FIDA Care Complete

Transcription

FIDA Care Complete

CENTERS PLAN
FOR HEALTHY LIVING
CENTERS PLAN
ADVANTAGE CARE (HMO)
CENTERS PLAN
CARE COMPLETE (MMP)
Centers Plan for FIDA Care Complete
(Piano Medicare-Medicaid)
Elenco dei farmaci inclusi nella
copertura (Formulario) 2016
Questo formulario è aggiornato al 09/01/2016. In caso di domande, contattare Centers Plan for
FIDA Care Complete al numero 1-888-266-7460, 7 giorni su 7, dalle 8:00 alle 20:00. Per gli utenti
TTY, chiamare il numero 1-800-421-1220. La chiamata è gratuita.
We CARE... about your CARE
H3018_16702_CY2016_Drug_List_IT
Centers Plan for FIDA Care Complete (Piano Medicare-Medicaid)
Elenco dei farmaci inclusi nella copertura (Formulario) 2016
Questo formulario è aggiornato al 01/09/2016. In caso di domande, contattare Centers Plan for
FIDA Care Complete al numero 1-888-266-7460, 7 giorni su 7, dalle 8:00 alle 20:00. Per gli utenti
TTY, chiamare il numero 1-800-421-1220. La chiamata è gratuita.
Per ulteriori informazioni, visitare il sito www.centersplan.com/fida/participants.
Data di decorrenza: 1° gennaio 2016
Ultimo aggiornamento: 01/09/2016
ID formulario: 16507, Versione n. 18
In caso di domande, contattare Centers Plan for FIDA Care Complete al numero 1-888-266-7460
(per gli utenti TTY/TDD, chiamare il numero 1-800-421-1220), 7 giorni su 7, dalle 8:00 alle 20:00.
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Centers Plan for FIDA Care Complete | Elenco dei farmaci inclusi nella
copertura per il 2016 (formulario)
Questo è un elenco dei farmaci che i partecipanti hanno diritto a ottenere nell'ambito di Centers Plan for FIDA
Care Complete.
 Centers Plan for FIDA Care Complete (piano Medicare-Medicaid) è un piano gestito di assistenza
sanitaria, che si accorda sia con Medicare che con il Dipartimento della salute dello Stato di New York
(Medicaid) per erogare ai suoi partecipanti prestazioni offerte da entrambi i programmi attraverso il
Programma Dimostrativo Fully Integrated Duals Advantage (FIDA).
 L'Elenco dei farmaci inclusi nella copertura e/o delle reti di farmacie e fornitori è soggetto a variazioni nel
corso dell'anno. Un'informativa verrà inviata prima di adottare qualsiasi cambiamento che possa
interessare il partecipante.
 Le prestazioni sono soggette a variazioni il 1° gennaio di ogni anno.
 L'Elenco dei farmaci inclusi nella copertura di Centers Plan for FIDA Care Complete è disponibile online
all'indirizzo www.centersplan.com/fida/participants oppure contattando telefonicamente i Servizi per i
partecipanti di Centers Plan for FIDA Care Complete al numero 1-888-266-7460.
 Possono essere applicate limitazioni e restrizioni. Per ulteriori informazioni, contattare i Servizi per i
partecipanti di Centers Plan for FIDA Care Complete oppure consultare la Guida del partecipante di
Centers Plan for FIDA Care Complete.
 Non è richiesto alcun contributo finanziario per i farmaci coperti.
 È possibile ottenere gratuitamente queste informazioni in altri formati, come la versione a caratteri grandi,
in Braille o in formato audio. Chiamare il numero 1-888-266-7460 e 1-800-421-1220 per gli utenti TTY/TDD
negli orari di lavoro: dalle 08:00 alle 20:00, 7 giorni su 7. La chiamata è gratuita.
 You can get this information for free in other languages. Call 1-888-266-7460, and TTY/TDD users call
1-800-421-1220, during our hours of operation: 8 am to 8pm, seven days a week. The call is free.
您可以免費獲得我們用其他語言提供的該資訊。請在我們的工作時間內致電 1-888-266-7460，TTY/TDD 使
用者可致電 1-800-421-1220，我們的工作時間是：每週 7 天、每天早 8 點至晚 8 點。致電是免費的。
Ou ka jwenn enfòmasyon sa a gratis nan lòt lang yo. Rele 1-888-266-7460, e itilizatè TTY/TDD yo ka rele
1-800-421-1220, pandan lè fonksyonman: 8 am a 8pm, sèt jou pa semèn. Apèl la gratis.
Queste informazioni sono disponibili gratuitamente in altre lingue. Chiamare x il numero 1-888-266-7460 e
1-800-421-1220 per gli utenti TTY/TDD negli orari di lavoro: dalle 08:00 alle 20:00, 7 giorni su 7. La
chiamata è gratuita.
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이 정보를 다른 언어로 무료로 받아 보실 수 있습니다. 1-888-266-7460번으로 전화주시고, TTY/TDD
사용자들은 1-800-421-1220번으로 영업 시간 동안 전화주십시오: 오전 8시 ~ 오후 8시, 매주 7일간 본
전화료는 무료입니다
Вы можете получить эту информацию бесплатно на других языках. Звоните по номеру 1-888-2667460, пользователи телетайпа/текстового телефона по номеру 1-800-421-1220, во время наших
часов работы: 08:00 – 20:00, семь дней в неделю. Звонок является бесплатным.
Puede obtener esta información en otros idiomas de manera gratuita. Llame al 1-888-266-7460, y los
usuarios de TTY/TDD pueden llamar al 1-800-421-1220, durante nuestras horas de operación: 8 a.m. a 8
p.m., los siete días de la semana. La llamada es gratuita.
 The State of New York has created a participant ombudsman program called the Independent Consumer
Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by
Centers Plan for FIDA Care Complete. ICAN may be reached toll-free at 1-844-614-8800 or online at
icannys.org.
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Domande frequenti (FAQ)
Qui il partecipante troverà le risposte alle domande relative a questo Elenco dei farmaci inclusi nella copertura.
Per avere maggiori informazioni potrà leggere tutte le FAQ o cercare domande e risposte specifiche.
1.
Quali farmaci soggetti a prescrizione rientrano nell’Elenco dei farmaci inclusi
nella copertura?
Per brevità, l'Elenco dei farmaci inclusi nella copertura sarà chiamato
“Elenco dei farmaci”.
I farmaci presenti nell'Elenco dei farmaci inclusi nella copertura che inizia a pag. 3 sono i farmaci coperti da
Centers Plan for FIDA Care Complete. Questi farmaci sono disponibili presso le farmacie della nostra rete.
Una farmacia è considerata nella nostra rete quando esiste un accordo tra noi e la farmacia per la fornitura dei
suoi servizi. Tali farmacie vengono definite "farmacie della rete".
→ Centers Plan for FIDA Care Complete coprirà tutti i farmaci indicati nell'Elenco farmaci se:
• il medico o un altro prescrivente dichiara che il partecipante necessita di detti farmaci per stare meglio o
guarire da una condizione medica,
• il farmaco è clinicamente necessario per la sua condizione, e
• il partecipante ha presentato la prescrizione a una farmacia della rete Centers Plan for FIDA Care Complete.
→ Centers Plan for FIDA Care Complete può prevedere ulteriori passaggi per accedere a determinati farmaci
(vedere domanda n. 5 a seguire). In certi casi, potrebbe essere richiesto di seguire una procedura
specifica, come provare prima altri farmaci.
È inoltre possibile visualizzare un elenco aggiornato dei farmaci da noi coperti visitando il nostro sito web
all'indirizzo www.centersplan.com/fida/participants oppure rivolgendosi telefonicamente ai Servizi per i
partecipanti al numero 1-888-266-7460.
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2.
L'Elenco dei farmaci è soggetto a variazioni?
Sì. Centers Plan for FIDA Care Complete può aggiungere o eliminare farmaci dall'Elenco dei farmaci nel corso
dell'anno. Generalmente,
l’Elenco dei Farmaci cambia:
• se si rende disponibile un nuovo farmaco che risulta altrettanto efficace rispetto a quello attualmente
incluso nell’Elenco dei farmaci oppure
• se veniamo a conoscenza del fatto che un farmaco non è sicuro.
Potremo anche cambiare le regole relative ai nostri farmaci. Per esempio, potremo:
• Decidere di richiedere o meno l’approvazione preventiva per un farmaco. (L'approvazione preventiva è
l'autorizzazione da parte di Centers Plan for FIDA Care Complete o del Team interdisciplinare (IDT)
prima di ottenere un farmaco).
• Aggiungere o modificare la quantità di un farmaco cui il partecipante ha diritto (chiamati "limiti
quantitativi").
• Aggiungere o cambiare le restrizioni di una terapia progressiva (step therapy) per un farmaco. (La step
therapy indica che il partecipante dovrà provare un farmaco prima che possiamo coprirne un altro).
(Per maggiori informazioni, consultare la pagina x).
Quando un farmaco presente nell'Elenco dei farmaci sarà rimosso, il partecipante verrà informato al più presto.
Il partecipante sarà anche informato di eventuali variazioni relative alle regole per la copertura di un farmaco.
Le domande 3, 4 e 7 di seguito permettono di raccogliere maggiori informazioni su cosa accade nel caso in cui
l’Elenco dei farmaci sia oggetto di una variazione.
→ Il partecipante potrà sempre consultare l'Elenco dei farmaci aggiornato di Centers Plan for FIDA Care
Complete all'indirizzo www.centersplan.com/fida/participants..
Potrà inoltre contattare telefonicamente i Servizi per i partecipanti al numero 1-888-266-7460 per
conoscere l'Elenco dei farmaci aggiornato.
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3.
Cosa succede se si rende disponibile un nuovo farmaco meno costoso che
ha la medesima efficacia del farmaco indicato nell'Elenco dei farmaci?
Se si rende disponibile un nuovo farmaco che risulta altrettanto efficace rispetto a quello attualmente esistente
nell’Elenco dei farmaci:
•
La prossima volta che il partecipante presenterà una prescrizione, il farmacista potrebbe consegnare il
farmaco meno costoso. Se il partecipante e il suo fornitore decidono che il farmaco più economico non è
adeguato per il suo caso, il fornitore potrà istruire il farmacista di continuare a fornire il farmaco abituale.
•
Centers Plan for FIDA Care Complete può decidere di eliminare il farmaco più costoso dall'Elenco dei
farmaci. Se il partecipante sta assumendo un farmaco che rimuoviamo dall'Elenco dei farmaci perché
si è reso disponibile un farmaco più economico che funziona altrettanto bene, lo avvertiremo almeno
60 giorni prima di rimuoverlo dall'Elenco dei farmaci oppure quando farà richiesta per una nuova
prescrizione. Il partecipante potrà ottenere una fornitura del farmaco per 60 giorni prima che la
modifica all’Elenco dei farmaci diventi effettiva. Se decidiamo di rimuovere un farmaco dall’Elenco,
informeremo il partecipante in forma scritta e/o telefonicamente almeno 60 giorni prima di eliminare il
farmaco dall'Elenco.
4.
Cosa accade se veniamo a conoscenza del fatto che un farmaco non è
sicuro?
Se la Food and Drug Administration (FDA) dichiara che un farmaco che il partecipante sta assumendo non è
sicuro, lo rimuoveremo immediatamente dall’Elenco dei farmaci. Gli invieremo anche una lettera e lo
chiameremo per informarlo della rimozione del farmaco non sicuro dall’Elenco dei farmaci. Dopo aver ricevuto
questa lettera e/o questa chiamata, il partecipante deve contattare il suo medico e chiedere che gli prescriva
un farmaco alternativo.
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5.
Ci sono restrizioni o limiti alla copertura dei farmaci? Oppure esistono
procedure precise da seguire per poter ottenere determinati farmaci?
Si, determinati farmaci sono sottoposti a specifiche regole sulla copertura o a limitazioni della quantità
ottenibile. In certi casi, al partecipante o al suo medico o a un altro prescrivente potrebbe essere richiesto di
seguire una procedura specifica per ottenere il farmaco. Per esempio:
• Approvazione preventiva (o autorizzazione preventiva): Per alcuni farmaci, il partecipante o il suo
medico dovranno ottenere l'approvazione dal piano Centers Plan for FIDA Care Complete o dall’IDT
prima di richiedere quanto previsto dalla prescrizione. Se non si ottenesse l'approvazione, Centers Plan
for FIDA Care Complete potrebbe non coprire il farmaco.
• Limiti quantitativi: Per alcuni farmaci, Centers Plan for FIDA Care Complete limita la quantità di cui si
può usufruire.
• Step therapy: A volte Centers Plan for FIDA Care Complete richiede l’applicazione di una step therapy.
Questo significa che il partecipante dovrà provare i farmaci in un ordine specifico in base alla sua
condizione medica. Potrebbe essergli richiesto di provare un farmaco prima di ottenere la copertura per
un altro farmaco. Se il medico ritiene che il primo farmaco non sia adatto al partecipante, allora noi
copriremo il secondo.
Il partecipante potrà scoprire se il suo farmaco prevede requisiti o limiti addizionali consultando le tabelle a
partire da pagina xviii9. Il partecipante può anche ottenere ulteriori informazioni visitando il nostro sito web
all'indirizzo www.centersplan.com/fida/participants. Abbiamo pubblicato documenti online che spiegano le
limitazioni della nostra autorizzazione preventiva e della terapia progressiva. Se il partecipante lo desidera,
può richiederne una copia.
Potrà anche chiedere una “deroga" rispetto a queste limitazioni. Per maggiori informazioni sulle deroghe,
consultare la domanda 11.
→ Se si trova in una struttura di cura o in un’altra struttura per le cure a lungo termine e necessita di un
farmaco non presente nell’Elenco dei farmaci, oppure se non può accedere facilmente al farmaco di cui ha
bisogno, il partecipante può ricevere il nostro aiuto. Ci occuperemo noi di una fornitura di emergenza di 31
giorni del farmaco che è necessario al partecipante (a meno che non abbia una prescrizione per un minor
numero di giorni), anche se non è un nuovo partecipante di Centers Plan for FIDA Care Complete. Questo
darà al partecipante il tempo di parlare con il suo medico o con un altro prescrivente. Potrà inoltre aiutarlo
a stabilire se esiste un farmaco simile nell’Elenco dei farmaci adatto alle sue esigenze oppure se richiedere
una deroga. Per maggiori informazioni sulle deroghe, consultare la domanda 11.
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6.
Come saprà il partecipante se il farmaco è soggetto a limitazioni, oppure se
sono previste procedure specifiche da seguire per ottenerlo?
L’Elenco dei farmaci inclusi nella copertura a pagina 20 ha una colonna dal titolo “Azioni necessarie, restrizioni
o limiti di utilizzo”.
7.
Che cosa succede se cambiamo le nostre regole relative alla copertura dei
farmaci? Per esempio, se aggiungiamo limitazioni all’autorizzazione
preventiva (approvazione), limiti quantitativi e/o restrizioni alla terapia
progressiva per un farmaco.
Comunicheremo al partecipante se aggiungiamo autorizzazione preventiva (approvazione), limiti quantitativi,
e/o restrizioni sulla step therapy di un farmaco. Lo informeremo almeno 60 giorni prima dell’implementazione
della restrizione, oppure quando farà richiesta per una nuova prescrizione. Il partecipante potrà ottenere una
fornitura del farmaco per 60 giorni prima che la modifica all’Elenco dei farmaci diventi effettiva. Questo gli darà
il tempo di consultare il suo medico o un altro prescrivente sulla procedura da seguire.
8.
Come farà il partecipante a trovare un farmaco nell'Elenco dei farmaci?
Di seguito sono descritti due modi per trovare un farmaco:
• Può cercare in ordine alfabetico (se si sa come si scrive il nome del farmaco), oppure
• Potrà eseguire la ricerca in base alla patologia.
Per effettuare la ricerca alfabetica, il partecipante deve andare alla sezione Elenco alfabetico a pagina I-1.
Quindi cercare il nome del farmaco nell’elenco.
Per ricercare in base alla patologia, trovare la sezione intitolata “Elenco dei farmaci per patologia” a pagina
20. I farmaci di questa sezione sono raggruppati in categorie a seconda del tipo di condizioni mediche per i
quali vengono usati per trattarle. Per esempio, in caso di problemi cardiaci il partecipante dovrà consultare la
categoria: agenti cardiovascolari. Qui troverà i farmaci per i suoi problemi di cuore.
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9.
Cosa accade se il farmaco che il partecipante vuole assumere non è
presente nell’Elenco dei farmaci?
Se il farmaco non è presente nell'Elenco dei farmaci, chiamare i Servizi per i partecipanti al numero 1-888-2667460 e chiedere informazioni. Se il partecipante sa che Centers Plan for FIDA Care Complete non coprirà il
farmaco, potrà scegliere una delle alternative proposte di seguito:
• Chiedere ai Servizi per i partecipanti un elenco dei farmaci equivalenti a quello che intende assumere.
Mostrare l’elenco al medico o a un altro prescrivente il quale potrà prescriverle un farmaco presente
nell’Elenco dei farmaci che ha le stesse proprietà di quello specifico che il partecipante cercava. Oppure
• Può richiedere al piano o al suo IDT di concedere una deroga in relazione alla copertura del farmaco.
Per maggiori informazioni sulle deroghe, consultare la domanda 11.
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10. Cosa fare se è un nuovo partecipante Centers Plan for FIDA Care Complete
non è in grado di trovare il suo farmaco nell'Elenco dei farmaci oppure ha
difficoltà a reperire il farmaco?
Noi possiamo fornirgli il nostro aiuto. Dobbiamo coprire fino a 90 giorni di forniture temporanee del farmaco, a
seconda di quanto necessario, nei primi 90 giorni di partecipazione a Centers Plan for FIDA Care Complete. Questo
darà al partecipante il tempo di parlare con il suo medico o con un altro prescrivente. Potrà inoltre aiutarlo a stabilire
se esiste un farmaco simile nell’Elenco dei farmaci adatto alle sue esigenze oppure se richiedere una deroga.
Forniremo fino a 90 giorni di forniture temporanee del farmaco se:
• il partecipante sta assumendo un farmaco che non è nel nostro Elenco dei farmaci, oppure
• il regolamento del piano di assistenza sanitaria non gli consente di ottenere la quantità ordinata dal suo
medico, oppure
• il farmaco richiede l'approvazione preventiva da parte di Centers Plan for FIDA Care Complete o dal
team interdisciplinare (IDT), oppure
• il partecipante sta assumendo un farmaco che fa parte di una terapia progressiva (step therapy).
Se il partecipante risiede in una struttura di cura o in altri tipi di strutture di cura a lungo termine, potrà
rinnovare la prescrizione fino a 98 giorni. Durante i primi 90 giorni di adesione al piano, il partecipante potrà
rinnovare la forniture del farmaco più volte. Questo darà al prescrivente il tempo di cambiare i farmaci del
partecipante con quelli presenti nell’Elenco dei farmaci o di chiedere una deroga.
Se uno dei seguenti scenari di cambiamento del livello di assistenza è applicabile al partecipante, può
avere diritto a una fornitura di transizione dei farmaci che sta assumendo attualmente:
Se il partecipante viene trasferito in una struttura di cure a lungo termine da un ospedale o da un
altro contesto
•
Se sta lasciando una struttura di cura a lungo termine per fare ritorno a casa
•
Se è stato dimesso dall'ospedale per fare ritorno alla sua abitazione
•
Se è stato dimesso da una Skilled Nursing Facility
•
Se la sua condizione passa da malato terminale a non terminale
•
Se viene dimesso da un ospedale psichiatrico con un piano di cura personalizzato
Le variazioni del livello di cura sopra indicate sono solo alcune delle ragioni per cui il partecipante potrebbe
essere idoneo a una fornitura di transizione. Per ulteriori informazioni, contattare i Servizi per i partecipanti
al numero 1-888-266-7460 Per gli utenti TTY, contattare il numero 1-800-421-1220. 7 giorni su 7, dalle 8:00
alle 20:00.
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11. Il partecipante può chiedere una deroga per coprire il suo farmaco?
Sì. Il partecipante può chiedere a Centers Plan for FIDA Care Complete o al suo team Interdisciplinare (IDT) di
concedere una deroga per coprire un farmaco che non è nell'Elenco dei farmaci.
Può anche chiedere a Centers Plan for FIDA Care Complete o al suo IDT di cambiare le regole sul quel
farmaco.
• Ad esempio, Centers Plan for FIDA Care Complete potrebbe limitare la quantità di un farmaco che
copriamo. Se il suo farmaco è soggetto a limitazioni, il partecipante può chiedere a noi o al suo IDT di
revocare la limitazione e aumentare la copertura.
• Altri esempi: Il partecipante può chiedere a noi o al suo IDT di revocare le restrizioni della step therapy o
i requisiti di approvazione preventiva.
12. Quanto tempo ci vuole per ottenere una deroga?
In primo luogo, Centers Plan for FIDA Care Complete o il team interdisciplinare (IDT) devono ricevere una
dichiarazione dal medico a supporto della richiesta di deroga. Dopo aver ricevuto la dichiarazione, al
partecipante verrà comunicata la decisione in merito alla sua richiesta di deroga entro 72 ore.
Se il partecipante o il prescrivente ritengono che la sua salute possa essere messa a repentaglio da un’attesa
di 72 ore, potranno richiedere una procedura di deroga rapida. Si tratta di una decisione in tempi più rapidi. Se
il medico avalla la richiesta, il partecipante otterrà una decisione entro 24 ore dalla ricezione della
dichiarazione del medico prescrivente.
13. Come si chiede una deroga?
Per chiedere una deroga, contattare il proprio Coordinatore sanitario. Il Coordinatore sanitario collaborerà con
il partecipante e il suo fornitore lo aiuterà a chiedere una deroga.
14. Cosa sono i farmaci generici?
I farmaci generici sono costituiti dagli stessi ingredienti dei farmaci di marca. Di solito costano meno rispetto al
farmaco di marca e di solito non hanno nomi noti. I farmaci generici sono approvati dalla Food and Drug
Administration (FDA).
Centers Plan for FIDA Care Complete copre sia i farmaci di marca, sia i farmaci generici.
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15. Cosa sono i farmaci OTC?
OTC significa "over-the-counter", vale a dire farmaci da banco. Centers Plan for FIDA Care Complete include
alcuni farmaci da banco quando sono indicati sulla prescrizione del proprio fornitore.
Per sapere quali sono i farmaci OTC coperti, leggere l'Elenco dei farmaci di Centers Plan for FIDA Care Complete.
16. Centers Plan for FIDA Care Complete copre i prodotti OTC non farmaceutici?
Centers Plan for FIDA Care Complete copre alcuni farmaci da banco quando sono indicati sulla prescrizione dal
proprio fornitore. Esempi di prodotti OTC non farmaceutici sono i tamponi imbevuti d’alcool e le garze sterili.
Per sapere quali sono i prodotti OTC non farmaceutici coperti, leggere l'Elenco dei farmaci di Centers Plan for
FIDA Care Complete.
Centers Plan for FIDA Care Complete offre anche una prestazione aggiuntiva di 25 dollari al mese per
l’acquisto di dispositivi OTC non coperti da Medicare e Medicaid. Le somme inutilizzate non verranno riportate
al mese successivo. Per ulteriori informazioni, contattare i Servizi per i partecipanti al numero 1-800-466-2745
(per gli utenti TTY, chiamare il numero 1-800-421-1220), 7 giorni su7, dalle 8:00 alle 20:00.
17. Qual è il contributo finanziario del partecipante?
Il partecipante non dovrà versare alcun contributo finanziario per i farmaci indicati nell'Elenco dei farmaci.
18. Quali sono i livelli dei farmaci?
I livelli sono gruppi di farmaci. Tutti i farmaci dell’Elenco dei farmaci del piano sono suddivisi in quattro (4) livelli.
I farmaci inclusi in questi quattro livelli sono gratuiti per il partecipante.
•
I farmaci di livello 1 sono farmaci generici coperti da Medicare. Questo è il livello più basso.
•
I farmaci di livello 2 sono specialità farmaceutiche coperte da Medicare.
•
I farmaci di livello 3 sono farmaci coperti da Medicare che non sono inclusi nella Parte D.
•
I farmaci di livello 4 sono farmaci da banco (OTC) coperti da Medicare. Questo è il livello più alto.
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Elenco dei farmaci inclusi nella copertura
L’Elenco dei farmaci coperti inizia a pagina 20 e offre informazioni sui farmaci coperti da Centers Plan for FIDA
Care Complete. In caso di problemi a trovare il farmaco nell'Elenco, consultare l'Indice che inizia a pag. I-1.
La prima colonna della tabella riporta il nome del farmaco. I farmaci di marca sono indicati in lettere maiuscole (ad
esempio NORTHERA), mentre i farmaci generici sono elencati in corsivo minuscolo (ad esempio atenololo).
Le informazioni contenute nella colonna azioni necessarie, restrizioni o limitazioni all'uso indicano se Centers
Plan for FIDA Care Complete applica delle regole di copertura del farmaco.
Le seguenti abbreviazioni sono contenute all'interno del corpo di questo documento
ABBREVIAZIONI USATE NELLA COPERTURA
ABBREVIAZIONE
DESCRIZIONE
SPIEGAZIONE
Utilizzo e gestione delle restrizioni
PA
Il partecipante (o il suo medico) saranno tenuti a
ottenere l'approvazione preventiva di Centers Plan
Limitazione autorizzazione
for FIDA Care Complete prima di presentare la
preventiva (Prior Authorization
prescrizione per questo farmaco. Senza tale
Restriction)
approvazione, Centers Plan for FIDA Care
Complete potrebbe non coprire questo farmaco.
PA BvD
Per questo farmaco può essere richiesto un
pagamento ai sensi di Medicare Parte B o Parte D.
preventiva (Prior Authorization Prima di presentare la prescrizione di questo
Restriction)
farmaco, il partecipante (o il suo medico) dovrà
per
chiedere un'approvazione preventiva a Centers
Determinazione Parte B vs Plan for FIDA Care Complete per sapere se è
Parte B (Part B vs Part B
coperto da Medicare Parte D. Senza tale
Determination)
xvi
ABBREVIAZIONE
DESCRIZIONE
SPIEGAZIONE
PA-HRM
CMS ha valutato che questo farmaco può essere
potenzialmente dannoso, ovvero un High Risk
Medication per i beneficiari di Medicare di almeno
65 anni di età. I partecipanti che hanno compiuto
preventiva
(Prior Authorization Restriction almeno 65 anni di età saranno tenuti a ottenere
for)
l'approvazione preventiva di Centers Plan for FIDA
Farmaci molto pericolosi (High Care Complete prima di presentare la prescrizione
Risk Medications)
per questo farmaco. Senza tale approvazione,
Centers Plan for FIDA Care Complete potrebbe
non coprire questo farmaco.
PA NSO
I nuovi partecipanti al pino o coloro che non hanno
mai assunto questo farmaco in precedenza,
preventiva (Prior Authorization dovranno chiedere un’autorizzazione preventiva a
Centers Plan for FIDA Care Complete prima di
Restriction for)
poter presentare la prescrizione. Senza tale
Nuovi partecipanti al piano
(New Starts Only)
QL
ST
Restrizione limite quantitativi
(Quantity Limit Restriction)
Centers Plan for FIDA Care Complete limita la
quantità di questo farmaco coperta per prescrizione
o per un determinato periodo di tempo.
Prima che Centers Plan for FIDA Care Complete
fornisca una copertura per questo farmaco, il
Restrizione Step Therapy (Step partecipante dovrà dapprima prova un altro
farmaco idoneo per la sua patologia. Questo
Therapy Restriction)
farmaco può essere coperto solo se l'altro farmaco
non si rivela efficace.
xvii
Le seguenti abbreviazioni sono contenute all'interno del corpo di questo documento
ALTRI REQUISITI SPECIALI DELLA COPERTURA
ABBREVIAZIONE
DESCRIZIONE
SPIEGAZIONE
LA
Questa prescrizione potrebbe essere disponibile solo
in determinate farmacie. Per ulteriori informazioni,
Farmaco con accesso limitato consultare l'Elenco delle farmacie o chiamare I
Servizi dei partecipanti al numero 1-888-266-7460, 7
(Limited Access Drug)
giorni su 7, dalle 8:00 alle 20:00. Per gli utenti TTY,
chiamare il numero 1-800-421-1220.
NM
Il partecipante può ricevere forniture superiori a un
mese per la maggior parte dei farmaci contenuti nel
Farmaco che non può essere
formulario, ordinandoli per posta a costi ridotti. I
ordinato per posta (Non-Mail
farmaci che non possono essere acquistati con
Order Drug)
ordine postale sono contrassegnati dalla sigla “NM”
nella colonna Requisiti/Limitazioni del formulario.
*
Farmaci che non rientrano nella Questo è un farmaco che non rientra nella Parte D
Parte D
oppure un farmaco o un prodotto OTC.
Nota: Il simbolo (*) dopo il nome di un farmaco indica che questo non è un “Farmaco della Parte D”. Questi
farmaci sono soggetti a regole diverse per i ricorsi. Un ricorso è una procedura formale di richiesta di revisione
e modifica di una decisione sulla copertura, se il partecipante ritiene che sia stato commesso un errore. Ad
esempio, Centers Plan for FIDA Care Complete o il team interdisciplinare (IDT) potrebbero decidere che il
farmaco che si desidera non è coperto o non è più coperto da Medicare o da Medicaid. Se il partecipante, il
suo medico o altro prescrivente non concordano con tale decisione, sarà possibile presentare ricorso. Per
chiedere istruzioni su come presentare ricorso, chiamare i Servizi per i partecipanti al numero 1-888-266-7460
oppure l'Independent Consumer Advocacy Network (ICAN) al numero 1-844-614-8800. Per sapere come
presentare un ricorso, consultare la guida per il partecipante.
xviii
Table of Contents
Analgesics.................................................................................................................................................................. 3
Anesthetics .............................................................................................................................................................. 14
Anti-Addiction/Substance Abuse Treatment Agents .......................................................................................... 14
Antianxiety Agents ................................................................................................................................................. 16
Antibacterials ......................................................................................................................................................... 17
Anticancer Agents .................................................................................................................................................. 28
Anticholinergic Agents .......................................................................................................................................... 38
Anticonvulsants ...................................................................................................................................................... 38
Antidementia Agents ............................................................................................................................................. 42
Antidepressants ...................................................................................................................................................... 43
Antidiabetic Agents................................................................................................................................................ 46
Antifungals.............................................................................................................................................................. 50
Antihistamines ........................................................................................................................................................ 54
Anti-Infectives (Skin And Mucous Membrane) .................................................................................................. 60
Antimigraine Agents .............................................................................................................................................. 60
Antimycobacterials ................................................................................................................................................ 61
Antinausea Agents ................................................................................................................................................. 62
Antiparasite Agents ............................................................................................................................................... 64
Antiparkinsonian Agents....................................................................................................................................... 65
Antipsychotic Agents ............................................................................................................................................. 66
Antivirals (Systemic) .............................................................................................................................................. 70
Blood Products/Modifiers/Volume Expanders ................................................................................................... 76
Caloric Agents ........................................................................................................................................................ 80
In caso di domande, contattare Centers Plan for FIDA Care Complete al numero 1-888-266-7460 (per
gli utenti TTY/TDD, chiamare il numero 1-800-421-1220), 7 giorni su 7, dalle 8:00 alle 20:00. Per
ulteriori informazioni, visitare il sito www.centersplan.com/fida/participants.
1
Cardiovascular Agents .......................................................................................................................................... 85
Central Nervous System Agents ......................................................................................................................... 100
Contraceptives ...................................................................................................................................................... 102
Cough And Cold Products .................................................................................................................................. 110
Dental And Oral Agents ...................................................................................................................................... 121
Dermatological Agents......................................................................................................................................... 122
Devices ................................................................................................................................................................... 130
Disinfectants (For Non-Dermatologic Use) ........................................................................................................ 131
Enzyme Replacement/Modifiers ......................................................................................................................... 131
Eye, Ear, Nose, Throat Agents ............................................................................................................................ 133
Gastrointestinal Agents ....................................................................................................................................... 141
Genitourinary Agents .......................................................................................................................................... 153
Heavy Metal Antagonists .................................................................................................................................... 154
Hormonal Agents, Stimulant/Replacement/Modifying .................................................................................... 154
Immunological Agents ......................................................................................................................................... 161
Inflammatory Bowel Disease Agents .................................................................................................................. 169
Irrigating Solutions .............................................................................................................................................. 170
Metabolic Bone Disease Agents .......................................................................................................................... 170
Miscellaneous Therapeutic Agents ..................................................................................................................... 172
Ophthalmic Agents .............................................................................................................................................. 177
Replacement Preparations .................................................................................................................................. 179
Respiratory Tract Agents .................................................................................................................................... 188
Skeletal Muscle Relaxants ................................................................................................................................... 192
Sleep Disorder Agents.......................................................................................................................................... 193
Vasodilating Agents ............................................................................................................................................. 194
Vitamins And Minerals ....................................................................................................................................... 195
2
Tier level
What the
drug will
cost you
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Analgesics
Analgesics, Miscellaneous
acephen 120 mg suppository outer
120 mg *
325 mg *
650 mg *
acetaminophen 120 mg suppos outer
120 mg *
acetaminophen 160 mg/5 ml elx 160
mg/5 ml *
acetaminophen 325 mg liqui-gel 325
mg *
acetaminophen 650 mg suppos 650
mg *
acetaminophen 80 mg rapid tab
children's 80 mg *
acetaminophen 80 mg/0.8 ml drp
infants 80 mg/0.8 ml *
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 25325 MG
ascomp with codeine oral capsule
30-50-325-40 mg
BELBUCA BUCCAL FILM 150
MCG, 300 MCG, 450 MCG, 600
MCG, 75 MCG, 750 MCG, 900
MCG
(Acetaminophen
with Codeine)
(Acetaminophen
with Codeine)
(Tylenol-Codeine
No.3)
(Tylenol-Codeine
No.3)
(Fiorinal with
Codeine #3)
QL (360 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
PA-HRM; QL (180 per
30 days)
ST; QL (60 per 30
days)
Il partecipante può trovare informazioni su ciò che significano i simboli e le abbreviazioni di questa
tabella consultando le pagine introduttive di questo documento.
3
Tier level
What the
drug will
cost you
1
$0
1
$0
(Fioricet with
Codeine)
1
$0
(Tencon)
1
$0
(Esgic)
1
$0
(Esgic)
1
$0
(Fiorinal)
1
$0
2
$0
Name of Drug
buprenorphine hcl injection syringe
0.3 mg/ml
butalbital compound w/codeine oral
capsule 30-50-325-40 mg
butalbital-acetaminop-caf-cod oral
capsule 50-300-40-30 mg, 50-32540-30 mg
butalbital-acetaminophen oral
tablet 50-325 mg
butalbital-acetaminophen-caff oral
capsule 50-325-40 mg
butalbital-acetaminophen-caff oral
tablet 50-325-40 mg
butalbital-aspirin-caffeine oral
capsule 50-325-40 mg
BUTRANS TRANSDERMAL
PATCH WEEKLY 10
MCG/HOUR, 15 MCG/HOUR, 20
MCG/HOUR, 5 MCG/HOUR, 7.5
MCG/HOUR
(Buprenorphine
HCl)
(Fiorinal with
Codeine #3)
capacet oral capsule 50-325-40 mg
(Esgic)
1
$0
(Acetaminophen)
4
$0
(Infants' Tylenol)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Tylenol Sore
Throat)
4
$0
(Codeine Sulfate)
1
$0
(Acetaminophen)
4
$0
child non-aspirin 160 mg/5 ml
children's 160 mg/5 ml *
child pain-fever 160 mg/5 ml
a/f,gluten/f,cherry 160 mg/5 ml *
child tactinal 80 mg tab chw 80 mg
*
children's mapap 80 mg rapid 80
mg *
children's silapap elixir 160 mg/5 ml
*
codeine sulfate oral tablet 15 mg, 30
mg, 60 mg
cvs child non-asa 80 mg tb chw 80
mg *
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
QL (4 per 28 days)
PA-HRM; QL (180 per
30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
4
Tier level
What the
drug will
cost you
(Acetaminophen)
4
$0
(Tylenol Sore
Throat)
4
$0
(Xolox)
1
$0
(Percodan)
1
$0
(Actiq)
1
$0
Name of Drug
cvs non-aspirin jr tab chew 160 mg
*
cvs pain relief adult liquid 500
mg/15 ml *
endocet oral tablet 10-325 mg, 2.5325 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 650 mg suppository adult,
outer 650 mg *
hydrocodone-acetaminophen oral
solution 10-325 mg/15 ml(15 ml),
2.5-167 mg/5 ml, 7.5-325 mg/15 ml
QL (30 per 30 days)
PA; QL (120 per 30
days)
QL (10 per 30 days)
(Duragesic)
1
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Hycet)
1
$0
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
tablet 10-300 mg, 5-300 mg, 7.5-300 (Norco)
mg
tablet 10-325 mg, 2.5-325 mg, 5-325
mg, 7.5-325 mg
hydrocodone-ibuprofen oral tablet
10-200 mg, 2.5-200 mg, 5-200 mg,
7.5-200 mg
hydromorphone (pf) injection
solution 10 mg/ml
hydromorphone (pf) injection
solution 4 mg/ml
Necessary Actions,
Restrictions, or
Limits on Use
1
$0
(Norco)
1
$0
(Ibudone)
1
$0
(Dilaudid-HP)
1
$0
(Dilaudid)
1
$0
(includes Vicodin,
Vicodin ES and
Vicodin HP); QL (390
per 30 days)
5
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
(Dilaudid)
1
$0
(Dilaudid)
1
$0
2
$0
4
$0
2
$0
(Norco)
1
$0
(Norco)
(Norco)
(Tylenol Sore
Throat)
1
1
$0
$0
4
$0
(Infants' Tylenol)
4
$0
(Tylenol)
(Acetaminophen)
(Tylenol)
(Tylenol Sore
Throat)
(Acetaminophen)
4
4
4
$0
$0
$0
4
$0
4
$0
(Tylenol Arthritis)
4
$0
(Esgic)
1
$0
Name of Drug
hydromorphone injection solution 2
mg/ml
hydromorphone injection syringe 2
mg/ml
hydromorphone oral liquid 1 mg/ml
hydromorphone oral tablet 2 mg, 4
mg
hydromorphone oral tablet 8 mg
HYSINGLA ER ORAL
TABLET,ORAL
ONLY,EXT.REL.24 HR 100 MG,
120 MG, 20 MG, 30 MG, 40 MG,
60 MG, 80 MG
junior mapap 160 mg rapid tab 160
mg *
LAZANDA NASAL SPRAY,NONAEROSOL 100 MCG/SPRAY, 300
MCG/SPRAY, 400 MCG/SPRAY
lorcet (hydrocodone) oral tablet 5325 mg
lorcet hd oral tablet 10-325 mg
lorcet plus oral tablet 7.5-325 mg
mapap 160 mg/5 ml elixir 160 mg/5
ml *
mapap 160 mg/5 ml suspension 160
mg/5 ml *
mapap 325 mg tablet 325 mg *
mapap 500 mg capsule 500 mg *
mapap 500 mg tablet 500 mg *
mapap 500 mg/15 ml liquid 500
mg/15 ml *
mapap 80 mg tablet chew 80 mg *
mapap arthritis er 650 mg cplt 650
mg *
margesic oral capsule 50-325-40
mg
(Hydromorphone
HCl)
(Hydromorphone
HCl)
(Dilaudid)
(Acetaminophen)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (30 per 30 days)
PA; QL (30 per 30
days)
QL (30 per 30 days)
PA-HRM; QL (180 per
30 days)
6
Tier level
What the
drug will
cost you
(Methadone HCl)
1
$0
(Methadone HCl)
1
$0
(Diskets)
(Diskets)
(Morphine
Sulfate/0.9%
Nacl/PF)
1
1
$0
$0
1
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
1
$0
(Morphine
Sulfate/D5W)
1
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
1
$0
Name of Drug
methadone injection solution 10
mg/ml
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
mg/ml
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
Necessary Actions,
Restrictions, or
Limits on Use
QL (90 per 30 days)
7
Tier level
What the
drug will
cost you
1
$0
2
$0
(MS Contin)
1
$0
(MS Contin)
1
$0
(Morphine Sulfate)
1
$0
(Tylenol Sore
Throat)
4
$0
(Acetaminophen)
4
$0
Name of Drug
morphine oral solution 20 mg/5 ml
(4 mg/ml)
MORPHINE ORAL TABLET 15
MG, 30 MG
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
non-aspirin x-str 167 mg/5 ml 500
mg/15 ml *
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
(Morphine Sulfate)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (60 per 30 days)
2
$0
2
$0
(Oxycodone HCl)
1
$0
(Oxycodone HCl)
1
$0
(Roxicodone)
1
$0
QL (60 per 30 days)
(Oxycontin)
1
$0
(Oxycontin)
2
$0
(Oxycodone
HCl/Acetaminophe
n)
tablet 10-325 mg, 2.5-325 mg, 5-325 (Xolox)
mg, 7.5-325 mg
1
$0
1
$0
8
Tier level
What the
drug will
cost you
(Xolox)
1
$0
(Xolox)
1
$0
(Percodan)
1
$0
Name of Drug
tablet 10-650 mg
tablet 7.5-500 mg
oxycodone-aspirin oral tablet
4.8355-325 mg
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 *
pain reliever er 650 mg caplet 8
hour, caplet 650 mg *
pharbetol 325 mg tablet regular
strength 325 mg *
pharbetol 500 mg caplet extra-str,
caplet 500 mg *
pv non-aspirin 500 mg softgel exstr,liq filled 500 mg *
q-pap 160 mg/5 ml solution a/f,
cherry 160 mg/5 ml *
q-pap 325 mg tablet 325 mg *
q-pap 80 mg/0.8 ml drops 80 mg/0.8
ml *
q-pap ex-str 500 mg tablet aspirin
free 500 mg *
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
2
$0
2
$0
(Opana)
1
$0
(Opana ER)
1
$0
(Opana ER)
1
$0
(Acetaminophen)
4
$0
(Tylenol Arthritis)
4
$0
(Tylenol)
4
$0
(Tylenol)
4
$0
(Acetaminophen)
4
$0
4
$0
4
$0
(Acetaminophen)
4
$0
(Tylenol)
4
$0
QL (60 per 30 days)
(Tylenol Sore
Throat)
(Tylenol)
QL (30 per 30 days)
9
Tier level
What the
drug will
cost you
(Acetaminophen)
4
$0
(Ibudone)
1
$0
Name of Drug
ra jr acetaminophen 160 mg tab
rapid melts 160 mg *
reprexain oral tablet 10-200 mg,
2.5-200 mg, 5-200 mg
(Oxycodone
HCl/Acetaminophe
n)
1
$0
(Acetaminophen)
4
$0
(Tylenol Arthritis)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Tylenol)
4
$0
(Tylenol)
4
$0
(Tencon)
1
$0
tramadol oral tablet 50 mg
(Ultram)
tramadol-acetaminophen oral tablet
(Ultracet)
37.5-325 mg
1
$0
1
$0
roxicet oral solution 5-325 mg/5 ml
silapap infant's drops infant's 80
mg/0.8 ml *
sm arthritis pain er 650 mg caplet
650 mg *
sm pain rel jr str tab chew 160 mg *
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
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
vicodin es oral tablet 7.5-300 mg
(Norco)
1
$0
vicodin hp oral tablet 10-300 mg
(Norco)
1
$0
vicodin oral tablet 5-300 mg
(Norco)
1
$0
xylon 10 oral tablet 10-200 mg
(Ibudone)
1
$0
zebutal oral capsule 50-325-40 mg
(Esgic)
1
$0
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
PA-HRM; QL (180 per
30 days)
(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)
10
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
(Aspirin)
4
$0
(Ecotrin)
4
$0
(Aspirin)
4
$0
4
$0
4
$0
4
4
$0
$0
(Ecotrin)
4
$0
(Ecotrin)
(Aspirin/Calcium
Carbonate/Mag)
4
$0
4
$0
2
$0
1
$0
4
$0
(Choline Sal/Mag
Salicylate)
1
$0
(Advil)
4
$0
Name of Drug
Nonsteroidal AntiInflammatory 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 *
aspirin 300 mg suppository 300 mg
*
aspirin 325 mg tablet 325 mg *
aspirin 600 mg suppository 600 mg
*
aspirin 81 mg chewable tablet 81
mg *
aspirin buffered 325 mg tab 325 mg
*
aspirin ec 325 mg tablet 325 mg *
aspirin ec 500 mg tablet 500 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 *
(Bayer Chewable
Aspirin)
(Aspirin/Calcium
Carbonate/Mag)
(Ecotrin)
(Ecotrin)
(Celebrex)
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
11
Tier level
What the
drug will
cost you
(Diclofenac
Potassium)
1
$0
(Voltaren-XR)
1
$0
(Diclofenac
Sodium)
1
$0
(Voltaren)
1
$0
(Arthrotec 50)
1
$0
(Diflunisal)
(Ecotrin)
1
4
$0
$0
(Etodolac)
1
$0
(Etodolac)
1
$0
(Etodolac)
1
$0
(Nalfon)
(Fenoprofen
Calcium)
1
$0
1
$0
2
$0
(Flurbiprofen)
1
$0
(Advil)
4
$0
(Children'S Advil)
4
$0
(Advil)
4
$0
(Ibuprofen)
1
$0
(Ibuprofen)
1
$0
(Indomethacin)
(Indomethacin)
1
1
$0
$0
Name of Drug
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
diflunisal oral tablet 500 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
Necessary Actions,
Restrictions, or
Limits on Use
PA
12
Tier level
What the
drug will
cost you
(Indomethacin)
1
$0
(Indomethacin
Sodium)
1
$0
(Infants' Motrin)
4
$0
3
$0
(Ketoprofen)
1
$0
(Ketoprofen)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
4
$0
4
$0
4
$0
Name of Drug
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 *
INFANTS' MOTRIN 50 MG/1.25
ML D/F, BERRY FLAVOR 50
MG/1.25 ML *
ketoprofen oral capsule 50 mg, 75
mg
ketoprofen oral capsule,ext rel.
