2015 formulary

Transcription

2015 formulary

ALOHACARE ADVANTAGE PLUS (HMO SNP) PLAN
2015 FORMULARY
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
Formulary ID 00015245, Version 18
This formulary was updated on March 1, 2015. For more recent information or other questions, please
contact AlohaCare Advantage Plus (HMO SNP) Member Services at 1-866-973-6395, or, for TTY/TDD
users, 1-877-447-5990, 8 a.m. to 8 p.m., 7 days a week, or visit www.AlohaCare.org.
AlohaCare Advantage Plus is an HMO plan with a Medicare contract and a contract with the Hawaii Medicaid
Program. Enrollment in AlohaCare Advantage Plus depends on contract renewal.
H5969_108503_1 CMS Accepted 09212014
Note to existing members: This formulary has
changed since last year. Please review this document
to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”,
or “our,” it means AlohaCare. When it refers to
“plan” or “our plan,” it means AlohaCare Advantage
Plus (HMO SNP).
This document includes list of the drugs (formulary)
for our plan which is current as of March 1,
2015. For an updated formulary, please contact us.
Our contact information, along with the date we last
updated the formulary, appears on the front and back
cover pages.
You must generally use network pharmacies to use
your prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance
may change on January 1, 2016, and from time to
time during the year.
What is the AlohaCare Advantage Plus
Formulary?
A formulary is a list of covered drugs selected by
AlohaCare Advantage Plus in consultation with a
team of health care providers, which represents the
prescription therapies believed to be a necessary
part of a quality treatment program. AlohaCare
Advantage Plus will generally cover the drugs listed
in our formulary as long as the drug is medically
necessary, the prescription is filled at an AlohaCare
Advantage Plus network pharmacy, and other plan
rules are followed. For more information on how to
fill your prescriptions, please review your Evidence
of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2015
formulary that was covered at the beginning of the
year, we will not discontinue or reduce coverage
of the drug during the 2015 coverage year except
when a new, less expensive generic drug becomes
available or when new adverse information about the
safety or effectiveness of a drug is released. Other
types of formulary changes, such as removing a drug
from our formulary, will not affect members who are
currently taking the drug. It will remain available
at the same cost-sharing for those members taking
it for the remainder of the coverage year. We feel
it is important that you have continued access for
the remainder of the coverage year to the formulary
drugs that were available when you chose our plan,
except for cases in which you can save additional
money or we can ensure your safety.
If we remove drugs from our formulary or add prior
authorization, quantity limits and/or step therapy
restrictions on a drug we must notify affected
members of the change at least 60 days before the
change becomes effective, or at the time the member
requests a refill of the drug, at which time the
member will receive a 60-day supply of the drug.
If the Food and Drug Administration deems a drug
on our formulary to be unsafe or the drug’s
manufacturer removes the drug from the market,
we will immediately remove the drug from our
formulary and provide notice to members who take
the drug. The enclosed formulary is current as of
March 1, 2015. To get updated information about
the drugs covered by AlohaCare Advantage Plus,
please contact us. Our contact information appears on
the front and back cover pages.
If we make any mid-year non-maintenance changes
to the AlohaCare Advantage Plus formulary, we
will mail you a copy of the formulary changes via
errata sheets to ensure that you have a complete and
updated formulary.
How do I use the Formulary?
There are two ways to find your drug within the
formulary:
Medical Condition
The formulary begins on page 1. The drugs in this
formulary are grouped into categories depending
on the type of medical conditions that they are
used to treat. For example, drugs used to treat
a heart condition are listed under the category,
”Cardiovascular, Hypertension/Lipids”. If you
know what your drug is used for, look for the
category name in the list that begins on page 1.
Then look under the category name for your drug.
Page i
Alphabetical Listing
If you are not sure what category to look under,
you should look for your drug in the Index
that begins on page 108. The Index provides an
alphabetical list of all of the drugs included in this
document. Both brand name drugs and generic
drugs are listed in the Index. Look in the Index
and find your drug. Next to your drug, you will
see the page number where you can find coverage
information. Turn to the page listed in the Index
and find the name of your drug in the first column
of the list.
What are generic drugs?
AlohaCare Advantage Plus covers both brand name
drugs and generic drugs. A generic drug is approved
by the FDA as having the same active ingredient as
the brand name drug. Generally, generic drugs cost
less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional
requirements or limits on coverage. These
requirements and limits may include:
• Prior Authorization: AlohaCare Advantage
Plus requires you or your physician to get
prior authorization for certain drugs. This
means that you will need to get approval from
AlohaCare Advantage Plus before you fill
your prescriptions. If you don’t get approval,
AlohaCare Advantage Plus may not cover the
drug.
• Quantity Limits: For certain drugs, AlohaCare
Advantage Plus limits the amount of the drug
that AlohaCare Advantage Plus will cover. For
example, AlohaCare Advantage Plus provides
60 capsules per prescription for Celebrex. This
may be in addition to a standard one-month or
three-month supply.
• Step Therapy: In some cases, AlohaCare
Advantage Plus requires you to first try certain
drugs to treat your medical condition before
we will cover another drug for that condition.
For example, if Drug A and Drug B both treat
your medical condition, AlohaCare Advantage
Plus may not cover Drug B unless you try
Page ii
Drug A first. If Drug A does not work for you,
AlohaCare Advantage Plus will then cover
Drug B.
You can find out if your drug has any additional
requirements or limits by looking in the formulary
that begins on page 1. You can also get more
information about the restrictions applied to specific
covered drugs by visiting our Web site. We have
posted on line documents that explain our prior
authorization and step therapy restrictions. You
may also ask us to send you a copy. Our contact
information, along with the date we last updated the
formulary, appears on the front and back cover pages.
You can ask AlohaCare Advantage Plus to make
an exception to these restrictions or limits or for
a list of other, similar drugs that may treat your
health condition. See the section, “How do I request
an exception to the AlohaCare Advantage Plus
formulary?” on page iii for information about how to
request an exception.
What are over-the counter (OTC) drugs?
OTC drugs are non-prescription drugs that are not
normally covered by a Medicare Prescription Drug
Plan. AlohaCare Advantage Plus pays for certain
OTC drugs: Prilosec OTC, Prevacid 24Hr, Allegra
Allergy OTC, loratadine OTC, and cetirizine.
AlohaCare Advantage Plus will provide these OTC
drugs at no cost to you. The cost to AlohaCare
Advantage Plus of these OTC drugs will not count
toward your total Part D drug costs (that is, the
amount you pay does not count for the coverage gap.)
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list
of covered drugs), you should first contact Member
Services and ask if your drug is covered.
If you learn that AlohaCare Advantage Plus does not
cover your drug, you have two options:
• You can ask Member Services for a list of
similar drugs that are covered by AlohaCare
Advantage Plus. When you receive the list,
show it to your doctor and ask him or her to
prescribe a similar drug that is covered by
AlohaCare Advantage Plus.
• You can ask AlohaCare Advantage Plus to
make an exception and cover your drug. See
below for information about how to request an
exception.
How do I request an exception to the
AlohaCare Advantage Plus Formulary?
You can ask AlohaCare Advantage Plus to make an
exception to our coverage rules. There are several
types of exceptions that you can ask us to make.
• You can ask us to cover a drug even if it is not
on our formulary. If approved, this drug will be
covered at a pre-determined cost-sharing level,
and you would not be able to ask us to provide
the drug at a lower cost-sharing level.
• You can ask us to waive coverage restrictions
or limits on your drug. For example, for certain
drugs, AlohaCare Advantage Plus limits the
amount of the drug that we will cover. If your
drug has a quantity limit, you can ask us to
waive the limit and cover a greater amount.
Generally, AlohaCare Advantage Plus will only
approve your request for an exception if the
alternative drugs included on the plan’s formulary
or additional utilization restrictions would not be
as effective in treating your condition and/or would
cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage
decision for a formulary or utilization restriction
exception. When you request a formulary, or
utilization restriction exception you should submit
a statement from your prescriber or physician
supporting your request. Generally, we must
make our decision within 72 hours of getting your
prescriber’s supporting statement. You can request
an expedited (fast) exception if you or your doctor
believe that your health could be seriously harmed by
waiting up to 72 hours for a decision. If your request
to expedite is granted, we must give you a decision
no later than 24 hours after we get a supporting
statement from your doctor or other prescriber.
What do I do before I can talk to my
doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan you may
be taking drugs that are not on our formulary. Or, you
may be taking a drug that is on our formulary but
your ability to get it is limited. For example, you may
need a prior authorization from us before you can fill
your prescription. You should talk to your doctor to
decide if you should switch to an appropriate drug
that we cover or request a formulary exception so that
we will cover the drug you take. While you talk to
your doctor to determine the right course of action for
you, we may cover your drug in certain cases during
the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary
or if your ability to get your drugs is limited, we will
cover a temporary 30 day supply (unless you have a
prescription written for fewer days) when you go to a
network pharmacy. After your first 30-day supply, we
will not pay for these drugs, even if you have been a
member of the plan less than 90 days.
If you are a resident of a long-term care facility, we
will allow you to refill your prescription until we
have provided you with 91-day transition supply,
consistent with dispensing increment, (unless you
have a prescription written for fewer days). We will
cover more than one refill of these drugs for the first
90 days you are a member of our plan. If you need
a drug that is not on our formulary or if your ability
to get your drugs is limited, but you are past the first
90 days of membership in our plan, we will cover a
31-day emergency supply of that drug (unless you
have a prescription for fewer days) while you pursue
a formulary exception.
Page iii
Transition policy for level of care changes
AlohaCare Advantage Plus’ Formulary
Upon notification, AlohaCare Advantage Plus will
cover up to a 60-day supply of a prescription drug
(unless you have a prescription written for fewer
days) for current members who have a level of care
change. A level of care change includes the following
situations:
The formulary that begins on the next page provides
coverage information about the drugs covered by
AlohaCare Advantage Plus. If you have trouble
finding your drug in the list, turn to the Index that
begins on page 108.
• if you enter a long-term care facility from a
hospital or other setting;
• if you leave a long-term care facility to return to
a community/ home setting;
• if you are discharged from a hospital to a
community/home setting;
• if you end your skilled nursing facility stay
covered under Medicare Part A and need to
revert to coverage under AlohaCare Advantage
Plus;
• if your hospice status reverts to standard
Medicare Part A and B benefits; or,
• if you are discharged from a psychiatric
hospital with a drug regimen that is highly
individualized.
For more information
For more detailed information about your AlohaCare
Advantage Plus prescription drug coverage, please
review your Evidence of Coverage and other plan
materials.
If you have questions about AlohaCare Advantage
Plus, please contact us. Our contact information,
along with the date we last updated the formulary,
appears on the front and back cover pages.
If you have general questions about Medicare
prescription drug coverage, please call Medicare
at 1-800-MEDICARE (1-800-633-4227) 24 hours
a day/7 days a week. TTY/TDD users should call
1-877-486-2048. Or, visit http://www.medicare.gov.
Page iv
The first column of the chart lists the drug name.
Brand name drugs are capitalized (e.g., ACTOS) and
generic drugs are listed in lower-case italics (e.g.,
pioglitazone).
The information in the Requirements/Limits column
tells you if AlohaCare Advantage Plus has any
special requirements for coverage of your drug.
The following abbreviations explain any restrictions
on coverage, which are described in more detail on
page ii.
BvsD = Part B versus Part D: This drug may be
covered under Medicare Part B or Part D, depending
on the circumstances
MO = Mail Order service available: This service
helps you save money on your prescription drug costs
and your drugs will be conveniently mailed to your
home.
PA = Prior Authorization
QL = Quantity Limit
ST = Step Therapy
LA = Limited Access: This prescription may be
available only at certain pharmacies.
For more information consult your Provider &
Pharmacy Directory or call Member Services at
1-866-973-6395, 8 a.m. to 8 p.m., 7 days a week.
TTY users should call 1-877-447-5990.
2015 AlohaCare Advantage Plus Formulary
CURRENT AS OF 3/1/2015
Drug
Tier
Requirements
/Limits
Anti - Infectives
Antifungal Agents
ABELCET
INTRAVENOUS
SUSPENSION 5
MG/ML
1
AMBISOME
INTRAVENOUS
SUSPENSION FOR
RECONSTITUTIO
N 50 MG
1
amphotericin B
injection recon soln
50 mg
1
ANCOBON ORAL
CAPSULE 250 MG,
500 MG
1
CANCIDAS
INTRAVENOUS
RECON SOLN 50
MG, 70 MG
1
clotrimazole mucous
membrane troche 10
mg
1
ERAXIS(WATER
DILUENT)
INTRAVENOUS
RECON SOLN 100
MG
1
fluconazole oral
suspension for
reconstitution 10
mg/mL, 40 mg/mL
1
fluconazole oral
tablet 100 mg, 200
mg, 50 mg
1
fluconazole oral
tablet 150 mg
1
BvsD
BvsD
BvsD
BvsD
BvsD
QL (2 EA per
30 days)
Drug
Tier
fluconazole in
dextrose(iso-o)
intravenous
piggyback 400
mg/200 mL
1
flucytosine oral
capsule 250 mg, 500
mg
1
GRIS-PEG
(ULTRAMICROSIZ
E) ORAL TABLET
125 MG, 250 MG
1
griseofulvin
microsize oral
suspension 125 mg/5
mL
1
griseofulvin
microsize oral tablet
500 mg
1
griseofulvin
ultramicrosize oral
tablet 125 mg, 250
mg
1
itraconazole oral
capsule 100 mg
1
ketoconazole oral
tablet 200 mg
1
MYCAMINE
INTRAVENOUS
RECON SOLN 100
MG, 50 MG
1
NOXAFIL ORAL
SUSPENSION 200
MG/5 ML (40
MG/ML)
1
nystatin oral
suspension 100,000
unit/mL
1
nystatin oral tablet
500,000 unit
1
ONMEL ORAL
TABLET 200 MG
1
Requirements
/Limits
BvsD
QL (120 EA
per 30 days)
BvsD
3
Drug
Tier
SPORANOX ORAL
SOLUTION 10
MG/ML
1
terbinafine HCl oral
tablet 250 mg
1
VFEND ORAL
SUSPENSION FOR
RECONSTITUTIO
N 200 MG/5 ML (40
MG/ML)
1
VFEND ORAL
TABLET 200 MG,
50 MG
1
VFEND IV
INTRAVENOUS
SOLUTION 200
MG
1
voriconazole
intravenous solution
200 mg
1
voriconazole oral
suspension for
reconstitution 200
mg/5 mL (40 mg/mL)
1
voriconazole oral
tablet 200 mg, 50 mg
1
Antivirals
abacavir oral tablet
300 mg
1
abacavirlamivudinezidovudine oral
tablet 300-150-300
mg
1
acyclovir oral
capsule 200 mg
1
acyclovir oral
suspension 200 mg/5
mL
1
acyclovir oral tablet
400 mg, 800 mg
1
4
Requirements
/Limits
BvsD
BvsD
Drug
Tier
acyclovir topical
ointment 5 %
1
acyclovir sodium
50 mg/mL
1
adefovir oral tablet
10 mg
1
amantadine HCl
oral capsule 100 mg
1
amantadine HCl
oral syrup 50 mg/5
mL
1
amantadine HCl
oral tablet 100 mg
1
APTIVUS ORAL
CAPSULE 250 MG
1
APTIVUS ORAL
SOLUTION 100
MG/ML
1
ATRIPLA ORAL
TABLET 600-200300 MG
1
BARACLUDE
ORAL SOLUTION
0.05 MG/ML
1
BARACLUDE
ORAL TABLET 0.5
MG, 1 MG
1
cidofovir
75 mg/mL
1
COMBIVIR ORAL
TABLET 150-300
MG
1
COMPLERA ORAL
TABLET 200-25300 MG
1
CRIXIVAN ORAL
CAPSULE 200 MG,
400 MG
1
Requirements
/Limits
Drug
Tier
Requirements
/Limits
Drug
Tier
BvsD
FUZEON
SUBCUTANEOUS
RECON SOLN 90
MG
1
ganciclovir sodium
intravenous recon
soln 500 mg
1
BvsD
1
PA
QL (30 EA per
30 days)
CYTOVENE
INTRAVENOUS
RECON SOLN 500
MG
1
didanosine oral
capsule,delayed
release(DR/EC) 125
mg, 200 mg, 250 mg,
400 mg
1
EDURANT ORAL
TABLET 25 MG
1
HARVONI ORAL
TABLET 90-400
MG
1
EMTRIVA ORAL
CAPSULE 200 MG
1
HEPSERA ORAL
TABLET 10 MG
1
INTELENCE ORAL
TABLET 100 MG,
200 MG, 25 MG
1
EMTRIVA ORAL
SOLUTION 10
MG/ML
1
INVIRASE ORAL
CAPSULE 200 MG
1
entecavir oral tablet
0.5 mg, 1 mg
1
EPIVIR ORAL
SOLUTION 10
MG/ML
1
INVIRASE ORAL
TABLET 500 MG
1
EPIVIR ORAL
TABLET 150 MG,
300 MG
1
Isentress oral
powder in packet
100 mg
ISENTRESS ORAL
TABLET 400 MG
1
EPIVIR HBV
ORAL SOLUTION
25 MG/5 ML (5
MG/ML)
1
ISENTRESS ORAL
TABLET,CHEWAB
LE 100 MG, 25 MG
1
EPIVIR HBV
ORAL TABLET
100 MG
1
KALETRA ORAL
SOLUTION 400100 MG/5 ML
1
EPZICOM ORAL
TABLET 600-300
MG
1
KALETRA ORAL
TABLET 100-25
MG, 200-50 MG
1
famciclovir oral
tablet 125 mg, 250
mg, 500 mg
1
lamivudine oral
tablet 100 mg, 150
mg, 300 mg
1
foscarnet
24 mg/mL
1
lamivudinezidovudine oral
tablet 150-300 mg
1
Requirements
/Limits
5
Drug
Tier
LEXIVA ORAL
SUSPENSION 50
MG/ML
1
LEXIVA ORAL
TABLET 700 MG
1
Moderiba oral tablet
200 mg
1
Moderiba Dose Pack
oral tablets,dose
pack 400 mg (7)400 mg (7), 600 mg
(7)- 600 mg (7)
1
nevirapine oral
suspension 50 mg/5
mL
1
nevirapine oral
tablet 200 mg
1
NORVIR ORAL
CAPSULE 100 MG
1
NORVIR ORAL
SOLUTION 80
MG/ML
1
NORVIR ORAL
TABLET 100 MG
1
OLYSIO ORAL
CAPSULE 150 MG
1
PREZISTA ORAL
SUSPENSION 100
MG/ML
Requirements
/Limits
Drug
Tier
RELENZA
DISKHALER
INHALATION
BLISTER WITH
DEVICE 5
MG/ACTUATION
1
RESCRIPTOR
ORAL TABLET
200 MG
1
RESCRIPTOR
ORAL TABLET,
DISPERSIBLE 100
MG
1
RETROVIR
INTRAVENOUS
SOLUTION 10
MG/ML
1
REYATAZ ORAL
CAPSULE 150 MG,
200 MG, 300 MG
1
RibaPak Dose Pack
oral tablets,dose
pack 400-400 mg
(28)-mg (28), 600400 mg (28)-mg
(28), 600-600 mg
(28)-mg (28)
1
Ribasphere oral
capsule 200 mg
1
1
1
PREZISTA ORAL
TABLET 150 MG,
600 MG, 75 MG,
800 MG
1
Ribasphere oral
tablet 200 mg, 400
mg, 600 mg
ribavirin oral
capsule 200 mg
1
REBETOL ORAL
SOLUTION 40
MG/ML
1
ribavirin oral tablet
200 mg
1
rimantadine oral
tablet 100 mg
1
SELZENTRY
ORAL TABLET
150 MG, 300 MG
1
6
PA
Requirements
/Limits
Drug
Tier
Requirements
/Limits
Drug
Tier
Requirements
/Limits
PA
valacyclovir oral
tablet 1 gram, 500
mg
1
QL (60 EA per
30 days)
VALCYTE ORAL
TABLET 450 MG
1
SOVALDI ORAL
TABLET 400 MG
1
stavudine oral
capsule 15 mg, 20
mg, 30 mg, 40 mg
1
stavudine oral recon
soln 1 mg/mL
1
valganciclovir oral
tablet 450 mg
1
STRIBILD ORAL
TABLET 150-150200-300 MG
1
VALTREX ORAL
TABLET 1 GRAM,
500 MG
1
SUSTIVA ORAL
CAPSULE 200 MG,
50 MG
1
1
SUSTIVA ORAL
TABLET 600 MG
1
VIDEX 2 GRAM
PEDIATRIC ORAL
RECON SOLN 10
MG/ML (FINAL)
1
SYNAGIS
INTRAMUSCULA
R SOLUTION 50
MG/0.5 ML
1
VIDEX EC ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
125 MG
TAMIFLU ORAL
CAPSULE 30 MG,
45 MG, 75 MG
1
VIRACEPT ORAL
TABLET 250 MG,
625 MG
1
TAMIFLU ORAL
SUSPENSION FOR
RECONSTITUTIO
N 6 MG/ML
1
VIRAMUNE ORAL
SUSPENSION 50
MG/5 ML
1
1
TIVICAY ORAL
TABLET 50 MG
1
VIRAMUNE ORAL
TABLET 200 MG
1
TRIUMEQ ORAL
TABLET 600-50300 MG
1
VIRAMUNE XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
400 MG
TRIZIVIR ORAL
TABLET 300-150300 MG
1
1
TRUVADA ORAL
TABLET 200-300
MG
1
VIREAD ORAL
POWDER 40
MG/SCOOP (40
MG/GRAM)
1
TYZEKA ORAL
TABLET 600 MG
1
VIREAD ORAL
TABLET 150 MG,
200 MG, 250 MG,
300 MG
QL (60 EA per
30 days)
7
Drug
Tier
VISTIDE
INTRAVENOUS
SOLUTION 75
MG/ML
1
ZERIT ORAL
CAPSULE 15 MG,
20 MG, 30 MG, 40
MG
1
ZERIT ORAL
RECON SOLN 1
MG/ML
1
ZIAGEN ORAL
SOLUTION 20
MG/ML
1
ZIAGEN ORAL
TABLET 300 MG
1
zidovudine oral
capsule 100 mg
1
zidovudine oral
syrup 10 mg/mL
1
zidovudine oral
tablet 300 mg
1
Cephalosporins
CEDAX ORAL
CAPSULE 400 MG
1
cefaclor oral capsule
250 mg, 500 mg
1
cefaclor oral tablet
extended release 12
hr 500 mg
1
cefadroxil oral
capsule 500 mg
1
cefadroxil oral
suspension for
reconstitution 250
mg/5 mL, 500 mg/5
mL
1
cefadroxil oral tablet
1 gram
1
8
Requirements
/Limits
Drug
Tier
BvsD
cefazolin injection
recon soln 1 gram,
10 gram, 500 mg
1
cefazolin in dextrose
(iso-os) intravenous
piggyback 1 gram/50
mL
1
cefdinir oral capsule
300 mg
1
cefdinir oral
suspension for
reconstitution 125
mg/5 mL, 250 mg/5
mL
1
cefepime injection
recon soln 1 gram, 2
gram
1
cefotaxime injection
gram, 500 mg
1
CEFOTETAN
INJECTION
RECON SOLN 1
GRAM, 2 GRAM
1
cefotetan
intravenous recon
soln 10 gram
1
cefoxitin intravenous
recon soln 1 gram,
10 gram, 2 gram
1
cefpodoxime oral
suspension for
reconstitution 100
mg/5 mL, 50 mg/5
mL
1
cefpodoxime oral
tablet 100 mg, 200
mg
1
Requirements
/Limits
Drug
Tier
Requirements
/Limits
Drug
Tier
cefprozil oral
suspension for
reconstitution 125
mg/5 mL, 250 mg/5
mL
1
cephalexin oral
suspension for
reconstitution 125
mg/5 mL, 250 mg/5
mL
1
cefprozil oral tablet
250 mg, 500 mg
1
1
ceftazidime injection
gram, 6 gram
1
cephalexin oral
tablet 250 mg, 500
mg
1
ceftazidime in D5W
intravenous
piggyback 1 gram/50
mL, 2 gram/50 mL
1
CLAFORAN
INJECTION
RECON SOLN 1
GRAM
1
CEFTIN ORAL
SUSPENSION FOR
RECONSTITUTIO
N 125 MG/5 ML,
250 MG/5 ML
1
CLAFORAN
INTRAVENOUS
RECON SOLN 1
GRAM
1
CEFTIN ORAL
TABLET 250 MG,
500 MG
1
CLAFORAN
INTRAVENOUS
RECON SOLN 2
GRAM
1
ceftriaxone injection
recon soln 10 gram,
250 mg, 500 mg
1
FORTAZ
INJECTION
RECON SOLN 6
GRAM
1
ceftriaxone
intravenous recon
soln 1 gram, 2 gram
1
FORTAZ
INTRAVENOUS
RECON SOLN 1
GRAM, 2 GRAM
cefuroxime axetil
oral tablet 250 mg,
500 mg
1
KEFLEX ORAL
CAPSULE 750 MG
1
1
cefuroxime sodium
1.5 gram, 750 mg
1
SUPRAX ORAL
CAPSULE 400 MG
1
cefuroxime sodium
intravenous recon
soln 7.5 gram
1
SUPRAX ORAL
SUSPENSION FOR
RECONSTITUTIO
N 100 MG/5 ML,
200 MG/5 ML, 500
MG/5 ML
cephalexin oral
capsule 250 mg, 500
mg
1
SUPRAX ORAL
TABLET,CHEWAB
LE 100 MG, 200
MG
1
BvsD
Requirements
/Limits
BvsD
9
Drug
Tier
Requirements
/Limits
Drug
Tier
ZINACEF
INJECTION
RECON SOLN 1.5
GRAM, 750 MG
1
ERY-TAB ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 500 MG
1
ZINACEF
INTRAVENOUS
RECON SOLN 7.5
GRAM
1
ERYPED 200
ORAL
SUSPENSION FOR
RECONSTITUTIO
N 200 MG/5 ML
1
ERYTHROCIN
INTRAVENOUS
RECON SOLN 500
MG
1
Erythrocin (as
stearate) oral tablet
250 mg
1
ERYTHROMYCIN
ORAL TABLET
250 MG, 500 MG
1
erythromycin
ethylsuccinate oral
tablet 400 mg
1
ZMAX ORAL
SUSPENSION,EXT
ENDED REL
RECON 2
GRAM/60 ML
1
Erythromycins / Other Macrolides
azithromycin
intravenous recon
soln 500 mg
1
azithromycin oral
packet 1 gram
1
azithromycin oral
suspension for
reconstitution 100
mg/5 mL, 200 mg/5
mL
1
azithromycin oral
tablet 250 mg, 500
mg, 600 mg
1
clarithromycin oral
suspension for
reconstitution 125
mg/5 mL, 250 mg/5
mL
1
clarithromycin oral
tablet 250 mg, 500
mg
1
clarithromycin oral
tablet extended
release 24 hr 500 mg
1
E.E.S. 400 oral
tablet 400 mg
1
Ery-Tab oral
tablet,delayed
release (DR/EC) 250
mg, 333 mg
1
10
Requirements
/Limits
BvsD
Miscellaneous Antiinfectives
ALBENZA ORAL
TABLET 200 MG
1
ALINIA ORAL
SUSPENSION FOR
RECONSTITUTIO
N 100 MG/5 ML
1
ALINIA ORAL
TABLET 500 MG
1
amikacin injection
solution 500 mg/2
mL
1
atovaquone oral
suspension 750 mg/5
mL
1
QL (6 EA per
30 days)
Drug
Tier
Requirements
/Limits
atovaquoneproguanil oral tablet
250-100 mg, 62.5-25
mg
1
AZACTAM
INJECTION
RECON SOLN 1
GRAM
1
AZACTAM IN
DEXTROSE (ISOOSM)
INTRAVENOUS
PIGGYBACK 1
GRAM/50 ML, 2
GRAM/50 ML
1
aztreonam injection
recon soln 1 gram
1
BACiiM
intramuscular recon
soln 50,000 unit
1
bacitracin
intramuscular recon
soln 50,000 unit
1
BILTRICIDE
ORAL TABLET
600 MG
1
CAPASTAT
INJECTION
RECON SOLN 1
GRAM
1
BvsD
CHLORAMPHENI
COL SOD
SUCCINATE
INTRAVENOUS
RECON SOLN 1
GRAM
1
BvsD
chloroquine
phosphate oral
tablet 250 mg, 500
mg
1
CLEOCIN ORAL
CAPSULE 75 MG
1
Drug
Tier
CLEOCIN ORAL
RECON SOLN 75
MG/5 ML
1
CLEOCIN IN 5 %
DEXTROSE
INTRAVENOUS
PIGGYBACK 300
MG/50 ML, 600
MG/50 ML, 900
MG/50 ML
1
clindamycin HCl
oral capsule 150 mg,
300 mg, 75 mg
1
clindamycin in 5 %
dextrose intravenous
piggyback 300
mg/50 mL, 600
mg/50 mL, 900
mg/50 mL
