1. Healthcare

Formulario Valor de 2015
(Lista de Medicamentos Cubiertos)
LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE ALGUNOS DE LOS
MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
Health Net Healthy Heart (HMO) en los Condados de Alameda, Los Angeles, Orange, Placer,
Riverside, Sacramento, San Bernardino, San Diego, San Francisco, Stanislaus y Yolo,
Health Net Jade (HMO SNP) en Arizona, Health Net Jade Cardiovascular (HMO SNP),
Health Net Ruby (HMO), Health Net Ruby 1 (HMO), Health Net Ruby 4 (HMO),
Health Net Ruby Select (HMO), Health Net Seniority Plus Ruby (HMO), Health Net Violet (PPO),
Health Net Violet Option 1 (PPO), Health Net Violet Option 2 (PPO) y Health Net Violet Option 3 (PPO)
Identiἀcación de Presentación del Archivo del Formulario Aprobado por HPMS 15441, Versión Número 12
Este formulario se actualizó el 1 de febrero de 2015. Si desea obtener información más reciente o si tiene
otras preguntas, comuníquese con Health Net al:
Planes de Arizona: 1-800-977-7522
Planes HMO de California: 1-800-275-4737
Planes HMO SNP de California: 1-800-431-9007
Planes PPO de California: 1-800-960-4638
Planes de Oregon/Washington: 1-888-445-8913
o para los usuarios de TTY: 711, de 8:00 a.m. a 8:00 p.m., los siete días de la semana
(algunos ἀnes de semana y días feriados se utiliza el servicio telefónico automático), o bien, visite
www.healthnet.com/medicare.
CA118621-1
N.º de Identificación del Material Y0035_2015_0011_SPN
(H0351, H0562, H5439, H5520, H6815, EG)
Aceptado por los CMS 07202014
Nota para los afiliados existentes: Se han registrado cambios en
este formulario desde el año pasado. Revise este documento para
asegurarse de que aún incluya los medicamentos que usted toma.
Cuando esta lista de medicamentos (formulario) dice “nosotros”
o “nuestro/a”, se refiere a Health Net. Cuando dice “plan” o
“nuestro plan”, se refiere a Health Net Healthy Heart (HMO) en los
Condados de Alameda, Los Angeles, Orange, Placer, Riverside,
Sacramento, San Bernardino, San Diego, San Francisco, Stanislaus
y Yolo, Health Net Jade (HMO SNP) en Arizona, Health Net Jade
Cardiovascular (HMO SNP), Health Net Ruby (HMO), Health Net
Ruby 1 (HMO), Health Net Ruby 4 (HMO), Health Net Ruby Select
(HMO), Health Net Seniority Plus Ruby (HMO), Health Net Violet
(PPO), Health Net Violet Option 1 (PPO), Health Net Violet
Option 2 (PPO) y Health Net Violet Option 3 (PPO).
Este documento incluye una lista de los medicamentos (formulario)
correspondientes a nuestro plan, que entra en vigencia a partir de
la fecha que figura en la portada y la contraportada. Para obtener
un formulario actualizado, comuníquese con nosotros. Nuestra
información de contacto, junto con la fecha en que actualizamos el
formulario por última vez, aparece en la portada y la contraportada.
Generalmente, usted debe usar las farmacias de la red para
acceder a su beneficio de medicamentos que requieren receta
médica. Los beneficios, el formulario, la red de farmacias y/o los
co-pagos/el coseguro pueden cambiar a partir del 1 de enero
de 2016 y ocasionalmente durante el año.
i
¿Qué es el Formulario Valor de
Health Net Healthy Heart (HMO)
en los Condados de Alameda,
Los Angeles, Orange, Placer,
Riverside, Sacramento,
San Bernardino, San Diego,
San Francisco, Stanislaus y Yolo,
Health Net Jade (HMO SNP)
en Arizona, Health Net Jade
Cardiovascular (HMO SNP),
Health Net Ruby (HMO),
Health Net Ruby 1 (HMO),
Health Net Ruby 4 (HMO),
Health Net Ruby Select (HMO),
Health Net Seniority Plus Ruby
(HMO), Health Net Violet (PPO),
Health Net Violet Option 1 (PPO),
Health Net Violet Option 2 (PPO)
y Health Net Violet Option 3
(PPO)?
Un formulario es una lista de
medicamentos cubiertos seleccionados
por nuestro plan en consulta con un
equipo de proveedores de cuidado de
la salud, que incluye las terapias con
medicamentos que requieren receta
médica consideradas como una parte
necesaria de un programa de tratamiento
de calidad. Generalmente, cubriremos los
medicamentos enumerados en nuestro
formulario, siempre que el medicamento
sea médicamente necesario, que la
receta se surta en una farmacia de la red
de Health Net y que se cumpla con las
demás reglas del plan. Para obtener más
información sobre cómo surtir sus recetas,
revise su Evidencia de Cobertura.
ii
¿Puede cambiar el Formulario
(lista de medicamentos)?
Por lo general, si usted está tomando un
medicamento de nuestro formulario de
2015 que estaba cubierto al comienzo del
año, no interrumpiremos ni reduciremos
la cobertura de dicho medicamento
durante el año de cobertura 2015, excepto
cuando se encuentre disponible un nuevo
medicamento genérico menos costoso o
cuando se divulgue nueva información
adversa sobre la seguridad o la eficacia
de un medicamento. Otros tipos de
cambios en nuestro formulario, como
la eliminación de un medicamento, no
afectarán a los afiliados que actualmente
estén tomando el medicamento. Durante
el resto del año de cobertura, seguirá
estando disponible al mismo costo
compartido para aquellos afiliados
que lo estén tomando. Creemos que es
importante que usted tenga un acceso
continuo durante el resto del año de
cobertura a los medicamentos del
formulario que estaban disponibles
cuando eligió nuestro plan, excepto en
los casos en que pueda ahorrar dinero
adicional o cuando podamos garantizar
su seguridad.
Si eliminamos medicamentos de nuestro
formulario, si agregamos requisitos de
autorización previa, límites de cantidad
y/o restricciones de terapia escalonada
a un medicamento, o si pasamos un
medicamento a un nivel de costos
compartidos más alto, debemos notificar
el cambio a los afiliados afectados al
menos 60 días antes de que dicho cambio
entre en vigencia, o bien, cuando el
afiliado solicite que le vuelvan a surtir el
medicamento, en cuyo caso el afiliado
recibirá un suministro de 60 días del
medicamento. Si la Administración
de Alimentos y Medicamentos de los
Estados Unidos (por sus siglas en inglés,
FDA) considera que un medicamento
de nuestro formulario no es seguro o si
el fabricante del medicamento lo retira
del mercado, nosotros eliminaremos de
inmediato dicho medicamento de nuestro
formulario y enviaremos un aviso a los
afiliados que lo toman. El formulario
adjunto entra en vigencia a partir de
la fecha que figura en la portada y la
contraportada. Para obtener información
actualizada sobre los medicamentos que
cubrimos, comuníquese con nosotros.
Nuestra información de contacto aparece
en la portada y la contraportada.
Si realizamos algún otro cambio negativo
en el formulario durante el año, se lo
notificaremos por correo, y los cambios se
publicarán en nuestro sitio Web.
¿Cómo utilizo el formulario?
Hay dos maneras de buscar su
medicamento en el formulario:
Condición Médica
El formulario comienza en la página 1.
Los medicamentos de este formulario
se agrupan en categorías según el
tipo de condición médica que traten.
Por ejemplo, los medicamentos
utilizados para tratar una condición
cardíaca se enumeran bajo la categoría
“AGENTES CARDIOVASCULARES DISPOSICIONES VARIAS”. Si sabe para
qué se utiliza su medicamento, busque
el nombre de la categoría en la lista que
comienza en la página 1. Luego busque
su medicamento bajo el nombre de la
categoría.
Lista Alfabética
Si no está seguro de la categoría bajo la
que se enumera su medicamento, debe
buscarlo en el Índice que comienza
en la página 1 del Índice. El Índice
proporciona una lista alfabética de todos
los medicamentos incluidos en este
documento. Tanto los medicamentos de
marca como los medicamentos genéricos
están enumerados en el Índice. Busque allí
y encontrará su medicamento. Junto a su
medicamento, verá el número de página
en la que puede encontrar la información
sobre la cobertura. Consulte la página que
aparece en el Índice y busque el nombre de
su medicamento en la primera columna de
la lista.
¿Qué son los medicamentos
genéricos?
Nuestro plan cubre tanto los
medicamentos de marca como
los medicamentos genéricos. Un
medicamento genérico es aprobado
por la FDA por contener los mismos
ingredientes activos que el medicamento
de marca. Por lo general, los
medicamentos genéricos cuestan menos
que los de marca.
¿Hay alguna restricción en mi
cobertura?
Algunos medicamentos cubiertos pueden
tener requisitos o límites adicionales en
la cobertura. Estos requisitos y límites
pueden incluir:
•Autorización Previa: Nuestro plan
les exige a usted o a su médico que
obtengan una autorización previa para
ciertos medicamentos. Esto significa que
deberá solicitar la aprobación de parte
nuestra antes de surtir sus recetas. Si no
obtiene la aprobación, es posible que no
cubramos el medicamento.
•Límites de Cantidad: Para ciertos
medicamentos, nuestro plan limita
la cantidad del medicamento que
cubriremos. Por ejemplo, nuestro plan
establece un máximo de dos tabletas por
día por receta de simvastatina 40 mg.
Esto puede sumarse a un suministro
estándar de un mes o de tres meses.
•Terapia Escalonada: En algunos casos,
nuestro plan exige que usted pruebe
primero determinados medicamentos
para tratar su condición médica
antes de cubrir otro medicamento
para esa condición. Por ejemplo, si
tanto el Medicamento A como el
Medicamento B tratan su condición
médica, posiblemente no cubramos el
Medicamento B, a menos que usted
pruebe primero el Medicamento A.
Si el Medicamento A no es eficaz
para su caso, entonces cubriremos el
Medicamento B.
iii
Para averiguar si su medicamento tiene
requisitos o límites adicionales, puede
consultar el formulario que comienza
en la página 1. También puede obtener
más información sobre las restricciones
que se aplican a medicamentos cubiertos
específicos visitando nuestro sitio Web.
Hemos publicado documentos en
línea que explican nuestros requisitos
de autorización previa y nuestras
restricciones de terapia escalonada.
Además, usted puede pedirnos que le
enviemos una copia. Nuestra información
de contacto, junto con la fecha en que
actualizamos el formulario por última vez,
aparece en la portada y la contraportada.
Puede solicitarnos que hagamos una
excepción a estas restricciones o límites,
o que le proporcionemos una lista de
otros medicamentos similares que puedan
tratar su condición de salud. Consulte la
sección “¿Cómo solicito una excepción
al Formulario Valor de Health Net
Healthy Heart (HMO) en los Condados
de Alameda, Los Angeles, Orange, Placer,
Riverside, Sacramento, San Bernardino,
San Diego, San Francisco, Stanislaus y Yolo,
Health Net Jade (HMO SNP) en Arizona,
Health Net Jade Cardiovascular
(HMO SNP), Health Net Ruby (HMO),
Health Net Ruby 1 (HMO), Health Net
Ruby 4 (HMO), Health Net Ruby Select
(HMO), Health Net Seniority Plus Ruby
(HMO), Health Net Violet (PPO),
Health Net Violet Option 1 (PPO),
Health Net Violet Option 2 (PPO) y
Health Net Violet Option 3 (PPO)?”,
que aparece en la página iv, para obtener
información sobre cómo solicitar una
excepción.
iv
¿Qué sucede si mi medicamento no
está en el formulario?
Si su medicamento no está incluido en
este formulario (lista de medicamentos
cubiertos), usted debe comunicarse
primero con el Departamento de Servicios
al Afiliado y preguntar si su medicamento
está cubierto.
Si se entera de que nuestro plan no cubre
su medicamento, tiene dos opciones
•Puede solicitar al Departamento
de Servicios al Afiliado una lista de
medicamentos similares que cubramos.
Cuando reciba la lista, muéstresela a
su médico y solicítele que le recete un
medicamento similar que esté cubierto
por nuestro plan.
•Puede solicitarnos que hagamos una
excepción y cubramos su medicamento.
Consulte la sección a continuación
para obtener información sobre cómo
solicitar una excepción.
¿Cómo solicito una excepción al
Formulario Valor de
Health Net Healthy Heart (HMO)
en los Condados de Alameda,
Los Angeles, Orange, Placer,
Riverside, Sacramento, San
Bernardino, San Diego, San
Francisco, Stanislaus y Yolo,
Health Net Jade (HMO SNP)
en Arizona, Health Net Jade
Cardiovascular (HMO SNP),
Health Net Ruby (HMO),
Health Net Ruby 1 (HMO),
Health Net Ruby 4 (HMO),
Health Net Ruby Select (HMO),
Health Net Seniority Plus Ruby
(HMO), Health Net Violet (PPO),
Health Net Violet Option 1 (PPO),
Health Net Violet Option 2 (PPO)
y Health Net Violet Option 3
(PPO)?
Usted puede solicitarnos que hagamos una
excepción a nuestras reglas de cobertura.
Existen varios tipos de excepciones que
usted puede solicitar.
•Puede pedirnos que cubramos un
medicamento aunque éste no se
encuentre en nuestro formulario.
Si se aprueba, este medicamento
estará cubierto a un nivel de costos
compartidos predeterminado, y
usted no podría solicitarnos que se lo
proporcionemos a un nivel de costos
compartido más bajo.
•Puede solicitarnos que cubramos un
medicamento del formulario a un nivel
de costos compartidos más bajo. Si se
aprueba, esto reduciría la cantidad que
usted debe pagar por su medicamento.
•Puede pedirnos que anulemos las
restricciones o límites de cobertura con
respecto a su medicamento. Por ejemplo,
para determinados medicamentos,
nuestro plan limita la cantidad del
medicamento que cubriremos. Si
su medicamento tiene un límite de
cantidad, usted puede solicitarnos que
anulemos dicho límite y cubramos una
cantidad mayor.
Generalmente, sólo aprobaremos
su solicitud de excepción si los
medicamentos alternativos incluidos en
el formulario del plan, el medicamento
de costos compartidos más bajos o las
restricciones de utilización adicionales no
fuesen tan eficaces en el tratamiento de
su condición y/o le ocasionaran efectos
médicos adversos.
Debe comunicarse con nosotros para
solicitarnos una decisión de cobertura
inicial para una excepción al formulario, al
nivel o a las restricciones de utilización. Si
solicita una excepción al formulario, al
nivel o a las restricciones de utilización,
debe enviar una declaración de parte de
su médico o profesional que receta para
respaldar su solicitud. Generalmente,
debemos tomar nuestra decisión dentro
de las 72 horas de haber recibido la
declaración de respaldo del profesional
que receta. Puede solicitar una excepción
acelerada (rápida) si usted o su médico
consideran que su salud podría verse
gravemente perjudicada al esperar las
72 horas para obtener una decisión. Si se
otorga su solicitud de excepción acelerada,
debemos informarle de la decisión en un
lapso de 24 horas como máximo después
de haber recibido una declaración de
respaldo de su médico u otro profesional
que receta.
¿Qué debo hacer antes de poder
hablar con mi médico sobre cómo
cambiar mis medicamentos o
solicitar una excepción?
Como afiliado nuevo o que continúa con
la cobertura de nuestro plan, es posible
que esté tomando medicamentos que no
se encuentran en nuestro formulario. O
quizás esté tomando un medicamento
que se encuentra en nuestro formulario,
pero sus posibilidades de obtenerlo son
limitadas. Por ejemplo, tal vez necesite
que le proporcionemos una autorización
previa antes de que pueda surtir su
receta. Le recomendamos que hable con
su médico para decidir si debe cambiar
el medicamento por uno adecuado que
cubramos o si debe solicitar una excepción
al formulario para que le cubramos el
medicamento que toma. Mientras habla
con su médico para determinar la forma
de proceder correcta para usted, en ciertos
casos, podemos cubrir su medicamento
durante los primeros 90 días de haberse
afiliado a nuestro plan.
Por cada uno de sus medicamentos que
no se encuentra en nuestro formulario
o si sus posibilidades de obtener sus
medicamentos son limitadas, cubriremos
un suministro temporal para 30 días (a
menos que tenga una receta hecha para
menos días) cuando vaya a una farmacia
de la red.
v
Después de obtener su primer suministro
para 30 días, no pagaremos por estos
medicamentos, aunque haya estado
afiliado al plan por menos de 90 días.
Si es residente de un centro de atención
a largo plazo, le permitiremos volver a
surtir su receta hasta que le hayamos
proporcionado un suministro de
transición para 102 días, de acuerdo con
el incremento de despacho (a menos
que tenga una receta hecha para menos
días). Cubriremos más de un resurtido
de estos medicamentos para los primeros
90 días de haberse afiliado a nuestro
plan. Si necesita un medicamento que
no se encuentra en nuestro formulario
o si sus posibilidades de obtener sus
medicamentos son limitadas, pero ya
transcurrieron los primeros 90 días de
su afiliación a nuestro plan, cubriremos
un suministro de emergencia de ese
medicamento para 34 días (a menos
que tenga una receta para menos días)
mientras solicita una excepción al
formulario.
Cambios en el nivel de atención
Si experimenta un cambio en su nivel
de atención, cubriremos un suministro
de transición de sus medicamentos. Un
cambio en el nivel de atención ocurre
cuando se le da de alta de un hospital o
se le traslada desde o hacia un centro de
atención a largo plazo.
•Si se traslada de un centro de atención
a largo plazo u hospital a su hogar y
necesita un suministro de transición,
cubriremos un suministro de 30 días.
Si su receta está hecha para menos
días, permitiremos que se surtan varias
recetas hasta alcanzar el total de un
suministro de 30 días.
vi
•Si se traslada de su hogar o de un
hospital a un centro de atención a
largo plazo y necesita un suministro de
transición, cubriremos un suministro
de 34 días. Si su receta está hecha para
menos días, permitiremos que se surtan
varias recetas hasta alcanzar el total de
un suministro de 34 días.
Entendemos que hay otras circunstancias
en las que se puede otorgar un
suministro adicional. Estas situaciones
se manejan según cada caso mediante
la comunicación entre la farmacia que
despacha el medicamento y Health Net.
Para obtener más información
Para obtener información más detallada
sobre la cobertura de medicamentos
que requieren receta médica de su plan,
revise su Evidencia de Cobertura y demás
materiales del plan.
Si tiene preguntas sobre nuestro plan,
comuníquese con nosotros. Nuestra
información de contacto, junto con la
fecha en que actualizamos el formulario
por última vez, aparece en la portada y la
contraportada.
