tablet 50 mg 1

diclofenac sodium oral tablet extended release 24 hr 100 mg

1

diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg

1

diflunisal oral tablet 500 mg 1

EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL 100-4 MG, 20-0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG

3 PA

ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) 4 PA

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) 4 PA

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) 4 PA

ENDOCET ORAL TABLET 2.5-325 MG 1 QL

ENTERIC COATED ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG 1

etodolac oral capsule 200 mg, 300 mg 1

etodolac oral tablet 400 mg, 500 mg 1

etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg

1

FELDENE ORAL CAPSULE 20 MG 1

fenoprofen oral capsule 400 mg 3

fenoprofen oral tablet 600 mg 2

fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg

4 PA; QL

fentanyl citrate buccal lozenge on a handle 400 mcg, 600 mcg, 800 mcg

4 PA

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr 2 PA; QL

fentanyl transdermal patch 72 hour 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour

2 PA

FENTORA BUCCAL TABLET, EFFERVESCENT 100 MCG 4 PA; QL

FENTORA BUCCAL TABLET, EFFERVESCENT 200 MCG, 400 MCG, 600 MCG, 800 MCG 4 PA

flurbiprofen oral tablet 100 mg, 50 mg 1

GENGRAF ORAL CAPSULE 100 MG, 25 MG, 50 MG 1

GENGRAF ORAL SOLUTION 100 MG/ML 2

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML 4 PA

HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML

4 PA


4

Drug Tier NotesHUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML 4 PA

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML 4 PA

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml

1

hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

1

hydrocodone-ibuprofen oral tablet 7.5-200 mg 1

hydromorphone oral liquid 1 mg/ml 2

hydromorphone oral tablet 2 mg, 4 mg, 8 mg 2

hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 32 mg, 8 mg

2 PA

hydroxychloroquine oral tablet 200 mg 1

HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

2 PA

ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1

ibuprofen-oxycodone oral tablet 400-5 mg 2 QL

INDOCIN ORAL SUSPENSION 25 MG/5 ML 3

indomethacin oral capsule 25 mg, 50 mg 1

indomethacin oral capsule, extended release 75 mg 1

ketoprofen oral capsule 50 mg, 75 mg 1

ketorolac oral tablet 10 mg 1 QL

LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY 4 PA; QL

leflunomide oral tablet 10 mg 1 QL

leflunomide oral tablet 20 mg 1

LORCET (HYDROCODONE) ORAL TABLET 5-325 MG 1 QL

LORCET HD ORAL TABLET 10-325 MG 1 QL

LORCET PLUS ORAL TABLET 7.5-325 MG 1 QL

LORTAB ELIXIR ORAL SOLUTION 10-300 MG/15 ML 2 QL

meclofenamate oral capsule 100 mg, 50 mg 2

mefenamic acid oral capsule 250 mg 2

meloxicam oral tablet 15 mg, 7.5 mg 1

methadone oral concentrate 10 mg/ml 2 PA; QL

methadone oral solution 10 mg/5 ml, 5 mg/5 ml 2 PA; QL

methadone oral tablet 10 mg, 5 mg 2 PA; QL

methotrexate sodium oral tablet 2.5 mg 1

minocycline oral capsule 100 mg, 50 mg, 75 mg 2

minocycline oral tablet 100 mg, 50 mg, 75 mg 2

MOBIC ORAL TABLET 15 MG 1

morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) 2 QL

morphine oral capsule, er multiphase 24 hr 120 mg, 30 mg 2 PA; QL


5

Drug Tier Notesmorphine oral capsule, er multiphase 24 hr 45 mg, 60 mg, 75 mg, 90 mg

2 PA

morphine oral capsule,extend.release pellets 10 mg, 100 mg, 20 mg

2 PA; QL

morphine oral capsule,extend.release pellets 30 mg, 50 mg, 60 mg, 80 mg

2 PA

morphine oral solution 10 mg/5 ml 2

morphine oral solution 20 mg/5 ml (4 mg/ml) 2 QL

morphine oral tablet 15 mg, 30 mg 2 QL

morphine oral tablet extended release 100 mg, 15 mg, 200 mg

2 PA; QL

morphine oral tablet extended release 30 mg, 60 mg 2 PA

mycophenolate mofetil oral capsule 250 mg 2

mycophenolate mofetil oral tablet 500 mg 2

nabumetone oral tablet 500 mg, 750 mg 1

NALFON ORAL CAPSULE 400 MG 3

naproxen oral suspension 125 mg/5 ml 1

naproxen oral tablet 250 mg, 375 mg, 500 mg 1

naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg

1

naproxen sodium oral tablet 275 mg, 550 mg 1

NEORAL ORAL CAPSULE 100 MG, 25 MG 4 PA

NEORAL ORAL SOLUTION 100 MG/ML 4 PA

NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG 3 PA; QL

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML 4 PA

ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML 4 PA

oxaprozin oral tablet 600 mg 2

oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg 2 QL

oxycodone-acetaminophen oral solution 5-325 mg/5 ml 1 QL

oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

1 QL

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG 2 PA; QL

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG

2 PA

oxymorphone oral tablet 10 mg 2

oxymorphone oral tablet 5 mg 2 QL

oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg

2 PA; QL

piroxicam oral capsule 10 mg, 20 mg 1

RIDAURA ORAL CAPSULE 3 MG 4 PA

ROXICODONE ORAL TABLET 15 MG, 30 MG, 5 MG 2

SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 200 MCG/SPRAY, 400 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY

4 PA


6

Drug Tier Notessulfasalazine oral tablet 500 mg 2

sulfasalazine oral tablet,delayed release (dr/ec) 500 mg 2

sulindac oral tablet 150 mg, 200 mg 1

tolmetin oral capsule 400 mg 2

tolmetin oral tablet 200 mg, 600 mg 2

tramadol oral capsule,er biphase 24 hr 25-75 150 mg 2 PA

tramadol oral tablet 50 mg 2 QL

tramadol oral tablet extended release 24 hr 100 mg, 200 mg, 300 mg

2 PA

tramadol oral tablet, er multiphase 24 hr 100 mg, 200 mg, 300 mg

2 PA

tramadol-acetaminophen oral tablet 37.5-325 mg 1

TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 2

XELJANZ ORAL TABLET 5 MG 4 PA; QL

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG 4 PA

ZEBUTAL ORAL CAPSULE 50-325-40 MG 1

ZIPSOR ORAL CAPSULE 25 MG 3

Anestheticslidocaine hcl laryngotracheal solution 4 % 2

lidocaine topical ointment 5 % 2

Anorectal PreparationsANUCORT-HC RECTAL SUPPOSITORY 25 MG 2 QL

hydrocortisone topical cream with perineal applicator 2.5 %

1

PROCTOSOL HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 % 1

PROCTOZONE-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 % 1

RECTIV RECTAL OINTMENT 0.4 % (W/W) 3

Antidotes And Other Reversal Agentsacetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %)

2

CHEMET ORAL CAPSULE 100 MG 3 PA

CUPRIMINE ORAL CAPSULE 250 MG 4 PA

FERRIPROX ORAL TABLET 500 MG 4 PA

JADENU ORAL TABLET 180 MG, 360 MG, 90 MG 4 PA

MOVANTIK ORAL TABLET 25 MG 2

naltrexone oral tablet 50 mg 2

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION 2

RADIOGARDASE ORAL CAPSULE 0.5 GRAM 3 PA

SYPRINE ORAL CAPSULE 250 MG 4 PA


7

Drug Tier Notes

Anti-Infective Agentsabacavir oral tablet 300 mg 4

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg

4

acyclovir oral capsule 200 mg 2

acyclovir oral suspension 200 mg/5 ml, 200 mg/5 ml (5 ml) 2

acyclovir oral tablet 400 mg, 800 mg 2

ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML 3 PA

ALINIA ORAL TABLET 500 MG 3 PA

amoxicillin oral capsule 250 mg, 500 mg 1

amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml

1

amoxicillin oral tablet 500 mg, 875 mg 1

amoxicillin oral tablet,chewable 125 mg, 250 mg, 400 mg 1

amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml

2

amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

2

amoxicillin-pot clavulanate oral tablet extended release 12 hr 1,000-62.5 mg

2

amoxicillin-pot clavulanate oral tablet,chewable 200-28.5 mg, 400-57 mg

2

ampicillin oral capsule 250 mg, 500 mg 1

APTIVUS ORAL CAPSULE 250 MG 4

APTIVUS ORAL SOLUTION 100 MG/ML 4

atovaquone oral suspension 750 mg/5 ml 2

atovaquone-proguanil oral tablet 250-100 mg, 62.5-25 mg 2

ATRIPLA ORAL TABLET 600-200-300 MG 4

AVIDOXY ORAL TABLET 100 MG 2

azithromycin oral packet 1 gram 3

azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml

1

azithromycin oral tablet 250 mg, 500 mg, 600 mg 1

BILTRICIDE ORAL TABLET 600 MG 3

CEDAX ORAL CAPSULE 400 MG 3

cefaclor oral capsule 250 mg, 500 mg 2

cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

2

cefaclor oral tablet extended release 12 hr 500 mg 2

cefadroxil oral capsule 500 mg 2

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

2

cefadroxil oral tablet 1 gram 2

cefdinir oral capsule 300 mg 1


8

Drug Tier Notescefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

1

cefditoren pivoxil oral tablet 200 mg, 400 mg 2

cefixime oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml

2

cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml

2

cefpodoxime oral tablet 100 mg, 200 mg 2

cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

2

cefprozil oral tablet 250 mg, 500 mg 2

cefuroxime axetil oral suspension for reconstitution 125 mg/5 ml

2

cefuroxime axetil oral tablet 250 mg, 500 mg 1

cephalexin oral capsule 250 mg 1

cephalexin oral capsule 500 mg 2

cephalexin oral suspension for reconstitution 125 mg/5 ml 2

cephalexin oral suspension for reconstitution 250 mg/5 ml 1

cephalexin oral tablet 250 mg 1

cephalexin oral tablet 500 mg 3

chloroquine phosphate oral tablet 250 mg, 500 mg 1

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg

1

ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml

2

clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

2

clarithromycin oral tablet 250 mg 3

clarithromycin oral tablet 500 mg 2

clarithromycin oral tablet extended release 24 hr 500 mg 2

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 2

clindamycin palmitate hcl oral recon soln 75 mg/5 ml 1

CLINDAMYCIN PEDIATRIC ORAL RECON SOLN75 MG/5 ML 1

COARTEM ORAL TABLET 20-120 MG 2

COMPLERA ORAL TABLET 200-25-300 MG 4

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 4

cycloserine oral capsule 250 mg 2

dapsone oral tablet 100 mg, 25 mg 1

DARAPRIM ORAL TABLET 25 MG 4 PA

demeclocycline oral tablet 150 mg, 300 mg 2

DESCOVY ORAL TABLET 200-25 MG 4

dicloxacillin oral capsule 250 mg, 500 mg 1

didanosine oral capsule,delayed release(dr/ec) 125 mg, 200 mg, 250 mg, 400 mg

4

DIFICID ORAL TABLET 200 MG 4 PA; QL


9

Drug Tier Notesdoxycycline hyclate oral capsule 100 mg, 50 mg 1

doxycycline hyclate oral tablet 100 mg 2

doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg

2

doxycycline monohydrate oral capsule 100 mg, 150 mg, 75 mg

2

doxycycline monohydrate oral capsule 50 mg 1

doxycycline monohydrate oral capsule,ir - delay rel,biphase40 mg

3

doxycycline monohydrate oral suspension for reconstitution25 mg/5 ml

2

doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg 2

E.E.S. 400 ORAL TABLET 400 MG 3

E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML 3

EDURANT ORAL TABLET 25 MG 4

EMTRIVA ORAL CAPSULE 200 MG 4

EMTRIVA ORAL SOLUTION 10 MG/ML 4

entecavir oral tablet 0.5 mg 4 QL

entecavir oral tablet 1 mg 4

EPCLUSA ORAL TABLET 400-100 MG 4 PA

EPZICOM ORAL TABLET 600-300 MG 4 PA

ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML 3

ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION 400 MG/5 ML 3

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 250 MG, 333 MG, 500 MG 1

ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG 1

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml

2

erythromycin ethylsuccinate oral tablet 400 mg 1

erythromycin oral tablet 250 mg, 500 mg 1

erythromycin stearate oral tablet 250 mg 1

ethambutol oral tablet 100 mg, 400 mg 2

EVOTAZ ORAL TABLET 300-150 MG 4

FACTIVE ORAL TABLET 320 MG 3

famciclovir oral tablet 125 mg, 250 mg, 500 mg 2 QL

fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml

2

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg 2

flucytosine oral capsule 250 mg, 500 mg 2

FUZEON SUBCUTANEOUS RECON SOLN 90 MG 4 PA

GENVOYA ORAL TABLET 150-150-200-10 MG 4

griseofulvin microsize oral suspension 125 mg/5 ml 2


10

Drug Tier Notesgriseofulvin microsize oral tablet 500 mg 2

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 2

HEPSERA ORAL TABLET 10 MG 4 PA

hydroxychloroquine oral tablet 200 mg 1

INVIRASE ORAL CAPSULE 200 MG 4

INVIRASE ORAL TABLET 500 MG 4

ISENTRESS ORAL POWDER IN PACKET 100 MG 4

ISENTRESS ORAL TABLET 400 MG 4

ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG 4

isoniazid oral solution 50 mg/5 ml 2

isoniazid oral tablet 100 mg, 300 mg 2

itraconazole oral capsule 100 mg 2 PA

ketoconazole oral tablet 200 mg 2

lamivudine oral tablet 100 mg, 150 mg, 300 mg 4

lamivudine-zidovudine oral tablet 150-300 mg 4

levofloxacin oral solution 250 mg/10 ml 2

levofloxacin oral tablet 250 mg, 500 mg, 750 mg 2

LEXIVA ORAL SUSPENSION 50 MG/ML 4

LEXIVA ORAL TABLET 700 MG 4

linezolid oral tablet 600 mg 2

lopinavir-ritonavir oral solution 400-100 mg/5 ml 4

MAVYRET ORAL TABLET 100-40 MG 4 PA

mefloquine oral tablet 250 mg 2

metronidazole oral capsule 375 mg 2

metronidazole oral tablet 250 mg, 500 mg 2

minocycline oral capsule 100 mg, 50 mg, 75 mg 2

minocycline oral tablet 100 mg, 50 mg, 75 mg 2

minocycline oral tablet extended release 24 hr 135 mg, 45 mg, 90 mg

2

MONDOXYNE NL ORAL CAPSULE 100 MG, 75 MG 2

MONDOXYNE NL ORAL CAPSULE 50 MG 1

MORGIDOX 1X100 KIT 100 MG 1

MORGIDOX 2X100 KIT 100 MG 1

MORGIDOX ORAL CAPSULE 100 MG 1

moxifloxacin oral tablet 400 mg 2

NEBUPENT INHALATION RECON SOLN 300 MG 4 PA

neomycin oral tablet 500 mg 1

nevirapine oral suspension 50 mg/5 ml 4

nevirapine oral tablet 200 mg 4

nevirapine oral tablet extended release 24 hr 400 mg 4

NORVIR ORAL CAPSULE 100 MG 4

NORVIR ORAL SOLUTION 80 MG/ML 4

NORVIR ORAL TABLET 100 MG 4


11

Drug Tier Notesnystatin oral tablet 500,000 unit 1

ODEFSEY ORAL TABLET 200-25-25 MG 4

ofloxacin oral tablet 300 mg, 400 mg 2

ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET 50 MG 3 PA

oseltamivir oral capsule 75 mg 1

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML 4 PA; QL

PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML 4 PA; QL

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML 4 PA; QL

penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml

1

penicillin v potassium oral tablet 250 mg, 500 mg 1

PREZISTA ORAL SUSPENSION 100 MG/ML 4

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG 4

PRIFTIN ORAL TABLET 150 MG 3

primaquine oral tablet 26.3 mg 3

PRIMSOL ORAL SOLUTION 50 MG/5 ML 2

pyrazinamide oral tablet 500 mg 2

quinine sulfate oral capsule 324 mg 2

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION 3 QL

RESCRIPTOR ORAL TABLET 200 MG 4

RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG 4

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG 4

REYATAZ ORAL POWDER IN PACKET 50 MG 4

RIBASPHERE ORAL CAPSULE 200 MG 4 PA

RIBASPHERE ORAL TABLET 200 MG, 400 MG, 600 MG 4 PA

RIBASPHERE RIBAPAK ORAL TABLETS,DOSE PACK 400 MG (7)- 400 MG (7), 400-400 MG (28)-MG (28), 600 MG (7)- 400 MG (7), 600 MG (7)- 600 MG (7), 600-400 MG (28)-MG (28), 600-600 MG (28)-MG (28)

4 PA

ribavirin oral capsule 200 mg 4 PA

ribavirin oral tablet 200 mg 4 PA

rifabutin oral capsule 150 mg 2

rifampin oral capsule 150 mg, 300 mg 2

RIFATER ORAL TABLET 50-120-300 MG 3

rimantadine oral tablet 100 mg 1

SELZENTRY ORAL TABLET 150 MG, 300 MG 4 PA

SIRTURO ORAL TABLET 100 MG 4 PA

SIVEXTRO ORAL TABLET 200 MG 4 PA

SOVALDI ORAL TABLET 400 MG 4 PAPA = Prior Authorization; ST = Step Therapy; QL = Quantity Limits

12

Drug Tier Notesstavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg 4

stavudine oral recon soln 1 mg/ml 4

STRIBILD ORAL TABLET 150-150-200-300 MG 4

STROMECTOL ORAL TABLET 3 MG 4 PA

sulfadiazine oral tablet 500 mg 2

sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml

1

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg

1

SULFATRIM ORAL SUSPENSION 200-40 MG/5 ML 1

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML 3

TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG 2 QL

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML 2 QL

TECHNIVIE ORAL TABLET 12.5-75-50 MG 4 PA

terbinafine hcl oral tablet 250 mg 2

tetracycline oral capsule 250 mg 1 PA

tetracycline oral capsule 500 mg 2

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG 4 PA; QL

TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG 4

TRECATOR ORAL TABLET 250 MG 3

trimethoprim oral tablet 100 mg 1

TRIUMEQ ORAL TABLET 600-50-300 MG 4

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG 4 QL

valacyclovir oral tablet 1 gram, 500 mg 2

VALCYTE ORAL TABLET 450 MG 4 PA

valganciclovir oral tablet 450 mg 4 PA

vancomycin oral capsule 125 mg, 250 mg 2 PA; QL

VIBRAMYCIN ORAL CAPSULE 100 MG 3

VIEKIRA PAK ORAL TABLETS,DOSE PACK 12.5 MG-75 MG -50 MG/250 MG 4 PA

VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR 8.33 MG-50 MG- 33.33 MG-200 MG 4 PA

VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) 4

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG 4

voriconazole oral tablet 200 mg, 50 mg 2 PA

XIFAXAN ORAL TABLET 200 MG, 550 MG 3 PA

ZEPATIER ORAL TABLET 50-100 MG 4 PA; QL

zidovudine oral capsule 100 mg 4

zidovudine oral syrup 10 mg/ml 4

zidovudine oral tablet 300 mg 4


13

Drug Tier NotesZITHROMAX ORAL PACKET 1 GRAM 3

ZITHROMAX ORAL TABLET 250 MG 1

ZMAX ORAL SUSPENSION,EXTENDED REL RECON 2 GRAM/60 ML 3

ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML 3 PA

ZYVOX ORAL TABLET 600 MG 3 PA

AntineoplasticsAFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG 4 PA

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG 4 PA; QL

ALECENSA ORAL CAPSULE 150 MG 4 PA

anastrozole oral tablet 1 mg 1 QL

bexarotene oral capsule 75 mg 4 PA

bicalutamide oral tablet 50 mg 1

CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG 4 PA

capecitabine oral tablet 150 mg, 500 mg 4 PA

COTELLIC ORAL TABLET 20 MG 4 PA

cromolyn oral concentrate 100 mg/5 ml 1

cyclophosphamide oral capsule 25 mg, 50 mg 4 PA

EMCYT ORAL CAPSULE 140 MG 4 PA

ERIVEDGE ORAL CAPSULE 150 MG 4 PA; QL

exemestane oral tablet 25 mg 2

FARESTON ORAL TABLET 60 MG 3 PA

FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG 4 PA

flutamide oral capsule 125 mg 2

GLEEVEC ORAL TABLET 100 MG, 400 MG 4 PA; QL

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG 4 PA

HEXALEN ORAL CAPSULE 50 MG 4 PA

hydroxyurea oral capsule 500 mg 2

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG 4 PA

ICLUSIG ORAL TABLET 15 MG, 45 MG 4 PA

imatinib oral tablet 100 mg, 400 mg 4 PA

IMBRUVICA ORAL CAPSULE 140 MG 4 PA

INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)

4 PA

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML 4 PA

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG 4 PA; QL


14

Drug Tier NotesLENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1)