1
Clindamycin
Pediatric oral recon
soln 75 mg/5 mL
1
clindamycin
phosphate
600 mg/4 mL
1
colistin
(colistimethate Na)
150 mg
1
CUBICIN
INTRAVENOUS
RECON SOLN 500
MG
1
DAPSONE ORAL
TABLET 100 MG,
25 MG
1
DARAPRIM ORAL
TABLET 25 MG
1
DORIBAX
INTRAVENOUS
RECON SOLN 500
MG
1
Requirements
/Limits
BvsD
BvsD
BvsD
11
Drug
Tier
Requirements
/Limits
Drug
Tier
Requirements
/Limits
ethambutol oral
tablet 100 mg, 400
mg
1
ISONIAZID ORAL
SOLUTION 50
MG/5 ML
1
FLAGYL ER ORAL
TABLET
EXTENDED
RELEASE 750 MG
1
isoniazid oral tablet
100 mg, 300 mg
1
ivermectin oral
tablet 3 mg
1
gentamicin injection
solution 40 mg/mL
1
1
gentamicin in NaCl
(iso-osm)
intravenous
piggyback 100
mg/100 mL, 80
mg/100 mL
1
KETEK ORAL
TABLET 300 MG,
400 MG
MALARONE
ORAL TABLET
250-100 MG
1
1
gentamicin in NaCl
(iso-osm)
intravenous
piggyback 60 mg/50
mL, 80 mg/50 mL
1
MALARONE
PEDIATRIC ORAL
TABLET 62.5-25
MG
mefloquine oral
tablet 250 mg
1
GENTAMICIN IN
NACL (ISO-OSM)
INTRAVENOUS
PIGGYBACK 70
MG/50 ML, 90
MG/100 ML
1
Mepron oral
suspension 750 mg/5
mL
1
meropenem
intravenous recon
soln 500 mg
1
BvsD
GENTAMICIN
SULFATE (PF)
INTRAVENOUS
SOLUTION 80
MG/8 ML
1
MERREM
INTRAVENOUS
RECON SOLN 500
MG
1
BvsD
hydroxychloroquine
oral tablet 200 mg
1
metronidazole oral
capsule 375 mg
1
imipenem-cilastatin
intravenous recon
soln 250 mg, 500 mg
1
BvsD
metronidazole oral
tablet 250 mg, 500
mg
1
INVANZ
INJECTION
RECON SOLN 1
GRAM
1
BvsD
metronidazole in
NaCl (iso-os)
intravenous
piggyback 500
mg/100 mL
1
isoniazid injection
solution 100 mg/mL
1
12
BvsD
Drug
Tier
Requirements
/Limits
Drug
Tier
BvsD
RIFATER ORAL
TABLET 50-120300 MG
1
STREPTOMYCIN
INTRAMUSCULA
R RECON SOLN 1
GRAM
1
STROMECTOL
ORAL TABLET 3
MG
1
SYNERCID
INTRAVENOUS
RECON SOLN 500
MG
1
tinidazole oral tablet
250 mg, 500 mg
1
TOBI
INHALATION
SOLUTION FOR
NEBULIZATION
300 MG/5 ML
1
BvsD
tobramycin in 0.225
% NaCl inhalation
solution for
nebulization 300
mg/5 mL
1
BvsD
TOBRAMYCIN IN
0.9 % NACL
INTRAVENOUS
PIGGYBACK 80
MG/100 ML
1
BvsD
tobramycin sulfate
injection solution 10
mg/mL, 40 mg/mL
1
NEBUPENT
INHALATION
RECON SOLN 300
MG
1
neomycin oral tablet
500 mg
1
paromomycin oral
capsule 250 mg
1
PASER ORAL
GRANULES DR
FOR SUSP IN
PACKET 4 GRAM
1
PENTAM
INJECTION
RECON SOLN 300
MG
1
polymyxin B sulfate
500,000 unit
1
PRIMAQUINE
ORAL TABLET
26.3 MG
1
PRIMAXIN IV
INTRAVENOUS
RECON SOLN 250
MG, 500 MG
1
pyrazinamide oral
tablet 500 mg
1
QUALAQUIN
ORAL CAPSULE
324 MG
1
quinine sulfate oral
capsule 324 mg
1
rifabutin oral
capsule 150 mg
1
TRECATOR ORAL
TABLET 250 MG
1
rifampin intravenous
recon soln 600 mg
1
1
rifampin oral
capsule 150 mg, 300
mg
1
TYGACIL
INTRAVENOUS
RECON SOLN 50
MG
BvsD
Requirements
/Limits
BvsD
BvsD
13
Drug
Tier
XIFAXAN ORAL
TABLET 200 MG,
550 MG
1
ZYVOX
INTRAVENOUS
PARENTERAL
SOLUTION 600
MG/300 ML
1
ZYVOX ORAL
SUSPENSION FOR
RECONSTITUTIO
N 100 MG/5 ML
1
ZYVOX ORAL
TABLET 600 MG
1
Penicillins
amoxicillin oral
capsule 250 mg, 500
mg
1
amoxicillin oral
suspension for
reconstitution 125
mg/5 mL, 200 mg/5
mL, 250 mg/5 mL,
400 mg/5 mL
1
amoxicillin oral
tablet 500 mg, 875
mg
1
amoxicillin oral
tablet,chewable 125
mg, 250 mg
1
amoxicillin-pot
clavulanate oral
suspension for
reconstitution 20028.5 mg/5 mL, 25062.5 mg/5 mL, 40057 mg/5 mL, 60042.9 mg/5 mL
1
amoxicillin-pot
clavulanate oral
tablet 250-125 mg,
500-125 mg, 875125 mg
1
14
Requirements
/Limits
BvsD
Drug
Tier
amoxicillin-pot
clavulanate oral
tablet,chewable 20028.5 mg, 400-57 mg
1
ampicillin oral
capsule 250 mg, 500
mg
1
ampicillin oral
suspension for
reconstitution 125
mg/5 mL, 250 mg/5
mL
1
ampicillin sodium
1 gram, 10 gram
1
AMPICILLIN
SODIUM
INJECTION
RECON SOLN 125
MG
1
ampicillin-sulbactam
15 gram, 3 gram
1
BICILLIN C-R
INTRAMUSCULA
R SYRINGE
1,200,000 UNIT/ 2
ML(600K/600K),
1,200,000 UNIT/ 2
ML(900K/300K)
1
BICILLIN L-A
INTRAMUSCULA
R SYRINGE
1,200,000 UNIT/2
ML, 2,400,000
UNIT/4 ML,
600,000 UNIT/ML
1
dicloxacillin oral
capsule 250 mg, 500
mg
1
nafcillin injection
recon soln 1 gram,
10 gram
1
Requirements
/Limits
Drug
Tier
NAFCILLIN IN
DEXTROSE ISOOSM
INTRAVENOUS
PIGGYBACK 1
GRAM/50 ML
1
OMECLAMOXPAK ORAL
COMBO PACK 20
MG (20)- 500 MG
(20)
1
OXACILLIN
INJECTION
RECON SOLN 10
GRAM
1
OXACILLIN
INTRAVENOUS
RECON SOLN 2
GRAM
1
OXACILLIN IN
DEXTROSE(ISOOSM)
INTRAVENOUS
PIGGYBACK 1
GRAM/50 ML, 2
GRAM/50 ML
1
PENICILLIN G
POT IN
DEXTROSE
INTRAVENOUS
PIGGYBACK 2
MILLION UNIT/50
ML, 3 MILLION
UNIT/50 ML
1
penicillin G
potassium injection
recon soln 5 million
unit
1
PENICILLIN G
PROCAINE
INTRAMUSCULA
R SYRINGE 1.2
MILLION UNIT/2
ML
1
Requirements
/Limits
BvsD
Drug
Tier
Requirements
/Limits
PENICILLIN G
SODIUM
INJECTION
RECON SOLN 5
MILLION UNIT
1
BvsD
penicillin V
potassium oral recon
soln 125 mg/5 mL,
250 mg/5 mL
1
penicillin V
potassium oral
tablet 250 mg, 500
mg
1
Pfizerpen-G
5 million unit
1
piperacillintazobactam
intravenous recon
soln 3.375 gram, 4.5
gram
1
BvsD
ZOSYN
INTRAVENOUS
RECON SOLN
3.375 GRAM
1
BvsD
ZOSYN IN
DEXTROSE (ISOOSM)
INTRAVENOUS
PIGGYBACK 2.25
GRAM/50 ML,
3.375 GRAM/50
ML
1
BvsD
Quinolones
BvsD
AVELOX ORAL
TABLET 400 MG
1
AVELOX ABC
PACK ORAL
TABLET 400 MG
1
15
Drug
Tier
Requirements
/Limits
Drug
Tier
BvsD
levofloxacin oral
solution 250 mg/10
mL
1
levofloxacin oral
tablet 250 mg, 500
mg, 750 mg
1
levofloxacin in D5W
intravenous
piggyback 500
mg/100 mL
1
ofloxacin oral tablet
400 mg
1
AVELOX IN NACL
(ISO-OSMOTIC)
INTRAVENOUS
PIGGYBACK 400
MG/250 ML
1
CIPRO ORAL
SUSPENSION,MIC
ROCAPSULE
RECON 250 MG/5
ML, 500 MG/5 ML
1
ciprofloxacin oral
suspension,microcap
sule recon 250 mg/5
mL, 500 mg/5 mL
1
ciprofloxacin
(mixture) oral tablet,
ER multiphase 24 hr
1,000 mg, 500 mg
1
ciprofloxacin HCl
oral tablet 100 mg,
250 mg, 500 mg, 750
mg
1
ciprofloxacin in 5 %
dextrose intravenous
piggyback 200
mg/100 mL
1
ciprofloxacin lactate
400 mg/40 mL
1
gatifloxacin
ophthalmic drops
0.5 %
1
demeclocycline oral
tablet 150 mg, 300
mg
1
LEVAQUIN ORAL
SOLUTION 250
MG/10 ML
1
doxycycline hyclate
intravenous recon
soln 100 mg
1
LEVAQUIN ORAL
TABLET 250 MG,
500 MG, 750 MG
1
doxycycline hyclate
50 mg
1
levofloxacin
25 mg/mL
1
doxycycline hyclate
oral tablet 100 mg,
20 mg
1
16
Sulfa's / Related Agents
sulfadiazine oral
tablet 500 mg
1
sulfamethoxazoletrimethoprim
400-80 mg/5 mL
1
sulfamethoxazoletrimethoprim oral
suspension 200-40
mg/5 mL
1
sulfamethoxazoletrimethoprim oral
tablet 400-80 mg,
800-160 mg
1
Tetracyclines
BvsD
Requirements
/Limits
BvsD
Drug
Tier
Requirements
/Limits
Drug
Tier
doxycycline
monohydrate oral
capsule 75 mg
1
methenamine
hippurate oral tablet
1 gram
1
doxycycline
monohydrate oral
suspension for
reconstitution 25
mg/5 mL
1
MONUROL ORAL
PACKET 3 GRAM
1
nitrofurantoin oral
suspension 25 mg/5
mL
1
doxycycline
monohydrate oral
tablet 150 mg, 50
mg, 75 mg
1
nitrofurantoin
macrocrystal oral
capsule 50 mg
1
minocycline oral
capsule 100 mg, 50
mg, 75 mg
1
nitrofurantoin
monohyd/m-cryst
oral capsule 100 mg
1
minocycline oral
tablet 100 mg, 50
mg, 75 mg
1
PRIMSOL ORAL
SOLUTION 50
MG/5 ML
1
minocycline oral
tablet extended
release 24 hr 135
mg, 45 mg, 90 mg
1
trimethoprim oral
tablet 100 mg
1
ORACEA ORAL
CAPSULE,IR &
DELAY
REL,BIPHASE 40
MG
1
tetracycline oral
capsule 250 mg, 500
mg
1
VIBRAMYCIN
ORAL SYRUP 50
MG/5 ML
1
Requirements
/Limits
Vancomycin
Urinary Tract Agents
FURADANTIN
ORAL
SUSPENSION 25
MG/5 ML
1
MACRODANTIN
ORAL CAPSULE
25 MG
1
VANCOCIN ORAL
CAPSULE 125 MG,
250 MG
1
vancomycin
intravenous recon
soln 1,000 mg
1
VANCOMYCIN
INTRAVENOUS
RECON SOLN 10
GRAM, 500 MG
1
vancomycin oral
capsule 125 mg, 250
mg
1
BvsD
Antineoplastic / Immunosuppressant Drugs
Adjunctive Agents
amifostine
crystalline
intravenous recon
soln 500 mg
1
17
Drug
Tier
Requirements
/Limits
Drug
AFINITOR ORAL
TABLET 10 MG,
2.5 MG, 5 MG, 7.5
MG
1
AFINITOR
DISPERZ ORAL
TABLET FOR
SUSPENSION 2
MG, 3 MG, 5 MG
1
ALIMTA
INTRAVENOUS
RECON SOLN 500
MG
1
BvsD
ALKERAN
INTRAVENOUS
RECON SOLN 50
MG
1
BvsD
anastrozole oral
tablet 1 mg
1
ARIMIDEX ORAL
TABLET 1 MG
1
AROMASIN ORAL
TABLET 25 MG
1
ARRANON
INTRAVENOUS
SOLUTION 250
MG/50 ML
1
ARZERRA
INTRAVENOUS
SOLUTION 100
MG/5 ML
1
ASTAGRAF XL
ORAL
CAPSULE,EXTEN
DED RELEASE
24HR 0.5 MG, 1
MG, 5 MG
1
BvsD
AVASTIN
INTRAVENOUS
SOLUTION 25
MG/ML
1
BvsD
dexrazoxane HCl
intravenous recon
soln 250 mg
1
BvsD
ELITEK
INTRAVENOUS
RECON SOLN 1.5
MG
1
BvsD
FUSILEV
INTRAVENOUS
RECON SOLN 50
MG
1
KEPIVANCE
INTRAVENOUS
RECON SOLN 6.25
MG
1
leucovorin calcium
100 mg, 350 mg
1
LEUCOVORIN
CALCIUM ORAL
TABLET 10 MG, 15
MG
1
leucovorin calcium
oral tablet 25 mg, 5
mg
1
mesna intravenous
solution 100 mg/mL
1
MESNEX ORAL
TABLET 400 MG
1
XGEVA
SUBCUTANEOUS
SOLUTION 120
MG/1.7 ML (70
MG/ML)
1
ZINECARD (AS
HCL)
INTRAVENOUS
RECON SOLN 250
MG
1
BvsD
BvsD
BvsD
BvsD
BvsD
BvsD
Antineoplastic / Immunosuppressant Drugs
18
Tier
Requirements
/Limits
BvsD
Drug
Tier
Requirements
/Limits
Drug
Tier
Requirements
/Limits
azacitidine injection
recon soln 100 mg
1
BvsD
CELLCEPT ORAL
TABLET 500 MG
1
BvsD
AZASAN ORAL
TABLET 100 MG,
75 MG
1
BvsD
1
BvsD
azathioprine oral
tablet 50 mg
1
BvsD
CELLCEPT
INTRAVENOUS
INTRAVENOUS
RECON SOLN 500
MG
BELEODAQ
INTRAVENOUS
RECON SOLN 500
MG
1
BvsD
cisplatin intravenous
solution 1 mg/mL
1
BvsD
1
BvsD
bicalutamide oral
tablet 50 mg
1
cladribine
10 mg/10 mL
1
BvsD
BICNU
INTRAVENOUS
RECON SOLN 100
MG
1
CLOLAR
INTRAVENOUS
SOLUTION 20
MG/20 ML
1
bleomycin injection
recon soln 30 unit
1
BOSULIF ORAL
TABLET 100 MG,
500 MG
1
BUSULFEX
INTRAVENOUS
SOLUTION 60
MG/10 ML
1
COMETRIQ ORAL
CAPSULE 100
MG/DAY(80
MG[1]-20 MG[1]),
140 MG/DAY(80
MG[1]-20 MG[3]),
60 MG/DAY (20
MG [3]/DAY)
1
BvsD
CAPRELSA ORAL
TABLET 100 MG,
300 MG
1
COSMEGEN
INTRAVENOUS
RECON SOLN 0.5
MG
1
BvsD
carboplatin
10 mg/mL
1
cyclophosphamide
oral capsule 25 mg,
50 mg
1
BvsD
CASODEX ORAL
TABLET 50 MG
1
cyclosporine
250 mg/5 mL
1
BvsD
CELLCEPT ORAL
CAPSULE 250 MG
1
BvsD
cyclosporine oral
capsule 100 mg, 25
mg
CELLCEPT ORAL
SUSPENSION FOR
RECONSTITUTIO
N 200 MG/ML
1
BvsD
cyclosporine
modified oral
capsule 100 mg, 25
mg
1
BvsD
BvsD
BvsD
BvsD
BvsD
19
Drug
Tier
Requirements
/Limits
Drug
DOXIL
INTRAVENOUS
SUSPENSION 2
MG/ML
1
BvsD
doxorubicin
50 mg/25 mL
1
BvsD
DROXIA ORAL
CAPSULE 200 MG,
300 MG, 400 MG
1
ELIGARD
SUBCUTANEOUS
SYRINGE 22.5 MG,
30 MG, 45 MG, 7.5
MG
1
BvsD
ELLENCE
INTRAVENOUS
SOLUTION 200
MG/100 ML
1
BvsD
ELOXATIN
INTRAVENOUS
SOLUTION 100
MG/20 ML
1
BvsD
EMCYT ORAL
CAPSULE 140 MG
1
epirubicin
50 mg/25 mL
1
BvsD
ERBITUX
INTRAVENOUS
SOLUTION 100
MG/50 ML
1
BvsD
ERIVEDGE ORAL
CAPSULE 150 MG
1
ERWINAZE
INTRAMUSCULA
R RECON SOLN
10,000 UNIT
1
BvsD
ETOPOPHOS
INTRAVENOUS
RECON SOLN 100
MG
1
BvsD
CYCLOSPORINE
MODIFIED ORAL
CAPSULE 50 MG
1
BvsD
cyclosporine
modified oral
solution 100 mg/mL
1
BvsD
cytarabine injection
solution 20 mg/mL
1
cytarabine (PF)
gram/20 mL (100
mg/mL)
1
dacarbazine
intravenous recon
soln 200 mg
1
BvsD
DACOGEN
INTRAVENOUS
RECON SOLN 50
MG
1
BvsD
DAUNORUBICIN
INTRAVENOUS
SOLUTION 5
MG/ML
1
BvsD
decitabine
intravenous recon
soln 50 mg
1
BvsD
DOCEFREZ
INTRAVENOUS
RECON SOLN 20
MG
1
docetaxel
80 mg/4 mL (20
mg/mL)
1
DOCETAXEL
INTRAVENOUS
SOLUTION 80
MG/8 ML (10
MG/ML)
1
20
BvsD
BvsD
BvsD
BvsD
BvsD
Tier
Requirements
/Limits
Drug
Tier
Requirements
/Limits
Drug
BvsD
HALAVEN
INTRAVENOUS
SOLUTION 1 MG/2
ML (0.5 MG/ML)
1
BvsD
HERCEPTIN
INTRAVENOUS
RECON SOLN 440
MG
1
BvsD
HEXALEN ORAL
CAPSULE 50 MG
1
HYCAMTIN
INTRAVENOUS
RECON SOLN 4
MG
1
hydroxyurea oral
capsule 500 mg
1
ICLUSIG ORAL
TABLET 15 MG
1
idarubicin
1 mg/mL
1
BvsD
IFEX
INTRAVENOUS
RECON SOLN 1
GRAM
1
BvsD
IFOSFAMIDE
INTRAVENOUS
RECON SOLN 1
GRAM
1
BvsD
IMBRUVICA
ORAL CAPSULE
140 MG
1
INLYTA ORAL
TABLET 1 MG, 5
MG
1
irinotecan
100 mg/5 mL
1
IXEMPRA
INTRAVENOUS
RECON SOLN 45
MG
1
etoposide
20 mg/mL
1
exemestane oral
tablet 25 mg
1
FARESTON ORAL
TABLET 60 MG
1
FASLODEX
INTRAMUSCULA
R SYRINGE 250
MG/5 ML
1
FEMARA ORAL
TABLET 2.5 MG
1
fludarabine
intravenous recon
soln 50 mg
1
BvsD
fluorouracil
2.5 gram/50 mL
1
BvsD
flutamide oral
capsule 125 mg
1
GEMCITABINE
INTRAVENOUS
RECON SOLN 1
GRAM
1
BvsD
GEMZAR
INTRAVENOUS
RECON SOLN 1
GRAM
1
BvsD
Gengraf oral
capsule 100 mg, 25
mg
1
BvsD
Gengraf oral
solution 100 mg/mL
1
BvsD
GILOTRIF ORAL
TABLET 20 MG, 30
MG, 40 MG
1
GLEEVEC ORAL
TABLET 100 MG,
400 MG
1
BvsD
Tier
Requirements
/Limits
BvsD
BvsD
21
Drug
Tier
JAKAFI ORAL
TABLET 10 MG, 15
MG, 20 MG, 25
MG, 5 MG
1
JEVTANA
INTRAVENOUS
SOLUTION 10
MG/ML (FIRST
DILUTION)
1
KEYTRUDA
INTRAVENOUS
RECON SOLN 50
MG
1
letrozole oral tablet
2.5 mg
Requirements
/Limits
Drug
Tier
Requirements
/Limits
LUPRON DEPOTPED
INTRAMUSCULA
R KIT 11.25 MG, 15
MG
1
LYSODREN ORAL
TABLET 500 MG
1
MATULANE
ORAL CAPSULE
50 MG
1
1
1
megestrol oral
suspension 400
mg/10 mL (40
mg/mL)
1
megestrol oral tablet
20 mg, 40 mg
1
LEUKERAN ORAL
TABLET 2 MG
1
leuprolide
subcutaneous kit 1
mg/0.2 mL
1
MEKINIST ORAL
TABLET 0.5 MG, 2
MG
1
lomustine oral
capsule 10 mg, 100
mg, 40 mg
1
melphalan HCl
intravenous recon
soln 50 mg
1
LUPRON DEPOT
INTRAMUSCULA
R SYRINGE KIT
3.75 MG, 7.5 MG
1
mercaptopurine oral
tablet 50 mg
methotrexate sodium
oral tablet 2.5 mg
1
BvsD
LUPRON DEPOT
(3 MONTH)
INTRAMUSCULA
R SYRINGE KIT
11.25 MG, 22.5 MG
1
BvsD
METHOTREXATE
SODIUM (PF)
INJECTION
RECON SOLN 1
GRAM
1
BvsD
LUPRON DEPOT
(4 MONTH)
INTRAMUSCULA
R SYRINGE KIT 30
MG
1
BvsD
methotrexate sodium
(PF) injection
solution 25 mg/mL
1
BvsD
1
BvsD
LUPRON DEPOT
(6 MONTH)
INTRAMUSCULA
R SYRINGE KIT 45
MG
1
mitomycin
intravenous recon
soln 20 mg
mitoxantrone
intravenous
concentrate 2 mg/mL
1
BvsD
22
BvsD
BvsD
BvsD
BvsD
BvsD
Drug
Tier
Requirements
/Limits
Drug
octreotide acetate
injection solution
1,000 mcg/mL, 100
mcg/mL, 200
mcg/mL, 50 mcg/mL,
500 mcg/mL
1
BvsD
ONCASPAR
INJECTION
SOLUTION 750
UNIT/ML
1
BvsD
oxaliplatin
100 mg/20 mL
1
BvsD
paclitaxel
intravenous
concentrate 6 mg/mL
1
BvsD
PERJETA
INTRAVENOUS
SOLUTION 420
MG/14 ML (30
MG/ML)
1
BvsD
POMALYST ORAL
CAPSULE 1 MG, 2
MG, 3 MG, 4 MG
1
PROGRAF
INTRAVENOUS
SOLUTION 5
MG/ML
1
BvsD
PROGRAF ORAL
CAPSULE 0.5 MG,
1 MG, 5 MG
1
BvsD
PURIXAN ORAL
SUSPENSION 20
MG/ML
1
RAPAMUNE
ORAL SOLUTION
1 MG/ML
1
BvsD
RAPAMUNE
ORAL TABLET 0.5
MG, 1 MG, 2 MG
1
BvsD
MUSTARGEN
INJECTION
RECON SOLN 10
MG
1
BvsD
mycophenolate
mofetil oral capsule
250 mg
1
BvsD
mycophenolate
mofetil oral
suspension for
reconstitution 200
mg/mL
1
mycophenolate
mofetil oral tablet
500 mg
1
mycophenolate
sodium oral
tablet,delayed
release (DR/EC) 180
mg, 360 mg
1
MYFORTIC ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 180 MG,
360 MG
1
NEORAL ORAL
CAPSULE 100 MG,
25 MG
1
BvsD
NEORAL ORAL
SOLUTION 100
MG/ML
1
BvsD
NEXAVAR ORAL
TABLET 200 MG
1
NILANDRON
ORAL TABLET
150 MG
1
NULOJIX
INTRAVENOUS
RECON SOLN 250
MG
1
BvsD
BvsD
BvsD
BvsD
Tier
Requirements
/Limits
23
Drug
Tier
Requirements
/Limits
Drug
LA
SPRYCEL ORAL
TABLET 100 MG,
140 MG, 20 MG, 50
MG, 70 MG, 80 MG
1
STIVARGA ORAL
TABLET 40 MG
1
SUTENT ORAL
CAPSULE 12.5
MG, 25 MG, 37.5
MG, 50 MG
1
SYLVANT
INTRAVENOUS
RECON SOLN 100
MG
1
SYNRIBO
SUBCUTANEOUS
RECON SOLN 3.5
MG
1
1
BvsD
TABLOID ORAL
TABLET 40 MG
1
BvsD
tacrolimus oral
capsule 0.5 mg, 1
mg, 5 mg
1
BvsD
TAFINLAR ORAL
CAPSULE 50 MG,
75 MG
tamoxifen oral tablet
10 mg, 20 mg
1
TARCEVA ORAL
TABLET 100 MG,
150 MG, 25 MG
1
TARGRETIN
ORAL CAPSULE
75 MG
1
TARGRETIN
TOPICAL GEL 1 %
1
TASIGNA ORAL
CAPSULE 150 MG,
200 MG
1
REVLIMID ORAL
CAPSULE 10 MG,
15 MG, 25 MG, 5
MG
1
REVLIMID ORAL
CAPSULE 2.5 MG,
20 MG
1
RHEUMATREX
ORAL
TABLETS,DOSE
PACK 2.5 MG
1
RITUXAN
INTRAVENOUS
CONCENTRATE
10 MG/ML
1
BvsD
SANDIMMUNE
INTRAVENOUS
SOLUTION 250
MG/5 ML
1
BvsD
SANDIMMUNE
ORAL CAPSULE
100 MG, 25 MG
1
SANDIMMUNE
ORAL SOLUTION
100 MG/ML
1
SIMULECT
INTRAVENOUS
RECON SOLN 20
MG
1
sirolimus oral tablet
0.5 mg, 1 mg, 2 mg
1
SOLTAMOX
ORAL SOLUTION
10 MG/5 ML
1
SOMATULINE
DEPOT
SUBCUTANEOUS
SYRINGE 120
MG/0.5 ML, 90
MG/0.3 ML
1
24
BvsD
BvsD
BvsD
Tier
Requirements
/Limits
BvsD
BvsD
Drug
Tier
Requirements
/Limits
THALOMID ORAL
CAPSULE 100 MG,
150 MG, 200 MG,
50 MG
1
topotecan
intravenous recon
soln 4 mg
1
BvsD
TORISEL
INTRAVENOUS
RECON SOLN 30
MG/3 ML (10
MG/ML) (FINAL)
1
BvsD
TREANDA
INTRAVENOUS
RECON SOLN 100
MG
1
TREANDA
INTRAVENOUS
SOLUTION 45
MG/0.5 ML
1
TRELSTAR
INTRAMUSCULA
R SYRINGE 11.25
MG/2 ML, 3.75
MG/2 ML
1
tretinoin
(chemotherapy) oral
capsule 10 mg
1
TREXALL ORAL
TABLET 10 MG, 15
MG, 5 MG, 7.5 MG
1
BvsD
TRISENOX
INTRAVENOUS
SOLUTION 10
MG/10 ML
1
BvsD
TYKERB ORAL
TABLET 250 MG
1
VECTIBIX
INTRAVENOUS
SOLUTION 100
MG/5 ML (20
MG/ML)
1
BvsD
BvsD
BvsD
BvsD
Drug
Tier
Requirements
/Limits
VELCADE
INJECTION
RECON SOLN 3.5
MG
1
BvsD
VIDAZA
INJECTION
RECON SOLN 100
MG
1
BvsD
vinblastine
1 mg/mL
1
BvsD
Vincasar PFS
1 mg/mL
1
BvsD
vincristine
1 mg/mL
1
BvsD
vinorelbine
50 mg/5 mL
1
BvsD
VOTRIENT ORAL
TABLET 200 MG
1
XALKORI ORAL
CAPSULE 200 MG,
250 MG
1
XTANDI ORAL
CAPSULE 40 MG
1
YERVOY
INTRAVENOUS
SOLUTION 50
MG/10 ML (5
MG/ML)
1
BvsD
ZALTRAP
INTRAVENOUS
SOLUTION 100
MG/4 ML (25
MG/ML)
1
BvsD
ZANOSAR
INTRAVENOUS
RECON SOLN 1
GRAM
1
BvsD
25
Drug
Tier
ZELBORAF ORAL
TABLET 240 MG
1
ZOLINZA ORAL
CAPSULE 100 MG
1
ZORTRESS ORAL
TABLET 0.25 MG,
0.5 MG, 0.75 MG
1
ZYDELIG ORAL
TABLET 100 MG,
150 MG
1
ZYKADIA ORAL
CAPSULE 150 MG
1
ZYTIGA ORAL
TABLET 250 MG
1
Requirements
/Limits
BvsD
Autonomic / Cns Drugs, Neurology / Psych
Anticonvulsants
Aptiom oral tablet
200 mg, 400 mg, 600
mg, 800 mg
1
BANZEL ORAL
SUSPENSION 40
MG/ML
1
BANZEL ORAL
TABLET 200 MG,
400 MG
1
carbamazepine oral
capsule, ER
multiphase 12 hr
100 mg, 200 mg, 300
mg
1
carbamazepine oral
suspension 100 mg/5
mL
1
carbamazepine oral
tablet 200 mg
1
carbamazepine oral
tablet extended
1
26
Drug
Tier
carbamazepine oral
tablet,chewable 100
mg
1
CARBATROL
ORAL CAPSULE,
ER MULTIPHASE
12 HR 100 MG, 200
MG, 300 MG
1
CELONTIN ORAL
CAPSULE 300 MG
1
DEPAKOTE ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 125 MG,
250 MG, 500 MG
1
DEPAKOTE ER
ORAL TABLET
EXTENDED
RELEASE 24 HR
250 MG, 500 MG
1
DEPAKOTE
SPRINKLES ORAL
CAPSULE,
SPRINKLE 125 MG
1
DILANTIN ORAL
CAPSULE 30 MG
1
DILANTIN
INFATABS ORAL
TABLET,CHEWAB
LE 50 MG
1
divalproex oral
capsule, sprinkle
125 mg
1
divalproex oral
tablet extended
release 24 hr 250
mg, 500 mg
1
divalproex oral
tablet,delayed
release (DR/EC) 125
mg, 250 mg, 500 mg
1
Requirements
/Limits
Drug
Tier
Epitol oral tablet
200 mg
1
EQUETRO ORAL
CAPSULE, ER
MULTIPHASE 12
HR 100 MG, 200
MG, 300 MG
1
ethosuximide oral
capsule 250 mg
1
ethosuximide oral
solution 250 mg/5
mL
1
felbamate oral
suspension 600 mg/5
mL
1
felbamate oral tablet
400 mg, 600 mg
1
FELBATOL ORAL
SUSPENSION 600
MG/5 ML
1
FELBATOL ORAL
TABLET 400 MG,
600 MG
1
fosphenytoin
injection solution
100 mg PE/2 mL
1
FYCOMPA ORAL
TABLET 10 MG, 12
MG, 2 MG, 4 MG, 6
MG, 8 MG
1
gabapentin oral
capsule 100 mg, 300
mg, 400 mg
1
gabapentin oral
tablet 600 mg, 800
mg
1
GABITRIL ORAL
TABLET 12 MG, 16
MG, 2 MG, 4 MG
1
Requirements
/Limits
Drug
Tier
GRALISE ORAL
TABLET
EXTENDED
RELEASE 24 HR
300 MG, 600 MG
1
GRALISE 30-DAY
STARTER PACK
ORAL TABLET
EXTENDED
RELEASE 24 HR
300 MG (9)- 600
MG (69)
1
KEPPRA ORAL
SOLUTION 100
MG/ML
1
KEPPRA ORAL
TABLET 1,000 MG,
250 MG, 500 MG,
750 MG
1
KEPPRA XR ORAL
TABLET
EXTENDED
RELEASE 24 HR
500 MG, 750 MG
1
LAMICTAL ORAL
TABLET 100 MG,
150 MG, 200 MG,
25 MG
1
LAMICTAL
STARTER (BLUE)
KIT ORAL
TABLETS,DOSE
PACK 25 MG (35)
1
LAMICTAL
STARTER
(GREEN) KIT
ORAL
TABLETS,DOSE
PACK 25 MG (84) 100 MG (14)
1
Requirements
/Limits
27
Drug
Tier
LAMICTAL
STARTER
(ORANGE) KIT
ORAL
TABLETS,DOSE
PACK 25 MG (42) 100 MG (7)
1
LAMICTAL XR
ORAL TABLET
EXTENDED
RELEASE 24HR
100 MG, 200 MG,
25 MG, 250 MG,
300 MG, 50 MG
1
LAMICTAL XR
STARTER (BLUE)
ORAL TABLET
EXTENDED
REL,DOSE PACK
25 MG (21) -50 MG
(7)
1
LAMICTAL XR
STARTER
(GREEN) ORAL
TABLET
EXTENDED
REL,DOSE PACK
50 MG(14)-100MG
(14)-200 MG (7)
1
LAMICTAL XR
STARTER
(ORANGE) ORAL
TABLET
EXTENDED
REL,DOSE PACK
25MG (14)-50 MG
(14)-100MG (7)
1
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
28
Requirements
/Limits
Drug
Tier
lamotrigine oral
tablet, chewable
dispersible 25 mg, 5
mg
1
levetiracetam
500 mg/5 mL
1
levetiracetam oral
solution 100 mg/mL
1
levetiracetam oral
tablet 1,000 mg, 250
mg, 500 mg, 750 mg
1
levetiracetam oral
tablet extended
release 24 hr 500
mg, 750 mg
1
LYRICA ORAL
CAPSULE 100 MG,
150 MG, 200 MG,
225 MG, 25 MG,
300 MG, 50 MG, 75
MG
1
LYRICA ORAL
SOLUTION 20
MG/ML
1
NEURONTIN
ORAL SOLUTION
250 MG/5 ML
1
ONFI ORAL
SUSPENSION 2.5
MG/ML
1
ONFI ORAL
TABLET 10 MG, 20
MG
1
1
oxcarbazepine oral
suspension 300 mg/5
mL
1
1
oxcarbazepine oral
tablet 150 mg, 300
mg, 600 mg
1
Requirements
/Limits
BvsD
Drug
Tier
Requirements
/Limits
Drug
Tier
Requirements
/Limits
OXTELLAR XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
150 MG, 300 MG,
600 MG
1
QUDEXY XR
ORAL
CAPSULE,SPRINK
LE,ER 24HR 100
MG, 150 MG, 200
MG, 25 MG, 50 MG
1
PEGANONE ORAL
TABLET 250 MG
1
1
LA
phenobarbital oral
elixir 20 mg/5 mL
1
SABRIL ORAL
POWDER IN
PACKET 500 MG
1
LA
phenobarbital oral
tablet 100 mg, 15
mg, 16.2 mg, 30 mg,
32.4 mg, 60 mg, 64.8
mg, 97.2 mg
1
SABRIL ORAL
TABLET 500 MG
1
PHENYTEK ORAL
CAPSULE 200 MG,
300 MG
1
TEGRETOL XR
ORAL TABLET
EXTENDED
RELEASE 12 HR
100 MG, 200 MG,
400 MG
1
phenytoin oral
suspension 125 mg/5
mL
1
tiagabine oral tablet
2 mg, 4 mg
1
phenytoin oral
tablet,chewable 50
mg
1
TOPAMAX ORAL
CAPSULE,
SPRINKLE 15 MG,
25 MG
1
PHENYTOIN
SODIUM
INTRAVENOUS
SOLUTION 50
MG/ML
1
TOPAMAX ORAL
TABLET 100 MG,
200 MG, 25 MG, 50
MG
1
phenytoin sodium
extended oral
capsule 100 mg, 200
mg, 300 mg
1
topiramate oral
capsule, sprinkle 15
mg, 25 mg
1
POTIGA ORAL
TABLET 200 MG,
300 MG, 400 MG,
50 MG
1
topiramate oral
capsule,sprinkle,ER
24hr 100 mg, 150
mg, 200 mg, 25 mg,
50 mg
1
primidone oral
1
topiramate oral
tablet 100 mg, 200
mg, 25 mg, 50 mg
TRILEPTAL ORAL
SUSPENSION 300
MG/5 ML
1
29
Drug
Tier
TRILEPTAL ORAL
TABLET 150 MG,
300 MG, 600 MG
1
TROKENDI XR
ORAL
CAPSULE,EXTEN
DED RELEASE
24HR 100 MG, 200
MG, 25 MG, 50 MG
1
valproate sodium
500 mg/5 mL (100
mg/mL)
1
valproic acid oral
capsule 250 mg
1
valproic acid (as
sodium salt) oral
solution 250 mg/5
mL
1
VIMPAT
INTRAVENOUS
SOLUTION 200
MG/20 ML
1
VIMPAT ORAL
SOLUTION 10
MG/ML
1
VIMPAT ORAL
TABLET 100 MG,
150 MG, 200 MG,
50 MG
1
zonisamide oral
capsule 100 mg, 25
mg, 50 mg
1
Requirements
/Limits
Antiparkinsonism Agents
APOKYN
SUBCUTANEOUS
CARTRIDGE 10
MG/ML
1
AZILECT ORAL
TABLET 0.5 MG, 1
MG
1
30
BvsD
Drug
Tier
BENZTROPINE
INJECTION
SOLUTION 2 MG/2
ML
1
benztropine oral
tablet 0.5 mg, 1 mg,
2 mg
1
bromocriptine oral
capsule 5 mg
1
bromocriptine oral
tablet 2.5 mg
1
carbidopa-levodopa
oral tablet 10-100
mg, 25-100 mg, 25250 mg
1
carbidopa-levodopa
oral tablet extended
release 25-100 mg,
50-200 mg
1
carbidopa-levodopa
oral
tablet,disintegrating
10-100 mg, 25-100
mg, 25-250 mg
1
carbidopa-levodopaentacapone oral
tablet 12.5-50-200
mg, 18.75-75-200
mg, 25-100-200 mg,
31.25-125-200 mg,
37.5-150-200 mg,
50-200-200 mg
1
COMTAN ORAL
TABLET 200 MG
1
entacapone oral
tablet 200 mg
1
MIRAPEX ORAL
TABLET 0.125 MG,
0.25 MG, 0.5 MG,
0.75 MG, 1 MG, 1.5
MG
1
Requirements
/Limits
Drug
Tier
MIRAPEX ER
ORAL TABLET
EXTENDED
RELEASE 24 HR
0.375 MG, 0.75 MG,
1.5 MG, 2.25 MG, 3
MG, 3.75 MG, 4.5
MG
1
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
1
pramipexole oral
tablet 0.125 mg, 0.25
mg, 0.5 mg, 0.75 mg,
1 mg, 1.5 mg
1
ropinirole oral tablet
0.25 mg, 0.5 mg, 1
mg, 2 mg, 3 mg, 4
mg, 5 mg
1
ropinirole oral tablet
extended release 24
hr 12 mg, 2 mg, 4
mg, 6 mg, 8 mg
1
selegiline HCl oral
capsule 5 mg
1
selegiline HCl oral
tablet 5 mg
1
STALEVO 100
ORAL TABLET 25100-200 MG
1
STALEVO 125
ORAL TABLET
31.25-125-200 MG
1
STALEVO 150
ORAL TABLET
37.5-150-200 MG
1
Requirements
/Limits
Drug
Tier
STALEVO 200
ORAL TABLET 50200-200 MG
1
STALEVO 50
ORAL TABLET
12.5-50-200 MG
1
STALEVO 75
ORAL TABLET
18.75-75-200 MG
1
TASMAR ORAL
TABLET 100 MG
1
trihexyphenidyl oral
elixir 0.4 mg/mL
1
trihexyphenidyl oral
tablet 2 mg, 5 mg
1
ZELAPAR ORAL
TABLET,DISINTE
GRATING 1.25 MG
1
Requirements
/Limits
Migraine / Cluster Headache Therapy
dihydroergotamine
mg/mL
1
MAXALT ORAL
TABLET 10 MG
1
QL (90 EA per
30 Days)
MAXALT ORAL
TABLET 5 MG
1
QL (180 EA
per 30 Days)
MAXALT-MLT
ORAL
TABLET,DISINTE
GRATING 10 MG
1
QL (90 EA per
30 Days)
MAXALT-MLT
ORAL
TABLET,DISINTE
GRATING 5 MG
1
QL (180 EA
per 30 Days)
MIGRANAL
NASAL
SPRAY,NONAEROSOL 0.5
MG/PUMP ACT. (4
MG/ML)
1
31
Drug
Tier
Requirements
/Limits
Drug
rizatriptan oral
tablet 10 mg
1
QL (90 EA per
30 Days)
rizatriptan oral
tablet 5 mg
1
QL (180 EA
per 30 Days)
zolmitriptan oral
5 mg
rizatriptan oral
10 mg
1
QL (90 EA per
30 Days)
ARICEPT ORAL
TABLET 10 MG, 23
MG, 5 MG
1
rizatriptan oral
5 mg
1
QL (180 EA
per 30 Days)
1
sumatriptan nasal
spray,non-aerosol
20 mg/actuation, 5
mg/actuation
1
QL (12 EA per
30 days)
COPAXONE
SUBCUTANEOUS
SYRINGE 40
MG/ML
donepezil oral tablet
10 mg, 5 mg
1
QL (30 EA per
30 days)
1
donepezil oral tablet
23 mg
1
sumatriptan
succinate oral tablet
100 mg
QL (30 EA per
30 Days)
1
QL (30 EA per
30 days)
sumatriptan
25 mg
1
donepezil oral
10 mg, 5 mg
1
sumatriptan
50 mg
1
EXELON ORAL
CAPSULE 1.5 MG,
3 MG, 4.5 MG, 6
MG
ST; QL (60
EA per 30
days)
ST
1
sumatriptan
succinate
subcutaneous
solution 6 mg/0.5
mL
1
EXELON
TRANSDERMAL
PATCH 24 HOUR
13.3 MG/24 HOUR,
4.6 MG/24 HR, 9.5
MG/24 HR
1
sumatriptan
succinate
subcutaneous pen
injector 6 mg/0.5 mL
galantamine oral
capsule,ext rel.
