Tiếng Việt - Santa Clara Family Health Plan

Transcription

SANTA CLARA FAMILY HEALTH PLAN
CAL MEDICONNECT PLAN
(CHƯƠNG TRÌNH MEDICARE-MEDICAID)
Danh Sách Thuốc Được Đài Thọ
(Tập Công Thức)
2016
Số Miễn phí: 1-877-723-4795
TTY: 1-800-735-2929
8 giờ sáng tới 8 giờ tối, 7 ngày một tuần, kể cả các ngày nghỉ lễ.
Nếu quý vị có câu hỏi, vui lòng gọi đến Santa Clara Family Health Plan.
Cuộc gọi được miễn phí. Để biết thêm thông tin, vui lòng truy cập www.scfhp.com.
Formulary ID: 16510.000 Version Number: 18
Last Updated: 09/30/2016
H7890_11088V_Final_10 Accepted
Chương Trình Cal MediConnect của SCFHP (Chương Trình
Medicare-Medicaid) | 2016 Danh Sách Thuốc Được Đài Thọ
(Dược Liễn)
Đây là danh sách các thuốc mà hội viên có thể nhận được trong Chương Trình Cal
MediConnect (Chương Trình Medicare-Medicaid) của Santa Clara Family Health Plan.

Chương Trình Cal MediConnect (Chương Trình Medicare-Medicaid) của Santa Clara
Family Health Plan là một chương trình sức khỏe hợp tác với cả Medicare và Medi-Cal
để cung cấp phúc lợi của cả hai chương trình này cho người ghi danh.

Danh Sách Thuốc Được Đài Thọ và/hoặc mạng lưới nhà thuốc và nhà cung cấp có thể
thay đổi trong suốt cả năm. Chúng tôi sẽ thông báo cho quý vị trước khi thực hiện thay
đổi có thể ảnh hưởng đến quý vị.

Phúc lợi có thể thay đổi vào ngày 1 tháng 1 hàng năm.

Quý vị luôn có thể kiểm tra Danh Sách Thuốc Được Đài Thọ cập nhật trong chương
trình Cal MediConnect của Santa Clara Family Health Plan (SCFHP) trực tuyến tại
www.scfhp.com hoặc bằng cách gọi đến Ban Dịch Vụ Hội Viên của SCFHP theo số 1877-723-4795, làm việc 7 ngày một tuần, 8 giờ sáng tới 8 giờ tối, kể cả các ngày nghỉ lễ.
Những người sử dụng TTY/TDD nên gọi số 1-800-735-2929.

Quý vị có thể nhận được thông tin miễn phí này ở các định dạng khác, như chữ in cỡ
lớn, chữ nổi, hoặc âm thanh. Gọi 1-877-723-4795. Cuộc gọi được miễn phí.

Các giới hạn và hạn chế có thể áp dụng. Để biết thêm thông tin, hãy gọi đến Ban Dịch
Vụ Hội Viên SCFHP hoặc đọc Sổ Tay Hội Viên Cal MediConnect của SCFHP.

You can get this information for free in other languages. Call 1-877-723-4795, 7 days a
week, 8 a.m. to 8 p.m., including holidays. TTY/TDD users call 1-800-735-2929. The call
is free.
Puede obtener esta información gratuita en otros idiomas. Llame al 1-877-723-4795, los
7 días de la semana, de 8:00 a. m. a 8:00 p. m., incluyendo días festivos. Los usuarios
de TTY/TDD deben llamar al 1-800-735-2929. La llamada es gratuita.
Quý vị có thể nhận thông tin này miễn phí theo các ngôn ngữ khác. Gọi số 1-877-7234795, 7 ngày một tuần, 8 giờ sáng đến 8 giờ tối kể cả các ngày nghỉ lễ. Những người sử
dụng TTY/TDD nên gọi số 1-800-735-2929. Cuộc gọi được miễn phí.
您可免费获得此信息的其他语言版本。请致电 1-877-723-4795，一周 7 天, 工作时间为
上午 8:00 至下午 8:00 (包含节假日)。TTY/TDD 使用者应拨打 1-800-735-2929。这是免
付费电话。
Makukuha mo nang libre ang impormasyong ito sa iba pang mga wika. Tumawag sa 1877-723-4795, 7 araw sa isang linggo, 8 a.m. hanggang 8 p.m., kabilang ang mga pista
opisyal. Ang mga gumagamit ng TTY/TDD ay dapat tumawag sa 1-800-735-2929. Libre
ang tawag.
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Nếu quý vị có thắc mắc, vui lòng gọi đến Santa Clara Family Health Plan theo số 1-877-7234795, 7 ngày một tuần, 8 giờ sáng đến 8 giờ tối kể cả các ngày nghỉ lễ. Những người dùng
TTY/TDD nên gọi số 1-800-735-2929. Cuộc gọi được miễn phí.
Để biết thêm thông tin, hãy truy cập www.scfhp.com.
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Câu Hỏi Thường Gặp (FAQ)
Tìm câu trả lời ở đây cho các câu hỏi của quý vị về Danh Sách Thuốc Được Đài Thọ này.
Quý vị có thể đọc toàn bộ Các Câu Hỏi Thường Gặp để tìm hiểu thêm, hoặc tìm câu hỏi và
câu trả lời.
1. Những thuốc theo toa nào nằm trong Danh Sách Thuốc Được Đài
Thọ? (Chúng tôi gọi tắt Danh Sách Thuốc Được Đài Thọ là “Danh
Sách Thuốc”)
Các thuốc trong Danh Sách Thuốc là các thuốc được Cal MediConnect của SCFHP đài thọ.
Những thuốc này có tại các nhà thuốc trong mạng lưới của chúng tôi. Một nhà thuốc được coi
là nằm trong mạng lưới của chúng tôi nếu chúng tôi có thỏa thuận hợp tác với họ và họ cung
cấp dịch vụ cho quý vị. Chúng tôi gọi những nhà thuốc này là “nhà thuốc trong mạng lưới.”
Cal MediConnect của SCFHP sẽ đài thọ tất cả các thuốc cần thiết về mặt y tế trong Danh Sách
Thuốc nếu:

bác sĩ hoặc người kê toa khác nói rằng quý vị cần thuốc đó để phục hồi hoặc duy trì sức
khỏe,và

quý vị mua thuốc theo toa tại một nhà thuốc trong mạng lưới của SCFHP.
Trong một số trường hợp, quý vị phải thực hiện một số thủ tục trước khi có thể nhận thuốc
(xem câu hỏi số # 5 bên dưới).
Quý vị cũng có thể xem danh sách thuốc cập nhật mà chúng tôi đài thọ trên trang mạng của
chúng tôi tại www.scfhp.com hoặc gọi đến Ban Dịch Vụ Hội Viên theo số 1-877-723-4795.
2. Danh Sách Thuốc có bao giờ thay đổi không?
Có. SCFHP có thể thêm hoặc loại bỏ thuốc ra khỏi Danh Sách Thuốc trong suốt năm. Thông
thường, Danh Sách Thuốc sẽ chỉ thay đổi nếu:

xuất hiện một loại thuốc rẻ hơn có tác dụng tương đương với thuốc trong Danh Sách
Thuốc hiện tại, hoặc

chúng tôi biết được rằng một loại thuốc không an toàn.
ii
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Chúng tôi cũng có thể thay đổi quy định của mình về các loại thuốc. Ví dụ, chúng tôi có thể:

Quyết định yêu cầu hoặc không yêu cầu phê duyệt trước cho một loại thuốc. (Phê duyệt
trước là sự cho phép của SCFHP trước khi quý vị có thể nhận một loại thuốc.)

Thêm hoặc thay đổi số lượng thuốc mà quý vị có thể nhận (được gọi là “giới hạn số
lượng”).

Thêm hoặc thay đổi các hạn chế đối với phương pháp trị liệu từng bước trên một loại
thuốc. (Phương pháp trị liệu từng bước có nghĩa là quý vị phải thử một loại thuốc trước
khi được chúng tôi đài thọ một loại thuốc khác.)
(Để biết thêm thông tin về các quy định về thuốc này, hãy xem trang iv.)
Chúng tôi sẽ thông báo cho quý vị khi một thuốc mà quý vị đang dùng bị loại ra khỏi Danh Sách
Thuốc. Chúng tôi cũng sẽ thông báo cho quý vị khi chúng tôi thay đổi các quy định đài thọ cho
một loại thuốc. Các câu hỏi 3, 4 và 7 bên dưới có thêm thông tin về những điều xảy ra khi Danh
Sách Thuốc thay đổi.

Quý vị luôn có thể kiểm tra Danh Sách Thuốc cập nhật của Cal MediConnect của SCFHP
trực tuyến tại www.scfhp.com. Quý vị cũng có thể gọi đến Ban Dịch Vụ Hội Viên để kiểm tra
Danh Sách Thuốc hiện tại theo số 1-877-723-4795.
3. Điều gì xảy ra khi xuất hiện một loại thuốc rẻ hơn có tác dụng
tương đương với thuốc trong Danh Sách Thuốc hiện tại?
Nếu quý vị đang dùng một loại thuốc bị loại ra do sự xuất hiện của một loại thuốc rẻ hơn có tác
dụng tương đương, chúng tôi sẽ thông báo cho quý vị. Chúng tôi sẽ thông báo cho quý vị ít
nhất là 60 ngày trước khi chúng tôi loại thuốc đó ra khỏi Danh Sách Thuốc hoặc khi quý vị yêu
cầu mua lại thuốc. Sau đó, quý vị có thể nhận lượng thuốc dùng trong 60 ngày trước khi thuốc
đó bị loại ra khỏi danh sách thuốc. Quý vị sẽ nhận được thư từ SCFHP ít nhất 60 ngày trước
khi thay đổi có hiệu lực. Thông tin này cũng sẽ được đăng trên www.scfhp.com.
4. Điều gì xảy ra khi chúng tôi phát hiện thuốc không an toàn?
Nếu Cơ Quan Quản Lý Thực Phẩm và Dược Phẩm (FDA) nói rằng loại thuốc mà quý vị đang
dùng không an toàn, chúng tôi sẽ loại thuốc đó ra khỏi Danh Sách Thuốc ngay lập tức. Chúng
tôi cũng sẽ gửi thư thông báo cho quý vị về điều đó. Vui lòng liên hệ với người kê toa thuốc cho
quý vị sau khi nhận được thư.
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Có bất kỳ hạn chế hay giới hạn nào cho khoản đài thọ thuốc hay
không? Hoặc có bất kỳ hành động bắt buộc nào cần thực hiện để
nhận được các loại thuốc nhất định hay không?
5.
Có, một số thuốc có các quy định về đài thọ hoặc có giới hạn về số lượng mà quý vị có thể
nhận. Trong một số trường hợp, quý vị hoặc bác sĩ hoặc người kê toa khác phải thực hiện một
số thủ tục trước khi có thể nhận thuốc. Ví dụ:

Phê duyệt trước (hoặc ủy quyền trước): Với một số thuốc, quý vị hoặc bác sĩ hay
người kê toa khác phải được sự phê duyệt từ SCFHP trước khi quý vị mua thuốc theo
toa của mình. Nếu quý vị không được phê duyệt, SCFHP có thể không đài thọ cho
thuốc đó.

Giới hạn số lượng: Đôi khi, SCFHP giới hạn số lượng đối với một loại thuốc mà quý vị
có thể nhận.

Phương pháp trị liệu từng bước: Đôi khi SCFHP yêu cầu quý vị thực hiện phương
pháp trị liệu từng bước. Điều này có nghĩa là quý vị sẽ phải thử các thuốc theo một trình
tự nhất định cho tình trạng bệnh lý của mình. Quý vị có thể phải thử một loại thuốc trước
khi được chúng tôi đài thọ cho một loại thuốc khác. Nếu bác sĩ của quý vị cho rằng loại
thuốc đầu tiên không có tác dụng với quý vị, thì chúng tôi sẽ đài thọ loại thuốc thứ hai.
Quý vị có thể tìm xem thuốc của quý vị có bất kỳ yêu cầu hoặc giới hạn nào khác không bằng
cách tra cứu các bảng bắt đầu từ trang 1. Quý vị cũng có thể tìm thêm thông tin bằng cách truy
cập trang mạng của chúng tôi tại www.scfhp.com. Chúng tôi đã đăng các tài liệu trực tuyến giải
thích về ủy quyền trước và các hạn chế đối với phương pháp trị liệu từng bước. Quý vị cũng có
thể yêu cầu chúng tôi gửi cho quý vị một bản sao.
Quý vị có thể yêu cầu một “ngoại lệ” đối với các giới hạn này. Hãy xem Câu hỏi 11 để biết thêm
thông tin về các ngoại lệ.

Nếu quý vị đang ở trong viện dưỡng lão hoặc cơ sở chăm sóc lâu dài và cần một loại thuốc
không nằm trong Danh Sách Thuốc hoặc nếu quý vị không thể dễ dàng nhận được thuốc
mình cần, chúng tôi có thể trợ giúp quý vị. Chúng tôi sẽ đài thọ lượng thuốc khẩn cấp dùng
trong 31 ngày mà quý vị cần (trừ khi quý vị có một toa thuốc dùng trong ít ngày hơn), cho dù
quý vị có phải là hội viên mới của SCFHP hay không. Việc này sẽ cho quý vị thời gian để
trao đổi với bác sĩ hoặc người kê toa khác của mình. Người đó có thể giúp quý vị quyết định
liệu có một thuốc tương tự trong Danh Sách Thuốc mà quý vị có thể dùng thay thế hay cần
yêu cầu một ngoại lệ. Hãy xem Câu hỏi 11 để biết thêm thông tin về các ngoại lệ.
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6. Làm cách nào quý vị biết được liệu thuốc mà quý vị cần có các
giới hạn không hay liệu có các hành động bắt buộc cần thực hiện
để nhận được thuốc không?
Danh Sách Thuốc Được Đài Thọ bắt đầu từ trang 3 có một cột được dán nhãn “Các hành động
cần thiết, hạn chế hoặc giới hạn sử dụng.”
7. Điều gì xảy ra nếu chúng tôi thay đổi các quy định về phương thức
đài thọ một số thuốc? Ví dụ, nếu chúng tôi thêm yêu cầu ủy quyền
trước (chấp thuận), các giới hạn về số lượng, và/hoặc các hạn chế
về phương pháp trị liệu từng bước đối với một loại thuốc.
Chúng tôi sẽ thông báo cho quý vị nếu chúng tôi thêm yêu cầu phê duyệt trước, các giới hạn về
số lượng, và/hoặc các hạn chế về phương pháp trị liệu từng bước đối với một loại thuốc.
Chúng tôi sẽ thông báo cho quý vị ít nhất 60 ngày trước khi các hạn chế được thêm vào hoặc
khi quý vị mua lại thuốc vào lần tiếp theo tại nhà thuốc. Sau đó, quý vị có thể nhận được lượng
thuốc dùng trong 60 ngày trước khi thay đổi về quy định đài thọ được thực hiện. Việc này cho
quý vị thời gian để trao đổi với bác sĩ hoặc người kê toa khác về thủ tục cần làm tiếp theo.
8. Làm cách nào quý vị có thể tìm thấy một loại thuốc trên Danh
Sách Thuốc?
Có hai cách để tìm thuốc:

Quý vị có thể tìm theo bảng chữ cái (nếu quý vị biết cách đánh vần thuốc đó), hoặc

Quý vị có thể tìm theo tình trạng bệnh lý.
Để tìm theo bảng chữ cái, hãy xem phần Danh Sách Theo Bảng Chữ Cái (Mục Lục). Quý vị có
thể tìm thấy phần này ở trang I-1.
Để tìm theo tình trạng bệnh lý, hãy tìm phần có nhãn “Danh mục thuốc theo tình trạng bệnh
lý” ở trang 3. Thuốc trong phần này được nhóm thành nhiều danh mục tùy thuộc vào loại tình
trạng bệnh lý mà những thuốc này được dùng để điều trị. Ví dụ, nếu quý vị bị bệnh tim, quý vị
nên tra cứu theo danh mục, Tác Nhân Gây Bệnh Tim. Đó là nơi quý vị sẽ tìm thấy các thuốc
điều trị các bệnh về tim.
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9. Chuyện gì xảy ra nếu thuốc mà quý vị muốn dùng không có trong
Danh Sách Thuốc?
Nếu quý vị không tìm thấy thuốc của mình trong Danh Sách Thuốc, hãy gọi đến Ban Dịch Vụ
Hội Viên theo số 1-877-723-4795 và hỏi về vấn đề đó. Nếu quý vị biết rằng Cal MediConnect
của SCFHP sẽ không đài thọ thuốc đó, quý vị có thể làm một trong những điều sau:

Hỏi Ban Dịch Vụ Hội Viên về danh sách các thuốc giống với thuốc mà quý vị muốn
dùng. Sau đó, đưa danh sách đó cho bác sĩ hoặc người kê toa khác của quý vị. Người đó
có thể kê một loại thuốc có trong Danh Sách Thuốc giống với thuốc mà quý vị muốn dùng.
Hoặc

Quý vị có thể yêu cầu chương trình sức khỏe thực hiện một ngoại lệ để đài thọ thuốc
của quý vị. Hãy xem Câu hỏi 11 để biết thêm thông tin về các ngoại lệ.
10. Chuyện gì xảy ra nếu quý vị là hội viên mới trong Cal MediConnect
của SCFHP và không thể tìm thấy thuốc của quý vị trong Danh
Sách Thuốc hoặc gặp vấn đề với việc nhận thuốc?
Chúng tôi có thể trợ giúp. Chúng tôi có thể đài thọ lượng thuốc tạm thời dùng trong 30 ngày
trong 90 ngày đầu tiên quý vị là hội viên chương trình Cal MediConnect của SCFHP. Việc này
sẽ cho quý vị thời gian để trao đổi với bác sĩ hoặc người kê toa khác của mình. Người đó có thể
giúp quý vị quyết định liệu có một thuốc tương tự trong Danh Sách Thuốc mà quý vị có thể
dùng thay thế hay cần yêu cầu một ngoại lệ.
Chúng tôi sẽ đài thọ lượng thuốc dùng trong 30 ngày nếu:

quý vị đang dùng một loại thuốc không nằm trong Danh Sách Thuốc của chúng tôi, hoặc

các quy định của chương trình sức khỏe không cho quý vị nhận lượng thuốc mà người
kê toa của quý vị yêu cầu, hoặc

thuốc đó cần phải được SCFHP chấp thuận trước, hoặc

quý vị đang dùng một loại thuốc là một phần trong hạn chế đối với phương pháp trị liệu
từng bước.
Nếu quý vị sống trong viện dưỡng lão hoặc cơ sở chăm sóc lâu dài khác, quý vị có thể mua lại
toa thuốc đó trong tối đa 91 ngày. Quý vị có thể mua lại thuốc nhiều lần trong 90 ngày đầu tiên
của chương trình. Điều này cho người kê toa của quý vị thời gian để thay đổi thuốc của quý vị
thành các thuốc có trong Danh Sách Thuốc hoặc yêu cầu một ngoại lệ.
Nếu quý vị đang chuyển tiếp giữa các mức độ chăm sóc khác nhau (ví dụ, vào hoặc ra khỏi một
cơ sở chăm sóc lâu dài hoặc một bệnh viện), SCFHP sẽ đài thọ lượng thuốc chuyển tiếp dùng
trong 31 ngày mới để quý vị sử dụng trong bối cảnh mới. Việc này sẽ giải quyết bất kỳ hạn chế
nào có thể tồn tại.
vi
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11. Quý vị có thể yêu cầu một ngoại lệ để đài thọ thuốc của mình
không?
Có. Quý vị có thể yêu cầu Cal MediConnect của SCFHP trao ngoại lệ để đài thọ một loại thuốc
không nằm trong Danh Sách Thuốc.
Quý vị cũng có thể yêu cầu chúng tôi thay đổi các quy định về thuốc của mình.

Ví dụ,Cal MediConnect của SCFHP có thể giới hạn số lượng của một loại thuốc mà
chúng tôi sẽ đài thọ. Nếu thuốc của quý vị có giới hạn, quý vị có thể yêu cầu chúng tôi
thay đổi giới hạn đó và đài thọ thêm.

Các ví dụ khác: Quý vị có thể yêu cầu chúng tôi bỏ hạn chế đối với phương pháp trị liệu
từng bước hoặc yêu cầu chấp thuận trước.
12. Mất bao nhiêu thời gian để nhận được ngoại lệ?
Đầu tiên, quý vị phải nhận được một bản tuyên bố từ người kê toa của mình ủng hộ yêu cầu xin
ngoại lệ của quý vị. Sau khi chúng tôi nhận được bản tuyên bố, chúng tôi sẽ trao cho quý vị
quyết định về yêu cầu ngoại lệ đó trong vòng 72 giờ.
Nếu quý vị hoặc người kê toa cho rằng sức khỏe của quý vị có thể bị nguy hiểm nếu quý vị phải
đợi quyết định trong 72 giờ, thì quý vị có thể yêu cầu xin ngoại lệ nhanh. Khi đó quyết định sẽ
được đưa ra nhanh hơn. Nếu người kê toa ủng hộ yêu cầu của quý vị, chúng tôi sẽ trao cho
quý vị một quyết định trong vòng 24 giờ kể từ khi nhận được bản tuyên bố ủng hộ từ người kê
toa của quý vị.
13. Quý vị có thể yêu cầu ngoại lệ bằng cách nào?
Để yêu cầu ngoại lệ, hãy gọi đến Ban Dịch Vụ Hội Viên. Ban Dịch Vụ Hội Viên sẽ hợp tác với
quý vị và nhà cung cấp của quý vị để giúp quý vị yêu cầu ngoại lệ.
14. Thuốc gốc là gì?
Thuốc gốc được bào chế với các thành phần giống với biệt dược. Chúng thường có giá thấp
hơn biệt dược và tên của chúng không được biết đến rộng rãi. Các thuốc gốc đều được chấp
thuận bởi Cơ Quan Quản Lý Thực Phẩm và Dược Phẩm (FDA).
Cal MediConnect của SCFHP đài thọ cả biệt dược và thuốc gốc.
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vii
15. Thuốc OTC là gì?
OTC là viết tắt của “over-the-counter” (không kê toa). Cal MediConnect của SCFHP đài thọ một
số thuốc OTC nếu các thuốc này được nhà cung cấp của quý vị ghi là thuốc theo toa.
Quý vị có thể đọc Danh Sách Thuốc trong chương trình Cal MediConnect của SCFHP để biết
thuốc OTC nào được đài thọ.
16. Cal MediConnect của SCFHP có đài thọ các sản phẩm không phải
là thuốc OTC hay không?
Cal MediConnect của SCFHP đài thọ một số sản phẩm không phải là thuốc OTC nếu các sản
phẩm này được nhà cung cấp của quý vị ghi là thuốc theo toa.
Quý vị có thể đọc Danh Sách Thuốc trong chương trình Cal MediConnect của SCFHP để biết
sản phẩm không phải là thuốc OTC nào được đài thọ.
17. Khoản đồng thanh toán của quý vị là gì?
Quý vị có thể đọc Danh Sách Thuốc trong Cal MediConnect của SCFHP để tìm hiểu về khoản
đồng thanh toán cho mỗi loại thuốc.
Các hội viên Cal MediConnect của SCFHP đang sống trong viện dưỡng lão hoặc các cơ sở
chăm sóc lâu dài khác sẽ không có các khoản đồng thanh toán. Một số hội viên đang nhận
chăm sóc lâu dài trong cộng đồng cũng sẽ không có các khoản đồng thanh toán.
Khoản đồng thanh toán được liệt kê theo bậc. Bậc là các nhóm thuốc trong dược liễn của Cal
MediConnect của SCFHP.

Thuốc bậc 1 có khoản đồng thanh toán $0. Chúng là các thuốc gốc.

Thuốc bậc 2 có khoản đồng thanh toán $0. Chúng là các biệt dược.

Thuốc bậc 3 có khoản đồng thanh toán $0. Chúng là các thuốc theo toa không thuộc
Medicare.