Si tiene preguntas generales acerca de la
cobertura de medicamentos que requieren
receta médica de Medicare, llame a
Medicare al 1-800-MEDICARE
(1-800-633-4227), las 24 horas del día, los
7 días de la semana. Los usuarios de TTY
deben llamar al 1-877-486-2048. O bien,
visite http://www.medicare.gov.
Formulario Valor de
Health Net Healthy Heart (HMO)
en los Condados de Alameda,
Los Angeles, Orange, Placer,
Riverside, Sacramento,
San Bernardino, San Diego,
San Francisco, Stanislaus y Yolo,
Health Net Jade (HMO SNP)
en Arizona, Health Net Jade
Cardiovascular (HMO SNP),
Health Net Ruby (HMO),
Health Net Ruby 1 (HMO),
Health Net Ruby 4 (HMO),
Health Net Ruby Select (HMO),
Health Net Seniority Plus Ruby
(HMO), Health Net Violet (PPO),
Health Net Violet Option 1 (PPO),
Health Net Violet Option 2 (PPO)
y Health Net Violet Option 3
(PPO)
El formulario que comienza en la página
1 brinda información de cobertura sobre
los medicamentos cubiertos por nuestro
plan. Si tiene dificultades para encontrar
su medicamento en la lista, vaya al Índice
que comienza en la página 1 del Índice.
La primera columna del cuadro menciona
el nombre del medicamento. Los
medicamentos de marca aparecen en letra
mayúscula (por ejemplo, LIPITOR) y los
medicamentos genéricos se enumeran
en letra minúscula cursiva (por ejemplo,
atorvastatina calcio).
La información de la columna Requisitos/
Límites le indica si nuestro plan tiene
algún requisito especial para la cobertura
de su medicamento.
vii
Descripciones de los niveles del formulario
Para determinar cuánto paga usted por un medicamento, consulte las siguientes
abreviaturas, que aparecen en la columna Nivel de Medicamentos del formulario. El nivel
de co-pago o coseguro se muestra en la columna Co-pago/Coseguro. Para conocer su
co-pago o coseguro correspondiente a cada nivel, consulte su Evidencia de Cobertura.
Abreviatura
Co-pago/Coseguro
Descripción
1
Co-pago del Nivel 1
Medicamentos genéricos
preferidos. Estos medicamentos
no son elegibles para excepciones
de pago en un nivel inferior.
2
Co-pago del Nivel 2
Medicamentos genéricos no
preferidos.
3
Co-pago del Nivel 3
Medicamentos de marca
preferidos y puede incluir algunos
medicamentos genéricos no
preferidos. Los medicamentos
de marca de este nivel no son
elegibles para excepciones de
pago en un nivel inferior.
4
Co-pago del Nivel 4
Medicamentos de marca no
preferidos y puede incluir algunos
medicamentos genéricos no
preferidos.
Co-pago o coseguro del
Nivel 5
Medicamentos de costo elevado.
Estos medicamentos no son
elegibles para excepciones de
pago en un nivel inferior.
$0 de co-pago
Algunos medicamentos genéricos
y de marca utilizados para tratar
condiciones crónicas específicas.
Fuera del formulario: Si
se aprueba una solicitud
de excepción para un
medicamento que está
fuera del formulario, se
aplica el co-pago del nivel
de Medicamentos de marca
no preferidos (Nivel 4).
No podrá solicitarnos
que proporcionemos el
medicamento a un nivel de
costos compartidos
más bajo.
Medicamentos que no están
cubiertos en el formulario de
Medicare Parte D de Health Net.
Puede solicitar una excepción
a Health Net para que cubra
estos medicamentos. Consulte
la sección “¿Cómo solicito una
excepción al Formulario Valor de
Health Net Medicare Parte D?”
5
(Medicamentos de
especialidades)
6
(Select Care)
NF
viii
Abreviaturas
Las siguientes abreviaturas pueden aparecer en la columna Requisito/Límites del
formulario.
Abreviatura
Definición
Descripción
AL
Límite de Edad
Es posible que algunos medicamentos requieran
una autorización previa si su edad no está dentro
de las recomendaciones clínicas, del fabricante o
de la FDA.
B/D
Medicare Parte B
frente a Medicare
Parte D
Algunos medicamentos requieren autorización
previa para determinar la cobertura conforme
al beneficio de Medicare Parte B o Parte D, de
acuerdo con las pautas de Medicare. Es posible
que su médico u otro profesional que receta
deban proporcionar información adicional
para ayudarnos a tomar la determinación de
cobertura.
GL
Límite de Género
Algunos medicamentos sólo están cubiertos para
hombres o mujeres según las recomendaciones
clínicas, del fabricante o de la FDA.
LA
Acceso Limitado
Algunos medicamentos pueden estar sujetos a
un acceso limitado o restringido. Esto significa
que un medicamento sólo puede estar disponible
en una farmacia o en una cantidad limitada de
farmacias. El acceso limitado puede deberse a los
siguientes motivos:
• L a FDA ha restringido la distribución de
un medicamento a determinados centros,
farmacias o profesionales que recetan; o bien,
•D
eterminados medicamentos requieren un
manejo especial, una coordinación de la
atención o una educación del paciente que
no pueden proporcionarse en una farmacia de
venta minorista; o bien,
Usted debe hablar con su médico u otro
profesional que receta, o con su farmacéutico
para solicitar detalles sobre cómo obtener
medicamentos de acceso limitado.
MO
Compra por
Correo
Este medicamento está disponible en una
farmacia de compra por correo de Health Net, así
como en otras farmacias de la red.
PA
Autorización
Previa
Health Net les exige a usted o a su médico que
obtengan una autorización previa para ciertos
medicamentos. Esto significa que deberá solicitar
la aprobación de parte nuestra antes de surtir sus
recetas. Si no obtiene la aprobación, es posible
que no cubramos el medicamento.
ix
Abreviatura
QL
RX/OTC
ST
Definición
Descripción
Límite de
Cantidad
Para ciertos medicamentos, Health Net limita
la cantidad del medicamento que cubriremos.
Por ejemplo, Health Net cubre un máximo de
dos tabletas por día por receta de simvastatina
40 mg. Esto puede sumarse a los límites de un
suministro estándar de un mes o de tres meses.
Medicamentos
que Requieren
Receta Médica y
de Venta Libre
Ciertos medicamentos se encuentran disponibles
tanto en forma de medicamento que requiere
receta médica como en forma de venta libre.
Salvo algunos tipos de insulinas y suministros
para insulina, los planes Health Net Medicare
Parte D sólo cubren los medicamentos que
requieren receta médica.
Terapia
Escalonada
En algunos casos, Health Net requiere que usted
pruebe primero determinados medicamentos
para tratar su condición médica antes de cubrir
otro medicamento para esa condición.
Por ejemplo, si tanto el Medicamento A como
el Medicamento B tratan su condición médica,
posiblemente no cubramos el Medicamento B,
a menos que usted pruebe primero el
Medicamento A. Si el Medicamento A no es
eficaz para su caso, entonces cubriremos el
Medicamento B.
*
x
Cobertura
Adicional en la
Brecha
Para planes Health Net Healthy Heart (HMO)
en los condados de Los Angeles, Orange,
Riverside y San Bernardino y el plan Health Net
Seniority Plus Ruby (HMO) en el Condado de
San Diego únicamente:
Proporcionamos cobertura adicional de este
medicamento que requiere receta médica en la
brecha de cobertura. Si desea más información
sobre esta cobertura, consulte su Evidencia de
Cobertura.
Drug Name
Drug Requirements/
Tier Limits
ADHD/ANTI-NARCOLEPSY/ANTIOBESITY/ANOREXIANTS - Drugs to Treat
ADHD, Sleep and Eating Disorders
Amphetamines
ADDERALL (Use
AmphetamineDextroamphetamine
ADDERALL XR (Use
AmphetamineDextroamphetamine
amphetaminedextroamphetamine cp24
1.25mg-1.25mg-1.25mg1.25mg, 2.5mg-2.5mg2.5mg-2.5mg, 3.75mg3.75mg-3.75mg-3.75mg,
5mg-5mg-5mg-5mg,
6.25mg-6.25mg-6.25mg6.25mg, 7.5mg-7.5mg7.5mg-7.5mg
amphetaminedextroamphetamine tabs
1.25mg-1.25mg-1.25mg1.25mg, 1.875mg1.875mg-1.875mg1.875mg, 2.5mg-2.5mg2.5mg-2.5mg, 3.125mg3.125mg-3.125mg3.125mg, 3.75mg-3.75mg3.75mg-3.75mg, 5mg-5mg5mg-5mg, 7.5mg-7.5mg7.5mg-7.5mg
DESOXYN (Use
Methamphetamine HCl
DEXEDRINE (Use
Dextroamphetamine
Sulfate
dextroamphetamine sulfate
cp24 or 10 mg, 15 mg, 5
mg
dextroamphetamine sulfate
tabs or 10 mg, 5 mg
1)
1)
MO
MO
MO
MO; *
1) MO
VYVANSE 40 MG, 50 MG,
60 MG, 70 MG
MO
MO
MO
methamphetamine hcl
MO
VYVANSE 20 MG
VYVANSE 30 MG
QL(3 ea daily);
MO
QL(2 ea daily);
MO
Drug Requirements/
Tier Limits
QL(1 ea daily);
MO
Attention-Deficit/Hyperactivity Disorder (ADHD)
MO; *
clonidine hcl (adhd)
guanfacine hcl (adhd)
AL; MO; *
INTUNIV (Use Guanfacine
HCl (ADHD
KAPVAY (Use Clonidine
HCl (ADHD
AL; MO
1) MO
STRATTERA 10 MG
STRATTERA 100 MG, 60
MG, 80 MG
STRATTERA 18 MG
STRATTERA 25 MG
STRATTERA 40 MG
Stimulants - Misc.
CONCERTA (Use
Methylphenidate HCl
1)
Drug Name
QL(10 ea
daily); MO
QL(1 ea daily);
MO
QL(5 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
1) MO
DAYTRANA 30 MG/9HR
MO
dexmethylphenidate hcl
cp24 15 mg
dexmethylphenidate hcl
tabs 10 mg, 2.5 mg, 5 mg
FOCALIN (Use
Dexmethylphenidate HCl
FOCALIN XR 10 MG, 20
MG
FOCALIN XR 15 MG (Use
Dexmethylphenidate HCl
METADATE CD (Use
Methylphenidate HCl
methylphenidate hcl cp24
or 20 mg, 40 mg
methylphenidate hcl cp24
or 30 mg
methylphenidate hcl cpcr or
10 mg, 20 mg, 30 mg, 40
mg, 50 mg, 60 mg
MO; *
MO; *
1) MO
MO
1) MO
1) MO
MO
MO; *
MO; *
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Drug Name
methylphenidate hcl er 54
mg
methylphenidate hcl tabs or
10 mg, 20 mg, 5 mg
methylphenidate hcl tbcr or
18 mg, 20 mg, 27 mg, 36
mg
Drug Requirements/
Tier Limits
MO
MO; *
tobramycin nebu in
MO
tobramycin sulfate soln ij
MO; *
1.2 gm/30ml, 40 mg/ml, 80
mg/2ml
tobramycin sulfate soln ij
*
10 mg/ml
tobramycin sulfate solr ij
*
1.2 gm
ANALGESICS - ANTI-INFLAMMATORY - Drugs
to Treat Pain, Swelling, Muscle and Joint
Conditions
Anti-TNF-alpha - Monoclonal Antibodies
PA
HUMIRA
PA; MO
modafinil 200 mg
PA; MO
NUVIGIL
PA; MO
PROVIGIL (Use Modafinil
PA; MO
RITALIN LA 10 MG
RITALIN LA 20 MG, 30
MG, 40 MG (Use
Methylphenidate HCl
RITALIN SR (Use
Methylphenidate HCl
1) MO
1)
Drug Requirements/
Tier Limits
TOBI PODHALER
modafinil 100 mg
RITALIN (Use
Methylphenidate HCl
Drug Name
MO
MO
1) MO
AMINOGLYCOSIDES - Drugs to Treat Bacterial
Infections
B/D; *
HUMIRA PEDIATRIC
CROHNS DISEASE
STARTER PACK
PA
HUMIRA PEN
PA
HUMIRA PEN-CROHNS
DISEASESTARTER
HUMIRA PEN-PSORIASIS
STARTER
PA
PA
SIMPONI
PA
SIMPONI ARIA
PA
Aminoglycosides
amikacin sulfate soln ij 1
gm/4ml, 500 mg/2ml
MO; *
BETHKIS
B/D
gentamicin in saline 0.9%0.8mg/ml
gentamicin in saline 0.9%1.2mg/ml
gentamicin in saline 0.9%1.6mg/ml, 0.9%-1mg/ml
gentamicin sulfate soln ij
10 mg/ml, 40 mg/ml
gentamicin sulfate soln iv
10 mg/ml
MO; *
*
Antirheumatic Antimetabolites
*
MO; *
*
neomycin sulfate tabs or
MO; *
Interleukin-1 Blockers
paromomycin sulfate
MO
ARCALYST
TOBI (Use Tobramycin
B/D
Interleukin-1 Receptor Antagonist (IL-1Ra)
Antirheumatic - Enzyme Inhibitors
PA
OTREXUP
PA
RHEUMATREX
MO
MO
LA
XELJANZ
Gold Compounds
RIDAURA
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SDJHL[
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Drug Name
KINERET
Drug Requirements/
Tier Limits
PA
Interleukin-1beta Blockers
ILARIS
LA
Interleukin-6 Receptor Inhibitors
ACTEMRA
PA
Nonsteroidal Anti-inflammatory Agents (NSAIDs)
ANAPROX (Use Naproxen 1) MO
Sodium
ANAPROX DS (Use
1) MO
Naproxen Sodium
ARTHROTEC 50 (Use
1) MO
Diclofenac w/ Misoprostol
ARTHROTEC 75 (Use
1) MO
Diclofenac w/ Misoprostol
CATAFLAM (Use
1) MO
Diclofenac Potassium
CELEBREX (Use
MO
Celecoxib
MO; *
celecoxib
DAYPRO (Use Oxaprozin
1) MO
Drug Requirements/
Tier Limits
flurbiprofen tabs or 100 mg, MO; *
50 mg
ibuprofen susp or 100
RX/OTC; MO; *
mg/5ml
QL(8 ea daily);
ibuprofen tabs or 400 mg
MO; *
QL(5 ea daily);
ibuprofen tabs or 600 mg
MO; *
QL(4 ea daily);
ibuprofen tabs or 800 mg
MO; *
INDOCIN SUSP OR 25
AL; MO
MG/5ML
indomethacin caps or 25
AL; MO; *
mg, 50 mg
indomethacin cpcr or 75
AL; MO; *
mg
ketoprofen caps or 50 mg,
MO; *
75 mg
ketorolac tromethamine
AL; MO; *
soln ij 15 mg/ml, 30 mg/ml
ketorolac tromethamine
AL; MO; *
soln im 30 mg/ml, 60
mg/2ml
ketorolac tromethamine
AL; MO; *
tabs or 10 mg
MO
mefenamic acid caps or
Drug Name
diclofenac potassium
MO; *
diclofenac sodium tb24 or
100 mg
diclofenac sodium tbec or
25 mg, 50 mg, 75 mg
MO; *
MO; *
diclofenac w/ misoprostol
MO
nabumetone
MO; *
DUEXIS
MO
NAPRELAN 375 MG, 750
MG
NAPROSYN TABS 250
MG, 375 MG, 500 MG (Use
Naproxen
naproxen sodium tabs or
275 mg, 550 mg
naproxen tabs or 250 mg,
375 mg, 500 mg
naproxen tbec or 375 mg,
500 mg
MO
EC-NAPROSYN (Use
Naproxen
etodolac caps or 200 mg,
300 mg
etodolac tabs or 400 mg,
500 mg
etodolac tb24 or 400 mg,
500 mg, 600 mg
FELDENE (Use
Piroxicam
1) MO
MO; *
MO; *
MO; *
1) MO
meloxicam tabs or 15 mg,
7.5 mg
MOBIC TABS 15 MG, 7.5
MG (Use Meloxicam
oxaprozin
MO; *
1) MO
1)
MO
MO; *
MO; *
MO; *
MO