pellets 24 hr 16 mg,
24 mg, 8 mg
1
QL (30 EA per
30 days)
zolmitriptan oral
tablet 2.5 mg
1
QL (12 EA per
30 days)
galantamine oral
solution 4 mg/mL
1
zolmitriptan oral
tablet 5 mg
1
QL (8 EA per
30 days)
1
zolmitriptan oral
2.5 mg
1
QL (12 EA per
30 days)
galantamine oral
tablet 12 mg, 4 mg, 8
mg
NAMENDA ORAL
SOLUTION 10
MG/5 ML
1
32
QL (9 EA per
30 days)
QL (18 EA per
30 days)
Tier
Requirements
/Limits
1
QL (8 EA per
30 days)
Miscellaneous Neurological Therapy
ST; QL (30
EA per 30
days)
Drug
Tier
NAMENDA XR
ORAL
CAP,SPRINKLE,E
R 24HR DOSE
PACK 7-14-21-28
MG
1
NAMENDA XR
ORAL
CAPSULE,SPRINK
LE,ER 24HR 14
MG, 21 MG, 28
MG, 7 MG
1
NUEDEXTA ORAL
CAPSULE 20-10
MG
Requirements
/Limits
Drug
Tier
Requirements
/Limits
chlorzoxazone oral
tablet 500 mg
1
PA
cyclobenzaprine oral
tablet 10 mg, 5 mg,
7.5 mg
1
PA
dantrolene oral
capsule 100 mg, 25
mg, 50 mg
1
guanidine oral tablet
125 mg
1
1
1
LORZONE ORAL
TABLET 375 MG,
750 MG
1
rivastigmine tartrate
oral capsule 1.5 mg,
3 mg, 4.5 mg, 6 mg
1
QL (60 EA per
30 days)
meprobamate oral
tablet 200 mg, 400
mg
1
BvsD; LA
MESTINON ORAL
SYRUP 60 MG/5
ML
1
TYSABRI
INTRAVENOUS
SOLUTION 300
MG/15 ML
1
XENAZINE ORAL
TABLET 12.5 MG,
25 MG
1
LA
MESTINON
TIMESPAN ORAL
TABLET
EXTENDED
RELEASE 180 MG
metaxalone oral
tablet 800 mg
1
PA
methocarbamol oral
tablet 500 mg, 750
mg
1
PA
orphenadrine citrate
release 100 mg
1
PA
pyridostigmine
bromide oral tablet
60 mg
1
SKELAXIN ORAL
TABLET 800 MG
1
SOMA ORAL
TABLET 250 MG
1
Muscle Relaxants / Antispasmodic Therapy
AMRIX ORAL
CAPSULE,EXTEN
DED RELEASE
24HR 15 MG, 30
MG
1
baclofen oral tablet
10 mg, 20 mg
1
carisoprodol oral
tablet 350 mg
1
PA
carisoprodol-ASAcodeine oral tablet
200-325-16 mg
1
PA; QL (2490
EA per 30
Days)
carisoprodol-aspirin
oral tablet 200-325
mg
1
PA
PA
33
Drug
Tier
Requirements
/Limits
Drug
Tier
Requirements
/Limits
codeine sulfate oral
tablet 15 mg
1
QL (2667 EA
per 30 Days)
1
QL (1333 EA
per 30 Days)
tizanidine oral
capsule 2 mg, 4 mg,
6 mg
1
tizanidine oral tablet
2 mg, 4 mg
1
tablet 30 mg
1
tablet 60 mg
1
ZANAFLEX ORAL
CAPSULE 2 MG, 4
MG, 6 MG
QL (667 EA
per 30 Days)
DILAUDID ORAL
LIQUID 1 MG/ML
1
QL (1500 ML
per 30 Days)
Duramorph (PF)
injection solution 0.5
mg/mL, 1 mg/mL
1
Endocet oral tablet
10-325 mg
1
QL (400 EA
per 30 Days)
Endocet oral tablet
5-325 mg
1
QL (800 EA
per 30 Days)
Endocet oral tablet
7.5-325 mg
1
QL (533 EA
per 30 Days)
fentanyl transdermal
patch 72 hour 100
mcg/hr
1
QL (25 EA per
30 Days)
patch 72 hour 12
mcg/hr
1
QL (208 EA
per 30 Days)
patch 72 hour 25
mcg/hr
1
QL (100 EA
per 30 Days)
patch 72 hour 50
mcg/hr
1
QL (50 EA per
30 Days)
patch 72 hour 75
mcg/hr
1
QL (33 EA per
30 Days)
fentanyl citrate
buccal lozenge on a
handle 1,200 mcg
1
PA; QL (40
EA per 30
Days)
fentanyl citrate
buccal lozenge on a
handle 1,600 mcg
1
PA; QL (30
EA per 30
Days)
Narcotic Analgesics
acetaminophencodeine oral solution
300 mg-30 mg /12.5
mL
1
acetaminophencodeine oral tablet
300-15 mg
1
300-30 mg
1
300-60 mg
1
Ascomp with
Codeine oral
capsule 30-50-32540 mg
1
buprenorphine HCl
injection syringe 0.3
mg/mL
1
buprenorphine HCl
sublingual tablet 2
mg, 8 mg
1
buprenorphinenaloxone sublingual
tablet 2-0.5 mg, 8-2
mg
1
butalbitalacetaminop-caf-cod
oral capsule 50-32540-30 mg
1
34
QL (8334 ML
per 15 Days)
QL (1333 EA
per 30 Days)
QL (667 EA
per 30 Days)
QL (1333 EA
per 30 Days)
QL (1333 EA
per 30 Days)
Drug
Tier
Requirements
/Limits
Drug
Tier
Requirements
/Limits
PA; QL (240
EA per 30
Days)
hydromorphone oral
tablet 8 mg
1
QL (188 EA
per 30 Days)
hydromorphone oral
tablet extended
release 24 hr 12 mg
1
QL (163 EA
per 30 days)
hydromorphone oral
tablet extended
release 24 hr 16 mg
1
QL (122 EA
per 30 days)
hydromorphone oral
tablet extended
release 24 hr 32 mg
1
QL (61 EA per
30 days)
hydromorphone oral
tablet extended
release 24 hr 8 mg
1
QL (245 EA
per 30 days)
hydromorphone
(PF) injection
solution 10 mg/mL
1
QL (150 ML
per 30 Days)
ibuprofen-oxycodone
oral tablet 400-5 mg
1
levorphanol tartrate
oral tablet 2 mg
1
meperidine oral
solution 50 mg/5 mL
1
meperidine oral
tablet 50 mg
1
Meperitab oral
tablet 100 mg
1
methadone injection
solution 10 mg/mL
1
QL (200 ML
per 30 Days)
fentanyl citrate
buccal lozenge on a
handle 200 mcg
1
fentanyl citrate
buccal lozenge on a
handle 400 mcg
1
fentanyl citrate
buccal lozenge on a
handle 600 mcg
1
fentanyl citrate
buccal lozenge on a
handle 800 mcg
1
hydrocodoneacetaminophen oral
solution 7.5-325
mg/15 mL
1
tablet 10-300 mg,
10-325 mg
1
tablet 2.5-325 mg
1
tablet 5-300 mg, 5325 mg
1
tablet 7.5-300 mg,
7.5-325 mg
1
hydrocodoneibuprofen oral tablet
7.5-200 mg
1
QL (800 EA
per 30 Days)
METHADONE
ORAL SOLUTION
10 MG/5 ML
1
QL (1000 ML
per 30 Days)
hydromorphone oral
liquid 1 mg/mL
1
QL (2021 ML
per 30 days)
METHADONE
ORAL SOLUTION
5 MG/5 ML
1
QL (2000 ML
per 30 Days)
hydromorphone oral
tablet 2 mg
1
QL (750 EA
per 30 Days)
methadone oral
tablet 10 mg
1
QL (200 EA
per 30 Days)
hydromorphone oral
tablet 4 mg
1
QL (375 EA
per 30 Days)
methadone oral
tablet 5 mg
1
QL (400 EA
per 30 Days)
PA; QL (120
EA per 30
Days)
PA; QL (80
EA per 30
Days)
PA; QL (60
EA per 30
Days)
QL (6000 ML
per 15 Days)
QL (600 EA
per 30 Days)
QL (1200 EA
per 30 Days)
QL (800 EA
per 30 Days)
35
Drug
Tier
Requirements
/Limits
Drug
Tier
Requirements
/Limits
morphine oral
capsule, ER
multiphase 24 hr
120 mg
1
QL (50 EA per
30 days)
morphine oral
capsule,extend.relea
se pellets 80 mg
1
QL (75 EA per
30 Days)
morphine oral
capsule, ER
multiphase 24 hr 30
mg
1
QL (200 EA
per 30 days)
morphine oral
solution 10 mg/5 mL
1
QL (3000 ML
per 30 Days)
morphine oral
solution 20 mg/5 mL
1
QL (1500 ML
per 30 Days)
morphine oral
capsule, ER
multiphase 24 hr 45
mg
1
morphine oral tablet
15 mg
1
QL (400 EA
per 30 Days)
30 mg
1
QL (200 EA
per 30 Days)
morphine oral
capsule, ER
multiphase 24 hr 60
mg
1
extended release 100
mg
1
QL (60 EA per
30 Days)
extended release 15
mg
1
QL (400 EA
per 30 Days)
morphine oral
capsule, ER
multiphase 24 hr 75
mg
1
mg
1
QL (30 EA per
30 Days)
morphine oral
capsule, ER
multiphase 24 hr 90
mg
1
extended release 30
mg
1
QL (200 EA
per 30 Days)
morphine oral
se pellets 10 mg, 100
mg
1
QL (60 EA per
30 Days)
extended release 60
mg
1
QL (100 EA
per 30 Days)
morphine oral
se pellets 20 mg
1
QL (300 EA
per 30 Days)
morphine
concentrate oral
solution 100 mg/5
mL (20 mg/mL)
1
QL (300 ML
per 30 Days)
morphine oral
se pellets 30 mg
1
QL (200 EA
per 30 Days)
OPANA ORAL
TABLET 10 MG
1
QL (200 EA
per 30 Days)
morphine oral
se pellets 50 mg
1
QL (120 EA
per 30 Days)
OPANA ORAL
TABLET 5 MG
1
QL (400 EA
per 30 Days)
1
morphine oral
se pellets 60 mg
1
OPANA ER ORAL
TABLET,ORAL
ONLY,EXT.REL.12
HR 10 MG, 20 MG,
30 MG
36
QL (134 EA
per 30 days)
QL (100 EA
per 30 days)
QL (80 EA per
30 days)
QL (67 EA per
30 days)
QL (100 EA
per 30 Days)
Drug
Tier
Requirements
/Limits
Drug
OPANA ER ORAL
TABLET,ORAL
ONLY,EXT.REL.12
HR 40 MG
1
QL (50 EA per
30 Days)
oxymorphone oral
tablet 5 mg
1
QL (400 EA
per 30 Days)
1
QL (200 EA
per 30 Days)
OPANA ER ORAL
TABLET,ORAL
ONLY,EXT.REL.12
HR 5 MG
1
oxymorphone oral
tablet extended
release 12 hr 10 mg
oxymorphone oral
tablet extended
release 12 hr 15 mg
1
QL (133 EA
per 30 Days)
oxycodone oral
capsule 5 mg
1
QL (800 EA
per 30 Days)
1
QL (100 EA
per 30 Days)
oxycodone oral
concentrate 20
mg/mL
1
QL (200 ML
per 30 Days)
oxymorphone oral
tablet extended
release 12 hr 20 mg
1
QL (67 EA per
30 Days)
oxycodone oral
solution 5 mg/5 mL
1
oxymorphone oral
tablet extended
release 12 hr 30 mg
1
oxycodone oral
tablet 10 mg
1
QL (400 EA
per 30 Days)
oxymorphone oral
tablet extended
release 12 hr 40 mg
QL (50 EA per
30 Days)
oxycodone oral
tablet 15 mg
1
QL (267 EA
per 30 Days)
1
QL (400 EA
per 30 Days)
oxycodone oral
tablet 20 mg
1
QL (200 EA
per 30 Days)
oxymorphone oral
tablet extended
release 12 hr 5 mg
1
oxycodone oral
tablet 30 mg
1
QL (133 EA
per 30 Days)
oxymorphone oral
tablet extended
release 12 hr 7.5 mg
QL (267 EA
per 30 Days)
oxycodone oral
tablet 5 mg
1
QL (800 EA
per 30 Days)
Reprexain oral
tablet 10-200 mg
1
QL (600 EA
per 30 Days)
oxycodone oral
tablet,oral
only,ext.rel.12 hr 10
mg, 20 mg, 40 mg,
80 mg
1
QL (60 EA per
30 days)
REPREXAIN
ORAL TABLET
2.5-200 MG
1
QL (2400 EA
per 30 Days)
1
QL (1200 EA
per 30 Days)
oxycodoneacetaminophen oral
tablet 10-325 mg,
2.5-325 mg, 5-325
mg, 7.5-325 mg
1
REPREXAIN
ORAL TABLET 5200 MG
Roxicet oral tablet
5-325 mg
1
oxycodone-aspirin
oral tablet 4.8355325 mg
1
oxymorphone oral
tablet 10 mg
1
QL (400 EA
per 30 Days)
QL (160 ML
per 30 Days)
Tier
Requirements
/Limits
Non-Narcotic Analgesics
QL (200 EA
per 30 Days)
ARTHROTEC 50
ORAL TABLET,IR
& DELAY
REL,BIPHASIC 50200 MG-MCG
1
37
Drug
Tier
ARTHROTEC 75
ORAL TABLET,IR
& DELAY
REL,BIPHASIC 75200 MG-MCG
1
Bunavail buccal film
2.1-0.3 mg, 4.2-0.7
mg, 6.3-1 mg
1
butorphanol tartrate
mg/mL, 2 mg/mL
1
butorphanol tartrate
nasal spray,nonaerosol 10 mg/mL
1
CELEBREX ORAL
CAPSULE 100 MG,
200 MG, 400 MG,
50 MG
1
celecoxib oral
capsule 100 mg, 200
mg, 400 mg, 50 mg
1
diclofenac potassium
oral tablet 50 mg
1
diclofenac sodium
1
diclofenac sodium
oral tablet,delayed
release (DR/EC) 25
mg, 50 mg, 75 mg
1
diclofenac sodium
topical drops 1.5 %
1
diclofenac sodium
topical gel 3 %
1
diclofenacmisoprostol oral
tablet,IR & delay
rel,biphasic 50-200
mg-mcg, 75-200 mgmcg
1
diflunisal oral tablet
500 mg
1
38
Requirements
/Limits
QL (60 EA per
30 days)
QL (60 EA per
30 days)
Drug
Tier
etodolac oral
capsule 200 mg
1
etodolac oral tablet
400 mg, 500 mg
1
etodolac oral tablet
extended release 24
hr 400 mg, 500 mg,
600 mg
1
fenoprofen oral
tablet 600 mg
1
flurbiprofen oral
1
ibuprofen oral
suspension 100 mg/5
mL
1
ibuprofen oral tablet
400 mg, 600 mg, 800
mg
1
INDOCIN ORAL
SUSPENSION 25
MG/5 ML
1
ketoprofen oral
capsule 50 mg, 75
mg
1
ketoprofen oral
capsule,ext rel.
pellets 24 hr 200 mg
1
ketorolac injection
solution 15 mg/mL,
30 mg/mL (1 mL)
1
ketorolac oral tablet
10 mg
1
meclofenamate oral
capsule 100 mg, 50
mg
1
mefenamic acid oral
capsule 250 mg
1
meloxicam oral
tablet 15 mg, 7.5 mg
1
Requirements
/Limits
QL (20 EA per
30 days)
Drug
Tier
nabumetone oral
tablet 500 mg, 750
mg
1
nalbuphine injection
solution 10 mg/mL,
20 mg/mL
1
naloxone injection
syringe 1 mg/mL
Requirements
/Limits
Drug
Tier
TALWIN
INJECTION
SOLUTION 30
MG/ML
1
tolmetin oral capsule
400 mg
1
1
tolmetin oral tablet
600 mg
1
naltrexone oral
tablet 50 mg
1
tramadol oral tablet
50 mg
1
naproxen oral
suspension 125 mg/5
mL
1
tramadol oral tablet
extended release 24
hr 100 mg, 200 mg
1
naproxen oral tablet
250 mg, 375 mg, 500
mg
1
tramadol oral tablet,
ER multiphase 24 hr
300 mg
1
naproxen oral
tablet,delayed
release (DR/EC) 375
mg, 500 mg
1
tramadolacetaminophen oral
tablet 37.5-325 mg
1
1
oxaprozin oral tablet
600 mg
1
VIVITROL
INTRAMUSCULA
R
SUSPENSION,EXT
ENDED REL
RECON 380 MG
1
naproxen sodium
oral tablet 275 mg,
550 mg
pentazocinenaloxone oral tablet
50-0.5 mg
1
VOLTAREN
TOPICAL GEL 1 %
1
piroxicam oral
capsule 10 mg, 20
mg
1
SUBOXONE
SUBLINGUAL
FILM 12-3 MG, 20.5 MG, 4-1 MG, 82 MG
1
sulindac oral tablet
150 mg, 200 mg
1
Requirements
/Limits
BvsD
BvsD
Psychotherapeutic Drugs
ABILIFY
INTRAMUSCULA
R SOLUTION 9.75
MG/1.3 ML
1
ABILIFY ORAL
SOLUTION 1
MG/ML
1
ABILIFY ORAL
TABLET 10 MG, 15
MG, 2 MG, 20 MG,
30 MG, 5 MG
1
39
Drug
Tier
ABILIFY
DISCMELT ORAL
TABLET,DISINTE
GRATING 10 MG,
15 MG
1
ABILIFY
MAINTENA
INTRAMUSCULA
R
SUSPENSION,EXT
ENDED REL
RECON 300 MG
1
ADDERALL XR
ORAL
CAPSULE,EXTEN
DED RELEASE
24HR 10 MG, 15
MG, 20 MG, 25
MG, 30 MG, 5 MG
1
alprazolam oral
tablet 0.25 mg, 0.5
mg, 1 mg, 2 mg
1
alprazolam oral
tablet extended
release 24 hr 0.5 mg,
1 mg, 2 mg, 3 mg
Requirements
/Limits
Drug
Tier
amoxapine oral
tablet 100 mg, 150
mg, 25 mg, 50 mg
1
Amphetamine Salt
Combo oral tablet
10 mg, 12.5 mg, 15
mg, 20 mg, 30 mg, 5
mg, 7.5 mg
1
APLENZIN ORAL
TABLET
EXTENDED
RELEASE 24 HR
174 MG, 348 MG,
522 MG
1
BRINTELLIX
ORAL TABLET 10
MG, 20 MG, 5 MG
1
BRISDELLE ORAL
CAPSULE 7.5 MG
1
bupropion HCl oral
1
1
bupropion HCl oral
tablet extended
release 100 mg, 150
mg, 200 mg
1
alprazolam oral
0.25 mg, 0.5 mg, 1
mg, 2 mg
1
bupropion HCl oral
tablet extended
release 24 hr 150
mg, 300 mg
1
Alprazolam Intensol
oral concentrate 1
mg/mL
1
buspirone oral tablet
10 mg, 15 mg, 30
mg, 5 mg, 7.5 mg
1
amitriptyline oral
tablet 10 mg, 100
mg, 150 mg, 25 mg,
50 mg, 75 mg
1
carbamazepine oral
tablet extended
1
1
amitriptylinechlordiazepoxide
oral tablet 12.5-5
mg, 25-10 mg
1
chlordiazepoxide
HCl oral capsule 10
mg, 25 mg, 5 mg
chlorpromazine
mg/mL
1
40
BvsD
Requirements
/Limits
PA
Drug
Tier
chlorpromazine oral
tablet 10 mg, 100
mg, 200 mg, 25 mg,
50 mg
1
citalopram oral
solution 10 mg/5 mL
1
citalopram oral
tablet 10 mg, 20 mg,
40 mg
1
clomipramine oral
capsule 25 mg, 50
mg, 75 mg
1
clonazepam oral
2 mg
1
clonazepam oral
0.125 mg, 0.25 mg,
0.5 mg, 1 mg, 2 mg
Requirements
/Limits
Drug
Tier
Requirements
/Limits
CYMBALTA
ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
20 MG, 30 MG, 60
MG
1
desipramine oral
tablet 10 mg, 100
mg, 150 mg, 25 mg,
50 mg, 75 mg
1
DESOXYN ORAL
TABLET 5 MG
1
1
1
desvenlafaxine oral
tablet extended
release 24 hr 100
mg, 50 mg
1
clorazepate
dipotassium oral
tablet 15 mg, 3.75
mg, 7.5 mg
1
dexmethylphenidate
oral capsule,ER
biphasic 50-50 15
mg, 30 mg, 40 mg
dexmethylphenidate
oral tablet 10 mg,
2.5 mg, 5 mg
1
clozapine oral tablet
100 mg, 25 mg, 50
mg
1
1
CLOZAPINE
ORAL TABLET
200 MG
1
dextroamphetamine
oral capsule,
extended release 10
mg, 15 mg, 5 mg
1
clozapine oral
100 mg, 12.5 mg, 25
mg
1
dextroamphetamine
mg
1
CLOZARIL ORAL
TABLET 100 MG,
25 MG
1
dextroamphetamineamphetamine oral
capsule,extended
release 24hr 10 mg,
15 mg, 20 mg, 25
mg, 30 mg, 5 mg
CONCERTA ORAL
TABLET
EXTENDED
RELEASE 24HR 18
MG, 27 MG, 36
MG, 54 MG
1
Diastat rectal kit 2.5
mg
1
PA
Diastat AcuDial
rectal kit 12.5-1517.5-20 mg, 5-7.5-10
mg
1
PA
41
Drug
Tier
diazepam oral
solution 5 mg/5 mL
1
diazepam oral tablet
10 mg, 2 mg, 5 mg
1
diazepam rectal kit
12.5-15-17.5-20 mg,
2.5 mg, 5-7.5-10 mg
1
Diazepam Intensol
oral concentrate 5
mg/mL
1
doxepin oral capsule
10 mg, 100 mg, 150
mg, 25 mg, 50 mg,
75 mg
1
doxepin oral
concentrate 10
mg/mL
1
DULOXETINE
ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
20 MG, 30 MG, 60
MG
1
EFFEXOR XR
ORAL
CAPSULE,EXTEN
DED RELEASE
24HR 150 MG, 37.5
MG, 75 MG
1
EMSAM
TRANSDERMAL
PATCH 24 HOUR
12 MG/24 HR, 6
MG/24 HR, 9
MG/24 HR
1
ergoloid oral tablet
1 mg
1
escitalopram oxalate
oral solution 5 mg/5
mL
1
42
Requirements
/Limits
Drug
Tier
escitalopram oxalate
mg, 5 mg
1
estazolam oral tablet
1 mg, 2 mg
1
eszopiclone oral
mg
1
FANAPT ORAL
TABLET 1 MG, 10
MG, 12 MG, 2 MG,
4 MG, 6 MG, 8 MG
1
FANAPT ORAL
TABLETS,DOSE
PACK 1MG(2)2MG(2)- 4MG(2)6MG(2)
1
FazaClo oral
100 mg, 12.5 mg,
150 mg, 200 mg, 25
mg
1
FETZIMA ORAL
CAPSULE,EXT
REL 24HR DOSE
PACK 20 MG (2)40 MG (26)
1
FETZIMA ORAL
CAPSULE,EXTEN
DED RELEASE 24
HR 120 MG, 20
MG, 40 MG, 80 MG
1
fluoxetine oral
capsule 10 mg, 20
mg, 40 mg
1
fluoxetine oral
capsule,delayed
release(DR/EC) 90
mg
1
fluoxetine oral
solution 20 mg/5 mL
1
Requirements
/Limits
PA
Drug
Tier
fluoxetine oral tablet
10 mg, 20 mg, 60 mg
1
fluphenazine
decanoate injection
solution 25 mg/mL
1
fluphenazine HCl
mg/mL
1
fluphenazine HCl
oral concentrate 5
mg/mL
1
fluphenazine HCl
oral elixir 2.5 mg/5
mL
1
fluphenazine HCl
mg, 2.5 mg, 5 mg
1
flurazepam oral
capsule 15 mg, 30
mg
1
fluvoxamine oral
capsule,extended
150 mg
1
fluvoxamine oral
tablet 100 mg, 25
mg, 50 mg
1
FOCALIN ORAL
TABLET 10 MG,
2.5 MG, 5 MG
1
FOCALIN XR
ORAL
CAPSULE,ER
BIPHASIC 50-50 10
MG, 15 MG, 20
MG, 25 MG, 30
MG, 35 MG, 40
MG, 5 MG
1
Requirements
/Limits
PA
Drug
Tier
FORFIVO XL
ORAL TABLET
EXTENDED
RELEASE 24 HR
450 MG
1
GEODON
INTRAMUSCULA
R RECON SOLN 20
MG/ML (FINAL
CONC.)
1
GEODON ORAL
CAPSULE 20 MG,
40 MG, 60 MG, 80
MG
1
guanfacine oral
tablet extended
release 24 hr 1 mg, 2
mg, 3 mg, 4 mg
1
HALDOL
INJECTION
SOLUTION 5
MG/ML
1
HALDOL
DECANOATE
INTRAMUSCULA
R SOLUTION 100
MG/ML, 50
MG/ML
1
haloperidol oral
10 mg, 2 mg, 20 mg,
5 mg
1
haloperidol
decanoate
intramuscular
solution 100 mg/mL,
50 mg/mL
1
haloperidol lactate
mg/mL
1
haloperidol lactate
oral concentrate 2
mg/mL
1
Requirements
/Limits
BvsD
43
Drug
Tier
imipramine HCl oral
50 mg
1
imipramine pamoate
125 mg, 150 mg, 75
mg
1
INVEGA ORAL
TABLET
EXTENDED
RELEASE 24HR
1.5 MG, 3 MG, 6
MG, 9 MG
1
INVEGA
SUSTENNA
INTRAMUSCULA
R SYRINGE 117
MG/0.75 ML, 156
MG/ML, 234
MG/1.5 ML, 39
MG/0.25 ML, 78
MG/0.5 ML
1
KHEDEZLA ORAL
TABLET
EXTENDED
RELEASE 24HR
100 MG, 50 MG
1
LATUDA ORAL
TABLET 120 MG,
20 MG, 40 MG, 60
MG, 80 MG
1
LEXAPRO ORAL
SOLUTION 5 MG/5
ML
1
LEXAPRO ORAL
TABLET 10 MG, 20
MG, 5 MG
lithium carbonate
300 mg
44
Requirements
/Limits
Drug
Tier
LITHIUM
CARBONATE
ORAL CAPSULE
600 MG
1
lithium carbonate
oral tablet 300 mg
1
lithium carbonate
release 300 mg, 450
mg
1
lithium citrate oral
solution 8 mEq/5 mL
1
lorazepam oral
2 mg
1
Lorazepam Intensol
oral concentrate 2
mg/mL
1
loxapine succinate
oral capsule 10 mg,
25 mg, 5 mg, 50 mg
1
maprotiline oral
75 mg
1
MARPLAN ORAL
TABLET 10 MG
1
METADATE CD
ORAL CAPSULE,
ER BIPHASIC 3070 10 MG, 20 MG,
30 MG, 40 MG, 50
MG, 60 MG
1
1
Metadate ER oral
tablet extended
release 20 mg
1
1
methamphetamine
oral tablet 5 mg
1
METHYLIN ORAL
SOLUTION 10
MG/5 ML, 5 MG/5
ML
1
BvsD
Requirements
/Limits
Drug
Tier
METHYLIN ORAL
TABLET,CHEWAB
LE 10 MG, 2.5 MG,
5 MG
1
methylphenidate
oral capsule, ER
biphasic 30-70 10
mg, 50 mg, 60 mg
1
methylphenidate
oral capsule,ER
biphasic 50-50 20
mg, 30 mg, 40 mg
Requirements
/Limits
Drug
Tier
nortriptyline oral
solution 10 mg/5 mL
1
NUVIGIL ORAL
TABLET 150 MG,
200 MG, 250 MG,
50 MG
1
1
1
olanzapine
intramuscular recon
soln 10 mg
1
methylphenidate
oral solution 10
mg/5 mL, 5 mg/5 mL
1
olanzapine oral
2.5 mg, 20 mg, 5 mg,
7.5 mg
1
methylphenidate
mg, 5 mg
1
olanzapine oral
10 mg, 15 mg, 20
mg, 5 mg
1
methylphenidate
release 24hr 18 mg,
27 mg
1
olanzapinefluoxetine oral
capsule 12-25 mg,
12-50 mg, 3-25 mg,
6-25 mg, 6-50 mg
1
methylphenidate
release 20 mg
ORAP ORAL
TABLET 1 MG, 2
MG
1
mirtazapine oral
45 mg, 7.5 mg
1
oxazepam oral
capsule 10 mg, 15
mg, 30 mg
1
mirtazapine oral
15 mg, 30 mg, 45 mg
1
paroxetine HCl oral
30 mg, 40 mg
1
modafinil oral tablet
100 mg, 200 mg
1
1
NARDIL ORAL
TABLET 15 MG
1
paroxetine HCl oral
tablet extended
release 24 hr 12.5
mg, 25 mg, 37.5 mg
nefazodone oral
tablet 100 mg, 150
mg, 200 mg, 250 mg,
50 mg
1
PAXIL ORAL
SUSPENSION 10
MG/5 ML
1
1
nortriptyline oral
capsule 10 mg, 25
mg, 50 mg, 75 mg
1
perphenazine oral
mg, 8 mg
PA
Requirements
/Limits
PA
PA
45
Drug
Tier
perphenazineamitriptyline oral
tablet 2-10 mg, 2-25
mg, 4-10 mg, 4-25
mg, 4-50 mg
1
PEXEVA ORAL
TABLET 10 MG, 20
MG, 30 MG, 40 MG
1
phenelzine oral
tablet 15 mg
1
PRISTIQ ORAL
TABLET
EXTENDED
RELEASE 24 HR
100 MG, 50 MG
1
protriptyline oral
tablet 10 mg, 5 mg
1
PROVIGIL ORAL
TABLET 100 MG,
200 MG
1
PROZAC WEEKLY
ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
90 MG
1
quetiapine oral
tablet 100 mg, 200
mg, 25 mg, 300 mg,
400 mg, 50 mg
1
Restoril oral capsule
15 mg, 22.5 mg, 30
mg, 7.5 mg
1
RISPERDAL
CONSTA
INTRAMUSCULA
R SYRINGE 12.5
MG/2 ML, 25 MG/2
ML, 37.5 MG/2 ML,
50 MG/2 ML
1
46
Requirements
/Limits
PA
BvsD
Drug
Tier
RISPERDAL MTAB ORAL
TABLET,DISINTE
GRATING 0.5 MG,
1 MG, 2 MG, 3 MG,
4 MG
1
risperidone oral
solution 1 mg/mL
1
risperidone oral
tablet 0.25 mg, 0.5
mg, 1 mg, 2 mg, 3
mg, 4 mg
1
RISPERIDONE
ORAL
TABLET,DISINTE
GRATING 0.25 MG
1
risperidone oral
0.5 mg, 1 mg, 2 mg,
3 mg, 4 mg
1
ROZEREM ORAL
TABLET 8 MG
1
SAPHRIS (BLACK
CHERRY)
SUBLINGUAL
TABLET 10 MG, 5
MG
1
SARAFEM ORAL
TABLET 10 MG, 20
MG
1
SEROQUEL ORAL
TABLET 100 MG,
200 MG, 25 MG,
300 MG, 400 MG,
50 MG
1
SEROQUEL XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
150 MG, 200 MG,
300 MG, 400 MG,
50 MG
1
Requirements
/Limits
PA
Drug
Tier
sertraline oral
concentrate 20
mg/mL
1
sertraline oral tablet
100 mg, 25 mg, 50
mg
1
STRATTERA
ORAL CAPSULE
10 MG, 100 MG, 18
MG, 25 MG, 40
MG, 60 MG, 80 MG
1
Surmontil oral
capsule 100 mg, 25
mg, 50 mg
1
SYMBYAX ORAL
CAPSULE 12-25
MG, 12-50 MG, 325 MG, 6-25 MG, 650 MG
1
temazepam oral
capsule 15 mg, 22.5
mg, 30 mg, 7.5 mg
1
thioridazine oral
tablet 10 mg, 100
mg, 25 mg, 50 mg
1
thiothixene oral
capsule 1 mg, 10 mg,
2 mg, 5 mg
1
TOFRANIL-PM
ORAL CAPSULE
100 MG, 125 MG,
150 MG, 75 MG
1
tranylcypromine
oral tablet 10 mg
1
trazodone oral tablet
100 mg, 150 mg, 300
mg, 50 mg
1
triazolam oral tablet
0.125 mg, 0.25 mg
1
trifluoperazine oral
mg, 5 mg
1
Requirements
/Limits
PA
Drug
Tier
venlafaxine oral
capsule,extended
37.5 mg, 75 mg
1
venlafaxine oral
tablet 100 mg, 25
mg, 37.5 mg, 50 mg,
75 mg
1
VENLAFAXINE
ORAL TABLET
EXTENDED
RELEASE 24HR
150 MG, 225 MG,
37.5 MG, 75 MG
1
Versacloz oral
suspension 50
mg/mL
1
VIIBRYD ORAL
TABLET 10 MG, 20
MG, 40 MG
1
VIIBRYD ORAL
TABLETS,DOSE
PACK 10 MG (7)20 MG (7)-40 MG
(16)
1
VYVANSE ORAL
CAPSULE 20 MG,
30 MG, 40 MG, 50
MG, 60 MG, 70 MG
1
XYREM ORAL
SOLUTION 500
MG/ML
1
zaleplon oral
capsule 10 mg, 5 mg
1
ziprasidone HCl
oral capsule 20 mg,
40 mg, 60 mg, 80 mg
1
zolpidem oral tablet
10 mg, 5 mg
1
Requirements
/Limits
LA
47
Drug
Tier
zolpidem oral
tablet,ext release
multiphase 12.5 mg,
6.25 mg
1
ZYPREXA
INTRAMUSCULA
R RECON SOLN 10
MG
1
ZYPREXA ORAL
TABLET 10 MG, 15
MG, 2.5 MG, 20
MG, 5 MG, 7.5 MG
1
ZYPREXA ZYDIS
ORAL
TABLET,DISINTE
GRATING 10 MG,
15 MG, 20 MG, 5
MG
1
Requirements
/Limits
Cardiovascular, Hypertension / Lipids
Antiarrhythmic Agents
Drug
Tier
Pacerone oral tablet
200 mg, 400 mg
1
procainamide
injection solution
100 mg/mL, 500
mg/mL
1
propafenone oral
capsule,extended
release 12 hr 225
mg, 325 mg, 425 mg
1
propafenone oral
tablet 150 mg, 225
mg, 300 mg
1
QUINIDINE
GLUCONATE
INJECTION
SOLUTION 80
MG/ML
1
quinidine gluconate
release 324 mg
1
quinidine sulfate
oral tablet 200 mg,
300 mg
1
quinidine sulfate
release 300 mg
1
Sorine oral tablet
120 mg, 160 mg, 240
mg, 80 mg
1
amiodarone
50 mg/mL
1
amiodarone oral
tablet 200 mg, 400
mg
1
disopyramide
phosphate oral
capsule 100 mg, 150
mg
1
flecainide oral tablet
100 mg, 150 mg, 50
mg
1
sotalol oral tablet
160 mg, 240 mg, 80
mg
1
mexiletine oral
capsule 150 mg, 200
mg, 250 mg
1
Sotalol AF oral
tablet 120 mg
1
1
PACERONE ORAL
TABLET 100 MG
1
TIKOSYN ORAL
CAPSULE 125
MCG, 250 MCG,
500 MCG
1
MULTAQ ORAL
TABLET 400 MG
48
QL (60 EA per
30 days)
Antihypertensive Therapy
Requirements
/Limits
Drug
Tier
Requirements
/Limits
Drug
Tier
Requirements
/Limits
AMTURNIDE
ORAL TABLET
150-5-12.5 MG,
300-10-12.5 MG,
300-10-25 MG, 3005-12.5 MG, 300-525 MG
1
QL (30 EA per
30 days)
atenolol oral tablet
100 mg, 25 mg, 50
mg
1
atenololchlorthalidone oral
tablet 100-25 mg,
50-25 mg
1
AZOR ORAL
TABLET 10-20
MG, 10-40 MG, 520 MG, 5-40 MG
1
acebutolol oral
capsule 200 mg, 400
mg
1
ADCIRCA ORAL
TABLET 20 MG
1
Afeditab CR oral
tablet extended
release 30 mg, 60
mg
1
ALDACTAZIDE
ORAL TABLET 5050 MG
1
amiloride oral tablet
5 mg
1
amiloridehydrochlorothiazide
oral tablet 5-50 mg
1
amlodipine oral
tablet 10 mg, 2.5 mg,
5 mg
1
benazepril oral
40 mg, 5 mg
1
amlodipinebenazepril oral
capsule 10-20 mg,
10-40 mg, 2.5-10
mg, 5-10 mg, 5-20
mg, 5-40 mg
1
benazeprilhydrochlorothiazide
oral tablet 10-12.5
mg, 20-12.5 mg, 2025 mg, 5-6.25 mg
1
1
amlodipinevalsartan oral tablet
10-160 mg, 10-320
mg, 5-160 mg, 5-320
mg
1
betaxolol oral tablet
10 mg, 20 mg
bisoprolol fumarate
mg
1
amlodipinevalsartan-hcthiazid
oral tablet 10-16012.5 mg, 10-160-25
mg, 10-320-25 mg,
5-160-12.5 mg, 5160-25 mg
1
bisoprololhydrochlorothiazide
oral tablet 10-6.25
mg, 2.5-6.25 mg, 56.25 mg
1
bumetanide injection
solution 0.25 mg/mL
1
bumetanide oral
2 mg
1
PA
QL (30 EA per
30 days)
QL (30 EA per
30 days)
49
Drug
Tier
BYSTOLIC ORAL
TABLET 10 MG,
2.5 MG, 20 MG, 5
MG
1
candesartan oral
4 mg, 8 mg
1
candesartanhydrochlorothiazid
oral tablet 16-12.5
mg, 32-12.5 mg, 3225 mg
1
captopril oral tablet
100 mg, 12.5 mg, 25
mg, 50 mg
1
captoprilhydrochlorothiazide
oral tablet 25-15 mg,
25-25 mg, 50-15 mg,
50-25 mg
1
CARDURA XL
ORAL TABLET
EXTENDED
RELEASE 24HR 4
MG, 8 MG
1
Cartia XT oral
capsule,extended
180 mg, 240 mg, 300
mg
1
carvedilol oral tablet
12.5 mg, 25 mg,
3.125 mg, 6.25 mg
1
chlorothiazide oral
tablet 250 mg, 500
mg
1
chlorothiazide
sodium intravenous
recon soln 500 mg
1
chlorthalidone oral
tablet 25 mg, 50 mg
1
50
Requirements
/Limits
QL (60 EA per
30 days)
BvsD
Drug
Tier
Requirements
/Limits
clonidine
transdermal patch
weekly 0.1 mg/24 hr,
0.2 mg/24 hr, 0.3
mg/24 hr
1
clonidine HCl oral
tablet 0.1 mg, 0.2
mg, 0.3 mg
1
clonidine HCl oral
tablet extended
release 12 hr 0.1 mg
1
CLORPRES ORAL
TABLET 0.1-15
MG, 0.2-15 MG,
0.3-15 MG
1
COREG CR ORAL
CAPSULE, ER
MULTIPHASE 24
HR 10 MG, 20 MG,
40 MG, 80 MG
1
COZAAR ORAL
TABLET 100 MG
1
ST; QL (30
EA per 30
days)
COZAAR ORAL
TABLET 25 MG, 50
MG
1
ST; QL (60
EA per 30
days)
DEMSER ORAL
CAPSULE 250 MG
1
DIBENZYLINE
ORAL CAPSULE
10 MG
1
DILT-XR oral
capsule,ext release
degradable 180 mg,
240 mg
1
DILTIAZEM HCL
INTRAVENOUS
RECON SOLN 100
MG
1
diltiazem HCl
5 mg/mL
1
Drug
Tier
diltiazem HCl oral
capsule, extended
release 180 mg, 360
mg, 420 mg
1
diltiazem HCl oral
capsule,extended
release 12 hr 120
mg, 60 mg, 90 mg
1
diltiazem HCl oral
capsule,extended
240 mg, 300 mg
Requirements
/Limits
Drug
Tier
EDARBI ORAL
TABLET 40 MG, 80
MG
1
EDARBYCLOR
ORAL TABLET 4012.5 MG, 40-25 MG
1
1
1
enalapril maleate
oral tablet 10 mg,
2.5 mg, 20 mg, 5 mg
1
diltiazem HCl oral
tablet 120 mg, 30
mg, 60 mg, 90 mg
1
enalaprilhydrochlorothiazide
5-12.5 mg
eplerenone oral
tablet 25 mg, 50 mg
1
DIOVAN ORAL
TABLET 160 MG,
40 MG, 80 MG
1
ST; QL (60
EA per 30
days)
eprosartan oral
tablet 600 mg
1
DIOVAN ORAL
TABLET 320 MG
1
ST; QL (30
EA per 30
days)
EXFORGE ORAL
TABLET 10-160
MG, 10-320 MG, 5160 MG, 5-320 MG
1
DIOVAN HCT
ORAL TABLET
160-12.5 MG, 16025 MG, 320-12.5
MG, 320-25 MG,
80-12.5 MG
1
ST; QL (30
EA per 30
days)
EXFORGE HCT
ORAL TABLET 10160-12.5 MG, 10160-25 MG, 10-32025 MG, 5-160-12.5
MG, 5-160-25 MG
1
DIURIL ORAL
SUSPENSION 250
MG/5 ML
1
1
DIURIL IV
INTRAVENOUS
RECON SOLN 500
MG
1
felodipine oral tablet
extended release 24
hr 10 mg, 2.5 mg, 5
mg
fosinopril oral tablet
10 mg, 20 mg, 40 mg
1
doxazosin oral tablet
1 mg, 2 mg, 4 mg, 8
mg
1
fosinoprilhydrochlorothiazide
oral tablet 10-12.5
mg, 20-12.5 mg
1
DYRENIUM ORAL
CAPSULE 100 MG,
50 MG
1
furosemide injection
solution 10 mg/mL
1
furosemide injection
syringe 10 mg/mL
1
BvsD
QL (60 EA per
30 days)
Requirements
/Limits
ST
51
Drug
Tier
Requirements
/Limits
Drug
Tier
furosemide oral
solution 10 mg/mL
1
isradipine oral
capsule 2.5 mg, 5 mg
1
FUROSEMIDE
ORAL SOLUTION
40 MG/5 ML
1
labetalol
5 mg/mL
1
furosemide oral
80 mg
1
labetalol oral tablet
100 mg, 200 mg, 300
mg
1
guanfacine oral
tablet 1 mg, 2 mg
1
1
hydralazine injection
solution 20 mg/mL
1
lisinopril oral tablet
10 mg, 2.5 mg, 20
mg, 30 mg, 40 mg, 5
mg
hydralazine oral
tablet 10 mg, 100
mg, 25 mg, 50 mg
1
1
hydrochlorothiazide
oral capsule 12.5 mg
1
lisinoprilhydrochlorothiazide
oral tablet 10-12.5
mg, 20-12.5 mg, 2025 mg
1
losartan oral tablet
100 mg, 25 mg, 50
mg
1
hydrochlorothiazide
oral tablet 12.5 mg,
25 mg, 50 mg
1
losartanhydrochlorothiazide
oral tablet 100-12.5
mg, 100-25 mg, 5012.5 mg
1
HYZAAR ORAL
TABLET 100-12.5
MG, 100-25 MG,
50-12.5 MG
indapamide oral
tablet 1.25 mg, 2.5
mg
1
methyclothiazide
oral tablet 5 mg
1
1
methyldopa oral
tablet 250 mg, 500
mg
1
INTUNIV ER
ORAL TABLET
EXTENDED
RELEASE 24 HR 1
MG, 2 MG, 3 MG, 4
MG
methyldopahydrochlorothiazide
oral tablet 250-15
mg, 250-25 mg
1
irbesartan oral
tablet 150 mg, 300
mg, 75 mg
1
metolazone oral
5 mg
1
irbesartanhydrochlorothiazide
mg, 300-12.5 mg
1
metoprolol succinate
release 24 hr 100
mg, 200 mg, 25 mg,
50 mg
1
52
ST; QL (30
EA per 30
days)
Requirements
/Limits
Drug
Tier
metoprolol tahydrochlorothiaz
oral tablet 100-25
mg, 100-50 mg, 5025 mg
1
metoprolol tartrate
5 mg/5 mL
1
metoprolol tartrate
oral tablet 100 mg,
25 mg, 50 mg
1
MICARDIS ORAL
TABLET 20 MG, 40
MG, 80 MG
1
MICARDIS HCT
ORAL TABLET 4012.5 MG, 80-12.5
MG, 80-25 MG
1
minoxidil oral tablet
10 mg, 2.5 mg
1
moexipril oral tablet
15 mg
1
moexiprilhydrochlorothiazide
oral tablet 15-12.5
mg, 15-25 mg, 7.512.5 mg
1
nadolol oral tablet
20 mg, 40 mg, 80 mg