Thuốc bậc 4 có khoản đồng thanh toán $0. Chúng là các thuốc OTC không thuộc
Medicare.
viii
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Danh Sách Thuốc Được Đài Thọ
Danh sách thuốc được đài thọ bắt đầu ở trang tiếp theo cung cấp cho quý vị thông tin về các
thuốc được đài thọ bởi Cal MediConnect của SCFHP. Nếu quý vị gặp khó khăn trong việc tìm
kiếm thuốc trong danh mục, hãy quay lại Mục Lục bắt đầu ở trang I-1.
Cột đầu tiên của bảng liệt kê tên thuốc. Các biệt dược được viết hoa (ví dụ, FLOVENT) và các
thuốc gốc được viết thường in nghiêng (ví dụ, fluticasone propionate).
Thông tin trong cột “Các hành động cần thiết, hạn chế, hoặc giới hạn sử dụng” cho quý vị biết
liệu SCFHP có bất kỳ quy định nào để đài thọ thuốc của quý vị không.
Lưu ý: Dấu hoa thị (*) bên cạnh một loại thuốc có nghĩa là thuốc đó không phải là “thuốc Phần
D.” Quý vị sẽ không phải thanh toán khoản đồng thanh toán cho những thuốc này. Các thuốc
này cũng có các quy định khác nhau cho việc kháng cáo. Kháng cáo là một cách chính thức để
yêu cầu chúng tôi xem xét lại một quyết định mà chúng tôi đã đưa ra về khoản đài thọ của quý
vị và thay đổi quyết định đó nếu quý vị cho rằng chúng tôi đã sai lầm. Ví dụ, chúng tôi có thể đã
quyết định rằng một loại thuốc mà quý vị muốn không được đài thọ bởi Medicare hoặc MediCal. Nếu quý vị hoặc bác sĩ của quý vị không đồng ý với quyết định của chúng tôi, quý vị có thể
kháng cáo. Nếu quý vị có thắc mắc, hãy gọi đến Ban Dịch Vụ Hội Viên theo số 1-877-723-4795.
Quý vị cũng có thể đọc Sổ Tay Hội Viên Cal MediConnect của SCFHP để biết cách kháng cáo
một quyết định.
Danh Sách Thuốc theo Tình Trạng Bệnh Lý
Thuốc trong phần này được nhóm thành nhiều danh mục tùy thuộc vào loại tình trạng bệnh lý
mà những thuốc này được dùng để điều trị. Ví dụ, nếu quý vị bị bệnh tim, quý vị nên tra cứu
theo danh mục, Tác Nhân Gây Bệnh Tim. Đó là nơi quý vị sẽ tìm thấy các thuốc điều trị các
bệnh về tim.
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ix
Danh sách các Ký Hiệu và Chữ Viết Tắt
Những chữ viết tắt sau có thể được dùng trong Danh Sách Thuốc.
CHỮ VIẾT TẮT TRONG GHI CHÚ VỀ KHOẢN ĐÀI THỌ
CHỮ VIẾT TẮT
MÔ TẢ
GIẢI THÍCH
Các Hạn Chế Quản Lý Sử Dụng
PA
Ủy Quyền Trước
Ủy Quyền Trước
PA BvD
cho việc
Xác định Phần B và
Phần D
Hạn Chế Ủy Quyền
Trước đối với
PA-HRM
Các Thuốc Có Rủi
Ro Cao
Quý vị (hoặc bác sĩ của quý vị) bắt buộc
phải nhận được sự ủy quyền trước từ
Cal MediConnect của SCFHP trước khi
quý vị nhận được thuốc theo toa của
mình.Nếu không có sự phê duyệt trước,
Cal MediConnect của SCFHP có thể không
đài thọ thuốc này.
Thuốc này có thể hội đủ điều kiện để được
thanh toán theo Medicare Phần B hoặc Phần
D. Quý vị (hoặc bác sĩ của quý vị) bắt buộc
phải nhận được sự ủy quyền trước từ Cal
MediConnect của SCFHP để xác định rằng
thuốc này được đài thọ theo Medicare Phần D
trước khi quý vị nhận được thuốc theo toa của
mình.Nếu không có sự phê duyệt trước, Cal
MediConnect của SCFHP có thể không đài thọ
thuốc này.
Thuốc này đã được CMS cho là có khả năng
gây nguy hiểm và do đó, là Thuốc Có Rủi Ro
Cao dành cho những người thụ hưởng
Medicare từ 65 tuổi trở lên.Các hội viên từ
65 tuổi trở lên bắt buộc phải nhận được ủy
quyền trước từ Cal MediConnect của SCFHP
trước khi nhận được thuốc theo toa của
mình.Nếu không được phê duyệt trước,
Cal MediConnect của SCFHP có thể không đài
thọ thuốc này.
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CHỮ VIẾT TẮT
MÔ TẢ
Ủy Quyền Trước Chỉ
đối với
PA NSO
QL
ST
Những Người Mới
Bắt Đầu
GIẢI THÍCH
Nếu quý vị là hội viên mới hoặc nếu quý vị là
hội viên mới gia hạn và chưa dùng thuốc này
trước đây, quý vị (hoặc bác sĩ của quý vị) bắt
buộc phải nhận được ủy quyền trước từ
Cal MediConnect của SCFHP trước khi quý vị
nhận được thuốc theo toa của mình.
Nếu không có sự phê duyệt trước, Cal
MediConnect của SCFHP có thể không đài thọ
thuốc này.
Giới Hạn Số Lượng
Cal MediConnect của SCFHP giới hạn số
lượng được đài thọ của thuốc này trên mỗi toa
thuốc hoặc trong một khung thời gian cụ thể.
Phương Pháp Trị
Liệu Từng Bước
Trước khi Cal MediConnect của SCFHP cung
cấp khoản đài thọ cho thuốc này, trước tiên quý
vị phải thử (các) thuốc khác để điều trị tình
trạng bệnh lý của mình. Thuốc này chỉ có thể
được đài thọ nếu (các) thuốc khác không có tác
dụng với quý vị.
Những chữ viết tắt sau cũng có thể được dùng trong Danh Sách Thuốc.
YÊU CẦU ĐẶC BIỆT KHÁC CHO KHOẢN ĐÀI THỌ
CHỮ VIẾT TẮT
MÔ TẢ
*
Không phải là Thuốc
Phần D
Thuốc này là thuốc không thuộc Phần D được
đài thọ bởi Medi-Cal.
Thuốc Tiếp Cận
Hạn Chế
Thuốc theo toa này có thể chỉ có ở các nhà
thuốc nhất định.Để biết thêm thông tin, hãy
tham khảo Danh Mục Nhà Thuốc của quý vị
hoặc gọi đến Ban Dịch Vụ Hội Viên theo số 1877-723-4795, 7 ngày một tuần, 8 giờ sáng tới
8 giờ tối, kể cả các ngày nghỉ lễ. Những người
dùng TTY/TDD nên gọi số 1-800-735-2929.
LA
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GIẢI THÍCH
xi
Table of Contents
Contents
of
Table
Analgesics ........................................................................................................................................................................................................................................................................................................ 3
Anesthetics ................................................................................................................................................................................................................................................................................................. 14
Anti-Addiction/Substance Abuse Treatment Agents ................................................................................................................................................................... 14
Antianxiety Agents ........................................................................................................................................................................................................................................................................ 16
Antibacterials ......................................................................................................................................................................................................................................................................................... 16
Anticancer Agents ........................................................................................................................................................................................................................................................................... 27
Anticholinergic Agents ............................................................................................................................................................................................................................................................. 37
Anticonvulsants .................................................................................................................................................................................................................................................................................. 37
Antidementia Agents .................................................................................................................................................................................................................................................................. 41
Antidepressants ................................................................................................................................................................................................................................................................................... 42
Antidiabetic Agents ...................................................................................................................................................................................................................................................................... 45
Antifungals ................................................................................................................................................................................................................................................................................................ 49
Antihistamines ...................................................................................................................................................................................................................................................................................... 53
Anti-Infectives (Skin And Mucous Membrane) .................................................................................................................................................................................. 60
Antimigraine Agents ................................................................................................................................................................................................................................................................... 60
Antimycobacterials ........................................................................................................................................................................................................................................................................ 61
Antinausea Agents ......................................................................................................................................................................................................................................................................... 62
Antiparasite Agents ...................................................................................................................................................................................................................................................................... 63
Antiparkinsonian Agents ...................................................................................................................................................................................................................................................... 64
Antipsychotic Agents ................................................................................................................................................................................................................................................................. 66
Antivirals (Systemic) ................................................................................................................................................................................................................................................................... 70
Blood Products/Modifiers/Volume Expanders ..................................................................................................................................................................................... 76
Caloric Agents ...................................................................................................................................................................................................................................................................................... 79
Cardiovascular Agents ............................................................................................................................................................................................................................................................. 84
Central Nervous System Agents ............................................................................................................................................................................................................................. 101
Contraceptives .................................................................................................................................................................................................................................................................................. 103
Cough And Cold Products ............................................................................................................................................................................................................................................. 111
Dental And Oral Agents .................................................................................................................................................................................................................................................... 113
Dermatological Agents ........................................................................................................................................................................................................................................................ 114
Devices ......................................................................................................................................................................................................................................................................................................... 123
Enzyme Replacement/Modifiers ............................................................................................................................................................................................................................ 148
Eye, Ear, Nose, Throat Agents ................................................................................................................................................................................................................................. 149
Gastrointestinal Agents ....................................................................................................................................................................................................................................................... 158
Genitourinary Agents ............................................................................................................................................................................................................................................................. 173
Heavy Metal Antagonists ................................................................................................................................................................................................................................................. 174
Hormonal Agents, Stimulant/Replacement/Modifying ....................................................................................................................................................... 174
Immunological Agents .......................................................................................................................................................................................................................................................... 181
Inflammatory Bowel Disease Agents ............................................................................................................................................................................................................... 190
Irrigating Solutions .................................................................................................................................................................................................................................................................... 190
Metabolic Bone Disease Agents .............................................................................................................................................................................................................................. 191
SCFHP Cal MediConnect Formulary
Formulary ID:16510.000 Version: 18
1
Effective: October 01, 2016
Contents
of
Table
Miscellaneous Therapeutic Agents ..................................................................................................................................................................................................................... 192
Ophthalmic Agents .................................................................................................................................................................................................................................................................... 197
Replacement Preparations .............................................................................................................................................................................................................................................. 199
Respiratory Tract Agents ................................................................................................................................................................................................................................................. 209
Skeletal Muscle Relaxants ............................................................................................................................................................................................................................................... 213
Sleep Disorder Agents ........................................................................................................................................................................................................................................................... 214
Urine And Feces Contents .............................................................................................................................................................................................................................................. 215
Vasodilating Agents .................................................................................................................................................................................................................................................................. 215
Vitamins And Minerals ....................................................................................................................................................................................................................................................... 217
2
What the
Necessary Actions,
drug will cost
Restrictions, or Limits
you (Tier
on Use
level)
Name of Drug
Analgesics
Analgesics, Miscellaneous
acephen 120 mg suppository outer 120 mg
*
acephen 325 mg suppository outer 325 mg
*
acetaminophen 120 mg suppos outer 120
mg *
acetaminophen 160 mg rapid tab 160 mg *
acetaminophen 160 mg/5 ml elx 160 mg/5
ml *
(Acetaminophen)
$0 (Tier 4)
QL (30 per 30 days)
(Acetaminophen)
$0 (Tier 4)
QL (30 per 30 days)
(Acetaminophen)
$0 (Tier 4)
QL (30 per 30 days)
(Acetaminophen)
(Acetaminophen)
$0 (Tier 4)
$0 (Tier 4)
acetaminophen 80 mg/0.8 ml drp infants
80 mg/0.8 ml *
(Acetaminophen)
$0 (Tier 4)
acetaminophen-codeine 120 mg-12 mg/5
ml solution 120-12 mg/5 ml
acetaminophen-codeine oral solution 300
mg-30 mg /12.5 ml
acetaminophen-codeine oral tablet 300-15
mg, 300-30 mg
acetaminophen-codeine oral tablet 300-60
mg
ALLZITAL ORAL TABLET 25-325
MG
ascomp with codeine oral capsule
30-50-325-40 mg
(Acetaminophen with
Codeine)
(Acetaminophen with
Codeine)
(Tylenol-Codeine
No.3)
(Tylenol-Codeine
No.3)
$0 (Tier 1)
QL (30 per 30 days)
PA; QL (240 per 30
days); AGE (Max 21
Years)
PA; QL (30 per 30
days); AGE (Max 21
Years)
QL (2700 per 30 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Fiorinal with
Codeine #3)
BELBUCA BUCCAL FILM 150 MCG,
300 MCG, 450 MCG, 600 MCG, 75
MCG, 750 MCG, 900 MCG
buprenorphine hcl injection syringe 0.3
(Buprenorphine HCl)
mg/ml
$0 (Tier 1)
$0 (Tier 2)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
ST; QL (60 per 30
days)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page x of
this document
3
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
(Fiorinal with
Codeine #3)
$0 (Tier 1)
butalbital-acetaminop-caf-cod oral capsule (Fioricet with
50-300-40-30 mg, 50-325-40-30 mg
Codeine)
$0 (Tier 1)
butalbital compound w/codeine oral
capsule 30-50-325-40 mg
butalbital-acetaminophen oral tablet
50-325 mg
(Tencon)
$0 (Tier 1)
butalbital-acetaminophen-caff oral capsule (Esgic)
50-325-40 mg
$0 (Tier 1)
butalbital-acetaminophen-caff oral tablet
50-325-40 mg
(Esgic)
$0 (Tier 1)
butalbital-aspirin-caffeine oral capsule
50-325-40 mg
(Fiorinal)
$0 (Tier 1)
BUTRANS TRANSDERMAL PATCH
WEEKLY 10 MCG/HOUR, 15
MCG/HOUR, 20 MCG/HOUR, 5
MCG/HOUR, 7.5 MCG/HOUR
capacet oral capsule 50-325-40 mg
(Esgic)
$0 (Tier 2)
$0 (Tier 1)
child non-aspirin 160 mg/5 ml children's
160 mg/5 ml *
(Acetaminophen)
$0 (Tier 4)
child pain-fever 160 mg/5 ml
a/f,gluten/f,cherry 160 mg/5 ml *
(Infants' Tylenol)
$0 (Tier 4)
child tactinal 80 mg tab chw 80 mg *
children's silapap elixir 160 mg/5 ml *
(Acetaminophen)
(Tylenol Sore Throat)
$0 (Tier 4)
$0 (Tier 4)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
QL (4 per 28 days)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
PA; QL (240 per 30
days); AGE (Max 21
Years)
PA; QL (240 per 30
days); AGE (Max 21
Years)
QL (30 per 30 days)
PA; QL (240 per 30
days); AGE (Max 21
Years)
this document
4
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
codeine sulfate oral tablet 15 mg, 30 mg,
60 mg
cvs child non-asa 80 mg tb chw 80 mg *
cvs non-aspirin jr tab chew 160 mg *
endocet oral tablet 10-325 mg, 2.5-325
mg, 5-325 mg, 7.5-325 mg
endodan oral tablet 4.8355-325 mg
fentanyl citrate buccal lozenge on a handle
1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg,
600 mcg, 800 mcg
fentanyl transdermal patch 72 hour 100
mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5
mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75
mcg/hr, 87.5 mcg/hour
feverall 120 mg suppository children's,
outer 120 mg *
feverall 325 mg suppository junior str,
outer 325 mg *
FEVERALL 80 MG SUPPOSITORY
INFANT'S, OUTER 80 MG *
hydrocodone-acetaminophen oral solution
10-325 mg/15 ml(15 ml), 2.5-167 mg/5
ml, 7.5-325 mg/15 ml
hydrocodone-acetaminophen oral tablet
10-300 mg, 5-300 mg, 7.5-300 mg
(Codeine Sulfate)
$0 (Tier 1)
(Acetaminophen)
(Acetaminophen)
(Xolox)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
QL (30 per 30 days)
QL (30 per 30 days)
(Percodan)
(Actiq)
$0 (Tier 1)
$0 (Tier 1)
PA; QL (120 per 30
days)
(Duragesic)
$0 (Tier 1)
QL (10 per 30 days)
(Acetaminophen)
$0 (Tier 4)
QL (30 per 30 days)
(Acetaminophen)
$0 (Tier 4)
QL (30 per 30 days)
$0 (Tier 4)
QL (30 per 30 days)
(Hycet)
$0 (Tier 1)
(Norco)
$0 (Tier 1)
$0 (Tier 1)
(includes Vicodin,
Vicodin ES and
Vicodin HP); QL (390
per 30 days)
$0 (Tier 1)
hydrocodone-acetaminophen oral tablet
(Norco)
10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325
mg
hydrocodone-ibuprofen oral tablet 10-200 (Ibudone)
mg, 2.5-200 mg, 5-200 mg, 7.5-200 mg
hydromorphone (pf) injection solution 10 (Dilaudid-HP)
mg/ml
$0 (Tier 1)
this document
5
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
hydromorphone (pf) injection solution 4
(Dilaudid)
mg/ml
hydromorphone injection solution 2 mg/ml (Hydromorphone
HCl)
hydromorphone injection syringe 2 mg/ml (Hydromorphone
HCl)
hydromorphone oral liquid 1 mg/ml
(Dilaudid)
hydromorphone oral tablet 2 mg, 4 mg
(Dilaudid)
hydromorphone oral tablet 8 mg
(Dilaudid)
HYSINGLA ER ORAL
TABLET,ORAL ONLY,EXT.REL.24
HR 100 MG, 120 MG, 20 MG, 30 MG,
40 MG, 60 MG, 80 MG
LAZANDA NASAL
SPRAY,NON-AEROSOL 100
MCG/SPRAY, 300 MCG/SPRAY, 400
MCG/SPRAY
lorcet (hydrocodone) oral tablet 5-325 mg (Norco)
lorcet hd oral tablet 10-325 mg
(Norco)
lorcet plus oral tablet 7.5-325 mg
(Norco)
mapap 160 mg/5 ml elixir 160 mg/5 ml *
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
QL (30 per 30 days)
$0 (Tier 2)
PA; QL (30 per 30
days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
PA; QL (240 per 30
days); AGE (Max 21
Years)
PA; QL (240 per 30
days); AGE (Max 21
Years)
QL (30 per 30 days)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
mapap 160 mg/5 ml suspension 160 mg/5
ml *
(Infants' Tylenol)
$0 (Tier 4)
mapap 325 mg tablet 325 mg *
mapap 500 mg capsule 500 mg *
mapap 500 mg tablet 500 mg *
mapap 80 mg tablet chew 80 mg *
margesic oral capsule 50-325-40 mg
(Tylenol)
(Acetaminophen)
(Tylenol)
(Acetaminophen)
(Esgic)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
methadone injection solution 10 mg/ml
(Methadone HCl)
$0 (Tier 1)
this document
6
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
methadone oral solution 10 mg/5 ml, 5
mg/5 ml
methadone oral tablet 10 mg, 5 mg
methadose oral tablet,soluble 40 mg
morphine (pf) in 0.9 % nacl intravenous pt
controlled analgesia syring 50 mg/25 ml (2
mg/ml)
morphine 10 mg/ml carpuject 10 mg/ml
morphine 8 mg/ml syringe 8 mg/ml
morphine concentrate oral solution 100
mg/5 ml (20 mg/ml)
morphine concentrate oral syringe 20
mg/ml
morphine in dextrose 5 % injection pt
controlled analgesia syring 100 mg/50 ml
(2 mg/ml), 50 mg/25 ml (2 mg/ml)
morphine injection solution 15 mg/ml, 8
mg/ml
morphine injection syringe 10 mg/ml
morphine intramuscular pen injector 10
mg/0.7 ml
morphine intravenous cartridge 15 mg/ml
morphine intravenous solution 25 mg/ml,
50 mg/ml
morphine intravenous syringe 10 mg/ml, 2
mg/ml, 4 mg/ml, 8 mg/ml
morphine oral solution 10 mg/5 ml
morphine oral solution 20 mg/5 ml (4
mg/ml)
MORPHINE ORAL TABLET 15 MG,
30 MG
(Methadone HCl)
$0 (Tier 1)
(Diskets)
(Diskets)
(Morphine
Sulfate/0.9%
Nacl/PF)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (90 per 30 days)
(Morphine Sulfate)
$0 (Tier 1)
(Morphine
Sulfate/D5W)
$0 (Tier 1)
(Morphine Sulfate)
$0 (Tier 1)
(Morphine Sulfate)
(Morphine Sulfate)
$0 (Tier 1)
$0 (Tier 1)
(Morphine Sulfate)
(Morphine Sulfate)
$0 (Tier 1)
$0 (Tier 1)
(Morphine Sulfate)
$0 (Tier 1)
(Morphine Sulfate)
(Morphine Sulfate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
this document
7
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
morphine oral tablet extended release 100
mg, 30 mg, 60 mg
morphine oral tablet extended release 15
mg, 200 mg
morphine rectal suppository 10 mg, 20 mg,
30 mg, 5 mg
nortemp 80 mg/0.8 ml drop 80 mg/0.8 ml *
NUCYNTA ER ORAL TABLET
EXTENDED RELEASE 12 HR 100
MG, 150 MG, 200 MG, 250 MG, 50 MG
NUCYNTA ORAL TABLET 100 MG,
50 MG, 75 MG
oxycodone oral concentrate 20 mg/ml
oxycodone oral solution 5 mg/5 ml
oxycodone oral tablet 10 mg, 15 mg, 20
mg, 30 mg, 5 mg
oxycodone oral tablet,oral only,ext.rel.12
hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60
mg
oxycodone oral tablet,oral only,ext.rel.12
hr 80 mg
oxycodone-acetaminophen oral solution
5-325 mg/5 ml
oxycodone-acetaminophen oral tablet
10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325
mg
10-650 mg
7.5-500 mg
oxycodone-aspirin oral tablet 4.8355-325
mg
(MS Contin)
$0 (Tier 1)
(MS Contin)
$0 (Tier 1)
(Morphine Sulfate)
$0 (Tier 1)
(Acetaminophen)
$0 (Tier 4)
$0 (Tier 2)
PA; QL (30 per 30
days); AGE (Max 21
Years)
QL (60 per 30 days)
$0 (Tier 2)
(Oxycodone HCl)
(Oxycodone HCl)
(Roxicodone)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Oxycontin)
$0 (Tier 1)
QL (60 per 30 days)
(Oxycontin)
$0 (Tier 2)
(Oxycodone
HCl/Acetaminophen)
(Xolox)
$0 (Tier 1)
$0 (Tier 1)
(Xolox)
$0 (Tier 1)
(Xolox)
$0 (Tier 1)
(Percodan)
$0 (Tier 1)
this document
8
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
OXYCONTIN ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 10 MG, 15
MG, 20 MG, 30 MG, 40 MG, 60 MG
OXYCONTIN ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 80 MG
oxymorphone oral tablet 10 mg, 5 mg
oxymorphone oral tablet extended release
12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg
oxymorphone oral tablet extended release
12 hr 30 mg, 40 mg
pain relief 500 mg capsule 500 mg *
pharbetol 325 mg tablet regular strength
325 mg *
pharbetol 500 mg caplet extra-str, caplet
500 mg *
pv non-aspirin 500 mg softgel ex-str,liq
filled 500 mg *
q-pap 160 mg/5 ml solution a/f, cherry 160
mg/5 ml *
$0 (Tier 2)
QL (60 per 30 days)
$0 (Tier 2)
(Opana)
(Opana ER)
$0 (Tier 1)
$0 (Tier 1)
QL (60 per 30 days)
(Opana ER)
$0 (Tier 1)
(Acetaminophen)
(Tylenol)
$0 (Tier 4)
$0 (Tier 4)
(Tylenol)
$0 (Tier 4)
(Acetaminophen)
$0 (Tier 4)
$0 (Tier 4)
(Tylenol)
(Acetaminophen)
$0 (Tier 4)
$0 (Tier 4)
q-pap ex-str 500 mg tablet aspirin free 500 (Tylenol)
mg *
reprexain oral tablet 10-200 mg, 2.5-200
(Ibudone)
mg, 5-200 mg
roxicet oral solution 5-325 mg/5 ml
(Oxycodone
HCl/Acetaminophen)
silapap infant's drops infant's 80 mg/0.8 ml (Acetaminophen)
*
$0 (Tier 4)
PA; QL (240 per 30
days); AGE (Max 21
Years)
PA; QL (30 per 30
days); AGE (Max 21
Years)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
sm pain rel jr str tab chew 160 mg *
$0 (Tier 4)
PA; QL (30 per 30
days); AGE (Max 21
Years)
QL (30 per 30 days)
q-pap 325 mg tablet 325 mg *
q-pap 80 mg/0.8 ml drops 80 mg/0.8 ml *
(Acetaminophen)
this document
9
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
sm pain reliever 80 mg tab children's 80
mg *
tactinal 325 mg tablet 325 mg *
tactinal 500 mg tablet extra-strength 500
mg *
tencon oral tablet 50-325 mg
(Acetaminophen)
$0 (Tier 4)
QL (30 per 30 days)
(Tylenol)
(Tylenol)
$0 (Tier 4)
$0 (Tier 4)
(Tencon)
$0 (Tier 1)
tramadol oral tablet 50 mg
tramadol-acetaminophen oral tablet
37.5-325 mg
vicodin es oral tablet 7.5-300 mg
(Ultram)
(Ultracet)
$0 (Tier 1)
$0 (Tier 1)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
(Norco)
$0 (Tier 1)
vicodin hp oral tablet 10-300 mg
(Norco)
$0 (Tier 1)
vicodin oral tablet 5-300 mg
(Norco)
$0 (Tier 1)
xylon 10 oral tablet 10-200 mg
zebutal oral capsule 50-325-40 mg
(Ibudone)
(Esgic)
$0 (Tier 1)
$0 (Tier 1)
Nonsteroidal Anti-Inflammatory
Agents
ADVIL 100 MG TABLET JR
STRENGTH,COATED 100 MG *
ADVIL 200 MG TABLET 200 MG *
ADVIL JR STR 100 MG TAB CHEW
TB CHEW,8 HOUR,GRAPE 100 MG *
(includes Vicodin,
Vicodin ES and
per 30 days)
(includes Vicodin,
Vicodin ES and
per 30 days)
(includes Vicodin,
Vicodin ES and
per 30 days)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
this document
10
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
aspirin 325 mg tablet 325 mg *
aspirin 81 mg chewable tablet 81 mg *
aspirin buffered 325 mg tab 325 mg *
aspirin ec 325 mg tablet 325 mg *
aspirin ec 650 mg tablet 650 mg *
aspirin ec 81 mg tablet low dose 81 mg *
aspir-low ec 81 mg tablet 81 mg *
bufferin 325 mg tablet coated 325 mg *
CALDOLOR INTRAVENOUS
RECON SOLN 400 MG/4 ML (100
MG/ML)
celecoxib oral capsule 100 mg, 200 mg,
400 mg, 50 mg
CHILDREN'S ADVIL 100 MG/5 ML
A/F (OTC) 100 MG/5 ML *
choline,magnesium salicylate oral liquid
500 mg/5 ml
cvs ibuprofen 200 mg softgel liquid
filled,softge 200 mg *
cvs naproxen sodium 220 mg cap liquidgel
220 mg *
diclofenac potassium oral tablet 50 mg
diclofenac sodium oral tablet extended
release 24 hr 100 mg
diclofenac sodium oral tablet,delayed
release (dr/ec) 25 mg, 50 mg, 75 mg
diclofenac sodium topical gel 3 %
diclofenac-misoprostol oral
tablet,ir,delayed rel,biphasic 50-200
mg-mcg, 75-200 mg-mcg
(Ecotrin)
(Bayer Chewable
Aspirin)
(Aspirin/Calcium
Carbonate/Mag)
(Ecotrin)
(Ecotrin)
(Ecotrin)
(Ecotrin)
(Aspirin/Calcium
Carbonate/Mag)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
(Celebrex)
$0 (Tier 1)
QL (60 per 30 days)
$0 (Tier 4)
(Choline Sal/Mag
Salicylate)
(Advil)
$0 (Tier 1)
(Aleve)
$0 (Tier 4)
(Diclofenac
Potassium)
(Voltaren-XR)
$0 (Tier 1)
(Diclofenac Sodium)
$0 (Tier 1)
(Voltaren)
(Arthrotec 50)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
this document
11
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
diflunisal oral tablet 500 mg
ecotrin ec 325 mg tablet saftey coated 325
mg *
ecpirin ec 325 mg tablet 325 mg *
etodolac oral capsule 200 mg, 300 mg
etodolac oral tablet 400 mg, 500 mg
etodolac oral tablet extended release 24 hr
400 mg, 500 mg, 600 mg
fenoprofen oral capsule 200 mg
fenoprofen oral tablet 600 mg
FLECTOR TRANSDERMAL PATCH
12 HOUR 1.3 %
flurbiprofen oral tablet 100 mg, 50 mg
gnp ibuprofen jr str 100 mg tb 100 mg *
ibuprofen 100 mg/5 ml susp children's
(otc) 100 mg/5 ml *
ibuprofen 200 mg tablet 200 mg *
ibuprofen oral suspension 100 mg/5 ml
ibuprofen oral tablet 400 mg, 600 mg, 800
mg
indomethacin oral capsule 25 mg
indomethacin oral capsule 50 mg
indomethacin oral capsule, extended
release 75 mg
indomethacin sodium intravenous recon
soln 1 mg
infant ibuprofen 50 mg/1.25 ml
d/f,a/f,non-staining 50 mg/1.25 ml *
ketoprofen oral capsule 50 mg, 75 mg
ketoprofen oral capsule,ext rel. pellets 24
hr 200 mg
(Diflunisal)
(Ecotrin)
$0 (Tier 1)
$0 (Tier 4)
(Ecotrin)
(Etodolac)
(Etodolac)
(Etodolac)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Nalfon)
(Fenoprofen
Calcium)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Flurbiprofen)
(Advil)
(Children'S Advil)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
(Advil)
(Ibuprofen)
(Ibuprofen)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
(Indomethacin)
(Indomethacin)
(Indomethacin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Indomethacin
Sodium)
(Infants' Motrin)
$0 (Tier 1)
(Ketoprofen)
(Ketoprofen)
$0 (Tier 1)
$0 (Tier 1)
PA
QL (60 per 30 days)
$0 (Tier 4)
this document
12
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ketorolac oral tablet 10 mg
mefenamic acid oral capsule 250 mg
meloxicam oral suspension 7.5 mg/5 ml
meloxicam oral tablet 15 mg, 7.5 mg
nabumetone oral tablet 500 mg, 750 mg
naproxen oral suspension 125 mg/5 ml
naproxen oral tablet 250 mg, 375 mg, 500
mg
naproxen oral tablet,delayed release
(dr/ec) 375 mg, 500 mg
naproxen sodium oral tablet 275 mg, 550
mg
piroxicam oral capsule 10 mg, 20 mg
ra aspirin tri-buffered tb 325 mg *
sm ibuprofen ib 100 mg tablet junior
strength 100 mg *
sm naproxen sod 220 mg caplet gluten
free, caplet 220 mg *
st. joseph aspirin 81 mg chew orange 81
mg *
st. joseph aspirin ec 81 mg tb enteric
coated 81 mg *
sulindac oral tablet 150 mg, 200 mg
tolmetin oral capsule 400 mg
tolmetin oral tablet 200 mg, 600 mg
VOLTAREN TOPICAL GEL 1 %
wal-profen 200 mg softgel softgel 200 mg
*
(Ketorolac
Tromethamine)
(Ponstel)
(Mobic)
(Mobic)
(Nabumetone)
(Naprosyn)
(Naprosyn)
$0 (Tier 1)
(Ec-Naprosyn)
$0 (Tier 1)
(Anaprox)
$0 (Tier 1)
(Feldene)
(Aspirin/Calcium
Carbonate/Mag)
(Advil)
$0 (Tier 1)
$0 (Tier 4)
(Midol)
$0 (Tier 4)
(Bayer Chewable
Aspirin)
(Ecotrin)
$0 (Tier 4)
(Sulindac)
(Tolmetin Sodium)
(Tolmetin Sodium)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
(Advil)
QL (20 per 30 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
this document
13
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
Anesthetics
Local Anesthetics
glydo mucous membrane jelly in applicator
2%
lidocaine (pf) injection solution 15 mg/ml
(1.5 %), 40 mg/ml (4 %), 5 mg/ml (0.5
%)
lidocaine 2% viscous soln 2 %
lidocaine hcl injection solution 10 mg/ml
(1 %), 20 mg/ml (2 %)
lidocaine hcl mucous membrane gel 2 %
lidocaine hcl mucous membrane solution 2
%, 4 % (40 mg/ml)
lidocaine topical adhesive patch,medicated
5%
lidocaine topical ointment 5 %
lidocaine-prilocaine topical cream 2.5-2.5
%
(Lidocaine HCl)
$0 (Tier 1)
(Xylocaine-MPF)
$0 (Tier 1)
(Xylocaine)
(Xylocaine)
$0 (Tier 1)
$0 (Tier 1)
(Lidocaine HCl)
(Xylocaine)
$0 (Tier 1)
$0 (Tier 1)
(Lidoderm)
$0 (Tier 1)
(Lidocaine)
(EMLA)
$0 (Tier 1)
$0 (Tier 1)
(Acamprosate
Calcium)
(Buprenorphine HCl)
$0 (Tier 1)
(Buprenorphine
HCl/Naloxone HCl)
(Zyban)
$0 (Tier 1)
PA
Anti-Addiction/Substance Abuse
Treatment Agents
Anti-Addiction/Substance Abuse
Treatment Agents
acamprosate oral tablet,delayed release
(dr/ec) 333 mg
buprenorphine hcl sublingual tablet 2 mg,
8 mg
buprenorphine-naloxone sublingual tablet
2-0.5 mg, 8-2 mg
bupropion hcl sr 150 mg tablet f/c 150 mg
CHANTIX CONTINUING MONTH
BOX ORAL TABLET 1 MG
CHANTIX ORAL TABLET 0.5 MG, 1
MG
$0 (Tier 1)
PA; QL (90 per 30
days)
PA; QL (90 per 30
days)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
this document
14
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
CHANTIX STARTING MONTH BOX
ORAL TABLETS,DOSE PACK 0.5
MG (11)- 1 MG (42)
disulfiram oral tablet 250 mg, 500 mg
naloxone injection solution 0.4 mg/ml
naloxone injection syringe 0.4 mg/ml, 1
mg/ml
naltrexone oral tablet 50 mg
NARCAN NASAL
SPRAY,NON-AEROSOL 4
MG/ACTUATION
nicorelief 2 mg gum 2 mg *
nicorelief 4 mg gum 4 mg *
nicorette 2 mg chewing gum white ice mint
2 mg *
nicotine 14 mg/24hr patch outer (otc) 14
mg/24 hr *
nicotine 2 mg chewing gum sugar free 2
mg *
nicotine 2 mg lozenge mint, 3 quittube 2
mg *
nicotine 21 mg/24hr patch step 1 (otc) 21
mg/24 hr *
nicotine 22 mg/24hr patch 1 week starter
kit 22 mg/24 hr *
nicotine 4 mg chewing gum 4 mg *
nicotine 4 mg lozenge mint, 3 quittube 4
mg *
nicotine 7 mg/24hr patch (otc) 7 mg/24 hr
*
NICOTROL INHALATION
CARTRIDGE 10 MG
$0 (Tier 2)
QL (53 per 28 days)
(Antabuse)
(Naloxone HCl)
(Naloxone HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Revia)
$0 (Tier 1)
$0 (Tier 2)
QL (4 per 30 days)
(Nicorette)
(Nicorette)
(Nicorette)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Nicoderm Cq)
$0 (Tier 4)
(Nicorette)
$0 (Tier 4)
(Nicorette)
$0 (Tier 4)
(Nicoderm Cq)
$0 (Tier 4)
(Nicoderm Cq)
$0 (Tier 4)
(Nicorette)
(Nicorette)
$0 (Tier 4)
$0 (Tier 4)
(Nicoderm Cq)
$0 (Tier 4)
$0 (Tier 2)
this document
15
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ZUBSOLV SUBLINGUAL TABLET
1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG,
5.7-1.4 MG, 8.6-2.1 MG
$0 (Tier 2)
PA; QL (90 per 30
days)
(Xanax)
$0 (Tier 1)
(Chlordiazepoxide
HCl)
(Klonopin)
(Klonopin)
(Clonazepam)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (90 per 30 days)
QL (90 per 30 days)
(Clonazepam)
(Tranxene T-Tab)
(Tranxene T-Tab)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (60 per 30 days)
(Diazepam)
(Diazepam)
$0 (Tier 1)
$0 (Tier 1)
QL (10 per 28 days)
(Diazepam)
$0 (Tier 1)
(Valium)
(Diastat)
$0 (Tier 1)
$0 (Tier 1)
(Ativan)
$0 (Tier 1)
$0 (Tier 2)
QL (90 per 30 days)
PA NSO; QL (480 per
30 days)
$0 (Tier 2)
PA BvD
Antianxiety Agents
Benzodiazepines
alprazolam oral tablet 0.25 mg, 0.5 mg, 1
mg, 2 mg
chlordiazepoxide hcl oral capsule 10 mg,
25 mg, 5 mg
clonazepam oral tablet 0.5 mg, 1 mg
clonazepam oral tablet 2 mg
clonazepam oral tablet,disintegrating
0.125 mg, 0.25 mg, 0.5 mg, 1 mg
clonazepam oral tablet,disintegrating 2 mg
clorazepate dipotassium oral tablet 15 mg
clorazepate dipotassium oral tablet 3.75
mg, 7.5 mg
diazepam injection syringe 5 mg/ml
diazepam intensol oral concentrate 5
mg/ml
diazepam oral solution 5 mg/5 ml (1
mg/ml)
diazepam oral tablet 10 mg, 2 mg, 5 mg
diazepam rectal kit 12.5-15-17.5-20 mg,
2.5 mg, 5-7.5-10 mg
lorazepam oral tablet 0.5 mg, 1 mg, 2 mg
ONFI ORAL SUSPENSION 2.5
MG/ML
Antibacterials
Aminoglycosides
BETHKIS INHALATION SOLUTION
FOR NEBULIZATION 300 MG/4 ML
this document
16
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
gentamicin in nacl (iso-osm) intravenous
piggyback 100 mg/100 ml, 100 mg/50 ml,
60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml,
80 mg/50 ml, 90 mg/100 ml
gentamicin injection solution 40 mg/ml
gentamicin ped 20 mg/2 ml vial latex-free,
sdv 20 mg/2 ml
gentamicin sulfate (pf) intravenous
solution 80 mg/8 ml
neomycin oral tablet 500 mg
streptomycin intramuscular recon soln 1
gram
TOBI PODHALER INHALATION
CAPSULE, W/INHALATION
DEVICE 28 MG
tobramycin in 0.225 % nacl inhalation
solution for nebulization 300 mg/5 ml
tobramycin in 0.9 % nacl intravenous
piggyback 60 mg/50 ml, 80 mg/100 ml
tobramycin sulfate injection solution 10
mg/ml, 40 mg/ml
Antibacterials, Miscellaneous
bacitracin intramuscular recon soln 50,000
unit
chloramphenicol sod succinate intravenous
recon soln 1 gram
clindamycin 75 mg/5 ml soln 75 mg/5 ml
clindamycin hcl oral capsule 150 mg, 300
mg, 75 mg
clindamycin in 5 % dextrose intravenous
piggyback 300 mg/50 ml, 600 mg/50 ml,
900 mg/50 ml
clindamycin pediatric oral recon soln 75
mg/5 ml
(Gentamicin In Nacl,
Iso-Osm)
$0 (Tier 1)
(Gentamicin Sulfate)
(Gentamicin
Sulfate/PF)
(Gentamicin
Sulfate/PF)
(Neomycin Sulfate)
(Streptomycin
Sulfate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Tobi)
$0 (Tier 1)
PA BvD
(Tobramycin/Sodium
Chloride)
(Tobramycin Sulfate)
$0 (Tier 1)
(Bacitracin)
$0 (Tier 1)
(Chloramphenicol
Sod Succ)
(Cleocin Palmitate)
(Cleocin HCl)
$0 (Tier 1)
(Cleocin Phosphate
In D5w)
$0 (Tier 1)
(Cleocin Palmitate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
this document
17
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
clindamycin phosphate injection solution
150 mg/ml
clindamycin phosphate intravenous
solution 600 mg/4 ml
colistin (colistimethate na) injection recon
soln 150 mg
CUBICIN INTRAVENOUS RECON
SOLN 500 MG
linezolid intravenous parenteral solution
600 mg/300 ml
linezolid oral suspension for reconstitution
100 mg/5 ml
linezolid oral tablet 600 mg
methenamine hippurate oral tablet 1 gram
metronidazole in nacl (iso-os) intravenous
piggyback 500 mg/100 ml
metronidazole oral capsule 375 mg
metronidazole oral tablet 250 mg, 500 mg
nitrofurantoin macrocrystal oral capsule
100 mg, 25 mg, 50 mg
(Cleocin Phosphate)
$0 (Tier 1)
(Cleocin Phosphate)
$0 (Tier 1)
(Coly-Mycin M
Parenteral)
$0 (Tier 1)
$0 (Tier 2)
(Zyvox)
$0 (Tier 1)
(Zyvox)
$0 (Tier 1)
(Zyvox)
(Hiprex)
(Metronidazole/Sodiu
m Chloride)
(Flagyl)
(Flagyl)
(Macrodantin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs);
QL (120 per 30 days);
AGE (Max 64 Years)
this document
18
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
nitrofurantoin monohyd/m-cryst oral
capsule 100 mg
(Macrobid)
$0 (Tier 1)
nitrofurantoin monohyd/m-cryst oral
capsule 100 mg (75/25)
(Macrobid)
$0 (Tier 1)
polymyxin b sulfate injection recon soln
500,000 unit
SYNERCID INTRAVENOUS RECON
SOLN 500 MG
trimethoprim oral tablet 100 mg
vancomycin hcl 1g/200 ml bag 1 gram/200
ml
vancomycin intravenous recon soln 1,000
mg, 10 gram, 750 mg
vancomycin intravenous recon soln 500 mg
(Polymyxin B Sulfate)
$0 (Tier 1)
vancomycin oral capsule 125 mg, 250 mg
XIFAXAN ORAL TABLET 200 MG
XIFAXAN ORAL TABLET 550 MG
ZYVOX ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML
PA-HRM; (High Risk
with over 90 days
cumulative use of
AGE (Max 64 Years)
PA-HRM; (High Risk
with over 90 days
cumulative use of
AGE (Max 64 Years)
$0 (Tier 2)
(Trimethoprim)
(Vancomycin Hcl In
Dextrose 5 %)
(Vancomycin HCl)
$0 (Tier 1)
$0 (Tier 1)
(Vancomycin Hcl In
Dextrose 5 %)
(Vancocin HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA; QL (9 per 30 days)
PA
this document
19
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
Cephalosporins
cefaclor oral capsule 250 mg, 500 mg
cefaclor oral suspension for reconstitution
125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
cefadroxil oral capsule 500 mg
cefadroxil oral suspension for
reconstitution 250 mg/5 ml, 500 mg/5 ml
cefadroxil oral tablet 1 gram
cefazolin in dextrose (iso-os) intravenous
piggyback 1 gram/50 ml, 2 gram/50 ml
cefazolin injection recon soln 1 gram, 10
gram, 500 mg
cefdinir oral capsule 300 mg
cefdinir oral suspension for reconstitution
125 mg/5 ml, 250 mg/5 ml
cefditoren pivoxil oral tablet 200 mg, 400
mg
CEFEPIME 2 GM INJECTION 2
GRAM/100 ML
CEFEPIME IN DEXTROSE 5 %
INTRAVENOUS PIGGYBACK 1
GRAM/50 ML, 2 GRAM/50 ML
cefepime injection recon soln 1 gram, 2
gram
cefotaxime injection recon soln 1 gram, 10
gram, 2 gram, 500 mg
cefoxitin in dextrose, iso-osm intravenous
piggyback 2 gram/50 ml
cefoxitin intravenous recon soln 1 gram,
10 gram, 2 gram
cefpodoxime oral suspension for
(Cefaclor)
(Cefaclor)
$0 (Tier 1)
$0 (Tier 1)
(Cefadroxil)
(Cefadroxil)
$0 (Tier 1)
$0 (Tier 1)
(Cefadroxil)
(Cefazolin
Sodium/Dextrose,
Iso)
(Cefazolin Sodium)
$0 (Tier 1)
$0 (Tier 1)
(Cefdinir)
(Cefdinir)
$0 (Tier 1)
$0 (Tier 1)
(Spectracef)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
(Maxipime)
$0 (Tier 1)
(Claforan)
$0 (Tier 1)
(Cefoxitin
Sodium/Dextrose,
Iso)
(Cefoxitin Sodium)
$0 (Tier 1)
(Cefpodoxime
Proxetil)
$0 (Tier 1)
$0 (Tier 1)
this document
20
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
(Cefpodoxime
Proxetil)
cefprozil oral suspension for reconstitution (Cefprozil)
125 mg/5 ml, 250 mg/5 ml
cefprozil oral tablet 250 mg, 500 mg
(Cefprozil)
ceftazidime injection recon soln 2 gram, 6 (Fortaz)
gram
ceftibuten oral capsule 400 mg
(Cedax)
ceftibuten oral suspension for
(Cedax)
reconstitution 180 mg/5 ml
ceftriaxone 1 gm piggyback 50ml
(Ceftriaxone
galaxycontainer 1 gram/50 ml
Na/Dextrose, Iso)
ceftriaxone 1 gm vial 10's, fliptop,l/f 1
(Rocephin)
gram
ceftriaxone 2 gm piggyback 50ml
(Ceftriaxone
galaxycontainer 2 gram/50 ml
Na/Dextrose, Iso)
ceftriaxone injection recon soln 10 gram,
(Rocephin)
250 mg, 500 mg
ceftriaxone intravenous recon soln 1 gram, (Ceftriaxone
2 gram
Na/Dextrose, Iso)
cefuroxime axetil oral tablet 250 mg, 500 (Ceftin)
mg
cefuroxime sodium injection recon soln 1.5 (Zinacef)
gram, 750 mg
cefuroxime sodium intravenous recon soln (Zinacef)
7.5 gram
cephalexin oral capsule 250 mg, 500 mg,
(Keflex)
750 mg
cephalexin oral suspension for
(Cephalexin)
cephalexin oral tablet 250 mg, 500 mg
(Cephalexin)
cefpodoxime oral tablet 100 mg, 200 mg
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
this document
21
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
MEFOXIN IN DEXTROSE
(ISO-OSM) INTRAVENOUS
PIGGYBACK 1 GRAM/50 ML, 2
GRAM/50 ML
SUPRAX ORAL
TABLET,CHEWABLE 100 MG, 200
MG
tazicef injection recon soln 2 gram, 6 gram
TEFLARO INTRAVENOUS RECON
SOLN 400 MG, 600 MG
Macrolides
azithromycin intravenous recon soln 500
mg
azithromycin oral packet 1 gram
azithromycin oral suspension for
azithromycin oral tablet 250 mg, 250 mg
(6 pack), 600 mg
azithromycin oral tablet 500 mg
clarithromycin oral suspension for
clarithromycin oral tablet 250 mg, 500 mg
clarithromycin oral tablet extended release
24 hr 500 mg
DIFICID ORAL TABLET 200 MG
e.e.s. 400 oral tablet 400 mg
$0 (Tier 2)
$0 (Tier 2)
(Fortaz)
$0 (Tier 1)
$0 (Tier 2)
(Zithromax)
$0 (Tier 1)
(Zithromax)
(Zithromax)
$0 (Tier 1)
$0 (Tier 1)
(Zithromax)
$0 (Tier 1)
(Zithromax)
(Biaxin)
$0 (Tier 1)
$0 (Tier 1)
(Biaxin)
(Clarithromycin)
$0 (Tier 1)
$0 (Tier 1)
(Erythromycin
Ethylsuccinate)
(Eryped 200)
e.e.s. granules oral suspension for
reconstitution 200 mg/5 ml
ery-tab oral tablet,delayed release (dr/ec) (Erythromycin Base)
250 mg, 500 mg
ERY-TAB ORAL
TABLET,DELAYED RELEASE
(DR/EC) 333 MG
$0 (Tier 2)
$0 (Tier 1)
QL (20 per 10 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
this document
22
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
erythrocin (as stearate) oral tablet 250
mg
ERYTHROCIN INTRAVENOUS
RECON SOLN 1,000 MG, 500 MG
erythromycin ethylsuccinate oral tablet
400 mg
erythromycin oral capsule,delayed
release(dr/ec) 250 mg
erythromycin oral tablet 250 mg, 500 mg
Miscellaneous B-Lactam
Antibiotics
aztreonam injection recon soln 1 gram
CAYSTON INHALATION
SOLUTION FOR NEBULIZATION 75
MG/ML
imipenem-cilastatin intravenous recon soln
250 mg, 500 mg
INVANZ INJECTION RECON SOLN
1 GRAM
meropenem intravenous recon soln 500 mg
meropenem iv 1 gm vial outer, latex-free 1
gram
Penicillins
amoxicillin oral capsule 250 mg, 500 mg
amoxicillin oral suspension for
reconstitution 125 mg/5 ml, 200 mg/5 ml,
250 mg/5 ml, 400 mg/5 ml
amoxicillin oral tablet 500 mg, 875 mg
amoxicillin oral tablet,chewable 125 mg,
250 mg
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
(Erythromycin
Stearate)
$0 (Tier 1)
$0 (Tier 2)
(Erythromycin
Ethylsuccinate)
(Erythromycin Base)
$0 (Tier 1)
(Erythromycin Base)
$0 (Tier 1)
(Azactam)
$0 (Tier 1)
$0 (Tier 2)
(Primaxin)
$0 (Tier 1)
LA
$0 (Tier 1)
$0 (Tier 2)
(Merrem)
(Merrem)
$0 (Tier 1)
$0 (Tier 1)
(Amoxicillin)
(Amoxicillin)
$0 (Tier 1)
$0 (Tier 1)
(Amoxicillin)
(Amoxicillin)
$0 (Tier 1)
$0 (Tier 1)
(Augmentin)
$0 (Tier 1)
this document
23
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
amoxicillin-pot clavulanate oral tablet
250-125 mg, 500-125 mg, 875-125 mg
amoxicillin-pot clavulanate oral tablet
extended release 12 hr 1,000-62.5 mg
amoxicillin-pot clavulanate oral
tablet,chewable 200-28.5 mg, 400-57 mg
ampicillin 2 gm vial 10's, latex-free 2 gram
ampicillin oral capsule 250 mg, 500 mg
(Augmentin)
$0 (Tier 1)
(Augmentin XR)
$0 (Tier 1)
(Amoxicillin/Potassiu
m Clav)
(Ampicillin Sodium)
(Ampicillin
Trihydrate)
(Ampicillin
Trihydrate)
(Ampicillin Sodium)
$0 (Tier 1)
ampicillin oral suspension for
ampicillin sodium injection recon soln 1
gram, 10 gram, 125 mg
ampicillin sodium intravenous recon soln 2 (Ampicillin Sodium)
gram
ampicillin-sulbactam injection recon soln
(Unasyn)
1.5 gram, 15 gram, 3 gram
BICILLIN C-R INTRAMUSCULAR
SYRINGE 1,200,000 UNIT/ 2
ML(600K/600K), 1,200,000 UNIT/ 2
ML(900K/300K)
BICILLIN L-A INTRAMUSCULAR
SYRINGE 1,200,000 UNIT/2 ML,
2,400,000 UNIT/4 ML, 600,000
UNIT/ML
dicloxacillin oral capsule 250 mg, 500 mg (Dicloxacillin
Sodium)
nafcillin 2 gm vial sterile, latex-free 2
(Nafcillin Sodium)
gram
nafcillin injection recon soln 1 gram, 10
(Nafcillin Sodium)
gram
nafcillin intravenous recon soln 2 gram
(Nafcillin Sodium)
oxacillin 1 gm add-vantage vl add-vantage, (Oxacillin Sodium)
inner 1 gram
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
this document
24
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
oxacillin in dextrose(iso-osm) intravenous (Oxacillin
Sodium/Dextrose,
Iso)
oxacillin injection recon soln 10 gram
(Oxacillin Sodium)
oxacillin intravenous recon soln 2 gram
(Oxacillin Sodium)
penicillin g pot in dextrose intravenous
(Pen G
piggyback 1 million unit/50 ml, 2 million
Pot/Dextrose-Water)
unit/50 ml, 3 million unit/50 ml
penicillin g potassium injection recon soln (Penicillin G
5 million unit
Potassium)
penicillin g procaine intramuscular syringe (Penicillin G
1.2 million unit/2 ml, 600,000 unit/ml
Procaine)
penicillin gk 20 million unit 20 million unit (Penicillin G
Potassium)
penicillin v potassium oral recon soln 125 (Penicillin V
mg/5 ml, 250 mg/5 ml
Potassium)
penicillin v potassium oral tablet 250 mg, (Penicillin V
500 mg
Potassium)
pfizerpen-g injection recon soln 20 million (Penicillin G
unit
Potassium)
piperacillin-tazobactam intravenous recon (Zosyn)
soln 2.25 gram, 3.375 gram, 4.5 gram
piperacil-tazobact 40.5 gram p/f,
(Zosyn)
latex-free 40.5 gram
Quinolones
ciprofloxacin hcl oral tablet 100 mg, 250
(Cipro)
mg, 500 mg, 750 mg
ciprofloxacin in 5 % dextrose intravenous (Cipro I.V.)
ciprofloxacin lactate intravenous solution (Ciprofloxacin
400 mg/40 ml
Lactate)
ciprofloxacin oral suspension,microcapsule (Cipro)
recon 250 mg/5 ml, 500 mg/5 ml
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
this document
25
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ciprofloxacn-d5w 400 mg/200 ml
p/f,latex/f, in d5w 400 mg/200 ml
levofloxacin in d5w intravenous piggyback
500 mg/100 ml, 750 mg/150 ml
levofloxacin intravenous solution 25 mg/ml
levofloxacin oral solution 250 mg/10 ml
levofloxacin oral tablet 250 mg, 500 mg,
750 mg
moxifloxacin oral tablet 400 mg
ofloxacin oral tablet 400 mg
Sulfonamides
sulfadiazine oral tablet 500 mg
sulfamethoxazole-trimethoprim
intravenous solution 400-80 mg/5 ml
sulfamethoxazole-trimethoprim oral
suspension 200-40 mg/5 ml
sulfamethoxazole-trimethoprim oral tablet
400-80 mg, 800-160 mg
sulfasalazine oral tablet 500 mg
sulfasalazine oral tablet,delayed release
(dr/ec) 500 mg
sulfatrim oral suspension 200-40 mg/5 ml
(Cipro I.V.)
$0 (Tier 1)
(Levaquin)
$0 (Tier 1)
(Levofloxacin)
(Levaquin)
(Levaquin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Avelox)
(Ofloxacin)
$0 (Tier 1)
$0 (Tier 1)
(Sulfadiazine)
(Sulfamethoxazole/Tr
imethoprim)
imethoprim)
(Bactrim)
$0 (Tier 1)
$0 (Tier 1)
(Azulfidine)
(Azulfidine)
$0 (Tier 1)
$0 (Tier 1)
imethoprim)
$0 (Tier 1)
Tetracyclines
doxy-100 intravenous recon soln 100 mg
(Doxycycline
Hyclate)
doxycycline hyclate 100 mg cap 100 mg
(Morgidox)
doxycycline hyclate 100 mg tab 100 mg
(Doryx)
doxycycline hyclate intravenous recon soln (Doxycycline
100 mg
Hyclate)
doxycycline hyclate oral capsule 100 mg
(Adoxa)
doxycycline hyclate oral capsule 50 mg
(Morgidox)
doxycycline hyclate oral tablet 100 mg, 50 (Avidoxy)
mg
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
this document
26
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
doxycycline hyclate oral tablet 20 mg
doxycycline mono 100 mg cap 100 mg
doxycycline mono 100 mg tablet f/c 100
mg
doxycycline mono 50 mg tablet 50 mg
doxycycline monohydrate oral capsule 150
mg, 50 mg, 75 mg
doxycycline monohydrate oral suspension
for reconstitution 25 mg/5 ml
doxycycline monohydrate oral tablet 150
mg, 75 mg
minocycline oral capsule 100 mg, 50 mg,
75 mg
minocycline oral tablet 100 mg, 50 mg, 75
mg
tetracycline oral capsule 250 mg, 500 mg
TYGACIL INTRAVENOUS RECON
SOLN 50 MG
(Doryx)
(Adoxa)
(Avidoxy)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Avidoxy)
(Adoxa)
$0 (Tier 1)
$0 (Tier 1)
(Vibramycin)
$0 (Tier 1)
(Avidoxy)
$0 (Tier 1)
(Minocin)
$0 (Tier 1)
(Minocycline HCl)
$0 (Tier 1)
(Tetracycline HCl)
$0 (Tier 1)
$0 (Tier 2)
Anticancer Agents
Anticancer Agents
ABRAXANE INTRAVENOUS
SUSPENSION FOR
RECONSTITUTION 100 MG
ADCETRIS INTRAVENOUS RECON
SOLN 50 MG
adriamycin intravenous recon soln 10 mg,
20 mg, 50 mg
adriamycin intravenous solution 10 mg/5
ml
adrucil 2,500 mg/50 ml vial outer,
latex-free 2.5 gram/50 ml
adrucil intravenous solution 500 mg/10 ml
$0 (Tier 2)
$0 (Tier 2)
(Doxorubicin HCl)
$0 (Tier 1)
PA NSO; QL (4 per 21
days)
PA BvD
(Doxorubicin HCl)
$0 (Tier 1)
PA BvD
(Fluorouracil)
$0 (Tier 1)
PA BvD
(Fluorouracil)
$0 (Tier 1)
PA BvD
this document
27
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
AFINITOR DISPERZ ORAL TABLET
FOR SUSPENSION 2 MG, 3 MG, 5
MG
AFINITOR ORAL TABLET 10 MG
$0 (Tier 2)
PA NSO; QL (112 per
28 days)
$0 (Tier 2)
AFINITOR ORAL TABLET 2.5 MG, 5
MG, 7.5 MG
ALECENSA ORAL CAPSULE 150
MG
ALIMTA INTRAVENOUS RECON
SOLN 500 MG
anastrozole oral tablet 1 mg
(Arimidex)
AVASTIN INTRAVENOUS
SOLUTION 25 MG/ML, 25 MG/ML
(16 ML)
azacitidine injection recon soln 100 mg
(Vidaza)
BELEODAQ INTRAVENOUS
RECON SOLN 500 MG
BENDEKA INTRAVENOUS
SOLUTION 25 MG/ML
bexarotene oral capsule 75 mg
(Targretin)
$0 (Tier 2)
PA NSO; QL (56 per
28 days)
PA NSO; QL (28 per
28 days)
PA NSO; QL (240 per
30 days)
bicalutamide oral tablet 50 mg
(Casodex)
bleomycin injection recon soln 30 unit
(Bleomycin Sulfate)
bleomycin sulfate 15 unit vial latex-free 15 (Bleomycin Sulfate)
unit
BLINCYTO INTRAVENOUS KIT 35
MCG
BOSULIF ORAL TABLET 100 MG
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
BOSULIF ORAL TABLET 500 MG
$0 (Tier 2)
CABOMETYX ORAL TABLET 20
MG, 60 MG
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
PA NSO
$0 (Tier 1)
$0 (Tier 2)
PA NSO
$0 (Tier 2)
PA NSO
$0 (Tier 1)
PA NSO; QL (420 per
30 days)
$0 (Tier 2)
$0 (Tier 2)
PA BvD
PA BvD
PA NSO; QL (140 per
365 days)
PA NSO; QL (120 per
30 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (30 per
30 days)
this document
28
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
CABOMETYX ORAL TABLET 40
MG
CAPRELSA ORAL TABLET 100 MG
$0 (Tier 2)
CAPRELSA ORAL TABLET 300 MG
$0 (Tier 2)
COMETRIQ ORAL CAPSULE 100
MG/DAY(80 MG X1-20 MG X1), 140
MG/DAY(80 MG X1-20 MG X3), 60
MG/DAY (20 MG X 3/DAY)
COTELLIC ORAL TABLET 20 MG
$0 (Tier 2)
cyclophosphamide intravenous recon soln
1 gram, 2 gram, 500 mg
CYCLOPHOSPHAMIDE ORAL
CAPSULE 25 MG, 50 MG
cyclophosphamide oral tablet 25 mg, 50
mg
CYRAMZA INTRAVENOUS
(50 ML)
dactinomycin intravenous recon soln 0.5
mg
DARZALEX INTRAVENOUS
SOLUTION 20 MG/ML
decitabine intravenous recon soln 50 mg
doxorubicin, peg-liposomal intravenous
suspension 2 mg/ml
DROXIA ORAL CAPSULE 200 MG,
300 MG, 400 MG
ELIGARD (3 MONTH)
SUBCUTANEOUS SYRINGE 22.5
MG
$0 (Tier 2)
$0 (Tier 2)
(Cyclophosphamide)
(Cyclophosphamide)
(Dactinomycin)
(Dacogen)
(Doxil)
PA NSO; QL (60 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (112 per
28 days)
$0 (Tier 1)
PA NSO; LA; QL (63
per 28 days)
PA BvD
$0 (Tier 2)
PA BvD; ST
$0 (Tier 1)
PA BvD; ST
$0 (Tier 2)
PA NSO
$0 (Tier 1)
$0 (Tier 2)
PA NSO; LA
$0 (Tier 1)
$0 (Tier 1)
PA BvD
$0 (Tier 2)
$0 (Tier 2)
QL (1 per 84 days)
this document
29
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ELIGARD (4 MONTH)
SUBCUTANEOUS SYRINGE 30 MG
ELIGARD (6 MONTH)
SUBCUTANEOUS SYRINGE 45 MG
ELIGARD SUBCUTANEOUS
SYRINGE 7.5 MG (1 MONTH)
EMCYT ORAL CAPSULE 140 MG
EMPLICITI INTRAVENOUS RECON
SOLN 300 MG, 400 MG
ERIVEDGE ORAL CAPSULE 150 MG
$0 (Tier 2)
QL (1 per 112 days)
$0 (Tier 2)
QL (1 per 168 days)
ETOPOPHOS INTRAVENOUS
RECON SOLN 100 MG
etoposide intravenous solution 20 mg/ml
exemestane oral tablet 25 mg
FARESTON ORAL TABLET 60 MG
FARYDAK ORAL CAPSULE 10 MG,
15 MG, 20 MG
FASLODEX INTRAMUSCULAR
SYRINGE 250 MG/5 ML
floxuridine injection recon soln 0.5 gram
fluorouracil 5,000 mg/100 ml latex-free 5
gram/100 ml
fluorouracil intravenous solution 1
gram/20 ml, 2.5 gram/50 ml, 500 mg/10 ml
flutamide oral capsule 125 mg
GAZYVA INTRAVENOUS
SOLUTION 1,000 MG/40 ML
GILOTRIF ORAL TABLET 20 MG, 30
MG, 40 MG
GLEOSTINE ORAL CAPSULE 10
MG, 100 MG, 40 MG
HERCEPTIN INTRAVENOUS
RECON SOLN 440 MG
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Etoposide)
(Aromasin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
PA NSO
PA NSO; QL (30 per
30 days)
PA NSO
$0 (Tier 2)
(Floxuridine)
(Fluorouracil)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
PA BvD
(Fluorouracil)
$0 (Tier 1)
PA BvD
(Flutamide)
$0 (Tier 1)
$0 (Tier 2)
PA NSO
$0 (Tier 2)
PA NSO; QL (30 per
30 days)
$0 (Tier 2)
$0 (Tier 2)
PA NSO
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30
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
HEXALEN ORAL CAPSULE 50 MG
hydroxyurea oral capsule 500 mg
IBRANCE ORAL CAPSULE 100 MG,
125 MG, 75 MG
ICLUSIG ORAL TABLET 15 MG
(Hydrea)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
ifosfamide 1 gm/20 ml vial suv 1 gram/20
ml
ifosfamide intravenous recon soln 1 gram
ifosfamide-mesna intravenous kit 1-1
gram, 3,000-1,000 mg
imatinib oral tablet 100 mg
(Ifex)
$0 (Tier 1)
PA NSO; QL (21 per
28 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (30 per
30 days)
PA BvD
(Ifex)
(Ifosfamide/Mesna)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
PA BvD
(Gleevec)
$0 (Tier 1)
imatinib oral tablet 400 mg
(Gleevec)
$0 (Tier 1)
PA NSO; QL (90 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO
$0 (Tier 2)
ICLUSIG ORAL TABLET 45 MG
$0 (Tier 2)
IMBRUVICA ORAL CAPSULE 140
MG
IMLYGIC INJECTION SUSPENSION
10EXP6 (1 MILLION) PFU/ML
IMLYGIC INJECTION SUSPENSION
10EXP8 (100 MILLION) PFU/ML
INLYTA ORAL TABLET 1 MG
$0 (Tier 2)
INLYTA ORAL TABLET 5 MG
$0 (Tier 2)
IRESSA ORAL TABLET 250 MG
$0 (Tier 2)
IXEMPRA 15 MG KIT WITH
DILUENT 15 MG
IXEMPRA INTRAVENOUS RECON
SOLN 45 MG
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA NSO; QL (4 per
365 days)
days)
PA NSO; QL (180 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (60 per
30 days)
$0 (Tier 2)
this document
31
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
JAKAFI ORAL TABLET 10 MG, 15
MG, 20 MG, 25 MG, 5 MG
KEYTRUDA INTRAVENOUS
RECON SOLN 50 MG
KEYTRUDA INTRAVENOUS
SOLUTION 100 MG/4 ML (25
MG/ML)
KYPROLIS INTRAVENOUS RECON
SOLN 60 MG
LENVIMA ORAL CAPSULE 10
MG/DAY (10 MG X 1/DAY), 14
MG/DAY(10 MG X 1-4 MG X 1), 18
MG/DAY (10 MG X 1-4 MG X2), 20
MG/DAY (10 MG X 2), 24
MG/DAY(10 MG X 2-4 MG X 1), 8
MG/DAY (4 MG X 2)
letrozole oral tablet 2.5 mg
LEUKERAN ORAL TABLET 2 MG
leuprolide subcutaneous kit 1 mg/0.2 ml
lipodox 50 intravenous suspension 2 mg/ml
lipodox intravenous suspension 2 mg/ml
lomustine oral capsule 10 mg, 100 mg, 40
mg
LONSURF ORAL TABLET 15-6.14
MG
LONSURF ORAL TABLET 20-8.19
MG
LUPRON DEPOT (3 MONTH)
INTRAMUSCULAR SYRINGE KIT
11.25 MG, 22.5 MG
30 MG
$0 (Tier 2)
$0 (Tier 2)
PA NSO; QL (60 per
30 days)
PA NSO
$0 (Tier 2)
PA NSO
$0 (Tier 2)
days)
PA NSO
$0 (Tier 2)
(Femara)
(Leuprolide Acetate)
(Doxil)
(Doxil)
(Lomustine)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
PA BvD
PA BvD
$0 (Tier 2)
PA NSO; QL (100 per
28 days)
PA NSO; QL (80 per
28 days)
QL (1 per 84 days)
$0 (Tier 2)
QL (1 per 84 days)
$0 (Tier 2)
this document
32
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
45 MG
LUPRON DEPOT
3.75 MG, 7.5 MG
LYNPARZA ORAL CAPSULE 50 MG
$0 (Tier 2)
LYSODREN ORAL TABLET 500 MG
MATULANE ORAL CAPSULE 50
MG
megestrol oral tablet 20 mg, 40 mg
MEKINIST ORAL TABLET 0.5 MG
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Megestrol Acetate)
MEKINIST ORAL TABLET 2 MG
mercaptopurine oral tablet 50 mg
methotrexate 50 mg/2 ml vial latex-free,
5's, mdv 25 mg/ml
methotrexate sodium (pf) injection recon
soln 1 gram
methotrexate sodium (pf) injection
solution 25 mg/ml
methotrexate sodium oral tablet 2.5 mg
mitoxantrone intravenous concentrate 2
mg/ml
NEXAVAR ORAL TABLET 200 MG
NILANDRON ORAL TABLET 150
MG
nilutamide oral tablet 150 mg
NINLARO ORAL CAPSULE 2.3 MG,
3 MG, 4 MG
QL (1 per 168 days)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
(Mercaptopurine)
(Methotrexate
Sodium)
(Methotrexate
Sodium/PF)
(Methotrexate
Sodium)
(Methotrexate
Sodium)
(Mitoxantrone HCl)
PA NSO; QL (480 per
30 days)
PA NSO; QL (90 per
30 days)
PA NSO; QL (30 per
30 days)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD; ST
$0 (Tier 1)
$0 (Tier 2)
PA NSO; QL (120 per
30 days)
$0 (Tier 2)
(Nilandron)
$0 (Tier 1)
$0 (Tier 2)
days)
this document
33
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ODOMZO ORAL CAPSULE 200 MG
ONCASPAR INJECTION SOLUTION
750 UNIT/ML
OPDIVO INTRAVENOUS
SOLUTION 40 MG/4 ML
POMALYST ORAL CAPSULE 1 MG,
2 MG, 3 MG, 4 MG
PORTRAZZA INTRAVENOUS
MG/ML)
PROLEUKIN INTRAVENOUS
RECON SOLN 22 MILLION UNIT
PURIXAN ORAL SUSPENSION 20
MG/ML
REVLIMID ORAL CAPSULE 10 MG,
15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG
RITUXAN INTRAVENOUS
CONCENTRATE 10 MG/ML
SOLTAMOX ORAL SOLUTION 10
MG/5 ML
SPRYCEL ORAL TABLET 100 MG,
140 MG, 50 MG, 70 MG, 80 MG
SPRYCEL ORAL TABLET 20 MG
$0 (Tier 2)
$0 (Tier 2)
PA NSO; LA
PA NSO
$0 (Tier 2)
PA NSO
$0 (Tier 2)
PA NSO; QL (21 per
28 days)
PA NSO; QL (100 per
21 days)
STIVARGA ORAL TABLET 40 MG
$0 (Tier 2)
SUTENT ORAL CAPSULE 12.5 MG,
25 MG, 37.5 MG, 50 MG
SYLVANT INTRAVENOUS RECON
SOLN 100 MG, 400 MG
SYNRIBO SUBCUTANEOUS RECON
SOLN 3.5 MG
TABLOID ORAL TABLET 40 MG
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA NSO; LA
$0 (Tier 2)
PA NSO
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA NSO; QL (30 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (84 per
28 days)
PA NSO; QL (30 per
30 days)
PA NSO
PA NSO; QL (28 per
28 days)
$0 (Tier 2)
this document
34
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
TAFINLAR ORAL CAPSULE 50 MG,
75 MG
TAGRISSO ORAL TABLET 40 MG,
80 MG
tamoxifen oral tablet 10 mg, 20 mg
(Tamoxifen Citrate)
TARCEVA ORAL TABLET 100 MG,
25 MG
TARCEVA ORAL TABLET 150 MG
$0 (Tier 2)
TARGRETIN ORAL CAPSULE 75
MG
TARGRETIN TOPICAL GEL 1 %
$0 (Tier 2)
TASIGNA ORAL CAPSULE 150 MG,
200 MG
TECENTRIQ INTRAVENOUS
SOLUTION 1,200 MG/20 ML (60
MG/ML)
TEMODAR INTRAVENOUS RECON
SOLN 100 MG
thiotepa injection recon soln 15 mg
(Thiotepa)
toposar intravenous solution 20 mg/ml
(Etoposide)
TREANDA 25 MG VIAL 25 MG
TREANDA INTRAVENOUS RECON
SOLN 100 MG
TREANDA INTRAVENOUS
SOLUTION 180 MG/2 ML, 45 MG/0.5
ML
TRELSTAR 22.5 MG SYRINGE
OUTER 22.5 MG/2 ML
TRELSTAR INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 22.5 MG
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA NSO; QL (120 per
30 days)
PA NSO; LA; QL (30
per 30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (90 per
30 days)
PA NSO; QL (420 per
30 days)
PA NSO; QL (60 per
28 days)
PA NSO; QL (112 per
28 days)
PA NSO; QL (20 per
21 days)
PA NSO; (vial only)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
QL (1 per 168 days)
$0 (Tier 2)
QL (1 per 168 days)
this document
35
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
SYRINGE 11.25 MG/2 ML
SYRINGE 3.75 MG/2 ML
tretinoin (chemotherapy) oral capsule 10 (Tretinoin)
mg
TREXALL ORAL TABLET 10 MG, 15
MG, 5 MG, 7.5 MG
TYKERB ORAL TABLET 250 MG
UNITUXIN INTRAVENOUS
SOLUTION 3.5 MG/ML
VALSTAR INTRAVESICAL
SOLUTION 40 MG/ML
VELCADE INJECTION RECON
SOLN 3.5 MG
VENCLEXTA ORAL TABLET 10 MG,
100 MG, 50 MG
VENCLEXTA STARTING PACK
ORAL TABLETS,DOSE PACK 10
MG-50 MG- 100 MG
vinorelbine intravenous solution 50 mg/5
(Navelbine)
ml
VOTRIENT ORAL TABLET 200 MG
$0 (Tier 2)
QL (1 per 84 days)
XALKORI ORAL CAPSULE 200 MG,
250 MG
XTANDI ORAL CAPSULE 40 MG
$0 (Tier 2)
YERVOY INTRAVENOUS
SOLUTION 50 MG/10 ML (5 MG/ML)
YONDELIS INTRAVENOUS RECON
SOLN 1 MG
ZELBORAF ORAL TABLET 240 MG
$0 (Tier 2)
PA NSO; QL (120 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (120 per
30 days)
PA NSO
$0 (Tier 2)
PA NSO
$0 (Tier 2)
PA NSO; QL (240 per
30 days)
$0 (Tier 2)
$0 (Tier 1)
(capsule: 10mg)
$0 (Tier 2)
PA BvD; ST
$0 (Tier 2)
$0 (Tier 2)
PA NSO
$0 (Tier 2)
$0 (Tier 2)
PA NSO
$0 (Tier 2)
PA NSO; LA
$0 (Tier 2)
PA NSO; LA
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
this document
36
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ZOLADEX SUBCUTANEOUS
IMPLANT 10.8 MG
ZOLADEX SUBCUTANEOUS
IMPLANT 3.6 MG
ZOLINZA ORAL CAPSULE 100 MG
ZYDELIG ORAL TABLET 100 MG,
150 MG
ZYKADIA ORAL CAPSULE 150 MG
$0 (Tier 2)
QL (1 per 84 days)
$0 (Tier 2)
QL (1 per 28 days)
ZYTIGA ORAL TABLET 250 MG
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA NSO; QL (60 per
30 days)
PA NSO; QL (140 per
28 days)
PA NSO; QL (120 per
30 days)
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine injection solution 0.4 mg/ml
atropine injection syringe 0.05 mg/ml, 0.1
mg/ml
propantheline oral tablet 15 mg
(Atropine Sulfate)
(Atropine Sulfate)
$0 (Tier 1)
$0 (Tier 1)
(Propantheline
Bromide)
$0 (Tier 1)
STIOLTO RESPIMAT INHALATION
MIST 2.5-2.5 MCG/ACTUATION
$0 (Tier 2)
QL (4 per 28 days)
$0 (Tier 2)
ST
$0 (Tier 2)
ST
$0 (Tier 2)
ST
$0 (Tier 2)
QL (80 per 30 days)
$0 (Tier 2)
$0 (Tier 2)
QL (60 per 30 days)
Anticonvulsants
Anticonvulsants
APTIOM ORAL TABLET 200 MG, 400
MG, 600 MG, 800 MG
BANZEL ORAL SUSPENSION 40
MG/ML
BANZEL ORAL TABLET 200 MG,
400 MG
BRIVIACT INTRAVENOUS
SOLUTION 50 MG/5 ML
BRIVIACT ORAL SOLUTION 10
MG/ML
BRIVIACT ORAL TABLET 10 MG,
100 MG, 25 MG, 50 MG, 75 MG
this document
37
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
carbamazepine oral capsule, er multiphase
12 hr 100 mg, 200 mg, 300 mg
carbamazepine oral suspension 100 mg/5
ml
carbamazepine oral tablet 200 mg
carbamazepine oral tablet extended
release 12 hr 100 mg, 200 mg, 400 mg
carbamazepine oral tablet,chewable 100
mg
CELONTIN ORAL CAPSULE 300 MG
DILANTIN ORAL CAPSULE 30 MG
divalproex oral capsule, sprinkle 125 mg
divalproex oral tablet extended release 24
hr 250 mg, 500 mg
divalproex oral tablet,delayed release
(dr/ec) 125 mg, 250 mg, 500 mg
epitol oral tablet 200 mg
ethosuximide oral capsule 250 mg
ethosuximide oral solution 250 mg/5 ml
felbamate oral suspension 600 mg/5 ml
felbamate oral tablet 400 mg, 600 mg
fosphenytoin 500 mg pe/10 ml
10's,sdv,latex-free 500 mg pe/10 ml
fosphenytoin injection solution 100 mg
pe/2 ml
FYCOMPA ORAL SUSPENSION 0.5
MG/ML
FYCOMPA ORAL TABLET 10 MG,
12 MG, 2 MG, 4 MG, 6 MG, 8 MG
gabapentin oral capsule 100 mg, 300 mg,
400 mg
gabapentin oral solution 250 mg/5 ml
gabapentin oral tablet 600 mg, 800 mg
(Carbatrol)
$0 (Tier 1)
(Tegretol)
$0 (Tier 1)
(Tegretol)
(Tegretol XR)
$0 (Tier 1)
$0 (Tier 1)
(Carbamazepine)
$0 (Tier 1)
(Depakote Sprinkle)
(Depakote ER)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Depakote)
$0 (Tier 1)
(Tegretol)
(Zarontin)
(Zarontin)
(Felbatol)
(Felbatol)
(Cerebyx)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Cerebyx)
$0 (Tier 1)
$0 (Tier 2)
ST
$0 (Tier 2)
ST
(Neurontin)
$0 (Tier 1)
(Neurontin)
(Neurontin)
$0 (Tier 1)
$0 (Tier 1)
this document
38
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
GABITRIL ORAL TABLET 12 MG, 16
MG
LAMICTAL ORAL TABLET,
CHEWABLE DISPERSIBLE 2 MG
lamotrigine oral tablet 100 mg, 150 mg,
200 mg, 25 mg
lamotrigine oral tablet extended release
24hr 100 mg, 200 mg, 25 mg, 250 mg, 300
mg, 50 mg
lamotrigine oral tablet, chewable
dispersible 25 mg, 5 mg
lamotrigine oral tablets,dose pack 25 mg
(35)
levetiracetam intravenous solution 500
mg/5 ml
levetiracetam oral solution 100 mg/ml
levetiracetam oral tablet 1,000 mg, 250
mg, 500 mg, 750 mg
levetiracetam oral tablet extended release
24 hr 500 mg, 750 mg
LYRICA ORAL CAPSULE 100 MG,
150 MG, 200 MG, 225 MG, 25 MG, 300
MG, 50 MG, 75 MG
LYRICA ORAL SOLUTION 20
MG/ML
oxcarbazepine oral suspension 300 mg/5
ml
oxcarbazepine oral tablet 150 mg, 300 mg,
600 mg
OXTELLAR XR ORAL TABLET
MG, 300 MG, 600 MG
PEGANONE ORAL TABLET 250 MG
$0 (Tier 2)
$0 (Tier 2)
(Lamictal)
$0 (Tier 1)
(Lamictal XR)
$0 (Tier 1)
(Lamictal)
$0 (Tier 1)
(Lamictal (Blue))
$0 (Tier 1)
(Keppra)
$0 (Tier 1)
(Keppra)
(Roweepra)
$0 (Tier 1)
$0 (Tier 1)
(Keppra XR)
$0 (Tier 1)
$0 (Tier 2)
QL (90 per 30 days)
$0 (Tier 2)
(Trileptal)
$0 (Tier 1)
(Trileptal)
$0 (Tier 1)
$0 (Tier 2)
ST
$0 (Tier 2)
this document
39
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
phenobarbital oral elixir 20 mg/5 ml (4
mg/ml)
phenobarbital oral tablet 100 mg, 15 mg,
16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2
mg
phenobarbital oral tablet 30 mg
phenobarbital sodium injection solution
130 mg/ml, 65 mg/ml
phenytoin oral suspension 125 mg/5 ml
phenytoin oral tablet,chewable 50 mg
phenytoin sodium extended oral capsule
100 mg, 200 mg, 300 mg
phenytoin sodium intravenous solution 50
mg/ml
phenytoin sodium intravenous syringe 50
mg/ml
POTIGA ORAL TABLET 200 MG, 300
MG, 400 MG
POTIGA ORAL TABLET 50 MG
primidone oral tablet 250 mg, 50 mg
ROWEEPRA ORAL TABLET 500 MG
SABRIL ORAL POWDER IN
PACKET 500 MG
SABRIL ORAL TABLET 500 MG
SPRITAM ORAL TABLET FOR
SUSPENSION 1,000 MG
SPRITAM ORAL TABLET FOR
SUSPENSION 250 MG, 500 MG, 750
MG
tiagabine oral tablet 2 mg, 4 mg
topiragen oral tablet 100 mg, 200 mg, 25
mg, 50 mg
topiramate oral capsule, sprinkle 15 mg,
25 mg
(Phenobarbital)
$0 (Tier 1)
(Phenobarbital)
$0 (Tier 1)
QL (90 per 30 days)
(Phenobarbital)
(Phenobarbital
Sodium)
(Dilantin-125)
(Dilantin)
(Dilantin)
$0 (Tier 1)
$0 (Tier 1)
QL (2 per 30 days)
(Phenytoin Sodium)
$0 (Tier 1)
(Phenytoin Sodium)
$0 (Tier 1)
(Mysoline)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
QL (90 per 30 days)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Gabitril)
(Topamax)
$0 (Tier 1)
$0 (Tier 1)
(Topamax)
$0 (Tier 1)
ST; QL (60 per 30
days)
ST; QL (120 per 30
days)
this document
40
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
topiramate oral capsule,sprinkle,er 24hr
100 mg, 150 mg, 200 mg, 25 mg, 50 mg
topiramate oral tablet 100 mg, 200 mg, 25
mg, 50 mg
TROKENDI XR ORAL
CAPSULE,EXTENDED RELEASE
24HR 100 MG, 200 MG, 25 MG, 50 MG
valproate sodium intravenous solution 500
mg/5 ml (100 mg/ml)
valproic acid (as sodium salt) oral
solution 250 mg/5 ml
valproic acid oral capsule 250 mg
VIMPAT INTRAVENOUS
SOLUTION 200 MG/20 ML
VIMPAT ORAL SOLUTION 10
MG/ML
VIMPAT ORAL TABLET 100 MG, 150
MG, 200 MG, 50 MG
zonisamide oral capsule 100 mg, 25 mg, 50
mg
(Qudexy XR)
$0 (Tier 1)
(Topamax)
$0 (Tier 1)
$0 (Tier 2)
ST
(Depacon)
$0 (Tier 1)
(Depakene)
$0 (Tier 1)
(Depakene)
$0 (Tier 1)
$0 (Tier 2)
QL (200 per 5 days)
$0 (Tier 2)
$0 (Tier 2)
QL (60 per 30 days)
(Zonegran)
$0 (Tier 1)
(Aricept)
(Donepezil HCl)
$0 (Tier 1)
$0 (Tier 1)
QL (30 per 30 days)
QL (30 per 30 days)
(Razadyne ER)
$0 (Tier 1)
QL (30 per 30 days)
(Galantamine Hbr)
(Razadyne)
(Namenda)
(Namenda)
(Namenda)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (60 per 30 days)
QL (60 per 30 days)
QL (49 per 28 days)
Antidementia Agents
Antidementia Agents
donepezil oral tablet 10 mg, 23 mg, 5 mg
donepezil oral tablet,disintegrating 10 mg,
5 mg
galantamine oral capsule,ext rel. pellets 24
hr 16 mg, 24 mg, 8 mg
galantamine oral solution 4 mg/ml
galantamine oral tablet 12 mg, 4 mg, 8 mg
memantine oral solution 2 mg/ml
memantine oral tablet 10 mg, 5 mg
memantine oral tablets,dose pack 5-10 mg
this document
41
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR DOSE
PACK 7-14-21-28 MG
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR 14
MG, 21 MG, 28 MG, 7 MG
NAMZARIC ORAL
CAPSULE,SPRINKLE,ER 24HR 14-10
MG, 28-10 MG
rivastigmine tartrate oral capsule 1.5 mg, (Exelon)
3 mg, 4.5 mg, 6 mg
rivastigmine transdermal patch 24 hour
(Exelon)
13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24
hr
$0 (Tier 2)
QL (28 per 28 days)
$0 (Tier 2)
QL (30 per 30 days)
$0 (Tier 2)
$0 (Tier 1)
QL (60 per 30 days)
$0 (Tier 1)
QL (30 per 30 days)
(Amitriptyline HCl)
$0 (Tier 1)
PA NSO-HRM
(Amoxapine)
$0 (Tier 1)
Antidepressants
Antidepressants
amitriptyline oral tablet 10 mg, 100 mg,
150 mg, 25 mg, 50 mg, 75 mg
amoxapine oral tablet 100 mg, 150 mg, 25
mg, 50 mg
BRINTELLIX ORAL TABLET 10 MG,
20 MG, 5 MG
buproban oral tablet extended release 150
mg
bupropion hcl (smoking deter) oral tablet
extended release 150 mg
bupropion hcl oral tablet 100 mg, 75 mg
bupropion hcl oral tablet extended release
100 mg, 150 mg, 200 mg
bupropion hcl oral tablet extended release
24 hr 150 mg, 300 mg
citalopram oral solution 10 mg/5 ml
$0 (Tier 2)
(Wellbutrin SR)
$0 (Tier 1)
(Wellbutrin SR)
$0 (Tier 1)
(Wellbutrin)
(Wellbutrin SR)
$0 (Tier 1)
$0 (Tier 1)