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SDJHL[
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Drug Name
piroxicam caps or 10 mg,
20 mg
PONSTEL (Use
Mefenamic Acid
Drug Requirements/
Tier Limits
MO; *
MO
SPRIX
AL; MO
sulindac tabs or 150 mg,
200 mg
tolmetin sodium caps 400
mg
tolmetin sodium tabs 200
mg
MO; *
MO; *
MO; *
VIMOVO
MO
VOLTAREN-XR (Use
Diclofenac Sodium
ZIPSOR
1) MO
MO
Phosphodiesterase 4 (PDE4) Inhibitors
PA
OTEZLA
Pyrimidine Synthesis Inhibitors
ARAVA (Use Leflunomide
leflunomide
1) MO
MO
Selective Costimulation Modulators
PA
ORENCIA
Soluble Tumor Necrosis Factor Receptor Agents
PA
ENBREL
ENBREL SURECLICK
PA
ANALGESICS - NonNarcotic - Drugs to Treat
Pain, Muscle and Joint Conditions
Salicylates
diflunisal tabs or
MO; *
ANALGESICS - OPIOID - Drugs to Treat Pain,
Muscle and Joint Conditions
Opioid Agonists
ABSTRAL 100 MCG
PA; QL(6 ea
daily)
Drug Requirements/
Tier Limits
PA; QL(6 ea
ABSTRAL 200 MCG
daily)
ABSTRAL 300 MCG, 400
PA; QL(4 ea
MCG, 600 MCG, 800 MCG
daily)
ACTIQ 1200 MCG, 1600
PA; QL(4 ea
MCG, 400 MCG, 600 MCG, daily); MO
800 MCG (Use Fentanyl
Citrate
ACTIQ 200 MCG (Use
PA; QL(6 ea
Fentanyl Citrate
daily); MO
AVINZA (Use Morphine
QL(5 ea daily);
Sulfate Beads
MO
CODEINE SULFATE 15
QL(53 ea
MG
daily); MO
QL(26 ea
codeine sulfate 30 mg
daily); MO; *
QL(13 ea
codeine sulfate 60 mg
daily); MO; *
DEMEROL TABS OR 100
1) QL(12 ea
MG (Use Meperidine HCl
daily); AL; MO
DEMEROL TABS OR 50
1) QL(24 ea
daily); AL; MO
MG (Use Meperidine HCl
DILAUDID LIQD OR 1
QL(30 ml
1) daily); MO
MG/ML (Use
Hydromorphone HCl
DILAUDID SOLN IJ 2
MO
1)
MG/ML (Use
Hydromorphone HCl
DILAUDID TABS OR 2 MG 1) QL(29 ea
(Use Hydromorphone HCl
daily); MO
DILAUDID TABS OR 4 MG 1) QL(14 ea
(Use Hydromorphone HCl
daily); MO
DILAUDID TABS OR 8 MG 1) QL(7 ea daily);
(Use Hydromorphone HCl
MO
DILAUDID-HP SOLN 10
MO
1)
MG/ML (Use
Hydromorphone HCl
DOLOPHINE (Use
1) QL(19 ea
Methadone HCl
daily); MO
DOLOPHINE HCL (Use
1) QL(38 ea
Methadone HCl
daily); MO
DURAGESIC 100 MCG/HR 1) QL(1 ea daily);
(Use Fentanyl
MO
DURAGESIC 12 MCG/HR
1) QL(1.44 ea
(Use Fentanyl
daily); MO
Drug Name
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Drug Name
DURAGESIC 25 MCG/HR
(Use Fentanyl
DURAGESIC 50 MCG/HR
(Use Fentanyl
DURAGESIC 75 MCG/HR
(Use Fentanyl
EXALGO 12 MG (Use
Hydromorphone HCl
EXALGO 16 MG (Use
Hydromorphone HCl
EXALGO 32 MG
EXALGO 8 MG (Use
Hydromorphone HCl
fentanyl 100 mcg/hr
fentanyl 12 mcg/hr
fentanyl 25 mcg/hr
fentanyl 50 mcg/hr
fentanyl 75 mcg/hr
fentanyl citrate lpop bu
1200 mcg, 1600 mcg, 400
mcg, 600 mcg, 800 mcg
fentanyl citrate lpop bu 200
mcg
FENTORA 100 MCG, 200
MCG
FENTORA 400 MCG, 600
MCG, 800 MCG
HYDROMORPHONE HCL
ER
hydromorphone hcl liqd or
1 mg/ml
hydromorphone hcl soln ij
10 mg/ml, 2 mg/ml, 50
mg/5ml, 500 mg/50ml
hydromorphone hcl t24a or
12 mg
hydromorphone hcl t24a or
16 mg
hydromorphone hcl t24a or
8 mg
Drug Requirements/
Tier Limits
1) QL(0.7 ea
daily); MO
1) QL(0.74 ea
daily); MO
1) QL(0.61 ea
daily); MO
QL(4 ea daily);
MO
QL(3.67 ea
daily); MO
QL(2 ea daily);
MO
QL(7 ea daily);
MO
QL(1 ea daily);
MO
QL(1.44 ea
daily); MO
QL(0.7 ea
daily); MO
QL(0.74 ea
daily); MO
QL(0.61 ea
daily); MO
PA; QL(4 ea
daily); MO
PA; QL(6 ea
daily); MO
PA; QL(6 ea
daily); MO
PA; QL(4 ea
daily); MO
QL(2 ea daily);
MO
QL(30 ml
daily); MO
MO
QL(4 ea daily);
MO; *
QL(3.67 ea
daily); MO; *
QL(7 ea daily);
MO; *
Drug Requirements/
Tier Limits
hydromorphone hcl tabs or
QL(29 ea
2 mg
daily); MO
hydromorphone hcl tabs or
QL(14 ea
daily); MO
4 mg
hydromorphone hcl tabs or
QL(7 ea daily);
8 mg
MO
KADIAN 10 MG (Use
1) QL(6 ea daily);
Morphine Sulfate
MO
KADIAN 100 MG (Use
QL(6 ea daily);
Morphine Sulfate
MO
PA; QL(1 ea
KADIAN 130 MG, 150 MG
daily)
KADIAN 20 MG, 30 MG, 50
QL(5 ea daily);
1) MO
MG, 60 MG, 80 MG (Use
Morphine Sulfate
PA; QL(5 ea
KADIAN 40 MG, 70 MG
daily); MO
PA; QL(6 ea
LAZANDA 100 MCG/ACT
daily); MO
PA; QL(4 ea
LAZANDA 400 MCG/ACT
daily)
QL(12 ea
meperidine hcl tabs or 100
daily); AL; MO;
mg
*
QL(24 ea
meperidine hcl tabs or 50
daily); AL; MO;
mg
*
Drug Name
methadone hcl soln or 10
mg/5ml
methadone hcl soln or 5
mg/5ml
methadone hcl tabs or 10
mg
methadone hcl tabs or 5
mg
morphine sulfate beads
morphine sulfate cp24 or
10 mg
morphine sulfate cp24 or
100 mg
morphine sulfate cp24 or
20 mg, 30 mg, 50 mg, 60
mg, 80 mg
morphine sulfate soln ij 0.5
mg/ml, 1 mg/ml
QL(20 ml
daily); MO; *
QL(40 ml
daily); MO; *
QL(19 ea
daily); MO; *
QL(38 ea
daily); MO; *
QL(5 ea daily);
MO; *
QL(6 ea daily);
MO; *
QL(6 ea daily);
MO
QL(5 ea daily);
MO
*
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Drug Name
morphine sulfate soln or 10
mg/5ml
morphine sulfate soln or
100 mg/5ml, 20 mg/ml
morphine sulfate soln or 20
mg/5ml
morphine sulfate tabs or 15
mg
MORPHINE SULFATE
TABS OR 30 MG
morphine sulfate tbcr or
100 mg
morphine sulfate tbcr or 15
mg
morphine sulfate tbcr or
200 mg
morphine sulfate tbcr or 30
mg, 60 mg
MS CONTIN 100 MG (Use
Morphine Sulfate
MS CONTIN 15 MG (Use
Morphine Sulfate
MS CONTIN 200 MG (Use
Morphine Sulfate
MS CONTIN 30 MG, 60
MG (Use Morphine Sulfate
NUCYNTA 100 MG
NUCYNTA 50 MG
NUCYNTA 75 MG
NUCYNTA ER 100 MG
NUCYNTA ER 150 MG,
200 MG, 250 MG
NUCYNTA ER 50 MG
OPANA TABS OR 10 MG
(Use Oxymorphone HCl
OPANA TABS OR 5 MG
(Use Oxymorphone HCl
OXECTA 5 MG
OXECTA 7.5 MG
Drug Requirements/
Tier Limits
QL(60 ml
daily); MO; *
QL(6 ml daily);
MO; *
QL(30 ml
daily); MO; *
QL(8 ea daily);
MO; *
QL(14 ea
daily); MO
QL(6 ea daily);
MO
QL(8 ea daily);
MO
QL(3 ea daily);
MO
QL(5 ea daily);
MO
1) QL(6 ea daily);
MO
1) QL(8 ea daily);
MO
1) QL(3 ea daily);
MO
1) QL(5 ea daily);
MO
QL(6 ea daily);
MO
QL(12 ea
daily); MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(8 ea daily);
MO
1) QL(4 ea daily);
MO
1) QL(8 ea daily);
MO
QL(17 ea
daily); MO
QL(11 ea
daily); MO
Drug Requirements/
Tier Limits
oxycodone hcl caps or 5
QL(17 ea
mg
daily); MO; *
oxycodone hcl conc or 100
QL(4 ml daily);
MO
mg/5ml
OXYCODONE HCL ER 10
QL(2 ea daily);
MG, 20 MG, 40 MG
MO
OXYCODONE HCL ER 80
QL(7 ea daily);
MG
MO
oxycodone hcl tabs or 10
QL(16 ea
daily); MO
mg
oxycodone hcl tabs or 15
QL(11 ea
mg
daily); MO
oxycodone hcl tabs or 20
QL(8 ea daily);
MO
mg
oxycodone hcl tabs or 30
QL(15 ea
mg
daily); MO
ea
oxycodone hcl tabs or 5 mg QL(17
daily); MO
OXYCONTIN 10 MG, 15
QL(2 ea daily);
MO
MG, 20 MG, 30 MG, 40
MG, 60 MG
QL(7 ea daily);
OXYCONTIN 80 MG
MO
oxymorphone hcl tabs 10
QL(4 ea daily);
mg
MO
ea daily);
oxymorphone hcl tabs 5 mg QL(8
MO
oxymorphone hcl tb12 10
QL(4 ea daily);
mg
MO
oxymorphone hcl tb12 15
QL(2.67 ea
mg
daily); MO
oxymorphone hcl tb12 20
QL(2 ea daily);
mg
MO
oxymorphone hcl tb12 30
QL(2 ea daily);
mg, 40 mg
MO; *
oxymorphone hcl tb12 5
QL(8 ea daily);
mg
MO; *
oxymorphone hcl tb12 7.5
QL(5 ea daily);
mg
MO
ROXICODONE 15 MG
1) QL(11 ea
(Use Oxycodone HCl
daily); MO
ROXICODONE 30 MG
1) QL(15 ea
(Use Oxycodone HCl
daily); MO
ROXICODONE 5 MG (Use 1) QL(17 ea
Oxycodone HCl
daily); MO
Drug Name
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Drug Name
SUBSYS 100 MCG, 200
MCG
SUBSYS 1200 MCG, 1600
MCG
SUBSYS 400 MCG, 600
MCG, 800 MCG
tramadol hcl tabs or 50 mg
tramadol hcl tb24 or 100
mg
tramadol hcl tb24 or 100
mg
tramadol hcl tb24 or 200
mg
tramadol hcl tb24 or 200
mg
tramadol hcl tb24 or 300
mg
tramadol hcl tb24 or 300
mg
ULTRAM (Use Tramadol
HCl
ULTRAM ER 100 MG (Use
Tramadol HCl
ULTRAM ER 200 MG (Use
Tramadol HCl
ULTRAM ER 300 MG (Use
Tramadol HCl
ZOHYDRO ER
Opioid Combinations
acetaminophen w/ codeine
soln 120mg/5ml-12mg/5ml
acetaminophen w/ codeine
tabs 300mg-15mg, 300mg30mg, 300mg-60mg
butalbital-acetaminophencaffeine w/ codeine 300mg50mg-40mg-30mg
butalbital-acetaminophencaffeine w/ codeine 325mg50mg-40mg-30mg
butalbital-aspirin-caffeine
w/cod
Drug Requirements/
Tier Limits
PA; QL(6 ea
daily); MO
PA; QL(4 ea
daily)
PA; QL(4 ea
daily); MO
QL(8 ea daily);
MO; *
Biphasic;QL(4
ea daily); MO
QL(4 ea daily);
MO
Biphasic;QL(2
ea daily); MO; *
QL(2 ea daily);
MO
Biphasic;QL(1
ea daily); MO; *
QL(1 ea daily);
MO
1) QL(8 ea daily);
MO
1) QL(4 ea daily);
MO
1) QL(2 ea daily);
MO
1) QL(1 ea daily);
MO
PA; QL(2 ea
daily); MO
QL(166 ml
daily); MO; *
QL(13 ea
daily); MO; *
QL(13 ea
daily); AL; MO
QL(12 ea
daily); AL; MO
AL; MO; *
Drug Name
FIORICET/CODEINE
300MG-50MG-40MG30MG (Use ButalbitalAcetaminophen-Caffeine w/
Codeine
FIORICET/CODEINE
325MG-50MG-40MG30MG (Use ButalbitalAcetaminophen-Caffeine w/
Codeine
FIORINAL/CODEINE #3
(Use Butalbital-AspirinCaffeine w/Cod
HYCET (Use
HydrocodoneAcetaminophen
hydrocodoneacetaminophen caps 5mg500mg
hydrocodoneacetaminophen soln
10mg/15ml-325mg/15ml,
2.5mg/5ml-108mg/5ml,
5mg/10ml-217mg/10ml,
7.5mg/15ml-325mg/15ml
hydrocodoneacetaminophen tabs 10mg300mg, 5mg-300mg,
7.5mg-300mg
hydrocodoneacetaminophen tabs 10mg325mg, 5mg-325mg,
7.5mg-325mg
hydrocodoneacetaminophen tabs 10mg750mg
hydrocodone-ibuprofen
200mg-10mg, 200mg-5mg,
200mg-7.5mg
IBUDONE (Use
Hydrocodone-Ibuprofen
MAXIDONE (Use
HydrocodoneAcetaminophen
NORCO (Use
HydrocodoneAcetaminophen
Drug Requirements/
Tier Limits
QL(13 ea
daily); AL; MO
1)
1)
1)
QL(12 ea
daily); AL; MO
AL; MO
QL(184 ml
1) daily); MO
QL(8 ea daily);
MO; *
QL(184 ml
daily); MO; *
QL(13 ea
daily); MO; *
QL(12 ea
daily); MO; *
QL(5 ea daily);
MO; *
MO
1) MO
QL(5 ea daily);
1) MO
QL(12 ea
1) daily); MO
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Drug Requirements/
Tier Limits
oxycodone w/
QL(12 ea
daily); MO
acetaminophen tabs 10mg325mg
QL(12 ea
oxycodone w/
acetaminophen tabs
daily); MO; *
2.5mg-325mg, 5mg325mg, 7.5mg-325mg
MO; *
oxycodone-aspirin
Drug Name
pentazocineacetaminophen
PERCOCET 10MG325MG, 2.5MG-325MG,
5MG-325MG, 7.5MG325MG (Use Oxycodone
w/ Acetaminophen
PERCODAN (Use
Oxycodone-Aspirin
REPREXAIN 200MG-5MG
(Use HydrocodoneIbuprofen
tramadol-acetaminophen
TYLENOL/CODEINE #3
(Use Acetaminophen w/
Codeine
TYLENOL/CODEINE #4
(Use Acetaminophen w/
Codeine
ULTRACET (Use
Tramadol-Acetaminophen
VICOPROFEN (Use
Hydrocodone-Ibuprofen
XODOL 5MG-300MG (Use
HydrocodoneAcetaminophen
1)
QL(6 ea daily);
AL; MO; *
QL(12 ea
daily); MO
1) MO
1)
MO
QL(8 ea daily);
MO; *
QL(13 ea
1) daily); MO
QL(13 ea
1) daily); MO
1) QL(8 ea daily);
MO
1) MO
QL(13 ea
1) daily); MO
Opioid Partial Agonists
BUNAVAIL
PA
buprenorphine hcl subl sl 2
mg
buprenorphine hcl subl sl 8
mg
buprenorphine hclnaloxone hcl dihydrate
2mg-0.5mg
PA; QL(16 ea
daily); MO
PA; QL(4 ea
daily); MO
PA; QL(16 ea
daily); MO
Drug Name
buprenorphine hclnaloxone hcl dihydrate
8mg-2mg
butorphanol tartrate soln na
10 mg/ml
Drug Requirements/
Tier Limits
PA; QL(4 ea
daily); MO
BUTRANS 10 MCG/HR
BUTRANS 15 MCG/HR
BUTRANS 20 MCG/HR,
7.5 MCG/HR
BUTRANS 5 MCG/HR
pentazocine w/ naloxone
SUBOXONE FILM 12MG3MG, 2MG-0.5MG, 4MG1MG, 8MG-2MG
SUBOXONE SUBL 2MG0.5MG (Use Buprenorphine
HCl-Naloxone HCl
Dihydrate
SUBOXONE SUBL 8MG2MG (Use Buprenorphine
HCl-Naloxone HCl
Dihydrate
QL(4.2 ml
daily); MO; *
QL(0.29 ea
daily); MO
QL(0.19 ea
daily); MO
QL(0.15 ea
daily); MO
QL(0.58 ea
daily); MO
AL; MO
PA; MO
PA; QL(16 ea
1) daily); MO
PA; QL(4 ea
1) daily); MO
TALWIN
AL
ZUBSOLV
PA; MO
ANDROGENS-ANABOLIC - Drugs to Regulate
Hormones
Anabolic Steroids
ANADROL-50
MO
OXANDRIN 10 MG (Use
Oxandrolone
OXANDRIN 2.5 MG (Use
Oxandrolone
MO
1) MO
oxandrolone tabs or 10 mg
MO
oxandrolone tabs or 2.5 mg
MO; *
GL; MO
Androgens
ANDRODERM
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Drug Name
ANDROGEL
Drug Requirements/
Tier Limits
GL; MO
Drug Name
Drug Requirements/
Tier Limits
Rectal Steroids
MO; *
ANDROGEL PUMP
GL; MO
hydrocortisone (rectal)
androxy
*
AVEED
LA
PROCTOCORT CREA 1 %
(Use Hydrocortisone
(Rectal
AXIRON
GL; MO
RECTIV
danazol caps or 100 mg,
200 mg
MO
ANTHELMINTICS - Drugs to Treat Worm
Infections
danazol caps or 50 mg
MO; *
DEPO-TESTOSTERONE
100 MG/ML (Use
Testosterone Cypionate
depo-testosterone 200
mg/ml
1)
MO
MO; *
FORTESTA
GL; MO
TESTIM
GL; MO
TESTOSTERONE 1 %, 10
MG/ACT
TESTOSTERONE 25
MG/2.5GM
GL; MO
GL; MO
testosterone cypionate
MO; *
testosterone enanthate
soln im
MO; *
TESTOSTERONE PUMP
GL; MO
VOGELXO
GL; MO
VOGELXO PUMP
GL; MO
ANORECTAL AGENTS - Rectal Drugs to Treat
Pain, Swelling and Itching
Intrarectal Steroids
CORTENEMA (Use
Hydrocortisone
(Intrarectal
1)
MO
CORTIFOAM
MO
hydrocortisone (intrarectal)
MO
1)
MO
Vasodilating Agents
MO
Anthelmintics
ALBENZA
MO
BILTRICIDE
MO
ivermectin tabs or
MO; *
STROMECTOL (Use
MO
Ivermectin
ANTI-INFECTIVE AGENTS - MISC. - Drugs to
Treat Bacterial Infections
Anti-infective Agents - Misc.