4 PA

letrozole oral tablet 2.5 mg 1

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg 2

LEUKERAN ORAL TABLET 2 MG 4 PA

leuprolide subcutaneous kit 1 mg/0.2 ml 4 PA

leuprolide subcutaneous solution 1 mg/0.2 ml 4 PA

LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG 4 PA

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 22.5 MG 4 PA

LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG 4 PA

LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG 4 PA

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT7.5 MG 4 PA

LYNPARZA ORAL CAPSULE 50 MG 4 PA

LYSODREN ORAL TABLET 500 MG 4 PA

MATULANE ORAL CAPSULE 50 MG 4 PA

megestrol oral tablet 20 mg, 40 mg 2

MEKINIST ORAL TABLET 0.5 MG, 2 MG 4 PA

mercaptopurine oral tablet 50 mg 1

methotrexate sodium (pf) injection recon soln 1 gram 1

methotrexate sodium (pf) injection solution 25 mg/ml 1

methotrexate sodium injection solution 25 mg/ml 1

methotrexate sodium oral tablet 2.5 mg 1

NEXAVAR ORAL TABLET 200 MG 4 PA; QL

NILANDRON ORAL TABLET 150 MG 3 PA

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG 4 PA

ODOMZO ORAL CAPSULE 200 MG 4 PA

PURIXAN ORAL SUSPENSION 20 MG/ML 4 PA

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG 4 PA; QL

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG 4 PA; QL

STIVARGA ORAL TABLET 40 MG 4 PA

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG 4 PA; QL

TABLOID ORAL TABLET 40 MG 4 PA

TAFINLAR ORAL CAPSULE 50 MG, 75 MG 4 PA

TAGRISSO ORAL TABLET 40 MG, 80 MG 4 PA

tamoxifen oral tablet 10 mg, 20 mg 1 QL

TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG 4 PA; QL

TARGRETIN ORAL CAPSULE 75 MG 4 PA


15

Drug Tier NotesTASIGNA ORAL CAPSULE 150 MG, 200 MG 4 PA; QL

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG 4 PA; QL

tretinoin (chemotherapy) oral capsule 10 mg 4 PA

TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 2

TYKERB ORAL TABLET 250 MG 4 PA; QL

VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG 4 PA

VOTRIENT ORAL TABLET 200 MG 4 PA; QL

XALKORI ORAL CAPSULE 200 MG 4 PA; QL

XALKORI ORAL CAPSULE 250 MG 4 PA

ZOLINZA ORAL CAPSULE 100 MG 4 PA; QL

ZYKADIA ORAL CAPSULE 150 MG 4 PA

ZYTIGA ORAL TABLET 250 MG 4 PA

BiologicalsAFLURIA 2017-2018 (PF) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML 0

AFLURIA 2017-2018 INTRAMUSCULAR SUSPENSION 45 MCG (15 MCG X 3)/0.5 ML 0

AFLURIA QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE 60 MCG/0.5 ML 0

AFLURIA QUAD 2017-2018 INTRAMUSCULAR SUSPENSION 60 MCG/0.5 ML 0

FLUAD 2017-2018 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML

0

FLUARIX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML 0

FLUBLOK 2017-2018 (PF) INTRAMUSCULAR SOLUTION 135 MCG (45 MCG X 3)/0.5 ML 0

FLUBLOK QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE 180 MCG (45 MCG X 4)/0.5 ML 0

FLUCELVAX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

0

FLUCELVAX QUAD 2017-2018 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML 0

FLULAVAL QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

0

FLULAVAL QUAD 2017-2018 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML 0

FLUMIST QUAD 2017-2018 NASAL NASAL SPRAY SYRINGE 10EXP6.5-7.5 FF UNIT/0.2 ML 0

FLUVIRIN 2017-2018 (PF) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML 0

FLUVIRIN 2017-2018 INTRAMUSCULAR SUSPENSION 45 MCG (15 MCG X 3)/0.5 ML 0


16

Drug Tier NotesFLUZONE HIGH-DOSE 2017-18 (PF) INTRAMUSCULAR SYRINGE 180 MCG/0.5 ML 0

FLUZONE INTRADERM QUAD 2017-18 INTRADERMAL SYRINGE 36 MCG/0.1 ML 0

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML 0

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML 0

FLUZONE QUAD 2017-2018 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML 0

FLUZONE QUAD PEDI 2017-18 (PF) INTRAMUSCULAR SYRINGE 30 MCG (7.5 MCG X 4)/0.25 ML

0

HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %)

4 PA

Cardiovascular Therapy Agentsacebutolol oral capsule 200 mg, 400 mg 2

ADCIRCA ORAL TABLET 20 MG 4 PA; QL

AFEDITAB CR ORAL TABLET EXTENDED RELEASE 30 MG, 60 MG 2

amiloride oral tablet 5 mg 1

amiloride-hydrochlorothiazide oral tablet 5-50 mg 1

amiodarone oral tablet 100 mg, 200 mg, 400 mg 1

amlodipine oral tablet 10 mg, 2.5 mg, 5 mg 1

amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 5-10 mg, 5-20 mg

1

amlodipine-valsartan oral tablet 5-160 mg 1

atenolol oral tablet 100 mg, 25 mg, 50 mg 1

atenolol-chlorthalidone oral tablet 100-25 mg 1

atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1 QL

benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1

benazepril-hydrochlorothiazide oral tablet 20-25 mg 1

betaxolol oral tablet 10 mg, 20 mg 1

bisoprolol fumarate oral tablet 10 mg, 5 mg 1

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

1

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG 3 QL

candesartan oral tablet 16 mg, 32 mg 1 QL

candesartan oral tablet 4 mg, 8 mg 1

candesartan-hydrochlorothiazid oral tablet 32-25 mg 2 QL

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1

CARTIA XT ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 180 MG, 240 MG, 300 MG 1


17

Drug Tier Notescarvedilol oral tablet 12.5 mg, 3.125 mg, 6.25 mg 1

carvedilol oral tablet 25 mg 2

chlorothiazide oral tablet 250 mg, 500 mg 1

chlorthalidone oral tablet 25 mg, 50 mg 1

cholestyramine (with sugar) oral powder 4 gram 1

cholestyramine (with sugar) oral powder in packet 4 gram 1

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1

clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr

2

colestipol oral granules 5 gram 2

colestipol oral packet 5 gram 2

colestipol oral tablet 1 gram 2

COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR 20 MG 2 QL

CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG 3 PA; QL

DIBENZYLINE ORAL CAPSULE 10 MG 4 PA

DIGOX ORAL TABLET 125 MCG, 250 MCG 1

digoxin oral solution 0.25 mg/5 ml (5 ml), 50 mcg/ml 3

digoxin oral tablet 125 mcg, 250 mcg 1

DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE 40 MG 1

diltiazem hcl oral capsule,ext.rel 24h degradable 120 mg, 180 mg, 240 mg

1

diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg

1

diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

1

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

1

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1

diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

1

DILT-XR ORAL CAPSULE,EXT.REL 24H DEGRADABLE 120 MG, 180 MG, 240 MG 1

disopyramide phosphate oral capsule 100 mg 2

DIURIL ORAL SUSPENSION 250 MG/5 ML 2

doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1

DYRENIUM ORAL CAPSULE 100 MG, 50 MG 3

EDARBI ORAL TABLET 40 MG, 80 MG 3 QL

EDECRIN ORAL TABLET 25 MG 3 PA

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1

enalapril-hydrochlorothiazide oral tablet 10-25 mg 1

epinephrine injection auto-injector 0.3 mg/0.3 ml 2 QL

eplerenone oral tablet 25 mg, 50 mg 2

eprosartan oral tablet 600 mg 1 QL


18

Drug Tier Notesezetimibe oral tablet 10 mg 1

felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg

2

fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg

1

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg 1

fenofibrate oral capsule 150 mg, 50 mg 3

fenofibrate oral tablet 160 mg, 54 mg 1

fenofibric acid oral tablet 105 mg 3

fenofibric acid oral tablet 35 mg 2

FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML 4 PA

flecainide oral tablet 100 mg, 150 mg, 50 mg 2

fluvastatin oral capsule 20 mg, 40 mg 1 QL

fluvastatin oral tablet extended release 24 hr 80 mg 1 QL

fosinopril oral tablet 10 mg, 20 mg, 40 mg 1

furosemide oral solution 10 mg/ml, 40 mg/4 ml 1

furosemide oral tablet 20 mg, 40 mg, 80 mg 1

gemfibrozil oral tablet 600 mg 1

guanfacine oral tablet 1 mg, 2 mg 1 QL

hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1

hydrochlorothiazide oral capsule 12.5 mg 1

hydrochlorothiazide oral tablet 12.5 mg, 25 mg 1

hydrochlorothiazide oral tablet 50 mg 2

indapamide oral tablet 1.25 mg, 2.5 mg 1

INDERAL LA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 80 MG 1

INDERAL XL ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 80 MG 1

irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 QL

irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg 1 QL

ISOCHRON ORAL TABLET EXTENDED RELEASE40 MG 1

ISORDIL ORAL TABLET 40 MG 1

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg 1

isosorbide dinitrate oral tablet extended release 40 mg 1

isosorbide mononitrate oral tablet 10 mg, 20 mg 1

isosorbide mononitrate oral tablet extended release 24 hr120 mg, 30 mg, 60 mg

1

isradipine oral capsule 2.5 mg, 5 mg 1

labetalol oral tablet 100 mg, 200 mg, 300 mg 1

LANOXIN ORAL TABLET 125 MCG, 250 MCG 1

LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG 3

LASIX ORAL TABLET 40 MG 1

LETAIRIS ORAL TABLET 10 MG, 5 MG 4 PA

LEVATOL ORAL TABLET 20 MG 3


19

Drug Tier Noteslisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

1

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

1

LIVALO ORAL TABLET 1 MG, 2 MG 3 PA; QL

LIVALO ORAL TABLET 4 MG 3 QL

losartan oral tablet 100 mg 1

losartan oral tablet 25 mg, 50 mg 1 QL

losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg

1

lovastatin oral tablet 10 mg, 20 mg, 40 mg 1 QL

MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 1

methazolamide oral tablet 25 mg, 50 mg 1

methyclothiazide oral tablet 5 mg 2

methyldopa oral tablet 250 mg, 500 mg 1

metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1

metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg

1

metoprolol ta-hydrochlorothiaz oral tablet 50-25 mg 1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1

mexiletine oral capsule 150 mg, 200 mg, 250 mg 2

midodrine oral tablet 10 mg, 2.5 mg, 5 mg 2

MINITRAN TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR 1

minoxidil oral tablet 10 mg, 2.5 mg 1

moexipril oral tablet 15 mg, 7.5 mg 1

MULTAQ ORAL TABLET 400 MG 3 QL

nadolol oral tablet 20 mg, 40 mg, 80 mg 1

NIACOR ORAL TABLET 500 MG 1

nicardipine oral capsule 20 mg, 30 mg 2

nifedipine oral capsule 10 mg, 20 mg 2

nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg

2

nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg 2

nimodipine oral capsule 30 mg 2

nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg

3

NITRO-BID TRANSDERMAL OINTMENT 2 % 1

nitroglycerin sublingual tablet 0.4 mg 1

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

1

nitroglycerin translingual aerosol,spray 400 mcg/spray 3

nitroglycerin translingual spray,non-aerosol 400 mcg/spray 3

NITROLINGUAL TRANSLINGUAL SPRAY,NON-AEROSOL 400 MCG/SPRAY 3


20

Drug Tier NotesNITROMIST TRANSLINGUAL AEROSOL,SPRAY400 MCG/SPRAY 3

NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG 2

NORPACE CR ORAL CAPSULE, EXTENDED RELEASE 100 MG, 150 MG 3 ST

olmesartan oral tablet 20 mg, 40 mg, 5 mg 2 QL

omega-3 acid ethyl esters oral capsule 1 gram 2

OPSUMIT ORAL TABLET 10 MG 4 PA

PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG 1

perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1

phenoxybenzamine oral capsule 10 mg 4 PA

pindolol oral tablet 10 mg, 5 mg 1

PRAVACHOL ORAL TABLET 40 MG 1 QL

pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1 QL

prazosin oral capsule 1 mg, 2 mg, 5 mg 1

PREVALITE ORAL POWDER 4 GRAM 1

PREVALITE ORAL POWDER IN PACKET 4 GRAM 1

propafenone oral capsule,extended release 12 hr 225 mg, 325 mg, 425 mg

1

propafenone oral tablet 150 mg, 225 mg, 300 mg 1

propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg

1

propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml)

1

propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1

QUESTRAN ORAL POWDER 4 GRAM 1

QUESTRAN ORAL POWDER IN PACKET 4 GRAM 1

quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1

quinapril-hydrochlorothiazide oral tablet 20-25 mg 1

quinidine gluconate oral tablet extended release 324 mg 2

quinidine sulfate oral tablet 200 mg, 300 mg 2

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1,000 MG, 500 MG 2

rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1

SAMSCA ORAL TABLET 15 MG, 30 MG 4 PA

sildenafil (antihypertensive) oral tablet 20 mg 4 PA; QL

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg 1 QL

SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG 1

sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1

spironolactone oral tablet 100 mg, 25 mg, 50 mg 1

spironolacton-hydrochlorothiaz oral tablet 25-25 mg 1


21

Drug Tier NotesTAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG

1

TEKTURNA ORAL TABLET 150 MG, 300 MG 3 QL

telmisartan oral tablet 20 mg, 40 mg, 80 mg 2 QL

terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1

TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG 3 PA

timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1

TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 200 MG, 25 MG, 50 MG 1

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1

TRACLEER ORAL TABLET 125 MG, 62.5 MG 4 PA

trandolapril oral tablet 1 mg, 2 mg, 4 mg 1

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg 1

triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, 75-50 mg

1

TRICOR ORAL TABLET 48 MG 3

valsartan oral tablet 160 mg, 320 mg, 80 mg 1

valsartan oral tablet 40 mg 1 QL

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-25 mg, 80-12.5 mg

1

VASCEPA ORAL CAPSULE 1 GRAM 3 QL

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML 4 PA

verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg

1

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg

1

verapamil oral tablet 120 mg, 40 mg, 80 mg 1

verapamil oral tablet extended release 120 mg, 180 mg, 240 mg

1

ZETIA ORAL TABLET 10 MG 3 PA; QL

Central Nervous System AgentsADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG 2

ADZENYS XR-ODT ORAL TABLET,DISINTEG ER BIPHASE 24H 12.5 MG, 15.7 MG, 18.8 MG, 3.1 MG, 6.3 MG, 9.4 MG

3 PA; QL

almotriptan malate oral tablet 12.5 mg, 6.25 mg 1

ALPRAZOLAM INTENSOL ORAL CONCENTRATE1 MG/ML 2

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 2

alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg, 3 mg

2

alprazolam oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg

2

amantadine hcl oral capsule 100 mg 2PA = Prior Authorization; ST = Step Therapy; QL = Quantity Limits

22

Drug Tier Notesamantadine hcl oral solution 50 mg/5 ml 2

amantadine hcl oral tablet 100 mg 2

amitriptyline oral tablet 10 mg, 100 mg, 25 mg, 50 mg, 75 mg

2

amitriptyline oral tablet 150 mg 1

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg 2

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG, 348 MG, 522 MG 3 ST

aripiprazole oral solution 1 mg/ml 2

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg

1 QL

aripiprazole oral tablet 15 mg, 2 mg, 20 mg, 5 mg 1

aripiprazole oral tablet 30 mg 2

armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg 1 QL

AXERT ORAL TABLET 12.5 MG, 6.25 MG 3 PA; QL

BANZEL ORAL SUSPENSION 40 MG/ML 3 PA

BANZEL ORAL TABLET 200 MG, 400 MG 3 PA

BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG 3 ST

benztropine oral tablet 0.5 mg, 1 mg, 2 mg 1

BRIVIACT ORAL SOLUTION 10 MG/ML 3 PA

BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG 3 PA

bromocriptine oral capsule 5 mg 1

bromocriptine oral tablet 2.5 mg 1

bupropion hcl oral tablet 100 mg, 75 mg 1

bupropion hcl oral tablet extended release 12 hr 100 mg, 150 mg, 200 mg

1

bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg

1

buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg 1

carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg

1

carbamazepine oral suspension 100 mg/5 ml, 100 mg/5 ml (5 ml), 200 mg/10 ml

1

carbamazepine oral tablet 200 mg 1

carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 mg

1

carbamazepine oral tablet,chewable 100 mg 1

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

1

carbidopa-levodopa oral tablet extended release 25-100 mg, 50-200 mg

1

carbidopa-levodopa oral tablet,disintegrating 10-100 mg, 25-100 mg, 25-250 mg

1

CELEXA ORAL TABLET 40 MG 1

CELONTIN ORAL CAPSULE 300 MG 3


23

Drug Tier Noteschlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 50 mg 1

chlorpromazine oral tablet 25 mg 2

citalopram oral solution 10 mg/5 ml 1

citalopram oral tablet 10 mg, 20 mg, 40 mg 1

clomipramine oral capsule 25 mg, 50 mg, 75 mg 1

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1

clorazepate dipotassium oral tablet 3.75 mg 1

clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg 3

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg 3

desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1

desvenlafaxine succinate oral tablet extended release 24 hr50 mg

2

dexmethylphenidate oral capsule,er biphasic 50-50 15 mg 2 QL

dexmethylphenidate oral capsule,er biphasic 50-50 30 mg, 40 mg

2

dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg 2 QL

dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg

2 QL

dextroamphetamine oral tablet 10 mg 2

dextroamphetamine oral tablet 5 mg 2 QL

dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg

2 QL

dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg

2 QL

diazepam injection solution 5 mg/ml 2

DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML 2

diazepam oral concentrate 5 mg/ml 2

diazepam oral solution 5 mg/5 ml (1 mg/ml), 5 mg/5 ml (1 mg/ml, 5 ml)

2

diazepam oral tablet 10 mg, 2 mg, 5 mg 2

dihydroergotamine injection solution 1 mg/ml 2 PA

dihydroergotamine nasal spray,non-aerosol 0.5 mg/pump act. (4 mg/ml)

2 PA

DILANTIN EXTENDED ORAL CAPSULE 100 MG 1

DILANTIN KAPSEAL ORAL CAPSULE 100 MG 1

DILANTIN KAPSEAL ORAL CAPSULE 30 MG 3

DILANTIN ORAL CAPSULE 30 MG 3

divalproex oral capsule, delayed rel sprinkle 125 mg 2

divalproex oral tablet extended release 24 hr 250 mg, 500 mg

2

divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg

2

doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1

doxepin oral concentrate 10 mg/ml 1PA = Prior Authorization; ST = Step Therapy; QL = Quantity Limits

24

Drug Tier Notesduloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 40 mg, 60 mg

2

EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR 37.5 MG 2 ST

eletriptan hbr oral tablet 20 mg, 40 mg 1 QL

EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR 4 PA

entacapone oral tablet 200 mg 2

EPITOL ORAL TABLET 200 MG 1

EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG 3

escitalopram oxalate oral solution 5 mg/5 ml 2

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg 2 QL

eszopiclone oral tablet 1 mg, 2 mg, 3 mg 2 QL

ethosuximide oral capsule 250 mg 2

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG 3 PA; QL

FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2) 3 PA; QL

felbamate oral suspension 600 mg/5 ml 2

felbamate oral tablet 400 mg, 600 mg 2

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG 3 PA

fluoxetine oral capsule 10 mg, 40 mg 1

fluoxetine oral capsule 20 mg 2

fluoxetine oral capsule,delayed release(dr/ec) 90 mg 1

fluoxetine oral solution 20 mg/5 ml (4 mg/ml) 1

fluoxetine oral tablet 10 mg, 20 mg 1

fluoxetine oral tablet 60 mg 2

fluphenazine hcl oral concentrate 5 mg/ml 1

fluphenazine hcl oral elixir 2.5 mg/5 ml 1

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg 1

fluvoxamine oral tablet 100 mg, 25 mg, 50 mg 2

FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG 3 ST

frovatriptan oral tablet 2.5 mg 2 QL

gabapentin oral capsule 100 mg, 300 mg, 400 mg 2

gabapentin oral solution 250 mg/5 ml, 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml)

2

gabapentin oral tablet 600 mg, 800 mg 2

guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg

2 QL

haloperidol lactate oral concentrate 2 mg/ml 2

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg

2

HORIZANT ORAL TABLET EXTENDED RELEASE300 MG 3


25

Drug Tier Noteshydroxyzine hcl oral solution 10 mg/5 ml, 10 mg/5 ml (5 ml) 1

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 1

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 2

imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg

1

INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 6 MG, 9 MG 3 PA; QL

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 2

lamotrigine oral tablet extended release 24hr 50 mg 2

lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg 2

lamotrigine oral tablets,dose pack 25 mg (35), 25 mg (84) -100 mg (14)

2

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG 3 PA; QL

levetiracetam oral solution 100 mg/ml, 500 mg/5 ml (5 ml) 2

levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg

2

levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg

2

lithium carbonate oral capsule 150 mg, 300 mg 1

lithium carbonate oral capsule 600 mg 2

lithium carbonate oral tablet 300 mg 1

lithium carbonate oral tablet extended release 300 mg, 450 mg

1

lithium citrate oral solution 8 meq/5 ml, 8 meq/5 ml (5 ml) 2

LODOSYN ORAL TABLET 25 MG 3 PA

LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML 2

lorazepam oral concentrate 2 mg/ml 2

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 2

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg 2

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG 2

LYRICA ORAL SOLUTION 20 MG/ML 2

maprotiline oral tablet 25 mg, 50 mg, 75 mg 2

MARPLAN ORAL TABLET 10 MG 3

meprobamate oral tablet 200 mg, 400 mg 2

METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG 2

methamphetamine oral tablet 5 mg 2 QL

methylphenidate hcl oral capsule, er biphasic 30-70 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