pellets 24 hr 200 mg
(Ketorolac
Tromethamine)
mefenamic acid oral capsule 250 mg (Ponstel)
meloxicam oral suspension 7.5 mg/5
(Mobic)
ml
meloxicam oral tablet 15 mg, 7.5 mg (Mobic)
nabumetone oral tablet 500 mg, 750
(Nabumetone)
mg
naproxen oral suspension 125 mg/5
(Naprosyn)
ml
naproxen oral tablet 250 mg, 375
(Naprosyn)
mg, 500 mg
naproxen oral tablet,delayed release
(Ec-Naprosyn)
(dr/ec) 375 mg, 500 mg
naproxen sodium oral tablet 275
(Anaprox)
mg, 550 mg
piroxicam oral capsule 10 mg, 20
(Feldene)
mg
(Aspirin/Calcium
ra aspirin tri-buffered tb 325 mg *
Carbonate/Mag)
sm ibuprofen ib 100 mg tablet junior
(Advil)
strength 100 mg *
st. joseph aspirin 81 mg chew
(Bayer Chewable
orange 81 mg *
Aspirin)
ketorolac oral tablet 10 mg
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
QL (20 per 30 days)
13
Tier level
What the
drug will
cost you
(Ecotrin)
4
$0
(Sulindac)
(Tolmetin Sodium)
(Tolmetin Sodium)
1
1
1
1
$0
$0
$0
$0
(Advil)
4
$0
(Lidocaine HCl)
1
$0
(Xylocaine-MPF)
1
$0
(Xylocaine)
1
$0
(Xylocaine)
1
$0
(Lidocaine HCl)
1
$0
(Xylocaine)
1
$0
(Lidoderm)
1
$0
(Lidocaine)
1
$0
(EMLA)
1
$0
1
$0
1
$0
Name of Drug
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 *
Necessary Actions,
Restrictions, or
Limits on Use
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 %
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
(Acamprosate
Calcium)
(Buprenorphine
HCl)
PA; QL (90 per 30
days)
14
Tier level
What the
drug will
cost you
(Buprenorphine
HCl/Naloxone
HCl)
1
$0
(Zyban)
1
$0
2
$0
2
$0
2
$0
(Antabuse)
1
$0
(Naloxone HCl)
1
$0
(Naloxone HCl)
1
$0
(Revia)
1
$0
2
$0
4
$0
4
$0
4
$0
(Nicorette)
(Nicorette)
4
4
$0
$0
(Nicorette)
4
$0
(Nicoderm Cq)
4
$0
(Nicorette)
4
$0
Name of Drug
buprenorphine-naloxone sublingual
tablet 2-0.5 mg, 8-2 mg
bupropion hcl (smoking deter) oral
tablet extended release 150 mg
CHANTIX CONTINUING
MONTH BOX ORAL TABLET 1
MG
CHANTIX ORAL TABLET 0.5
MG, 1 MG
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,NONAEROSOL 4 MG/ACTUATION
NICODERM CQ 14 MG/24HR
PATCH 14 MG/24 HR *
PATCH 21 MG/24 HR *
PATCH 7 MG/24 HR *
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 *
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (90 per 30
days)
QL (53 per 28 days)
QL (4 per 30 days)
15
Tier level
What the
drug will
cost you
(Nicorette)
4
$0
(Nicoderm Cq)
4
$0
(Nicoderm Cq)
4
$0
(Nicorette)
4
$0
(Nicorette)
4
$0
(Nicoderm Cq)
4
$0
2
$0
Name of Drug
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
ZUBSOLV SUBLINGUAL
TABLET 1.4-0.36 MG, 11.4-2.9
MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.62.1 MG
2
$0
1
$0
1
$0
1
1
$0
$0
(Clonazepam)
1
$0
(Clonazepam)
1
$0
(Tranxene T-Tab)
1
$0
(Tranxene T-Tab)
1
$0
(Diazepam)
1
$0
(Diazepam)
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (90 per 30
days)
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
(Xanax)
(Chlordiazepoxide
HCl)
(Klonopin)
(Klonopin)
QL (90 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (10 per 28 days)
16
Tier level
What the
drug will
cost you
(Diazepam)
1
$0
(Valium)
1
$0
(Diastat)
1
$0
(Ativan)
1
$0
2
$0
Name of Drug
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
Necessary Actions,
Restrictions, or
Limits on Use
QL (90 per 30 days)
PA NSO; QL (480 per
30 days)
Antibacterials
Aminoglycosides
BETHKIS INHALATION
SOLUTION FOR
NEBULIZATION 300 MG/4 ML
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
PA BvD
(Gentamicin In
Nacl, Iso-Osm)
(Gentamicin
Sulfate)
(Gentamicin
Sulfate/PF)
(Gentamicin
Sulfate/PF)
(Neomycin Sulfate)
(Streptomycin
Sulfate)
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
PA BvD
(Tobi)
1
$0
17
Tier level
What the
drug will
cost you
(Tobramycin/Sodiu
m Chloride)
1
$0
(Tobramycin
Sulfate)
1
$0
(Bacitracin)
1
$0
(Chloramphenicol
Sod Succ)
1
$0
(Cleocin Palmitate)
1
$0
(Cleocin HCl)
1
$0
(Cleocin Phosphate
In D5w)
1
$0
(Cleocin Palmitate)
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
(Zyvox)
1
$0
(Zyvox)
1
$0
(Zyvox)
1
$0
(Hiprex)
1
$0
Name of Drug
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
ml, 600 mg/50 ml, 900 mg/50 ml
clindamycin pediatric oral recon
soln 75 mg/5 ml
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
CUBICIN RF INTRAVENOUS
RECON SOLN 500 MG
linezolid intravenous parenteral
linezolid oral suspension for
reconstitution 100 mg/5 ml
linezolid oral tablet 600 mg
methenamine hippurate oral tablet 1
gram
(Cleocin
Phosphate)
(Cleocin
Phosphate)
(Coly-Mycin M
Parenteral)
Necessary Actions,
Restrictions, or
Limits on Use
18
Tier level
What the
drug will
cost you
(Metronidazole/So
dium Chloride)
1
$0
(Flagyl)
1
$0
(Flagyl)
1
$0
Name of Drug
metronidazole in nacl (iso-os)
ml
metronidazole oral capsule 375 mg
metronidazole oral tablet 250 mg,
500 mg
nitrofurantoin macrocrystal oral
capsule 100 mg, 25 mg, 50 mg
(Macrodantin)
1
$0
nitrofurantoin monohyd/m-cryst
oral capsule 100 mg
(Macrobid)
1
$0
oral capsule 100 mg (75/25)
(Macrobid)
1
$0
(Polymyxin B
Sulfate)
1
$0
2
$0
1
$0
1
$0
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
(Trimethoprim)
(Vancomycin Hcl
In Dextrose 5 %)
Necessary Actions,
Restrictions, or
Limits on Use
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);
PA-HRM; (High Risk
with over 90 days
cumulative use of
PA-HRM; (High Risk
with over 90 days
cumulative use of
19
Tier level
What the
drug will
cost you
(Vancomycin HCl)
1
$0
(Vancomycin Hcl
In Dextrose 5 %)
1
$0
(Vancocin HCl)
1
$0
2
$0
2
$0
2
$0
(Cefaclor)
1
$0
(Cefaclor)
1
$0
(Cefadroxil)
1
$0
(Cefadroxil)
1
$0
(Cefadroxil)
(Cefazolin
Sodium/Dextrose,
Iso)
1
$0
1
$0
(Cefazolin Sodium)
1
$0
(Cefdinir)
1
$0
(Cefdinir)
1
$0
(Spectracef)
1
$0
2
$0
Name of Drug
vancomycin intravenous recon soln
1,000 mg, 10 gram, 750 mg
vancomycin intravenous recon soln
500 mg
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
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
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
mg/5 ml
cefditoren pivoxil oral tablet 200
mg, 400 mg
CEFEPIME 2 GM INJECTION 2
GRAM/100 ML
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (9 per 30 days)
PA
20
Tier level
What the
drug will
cost you
2
$0
(Maxipime)
1
$0
(Claforan)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
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
cefoxitin in dextrose, iso-osm
Sodium/Dextrose,
intravenous piggyback 2 gram/50 ml
Iso)
cefoxitin intravenous recon soln 1
(Cefoxitin Sodium)
gram, 10 gram, 2 gram
cefpodoxime oral suspension for
(Cefpodoxime
reconstitution 100 mg/5 ml, 50 mg/5
Proxetil)
ml
cefpodoxime oral tablet 100 mg, 200 (Cefpodoxime
mg
Proxetil)
cefprozil oral suspension for
(Cefprozil)
mg/5 ml
cefprozil oral tablet 250 mg, 500 mg (Cefprozil)
ceftazidime injection recon soln 2
(Fortaz)
gram, 6 gram
ceftibuten oral capsule 400 mg
(Cedax)
ceftibuten oral suspension for
(Cedax)
ceftriaxone 1 gm piggyback 50ml
(Ceftriaxone
galaxycontainer 1 gram/50 ml
Na/Dextrose, Iso)
ceftriaxone 1 gm vial 10's, fliptop,l/f
(Rocephin)
1 gram
ceftriaxone 2 gm piggyback 50ml
(Ceftriaxone
galaxycontainer 2 gram/50 ml
Na/Dextrose, Iso)
ceftriaxone injection recon soln 10
(Rocephin)
gram, 250 mg, 500 mg
ceftriaxone intravenous recon soln 1 (Ceftriaxone
gram, 2 gram
Na/Dextrose, Iso)
Necessary Actions,
Restrictions, or
Limits on Use
21
Tier level
What the
drug will
cost you
(Ceftin)
1
$0
(Zinacef)
1
$0
(Zinacef)
1
$0
(Keflex)
1
$0
(Cephalexin)
1
$0
(Cephalexin)
1
$0
2
$0
2
$0
1
$0
2
$0
(Zithromax)
1
$0
(Zithromax)
1
$0
(Zithromax)
1
$0
(Zithromax)
1
$0
(Zithromax)
1
$0
(Biaxin)
1
$0
Name of Drug
cefuroxime axetil oral tablet 250
mg, 500 mg
cefuroxime sodium injection recon
soln 1.5 gram, 750 mg
cefuroxime sodium intravenous
recon soln 7.5 gram
cephalexin oral capsule 250 mg,
500 mg, 750 mg
cephalexin oral suspension for
mg/5 ml
cephalexin oral tablet 250 mg, 500
mg
MEFOXIN IN DEXTROSE (ISOOSM) 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
mg/5 ml
azithromycin oral tablet 250 mg,
250 mg (6 pack), 600 mg
azithromycin oral tablet 500 mg
clarithromycin oral suspension for
mg/5 ml
(Fortaz)
Necessary Actions,
Restrictions, or
Limits on Use
22
Tier level
What the
drug will
cost you
(Biaxin)
1
$0
(Clarithromycin)
1
$0
2
$0
(Erythromycin
Ethylsuccinate)
1
$0
(Eryped 200)
1
$0
(Erythromycin
Base)
1
$0
2
$0
1
$0
2
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
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
e.e.s. granules oral suspension for
ery-tab oral tablet,delayed release
(dr/ec) 250 mg, 500 mg
ERY-TAB ORAL
TABLET,DELAYED RELEASE
(DR/EC) 333 MG
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
(Erythromycin
Stearate)
(Erythromycin
Ethylsuccinate)
(Erythromycin
Base)
(Erythromycin
Base)
(Azactam)
Necessary Actions,
Restrictions, or
Limits on Use
QL (20 per 10 days)
LA
(Primaxin)
(Merrem)
2
$0
1
$0
2
$0
1
$0
23
Tier level
What the
drug will
cost you
(Merrem)
1
$0
(Amoxicillin)
1
$0
(Amoxicillin)
1
$0
(Amoxicillin)
1
$0
(Amoxicillin)
1
$0
(Augmentin)
1
$0
(Augmentin)
1
$0
(Augmentin XR)
1
$0
(Amoxicillin/Potas
sium Clav)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
meropenem iv 1 gm vial outer, latexfree 1 gram
Penicillins
amoxicillin oral capsule 250 mg,
500 mg
amoxicillin oral suspension for
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 20028.5 mg/5 ml, 250-62.5 mg/5 ml,
400-57 mg/5 ml, 600-42.9 mg/5 ml
tablet 250-125 mg, 500-125 mg,
875-125 mg
tablet extended release 12 hr 1,00062.5 mg
tablet,chewable 200-28.5 mg, 40057 mg
ampicillin 2 gm vial 10's, latex-free
2 gram
ampicillin oral capsule 250 mg, 500
mg
ampicillin oral suspension for
mg/5 ml
ampicillin sodium injection recon
soln 1 gram, 10 gram, 125 mg
ampicillin sodium intravenous recon
soln 2 gram
(Ampicillin
Sodium)
(Ampicillin
Trihydrate)
(Ampicillin
Trihydrate)
(Ampicillin
Sodium)
(Ampicillin
Sodium)
Necessary Actions,
Restrictions, or
Limits on Use
24
Tier level
What the
drug will
cost you
(Unasyn)
1
$0
(Unasyn)
1
$0
(Unasyn)
1
$0
2
$0
2
$0
(Dicloxacillin
Sodium)
1
$0
(Nafcillin Sodium)
1
$0
(Nafcillin Sodium)
1
$0
(Nafcillin Sodium)
1
$0
(Oxacillin Sodium)
1
$0
(Oxacillin
Sodium/Dextrose,
Iso)
1
$0
(Oxacillin Sodium)
1
$0
(Oxacillin Sodium)
1
$0
(Pen G
Pot/DextroseWater)
1
$0
(Penicillin G
Potassium)
1
$0
Name of Drug
ampicillin-sulbactam 1.5 gm vl p/f,
latex-free 1.5 gram
ampicillin-sulbactam injection
recon soln 15 gram, 3 gram
ampicillin-sulbactam intravenous
recon soln 1.5 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
1,200,000 UNIT/2 ML, 2,400,000
UNIT/4 ML, 600,000 UNIT/ML
dicloxacillin oral capsule 250 mg,
500 mg
nafcillin 2 gm vial sterile, latex-free
2 gram
nafcillin injection recon soln 1
gram, 10 gram
nafcillin intravenous recon soln 2
gram
oxacillin 1 gm add-vantage vl addvantage, inner 1 gram
oxacillin in dextrose(iso-osm)
ml, 2 gram/50 ml
oxacillin injection recon soln 10
gram
oxacillin intravenous recon soln 2
gram
penicillin g pot in dextrose
intravenous piggyback 1 million
unit/50 ml, 2 million unit/50 ml, 3
million unit/50 ml
penicillin g potassium injection
recon soln 5 million unit
Necessary Actions,
Restrictions, or
Limits on Use
25
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
(Zosyn)
1
$0
(Zosyn)
1
$0
(Cipro)
1
$0
(Cipro I.V.)
1
$0
(Ciprofloxacin
Lactate)
1
$0
(Cipro)
1
$0
(Cipro I.V.)
1
$0
(Levaquin)
1
$0
(Levofloxacin)
1
$0
(Levaquin)
1
$0
Name of Drug
penicillin g procaine intramuscular
syringe 1.2 million unit/2 ml,
600,000 unit/ml
penicillin gk 20 million unit 20
million unit
penicillin v potassium oral recon
soln 125 mg/5 ml, 250 mg/5 ml
penicillin v potassium oral tablet
250 mg, 500 mg
pfizerpen-g injection recon soln 20
million unit
piperacillin-tazobactam intravenous
recon soln 2.25 gram, 3.375 gram,
4.5 gram
piperacil-tazobact 40.5 gram p/f,
latex-free 40.5 gram
Quinolones
ciprofloxacin hcl oral tablet 100 mg,
250 mg, 500 mg, 750 mg
ciprofloxacin in 5 % dextrose
ml
ciprofloxacin lactate intravenous
ciprofloxacin oral
suspension,microcapsule recon 250
mg/5 ml, 500 mg/5 ml
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
(Penicillin G
Procaine)
(Penicillin G
Potassium)
(Penicillin V
Potassium)
(Penicillin V
Potassium)
(Penicillin G
Potassium)
Necessary Actions,
Restrictions, or
Limits on Use
26
Tier level
What the
drug will
cost you
(Levaquin)
1
$0
(Avelox)
(Ofloxacin)
1
1
$0
$0
(Sulfadiazine)
1
$0
(Sulfamethoxazole/
Trimethoprim)
1
$0
(Sulfamethoxazole/
Trimethoprim)
1
$0
(Bactrim)
1
$0
(Azulfidine)
1
$0
(Azulfidine)
1
$0
(Sulfamethoxazole/
Trimethoprim)
1
$0
(Doxycycline
Hyclate)
1
$0
(Morgidox)
1
$0
(Doryx)
1
$0
(Doxycycline
Hyclate)
1
$0
(Adoxa)
1
$0
(Morgidox)
1
$0
(Avidoxy)
1
$0
(Doryx)
1
$0
(Adoxa)
1
$0
Name of Drug
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
Tetracyclines
doxy 100 vial 10's, p/f 100 mg
doxycycline hyclate 100 mg cap 100
mg
doxycycline hyclate 100 mg tab 100
mg
doxycycline hyclate intravenous
recon soln 100 mg
doxycycline hyclate oral capsule
100 mg
doxycycline hyclate oral capsule 50
mg
doxycycline hyclate oral tablet 100
mg, 50 mg
doxycycline hyclate oral tablet 20
mg
doxycycline mono 100 mg cap 100
mg
Necessary Actions,
Restrictions, or
Limits on Use
27
Tier level
What the
drug will
cost you
(Avidoxy)
1
$0
(Avidoxy)
1
$0
(Adoxa)
1
$0
(Vibramycin)
1
$0
(Avidoxy)
1
$0
(Minocin)
1
$0
(Minocycline HCl)
1
$0
(Tetracycline HCl)
1
$0
2
$0
2
$0
2
$0
(Doxorubicin HCl)
1
$0
(Doxorubicin HCl)
1
$0
(Fluorouracil)
1
$0
(Fluorouracil)
1
$0
2
$0
Name of Drug
doxycycline mono 100 mg tablet f/c
100 mg
doxycycline mono 50 mg tablet 50
mg
doxycycline monohydrate oral
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
Necessary Actions,
Restrictions, or
Limits on Use
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
AFINITOR DISPERZ ORAL
TABLET FOR SUSPENSION 2
MG, 3 MG, 5 MG
PA NSO; QL (4 per 21
days)
PA BvD
PA BvD
PA BvD
PA BvD
PA NSO; QL (112 per
28 days)
28
Name of Drug
AFINITOR ORAL TABLET 10
MG
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
(Vidaza)
mg
BELEODAQ INTRAVENOUS
RECON SOLN 500 MG
BENDEKA INTRAVENOUS
SOLUTION 25 MG/ML
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (56 per
28 days)
PA NSO; QL (28 per
28 days)
PA NSO; QL (240 per
30 days)
PA NSO
2
$0
1
$0
2
$0
2
$0
bexarotene oral capsule 75 mg
(Targretin)
1
$0
bicalutamide oral tablet 50 mg
bleomycin injection recon soln 30
unit
bleomycin sulfate 15 unit vial latexfree 15 unit
BLINCYTO INTRAVENOUS KIT
35 MCG
BOSULIF ORAL TABLET 100
MG
BOSULIF ORAL TABLET 500
MG
CABOMETYX ORAL TABLET 20
MG, 60 MG
CABOMETYX ORAL TABLET 40
MG
CAPRELSA ORAL TABLET 100
MG
(Casodex)
(Bleomycin
Sulfate)
(Bleomycin
Sulfate)
1
$0
1
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
PA NSO
PA NSO
PA NSO; QL (420 per
30 days)
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)
PA NSO; QL (60 per
30 days)
PA NSO; QL (60 per
30 days)
29
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
1
$0
2
$0
1
$0
2
$0
1
$0
2
$0
(Dacogen)
1
$0
(Doxil)
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Name of Drug
CAPRELSA ORAL TABLET 300
MG
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
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
MG/ML (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 SUBCUTANEOUS
SYRINGE 22.5 MG (3 MONTH)
SYRINGE 30 MG (4 MONTH)
SYRINGE 45 MG (6 MONTH)
SYRINGE 7.5 MG (1 MONTH)
(Cyclophosphamid
e)
(Cyclophosphamid
e)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (30 per
30 days)
PA NSO; QL (112 per
28 days)
PA NSO; LA; QL (63
per 28 days)
PA BvD
PA BvD; ST
PA BvD; ST
PA NSO
(Dactinomycin)
PA NSO; LA
PA BvD
QL (1 per 84 days)
QL (1 per 112 days)
QL (1 per 168 days)
30
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
(Etoposide)
1
$0
(Aromasin)
1
$0
2
$0
2
$0
2
$0
(Floxuridine)
1
$0
(Fluorouracil)
1
$0
Name of Drug
EMCYT ORAL CAPSULE 140
MG
EMPLICITI INTRAVENOUS
ERIVEDGE ORAL CAPSULE 150
MG
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 latexfree 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
HEXALEN ORAL CAPSULE 50
MG
hydroxyurea oral capsule 500 mg
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO
PA NSO; QL (30 per
30 days)
PA NSO
PA BvD
PA BvD
PA BvD
(Fluorouracil)
1
$0
(Flutamide)
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
(Hydrea)
PA NSO
PA NSO; QL (30 per
30 days)
PA NSO
31
Tier level
What the
drug will
cost you
IBRANCE ORAL CAPSULE 100
MG, 125 MG, 75 MG
2
$0
ICLUSIG ORAL TABLET 15 MG
2
$0
ICLUSIG ORAL TABLET 45 MG
2
$0
(Ifex)
1
$0
(Ifex)
1
$0
(Ifosfamide/Mesna
)
1
$0
imatinib oral tablet 100 mg
(Gleevec)
1
$0
imatinib oral tablet 400 mg
(Gleevec)
1
$0
2
$0
Name of Drug
ifosfamide 1 gm/20 ml vial suv 1
gram/20 ml
ifosfamide intravenous recon soln 1
gram
ifosfamide-mesna intravenous kit 11 gram, 3,000-1,000 mg
IMBRUVICA ORAL CAPSULE
140 MG
IMLYGIC INJECTION
SUSPENSION 10EXP6 (1
MILLION) PFU/ML
IMLYGIC INJECTION
SUSPENSION 10EXP8 (100
MILLION) PFU/ML
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (21 per
28 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (30 per
30 days)
PA BvD
PA BvD
PA BvD
PA NSO; QL (90 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO
2
$0
PA NSO; QL (4 per
365 days)
2
$0
days)
INLYTA ORAL TABLET 1 MG
2
$0
INLYTA ORAL TABLET 5 MG
2
$0
IRESSA ORAL TABLET 250 MG
2
$0
2
$0
2
$0
2
$0
IXEMPRA 15 MG KIT WITH
DILUENT 15 MG
IXEMPRA INTRAVENOUS
RECON SOLN 45 MG
JAKAFI ORAL TABLET 10 MG,
15 MG, 20 MG, 25 MG, 5 MG
PA NSO; QL (180 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (60 per
30 days)
32
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
(Leuprolide
Acetate)
1
$0
(Doxil)
1
$0
(Doxil)
1
$0
(Lomustine)
1
$0
2
$0
2
$0
2
$0
Name of Drug
KEYTRUDA INTRAVENOUS
RECON SOLN 50 MG
KEYTRUDA INTRAVENOUS
SOLUTION 100 MG/4 ML (25
MG/ML)
KYPROLIS INTRAVENOUS
RECON SOLN 30 MG
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 156.14 MG
LONSURF ORAL TABLET 208.19 MG
LUPRON DEPOT (3 MONTH)
KIT 11.25 MG, 22.5 MG
KIT 30 MG
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO
PA NSO
(Femara)
PA NSO; QL (12 per
28 days)
days)
PA NSO
PA BvD
PA BvD
PA NSO; QL (100 per
28 days)
PA NSO; QL (80 per
28 days)
QL (1 per 84 days)
QL (1 per 84 days)
2
$0
33
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
MEKINIST ORAL TABLET 0.5
MG
2
$0
MEKINIST ORAL TABLET 2 MG
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
1
$0
2
$0
Name of Drug
KIT 45 MG
LUPRON DEPOT
KIT 3.75 MG, 7.5 MG
LYNPARZA ORAL CAPSULE 50
MG
LYSODREN ORAL TABLET 500
MG
MATULANE ORAL CAPSULE 50
MG
megestrol oral tablet 20 mg, 40 mg
mercaptopurine oral tablet 50 mg
methotrexate 50 mg/2 ml vial latexfree, 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
Necessary Actions,
Restrictions, or
Limits on Use
QL (1 per 168 days)
(Megestrol
Acetate)
(Mercaptopurine)
(Methotrexate
Sodium)
(Methotrexate
Sodium/PF)
(Methotrexate
Sodium)
(Methotrexate
Sodium)
(Mitoxantrone
HCl)
(Nilandron)
PA NSO; QL (480 per
30 days)
PA NSO; QL (90 per
30 days)
PA NSO; QL (30 per
30 days)
PA BvD
PA BvD
PA BvD
PA BvD; ST
PA NSO; QL (120 per
30 days)
days)
34
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
STIVARGA ORAL TABLET 40
MG
SUTENT ORAL CAPSULE 12.5
MG, 25 MG, 37.5 MG, 50 MG
SYLVANT INTRAVENOUS
SYNRIBO SUBCUTANEOUS
RECON SOLN 3.5 MG
TABLOID ORAL TABLET 40 MG
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; LA
PA NSO
PA NSO
PA NSO; QL (21 per
28 days)
PA NSO; QL (100 per
21 days)
PA NSO; LA
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
PA NSO
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)
35
Tier level
What the
drug will
cost you
2
$0
2
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
(Thiotepa)
1
$0
(Etoposide)
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
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
TARGRETIN ORAL CAPSULE 75
MG
TARGRETIN TOPICAL GEL 1 %
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
toposar intravenous solution 20
mg/ml
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
WITH MIXJECT 22.5 MG/2 ML
TRELSTAR INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 22.5 MG
SYRINGE 11.25 MG/2 ML
Necessary Actions,
Restrictions, or
Limits on Use
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)
QL (1 per 168 days)
QL (1 per 168 days)
QL (1 per 84 days)
36
Name of Drug
SYRINGE 3.75 MG/2 ML
tretinoin (chemotherapy) oral
(Tretinoin)
capsule 10 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
(Navelbine)
mg/5 ml
VOTRIENT ORAL TABLET 200
MG
XALKORI ORAL CAPSULE 200
MG, 250 MG
XTANDI ORAL CAPSULE 40 MG
YERVOY INTRAVENOUS
MG/ML)
YONDELIS INTRAVENOUS
RECON SOLN 1 MG
ZELBORAF ORAL TABLET 240
MG
ZOLADEX SUBCUTANEOUS
IMPLANT 10.8 MG
ZOLADEX SUBCUTANEOUS
IMPLANT 3.6 MG
Tier level
What the
drug will
cost you
2
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
(capsule: 10mg)
PA BvD; ST
PA NSO
PA NSO
PA NSO; LA
PA NSO; LA
2
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
PA NSO; QL (120 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (120 per
30 days)
PA NSO
PA NSO
PA NSO; QL (240 per
30 days)
QL (1 per 84 days)
QL (1 per 28 days)
37
Name of Drug
ZOLINZA ORAL CAPSULE 100
MG
ZYDELIG ORAL TABLET 100
MG, 150 MG
ZYKADIA ORAL CAPSULE 150
MG
ZYTIGA ORAL TABLET 250 MG
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (60 per
30 days)
PA NSO; QL (140 per
28 days)
PA NSO; QL (120 per
30 days)
Anticholinergic Agents
Antimuscarinics/Antispasm
odics
atropine injection solution 0.4
(Atropine Sulfate)
mg/ml
atropine injection syringe 0.05
(Atropine Sulfate)
mg/ml, 0.1 mg/ml
(Propantheline
propantheline oral tablet 15 mg
Bromide)
STIOLTO RESPIMAT
INHALATION MIST 2.5-2.5
MCG/ACTUATION
QL (4 per 28 days)
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
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
ST
ST
ST
QL (80 per 30 days)
QL (60 per 30 days)
2
$0
38
Tier level
What the
drug will
cost you
(Carbatrol)
1
$0
(Tegretol)
1
$0
(Tegretol)
1
$0
(Tegretol XR)
1
$0
(Carbamazepine)
1
$0
2
$0
1
$0
(Depakote
Sprinkle)
1
$0
(Depakote ER)
1
$0
(Depakote)
1
$0
(Tegretol)
(Zarontin)
1
1
$0
$0
(Zarontin)
1
$0
(Felbatol)
1
$0
(Felbatol)
1
$0
(Cerebyx)
1
$0
(Cerebyx)
1
$0
2
$0
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
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
Necessary Actions,
Restrictions, or
Limits on Use
ST
39
Tier level
What the
drug will
cost you
2
$0
(Neurontin)
1
$0
(Neurontin)
1
$0
(Neurontin)
1
$0
2
$0
2
$0
(Lamictal)
1
$0
(Lamictal XR)
1
$0
(Lamictal)
1
$0
(Lamictal (Blue))
1
$0
(Keppra)
1
$0
(Keppra)
1
$0
(Keppra)
1
$0
(Keppra XR)
1
$0
Name of Drug
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
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
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
Necessary Actions,
Restrictions, or
Limits on Use
ST
QL (90 per 30 days)
(Trileptal)
2
$0
2
$0
1
$0
40
Name of Drug
oxcarbazepine oral tablet 150 mg,
300 mg, 600 mg
OXTELLAR XR ORAL TABLET
MG, 300 MG, 600 MG
PEGANONE ORAL TABLET 250
MG
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
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
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
(Trileptal)
Tier level
What the
drug will
cost you
1
$0
2
$0
2
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST
(Phenobarbital)
QL (90 per 30 days)
(Phenobarbital)
1
$0
(Phenobarbital)
(Phenobarbital
Sodium)
1
$0
1
$0
(Dilantin-125)
1
$0
(Dilantin)
1
$0
(Dilantin)
1
$0
1
$0
1
$0
2
$0
2
1
$0
$0
2
$0
2
$0
2
$0
2
$0
(Phenytoin
Sodium)
(Phenytoin
Sodium)
(Mysoline)
QL (2 per 30 days)
QL (90 per 30 days)
ST; QL (60 per 30
days)
ST; QL (120 per 30
days)
41
Tier level
What the
drug will
cost you
(Gabitril)
1
$0
(Topamax)
1
$0
(Topamax)
1
$0
(Qudexy XR)
1
$0
(Topamax)
1
$0
Name of Drug
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
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
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
Necessary Actions,
Restrictions, or
Limits on Use
ST
2
$0
(Depacon)
1
$0
(Depakene)
1
$0
(Depakene)
1
$0
2
$0
2
$0
2
$0
(Zonegran)
1
$0
(Aricept)
1
$0
(Donepezil HCl)
1
$0
(Razadyne ER)
1
$0
(Galantamine Hbr)
1
$0
QL (200 per 5 days)
QL (60 per 30 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
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
42
Tier level
What the
drug will
cost you
(Razadyne)
1
$0
(Namenda)
(Namenda)
1
1
$0
$0
(Namenda)
1
$0
2
$0
Name of Drug
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 510 mg
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, 3 mg, 4.5 mg, 6 mg
rivastigmine transdermal patch 24
hour 13.3 mg/24 hour, 4.6 mg/24 hr,
9.5 mg/24 hr
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
QL (60 per 30 days)
QL (49 per 28 days)
QL (28 per 28 days)
QL (30 per 30 days)
(Exelon)
2
$0
2
$0
1
$0
QL (60 per 30 days)
QL (30 per 30 days)
(Exelon)
1
$0
(Amitriptyline
HCl)
1
$0
(Amoxapine)
1
$0
2
$0
(Wellbutrin SR)
1
$0
(Wellbutrin)
1
$0
(Wellbutrin SR)
1
$0
(Wellbutrin XL)
1
$0
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 oral tablet 100 mg,
75 mg
bupropion hcl oral tablet extended
bupropion hcl oral tablet extended
PA NSO-HRM
ST
43
Tier level
What the
drug will
cost you
(Citalopram
Hydrobromide)
1
$0
(Celexa)
1
$0
(Anafranil)
1
$0
(Norpramin)
1
$0
(Doxepin HCl)
1
$0
(Doxepin HCl)
1
$0
(Duloxetine)
1
$0
(Duloxetine)
1
$0
(Duloxetine)
1
$0
2
$0
(Lexapro)
1
$0
(Lexapro)
1
$0
2
$0
Name of Drug
citalopram oral solution 10 mg/5 ml
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
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)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
PA NSO-HRM
PA NSO-HRM
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)
ST
ST
2
$0
(Prozac)
1
$0
(Prozac Weekly)
1
$0
(Fluoxetine HCl)
1
$0
44
Tier level
What the
drug will
cost you
(Fluoxetine HCl)
(Fluvoxamine
Maleate)
(Fluvoxamine
Maleate)
1
$0
1
$0
1
$0
(Tofranil)
1
$0
(Tofranil-Pm)
1
$0
(Maprotiline HCl)
1
$0
2
$0
(Remeron)
1
$0
(Remeron)
1
$0
(Nefazodone HCl)
1
$0
(Pamelor)
1
$0
(Nortriptyline HCl)
1
$0
(Symbyax)
1
$0
(Paxil)
1
$0
(Paxil CR)
1
$0
2
$0
1
$0
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
(Perphenazine/Ami
triptyline HCl)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO-HRM
PA NSO-HRM
PA NSO-HRM
45
Name of Drug
phenelzine oral tablet 15 mg
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)
(Nardil)
Tier level
What the
drug will
cost you
1
$0
2
$0
(Protriptyline HCl)
1
$0
(Zoloft)
1
$0
(Zoloft)
1
$0
2
$0
2
$0
(Parnate)
1
$0
(Trazodone HCl)
1
$0
(Trimipramine
Maleate)
1
$0
2
$0
(Effexor XR)
1
$0
(Venlafaxine HCl)
1
$0
(Venlafaxine HCl)
1
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (30 per 30
days)
QL (30 per 30 days)
PA NSO-HRM
PA NSO-HRM
ST
Antidiabetic Agents
Antidiabetic Agents,
Miscellaneous
46
Name of Drug
acarbose oral tablet 100 mg, 25 mg,
50 mg
CYCLOSET ORAL TABLET 0.8
MG
GLYXAMBI ORAL TABLET 10-5
MG, 25-5 MG
INVOKAMET ORAL TABLET
150-1,000 MG, 150-500 MG, 501,000 MG, 50-500 MG
INVOKANA ORAL TABLET 100
MG, 300 MG
JANUMET ORAL TABLET 501,000 MG, 50-500 MG
JANUMET XR ORAL TABLET,
ER MULTIPHASE 24 HR 1001,000 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
(Precose)
Tier level
What the
drug will
cost you
1
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (90 per 30 days)
ST
ST
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
(Glucophage)
(Glucophage)
(Glucophage)
1
1
1
$0
$0
$0
(Glucophage XR)
1
$0
(Glucophage XR)
1
$0
ST
ST
PA; QL (112 per 28
days)
QL (75 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
47
Tier level
What the
drug will
cost you
(Fortamet)
1
$0
(Fortamet)
1
$0
(Glyset)
1
$0
(Starlix)
1
$0
(Actos)
1
$0
(Duetact)
1
$0
(Actoplus Met)
1
$0
(Prandin)
1
$0
(Prandimet)
1
$0
Name of Drug
release 24hr 1,000 mg
release 24hr 500 mg
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 1500 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 12.51,000 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
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
PA; QL (10.8 per 28
days)
ST
48
Name of Drug
HUMULIN R U-500 (CONC)
KWIKPEN SUBCUTANEOUS
INSULIN PEN 500 UNIT/ML (3
ML)
HUMULIN R U-500
(CONCENTRATED)
SUBCUTANEOUS SOLUTION
500 UNIT/ML
LANTUS SOLOSTAR
SUBCUTANEOUS INSULIN PEN
100 UNIT/ML (3 ML)
LANTUS SUBCUTANEOUS
NOVOLIN 70/30
SUBCUTANEOUS SUSPENSION
100 UNIT/ML (70-30)
NOVOLIN N SUBCUTANEOUS
SUSPENSION 100 UNIT/ML
NOVOLIN R INJECTION
NOVOLOG FLEXPEN
100 UNIT/ML
NOVOLOG MIX 70-30 FLEXPEN
100 UNIT/ML (70-30)
NOVOLOG MIX 70-30
100 UNIT/ML (70-30)
NOVOLOG PENFILL
SUBCUTANEOUS CARTRIDGE
100 UNIT/ML
NOVOLOG SUBCUTANEOUS
TOUJEO SOLOSTAR
300 UNIT/ML (1.5 ML)
Sulfonylureas
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
QL (24 per 28 days)
2
$0
QL (40 per 28 days)
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
QL (40 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
2
$0
2
$0
2
$0
QL (30 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
2
$0
2
$0
2
$0
QL (40 per 28 days)
49
Name of Drug
Tier level
What the
drug will
cost you
glimepiride oral tablet 1 mg, 2 mg
glimepiride oral tablet 4 mg
glipizide oral tablet 10 mg
glipizide oral tablet 5 mg
glipizide oral tablet extended
release 24hr 10 mg
glipizide oral tablet extended
release 24hr 2.5 mg, 5 mg
glipizide-metformin oral tablet 2.5250 mg
glipizide-metformin oral tablet 2.5500 mg, 5-500 mg
glyburide micronized oral tablet 1.5
mg
glyburide micronized oral tablet 3
mg
glyburide micronized oral tablet 6
mg
(Amaryl)
(Amaryl)
(Glucotrol)
(Glucotrol)
1
1
1
1
$0
$0
$0
$0
(Glucotrol XL)
1
$0
(Glucotrol XL)
1
$0
1
$0
1
$0
(Glynase)
1
$0
(Glynase)
1
$0
(Glynase)
1
$0
glyburide oral tablet 1.25 mg
(Glyburide)
1
$0
glyburide oral tablet 2.5 mg
(Glyburide)
1
$0
glyburide oral tablet 5 mg
(Glyburide)
1
$0
(Glucovance)
1
$0
(Glucovance)
1
$0
(Tolazamide)
(Tolazamide)
(Tolbutamide)
1
1
1
$0
$0
$0
2
$0
glyburide-metformin oral tablet
1.25-250 mg
glyburide-metformin oral tablet 2.5500 mg, 5-500 mg
tolazamide oral tablet 250 mg
tolazamide oral tablet 500 mg
tolbutamide oral tablet 500 mg
(Glipizide/Metform
in HCl)
(Glipizide/Metform
in HCl)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
PA-HRM; QL (400 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (280 per
30 days)
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
QL (60 per 30 days)
Antifungals
Antifungals
ABELCET INTRAVENOUS
SUSPENSION 5 MG/ML
PA BvD
50
Tier level
What the
drug will
cost you
4
$0
2
$0
(Amphotericin B)
1
$0
(Tolnaftate)
4
$0
(Nuzole)
4
$0
(Tolnaftate)
4
$0
2
$0
(Loprox)
(Loprox)
(Loprox)
(Penlac)
(Ciclopirox
Olamine)
1
1
1
1
$0
$0
$0
$0
1
$0
(Ciclodan)
1
$0
(Gyne-Lotrimin)
(Lotrimin AF)
4
4
$0
$0
(Clotrimazole)
4
$0
(Clotrimazole)
4
$0
(Clotrimazole)
1
$0
(Clotrimazole)
(Clotrimazole)
(Gyne-Lotrimin)
1
1
4
$0
$0
$0
(Lotrisone)
1
$0
1
$0
4
$0
Name of Drug
aloe vesta 2% antifungal oint 2 % *
AMBISOME INTRAVENOUS
SUSPENSION FOR
amphotericin b injection recon soln
50 mg
anti-fungal 1% powder 1 % *
baza antifungal 2% cream 12's 2 %
*
blis-to-sol 1% liquid 1 % *
CANCIDAS INTRAVENOUS
ciclopirox topical cream 0.77 %
ciclopirox topical gel 0.77 %
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 % *
(Miconazole
Nitrate)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
(Clotrimazole/Beta
methasone Dip)
(Miconazole
Nitrate)
PA BvD
51
Tier level
What the
drug will
cost you
(Gyne-Lotrimin)
(Tinactin)
4
4
$0
$0
(Miconazole
Nitrate)
4
$0
4
$0
1
$0
(Undecylenic Acid)
4
$0
(Fluconazole In
Nacl,Iso-Osm)
1
$0
(Fluconazole In
Nacl,Iso-Osm)
1
$0
(Diflucan)
1
$0
(Diflucan)
1
$0
(Fluconazole In
Nacl,Iso-Osm)
1
$0
(Ancobon)
1
$0
(Clotrimazole)
4
4
4
$0
$0
$0
4
$0
(Grifulvin V)
1
$0
(Nuzole)
(Sporanox)
(Ketoconazole)
(Ketoconazole)
(Nizoral)
4
1
1
1
1
$0
$0
$0
$0
$0
Name of Drug
cvs 3-day vaginal cream 2 % *
cvs af 1% spray powder 1 % *
cvs miconazole 3 combo pack 3pref
applic w/cream 4 % (200 mg)- 2 %
(9 gram) *
dermafungal 2% ointment 2 % *
econazole topical cream 1 %
elon dual defense 25% solution 25
%*
fluconazole in dextrose(iso-o)
ml
fluconazole in nacl (iso-osm)
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
inzo antifungal 2% cream 2 % *
itraconazole oral capsule 100 mg
ketoconazole oral tablet 200 mg
ketoconazole topical cream 2 %
ketoconazole topical shampoo 2 %
(Miconazole
Nitrate)
(Econazole Nitrate)
(Tinactin)
(Miconazole
Nitrate)
Necessary Actions,
Restrictions, or
Limits on Use
52
Tier level
What the
drug will
cost you
(Tinactin)
4
$0
(Tolnaftate)
4
$0
4
$0
(Nuzole)
4
4
$0
$0
(Monistat 3)
4
$0
4
$0
4
$0
4
$0
1
$0
4
$0
4
$0
4
$0
4
$0
2
$0
2
$0
(Nystatin)
1
$0
(Nystatin)
1
$0
(Nystatin)
1
$0
(Nystatin)
1
$0
Name of Drug
lamisil af defens 1% spray pwd 1 %
*
lamisil af defense 1% powder 1 % *
LAMISIL ANTIFUNGAL 1%
SPRAY FOR ATHLETES FOOT 1
%*
LAMISIL AT 1% GEL 1 % *
micatin 2% antifungal cream 2 % *
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
MONISTAT 3 COMBO PACK 3
SUPP, 9 GM CREAM 200 MG- 2
% (9 GRAM) *
MONISTAT 3 COMBO PACK 4 %
(200 MG)- 2 % (9 GRAM) *
monistat 7 cream 7 applicators 2 %
*
myco nail a 25% solution 25 % *
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
(Miconazole
Nitrate)
(Nuzole)
(Miconazole
Nitrate)
(Miconazole
Nitrate)
(Miconazole
Nitrate)
(Undecylenic Acid)
Necessary Actions,
Restrictions, or
Limits on Use
53
Tier level
What the
drug will
cost you
(Nystatin)
1
$0
(Nystatin)
1
$0
1
$0
1
$0
(Nystatin)
1
$0
(Tinactin)
4
$0
(Miconazole
Nitrate)
4
$0
(Tolnaftate)
4
$0
4
$0
4
1
4
4
$0
$0
$0
$0
4
$0
(Vfend IV)
1
$0
(Vfend)
1
$0
(Vfend)
1
$0
4
$0
4
$0
Name of Drug
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
pv foot odor control 1% powder 1 %
*
qc 3 day vaginal 4% cream 200
mg/5 gram (4 %) *
ra antifungal 1% liquid spray liquid
spray 1 % *
remedy phytplx antifungal oint 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 % *
voriconazole intravenous solution
200 mg
voriconazole oral suspension for
reconstitution 200 mg/5 ml (40
mg/ml)
voriconazole oral tablet 200 mg, 50
mg
(Nystatin/Triamcin
)
(Nystatin/Triamcin
)
(Miconazole
Nitrate)
(Lamisil At)
(Lamisil)
(Tinactin)
(Tolnaftate)
(Miconazole
Nitrate)
Necessary Actions,
Restrictions, or
Limits on Use
Antihistamines
Antihistamines
alavert 10 mg odt non-drowsy, mint
(Claritin)
10 mg *
alavert d-12 allergy-sinus tab 5-120 (Claritin-D 12
mg *
Hour)
54
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Zzzquil)
4
$0
(Diphenhydramine
HCl)
4
$0
(Children'S Zyrtec)
4
$0
(Zyrtec)
4
$0
(Zyrtec)
4
$0
(Zyrtec-D)
4
$0
(Fexofenadine
HCl)
4
$0
Name of Drug
ALLEGRA ALLERGY 180 MG
TABLET 180 MG *
ALLEGRA ALLERGY 60 MG
TABLET 60 MG *
aller-chlor 2 mg/5 ml syrup 2 mg/5
ml *
aller-chlor 4 mg tablet 4 mg *
allerclear d-12hr tablet 5-120 mg *
allerclear d-24hr er tablet nondrowsy 10-240 mg *
allergy 4 mg tablet 4 mg *
allerhist-1 1.34 mg tablet 1.34 mg *
aller-tec d 5-120 mg tablet 5-120
mg *
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-pse er 5-120 mg tab 5-120
mg *
child allegra allergy 30 mg/5 ml
suspension 30 mg/5 ml *
(Chlorpheniramine
Maleate)
(Chlor-Trimeton)
(Claritin-D 12
Hour)
(Claritin-D 24
Hour)
(Chlor-Trimeton)
(Clemastine
Fumarate)
(Zyrtec-D)
(Chlorpheniramine/
Pseudoephed)
(Triprolidine/Pseud
oephedrine)
(Zzzquil)
(Diphenhydramine
HCl)
Necessary Actions,
Restrictions, or
Limits on Use
55
Tier level
What the
drug will
cost you
4
$0
(Dimetapp)
4
$0
(Dimetapp)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Zzzquil)
4
$0
(Zyrtec)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
CHILD CLARITIN 5 MG/5 ML
SOLN A/F,D/F,S/F,GRAPE 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 ml *
CHILD ZYRTEC 1 MG/ML
SOLUTION D/F,S/F,GRAPE 1
MG/ML *
children's allegra allergy oral tablet
30 mg *
CHILDREN'S ZYRTEC 10 MG
ODT 10 MG *
child's aller-tec 1 mg/ml soln 1
mg/ml *
CHILD'S CLARITIN 5 MG TAB
CHEW 5 MG *
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 *
CLARITIN 10 MG LIQUI-GEL
CAP 10 MG *
CLARITIN 10 MG REDITABS 10
MG *
CLARITIN 10 MG TABLET
(OTC) 10 MG *
CLARITIN 5 MG REDITABS 5
MG *
cold-allergy-sinus oral tablet 2.5-60
mg *
compoz 25 mg gelcap 25 mg *
cvs allergy 25 mg tablet 25 mg *
(Allegra Allergy)
(Children'S Zyrtec)
(Triprolidine/Pseud
oephedrine)
(Diphenhydramine
HCl)
(Diphenhydramine
HCl)
Necessary Actions,
Restrictions, or
Limits on Use
56
Tier level
What the
drug will
cost you
(Zyrtec)
4
$0
(Zyrtec)
4
$0
4
$0
1
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
4
$0
4
$0
Name of Drug
cvs allergy relief 10 mg sftgl 10 mg
*
cvs child allergy 10 mg chw tb 24
hr,indoor/outdoor 10 mg *
(Triaminic
cvs cold & cough nighttime liq 6.25Nighttime Cold2.5 mg/5 ml *
Cough)
cyproheptadine oral syrup 2 mg/5
(Cyproheptadine
ml
HCl)
(Cyproheptadine
cyproheptadine oral tablet 4 mg
HCl)
(Clemastine
dailyhist-1 1.34 mg tablet 1.34 mg *
Fumarate)
dayhist allergy 1.34 mg tablet 12 hr (Clemastine
relief 1.34 mg *
Fumarate)
dimaphen elixir a/f, grape, gluten-f
(Dimetapp)
1-2.5 mg/5 ml *
(Triaminic
dimetapp cold & congest liquid
Nighttime Cold6.25-2.5 mg/5 ml *
Cough)
diphenhist 12.5 mg/5 ml soln 12.5
(Zzzquil)
mg/5 ml *
diphenhist 25 mg capsule 25 mg *
(Zzzquil)
diphenhist 25 mg captab captab 25 (Diphenhydramine
mg *
HCl)
diphenhydramine 25 mg capsule
(Zzzquil)
(otc) 25 mg *
diphenhydramine 50 mg capsule
(Zzzquil)
(otc) 50 mg *
diphenhydramine 50 mg tablet 50
(Diphenhydramine
mg *
HCl)
diphenhydramine hcl injection
(Diphenhydramine
solution 50 mg/ml
HCl)
(Chlorpheniramine
ed chlorped jr syrup 2 mg/5 ml *
Maleate)
ed-a-hist 4 mg-10 mg tablet 4-10 mg (Chlorpheniramine/
*
Phenylephrine)
Necessary Actions,
Restrictions, or
Limits on Use
57
Tier level
What the
drug will
cost you
(Allegra Allergy)
4
$0
(Fexofenadine
HCl)
4
$0
(Allegra Allergy)
4
$0
(Zzzquil)
4
$0
(Xyzal)
1
$0
(Xyzal)
(Claritin)
(Children'S
Claritin)
(Claritin-D 12
Hour)
(Claritin-D 24
Hour)
(Promethazine
HCl)
(Diphenhydramine
HCl)
1
4
$0
$0
4
$0
4
$0
4
$0
1
$0
4
$0
(Zzzquil)
4
$0
(Zzzquil)
4
$0
(Zzzquil)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
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 *
hm z-sleep 25 mg softgel 25 mg *
levocetirizine oral solution 2.5 mg/5
ml
levocetirizine oral tablet 5 mg
loratadine 10 mg tablet 10 mg *
loratadine allergy 5 mg/5 ml d/f, a/f,
s/f 5 mg/5 ml *
loratadine-d 12 hour tablet nondrowsy 5-120 mg *
loratadine-d 24hr tablet 10-240 mg
*