AZACTAM 1 GM (Use
1) MO
Aztreonam
AZACTAM 2 GM (Use
1)
Aztreonam
MO; *
aztreonam 1 gm
aztreonam 2 gm
*
CAYSTON
LA
colistimethate sodium solr ij
MO; *
COLY-MYCIN M (Use
Colistimethate Sodium
FLAGYL CAPS 375 MG
(Use Metronidazole
1) MO
FLAGYL ER
1) QL(10 ea
daily); MO
QL(5 ea daily)
FLAGYL TABS 250 MG
(Use Metronidazole
FLAGYL TABS 500 MG
(Use Metronidazole
1) QL(16 ea
daily); MO
1) QL(8 ea daily);
MO
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Drug Name
metronidazole caps or 375
mg
metronidazole in nacl
Drug Requirements/
Tier Limits
QL(10 ea
daily); MO; *
MO; *
metronidazole tabs or 250
mg
metronidazole tabs or 500
mg
NEBUPENT
PENTAM 300
MO
MO
PRIMSOL
TINDAMAX (Use
Tinidazole
tinidazole tabs or 250 mg,
500 mg
QL(16 ea
daily); MO; *
QL(8 ea daily);
MO; *
MO; B/D
1) MO
MO; *
trimethoprim tabs or
MO; *
VANCOCIN HCL (Use
Vancomycin HCl
vancomycin hcl caps or
125 mg, 250 mg
VANCOMYCIN HCL IN
DEXTROSE
vancomycin hcl solr iv 10
gm, 1000 mg, 5000 mg
vancomycin hcl solr iv 500
mg
PA; MO
PA; MO
B/D
B/D; *
MO; B/D; *
XIFAXAN
MO
Anti-infective Misc. - Combinations
BACTRIM (Use
MO
1)
SulfamethoxazoleTrimethoprim
BACTRIM DS (Use
MO
1)
SulfamethoxazoleTrimethoprim
sulfamethoxazoleMO; *
trimethoprim susp
160mg/20ml-800mg/20ml,
40mg/5ml-200mg/5ml
sulfamethoxazoleMO; *
trimethoprim tabs 160mg800mg, 80mg-400mg
Drug Requirements/
Tier Limits
sulfamethoxazole/trimethop MO; *
rim
Drug Name
Antiprotozoal Agents
ALINIA TABS 500 MG
MO
atovaquone
MO
MEPRON (Use
Atovaquone
Carbapenems
MO
DORIBAX 500 MG
imipenem-cilastatin 250mg250mg
imipenem-cilastatin 500mg500mg
MO; *
MO
INVANZ IJ
MO
meropenem 1 gm
MO
meropenem 500 mg
MO; *
MERREM 1 GM (Use
Meropenem
MERREM 500 MG (Use
Meropenem
PRIMAXIN IV (Use
Imipenem-Cilastatin
PRIMAXIN IV ADDVANTAGE (Use
Imipenem-Cilastatin
Chloramphenicols
chloramphenicol sodium
succinate
Cyclic Lipopeptides
MO
CUBICIN
1) MO
1) MO
1)
MO
*
B/D
Glycylcyclines
TYGACIL
Ketolides
KETEK 300 MG
KETEK 400 MG
MO
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Drug Name
Leprostatics
dapsone tabs or 100 mg,
25 mg
Lincosamides
CLEOCIN CAPS OR 150
MG, 300 MG, 75 MG (Use
Clindamycin HCl)
CLEOCIN IN D5W (Use
Clindamycin Phosphate in
D5W)
CLEOCIN PEDIATRIC
GRANULES (Use
Clindamycin Palmitate
Hydrochloride)
CLEOCIN PHOSPHATE IJ
600 MG/4ML, 900 MG/6ML
(Use Clindamycin
Phosphate)
CLEOCIN PHOSPHATE IV
300MG/50ML-5%,
600MG/50ML-5%,
900MG/50ML-5% (Use
Clindamycin Phosphate in
D5W)
clindamycin hcl caps or
150 mg, 300 mg, 75 mg
clindamycin palmitate
hydrochloride
clindamycin phosphate in
d5w
clindamycin phosphate
soln ij 150 mg/ml, 9000
mg/60ml
clindamycin phosphate
soln ij 600 mg/4ml, 900
mg/6ml
clindamycin phosphate
soln iv 150 mg/ml
LINCOCIN
Drug Requirements/
Tier Limits
2
MO; *
SIVEXTRO
ZYVOX SOLN IV 2 MG/ML
(Use Linezolid)
ZYVOX SUSR OR 100
MG/5ML
ZYVOX TABS OR 600 MG
MO
Drug Requirements/
Tier Limits
5 MO
5
MO
2
*
Polymyxins
polymyxin b sulfate solr ij
NF
Streptogramins
4
SYNERCID
MO
NF
5
ANTIANGINAL AGENTS - Drugs to Treat Chest
Pain
Antianginals-Other
MO
NF
RANEXA
DILATRATE SR
4
2
MO; *
3
MO
2
*
*
1
MO; *
1
2
*
4
MO
5
5
5
4
PA; MO
4
MO
Nitrates
Oxazolidinones
linezolid
Drug Name
MO
IMDUR (Use Isosorbide
Mononitrate)
ISORDIL TITRADOSE 40
MG
ISORDIL TITRADOSE 5
MG (Use Isosorbide
Dinitrate)
isosorbide dinitrate subl sl
2.5 mg
isosorbide dinitrate tabs or
10 mg, 20 mg, 30 mg, 5 mg
isosorbide dinitrate tbcr or
40 mg
isosorbide mononitrate tabs
10 mg
isosorbide mononitrate tabs
20 mg
isosorbide mononitrate
tb24 120 mg, 30 mg, 60 mg
NITRO-DUR 0.1 MG/HR,
0.2 MG/HR, 0.4 MG/HR,
0.6 MG/HR (Use
Nitroglycerin)
NITRO-DUR 0.3 MG/HR,
0.8 MG/HR
NITROGLYCERIN
LINGUAL
NF MO
4
MO
MO
NF
1
*
1
MO; *
1
MO; *
2
MO; *
1
MO; *
1
MO; *
MO
NF
4
MO
4
MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
11
Drug Name
nitroglycerin pt24 td 0.1
mg/hr, 0.2 mg/hr, 0.4
mg/hr, 0.6 mg/hr
nitroglycerin soln tl 0.4
mg/spray
NITROLINGUAL
PUMPSPRAY (Use
Nitroglycerin)
Drug Requirements/
Tier Limits
MO; *
1
2
MO; *
Drug Name
chlordiazepoxide hcl
Drug Requirements/
Tier Limits
1 MO; *
clorazepate dipotassium
1
MO; *
diazepam conc or 5 mg/ml
2
MO; *
diazepam soln ij 5 mg/ml
2
MO; *
MO
NF
NITROMIST
4
MO
diazepam soln or 1 mg/ml
2
MO; *
NITROSTAT
3
MO
diazepam tabs or 10 mg, 2
mg, 5 mg
2
MO; *
lorazepam conc or 2 mg/ml
2
MO; *
ANTIANXIETY AGENTS - Drugs to Treat Anxiety
Antianxiety Agents - Misc.
buspirone hcl tabs or 10
mg, 15 mg, 30 mg, 5 mg,
7.5 mg
hydroxyzine hcl soln im 50
mg/ml
hydroxyzine hcl soln or 10
mg/5ml
hydroxyzine hcl syrp or 10
mg/5ml
hydroxyzine hcl tabs or 10
mg, 25 mg, 50 mg
hydroxyzine pamoate caps
or 25 mg, 50 mg
meprobamate
VISTARIL (Use
Hydroxyzine Pamoate)
Benzodiazepines
alprazolam tabs or 0.25
mg, 0.5 mg, 1 mg, 2 mg
alprazolam tb24 or 0.5 mg,
1 mg, 2 mg, 3 mg
alprazolam tbdp or 0.25
mg, 0.5 mg, 1 mg, 2 mg
ATIVAN SOLN IJ 2 MG/ML
(Use Lorazepam)
ATIVAN SOLN IJ 4 MG/ML
(Use Lorazepam)
ATIVAN TABS OR 0.5 MG,
1 MG, 2 MG (Use
Lorazepam)
MO; *
2
LORAZEPAM INTENSOL
(Use Lorazepam)
lorazepam soln ij 2 mg/ml,
20 mg/10ml
lorazepam soln ij 4 mg/ml
NF MO
2
MO; *
2
*
2
MO; *
2
AL; MO; *
2
AL; MO; *
2
AL; MO; *
lorazepam tabs or 0.5 mg,
1 mg, 2 mg
NIRAVAM (Use
Alprazolam)
2
AL; MO; *
oxazepam
2
AL; MO; *
TRANXENE T (Use
Clorazepate Dipotassium)
NF MO
3
AL; MO
VALIUM (Use Diazepam)
NF MO
XANAX (Use Alprazolam)
NF MO
XANAX XR (Use
Alprazolam)
NF MO
NF AL; MO
NF MO
1
MO; *
2
MO; *
ANTIARRHYTHMICS - Drugs to treat abnormal
heart rhythms
2
MO; *
2
MO; *
Antiarrhythmics Type I-A
disopyramide phosphate
caps or 100 mg, 150 mg
NORPACE (Use
Disopyramide Phosphate)
NF MO
NF
MO
NF
2
AL; MO; *
NF AL; MO
NORPACE CR 100 MG
4
AL; MO
quinidine gluconate tbcr or
324 mg
1
MO; *
quinidine sulfate
1
MO; *
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
12
Drug Name
Drug Requirements/
Tier Limits
Antiarrhythmics Type I-B
lidocaine hcl (cardiac)
1
MO; *
mexiletine hcl
1
MO; *
XYLOCAINE IV 20 MG/ML
(Use Lidocaine HCl
(Cardiac))
MO
Drug Requirements/
Tier Limits
4 QL(0.86 gm
ATROVENT HFA
daily); MO
1 MO; B/D; *
ipratropium bromide soln in
Drug Name
SPIRIVA HANDIHALER
3
SPIRIVA RESPIMAT
3
SPIRIVA RESPIMAT
3
TUDORZA PRESSAIR
3
NF
Antiarrhythmics Type I-C
flecainide acetate 100 mg
1
flecainide acetate 150 mg
1
flecainide acetate 50 mg
1
propafenone hcl
1
RYTHMOL (Use
Propafenone HCl)
RYTHMOL SR (Use
Propafenone HCl)
TAMBOCOR 100 MG (Use
Flecainide Acetate)
TAMBOCOR 150 MG (Use
Flecainide Acetate)
TAMBOCOR 50 MG (Use
Flecainide Acetate)
Antiarrhythmics Type III
amiodarone hcl tabs or 100
mg, 200 mg, 400 mg
CORDARONE (Use
Amiodarone HCl)
QL(4 ea daily);
MO; *
QL(2 ea daily);
MO; *
QL(8 ea daily);
MO; *
MO; *
NF MO
NF MO
NF QL(4 ea daily);
MO
NF QL(2 ea daily);
MO
NF QL(8 ea daily);
MO
1
MO; *
NF MO
MULTAQ
3
TIKOSYN
4
MO
Leukotriene Modulators
ACCOLATE (Use
Zafirlukast)
montelukast sodium chew
4 mg, 5 mg
montelukast sodium tabs
10 mg
SINGULAIR CHEW 4 MG,
5 MG (Use Montelukast
Sodium)
SINGULAIR TABS 10 MG
(Use Montelukast Sodium)
zafirlukast
ZYFLO CR
NF MO
QL(1 ea daily);
MO
3 QL(1 ea daily);
MO
QL(1 ea daily);
NF MO
3
NF QL(1 ea daily);
MO
1 MO; *
5
Steroid Inhalants
3
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS - Drugs to Treat Lung Conditions
ALVESCO 160 MCG/ACT
4
Anti-Inflammatory Agents
ALVESCO 80 MCG/ACT
4
1
QL(4 ea daily);
MO
Selective Phosphodiesterase 4 (PDE4) Inhibitors
4 QL(1 ea daily);
DALIRESP
MO
AEROSPAN
cromolyn sodium nebu in
QL(1 ea daily);
MO
28
actuations;QL(
0.28 gm daily)
60
actuations;QL(
0.14 gm daily)
QL(0.04 ea
daily); MO
MO; B/D; *
Antiasthmatic - Monoclonal Antibodies
5 PA; LA
XOLAIR
ASMANEX TWISTHALER
120 METERED DOSES
ASMANEX TWISTHALER
14 METERED DOSES
3
3
QL(0.6 gm
daily); MO
QL(0.41 gm
daily); MO
QL(0.82 gm
daily); MO
QL(0.04 ea
daily); MO
QL(0.29 ea
daily); MO
Bronchodilators - Anticholinergics
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
13
Drug Requirements/
Tier Limits
ASMANEX TWISTHALER
QL(0.04 ea
3 daily); MO
30 METERED DOSES 110
MCG/INH
ASMANEX TWISTHALER
QL(0.14 ea
3 daily); MO
30 METERED DOSES 220
MCG/INH
ASMANEX TWISTHALER
3 QL(0.07 ea
60 METERED DOSES
daily); MO
ASMANEX TWISTHALER
3 QL(0.14 ea
7 METERED DOSES
daily); MO
budesonide (inhalation)
1 QL(8 ml daily);
0.25 mg/2ml
MO; B/D; *
budesonide (inhalation) 0.5
1 QL(4 ml daily);
MO; B/D; *
mg/2ml
FLOVENT DISKUS 100
3 QL(20 ea
MCG/BLIST
daily); MO
FLOVENT DISKUS 250
QL(8
ea daily);
3
MCG/BLIST
MO
FLOVENT DISKUS 50
3 QL(40 ea
MCG/BLIST
daily); MO
FLOVENT HFA 110
3 QL(0.8 gm
MCG/ACT, 220 MCG/ACT
daily); MO
FLOVENT HFA 44
3 QL(0.36 gm
MCG/ACT
daily); MO
QL(8 ml daily);
PULMICORT 0.25 MG/2ML
NF MO; B/D
(Use Budesonide
(Inhalation))
QL(4 ml daily);
PULMICORT 0.5 MG/2ML
NF MO; B/D
(Use Budesonide
(Inhalation))
4 QL(2 ml daily);
PULMICORT 1 MG/2ML
MO; B/D
PULMICORT FLEXHALER
4 QL(0.07 ea
180 MCG/ACT
daily); MO
PULMICORT FLEXHALER
4 QL(0.27 ea
90 MCG/ACT
daily); MO
3 QL(0.87 gm
QVAR
daily); MO
Drug Name
Sympathomimetics
ACCUNEB (Use Albuterol
Sulfate)
NF MO; B/D
ADVAIR DISKUS
3
ADVAIR HFA
3
QL(2 ea daily);
MO
QL(4 gm daily);
MO
Drug Name
albuterol sulfate nebu in
0.083 %, 0.5 %, 0.63
mg/3ml, 1.25 mg/3ml
albuterol sulfate syrp or 2
mg/5ml
albuterol sulfate tabs or 2
mg, 4 mg
albuterol sulfate tb12 or 4
mg, 8 mg
Drug Requirements/
Tier Limits
MO; B/D; *
1
1
MO; *
1
MO; *
1
MO; *
ANORO ELLIPTA
3
ARCAPTA NEOHALER
4
BREO ELLIPTA
3
BROVANA
4
QL(2 ea daily);
MO
QL(1 ea daily);
MO
QL(2 ea daily);
MO
MO; B/D
COMBIVENT RESPIMAT
DULERA
DUONEB (Use
Ipratropium-Albuterol)
epinephrine hcl sosy 0.1
mg/ml
QL(0.2 gm
daily); MO
3 QL(4 gm daily);
MO
MO;
B/D
NF
4
2
MO; *
FORADIL AEROLIZER
3
ipratropium-albuterol
1
QL(2 ea daily);
MO
MO; B/D; *
levalbuterol hcl nebu in
0.31 mg/3ml, 0.63 mg/3ml,
1.25 mg/0.5ml, 1.25
mg/3ml
1
PERFOROMIST
4
PROAIR HFA
3
QL(4 ml daily);
MO; B/D
MO
PROVENTIL HFA
3
MO
SEREVENT DISKUS
3
STRIVERDI RESPIMAT
3
STRIVERDI RESPIMAT
(institutional pack)
3
SYMBICORT
4
QL(2 ea daily);
MO
QL(0.14 gm
daily); MO
QL(0.28 gm
daily); MO
QL(0.34 gm
daily); MO
MO; B/D; *
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
14
Drug Name
terbutaline sulfate tabs or
2.5 mg, 5 mg
VENTOLIN HFA
VOSPIRE ER (Use
Albuterol Sulfate)
XOPENEX (Use
Levalbuterol HCl)
XOPENEX
CONCENTRATE (Use
Levalbuterol HCl)
XOPENEX HFA
Drug Requirements/
Tier Limits
1 MO; *
4
MO
NF MO
NF MO; B/D
MO; B/D
NF
4
MO
Xanthines
aminophylline
theophylline tb12 100 mg,
200 mg, 300 mg, 450 mg
theophylline tb24 400 mg,
600 mg
2
MO; *
1
MO; *
1
MO; *
ANTICOAGULANTS - Blood Thinners
Coumarin Anticoagulants
COUMADIN TABS OR 1
MG, 10 MG, 2 MG, 2.5 MG,
3 MG, 4 MG, 5 MG, 6 MG,
7.5 MG (Use Warfarin
Sodium)
MO
4
1
MO; *
4
MO
XARELTO
3
MO
XARELTO STARTER
PACK
3
warfarin sodium
Direct Factor Xa Inhibitors
ELIQUIS
Heparins And Heparinoid-Like Agents
ARIXTRA 10 MG/0.8ML, 5
MO
MG/0.4ML, 7.5 MG/0.6ML
5
(Use Fondaparinux
Sodium)
ARIXTRA 2.5 MG/0.5ML
MO
NF
(Use Fondaparinux
Sodium)
Drug Name
enoxaparin sodium ij 300
mg/3ml
enoxaparin sodium sc 100
mg/ml, 60 mg/0.6ml, 80
mg/0.8ml
enoxaparin sodium sc 120
mg/0.8ml, 150 mg/ml
enoxaparin sodium sc 30
mg/0.3ml, 40 mg/0.4ml
fondaparinux sodium 10
mg/0.8ml, 5 mg/0.4ml, 7.5
mg/0.6ml
fondaparinux sodium 2.5
mg/0.5ml
FRAGMIN 10000 UNIT/ML,
2500 UNIT/0.2ML, 5000
UNIT/0.2ML
FRAGMIN 12500
UNIT/0.5ML, 15000
UNIT/0.6ML, 18000
UNT/0.72ML, 25000
UNIT/ML, 7500
UNIT/0.3ML
heparin sodium (porcine)
1000 unit/ml
heparin sodium (porcine)
10000 unit/ml, 20000
unit/ml, 5000 unit/0.5ml,
5000 unit/ml
LOVENOX IJ 300 MG/3ML
(Use Enoxaparin Sodium)
LOVENOX SC 100 MG/ML,
30 MG/0.3ML, 40
MG/0.4ML, 60 MG/0.6ML,
80 MG/0.8ML (Use
Enoxaparin Sodium)
LOVENOX SC 120
MG/0.8ML, 150 MG/ML
(Use Enoxaparin Sodium)
Thrombin Inhibitors
Drug Requirements/
Tier Limits
4 MO
MO
3
5
MO
4
MO
MO
5
1
MO; *
MO
4
MO
5
2
MO; B/D; *
MO; B/D; *
1
NF MO
MO
NF
MO
4
argatroban 100 mg/ml
2
MO; *
PRADAXA
3
MO
ANTICONVULSANTS - Drugs to Treat Seizures
AMPA Glutamate Receptor Antagonists
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
15
Drug Name
FYCOMPA 10 MG
FYCOMPA 12 MG
FYCOMPA 2 MG
FYCOMPA 4 MG
FYCOMPA 6 MG
FYCOMPA 8 MG
Drug Requirements/
Tier Limits
4 QL(1.2 ea
daily); MO
4 QL(1 ea daily);
MO
4 QL(6 ea daily);
MO
4 QL(3 ea daily);
MO
4 QL(2 ea daily);
MO
4 QL(1.5 ea
daily); MO
Anticonvulsants - Benzodiazepines
2 QL(40 ea
clonazepam tabs or 0.5 mg
daily); MO; *
2 QL(20 ea
clonazepam tabs or 1 mg
daily); MO; *
2 QL(10 ea
clonazepam tabs or 2 mg
daily); MO; *
clonazepam tbdp or 0.125
MO; *
mg, 0.25 mg, 0.5 mg, 1 mg, 2
2 mg
4 MO
DIASTAT ACUDIAL
DIASTAT PEDIATRIC
DIAZEPAM GEL RE 10
MG, 2.5 MG, 20 MG
KLONOPIN 0.5 MG (Use
Clonazepam)
KLONOPIN 1 MG (Use
Clonazepam)
KLONOPIN 2 MG (Use
Clonazepam)
ONFI SUSP 2.5 MG/ML
4
MO
4
MO
4
4
4
4
QL(40 ea
daily); MO
QL(20 ea
daily); MO
QL(10 ea
daily); MO
MO
ONFI TABS 10 MG, 5 MG
4
MO
ONFI TABS 20 MG
5
MO
Anticonvulsants - Misc.