1
nadololbendroflumethiazide
80-5 mg
1
nicardipine oral
capsule 20 mg, 30
mg
1
Nifedical XL oral
tablet extended
release 24hr 30 mg,
60 mg
1
Requirements
/Limits
BvsD
QL (30 EA per
30 days)
QL (30 EA per
30 days)
Drug
Tier
nifedipine oral
capsule 10 mg, 20
mg
1
nifedipine oral tablet
extended release
24hr 30 mg, 60 mg,
90 mg
1
nimodipine oral
capsule 30 mg
1
nisoldipine oral
tablet extended
release 24 hr 20 mg,
30 mg, 40 mg
1
pindolol oral tablet
10 mg, 5 mg
1
prazosin oral
capsule 1 mg, 2 mg,
5 mg
1
propranolol
1 mg/mL
1
propranolol oral
capsule,extended
release 24 hr 120
mg, 160 mg, 60 mg,
80 mg
1
propranolol oral
solution 20 mg/5
mL, 40 mg/5 mL
1
propranolol oral
40 mg, 60 mg, 80 mg
1
propranololhydrochlorothiazid
80-25 mg
1
quinapril oral tablet
10 mg, 20 mg, 40
mg, 5 mg
1
Requirements
/Limits
53
Drug
Tier
Requirements
/Limits
Drug
Tier
quinaprilhydrochlorothiazide
oral tablet 10-12.5
mg, 20-12.5 mg, 2025 mg
1
telmisartanamlodipine oral
tablet 40-10 mg, 405 mg, 80-10 mg, 805 mg
1
ramipril oral
capsule 1.25 mg, 10
mg, 2.5 mg, 5 mg
1
terazosin oral
capsule 1 mg, 10 mg,
2 mg, 5 mg
1
REMODULIN
INJECTION
SOLUTION 1
MG/ML, 10
MG/ML, 2.5
MG/ML, 5 MG/ML
1
timolol maleate oral
5 mg
1
1
reserpine oral tablet
0.1 mg, 0.25 mg
1
TORSEMIDE
INTRAVENOUS
SOLUTION 20
MG/2 ML (10
MG/ML)
spironolactonhydrochlorothiaz
oral tablet 25-25 mg
1
torsemide oral tablet
10 mg, 100 mg, 20
mg, 5 mg
1
spironolactone oral
tablet 100 mg, 25
mg, 50 mg
1
trandolapril oral
mg
1
SULAR ORAL
TABLET
EXTENDED
RELEASE 24 HR
34 MG, 8.5 MG
1
triamterenehydrochlorothiazid
oral capsule 37.5-25
mg, 50-25 mg
1
1
triamterenehydrochlorothiazid
oral tablet 37.5-25
mg, 75-50 mg
1
Taztia XT oral
capsule, extended
release 120 mg, 180
mg, 240 mg, 300 mg,
360 mg
1
TEKTURNA ORAL
TABLET 150 MG,
300 MG
1
valsartan oral tablet
160 mg, 320 mg, 40
mg, 80 mg
1
TEKTURNA HCT
ORAL TABLET
150-12.5 MG, 15025 MG, 300-12.5
MG, 300-25 MG
1
valsartanhydrochlorothiazide
mg, 160-25 mg, 32012.5 mg, 320-25 mg,
80-12.5 mg
1
verapamil
2.5 mg/mL
1
telmisartan oral
80 mg
54
BvsD
Requirements
/Limits
QL (30 EA per
30 days)
Drug
Tier
verapamil oral
capsule, 24 hr ER
pellet CT 100 mg,
200 mg, 300 mg
1
verapamil oral
capsule,ext rel.
pellets 24 hr 120 mg,
180 mg, 240 mg, 360
mg
1
verapamil oral tablet
120 mg, 40 mg, 80
mg
1
verapamil oral tablet
mg, 180 mg, 240 mg
1
Requirements
/Limits
Cardiac Glycosides
Digitek oral tablet
125 mcg, 250 mcg
1
digoxin oral solution
50 mcg/mL
1
digoxin oral tablet
125 mcg, 250 mcg
1
LANOXIN
INJECTION
SOLUTION 250
MCG/ML
1
BvsD
Coagulation Therapy
AGGRENOX
ORAL CAPSULE,
ER MULTIPHASE
12 HR 25-200 MG
1
ARIXTRA
SUBCUTANEOUS
SYRINGE 10
MG/0.8 ML, 2.5
MG/0.5 ML, 5
MG/0.4 ML, 7.5
MG/0.6 ML
1
BRILINTA ORAL
TABLET 90 MG
1
BvsD
Drug
Tier
Requirements
/Limits
cilostazol oral tablet
100 mg, 50 mg
1
clopidogrel oral
tablet 300 mg
1
clopidogrel oral
tablet 75 mg
1
CYKLOKAPRON
INTRAVENOUS
SOLUTION 1,000
MG/10 ML (100
MG/ML)
1
dipyridamole oral
75 mg
1
ELIQUIS ORAL
TABLET 2.5 MG, 5
MG
1
enoxaparin
subcutaneous
solution 300 mg/3
mL
1
enoxaparin
subcutaneous
syringe 100 mg/mL
1
enoxaparin
subcutaneous
syringe 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
1
BvsD
fondaparinux
subcutaneous
syringe 10 mg/0.8
mL, 2.5 mg/0.5 mL,
5 mg/0.4 mL, 7.5
mg/0.6 mL
1
BvsD
QL (30 EA per
30 days)
55
Drug
Tier
FRAGMIN
SUBCUTANEOUS
SYRINGE 10,000
ANTI-XA
UNIT/ML, 12,500
ANTI-XA UNIT/0.5
ML, 15,000 ANTIXA UNIT/0.6 ML,
18,000 ANTI-XA
UNIT/0.72 ML,
2,500 ANTI-XA
UNIT/0.2 ML, 5,000
ANTI-XA UNIT/0.2
ML
1
heparin (porcine)
injection solution
1,000 unit/mL,
10,000 unit/mL,
20,000 unit/mL,
5,000 unit/mL
1
heparin (porcine) in
5 % dex intravenous
parenteral solution
20,000 unit/500 mL
(40 unit/mL)
1
HEPARIN
(PORCINE) IN 5 %
DEX
INTRAVENOUS
PARENTERAL
SOLUTION 25,000
UNIT/250 ML(100
UNIT/ML), 25,000
UNIT/500 ML (50
UNIT/ML)
1
Jantoven oral tablet
1 mg, 10 mg, 2 mg,
2.5 mg, 3 mg, 4 mg,
5 mg, 6 mg, 7.5 mg
1
LOVENOX
SUBCUTANEOUS
SOLUTION 300
MG/3 ML
1
56
Requirements
/Limits
Drug
BvsD
LOVENOX
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
1
LYSTEDA ORAL
TABLET 650 MG
1
pentoxifylline oral
tablet extended
release 400 mg
1
PLAVIX ORAL
TABLET 300 MG
1
PLAVIX ORAL
TABLET 75 MG
1
PRADAXA ORAL
CAPSULE 150 MG,
75 MG
1
PROMACTA
ORAL TABLET
12.5 MG, 25 MG, 50
MG, 75 MG
1
ticlopidine oral
tablet 250 mg
1
tranexamic acid oral
tablet 650 mg
1
warfarin oral tablet
1 mg, 10 mg, 2 mg,
2.5 mg, 3 mg, 4 mg,
5 mg, 6 mg, 7.5 mg
1
XARELTO ORAL
TABLET 10 MG, 15
MG, 20 MG
1
BvsD
Tier
Requirements
/Limits
BvsD
QL (30 EA per
30 days)
Lipid/Cholesterol Lowering Agents
Drug
Tier
Requirements
/Limits
ADVICOR ORAL
TABLET, ER
MULTIPHASE 24
HR 1,000-20 MG,
1,000-40 MG, 50020 MG, 750-20 MG
1
atorvastatin oral
40 mg, 80 mg
1
ST
CADUET ORAL
TABLET 10-10
MG, 10-20 MG, 1040 MG, 10-80 MG,
2.5-10 MG, 2.5-20
MG, 2.5-40 MG, 510 MG, 5-20 MG, 540 MG, 5-80 MG
1
QL (30 EA per
30 days)
Cholestyramine
Light oral powder in
packet 4 gram
1
colestipol oral
granules 5 gram
1
colestipol oral tablet
1 gram
1
CRESTOR ORAL
TABLET 10 MG, 20
MG, 40 MG, 5 MG
1
fenofibrate oral
capsule 150 mg, 50
mg
1
fenofibrate oral
1
fenofibrate
micronized oral
capsule 130 mg, 134
mg, 200 mg, 43 mg,
67 mg
1
fenofibrate
nanocrystallized
oral tablet 145 mg,
48 mg
1
ST
Drug
Tier
fenofibric acid
(choline) oral
capsule,delayed
release(DR/EC) 135
mg, 45 mg
1
FIBRICOR ORAL
TABLET 105 MG,
35 MG
1
fluvastatin oral
capsule 20 mg, 40
mg
1
gemfibrozil oral
tablet 600 mg
1
lovastatin oral tablet
10 mg, 20 mg, 40 mg
1
LOVAZA ORAL
CAPSULE 1 GRAM
1
niacin oral tablet
extended release 24
hr 1,000 mg, 500
mg, 750 mg
1
NIACOR ORAL
TABLET 500 MG
1
NIASPAN
EXTENDEDRELEASE ORAL
TABLET
EXTENDED
RELEASE 24 HR
1,000 MG, 500 MG,
750 MG
1
omega-3 acid ethyl
esters oral capsule 1
gram
1
pravastatin oral
40 mg, 80 mg
1
Prevalite oral
powder 4 gram
1
simvastatin oral
40 mg, 5 mg, 80 mg
1
Requirements
/Limits
57
Drug
Tier
Requirements
/Limits
Drug
VYTORIN 10-10
ORAL TABLET 1010 MG
1
QL (30 EA per
30 days)
1
VYTORIN 10-20
ORAL TABLET 1020 MG
1
QL (30 EA per
30 days)
MINITRAN
TRANSDERMAL
PATCH 24 HOUR
0.1 MG/HR, 0.2
MG/HR, 0.4
MG/HR, 0.6
MG/HR
VYTORIN 10-40
ORAL TABLET 1040 MG
1
QL (30 EA per
30 days)
Nitro-Bid
transdermal
ointment 2 %
1
VYTORIN 10-80
ORAL TABLET 1080 MG
1
QL (30 EA per
30 days)
1
WELCHOL ORAL
POWDER IN
PACKET 3.75
GRAM
1
nitroglycerin
50 mg/10 mL (5
mg/mL)
1
WELCHOL ORAL
TABLET 625 MG
1
nitroglycerin
transdermal patch
24 hour 0.1 mg/hr,
0.2 mg/hr, 0.4
mg/hr, 0.6 mg/hr
ZETIA ORAL
TABLET 10 MG
1
nitroglycerin
translingual
spray,non-aerosol
400 mcg/spray
1
NITROLINGUAL
TRANSLINGUAL
SPRAY,NONAEROSOL 400
MCG/SPRAY
1
NITROSTAT
SUBLINGUAL
TABLET 0.3 MG,
0.4 MG, 0.6 MG
1
QL (30 EA per
30 days)
Miscellaneous Cardiovascular Agents
RANEXA ORAL
TABLET
EXTENDED
RELEASE 12 HR
1,000 MG, 500 MG
1
Nitrates
isosorbide dinitrate
mg, 30 mg, 5 mg
1
isosorbide dinitrate
release 40 mg
1
isosorbide
mononitrate oral
tablet 10 mg, 20 mg
1
isosorbide
mononitrate oral
tablet extended
release 24 hr 120
mg, 30 mg, 60 mg
1
58
PA
Tier
Requirements
/Limits
Central Nervous System Agents
Miscellaneous Agents
riluzole oral tablet
50 mg
1
Dermatologicals/Topical Therapy
Antipsoriatic / Antiseborrheic
acitretin oral
capsule 10 mg, 17.5
mg, 25 mg
1
Drug
Tier
Requirements
/Limits
Drug
Tier
calcipotriene topical
cream 0.005 %
1
ELIDEL TOPICAL
CREAM 1 %
1
ointment 0.005 %
1
fluorouracil topical
cream 0.5 %, 5 %
1
solution 0.005 %
1
fluorouracil topical
solution 2 %, 5 %
1
calcitriol topical
ointment 3
mcg/gram
1
imiquimod topical
cream in packet 5 %
1
1
methoxsalen rapid
oral capsule 10 mg
1
DOVONEX
TOPICAL CREAM
0.005 %
1
selenium sulfide
topical suspension
2.5 %
1
OXSORALEN
TOPICAL LOTION
1%
1
SORIATANE
ORAL CAPSULE
10 MG, 17.5 MG, 25
MG
1
OXSORALEN
ULTRA ORAL
CAPSULE 10 MG
PANRETIN
TOPICAL GEL 0.1
%
1
TACLONEX
TOPICAL
SUSPENSION
0.005-0.064 %
1
podofilox topical
solution 0.5 %
1
1
silver sulfadiazine
topical cream 1 %
1
PROTOPIC
TOPICAL
OINTMENT 0.03
%, 0.1 %
1
SSD topical cream 1
%
1
Prudoxin topical
cream 5 %
SOLARAZE
TOPICAL GEL 3 %
1
tacrolimus topical
ointment 0.03 %, 0.1
%
1
U-CORT TOPICAL
CREAM 1-10 %
1
UVADEX
INJECTION
SOLUTION 20
MCG/ML
1
Burn Therapy
Miscellaneous Dermatologicals
8-MOP ORAL
CAPSULE 10 MG
1
ALDARA
TOPICAL CREAM
IN PACKET 5 %
1
ammonium lactate
topical cream 12 %
1
ammonium lactate
topical lotion 12 %
1
CARAC TOPICAL
CREAM 0.5 %
1
Requirements
/Limits
BvsD
59
Drug
Tier
Requirements
/Limits
Drug
Tier
VALCHLOR
TOPICAL GEL
0.016 %
1
clindamycin-benzoyl
peroxide topical gel
1-5 %
1
VEREGEN
TOPICAL
OINTMENT 15 %
1
Ery Pads topical
swab 2 %
1
erythromycin with
ethanol topical gel 2
%
1
erythromycin with
ethanol topical
solution 2 %
1
erythromycinbenzoyl peroxide
topical gel 3-5 %
1
FINACEA
TOPICAL GEL 15
%
1
METROGEL
TOPICAL GEL 1 %
1
metronidazole
topical cream 0.75
%
1
metronidazole
topical gel 0.75 %
1
metronidazole
topical lotion 0.75 %
1
NORITATE
TOPICAL CREAM
1%
1
TAZORAC
TOPICAL CREAM
0.05 %, 0.1 %
1
TAZORAC
TOPICAL GEL 0.05
%, 0.1 %
1
tretinoin topical
cream 0.025 %, 0.05
%, 0.1 %
1
tretinoin topical gel
0.01 %, 0.025 %
1
Therapy For Acne
ACANYA
TOPICAL GEL 1.22.5 %
1
adapalene topical
cream 0.1 %
1
adapalene topical
gel 0.1 %
1
Amnesteem oral
capsule 10 mg, 20
mg, 40 mg
1
Avita topical cream
0.025 %
1
AZELEX TOPICAL
CREAM 20 %
1
BENZACLIN
TOPICAL GEL 1-5
%
1
Claravis oral
capsule 10 mg, 20
mg, 30 mg, 40 mg
1
clindamycin
phosphate topical
gel 1 %
1
clindamycin
phosphate topical
lotion 1 %
1
clindamycin
phosphate topical
solution 1 %
1
clindamycin
phosphate topical
swab 1 %
1
60
Requirements
/Limits
Drug
tretinoin
microspheres topical
gel with pump 0.04
%, 0.1 %
Tier
Requirements
/Limits
1
Topical Anesthetics
Tier
ALTABAX
TOPICAL
OINTMENT 1 %
1
BACTROBAN
TOPICAL CREAM
2%
1
CORTISPORIN
TOPICAL CREAM
3.5-10,000-0.5
MG/G-UNIT/G-%
1
gentamicin topical
cream 0.1 %
1
gentamicin topical
ointment 0.1 %
1
mupirocin topical
ointment 2 %
1
lidocaine topical
adhesive
patch,medicated 5
%(700 mg/patch)
1
lidocaine topical
ointment 5 %
1
lidocaine (PF)
mg/mL (0.5 %)
1
lidocaine HCl
mucous membrane
gel 2 %
1
1
mupirocin calcium
topical cream 2 %
1
lidocaine HCl
mucous membrane
jelly in applicator 2
%
1
lidocaine HCl
mucous membrane
solution 2 %, 4 %
(40 mg/mL)
1
sulfacetamide
sodium (acne)
topical suspension
10 %
SULFAMYLON
TOPICAL CREAM
85 MG/G
1
lidocaine-prilocaine
topical cream 2.52.5 %
1
SULFAMYLON
TOPICAL PACKET
50 GRAM
1
LIDODERM
TOPICAL
ADHESIVE
PATCH,MEDICAT
ED 5 %(700
MG/PATCH)
1
SYNERA TOPICAL
PATCH,
MEDICATED
SELF-HEATING
70-70 MG
1
Topical Antibacterials
PA
Drug
PA
Requirements
/Limits
Topical Antifungals
ciclopirox topical
cream 0.77 %
1
ciclopirox topical
gel 0.77 %
1
ciclopirox topical
solution 8 %
1
ciclopirox topical
suspension 0.77 %
1
clotrimazole topical
cream 1 %
1
61
Drug
Tier
clotrimazole topical
solution 1 %
1
clotrimazolebetamethasone
topical cream 1-0.05
%
1
clotrimazolebetamethasone
topical lotion 1-0.05
%
1
econazole topical
cream 1 %
1
ERTACZO
TOPICAL CREAM
2%
1
EXELDERM
TOPICAL CREAM
1%
1
EXELDERM
TOPICAL
SOLUTION 1 %
1
EXTINA TOPICAL
FOAM 2 %
1
ketoconazole topical
cream 2 %
1
ketoconazole topical
shampoo 2 %
1
Nyamyc topical
powder 100,000
unit/gram
1
nystatin topical
cream 100,000
unit/gram
1
nystatin topical
ointment 100,000
unit/gram
1
nystatin topical
powder 100,000
unit/gram
1
62
Requirements
/Limits
Drug
Tier
nystatintriamcinolone
topical cream
100,000-0.1 unit/g%
1
nystatintriamcinolone
topical ointment
100,000-0.1
unit/gram-%
1
Nystop topical
powder 100,000
unit/gram
1
Topical Antivirals
DENAVIR
TOPICAL CREAM
1%
1
ZOVIRAX
TOPICAL CREAM
5%
1
ZOVIRAX
TOPICAL
OINTMENT 5 %
1
Topical Corticosteroids
Ala-Cort topical
cream 1 %
1
ALA-SCALP
TOPICAL LOTION
2%
1
alclometasone
topical cream 0.05
%
1
alclometasone
topical ointment
0.05 %
1
amcinonide topical
cream 0.1 %
1
amcinonide topical
lotion 0.1 %
1
amcinonide topical
ointment 0.1 %
1
Requirements
/Limits
Drug
Tier
betamethasone
dipropionate topical
cream 0.05 %
1
betamethasone
lotion 0.05 %
1
betamethasone
ointment 0.05 %
1
betamethasone
valerate topical
cream 0.1 %
1
betamethasone
valerate topical
foam 0.12 %
1
betamethasone
valerate topical
lotion 0.1 %
1
betamethasone
valerate topical
ointment 0.1 %
1
betamethasone,
augmented topical
cream 0.05 %
1
betamethasone,
augmented topical
gel 0.05 %
Requirements
/Limits
Drug
Tier
clobetasol topical
ointment 0.05 %
1
clobetasol topical
shampoo 0.05 %
1
clobetasol topical
solution 0.05 %
1
clobetasol-emollient
topical cream 0.05
%
1
DESONATE
TOPICAL GEL 0.05
%
1
desonide topical
cream 0.05 %
1
desonide topical
lotion 0.05 %
1
desonide topical
ointment 0.05 %
1
desoximetasone
topical cream 0.05
%, 0.25 %
1
desoximetasone
topical gel 0.05 %
1
1
desoximetasone
topical ointment
0.05 %, 0.25 %
1
betamethasone,
augmented topical
lotion 0.05 %
1
diflorasone topical
cream 0.05 %
1
1
betamethasone,
augmented topical
ointment 0.05 %
1
diflorasone topical
ointment 0.05 %
1
CAPEX TOPICAL
SHAMPOO 0.01 %
1
fluocinolone topical
cream 0.01 %, 0.025
%
1
clobetasol topical
foam 0.05 %
1
oil 0.01 %
1
clobetasol topical
gel 0.05 %
1
ointment 0.025 %
1
solution 0.01 %
1
clobetasol topical
lotion 0.05 %
Requirements
/Limits
63
Drug
Tier
fluocinonide topical
cream 0.1 %
1
gel 0.05 %
1
ointment 0.05 %
1
solution 0.05 %
1
Fluocinonide-E
topical cream 0.05
%
1
fluticasone topical
cream 0.05 %
1
fluticasone topical
lotion 0.05 %
1
fluticasone topical
ointment 0.005 %
Requirements
/Limits
Drug
Tier
hydrocortisone
butyrate topical
ointment 0.1 %
1
hydrocortisone
butyrate topical
solution 0.1 %
1
hydrocortisone
valerate topical
cream 0.2 %
1
hydrocortisone
valerate topical
ointment 0.2 %
1
KENALOG
TOPICAL
AEROSOL 0.147
MG/GRAM
1
1
mometasone topical
cream 0.1 %
1
halobetasol
propionate topical
cream 0.05 %
1
mometasone topical
ointment 0.1 %
1
1
halobetasol
propionate topical
ointment 0.05 %
1
mometasone topical
solution 0.1 %
1
HALOG TOPICAL
CREAM 0.1 %
1
prednicarbate
topical ointment 0.1
%
1
Procto-Pak rectal
cream 1 %
1
HALOG TOPICAL
OINTMENT 0.1 %
1
hydrocortisone
topical cream 1 %,
2.5 %
1
Proctozone-HC
rectal cream 2.5 %
1
hydrocortisone
topical lotion 2.5 %
1
triamcinolone
acetonide topical
cream 0.025 %, 0.1
%, 0.5 %
hydrocortisone
topical ointment 1
%, 2.5 %
1
1
hydrocortisone
butyr-emollient
topical cream 0.1 %
1
triamcinolone
acetonide topical
lotion 0.025 %, 0.1
%
triamcinolone
acetonide topical
ointment 0.025 %,
0.1 %, 0.5 %
1
64
Requirements
/Limits
Drug
Triderm topical
cream 0.1 %
Tier
Requirements
/Limits
1
Topical Enzymes
SANTYL TOPICAL
OINTMENT 250
UNIT/GRAM
1
Topical Scabicides / Pediculicides
Drug
Tier
Requirements
/Limits
ADAGEN
INTRAMUSCULA
R SOLUTION 250
UNIT/ML
1
BvsD
alendronate oral
tablet 40 mg
1
anagrelide oral
capsule 0.5 mg, 1 mg
1
ANTABUSE ORAL
TABLET 250 MG,
500 MG
1
ARALAST NP
INTRAVENOUS
RECON SOLN 500
MG
1
BvsD
1
BvsD
EURAX TOPICAL
CREAM 10 %
1
EURAX TOPICAL
LOTION 10 %
1
LINDANE
TOPICAL LOTION
1%
1
LINDANE
TOPICAL
SHAMPOO 1 %
1
malathion topical
lotion 0.5 %
1
CARNITOR
INTRAVENOUS
SOLUTION 200
MG/ML
1
permethrin topical
cream 5 %
1
cevimeline oral
capsule 30 mg
CHEMET ORAL
CAPSULE 100 MG
1
CLINIMIX
4.25%/D5W
SULFIT FREE
INTRAVENOUS
PARENTERAL
SOLUTION 4.25 %
1
BvsD
CLINIMIX E
2.75%/D10W SUL
FREE
INTRAVENOUS
PARENTERAL
SOLUTION 2.75 %
1
BvsD
CLINIMIX E
2.75%/D5W SULF
FREE
INTRAVENOUS
PARENTERAL
SOLUTION 2.75 %
1
BvsD
Diagnostics / Miscellaneous Agents
Irrigating Solutions
lactated ringers
irrigation solution
1
neomycin-polymyxin
B GU irrigation
solution 40 mg200,000 unit/mL
1
ringers irrigation
solution
1
acamprosate oral
tablet,delayed
release (DR/EC) 333
mg
1
ACTONEL ORAL
TABLET 30 MG
1
ST; QL (30
EA per 30
days)
65
Drug
Tier
Requirements
/Limits
Drug
BvsD
disulfiram oral
tablet 250 mg, 500
mg
1
etidronate disodium
oral tablet 200 mg,
400 mg
1
EVOXAC ORAL
CAPSULE 30 MG
1
EXJADE ORAL
TABLET,
DISPERSIBLE 125
MG, 250 MG, 500
MG
1
FOSRENOL ORAL
TABLET,CHEWAB
LE 1,000 MG, 500
MG, 750 MG
1
INCRELEX
SUBCUTANEOUS
SOLUTION 10
MG/ML
1
Kionex oral powder
1
LEVOCARNITINE
INTRAVENOUS
SOLUTION 200
MG/ML
1
levocarnitine oral
tablet 330 mg
1
levocarnitine (with
sugar) oral solution
100 mg/mL
1
midodrine oral
5 mg
1
pilocarpine HCl oral
tablet 5 mg, 7.5 mg
1
potassium citrate
release 10 mEq
(1,080 mg), 5 mEq
(540 mg)
1
D10 % & 0.45 %
SODIUM
CHLORIDE
INTRAVENOUS
PARENTERAL
SOLUTION
1
D2.5 %-0.45 %
sodium chloride
intravenous
parenteral solution
1
D5 % and 0.9 %
sodium chloride
intravenous
parenteral solution
1
BvsD
D5 %-0.45 %
sodium chloride
intravenous
parenteral solution
1
BvsD
DEXTROSE 10 %
AND 0.2 % NACL
INTRAVENOUS
PARENTERAL
SOLUTION
1
BvsD
dextrose 10 % in
water (D10W)
intravenous
parenteral solution
10 %
1
BvsD
dextrose 5 % in
water (D5W)
intravenous
parenteral solution
1
BvsD
dextrose 5%-0.2 %
sod chloride
intravenous
parenteral solution
1
BvsD
DEXTROSE 5%-0.3
% SOD.CHLORIDE
INTRAVENOUS
PARENTERAL
SOLUTION
1
BvsD
66
BvsD
Tier
Requirements
/Limits
BvsD
BvsD
Drug
Tier
PROLASTIN-C
INTRAVENOUS
RECON SOLN
1,000 MG
1
RENAGEL ORAL
TABLET 400 MG,
800 MG
1
RENVELA ORAL
POWDER IN
PACKET 0.8
GRAM, 2.4 GRAM
1
RENVELA ORAL
TABLET 800 MG
1
RILUTEK ORAL
TABLET 50 MG
1
sodium chloride
irrigation solution
0.9 %
1
sodium chloride 0.9
% intravenous
parenteral solution
0.9 %
1
sodium polystyrene
(sorb free) oral
suspension 15
gram/60 mL
1
SYPRINE ORAL
CAPSULE 250 MG
1
water for irrigation,
sterile irrigation
solution
1
ZEMAIRA
INTRAVENOUS
RECON SOLN
1,000 MG
1
Drug
BvsD
CHANTIX ORAL
TABLET 0.5 MG, 1
MG
1
PA
CHANTIX
STARTING
MONTH BOX
ORAL
TABLETS,DOSE
PACK 0.5 MG (11)1 MG (42)
1
PA
NICOTROL
INHALATION
CARTRIDGE 10
MG
1
NICOTROL NS
NASAL
SPRAY,NONAEROSOL 10
MG/ML
1
ZYBAN ORAL
TABLET
EXTENDED
RELEASE 150 MG
1
BvsD
Tier
Requirements
/Limits
Ear, Nose / Throat Medications
Smoking Deterrents
Buproban oral tablet
mg
Requirements
/Limits
1
BvsD
azelastine nasal
aerosol,spray 137
mcg
1
azelastine nasal
spray,non-aerosol
0.15 % (205.5 mcg)
1
BACTROBAN
NASAL NASAL
OINTMENT 2 %
1
chlorhexidine
gluconate mucous
membrane
mouthwash 0.12 %
1
ipratropium bromide
nasal spray,nonaerosol 0.03 %, 0.06
%
1
67
Drug
Tier
olopatadine nasal
spray,non-aerosol
0.6 %
1
PATANASE
NASAL
SPRAY,NONAEROSOL 0.6 %
1
Periogard mucous
membrane
mouthwash 0.12 %
1
triamcinolone
acetonide dental
paste 0.1 %
1
TYZINE NASAL
DROPS 0.05 %
1
Requirements
/Limits
neomycinpolymyxin-HC otic
solution 3.5-10,0001 mg/mL-unit/mL-%
Tier
Requirements
/Limits
1
Endocrine/Diabetes
Adrenal Hormones
Miscellaneous Otic Preparations
Acetasol HC otic
drops 1-2 %
1
acetic acid otic
solution 2 %
1
fluocinolone
acetonide oil otic
drops 0.01 %
1
hydrocortisoneacetic acid otic
drops 1-2 %
1
ofloxacin otic drops
0.3 %
1
Otic Steroid / Antibiotic
CIPRO HC OTIC
DROPS,SUSPENSI
ON 0.2-1 %
1
CIPRODEX OTIC
DROPS,SUSPENSI
ON 0.3-0.1 %
1
neomycinpolymyxin-HC otic
drops,suspension
3.5-10,000-1
mg/mL-unit/mL-%
1
68
Drug
A-Hydrocort
100 mg
1
cortisone oral tablet
25 mg
1
dexamethasone oral
elixir 0.5 mg/5 mL
1
dexamethasone oral
tablet 0.5 mg, 0.75
mg, 1.5 mg, 4 mg, 6
mg
1
DEXAMETHASON
E ORAL TABLET 1
MG, 2 MG
1
DEXAMETHASON
E INTENSOL
ORAL DROPS 1
MG/ML
1
dexamethasone
sodium phosphate
mg/mL
1
dexamethasone
sodium phosphate
mg/mL
1
DEXPAK 13 DAY
ORAL
TABLETS,DOSE
PACK 1.5 MG (51
TABS)
1
fludrocortisone oral
tablet 0.1 mg
1
BvsD
BvsD
Drug
Tier
hydrocortisone oral
5 mg
1
KENALOG
INJECTION
SUSPENSION 10
MG/ML, 40
MG/ML
1
methylprednisolone
mg, 8 mg
1
methylprednisolone
oral tablets,dose
pack 4 mg
1
methylprednisolone
acetate injection
suspension 40
mg/mL, 80 mg/mL
1
methylprednisolone
sodium succ
125 mg, 40 mg
1
MILLIPRED ORAL
SOLUTION 10
MG/5 ML
1
ORAPRED ODT
ORAL
TABLET,DISINTE
GRATING 15 MG,
30 MG
1
prednisolone sodium
phosphate oral
solution 15 mg/5
mL, 25 mg/5 mL (5
mg/mL), 5 mg base/5
mL (6.7 mg/5 mL)
1
prednisolone sodium
phosphate oral
10 mg, 15 mg, 30 mg
1
prednisone oral
solution 5 mg/5 mL
1
Requirements
/Limits
Drug
Tier
Requirements
/Limits
prednisone oral
tablet 1 mg, 10 mg,
2.5 mg, 20 mg, 5 mg,
50 mg
1
PREDNISONE
INTENSOL ORAL
CONCENTRATE 5
MG/ML
1
BvsD
SOLU-CORTEF
(PF) INJECTION
RECON SOLN 100
MG/2 ML, 250
MG/2 ML
1
BvsD
1
BvsD
BvsD
SOLU-MEDROL
INTRAVENOUS
RECON SOLN 2
GRAM
1
BvsD
BvsD
SOLU-MEDROL
(PF) INJECTION
RECON SOLN 40
MG/ML
Solu-Medrol (PF)
intravenous recon
soln 500 mg/4 mL
1
BvsD
triamcinolone
acetonide injection
suspension 10
mg/mL, 40 mg/mL
1
BvsD
VERIPRED 20
ORAL SOLUTION
20 MG/5 ML
1
BvsD
Antithyroid Agents
methimazole oral
tablet 10 mg, 5 mg
1
propylthiouracil oral
tablet 50 mg
1
Diabetes Therapy
acarbose oral tablet
100 mg, 25 mg, 50
mg
1
69
Drug
Tier
Requirements
/Limits
Drug
Tier
Requirements
/Limits
ACTOPLUS MET
ORAL TABLET 15500 MG, 15-850
MG
1
glipizide oral tablet
extended release
24hr 10 mg, 2.5 mg,
5 mg
1
ACTOPLUS MET
XR ORAL
TABLET, ER
MULTIPHASE 24
HR 15-1,000 MG,
30-1,000 MG
1
glipizide-metformin
oral tablet 2.5-250
mg, 2.5-500 mg, 5500 mg
1
1
ACTOS ORAL
TABLET 15 MG, 30
MG, 45 MG
1
GLUCAGEN
HYPOKIT
INJECTION
RECON SOLN 1
MG
BYDUREON
SUBCUTANEOUS
PEN INJECTOR 2
MG/0.65 ML
1
1
BYDUREON
SUBCUTANEOUS
SUSPENSION,EXT
ENDED REL
RECON 2 MG
1
GLUCAGON
EMERGENCY KIT
(HUMAN)
INJECTION KIT 1
MG
glyburide oral tablet
1.25 mg, 2.5 mg, 5
mg
1
ST
1
ST
BYETTA
SUBCUTANEOUS
PEN INJECTOR 10
MCG/DOSE(250
MCG/ML) 2.4 ML,
5 MCG/DOSE (250
MCG/ML) 1.2 ML
1
glyburide
micronized oral
6 mg
glyburide-metformin
oral tablet 1.25-250
mg, 2.5-500 mg, 5500 mg
1
ST
chlorpropamide oral
tablet 100 mg, 250
mg
1
1
CYCLOSET ORAL
TABLET 0.8 MG
1
HUMALOG MIX
50-50
SUBCUTANEOUS
SUSPENSION 100
UNIT/ML (50-50)
DUETACT ORAL
TABLET 30-2 MG,
30-4 MG
1
1
glimepiride oral
mg
1
HUMALOG MIX
50-50 KWIKPEN
SUBCUTANEOUS
INSULIN PEN 100
UNIT/ML (50-50)
glipizide oral tablet
10 mg, 5 mg
1
70
ST; QL (30
EA per 30
days)
ST
ST
Drug
Tier
Requirements
/Limits
Drug
Tier
HUMALOG MIX
75-25
SUBCUTANEOUS
SUSPENSION 100
UNIT/ML (75-25)
1
LANTUS
SOLOSTAR
SUBCUTANEOUS
INSULIN PEN 100
UNIT/ML (3 ML)
1
HUMALOG MIX
75-25 KWIKPEN
SUBCUTANEOUS
INSULIN PEN 100
UNIT/ML (75-25)
1
LEVEMIR
SUBCUTANEOUS
SOLUTION 100
UNIT/ML
1
1
JANUMET ORAL
TABLET 50-1,000
MG, 50-500 MG
1
JANUMET XR
ORAL TABLET,
ER MULTIPHASE
24 HR 100-1,000
MG, 50-1,000 MG,
50-500 MG
1
LEVEMIR
FLEXTOUCH
SUBCUTANEOUS
INSULIN PEN 100
UNIT/ML (3 ML)
metformin oral
tablet 1,000 mg, 500
mg, 850 mg
1
1
JANUVIA ORAL
TABLET 100 MG,
25 MG, 50 MG
1
metformin oral
tablet extended
release 24 hr 500
mg, 750 mg
1
JENTADUETO
ORAL TABLET
2.5-1,000 MG, 2.5500 MG, 2.5-850
MG
1
metformin oral
tablet extended
release 24hr 1,000
mg
nateglinide oral
1
KAZANO ORAL
TABLET 12.5-1,000
MG, 12.5-500 MG
1
NESINA ORAL
TABLET 12.5 MG,
25 MG, 6.25 MG
1
KOMBIGLYZE XR
ORAL TABLET,
ER MULTIPHASE
24 HR 2.5-1,000
MG, 5-1,000 MG, 5500 MG
1
NOVOLIN 70/30
SUBCUTANEOUS
SUSPENSION 100
UNIT/ML (70-30)
1
1
LANTUS
SUBCUTANEOUS
SOLUTION 100
UNIT/ML
1
NOVOLIN N
SUBCUTANEOUS
SUSPENSION 100
UNIT/ML
NOVOLIN R
INJECTION
SOLUTION 100
UNIT/ML
1
ST
Requirements
/Limits
ST
71
Drug
Tier
Requirements
/Limits
Drug
Tier
NOVOLOG
SUBCUTANEOUS
SOLUTION 100
UNIT/ML
1
NOVOLOG
FLEXPEN
SUBCUTANEOUS
INSULIN PEN 100
UNIT/ML
1
NOVOLOG MIX
70-30
SUBCUTANEOUS
SOLUTION 100
UNIT/ML (70-30)
1
NOVOLOG MIX
70-30 FLEXPEN
SUBCUTANEOUS
INSULIN PEN 100
UNIT/ML (70-30)
1
ONGLYZA ORAL
TABLET 2.5 MG, 5
MG
1
ST
OSENI ORAL
TABLET 12.5-15
MG, 12.5-30 MG,
12.5-45 MG, 25-15
MG, 25-30 MG, 2545 MG
1
ST
pioglitazone oral
45 mg
1
ST
pioglitazoneglimepiride oral
tablet 30-2 mg, 30-4
mg
1
ST
pioglitazonemetformin oral
tablet 15-500 mg,
15-850 mg
1
Miscellaneous Hormones
1
PRANDIMET
ORAL TABLET 1500 MG, 2-500 MG
1
ALDURAZYME
INTRAVENOUS
SOLUTION 2.9
MG/5 ML
ANADROL-50
ORAL TABLET 50
MG
1
72
Requirements
/Limits
PRANDIN ORAL
TABLET 0.5 MG, 1
MG, 2 MG
1
PROGLYCEM
ORAL
SUSPENSION 50
MG/ML
1
repaglinide oral
2 mg
1
RIOMET ORAL
SOLUTION 500
MG/5 ML
1
SYMLINPEN 120
SUBCUTANEOUS
PEN INJECTOR
2,700 MCG/2.7 ML
1
PA
SYMLINPEN 60
SUBCUTANEOUS
PEN INJECTOR
1,500 MCG/1.5 ML
1
PA
tolazamide oral
tablet 250 mg, 500
mg
1
tolbutamide oral
tablet 500 mg
1
TRADJENTA
ORAL TABLET 5
MG
1
VICTOZA 3-PAK
SUBCUTANEOUS
PEN INJECTOR 0.6
MG/0.1 ML (18
MG/3 ML)
1
ST
BvsD
Drug
Tier
ANDRODERM
TRANSDERMAL
PATCH 24 HOUR 2
MG/24 HOUR, 4
MG/24 HR
1
ANDROGEL
TRANSDERMAL
GEL IN
METERED-DOSE
PUMP 1.25 GRAM/
ACTUATION (1
%), 20.25 MG/1.25
GRAM (1.62 %)
1
ANDROGEL
TRANSDERMAL
GEL IN PACKET 1
% (25
MG/2.5GRAM), 1
% (50 MG/5
GRAM), 1.62 %
(20.25 MG/1.25
GRAM), 1.62 %
(40.5 MG/2.5
GRAM)
1
cabergoline oral
tablet 0.5 mg
1
calcitonin (salmon)
nasal spray,nonaerosol 200
unit/actuation
1
calcitriol
1 mcg/mL
Requirements
/Limits
Drug
Tier
Requirements
/Limits
danazol oral capsule
100 mg, 200 mg, 50
mg
1
desmopressin
mcg/mL
1
desmopressin oral
tablet 0.1 mg, 0.2 mg
1
doxercalciferol
4 mcg/2 mL
1
doxercalciferol oral
capsule 0.5 mcg, 1
mcg, 2.5 mcg
1
ELAPRASE
INTRAVENOUS
SOLUTION 6 MG/3
ML
1
BvsD
FABRAZYME
INTRAVENOUS
RECON SOLN 35
MG
1
BvsD
FORTICAL nasal
spray,non-aerosol
200 unit/actuation
1
KUVAN ORAL
TABLET,SOLUBL
E 100 MG
1
1
METHITEST
ORAL TABLET 10
MG
1
calcitriol oral
capsule 0.25 mcg,
0.5 mcg
1
1
calcitriol oral
solution 1 mcg/mL
1
MIACALCIN
INJECTION
SOLUTION 200
UNIT/ML
1
Cerezyme
intravenous recon
soln 400 unit
1
MYOZYME
INTRAVENOUS
RECON SOLN 50
MG
BvsD
BvsD
BvsD
BvsD
73
Drug
Tier
Requirements
/Limits
Drug
Tier
BvsD
testosterone
transdermal gel in
metered-dose pump
1.25 gram/ actuation
(1 %), 10 mg/0.5
gram /actuation
1
testosterone
transdermal gel in
packet 1 % (50 mg/5
gram)
1
testosterone
cypionate
intramuscular oil
100 mg/mL
1
testosterone
cypionate
intramuscular oil
200 mg/mL
1
testosterone
enanthate
intramuscular oil
200 mg/mL
1
TESTRED ORAL
CAPSULE 10 MG
1
ZAVESCA ORAL
CAPSULE 100 MG
1
Requirements
/Limits
NAGLAZYME
INTRAVENOUS
SOLUTION 5 MG/5
ML
1
oxandrolone oral
tablet 10 mg, 2.5 mg
1
pamidronate
30 mg/10 mL (3
mg/mL), 90 mg/10
mL (9 mg/mL)
1
PAMIDRONATE
INTRAVENOUS
SOLUTION 60
MG/10 ML (6
MG/ML)
1
paricalcitol oral
capsule 1 mcg, 2
mcg, 4 mcg
1
SENSIPAR ORAL
TABLET 30 MG, 60
MG, 90 MG
1
SOMAVERT
SUBCUTANEOUS
RECON SOLN 10
MG, 15 MG, 20 MG
1
STIMATE NASAL
SPRAY,NONAEROSOL 150
MCG/SPRAY (0.1
ML)
1
ZEMPLAR
INTRAVENOUS
SOLUTION 2
MCG/ML, 5
MCG/ML
1
SYNAREL NASAL
SPRAY,NONAEROSOL 2
MG/ML
1
ZEMPLAR ORAL
CAPSULE 1 MCG,
2 MCG
1
BvsD
1
zoledronic acid
4 mg/5 mL
1
TESTIM
TRANSDERMAL
GEL 50 MG/5
GRAM (1 %)
1
BvsD
testosterone
transdermal gel 50
mg/5 gram (1 %)
1
ZOMETA
INTRAVENOUS
SOLUTION 4 MG/5
ML
74
BvsD
Thyroid Hormones
BvsD
BvsD
Drug
Tier
levothyroxine oral
tablet 100 mcg, 112
mcg, 125 mcg, 137
mcg, 150 mcg, 175
mcg, 200 mcg, 25
mcg, 300 mcg, 50
mcg, 75 mcg, 88 mcg
1
Levoxyl oral tablet
100 mcg, 112 mcg,
125 mcg, 137 mcg,
150 mcg, 175 mcg,
200 mcg, 25 mcg, 50
mcg, 75 mcg, 88 mcg
1
liothyronine
10 mcg/mL
Requirements
/Limits
Drug
Tier
dicyclomine oral
capsule 10 mg
1
dicyclomine oral
solution 10 mg/5 mL
1
dicyclomine oral
tablet 20 mg
1
diphenoxylateatropine oral liquid
2.5-0.025 mg/5 mL
1
diphenoxylateatropine oral tablet
2.5-0.025 mg
1
1
glycopyrrolate
mg/mL
1
liothyronine oral
tablet 25 mcg, 5
mcg, 50 mcg
1
glycopyrrolate oral
tablet 1 mg, 2 mg
1
SYNTHROID
ORAL TABLET
100 MCG, 112
MCG, 125 MCG,
137 MCG, 150
MCG, 175 MCG,
200 MCG, 25 MCG,
300 MCG, 50 MCG,
75 MCG, 88 MCG
1
loperamide oral
capsule 2 mg
1
methscopolamine
oral tablet 2.5 mg, 5
mg
1
propantheline oral
tablet 15 mg
1
TRANSDERMSCOP
TRANSDERMAL
PATCH 72 HOUR
1.5 MG
1
Gastroenterology
Antidiarrheals / Antispasmodics
ATROPINE
INJECTION
SYRINGE 0.05
MG/ML
1
atropine injection
syringe 0.1 mg/mL
1
BENTYL
INTRAMUSCULA
R SOLUTION 10
MG/ML
1
CANTIL ORAL
TABLET 25 MG
1
Requirements
/Limits
Miscellaneous Gastrointestinal Agents
BvsD
ALOXI
INTRAVENOUS
SOLUTION 0.25
MG/5 ML
1
BvsD
AMITIZA ORAL
CAPSULE 24 MCG,
8 MCG
1
PA
75
Drug
Tier
Requirements
/Limits
amoxicilclarithromylansopraz oral
combo pack 500500-30 mg
1
ANZEMET
INTRAVENOUS
SOLUTION 100
MG/5 ML
1
BvsD
ANZEMET ORAL
TABLET 100 MG,
50 MG
1
BvsD; QL (7
EA per 30
days)
APRISO ORAL
CAPSULE,EXTEN
DED RELEASE
24HR 0.375 GRAM
1
ASACOL HD
ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 800 MG
1
balsalazide oral
capsule 750 mg
1
budesonide oral
capsule,delayed,exte
nd.release 3 mg
1