promethazine oral syrup 6.25 mg/5
ml
pv nyt-time sleep 25 mg caplet 25
mg *
q-dryl 12.5 mg/5 ml liquid a/f 12.5
mg/5 ml *
ra sleep aid 50 mg/30 ml liq 50
mg/30 ml *
siladryl 12.5 mg/5 ml liquid 12.5
mg/5 ml *
simply sleep 25 mg caplet caplet 25
mg *
sleep aid 25 mg tablet 25 mg *
sm allergy relief 1.34 mg tab 1.34
mg *
sm sinus and allergy tablet
maximum strength 4-60 mg *
sm z-sleep 50 mg/30 ml liquid
berry,gluten-free 50 mg/30 ml *
(Diphenhydramine
HCl)
(Doxylamine
Succinate)
(Clemastine
Fumarate)
(Chlorpheniramine/
Pseudoephed)
(Zzzquil)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
58
Tier level
What the
drug will
cost you
4
$0
4
$0
(Zzzquil)
4
$0
(Triprolidine/Pseud
oephedrine)
4
$0
(Zzzquil)
4
$0
(Diphenhydramine
HCl)
4
$0
(Allegra Allergy)
4
$0
(Allegra Allergy)
(Chlor-Trimeton)
(Chlorpheniramine/
Pseudoephed)
4
4
$0
$0
4
$0
(Claritin)
4
$0
(Claritin)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
sudogest sinus & allergy tab 4-60
mg *
TRIAMINIC NIGHTTIME COLDCOUGH CHILDREN'S, GRAPE
6.25-2.5 MG/5 ML *
unisom 50 mg sleepgels softgel 50
mg *
wal-act d cold & allergy tab 2.5-60
mg *
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 *
wal-fex allergy 60 mg tablet 60 mg *
wal-finate 4 mg tablet 4 mg *
wal-finate-d tablet 4-60 mg *
wal-itin 10 mg odt non-drowsy 10
mg *
wal-itin 10 mg tablet non-drowsy 10
mg *
wal-itin 5 mg/5 ml syrup children's,
grape 5 mg/5 ml *
(Chlorpheniramine/
Pseudoephed)
(Children'S
Claritin)
(Claritin-D 12
wal-itin d 12 hour tablet 5-120 mg *
Hour)
wal-itin d 24 hour tablet 10-240 mg (Claritin-D 24
*
Hour)
wal-phed pe sinus & allergy tb 4-10 (Chlorpheniramine/
mg *
Phenylephrine)
wal-phed sinus and allergy tab 4-60 (Chlorpheniramine/
mg *
Pseudoephed)
(Unisom
wal-sleep z 25 mg odt 25 mg *
Sleepmelts)
wal-sleep z 25 mg softgel 25 mg *
(Zzzquil)
Necessary Actions,
Restrictions, or
Limits on Use
59
Name of Drug
Tier level
What the
drug will
cost you
wal-sleep z 50 mg/30 ml liquid
berry, a/f, d/f, s/f 50 mg/30 ml *
(Zzzquil)
4
$0
wal-som 25 mg tablet 25 mg *
(Doxylamine
Succinate)
4
$0
(Zzzquil)
4
$0
(Dimetapp)
(Zyrtec)
(Zyrtec-D)
4
4
4
$0
$0
$0
(Children'S Zyrtec)
4
$0
4
$0
4
$0
4
$0
4
$0
2
$0
(Cleocin)
1
$0
(Metrogel-Vaginal)
1
$0
(Terazol 7)
1
$0
(Terconazole)
1
$0
(D.H.E.45)
1
$0
wal-som 50 mg softgel softgel 50 mg
*
wal-tap elixir 1-2.5 mg/5 ml *
wal-zyr 10 mg tablet 10 mg *
wal-zyr d tablet 12 hr 5-120 mg *
wal-zyr solution children's, a/f 1
mg/ml *
ZYRTEC 10 MG LIQUID GELS 10
MG *
ZYRTEC 10 MG ODT 10 MG *
ZYRTEC 10 MG TABLET
INDOOR/OUTDOOR 24 HR
(OTC) 10 MG *
Necessary Actions,
Restrictions, or
Limits on Use
Anti-Infectives (Skin And
Mucous Membrane)
Anti-Infectives (Skin And
Mucous Membrane)
ABREVA 10% CREAM 10 % *
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
Antimigraine Agents
Antimigraine Agents
dihydroergotamine injection
solution 1 mg/ml
QL (30 per 28 days)
60
Tier level
What the
drug will
cost you
1
$0
2
$0
(Amerge)
(Maxalt)
1
1
$0
$0
(Maxalt Mlt)
1
$0
(Sumatriptan
Succinate)
1
$0
Name of Drug
dihydroergotamine nasal spray,nonaerosol 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,nonaerosol 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
pen injector 4 mg/0.5 ml
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
(Migranal)
Necessary Actions,
Restrictions, or
Limits on Use
QL (8 per 28 days)
QL (40 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
QL (4 per 28 days)
QL (12 per 28 days)
(Imitrex)
1
$0
(Imitrex)
1
$0
(Sumatriptan
Succinate)
1
$0
(Imitrex)
1
$0
(Sumatriptan
Succinate)
1
$0
QL (18 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
(Sumatriptan
Succinate)
1
$0
(Imitrex)
1
$0
(Zomig)
1
$0
(Zomig Zmt)
1
$0
2
$0
(Dapsone)
1
$0
(Myambutol)
1
$0
QL (4 per 28 days)
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
61
Tier level
What the
drug will
cost you
(Isoniazid)
1
$0
(Isoniazid)
1
$0
2
$0
(Pyrazinamide)
(Mycobutin)
2
1
1
$0
$0
$0
(Rifadin)
1
$0
(Rifadin)
1
$0
2
$0
2
$0
2
$0
2
$0
(Compazine)
1
$0
(Dimenhydrinate)
4
$0
(Dimenhydrinate)
1
$0
(Dimenhydrinate)
4
$0
(Meclizine HCl)
4
$0
(Dimenhydrinate)
4
$0
(Marinol)
1
$0
2
$0
Name of Drug
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 50-120300 MG
SIRTURO ORAL TABLET 100
MG
TRECATOR ORAL TABLET 250
MG
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (188 per 168
days)
Antinausea Agents
Antinausea Agents
AKYNZEO ORAL CAPSULE 3000.5 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 *
driminate 50 mg tablet 50 mg *
dronabinol oral capsule 10 mg, 2.5
mg, 5 mg
EMEND INTRAVENOUS RECON
SOLN 115 MG, 150 MG
PA BvD
QL (2 per 28 days)
62
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
(Granisetron
HCl/PF)
1
$0
(Granisetron HCl)
1
$0
(Granisetron HCl)
1
$0
(Meclizine HCl)
4
$0
(Meclizine HCl)
(Meclizine HCl)
4
1
$0
$0
(Meclizine HCl)
4
$0
1
$0
1
$0
(Zofran)
1
$0
(Zofran)
1
$0
(Zofran Odt)
1
$0
(Phenergan)
1
$0
(Prochlorperazine
Edisylate)
1
$0
(Compazine)
1
$0
(Compazine)
1
$0
Name of Drug
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 *
meclizine oral tablet 12.5 mg, 25 mg
motion sickness 25 mg tablet 25 mg
*
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
prochlorperazine maleate oral
tablet 10 mg, 5 mg
prochlorperazine rectal suppository
25 mg
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
(Ondansetron
HCl/PF)
(Ondansetron
HCl/PF)
PA BvD
PA BvD
PA BvD
PA BvD
PA-HRM
63
Tier level
What the
drug will
cost you
(Promethazine
HCl)
1
$0
(Phenergan)
1
$0
(Phenergan)
1
$0
Name of Drug
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 *
wal-dram 50 mg tablet 50 mg *
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
PA-HRM
PA-HRM
QL (10 per 30 days)
2
$0
(Bonine)
4
$0
(Dimenhydrinate)
4
$0
2
$0
2
$0
2
$0
(Mepron)
1
$0
(Malarone)
1
$0
(Chloroquine
Phosphate)
1
$0
2
$0
2
$0
1
$0
(Plaquenil)
1
$0
(Stromectol)
(Mefloquine HCl)
1
1
$0
$0
Antiparasite Agents
Antiparasite Agents
ALBENZA ORAL TABLET 200
MG
ALINIA ORAL SUSPENSION
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 20120 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
QL (6 per 21 days)
64
Tier level
What the
drug will
cost you
2
$0
1
$0
2
$0
2
$0
(Qualaquin)
1
$0
(Amantadine HCl)
1
$0
(Amantadine HCl)
1
$0
(Amantadine HCl)
1
$0
2
$0
2
$0
1
$0
1
1
1
1
$0
$0
$0
$0
(Sinemet CR)
1
$0
(Sinemet CR)
1
$0
(Stalevo 50)
1
$0
(Comtan)
1
$0
Name of Drug
NEBUPENT INHALATION
RECON SOLN 300 MG
paromomycin oral capsule 250 mg
PENTAM INJECTION RECON
SOLN 300 MG
PRIMAQUINE ORAL TABLET
26.3 MG
quinine sulfate oral capsule 324 mg
(Paromomycin
Sulfate)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
QL (90 per 30 days)
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl oral capsule 100 mg
amantadine hcl oral solution 50
mg/5 ml
amantadine hcl oral tablet 100 mg
APOKYN SUBCUTANEOUS
CARTRIDGE 10 MG/ML
AZILECT ORAL TABLET 0.5
MG, 1 MG
benztropine oral tablet 0.5 mg, 1
mg, 2 mg
bromocriptine oral capsule 5 mg
bromocriptine oral tablet 2.5 mg
cabergoline oral tablet 0.5 mg
carbidopa oral tablet 25 mg
carbidopa-levodopa oral tablet 10100 mg, 25-100 mg, 25-250 mg
carbidopa-levodopa oral tablet
extended release 25-100 mg, 50-200
mg
carbidopa-levodopa-entacapone
oral tablet 12.5-50-200 mg, 18.7575-200 mg, 25-100-200 mg, 31.25125-200 mg, 37.5-150-200 mg, 50200-200 mg
entacapone oral tablet 200 mg
(Benztropine
Mesylate)
(Parlodel)
(Parlodel)
(Cabergoline)
(Lodosyn)
QL (60 per 30 days)
PA-HRM
65
Tier level
What the
drug will
cost you
2
$0
(Mirapex)
1
$0
(Requip)
1
$0
(Requip XL)
1
$0
1
1
$0
$0
1
$0
1
$0
2
$0
Name of Drug
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 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5
mg
ropinirole oral tablet 0.25 mg, 0.5
mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg
ropinirole oral tablet extended
release 24 hr 12 mg, 2 mg, 4 mg, 6
mg, 8 mg
selegiline hcl oral capsule 5 mg
selegiline hcl oral tablet 5 mg
(Eldepryl)
(Selegiline HCl)
(Trihexyphenidyl
trihexyphenidyl oral elixir 0.4 mg/ml
HCl)
trihexyphenidyl oral tablet 2 mg, 5
(Trihexyphenidyl
mg
HCl)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
PA-HRM
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
QL (1 per 28 days)
2
$0
QL (1 per 28 days)
2
$0
(Abilify)
1
$0
(Abilify)
1
$0
(Abilify)
1
$0
QL (30 per 30 days)
QL (60 per 30 days)
66
Tier level
What the
drug will
cost you
(Abilify Discmelt)
1
$0
(Abilify Discmelt)
1
$0
Name of Drug
aripiprazole oral
aripiprazole oral
ARISTADA INTRAMUSCULAR
SYRING 441 MG/1.6 ML
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
Necessary Actions,
Restrictions, or
Limits on Use
QL (90 per 30 days)
QL (60 per 30 days)
QL (1.6 per 28 days)
2
$0
2
$0
2
$0
1
$0
1
$0
1
1
1
$0
$0
$0
1
$0
(Chlorpromazine
HCl)
(Chlorpromazine
HCl)
(Clozaril)
(Clozaril)
(Clozaril)
(Fazaclo)
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
QL (90 per 30 days)
ST
ST; QL (60 per 30
days)
ST; QL (8 per 28 days)
(Fluphenazine
Decanoate)
(Fluphenazine
HCl)
(Fluphenazine
HCl)
(Fluphenazine
HCl)
67
Name of Drug
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
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
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
273 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
olanzapine intramuscular recon soln
10 mg
(Fluphenazine
HCl)
Tier level
What the
drug will
cost you
1
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
2
$0
1
$0
1
1
1
$0
$0
$0
2
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (6 per 28 days)
(Haloperidol
Decanoate)
(Haldol Decanoate
50)
(Haloperidol
Lactate)
(Haloperidol
Lactate)
(Haloperidol)
(Loxapine
Succinate)
(Molindone HCl)
(Molindone HCl)
(Molindone HCl)
(Zyprexa)
PA NSO; QL (60 per
30 days)
QL (30 per 30 days)
68
Tier level
What the
drug will
cost you
(Zyprexa)
1
$0
(Zyprexa Zydis)
1
$0
(Zyprexa Zydis)
1
$0
(Invega)
1
$0
(Invega)
1
$0
(Perphenazine)
1
$0
(Orap)
1
$0
(Seroquel)
1
$0
2
$0
2
$0
2
$0
Name of Drug
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
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
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
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (30 per 30 days)
QL (31 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (4 per 28 days)
2
$0
(Risperdal)
1
$0
(Risperdal)
1
$0
(Risperdal M-Tab)
1
$0
(Risperdal M-Tab)
1
$0
2
$0
1
$0
QL (60 per 30 days)
QL (60 per 30 days)
(Thioridazine HCl)
ST; QL (60 per 30
days)
PA NSO-HRM
69
Tier level
What the
drug will
cost you
(Thiothixene)
1
$0
(Trifluoperazine
HCl)
1
$0
2
$0
2
$0
2
$0
1
$0
2
$0
2
$0
1
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Name of Drug
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
VRAYLAR ORAL
CAPSULE,DOSE PACK 1.5 MG
(1)- 3 MG (6)
ziprasidone hcl oral capsule 20 mg,
40 mg, 60 mg, 80 mg
ZYPREXA RELPREVV 405 MG
VL KIT W/ DILUENT, OUTER
405 MG
ZYPREXA RELPREVV
INTRAMUSCULAR
SUSPENSION FOR
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (540 per 30
days)
QL (30 per 30 days)
QL (7 per 30 days)
(Geodon)
QL (60 per 30 days)
Antivirals (Systemic)
Antiretrovirals
abacavir oral tablet 300 mg
(Ziagen)
abacavir-lamivudine-zidovudine
(Trizivir)
oral tablet 300-150-300 mg
APTIVUS ORAL CAPSULE 250
MG
APTIVUS ORAL SOLUTION 100
MG/ML
ATRIPLA ORAL TABLET 600200-300 MG
COMPLERA ORAL TABLET 20025-300 MG
CRIXIVAN ORAL CAPSULE 200
MG, 400 MG
DESCOVY ORAL TABLET 20025 MG
70
Name of Drug
didanosine oral capsule,delayed
release(dr/ec) 125 mg, 200 mg, 250 (Videx EC)
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)
EPZICOM ORAL TABLET 600300 MG
EVOTAZ ORAL TABLET 300-150
MG
FUZEON SUBCUTANEOUS
RECON SOLN 90 MG
GENVOYA ORAL TABLET 150150-200-10 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 10025 MG, 200-50 MG
lamivudine oral solution 10 mg/ml
(Epivir)
Tier level
What the
drug will
cost you
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
71
Tier level
What the
drug will
cost you
(Epivir)
1
$0
(Combivir)
1
$0
2
$0
2
$0
(Viramune)
1
$0
(Viramune)
1
$0
(Viramune XR)
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Name of Drug
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
NORVIR ORAL CAPSULE 100
MG
NORVIR ORAL SOLUTION 80
MG/ML
NORVIR ORAL TABLET 100 MG
ODEFSEY ORAL TABLET 20025-25 MG
PREZCOBIX ORAL TABLET 800150 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
Necessary Actions,
Restrictions, or
Limits on Use
72
Name of Drug
SELZENTRY ORAL TABLET 150
MG, 300 MG
stavudine oral capsule 15 mg, 20
(Zerit)
mg, 30 mg, 40 mg
stavudine oral recon soln 1 mg/ml
(Zerit)
STRIBILD ORAL TABLET 150150-200-300 MG
SUSTIVA ORAL CAPSULE 200
MG, 50 MG
SUSTIVA ORAL TABLET 600
MG
TIVICAY ORAL TABLET 10 MG,
25 MG, 50 MG
TRIUMEQ ORAL TABLET 60050-300 MG
TRUVADA ORAL TABLET 100150 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
(Retrovir)
Tier level
What the
drug will
cost you
2
$0
1
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
73
Tier level
What the
drug will
cost you
(Retrovir)
(Zidovudine)
1
1
$0
$0
(Foscavir)
1
$0
2
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Name of Drug
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
SYNAGIS INTRAMUSCULAR
SOLUTION 50 MG/0.5 ML
TAMIFLU ORAL CAPSULE 30
MG
MG
MG
TAMIFLU ORAL SUSPENSION
MG/ML
Hcv Antivirals
DAKLINZA ORAL TABLET 30
MG, 60 MG, 90 MG
EPCLUSA ORAL TABLET 400100 MG
HARVONI ORAL TABLET 90-400
MG
OLYSIO ORAL CAPSULE 150
MG
SOVALDI ORAL TABLET 400
MG
TECHNIVIE ORAL TABLET 12.575-50 MG
(Flumadine)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
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)
74
Name of Drug
VIEKIRA PAK ORAL
TABLETS,DOSE PACK 12.5 MG75 MG -50 MG/250 MG
ZEPATIER ORAL TABLET 50100 MG
Interferons
INTRON A 25 MILLION UNIT/2.5
ML 10 MILLION UNIT/ML
INTRON A INJECTION RECON
SOLN 10 MILLION UNIT (1 ML)
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
(Zovirax)
acyclovir oral suspension 200 mg/5
(Zovirax)
ml
acyclovir oral tablet 400 mg, 800
(Zovirax)
mg
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (112 per 28
days)
PA; QL (30 per 30
days)
PA NSO
PA NSO
PA NSO
PA NSO
PA
2
$0
2
$0
2
$0
PA
PA
PA
2
$0
2
$0
1
$0
1
$0
1
$0
days)
75
Tier level
What the
drug will
cost you
1
$0
1
1
$0
$0
(Famvir)
1
$0
(Cytovene)
1
$0
(Rebetol)
1
$0
(Copegus)
1
$0
2
$0
(Valtrex)
1
$0
(Valcyte)
1
$0
2
$0
2
$0
2
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Arixtra)
1
$0
(Arixtra)
1
$0
Name of Drug
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
valganciclovir oral tablet 450 mg
VIRAZOLE INHALATION
RECON SOLN 6 GRAM
(Acyclovir
Sodium)
(Hepsera)
(Baraclude)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
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
2.5 mg/0.5 ml
QL (24 per 30 days)
QL (15 per 30 days)
76
Tier level
What the
drug will
cost you
(Arixtra)
1
$0
(Arixtra)
1
$0
(Heparin
Sodium,Porcine/D5
W)
1
$0
(Heparin Sod,Pork
In 0.45% NaCl)
1
$0
(Heparin
Sodium,Porcine/Ns
/PF)
1
$0
(Heparin
Sodium,Porcine)
1
$0
1
$0
1
$0
(Heparin Sod,Pork
In 0.45% NaCl)
1
$0
(Heparin
Sodium,Porcine/D5
W)
1
$0
2
$0
1
$0
2
$0
Name of Drug
5 mg/0.4 ml
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
25,000 unit/250 ml(100 unit/ml)
heparin (porcine) in nacl (pf)
1,000 unit/500 ml
heparin (porcine) injection solution
1,000 unit/ml, 10,000 unit/ml,
20,000 unit/ml, 5,000 unit/ml
heparin, porcine (pf) injection
solution 5,000 unit/0.5 ml
heparin, porcine (pf) injection
syringe 5,000 unit/0.5 ml
heparin-0.45% nacl 25,000
units/250 ml (100 units/ml) bag
latex-free, inner 25,000 unit/250 ml
heparin-d5w 25,000 units/250 ml
(100 units/ml) bag excel container
25,000 unit/250 ml(100 unit/ml)
IPRIVASK SUBCUTANEOUS
RECON SOLN 15 MG
jantoven oral tablet 1 mg, 10 mg, 2
mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg,
7.5 mg
PRADAXA ORAL CAPSULE 110
MG, 150 MG, 75 MG
(Heparin
Sodium,Porcine/PF
)
(Monoject Prefill
Advanced)
(Coumadin)
Necessary Actions,
Restrictions, or
Limits on Use
QL (12 per 30 days)
QL (18 per 30 days)
PA; QL (24 per 28
days)
ST; QL (60 per 30
days)
77
Name of Drug
warfarin oral tablet 1 mg, 10 mg, 2
mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, (Coumadin)
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
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 MCG/0.3 ML, 75 MCG/0.3
ML
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
Tier level
What the
drug will
cost you
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA; QL (12 per 28
days)
PA; QL (12 per 28
days)
PA; QL (0.6 per 28
days)
78
Name of Drug
NEUPOGEN INJECTION
SOLUTION 300 MCG/ML, 480
MCG/1.6 ML
NEUPOGEN INJECTION
MCG/0.8 ML
PROCRIT 10,000 UNITS/ML
VIAL 4'S, MDV, OUTER 20,000
UNIT/2 ML
PROCRIT INJECTION
SOLUTION 10,000 UNIT/ML,
2,000 UNIT/ML, 20,000 UNIT/ML,
3,000 UNIT/ML, 4,000 UNIT/ML
PROCRIT INJECTION
SOLUTION 40,000 UNIT/ML
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
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
1
$0
(Agrylin)
1
$0
(Protamine Sulfate)
1
$0
(Tranexamic Acid)
1
$0
(Lysteda)
1
$0
(Aggrenox)
1
$0
(Aminocaproic
Acid)
(Aminocaproic
Acid)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (12 per 28
days)
PA; QL (12 per 28
days)
PA; QL (30 per 30
days)
QL (30 per 30 days)
79
Tier level
What the
drug will
cost you
2
$0
(Pletal)
1
$0
(Plavix)
1
$0
(Persantine)
1
$0
2
$0
1
$0
2
$0
2
$0
Name of Drug
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
(Pentoxifylline)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
Caloric Agents
Caloric Agents
AMINO ACIDS 15 %
INTRAVENOUS PARENTERAL
SOLUTION 15 %
AMINOSYN 10 %
SOLUTION 10 %
AMINOSYN 3.5 %
SOLUTION 3.5 %
AMINOSYN 7 % INTRAVENOUS
PARENTERAL SOLUTION 7 %
AMINOSYN 7 % WITH
ELECTROLYTES
SOLUTION 7 %
AMINOSYN 8.5 %
SOLUTION 8.5 %
AMINOSYN 8.5 %ELECTROLYTES
SOLUTION 8.5 %
PA BvD
PA BvD
PA BvD
2
$0
2
$0
PA BvD
PA BvD
2
$0
2
$0
PA BvD
PA BvD
2
$0
80
Name of Drug
AMINOSYN II 10 %
SOLUTION 10 %
AMINOSYN II 15 %
SOLUTION 15 %
AMINOSYN II 7 %
SOLUTION 7 %
AMINOSYN II 8.5 %
SOLUTION 8.5 %
AMINOSYN II 8.5 %ELECTROLYTES
SOLUTION 8.5 %
AMINOSYN M 3.5 %
SOLUTION 3.5 %
AMINOSYN-HBC 7%
SOLUTION 7 %
AMINOSYN-PF 10 %
SOLUTION 10 %
AMINOSYN-PF 7 % (SULFITEFREE) INTRAVENOUS
AMINOSYN-RF 5.2 %
SOLUTION 5.2 %
CLINIMIX 5%/D15W SULFITE
FREE INTRAVENOUS
CLINIMIX 5%/D25W SULFITEFREE INTRAVENOUS
Tier level
What the
drug will
cost you
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
2
$0
2
$0
2
$0
PA BvD
PA BvD
PA BvD
2
$0
2
$0
PA BvD
PA BvD
2
$0
PA BvD
2
$0
2
$0
2
$0
PA BvD
PA BvD
PA BvD
2
$0
2
$0
PA BvD
81
Name of Drug
CLINIMIX 2.75%/D5W SULFIT
FREE INTRAVENOUS
PARENTERAL SOLUTION 2.75
%
CLINIMIX 4.25%/D10W SULF
FREE INTRAVENOUS
%
CLINIMIX 4.25%/D5W SULFIT
FREE INTRAVENOUS
%
CLINIMIX 4.25%-D20W SULFFREE INTRAVENOUS
%
CLINIMIX 4.25%-D25W SULFFREE INTRAVENOUS
%
CLINIMIX 5%-D20W(SULFITEFREE) INTRAVENOUS
CLINIMIX E 2.75%/D10W SUL
FREE INTRAVENOUS
%
CLINIMIX E 2.75%/D5W SULF
FREE INTRAVENOUS
%
FREE INTRAVENOUS
%
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
PA BvD
2
$0
82
Name of Drug
FREE INTRAVENOUS
%
CLINIMIX E 4.25%/D5W SULF
FREE INTRAVENOUS
%
CLINIMIX E 5%/D15W SULFIT
FREE INTRAVENOUS
FREE INTRAVENOUS
FREE INTRAVENOUS
CLINISOL SF 15 %
SOLUTION 15 %
cysteine (l-cysteine) intravenous
solution 50 mg/ml
dex4 glucose 4 gm tablet chew
grape flavor 4 gram *
dextrose 10 % in water (d10w)
intravenous parenteral solution 10
%
intravenous solution
%
intravenous syringe
%
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
2
$0
PA BvD
2
$0
2
$0
2
$0
PA BvD
PA BvD
PA BvD
2
$0
PA BvD
2
$0
(Cysteine HCl)
1
$0
(Dextrose)
4
$0
PA BvD
(Dextrose 10 % in
Water)
1
$0
(Dextrose 10 % in
Water)
1
$0
PA BvD
PA BvD
(Dextrose 20 % in
Water)
1
$0
(Dextrose 25 % in
Water)
1
$0
(Dextrose 40 % in
Water)
PA BvD
PA BvD
PA BvD
1
$0
83
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
(Dextrose)
4
$0
(Dextrose)
4
$0
(Dextrose)
4
$0
(Dextrose)
4
$0
Name of Drug
dextrose 5 % in ringers intravenous
parenteral solution 5 %
intravenous syringe
FREAMINE HBC 6.9 %
SOLUTION 6.9 %
FREAMINE III 10 %
SOLUTION 10 %
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%
SOLUTION 8 %
HEPATASOL 8 %
SOLUTION 8 %
insta-glucose gel 24 gram/31 gram
*
INTRALIPID INTRAVENOUS
EMULSION 20 %, 30 %
KABIVEN INTRAVENOUS
EMULSION 3.31-9.8-3.9 %
(Dextrose 5 % In
Ringers)
(Dextrose 5 % in
Water)
(Dextrose 50 % in
Water)
(Dextrose 50 % in
Water)
(Dextrose 70 % in
Water)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
2
$0
2
$0
4
$0
2
$0
2
$0
PA BvD
(Dextrose/Dextrin/
Maltose)
PA BvD
PA BvD
84
Name of Drug
NEPHRAMINE 5.4 %
SOLUTION 5.4 %
NUTRILIPID INTRAVENOUS
EMULSION 20 %
PERIKABIVEN INTRAVENOUS
EMULSION 2.36-6.8-3.5 %
PREMASOL 10 %
SOLUTION 10 %
PREMASOL 6 % INTRAVENOUS
PROCALAMINE 3%
SOLUTION 3 %
PROSOL 20 % INTRAVENOUS
PARENTERAL SOLUTION
TRAVASOL 10 %
SOLUTION 10 %
TROPHAMINE 10 %
SOLUTION 10 %
TROPHAMINE 6%
SOLUTION 6 %
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
2
$0
(Catapres)
1
$0
(Catapres-Tts 1)
1
$0
(Catapres-Tts 1)
1
$0
(Clonidine
HCl/Chlorthalidon
e)
1
$0
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
clorpres oral tablet 0.1-15 mg, 0.215 mg, 0.3-15 mg
QL (4 per 28 days)
QL (8 per 28 days)
85
Tier level
What the
drug will
cost you
(Cardura)
1
$0
(Tenex)
1
$0
(Midodrine HCl)
1
$0
2
$0
(Vazculep)
1
$0
(Minipress)
1
$0
2
$0
2
$0
(Atacand)
1
$0
(Atacand HCT)
1
$0
2
$0
(Avapro)
1
$0
(Avalide)
1
$0
(Cozaar)
1
$0
(Hyzaar)
1
$0
(Micardis)
1
$0
Name of Drug
doxazosin oral tablet 1 mg, 2 mg, 4
mg, 8 mg
guanfacine oral tablet 1 mg, 2 mg
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, 5012.5 mg
telmisartan oral tablet 20 mg, 40
mg, 80 mg
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
PA; QL (180 per 30
days)
PA; QL (60 per 30
days)
86
Name of Drug
telmisartan-hydrochlorothiazid oral
tablet 40-12.5 mg, 80-12.5 mg, 8025 mg
TRIBENZOR ORAL TABLET 205-12.5 MG, 40-10-12.5 MG, 40-1025 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, 32012.5 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, 2025 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
(Micardis HCT)
Tier level
What the
drug will
cost you
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST
2
$0
(Diovan)
1
$0
(Diovan HCT)
1
$0
(Lotensin)
1
$0
(Lotensin HCT)
1
$0
(Captopril)
1
$0
(Captopril/Hydroch
lorothiazide)
1
$0
(Vasotec)
1
$0
(Enalaprilat
Dihydrate)
1
$0
(Vaseretic)
1
$0
1
$0
1
$0
1
$0
(Fosinopril
Sodium)
(Fosinopril/Hydroc
hlorothiazide)
(Zestril)
87
Tier level
What the
drug will
cost you
(Zestoretic)
1
$0
(Moexipril HCl)
1
$0
(Moexipril/Hydroc
hlorothiazide)
1
$0
(Aceon)
1
$0
(Accupril)
1
$0
(Accuretic)
1
$0
(Altace)
1
$0
(Mavik)
1
$0
(Cordarone)
1
$0
(Norpace)
1
$0
(Tikosyn)
1
$0
(Tambocor)
1
$0
(Lidocaine
HCl/PF)
1
$0
(Lidocaine
HCl/D5w/PF)
1
$0
(Mexiletine HCl)
1
$0
2
$0
Name of Drug
lisinopril-hydrochlorothiazide oral
tablet 10-12.5 mg, 20-12.5 mg, 2025 mg
moexipril oral tablet 15 mg, 7.5 mg
moexipril-hydrochlorothiazide oral
tablet 15-12.5 mg, 15-25 mg, 7.512.5 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, 2025 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)
mg/ml (0.8 %)
mexiletine oral capsule 150 mg, 200
mg, 250 mg
MULTAQ ORAL TABLET 400
MG
Necessary Actions,
Restrictions, or
Limits on Use
88
Tier level
What the
drug will
cost you
(Cordarone)
1
$0
(Procainamide
HCl)
1
$0
(Rythmol SR)
1
$0
(Rythmol)
1
$0
(Quinidine
Gluconate)
1
$0
(Quinidine Sulfate)
1
$0
(Quinidine Sulfate)
1
$0
2
$0
(Sectral)
1
$0
(Tenormin)
1
$0
(Tenoretic 50)
1
$0
(Betaxolol HCl)
1
$0
(Zebeta)
1
$0
(Ziac)
1
$0
2
$0
(Coreg)
1
$0
(Brevibloc)
1
$0
Name of Drug
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
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
TIKOSYN ORAL CAPSULE 125
MCG, 250 MCG, 500 MCG
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, 56.25 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)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
89
Tier level
What the
drug will
cost you
(Labetalol HCl)
1
$0
(Trandate)
1
$0
(Toprol XL)
1
$0
(Lopressor HCT)
1
$0
(Lopressor)
1
$0
(Lopressor)
1
$0
(Corgard)
1
$0
(Pindolol)
1
$0
(Propranolol HCl)
1
$0
(Inderal LA)
1
$0
(Propranolol HCl)
1
$0
(Propranolol HCl)
1
$0
(Propranolol/Hydro
chlorothiazid)
1
$0
(Betapace)
1
$0
(Betapace)
(Betapace)
1
1
$0
$0
(Betapace)
1
$0
(Timolol Maleate)
1
$0
Name of Drug
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
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
Necessary Actions,
Restrictions, or
Limits on Use
90
Tier level
What the
drug will
cost you
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem LA)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Verapamil HCl)
1
$0
(Verelan Pm)
1
$0
Name of Drug
Calcium-Channel Blocking
Agents
cartia xt oral capsule,extended
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
diltiazem hcl oral capsule,extended
release 12 hr 120 mg, 60 mg, 90 mg
diltiazem hcl oral capsule,extended
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
Necessary Actions,
Restrictions, or
Limits on Use
91
Tier level
What the
drug will
cost you
(Verelan)
1
$0
(Calan)
1
$0
(Calan SR)
1
$0
2
$0
2
$0
Name of Drug
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
Cardiovascular Agents,
Miscellaneous
CORLANOR ORAL TABLET 5
MG, 7.5 MG
DEMSER ORAL CAPSULE 250
MG
digitek oral tablet 125 mcg
(Lanoxin)
1
$0
digitek oral tablet 250 mcg
(Lanoxin)
1
$0
digox 125 mcg tablet 125 mcg
(Lanoxin)
1
$0
digox 250 mcg tablet 250 mcg
(Lanoxin)
1
$0
digoxin 0.25 mg/ml syringe 250
mcg/ml
(Digoxin)
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST
(High Risk Med for
Ages 65 and Older and
Dose is Greater Than
125mcg Per Day); QL
(30 per 30 days)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per
30 days)
(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)
PA-HRM
92
Name of Drug
digoxin injection solution 250
mcg/ml
DIGOXIN ORAL SOLUTION 50
MCG/ML
(Digoxin)
Tier level
What the
drug will
cost you
1
$0
2
$0
digoxin oral tablet 125 mcg
(Lanoxin)
1
$0
digoxin oral tablet 250 mcg
(Lanoxin)
1
$0
(Dobutamine
HCl/D5W)
1
$0
(Dobutamine HCl)
1
$0
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
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
PA-HRM; QL (300 per
30 days)
(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)
PA BvD
PA BvD
PA BvD
(Dopamine
HCl/D5W)
1
$0
PA BvD
(Dopamine HCl)
1
$0
(Ephedrine Sulfate)
1
$0
(Epinephrine
HCl/PF)
1
$0
(Adrenaclick)
1
$0
93
Name of Drug
epinephrine injection solution 1
(Epinephrine)
mg/ml (1 ml)
epinephrine injection syringe 0.1
(Epinephrine)
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
(Ethanolamine
ethamolin intravenous solution 5 %
Oleate)
FIRAZYR SUBCUTANEOUS
SYRINGE 30 MG/3 ML
hydralazine injection solution 20
(Hydralazine HCl)
mg/ml
hydralazine oral tablet 10 mg, 100
(Hydralazine HCl)
mg, 25 mg, 50 mg
Tier level
What the
drug will
cost you
1
$0
1
$0
2
$0
2
$0
1
$0
2
$0
1
$0
1
$0
LANOXIN ORAL TABLET 187.5
MCG
2
$0
LANOXIN ORAL TABLET 62.5
MCG
2
$0
(Milrinone
Lactate/D5W)
1
$0
(Milrinone Lactate)
1
$0
(Levophed
Bitartrate)
1
$0
(Papaverine HCl)
1
$0
milrinone in 5 % dextrose
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
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
30 days)
(High Risk Med for
125mcg Per Day); QL
(30 per 30 days)
PA BvD
PA BvD
PA BvD
PA
94
Tier level
What the
drug will
cost you
1
$0
2
$0
(Adalat CC)
1
$0
(Norvasc)
1
$0
(Lotrel)
1
$0
(Exforge)
1
$0
(Exforge HCT)
1
$0
2
$0
2
$0
(Felodipine)
1
$0
(Isradipine)
1
$0
(Nicardipine HCl)
1
$0
(Procardia XL)
1
$0
(Adalat CC)
1
$0
(Adalat CC)
1
$0
(Procardia XL)
1
$0
Name of Drug
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
amlodipine oral tablet 10 mg, 2.5
mg, 5 mg
amlodipine-benazepril oral capsule
10-20 mg, 10-40 mg, 2.5-10 mg, 510 mg, 5-20 mg, 5-40 mg
amlodipine-valsartan oral tablet 10160 mg, 10-320 mg, 5-160 mg, 5320 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
nifedipine er 30 mg tablet f/c 30 mg
nifedipine oral tablet extended
release 24hr 30 mg
nifedipine oral tablet extended
Diuretics
(Papaverine HCl)
Necessary Actions,
Restrictions, or
Limits on Use
PA
ST
95
Tier level
What the
drug will
cost you
(Amiloride HCl)
(Amiloride/Hydroc
hlorothiazide)
1
$0
1
$0
(Bumetanide)
1
$0
(Bumetanide)
1
$0
(Chlorothiazide)
1
$0
(Sodium Diuril)
1
$0
(Chlorthalidone)
1
$0
2
$0
(Furosemide)
1
$0
(Furosemide)
1
$0
(Furosemide)
1
$0
(Lasix)
1
$0
(Microzide)
1
$0
(Hydrochlorothiazi
de)
1
$0
(Indapamide)
1
$0
(Methyclothiazide)
1
$0
(Zaroxolyn)
1
$0
(Demadex)
1
$0
(Dyazide)
1
$0
Name of Drug
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
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
Necessary Actions,
Restrictions, or
Limits on Use
96
Tier level
What the
drug will
cost you
(Maxzide)
1
$0
(Caduet)
1
$0
(Lipitor)
1
$0
(Questran)
1
$0
(Questran)
1
$0
(Colestid)
1
$0
(Colestid)
(Colestid)
1
1
$0
$0
1
$0
(Slo-Niacin)
4
$0
(Lofibra)
1
$0
(Tricor)
1
$0
(Lofibra)
1
$0
(Trilipix)
1
$0
(Fibricor)
1
$0
(Lopid)
1
$0
2
$0
Name of Drug
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, 1080 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40
mg, 5-10 mg, 5-20 mg, 5-40 mg, 580 mg
atorvastatin oral tablet 10 mg, 20
mg, 40 mg, 80 mg
cholestyramine light oral powder in
packet 4 gram
cholestyramine packet 4 gram
colestipol hcl granules packet 5
gram
colestipol oral granules 5 gram
colestipol oral tablet 1 gram
CRESTOR ORAL TABLET 10
MG, 20 MG, 40 MG, 5 MG
endur-acin sr 500 mg tablet 500 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
gemfibrozil oral tablet 600 mg
JUXTAPID ORAL CAPSULE 10
MG, 20 MG, 30 MG, 40 MG, 5
MG, 60 MG
Necessary Actions,
Restrictions, or
Limits on Use
PA
97
Tier level
What the
drug will
cost you
2
$0
(Mevacor)
1
$0
(Slo-Niacin)
(Niacin)
(Slo-Niacin)
4
4
4
$0
$0
$0
(Niaspan)
1
$0
(Slo-Niacin)
4
$0
(Niacinamide)
(Niacin)
4
1
$0
$0
(Lovaza)
1
$0
Name of Drug
KYNAMRO SUBCUTANEOUS
SYRINGE 200 MG/ML
lovastatin oral tablet 10 mg, 20 mg,
40 mg
niacin 50 mg tablet 50 mg *
niacin 500 mg capsule sa 500 mg *
niacin 500 mg tablet 500 mg *
niacin oral tablet extended release
24 hr 1,000 mg, 500 mg, 750 mg
niacin tr 500 mg caplet caplet 500
mg *
niacinamide 500 mg tablet 500 mg *
niacor oral tablet 500 mg
omega-3 acid ethyl esters oral
capsule 1 gram
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
REPATHA PUSHTRONEX
SUBCUTANEOUS WEARABLE
INJECTOR 420 MG/3.5 ML
REPATHA SURECLICK
SUBCUTANEOUS PEN
INJECTOR 140 MG/ML
REPATHA SYRINGE
MG/ML
Necessary Actions,
Restrictions, or
Limits on Use
2
$0
(Pravachol)
(Cholestyramine/A
spartame)
(Cholestyramine/A
spartame)
2
$0
1
$0
1
$0
1
$0
2
$0
2
$0
PA; QL (3.5 per 28
days)
2
$0
98
Tier level
What the
drug will
cost you
(Crestor)
1
$0
(Zocor)
1
$0
(Zocor)
1
$0
2
$0
2
$0
2
$0
2
$0
(Inspra)
1
$0
(Aldactone)
1
$0
(Aldactazide)
1
$0
2
$0
(Isochron)
1
$0
(Isochron)
1
$0
1
$0
1
$0
(Imdur)
1
$0
(Nitro-Dur)
1
$0
Name of Drug
rosuvastatin oral tablet 10 mg, 20
mg, 40 mg, 5 mg
simvastatin oral tablet 10 mg, 20
mg, 40 mg, 5 mg
simvastatin oral tablet 80 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-AngiotensinAldosterone 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
isosorbide dinitrate oral tablet 10
mg, 20 mg, 30 mg, 5 mg
isosorbide dinitrate oral tablet
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
(Isosorbide
Dinitrate)
(Isosorbide
Mononitrate)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (30 per 30 days)
99
Tier level
What the
drug will
cost you
(Nitro-Dur)
1
$0
(Minoxidil)
1
$0
1
$0
(Nitroglycerin/D5
W)
1
$0
(Nitroglycerin)
1
$0
(Nitro-Dur)
1
$0
(Nitro-Dur)
1
$0
2
$0
2
$0
Name of Drug
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
(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
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
Central Nervous System
Agents
Central Nervous System
Agents
AMPYRA ORAL TABLET
MG
caffeine citrated intravenous
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
2
$0
(Cafcit)
1
$0
(Cafcit)
1
$0
(Caffeine/Sodium
Benzoate)
1
$0
(Kapvay)
1
$0
PA; QL (60 per 30
days)
100
Tier level
What the
drug will
cost you
(Focalin)
1
$0
(Dexedrine)
1
$0
(Dexedrine)
1
$0
(Adderall XR)
1
$0
(Adderall XR)
1
$0
Name of Drug
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
oral capsule,extended release 24hr
20 mg, 25 mg, 30 mg
oral 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
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
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
(Adderall)
1
$0
(Romazicon)
1
$0
(Intuniv)
1
$0
(Lithium
Carbonate)
1
$0
(Lithobid)
1
$0
(Lithobid)
1
$0
(Lithium Citrate)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
101
Tier level
What the
drug will
cost you
(Metadate Cd)
1
$0
(Methylin)
1
$0
(Ritalin)
1
$0
(Methylphenidate
HCl)
1
$0
(Concerta)
1
$0
(Concerta)
1
$0
2
$0
2
$0
1
$0
2
$0
Name of Drug
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
extended release 24hr 18 mg, 27
mg, 54 mg
extended release 24hr 36 mg
NUEDEXTA ORAL CAPSULE 2010 MG
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
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
(Rilutek)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
(Xenazine)
2
$0
2
$0
1
$0
3
$0
1
$0
PA; QL (112 per 28
days)
Contraceptives
Contraceptives
AFTERA 1.5 MG TABLET 1.5 MG
*
altavera (28) oral tablet 0.15-0.03
(Amethyst)
mg
QL (6 per 365 days)
102
Tier level
What the
drug will
cost you
(Modicon)
1
$0
(Modicon)
1
$0
Name of Drug
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
(7)
apri oral tablet 0.15-0.03 mg
aranelle (28) oral tablet 0.5/1/0.535 mg-mcg
ashlyna oral tablets,dose pack,3
(7)
aubra oral tablet 0.1-20 mg-mcg
aviane oral tablet 0.1-20 mg-mcg
azurette (28) oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
balziva (28) oral tablet 0.4-35 mgmcg
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 mg20 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
(7)
Necessary Actions,
Restrictions, or
Limits on Use
QL (91 per 84 days)
(Seasonique)
1
$0
(Seasonique)
1
$0
(Desogen)
1
$0
(Modicon)
1
$0
(Seasonique)
1
$0
(Amethyst)
(Amethyst)
1
1
$0
$0
(Mircette)
1
$0
(Modicon)
1
$0
(Mircette)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Modicon)
(Nor-Q-D)
1
1
$0
$0
QL (91 per 84 days)
QL (91 per 84 days)
(Seasonique)
1
$0
103
Tier level
What the
drug will
cost you
(Seasonique)
1
$0
(Desogen)
1
$0
(Norgestrel-Ethinyl
Estradiol)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
(Desogen)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
(Seasonique)
1
$0
(Nor-Q-D)
1
$0
(Amethyst)
1
$0
(Mircette)
1
$0
(Desogen)
1
$0
(Yaz)
1
$0
(Aftera)
4
$0
(Norgestrel-Ethinyl
Estradiol)
1
$0
2
1
$0
$0
1
$0
1
$0
Name of Drug
camrese oral tablets,dose pack,3
(7)
caziant (28) oral tablet 0.1/.125/.1525 mg-mcg
cryselle (28) oral tablet 0.3-30 mgmcg
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
(7)
deblitane oral tablet 0.35 mg
delyla (28) oral tablet 0.1-20 mgmcg
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
Necessary Actions,
Restrictions, or
Limits on Use
QL (91 per 84 days)
QL (91 per 84 days)
ELLA ORAL TABLET 30 MG
emoquette oral tablet 0.15-0.03 mg (Desogen)
enpresse oral tablet 50-30 (6)/75-40
(Amethyst)
(5)/125-30(10)
enskyce oral tablet 0.15-0.03 mg
(Desogen)
QL (6 per 365 days)
QL (6 per 365 days)
104
Tier level
What the
drug will
cost you
(Nor-Q-D)
(Ortho-Cyclen)
1
1
$0
$0
(Amethyst)
1
$0
(Yaz)
(Modicon)
1
1
$0
$0
(Loestrin)
1
$0
(Loestrin)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Nor-Q-D)
(LevonorgestrelEthin Estradiol)
(Nor-Q-D)
(Nor-Q-D)
(Desogen)
1
$0
1
$0
1
$0
1
$0
1
1
$0
$0
(Loestrin)
1
$0
(Loestrin)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Mircette)
1
$0
Name of Drug
errin oral tablet 0.35 mg
estarylla oral tablet 0.25-35 mg-mcg
falmina (28) oral tablet 0.1-20 mgmcg
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 mg20 mcg (21)/75 mg (7)
heather oral tablet 0.35 mg
introvale oral tablets,dose pack,3
month 0.15-30 mg-mcg
jencycla oral tablet 0.35 mg
jolessa oral tablets,dose pack,3
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 mgmcg
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 mg20 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
Necessary Actions,
Restrictions, or
Limits on Use
QL (91 per 84 days)
QL (91 per 84 days)
105
Tier level
What the
drug will
cost you
(Demulen 1-50-21)
1
$0
(Mircette)
1
$0
(Amethyst)
1
$0
Name of Drug
kelnor 1/35 (28) oral tablet 1-35
mg-mcg
kimidess (28) oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
kurvelo oral tablet 0.15-0.03 mg
l norgest/e.estradiol-e.estrad oral
tablets,dose pack,3 month 0.10 mg20 mcg (84)/10 mcg (7), 0.15 mg-30
mcg (84)/10 mcg (7)
larin 1.5/30 (21) oral tablet 1.5-30
mg-mcg
larin 1/20 (21) oral tablet 1-20 mgmcg
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 mg20 mcg (21)/75 mg (7)
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 0.15-30
mg-mcg
Necessary Actions,
Restrictions, or
Limits on Use
QL (91 per 84 days)
(Seasonique)
1
$0
(Loestrin)
1
$0
(Loestrin)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Modicon)
1
$0
(Amethyst)
1
$0
(Amethyst)
1
$0
(Amethyst)
1
$0
(Aftera)
4
$0
(Plan B One-Step)
(Plan B One-Step)
1
1
$0
$0
(Amethyst)
1
$0
QL (91 per 84 days)
QL (6 per 365 days)
QL (6 per 365 days)
QL (91 per 84 days)
(Amethyst)
1
$0
106
Tier level
What the
drug will
cost you
(Amethyst)
1
$0
(Amethyst)
1
$0
(Loestrin Fe)
1
$0
(Yaz)
(Norgestrel-Ethinyl
Estradiol)
1
$0
1
$0
(Amethyst)
1
$0
(Nor-Q-D)
(Amethyst)
1
1
$0
$0
(Loestrin)
1
$0
(Loestrin)
1
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Ortho-Cyclen)
1
$0
(Ortho-Cyclen)
1
$0
(Aftera)
4
$0
(Amethyst)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
(Norinyl 1+50)
1
$0
(Modicon)
1
$0
Name of Drug
levonorg-eth estrad triphasic oral
tablet 50-30 (6)/75-40 (5)/12530(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 mgmcg
lyza oral tablet 0.35 mg
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 120 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 mgmcg
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 mgmcg
necon 1/50 (28) oral tablet 1-50 mgmcg
necon 10/11 (28) oral tablet 0.535/1-35 mg-mcg/mg-mcg
Necessary Actions,
Restrictions, or
Limits on Use
QL (91 per 84 days)
QL (6 per 365 days)
107
Tier level
What the
drug will
cost you
(Modicon)
1
$0