2 QL

methylphenidate hcl oral capsule,er biphasic 50-50 20 mg, 30 mg, 40 mg

2 QL

methylphenidate hcl oral solution 10 mg/5 ml, 5 mg/5 ml 2 QL

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg 2 QLPA = Prior Authorization; ST = Step Therapy; QL = Quantity Limits

26

Drug Tier Notesmethylphenidate hcl oral tablet extended release 10 mg, 20 mg

2 QL

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg

3 QL

methylphenidate hcl oral tablet,chewable 10 mg, 2.5 mg, 5 mg

3 QL

MIGRANAL NASAL SPRAY,NON-AEROSOL 0.5 MG/PUMP ACT. (4 MG/ML) 2 QL

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg 2

mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg 2

modafinil oral tablet 100 mg, 200 mg 1 QL

naratriptan oral tablet 1 mg, 2.5 mg 2 QL

nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg

2

nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg 2

nortriptyline oral solution 10 mg/5 ml 2

NUPLAZID ORAL TABLET 17 MG 4 PA

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

2 QL

olanzapine oral tablet,disintegrating 10 mg 2

olanzapine oral tablet,disintegrating 15 mg, 5 mg 2 QL

ORAP ORAL TABLET 1 MG, 2 MG 3 PA

oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) 2

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 2

paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 6 mg, 9 mg

2 PA

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg 2

paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg

2

PEGANONE ORAL TABLET 250 MG 3

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 1

phenelzine oral tablet 15 mg 2

phenobarbital oral tablet 15 mg, 30 mg 2

phenobarbital oral tablet 64.8 mg 1

PHENYTEK ORAL CAPSULE 300 MG 2

phenytoin oral suspension 100 mg/4 ml, 125 mg/5 ml 1

phenytoin oral tablet,chewable 50 mg 1

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

1

pimozide oral tablet 1 mg, 2 mg 2

pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

2

pramipexole oral tablet extended release 24 hr 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg

2

primidone oral tablet 250 mg, 50 mg 1

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 50 MG 3 PA; QL


27

Drug Tier Notesprotriptyline oral tablet 10 mg, 5 mg 2

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

2 QL

quetiapine oral tablet extended release 24 hr 150 mg 3 QL

QUILLICHEW ER ORAL TABLET,CHEW,IR-ER.BIPHASIC24HR 20 MG, 30 MG, 40 MG 2 QL

QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML) 2 QL

rasagiline oral tablet 1 mg 2

RELPAX ORAL TABLET 20 MG, 40 MG 3 QL

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG 3 PA; QL

risperidone oral solution 1 mg/ml 2 QL

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

2 QL

risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

2 QL

rizatriptan oral tablet 10 mg, 5 mg 2 QL

rizatriptan oral tablet,disintegrating 10 mg 2 QL

ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

1

ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg

2

ROZEREM ORAL TABLET 8 MG 3 ST; QL

SABRIL ORAL POWDER IN PACKET 500 MG 4 PA

SABRIL ORAL TABLET 500 MG 4 PA

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG 3 PA; QL

SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG 3

selegiline hcl oral capsule 5 mg 2

selegiline hcl oral tablet 5 mg 2

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG, 50 MG 3 QL

sertraline oral concentrate 20 mg/ml 1

sertraline oral tablet 100 mg, 25 mg, 50 mg 1

STRATTERA ORAL CAPSULE 10 MG, 100 MG, 25 MG, 40 MG, 60 MG, 80 MG 3 ST; QL

STRATTERA ORAL CAPSULE 18 MG 2 ST; QL

sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 mg/actuation

1 QL

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg 1 QL

sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml

1 QL

sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml

1 QL

sumatriptan succinate subcutaneous solution 6 mg/0.5 ml 1 QL


28

Drug Tier Notessumatriptan succinate subcutaneous syringe 6 mg/0.5 ml 1

SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 MG/0.5 ML, 6 MG/0.5 ML 3 PA

TASMAR ORAL TABLET 100 MG 4 PA

temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg 2

tetrabenazine oral tablet 12.5 mg, 25 mg 4 PA

thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1

tiagabine oral tablet 2 mg, 4 mg 2

tolcapone oral tablet 100 mg 4 PA

topiramate oral capsule,sprinkle,er 24hr 100 mg, 150 mg, 200 mg, 25 mg, 50 mg

3

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1

tranylcypromine oral tablet 10 mg 2

trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg 2

triazolam oral tablet 0.25 mg 1

trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg 1

trihexyphenidyl oral elixir 0.4 mg/ml 1

trihexyphenidyl oral tablet 2 mg, 5 mg 1

trimipramine oral capsule 100 mg, 25 mg, 50 mg 2

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG 3 PA

valproic acid (as sodium salt) oral solution 250 mg/5 ml, 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml)

1

valproic acid oral capsule 250 mg 1

venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg

2

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 75 mg 2

venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg

2

venlafaxine oral tablet extended release 24hr 225 mg 2 ST

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG 3 ST

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) 3 ST

VIMPAT ORAL SOLUTION 10 MG/ML 3 PA

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 3 PA

VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG 3 ST

VYVANSE ORAL CAPSULE 10 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG 3

VYVANSE ORAL CAPSULE 20 MG 3 QL

WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 150 MG 1

XENAZINE ORAL TABLET 12.5 MG, 25 MG 4 PA

zaleplon oral capsule 10 mg, 5 mg 2 QL


29

Drug Tier NotesZELAPAR ORAL TABLET,DISINTEGRATING 1.25 MG 3 PA

ZENZEDI ORAL TABLET 10 MG, 5 MG 2

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg 2 QL

zolmitriptan oral tablet 2.5 mg, 5 mg 1

zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg 1

ZOLOFT ORAL TABLET 100 MG 1

zolpidem oral tablet 10 mg, 5 mg 2 QL

zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 mg

2 QL

ZOMIG ORAL TABLET 2.5 MG, 5 MG 3 PA; QL

ZOMIG ZMT ORAL TABLET,DISINTEGRATING 2.5 MG 3 PA; QL

ZOMIG ZMT ORAL TABLET,DISINTEGRATING 5 MG 3 PA

zonisamide oral capsule 100 mg, 25 mg, 50 mg 2

Chemical Dependency, Agents To Treatbuprenorphine hcl sublingual tablet 2 mg, 8 mg 1 QL

buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 mg 1 QL

bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg

1 QL

bupropion hcl oral tablet extended release 12 hr 150 mg 1

CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG 1 QL

CHANTIX ORAL TABLET 0.5 MG, 1 MG 1 QL

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) 1 QL

disulfiram oral tablet 250 mg, 500 mg 1

nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr

0

NICOTROL INHALATION CARTRIDGE 10 MG 1 QL

NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML 1 QL

SUBOXONE SUBLINGUAL FILM 8-2 MG 3 PA

Chemicals-Pharmaceutical Adjuvantsbenzoin compound (bulk) tincture 2

isopropyl alcohol solution 70 % 2

polyethylene glycol 3350(bulk) powder 1

Cognitive Disorder Therapydonepezil oral tablet 10 mg, 5 mg 1

donepezil oral tablet,disintegrating 10 mg, 5 mg 1

ergoloid oral tablet 1 mg 1

galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg

2

galantamine oral solution 4 mg/ml 2

galantamine oral tablet 12 mg, 4 mg, 8 mg 2PA = Prior Authorization; ST = Step Therapy; QL = Quantity Limits

30

Drug Tier Notesmemantine oral tablet 10 mg 1

NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG 3 ST

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

2

ContraceptivesAFTERA ORAL TABLET 1.5 MG 1

AMETHIA LO ORAL TABLETS,DOSE PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7) 1

AMETHIA ORAL TABLETS,DOSE PACK,3 MONTH0.15 MG-30 MCG (84)/10 MCG (7) 1

AMETHYST ORAL TABLET 90-20 MCG 0

APRI ORAL TABLET 0.15-0.03 MG 0

ASHLYNA ORAL TABLETS,DOSE PACK,3 MONTH0.15 MG-30 MCG (84)/10 MCG (7) 1

AVIANE ORAL TABLET 0.1-20 MG-MCG 0

AZURETTE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 0

BALZIVA (28) ORAL TABLET 0.4-35 MG-MCG 0

BEKYREE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 1

BLISOVI 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4) 1

BLISOVI FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) 1

BLISOVI FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) 1

CAMILA ORAL TABLET 0.35 MG 1

CAMRESE ORAL TABLETS,DOSE PACK,3 MONTH0.15 MG-30 MCG (84)/10 MCG (7) 1

CAZIANT (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG 0

CRYSELLE (28) ORAL TABLET 0.3-30 MG-MCG 0

CYCLAFEM 1/35 (28) ORAL TABLET 1-35 MG-MCG 0

CYCLAFEM 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG 0

CYRED ORAL TABLET 0.15-0.03 MG 1

DASETTA 1/35 (28) ORAL TABLET 1-35 MG-MCG 0

DASETTA 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG 0

DEBLITANE ORAL TABLET 0.35 MG 1

DELYLA (28) ORAL TABLET 0.1-20 MG-MCG 1

desog-e.estradiol/e.estradiol oral tablet 0.15-0.02 mgx21 /0.01 mg x 5

1

desogestrel-ethinyl estradiol oral tablet 0.15-0.03 mg 1

drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg

0

ECONTRA EZ ORAL TABLET 1.5 MG 1PA = Prior Authorization; ST = Step Therapy; QL = Quantity Limits

31

Drug Tier NotesELINEST ORAL TABLET 0.3-30 MG-MCG 0

ELLA ORAL TABLET 30 MG 1

EMOQUETTE ORAL TABLET 0.15-0.03 MG 0

ENSKYCE ORAL TABLET 0.15-0.03 MG 1

ERRIN ORAL TABLET 0.35 MG 1

ESTARYLLA ORAL TABLET 0.25-35 MG-MCG 1

FALMINA (28) ORAL TABLET 0.1-20 MG-MCG 0

GIANVI (28) ORAL TABLET 3-0.02 MG 0

GILDAGIA ORAL TABLET 0.4-35 MG-MCG 1

HEATHER ORAL TABLET 0.35 MG 1

JENCYCLA ORAL TABLET 0.35 MG 1

JOLESSA ORAL TABLETS,DOSE PACK,3 MONTH0.15 MG-30 MCG 0

JOLIVETTE ORAL TABLET 0.35 MG 0

JULEBER ORAL TABLET 0.15-0.03 MG 1

JUNEL 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 0

JUNEL 1/20 (21) ORAL TABLET 1-20 MG-MCG 0

JUNEL FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) 0

JUNEL FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) 0

JUNEL FE 24 ORAL TABLET 1 MG-20 MCG (24)/75 MG (4) 1

KAITLIB FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4) 1

KARIVA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 0

KELNOR 1/35 (28) ORAL TABLET 1-35 MG-MCG 0

KIMIDESS (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 1

KURVELO ORAL TABLET 0.15-0.03 MG 0

LARIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 1

LARIN 1/20 (21) ORAL TABLET 1-20 MG-MCG 1

LARIN 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4) 1

LARIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) 1

LARIN FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) 1

LARISSIA ORAL TABLET 0.1-20 MG-MCG 1

LAYOLIS FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4) 1

LESSINA ORAL TABLET 0.1-20 MG-MCG 0

LEVONEST (28) ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10) 0

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg

0


32

Drug Tier Noteslevonorgestrel-ethinyl estrad oral tablets,dose pack,3 month0.15 mg-30 mcg

0

LEVORA 0.15/30 (28) ORAL TABLET 0.15-0.03 MG 0

LEVORA-28 ORAL TABLET 0.15-0.03 MG 0

LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)/10 MCG (2) 2

LOMEDIA 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4) 1

LORYNA (28) ORAL TABLET 3-0.02 MG 0

LOW-OGESTREL (28) ORAL TABLET 0.3-30 MG-MCG 0

LUTERA (28) ORAL TABLET 0.1-20 MG-MCG 0

LYZA ORAL TABLET 0.35 MG 1

MARLISSA ORAL TABLET 0.15-0.03 MG 0

medroxyprogesterone intramuscular suspension 150 mg/ml 1

medroxyprogesterone intramuscular syringe 150 mg/ml 1

MICROGESTIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 0

MICROGESTIN 1/20 (21) ORAL TABLET 1-20 MG-MCG 0

MICROGESTIN 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4) 1

MICROGESTIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) 0

MICROGESTIN FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) 0

MIRENA INTRAUTERINE INTRAUTERINE DEVICE 20 MCG/24 HR (5 YEARS) 0

MONO-LINYAH ORAL TABLET 0.25-35 MG-MCG 1

MONONESSA (28) ORAL TABLET 0.25-35 MG-MCG 0

MYZILRA ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10) 0

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG 0

NECON 1/50 (28) ORAL TABLET 1-50 MG-MCG 0

NECON 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG 0

NIKKI (28) ORAL TABLET 3-0.02 MG 1

NORA-BE ORAL TABLET 0.35 MG 0

noreth-ethinyl estradiol-iron oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4)

1

norethindrone (contraceptive) oral tablet 0.35 mg 1

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg 1

norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7)

1

norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-35 mcg (28)

0

NORLYROC ORAL TABLET 0.35 MG 1


33

Drug Tier NotesNORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG 0

NUVARING VAGINAL RING 0.12-0.015 MG/24 HR 0

OCELLA ORAL TABLET 3-0.03 MG 0

OPCICON ONE-STEP ORAL TABLET 1.5 MG 1

ORSYTHIA ORAL TABLET 0.1-20 MG-MCG 0

ORTHO TRI-CYCLEN LO (28) ORAL TABLET0.18/0.215/0.25 MG-25 MCG 0

PIMTREA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 1

PIRMELLA ORAL TABLET 0.5/0.75/1 MG- 35 MCG, 1-35 MG-MCG 1

PORTIA ORAL TABLET 0.15-0.03 MG 0

PREVIFEM ORAL TABLET 0.25-35 MG-MCG 0

QUASENSE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG 0

RECLIPSEN (28) ORAL TABLET 0.15-0.03 MG 0

SETLAKIN ORAL TABLETS,DOSE PACK,3 MONTH0.15 MG-30 MCG 1

SHAROBEL ORAL TABLET 0.35 MG 1

SPRINTEC (28) ORAL TABLET 0.25-35 MG-MCG 0

SRONYX ORAL TABLET 0.1-20 MG-MCG 0

TAKE ACTION ORAL TABLET 1.5 MG 1

TARINA FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) 1

TAYTULLA ORAL CAPSULE 1 MG-20 MCG (24)/75 MG (4) 3

TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) 1

TRI-LINYAH ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) 0

TRI-LO-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-25 MCG 1

TRI-LO-MARZIA ORAL TABLET 0.18/0.215/0.25 MG-25 MCG 0

TRI-LO-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-25 MCG 1

TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) 0

TRINESSA LO ORAL TABLET 0.18/0.215/0.25 MG-25 MCG 1

TRI-PREVIFEM (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) 0

TRI-SPRINTEC (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) 0

VELIVET TRIPHASIC REGIMEN (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG 0