APTIOM 200 MG
4
APTIOM 400 MG
5
QL(6 ea daily);
MO
QL(3 ea daily);
MO
Drug Name
APTIOM 600 MG
APTIOM 800 MG
BANZEL SUSP 40 MG/ML
Drug Requirements/
Tier Limits
5 QL(2 ea daily);
MO
5 QL(1 ea daily);
MO
4 MO
BANZEL TABS 200 MG
4
MO
BANZEL TABS 400 MG
5
MO
2
MO; *
3
MO
2
MO; *
2
MO; *
2
MO; *
carbamazepine chew or
100 mg
carbamazepine cp12 or
100 mg, 200 mg, 300 mg
carbamazepine susp or
100 mg/5ml
carbamazepine tabs or 200
mg
carbamazepine tb12 or 200
mg, 400 mg
CARBATROL (Use
Carbamazepine)
gabapentin caps or 100
mg, 300 mg, 400 mg
gabapentin soln or 250
mg/5ml
gabapentin tabs or 600 mg,
800 mg
KEPPRA (Use
Levetiracetam)
KEPPRA XR (Use
Levetiracetam)
LAMICTAL CHEWABLE
DISPERSIBLE (Use
Lamotrigine)
LAMICTAL ODT TBDP 100
MG, 200 MG, 25 MG, 50
MG
LAMICTAL STARTER/NOT
TAKING
CARBAMAZEPINE
LAMICTAL
STARTER/TAKING
CARBAMAZEPINE/NOT
TAKING VALPROATE
NF MO
2
MO; *
2
MO; *
2
MO; *
4
MO
4
MO
MO
4
MO
4
MO
4
MO
4
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
16
Drug Name
LAMICTAL
STARTER/TAKING
VALPROATE
LAMICTAL TABS 100 MG,
150 MG, 200 MG, 25 MG
(Use Lamotrigine)
LAMICTAL XR KIT
LAMICTAL XR TB24 100
MG, 250 MG (Use
Lamotrigine)
LAMICTAL XR TB24 200
MG, 25 MG, 300 MG, 50
MG (Use Lamotrigine)
lamotrigine chew 25 mg, 5
mg
lamotrigine tabs 100 mg,
150 mg, 200 mg, 25 mg
lamotrigine tb24 100 mg,
250 mg
lamotrigine tb24 200 mg,
25 mg, 300 mg, 50 mg
LEVETIRACETAM SOLN
IV 1000MG/100ML750MG/100ML,
1500MG/100ML540MG/100ML,
500MG/100ML820MG/100ML
levetiracetam soln iv 500
mg/5ml
levetiracetam soln or 100
mg/ml, 500 mg/5ml
levetiracetam tabs or 1000
mg, 250 mg, 500 mg, 750
mg
levetiracetam tb24 or 500
mg, 750 mg
LYRICA CAPS 100 MG
Drug Requirements/
Tier Limits
MO
4
MO
4
4
MO
MO
MO
NF
2
MO; *
2
MO; *
2
MO; *
4
MO
4
3
MO
3
MO
MO
3
3
LYRICA CAPS 150 MG
3
LYRICA CAPS 200 MG
3
LYRICA CAPS 225 MG,
300 MG
3
LYRICA CAPS 25 MG
LYRICA CAPS 50 MG
LYRICA CAPS 75 MG
4
3
Drug Name
MO
QL(6 ea daily);
MO
QL(4 ea daily);
MO
QL(3 ea daily);
MO
QL(2 ea daily);
MO
LYRICA SOLN 20 MG/ML
MYSOLINE (Use
Primidone)
NEURONTIN (Use
Gabapentin)
oxcarbazepine susp 300
mg/5ml, 60 mg/ml
oxcarbazepine tabs 150
mg, 300 mg, 600 mg
Drug Requirements/
Tier Limits
3 QL(24 ea
daily); MO
3 QL(12 ea
daily); MO
3 QL(8 ea daily);
MO
3 QL(30 ml
daily); MO
4 MO
4
MO
3
MO
2
MO; *
2
QL(6 ea daily);
MO
QL(4 ea daily);
MO
QL(3 ea daily);
MO
QL(24 ea
daily); MO
MO; *
4
MO
4
MO
4
MO
4
MO
2
MO; *
2
MO; *
POTIGA 200 MG
5
POTIGA 300 MG
4
POTIGA 400 MG
4
POTIGA 50 MG
5
primidone tabs or 250 mg,
50 mg
TEGRETOL (Use
Carbamazepine)
TEGRETOL-XR (Use
Carbamazepine)
TOPAMAX (Use
Topiramate)
TOPAMAX SPRINKLE
(Use Topiramate)
topiramate cpsp or 15 mg,
25 mg
topiramate tabs or 100 mg,
200 mg, 25 mg, 50 mg
TRILEPTAL SUSP 300
MG/5ML (Use
Oxcarbazepine)
TRILEPTAL TABS 150
MG, 300 MG, 600 MG (Use
Oxcarbazepine)
VIMPAT SOLN IV 200
MG/20ML
MO
NF
MO
4
4
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
17
Drug Name
VIMPAT SOLN OR 10
MG/ML
VIMPAT TABS OR 100
MG, 150 MG, 200 MG, 50
MG
ZONEGRAN (Use
Zonisamide)
Drug Requirements/
Tier Limits
4 MO
MO
4
Drug Name
fosphenytoin sodium 500
mg pe/10ml
PEGANONE
4
MO
phenytek 200 mg, 300 mg
2
MO; *
phenytoin chew or 50 mg
2
MO; *
phenytoin sodium extended
2
MO; *
2
*
2
MO; *
4
MO
1
MO; *
2
MO; *
4
MO
4
MO
2
MO; *
2
MO; *
phenytoin sodium soln ij
felbamate tabs 400 mg
2
MO; *
felbamate tabs 600 mg
5
MO
phenytoin susp or 125
mg/5ml
Succinimides
4
MO
4
MO
5
MO
4
MO
zonisamide
Carbamates
felbamate susp 600
mg/5ml
FELBATOL SUSP 600
MG/5ML (Use Felbamate)
FELBATOL TABS 400 MG
(Use Felbamate)
FELBATOL TABS 600 MG
(Use Felbamate)
CELONTIN
GABA Modulators
GABITRIL 12 MG, 16 MG
GABITRIL 2 MG, 4 MG
(Use Tiagabine HCl)
NF MO
SABRIL
5
LA
tiagabine hcl
4
MO
Hydantoins
CEREBYX 100 MG
PE/2ML (Use Fosphenytoin
Sodium)
CEREBYX 500 MG
PE/10ML (Use
Fosphenytoin Sodium)
dilantin caps 100 mg, 30
mg
dilantin infatabs
DILANTIN SUSP 125
MG/5ML (Use Phenytoin)
fosphenytoin sodium 100
mg pe/2ml
4
MO
4
2
2
4
2
MO; *
MO; *
MO
*
Drug Requirements/
Tier Limits
2 MO; *
ethosuximide caps or 250
mg
ethosuximide soln or 250
mg/5ml
ZARONTIN CAPS 250 MG
(Use Ethosuximide)
ZARONTIN SOLN 250
MG/5ML (Use
Ethosuximide)
Valproic Acid
DEPACON (Use Valproate
Sodium)
DEPAKENE (Use
Valproate Sodium)
DEPAKENE (Use Valproic
Acid)
DEPAKOTE (Use
Divalproex Sodium)
DEPAKOTE ER (Use
Divalproex Sodium)
DEPAKOTE SPRINKLES
(Use Divalproex Sodium)
divalproex sodium
valproate sodium soln iv
100 mg/ml, 500 mg/5ml
valproate sodium soln or
250 mg/5ml
MO
NF
4
4
MO
4
MO
4
MO
4
MO
4
MO
2
MO; *
2
*
2
MO; *
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
18
Drug Name
valproate sodium syrp or
250 mg/5ml
valproic acid caps or
Drug Requirements/
Tier Limits
2 MO; *
2
MO; *
ANTIDEPRESSANTS - Drugs to Treat Depression
Alpha-2 Receptor Antagonists (Tetracyclics)
2 MO; *
mirtazapine
REMERON (Use
Mirtazapine)
REMERON SOLTAB (Use
Mirtazapine)
NF MO
NF MO
Antidepressants - Misc.
FORFIVO XL
4
maprotiline hcl 25 mg, 50
mg
1
ST; QL(3 ea
daily); MO
ST; QL(1 ea
daily); MO
QL(4.5 ea
daily); MO
QL(6 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(3 ea daily);
MO
QL(1 ea daily);
MO
ST; QL(1 ea
daily); MO
MO; *
maprotiline hcl 75 mg
2
MO; *
APLENZIN 174 MG
APLENZIN 348 MG, 522
MG
bupropion hcl tabs or 100
mg
bupropion hcl tabs or 75
mg
bupropion hcl tb12 or 100
mg
bupropion hcl tb12 or 150
mg, 200 mg
bupropion hcl tb24 or 150
mg
bupropion hcl tb24 or 300
mg
WELLBUTRIN 100 MG
(Use Bupropion HCl)
WELLBUTRIN 75 MG (Use
Bupropion HCl)
WELLBUTRIN SR 100 MG
(Use Bupropion HCl)
WELLBUTRIN SR 150 MG,
200 MG (Use Bupropion
HCl)
4
4
3
3
3
3
3
3
NF QL(4.5 ea
daily); MO
NF QL(6 ea daily);
MO
NF QL(4 ea daily);
MO
QL(2 ea daily);
NF MO
Drug Name
WELLBUTRIN XL 150 MG
(Use Bupropion HCl)
WELLBUTRIN XL 300 MG
(Use Bupropion HCl)
Drug Requirements/
Tier Limits
NF QL(3 ea daily);
MO
NF QL(1 ea daily);
MO
Monoamine Oxidase Inhibitors (MAOIs)
5 MO
EMSAM
MARPLAN
NARDIL (Use Phenelzine
Sulfate)
PARNATE (Use
Tranylcypromine Sulfate)
4
MO
NF MO
NF MO
phenelzine sulfate tabs or
4
MO
tranylcypromine sulfate
3
MO
Selective Serotonin Reuptake Inhibitors (SSRIs)
CELEXA 10 MG (Use
NF QL(4 ea daily);
Citalopram Hydrobromide)
MO
CELEXA 20 MG (Use
NF QL(2 ea daily);
Citalopram Hydrobromide)
MO
CELEXA 40 MG (Use
NF QL(1 ea daily);
Citalopram Hydrobromide)
MO
citalopram hydrobromide
4 QL(20 ml
soln 10 mg/5ml
daily); MO
citalopram hydrobromide
1 QL(4 ea daily);
tabs 10 mg
MO; *
citalopram hydrobromide
1 QL(2 ea daily);
tabs 20 mg
MO; *
citalopram hydrobromide
1 QL(1 ea daily);
tabs 40 mg
MO; *
3 MO
escitalopram oxalate
fluoxetine hcl caps or 10
mg, 20 mg, 40 mg
2
MO; *
fluoxetine hcl cpdr or 90 mg
2
MO; *
2
MO; *
2
MO; *
4
MO
3
MO
fluoxetine hcl soln or 20
mg/5ml
fluoxetine hcl tabs or 10
mg, 20 mg
FLUOXETINE HCL TABS
OR 60 MG
fluvoxamine maleate cp24
100 mg, 150 mg
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
19
Drug Name
fluvoxamine maleate tabs
100 mg, 25 mg, 50 mg
LEXAPRO (Use
Escitalopram Oxalate)
LUVOX CR (Use
Fluvoxamine Maleate)
paroxetine hcl
PAXIL CR (Use
Paroxetine HCl)
Drug Requirements/
Tier Limits
2 MO; *
NF MO
NF MO
2
NF MO
PAXIL SUSP 10 MG/5ML
4
PAXIL TABS 10 MG, 20
MG, 30 MG, 40 MG (Use
Paroxetine HCl)
NF
PEXEVA
PROZAC (Use Fluoxetine
HCl)
PROZAC WEEKLY (Use
Fluoxetine HCl)
sertraline hcl conc or 20
mg/ml
sertraline hcl tabs or 100
mg, 25 mg, 50 mg
ZOLOFT (Use Sertraline
HCl)
MO; *
MO
MO
4
ST; MO
DESVENLAFAXINE ER
100 MG, 50 MG
DESVENLAFAXINE ER
100 MG, 50 MG
duloxetine hcl
EFFEXOR XR 150 MG
(Use Venlafaxine HCl)
EFFEXOR XR 37.5 MG
(Use Venlafaxine HCl)
EFFEXOR XR 75 MG (Use
Venlafaxine HCl)
FETZIMA 120 MG, 40 MG,
80 MG
FETZIMA 20 MG
Drug Requirements/
Tier Limits
4 ST; Fumarate
4
ST; MO
3
MO
NF QL(1 ea daily);
MO
NF QL(6 ea daily);
MO
NF QL(3 ea daily);
MO
4 ST; QL(1 ea
daily); MO
4 ST; QL(2 ea
daily); MO
4 ST; MO
NF MO
FETZIMA TITRATION
PACK
NF MO
KHEDEZLA
4
ST; MO
PRISTIQ
4
ST; MO
2
MO; *
1
MO; *
NF MO
Serotonin Modulators
BRINTELLIX 10 MG
4
BRINTELLIX 20 MG
4
BRINTELLIX 5 MG
4
nefazodone hcl
2
ST; QL(2 ea
daily); MO
ST; QL(1 ea
daily); MO
ST; QL(4 ea
daily); MO
MO; *
OLEPTRO
4
MO
trazodone hcl tabs or 100
mg, 150 mg, 300 mg, 50
mg
1
VIIBRYD
Drug Name
MO; *
4
ST; MO
Serotonin-Norepinephrine Reuptake Inhibitors
CYMBALTA (Use
NF MO
Duloxetine HCl)
venlafaxine hcl cp24 150
mg
venlafaxine hcl cp24 37.5
mg
3
3
venlafaxine hcl cp24 75 mg
3
venlafaxine hcl er 150 mg
2
VENLAFAXINE HCL ER
225 MG
4
venlafaxine hcl er 37.5 mg
2
venlafaxine hcl er 75 mg
2
venlafaxine hcl tabs 100
mg
2
venlafaxine hcl tabs 25 mg
2
venlafaxine hcl tabs 37.5
mg
2
venlafaxine hcl tabs 50 mg
2
venlafaxine hcl tabs 75 mg
2
QL(1 ea daily);
MO
QL(6 ea daily);
MO
QL(3 ea daily);
MO
QL(1 ea daily);
MO; *
ST; QL(1 ea
daily); MO
QL(6 ea daily);
MO; *
QL(3 ea daily);
MO; *
QL(3.5 ea
daily); MO; *
QL(15 ea
daily); MO; *
QL(10 ea
daily); MO; *
QL(7.5 ea
daily); MO; *
QL(5 ea daily);
MO; *
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
20
Drug Requirements/
Tier Limits
venlafaxine hcl tb24 150
2 QL(1 ea daily);
mg
MO; *
venlafaxine hcl tb24 37.5
2 QL(6 ea daily);
mg
MO; *
2 QL(3 ea daily);
venlafaxine hcl tb24 75 mg
MO; *
Drug Name
Tricyclic Agents
amitriptyline hcl
2
AL; MO; *
amoxapine 100 mg, 25 mg,
50 mg
1
MO; *
amoxapine 150 mg
2
MO; *
ANAFRANIL (Use
Clomipramine HCl)
clomipramine hcl caps or
25 mg, 50 mg
clomipramine hcl caps or
75 mg
desipramine hcl tabs or 10
mg, 100 mg, 150 mg, 25
mg, 50 mg, 75 mg
doxepin hcl caps or 10 mg,
100 mg, 150 mg, 25 mg, 50
mg, 75 mg
doxepin hcl conc or 10
mg/ml
imipramine hcl tabs or 10
mg, 25 mg, 50 mg
imipramine pamoate 100
mg
imipramine pamoate 125
mg, 150 mg, 75 mg
NORPRAMIN (Use
Desipramine HCl)
nortriptyline hcl caps or 10
mg, 25 mg, 50 mg, 75 mg
nortriptyline hcl soln or 10
mg/5ml
PAMELOR (Use
Nortriptyline HCl)
NF AL; MO
3
AL; MO
2
AL; MO; *
MO
4
Drug Name
TOFRANIL (Use
Imipramine HCl)
TOFRANIL-PM 100 MG
(Use Imipramine Pamoate)
TOFRANIL-PM 125 MG,
150 MG, 75 MG (Use
Imipramine Pamoate)
trimipramine maleate caps
or 100 mg
trimipramine maleate caps
or 25 mg, 50 mg
Drug Requirements/
Tier Limits
NF AL; MO
NF PA; MO
AL; MO
NF
2
AL; MO; *
4
AL; MO
ANTIDIABETICS - Drugs to Regulate Blood Sugar
Alpha-Glucosidase Inhibitors
acarbose
GLYSET
PRECOSE (Use
Acarbose)
QL(3 ea daily);
MO; *
6 QL(3 ea daily);
MO; *
NF QL(3 ea daily);
MO
6
Antidiabetic - Amylin Analogs
AL; MO; *
SYMLINPEN 120
4
SYMLINPEN 60
4
2
2
AL; MO; *
2
AL; MO; *
4
PA; MO
4
AL; MO
NF MO
1
MO; *
2
MO; *
NF MO
protriptyline hcl
1
MO; *
SURMONTIL
4
AL; MO
Antidiabetic Combinations
ACTOPLUS MET (Use
Pioglitazone HCl-Metformin
HCl)
ACTOPLUS MET XR
15MG-1000MG
ACTOPLUS MET XR
30MG-1000MG
AVANDAMET 2MG1000MG, 4MG-500MG
AVANDAMET 2MG-500MG
AVANDAMET 4MG1000MG
AVANDARYL 4MG-1MG,
4MG-2MG, 4MG-4MG,
8MG-4MG
AVANDARYL 8MG-2MG
QL(0.4 ml
daily); MO
QL(0.4 ml
daily); MO
QL(3 ea daily);
NF MO
6
6
6
6
6
6
6
QL(2 ea daily);
MO; *
QL(1 ea daily);
MO; *
QL(2 ea daily);
LA; MO; *
QL(4 ea daily);
LA; *
QL(2 ea daily);
LA; *
QL(1 ea daily);
LA; MO; *
QL(1 ea daily);
LA; *
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
21
Drug Name
DUETACT (Use
Pioglitazone HClGlimepiride)
glipizide-metformin hcl
2.5mg-250mg
glipizide-metformin hcl
2.5mg-500mg, 5mg-500mg
GLUCOVANCE 1.25MG250MG (Use GlyburideMetformin)
GLUCOVANCE 2.5MG500MG, 5MG-500MG (Use
Glyburide-Metformin)
glyburide-metformin
1.25mg-250mg
glyburide-metformin 2.5mg500mg, 5mg-500mg
INVOKAMET 150MG1000MG, 150MG-500MG,