(Wellbutrin XL)
$0 (Tier 1)
(Citalopram
Hydrobromide)
$0 (Tier 1)
ST
this document
42
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
citalopram oral tablet 10 mg, 20 mg, 40
mg
clomipramine oral capsule 25 mg, 50 mg,
75 mg
desipramine oral tablet 10 mg, 100 mg,
150 mg, 25 mg, 50 mg, 75 mg
doxepin oral capsule 10 mg, 100 mg, 150
mg, 25 mg, 50 mg, 75 mg
doxepin oral concentrate 10 mg/ml
duloxetine oral capsule,delayed
release(dr/ec) 20 mg, 60 mg
EMSAM TRANSDERMAL PATCH 24
HOUR 12 MG/24 HR, 6 MG/24 HR, 9
MG/24 HR
escitalopram oxalate oral solution 5 mg/5
ml
escitalopram oxalate oral tablet 10 mg, 20
mg, 5 mg
FETZIMA ORAL CAPSULE,EXT
REL 24HR DOSE PACK 20 MG (2)- 40
MG (26)
FETZIMA ORAL
CAPSULE,EXTENDED RELEASE 24
HR 120 MG, 20 MG, 40 MG, 80 MG
fluoxetine oral capsule 10 mg, 20 mg, 40
mg
fluoxetine oral capsule,delayed
fluoxetine oral solution 20 mg/5 ml (4
mg/ml)
(Celexa)
$0 (Tier 1)
QL (30 per 30 days)
(Anafranil)
$0 (Tier 1)
PA NSO-HRM
(Norpramin)
$0 (Tier 1)
(Doxepin HCl)
$0 (Tier 1)
PA NSO-HRM
(Doxepin HCl)
(Duloxetine)
$0 (Tier 1)
$0 (Tier 1)
(Duloxetine)
$0 (Tier 1)
(Duloxetine)
$0 (Tier 1)
PA NSO-HRM
(Cymbalta); QL (60
per 30 days)
(Cymbalta); QL (30
per 30 days)
(Irenka); QL (30 per 30
days)
QL (30 per 30 days)
$0 (Tier 2)
(Lexapro)
$0 (Tier 1)
(Lexapro)
$0 (Tier 1)
$0 (Tier 2)
ST
$0 (Tier 2)
ST
(Prozac)
$0 (Tier 1)
(Prozac Weekly)
$0 (Tier 1)
(Fluoxetine HCl)
$0 (Tier 1)
this document
43
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
fluoxetine oral tablet 10 mg, 20 mg
fluvoxamine oral capsule,extended release
24hr 100 mg, 150 mg
fluvoxamine oral tablet 100 mg, 25 mg, 50
mg
imipramine hcl oral tablet 10 mg, 25 mg,
50 mg
imipramine pamoate oral capsule 100 mg,
125 mg, 150 mg, 75 mg
maprotiline oral tablet 25 mg, 50 mg, 75
mg
MARPLAN ORAL TABLET 10 MG
mirtazapine oral tablet 15 mg, 30 mg, 45
mg, 7.5 mg
mirtazapine oral tablet,disintegrating 15
mg, 30 mg, 45 mg
nefazodone oral tablet 100 mg, 150 mg,
200 mg, 250 mg, 50 mg
nortriptyline oral capsule 10 mg, 25 mg,
50 mg, 75 mg
nortriptyline oral solution 10 mg/5 ml
olanzapine-fluoxetine oral capsule 12-25
mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg
paroxetine hcl oral tablet 10 mg, 20 mg,
30 mg, 40 mg
paroxetine hcl oral tablet extended release
24 hr 12.5 mg, 25 mg, 37.5 mg
PAXIL ORAL SUSPENSION 10 MG/5
ML
perphenazine-amitriptyline oral tablet
2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50
mg
phenelzine oral tablet 15 mg
(Fluoxetine HCl)
(Fluvoxamine
Maleate)
(Fluvoxamine
Maleate)
(Tofranil)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA NSO-HRM
(Tofranil-Pm)
$0 (Tier 1)
PA NSO-HRM
(Maprotiline HCl)
$0 (Tier 1)
(Remeron)
$0 (Tier 2)
$0 (Tier 1)
(Remeron)
$0 (Tier 1)
(Nefazodone HCl)
$0 (Tier 1)
(Pamelor)
$0 (Tier 1)
(Nortriptyline HCl)
(Symbyax)
$0 (Tier 1)
$0 (Tier 1)
(Paxil)
$0 (Tier 1)
(Paxil CR)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Perphenazine/Amitri
ptyline HCl)
$0 (Tier 1)
(Nardil)
$0 (Tier 1)
PA NSO-HRM
this document
44
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
PRISTIQ ORAL TABLET
MG, 25 MG, 50 MG
protriptyline oral tablet 10 mg, 5 mg
sertraline oral concentrate 20 mg/ml
sertraline oral tablet 100 mg, 25 mg, 50
mg
SILENOR ORAL TABLET 3 MG, 6
MG
SURMONTIL ORAL CAPSULE 100
MG, 25 MG, 50 MG
tranylcypromine oral tablet 10 mg
trazodone oral tablet 100 mg, 150 mg, 300
mg, 50 mg
trimipramine oral capsule 100 mg, 25 mg,
50 mg
TRINTELLIX ORAL TABLET 10 MG,
20 MG, 5 MG
venlafaxine oral capsule,extended release
24hr 150 mg, 37.5 mg, 75 mg
venlafaxine oral tablet 100 mg, 25 mg,
37.5 mg, 50 mg, 75 mg
venlafaxine oral tablet extended release
24hr 150 mg, 37.5 mg, 75 mg
VIIBRYD ORAL TABLET 10 MG, 20
MG, 40 MG
VIIBRYD ORAL TABLETS,DOSE
PACK 10 MG (7)- 20 MG (23), 10 MG
(7)-20 MG (7)-40 MG (16)
$0 (Tier 2)
(Protriptyline HCl)
(Zoloft)
(Zoloft)
ST; QL (30 per 30
days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
QL (30 per 30 days)
$0 (Tier 2)
PA NSO-HRM
(Parnate)
(Trazodone HCl)
$0 (Tier 1)
$0 (Tier 1)
(Trimipramine
Maleate)
$0 (Tier 1)
PA NSO-HRM
$0 (Tier 2)
ST
(Effexor XR)
$0 (Tier 1)
(Venlafaxine HCl)
$0 (Tier 1)
(Venlafaxine HCl)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
acarbose oral tablet 100 mg, 25 mg, 50 mg (Precose)
CYCLOSET ORAL TABLET 0.8 MG
$0 (Tier 1)
$0 (Tier 2)
QL (90 per 30 days)
this document
45
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
GLYXAMBI ORAL TABLET 10-5
MG, 25-5 MG
INVOKAMET ORAL TABLET
150-1,000 MG, 150-500 MG, 50-1,000
MG, 50-500 MG
INVOKANA ORAL TABLET 100 MG,
300 MG
JANUMET ORAL TABLET 50-1,000
MG, 50-500 MG
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 100-1,000 MG,
50-1,000 MG, 50-500 MG
JANUVIA ORAL TABLET 100 MG, 25
MG, 50 MG
JARDIANCE ORAL TABLET 10 MG,
25 MG
JENTADUETO ORAL TABLET
2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG
JENTADUETO XR ORAL TABLET,
IR - ER, BIPHASIC 24HR 2.5-1,000
MG, 5-1,000 MG
KORLYM ORAL TABLET 300 MG
metformin oral tablet 1,000 mg
metformin oral tablet 500 mg
metformin oral tablet 850 mg
metformin oral tablet extended release 24
hr 500 mg
metformin oral tablet extended release 24
hr 750 mg
metformin oral tablet extended release
24hr 1,000 mg
metformin oral tablet extended release
24hr 500 mg
$0 (Tier 2)
ST
$0 (Tier 2)
ST
$0 (Tier 2)
ST
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
ST
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Glucophage)
(Glucophage)
(Glucophage)
(Glucophage XR)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA; QL (112 per 28
days)
QL (75 per 30 days)
QL (90 per 30 days)
(Glucophage XR)
$0 (Tier 1)
QL (90 per 30 days)
(Fortamet)
$0 (Tier 1)
QL (60 per 30 days)
(Fortamet)
$0 (Tier 1)
this document
46
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
miglitol oral tablet 100 mg, 25 mg, 50 mg
nateglinide oral tablet 120 mg, 60 mg
pioglitazone oral tablet 15 mg, 30 mg, 45
mg
pioglitazone-glimepiride oral tablet 30-2
mg, 30-4 mg
pioglitazone-metformin oral tablet 15-500
mg, 15-850 mg
repaglinide oral tablet 0.5 mg, 1 mg, 2 mg
repaglinide-metformin oral tablet 1-500
mg, 2-500 mg
SYMLINPEN 120 SUBCUTANEOUS
PEN INJECTOR 2,700 MCG/2.7 ML
SYMLINPEN 60 SUBCUTANEOUS
PEN INJECTOR 1,500 MCG/1.5 ML
SYNJARDY ORAL TABLET
12.5-1,000 MG, 12.5-500 MG, 5-1,000
MG, 5-500 MG
TRADJENTA ORAL TABLET 5 MG
TRULICITY SUBCUTANEOUS PEN
INJECTOR 0.75 MG/0.5 ML, 1.5
MG/0.5 ML
VICTOZA 3-PAK SUBCUTANEOUS
PEN INJECTOR 0.6 MG/0.1 ML (18
MG/3 ML)
Insulins
HUMULIN R U-500 (CONC)
KWIKPEN SUBCUTANEOUS
INSULIN PEN 500 UNIT/ML (3 ML)
HUMULIN R U-500
(CONCENTRATED)
SUBCUTANEOUS SOLUTION 500
UNIT/ML
(Glyset)
(Starlix)
(Actos)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
(Duetact)
$0 (Tier 1)
QL (30 per 30 days)
(Actoplus Met)
$0 (Tier 1)
QL (90 per 30 days)
(Prandin)
(Prandimet)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
PA; QL (10.8 per 28
days)
$0 (Tier 2)
ST
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
QL (24 per 28 days)
$0 (Tier 2)
QL (40 per 28 days)
this document
47
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
LANTUS SOLOSTAR
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (3 ML)
LANTUS SUBCUTANEOUS
SOLUTION 100 UNIT/ML
NOVOLIN 70/30 SUBCUTANEOUS
SUSPENSION 100 UNIT/ML (70-30)
NOVOLIN N SUBCUTANEOUS
SUSPENSION 100 UNIT/ML
NOVOLIN R INJECTION SOLUTION
100 UNIT/ML
NOVOLOG FLEXPEN
UNIT/ML
NOVOLOG MIX 70-30 FLEXPEN
UNIT/ML (70-30)
NOVOLOG MIX 70-30
SUBCUTANEOUS SOLUTION 100
UNIT/ML (70-30)
NOVOLOG PENFILL
SUBCUTANEOUS CARTRIDGE 100
UNIT/ML
NOVOLOG SUBCUTANEOUS
TOUJEO SOLOSTAR
UNIT/ML (1.5 ML)
Sulfonylureas
glimepiride oral tablet 1 mg, 2 mg
glimepiride oral tablet 4 mg
glipizide oral tablet 10 mg
glipizide oral tablet 5 mg
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
QL (40 per 28 days)
$0 (Tier 2)
QL (40 per 28 days)
$0 (Tier 2)
QL (40 per 28 days)
$0 (Tier 2)
QL (30 per 28 days)
$0 (Tier 2)
QL (30 per 28 days)
$0 (Tier 2)
QL (40 per 28 days)
$0 (Tier 2)
QL (30 per 28 days)
$0 (Tier 2)
QL (40 per 28 days)
$0 (Tier 2)
(Amaryl)
(Amaryl)
(Glucotrol)
(Glucotrol)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
this document
48
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
glipizide oral tablet extended release 24hr (Glucotrol XL)
10 mg
glipizide oral tablet extended release 24hr (Glucotrol XL)
2.5 mg, 5 mg
glipizide-metformin oral tablet 2.5-250 mg (Glipizide/Metformin
HCl)
glipizide-metformin oral tablet 2.5-500
(Glipizide/Metformin
mg, 5-500 mg
HCl)
glyburide micronized oral tablet 1.5 mg, 3 (Glynase)
mg, 6 mg
glyburide oral tablet 1.25 mg, 2.5 mg, 5
(Glyburide)
mg
glyburide-metformin oral tablet 1.25-250 (Glucovance)
mg, 2.5-500 mg, 5-500 mg
tolazamide oral tablet 250 mg
(Tolazamide)
tolazamide oral tablet 500 mg
(Tolazamide)
tolbutamide oral tablet 500 mg
(Tolbutamide)
$0 (Tier 1)
QL (60 per 30 days)
$0 (Tier 1)
QL (30 per 30 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
QL (60 per 30 days)
$0 (Tier 2)
PA BvD
$0 (Tier 4)
$0 (Tier 2)
PA BvD
$0 (Tier 1)
$0 (Tier 1)
Antifungals
Antifungals
ABELCET INTRAVENOUS
SUSPENSION 5 MG/ML
aloe vesta 2% antifungal oint 2 % *
AMBISOME INTRAVENOUS
SUSPENSION FOR
RECONSTITUTION 50 MG
amphotericin b injection recon soln 50 mg
anti-fungal 1% powder 1 % *
athlete's foot 2% powder 2 % *
baza antifungal 2% cream 12's 2 % *
CANCIDAS INTRAVENOUS RECON
SOLN 50 MG, 70 MG
ciclopirox topical cream 0.77 %
ciclopirox topical gel 0.77 %
(Miconazole Nitrate)
(Amphotericin B)
(Tolnaftate)
(Lotrimin AF)
(Nuzole)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
(Loprox)
(Loprox)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
this document
49
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ciclopirox topical shampoo 1 %
ciclopirox topical solution 8 %
ciclopirox topical suspension 0.77 %
ciclopirox-ure-camph-menth-euc topical
solution 8 %
clotrim 1% vaginal cream 1 % *
clotrimazole 1% cream (otc) 1 % *
clotrimazole 1% solution (otc) 1 % *
clotrimazole insert 100 mg *
clotrimazole mucous membrane troche 10
mg
clotrimazole topical cream 1 %
clotrimazole topical solution 1 %
clotrimazole-7 cream 1 % *
clotrimazole-betamethasone topical cream
1-0.05 %
clotrimazole-betamethasone topical lotion
1-0.05 %
critic-aid clear af 2% oint 12's, w/
antifungal 2 % *
cvs af 1% spray powder 1 % *
cvs anti-fungal 2% powder 2 % *
cvs athlete's foot powd spray 2 % *
cvs miconazole 1 combo pack sftgl
insert/9gm crm 1,200-2 mg-% *
cvs miconazole 3 combo pack 3pref applic
w/cream 4 % (200 mg)- 2 % (9 gram) *
cvs tioconazole 1 6.5% ointmnt 6.5 % *
dermafungal 2% ointment 2 % *
desenex 2% powder 2 % *
desenex 2% spray powder 2 % *
econazole topical cream 1 %
elon dual defense 25% solution 25 % *
(Loprox)
(Penlac)
(Ciclopirox Olamine)
(Ciclodan)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Gyne-Lotrimin)
(Lotrimin AF)
(Clotrimazole)
(Clotrimazole)
(Clotrimazole)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
(Clotrimazole)
(Clotrimazole)
(Gyne-Lotrimin)
(Lotrisone)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
(Clotrimazole/Betame
thasone Dip)
$0 (Tier 1)
(Tinactin)
(Lotrimin AF)
(Lotrimin AF)
(Monistat 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Tioconazole)
(Lotrimin AF)
(Lotrimin AF)
(Econazole Nitrate)
(Undecylenic Acid)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
this document
50
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
fluconazole in dextrose(iso-o) intravenous
fluconazole in nacl (iso-osm) intravenous
piggyback 100 mg/50 ml, 200 mg/100 ml
fluconazole oral suspension for
reconstitution 10 mg/ml, 40 mg/ml
fluconazole oral tablet 100 mg, 150 mg,
200 mg, 50 mg
fluconazole-nacl 400 mg/200 ml
10's,latex-free, p/f 400 mg/200 ml
flucytosine oral capsule 250 mg, 500 mg
fungi cure intensive 1% spray 1 % *
FUNGI-NAIL TINCTURE *
fungoid-d 1% cream 1 % *
gnp miconazole 3 combo pack 4 % (200
mg)- 2 % (9 gram) *
griseofulvin microsize oral tablet 500 mg
HONGO CURA ANTI-FUNGAL 25%
SPR 25 % *
inzo antifungal 2% cream 2 % *
itraconazole oral capsule 100 mg
ketoconazole oral tablet 200 mg
ketoconazole topical cream 2 %
ketoconazole topical shampoo 2 %
lamisil af defens 1% spray pwd 1 % *
lamisil af defense 1% powder 1 % *
LAMISIL ANTIFUNGAL 1% SPRAY
FOR ATHLETES FOOT 1 % *
LAMISIL AT 1% CREAM
ATHLETE'S FOOT 1 % *
LAMISIL AT 1% GEL 1 % *
micatin 2% antifungal cream 2 % *
(Fluconazole In
Nacl,Iso-Osm)
(Fluconazole In
Nacl,Iso-Osm)
(Diflucan)
$0 (Tier 1)
(Diflucan)
$0 (Tier 1)
(Fluconazole In
Nacl,Iso-Osm)
(Ancobon)
(Clotrimazole)
$0 (Tier 1)
(Tinactin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Grifulvin V)
$0 (Tier 1)
$0 (Tier 4)
(Nuzole)
(Sporanox)
(Ketoconazole)
(Ketoconazole)
(Nizoral)
(Tinactin)
(Tolnaftate)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Nuzole)
$0 (Tier 4)
$0 (Tier 4)
this document
51
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
miconazole 3 combo pack 3 sup,9gm crm
w/app 200 mg- 2 % (9 gram) *
miconazole 7 100 mg vag supp 100 mg *
miconazole nitrate 2% cream 2 % *
miconazole nitrate 2% cream 2 % *
miconazole-3 vaginal suppository 200 mg
micro-guard 2% powder 12's,antifungal 2
%*
MONISTAT 3 COMBO PACK 4 % (200
MG)- 2 % (9 GRAM) *
monistat 7 cream 7 applicators 2 % *
myco nail a 25% solution 25 % *
NIZORAL A-D 1% SHAMPOO 1 % *
NOXAFIL ORAL SUSPENSION 200
MG/5 ML (40 MG/ML)
NOXAFIL ORAL
(DR/EC) 100 MG
nyamyc topical powder 100,000 unit/gram
nystatin oral suspension 100,000 unit/ml
nystatin oral tablet 500,000 unit
nystatin topical cream 100,000 unit/gram
nystatin topical ointment 100,000
unit/gram
nystatin topical powder 100,000 unit/gram
nystatin-triamcinolone topical cream
100,000-0.1 unit/g-%
nystatin-triamcinolone topical ointment
100,000-0.1 unit/gram-%
nystop topical powder 100,000 unit/gram
podactin 1% powder 1 % *
qc 3 day vaginal 4% cream 200 mg/5 gram
(4 %) *
(Monistat 3)
$0 (Tier 4)
(Nuzole)
(Lotrimin AF)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
(Undecylenic Acid)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
(Nystatin)
(Nystatin)
(Nystatin)
(Nystatin)
(Nystatin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Nystatin)
(Nystatin/Triamcin)
$0 (Tier 1)
$0 (Tier 1)
(Nystatin/Triamcin)
$0 (Tier 1)
(Nystatin)
(Tolnaftate)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
this document
52
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ra anti-fungal liquid 12.5 % *
ra miconazole 3 kit 3pref app w/crm+6wip
4 % (200 mg)- 2 % (9 gram) *
remedy phytoplex antifungal 2% 2 % *
terbinafine 1% cream 1 % *
terbinafine hcl oral tablet 250 mg
tolnaftate 1% cream 1 % *
tolnaftate 1% solution 1 % *
triple paste af 2% ointment 2 % *
vagistat-1 6.5% ointment 6.5 % *
vagistat-3 combo pack 200 mg- 2 % (9
gram) *
voriconazole intravenous solution 200 mg
voriconazole oral suspension for
reconstitution 200 mg/5 ml (40 mg/ml)
voriconazole oral tablet 200 mg, 50 mg
zeasorb 2% powder athlete's foot 2 % *
(Undecylenic Acid)
(Miconazole/Skin
Cleanser No.17)
(Lotrimin AF)
(Lamisil At)
(Lamisil)
(Tinactin)
(Tolnaftate)
(Tioconazole)
(Monistat 3)
$0 (Tier 4)
$0 (Tier 4)
(Vfend IV)
(Vfend)
$0 (Tier 1)
$0 (Tier 1)
(Vfend)
(Lotrimin AF)
$0 (Tier 1)
$0 (Tier 4)
(Dexbromphenir/Pseu
doephed Sulf)
(Triaminic Nighttime
Cold-Cough)
(Dexbrompheniramin
e Maleate)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
Antihistamines
Antihistamines
12 hour relief tablet 6-120 mg *
25dph-7.5peh liquid 25-7.5 mg/5 ml *
ala-hist ir 2 mg tablet 2 mg *
$0 (Tier 4)
$0 (Tier 4)
ALA-HIST PE TABLET 2-10 MG *
$0 (Tier 4)
alavert 10 mg odt non-drowsy, mint 10 mg (Claritin)
*
ALLEGRA ALLERGY 180 MG
TABLET 180 MG *
ALLEGRA ALLERGY 60 MG
TABLET 60 MG *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
this document
53
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
aller-chlor 2 mg/5 ml syrup 2 mg/5 ml *
$0 (Tier 4)
aller-chlor 4 mg tablet 4 mg *
(Chlorpheniramine
Maleate)
(Chlor-Trimeton)
allergy 4 mg tablet 4 mg *
(Chlor-Trimeton)
$0 (Tier 4)
allerhist-1 1.34 mg tablet 1.34 mg *
(Clemastine
Fumarate)
(Chlorpheniramine/Ps
eudoephed)
(Triprolidine/Pseudoe
phedrine)
(Zzzquil)
(Diphenhydramine
HCl)
(Zzzquil)
$0 (Tier 4)
ambi 60pse-4cpm tablet 4-60 mg *
aprodine tablet 2.5-60 mg *
banophen 25 mg capsule 25 mg *
banophen 25 mg tablet 25 mg *
banophen allergy 12.5 mg/5 ml a/f 12.5
mg/5 ml *
benadryl allergy 25 mg ultratb ultratab 25
mg *
cetirizine hcl 1 mg/1 ml soln children, s/f,
grape (otc) 1 mg/ml *
cetirizine hcl 10 mg tablet indoor &
outdoor 10 mg *
cetirizine hcl 5 mg chew tab
children's,outer,u-d 5 mg *
cetirizine hcl 5 mg tablet indoor & outdoor
5 mg *
cetirizine oral solution 1 mg/ml
child allegra allergy 30 mg/5 ml
suspension 30 mg/5 ml *
child benadryl-d aller-sin liq 12.5-5 mg/5
ml *
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
PA
$0 (Tier 4)
PA
(Diphenhydramine
HCl)
(Children'S Zyrtec)
$0 (Tier 4)
PA
$0 (Tier 4)
(Zyrtec)
$0 (Tier 4)
(Zyrtec)
$0 (Tier 4)
(Zyrtec)
$0 (Tier 4)
(Cetirizine HCl)
$0 (Tier 4)
(Fexofenadine HCl)
$0 (Tier 4)
(Phenylephrine/Diphe
nhydramine)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
this document
54
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
child dometuss-da liquid 1-2.5 mg/5 ml *
child triaminic cold & allergy 1-2.5 mg/5
ml *
child wal-tap cold-allergy elx 1-2.5 mg/5
(Dimetapp)
ml *
children's allegra allergy oral tablet 30 mg (Allegra Allergy)
*
child's aller-tec 1 mg/ml soln 1 mg/ml *
(Children'S Zyrtec)
$0 (Tier 4)
CHILD'S BENADRYL 12.5 MG/5 ML
12.5 MG/5 ML *
child's wal-dryl 12.5 mg/5 ml
a/f,s/f,d/f,bubb gum 12.5 mg/5 ml *
child's wal-zyr 10 mg chew tab 10 mg *
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
(Zzzquil)
$0 (Tier 4)
PA
(Zyrtec)
$0 (Tier 4)
(Chlor-Trimeton
Allergy)
phedrine)
(Diphenhydramine
HCl)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
chlorpheniramine er 12 mg tab 12 mg *
cold-allergy-sinus oral tablet 2.5-60 mg *
compoz 25 mg gelcap 25 mg *
(Triaminic
Cold-Allergy Pe)
(Dimetapp)
CONEX SOLUTION 1-30 MG/5 ML *
conex tablet 2-60 mg *
cvs allergy 25 mg tablet 25 mg *
cvs child allergy 10 mg chw tb 24
hr,indoor/outdoor 10 mg *
cvs cold & cough nighttime liq 6.25-2.5
mg/5 ml *
cyproheptadine oral syrup 2 mg/5 ml
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Dexbrompheniramin
e/Pseudoephed)
(Diphenhydramine
HCl)
(Zyrtec)
$0 (Tier 4)
Cold-Cough)
(Cyproheptadine
HCl)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
$0 (Tier 1)
this document
55
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
cyproheptadine oral tablet 4 mg
dailyhist-1 1.34 mg tablet 1.34 mg *
DALLERGY 1-5 MG TABLET 1-5 MG
*
dayhist allergy 1.34 mg tablet 12 hr relief
1.34 mg *
dimaphen elixir a/f, grape, gluten-f 1-2.5
mg/5 ml *
dimetapp cold & congest liquid 6.25-2.5
mg/5 ml *
diphenhist 12.5 mg/5 ml soln 12.5 mg/5 ml
*
diphenhist 25 mg capsule 25 mg *
diphenhist 25 mg captab captab 25 mg *
diphenhydramine 25 mg capsule (otc) 25
mg *
diphenhydramine 50 mg capsule (otc) 50
mg *
diphenhydramine 50 mg tablet 50 mg *
diphenhydramine hcl injection solution 50
mg/ml
ed chlorped drops 2 mg/ml *
ed chlorped jr syrup 2 mg/5 ml *
ed-a-hist 4 mg-10 mg tablet 4-10 mg *
entre-hist pse liquid 0.938-10 mg/ml *
(Cyproheptadine
HCl)
(Clemastine
Fumarate)
$0 (Tier 1)
$0 (Tier 4)
(Clemastine
Fumarate)
(Dimetapp)
$0 (Tier 4)
Cold-Cough)
(Zzzquil)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
(Zzzquil)
(Diphenhydramine
HCl)
(Zzzquil)
$0 (Tier 4)
$0 (Tier 4)
PA
PA
$0 (Tier 4)
PA
(Zzzquil)
$0 (Tier 4)
PA
(Diphenhydramine
HCl)
(Diphenhydramine
HCl)
(Chlorpheniramine
Maleate)
(Chlorpheniramine
Maleate)
(Chlorpheniramine/P
henylephrine)
phedrine)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
this document
56
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
eq allergy & sinus relief tab 25-10 mg *
fexofenadine hcl 180 mg tablet
24hr,original str (otc) 180 mg *
fexofenadine hcl 30 mg/5 ml 30 mg/5 ml *
fexofenadine hcl 60 mg tablet
indoor/outdoor (otc) 60 mg *
histex-pe syrup 2.5-10 mg/5 ml *
nhydramine)
(Allegra Allergy)
$0 (Tier 4)
(Fexofenadine HCl)
$0 (Tier 4)
(Allegra Allergy)
$0 (Tier 4)
(Phenylephrine/Tripr
olidine)
hm z-sleep 25 mg softgel 25 mg *
(Zzzquil)
levocetirizine oral solution 2.5 mg/5 ml
(Xyzal)
levocetirizine oral tablet 5 mg
(Xyzal)
lohist-d liquid 2-30 mg/5 ml *
eudoephed)
lohist-peb liquid 12's, s/f, a/f, d/f 4-10 mg/5 (Brovex Peb)
ml *
loratadine 10 mg tablet 10 mg *
(Claritin)
loratadine allergy 5 mg/5 ml d/f, a/f, s/f 5
mg/5 ml *
nohist-lq liquid 4-10 mg/5 ml *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Children'S Claritin)
$0 (Tier 4)
(Triaminic
Cold-Allergy Pe)
$0 (Tier 4)
PEDIAVENT 1 MG TABLET CHEW 1
MG *
PEDIAVENT 2 MG/5 ML SYRUP 2
MG/5 ML *
phenylephrine-pyrilamine 10-25 25-10 mg (Poly Hist Forte)
*
promethazine oral syrup 6.25 mg/5 ml
(Promethazine HCl)
$0 (Tier 4)
pv nyt-time sleep 25 mg caplet 25 mg *
$0 (Tier 4)
(Diphenhydramine
HCl)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA-HRM; AGE (Max
64 Years)
PA
this document
57
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
pv sinus nighttime tablet 2.5-10 mg *
(Phenylephrine/Tripr
olidine)
pyrilamine-phenylephrine susp 16-5 mg/5 (Phenylephrine/Pyrila
ml *
mine)
q-dryl 12.5 mg/5 ml liquid a/f 12.5 mg/5 ml (Zzzquil)
*
q-tapp elixir a/f,grape,unboxed 1-15 mg/5 (Brompheniramin/Pse
ml *
udoephedrine)
ra allergy plus sinus tablet 25-10 mg *
nhydramine)
ritifed syrup 1.25-30 mg/5 ml *
phedrine)
RYMED TABLET 2-10 MG *
$0 (Tier 4)
siladryl 12.5 mg/5 ml liquid 12.5 mg/5 ml * (Zzzquil)
simply sleep 25 mg caplet caplet 25 mg *
(Diphenhydramine
HCl)
sm allergy relief 1.34 mg tab 1.34 mg *
(Clemastine
Fumarate)
sm sinus and allergy tablet maximum
strength 4-60 mg *
eudoephed)
sm triacting cold-allergy syr 1-15 mg/5 ml
*
sudogest sinus & allergy tab 4-60 mg *
eudoephed)
TRIAMINIC NIGHTTIME
COLD-COUGH CHILDREN'S,
GRAPE 6.25-2.5 MG/5 ML *
unisom 50 mg sleepgels softgel 50 mg *
(Zzzquil)
vazobid-pd suspension 6-10 mg/5 ml *
(Brompheniramin/Ph
enylephrine)
v-r triacting orange syrup 1-15 mg/5 ml * (Chlorpheniramine/Ps
eudoephed)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
PA
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
this document
58
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
wal-act d cold & allergy tab 2.5-60 mg *
$0 (Tier 4)
wal-dryl allergy 25 mg capsule 25 mg *
wal-dryl allergy 25 mg minitab minitab,
coated 25 mg *
wal-fex allergy 180 mg tablet 180 mg *
phedrine)
(Zzzquil)
(Diphenhydramine
HCl)
(Allegra Allergy)
wal-fex allergy 60 mg tablet 60 mg *
(Allegra Allergy)
$0 (Tier 4)
wal-finate 4 mg tablet 4 mg *
(Chlor-Trimeton)
$0 (Tier 4)
wal-finate-d tablet 4-60 mg *
$0 (Tier 4)
wal-itin 10 mg odt non-drowsy 10 mg *
eudoephed)
(Claritin)
wal-itin 10 mg tablet non-drowsy 10 mg *
(Claritin)
$0 (Tier 4)
wal-itin 5 mg/5 ml syrup children's, grape
5 mg/5 ml *
wal-phed pe sinus-allergy tab 4-10 mg *
(Children'S Claritin)
$0 (Tier 4)
$0 (Tier 4)
wal-sleep z 25 mg softgel 25 mg *
(Chlorpheniramine/P
henylephrine)
eudoephed)
(Zzzquil)
wal-som 25 mg odt 25 mg *
(Unisom Sleepmelts)
$0 (Tier 4)
wal-som 50 mg softgel softgel 50 mg *
wal-tap elixir 1-2.5 mg/5 ml *
(Zzzquil)
(Dimetapp)
$0 (Tier 4)
$0 (Tier 4)
wal-zyr 10 mg tablet 10 mg *
(Zyrtec)
$0 (Tier 4)
wal-zyr solution children's, a/f 1 mg/ml *
(Children'S Zyrtec)
$0 (Tier 4)
wal-phed sinus and allergy tab 4-60 mg *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA
PA
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
this document
59
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
Anti-Infectives (Skin And Mucous
Membrane)
Anti-Infectives (Skin And Mucous
Membrane)
AVC VAGINAL VAGINAL CREAM
15 %
clindamycin phosphate vaginal cream 2 %
metronidazole vaginal gel 0.75 %
terconazole vaginal cream 0.4 %, 0.8 %
terconazole vaginal suppository 80 mg
$0 (Tier 2)
(Cleocin)
(Metrogel-Vaginal)
(Terazol 7)
(Terconazole)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(D.H.E.45)
$0 (Tier 1)
QL (30 per 28 days)
(Migranal)
$0 (Tier 1)
QL (8 per 28 days)
$0 (Tier 2)
QL (40 per 28 days)
(Amerge)
(Maxalt)
(Maxalt Mlt)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (18 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
(Sumatriptan
Succinate)
(Imitrex)
$0 (Tier 1)
QL (4 per 28 days)
$0 (Tier 1)
QL (12 per 28 days)
(Imitrex)
$0 (Tier 1)
QL (18 per 28 days)
(Sumatriptan
Succinate)
(Imitrex)
$0 (Tier 1)
QL (4 per 28 days)
$0 (Tier 1)
QL (4 per 28 days)
Antimigraine Agents
Antimigraine Agents
dihydroergotamine injection solution 1
mg/ml
dihydroergotamine nasal
spray,non-aerosol 0.5 mg/pump act. (4
mg/ml)
ERGOMAR SUBLINGUAL TABLET
2 MG
naratriptan oral tablet 1 mg, 2.5 mg
rizatriptan oral tablet 10 mg, 5 mg
rizatriptan oral tablet,disintegrating 10
mg, 5 mg
sumatriptan 6 mg/0.5 ml syrng
p/f,dehp/f,pvc/f 6 mg/0.5 ml
sumatriptan nasal spray,non-aerosol 20
mg/actuation, 5 mg/actuation
sumatriptan succinate oral tablet 100 mg,
25 mg, 50 mg
sumatriptan succinate subcutaneous
cartridge 4 mg/0.5 ml
cartridge 6 mg/0.5 ml
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60
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
sumatriptan succinate subcutaneous pen
injector 4 mg/0.5 ml
sumatriptan succinate subcutaneous pen
injector 6 mg/0.5 ml, 6 mg/0.5 ml
(auto-injector)
solution 6 mg/0.5 ml
zolmitriptan oral tablet 2.5 mg, 5 mg
zolmitriptan oral tablet,disintegrating 2.5
mg, 5 mg
(Sumatriptan
Succinate)
(Sumatriptan
Succinate)
$0 (Tier 1)
QL (4 per 28 days)
$0 (Tier 1)
QL (4 per 28 days)
(Imitrex)
$0 (Tier 1)
QL (4 per 28 days)
(Zomig)
(Zomig Zmt)
$0 (Tier 1)
$0 (Tier 1)
QL (12 per 28 days)
QL (12 per 28 days)
Antimycobacterials
Antimycobacterials
CAPASTAT INJECTION RECON
SOLN 1 GRAM
dapsone oral tablet 100 mg, 25 mg
ethambutol oral tablet 100 mg, 400 mg
isoniazid oral solution 50 mg/5 ml
isoniazid oral tablet 100 mg, 300 mg
PASER ORAL GRANULES DR FOR
SUSP IN PACKET 4 GRAM
PRIFTIN ORAL TABLET 150 MG
pyrazinamide oral tablet 500 mg
rifabutin oral capsule 150 mg
rifampin intravenous recon soln 600 mg
rifampin oral capsule 150 mg, 300 mg
RIFATER ORAL TABLET 50-120-300
MG
SIRTURO ORAL TABLET 100 MG
$0 (Tier 2)
(Dapsone)
(Myambutol)
(Isoniazid)
(Isoniazid)
(Pyrazinamide)
(Mycobutin)
(Rifadin)
(Rifadin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
TRECATOR ORAL TABLET 250 MG
PA; QL (188 per 168
days)
$0 (Tier 2)
this document
61
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
Antinausea Agents
Antinausea Agents
AKYNZEO ORAL CAPSULE 300-0.5
MG
compro rectal suppository 25 mg
cvs motion sickness 50 mg tab 50 mg *
dimenhydrinate injection solution 50
mg/ml
dramamine 50 mg tablet 50 mg *
dramamine less drowsy 25 mg tb 25 mg *
$0 (Tier 2)
(Compazine)
(Dimenhydrinate)
(Dimenhydrinate)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
(Dimenhydrinate)
(Meclizine HCl)
$0 (Tier 4)
$0 (Tier 4)
driminate 50 mg tablet 50 mg *
dronabinol oral capsule 10 mg, 2.5 mg, 5
mg
EMEND INTRAVENOUS RECON
SOLN 150 MG
EMEND ORAL CAPSULE 125 MG, 80
MG
EMEND ORAL CAPSULE 40 MG
EMEND ORAL CAPSULE,DOSE
PACK 125 MG (1)- 80 MG (2)
EMEND ORAL SUSPENSION FOR
RECONSTITUTION 125 MG (25 MG/
ML FINAL CONC.)
granisetron (pf) intravenous solution 100
mcg/ml
granisetron hcl intravenous solution 1
mg/ml (1 ml)
granisetron hcl oral tablet 1 mg
meclizine 12.5 mg caplet caplet (otc) 12.5
mg *
meclizine 25 mg tablet (otc) 25 mg *
(Dimenhydrinate)
(Marinol)
$0 (Tier 4)
$0 (Tier 1)
meclizine oral tablet 12.5 mg, 25 mg
PA BvD
PA; AGE (Min 2
Years)
$0 (Tier 2)
QL (2 per 28 days)
$0 (Tier 2)
PA BvD
$0 (Tier 2)
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
(Granisetron
HCl/PF)
(Granisetron HCl)
$0 (Tier 1)
(Granisetron HCl)
(Meclizine HCl)
$0 (Tier 1)
$0 (Tier 4)
(Meclizine HCl)
$0 (Tier 4)
(Meclizine HCl)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
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62
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
motion sickness 25 mg tablet 25 mg *
(Meclizine HCl)
$0 (Tier 4)
PA; AGE (Min 2
Years)
ondansetron hcl (pf) injection solution 4
mg/2 ml
ondansetron hcl (pf) injection syringe 4
mg/2 ml
ondansetron hcl oral solution 4 mg/5 ml
ondansetron hcl oral tablet 24 mg, 4 mg, 8
mg
ondansetron oral tablet,disintegrating 4
mg, 8 mg
phenadoz rectal suppository 12.5 mg, 25
mg
prochlorperazine edisylate injection
solution 10 mg/2 ml (5 mg/ml)
prochlorperazine maleate oral tablet 10
mg, 5 mg
prochlorperazine rectal suppository 25 mg
promethazine oral tablet 12.5 mg, 25 mg,
50 mg
promethazine rectal suppository 12.5 mg,
25 mg, 50 mg
promethegan rectal suppository 12.5 mg,
25 mg, 50 mg
TRANSDERM-SCOP
TRANSDERMAL PATCH 3 DAY 1.5
MG (1 MG OVER 3 DAYS)
travel sickness 25 mg tab chew 25 mg *
(Ondansetron
HCl/PF)
(Ondansetron
HCl/PF)
(Zofran)
(Zofran)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
PA BvD
(Zofran Odt)
$0 (Tier 1)
PA BvD
(Phenergan)
$0 (Tier 1)
PA-HRM; AGE (Max
64 Years)
(Prochlorperazine
Edisylate)
(Compazine)
$0 (Tier 1)
(Compazine)
(Promethazine HCl)
$0 (Tier 1)
$0 (Tier 1)
(Phenergan)
$0 (Tier 1)
(Phenergan)
$0 (Tier 1)
(Bonine)
$0 (Tier 4)
wal-dram 50 mg tablet 50 mg *
(Dimenhydrinate)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
QL (10 per 30 days)
PA; AGE (Min 2
Years)
Antiparasite Agents
Antiparasite Agents
ALBENZA ORAL TABLET 200 MG
$0 (Tier 2)
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63
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ALINIA ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML
ALINIA ORAL TABLET 500 MG
atovaquone oral suspension 750 mg/5 ml
atovaquone-proguanil oral tablet 250-100
mg, 62.5-25 mg
chloroquine phosphate oral tablet 250 mg,
500 mg
COARTEM ORAL TABLET 20-120
MG
DARAPRIM ORAL TABLET 25 MG
EMVERM ORAL
TABLET,CHEWABLE 100 MG
hydroxychloroquine oral tablet 200 mg
ivermectin oral tablet 3 mg
mefloquine oral tablet 250 mg
NEBUPENT INHALATION RECON
SOLN 300 MG
paromomycin oral capsule 250 mg
$0 (Tier 2)
(Mepron)
(Malarone)
(Chloroquine
Phosphate)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Plaquenil)
(Stromectol)
(Mefloquine HCl)
(Paromomycin
Sulfate)
PENTAM INJECTION RECON SOLN
300 MG
pin-x 144 mg/ml (50 mg/ml base) s/f,
(Pyrantel Pamoate)
caramel flavor 50 mg/ml *
PRIMAQUINE ORAL TABLET 26.3
MG
quinine sulfate oral capsule 324 mg
(Qualaquin)
reese's pinworm 144 mg/ml susp 50 mg/ml (Pyrantel Pamoate)
*
$0 (Tier 2)
$0 (Tier 1)
QL (6 per 21 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
PA BvD
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 2)
QL (90 per 30 days)
$0 (Tier 1)
$0 (Tier 4)
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl oral capsule 100 mg
amantadine hcl oral solution 50 mg/5 ml
(Amantadine HCl)
(Amantadine HCl)
$0 (Tier 1)
$0 (Tier 1)
this document
64
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
amantadine hcl oral tablet 100 mg
(Amantadine HCl)
APOKYN SUBCUTANEOUS
CARTRIDGE 10 MG/ML
AZILECT ORAL TABLET 0.5 MG, 1
MG
benztropine oral tablet 0.5 mg, 1 mg, 2 mg (Benztropine
Mesylate)
bromocriptine oral capsule 5 mg
(Parlodel)
bromocriptine oral tablet 2.5 mg
(Parlodel)
cabergoline oral tablet 0.5 mg
(Cabergoline)
carbidopa oral tablet 25 mg
(Lodosyn)
carbidopa-levodopa oral tablet 10-100 mg, (Sinemet CR)
25-100 mg, 25-250 mg
carbidopa-levodopa oral tablet extended
(Sinemet CR)
release 25-100 mg, 50-200 mg
carbidopa-levodopa-entacapone oral tablet (Stalevo 50)
12.5-50-200 mg, 18.75-75-200 mg,
25-100-200 mg, 31.25-125-200 mg,
37.5-150-200 mg, 50-200-200 mg
entacapone oral tablet 200 mg
(Comtan)
NEUPRO TRANSDERMAL PATCH
24 HOUR 1 MG/24 HOUR, 2 MG/24
HOUR, 3 MG/24 HOUR, 4 MG/24
HOUR, 6 MG/24 HOUR, 8 MG/24
HOUR
pramipexole oral tablet 0.125 mg, 0.25
(Mirapex)
mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg
ropinirole oral tablet 0.25 mg, 0.5 mg, 1
(Requip)
mg, 2 mg, 3 mg, 4 mg, 5 mg
ropinirole oral tablet extended release 24 (Requip XL)
hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg
selegiline hcl oral capsule 5 mg
(Eldepryl)
selegiline hcl oral tablet 5 mg
(Selegiline HCl)
$0 (Tier 1)
$0 (Tier 2)
QL (60 per 30 days)
$0 (Tier 2)
$0 (Tier 1)
PA-HRM; AGE (Max
64 Years)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
this document
65
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
trihexyphenidyl oral elixir 0.4 mg/ml
trihexyphenidyl oral tablet 2 mg, 5 mg
(Trihexyphenidyl
HCl)
(Trihexyphenidyl
HCl)
$0 (Tier 1)
$0 (Tier 1)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
Antipsychotic Agents
Antipsychotic Agents
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
RECON 300 MG
ABILIFY MAINTENA
INTRAMUSCULAR
RECON 400 MG
ABILIFY MAINTENA
INTRAMUSCULAR
SYRING 300 MG, 400 MG
aripiprazole oral solution 1 mg/ml
aripiprazole oral tablet 10 mg, 15 mg, 20
mg, 30 mg, 5 mg
aripiprazole oral tablet 2 mg
aripiprazole oral tablet,disintegrating 10
mg
aripiprazole oral tablet,disintegrating 15
mg
ARISTADA INTRAMUSCULAR
SYRING 441 MG/1.6 ML
$0 (Tier 2)
$0 (Tier 2)
QL (1 per 28 days)
$0 (Tier 2)
QL (1 per 28 days)
(Abilify)
(Abilify)
$0 (Tier 1)
$0 (Tier 1)
QL (30 per 30 days)
(Abilify)
(Abilify Discmelt)
$0 (Tier 1)
$0 (Tier 1)
QL (60 per 30 days)
QL (90 per 30 days)
(Abilify Discmelt)
$0 (Tier 1)
QL (60 per 30 days)
$0 (Tier 2)
QL (1.6 per 28 days)
$0 (Tier 2)
this document
66
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
chlorpromazine injection solution 25
mg/ml
chlorpromazine oral tablet 10 mg, 100 mg,
200 mg, 25 mg, 50 mg
clozapine oral tablet 100 mg
clozapine oral tablet 200 mg
clozapine oral tablet 25 mg, 50 mg
clozapine oral tablet,disintegrating 100
mg, 12.5 mg, 150 mg, 200 mg, 25 mg
FANAPT ORAL TABLET 1 MG, 10
MG, 12 MG, 2 MG, 4 MG, 6 MG, 8
MG
FANAPT ORAL TABLETS,DOSE
PACK 1MG(2)-2MG(2)4MG(2)-6MG(2)
fluphenazine decanoate injection solution
25 mg/ml
fluphenazine hcl injection solution 2.5
mg/ml
fluphenazine hcl oral concentrate 5 mg/ml
fluphenazine hcl oral elixir 2.5 mg/5 ml
fluphenazine hcl oral tablet 1 mg, 10 mg,
2.5 mg, 5 mg
GEODON INTRAMUSCULAR
RECON SOLN 20 MG/ML (FINAL
CONC.)
haloperidol decanoate intramuscular
solution 100 mg/ml
haloperidol decanoate intramuscular
solution 50 mg/ml
$0 (Tier 2)
(Chlorpromazine
HCl)
(Chlorpromazine
HCl)
(Clozaril)
(Clozaril)
(Clozaril)
(Fazaclo)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (90 per 30 days)
ST
$0 (Tier 2)
ST; QL (60 per 30
days)
$0 (Tier 2)
ST; QL (8 per 28 days)
(Fluphenazine
Decanoate)
(Fluphenazine HCl)
$0 (Tier 1)
(Fluphenazine HCl)
(Fluphenazine HCl)
(Fluphenazine HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Haloperidol
Decanoate)
(Haldol Decanoate
50)
QL (6 per 28 days)
$0 (Tier 1)
$0 (Tier 1)
this document
67
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
haloperidol lactate injection solution 5
mg/ml
haloperidol lactate oral concentrate 2
mg/ml
haloperidol oral tablet 0.5 mg, 1 mg, 10
mg, 2 mg, 20 mg, 5 mg
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 117
MG/0.75 ML, 156 MG/ML, 234 MG/1.5
ML, 39 MG/0.25 ML, 78 MG/0.5 ML
INVEGA TRINZA
MG/0.875 ML, 410 MG/1.315 ML, 546
MG/1.75 ML, 819 MG/2.625 ML
LATUDA ORAL TABLET 120 MG, 20
MG, 40 MG, 60 MG, 80 MG
loxapine succinate oral capsule 10 mg, 25
mg, 5 mg, 50 mg
molindone oral tablet 10 mg
NUPLAZID ORAL TABLET 17 MG
(Haloperidol Lactate)
$0 (Tier 1)
(Haloperidol Lactate)
$0 (Tier 1)
(Haloperidol)
$0 (Tier 1)
olanzapine intramuscular recon soln 10 mg
olanzapine oral tablet 10 mg, 15 mg, 2.5
mg, 20 mg, 5 mg, 7.5 mg
olanzapine oral tablet,disintegrating 10
mg, 15 mg, 5 mg
olanzapine oral tablet,disintegrating 20
mg
paliperidone oral tablet extended release
24hr 1.5 mg, 3 mg, 9 mg
paliperidone oral tablet extended release
24hr 6 mg
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Loxapine Succinate)
$0 (Tier 1)
(Molindone HCl)
(Molindone HCl)
(Molindone HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Zyprexa)
(Zyprexa)
$0 (Tier 1)
$0 (Tier 1)
PA NSO; QL (60 per
30 days)
QL (30 per 30 days)
QL (30 per 30 days)
(Zyprexa Zydis)
$0 (Tier 1)
QL (30 per 30 days)
(Zyprexa Zydis)
$0 (Tier 1)
QL (31 per 30 days)
(Invega)
$0 (Tier 1)
QL (30 per 30 days)
(Invega)
$0 (Tier 1)
QL (60 per 30 days)
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68
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
perphenazine oral tablet 16 mg, 2 mg, 4
mg, 8 mg
pimozide oral tablet 1 mg, 2 mg
quetiapine oral tablet 100 mg, 200 mg, 25
mg, 300 mg, 400 mg, 50 mg
REXULTI ORAL TABLET 0.25 MG
REXULTI ORAL TABLET 0.5 MG
REXULTI ORAL TABLET 1 MG, 2
MG, 3 MG, 4 MG
RISPERDAL CONSTA
INTRAMUSCULAR SYRINGE 12.5
MG/2 ML, 25 MG/2 ML, 37.5 MG/2
ML, 50 MG/2 ML
risperidone oral solution 1 mg/ml
risperidone oral tablet 0.25 mg, 0.5 mg, 1
mg, 2 mg, 3 mg, 4 mg
risperidone oral tablet,disintegrating 0.25
mg, 0.5 mg, 1 mg, 2 mg
risperidone oral tablet,disintegrating 3 mg,
4 mg
SAPHRIS (BLACK CHERRY)
SUBLINGUAL TABLET 10 MG, 2.5
MG, 5 MG
thioridazine oral tablet 10 mg, 100 mg, 25
mg, 50 mg
thiothixene oral capsule 1 mg, 10 mg, 2
mg, 5 mg
trifluoperazine oral tablet 1 mg, 10 mg, 2
mg, 5 mg
VERSACLOZ ORAL SUSPENSION 50
MG/ML
VRAYLAR ORAL CAPSULE 1.5 MG,
3 MG, 4.5 MG, 6 MG
(Perphenazine)
$0 (Tier 1)
(Orap)
(Seroquel)
$0 (Tier 1)
$0 (Tier 1)
QL (90 per 30 days)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
QL (60 per 30 days)
QL (30 per 30 days)
$0 (Tier 2)
QL (4 per 28 days)
(Risperdal)
(Risperdal)
$0 (Tier 1)
$0 (Tier 1)
QL (60 per 30 days)
(Risperdal M-Tab)
$0 (Tier 1)
QL (60 per 30 days)
(Risperdal M-Tab)
$0 (Tier 1)
$0 (Tier 2)
ST; QL (60 per 30
days)
(Thioridazine HCl)
$0 (Tier 1)
PA NSO-HRM
(Thiothixene)
$0 (Tier 1)
(Trifluoperazine HCl)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
ST; QL (540 per 30
days)
QL (30 per 30 days)
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69
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
VRAYLAR ORAL CAPSULE,DOSE
PACK 1.5 MG (1)- 3 MG (6)
ziprasidone hcl oral capsule 20 mg, 40 mg, (Geodon)
60 mg, 80 mg
ZYPREXA RELPREVV 405 MG VL
KIT W/ DILUENT, OUTER 405 MG
ZYPREXA RELPREVV
INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION 210 MG
$0 (Tier 2)
QL (7 per 30 days)
$0 (Tier 1)
QL (60 per 30 days)
$0 (Tier 2)
$0 (Tier 2)
Antivirals (Systemic)
Antiretrovirals
abacavir oral tablet 300 mg
(Ziagen)
abacavir-lamivudine-zidovudine oral tablet (Trizivir)
300-150-300 mg
APTIVUS ORAL CAPSULE 250 MG
APTIVUS ORAL SOLUTION 100
MG/ML
ATRIPLA ORAL TABLET 600-200-300
MG
COMPLERA ORAL TABLET
200-25-300 MG
CRIXIVAN ORAL CAPSULE 200
MG, 400 MG
DESCOVY ORAL TABLET 200-25
MG
didanosine oral capsule,delayed
(Videx EC)
release(dr/ec) 125 mg, 200 mg, 250 mg,
400 mg
EDURANT ORAL TABLET 25 MG
EMTRIVA ORAL CAPSULE 200 MG
EMTRIVA ORAL SOLUTION 10
MG/ML
EPIVIR HBV ORAL SOLUTION 25
MG/5 ML (5 MG/ML)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
this document
70
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
EPZICOM ORAL TABLET 600-300
MG
EVOTAZ ORAL TABLET 300-150 MG
FUZEON SUBCUTANEOUS RECON
SOLN 90 MG
GENVOYA ORAL TABLET
150-150-200-10 MG
INTELENCE ORAL TABLET 100
MG, 200 MG, 25 MG
INVIRASE ORAL CAPSULE 200 MG
INVIRASE ORAL TABLET 500 MG
ISENTRESS ORAL POWDER IN
PACKET 100 MG
ISENTRESS ORAL TABLET 400 MG
ISENTRESS ORAL
TABLET,CHEWABLE 100 MG, 25
MG
KALETRA ORAL SOLUTION 400-100
MG/5 ML
KALETRA ORAL TABLET 100-25
MG, 200-50 MG
lamivudine oral solution 10 mg/ml
lamivudine oral tablet 100 mg, 150 mg,
300 mg
lamivudine-zidovudine oral tablet 150-300
mg
LEXIVA ORAL SUSPENSION 50
MG/ML
LEXIVA ORAL TABLET 700 MG
nevirapine oral suspension 50 mg/5 ml
nevirapine oral tablet 200 mg
nevirapine oral tablet extended release 24
hr 100 mg, 400 mg
NORVIR ORAL CAPSULE 100 MG
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Epivir)
(Epivir)
$0 (Tier 1)
$0 (Tier 1)
(Combivir)
$0 (Tier 1)
$0 (Tier 2)
(Viramune)
(Viramune)
(Viramune XR)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
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71
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
NORVIR ORAL SOLUTION 80
MG/ML
NORVIR ORAL TABLET 100 MG
ODEFSEY ORAL TABLET 200-25-25
MG
PREZCOBIX ORAL TABLET 800-150
MG-MG
PREZISTA ORAL SUSPENSION 100
MG/ML
PREZISTA ORAL TABLET 150 MG,
400 MG, 600 MG, 75 MG, 800 MG
RESCRIPTOR ORAL TABLET 200
MG
RESCRIPTOR ORAL TABLET,
DISPERSIBLE 100 MG
RETROVIR INTRAVENOUS
SOLUTION 10 MG/ML
REYATAZ ORAL CAPSULE 150 MG,
200 MG, 300 MG
REYATAZ ORAL POWDER IN
PACKET 50 MG
SELZENTRY ORAL TABLET 150
MG, 300 MG
stavudine oral capsule 15 mg, 20 mg, 30
(Zerit)
mg, 40 mg
stavudine oral recon soln 1 mg/ml
(Zerit)
STRIBILD ORAL TABLET
150-150-200-300 MG
SUSTIVA ORAL CAPSULE 200 MG,
50 MG
SUSTIVA ORAL TABLET 600 MG
TIVICAY ORAL TABLET 10 MG, 25
MG, 50 MG
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
this document
72
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
TRIUMEQ ORAL TABLET 600-50-300
MG
TRUVADA ORAL TABLET 100-150
MG, 133-200 MG, 167-250 MG, 200-300
MG
VIDEX 2 GRAM PEDIATRIC ORAL
RECON SOLN 10 MG/ML (FINAL)
VIDEX 4 GM PEDIATRIC SOLN 10
MG/ML (FINAL)
VIRACEPT ORAL TABLET 250 MG,
625 MG
VIRAMUNE XR ORAL TABLET
MG
VIREAD ORAL POWDER 40
MG/SCOOP (40 MG/GRAM)
VIREAD ORAL TABLET 150 MG, 200
MG, 250 MG, 300 MG
VITEKTA ORAL TABLET 150 MG, 85
MG
ZIAGEN ORAL SOLUTION 20
MG/ML
zidovudine oral capsule 100 mg
zidovudine oral syrup 10 mg/ml
zidovudine oral tablet 300 mg
Antivirals, Miscellaneous
foscarnet intravenous solution 24 mg/ml
RELENZA DISKHALER
INHALATION BLISTER WITH
DEVICE 5 MG/ACTUATION
rimantadine oral tablet 100 mg
SYNAGIS 100 MG/1 ML VIAL 100
MG/ML
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Retrovir)
(Retrovir)
(Zidovudine)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Foscavir)
$0 (Tier 1)
$0 (Tier 2)
(Flumadine)
$0 (Tier 1)
$0 (Tier 2)
PA BvD
this document
73
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
SYNAGIS INTRAMUSCULAR
SOLUTION 50 MG/0.5 ML
TAMIFLU ORAL CAPSULE 30 MG
TAMIFLU ORAL SUSPENSION FOR
RECONSTITUTION 6 MG/ML
Hcv Antivirals
DAKLINZA ORAL TABLET 30 MG,
60 MG, 90 MG
EPCLUSA ORAL TABLET 400-100
MG
HARVONI ORAL TABLET 90-400
MG
OLYSIO ORAL CAPSULE 150 MG
$0 (Tier 2)
SOVALDI ORAL TABLET 400 MG
$0 (Tier 2)
TECHNIVIE ORAL TABLET
12.5-75-50 MG
VIEKIRA PAK ORAL
TABLETS,DOSE PACK 12.5 MG-75
MG -50 MG/250 MG
VIEKIRA XR ORAL TABLET, IR ER, BIPHASIC 24HR 8.33 MG-50 MG33.33 MG-200 MG
ZEPATIER ORAL TABLET 50-100
MG
Interferons
INTRON A 25 MILLION UNIT/2.5
ML 10 MILLION UNIT/ML
INTRON A INJECTION RECON
SOLN 10 MILLION UNIT (1 ML)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
PA; QL (30 per 30
days)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
PA; QL (56 per 28
days)
PA; QL (112 per 28
days)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA; QL (84 per 28
days)
$0 (Tier 2)
PA; QL (30 per 30
days)
$0 (Tier 2)
PA NSO
$0 (Tier 2)
PA NSO
this document
74
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
INTRON A INJECTION RECON
SOLN 18 MILLION UNIT (1 ML), 50
MILLION UNIT (1 ML)
INTRON A INJECTION SOLUTION 6
MILLION UNIT/ML
PEGASYS PROCLICK
SUBCUTANEOUS PEN INJECTOR
135 MCG/0.5 ML, 180 MCG/0.5 ML
PEGASYS SUBCUTANEOUS
SOLUTION 180 MCG/ML
PEGASYS SUBCUTANEOUS
SYRINGE 180 MCG/0.5 ML
PEGINTRON SUBCUTANEOUS KIT
120 MCG/0.5 ML, 150 MCG/0.5 ML, 50
MCG/0.5 ML, 80 MCG/0.5 ML
SYLATRON SUBCUTANEOUS KIT
200 MCG, 300 MCG, 600 MCG
Nucleosides And Nucleotides
acyclovir oral capsule 200 mg
acyclovir oral suspension 200 mg/5 ml
acyclovir oral tablet 400 mg, 800 mg
acyclovir sodium intravenous solution 50
mg/ml
adefovir oral tablet 10 mg
entecavir oral tablet 0.5 mg, 1 mg
famciclovir oral tablet 125 mg, 250 mg,
500 mg
ganciclovir sodium intravenous recon soln
500 mg
ribasphere oral capsule 200 mg
ribasphere oral tablet 200 mg, 400 mg,
600 mg
TYZEKA ORAL TABLET 600 MG
valacyclovir oral tablet 1 gram, 500 mg
$0 (Tier 2)
PA NSO
$0 (Tier 2)
PA NSO
$0 (Tier 2)
PA
$0 (Tier 2)
PA
$0 (Tier 2)
PA
$0 (Tier 2)
PA
$0 (Tier 2)
days)
(Zovirax)
(Zovirax)
(Zovirax)
(Acyclovir Sodium)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Hepsera)
(Baraclude)
(Famvir)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Cytovene)
$0 (Tier 1)
(Rebetol)
(Copegus)
$0 (Tier 1)
$0 (Tier 1)
(Valtrex)
$0 (Tier 2)
$0 (Tier 1)
PA BvD
PA BvD
this document
75
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
valganciclovir oral tablet 450 mg
VIRAZOLE INHALATION RECON
SOLN 6 GRAM
(Valcyte)
$0 (Tier 1)
$0 (Tier 2)
PA BvD
Blood Products/Modifiers/Volume
Expanders
Anticoagulants
CEPROTIN (BLUE BAR)
INTRAVENOUS RECON SOLN 500
UNIT
ELIQUIS ORAL TABLET 2.5 MG, 5
MG
enoxaparin subcutaneous solution 300
mg/3 ml
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
fondaparinux subcutaneous syringe 10
mg/0.8 ml
fondaparinux subcutaneous syringe 2.5
mg/0.5 ml
fondaparinux subcutaneous syringe 5
mg/0.4 ml
fondaparinux subcutaneous syringe 7.5
mg/0.6 ml
heparin (porcine) in 5 % dex intravenous
parenteral solution 12,500 unit/250 ml,
20,000 unit/500 ml (40 unit/ml), 25,000
unit/500 ml (50 unit/ml)
heparin (porcine) in 5 % dex intravenous
parenteral solution 25,000 unit/250
ml(100 unit/ml)
$0 (Tier 2)
$0 (Tier 2)
(Lovenox)
$0 (Tier 1)
(Lovenox)
$0 (Tier 1)
(Arixtra)
$0 (Tier 1)
QL (24 per 30 days)
(Arixtra)
$0 (Tier 1)
QL (15 per 30 days)
(Arixtra)
$0 (Tier 1)
QL (12 per 30 days)
(Arixtra)
$0 (Tier 1)
QL (18 per 30 days)
(Heparin
Sodium,Porcine/D5W
)
$0 (Tier 1)
(Heparin Sod,Pork In
0.45% NaCl)
$0 (Tier 1)
this document
76
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
heparin (porcine) in nacl (pf) intravenous (Heparin
parenteral solution 1,000 unit/500 ml
Sodium,Porcine/Ns/P
F)
heparin (porcine) injection solution 1,000 (Heparin
unit/ml, 10,000 unit/ml, 20,000 unit/ml,
Sodium,Porcine)
5,000 unit/ml
heparin, porcine (pf) injection solution
(Heparin
5,000 unit/0.5 ml
Sodium,Porcine/PF)
heparin, porcine (pf) injection syringe
(Heparin
5,000 unit/0.5 ml
Sodium,Porcine/PF)
heparin-0.45% nacl 25,000 units/250 ml
(Heparin Sod,Pork In
(100 units/ml) bag latex-free, inner
0.45% NaCl)
25,000 unit/250 ml
heparin-d5w 25,000 units/250 ml (100
(Heparin
units/ml) bag excel container 25,000
Sodium,Porcine/D5W
unit/250 ml(100 unit/ml)
)
IPRIVASK SUBCUTANEOUS
RECON SOLN 15 MG
jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 (Coumadin)
mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
PRADAXA ORAL CAPSULE 110 MG,
150 MG, 75 MG
warfarin oral tablet 1 mg, 10 mg, 2 mg,
(Coumadin)
2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
XARELTO ORAL TABLET 10 MG, 15
MG, 20 MG
XARELTO ORAL TABLETS,DOSE
PACK 15 MG (42)- 20 MG (9)
Blood Formation Modifiers
CINRYZE INTRAVENOUS RECON
SOLN 500 UNIT (5 ML)
EPOGEN 10,000 UNITS/ML VIAL
SDV, P/F, OUTER 10,000 UNIT/ML
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
PA; QL (24 per 28
days)
$0 (Tier 1)
$0 (Tier 2)
ST; QL (60 per 30
days)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA
$0 (Tier 2)
PA; QL (12 per 28
days)
this document
77
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
EPOGEN INJECTION SOLUTION
2,000 UNIT/ML, 20,000 UNIT/2 ML,
20,000 UNIT/ML, 3,000 UNIT/ML,
4,000 UNIT/ML
GRANIX SUBCUTANEOUS
SYRINGE 300 MCG/0.5 ML, 480
MCG/0.8 ML
LEUKINE INJECTION RECON
SOLN 250 MCG
MIRCERA INJECTION SYRINGE
100 MCG/0.3 ML, 200 MCG/0.3 ML, 50
MOZOBIL SUBCUTANEOUS
SOLUTION 24 MG/1.2 ML (20
MG/ML)
NEULASTA SUBCUTANEOUS
SYRINGE 6 MG/0.6ML
NEULASTA SUBCUTANEOUS
SYRINGE, W/ WEARABLE
INJECTOR 6 MG/0.6 ML
NEUMEGA SUBCUTANEOUS
RECON SOLN 5 MG
NEUPOGEN INJECTION SOLUTION
300 MCG/ML, 480 MCG/1.6 ML
NEUPOGEN INJECTION SYRINGE
300 MCG/0.5 ML, 480 MCG/0.8 ML
PROCRIT 10,000 UNITS/ML VIAL
4'S, MDV, OUTER 20,000 UNIT/2 ML
PROCRIT INJECTION SOLUTION
4,000 UNIT/ML
PROCRIT INJECTION SOLUTION
40,000 UNIT/ML
$0 (Tier 2)
PA; QL (12 per 28
days)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA; QL (0.6 per 28
days)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA; QL (12 per 28
days)
PA; QL (12 per 28
days)
this document
78
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
PROMACTA ORAL TABLET 12.5
MG, 25 MG, 50 MG, 75 MG
ZARXIO INJECTION SYRINGE 300
MCG/0.5 ML, 480 MCG/0.8 ML
Hematologic Agents, Miscellaneous
aminocaproic acid oral solution 250 mg/ml
(25 %)
aminocaproic acid oral tablet 1,000 mg,
500 mg
anagrelide oral capsule 0.5 mg, 1 mg
protamine intravenous solution 10 mg/ml
tranexamic acid intravenous solution
1,000 mg/10 ml (100 mg/ml)
tranexamic acid oral tablet 650 mg
Platelet-Aggregation Inhibitors
aspirin-dipyridamole oral capsule, er
multiphase 12 hr 25-200 mg
BRILINTA ORAL TABLET 60 MG, 90
MG
cilostazol oral tablet 100 mg, 50 mg
clopidogrel oral tablet 300 mg, 75 mg
dipyridamole oral tablet 25 mg, 50 mg, 75
mg
EFFIENT ORAL TABLET 10 MG, 5
MG
pentoxifylline oral tablet extended release
400 mg
$0 (Tier 2)
PA; QL (30 per 30
days)
$0 (Tier 2)
(Aminocaproic Acid)
$0 (Tier 1)
(Aminocaproic Acid)
$0 (Tier 1)
(Agrylin)
(Protamine Sulfate)
(Tranexamic Acid)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Lysteda)
$0 (Tier 1)
(Aggrenox)
$0 (Tier 1)
QL (30 per 30 days)
$0 (Tier 2)
(Pletal)
(Plavix)
(Persantine)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Pentoxifylline)
QL (30 per 30 days)
$0 (Tier 1)
Caloric Agents
Caloric Agents
AMINO ACIDS 15 % INTRAVENOUS
PARENTERAL SOLUTION 15 %
AMINOSYN 10 % INTRAVENOUS
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
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79
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
AMINOSYN 3.5 % INTRAVENOUS
PARENTERAL SOLUTION 3.5 %
AMINOSYN 7 % INTRAVENOUS
AMINOSYN 7 % WITH
ELECTROLYTES INTRAVENOUS
AMINOSYN 8.5 % INTRAVENOUS
AMINOSYN 8.5 %-ELECTROLYTES
INTRAVENOUS PARENTERAL
SOLUTION 8.5 %
AMINOSYN II 10 % INTRAVENOUS
AMINOSYN II 8.5 % INTRAVENOUS
AMINOSYN II 8.5
%-ELECTROLYTES INTRAVENOUS
AMINOSYN M 3.5 %
SOLUTION 3.5 %
AMINOSYN-HBC 7%
SOLUTION 7 %
AMINOSYN-PF 10 %
SOLUTION 10 %
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
this document
80
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
AMINOSYN-PF 7 %
(SULFITE-FREE) INTRAVENOUS
AMINOSYN-RF 5.2 %
SOLUTION 5.2 %
CLINIMIX 5%/D15W SULFITE
FREE INTRAVENOUS
CLINIMIX 5%/D25W
SULFITE-FREE INTRAVENOUS
CLINIMIX 2.75%/D5W SULFIT FREE
SOLUTION 2.75 %
CLINIMIX 4.25%/D10W SULF FREE
SOLUTION 4.25 %
CLINIMIX 4.25%/D5W SULFIT FREE
SOLUTION 4.25 %
CLINIMIX 4.25%-D20W SULF-FREE
SOLUTION 4.25 %
CLINIMIX 4.25%-D25W SULF-FREE
SOLUTION 4.25 %
CLINIMIX
5%-D20W(SULFITE-FREE)
SOLUTION 5 %
CLINIMIX E 2.75%/D10W SUL FREE
SOLUTION 2.75 %
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
this document
81
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
CLINIMIX E 2.75%/D5W SULF FREE
SOLUTION 2.75 %
SOLUTION 4.25 %
SOLUTION 4.25 %
CLINIMIX E 4.25%/D5W SULF FREE
SOLUTION 4.25 %
CLINIMIX E 5%/D15W SULFIT
FREE INTRAVENOUS
FREE INTRAVENOUS
FREE INTRAVENOUS
CLINISOL SF 15 % INTRAVENOUS
cvs glucose bits tablet chew 1 gram *
cvs glucose liquid shot concord grape 15
gram/59 ml *
cysteine (l-cysteine) intravenous solution
50 mg/ml
dex4 glucose 4 gm tablet chew grape
flavor 4 gram *
dex4 glucose bits tablet chew 1 gram *
dextrose 10 % in water (d10w)
intravenous parenteral solution 10 %
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
(Dextrose)
(Gluco Shot)
$0 (Tier 4)
$0 (Tier 4)
(Cysteine HCl)
$0 (Tier 1)
(Dextrose)
$0 (Tier 4)
(Dextrose)
(Dextrose 10 % in
Water)
$0 (Tier 4)
$0 (Tier 1)
PA BvD
PA BvD
this document
82
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
intravenous solution
intravenous syringe
dextrose 5 % in ringers intravenous
parenteral solution 5 %
dextrose 5 % in water (d5w) intravenous
parenteral solution
intravenous parenteral solution
intravenous syringe
FREAMINE HBC 6.9 %
SOLUTION 6.9 %
FREAMINE III 10 % INTRAVENOUS
gluco burst 40% gel 40 % *
glucose 4 gram tablet chew na/f, caffeine
free 4 gram *
glucose 40% gel tropical fruit 40 % *
glutose 15 gel 3 pak, outer, u-d 40 % *
HEPATAMINE 8% INTRAVENOUS
HEPATASOL 8 % INTRAVENOUS
INTRALIPID INTRAVENOUS
EMULSION 20 %, 30 %
(Dextrose 10 % in
Water)
(Dextrose 20 % in
Water)
(Dextrose 25 % in
Water)
(Dextrose 40 % in
Water)
(Dextrose 5 % In
Ringers)
(Dextrose 5 % in
Water)
(Dextrose 50 % in
Water)
(Dextrose 50 % in
Water)
(Dextrose 70 % in
Water)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
(Dextrose)
(Dextrose)
$0 (Tier 4)
$0 (Tier 4)
(Dextrose)
(Dextrose)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
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83
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
KABIVEN INTRAVENOUS
EMULSION 3.31-9.8-3.9 %
NEPHRAMINE 5.4 %
SOLUTION 5.4 %
NUTRILIPID INTRAVENOUS
EMULSION 20 %
PERIKABIVEN INTRAVENOUS
EMULSION 2.36-6.8-3.5 %
PREMASOL 10 % INTRAVENOUS
PREMASOL 6 % INTRAVENOUS
PROCALAMINE 3% INTRAVENOUS
PROSOL 20 % INTRAVENOUS
PARENTERAL SOLUTION
smoflipid intravenous emulsion 20 %
(Fat
Emul/Soy/Mct/Oliv/F
ish Oil)
TRAVASOL 10 % INTRAVENOUS
TROPHAMINE 10 % INTRAVENOUS
TROPHAMINE 6% INTRAVENOUS
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl oral tablet 0.1 mg, 0.2 mg,
0.3 mg
clonidine transdermal patch weekly 0.1
mg/24 hr, 0.2 mg/24 hr
clonidine transdermal patch weekly 0.3
mg/24 hr
(Catapres)
$0 (Tier 1)
(Catapres-Tts 1)
$0 (Tier 1)
QL (4 per 28 days)
(Catapres-Tts 1)
$0 (Tier 1)
QL (8 per 28 days)
this document
84
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
clorpres oral tablet 0.1-15 mg, 0.2-15 mg,
0.3-15 mg
doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8
mg
guanfacine oral tablet 1 mg, 2 mg
(Clonidine
HCl/Chlorthalidone)
(Cardura)
$0 (Tier 1)
(Tenex)
$0 (Tier 1)
midodrine oral tablet 10 mg, 2.5 mg, 5 mg
NORTHERA ORAL CAPSULE 100
MG, 200 MG, 300 MG
phenylephrine hcl injection solution 10
mg/ml
prazosin oral capsule 1 mg, 2 mg, 5 mg
Angiotensin Ii Receptor
Antagonists
BENICAR HCT ORAL TABLET
20-12.5 MG, 40-12.5 MG, 40-25 MG
BENICAR ORAL TABLET 20 MG, 40
MG, 5 MG
candesartan oral tablet 16 mg, 32 mg, 4
mg, 8 mg
candesartan-hydrochlorothiazid oral tablet
16-12.5 mg, 32-12.5 mg, 32-25 mg
ENTRESTO ORAL TABLET 24-26
MG, 49-51 MG, 97-103 MG
irbesartan oral tablet 150 mg, 300 mg, 75
mg
irbesartan-hydrochlorothiazide oral tablet
150-12.5 mg, 300-12.5 mg
losartan oral tablet 100 mg, 25 mg, 50 mg
losartan-hydrochlorothiazide oral tablet
100-12.5 mg, 100-25 mg, 50-12.5 mg
telmisartan oral tablet 20 mg, 40 mg, 80
mg
(Midodrine HCl)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
(Vazculep)
$0 (Tier 1)
(Minipress)
$0 (Tier 1)
PA-HRM; AGE (Max
64 Years)
PA; QL (180 per 30
days)
$0 (Tier 2)
$0 (Tier 2)
(Atacand)
$0 (Tier 1)
(Atacand HCT)
$0 (Tier 1)
$0 (Tier 2)
(Avapro)
$0 (Tier 1)
(Avalide)
$0 (Tier 1)
(Cozaar)
(Hyzaar)
$0 (Tier 1)
$0 (Tier 1)
(Micardis)
$0 (Tier 1)
PA; QL (60 per 30
days)
this document
85
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
telmisartan-hydrochlorothiazid oral tablet
40-12.5 mg, 80-12.5 mg, 80-25 mg
TRIBENZOR ORAL TABLET
20-5-12.5 MG, 40-10-12.5 MG, 40-10-25
MG, 40-5-12.5 MG, 40-5-25 MG
valsartan oral tablet 160 mg, 320 mg, 40
mg, 80 mg
valsartan-hydrochlorothiazide oral tablet
160-12.5 mg, 160-25 mg, 320-12.5 mg,
320-25 mg, 80-12.5 mg
Angiotensin-Converting Enzyme
Inhibitors
benazepril oral tablet 10 mg, 20 mg, 40
mg, 5 mg
benazepril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25
mg
captopril oral tablet 100 mg, 12.5 mg, 25
mg, 50 mg
captopril-hydrochlorothiazide oral tablet
25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg
enalapril maleate oral tablet 10 mg, 2.5
mg, 20 mg, 5 mg
enalaprilat intravenous solution 1.25
mg/ml
enalapril-hydrochlorothiazide oral tablet
10-25 mg, 5-12.5 mg
fosinopril oral tablet 10 mg, 20 mg, 40 mg
fosinopril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg,
30 mg, 40 mg, 5 mg
lisinopril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg, 20-25 mg
(Micardis HCT)
$0 (Tier 1)
$0 (Tier 2)
(Diovan)
$0 (Tier 1)
(Diovan HCT)
$0 (Tier 1)
(Lotensin)
$0 (Tier 1)
(Lotensin HCT)
$0 (Tier 1)
(Captopril)
$0 (Tier 1)
(Captopril/Hydrochlo
rothiazide)
(Vasotec)
$0 (Tier 1)
(Enalaprilat
Dihydrate)
(Vaseretic)
$0 (Tier 1)
(Fosinopril Sodium)
(Fosinopril/Hydrochl
orothiazide)
(Zestril)
$0 (Tier 1)
$0 (Tier 1)
(Zestoretic)
$0 (Tier 1)
ST
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
this document
86
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
moexipril oral tablet 15 mg, 7.5 mg
moexipril-hydrochlorothiazide oral tablet
15-12.5 mg, 15-25 mg, 7.5-12.5 mg
perindopril erbumine oral tablet 2 mg, 4
mg, 8 mg
quinapril oral tablet 10 mg, 20 mg, 40 mg,
5 mg
quinapril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg, 20-25 mg
ramipril oral capsule 1.25 mg, 10 mg, 2.5
mg, 5 mg
trandolapril oral tablet 1 mg, 2 mg, 4 mg
Antiarrhythmic Agents
amiodarone oral tablet 100 mg, 200 mg,
400 mg
disopyramide phosphate oral capsule 100
mg, 150 mg
dofetilide oral capsule 125 mcg, 250 mcg,
500 mcg
flecainide oral tablet 100 mg, 150 mg, 50
mg
lidocaine (pf) intravenous syringe 50 mg/5
ml (1 %)
lidocaine in 5 % dextrose (pf) intravenous
parenteral solution 8 mg/ml (0.8 %)
mexiletine oral capsule 150 mg, 200 mg,
250 mg
MULTAQ ORAL TABLET 400 MG
pacerone oral tablet 100 mg, 200 mg, 400
mg
procainamide injection solution 100
mg/ml, 500 mg/ml
propafenone oral capsule,extended release
12 hr 225 mg, 325 mg, 425 mg
(Moexipril HCl)
(Moexipril/Hydrochl
orothiazide)
(Aceon)
$0 (Tier 1)
$0 (Tier 1)
(Accupril)
$0 (Tier 1)
(Accuretic)
$0 (Tier 1)
(Altace)
$0 (Tier 1)
(Mavik)
$0 (Tier 1)
(Cordarone)
$0 (Tier 1)
(Norpace)
$0 (Tier 1)
(Tikosyn)
$0 (Tier 1)
(Tambocor)
$0 (Tier 1)
(Lidocaine HCl/PF)
$0 (Tier 1)
(Lidocaine
HCl/D5w/PF)
(Mexiletine HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Cordarone)
$0 (Tier 2)
$0 (Tier 1)
(Procainamide HCl)
$0 (Tier 1)
(Rythmol SR)
$0 (Tier 1)
this document
87
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
propafenone oral tablet 150 mg, 225 mg,
300 mg
quinidine gluconate oral tablet extended
release 324 mg
quinidine sulfate oral tablet 200 mg, 300
mg
quinidine sulfate oral tablet extended
release 300 mg
Beta-Adrenergic Blocking Agents
acebutolol oral capsule 200 mg, 400 mg
atenolol oral tablet 100 mg, 25 mg, 50 mg
atenolol-chlorthalidone oral tablet 100-25
mg, 50-25 mg
betaxolol oral tablet 10 mg, 20 mg
bisoprolol fumarate oral tablet 10 mg, 5
mg
bisoprolol-hydrochlorothiazide oral tablet
10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg
BYSTOLIC ORAL TABLET 10 MG,
2.5 MG, 20 MG, 5 MG
carvedilol oral tablet 12.5 mg, 25 mg,
3.125 mg, 6.25 mg
esmolol intravenous solution 100 mg/10 ml
(10 mg/ml)
labetalol intravenous solution 5 mg/ml
labetalol oral tablet 100 mg, 200 mg, 300
mg
metoprolol succinate oral tablet extended
release 24 hr 100 mg, 200 mg, 25 mg, 50
mg
metoprolol ta-hydrochlorothiaz oral tablet
100-25 mg, 100-50 mg, 50-25 mg
metoprolol tartrate intravenous solution 5
mg/5 ml
(Rythmol)
$0 (Tier 1)
(Quinidine
Gluconate)
(Quinidine Sulfate)
$0 (Tier 1)
(Quinidine Sulfate)
$0 (Tier 1)
(Sectral)
(Tenormin)
(Tenoretic 50)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Betaxolol HCl)
(Zebeta)
$0 (Tier 1)
$0 (Tier 1)
(Ziac)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Coreg)
$0 (Tier 1)
(Brevibloc)
$0 (Tier 1)
(Labetalol HCl)
(Trandate)
$0 (Tier 1)
$0 (Tier 1)
(Toprol XL)
$0 (Tier 1)
(Lopressor HCT)
$0 (Tier 1)
(Metoprolol Tartrate)
$0 (Tier 1)
PA BvD
this document
88
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
metoprolol tartrate intravenous syringe 5
mg/5 ml
metoprolol tartrate oral tablet 100 mg, 25
mg, 37.5 mg, 50 mg, 75 mg
nadolol oral tablet 20 mg, 40 mg, 80 mg
pindolol oral tablet 10 mg, 5 mg
propranolol intravenous solution 1 mg/ml
propranolol oral capsule,extended release
24 hr 120 mg, 160 mg, 60 mg, 80 mg
propranolol oral solution 20 mg/5 ml (4
mg/ml), 40 mg/5 ml (8 mg/ml)
propranolol oral tablet 10 mg, 20 mg, 40
mg, 60 mg, 80 mg
propranolol-hydrochlorothiazid oral tablet
40-25 mg, 80-25 mg
sorine oral tablet 120 mg, 160 mg, 240 mg,
80 mg
sotalol 120 mg tablet 120 mg
sotalol af oral tablet 120 mg
sotalol oral tablet 160 mg, 240 mg, 80 mg
timolol maleate oral tablet 10 mg, 20 mg,
5 mg
Calcium-Channel Blocking Agents
cartia xt oral capsule,extended release
24hr 120 mg, 180 mg, 240 mg, 300 mg
diltiazem 24hr er 180 mg cap 180 mg
diltiazem 24hr er 360 mg cap 360 mg
diltiazem hcl intravenous recon soln 100
mg
diltiazem hcl intravenous solution 5 mg/ml
diltiazem hcl oral capsule, extended
release 180 mg, 360 mg, 420 mg
diltiazem hcl oral capsule,extended release
12 hr 120 mg, 60 mg, 90 mg
(Metoprolol Tartrate)
$0 (Tier 1)
(Lopressor)
$0 (Tier 1)
(Corgard)
(Pindolol)
(Propranolol HCl)
(Inderal LA)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Propranolol HCl)
$0 (Tier 1)
(Propranolol HCl)
$0 (Tier 1)
(Propranolol/Hydroc
hlorothiazid)
(Betapace)
$0 (Tier 1)
(Betapace)
(Betapace)
(Betapace)
(Timolol Maleate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Cardizem CD)
$0 (Tier 1)
(Cardizem CD)
(Cardizem CD)
(Cardizem CD)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Cardizem CD)
(Cardizem CD)
$0 (Tier 1)
$0 (Tier 1)
(Cardizem CD)
$0 (Tier 1)
$0 (Tier 1)
this document
89
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
diltiazem hcl oral capsule,extended release
24hr 120 mg, 240 mg, 300 mg
diltiazem hcl oral tablet 120 mg, 30 mg, 60
mg, 90 mg
diltiazem hcl oral tablet extended release
24 hr 180 mg, 240 mg, 300 mg, 360 mg,
420 mg
dilt-xr oral capsule,ext release degradable
120 mg, 180 mg, 240 mg
matzim la oral tablet extended release 24
hr 180 mg, 240 mg, 300 mg, 360 mg, 420
mg
taztia xt oral capsule, extended release
120 mg, 180 mg, 240 mg, 300 mg, 360 mg
verapamil intravenous syringe 2.5 mg/ml
verapamil oral capsule, 24 hr er pellet ct
100 mg, 200 mg, 300 mg
verapamil oral capsule,ext rel. pellets 24
hr 120 mg, 180 mg, 240 mg, 360 mg
verapamil oral tablet 120 mg, 40 mg, 80
mg
verapamil oral tablet extended release 120
mg, 180 mg, 240 mg
Cardiovascular Agents,
Miscellaneous
CORLANOR ORAL TABLET 5 MG,
7.5 MG
DEMSER ORAL CAPSULE 250 MG
digitek oral tablet 125 mcg
(Cardizem CD)
$0 (Tier 1)
(Cardizem CD)
$0 (Tier 1)
(Cardizem LA)
$0 (Tier 1)
(Cardizem CD)
$0 (Tier 1)
(Cardizem CD)
$0 (Tier 1)
(Cardizem CD)
$0 (Tier 1)
(Verapamil HCl)
(Verelan Pm)
$0 (Tier 1)
$0 (Tier 1)
(Verelan)
$0 (Tier 1)
(Calan)
$0 (Tier 1)
(Calan SR)
$0 (Tier 1)
$0 (Tier 2)
(Lanoxin)
$0 (Tier 2)
$0 (Tier 1)
ST
(High Risk Med for
Ages 65 and Older and
Dose is Greater Than
125mcg Per Day); QL
(30 per 30 days)
this document
90
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
digitek oral tablet 250 mcg
(Lanoxin)
$0 (Tier 1)
digox 125 mcg tablet 125 mcg
(Lanoxin)
$0 (Tier 1)
digox 250 mcg tablet 250 mcg
(Lanoxin)
$0 (Tier 1)
digoxin 0.25 mg/ml syringe 250 mcg/ml
(Digoxin)
$0 (Tier 1)
digoxin injection solution 250 mcg/ml
(Digoxin)
$0 (Tier 1)
DIGOXIN ORAL SOLUTION 50
MCG/ML
digoxin oral tablet 125 mcg
$0 (Tier 2)
(Lanoxin)
$0 (Tier 1)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per
30 days); AGE (Max
64 Years)
(High Risk Med for
125mcg Per Day); QL
(30 per 30 days)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
30 days); AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; QL (300 per
30 days); AGE (Max
64 Years)
(High Risk Med for
125mcg Per Day); QL
(30 per 30 days)
this document
91
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
digoxin oral tablet 250 mcg
(Lanoxin)
$0 (Tier 1)
dobutamine in d5w intravenous parenteral
solution 1,000 mg/250 ml (4,000 mcg/ml),
250 mg/250 ml (1 mg/ml), 500 mg/250 ml
(2,000 mcg/ml)
dobutamine intravenous solution 250
mg/20 ml (12.5 mg/ml)
dopamine in 5 % dextrose intravenous
solution 200 mg/250 ml (800 mcg/ml), 400
mg/250 ml (1,600 mcg/ml), 800 mg/250
ml (3,200 mcg/ml)
dopamine intravenous solution 200 mg/5
ml (40 mg/ml), 400 mg/5 ml (80 mg/ml),
800 mg/10 ml (80 mg/ml), 800 mg/5 ml
(160 mg/ml)
ephedrine sulfate injection solution 50
mg/ml
epinephrine hcl (pf) intravenous solution 1
mg/ml (1 ml)
epinephrine injection auto-injector 0.15
mg/0.15 ml, 0.3 mg/0.3 ml
epinephrine injection solution 1 mg/ml (1
ml)
epinephrine injection syringe 0.1 mg/ml
EPIPEN 2-PAK INJECTION
AUTO-INJECTOR 0.3 MG/0.3 ML
EPIPEN JR 2-PAK INJECTION
AUTO-INJECTOR 0.15 MG/0.3 ML
(Dobutamine
HCl/D5W)
$0 (Tier 1)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
30 days); AGE (Max
64 Years)
PA BvD
(Dobutamine HCl)
$0 (Tier 1)
PA BvD
(Dopamine
HCl/D5W)
$0 (Tier 1)
PA BvD
(Dopamine HCl)
$0 (Tier 1)
PA BvD
(Ephedrine Sulfate)
$0 (Tier 1)
(Epinephrine
HCl/PF)
(Adrenaclick)
$0 (Tier 1)
(Epinephrine)
$0 (Tier 1)
(Epinephrine)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
this document
92
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ethamolin intravenous solution 5 %
FIRAZYR SUBCUTANEOUS
SYRINGE 30 MG/3 ML
hydralazine injection solution 20 mg/ml
hydralazine oral tablet 10 mg, 100 mg, 25
mg, 50 mg
LANOXIN ORAL TABLET 187.5
MCG
(Ethanolamine
Oleate)
$0 (Tier 2)
(Hydralazine HCl)
(Hydralazine HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Milrinone
Lactate/D5W)
$0 (Tier 1)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
30 days); AGE (Max
64 Years)
(High Risk Med for
125mcg Per Day); QL
(30 per 30 days)
PA BvD
(Milrinone Lactate)
(Levophed Bitartrate)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
PA BvD
(Papaverine HCl)
(Papaverine HCl)
$0 (Tier 1)
$0 (Tier 1)
PA
PA
LANOXIN ORAL TABLET 62.5 MCG
milrinone in 5 % dextrose intravenous
piggyback 20 mg/100 ml (200 mcg/ml), 40
mg/200 ml (200 mcg/ml)
milrinone intravenous solution 1 mg/ml
norepinephrine bitartrate intravenous
solution 1 mg/ml
papaverine injection solution 30 mg/ml
papaverine oral capsule, extended release
150 mg
RANEXA ORAL TABLET
EXTENDED RELEASE 12 HR 1,000
MG, 500 MG
Dihydropyridines
afeditab cr oral tablet extended release 30
mg, 60 mg
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
(Adalat CC)
$0 (Tier 1)
this document
93
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
amlodipine oral tablet 10 mg, 2.5 mg, 5
mg
amlodipine-benazepril oral capsule 10-20
mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20
mg, 5-40 mg
amlodipine-valsartan oral tablet 10-160
mg, 10-320 mg, 5-160 mg, 5-320 mg
amlodipine-valsartan-hcthiazid oral tablet
10-160-12.5 mg, 10-160-25 mg, 10-320-25
mg, 5-160-12.5 mg, 5-160-25 mg
AZOR ORAL TABLET 10-20 MG,
10-40 MG, 5-20 MG, 5-40 MG
CLEVIPREX INTRAVENOUS
EMULSION 50 MG/100 ML
felodipine oral tablet extended release 24
hr 10 mg, 2.5 mg, 5 mg
isradipine oral capsule 2.5 mg, 5 mg
nicardipine oral capsule 20 mg, 30 mg
nifedical xl oral tablet extended release
24hr 30 mg, 60 mg
nifedipine er 30 mg tablet f/c 30 mg
nifedipine oral tablet extended release
24hr 30 mg
nifedipine oral tablet extended release
24hr 60 mg, 90 mg
Diuretics
amiloride oral tablet 5 mg
amiloride-hydrochlorothiazide oral tablet
5-50 mg
bumetanide injection solution 0.25 mg/ml
bumetanide oral tablet 0.5 mg, 1 mg, 2 mg
chlorothiazide oral tablet 250 mg, 500 mg
chlorothiazide sodium intravenous recon
soln 500 mg
(Norvasc)
$0 (Tier 1)
(Lotrel)
$0 (Tier 1)
(Exforge)
$0 (Tier 1)
(Exforge HCT)
$0 (Tier 1)
$0 (Tier 2)
ST
$0 (Tier 2)
(Felodipine)
$0 (Tier 1)
(Isradipine)
(Nicardipine HCl)
(Procardia XL)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Adalat CC)
(Adalat CC)
$0 (Tier 1)
$0 (Tier 1)
(Procardia XL)
$0 (Tier 1)
(Amiloride HCl)
(Amiloride/Hydrochl
orothiazide)
(Bumetanide)
(Bumetanide)
(Chlorothiazide)
(Sodium Diuril)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
this document
94
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
chlorthalidone oral tablet 25 mg, 50 mg
DYRENIUM ORAL CAPSULE 100
MG, 50 MG
furosemide injection solution 10 mg/ml
furosemide injection syringe 10 mg/ml
furosemide oral solution 10 mg/ml, 40
mg/5 ml (8 mg/ml)
furosemide oral tablet 20 mg, 40 mg, 80
mg
hydrochlorothiazide oral capsule 12.5 mg
hydrochlorothiazide oral tablet 12.5 mg,
25 mg, 50 mg
indapamide oral tablet 1.25 mg, 2.5 mg
methyclothiazide oral tablet 5 mg
metolazone oral tablet 10 mg, 2.5 mg, 5
mg
torsemide oral tablet 10 mg, 100 mg, 20
mg, 5 mg
triamterene-hydrochlorothiazid oral
capsule 37.5-25 mg, 50-25 mg
triamterene-hydrochlorothiazid oral tablet
37.5-25 mg, 75-50 mg
Dyslipidemics
amlodipine-atorvastatin oral tablet 10-10
mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10
mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20
mg, 5-40 mg, 5-80 mg
atorvastatin oral tablet 10 mg, 20 mg, 40
mg, 80 mg
cholestyramine light oral powder 4 gram
(Chlorthalidone)
$0 (Tier 1)
$0 (Tier 2)
(Furosemide)
(Furosemide)
(Furosemide)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Lasix)
$0 (Tier 1)
(Microzide)
(Hydrochlorothiazide
)
(Indapamide)
(Methyclothiazide)
(Zaroxolyn)
$0 (Tier 1)
$0 (Tier 1)
(Demadex)
$0 (Tier 1)
(Dyazide)
$0 (Tier 1)
(Maxzide)
$0 (Tier 1)
(Caduet)
$0 (Tier 1)
(Lipitor)
$0 (Tier 1)
(Cholestyramine/Asp
artame)
cholestyramine light oral powder in packet (Questran)
4 gram
cholestyramine packet 4 gram
(Questran)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
this document
95
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
colestipol hcl granules packet 5 gram
colestipol oral granules 5 gram
colestipol oral tablet 1 gram
cvs fish oil 1,200 mg softgel softgel,
natural 360-1,200 mg *
cvs niacin flush free 500 mg 400 mg niacin
(500 mg) *
cvs omega-3 gummy fish child, brain
booster 100 mg *
endur-acin sr 250 mg tablet 250 mg *
endur-acin sr 500 mg tablet 500 mg *
eql omega 3 fish oil softgel 684-1,200 mg *
fenofibrate micronized oral capsule 130
mg, 134 mg, 200 mg, 43 mg, 67 mg
fenofibrate nanocrystallized oral tablet
145 mg, 48 mg
fenofibrate oral tablet 120 mg, 160 mg, 40
mg, 54 mg
fenofibric acid (choline) oral
capsule,delayed release(dr/ec) 135 mg, 45
mg
fenofibric acid oral tablet 105 mg, 35 mg
fish oil 1,000 mg capsule 340-1,000 mg *
(Colestid)
(Colestid)
(Colestid)
(Omega-3 Fatty
Acids/Fish Oil)
(Niacin (Inositol
Niacinate))
(Omega-3 Fatty
Acids)
(Slo-Niacin)
(Slo-Niacin)
(Omega-3 Fatty
Acids/Fish Oil)
(Lofibra)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
(Tricor)
$0 (Tier 1)
(Lofibra)
$0 (Tier 1)
(Trilipix)
$0 (Tier 1)
(Fibricor)
(Omega-3 Fatty
Acids/Fish Oil)
fish oil 1,000 mg softgel 500 mg *
(Omega-3 Fatty
Acids)
fish oil 1,000 mg softgel s/f,na/f, yeast free (Omega-3 Fatty
300-1,000 mg *
Acids/Fish Oil)
fish oil 1,000 mg softgel softgel, s/f, na/f
(Omega-3 Fatty
340-1,000 mg *
Acids/Fish Oil)
fish oil 1,000 mg softgel softgel, s/f, p/f
(Omega-3 Fatty
300-1,000 mg *
Acids/Fish Oil)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
this document
96
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
(Omega-3 Fatty
Acids/Fish Oil)
(Salmon Oil/Omega-3
Fatty Acids)
fish oil concentrate softgel softgel,
(Omega-3 Fatty
ex-strengh 435-880 mg *
Acids/Fish Oil)
fish oil dr 1,000 mg softgel 300-1,000 mg * (Omega-3 Fatty
Acids/Fish Oil)
fish oil dr 500 mg softgel 60-90-500 mg * (Omega-3 Fatty
Acids)
fish oil pearls softgel 150-400 mg, 180-400 (Omega-3 Fatty
mg, 300-400 mg *
Acids/Fish Oil)
gemfibrozil oral tablet 600 mg
(Lopid)
JUXTAPID ORAL CAPSULE 10 MG,
20 MG, 30 MG, 40 MG, 5 MG, 60 MG
KYNAMRO SUBCUTANEOUS
SYRINGE 200 MG/ML
LIVALO ORAL TABLET 1 MG, 2
MG, 4 MG
lovastatin oral tablet 10 mg, 20 mg, 40 mg (Mevacor)
maxepa capsule 500 mg *
(Omega-3 Fatty
Acids)
niacin 100 mg tablet 100 mg *
(Slo-Niacin)
niacin 125 mg capsule sa (otc) 125 mg *
(Niacin)
(Slo-Niacin)
niacin 250 mg tablet sa p/f,s/f 250 mg *
(Slo-Niacin)
niacin 400 mg capsule sa 400 mg *
(Niacin)
(Slo-Niacin)
niacin 500 mg capsule sa 500 mg *
(Niacin)
(Slo-Niacin)
niacin 750 mg tablet sa 750 mg *
(Slo-Niacin)
niacin er 1,000 mg tablet 1,000 mg *
(Slo-Niacin)
fish oil 1,200 mg softgel s/f, gluten-free
360-1,200 mg *
fish oil 500 mg softgel 500-100 mg *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 2)
PA
$0 (Tier 2)
$0 (Tier 2)
QL (30 per 30 days)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
this document
97
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
niacin flush-free 500 mg cap s/f,p/f,na/f
400 mg niacin (500 mg) *
niacin inositol 500 mg capsule 400 mg
niacin (500 mg) *
niacin oral tablet extended release 24 hr
1,000 mg, 500 mg, 750 mg
niacin sa 250 mg capsule (otc) 250 mg *
niacin tr 500 mg caplet caplet 500 mg *
niacinamide 500 mg tablet 500 mg *
niacor oral tablet 500 mg
omega 3 fish oil softgel 684-1,200 mg *
omega-3 acid ethyl esters oral capsule 1
gram
omega-3 fish oil 1,760 mg stgl 440-880 mg
*
PRALUENT PEN SUBCUTANEOUS
PEN INJECTOR 150 MG/ML, 75
MG/ML
PRALUENT SYRINGE
SUBCUTANEOUS SYRINGE 150
MG/ML, 75 MG/ML
pravastatin oral tablet 10 mg, 20 mg, 40
mg, 80 mg
prevalite oral powder 4 gram
prevalite packet outer 4 gram
ra fish oil 1,000 mg softgel softgel,s/f,p/f
300-500 mg *
ra niacin 500 mg tablet no flush 500 mg *
(Niacin (Inositol
Niacinate))
(Niacin (Inositol
Niacinate))
(Niaspan)
$0 (Tier 4)
(Niacin)
(Slo-Niacin)
(Niacinamide)
(Niacin)
(Omega-3 Fatty
Acids/Fish Oil)
(Lovaza)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
(Omega-3 Fatty
Acids/Fish Oil)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
(Pravachol)
$0 (Tier 1)
(Cholestyramine/Asp
artame)
(Cholestyramine/Asp
artame)
(Omega-3 Fatty
Acids/Fish Oil)
(Niacin (Inositol
Niacinate))
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
this document
98
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
REPATHA PUSHTRONEX
SUBCUTANEOUS WEARABLE
INJECTOR 420 MG/3.5 ML
REPATHA SURECLICK
140 MG/ML
REPATHA SYRINGE
MG/ML
rosuvastatin oral tablet 10 mg, 20 mg, 40
mg, 5 mg
sea-omega 30 capsule p/f,s/f,gluten free