VESTURA (28) ORAL TABLET 3-0.02 MG 0

VIENVA ORAL TABLET 0.1-20 MG-MCG 1


34

Drug Tier NotesVIORELE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 0

VYFEMLA (28) ORAL TABLET 0.4-35 MG-MCG 1

WERA (28) ORAL TABLET 0.5-35 MG-MCG 0

WYMZYA FE ORAL TABLET,CHEWABLE 0.4MG-35MCG(21) AND 75 MG (7) 1

XULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24 HR 1

ZARAH ORAL TABLET 3-0.03 MG 0

DermatologicalACANYA TOPICAL GEL WITH PUMP 1.2-2.5 % 3 ST

acitretin oral capsule 10 mg, 17.5 mg, 25 mg 2 PA

acyclovir topical ointment 5 % 2 QL

adapalene topical cream 0.1 % 2

adapalene topical gel 0.1 %, 0.3 % 2

adapalene topical gel with pump 0.3 % 2

AGONEAZE TOPICAL KIT 2.5-2.5 % 1

alclometasone topical cream 0.05 % 2

alclometasone topical ointment 0.05 % 2

ALTABAX TOPICAL OINTMENT 1 % 3

amcinonide topical cream 0.1 % 2

amcinonide topical lotion 0.1 % 2

amcinonide topical ointment 0.1 % 2

ammonium lactate topical cream 12 % 2

ANODYNE LPT TOPICAL KIT 2.5-2.5 % 1

AVITA TOPICAL CREAM 0.025 % 2

AVITA TOPICAL GEL 0.025 % 2

AZELEX TOPICAL CREAM 20 % 3 ST

bacitracin topical ointment 500 unit/gram 2

bacitracin topical packet 500 unit/gram 2

benzoin compound (bulk) tincture 2

benzoin compound topical tincture 2

BENZOIN COMPOUND TOPICAL TINCTURE 10-2-8-4 % 2

betamethasone dipropionate topical cream 0.05 % 2

betamethasone dipropionate topical lotion 0.05 % 2

betamethasone dipropionate topical ointment 0.05 % 2

betamethasone valerate topical cream 0.1 % 2

betamethasone valerate topical lotion 0.1 % 2

betamethasone valerate topical ointment 0.1 % 2

betamethasone, augmented topical cream 0.05 % 2

betamethasone, augmented topical gel 0.05 % 2

betamethasone, augmented topical lotion 0.05 % 2

betamethasone, augmented topical ointment 0.05 % 2


35

Drug Tier Notescalcipotriene scalp solution 0.005 % 2

calcipotriene topical cream 0.005 % 2

calcitriol topical ointment 3 mcg/gram 2

camphor topical spirit 2

CICLODAN KIT TOPICAL COMBO PACK 0.77 % 2

CICLODAN KIT TOPICAL SOLUTION 8 % 2

CICLODAN TOPICAL CREAM 0.77 % 2

CICLODAN TOPICAL SOLUTION 8 % 2

ciclopirox topical cream 0.77 % 2

ciclopirox topical gel 0.77 % 2

ciclopirox topical shampoo 1 % 2

ciclopirox topical solution 8 % 2

ciclopirox topical suspension 0.77 % 2

ciclopirox-ure-camph-menth-euc topical solution 8 % 2

CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG 2 QL

CLINDACIN ETZ TOPICAL KIT 1 % 1

CLINDACIN ETZ TOPICAL SWAB 1 % 1

CLINDACIN P TOPICAL SWAB 1 % 1

CLINDACIN PAC TOPICAL KIT 1 % 1

CLINDAGEL TOPICAL GEL 1 % 3

clindamycin phosphate topical foam 1 % 2

clindamycin phosphate topical gel 1 % 2

clindamycin phosphate topical lotion 1 % 2

clindamycin phosphate topical solution 1 % 1

clindamycin phosphate topical swab 1 % 1

clindamycin-benzoyl peroxide topical gel 1-5 % 2

clindamycin-benzoyl peroxide topical gel with pump 1-5 % 2

clobetasol scalp solution 0.05 % 2

clobetasol topical cream 0.05 % 2

clobetasol topical foam 0.05 % 2

clobetasol topical gel 0.05 % 2

clobetasol topical lotion 0.05 % 2

clobetasol topical ointment 0.05 % 2

clobetasol topical shampoo 0.05 % 2

clobetasol topical spray,non-aerosol 0.05 % 2

clobetasol-emollient topical cream 0.05 % 2

clobetasol-emollient topical foam 0.05 % 2

clocortolone pivalate topical cream 0.1 % 3

CLODAN KIT TOPICAL KIT,SHAMPOO AND CLEANSER 0.05 % 2

CLODAN TOPICAL SHAMPOO 0.05 % 2

clotrimazole-betamethasone topical cream 1-0.05 % 1

CORDRAN TOPICAL LOTION 0.05 % 3 PA


36

Drug Tier NotesCORMAX SCALP SOLUTION 0.05 % 2

CORTISPORIN TOPICAL CREAM 3.5-10,000-0.5 MG/G-UNIT/G-% 3

CORTISPORIN TOPICAL OINTMENT 1 % 3

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML 4 PA

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MG/ML 4 PA

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR150 MG/ML 4 PA

COSENTYX SUBCUTANEOUS SYRINGE 150 MG/ML 4 PA

DENAVIR TOPICAL CREAM 1 % 3 PA; QL

DERMACINRX EMPRICAINE TOPICAL KIT 2.5-2.5 % 1

DERMACINRX SILAZONE TOPICAL KIT 0.1 % 2

DESONATE TOPICAL GEL 0.05 % 3

desonide topical cream 0.05 % 2

desonide topical lotion 0.05 % 2

desonide topical ointment 0.05 % 2

desoximetasone topical cream 0.05 %, 0.25 % 2

desoximetasone topical gel 0.05 % 2

desoximetasone topical ointment 0.05 % 3

desoximetasone topical ointment 0.25 % 2

diclofenac sodium topical drops 1.5 % 2 QL

diclofenac sodium topical gel 1 % 2 QL

DICLOZOR TOPICAL KIT 1 % 2

diflorasone topical cream 0.05 % 2

diflorasone topical ointment 0.05 % 2

doxepin topical cream 5 % 2 PA

doxycycline monohydrate oral capsule,ir - delay rel,biphase40 mg

3

econazole topical cream 1 % 2

ELIDEL TOPICAL CREAM 1 % 3

ELIMITE TOPICAL CREAM 5 % 1

EPIDUO TOPICAL GEL WITH PUMP 0.1-2.5 % 3 ST

ERTACZO TOPICAL CREAM 2 % 3 PA

ERY PADS TOPICAL SWAB 2 % 1

erythromycin with ethanol topical gel 2 % 2

erythromycin with ethanol topical solution 2 % 1

erythromycin with ethanol topical swab 2 % 1

EURAX TOPICAL CREAM 10 % 3

EURAX TOPICAL LOTION 10 % 3

EVOCLIN TOPICAL FOAM 1 % 3

EXELDERM TOPICAL CREAM 1 % 3 ST


37

Drug Tier NotesEXELDERM TOPICAL SOLUTION 1 % 3 ST

FINACEA TOPICAL GEL 15 % 3

finasteride oral tablet 1 mg 2

fluocinolone and shower cap scalp oil 0.01 % 2

fluocinolone topical cream 0.01 %, 0.025 % 2

fluocinolone topical oil 0.01 % 2

fluocinolone topical ointment 0.025 % 2

fluocinolone topical solution 0.01 % 2

fluocinonide topical cream 0.05 %, 0.1 % 2

fluocinonide topical gel 0.05 % 2

fluocinonide topical ointment 0.05 % 2

fluocinonide topical solution 0.05 % 2

FLUOCINONIDE-E TOPICAL CREAM 0.05 % 2

fluocinonide-emollient topical cream 0.05 % 2

FLUOROPLEX TOPICAL CREAM 1 % 2 PA

fluorouracil topical cream 5 % 2

fluorouracil topical solution 2 %, 5 % 2

fluticasone topical cream 0.05 % 2

fluticasone topical lotion 0.05 % 2

fluticasone topical ointment 0.005 % 2

gentamicin topical cream 0.1 % 1

gentamicin topical ointment 0.1 % 1

GLYDO MUCOUS MEMBRANE JELLY IN APPLICATOR 2 % 2

halobetasol propionate topical cream 0.05 % 2

halobetasol propionate topical ointment 0.05 % 2 ST

HALOG TOPICAL CREAM 0.1 % 3 ST

HALOG TOPICAL OINTMENT 0.1 % 3 ST

hydrocortisone butyrate topical cream 0.1 % 2

hydrocortisone butyrate topical ointment 0.1 % 2

hydrocortisone butyrate topical solution 0.1 % 2

hydrocortisone butyr-emollient topical cream 0.1 % 2

hydrocortisone topical cream 2.5 % 1

hydrocortisone topical cream with perineal applicator 2.5 %

1

hydrocortisone topical lotion 2.5 % 2

hydrocortisone topical ointment 2.5 % 1

hydrocortisone valerate topical cream 0.2 % 2

hydrocortisone valerate topical ointment 0.2 % 2

imiquimod topical cream in packet 5 % 1

JUBLIA TOPICAL SOLUTION WITH APPLICATOR10 % 3 ST

KERYDIN TOPICAL SOLUTION WITH APPLICATOR 5 % 3 ST


38

Drug Tier Notesketoconazole topical cream 2 % 2

ketoconazole topical foam 2 % 2

ketoconazole topical shampoo 2 % 2

LEVA SET TOPICAL KIT 2.5-2.5 % 1

lidocaine hcl mucous membrane jelly 2 % 2

lidocaine hcl mucous membrane jelly in applicator 2 % 2

lidocaine topical adhesive patch,medicated 5 % 2 QL

lidocaine topical ointment 5 % 2

lidocaine-prilocaine topical cream 2.5-2.5 % 1

lidocaine-prilocaine topical kit 2.5-2.5 % 1

LIDOPAC TOPICAL KIT 5 % 2

LIDOPRIL TOPICAL KIT 2.5-2.5 % 1

LIDOPRIL XR TOPICAL KIT 2.5-2.5 % 1

LIDO-PRILO CAINE PACK TOPICAL KIT 2.5-2.5 % 1

LIDORXKIT TOPICAL COMBO PACK,OINTMENT AND CREAM 5 % 2

LIDOTREX TOPICAL GEL 2 % 2

lindane topical shampoo 1 % 2

LIPROZONEPAK TOPICAL KIT 2.5-2.5 % 1

LIVIXIL PAK TOPICAL KIT 2.5-2.5 % 1

LOPROX (AS OLAMINE) TOPICAL CREAM 0.77 % 1

LOPROX KIT TOPICAL COMBO PACK 0.77 % 1

LOTRISONE TOPICAL CREAM 1-0.05 % 3 PA

LP LITE PAK TOPICAL KIT 2.5-2.5 % 1

malathion topical lotion 0.5 % 2

MEDOLOR PAK TOPICAL KIT 2.5-2.5 % 1

MENTAX TOPICAL CREAM 1 % 3 ST

METROGEL TOPICAL GEL 1 % 3

METROGEL TOPICAL GEL WITH PUMP 1 % 3

metronidazole topical cream 0.75 % 2

metronidazole topical gel 0.75 %, 1 % 2

metronidazole topical gel with pump 1 % 2

metronidazole topical lotion 0.75 % 2

minocycline oral tablet extended release 24 hr 135 mg, 45 mg, 90 mg

2

mometasone topical cream 0.1 % 2

mometasone topical ointment 0.1 % 2

mometasone topical solution 0.1 % 2

mupirocin topical ointment 2 % 2

MYORISAN ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG 2

NORITATE TOPICAL CREAM 1 % 3

NYAMYC TOPICAL POWDER 100,000 UNIT/GRAM 1

nystatin topical cream 100,000 unit/gram 1


39

Drug Tier Notesnystatin topical ointment 100,000 unit/gram 1

nystatin topical powder 100,000 unit/gram 1

nystatin-triamcinolone topical cream 100,000-0.1 unit/g-% 2

nystatin-triamcinolone topical ointment 100,000-0.1 unit/gram-%

1

NYSTOP TOPICAL POWDER 100,000 UNIT/GRAM 1

PANDEL TOPICAL CREAM 0.1 % 2

PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 20 MG/GRAM /ACTUATION(2 %) 3

PENNSAID TOPICAL SOLUTION IN PACKET 2 % 3

permethrin topical cream 5 % 1

PICATO TOPICAL GEL 0.015 % 3 PA

PICATO TOPICAL GEL 0.05 % 2

podofilox topical solution 0.5 % 2

prednicarbate topical cream 0.1 % 2

prednicarbate topical ointment 0.1 % 2

PRILOLID TOPICAL KIT 2.5-2.5 % 1

PROCTOSOL HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 % 1

PROCTOZONE-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 % 1

PRUDOXIN TOPICAL CREAM 5 % 2 PA

REFISSA TOPICAL CREAM 0.05 % 2

REGRANEX TOPICAL GEL 0.01 % 3 PA

ROSADAN TOPICAL CREAM 0.75 % 2

ROSADAN TOPICAL GEL 0.75 % 2

ROSADAN TOPICAL KIT, CLEANSER AND GEL0.75 % 2

ROSADAN TOPICAL KIT,CLEANSER AND CREAM0.75 % 2

SANTYL TOPICAL OINTMENT 250 UNIT/GRAM 3

SCALACORT TOPICAL LOTION 2 % 2

selenium sulfide topical lotion 2.5 % 2

selenium sulfide topical shampoo 2.25 % 1

SILAZONE-II TOPICAL KIT 0.1 % 2

silver sulfadiazine topical cream 1 % 1

SKLICE TOPICAL LOTION 0.5 % 3

SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG 3 PA

spinosad topical suspension 0.9 % 3

SSD TOPICAL CREAM 1 % 1

STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML 4 PA

STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML 4 PA

sulfacetamide sodium (acne) topical suspension 10 % 2


40

Drug Tier NotesSULFAMYLON TOPICAL CREAM 85 MG/G 3

SULFAMYLON TOPICAL PACKET 50 GRAM 3

SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING 70-70 MG 3

tacrolimus topical ointment 0.03 %, 0.1 % 2

TALTZ SYRINGE (2 PACK) SUBCUTANEOUS SYRINGE 80 MG/ML 4 PA

TALTZ SYRINGE (3 PACK) SUBCUTANEOUS SYRINGE 80 MG/ML 4 PA

TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MG/ML 4 PA

TARGRETIN TOPICAL GEL 1 % 4 PA

TAZORAC TOPICAL CREAM 0.05 %, 0.1 % 3 PA

TAZORAC TOPICAL GEL 0.05 %, 0.1 % 3 PA

THERMAZENE TOPICAL CREAM 1 % 1

tretinoin (emollient) topical cream 0.05 % 2

tretinoin microspheres topical gel 0.1 % 2

tretinoin microspheres topical gel with pump 0.1 % 2

tretinoin topical cream 0.025 %, 0.05 %, 0.1 % 2

tretinoin topical gel 0.01 %, 0.025 %, 0.05 % 2

TRETIN-X CREAM KIT TOPICAL COMBO PACK0.025 %, 0.05 %, 0.1 % 2

TRETIN-X TOPICAL CREAM 0.075 % 2

triamcinolone acetonide topical cream 0.025 %, 0.1 %, 0.5 %

2

triamcinolone acetonide topical lotion 0.025 %, 0.1 % 2

triamcinolone acetonide topical ointment 0.025 %, 0.1 % 2

triamcinolone acetonide topical ointment 0.5 % 3

TRIDERM TOPICAL CREAM 0.1 % 2

ULESFIA TOPICAL LOTION 5 % 3

VERDESO TOPICAL FOAM 0.05 % 3

VEREGEN TOPICAL OINTMENT 15 % 3 PA

XOLEGEL TOPICAL GEL 2 % 3 ST

XRYLIX TOPICAL KIT 1.5 % 2

ZENATANE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG 2

Diagnostic AgentsGLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN 1 MG/ML 2

glucagon hcl injection recon soln 1 mg 2

Eating Disorder Therapydronabinol oral capsule 10 mg, 2.5 mg, 5 mg 2 QL

megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml), 800 mg/20 ml (20 ml)

2


41

Drug Tier Notes

Electrolyte Balance-Nutritional Productscalcitriol oral capsule 0.25 mcg, 0.5 mcg 1

calcitriol oral solution 1 mcg/ml 1

calcium acetate oral tablet 667 mg 2

cyanocobalamin (vitamin b-12) injection solution 1,000 mcg/ml

2

ergocalciferol (vitamin d2) oral capsule 50,000 unit 1 QL

folic acid oral tablet 1 mg 1

KALEXATE ORAL POWDER IN PACKET 15 GRAM 1

K-EFFERVESCENT ORAL TABLET, EFFERVESCENT 25 MEQ 1

KIONEX (WITH SORBITOL) ORAL SUSPENSION15-19.3 GRAM/60 ML 1

KIONEX ORAL POWDER 1

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ 1

KLOR-CON 8 ORAL TABLET EXTENDED RELEASE 8 MEQ 1

KLOR-CON M10 ORAL TABLET,ER PARTICLES/CRYSTALS 10 MEQ 1



KLOR-CON SPRINKLE ORAL CAPSULE, EXTENDED RELEASE 10 MEQ, 8 MEQ 1

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ, 8 MEQ 1

PHYSIOLYTE IRRIGATION SOLUTION 140-5-3-98 MEQ/L 3

PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 140-5-3-98 MEQ/L 3

potassium bicarb-citric acid oral tablet, effervescent 25 meq

1

potassium chloride oral capsule, extended release 10 meq, 8 meq

1

potassium chloride oral tablet extended release 10 meq, 20 meq, 8 meq

1

potassium chloride oral tablet,er particles/crystals 10 meq, 20 meq

1

PRENATAL PLUS (CALCIUM CARB) ORAL TABLET 27 MG IRON- 1 MG 0

ROCALTROL ORAL CAPSULE 0.25 MCG 1

SODIUM POLYSTYRENE (SORB FREE) ORAL SUSPENSION 15 GRAM/60 ML 1

sodium polystyrene sulfonate oral powder 1

sodium polystyrene sulfonate oral suspension 15 gram/60 ml

1


42

Drug Tier Notessodium polystyrene sulfonate rectal enema 30 gram/120 ml, 50 gram/200 ml

1

SPS (WITH SORBITOL) ORAL SUSPENSION 15-20 GRAM/60 ML 1

SPS (WITH SORBITOL) RECTAL ENEMA 30-40 GRAM/120 ML 1

VITAMIN B-12 INJECTION SOLUTION 1,000 MCG/ML 2

VITAMIN D2 ORAL CAPSULE 50,000 UNIT 1 QL

Endocrineacarbose oral tablet 100 mg, 25 mg, 50 mg 1

alendronate oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg 1

AMABELZ ORAL TABLET 0.5-0.1 MG, 1-0.5 MG 1

ANADROL-50 ORAL TABLET 50 MG 3 PA

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) 2 PA; QL

ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)

2 PA; QL

ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 30 MG, 60 MG, 90 MG 3

AVANDIA ORAL TABLET 2 MG, 4 MG 3 ST

BASAGLAR KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) 2

BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML 2 ST; QL

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG 2 ST; QL

BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML

2 PA; ST; QL

cabergoline oral tablet 0.5 mg 2

calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation

2

chlorpropamide oral tablet 100 mg, 250 mg 1

cortisone oral tablet 25 mg 1

CRINONE VAGINAL GEL 8 % 4 PA

danazol oral capsule 100 mg, 200 mg, 50 mg 2

DEPO-TESTOSTERONE INTRAMUSCULAR OIL100 MG/ML, 200 MG/ML 2

desmopressin injection solution 4 mcg/ml 2

desmopressin nasal aerosol,spray 10 mcg/spray (0.1 ml) 2

desmopressin nasal solution 0.1 mg/ml (refrigerate) 2

desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml)

2

desmopressin oral tablet 0.1 mg, 0.2 mg 2

DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML 1


43

Drug Tier Notesdexamethasone oral elixir 0.5 mg/5 ml 3

dexamethasone oral solution 0.5 mg/5 ml 3

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1.5 mg, 4 mg, 6 mg

1

dexamethasone oral tablet 1 mg, 2 mg 3

DEXPAK 10 DAY ORAL TABLETS,DOSE PACK 1.5 MG (35 TABS) 3



DIVIGEL TRANSDERMAL GEL IN PACKET 0.25 MG/0.25 GRAM (0.1 %), 0.5 MG/0.5 GRAM (0.1 %), 1 MG/GRAM (0.1 %)

3

DM2 COMBO PACK, TABLET AND STRIP 500 MG 1

DUAVEE ORAL TABLET 0.45-20 MG 2

ELESTRIN TRANSDERMAL GEL IN METERED-DOSE PUMP 0.87 GRAM/ACTUATION 3

ENDOMETRIN VAGINAL INSERT 100 MG 3

estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1

estradiol transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

1

ESTRADIOL TRANSDERMAL PATCH TRANSDERMAL PATCH WEEKLY 0.05 MG/24 HR, 0.1 MG/24 HR

1

estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

1

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml 2

estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg

1

estrogens-methyltestosterone oral tablet 0.625-1.25 mg, 1.25-2.5 mg

2

estropipate oral tablet 0.75 mg, 1.5 mg 1

estropipate oral tablet 3 mg 2

etidronate disodium oral tablet 200 mg, 400 mg 2

EVAMIST TRANSDERMAL SPRAY,NON-AEROSOL1.53 MG/SPRAY (1.7%) 3

FARXIGA ORAL TABLET 10 MG, 5 MG 2 ST

fludrocortisone oral tablet 0.1 mg 2

FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 MCG/2.4 ML 4 PA

FOSAMAX PLUS D ORAL TABLET 70 MG- 2,800 UNIT, 70 MG- 5,600 UNIT 3

ganirelix subcutaneous syringe 250 mcg/0.5 ml 4 PA

glimepiride oral tablet 1 mg, 2 mg, 4 mg 1

glipizide oral tablet 10 mg, 5 mg 1


44

Drug Tier Notesglipizide oral tablet extended release 24hr 10 mg, 2.5 mg, 5 mg

1

GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG 2

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG 2

glucagon hcl injection recon soln 1 mg 2

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg 1

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg 1

GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG 3 PA

HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 200 UNIT/ML (3 ML) 2

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) 2

HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) 2

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25) 2

HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) 2

HUMALOG SUBCUTANEOUS CARTRIDGE 100 UNIT/ML 2

HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML 2

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION100 UNIT/ML (70-30) 2

HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML 2

HUMULIN R U-100 INJECTION SOLUTION 100 UNIT/ML 2

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML)

2

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML 2 PA

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1

hydroxyprogesterone capr(bulk) powder 100 % 1

hydroxyprogesterone caproate intramuscular oil 250 mg/ml 4 PA

ibandronate oral tablet 150 mg 1

INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML 4 PA

INVOKANA ORAL TABLET 100 MG, 300 MG 3 ST

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG 2 QL

LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) 3 ST

LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML 3

LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) 3 ST


45

Drug Tier NotesLEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML 3 ST

levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

1

LEVOXYL ORAL TABLET 100 MCG, 125 MCG, 75 MCG, 88 MCG 3

liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg 1

LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET 3.75 MG -5 MG (30) 4 PA

LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET 11.25 MG -5 MG (90) 4 PA

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG 4 PA

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT3.75 MG 4 PA

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 30 MG 4 PA

LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG (PED) 4 PA

medroxyprogesterone oral tablet 10 mg, 2.5 mg 1

medroxyprogesterone oral tablet 5 mg 2

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG 2

MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG/24 HR 3

metformin oral tablet 1,000 mg, 500 mg, 850 mg 1

metformin oral tablet extended release 24 hr 500 mg, 750 mg

1

metformin oral tablet,er gast.retention 24 hr 500 mg 1

methimazole oral tablet 10 mg, 5 mg 2

METHITEST ORAL TABLET 10 MG 2 PA

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1

methylprednisolone oral tablets,dose pack 4 mg 1

methyltestosterone oral capsule 10 mg 2

MIACALCIN INJECTION SOLUTION 200 UNIT/ML 4 PA

MILLIPRED DP ORAL TABLETS,DOSE PACK 5 MG (21 TABS), 5 MG (48 TABS) 2

MILLIPRED ORAL SOLUTION 10 MG/5 ML 2

MILLIPRED ORAL TABLET 5 MG 2

MIMVEY LO ORAL TABLET 0.5-0.1 MG 1

MIMVEY ORAL TABLET 1-0.5 MG 1

MYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML (FINAL CONC.) 4 PA

nateglinide oral tablet 120 mg, 60 mg 2

NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

2

NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG 3 PA; QL


46

Drug Tier Notesnorethindrone acetate oral tablet 5 mg 2

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) 2

NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML 2

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML 2

NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML 2

NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) 2

NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION100 UNIT/ML (70-30) 2

NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE 100 UNIT/ML 2

NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML 2

NP THYROID ORAL TABLET 30 MG, 60 MG, 90 MG 1

NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML)

4 PA

octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

4 PA

OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) 4 PA

OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG 4 PA

OSPHENA ORAL TABLET 60 MG 3

oxandrolone oral tablet 10 mg, 2.5 mg 2 PA

PEDIAPRED ORAL SOLUTION 5 MG BASE/5 ML (6.7 MG/5 ML) 1

pioglitazone oral tablet 15 mg, 30 mg, 45 mg 2 QL

PRANDIN ORAL TABLET 1 MG, 2 MG 1

prednisolone oral solution 15 mg/5 ml 2

prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

2

PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML 1

prednisone oral solution 5 mg/5 ml 1

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

1

prednisone oral tablets,dose pack 10 mg, 5 mg 1

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG 2

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.625-2.5 MG 3

progesterone micronized oral capsule 100 mg, 200 mg 2

propylthiouracil oral tablet 50 mg 2


47

Drug Tier Notesraloxifene oral tablet 60 mg 1 QL

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 1

RIOMET ORAL SOLUTION 500 MG/5 ML 3 PA

risedronate oral tablet 150 mg 2

risedronate oral tablet 30 mg, 35 mg, 5 mg 1

risedronate oral tablet,delayed release (dr/ec) 35 mg 1

SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG 3 PA

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML)

4 PA

SOMAVERT SUBCUTANEOUS RECON SOLN 15 MG, 20 MG 4 PA

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR2,700 MCG/2.7 ML 3 PA

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR1,500 MCG/1.5 ML 3 PA

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

3 ST

TANZEUM SUBCUTANEOUS PEN INJECTOR 30 MG/0.5 ML 3 ST; QL

testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml

2

testosterone enanthate intramuscular oil 200 mg/ml 2

testosterone transdermal gel 50 mg/5 gram (1 %) 2 PA

testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram)