50MG-1000MG
INVOKAMET 50MG500MG
JANUMET
JANUMET XR 100MG1000MG
JANUMET XR 50MG1000MG, 50MG-500MG
Drug Requirements/
Tier Limits
QL(1 ea daily);
NF MO
QL(8 ea daily);
MO; *
6 QL(4 ea daily);
MO; *
QL(8 ea daily);
NF AL; MO
QL(4 ea daily);
NF AL; MO
2
2
4
4
6
6
6
6
JUVISYNC 100MG-20MG
6
KAZANO
3
OSENI 12.5MG-15MG
OSENI 12.5MG-30MG,
12.5MG-45MG, 25MG15MG, 25MG-30MG,
25MG-45MG
pioglitazone hcl-glimepiride
pioglitazone hcl-metformin
hcl
PRANDIMET
6
JENTADUETO
KOMBIGLYZE XR 2.5MG1000MG
KOMBIGLYZE XR 5MG1000MG, 5MG-500MG
Drug Name
3
3
3
3
6
QL(8 ea daily);
AL; MO; *
QL(4 ea daily);
AL; MO; *
QL(2 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO; *
QL(1 ea daily);
MO; *
QL(2 ea daily);
MO; *
QL(2 ea daily);
MO; *
QL(1 ea daily);
*
QL(2 ea daily);
MO
QL(2 ea daily);
MO
QL(1 ea daily);
MO
QL(2 ea daily);
MO
QL(1 ea daily);
MO
QL(1 ea daily);
MO; *
Biguanides
FORTAMET 1000 MG (Use
Metformin HCl)
FORTAMET 500 MG (Use
Metformin HCl)
GLUCOPHAGE 1000 MG
(Use Metformin HCl)
GLUCOPHAGE 500 MG
(Use Metformin HCl)
GLUCOPHAGE 850 MG
(Use Metformin HCl)
GLUCOPHAGE XR 500
MG (Use Metformin HCl)
GLUCOPHAGE XR 750
MG (Use Metformin HCl)
GLUMETZA 1000 MG
GLUMETZA 500 MG
metformin hcl tabs or 1000
mg
metformin hcl tabs or 500
mg
metformin hcl tabs or 850
mg
metformin hcl tb24 or 1000
mg
metformin hcl tb24 or 500
mg
metformin hcl tb24 or 500
mg
metformin hcl tb24 or 750
mg
RIOMET
Drug Requirements/
Tier Limits
6 QL(3 ea daily);
MO; *
6 QL(5 ea daily);
MO; *
NF Osmotic;QL(2
ea daily); MO
NF Osmotic;QL(5
ea daily); MO
NF QL(2.5 ea
daily); MO
NF QL(5 ea daily);
MO
NF QL(3 ea daily);
MO
NF QL(4 ea daily);
MO
NF QL(2 ea daily);
MO
6 QL(2 ea daily);
MO; *
6 QL(4 ea daily);
MO; *
6 QL(2.5 ea
daily); MO; *
6 QL(5 ea daily);
MO; *
6 QL(3 ea daily);
MO; *
6 Osmotic;QL(2
ea daily); MO; *
6 QL(4 ea daily);
MO; *
6 Osmotic;QL(5
ea daily); MO; *
6 QL(2 ea daily);
MO; *
6 QL(25.5 ml
daily); MO; *
Diabetic Other
GLUCAGEN
3
MO
GLUCAGEN HYPOKIT
3
MO
glucagon emergency kit
1
MO; *
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
22
Drug Name
PROGLYCEM
Drug Requirements/
Tier Limits
4 MO
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
6 QL(1 ea daily);
JANUVIA 100 MG
MO; *
6 QL(4 ea daily);
JANUVIA 25 MG
MO; *
6 QL(2 ea daily);
JANUVIA 50 MG
MO; *
3 QL(1 ea daily);
NESINA
MO
3 QL(2 ea daily);
ONGLYZA 2.5 MG
MO
3 QL(1 ea daily);
ONGLYZA 5 MG
MO
6 QL(1 ea daily);
TRADJENTA
MO; *
Dopamine Receptor Agonists - Antidiabetic
4 QL(6 ea daily);
CYCLOSET
MO
Incretin Mimetic Agents (GLP-1 Receptor
6 ST; MO; *
BYDUREON
BYETTA
6
ST; MO; *
TANZEUM
4
ST; MO
VICTOZA
6
ST; MO; *
Insulin Sensitizing Agents
ACTOS (Use Pioglitazone
HCl)
AVANDIA 2 MG
AVANDIA 4 MG, 8 MG
pioglitazone hcl
NF QL(1 ea daily);
MO
6 QL(2 ea daily);
LA; MO; *
6 QL(1 ea daily);
LA; MO; *
6 QL(1 ea daily);
MO; *
Insulin
APIDRA
4
APIDRA SOLOSTAR
4
HUMALOG
3
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
Drug Requirements/
Tier Limits
3 QL(1.5 ml
HUMALOG KWIKPEN
daily); MO
3 QL(1.5 ml
HUMALOG MIX 50/50
daily); MO
HUMALOG MIX 50/50
3 QL(1.5 ml
KWIKPEN
daily); MO
3 QL(1.5 ml
HUMALOG MIX 75/25
daily); MO
HUMALOG MIX 75/25
3 QL(1.5 ml
KWIKPEN
daily); MO
3 QL(1.5 ml
HUMULIN 70/30
daily); MO
ml
HUMULIN 70/30 KWIKPEN 3 QL(1.5
daily); MO
3 QL(1.5 ml
HUMULIN 70/30 PEN
daily); MO
3 QL(1.5 ml
HUMULIN N
daily); MO
3 QL(1.5 ml
HUMULIN N KWIKPEN
daily); MO
3 QL(1.5 ml
HUMULIN N U-100 PEN
daily); MO
3 QL(1.5 ml
HUMULIN R
daily); MO
HUMULIN R U-500
3 QL(1.5 ml
(CONCENTRATED)
daily); MO
3 QL(1.5 ml
LANTUS
daily); MO
3 QL(1.5 ml
LANTUS SOLOSTAR
daily); MO
3 QL(1.5 ml
LEVEMIR
daily); MO
3 QL(1.5 ml
LEVEMIR FLEXPEN
daily); MO
3 QL(1.5 ml
LEVEMIR FLEXTOUCH
daily); MO
4 QL(1.5 ml
NOVOLIN 70/30
daily); MO
4 QL(1.5 ml
NOVOLIN 70/30 RELION
daily); MO
4 QL(1.5 ml
NOVOLIN N
daily); MO
4 QL(1.5 ml
NOVOLIN N RELION
daily); MO
4 QL(1.5 ml
NOVOLIN R
daily); MO
Drug Name
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
23
Drug Name
NOVOLIN R RELION
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30
PREFILLED FLEXPEN
NOVOLOG PENFILL
Drug Requirements/
Tier Limits
4 QL(1.5 ml
daily); MO
4 QL(1.5 ml
daily); MO
4 QL(1.5 ml
daily); MO
4 QL(1.5 ml
daily); MO
4 QL(1.5 ml
daily); MO
4 QL(1.5 ml
daily); MO
Meglitinide Analogues
nateglinide
PRANDIN 0.5 MG, 1 MG
(Use Repaglinide)
PRANDIN 2 MG (Use
Repaglinide)
repaglinide 0.5 mg, 1 mg
repaglinide 2 mg
STARLIX (Use
Nateglinide)
QL(3 ea daily);
MO; *
NF QL(4 ea daily);
MO
NF QL(8 ea daily);
MO
6 QL(4 ea daily);
MO; *
6 QL(8 ea daily);
MO; *
NF QL(3 ea daily);
MO
6
Sodium-Glucose Co-Transporter 2 (SGLT2)
4 MO
FARXIGA
INVOKANA 100 MG
3
INVOKANA 300 MG
3
Sulfonylureas
AMARYL (Use
Glimepiride)
chlorpropamide
DIABETA
glimepiride
glipizide tabs or 10 mg, 5
mg
glipizide tb24 or 10 mg, 2.5
mg, 5 mg
QL(2 ea daily);
MO
QL(1 ea daily);
MO
NF QL(2 ea daily);
MO
2 QL(2 ea daily);
AL; MO; *
4 QL(4 ea daily);
AL; MO
6 QL(2 ea daily);
MO; *
6 QL(4 ea daily);
MO; *
6 QL(2 ea daily);
MO; *
Drug Name
GLUCOTROL (Use
Glipizide)
GLUCOTROL XL (Use
Glipizide)
glyburide micronized 1.5
mg
glyburide micronized 3 mg
glyburide micronized 6 mg
glyburide tabs or 1.25 mg,
2.5 mg, 5 mg
GLYNASE 1.5 MG (Use
Glyburide Micronized)
GLYNASE 3 MG (Use
Glyburide Micronized)
GLYNASE 6 MG (Use
Glyburide Micronized)
tolazamide 250 mg
tolazamide 500 mg
tolbutamide
Drug Requirements/
Tier Limits
NF QL(4 ea daily);
MO
NF QL(2 ea daily);
MO
2 QL(8 ea daily);
AL; MO; *
2 QL(4 ea daily);
AL; MO; *
2 QL(2 ea daily);
AL; MO; *
2 QL(4 ea daily);
AL; MO; *
NF QL(8 ea daily);
AL; MO
NF QL(4 ea daily);
AL; MO
NF QL(2 ea daily);
AL; MO
6 QL(4 ea daily);
MO; *
6 QL(2 ea daily);
MO; *
6 QL(6 ea daily);
MO; *
ANTIDIARRHEALS - Drugs to Treat Diarrhea
Antidiarrheal - Chloride Channel Antagonists
4 PA; QL(2 ea
FULYZAQ
daily); MO
Antiperistaltic Agents
diphenoxylate w/ atropine
LOMOTIL (Use
Diphenoxylate w/ Atropine)
loperamide hcl caps or 2
mg
2
MO; *
NF MO
2
RX/OTC; MO; *
MOTOFEN
4
MO
opium tincture
5
MO
ANTIDOTES - Drugs to Treat Overdose or
Toxicity
Antidotes - Chelating Agents
CHEMET
4
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
24
Drug Name
EXJADE
Opioid Antagonists
naloxone hcl soln ij 1
mg/ml
naltrexone hcl tabs or
REVIA (Use Naltrexone
HCl)
Drug Requirements/
Tier Limits
5 LA
Drug Requirements/
Tier Limits
trimethobenzamide hcl soln 1 AL; MO; *
im 100 mg/ml
Drug Name
Antiemetics - Miscellaneous
2
*
1
MO; *
NF MO
ANTIEMETICS - Drugs to Treat Nausea and
Vomiting
CESAMET
4
MO; B/D
dronabinol 10 mg
5
MO; B/D
dronabinol 2.5 mg
2
MO; B/D; *
dronabinol 5 mg
4
MO; B/D
5
MO; B/D
MARINOL 10 MG, 5 MG
(Use Dronabinol)
MARINOL 2.5 MG (Use
Dronabinol)
5-HT3 Receptor Antagonists
granisetron hcl tabs or 1
3
mg
MO; B/D
ondansetron
2
MO; B/D; *
3
MO
2
MO; *
Substance P/Neurokinin 1 (NK1) Receptor
EMEND CAPS OR 125
4 MO; B/D
MG, 80 MG
4 PA; MO
EMEND CAPS OR 40 MG
2
MO; B/D; *
ANTIFUNGALS - Drugs to Treat Fungal Infections
2
MO; B/D; *
5
MO
ondansetron hcl soln ij 4
mg/2ml
ondansetron hcl soln ij 40
mg/20ml
ondansetron hcl soln or 4
mg/5ml
ondansetron hcl tabs or 24
mg, 4 mg, 8 mg
SANCUSO
ZOFRAN ODT (Use
Ondansetron)
ZOFRAN SOLN IJ 40
MG/20ML (Use
Ondansetron HCl)
ZOFRAN SOLN OR 4
MG/5ML (Use
Ondansetron HCl)
ZOFRAN TABS OR 4 MG,
8 MG (Use Ondansetron
HCl)
NF MO; B/D
MO
NF
Antifungal - Glucan Synthesis Inhibitors
ERAXIS 100 MG
4
MYCAMINE 100 MG
5
MO; B/D
NF
2
AL; MO; *
MO
Antifungals
ABELCET
5
AMBISOME
5
MO
amphotericin b solr ij 50 mg
1
MO; *
MO; B/D
NF
Antiemetics - Anticholinergic
meclizine hcl tabs or 12.5
2 RX/OTC; MO; *
mg, 25 mg
TIGAN (Use
NF AL; MO
Trimethobenzamide HCl)
4 MO
TRANSDERM-SCOP
trimethobenzamide hcl
caps or 300 mg
NF MO; B/D
ANCOBON 250 MG (Use
Flucytosine)
ANCOBON 500 MG (Use
Flucytosine)
NF
NF MO
flucytosine 250 mg
2
*
flucytosine 500 mg
2
MO; *
GRIFULVIN V (Use
Griseofulvin Microsize)
GRIS-PEG (Use
Griseofulvin Ultramicrosize)
NF MO
NF MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
25
Drug Requirements/
Tier Limits
griseofulvin microsize susp
2 MO; *
125 mg/5ml
griseofulvin microsize tabs
3 MO
500 mg
griseofulvin ultramicrosize
1 MO; *
125 mg
griseofulvin ultramicrosize
3 MO
250 mg
LAMISIL PACK 125 MG,
3 PA; MO
187.5 MG
LAMISIL TABS 250 MG
NF MO
(Use Terbinafine HCl)
1 MO; *
nystatin tabs or
Drug Name
terbinafine hcl tabs or
2
MO; *
Imidazole-Related Antifungals
DIFLUCAN (Use
NF MO
Fluconazole)
2 *
fluconazole in dextrose
fluconazole in nacl
200mg/100ml-0.9%,
400mg/200ml-0.9%
fluconazole susr or 10
mg/ml
fluconazole susr or 40
mg/ml
fluconazole tabs or 100
mg, 150 mg, 200 mg, 50
mg
*
1
2
MO; *
3
MO
MO; *
1
4
MO
ketoconazole tabs or
2
MO; *
ONMEL
SPORANOX CAPS 100
MG (Use Itraconazole)
SPORANOX PULSEPAK
(Use Itraconazole)
SPORANOX SOLN 10
MG/ML
VFEND IV (Use
Voriconazole)
VFEND TABS 200 MG, 50
MG (Use Voriconazole)
5
5
MO
5
MO
4
MO
NF MO
NF MO
Drug Requirements/
Tier Limits
5 MO
NF
5
MO
voriconazole solr iv 200 mg
2
*
voriconazole tabs or 200
mg, 50 mg
5
MO
ANTIHISTAMINES - Drugs to Treat Allergies
Antihistamines - Ethanolamines
carbinoxamine maleate
2
soln or 4 mg/5ml
carbinoxamine maleate
2
tabs or 4 mg
clemastine fumarate tabs
2
or 2.68 mg
diphenhydramine hcl soln ij
1
50 mg/ml
PALGIC (Use
NF
Carbinoxamine Maleate)
AL; MO; *
AL; MO; *
AL; MO; *
PA; MO; *
AL; MO
Antihistamines - Non-Sedating
cetirizine hcl soln 1 mg/ml
itraconazole caps or
NOXAFIL SOLN IV 300
MG/16.7ML
NOXAFIL SUSP OR 40
MG/ML
NOXAFIL TBEC OR 100
MG
Drug Name
cetirizine hcl syrp 1 mg/ml,
5 mg/5ml
CLARINEX REDITABS 5
MG (Use Desloratadine)
CLARINEX TABS 5 MG
(Use Desloratadine)
1
RX/OTC; MO; *
1
RX/OTC; MO; *
NF MO
NF MO
desloratadine tabs 5 mg
3
MO
desloratadine tbdp 5 mg
3
MO
levocetirizine
3
dihydrochloride soln 2.5
mg/5ml
levocetirizine
2
dihydrochloride tabs 5 mg
XYZAL (Use Levocetirizine NF
Dihydrochloride)
Antihistamines - Phenothiazines
PHENERGAN (Use
NF
Promethazine HCl)
MO
MO; *
MO
AL; MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
26
Drug Name
Drug Requirements/
Tier Limits
2 AL; MO; *
Drug Name
promethazine hcl soln ij 25
mg/ml, 50 mg/ml
promethazine hcl soln or
2 AL; MO; *
6.25 mg/5ml
promethazine hcl supp re
2 AL; MO; *
12.5 mg, 25 mg, 50 mg
promethazine hcl syrp or
2 AL; MO; *
6.25 mg/5ml
promethazine hcl tabs or
2 AL; MO; *
12.5 mg, 25 mg, 50 mg
Antihistamines - Piperidines
cyproheptadine hcl syrp or
2 AL; MO; *
2 mg/5ml
cyproheptadine hcl tabs or
2 AL; MO; *
4 mg
ANTIHYPERLIPIDEMICS - Drugs to Treat High
Cholesterol
Antihyperlipidemics - Combinations
COLESTID (Use
Colestipol HCl)
COLESTID FLAVORED
GRAN 5 GM (Use
Colestipol HCl)
LIPTRUZET
3
VYTORIN 10MG-10MG
3
Fibric Acid Derivatives
ANTARA 130 MG (Use
Fenofibrate Micronized)
VYTORIN 10MG-20MG
3
VYTORIN 40MG-10MG
3
VYTORIN 80MG-10MG
3
QL(8 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
PA; QL(1 ea
daily); MO
KYNAMRO
5
PA; LA
LOVAZA (Use Omega-3acid Ethyl Esters)
4
MO
omega-3-acid ethyl esters
2
MO; *
4
MO
1
MO; *
2
MO; *
VASCEPA
Bile Acid Sequestrants
cholestyramine light
cholestyramine pack or 4
gm
cholestyramine powd or 4
gm/dose
2
Powder
Canister;MO; *
MO
NF
colestipol hcl gran 5 gm
1
MO; *
colestipol hcl pack 5 gm
2
MO; *
colestipol hcl tabs 1 gm
1
MO; *
QUESTRAN LIGHT (Use
Cholestyramine Light)
QUESTRAN PACK 4 GM
(Use Cholestyramine)
QUESTRAN POWD 4
GM/DOSE (Use
Cholestyramine)
WELCHOL
ANTARA 30 MG
ANTARA 43 MG (Use
Fenofibrate Micronized)
ANTARA 90 MG
choline fenofibrate
Antihyperlipidemics - Misc.