360-1,200 mg *
simvastatin oral tablet 10 mg, 20 mg, 40
mg, 5 mg
simvastatin oral tablet 80 mg
sm fish oil 1,200 mg softgel softgel,
gluten-free 360-1,200 mg *
SUPER TWIN EPA-DHA 1,250 MG
1,250 MG *
VASCEPA ORAL CAPSULE 1 GRAM
WELCHOL ORAL POWDER IN
PACKET 3.75 GRAM
WELCHOL ORAL TABLET 625 MG
ZETIA ORAL TABLET 10 MG
Renin-Angiotensin-Aldosterone
System Inhibitors
eplerenone oral tablet 25 mg, 50 mg
spironolactone oral tablet 100 mg, 25 mg,
50 mg
spironolacton-hydrochlorothiaz oral tablet
25-25 mg
Vasodilators
BIDIL ORAL TABLET 20-37.5 MG
$0 (Tier 2)
PA; QL (3.5 per 28
days)
$0 (Tier 2)
$0 (Tier 2)
(Crestor)
$0 (Tier 1)
(Omega-3 Fatty
Acids/Fish Oil)
(Zocor)
$0 (Tier 4)
(Zocor)
(Omega-3 Fatty
Acids/Fish Oil)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
QL (30 per 30 days)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Inspra)
(Aldactone)
$0 (Tier 1)
$0 (Tier 1)
(Aldactazide)
$0 (Tier 1)
$0 (Tier 2)
this document
99
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
isosorbide dinitrate oral tablet 10 mg, 20
mg, 30 mg, 5 mg
isosorbide dinitrate oral tablet extended
release 40 mg
isosorbide dinitrate sublingual tablet 2.5
mg, 5 mg
isosorbide mononitrate oral tablet 10 mg,
20 mg
isosorbide mononitrate oral tablet
extended release 24 hr 120 mg, 30 mg, 60
mg
minitran transdermal patch 24 hour 0.1
mg/hr, 0.2 mg/hr, 0.6 mg/hr
minitran transdermal patch 24 hour 0.4
mg/hr
minoxidil oral tablet 10 mg, 2.5 mg
NITRO-BID TRANSDERMAL
OINTMENT 2 %
nitroglycerin in 5 % dextrose intravenous
solution 100 mg/250 ml (400 mcg/ml), 25
mg/250 ml (100 mcg/ml), 50 mg/250 ml
(200 mcg/ml)
nitroglycerin intravenous solution 50
mg/10 ml (5 mg/ml)
nitroglycerin transdermal patch 24 hour
0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr
nitroglycerin transdermal patch 24 hour
0.4 mg/hr
NITROSTAT SUBLINGUAL
TABLET 0.3 MG, 0.4 MG, 0.6 MG
PROGLYCEM ORAL SUSPENSION
50 MG/ML
(Isochron)
$0 (Tier 1)
(Isochron)
$0 (Tier 1)
(Isosorbide Dinitrate)
$0 (Tier 1)
(Isosorbide
Mononitrate)
(Imdur)
$0 (Tier 1)
(Nitro-Dur)
$0 (Tier 1)
QL (30 per 30 days)
(Nitro-Dur)
$0 (Tier 1)
QL (60 per 30 days)
(Minoxidil)
$0 (Tier 1)
$0 (Tier 1)
(Nitroglycerin/D5W)
$0 (Tier 1)
(Nitroglycerin)
$0 (Tier 1)
(Nitro-Dur)
$0 (Tier 1)
QL (30 per 30 days)
(Nitro-Dur)
$0 (Tier 1)
QL (60 per 30 days)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
this document
100
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
Central Nervous System Agents
Central Nervous System Agents
AMPYRA ORAL TABLET
EXTENDED RELEASE 12 HR 10 MG
caffeine citrated intravenous solution 60
mg/3 ml (20 mg/ml)
caffeine citrated oral solution 60 mg/3 ml
(20 mg/ml)
caffeine-sodium benzoate injection
solution 250 mg/ml (125 mg/ml caffeine)
clonidine hcl oral tablet extended release
12 hr 0.1 mg
dexmethylphenidate oral tablet 10 mg, 2.5
mg, 5 mg
dextroamphetamine oral capsule, extended
release 10 mg, 15 mg, 5 mg
dextroamphetamine oral tablet 10 mg, 5
mg
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 10 mg, 15
mg, 5 mg
capsule,extended release 24hr 20 mg, 25
mg, 30 mg
tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30
mg, 5 mg, 7.5 mg
flumazenil intravenous solution 0.1 mg/ml
guanfacine oral tablet extended release 24
hr 1 mg, 2 mg, 3 mg, 4 mg
lithium carbonate oral capsule 150 mg,
300 mg, 600 mg
lithium carbonate oral tablet 300 mg
$0 (Tier 2)
PA; QL (60 per 30
days)
(Cafcit)
$0 (Tier 1)
(Cafcit)
$0 (Tier 1)
(Caffeine/Sodium
Benzoate)
(Kapvay)
$0 (Tier 1)
(Focalin)
$0 (Tier 1)
QL (60 per 30 days)
(Dexedrine)
$0 (Tier 1)
(Dexedrine)
$0 (Tier 1)
(Adderall XR)
$0 (Tier 1)
QL (30 per 30 days)
(Adderall XR)
$0 (Tier 1)
QL (60 per 30 days)
(Adderall)
$0 (Tier 1)
QL (60 per 30 days)
(Romazicon)
(Intuniv)
$0 (Tier 1)
$0 (Tier 1)
(Lithium Carbonate)
$0 (Tier 1)
(Lithobid)
$0 (Tier 1)
$0 (Tier 1)
this document
101
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
lithium carbonate oral tablet extended
release 300 mg, 450 mg
lithium citrate oral solution 8 meq/5 ml
methylphenidate cd 20 mg cap 20 mg
methylphenidate cd 40 mg cap 40 mg
methylphenidate oral capsule, er biphasic
30-70 10 mg, 50 mg, 60 mg
methylphenidate oral capsule, er biphasic
30-70 30 mg
methylphenidate oral capsule,er biphasic
50-50 20 mg, 40 mg
methylphenidate oral solution 10 mg/5 ml,
5 mg/5 ml
methylphenidate oral tablet 10 mg, 20 mg,
5 mg
methylphenidate oral tablet extended
release 10 mg, 20 mg
release 24hr 18 mg, 27 mg, 54 mg
release 24hr 36 mg
NUEDEXTA ORAL CAPSULE 20-10
MG
phentermine 15 mg capsule 15 mg *
(Lithobid)
$0 (Tier 1)
(Lithium Citrate)
(Metadate Cd)
(Metadate Cd)
(Metadate Cd)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
(Metadate Cd)
$0 (Tier 1)
QL (60 per 30 days)
(Metadate Cd)
$0 (Tier 1)
QL (30 per 30 days)
(Methylin)
$0 (Tier 1)
(Ritalin)
$0 (Tier 1)
QL (90 per 30 days)
(Methylphenidate
HCl)
(Concerta)
$0 (Tier 1)
QL (90 per 30 days)
$0 (Tier 1)
QL (30 per 30 days)
(Concerta)
$0 (Tier 1)
QL (60 per 30 days)
$0 (Tier 2)
QL (60 per 30 days)
(Adipex-P)
$0 (Tier 3)
phentermine 30 mg capsule pelletized 30
mg *
phentermine 37.5 mg capsule 37.5 mg *
(Adipex-P)
$0 (Tier 3)
(Adipex-P)
$0 (Tier 3)
phentermine 37.5 mg tablet 37.5 mg *
(Adipex-P)
$0 (Tier 3)
PA; QL (30 per 30
days)
PA; QL (30 per 30
days)
PA; QL (30 per 30
days)
PA; QL (30 per 30
days)
this document
102
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
QUILLIVANT XR ORAL
SUSPENSION,EXT REL
24HR,RECON 5 MG/ML (25 MG/5
ML)
riluzole oral tablet 50 mg
SAVELLA ORAL TABLET 100 MG,
12.5 MG, 25 MG, 50 MG
SAVELLA ORAL TABLETS,DOSE
PACK 12.5 MG (5)-25 MG(8)-50
MG(42)
STRATTERA ORAL CAPSULE 10
MG, 100 MG, 18 MG, 25 MG, 40 MG,
60 MG, 80 MG
tetrabenazine oral tablet 12.5 mg, 25 mg
$0 (Tier 2)
(Rilutek)
$0 (Tier 1)
$0 (Tier 2)
QL (60 per 30 days)
$0 (Tier 2)
QL (60 per 30 days)
$0 (Tier 2)
(Xenazine)
$0 (Tier 1)
PA; QL (112 per 28
days)
(Amethyst)
(Modicon)
(Modicon)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Seasonique)
$0 (Tier 1)
QL (91 per 84 days)
(Seasonique)
$0 (Tier 1)
QL (91 per 84 days)
(Desogen)
(Modicon)
$0 (Tier 1)
$0 (Tier 1)
(Seasonique)
$0 (Tier 1)
(Amethyst)
(Amethyst)
$0 (Tier 1)
$0 (Tier 1)
Contraceptives
Contraceptives
AIMSCO LATEX CONDOM *
altavera (28) oral tablet 0.15-0.03 mg
alyacen 1/35 (28) oral tablet 1-35 mg-mcg
alyacen 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
amethia lo oral tablets,dose pack,3 month
0.10 mg-20 mcg (84)/10 mcg (7)
amethia oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
apri oral tablet 0.15-0.03 mg
aranelle (28) oral tablet 0.5/1/0.5-35
mg-mcg
ashlyna oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
aubra oral tablet 0.1-20 mg-mcg
aviane oral tablet 0.1-20 mg-mcg
this document
103
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
azurette (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
balziva (28) oral tablet 0.4-35 mg-mcg
bekyree (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
blisovi 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30
mcg (21)/75 mg (7)
blisovi fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
briellyn oral tablet 0.4-35 mg-mcg
camila oral tablet 0.35 mg
camrese lo oral tablets,dose pack,3 month
0.10 mg-20 mcg (84)/10 mcg (7)
camrese oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
caziant (28) oral tablet 0.1/.125/.15-25
mg-mcg
CONDOMS LUBRICATED *
cryselle (28) oral tablet 0.3-30 mg-mcg
cyclafem 1/35 (28) oral tablet 1-35
mg-mcg
cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
cyred oral tablet 0.15-0.03 mg
dasetta 1/35 (28) oral tablet 1-35 mg-mcg
dasetta 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
daysee oral tablets,dose pack,3 month 0.15
mg-30 mcg (84)/10 mcg (7)
deblitane oral tablet 0.35 mg
delyla (28) oral tablet 0.1-20 mg-mcg
(Mircette)
$0 (Tier 1)
(Modicon)
(Mircette)
$0 (Tier 1)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Modicon)
(Nor-Q-D)
(Seasonique)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (91 per 84 days)
(Seasonique)
$0 (Tier 1)
QL (91 per 84 days)
(Desogen)
$0 (Tier 1)
(Norgestrel-Ethinyl
Estradiol)
(Modicon)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
(Modicon)
$0 (Tier 1)
(Desogen)
(Modicon)
(Modicon)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Seasonique)
$0 (Tier 1)
(Nor-Q-D)
(Amethyst)
$0 (Tier 1)
$0 (Tier 1)
QL (91 per 84 days)
this document
104
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
desog-e.estradiol/e.estradiol oral tablet
0.15-0.02 mgx21 /0.01 mg x 5
desogestrel-ethinyl estradiol oral tablet
0.15-0.03 mg
drospirenone-ethinyl estradiol oral tablet
3-0.02 mg, 3-0.03 mg
econtra ez 1.5 mg tablet inner 1.5 mg *
elinest oral tablet 0.3-30 mg-mcg
ELLA ORAL TABLET 30 MG
emoquette oral tablet 0.15-0.03 mg
enpresse oral tablet 50-30 (6)/75-40
(5)/125-30(10)
enskyce oral tablet 0.15-0.03 mg
errin oral tablet 0.35 mg
estarylla oral tablet 0.25-35 mg-mcg
fallback solo 1.5 mg tablet inner 1.5 mg *
falmina (28) oral tablet 0.1-20 mg-mcg
FANTASY CONDOM *
gianvi (28) oral tablet 3-0.02 mg
gildagia oral tablet 0.4-35 mg-mcg
gildess 1.5/30 (21) oral tablet 1.5-30
mg-mcg
gildess 1/20 (21) oral tablet 1-20 mg-mcg
gildess 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
gildess fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
gildess fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
GYNOL II 3% GEL 3 % *
heather oral tablet 0.35 mg
(Mircette)
$0 (Tier 1)
(Desogen)
$0 (Tier 1)
(Yaz)
$0 (Tier 1)
(Aftera)
(Norgestrel-Ethinyl
Estradiol)
$0 (Tier 4)
$0 (Tier 1)
QL (6 per 365 days)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
QL (6 per 365 days)
(Desogen)
(Amethyst)
(Desogen)
(Nor-Q-D)
(Ortho-Cyclen)
(Aftera)
(Amethyst)
(Yaz)
(Modicon)
(Loestrin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Loestrin)
(Loestrin Fe)
$0 (Tier 1)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Nor-Q-D)
$0 (Tier 4)
$0 (Tier 1)
QL (6 per 365 days)
this document
105
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
introvale oral tablets,dose pack,3 month
0.15 mg-30 mcg
jencycla oral tablet 0.35 mg
jolessa oral tablets,dose pack,3 month 0.15
mg-30 mcg
jolivette oral tablet 0.35 mg
juleber oral tablet 0.15-0.03 mg
junel 1.5/30 (21) oral tablet 1.5-30
mg-mcg
junel 1/20 (21) oral tablet 1-20 mg-mcg
junel fe 1.5/30 (28) oral tablet 1.5 mg-30
mcg (21)/75 mg (7)
junel fe 1/20 (28) oral tablet 1 mg-20 mcg
(21)/75 mg (7)
junel fe 24 oral tablet 1 mg-20 mcg
(24)/75 mg (4)
kariva (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
kelnor 1/35 (28) oral tablet 1-35 mg-mcg
kimidess (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
KIMONO CONDOMS *
KIMONO MAXX CONDOM *
KIMONO MICROTHIN AQUA LUBE
*
KIMONO MICROTHIN CONDOM *
KIMONO MICROTHIN LARGE
CONDOM *
KIMONO TEXTURED CONDOM *
kurvelo oral tablet 0.15-0.03 mg
l norgest/e.estradiol-e.estrad oral
tablets,dose pack,3 month 0.10 mg-20 mcg
(84)/10 mcg (7), 0.15 mg-30 mcg (84)/10
mcg (7)
(Levonorgestrel-Ethi
n Estradiol)
(Nor-Q-D)
n Estradiol)
(Nor-Q-D)
(Desogen)
(Loestrin)
$0 (Tier 1)
QL (91 per 84 days)
$0 (Tier 1)
$0 (Tier 1)
QL (91 per 84 days)
(Loestrin)
(Loestrin Fe)
$0 (Tier 1)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Mircette)
$0 (Tier 1)
(Demulen 1-50-21)
(Mircette)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Amethyst)
(Seasonique)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
QL (91 per 84 days)
this document
106
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
larin 1.5/30 (21) oral tablet 1.5-30
mg-mcg
larin 1/20 (21) oral tablet 1-20 mg-mcg
larin 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
larin fe 1.5/30 (28) oral tablet 1.5 mg-30
mcg (21)/75 mg (7)
larin fe 1/20 (28) oral tablet 1 mg-20 mcg
(21)/75 mg (7)
larissia oral tablet 0.1-20 mg-mcg
leena 28 oral tablet 0.5/1/0.5-35 mg-mcg
lessina oral tablet 0.1-20 mg-mcg
levonest (28) oral tablet 50-30 (6)/75-40
(5)/125-30(10)
levonor-eth estrad 0.15-0.03 outer
0.15-0.03 mg
levonorgestrel 1.5 mg tablet (otc) 1.5 mg
*
levonorgestrel oral tablet 0.75 mg
levonorgestrel oral tablet 1.5 mg
levonorgestrel-ethinyl estrad oral tablet
0.1-20 mg-mcg
levonorgestrel-ethinyl estrad oral
tablets,dose pack,3 month 0.15 mg-30 mcg
levonorg-eth estrad triphasic oral tablet
50-30 (6)/75-40 (5)/125-30(10)
levora-28 oral tablet 0.15-0.03 mg
lomedia 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
loryna (28) oral tablet 3-0.02 mg
low-ogestrel (28) oral tablet 0.3-30
mg-mcg
lutera (28) oral tablet 0.1-20 mg-mcg
lyza oral tablet 0.35 mg
(Loestrin)
$0 (Tier 1)
(Loestrin)
(Loestrin Fe)
$0 (Tier 1)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Amethyst)
(Modicon)
(Amethyst)
(Amethyst)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Amethyst)
$0 (Tier 1)
QL (91 per 84 days)
(Aftera)
$0 (Tier 4)
QL (6 per 365 days)
(Plan B One-Step)
(Plan B One-Step)
(Amethyst)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (6 per 365 days)
(Amethyst)
$0 (Tier 1)
QL (91 per 84 days)
(Amethyst)
$0 (Tier 1)
QL (91 per 84 days)
(Amethyst)
(Loestrin Fe)
$0 (Tier 1)
$0 (Tier 1)
(Yaz)
(Norgestrel-Ethinyl
Estradiol)
(Amethyst)
(Nor-Q-D)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
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107
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
marlissa oral tablet 0.15-0.03 mg
microgestin 1.5/30 (21) oral tablet 1.5-30
mg-mcg
microgestin 1/20 (21) oral tablet 1-20
mg-mcg
microgestin fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
microgestin fe 1/20 (28) oral tablet 1
mg-20 mcg (21)/75 mg (7)
mono-linyah oral tablet 0.25-35 mg-mcg
mononessa (28) oral tablet 0.25-35
mg-mcg
my way 1.5 mg tablet (otc) 1.5 mg *
myzilra oral tablet 50-30 (6)/75-40
(5)/125-30(10)
necon 0.5/35 (28) oral tablet 0.5-35
mg-mcg
necon 1/35 (28) oral tablet 1-35 mg-mcg
necon 1/50 (28) oral tablet 1-50 mg-mcg
necon 10/11 (28) oral tablet 0.5-35/1-35
mg-mcg/mg-mcg
necon 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
next choice one dose 1.5 mg tb (otc) 1.5
mg *
next choice one dose oral tablet 1.5 mg
nikki (28) oral tablet 3-0.02 mg
nora-be oral tablet 0.35 mg
norethindrone (contraceptive) oral tablet
0.35 mg
norethindrone ac-eth estradiol oral tablet
1-20 mg-mcg
norethindrone-e.estradiol-iron oral tablet 1
mg-20 mcg (24)/75 mg (4)
(Amethyst)
(Loestrin)
$0 (Tier 1)
$0 (Tier 1)
(Loestrin)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Ortho-Cyclen)
(Ortho-Cyclen)
$0 (Tier 1)
$0 (Tier 1)
(Aftera)
(Amethyst)
$0 (Tier 4)
$0 (Tier 1)
(Modicon)
$0 (Tier 1)
(Modicon)
(Norinyl 1+50)
(Modicon)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Modicon)
$0 (Tier 1)
(Aftera)
$0 (Tier 4)
QL (6 per 365 days)
(Plan B One-Step)
(Yaz)
(Nor-Q-D)
(Nor-Q-D)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (6 per 365 days)
(Loestrin)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
QL (6 per 365 days)
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108
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
norg-ee 0.18-0.215-0.25/0.035 3x28 day
regimen 0.18/0.215/0.25 mg-35 mcg (28)
norgestimate-ethinyl estradiol oral tablet
0.18/0.215/0.25 mg-25 mcg, 0.25-35
mg-mcg
norlyroc oral tablet 0.35 mg
nortrel 0.5/35 (28) oral tablet 0.5-35
mg-mcg
nortrel 1/35 (21) oral tablet 1-35 mg-mcg
nortrel 1/35 (28) oral tablet 1-35 mg-mcg
nortrel 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
NUVARING VAGINAL RING
0.12-0.015 MG/24 HR
ocella oral tablet 3-0.03 mg
ogestrel (28) oral tablet 0.5-50 mg-mcg
opcicon one-step 1.5 mg tablet 1.5 mg *
orsythia oral tablet 0.1-20 mg-mcg
philith oral tablet 0.4-35 mg-mcg
pimtrea (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
pirmella oral tablet 0.5/0.75/1 mg- 35 mcg,
1-35 mg-mcg
portia oral tablet 0.15-0.03 mg
previfem oral tablet 0.25-35 mg-mcg
quasense oral tablets,dose pack,3 month
0.15 mg-30 mcg
react 1.5 mg tablet 1.5 mg *
reclipsen (28) oral tablet 0.15-0.03 mg
setlakin oral tablets,dose pack,3 month
0.15 mg-30 mcg
sharobel oral tablet 0.35 mg
(Ortho-Cyclen)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Nor-Q-D)
(Modicon)
$0 (Tier 1)
$0 (Tier 1)
(Modicon)
(Modicon)
(Modicon)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Yaz)
(Norgestrel-Ethinyl
Estradiol)
(Aftera)
(Amethyst)
(Modicon)
(Mircette)
$0 (Tier 1)
$0 (Tier 1)
(Modicon)
$0 (Tier 1)
(Amethyst)
(Ortho-Cyclen)
n Estradiol)
(Aftera)
(Desogen)
n Estradiol)
(Nor-Q-D)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
ST; QL (1 per 28 days)
QL (6 per 365 days)
QL (91 per 84 days)
QL (6 per 365 days)
QL (91 per 84 days)
$0 (Tier 1)
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109
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
sprintec (28) oral tablet 0.25-35 mg-mcg
sronyx oral tablet 0.1-20 mg-mcg
syeda oral tablet 3-0.03 mg
tarina fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
tilia fe oral tablet 1-20(5)/1-30(7)
/1mg-35mcg (9)
tri-estarylla oral tablet 0.18/0.215/0.25
mg-35 mcg (28)
tri-legest fe oral tablet 1-20(5)/1-30(7)
/1mg-35mcg (9)
tri-linyah oral tablet 0.18/0.215/0.25
mg-35 mcg (28)
tri-lo-estarylla oral tablet 0.18/0.215/0.25
mg-25 mcg
tri-lo-marzia oral tablet 0.18/0.215/0.25
mg-25 mcg
tri-lo-sprintec oral tablet 0.18/0.215/0.25
mg-25 mcg
trinessa (28) oral tablet 0.18/0.215/0.25
mg-35 mcg (28)
tri-previfem (28) oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
tri-sprintec (28) oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
trivora (28) oral tablet 50-30 (6)/75-40
(5)/125-30(10)
TRUSTEX CONDOM *
TRUSTEX CONDOM 12'S,EXTRA
STRENGTH *
TRUSTEX LATEX CONDOM 12'S *
TRUSTEX-RIA CONDOM
12'S,W/SPERMICIDE *
(Ortho-Cyclen)
(Amethyst)
(Yaz)
(Loestrin Fe)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Amethyst)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
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110
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
TRUSTEX-RIA CONDOM
48'S,NON-LUBRICATED *
vcf contraceptive foam 12.5 % *
velivet triphasic regimen (28) oral tablet
0.1/.125/.15-25 mg-mcg
vestura (28) oral tablet 3-0.02 mg
vienva oral tablet 0.1-20 mg-mcg
viorele (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
vyfemla (28) oral tablet 0.4-35 mg-mcg
wera (28) oral tablet 0.5-35 mg-mcg
WIDE SEAL DIAPHRAGM 70MM 70
MM *
xulane transdermal patch weekly 150-35
mcg/24 hr
zarah oral tablet 3-0.03 mg
zenchent (28) oral tablet 0.4-35 mg-mcg
zovia 1/35e (28) oral tablet 1-35 mg-mcg
zovia 1/50e (28) oral tablet 1-50 mg-mcg
$0 (Tier 4)
(Nonoxynol 9)
(Desogen)
$0 (Tier 4)
$0 (Tier 1)
(Yaz)
(Amethyst)
(Mircette)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Modicon)
(Modicon)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 3)
(Ortho Evra)
$0 (Tier 1)
(Yaz)
(Modicon)
(Demulen 1-50-21)
(Demulen 1-50-21)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (3 per 28 days)
Cough And Cold Products
Cough And Cold Products
adult wal-tussin liquid 100 mg/5 ml *
(Robitussin
Mucus-Chest
Congest)
benzonatate 100 mg capsule 100 mg *
(Zonatuss)
(Zonatuss)
(Zonatuss)
cheratussin ac syrup (otc) 10-100 mg/5 ml (M-Clear Wc)
*
children's silfedrine liq 15 mg/5 ml *
(Pseudoephedrine
HCl)
childs sudafed 15 mg/5 ml liq
(Pseudoephedrine
non-drowsy,a/f,s/f 15 mg/5 ml *
HCl)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
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111
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
chl mucinex chest congest liq a/f 100 mg/5 (Robitussin
ml *
Mucus-Chest
Congest)
cvs child's chest congest liq 100 mg/5 ml * (Robitussin
Mucus-Chest
Congest)
diabetic tussin ex liquid a/f,d/f,na/f,s/f 100 (Robitussin
mg/5 ml *
Mucus-Chest
Congest)
expectorant 100 mg/5 ml syrup 100 mg/5 (Robitussin
ml *
Mucus-Chest
Congest)
liquituss gg 200 mg/5 ml liq 200 mg/5 ml * (Robitussin
Mucus-Chest
Congest)
mar-cof cg liquid 7.5-225 mg/5 ml *
(M-Clear Wc)
nasal-sinus decongest tab 30 mg *
(Sudafed 12-Hour)
$0 (Tier 4)
ninjacof-xg liquid 8-200 mg/5 ml *
(M-Clear Wc)
phenylhistine dh liquid (otc) 2-30-10 mg/5 (P-Ephed
ml *
HCl/Cod/Chlorpheni
r)
promethazine vc-codeine syrup 6.25-5-10 (Promethazine/Pheny
mg/5 ml *
leph/Codeine)
promethazine-codeine syrup 6.25-10 mg/5 (Promethazine
ml *
HCl/Codeine)
promethazine-dm syrup 6.25-15 mg/5 ml * (Promethazine/Dextr
omethorphan)
pseudoephed 30 mg/5 ml soln 30 mg/5 ml * (Pseudoephedrine
HCl)
pseudoephedrine 30 mg tablet 30 mg *
(Sudafed 12-Hour)
$0 (Tier 3)
$0 (Tier 4)
pseudoephedrine 60 mg tablet ex-str, non
drowsy (otc) 60 mg *
(Sudafed 12-Hour)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
this document
112
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
(Robitussin
Mucus-Chest
Congest)
relcof c liquid 6.3-100 mg/5 ml *
(M-Clear Wc)
robafen 100 mg/5 ml syrup 100 mg/5 ml * (Robitussin
Mucus-Chest
Congest)
scot-tussin 100 mg/5 ml liq 100 mg/5 ml * (Robitussin
Mucus-Chest
Congest)
siltussin sa 100 mg/5 ml syr 100 mg/5 ml * (Robitussin
Mucus-Chest
Congest)
sm adult nasal decongestant lq 15 mg/5 ml (Pseudoephedrine
*
HCl)
sudafed 30 mg tablet non-drowsy,max-str (Sudafed 12-Hour)
30 mg *
sudogest 30 mg tablet boxed 30 mg *
(Sudafed 12-Hour)
$0 (Tier 4)
sudogest 60 mg tablet 60 mg *
(Sudafed 12-Hour)
$0 (Tier 4)
(Pseudoephedrine
HCl)
trymine cg liquid 7.5-225 mg/5 ml *
(M-Clear Wc)
valu-tapp decongestant drop 7.5 mg/0.8 ml (Pseudoephedrine
*
HCl)
virtussin ac liquid 10-100 mg/5 ml *
(M-Clear Wc)
wal-phed 30 mg tablet non-drowsy 30 mg * (Sudafed 12-Hour)
$0 (Tier 4)
zephrex-d 30 mg tablet 30 mg *
(Sudafed 12-Hour)
$0 (Tier 4)
(Evoxac)
$0 (Tier 1)
q-tussin 100 mg/5 ml solution a/f,
non-drowsy 100 mg/5 ml *
suphedrin liquid 15 mg/5 ml *
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
Dental And Oral Agents
Dental And Oral Agents
cevimeline oral capsule 30 mg
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113
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
chlorhexidine gluconate mucous
membrane mouthwash 0.12 %
dry mouth mouthwash a/f, mint flavor *
oralone dental paste 0.1 %
(Peridex)
$0 (Tier 1)
(Saliva Substitute
Combo No.7)
(Triamcinolone
Acetonide)
(Peridex)
$0 (Tier 4)
periogard mucous membrane mouthwash
0.12 %
pilocarpine hcl oral tablet 5 mg, 7.5 mg
(Salagen)
triamcinolone acetonide dental paste 0.1 % (Triamcinolone
Acetonide)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
Dermatological Agents
Dermatological Agents, Other
8-MOP ORAL CAPSULE 10 MG
acitretin oral capsule 10 mg, 17.5 mg, 25
mg
acne & blackhead 2.5% gel 2.5 % *
acne foaming 10% wash 10 % *
acne medication 5% gel 5 % *
ACNE MEDICATION 5% LOTION 5
%*
acneclear gel 10 % *
acyclovir topical ointment 5 %
ALCOHOL PADS TOPICAL PADS,
MEDICATED
ALCOHOL PREP PADS
ammonium lactate topical cream 12 %
ammonium lactate topical lotion 12 %
ANACAINE TOPICAL OINTMENT
10 %
benzoyl peroxide 10% gel aqueous (otc)
10 % *
benzoyl peroxide 2.5% gel (otc) 2.5 % *
(Soriatane)
$0 (Tier 2)
$0 (Tier 1)
(Benzoyl Peroxide)
(Bp Wash)
(Benzoyl Peroxide)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Benzoyl Peroxide)
(Zovirax)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
(Lac-Hydrin)
(Lac-Hydrin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Benzoyl Peroxide)
$0 (Tier 4)
(Benzoyl Peroxide)
$0 (Tier 4)
QL (30 per 30 days)
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114
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
benzoyl peroxide 3% cleanser (otc) 3 % *
benzoyl peroxide 5% gel aqueous (otc) 5
%*
benzoyl peroxide 5% wash (otc) 5 % *
calamine lotion *
calcipotriene scalp solution 0.005 %
calcipotriene topical cream 0.005 %
calcipotriene topical ointment 0.005 %
calcitrene topical ointment 0.005 %
calcitriol topical ointment 3 mcg/gram
clearasil daily clear 10% crm 10 % *
CONDYLOX TOPICAL GEL 0.5 %
COSENTYX (150 MG/ML) 300 MG
DOSE-2 PENS 150 MG/ML
COSENTYX (150 MG/ML) 300 MG
DOSE-2 SYRINGES 150 MG/ML
COSENTYX PEN SUBCUTANEOUS
PEN INJECTOR 150 MG/ML
COSENTYX SUBCUTANEOUS
SYRINGE 150 MG/ML
cvs acne foaming face 10% wash 10 % *
cvs adv exfoliating 5% cleansr 5 % *
elta tar 2% ointment 2 % *
fluorouracil topical cream 0.5 %, 5 %
fluorouracil topical solution 2 %, 5 %
ichthammol 20% ointment 20 % *
imiquimod topical cream in packet 5 %
(Bp Wash)
(Benzoyl Peroxide)
$0 (Tier 4)
$0 (Tier 4)
(Bp Wash)
(Bp Wash)
(Bp Wash)
(Calamine)
(Calcipotriene)
(Dovonex)
(Calcipotriene)
(Calcipotriene)
(Vectical)
(Benzoyl Peroxide)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
PA
$0 (Tier 2)
PA
$0 (Tier 2)
PA
$0 (Tier 2)
PA
(Bp Wash)
(Bp Wash)
(Coal Tar)
(Carac)
(Fluorouracil)
(Ichthammol)
(Aldara)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
methoxsalen rapid oral capsule 10 mg
mg217 psoriasis ointment 2 % *
panoxyl 10% acne foaming wash 10 % *
(Oxsoralen-Ultra)
(Coal Tar)
(Bp Wash)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
PA NSO; QL (24 per
30 days)
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115
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
panoxyl-4 acne creamy wash 4 % *
PANRETIN TOPICAL GEL 0.1 %
persa-gel 10% 12's,max-strength 10 % *
PICATO TOPICAL GEL 0.015 %
PICATO TOPICAL GEL 0.05 %
podocon topical liquid 25 %
podofilox topical solution 0.5 %
potassium hydroxide topical solution 5 %
pub calamine lotion *
pv acne pimple 10% gel 10 % *
ra scalp itch-dandruff rel liq 3 % *
SANTYL TOPICAL OINTMENT 250
UNIT/GRAM
TALTZ AUTOINJECTOR
SUBCUTANEOUS AUTO-INJECTOR
80 MG/ML
TALTZ SYRINGE SUBCUTANEOUS
SYRINGE 80 MG/ML
TOLAK TOPICAL CREAM 4 %
VALCHLOR TOPICAL GEL 0.016 %
zenatane oral capsule 10 mg, 20 mg, 30
mg, 40 mg
ZOVIRAX TOPICAL CREAM 5 %
Dermatological Antibacterials
bacitracin 500 unit/gm ointmnt 500
unit/gram *
bacitracin-polymyxin ointment 500-10,000
unit/gram *
bacitraycin plus 500 unit/gm 500
unit/gram *
clindamycin phosphate topical gel 1 %
(Bp Wash)
(Benzoyl Peroxide)
(Podophyllum Resin)
(Condylox)
(Potassium
Hydroxide)
(Calamine/Zinc
Oxide)
(Benzoyl Peroxide)
(Salicylic Acid)
(Isotretinoin)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (3 per 56 days)
QL (2 per 56 days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
PA
$0 (Tier 2)
PA
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
(Bacitracin)
$0 (Tier 4)
(Bacitracin/Polymyxi
n B Sulfate)
(Bacitracin)
$0 (Tier 4)
(Cleocin T)
$0 (Tier 1)
QL (15 per 30 days)
$0 (Tier 4)
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116
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
clindamycin phosphate topical lotion 1 %
clindamycin phosphate topical solution 1
%
clindamycin phosphate topical swab 1 %
cvs antibiotic plus cream 3.5-10,000-10
mg-unit-mg/gram *
ery pads topical swab 2 %
(Cleocin T)
(Cleocin T)
(Cleocin T)
(Neomycin Su/Plymx
B Su/Pram)
(Erythromycin
Base/Ethanol)
erythromycin with ethanol topical gel 2 % (Erygel)
erythromycin with ethanol topical solution (Erythromycin
2%
Base/Ethanol)
erythromycin with ethanol topical swab 2 (Erythromycin
%
Base/Ethanol)
gentamicin topical cream 0.1 %
gentamicin topical ointment 0.1 %
metronidazole topical cream 0.75 %
(Metrocream)
metronidazole topical gel 0.75 %, 1 %
(Rosadan)
metronidazole topical lotion 0.75 %
(Metrolotion)
multi antibiotic plus cream 3.5-10,000-10 (Neomycin Su/Plymx
mg-unit-mg/gram *
B Su/Pram)
mupirocin calcium topical cream 2 %
(Bactroban)
mupirocin topical ointment 2 %
(Centany)
neomycin-polymyxin b gu irrigation
(Neosporin G.U.
solution 40 mg-200,000 unit/ml
Irrigant)
neosporin + pain relief cream maximum
(Neomycin Su/Plymx
strength 3.5-10,000-10 mg-unit-mg/gram * B Su/Pram)
polysporin ointment (otc) 500-10,000
unit/gram *
n B Sulfate)
rosadan topical cream 0.75 %
(Metrocream)
selenium sulfide topical lotion 2.5 %
(Selenium Sulfide)
selenium sulfide topical shampoo 2.25 %
(Selenium Sulfide)
silver nitrate topical ointment 10 %
(Silver Nitrate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
this document
117
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
silver nitrate topical solution 0.5 %, 10 %,
25 %, 50 %
silver sulfadiazine topical cream 1 %
ssd topical cream 1 %
sulfacetamide sodium (acne) topical
suspension 10 %
Dermatological Anti-Inflammatory
Agents
ala-cort topical cream 1 %
ala-scalp topical lotion 2 %
alclometasone topical cream 0.05 %
(Silver Nitrate)
$0 (Tier 1)
(Silvadene)
(Silvadene)
(Klaron)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Anusol-HC)
(Scalacort)
(Alclometasone
Dipropionate)
alclometasone topical ointment 0.05 %
(Alclometasone
Dipropionate)
aquanil hc 1% lotion 1 % *
(Cortizone-10)
beta hc 1% lotion 1 % *
(Cortizone-10)
betamethasone dipropionate topical cream (Betamethasone
0.05 %
Dipropionate)
betamethasone dipropionate topical lotion (Betamethasone
0.05 %
Dipropionate)
betamethasone dipropionate topical
(Betamethasone
ointment 0.05 %
Dipropionate)
betamethasone valerate topical cream 0.1 (Betamethasone
%
Valerate)
betamethasone valerate topical foam 0.12 (Luxiq)
%
betamethasone valerate topical lotion 0.1 (Betamethasone
%
Valerate)
betamethasone valerate topical ointment
(Betamethasone
0.1 %
Valerate)
betamethasone, augmented topical cream (Diprolene AF)
0.05 %
betamethasone, augmented topical gel
(Betamethasone
0.05 %
Dipropionate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
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What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
betamethasone, augmented topical lotion
0.05 %
betamethasone, augmented topical
ointment 0.05 %
clobetasol 0.05% cream 0.05 %
clobetasol scalp solution 0.05 %
(Diprolene)
$0 (Tier 1)
(Diprolene)
$0 (Tier 1)
(Temovate)
(Clobetasol
Propionate)
clobetasol topical foam 0.05 %
(Olux)
clobetasol topical gel 0.05 %
(Clobetasol
Propionate)
clobetasol topical lotion 0.05 %
(Clobex)
clobetasol topical ointment 0.05 %
(Temovate)
clobetasol topical shampoo 0.05 %
(Clobex)
clobetasol-emollient topical cream 0.05 % (Temovate)
clocortolone pivalate topical cream 0.1 % (Cloderm)
colocort rectal enema 100 mg/60 ml
(Cortenema)
cormax scalp solution 0.05 %
(Clobetasol
Propionate)
cortaid 1% cream 12 hr, anti-itch 1 % *
(Hydrocortisone)
cortizone-10 1% creme maximum strength (Hydrocortisone)
1%*
CORTIZONE-10 1% LOTION 1 % *
cortizone-10 1% ointment 1 % *
(Hydrocortisone)
cvs hydrocortisone 0.5% crm 0.5 % *
(Hydrocortisone
Acetate)
dermarest eczema 1% lotion 1 % *
(Cortizone-10)
desonide topical cream 0.05 %
(Desowen)
desonide topical ointment 0.05 %
(Desonide)
desoximetasone topical cream 0.05 %,
(Topicort)
0.25 %
desoximetasone topical gel 0.05 %
(Topicort)
desoximetasone topical ointment 0.05 %, (Topicort)
0.25 %
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
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119
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ELIDEL TOPICAL CREAM 1 %
fluocinonide topical cream 0.05 %
fluocinonide topical gel 0.05 %
fluocinonide topical ointment 0.05 %
fluocinonide topical solution 0.05 %
fluticasone topical cream 0.05 %
fluticasone topical ointment 0.005 %
halobetasol propionate topical cream 0.05
%
halobetasol propionate topical ointment
0.05 %
hydro skin 1% lotion 1 % *
hydrocortisone 0.5% cream (otc) 0.5 % *
hydrocortisone 0.5% ointment 0.5 % *
hydrocortisone 1% cream maximum
strength (otc) 1 % *
hydrocortisone 1% cream maximum
strength 1 % *
hydrocortisone 1% lotion (otc) 1 % *
hydrocortisone 1% ointment carton (otc)
1%*
hydrocortisone acet-aloe vera topical gel 2
%
hydrocortisone buty 0.1% cream 0.1 %
hydrocortisone butyrate topical ointment
0.1 %
hydrocortisone butyrate topical solution
0.1 %
hydrocortisone butyr-emollient topical
cream 0.1 %
hydrocortisone rectal enema 100 mg/60 ml
(Vanos)
(Fluocinonide)
(Fluocinonide)
(Fluocinonide)
(Cutivate)
(Fluticasone
Propionate)
(Ultravate)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Ultravate)
$0 (Tier 1)
(Cortizone-10)
(Hydrocortisone)
(Hydrocortisone)
(Hydrocortisone)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Hydrocortisone
Acetate)
(Cortizone-10)
(Hydrocortisone)
$0 (Tier 4)
(Hydrocortisone
Acetate/Aloe V)
(Hydrocortisone
Butyrate)
(Locoid)
$0 (Tier 1)
(Locoid)
$0 (Tier 1)
(Hydrocortisone
Butyrate)
(Cortenema)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
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120
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
hydrocortisone topical cream 1 %, 2.5 %
hydrocortisone topical lotion 2.5 %
hydrocortisone topical ointment 1 %, 2.5
%
hydrocortisone valerate topical cream 0.2
%
hydrocortisone valerate topical ointment
0.2 %
mometasone topical cream 0.1 %
mometasone topical ointment 0.1 %
mometasone topical solution 0.1 %
neosporin 1% anti-itch cream 1 % *
obagi nu-derm tolereen lotion 0.5 % *
ONFI ORAL TABLET 10 MG, 20 MG
(Anusol-HC)
(Scalacort)
(Hydrocortisone)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Hydrocortisone
Valerate)
(Westcort)
$0 (Tier 1)
(Elocon)
(Elocon)
(Elocon)
(Hydrocortisone)
(Cortizone-10)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
prednicarbate topical cream 0.1 %
prednicarbate topical ointment 0.1 %
preparation h hc 1% cream 1 % *
procto-med hc rectal cream 2.5 %
procto-pak rectal cream 1 %
proctosol hc rectal cream 2.5 %
proctozone-hc rectal cream 2.5 %
recort plus 1% cream 1 % *
tacrolimus topical ointment 0.03 %, 0.1 %
triamcinolone acetonide topical cream
0.025 %, 0.1 %, 0.5 %
triamcinolone acetonide topical lotion
0.025 %, 0.1 %
triamcinolone acetonide topical ointment
0.025 %, 0.1 %, 0.5 %
trianex topical ointment 0.05 %
(Dermatop)
(Dermatop)
(Hydrocortisone)
(Hydrocortisone)
(Anusol-HC)
(Hydrocortisone)
(Hydrocortisone)
(Hydrocortisone)
(Protopic)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
$0 (Tier 1)
PA NSO; QL (60 per
30 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
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121
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
u-cort topical cream 1-10 %
Dermatological Retinoids
adapalene topical cream 0.1 %
adapalene topical gel 0.1 %
TAZORAC TOPICAL CREAM 0.05 %,
0.1 %
tretinoin gel micro 0.04% tube 0.04 %
tretinoin gel micro 0.1% tube 0.1 %
tretinoin microspheres topical gel with
pump 0.04 %, 0.1 %
tretinoin topical cream 0.025 %, 0.05 %,
0.1 %
tretinoin topical gel 0.01 %, 0.025 %, 0.05
%
Scabicides And Pediculicides
bedding 0.5% spray 0.5 % *
cvs lice bedding spray 0.5 % *
cvs lice killing shampoo maximum
strength 0.33-4 % *
cvs lice solution kit shamp/gel/spray/comb
4-0.33-0.5 % *
cvs permethrin 1% lotion 1 % *
eql lice treatment kit 0.33-4 % *
lice treatment liquid *
malathion topical lotion 0.5 %
NIX 1% CREME RINSE LIQUID W/
NIT COMB 1 % *
permethrin topical cream 5 %
ra lice treatment 1% crm rinse 2x59ml, 2
combs 1 % *
(Hydrocortisone
Acetate/Urea)
$0 (Tier 1)
(Differin)
(Differin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Retin-A Micro)
(Retin-A Micro)
(Retin-A Micro)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA
PA
PA
(Retin-A)
$0 (Tier 1)
PA
(Retin-A)
$0 (Tier 1)
PA
(Permethrin)
(Permethrin)
(Piperonyl
Butoxide/Pyrethrins)
(Pip
Butox/Pyrethrins/Per
meth)
(Nix)
(Piperonyl
(Piperonyl
(Ovide)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Elimite)
(Nix)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
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122
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
rid lice killing shampoo 0.33-4 % *
rid pediculicides spray 0.5 % *
sm lice treatment permethrin 2's 1 % *
stop lice 0.5% spray 0.5 % *
v-r lice cream rinse 1 % *
(Piperonyl
(Permethrin)
(Nix)
(Permethrin)
(Nix)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
Devices
Devices
1ST CHOICE SUPER THIN
LANCETS *
1ST TIER COMFORTOUCH 28G
LANCT 28 GAUGE *
1ST TIER COMFORTOUCH 30G
LANCT 30 GAUGE *
ACCU-CHEK ACTIVE TEST STRIP *
ACCU-CHEK AVIVA PLUS TEST
STRP *
ACCU-CHEK AVIVA TEST STRIPS
NOT FOR RETAIL SALE *
ACCU-CHEK COMPACT PLUS
STRIPS *
ACCU-CHEK FASTCLIX LANCETS
*
ACCU-CHEK MULTICLIX
LANCETS *
ACCU-CHEK SAFE-T-PRO 23G
LANCT 23 GAUGE *
ACCU-CHEK SAFE-T-PRO PLUS
23G 23 GAUGE *
ACCU-CHEK SMARTVIEW TEST
STRIP *
ACCU-CHEK SOFTCLIX LANCETS
*
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
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123
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ACCUTREND GLUCOSE TEST
STRIP *
ACE AEROSOL CLOUD
ENHANCER *
ACTI-LANCE LITE 28G LANCETS 28
GAUGE *
ACTI-LANCE SPECIAL 17G
LANCETS 17 GAUGE *
ACTI-LANCE UNIVERS 23G
LANCETS 23 GAUGE *
ACURA TEST STRIPS *
ADVANCED TRAVEL 28G
LANCETS 28G,SINGLE-USE,STRL
28 GAUGE *
ADVANCED TRAVEL 30G
LANCETS 30 GAUGE *
ADVOCATE 26G LANCETS 26
G,STERILE 26 GAUGE *
ADVOCATE 26G LANCETS
STERILE 26 GAUGE *
ADVOCATE 30G LANCETS TWIST
TOP 30 GAUGE *
ADVOCATE REDI-CODE TEST
STRIP *
ADVOCATE REDI-CODE+ TEST
STRIP NO CODING *
ADVOCATE TEST STRIP *
AEROCHAMBER MINI 10'S,
LATEX-FREE *
AEROCHAMBER MV HOLD
CHAMBER *
AEROCHAMBER PLUS FLOW-VU *
AEROCHAMBER PLUS FLOW-VU
MED *
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
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124
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
AEROCHAMBER PLUS FLOW-VU
MED WITH MASK *
AEROCHAMBER PLUS
W-FLOWSIGNAL *
AEROCHAMBER PLUS Z STAT
MEDIUM 10'S, W/MEDIUM MASK *
AEROCHAMBER Z-STAT PLUS
W-FLOW *
AEROTRACH HOLDING
CHAMBER *
AEROVENT PLUS HOLDING
CHAMBER *
AGAMATRIX AMP TEST STRIPS *
ALTERNATE SITE 26G LANCETS
26G, STRL 26 GAUGE *
ASSURE 4 TEST STRIPS *
ASSURE HAEMOLANCE PLUS 18G
18 GAUGE *
21 GAUGE *
25 GAUGE *
28 GAUGE *
ASSURE ID INSULIN SAFETY
SYRINGE 1 ML 29 GAUGE X 1/2"
ASSURE LANCE 25G LANCETS 25
GAUGE *
ASSURE LANCE 28G LANCETS 28
GAUGE *
ASSURE LANCE PLUS 21G
LANCETS 21 GAUGE *
LANCETS 25 GAUGE *
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
this document
125
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
LANCETS 30 GAUGE *
ASSURE PLATINUM TEST STRIPS *
ASSURE PRISM MULTI TEST
STRIPS *
BD 3 ML SYRINGE 25GX1" 3 ML 25
GAUGE X 1" *
BD 3 ML SYRINGE 25GX1-1/2" 3 ML
25 X 1 1/2 " *
BD 3 ML SYRINGE WITH NEEDLE 3
ML 24 X 1", 3 ML 26 X 5/8" *
BD BULK SYRINGE 3 ML 3 ML *
BD ECLIPSE SYRINGE 3 ML 25GX1"
3 ML 25 GAUGE X 1" *
BD INSULIN SYR 0.3 ML 31GX5/16
0.3 ML 31 GAUGE X 5/16
BD INSULIN SYR 0.5 ML 31GX5/16"
0.5 ML 31 GAUGE X 5/16
BD INSULIN SYR 1 ML 31GX5/16" 1
ML 31 GAUGE X 5/16
BD INTEGRA SYR 3 ML 25GX5/8" 3
ML 25 GAUGE X 5/8" *
BD INTEGRA SYRINGE 3 ML
25GX1" 3 ML 25 GAUGE X 1" *
BD LANCETS 33G 33 GAUGE *
$0 (Tier 4)
BD LUER-LOK SYR 3 ML 25GX5/8" 3
ML 25 X 5/8" *
BD LUER-LOK SYRINGE 3 ML
LUER-LOK TIP 3 ML *
BD MEDSAVER SYRINGE 3 ML 25
GAUGE X 1", 3 ML 25 X 5/8" *
BD MICROTAINER 21G LANCETS
21 GAUGE *
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
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126
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
BD MICROTAINER 30G LANCETS
30 GAUGE *
BD SAFETYGLIDE TB 1 ML SYR 1
ML 27 X 1/2" *
BD SYRINGE 3 ML 3 ML *
BD SYRINGE-SAFETY GLIDE 3 ML
25 X 5/8" *
BD TB SYRINGE 21GX1" 1 ML 21
GAUGE X 1" *
BD TB SYRINGE 22GX1" 1 ML 22 X
1" *
BD TB SYRINGE 25GX5/8" 1 ML 25
GAUGE X 5/8" *
BD TB SYRINGE 26GX3/8" 1 ML 26 X
3/8" *
BD TB SYRINGE 27GX1/2" 1 ML 27 X
1/2" *
BD TB SYRNGE 27GX1/2" 1/2 ML 27
X 1/2 " *
BD TUBERCULIN 1 ML SYRINGE 1
ML *
BD ULTRA-FINE 33G LANCETS 33
GAUGE *
BD ULTRA-FINE II 30G LANCETS
30 GAUGE *
BD ULTRA-FINE PEN NDL
8MMX31G SHORT 31 GAUGE X
5/16"
BG-STAR GLUCOSE TEST STRIPS *
BLOOD GLUCOSE TEST STRIP NO
CODING *
BLOOD GLUCOSE TEST STRIPS *
BLOOD LANCETS 30G EASY TWIST
30 GAUGE *
$0 (Tier 4)
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 1)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
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127
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
BREATHERITE MDI SPACER *
BREATHRITE VALVED MDI
SPACER *
BULLSEYE MINI SAFETY 21G 21
GAUGE *
BULLSEYE MINI SAFETY 25G
LANCT 25 GAUGE *
CAREONE THIN LANCET *
$0 (Tier 3)
$0 (Tier 3)
CARESENS N TEST STRIPS NO
CODING *
CARESENS ULTRA THIN 30G
LANCET 30 GAUGE *
CHOICEDM CLARUS TEST STRIPS
*
CLEVER CHEK ULTRA THIN 30G
30 GAUGE *
CLEVER CHOICE MICRO TEST
STRIP *
CLEVER CHOICE PRO TEST STRIP
*
CLEVER CHOICE TALK TEST
STRIPS *
CLEVER CHOICE TEST STRIPS
AUTO-CODE *
CLEVER CHOICE VOICE+ TST
STRIP AUTO-CODE *
COAGUCHEK LANCETS *
$0 (Tier 3)
COMFORT EZ SAFETY 21G
LANCETS 21 GAUGE *
LANCETS 23 GAUGE *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 3)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 4)
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128
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
LANCETS 28 GAUGE *
COMFORT LANCETS *
$0 (Tier 4)
COMPACT SPACE CHAMBER *
COMPACT SPACE CHAMBER PLUS
*
CONTOUR NEXT STRIPS *
CONTOUR TEST STRIPS *
$0 (Tier 3)
$0 (Tier 3)
CONTROL AST TEST STRIP *
CONTROL G3 TEST STRIP *
COOL GLUCOSE TEST STRIP *
CVS ADVANCED GLUCOSE TEST
STR *
CVS THIN 26G LANCETS 26 GAUGE
*
CVS ULTRA THIN 30G LANCETS 30
GAUGE *
DIATRUE PLUS TEST STRIP *
DROPLET 30G LANCETS 30 GAUGE
*
EASIVENT HOLDING CHAMBER
RETAIL PACK *
EASY COMFORT 30G LANCETS
30G,TWIST TOP,STRL 30 GAUGE *
EASY PLUS GLUCOSE TEST STRIP
*
EASY PLUS II TEST STRIPS *
EASY STEP GLUCOSE TEST STRIPS
*
EASY TALK GLUCOSE TEST STRIP
*
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
this document
129
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
EASY TOUCH 28G LANCETS
28G,PULL TOP,STERILE 28 GAUGE
*
EASY TOUCH FLIPLOK 3 ML
25GX5/8 3 ML 25 GAUGE X 5/8" *
EASY TOUCH GLUCOSE TEST
STRIP *
EASY TOUCH SAFETY 21G
LANCETS 21 GAUGE *
LANCETS 23 GAUGE *
LANCETS 26 GAUGE *
EASY TOUCH SHEATH 3 ML
25GX5/8 3 ML 25 GAUGE X 5/8" *
EASY TOUCH SYR 3 ML 25GX5/8" 3
ML 25 X 5/8" *
EASY TOUCH SYRINGE 3 ML
25GX1" 3 ML 25 GAUGE X 1" *
EASY TOUCH TWIST 28G LANCETS
28 GAUGE *
30 GAUGE *
32 GAUGE *
33 GAUGE *
EASY TRAK GLUCOSE TEST STRIP
*
EASY TWIST & CAP 28G LANCETS
28 GAUGE *
EASYGLUCO PLUS TEST STRIPS *
EASYGLUCO TEST STRIPS *
$0 (Tier 4)
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
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130
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
EASYMAX 15 GLUCOSE TEST
STRIP *
EASYMAX GLUCOSE TEST STRIPS
MEDICAL BENEFIT USE *
ELEMENT COMPACT TEST STRIPS
*
ELEMENT TEST STRIPS *
EMBRACE 30G LANCETS 30
GAUGE *
EMBRACE EVO TEST STRIPS *
EMBRACE PRO TEST STRIPS *
EMBRACE TEST STRIPS *
EVENCARE G2 TEST STRIP *
EVENCARE G3 TEST STRIP *
EVENCARE GLUCOSE TST STRIPS
*
EVENCARE MINI GLUCOSE TEST
STR *
EVOLUTION TEST STRIPS *
EXEL SYRINGE 25GX1" 3 ML 3 ML
25 GAUGE X 1" *
EXEL SYRINGE 25GX5/8" 3 ML 3 ML
25 X 5/8" *
EXEL SYRINGE 3 ML 3 ML *
EXEL TB WITH NEEDLE 25GX5/8" 1
ML 26 X 3/8" *
ML 27 X 1/2" *
EXEL TUBERCULIN SYRINGE 1
ML 1 ML *
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
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131
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
E-Z JECT LANCETS *
$0 (Tier 4)
EZ SMART 28G LANCETS 28
GAUGE *
EZ SMART PLUS TEST STRIPS *
EZ SMART TEST STRIPS *
E-Z SPACER *
E-ZJECT COLOR 32G LANCETS 32
GAUGE *
E-ZJECT COLOR 33G LANCETS 33
GAUGE *
E-ZJECT SUPER THIN 30G
LANCETS SUPER THIN 30 GAUGE *
E-ZJECT THIN LANCETS 26 GAUGE
*
FIFTY50 GLUCOSE TEST STRIP *
FIFTY50 SAFETY SEAL 30G
LANCET 30 GAUGE *
FIFTY50 SAFETY SEAL 32G
LANCET 32 GAUGE *
FINE 30 UNIVERSAL 30G LANCETS
30 GAUGE *
FINGERSTIX LANCETS *
$0 (Tier 4)
FLEXICHAMBER *
FORA 30G LANCETS TWIST
OFF,SINGLE USE 30 GAUGE *
FORA BLOOD GLUCOSE TEST
STRIP *
FORA D10 GLUCOSE TEST STRIPS *
FORA D15G GLUCOSE TEST
STRIPS *
FORA D20 GLUCOSE TEST STRIPS *
FORA D40-G31 TEST STRIPS *
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 3)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
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132
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
FORA G20 GLUCOSE TEST STRIPS *
FORA G30A GLUCOSE TEST STRIP
*
FORA GD50 TEST STRIPS *
FORA TN'G VOICE TEST STRIPS *
FORA V10 GLUCOSE TEST STRIP *
FORA V12 GLUCOSE TEST STRIP *
FORA V20 GLUCOSE TEST STRIPS *
FORA V30A GLUCOSE TEST STRIP
*
FORACARE 30G LANCETS 30
GAUGE *
FORACARE GD20 TEST STRIPS *
FORACARE GD40 GLUCOSE
STRIPS *
FORTISCARE GLUCOSE TEST
STRIPS *
FREESTYLE 28G LANCETS 28
GAUGE *
FREESTYLE INSULINX TEST STRIP
NO CODE *
FREESTYLE INSULINX TEST
STRIPS *
FREESTYLE LITE TEST STRIP *
FREESTYLE LITE TEST STRIPS *
FREESTYLE PREC NEO TEST
STRIPS *
FREESTYLE TEST STRIPS *
FREESTYLE UNISTIK 2 LANCETS *
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
G-4 TEST STRIPS *
GE100 BLOOD GLUCOSE TEST
STRIP 2 VIALS X 25 STRIPS *
$0 (Tier 3)
$0 (Tier 3)
PA; QL (100 per 20
days)
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133
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
GENSTRIP GLUCOSE TEST STRIP *
GENULTIMATE TEST STRIP *
$0 (Tier 3)
$0 (Tier 3)
GLUCO NAVII GLUCOSE TEST
STRIP *
GLUCOCARD 01 SENSOR PLUS
STRIP *
GLUCOCARD EXPRESSION TEST
STRP *
GLUCOCARD SHINE TEST STRIPS
*
GLUCOCARD VITAL SENSOR
STRIP *
GLUCOCARD VITAL TEST STRIPS
*
GLUCOCOM 28G LANCETS 28
GAUGE *
GAUGE *
GAUGE *
GLUCOCOM GLUCOSE TEST STRIP
*
GLUCOSOURCE LANCETS *
$0 (Tier 3)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
GMATE 30G LANCETS 30 GAUGE *
$0 (Tier 4)
GMATE TEST STRIPS *
GNP UNIVERSAL 1 STANDARD
21G 21 GAUGE *
GNP UNIVERSAL 1 SUPER THIN
30G 30 GAUGE *
HEALTHPRO GLUCOSE TEST
STRIPS *
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
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134
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
HEALTHY ACCENTS UNILET 30G
30 GAUGE *
INCONTROL SUPER THIN 30G
LANCT 30 GAUGE *
INCONTROL ULTRA THIN 28G
LANCT 28 GAUGE *
INFINITY TEST STRIPS *
INJECT EASE 28G LANCETS 28
GAUGE *
INJECT EASE 30G LANCETS 30
GAUGE *
INSPIRACHAMBER *
INSPIRACHAMBER WITH
MASK-MED *
INSULIN SYRINGE-NEEDLE U-100
SYRINGE 0.3 ML 29 GAUGE, 1 ML
29 GAUGE X 1/2", 1/2 ML 28 GAUGE
INVACARE 30G LANCETS 30
GAUGE *
KINNEY BRAND 23G LANCETS 23
GAUGE *
KRO PREMIUM BLOOD GLUCOSE
TEST NO CODING,PREMIUM *
KRO UNIVERSAL 1 THIN 26G
LANCT 26 GAUGE *
KROGER SUPER THIN LANCETS *
$0 (Tier 4)
LANCETS THIN 23G 23 GAUGE *
$0 (Tier 4)
LANCETS ULTRA THIN 26G 26
GAUGE *
LIBERTY TEST STRIPS BLOOD
GLUCOSE *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
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135
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
LITE TOUCH 30G LANCETS 30
GAUGE *
LITE TOUCH 33G LANCETS 33
GAUGE *
LITEAIRE MDI CHAMBER *
LONGS THIN LANCETS 30G 30G *
$0 (Tier 4)
MAGELLAN TUBERCULIN SYR 1
ML 1 ML 27 GAUGE X 1/2" *
MAXIMA TEST STRIP *
MEDI-LANCE LANCETS *
$0 (Tier 4)
MEDISENSE THIN 28G LANCETS 28
GAUGE *
MEDLANCE PLUS 21G LANCETS
UNIVERSAL, 1.8MM 21 GAUGE *
MEDLANCE PLUS 30G LANCETS
SUPERLITE, 1.2MM 30 GAUGE *
MEDLANCE PLUS LITE 25G
LANCETS STERILE, 1.5MM 25
GAUGE *
MICRO THIN 33G LANCETS
UNIVERSAL 1 33 GAUGE *
MICROCHAMBER LATEX/F *
MICRODOT TEST STRIPS *
MICRODOT XTRA TEST STRIPS *
MICROLET LANCETS *
$0 (Tier 4)
MICROSPACER FOR AEROSOL
DEVICE LATEX/F *
MONAGHAN Z STAT
CHAMBER-MD MSK *
MONOJECT 1 ML TB SYRN 25X5/8"
1 ML 25 GAUGE X 5/8" *
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 4)
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136
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
MONOJECT 3 ML SYRINGE 3 ML *
MONOJECT 3 ML SYRN 25GX1" 3
ML 25 GAUGE X 1" *
MONOJECT 3 ML SYRN 25GX5/8"
LUER-LOCK, SOFTPACK 3 ML 25 X
5/8" *
MONOJECT 3 ML SYRN 27GX1.25"
LUER LOCK,SOFTPACK 3 ML 27
GAUGE X 1 1/4" *
MONOJECT LUER LOCK TB SYR 1
ML 1 ML *
MONOJECT PHARMACY TRAY 40'S
(OTC) 1 ML *
MONOJECT PHARMACY TRAY
LATEX-FREE (RX) 1 ML *
MONOJECT SAFETY SYRINGE 3
ML *
MONOJECT SYR PHARM TRAY PK
3 ML *
MONOJECT SYRINGE 3 ML
SOFTPK, REG LUER TIP 3 ML *
MONOJECT TB 1 ML SYRN 26X3/8"
1 ML 26 X 3/8" *
MONOJECT TB 1 ML SYRN 28GX1/2
1 ML 28 GAUGE X 1/2" *
MONOJECT TB SAFETY SYRINGE 1
MONOJECT TB SYRN 27GX1/2" 1
ML 27 X 1/2" *
MONOJECT TUBERCULIN SYR 1
ML REGULAR LUER TIP (OTC) 1
ML *
MONOLET 21G LANCETS 21
GAUGE *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
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137
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
MONOLET THIN 28G LANCETS 28
GAUGE *
MYGLUCOHEALTH 30G LANCETS
30 GAUGE *
MYGLUCOHEALTH TEST STRIPS *
NEUTEK 2TEK TEST STRIPS *
NOVA MAX GLUCOSE TEST STRIP
*
NOVA SAFETY 23G LANCETS 23
GAUGE *
NOVA SAFETY 28G LANCETS 28
GAUGE *
NOVA SUREFLEX THIN LANCETS
*
ON CALL 30G LANCET 30 GAUGE *
$0 (Tier 4)
ON CALL EXPRESS TEST STRIP *
ON CALL PLUS 30G LANCET 30
GAUGE *
ON CALL PLUS TEST STRIP *
ON CALL VIVID TEST STRIP *
ONE TOUCH DELICA 33G
LANCETS 33 GAUGE *
ONETOUCH DELICA 30G LANCETS
30 GAUGE *
ONETOUCH DELICA 33G LANCETS
33 GAUGE *
ONETOUCH FINEPOINT 25G
LANCETS 25 GAUGE *
ONETOUCH ULTRA TEST STRIPS *
ONETOUCH ULTRASOFT
LANCETS *
ONETOUCH VERIO TEST STRIP *
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
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138
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
OPTICHAMBER ADULT
MASK-LARGE *
OPTICHAMBER DIAMOND VHC *
OPTIUM EZ TEST STRIP *
OPTIUM TEST STRIP *
OPTUMRX TEST STRIP *
PEN NEEDLE, DIABETIC NEEDLE
29 GAUGE X 1/2"
PHARMACIST CHOICE 30G
LANCETS ULTRA THIN 30 GAUGE
*
PHARMACIST CHOICE TEST
STRIPS *
PHARMACIST CHOICE TEST
STRIPS *
POCKET CHAMBER *
PRECISION PCX PLUS TEST STR *
PRECISION PCX TEST STRIPS *
PRECISION POINT OF CARE STR *
PRECISION Q-I-D TEST STRIPS *
PRECISION XTRA TEST STRIPS *
PREMIUM V10 GLUCOSE TEST
STRIP *
PRESSURE ACTIVATED 21G
LANCETS 21 GAUGE *
PRESSURE ACTIVATED 28G
LANCETS 28 GAUGE *
PRIMEAIRE CHAMBER *
PROCHAMBER HOLDING
CHAMBER *
PRODIGY NO CODING TEST
STRIPS 50 STRIPS *
PRODIGY PRESSURE ACTIVATED
28G 28 GAUGE *
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 1)
$0 (Tier 4)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
this document
139
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
PRODIGY SAFETY 26G LANCETS
26 GAUGE *
PRODIGY TWIST TOP 28G LANCET
28 GAUGE *
PUB 28G LANCETS 28 GAUGE *
$0 (Tier 4)
PUSH BUTTON SAFETY 21G
LANCET 21 GAUGE *
PUSH BUTTON SAFETY 28G
LANCET 28 GAUGE *
PV TRUETRACK SMART SYS
STRIPS *
QC UNILET SUPER THIN 30G
LANCT 30 GAUGE *
QUINTET AC GLUCOSE TEST
STRIPS *
QUINTET GLUCOSE TEST STRIPS *
RA E-ZJECT 26G LANCETS 26
GAUGE *
RA E-ZJECT 28G LANCETS 28
GAUGE *
REFUAH PLUS TEST STRIPS *
RELIAMED 30G LANCETS 30
GAUGE *
RELIAMED SAFETY 23G LANCETS
23 GAUGE *
RELIAMED SAFETY 28G LANCETS
LATEX-FREE 28 GAUGE *
RELIAMED SAFETY SEAL 28G
LANCT 28 GAUGE *
RELIAMED SAFETY SEAL 30G
LANCT 30 GAUGE *
RELION CONFIRM-MICRO TEST
STRP *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
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140
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
RELION MICRO TEST STRIPS *
RELION PRIME TEST STRIPS *
RELION THIN 26G LANCETS 26
GAUGE *
RELION ULTIMA TEST STRIPS *
RELION ULTRA THIN PLUS 33G 33
GAUGE *
RELION ULTRA THIN PLUS
LANCETS *
REVEAL TEST STRIP *
RIGHTEST GL300 30G LANCETS 30
GAUGE *
RIGHTEST GS100 TEST STRIPS *
RIGHTEST GS250S TEST STRIPS *
RITEFLO SPACER *
SAFESNAP SYRINGE 3 ML 3 ML 25
GAUGE X 5/8", 3 ML 25 X 1" *
SAFESNAP TUBERCULIN SYR 1
ML 1 ML 25 GAUGE X 5/8" *
SAFESNAP TUBERCULIN SYR 1
ML 27GX0.5",LATEX-FREE 1 ML 27
GAUGE X 1/2" *
SAFETY 21G LANCETS
SAFETY 28G LANCETS
SAFETY LANCETS 26G 26 GAUGE *
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
SAFETY SEAL 28G LANCETS 28
GAUGE *
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
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141
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
SAFETY SEAL 30G LANCETS 30
GAUGE *
SAFETY SYRINGE W-SHIELD 3 ML
3 ML 25 GAUGE X 5/8" *
SAFETY-LET 30G LANCETS 30
GAUGE *
SAFETY-LOK 3 ML SYRINGE 3 ML
*
SAFETY-LOK 3 ML SYRINGE 3 ML
25 GAUGE X 5/8" *
SHOPKO ON-THE-GO 30G
LANCETS GENTLE 30 GAUGE *
SHOPKO UNILET ULTRA THIN 28G
STERILE 28 GAUGE *
SINGLE-LET LANCETS *
$0 (Tier 4)
SM COLOR LANCETS 21G 21
GAUGE *
SM LANCETS 21G 21 GAUGE *
$0 (Tier 4)
SM THIN LANCETS 26G 26 GAUGE
*
SMART SENSE COLOR 33G
LANCETS 33 GAUGE *
SMART SENSE STANDARD 21G 21
GAUGE *
SMART SENSE TEST STRIPS
PREMIUM, NO CODE *
SMART SENSE THIN 26G LANCETS
26 GAUGE *
SMARTEST LANCET *
$0 (Tier 4)
SMARTEST TEST STRIPS *
$0 (Tier 3)
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
this document
142
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
SOFT TOUCH LANCETS *
$0 (Tier 4)
SOLUS V2 28G LANCETS 28 GAUGE
*
SOLUS V2 30G TWIST LANCETS 30
GAUGE *
SOLUS V2 AUDIBLE TEST STRIPS *
SPACE CHAMBER PLUS *
STERILANCE TL TWIST 30G
LANCET 30 GAUGE *
STERILANCE TL TWIST 32G
LANCET 32 GAUGE *
SUPER THIN 28G LANCETS
STERILE 28 GAUGE *
SUPER THIN 33G LANCETS 33
GAUGE *
SURE COMFORT 28G LANCETS 28
GAUGE *
SURE COMFORT 30G LANCETS 30
GAUGE *
SURE-LANCE 26G LANCETS 26
GAUGE *
SURE-LANCE FLAT LANCETS *
$0 (Tier 4)
SURE-LANCE THIN 28G LANCETS
28 GAUGE *
SURE-LANCE ULTRA THIN 30G 30
GAUGE *
SURE-TEST EASYPLUS MINI STRIP
*
SURE-TOUCH LANCET *
$0 (Tier 4)
TD GOLD TEST STRIP *
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
this document
143
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
TECHLITE 28G LANCETS 28
GAUGE *
TECHLITE 30G LANCETS 30
GAUGE *
TELCARE TEST STRIPS *
TELCARE ULTRA THIN 30G
LANCETS 30 GAUGE *
TERUMO SURGUARD2 SYR 25G 3
ML 3 ML 25 GAUGE X 1", 3 ML 25
GAUGE X 5/8" *
TERUMO SYRINGE 3 ML 3 ML 25
GAUGE X 1", 3 ML 25 X 5/8" *
TEST N'GO GLUCOSE TEST STRIP *
THIN LANCETS 28G 28 GAUGE *
$0 (Tier 4)
TOPCARE UNIVERSAL1 33G
LANCETS 33 GAUGE *
TOPCARE UNIVERSAL1 THIN
LANCET ULTRA THIN, 30G *
TRUE METRIX GLUCOSE TEST
STRIP *
TRUEPLUS 26G LANCETS 26
GAUGE *
TRUEPLUS 33G LANCETS 33
GAUGE *
TRUEPLUS SAFETY 28G LANCETS
28G, STERILE 28 GAUGE *
TRUEPLUS SUPER THIN 28G
LANCET 28G, STERILE 28 GAUGE *
TRUEPLUS ULTRA THIN 30G
LANCET 30 GAUGE *
TRUETEST GLUCOSE TEST STRIPS
*
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
this document
144
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
TRUETEST GLUCOSE TEST STRIPS
HRI *
TRUETRACK GLUCOSE TEST
STRIPS *
TUBERCULIN 1 ML SYRINGE SLIP
TIP DET.NEEDLE (OTC) 1 ML 25
GAUGE X 1" *
TUBERCULIN SYRINGE 1 ML 28
GAUGE X 1/2" *
TUBERCULIN SYRINGES 1/2 ML 28
X 1/2" *
ULTILET 28G LANCETS 28 GAUGE
*
*
*
ULTILET BASIC 30G LANCETS 30
GAUGE *
ULTILET CLASSIC 26G LANCETS *
$0 (Tier 3)
$0 (Tier 3)
ULTILET CLASSIC 28G LANCETS 28
GAUGE *
GAUGE *
GAUGE *
ULTILET SAFETY 23G LANCETS 23
GAUGE *
ULTIMA TEST STRIPS *
ULTRA THIN 28G LANCETS
ULTRA THIN 28 GAUGE *
ULTRA THIN 30G LANCETS
STERILE 30 GAUGE *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
this document
145
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ULTRA THIN 31G LANCETS 31
GAUGE *
ULTRA THIN 33G LANCETS 33
GAUGE *
ULTRALANCE 26G LANCETS 26
GAUGE *
ULTRALANCE 28G LANCETS 28
GAUGE *
ULTRA-THIN II 26G LANCET 26
GAUGE *
ULTRA-THIN II 28G LANCETS 28
GAUGE *
ULTRA-THIN II 30G LANCETS 30
GAUGE *
ULTRATLC LANCETS *
$0 (Tier 4)
ULTRATRAK TEST STRIP *
ULTRATRAK ULTIMATE TEST
STRIPS *
UNILET COMFORTOUCH 26G
LANCETS 26 GAUGE *
UNILET COMFORTOUCH LANCET
*
UNILET EXCELITE II LANCET *
$0 (Tier 3)
$0 (Tier 3)
UNILET EXCELITE LANCET *
$0 (Tier 4)
UNILET GP LANCET *
$0 (Tier 4)
UNILET LANCET SUPERLITE *
$0 (Tier 4)
UNILET MICRO THIN 33G
LANCETS 33 GAUGE *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
this document
146
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
UNISTIK 3 COMFORT LANCET *
$0 (Tier 4)
UNISTIK 3 EXTRA 21G LANCETS 21
GAUGE *
UNISTIK 3 GENTLE ON-THE-GO
30G 30 GAUGE *
UNISTIK 3 NORMAL 23G LANCETS
23 GAUGE *
UNISTIK 3 SAFETY 21G LANCETS
21 GAUGE *
UNISTIK CZT COMFORT 28G
LANCET 28 GAUGE *
UNISTIK CZT NORMAL 23G
LANCETS 23 GAUGE *
UNISTIK SAFETY 28G LANCET 28
GAUGE *
UNISTIK SAFETY 30G LANCETS 30
GAUGE *
UNISTIK TOUCH 21G LANCETS 21
GAUGE *
GAUGE *
GAUGE *
GAUGE *
UNISTRIP1 GLUCOSE TEST STRIP *
UNIVERSAL 1 33G LANCETS FOR
MEIJER 33 GAUGE *
UP & UP BLOOD GLUCOSE TST
STRP NO CODING *
VANISHPOINT 25GX1" 3 ML
SYRING 3 ML 25 GAUGE X 1" *
VGO 40 DISPOSABLE DEVICE
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 1)
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147
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
VORTEX HOLDING CHAMBER *
VORTEX VHC FROG CHILD MASK
*
WALGREENS ULTRA THIN
LANCETS *
WAVESENSE JAZZ TEST STRIPS *
WAVESENSE PRESTO TEST STRIPS
*
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
PA; QL (100 per 20
days)
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN INTRAMUSCULAR
ALDURAZYME INTRAVENOUS
SOLUTION 2.9 MG/5 ML
CEREZYME INTRAVENOUS
RECON SOLN 400 UNIT
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
ELAPRASE INTRAVENOUS
SOLUTION 6 MG/3 ML
ELITEK INTRAVENOUS RECON
SOLN 1.5 MG, 7.5 MG
FABRAZYME INTRAVENOUS
RECON SOLN 35 MG
KANUMA INTRAVENOUS
SOLUTION 2 MG/ML
KRYSTEXXA INTRAVENOUS
SOLUTION 8 MG/ML
KUVAN ORAL TABLET,SOLUBLE
100 MG
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA
$0 (Tier 2)
$0 (Tier 2)
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148
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
MYOZYME INTRAVENOUS RECON
SOLN 50 MG
NAGLAZYME INTRAVENOUS
SOLUTION 5 MG/5 ML
ORFADIN ORAL CAPSULE 10 MG, 2
MG, 20 MG, 5 MG
pancrelipase 5000 oral capsule,delayed
(Zenpep)
release(dr/ec) 5,000-17,000 -27,000 unit
PULMOZYME INHALATION
SOLUTION 1 MG/ML
STRENSIQ SUBCUTANEOUS
VIMIZIM INTRAVENOUS
SOLUTION 5 MG/5 ML (1 MG/ML)
VPRIV INTRAVENOUS RECON
SOLN 400 UNIT
ZAVESCA ORAL CAPSULE 100 MG
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
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA; LA
$0 (Tier 2)
PA
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
QL (90 per 30 days)
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents,
Miscellaneous
advanced eye relief opth oint 80-20 % *
(Genteal Pm)
AKTEN (PF) OPHTHALMIC GEL 3.5
%
alaway 0.025% eye drops 0.025 % (0.035 (Zaditor)
%) *
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 4)
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149
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
alcaine ophthalmic drops 0.5 %
altacaine ophthalmic drops 0.5 %
altamist 0.65% nose spray 0.65 % *
altazine 0.05% eye drops 0.05 % *
apraclonidine ophthalmic drops 0.5 %
artificial tears *
artificial tears 1.4 % drops 1.4 % *
artificial tears drops p/f, sterile 0.1-0.3 %
*
artificial tears drops sterile, lubricant
1-0.2-0.2 % *
artificial tears eye drops strl 0.1-0.3 % *
artificial tears eye ointment 83-15 % *
atropine ophthalmic drops 1 %
atropine ophthalmic ointment 1 %
atropine-care ophthalmic drops 1 %
ayr saline 0.65% nose drops 0.65 % *
ayr saline 0.65% nose spray 0.65 % *
azelastine nasal aerosol,spray 137 mcg
(0.1 %)
azelastine ophthalmic drops 0.05 %
bion tears eye drops 0.1-0.3 % *
(Proparacaine HCl)
(Tetravisc)
(Little Remedies)
(Visine)
(Iopidine)
(Dextran
70/Hypromellose)
(Polyvinyl Alcohol)
(Dextran
70/Hypromellose/PF)
(Visine)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
(Tears Naturale)
(Genteal Pm)
(Isopto Atropine)
(Atropine Sulfate)
(Isopto Atropine)
(Sodium Chloride)
(Little Remedies)
(Astepro)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
(Azelastine HCl)
(Dextran
70/Hypromellose/PF)
carteolol ophthalmic drops 1 %
(Carteolol HCl)
cromolyn ophthalmic drops 4 %
(Cromolyn Sodium)
cvs eye allergy relief eye drp 0.025-0.3 % * (Opcon-A)
cvs eye drops dual action sterile 0.05-0.25 (Visine Allergy
%*
Relief)
cvs eye wash solution *
(Sodium/Potassium/S
od Chl)
cvs lubricant 0.5% eye drops sterile 0.5 % (Refresh Tears)
*
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
QL (30 per 25 days)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
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150
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
cvs lubricant dry eye rlf 1% 1 % *
cvs lubricant eye ointment p/f 57.3-42.5 %
*
cvs lubricating eye drops dry eye soln
0.5-0.9 % *
cvs maximum redness relief drp 0.03-0.5 %
*
cvs natural tears drops 0.1-0.3 % *
cvs redness relief drops original 0.012-0.2
%*
cvs redness relief eye drops sterile
0.012-0.2 % *
cvs saline 3% nasal mist 3 % *
cyclopentolate ophthalmic drops 0.5 %, 1
%, 2 %
CYSTARAN OPHTHALMIC DROPS
0.44 %
deep sea 0.65% nose spray 0.65 % *
dristan long lasting mist 0.05 % *
epinastine ophthalmic drops 0.05 %
eq gentle 0.3% eye drops 0.3 % *
eq revive plus 0.5% eye drops 0.5 % *
eql nasal decngstnt nose drops 1 % *
eye drops max relief,strl 0.05-0.1-1-1 % *
flucaine ophthalmic drops 0.25-0.5 %
for sty relief eye ointment *
GENTEAL GEL DROPS 0.25-0.3 % *
genteal tears 0.1%-0.3% drop 0.1-0.3 % *
(Carboxymethylcellul
ose Sodium)
(Genteal Pm)
$0 (Tier 4)
(Refresh Optive)
$0 (Tier 4)
(Advanced Eye Relief
Redness)
(Dextran
70/Hypromellose/PF)
(Naphazoline
HCl/Peg 300)
(Clear Eyes Redness
Relief)
(Sodium Chloride)
(Cyclogyl)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 2)
(Little Remedies)
(Oxymetazoline HCl)
(Elestat)
(Genteal Mild To
Moderate)
ose Sodium)
(Phenylephrine HCl)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
(Visine Advanced)
(Proparacaine/Fluore
scein Sod)
(Genteal Pm)
$0 (Tier 4)
$0 (Tier 1)
(Tears Naturale)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
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151
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
homatropaire ophthalmic drops 5 %
homatropine hbr ophthalmic drops 5 %
ipratropium bromide nasal
spray,non-aerosol 0.03 %
ipratropium bromide nasal
spray,non-aerosol 0.06 %
ketotifen fum 0.025% eye drops (otc)
0.025 % (0.035 %) *
LACRISERT OPHTHALMIC INSERT
5 MG
little remedies stuffy nose kt w/ nasal
aspirator 0.65 % *
lubricant 0.6% eye drops 0.6 % *
lubricant pm eye ointment p/f 57.3-42.5 %
*
lubricant redness eye drops redness
relief,strl 0.03-0.5 % *
lubricant redness reliever drp 0.05-1 % *
lubrifresh pm eye ointment 83-15 % *
mucinex sinus-max nasal spray full force
0.05 % *
muro-128 2% eye drops 2 % *
muro-128 5% eye drops 5 % *
muro-128 5% eye ointment 5 % *
naphazoline ophthalmic drops 0.1 %
nasal decongestant 0.05% spray 0.05 % *
natural balance tears drops 0.4 % *
nature's tears drops 0.4 % *
neo-synephrine 12 hour spray 0.05 % *
(Isopto
Homatropine)
(Isopto
Homatropine)
(Atrovent)
$0 (Tier 1)
$0 (Tier 1)
QL (30 per 28 days)
(Atrovent)
$0 (Tier 1)
QL (15 per 10 days)
(Zaditor)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 2)
(Little Remedies)
$0 (Tier 4)
(Propylene Glycol)
(Genteal Pm)
$0 (Tier 4)
$0 (Tier 4)
Redness)
(Tetrahydrozoline
HCl/Peg)
(Genteal Pm)
(Afrin)
$0 (Tier 4)
(Sodium Chloride)
(Sodium Chloride)
(Sodium Chloride)
(Naphazoline HCl)
(Afrin)
(Genteal Mild To
Moderate)
(Genteal Mild To
Moderate)
(Oxymetazoline HCl)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
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152
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ocean 0.65% nasal spray 0.65 % *
olopatadine ophthalmic drops 0.1 %
opti-clear 0.05% eye drops 0.05 % *
PATADAY OPHTHALMIC DROPS
0.2 %
phenylephrine hcl ophthalmic drops 10 %,
2.5 %
proparacaine ophthalmic drops 0.5 %
puralube ophthalmic ointment p/f, sterile,
outer 85-15 % *
pure & gentle eye drops lubricant 0.3 % *
pv artificial tears 0.4 % *
pv lubricant 1.4 % eye drops 1.4 % *
pv pure-gentle eye drops sterile 0.3 % *
ra eye allergy relief drops 0.02675-0.315
%*
ra sterile eye drops 0.012-0.2 % *
ra sterile eye drops 0.03-0.5 % *
redness lubricant eye drops regular, strl
0.012-0.2 % *
redness relief eye drops 0.012-0.25 %,
0.03-0.5 % *
REFRESH TEARS 0.5% EYE DROPS
0.5 % *
retaine cmc 0.5% eye drops 0.5 % *
retaine hpmc 0.3% eye drops 0.3 % *
retaine pm eye ointment 80-20 % *
saline mist 0.65% nose spry 0.65 % *
(Little Remedies)
(Patanol)
(Visine)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 2)
(Mydfrin)
$0 (Tier 1)
(Proparacaine HCl)
(Genteal Pm)
$0 (Tier 1)
$0 (Tier 4)
(Genteal Mild To
Moderate)
(Genteal Mild To
Moderate)
(Polyvinyl Alcohol)
(Genteal Mild To
Moderate)
(Opcon-A)
$0 (Tier 4)
(Naphazoline
HCl/Peg 300)
Redness)
(Naphazoline
HCl/Peg 300)
(Clear Eyes Redness
Relief)
$0 (Tier 4)
ST
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
ose Sodium)
(Hypromellose/PF)
(Genteal Pm)
(Little Remedies)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
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153
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
sea soft 0.65% nasal mist 0.65 % *
sm eye wash solution *
sm nose drops 1 % *
sochlor 5% eye drops 5 % *
sodium chloride 5% eye drop 5 % *
sodium chloride 5% eye oint 5 % *
SYSTANE BALANCE 0.6% EYE
DROP CLINICAL STRENGTH 0.6 %
*
systane nighttime eye oint 94-3 % *
tears again 1.4 % drops 1.4 % *
tears naturale free drops u-d,36x.9ml,p/f
0.1-0.3 % *
tears naturale pm eye oint 94-3 % *
tetracaine hcl (pf) ophthalmic drops 0.5 %
vicks qlearquil 0.05% mist 0.05 % *
vicks sinex 12 hour spray 0.05 % *
VISINE MAX REDNESS RELIEF
DROP 0.05-1-0.36-0.2 % *
VISINE TOTALITY EYE DROPS 0.05
%-0.25 %- 1 %-0.36 % *
visine-a eye allergy drops 0.025-0.3 % *
wal-zyr 0.025% eye drops 0.025 % (0.035
%) *
zyrtec itchy eye 0.025% drops 0.025 %
(0.035 %) *
Eye, Ear, Nose, Throat
Anti-Infectives Agents
acetic acid otic solution 2 %
auraphene-b 6.5% ear drops 6.5 % *
auro 6.5% ear drops 6.5 % *
(Little Remedies)
(Sodium/Potassium/S
od Chl)
(Phenylephrine HCl)
$0 (Tier 4)
$0 (Tier 4)
(Sodium Chloride)
(Sodium Chloride)
(Sodium Chloride)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Genteal Pm)
(Polyvinyl Alcohol)
(Dextran
70/Hypromellose/PF)
(Genteal Pm)
(Tetracaine HCl/PF)
(Oxymetazoline HCl)
(Afrin)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Opcon-A)
(Zaditor)
$0 (Tier 4)
$0 (Tier 4)
(Zaditor)
$0 (Tier 4)
(Acetic Acid)
(Carbamide Peroxide)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
this document
154
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
bacitracin ophthalmic ointment 500
unit/gram
bacitracin-polymyxin b ophthalmic
ointment 500-10,000 unit/gram
bleph-10 ophthalmic drops 10 %
CIPRODEX OTIC
DROPS,SUSPENSION 0.3-0.1 %
ciprofloxacin hcl ophthalmic drops 0.3 %
ciprofloxacin hcl otic dropperette 0.2 %
COLY-MYCIN S OTIC
DROPS,SUSPENSION 3.3-3-10-0.5
MG/ML
debrox 6.5% ear drops 6.5 % *
ear drops 6.5% 6.5 % *
erythromycin ophthalmic ointment 5
mg/gram (0.5 %)
gatifloxacin ophthalmic drops 0.5 %
gentak ophthalmic ointment 0.3 % (3
mg/gram)
gentamicin ophthalmic drops 0.3 %
gentamicin ophthalmic ointment 0.3 % (3
mg/gram)
levofloxacin ophthalmic drops 0.5 %
MOXEZA OPHTHALMIC DROPS,
VISCOUS 0.5 %
murine 6.5% ear drops 6.5 % *
murine ear wax removal system 6.5 % *
NATACYN OPHTHALMIC
DROPS,SUSPENSION 5 %
neomycin-bacitracin-poly-hc ophthalmic
ointment 3.5-400-10,000 mg-unit/g-1%
(Bacitracin)
$0 (Tier 1)
n B Sulfate)
(Sulfacetamide
Sodium)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Ciloxan)
(Cetraxal)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Ilotycin)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
(Zymaxid)
(Garamycin)
$0 (Tier 1)
$0 (Tier 1)
(Garamycin)
(Garamycin)
$0 (Tier 1)
$0 (Tier 1)
(Levofloxacin)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
(Neomycin Su/Baci
Zn/Poly/HC)
$0 (Tier 1)
this document
155
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
neomycin-bacitracin-polymyxin
ophthalmic ointment 3.5-400-10,000
mg-unit-unit/g
neomycin-polymyxin b-dexameth
ophthalmic drops,suspension
3.5mg/ml-10,000 unit/ml-0.1 %
ophthalmic ointment 3.5 mg/g-10,000
unit/g-0.1 %
neomycin-polymyxin-gramicidin
ophthalmic drops 1.75 mg-10,000
unit-0.025mg/ml
neomycin-polymyxin-hc ophthalmic
drops,suspension 3.5-10,000-10
mg-unit-mg/ml
neomycin-polymyxin-hc otic
drops,suspension 3.5-10,000-1
mg/ml-unit/ml-%
neomycin-polymyxin-hc otic solution
3.5-10,000-1 mg/ml-unit/ml-%
neo-polycin hc ophthalmic ointment
3.5-400-10,000 mg-unit/g-1%
neo-polycin ophthalmic ointment
3.5-400-10,000 mg-unit-unit/g
(Neomycin
Su/Bacitra/Polymyxin
)
(Maxitrol)
$0 (Tier 1)
(Maxitrol)
$0 (Tier 1)
(Neosporin)
$0 (Tier 1)
(Neomycin/Polymyxi
n B Sulf/HC)
$0 (Tier 1)
(Neomycin/Polymyxi
n B Sulf/HC)
$0 (Tier 1)
(Cortisporin)
$0 (Tier 1)
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin
Su/Bacitra/Polymyxin
)
ofloxacin ophthalmic drops 0.3 %
(Floxin)
ofloxacin otic drops 0.3 %
(Floxin)
polymyxin b sulf-trimethoprim ophthalmic (Polytrim)
drops 10,000 unit- 1 mg/ml
sulfacetamide sodium ophthalmic drops 10 (Sulfacetamide
%
Sodium)
sulfacetamide sodium ophthalmic ointment (Sulfacetamide
10 %
Sodium)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
this document
156
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
sulfacetamide-prednisolone ophthalmic
drops 10 %-0.23 % (0.25 %)
TOBRADEX OPHTHALMIC
OINTMENT 0.3-0.1 %
TOBRADEX ST OPHTHALMIC
tobramycin ophthalmic drops 0.3 %
tobramycin-dexamethasone ophthalmic
drops,suspension 0.3-0.1 %
trifluridine ophthalmic drops 1 %
VIGAMOX OPHTHALMIC DROPS
0.5 %
ZIRGAN OPHTHALMIC GEL 0.15 %
ZYLET OPHTHALMIC
Eye, Ear, Nose, Throat
Anti-Inflammatory Agents
ALREX OPHTHALMIC
DROPS,SUSPENSION 0.2 %
bromfenac ophthalmic drops 0.09 %
CHILD NASACORT ALLERGY 24
HR 55 MCG *
dexamethasone sodium phosphate
ophthalmic drops 0.1 %
diclofenac sodium ophthalmic drops 0.1 %
DUREZOL OPHTHALMIC DROPS
0.05 %
FLONASE ALLERGY RLF 50 MCG
SPR 120 METERED SPRAYS 50
MCG/ACTUATION *
flunisolide nasal spray,non-aerosol 25 mcg
(0.025 %)
fluorometholone ophthalmic
drops,suspension 0.1 %
(Sulfacetamide/Predn
isolone Sp)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
(Tobrex)
(Tobradex)
$0 (Tier 1)
$0 (Tier 1)
(Viroptic)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Bromfenac Sodium)
$0 (Tier 1)
$0 (Tier 4)
(Dexasol)
$0 (Tier 1)
(Diclofenac Sodium)
$0 (Tier 1)
$0 (Tier 2)
ST
$0 (Tier 4)
(Flunisolide)
$0 (Tier 1)
(FML)
$0 (Tier 1)
QL (50 per 25 days)
this document
157
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
flurbiprofen sodium ophthalmic drops 0.03
%
fluticasone nasal spray,suspension 50
mcg/actuation
ILEVRO OPHTHALMIC
ketorolac ophthalmic drops 0.4 %, 0.5 %
LOTEMAX OPHTHALMIC
DROPS,GEL 0.5 %
LOTEMAX OPHTHALMIC
LOTEMAX OPHTHALMIC
OINTMENT 0.5 %
NASACORT ALLERGY 24HR
SPRAY MULTI-SYMP,60 SPRAYS 55
MCG *
nasal allergy 24hr spray 55 mcg *
NEVANAC OPHTHALMIC
prednisolone acetate ophthalmic
drops,suspension 1 %
prednisolone sodium phosphate ophthalmic
drops 1 %
PROLENSA OPHTHALMIC DROPS
0.07 %
RESTASIS OPHTHALMIC
DROPPERETTE 0.05 %
triamcinolone 55 mcg nasal spr (otc) 55
mcg *
XIIDRA OPHTHALMIC
DROPPERETTE 5 %
(Ocufen)
$0 (Tier 1)
(Fluticasone
Propionate)
$0 (Tier 1)
$0 (Tier 2)
(Acular)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 4)
(Nasacort)
$0 (Tier 4)
$0 (Tier 2)
(Omnipred)
$0 (Tier 1)
(Prednisolone Sod
Phosphate)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
(Nasacort)
QL (60 per 30 days)
$0 (Tier 4)
$0 (Tier 2)
PA; QL (60 per 30
days)
Gastrointestinal Agents
Antiflatulents
bicarsim forte 125 mg tablet 125 mg *
(Simethicone)
$0 (Tier 4)
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158
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
cvs gas relief 125 mg chew tab extra
strength 125 mg *
cvs gas relief 125 mg softgel softgel 125
mg *
cvs gas relief 80 mg tab chew 80 mg *
gas relief 125 mg chew tablet max
str,lactose-free 125 mg *
gas relief 80 mg tablet chew lactose-free
80 mg *
gas-x extra strength softgel softgel,
ex-strength 125 mg *
gas-x ultra strength softgel 180 mg *
mi-acid gas 80 mg tab chew 80 mg *
mytab gas 80 mg tablet chew 80 mg *
mytab gas max str 125 mg tab 125 mg *
simethicone 180 mg softgel 180 mg *
simethicone 40 mg/0.6 ml drop 40 mg/0.6
ml *
v-r anti-gas 166 mg softgel 166 mg *
Antiulcer Agents And Acid
Suppressants
acid reducer 20 mg tablet maximum
strength 20 mg *
amoxicil-clarithromy-lansopraz oral
combo pack 500-500-30 mg
CARAFATE ORAL SUSPENSION 100
MG/ML
cimetidine hcl oral solution 300 mg/5 ml
cimetidine oral tablet 200 mg, 300 mg, 400
mg, 800 mg
cvs cimetidine 200 mg tablet (otc) 200 mg
*
esomeprazole sodium intravenous recon
soln 20 mg, 40 mg
(Gas-X)
$0 (Tier 4)
(Phazyme)
$0 (Tier 4)
(Gas-X)
(Gas-X)
$0 (Tier 4)
$0 (Tier 4)
(Gas-X)
$0 (Tier 4)
(Phazyme)
$0 (Tier 4)
(Phazyme)
(Gas-X)
(Gas-X)
(Gas-X)
(Phazyme)
(Simethicone)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Phazyme)
$0 (Tier 4)
(Pepcid Ac)
$0 (Tier 4)
(Prevpac)
$0 (Tier 1)
$0 (Tier 2)
(Cimetidine HCl)
(Cimetidine)
$0 (Tier 1)
$0 (Tier 1)
(Tagamet Hb)
$0 (Tier 4)
(Nexium I.V.)
$0 (Tier 1)
(Rx Product Only)
this document
159
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
famotidine (pf) intravenous solution 20
mg/2 ml
famotidine (pf)-nacl (iso-os) intravenous
famotidine 40 mg/4 ml vial 25's,outer 10
mg/ml
famotidine oral tablet 20 mg, 40 mg
gnp acid reducer 10 mg tablet 10 mg *
lansoprazole dr 15 mg capsule na/f (otc)
15 mg *
lansoprazole oral capsule,delayed
release(dr/ec) 15 mg, 30 mg
misoprostol oral tablet 100 mcg, 200 mcg
NEXIUM 24HR 22.3 MG CAPSULE
22.3 MG *
omeprazole dr 20 mg tablet 20 mg *
omeprazole mag dr 20.6 mg cap two
14-days course 20 mg *
omeprazole oral capsule,delayed
release(dr/ec) 10 mg, 20 mg, 40 mg
pantoprazole intravenous recon soln 40 mg
pantoprazole oral tablet,delayed release
(dr/ec) 20 mg, 40 mg
pub famotidine 20 mg tablet max strength
(otc) 20 mg *
pv acid relief 200 mg tablet 200 mg *
ra omeprazole-bicarb 20-1,100 3x14 day
course (otc) 20-1.1 mg-gram *
ranitidine 150 mg tablet maximum
strength (otc) 150 mg *
ranitidine 75 mg tablet s/f, sodium-free 75
mg *
ranitidine hcl 50 mg/2 ml vial sdv 50 mg/2
ml (25 mg/ml)
(Famotidine)
$0 (Tier 1)
(Famotidine In
Nacl,Iso-Osm/PF)
(Famotidine)
$0 (Tier 1)
(Pepcid)
(Pepcid Ac)
(Prevacid 24hr)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
(Rx Product Only)
(Prevacid)
$0 (Tier 1)
(Rx Product Only)