CANASA RECTAL
SUPPOSITORY
1,000 MG
1
CESAMET ORAL
CAPSULE 1 MG
1
Compro rectal
suppository 25 mg
1
Constulose oral
solution 10 gram/15
mL
1
76
BvsD
Drug
Tier
Requirements
/Limits
CREON ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
12,000-38,000 60,000 UNIT,
24,000-76,000 120,000 UNIT,
3,000-9,500- 15,000
UNIT, 6,000-19,000
-30,000 UNIT
1
cromolyn oral
solution 100 mg/5
mL
1
CYSTADANE
ORAL POWDER 1
GRAM/1.7 ML
1
DELZICOL ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
400 MG
1
DIPENTUM ORAL
CAPSULE 250 MG
1
dronabinol oral
capsule 10 mg, 2.5
mg, 5 mg
1
BvsD
EMEND ORAL
CAPSULE 125 MG
1
BvsD; QL (2
EA per 30
days)
EMEND ORAL
CAPSULE 40 MG
1
BvsD
EMEND ORAL
CAPSULE 80 MG
1
BvsD; QL (4
EA per 30
days)
EMEND ORAL
CAPSULE,DOSE
PACK 125 MG (1)80 MG (2)
1
BvsD; QL (6
EA per 30
days)
Drug
Tier
ENTOCORT EC
ORAL
CAPSULE,DELAY
ED,EXTEND.RELE
ASE 3 MG
1
Enulose oral
solution 10 gram/15
mL
1
Gavilyte-C oral
recon soln 24022.72-6.72 gram
1
GaviLyte-N oral
recon soln 420 gram
1
Generlac oral
solution 10 gram/15
mL
Requirements
/Limits
Drug
Tier
Requirements
/Limits
LINZESS ORAL
CAPSULE 145
MCG, 290 MCG
1
LOTRONEX ORAL
TABLET 0.5 MG, 1
MG
1
meclizine oral tablet
12.5 mg, 25 mg
1
mesalamine with
cleansing wipe
rectal enema kit 4
gram/60 mL
1
metoclopramide HCl
mg/mL
1
1
1
metoclopramide HCl
mL
1
GOLYTELY ORAL
POWDER IN
PACKET 227.121.5-6.36 GRAM
1
GOLYTELY ORAL
RECON SOLN 23622.74-6.74 GRAM
1
metoclopramide HCl
mg
1
granisetron (PF)
100 mcg/mL
1
MOVIPREP ORAL
POWDER IN
PACKET 100-7.52.691 GRAM
1
granisetron HCl
1 mg/mL (1 mL)
1
BvsD
NULYTELY WITH
FLAVOR PACKS
ORAL RECON
SOLN 420 GRAM
granisetron HCl
oral tablet 1 mg
1
BvsD
1
BvsD
hydrocortisone
rectal enema 100
mg/60 mL
1
ondansetron oral
4 mg, 8 mg
1
BvsD
lactulose oral
solution 10 gram/15
mL
1
ondansetron HCl
mL
1
BvsD
LIALDA ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 1.2 GRAM
1
ondansetron HCl
mg, 8 mg
ondansetron HCl
(PF) injection
solution 4 mg/2 mL
1
BvsD
BvsD
QL (60 EA per
30 days)
BvsD
77
Drug
Tier
OSMOPREP ORAL
TABLET 1.5
GRAM
1
PANCREAZE
ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
10,500-25,000 43,750 UNIT,
16,800-40,000 70,000 UNIT,
21,000-37,000 61,000 UNIT, 4,20010,000 -17,500
UNIT
1
PENTASA ORAL
CAPSULE,
EXTENDED
RELEASE 250 MG,
500 MG
1
PERTZYE ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
16,000-57,50060,500 UNIT, 8,00028,750- 30,250
UNIT
1
Phenadoz rectal
suppository 25 mg
1
polyethylene glycol
3350 oral powder 17
gram/dose
1
prochlorperazine
Edisylate injection
solution 10 mg/2 mL
(5 mg/mL)
1
prochlorperazine
maleate oral tablet
10 mg, 5 mg
1
prochlorperazine
maleate rectal
suppository 25 mg
1
78
Requirements
/Limits
Drug
Tier
Proctosol HC rectal
cream 2.5 %
1
RECTIV RECTAL
OINTMENT 0.4 %
(W/W)
1
RELISTOR
SUBCUTANEOUS
SOLUTION 12
MG/0.6 ML
1
REMICADE
INTRAVENOUS
RECON SOLN 100
MG
1
SUCRAID ORAL
SOLUTION 8,500
UNIT/ML
1
sulfasalazine oral
tablet 500 mg
1
Sulfazine EC oral
tablet,delayed
release (DR/EC) 500
mg
1
TriLyte With Flavor
Packets oral recon
soln 420 gram
1
ULTRESA ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
13,800-27,600
UNIT, 20,70041,400 UNIT,
23,000-46,000 UNIT
1
URSO 250 ORAL
TABLET 250 MG
1
URSO FORTE
ORAL TABLET
500 MG
1
ursodiol oral
capsule 300 mg
1
ursodiol oral tablet
250 mg, 500 mg
1
Requirements
/Limits
BvsD
Drug
Tier
VIOKACE ORAL
TABLET 10,44039,150- 39,150
UNIT, 20,88078,300- 78,300
UNIT
1
ZENPEP ORAL
CAPSULE,DELAY
ED
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, 5,00017,000 -27,000
UNIT
1
Requirements
/Limits
Drug
Tier
famotidine oral
suspension 40 mg/5
mL
1
famotidine oral
tablet 20 mg, 40 mg
1
famotidine (PF)
20 mg/2 mL
1
famotidine (PF)NaCl (iso-os)
intravenous
piggyback 20 mg/50
mL
1
lansoprazole oral
capsule,delayed
release(DR/EC) 15
mg, 30 mg
1
misoprostol oral
tablet 100 mcg, 200
mcg
1
1
CARAFATE ORAL
SUSPENSION 100
MG/ML
1
nizatidine oral
capsule 150 mg, 300
mg
1
cimetidine oral
tablet 200 mg, 300
mg, 400 mg, 800 mg
1
nizatidine oral
solution 150 mg/10
mL
1
cimetidine HCl oral
solution 300 mg/5
mL
1
omeprazole oral
capsule,delayed
release(DR/EC) 10
mg, 20 mg, 40 mg
DEXILANT ORAL
CAPSULE,BIPHAS
E DELAYED
RELEAS 30 MG, 60
MG
1
pantoprazole oral
tablet,delayed
release (DR/EC) 20
mg, 40 mg
1
1
esomeprazole
strontium oral
capsule,delayed
release(DR/EC) 49.3
mg
1
PEPCID ORAL
SUSPENSION 40
MG/5 ML
PREVACID
SOLUTAB ORAL
TABLET,DISINTE
GRAT, DELAY
REL 15 MG, 30 MG
1
Ulcer Therapy
ST
ST
Requirements
/Limits
ST
ST
79
Drug
Tier
PREVPAC ORAL
COMBO PACK
500-500-30 MG
1
PROTONIX
INTRAVENOUS
RECON SOLN 40
MG
1
PYLERA ORAL
CAPSULE 140-125125 MG
1
rabeprazole oral
tablet,delayed
release (DR/EC) 20
mg
1
ranitidine HCl
mg/mL
1
ranitidine HCl oral
capsule 150 mg, 300
mg
1
ranitidine HCl oral
syrup 15 mg/mL
1
ranitidine HCl oral
tablet 150 mg, 300
mg
1
sucralfate oral tablet
1 gram
1
Requirements
/Limits
ST
Immunology, Vaccines / Biotechnology
Biotechnology Drugs
ACTIMMUNE
SUBCUTANEOUS
SOLUTION 100
MCG/0.5 ML
80
1
Drug
Tier
Requirements
/Limits
ARANESP (IN
POLYSORBATE)
INJECTION
SOLUTION 100
MCG/ML, 200
MCG/ML, 25
MCG/ML, 300
MCG/ML, 40
MCG/ML, 60
MCG/ML
1
BvsD
ARANESP (IN
POLYSORBATE)
INJECTION
SYRINGE 100
MCG/0.5 ML, 150
MCG/0.3 ML, 200
MCG/0.4 ML, 25
MCG/0.42 ML, 300
MCG/0.6 ML, 40
MCG/0.4 ML, 500
MCG/ML, 60
MCG/0.3 ML
1
BvsD
ARCALYST
SUBCUTANEOUS
RECON SOLN 220
MG
1
BvsD; LA
AVONEX
INTRAMUSCULA
R SYRINGE KIT 30
MCG/0.5 ML
1
BvsD
AVONEX (WITH
ALBUMIN)
INTRAMUSCULA
R KIT 30 MCG
1
BvsD
BETASERON
SUBCUTANEOUS
KIT 0.3 MG
1
BvsD
COPAXONE
SUBCUTANEOUS
SYRINGE 20
MG/ML
1
Drug
Tier
Requirements
/Limits
Drug
BvsD
INTRON A
INJECTION
SOLUTION 6
MILLION
UNIT/ML
1
BvsD
LEUKINE
INJECTION
RECON SOLN 250
MCG
1
BvsD
NEULASTA
SUBCUTANEOUS
SYRINGE 6
MG/0.6ML
1
BvsD
NEUMEGA
SUBCUTANEOUS
RECON SOLN 5
MG
1
BvsD
NEUPOGEN
INJECTION
SOLUTION 480
MCG/1.6 ML
1
BvsD
NEUPOGEN
INJECTION
SYRINGE 300
MCG/0.5 ML, 480
MCG/0.8 ML
1
BvsD
NORDITROPIN
FLEXPRO
SUBCUTANEOUS
PEN INJECTOR 10
MG/1.5 ML (6.7
MG/ML), 15
MG/1.5 ML (10
MG/ML), 5 MG/1.5
ML (3.3 MG/ML)
1
PA
NUTROPIN AQ
SUBCUTANEOUS
CARTRIDGE 20
MG/2 ML (10
MG/ML)
1
PA
EPOGEN
INJECTION
SOLUTION 2,000
UNIT/ML, 20,000
UNIT/2 ML, 20,000
UNIT/ML, 3,000
UNIT/ML, 4,000
UNIT/ML
1
GENOTROPIN
SUBCUTANEOUS
CARTRIDGE 12
MG/ML (36
UNIT/ML), 5
MG/ML (15
UNIT/ML)
1
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
1
GILENYA ORAL
CAPSULE 0.5 MG
1
HUMATROPE
INJECTION
CARTRIDGE 12
MG (36 UNIT), 24
MG (72 UNIT)
1
PA
INTRON A
INJECTION
RECON SOLN 10
MILLION UNIT (1
ML), 18 MILLION
UNIT (1 ML), 50
MILLION UNIT (1
ML)
1
BvsD
PA
PA
Tier
Requirements
/Limits
81
Drug
Tier
Requirements
/Limits
Drug
PEGINTRON
REDIPEN
SUBCUTANEOUS
PEN INJECTOR
KIT 120 MCG/0.5
ML, 150 MCG/0.5
ML, 50 MCG/0.5
ML, 80 MCG/0.5
ML
1
PROCRIT
INJECTION
SOLUTION 10,000
UNIT/ML, 2,000
UNIT/ML, 20,000
UNIT/ML, 3,000
UNIT/ML, 4,000
UNIT/ML, 40,000
UNIT/ML
1
BvsD
PROLEUKIN
INTRAVENOUS
RECON SOLN 22
MILLION UNIT
1
BvsD
REBIF (WITH
ALBUMIN)
SUBCUTANEOUS
SYRINGE 22
MCG/0.5 ML, 44
MCG/0.5 ML
1
REBIF TITRATION
PACK
SUBCUTANEOUS
SYRINGE
8.8MCG/0.2ML-22
MCG/0.5ML (6)
1
SAIZEN
SUBCUTANEOUS
RECON SOLN 5
MG
1
PA
SAIZEN
CLICK.EASY
SUBCUTANEOUS
CARTRIDGE 8.8
MG/1.5 ML (FNL)
1
PA
NUTROPIN AQ
NUSPIN
SUBCUTANEOUS
CARTRIDGE 5
MG/2 ML (2.5
MG/ML)
1
PA
OMNITROPE
SUBCUTANEOUS
CARTRIDGE 10
MG/1.5 ML (6.7
MG/ML)
1
PA
Omnitrope
subcutaneous
cartridge 5 mg/1.5
mL (3.3 mg/mL)
1
PA
OMNITROPE
SUBCUTANEOUS
RECON SOLN 5.8
MG
1
PA
PEGASYS
SUBCUTANEOUS
SOLUTION 180
MCG/ML
1
PEGASYS
SUBCUTANEOUS
SYRINGE 180
MCG/0.5 ML
1
PEGASYS
PROCLICK
SUBCUTANEOUS
PEN INJECTOR
135 MCG/0.5 ML
1
PEGINTRON
SUBCUTANEOUS
KIT 50 MCG/0.5
ML
1
82
Tier
Requirements
/Limits
Drug
Tier
SEROSTIM
SUBCUTANEOUS
RECON SOLN 4
MG, 5 MG, 6 MG
1
SYLATRON
SUBCUTANEOUS
KIT 200 MCG, 300
MCG, 600 MCG
1
ZORBTIVE
SUBCUTANEOUS
RECON SOLN 8.8
MG
1
Requirements
/Limits
Drug
PA
CARIMUNE NF
NANOFILTERED
INTRAVENOUS
RECON SOLN 6
GRAM
1
CERVARIX
VACCINE (PF)
INTRAMUSCULA
R SYRINGE 20-20
MCG/0.5 ML
1
Cinryze intravenous
recon soln 500 unit
(5 mL)
1
COMVAX (PF)
INTRAMUSCULA
R SUSPENSION 57.5-125 MCG/0.5
ML
1
DAPTACEL (DTAP
PEDIATRIC) (PF)
INTRAMUSCULA
R SUSPENSION
15-10-5 LF-MCGLF/0.5ML
1
ENGERIX-B (PF)
INTRAMUSCULA
R SYRINGE 20
MCG/ML
1
BvsD
ENGERIX-B
PEDIATRIC (PF)
INTRAMUSCULA
R SUSPENSION 10
MCG/0.5 ML
1
BvsD
ENGERIX-B
PEDIATRIC (PF)
INTRAMUSCULA
R SYRINGE 10
MCG/0.5 ML
1
BvsD
Firazyr
subcutaneous
syringe 30 mg/3 mL
1
PA
Vaccines / Miscellaneous Immunologicals
ACTHIB (PF)
INTRAMUSCULA
R RECON SOLN 10
MCG/0.5 ML
1
ADACEL(TDAP
ADOLESN/ADULT
)(PF)
INTRAMUSCULA
R SUSPENSION 2
LF-(2.5-5-3-5
MCG)-5LF/0.5 ML
1
ATGAM
INTRAVENOUS
INJECTABLE 50
MG/ML
1
BCG VACCINE,
LIVE (PF)
PERCUTANEOUS
SUSPENSION FOR
RECONSTITUTIO
N 50 MG
1
BOOSTRIX TDAP
INTRAMUSCULA
R SUSPENSION
2.5-8-5 LF-MCGLF/0.5ML
1
BOOSTRIX TDAP
INTRAMUSCULA
R SYRINGE 2.5-8-5
LF-MCG-LF/0.5ML
1
BvsD
Tier
Requirements
/Limits
BvsD
BvsD
83
Drug
Tier
Requirements
/Limits
fomepizole
1 gram/mL
1
GAMASTAN S/D
INTRAMUSCULA
R SOLUTION 15-18
% RANGE
1
Gammagard Liquid
10 %
1
BvsD
GAMUNEX-C
INJECTION
SOLUTION 1
GRAM/10 ML (10
%)
1
BvsD
GARDASIL (PF)
INTRAMUSCULA
R SUSPENSION
20-40-40-20
MCG/0.5 ML
1
GARDASIL (PF)
INTRAMUSCULA
R SYRINGE 20-4040-20 MCG/0.5 ML
1
GARDASIL 9 (PF)
INTRAMUSCULA
R SUSPENSION 0.5
ML
1
GARDASIL 9 (PF)
INTRAMUSCULA
R SYRINGE 0.5
ML
1
HAVRIX (PF)
INTRAMUSCULA
R SUSPENSION
1,440 ELISA
UNIT/ML
1
HAVRIX (PF)
INTRAMUSCULA
R SYRINGE 720
ELISA UNIT/0.5
ML
1
84
BvsD
BvsD
BvsD
Drug
Tier
IMOVAX RABIES
VACCINE (PF)
INTRAMUSCULA
R RECON SOLN
2.5 UNIT
1
INFANRIX (DTAP)
(PF)
INTRAMUSCULA
R SUSPENSION
25-58-10 LF-MCGLF/0.5ML
1
IPOL INJECTION
SUSPENSION 40-832 UNIT/0.5 ML
1
IPOL INJECTION
SYRINGE 40-8-32
UNIT/0.5 ML
1
IXIARO (PF)
INTRAMUSCULA
R SYRINGE 6
MCG/0.5 ML
1
M-M-R II (PF)
SUBCUTANEOUS
RECON SOLN
1,000-12,500
TCID50/0.5 ML
1
MENACTRA (PF)
INTRAMUSCULA
R SOLUTION 4
MCG/0.5 ML
1
MENOMUNE A/C/Y/W-135 (PF)
SUBCUTANEOUS
RECON SOLN 50
MCG
1
MENVEO A-C-YW-135-DIP (PF)
INTRAMUSCULA
R KIT 10-5
MCG/0.5 ML
1
Requirements
/Limits
Drug
Tier
Requirements
/Limits
PEDVAX HIB (PF)
INTRAMUSCULA
R SOLUTION 7.5
MCG/0.5 ML
1
PROQUAD (PF)
SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTIO
N 10EXP3-4.3-33.99 TCID50/0.5
1
RABAVERT (PF)
INTRAMUSCULA
R SUSPENSION
FOR
RECONSTITUTIO
N 2.5 UNIT
1
RECOMBIVAX HB
(PF)
INTRAMUSCULA
R SUSPENSION 10
MCG/ML, 40
MCG/ML
1
BvsD
RECOMBIVAX HB
(PF)
INTRAMUSCULA
R SYRINGE 10
MCG/ML, 5
MCG/0.5 ML
1
BvsD
ROTARIX ORAL
SUSPENSION FOR
RECONSTITUTIO
N 10EXP6
CCID50/ML
1
ROTATEQ
VACCINE ORAL
SUSPENSION 2
ML
1
TETANUS
TOXOID,ADSORB
ED (PF)
INTRAMUSCULA
R SUSPENSION 5
LF UNIT/0.5 ML
1
BvsD
Drug
Tier
Requirements
/Limits
TETANUS,DIPHTH
ERIA TOX
PED(PF)
INTRAMUSCULA
R SUSPENSION 525 LF UNIT/0.5 ML
1
BvsD
TETANUSDIPHTHERIA
TOXOIDS-TD
INTRAMUSCULA
R SUSPENSION 22 LF UNIT/0.5 ML
1
BvsD
THYMOGLOBULI
N INTRAVENOUS
RECON SOLN 25
MG
1
BvsD
TWINRIX (PF)
INTRAMUSCULA
R SUSPENSION
720 ELISA UNIT 20 MCG/ML
1
BvsD
TYPHIM VI
INTRAMUSCULA
R SOLUTION 25
MCG/0.5 ML
1
VAQTA (PF)
INTRAMUSCULA
R SUSPENSION 25
UNIT/0.5 ML
1
VAQTA (PF)
INTRAMUSCULA
R SUSPENSION 50
UNIT/ML
1
VARIVAX (PF)
SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTIO
N 1,350 UNIT/0.5
ML
1
BvsD
85
Drug
Tier
YF-VAX (PF)
SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTIO
N 10 EXP4.74
UNIT/0.5 ML
1
ZOSTAVAX (PF)
SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTIO
N 19,400 UNIT/0.65
ML
1
Requirements
/Limits
Musculoskeletal / Rheumatology
Gout Therapy
allopurinol oral
tablet 100 mg, 300
mg
1
ALOPRIM
INTRAVENOUS
RECON SOLN 500
MG
1
colchicineprobenecid oral
tablet 0.5-500 mg
1
COLCRYS ORAL
TABLET 0.6 MG
1
probenecid oral
tablet 500 mg
1
ULORIC ORAL
TABLET 40 MG, 80
MG
1
BvsD
ST
Osteoporosis Therapy
ACTONEL ORAL
TABLET 150 MG
1
ACTONEL ORAL
TABLET 35 MG
1
ACTONEL ORAL
TABLET 5 MG
1
86
ST; QL (1 EA
per 30 days)
ST; QL (4 EA
per 30 days)
ST; QL (90
EA per 30
days)
Drug
Tier
Requirements
/Limits
alendronate oral
solution 70 mg/75
mL
1
alendronate oral
tablet 10 mg
1
QL (60 EA per
30 days)
alendronate oral
tablet 35 mg, 70 mg
1
QL (4 EA per
28 days)
alendronate oral
tablet 5 mg
1
QL (30 EA per
30 days)
ATELVIA ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 35 MG
1
ST
BONIVA
INTRAVENOUS
SYRINGE 3 MG/3
ML
1
BvsD
FORTEO
SUBCUTANEOUS
PEN INJECTOR 20
MCG/DOSE - 600
MCG/2.4 ML
1
PA; BvsD
FOSAMAX PLUS
D ORAL TABLET
70-2,800 MG-UNIT,
70-5,600 MG-UNIT
1
ST
ibandronate
3 mg/3 mL
1
BvsD
ibandronate oral
tablet 150 mg
1
QL (1 EA per
30 days)
raloxifene oral tablet
60 mg
1
risedronate oral
tablet 150 mg
1
ST; QL (1 EA
per 30 days)
1
BvsD
Other Rheumatologicals
BENLYSTA
INTRAVENOUS
RECON SOLN 120
MG
Drug
Tier
CUPRIMINE ORAL
CAPSULE 250 MG
1
DEPEN
TITRATABS ORAL
TABLET 250 MG
1
ENBREL
SUBCUTANEOUS
RECON SOLN 25
MG (1 ML)
1
ENBREL
SUBCUTANEOUS
SYRINGE 25
MG/0.5ML (0.51),
50 MG/ML (0.98
ML)
1
HUMIRA
SUBCUTANEOUS
SYRINGE KIT 10
MG/0.2 ML
1
HUMIRA
SUBCUTANEOUS
SYRINGE KIT 20
MG/0.4 ML, 40
MG/0.8 ML
1
HUMIRA
CROHN'S DIS
START PCK
SUBCUTANEOUS
PEN INJECTOR
KIT 40 MG/0.8 ML
1
KINERET
SUBCUTANEOUS
SYRINGE 100
MG/0.67 ML
1
leflunomide oral
tablet 10 mg, 20 mg
1
RIDAURA ORAL
CAPSULE 3 MG
1
Obstetrics / Gynecology
Estrogens / Progestins
Camila oral tablet
0.35 mg
1
Requirements
/Limits
BvsD
BvsD
BvsD
Drug
Tier
DEPO-ESTRADIOL
INTRAMUSCULA
R OIL 5 MG/ML
1
DEPO-PROVERA
INTRAMUSCULA
R SOLUTION 400
MG/ML
1
DEPO-SUBQ
PROVERA 104
SUBCUTANEOUS
SYRINGE 104
MG/0.65 ML
1
DIVIGEL
TRANSDERMAL
GEL IN PACKET
0.5 (0.1) MG (%)
1
ENJUVIA ORAL
TABLET 0.3 MG,
0.45 MG, 0.625 MG,
0.9 MG, 1.25 MG
1
Errin oral tablet
0.35 mg
1
ESTRACE
VAGINAL CREAM
0.01 % (0.1
MG/GRAM)
1
estradiol oral tablet
0.5 mg, 1 mg, 2 mg
1
estradiol
transdermal patch
weekly 0.025 mg/24
hr, 0.0375 mg/24 hr,
0.05 mg/24 hr, 0.06
mg/24 hr, 0.075
mg/24 hr, 0.1 mg/24
hr
1
estradiol valerate
intramuscular oil 20
mg/mL
1
estradiolnorethindrone acet
oral tablet 1-0.5 mg
1
Requirements
/Limits
BvsD
87
Drug
Tier
Requirements
/Limits
Drug
ESTRING
VAGINAL RING 2
MG
1
QL (1 EA per
90 days)
1
estropipate oral
tablet 0.75 mg, 1.5
mg, 3 mg
1
EVAMIST
TRANSDERMAL
SPRAY,NONAEROSOL 1.53
MG/SPRAY (1.7%)
1
MINIVELLE
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
norethindrone
(contraceptive) oral
tablet 0.35 mg
1
FEMRING
VAGINAL RING
0.05 MG/24 HR, 0.1
MG/24 HR
1
norethindrone
acetate oral tablet 5
mg
1
Jolivette oral tablet
0.35 mg
1
1
Lyza oral tablet 0.35
mg
1
PREMARIN
INJECTION
RECON SOLN 25
MG
1
PREMARIN ORAL
TABLET 0.3 MG,
0.45 MG, 0.625 MG,
0.9 MG, 1.25 MG
1
medroxyprogesteron
e intramuscular
suspension 150
mg/mL
1
medroxyprogesteron
e oral tablet 10 mg,
2.5 mg, 5 mg
1
PREMARIN
VAGINAL CREAM
0.625 MG/GRAM
1
MENEST ORAL
TABLET 0.3 MG,
0.625 MG, 1.25 MG,
2.5 MG
1
PREMPHASE
ORAL TABLET
0.625 MG (14)/
0.625MG-5MG(14)
1
progesterone
micronized oral
capsule 100 mg, 200
mg
1
MENOSTAR
TRANSDERMAL
PATCH WEEKLY
14 MCG/24 HR
1
VIVELLE-DOT
TRANSDERMAL
PATCH
SEMIWEEKLY
0.025 MG/24 HR,
0.0375 MG/24 HR,
0.05 MG/24 HR,
0.075 MG/24 HR,
0.1 MG/24 HR
1
Mimvey Lo oral
tablet 0.5-0.1 mg
88
QL (1 EA per
90 days)
Tier
Requirements
/Limits
BvsD
QL (30 EA per
30 days)
Drug
Tier
Requirements
/Limits
Miscellaneous Ob/Gyn
clindamycin
phosphate vaginal
cream 2 %
1
metronidazole
topical gel 1 %
1
metronidazole
vaginal gel 0.75 %
1
Miconazole-3
vaginal suppository
200 mg
1
terconazole vaginal
cream 0.4 %, 0.8 %
1
terconazole vaginal
suppository 80 mg
1
Vandazole vaginal
gel 0.75 %
1
Oral Contraceptives / Related Agents
Drug
Tier
Cyclafem 1/35 (28)
oral tablet 1-35 mgmcg
1
Cyclafem 7/7/7 (28)
oral tablet 0.5/0.75/1
mg- 35 mcg
1
drospirenone-ethinyl
estradiol oral tablet
3-0.03 mg
1
Ella oral tablet 30
mg
1
Emoquette oral
tablet 0.15-0.03 mg
1
Enpresse oral tablet
50-30 (6)/75-40
(5)/125-30(10)
1
estradiolnorethindrone acet
oral tablet 0.5-0.1
mg
1
FEMCON FE
ORAL
TABLET,CHEWAB
LE 0.4MG35MCG(21) & 75
MG (7)
1
Gildagia oral tablet
0.4-35 mg-mcg
1
Introvale oral
tablets,dose pack,3
month 0.15-30 mgmcg
1
Amethia oral
tablets,dose pack,3
month 0.15 mg-30
mcg (84)/10 mcg (7)
1
Amethyst oral tablet
90-20 mcg
1
Apri oral tablet
0.15-0.03 mg
1
Aranelle (28) oral
tablet 0.5/1/0.5-35
mg-mcg
1
Aviane oral tablet
0.1-20 mg-mcg
1
1
Junel 1.5/30 (21)
oral tablet 1.5-30
mg-mcg
1
Balziva (28) oral
tablet 0.4-35 mgmcg
1
Junel 1/20 (21) oral
tablet 1-20 mg-mcg
1
Briellyn oral tablet
0.4-35 mg-mcg
1
Junel FE 1.5/30 (28)
oral tablet 1.5 mg-30
mcg (21)/75 mg (7)
1
Cryselle (28) oral
tablet 0.3-30 mgmcg
Requirements
/Limits
89
Drug
Tier
Junel FE 1/20 (28)
oral tablet 1 mg-20
mcg (21)/75 mg (7)
1
Kariva (28) oral
tablet 0.15-0.02
mgx21 /0.01 mg x 5
1
Kelnor 1/35 (28)
1
Lessina oral tablet
0.1-20 mg-mcg
1
Levonest (28) oral
tablet 50-30 (6)/7540 (5)/125-30(10)
1
levonorgestrelethinyl estrad oral
tablets,dose pack,3
month 0.15-30 mgmcg
1
Levora-28 oral
tablet 0.15-0.03 mg
1
Low-Ogestrel (28)
oral tablet 0.3-30
mg-mcg
1
Lutera (28) oral
tablet 0.1-20 mgmcg
1
Marlissa oral tablet
0.15-0.03 mg
1
Microgestin 1.5/30
(21) oral tablet 1.530 mg-mcg
1
Microgestin 1/20
(21) oral tablet 1-20
mg-mcg
1
Microgestin Fe
1.5/30 (28) oral
tablet 1.5 mg-30 mcg
(21)/75 mg (7)
1
90
Requirements
/Limits
Drug
Tier
Microgestin FE 1/20
(28) oral tablet 1
mg-20 mcg (21)/75
mg (7)
1
Mononessa (28) oral
tablet 0.25-35 mgmcg
1
Necon 0.5/35 (28)
oral tablet 0.5-35
mg-mcg
1
Necon 1/35 (28) oral
tablet 1-35 mg-mcg
1
Necon 10/11 (28)
oral tablet 0.5-35/135 mg-mcg/mg-mcg
1
Necon 7/7/7 (28)
mg- 35 mcg
1
norethindronee.estradiol-iron oral
tablet 1 mg-20 mcg
(24)/75 mg (4)
1
Nortrel 0.5/35 (28)
oral tablet 0.5-35
mg-mcg
1
Nortrel 1/35 (21)
1
Nortrel 1/35 (28)
1
Nortrel 7/7/7 (28)
mg- 35 mcg
1
Ogestrel (28) oral
tablet 0.5-50 mgmcg
1
Orsythia oral tablet
0.1-20 mg-mcg
1
Requirements
/Limits
Drug
Tier
ORTHO TRICYCLEN LO (28)
ORAL TABLET
0.18/0.215/0.25 MG25 MCG (28)
1
Pimtrea (28) oral
tablet 0.15-0.02
mgx21 /0.01 mg x 5
1
Pirmella oral tablet
1-35 mg-mcg
1
Portia oral tablet
0.15-0.03 mg
1
Previfem oral tablet
0.25-35 mg-mcg
1
Quasense oral
tablets,dose pack,3
month 0.15-30 mgmcg
1
Reclipsen (28) oral
tablet 0.15-0.03 mg
1
SEASONIQUE
ORAL
TABLETS,DOSE
PACK,3 MONTH
0.15 MG-30 MCG
(84)/10 MCG (7)
1
Sprintec (28) oral
tablet 0.25-35 mgmcg
1
Sronyx oral tablet
0.1-20 mg-mcg
1
Tri-Legest Fe oral
tablet 1-20(5)/130(7) /1mg-35mcg
(9)
1
Tri-Previfem (28)
oral tablet
0.18/0.215/0.25 mg35 mcg (28)
1
Requirements
/Limits
Drug
Tier
Tri-Sprintec (28)
oral tablet
0.18/0.215/0.25 mg35 mcg (28)
1
TriNessa (28) oral
tablet
0.18/0.215/0.25 mg35 mcg (28)
1
Trivora (28) oral
tablet 50-30 (6)/7540 (5)/125-30(10)
1
Velivet Triphasic
Regimen (28) oral
tablet 0.1/.125/.1525 mg-mcg
1
Vestura (28) oral
tablet 3-0.02 mg
1
ZenChent (28) oral
tablet 0.4-35 mgmcg
1
Zovia 1/35E (28)
1
Zovia 1/50E (28)
1
Requirements
/Limits
Oxytocics
methylergonovine
oral tablet 0.2 mg
1
Ophthalmology
Antibiotics
AZASITE
OPHTHALMIC
DROPS 1 %
1
bacitracin
ophthalmic ointment
500 unit/gram
1
91
Drug
Tier
bacitracinpolymyxin B
ophthalmic ointment
500-10,000
unit/gram
1
CILOXAN
OPHTHALMIC
OINTMENT 0.3 %
1
ciprofloxacin HCl
ophthalmic drops
0.3 %
1
erythromycin
ophthalmic ointment
5 mg/gram (0.5 %)
1
Garamycin
ophthalmic drops
0.3 %
1
Gentak ophthalmic
ointment 0.3 % (3
mg/gram)
Requirements
/Limits
Drug
Tier
neomycinbacitracinpolymyxin
ophthalmic ointment
3.5-400-10,000 mgunit-unit/g
1
neomycinpolymyxingramicidin
ophthalmic drops
1.75 mg-10,000 unit0.025mg/mL
1
ofloxacin ophthalmic
drops 0.3 %
1
1
1
polymyxin B sulftrimethoprim
ophthalmic drops
10,000 unit- 1
mg/mL
1
gentamicin
ophthalmic drops
0.3 %
1
tobramycin
ophthalmic drops
0.3 %
1
gentamicin
ophthalmic ointment
0.3 % (3 mg/gram)
1
TOBREX
OPHTHALMIC
OINTMENT 0.3 %
1
levofloxacin
ophthalmic drops
0.5 %
1
VIGAMOX
OPHTHALMIC
DROPS 0.5 %
MOXEZA
OPHTHALMIC
DROPS, VISCOUS
0.5 %
1
NATACYN
OPHTHALMIC
DROPS,SUSPENSI
ON 5 %
1
Antivirals
trifluridine
ophthalmic drops 1
%
1
VIROPTIC
OPHTHALMIC
DROPS 1 %
1
ZIRGAN
OPHTHALMIC
GEL 0.15 %
1
Beta-Blockers
betaxolol ophthalmic
drops 0.5 %
92
1
Requirements
/Limits
Drug
Tier
BETOPTIC S
OPHTHALMIC
DROPS,SUSPENSI
ON 0.25 %
1
carteolol ophthalmic
drops 1 %
1
levobunolol
ophthalmic drops
0.5 %
Requirements
/Limits
Drug
Tier
azelastine
ophthalmic drops
0.05 %
1
cromolyn
ophthalmic drops 4
%
1
1
ELESTAT
OPHTHALMIC
DROPS 0.05 %
1
metipranolol
ophthalmic drops
0.3 %
1
EMADINE
OPHTHALMIC
DROPS 0.05 %
1
timolol maleate
ophthalmic drops
0.25 %, 0.5 %
1
epinastine
ophthalmic drops
0.05 %
1
timolol maleate
ophthalmic gel
forming solution
0.25 %, 0.5 %
1
PATADAY
OPHTHALMIC
DROPS 0.2 %
1
PATANOL
OPHTHALMIC
DROPS 0.1 %
1
proparacaine
ophthalmic drops
0.5 %
1
RESTASIS
OPHTHALMIC
DROPPERETTE
0.05 %
1
Cholinesterase Inhibitor Miotics
PHOSPHOLINE
IODIDE
OPHTHALMIC
DROPS 0.125 %
1
Direct Acting Miotics
ISOPTO CARPINE
OPHTHALMIC
DROPS 1 %, 2 %, 4
%
1
pilocarpine HCl
ophthalmic drops 1
%, 2 %, 4 %
1
Requirements
/Limits
QL (60 EA per
30 days)
Non-Steroidal Anti-Inflammatory Agents
Miscellaneous Ophthalmologics
ALOCRIL
OPHTHALMIC
DROPS 2 %
1
ALOMIDE
OPHTHALMIC
DROPS 0.1 %
1
ACUVAIL (PF)
OPHTHALMIC
DROPPERETTE
0.45 %
1
bromfenac
ophthalmic drops
0.09 %
1
diclofenac sodium
ophthalmic drops
0.1 %
1
93
Drug
Tier
Requirements
/Limits
Drug
Tier
flurbiprofen sodium
ophthalmic drops
0.03 %
1
LUMIGAN
OPHTHALMIC
DROPS 0.01 %
1
ketorolac
ophthalmic drops
0.4 %, 0.5 %
1
TRAVATAN Z
OPHTHALMIC
DROPS 0.004 %
1
NEVANAC
OPHTHALMIC
DROPS,SUSPENSI
ON 0.1 %
1
travoprost
(benzalkonium)
ophthalmic drops
0.004 %
1
Oral Drugs For Glaucoma
XALATAN
OPHTHALMIC
DROPS 0.005 %
1
acetazolamide oral
capsule, extended
release 500 mg
1
acetazolamide oral
tablet 125 mg, 250
mg
1
acetazolamide
sodium injection
recon soln 500 mg
1
methazolamide oral
tablet 25 mg, 50 mg
1
Steroid-Antibiotic Combinations
Other Glaucoma Drugs
AZOPT
OPHTHALMIC
DROPS,SUSPENSI
ON 1 %
1
COMBIGAN
OPHTHALMIC
DROPS 0.2-0.5 %
1
dorzolamide
ophthalmic drops 2
%
1
dorzolamide-timolol
ophthalmic drops
22.3-6.8 mg/mL
1
latanoprost
ophthalmic drops
0.005 %
1
94
Requirements
/Limits
neomycinbacitracin-poly-HC
ophthalmic ointment
3.5-400-10,000 mgunit/g-1%
1
neomycin-polymyxin
B-dexameth
ophthalmic
drops,suspension
3.5mg/mL-10,000
unit/mL-0.1 %
1
neomycin-polymyxin
B-dexameth
ophthalmic ointment
3.5 mg/g-10,000
unit/g-0.1 %
1
neomycinpolymyxin-HC
ophthalmic
drops,suspension
3.5-10,000-10 mgunit-mg/mL
1
PRED-G
OPHTHALMIC
DROPS,SUSPENSI
ON 0.3-1 %
1
Drug
Tier
PRED-G S.O.P.
OPHTHALMIC
OINTMENT 0.3-0.6
%
1
TOBRADEX
OPHTHALMIC
OINTMENT 0.3-0.1
%
1
tobramycindexamethasone
ophthalmic
drops,suspension
0.3-0.1 %
1
ZYLET
OPHTHALMIC
DROPS,SUSPENSI
ON 0.3-0.5 %
1
Steroids
Requirements
/Limits
Drug
Tier
LOTEMAX
OPHTHALMIC
DROPS,GEL 0.5 %
1
LOTEMAX
OPHTHALMIC
DROPS,SUSPENSI
ON 0.5 %
1
LOTEMAX
OPHTHALMIC
OINTMENT 0.5 %
1
MAXIDEX
OPHTHALMIC
DROPS,SUSPENSI
ON 0.1 %
1
PRED FORTE
OPHTHALMIC
DROPS,SUSPENSI
ON 1 %
1
Requirements
/Limits
ALREX
OPHTHALMIC
DROPS,SUSPENSI
ON 0.2 %
1
prednisolone sodium
phosphate
ophthalmic drops 1
%
1
dexamethasone
sodium phosphate
ophthalmic drops
0.1 %
1
VEXOL
OPHTHALMIC
DROPS,SUSPENSI
ON 1 %
1
FLAREX
OPHTHALMIC
DROPS,SUSPENSI
ON 0.1 %
1
Steroid-Sulfonamide Combinations
1
fluorometholone
ophthalmic
drops,suspension 0.1
%
1
BLEPHAMIDE
OPHTHALMIC
DROPS,SUSPENSI
ON 10-0.2 %
1
FML FORTE
OPHTHALMIC
DROPS,SUSPENSI
ON 0.25 %
1
BLEPHAMIDE
S.O.P.
OPHTHALMIC
OINTMENT 10-0.2
%
1
FML S.O.P.
OPHTHALMIC
OINTMENT 0.1 %
1
sulfacetamideprednisolone
ophthalmic drops 10
%-0.23 % (0.25 %)
Sulfonamides
95
Drug
Tier
BLEPH-10
OPHTHALMIC
DROPS 10 %
1
sulfacetamide
sodium ophthalmic
drops 10 %
sulfacetamide
sodium ophthalmic
ointment 10 %
Tier
1
1
1
Insulin Syringe
syringe 1/2 mL 29 x
1/2"
1
1
insulin syringe
needleless syringe 1
mL
insulin syringeneedle U-100
syringe 0.3 mL 31 x
5/16"
1
Prenatal Vitamin
oral tablet
1
ALPHAGAN P
OPHTHALMIC
DROPS 0.1 %, 0.15
%
1
apraclonidine
ophthalmic drops
0.5 %
1
brimonidine
ophthalmic drops
0.15 %, 0.2 %
1
IOPIDINE
OPHTHALMIC
DROPPERETTE 1
%
1
IOPIDINE
OPHTHALMIC
DROPS 0.5 %
1
Requirements
/Limits
Respiratory And Allergy
Antihistamine / Antiallergenic Agents
Vasoconstrictor Decongestants
1
Otc-Product
Otc-Product
Alcohol Pads topical
pads, medicated
1
Assure ID Insulin
Safety syringe 1 mL
29 x 1/2"
1
Curity Gauze topical
bandage 2 X 2 "
1
96
Drug
Insulin Pen Needle
needle 31
Sympathomimetics
naphazoline
ophthalmic drops
0.1 %
Requirements
/Limits
carbinoxamine
maleate oral liquid 4
mg/5 mL
1
carbinoxamine
maleate oral tablet 4
mg
1
cetirizine oral
solution 1 mg/mL
1
CLARINEX ORAL
SYRUP 2.5 MG/5
ML (0.5 MG/ML)
1
ST
CLARINEX ORAL
TABLET 5 MG
1
ST
CLARINEX-D 12
HOUR ORAL
TABLET, ER
MULTIPHASE 12
HR 2.5-120 MG
1
desloratadine oral
tablet 5 mg
1
desloratadine oral
2.5 mg, 5 mg
1
Drug
Tier
Requirements
/Limits
EPIPEN 2-PAK
INJECTION AUTOINJECTOR 0.3
MG/0.3 ML
(1:1,000)
1
EPIPEN JR 2-PAK
INJECTION AUTOINJECTOR 0.15
MG/0.3 ML
(1:2,000)
1
hydroxyzine HCl
intramuscular
solution 25 mg/mL,
50 mg/mL
1
hydroxyzine HCl
oral syrup 10 mg/5
mL
1
PA
hydroxyzine HCl
mg, 50 mg
1
PA
hydroxyzine
pamoate oral
capsule 100 mg, 25
mg, 50 mg
1
PA
levocetirizine oral
solution 2.5 mg/5
mL
1
levocetirizine oral
tablet 5 mg
1
Phenadoz rectal
suppository 12.5 mg
1
PHENERGAN
RECTAL
SUPPOSITORY
12.5 MG, 25 MG, 50
MG
1
promethazine rectal
suppository 50 mg
1
Promethegan rectal
suppository 25 mg,
50 mg
1
Drug
Tier
Requirements
/Limits
XYZAL ORAL
SOLUTION 2.5
MG/5 ML
1
ST
XYZAL ORAL
TABLET 5 MG
1
ST
Kalydeco oral tablet
150 mg
1
Pulmonary Agents
ACCOLATE ORAL
TABLET 10 MG, 20
MG
1
acetylcysteine
solution 100 mg/mL
(10 %), 200 mg/mL
(20 %)
1
ADVAIR DISKUS
INHALATION
BLISTER WITH
DEVICE 100-50
MCG/DOSE, 25050 MCG/DOSE,
500-50 MCG/DOSE
1
ADVAIR HFA
INHALATION HFA
AEROSOL
INHALER 115-21
MCG/ACTUATION
, 230-21
MCG/ACTUATION
, 45-21
MCG/ACTUATION
1
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
1
albuterol sulfate oral
syrup 2 mg/5 mL
1
tablet 2 mg, 4 mg
1
BvsD
BvsD
97
Drug
Tier
Requirements
/Limits
tablet extended
release 12 hr 4 mg, 8
mg
1
aminophylline
250 mg/10 mL
1
ASMANEX
TWISTHALER
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED 110
MCG (30 DOSES)
1
ATROVENT HFA
INHALATION HFA
AEROSOL
INHALER 17
MCG/ACTUATION
1
BECONASE AQ
NASAL
SPRAY,NONAEROSOL 42 MCG
(0.042 %)
1
BREO ELLIPTA
INHALATION
BLISTER WITH
DEVICE 100-25
MCG/DOSE
1
BROVANA
INHALATION
SOLUTION FOR
NEBULIZATION
15 MCG/2 ML
1
BvsD
budesonide
inhalation
suspension for
nebulization 0.25
mg/2 mL, 0.5 mg/2
mL
1
BvsD
budesonide nasal
spray,non-aerosol
32 mcg/actuation
1
98
Drug
Tier
Requirements
/Limits
COMBIVENT
RESPIMAT
INHALATION
MIST 20-100
MCG/ACTUATION
1
cromolyn inhalation
solution for
nebulization 20 mg/2
mL
1
DALIRESP ORAL
TABLET 500 MCG
1
ELIXOPHYLLIN
ORAL ELIXIR 80
MG/15 ML
1
FLOVENT HFA
INHALATION HFA
AEROSOL
INHALER 110
MCG/ACTUATION
, 220
MCG/ACTUATION
, 44
MCG/ACTUATION
1
fluticasone nasal
spray,suspension 50
mcg/actuation
1
ipratropium bromide
inhalation solution
0.02 %
1
BvsD
ipratropiumalbuterol inhalation
solution for
nebulization 0.5 mg3 mg(2.5 mg base)/3
mL
1
BvsD
LETAIRIS ORAL
TABLET 10 MG, 5
MG
1
levalbuterol HCl
inhalation solution
mg/3 mL, 0.63 mg/3
mL
1
BvsD
BvsD
Drug
Tier
levalbuterol HCl
inhalation solution
mg/0.5 mL
1
LUFYLLIN ORAL
TABLET 200 MG
1
metaproterenol oral
syrup 10 mg/5 mL
1
metaproterenol oral
tablet 10 mg, 20 mg
1
montelukast oral
granules in packet 4
mg
1
montelukast oral
tablet 10 mg
1
montelukast oral
tablet,chewable 4
mg, 5 mg
1
NASONEX NASAL
SPRAY,NONAEROSOL 50
MCG/ACTUATION
1
OMNARIS NASAL
SPRAY,NONAEROSOL 50 MCG
1
PERFOROMIST
INHALATION
SOLUTION FOR
NEBULIZATION
20 MCG/2 ML
1
ProAir HFA
inhalation HFA
aerosol inhaler 90
mcg/actuation
1
PROVENTIL HFA
INHALATION HFA
AEROSOL
INHALER 90
MCG/ACTUATION
1
Requirements
/Limits
Drug
BvsD; BvsD
PULMICORT
INHALATION
SUSPENSION FOR
NEBULIZATION 1
MG/2 ML
1
PULMICORT
FLEXHALER
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED 180
MCG/ACTUATION
, 90
MCG/ACTUATION
1
PULMOZYME
INHALATION
SOLUTION 1
MG/ML
1
QVAR
INHALATION
AEROSOL 40
MCG/ACTUATION
, 80
MCG/ACTUATION
1
REVATIO ORAL
SUSPENSION FOR
RECONSTITUTIO
N 10 MG/ML
1
PA
REVATIO ORAL
TABLET 20 MG
1
PA
SEREVENT
DISKUS
INHALATION
BLISTER WITH
DEVICE 50
MCG/DOSE
1
sildenafil oral tablet
20 mg
1
SINGULAIR ORAL
GRANULES IN
PACKET 4 MG
1
SINGULAIR ORAL