Drug Requirements/
Tier Limits
NF MO
FENOFIBRATE CAPS 150
MG, 50 MG
fenofibrate micronized 130
mg
fenofibrate micronized 134
mg, 200 mg, 67 mg
fenofibrate micronized 43
mg
fenofibrate tabs 145 mg, 48
mg
fenofibrate tabs 160 mg, 54
mg
NF MO
NF MO
Powder
NF Canister;MO
4
MO
NF QL(1 ea daily);
MO
4 QL(3 ea daily);
MO
NF QL(3 ea daily);
MO
4 QL(1 ea daily);
MO
2 MO; *
4
2
1
MO
QL(1 ea daily);
MO; *
MO; *
2
QL(3 ea daily);
MO; *
MO; *
1
MO; *
FENOGLIDE
4
MO
gemfibrozil tabs or
1
MO; *
2
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
27
Drug Name
LIPOFEN
Drug Requirements/
Tier Limits
4 MO
Drug Name
simvastatin tabs or 20 mg
LOFIBRA (Use
Fenofibrate Micronized)
LOFIBRA (Use
Fenofibrate)
NF MO
simvastatin tabs or 40 mg
NF MO
simvastatin tabs or 5 mg
LOPID (Use Gemfibrozil)
NF MO
simvastatin tabs or 80 mg
TRICOR (Use Fenofibrate)
NF MO
TRIGLIDE 50 MG
TRILIPIX (Use Choline
Fenofibrate)
4
NF MO
HMG CoA Reductase Inhibitors
ADVICOR
4
MO
ALTOPREV
4
MO
atorvastatin calcium
6
MO; *
CRESTOR
4
ST; MO
fluvastatin sodium
6
MO; *
LESCOL (Use Fluvastatin
Sodium)
LESCOL XL
LIPITOR (Use Atorvastatin
Calcium)
NF MO
4
MO
NF MO
LIVALO
4
MO
lovastatin
6
MO; *
MEVACOR (Use
Lovastatin)
PRAVACHOL (Use
Pravastatin Sodium)
pravastatin sodium
SIMCOR 20MG-1000MG,
20MG-500MG, 20MG750MG
SIMCOR 40MG-1000MG,
40MG-500MG
simvastatin tabs or 10 mg
NF MO
NF MO
6
MO; *
4
QL(2 ea daily);
MO
4
6
QL(1 ea daily);
MO
QL(8 ea daily);
MO; *
ZOCOR 10 MG (Use
Simvastatin)
ZOCOR 20 MG (Use
Simvastatin)
ZOCOR 40 MG (Use
Simvastatin)
ZOCOR 5 MG (Use
Simvastatin)
ZOCOR 80 MG (Use
Simvastatin)
Drug Requirements/
Tier Limits
6 QL(4 ea daily);
MO; *
6 QL(2 ea daily);
MO; *
6 QL(16 ea
daily); MO; *
6 QL(1 ea daily);
MO; *
NF QL(8 ea daily);
MO
NF QL(4 ea daily);
MO
NF QL(2 ea daily);
MO
NF QL(16 ea
daily); MO
NF QL(1 ea daily);
MO
Intestinal Cholesterol Absorption Inhibitors
3 MO
ZETIA
Microsomal Triglyceride Transfer Protein (MTP)
5 PA; QL(6 ea
JUXTAPID 10 MG
daily); LA
5 PA; QL(3 ea
JUXTAPID 20 MG
daily); LA
5 PA; QL(12 ea
JUXTAPID 5 MG
daily); LA
Nicotinic Acid Derivatives
niacin (antihyperlipidemic)
NIASPAN (Use Niacin
(Antihyperlipidemic))
2
MO; *
NF MO
ANTIHYPERTENSIVES - Drugs to Treat High
Blood Pressure
ACE Inhibitors
ACCUPRIL (Use Quinapril
HCl)
ACEON 4 MG (Use
Perindopril Erbumine)
ACEON 8 MG (Use
Perindopril Erbumine)
ALTACE (Use Ramipril)
NF MO
NF QL(4 ea daily);
MO
NF QL(2 ea daily);
MO
NF MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
28
Drug Name
benazepril hcl tabs or 10
mg, 20 mg, 40 mg, 5 mg
captopril tabs or 100 mg,
12.5 mg, 25 mg, 50 mg
enalapril maleate tabs or
10 mg
enalapril maleate tabs or
2.5 mg
enalapril maleate tabs or
20 mg
enalapril maleate tabs or 5
mg
Drug Requirements/
Tier Limits
6 MO; *
6
ZESTRIL (Use Lisinopril)
Agents for Pheochromocytoma
enalaprilat
6
fosinopril sodium
6
MO; *
lisinopril tabs or 10 mg, 2.5
mg, 20 mg, 30 mg, 40 mg,
5 mg
LOTENSIN (Use
Benazepril HCl)
MAVIK (Use Trandolapril)
moexipril hcl
perindopril erbumine 2 mg
perindopril erbumine 4 mg
perindopril erbumine 8 mg
PRINIVIL (Use Lisinopril)
6
6
6
MO; *
6
NF MO
NF MO
6
MO; *
6 QL(8 ea daily);
MO; *
6 QL(4 ea daily);
MO; *
6 QL(2 ea daily);
MO; *
NF MO
quinapril hcl
6
MO; *
ramipril
6
MO; *
trandolapril
6
MO; *
UNIVASC (Use Moexipril
HCl)
VASOTEC 10 MG (Use
Enalapril Maleate)
VASOTEC 2.5 MG (Use
Enalapril Maleate)
VASOTEC 20 MG (Use
Enalapril Maleate)
VASOTEC 5 MG (Use
Enalapril Maleate)
Drug Requirements/
Tier Limits
NF QL(8 ea daily);
MO
NF MO
MO; *
QL(4 ea daily);
MO; *
QL(16 ea
daily); MO; *
QL(2 ea daily);
MO; *
QL(8 ea daily);
MO; *
*
6
Drug Name
NF MO
NF QL(4 ea daily);
MO
NF QL(16 ea
daily); MO
NF QL(2 ea daily);
MO
DEMSER
5
MO
DIBENZYLINE
4
MO
Angiotensin II Receptor Antagonists
ATACAND (Use
NF MO
Candesartan Cilexetil)
AVAPRO (Use Irbesartan) NF MO
BENICAR
3
MO
candesartan cilexetil
6
MO; *
COZAAR (Use Losartan
Potassium)
NF MO
DIOVAN (Use Valsartan)
3
MO
EDARBI
4
MO
eprosartan mesylate
6
MO; *
irbesartan
6
MO; *
losartan potassium
6
MO; *
MICARDIS (Use
Telmisartan)
4
MO
telmisartan
2
MO; *
TEVETEN 400 MG
6
*
TEVETEN 600 MG (Use
Eprosartan Mesylate)
valsartan
NF MO
2
MO; *
Antiadrenergic Antihypertensives
CARDURA (Use
NF MO
Doxazosin Mesylate)
CATAPRES (Use
NF MO
Clonidine HCl)
CATAPRES-TTS-1 (Use
NF MO
Clonidine HCl)
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
29
Drug Name
CATAPRES-TTS-2 (Use
Clonidine HCl)
CATAPRES-TTS-3 (Use
Clonidine HCl)
clonidine hcl ptwk td 0.1
mg/24hr, 0.2 mg/24hr, 0.3
mg/24hr
clonidine hcl tabs or 0.1
mg, 0.2 mg, 0.3 mg
doxazosin mesylate
guanfacine hcl
methyldopa tabs or 250
mg, 500 mg
MINIPRESS (Use
Prazosin HCl)
prazosin hcl
reserpine tabs or 0.1 mg,
0.25 mg
TENEX (Use Guanfacine
HCl)
terazosin hcl
Drug Requirements/
Tier Limits
NF MO
NF MO
MO; *
1
1
1
MO; *
2
AL; MO; *
2
AL; MO; *
NF MO
1
MO; *
2
MO; *
NF AL; MO
1
Antihypertensive Combinations
ACCURETIC (Use
NF
QuinaprilHydrochlorothiazide)
amlodipine besylate6
benazepril hcl
amlodipine besylate2
valsartan
amlodipine-valsartan2
hydrochlorothiazide
AMTURNIDE
ATACAND HCT (Use
Candesartan CilexetilHydrochlorothiazide)
atenolol & chlorthalidone
AVALIDE (Use IrbesartanHydrochlorothiazide)
AZOR
MO; *
3
MO; *
MO
MO; *
MO; *
MO; *
MO
MO
NF
1
MO; *
NF MO
3
MO
Drug Name
benazepril &
hydrochlorothiazide
BENICAR HCT
bisoprolol &
hydrochlorothiazide
candesartan cilexetilhydrochlorothiazide
CAPTOPRIL/HYDROCHL
OROTHIAZIDE
CORZIDE (Use Nadolol &
Bendroflumethiazide)
DIOVAN HCT (Use
ValsartanHydrochlorothiazide)
EDARBYCLOR
enalapril maleate &
hydrochlorothiazide
EXFORGE (Use
Amlodipine BesylateValsartan)
EXFORGE HCT (Use
Amlodipine-ValsartanHydrochlorothiazide)
fosinopril sodium &
hydrochlorothiazide
HYZAAR (Use Losartan
Potassium &
Hydrochlorothiazide)
irbesartanhydrochlorothiazide
lisinopril &
hydrochlorothiazide
LOPRESSOR HCT (Use
Metoprolol &
Hydrochlorothiazide)
losartan potassium &
hydrochlorothiazide
LOTENSIN HCT (Use
Benazepril &
Hydrochlorothiazide)
LOTREL (Use Amlodipine
Besylate-Benazepril HCl)
metoprolol &
hydrochlorothiazide
100mg-25mg, 50mg-25mg
Drug Requirements/
Tier Limits
6 MO; *
3
MO
1
MO; *
6
MO; *
6
MO; *
NF MO
MO
NF
4
MO
6
MO; *
MO
3
MO
3
6
MO; *
MO
NF
6
MO; *
6
MO; *
MO
NF
6
MO; *
MO
NF
NF MO
MO; *
1
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
30
Drug Name
metoprolol &
hydrochlorothiazide
100mg-50mg
MICARDIS HCT (Use
TelmisartanHydrochlorothiazide)
moexiprilhydrochlorothiazide
nadolol &
bendroflumethiazide 40mg5mg
nadolol &
bendroflumethiazide 80mg5mg
quinaprilhydrochlorothiazide
Drug Requirements/
Tier Limits
MO; *
2
MO
4
6
MO; *
Drug Name
Drug Requirements/
Tier Limits
Selective Aldosterone Receptor Antagonists
1 MO; *
eplerenone 25 mg
eplerenone 50 mg
INSPRA (Use Eplerenone)
2
MO; *
NF MO
MO; *
Vasodilators
hydralazine hcl tabs or 10
mg, 100 mg, 25 mg, 50 mg
minoxidil tabs or 10 mg, 2.5
mg
6
MO; *
ANTIMALARIALS - Drugs to Treat Malaria
(Parasitic Infections)
TEKAMLO
3
MO
TEKTURNA HCT
3
MO
telmisartan-amlodipine
2
MO; *
2
MO; *
telmisartanhydrochlorothiazide
TENORETIC 100 (Use
Atenolol & Chlorthalidone)
TENORETIC 50 (Use
Atenolol & Chlorthalidone)
TRIBENZOR
TWYNSTA (Use
Telmisartan-Amlodipine)
UNIRETIC (Use MoexiprilHydrochlorothiazide)
valsartanhydrochlorothiazide
VASERETIC (Use
Enalapril Maleate &
Hydrochlorothiazide)
ZESTORETIC (Use
Lisinopril &
Hydrochlorothiazide)
ZIAC (Use Bisoprolol &
Hydrochlorothiazide)
MO; *
1
2
COARTEM
NF MO
NF MO
3
MO
4
MO
NF MO
6
Antimalarials
ARALEN (Use
Chloroquine Phosphate)
chloroquine phosphate tabs
or 250 mg, 500 mg
1
MO; *
3
MO
2
MO; *
3
MO
MO
NF
MO
4
NF MO
1
MO; *
DARAPRIM
4
MO
MO
hydroxychloroquine sulfate
tabs or
2
MO; *
mefloquine hcl
1
MO; *
NF
MO
NF
NF MO
3
MALARONE 250MG100MG (Use AtovaquoneProguanil HCl)
MALARONE 62.5MG25MG (Use AtovaquoneProguanil HCl)
MO; *
MO; *
Direct Renin Inhibitors
TEKTURNA
Antimalarial Combinations
atovaquone-proguanil hcl
250mg-100mg
atovaquone-proguanil hcl
62.5mg-25mg
1
MO
PLAQUENIL (Use
Hydroxychloroquine
Sulfate)
PRIMAQUINE
PHOSPHATE TABS OR
QUALAQUIN (Use Quinine
Sulfate)
MO
NF
4
MO
NF PA; MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
31
Drug Name
quinine sulfate caps or
Drug Requirements/
Tier Limits
3 PA; MO
Drug Name
Drug Requirements/
Tier Limits
SIRTURO
5
ANTIMYASTHENIC/CHOLINERGIC AGENTS
TRECATOR
4
Antimyasthenic/Cholinergic Agents
2 *
guanidine hcl
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES - Drugs to Treat Cancer
MESTINON TABS 60 MG
(Use Pyridostigmine
Bromide)
MESTINON TIMESPAN
MO
NF
4
MO
pyridostigmine bromide
2 MO; *
tabs or
ANTIMYCOBACTERIAL AGENTS - Drugs to
Treat Tuberculosis (Bacterial Infections)
Anti TB Combinations
2 MO; *
rifamate
RIFATER
4
MO
Antimycobacterial Agents
CAPASTAT SULFATE
ethambutol hcl tabs or 100
mg, 400 mg
isoniazid tabs or 100 mg,
300 mg
MYAMBUTOL (Use
Ethambutol HCl)
MYCOBUTIN (Use
Rifabutin)
4
1
MO; *
1
MO; *
NF MO
4
MO
paser
2
MO; *
PRIFTIN
4
MO
pyrazinamide
1
MO; *
rifabutin
2
MO; *
RIFADIN (Use Rifampin)
rifampin caps or 150 mg,
300 mg
rifampin solr iv 600 mg
NF MO
2
MO; *
2
MO; *
Alkylating Agents
ALKERAN SOLR IV 50 MG
(Use Melphalan HCl)
4
ALKERAN TABS OR 2 MG
4
BICNU
4
BUSULFEX
4
carboplatin soln iv 150
mg/15ml, 600 mg/60ml
carboplatin soln iv 450
mg/45ml, 50 mg/5ml
CEENU (Use Lomustine)
cisplatin soln iv 100
mg/100ml, 50 mg/50ml
CISPLATIN SOLN IV 200
MG/200ML
cyclophosphamide solr ij 1
gm, 500 mg
cyclophosphamide tabs or
25 mg
cyclophosphamide tabs or
50 mg
ELOXATIN 100 MG/20ML
(Use Oxaliplatin)
ELOXATIN 50 MG/10ML
(Use Oxaliplatin)
MO
B/D
1
*
1
MO; *
3
4
4
1
MO; *
1
B/D; *
1
MO; B/D; *
NF MO
5
MO
HEXALEN
5
MO
IFEX (Use Ifosfamide)
4
ifosfamide soln 1 gm/20ml,
3 gm/60ml
2
*
ifosfamide solr 1 gm
2
*
IFOSFAMIDE SOLR 3 GM
4
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
32
Drug Name
LEUKERAN
Drug Requirements/
Tier Limits
4 MO
lomustine 10 mg
1
*
lomustine 100 mg, 40 mg
2
*
melphalan hcl
2
*
MUSTARGEN
4
Drug Name
FLUDARA (Use
Fludarabine Phosphate)
fludarabine phosphate solr
50 mg
fluorouracil soln iv 1
gm/20ml
fluorouracil soln iv 2.5
gm/50ml, 500 mg/10ml
Drug Requirements/
Tier Limits
4 MO
2
4
4
FOLOTYN
5
GEMCITABINE
5
gemcitabine hcl 1 gm
1
5
gemcitabine hcl 2 gm
5
5
gemcitabine hcl 200 mg
5
TREANDA
5
ZANOSAR
4
GEMZAR 1 GM (Use
Gemcitabine HCl)
GEMZAR 200 MG (Use
Gemcitabine HCl)
oxaliplatin soln 100
mg/20ml
2
MO; *
oxaliplatin soln 50 mg/10ml
5
MO
oxaliplatin solr 100 mg, 50
mg
TEMODAR SOLR IV 100
MG
MO
Antimetabolites
ALIMTA 100 MG
5
ALIMTA 500 MG
5
ARRANON
5
azacitidine
5
cladribine
2
CLOLAR
4
cytarabine soln 100 mg/ml
1
cytarabine soln 20 mg/ml
1
cytarabine soln 20 mg/ml
cytarabine solr 500 mg
DACOGEN (Use
Decitabine)
decitabine
mercaptopurine tabs or
MO
MO; *
*
methotrexate sodium soln ij
1 gm/40ml, 100 mg/4ml,
200 mg/8ml, 25 mg/ml, 250
mg/10ml, 50 mg/2ml
methotrexate sodium soln ij
25 mg/ml
methotrexate sodium solr ij
1 gm
methotrexate sodium tabs
or 2.5 mg
PURINETHOL (Use
Mercaptopurine)
MO; *
MO
MO; *
MO
NF MO
5
MO
2
MO; *
1
Preservative
Free;MO; *
2
MO; *
2
*
1
MO; *
NF MO
PURIXAN
5
2
Preservative
Free;MO; *
MO; *
TABLOID
3
MO
2
*
trexall 10 mg, 15 mg
1
MO; *
trexall 5 mg, 7.5 mg
2
MO; *
VIDAZA (Use Azacitidine)
5
NF
2
*
Antineoplastic - Angiogenesis Inhibitors
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
33
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
AVASTIN
5
ELIGARD
4
CYRAMZA
5
EMCYT
4
MO
ZALTRAP
5
exemestane
3
MO
FARESTON
5
MO
FASLODEX
5
MO
Antineoplastic - Antibodies
ARZERRA
5
BLINCYTO
5
ERBITUX
5
GAZYVA
5
HERCEPTIN
5
KADCYLA
5
KEYTRUDA
5
PA
OPDIVO
5
PA
PERJETA
5
RITUXAN
5
VECTIBIX
5
YERVOY
5
PA
FEMARA (Use Letrozole)
Antineoplastic - Hormonal and Related Agents
2 MO; *
anastrozole tabs or
bicalutamide
CASODEX (Use
Bicalutamide)
DEPO-PROVERA
NF MO
NF MO
2
MO; *
NF MO
4
FIRMAGON 120 MG
5
FIRMAGON 80 MG
4
flutamide
3
MO
letrozole
2
MO; *
leuprolide acetate kit ij
1
*
LUPRON DEPOT
5
LYSODREN
3
LA
Antineoplastic - Hedgehog Pathway Inhibitors
5 LA
ERIVEDGE
ARIMIDEX (Use
Anastrozole)
AROMASIN (Use
Exemestane)
NF MO
MO
MEGACE ORAL (Use
Megestrol Acetate)
megestrol acetate susp or
40 mg/ml, 400 mg/10ml
megestrol acetate tabs or
20 mg, 40 mg
MO
NF AL; MO
2
AL; MO; *
2
AL; MO; *
NILANDRON
5
MO
SOLTAMOX
4
MO
tamoxifen citrate tabs or 10
mg, 20 mg
2
MO; *
TRELSTAR DEPOT
5
TRELSTAR DEPOT
MIXJECT
5
TRELSTAR LA
5
TRELSTAR LA MIXJECT
5
TRELSTAR MIXJECT
5
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
34
Drug Name
Drug Requirements/
Tier Limits
VANTAS
5
XTANDI
5
ZOLADEX
4
ZYTIGA
5
Drug Name
VALSTAR
PA; LA
Drug Requirements/
Tier Limits
5
Antineoplastic Enzyme Inhibitors
AFINITOR
5
AFINITOR DISPERZ
5
Antineoplastic - Immunomodulators
5 LA
POMALYST
BELEODAQ
5
BOSULIF
5
PA
Antineoplastic Antibiotics
CAPRELSA
5
LA
COMETRIQ
5
LA
COMETRIQ
5
GILOTRIF
5
GLEEVEC
5
ICLUSIG
5
LA
IMBRUVICA
5
PA; LA
INLYTA
5
PA; LA
ISTODAX
5
bleomycin sulfate 15 unit
2
MO; *
bleomycin sulfate 30 unit
2
*
4
MO
2
*
COSMEGEN (Use
Dactinomycin)
daunorubicin hcl inj 5
mg/ml
DAUNOXOME
4
140 MG Dose
Kit;LA; MO
LA
DOXIL (Use Doxorubicin
HCl Liposomal)
NF
doxorubicin hcl liposomal
2
*
doxorubicin hcl soln 2
mg/ml
1
MO; *
doxorubicin hcl solr 10 mg
1
*
JAKAFI
5
LA
doxorubicin hcl solr 50 mg
1
MO; *
LYNPARZA
5
PA
4
MO
MEKINIST
5
4
MO
NEXAVAR
5
2
MO; *
SPRYCEL
5
STIVARGA
5
ELLENCE (Use Epirubicin
HCl)
epirubicin hcl soln 200
mg/100ml
epirubicin hcl soln 50
mg/25ml
IDAMYCIN PFS (Use
Idarubicin HCl)
4
idarubicin hcl
2
*
SUTENT
5
mitomycin solr iv 20 mg, 40
mg, 5 mg
2
MO; *
TAFINLAR
5
mitoxantrone hcl
2
*
TARCEVA
5
TASIGNA
5
LA
PA; LA
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
35
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
TORISEL
5
SYLATRON
5
TYKERB
5
SYNRIBO
5
VELCADE
5
TARGRETIN
5
VOTRIENT
5
THERACYS
5
MO
XALKORI
5
TICE BCG
5
MO
ZELBORAF
5
tretinoin (chemotherapy)
5
MO
ZOLINZA
5
TRISENOX
4
MO
ZYDELIG
5
PA; LA
UVADEX
4
ZYKADIA
5
PA; LA
Chemotherapy Adjuncts
LA
Antineoplastic Enzymes
ELITEK
5
5
MO
ERWINAZE
5
KEPIVANCE
ONCASPAR
5
Chemotherapy Rescue/Antidote Agents
2 MO; *
amifostine crystalline
Antineoplastics Misc.