(Cytotec)
$0 (Tier 1)
$0 (Tier 4)
(Omeprazole)
(Omeprazole
Magnesium)
(Prilosec)
$0 (Tier 4)
$0 (Tier 4)
(Protonix IV)
(Protonix)
$0 (Tier 1)
$0 (Tier 1)
(Pepcid Ac)
$0 (Tier 4)
(Tagamet Hb)
(Zegerid Otc)
$0 (Tier 4)
$0 (Tier 4)
(Zantac)
$0 (Tier 4)
(Zantac)
$0 (Tier 4)
(Ranitidine HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Rx Product Only)
this document
160
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ranitidine hcl injection solution 25 mg/ml
ranitidine hcl oral capsule 150 mg, 300 mg
ranitidine hcl oral syrup 15 mg/ml
ranitidine hcl oral tablet 150 mg, 300 mg
sucralfate oral suspension 100 mg/ml
sucralfate oral tablet 1 gram
wal-zan 75 mg tablet 75 mg *
Gastrointestinal Agents, Other
acid gone antacid liquid 95-358 mg/15 ml
*
acid gone tablet chew 160-105 mg *
ALKA-SELTZER GOLD TAB EFF
344-1,050-1,000 MG *
almacone liquid 200-200-20 mg/5 ml *
almacone-2 liquid 400-400-40 mg/5 ml *
aluminum hydroxide gel 600 mg/5 ml *
aluminum hydroxide gel sugar-free 320
mg/5 ml *
AMITIZA ORAL CAPSULE 24 MCG,
8 MCG
antacid 1000-200 mg tab chew 1,000-200
mg *
antacid 675-135 mg tab chew ex-str, asstd
fruit 675-135 mg *
antacid chewable tablet peppermint flavor
550-110 mg *
antacid plus x-stren susp 500-450-40 mg/5
ml *
antacid ultra tablet chew 400 mg (1,000
mg) *
(Ranitidine HCl)
(Ranitidine HCl)
(Ranitidine HCl)
(Zantac)
(Sucralfate)
(Carafate)
(Zantac)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
(Gaviscon)
$0 (Tier 4)
(Gaviscon)
$0 (Tier 4)
$0 (Tier 4)
(Maalox Maximum
Strength)
(Maalox Maximum
Strength)
(Aluminum
Hydroxide)
(Aluminum
Hydroxide)
$0 (Tier 4)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
(Rolaids)
$0 (Tier 4)
(Rolaids)
$0 (Tier 4)
(Rolaids)
$0 (Tier 4)
(Maalox Maximum
Strength)
(Tums)
$0 (Tier 4)
QL (60 per 30 days)
$0 (Tier 4)
this document
161
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
antacid xtra strength chew tab
extra-strength 300 mg (750 mg) *
antacid-antigas liquid 200-200-20 mg/5 ml
*
anti-diarrheal 2 mg caplet caplet 2 mg *
bismatrol 525 mg/15 ml susp 525 mg/15 ml
*
bismatrol suspension 262 mg/15 ml *
BUPHENYL ORAL TABLET 500 MG
calci-chew tablet 500 mg calcium (1,250
mg) *
calcium 500 mg chewable tablet tab
chew,p/f 500 mg calcium (1,250 mg) *
calcium antacid 500 mg chw tab assorted
fruit 200 mg calcium (500 mg) *
cal-gest 500 mg tablet chew 200 mg
calcium (500 mg) *
CARBAGLU ORAL TABLET,
DISPERSIBLE 200 MG
child soothe 400 mg tab chew 400 mg *
children pepto 400 mg tab chew bubble
gum, na/f 400 mg *
comfort gel max str susp max-str
400-400-40 mg/5 ml *
comfort gel suspension regular str, cherry
200-200-20 mg/5 ml *
constulose oral solution 10 gram/15 ml
cromolyn oral concentrate 100 mg/5 ml
cvs antacid supreme liquid 400-135 mg/5
ml *
cvs anti-diarrheal 2 mg sftgel softgel 2 mg
*
(Tums)
$0 (Tier 4)
(Maalox Maximum
Strength)
(Imodium A-D)
(Pepto-Bismol)
$0 (Tier 4)
(Pepto-Bismol)
(Tums)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 4)
(Tums)
$0 (Tier 4)
(Tums)
$0 (Tier 4)
(Tums)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
(Tums)
(Tums)
$0 (Tier 4)
$0 (Tier 4)
(Maalox Maximum
Strength)
(Maalox Maximum
Strength)
(Lactulose)
(Gastrocrom)
(Calcium
Carb/Magnesium
Hydrox)
(Loperamide HCl)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
this document
162
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
cvs anti-diarrheal suspension 262 mg/15 ml
*
cvs heartburn relief chew tab 160-105 mg
*
cvs loperamide 1 mg/7.5 ml liq mint 1
mg/7.5 ml *
diamode 2 mg tablet outer, f/c 2 mg *
dicyclomine oral capsule 10 mg
dicyclomine oral solution 10 mg/5 ml
dicyclomine oral tablet 20 mg
diotame instydose 524 mg/30 ml 524
mg/30 ml *
diphenoxylate-atropine oral liquid
2.5-0.025 mg/5 ml
diphenoxylate-atropine oral tablet
2.5-0.025 mg
enulose oral solution 10 gram/15 ml
flanax antacid liquid 200-200-20 mg/5 ml
*
FLEET PEDIA-LAX TABLET CHEW
400 MG (170 MG) *
foaming antacid liquid 95-358 mg/15 ml *
GATTEX 5 MG 30-VIAL KIT 5 MG
GATTEX ONE-VIAL
SUBCUTANEOUS KIT 5 MG
GAVISCON ES TABLET CHEW
EXTRA STRENGTH 160-105 MG *
gelusil antacid & antigas liq 400-400-40
mg/5 ml *
gelusil tablet chewable cool mint
200-200-25 mg *
generlac oral solution 10 gram/15 ml
glycopyrrolate injection solution 0.2
mg/ml
(Pepto-Bismol)
$0 (Tier 4)
(Gaviscon)
$0 (Tier 4)
(Loperamide HCl)
$0 (Tier 4)
(Imodium A-D)
(Bentyl)
(Dicyclomine HCl)
(Bentyl)
(Bismuth
Subsalicylate)
(Diphenoxylate
HCl/Atropine)
(Lomotil)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
(Lactulose)
(Maalox Maximum
Strength)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
(Gaviscon)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
PA
PA
$0 (Tier 4)
(Maalox Maximum
Strength)
(Almacone)
$0 (Tier 4)
(Lactulose)
(Robinul)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
this document
163
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
glycopyrrolate oral tablet 1 mg, 2 mg
heartburn antacid chew tablet 160-105 mg
*
imodium a-d 1 mg/7.5 ml liquid mint 1
mg/7.5 ml *
kaopectate 262 mg/15 ml susp vanilla
flavor 262 mg/15 ml *
kaopectate extra strength liq peppermint
525 mg/15 ml *
kionex 15 gm/60 ml suspension 15-19.3
gram/60 ml
kionex oral powder
lactulose oral solution 10 gram/15 ml
LINZESS ORAL CAPSULE 145 MCG,
290 MCG
loperamide 1 mg/5 ml liquid 1 mg/5 ml *
loperamide oral capsule 2 mg
LOTRONEX ORAL TABLET 0.5 MG,
1 MG
maalox advanced suspension regular
strength 200-200-20 mg/5 ml *
MAALOX MAXIMUM STRENGTH
SUSP MINT, MAX STRENGTH
400-400-40 MG/5 ML *
MAG-AL LIQUID 200-200 MG/5 ML *
MAGNESIUM 400 MG CAPS 400 MG
*
magnesium 500 mg capsule s/f,na/f 500 mg
*
magnesium oxide 250 mg tablet 250 mg *
magnesium oxide 400 mg tablet
s/f,p/f,gluten-free 400 mg *
(Robinul)
(Gaviscon)
$0 (Tier 1)
$0 (Tier 4)
(Loperamide HCl)
$0 (Tier 4)
(Pepto-Bismol)
$0 (Tier 4)
(Pepto-Bismol)
$0 (Tier 4)
(Sodium Polystyrene
Sulfonate)
(Sodium Polystyrene
Sulfonate)
(Lactulose)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Loperamide HCl)
(Loperamide HCl)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 2)
(Maalox Maximum
Strength)
$0 (Tier 4)
QL (30 per 30 days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Uromag)
$0 (Tier 4)
(Magox 400)
(Magox 400)
$0 (Tier 4)
$0 (Tier 4)
this document
164
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
magnesium oxide 420 mg tablet 253mg
elem magnesium 420 mg *
magnesium oxide 500 mg tablet
p/f,s/f,lactose-free 500 mg *
MAGOX 400 TABLET S/F, GLUTEN
FREE 400 MG *
masanti liquid 400-400-40 mg/5 ml *
medi-first pep-t-med tab chew 262 mg *
methscopolamine oral tablet 2.5 mg, 5 mg
metoclopramide hcl injection solution 5
mg/ml
metoclopramide hcl oral solution 5 mg/5
ml
metoclopramide hcl oral tablet 10 mg, 5
mg
mi acid suspension 200-200-20 mg/5 ml,
400-400-40 mg/5 ml *
mi-acid ds tablet 700-300 mg *
mintox maximum strength susp max str,
lemon creme 400-400-40 mg/5 ml *
mintox plus tablet chewable 200-200-25
mg *
mintox suspension mint creme 200-200-20
mg/5 ml *
MOVANTIK ORAL TABLET 12.5
MG, 25 MG
NUTRESTORE ORAL POWDER IN
PACKET 5 GRAM
OCALIVA ORAL TABLET 10 MG, 5
MG
phillips 500 mg caplet 500 mg *
(Magox 400)
$0 (Tier 4)
(Magox 400)
$0 (Tier 4)
$0 (Tier 4)
(Maalox Maximum
Strength)
(Pepto-Bismol
To-Go)
(Methscopolamine
Bromide)
(Metoclopramide
HCl)
(Metoclopramide
HCl)
(Reglan)
$0 (Tier 4)
(Maalox Maximum
Strength)
(Rolaids)
(Maalox Maximum
Strength)
(Almacone)
$0 (Tier 4)
(Maalox Maximum
Strength)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
QL (30 per 30 days)
$0 (Tier 2)
$0 (Tier 2)
(Magox 400)
PA; QL (30 per 30
days)
$0 (Tier 4)
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165
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
PHILLIPS' MOM TABLET CHEW 311
MG *
pink bismuth tablet chew 262 mg *
(Pepto-Bismol
To-Go)
pv anti-diarrheal+gas relief caplet 2-125
(Imodium
mg *
Multi-Symptom
Relief)
pv foaming antacid chew tablet
(Gaviscon)
ex-strength 160-105 mg *
pv supreme antacid suspension 400-135
(Calcium
mg/5 ml *
Carb/Magnesium
Hydrox)
ra loperamide 1 mg/7.5 ml susp mint 1
(Loperamide HCl)
mg/7.5 ml *
ra magnesium 500 mg capsule 500 mg *
(Uromag)
RAVICTI ORAL LIQUID 1.1
GRAM/ML
RELISTOR ORAL TABLET 150 MG
$0 (Tier 4)
RELISTOR SUBCUTANEOUS
RELISTOR SUBCUTANEOUS
SYRINGE 12 MG/0.6 ML, 8 MG/0.4
ML
ri-gel ii suspension 400-400-40 mg/5 ml *
$0 (Tier 2)
riginic suspension 131-31.7 mg/5 ml *
ri-mox plus suspension 225-200-25 mg/5
ml *
ri-mox suspension 200-200-20 mg/5 ml *
sm foaming antacid tablet chew 80-20 mg
*
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Maalox Maximum
Strength)
(Gaviscon)
(Maalox Maximum
Strength)
(Maalox Maximum
Strength)
(Gaviscon)
PA
PA; QL (90 per 30
days)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
this document
166
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
sm stomach relief caplet 262 mg *
(Bismuth
Subsalicylate)
sodium bicarb 325 mg tablet 325 mg *
(Sodium Bicarbonate)
sodium bicarb 650 mg tablet 10 gr 650 mg (Sodium Bicarbonate)
*
sodium polystyrene (sorb free) oral
(Sodium Polystyrene
suspension 15 gram/60 ml
Sulfonate)
sodium polystyrene sulfonate rectal enema (Sodium Polystyrene
30 gram/120 ml
Sulfonate)
soothe 262 mg caplet caplet 262 mg *
(Bismuth
Subsalicylate)
soothe 262 mg/15 ml suspension s/f,cherry (Pepto-Bismol)
262 mg/15 ml *
sps (with sorbitol) oral suspension 15-20
(Sodium Polystyrene
gram/60 ml
Sulfonate)
ursodiol oral capsule 300 mg
(Actigall)
ursodiol oral tablet 250 mg, 500 mg
(Urso)
VIBERZI ORAL TABLET 100 MG, 75
MG
Laxatives
alophen pills 5 mg *
(Dulcolax)
bisac-evac 10 mg suppository 10 mg *
(Dulcolax)
bisacodyl 10 mg suppository 10 mg *
(Dulcolax)
bisacodyl ec 5 mg tablet 5 mg *
(Dulcolax)
biscolax 10 mg suppository 10 mg *
(Dulcolax)
BLADDER CONTROL PAD X-LONG
9'S,X-LONG *
CASTOR OIL *
CEO-TWO SUPPOSITORY 0.9-0.6
GRAM *
chocolated laxative regular strength 15 mg (Sennosides)
*
citroma solution *
(Magnesium Citrate)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
ST; QL (60 per 30
days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
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167
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
CITRUCEL 500 MG CAPLET 500 MG
*
CITRUCEL POWDER *
COLACE 100 MG CAPSULE 100 MG
*
COLACE CLEAR 50 MG SOFTGEL
50 MG *
cvs castor oil 67% *
cvs child suppository *
cvs enema disposable 19-7 gram/118 ml *
cvs fiber 0.52 g capsule 0.52 gram *
cvs fiber therapy 500 mg caplt soluble,
caplet 500 mg *
cvs glycerin suppository child size *
cvs glycerin suppository laxative *
cvs kids 100 mg mini enema 100 mg/5 ml *
cvs laxative 15 mg pills pills, chocolate 15
mg *
cvs magnesium citrate soln *
cvs natural daily fiber powder 3.4
gram/5.8 gram *
cvs natural daily fiber powder 3.4 gram/7
gram *
cvs purelax powder 14 once-daily doses 17
gram/dose *
cvs purelax powder packet s/f, 10 daily
doses 17 gram *
cvs senna laxative 8.6 mg tab 8.6 mg *
cvs senna-extra 17.2 mg tablet 17.2 mg *
cvs stool softener 50 mg sftgl 50 mg *
cvs stool softener 50 mg softgel 50 mg *
cvs stool softener softgel softgel 240 mg *
cvs suppository *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Castor Oil)
(Glycerin)
(Enema)
(Metamucil)
(Citrucel)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Glycerin)
(Glycerin)
(Docusate Sodium)
(Sennosides)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Magnesium Citrate)
(Psyllium
Husk/Aspartame)
(Metamucil)
$0 (Tier 4)
$0 (Tier 4)
(Gavilax)
$0 (Tier 4)
(Miralax)
$0 (Tier 4)
(Senokot)
(Senokot)
(Colace Clear)
(Colace Clear)
(Surfak)
(Glycerin)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
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168
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
doc-q-lace 100 mg softgel 100 mg *
docu liquid 50 mg/5 ml 50 mg/5 ml *
docusate sodium 100 mg tablet crushable
100 mg *
docusate sodium 250 mg softgel softgel
250 mg *
docusol mini-enema outer 283 mg *
dok 100 mg softgel softgel 100 mg *
dok 100 mg tablet 100 mg *
dulcolax ss 100 mg softgel 100 mg *
enema disposable 19-7 gram/118 ml *
enema ready to use latex-free 19-7
gram/118 ml *
enemeez mini enema 5cc tubes, outer 283
mg/5 ml *
enemeez plus mini enema outer 283-20
mg/5 ml *
eq fiber therapy powder *
(Colace Clear)
(Docusate Sodium)
(Docusate Sodium)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Colace Clear)
$0 (Tier 4)
(Docusate Sodium)
(Colace Clear)
(Docusate Sodium)
(Colace Clear)
(Enema)
(Enema)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Docusate Sodium)
$0 (Tier 4)
(Docusol Plus)
$0 (Tier 4)
(Psyllium Seed (With
Sugar))
equalactin 500 mg tab chew 500 mg *
(Calcium
Polycarbophil)
ex-lax chocolate chocolate 15 mg *
(Sennosides)
ex-lax pills 15 mg *
(Senokot)
fiber tablet unboxed 625 mg *
(Fibercon)
fiber therapy (psyllium) oral powder *
(Psyllium Seed)
fiber therapy powder 2 gram/19 gram *
(Citrucel)
fiber-lax captabs 500mg polycarbophil 625 (Fibercon)
mg *
fibertab oral tablet 625 mg *
(Fibercon)
fleet glycerin adult suppos *
(Glycerin)
fleet pedia-lax stool softener 50 mg/15 ml (Docusate Sodium)
*
fleet pedia-lax suppositories *
(Glycerin)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
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169
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
gavilyte-c oral recon soln 240-22.72-6.72
-5.84 gram
gavilyte-g oral recon soln 236-22.74-6.74
-5.86 gram
gavilyte-n oral recon soln 420 gram
gentlelax powder 30 once-daily doses 17
gram/dose *
glycerin adult suppository *
glycerin suppository *
glycolax powder 7 doses (otc) 17
gram/dose *
healthylax powder packet 14x17gm, outer
17 gram *
hydrocil instant packet *
konsyl 520 mg capsule 0.52 gram *
konsyl fiber 625 mg caplet caplet, s/f 625
mg *
konsyl psyllium fiber packet orange,
gluten free 3.4 gram *
laxative 15 mg pills 15 mg *
laxative 15 mg pills 15 mg *
magic bullet 10 mg suppos 10 mg *
magnesium citrate solution lemon *
MILK OF MAGNESIA
CONCENTRATED 2,400 MG/10 ML *
milk of magnesia suspension 400 mg/5 ml
*
mineral oil enema latex-free *
mineral oil laxative *
MOVIPREP ORAL POWDER IN
PACKET 100-7.5-2.691 GRAM
natural fiber lax powder *
(Golytely)
$0 (Tier 1)
(Golytely)
$0 (Tier 1)
(Nulytely with Flavor
Packs)
(Gavilax)
$0 (Tier 1)
(Glycerin)
(Glycerin)
(Gavilax)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Miralax)
$0 (Tier 4)
(Psyllium Seed)
(Metamucil)
(Fibercon)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Psyllium Husk (With
Sugar))
(Senokot)
(Senokot)
(Dulcolax)
(Magnesium Citrate)
$0 (Tier 4)
(Milk Of Magnesia)
$0 (Tier 4)
(Mineral Oil Enema)
(Mineral Oil)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
Sugar))
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
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170
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
oral saline laxative liquid s/f, ginger lemon
7.2-2.7 gram/15 ml *
peg 3350-electrolytes oral recon soln
236-22.74-6.74 -5.86 gram,
240-22.72-6.72 -5.84 gram
peg-electrolyte soln oral recon soln 420
gram
perdiem overnight relief tb 15 mg *
phillips' lax liqui-gels 100 mg *
PHILLIPS' MILK OF MAGNESIA 400
MG/5 ML *
phosphate oral saline laxative s/f, ginger
lemon 7.2-2.7 gram/15 ml *
polyethylene glycol 3350 oral powder 17
gram/dose
polyethylene glycol 3350 oral powder in
packet 17 gram
polyethylene glycol 3350 powd 14
once-daily doses (otc) 17 gram/dose *
polyethylene glycol 3350 powd 17 grams
pkts,outer (otc) 17 gram *
POLYETHYLENE GLYCOL 3350
POWD NF, PEG-75 *
polyethylene glycol 3350 powd outer,s/f
(otc) 17 gram *
promolaxin 100 mg tablet 100 mg *
psyllium capsule 0.4 gram *
pv enema *
pv fiber therapy powder *
pv senna 8.6 mg softgel 8.6 mg *
qc natural vegetable powder 48 doses, reg
flavor *
ra citrate of magnesia soln *
ra col-rite 50 mg softgel 50 mg *
(Na Phos,M-B/Na
Phos,Di-Ba)
(Golytely)
$0 (Tier 4)
Packs)
(Senokot)
(Colace Clear)
$0 (Tier 1)
(Na Phos,M-B/Na
Phos,Di-Ba)
(Polyethylene Glycol
3350)
(Polyethylene Glycol
3350)
(Gavilax)
$0 (Tier 4)
(Miralax)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
(Miralax)
$0 (Tier 4)
(Docusate Sodium)
(Metamucil)
(Mineral Oil Enema)
(Methylcellulose)
(Sennosides)
Dextrose))
(Magnesium Citrate)
(Colace Clear)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
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171
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ra enema twin pack 2 x 4.5oz, rtu 19-7
gram/118 ml *
ra laxative 17.2 mg tablet 17.2 mg *
ra laxative peg 3350 powder 14 once-daily
doses 17 gram/dose *
reguloid capsule 0.52 gram *
reguloid powder orange *
sani-supp adult suppository outer *
sani-supp pediatric suppos outer *
senexon 8.8 mg/5 ml liquid 8.8 mg/5 ml *
senexon tablet 8.6 mg *
senna 8.8 mg/5 ml syrup a/f, chocolate 8.8
mg/5 ml *
senna-lax 8.6 mg tablet 8.6 mg *
silace 50 mg/5 ml liquid 50 mg/5 ml *
silace 60 mg/15 ml syrup 60 mg/15 ml *
sm castor oil 95 % *
sm clearlax powder 14 once-daily doses 17
gram/dose *
sm fiber laxative 500 mg cplt 500 mg *
sm fiber laxative capsule 0.52 gram *
sm fiber smooth powder *
sm glycerin pediatric suppo *
sm laxative pediatric suppos *
sm senna laxative pills 25 mg *
smoothlax powder packet 10 once-daily
doses 17 gram *
trilyte with flavor packets oral recon soln
420 gram
wal-mucil 0.52 g capsule 0.52 gram *
(Enema)
$0 (Tier 4)
(Senokot)
(Gavilax)
$0 (Tier 4)
$0 (Tier 4)
(Metamucil)
Sugar))
(Glycerin)
(Glycerin)
(Sennosides)
(Senokot)
(Sennosides)
$0 (Tier 4)
$0 (Tier 4)
(Senokot)
(Docusate Sodium)
(Docusate Sodium)
(Castor Oil)
(Gavilax)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Citrucel)
(Metamucil)
(Psyllium Seed)
(Glycerin)
(Glycerin)
(Senokot)
(Miralax)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
Packs)
(Metamucil)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
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172
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
Phosphate Binders
CALCIUM ACETATE 668 MG
TABLET 668 MG (169 MG
CALCIUM) *
calcium acetate oral capsule 667 mg
calcium acetate oral tablet 667 mg
eliphos oral tablet 667 mg
magnebind 400 oral tablet 400-200-1 mg
$0 (Tier 4)
(Phoslo)
(Calcium Acetate)
(Calcium Acetate)
(Calcium
Carbonate/Mag
Carb/Fa)
PHOSLYRA ORAL SOLUTION 667
MG (169 MG CALCIUM)/5 ML
RENAGEL ORAL TABLET 400 MG,
800 MG
RENVELA ORAL POWDER IN
PACKET 0.8 GRAM, 2.4 GRAM
RENVELA ORAL TABLET 800 MG
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
Genitourinary Agents
Antispasmodics, Urinary
MYRBETRIQ ORAL TABLET
EXTENDED RELEASE 24 HR 25 MG,
50 MG
oxybutynin chloride oral syrup 5 mg/5 ml (Oxybutynin
Chloride)
oxybutynin chloride oral tablet 5 mg
(Oxybutynin
Chloride)
oxybutynin chloride oral tablet extended
(Ditropan XL)
release 24hr 10 mg, 15 mg, 5 mg
tolterodine oral capsule,extended release
(Detrol LA)
24hr 2 mg, 4 mg
tolterodine oral tablet 1 mg, 2 mg
(Detrol)
TOVIAZ ORAL TABLET
EXTENDED RELEASE 24 HR 4 MG,
8 MG
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
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173
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
trospium oral capsule,extended release
24hr 60 mg
trospium oral tablet 20 mg
Genitourinary Agents,
Miscellaneous
alfuzosin oral tablet extended release 24
hr 10 mg
tamsulosin oral capsule,extended release
24hr 0.4 mg
terazosin oral capsule 1 mg, 10 mg, 2 mg,
5 mg
(Trospium Chloride)
$0 (Tier 1)
(Trospium Chloride)
$0 (Tier 1)
(Uroxatral)
$0 (Tier 1)
(Flomax)
$0 (Tier 1)
(Terazosin HCl)
$0 (Tier 1)
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine injection recon soln 2 gram, (Desferal)
500 mg
DEPEN TITRATABS ORAL TABLET
250 MG
EXJADE ORAL TABLET,
DISPERSIBLE 125 MG, 250 MG, 500
MG
FERRIPROX ORAL SOLUTION 100
MG/ML
FERRIPROX ORAL TABLET 500 MG
sodium thiosulfate intravenous solution 1
(Sodium Thiosulfate)
gram/10 ml (100 mg/ml), 12.5 gram/50 ml
(250 mg/ml)
SYPRINE ORAL CAPSULE 250 MG
$0 (Tier 1)
PA BvD
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
Hormonal Agents,
Stimulant/Replacement/Modifying
Androgens
ANDRODERM TRANSDERMAL
PATCH 24 HOUR 2 MG/24 HOUR, 4
MG/24 HR
$0 (Tier 2)
PA; QL (30 per 30
days)
this document
174
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ANDROGEL TRANSDERMAL GEL
IN METERED-DOSE PUMP 20.25
MG/1.25 GRAM (1.62 %)
ANDROGEL TRANSDERMAL GEL
IN PACKET 1.62 % (20.25 MG/1.25
GRAM), 1.62 % (40.5 MG/2.5 GRAM)
androxy oral tablet 10 mg
danazol oral capsule 100 mg, 200 mg, 50
mg
oxandrolone oral tablet 10 mg, 2.5 mg
testosterone cypionate intramuscular oil
100 mg/ml, 200 mg/ml
testosterone enanthate intramuscular oil
200 mg/ml
testosterone transdermal gel 50 mg/5 gram
(1 %)
testosterone transdermal gel in
metered-dose pump 1.25 gram/ actuation
(1 %)
testosterone transdermal gel in packet 1 %
(25 mg/2.5gram)
testosterone transdermal gel in packet 1 %
(50 mg/5 gram)
Estrogens And Antiestrogens
COMBIPATCH TRANSDERMAL
PATCH SEMIWEEKLY 0.05-0.14
MG/24 HR, 0.05-0.25 MG/24 HR
DUAVEE ORAL TABLET 0.45-20 MG
ESTRACE VAGINAL CREAM 0.01 %
(0.1 MG/GRAM)
estradiol oral tablet 0.5 mg, 1 mg, 2 mg
$0 (Tier 2)
PA; QL (150 per 30
days)
$0 (Tier 2)
PA; QL (150 per 30
days)
(Fluoxymesterone)
(Danazol)
$0 (Tier 1)
$0 (Tier 1)
(Oxandrin)
(Depo-Testosterone)
$0 (Tier 1)
$0 (Tier 1)
PA
(Testosterone
Enanthate)
(Testim)
$0 (Tier 1)
$0 (Tier 1)
(Vogelxo)
$0 (Tier 1)
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
(Androgel)
$0 (Tier 1)
(Testim)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
PA-HRM; QL (8 per
28 days); AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
$0 (Tier 2)
(Estrace)
$0 (Tier 1)
PA-HRM; AGE (Max
64 Years)
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175
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
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
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
estradiol valerate intramuscular oil 10
mg/ml, 20 mg/ml, 40 mg/ml
estradiol-norethindrone acet oral tablet
0.5-0.1 mg, 1-0.5 mg
estropipate oral tablet 0.75 mg, 1.5 mg, 3
mg
FEMRING VAGINAL RING 0.05
MG/24 HR, 0.1 MG/24 HR
MENEST ORAL TABLET 0.3 MG,
0.625 MG, 1.25 MG, 2.5 MG
mimvey lo oral tablet 0.5-0.1 mg
(Vivelle-Dot)
$0 (Tier 1)
(Climara)
$0 (Tier 1)
(Delestrogen)
$0 (Tier 1)
(Activella)
$0 (Tier 1)
(Estropipate)
$0 (Tier 1)
(Activella)
$0 (Tier 1)
mimvey oral tablet 1-0.5 mg
(Activella)
$0 (Tier 1)
PREMARIN INJECTION RECON
SOLN 25 MG
PREMARIN ORAL TABLET 0.3 MG,
0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG
PREMARIN VAGINAL CREAM
0.625 MG/GRAM
PREMPHASE ORAL TABLET 0.625
MG (14)/ 0.625MG-5MG(14)
PREMPRO ORAL TABLET 0.3-1.5
MG, 0.45-1.5 MG, 0.625-2.5 MG,
0.625-5 MG
raloxifene oral tablet 60 mg
$0 (Tier 2)
$0 (Tier 2)
PA-HRM; QL (8 per
28 days); AGE (Max
64 Years)
PA-HRM; QL (4 per
28 days); AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
QL (1 per 84 days)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
$0 (Tier 2)
$0 (Tier 2)
PA-HRM; AGE (Max
64 Years)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Evista)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
$0 (Tier 1)
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176
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
VAGIFEM VAGINAL TABLET 10
MCG
Glucocorticoids/Mineralocorticoids
a-hydrocort injection recon soln 100 mg
(Hydrocortisone Sod
Succinate)
betamethasone acet,sod phos injection
(Celestone)
suspension 6 mg/ml
cortisone oral tablet 25 mg
(Cortisone Acetate)
dexamethasone oral elixir 0.5 mg/5 ml
(Dexamethasone)
dexamethasone oral tablet 0.5 mg, 0.75
(Dexamethasone)
mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg
(Dexamethasone Sod
injection solution 10 mg/ml, 4 mg/ml
Phosphate)
fludrocortisone oral tablet 0.1 mg
(Fludrocortisone
Acetate)
hydrocortisone oral tablet 10 mg, 20 mg, 5 (Cortef)
mg
methylprednisolone acetate injection
(Depo-Medrol)
suspension 40 mg/ml, 80 mg/ml
methylprednisolone oral tablet 16 mg, 32 (Medrol)
mg, 4 mg, 8 mg
methylprednisolone oral tablets,dose pack (Medrol)
4 mg
methylprednisolone sodium succ injection (Solu-Medrol)
recon soln 125 mg, 40 mg
methylprednisolone ss 1 gm vl
(Solu-Medrol)
mdv,latex-free 1,000 mg
prednisolone sodium phosphate oral
(Pediapred)
solution 15 mg/5 ml (3 mg/ml), 25 mg/5
ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5
ml)
prednisone oral solution 5 mg/5 ml
(Prednisone)
prednisone oral tablet 1 mg, 2.5 mg, 20
(Prednisone)
mg, 5 mg, 50 mg
$0 (Tier 2)
QL (18 per 28 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
PA BvD
PA BvD
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
$0 (Tier 1)
PA BvD
PA BvD
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177
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
prednisone oral tablet 10 mg
prednisone oral tablets,dose pack 10 mg,
10 mg (48 pack), 5 mg, 5 mg (48 pack)
SOLU-CORTEF (PF) INJECTION
RECON SOLN 100 MG/2 ML
triamcinolone acetonide injection
suspension 10 mg/ml, 40 mg/ml
Pituitary
desmopressin injection solution 4 mcg/ml
desmopressin nasal solution 0.1 mg/ml
(refrigerate)
desmopressin nasal spray,non-aerosol 10
mcg/spray (0.1 ml)
desmopressin oral tablet 0.1 mg, 0.2 mg
GENOTROPIN MINIQUICK
SUBCUTANEOUS SYRINGE 0.2
MG/0.25 ML, 0.4 MG/0.25 ML, 0.6
MG/0.25 ML, 0.8 MG/0.25 ML, 1
MG/0.25 ML, 1.2 MG/0.25 ML, 1.4
MG/0.25 ML, 1.6 MG/0.25 ML, 1.8
MG/0.25 ML, 2 MG/0.25 ML
GENOTROPIN SUBCUTANEOUS
CARTRIDGE 12 MG/ML (36
UNIT/ML), 5 MG/ML (15 UNIT/ML)
INCRELEX SUBCUTANEOUS
SOLUTION 10 MG/ML
LUPRON DEPOT-PED (3 MONTH)
30 MG
LUPRON DEPOT-PED
INTRAMUSCULAR KIT 11.25 MG,
15 MG, 7.5 MG (PED)
(Prednisone)
(Prednisone)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
PA BvD
$0 (Tier 2)
(Triamcinolone
Acetonide)
$0 (Tier 1)
(Desmopressin
Acetate)
(DDAVP)
$0 (Tier 1)
$0 (Tier 1)
QL (15 per 30 days)
(Desmopressin
Acetate)
(DDAVP)
$0 (Tier 1)
QL (15 per 30 days)
$0 (Tier 1)
$0 (Tier 2)
PA
$0 (Tier 2)
PA
$0 (Tier 2)
$0 (Tier 2)
QL (1 per 84 days)
$0 (Tier 2)
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178
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
NORDITROPIN FLEXPRO
10 MG/1.5 ML (6.7 MG/ML), 15
MG/1.5 ML (10 MG/ML), 30 MG/3 ML
(10 MG/ML), 5 MG/1.5 ML (3.3
MG/ML)
octreotide acet 50 mcg/ml syr
(Octreotide Acetate)
outer,single-dose,10 50 mcg/ml (1 ml)
octreotide acetate injection solution 1,000 (Sandostatin)
mcg/ml, 100 mcg/ml, 200 mcg/ml, 500
mcg/ml
octreotide acetate injection solution 50
(Octreotide Acetate)
mcg/ml
SAIZEN CLICK.EASY
SUBCUTANEOUS CARTRIDGE 8.8
MG/1.5 ML (FNL)
SAIZEN SUBCUTANEOUS RECON
SOLN 5 MG, 8.8 MG
SANDOSTATIN LAR 10 MG KIT 10
MG
MG
MG
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR
RECON 10 MG, 20 MG, 30 MG
SEROSTIM SUBCUTANEOUS
RECON SOLN 4 MG, 5 MG, 6 MG
SOMATULINE DEPOT
MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3
ML
$0 (Tier 2)
PA
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
PA
$0 (Tier 2)
PA
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA
$0 (Tier 2)
QL (1 per 28 days)
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179
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
SOMAVERT SUBCUTANEOUS
RECON SOLN 10 MG, 15 MG, 20 MG,
25 MG, 30 MG
SUPPRELIN LA IMPLANT KIT 50
MG (65 MCG/DAY)
Progestins
DEPO-PROVERA
INTRAMUSCULAR SOLUTION 400
MG/ML
hydroxyprogesterone caproate
intramuscular oil 250 mg/ml
medroxyprogesterone intramuscular
suspension 150 mg/ml
medroxyprogesterone intramuscular
syringe 150 mg/ml
medroxyprogesterone oral tablet 10 mg,
2.5 mg, 5 mg
MEGACE ES ORAL SUSPENSION
625 MG/5 ML
megestrol oral suspension 400 mg/10 ml
(40 mg/ml), 625 mg/5 ml
norethindrone acetate oral tablet 5 mg
progesterone in oil intramuscular oil 50
mg/ml
progesterone micronized oral capsule 100
mg, 200 mg
Thyroid And Antithyroid Agents
levothyroxine intravenous recon soln 100
mcg, 200 mcg, 500 mcg
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
$0 (Tier 2)
(Hydroxyprogesteron
e Caproate)
(Depo-Provera)
(Provera)
$0 (Tier 2)
QL (1 per 360 days)
$0 (Tier 2)
QL (10 per 28 days)
$0 (Tier 1)
PA NSO
$0 (Tier 1)
QL (1 per 84 days)
$0 (Tier 1)
QL (1 per 84 days)
$0 (Tier 1)
$0 (Tier 2)
(Megace Es)
$0 (Tier 1)
(Aygestin)
(Progesterone)
$0 (Tier 1)
$0 (Tier 1)
(Prometrium)
$0 (Tier 1)
(Levothyroxine
Sodium)
(Levoxyl)
$0 (Tier 1)
$0 (Tier 1)
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180
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
liothyronine oral tablet 25 mcg, 5 mcg, 50
mcg
methimazole oral tablet 10 mg, 5 mg
propylthiouracil oral tablet 50 mg
(Cytomel)
$0 (Tier 1)
(Tapazole)
(Propylthiouracil)
$0 (Tier 1)
$0 (Tier 1)
Immunological Agents
Immunological Agents
ARCALYST SUBCUTANEOUS
RECON SOLN 220 MG
ASTAGRAF XL ORAL
24HR 0.5 MG, 1 MG, 5 MG
AUBAGIO ORAL TABLET 14 MG, 7
MG
azathioprine oral tablet 50 mg
azathioprine sodium injection recon soln
100 mg
CARIMUNE NF NANOFILTERED
GRAM
CELLCEPT INTRAVENOUS
MG
CIMZIA POWDER FOR RECONST
SUBCUTANEOUS KIT 400 MG (200
MG X 2 VIALS)
CIMZIA SUBCUTANEOUS
SYRINGE KIT 400 MG/2 ML (200
MG/ML X 2)
cyclosporine intravenous solution 250
mg/5 ml
cyclosporine modified oral capsule 100
mg, 25 mg, 50 mg
cyclosporine modified oral solution 100
mg/ml
$0 (Tier 2)
$0 (Tier 2)
PA BvD
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
PA; QL (28 per 28
days)
PA BvD
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA
$0 (Tier 2)
PA
(Sandimmune)
$0 (Tier 1)
PA BvD
(Neoral)
$0 (Tier 1)
PA BvD
(Neoral)
$0 (Tier 1)
PA BvD
(Imuran)
(Azathioprine
Sodium)
this document
181
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
cyclosporine oral capsule 100 mg, 25 mg
(Sandimmune)
ENBREL SUBCUTANEOUS RECON
SOLN 25 MG (1 ML)
ENBREL SUBCUTANEOUS
SYRINGE 25 MG/0.5ML (0.51), 50
MG/ML (0.98 ML)
ENBREL SURECLICK
50 MG/ML (0.98 ML)
ENVARSUS XR ORAL TABLET
EXTENDED RELEASE 24 HR 0.75
MG, 1 MG, 4 MG
FLEBOGAMMA DIF
INTRAVENOUS SOLUTION 10 %, 5
%
GAMASTAN S/D
INTRAMUSCULAR SOLUTION
15-18 % RANGE
GAMMAGARD LIQUID INJECTION
SOLUTION 10 %
GAMMAPLEX INTRAVENOUS
SOLUTION 5 %
gengraf oral capsule 100 mg, 25 mg, 50
(Neoral)
mg
gengraf oral solution 100 mg/ml
(Neoral)
HUMIRA PEDIATRIC CROHN'S
START SUBCUTANEOUS SYRINGE
KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6
PACK)
HUMIRA PEN CROHN'S-UC-HS
START SUBCUTANEOUS PEN
INJECTOR KIT 40 MG/0.8 ML
$0 (Tier 1)
$0 (Tier 2)
PA BvD
PA
$0 (Tier 2)
PA
$0 (Tier 2)
PA
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 1)
PA BvD
$0 (Tier 1)
$0 (Tier 2)
PA BvD
PA
$0 (Tier 2)
PA
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182
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
HUMIRA PEN PSORIASIS-UVEITIS
KIT 40 MG/0.8 ML
HUMIRA PEN SUBCUTANEOUS
PEN INJECTOR KIT 40 MG/0.8 ML
HUMIRA SUBCUTANEOUS
SYRINGE KIT 10 MG/0.2 ML, 20
MG/0.4 ML, 40 MG/0.8 ML
HYPERRAB S/D (PF)
UNIT/ML, 150 UNIT/ML (10 ML)
HYQVIA IG COMPONENT
SUBCUTANEOUS SOLUTION 2.5
GRAM/25 ML (10 %)
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 %)
ILARIS (PF) SUBCUTANEOUS
RECON SOLN 180 MG/1.2 ML (150
MG/ML)
IMOGAM RABIES-HT (PF)
UNIT/ML
KINERET SUBCUTANEOUS
SYRINGE 100 MG/0.67 ML
leflunomide oral tablet 10 mg, 20 mg
mycophenolate mofetil oral capsule 250
mg
mycophenolate mofetil oral suspension for
reconstitution 200 mg/ml
mycophenolate mofetil oral tablet 500 mg
$0 (Tier 2)
PA
$0 (Tier 2)
PA
$0 (Tier 2)
PA
$0 (Tier 2)
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA
$0 (Tier 2)
$0 (Tier 2)
PA; QL (18.76 per 28
days)
(Arava)
(Cellcept)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
(Cellcept)
$0 (Tier 1)
PA BvD
(Cellcept)
$0 (Tier 1)
PA BvD
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183
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
mycophenolate sodium oral tablet,delayed (Myfortic)
release (dr/ec) 180 mg, 360 mg
NULOJIX INTRAVENOUS RECON
SOLN 250 MG
OCTAGAM INTRAVENOUS
SOLUTION 10 %, 5 %
ORENCIA (WITH MALTOSE)
MG
ORENCIA SUBCUTANEOUS
SYRINGE 125 MG/ML
PRIVIGEN INTRAVENOUS
SOLUTION 10 %
PROGRAF INTRAVENOUS
SOLUTION 5 MG/ML
RAPAMUNE ORAL SOLUTION 1
MG/ML
RIDAURA ORAL CAPSULE 3 MG
sirolimus oral tablet 0.5 mg, 1 mg, 2 mg
(Rapamune)
tacrolimus oral capsule 0.5 mg, 1 mg, 5
(Hecoria)
mg
TYSABRI INTRAVENOUS
ZORTRESS ORAL TABLET 0.25 MG,
0.5 MG, 0.75 MG
Vaccines
ACTHIB (PF) INTRAMUSCULAR
RECON SOLN 10 MCG/0.5 ML
ADACEL(TDAP
ADOLESN/ADULT)(PF)
INTRAMUSCULAR SUSPENSION 2
LF-(2.5-5-3-5 MCG)-5LF/0.5 ML
$0 (Tier 1)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA
$0 (Tier 2)
PA
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
PA BvD
$0 (Tier 2)
$0 (Tier 2)
PA; LA; QL (15 per 28
days)
PA BvD; QL (120 per
30 days)
$0 (Tier 2)
$0 (Tier 2)
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184
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ADACEL(TDAP
ADOLESN/ADULT)(PF)
LF-(2.5-5-3-5 MCG)-5LF/0.5 ML
BCG (TICE STRAIN) VIAL
LATEX-FREE, OUTER 50 MG
BCG VACCINE, LIVE (PF)
PERCUTANEOUS SUSPENSION
FOR RECONSTITUTION 50 MG
BEXSERO (PF) INTRAMUSCULAR
SYRINGE 50-50-50-25 MCG/0.5 ML
BOOSTRIX TDAP
2.5-8-5 LF-MCG-LF/0.5ML
BOOSTRIX TDAP
INTRAMUSCULAR SYRINGE
2.5-8-5 LF-MCG-LF/0.5ML
CERVARIX VACCINE (PF)
INTRAMUSCULAR SYRINGE 20-20
MCG/0.5 ML
COMVAX (PF) INTRAMUSCULAR
SUSPENSION 5-7.5-125 MCG/0.5 ML
DAPTACEL (DTAP PEDIATRIC)
(PF) INTRAMUSCULAR
SUSPENSION 15-10-5
LF-MCG-LF/0.5ML
ENGERIX-B (PF)
MCG/ML
ENGERIX-B 20 MCG/ML VIAL
10'S,ADULT,P/F,OUTER 20 MCG/ML
ENGERIX-B PEDIATRIC (PF)
MCG/0.5 ML
$0 (Tier 2)
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA BvD; QL (3 per
365 days)
$0 (Tier 2)
PA BvD; QL (3 per
365 days)
PA BvD; QL (3 per
365 days)
$0 (Tier 2)
this document
185
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
MCG/0.5 ML
GARDASIL (PF) INTRAMUSCULAR
SUSPENSION 20-40-40-20 MCG/0.5
ML
GARDASIL (PF) INTRAMUSCULAR
SYRINGE 20-40-40-20 MCG/0.5 ML
GARDASIL 9 (PF)
0.5 ML
GARDASIL 9 (PF)
INTRAMUSCULAR SYRINGE 0.5
ML
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION 1,440 ELISA UNIT/ML
HAVRIX (PF) INTRAMUSCULAR
SYRINGE 1,440 ELISA UNIT/ML, 720
ELISA UNIT/0.5 ML
HIBERIX (PF) INTRAMUSCULAR
RECON SOLN 10 MCG/0.5 ML
IMOVAX RABIES VACCINE (PF)
INTRAMUSCULAR RECON SOLN
2.5 UNIT
INFANRIX (DTAP) (PF)
25-58-10 LF-MCG-LF/0.5ML
IPOL INJECTION SUSPENSION
40-8-32 UNIT/0.5 ML
IPOL INJECTION SYRINGE 40-8-32
UNIT/0.5 ML
IXIARO (PF) INTRAMUSCULAR
$0 (Tier 2)
PA BvD; QL (3 per
365 days)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA BvD
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
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186
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
KINRIX (PF) INTRAMUSCULAR
SUSPENSION 25 LF-58 MCG-10
LF/0.5 ML
KINRIX (PF) INTRAMUSCULAR
SYRINGE 25 LF-58 MCG-10 LF/0.5
ML
MENACTRA (PF)
MCG/0.5 ML
MENHIBRIX (PF)
5-2.5 MCG/0.5 ML
MENOMUNE - A/C/Y/W-135 (PF)
SUBCUTANEOUS RECON SOLN 50
MCG
MENVEO A-C-Y-W-135-DIP (PF)
INTRAMUSCULAR KIT 10-5
MCG/0.5 ML
MENVEO MENA COMPONENT (PF)
10 MCG /0.5 ML (FINAL)
MENVEO MENCYW-135 COMPNT
(PF) INTRAMUSCULAR RECON
SOLN 5 MCG X 3/ 0.5 ML (FINAL)
M-M-R II (PF) SUBCUTANEOUS
RECON SOLN 1,000-12,500
TCID50/0.5 ML
PEDIARIX (PF) INTRAMUSCULAR
SYRINGE 10 MCG-25LF-25
MCG-10LF/0.5 ML
PEDVAX HIB (PF)
INTRAMUSCULAR SOLUTION 7.5
MCG/0.5 ML
PENTACEL (PF) INTRAMUSCULAR
KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
QL (2 per 365 days)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
this document
187
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
PENTACEL ACTHIB COMPONENT
(PF) INTRAMUSCULAR RECON
SOLN 10 MCG/0.5 ML
PROQUAD (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 10EXP3-4.3-33.99 TCID50/0.5
QUADRACEL (PF)
LF-48 MCG- 5 LF UNIT/0.5ML
RABAVERT (PF)
FOR RECONSTITUTION 2.5 UNIT
RECOMBIVAX HB (PF)
MCG/ML, 40 MCG/ML
RECOMBIVAX HB (PF)
MCG/ML, 5 MCG/0.5 ML
ROTARIX ORAL SUSPENSION FOR
RECONSTITUTION 10EXP6
CCID50/ML
ROTATEQ VACCINE ORAL
SUSPENSION 2 ML
TENIVAC (PF) INTRAMUSCULAR
SYRINGE 5-2 LF UNIT/0.5 ML
TETANUS TOXOID,ADSORBED
(PF) INTRAMUSCULAR
SUSPENSION 5 LF UNIT/0.5 ML
TETANUS,DIPHTHERIA TOX
PED(PF) INTRAMUSCULAR
SUSPENSION 5-25 LF UNIT/0.5 ML
tetanus-diphtheria toxoids-td
(Tetanus, Diphtheria
intramuscular suspension 2-2 lf unit/0.5 ml Tox,Adult)
$0 (Tier 2)
$0 (Tier 2)
QL (2 per 365 days)
$0 (Tier 2)
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD; QL (3 per
365 days)
$0 (Tier 2)
PA BvD; QL (3 per
365 days)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA BvD
$0 (Tier 2)
$0 (Tier 2)
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188
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
TRUMENBA INTRAMUSCULAR
TWINRIX (PF) INTRAMUSCULAR
SUSPENSION 720 ELISA UNIT -20
MCG/ML
TWINRIX (PF) INTRAMUSCULAR
SYRINGE 720 ELISA UNIT -20
MCG/ML
TYPHIM VI INTRAMUSCULAR
SOLUTION 25 MCG/0.5 ML
TYPHIM VI INTRAMUSCULAR
VAQTA (PF) INTRAMUSCULAR
SUSPENSION 50 UNIT/ML
VAQTA (PF) INTRAMUSCULAR
SYRINGE 25 UNIT/0.5 ML, 50
UNIT/ML
VAQTA 25 UNITS/0.5 ML VIAL SDV,
OUTER 25 UNIT/0.5 ML
VARIVAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 1,350 UNIT/0.5
ML
YF-VAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 10 EXP4.74
UNIT/0.5 ML
ZOSTAVAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 19,400 UNIT/0.65
ML
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
QL (2 per 365 days)
$0 (Tier 2)
$0 (Tier 2)
QL (1 per 365 days)
this document
189
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease
Agents
alosetron oral tablet 0.5 mg, 1 mg
APRISO ORAL
24HR 0.375 GRAM
ASACOL HD ORAL
(DR/EC) 800 MG
balsalazide oral capsule 750 mg
budesonide oral
capsule,delayed,extend.release 3 mg
DELZICOL ORAL CAPSULE (WITH
DEL REL TABLETS) 400 MG
DIPENTUM ORAL CAPSULE 250
MG
mesalamine oral tablet,delayed release
(dr/ec) 800 mg
(Alosetron HCl)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
(Colazal)
(Entocort EC)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
(Asacol Hd)
ST
$0 (Tier 1)
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation solution 0.25 %
(Acetic Acid)
LACTATED RINGERS IRRIGATION
SOLUTION
ringers irrigation solution
(Ringers Solution)
sodium chloride irrigation solution 0.9 %
(Sodium Chloride
Irrig Solution)
sorbitol irrigation solution 3 %, 3.3 %
(Sorbitol Solution)
sorbitol-mannitol urethral solution
(Mannitol/Sorbitol
2.7-0.54 g/100 ml
Solution)
water for irrigation, sterile irrigation
(Water For
solution
Irrigation,Sterile)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
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190
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate oral solution 70 mg/75 ml
alendronate oral tablet 10 mg, 40 mg, 5
mg
alendronate oral tablet 35 mg, 70 mg
calcitonin (salmon) nasal
spray,non-aerosol 200 unit/actuation
calcitriol intravenous solution 1 mcg/ml
calcitriol oral capsule 0.25 mcg, 0.5 mcg
calcitriol oral solution 1 mcg/ml
doxercalciferol intravenous solution 4
mcg/2 ml
doxercalciferol oral capsule 0.5 mcg, 1
mcg, 2.5 mcg
FORTEO SUBCUTANEOUS PEN
INJECTOR 20 MCG/DOSE - 600
MCG/2.4 ML
FORTICAL NASAL
SPRAY,NON-AEROSOL 200
UNIT/ACTUATION
ibandronate intravenous solution 3 mg/3
ml
ibandronate intravenous syringe 3 mg/3 ml
ibandronate oral tablet 150 mg
MIACALCIN INJECTION
NATPARA SUBCUTANEOUS
CARTRIDGE 100 MCG/DOSE, 25
MCG/DOSE, 50 MCG/DOSE, 75
MCG/DOSE
paricalcitol oral capsule 1 mcg, 2 mcg, 4
mcg
(Alendronate
Sodium)
(Fosamax)
$0 (Tier 1)
(Fosamax)
(Miacalcin)
$0 (Tier 1)
$0 (Tier 1)
(Calcitriol)
(Rocaltrol)
(Rocaltrol)
(Doxercalciferol)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Hectorol)
$0 (Tier 1)
(Ibandronate
Sodium)
(Boniva)
(Boniva)
(Zemplar)
$0 (Tier 1)
QL (4 per 28 days)
$0 (Tier 2)
PA; QL (2.4 per 28
days)
$0 (Tier 2)
$0 (Tier 1)
QL (3 per 84 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
QL (3 per 84 days)
QL (1 per 28 days)
$0 (Tier 2)
$0 (Tier 1)
this document
191
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
PROLIA SUBCUTANEOUS
SYRINGE 60 MG/ML
risedronate oral tablet 150 mg
risedronate oral tablet 30 mg, 5 mg
ZEMPLAR INTRAVENOUS
SOLUTION 2 MCG/ML, 5 MCG/ML
zoledronic acid intravenous solution 4
mg/5 ml
zoledronic acid-mannitol-water
intravenous piggyback 4 mg/100 ml
intravenous solution 5 mg/100 ml
ZOMETA INTRAVENOUS
$0 (Tier 2)
QL (1 per 180 days)
(Actonel)
(Actonel)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
QL (1 per 28 days)
QL (30 per 28 days)
(Zometa)
$0 (Tier 1)
(Zoledronic
Acid/Mannitol and
Water)
(Reclast)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA INTRAVENOUS
MG/ML), 400 MG/20 ML (20 MG/ML),
80 MG/4 ML (20 MG/ML)
ACTEMRA SUBCUTANEOUS
SYRINGE 162 MG/0.9 ML
ACTIMMUNE SUBCUTANEOUS
SOLUTION 100 MCG/0.5 ML
allopurinol oral tablet 100 mg, 300 mg
amifostine crystalline intravenous recon
soln 500 mg
anticoag citrate phos dextrose solution
2.63-222 gram-mg/100ml
AVONEX (WITH ALBUMIN)
INTRAMUSCULAR KIT 30 MCG
AVONEX INTRAMUSCULAR PEN
INJECTOR KIT 30 MCG/0.5 ML
$0 (Tier 2)
PA
$0 (Tier 2)
PA
$0 (Tier 2)
(Zyloprim)
(Ethyol)
$0 (Tier 1)
$0 (Tier 1)
(Citrate Phosphate
Dextros Soln)
$0 (Tier 1)
$0 (Tier 2)
ST
$0 (Tier 2)
ST
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192
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
AVONEX INTRAMUSCULAR
SYRINGE KIT 30 MCG/0.5 ML
BENLYSTA INTRAVENOUS RECON
SOLN 120 MG, 400 MG
BETASERON SUBCUTANEOUS KIT
0.3 MG
bethanechol chloride oral tablet 10 mg, 25
mg, 5 mg, 50 mg
buspirone oral tablet 10 mg, 15 mg, 30 mg,
5 mg, 7.5 mg
CERDELGA ORAL CAPSULE 84 MG
CETYLEV ORAL TABLET,
EFFERVESCENT 2.5 GRAM, 500 MG
colchicine oral tablet 0.6 mg
colchicine-probenecid oral tablet 0.5-500
mg
COPAXONE SUBCUTANEOUS
SYRINGE 20 MG/ML, 40 MG/ML
CYSTADANE ORAL POWDER 1
GRAM/1.7 ML
droperidol injection solution 2.5 mg/ml
dutasteride oral capsule 0.5 mg
dutasteride-tamsulosin oral capsule, er
multiphase 24 hr 0.5-0.4 mg
ELMIRON ORAL CAPSULE 100 MG
ergoloid oral tablet 1 mg
EXTAVIA SUBCUTANEOUS KIT 0.3
MG
finasteride oral tablet 5 mg
fomepizole intravenous solution 1 gram/ml
FUSILEV INTRAVENOUS RECON
SOLN 50 MG
GAUZE PAD TOPICAL BANDAGE 2
X2"
$0 (Tier 2)
ST
$0 (Tier 2)
PA
$0 (Tier 2)
ST
(Urecholine)
$0 (Tier 1)
(Buspirone HCl)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
(Colcrys)
(Colchicine/Probeneci
d)
PA
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
(Droperidol)
(Avodart)
(Jalyn)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (30 per 30 days)
(Ergoloid Mesylates)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
ST
(Proscar)
(Fomepizole)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
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193
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
GILENYA ORAL CAPSULE 0.5 MG
GLUCAGEN HYPOKIT INJECTION
RECON SOLN 1 MG
GLUCAGON EMERGENCY KIT
(HUMAN) INJECTION KIT 1 MG
gnp epsom salt granules 495 mg/5 gram *
guanidine oral tablet 125 mg
hydroxyzine hcl intramuscular solution 25
mg/ml, 50 mg/ml
hydroxyzine hcl oral solution 10 mg/5 ml
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Magnesium Sulfate)
(Guanidine HCl)
(Hydroxyzine HCl)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
(Hydroxyzine HCl)
$0 (Tier 1)
hydroxyzine hcl oral tablet 10 mg, 25 mg, (Hydroxyzine HCl)
50 mg
hydroxyzine pamoate oral capsule 100 mg, (Vistaril)
25 mg, 50 mg
KEVEYIS ORAL TABLET 50 MG
$0 (Tier 1)
LEMTRADA INTRAVENOUS
leucovorin calcium 200 mg vial sdv, p/f,
latex-free 200 mg
leucovorin calcium injection recon soln 100
mg, 350 mg
leucovorin calcium oral tablet 10 mg, 15
mg, 25 mg, 5 mg
levocarnitine (with sugar) oral solution
100 mg/ml
levocarnitine oral tablet 330 mg
levoleucovorin calcium intravenous recon
soln 50 mg
licide spray 0.2-1 % *
$0 (Tier 2)
mesna intravenous solution 100 mg/ml
MESNEX ORAL TABLET 400 MG
QL (28 per 28 days)
$0 (Tier 1)
$0 (Tier 2)
(Leucovorin Calcium)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Levocarnitine (With
Sugar))
(Carnitor)
(Fusilev)
$0 (Tier 1)
(Piperonyl
(Mesnex)
$0 (Tier 4)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA NSO; QL (120 per
30 days)
PA
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
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194
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
MESTINON ORAL SYRUP 60 MG/5
ML
MESTINON TIMESPAN ORAL
TABLET EXTENDED RELEASE 180
MG
morrhuate sodium intravenous solution 5
(Sodium Morrhuate)
%
ORENCIA CLICKJECT
SUBCUTANEOUS AUTO-INJECTOR
125 MG/ML
ORFADIN ORAL SUSPENSION 4
MG/ML
OTEZLA ORAL TABLET 30 MG
$0 (Tier 2)
OTEZLA STARTER ORAL
TABLETS,DOSE PACK 10 MG (4)-20
MG (4)-30 MG (47), 10 MG (4)-20 MG
(4)-30 MG(19)
OTREXUP (PF) SUBCUTANEOUS
AUTO-INJECTOR 10 MG/0.4 ML,
12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5
MG/0.4 ML, 20 MG/0.4 ML, 22.5
MG/0.4 ML, 25 MG/0.4 ML, 7.5
MG/0.4 ML
PANTILINERS PAD *
PLEGRIDY SUBCUTANEOUS PEN
INJECTOR 125 MCG/0.5 ML, 63
MCG/0.5 ML- 94 MCG/0.5 ML
PLEGRIDY SUBCUTANEOUS
SYRINGE 125 MCG/0.5 ML, 63
MCG/0.5 ML- 94 MCG/0.5 ML
POLYETHYLENE GLYCOL 3350
GRAN *
probenecid oral tablet 500 mg
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
PA
$0 (Tier 2)
$0 (Tier 2)
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 2)
ST
$0 (Tier 2)
ST
$0 (Tier 4)
(Probenecid)
$0 (Tier 1)
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195
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
PROCYSBI ORAL CAPSULE,
DELAYED REL SPRINKLE 25 MG,
75 MG
pyridostigmine bromide oral tablet 60 mg (Mestinon)
pyridostigmine bromide oral tablet
(Mestinon)
extended release 180 mg
RASUVO (PF) SUBCUTANEOUS
AUTO-INJECTOR 10 MG/0.2 ML,
12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5
MG/0.35 ML, 20 MG/0.4 ML, 22.5
MG/0.45 ML, 25 MG/0.5 ML, 27.5
MG/0.55 ML, 30 MG/0.6 ML, 7.5
MG/0.15 ML
REBIF (WITH ALBUMIN)
REBIF REBIDOSE SUBCUTANEOUS
PEN INJECTOR 22 MCG/0.5 ML, 44
MCG/0.5 ML, 8.8MCG/0.2ML-22
MCG/0.5ML (6)
REBIF TITRATION PACK
SUBCUTANEOUS SYRINGE
8.8MCG/0.2ML-22 MCG/0.5ML (6)
REMICADE INTRAVENOUS
RECON SOLN 100 MG
SENSIPAR ORAL TABLET 30 MG, 60
MG, 90 MG
SIGNIFOR SUBCUTANEOUS
SOLUTION 0.3 MG/ML (1 ML), 0.6
MG/ML (1 ML), 0.9 MG/ML (1 ML)
SIMPONI ARIA INTRAVENOUS
SOLUTION 12.5 MG/ML
SIMPONI SUBCUTANEOUS PEN
INJECTOR 100 MG/ML, 50 MG/0.5
ML
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA
$0 (Tier 2)
$0 (Tier 2)
QL (60 per 30 days)
$0 (Tier 2)
PA
$0 (Tier 2)
PA
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196
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
SIMPONI SUBCUTANEOUS
SYRINGE 100 MG/ML, 50 MG/0.5 ML
STELARA SUBCUTANEOUS
SYRINGE 45 MG/0.5 ML, 90 MG/ML
STERILE PADS 2" X 2" 2 X 2 "
SYNAREL NASAL
SPRAY,NON-AEROSOL 2 MG/ML
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG (14)- 240
MG (46), 240 MG
THALOMID ORAL CAPSULE 100
MG, 150 MG, 200 MG, 50 MG
TYBOST ORAL TABLET 150 MG
ULORIC ORAL TABLET 40 MG, 80
MG
XELJANZ ORAL TABLET 5 MG
$0 (Tier 2)
PA
$0 (Tier 2)
PA
XELJANZ XR ORAL TABLET
EXTENDED RELEASE 24 HR 11 MG
ZINBRYTA SUBCUTANEOUS
SYRINGE 150 MG/ML
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
QL (14 per 30 days)
$0 (Tier 2)
QL (60 per 30 days)
$0 (Tier 2)
PA NSO; QL (60 per
30 days)
QL (30 per 30 days)
QL (30 per 30 days)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA; QL (60 per 30
days)
PA; QL (30 per 30
days)
ST
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide oral capsule, extended
release 500 mg
acetazolamide oral tablet 125 mg, 250 mg
acetazolamide sodium injection recon soln
500 mg
ALPHAGAN P OPHTHALMIC
DROPS 0.1 %
(Diamox Sequels)
$0 (Tier 1)
(Acetazolamide)
(Acetazolamide
Sodium)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
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197
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
AZOPT OPHTHALMIC
DROPS,SUSPENSION 1 %
betaxolol ophthalmic drops 0.5 %
bimatoprost ophthalmic drops 0.03 %
brimonidine ophthalmic drops 0.15 %, 0.2
%
COMBIGAN OPHTHALMIC DROPS
0.2-0.5 %
dorzolamide ophthalmic drops 2 %
dorzolamide-timolol ophthalmic drops
22.3-6.8 mg/ml
latanoprost ophthalmic drops 0.005 %
levobunolol ophthalmic drops 0.25 %, 0.5
%
LUMIGAN OPHTHALMIC DROPS
0.01 %
methazolamide oral tablet 25 mg, 50 mg
metipranolol ophthalmic drops 0.3 %
PHOSPHOLINE IODIDE
OPHTHALMIC DROPS 0.125 %
pilocarpine hcl ophthalmic drops 1 %, 2 %,
4%
SIMBRINZA OPHTHALMIC
DROPS,SUSPENSION 1-0.2 %
timolol maleate ophthalmic drops 0.25 %,
0.5 %
timolol maleate ophthalmic gel forming
solution 0.25 %, 0.5 %
TRAVATAN Z OPHTHALMIC
DROPS 0.004 %
travoprost (benzalkonium) ophthalmic
drops 0.004 %
$0 (Tier 2)
(Betaxolol HCl)
(Bimatoprost)
(Alphagan P)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(drops: 0.15%, 0.20%)
$0 (Tier 2)
(Trusopt)
(Cosopt)
$0 (Tier 1)
$0 (Tier 1)
(Xalatan)
(Betagan)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Neptazane)
(Metipranolol)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Isopto Carpine)
$0 (Tier 1)
$0 (Tier 2)
(Timoptic)
$0 (Tier 1)
(Timoptic-Xe)
$0 (Tier 1)
(Travoprost
(Benzalkonium))
$0 (Tier 2)
$0 (Tier 1)
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198
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
Replacement Preparations
Replacement Preparations
calci-mix 1.25 gm capsule 500 mg calcium
(1,250 mg) *
calcitrate + vit d caplet 315-250 mg-unit *
calcitrate 200 mg (950 mg) tab 200 mg
(950 mg) *
cal-citrate plus vitamin d tab 250-100
mg-unit *
calcium 500+d tablet chew 500
mg(1,250mg) -400 unit *
calcium 500-vit d3 200 tablet 500
mg(1,250mg) -200 unit *
calcium 500-vit d3 400 tablet p/f,na/f,no
lactose 500 mg(1,250mg) -400 unit *
calcium 600 + vit d 400 caplet s/f, p/f,
caplet 600 mg(1,500mg) -400 unit *
calcium 600 + vit d 400 softgl 600
mg(1,500mg) -400 unit *
(Calcium Carbonate)
$0 (Tier 4)
(Citracal-Vitamin D)
(Calcium Citrate)
$0 (Tier 4)
$0 (Tier 4)
(Calcium
Citrate/Vitamin D2)
(Calcium 600 + Vit
D)
(Caltrate 600 Plus
D3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Calcium
Carbonate/Vitamin
D3)
calcium 600 + vit d tablet 600-125 mg-unit (Caltrate 600 Plus
*
D3)
calcium 600 + vitamin d sftgl rapid
(Calcium
release, sftgl 600 mg(1,500mg) -500 unit Carbonate/Vitamin
*
D3)
calcium 600+d softgel 600 mg calcium(Calcium
200 unit *
Carbonate/Vitamin
D3)
(Caltrate 600 Plus
mg(1,500mg) -200 unit *
D3)
(Caltrate 600 Plus
mg(1,500mg) -400 unit *
D3)
calcium adult gummies 250 mg calcium(Citracal + D3)
350 unit *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
this document
199
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
calcium carbonate 648 mg tab 260 mg
calcium (648 mg) *
calcium chloride intravenous solution 100
mg/ml (10 %)
calcium chloride intravenous syringe 100
mg/ml (10 %)
calcium citrate - vit d caplet caplet, coated
315-200 mg-unit *
calcium citrate malate with d 250-100
mg-unit *
calcium citrate with d tablet p/f,s/f
200-125 mg-unit *
calcium citrate-vit d3 caplet s/f, p/f
315-250 mg-unit *
calcium cit-vit d 250-200 cplt s/f, p/f,
caplet 250 mg calcium- 200 unit *
calcium cit-vit d 250-200 tab p/f,coated,no
lact 250 mg calcium- 200 unit *
calcium gluconate 50 mg tablet 50 mg
calcium *
calcium gluconate 500 mg tab 45 mg (500
mg) *
mg) *
mg) *
calcium gluconate intravenous solution
100 mg/ml (10%)
calcium gummies 250 mg calcium- 500
unit *
calcium lactate 648 mg tablet 84 mg (648
mg) *
calcium with magnesium tab 300-300 mg *
(Calcium Carbonate)
$0 (Tier 4)
(Calcium Chloride)
$0 (Tier 1)
(Calcium Chloride)
$0 (Tier 1)
$0 (Tier 4)
(Calcium Cit
Malate/Vitamin D3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Calcium Gluconate)
$0 (Tier 4)
(Calcium Gluconate)
$0 (Tier 4)
(Calcium Gluconate)
$0 (Tier 4)
(Calcium Gluconate)
$0 (Tier 4)
(Calcium Gluconate)
$0 (Tier 1)
(Citracal + D3)
$0 (Tier 4)
(Calcium Lactate)
$0 (Tier 4)
(Calcium/Magnesium
)
$0 (Tier 4)
$0 (Tier 4)
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200
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
calcium with vit d tablet 600-125 mg-unit
*
calcium with vit d tablet caplet,s/f,na/f,p/f
1,500-200 mg-unit *
CALTRATE 600 + D SOFT CHEW
TAB VANILLA CREME 600 MG
(1,500 MG)-800 UNIT *
CALTRATE 600 PLUS D3 TABLET
600 MG(1,500MG) -800 UNIT *
citracal + d maximum caplet 315-250
mg-unit *
citrus calcium + d tablet 315-250 mg-unit
*
citrus calcium-vit d 200-250 200 mg
calcium -250 unit *
cvs calcium + vit d3 gummies 250-400
mg-unit *
cvs calcium + vitamin d3 sftgl absorbable
600 mg(1,500mg) -500 unit *
(Calcium
Carbonate/Vitamin
D2)
(Calcium
Citrate/Vitamin D2)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Citracal + D3)
$0 (Tier 4)
(Calcium
Carbonate/Vitamin
D3)
cvs calcium 500 + vit d 200 tb 500
(Caltrate 600 Plus
mg(1,250mg) -200 unit *
D3)
cvs calcium 500 + vit d tablet oyster shell (Caltrate 600 Plus
500 mg(1,250mg) -125 unit *
D3)
cvs calcium 600-vit d3 800 tab p/f,
(Caltrate 600 Plus
s/f,gluten-free 600 mg(1,500mg) -800 unit D3)
*
cvs magnesium 250 mg tablet 250 mg *
(Magnesium)
cvs pediatric electrolyte soln *
(Pedialyte)
cvs pediatric electrolyte soln a/f, p/f *
(Pedialyte)
d10 %-0.45 % sodium chloride intravenous (Dextrose 10 % and
parenteral solution
0.45 % NaCl)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
this document
201
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
d2.5 %-0.45 % sodium chloride
d5 % and 0.9 % sodium chloride
d5 %-0.45 % sodium chloride intravenous
parenteral solution
dextrose 10 % and 0.2 % nacl intravenous
parenteral solution
dextrose 5 %-lactated ringers intravenous
parenteral solution
dextrose 5%-0.2 % sod chloride
dextrose 5%-0.3 % sod.chloride
dextrose with sodium chloride intravenous
parenteral solution 5-0.2 %
dextrose-kcl-nacl intravenous solution
5-0.224-0.225 %
effer-k oral tablet, effervescent 25 meq
electrolyte-48 in d5w intravenous
parenteral solution
eql calcium 600 mg + d softgel 600
mg(1,500mg) -100 unit *
eql children's calcium gummies 100 mg
calcium -100 unit *
gnp calcium 500-vit d3 600 tab 500mg
(1,250mg) -600 unit *
hm calcium citrate-vit d cplt caplet,
gluten-free 315-250 mg-unit *
HYPERLYTE CR INTRAVENOUS
SOLUTION 25-20-5-5-30-30 MEQ/20
ML
(Dextrose 2.5 % and
0.45 % NaCl)
(Dextrose 5 % and 0.9
% NaCl)
(Dextrose 5 %-0.45 %
NaCl)
(Dextrose 10 % and
0.2 % NaCl)
(Dextrose
5%-Lactated Ringers)
(Dextrose 5 %-0.2 %
NaCl)
(Dextrose 5 % and 0.3
% NaCl)
(Dextrose 5 %-0.2 %
NaCl)
(Potassium
Chloride/D5-0.2%Na
Cl)
(Klor-Con-Ef)
(Electrolyte-48
Solution/D5W)
(Calcium
Carbonate/Vitamin
D3)
(Calcium Phos
Tribas/Vitamin D2)
(Caltrate 600 Plus
D3)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
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202
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
IONOSOL-B IN D5W
SOLUTION 5 %
IONOSOL-MB IN D5W
SOLUTION 5 %
ISOLYTE M IN 5 % DEXTROSE
SOLUTION
ISOLYTE-H IN 5 % DEXTROSE
SOLUTION 5 %
ISOLYTE-P IN 5 % DEXTROSE
SOLUTION 5 %
ISOLYTE-S INTRAVENOUS
PARENTERAL SOLUTION
k-effervescent oral tablet, effervescent 25
meq
KLOR-CON 10 ORAL TABLET
EXTENDED RELEASE 10 MEQ
klor-con m10 oral tablet,er
particles/crystals 10 meq
klor-con sprinkle oral capsule, extended
release 10 meq, 8 meq
liquid calcium 600-vit d3 sfgl 600
mg(1,500mg) -400 unit *
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Klor-Con-Ef)
$0 (Tier 1)
$0 (Tier 1)
(Potassium Chloride)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Calcium
Carbonate/Vitamin
D3)
$0 (Tier 4)
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203
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
liquid calcium 600-vit d3 sfgl
softgel,p/f,gluten-f 600 mg(1,500mg) -500
unit *
liquid calcium with vitamin d softgel, s/f,
p/f 600 mg calcium- 200 unit *
mag delay dr 64 mg tablet 64 mg *
mag64 dr 64 mg tablet 64 mg *
magbid er 84 mg tablet 84 mg *
mag-g 500 mg tablet 27 mg (500 mg) *
magnesium 200 mg tablet
salt,starch,s/f,p/f 200 mg *
magnesium 250 mg tablet 250 mg *
MAGNESIUM CHLORIDE 64 MG
TAB SLOW, E/C, W/CALCIUM 64
MG *
magnesium chloride injection solution 200
mg/ml (20 %)
MAGNESIUM CITRATE 100 MG
TAB 100 MG *
magnesium gluc 500 mg tablet 27 mg (500
mg) *
magnesium sulf in 0.45% nacl intravenous
solution 20 gram/500 ml (40 mg/ml)
magnesium sulfate in d5w intravenous
magnesium sulfate in water intravenous
parenteral solution 20 gram/500 ml (4 %),
40 gram/1,000 ml (4 %)
magnesium sulfate in water intravenous
piggyback 2 gram/50 ml (4 %), 4
gram/100 ml (4 %), 4 gram/50 ml (8 %)
magnesium sulfate injection solution 4
meq/ml (50 %)
(Calcium
Carbonate/Vitamin
D3)
(Calcium
Carbonate/Vitamin
D3)
(Slow-Mag)
(Slow-Mag)
(Mag-Tab SR)
(Magonate)
(Magnesium)
$0 (Tier 4)
(Magnesium)
$0 (Tier 4)
$0 (Tier 4)
(Magnesium
Chloride)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Magonate)
$0 (Tier 4)
(Magnesium Sulf In
0.45% NaCl)
(Magnesium
Sulfate/D5W)
(Magnesium Sulfate
in Water)
$0 (Tier 1)
(Magnesium Sulfate
in Water)
$0 (Tier 1)
(Magnesium Sulfate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
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204
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
magnesium sulfate injection syringe 4
meq/ml
MAGONATE 27 MG TABLET 27 MG
(500 MG) *
MAGONATE 54 MG/5 ML LIQUID 54
MG/5 ML *
natural calcium 500 mg tablet 500 mg
calcium (1,250 mg) *
NORMOSOL-M IN 5 % DEXTROSE
SOLUTION
NORMOSOL-R PH 7.4
SOLUTION
nu-mag 71.5 mg tablet 71.5 mg *
NUTRILYTE II INTRAVENOUS
SOLUTION 35-20-5 MEQ/20 ML
NUTRILYTE INTRAVENOUS
SOLUTION 25-40.6-5 MEQ/20 ML
oralyte electrolyte soln *
oralyte freezer pops *
oysco 500-vit d3 200 tablet 500
mg(1,250mg) -200 unit *
oysco-500 tablet 500 mg calcium (1,250
mg) *
oyster shell 500-vit d3 200 tb 500
mg(1,250mg) -200 unit *
oyster shell calcium 500 mg tb 500mg
elemental ca 500 mg calcium (1,250 mg) *
oyster shell calcium tablet 500
mg(1,250mg) -400 unit *
oyster shell calcium-vit d tab
p/f,s/f,gluten-free 500 mg(1,250mg) -400
unit *
(Magnesium Sulfate)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
(Calcium Carbonate)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
(Slow-Mag)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
(Pedialyte)
(Pedialyte)
(Caltrate 600 Plus
D3)
(Calcium Carbonate)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Caltrate 600 Plus
D3)
(Calcium Carbonate)
$0 (Tier 4)
(Caltrate 600 Plus
D3)
(Caltrate 600 Plus
D3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
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205
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
oystercal-d 500 mg-400 unit tb 500
mg(1,250mg) -400 unit *
PEDIALYTE SOLUTION *
pediatric electrolyte pwd pack natural
flavor 10.6-4.7 meq/8.5 gram *
pediatric electrolyte solution *
phospha 250 neutral oral tablet 250 mg
PLASMA-LYTE 148 INTRAVENOUS
PARENTERAL SOLUTION
PLASMA-LYTE A INTRAVENOUS
PARENTERAL SOLUTION
PLASMA-LYTE-56 IN 5 %
DEXTROSE INTRAVENOUS
potassium acetate intravenous solution 2
meq/ml, 4 meq/ml
potassium bicarb and chloride oral tablet,
effervescent 25 meq
potassium bicarb-citric acid oral tablet,
effervescent 25 meq
potassium chlorid-d5-0.45%nacl
intravenous parenteral solution 10 meq/l,
20 meq/l, 30 meq/l, 40 meq/l
potassium chloride in 0.9%nacl
40 meq/l
potassium chloride in 5 % dex intravenous
parenteral solution 20 meq/l, 30 meq/l, 40
meq/l
potassium chloride in lr-d5 intravenous
parenteral solution 20 meq/l
potassium chloride intravenous piggyback
10 meq/100 ml, 20 meq/100 ml, 30
meq/100 ml, 40 meq/100 ml
(Caltrate 600 Plus
D3)
(Pedialyte)
(Pedialyte)
(K-Phos Neutral)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Potassium Acetate)
$0 (Tier 1)
(Pot Chloride/Pot
Bicarb/Cit Ac)
(Klor-Con-Ef)
$0 (Tier 1)
(Potassium
Chloride/D5-0.45nacl
)
(Potassium Chloride
In 0.9%NaCl)
$0 (Tier 1)
(Potassium Chloride
In D5w)
$0 (Tier 1)
(Potassium Chloride
In Lr-D5)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
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206
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
potassium chloride intravenous solution 2
meq/ml
potassium chloride oral capsule, extended
release 10 meq, 8 meq
potassium chloride oral liquid 20 meq/15
ml, 40 meq/15 ml
potassium chloride oral packet 20 meq
potassium chloride oral tablet extended
release 8 meq
potassium chloride oral tablet,er
potassium chloride oral tablet,er
potassium chloride-0.45 % nacl
intravenous parenteral solution 20 meq/l
potassium chloride-d5-0.2%nacl
20 meq/l, 30 meq/l, 40 meq/l
intravenous parenteral solution 20 meq/l
40 meq/l
potassium citrate oral tablet extended
release 10 meq (1,080 mg), 15 meq, 5 meq
(540 mg)
potassium citrate-citric acid oral packet
3,300-1,002 mg
potassium cl 10 meq/50 ml sol 10 meq/50
ml
potassium cl 20 meq/50 ml sol 20 meq/50
ml
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Klor-Con)
(Klor-Con 10)
$0 (Tier 1)
$0 (Tier 1)
(Klor-Con 10)
$0 (Tier 1)
$0 (Tier 1)
(Potassium
Chloride-0.45%
NaCl)
(Potassium
Chloride/D5-0.2%Na
Cl)
(Potassium
Chloride/D5-0.3%Na
Cl)
(Potassium
Chloride/D5-0.9%Na
Cl)
(Urocit-K)
$0 (Tier 1)
(Potassium
Citrate/Citric Acid)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
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207
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
potassium cl er 10 meq tablet 10 meq
potassium cl er 10 meq tablet f/c 10 meq
potassium cl er 20 meq tablet 20 meq
potassium phosphate m-/d-basic
intravenous solution 3 mmol/ml
ra pediatric electrolyte soln a/f *
ra pediatric freezer pops *
ringers intravenous parenteral solution
risacal-d tablet 105-120 mg-unit *
sm calcium 600-vit d3 800 tab 600
mg(1,500mg) -800 unit *
sm magnesium 250 mg tablet 250 mg *
sm pediatric electrolyte soln *
sodium acetate intravenous solution 2
meq/ml, 4 meq/ml
sodium bicarbonate intravenous solution 1
meq/ml (8.4 %)
sodium bicarbonate intravenous syringe 10
meq/10 ml (8.4 %), 4.2 % (0.5 meq/ml),
7.5 % (0.9 meq/ml), 8.4 % (1 meq/ml)
sodium chloride 0.45 % intravenous
parenteral solution 0.45 %
sodium chloride 0.9 % intravenous
parenteral solution 0.9 %
sodium chloride 3 % intravenous
sodium chloride 5 % intravenous
sodium chloride intravenous parenteral
solution 2.5 meq/ml, 4 meq/ml
sodium lactate intravenous parenteral
solution 167 meq/l
(Klor-Con 10)
(Potassium
Phos,M-Basic-D-Basi
c)
(Pedialyte)
(Pedialyte)
(Ringers Solution)
(Calcium Phosphate
Dibas/Vit D3)
(Caltrate 600 Plus
D3)
(Magnesium)
(Pedialyte)
(Sodium Acetate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Sodium Chloride
0.45 %)
(0.9 % Sodium
Chloride)
(Sodium Chloride 3
%)
(Sodium Chloride 5
%)
(Sodium Chloride)
$0 (Tier 1)
(Sodium Lactate)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
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208
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
sodium lactate intravenous solution 5
meq/ml
sodium phosphate intravenous solution 3
mmol/ml
TPN ELECTROLYTES II IV SOLN
25'S,20ML/50ML FTV 18-18-5-4.5-35
MEQ/20 ML
TPN ELECTROLYTES
INTRAVENOUS SOLUTION 35-20-5
MEQ/20 ML
virt-phos 250 neutral oral tablet 250 mg
(Sodium Lactate)
$0 (Tier 1)
(Sodium
Phos,M-Basic-D-Basi
c)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
(K-Phos Neutral)
$0 (Tier 1)
Respiratory Tract Agents
Anti-Inflammatories, Inhaled
Corticosteroids
ADVAIR DISKUS INHALATION
BLISTER WITH DEVICE 100-50
MCG/DOSE, 250-50 MCG/DOSE,
500-50 MCG/DOSE
ADVAIR HFA INHALATION HFA
AEROSOL INHALER 115-21
MCG/ACTUATION, 230-21
MCG/ACTUATION
BREO ELLIPTA INHALATION
BLISTER WITH DEVICE 100-25
MCG/DOSE, 200-25 MCG/DOSE
DULERA INHALATION HFA
AEROSOL INHALER 100-5
MCG/ACTUATION
$0 (Tier 2)
QL (60 per 30 days)
$0 (Tier 2)
QL (12 per 28 days)
$0 (Tier 2)
QL (60 per 30 days)
$0 (Tier 2)
QL (13 per 28 days)
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209
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
FLOVENT DISKUS INHALATION
BLISTER WITH DEVICE 100
MCG/ACTUATION, 50
MCG/ACTUATION
FLOVENT DISKUS INHALATION
MCG/ACTUATION
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 110
MCG/ACTUATION
AEROSOL INHALER 220
MCG/ACTUATION
AEROSOL INHALER 44
MCG/ACTUATION
QVAR INHALATION AEROSOL 40
MCG/ACTUATION, 80
MCG/ACTUATION
Antileukotrienes
montelukast oral granules in packet 4 mg
montelukast oral tablet 10 mg
montelukast oral tablet,chewable 4 mg, 5
mg
zafirlukast oral tablet 10 mg, 20 mg
Bronchodilators
albuterol sulfate inhalation solution for
nebulization 0.63 mg/3 ml, 1.25 mg/3 ml,
2.5 mg /3 ml (0.083 %), 5 mg/ml
albuterol sulfate oral syrup 2 mg/5 ml
albuterol sulfate oral tablet 2 mg, 4 mg
albuterol sulfate oral tablet extended
release 12 hr 4 mg, 8 mg
$0 (Tier 2)
QL (60 per 30 days)
$0 (Tier 2)
$0 (Tier 2)
QL (12 per 28 days)
$0 (Tier 2)
QL (24 per 28 days)
$0 (Tier 2)
$0 (Tier 2)
(Singulair)
(Singulair)
(Singulair)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Accolate)
$0 (Tier 1)
(Albuterol Sulfate)
$0 (Tier 1)
(Albuterol Sulfate)
(Albuterol Sulfate)
(Vospire ER)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
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210
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ATROVENT HFA INHALATION
HFA AEROSOL INHALER 17
MCG/ACTUATION
COMBIVENT RESPIMAT
INHALATION MIST 20-100
MCG/ACTUATION
ipratropium bromide inhalation solution
0.02 %
ipratropium-albuterol inhalation solution
for nebulization 0.5 mg-3 mg(2.5 mg
base)/3 ml
metaproterenol oral syrup 10 mg/5 ml
metaproterenol oral tablet 10 mg, 20 mg
PROAIR HFA INHALATION HFA
AEROSOL INHALER 90
MCG/ACTUATION
PROAIR RESPICLICK
INHALATION AEROSOL POWDR
BREATH ACTIVATED 90
MCG/ACTUATION
SEREVENT DISKUS INHALATION
MCG/DOSE
SPIRIVA RESPIMAT INHALATION
MIST 1.25 MCG/ACTUATION, 2.5
MCG/ACTUATION
SPIRIVA WITH HANDIHALER
INHALATION CAPSULE,
W/INHALATION DEVICE 18 MCG
STRIVERDI RESPIMAT
INHALATION MIST 2.5
MCG/ACTUATION
terbutaline oral tablet 2.5 mg, 5 mg
$0 (Tier 2)
$0 (Tier 2)
QL (8 per 30 days)
(Ipratropium
Bromide)
(Ipratropium/Albuter
ol Sulfate)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
(Metaproterenol
Sulfate)
(Metaproterenol
Sulfate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Terbutaline Sulfate)
$0 (Tier 1)
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211
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
terbutaline subcutaneous solution 1 mg/ml
theochron oral tablet extended release 12
hr 100 mg, 200 mg, 300 mg
theophylline in dextrose 5 % intravenous
parenteral solution 200 mg/100 ml, 200
mg/50 ml, 400 mg/250 ml, 400 mg/500 ml,
800 mg/250 ml
theophylline oral solution 80 mg/15 ml
theophylline oral tablet extended release
12 hr 100 mg, 200 mg, 300 mg, 450 mg
theophylline oral tablet extended release
24 hr 400 mg, 600 mg
TUDORZA PRESSAIR
INHALATION AEROSOL POWDR
BREATH ACTIVATED 400
MCG/ACTUATION, 400
MCG/ACTUATION (30 ACTUAT)
VENTOLIN HFA INHALATION
HFA AEROSOL INHALER 90
MCG/ACTUATION
Respiratory Tract Agents, Other
acetylcysteine intravenous solution 200
mg/ml (20 %)
acetylcysteine solution 100 mg/ml (10 %),
200 mg/ml (20 %)
CINQAIR INTRAVENOUS
SOLUTION 10 MG/ML
cromolyn inhalation solution for
nebulization 20 mg/2 ml
cromolyn sodium nasal spray 5.2 mg/spray
(4 %) *
DALIRESP ORAL TABLET 500 MCG
(Terbutaline Sulfate)
(Theophylline
Anhydrous)
(Theophylline/D5W)
$0 (Tier 1)
$0 (Tier 1)
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
QL (2 per 28 days)
$0 (Tier 2)
(Acetadote)
$0 (Tier 1)
PA BvD
(Acetadote)
$0 (Tier 1)
PA BvD
$0 (Tier 2)
PA
(Cromolyn Sodium)
$0 (Tier 1)
PA BvD
(Nasalcrom)
$0 (Tier 4)
$0 (Tier 2)
QL (30 per 30 days)
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212
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ESBRIET ORAL CAPSULE 267 MG
$0 (Tier 2)
KALYDECO ORAL GRANULES IN
PACKET 50 MG, 75 MG
KALYDECO ORAL TABLET 150 MG
$0 (Tier 2)
NUCALA SUBCUTANEOUS RECON
SOLN 100 MG
OFEV ORAL CAPSULE 100 MG, 150
MG
ORKAMBI ORAL TABLET 200-125
MG
PROLASTIN-C INTRAVENOUS
RECON SOLN 1,000 MG
sodium chloride 0.9% inhal vl u-d, suv, p/f (Pulmosal)
(rx) 0.9 % *
XOLAIR SUBCUTANEOUS RECON
SOLN 150 MG
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA; QL (270 per 30
days)
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
days)
PA
PA; QL (120 per 30
days)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 2)
PA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen oral tablet 10 mg, 20 mg
carisoprodol oral tablet 250 mg, 350 mg
(Baclofen)
(Soma)
$0 (Tier 1)
$0 (Tier 1)
chlorzoxazone oral tablet 500 mg
(Parafon Forte DSC)
$0 (Tier 1)
cyclobenzaprine oral tablet 10 mg, 5 mg
(Fexmid)
$0 (Tier 1)
dantrolene oral capsule 100 mg, 25 mg, 50 (Dantrium)
mg
metaxall oral tablet 800 mg
(Skelaxin)
metaxalone oral tablet 400 mg, 800 mg
(Skelaxin)
PA-HRM; QL (120 per
30 days); AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
this document
213
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
methocarbamol oral tablet 500 mg, 750
mg
revonto intravenous recon soln 20 mg
tizanidine oral capsule 2 mg, 4 mg, 6 mg
tizanidine oral tablet 2 mg, 4 mg
(Robaxin)
$0 (Tier 1)
PA-HRM; AGE (Max
64 Years)
(Dantrium)
(Zanaflex)
(Zanaflex)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Nuvigil)
$0 (Tier 1)
PA
$0 (Tier 2)
QL (30 per 30 days)
$0 (Tier 1)
PA-HRM; QL (30 per
30 days); AGE (Max
64 Years)
PA
Sleep Disorder Agents
Sleep Disorder Agents
armodafinil oral tablet 150 mg, 200 mg,
250 mg, 50 mg
BELSOMRA ORAL TABLET 10 MG,
15 MG, 20 MG, 5 MG
eszopiclone oral tablet 1 mg, 2 mg, 3 mg
HETLIOZ ORAL CAPSULE 20 MG
ROZEREM ORAL TABLET 8 MG
XYREM ORAL SOLUTION 500
MG/ML
zaleplon oral capsule 10 mg, 5 mg
(Lunesta)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Sonata)
$0 (Tier 1)
LA
PA-HRM; (High Risk
with over 90 days
cumulative use with
any
non-benzodiazepine
hypnotic drug); QL (60
per 30 days); AGE
(Max 64 Years)
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214
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
zolpidem oral tablet 10 mg, 5 mg
(Ambien)
zolpidem oral tablet,ext release multiphase (Ambien CR)
12.5 mg, 6.25 mg
$0 (Tier 1)
$0 (Tier 1)
PA-HRM; (High Risk
with over 90 days
cumulative use with
any
non-benzodiazepine
per 30 days); AGE
(Max 64 Years)
PA-HRM; (High Risk
with over 90 days
cumulative use with
any
non-benzodiazepine
per 30 days); AGE
(Max 64 Years)
Urine And Feces Contents
Ketones
KETONE CARE TEST STRIPS *
KETONE TEST STRIPS *
KETOSTIX REAGENT STRIPS *
Urine And Feces Contents
KETO-DIASTIX REAGENT STRIPS *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
Vasodilating Agents
Vasodilating Agents
ADCIRCA ORAL TABLET 20 MG
$0 (Tier 2)
PA; QL (60 per 30
days)
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215
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ADEMPAS ORAL TABLET 0.5 MG, 1
MG, 1.5 MG, 2 MG, 2.5 MG
epoprostenol (glycine) intravenous recon (Flolan)
soln 0.5 mg, 1.5 mg
LETAIRIS ORAL TABLET 10 MG, 5
MG
OPSUMIT ORAL TABLET 10 MG
$0 (Tier 2)
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.125 MG,
0.25 MG, 1 MG, 2.5 MG
REMODULIN INJECTION
SOLUTION 1 MG/ML, 10 MG/ML, 2.5
MG/ML, 5 MG/ML
sildenafil intravenous solution 10 mg/12.5 (Revatio)
ml
sildenafil oral tablet 20 mg
(Revatio)
$0 (Tier 2)
PA; QL (30 per 30
days)
PA; QL (30 per 30
days)
PA
$0 (Tier 2)
PA BvD
$0 (Tier 1)
TRACLEER ORAL TABLET 125 MG,
62.5 MG
TYVASO INHALATION SOLUTION
FOR NEBULIZATION 1.74 MG/2.9
ML (0.6 MG/ML)
TYVASO REFILL KIT INHALATION
SOLUTION FOR NEBULIZATION
1.74 MG/2.9 ML (0.6 MG/ML)
TYVASO STARTER KIT
INHALATION SOLUTION FOR
NEBULIZATION 1.74 MG/2.9 ML
UPTRAVI ORAL TABLET 1,000
MCG, 1,200 MCG, 1,400 MCG, 1,600
MCG, 400 MCG, 600 MCG, 800 MCG
UPTRAVI ORAL TABLET 200 MCG
$0 (Tier 2)
$0 (Tier 2)
PA; QL (37.5 per 1
day)
PA; QL (90 per 30
days)
days)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA; QL (60 per 30
days)
$0 (Tier 2)
PA; QL (240 per 30
days)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
PA; QL (90 per 30
days)
PA BvD
this document
216
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
UPTRAVI ORAL TABLETS,DOSE
PACK 200 MCG (140)- 800 MCG (60)
$0 (Tier 2)
PA; QL (200 per 365
days)
Vitamins And Minerals
Vitamins And Minerals
abaneu-sl tablet sl 600-600 mcg *
(Cyanocobalamin/Me
cobalamin)
(Om-3/Calcium/D3/F
a/Mv Cmb 13)
advanced am/pm combo pack
650-1000-800 mg *
AQUASOL A 50,000 UNITS/ML VIAL
SDV, LATEX-FREE 50,000 UNIT/ML
*
ascorbic acid 500 mg/ml vial 500 mg/ml * (Ascorbic Acid)
b-12 1,000 mcg sub tablet 1,000-400 mcg * (Cyanocobalamin/Fol
ic Acid)
b-12 2,500 mcg tablet sl 2,500 mcg *
(B-12)
b-12 500 mcg tablet 500 mcg *
(B-12)
b-12 dots 500 mcg tablet 500 mcg *
(B-12)
bacmin caplet 27-1 mg *
(Multivit, Min
Cmb#20/Iron/Fa)
b-complex 100 injection 100-2-100-2-2
(Vitamins
mg/ml *
B1,B2,B3,B5, and B6)
b-complex with c tablet *
(Vita-Bee with C)
B-NATAL 25 MG THERAPOPS 25
MG *
calcidol drops 8,000 unit/ml *
(Drisdol)
child ferrous sulfate 15 mg/ml 15 mg iron (Fer-In-Sol)
(75 mg)/ml *
corvita 150 tablet 150-1.25-120-10 mg *
(Corvite 150)
cvs b-12 1,000 mcg/15 ml liq 1,000 mcg/15 (Cyanocobalamin
ml *
(Vitamin B-12))
cvs children's vit d 400 unit 400 unit *
(Vitamin D3)
cvs daily multiple tablet *
(Multivitamin)
cvs daily multiple tablet for women *
(Multivitamin)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
this document
217
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
cvs iron 27 mg tablet 240 mg (27 mg iron)
*
cvs men's multi-vit tablet *
cvs prenatal gummy vitamins 400 mcg-35
mg -25 mg-5 mg *
cvs prenatal vitamin tablet *
(Fergon)
(Multivitamin)
(Pnv62/Fa/Om3/Dha/
Epa/Fish Oil)
(Prenatal Vit
Calc,Iron,Folic)
cvs vitamin d3 1,000 unit sfgl softgel 1,000 (Vitamin D3)
unit *
cvs women's prenatal + dha 28-975-200
(Pnv with
mg-mcg-mg *
Ca,No.61/Iron/Fa/Dh
a)
cyanocobalamin 1,000 mcg/ml 25's 1,000 (Cyanocobalamin
mcg/ml *
(Vitamin B-12))
d3 dots 2,000 unit tablet p/f 2,000 unit *
(Vitamin D3)
D3-50 50,000 UNITS CAPSULE
S/F,D/F,P/F 50,000 UNIT *
daily multiple vitamin tab sugar coated * (Multivitamin)