TABLET 10 MG
1
BvsD
Tier
Requirements
/Limits
BvsD
BvsD
PA
99
Drug
Tier
SINGULAIR ORAL
TABLET,CHEWAB
LE 4 MG, 5 MG
1
SPIRIVA
RESPIMAT
INHALATION
MIST 2.5
MCG/ACTUATION
1
SPIRIVA WITH
HANDIHALER
INHALATION
CAPSULE,
W/INHALATION
DEVICE 18 MCG
1
SYMBICORT
INHALATION HFA
AEROSOL
INHALER 160-4.5
MCG/ACTUATION
, 80-4.5
MCG/ACTUATION
1
terbutaline oral
tablet 2.5 mg, 5 mg
1
terbutaline
subcutaneous
solution 1 mg/mL
1
theophylline oral
tablet extended
release 400 mg, 600
mg
1
theophylline oral
tablet extended
release 12 hr 100
mg, 200 mg, 300 mg,
450 mg
1
TRACLEER ORAL
TABLET 125 MG,
62.5 MG
1
triamcinolone
acetonide nasal
aerosol,spray 55
mcg
1
100
Requirements
/Limits
BvsD
Drug
Tier
Requirements
/Limits
VENTOLIN HFA
INHALATION HFA
AEROSOL
INHALER 90
MCG/ACTUATION
1
XOLAIR
SUBCUTANEOUS
RECON SOLN 150
MG
1
BvsD
XOPENEX
INHALATION
SOLUTION FOR
NEBULIZATION
0.31 MG/3 ML, 0.63
MG/3 ML, 1.25
MG/3 ML
1
BvsD; BvsD
XOPENEX HFA
INHALATION HFA
AEROSOL
INHALER 45
MCG/ACTUATION
1
zafirlukast oral
tablet 10 mg, 20 mg
1
ZYFLO ORAL
TABLET 600 MG
1
ZYFLO CR ORAL
TABLET, ER
MULTIPHASE 12
HR 600 MG
1
Topical Corticosteroids Low Potency
Topical Corticosteroids
Proctozone-HC
rectal cream 2.5 %
1
Urologicals
PA; LA
Anticholinergics / Antispasmodics
DETROL ORAL
TABLET 1 MG, 2
MG
1
Drug
Tier
Requirements
/Limits
Drug
Tier
Requirements
/Limits
ENABLEX ORAL
TABLET
EXTENDED
RELEASE 24 HR
15 MG, 7.5 MG
1
QL (30 EA per
30 days)
finasteride oral
tablet 5 mg
1
QL (30 EA per
30 days)
JALYN ORAL
CAPSULE, ER
MULTIPHASE 24
HR 0.5-0.4 MG
1
flavoxate oral tablet
100 mg
1
MYRBETRIQ
ORAL TABLET
EXTENDED
RELEASE 24 HR
25 MG, 50 MG
1
tamsulosin oral
capsule,extended
release 24hr 0.4 mg
1
QL (60 EA per
30 days)
UROXATRAL
ORAL TABLET
EXTENDED
RELEASE 24 HR
10 MG
1
QL (30 EA per
30 days)
oxybutynin chloride
oral syrup 5 mg/5
mL
1
oxybutynin chloride
oral tablet 5 mg
1
oxybutynin chloride
release 24hr 10 mg,
15 mg, 5 mg
1
tolterodine oral
capsule,extended
release 24hr 2 mg, 4
mg
1
tolterodine oral
tablet 1 mg, 2 mg
1
trospium oral
capsule,extended
release 24hr 60 mg
1
QL (30 EA per
30 days)
trospium oral tablet
20 mg
1
QL (60 EA per
30 days)
VESICARE ORAL
TABLET 10 MG, 5
MG
1
QL (30 EA per
30 days)
Cholinergic Stimulants
bethanechol chloride
mg, 5 mg, 50 mg
1
Miscellaneous Urologicals
Benign Prostatic Hyperplasia(Bph) Therapy
alfuzosin oral tablet
extended release 24
hr 10 mg
1
AVODART ORAL
CAPSULE 0.5 MG
1
QL (30 EA per
30 days)
QL (30 EA per
30 days)
AMMONIUM
CHLORIDE
INTRAVENOUS
SOLUTION 5
MEQ/ML
1
CYSTAGON ORAL
CAPSULE 150 MG,
50 MG
1
ELMIRON ORAL
CAPSULE 100 MG
1
potassium citrate
release 15 mEq
1
sodium
phenylbutyrate oral
powder 0.94
gram/gram
1
BvsD
Vitamins, Hematinics / Electrolytes
Electrolytes
calcium acetate oral
capsule 667 mg
1
101
Drug
Tier
dextrose 5 %lactated ringers
intravenous
parenteral solution
1
Eliphos oral tablet
667 mg
1
Klor-Con 10 oral
tablet extended
release 10 mEq
1
Klor-Con 8 oral
tablet extended
release 8 mEq
1
KLOR-CON M15
ORAL TABLET,ER
PARTICLES/CRYS
TALS 15 MEQ
1
Klor-Con M20 oral
tablet,ER
particles/crystals 20
mEq
1
LACTATED
RINGERS
INTRAVENOUS
PARENTERAL
SOLUTION
1
magnesium sulfate
mEq/mL (50 %)
1
MAGNESIUM
SULFATE
INJECTION
SYRINGE 4
MEQ/ML
1
NORMOSOL-R IN
5 % DEXTROSE
INTRAVENOUS
PARENTERAL
SOLUTION 5 %
1
102
Requirements
/Limits
BvsD
BvsD
BvsD
Drug
Tier
Requirements
/Limits
potassium chloridD5-0.45%NaCl
intravenous
parenteral solution
10 mEq/L, 20
mEq/L, 40 mEq/L
1
BvsD
POTASSIUM
CHLORID-D50.45%NACL
INTRAVENOUS
PARENTERAL
SOLUTION 30
MEQ/L
1
BvsD
potassium chloride
intravenous
piggyback 10
mEq/100 mL, 20
mEq/100 mL
1
BvsD
POTASSIUM
CHLORIDE
INTRAVENOUS
PIGGYBACK 40
MEQ/100 ML
1
BvsD
potassium chloride
2 mEq/mL
1
BvsD
potassium chloride
oral capsule,
extended release 10
mEq, 8 mEq
1
potassium chloride
release 8 mEq
1
potassium chloride
oral tablet,ER
particles/crystals 10
mEq, 20 mEq
1
potassium chloride
in 0.9%NaCl
intravenous
parenteral solution
20 mEq/L
1
BvsD
Drug
Tier
POTASSIUM
CHLORIDE IN
0.9%NACL
INTRAVENOUS
PARENTERAL
SOLUTION 40
MEQ/L
1
POTASSIUM
CHLORIDE IN 5 %
DEX
INTRAVENOUS
PARENTERAL
SOLUTION 20
MEQ/L
1
potassium chloride
in 5 % dex
intravenous
parenteral solution
40 mEq/L
1
potassium chloride
in LR-D5
intravenous
parenteral solution
20 mEq/L
1
POTASSIUM
CHLORIDE-0.45 %
NACL
INTRAVENOUS
PARENTERAL
SOLUTION 20
MEQ/L
1
POTASSIUM
CHLORIDE-D50.2%NACL
INTRAVENOUS
PARENTERAL
SOLUTION 20
MEQ/L
1
potassium chlorideD5-0.3%NaCl
intravenous
parenteral solution
20 mEq/L
1
Requirements
/Limits
Drug
BvsD
potassium chlorideD5-0.9%NaCl
intravenous
parenteral solution
20 mEq/L, 40 mEq/L
1
ringers intravenous
parenteral solution
1
sodium chloride
intravenous
parenteral solution
2.5 mEq/mL
1
BvsD
sodium chloride 0.45
% intravenous
parenteral solution
0.45 %
1
BvsD
sodium chloride 3 %
intravenous
parenteral solution 3
%
1
BvsD
sodium chloride 5 %
intravenous
parenteral solution 5
%
1
BvsD
sodium lactate
5 mEq/mL
1
BvsD
BvsD
BvsD
BvsD
Tier
Requirements
/Limits
BvsD
Miscellaneous Nutrition Products
BvsD
BvsD
AMINOSYN 7 %
WITH
ELECTROLYTES
INTRAVENOUS
PARENTERAL
SOLUTION 7 %
1
AMINOSYN II 10
% INTRAVENOUS
PARENTERAL
SOLUTION 10 %
1
BvsD
Aminosyn II 15 %
intravenous
parenteral solution
15 %
1
BvsD
103
Drug
Tier
Requirements
/Limits
Drug
CLINIMIX
2.75%/D5W
SULFIT FREE
INTRAVENOUS
PARENTERAL
SOLUTION 2.75 %
1
BvsD
CLINIMIX 4.25%D20W SULF-FREE
INTRAVENOUS
PARENTERAL
SOLUTION 4.25 %
1
BvsD
CLINIMIX
4.25%/D10W SULF
FREE
INTRAVENOUS
PARENTERAL
SOLUTION 4.25 %
1
BvsD
CLINIMIX 5%D20W(SULFITEFREE)
INTRAVENOUS
PARENTERAL
SOLUTION 5 %
1
BvsD
CLINIMIX E
4.25%/D25W SUL
FREE
INTRAVENOUS
PARENTERAL
SOLUTION 4.25 %
1
BvsD
CLINIMIX E
4.25%/D5W SULF
FREE
INTRAVENOUS
PARENTERAL
SOLUTION 4.25 %
1
BvsD
CLINIMIX E
5%/D15W SULFIT
FREE
INTRAVENOUS
PARENTERAL
SOLUTION 5 %
1
BvsD
AMINOSYN II 7 %
INTRAVENOUS
PARENTERAL
SOLUTION 7 %
1
BvsD
AMINOSYN II 8.5
% INTRAVENOUS
PARENTERAL
SOLUTION 8.5 %
1
BvsD
AMINOSYN M 3.5
% INTRAVENOUS
PARENTERAL
SOLUTION 3.5 %
1
AMINOSYN-HBC
7%
INTRAVENOUS
PARENTERAL
SOLUTION 7 %
1
BvsD
AMINOSYN-PF 10
% INTRAVENOUS
PARENTERAL
SOLUTION 10 %
1
BvsD
AMINOSYN-PF 7
% (SULFITEFREE)
INTRAVENOUS
PARENTERAL
SOLUTION 7 %
1
BvsD
AMINOSYN-RF 5.2
% INTRAVENOUS
PARENTERAL
SOLUTION 5.2 %
1
CLINIMIX
5%/D15W
SULFITE FREE
INTRAVENOUS
PARENTERAL
SOLUTION 5 %
1
CLINIMIX
5%/D25W
SULFITE-FREE
INTRAVENOUS
PARENTERAL
SOLUTION 5 %
1
104
BvsD
BvsD
BvsD
Tier
Requirements
/Limits
Drug
Tier
Requirements
/Limits
Drug
BvsD
NEPHRAMINE 5.4
% INTRAVENOUS
PARENTERAL
SOLUTION 5.4 %
1
BvsD
NORMOSOL-R PH
7.4
INTRAVENOUS
PARENTERAL
SOLUTION
1
BvsD
PLASMA-LYTE
148
INTRAVENOUS
PARENTERAL
SOLUTION
1
BvsD
PLASMA-LYTE A
INTRAVENOUS
PARENTERAL
SOLUTION
1
BvsD
PLASMA-LYTE-56
IN 5 % DEXTROSE
INTRAVENOUS
PARENTERAL
SOLUTION 5 %
1
BvsD
Premasol 10 %
intravenous
parenteral solution
10 %
1
BvsD
PREMASOL 6 %
INTRAVENOUS
PARENTERAL
SOLUTION 6 %
1
BvsD
PROCALAMINE
3%
INTRAVENOUS
PARENTERAL
SOLUTION 3 %
1
BvsD
PROSOL 20 %
INTRAVENOUS
PARENTERAL
SOLUTION
1
BvsD
CLINIMIX E
5%/D20W SULFIT
FREE
INTRAVENOUS
PARENTERAL
SOLUTION 5 %
1
CLINIMIX E
5%/D25W SULFIT
FREE
INTRAVENOUS
PARENTERAL
SOLUTION 5 %
1
HEPATAMINE 8%
INTRAVENOUS
PARENTERAL
SOLUTION 8 %
1
Intralipid
intravenous
emulsion 20 %
1
INTRALIPID
INTRAVENOUS
EMULSION 30 %
1
BvsD
IONOSOL-B IN
D5W
INTRAVENOUS
PARENTERAL
SOLUTION 5 %
1
BvsD
IONOSOL-MB IN
D5W
INTRAVENOUS
PARENTERAL
SOLUTION 5 %
1
ISOLYTE-P IN 5 %
DEXTROSE
INTRAVENOUS
PARENTERAL
SOLUTION 5 %
1
ISOLYTE-S
INTRAVENOUS
PARENTERAL
SOLUTION
1
BvsD
BvsD
BvsD
BvsD
BvsD
BvsD
Tier
Requirements
/Limits
105
Drug
Tier
Requirements
/Limits
Travasol 10 %
intravenous
parenteral solution
10 %
1
BvsD
TROPHAMINE 10
% INTRAVENOUS
PARENTERAL
SOLUTION 10 %
1
BvsD
TROPHAMINE 6%
INTRAVENOUS
PARENTERAL
SOLUTION 6 %
1
BvsD
106
OTC Drugs
Drug
Tier
Drug
Requirements
/Limits
Tier
Non-Drowsy Allergy
oral tablet 10 mg
1
omeprazole oral
tablet,delayed
release (DR/EC) 20
mg
1
omeprazole
magnesium oral
capsule,delayed
release(DR/EC) 20
mg
1
Prevacid 24Hr oral
capsule,delayed
release(DR/EC) 15
mg
1
1
Alavert oral
10 mg
1
All Day Allergy
(cetirizine) oral
tablet,chewable 10
mg
1
Allegra Allergy oral
1
Aller-ease oral
tablet 180 mg
1
Allergy Relief
(fexofenadine) oral
tablet 180 mg
1
Allergy Relief
(loratadine) oral
tablet 10 mg
1
Prilosec OTC oral
tablet,delayed
release (DR/EC) 20
mg
Children's Allegra
Allergy oral
suspension 30 mg/5
mL
1
Wal-itin oral tablet
10 mg
1
Wal-Zyr (cetirizine)
oral tablet 10 mg
1
Children's Allegra
Allergy oral tablet
30 mg
1
Children's Allegra
Allergy oral
30 mg
1
Children's Allergy
Relief(lor) oral
solution 5 mg/5 mL
1
Children's ClearAtadine oral
10 mg
1
loratadine oral
solution 5 mg/5 mL
1
loratadine oral
tablet 10 mg
1
Requirements
/Limits
107
Index
8
8-MOP .................................. 59
A
abacavir .................................. 4
abacavir-lamivudinezidovudine .......................... 4
ABELCET .............................. 3
ABILIFY .............................. 39
ABILIFY DISCMELT ......... 40
ABILIFY MAINTENA ........ 40
acamprosate .......................... 65
ACANYA ............................. 60
acarbose ................................ 69
ACCOLATE......................... 97
acebutolol ............................. 49
acetaminophen-codeine ........ 34
Acetasol HC ......................... 68
acetazolamide ....................... 94
acetazolamide sodium .......... 94
acetic acid ............................. 68
acetylcysteine ....................... 97
acitretin ................................. 58
ACTHIB (PF) ....................... 83
ACTIMMUNE ..................... 80
ACTONEL ..................... 65, 86
ACTOPLUS MET ................ 70
ACTOPLUS MET XR ......... 70
ACTOS ................................. 70
ACUVAIL (PF) .................... 93
acyclovir ................................. 4
acyclovir sodium .................... 4
ADACEL(TDAP
ADOLESN/ADULT)(PF) 83
ADAGEN ............................. 65
adapalene .............................. 60
ADCIRCA ............................ 49
ADDERALL XR .................. 40
adefovir................................... 4
ADVAIR DISKUS ............... 97
ADVAIR HFA ..................... 97
ADVICOR ............................ 57
Afeditab CR.......................... 49
AFINITOR ........................... 18
AFINITOR DISPERZ .......... 18
AGGRENOX ....................... 55
A-Hydrocort ......................... 68
Ala-Cort ................................ 62
ALA-SCALP ........................ 62
108
Alavert ................................ 107
ALBENZA ........................... 10
albuterol sulfate .............. 97, 98
alclometasone ....................... 62
Alcohol Pads......................... 96
ALDACTAZIDE .................. 49
ALDARA ............................. 59
ALDURAZYME .................. 72
alendronate ..................... 65, 86
alfuzosin ............................. 101
ALIMTA .............................. 18
ALINIA ................................ 10
ALKERAN ........................... 18
All Day Allergy (cetirizine) 107
Allegra Allergy ................... 107
Aller-ease............................ 107
Allergy Relief (fexofenadine)
........................................ 107
Allergy Relief (loratadine) . 107
allopurinol ............................ 86
ALOCRIL ............................. 93
ALOMIDE............................ 93
ALOPRIM ............................ 86
ALOXI.................................. 75
ALPHAGAN P ..................... 96
alprazolam ............................ 40
Alprazolam Intensol ............. 40
ALREX ................................. 95
ALTABAX ........................... 61
amantadine HCl ...................... 4
AMBISOME .......................... 3
amcinonide ........................... 62
Amethia ................................ 89
Amethyst .............................. 89
amifostine crystalline ........... 17
amikacin ............................... 10
amiloride............................... 49
amiloride-hydrochlorothiazide
.......................................... 49
aminophylline ....................... 98
AMINOSYN 7 % WITH
ELECTROLYTES.......... 103
AMINOSYN II 10 % ......... 103
Aminosyn II 15 % .............. 103
AMINOSYN II 7 % ........... 104
AMINOSYN II 8.5 % ........ 104
AMINOSYN M 3.5 %........ 104
AMINOSYN-HBC 7%....... 104
AMINOSYN-PF 10 % ....... 104
AMINOSYN-PF 7 %
(SULFITE-FREE) .......... 104
AMINOSYN-RF 5.2 % ...... 104
amiodarone ........................... 48
AMITIZA ............................. 75
amitriptyline .........................40
amitriptyline-chlordiazepoxide
.......................................... 40
amlodipine ............................ 49
amlodipine-benazepril .......... 49
amlodipine-valsartan ............ 49
amlodipine-valsartan-hcthiazid
.......................................... 49
AMMONIUM CHLORIDE101
ammonium lactate ................ 59
Amnesteem ........................... 60
amoxapine............................. 40
amoxicil-clarithromy-lansopraz
.......................................... 76
amoxicillin ............................ 14
amoxicillin-pot clavulanate .. 14
Amphetamine Salt Combo ... 40
amphotericin B ....................... 3
ampicillin .............................. 14
ampicillin sodium .................14
AMPICILLIN SODIUM ...... 14
ampicillin-sulbactam ............ 14
AMRIX ................................. 33
AMTURNIDE ...................... 49
ANADROL-50 ..................... 72
anagrelide ............................. 65
anastrozole ............................ 18
ANCOBON ............................ 3
ANDRODERM .................... 73
ANDROGEL ........................ 73
ANTABUSE ......................... 65
ANZEMET ........................... 76
APLENZIN........................... 40
APOKYN ............................. 30
apraclonidine ........................ 96
Apri ....................................... 89
APRISO ................................ 76
Aptiom .................................. 26
APTIVUS ............................... 4
ARALAST NP...................... 65
Aranelle (28) ......................... 89
ARANESP (IN
POLYSORBATE) ............ 80
ARCALYST ......................... 80
ARICEPT ............................. 32
ARIMIDEX .......................... 18
ARIXTRA ............................ 55
AROMASIN......................... 18
ARRANON .......................... 18
ARTHROTEC 50 ................. 37
ARTHROTEC 75 ................. 38
ARZERRA ........................... 18
ASACOL HD ....................... 76
Ascomp with Codeine .......... 34
ASMANEX TWISTHALER 98
Assure ID Insulin Safety ...... 96
ASTAGRAF XL .................. 18
ATELVIA............................. 86
atenolol ................................. 49
atenolol-chlorthalidone......... 49
ATGAM ............................... 83
atorvastatin ........................... 57
atovaquone ........................... 10
atovaquone-proguanil ........... 11
ATRIPLA ............................... 4
atropine ................................. 75
ATROPINE .......................... 75
ATROVENT HFA ............... 98
AVASTIN ............................ 18
AVELOX ............................. 15
AVELOX ABC PACK......... 15
AVELOX IN NACL (ISOOSMOTIC)....................... 16
Aviane .................................. 89
Avita ..................................... 60
AVODART ........................ 101
AVONEX ............................. 80
AVONEX (WITH ALBUMIN)
.......................................... 80
azacitidine............................. 19
AZACTAM .......................... 11
AZACTAM IN DEXTROSE
(ISO-OSM) ....................... 11
AZASAN.............................. 19
AZASITE ............................. 91
azathioprine .......................... 19
azelastine ........................ 67, 93
AZELEX .............................. 60
AZILECT ............................. 30
azithromycin ......................... 10
AZOPT ................................. 94
AZOR ................................... 49
aztreonam ............................. 11
B
BACiiM ................................ 11
bacitracin ........................ 11, 91
bacitracin-polymyxin B ........ 92
baclofen ................................ 33
BACTROBAN ..................... 61
BACTROBAN NASAL ....... 67
balsalazide ............................ 76
Balziva (28) .......................... 89
BANZEL .............................. 26
BARACLUDE........................ 4
BCG VACCINE, LIVE (PF) 83
BECONASE AQ .................. 98
BELEODAQ ........................ 19
benazepril ............................. 49
benazepril-hydrochlorothiazide
.......................................... 49
BENLYSTA ......................... 86
BENTYL .............................. 75
BENZACLIN ....................... 60
benztropine ........................... 30
BENZTROPINE ................... 30
betamethasone dipropionate . 63
betamethasone valerate......... 63
betamethasone, augmented ... 63
BETASERON ...................... 80
betaxolol ......................... 49, 92
bethanechol chloride........... 101
BETOPTIC S ........................ 93
bicalutamide ......................... 19
BICILLIN C-R ..................... 14
BICILLIN L-A ..................... 14
BICNU.................................. 19
BILTRICIDE ........................ 11
bisoprolol fumarate............... 49
bisoprolol-hydrochlorothiazide
.......................................... 49
bleomycin ............................. 19
BLEPH-10 ............................ 96
BLEPHAMIDE .................... 95
BLEPHAMIDE S.O.P. ......... 95
BONIVA .............................. 86
BOOSTRIX TDAP............... 83
BOSULIF ............................. 19
BREO ELLIPTA .................. 98
Briellyn ................................. 89
BRILINTA ........................... 55
brimonidine .......................... 96
BRINTELLIX ....................... 40
BRISDELLE......................... 40
bromfenac ............................. 93
bromocriptine ....................... 30
BROVANA .......................... 98
budesonide ...................... 76, 98
bumetanide ........................... 49
Bunavail ................................ 38
buprenorphine HCl ............... 34
buprenorphine-naloxone ....... 34
Buproban .............................. 67
bupropion HCl ...................... 40
buspirone .............................. 40
BUSULFEX .........................19
butalbital-acetaminop-caf-cod
.......................................... 34
butorphanol tartrate .............. 38
BYDUREON ........................ 70
BYETTA .............................. 70
BYSTOLIC........................... 50
C
cabergoline ........................... 73
CADUET .............................. 57
calcipotriene ......................... 59
calcitonin (salmon) ............... 73
calcitriol .......................... 59, 73
calcium acetate ................... 101
Camila................................... 87
CANASA .............................. 76
CANCIDAS ............................ 3
candesartan ........................... 50
candesartan-hydrochlorothiazid
.......................................... 50
CANTIL ............................... 75
CAPASTAT .........................11
CAPEX ................................. 63
CAPRELSA .......................... 19
captopril ................................ 50
captopril-hydrochlorothiazide
.......................................... 50
CARAC ................................ 59
CARAFATE ......................... 79
carbamazepine ................ 26, 40
CARBATROL ...................... 26
carbidopa-levodopa .............. 30
carbidopa-levodopaentacapone ........................ 30
carbinoxamine maleate ......... 96
carboplatin ............................ 19
CARDURA XL .................... 50
109
CARIMUNE NF
NANOFILTERED ........... 83
carisoprodol .......................... 33
carisoprodol-ASA-codeine ... 33
carisoprodol-aspirin .............. 33
CARNITOR ......................... 65
carteolol ................................ 93
Cartia XT .............................. 50
carvedilol .............................. 50
CASODEX ........................... 19
CEDAX .................................. 8
cefaclor ................................... 8
cefadroxil................................ 8
cefazolin ................................. 8
cefazolin in dextrose (iso-os) . 8
cefdinir ................................... 8
cefepime ................................. 8
cefotaxime .............................. 8
cefotetan ................................. 8
CEFOTETAN......................... 8
cefoxitin.................................. 8
cefpodoxime ........................... 8
cefprozil .................................. 9
ceftazidime ............................. 9
ceftazidime in D5W ............... 9
CEFTIN .................................. 9
ceftriaxone .............................. 9
cefuroxime axetil .................... 9
cefuroxime sodium ................. 9
CELEBREX ......................... 38
celecoxib............................... 38
CELLCEPT .......................... 19
CELLCEPT INTRAVENOUS
.......................................... 19
CELONTIN .......................... 26
cephalexin............................... 9
Cerezyme .............................. 73
CERVARIX VACCINE (PF)
.......................................... 83
CESAMET ........................... 76
cetirizine ............................... 96
cevimeline ............................ 65
CHANTIX ............................ 67
CHANTIX STARTING
MONTH BOX .................. 67
CHEMET ............................. 65
Children's Allegra Allergy . 107
Children's Allergy Relief(lor)
........................................ 107
Children's Clear-Atadine .... 107
110
CHLORAMPHENICOL SOD
SUCCINATE.................... 11
chlordiazepoxide HCl ........... 40
chlorhexidine gluconate ....... 67
chloroquine phosphate .......... 11
chlorothiazide ....................... 50
chlorothiazide sodium .......... 50
chlorpromazine ............... 40, 41
chlorpropamide ..................... 70
chlorthalidone ....................... 50
chlorzoxazone....................... 33
Cholestyramine Light ........... 57
ciclopirox .............................. 61
cidofovir ................................. 4
cilostazol............................... 55
CILOXAN ............................ 92
cimetidine ............................. 79
cimetidine HCl ..................... 79
Cinryze ................................. 83
CIPRO .................................. 16
CIPRO HC ............................ 68
CIPRODEX .......................... 68
ciprofloxacin ......................... 16
ciprofloxacin (mixture)......... 16
ciprofloxacin HCl ........... 16, 92
ciprofloxacin in 5 % dextrose
.......................................... 16
ciprofloxacin lactate ............. 16
cisplatin ................................ 19
citalopram ............................. 41
cladribine .............................. 19
CLAFORAN .......................... 9
Claravis ................................. 60
CLARINEX .......................... 96
CLARINEX-D 12 HOUR .... 96
clarithromycin ...................... 10
CLEOCIN ............................. 11
CLEOCIN IN 5 %
DEXTROSE ..................... 11
clindamycin HCl................... 11
clindamycin in 5 % dextrose 11
Clindamycin Pediatric .......... 11
clindamycin phosphate .. 11, 60,
89
clindamycin-benzoyl peroxide
.......................................... 60
CLINIMIX 5%/D15W
SULFITE FREE ............. 104
CLINIMIX 5%/D25W
SULFITE-FREE ............. 104
CLINIMIX 2.75%/D5W
SULFIT FREE ................ 104
CLINIMIX 4.25%/D10W
SULF FREE.................... 104
CLINIMIX 4.25%/D5W
SULFIT FREE .................. 65
CLINIMIX 4.25%-D20W
SULF-FREE ................... 104
CLINIMIX 5%D20W(SULFITE-FREE) 104
CLINIMIX E 2.75%/D10W
SUL FREE ........................ 65
SULF FREE...................... 65
SUL FREE ...................... 104
SULF FREE.................... 104
CLINIMIX E 5%/D15W
SULFIT FREE ................ 104
CLINIMIX E 5%/D20W
SULFIT FREE ................ 105
CLINIMIX E 5%/D25W
SULFIT FREE ................ 105
clobetasol .............................. 63
clobetasol-emollient ............. 63
CLOLAR .............................. 19
clomipramine ........................ 41
clonazepam ........................... 41
clonidine ............................... 50
clonidine HCl........................ 50
clopidogrel ............................ 55
clorazepate dipotassium........ 41
CLORPRES .......................... 50
clotrimazole ................ 3, 61, 62
clotrimazole-betamethasone . 62
clozapine ............................... 41
CLOZAPINE ........................ 41
CLOZARIL .......................... 41
codeine sulfate ...................... 34
colchicine-probenecid........... 86
COLCRYS ............................ 86
colestipol............................... 57
colistin (colistimethate Na)... 11
COMBIGAN ........................ 94
COMBIVENT RESPIMAT.. 98
COMBIVIR ............................ 4
COMETRIQ ......................... 19
COMPLERA .......................... 4
Compro ................................. 76
COMTAN............................. 30
COMVAX (PF) .................... 83
CONCERTA ........................ 41
Constulose ............................ 76
COPAXONE .................. 32, 80
COREG CR .......................... 50
cortisone ............................... 68
CORTISPORIN .................... 61
COSMEGEN ........................ 19
COZAAR ............................. 50
CREON ................................ 76
CRESTOR ............................ 57
CRIXIVAN ............................ 4
cromolyn................... 76, 93, 98
Cryselle (28) ......................... 89
CUBICIN ............................. 11
CUPRIMINE ........................ 87
Curity Gauze ........................ 96
Cyclafem 1/35 (28)............... 89
Cyclafem 7/7/7 (28) ............. 89
cyclobenzaprine .................... 33
cyclophosphamide ................ 19
CYCLOSET ......................... 70
cyclosporine ......................... 19
cyclosporine modified .... 19, 20
CYCLOSPORINE MODIFIED
.......................................... 20
CYKLOKAPRON ................ 55
CYMBALTA ....................... 41
CYSTADANE ...................... 76
CYSTAGON ...................... 101
cytarabine ............................. 20
cytarabine (PF) ..................... 20
CYTOVENE .......................... 5
D
D10 % & 0.45 % SODIUM
CHLORIDE ...................... 66
D2.5 %-0.45 % sodium
chloride ............................. 66
D5 % and 0.9 % sodium
chloride ............................. 66
D5 %-0.45 % sodium chloride
.......................................... 66
dacarbazine ........................... 20
DACOGEN .......................... 20
DALIRESP ........................... 98
danazol ................................. 73
dantrolene ............................. 33
DAPSONE ........................... 11
DAPTACEL (DTAP
PEDIATRIC) (PF) ............ 83
DARAPRIM ......................... 11
DAUNORUBICIN ............... 20
decitabine.............................. 20
DELZICOL .......................... 76
demeclocycline ..................... 16
DEMSER .............................. 50
DENAVIR ............................ 62
DEPAKOTE ......................... 26
DEPAKOTE ER ................... 26
DEPAKOTE SPRINKLES .. 26
DEPEN TITRATABS .......... 87
DEPO-ESTRADIOL ............ 87
DEPO-PROVERA................ 87
DEPO-SUBQ PROVERA 104
.......................................... 87
desipramine .......................... 41
desloratadine ......................... 96
desmopressin ........................ 73
DESONATE ......................... 63
desonide ................................ 63
desoximetasone .................... 63
DESOXYN ........................... 41
desvenlafaxine ...................... 41
DETROL ............................ 100
dexamethasone ..................... 68