(Aftera)
4
$0
(Plan B One-Step)
1
$0
(Yaz)
(Nor-Q-D)
1
1
$0
$0
(Nor-Q-D)
1
$0
(Loestrin)
1
$0
(Loestrin Fe)
1
$0
(Ortho-Cyclen)
1
$0
(Ortho-Cyclen)
1
$0
(Nor-Q-D)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
2
$0
(Yaz)
(Norgestrel-Ethinyl
Estradiol)
1
$0
1
$0
(Aftera)
4
$0
(Amethyst)
1
$0
Name of Drug
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)
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 mgmcg
opcicon one-step 1.5 mg tablet 1.5
mg *
orsythia oral tablet 0.1-20 mg-mcg
Necessary Actions,
Restrictions, or
Limits on Use
QL (6 per 365 days)
QL (6 per 365 days)
ST; QL (1 per 28 days)
QL (6 per 365 days)
108
Tier level
What the
drug will
cost you
(Modicon)
1
$0
(Mircette)
1
$0
(Modicon)
1
$0
3
$0
(Amethyst)
(Ortho-Cyclen)
(Aftera)
1
1
$0
$0
1
$0
4
$0
(Desogen)
1
$0
1
$0
1
$0
(Ortho-Cyclen)
1
$0
(Amethyst)
(Yaz)
1
1
$0
$0
(Loestrin Fe)
1
$0
(Loestrin Fe)
1
$0
(Ortho-Cyclen)
1
$0
(Loestrin Fe)
1
$0
(Ortho-Cyclen)
1
$0
(Ortho-Cyclen)
1
$0
(Ortho-Cyclen)
1
$0
(Ortho-Cyclen)
1
$0
Name of Drug
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 mg35 mcg, 1-35 mg-mcg
PLAN B ONE-STEP 1.5 MG
TABLET (OTC) 1.5 MG *
portia oral tablet 0.15-0.03 mg
previfem oral tablet 0.25-35 mg-mcg
quasense oral tablets,dose pack,3
react 1.5 mg tablet 1.5 mg *
reclipsen (28) oral tablet 0.15-0.03
mg
setlakin oral tablets,dose pack,3
sharobel oral tablet 0.35 mg
sprintec (28) oral tablet 0.25-35 mgmcg
sronyx oral tablet 0.1-20 mg-mcg
syeda oral tablet 3-0.03 mg
tarina fe 1/20 (28) oral tablet 1 mg20 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)/130(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
(Nor-Q-D)
Necessary Actions,
Restrictions, or
Limits on Use
QL (6 per 365 days)
QL (91 per 84 days)
QL (6 per 365 days)
QL (91 per 84 days)
109
Tier level
What the
drug will
cost you
(Ortho-Cyclen)
1
$0
(Ortho-Cyclen)
1
$0
(Ortho-Cyclen)
1
$0
(Amethyst)
1
$0
(Desogen)
1
$0
(Yaz)
(Amethyst)
1
1
$0
$0
(Mircette)
1
$0
(Modicon)
1
$0
(Modicon)
1
$0
(Ortho Evra)
1
$0
(Yaz)
1
$0
(Modicon)
1
$0
(Demulen 1-50-21)
1
$0
(Demulen 1-50-21)
1
$0
4
$0
4
$0
(Trispec Pse)
4
$0
(Brompheniramine/
Pseudoephed/Dm)
4
$0
Name of Drug
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)/7540 (5)/125-30(10)
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 mgmcg
wera (28) oral tablet 0.5-35 mg-mcg
xulane transdermal patch weekly
150-35 mcg/24 hr
zarah oral tablet 3-0.03 mg
zenchent (28) oral tablet 0.4-35 mgmcg
zovia 1/35e (28) oral tablet 1-35
mg-mcg
zovia 1/50e (28) oral tablet 1-50
mg-mcg
Necessary Actions,
Restrictions, or
Limits on Use
QL (3 per 28 days)
Cough And Cold Products
Cough And Cold Products
15dm-5peh-2cpm liquid strawberry
2-5-15 mg/5 ml *
25cpd-200gfn liquid 25-200 mg/5 ml
*
30pse-150gfn-15dm liquid 30-15150 mg/5 ml *
3brm-15dm-30pse liquid 3-30-15
mg/5 ml *
(Chlorpheniramine/
Phenyleph/Dm)
(Chlophedianol
HCl/Guaifenesin)
110
Tier level
What the
drug will
cost you
(Brompheniramine/
Pseudoephed/Dm)
4
$0
(Trispec Pse)
4
$0
(Dextromethorphan
Hbr)
4
$0
(G-Zyncof)
4
$0
(G-Zyncof)
4
$0
(G-Zyncof)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
3
$0
3
$0
4
$0
4
$0
4
$0
Name of Drug
3brm-30dm-50pse liquid (otc) 3-5030 mg/5 ml *
actinel pediatric liquid 15-5-50
mg/5 ml *
adt robitussin linger cold syr 15
mg/5 ml *
adt robitussin peak cld dm max 10200 mg/5 ml *
adult robitussin peak cold liq nondrowsy 10-100 mg/5 ml *
adult wal-tussin dm max liq
a/f,cherry menthol 10-200 mg/5 ml *
adult wal-tussin dm syrup
a/f,cherry,adult 10-100 mg/5 ml *
(Cough Formula
Dm)
(Robitussin
adult wal-tussin liquid 100 mg/5 ml
Mucus-Chest
*
Congest)
alka-seltzer plus mucus-conges 10- (Guaifenesin/Dextr
200 mg *
omethorphan)
ambi 10peh-4cpm-20dm tablet 4-10- (Chlorpheniramine/
20 mg *
Phenyleph/Dm)
ambi 20dm-4cpm tablet 4-20 mg *
(Coricidin Hbp)
ambi 40pse-400gfn-20dm tablet 40- (Guaifenesin/Dm/P
20-400 mg *
seudoephedrine)
ambi 60pse-4cpm-20dm tablet 4-60- (Chlorpheniramin/
20 mg *
Pseudoephed/Dm)
benzonatate 100 mg capsule 100 mg
(Zonatuss)
*
(Zonatuss)
*
(Zonatuss)
*
bio-dtuss dmx liquid 1-30-20 mg/5
(Brompheniramine/
ml *
Pseudoephed/Dm)
bionel pediatric liquid 15-5-50 mg/5
(Trispec Pse)
ml *
biospec dmx liquid 15-25 mg/5 ml * (G-Zyncof)
Necessary Actions,
Restrictions, or
Limits on Use
111
Tier level
What the
drug will
cost you
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
(G-Zyncof)
4
$0
(Tusnel C)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
bp 8 cough oral suspension a/f,
grape (otc) 30-15-175 mg/5 ml *
bpm-pse-dm liquid a/f, cotton candy
(otc) 4-20-20 mg/5 ml *
bromfed dm cough syrup 2-30-10
mg/5 ml *
bromphenex dm syrup (otc) 4-60-30
mg/5 ml *
bromphenir-pseudoephed-dm syr
(rx) 2-30-10 mg/5 ml *
brom-pse-dm cough syrup butter
scotch (otc) 2-30-10 mg/5 ml *
centergy dm pediatric drops 1-2-3
mg/ml *
cheracol d cough formula 10-100
mg/5 ml *
cheratussin dac syrup 30-10-100
mg/5 ml *
child sudafed pe cough-cold lq 2.5-5
mg/5 ml *
child triaminic cgh-congst syr 5-100
mg/5 ml *
(Guaifenesin/Dm/P
seudoephedrine)
(Brompheniramine/
Pseudoephed/Dm)
(Brompheniramine/
Pseudoephed/Dm)
(Brompheniramine/
Pseudoephed/Dm)
(Brompheniramine/
Pseudoephed/Dm)
(Brompheniramine/
Pseudoephed/Dm)
(Chlorpheniramine/
Phenyleph/Dm)
(Dextromethorphan
/Phenylephrine)
(Cough Formula
Dm)
(Dextromethorphan
child wal-tussin 7.5 mg odt 7.5 mg *
Hbr)
children's mucinex cough liq a/f 5(G-Zyncof)
100 mg/5 ml *
children's silfedrine liq 15 mg/5 ml (Pseudoephedrine
*
HCl)
childs sudafed 15 mg/5 ml liq non(Pseudoephedrine
drowsy,a/f,s/f 15 mg/5 ml *
HCl)
(Robitussin
chl mucinex chest congest liq a/f
Mucus-Chest
100 mg/5 ml *
Congest)
chld triaminic cgh-sor thr sus 160-5 (Acetaminophen/D
mg/5 ml *
extromethorphan)
codituss dm syrup 8.33-5-10 mg/5
(Pyrilamine/Pe/De
ml *
xtromethorphan)
Necessary Actions,
Restrictions, or
Limits on Use
112
Name of Drug
cold multi-symptom day-night
pseudoephedrine-free 2-5-10-325
mg *
(Dm
Hb/Pe/Acetaminop
hen/Chlorph)
(Dm
cold relief multi-symp caplet cplt,12
Hb/Pe/Acetaminop
day,12 night 2-5-10-325 mg *
hen/Chlorph)
cold-flu relief d/n softgel 10-5(Vicks Dayquil325mg(d)/ 15-325-6.25mg *
Nyquil)
(Dcold-flu relief liquid 12.5-30-1,000
Methorphan/Aceta
mg/30 ml *
min/Doxylamn)
(Guaifenesin/Pseud
congestac tablet 60-400 mg *
oephedrne HCl)
congest-eze 60-400 mg caplet 60(Guaifenesin/Pseud
400 mg *
oephedrne HCl)
(Dcoricidin hbp cold-multi sympt 6.25Methorphan/Aceta
15-325 mg/15 ml *
min/Doxylamn)
(Guaifenesin/Dextr
coricidin hbp softgel 10-200 mg *
omethorphan)
cough & cold tablet 4-30 mg *
(Coricidin Hbp)
cvs chest cong relief pe tab 10-400
(Maxiphen)
mg *
cvs chest congest relief dm tb 20(Allfen Dm)
400 mg *
cvs child cold-cough day liq 2.5-5
(Dextromethorphan
mg/5 ml *
/Phenylephrine)
(Robitussin
cvs child's chest congest liq 100
Mucus-Chest
mg/5 ml *
Congest)
cvs cough & sore throat susp 160-5 (Acetaminophen/D
mg/5 ml *
extromethorphan)
cvs cough relief liquid a/f, grape 15 (Dextromethorphan
mg/5 ml *
Hbr)
cvs daytime-nighttime cold-flu
(Dm/Pe/Acetamino
multi-symp,twin pack 6.25-5-10-325
phen/Doxylamine)
mg/15 ml *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
113
Tier level
What the
drug will
cost you
(Robitussin)
4
$0
(G-Zyncof)
4
$0
(Dextromethorphan
Hbr)
4
$0
(Triaminic)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
cvs tussin cgh 15 mg liq gels nondrowsy, liq gels 15 mg *
cvs tussin dm cough-chest liq 10200 mg/5 ml *
cvs tussin max-str syrup 15 mg/5 ml
*
daytime cold & cough liquid 1,00030 mg/30 ml *
(DMethorphan/Pe/Ac
etaminophen)
daytime cough liquid a/f, gluten-free (Dextromethorphan
5 mg/5 ml *
Hbr)
daytime-nighttime cough liquid
(Dextromethorphan
15mg/15ml(d)/ 12.5-30mg/30ml *
Hb/Doxylamine)
delsym cough+chest cngst dm lq 5(G-Zyncof)
100 mg/5 ml *
(Guaifenesin/Dm/P
despec-dm tablet 30-10-200 mg *
seudoephedrine)
dextromethorphan er 30 mg/5 ml 30
(Delsym)
mg/5 ml *
diabetic tussin dm liquid 10-100
(G-Zyncof)
mg/5 ml *
diabetic tussin dm max-str liq 10(G-Zyncof)
200 mg/5 ml *
ed bron gp liquid 5-100 mg/5 ml *
(Despec)
entre-cough liquid 30-15-175 mg/5
(Trispec Pse)
ml *
(Robitussin
expectorant 100 mg/5 ml syrup 100
Mucus-Chest
mg/5 ml *
Congest)
expectorant dm cough liquid 20-300
(G-Zyncof)
mg/5 ml *
expectorant max cough-cold 30-15 (Dextromethorphan
mg/5 ml *
/Pseudoephed)
geri-tussin dm syrup 10-100 mg/5
(Cough Formula
ml *
Dm)
daytime cold-flu liquid a/f, glutenfree 5-10-325 mg/15 ml *
Necessary Actions,
Restrictions, or
Limits on Use
114
Name of Drug
guaifenesin 200 mg tablet (otc) 200
(Allfen)
mg *
guaifenesin dac oral solution 30-10(Tusnel C)
100 mg/5 ml *
guaifenesin er 600 mg tablet 600 mg
(Mucinex)
*
(Dm
head congestion day-night pack 2-5Hb/Pe/Acetaminop
10-325 mg *
hen/Chlorph)
hydrocodone-chlorphen er susp 10(Tussionex)
8 mg/5 ml *
hydrocodone-homatropine 5-1.5 mg
(Tussigon)
tablet 5-1.5 mg *
(Hydrocodone
hydromet syrup 5-1.5 mg/5 ml *
Bit/Homatrop MeBr)
liquibid d-r tablet 10-400 mg *
(Maxiphen)
lohist-dm syrup 2-5-10 mg/5 ml *
(Ala-Hist Dm)
lortuss ex liquid 30-10-100 mg/5 ml
(Tusnel C)
*
mar-cof bp liquid 2-30-7.5 mg/5 ml (Bromphenira/Pseu
*
doephed/Codein)
mar-cof cg liquid 7.5-225 mg/5 ml * (M-Clear Wc)
mesehist dm oral syrup 2-15-15
(Chlorpheniramin/
mg/5 ml *
Pseudoephed/Dm)
mucus dm 600-30 mg tablet 30-600
(Mucinex Dm)
mg *
mucus dm max tablet 60-1,200 mg * (Mucinex Dm)
mucus relief 400 mg tablet d/f 400
(Allfen)
mg *
nasal-sinus decongest tab 30 mg *
(Sudafed 12-Hour)
nasohist dm pediatric drops 1-2-3
(Chlorpheniramine/
mg/ml *
Phenyleph/Dm)
neo-tuss liquid 30-200 mg/5 ml *
(G-Zyncof)
NEXAFED 30 MG TABLET 30
MG *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
3
$0
3
$0
3
$0
4
3
$0
$0
4
$0
3
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
115
Name of Drug
NIGHT TIME COLD-FLU RLF
SFTGL SFTGL, MULTISYMPTOM 6.25-15-325 MG *
(Dnight time cough & sore throat 12.5Methorphan/Aceta
30-1,000 mg/30 ml *
min/Doxylamn)
nighttime cough liquid gluten-free, (Dextromethorphan
cherry 6.25-15 mg/15 ml *
Hb/Doxylamine)
nighttime d cold-flu rlf liq multi(Dm/Psymptom,cherry 6.25-30-15-500
Ephed/Acetaminop
mg/15 ml *
h/Doxylam)
(Chlorpheniramine/
nohist-dm liquid 4-10-15 mg/5 ml *
Phenyleph/Dm)
pecgen dmx 125-15 mg/5 ml liq 15(G-Zyncof)
125 mg/5 ml *
pedia relief cough-cold liquid a/f,
(Chlorpheniramin/
cherry 1-15-5 mg/5 ml *
Pseudoephed/Dm)
pediacare multi-symt cold liq non
(Dextromethorphan
drowsy, grape 2.5-5 mg/5 ml *
/Phenylephrine)
(P-Ephed
phenylhistine dh liquid (otc) 2-30-10
HCl/Cod/Chlorphe
mg/5 ml *
nir)
poly-tussin liquid 9.375-10 mg/5 ml (Chlorcyclizine/Co
*
deine)
promethazine vc-codeine syrup
(Promethazine/Phe
6.25-5-10 mg/5 ml *
nyleph/Codeine)
promethazine-codeine syrup 6.25-10 (Promethazine
mg/5 ml *
HCl/Codeine)
promethazine-dm syrup 6.25-15
(Promethazine/Dex
mg/5 ml *
tromethorphan)
pseudoephed 30 mg/5 ml soln 30
(Pseudoephedrine
mg/5 ml *
HCl)
pseudoephedrine 30 mg tablet 30
(Sudafed 12-Hour)
mg *
pseudoephedrine 60 mg tablet ex(Sudafed 12-Hour)
str, non drowsy (otc) 60 mg *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
3
$0
3
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
116
Name of Drug
(DMethorphan/Pe/Ac
etaminophen)
(Dm/Ppv night-time softgel multiEphed/Acetaminop
sympt.,softgel 6.25-30-15-325 mg *
h/Doxylam)
pv tussin pe liquid 5-100 mg/5 ml * (Despec)
(Brompheniramine/
q-tapp dm elixir 1-15-5 mg/5 ml *
Pseudoephed/Dm)
(Robitussin
q-tussin 100 mg/5 ml solution a/f,
Mucus-Chest
non-drowsy 100 mg/5 ml *
Congest)
(Cough Formula
q-tussin dm syrup 10-100 mg/5 ml *
Dm)
ra child plus cough-runny nose
(Dextromethorphn/
pseudoephedrine free 1-5-160 mg/5
Acetaminoph/Cp)
ml *
ra daytime-nighttime softgel cold-flu
(Vicks Dayquilrelief 10-5-325mg(d)/ 15-325Nyquil)
6.25mg *
ra flu formula gelcap 12.5-5-10-325 (Dm/Pe/Acetamino
mg *
ph/Diphenhydram)
ra maximum strength flu tablet 2(Coricidin Hbp)
15-500 mg *
ra mucus relief 400 mg tablet 400
(Allfen)
mg *
(Dm
ra multi-symptom cold caplet
Hb/Pe/Acetaminop
nighttime,cplt 2-5-10-325 mg *
hen/Chlorph)
ra tussin dm syrup a/f 10-100 mg/5 (Cough Formula
ml *
Dm)
refenesen 200 mg tablet 200 mg *
(Allfen)
refenesen pe caplet 10-400 mg *
(Maxiphen)
relcof c liquid 6.3-100 mg/5 ml *
(M-Clear Wc)
REZIRA SOLUTION 60-5 MG/5
ML *
pv flu relief therapy liquid daytime
5-10-325 mg/15 ml *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
3
$0
$0
$0
3
$0
Necessary Actions,
Restrictions, or
Limits on Use
117
Name of Drug
Tier level
What the
drug will
cost you
robafen 100 mg/5 ml syrup 100
mg/5 ml *
(Robitussin
Mucus-Chest
Congest)
4
$0
robafen cough 15 mg liquidgel nondrowsy,liquidgel 15 mg *
(Robitussin)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
robafen-dm syrup 10-100 mg/5 ml *
robitussin cough-chest-cong dm 10200 mg *
ROBITUSSIN LONG-ACTING
LIQ 1-7.5 MG/5 ML *
robitussin pediatric cough syp
a/f,long-acting 7.5 mg/5 ml *
rydex liquid 1.3-10-6.3 mg/5 ml *
(Cough Formula
Dm)
(Guaifenesin/Dextr
omethorphan)
(Dextromethorphan
Hbr)
(Bromphenira/Pseu
doephed/Codein)
(Brompheniram/Ph
enylephrine/Dm)
rynex dm liquid a/f, prof use only 12.5-5 mg/5 ml *
safetussin dm liquid 10-100 mg/5 ml
(G-Zyncof)
*
(Robitussin
scot-tussin 100 mg/5 ml liq 100
Mucus-Chest
mg/5 ml *
Congest)
scot-tussin dm s-f liquid 2-15 mg/5
(Vicks Children'S
ml *
Nyquil)
siltussin dm cough syrup 10-100
(Cough Formula
mg/5 ml *
Dm)
(Robitussin
siltussin sa 100 mg/5 ml syr 100
Mucus-Chest
mg/5 ml *
Congest)
sm adult nasal decongestant lq 15
(Pseudoephedrine
mg/5 ml *
HCl)
sm childrens plus cold susp
(Dm
grape,multi-symptom 1-2.5-5-160
Hb/Pe/Acetaminop
mg/5 ml *
hen/Chlorph)
sm cold-cough child elixir 1-15-5
(Brompheniramine/
mg/5 ml *
Pseudoephed/Dm)
Necessary Actions,
Restrictions, or
Limits on Use
118
Tier level
What the
drug will
cost you
(Vicks Children'S
Nyquil)
4
$0
(Trispec Pse)
4
$0
(Dm
Hb/Pseudoephed/A
cetamin/Cp)
4
$0
(G-Zyncof)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
sm cough & runny nose liquid 1-5
mg/5 ml *
sm cough-head congestion lq 20-1066.7 mg/5 ml *
sm flu severe cold-congestion
maximum strength 4-60-30-1,000
mg *
sm mucus relief cough liquid
childrens, a/f 5-100 mg/5 ml *
(Dm/PEphed/Acetaminop
h/Doxylam)
(Dm/Psm nite time cold-flu rel sfgl softgel
Ephed/Acetaminop
6.25-30-15-325 mg *
h/Doxylam)
(Dm
sm pain reliever cold caplet 2-30Hb/Pseudoephed/A
15-325 mg *
cetamin/Cp)
sm pedia relief liquid 1-15-5 mg/5
(Chlorpheniramin/
ml *
Pseudoephed/Dm)
sm severe cold m-s caplet 30-15-500 (Dm/Pseudoephed/
mg *
Acetaminophen)
sm tussin cf syrup 30-10-100 mg/5
(Guaifenesin/Dm/P
ml *
seudoephedrine)
sudafed 30 mg tablet non(Sudafed 12-Hour)
drowsy,max-str 30 mg *
sudogest 30 mg tablet boxed 30 mg
(Sudafed 12-Hour)
*
sudogest 60 mg tablet 60 mg *
(Sudafed 12-Hour)
(Pseudoephedrine
suphedrin liquid 15 mg/5 ml *
HCl)
suphedrine pe combo pack cplt 5(Diphenhydram/Pe/
10-325 mg *
Dm/Acetamin/Gg)
THERAFLU COLD AND COUGH
POWDER 10-20-650 MG *
THERAFLU MULTI-SYMP COLD
CPLT 5-10-325 MG *
sm nite time cold-flu liquid 7.5-6030-1,000 mg/30 ml *
Necessary Actions,
Restrictions, or
Limits on Use
119
Name of Drug
TRIAMINIC COUGH-SORE
THROAT LQ A/F,CHILDREN'S
160-5 MG/5 ML *
triaminic daytime cold-cough
children's, cherry 2.5-5 mg/5 ml *
tri-dex pe oral syrup 2-10-15 mg/5
ml *
trymine cg liquid 7.5-225 mg/5 ml *
tusnel diabetic liquid (otc) 10-100
mg/5 ml *
TUSNEL LIQUID A/F,A/F,D/F 3015-200 MG/5 ML *
TUSNEL PEDIATRIC LIQUID
(RX) 15-5-50 MG/5 ML *
TUSSI PRES-B LIQUID 4-10-30
MG/5 ML *
tussin cf cough & cold syrup a/f 510-100 mg/5 ml *
tussin cold-congestion gelcap liquid
gelcap 30-10-200 mg *
tussin dm syrup 15-100 mg/5 ml *
VANACOF LIQUID 1-30-12.5
MG/5 ML *
vicks dayquil cough liquid a/f,8 hr
rlf 5 mg/5 ml *
(Dextromethorphan
/Phenylephrine)
(Chlorpheniramine/
Phenyleph/Dm)
(M-Clear Wc)
(G-Zyncof)
(Tussi-Pres
Pediatric)
(Guaifenesin/Dm/P
seudoephedrine)
(Cough Formula
Dm)
(Dextromethorphan
Hbr)
(Dvicks dayquil liquicaps cold & flu 5Methorphan/Pe/Ac
10-325 mg *
etaminophen)
vicks nature fusion cough liq 5 mg/5 (Dextromethorphan
ml *
Hbr)
vicks nyquil severe cold-flu 6.25-5- (Dm/Pe/Acetamino
10-325 mg/15 ml *
phen/Doxylamine)
(Chlorpheniramine/
virdec dm drops 1-3.5-3 mg/ml *
Phenyleph/Dm)
virtussin ac liquid 10-100 mg/5 ml * (M-Clear Wc)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
120
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
(Sudafed 12-Hour)
4
$0
(Diphenhydram/Pe/
Dm/Acetamin/Gg)
4
$0
(Tussi-Pres
Pediatric)
4
$0
(Robitussin)
4
$0
4
$0
4
$0
3
$0
(G-Zyncof)
4
$0
(Evoxac)
1
$0
(Peridex)
1
$0
(Triamcinolone
Acetonide)
1
$0
1
$0
1
$0
Name of Drug
v-r infant non-asa cold drp 15-5-160
mg/1.6 ml *
v-r non-aspirin flu gelcap gelatin
caplet 30-15-500 mg *
v-r pedia relief inf drops
decongestant + 7.5-2.5 mg/0.8 ml *
vr triacting cold-cough liq 1-15-5
mg/5 ml *
v-r tussin cf syrup 30-10-100 mg/5
ml *
wal-phed 30 mg tablet non-drowsy
30 mg *
wal-phed pe day-night combo pk
gluten-free 5-10-325 mg *
wal-tussin cough & cold cf
pseudoephedrine free 5-10-100
mg/5 ml *
wal-tussin cough 15 mg softgel 15
mg *
wal-tussin cough 15 mg/5 ml 15
mg/5 ml *
zephrex-d 30 mg tablet 30 mg *
ZONATUSS 150 MG CAPSULE
150 MG *
zyncof 20-400 mg/5 ml liquid 20400 mg/5 ml *
(Dm/Pseudoephed/
Acetaminophen)
(Dm/Pseudoephed/
Acetaminophen)
(Dextromethorphan
/Pseudoephed)
(Chlorpheniramin/
Pseudoephed/Dm)
(Guaifenesin/Dm/P
seudoephedrine)
(Dextromethorphan
Hbr)
(Sudafed 12-Hour)
Necessary Actions,
Restrictions, or
Limits on Use
Dental And Oral Agents
Dental And Oral Agents
cevimeline oral capsule 30 mg
chlorhexidine gluconate mucous
membrane mouthwash 0.12 %
oralone dental paste 0.1 %
periogard mucous membrane
(Peridex)
mouthwash 0.12 %
pilocarpine hcl oral tablet 5 mg, 7.5
(Salagen)
mg
121
Tier level
What the
drug will
cost you
1
$0
(Sodium Fluoride)
1
$0
(Triamcinolone
Acetonide)
1
$0
2
$0
(Soriatane)
1
$0
(Benzoyl Peroxide)
4
$0
4
$0
4
1
$0
$0
1
$0
1
$0
4
$0
4
$0
4
$0
(Lac-Hydrin)
1
$0
(Lac-Hydrin)
1
$0
2
$0
(Benzoyl Peroxide)
4
$0
(Benzoyl Peroxide)
4
$0
Name of Drug
PREVIDENT 5000 SENSITIVE
DENTAL PASTE 1.1-5 %
sodium fluoride oral
tablet,chewable 0.25 mg fluorid
(0.55 mg)
triamcinolone acetonide dental
paste 0.1 %
Necessary Actions,
Restrictions, or
Limits on Use
Dermatological Agents
Dermatological Agents,
Other
8-MOP ORAL CAPSULE 10 MG
acitretin oral capsule 10 mg, 17.5
mg, 25 mg
acne medication 10% lotion 10 % *
ACNE MEDICATION 5%
LOTION 5 % *
acneclear gel 10 % *
acyclovir topical ointment 5 %
ALCOHOL PADS TOPICAL
PADS, MEDICATED
ALCOHOL PREP PADS
amlactin 12% lotion 12 % *
ammonium lactate 12% cream
fragrance free (otc) 12 % *
ammonium lactate 12% lotion (otc)
12 % *
ammonium lactate topical cream 12
%
ammonium lactate topical lotion 12
%
ANACAINE TOPICAL
OINTMENT 10 %
benzoyl peroxide 10% gel aqueous
(otc) 10 % *
benzoyl peroxide 5% gel aqueous
(otc) 5 % *
(Benzoyl Peroxide)
(Zovirax)
(Ammonium
Lactate)
(Ammonium
Lactate)
(Ammonium
Lactate)
QL (30 per 30 days)
122
Tier level
What the
drug will
cost you
(Calcipotriene)
(Dovonex)
4
1
1
$0
$0
$0
(Calcipotriene)
1
$0
(Calcipotriene)
1
$0
(Vectical)
1
$0
4
$0
2
$0
2
$0
Name of Drug
BETADINE 5% SPRAY 5 % *
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
CASTELLANI PAINT MODIFIED
1.5 % *
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 skin treatment body lotion 12 %
*
fluorouracil topical cream 0.5 %, 5
%
fluorouracil topical solution 2 %, 5
%
geri-hydrolac 12% lotion 12 % *
geri-hydrolac 5% lotion 5 % *
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
2
$0
2
$0
2
$0
(Ammonium
Lactate)
4
$0
(Carac)
1
$0
(Fluorouracil)
1
$0
4
$0
4
$0
1
$0
4
4
$0
$0
PA
(Ammonium
Lactate)
(Ammonium
Lactate)
imiquimod topical cream in packet 5
(Aldara)
%
LACTINOL HX CREAM *
lobana bath oil *
(Mineral Oil)
PA
PA NSO; QL (24 per
30 days)
123
Name of Drug
methoxsalen rapid oral capsule 10
(Oxsoralen-Ultra)
mg
PANRETIN TOPICAL GEL 0.1 %
persa-gel 10% 12's,max-strength 10
(Benzoyl Peroxide)
%*
PICATO TOPICAL GEL 0.015 %
PICATO TOPICAL GEL 0.05 %
(Podophyllum
podocon topical liquid 25 %
Resin)
podofilox topical solution 0.5 %
(Condylox)
potassium hydroxide topical
(Potassium
solution 5 %
Hydroxide)
pv acne pimple 10% gel 10 % *
(Benzoyl Peroxide)
SANTYL TOPICAL OINTMENT
250 UNIT/GRAM
TALTZ AUTOINJECTOR
SUBCUTANEOUS AUTOINJECTOR 80 MG/ML
TALTZ SYRINGE
MG/ML
TOLAK TOPICAL CREAM 4 %
VALCHLOR TOPICAL GEL 0.016
%
zenatane oral capsule 10 mg, 20 mg,
(Isotretinoin)
30 mg, 40 mg
zinc oxide 20% ointment 20 % *
(Boudreauxs)
ZOVIRAX TOPICAL CREAM 5 %
Dermatological
Antibacterials
bacitracin 500 unit/gm ointmnt 500
(Bacitracin)
unit/gram *
bacitraycin plus 500 unit/gm 500
(Bacitracin)
unit/gram *
clindamycin phosphate topical gel 1
(Cleocin T)
%
Tier level
What the
drug will
cost you
1
$0
2
$0
4
$0
2
2
$0
$0
1
$0
1
$0
1
$0
4
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (3 per 56 days)
QL (2 per 56 days)
PA
2
$0
2
$0
2
$0
2
$0
1
$0
4
2
$0
$0
4
$0
4
$0
1
$0
PA
QL (15 per 30 days)
124
Name of Drug
clindamycin phosphate topical
(Cleocin T)
lotion 1 %
clindamycin phosphate topical
(Cleocin T)
solution 1 %
clindamycin phosphate topical swab
(Cleocin T)
1%
(Neomycin
cvs triple antibiotic ointment 3.5mgSu/Bacitrac
400 unit- 5,000 unit/gram *
Zn/Poly)
(Erythromycin
ery pads topical swab 2 %
Base/Ethanol)
erythromycin with ethanol topical
(Emgel)
gel 2 %
(Erythromycin
solution 2 %
Base/Ethanol)
(Erythromycin
swab 2 %
Base/Ethanol)
(Gentamicin
gentamicin topical cream 0.1 %
Sulfate)
(Gentamicin
gentamicin topical ointment 0.1 %
Sulfate)
metronidazole topical cream 0.75 % (Metrocream)
metronidazole topical gel 0.75 %, 1
(Rosadan)
%
metronidazole topical lotion 0.75 % (Metrolotion)
mupirocin calcium topical cream 2
(Bactroban)
%
mupirocin topical ointment 2 %
neomycin-polymyxin b gu irrigation (Neosporin G.U.
solution 40 mg-200,000 unit/ml
Irrigant)
(Neomycin
neosporin ointment 3.5mg-400 unitSu/Bacitrac
5,000 unit/gram *
Zn/Poly)
rosadan topical cream 0.75 %
(Metrocream)
selenium sulfide topical lotion 2.5 % (Selenium Sulfide)
selenium sulfide topical shampoo
(Selenium Sulfide)
2.25 %
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
4
$0
1
1
$0
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
125
Tier level
What the
drug will
cost you
(Silver Nitrate)
1
$0
(Silver Nitrate)
1
$0
(Silvadene)
1
$0
(Silvadene)
1
$0
(Klaron)
1
$0
(Neomycin
Su/Bacitrac
Zn/Poly)
4
$0
(Anusol-HC)
(Scalacort)
(Alclometasone
Dipropionate)
(Alclometasone
Dipropionate)
(Cortizone-10)
(Cortizone-10)
(Betamethasone
Dipropionate)
(Betamethasone
Dipropionate)
(Betamethasone
Dipropionate)
(Betamethasone
Valerate)
1
1
$0
$0
1
$0
1
$0
4
4
$0
$0
1
$0
1
$0
1
$0
1
$0
(Luxiq)
1
$0
1
$0
1
$0
1
$0
Name of Drug
silver nitrate topical ointment 10 %
silver nitrate topical solution 0.5 %,
10 %, 25 %, 50 %
silver sulfadiazine topical cream 1
%
ssd topical cream 1 %
sulfacetamide sodium (acne) topical
suspension 10 %
triple antibiotic ointment carton
3.5mg-400 unit- 5,000 unit/gram *
Dermatological AntiInflammatory Agents
ala-cort topical cream 1 %
ala-scalp topical lotion 2 %
alclometasone topical cream 0.05 %
alclometasone topical ointment 0.05
%
aquanil hc 1% lotion 1 % *
beta hc 1% lotion 1 % *
betamethasone dipropionate topical
cream 0.05 %
lotion 0.05 %
ointment 0.05 %
betamethasone valerate topical
cream 0.1 %
foam 0.12 %
lotion 0.1 %
ointment 0.1 %
betamethasone, augmented topical
cream 0.05 %
(Betamethasone
Valerate)
(Betamethasone
Valerate)
(Diprolene AF)
Necessary Actions,
Restrictions, or
Limits on Use
126
Tier level
What the
drug will
cost you
(Betamethasone
Dipropionate)
1
$0
(Diprolene)
1
$0
(Diprolene)
1
$0
(Temovate)
(Clobetasol
Propionate)
(Olux)
(Clobetasol
Propionate)
(Clobex)
(Temovate)
(Clobex)
1
$0
1
$0
1
$0
1
$0
1
1
1
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
4
$0
4
$0
4
4
1
1
$0
$0
$0
$0
1
$0
1
$0
1
$0
2
$0
Name of Drug
gel 0.05 %
lotion 0.05 %
ointment 0.05 %
clobetasol 0.05% cream 0.05 %
clobetasol scalp solution 0.05 %
clobetasol topical foam 0.05 %
clobetasol topical gel 0.05 %
clobetasol topical lotion 0.05 %
clobetasol topical ointment 0.05 %
clobetasol topical shampoo 0.05 %
clobetasol-emollient topical cream
(Temovate)
0.05 %
clocortolone pivalate topical cream
(Cloderm)
0.1 %
colocort rectal enema 100 mg/60 ml (Cortenema)
(Clobetasol
cormax scalp solution 0.05 %
Propionate)
cortizone-10 1% creme maximum
(Hydrocortisone)
strength 1 % *
CORTIZONE-10 1% LOTION 1 %
*
cortizone-10 1% ointment 1 % *
(Hydrocortisone)
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
(Topicort)
0.05 %, 0.25 %
ELIDEL TOPICAL CREAM 1 %
Necessary Actions,
Restrictions, or
Limits on Use
127
Tier level
What the
drug will
cost you
(Vanos)
(Fluocinonide)
1
1
$0
$0
(Fluocinonide)
1
$0
1
1
1
$0
$0
$0
1
$0
1
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
fluocinonide 0.05% cream 0.05 %
fluocinonide topical gel 0.05 %
fluocinonide topical ointment 0.05
%
fluocinonide topical solution 0.05 %
fluocinonide-e topical cream 0.05 %
fluticasone topical cream 0.05 %
(Fluocinonide)
(Vanos)
(Cutivate)
(Fluticasone
fluticasone topical ointment 0.005 %
Propionate)
halobetasol propionate topical
(Ultravate)
cream 0.05 %
halobetasol propionate topical
(Ultravate)
ointment 0.05 %
hydro skin 1% lotion 1 % *
(Cortizone-10)
hydrocortisone 0.5% cream (otc)
(Hydrocortisone)
0.5 % *
hydrocortisone 0.5% ointment 0.5 %
(Hydrocortisone)
*
hydrocortisone 1% cream maximum
(Hydrocortisone)
strength (otc) 1 % *
hydrocortisone 1% cream maximum (Hydrocortisone
strength 1 % *
Acetate)
hydrocortisone 1% lotion (otc) 1 %
(Cortizone-10)
*
hydrocortisone 1% ointment carton
(Hydrocortisone)
(otc) 1 % *
hydrocortisone acet-aloe vera
(Hydrocortisone
topical gel 2 %
Acetate/Aloe V)
hydrocortisone buty 0.1% cream 0.1 (Hydrocortisone
%
Butyrate)
hydrocortisone butyrate topical
(Locoid)
ointment 0.1 %
hydrocortisone butyrate topical
(Locoid)
solution 0.1 %
hydrocortisone butyr-emollient
(Hydrocortisone
topical cream 0.1 %
Butyrate)
Necessary Actions,
Restrictions, or
Limits on Use
128
Tier level
What the
drug will
cost you
(Cortenema)
1
$0
(Anusol-HC)
1
$0
(Scalacort)
1
$0
(Hydrocortisone)
1
$0
(Hydrocortisone
Valerate)
1
$0
(Westcort)
1
$0
(Elocon)
(Elocon)
(Elocon)
(Hydrocortisone)
1
1
1
4
$0
$0
$0
$0
2
$0
(Dermatop)
1
$0
(Dermatop)
1
$0
(Hydrocortisone)
(Hydrocortisone)
(Anusol-HC)
(Hydrocortisone)
(Hydrocortisone)
(Hydrocortisone)
4
1
1
1
1
4
$0
$0
$0
$0
$0
$0
(Protopic)
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
hydrocortisone rectal enema 100
mg/60 ml
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 % *
ONFI ORAL TABLET 10 MG, 20
MG
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 %
lotion 0.025 %, 0.1 %
ointment 0.025 %, 0.1 %, 0.5 %
trianex topical ointment 0.05 %
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (60 per
30 days)
129
Tier level
What the
drug will
cost you
(Hydrocortisone
Acetate/Urea)
1
$0
(Differin)
(Differin)
1
1
$0
$0
2
$0
(Retin-A Micro)
1
$0
(Retin-A Micro)
1
$0
(Retin-A Micro)
1
$0
(Retin-A)
1
$0
(Retin-A)
1
$0
4
$0
4
1
$0
$0
4
$0
(Elimite)
1
$0
(Nix)
4
$0
(Nix)
4
$0
(Nix)
4
$0
1
$0
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
cvs lice killing shampoo maximum
strength 0.33-4 % *
cvs permethrin 1% lotion 1 % *
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 % *
sm lice treatment permethrin 2's 1
%*
v-r lice cream rinse 1 % *
(Piperonyl
Butoxide/Pyrethrin
s)
(Nix)
(Ovide)
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
PA
PA
PA
Devices
Devices
ASSURE ID INSULIN SAFETY
SYRINGE 1 ML 29 GAUGE X 1/2"
130
Name of Drug
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 ULTRA-FINE PEN NDL
8MMX31G SHORT 31 GAUGE X
5/16"
INSULIN SYRINGE-NEEDLE U100 SYRINGE 0.3 ML 29, 1 ML 29
GAUGE X 1/2", 1/2 ML 28
GAUGE
PEN NEEDLE, DIABETIC
NEEDLE 29 GAUGE X 1/2"
VGO 40 DISPOSABLE DEVICE
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
4
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
Disinfectants (For NonDermatologic Use)
Disinfectants (For NonDermatologic Use)
sm iodine tincture *
(Iodine)
Enzyme
Replacement/Modifiers
Enzyme
Replacement/Modifiers
ADAGEN INTRAMUSCULAR
ALDURAZYME INTRAVENOUS
SOLUTION 2.9 MG/5 ML
CEREZYME INTRAVENOUS
RECON SOLN 400 UNIT
131
Name of Drug
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
MYOZYME INTRAVENOUS
RECON SOLN 50 MG
NAGLAZYME INTRAVENOUS
SOLUTION 5 MG/5 ML
ORFADIN ORAL CAPSULE 10
MG, 2 MG, 5 MG
pancrelipase 5000 oral
(Lipase/Protease/A
capsule,delayed release(dr/ec)
mylase)
5,000-17,000 -27,000 unit
PULMOZYME INHALATION
SOLUTION 1 MG/ML
STRENSIQ SUBCUTANEOUS
MG/ML
VIMIZIM INTRAVENOUS
MG/ML)
VPRIV INTRAVENOUS RECON
SOLN 400 UNIT
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA BvD
PA; LA
PA
2
$0
2
$0
132
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
(Proparacaine HCl)
(Tetravisc)
(Little Remedies)
1
1
4
$0
$0
$0
(Iopidine)
1
$0
4
$0
4
$0
(Tears Naturale)
4
$0
(Genteal Pm)
4
$0
(Isopto Atropine)
(Atropine Sulfate)
(Isopto Atropine)
1
1
1
$0
$0
$0
(Sodium Chloride)
4
$0
Name of Drug
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, 25,000-85,000136,000 UNIT, 3,000-10,00016,000 UNIT, 40,000-136,000218,000 UNIT, 5,000-17,000 27,000 UNIT
Necessary Actions,
Restrictions, or
Limits on Use
QL (90 per 30 days)
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat
Agents, Miscellaneous
AKTEN (PF) OPHTHALMIC GEL
3.5 %
alcaine ophthalmic drops 0.5 %
altacaine ophthalmic drops 0.5 %
altamist 0.65% nose spray 0.65 % *
apraclonidine ophthalmic drops 0.5
%
artificial tears 1.4 % drops 1.4 % *
artificial tears drops p/f, sterile 0.10.3 % *
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 %
*
(Polyvinyl
Alcohol)
(Dextran
70/Hypromellose/P
F)
133
Name of Drug
ayr saline 0.65% nose spray 0.65 %
(Little Remedies)
*
azelastine nasal aerosol,spray 137
(Astepro)
mcg (0.1 %)
azelastine ophthalmic drops 0.05 % (Azelastine HCl)
(Dextran
bion tears eye drops 0.1-0.3 % *
70/Hypromellose/P
F)
carteolol ophthalmic drops 1 %
(Carteolol HCl)
(Cromolyn
cromolyn ophthalmic drops 4 %
Sodium)
cvs artificial tears drops sterile 1(Glycerin/Propylen
0.3 % *
e Glycol)
cvs lubricant 0.5% eye drops sterile
(Refresh Tears)
0.5 % *
(Carboxymethylcel
cvs lubricant dry eye rlf 1% 1 % *
lulose Sodium)
cvs lubricant eye ointment p/f 57.3(Genteal Pm)
42.5 % *
cvs lubricant gel eye drops 0.25-0.3 (Carboxymethylcel
%*
l/Hypromellose)
cvs lubricating eye drops dry eye
(Refresh Optive)
soln 0.5-0.9 % *
(Dextran
cvs natural tears drops 0.1-0.3 % * 70/Hypromellose/P
F)
cyclopentolate ophthalmic drops 0.5
(Cyclogyl)
%, 1 %, 2 %
CYSTARAN OPHTHALMIC
DROPS 0.44 %
deep sea 0.65% nose spray 0.65 % * (Little Remedies)
(Oxymetazoline
dristan long lasting mist 0.05 % *
HCl)
epinastine ophthalmic drops 0.05 % (Elestat)
(Genteal Mild To
eq gentle 0.3% eye drops 0.3 % *
Moderate)
Tier level
What the
drug will
cost you
4
$0
1
$0
1
$0
4
$0
1
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
2
$0
4
$0
4
$0
1
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 25 days)
134
Tier level
What the
drug will
cost you
4
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
1
$0
(Atrovent)
1
$0
(Atrovent)
1
$0
(Genteal Mild To
Moderate)
4
$0
2
$0
(Carboxymethylcel
l/Glycerin/PF)
4
$0
(Refresh Optive)
4
$0
(Propylene Glycol)
4
$0
(Genteal Pm)
4
$0
(Sodium Chloride)
(Sodium Chloride)
(Sodium Chloride)
4
4
4
$0
$0
$0
Name of Drug
eq revive plus 0.5% eye drops 0.5 %
*
flucaine ophthalmic drops 0.25-0.5
%
GENTEAL GEL DROPS 0.25-0.3
%*
GENTEAL MILD 0.2% EYE
DROPS 0.2 % *
GENTEAL MILD-MODERATE
EYE DROP P/F, DRY EYE
RELIEF 0.3 % *
GENTEAL SEVERE 0.3% EYE
GEL P/F, STRL, INNER 0.3 % *
genteal tears 0.1%-0.3% drop 0.10.3 % *
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 %
isopto tears 0.5% eye drops 0.5 % *
LACRISERT OPHTHALMIC
INSERT 5 MG
lubricant 0.5-0.9% eye drops 0.50.9 % *
lubricant 0.5-0.9% eye drops 0.50.9 % *
lubricant 0.6% eye drops 0.6 % *
lubrifresh pm eye ointment 83-15 %
*
muro-128 2% eye drops 2 % *
muro-128 5% eye drops 5 % *
muro-128 5% eye ointment 5 % *
(Carboxymethylcel
lulose Sodium)
(Proparacaine/Fluo
rescein Sod)
(Tears Naturale)
(Isopto
Homatropine)
(Isopto
Homatropine)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 28 days)
QL (15 per 10 days)
135
Name of Drug
naphazoline ophthalmic drops 0.1 % (Naphazoline HCl)
nasal decongestant 0.05% spray
(Afrin)
0.05 % *
(Genteal Mild To
natural balance tears drops 0.4 % *
Moderate)
(Genteal Mild To
nature's tears drops 0.4 % *
Moderate)
neo-synephrine 12 hour spray 0.05 (Oxymetazoline
%*
HCl)
ocean 0.65% nasal spray 0.65 % * (Little Remedies)
olopatadine ophthalmic drops 0.1 % (Patanol)
PATADAY OPHTHALMIC
DROPS 0.2 %
phenylephrine hcl ophthalmic drops
(Mydfrin)
10 %, 2.5 %
proparacaine ophthalmic drops 0.5
(Proparacaine HCl)
%
pure & gentle eye drops lubricant
(Genteal Mild To
0.3 % *
Moderate)
(Genteal Mild To
pv artificial tears 0.4 % *
Moderate)
pv lubricant 1.4 % eye drops 1.4 % (Polyvinyl
*
Alcohol)
pv pure-gentle eye drops sterile 0.3 (Genteal Mild To
%*
Moderate)
REFRESH CELLUVISC 1% EYE
DROPS 1 % *
REFRESH CLASSIC EYE DROPS
U-D,P/F,30X.4ML 1.4-0.6 % *
REFRESH LACRI-LUBE
OINTMENT 56.8-42.5 % *
REFRESH OPTIVE EYE DROPS
0.5-0.9 % *
(Carboxymethylcel
retaine cmc 0.5% eye drops 0.5 % *
lulose Sodium)
saline mist 0.65% nose spry 0.65 %
(Little Remedies)
*
Tier level
What the
drug will
cost you
1
$0
4
$0
4
$0
4
$0
4
$0
4
1
$0
$0
2
$0
1
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST
136
Tier level
What the
drug will
cost you
(Little Remedies)
4
$0
(Systane)
4
$0
(Sodium Chloride)
(Sodium Chloride)
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
4
$0
4
$0
4
$0
1
$0
1
$0
1
$0
1
$0
2
$0
1
$0
1
$0
Name of Drug
sea soft 0.65% nasal mist 0.65 % *
sm lubricant eye drops strl 0.4-0.3
%*
sodium chloride 5% eye drop 5 % *
sodium chloride 5% eye oint 5 % *
SYSTANE 0.3-0.4% EYE DROPS
0.4-0.3 % *
SYSTANE GEL EYE DROPS 0.40.3 % *
(Polyvinyl
Alcohol)
tears again eye ointment 80-20 % * (Genteal Pm)
(Dextran
tears naturale free drops u70/Hypromellose/P
d,36x.9ml,p/f 0.1-0.3 % *
F)
tetracaine hcl (pf) ophthalmic drops (Tetracaine
0.5 %
HCl/PF)
(Lanolin/Mineral
ultra fresh pm ointment *
Oil/Petrolatum)
(Oxymetazoline
vicks qlearquil 0.05% mist 0.05 % *
HCl)
vicks sinex 12 hour spray 0.05 % * (Afrin)
Anti-Infectives Agents
acetic acid otic solution 2 %
(Acetic Acid)
bacitracin ophthalmic ointment 500
(Bacitracin)
unit/gram
bacitracin-polymyxin b ophthalmic (Bacitracin/Polymy
ointment 500-10,000 unit/gram
xin B Sulfate)
(Sulfacetamide
bleph-10 ophthalmic drops 10 %
Sodium)
CIPRODEX OTIC
DROPS,SUSPENSION 0.3-0.1 %
ciprofloxacin hcl ophthalmic drops
(Ciloxan)
0.3 %
ciprofloxacin hcl otic dropperette
(Cetraxal)
0.2 %
tears again 1.4 % drops 1.4 % *
Necessary Actions,
Restrictions, or
Limits on Use
137
Tier level
What the
drug will
cost you
2
$0
(Ilotycin)
1
$0
(Zymaxid)
1
$0
(Garamycin)
1
$0
(Garamycin)
1
$0
(Garamycin)
1
$0
(Levofloxacin)
1
$0
2
$0
2
$0
(Neomycin Su/Baci
Zn/Poly/HC)
1
$0
(Neomycin
Su/Bacitra/Polymy
xin)
1
$0
(Maxitrol)
1
$0
(Maxitrol)
1
$0
(Neosporin)
1
$0
(Neomycin/Polymy
xin B Sulf/HC)
1
$0
(Neomycin/Polymy
xin B Sulf/HC)
1
$0
Name of Drug
COLY-MYCIN S OTIC
DROPS,SUSPENSION 3.3-3-100.5 MG/ML
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 %
NATACYN OPHTHALMIC
DROPS,SUSPENSION 5 %
neomycin-bacitracin-poly-hc
ophthalmic ointment 3.5-400-10,000
mg-unit/g-1%
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 %
neomycin-polymyxin b-dexameth
ophthalmic ointment 3.5 mg/g10,000 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 mgunit-mg/ml
neomycin-polymyxin-hc otic
drops,suspension 3.5-10,000-1
mg/ml-unit/ml-%
Necessary Actions,
Restrictions, or
Limits on Use
138
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
1
$0
$0
1
$0
4
$0
1
$0
1
$0
1
$0
2
$0
2
$0
(Tobrex)
1
$0
(Tobradex)
1
$0
(Viroptic)
1
$0
2
$0
2
$0
2
$0
Name of Drug
neomycin-polymyxin-hc otic
solution 3.5-10,000-1 mg/mlunit/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
ofloxacin ophthalmic drops 0.3 %
ofloxacin otic drops 0.3 %
polymyxin b sulf-trimethoprim
ophthalmic drops 10,000 unit- 1
mg/ml
REFRESH OPTIVE ADVANCED
DROPS 0.5-1-0.5 % *
sulfacetamide sodium ophthalmic
drops 10 %
sulfacetamide sodium ophthalmic
ointment 10 %
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
(Cortisporin)
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin
Su/Bacitra/Polymy
xin)
(Ocuflox)
(Ocuflox)
(Polytrim)
(Sulfacetamide
Sodium)
(Sulfacetamide
Sodium)
(Sulfacetamide/Pre
dnisolone Sp)
Necessary Actions,
Restrictions, or
Limits on Use
139
Tier level
What the
drug will
cost you
2
$0
(Bromfenac
Sodium)
1
$0
(Dexasol)
1
$0
(Diclofenac
Sodium)
1
$0
2
$0
(Flunisolide)
1
$0
(FML)
1
$0
(Ocufen)
1
$0
(Fluticasone
Propionate)
1
$0
2
$0
1
$0
2
$0
2
$0
2
$0
2
$0
(Omnipred)
1
$0
(Prednisolone Sod
Phosphate)
1
$0
Name of Drug
Anti-Inflammatory Agents
ALREX OPHTHALMIC
DROPS,SUSPENSION 0.2 %
bromfenac ophthalmic drops 0.09 %
dexamethasone sodium phosphate
ophthalmic drops 0.1 %
diclofenac sodium ophthalmic drops
0.1 %
DUREZOL OPHTHALMIC
DROPS 0.05 %
flunisolide nasal spray,non-aerosol
25 mcg (0.025 %)
fluorometholone ophthalmic
drops,suspension 0.1 %
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 %
NEVANAC OPHTHALMIC
prednisolone acetate ophthalmic
drops,suspension 1 %
prednisolone sodium phosphate
ophthalmic drops 1 %
(Acular)
Necessary Actions,
Restrictions, or
Limits on Use
ST
QL (50 per 25 days)
140
Tier level
What the
drug will
cost you
2
$0
2
$0
(Simethicone)
4
$0
(Gas-X)
4
$0
(Phazyme)
4
$0
(Gas-X)
4
$0
(Gas-X)
4
$0
(Gas-X)
4
$0
(Phazyme)
4
$0
(Gas-X)
4
$0
(Gas-X)
4
$0
(Gas-X)
4
$0
(Phazyme)
4
$0
(Simethicone)
4
$0
(Phazyme)
4
$0
(Pepcid Ac)
4
$0
(Prevpac)
1
$0
Name of Drug
PROLENSA OPHTHALMIC
DROPS 0.07 %
RESTASIS OPHTHALMIC
DROPPERETTE 0.05 %
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
Gastrointestinal Agents
Antiflatulents
bicarsim forte 125 mg tablet 125 mg
*
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 lactosefree 80 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
141
Tier level
What the
drug will
cost you
2
$0
(Cimetidine HCl)
1
$0
(Cimetidine)
1
$0
(Tagamet Hb)
4
$0
(Nexium I.V.)