daily prenatal combo pack 28-800-440
(One-A-Day
mg-mcg-mg *
Women'S Prenatal
Dha)
daily value multivitamin tab s/f *
(Multivitamin)
daily vitamin formula tablet *
(Multivitamin)
daily vitamin tablet p/f,na/f *
(Multivitamin)
daily vite tablet s/f, p/f *
(Multivitamin)
daily vite tablet s/f,p/f *
(Multivitamin)
daily-vite tablet *
(Multivitamin)
ddrops 1,000 unit/drop 1,000 unit/drop *
(Just D)
ddrops 2,000 unit/drop 2,000 unit/drop *
(Just D)
decara 50,000 unit softgel 50,000 unit *
(Vitamin D3)
delta d3 400 unit tablet lactose free, s/f
(Vitamin D3)
400 unit *
dialyvite 3,000 tablet 3-70-15 mg-mcg-mg (Folic Acid/B
*
Cplx/C/Selen/Zinc)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
this document
218
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
dialyvite 800 with iron tab 29-800 mg-mcg (Fe Fumarate/Fa/Vit
*
Bcomp,C)
dialyvite tablet 100-1 mg *
(Folic Acid/Vit
Bcomp,C)
dialyvite with zinc tablet 1-100-300-50
(Vit B Cplx
mg-mg-mcg-mg *
#11/Fa/C/Biot/Zn
Ox)
DRISDOL 8,000 UNITS/ML DROPS
8,000 UNIT/ML *
d-vi-sol 400 units/ml drop 400 unit/ml *
(Just D)
elfolate 7.5 mg tablet 7.5 mg *
(Levomefolate
Calcium)
eql one daily essential tablet *
(Multivitamin)
eql prenatal vitamin tablet 28 mg iron- 800 (Prenatal Vit
mcg *
No.128/Iron/Fa)
ergocalciferol 8,000 units/ml 8,000 unit/ml (Drisdol)
*
EXPECTA PRENATAL COMBO
PACK 28 MG IRON-800 MCG-200
MG *
ezfe forte capsule 155-1,000 mg iron-mcg (Pnv No.23-Iron Ps
*
Complex-Fa)
fabb tablet 2.2-25-1 mg *
(Foltx)
FEOSOL 45 MG CAPLET
CPLT,NATURAL RELEASE 45 MG *
feosol 65 mg tablet 325 mg (65 mg iron) * (Slow Fe)
ferocon capsule 110-0.5 mg *
(Fe Fumarate/Vit
C/B12-If/Fa)
ferretts 325 mg tablet 325 mg (106 mg
(Ferrous Fumarate)
iron) *
FERRETTS IRON 18 MG TABLET
CHW 18 MG IRON *
ferrex 150 forte capsule 150-25-1
(Iron Ps Cmplx/Vit
mg-mcg-mg *
B12/Fa)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
this document
219
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ferrex 150 forte plus capsule 150-60-25-1
mg-mg-mcg-mg *
ferrex 28 tablet 151-200-1-0.8 mg *
ferrocite plus tablet 106 mg iron- 1 mg *
ferrocite tablet 324 mg (106 mg iron) *
ferrogels forte softgel 460-60-0.01-1 mg *
ferrous fumarate 324 mg tab 324 mg (106
mg iron) *
ferrous gluconate 240 mg tab
240mg=27mg elemental 240 mg (27 mg
iron) *
ferrous gluconate 324 mg tab 324 mg (36
mg iron), 324 mg (37.5 mg iron), 324 mg
(38 mg iron) *
ferrous sulf 220 mg/5 ml elix 220 mg (44
mg iron)/5 ml *
ferrous sulf 300 mg/5 ml liq 300 mg (60
mg iron)/5 ml *
ferrous sulfate 325 mg tablet red 325 mg
(65 mg iron) *
folbee plus cz tablet 5-1.5-25 mg *
folbee plus tablet 5 mg *
folbee tablet 2.5-25-1 mg *
folbic tablet a/f,s/f,lactose free 2.5-25-2
mg *
folic acid 0.8 mg tablet 800 mcg *
folic acid 1 mg tablet (rx) 1 mg *
(Iron Aspgly and
Ps/C/B12/Fa/Ca/Suc)
(Iron Ag and
Fum/C/Fa/Mv
Cmb11/Ca-T)
(Iron/Fa/Vit
Bcomp,C/Minerals)
(Ferrous Fumarate)
(Iron Fumarate/Vit
C/Vit B12/Fa)
(Ferrous Fumarate)
$0 (Tier 3)
(Fergon)
$0 (Tier 4)
(Fergon)
$0 (Tier 4)
(Ferrous Sulfate)
$0 (Tier 4)
(Ferrous Sulfate)
$0 (Tier 4)
(Slow Fe)
$0 (Tier 4)
(Folic Acid/Vit
Bcomp,C/Cu/Znox)
(Folic Acid/Vit
Bcomp,C)
(Foltx)
(Foltx)
$0 (Tier 3)
(Folic Acid)
(Folic Acid)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
this document
220
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
folic acid 1,000 mcg tablet p/f,s/f (otc) 1
mg *
folic acid 2.5 mg tablet 2.5-25-2 mg *
folic acid 400 mcg tablet
s/f,p/f,lactose-free 400 mcg *
folic acid 5 mg/ml vial latex-free 5 mg/ml
*
folic acid-vit b6-vit b12 tab 2.2-25-0.5 mg
*
folivane-f capsule 125-1-40-3 mg *
folivane-plus capsule 125-1 mg *
folplex 2.2 tablet 2.2-25-0.5 mg *
gnp one daily essential tablet *
gs prenatal vitamins tablet 28-800 mg-mcg
*
hematinic-folic acid tablet 324 mg (106
mg iron)-1 mg *
hematinic-vitamin-mineral tab 106 mg
iron- 1 mg *
hematogen fa softgel 200-250-0.01-1 mg *
hematogen forte softgel 460-60-0.01-1 mg
*
hematogen softgel 200 (66)-10-250
mg-mg-mcg-mg *
hemocyte tablet u-u,blister pk 324 mg
(106 mg iron) *
hydroxocobalamin 1,000 mcg/ml 1,000
mcg/ml *
ICAR 15 MG/1.25 ML SUSPENSION
15 MG/1.25 ML *
iferex 150 forte capsule 150-25-1
mg-mcg-mg *
iron 27 mg tablet 236 mg (27 mg iron) *
(Folic Acid)
$0 (Tier 3)
(Foltx)
(Folic Acid)
$0 (Tier 3)
$0 (Tier 4)
(Folic Acid)
$0 (Tier 3)
(Foltx)
$0 (Tier 3)
(Integra F)
(Integra Plus)
(Foltx)
(Multivitamin)
(Pnv133/Ferrous
Fumarate/Fa)
(Hemocyte-F)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
(Iron/Fa/Vit
Bcomp,C/Minerals)
(Iron Fumarate/Vit
C/Vit B12/Fa)
(Iron Fumarate/Vit
C/Vit B12/Fa)
(Fe Fumarate/Vit
C/B12/Stomc)
(Ferrous Fumarate)
$0 (Tier 3)
(Hydroxocobalamin)
$0 (Tier 3)
PA; AGE (Max 46
Years)
PA
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
(Iron Ps Cmplx/Vit
B12/Fa)
(Fergon)
$0 (Tier 3)
$0 (Tier 4)
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221
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
iron 28 mg tablet 256 mg (28 mg iron) *
kpn tablet *
liquid b12 1,000 mcg/15 ml *
l-methylfolate 7.5 mg tablet 7.5 mg *
l-methylfolate calcium 7.5 mg labeled as
med food (otc) 7.5 mg *
MEPHYTON 5 MG TABLET 5 MG *
metafolbic tablet 6-5-50-1 mg *
multigen caplet 70 mg-150 mg-10 mcg-2
mg-75 mg *
multigen folic caplet 70-150-10-1-2
mg-mg-mcg-mg-mg *
multigen plus caplet 151-60-10-1
mg-mg-mcg-mg *
multiple vitamins tablet one daily *
multi-vitamin daily tablet *
multivitamins men tablet *
multivitamins tablet *
multivit-fluor 0.5 mg tab chew chewable,
d/f, s/f 0.5 mg
myferon-150 forte capsule 150-25-1
mg-mcg-mg *
NASCOBAL 500 MCG NASAL
SPRAY 500 MCG/SPRAY *
nephplex rx tablet 1-60-300-12.5
mg-mg-mcg-mg *
(Fergon)
(Prenatal Vit
Calc,Iron,Folic)
(Cyanocobalamin
(Vitamin B-12))
(Levomefolate
Calcium)
(Levomefolate
Calcium)
(Cerefolin)
(Iron
Ag/C/B12/Ca/Suc.Aci
d/Stom)
(Iron
Aspgly/C/B12/Fa/CaTh/Suc)
(Iron Fum and
Ag/C/B12/Fa/Ca/Suc
c)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Pedi M.Vit No.17
with Fluoride)
(Iron Ps Cmplx/Vit
B12/Fa)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 3)
$0 (Tier 3)
(Vit B Cmplx
No3/Fa/C/Biot/Zinc)
$0 (Tier 3)
this document
222
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
nephron fa tablet 66.6-75-1 mg *
(Fe
Fumarate/Doss/Fa/B
comp,C)
nephro-vite rx tablet 1-60-300 mg-mg-mcg (Vit B Cmplx
*
3/Fa/Vit C/Biotin)
neurin-sl tablet sl 600-600 mcg *
(Cyanocobalamin/Me
cobalamin)
niacinamide 100 mg tablet 100 mg *
(Niacinamide)
niacinamide er 500 mg tablet 500 mg *
(Niacinamide)
once daily tablet *
(Multivitamin)
ONE A DAY PRENATAL DHA
PACK 30 LIQ GELS,30 TABS 28 MG
IRON- 800 MCG *
one daily essential tablet *
(Multivitamin)
one daily multivitamin tab *
(Multivitamin)
one daily tablet *
(Multivitamin)
one daily tablet men's formula *
(Multivitamin)
one-a-day essential tablet *
(Multivitamin)
ONE-A-DAY PRENATAL 1 DHA
SFGL 28 MG IRON- 800 MCG-235
MG *
optimal d3 50,000 units cap 50,000 unit * (Vitamin D3)
PERFECT IRON 25 MG TABLET 25
MG IRON *
perry prenatal capsule 13.5-0.4 mg *
(Pnv with Ca
No.36/Iron/Fa)
pharmacist multi-vite tab *
(Multivitamin)
pnv prenatal plus multivit tab s/f,
(Pnv with
gluten-free 27 mg iron- 1 mg
Ca,No.72/Iron/Fa)
poly-iron 150 forte capsule 150-25-1
(Iron Ps Cmplx/Vit
mg-mcg-mg *
B12/Fa)
poly-vita with iron drops 1,500 unit-400
(Ped Multivit
unit-10 mg/ml *
#46/Iron Sulfate)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
PA
(All Rx Prenatal
Vitamins Covered)
$0 (Tier 3)
$0 (Tier 4)
PA; AGE (Max 4
Years)
this document
223
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
polyvitamin w-iron drops 1,500 unit-400
unit-10 mg/ml *
prenatal + dha combo pack 28 mg iron975 mcg-200 mg *
prenatal 19 chewable tablet (otc) 29 mg
iron- 1 mg *
PRENATAL DHA+COMPLETE
PRENATAL 30-975-300
MG-MCG-MG *
prenatal formula tablet 28 mg iron- 800
mcg *
prenatal formula tablet 9 mg iron- 500
mcg *
prenatal gummies 400-32.5 mcg-mg *
PRENATAL MULTI + DHA
SOFTGEL P/F, GLUTEN-FREE 27
MG IRON-800 MCG-228 MG *
prenatal multi-dha softgel 27mg iron- 800
mcg-250 mg *
prenatal multivitamins tablet 28 mg iron800 mcg *
prenatal one daily tablet 27 mg iron- 800
mcg *
prenatal one tablet 30 mg iron- 800 mcg *
prenatal tablet (otc) 27-0.8 mg *
prenatal tablet (otc) 27-0.8 mg *
prenatal tablet 27 mg iron- 800 mcg *
(Ped Multivit
#46/Iron Sulfate)
(Prenatal Vit #91/Fe
Fum/Fa/Dha)
(Pnv No.118/Iron
Fumarate/Fa)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Max 4
Years)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
(Prenatal)
$0 (Tier 4)
PA
(Prenatal Vits
#90/Iron Fum/Fa)
(Pnv103/Fa/Omega3/
Dha/Fish Oil)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
(Prenatal
No.40/Iron/Fa/Dha)
(Prenatal)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
(Prenatal Vit
No.129/Iron/Fa)
(Prenatal Vit
#108/Iron/Fa)
(Prenatal Vit
No.130/Iron/Fa)
(Prenatal Vit/Iron
Fumarate/Fa)
(Prenatal
Vit#96/Ferrous
Fum/Fa)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
this document
224
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
prenatal tablet 28 mg iron- 800 mcg *
PRENATAL TABLET 28 MG IRON800 MCG *
prenatal vitamin plus low iron oral tablet
27 mg iron- 1 mg
prenatal vitamin tablet 27 mg iron- 800
mcg *
prenatal vitamin tablet 28 mg iron- 800
mcg *
prenatal vitamins tablet phosphorus free
28 mg iron- 800 mcg *
prenatal-1 capsule 30-975-200 mg-mcg-mg
*
PROFE FORTE CAPSULE 155-1,000
MG IRON-MCG *
pv prenatal formula tablet 28 mg iron- 800
mcg *
pv prenatal formula tablet 28 mg iron- 800
mcg *
pyridoxine 100 mg/ml vial 25's 100 mg/ml
*
pyridoxine 250 mg tablet 250 mg *
ra one daily prenatal dha pack 30's tab &
30's cap 28-800-440 mg-mcg-mg *
ra one daily tablet p/f *
ra prenatal tablet 28 mg iron- 800 mcg *
ra vitamin b-12 1,000 mcg tab
timed-release 1,000 mcg *
ra vitamin d3 1,000 unit tab
s/f,gluten/f,yeast/f 1,000 unit *
(Prenatal Vit/Iron
Fumarate/Fa)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
(Pnv with
Ca,No.72/Iron/Fa)
(Prenatal Vit
No.124/Iron/Fa)
(Prenatal Vit/Iron
Fumarate/Fa)
(Prenatal)
$0 (Tier 2)
$0 (Tier 4)
(All Rx Prenatal
Vitamins Covered)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
(Pnv No.25/Iron
Fumarate/Fa/Dha)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
(Prenatal Vit
No.131/Iron/Fa)
(Prenatal Vit/Iron
Fumarate/Fa)
(Pyridoxine HCl)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
(Pyridoxine HCl)
(One-A-Day
Women'S Prenatal
Dha)
(Multivitamin)
(Prenatal Vit/Iron
Fumarate/Fa)
(B-12)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
PA
(Vitamin D3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
this document
225
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
ra vitamin e 400 unit softgel p/f,s/f,softgel
400 unit *
renal caps softgel 1 mg *
rena-vite rx tablet 1-60-300 mg-mg-mcg *
reno caps softgel 1 mg *
riboflavin 100 mg tablet 100 mg *
riboflavin 50 mg tablet 50 mg *
right step prenatal vit tab 27-0.8 mg *
se-tan plus capsule 162-115.2-1 mg *
siderol tablet *
SIMILAC PRENATAL COMBO
PACK 27 MG IRON-800 MCG-200
MG *
sm multivitamins tablet *
sm one daily prenatal combo pk 28 mg
iron- 800 mcg *
sm prenatal vitamins tablet 28 mg iron800 mcg *
sm vitamin d3 4,000 unit sftgl softgel,
gluten-free 4,000 unit *
sodium fluoride oral tablet 1 mg fluoride
(2.2 mg)
strovite forte caplet 10-1 mg *
(Vitamin E)
$0 (Tier 4)
(B Complex and C
No.20/Folic Acid)
(Vit B Cmplx
3/Fa/Vit C/Biotin)
(B Complex and C
No.20/Folic Acid)
(Riboflavin)
(Riboflavin)
(Prenatal Vit/Iron
Fumarate/Fa)
(Tandem Plus)
(Iron/Liver Ext/Vit
Bcomp,C/Min)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
PA
(Multivitamin)
(One-A-Day
Women'S Prenatal
Dha)
(Prenatal)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
(Vitamin D3)
$0 (Tier 4)
(Pedi M.Vit No.17
with Fluoride)
(Multivit, Iron, Min
#5, Fa)
$0 (Tier 1)
STROVITE ONE CAPLET 1-1,000-15-5
MG-UNIT-MG-MG *
STUART ONE CAPSULE 27 MG
IRON- 800 MCG-200 MG *
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
PA
this document
226
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
super multivitamin tablet *
support-500 softgel *
tab-a-vite tablet *
taron forte capsule 150-60-25-1
mg-mg-mcg-mg *
thera-d 2000 tablet 2,000 unit *
THERANATAL CORE NUTRITION
TAB 27-1 MG *
THERANATAL ONE SOFTGEL 27
MG IRON-1000 MCG-300 MG *
THERANATAL OVAVITE COMBO
PACK 18-1-125 MG-MG-UNIT *
THERANATAL PLUS COMBO PACK
27 MG IRON- 1 MG-300 MG *
thiamine 200 mg/2 ml vial 25's,mdv,outer
100 mg/ml *
thiamine 250 mg tablet 250 mg *
thiamine 500 mg tablet 500 mg *
tl gard rx tablet 2.2-25-1 mg *
tl-hem 150 caplet 150-1-50 mg *
trigels-f forte softgel 460-60-0.01-1 mg *
tri-vi-sol drops 750 unit-35 mg -400
unit/ml *
tri-vita drops 1,500-35-400
unit-mg-unit/ml *
tri-vitamin drops 1,500-35-400
unit-mg-unit/ml *
v-c forte capsule 1 mg *
vic-forte capsule 1 mg *
(Multivitamin)
(B Complex with
Vitamin C)
(Multivitamin)
(Iron
Bg,Ps/Vitc/B12/Fa/Ca
lcium)
(Vitamin D3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
(Thiamine HCl)
$0 (Tier 3)
(Thiamine HCl)
(Thiamine HCl)
(Foltx)
(Hemax)
(Iron Fumarate/Vit
C/Vit B12/Fa)
(Vit A Palmitate/Vit
C/Vit D3)
(Pedi Multivits A,C,
and D3 No.21)
(Pedi Multivits A,C,
and D3 No.21)
(Multivitamin-Miner
als No.7/Fa)
(Multivitamin-Miner
als No.7/Fa)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Max 4
Years)
PA; AGE (Max 4
Years)
PA; AGE (Max 4
Years)
$0 (Tier 3)
$0 (Tier 3)
this document
227
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
vinacal b prenatal combo pack 20 mg
iron-1 mg -25 mg/25 mg *
vit d2 1.25 mg (50,000 unit) 50,000 unit *
vit e nat'l blnd 1,000 unit cp 1,000 unit *
vitacel tablet 800-250-750 mcg *
vitafol caplet 65-1 mg *
VITAFOL FE+ (WITH DOCUSATE)
ORAL CAPSULE 90 MG IRON-1 MG
-50 MG-200 MG
vital-d rx tablet 1,750-60-1-12.5
unit-mg-mg-mg *
vitamin a 10,000 units capsule soluble
10,000 unit *
vitamin b-1 100 mg tablet 100 mg *
vitamin b-12 1,000 mcg tablet 1,000 mcg *
vitamin b-12 100 mcg tablet 100 mcg *
vitamin b-12 250 mcg tablet 250 mcg *
vitamin b12 500 mcg tablet 500 mcg *
vitamin b-12 tr 1,000 mcg tab lactose free
1,000 mcg *
vitamin b-6 250 mg tablet p/f 250 mg *
vitamin b-6 50 mg capsule 50 mg *
vitamin b-6 sr 200 mg tablet 200 mg *
vitamin c 1,000 mg tablet 1,000 mg *
vitamin c 100 mg tablet 100 mg *
(Prenatal #48/Iron
Cb,Glu/Fa/B6)
(Drisdol)
(Vitamin E Mixed)
(Biocel)
(Fe
Fumarate/Cal/E/Fa/
Multivit)
$0 (Tier 4)
PA
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 2)
(B Cmplx 4/Vit
D3/C/Fa/Zinc Ox)
(Vitamin A)
$0 (Tier 3)
(Thiamine HCl)
(Thiamine HCl)
(B-12)
(B-12)
(B-12)
(B-12)
(Cyanocobalamin
(Vitamin B-12))
(Riboflavin)
(Riboflavin)
(Pyridoxine HCl)
(Pyridoxine HCl)
(Pyridoxine HCl)
(Pyridoxine HCl)
(Pyridoxine HCl)
(Pyridoxine HCl)
(Ascorbic Acid)
(Ascorbic Acid)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
this document
228
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
vitamin c 500 mg tablet buffered 500 mg *
vitamin d 1,000 unit tablet 1,000 unit *
vitamin d 400 unit tablet p/f,na/f,s/f 400
unit *
VITAMIN D2 2,000 UNIT TABLET
2,000 UNIT *
vitamin d2 400 unit tablet
s/f,l/f,y/f,gluten/f 400 unit *
vitamin d3 1,000 unit tablet s/f,p/f 1,000
unit *
vitamin d3 1,000 units softgel softgel, p/f,
s/f 1,000 unit *
vitamin d3 10,000 unit softgel softgel
10,000 unit *
vitamin d3 10,000 unit softgel
softgel,p/f,s/f 10,000 unit *
vitamin d3 2,000 unit softgel 2,000 unit *
vitamin d3 2,000 unit tablet s/f,p/f 2,000
unit *
VITAMIN D3 400 UNIT SOFTGEL
SOFTGEL,P/F,S/F 400 UNIT *
vitamin d3 400 unit tab chew orange, p/f
400 unit *
vitamin d3 400 unit tablet s/f,p/f 400 unit *
vitamin d3 400 unit/5 ml liq 400 unit/5 ml
*
vitamin d3 400 unit/ml drop a/f, s/f, fruit
400 unit/ml *
vitamin d3 5,000 unit capsule s/f, p/f 5,000
unit *
VITAMIN D3 5,000 UNIT TABLET
S/F, P/F, 5,000 UNIT *
(Ascorbic Acid)
(Ascorbic Acid)
(Ascorbate Calcium)
(Vitamin D3)
(Ergocalciferol
(Vitamin D2))
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Ergocalciferol
(Vitamin D2))
(Vitamin D3)
$0 (Tier 4)
(Vitamin D3)
$0 (Tier 4)
(Vitamin D3)
$0 (Tier 4)
(Vitamin D3)
$0 (Tier 4)
(Vitamin D3)
(Vitamin D3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Vitamin D3)
$0 (Tier 4)
(Vitamin D3)
(Cholecalciferol
(Vitamin D3))
(Just D)
$0 (Tier 4)
$0 (Tier 4)
(Vitamin D3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
this document
229
What the
Necessary Actions,
drug will cost
you (Tier
on Use
level)
Name of Drug
vitamin d3 5,000 unit/ml drops a/f,
p/f,gluten-free 5,000 unit/ml *
VITAMIN D3 LIQUID 1 MILLION
UNIT/GRAM *
vitamin e 1,000 units capsule 1,000 unit *
vitamin e 100 unit softgel softgel 100 unit
*
vitamin e 200 unit capsule 200 unit *
vitamin e 400 unit softgel
softgel,s/f,p/f,na/f 400 unit *
vitamin k 100 mcg tablet p/f, gluten-free
100 mcg *
vitamin k-1 10 mg/ml ampul
25's,latex-free 10 mg/ml *
vitamins for hair tablet *
VITA-RESPA TABLET 2.2-25-1.3 MG
*
vp-vite rx tablet 1-60-300 mg-mg-mcg *
wee care 15 mg/1.25 ml susp 15 mg/1.25
ml *
(Just D)
$0 (Tier 4)
$0 (Tier 4)
(Vitamin E)
(Vitamin E
(Dl,Tocopheryl
Acet))
(Vitamin E)
(Vitamin E
(Dl,Tocopheryl
Acet))
(Phytonadione)
$0 (Tier 4)
$0 (Tier 4)
(Phytonadione)
$0 (Tier 3)
(Multivitamin)
$0 (Tier 4)
$0 (Tier 3)
(Vit B Cmplx
3/Fa/Vit C/Biotin)
(Icar)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
this document
230
INDEX
I-1
ADVANCED GLUC METER
TEST STRIP ................................................ 129
ADVANCED TRAVEL
LANCETS ...................................................... 124
ADVIL ..................................................................... 10
ADVOCATE LANCET ............. 124
ADVOCATE REDI-CODE
........................................................................................... 124
ADVOCATE REDI-CODE+
........................................................................................... 124
ADVOCATE TEST STRIPS
........................................................................................... 124
AEROCHAMBER MINI ....... 124
AEROCHAMBER MV .............. 124
AEROCHAMBER PLUS
FLOW-VU ...................................................... 124
AEROCHAMBER PLUS
FLOW-VU,M MSK .......... 124, 125
AEROCHAMBER PLUS Z
STAT MD MSK .................................... 125
AEROCHAMBER WITH
FLOWSIGNAL ...................................... 125
AEROCHAMBER Z-STAT
PLUS-FLW SG ....................................... 125
AEROTRACH PLUS ................... 125
AEROVENT PLUS .......................... 125
af ........................................................................................ 50
afeditab cr ............................................................. 93
AFINITOR ....................................................... 28
AFINITOR DISPERZ .................... 28
AGAMATRIX AMP TEST
STRIPS ................................................................ 125
a-hydrocort ...................................................... 177
AIMSCO ........................................................... 103
AKTEN (PF) .............................................. 149
AKYNZEO ....................................................... 62
ala-cort .................................................................. 118
ala-hist ir ................................................................ 53
ALA-HIST PE .............................................. 53
ala-scalp ............................................................... 118
alavert ......................................................................... 53
alaway ..................................................................... 149
Index
acetic acid ........................................... 154, 190
acetylcysteine ................................................ 212
acid gone antacid ..................................... 161
acid gone antacid e.strength ..... 161
acid reducer (famotidine)
............................................................................ 159, 160
acid relief (cimetidine) .................... 160
acitretin ................................................................. 114
acne and blackhead terminator
........................................................................................... 114
acne foaming wash ................................. 114
acne medication .......................... 114, 116
ACNE MEDICATION ............... 114
acne-clear ........................................................... 114
ACTEMRA ................................................... 192
ACTHIB (PF) ............................................ 184
ACTI-LANCE LANCETS .... 124
ACTIMMUNE ........................................ 192
ACURA TEST STRIPS ............. 124
acyclovir ................................................... 75, 114
acyclovir sodium ........................................... 75
ADACEL(TDAP
ADOLESN/ADULT)(PF)
............................................................................ 184, 185
ADAGEN ........................................................ 148
adapalene ............................................................ 122
ADCETRIS ...................................................... 27
ADCIRCA ...................................................... 215
adefovir ..................................................................... 75
ADEMPAS .................................................... 216
adriamycin ............................................................ 27
adrucil ......................................................................... 27
adult nasal decongestant ............... 113
adult wal-tussin .......................................... 111
ADVAIR DISKUS ............................ 209
ADVAIR HFA ........................................ 209
advanced am-pm ....................................... 217
advanced exfoliating cleanser
........................................................................................... 115
advanced eye relief (mo-wpet)
........................................................................................... 149
Index
Index
12 hour relief ..................................................... 53
1ST TIER UNILET
COMFORTOUCH ............................ 123
3 day vaginal ..................................................... 52
8-MOP ................................................................... 114
abacavir .................................................................... 70
abacavir-lamivudine-zidovudine
............................................................................................... 70
abaneu-sl ............................................................. 217
ABELCET .......................................................... 49
ABILIFY MAINTENA ................. 66
ABRAXANE .................................................. 27
acamprosate ....................................................... 14
acarbose ................................................................... 45
ACCU-CHEK ACTIVE TEST
........................................................................................... 123
ACCU-CHEK AVIVA ................ 123
ACCU-CHEK AVIVA PLUS
TEST STRP .................................................. 123
ACCU-CHEK COMPACT
PLUS TEST .................................................. 123
ACCU-CHEK FASTCLIX ... 123
ACCU-CHEK MULTICLIX
LANCET .......................................................... 123
ACCU-CHEK SAFE-T-PRO
........................................................................................... 123
ACCU-CHEK SAFE-T-PRO
PLUS ....................................................................... 123
ACCU-CHEK SMARTVIEW
TEST STRIP ................................................ 123
ACCU-CHEK SOFTCLIX
LANCETS ...................................................... 123
ACCUTREND GLUCOSE
........................................................................................... 124
ACE AEROSOL CLOUD
ENHANCER ............................................. 124
acebutolol ............................................................... 88
acephen ......................................................................... 3
acetaminophen .................................................... 3
acetaminophen-codeine ........................... 3
acetazolamide ............................................... 197
acetazolamide sodium ....................... 197
I-2
AMPYRA ........................................................ 101
ANACAINE ................................................ 114
anagrelide .............................................................. 79
anastrozole ........................................................... 28
ANDRODERM ..................................... 174
ANDROGEL ............................................. 175
androxy ................................................................. 175
antacid (calcium carb-mag hyd)
........................................................................................... 161
antacid anti-gas ......................................... 162
antacid exst (ca carb-mag hyd)
........................................................................................... 161
antacid extra-strength ...................... 162
antacid plus extra strength ......... 161
antacid supreme ......................................... 162
antibiotic plus (pramoxine) ..... 117
anticoag citrate phos dextrose
........................................................................................... 192
anti-diarrheal ................................................ 163
anti-diarrheal (lope)-anti-gas
........................................................................................... 166
anti-diarrheal (loperamide) ..... 162
antifungal ............................................................... 53
anti-fungal ............................................................ 50
antifungal (tolnaftate) ........................ 49
anti-gas maximum strength ....... 159
APOKYN ............................................................ 65
apraclonidine ................................................. 150
apri .............................................................................. 103
APRISO .............................................................. 190
aprodine ................................................................... 54
APTIOM ............................................................... 37
APTIVUS ............................................................. 70
aquanil hc ........................................................... 118
AQUASOL A ............................................. 217
aranelle (28) ................................................. 103
ARCALYST ................................................ 181
aripiprazole ......................................................... 66
ARISTADA .......................................... 66, 67
armodafinil ....................................................... 214
artificial tears (petro/min) ........ 150
artificial tears (pf) ................................ 150
artificial tears (polyvin alc) ..... 150
artificial tears(dext70-hypro)
........................................................................................... 150
Index
amiloride ................................................................. 94
amiloride-hydrochlorothiazide
............................................................................................... 94
AMINO ACIDS 15 % ....................... 79
aminocaproic acid ...................................... 79
AMINOSYN 10 % ................................. 79
AMINOSYN 3.5 % ............................... 80
AMINOSYN 7 % ..................................... 80
AMINOSYN 7 % WITH
ELECTROLYTES ................................. 80
AMINOSYN 8.5 % ............................... 80
AMINOSYN 8.5
%-ELECTROLYTES ........................ 80
AMINOSYN II 10 % .......................... 80
AMINOSYN II 15 % .......................... 80
AMINOSYN II 7 % ............................. 80
AMINOSYN II 8.5 % ........................ 80
AMINOSYN II 8.5
%-ELECTROLYTES ........................ 80
AMINOSYN M 3.5 % ...................... 80
AMINOSYN-HBC 7% .................... 80
AMINOSYN-PF 10 % ..................... 80
AMINOSYN-PF 7 %
(SULFITE-FREE) ................................. 81
AMINOSYN-RF 5.2 % .................. 81
amiodarone .......................................................... 87
AMITIZA ........................................................ 161
amitriptyline ...................................................... 42
amlodipine ............................................................. 94
amlodipine-atorvastatin ..................... 95
amlodipine-benazepril ........................... 94
amlodipine-valsartan .............................. 94
amlodipine-valsartan-hcthiazid
............................................................................................... 94
ammonium lactate .................................. 114
amoxapine ............................................................ 42
amoxicil-clarithromy-lansopraz
........................................................................................... 159
amoxicillin ............................................................ 23
amoxicillin-pot clavulanate
.................................................................................... 23, 24
amphotericin b ................................................ 49
ampicillin ................................................................ 24
ampicillin sodium ........................................ 24
ampicillin-sulbactam .............................. 24
Index
Index
ALBENZA ......................................................... 63
albuterol sulfate ......................................... 210
alcaine ..................................................................... 150
alclometasone ............................................... 118
ALCOHOL PADS .............................. 114
ALCOHOL PREP PADS ........ 114
ALDURAZYME ................................. 148
ALECENSA .................................................... 28
alendronate ...................................................... 191
alfuzosin ............................................................... 174
ALIMTA ............................................................... 28
ALINIA .................................................................. 64
ALKA-SELTZER GOLD ...... 161
ALLEGRA ALLERGY ................ 53
aller-chlor .............................................................. 54
allergy (chlorpheniramine) ........... 54
allergy (diphenhydramine) ........... 55
allergy and sinus relief .............. 57, 58
allergy relief (clemastine) .............. 58
allerhist-1 ............................................................... 54
allopurinol ......................................................... 192
ALLZITAL ........................................................... 3
almacone ............................................................. 161
almacone-2 ....................................................... 161
aloe vesta antifungal (micon) .... 49
alophen ................................................................... 167
alosetron .............................................................. 190
ALPHAGAN P ....................................... 197
alprazolam ............................................................ 16
ALREX ............................................................... 157
altacaine ............................................................... 150
altamist ................................................................. 150
altavera (28) ................................................. 103
altazine .................................................................. 150
ALTERNATE SITE LANCET
........................................................................................... 125
aluminum hydroxide gel ................. 161
alyacen 1/35 (28) ................................... 103
alyacen 7/7/7 (28) ................................. 103
amantadine hcl .................................... 64, 65
ambi 60pse-4cpm ......................................... 54
AMBISOME ................................................... 49
amethia .................................................................. 103
amethia lo .......................................................... 103
amifostine crystalline ......................... 192
...........................................................................................
artificial tears(pg-hypm-glyc)
153
150
ASACOL HD ............................................. 190
ascomp with codeine ................................... 3
ascorbic acid (vitamin c) ............. 217
ashlyna ................................................................... 103
aspirin ......................................................................... 11
aspirin, buffered ............................................ 11
aspirin-dipyridamole ............................... 79
aspir-low .................................................................. 11
ASSURE 4 STRIPS .......................... 125
ASSURE HAEMOLANCE
PLUS ....................................................................... 125
ASSURE ID INSULIN
SAFETY ............................................................ 125
ASSURE LANCE ............................... 125
ASSURE LANCE PLUS
............................................................................ 125, 126
ASSURE PLATINUM ................ 126
ASSURE PRISM MULTI
STRIP .................................................................... 126
ASTAGRAF XL ................................... 181
atenolol ..................................................................... 88
atenolol-chlorthalidone ....................... 88
athlete's foot ............................................ 49, 50
atorvastatin ......................................................... 95
atovaquone ........................................................... 64
atovaquone-proguanil ............................ 64
ATRIPLA ............................................................ 70
atropine ...................................................... 37, 150
atropine-care ................................................. 150
ATROVENT HFA ............................ 211
AUBAGIO ..................................................... 181
aubra ......................................................................... 103
auraphene-b ..................................................... 154
auro eardrops ................................................ 154
AVASTIN ........................................................... 28
AVC VAGINAL ....................................... 60
aviane ....................................................................... 103
AVONEX .......................................... 192, 193
AVONEX (WITH ALBUMIN)
........................................................................................... 192
ayr saline ............................................................. 150
...........................................................................................
I-3
BD TUBERCULIN SLIP-TIP
........................................................................................... 127
BD TUBERCULIN SYRINGE
........................................................................................... 127
BD ULTRA FINE LANCETS
........................................................................................... 127
BD ULTRA-FINE II
LANCETS ...................................................... 127
bekyree (28) .................................................. 104
BELBUCA ............................................................. 3
BELEODAQ ................................................... 28
BELSOMRA ............................................... 214
benadryl allergy ............................................ 54
BENADRYL ALLERGY .......... 55
benazepril ............................................................... 86
benazepril-hydrochlorothiazide
............................................................................................... 86
BENDEKA ....................................................... 28
BENICAR .......................................................... 85
BENICAR HCT ........................................ 85
BENLYSTA ................................................. 193
benzonatate ..................................................... 111
benzoyl peroxide ........................ 114, 115
benztropine .......................................................... 65
beta-hc .................................................................... 118
betamethasone acet,sod phos
........................................................................................... 177
betamethasone dipropionate ..... 118
betamethasone valerate ................... 118
betamethasone, augmented
............................................................................ 118, 119
BETASERON ........................................... 193
betaxolol .................................................. 88, 198
bethanechol chloride ............................ 193
BETHKIS ............................................................ 16
bexarotene ............................................................ 28
BEXSERO (PF) ...................................... 185
BG-STAR ........................................................ 127
bicalutamide ....................................................... 28
bicarsim forte ................................................ 158
BICILLIN C-R ............................................ 24
BICILLIN L-A ............................................ 24
BIDIL ........................................................................ 99
bimatoprost ..................................................... 198
bion tears (pf) ............................................. 150
Index
azacitidine ............................................................. 28
azathioprine .................................................... 181
azathioprine sodium ............................. 181
azelastine ............................................................ 150
AZILECT ............................................................ 65
azithromycin ...................................................... 22
AZOPT ................................................................. 198
AZOR ........................................................................ 94
aztreonam .............................................................. 23
azurette (28) ................................................. 104
b complex 100 .............................................. 217
b-12 dots .............................................................. 217
bacitracin .................................. 17, 116, 155
bacitracin-polymyxin b ..... 116, 155
bacitraycin plus .......................................... 116
baclofen ................................................................. 213
bacmin .................................................................... 217
balsalazide ........................................................ 190
balziva (28) .................................................... 104
banophen ................................................................. 54
banophen allergy .......................................... 54
BANZEL .............................................................. 37
baza antifungal ............................................... 49
BCG VACCINE, LIVE (PF)
........................................................................................... 185
b-complex with vitamin c .............. 217
BD BULK LUER-LOK
NON-STERILE ...................................... 126
BD INSULIN PEN NEEDLE
UF SHORT ................................................... 127
BD INSULIN SYRINGE
ULTRA-FINE .......................................... 126
BD INTEGRA SYRINGE .... 126
BD LUER-LOK SYRINGE
........................................................................................... 126
BD MICROTAINER LANCET
............................................................................ 126, 127
BD SAFETYGLIDE
SYRINGE ....................................................... 127
BD SAFETYGLIDE TB REG
BEVEL ................................................................. 127
BD SAFETY-LOK
DETACHABLE NEEDL ........ 142
BD SAFETY-LOK WITH
LUER-LOK ................................................. 142
Index
Index
artificial tears(hypromellose)
I-4
calcium phosphate-vitamin d3
............................................................................ 200, 201
calcium-magnesium .............................. 200
CALDOLOR .................................................. 11
cal-gest antacid .......................................... 162
CALTRATE 600 + D ..................... 201
CALTRATE WITH VITAMIN
D3 ................................................................................ 201
camila ...................................................................... 104
camrese ................................................................. 104
camrese lo .......................................................... 104
CANCIDAS ..................................................... 49
candesartan ......................................................... 85
candesartan-hydrochlorothiazid
............................................................................................... 85
capacet .......................................................................... 4
CAPASTAT ..................................................... 61
CAPRELSA ..................................................... 29
captopril ................................................................... 86
captopril-hydrochlorothiazide ... 86
CARAFATE ............................................... 159
CARBAGLU .............................................. 162
carbamazepine ................................................ 38
carbidopa ................................................................ 65
carbidopa-levodopa .................................. 65
carbidopa-levodopa-entacapone
............................................................................................... 65
CAREONE THIN LANCET
........................................................................................... 128
CARESENS LANCETS ............ 128
CARESENS N TEST STRIPS
........................................................................................... 128
CARIMUNE NF
NANOFILTERED ........................... 181
carisoprodol .................................................... 213
carteolol ............................................................... 150
cartia xt .................................................................... 89
carvedilol ................................................................ 88
CASTOR OIL ............................................ 167
castor oil ............................................... 168, 172
CAYSTON ........................................................ 23
caziant (28) .................................................... 104
cefaclor ...................................................................... 20
cefadroxil ............................................................... 20
cefazolin ................................................................... 20
Index
butalbital compound w/codeine .... 4
butalbital-acetaminop-caf-cod ...... 4
butalbital-acetaminophen .................... 4
butalbital-acetaminophen-caff ...... 4
butalbital-aspirin-caffeine ................... 4
BUTRANS ............................................................ 4
BYSTOLIC ........................................................ 88
cabergoline ........................................................... 65
CABOMETYX ................................. 28, 29
caffeine citrated ......................................... 101
caffeine-sodium benzoate ............. 101
calamine ............................................................... 115
calamine-zinc oxide .............................. 116
calci-chew ........................................................... 162
calcidol ................................................................... 217
calci-mix .............................................................. 199
calcipotriene ................................................... 115
calcitonin (salmon) .............................. 191
calcitrate ............................................................. 199
cal-citrate ........................................................... 199
calcitrate-vitamin d ............................... 199
calcitrene ............................................................. 115
calcitriol ................................................ 115, 191
calcium 500 + d ........................... 199, 201
calcium 500 + d (d3) ......................... 201
calcium 600 + d(3) .............................. 199
calcium 600 with vitamin d3
............................................................................ 203, 204
CALCIUM ACETATE ............... 173
calcium acetate ........................................... 173
calcium adult (calcium phos)
........................................................................................... 199
calcium antacid .......................................... 162
calcium carbonate .................... 162, 200
calcium carbonate-vitamin d2
........................................................................................... 201
calcium carbonate-vitamin d3
.............................................. 199, 201, 202, 208
calcium chloride ........................................ 200
calcium citrate malate-vit d3 ... 200
calcium citrate-vitamin d2 .......... 201
calcium citrate-vitamin d3
............................................................................ 200, 202
calcium gluconate ................................... 200
calcium lactate ............................................ 200
Index
Index
BIONIME RIGHTEST TEST
STRIPS ................................................................ 141
bisac-evac ........................................................... 167
bisacodyl .............................................................. 167
biscolax ................................................................. 167
bismatrol ............................................................. 162
bisoprolol fumarate .................................. 88
bisoprolol-hydrochlorothiazide
............................................................................................... 88
bleomycin ............................................................... 28
bleph-10 ................................................................ 155
BLINCYTO ...................................................... 28
blisovi 24 fe ...................................................... 104
blisovi fe 1.5/30 (28) .......................... 104
blisovi fe 1/20 (28) ................................ 104
BLOOD GLUCOSE TEST
.............................................. 127, 135, 139, 147
B-NATAL THERAPOPS ........ 217
BOOSTRIX TDAP ............................ 185
BOSULIF ............................................................ 28
BREATHERITE RIGID
SPACER-MASK .................................. 128
BREATHERITE VALVED
MDI SPACER .......................................... 128
BREO ELLIPTA .................................. 209
briellyn ................................................................... 104
BRILINTA ........................................................ 79
brimonidine ...................................................... 198
BRINTELLIX .............................................. 42
BRIVIACT ........................................................ 37
bromfenac .......................................................... 157
bromocriptine ................................................... 65
budesonide ......................................................... 190
bufferin ...................................................................... 11
BULLSEYE MINI SAFETY
LANCETS ...................................................... 128
bumetanide ........................................................... 94
BUPHENYL ............................................... 162
buprenorphine hcl ................................ 3, 14
buprenorphine-naloxone .................... 14
buproban ................................................................. 42
bupropion hcl .................................................... 42
bupropion hcl (smoking deter)
.................................................................................... 14, 42
buspirone ............................................................. 193
I-5
ciclopirox-ure-camph-menth-euc
............................................................................................... 50
cilostazol ................................................................. 79
cimetidine ........................................................... 159
cimetidine hcl ................................................ 159
CIMZIA ............................................................. 181
CIMZIA POWDER FOR
RECONST ...................................................... 181
CINQAIR ........................................................ 212
CINRYZE .......................................................... 77
CIPRODEX .................................................. 155
ciprofloxacin ...................................................... 25
ciprofloxacin hcl ............................ 25, 155
ciprofloxacin in 5 % dextrose
.................................................................................... 25, 26
ciprofloxacin lactate ............................... 25
citalopram .................................................. 42, 43
citracal + d maximum ...................... 201
citrate of magnesia ................................ 171
citroma ................................................................... 167
CITRUCEL .................................................. 168
CITRUCEL (SUCROSE) ........ 168
citrus calcium ................................................ 201
clarithromycin ................................................. 22
clearasil daily clear(benzoyl)
........................................................................................... 115
clearlax ................................................................. 172
CLEVER CHEK LANCETS
........................................................................................... 128
CLEVER CHOICE MICRO
TEST STRIP ................................................ 128
CLEVER CHOICE PRO ......... 128
CLEVER CHOICE TALK
TEST ....................................................................... 128
CLEVER CHOICE TEST
STRIPS ................................................................ 128
CLEVER CHOICE VOICE+
TEST ....................................................................... 128
CLEVIPREX .................................................. 94
clindamycin hcl ............................................... 17
clindamycin in 5 % dextrose ........ 17
clindamycin palmitate hcl ................ 17
clindamycin pediatric ............................. 17
clindamycin phosphate
...................................................... 18, 60, 116, 117
Index
child wal-tap cold-allergy ................ 55
CHILDREN'S ADVIL .................... 11
children's allegra allergy ........ 54, 55
children's aller-tec ...................................... 55
children's calcium gummies ........ 202
children's chest congestion .......... 112
CHILDREN'S NASACORT
........................................................................................... 157
children's non-aspirin ......................... 4, 5
children's pain reliever .......................... 10
children's pain-fever relief ................... 4
children's pepto ........................................... 162
children's silapap .............................................. 4
children's silfedrine ................................ 111
children's soothe ........................................ 162
children's sudafed ..................................... 111
children's tactinal ............................................ 4
children's vitamin d ................................ 217
children's wal-dryl allergy ............... 55
children's wal-zyr ......................................... 55
child's benadryl-d allergy-sin ....... 54
chloramphenicol sod succinate
............................................................................................... 17
chlordiazepoxide hcl ............................... 16
chlorhexidine gluconate .................. 114
chloroquine phosphate .......................... 64
chlorothiazide ................................................... 94
chlorothiazide sodium ........................... 94
chlorpheniramine maleate ............... 55
chlorpromazine ............................................... 67
chlorthalidone .................................................. 95
chlorzoxazone .............................................. 213
chocolate laxative ................................... 167
CHOICEDM CLARUS ............. 128
CHOLECALCIFEROL (VIT
D3)(BULK) ................................................... 230
cholecalciferol (vitamin d3)
............................................................. 218, 229, 230
CHOLECALCIFEROL
(VITAMIN D3) ....................................... 218
cholestyramine (with sugar) ....... 95
cholestyramine light ................................ 95
choline,magnesium salicylate ..... 11
ciclopirox .................................................... 49, 50
Index
Index
cefazolin in dextrose (iso-os) .... 20
cefdinir ....................................................................... 20
cefditoren pivoxil ......................................... 20
cefepime ................................................................... 20
CEFEPIME IN DEXTROSE 5
% ........................................................................................ 20
CEFEPIME IN
DEXTROSE,ISO-OSM .................. 20
cefotaxime ............................................................ 20
cefoxitin ................................................................... 20
cefoxitin in dextrose, iso-osm ..... 20
cefpodoxime ............................................ 20, 21
cefprozil .................................................................... 21
ceftazidime ........................................................... 21
ceftibuten ................................................................ 21
ceftriaxone ........................................................... 21
ceftriaxone in dextrose,iso-os .... 21
cefuroxime axetil ........................................ 21
cefuroxime sodium .................................... 21
celecoxib .................................................................. 11
CELLCEPT INTRAVENOUS
........................................................................................... 181
CELONTIN ..................................................... 38
CEO-TWO ...................................................... 167
cephalexin ............................................................. 21
CEPROTIN (BLUE BAR) ........ 76
CERDELGA ............................................... 193
CEREZYME ............................................... 148
CERVARIX VACCINE (PF)
........................................................................................... 185
cetirizine .................................................................. 54
CETYLEV ...................................................... 193
cevimeline ........................................................... 113
CHANTIX ......................................................... 14
CHANTIX CONTINUING
MONTH BOX .............................................. 14
CHANTIX STARTING
MONTH BOX .............................................. 15
cheratussin ac ............................................... 111
child allergy relf(cetirizine) ......... 55
child dometuss-da ....................................... 55
child mucinex chest congestion
........................................................................................... 112
child suppository ....................................... 168
child triaminic cold-allergy ............ 55
I-6
CONTOUR NEXT STRIPS
Index
clotrimazole-7 .................................................. 50
clotrimazole-betamethasone ........ 50
clozapine ................................................................. 67
COAGUCHEK LANCETS
........................................................................................... 128
COARTEM ...................................................... 64
codeine sulfate ..................................................... 5
COLACE .......................................................... 168
COLACE CLEAR .............................. 168
colchicine ............................................................ 193
colchicine-probenecid ......................... 193
cold and cough (diphenhydr-pe)
............................................................................................... 55
cold-allergy-sinus ........................................ 55
colestipol ................................................................. 96
colistin (colistimethate na) ........... 18
colocort ................................................................. 119
COLOR LANCETS ......................... 142
col-rite .................................................................... 171
COLY-MYCIN S ................................. 155
COMBIGAN .............................................. 198
COMBIPATCH ...................................... 175
COMBIVENT RESPIMAT
........................................................................................... 211
COMETRIQ .................................................... 29
COMFORT EZ LANCETS
............................................................................ 128, 129
comfort gel ....................................................... 162
comfort gel extra strength ........... 162
COMFORT LANCETS ............. 129
COMPACT SPACE
CHAMBER .................................................. 129
COMPACT SPACE
CHAMBER PLUS ............................. 129
COMPLERA .................................................. 70
compoz ....................................................................... 55
compro ....................................................................... 62
COMVAX (PF) ....................................... 185
CONDOMS-PREM
LUBRICATED ....................................... 104
CONDYLOX ............................................. 115
CONEX .................................................................. 55
conex ............................................................................ 55
constulose ........................................................... 162
Index
Index
CLINIMIX 5%/D15W
SULFITE FREE ....................................... 81
CLINIMIX 5%/D25W
SULFITE-FREE ...................................... 81
CLINIMIX 2.75%/D5W
SULFIT FREE ............................................ 81
CLINIMIX 4.25%/D10W SULF
FREE ......................................................................... 81
CLINIMIX 4.25%/D5W
SULFIT FREE ............................................ 81
CLINIMIX 4.25%-D20W
SULF-FREE ................................................... 81
CLINIMIX 4.25%-D25W
SULF-FREE ................................................... 81
CLINIMIX
5%-D20W(SULFITE-FREE)
............................................................................................... 81
CLINIMIX E 2.75%/D10W
SUL FREE ......................................................... 81
SULF FREE .................................................... 82
SUL FREE ......................................................... 82
SUL FREE ......................................................... 82
SULF FREE .................................................... 82
CLINIMIX E 5%/D15W
SULFIT FREE ............................................ 82
CLINIMIX E 5%/D20W
SULFIT FREE ............................................ 82
CLINIMIX E 5%/D25W
SULFIT FREE ............................................ 82
CLINISOL SF 15 % ............................. 82
clobetasol ............................................................ 119
clobetasol-emollient ............................. 119
clocortolone pivalate ........................... 119
clomipramine .................................................... 43
clonazepam .......................................................... 16
clonidine ................................................................... 84
clonidine hcl ......................................... 84, 101
clopidogrel ............................................................ 79
clorazepate dipotassium ..................... 16
clorpres ...................................................................... 85
clotrimazole ........................................................ 50
...........................................................................................
CONTOUR TEST STRIPS
129
129
CONTROL G3 ........................................ 129
CONTROL TEST ............................... 129
COOL GLUCOSE TEST
STRIP .................................................................... 129
COPAXONE ............................................... 193
CORLANOR ................................................. 90
cormax ................................................................... 119
cortaid ..................................................................... 119
cortisone ............................................................... 177
cortizone-10 .................................................... 119
CORTIZONE-10 .................................. 119
corvita 150 ........................................................ 217
COSENTYX ................................................ 115
COSENTYX (2 SYRINGES)
........................................................................................... 115
COSENTYX PEN ............................... 115
COSENTYX PEN (2 PENS)
........................................................................................... 115
COTELLIC ....................................................... 29
CREON ............................................................... 148
critic-aid clear af ......................................... 50
CRIXIVAN ...................................................... 70
cromolyn ................................ 150, 162, 212
cryselle (28) ................................................... 104
CUBICIN ............................................................. 18
cyanocobalamin (vitamin b-12)
.............................................. 217, 218, 225, 228
cyclafem 1/35 (28) ............................... 104
cyclafem 7/7/7 (28) ............................. 104
cyclobenzaprine ......................................... 213
cyclopentolate .............................................. 151
cyclophosphamide ...................................... 29
CYCLOPHOSPHAMIDE ......... 29
CYCLOSET ..................................................... 45
cyclosporine ..................................... 181, 182
cyclosporine modified ........................ 181
cyproheptadine .................................... 55, 56
CYRAMZA ...................................................... 29
cyred .......................................................................... 104
CYSTADANE .......................................... 193
CYSTARAN ............................................... 151
...........................................................................................
I-7
Index
delyla (28) ....................................................... 104
DELZICOL ................................................... 190
DEMSER ............................................................. 90
DEPEN TITRATABS .................. 174
DEPO-PROVERA ............................. 180
dermafungal ........................................................ 50
dermarest eczema (hydrocort)
........................................................................................... 119
DESCOVY ......................................................... 70
desenex ...................................................................... 50
desenex spray ................................................... 50
desipramine ......................................................... 43
desmopressin .................................................. 178
desog-e.estradiol/e.estradiol ..... 105
desogestrel-ethinyl estradiol ..... 105
desonide ................................................................ 119
desoximetasone .......................................... 119
dex4 glucose ....................................................... 82
dex4 glucose bits .......................................... 82
dexamethasone ........................................... 177
............................................................................ 157, 177
dexmethylphenidate ............................. 101
dextroamphetamine ............................. 101
dextroamphetamine-amphetamine
........................................................................................... 101
dextrose .................................................................... 82
dextrose 10 % and 0.2 % nacl
........................................................................................... 202
.................................................................................... 82, 83
............................................................................................... 83
............................................................................................... 83
............................................................................................... 83
dextrose 5 % in ringers ........................ 83
dextrose 5 % in water (d5w) ...... 83
dextrose 5 %-lactated ringers
........................................................................................... 202
dextrose 5%-0.2 % sod chloride
........................................................................................... 202
dextrose 5%-0.3 % sod.chloride
........................................................................................... 202
Index
Index
cysteine (l-cysteine) ............................... 82
d10 %-0.45 % sodium chloride
........................................................................................... 201
d2.5 %-0.45 % sodium chloride
........................................................................................... 202
d3 dots .................................................................... 218
d5 % and 0.9 % sodium chloride
........................................................................................... 202
d5 %-0.45 % sodium chloride
........................................................................................... 202
dactinomycin ..................................................... 29
daily fiber (psyllium-sucrose)
........................................................................................... 168
daily multiple .................................. 217, 218
daily multi-vitamin ................................ 222
daily prenatal ................................................ 218
daily value ......................................................... 218
daily vitamin ................................................... 218
daily vitamin formula ......................... 218
dailyhist-1 .............................................................. 56
daily-vite .............................................................. 218
DAKLINZA .................................................... 74
DALIRESP .................................................... 212
DALLERGY
(DEXBROMPHENIRAMN-PE
) ........................................................................................... 56
danazol ................................................................... 175
dantrolene .......................................................... 213
dapsone ..................................................................... 61
DAPTACEL (DTAP
PEDIATRIC) (PF) ............................. 185
DARAPRIM .................................................. 64
DARZALEX .................................................. 29
dasetta 1/35 (28) ..................................... 104
dasetta 7/7/7 (28) .................................. 104
dayhist allergy ................................................. 56
daysee ...................................................................... 104
ddrops ...................................................................... 218
deblitane ............................................................... 104
debrox ..................................................................... 155
decara ...................................................................... 218
decitabine ............................................................... 29
deep sea nasal ............................................... 151
deferoxamine ................................................. 174
delta d3 .................................................................. 218
...............................................................................................
...............................................................................................
dextrose with sodium chloride
83
83
202
dextrose-kcl-nacl ..................................... 202
diabetic tussin ex ...................................... 112
dialyvite ................................................................ 219
dialyvite 3000 ................................................ 218
dialyvite 800 with iron ...................... 219
diamode ................................................................. 163
DIATRUE PLUS TEST STRIP
........................................................................................... 129
diazepam ................................................................. 16
diazepam intensol ........................................ 16
diclofenac potassium ............................... 11
diclofenac sodium ......................... 11, 157
diclofenac-misoprostol ......................... 11
dicloxacillin ......................................................... 24
dicyclomine ...................................................... 163
didanosine .............................................................. 70
DIFICID ............................................................... 22
diflunisal .................................................................. 12
digitek .............................................................. 90, 91
digox ............................................................................. 91
digoxin ............................................................ 91, 92
DIGOXIN ........................................................... 91
dihydroergotamine .................................... 60
DILANTIN ...................................................... 38
diltiazem hcl ............................................ 89, 90
dilt-xr .......................................................................... 90
dimaphen (pe) ................................................ 56
dimenhydrinate ............................................... 62
dimetapp cold-congestion ................. 56
diotame instydose .................................... 163
DIPENTUM ................................................ 190
diphenhist ............................................................... 56
diphenhydramine hcl ............................... 56
diphenhydramine-phenylephrine
............................................................................................... 53
diphenoxylate-atropine .................... 163
dipyridamole ...................................................... 79
disopyramide phosphate ..................... 87
disulfiram ............................................................... 15
...........................................................................................
I-8
ELEMENT COMPACT TEST
STRIPS ................................................................ 131
ELEMENT TEST STRIPS .... 131
elfolate ................................................................... 219
ELIDEL .............................................................. 120
ELIGARD .......................................................... 30