2 PA; QL

THYROLAR-1 ORAL TABLET 12.5-50 MCG 1

THYROLAR-1/2 ORAL TABLET 6.25-25 MCG 1

THYROLAR-1/4 ORAL TABLET 3.1-12.5 MCG 1

THYROLAR-2 ORAL TABLET 25-100 MCG 1

THYROLAR-3 ORAL TABLET 37.5-150 MCG 1

TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

1

tolazamide oral tablet 250 mg, 500 mg 1

tolbutamide oral tablet 500 mg 1

TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) 3 ST

TRADJENTA ORAL TABLET 5 MG 3 ST; QL

TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) 3 PA

TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) 3 PA

TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML 2 ST


48

Drug Tier NotesUNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

1

VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR0.6 MG/0.1 ML (18 MG/3 ML) 3 ST; QL

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR0.6 MG/0.1 ML (18 MG/3 ML) 3 ST

VIVELLE-DOT TRANSDERMAL PATCH SEMIWEEKLY 0.025 MG/24 HR, 0.1 MG/24 HR 2

WP THYROID ORAL TABLET 65 MG 3

Gastrointestinal Therapy AgentsAKYNZEO ORAL CAPSULE 300-0.5 MG 3 PA

alosetron oral tablet 0.5 mg, 1 mg 2 PA

ANZEMET ORAL TABLET 100 MG 3 PA

ANZEMET ORAL TABLET 50 MG 3 PA; QL

aprepitant oral capsule 125 mg, 40 mg, 80 mg 2 QL

aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2) 2 QL

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR 0.375 GRAM 3 QL

balsalazide oral capsule 750 mg 2

budesonide oral capsule,delayed,extend.release 3 mg 2 ST

CARAFATE ORAL SUSPENSION 100 MG/ML 3

CESAMET ORAL CAPSULE 1 MG 3 PA

cimetidine hcl oral solution 300 mg/5 ml 2

CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) 4 PA

CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) 4 PA

CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) 4 PA

COLOCORT RECTAL ENEMA 100 MG/60 ML 2

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT

2 PA

DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG 2

DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS 30 MG 3 PA

DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS 60 MG 3 PA; QL

dicyclomine oral capsule 10 mg 1

dicyclomine oral solution 10 mg/5 ml 1

dicyclomine oral tablet 20 mg 1

DIPENTUM ORAL CAPSULE 250 MG 3 PA

diphenoxylate-atropine oral tablet 2.5-0.025 mg 1

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 2 QLPA = Prior Authorization; ST = Step Therapy; QL = Quantity Limits

49

Drug Tier Notesesomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg

2

GAVILYTE-G ORAL RECON SOLN 236-22.74-6.74 -5.86 GRAM 1

GAVILYTE-N ORAL RECON SOLN 420 GRAM 1

GIAZO ORAL TABLET 1.1 GRAM 3 PA

glycopyrrolate oral tablet 1 mg, 2 mg 2

granisetron hcl oral tablet 1 mg 2 QL

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML 4 PA

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML 4 PA

hydrocortisone rectal enema 100 mg/60 ml 2

hyoscyamine sulfate oral tablet 0.125 mg 1

hyoscyamine sulfate oral tablet extended release 12 hr0.375 mg

1

hyoscyamine sulfate sublingual tablet 0.125 mg 1

lactulose oral solution 10 gram/15 ml, 10 gram/15 ml (15 ml), 20 gram/30 ml

2

lansoprazole oral capsule,delayed release(dr/ec) 30 mg 2 QL

LINZESS ORAL CAPSULE 145 MCG, 290 MCG 3 PA

LOTRONEX ORAL TABLET 0.5 MG, 1 MG 3 PA; QL

meclizine oral tablet 25 mg 2

MEDI-MECLIZINE ORAL TABLET 25 MG 2

mesalamine rectal enema 4 gram/60 ml 2

mesalamine with cleansing wipe rectal enema kit 4 gram/60 ml

2

methscopolamine oral tablet 2.5 mg, 5 mg 2

metoclopramide hcl oral solution 5 mg/5 ml 1

metoclopramide hcl oral tablet 10 mg, 5 mg 1

metoclopramide hcl oral tablet,disintegrating 10 mg, 5 mg 1

MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5 ML 1

misoprostol oral tablet 100 mcg, 200 mcg 2

MOTION RELIEF (MECLIZINE) ORAL TABLET 25 MG 2

MOTION SICKNESS (MECLIZINE) ORAL TABLET25 MG 2

MOTION SICKNESS II ORAL TABLET 25 MG 2

MOTION SICKNESS RELIEF(MECLIZ) ORAL TABLET 25 MG 2

MOTOFEN ORAL TABLET 1-0.025 MG 3

MOVIPREP ORAL POWDER IN PACKET 100-7.5-2.691 GRAM 1 PA

nizatidine oral capsule 150 mg, 300 mg 1

nizatidine oral solution 150 mg/10 ml 2


50

Drug Tier Notesoctreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

4 PA

omeprazole oral capsule,delayed release(dr/ec) 10 mg 1 QL

omeprazole oral capsule,delayed release(dr/ec) 20 mg, 40 mg

1

ondansetron hcl (pf) injection syringe 4 mg/2 ml 2 PA

ondansetron hcl oral solution 4 mg/5 ml 2 QL

ondansetron hcl oral tablet 24 mg 2 QL

ondansetron hcl oral tablet 4 mg, 8 mg 1 QL

ondansetron oral tablet,disintegrating 4 mg, 8 mg 1 QL

PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800-56,800- 98,400 UNIT, 21,000-54,700- 83,900 UNIT, 4,200-14,200- 24,600 UNIT

3 PA

pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg

1 QL

peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram

1

peg-electrolyte soln oral recon soln 420 gram 1

PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 16,000-57,500- 60,500 UNIT, 8,000-28,750- 30,250 UNIT

3 PA

PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG 1

PHENERGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG 1

polyethylene glycol 3350 oral powder 17 gram/dose 1

polyethylene glycol 3350 oral powder in packet 17 gram 1

PREPOPIK ORAL POWDER IN PACKET 10 MG-3.5 GRAM-12 GRAM 1

prochlorperazine maleate oral tablet 10 mg, 5 mg 1

prochlorperazine rectal suppository 25 mg 1

promethazine oral syrup 6.25 mg/5 ml 2

promethazine oral tablet 12.5 mg, 25 mg, 50 mg 2

promethazine rectal suppository 12.5 mg, 25 mg, 50 mg 1

PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG 1

rabeprazole oral tablet,delayed release (dr/ec) 20 mg 1 QL

ranitidine hcl oral syrup 15 mg/ml 1

SANCUSO TRANSDERMAL PATCH WEEKLY 3.1 MG/24 HOUR 3 PA; QL

STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML 4 PA

STELARA SUBCUTANEOUS SYRINGE 90 MG/ML 4 PA

sucralfate oral suspension 100 mg/ml 3

sucralfate oral tablet 1 gram 1

sulfasalazine oral tablet 500 mg 2


51

Drug Tier Notessulfasalazine oral tablet,delayed release (dr/ec) 500 mg 2

SUPREP BOWEL PREP KIT ORAL RECON SOLN17.5-3.13-1.6 GRAM 1

TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1 MG OVER 3 DAYS 3

TRILYTE WITH FLAVOR PACKETS ORAL RECON SOLN 420 GRAM 1

trimethobenzamide oral capsule 300 mg 1

ursodiol oral capsule 300 mg 2

ursodiol oral tablet 250 mg, 500 mg 2

VIBERZI ORAL TABLET 100 MG, 75 MG 3 PA

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000 -55,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,000-68,000 -109,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,000-10,000- 16,000 UNIT, 40,000-136,000- 218,000 UNIT, 5,000-17,000 -27,000 UNIT

3 PA

Genitourinary Therapyalfuzosin oral tablet extended release 24 hr 10 mg 2

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg 1

calcium acetate oral capsule 667 mg 2

calcium acetate oral tablet 667 mg 2

CIALIS ORAL TABLET 2.5 MG, 5 MG 3 PA; QL

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr1,000 mg, 500 mg

1

CYSTAGON ORAL CAPSULE 150 MG, 50 MG 4 PA

dutasteride oral capsule 0.5 mg 1 QL

ELIPHOS ORAL TABLET 667 MG 2

ELMIRON ORAL CAPSULE 100 MG 3 PA

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HR 15 MG, 7.5 MG 3 PA

finasteride oral tablet 5 mg 1

flavoxate oral tablet 100 mg 1

FOSRENOL ORAL POWDER IN PACKET 1,000 MG, 750 MG 3

FOSRENOL ORAL TABLET,CHEWABLE 1,000 MG, 500 MG, 750 MG 3

GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP 100 MG/GRAM (10 %) 3

GELNIQUE TRANSDERMAL GEL IN PACKET 10 % (100 MG/GRAM) 3

methenamine hippurate oral tablet 1 gram 3

MONUROL ORAL PACKET 3 GRAM 3

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG 3 ST

nitrofurantoin macrocrystal oral capsule 100 mg 2

nitrofurantoin macrocrystal oral capsule 25 mg, 50 mg 1


52

Drug Tier Notesnitrofurantoin monohyd/m-cryst oral capsule 100 mg 2

nitrofurantoin oral suspension 25 mg/5 ml 2

oxybutynin chloride oral syrup 5 mg/5 ml 1

oxybutynin chloride oral tablet 5 mg 1

oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg, 5 mg

1

phenazopyridine oral tablet 100 mg 1

phenazopyridine oral tablet 200 mg 2

PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)/5 ML 3

potassium citrate oral tablet extended release 10 meq (1,080 mg), 15 meq, 5 meq (540 mg)

2

RAPAFLO ORAL CAPSULE 4 MG, 8 MG 3 ST

RENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM 3 PA

RENVELA ORAL TABLET 800 MG 3 PA

sevelamer carbonate oral tablet 800 mg 3

tamsulosin oral capsule,extended release 24hr 0.4 mg 1

tolterodine oral capsule,extended release 24hr 2 mg, 4 mg 1

tolterodine oral tablet 1 mg, 2 mg 1

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG 2 ST

trospium oral capsule,extended release 24hr 60 mg 1

trospium oral tablet 20 mg 1

VESICARE ORAL TABLET 10 MG, 5 MG 3 ST

Gout And Hyperuricemia Therapyallopurinol oral tablet 100 mg, 300 mg 1

colchicine oral capsule 0.6 mg 3

colchicine oral tablet 0.6 mg 3

COLCRYS ORAL TABLET 0.6 MG 3

MITIGARE ORAL CAPSULE 0.6 MG 3

probenecid oral tablet 500 mg 1

probenecid-colchicine oral tablet 500-0.5 mg 1

ULORIC ORAL TABLET 40 MG, 80 MG 2 QL

Hematological Agentsanagrelide oral capsule 0.5 mg, 1 mg 1

aspirin oral tablet 325 mg 1 QL

aspirin oral tablet,delayed release (dr/ec) 81 mg 1

BERINERT INTRAVENOUS KIT 500 UNIT (10 ML) 4 PA

BERINERT INTRAVENOUS RECON SOLN 500 UNIT (10 ML) 4 PA

BRILINTA ORAL TABLET 60 MG, 90 MG 2 QL

cilostazol oral tablet 100 mg, 50 mg 1

clopidogrel oral tablet 300 mg, 75 mg 1

COUMADIN ORAL TABLET 5 MG 1


53

Drug Tier Notesdipyridamole oral tablet 25 mg, 50 mg, 75 mg 1

DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG 3

EFFIENT ORAL TABLET 10 MG, 5 MG 3 ST

ELIQUIS ORAL TABLET 2.5 MG 2 QL

ELIQUIS ORAL TABLET 5 MG 2

enoxaparin subcutaneous solution 300 mg/3 ml 2

enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml

2

ENTERIC COATED ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG 1

fondaparinux subcutaneous syringe 10 mg/0.8 ml, 2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

4 PA

FRAGMIN SUBCUTANEOUS SOLUTION 25,000 ANTI-XA UNIT/ML 3

FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML, 7,500 ANTI-XA UNIT/0.3 ML

3

HEP FLUSH-10 (PF) INTRAVENOUS SOLUTION 10 UNIT/ML 1

heparin (porcine) injection cartridge 5,000 unit/ml (1 ml) 1

heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml

1

heparin lock flush (porcine) intravenous solution 10 unit/ml, 100 unit/ml

1

heparin lock flush (porcine) intravenous syringe 100 unit/ml 1

HEPARIN LOCKFLUSH(PORCINE)(PF) INTRAVENOUS SYRINGE 10 UNIT/ML, 100 UNIT/ML

1

heparin, porcine (pf) injection solution 1,000 unit/ml, 5,000 unit/0.5 ml

1

heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml)

1

heparin, porcine (pf) intravenous syringe 10 unit/ml, 100 unit/ml

1

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG 1

MIRCERA INJECTION SYRINGE 100 MCG/0.3 ML, 150 MCG/0.3 ML, 200 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML

4 PA

NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML 4 PA

NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML 4 PA

pentoxifylline oral tablet extended release 400 mg 1

PLAVIX ORAL TABLET 75 MG 1

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG 3 QL


54

Drug Tier NotesPROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML

4 PA

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG 4 PA

SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG 3

ticlopidine oral tablet 250 mg 1

tranexamic acid oral tablet 650 mg 1

warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

1

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG 3 QL

XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) 3

ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML 4 PA

ZONTIVITY ORAL TABLET 2.08 MG 3

Immunosuppressive AgentsASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG, 5 MG 4

AZASAN ORAL TABLET 100 MG, 75 MG 3 PA

azathioprine oral tablet 50 mg 1

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 1

cyclosporine modified oral solution 100 mg/ml 2



GENGRAF ORAL CAPSULE 100 MG, 25 MG, 50 MG 1

GENGRAF ORAL SOLUTION 100 MG/ML 2

mycophenolate mofetil oral capsule 250 mg 2

mycophenolate mofetil oral tablet 500 mg 2

mycophenolate sodium oral tablet,delayed release (dr/ec)180 mg, 360 mg

2

NEORAL ORAL CAPSULE 100 MG, 25 MG 4 PA

NEORAL ORAL SOLUTION 100 MG/ML 4 PA

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 4

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 2

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG 4

Locomotor Systembaclofen oral tablet 10 mg, 20 mg 2

carisoprodol oral tablet 250 mg, 350 mg 1

chlorzoxazone oral tablet 500 mg 1

COMFORT PAC-CYCLOBENZAPRINE KIT 10 MG 1

COMFORT PAC-TIZANIDINE KIT 4 MG 2

cyclobenzaprine oral tablet 10 mg, 5 mg, 7.5 mg 1

dantrolene oral capsule 100 mg, 25 mg, 50 mg 2


55

Drug Tier Notesguanidine oral tablet 125 mg 2

LORZONE ORAL TABLET 375 MG, 750 MG 1

MESTINON ORAL SYRUP 60 MG/5 ML 3 PA

metaxalone oral tablet 800 mg 2

methocarbamol oral tablet 500 mg, 750 mg 1

orphenadrine citrate oral tablet extended release 100 mg 1

pyridostigmine bromide oral tablet 60 mg 2

RILUTEK ORAL TABLET 50 MG 4 PA

riluzole oral tablet 50 mg 2

tizanidine oral capsule 2 mg, 4 mg, 6 mg 2

tizanidine oral tablet 2 mg, 4 mg 2

ZANAFLEX ORAL TABLET 4 MG 2

Medical Supplies And Durable Medical Equipment (Dme)BD INSULIN PEN NEEDLE UF MINI NEEDLE 31 GAUGE X 3/16" 3

BD INSULIN PEN NEEDLE UF ORIG NEEDLE 29 GAUGE X 1/2" 3

BD INSULIN PEN NEEDLE UF SHORT NEEDLE 31 GAUGE X 5/16" 3

BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 31 GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16, 0.5 ML 31 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16

3

BD REGULAR BEVEL NEEDLES NEEDLE 18 GAUGE X 1" 3

BD ULTRA-FINE MICRO PEN NEEDLE NEEDLE 32 GAUGE X 1/4" 3

BD ULTRA-FINE NANO PEN NEEDLES NEEDLE 32 GAUGE X 5/32" 3

FREESTYLE INSULINX STRIP 2

FREESTYLE INSULINX TEST STRIPS STRIP 2

FREESTYLE LITE STRIPS STRIP 2

FREESTYLE PRECISION NEO STRIPS STRIP 2

FREESTYLE TEST STRIP 2

NOVOFINE 30 NEEDLE 30 GAUGE X 1/3" 1

ONETOUCH ULTRA TEST STRIP 2

ONETOUCH VERIO STRIP 2

PEN NEEDLE NEEDLE 31 GAUGE X 5/16" 1

pen needle, diabetic needle 31 gauge x 1/4", 31 gauge x 5/16"

1

RELION NEEDLES NEEDLE 31 GAUGE X 1/4" 1

RELION PEN NEEDLES NEEDLE 32 GAUGE X 5/32" 1

UNIFINE PENTIPS NEEDLE 31 GAUGE X 1/4" 1

Medical Supply, Fdb SupersetBD INSULIN PEN NEEDLE UF MINI NEEDLE 31 GAUGE X 3/16" 3


56

Drug Tier NotesBD INSULIN PEN NEEDLE UF ORIG NEEDLE 29 GAUGE X 1/2" 3

BD INSULIN PEN NEEDLE UF SHORT NEEDLE 31 GAUGE X 5/16" 3

BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 31 GAUGE X 15/64", 0.5 ML 31 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16

3

BD REGULAR BEVEL NEEDLES NEEDLE 18 GAUGE X 1" 3

BD ULTRA-FINE NANO PEN NEEDLES NEEDLE 32 GAUGE X 5/32" 3

CONTOUR NEXT STRIPS STRIP 3

CONTOUR TEST STRIPS STRIP 3

NOVOFINE 30 NEEDLE 30 GAUGE X 1/3" 1

ONETOUCH ULTRA TEST STRIP 2

PEN NEEDLE NEEDLE 31 GAUGE X 5/16" 1

pen needle, diabetic needle 31 gauge x 1/4", 31 gauge x 5/16"

1

PRODIGY NO CODING STRIP 3

UNIFINE PENTIPS NEEDLE 31 GAUGE X 1/4" 1

Metabolic Modifierscalcitriol oral capsule 0.25 mcg, 0.5 mcg 1

calcitriol oral solution 1 mcg/ml 1

CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG 4 PA

CERDELGA ORAL CAPSULE 84 MG 4 PA

CYSTADANE ORAL POWDER 1 GRAM/1.7 ML 4 PA

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg 2

paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 1

ROCALTROL ORAL CAPSULE 0.25 MCG 1

TYBOST ORAL TABLET 150 MG 4

ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG 4 PA

Mouth-Throat-Dental - Preparationscevimeline oral capsule 30 mg 3

chlorhexidine gluconate mucous membrane mouthwash0.12 %

1

clotrimazole mucous membrane troche 10 mg 2

CUVPOSA ORAL SOLUTION 1 MG/5 ML (0.2 MG/ML) 3 PA

doxycycline hyclate oral tablet 20 mg 2

fluoride (sodium) oral drops 0.5 mg (1.1 mg sod.fluorid)/ml 0

lidocaine hcl mucous membrane jelly 2 % 2

lidocaine hcl mucous membrane solution 4 % (40 mg/ml) 2

LIDOCAINE VISCOUS MUCOUS MEMBRANE SOLUTION 2 % 1


57

Drug Tier NotesLUDENT FLUORIDE ORAL TABLET,CHEWABLE0.25 MG(0.55 MG SOD. FLUORIDE), 0.5 MG (1.1 MG SODIUM FLUORID)

0

nystatin oral suspension 100,000 unit/ml 1

ORALONE DENTAL PASTE 0.1 % 1

PAROEX ORAL RINSE MUCOUS MEMBRANE MOUTHWASH 0.12 % 1

PERIOGARD MUCOUS MEMBRANE MOUTHWASH 0.12 % 1

pilocarpine hcl oral tablet 5 mg, 7.5 mg 1

triamcinolone acetonide dental paste 0.1 % 1

Multiple Sclerosis AgentsAMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG 4 PA

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG 4 PA; QL

AVONEX INTRAMUSCULAR PEN INJECTOR KIT30 MCG/0.5 ML 4 PA; QL

AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML 4 PA; QL

BETASERON SUBCUTANEOUS KIT 0.3 MG 4 PA

BETASERON SUBCUTANEOUS RECON SOLN 0.3 MG 4 PA

EXTAVIA SUBCUTANEOUS KIT 0.3 MG 4 PA; QL

EXTAVIA SUBCUTANEOUS RECON SOLN 0.3 MG 4 PA; QL

glatiramer subcutaneous syringe 20 mg/ml, 40 mg/ml 4 PA

GLATOPA SUBCUTANEOUS SYRINGE 20 MG/ML 4 PA; QL

PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML 4 PA

PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML 4 PA

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML 4 PA; QL

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6)