1
$0
(Famotidine)
1
$0
(Famotidine In
Nacl,Iso-Osm/PF)
1
$0
(Famotidine)
1
$0
(Pepcid)
1
$0
(Pepcid Ac)
4
$0
(Prevacid 24hr)
4
$0
(Prevacid)
1
$0
(Cytotec)
1
$0
(Omeprazole)
(Omeprazole
Magnesium)
4
$0
4
$0
(Prilosec)
1
$0
(Zegerid)
1
$0
(Protonix)
1
$0
4
$0
Name of Drug
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
famotidine (pf) intravenous solution
20 mg/2 ml
famotidine (pf)-nacl (iso-os)
intravenous piggyback 20 mg/50 ml
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
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
omeprazole-sodium bicarbonate
oral capsule 20-1.1 mg-gram
pantoprazole oral tablet,delayed
release (dr/ec) 20 mg, 40 mg
PRILOSEC OTC 20.6 MG
TABLET OTC 20 MG *
Necessary Actions,
Restrictions, or
Limits on Use
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
142
Tier level
What the
drug will
cost you
(Pepcid Ac)
4
$0
(Tagamet Hb)
4
$0
(Zegerid Otc)
4
$0
(Zantac)
4
$0
(Zantac)
4
$0
(Zantac)
1
$0
(Zantac)
1
$0
(Ranitidine HCl)
1
$0
(Ranitidine HCl)
1
$0
(Zantac)
1
$0
(Sucralfate)
1
$0
(Carafate)
(Zantac)
1
4
$0
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
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 mggram *
ranitidine 150 mg tablet maximum
strength (otc) 150 mg *
ranitidine 75 mg tablet s/f, sodiumfree 75 mg *
ranitidine hcl 50 mg/2 ml vial sdv 50
mg/2 ml (25 mg/ml)
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 *
ZANTAC 150 MG TABLET TWIN
PACK(2X45TABS) (OTC) 150 MG
*
ZANTAC 150 MG TABLET TWIN
PK, MAX STRGTH (OTC) 150
MG *
ZANTAC 75 MG TABLET 75 MG
*
Gastrointestinal Agents,
Other
acid gone antacid liquid 95-358
mg/15 ml *
(Gaviscon)
Necessary Actions,
Restrictions, or
Limits on Use
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
143
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
2
$0
(Maalox Maximum
Strength)
4
$0
(Tums)
4
$0
(Tums)
4
$0
(Maalox Maximum
Strength)
4
$0
(Imodium A-D)
4
$0
(Pepto-Bismol)
4
$0
2
$0
(Tums)
4
$0
(Tums)
4
$0
(Tums)
4
$0
4
$0
4
$0
2
$0
Name of Drug
almacone liquid 200-200-20 mg/5
ml *
almacone-2 liquid 400-400-40 mg/5
ml *
aluminum hydroxide gel sugar-free
320 mg/5 ml *
AMITIZA ORAL CAPSULE 24
MCG, 8 MCG
antacid plus x-stren susp 500-45040 mg/5 ml *
antacid ultra tablet chew 400 mg
(1,000 mg) *
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 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) *
CALCIUM-500 MG TABLET
CHEWABLE SOY FREE, YEAST
FREE 500-100 MG-UNIT *
cal-gest 500 mg tablet chew 200 mg
calcium (500 mg) *
CARBAGLU ORAL TABLET,
DISPERSIBLE 200 MG
(Maalox Maximum
Strength)
(Maalox Maximum
Strength)
(Aluminum
Hydroxide)
(Tums)
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
144
Tier level
What the
drug will
cost you
(Tums)
4
$0
(Tums)
4
$0
4
$0
4
$0
(Lactulose)
1
$0
(Gastrocrom)
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
4
$0
4
$0
Name of Drug
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
(Maalox Maximum
Strength)
(Maalox Maximum
Strength)
(Calcium
cvs antacid-antigas tab chew 1,000Carbonate/Simethi
60 mg *
cone)
cvs anti-diarrheal 2 mg sftgel softgel
(Loperamide HCl)
2 mg *
cvs anti-diarrheal suspension 262
(Pepto-Bismol)
mg/15 ml *
cvs loperamide 1 mg/7.5 ml liq mint
(Loperamide HCl)
1 mg/7.5 ml *
diamode 2 mg tablet outer, f/c 2 mg
(Imodium A-D)
*
dicyclomine oral capsule 10 mg
(Bentyl)
dicyclomine oral solution 10 mg/5
(Dicyclomine HCl)
ml
dicyclomine oral tablet 20 mg
(Bentyl)
diphenoxylate-atropine oral liquid
(Diphenoxylate
2.5-0.025 mg/5 ml
HCl/Atropine)
diphenoxylate-atropine oral tablet
(Lomotil)
2.5-0.025 mg
enulose oral solution 10 gram/15 ml (Lactulose)
flanax antacid liquid 200-200-20
(Maalox Maximum
mg/5 ml *
Strength)
foaming antacid liquid 95-358
(Gaviscon)
mg/15 ml *
Necessary Actions,
Restrictions, or
Limits on Use
145
Tier level
What the
drug will
cost you
2
$0
2
$0
(Maalox Maximum
Strength)
4
$0
(Almacone)
4
$0
(Lactulose)
1
$0
(Robinul)
1
$0
(Robinul)
1
$0
(Loperamide HCl)
4
$0
4
$0
4
$0
1
$0
1
$0
1
$0
2
$0
(Loperamide HCl)
4
$0
(Loperamide HCl)
1
$0
2
$0
Name of Drug
GATTEX 5 MG 30-VIAL KIT 5
MG
GATTEX ONE-VIAL
SUBCUTANEOUS KIT 5 MG
gelusil antacid & antigas liq 400400-40 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
glycopyrrolate oral tablet 1 mg, 2
mg
imodium a-d 1 mg/7.5 ml liquid mint
1 mg/7.5 ml *
IMODIUM A-D 2 MG CAPLET
CAPLET 2 MG *
kaopectate 262 mg/15 ml susp
vanilla flavor 262 mg/15 ml *
kionex 15 gm/60 ml suspension 15
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
(Pepto-Bismol)
(Sodium
Polystyrene
Sulfonate)
(Sodium
Polystyrene
Sulfonate)
(Lactulose)
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
QL (30 per 30 days)
146
Tier level
What the
drug will
cost you
4
$0
4
$0
(Uromag)
4
$0
(Magox 400)
4
$0
(Magox 400)
4
$0
(Magox 400)
4
$0
4
$0
4
$0
1
$0
1
$0
1
$0
(Reglan)
1
$0
(Magox 400)
(Maalox Maximum
Strength)
(Rolaids)
4
$0
4
$0
4
$0
(Maalox Maximum
Strength)
4
$0
(Almacone)
4
$0
(Maalox Maximum
Strength)
4
$0
Name of Drug
maalox advanced suspension
regular strength 200-200-20 mg/5
ml *
MAGNEBIND 300 TABLET 250300 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 *
magnesium oxide 500 mg tablet
p/f,s/f,lactose-free 500 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
mgo 400 mg tablet 400 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 200200-25 mg *
mintox suspension mint creme 200200-20 mg/5 ml *
(Maalox Maximum
Strength)
(Maalox Maximum
Strength)
(Pepto-Bismol ToGo)
(Methscopolamine
Bromide)
(Metoclopramide
HCl)
(Metoclopramide
HCl)
Necessary Actions,
Restrictions, or
Limits on Use
147
Name of Drug
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)
(Pepto-Bismol Topink bismuth tablet chew 262 mg *
Go)
ra loperamide 1 mg/7.5 ml susp mint
(Loperamide HCl)
1 mg/7.5 ml *
ra magnesium 500 mg capsule 500
(Uromag)
mg *
RAVICTI ORAL LIQUID 1.1
GRAM/ML
RELISTOR SUBCUTANEOUS
RELISTOR SUBCUTANEOUS
SYRINGE 12 MG/0.6 ML, 8
MG/0.4 ML
ri-gel ii suspension 400-400-40
(Maalox Maximum
mg/5 ml *
Strength)
ri-mox suspension 200-200-20 mg/5 (Maalox Maximum
ml *
Strength)
sm foaming antacid tablet chew 80(Gaviscon)
20 mg *
(Bismuth
sm stomach relief caplet 262 mg *
Subsalicylate)
sodium bicarb 650 mg tablet 10 gr
(Sodium
650 mg *
Bicarbonate)
(Sodium
sodium polystyrene (sorb free) oral
Polystyrene
suspension 15 gram/60 ml
Sulfonate)
(Sodium
sodium polystyrene sulfonate rectal
Polystyrene
enema 30 gram/120 ml
Sulfonate)
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
4
$0
4
$0
4
$0
4
$0
2
$0
2
$0
2
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
PA; QL (30 per 30
days)
PA
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
148
Name of Drug
soothe 262 mg caplet caplet 262 mg (Bismuth
*
Subsalicylate)
soothe 262 mg/15 ml suspension
(Pepto-Bismol)
s/f,cherry 262 mg/15 ml *
(Sodium
sps 15 gm/60 ml suspension 15
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 XLONG 9'S,X-LONG *
COLACE 100 MG CAPSULE 100
MG *
cvs enema disposable 19-7
(Enema)
gram/118 ml *
cvs fiber therapy 500 mg caplt
(Citrucel)
soluble, caplet 500 mg *
cvs kids 100 mg mini enema 100
(Docusate Sodium)
mg/5 ml *
cvs purelax powder 14 once-daily
(Gavilax)
doses 17 gram/dose *
cvs purelax powder packet s/f, 10
(Miralax)
daily doses 17 gram *
cvs senna laxative 8.6 mg tab 8.6 mg
(Senokot)
*
cvs stool softener softgel softgel 240
(Surfak)
mg *
Tier level
What the
drug will
cost you
4
$0
4
$0
1
$0
1
1
$0
$0
2
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (60 per 30
days)
149
Tier level
What the
drug will
cost you
(Colace)
4
$0
(Docusate Sodium)
4
$0
(Docusate Sodium)
4
$0
4
$0
4
4
4
4
$0
$0
$0
$0
(Enema)
4
$0
(Enema)
4
$0
(Docusate Sodium)
4
$0
(Docusol Plus)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
1
$0
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-senna tablet 8.6-50
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 28320 mg/5 ml *
(Sennosides/Docus
ate Sodium)
(Docusate Sodium)
(Colace)
(Docusate Sodium)
(Colace)
(Psyllium Seed
(With Sugar))
equalactin 500 mg tab chew 500 mg (Calcium
*
Polycarbophil)
fiber tablet unboxed 625 mg *
(Fibercon)
fiber therapy (psyllium) oral powder
(Psyllium Seed)
*
fiber therapy powder 2 gram/19
(Citrucel)
gram *
fiber-lax captabs 500mg
(Fibercon)
polycarbophil 625 mg *
fibertab oral tablet 625 mg *
(Fibercon)
FLEET BISACODYL 10 MG
ENEMA 10 MG/30 ML *
gavilyte-c oral recon soln 240(Golytely)
22.72-6.72 -5.84 gram
gavilyte-g oral recon soln 236(Golytely)
22.74-6.74 -5.86 gram
eq fiber therapy powder *
Necessary Actions,
Restrictions, or
Limits on Use
150
Tier level
What the
drug will
cost you
(Nulytely with
Flavor Packs)
1
$0
(Gavilax)
4
$0
(Gavilax)
3
$0
(Miralax)
4
$0
(Psyllium Seed)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
2
$0
4
$0
4
$0
1
$0
1
$0
4
$0
4
$0
4
$0
1
$0
Name of Drug
gavilyte-n oral recon soln 420 gram
gentlelax powder 30 once-daily
glycolax powder 7 doses (otc) 17
gram/dose *
healthylax powder packet 14x17gm,
outer 17 gram *
hydrocil instant packet *
KONSYL 6 GM PACKET S/F,
GLUTEN-F, OUTER 6 GRAM *
konsyl fiber 625 mg caplet caplet, s/f
625 mg *
konsyl psyllium fiber packet orange,
gluten free 3.4 gram *
magic bullet 10 mg suppos 10 mg *
milk of magnesia suspension 400
mg/5 ml *
mineral oil laxative *
MOVIPREP ORAL POWDER IN
PACKET 100-7.5-2.691 GRAM
(Fibercon)
(Psyllium Husk
(With Sugar))
(Dulcolax)
(Milk Of
Magnesia)
(Mineral Oil)
(Psyllium Seed
(With Sugar))
oral saline laxative liquid s/f, ginger (Na Phos,M-B/Na
lemon 7.2-2.7 gram/15 ml *
Phos,Di-Ba)
peg 3350-electrolytes oral recon
soln 236-22.74-6.74 -5.86 gram,
(Golytely)
240-22.72-6.72 -5.84 gram
peg-electrolyte soln oral recon soln (Nulytely with
420 gram
Flavor Packs)
(Sennosides/Docus
peri-colace tablet 8.6-50 mg *
ate Sodium)
phillips' lax liqui-gels 100 mg *
(Colace)
phosphate oral saline laxative s/f,
(Na Phos,M-B/Na
ginger lemon 7.2-2.7 gram/15 ml * Phos,Di-Ba)
polyethylene glycol 3350 oral
(Polyethylene
powder 17 gram/dose
Glycol 3350)
natural fiber lax powder *
Necessary Actions,
Restrictions, or
Limits on Use
151
Tier level
What the
drug will
cost you
(Polyethylene
Glycol 3350)
1
$0
(Gavilax)
4
$0
(Miralax)
4
$0
(Miralax)
4
$0
(Docusate Sodium)
(Sennosides)
4
4
$0
$0
(Enema)
4
$0
(Gavilax)
4
$0
(Psyllium Seed
(With Sugar))
4
$0
(Sennosides)
4
$0
(Senokot)
4
$0
(Sennosides)
4
$0
(Senokot)
(Sennosides/Docus
ate Sodium)
4
$0
4
$0
(Docusate Sodium)
4
$0
(Docusate Sodium)
4
$0
(Gavilax)
4
$0
(Citrucel)
4
$0
(Psyllium Seed)
4
$0
(Miralax)
4
$0
Name of Drug
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
outer,s/f (otc) 17 gram *
promolaxin 100 mg tablet 100 mg *
pv senna 8.6 mg softgel 8.6 mg *
ra enema twin pack 2 x 4.5oz, rtu
19-7 gram/118 ml *
ra laxative peg 3350 powder 14
once-daily doses 17 gram/dose *
reguloid powder orange *
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 *
senokot-s tablet 8.6-50 mg *
silace 50 mg/5 ml liquid 50 mg/5 ml
*
silace 60 mg/15 ml syrup 60 mg/15
ml *
sm clearlax powder 14 once-daily
sm fiber laxative 500 mg cplt 500
mg *
sm fiber smooth powder *
smoothlax powder packet 10 oncedaily doses 17 gram *
Necessary Actions,
Restrictions, or
Limits on Use
152
Name of Drug
trilyte with flavor packets oral recon
soln 420 gram
Phosphate Binders
calcium acetate oral capsule 667 mg
calcium acetate oral tablet 667 mg
calphron 667 mg tablet 667 mg *
eliphos oral tablet 667 mg
(Nulytely with
Flavor Packs)
(Phoslo)
(Calcium Acetate)
(Calcium Acetate)
(Calcium Acetate)
(Calcium
magnebind 400 oral tablet 400-200Carbonate/Mag
1 mg
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
Tier level
What the
drug will
cost you
1
$0
1
1
4
1
$0
$0
$0
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
Genitourinary Agents
Antispasmodics, Urinary
MYRBETRIQ ORAL TABLET
MG, 50 MG
oxybutynin chloride oral syrup 5
mg/5 ml
(Oxybutynin
Chloride)
(Oxybutynin
oxybutynin chloride oral tablet 5 mg
Chloride)
oxybutynin chloride oral tablet
extended release 24hr 10 mg, 15
(Ditropan XL)
mg, 5 mg
tolterodine oral capsule,extended
(Detrol LA)
tolterodine oral tablet 1 mg, 2 mg
(Detrol)
TOVIAZ ORAL TABLET
MG, 8 MG
153
Tier level
What the
drug will
cost you
1
$0
1
$0
(Uroxatral)
1
$0
(Flomax)
1
$0
(Terazosin HCl)
1
$0
(Desferal)
1
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
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)
(Trospium
Chloride)
Necessary Actions,
Restrictions, or
Limits on Use
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine injection recon soln 2
gram, 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 gram/10 ml (100 mg/ml),
12.5 gram/50 ml (250 mg/ml)
SYPRINE ORAL CAPSULE 250
MG
(Sodium
Thiosulfate)
PA BvD
Hormonal Agents,
Stimulant/Replacement/Modif
ying
Androgens
ANDRODERM TRANSDERMAL
PATCH 24 HOUR 2 MG/24
HOUR, 4 MG/24 HR
2
$0
PA; QL (30 per 30
days)
154
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 %)
packet 1 % (25 mg/2.5gram)
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
Tier level
What the
drug will
cost you
2
$0
2
$0
(Fluoxymesterone)
1
$0
(Danazol)
1
$0
(Oxandrin)
1
$0
(DepoTestosterone)
1
$0
(Testosterone
Enanthate)
1
$0
(Testim)
1
$0
(Vogelxo)
1
$0
(Androgel)
1
$0
(Testim)
1
$0
(Estrace)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (150 per 30
days)
PA; QL (150 per 30
days)
PA
2
$0
2
$0
2
$0
1
$0
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
PA-HRM; QL (8 per
28 days)
PA-HRM
PA-HRM
155
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
mimvey oral tablet 1-0.5 mg
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 0.31.5 MG, 0.45-1.5 MG, 0.625-2.5
MG, 0.625-5 MG
raloxifene oral tablet 60 mg
VAGIFEM VAGINAL TABLET 10
MCG
Glucocorticoids/Mineraloco
rticoids
Tier level
(Vivelle-Dot)
1
What the
drug will
cost you
$0
(Climara)
1
$0
(Delestrogen)
1
$0
(Activella)
1
$0
(Estropipate)
1
$0
2
$0
2
$0
1
1
$0
$0
2
$0
(Activella)
(Activella)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; QL (8 per
28 days)
PA-HRM; QL (4 per
28 days)
PA-HRM
PA-HRM
QL (1 per 84 days)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
PA-HRM
PA-HRM
(Evista)
QL (18 per 28 days)
156
Tier level
What the
drug will
cost you
(Hydrocortisone
Sod Succinate)
1
$0
(Celestone)
1
$0
(Cortisone Acetate)
1
$0
(Dexamethasone)
1
$0
Name of Drug
a-hydrocort injection recon soln 100
mg
betamethasone acet,sod phos
injection suspension 6 mg/ml
cortisone oral tablet 25 mg
dexamethasone oral elixir 0.5 mg/5
ml
dexamethasone oral tablet 0.5 mg,
0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg,
6 mg
dexamethasone sodium phosphate
injection solution 10 mg/ml, 4 mg/ml
fludrocortisone oral tablet 0.1 mg
hydrocortisone oral tablet 10 mg, 20
mg, 5 mg
methylprednisolone 125 mg vial 2ml
sdv, 25's,l/f 125 mg
methylprednisolone acetate
injection suspension 40 mg/ml, 80
mg/ml
methylprednisolone oral tablet 16
mg, 32 mg, 4 mg, 8 mg
methylprednisolone oral
tablets,dose pack 4 mg
methylprednisolone sodium succ
injection recon soln 125 mg, 40 mg
methylprednisolone ss 1 gm vl
mdv,latex-free 1,000 mg
prednisolone sodium phosphate oral
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 oral tablet 1 mg, 2.5 mg,
20 mg, 5 mg, 50 mg
prednisone oral tablet 10 mg
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
(Dexamethasone)
1
$0
1
$0
1
$0
(Cortef)
1
$0
(Solu-Medrol)
1
$0
(Depo-Medrol)
1
$0
(Medrol)
1
$0
(Medrol)
1
$0
(Solu-Medrol)
1
$0
(Solu-Medrol)
1
$0
(Dexamethasone
Sod Phosphate)
(Fludrocortisone
Acetate)
PA BvD
PA BvD
PA BvD
PA BvD
(Pediapred)
1
$0
(Prednisone)
1
$0
(Prednisone)
1
$0
(Prednisone)
1
$0
PA BvD
PA BvD
PA BvD
157
Tier level
What the
drug will
cost you
1
$0
2
$0
(Triamcinolone
Acetonide)
1
$0
(Desmopressin
Acetate)
1
$0
(DDAVP)
1
$0
(Desmopressin
Acetate)
1
$0
(DDAVP)
1
$0
Name of Drug
prednisone oral tablets,dose pack 10
mg, 5 mg
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,nonaerosol 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) INTRAMUSCULAR
SYRINGE KIT 30 MG
LUPRON DEPOT-PED
INTRAMUSCULAR KIT 11.25
MG, 15 MG, 7.5 MG (PED)
(Prednisone)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
QL (15 per 30 days)
QL (15 per 30 days)
PA
2
$0
PA
2
$0
2
$0
QL (1 per 84 days)
2
$0
2
$0
158
Name of Drug
NORDITROPIN FLEXPRO
SUBCUTANEOUS PEN
INJECTOR 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
outer,single-dose,10 50 mcg/ml (1
ml)
octreotide acetate injection solution
1,000 mcg/ml, 100 mcg/ml, 200
mcg/ml, 500 mcg/ml
octreotide acetate injection solution
50 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
20 MG
30 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
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA
2
$0
(Octreotide
Acetate)
1
$0
(Sandostatin)
1
$0
(Octreotide
Acetate)
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
PA
PA
PA
QL (1 per 28 days)
2
$0
159
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
liothyronine oral tablet 25 mcg, 5
mcg, 50 mcg
Tier level
What the
drug will
cost you
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (1 per 360 days)
QL (10 per 28 days)
2
$0
(Hydroxyprogester
one Caproate)
1
$0
(Depo-Provera)
1
$0
(Medroxyprogester
one Acetate)
1
$0
(Provera)
1
$0
2
$0
(Megace Es)
1
$0
(Aygestin)
1
$0
(Progesterone)
1
$0
(Prometrium)
1
$0
(Levothyroxine
Sodium)
1
$0
(Levoxyl)
1
$0
(Cytomel)
1
$0
PA NSO
QL (1 per 84 days)
QL (1 per 84 days)
160
Name of Drug
methimazole oral tablet 10 mg, 5 mg (Tapazole)
propylthiouracil oral tablet 50 mg
(Propylthiouracil)
Tier level
What the
drug will
cost you
1
1
$0
$0
2
$0
2
$0
2
$0
1
$0
1
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
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
INTRAVENOUS RECON SOLN 6
GRAM
CELLCEPT INTRAVENOUS
500 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
cyclosporine oral capsule 100 mg,
25 mg
ENBREL SUBCUTANEOUS
RECON SOLN 25 MG (1 ML)
PA BvD
(Imuran)
(Azathioprine
Sodium)
PA; QL (28 per 28
days)
PA BvD
PA BvD
PA BvD
PA BvD
PA
2
$0
2
$0
(Sandimmune)
1
$0
(Neoral)
1
$0
(Neoral)
1
$0
(Sandimmune)
1
$0
2
$0
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA
161
Name of Drug
ENBREL SUBCUTANEOUS
SYRINGE 25 MG/0.5ML (0.51), 50
MG/ML (0.98 ML)
ENBREL SURECLICK
SUBCUTANEOUS PEN
INJECTOR 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
15-18 % RANGE
GAMMAGARD LIQUID
INJECTION SOLUTION 10 %
GAMMAPLEX INTRAVENOUS
SOLUTION 5 %
gengraf oral capsule 100 mg, 25
(Neoral)
mg, 50 mg
gengraf oral solution 100 mg/ml
(Neoral)
HUMIRA PEN CROHN'S-UC-HS
START SUBCUTANEOUS PEN
INJECTOR 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)
150 UNIT/ML, 150 UNIT/ML (10
ML)
HYQVIA IG COMPONENT
2.5 GRAM/25 ML (10 %)
Tier level
What the
drug will
cost you
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
2
$0
2
$0
2
$0
PA BvD
PA BvD
PA BvD
2
$0
2
$0
2
$0
1
$0
1
$0
2
$0
2
$0
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
PA
2
$0
2
$0
PA BvD
2
$0
162
Name of Drug
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)
150 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
mycophenolate sodium oral
tablet,delayed release (dr/ec) 180
mg, 360 mg
NULOJIX INTRAVENOUS
RECON SOLN 250 MG
OCTAGAM INTRAVENOUS
SOLUTION 10 %, 5 %
ORENCIA (WITH MALTOSE)
250 MG
ORENCIA SUBCUTANEOUS
SYRINGE 125 MG/ML
PRIVIGEN INTRAVENOUS
SOLUTION 10 %
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
2
$0
2
$0
2
$0
2
$0
(Arava)
1
$0
(Cellcept)
1
$0
(Cellcept)
1
$0
(Cellcept)
1
$0
(Myfortic)
1
$0
2
$0
2
$0
PA
PA; QL (18.76 per 28
days)
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA
2
$0
2
$0
2
$0
PA
PA BvD
163
Name of Drug
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
(Rapamune)
mg
tacrolimus oral capsule 0.5 mg, 1
(Hecoria)
mg, 5 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
ADACEL(TDAP
ADOLESN/ADULT)(PF)
INTRAMUSCULAR SYRINGE 2
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)
50-50-50-25 MCG/0.5 ML
BOOSTRIX TDAP
INTRAMUSCULAR
SUSPENSION 2.5-8-5 LF-MCGLF/0.5ML
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
1
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA; LA; QL (15 per 28
days)
PA BvD; QL (120 per
30 days)
PA BvD
PA BvD
2
$0
2
$0
2
$0
164
Name of Drug
BOOSTRIX TDAP
2.5-8-5 LF-MCG-LF/0.5ML
CERVARIX VACCINE (PF)
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-MCGLF/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)
INTRAMUSCULAR
SUSPENSION 10 MCG/0.5 ML
MCG/0.5 ML
GARDASIL (PF)
INTRAMUSCULAR
SUSPENSION 20-40-40-20
MCG/0.5 ML
GARDASIL (PF)
20-40-40-20 MCG/0.5 ML
GARDASIL 9 (PF)
INTRAMUSCULAR
SUSPENSION 0.5 ML
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
$0
PA BvD; QL (3 per
365 days)
2
$0
PA BvD; QL (3 per
365 days)
2
$0
PA BvD; QL (3 per
365 days)
2
$0
PA BvD; QL (3 per
365 days)
2
2
$0
2
$0
2
$0
165
Name of Drug
GARDASIL 9 (PF)
INTRAMUSCULAR SYRINGE 0.5
ML
HAVRIX (PF)
INTRAMUSCULAR
SUSPENSION 1,440 ELISA
UNIT/ML
HAVRIX (PF)
1,440 ELISA UNIT/ML, 720
ELISA UNIT/0.5 ML
IMOVAX RABIES VACCINE (PF)
INTRAMUSCULAR RECON
SOLN 2.5 UNIT
INFANRIX (DTAP) (PF)
INTRAMUSCULAR
SUSPENSION 25-58-10 LF-MCGLF/0.5ML
IPOL INJECTION SUSPENSION
40-8-32 UNIT/0.5 ML
IPOL INJECTION SYRINGE 40-832 UNIT/0.5 ML
IXIARO (PF) INTRAMUSCULAR
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)
INTRAMUSCULAR SOLUTION 4
MCG/0.5 ML
MENHIBRIX (PF)
INTRAMUSCULAR RECON
SOLN 5-2.5 MCG/0.5 ML
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
166
Name of Drug
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) INTRAMUSCULAR RECON
SOLN 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)
MCG-25LF-25 MCG-10LF/0.5 ML
PEDVAX HIB (PF)
7.5 MCG/0.5 ML
PENTACEL (PF)
INTRAMUSCULAR KIT 15 LF
UNIT-20 MCG-5 LF/0.5 ML
PENTACEL ACTHIB
COMPONENT (PF)
INTRAMUSCULAR RECON
SOLN 10 MCG/0.5 ML
PROQUAD (PF)
FOR RECONSTITUTION
10EXP3-4.3-3- 3.99 TCID50/0.5
QUADRACEL (PF)
INTRAMUSCULAR
SUSPENSION 15 LF-48 MCG- 5
LF UNIT/0.5ML
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (2 per 365 days)
2
$0
2
$0
2
$0
2
$0
2
$0
QL (2 per 365 days)
2
$0
2
$0
167
Name of Drug
RABAVERT (PF)
INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 2.5 UNIT
RECOMBIVAX HB (PF)
INTRAMUSCULAR
SUSPENSION 10 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 52 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,
intramuscular suspension 2-2 lf
Diphtheria
unit/0.5 ml
Tox,Adult)
TRUMENBA INTRAMUSCULAR
TWINRIX (PF)
INTRAMUSCULAR
SUSPENSION 720 ELISA UNIT 20 MCG/ML
TWINRIX (PF)
720 ELISA UNIT -20 MCG/ML
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
PA BvD; QL (3 per
365 days)
PA BvD; QL (3 per
365 days)
PA BvD
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
168
Name of Drug
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)
FOR RECONSTITUTION 1,350
UNIT/0.5 ML
YF-VAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 10 EXP4.74
UNIT/0.5 ML
ZOSTAVAX (PF)
FOR RECONSTITUTION 19,400
UNIT/0.65 ML
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (2 per 365 days)
2
$0
2
$0
QL (1 per 365 days)
2
$0
1
$0
2
$0
2
$0
1
$0
1
$0
Inflammatory Bowel Disease
Agents
Inflammatory Bowel
Disease Agents
alosetron oral tablet 0.5 mg, 1 mg
(Alosetron HCl)
APRISO ORAL
24HR 0.375 GRAM
ASACOL HD ORAL
(DR/EC) 800 MG
balsalazide oral capsule 750 mg
(Colazal)
budesonide oral
(Entocort EC)
capsule,delayed,extend.release 3 mg
169
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
1
$0
2
$0
(Ringers Solution)
(Sodium Chloride
Irrig Solution)
1
$0
1
$0
(Sorbitol Solution)
1
$0
1
$0
1
$0
(Alendronate
Sodium)
1
$0
(Fosamax)
1
$0
(Fosamax)
1
$0
Name of Drug
DELZICOL DR 400 MG
CAPSULE 400 MG
DELZICOL ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 400 MG
DIPENTUM ORAL CAPSULE 250
MG
Necessary Actions,
Restrictions, or
Limits on Use
ST
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation solution 0.25
%
LACTATED RINGERS
IRRIGATION SOLUTION
ringers irrigation solution
sodium chloride irrigation solution
0.9 %
sorbitol irrigation solution 3 %, 3.3
%
sorbitol-mannitol urethral solution
2.7-0.54 g/100 ml
water for irrigation, sterile
irrigation solution
(Acetic Acid)
(Mannitol/Sorbitol
Solution)
(Water For
Irrigation,Sterile)
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
QL (4 per 28 days)
(Miacalcin)
1
$0
(Calcitriol)
1
$0
170
Tier level
What the
drug will
cost you
(Rocaltrol)
1
$0
(Rocaltrol)
1
$0
(Doxercalciferol)
1
$0
(Hectorol)
1
$0
Name of Drug
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,NONAEROSOL 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
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
2
$0
2
$0
(Ibandronate
Sodium)
1
$0
(Boniva)
1
$0
(Boniva)
1
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (2.4 per 28
days)
QL (3 per 84 days)
QL (3 per 84 days)
QL (1 per 28 days)
(Zemplar)
(Actonel)
(Actonel)
(Zometa)
2
$0
1
$0
2
$0
1
1
$0
$0
2
$0
1
$0
QL (1 per 180 days)
QL (1 per 28 days)
QL (30 per 28 days)
171
Tier level
What the
drug will
cost you
(Zoledronic
Acid/Mannitol and
Water)
1
$0
(Reclast)
1
$0
2
$0
Name of Drug
zoledronic acid-mannitol-water
intravenous piggyback 4 mg/100 ml
ZOMETA INTRAVENOUS
Necessary Actions,
Restrictions, or
Limits on Use
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
AVONEX INTRAMUSCULAR
SYRINGE KIT 30 MCG/0.5 ML
BENLYSTA INTRAVENOUS
BETASERON SUBCUTANEOUS
KIT 0.3 MG
PA
(Zyloprim)
(Amifostine
Crystalline)
(Citrate Phosphate
Dextros Soln)
2
$0
2
$0
2
$0
1
$0
1
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
PA
ST
ST
ST
PA
ST
172
Tier level
What the
drug will
cost you
(Urecholine)
1
$0
(Buspirone HCl)
1
$0
2
$0
1
$0
1
$0
2
$0
2
$0
(Droperidol)
1
$0
(Avodart)
1
$0
(Jalyn)
1
$0
2
$0
1
$0
2
$0
1
$0
1
$0
2
$0
1
$0
2
$0
2
$0
2
$0
Name of Drug
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
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
(Colcrys)
(Colchicine/Proben
ecid)
(Ergoloid
Mesylates)
EXTAVIA SUBCUTANEOUS KIT
0.3 MG
finasteride oral tablet 5 mg
(Proscar)
fomepizole intravenous solution 1
(Fomepizole)
gram/ml
FUSILEV INTRAVENOUS
RECON SOLN 50 MG
GAUZE PAD TOPICAL
BANDAGE 2 X 2 "
GILENYA ORAL CAPSULE 0.5
MG
GLUCAGEN HYPOKIT
INJECTION RECON SOLN 1 MG
GLUCAGON EMERGENCY KIT
(HUMAN) INJECTION KIT 1 MG
Necessary Actions,
Restrictions, or
Limits on Use
PA
QL (30 per 30 days)
ST
QL (28 per 28 days)
173
Tier level
What the
drug will
cost you
(Guanidine HCl)
1
$0
(Hydroxyzine HCl)
1
$0
(Hydroxyzine HCl)
1
$0
(Hydroxyzine HCl)
1
$0
(Vistaril)
1
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
2
$0
4
$0
1
$0
2
$0
Name of Drug
guanidine oral tablet 125 mg
hydroxyzine hcl intramuscular
solution 25 mg/ml, 50 mg/ml
hydroxyzine hcl oral solution 10
mg/5 ml
hydroxyzine hcl oral tablet 10 mg,
25 mg, 50 mg
hydroxyzine pamoate oral capsule
100 mg, 25 mg, 50 mg
KEVEYIS ORAL TABLET 50 MG
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
mesna intravenous solution 100
mg/ml
MESNEX ORAL TABLET 400
MG
MESTINON ORAL SYRUP 60
MG/5 ML
MESTINON TIMESPAN ORAL
TABLET EXTENDED RELEASE
180 MG
MINERAL OIL HEAVY *
morrhuate sodium intravenous
solution 5 %
ORENCIA CLICKJECT
SUBCUTANEOUS AUTOINJECTOR 125 MG/ML
(Leucovorin
Calcium)
(Leucovorin
Calcium)
(Leucovorin
Calcium)
(Levocarnitine
(With Sugar))
(Carnitor)
(Mesnex)
(Sodium
Morrhuate)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
PA-HRM
PA-HRM
PA-HRM
PA NSO; QL (120 per
30 days)
PA
PA
174
Name of Drug
Tier level
What the
drug will
cost you
ORFADIN ORAL SUSPENSION 4
MG/ML
2
$0
OTEZLA ORAL TABLET 30 MG
2
$0
2
$0
2
$0
4
$0
2
$0
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 AUTOINJECTOR 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
MCG/0.5 ML- 94 MCG/0.5 ML
probenecid oral tablet 500 mg
PROCYSBI ORAL CAPSULE,
DELAYED REL SPRINKLE 25
MG, 75 MG
pv extra cleansing douche *
pyridostigmine bromide oral tablet
60 mg
pyridostigmine bromide oral tablet
qc mineral oil heavy *
ra feminine care douche *
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
ST
ST
2
$0
1
$0
2
$0
(Acetic Acid)
4
$0
(Mestinon)
1
$0
(Mestinon)
1
$0
(Mineral Oil)
(Acetic Acid)
4
4
$0
$0
(Probenecid)
175
Name of Drug
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)
MCG/0.5 ML, 44 MCG/0.5 ML
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
sb disp douche extra clns v&w *
(Acetic Acid)
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
SIMPONI SUBCUTANEOUS
SYRINGE 100 MG/ML, 50 MG/0.5
ML
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
4
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
QL (60 per 30 days)
2
$0
2
$0
PA
PA
2
$0
PA
2
$0
176
Name of Drug
STELARA SUBCUTANEOUS
SYRINGE 45 MG/0.5 ML, 90
MG/ML
STERILE PADS 2" X 2" 2 X 2 "
summer's eve dche-xtra clns
(Acetic Acid)
12's,extra-cleansing *
summer's eve douche-ultra clns
(Acetic Acid)
12's,2pk,ultra clns *
SYNAREL NASAL SPRAY,NONAEROSOL 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
topical light mineral oil *
(Mineral Oil)
TYBOST ORAL TABLET 150 MG
ULORIC ORAL TABLET 40 MG,
80 MG
Tier level
What the
drug will
cost you
2
$0
1
$0
4
$0
4
$0
2
$0
2
$0
PA
QL (14 per 30 days)
QL (60 per 30 days)
2
$0
2
$0
4
2
$0
$0
2
$0
2
$0
2
$0
2
$0
(Diamox Sequels)
1
$0
(Acetazolamide)
1
$0
XELJANZ ORAL TABLET 5 MG
XELJANZ XR ORAL TABLET
MG
ZINBRYTA SUBCUTANEOUS
SYRINGE 150 MG/ML
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (60 per
30 days)
QL (30 per 30 days)
QL (30 per 30 days)
PA; QL (60 per 30
days)
PA; QL (30 per 30
days)
ST
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide oral capsule,
acetazolamide oral tablet 125 mg,
250 mg
177
Tier level
What the
drug will
cost you
1
$0
2
$0
2
$0
(Betaxolol HCl)
1
$0
(Bimatoprost)
1
$0
(Alphagan P)
1
$0
2
$0
(Trusopt)
1
$0
(Cosopt)
1
$0
(Xalatan)
1
$0
(Betagan)
1
$0
2
$0
(Neptazane)
1
$0
(Metipranolol)
1
$0
2
$0
1
$0
2
$0
(Timoptic)
1
$0
(Timoptic-Xe)
1
$0
Name of Drug
acetazolamide sodium injection
recon soln 500 mg
ALPHAGAN P OPHTHALMIC
DROPS 0.1 %
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 %
(Acetazolamide
Sodium)
(Isopto Carpine)
Necessary Actions,
Restrictions, or
Limits on Use
(drops: 0.15%, 0.20%)
178
Tier level
What the
drug will
cost you
2
$0
(Travoprost
(Benzalkonium))
1
$0
(Citracal-Vitamin
D)
4
$0
(Calcium Citrate)
4
$0
(Caltrate 600 Plus
D3)
4
$0
(Caltrate 600 Plus
D3)
4
$0
(Calcium 600 + Vit
D)
4
$0
(Caltrate 600 Plus
D3)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
TRAVATAN Z OPHTHALMIC
DROPS 0.004 %
travoprost (benzalkonium)
ophthalmic drops 0.004 %
Necessary Actions,
Restrictions, or
Limits on Use
Replacement Preparations
Replacement Preparations
calcitrate + vit d caplet 315-250
mg-unit *
calcitrate 200 mg (950 mg) tab 200
mg (950 mg) *
calcium 1,000 + d3 caplet 1,000
mg(2,500 mg)-800 unit *
calcium 500 + d tablet p/f,na/f,no
lactose 500 mg(1,250mg) -400 unit
*
calcium 500+d tablet chew 500
mg(1,250mg) -400 unit *
calcium 600 + vit d 400 caplet s/f,
p/f, caplet 600 mg(1,500mg) -400
unit *
(Calcium
Carbonate/Vitamin
D3)
calcium 600 + vit d tablet 600-125 (Caltrate 600 Plus
mg-unit *
D3)
calcium 600 + vitamin d sftgl rapid (Calcium
release, sftgl 600 mg(1,500mg) -500 Carbonate/Vitamin
unit *
D3)
calcium 600 mg tablet 600 mg
(Calcium
(1,500 mg) *
Carbonate)
(Calcium
calcium 600+d softgel 600 mg
Carbonate/Vitamin
calcium- 200 unit *
D3)
calcium 600-vit d3 200 tablet 600
(Caltrate 600 Plus
mg(1,500mg) -200 unit *
D3)
calcium 600-vit d3 400 tablet 600
(Caltrate 600 Plus
mg(1,500mg) -400 unit *
D3)
calcium 600 + vit d 400 softgl 600
mg(1,500mg) -400 unit *
179
Tier level
What the
drug will
cost you
4
$0
4
$0
(Calcium Chloride)
1
$0
(Calcium Chloride)
1
$0
4
$0
4
$0
4
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
calcium carb 1,250 mg/5 ml sus 500
mg/5 ml (1,250 mg/5 ml) *
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-vit d3 caplet s/f, p/f
315-250 mg-unit *
calcium gluconate 500 mg tab 45
mg (500 mg) *
calcium gluconate intravenous
solution 100 mg/ml (10%)
calcium with vit d tablet 600-125
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 315250 mg-unit *
citrus calcium + d tablet 315-250
mg-unit *
cvs calcium + vitamin d3 sftgl
absorbable 600 mg(1,500mg) -500
unit *
cvs calcium 500 + vit d 200 tb 500
mg(1,250mg) -200 unit *
cvs calcium 500 + vit d tablet oyster
shell 500 mg(1,250mg) -125 unit *
(Calcium
Carbonate)
(Calcium
Carbonate)
(Citracal-Vitamin
D)
(Citracal-Vitamin
D)
(Calcium
Gluconate)
(Calcium
Gluconate)
(Calcium
Carbonate/Vitamin
D2)
(Citracal-Vitamin
D)
(Citracal-Vitamin
D)
(Calcium
Carbonate/Vitamin
D3)
(Caltrate 600 Plus
D3)
(Caltrate 600 Plus
D3)
Necessary Actions,
Restrictions, or
Limits on Use
180
Tier level
What the
drug will
cost you
(Caltrate 600 Plus
D3)
4
$0
(Magnesium)
4
$0
(Pedialyte)
4
$0
(Pedialyte)
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
(Dextrose 5 %-0.2
% NaCl)
1
$0
(Potassium
Chloride/D50.2%NaCl)
1
$0
(Klor-Con-Ef)
1
$0
1
$0
4
$0
Name of Drug
cvs calcium 600-vit d3 800 tab p/f,
s/f,gluten-free 600 mg(1,500mg) 800 unit *
cvs magnesium 250 mg tablet 250
mg *
cvs pediatric electrolyte soln *
cvs pediatric electrolyte soln a/f, p/f
*
d10 %-0.45 % sodium chloride
d2.5 %-0.45 % sodium chloride
d5 % and 0.9 % sodium chloride
dextrose 10 % and 0.2 % nacl
dextrose 5 %-lactated ringers
dextrose 5%-0.2 % sod chloride
dextrose 5%-0.3 % sod.chloride
dextrose with sodium chloride
intravenous parenteral solution 50.2 %
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 *
(Dextrose 10 %
and 0.45 % NaCl)
(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)
(Electrolyte-48
Solution/D5W)
(Calcium
Carbonate/Vitamin
D3)
Necessary Actions,
Restrictions, or
Limits on Use
181
Name of Drug
gnp calcium 500-vit d3 600 tab
500mg (1,250mg) -600 unit *
gnp calcium 600+d3+min chew tb
p/f,gluten/f,yeast/f 600 mg calcium800 unit-40 mg *
hm calcium 600+d plus tab chew
gluten-free 600 mg calcium- 800
unit-40 mg *
hm calcium citrate-vit d cplt caplet,
gluten-free 315-250 mg-unit *
HYPERLYTE CR
INTRAVENOUS SOLUTION 2520-5-5-30-30 MEQ/20 ML
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
KELP 150 MCG TABLET 150
MCG *
klor-con 10 oral tablet extended
release 10 meq
klor-con m10 tablet 10 meq
(Caltrate 600 Plus
D3)
(Ca/D3/Mag
Ox/Zinc/Cop/Mang
/Bor)
(Ca/D3/Mag
Ox/Zinc/Cop/Mang
/Bor)
(Citracal-Vitamin
D)
(Klor-Con-Ef)
(Potassium
Chloride)
(Potassium
Chloride)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
4
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
182
Name of Drug
klor-con m15 oral tablet,er
particles/crystals 15 meq
klor-con m20 oral tablet,er
klor-con sprinkle oral capsule,
extended release 10 meq, 8 meq
(Potassium
Chloride)
(Potassium
Chloride)
(Potassium
Chloride)
(Calcium
liquid calcium 600-vit d3 sfgl 600
Carbonate/Vitamin
mg(1,500mg) -400 unit *
D3)
liquid calcium 600-vit d3 sfgl
(Calcium
softgel,p/f,gluten-f 600 mg(1,500mg) Carbonate/Vitamin
-500 unit *
D3)
liquid calcium with vitamin d
(Calcium
softgel, s/f, p/f 600 mg calcium- 200 Carbonate/Vitamin
unit *
D3)
mag delay dr 64 mg tablet 64 mg * (Slow-Mag)
mag64 dr 64 mg tablet 64 mg *
(Slow-Mag)
mag-g 500 mg tablet 27 mg (500
(Magonate)
mg) *
magnesium 250 mg tablet 250 mg * (Magnesium)
(Magnesium
magnesium 300 mg capsule 300 mg
Oxide/Mag Aa
*
Chelate)
magnesium chloride injection
(Magnesium
solution 200 mg/ml (20 %)
Chloride)
magnesium gluc 500 mg tablet 27
(Magonate)
mg (500 mg) *
magnesium sulf in 0.45% nacl
(Magnesium Sulf
intravenous solution 20 gram/500
In 0.45% NaCl)
ml (40 mg/ml)
magnesium sulfate in d5w
(Magnesium
Sulfate/D5W)
ml, 4 gram/100 ml
magnesium sulfate in water
(Magnesium
gram/500 ml (4 %), 40 gram/1,000 Sulfate in Water)
ml (4 %)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
1
$0
4
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
183
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
4
$0
2
$0
2
$0
4
$0
2
$0
2
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Calcium
Carbonate)
4
$0
(Caltrate 600 Plus
D3)
4
$0
Name of Drug
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 %)
magnesium sulfate injection syringe
4 meq/ml
natural calcium 500 mg tablet 500
mg calcium (1,250 mg) *
NORMOSOL-M IN 5 %
DEXTROSE INTRAVENOUS
PARENTERAL 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
oysco 500-vit d3 200 tablet 500
mg(1,250mg) -200 unit *
oysco d tablet 250-125 mg-unit *
oysco-500 tablet 500 mg calcium
(1,250 mg) *
oyster shell 250 mg + vit d tb 250125 mg-unit *
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 *
(Magnesium
Sulfate in Water)
(Magnesium
Sulfate)
(Magnesium
Sulfate)
(Calcium
Carbonate)
(Slow-Mag)
(Caltrate 600 Plus
D3)
(Caltrate 600 Plus
D3)
(Calcium
Carbonate)
(Caltrate 600 Plus
D3)
(Caltrate 600 Plus
D3)
Necessary Actions,
Restrictions, or
Limits on Use
184
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
1
$0
2
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
(Potassium
Chloride In D5w)
1
$0
(Potassium
Chloride In Lr-D5)
1
$0
Name of Drug
oyster shell calcium-vit d tab
p/f,s/f,gluten-free 500 mg(1,250mg)
-400 unit *
oystercal-d 500 mg-400 unit tb 500
mg(1,250mg) -400 unit *
pediatric electrolyte solution *
PHOS-NAK PACKET 280-160-250
MG *
phospha 250 neutral oral tablet 250
mg
PLASMA-LYTE 148
SOLUTION
PLASMA-LYTE A
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
meq/l, 20 meq/l, 30 meq/l, 40 meq/l
potassium chloride in 0.9%nacl
meq/l, 40 meq/l
potassium chloride in 5 % dex
meq/l, 30 meq/l, 40 meq/l
potassium chloride in lr-d5
meq/l
(Caltrate 600 Plus
D3)
(Caltrate 600 Plus
D3)
(Pedialyte)
(K-Phos Neutral)
(Potassium
Acetate)
(Pot Chloride/Pot
Bicarb/Cit Ac)
(Klor-Con-Ef)
(Potassium
Chloride/D50.45nacl)
(Potassium
Chloride In
0.9%NaCl)
Necessary Actions,
Restrictions, or
Limits on Use
185
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
(Klor-Con)
1
$0
(K-Tab ER)
1
$0
(K-Tab ER)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
potassium chloride intravenous
piggyback 10 meq/100 ml, 20
meq/100 ml, 30 meq/100 ml, 40
meq/100 ml
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
meq/l
potassium chloride-d5-0.2%nacl
meq/l, 20 meq/l, 30 meq/l, 40 meq/l
meq/l
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
Chloride)
(Potassium
Chloride)
(Potassium
Chloride)
(Potassium
Chloride)
(Potassium
Chloride)
(Potassium
Chloride-0.45%
NaCl)
(Potassium
(Potassium
(Potassium
(Urocit-K)
(Potassium
Citrate/Citric Acid)
(Potassium
Chloride)
Necessary Actions,
Restrictions, or
Limits on Use
186
Tier level
What the
drug will
cost you
(Potassium
Chloride)
1
$0
(K-Tab ER)
1
$0
1
$0
4
$0
4
$0
4
4
$0
$0
1
$0
4
$0
4
$0
(Sodium Acetate)
1
$0
(Sodium
Bicarbonate)
1
$0
(Sodium
Bicarbonate)
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
potassium cl 20 meq/50 ml sol 20
meq/50 ml
potassium cl er 10 meq tablet f/c 10
meq
potassium phosphate m-/d-basic
intravenous solution 3 mmol/ml
ra hi-cal plus vitamin d tab 500
mg(1,250mg) -200 unit *
ra oyster shell-vitamin d tab s/f, p/f
250 (625)-125 mg-unit *
ra pediatric electrolyte soln a/f *
ra pediatric freezer pops *
ringers intravenous parenteral
solution
sm calcium 600-vit d3 800 tab 600
mg(1,500mg) -800 unit *
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
(Potassium
Phos,M-Basic-DBasic)
(Caltrate 600 Plus
D3)
(Calcium
Carbonate/Vitamin
D2)
(Pedialyte)
(Pedialyte)
(Ringers Solution)
(Caltrate 600 Plus
D3)
(Pedialyte)
(Sodium Chloride
0.45 %)
(0.9 % Sodium
Chloride)
(Sodium Chloride
3 %)
(Sodium Chloride
5 %)
Necessary Actions,
Restrictions, or
Limits on Use
187
Tier level
What the
drug will
cost you
(Sodium Chloride)
1
$0
(Sodium Lactate)
1
$0
(Sodium Lactate)
1
$0
(Sodium Phos,MBasic-D-Basic)
1
$0
2
$0
2
$0
(K-Phos Neutral)
1
$0
(Caltrate 600 Plus
D3)
4
$0
Name of Drug
sodium chloride intravenous
parenteral solution 2.5 meq/ml, 4
meq/ml
sodium lactate intravenous
parenteral solution 167 meq/l
sodium lactate intravenous solution
5 meq/ml
sodium phosphate intravenous
solution 3 mmol/ml
TPN ELECTROLYTES II IV
SOLN 25'S,20ML/50ML FTV 1818-5-4.5-35 MEQ/20 ML
TPN ELECTROLYTES
INTRAVENOUS SOLUTION 3520-5 MEQ/20 ML
virt-phos 250 neutral oral tablet 250
mg
v-r calcium 400 + d 133 caplet 400133.3 mg-unit *
Necessary Actions,
Restrictions, or
Limits on Use
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
QL (60 per 30 days)
2
$0
QL (12 per 28 days)
2
$0
2
$0
QL (60 per 30 days)
188
Name of Drug
DULERA INHALATION HFA
AEROSOL INHALER 100-5
MCG/ACTUATION
FLOVENT DISKUS
DEVICE 100 MCG/ACTUATION,
50 MCG/ACTUATION
FLOVENT DISKUS
DEVICE 250 MCG/ACTUATION
FLOVENT HFA INHALATION
HFA AEROSOL INHALER 110
MCG/ACTUATION
MCG/ACTUATION
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
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
QL (13 per 28 days)
2
$0
QL (60 per 30 days)
2
$0
2
$0
2
$0
QL (12 per 28 days)
QL (24 per 28 days)
2
$0
2
$0
2
$0
(Singulair)
1
$0
(Singulair)
1
$0
(Singulair)
1
$0
(Accolate)
1
$0
PA BvD
(Albuterol Sulfate)
1
$0
(Albuterol Sulfate)
1
$0
189
Tier level
What the
drug will
cost you
(Albuterol Sulfate)
1
$0
(Vospire ER)
1
$0
Name of Drug
albuterol sulfate oral tablet 2 mg, 4
mg
albuterol sulfate oral tablet
extended release 12 hr 4 mg, 8 mg
ATROVENT HFA INHALATION
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
DEVICE 50 MCG/DOSE
SPIRIVA RESPIMAT
INHALATION MIST 1.25
MCG/ACTUATION, 2.5
MCG/ACTUATION
SPIRIVA WITH HANDIHALER
INHALATION CAPSULE,
W/INHALATION DEVICE 18
MCG
Necessary Actions,
Restrictions, or
Limits on Use
2
$0
2
$0
(Ipratropium
Bromide)
1
$0
(Ipratropium/Albut
erol Sulfate)
1
$0
1
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
QL (8 per 30 days)
(Metaproterenol
Sulfate)
(Metaproterenol
Sulfate)
PA BvD
PA BvD
190
Tier level
What the
drug will
cost you
2
$0
1
$0
1
$0
(Theophylline
Anhydrous)
1
$0
(Theophylline/D5
W)
1
$0
(Theophylline
Anhydrous)
1
$0
(Theophylline
Anhydrous)
1
$0
(Theophylline
Anhydrous)
1
$0
Name of Drug
STRIVERDI RESPIMAT
INHALATION MIST 2.5
MCG/ACTUATION
terbutaline oral tablet 2.5 mg, 5 mg
terbutaline subcutaneous solution 1
mg/ml
theochron oral tablet extended
release 12 hr 100 mg, 200 mg, 300
mg
theophylline in dextrose 5 %
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
TUDORZA PRESSAIR
INHALATION AEROSOL
POWDR BREATH ACTIVATED
400 MCG/ACTUATION, 400
MCG/ACTUATION (30 ACTUAT)
VENTOLIN HFA INHALATION
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
(Terbutaline
Sulfate)
(Terbutaline
Sulfate)
Necessary Actions,
Restrictions, or
Limits on Use
QL (2 per 28 days)
2
$0
2
$0
(Acetadote)
1
$0
(Acetadote)
1
$0
2
$0
PA BvD
PA BvD
PA
191
Tier level
What the
drug will
cost you
(Cromolyn
Sodium)
1
$0
(Nasalcrom)
4
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
3
$0
2
$0
(Baclofen)
1
$0
(Soma)
1
$0
(Parafon Forte
DSC)
1
$0
1
$0
1
$0
1
$0
Name of Drug
cromolyn inhalation solution for
nebulization 20 mg/2 ml
cromolyn sodium nasal spray 5.2
mg/spray (4 %) *
DALIRESP ORAL TABLET 500
MCG
ESBRIET ORAL CAPSULE 267
MG
KALYDECO ORAL GRANULES
IN PACKET 50 MG, 75 MG
KALYDECO ORAL TABLET 150
MG
NUCALA SUBCUTANEOUS
RECON SOLN 100 MG
OFEV ORAL CAPSULE 100 MG,
150 MG
ORKAMBI ORAL TABLET 200125 MG
PROLASTIN-C INTRAVENOUS
RECON SOLN 1,000 MG
sodium chloride 0.9% inhal vl u-d,
suv, p/f (rx) 0.9 % *
XOLAIR SUBCUTANEOUS
RECON SOLN 150 MG
(Pulmosal)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
QL (30 per 30 days)
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)
PA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen oral tablet 10 mg, 20 mg
carisoprodol oral tablet 250 mg,
350 mg
chlorzoxazone oral tablet 500 mg
cyclobenzaprine oral tablet 10 mg, 5
(Fexmid)
mg
dantrolene oral capsule 100 mg, 25
(Dantrium)
mg, 50 mg
metaxall oral tablet 800 mg
(Skelaxin)
PA-HRM; QL (120 per
30 days)
PA-HRM
PA-HRM
PA-HRM
192
Tier level
What the
drug will
cost you
(Skelaxin)
1
$0
(Robaxin)
1
$0
(Dantrium)
1
$0
(Zanaflex)
1
$0
(Zanaflex)
1
$0
1
$0
2
$0
1
$0
2
$0
2
$0
2
$0
2
$0
Name of Drug
metaxalone oral tablet 400 mg, 800
mg
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
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
PA-HRM
Sleep Disorder Agents
Sleep Disorder Agents
armodafinil oral tablet 150 mg, 200
(Nuvigil)
mg, 250 mg, 50 mg
BELSOMRA ORAL TABLET 10
MG, 15 MG, 20 MG, 5 MG
eszopiclone oral tablet 1 mg, 2 mg,
(Lunesta)
3 mg
HETLIOZ ORAL CAPSULE 20
MG
NUVIGIL ORAL TABLET 150
MG, 200 MG, 250 MG, 50 MG
ROZEREM ORAL TABLET 8 MG
XYREM ORAL SOLUTION 500
MG/ML
zaleplon oral capsule 10 mg, 5 mg
(Sonata)
1
$0
PA
QL (30 per 30 days)
PA-HRM; QL (30 per
30 days)
PA
PA
LA
PA-HRM; (High Risk
with over 90 days
cumulative use with
any nonbenzodiazepine
hypnotic drug); QL (60
per 30 days)
193
Name of Drug
Tier level
What the
drug will
cost you
zolpidem oral tablet 10 mg, 5 mg
(Ambien)
1
$0
zolpidem oral tablet,ext release
multiphase 12.5 mg, 6.25 mg
(Ambien CR)
1
$0
2
$0
2
$0
1
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
Vasodilating Agents
Vasodilating Agents
ADCIRCA ORAL TABLET 20 MG
ADEMPAS ORAL TABLET 0.5
MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG
epoprostenol (glycine) intravenous
(Flolan)
recon soln 0.5 mg, 1.5 mg
LETAIRIS ORAL TABLET 10
MG, 5 MG
OPSUMIT ORAL TABLET 10 MG
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.125 MG,
0.25 MG, 1 MG, 2.5 MG
REMODULIN INJECTION
MG/ML, 2.5 MG/ML, 5 MG/ML
PA; QL (60 per 30
days)
PA; QL (90 per 30
days)
PA BvD
PA; QL (30 per 30
days)
PA; QL (30 per 30
days)
PA
PA BvD
194
Name of Drug
Tier level
What the
drug will
cost you
sildenafil intravenous solution 10
mg/12.5 ml
(Revatio)
1
$0
sildenafil oral tablet 20 mg
(Revatio)
1
$0
2
$0
2
$0
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
(0.6 MG/ML)
TYVASO STARTER KIT
INHALATION SOLUTION FOR
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
UPTRAVI ORAL
TABLETS,DOSE PACK 200 MCG
(140)- 800 MCG (60)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (37.5 per 1
day)
PA; QL (90 per 30
days)
days)
PA BvD
PA BvD
2
$0
2
$0
PA BvD
2
$0
2
$0
2
$0
4
$0
4
$0
(Biocel)
4
$0
(Biocel)
4
$0
PA; QL (60 per 30
days)
PA; QL (240 per 30
days)
PA; QL (200 per 365
days)
Vitamins And Minerals
Vitamins And Minerals
a thru z advanced formula tab
gluten-free 18-400 mg-mcg *
a thru z advanced formula tab new
formula *
a thru z select 50+ formula tb
advanced formula 0.4-300-250 mgmcg-mcg *
a thru z select men 50+ tablet 300600-300 mcg *
(Multivitamin/Iron/
Folic Acid)
(Multivitamin with
Minerals/Lut)
195
Tier level
What the
drug will
cost you
(Biocel)
4
$0
(Biocel)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Biocel)
4
$0
(Biocel)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
Name of Drug
a thru z select multivit tab 500-300250 mcg *
a thru z select tablet adults
50+,iron-free 0.4-300-250 mg-mcgmcg *
a thru z select tablet new
formulation *
a thru z select women's tablet *
abc plus tablet 0.4-300-250 mgmcg-mcg *
adult multi gummies 200 mcg *
adult one daily gummies 200 mcg *
adults' 50+ daily formula tab 0.4300-250 mg-mcg-mcg *
adults 50+ multivitamin tablet 0.4300-250 mg-mcg-mcg *
adults' daily formula tablet 18-400
mg-mcg *
animal chews tablet *