DEXAMETHASONE .......... 68
DEXAMETHASONE
INTENSOL ...................... 68
dexamethasone sodium
phosphate .................... 68, 95
DEXILANT .......................... 79
dexmethylphenidate.............. 41
DEXPAK 13 DAY ............... 68
dexrazoxane HCl .................. 18
dextroamphetamine .............. 41
dextroamphetamineamphetamine .................... 41
DEXTROSE 10 % AND 0.2 %
NACL ............................... 66
dextrose 10 % in water
(D10W)............................. 66
dextrose 5 % in water (D5W)
.......................................... 66
dextrose 5 %-lactated ringers
........................................ 102
dextrose 5%-0.2 % sod
chloride ............................. 66
DEXTROSE 5%-0.3 %
SOD.CHLORIDE ............. 66
Diastat ................................... 41
Diastat AcuDial .................... 41
diazepam ............................... 42
Diazepam Intensol ................ 42
DIBENZYLINE ................... 50
diclofenac potassium ............ 38
diclofenac sodium ........... 38, 93
diclofenac-misoprostol ......... 38
dicloxacillin .......................... 14
dicyclomine .......................... 75
didanosine ............................... 5
diflorasone ............................ 63
diflunisal ............................... 38
Digitek .................................. 55
digoxin .................................. 55
dihydroergotamine ................ 31
DILANTIN ........................... 26
DILANTIN INFATABS ...... 26
DILAUDID........................... 34
diltiazem HCl..................50, 51
DILTIAZEM HCL ............... 50
DILT-XR .............................. 50
DIOVAN .............................. 51
DIOVAN HCT ..................... 51
DIPENTUM .........................76
diphenoxylate-atropine ......... 75
dipyridamole ......................... 55
disopyramide phosphate ....... 48
disulfiram .............................. 66
DIURIL................................. 51
DIURIL IV ........................... 51
divalproex ............................. 26
DIVIGEL .............................. 87
DOCEFREZ .........................20
docetaxel ............................... 20
DOCETAXEL ...................... 20
donepezil............................... 32
DORIBAX ............................ 11
dorzolamide .......................... 94
dorzolamide-timolol ............. 94
DOVONEX .......................... 59
doxazosin .............................. 51
doxepin ................................. 42
doxercalciferol ...................... 73
DOXIL .................................. 20
doxorubicin ........................... 20
doxycycline hyclate .............. 16
doxycycline monohydrate .... 17
111
dronabinol............................. 76
drospirenone-ethinyl estradiol
.......................................... 89
DROXIA .............................. 20
DUETACT ........................... 70
DULOXETINE .................... 42
Duramorph (PF) ................... 34
DYRENIUM ........................ 51
E
E.E.S. 400 ............................. 10
econazole .............................. 62
EDARBI ............................... 51
EDARBYCLOR ................... 51
EDURANT ............................. 5
EFFEXOR XR...................... 42
ELAPRASE .......................... 73
ELESTAT............................. 93
ELIDEL ................................ 59
ELIGARD ............................ 20
Eliphos................................ 102
ELIQUIS .............................. 55
ELITEK ................................ 18
ELIXOPHYLLIN ................. 98
Ella ....................................... 89
ELLENCE ............................ 20
ELMIRON .......................... 101
ELOXATIN .......................... 20
EMADINE ........................... 93
EMCYT ................................ 20
EMEND................................ 76
Emoquette............................. 89
EMSAM ............................... 42
EMTRIVA .............................. 5
ENABLEX ......................... 101
enalapril maleate .................. 51
enalapril-hydrochlorothiazide
.......................................... 51
ENBREL .............................. 87
Endocet ................................. 34
ENGERIX-B (PF) ................ 83
ENGERIX-B PEDIATRIC
(PF) ................................... 83
ENJUVIA ............................. 87
enoxaparin ............................ 55
Enpresse ............................... 89
entacapone ............................ 30
entecavir ................................. 5
ENTOCORT EC .................. 77
Enulose ................................. 77
epinastine.............................. 93
112
EPIPEN 2-PAK .................... 97
EPIPEN JR 2-PAK ............... 97
epirubicin .............................. 20
Epitol .................................... 27
EPIVIR ................................... 5
EPIVIR HBV .......................... 5
eplerenone ............................ 51
EPOGEN .............................. 81
eprosartan ............................. 51
EPZICOM .............................. 5
EQUETRO ........................... 27
ERAXIS(WATER DILUENT)
............................................ 3
ERBITUX ............................. 20
ergoloid ................................. 42
ERIVEDGE .......................... 20
Errin ...................................... 87
ERTACZO............................ 62
ERWINAZE ......................... 20
Ery Pads ................................ 60
ERYPED 200 ....................... 10
Ery-Tab ................................. 10
ERY-TAB ............................. 10
ERYTHROCIN .................... 10
Erythrocin (as stearate) ......... 10
erythromycin ........................ 92
ERYTHROMYCIN .............. 10
erythromycin ethylsuccinate. 10
erythromycin with ethanol.... 60
erythromycin-benzoyl peroxide
.......................................... 60
escitalopram oxalate ............. 42
esomeprazole strontium ........ 79
estazolam .............................. 42
ESTRACE ............................ 87
estradiol ................................ 87
estradiol valerate................... 87
estradiol-norethindrone acet 87,
89
ESTRING ............................. 88
estropipate ............................ 88
eszopiclone ........................... 42
ethambutol ............................ 12
ethosuximide ........................ 27
etidronate disodium .............. 66
etodolac ................................ 38
ETOPOPHOS ....................... 20
etoposide............................... 21
EURAX ................................ 65
EVAMIST ............................ 88
EVOXAC ............................. 66
EXELDERM ........................ 62
EXELON .............................. 32
exemestane ........................... 21
EXFORGE ............................ 51
EXFORGE HCT ................... 51
EXJADE ............................... 66
EXTINA ............................... 62
F
FABRAZYME ..................... 73
famciclovir .............................. 5
famotidine ............................. 79
famotidine (PF) ..................... 79
famotidine (PF)-NaCl (iso-os)
.......................................... 79
FANAPT............................... 42
FARESTON .........................21
FASLODEX ......................... 21
FazaClo ................................. 42
felbamate .............................. 27
FELBATOL .......................... 27
felodipine .............................. 51
FEMARA ............................. 21
FEMCON FE ........................ 89
FEMRING ............................ 88
fenofibrate............................. 57
fenofibrate micronized.......... 57
fenofibrate nanocrystallized . 57
fenofibric acid (choline) ....... 57
fenoprofen............................. 38
fentanyl ................................. 34
fentanyl citrate ................ 34, 35
FETZIMA ............................. 42
FIBRICOR ............................ 57
FINACEA ............................. 60
finasteride ........................... 101
Firazyr................................... 83
FLAGYL ER ........................ 12
FLAREX............................... 95
flavoxate ............................. 101
flecainide .............................. 48
FLOVENT HFA ................... 98
fluconazole ............................. 3
fluconazole in dextrose(iso-o) 3
flucytosine .............................. 3
fludarabine ............................ 21
fludrocortisone ...................... 68
fluocinolone .......................... 63
fluocinolone acetonide oil .... 68
fluocinonide .......................... 64
Fluocinonide-E ..................... 64
fluorometholone ................... 95
fluorouracil ..................... 21, 59
fluoxetine........................ 42, 43
fluphenazine decanoate ........ 43
fluphenazine HCl.................. 43
flurazepam ............................ 43
flurbiprofen........................... 38
flurbiprofen sodium .............. 94
flutamide............................... 21
fluticasone ...................... 64, 98
fluvastatin ............................. 57
fluvoxamine.......................... 43
FML FORTE ........................ 95
FML S.O.P. .......................... 95
FOCALIN............................. 43
FOCALIN XR ...................... 43
fomepizole ............................ 84
fondaparinux......................... 55
FORFIVO XL ...................... 43
FORTAZ ................................ 9
FORTEO .............................. 86
FORTICAL .......................... 73
FOSAMAX PLUS D ............ 86
foscarnet ................................. 5
fosinopril .............................. 51
fosinopril-hydrochlorothiazide
.......................................... 51
fosphenytoin ......................... 27
FOSRENOL ......................... 66
FRAGMIN ........................... 56
FURADANTIN .................... 17
furosemide ...................... 51, 52
FUROSEMIDE .................... 52
FUSILEV ............................. 18
FUZEON ................................ 5
FYCOMPA .......................... 27
G
gabapentin ............................ 27
GABITRIL ........................... 27
galantamine .......................... 32
GAMASTAN S/D ................ 84
Gammagard Liquid .............. 84
GAMUNEX-C ..................... 84
ganciclovir sodium ................. 5
Garamycin ............................ 92
GARDASIL (PF).................. 84
GARDASIL 9 (PF)............... 84
gatifloxacin ........................... 16
Gavilyte-C ............................ 77
GaviLyte-N ........................... 77
GEMCITABINE .................. 21
gemfibrozil ........................... 57
GEMZAR ............................. 21
Generlac................................ 77
Gengraf ................................. 21
GENOTROPIN .................... 81
GENOTROPIN MINIQUICK
.......................................... 81
Gentak .................................. 92
gentamicin ................ 12, 61, 92
gentamicin in NaCl (iso-osm)
.......................................... 12
GENTAMICIN IN NACL
(ISO-OSM) ....................... 12
GENTAMICIN SULFATE
(PF) ................................... 12
GEODON ............................. 43
Gildagia ................................ 89
GILENYA ............................ 81
GILOTRIF ............................ 21
GLEEVEC ............................ 21
glimepiride............................ 70
glipizide ................................ 70
glipizide-metformin .............. 70
GLUCAGEN HYPOKIT ..... 70
GLUCAGON EMERGENCY
KIT (HUMAN)................. 70
glyburide ............................... 70
glyburide micronized ............ 70
glyburide-metformin ............ 70
glycopyrrolate ....................... 75
GOLYTELY ......................... 77
GRALISE ............................. 27
GRALISE 30-DAY STARTER
PACK ............................... 27
granisetron (PF) .................... 77
granisetron HCl .................... 77
griseofulvin microsize ............ 3
griseofulvin ultramicrosize ..... 3
GRIS-PEG
(ULTRAMICROSIZE) ...... 3
guanfacine ...................... 43, 52
guanidine .............................. 33
H
HALAVEN ........................... 21
HALDOL.............................. 43
HALDOL DECANOATE .... 43
halobetasol propionate .......... 64
HALOG ................................ 64
haloperidol ............................ 43
haloperidol decanoate ........... 43
haloperidol lactate ................ 43
HARVONI .............................. 5
HAVRIX (PF) ...................... 84
heparin (porcine) .................. 56
heparin (porcine) in 5 % dex 56
HEPARIN (PORCINE) IN 5 %
DEX .................................. 56
HEPATAMINE 8% ............ 105
HEPSERA .............................. 5
HERCEPTIN ........................ 21
HEXALEN ........................... 21
HUMALOG MIX 50-50....... 70
HUMALOG MIX 50-50
KWIKPEN ........................ 70
HUMALOG MIX 75-25....... 71
HUMALOG MIX 75-25
KWIKPEN ........................ 71
HUMATROPE ..................... 81
HUMIRA .............................. 87
HUMIRA CROHN'S DIS
START PCK ..................... 87
HYCAMTIN......................... 21
hydralazine ........................... 52
hydrochlorothiazide .............. 52
hydrocodone-acetaminophen 35
hydrocodone-ibuprofen ........ 35
hydrocortisone .......... 64, 69, 77
hydrocortisone butyrate ........ 64
hydrocortisone butyr-emollient
.......................................... 64
hydrocortisone valerate ........ 64
hydrocortisone-acetic acid .... 68
hydromorphone..................... 35
hydromorphone (PF) ............ 35
hydroxychloroquine .............. 12
hydroxyurea .......................... 21
hydroxyzine HCl .................. 97
hydroxyzine pamoate............ 97
HYZAAR ............................. 52
I
ibandronate ........................... 86
ibuprofen............................... 38
ibuprofen-oxycodone ............ 35
ICLUSIG .............................. 21
idarubicin .............................. 21
IFEX ..................................... 21
IFOSFAMIDE ...................... 21
IMBRUVICA ....................... 21
113
imipenem-cilastatin .............. 12
imipramine HCl .................... 44
imipramine pamoate ............. 44
imiquimod ............................ 59
IMOVAX RABIES VACCINE
(PF) ................................... 84
INCRELEX .......................... 66
indapamide ........................... 52
INDOCIN ............................. 38
INFANRIX (DTAP) (PF)..... 84
INLYTA ............................... 21
Insulin Pen Needle ............... 96
Insulin Syringe ..................... 96
insulin syringe needleless ..... 96
insulin syringe-needle U-10096
INTELENCE .......................... 5
Intralipid ............................. 105
INTRALIPID ..................... 105
INTRON A ........................... 81
Introvale ............................... 89
INTUNIV ER ....................... 52
INVANZ............................... 12
INVEGA............................... 44
INVEGA SUSTENNA ......... 44
INVIRASE ............................. 5
IONOSOL-B IN D5W ....... 105
IONOSOL-MB IN D5W .... 105
IOPIDINE............................. 96
IPOL ..................................... 84
ipratropium bromide ....... 67, 98
ipratropium-albuterol ........... 98
irbesartan .............................. 52
irbesartan-hydrochlorothiazide
.......................................... 52
irinotecan .............................. 21
Isentress .................................. 5
ISENTRESS ........................... 5
ISOLYTE-P IN 5 %
DEXTROSE ................... 105
ISOLYTE-S ........................ 105
isoniazid ............................... 12
ISONIAZID .......................... 12
ISOPTO CARPINE .............. 93
isosorbide dinitrate ............... 58
isosorbide mononitrate ......... 58
isradipine .............................. 52
itraconazole ............................ 3
ivermectin ............................. 12
IXEMPRA ............................ 21
IXIARO (PF) ........................ 84
114
J
JAKAFI ................................ 22
JALYN ............................... 101
Jantoven ................................ 56
JANUMET ........................... 71
JANUMET XR ..................... 71
JANUVIA ............................. 71
JENTADUETO .................... 71
JEVTANA ............................ 22
Jolivette ................................ 88
Junel 1.5/30 (21) ................... 89
Junel 1/20 (21) ...................... 89
Junel FE 1.5/30 (28) ............. 89
Junel FE 1/20 (28) ................ 90
K
KALETRA ............................. 5
Kalydeco ............................... 97
Kariva (28) ........................... 90
KAZANO ............................. 71
KEFLEX ................................. 9
Kelnor 1/35 (28) ................... 90
KENALOG ..................... 64, 69
KEPIVANCE ....................... 18
KEPPRA............................... 27
KEPPRA XR ........................ 27
KETEK ................................. 12
ketoconazole ..................... 3, 62
ketoprofen ............................. 38
ketorolac ......................... 38, 94
KEYTRUDA ........................ 22
KHEDEZLA ......................... 44
KINERET ............................. 87
Kionex .................................. 66
Klor-Con 10 ........................ 102
Klor-Con 8 .......................... 102
KLOR-CON M15 ............... 102
Klor-Con M20 .................... 102
KOMBIGLYZE XR ............. 71
KUVAN................................ 73
L
labetalol ................................ 52
lactated ringers ..................... 65
LACTATED RINGERS ..... 102
lactulose ................................ 77
LAMICTAL ......................... 27
LAMICTAL STARTER
(BLUE) KIT ..................... 27
LAMICTAL STARTER
(GREEN) KIT .................. 27
LAMICTAL STARTER
(ORANGE) KIT ............... 28
LAMICTAL XR ................... 28
LAMICTAL XR STARTER
(BLUE) ............................. 28
LAMICTAL XR STARTER
(GREEN) .......................... 28
LAMICTAL XR STARTER
(ORANGE) ....................... 28
lamivudine .............................. 5
lamivudine-zidovudine ........... 5
lamotrigine ............................ 28
LANOXIN ............................ 55
lansoprazole .......................... 79
LANTUS .............................. 71
LANTUS SOLOSTAR ......... 71
latanoprost ............................ 94
LATUDA .............................. 44
leflunomide ........................... 87
Lessina .................................. 90
LETAIRIS ............................ 98
letrozole ................................ 22
leucovorin calcium ............... 18
LEUCOVORIN CALCIUM . 18
LEUKERAN......................... 22
LEUKINE ............................. 81
leuprolide .............................. 22
levalbuterol HCl ............. 98, 99
LEVAQUIN .........................16
LEVEMIR ............................ 71
LEVEMIR FLEXTOUCH.... 71
levetiracetam......................... 28
levobunolol ........................... 93
levocarnitine ......................... 66
LEVOCARNITINE .............. 66
levocarnitine (with sugar) ..... 66
levocetirizine ........................ 97
levofloxacin .................... 16, 92
levofloxacin in D5W ............16
Levonest (28) ........................ 90
levonorgestrel-ethinyl estrad 90
Levora-28 ............................. 90
levorphanol tartrate ............... 35
levothyroxine ........................ 75
Levoxyl ................................. 75
LEXAPRO ............................ 44
LEXIVA ................................. 6
LIALDA ............................... 77
lidocaine ............................... 61
lidocaine (PF) ....................... 61
lidocaine HCl........................ 61
lidocaine-prilocaine .............. 61
LIDODERM ......................... 61
LINDANE ............................ 65
LINZESS .............................. 77
liothyronine .......................... 75
lisinopril ............................... 52
lisinopril-hydrochlorothiazide
.......................................... 52
lithium carbonate .................. 44
LITHIUM CARBONATE.... 44
lithium citrate ....................... 44
lomustine .............................. 22
loperamide ............................ 75
loratadine ............................ 107
lorazepam ............................. 44
Lorazepam Intensol .............. 44
LORZONE ........................... 33
losartan ................................. 52
losartan-hydrochlorothiazide 52
LOTEMAX .......................... 95
LOTRONEX ........................ 77
lovastatin .............................. 57
LOVAZA ............................. 57
LOVENOX........................... 56
Low-Ogestrel (28) ................ 90
loxapine succinate ................ 44
LUFYLLIN .......................... 99
LUMIGAN ........................... 94
LUPRON DEPOT ................ 22
LUPRON DEPOT (3
MONTH) .......................... 22
LUPRON DEPOT (4
MONTH) .......................... 22
LUPRON DEPOT (6
MONTH) .......................... 22
LUPRON DEPOT-PED ....... 22
Lutera (28) ............................ 90
LYRICA ............................... 28
LYSODREN......................... 22
LYSTEDA ............................ 56
Lyza ...................................... 88
M
MACRODANTIN ................ 17
magnesium sulfate .............. 102
MAGNESIUM SULFATE. 102
MALARONE ....................... 12
MALARONE PEDIATRIC . 12
malathion .............................. 65
maprotiline ........................... 44
Marlissa ................................ 90
MARPLAN .......................... 44
MATULANE........................ 22
MAXALT ............................. 31
MAXALT-MLT ................... 31
MAXIDEX ........................... 95
meclizine .............................. 77
meclofenamate...................... 38
medroxyprogesterone ........... 88
mefenamic acid..................... 38
mefloquine ............................ 12
megestrol .............................. 22
MEKINIST ........................... 22
meloxicam ............................ 38
melphalan HCl ...................... 22
MENACTRA (PF) ............... 84
MENEST .............................. 88
MENOMUNE - A/C/Y/W-135
(PF) ................................... 84
MENOSTAR ........................ 88
MENVEO A-C-Y-W-135-DIP
(PF) ................................... 84
meperidine ............................ 35
Meperitab.............................. 35
meprobamate ........................ 33
Mepron ................................. 12
mercaptopurine ..................... 22
meropenem ........................... 12
MERREM............................. 12
mesalamine with cleansing
wipe .................................. 77
mesna .................................... 18
MESNEX.............................. 18
MESTINON ......................... 33
MESTINON TIMESPAN .... 33
METADATE CD ................. 44
Metadate ER ......................... 44
metaproterenol ...................... 99
metaxalone............................ 33
metformin ............................. 71
methadone ............................ 35
METHADONE ..................... 35
methamphetamine ................ 44
methazolamide...................... 94
methenamine hippurate ........ 17
methimazole ......................... 69
METHITEST ........................ 73
methocarbamol ..................... 33
methotrexate sodium ............ 22
methotrexate sodium (PF) .... 22
METHOTREXATE SODIUM
(PF) ................................... 22
methoxsalen rapid ................. 59
methscopolamine .................. 75
methyclothiazide................... 52
methyldopa ........................... 52
methyldopahydrochlorothiazide .......... 52
methylergonovine ................. 91
METHYLIN ................... 44, 45
methylphenidate ................... 45
methylprednisolone .............. 69
methylprednisolone acetate .. 69
methylprednisolone sodium
succ ................................... 69
metipranolol .......................... 93
metoclopramide HCl ............ 77
metolazone ............................ 52
metoprolol succinate ............. 52
metoprolol ta-hydrochlorothiaz
.......................................... 53
metoprolol tartrate ................ 53
METROGEL ........................ 60
metronidazole ........... 12, 60, 89
metronidazole in NaCl (iso-os)
.......................................... 12
mexiletine ............................. 48
MIACALCIN ....................... 73
MICARDIS........................... 53
MICARDIS HCT.................. 53
Miconazole-3 ........................ 89
Microgestin 1.5/30 (21) ........ 90
Microgestin 1/20 (21) ........... 90
Microgestin Fe 1.5/30 (28) ... 90
Microgestin FE 1/20 (28) ..... 90
midodrine .............................. 66
MIGRANAL......................... 31
MILLIPRED ......................... 69
Mimvey Lo ........................... 88
MINITRAN .......................... 58
MINIVELLE ........................ 88
minocycline .......................... 17
minoxidil............................... 53
MIRAPEX ............................ 30
MIRAPEX ER ...................... 31
mirtazapine ........................... 45
misoprostol ........................... 79
mitomycin ............................. 22
mitoxantrone ......................... 22
M-M-R II (PF) ...................... 84
115
modafinil .............................. 45
Moderiba ................................ 6
Moderiba Dose Pack .............. 6
moexipril .............................. 53
moexipril-hydrochlorothiazide
.......................................... 53
mometasone.......................... 64
Mononessa (28) .................... 90
montelukast .......................... 99
MONUROL.......................... 17
morphine............................... 36
morphine concentrate ........... 36
MOVIPREP .......................... 77
MOXEZA ............................. 92
MULTAQ ............................. 48
mupirocin ............................. 61
mupirocin calcium ................ 61
MUSTARGEN ..................... 23
MYCAMINE.......................... 3
mycophenolate mofetil ......... 23
mycophenolate sodium ......... 23
MYFORTIC ......................... 23
MYOZYME ......................... 73
MYRBETRIQ .................... 101
N
nabumetone .......................... 39
nadolol .................................. 53
nadolol-bendroflumethiazide 53
nafcillin................................. 14
NAFCILLIN IN DEXTROSE
ISO-OSM ......................... 15
NAGLAZYME..................... 74
nalbuphine ............................ 39
naloxone ............................... 39
naltrexone ............................. 39
NAMENDA ......................... 32
NAMENDA XR ................... 33
naphazoline........................... 96
naproxen ............................... 39
naproxen sodium .................. 39
NARDIL ............................... 45
NASONEX ........................... 99
NATACYN .......................... 92
nateglinide ............................ 71
NEBUPENT ......................... 13
Necon 0.5/35 (28) ................. 90
Necon 1/35 (28) .................... 90
Necon 10/11 (28) .................. 90
Necon 7/7/7 (28)................... 90
nefazodone ........................... 45
116
neomycin .............................. 13
neomycin-bacitracin-poly-HC
.......................................... 94
neomycin-bacitracinpolymyxin ......................... 92
neomycin-polymyxin B GU . 65
neomycin-polymyxin Bdexameth .......................... 94
neomycin-polymyxingramicidin ......................... 92
neomycin-polymyxin-HC.... 68,
94
NEORAL .............................. 23
NEPHRAMINE 5.4 % ....... 105
NESINA ............................... 71
NEULASTA ......................... 81