4 PA; QL

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) 4 PA; QL

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG

4 PA

Ophthalmic AgentsALOCRIL OPHTHALMIC (EYE) DROPS 2 % 2

ALOMIDE OPHTHALMIC (EYE) DROPS 0.1 % 2

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % 3

ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION0.2 % 3 ST

apraclonidine ophthalmic (eye) drops 0.5 % 1


58

Drug Tier NotesAZASITE OPHTHALMIC (EYE) DROPS 1 % 3

azelastine ophthalmic (eye) drops 0.05 % 2

AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION1 % 3

bacitracin ophthalmic (eye) ointment 500 unit/gram 2

BEPREVE OPHTHALMIC (EYE) DROPS 1.5 % 3

BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.6 % 3

betaxolol ophthalmic (eye) drops 0.5 % 2

BETIMOL OPHTHALMIC (EYE) DROPS 0.25 %, 0.5 % 3

BETOPTIC S OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 % 3

brimonidine ophthalmic (eye) drops 0.15 %, 0.2 % 1

bromfenac ophthalmic (eye) drops 0.09 % 1

carteolol ophthalmic (eye) drops 1 % 2

ciprofloxacin hcl ophthalmic (eye) drops 0.3 % 2

COMBIGAN OPHTHALMIC (EYE) DROPS 0.2-0.5 % 3

cromolyn ophthalmic (eye) drops 4 % 2

cyclopentolate ophthalmic (eye) drops 1 % 1

dexamethasone sodium phosphate ophthalmic (eye) drops0.1 %

1

diclofenac sodium ophthalmic (eye) drops 0.1 % 1

dorzolamide ophthalmic (eye) drops 2 % 2

dorzolamide-timolol ophthalmic (eye) drops 22.3-6.8 mg/ml 2

DUREZOL OPHTHALMIC (EYE) DROPS 0.05 % 3

EMADINE OPHTHALMIC (EYE) DROPS 0.05 % 2

epinastine ophthalmic (eye) drops 0.05 % 2

erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) 1

FLAREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % 3

fluorometholone ophthalmic (eye) drops,suspension 0.1 % 2

flurbiprofen sodium ophthalmic (eye) drops 0.03 % 2

FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 % 2

FML S.O.P. OPHTHALMIC (EYE) OINTMENT 0.1 % 2

gatifloxacin ophthalmic (eye) drops 0.5 % 1

GENTAK OPHTHALMIC (EYE) OINTMENT 0.3 % (3 MG/GRAM) 2

gentamicin ophthalmic (eye) drops 0.3 % 1

gentamicin ophthalmic (eye) ointment 0.3 % (3 mg/gram) 2

ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3 % 3

ISTALOL OPHTHALMIC (EYE) DROPS, ONCE DAILY 0.5 % 3

ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % 2


59

Drug Tier NotesLACRISERT OPHTHALMIC (EYE) INSERT 5 MG 3 PA

LASTACAFT OPHTHALMIC (EYE) DROPS 0.25 % 3

latanoprost ophthalmic (eye) drops 0.005 % 2

levobunolol ophthalmic (eye) drops 0.5 % 1

levofloxacin ophthalmic (eye) drops 0.5 % 2

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 0.5 % 3 ST

LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.5 % 3 ST

LOTEMAX OPHTHALMIC (EYE) OINTMENT 0.5 % 3 ST

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % 2 ST

MAXIDEX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % 3

metipranolol ophthalmic (eye) drops 0.3 % 2

MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS0.5 % 3

moxifloxacin ophthalmic (eye) drops 0.5 % 1

NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % 3

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 %

1

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment3.5 mg/g-10,000 unit/g-0.1 %

1

NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % 3

ofloxacin ophthalmic (eye) drops 0.3 % 2

olopatadine ophthalmic (eye) drops 0.1 % 1

PATANOL OPHTHALMIC (EYE) DROPS 0.1 % 3 PA

PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS 0.125 % 2

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 % 1

polymyxin b sulf-trimethoprim ophthalmic (eye) drops10,000 unit- 1 mg/ml

1

PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.12 % 3

prednisolone acetate ophthalmic (eye) drops,suspension 1 %

1

prednisolone sodium phosphate ophthalmic (eye) drops 1 % 2

SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION 1-0.2 % 3

sulfacetamide sodium ophthalmic (eye) drops 10 % 2

timolol maleate ophthalmic (eye) drops 0.5 % 2

timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 %

2

TIMOPTIC OPHTHALMIC (EYE) DROPS 0.25 %, 0.5 % 3

TOBRADEX OPHTHALMIC (EYE) OINTMENT 0.3-0.1 % 2


60

Drug Tier Notestobramycin ophthalmic (eye) drops 0.3 % 1

tobramycin-dexamethasone ophthalmic (eye) drops,suspension 0.3-0.1 %

1

TRAVATAN Z OPHTHALMIC (EYE) DROPS 0.004 % 3 ST

trifluridine ophthalmic (eye) drops 1 % 2

tropicamide ophthalmic (eye) drops 0.5 %, 1 % 2

VIGAMOX OPHTHALMIC (EYE) DROPS 0.5 % 3

XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 % 3 PA

ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % 3

Oticacetic acid otic (ear) solution 2 % 2

CIPRO HC OTIC (EAR) DROPS,SUSPENSION 0.2-1 % 2

CIPRODEX OTIC (EAR) DROPS,SUSPENSION 0.3-0.1 % 2

COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION3.3-3-10-0.5 MG/ML 3

fluocinolone acetonide oil otic (ear) drops 0.01 % 2

hydrocortisone-acetic acid otic (ear) drops 1-2 % 2

neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-10,000-1 mg/ml-unit/ml-%

1

neomycin-polymyxin-hc otic (ear) solution 3.5-10,000-1 mg/ml-unit/ml-%

1

ofloxacin otic (ear) drops 0.3 % 2

OTIPRIO INTRATYMPANIC SUSPENSION 6 % (6 MG/0.1 ML) 3 PA

OTOVEL OTIC (EAR) SOLUTION 0.3-0.025 % (0.25 ML) 3 ST

Respiratory Therapy Agents24 HOUR ALLERGY RELIEF NASAL SPRAY,SUSPENSION 50 MCG/ACTUATION 1

acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %)

2

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE

3

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml

1

albuterol sulfate oral syrup 2 mg/5 ml 1

albuterol sulfate oral tablet 2 mg, 4 mg 1

albuterol sulfate oral tablet extended release 12 hr 8 mg 1

ALLERGY RELIEF (FLUTICASONE) NASAL SPRAY,SUSPENSION 50 MCG/ACTUATION 1

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION 2 QL


61

Drug Tier NotesARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 75 MCG 3 QL

ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION 3 QL

ASMANEX HFA INHALATION HFA AEROSOL INHALER 200 MCG/ACTUATION 3

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES)

3 QL

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)

3

azelastine nasal aerosol,spray 137 mcg (0.1 %) 1 QL

azelastine nasal spray,non-aerosol 0.15 % (205.5 mcg) 1 QL

BACTROBAN NASAL NASAL OINTMENT 2 % 3

benzonatate oral capsule 100 mg, 200 mg 1

BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE 3 QL

budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml

2 QL

budesonide nasal spray,non-aerosol 32 mcg/actuation 2 QL

carbinoxamine maleate oral liquid 4 mg/5 ml 1

carbinoxamine maleate oral tablet 4 mg 1

CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 4 PA

clemastine oral tablet 2.68 mg 2

cromolyn inhalation solution for nebulization 20 mg/2 ml 2

cyproheptadine oral syrup 2 mg/5 ml 2

cyproheptadine oral tablet 4 mg 2

DALIRESP ORAL TABLET 500 MCG 3 PA

desloratadine oral tablet 5 mg 2

desloratadine oral tablet,disintegrating 2.5 mg, 5 mg 2

diphenhydramine hcl injection solution 50 mg/ml 1

DULERA INHALATION HFA AEROSOL INHALER100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION 3

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML 2

epinephrine injection syringe 0.1 mg/ml 2 QL

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION

3 QL

FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION

3 QL

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) 1

fluticasone nasal spray,suspension 50 mcg/actuation 1 QL


62

Drug Tier Notesfluticasone-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation

1

hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr 10-8 mg/5 ml

1

hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml, 5-1.5 mg/5 ml (5 ml)

1

ipratropium bromide inhalation solution 0.02 % 2

ipratropium bromide nasal spray,non-aerosol 0.03 %, 0.06 %

1

ipratropium-albuterol inhalation solution for nebulization0.5 mg-3 mg(2.5 mg base)/3 ml

1

levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/3 ml

1 QL

levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml

2 QL

levalbuterol tartrate inhalation hfa aerosol inhaler 45 mcg/actuation

1

levocetirizine oral solution 2.5 mg/5 ml 2

levocetirizine oral tablet 5 mg 2

metaproterenol oral syrup 10 mg/5 ml 1

metaproterenol oral tablet 10 mg, 20 mg 1

mometasone nasal spray,non-aerosol 50 mcg/actuation 1

montelukast oral granules in packet 4 mg 1 QL

montelukast oral tablet 10 mg 1 QL

montelukast oral tablet,chewable 4 mg 1 QL

montelukast oral tablet,chewable 5 mg 1

NASAL ALLERGY NASAL AEROSOL,SPRAY 55 MCG 3

olopatadine nasal spray,non-aerosol 0.6 % 3 QL

PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG 1

PHENERGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG 1

PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION 3 QL

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION

3 QL

promethazine oral syrup 6.25 mg/5 ml 2

promethazine oral tablet 12.5 mg, 25 mg, 50 mg 2

promethazine rectal suppository 12.5 mg, 25 mg, 50 mg 1

promethazine-codeine oral syrup 6.25-10 mg/5 ml 1

promethazine-dm oral syrup 6.25-15 mg/5 ml 1

PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG 1


63

Drug Tier NotesPULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION

2 QL

QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION 2 QL

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE 3 QL

SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION 3 QL

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG 3 QL

STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION 2 QL

terbutaline oral tablet 2.5 mg, 5 mg 1

THEO-24 ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 300 MG, 400 MG 2

THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 200 MG, 300 MG 1

theophylline oral elixir 80 mg/15 ml 2

theophylline oral solution 80 mg/15 ml 2

theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg

1

theophylline oral tablet extended release 24 hr 400 mg, 600 mg

1

tobramycin in 0.225 % nacl inhalation solution for nebulization 300 mg/5 ml

4 PA

tobramycin with nebulizer inhalation solution for nebulization 300 mg/5 ml

4 PA

triamcinolone acetonide nasal aerosol,spray 55 mcg 3

VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION 3 QL

VITUZ ORAL SOLUTION 5-4 MG/5 ML 3

XOPENEX HFA INHALATION HFA AEROSOL INHALER 45 MCG/ACTUATION 3 QL

zafirlukast oral tablet 10 mg 2 QL

zafirlukast oral tablet 20 mg 2

ZYFLO CR ORAL TABLET, ER MULTIPHASE 12 HR 600 MG 3 PA

Vaginal Productsclindamycin phosphate vaginal cream 2 % 1

CRINONE VAGINAL GEL 4 % 4 PA

ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM) 2

ESTRING VAGINAL RING 2 MG (7.5 MCG /24 HOUR) 2

FEMRING VAGINAL RING 0.05 MG/24 HR, 0.1 MG/24 HR 3

metronidazole vaginal gel 0.75 % 2


64

Drug Tier NotesPREMARIN VAGINAL CREAM 0.625 MG/GRAM 2

terconazole vaginal cream 0.4 %, 0.8 % 2

terconazole vaginal suppository 80 mg 2

VAGIFEM VAGINAL TABLET 10 MCG 2

VANDAZOLE VAGINAL GEL 0.75 % 2

YUVAFEM VAGINAL TABLET 10 MCG 1


65


66

IndexIndex

24 HOUR ALLERGY RELIEF ..........61abacavir ................................................... 8abacavir-lamivudine-zidovudine ............. 8ABSTRAL .............................................. 3ACANYA .............................................. 35acarbose .................................................43acebutolol .............................................. 17acetaminophen-codeine ........................... 3acetic acid ..............................................61acetylcysteine .....................................7, 61acitretin ..................................................35ACTEMRA .............................................3acyclovir ............................................ 8, 35adapalene ...............................................35ADCIRCA ............................................ 17ADDERALL .........................................22ADVAIR DISKUS ............................... 61ADZENYS XR-ODT ........................... 22AFEDITAB CR ....................................17AFINITOR ........................................... 14AFINITOR DISPERZ ......................... 14AFLURIA 2017-2018 ...........................16AFLURIA 2017-2018 (PF) .................. 16AFLURIA QUAD 2017-2018 .............. 16AFLURIA QUAD 2017-2018 (PF) ..... 16AFTERA ...............................................31AGONEAZE ........................................ 35AKYNZEO ........................................... 49albuterol sulfate ..................................... 61alclometasone ........................................ 35ALECENSA ..........................................14alendronate ............................................ 43alfuzosin .................................................52ALINIA ...................................................8ALLERGY RELIEF (FLUTICASONE) ................................61allopurinol ............................................. 53almotriptan malate .................................22ALOCRIL .............................................58ALOMIDE ............................................58alosetron ................................................ 49ALPHAGAN P ..................................... 58alprazolam ............................................. 22ALPRAZOLAM INTENSOL .............22ALREX ................................................. 58ALTABAX ............................................35AMABELZ ........................................... 43amantadine hcl .................................22, 23amcinonide .............................................35AMETHIA ............................................31AMETHIA LO ..................................... 31AMETHYST ........................................ 31amiloride ................................................17amiloride-hydrochlorothiazide .............. 17amiodarone ............................................ 17amitriptyline ...........................................23amlodipine ............................................. 17amlodipine-benazepril ........................... 17amlodipine-valsartan .............................17ammonium lactate ..................................35amoxapine ..............................................23amoxicillin ............................................... 8

Index

amoxicillin-pot clavulanate ..................... 8ampicillin ................................................. 8AMPYRA ..............................................58ANADROL-50 ......................................43anagrelide .............................................. 53anastrozole .............................................14ANDROGEL ........................................ 43ANODYNE LPT .................................. 35ANORO ELLIPTA ..............................61ANUCORT-HC ......................................7ANZEMET ........................................... 49APLENZIN ...........................................23apraclonidine .........................................58aprepitant ...............................................49APRI ......................................................31APRISO ................................................ 49APTIVUS ................................................8ARCAPTA NEOHALER ....................62aripiprazole ............................................23armodafinil ............................................ 23ARMOUR THYROID .........................43ASHLYNA ............................................31ASMANEX HFA ..................................62ASMANEX TWISTHALER ...............62aspirin ................................................ 3, 53ASTAGRAF XL ...................................55atenolol .................................................. 17atenolol-chlorthalidone ......................... 17atorvastatin ............................................ 17atovaquone ...............................................8atovaquone-proguanil ..............................8ATRIPLA ............................................... 8AVANDIA ............................................ 43AVIANE ................................................31AVIDOXY .............................................. 8AVITA .................................................. 35AVONEX .............................................. 58AVONEX (WITH ALBUMIN) ...........58AXERT ................................................. 23AZASAN ...........................................3, 55AZASITE ..............................................59azathioprine ....................................... 3, 55azelastine ......................................... 59, 62AZELEX ...............................................35azithromycin ............................................ 8AZOPT ..................................................59AZURETTE (28) ..................................31bacitracin .........................................35, 59baclofen ..................................................55BACTROBAN NASAL ....................... 62balsalazide ............................................. 49BALZIVA (28) ..................................... 31BANZEL ...............................................23BASAGLAR KWIKPEN .................... 43BD INSULIN PEN NEEDLE UF MINI ......................................................56BD INSULIN PEN NEEDLE UF ORIG ...............................................56, 57BD INSULIN PEN NEEDLE UF SHORT ........................................... 56, 57BD INSULIN SYRINGE ULTRA-FINE ................................................56, 57

Index

BD REGULAR BEVEL NEEDLES..........................................................56, 57BD ULTRA-FINE MICRO PEN NEEDLE ...............................................56BD ULTRA-FINE NANO PEN NEEDLES .......................................56, 57BEKYREE (28) .................................... 31BELSOMRA ........................................ 23benazepril .............................................. 17benazepril-hydrochlorothiazide .............17benzoin compound ................................. 35BENZOIN COMPOUND ....................35benzoin compound (bulk) .................30, 35benzonatate ............................................ 62benztropine ............................................ 23BEPREVE ............................................ 59BERINERT .......................................... 53BESIVANCE ........................................ 59betamethasone dipropionate ..................35betamethasone valerate ......................... 35betamethasone, augmented ....................35BETASERON .......................................58betaxolol .......................................... 17, 59bethanechol chloride ............................. 52BETIMOL ............................................ 59BETOPTIC S ....................................... 59bexarotene ..............................................14bicalutamide .......................................... 14BILTRICIDE ......................................... 8bisoprolol fumarate ............................... 17bisoprolol-hydrochlorothiazide ............. 17BLISOVI 24 FE ....................................31BLISOVI FE 1.5/30 (28) ......................31BLISOVI FE 1/20 (28) .........................31BREO ELLIPTA ................................. 62BRILINTA ............................................53brimonidine ............................................59BRIVIACT ........................................... 23bromfenac .............................................. 59bromocriptine ........................................ 23budesonide ....................................... 49, 62bumetanide .............................................17buprenorphine hcl ..............................3, 30buprenorphine-naloxone ........................30bupropion hcl ...................................23, 30bupropion hcl (smoking deter) ...............30buspirone ............................................... 23BUTALBITAL COMPOUND W/CODEINE ..........................................3BUTALBITAL COMPOUND-CODEINE ...............................................3butalbital-acetaminop-caf-cod ................ 3butalbital-acetaminophen-caff .................3butalbital-aspirin-caffeine ....................... 3butorphanol tartrate ................................ 3BUTRANS .............................................. 3BYDUREON ........................................ 43BYETTA ...............................................43BYSTOLIC ...........................................17cabergoline ............................................ 43CABOMETYX .....................................14calcipotriene .......................................... 36

67

Index

calcitonin (salmon) ................................ 43calcitriol .....................................36, 42, 57calcium acetate ................................ 42, 52CAMILA ...............................................31camphor ................................................. 36CAMRESE ........................................... 31candesartan ............................................17candesartan-hydrochlorothiazid ............17capecitabine ...........................................14captopril .................................................17CARAFATE ......................................... 49CARBAGLU ........................................ 57carbamazepine .......................................23carbidopa-levodopa ...............................23carbinoxamine maleate ..........................62carisoprodol ...........................................55carteolol .................................................59CARTIA XT ......................................... 17carvedilol ............................................... 18CAYSTON ............................................62CAZIANT (28) ..................................... 31CEDAX ................................................... 8cefaclor .................................................... 8cefadroxil ................................................. 8cefdinir .................................................8, 9cefditoren pivoxil ..................................... 9cefixime .................................................... 9cefpodoxime ............................................. 9cefprozil ................................................... 9cefuroxime axetil ......................................9CELEBREX ........................................... 3celecoxib .................................................. 3CELEXA ...............................................23CELONTIN .......................................... 23cephalexin ................................................ 9CERDELGA .........................................57CESAMET ............................................49cevimeline .............................................. 57CHANTIX ............................................ 30CHANTIX CONTINUING MONTH BOX .......................................................30CHANTIX STARTING MONTH BOX .......................................................30CHEMET ................................................7chlorhexidine gluconate .........................57chloroquine phosphate .............................9chlorothiazide ........................................ 18chlorpromazine ...................................... 24chlorpropamide ......................................43chlorthalidone ........................................18chlorzoxazone ........................................ 55cholestyramine (with sugar) .................. 18CIALIS ..................................................52CICLODAN ..........................................36CICLODAN KIT ................................. 36ciclopirox ............................................... 36ciclopirox-ure-camph-menth-euc .......... 36cilostazol ................................................ 53cimetidine hcl .........................................49CIMZIA ............................................ 3, 49CIMZIA POWDER FOR RECONST............................................................3, 49CIMZIA STARTER KIT ................3, 49

Index

CIPRO HC ........................................... 61CIPRODEX .......................................... 61ciprofloxacin ............................................ 9ciprofloxacin (mixture) .......................... 52ciprofloxacin hcl ................................ 9, 59citalopram ..............................................24CLARAVIS .......................................... 36clarithromycin ..........................................9clemastine .............................................. 62CLINDACIN ETZ ............................... 36CLINDACIN P .....................................36CLINDACIN PAC ............................... 36CLINDAGEL ....................................... 36clindamycin hcl ........................................9clindamycin palmitate hcl ........................9CLINDAMYCIN PEDIATRIC ............ 9clindamycin phosphate .................... 36, 64clindamycin-benzoyl peroxide ............... 36clobetasol ...............................................36clobetasol-emollient ...............................36clocortolone pivalate ............................. 36CLODAN .............................................. 36CLODAN KIT ......................................36clomipramine ......................................... 24clonazepam ............................................ 24clonidine ................................................ 18clonidine hcl ...........................................18clopidogrel .............................................53clorazepate dipotassium ........................ 24clotrimazole ........................................... 57clotrimazole-betamethasone .................. 36clozapine ................................................ 24COARTEM ............................................ 9codeine sulfate ......................................... 3colchicine ...............................................53COLCRYS ............................................53colestipol ................................................18COLOCORT ........................................ 49COLY-MYCIN S ................................. 61COMBIGAN ........................................ 59COMFORT PAC-CYCLOBENZAPRINE .......................55COMFORT PAC-IBUPROFEN .......... 3COMFORT PAC-MELOXICAM ........3COMFORT PAC-NAPROXEN ........... 3COMFORT PAC-TIZANIDINE ........55COMPLERA .......................................... 9CONTOUR NEXT STRIPS ................57CONTOUR TEST STRIPS .................57CORDRAN ...........................................36COREG CR ..........................................18CORMAX .............................................37cortisone ................................................ 43CORTISPORIN ................................... 37COSENTYX ......................................... 37COSENTYX (2 SYRINGES) .............. 37COSENTYX PEN ................................ 37COSENTYX PEN (2 PENS) ............... 37COTELLIC .......................................... 14COUMADIN ........................................ 53CREON .................................................49CRESTOR ............................................ 18CRINONE ...................................... 43, 64