antioxidant softgel softgel *
apatate forte liquid *
b complete tablet *
b complex capsule *
b complex formula #1 tablet *
b complex tablet *
b-12 500 mcg tablet 500 mcg *
b-12 dots 500 mcg tablet 500 mcg *
(Multivitamin with
Minerals/Lut)
(Mv,Fe,Min/Lutein
)
(Biocel)
(One-A-Day
Vitacraves)
(One-A-Day
Vitacraves)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Beta-Carotene(A)
W-C and E/Min)
(Multivitamin with
Minerals)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
(B-12)
(B-12)
Necessary Actions,
Restrictions, or
Limits on Use
196
Name of Drug
(Vitamin B
Complex)
(Vitamin B
balance b-50 tablet *
Complex)
balance b-50 tablet inner,p/f,gluten/f (Vitamin B
*
Complex)
(Vitamin B
balanced b-100 tablet *
Complex)
(Vit B Complex
balanced b-100 tablet 100 mg *
100 No.3/Herbal)
(Vitamin B
Complex)
(Vitamin B
Complex)
balanced b-complex caplet p/f,no(Dialyvite 800)
lactose 400 mcg *
b-complex plus vitamin c cplt caplet
(Vita-Bee with C)
*
(Vitamin B
b-complex with b12 tablet *
Complex)
b-complex with c tablet *
(Vita-Bee with C)
b-complex with vit c caplet
(Dialyvite 800)
s/f,p/f,gluten-free 400 mcg *
(Multivitamin with
biosupp liquid *
Minerals)
biotin 300 mcg tablet 300 mcg *
(Biotin)
(Multivitamin with
biovol syrup *
Minerals)
c complex 500 mg tablet sa 500 mg
(Ascorbic Acid)
*
calcidol drops 8,000 unit/ml *
(Drisdol)
(Multivitcentamin liquid 9 mg iron/15 ml *
Minerals/Ferrous
Gluc)
(Multivit with Ironcentral-vite seniors tablet *
Minerals)
balance b-100 tablet *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
197
Name of Drug
centram-care multivit-min liq 9 mg
iron/15 ml *
centravites 50 plus tablet *
centrum complete multivit tab 18400 mg-mcg *
centrum multivit-mineral liq 9 mg
iron/15 ml *
(MultivitMinerals/Ferrous
Gluc)
(Multivit with IronMinerals)
(Multivitamin/Iron/
Folic Acid)
(MultivitMinerals/Ferrous
Gluc)
centrum silver tablet adults 50 +
(Biocel)
0.4-300-250 mg-mcg-mcg *
century adults 50+ tablet gluten free
(Biocel)
0.4-300-250 mg-mcg-mcg *
(Multivitamin with
century mature tablet *
Minerals/Lut)
century ultimate women's tab 18(Multivitamin/Iron/
400 mg-mcg *
Folic Acid)
cerovite advanced form tab 18-400 (Multivitamin/Iron/
mg-mcg *
Folic Acid)
(Multivitcerovite liquid 9 mg iron/15 ml *
Minerals/Ferrous
Gluc)
certavite sr-antioxidant tab 0.4-300(Biocel)
250 mg-mcg-mcg *
(Multivitcertavite-antioxidant liquid 9 mg
Minerals/Ferrous
iron/15 ml *
Gluc)
certavite-antioxidant tablet 18-400 (Multivitamin/Iron/
mg-mcg *
Folic Acid)
(Multivitamin with
child chew + iron tab chew *
Iron)
child chew vitamin tablet *
(Multivitamin)
child ferrous sulfate 15 mg/ml 15
(Fer-In-Sol)
mg iron (75 mg)/ml *
children's chewable vitamin *
(Multivitamin)
childrens multivit tab chew *
(Multivitamin)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
198
Name of Drug
complete multi 50+ tablet 500-300250 mcg *
(Biocel)
(Multivit,Th
Iron,Other Min)
(Multivit with Ironcomplete senior tablet *
Minerals)
(Vitamin B
cvs bal b-100 tablet *
Complex)
(Vitamin B
cvs bal b-50 tablet *
Complex)
(Vitamin B
cvs balanced b-150 tablet *
Complex)
cvs b-complex-vit c caplet caplet * (Vita-Bee with C)
(Multivit with Ironcvs child vit-mineral tab *
Minerals)
cvs children's chewable vit *
(Multivitamin)
cvs childs vit with c tab chew *
(Multivitamin)
(Multivitamin with
cvs child's vitamin-iron tb *
Iron)
cvs daily gummies complete adult vit (One-A-Day
200 mcg *
Vitacraves)
cvs daily multiple tablet *
(Multivitamin)
cvs daily multiple tablet for women
(Multivitamin)
*
cvs daily teen multi-vitamin 18-400 (Multivitamin/Iron/
mg-mcg *
Folic Acid)
cvs gummy swirls chewable *
(Multivitamin)
cvs iron 27 mg tablet 240 mg (27 mg
(Fergon)
iron) *
cvs men's daily gummies p/f, gluten- (One-A-Day
free 200 mcg *
Vitacraves)
cvs men's multi-vit tablet *
(Multivitamin)
(Prenatal Vit
cvs prenatal vitamin tablet *
Calc,Iron,Folic)
cvs spectravite adult 50+ tabs 0.4(Biocel)
300-250 mg-mcg-mcg *
complete multivitamin tab *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
199
Name of Drug
cvs spectravite advanced tab 18-400 (Multivitamin/Iron/
mg-mcg *
Folic Acid)
cvs spectravite liquid *
(Pediavit)
(Multivitamin with
cvs spectravite senior *
Minerals/Lut)
(Multivit with Ironcvs spectravite senior tab *
Minerals)
cvs spectravite senior tablet 500(Biocel)
300-250 mcg *
(Multivitamin with
cvs spectravite tablet chew *
Iron)
cvs spectravite ultra women tb 18(Multivitamin/Iron/
400 mg-mcg *
Folic Acid)
cvs super b complx & c cplt caplet,
(Vita-Bee with C)
p/f *
cvs vision formula tablet 1,000 unit- (Vit A,C and
200 mg-60 unit-2 mg *
E/Lutein/Minerals)
(Vitamin B
cvs vitamin b-100 complx tb *
Complex)
cvs vitamin c 1,000 mg tb chw 1,000
(Ascorbic Acid)
mg *
cvs vitamin d3 1,000 unit sfgl softgel
(D3-50)
1,000 unit *
cvs women's daily gummies p/f,
(One-A-Day
gluten-free 200 mcg *
Vitacraves)
cyanocobalamin 1,000 mcg/ml 25's (Cyanocobalamin
1,000 mcg/ml *
(Vitamin B-12))
d3 dots 2,000 unit tablet p/f 2,000
(Vitamin D3)
unit *
(Multivitamin with
daily multi vitamin-iron tab *
Iron)
daily multiple tablet 18-400 mg-mcg (Multivitamin/Iron/
*
Folic Acid)
daily multiple vitamin tab sugar
(Multivitamin)
coated *
daily multivitamin-iron tablet 18(Multivitamin/Iron/
400 mg-mcg *
Folic Acid)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
200
Name of Drug
Tier level
What the
drug will
cost you
daily value multivitamin tab s/f *
daily vit formula + iron tab 18-400
mg-mcg *
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Multivitamin)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin with
daily vitamin + iron tablet *
Iron)
daily vitamin formula tablet *
(Multivitamin)
(Multivitamin with
daily vitamin formula tablet *
Minerals)
daily vitamin tablet p/f,na/f *
(Multivitamin)
daily vite tablet s/f, p/f *
(Multivitamin)
daily vite tablet s/f,p/f *
(Multivitamin)
(Multivitamin with
daily vite with iron tablet *
Iron)
dino-life extra c tab chew *
(Multivitamin)
(Multivit with Irondino-life iron-zinc tb chew *
Minerals)
dino-life tablet chewable *
(Multivitamin)
(B1,B2,B3,B6,B12
eldertonic elixir 0.5-0.6-7-0.7 mg *
/Dexpan/Zn/Mang)
(Multivitamin with
ellis tonic *
Minerals)
(Pedi Mv
eq child complete chew tablet 18 mg
No.58/Ferrous
iron *
Fumarate)
eq complete multivitamin tab 0.4(Biocel)
eq complete multivitamin tab gluten- (Multivitamin/Iron/
free 18-400 mg-mcg *
Folic Acid)
(Multivitamin with
eql central-vite select tablet *
Minerals/Lut)
eql century mature tablet 500-300(Biocel)
250 mcg *
eql chewable multi vitamin tab *
(Multivitamin)
eql child's multivit tab chew with
(Multivitamin)
vitamin c *
(Multivit with Ironeql childs multivit-mineral tb *
Minerals)
Necessary Actions,
Restrictions, or
Limits on Use
201
Name of Drug
eql eye health plus lutein tab 1,000
unit-200 mg-60 unit-2 mg *
eql one daily 50 plus tablet *
(Beta-Carotene(A)
W-C and E/Min)
(Multivitamin with
Minerals)
(Multivitamin)
eql one daily essential tablet *
eql one daily maximum tablet 18-0.4
(Tab A Vite)
mg *
(Multivitamin with
eql one daily men's tablet *
Minerals)
ergocalciferol 8,000 units/ml 8,000
(Drisdol)
unit/ml *
(Multivitamin/Iron/
essentia tablet 18-400 mg-mcg *
Folic Acid)
(Mv,Fe,Min/Lutein
essential balance tablet *
)
essential daily tablet w/iron &
(Tab A Vite)
calcium 18-0.4 mg *
(Fe Fumarate/Vit
ferocon capsule 110-0.5 mg *
C/B12-If/Fa)
ferretts 325 mg tablet 325 mg (106
(Ferrous Fumarate)
mg iron) *
(Iron
ferrex 150 capsule outer, u-d 150
Polysaccharide
mg iron *
Complex)
(Iron
ferrex 150 plus capsule 150-50-50
Aspgly,Ps/C/Succi
mg *
nic Acid)
ferrocite tablet 324 mg (106 mg
(Ferrous Fumarate)
iron) *
ferrous fumarate 324 mg tab 324 mg
(Ferrous Fumarate)
(106 mg iron) *
ferrous gluconate 240 mg tab
240mg=27mg elemental 240 mg (27 (Fergon)
mg iron) *
ferrous gluconate 324 mg tab 324
mg (36 mg iron), 324 mg (38 mg
(Fergon)
iron) *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
202
Tier level
What the
drug will
cost you
(Fergon)
4
$0
(Ferrous Sulfate)
4
$0
(Ferrous Sulfate)
4
$0
(Ferrous Sulfate)
4
$0
(Ferrous Sulfate)
4
$0
4
$0
4
4
$0
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
ferrous gluconate 325 mg tab
p/f,s/f,gluten-free 325 mg (36 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 sulf ec 324 mg tablet 324 mg
(65 mg iron) *
ferrous sulfate 325 mg tablet red
325 mg (65 mg iron) *
flintstones extra c tab chew *
(Multivitamin)
flintstones tablet chewable *
(Multivitamin)
(Pedi Mv
flintstones with iron tab chew 18 mg
No.79/Ferrous
iron *
Fumarate)
folic acid 1 mg tablet (rx) 1 mg *
(Folic Acid)
folic acid 1,000 mcg tablet p/f,s/f
(Folic Acid)
(otc) 1 mg *
FOLIC ACID 20 MG CAPSULE 20
MG *
folic acid 400 mcg tablet
(Folic Acid)
s/f,p/f,lactose-free 400 mcg *
(Calcium/Multivita
fosfree tablet 175.5-14.5 mg *
min with Iron)
geravim liquid *
(Pediavit)
geriaton liquid *
(Pediavit)
gnp century mature tablet gluten(Biocel)
free 0.4-300-250 mg-mcg-mcg *
gnp century tablet gluten-free 18(Multivitamin/Iron/
400 mg-mcg *
Folic Acid)
gnp one daily essential tablet *
(Multivitamin)
gs prenatal vitamins tablet 28-800
(Pnv133/Ferrous
mg-mcg *
Fumarate/Fa)
flintstones complete tablet *
Necessary Actions,
Restrictions, or
Limits on Use
203
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
(Ferrous Fumarate)
4
$0
(Vitamin B
Complex)
4
$0
(Biocel)
4
$0
(Multivitamin/Iron/
Folic Acid)
4
$0
(Dialyvite 800)
4
$0
(Multivitamin)
(Multivitamin with
Minerals)
(Iron
Polysaccharide
Complex)
4
$0
4
$0
4
$0
4
$0
(Fergon)
4
$0
(Fergon)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
gummi bear multivit tab chew
multivit & minerals *
hair vitamins *
healthy eyes caplet caplet 1,000
hemocyte tablet u-u,blister pk 324
mg (106 mg iron) *
hi-b complex tablet *
hm complete 50+ tablet 0.4-300-250
mg-mcg-mcg *
hm one daily with iron tablet glutenfree 18-400 mg-mcg *
hm super vitamin b complex glutenfree 400 mcg *
honey bears chew tab *
honey bears-iron-zinc tab chew *
icaps plus tablet lactose free *
iferex 150 capsule 150 mg iron *
iron 27 mg tablet 236 mg (27 mg
iron) *
iron 28 mg tablet 256 mg (28 mg
iron) *
kenwood therapeutic liquid *
life-pack women's p/f,s/f 0.8 mg *
LIQUI-E LIQUID 400 UNIT/15
ML *
little animals child tb chw *
little animals-iron tab chew *
(Multivitamin)
(Multivitamin with
Iron)
(Vit A,C and
E/Lutein/Minerals)
(Multivitamin,Ther
apeutic)
(Multivitamin)
(Multivitamin with
Iron)
Necessary Actions,
Restrictions, or
Limits on Use
204
Name of Drug
lysiplex plus liquid *
(Pediavit)
MACUVITE EYE CARE TABLET
7,160 UNIT-113 MG-100 UNIT *
MACUVITE TABLET 5,000-60-30
UNIT-MG-UNIT *
(Multivitamin with
mega multivitamin-mineral tab *
Minerals)
(Multivitamin with
mega multivit-chelated min tab *
Minerals)
MEPHYTON 5 MG TABLET 5
MG *
(Multivitamin with
milltrium senior multivit tab *
Minerals/Lut)
multi complete-iron tablet 18-400
(Multivitamin/Iron/
mg-mcg *
Folic Acid)
multi-day plus iron tablet 18-400
(Multivitamin/Iron/
mg-mcg *
Folic Acid)
multi-delyn with iron liquid 10 mg
(Multivitamin/Ferr
iron/5 ml *
ous Gluconate)
(Multivitamin with
multiple vitamin with iron tab *
Iron)
(Multivitamin with
multiple vitamin w-minerals tb *
Minerals)
multiple vitamins tablet one daily * (Multivitamin)
multivitamin child tab chew *
(Multivitamin)
multi-vitamin daily tablet *
(Multivitamin)
(Multivitmultivitamin-mineral liquid 9 mg
Minerals/Ferrous
iron/15 ml *
Gluc)
multivit-fluor 0.5 mg tab chew
(Pedi M.Vit No.17
chewable, d/f, s/f 0.5 mg
with Fluoride)
multivit-iron child tab chew
(Multivitamin with
children's *
Iron)
(Multivitamin,Ther
multivit-mineral hp cap *
and Minerals)
(Multivitamin with
multivit-minerals tablet s/f,p/f *
Minerals)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
1
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
205
Name of Drug
my favorite multiple liquid *
myvitalife soft-gel capsule *
(Multivitamin)
(Multivitamin with
Minerals)
NASCOBAL 500 MCG NASAL
SPRAY 500 MCG/SPRAY *
nephplex rx tablet 1-60-300-12.5
mg-mg-mcg-mg *
nephron fa tablet 66.6-75-1 mg *
nephro-vite rx tablet 1-60-300 mgmg-mcg *
niacinamide er 500 mg tablet 500
mg *
nu-iron 150 capsule 150 mg iron *
ocutabs tablet s/f, w/lutein *
oncovite tablet *
one daily complete tablet *
one daily essential tablet *
one daily multivitamin tab *
one daily multivitamin tablet *
one daily multivitamin tablet 400
mcg *
one daily multivitamin-iron tb 18400 mg-mcg *
one daily plus iron tablet 18-400
mg-mcg *
one daily tablet *
one daily tablet *
(Vit B Cmplx
No3/Fa/C/Biot/Zin
c)
(Fe
Fumarate/Doss/Fa/
Bcomp,C)
(Vit B Cmplx
3/Fa/Vit C/Biotin)
(Niacinamide)
(Iron
Polysaccharide
Complex)
(Beta-Carotene(A)
W-C and E/Min)
(Multivitamin,Ther
apeutic)
(Multivitamin with
Minerals)
(Multivitamin)
(Multivitamin)
(Multivitamin with
Iron)
(Quintabs)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin with
Iron)
Tier level
What the
drug will
cost you
4
$0
4
$0
3
$0
3
$0
3
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
206
Name of Drug
one daily tablet men's formula *
(Multivitamin)
(Multivitamin with
one daily with minerals tablet *
Minerals)
one-a-day essential tablet *
(Multivitamin)
(Multivitamin with
one-a-day max formula tab *
Minerals)
one-a-day teen advantage tab 18(Multivitamin/Iron/
400 mg-mcg *
Folic Acid)
one-a-day teen advantage tab 9 mg (Multivits,Ca,Mine
iron-400 mcg *
rals/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)
(Iron
poly-iron 150 mg capsule 150 mg
Polysaccharide
iron *
Complex)
(Pediatric
poly-vita drops 1,500-35-400 unitMultivitamin
mg-unit/ml *
No.20)
poly-vita with iron drops 1,500 unit- (Ped Multivit
400 unit-10 mg/ml *
#46/Iron Sulfate)
(Pediatric
poly-vitamin drops 1,500-35-400
Multivitamin
unit-mg-unit/ml *
No.20)
poly-vitamin tab chew *
(Multivitamin)
polyvitamin w-iron drops 1,500
(Ped Multivit
unit-400 unit-10 mg/ml *
#46/Iron Sulfate)
(Prenatal Vit
prenatal tablet (otc) 27-0.8 mg *
No.130/Iron/Fa)
(Prenatal
prenatal tablet 27 mg iron- 800 mcg
Vit#96/Ferrous
*
Fum/Fa)
prenatal tablet 28 mg iron- 800 mcg (Prenatal Vit/Iron
*
Fumarate/Fa)
prenatal vitamin plus low iron oral (Pnv with
tablet 27 mg iron- 1 mg
Ca,No.72/Iron/Fa)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
2
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
(All Rx Prenatal
Vitamins Covered)
(All Rx Prenatal
Vitamins Covered)
207
Tier level
What the
drug will
cost you
(Prenatal Vit/Iron
Fumarate/Fa)
4
$0
(Prenatal)
4
$0
4
$0
4
$0
4
$0
4
$0
(Multivitamin)
4
$0
(Multivitamin)
(Multivitamin with
Iron)
(Multivitamin)
(Multivitamin)
(Ped Multivit
#17/Iron Fumarate)
(Multivitamin with
Minerals/Lut)
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
(Biocel)
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
Name of Drug
prenatal vitamin tablet 28 mg iron800 mcg *
prenatal vitamins tablet phosphorus
free 28 mg iron- 800 mcg *
prosight tablet 5,000-60-30 unit-mgunit *
pub multivitamin 50 plus tab *
pv b-100 complex *
pv b-50 complex *
pv kid's gummy bear tab chew
chewable *
pv kid's vit + extra c chew tb *
pv kid's vit + iron tab chew *
pv kid's vit complete tab chew *
pv kid's vitamins chew tab *
pv kids vitamins+iron tab chew 15
mg iron *
pv multivital platinum tablet *
pv multivital platinum tablet
w/lutein & lycopene 500-300-250
mcg *
pv prenatal formula tablet 28 mg
iron- 800 mcg *
pv stress 500 plus zinc tab *
pyridoxine 100 mg/ml vial 100
mg/ml *
qc child complete vit chew tab 18
mg iron *
qc children's chewable tablet *
(A/C/E/Zinc/Sod
Selenate/Copper)
(Multivitamin with
Minerals/Lut)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Prenatal Vit
No.131/Iron/Fa)
(Multivitamin,Stres
s Formula/Zn)
(Pyridoxine HCl)
(Pedi Mv
No.67/Ferrous
Fumarate)
(Multivitamin)
Necessary Actions,
Restrictions, or
Limits on Use
208
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Biocel)
4
$0
(Biocel)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Tab A Vite)
4
$0
(Cyanocobalamin
(Vitamin B-12))
4
$0
Name of Drug
qc maximum daily multivit tab 180.4 mg *
qc multi-vite 50 & over tablet
w/lycopene *
qc multi-vite tablet 18-400 mg-mcg
*
qc women's daily multivit tab 18-0.4
mg *
ra balanced b-100 tablet 0.4 mg *
ra b-complex tablet p/f *
ra b-complex tablet p/f *
ra central vite select tab p/f *
ra central-vite select tab p/f *
ra central-vite senior tablet 0.4-300250 mg-mcg-mcg *
ra central-vite tablet 0.4-300-250
mg-mcg-mcg *
ra central-vite tablet 18-400 mgmcg *
ra one daily energy tablet *
ra one daily plus iron tablet *
ra one daily tablet p/f *
ra prenatal tablet 28 mg iron- 800
mcg *
ra therapeutic m multivit tab 18-0.4
mg *
ra vit b-12 1,000 mcg/ml liq 1,000
mcg/ml *
(Tab A Vite)
(Multivitamin with
Minerals/Lut)
(Multivitamin/Iron/
Folic Acid)
(Tab A Vite)
(Vitamin B
Complex/Folic
Acid)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Multivitamin with
Minerals/Lut)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin with
Minerals)
(Multivitamin with
Iron)
(Multivitamin)
(Prenatal Vit/Iron
Fumarate/Fa)
Necessary Actions,
Restrictions, or
Limits on Use
209
Tier level
What the
drug will
cost you
(B-12)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
ra vitamin b-12 1,000 mcg tab
timed-release 1,000 mcg *
ra vitamin c 1,000 mg tab sa
w/bioflavonoids 1,000 mg *
ra vitamin c 500 mg tab chew p/f
500 mg *
ra vitamin c tr 500 mg caplet
caplet,p/f,s/f 500 mg *
rena-vite rx tablet 1-60-300 mg-mgmcg *
scooby-doo one a day tablet *
(Vit B Cmplx
3/Fa/Vit C/Biotin)
senior tabs 0.4-300-250 mg-mcg(Biocel)
mcg *
sentry senior multivitamin tab
(Biocel)
sodium/f,yeast/f 500-300-250 mcg *
sentry senior tablet 0.4-300-250 mg(Biocel)
mcg-mcg *
(Multivitamin/Iron/
sentry tablet 18-400 mg-mcg *
Folic Acid)
(Vit A,C, and
sm airshield effervescent tab 5,000E/Dietary Supp
1000-30 unit-mg-unit *
No.12)
sm animal shapes tab chew *
(Multivitamin)
sm animal shapes tab chew toddlers
(Multivitamin)
*
sm animal shapes w-iron tab
(Multivitamin with
children's *
Iron)
sm antioxidant vitamins tablet 1,000 (Vit A,C and
E/Lutein/Minerals)
sm b complex with vit c tablet
(Vita-Bee with C)
gluten-free *
sm complete multi-vit-mineral
(Multivitamin/Iron/
advanced formula 18-400 mg-mcg * Folic Acid)
(Multivit with Ironsm complete senior formula tab *
Minerals)
Necessary Actions,
Restrictions, or
Limits on Use
210
Name of Drug
sm complete senior formula tab 0.4(Biocel)
sm hair, skin and nails caplet caplet, (Multivitamin with
gluten-free *
Minerals)
(Multivitamin with
sm multivitamin w-iron tab *
Iron)
(Vit B Complex
sm natural balanced b-100 tab 100
100 Cmb
mg *
#2/Herbs)
sm opti-vitamin tablet 1,000 unit(Vit A,C and
200 mg-60 unit-2 mg *
E/Lutein/Minerals)
sm prenatal vitamins tablet 28 mg
(Prenatal)
iron- 800 mcg *
sm super b complex-c caplet caplet
(Vita-Bee with C)
*
(Multivit,Tx,Iron/C
sm therapeutic m tablet 27-0.4 mg *
alcm/Fa/Mins)
(Vitamin B
sm vitamin b complex tablet glutenComplex/Folic
free 0.4 mg *
Acid)
(Vitamin B
sm vitamin b-100 complex tab
Complex/Folic
gluten-free 0.4 mg *
Acid)
sm vitamin d3 4,000 unit sftgl
(D3-50)
softgel, gluten-free 4,000 unit *
sodium fluoride oral tablet 1 mg
(Pedi M.Vit No.17
fluoride (2.2 mg)
with Fluoride)
(Vitamin B
stress b tablet *
Complex)
(Multivitamin,Stres
stress b with zinc tablet *
s Formula/Zn)
(Multivitamin,Stres
stress formula tablet *
s Formula)
(Iron/Mv,Stress
stress formula with iron tab *
Form)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
211
Name of Drug
(Vit B
stress formula with iron tab 500 mgComp/C/Fa/Iron/Vi
400 mcg- 18 mg iron *
t E)
(Multivitamin,Stres
stress formula with zinc tab *
s Formula/Zn)
(Vit B
stress-c with iron tablet 500 mg-400
Comp/C/Fa/Iron/Vi
mcg- 18 mg iron *
t E)
(Mv-Min/Iron
sunvite tablet 18 mg iron-400 mcgFum/Fa/K/Lyco/Lu
25 mcg *
tn)
super b complex-c caplet caplet * (Vita-Bee with C)
(Vitamin B
super b maxi complex caplet 0.4 mg
Complex/Folic
*
Acid)
(B Complex with
super b with vit c capsule *
Vitamin C)
(Vitamin B
super b-50 complex capsule *
Complex)
(Vitamin B
super b-50 complex plus tab *
Complex)
super b-complex folic-vit c tb p/f
(Dialyvite 800)
400 mcg *
(Multivit with Ironsuper multiple vit-mineral tab *
Minerals)
super multivitamin tablet *
(Multivitamin)
(Vitamin B
super quints b-50 tablet 0.4 mg *
Complex/Folic
Acid)
(Vitamin B
super quints b-50 tablets *
Complex)
(Multivitamin,Ther
super thera vite m tablet *
and Minerals)
(Multivit with Ironsuperior 35 vit-mineral tab sa *
Minerals)
superplex-t tablet *
(Vita-Bee with C)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
212
Name of Drug
(Multivitamin with
Minerals)
(B Complex with
support-500 softgel *
Vitamin C)
sv hair, skin and nails caplet 1 mg
(Mv,Ca,Min/Iron
iron-66.7 mcg-1,000 mcg *
Gluc/Fa/Biotin)
tab-a-vite tablet *
(Multivitamin)
(Multivitamin with
tab-a-vite with iron tablet *
Iron)
(Multivitamin with
tab-a-vite-minerals tablet *
Minerals)
thera m plus tablet 9 mg iron-400
(Multivits,Ca,Mine
mcg *
rals/Iron/Fa)
(Multivitamin,Ther
thera tablet *
apeutic)
thera-d 2000 tablet 2,000 unit *
(Vitamin D3)
(Multivit,Tx,Iron/C
theradex m tablet 27-0.4 mg *
alcm/Fa/Mins)
(Multivit,Tx,Iron/C
thera-m caplet caplet 27-0.4 mg *
alcm/Fa/Mins)
thera-m tablet w/beta carotene 9 mg (Multivits,Ca,Mine
iron-400 mcg *
rals/Iron/Fa)
therapeutic-m caplet p/f, s/f, caplet 9 (Multivits,Ca,Mine
mg iron-400 mcg *
rals/Iron/Fa)
(Multivitamin,Ther
thera-tabs tablet *
apeutic)
(Multivitamin with
theratrum compl 50 plus tab *
Minerals/Lut)
theratrum complete 50 plus
(Multivit with Ironp/f,caplet *
Minerals)
thiamine 200 mg/2 ml vial
(Thiamine HCl)
25's,mdv,outer 100 mg/ml *
thiamine 500 mg tablet 500 mg *
(Thiamine HCl)
total b with vit c caplet *
(Vita-Bee with C)
(Multivitamin with
totalday multiple tablet sa *
Minerals)
support liquid *
Tier level
What the
drug will
cost you
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
4
$0
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
213
Name of Drug
(Vit A
tri-vi-sol drops 750 unit-35 mg -400
Palmitate/Vit C/Vit
unit/ml *
D3)
(Pedi Multivits
tri-vita drops 1,500-35-400 unit-mgA,C, and D3
unit/ml *
No.21)
(Pedi Multivits
tri-vitamin drops 1,500-35-400 unitA,C, and D3
mg-unit/ml *
No.21)
(Vitamin B
ultra b-100 complex tablet *
Complex)
(Multivitaminv-c forte capsule 1 mg *
Minerals No.7/Fa)
(Multivitaminvic-forte capsule 1 mg *
Minerals No.7/Fa)
(Multivitamin with
vision plus lutein vitamin tab *
Minerals/Lut)
(Beta-Carotene(A)
vision vitamins *
W-C and E/Min)
vision vitamins tablet w/lutein,p/f
(Vit A,C and
1,000 unit-200 mg-60 unit-2 mg *
E/Lutein/Minerals)
vit d2 1.25 mg (50,000 unit) 50,000
(Drisdol)
unit *
VITAFOL FE+ (WITH
DOCUSATE) ORAL CAPSULE 90
MG IRON-1 MG -50 MG-200 MG
vitalets tablet chewable child,
(Multivitamin with
orange,s/f *
Iron)
vitamin a 10,000 units capsule
(Vitamin A)
soluble 10,000 unit *
vitamin a 25,000 units capsule
(Vitamin A)
softgel 25,000 unit *
(Multivitamin,Ther
vitamin and minerals tablet *
and Minerals)
(Vit B
vitamin b complex tablet 500 mgComp/C/Fa/Iron/Vi
400 mcg- 18 mg iron *
t E)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
3
$0
3
$0
4
$0
4
$0
4
$0
3
$0
2
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
214
Tier level
What the
drug will
cost you
4
$0
4
$0
(B-12)
4
$0
(B-12)
4
$0
(B-12)
4
$0
(B-12)
4
$0
4
$0
4
$0
(Pyridoxine HCl)
4
$0
(Pyridoxine HCl)
(Fa/Vit B Complex
and C/Rice Bran)
4
$0
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Vitamin D3)
4
$0
(Vitamin D3)
4
$0
(D3-50)
4
$0
(D3-50)
4
$0
Name of Drug
vitamin b complex-vit c cap *
vitamin b complex-vit c tablet *
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 b12-folic acid tablet 500400 mcg *
vitamin b-6 250 mg tablet p/f 250
mg *
vitamin b-6 50 mg tablet 50 mg *
vitamin b-complex & c caplet p/f,no
lactose,cplt 400-500 mcg-mg *
vitamin c 1,000 mg tablet 1,000 mg
*
vitamin c 1,500 mg tablet sa
na/f,s/f,starch/free 1,500 mg *
vitamin c 250 mg tablet 250 mg *
vitamin c 250 mg tablet chew 250
mg *
vitamin c 500 mg/5 ml liquid 500
mg/5 ml *
vitamin d 1,000 unit tablet 1,000
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 *
(B Complex with
Vitamin C)
(Vita-Bee with C)
(Cyanocobalamin
(Vitamin B-12))
(Cyanocobalamin/
Folic Acid)
Necessary Actions,
Restrictions, or
Limits on Use
215
Tier level
What the
drug will
cost you
(Vitamin D3)
4
$0
(Vitamin D3)
4
$0
(Vitamin D3)
4
$0
(Cholecalciferol
(Vitamin D3))
4
$0
(D3-50)
4
$0
(Just D)
4
$0
(Phytonadione)
4
$0
(Multivitamin)
4
$0
(Biocel)
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
vitamin d3 2,000 unit tablet s/f,p/f
2,000 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 5,000 unit capsule s/f, p/f
5,000 unit *
vitamin d3 5,000 unit/ml drops a/f,
p/f,gluten-free 5,000 unit/ml *
vitamin k 100 mcg tablet p/f, glutenfree 100 mcg *
vitamins for hair tablet *
vitrum 50+ senior tablet 500-300250 mcg *
vitrum senior tablet f/f,p/f *
v-r natural b-100 tablet *
yelets tablet 18-400 mg-mcg *
zoo chews gummie tablet *
(Multivitamin with
Minerals/Lut)
(Vitamin B
Complex)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
Necessary Actions,
Restrictions, or
Limits on Use
216
INDEX
3
3 day vaginal .......................... 54
30pse-150gfn-15dm ............. 110
3-day vaginal .......................... 52
8
8-MOP.................................. 122
A
a thru z advanced formula .... 195
a thru z high potency ............ 195
a thru z select ............... 195, 196
a thru z select 50+ formula.. 195,
196
a thru z select women's ........ 196
abacavir .................................. 70
abacavir-lamivudine-zidovudine
............................................ 70
abc plus ................................ 196
ABELCET.............................. 50
ABILIFY MAINTENA ......... 66
ABRAXANE ......................... 28
ABREVA ............................... 60
acamprosate............................ 14
acarbose............................ 46, 47
acebutolol ............................... 89
acephen .................................... 3
acetaminophen ......................... 3
acetaminophen-codeine............ 3
acetazolamide ....................... 177
acetazolamide sodium .......... 178
acetic acid..................... 137, 170
acetylcysteine ....................... 191
acid gone antacid.................. 143
acid reducer (famotidine) .... 141,
142
acid relief (cimetidine) ......... 143
acitretin ................................ 122
acne medication ........... 122, 124
ACNE MEDICATION ........ 122
acne-clear ............................. 122
ACTEMRA .......................... 172
ACTHIB (PF) ....................... 164
ACTIMMUNE ..................... 172
actinel pediatric .................... 111
acyclovir ......................... 75, 122
acyclovir sodium .................... 76
ADACEL(TDAP
ADOLESN/ADULT)(PF) 164
ADAGEN ............................. 131
adapalene .............................. 130
ADCETRIS ............................ 28
ADCIRCA ............................ 194
adefovir .................................. 76
ADEMPAS........................... 194
adriamycin .............................. 28
adrucil..................................... 28
adt robitussin peak cld dm max
.......................................... 111
adult multivitamin gummies 196
adult nasal decongestant....... 118
adult one daily gummies ...... 196
adult robitussin lingering cld 111
adult robitussin peak cold dm
.......................................... 111
adult wal-tussin .................... 111
adult wal-tussin dm max ...... 111
adults 50 plus ....................... 196
adults 50+ daily formula ...... 196
adults' daily formula ............. 196
ADVAIR DISKUS ............... 188
ADVAIR HFA ..................... 188
ADVIL ................................... 11
af 52
afeditab cr ............................... 95
AFINITOR ............................. 29
AFINITOR DISPERZ ............ 28
AFTERA .............................. 102
a-hydrocort ................... 156, 157
airshield ................................ 210
AKTEN (PF) ........................ 133
AKYNZEO ............................ 62
ala-cort.................................. 126
ala-scalp................................ 126
alavert ..................................... 54
alavert d-12 allergy-sinus ....... 54
ALBENZA ............................. 64
albuterol sulfate ............ 189, 190
alcaine .................................. 133
alclometasone ....................... 126
ALCOHOL PADS ............... 122
ALCOHOL PREP PADS ..... 122
ALDURAZYME .................. 131
ALECENSA ........................... 29
alendronate ........................... 170
alfuzosin ............................... 154
ALIMTA ................................ 29
ALINIA .................................. 64
alka-seltzer plus mucus-conges
.......................................... 111
ALLEGRA ALLERGY ......... 55
aller-chlor ............................... 55
allerclear d-12hr ..................... 55
allerclear d-24hr ..................... 55
allergy (chlorpheniramine) ..... 55
allergy (diphenhydramine) ..... 56
allergy relief (cetirizine) ......... 57
allergy relief (clemastine) ...... 58
allerhist-1................................ 55
aller-tec d ................................ 55
allopurinol ............................ 172
ALLZITAL .............................. 3
almacone .............................. 144
almacone-2 ........................... 144
aloe vesta antifungal (micon) . 51
alophen ................................. 149
I-1
1
alosetron ............................... 169
ALPHAGAN P .................... 178
alprazolam .............................. 16
ALREX ................................ 140
altacaine ............................... 133
altamist ................................. 133
altavera (28) ......................... 102
aluminum hydroxide gel ...... 144
alyacen 1/35 (28).................. 103
alyacen 7/7/7 (28) ................ 103
amantadine hcl ....................... 65
ambi 10peh-4cpm-20dm ...... 111
ambi 20dm-4cpm ................. 111
ambi 40pse-400gfn-20dm .... 111
ambi 60pse-4cpm ................... 55
ambi 60pse-4cpm-20dm....... 111
AMBISOME .......................... 51
amethia ................................. 103
amethia lo ............................. 103
amifostine crystalline ........... 172
amiloride .......................... 95, 96
amiloride-hydrochlorothiazide96
AMINO ACIDS 15 % ............ 80
aminocaproic acid .................. 79
AMINOSYN 10 % ................. 80
AMINOSYN 3.5 % ................ 80
AMINOSYN 7 % ................... 80
AMINOSYN 7 % WITH
ELECTROLYTES ............. 80
AMINOSYN 8.5 % ................ 80
AMINOSYN 8.5 %ELECTROLYTES ............. 80
AMINOSYN II 10 % ............. 81
AMINOSYN II 15 % ............. 81
AMINOSYN II 7 % ............... 81
AMINOSYN II 8.5 % ............ 81
AMINOSYN II 8.5 %ELECTROLYTES ............. 81
AMINOSYN M 3.5 % ........... 81
AMINOSYN-HBC 7% .......... 81
AMINOSYN-PF 10 % ........... 81
AMINOSYN-PF 7 %
(SULFITE-FREE) .............. 81
AMINOSYN-RF 5.2 %.......... 81
amiodarone ............................. 88
AMITIZA ............................. 144
amitriptyline ........................... 43
amlactin ................................ 122
amlodipine.............................. 95
amlodipine-atorvastatin .......... 97
amlodipine-benazepril ............ 95
amlodipine-valsartan .............. 95
amlodipine-valsartan-hcthiazid
............................................ 95
ammonium lactate ................ 122
amoxapine .............................. 43
amoxicil-clarithromy-lansopraz
.......................................... 141
amoxicillin ............................. 24
amoxicillin-pot clavulanate .... 24
amphotericin b........................ 51
ampicillin ............................... 24
ampicillin sodium................... 24
ampicillin-sulbactam .............. 25
AMPYRA............................. 100
ANACAINE ......................... 122
anagrelide ............................... 79
anastrozole ............................. 29
ANDRODERM .................... 154
ANDROGEL ........................ 155
androxy................................. 155
animal chews ........................ 196
animal shape vitamins .......... 210
animal shapes plus iron ........ 210
antacid anti-gas .................... 144
antacid anti-gas (ca carb-sim)
.......................................... 145
antacid extra-strength ........... 144
antacid plus extra strength.... 144
anticoag citrate phos dextrose
.......................................... 172
anti-diarrheal ........................ 145
anti-diarrheal (loperamide).. 144,
145
antifungal (tolnaftate) ....... 51, 54
anti-gas maximum strength .. 141
antioxidant ............................ 196
antioxidant vitamins ............. 210
apatate forte .......................... 196
APOKYN ............................... 65
apraclonidine ........................ 133
apri........................................ 103
APRISO................................ 169
aprodine .................................. 55
APTIOM ................................ 38
APTIVUS ............................... 70
aquanil hc ............................. 126
aranelle (28) ......................... 103
ARCALYST ......................... 161
aripiprazole ....................... 66, 67
ARISTADA............................ 67
armodafinil ........................... 193
arthritis pain relief (acetam) ... 10
artificial tears (petro/min) .... 133
artificial tears (pf) ................. 133
artificial tears (polyvin alc) .. 133
artificial tears(dext70-hypro) 133
artificial tears(glycerin-peg) . 134
artificial tears(hypromellose) 136
ASACOL HD ....................... 169
ascomp with codeine ................ 3
ascorbic acid (vitamin c) ..... 200,
215
ashlyna.................................. 103
aspirin ..................................... 11
aspirin, buffered ..................... 11
aspirin-dipyridamole .............. 79
aspir-low ................................. 11
ASSURE ID INSULIN
SAFETY ........................... 130
ASTAGRAF XL .................. 161
atenolol ................................... 89
atenolol-chlorthalidone .......... 89
atorvastatin ............................. 97
I-2
2
atovaquone ............................. 64
atovaquone-proguanil ............ 64
ATRIPLA ............................... 70
atropine .......................... 38, 133
atropine-care ........................ 133
ATROVENT HFA ............... 190
AUBAGIO ........................... 161
aubra ..................................... 103
AVASTIN .............................. 29
AVC VAGINAL .................... 60
aviane ................................... 103
AVONEX ............................. 172
AVONEX (WITH ALBUMIN)
.......................................... 172
ayr saline ...................... 133, 134
azacitidine .............................. 29
azathioprine .......................... 161
azathioprine sodium ............. 161
azelastine .............................. 134
AZILECT ............................... 65
azithromycin .......................... 22
AZOPT ................................. 178
AZOR ..................................... 95
aztreonam ............................... 23
azurette (28) ......................... 103
B
b complete ............................ 196
b complex 1 .......................... 196
b complex 100 ...................... 211
b complex-vitamin b12 ........ 197
b complex-vitamin c-folic acid
.......................... 197, 204, 212
b-100 complex ..................... 208
b-12 dots............................... 196
b-50 complex ....................... 208
bacitracin ................ 18, 124, 137
bacitracin-polymyxin b ........ 137
bacitraycin plus .................... 124
baclofen ................................ 192
bal b-100 .............................. 199
bal b-50 ................................ 199
balance b-100 ....................... 197
balance b-50 ......................... 197
balanced b-100 ............. 197, 209
balanced b-150 ..................... 199
balanced b-50 ....................... 197
balanced b-50 complex ........ 197
balsalazide ............................ 169
balziva (28) .......................... 103
banophen ................................ 55
banophen allergy .................... 55
BANZEL ................................ 38
baza antifungal ....................... 51
BCG VACCINE, LIVE (PF) 164
b-complex............................. 209
b-complex with vitamin c ... 197,
199, 210, 215
BD INSULIN PEN NEEDLE
UF SHORT ...................... 131
BD INSULIN SYRINGE
ULTRA-FINE .................. 131
bekyree (28) ......................... 103
BELBUCA ............................... 3
BELEODAQ .......................... 29
BELSOMRA ........................ 193
benadryl allergy...................... 55
benazepril ............................... 87
benazepril-hydrochlorothiazide
............................................ 87
BENDEKA............................. 29
BENICAR .............................. 86
BENICAR HCT ..................... 86
BENLYSTA ......................... 172
benzonatate........................... 111
benzoyl peroxide .................. 122
benztropine ............................. 65
BETADINE .......................... 123
beta-hc .................................. 126
betamethasone acet,sod phos 157
betamethasone dipropionate . 126
betamethasone valerate ........ 126
betamethasone, augmented . 126,
127
BETASERON ...................... 172
betaxolol ......................... 89, 178
bethanechol chloride ............ 173
BETHKIS ............................... 17
bexarotene .............................. 29
BEXSERO (PF) ................... 164
bicalutamide ........................... 29
bicarsim forte ....................... 141
BICILLIN C-R ....................... 25
BICILLIN L-A ....................... 25
BIDIL ..................................... 99
bimatoprost ........................... 178
bio-dtuss dmx ....................... 111
bion tears (pf) ....................... 134
bionel pediatric ..................... 111
biospec dmx ......................... 111
biosupp ................................. 197
biotin .................................... 197
biovol.................................... 197
bisac-evac ............................. 149
bisacodyl .............................. 149
biscolax ................................ 149
bismatrol ............................... 144
bisoprolol fumarate ................ 89
bisoprolol-hydrochlorothiazide
............................................ 89
bleomycin ............................... 29
bleph-10................................ 137
BLINCYTO............................ 29
blisovi 24 fe .......................... 103
blisovi fe 1.5/30 (28) ............ 103
blisovi fe 1/20 (28) ............... 103
blis-to-sol (tolnaftate) ............. 51
BOOSTRIX TDAP ...... 164, 165
BOSULIF ............................... 29
bp 8 cough ............................ 112
BREO ELLIPTA .................. 188
briellyn ................................. 103
BRILINTA ............................. 80
brimonidine .......................... 178
BRINTELLIX ........................ 43
BRIVIACT ............................. 38
bromfed dm .......................... 112
I-3
3
bromfenac ............................ 140
bromocriptine ......................... 65
bromphenex dm ................... 112
brompheniramine-pseudoephdm .................... 110, 111, 112
budesonide ........................... 169
bufferin ................................... 11
bumetanide ............................. 96
BUPHENYL ........................ 144
buprenorphine hcl .............. 4, 14
buprenorphine-naloxone ........ 15
buproban ................................ 43
bupropion hcl ......................... 43
bupropion hcl (smoking deter)15
buspirone .............................. 173
butalbital compound w/codeine 4
butalbital-acetaminop-caf-cod . 4
butalbital-acetaminophen ......... 4
butalbital-acetaminophen-caff . 4
butalbital-aspirin-caffeine ........ 4
BUTRANS ............................... 4
BYSTOLIC ............................ 89
C
c complex ............................. 197
cabergoline ............................. 65
CABOMETYX ...................... 29
ca-d3-mag ox-zinc-cop-mangbor .................................... 182
caffeine citrated .................... 100
caffeine-sodium benzoate .... 100
calci-chew ............................ 144
calcidol ................................. 197
calcipotriene ......................... 123
calcitonin (salmon)............... 170
calcitrate ............................... 179
calcitrate-vitamin d .............. 179
calcitrene .............................. 123
calcitriol ............... 123, 170, 171
calcium 500 + d............ 179, 180
calcium 500 + d (d3) ............ 180
calcium 600 .......................... 179
calcium 600 + d(3) ............... 179
calcium 600 with vitamin d3 183
calcium acetate ..................... 153
calcium antacid .................... 144
calcium carbonate ........ 144, 180
calcium carbonate-vitamin d2
.......................................... 180
calcium carbonate-vitamin d3
.......... 179, 180, 181, 182, 187
CALCIUM CARBONATEVITAMIN D3 .................. 144
calcium chloride ................... 180
calcium citrate-vitamin d3 .. 180,
182
calcium gluconate ................ 180
calcium+d ............................. 188
CALDOLOR .......................... 11
cal-gest antacid ..................... 144
calphron ................................ 153
CALTRATE 600 + D ........... 180
CALTRATE WITH VITAMIN
D3 ..................................... 180
camila ................................... 103
camrese................................. 104
camrese lo ............................ 103
CANCIDAS ........................... 51
candesartan ............................. 86
candesartan-hydrochlorothiazid
............................................ 86
capacet ...................................... 4
CAPASTAT ........................... 61
CAPRELSA ..................... 29, 30
captopril ................................. 87
captopril-hydrochlorothiazide 87
CARAFATE......................... 142
CARBAGLU ........................ 144
carbamazepine ........................ 39
carbidopa ................................ 65
carbidopa-levodopa ................ 65
carbidopa-levodopa-entacapone
............................................ 65
CARIMUNE NF
NANOFILTERED ........... 161
carisoprodol .......................... 192
carteolol ................................ 134
cartia xt ................................... 91
carvedilol ................................ 89
CASTELLANI PAINT
MODIFIED ...................... 123
CAYSTON ............................. 23
caziant (28) ........................... 104
cefaclor ................................... 20
cefadroxil................................ 20
cefazolin ................................. 20
cefazolin in dextrose (iso-os) . 20
cefdinir ................................... 20
cefditoren pivoxil ................... 20
cefepime ................................. 21
CEFEPIME IN DEXTROSE 5
% ........................................ 21
CEFEPIME IN
DEXTROSE,ISO-OSM ..... 20
cefotaxime .............................. 21
cefoxitin.................................. 21
cefoxitin in dextrose, iso-osm 21
cefpodoxime ........................... 21
cefprozil.................................. 21
ceftazidime ............................. 21
ceftibuten ................................ 21
ceftriaxone .............................. 21
ceftriaxone in dextrose,iso-os. 21
cefuroxime axetil .................... 22
cefuroxime sodium ................. 22
celecoxib ................................ 11
CELLCEPT INTRAVENOUS
.......................................... 161
CELONTIN ............................ 39
centamin ............................... 197
centergy dm .......................... 112
central vite with lutein .......... 209
central-vite............................ 209
central-vite for seniors.......... 197
central-vite select ......... 201, 209
central-vite senior ................. 209
centram-care ......................... 198
I-4
4
centravites 50 plus................ 198
centrum ................................ 198
centrum complete ................. 198
centrum silver....................... 198
century.................................. 203
century adults 50+ ................ 198
century mature ..... 198, 201, 203
century ultimate women's .... 198
cephalexin .............................. 22
CEPROTIN (BLUE BAR) ..... 76
CERDELGA ........................ 173
CEREZYME ........................ 131
cerovite ................................. 198
cerovite advanced formula ... 198
certavite senior-antioxidant .. 198
certavite-antioxid (iron gluc) 198
certavite-antioxidant ............ 198
CERVARIX VACCINE (PF)
.......................................... 165
cetirizine ................................. 55
cetirizine-pseudoephedrine .... 55
cevimeline ............................ 121
CHANTIX.............................. 15
CHANTIX CONTINUING
MONTH BOX ................... 15
CHANTIX STARTING
MONTH BOX ................... 15
cheracol d ............................. 112
cheratussin dac ..................... 112
chest congestion relief + dm 113
chest congestion relief pe ..... 113
chewable multi vitamin ........ 201
child allergy relf(cetirizine) ... 57
child complete multivitamin 201
child cough and sore throat .. 113
child mucinex chest congestion
.......................................... 112
child plus cough and runnynose
.......................................... 117
child triaminic cold-allergy .... 56
child triaminic cough-congest
.......................................... 112
child triaminic cough-sore thr
.......................................... 112
child vitamin with minerals.. 199
child wal-tap cold-allergy ...... 56
child wal-tussin cough relief 112
CHILDREN'S ADVIL ........... 11
children's allegra allergy .. 55, 56
children's aller-tec .................. 56
children's chest congestion ... 113
children's chewable .............. 208
children's chewable complete
.......................................... 199
children's chewable vitamin . 198
children's chewable w/minerals
.......................................... 201
CHILDREN'S CLARITIN ..... 56
children's cold-cough daytime
.......................................... 113
children's complete vitamin . 208
children's mapap ....................... 4
children's mucinex cough ..... 112
children's multivit w/extra c . 201