NEUMEGA .......................... 81
NEUPOGEN ........................ 81
NEUPRO .............................. 31
NEURONTIN ....................... 28
NEVANAC .......................... 94
nevirapine ............................... 6
NEXAVAR .......................... 23
niacin .................................... 57
NIACOR ............................... 57
NIASPAN EXTENDEDRELEASE ........................ 57
nicardipine ............................ 53
NICOTROL .......................... 67
NICOTROL NS .................... 67
Nifedical XL ......................... 53
nifedipine .............................. 53
NILANDRON ...................... 23
nimodipine ............................ 53
nisoldipine ............................ 53
Nitro-Bid .............................. 58
nitrofurantoin ........................ 17
nitrofurantoin macrocrystal .. 17
nitrofurantoin monohyd/mcryst .................................. 17
nitroglycerin ......................... 58
NITROLINGUAL ................ 58
NITROSTAT ........................ 58
nizatidine .............................. 79
Non-Drowsy Allergy .......... 107
NORDITROPIN FLEXPRO 81
norethindrone (contraceptive)
.......................................... 88
norethindrone acetate ........... 88
norethindrone-e.estradiol-iron
.......................................... 90
NORITATE .......................... 60
NORMOSOL-R IN 5 %
DEXTROSE ................... 102
NORMOSOL-R PH 7.4...... 105
Nortrel 0.5/35 (28) ................ 90
Nortrel 1/35 (21) ................... 90
Nortrel 1/35 (28) ................... 90
Nortrel 7/7/7 (28) .................. 90
nortriptyline .......................... 45
NORVIR ................................. 6
NOVOLIN 70/30 .................. 71
NOVOLIN N ........................ 71
NOVOLIN R ........................ 71
NOVOLOG .......................... 72
NOVOLOG FLEXPEN ........ 72
NOVOLOG MIX 70-30 ....... 72
NOVOLOG MIX 70-30
FLEXPEN......................... 72
NOXAFIL............................... 3
NUEDEXTA ........................ 33
NULOJIX ............................. 23
NULYTELY WITH FLAVOR
PACKS ............................. 77
NUTROPIN AQ ................... 81
NUTROPIN AQ NUSPIN .... 82
NUVIGIL ............................. 45
Nyamyc................................. 62
nystatin ............................. 3, 62
nystatin-triamcinolone .......... 62
Nystop................................... 62
O
octreotide acetate .................. 23
ofloxacin ................... 16, 68, 92
Ogestrel (28) ......................... 90
olanzapine ............................. 45
olanzapine-fluoxetine ........... 45
olopatadine ........................... 68
OLYSIO ................................. 6
OMECLAMOX-PAK........... 15
omega-3 acid ethyl esters ..... 57
omeprazole ................... 79, 107
omeprazole magnesium ...... 107
OMNARIS ............................ 99
Omnitrope ............................. 82
OMNITROPE ....................... 82
ONCASPAR ......................... 23
ondansetron........................... 77
ondansetron HCl ................... 77
ondansetron HCl (PF)........... 77
ONFI..................................... 28
ONGLYZA........................... 72
ONMEL.................................. 3
OPANA ................................ 36
OPANA ER .................... 36, 37
ORACEA ............................. 17
ORAP ................................... 45
ORAPRED ODT .................. 69
orphenadrine citrate .............. 33
Orsythia ................................ 90
ORTHO TRI-CYCLEN LO
(28) ................................... 91
OSENI .................................. 72
OSMOPREP ......................... 78
OXACILLIN ........................ 15
OXACILLIN IN
DEXTROSE(ISO-OSM) .. 15
oxaliplatin ............................. 23
oxandrolone .......................... 74
oxaprozin .............................. 39
oxazepam.............................. 45
oxcarbazepine ....................... 28
OXSORALEN ...................... 59
OXSORALEN ULTRA ....... 59
OXTELLAR XR .................. 29
oxybutynin chloride............ 101
oxycodone ............................ 37
oxycodone-acetaminophen ... 37
oxycodone-aspirin ................ 37
oxymorphone........................ 37
P
Pacerone ............................... 48
PACERONE ......................... 48
paclitaxel .............................. 23
pamidronate .......................... 74
PAMIDRONATE ................. 74
PANCREAZE ...................... 78
PANRETIN .......................... 59
pantoprazole ......................... 79
paricalcitol ............................ 74
paromomycin ........................ 13
paroxetine HCl ..................... 45
PASER ................................. 13
PATADAY ........................... 93
PATANASE ......................... 68
PATANOL ........................... 93
PAXIL .................................. 45
PEDVAX HIB (PF) .............. 85
PEGANONE ........................ 29
PEGASYS ............................ 82
PEGASYS PROCLICK ....... 82
PEGINTRON ....................... 82
PEGINTRON REDIPEN ..... 82
PENICILLIN G POT IN
DEXTROSE ..................... 15
penicillin G potassium .......... 15
PENICILLIN G PROCAINE
.......................................... 15
PENICILLIN G SODIUM ... 15
penicillin V potassium .......... 15
PENTAM.............................. 13
PENTASA ............................ 78
pentazocine-naloxone ........... 39
pentoxifylline........................ 56
PEPCID ................................ 79
PERFOROMIST .................. 99
Periogard .............................. 68
PERJETA ............................. 23
permethrin ............................ 65
perphenazine ......................... 45
perphenazine-amitriptyline ... 46
PERTZYE ............................ 78
PEXEVA .............................. 46
Pfizerpen-G .......................... 15
Phenadoz ........................ 78, 97
phenelzine............................. 46
PHENERGAN ...................... 97
phenobarbital ........................ 29
PHENYTEK ......................... 29
phenytoin .............................. 29
PHENYTOIN SODIUM ...... 29
phenytoin sodium extended .. 29
PHOSPHOLINE IODIDE .... 93
pilocarpine HCl .............. 66, 93
Pimtrea (28) .......................... 91
pindolol................................. 53
pioglitazone .......................... 72
pioglitazone-glimepiride ...... 72
pioglitazone-metformin ........ 72
piperacillin-tazobactam ........ 15
Pirmella ................................ 91
piroxicam .............................. 39
PLASMA-LYTE 148 ......... 105
PLASMA-LYTE A ............ 105
PLASMA-LYTE-56 IN 5 %
DEXTROSE ................... 105
PLAVIX ............................... 56
podofilox .............................. 59
polyethylene glycol 3350 ..... 78
polymyxin B sulfate ............. 13
polymyxin B sulf-trimethoprim
.......................................... 92
POMALYST......................... 23
Portia..................................... 91
potassium chlorid-D50.45%NaCl ..................... 102
POTASSIUM CHLORID-D50.45%NACL ................... 102
potassium chloride .............. 102
POTASSIUM CHLORIDE 102
potassium chloride in
0.9%NaCl ....................... 102
POTASSIUM CHLORIDE IN
0.9%NACL ..................... 103
potassium chloride in 5 % dex
........................................ 103
POTASSIUM CHLORIDE IN
5 % DEX......................... 103
potassium chloride in LR-D5
........................................ 103
POTASSIUM CHLORIDE0.45 % NACL ................. 103
POTASSIUM CHLORIDED5-0.2%NACL ............... 103
potassium chloride-D50.3%NaCl ....................... 103
potassium chloride-D50.9%NaCl ....................... 103
potassium citrate ........... 66, 101
POTIGA ............................... 29
PRADAXA ........................... 56
pramipexole .......................... 31
PRANDIMET ....................... 72
PRANDIN ............................ 72
pravastatin............................. 57
prazosin................................. 53
PRED FORTE ...................... 95
PRED-G ................................ 94
PRED-G S.O.P. .................... 95
prednicarbate ........................ 64
prednisolone sodium phosphate
.................................... 69, 95
prednisone............................. 69
PREDNISONE INTENSOL . 69
PREMARIN .........................88
Premasol 10 % .................... 105
PREMASOL 6 % ............... 105
PREMPHASE....................... 88
Prenatal Vitamin ................... 96
117
Prevacid 24Hr ..................... 107
PREVACID SOLUTAB ...... 79
Prevalite ................................ 57
Previfem ............................... 91
PREVPAC ............................ 80
PREZISTA ............................. 6
Prilosec OTC ...................... 107
PRIMAQUINE ..................... 13
PRIMAXIN IV ..................... 13
primidone ............................. 29
PRIMSOL............................. 17
PRISTIQ ............................... 46
ProAir HFA .......................... 99
probenecid ............................ 86
procainamide ........................ 48
PROCALAMINE 3% ......... 105
prochlorperazine Edisylate ... 78
prochlorperazine maleate ..... 78
PROCRIT ............................. 82
Procto-Pak ............................ 64
Proctosol HC ........................ 78
Proctozone-HC ............. 64, 100
progesterone micronized ...... 88
PROGLYCEM ..................... 72
PROGRAF ........................... 23
PROLASTIN-C .................... 67
PROLEUKIN ....................... 82
PROMACTA........................ 56
promethazine ........................ 97
Promethegan ......................... 97
propafenone .......................... 48
propantheline ........................ 75
proparacaine ......................... 93
propranolol ........................... 53
propranolol-hydrochlorothiazid
.......................................... 53
propylthiouracil .................... 69
PROQUAD (PF) .................. 85
PROSOL 20 % ................... 105
PROTONIX .......................... 80
PROTOPIC........................... 59
protriptyline .......................... 46
PROVENTIL HFA ............... 99
PROVIGIL ........................... 46
PROZAC WEEKLY ............ 46
Prudoxin ............................... 59
PULMICORT ....................... 99
PULMICORT FLEXHALER
.......................................... 99
PULMOZYME..................... 99
118
PURIXAN ............................ 23
PYLERA .............................. 80
pyrazinamide ........................ 13
pyridostigmine bromide ....... 33
Q
QUALAQUIN ...................... 13
Quasense ............................... 91
QUDEXY XR....................... 29
quetiapine ............................. 46
quinapril................................ 53
quinapril-hydrochlorothiazide
.......................................... 54
quinidine gluconate .............. 48
QUINIDINE GLUCONATE 48
quinidine sulfate ................... 48
quinine sulfate ...................... 13
QVAR ................................... 99
R
RABAVERT (PF) ................ 85
rabeprazole ........................... 80
raloxifene .............................. 86
ramipril ................................. 54
RANEXA ............................. 58
ranitidine HCl ....................... 80
RAPAMUNE........................ 23
REBETOL .............................. 6
REBIF (WITH ALBUMIN) . 82
REBIF TITRATION PACK. 82
Reclipsen (28)....................... 91
RECOMBIVAX HB (PF) .... 85
RECTIV................................ 78
RELENZA DISKHALER ...... 6
RELISTOR ........................... 78
REMICADE ......................... 78
REMODULIN ...................... 54
RENAGEL ........................... 67
RENVELA ........................... 67
repaglinide ............................ 72
Reprexain.............................. 37
REPREXAIN........................ 37
RESCRIPTOR ........................ 6
reserpine ............................... 54
RESTASIS............................ 93
Restoril ................................. 46
RETROVIR ............................ 6
REVATIO ............................ 99
REVLIMID .......................... 24
REYATAZ ............................. 6
RHEUMATREX .................. 24
RibaPak Dose Pack ................ 6
Ribasphere .............................. 6
ribavirin .................................. 6
RIDAURA ............................ 87
rifabutin ................................ 13
rifampin ................................ 13
RIFATER ............................. 13
RILUTEK ............................. 67
riluzole .................................. 58
rimantadine ............................. 6
ringers ........................... 65, 103
RIOMET ............................... 72
risedronate ............................ 86
RISPERDAL CONSTA ....... 46
RISPERDAL M-TAB .......... 46
risperidone ............................ 46
RISPERIDONE .................... 46
RITUXAN ............................ 24
rivastigmine tartrate .............. 33
rizatriptan .............................. 32
ropinirole .............................. 31
ROTARIX ............................ 85
ROTATEQ VACCINE ......... 85
Roxicet .................................. 37
ROZEREM ........................... 46
S
SABRIL ................................ 29
SAIZEN ................................ 82
SAIZEN CLICK.EASY ....... 82
SANDIMMUNE................... 24
SANTYL .............................. 65
SAPHRIS (BLACK
CHERRY)......................... 46
SARAFEM ........................... 46
SEASONIQUE ..................... 91
selegiline HCl ....................... 31
selenium sulfide .................... 59
SELZENTRY ......................... 6
SENSIPAR ........................... 74
SEREVENT DISKUS .......... 99
SEROQUEL ......................... 46
SEROQUEL XR ................... 46
SEROSTIM .......................... 83
sertraline ............................... 47
sildenafil ............................... 99
silver sulfadiazine ................. 59
SIMULECT .......................... 24
simvastatin ............................ 57
SINGULAIR................. 99, 100
sirolimus ............................... 24
SKELAXIN .......................... 33
sodium chloride ............ 67, 103
sodium chloride 0.45 %...... 103
sodium chloride 0.9 %.......... 67
sodium chloride 3 %........... 103
sodium chloride 5 %........... 103
sodium lactate..................... 103
sodium phenylbutyrate ....... 101
sodium polystyrene (sorb free)
.......................................... 67
SOLARAZE ......................... 59
SOLTAMOX ........................ 24
SOLU-CORTEF (PF) ........... 69
SOLU-MEDROL ................. 69
Solu-Medrol (PF) ................. 69
SOLU-MEDROL (PF) ......... 69
SOMA .................................. 33
SOMATULINE DEPOT ...... 24
SOMAVERT ........................ 74
SORIATANE ....................... 59
Sorine ................................... 48
sotalol ................................... 48
Sotalol AF ............................ 48
SOVALDI .............................. 7
SPIRIVA RESPIMAT ....... 100
SPIRIVA WITH
HANDIHALER .............. 100
spironolactone ...................... 54
spironolacton-hydrochlorothiaz
.......................................... 54
SPORANOX .......................... 4
Sprintec (28) ......................... 91
SPRYCEL ............................ 24
Sronyx .................................. 91
SSD....................................... 59
STALEVO 100 ..................... 31
STALEVO 125 ..................... 31
STALEVO 150 ..................... 31
STALEVO 200 ..................... 31
STALEVO 50 ....................... 31
STALEVO 75 ....................... 31
stavudine................................. 7
STIMATE............................. 74
STIVARGA .......................... 24
STRATTERA ....................... 47
STREPTOMYCIN ............... 13
STRIBILD .............................. 7
STROMECTOL ................... 13
SUBOXONE ........................ 39
SUCRAID ............................ 78
sucralfate .............................. 80
SULAR ................................. 54
sulfacetamide sodium ........... 96
sulfacetamide sodium (acne) 61
sulfacetamide-prednisolone .. 95
sulfadiazine........................... 16
sulfamethoxazole-trimethoprim
.......................................... 16
SULFAMYLON ................... 61
sulfasalazine ......................... 78
Sulfazine EC ......................... 78
sulindac................................. 39
sumatriptan ........................... 32
sumatriptan succinate ........... 32
SUPRAX ................................ 9
Surmontil .............................. 47
SUSTIVA ............................... 7
SUTENT............................... 24
SYLATRON ......................... 83
SYLVANT ........................... 24
SYMBICORT ..................... 100
SYMBYAX .......................... 47
SYMLINPEN 120 ................ 72
SYMLINPEN 60 .................. 72
SYNAGIS ............................... 7
SYNAREL............................ 74
SYNERA .............................. 61
SYNERCID .......................... 13
SYNRIBO ............................ 24
SYNTHROID ....................... 75
SYPRINE ............................. 67
T
TABLOID ............................ 24
TACLONEX ........................ 59
tacrolimus ....................... 24, 59
TAFINLAR .......................... 24
TALWIN .............................. 39
TAMIFLU .............................. 7
tamoxifen .............................. 24
tamsulosin........................... 101
TARCEVA ........................... 24
TARGRETIN ....................... 24
TASIGNA ............................ 24
TASMAR ............................. 31
TAZORAC ........................... 60
Taztia XT.............................. 54
TEGRETOL XR ................... 29
TEKTURNA ........................ 54
TEKTURNA HCT ............... 54
telmisartan ............................ 54
telmisartan-amlodipine ......... 54
temazepam ............................ 47
terazosin ................................ 54
terbinafine HCl ....................... 4
terbutaline ........................... 100
terconazole ............................ 89
TESTIM ................................ 74
testosterone ........................... 74
testosterone cypionate .......... 74
testosterone enanthate ........... 74
TESTRED............................. 74
TETANUS
TOXOID,ADSORBED (PF)
.......................................... 85
TETANUS,DIPHTHERIA
TOX PED(PF) .................. 85
TETANUS-DIPHTHERIA
TOXOIDS-TD .................. 85
tetracycline ........................... 17
THALOMID ......................... 25
theophylline ........................ 100
thioridazine ........................... 47
thiothixene ............................ 47
THYMOGLOBULIN ........... 85
tiagabine ............................... 29
ticlopidine ............................. 56
TIKOSYN............................. 48
timolol maleate ............... 54, 93
tinidazole .............................. 13
TIVICAY ................................ 7
tizanidine .............................. 34
TOBI ..................................... 13
TOBRADEX ........................ 95
tobramycin ............................ 92
tobramycin in 0.225 % NaCl 13
TOBRAMYCIN IN 0.9 %
NACL ............................... 13
tobramycin sulfate ................ 13
tobramycin-dexamethasone .. 95
TOBREX .............................. 92
TOFRANIL-PM ................... 47
tolazamide............................. 72
tolbutamide ........................... 72
tolmetin ................................. 39
tolterodine ........................... 101
TOPAMAX .......................... 29
topiramate ............................. 29
topotecan............................... 25
TORISEL .............................. 25
torsemide .............................. 54
TORSEMIDE ....................... 54
119
TRACLEER ....................... 100
TRADJENTA ....................... 72
tramadol ................................ 39
tramadol-acetaminophen ...... 39
trandolapril ........................... 54
tranexamic acid .................... 56
TRANSDERM-SCOP .......... 75
tranylcypromine ................... 47
Travasol 10 %..................... 106
TRAVATAN Z .................... 94
travoprost (benzalkonium) ... 94
trazodone .............................. 47
TREANDA ........................... 25
TRECATOR ......................... 13
TRELSTAR .......................... 25
tretinoin ................................ 60
tretinoin (chemotherapy) ...... 25
tretinoin microspheres .......... 61
TREXALL............................ 25
triamcinolone acetonide 64, 68,
69, 100
triamterene-hydrochlorothiazid
.......................................... 54
triazolam ............................... 47
Triderm ................................. 65
trifluoperazine ...................... 47
trifluridine............................. 92
trihexyphenidyl..................... 31
Tri-Legest Fe ........................ 91
TRILEPTAL................... 29, 30
TriLyte With Flavor Packets 78
trimethoprim ......................... 17
TriNessa (28) ........................ 91
Tri-Previfem (28) ................. 91
TRISENOX .......................... 25
Tri-Sprintec (28) ................... 91
TRIUMEQ .............................. 7
Trivora (28) .......................... 91
TRIZIVIR ............................... 7
TROKENDI XR ................... 30
TROPHAMINE 10 % ........ 106
TROPHAMINE 6% ........... 106
trospium.............................. 101
TRUVADA ............................ 7
TWINRIX (PF) .................... 85
TYGACIL ............................ 13
TYKERB .............................. 25
TYPHIM VI ......................... 85
TYSABRI ............................. 33
TYZEKA ................................ 7
120
TYZINE................................ 68
U
U-CORT ............................... 59
ULORIC ............................... 86
ULTRESA ............................ 78
UROXATRAL ................... 101
URSO 250 ............................ 78
URSO FORTE ...................... 78
ursodiol ................................. 78
UVADEX ............................. 59
V
valacyclovir ............................ 7
VALCHLOR ........................ 60
VALCYTE ............................. 7
valganciclovir ......................... 7
valproate sodium .................. 30
valproic acid ......................... 30
valproic acid (as sodium salt)
.......................................... 30
valsartan................................ 54
valsartan-hydrochlorothiazide
.......................................... 54
VALTREX ............................. 7
VANCOCIN ......................... 17
vancomycin .......................... 17
VANCOMYCIN .................. 17
Vandazole ............................. 89
VAQTA (PF) ........................ 85
VARIVAX (PF) ................... 85
VECTIBIX ........................... 25
VELCADE ........................... 25
Velivet Triphasic Regimen
(28) ................................... 91
venlafaxine ........................... 47
VENLAFAXINE .................. 47
VENTOLIN HFA ............... 100
verapamil ........................ 54, 55
VEREGEN ........................... 60
VERIPRED 20 ..................... 69
Versacloz .............................. 47
VESICARE ........................ 101
Vestura (28) .......................... 91
VEXOL ................................ 95
VFEND ................................... 4
VFEND IV ............................. 4
VIBRAMYCIN .................... 17
VICTOZA 3-PAK ................ 72
VIDAZA ............................... 25
VIDEX 2 GRAM PEDIATRIC
............................................ 7
VIDEX EC.............................. 7
VIGAMOX ........................... 92
VIIBRYD ............................. 47
VIMPAT ............................... 30
vinblastine............................. 25
Vincasar PFS ........................ 25
vincristine ............................. 25
vinorelbine ............................ 25
VIOKACE ............................ 79
VIRACEPT............................. 7
VIRAMUNE........................... 7
VIRAMUNE XR .................... 7
VIREAD ................................. 7
VIROPTIC ............................ 92
VISTIDE................................. 8
VIVELLE-DOT .................... 88
VIVITROL ........................... 39
VOLTAREN......................... 39
voriconazole ........................... 4
VOTRIENT .......................... 25
VYTORIN 10-10 .................. 58
VYTORIN 10-20 .................. 58
VYTORIN 10-40 .................. 58
VYTORIN 10-80 .................. 58
VYVANSE ........................... 47
W
Wal-itin ............................... 107
Wal-Zyr (cetirizine) ............ 107
warfarin................................. 56
water for irrigation, sterile .... 67
WELCHOL........................... 58
X
XALATAN ........................... 94
XALKORI ............................ 25
XARELTO ........................... 56
XENAZINE .......................... 33
XGEVA ................................ 18
XIFAXAN ............................ 14
XOLAIR ............................. 100
XOPENEX ......................... 100
XOPENEX HFA ................ 100
XTANDI ............................... 25
XYREM ................................ 47
XYZAL................................. 97
Y
YERVOY ............................. 25
YF-VAX (PF) ....................... 86
Z
zafirlukast ........................... 100
zaleplon................................. 47
ZALTRAP ............................ 25
ZANAFLEX ......................... 34
ZANOSAR ........................... 25
ZAVESCA ........................... 74
ZELAPAR ............................ 31
ZELBORAF ......................... 26
ZEMAIRA ............................ 67
ZEMPLAR ........................... 74
ZenChent (28) ...................... 91
ZENPEP ............................... 79
ZERIT..................................... 8
ZETIA .................................. 58
ZIAGEN ................................. 8
zidovudine .............................. 8
ZINACEF ............................. 10
ZINECARD (AS HCL) ........ 18
ziprasidone HCl .................... 47
ZIRGAN ............................... 92
ZMAX .................................. 10
zoledronic acid ..................... 74
ZOLINZA ............................. 26
zolmitriptan .......................... 32
zolpidem ......................... 47, 48
ZOMETA ............................. 74
zonisamide ............................ 30
ZORBTIVE .......................... 83
ZORTRESS .......................... 26
ZOSTAVAX (PF) ................ 86
ZOSYN ................................. 15
ZOSYN IN DEXTROSE (ISOOSM) ................................ 15
Zovia 1/35E (28)................... 91
Zovia 1/50E (28)................... 91
ZOVIRAX ............................ 62
ZYBAN ................................ 67
ZYDELIG ............................. 26
ZYFLO ............................... 100
ZYFLO CR ......................... 100
ZYKADIA ............................ 26
ZYLET ................................. 95
ZYPREXA ............................ 48
ZYPREXA ZYDIS ............... 48
ZYTIGA ............................... 26
ZYVOX ................................ 14
121
This formulary was updated on March 1, 2015. For more recent information or other questions, please
contact AlohaCare Advantage Plus (HMO SNP) Member Services at 1-866-973-6395, or, for TTY/TDD
users, 1-877-447-5990, 8 a.m. to 8 p.m., 7 days a week, or visit www.AlohaCare.org.
AlohaCare • 1357 Kapiolani Blvd, Suite 1250, Honolulu, HI 96814 • www.AlohaCare.org

2015 formulary

Transcription

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