Index

CRIXIVAN .............................................9cromolyn .................................... 14, 59, 62CRYSELLE (28) .................................. 31CUPRIMINE ......................................3, 7CUVPOSA ............................................ 57cyanocobalamin (vitamin b-12) .............42CYCLAFEM 1/35 (28) ........................ 31CYCLAFEM 7/7/7 (28) ....................... 31cyclobenzaprine ..................................... 55cyclopentolate ........................................ 59cyclophosphamide ..............................3, 14cycloserine ............................................... 9cyclosporine .......................................4, 55cyclosporine modified ........................3, 55cyproheptadine ...................................... 62CYRED ................................................. 31CYSTADANE ...................................... 57CYSTAGON .........................................52DALIRESP ........................................... 62danazol ...................................................43dantrolene .............................................. 55dapsone .................................................... 9DARAPRIM ........................................... 9DASETTA 1/35 (28) .............................31DASETTA 7/7/7 (28) ............................31DEBLITANE ........................................31DELYLA (28) ....................................... 31DELZICOL .......................................... 49demeclocycline .........................................9DENAVIR .............................................37DEPO-TESTOSTERONE .................. 43DERMACINRX EMPRICAINE ........37DERMACINRX SILAZONE ............. 37DESCOVY ..............................................9desipramine ............................................24desloratadine ......................................... 62desmopressin ..........................................43desog-e.estradiol/e.estradiol ..................31desogestrel-ethinyl estradiol ..................31DESONATE ......................................... 37desonide ................................................. 37desoximetasone ...................................... 37desvenlafaxine succinate ....................... 24dexamethasone .......................................44DEXAMETHASONE INTENSOL .... 43dexamethasone sodium phosphate .........59DEXILANT .......................................... 49dexmethylphenidate ............................... 24DEXPAK 10 DAY ................................44DEXPAK 13 DAY ................................44DEXPAK 6 DAY ..................................44dextroamphetamine ................................24dextroamphetamine-amphetamine .........24diazepam ................................................ 24DIAZEPAM INTENSOL ....................24DIBENZYLINE ................................... 18diclofenac potassium ............................... 4diclofenac sodium ........................ 4, 37, 59dicloxacillin ............................................. 9DICLOZOR ..........................................37dicyclomine ............................................ 49didanosine ................................................9DIFICID ..................................................9

68

Index

diflorasone ............................................. 37diflunisal .................................................. 4DIGOX ..................................................18digoxin ................................................... 18dihydroergotamine .................................24DILANTIN ........................................... 24DILANTIN EXTENDED .................... 24DILANTIN KAPSEAL ....................... 24DILATRATE-SR ................................. 18diltiazem hcl ...........................................18DILT-XR .............................................. 18DIPENTUM ..........................................49diphenhydramine hcl ............................. 62diphenoxylate-atropine .......................... 49dipyridamole .......................................... 54disopyramide phosphate ........................ 18disulfiram ...............................................30DIURIL .................................................18divalproex .............................................. 24DIVIGEL .............................................. 44DM2 .......................................................44donepezil ................................................ 30dorzolamide ........................................... 59dorzolamide-timolol ...............................59doxazosin ............................................... 18doxepin .............................................24, 37doxercalciferol .......................................57doxycycline hyclate ..........................10, 57doxycycline monohydrate ................ 10, 37dronabinol ........................................41, 49drospirenone-ethinyl estradiol ...............31DROXIA ............................................... 54DUAVEE .............................................. 44DULERA .............................................. 62duloxetine ...............................................25DUREZOL ............................................59dutasteride ............................................. 52DYRENIUM .........................................18E.E.S. 400 ..............................................10E.E.S. GRANULES ..............................10econazole ............................................... 37ECONTRA EZ ..................................... 31EDARBI ................................................18EDECRIN .............................................18EDURANT ............................................10EFFEXOR XR ..................................... 25EFFIENT .............................................. 54ELESTRIN ........................................... 44eletriptan hbr ......................................... 25ELIDEL ................................................ 37ELIMITE ..............................................37ELINEST .............................................. 32ELIPHOS ..............................................52ELIQUIS ...............................................54ELIXOPHYLLIN ................................ 62ELLA .................................................... 32ELMIRON ............................................52EMADINE ............................................ 59EMBEDA ................................................4EMCYT ................................................ 14EMOQUETTE ..................................... 32EMSAM ................................................ 25EMTRIVA ............................................ 10

Index

ENABLEX ............................................ 52enalapril maleate ................................... 18enalapril-hydrochlorothiazide ...............18ENBREL .................................................4ENBREL SURECLICK ........................ 4ENDOCET ..............................................4ENDOMETRIN ................................... 44enoxaparin ............................................. 54ENSKYCE ............................................ 32entacapone .............................................25entecavir ................................................ 10ENTERIC COATED ASPIRIN ......4, 54EPCLUSA .............................................10EPIDUO ................................................37epinastine ...............................................59epinephrine ...................................... 18, 62EPITOL ................................................ 25eplerenone ..............................................18eprosartan ..............................................18EPZICOM ............................................ 10EQUETRO ........................................... 25ergocalciferol (vitamin d2) .................... 42ergoloid ..................................................30ERIVEDGE .......................................... 14ERRIN .................................................. 32ERTACZO ............................................37ERY PADS ........................................... 37ERYPED 200 ........................................10ERYPED 400 ........................................10ERY-TAB ............................................. 10ERYTHROCIN (AS STEARATE) .... 10erythromycin .................................... 10, 59erythromycin ethylsuccinate .................. 10erythromycin stearate ............................ 10erythromycin with ethanol ..................... 37escitalopram oxalate ..............................25esomeprazole magnesium ...................... 50ESTARYLLA .......................................32ESTRACE ............................................ 64estradiol ................................................. 44ESTRADIOL TRANSDERMAL PATCH ................................................. 44estradiol valerate ................................... 44estradiol-norethindrone acet ................. 44ESTRING ............................................. 64estrogens-methyltestosterone .................44estropipate ............................................. 44eszopiclone .............................................25ethambutol ............................................. 10ethosuximide .......................................... 25etidronate disodium ............................... 44etodolac ....................................................4EURAX ................................................. 37EVAMIST .............................................44EVOCLIN .............................................37EVOTAZ .............................................. 10EXELDERM .................................. 37, 38exemestane .............................................14EXTAVIA .............................................58ezetimibe ................................................ 19FACTIVE ............................................. 10FALMINA (28) .....................................32famciclovir ............................................. 10

Index

FANAPT ............................................... 25FARESTON ..........................................14FARXIGA .............................................44FARYDAK ........................................... 14felbamate ................................................25FELDENE .............................................. 4felodipine ............................................... 19FEMRING ............................................ 64fenofibrate ..............................................19fenofibrate micronized ........................... 19fenofibrate nanocrystallized .................. 19fenofibric acid ........................................19fenoprofen ................................................ 4fentanyl .................................................... 4fentanyl citrate ......................................... 4FENTORA ..............................................4FERRIPROX ..........................................7FETZIMA .............................................25FINACEA ............................................. 38finasteride ........................................ 38, 52FIRAZYR ............................................. 19FLAREX ...............................................59flavoxate .................................................52flecainide ................................................19FLOVENT DISKUS ............................ 62FLOVENT HFA ...................................62FLUAD 2017-2018 (65 YR UP)(PF) ...16FLUARIX QUAD 2017-2018 (PF) ..... 16FLUBLOK 2017-2018 (PF) .................16FLUBLOK QUAD 2017-2018 (PF) .... 16FLUCELVAX QUAD 2017-2018 ....... 16FLUCELVAX QUAD 2017-2018 (PF) ........................................................16fluconazole .............................................10flucytosine .............................................. 10fludrocortisone .......................................44FLULAVAL QUAD 2017-2018 .......... 16FLULAVAL QUAD 2017-2018 (PF) ..16FLUMIST QUAD 2017-2018 .............. 16flunisolide .............................................. 62fluocinolone ........................................... 38fluocinolone acetonide oil ......................61fluocinolone and shower cap ................. 38fluocinonide ........................................... 38FLUOCINONIDE-E ............................38fluocinonide-emollient ........................... 38fluoride (sodium) ................................... 57fluorometholone .....................................59FLUOROPLEX ....................................38fluorouracil ............................................ 38fluoxetine ................................................25fluphenazine hcl ..................................... 25flurbiprofen .............................................. 4flurbiprofen sodium ............................... 59flutamide ................................................ 14fluticasone ........................................38, 62fluticasone-salmeterol ............................63fluvastatin .............................................. 19FLUVIRIN 2017-2018 ......................... 16FLUVIRIN 2017-2018 (PF) .................16fluvoxamine ............................................25FLUZONE HIGH-DOSE 2017-18 (PF) ........................................................17

69

Index

FLUZONE INTRADERM QUAD 2017-18 .................................................. 17FLUZONE QUAD 2017-2018 .............17FLUZONE QUAD 2017-2018 (PF) .... 17FLUZONE QUAD PEDI 2017-18 (PF) ........................................................17FML FORTE ........................................59FML S.O.P. ...........................................59folic acid ................................................ 42fondaparinux ..........................................54FORFIVO XL ...................................... 25FORTEO .............................................. 44FOSAMAX PLUS D ............................ 44fosinopril ................................................19FOSRENOL ......................................... 52FRAGMIN ............................................54FREESTYLE INSULINX ................... 56FREESTYLE INSULINX TEST STRIPS ................................................. 56FREESTYLE LITE STRIPS .............. 56FREESTYLE PRECISION NEO STRIPS ................................................. 56FREESTYLE TEST ............................ 56frovatriptan ............................................ 25furosemide ..............................................19FUZEON ...............................................10gabapentin ............................................. 25galantamine ........................................... 30ganirelix .................................................44gatifloxacin ............................................ 59GAVILYTE-G ......................................50GAVILYTE-N ......................................50GELNIQUE ..........................................52gemfibrozil ............................................. 19GENGRAF ....................................... 4, 55GENTAK .............................................. 59gentamicin ........................................38, 59GENVOYA ...........................................10GIANVI (28) .........................................32GIAZO .................................................. 50GILDAGIA ...........................................32glatiramer .............................................. 58GLATOPA ............................................58GLEEVEC ............................................14GLEOSTINE ........................................14glimepiride .............................................44glipizide ............................................44, 45GLUCAGEN DIAGNOSTIC KIT ..... 41GLUCAGEN HYPOKIT .................... 45GLUCAGON EMERGENCY KIT (HUMAN) ............................................. 45glucagon hcl .....................................41, 45glyburide ................................................ 45glyburide micronized ............................. 45glycopyrrolate ........................................50GLYDO .................................................38GLYSET ............................................... 45granisetron hcl .......................................50griseofulvin microsize ......................10, 11griseofulvin ultramicrosize .................... 11guanfacine ........................................19, 25guanidine ............................................... 56halobetasol propionate .......................... 38

Index

HALOG ................................................ 38haloperidol .............................................25haloperidol lactate .................................25HEATHER ........................................... 32HEP FLUSH-10 (PF) ...........................54heparin (porcine) ................................... 54heparin lock flush (porcine) ...................54HEPARIN LOCKFLUSH(PORCINE)(PF) ..........54heparin, porcine (pf) ..............................54HEPSERA ............................................ 11HEXALEN ............................................14HORIZANT ..........................................25HUMALOG ..........................................45HUMALOG KWIKPEN ..................... 45HUMALOG MIX 50-50 ...................... 45HUMALOG MIX 50-50 KWIKPEN . 45HUMALOG MIX 75-25 ...................... 45HUMALOG MIX 75-25 KWIKPEN . 45HUMIRA .......................................... 5, 50HUMIRA PEDIATRIC CROHN'S START .............................................. 4, 50HUMIRA PEN ....................................... 5HUMIRA PEN CROHN'S-UC-HS START .................................................... 4HUMULIN 70/30 ................................. 45HUMULIN N ........................................45HUMULIN R U-100 ............................ 45HUMULIN R U-500 (CONC) KWIKPEN ............................................45HUMULIN R U-500 (CONCENTRATED) ...........................45hydralazine ............................................ 19hydrochlorothiazide ...............................19hydrocodone-acetaminophen ...................5hydrocodone-chlorpheniramine ............ 63hydrocodone-homatropine .....................63hydrocodone-ibuprofen ............................5hydrocortisone ....................... 7, 38, 45, 50hydrocortisone butyrate .........................38hydrocortisone butyr-emollient ............. 38hydrocortisone valerate ......................... 38hydrocortisone-acetic acid .................... 61hydromorphone ........................................5hydroxychloroquine ........................... 5, 11hydroxyprogesterone capr(bulk) ........... 45hydroxyprogesterone caproate .............. 45hydroxyurea ........................................... 14hydroxyzine hcl ...................................... 26hydroxyzine pamoate ............................. 26hyoscyamine sulfate ............................... 50HYQVIA ...............................................17HYSINGLA ER ..................................... 5ibandronate ............................................45IBRANCE .............................................14ibuprofen ..................................................5ibuprofen-oxycodone ............................... 5ICLUSIG .............................................. 14ILEVRO ................................................59imatinib .................................................. 14IMBRUVICA ....................................... 14imipramine hcl ....................................... 26imipramine pamoate .............................. 26

Index

imiquimod .............................................. 38INCRELEX .......................................... 45indapamide ............................................ 19INDERAL LA ...................................... 19INDERAL XL ...................................... 19INDOCIN ................................................5indomethacin ............................................5INTRON A ........................................... 14INVEGA ............................................... 26INVIRASE ............................................11INVOKANA ......................................... 45ipratropium bromide ..............................63ipratropium-albuterol ............................ 63irbesartan ...............................................19irbesartan-hydrochlorothiazide .............19ISENTRESS ......................................... 11ISOCHRON ..........................................19isoniazid .................................................11isopropyl alcohol ................................... 30ISORDIL .............................................. 19isosorbide dinitrate ................................19isosorbide mononitrate .......................... 19isradipine ............................................... 19ISTALOL ..............................................59itraconazole ........................................... 11JADENU ................................................. 7JAKAFI ................................................ 14JANTOVEN ......................................... 54JANUVIA ............................................. 45JENCYCLA ..........................................32JOLESSA ..............................................32JOLIVETTE ........................................ 32JUBLIA .................................................38JULEBER .............................................32JUNEL 1.5/30 (21) ............................... 32JUNEL 1/20 (21) .................................. 32JUNEL FE 1.5/30 (28) ......................... 32JUNEL FE 1/20 (28) ............................ 32JUNEL FE 24 ....................................... 32KAITLIB FE ........................................ 32KALEXATE .........................................42KARIVA (28) ....................................... 32K-EFFERVESCENT ...........................42KELNOR 1/35 (28) .............................. 32KERYDIN ............................................ 38ketoconazole .................................... 11, 39ketoprofen ................................................ 5ketorolac ............................................ 5, 59KIMIDESS (28) ....................................32KIONEX ............................................... 42KIONEX (WITH SORBITOL) .......... 42KLOR-CON 10 .................................... 42KLOR-CON 8 ...................................... 42KLOR-CON M10 .................................42KLOR-CON M15 .................................42KLOR-CON M20 .................................42KLOR-CON SPRINKLE ....................42K-TAB ...................................................42KURVELO ........................................... 32labetalol ................................................. 19LACRISERT ........................................ 60lactulose .................................................50lamivudine ..............................................11

70

Index

lamivudine-zidovudine ...........................11lamotrigine .............................................26LANOXIN ............................................ 19lansoprazole ...........................................50LANTUS ............................................... 45LANTUS SOLOSTAR ........................ 45LARIN 1.5/30 (21) ................................32LARIN 1/20 (21) ...................................32LARIN 24 FE ....................................... 32LARIN FE 1.5/30 (28) ..........................32LARIN FE 1/20 (28) .............................32LARISSIA ............................................ 32LASIX ................................................... 19LASTACAFT ....................................... 60latanoprost .............................................60LATUDA .............................................. 26LAYOLIS FE ....................................... 32LAZANDA ..............................................5leflunomide .............................................. 5LENVIMA ............................................ 15LESSINA .............................................. 32LETAIRIS ............................................ 19letrozole ................................................. 15leucovorin calcium .................................15LEUKERAN .........................................15leuprolide ...............................................15LEVA SET ............................................39levalbuterol hcl ...................................... 63levalbuterol tartrate ...............................63LEVATOL ............................................19LEVEMIR ............................................ 46LEVEMIR FLEXTOUCH ..................45levetiracetam ..........................................26levobunolol ............................................ 60levocetirizine ..........................................63levofloxacin ......................................11, 60LEVONEST (28) ..................................32levonorgestrel-ethinyl estrad ........... 32, 33LEVORA 0.15/30 (28) ......................... 33LEVORA-28 .........................................33levothyroxine ..........................................46LEVOXYL ............................................46LEXIVA ................................................11lidocaine ............................................ 7, 39lidocaine hcl .................................7, 39, 57LIDOCAINE VISCOUS ..................... 57lidocaine-prilocaine ...............................39LIDOPAC .............................................39LIDOPRIL ............................................39LIDOPRIL XR .....................................39LIDO-PRILO CAINE PACK .............39LIDORXKIT ........................................ 39LIDOTREX .......................................... 39lindane ................................................... 39linezolid ..................................................11LINZESS .............................................. 50liothyronine ............................................46LIPROZONEPAK ...............................39lisinopril .................................................20lisinopril-hydrochlorothiazide ...............20lithium carbonate ...................................26lithium citrate .........................................26LIVALO ................................................20

Index

LIVIXIL PAK ...................................... 39LO LOESTRIN FE ..............................33LODOSYN ............................................26LOMEDIA 24 FE .................................33LONSURF ............................................ 15lopinavir-ritonavir ................................. 11LOPROX (AS OLAMINE) .................39LOPROX KIT ......................................39lorazepam .............................................. 26LORAZEPAM INTENSOL ................26LORCET (HYDROCODONE) ............ 5LORCET HD ......................................... 5LORCET PLUS ..................................... 5LORTAB ELIXIR ................................. 5LORYNA (28) ...................................... 33LORZONE ........................................... 56losartan .................................................. 20losartan-hydrochlorothiazide ................ 20LOTEMAX ...........................................60LOTRISONE ........................................39LOTRONEX ........................................ 50lovastatin ................................................20LOW-OGESTREL (28) .......................33loxapine succinate ................................. 26LP LITE PAK ...................................... 39LUDENT FLUORIDE .........................58LUMIGAN ............................................60LUPANETA PACK (1 MONTH) .......46LUPANETA PACK (3 MONTH) .......46LUPRON DEPOT ..........................15, 46LUPRON DEPOT (3 MONTH) ... 15, 46LUPRON DEPOT (4 MONTH) ......... 15LUPRON DEPOT (6 MONTH) ......... 15LUPRON DEPOT-PED ...................... 46LUPRON DEPOT-PED (3 MONTH) 46LUTERA (28) ....................................... 33LYNPARZA ......................................... 15LYRICA ................................................26LYSODREN ......................................... 15LYZA .................................................... 33malathion ............................................... 39maprotiline .............................................26MARLISSA .......................................... 33MARPLAN ...........................................26MATULANE ........................................ 15MATZIM LA ....................................... 20MAVYRET ...........................................11MAXIDEX ............................................60meclizine ................................................ 50meclofenamate ......................................... 5MEDI-MECLIZINE ............................50MEDOLOR PAK .................................39medroxyprogesterone ...................... 33, 46mefenamic acid ........................................ 5mefloquine ..............................................11megestrol ..........................................15, 41MEKINIST ...........................................15meloxicam ................................................ 5memantine ..............................................31MENEST .............................................. 46MENOSTAR ........................................ 46MENTAX ..............................................39meprobamate ......................................... 26