children's non-aspirin ............... 4
children's pain reliever ........... 10
children's pain-fever relief ....... 4
children's pepto .................... 145
childrens plus multi-symp cold
.......................................... 118
children's silapap ...................... 4
children's silfedrine .............. 112
children's soothe ................... 145
children's sudafed ................. 112
children's sudafed pe cough . 112
children's tactinal ..................... 4
children's wal-dryl allergy...... 56
children's wal-zyr ................... 56
CHILDREN'S ZYRTEC
ALLERGY ......................... 56
childs chew vite .................... 198
child's vitamin with iron....... 199
child's vitamin with vitamin c
.......................................... 199
childs/iron............................. 198
chlophedianol-guaifenesin ... 110
chloramphenicol sod succinate
............................................ 18
chlordiazepoxide hcl .............. 16
chlorhexidine gluconate ....... 121
chloroquine phosphate ........... 64
chlorothiazide ......................... 96
chlorothiazide sodium ............ 96
chlorpheniramine-phenyleph-dm
.......................................... 110
chlorpromazine ....................... 67
chlorthalidone ......................... 96
chlorzoxazone ...................... 192
cholecalciferol (vitamin d3) 200,
215, 216
cholestyramine (with sugar) ... 97
cholestyramine light ............... 97
choline,magnesium salicylate 11
ciclopirox................................ 51
ciclopirox-ure-camph-menth-euc
............................................ 51
cilostazol ................................ 80
cimetidine ............................. 142
cimetidine hcl ....................... 142
CIMZIA................................ 161
CIMZIA POWDER FOR
RECONST........................ 161
CINQAIR ............................. 191
CINRYZE .............................. 78
CIPRODEX .......................... 137
ciprofloxacin .......................... 26
ciprofloxacin hcl............. 26, 137
ciprofloxacin in 5 % dextrose 26
ciprofloxacin lactate ............... 26
citalopram ............................... 44
citracal + d maximum........... 180
citrus calcium ....................... 180
clarithromycin .................. 22, 23
CLARITIN ............................. 56
CLARITIN LIQUI-GEL ........ 56
CLARITIN REDITABS......... 56
I-5
5
clearlax ................................. 152
CLEVIPREX.......................... 95
clindamycin hcl ...................... 18
clindamycin in 5 % dextrose .. 18
clindamycin palmitate hcl ...... 18
clindamycin pediatric ............. 18
clindamycin phosphate.... 18, 60,
124, 125
CLINIMIX 5%/D15W
SULFITE FREE ................. 81
CLINIMIX 5%/D25W
SULFITE-FREE ................ 81
CLINIMIX 2.75%/D5W
SULFIT FREE ................... 82
CLINIMIX 4.25%/D10W SULF
FREE .................................. 82
CLINIMIX 4.25%/D5W
SULFIT FREE ................... 82
CLINIMIX 4.25%-D20W
SULF-FREE ....................... 82
CLINIMIX 4.25%-D25W
SULF-FREE ....................... 82
CLINIMIX 5%D20W(SULFITE-FREE) ... 82
CLINIMIX E 2.75%/D10W
SUL FREE ......................... 82
SULF FREE ....................... 82
SUL FREE ......................... 82
SUL FREE ......................... 83
SULF FREE ....................... 83
CLINIMIX E 5%/D15W
SULFIT FREE ................... 83
CLINIMIX E 5%/D20W
SULFIT FREE ................... 83
CLINIMIX E 5%/D25W
SULFIT FREE ................... 83
CLINISOL SF 15 %............... 83
clobetasol ............................. 127
clobetasol-emollient ............. 127
clocortolone pivalate ............ 127
clomipramine ......................... 44
clonazepam............................. 16
clonidine ................................. 85
clonidine hcl ................... 85, 100
clopidogrel ............................. 80
clorazepate dipotassium ......... 16
clorpres ................................... 85
clotrimazole ............................ 51
clotrimazole-7 ........................ 51
clotrimazole-betamethasone... 51
clozapine ................................ 67
COARTEM ............................ 64
codeine sulfate.......................... 4
codituss dm .......................... 112
COLACE .............................. 149
colchicine ............................. 173
colchicine-probenecid .......... 173
cold and cough (diphenhydr-pe)
............................................ 57
cold multi-symptom day/night
.......................................... 113
cold relief m/s day/night ...... 113
cold-allergy-sinus ................... 56
cold-flu relief........................ 113
cold-flu relief, day/night ...... 113
colestipol ................................ 97
colistin (colistimethate na) ..... 18
colocort................................. 127
COLY-MYCIN S ................. 138
COMBIGAN ........................ 178
COMBIPATCH ................... 155
COMBIVENT RESPIMAT . 190
COMETRIQ ........................... 30
comfort gel ........................... 145
comfort gel extra strength .... 145
COMPLERA .......................... 70
complete 50+ ........................ 204
complete multi 50+ .............. 199
complete multivitamin . 199, 201
complete multivitamin-mineral
.................................. 201, 210
complete senior .... 199, 210, 211
compoz ................................... 56
compro.................................... 62
COMVAX (PF) .................... 165
CONDYLOX ....................... 123
congestac .............................. 113
congest-eze ........................... 113
constulose ............................. 145
COPAXONE ........................ 173
coricidin hbp......................... 113
coricidin hbp cold-multi sympt
.......................................... 113
CORLANOR .......................... 92
cormax .................................. 127
cortisone ............................... 157
cortizone-10.......................... 127
CORTIZONE-10 .................. 127
COSENTYX ........................ 123
COSENTYX (2 SYRINGES)
.......................................... 123
COSENTYX PEN ................ 123
COSENTYX PEN (2 PENS) 123
COTELLIC ............................ 30
cough and cold ..................... 113
cough and runny nose........... 119
cough relief........................... 113
CREON ................................ 132
CRESTOR .............................. 97
critic-aid clear af .................... 51
CRIXIVAN ............................ 70
cromolyn .............. 134, 145, 192
cryselle (28) .......................... 104
CUBICIN ............................... 18
CUBICIN RF ......................... 18
cyanocobalamin (vitamin b-12)
.......... 196, 200, 209, 210, 215
cyclafem 1/35 (28) ............... 104
cyclafem 7/7/7 (28) .............. 104
cyclobenzaprine.................... 192
cyclopentolate ...................... 134
I-6
6
cyclophosphamide.................. 30
CYCLOPHOSPHAMIDE...... 30
CYCLOSET ........................... 47
cyclosporine ......................... 161
cyclosporine modified .......... 161
cyproheptadine ....................... 57
CYRAMZA............................ 30
cyred ..................................... 104
CYSTADANE ..................... 173
CYSTARAN ........................ 134
cysteine (l-cysteine) ............... 83
D
.......................................... 181
d2.5 %-0.45 % sodium chloride
.......................................... 181
d3 dots .................................. 200
d5 % and 0.9 % sodium chloride
.......................................... 181
.......................................... 181
dactinomycin .......................... 30
daily gummies ...................... 199
daily multiple ............... 199, 200
daily multi-vitamin............... 205
daily multivitamin with iron 200
daily multi-vitamins/iron ..... 200
daily teen multi-vitamin ....... 199
daily value ............................ 201
daily vitamin ........................ 201
daily vitamin formula ........... 201
daily vitamin formula + iron 201
daily vitamin formula-minerals
.......................................... 201
daily vitamin with iron ......... 201
daily vites/iron ..................... 201
dailyhist-1 .............................. 57
daily-vite .............................. 201
DAKLINZA ........................... 74
DALIRESP .......................... 192
danazol ................................. 155
dantrolene ............................. 192
dapsone................................... 61
DAPTACEL (DTAP
PEDIATRIC) (PF) ........... 165
DARAPRIM........................... 64
DARZALEX .......................... 30
dasetta 1/35 (28) ................... 104
dasetta 7/7/7 (28) .................. 104
dayhist allergy ........................ 57
daysee ................................... 104
daytime cold and cough ....... 114
daytime cold-flu ................... 114
day-time cough ..................... 114
daytime-nighttime ................ 117
daytime-nighttime cold-flu .. 113
daytime-nighttime cough ..... 114
deblitane ............................... 104
decitabine ............................... 30
decongestant cough .............. 119
deep sea nasal ....................... 134
deferoxamine ........................ 154
delsym cough-chest congest dm
.......................................... 114
delyla (28) ............................ 104
DELZICOL .......................... 170
DEMSER ............................... 92
DEPEN TITRATABS .......... 154
DEPO-PROVERA ............... 160
dermafungal ........................... 52
dermarest eczema (hydrocort)
.......................................... 127
DESCOVY ............................. 70
desipramine ............................ 44
desmopressin ........................ 158
desog-e.estradiol/e.estradiol . 104
desogestrel-ethinyl estradiol 104
desonide ............................... 127
desoximetasone .................... 127
despec-dm (pseudoeph-dmguaif) ................................ 114
dex4 glucose ........................... 83
dexamethasone ..................... 157
dexamethasone sodium
phosphate.................. 140, 157
dexmethylphenidate ............. 101
dextroamphetamine .............. 101
dextroamphetamineamphetamine .................... 101
dextromethorphan polistirex 114
dextrose 10 % and 0.2 % nacl
.......................................... 181
............................................ 83
............................................ 83
............................................ 83
............................................ 83
dextrose 5 % in ringers ........... 84
dextrose 5 % in water (d5w) .. 84
dextrose 5 %-lactated ringers181
dextrose 5%-0.2 % sod chloride
.......................................... 181
dextrose 5%-0.3 % sod.chloride
.......................................... 181
............................................ 84
............................................ 84
dextrose with sodium chloride
.......................................... 181
dextrose-kcl-nacl .................. 181
diabetic tussin dm ................. 114
diamode ................................ 145
diazepam .......................... 16, 17
diazepam intensol ................... 16
diclofenac potassium .............. 12
diclofenac sodium .......... 12, 140
diclofenac-misoprostol ........... 12
dicloxacillin ............................ 25
dicyclomine .......................... 145
didanosine .............................. 71
DIFICID ................................. 23
I-7
7
diflunisal ................................ 12
digitek .................................... 92
digox ...................................... 92
digoxin ............................. 92, 93
DIGOXIN .............................. 93
dihydroergotamine ........... 60, 61
DILANTIN ............................ 39
diltiazem hcl ........................... 91
dilt-xr...................................... 91
dimaphen (pe) ........................ 57
dimenhydrinate ...................... 62
dimetapp cold-congestion ...... 57
dino-life ................................ 201
dino-life with extra c ............ 201
dino-life with iron-zinc ........ 201
DIPENTUM ......................... 170
diphenhist ............................... 57
diphenhydramine hcl .............. 57
diphenoxylate-atropine ........ 145
dipyridamole .......................... 80
disopyramide phosphate......... 88
disulfiram ............................... 15
divalproex .............................. 39
dobutamine............................. 93
dobutamine in d5w................. 93
doc-q-lace ............................. 150
docu ...................................... 150
docusate sodium ................... 150
docusol ................................. 150
dofetilide ................................ 88
dok........................................ 150
donepezil ................................ 42
dopamine ................................ 93
dopamine in 5 % dextrose ...... 93
dorzolamide.......................... 178
dorzolamide-timolol............. 178
douche vinegar and water extra
.......................................... 176
doxazosin ............................... 86
doxepin................................... 44
doxercalciferol ..................... 171
doxorubicin, peg-liposomal ... 30
doxy-100 ................................ 27
doxycycline hyclate................ 27
doxycycline monohydrate 27, 28
dramamine .............................. 62
dramamine less drowsy .......... 62
driminate ................................ 62
dristan long lasting ............... 134
dronabinol .............................. 62
droperidol ............................. 173
drospirenone-ethinyl estradiol
.......................................... 104
DROXIA ................................ 30
DUAVEE ............................. 155
dulcolax stool softener (dss) 150
DULERA ............................. 189
duloxetine ............................... 44
DUREZOL ........................... 140
dutasteride ............................ 173
dutasteride-tamsulosin ......... 173
DYRENIUM .......................... 96
E
e.c. prin ................................... 12
e.e.s. 400................................. 23
e.e.s. granules ......................... 23
econazole ................................ 52
econtra ez ............................. 104
ed a-hist .................................. 57
ed bron gp............................. 114
ed chlorped jr ......................... 57
EDURANT............................. 71
effer-k ................................... 181
EFFIENT ................................ 80
ELAPRASE ......................... 132
eldertonic .............................. 201
electrolyte-48 in d5w ........... 181
ELIDEL ................................ 127
ELIGARD .............................. 30
elinest ................................... 104
eliphos .................................. 153
ELIQUIS ................................ 76
ELITEK ................................ 132
ELLA ................................... 104
ellis tonic .............................. 201
ELMIRON............................ 173
elon dual defense .................... 52
EMCYT .................................. 31
EMEND............................ 62, 63
emoquette ............................. 104
EMPLICITI ............................ 31
EMSAM ................................. 44
EMTRIVA.............................. 71
EMVERM .............................. 64
enalapril maleate .................... 87
enalaprilat ............................... 87
enalapril-hydrochlorothiazide 87
ENBREL ...................... 161, 162
ENBREL SURECLICK ....... 162
endocet ..................................... 5
endodan .................................... 5
endur-acin ............................... 97
enema ........................... 150, 152
enema disposable ......... 149, 150
enemeez ................................ 150
enemeez plus ........................ 150
ENGERIX-B (PF) ................ 165
.......................................... 165
enoxaparin .............................. 76
enpresse ................................ 104
enskyce ................................. 104
entacapone .............................. 65
entecavir ................................. 76
entre-cough ........................... 114
ENTRESTO ........................... 86
enulose.................................. 145
ENVARSUS XR .................. 162
EPCLUSA .............................. 74
ephedrine sulfate .................... 93
epinastine.............................. 134
epinephrine ....................... 93, 94
epinephrine hcl (pf) ................ 93
EPIPEN 2-PAK ...................... 94
EPIPEN JR 2-PAK................. 94
epitol ....................................... 39
I-8
8
EPIVIR HBV ......................... 71
eplerenone .............................. 99
EPOGEN ................................ 78
epoprostenol (glycine) ......... 194
EPZICOM .............................. 71
eq gentle ............................... 134
equalactin ............................. 150
ergocalciferol (vitamin d2) . 202,
214
ergoloid ................................ 173
ERGOMAR............................ 61
ERIVEDGE............................ 31
errin ...................................... 105
ery pads ................................ 125
ery-tab .................................... 23
ERY-TAB .............................. 23
ERYTHROCIN ...................... 23
erythrocin (as stearate) ........... 23
erythromycin .................. 23, 138
erythromycin ethylsuccinate .. 23
erythromycin with ethanol ... 125
ESBRIET ............................. 192
escitalopram oxalate............... 44
esmolol ................................... 89
esomeprazole sodium ........... 142
essentia ................................. 202
essential balance with lutein 202
essential daily ....................... 202
estarylla ................................ 105
ESTRACE ............................ 155
estradiol ........................ 155, 156
estradiol valerate .................. 156
estradiol-norethindrone acet. 156
estropipate ............................ 156
eszopiclone........................... 193
ethambutol.............................. 61
ethamolin................................ 94
ethosuximide .......................... 39
etodolac .................................. 12
ETOPOPHOS ........................ 31
etoposide ................................ 31
EVOTAZ................................ 71
exemestane ............................. 31
EXJADE............................... 154
expectorant ........................... 114
expectorant dm ..................... 114
expectorant max strength ..... 114
EXTAVIA ............................ 173
extra cleansing douche ......... 175
eye health plus lutein............ 202
F
FABRAZYME ..................... 132
falmina (28) .......................... 105
famciclovir ............................. 76
famotidine .................... 142, 143
famotidine (pf) ..................... 142
famotidine (pf)-nacl (iso-os) 142
FANAPT ................................ 67
FARESTON ........................... 31
FARYDAK ............................ 31
FASLODEX ........................... 31
felbamate ................................ 39
felodipine ............................... 95
feminine care douche ........... 175
FEMRING ............................ 156
fenofibrate .............................. 97
fenofibrate micronized ........... 97
fenofibrate nanocrystallized ... 97
fenofibric acid ........................ 97
fenofibric acid (choline) ......... 97
fenoprofen .............................. 12
fentanyl..................................... 5
fentanyl citrate.......................... 5
ferocon ................................. 202
ferretts .................................. 202
ferrex 150 ............................. 202
ferrex 150 plus ..................... 202
FERRIPROX ........................ 154
ferrocite ................................ 202
ferrous fumarate ................... 202
ferrous gluconate .. 202, 203, 204
ferrous sulfate ............... 198, 203
FETZIMA .............................. 44
feverall ..................................... 5
fexofenadine ........................... 58
fiber (calcium polycarbophil)
.......................................... 150
fiber laxative (methylcellulo)152
fiber smooth ......................... 152
fiber therapy (m-cell/sugar).. 150
fiber therapy (m-cellulose) ... 149
fiber therapy (psyllium)........ 150
fiber therapy (psyllium/sugar)
.......................................... 150
fiber-lax ................................ 150
fibertab ................................. 150
finasteride ............................. 173
FIRAZYR ............................... 94
flanax antacid ....................... 145
FLEBOGAMMA DIF .......... 162
flecainide ................................ 88
FLECTOR .............................. 12
FLEET BISACODYL .......... 150
flintstones complete (iron) ... 203
flintstones multivitamin ....... 203
flintstones with iron.............. 203
flintstones/extra c ................. 203
FLOVENT DISKUS ............ 189
FLOVENT HFA................... 189
floxuridine .............................. 31
flu formula daytime-nighttime
.......................................... 117
flu relief therapy daytime ..... 117
flu severe cold-congestion.... 119
flucaine ................................. 135
fluconazole ............................. 52
fluconazole in dextrose(iso-o) 52
fluconazole in nacl (iso-osm) . 52
flucytosine .............................. 52
fludrocortisone ..................... 157
flumazenil ............................. 101
flunisolide............................. 140
fluocinonide.......................... 128
fluocinonide-e ...................... 128
fluorometholone ................... 140
fluorouracil ..................... 31, 123
I-9
9
fluoxetine ......................... 44, 45
fluphenazine decanoate .......... 67
fluphenazine hcl ............... 67, 68
flurbiprofen ............................ 12
flurbiprofen sodium ............. 140
flutamide ................................ 31
fluticasone .................... 128, 140
fluvoxamine ........................... 45
foaming antacid ............ 145, 148
folic acid............................... 203
FOLIC ACID ....................... 203
fomepizole............................ 173
fondaparinux .................... 76, 77
foot odor control .................... 54
FORTEO .............................. 171
FORTICAL .......................... 171
foscarnet ................................. 74
fosfree .................................. 203
fosinopril ................................ 87
fosinopril-hydrochlorothiazide
............................................ 87
fosphenytoin ........................... 39
FREAMINE HBC 6.9 %........ 84
FREAMINE III 10 % ............. 84
fungi cure ............................... 52
FUNGI-NAIL ........................ 52
fungoid-d ................................ 52
furosemide.............................. 96
FUSILEV ............................. 173
FUZEON ................................ 71
FYCOMPA ...................... 39, 40
G
gabapentin .............................. 40
GABITRIL ............................. 40
galantamine ...................... 42, 43
GAMASTAN S/D ................ 162
GAMMAGARD LIQUID .... 162
GAMMAPLEX .................... 162
ganciclovir sodium ................. 76
GARDASIL (PF) ................. 165
GARDASIL 9 (PF) ...... 165, 166
gas relief ............................... 141
gas relief extra strength ........ 141
gas-x ultra-strength .............. 141
gatifloxacin........................... 138
GATTEX 30-VIAL .............. 146
GATTEX ONE-VIAL.......... 146
GAUZE PAD ....................... 173
gavilyte-c .............................. 150
gavilyte-g ............................. 150
gavilyte-n ............................. 151
GAZYVA ............................... 31
gelusil antacid and anti-gas .. 146
gemfibrozil ............................. 97
generlac ................................ 146
gengraf ................................. 162
GENOTROPIN .................... 158
GENOTROPIN MINIQUICK
.......................................... 158
gentak ................................... 138
gentamicin .............. 17, 125, 138
gentamicin in nacl (iso-osm) .. 17
gentamicin sulfate (ped) (pf) .. 17
gentamicin sulfate (pf) ........... 17
GENTEAL MILD TO
MODERATE ................... 135
GENTEAL GEL .................. 135
GENTEAL MILD ................ 135
GENTEAL SEVERE ........... 135
genteal tears.......................... 135
gentlelax ............................... 151
GENVOYA ............................ 71
GEODON ............................... 68
geravim................................. 203
geriaton................................. 203
geri-hydrolac ........................ 123
geri-tussin dm ....................... 114
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 ............................ 173
GILOTRIF.............................. 31
GLEOSTINE .......................... 31
glimepiride ....................... 49, 50
glipizide .................................. 50
glipizide-metformin................ 50
GLUCAGEN HYPOKIT ..... 173
GLUCAGON EMERGENCY
KIT (HUMAN) ................ 173
gluco burst .............................. 84
glucose.................................... 84
glucose gel .............................. 84
glutose 15 ............................... 84
glyburide ................................ 50
glyburide micronized ............. 50
glyburide-metformin .............. 50
glycolax ................................ 151
glycopyrrolate ...................... 146
glydo ....................................... 14
GLYXAMBI .......................... 47
granisetron (pf) ....................... 63
granisetron hcl ........................ 63
GRANIX ................................ 78
griseofulvin microsize ............ 52
guaifenesin ........................... 115
guaifenesin dac ..................... 115
guanfacine ...................... 86, 101
guanidine .............................. 174
gummi bear multivitamin .... 204,
208
gummy swirls ....................... 199
H
hair vitamins ......................... 204
hair,skin and nails......... 211, 213
halobetasol propionate ......... 128
haloperidol.............................. 68
haloperidol decanoate............. 68
haloperidol lactate .................. 68
HARVONI ............................. 74
HAVRIX (PF) ...................... 166
head congestion day-night.... 115
healthy eyes .......................... 204
I-10
10
healthylax ............................. 151
heather .................................. 105
hemocyte .............................. 204
heparin (porcine) .................... 77
heparin (porcine) in 5 % dex .. 77
heparin (porcine) in nacl (pf) . 77
heparin(porcine) in 0.45% nacl
............................................ 77
heparin, porcine (pf)............... 77
HEPATAMINE 8% ............... 84
HEPATASOL 8 % ................. 84
HERCEPTIN.......................... 31
HETLIOZ ............................. 193
HEXALEN ............................. 31
hi-b complex ........................ 204
hi-cal plus vit d..................... 187
homatropaire ........................ 135
homatropine hbr ................... 135
honey bears .......................... 204
honey bears with iron-zinc ... 204
HUMIRA ............................. 162
HUMIRA PEN ..................... 162
HUMIRA PEN CROHN'S-UCHS START ....................... 162
HUMULIN R U-500 (CONC)
KWIKPEN ................... 48, 49
HUMULIN R U-500
(CONCENTRATED) ......... 49
hydralazine ............................. 94
hydrochlorothiazide ............... 96
hydrocil instant..................... 151
hydrocodone-acetaminophen ... 5
hydrocodone-chlorpheniramine
.......................................... 115
hydrocodone-homatropine ... 115
hydrocodone-ibuprofen ............ 5
hydrocortisone...... 128, 129, 157
hydrocortisone acet-aloe vera
.......................................... 128
hydrocortisone acetate ......... 128
hydrocortisone butyrate ....... 128
hydrocortisone butyr-emollient
.......................................... 128
hydrocortisone valerate ........ 129
hydromet .............................. 115
hydromorphone ........................ 6
hydromorphone (pf) ................. 5
hydroskin .............................. 128
hydroxychloroquine ............... 64
hydroxyprogesterone caproate
.......................................... 160
hydroxyurea ........................... 31
hydroxyzine hcl .................... 174
hydroxyzine pamoate ........... 174
HYPERLYTE CR ................ 182
HYPERRAB S/D (PF) ......... 162
HYQVIA .............................. 163
HYQVIA IG COMPONENT
.......................................... 162
HYSINGLA ER ....................... 6
I
ibandronate ........................... 171
IBRANCE .............................. 32
ibuprofen .................... 11, 12, 13
ibuprofen jr strength ............... 12
icaps plus .............................. 204
ICLUSIG ................................ 32
iferex 150 ............................. 204
ifosfamide............................... 32
ifosfamide-mesna ................... 32
ILARIS (PF) ......................... 163
ILEVRO ............................... 140
imatinib .................................. 32
IMBRUVICA ......................... 32
imipenem-cilastatin ................ 23
imipramine hcl ....................... 45
imipramine pamoate ............... 45
imiquimod ............................ 123
IMLYGIC............................... 32
imodium a-d ......................... 146
IMODIUM A-D ................... 146
IMOGAM RABIES-HT (PF)
.......................................... 163
IMOVAX RABIES VACCINE
(PF) ................................... 166
INCRELEX .......................... 158
indapamide ............................. 96
indomethacin .................... 12, 13
indomethacin sodium ............. 13
INFANRIX (DTAP) (PF) .... 166
infant's ibuprofen .................... 13
INFANT'S MOTRIN ............. 13
infants' non-aspirin cold ....... 121
INLYTA ................................. 32
insta-glucose ........................... 84
INSULIN SYRINGE-NEEDLE
U-100................................ 131
INTELENCE .......................... 71
INTRALIPID ......................... 84
INTRON A ............................. 75
introvale................................ 105
INVANZ ................................ 23
INVEGA SUSTENNA........... 68
INVEGA TRINZA ................. 68
INVIRASE ............................. 71
INVOKAMET........................ 47
INVOKANA .......................... 47
inzo antifungal ........................ 52
iodine .................................... 131
IONOSOL-B IN D5W ......... 182
IONOSOL-MB IN D5W ...... 182
IPOL ..................................... 166
ipratropium bromide..... 135, 190
ipratropium-albuterol ........... 190
IPRIVASK ............................. 77
irbesartan ................................ 86
irbesartan-hydrochlorothiazide
............................................ 86
IRESSA .................................. 32
iron high potency.................. 199
ISENTRESS ........................... 71
ISOLYTE M IN 5 %
DEXTROSE ..................... 182
ISOLYTE-H IN 5 %
DEXTROSE ..................... 182
I-11
11
ISOLYTE-P IN 5 %
DEXTROSE ..................... 182
ISOLYTE-S ......................... 182
isoniazid ................................. 62
isopto tears ........................... 135
isosorbide dinitrate ................. 99
isosorbide mononitrate ........... 99
isradipine ................................ 95
itraconazole ............................ 52
ivermectin .............................. 64
IXEMPRA.............................. 32
IXIARO (PF) ....................... 166
J
JAKAFI .................................. 32
jantoven .................................. 77
JANUMET ............................. 47
JANUMET XR ...................... 47
JANUVIA .............................. 47
JARDIANCE ......................... 47
jencycla ................................ 105
JENTADUETO ...................... 47
JENTADUETO XR ............... 47
jolessa ................................... 105
jolivette ................................ 105
jr. acetaminophen ................... 10
juleber .................................. 105
junel 1.5/30 (21) ................... 105
junel 1/20 (21) ...................... 105
junel fe 1.5/30 (28) ............... 105
junel fe 1/20 (28) .................. 105
junel fe 24 ............................ 105
junior mapap ............................ 6
JUXTAPID ............................ 97
K
KABIVEN.............................. 84
KALETRA ............................. 71
KALYDECO........................ 192
KANUMA............................ 132
kaopectate (bismuth subsalicy)
.......................................... 146
kariva (28) ............................ 105
k-effervescent ....................... 182
kelnor 1/35 (28) .................... 106
KELP (IODINE) .................. 182
ketoconazole........................... 52
ketoprofen .............................. 13
ketorolac ......................... 13, 140
KEVEYIS............................. 174
KEYTRUDA .......................... 33
kids mini enema ................... 149
kid's vitamins ....................... 208
kid's vitamins + extra c ........ 208
kids vitamins + iron ............. 208
kid's vitamins + iron ............. 208
kimidess (28) ........................ 106
KINERET............................. 163
KINRIX (PF)........................ 166
kionex ................................... 146
klor-con 10 ........................... 182
klor-con m10 ........................ 182
klor-con m15 ........................ 183
klor-con m20 ........................ 183
klor-con sprinkle .................. 183
konsyl (sugar) ....................... 151
konsyl fiber .......................... 151
KONSYL SUGAR-FREE .... 151
KORLYM .............................. 47
KRYSTEXXA ..................... 132
kurvelo ................................. 106
KUVAN ............................... 132
KYNAMRO ........................... 98
KYPROLIS ............................ 33
L
l norgest/e.estradiol-e.estrad 106
labetalol .................................. 90
LACRISERT ........................ 135
LACTATED RINGERS ...... 170
LACTINOL HX ................... 123
lactulose ............................... 146
LAMICTAL ........................... 40
LAMISIL (AEROSOL) ......... 53
lamisil af................................. 53
LAMISIL AT ......................... 53
lamivudine........................ 71, 72
lamivudine-zidovudine........... 72
lamotrigine ............................. 40
LANOXIN.............................. 94
lansoprazole.......................... 142
LANTUS ................................ 49
LANTUS SOLOSTAR .......... 49
larin 1.5/30 (21) .................... 106
larin 1/20 (21) ....................... 106
larin 24 fe ............................. 106
larin fe 1.5/30 (28)................ 106
larin fe 1/20 (28)................... 106
latanoprost ............................ 178
LATUDA ............................... 68
laxative peg 3350 ................. 152
LAZANDA .............................. 6
leena 28 ................................ 106
leflunomide .......................... 163
LEMTRADA........................ 174
LENVIMA ............................. 33
lessina ................................... 106
LETAIRIS ............................ 194
letrozole .................................. 33
leucovorin calcium ............... 174
LEUKERAN .......................... 33
LEUKINE .............................. 78
leuprolide................................ 33
levetiracetam .......................... 40
levobunolol ........................... 178
levocarnitine ......................... 174
levocarnitine (with sugar) .... 174
levocetirizine .......................... 58
levofloxacin .............. 26, 27, 138
levofloxacin in d5w ................ 26
levonest (28) ......................... 106
levonorgestrel ....................... 106
levonorgestrel-ethinyl estrad 106
levonorg-eth estrad triphasic 107
levora-28 .............................. 107
levothyroxine........................ 160
LEXIVA ................................. 72
lice cream rinse .................... 130
lice killing............................. 130
I-12
12
lice treatment ........................ 130
lice treatment (permethrin) .. 130
lidocaine ................................. 14
lidocaine (pf) .................... 14, 88
lidocaine hcl ........................... 14
lidocaine in 5 % dextrose (pf) 88
lidocaine viscous .................... 14
lidocaine-prilocaine................ 14
life-pack women's ................ 204
linezolid.................................. 18
LINZESS.............................. 146
liothyronine .......................... 160
lipodox ................................... 33
lipodox 50 .............................. 33
liquibid d-r ........................... 115
liquid calcium with vitamin d
.......................................... 183
LIQUI-E ............................... 204
lisinopril ................................. 87
lisinopril-hydrochlorothiazide 88
lithium carbonate ................. 101
lithium citrate ....................... 101
little animals ......................... 204
little animals-iron ................. 204
lobana bath ........................... 123
lohist-dm .............................. 115
lomedia 24 fe........................ 107
lomustine ................................ 33
LONSURF ............................. 33
loperamide............ 145, 146, 148
loratadine................................ 58
loratadine-d ............................ 58
lorazepam ............................... 17
lorcet (hydrocodone) ................ 6
lorcet hd ................................... 6
lorcet plus ................................. 6
lortuss ex .............................. 115
loryna (28) ............................ 107
losartan ................................... 86
losartan-hydrochlorothiazide . 86
LOTEMAX .......................... 140
LOTRONEX ........................ 146
lovastatin ................................ 98
low-ogestrel (28) .................. 107
loxapine succinate .................. 68
lubricant dry eye relief ......... 134
lubricant eye ......................... 134
lubricant eye (cmc-glycer)(pf)
.......................................... 135
lubricant eye (cmc-glycerin) 135
lubricant eye (pg-peg 400) ... 137
lubricant eye (polyv alcohol) 136
lubricant eye (propyl glycol) 135
lubricant eye drops ............... 134
lubricant gel.......................... 134
lubricating drops .................. 134
lubrifresh pm ........................ 135
LUMIGAN ........................... 178
LUPRON DEPOT .................. 34
............................................ 33
............................................ 33
............................................ 34
LUPRON DEPOT-PED ....... 158
LUPRON DEPOT-PED (3
MONTH) .......................... 158
lutera (28) ............................. 107
LYNPARZA .......................... 34
LYRICA ................................. 40
lysiplex plus ......................... 205
LYSODREN .......................... 34
lyza ....................................... 107
M
maalox advanced .................. 147
MACUVITE......................... 205
MACUVITE EYE CARE .... 205
mag 64 .................................. 183
mag-delay ............................. 183
mag-g ................................... 183
MAGNEBIND 300 .............. 147
magnebind 400 ..................... 153
magnesium ................... 181, 183
magnesium (oxide/aa chelate)
.......................................... 183
magnesium chloride ............. 183
magnesium gluconate ........... 183
magnesium oxide ......... 147, 148
magnesium sulf in 0.45% nacl
.......................................... 183
magnesium sulfate ................ 184
magnesium sulfate in d5w .... 183
magnesium sulfate in water . 183,
184
malathion .............................. 130
mapap (acetaminophen) ........... 6
mapap arthritis pain .................. 6
mapap extra strength ................ 6
maprotiline ............................. 45
mar-cof bp ............................ 115
mar-cof cg ............................ 115
margesic ................................... 6
marlissa ................................ 107
MARPLAN ............................ 45
masanti double strength........ 147
MATULANE ......................... 34
matzim la ................................ 91
maximum daily multivitamin
.......................................... 209
maximum strength flu .......... 117
meclizine ................................ 63
medroxyprogesterone ........... 160
mefenamic acid ...................... 13
mefloquine.............................. 64
MEFOXIN IN DEXTROSE
(ISO-OSM) ......................... 22
mega multiple/chelated mineral
.......................................... 205
mega multivitamin with mineral
.......................................... 205
MEGACE ES ....................... 160
megestrol ........................ 34, 160
MEKINIST ............................. 34
meloxicam .............................. 13
memantine .............................. 43
I-13
13
MENACTRA (PF) ............... 166
MENEST.............................. 156
MENHIBRIX (PF) ............... 166
MENOMUNE - A/C/Y/W-135
(PF) .................................. 167
men's daily gummies ............ 199
men's multi-vitamin ............. 199
men's one daily..................... 202
MENVEO A-C-Y-W-135-DIP
(PF) .................................. 167
MENVEO MENA
COMPONENT (PF)......... 167
MENVEO MENCYW-135
COMPNT (PF) ................. 167
MEPHYTON ....................... 205
mercaptopurine ...................... 34
meropenem ....................... 23, 24
mesehist dm ......................... 115
mesna ................................... 174
MESNEX ............................. 174
MESTINON ......................... 174
MESTINON TIMESPAN .... 174
metaproterenol ..................... 190
metaxall ................................ 192
metaxalone ........................... 193
metformin ......................... 47, 48
methadone ................................ 7
methadose ................................ 7
methazolamide ..................... 178
methenamine hippurate .......... 18
methimazole ......................... 161
methocarbamol ..................... 193
methotrexate sodium .............. 34
methotrexate sodium (pf) ....... 34
methoxsalen rapid ................ 124
methscopolamine ................. 147
methyclothiazide .................... 96
methylphenidate ........... 101, 102
methylprednisolone .............. 157
methylprednisolone acetate .. 157
methylprednisolone sodium succ
.......................................... 157
metipranolol ......................... 178
metoclopramide hcl .............. 147
metolazone ............................. 96
metoprolol succinate .............. 90
metoprolol ta-hydrochlorothiaz
............................................ 90
metoprolol tartrate .................. 90
metronidazole ........... 19, 60, 125
metronidazole in nacl (iso-os) 19
mexiletine ............................... 88
mgo....................................... 147
MIACALCIN ....................... 171
mi-acid ................................. 147
mi-acid gas relief .................. 141
micatin .................................... 53
miconazole 7 .......................... 53
miconazole nitrate ............ 52, 53
miconazole-3 .......................... 53
microgestin 1.5/30 (21) ........ 107
microgestin 1/20 (21) ........... 107
microgestin fe 1.5/30 (28) .... 107
microgestin fe 1/20 (28) ....... 107
midodrine ............................... 86
miglitol ................................... 48
milk of magnesia .................. 151
milltrium senior .................... 205
milrinone ................................ 94
milrinone in 5 % dextrose ...... 94
mimvey................................. 156
mimvey lo ............................ 156
mineral oil .................... 175, 177
MINERAL OIL .................... 174
mineral oil laxative............... 151
minitran .......................... 99, 100
minocycline ............................ 28
minoxidil .............................. 100
mintox .................................. 147
mintox maximum strength ... 147
mintox plus........................... 147
MIRCERA ............................. 78
mirtazapine ............................. 45
misoprostol ........................... 142
mitoxantrone .......................... 34
M-M-R II (PF)...................... 167
moexipril ................................ 88
moexipril-hydrochlorothiazide
............................................ 88
molindone............................... 68
mometasone.......................... 129
MONISTAT 3 ........................ 53
monistat 7 ............................... 53
mono-linyah ......................... 107
mononessa (28) .................... 107
montelukast .......................... 189
morphine .............................. 7, 8
MORPHINE ............................. 8
morphine (pf) in 0.9 % nacl ..... 7
morphine concentrate ............... 7
morphine in dextrose 5 % ........ 7
morrhuate sodium................. 174
motion sickness ...................... 62
motion sickness (meclizine) ... 63
MOVANTIK ........................ 148
MOVIPREP.......................... 151
MOXEZA ............................. 138
moxifloxacin .......................... 27
MOZOBIL.............................. 78
mucus dm ............................. 115
mucus dm max ..................... 115
mucus relief .................. 115, 117
mucus relief cough ............... 119
MULTAQ ............................... 88
multi complete with iron ...... 205
multi-day with iron ............... 205
multi-delyn with iron............ 205
multiple vitamin-minerals .... 205
multiple vitamins.................. 205
multiple vitamins with iron .. 205
multi-symptom cold night time
.......................................... 117
multivital platinum ............... 208
multivitamin 50 plus ............ 208
multi-vitamin hp/minerals .... 205