ELIGARD (3 MONTH) ............... 29
ELIGARD (4 MONTH) ............... 30
ELIGARD (6 MONTH) ............... 30
elinest ....................................................................... 105
eliphos ..................................................................... 173
ELIQUIS ............................................................... 76
ELITEK .............................................................. 148
ELLA ...................................................................... 105
ELMIRON ..................................................... 193
elon dual defense .......................................... 50
elta tar .................................................................... 115
EMBRACE BLOOD
GLUCOSE SYSTEM .................... 131
EMBRACE EVO TEST
STRIPS ................................................................ 131
EMBRACE LANCETS .............. 131
EMBRACE PRO TEST
STRIPS ................................................................ 131
EMCYT .................................................................. 30
EMEND ................................................................. 62
emoquette ........................................................... 105
EMPLICITI ...................................................... 30
EMSAM ................................................................. 43
EMTRIVA ......................................................... 70
EMVERM .......................................................... 64
enalapril maleate ......................................... 86
enalaprilat ............................................................. 86
enalapril-hydrochlorothiazide .... 86
ENBREL ........................................................... 182
ENBREL SURECLICK ............ 182
endocet .......................................................................... 5
endodan ........................................................................ 5
endur-acin .............................................................. 96
enema ......................................... 169, 171, 172
enema disposable ....................... 168, 169
enemeez ................................................................. 169
enemeez plus ................................................... 169
ENGERIX-B (PF) .............................. 185
Index
ear drops (carbamide peroxide)
........................................................................................... 155
EASIVENT HOLDING
CHAMBER .................................................. 129
EASY COMFORT LANCETS
........................................................................................... 129
EASY PLUS ................................................ 129
EASY PLUS II TEST .................... 129
EASY STEP .................................................. 129
EASY TALK GLUCOSE TEST
........................................................................................... 129
EASY TOUCH ........................................ 130
EASY TOUCH FLIPLOCK
SYRINGE ....................................................... 130
EASY TOUCH LANCETS
........................................................................................... 130
EASY TOUCH SAFETY
LANCETS ...................................................... 130
EASY TOUCH
SHEATHLOCK SYRG-NDL
........................................................................................... 130
EASY TOUCH TEST STRIP
........................................................................................... 130
EASY TOUCH TWIST
LANCETS ...................................................... 130
EASY TRAK GLUCOSE TEST
........................................................................................... 130
EASY TWIST AND CAP
LANCETS ...................................................... 130
EASYGLUCO PLUS .................... 130
EASYGLUCO TEST ..................... 130
EASYMAX ................................................... 131
EASYMAX 15 .......................................... 131
ECLIPSE SYRINGE ...................... 126
econazole ................................................................ 50
econtra ez ........................................................... 105
ecotrin ......................................................................... 12
ed a-hist .................................................................... 56
ed chlorped jr .................................................... 56
ed-chlorped .......................................................... 56
EDURANT ...................................................... 70
effer-k ...................................................................... 202
EFFIENT ............................................................ 79
ELAPRASE .................................................. 148
electrolyte-48 in d5w ........................... 202
Index
Index
divalproex .............................................................. 38
dobutamine .......................................................... 92
dobutamine in d5w ..................................... 92
doc-q-lace ........................................................... 169
docu ............................................................................ 169
docusate sodium ........................................ 169
docusol ................................................................... 169
dofetilide ................................................................. 87
dok ............................................................................... 169
donepezil ................................................................. 41
dopamine ................................................................. 92
dopamine in 5 % dextrose ................ 92
dorzolamide ..................................................... 198
dorzolamide-timolol ............................. 198
doxazosin ............................................................... 85
doxepin ...................................................................... 43
doxercalciferol ............................................ 191
doxorubicin, peg-liposomal ........... 29
doxy-100 ................................................................. 26
doxycycline hyclate ....................... 26, 27
doxycycline monohydrate ................ 27
dramamine ............................................................ 62
dramamine less drowsy ....................... 62
driminate ................................................................. 62
DRISDOL ....................................................... 219
dristan long lasting ................................ 151
dronabinol ............................................................. 62
droperidol ........................................................... 193
DROPLET LANCETS ................ 129
drospirenone-ethinyl estradiol
........................................................................................... 105
DROXIA .............................................................. 29
dry mouth ........................................................... 114
DUAVEE ......................................................... 175
dulcolax stool softener (dss) ... 169
DULERA ......................................................... 209
duloxetine .............................................................. 43
DUREZOL .................................................... 157
dutasteride ........................................................ 193
dutasteride-tamsulosin ..................... 193
d-vi-sol .................................................................... 219
DYRENIUM ................................................. 95
e.c. prin ..................................................................... 12
e.e.s. 400 .................................................................. 22
e.e.s. granules ................................................... 22
I-9
falmina (28) .................................................. 105
famciclovir ............................................................ 75
famotidine .......................................................... 160
famotidine (pf) .......................................... 160
famotidine (pf)-nacl (iso-os)
........................................................................................... 160
FANAPT .............................................................. 67
FANTASY ..................................................... 105
FARESTON .................................................... 30
FARYDAK ...................................................... 30
FASLODEX .................................................... 30
felbamate ................................................................ 38
felodipine ................................................................ 94
FEMRING .................................................... 176
fenofibrate ............................................................ 96
fenofibrate micronized ......................... 96
fenofibrate nanocrystallized ......... 96
fenofibric acid .................................................. 96
fenofibric acid (choline) ................... 96
fenoprofen ............................................................. 12
fentanyl ......................................................................... 5
fentanyl citrate ................................................... 5
FEOSOL ............................................................ 219
feosol ........................................................................ 219
ferocon ................................................................... 219
ferretts .................................................................... 219
FERRETTS CARBONYL
IRON ...................................................................... 219
ferrex 150 forte .......................................... 219
ferrex 150 forte plus ............................ 220
ferrex 28 .............................................................. 220
FERRIPROX ............................................. 174
ferrocite ................................................................ 220
ferrocite plus .................................................. 220
ferrogels forte ............................................... 220
ferrous fumarate ....................................... 220
ferrous gluconate ........ 220, 221, 222
ferrous sulfate ............................... 217, 220
FETZIMA .......................................................... 43
feverall ........................................................................... 5
FEVERALL ........................................................ 5
fexofenadine ....................................................... 57
fiber (calcium polycarbophil)
........................................................................................... 169
Index
esmolol ....................................................................... 88
esomeprazole sodium .......................... 159
estarylla ................................................................ 105
ESTRACE ....................................................... 175
estradiol ................................................. 175, 176
estradiol valerate ...................................... 176
estradiol-norethindrone acet .... 176
estropipate ........................................................ 176
eszopiclone ........................................................ 214
ethambutol ............................................................ 61
ethamolin ................................................................ 93
ethosuximide ...................................................... 38
etodolac .................................................................... 12
ETOPOPHOS ................................................ 30
etoposide ................................................................. 30
EVENCARE G2 .................................... 131
EVENCARE G3 TEST ............... 131
EVENCARE MINI GLUCOSE
TEST STR ....................................................... 131
EVENCARE TEST ........................... 131
EVOLUTION TEST STRIPS
........................................................................................... 131
EVOTAZ .............................................................. 71
EXEL SYRINGE ................................. 131
exemestane ........................................................... 30
EXJADE ............................................................ 174
ex-lax (sennosides) .............................. 169
EXPECTA PRENATAL .......... 219
expectorant ...................................................... 112
EXTAVIA ....................................................... 193
eye allergy relief ......................... 150, 153
eye drops ............................................................. 150
eye drops (with povidone) .......... 151
eye wash ................................................ 150, 154
E-Z JECT LANCETS ..... 132, 140
E-Z JECT THIN LANCETS
........................................................................................... 140
EZ SMART LANCETS ............. 132
EZ SMART PLUS TEST ......... 132
EZ SMART TEST .............................. 132
E-Z SPACER .............................................. 132
ezfe forte .............................................................. 219
fabb ............................................................................. 219
FABRAZYME ........................................ 148
fallback solo ................................................... 105
Index
Index
............................................................................ 185, 186
enoxaparin ............................................................ 76
enpresse ................................................................. 105
enskyce .................................................................. 105
entacapone ............................................................ 65
entecavir .................................................................. 75
entre-hist pse ..................................................... 56
ENTRESTO ..................................................... 85
enulose .................................................................... 163
ENVARSUS XR ................................... 182
EPCLUSA .......................................................... 74
ephedrine sulfate .......................................... 92
epinastine ............................................................ 151
epinephrine ........................................................... 92
epinephrine hcl (pf) ................................. 92
EPIPEN 2-PAK .......................................... 92
EPIPEN JR 2-PAK ............................... 92
epitol ............................................................................. 38
EPIVIR HBV .................................................. 70
eplerenone ............................................................. 99
EPOGEN ................................................... 77, 78
epoprostenol (glycine) ..................... 216
epsom salt .......................................................... 194
EPZICOM .......................................................... 71
eq gentle ............................................................... 151
equalactin ........................................................... 169
ergocalciferol (vitamin d2)
............................................................. 219, 228, 229
ERGOCALCIFEROL
(VITAMIN D2) ....................................... 229
ergoloid ................................................................. 193
ERGOMAR ..................................................... 60
ERIVEDGE ..................................................... 30
errin ............................................................................ 105
ery pads ................................................................. 117
ery-tab ........................................................................ 22
ERY-TAB ............................................................ 22
ERYTHROCIN ......................................... 23
erythrocin (as stearate) .................... 23
erythromycin ...................................... 23, 155
erythromycin ethylsuccinate ........ 23
erythromycin with ethanol .......... 117
ESBRIET .......................................................... 213
escitalopram oxalate .............................. 43
172
fiber laxative (psyllium husk)
............................................................................ 168, 172
fiber smooth .................................................... 172
fiber therapy (m-cell/sugar) .... 169
fiber therapy (m-cellulose) ........ 168
fiber therapy (psyllium) ................ 169
fiber therapy (psyllium/sugar)
........................................................................................... 169
fiber therapy sugar free ................... 171
fiber-lax ................................................................ 169
fibertab .................................................................. 169
FIFTY50 SAFETY SEAL
LANCETS ...................................................... 132
FIFTY50 TEST STRIP ............... 132
finasteride .......................................................... 193
FINE 30 UNIVERSAL
LANCETS ...................................................... 132
FINGERSTIX LANCETS .... 132
FIRAZYR .......................................................... 93
FIRST CHOICE LANCETS
THIN ...................................................................... 123
fish oil ........................................ 96, 97, 98, 99
fish oil extra strength ............................ 97
fish oil omega 3-6-9 .................................. 97
fish oil pearls ..................................................... 97
flanax antacid .............................................. 163
FLEBOGAMMA DIF ................. 182
flecainide ................................................................. 87
FLECTOR .......................................................... 12
fleet glycerin (adult) .......................... 169
fleet glycerin (child) ........................... 169
FLEXICHAMBER ........................... 132
FLONASE ALLERGY
RELIEF .............................................................. 157
FLOVENT DISKUS ...................... 210
FLOVENT HFA ................................... 210
floxuridine ............................................................. 30
flucaine .................................................................. 151
fluconazole ........................................................... 51
fluconazole in dextrose(iso-o)
............................................................................................... 51
fluconazole in nacl (iso-osm) ..... 51
flucytosine ............................................................. 51
...........................................................................................
I-10
FORACARE GD20 ......................... 133
FORACARE GD40 ......................... 133
FORACARE LANCETS ......... 133
FORTEO .......................................................... 191
FORTICAL .................................................. 191
FORTISCARE GLUCOSE
TEST STRIPS ........................................... 133
foscarnet .................................................................. 73
fosinopril ................................................................. 86
fosinopril-hydrochlorothiazide
............................................................................................... 86
fosphenytoin ....................................................... 38
FREAMINE HBC 6.9 % .............. 83
FREAMINE III 10 % ........................ 83
FREESTYLE INSULINX ..... 133
FREESTYLE INSULINX
TEST STRIPS ........................................... 133
FREESTYLE LANCETS ....... 133
FREESTYLE LITE STRIPS
........................................................................................... 133
FREESTYLE PRECISION
NEO STRIPS .............................................. 133
FREESTYLE TEST ......................... 133
FREESTYLE UNISTIK 2 ..... 133
fungi cure ................................................................ 51
FUNGI-NAIL .............................................. 51
fungoid-d ................................................................. 51
furosemide ............................................................. 95
FUSILEV ......................................................... 193
FUZEON ............................................................. 71
FYCOMPA ....................................................... 38
G-4 TEST ......................................................... 133
gabapentin ............................................................ 38
GABITRIL ........................................................ 39
galantamine ........................................................ 41
GAMASTAN S/D ............................... 182
GAMMAGARD LIQUID .... 182
GAMMAPLEX ...................................... 182
ganciclovir sodium ..................................... 75
GARDASIL (PF) ................................. 186
GARDASIL 9 (PF) ........................... 186
gas relief .............................................................. 159
gas relief extra strength ................. 159
gas-x extra strength ............................. 159
gas-x ultra-strength .............................. 159
Index
fludrocortisone ............................................ 177
flumazenil ........................................................... 101
flunisolide ........................................................... 157
fluocinonide ..................................................... 120
fluorometholone ........................................ 157
fluorouracil ........................................... 30, 115
fluoxetine .................................................... 43, 44
fluphenazine decanoate ....................... 67
fluphenazine hcl ............................................. 67
flurbiprofen .......................................................... 12
flurbiprofen sodium .............................. 158
flutamide ................................................................. 30
fluticasone .......................................... 120, 158
fluvoxamine ........................................................ 44
foaming acne face wash .................. 115
foaming antacid .......................... 163, 166
foaming antacid extra strength
........................................................................................... 166
folbee ........................................................................ 220
folbee plus .......................................................... 220
folbic ......................................................................... 220
folic acid ............................................... 220, 221
folic acid-vit b6-vit b12 .................... 221
folivane-f ............................................................. 221
folivane-plus .................................................... 221
folplex 2.2 .......................................................... 221
fomepizole ......................................................... 193
fondaparinux ..................................................... 76
for sty relief ..................................................... 151
FORA D10 ..................................................... 132
FORA D15G ............................................... 132
FORA D20 ..................................................... 132
FORA D40-G31 TEST STRIPS
........................................................................................... 132
FORA G20 ..................................................... 133
FORA G30A ............................................... 133
FORA GD50 TEST STRIPS
........................................................................................... 133
FORA TEST STRIP ........................ 132
FORA TN'G VOICE TEST
STRIPS ................................................................ 133
FORA V10 ...................................................... 133
FORA V12 GLUCOSE ............... 133
FORA V20 ...................................................... 133
FORA V30A ................................................ 133
Index
Index
fiber laxative (methylcellulo)
I-11
HARVONI ......................................................... 74
HAVRIX (PF) ........................................... 186
HEALTHPRO TEST STRIPS
........................................................................................... 134
HEALTHY ACCENTS
UNILET LANCET ........................... 135
healthylax .......................................................... 170
heartburn antacid .................................... 164
heartburn relief ........................................... 163
heather ................................................................... 105
hematinic plus vit/minerals ......... 221
hematinic/folic acid ............................... 221
hematogen ......................................................... 221
hematogen fa ................................................. 221
hematogen forte ......................................... 221
hemocyte ............................................................. 221
heparin (porcine) ....................................... 77
heparin (porcine) in 5 % dex
.................................................................................... 76, 77
heparin (porcine) in nacl (pf)
............................................................................................... 77
heparin(porcine) in 0.45% nacl
............................................................................................... 77
heparin, porcine (pf) ............................. 77
HEPATAMINE 8% ............................. 83
HEPATASOL 8 % .................................. 83
HERCEPTIN ................................................. 30
HETLIOZ ........................................................ 214
HEXALEN ........................................................ 31
HIBERIX (PF) ......................................... 186
histex pe ................................................................... 57
homatropaire ................................................. 152
homatropine hbr ........................................ 152
HONGO CURA SPRAY ............ 51
HUMIRA ......................................................... 183
HUMIRA PEDIATRIC
CROHN'S START ............................. 182
HUMIRA PEN ....................................... 183
HUMIRA PEN
CROHN'S-UC-HS START
........................................................................................... 182
HUMIRA PEN
PSORIASIS-UVEITIS ................. 183
HUMULIN R U-500 (CONC)
KWIKPEN ........................................................ 47
Index
GLUCAGON EMERGENCY
KIT (HUMAN) ...................................... 194
gluco burst ............................................................ 83
GLUCO NAVII TEST STRIP
........................................................................................... 134
GLUCOCARD 01 SENSOR
PLUS ....................................................................... 134
GLUCOCARD EXPRESSION
........................................................................................... 134
GLUCOCARD SHINE TEST
STRIPS ................................................................ 134
GLUCOCARD VITAL
SENSOR ............................................................ 134
GLUCOCARD VITAL TEST
STRIPS ................................................................ 134
GLUCOCOM GLUCOSE ..... 134
GLUCOCOM LANCETS ...... 134
glucose ........................................................................ 83
glucose bits ........................................................... 82
glucose gel ............................................................. 83
GLUCOSOURCE .............................. 134
glutose 15 ............................................................... 83
glyburide ................................................................. 49
glyburide micronized .............................. 49
glyburide-metformin ............................... 49
glycerin (adult) .......................... 168, 170
glycerin (child) ........................... 168, 172
glycolax ................................................................ 170
glycopyrrolate ............................... 163, 164
glydo ............................................................................. 14
GLYXAMBI ................................................... 46
GM100 .................................................................. 141
GMATE LANCETS ........................ 134
GMATE TEST STRIPS ............. 134
granisetron (pf) ............................................ 62
granisetron hcl ................................................ 62
GRANIX .............................................................. 78
griseofulvin microsize ............................ 51
guanfacine .............................................. 85, 101
guanidine ............................................................. 194
GYNOL II ...................................................... 105
halobetasol propionate ..................... 120
haloperidol ............................................................ 68
haloperidol decanoate ........................... 67
haloperidol lactate ..................................... 68
Index
Index
gatifloxacin ...................................................... 155
GATTEX 30-VIAL ............................ 163
GATTEX ONE-VIAL .................. 163
GAUZE PAD ............................................ 193
gavilyte-c ............................................................. 170
gavilyte-g ............................................................ 170
gavilyte-n ............................................................ 170
GAVISCON EXTRA
STRENGTH ............................................... 163
GAZYVA ............................................................. 30
GE100 BLOOD GLUCOSE
TEST STRIP ................................................ 133
gelusil antacid and anti-gas ....... 163
gemfibrozil ........................................................... 97
generlac ................................................................. 163
gengraf ................................................................... 182
GENOTROPIN ...................................... 178
GENOTROPIN MINIQUICK
........................................................................................... 178
GENSTRIP TEST STRIP ....... 134
gentak ...................................................................... 155
gentamicin ............................... 17, 117, 155
gentamicin in nacl (iso-osm) ...... 17
gentamicin sulfate (ped) (pf) ... 17
gentamicin sulfate (pf) ....................... 17
GENTEAL GEL ................................... 151
genteal tears ................................................... 151
gentlelax .............................................................. 170
GENULTIMATE TEST ........... 134
GENVOYA ...................................................... 71
GEODON ........................................................... 67
gianvi (28) ....................................................... 105
gildagia .................................................................. 105
gildess 1.5/30 (21) ................................. 105
gildess 1/20 (21) ...................................... 105
gildess 24 fe ..................................................... 105
gildess fe 1.5/30 (28) ......................... 105
gildess fe 1/20 (28) ............................... 105
GILENYA ...................................................... 194
GILOTRIF ........................................................ 30
GLEOSTINE ................................................. 30
glimepiride ............................................................ 48
glipizide ......................................................... 48, 49
glipizide-metformin .................................. 49
GLUCAGEN HYPOKIT ....... 194
I-12
IPRIVASK ......................................................... 77
irbesartan ............................................................... 85
irbesartan-hydrochlorothiazide
............................................................................................... 85
IRESSA ................................................................... 31
iron high potency ...................................... 218
ISENTRESS .................................................... 71
ISOLYTE M IN 5 %
DEXTROSE ................................................ 203
ISOLYTE-H IN 5 %
DEXTROSE ................................................ 203
ISOLYTE-P IN 5 %
DEXTROSE ................................................ 203
ISOLYTE-S ................................................... 203
isoniazid ................................................................... 61
isosorbide dinitrate ................................ 100
isosorbide mononitrate ..................... 100
isradipine ................................................................ 94
itraconazole ........................................................ 51
ivermectin .............................................................. 64
IXEMPRA ......................................................... 31
IXIARO (PF) .............................................. 186
JAKAFI ................................................................. 32
jantoven .................................................................... 77
JANUMET ........................................................ 46
JANUMET XR .......................................... 46
JANUVIA ........................................................... 46
JARDIANCE ................................................ 46
jencycla ................................................................. 106
JENTADUETO ......................................... 46
JENTADUETO XR ............................ 46
jolessa ...................................................................... 106
jolivette .................................................................. 106
juleber ...................................................................... 106
junel 1.5/30 (21) ...................................... 106
junel 1/20 (21) ............................................ 106
junel fe 1.5/30 (28) ............................... 106
junel fe 1/20 (28) .................................... 106
junel fe 24 ........................................................... 106
JUXTAPID ....................................................... 97
KABIVEN .......................................................... 84
KALETRA ........................................................ 71
KALYDECO .............................................. 213
KANUMA ..................................................... 148
Index
imipenem-cilastatin .................................. 23
imipramine hcl ................................................. 44
imipramine pamoate ............................... 44
imiquimod .......................................................... 115
IMLYGIC ........................................................... 31
imodium a-d .................................................... 164
IMOGAM RABIES-HT (PF)
........................................................................................... 183
IMOVAX RABIES VACCINE
(PF) ............................................................................ 186
INCONTROL SUPER THIN
LANCETS ...................................................... 135
INCONTROL ULTRA THIN
LANCETS ...................................................... 135
INCRELEX .................................................. 178
indapamide ........................................................... 95
indomethacin ..................................................... 12
indomethacin sodium .............................. 12
INFANRIX (DTAP) (PF) ...... 186
infant's ibuprofen ......................................... 12
INFINITY TEST STRIPS ..... 135
INJECT EASE LANCETS .... 135
INLYTA ................................................................ 31
INSPIRACHAMBER ................... 135
INSPIRACHAMBER WITH
MASK-MED .............................................. 135
INSULIN SYRINGE-NEEDLE
U-100 ....................................................................... 135
INTELENCE ................................................. 71
INTRALIPID ................................................ 83
INTRON A ............................................ 74, 75
introvale ............................................................... 106
INVACARE LANCETS ........... 135
INVANZ ............................................................... 23
INVEGA SUSTENNA ................... 68
INVEGA TRINZA ............................... 68
INVIRASE ........................................................ 71
INVOKAMET ............................................. 46
INVOKANA .................................................. 46
inzo antifungal ................................................ 51
IONOSOL-B IN D5W .................. 203
IONOSOL-MB IN D5W ........... 203
IPOL ........................................................................ 186
ipratropium bromide ............ 152, 211
ipratropium-albuterol ........................ 211
Index
Index
HUMULIN R U-500
(CONCENTRATED) ....................... 47
hydralazine .......................................................... 93
hydrochlorothiazide ................................. 95
hydrocil instant ........................................... 170
hydrocodone-acetaminophen ........... 5
hydrocodone-ibuprofen ........................... 5
hydrocortisone ............... 120, 121, 177
hydrocortisone acet-aloe vera
........................................................................................... 120
hydrocortisone acetate ...... 119, 120
hydrocortisone butyrate ................. 120
hydrocortisone butyr-emollient
........................................................................................... 120
hydrocortisone valerate ................... 121
hydromorphone .................................................. 6
hydromorphone (pf) ........................... 5, 6
hydroskin ............................................................ 120
hydroxocobalamin ................................. 221
hydroxychloroquine ................................. 64
hydroxyprogesterone caproate
........................................................................................... 180
hydroxyurea ....................................................... 31
hydroxyzine hcl .......................................... 194
hydroxyzine pamoate ......................... 194
HYPERLYTE CR .............................. 202
HYPERRAB S/D (PF) ................. 183
HYQVIA ........................................................... 183
HYQVIA IG COMPONENT
........................................................................................... 183
HYSINGLA ER ............................................ 6
ibandronate ...................................................... 191
IBRANCE .......................................................... 31
ibuprofen .......................................... 11, 12, 13
ibuprofen jr strength ............................... 12
ICAR ....................................................................... 221
ichthammol ...................................................... 115
ICLUSIG .............................................................. 31
iferex 150 forte ........................................... 221
ifosfamide .............................................................. 31
ifosfamide-mesna ......................................... 31
ILARIS (PF) ................................................ 183
ILEVRO ............................................................. 158
imatinib ..................................................................... 31
IMBRUVICA ................................................ 31
I-13
leflunomide ....................................................... 183
LEMTRADA ............................................. 194
LENVIMA ......................................................... 32
lessina ...................................................................... 107
LETAIRIS ...................................................... 216
letrozole .................................................................... 32
leucovorin calcium .................................. 194
LEUKERAN .................................................. 32
LEUKINE .......................................................... 78
leuprolide ................................................................ 32
levetiracetam ..................................................... 39
levobunolol ........................................................ 198
levocarnitine ................................................... 194
levocarnitine (with sugar) .......... 194
levocetirizine ...................................................... 57
levofloxacin .......................................... 26, 155
levofloxacin in d5w ................................... 26
levoleucovorin calcium ..................... 194
levomefolate calcium .......................... 222
levonest (28) ................................................. 107
levonorgestrel ................................................ 107
levonorgestrel-ethinyl estrad .... 107
levonorg-eth estrad triphasic ... 107
levora-28 .............................................................. 107
levothyroxine ................................................. 180
LEXIVA ................................................................. 71
LIBERTY TEST .................................... 135
lice bedding spray .................................... 122
lice cream rinse ........................................... 123
lice killing ........................................................... 122
lice solution ...................................................... 122
lice treatment ................................................ 122
lice treatment (permethrin) ...... 123
licide spray ....................................................... 194
lidocaine ................................................................... 14
lidocaine (pf) ........................................ 14, 87
lidocaine hcl ........................................................ 14
lidocaine in 5 % dextrose (pf)
............................................................................................... 87
lidocaine viscous ........................................... 14
lidocaine-prilocaine .................................. 14
linezolid .................................................................... 18
LINZESS .......................................................... 164
liothyronine ...................................................... 181
lipodox ....................................................................... 32
Index
konsyl sugar-free ...................................... 170
KORLYM ........................................................... 46
kpn ............................................................................... 222
KRYSTEXXA .......................................... 148
kurvelo .................................................................... 106
KUVAN ............................................................. 148
KYNAMRO .................................................... 97
KYPROLIS ...................................................... 32
l norgest/e.estradiol-e.estrad .... 106
labetalol ................................................................... 88
LACRISERT .............................................. 152
LACTATED RINGERS ........... 190
lactulose ............................................................... 164
LAMICTAL .................................................... 39
LAMISIL (AEROSOL) .................. 51
lamisil af .................................................................. 51
LAMISIL AT ................................................. 51
lamivudine ............................................................. 71
lamivudine-zidovudine .......................... 71
lamotrigine ........................................................... 39
LANCETS ...................................................................
126, 127, 129, 132, 139, 140, 142
LANCETS, SUPER THIN ... 135
LANCETS,THIN ... 135, 136, 144
LANCETS,ULTRA THIN
............................................................................ 135, 148
LANOXIN ......................................................... 93
lansoprazole .................................................... 160
LANTUS .............................................................. 48
LANTUS SOLOSTAR .................... 48
larin 1.5/30 (21) ....................................... 107
larin 1/20 (21) ............................................ 107
larin 24 fe ........................................................... 107
larin fe 1.5/30 (28) ............................... 107
larin fe 1/20 (28) ..................................... 107
larissia .................................................................... 107
latanoprost ....................................................... 198
LATUDA ............................................................. 68
laxative (glycerin-pediatric) ... 172
laxative (sennosides)
............................................................. 168, 170, 172
laxative peg 3350 ..................................... 172
laxative pills regular ............................ 170
LAZANDA ........................................................... 6
leena 28 ................................................................. 107
Index
Index
kaopectate (bismuth subsalicy)
........................................................................................... 164
kaopectate ex str (bismuth ss)
........................................................................................... 164
kariva (28) ...................................................... 106
k-effervescent ................................................ 203
kelnor 1/35 (28) ....................................... 106
ketoconazole ...................................................... 51
KETO-DIASTIX .................................. 215
KETONE CARE .................................. 215
KETONE URINE TEST ......... 215
ketoprofen ............................................................. 12
ketorolac .................................................. 13, 158
KETOSTIX ................................................... 215
ketotifen fumarate ................................. 152
KEVEYIS ........................................................ 194
KEYTRUDA ................................................. 32
kids mini enema ......................................... 168
kimidess (28) ............................................... 106
KIMONO
CONDOMS(NON-LUBRICAT
ED) ............................................................................. 106
KIMONO MAXX CONDOMS
........................................................................................... 106
KIMONO MICROTHIN
AQUA LUBE CON ......................... 106
KIMONO MICROTHIN
CONDOMS .................................................. 106
KIMONO MICROTHIN
LARGE CONDOMS ..................... 106
KIMONO TEXTURED
CONDOMS .................................................. 106
KINERET ....................................................... 183
KINNEY BRAND LANCETS
........................................................................................... 135
KINRIX (PF) ............................................. 187
kionex ...................................................................... 164
kionex (with sorbitol) ...................... 164
KLOR-CON 10 ....................................... 203
klor-con m10 .................................................. 203
klor-con m15 .................................................. 203
klor-con m20 .................................................. 203
klor-con sprinkle ....................................... 203
konsyl (sugar) ............................................ 170
konsyl fiber ...................................................... 170
I-14
maprotiline ........................................................... 44
mar-cof cg ......................................................... 112
margesic ...................................................................... 6
marlissa ................................................................. 108
MARPLAN ...................................................... 44
masanti double strength .................. 165
MATULANE ................................................ 33
matzim la ................................................................ 90
maxepa ...................................................................... 97
MAXIMA ........................................................ 136
maximum redness relief .................. 151
meclizine .................................................................. 62
MEDI-LANCE LANCETS
........................................................................................... 136
MEDISENSE THIN
LANCETS ...................................................... 136
MEDLANCE PLUS LANCETS
........................................................................................... 136
medroxyprogesterone ........................ 180
MEDSAVER SYRINGE ......... 126
mefenamic acid ............................................... 13
mefloquine ............................................................. 64
MEFOXIN IN DEXTROSE
(ISO-OSM) ......................................................... 22
MEGACE ES ............................................. 180
megestrol ................................................. 33, 180
MEKINIST ....................................................... 33
meloxicam ............................................................. 13
memantine ............................................................. 41
MENACTRA (PF) ............................ 187
MENEST .......................................................... 176
MENHIBRIX (PF) ............................ 187
MENOMUNE - A/C/Y/W-135
(PF) ............................................................................ 187
men's multi-vitamin ............................... 218
MENVEO A-C-Y-W-135-DIP
(PF) ............................................................................ 187
MENVEO MENA
COMPONENT (PF) ........................ 187
MENVEO MENCYW-135
COMPNT (PF) ........................................ 187
MEPHYTON ............................................. 222
mercaptopurine .............................................. 33
meropenem ........................................................... 23
mesalamine ...................................................... 190
Index
............................................................................................... 32
............................................................................................... 32
............................................................................................... 33
LUPRON DEPOT-PED ........... 178
LUPRON DEPOT-PED (3
MONTH) .......................................................... 178
lutera (28) ........................................................ 107
LYNPARZA ................................................... 33
LYRICA ................................................................ 39
LYSODREN ................................................... 33
lyza .............................................................................. 107
maalox advanced ..................................... 164
MAALOX MAXIMUM
STRENGTH ............................................... 164
mag 64 .................................................................... 204
MAG-AL .......................................................... 164
magbid er ............................................................ 204
mag-delay .......................................................... 204
MAGELLAN SYRINGE ....... 136
mag-g ....................................................................... 204
magnebind 400 ............................................ 173
magnesium .......................... 201, 204, 208
MAGNESIUM CHLORIDE
........................................................................................... 204
magnesium chloride .............................. 204
magnesium citrate ................... 168, 170
MAGNESIUM CITRATE .... 204
magnesium gluconate ......................... 204
MAGNESIUM OXIDE ............. 164
magnesium oxide ........ 164, 165, 166
magnesium sulf in 0.45% nacl
........................................................................................... 204
magnesium sulfate ................... 204, 205
magnesium sulfate in d5w ............ 204
magnesium sulfate in water ....... 204
MAGONATE ............................................ 205
MAGONATE (MAGNESIUM
CARB) .................................................................. 205
MAGOX ............................................................ 165
malathion ............................................................ 122
mapap (acetaminophen) ...................... 6
mapap extra strength ................................ 6
Index
Index
lipodox 50 .............................................................. 32
liquid b 12 .......................................................... 222
liquid calcium with vitamin d ... 204
liquituss gg ........................................................ 112
lisinopril ................................................................... 86
lisinopril-hydrochlorothiazide .... 86
LITE TOUCH LANCETS ..... 136
LITEAIRE MDI CHAMBER
........................................................................................... 136
lithium carbonate ...................... 101, 102
lithium citrate ............................................... 102
little remedies ............................................... 152
LIVALO ................................................................. 97
l-methylfolate ............................................... 222
lohist - d ................................................................... 57
lohist-peb ................................................................ 57
lomedia 24 fe ................................................. 107
lomustine ................................................................. 32
LONSURF ........................................................ 32
loperamide ........................... 163, 164, 166
loratadine ............................................................... 57
lorazepam .............................................................. 16
lorcet (hydrocodone) ................................ 6
lorcet hd ....................................................................... 6
lorcet plus .................................................................. 6
loryna (28) ...................................................... 107
losartan ..................................................................... 85
losartan-hydrochlorothiazide ...... 85
LOTEMAX ................................................... 158
LOTRONEX ............................................... 164
lovastatin ................................................................ 97
low-ogestrel (28) ..................................... 107
loxapine succinate ...................................... 68
lubricant dry eye relief ..................... 151
lubricant eye .................................... 151, 152
lubricant eye (polyv alcohol)
........................................................................................... 153
lubricant eye (propyl glycol)
........................................................................................... 152
lubricant eye drops ................................ 150
lubricant redness reliever .............. 152
lubricating drops ....................................... 151
lubrifresh pm .................................................. 152
LUMIGAN ................................................... 198
LUPRON DEPOT ................................. 33
53
MICRO BLOOD GLUCOSE
........................................................................................... 141
MICRO THIN LANCETS .... 136
MICROCHAMBER ....................... 136
MICRODOT BLOOD
GLUCOSE SYSTEM .................... 136
MICRODOT XTRA BLOOD
GLUCOSE ..................................................... 136
microgestin 1.5/30 (21) .................. 108
microgestin 1/20 (21) ....................... 108
microgestin fe 1.5/30 (28) .......... 108
microgestin fe 1/20 (28) ................ 108
micro-guard ........................................................ 52
MICROLET LANCET ............... 136
MICROSPACER ................................. 136
midodrine ............................................................... 85
miglitol ...................................................................... 47
milk of magnesia ...................................... 170
MILK OF MAGNESIA
CONCENTRATED ......................... 170
milrinone ................................................................. 93
milrinone in 5 % dextrose ................ 93
mimvey ................................................................... 176
mimvey lo ........................................................... 176
mineral oil .......................................................... 170
mineral oil laxative ............................... 170
minitran ................................................................ 100
minocycline .......................................................... 27
minoxidil ............................................................. 100
mintox ..................................................................... 165
mintox maximum strength ......... 165
mintox plus ....................................................... 165
MIRCERA ........................................................ 78
mirtazapine .......................................................... 44
misoprostol ....................................................... 160
mitoxantrone ..................................................... 33
M-M-R II (PF) ......................................... 187
moexipril ................................................................. 87
moexipril-hydrochlorothiazide
............................................................................................... 87
molindone ............................................................... 68
mometasone .................................................... 121
...............................................................................................
I-15
MONAGHAN Z STAT
CHAMBER-MD MSK ............... 136
MONISTAT 3 ............................................... 52
monistat 7 .............................................................. 52
MONOJECT LUER-LOCK
TIP .............................................................................. 137
MONOJECT PHARMACY
TRAY LUER ............................................. 137
MONOJECT PHARMACY
TRAY REG TIP .................................... 137
MONOJECT SAFETY LUER
LOCK TIP ...................................................... 137
MONOJECT SAFETY
SYRINGES ................................................... 142
MONOJECT SYRINGE .......... 137
MONOJECT TB ................................... 137
MONOJECT TB LUER LOK
........................................................................................... 137
MONOJECT TB SAFETY
SYRINGE ....................................................... 137
MONOJECT TUBERCULIN
SYRINGE ......................... 136, 137, 145
MONOLET LANCETS ............. 137
MONOLET THIN LANCETS
........................................................................................... 138
mono-linyah .................................................... 108
mononessa (28) ......................................... 108
montelukast ..................................................... 210
morphine .............................................................. 7, 8
MORPHINE ....................................................... 7
morphine (pf) in 0.9 % nacl ............. 7
morphine concentrate ................................ 7
morphine in dextrose 5 % .................... 7
morrhuate sodium ................................... 195
motion sickness .............................................. 62
motion sickness (meclizine) ......... 63
MOVANTIK .............................................. 165
MOVIPREP .................................................. 170
MOXEZA ........................................................ 155
moxifloxacin ...................................................... 26
MOZOBIL .......................................................... 78
mucinex sinus-max ................................ 152
MULTAQ ........................................................... 87
multi antibiotic plus .............................. 117
multigen ................................................................ 222
Index
miconazole-3 prefil,cream,wipe
Index
Index
mesna ....................................................................... 194
MESNEX ......................................................... 194
MESTINON ................................................ 195
MESTINON TIMESPAN ...... 195
metafolbic .......................................................... 222
metaproterenol ............................................ 211
metaxall ............................................................... 213
metaxalone ....................................................... 213
metformin .............................................................. 46
methadone ......................................................... 6, 7
methadose ................................................................. 7
methazolamide ............................................ 198
methenamine hippurate ....................... 18
methimazole .................................................... 181
methocarbamol ........................................... 214
methotrexate sodium .............................. 33
methotrexate sodium (pf) .............. 33
methoxsalen rapid .................................. 115
methscopolamine ...................................... 165
methyclothiazide .......................................... 95
methylphenidate ........................................ 102
methylprednisolone ............................... 177
methylprednisolone acetate ....... 177
methylprednisolone sodium succ
........................................................................................... 177
metipranolol .................................................... 198
metoclopramide hcl ............................... 165
metolazone ........................................................... 95
metoprolol succinate ............................... 88
metoprolol ta-hydrochlorothiaz
............................................................................................... 88
metoprolol tartrate ........................ 88, 89
metronidazole ......................... 18, 60, 117
metronidazole in nacl (iso-os)
............................................................................................... 18
mexiletine .............................................................. 87
mg217 psoriasis ......................................... 115
MIACALCIN ............................................ 191
mi-acid ................................................................... 165
mi-acid gas relief ...................................... 159
micatin ....................................................................... 51
miconazole 7 ...................................................... 52
miconazole nitrate ............... 50, 51, 52
miconazole-3 ...................................................... 52
I-16
NEUTEK 2TEK TEST STRIPS
........................................................................................... 138
NEVANAC ................................................... 158
nevirapine ............................................................... 71
NEXAVAR ....................................................... 33
NEXIUM 24HR .................................... 160
next choice one dose ............................ 108
niacin ................................................................ 97, 98
niacin (inositol niacinate) .............. 98
niacin flush free .................................. 96, 98
niacinamide .......................................... 98, 223
niacor ........................................................................... 98
nicardipine ............................................................ 94
nicorelief .................................................................. 15
nicorette ................................................................... 15
nicotine ...................................................................... 15
nicotine (polacrilex) .............................. 15
NICOTROL ..................................................... 15
nifedical xl ............................................................ 94
nifedipine ................................................................ 94
nikki (28) .......................................................... 108
NILANDRON ............................................. 33
nilutamide .............................................................. 33
ninjacof-xg ........................................................ 112
NINLARO ......................................................... 33
NITRO-BID ................................................. 100
nitrofurantoin macrocrystal ......... 18
nitrofurantoin monohyd/m-cryst
............................................................................................... 19
nitroglycerin ................................................... 100
nitroglycerin in 5 % dextrose
........................................................................................... 100
NITROSTAT ............................................. 100
NIX CREME RINSE .................... 122
NIZORAL A-D .......................................... 52
nohist-lq ................................................................... 57
non-aspirin extra strength .................. 9
non-aspirin jr strength .............................. 5
nora-be ................................................................... 108
NORDITROPIN FLEXPRO
........................................................................................... 179
norepinephrine bitartrate ................. 93
norethindrone (contraceptive)
........................................................................................... 108
norethindrone acetate ........................ 180
Index
NATACYN ................................................... 155
nateglinide ............................................................. 47
NATPARA .................................................... 191
natural balance ........................................... 152
natural calcium ........................................... 205
natural daily fiber ................................... 168
natural fiber laxative therapy
........................................................................................... 170
natural tears (pf) .................................... 151
natural vegetable ...................................... 171
nature's tears (hypromellose)
........................................................................................... 152
NEBUPENT .................................................... 64
necon 0.5/35 (28) ................................... 108
necon 1/35 (28) ......................................... 108
necon 1/50 (28) ......................................... 108
necon 10/11 (28) ..................................... 108
necon 7/7/7 (28) ....................................... 108
nefazodone ............................................................ 44
neomycin ................................................................. 17
neomycin-bacitracin-poly-hc ... 155
neomycin-bacitracin-polymyxin
........................................................................................... 156
neomycin-polymyxin b gu ............ 117
........................................................................................... 156
neomycin-polymyxin-gramicidin
........................................................................................... 156
neomycin-polymyxin-hc ................. 156
neo-polycin ....................................................... 156
neo-polycin hc .............................................. 156
neosporin + pain relief ...................... 117
neosporin anti-itch ................................. 121
neo-synephrine 12 h spr (oxym)
........................................................................................... 152
nephplex rx ...................................................... 222
NEPHRAMINE 5.4 % ..................... 84
nephron fa .......................................................... 223
nephro-vite rx ............................................... 223
NEULASTA .................................................... 78
NEUMEGA ..................................................... 78
NEUPOGEN .................................................. 78
NEUPRO ............................................................. 65
neurin-sl ................................................................ 223
Index
Index
multigen folic ................................................. 222
multigen plus .................................................. 222
multiple vitamins ...................................... 222
multivitamin ..................................... 222, 226
multivitamin with fluoride ........... 222
mupirocin ............................................................ 117
mupirocin calcium .................................. 117
murine ear ......................................................... 155
murine ear wax removal system
........................................................................................... 155
muro 128 ............................................................. 152
my way ................................................................... 108
myco nail a ........................................................... 52
mycophenolate mofetil ..................... 183
mycophenolate sodium ..................... 184
myferon 150 forte ................................... 222
MYGLUCOHEALTH ................. 138
MYGLUCOHEALTH
LANCETS ...................................................... 138
MYOZYME ................................................. 149
MYRBETRIQ ........................................... 173
mytab gas ........................................................... 159
mytab gas maximum strength
........................................................................................... 159
myzilra ................................................................... 108
nabumetone ......................................................... 13
nadolol ....................................................................... 89
nafcillin ..................................................................... 24
NAGLAZYME ....................................... 149
naloxone .................................................................. 15
naltrexone ............................................................. 15
NAMENDA XR ....................................... 42
NAMZARIC .................................................. 42
naphazoline ...................................................... 152
naproxen ................................................................. 13
naproxen sodium ............................... 11, 13
naratriptan ........................................................... 60
NARCAN ........................................................... 15
NASACORT ............................................... 158