Index

mercaptopurine ......................................15mesalamine ............................................ 50mesalamine with cleansing wipe ........... 50MESTINON ..........................................56METADATE ER ..................................26metaproterenol .......................................63metaxalone .............................................56metformin ...............................................46methadone ................................................5methamphetamine .................................. 26methazolamide ....................................... 20methenamine hippurate ......................... 52methimazole ........................................... 46METHITEST ....................................... 46methocarbamol ...................................... 56methotrexate sodium ..........................5, 15methotrexate sodium (pf) ....................... 15methscopolamine ................................... 50methyclothiazide .................................... 20methyldopa .............................................20methylphenidate hcl ......................... 26, 27methylprednisolone ................................46methyltestosterone ................................. 46metipranolol ...........................................60metoclopramide hcl ............................... 50metolazone ............................................. 20metoprolol succinate ..............................20metoprolol ta-hydrochlorothiaz .............20metoprolol tartrate .................................20METROGEL ........................................39metronidazole ............................ 11, 39, 64mexiletine ...............................................20MIACALCIN ....................................... 46MICROGESTIN 1.5/30 (21) ............... 33MICROGESTIN 1/20 (21) .................. 33MICROGESTIN 24 FE .......................33MICROGESTIN FE 1.5/30 (28) ......... 33MICROGESTIN FE 1/20 (28) ............ 33midodrine ...............................................20MIGRANAL .........................................27MILK OF MAGNESIA .......................50MILLIPRED ........................................ 46MILLIPRED DP ..................................46MIMVEY ..............................................46MIMVEY LO ....................................... 46MINITRAN .......................................... 20minocycline .................................. 5, 11, 39minoxidil ................................................ 20MIRCERA ............................................54MIRENA ...............................................33mirtazapine ............................................ 27misoprostol ............................................ 50MITIGARE .......................................... 53MOBIC ................................................... 5modafinil ................................................ 27moexipril ................................................ 20mometasone ..................................... 39, 63MONDOXYNE NL ..............................11MONO-LINYAH ................................. 33MONONESSA (28) ..............................33montelukast ............................................ 63MONUROL .......................................... 52MORGIDOX ........................................ 11

71

Index

MORGIDOX 1X100 ............................ 11MORGIDOX 2X100 ............................ 11morphine .............................................. 5, 6morphine concentrate .............................. 5MOTION RELIEF (MECLIZINE) ... 50MOTION SICKNESS (MECLIZINE) ..................................... 50MOTION SICKNESS II ..................... 50MOTION SICKNESS RELIEF(MECLIZ) ..............................50MOTOFEN ...........................................50MOVANTIK .......................................... 7MOVIPREP ..........................................50MOXEZA ............................................. 60moxifloxacin .....................................11, 60MULTAQ ............................................. 20mupirocin ...............................................39MYALEPT ........................................... 46mycophenolate mofetil ....................... 6, 55mycophenolate sodium ...........................55MYORISAN ......................................... 39MYRBETRIQ ...................................... 52MYZILRA ............................................ 33nabumetone ..............................................6nadolol ................................................... 20NALFON ................................................ 6naltrexone ................................................ 7NAMENDA XR ....................................31naproxen .................................................. 6naproxen sodium ......................................6naratriptan .............................................27NARCAN ................................................ 7NASAL ALLERGY ............................. 63NATACYN ........................................... 60nateglinide ............................................. 46NATURE-THROID .............................46NEBUPENT ..........................................11NECON 0.5/35 (28) .............................. 33NECON 1/50 (28) ................................. 33NECON 7/7/7 (28) ................................ 33nefazodone ............................................. 27neomycin ................................................ 11neomycin-polymyxin b-dexameth ...........60neomycin-polymyxin-hc ......................... 61NEORAL .......................................... 6, 55NESINA ................................................ 46NEULASTA ..........................................54NEVANAC ........................................... 60nevirapine .............................................. 11NEXAVAR ........................................... 15NIACOR ............................................... 20nicardipine .............................................20nicotine .................................................. 30NICOTROL ..........................................30NICOTROL NS ................................... 30nifedipine ............................................... 20NIKKI (28) ........................................... 33NILANDRON .......................................15nimodipine ............................................. 20NINLARO ............................................ 15nisoldipine ..............................................20NITRO-BID ..........................................20nitrofurantoin .........................................53

Index

nitrofurantoin macrocrystal ...................52nitrofurantoin monohyd/m-cryst ............53nitroglycerin .......................................... 20NITROLINGUAL ................................20NITROMIST ........................................ 21NITROSTAT ........................................21nizatidine ................................................50NORA-BE .............................................33noreth-ethinyl estradiol-iron ................. 33norethindrone (contraceptive) ............... 33norethindrone acetate ............................47norethindrone ac-eth estradiol .............. 33norethindrone-e.estradiol-iron .............. 33norgestimate-ethinyl estradiol ............... 33NORITATE .......................................... 39NORLYROC ........................................ 33NORPACE CR .....................................21NORTREL 1/35 (28) ............................34nortriptyline ........................................... 27NORVIR ............................................... 11NOVOFINE 30 ...............................56, 57NOVOLIN 70/30 .................................. 47NOVOLIN N ........................................ 47NOVOLIN R ........................................ 47NOVOLOG .......................................... 47NOVOLOG FLEXPEN .......................47NOVOLOG MIX 70-30 .......................47NOVOLOG MIX 70-30 FLEXPEN ... 47NOVOLOG PENFILL ........................ 47NP THYROID ......................................47NUCYNTA ............................................. 6NUPLAZID .......................................... 27NUTROPIN AQ NUSPIN ................... 47NUVARING ......................................... 34NYAMYC ............................................. 39nystatin .................................12, 39, 40, 58nystatin-triamcinolone ...........................40NYSTOP ............................................... 40OCELLA .............................................. 34octreotide acetate .............................47, 51ODEFSEY ............................................ 12ODOMZO .............................................15ofloxacin .................................... 12, 60, 61olanzapine ..............................................27olmesartan ............................................. 21olopatadine ...................................... 60, 63omega-3 acid ethyl esters ...................... 21omeprazole .............................................51OMNITROPE ...................................... 47ondansetron ........................................... 51ondansetron hcl ..................................... 51ondansetron hcl (pf) ...............................51ONETOUCH ULTRA TEST ........56, 57ONETOUCH VERIO ..........................56OPCICON ONE-STEP ....................... 34OPSUMIT .............................................21ORALONE ........................................... 58ORAP .................................................... 27ORAVIG ...............................................12ORENCIA .............................................. 6ORENCIA CLICKJECT ...................... 6orphenadrine citrate .............................. 56ORSYTHIA .......................................... 34

Index

ORTHO TRI-CYCLEN LO (28) ........34oseltamivir ............................................. 12OSPHENA ............................................ 47OTIPRIO .............................................. 61OTOVEL .............................................. 61oxandrolone ........................................... 47oxaprozin ................................................. 6oxcarbazepine ........................................ 27oxybutynin chloride ............................... 53oxycodone ................................................ 6oxycodone-acetaminophen ...................... 6OXYCONTIN ........................................ 6oxymorphone ............................................6PACERONE .........................................21paliperidone ...........................................27PANCREAZE ...................................... 51PANDEL ...............................................40pantoprazole .......................................... 51paricalcitol .............................................57PAROEX ORAL RINSE .....................58paroxetine hcl ........................................ 27PATANOL ............................................60PEDIAPRED ........................................ 47peg 3350-electrolytes .............................51PEGANONE .........................................27PEGASYS .............................................12PEGASYS PROCLICK ...................... 12peg-electrolyte soln ................................51PEGINTRON ....................................... 12PEN NEEDLE ................................56, 57pen needle, diabetic ......................... 56, 57penicillin v potassium ............................ 12PENNSAID ...........................................40pentoxifylline ..........................................54perindopril erbumine ............................. 21PERIOGARD .......................................58permethrin ..............................................40perphenazine ..........................................27PERTZYE ............................................ 51PHENADOZ ...................................51, 63phenazopyridine .....................................53phenelzine .............................................. 27PHENERGAN ................................51, 63phenobarbital .........................................27phenoxybenzamine .................................21PHENYTEK .........................................27phenytoin ................................................27phenytoin sodium extended ....................27PHOSLYRA ......................................... 53PHOSPHOLINE IODIDE .................. 60PHYSIOLYTE ..................................... 42PHYSIOSOL IRRIGATION ..............42PICATO ................................................40pilocarpine hcl ................................. 58, 60pimozide .................................................27PIMTREA (28) .....................................34pindolol .................................................. 21pioglitazone ............................................47PIRMELLA ..........................................34piroxicam ................................................. 6PLAVIX ................................................ 54PLEGRIDY .......................................... 58podofilox ................................................ 40

72

Index

polyethylene glycol 3350 ....................... 51polyethylene glycol 3350(bulk) ..............30polymyxin b sulf-trimethoprim ...............60PORTIA ................................................34potassium bicarb-citric acid .................. 42potassium chloride .................................42potassium citrate ....................................53PRADAXA ............................................54pramipexole ........................................... 27PRANDIN .............................................47PRAVACHOL ......................................21pravastatin ............................................. 21prazosin ..................................................21PRED MILD .........................................60prednicarbate .........................................40prednisolone .......................................... 47prednisolone acetate ..............................60prednisolone sodium phosphate ...... 47, 60prednisone ..............................................47PREDNISONE INTENSOL ............... 47PREMARIN ................................... 47, 65PREMPRO ........................................... 47PRENATAL PLUS (CALCIUM CARB) ...................................................42PREPOPIK ...........................................51PREVALITE ........................................ 21PREVIFEM .......................................... 34PREZISTA ........................................... 12PRIFTIN ...............................................12PRILOLID ............................................40primaquine .............................................12primidone ...............................................27PRIMSOL .............................................12PRISTIQ ...............................................27PROAIR HFA ...................................... 63PROAIR RESPICLICK ......................63probenecid ............................................. 53probenecid-colchicine ............................53prochlorperazine ....................................51prochlorperazine maleate ......................51PROCRIT .............................................55PROCTOSOL HC ........................... 7, 40PROCTOZONE-HC ........................7, 40PRODIGY NO CODING .................... 57progesterone micronized ....................... 47PROMACTA ........................................55promethazine ....................................51, 63promethazine-codeine ............................63promethazine-dm ................................... 63PROMETHEGAN ......................... 51, 63propafenone ........................................... 21propranolol ............................................ 21propylthiouracil ..................................... 47protriptyline ........................................... 28PRUDOXIN ..........................................40PULMICORT FLEXHALER .............64PURIXAN .............................................15pyrazinamide ..........................................12pyridostigmine bromide ......................... 56QUASENSE ..........................................34QUESTRAN ......................................... 21quetiapine .............................................. 28QUILLICHEW ER ..............................28

Index

QUILLIVANT XR ...............................28quinapril ................................................ 21quinapril-hydrochlorothiazide ...............21quinidine gluconate ............................... 21quinidine sulfate .....................................21quinine sulfate ........................................12QVAR ....................................................64rabeprazole ............................................ 51RADIOGARDASE ................................ 7raloxifene ............................................... 48ramipril .................................................. 21RANEXA .............................................. 21ranitidine hcl ..........................................51RAPAFLO ............................................ 53rasagiline ............................................... 28REBIF (WITH ALBUMIN) ................58REBIF REBIDOSE ............................. 58REBIF TITRATION PACK ...............58RECLIPSEN (28) .................................34RECTIV ..................................................7REFISSA .............................................. 40REGRANEX ........................................ 40RELENZA DISKHALER ................... 12RELION NEEDLES ............................56RELION PEN NEEDLES ...................56RELPAX ...............................................28RENVELA ............................................53repaglinide .............................................48RESCRIPTOR ..................................... 12REVLIMID .......................................... 15REXULTI ............................................. 28REYATAZ ............................................12RIBASPHERE ..................................... 12RIBASPHERE RIBAPAK ..................12ribavirin ................................................. 12RIDAURA .............................................. 6rifabutin ................................................. 12rifampin ..................................................12RIFATER ............................................. 12RILUTEK .............................................56riluzole ................................................... 56rimantadine ............................................12RIOMET ...............................................48risedronate .............................................48risperidone .............................................28rivastigmine tartrate .............................. 31rizatriptan .............................................. 28ROCALTROL ................................42, 57ropinirole ............................................... 28ROSADAN ............................................40rosuvastatin ............................................21ROXICODONE ..................................... 6ROZEREM ...........................................28SABRIL ................................................ 28SAMSCA .............................................. 21SANCUSO ............................................ 51SANTYL ............................................... 40SAPHRIS (BLACK CHERRY) ..........28SAVAYSA ............................................ 55SAVELLA ............................................ 28SCALACORT ...................................... 40selegiline hcl .......................................... 28selenium sulfide ..................................... 40

Index

SELZENTRY ....................................... 12SENSIPAR ............................................48SEREVENT DISKUS ..........................64SEROQUEL XR .................................. 28sertraline ................................................28SETLAKIN ...........................................34sevelamer carbonate ..............................53SHAROBEL ......................................... 34SIGNIFOR ............................................48SILAZONE-II ...................................... 40sildenafil (antihypertensive) .................. 21silver sulfadiazine .................................. 40SIMBRINZA ........................................ 60simvastatin ............................................. 21sirolimus ................................................ 55SIRTURO ............................................. 12SIVEXTRO .......................................... 12SKLICE ................................................ 40SODIUM POLYSTYRENE (SORB FREE) ................................................... 42sodium polystyrene sulfonate ...........42, 43SOMAVERT ........................................ 48SORIATANE ........................................40SORINE ................................................ 21sotalol .................................................... 21SOVALDI ............................................. 12spinosad ................................................. 40SPIRIVA RESPIMAT .........................64SPIRIVA WITH HANDIHALER ...... 64spironolactone ....................................... 21spironolacton-hydrochlorothiaz ............ 21SPRINTEC (28) ................................... 34SPRYCEL .............................................15SPS (WITH SORBITOL) ....................43SRONYX .............................................. 34SSD ........................................................ 40stavudine ................................................ 13STELARA ...................................... 40, 51STIVARGA .......................................... 15STRATTERA .......................................28STRIBILD ............................................ 13STRIVERDI RESPIMAT ................... 64STROMECTOL ...................................13SUBOXONE .........................................30SUBSYS .................................................. 6sucralfate ............................................... 51sulfacetamide sodium .............................60sulfacetamide sodium (acne) ................. 40sulfadiazine ............................................ 13sulfamethoxazole-trimethoprim ............. 13SULFAMYLON ...................................41sulfasalazine ................................ 7, 51, 52SULFATRIM ....................................... 13sulindac ....................................................7sumatriptan ............................................ 28sumatriptan succinate ......................28, 29SUMAVEL DOSEPRO ....................... 29SUPRAX ............................................... 13SUPREP BOWEL PREP KIT ............52SUTENT ............................................... 15SYMLINPEN 120 ................................ 48SYMLINPEN 60 .................................. 48SYNERA ...............................................41

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Index

SYNTHROID ....................................... 48SYPRINE ................................................7TABLOID .............................................15tacrolimus ........................................ 41, 55TAFINLAR .......................................... 15TAGRISSO ...........................................15TAKE ACTION ................................... 34TALTZ SYRINGE ...............................41TALTZ SYRINGE (2 PACK) .............41TALTZ SYRINGE (3 PACK) .............41TAMIFLU ............................................ 13tamoxifen ................................................15tamsulosin .............................................. 53TANZEUM ...........................................48TARCEVA ............................................15TARGRETIN ................................. 15, 41TARINA FE 1/20 (28) ..........................34TASIGNA ............................................. 16TASMAR .............................................. 29TAYTULLA ......................................... 34TAZORAC ........................................... 41TAZTIA XT ......................................... 22TECFIDERA ........................................58TECHNIVIE ........................................ 13TEKTURNA .........................................22telmisartan ............................................. 22temazepam ............................................. 29terazosin .................................................22terbinafine hcl ........................................13terbutaline ..............................................64terconazole .............................................65testosterone ............................................ 48testosterone cypionate ........................... 48testosterone enanthate ........................... 48tetrabenazine ..........................................29tetracycline ............................................ 13THALOMID ...................................13, 16THEO-24 .............................................. 64THEOCHRON .....................................64theophylline ............................................64THERMAZENE .................................. 41thioridazine ............................................ 29thiothixene ..............................................29THYROLAR-1 .....................................48THYROLAR-1/2 ..................................48THYROLAR-1/4 ..................................48THYROLAR-2 .....................................48THYROLAR-3 .....................................48tiagabine ................................................ 29ticlopidine .............................................. 55TIKOSYN .............................................22timolol maleate ................................ 22, 60TIMOPTIC ...........................................60TIROSINT ............................................48TIVICAY .............................................. 13tizanidine ................................................56TOBRADEX .........................................60tobramycin ............................................. 61tobramycin in 0.225 % nacl ...................64tobramycin with nebulizer ..................... 64tobramycin-dexamethasone ................... 61tolazamide ..............................................48tolbutamide ............................................ 48

Index

tolcapone ................................................29tolmetin .................................................... 7tolterodine ..............................................53topiramate ..............................................29TOPROL XL ........................................22torsemide ................................................22TOUJEO SOLOSTAR ........................ 48TOVIAZ ................................................53TRACLEER ......................................... 22TRADJENTA .......................................48tramadol ...................................................7tramadol-acetaminophen .........................7trandolapril ............................................22tranexamic acid ..................................... 55TRANSDERM-SCOP ..........................52tranylcypromine .....................................29TRAVATAN Z ..................................... 61trazodone ............................................... 29TRECATOR .........................................13TRESIBA FLEXTOUCH U-100 ........ 48TRESIBA FLEXTOUCH U-200 ........ 48tretinoin ..................................................41tretinoin (chemotherapy) ....................... 16tretinoin (emollient) ............................... 41tretinoin microspheres ........................... 41TRETIN-X ............................................41TRETIN-X CREAM KIT ................... 41TREXALL ........................................ 7, 16triamcinolone acetonide ............ 41, 58, 64triamterene-hydrochlorothiazid .............22triazolam ................................................ 29TRICOR ............................................... 22TRIDERM ............................................ 41TRI-ESTARYLLA .............................. 34trifluoperazine ........................................29trifluridine ..............................................61trihexyphenidyl ...................................... 29TRI-LINYAH .......................................34TRI-LO-ESTARYLLA ....................... 34TRI-LO-MARZIA ............................... 34TRI-LO-SPRINTEC ............................34TRILYTE WITH FLAVOR PACKETS ............................................ 52trimethobenzamide .................................52trimethoprim .......................................... 13trimipramine .......................................... 29TRINESSA (28) ....................................34TRINESSA LO .....................................34TRINTELLIX ...................................... 29TRI-PREVIFEM (28) ..........................34TRI-SPRINTEC (28) ........................... 34TRIUMEQ ............................................13tropicamide ............................................ 61trospium ................................................. 53TRULICITY .........................................48TRUVADA ........................................... 13TYBOST ............................................... 57TYKERB .............................................. 16ULESFIA .............................................. 41ULORIC ............................................... 53UNIFINE PENTIPS .......................56, 57UNITHROID ........................................49ursodiol .................................................. 52

Index

VAGIFEM ............................................ 65valacyclovir ............................................13VALCYTE ............................................13valganciclovir ........................................ 13valproic acid .......................................... 29valproic acid (as sodium salt) ................29valsartan ................................................ 22valsartan-hydrochlorothiazide .............. 22vancomycin ............................................ 13VANDAZOLE ......................................65VASCEPA ............................................ 22VELIVET TRIPHASIC REGIMEN (28) .........................................................34VENCLEXTA ...................................... 16venlafaxine .............................................29VENTAVIS ...........................................22VENTOLIN HFA .................................64verapamil ............................................... 22VERDESO ............................................ 41VEREGEN ............................................41VESICARE ...........................................53VESTURA (28) .....................................34VIBERZI .............................................. 52VIBRAMYCIN .................................... 13VICTOZA 2-PAK ................................49VICTOZA 3-PAK ................................49VIEKIRA PAK .................................... 13VIEKIRA XR ....................................... 13VIENVA ................................................34VIGAMOX ........................................... 61VIIBRYD .............................................. 29VIMPAT ............................................... 29VIORELE (28) ..................................... 35VIREAD ................................................13VITAMIN B-12 .................................... 43VITAMIN D2 ....................................... 43VITUZ ...................................................64VIVELLE-DOT ................................... 49voriconazole ...........................................13VOTRIENT .......................................... 16VRAYLAR ........................................... 29VYFEMLA (28) ................................... 35VYVANSE ............................................ 29warfarin ................................................. 55WELLBUTRIN SR ..............................29WERA (28) ........................................... 35WP THYROID .....................................49WYMZYA FE ...................................... 35XALKORI ............................................ 16XARELTO ............................................55XELJANZ ...............................................7XELJANZ XR ........................................7XENAZINE .......................................... 29XIFAXAN .............................................13XIIDRA .................................................61XOLEGEL ............................................41XOPENEX HFA .................................. 64XRYLIX ................................................41XULANE .............................................. 35YUVAFEM ...........................................65zafirlukast .............................................. 64zaleplon ..................................................29ZANAFLEX ......................................... 56

74

Index

ZARAH .................................................35ZARXIO ............................................... 55ZEBUTAL .............................................. 7ZELAPAR ............................................ 30ZEMPLAR ........................................... 57ZENATANE ......................................... 41ZENPEP ................................................52ZENZEDI ............................................. 30ZEPATIER ...........................................13ZETIA ...................................................22zidovudine .............................................. 13ziprasidone hcl .......................................30ZIPSOR .................................................. 7ZIRGAN ............................................... 61ZITHROMAX ......................................14ZMAX ................................................... 14ZOLINZA .............................................16zolmitriptan ............................................30ZOLOFT ...............................................30zolpidem .................................................30ZOMIG ................................................. 30ZOMIG ZMT ....................................... 30zonisamide ............................................. 30ZONTIVITY ........................................ 55ZORTRESS .......................................... 55ZYFLO CR ...........................................64ZYKADIA ............................................ 16ZYTIGA ................................................16ZYVOX .................................................14

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