multivitamin with fluoride ... 205
I-14
14
multivitamin with iron . 205, 211
multivitamin with minerals .. 205
multi-vite .............................. 209
multi-vite 50 and over .......... 209
mupirocin ............................. 125
mupirocin calcium ............... 125
muro 128 .............................. 135
my favorite multiple ............. 206
my way ................................. 107
myco nail a ............................. 53
mycophenolate mofetil......... 163
mycophenolate sodium ........ 163
MYOZYME ......................... 132
MYRBETRIQ ...................... 153
mytab gas ............................. 141
mytab gas maximum strength
.......................................... 141
my-vitalife ............................ 206
myzilra ................................. 107
N
nabumetone ............................ 13
nadolol.................................... 90
nafcillin .................................. 25
NAGLAZYME .................... 132
naloxone ................................. 15
naltrexone............................... 15
NAMENDA XR..................... 43
NAMZARIC .......................... 43
naphazoline .......................... 136
naproxen ................................. 13
naproxen sodium .................... 13
naratriptan .............................. 61
NARCAN............................... 15
nasal and sinus decongestant 115
nasal decongestant (oxymetazl)
.......................................... 136
NASCOBAL ........................ 206
nasohist dm .......................... 115
NATACYN .......................... 138
nateglinide .............................. 48
NATPARA ........................... 171
natural b-100 ........................ 216
natural b-100 complex ......... 211
natural balance ..................... 136
natural calcium ..................... 184
natural fiber laxative therapy 151
natural tears (pf) ................... 134
nature's tears (hypromellose) 136
NEBUPENT ........................... 65
necon 0.5/35 (28) ................. 107
necon 1/35 (28) .................... 107
necon 1/50 (28) .................... 107
necon 10/11 (28) .................. 107
necon 7/7/7 (28) ................... 108
nefazodone ............................. 45
neomycin ................................ 17
neomycin-bacitracin-poly-hc 138
neomycin-bacitracin-polymyxin
.......................................... 138
neomycin-polymyxin b gu ... 125
neomycin-polymyxin bdexameth .......................... 138
neomycin-polymyxingramicidin ........................ 138
neomycin-polymyxin-hc ..... 138,
139
neo-polycin........................... 139
neo-polycin hc ...................... 139
neosporin (neo-bac-polym) .. 125
neosporin anti-itch................ 129
neo-synephrine 12 h spr (oxym)
.......................................... 136
neo-tuss ................................ 115
nephplex rx........................... 206
NEPHRAMINE 5.4 % ........... 85
nephron fa ............................ 206
nephro-vite rx ....................... 206
NEULASTA........................... 78
NEUMEGA ............................ 78
NEUPOGEN .......................... 79
NEUPRO................................ 66
NEVANAC .......................... 140
nevirapine ............................... 72
NEXAFED ........................... 115
NEXAVAR ............................ 34
next choice one dose ............ 108
niacin ...................................... 98
niacinamide .................... 98, 206
niacor ...................................... 98
nicardipine .............................. 95
NICODERM CQ .................... 15
nicorelief ................................ 15
nicorette .................................. 15
nicotine ............................. 15, 16
nicotine (polacrilex) ......... 15, 16
NICOTROL............................ 16
nifedical xl .............................. 95
nifedipine................................ 95
night time ............................. 117
night time cold-flu ................ 119
night time cold-flu relief ...... 119
night time cough-sore throat 116
nighttime cough .................... 116
nikki (28) .............................. 108
NILANDRON ........................ 34
nilutamide............................... 34
NINLARO .............................. 34
NITE TIME COLD-FLU
RELIEF ............................ 116
nite time-d cold-flu relief ..... 116
NITRO-BID ......................... 100
nitrofurantoin macrocrystal .... 19
............................................ 19
nitroglycerin ......................... 100
nitroglycerin in 5 % dextrose100
NITROSTAT........................ 100
NIX CREME RINSE ........... 130
nohist-dm.............................. 116
non-aspirin cold .................... 119
non-aspirin extra strength ..... 8, 9
non-aspirin flu ...................... 121
non-aspirin jr strength .............. 5
nora-be.................................. 108
NORDITROPIN FLEXPRO 159
norepinephrine bitartrate ........ 94
I-15
15
norethindrone (contraceptive)
.......................................... 108
norethindrone acetate ........... 160
norethindrone ac-eth estradiol
.......................................... 108
norethindrone-e.estradiol-iron
.......................................... 108
norgestimate-ethinyl estradiol
.......................................... 108
norlyroc ................................ 108
NORMOSOL-M IN 5 %
DEXTROSE ..................... 184
NORMOSOL-R PH 7.4 ....... 184
nortemp .................................... 8
NORTHERA .......................... 86
nortrel 0.5/35 (28) ................ 108
nortrel 1/35 (21) ................... 108
nortrel 1/35 (28) ................... 108
nortrel 7/7/7 (28) .................. 108
nortriptyline............................ 45
NORVIR ................................ 72
NOVOLIN 70/30 ................... 49
NOVOLIN N ......................... 49
NOVOLIN R .......................... 49
NOVOLOG ............................ 49
NOVOLOG FLEXPEN ......... 49
NOVOLOG MIX 70-30 ......... 49
NOVOLOG MIX 70-30
FLEXPEN .......................... 49
NOVOLOG PENFILL ........... 49
NOXAFIL .............................. 53
NUCALA ............................. 192
NUCYNTA .............................. 8
NUCYNTA ER ........................ 8
NUEDEXTA ........................ 102
nu-iron .................................. 206
NULOJIX ............................. 163
nu-mag ................................. 184
NUPLAZID............................ 68
NUTRESTORE.................... 148
NUTRILIPID ......................... 85
NUTRILYTE ....................... 184
NUTRILYTE II.................... 184
NUVARING ........................ 108
NUVIGIL ............................. 193
nyamyc ................................... 53
nystatin ............................. 53, 54
nystatin-triamcinolone ........... 54
nystop ..................................... 54
nyt-time sleep ......................... 58
O
OCALIVA ............................ 148
ocean nasal ........................... 136
ocella .................................... 108
OCTAGAM ......................... 163
octreotide acetate.................. 159
ocutabs ................................. 206
ODEFSEY .............................. 72
ODOMZO .............................. 35
OFEV ................................... 192
ofloxacin......................... 27, 139
ogestrel (28) ......................... 108
olanzapine ........................ 68, 69
olanzapine-fluoxetine ............. 45
olopatadine ........................... 136
OLYSIO ................................. 74
omega-3 acid ethyl esters ....... 98
omeprazole ........................... 142
omeprazole magnesium........ 142
omeprazole-sodium bicarbonate
.................................. 142, 143
ONCASPAR .......................... 35
oncovite ................................ 206
ondansetron ............................ 63
ondansetron hcl ...................... 63
ondansetron hcl (pf) ............... 63
one daily ............... 206, 207, 209
one daily 50 plus .................. 202
one daily complete ............... 206
one daily energy ................... 209
one daily essential 202, 203, 206
one daily maximum (with ca)
.......................................... 202
one daily multi-vit w-mineral
.......................................... 206
one daily multivitamin ......... 206
one daily multivit-iron(folic) 206
one daily plus iron 204, 206, 209
one daily plus minerals......... 207
one daily with iron ............... 206
one-a-day essential ............... 207
one-a-day maximum formula207
one-a-day teen advantage ..... 207
ONFI .............................. 17, 129
opcicon one-step................... 108
OPDIVO ................................. 35
OPSUMIT ............................ 194
opti-vitamins ........................ 211
oral saline laxative................ 151
oralone .................................. 121
ORENCIA ............................ 163
ORENCIA (WITH MALTOSE)
.......................................... 163
ORENCIA CLICKJECT ...... 174
ORENITRAM ...................... 194
ORFADIN .................... 132, 175
ORKAMBI ........................... 192
orsythia ................................. 108
OTEZLA .............................. 175
OTEZLA STARTER ........... 175
OTREXUP (PF) ................... 175
oxacillin .................................. 25
oxacillin in dextrose(iso-osm) 25
oxandrolone .......................... 155
oxcarbazepine ................... 40, 41
OXTELLAR XR .................... 41
oxybutynin chloride ............. 153
oxycodone ................................ 8
oxycodone-acetaminophen ... 8, 9
oxycodone-aspirin .................... 9
OXYCONTIN .......................... 9
oxymorphone............................ 9
oysco 500/d .......................... 184
oysco d ................................. 184
oysco-500 ............................. 184
I-16
16
oyster shell calcium 500....... 184
oyster shell calcium with d .. 187
oyster shell calcium-vit d3 .. 184,
185
oystercal-d ............................ 185
P
pacerone ................................. 89
pain relief ................................. 9
pain relief adult ........................ 5
pain reliever jr strength .......... 10
paliperidone............................ 69
pancrelipase 5000................. 132
PANRETIN .......................... 124
PANTILINERS .................... 175
pantoprazole ......................... 142
papaverine ........................ 94, 95
paricalcitol............................ 171
paromomycin ......................... 65
paroxetine hcl ......................... 45
PASER ................................... 62
PATADAY .......................... 136
PAXIL .................................... 45
pecgen dmx .......................... 116
pedia relief ........................... 119
pedia relief cough-cold ........ 116
pedia relief infant ................. 121
pediacare multi-symptom cold
.......................................... 116
PEDIARIX (PF) ................... 167
pediatric electrolyte ..... 181, 185,
187
pediatric freezer pops ........... 187
pediatric multivitamin .. 205, 210
PEDVAX HIB (PF) ............. 167
peg 3350-electrolytes ........... 151
PEGANONE .......................... 41
PEGASYS .............................. 75
PEGASYS PROCLICK ......... 75
peg-electrolyte soln .............. 151
PEGINTRON ......................... 75
PEN NEEDLE, DIABETIC . 131
penicillin g pot in dextrose ..... 25
penicillin g potassium ...... 25, 26
penicillin g procaine ............... 26
penicillin v potassium ............ 26
PENTACEL (PF) ................. 167
PENTACEL ACTHIB
COMPONENT (PF) ......... 167
PENTAM ............................... 65
pentoxifylline ......................... 80
pep-t-med ............................. 147
peri-colace ............................ 151
PERIKABIVEN ..................... 85
perindopril erbumine .............. 88
periogard .............................. 121
permethrin ............................ 130
perphenazine .......................... 69
perphenazine-amitriptyline .... 45
persa-gel ............................... 124
pfizerpen-g ............................. 26
pharbetol................................... 9
pharmacist favorite multi-vit 207
phenadoz ................................ 63
phenelzine .............................. 46
phenobarbital .......................... 41
phenobarbital sodium ............. 41
phenylephrine hcl ........... 86, 136
phenylhistine dh ................... 116
phenytoin ................................ 41
phenytoin sodium ................... 41
phenytoin sodium extended ... 41
philith ................................... 109
phillips.................................. 148
phillips liqui-gels.................. 151
PHOSLYRA......................... 153
PHOS-NAK ......................... 185
phospha 250 neutral ............. 185
phosphate laxative ................ 151
PHOSPHOLINE IODIDE.... 178
phytonadione (vitamin k1) ... 216
PICATO ............................... 124
pilocarpine hcl .............. 121, 178
pimozide ................................. 69
pimtrea (28) .......................... 109
pindolol .................................. 90
pink bismuth ......................... 148
pioglitazone ............................ 48
pioglitazone-glimepiride ........ 48
pioglitazone-metformin .......... 48
piperacillin-tazobactam .......... 26
pirmella ................................ 109
piroxicam................................ 13
PLAN B ONE-STEP ............ 109
PLASMA-LYTE 148 ........... 185
PLASMA-LYTE A .............. 185
PLASMA-LYTE-56 IN 5 %
DEXTROSE ..................... 185
PLEGRIDY .......................... 175
podocon ................................ 124
podofilox .............................. 124
polyethylene glycol 3350 .... 151,
152
poly-iron ............................... 207
polymyxin b sulfate ................ 19
polymyxin b sulf-trimethoprim
.......................................... 139
poly-tussin ............................ 116
poly-vita ............................... 207
poly-vita (iron) ..................... 207
poly-vitamin ......................... 207
poly-vitamin with iron.......... 207
poly-vitamins........................ 207
POMALYST .......................... 35
portia .................................... 109
PORTRAZZA ........................ 35
potassium acetate ................. 185
potassium bicarb and chloride
.......................................... 185
potassium bicarb-citric acid . 185
potassium chlorid-d5-0.45%nacl
.......................................... 185
potassium chloride ....... 186, 187
potassium chloride in 0.9%nacl
.......................................... 185
potassium chloride in 5 % dex
.......................................... 185
I-17
17
potassium chloride in lr-d5 .. 185
potassium chloride-0.45 % nacl
.......................................... 186
.......................................... 186
.......................................... 186
.......................................... 186
potassium citrate .................. 186
potassium citrate-citric acid . 186
potassium hydroxide ............ 124
potassium phosphate m-/d-basic
.......................................... 187
POTIGA ................................. 41
PRADAXA ............................ 77
PRALUENT PEN .................. 98
PRALUENT SYRINGE ........ 98
pramipexole............................ 66
pravastatin .............................. 98
prazosin .................................. 86
prednicarbate ........................ 129
prednisolone acetate ............. 140
prednisolone sodium phosphate
.................................. 140, 157
prednisone .................... 157, 158
PREMARIN ......................... 156
PREMASOL 10 % ................. 85
PREMASOL 6 % ................... 85
PREMPHASE ...................... 156
PREMPRO ........................... 156
prenatal ................. 203, 208, 211
prenatal formula ................... 208
prenatal plus (calcium carb) . 207
prenatal tablet ....................... 209
prenatal vit#96-ferrous fum-fa
.......................................... 207
prenatal vitamin ........... 199, 207
prenatal vitamin plus low iron
.......................................... 207
prenatal vitamin with minerals
.......................................... 208
prenatal vit-iron fumarate-fa 207
preparation h hydrocortisone 129
PREVAIL BLADDER
CONTROL PAD .............. 149
prevalite .................................. 98
PREVIDENT 5000 SENSITIVE
.......................................... 122
previfem ............................... 109
PREZCOBIX ......................... 72
PREZISTA ............................. 72
PRIFTIN................................. 62
PRILOSEC OTC .................. 142
PRIMAQUINE....................... 65
primidone ............................... 41
PRISTIQ................................. 46
PRIVIGEN ........................... 163
PROAIR HFA ...................... 190
PROAIR RESPICLICK ....... 190
probenecid ............................ 175
procainamide .......................... 89
PROCALAMINE 3% ............ 85
prochlorperazine..................... 63
prochlorperazine edisylate ..... 63
prochlorperazine maleate ....... 63
PROCRIT ............................... 79
procto-med hc ...................... 129
procto-pak ............................ 129
proctosol hc .......................... 129
proctozone-hc ....................... 129
PROCYSBI .......................... 175
progesterone in oil ................ 160
progesterone micronized ...... 160
PROGLYCEM ..................... 100
PROGRAF ........................... 164
PROLASTIN-C .................... 192
PROLENSA ......................... 141
PROLEUKIN ......................... 35
PROLIA ............................... 171
PROMACTA ......................... 79
promethazine .................... 58, 64
promethazine vc-codeine ..... 116
promethazine-codeine .......... 116
promethazine-dm.................. 116
promethegan ........................... 64
promolaxin ........................... 152
propafenone ............................ 89
propantheline .......................... 38
proparacaine ......................... 136
propranolol ............................. 90
propranolol-hydrochlorothiazid
............................................ 90
propylthiouracil .................... 161
PROQUAD (PF) .................. 167
prosight ................................. 208
PROSOL 20 % ....................... 85
protamine................................ 79
protriptyline ............................ 46
pseudoephedrine hcl ............. 116
PULMOZYME .................... 132
pure and gentle eye............... 136
purelax .................................. 149
PURIXAN .............................. 35
pyrazinamide .......................... 62
pyridostigmine bromide ....... 175
pyridoxine (vitamin b6)........ 208
Q
q-dryl ...................................... 58
q-pap ......................................... 9
q-pap extra strength .................. 9
q-tapp dm ............................. 117
q-tussin ................................. 117
q-tussin dm ........................... 117
QUADRACEL (PF) ............. 167
quasense ............................... 109
quetiapine ............................... 69
QUILLIVANT XR ............... 102
quinapril ................................. 88
quinapril-hydrochlorothiazide 88
quinidine gluconate ................ 89
quinidine sulfate ..................... 89
quinine sulfate ........................ 65
QVAR .................................. 189
R
RABAVERT (PF) ................ 168
I-18
18
raloxifene ............................. 156
ramipril ................................... 88
RANEXA ............................... 95
ranitidine hcl ........................ 143
RAPAMUNE ....................... 164
RASUVO (PF) ..................... 176
RAVICTI ............................. 148
react ...................................... 109
REBIF (WITH ALBUMIN) 176
REBIF REBIDOSE .............. 176
REBIF TITRATION PACK 176
reclipsen (28) ....................... 109
RECOMBIVAX HB (PF) .... 168
recort plus............................. 129
refenesen .............................. 117
refenesen pe ......................... 117
REFRESH CELLUVISC ..... 136
REFRESH CLASSIC (PF) .. 136
REFRESH LACRI-LUBE ... 136
REFRESH OPTIVE ............. 136
REFRESH OPTIVE
ADVANCED ................... 139
reguloid ................................ 152
relcof c ................................. 117
RELENZA DISKHALER ...... 74
RELISTOR .......................... 148
remedy phytoplex antifungal . 54
REMICADE ......................... 176
REMODULIN...................... 194
RENAGEL ........................... 153
rena-vite rx ........................... 210
RENVELA ........................... 153
repaglinide.............................. 48
repaglinide-metformin ........... 48
REPATHA PUSHTRONEX .. 98
REPATHA SURECLICK ...... 98
REPATHA SYRINGE ........... 98
reprexain ................................ 10
RESCRIPTOR ....................... 72
RESTASIS ........................... 141
retaine cmc ........................... 136
RETROVIR............................ 72
revive plus ............................ 135
REVLIMID ............................ 35
revonto ................................. 193
REXULTI............................... 69
REYATAZ ............................. 72
REZIRA ............................... 117
ribasphere ............................... 76
RIDAURA ........................... 164
rifabutin .................................. 62
rifampin .................................. 62
RIFATER ............................... 62
ri-gel ii .................................. 148
riluzole ................................. 102
rimantadine............................. 74
ri-mox ................................... 148
ringers........................... 170, 187
risedronate ............................ 171
RISPERDAL CONSTA ......... 69
risperidone .............................. 69
RITUXAN .............................. 35
rivastigmine ............................ 43
rivastigmine tartrate ............... 43
rizatriptan ............................... 61
robafen ................................. 118
robafen cough ....................... 118
robafen dm ........................... 118
robitussin cough-chest cong dm
.......................................... 118
ROBITUSSIN LONG-ACTING
.......................................... 118
robitussin pediatric ............... 118
ropinirole ................................ 66
rosadan ................................. 125
rosuvastatin ............................ 99
ROTARIX ............................ 168
ROTATEQ VACCINE ........ 168
roxicet..................................... 10
ROZEREM........................... 193
rydex..................................... 118
rynex dm .............................. 118
S
SABRIL ................................. 41
safe tussin dm ....................... 118
SAIZEN................................ 159
SAIZEN CLICK.EASY ....... 159
saline mist............................. 136
SANDOSTATIN LAR DEPOT
.......................................... 159
SANTYL .............................. 124
SAPHRIS (BLACK CHERRY)
............................................ 69
SAVELLA............................ 102
scooby-doo one a day ........... 210
scot-tussin dm....................... 118
scot-tussin expectorant ......... 118
sea soft nasal mist................. 137
selegiline hcl........................... 66
selenium sulfide ................... 125
SELZENTRY ......................... 73
senexon ................................. 152
senior tabs............................. 210
senna ..................................... 152
senna lax ............................... 152
senna laxative ....................... 149
senna with docusate sodium . 150
senokot-s .............................. 152
SENSIPAR ........................... 176
sentry .................................... 210
sentry senior ......................... 210
SEREVENT DISKUS .......... 190
SEROSTIM .......................... 159
sertraline ................................. 46
setlakin ................................. 109
sharobel ................................ 109
SIGNIFOR ........................... 176
silace ..................................... 152
siladryl sa ............................... 58
silapap .................................... 10
sildenafil ............................... 195
SILENOR ............................... 46
siltussin sa ............................ 118
siltussin-dm .......................... 118
silver nitrate .......................... 126
silver sulfadiazine................. 126
I-19
19
SIMBRINZA........................ 178
simethicone .......................... 141
simply sleep ........................... 58
SIMPONI ............................. 176
SIMPONI ARIA .................. 176
simvastatin ............................. 99
sinus and allergy(pseudoephed)
............................................ 58
sirolimus............................... 164
SIRTURO .............................. 62
skin treatment ....................... 123
sleep aid (diphenhydramine) .. 58
sleep aid (doxylamine) ........... 58
smoothlax ............................. 152
sodium acetate ...................... 187
sodium bicarbonate ...... 148, 187
sodium chloride ... 137, 170, 188,
192
sodium chloride 0.45 % ....... 187
sodium chloride 0.9 % ......... 187
sodium chloride 3 % ............ 187
sodium chloride 5 % ............ 187
sodium fluoride ............ 122, 211
sodium lactate ...................... 188
sodium phosphate................. 188
sodium polystyrene (sorb free)
.......................................... 148
sodium polystyrene sulfonate
.......................................... 148
sodium thiosulfate ................ 154
SOLTAMOX ......................... 35
SOLU-CORTEF (PF) .......... 158
SOMATULINE DEPOT ...... 159
SOMAVERT........................ 160
soothe (bismuth subsalicylate)
.......................................... 149
soothe regular strength ......... 149
sorbitol ................................. 170
sorbitol-mannitol .................. 170
sorine ...................................... 90
sotalol ..................................... 90
sotalol af ................................. 90
SOVALDI .............................. 74
spectravite ............................ 200
spectravite adult 50+ ............ 199
spectravite advanced formula
.......................................... 200
spectravite senior.................. 200
spectravite senior w-lycopene
.......................................... 200
spectravite ultra women ....... 200
SPIRIVA RESPIMAT ......... 190
SPIRIVA WITH
HANDIHALER ............... 190
spironolactone ........................ 99
spironolacton-hydrochlorothiaz
............................................ 99
sprintec (28) ......................... 109
SPRITAM .............................. 41
SPRYCEL .............................. 35
sps......................................... 149
sronyx ................................... 109
ssd......................................... 126
st joseph aspirin ...................... 13
st. joseph aspirin ..................... 14
stavudine ................................ 73
STELARA ............................ 177
STERILE PADS .................. 177
STIOLTO RESPIMAT .......... 38
STIVARGA ........................... 35
stomach relief ....................... 148
stool softener ........................ 149
STRATTERA....................... 102
STRENSIQ........................... 132
streptomycin ........................... 17
stress 500 plus zinc .............. 208
stress b with zinc .................. 211
stress b-biotin ....................... 211
stress formula ....................... 211
stress formula plus iron ........ 211
stress formula with iron........ 212
stress formula with zinc ....... 212
STRIBILD .............................. 73
STRIVERDI RESPIMAT .... 191
sucralfate .............................. 143
sudafed ................................. 119
sudogest ................................ 119
sudogest sinus and allergy ...... 59
sulfacetamide sodium ........... 139
sulfacetamide sodium (acne) 126
sulfacetamide-prednisolone.. 139
sulfadiazine ............................ 27
sulfamethoxazole-trimethoprim
............................................ 27
sulfasalazine ........................... 27
sulfatrim ................................. 27
sulindac .................................. 14
sumatriptan ............................. 61
sumatriptan succinate ............. 61
summer's eve disposable douche
.......................................... 177
summers eve extra cleansing 177
sunvite .................................. 212
super b complex-vitamin c .. 200,
211, 212
super b maxi complex .......... 212
super b/c ............................... 212
super b-50 complex .............. 212
super b-50 complex plus ...... 212
super multiple ....................... 212
super multivitamin ............... 212
super quints .......................... 212
super quints b-50 .................. 212
super thera vite m ................. 212
superior 35 ............................ 212
superplex-t ............................ 212
suphedrin .............................. 119
suphedrine pe day-night ....... 119
suphedrine severe cold max str
.......................................... 119
support .................................. 213
support-500 .......................... 213
SUPPRELIN LA .................. 160
SUPRAX ................................ 22
SURMONTIL ........................ 46
SUSTIVA ............................... 73
I-20
20
SUTENT ................................ 35
syeda .................................... 109
SYLATRON .......................... 75
SYLVANT ............................. 35
SYMLINPEN 120 .................. 48
SYMLINPEN 60 .................... 48
SYNAGIS .............................. 74
SYNAREL ........................... 177
SYNERCID............................ 19
SYNJARDY........................... 48
SYNRIBO .............................. 35
SYPRINE ............................. 154
SYSTANE (PROPYLENE
GLYCOL) ........................ 137
SYSTANE GEL ................... 137
T
tab-a-vite .............................. 213
tab-a-vite/iron ....................... 213
tab-a-vite-minerals ............... 213
TABLOID .............................. 35
tacrolimus ..................... 129, 164
tactinal .................................... 10
tactinal extra strength ............. 10
TAFINLAR ............................ 36
TAGRISSO ............................ 36
TALTZ AUTOINJECTOR .. 124
TALTZ SYRINGE............... 124
TAMIFLU .............................. 74
tamoxifen ............................... 36
tamsulosin ............................ 154
TARCEVA ............................. 36
TARGRETIN ......................... 36
tarina fe 1/20 (28)................. 109
TASIGNA .............................. 36
tazicef ..................................... 22
TAZORAC ........................... 130
taztia xt ................................... 91
tears again ............................ 137
tears again (pva) ................... 137
tears naturale free (pf) .......... 137
TECENTRIQ ......................... 36
TECFIDERA........................ 177
TECHNIVIE .......................... 74
TEFLARO .............................. 22
telmisartan .............................. 86
telmisartan-hydrochlorothiazid
............................................ 87
TEMODAR ............................ 36
tencon ..................................... 10
TENIVAC (PF) .................... 168
terazosin ............................... 154
terbinafine hcl ........................ 54
terbutaline............................. 191
terconazole ............................. 60
testosterone........................... 155
testosterone cypionate .......... 155
testosterone enanthate .......... 155
TETANUS
TOXOID,ADSORBED (PF)
.......................................... 168
TETANUS,DIPHTHERIA TOX
PED(PF) ........................... 168
tetanus-diphtheria toxoids-td 168
tetrabenazine ........................ 102
tetracaine hcl (pf) ................. 137
tetracycline ............................. 28
THALOMID ........................ 177
the magic bullet .................... 151
theochron .............................. 191
theophylline .......................... 191
theophylline in dextrose 5 % 191
thera m plus (ferrous fumarat)
.......................................... 213
thera vitamin ........................ 213
thera-d .................................. 213
theradex m ............................ 213
THERAFLU DAYTIME
COLD-COUGH ............... 119
THERAFLU MULTISYMPTOM COLD .......... 119
thera-m ................................. 213
therapeutic liquid.................. 204
therapeutic m + beta-carotene
.......................................... 209
therapeutic-m........................ 213
therapeutic-m vitamin/minerals
.......................................... 211
thera-tabs .............................. 213
theratrum complete 50 plus .. 213
theratrum complete 50 plus/lut
.......................................... 213
thiamine hcl (vitamin b1) ..... 213
thioridazine ............................. 69
thiotepa ................................... 36
thiothixene .............................. 70
tiagabine ................................. 42
TICE BCG ............................ 164
TIKOSYN .............................. 89
tilia fe ................................... 109
timolol maleate ............... 90, 178
TIVICAY ............................... 73
tizanidine .............................. 193
TOBI PODHALER ................ 17
TOBRADEX ........................ 139
TOBRADEX ST .................. 139
tobramycin............................ 139
tobramycin in 0.225 % nacl ... 17
tobramycin in 0.9 % nacl ....... 18
tobramycin sulfate .................. 18
tobramycin-dexamethasone.. 139
TOLAK ................................ 124
tolazamide .............................. 50
tolbutamide............................. 50
tolmetin .................................. 14
tolnaftate ................................. 54
tolterodine ............................ 153
topiragen ................................. 42
topiramate ............................... 42
toposar .................................... 36
torsemide ................................ 96
total b/c ................................. 213
totalday multiple................... 213
TOUJEO SOLOSTAR ........... 49
TOVIAZ ............................... 153
TPN ELECTROLYTES ....... 188
TPN ELECTROLYTES II ... 188
I-21
21
TRACLEER ......................... 195
TRADJENTA ........................ 48
tramadol ................................. 10
tramadol-acetaminophen ........ 10
trandolapril ............................. 88
tranexamic acid ...................... 79
TRANSDERM-SCOP............ 64
tranylcypromine ..................... 46
TRAVASOL 10 % ................. 85
TRAVATAN Z .................... 179
travel sickness (meclizine) ..... 64
travoprost (benzalkonium) ... 179
trazodone ................................ 46
TREANDA ............................ 36
TRECATOR .......................... 62
TRELSTAR ..................... 36, 37
tretinoin ................................ 130
tretinoin (chemotherapy) ........ 37
tretinoin microspheres .......... 130
TREXALL ............................. 37
triacting m-sym cold/cough . 121
triamcinolone acetonide ...... 122,
129, 158
triaminic cold and cough (pe)
.......................................... 120
TRIAMINIC COLD AND
COUGHNT(PE) ................. 59
TRIAMINIC COUGH-SORE
THROAT ......................... 120
triamterene-hydrochlorothiazid
...................................... 96, 97
trianex .................................. 129
TRIBENZOR ......................... 87
tri-buffered aspirin ................. 13
tri-dex pe .............................. 120
tri-estarylla ........................... 109
trifluoperazine ........................ 70
trifluridine ............................ 139
trihexyphenidyl ...................... 66
tri-legest fe ........................... 109
tri-linyah ............................... 109
tri-lo-estarylla ....................... 109
tri-lo-marzia ......................... 109
tri-lo-sprintec ........................ 109
trilyte with flavor packets .... 153
trimethoprim........................... 19
trimipramine ........................... 46
trinessa (28) .......................... 110
TRINTELLIX ........................ 46
triple antibiotic ............. 125, 126
triple paste af .......................... 54
tri-previfem (28) ................... 110
tri-sprintec (28) .................... 110
TRIUMEQ ............................. 73
tri-vi-sol ................................ 214
tri-vita ................................... 214
tri-vitamin............................. 214
trivora (28) ........................... 110
TROKENDI XR ..................... 42
TROPHAMINE 10 % ............ 85
TROPHAMINE 6% ............... 85
trospium ............................... 154
TRULICITY........................... 48
TRUMENBA ....................... 168
TRUVADA ............................ 73
trymine cg ............................ 120
TUDORZA PRESSAIR ....... 191
tusnel diabetic ...................... 120
TUSNEL NEW FORMULA 120
TUSNEL PEDIATRIC ........ 120
TUSSI PRES-B .................... 120
tussin cf ........................ 119, 121
tussin cf cough-cold ............. 120
tussin cold-congestion .......... 120
tussin cough (dm only) ......... 114
tussin dm ...................... 117, 120
tussin dm cough and chest ... 114
tussin maximum strength ..... 114
tussin pe................................ 117
TWINRIX (PF) .................... 168
TYBOST .............................. 177
TYGACIL .............................. 28
TYKERB ................................ 37
TYPHIM VI ......................... 169
TYSABRI............................. 164
TYVASO.............................. 195
TYVASO REFILL KIT ....... 195
TYVASO STARTER KIT ... 195
TYZEKA ................................ 76
U
u-cort .................................... 130
ULORIC ............................... 177
ultra b-100 complex ............. 214
ultra fresh pm ....................... 137
ultra strength antacid ............ 144
unisom sleepgels .................... 59
UNITUXIN ............................ 37
UPTRAVI ............................ 195
ursodiol ................................. 149
V
VAGIFEM............................ 156
valacyclovir ............................ 76
VALCHLOR ........................ 124
valganciclovir ......................... 76
valproate sodium .................... 42
valproic acid ........................... 42
valproic acid (as sodium salt) . 42
valsartan ................................. 87
valsartan-hydrochlorothiazide 87
VALSTAR ............................. 37
valu-tapp dm......................... 118
VANACOF .......................... 120
vancomycin ............................ 20
vancomycin in dextrose 5 % .. 19
VAQTA (PF) ........................ 169
VARIVAX (PF) ................... 169
VASCEPA.............................. 99
v-c forte ................................ 214
VELCADE ............................. 37
velivet triphasic regimen (28)
.......................................... 110
VENCLEXTA ........................ 37
VENCLEXTA STARTING
PACK ................................. 37
venlafaxine ............................. 46
VENTOLIN HFA................. 191
I-22
22
verapamil.......................... 91, 92
VERSACLOZ ........................ 70
vestura (28) .......................... 110
VGO 40 ................................ 131
VIBERZI .............................. 149
vic-forte ................................ 214
vicks dayquil cold-flu relief . 120
vicks dayquil cough ............. 120
vicks nature fusion cough .... 120
vicks nyquil severe cold-flu . 120
vicks qlearquil(oxymetazoline)
.......................................... 137
vicks sinex 12-hour .............. 137
vicodin.................................... 10
vicodin es ............................... 10
vicodin hp............................... 10
VICTOZA .............................. 48
............................................ 73
............................................ 73
VIEKIRA PAK ...................... 75
vienva ................................... 110
VIGAMOX .......................... 139
VIIBRYD ............................... 46
VIMIZIM ............................. 132
VIMPAT ................................ 42
vinorelbine ............................. 37
viorele (28) ........................... 110
VIRACEPT ............................ 73
VIRAMUNE XR ................... 73
VIRAZOLE............................ 76
virdec dm ............................. 120
VIREAD ................................ 73
virt-phos 250 neutral ............ 188
virtussin ac ........................... 120
vision .................................... 214
vision formula (with lutein) 200,
214
vision plus lutein .................. 214
vit b complex-folic acid ....... 211
VITAFOL FE+ (WITH
DOCUSATE) ................... 214
vitalets .................................. 214
vitamin a............................... 214
vitamin b complex ........ 196, 209
vitamin b-100 complex ........ 200
vitamin b12-folic acid .......... 215
vitamin b-6 ........................... 215
vitamin c....................... 210, 215
vitamin d3 ............ 211, 215, 216
vitamins and minerals .......... 214
vitamins b complex ...... 196, 214
vitamins for hair ................... 216
VITEKTA .............................. 73
vitrum senior ........................ 216
VOLTAREN .......................... 14
voriconazole ........................... 54
VOTRIENT ............................ 37
VPRIV .................................. 132
VRAYLAR ............................ 70
vyfemla (28) ......................... 110
W
wal-act d cold and allergy ...... 59
wal-dram ................................ 64
wal-dryl allergy ...................... 59
wal-fex allergy ....................... 59
wal-finate ............................... 59
wal-finate-d ............................ 59
wal-itin ................................... 59
wal-itin d ................................ 59
wal-itin d 12 hour ................... 59
wal-phed ......................... 59, 121
wal-phed pe day-night .......... 121
wal-phed pe sinus and allergy 59
wal-profen .............................. 14
wal-sleep z........................ 59, 60
wal-som (diphenhydramine) .. 60
wal-som (doxylamine) ........... 60
wal-tap .................................... 60
wal-tussin cough .................. 121
wal-tussin cough and cold cf 121
wal-tussin dm ....................... 111
wal-zan 75 ............................ 143
wal-zyr (cetirizine) ................. 60
wal-zyr d................................. 60
warfarin .................................. 78
water for irrigation, sterile.... 170
WELCHOL ............................ 99
wera (28) .............................. 110
womens daily gummies ........ 200
women's daily multivitamin . 209
X
XALKORI .............................. 37
XARELTO ............................. 78
XELJANZ ............................ 177
XELJANZ XR ...................... 177
XIFAXAN .............................. 20
XOLAIR ............................... 192
XTANDI ................................ 37
xulane ................................... 110
xylon 10 .................................. 10
XYREM ............................... 193
Y
yelets .................................... 216
YERVOY ............................... 37
YF-VAX (PF)....................... 169
YONDELIS ............................ 37
Z
zafirlukast ............................. 189
zaleplon ................................ 193
ZANTAC.............................. 143
ZANTAC 75......................... 143
zarah ..................................... 110
ZARXIO ................................. 79
ZAVESCA ........................... 133
zebutal .................................... 10
ZELBORAF ........................... 37
ZEMPLAR ........................... 171
zenatane ................................ 124
zenchent (28) ........................ 110
ZENPEP ............................... 133
ZEPATIER ............................. 75
zephrex-d .............................. 121
ZETIA .................................... 99
I-23
23
ZIAGEN ................................. 73
zidovudine ........................ 73, 74
ZINBRYTA ......................... 177
zinc oxide ............................. 124
ziprasidone hcl ....................... 70
ZIRGAN .............................. 139
ZOLADEX ............................. 37
zoledronic acid ..................... 171
.......................................... 172
ZOLINZA .............................. 38
zolmitriptan ............................ 61
zolpidem ............................... 194
ZOMETA ............................. 172
ZONATUSS ......................... 121
zonisamide ............................. 42
zoo chews ............................. 216
ZORTRESS .......................... 164
ZOSTAVAX (PF) ................ 169
zovia 1/35e (28) ................... 110
zovia 1/50e (28) ................... 110
ZOVIRAX ............................ 124
z-sleep .................................... 58
ZUBSOLV ............................. 16
ZYDELIG .............................. 38
ZYKADIA.............................. 38
ZYLET ................................. 139
zyncof ................................... 121
ZYPREXA RELPREVV ........ 70
ZYRTEC ................................ 60
ZYTIGA ................................. 38
ZYVOX .................................. 20
I-24
24
CENTERS PLAN
FOR HEALTHY LIVING
Centers Plan for FIDA Care Complete (Piano Medicare-Medicaid)
Telefono: 1-800-466-2745 (numero verde)
TTY: 1-800-421-1220
Giorni e orari
di disponibilità:
7 giorni su 7, dalle 08:00 alle 20:00
ADVANTAGE
CARE (HMO)
E-mail: CustomerCareGroup@centersplan.com
Sito Web: www.centersplan.com/fida/participants
CENTERS PLAN
CENTERS PLAN
CARE COMPLETE (MMP)

FIDA Care Complete

Transcription

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