nasal allergy ................................................... 158
nasal and sinus decongestant ... 112
nasal decongestant (oxymetazl)
........................................................................................... 152
nasal decongestant (pe) ................. 151
NASCOBAL ................................................ 222
...........................................................................................
norethindrone-e.estradiol-iron
...........................................................................................
norgestimate-ethinyl estradiol
108
108
109
norlyroc ................................................................. 109
NORMOSOL-M IN 5 %
DEXTROSE ................................................ 205
NORMOSOL-R PH 7.4 ............. 205
nortemp ........................................................................ 8
NORTHERA ................................................. 85
nortrel 0.5/35 (28) ................................ 109
nortrel 1/35 (21) ...................................... 109
nortrel 1/35 (28) ...................................... 109
nortrel 7/7/7 (28) .................................... 109
nortriptyline ........................................................ 44
NORVIR ................................................... 71, 72
nose drops .......................................................... 154
NOVA MAX GLUCOSE TEST
........................................................................................... 138
NOVA SAFETY LANCETS
........................................................................................... 138
NOVA SUREFLEX LANCETS
........................................................................................... 138
NOVOLIN 70/30 ....................................... 48
NOVOLIN N ................................................. 48
NOVOLIN R .................................................. 48
NOVOLOG ...................................................... 48
NOVOLOG FLEXPEN ................. 48
NOVOLOG MIX 70-30 .................. 48
NOVOLOG MIX 70-30
FLEXPEN .......................................................... 48
NOVOLOG PENFILL .................... 48
NOXAFIL .......................................................... 52
NUCALA ........................................................ 213
NUCYNTA .......................................................... 8
NUCYNTA ER ............................................. 8
NUEDEXTA .............................................. 102
NULOJIX ........................................................ 184
nu-mag ................................................................... 205
NUPLAZID ..................................................... 68
NUTRESTORE ..................................... 165
NUTRILIPID ............................................... 84
NUTRILYTE ............................................ 205
...........................................................................................
I-17
ONE A DAY WOMEN'S
PRENATAL DHA ............................ 223
one daily ................................................ 223, 225
one daily essential ..... 219, 221, 223
one daily multivitamin ...................... 223
one daily prenatal ..................... 225, 226
one-a-day essential ................................ 223
ONE-A-DAY WOMEN'S
PRENATAL 1 .......................................... 223
one-per-day omega-3 .............................. 98
ONETOUCH DELICA
LANCETS ...................................................... 138
ONETOUCH FINEPOINT
LANCETS ...................................................... 138
ONETOUCH ULTRA TEST
........................................................................................... 138
ONETOUCH ULTRASOFT
LANCETS ...................................................... 138
ONETOUCH VERIO ................... 138
ONFI ........................................................... 16, 121
ON-THE-GO LANCETS ........ 142
opcicon one-step ........................................ 109
OPDIVO ................................................................ 34
OPSUMIT ....................................................... 216
OPTICHAMBER ADULT
MASK-LARGE ..................................... 139
OPTICHAMBER DIAMOND
VHC .......................................................................... 139
opti-clear ............................................................. 153
optimal d3 .......................................................... 223
OPTIUM EZ ............................................... 139
OPTIUM TEST ...................................... 139
OPTUMRX .................................................. 139
oral saline laxative ................................ 171
oralone ................................................................... 114
oralyte ..................................................................... 205
ORENCIA ...................................................... 184
ORENCIA (WITH MALTOSE)
........................................................................................... 184
ORENCIA CLICKJECT ......... 195
ORENITRAM ......................................... 216
ORFADIN ...................................... 149, 195
ORKAMBI .................................................... 213
orsythia ................................................................. 109
OTEZLA ........................................................... 195
Index
NUTRILYTE II ..................................... 205
NUVARING .............................................. 109
nyamyc ...................................................................... 52
nystatin ..................................................................... 52
nystatin-triamcinolone ......................... 52
nystop .......................................................................... 52
nyt-time sleep ................................................... 57
obagi nu-derm tolereen .................... 121
OCALIVA ....................................................... 165
ocean nasal ....................................................... 153
ocella ........................................................................ 109
OCTAGAM .................................................. 184
octreotide acetate .................................... 179
ODEFSEY .......................................................... 72
ODOMZO ........................................................... 34
OFEV ..................................................................... 213
ofloxacin .................................................. 26, 156
ogestrel (28) .................................................. 109
olanzapine ............................................................. 68
olanzapine-fluoxetine ............................ 44
olopatadine ....................................................... 153
OLYSIO ................................................................. 74
omega 3 fish oil .............................................. 96
omega-3 acid ethyl esters ................. 98
omega-3 fatty acids .................................. 96
omega-3 fatty acids-fish oil
.................................................................................... 97, 98
omeprazole ....................................................... 160
omeprazole magnesium ................... 160
omeprazole-sodium bicarbonate
........................................................................................... 160
ON CALL EXPRESS TEST
STRIP .................................................................... 138
ON CALL LANCET ...................... 138
ON CALL PLUS LANCET
........................................................................................... 138
ON CALL PLUS TEST STRIP
........................................................................................... 138
ON CALL VIVID TEST STRIP
........................................................................................... 138
ONCASPAR ................................................... 34
once daily ........................................................... 223
ondansetron ......................................................... 63
ondansetron hcl .............................................. 63
ondansetron hcl (pf) ............................... 63
Index
Index
norethindrone ac-eth estradiol
I-18
PHILLIPS MILK OF
MAGNESIA ................................. 166, 171
PHOSLYRA ................................................ 173
phospha 250 neutral ............................. 206
phosphate laxative ................................. 171
PHOSPHOLINE IODIDE ..... 198
phytonadione (vitamin k1) ........ 230
PICATO ............................................................. 116
pilocarpine hcl ............................... 114, 198
pimozide ................................................................... 69
pimtrea (28) .................................................. 109
pindolol ..................................................................... 89
pink bismuth ................................................... 166
pin-x .............................................................................. 64
pioglitazone ......................................................... 47
pioglitazone-glimepiride .................... 47
pioglitazone-metformin ....................... 47
piperacillin-tazobactam ...................... 25
pirmella ................................................................. 109
piroxicam ............................................................... 13
PLASMA-LYTE 148 ...................... 206
PLASMA-LYTE A ............................ 206
PLASMA-LYTE-56 IN 5 %
DEXTROSE ................................................ 206
PLEGRIDY .................................................. 195
POCKET CHAMBER ................. 139
podactin .................................................................... 52
podocon ................................................................. 116
podofilox ............................................................. 116
polyethylene glycol 3350 ............... 171
POLYETHYLENE GLYCOL
3350 ........................................................................... 171
POLYETHYLENE GLYCOL
3350(BULK) ................................................. 195
poly-iron 150 forte ................................. 223
polymyxin b sulfate .................................. 19
polymyxin b sulf-trimethoprim
........................................................................................... 156
polysporin .......................................................... 117
poly-vita (iron) .......................................... 223
poly-vitamin with iron ....................... 224
POMALYST ................................................... 34
portia ........................................................................ 109
PORTRAZZA .............................................. 34
potassium acetate .................................... 206
Index
peg 3350-electrolytes .......................... 171
PEGANONE .................................................. 39
PEGASYS ........................................................... 75
PEGASYS PROCLICK ................. 75
peg-electrolyte soln ............................... 171
PEGINTRON ............................................... 75
PEN NEEDLE, DIABETIC
........................................................................................... 139
penicillin g pot in dextrose .............. 25
penicillin g potassium ............................ 25
penicillin g procaine ................................. 25
penicillin v potassium ............................. 25
PENTACEL (PF) ................................. 187
PENTACEL ACTHIB
COMPONENT (PF) ........................ 188
PENTAM ............................................................. 64
pentoxifylline .................................................... 79
pep-t-med ............................................................ 165
perdiem overnight relief .................. 171
PERFECT IRON ................................. 223
PERIKABIVEN ........................................ 84
perindopril erbumine ............................... 87
periogard ............................................................. 114
permethrin ......................................................... 122
perphenazine ...................................................... 69
perphenazine-amitriptyline ............ 44
perry prenatal ............................................... 223
persa-gel ............................................................... 116
pfizerpen-g ............................................................ 25
pharbetol ..................................................................... 9
PHARMACIST CHOICE ...... 139
pharmacist favorite multi-vit ... 223
phenadoz ................................................................. 63
phenelzine .............................................................. 44
phenobarbital .................................................... 40
phenobarbital sodium ............................ 40
phentermine ..................................................... 102
phenylephrine hcl .......................... 85, 153
phenylhistine dh ......................................... 112
phenytoin ................................................................ 40
phenytoin sodium ......................................... 40
phenytoin sodium extended ........... 40
philith ....................................................................... 109
phillips .................................................................... 165
phillips liqui-gels ....................................... 171
Index
Index
OTEZLA STARTER ..................... 195
OTREXUP (PF) ..................................... 195
oxacillin ........................................................ 24, 25
oxacillin in dextrose(iso-osm)
............................................................................................... 25
oxandrolone .................................................... 175
oxcarbazepine .................................................. 39
OXTELLAR XR ...................................... 39
oxybutynin chloride .............................. 173
oxycodone ................................................................. 8
oxycodone-acetaminophen ................. 8
oxycodone-aspirin .......................................... 8
OXYCONTIN .................................................. 9
oxymorphone ........................................................ 9
oysco 500/d ...................................................... 205
oysco-500 ............................................................ 205
oyster shell calcium 500 .................. 205
oyster shell calcium-vit d3 ........... 205
oystercal-d ........................................................ 206
pacerone ................................................................... 87
pain relief ................................................................... 9
pain reliever jr strength ........................... 9
paliperidone ........................................................ 68
pancrelipase 5000 .................................... 149
panoxyl .................................................................. 115
panoxyl-4 ............................................................ 116
PANRETIN .................................................. 116
PANTILINERS ...................................... 195
pantoprazole ................................................... 160
papaverine ............................................................. 93
paricalcitol ........................................................ 191
paromomycin .................................................... 64
paroxetine hcl ................................................... 44
PASER ..................................................................... 61
PATADAY .................................................... 153
PAXIL ...................................................................... 44
PEDIA-LAX ............................................... 163
pedia-lax stool softener ................... 169
PEDIALYTE .............................................. 206
PEDIARIX (PF) .................................... 187
pediatric electrolyte
............................................................. 201, 206, 208
pediatric freezer pops ......................... 208
PEDIAVENT ................................................. 57
PEDVAX HIB (PF) .......................... 187
206
potassium bicarb-citric acid ...... 206
potassium chlorid-d5-0.45%nacl
........................................................................................... 206
potassium chloride .... 206, 207, 208
potassium chloride in 0.9%nacl
........................................................................................... 206
potassium chloride in 5 % dex
........................................................................................... 206
potassium chloride in lr-d5 ......... 206
potassium chloride-0.45 % nacl
........................................................................................... 207
........................................................................................... 207
........................................................................................... 207
........................................................................................... 207
potassium citrate ...................................... 207
potassium citrate-citric acid ..... 207
potassium hydroxide ........................... 116
potassium phosphate m-/d-basic
........................................................................................... 208
POTIGA ................................................................ 40
PRADAXA ....................................................... 77
PRALUENT PEN .................................. 98
PRALUENT SYRINGE .............. 98
pramipexole ........................................................ 65
pravastatin ............................................................ 98
prazosin .................................................................... 85
PRECISION PCX PLUS TEST
........................................................................................... 139
PRECISION PCX TEST .......... 139
PRECISION POINT OF CARE
TEST ....................................................................... 139
PRECISION Q-I-D TEST ...... 139
PRECISION XTRA TEST .... 139
prednicarbate ................................................ 121
prednisolone acetate ............................ 158
prednisolone sodium phosphate
............................................................................ 158, 177
prednisone ........................................... 177, 178
PREMARIN ................................................ 176
PREMASOL 10 % .................................. 84
...........................................................................................
I-19
PRIFTIN .............................................................. 61
PRIMAQUINE .......................................... 64
PRIMEAIRE .............................................. 139
primidone ............................................................... 40
PRISTIQ ............................................................... 45
PRIVIGEN .................................................... 184
PROAIR HFA .......................................... 211
PROAIR RESPICLICK ............ 211
probenecid ......................................................... 195
procainamide ..................................................... 87
PROCALAMINE 3% ........................ 84
PROCHAMBER .................................. 139
prochlorperazine ........................................... 63
prochlorperazine edisylate .............. 63
prochlorperazine maleate ................. 63
PROCRIT ........................................................... 78
procto-med hc ............................................... 121
procto-pak ......................................................... 121
proctosol hc ..................................................... 121
proctozone-hc ............................................... 121
PROCYSBI .................................................... 196
PRODIGY LANCETS
............................................................................ 139, 140
PRODIGY NO CODING ...... 139
PRODIGY TWIST TOP
LANCET .......................................................... 140
PROFE FORTE ..................................... 225
progesterone in oil .................................. 180
progesterone micronized ................ 180
PROGLYCEM ........................................ 100
PROGRAF .................................................... 184
PROLASTIN-C ...................................... 213
PROLENSA ................................................. 158
PROLEUKIN ............................................... 34
PROLIA ............................................................. 192
PROMACTA ................................................. 79
promethazine .......................................... 57, 63
promethazine vc-codeine ................ 112
promethazine-codeine ........................ 112
promethazine-dm ..................................... 112
promethegan ...................................................... 63
promolaxin ....................................................... 171
propafenone ............................................. 87, 88
propantheline .................................................... 37
proparacaine .................................................. 153
Index
PREMASOL 6 % ...................................... 84
PREMIUM V10 ..................................... 139
PREMPHASE ........................................... 176
PREMPRO .................................................... 176
prenatal ................................... 221, 225, 226
PRENATAL ................................................ 225
prenatal + dha ............................................. 224
prenatal 19 ........................................................ 224
PRENATAL
DHA+COMPLETE
PRENATAL ................................................ 224
prenatal formula ........................ 224, 225
prenatal gummy ......................................... 218
PRENATAL MULTI-DHA
........................................................................................... 224
prenatal multi-dha (algal oil)
........................................................................................... 224
prenatal multivitamins ...................... 224
prenatal one .................................................... 224
prenatal one daily .................................... 224
prenatal plus (calcium carb) ... 223
prenatal tablet .............................................. 225
prenatal vit no.90-iron fum-fa
........................................................................................... 224
prenatal vit#96-ferrous fum-fa
........................................................................................... 224
prenatal vitamin .....................................................
218, 219, 224, 225
prenatal vitamin plus low iron
........................................................................................... 225
prenatal vitamin with minerals
........................................................................................... 225
prenatal vit-iron fumarate-fa ... 225
prenatal with dha-folic acid ....... 224
prenatal-1 ........................................................... 225
preparation h hydrocortisone
........................................................................................... 121
PRESSURE ACTIVATED
LANCETS ...................................................... 139
PREVAIL BLADDER
CONTROL PAD .................................. 167
prevalite .................................................................... 98
previfem ................................................................ 109
PREZCOBIX ................................................. 72
PREZISTA ........................................................ 72
Index
Index
potassium bicarb and chloride
I-20
REPATHA SYRINGE ................... 99
reprexain .................................................................... 9
RESCRIPTOR ............................................. 72
RESTASIS ...................................................... 158
retaine cmc ....................................................... 153
retaine hpmc ................................................... 153
retaine pm .......................................................... 153
RETROVIR ..................................................... 72
REVEAL TEST STRIP .............. 141
revive plus .......................................................... 151
REVLIMID ...................................................... 34
revonto ................................................................... 214
REXULTI ........................................................... 69
REYATAZ ........................................................ 72
ribasphere .............................................................. 75
riboflavin (vitamin b2) .................... 226
rid complete lice elim kit ............... 123
rid lice killing ................................................ 123
RIDAURA .................................................... 184
rifabutin ................................................................... 61
rifampin .................................................................... 61
RIFATER ........................................................... 61
ri-gel ii .................................................................... 166
right step prenatal vitamins ....... 226
RIGHTEST GL300 LANCETS
........................................................................................... 141
RIGHTEST GS250S TEST
STRIPS ................................................................ 141
RIGHTEST GS260 TEST
STRIPS ................................................................ 141
RIGHTEST GS550 TEST
STRIPS ................................................................ 141
riginic ....................................................................... 166
riluzole .................................................................... 103
rimantadine ......................................................... 73
ri-mox ..................................................................... 166
ri-mox plus ....................................................... 166
ringers ...................................................... 190, 208
risacal-d ................................................................ 208
risedronate ........................................................ 192
RISPERDAL CONSTA ................ 69
risperidone ............................................................ 69
RITEFLO AEROCHAMBER
........................................................................................... 141
ritifed ........................................................................... 58
Index
RASUVO (PF) .......................................... 196
RAVICTI .......................................................... 166
react ........................................................................... 109
REBIF (WITH ALBUMIN)
........................................................................................... 196
REBIF REBIDOSE .......................... 196
REBIF TITRATION PACK
........................................................................................... 196
reclipsen (28) ............................................... 109
RECOMBIVAX HB (PF) ........ 188
recort plus .......................................................... 121
redness relief ................................... 151, 153
redness reliever lubricant
............................................................................ 151, 153
reese's pinworm medicine ................. 64
REFRESH TEARS ........................... 153
REFUAH PLUS ................................... 140
reguloid ................................................................. 172
relcof c .................................................................... 113
RELENZA DISKHALER ......... 73
RELIAMED LANCET .............. 140
RELIAMED SAFETY SEAL
LANCETS ...................................................... 140
RELION CONFIRM-MICRO
........................................................................................... 140
RELION PRIME TEST
STRIPS ................................................................ 141
RELION THIN LANCETS
........................................................................................... 141
RELION ULTRA THIN PLUS
LANCETS ...................................................... 141
RELISTOR ................................................... 166
remedy phytoplex antifungal ....... 53
REMICADE ............................................... 196
REMODULIN ......................................... 216
RENAGEL .................................................... 173
renal caps ........................................................... 226
rena-vite rx ....................................................... 226
reno caps ............................................................. 226
RENVELA ..................................................... 173
repaglinide ............................................................ 47
repaglinide-metformin .......................... 47
REPATHA PUSHTRONEX
............................................................................................... 99
REPATHA SURECLICK ......... 99
Index
Index
propranolol .......................................................... 89
propranolol-hydrochlorothiazid
............................................................................................... 89
propylthiouracil ......................................... 181
PROQUAD (PF) ................................... 188
PROSOL 20 % .............................................. 84
protamine ............................................................... 79
protriptyline ........................................................ 45
pseudoephedrine hcl ............................. 112
psyllium husk ................................................. 171
PULMOZYME ....................................... 149
puralube ................................................................ 153
pure and gentle eye ................................ 153
purelax ................................................................... 168
PURIXAN ......................................................... 34
PUSH BUTTON SAFETY
LANCETS ...................................................... 140
pyrazinamide ..................................................... 61
pyridostigmine bromide .................. 196
pyridoxine (vitamin b6) ................ 225
pyrilamine-phenylephrine ..... 57, 58
q-dryl ............................................................................ 58
q-pap ................................................................................ 9
q-pap extra strength ................................... 9
q-tapp .......................................................................... 58
q-tussin ................................................................... 113
QUADRACEL (PF) ........................ 188
quasense ............................................................... 109
quetiapine ............................................................... 69
QUILLIVANT XR ............................ 103
quinapril ................................................................... 87
quinapril-hydrochlorothiazide ... 87
quinidine gluconate ................................... 88
quinidine sulfate ............................................ 88
quinine sulfate .................................................. 64
QUINTET AC .......................................... 140
QUINTET GLUCOSE TEST
STRIPS ................................................................ 140
QVAR .................................................................... 210
RABAVERT (PF) ............................... 188
raloxifene ........................................................... 176
ramipril ..................................................................... 87
RANEXA ............................................................ 93
ranitidine hcl ................................... 160, 161
RAPAMUNE ............................................ 184
I-21
sodium chloride 0.9 % ....................... 208
sodium chloride 3 % ............................. 208
sodium chloride 5 % ............................. 208
sodium fluoride ........................................... 226
sodium lactate ............................... 208, 209
sodium phosphate .................................... 209
sodium polystyrene (sorb free)
........................................................................................... 167
sodium polystyrene sulfonate
........................................................................................... 167
sodium thiosulfate ................................... 174
SOFT TOUCH LANCETS ... 143
SOLTAMOX .................................................. 34
SOLU-CORTEF (PF) ................... 178
SOLUS V2 LANCETS ................. 143
SOLUS V2 TEST STRIPS ...... 143
SOMATULINE DEPOT .......... 179
SOMAVERT ............................................... 180
soothe (bismuth subsalicylate)
........................................................................................... 167
soothe regular strength .................... 167
sorbitol ................................................................... 190
sorbitol-mannitol ...................................... 190
sorine ............................................................................ 89
sotalol .......................................................................... 89
sotalol af .................................................................. 89
SOVALDI ........................................................... 74
SPACE CHAMBER PLUS ... 143
SPIRIVA RESPIMAT .................. 211
SPIRIVA WITH
HANDIHALER .................................... 211
spironolactone ................................................. 99
spironolacton-hydrochlorothiaz
............................................................................................... 99
sprintec (28) .................................................. 110
SPRITAM ........................................................... 40
SPRYCEL ........................................................... 34
sps (with sorbitol) ................................. 167
sronyx ..................................................................... 110
ssd ................................................................................. 118
st joseph aspirin ............................................. 13
st. joseph aspirin ........................................... 13
stavudine ................................................................. 72
STELARA ...................................................... 197
STERILANCE TL ............................. 143
Index
senna-extra ...................................................... 168
SENSIPAR .................................................... 196
SEREVENT DISKUS .................. 211
SEROSTIM ................................................... 179
sertraline ................................................................. 45
se-tan plus .......................................................... 226
setlakin .................................................................. 109
sharobel ................................................................. 109
siderol ...................................................................... 226
SIGNIFOR .................................................... 196
silace ......................................................................... 172
siladryl sa ............................................................... 58
silapap ............................................................................ 9
sildenafil ............................................................... 216
SILENOR ............................................................ 45
siltussin sa ......................................................... 113
silver nitrate ..................................... 117, 118
silver sulfadiazine .................................... 118
SIMBRINZA .............................................. 198
simethicone ...................................................... 159
SIMILAC PRENATAL ............. 226
simply sleep ......................................................... 58
SIMPONI .......................................... 196, 197
SIMPONI ARIA ................................... 196
simvastatin ........................................................... 99
SINGLE-LET ............................................ 142
sinus and allergy(pseudoephed)
............................................................................................... 58
sinus nighttime ................................................ 58
sirolimus ............................................................... 184
SIRTURO ........................................................... 61
SMART SENSE LANCETS
........................................................................................... 142
SMART SENSE TEST STRIPS
........................................................................................... 142
SMARTEST LANCET ............... 142
SMARTEST TEST ............................ 142
smoflipid .................................................................. 84
smoothlax .......................................................... 172
sochlor .................................................................... 154
sodium acetate ............................................. 208
sodium bicarbonate ................ 167, 208
sodium chloride .......................................................
154, 190, 208, 213
sodium chloride 0.45 % .................... 208
Index
Index
RITUXAN ......................................................... 34
rivastigmine ......................................................... 42
rivastigmine tartrate ............................... 42
rizatriptan ............................................................. 60
robafen ................................................................... 113
ropinirole ................................................................ 65
rosadan .................................................................. 117
rosuvastatin ......................................................... 99
ROTARIX ...................................................... 188
ROTATEQ VACCINE ............... 188
ROWEEPRA .................................................. 40
roxicet ............................................................................ 9
ROZEREM ................................................... 214
RYMED
(DEXCHLORPHENIRAMINE
-PE) ................................................................................ 58
SABRIL .................................................................. 40
SAFESNAP SYRINGE ............. 141
SAFETY LANCETS ...................... 141
SAFETY SEAL LANCETS
............................................................................ 141, 142
SAFETY-LET LANCETS ..... 142
SAIZEN .............................................................. 179
SAIZEN CLICK.EASY ............. 179
saline mist .......................................................... 153
saline nasal mist ........................................ 151
SANDOSTATIN LAR DEPOT
........................................................................................... 179
sani-supp (adult) ..................................... 172
sani-supp (infant) .................................. 172
SANTYL ........................................................... 116
SAPHRIS (BLACK CHERRY)
............................................................................................... 69
SAVELLA ....................................................... 103
scalp itch-dandruff relief ............... 116
scot-tussin expectorant .................... 113
sea soft nasal mist ................................... 154
sea-omega 30 .................................................... 99
selegiline hcl ....................................................... 65
selenium sulfide .......................................... 117
SELZENTRY ................................................ 72
senexon .................................................................. 172
senna .......................................................... 171, 172
senna lax ............................................................. 172
senna laxative ................................ 168, 172
I-22
tears again (pva) ..................................... 154
tears naturale free (pf) ................... 154
tears naturale pm ..................................... 154
TECENTRIQ ................................................. 35
TECFIDERA ............................................. 197
TECHLITE LANCETS .............. 144
TECHNIVIE ................................................... 74
TEFLARO ......................................................... 22
TELCARE LANCETS ................ 144
TELCARE TEST STRIPS ..... 144
telmisartan ........................................................... 85
telmisartan-hydrochlorothiazid
............................................................................................... 86
TEMODAR ...................................................... 35
tencon .......................................................................... 10
TENIVAC (PF) ....................................... 188
terazosin ............................................................... 174
terbinafine hcl .................................................. 53
terbutaline .......................................... 211, 212
terconazole ........................................................... 60
TERUMO SYRINGE .................. 144
TEST N'GO TEST .............................. 144
testosterone ...................................................... 175
testosterone cypionate ...................... 175
testosterone enanthate ...................... 175
TETANUS
TOXOID,ADSORBED (PF)
........................................................................................... 188
TETANUS,DIPHTHERIA
TOX PED(PF) .......................................... 188
tetanus-diphtheria toxoids-td
........................................................................................... 188
tetrabenazine ................................................. 103
tetracaine hcl (pf) .................................. 154
tetracycline .......................................................... 27
THALOMID ............................................... 197
the magic bullet .......................................... 170
theochron ............................................................ 212
theophylline ..................................................... 212
theophylline in dextrose 5 % .... 212
thera-d .................................................................... 227
THERANATAL .................................... 227
THERANATAL ONE ................. 227
THERANATAL OVAVITE
........................................................................................... 227
Index
SURE-TEST EASYPLUS
MINI ....................................................................... 143
SURE-TOUCH LANCET ..... 143
SURGUARD2 SAFETY ......... 144
SURMONTIL .............................................. 45
SUSTIVA ............................................................. 72
SUTENT ............................................................... 34
syeda ......................................................................... 110
SYLATRON ................................................... 75
SYLVANT ......................................................... 34
SYMLINPEN 120 ................................... 47
SYMLINPEN 60 ...................................... 47
SYNAGIS ................................................ 73, 74
SYNAREL ..................................................... 197
SYNERCID ..................................................... 19
SYNJARDY .................................................... 47
SYNRIBO ........................................................... 34
SYPRINE ........................................................ 174
SYRINGE (DISPOSABLE)
............................................................................ 127, 131
SYRINGE 3CC/25GX1" ........... 131
SYSTANE BALANCE ............... 154
systane nighttime ..................................... 154
tab-a-vite ............................................................. 227
TABLOID ........................................................... 34
tacrolimus ........................................... 121, 184
tactinal ....................................................................... 10
tactinal extra strength .......................... 10
TAFINLAR ..................................................... 35
TAGRISSO ....................................................... 35
TALTZ AUTOINJECTOR
........................................................................................... 116
TALTZ SYRINGE ............................ 116
TAMIFLU ......................................................... 74
tamoxifen ............................................................... 35
tamsulosin .......................................................... 174
TARCEVA ........................................................ 35
TARGRETIN ............................................... 35
tarina fe 1/20 (28) ................................. 110
taron forte ......................................................... 227
TASIGNA ........................................................... 35
tazicef .......................................................................... 22
TAZORAC .................................................... 122
taztia xt .................................................................... 90
TD GOLD TEST STRIP .......... 143
Index
Index
sterile eye drops ......................................... 153
STERILE PADS .................................... 197
STIOLTO RESPIMAT ................... 37
STIVARGA ...................................................... 34
stomach relief ............................................... 167
stool softener ................................................. 168
stop lice ................................................................. 123
STRATTERA ............................................ 103
STRENSIQ .................................................... 149
streptomycin ...................................................... 17
STRIBILD .......................................................... 72
STRIVERDI RESPIMAT ...... 211
strovite forte ................................................... 226
STROVITE ONE ................................. 226
STUART ONE ........................................ 226
sucralfate ............................................................ 161
sudafed ................................................................... 113
sudogest ................................................................ 113
sudogest sinus and allergy ............... 58
sulfacetamide sodium ......................... 156
sulfacetamide sodium (acne)
........................................................................................... 118
sulfacetamide-prednisolone ........ 157
sulfadiazine .......................................................... 26
sulfamethoxazole-trimethoprim
............................................................................................... 26
sulfasalazine ....................................................... 26
sulfatrim .................................................................. 26
sulindac ..................................................................... 13
sumatriptan ......................................................... 60
sumatriptan succinate ................ 60, 61
super multivitamin ................................. 227
SUPER THIN LANCETS ..... 143
SUPER TWIN EPA-DHA ........ 99
suphedrin ............................................................. 113
support-500 ...................................................... 227
suppository adult ...................................... 168
SUPPRELIN LA .................................. 180
SUPRAX .............................................................. 22
supreme antacid ......................................... 166
SURE COMFORT LANCETS
........................................................................................... 143
SURE-LANCE ........................................ 143
SURE-LANCE ULTRA THIN
........................................................................................... 143
I-23
tri-vitamin .......................................................... 227
trivora (28) ..................................................... 110
TROKENDI XR ...................................... 41
TROPHAMINE 10 % ....................... 84
TROPHAMINE 6% ............................. 84
trospium ............................................................... 174
TRUE METRIX GLUCOSE
TEST STRIP ................................................ 144
TRUEPLUS LANCETS ........... 144
TRUETEST TEST STRIPS
............................................................................ 144, 145
TRUETRACK SMART
SYSTEM ........................................................... 140
TRUETRACK TEST .................... 145
TRULICITY ................................................... 47
TRUMENBA ............................................. 189
TRUSTEX LATEX CONDOM
........................................................................................... 110
TRUSTEX LUBRICATED
CONDOMS .................................................. 110
TRUSTEX NON-LUB
CONDOMS .................................................. 110
TRUSTEX-RIA
LUB/SPERMICIDE ........................ 110
TRUSTEX-RIA NON-LUB
CONDOMS .................................................. 111
TRUVADA ...................................................... 73
trymine cg .......................................................... 113
TUBERCULIN SYRINGE
............................................................................ 131, 145
TUBERCULIN-ALLERGY
SYRINGES ................................................... 131
TUDORZA PRESSAIR ............ 212
TWINRIX (PF) ....................................... 189
TYBOST ............................................................ 197
TYGACIL .......................................................... 27
TYKERB .............................................................. 36
TYPHIM VI ................................................. 189
TYSABRI ........................................................ 184
TYVASO ........................................................... 216
TYVASO REFILL KIT ............. 216
TYVASO STARTER KIT ..... 216
TYZEKA .............................................................. 75
u-cort ........................................................................ 122
ULORIC ............................................................ 197
Index
TRANSDERM-SCOP ..................... 63
tranylcypromine ............................................ 45
TRAVASOL 10 % ................................... 84
TRAVATAN Z ....................................... 198
travel sickness (meclizine) ............ 63
travoprost (benzalkonium) ....... 198
trazodone ................................................................ 45
TREANDA ....................................................... 35
TRECATOR ................................................... 61
TRELSTAR .......................................... 35, 36
tretinoin ................................................................ 122
tretinoin (chemotherapy) ................ 36
tretinoin microspheres ...................... 122
TREXALL ......................................................... 36
triacting orange ............................................. 58
triamcinolone acetonide
.............................................. 114, 121, 158, 178
TRIAMINIC COLD AND
COUGHNT(PE) ....................................... 58
triamterene-hydrochlorothiazid
............................................................................................... 95
trianex .................................................................... 121
TRIBENZOR ................................................ 86
tri-buffered aspirin .................................... 13
tri-estarylla ...................................................... 110
trifluoperazine ................................................. 69
trifluridine ......................................................... 157
trigels-f forte .................................................. 227
trihexyphenidyl .............................................. 66
tri-legest fe ....................................................... 110
tri-linyah .............................................................. 110
tri-lo-estarylla .............................................. 110
tri-lo-marzia ................................................... 110
tri-lo-sprintec ................................................ 110
trilyte with flavor packets ............ 172
trimethoprim ...................................................... 19
trimipramine ...................................................... 45
trinessa (28) .................................................. 110
TRINTELLIX .............................................. 45
triple paste af .................................................... 53
tri-previfem (28) ..................................... 110
tri-sprintec (28) ........................................ 110
TRIUMEQ ........................................................ 73
tri-vi-sol ................................................................ 227
tri-vita ..................................................................... 227
Index
Index
THERANATAL PLUS .............. 227
thiamine hcl (vitamin b1) ............ 227
THIN LANCETS ................................. 142
thioridazine .......................................................... 69
thiotepa ..................................................................... 35
thiothixene ............................................................ 69
tiagabine .................................................................. 40
TICE BCG ...................................................... 185
tilia fe ....................................................................... 110
timolol maleate ................................ 89, 198
tioconazole ........................................................... 50
TIVICAY ............................................................. 72
tizanidine ............................................................. 214
tl gard rx ............................................................. 227
tl-hem 150 .......................................................... 227
TOBI PODHALER .............................. 17
TOBRADEX ............................................... 157
TOBRADEX ST .................................... 157
tobramycin ........................................................ 157
tobramycin in 0.225 % nacl ........... 17
tobramycin in 0.9 % nacl .................. 17
tobramycin sulfate ..................................... 17
tobramycin-dexamethasone ...... 157
TOLAK ............................................................... 116
tolazamide ............................................................. 49
tolbutamide .......................................................... 49
tolmetin ..................................................................... 13
tolnaftate ................................................................ 53
tolterodine ......................................................... 173
TOPCARE UNIVERSAL1
LANCET .......................................................... 144
topiragen ................................................................. 40
topiramate ................................................. 40, 41
toposar ....................................................................... 35
torsemide ................................................................ 95
TOUJEO SOLOSTAR ..................... 48
TOVIAZ ............................................................. 173
TPN ELECTROLYTES ............ 209
TPN ELECTROLYTES II .... 209
TRACLEER ................................................ 216
TRADJENTA ............................................... 47
tramadol .................................................................. 10
tramadol-acetaminophen .................. 10
trandolapril .......................................................... 87
tranexamic acid ............................................. 79
I-24
vicks qlearquil(oxymetazoline)
........................................................................................... 154
vicks sinex 12-hour ................................ 154
vicodin ........................................................................ 10
vicodin es ................................................................ 10
vicodin hp ............................................................... 10
VICTOZA ........................................................... 47
VIDEX 2 GRAM PEDIATRIC
............................................................................................... 73
VIDEX 4 GRAM PEDIATRIC
............................................................................................... 73
VIEKIRA PAK .......................................... 74
VIEKIRA XR ............................................... 74
vienva ....................................................................... 111
VIGAMOX .................................................... 157
VIIBRYD ............................................................. 45
VIMIZIM ......................................................... 149
VIMPAT ............................................................... 41
vinacal b ............................................................... 228
vinorelbine ............................................................. 36
viorele (28) ..................................................... 111
VIRACEPT ....................................................... 73
VIRAMUNE XR ..................................... 73
VIRAZOLE ...................................................... 76
VIREAD ............................................................... 73
virt-phos 250 neutral ........................... 209
virtussin ac ........................................................ 113
VISINE MAX REDNESS
RELIEF .............................................................. 154
VISINE TOTALITY ....................... 154
visine-a ................................................................... 154
vitacel (with lutein) ............................. 228
vitafol ....................................................................... 228
VITAFOL FE+ (WITH
DOCUSATE) ............................................. 228
vital-d rx .............................................................. 228
vitamin a .............................................................. 228
vitamin b-1 ........................................................ 228
vitamin b12-folic acid ........................ 217
vitamin b-2 ........................................................ 228
vitamin b-6 ........................................................ 228
vitamin c ............................................... 228, 229
vitamin d3 ............................ 225, 226, 229
VITAMIN D3 ............................................ 229
vitamin e ............................................... 226, 230
Index
UNISTIK TOUCH LANCETS
........................................................................................... 147
UNISTRIP1 TEST STRIP ..... 147
UNITUXIN ..................................................... 36
UNIVERSAL 1 LANCETS
............................................................. 134, 135, 147
UPTRAVI ........................................ 216, 217
ursodiol .................................................................. 167
VAGIFEM ..................................................... 177
vaginal contraceptive foam ........ 111
vagistat-1 ................................................................ 53
vagistat-3 ................................................................ 53
valacyclovir ......................................................... 75
VALCHLOR ............................................... 116
valganciclovir .................................................... 76
valproate sodium .......................................... 41
valproic acid ....................................................... 41
valproic acid (as sodium salt) ... 41
valsartan .................................................................. 86
valsartan-hydrochlorothiazide ... 86
VALSTAR .......................................................... 36
valu-tapp decongestant .................... 113
vancomycin .......................................................... 19
vancomycin in dextrose 5 % ......... 19
VANISHPOINT SYRINGE
........................................................................................... 147
VAQTA (PF) ............................................... 189
VARIVAX (PF) ...................................... 189
VASCEPA .......................................................... 99
vazobid-pd ............................................................. 58
v-c forte ................................................................. 227
VELCADE ......................................................... 36
velivet triphasic regimen (28)
........................................................................................... 111
VENCLEXTA .............................................. 36
VENCLEXTA STARTING
PACK ........................................................................ 36
venlafaxine ........................................................... 45
VENTOLIN HFA ............................... 212
verapamil ................................................................ 90
VERSACLOZ ............................................... 69
vestura (28) .................................................... 111
VGO 40 ................................................................ 147
VIBERZI ........................................................... 167
vic-forte ................................................................. 227
Index
Index
ULTILET BASIC LANCETS
........................................................................................... 145
ULTILET CLASSIC
LANCETS ...................................................... 145
ULTILET LANCETS ................... 145
ULTILET SAFETY LANCETS
........................................................................................... 145
ULTIMA TEST STRIPS
............................................................................ 141, 145
ultra strength antacid ........................ 161
ULTRA THIN II LANCETS
........................................................................................... 146
ULTRA THIN LANCETS
............................................................. 129, 145, 146
ULTRA THIN PLUS
LANCETS ...................................................... 141
ULTRA TLC LANCETS ........ 146
ULTRALANCE LANCETS
........................................................................................... 146
ULTRA-THIN II LANCETS
........................................................................................... 146
ULTRATRAK ......................................... 146
ULTRATRAK ULTIMATE
........................................................................................... 146
UNILET COMFORTOUCH
LANCET .......................................................... 146
UNILET EXCELITE II
LANCET .......................................................... 146
UNILET EXCELITE LANCET
........................................................................................... 146
UNILET GP LANCET .............. 146
UNILET LANCET ............ 142, 146
UNILET SUPER THIN
LANCETS ...................................................... 140
unisom sleepgels ............................................ 58
UNISTIK 3 COMFORT
LANCET .......................................................... 147
UNISTIK 3 EXTRA LANCET
........................................................................................... 147
UNISTIK 3 GENTLE .................. 147
UNISTIK 3 LANCETS .............. 147
UNISTIK 3 NORMAL
LANCET .......................................................... 147
UNISTIK CZT LANCET ....... 147
UNISTIK SAFETY ......................... 147
I-25
zovia 1/50e (28) ........................................ 111
ZOVIRAX ...................................................... 116
z-sleep ......................................................................... 57
ZUBSOLV .......................................................... 16
ZYDELIG .......................................................... 37
ZYKADIA ......................................................... 37
ZYLET ................................................................. 157
ZYPREXA RELPREVV .............. 70
zyrtec itchy eye drops (keto)
........................................................................................... 154
ZYTIGA ................................................................ 37
ZYVOX ................................................................... 19
Index
XARELTO ........................................................ 77
XELJANZ ....................................................... 197
XELJANZ XR .......................................... 197
XIFAXAN ......................................................... 19
XIIDRA ............................................................. 158
XOLAIR ............................................................ 213
XTANDI ............................................................... 36
xulane ...................................................................... 111
xylon 10 .................................................................... 10
XYREM ............................................................. 214
YERVOY ............................................................. 36
YF-VAX (PF) ............................................ 189
YONDELIS ...................................................... 36
zafirlukast ......................................................... 210
zaleplon ................................................................. 214
zarah ......................................................................... 111
ZARXIO ............................................................... 79
ZAVESCA ...................................................... 149
zeasorb (miconazole) ........................... 53
zebutal ........................................................................ 10
ZELBORAF .................................................... 36
ZEMPLAR .................................................... 192
zenatane ............................................................... 116
zenchent (28) ............................................... 111
ZENPEP ............................................................ 149
ZEPATIER ........................................................ 74
zephrex-d ............................................................ 113
ZETIA ....................................................................... 99
ZIAGEN ............................................................... 73
zidovudine .............................................................. 73
ZINBRYTA ................................................. 197
ziprasidone hcl ................................................. 70
ZIRGAN ........................................................... 157
ZOLADEX ........................................................ 37
zoledronic acid ............................................ 192
........................................................................................... 192
ZOLINZA ........................................................... 37
zolmitriptan ........................................................ 61
zolpidem ............................................................... 215
ZOMETA ......................................................... 192
zonisamide ............................................................ 41
ZORTRESS .................................................. 184
ZOSTAVAX (PF) ................................ 189
zovia 1/35e (28) ........................................ 111
Index
Index
vitamin e (dl, acetate) ...................... 230
vitamin e natural blend .................... 228
vitamin k1 .......................................................... 230
vitamins for hair ........................................ 230
VITA-RESPA ............................................ 230
VITEKTA ........................................................... 73
VOLTAREN ................................................... 13
voriconazole ........................................................ 53
VORTEX HOLDING
CHAMBER .................................................. 148
VORTEX VHC FROG
MASK-CHILD ....................................... 148
VOTRIENT ...................................................... 36
VPRIV ................................................................... 149
vp-vite rx ............................................................. 230
VRAYLAR ............................................ 69, 70
vyfemla (28) .................................................. 111
wal-act d cold and allergy ................ 59
wal-dram ................................................................. 63
wal-dryl allergy .............................................. 59
wal-fex allergy ................................................ 59
wal-finate ............................................................... 59
wal-finate-d ......................................................... 59
wal-itin ....................................................................... 59
wal-mucil fiber ............................................ 172
wal-phed .................................................... 59, 113
wal-phed pe sinus and allergy ..... 59
wal-profen ............................................................. 13
wal-sleep z ............................................................. 59
wal-som (diphenhydramine) ....... 59
wal-tap ....................................................................... 59
wal-zan 75 ......................................................... 161
wal-zyr (cetirizine) .................................. 59
wal-zyr (ketotifen) ............................... 154
warfarin .................................................................... 77
water for irrigation, sterile ......... 190
WAVESENSE JAZZ ...................... 148
WAVESENSE PRESTO ........... 148
wee care ................................................................ 230
WELCHOL ....................................................... 99
wera (28) ........................................................... 111
WIDE-SEAL DIAPHRAGM 70
........................................................................................... 111
women's prenatal + dha .................. 218
XALKORI ......................................................... 36
Văn Phòng Chính
210 E Hacienda Ave
Campbell, CA 95008-6617
1-877-723-4795 - Số Miễn phí
1-800-735-2929 - TTY
8 giờ sáng tới 8 giờ tối, 7 ngày một tuần, kể cả các ngày nghỉ lễ.
Nếu quý vị có câu hỏi, vui lòng gọi đến Santa Clara Family Health Plan.
Cuộc gọi được miễn phí. Để biết thêm thông tin, vui lòng truy cập www.scfhp.com.
Formulary ID: 16510.000, Version Number: 18
Last Updated: 09/30/2016
© 2016, Santa Clara Family Health Plan. All rights reserved.
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