ACTIMMUNE
5
LA
dexrazoxane 250 mg
4
dacarbazine solr iv 100 mg
2
*
dexrazoxane 500 mg
2
*
dacarbazine solr iv 200 mg
2
MO; *
ETHYOL (Use Amifostine
Crystalline)
4
MO
FUSILEV
4
HYDREA (Use
Hydroxyurea)
NF MO
MO; *
leucovorin calcium solr ij
100 mg, 200 mg, 350 mg
leucovorin calcium solr ij 50
mg, 500 mg
leucovorin calcium tabs or
10 mg, 15 mg, 25 mg, 5 mg
hydroxyurea caps or
2
INTRON A
5
INTRON-A 10 MU/ML
5
INTRON-A 6000000
UNIT/ML
4
mesna
INTRON-A W/DILUENT
5
MATULANE
5
NIPENT
4
MESNEX SOLN IV 100
MG/ML (Use Mesna)
MESNEX TABS OR 400
MG
PROLEUKIN
5
LA
2
MO; *
2
*
2
MO; *
2
MO; *
4
MO
5
MO
TOTECT
4
ZINECARD (Use
Dexrazoxane)
4
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
36
Drug Name
Drug Requirements/
Tier Limits
Mitotic Inhibitors
ABRAXANE
5
DOCEFREZ
5
DOCETAXEL CONC 140
MG/7ML, 20 MG/ML, 80
MG/2ML, 80 MG/4ML
DOCETAXEL CONC 20
MG/0.5ML
docetaxel conc 20 mg/ml,
80 mg/4ml
DOCETAXEL SOLN 160
MG/16ML, 20 MG/2ML, 80
MG/8ML
ETOPOPHOS
etoposide soln iv 1
gm/50ml, 100 mg/5ml
etoposide soln iv 500
mg/25ml
5
5
MO
5
2
MO; *
topotecan hcl solr 4 mg
2
MO; *
4
MO
Antiparkinson Adjuvants
carbidopa tabs or
2
MO; *
2
MO; *
4
2
LODOSYN (Use
Carbidopa)
MO
*
5
IXEMPRA KIT
5
JEVTANA
5
NF MO
2
MO; *
paclitaxel 150 mg/25ml
2
*
TAXOL (Use Paclitaxel)
4
MO
TAXOTERE (Use
Docetaxel)
vinblastine sulfate soln 1
mg/ml
vinblastine sulfate solr 10
mg
irinotecan hcl
ANTIPARKINSON AGENTS - Drugs to Treat
Parkinson's Disease
5
HALAVEN
NAVELBINE (Use
Vinorelbine Tartrate)
paclitaxel 100 mg/16.7ml,
30 mg/5ml, 300 mg/50ml
MO
Drug Requirements/
Tier Limits
CAMPTOSAR 100
MO
4
MG/5ML, 40 MG/2ML (Use
Irinotecan HCl)
CAMPTOSAR 300
4
MG/15ML
HYCAMTIN SOLR IV 4 MG
4 MO
(Use Topotecan HCl)
2 *
irinotecan
Drug Name
5
2
MO; *
2
*
vincristine sulfate
1
MO; *
vinorelbine tartrate
2
MO; *
Topoisomerase I Inhibitors
Antiparkinson Anticholinergics
benztropine mesylate soln
2
ij 1 mg/ml
benztropine mesylate tabs
2
or 0.5 mg, 1 mg, 2 mg
COGENTIN (Use
4
Benztropine Mesylate)
trihexyphenidyl hcl
2
MO; *
AL; MO; *
MO
AL; MO; *
Antiparkinson COMT Inhibitors
COMTAN (Use
NF QL(8 ea daily);
Entacapone)
MO
4 QL(8 ea daily);
entacapone
MO
4 MO
TASMAR
Antiparkinson Dopaminergics
amantadine hcl caps or 100 2
mg
amantadine hcl syrp or 50
2
mg/5ml
amantadine hcl tabs or 100
2
mg
APOKYN
5
MO; *
MO; *
MO; *
LA
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
37
Drug Name
bromocriptine mesylate
caps or 5 mg
bromocriptine mesylate
tabs or 2.5 mg
carbidopa-levodopa
carbidopa-levodopaentacapone
MIRAPEX (Use
Pramipexole
Dihydrochloride)
MIRAPEX ER
NEUPRO
PARCOPA (Use
Carbidopa-Levodopa)
PARLODEL (Use
Bromocriptine Mesylate)
pramipexole
dihydrochloride
REQUIP (Use Ropinirole
Hydrochloride)
REQUIP XL (Use
Ropinirole Hydrochloride)
ropinirole hydrochloride
tabs 0.25 mg, 0.5 mg, 1
mg, 2 mg, 3 mg, 4 mg, 5
mg
ropinirole hydrochloride
tb24 12 mg, 2 mg, 4 mg, 6
mg, 8 mg
SINEMET (Use
Carbidopa-Levodopa)
SINEMET CR (Use
Carbidopa-Levodopa)
STALEVO 100 (Use
Carbidopa-LevodopaEntacapone)
STALEVO 125 (Use
Carbidopa-LevodopaEntacapone)
STALEVO 150 (Use
Carbidopa-LevodopaEntacapone)
Drug Requirements/
Tier Limits
1 MO; *
Drug Name
Drug Requirements/
Tier Limits
MO
NF
MO
STALEVO 200 (Use
Carbidopa-LevodopaEntacapone)
STALEVO 50 (Use
Carbidopa-LevodopaEntacapone)
STALEVO 75 (Use
Carbidopa-LevodopaEntacapone)
4
MO
Antiparkinson Monoamine Oxidase Inhibitors
3 MO
AZILECT
4
MO
ELDEPRYL (Use
Selegiline HCl)
1
MO; *
2
MO; *
2
MO; *
NF
MO
NF
MO
NF
NF MO
NF MO
selegiline hcl caps or
2
MO; *
NF MO
selegiline hcl tabs or
2
MO; *
ZELAPAR
4
MO
2
MO; *
NF MO
NF MO
MO; *
2
MO
3
NF MO
NF MO
MO
NF
MO
NF
MO
NF
ANTIPSYCHOTICS/ANTIMANIC AGENTS Drugs to Treat Mood Disorders
Antimanic Agents
lithium
lithium carbonate caps or
150 mg, 300 mg, 600 mg
lithium carbonate tabs or
300 mg
lithium carbonate tbcr or
300 mg, 450 mg
LITHOBID (Use Lithium
Carbonate)
Antipsychotics - Misc.
EQUETRO
1
MO; *
2
MO; *
2
MO; *
2
MO; *
NF MO
4
GEODON CAPS OR 20
MG, 40 MG, 60 MG, 80 MG
(Use Ziprasidone HCl)
NF
GEODON SOLR IM 20 MG
4
LATUDA 120 MG
5
LATUDA 20 MG
5
MO
MO
MO
PA; QL(1 ea
daily); MO
PA; QL(8 ea
daily); MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
38
Drug Name
LATUDA 40 MG
LATUDA 60 MG
LATUDA 80 MG
ziprasidone hcl
Benzisoxazoles
FANAPT 1 MG, 10 MG, 12
MG, 2 MG, 4 MG
Drug Requirements/
Tier Limits
5 PA; QL(4 ea
daily); MO
4 PA; QL(2.67 ea
daily); MO
5 PA; QL(2 ea
daily); MO
4 MO
4
MO
FANAPT 6 MG, 8 MG
5
MO
FANAPT TITRATION
PACK
4
INVEGA 1.5 MG
5
INVEGA 3 MG
5
INVEGA 6 MG
5
INVEGA 9 MG
5
INVEGA SUSTENNA 117
MG/0.75ML, 156 MG/ML,
234 MG/1.5ML
INVEGA SUSTENNA 39
MG/0.25ML, 78 MG/0.5ML
RISPERDAL (Use
Risperidone)
RISPERDAL CONSTA
12.5 MG
RISPERDAL CONSTA 25
MG
RISPERDAL CONSTA
37.5 MG, 50 MG
RISPERDAL M-TAB (Use
Risperidone)
risperidone soln 1 mg/ml
risperidone tabs 0.25 mg,
0.5 mg, 1 mg, 2 mg, 3 mg,
4 mg
risperidone tbdp 0.25 mg, 3
mg, 4 mg
QL(8 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(1 ea daily);
MO
MO
5
4
MO
NF MO
4 QL(0.29 ea
daily); MO
4 QL(0.15 ea
daily); MO
5 QL(0.08 ea
daily); MO
NF MO
3
MO
MO; *
2
2
MO; *
Drug Name
risperidone tbdp 0.5 mg, 1
mg, 2 mg
Butyrophenones
HALDOL (Use Haloperidol
Lactate)
HALDOL DECANOATE
100 (Use Haloperidol
Decanoate)
HALDOL DECANOATE 50
(Use Haloperidol
Decanoate)
Drug Requirements/
Tier Limits
3 MO
NF MO
MO
NF
MO
NF
haloperidol
2
MO; *
haloperidol decanoate
2
MO; *
haloperidol lactate
1
MO; *
Dibenzapines
ADASUVE
4
clozapine 100 mg, 25 mg
3
clozapine 200 mg, 50 mg
2
CLOZAPINE ODT
4
CLOZARIL (Use
Clozapine)
NF
*
FAZACLO
4
loxapine succinate caps or
10 mg, 25 mg, 5 mg, 50 mg
2
MO; *
loxitane 10 mg, 25 mg
2
MO; *
olanzapine solr im 10 mg
3
MO
olanzapine tabs or 10 mg,
15 mg, 2.5 mg, 20 mg, 5
mg, 7.5 mg
olanzapine tbdp or 10 mg,
15 mg, 20 mg, 5 mg
MO
3
4
MO
quetiapine fumarate
3
MO
SAPHRIS 10 MG
4
SAPHRIS 5 MG
4
QL(2 ea daily);
MO
QL(4 ea daily);
MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
39
Drug Name
SEROQUEL (Use
Quetiapine Fumarate)
SEROQUEL XR 150 MG,
200 MG, 300 MG, 50 MG
SEROQUEL XR 400 MG
VERSACLOZ
ZYPREXA (Use
Olanzapine)
ZYPREXA ZYDIS (Use
Olanzapine)
Phenothiazines
chlorpromazine hcl soln ij
25 mg/ml
chlorpromazine hcl tabs or
10 mg, 100 mg, 200 mg, 25
mg, 50 mg
COMPAZINE (Use
Prochlorperazine Maleate)
fluphenazine decanoate
soln ij
fluphenazine hcl conc or 5
mg/ml
fluphenazine hcl soln ij 2.5
mg/ml
fluphenazine hcl tabs or 1
mg, 10 mg, 2.5 mg, 5 mg
perphenazine tabs or 16
mg, 2 mg, 4 mg, 8 mg
prochlorperazine
prochlorperazine edisylate
soln ij
prochlorperazine maleate
tabs or 10 mg, 5 mg
thioridazine hcl tabs or 10
mg, 100 mg, 25 mg, 50 mg
trifluoperazine hcl
Quinolinone Derivatives
ABILIFY DISCMELT 10
MG
ABILIFY DISCMELT 15
MG
Drug Requirements/
Tier Limits
NF MO
MO
Drug Requirements/
Tier Limits
5 QL(0.04 ea
ABILIFY MAINTENA
daily); MO
ABILIFY SOLN IM 9.75
4 QL(4 ml daily);
MG/1.3ML
MO
ABILIFY SOLN OR 1
5 QL(30 ml
MG/ML
daily); MO
5 QL(3 ea daily);
ABILIFY TABS OR 10 MG
MO
5 QL(2 ea daily);
ABILIFY TABS OR 15 MG
MO
5 QL(15 ea
ABILIFY TABS OR 2 MG
daily); MO
ABILIFY TABS OR 20 MG,
5 QL(1 ea daily);
30 MG
MO
5 QL(6 ea daily);
ABILIFY TABS OR 5 MG
MO
4
MO
Thioxanthenes
thiothixene caps or 1 mg,
10 mg, 2 mg, 5 mg
2
MO; *
ANTISEPTICS & DISINFECTANTS - Drugs to
Prevent Bacterial Skin Infections
2
MO; *
Chlorine Antiseptics
2
MO; *
2
MO; *
2
MO; *
abacavir sulfate
4
MO
2
MO; *
abacavir sulfatelamivudine-zidovudine
5
MO
2
MO; *
APTIVUS CAPS 250 MG
5
MO
2
MO; *
APTIVUS SOLN 100
MG/ML
3
2
AL; MO; *
ATRIPLA
5
MO
MO; *
COMBIVIR (Use
Lamivudine-Zidovudine)
5
MO
1
COMPLERA
5
MO
CRIXIVAN
4
MO
didanosine 125 mg
2
MO; *
4
PA; MO
5
PA; MO
PA; QL(18 ml
daily)
NF MO
5
NF MO
2
MO; *
3
5
5
Drug Name
PHISOHEX
2
MO; *
3
ANTIVIRALS - Drugs to Treat Viral Infections
QL(3 ea daily);
MO
QL(2 ea daily);
MO
Antiretrovirals
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
40
Drug Name
didanosine 200 mg, 250
mg, 400 mg
Drug Requirements/
Tier Limits
1 MO; *
Drug Name
NEVIRAPINE SUSP 50
MG/5ML
Drug Requirements/
Tier Limits
4 MO
EDURANT
5
MO
nevirapine tabs 200 mg
3
MO
EMTRIVA
4
MO
nevirapine tb24 400 mg
2
MO; *
3
MO
NORVIR
4
MO
3
MO
PREZISTA SUSP 100
MG/ML
5
MO
NF MO
PREZISTA TABS 150 MG
4
MO
MO
PREZISTA TABS 400 MG
5
PREZISTA TABS 600 MG,
800 MG
5
PREZISTA TABS 75 MG
4
RESCRIPTOR 100 MG
3
MO
RESCRIPTOR 200 MG
4
RETROVIR (Use
Zidovudine)
4
QL(6 ea daily);
MO
QL(24 ea
daily); MO
QL(2 ea daily)
5
EPIVIR HBV (Use
Lamivudine)
EPIVIR SOLN 10 MG/ML
(Use Lamivudine)
EPIVIR TABS 150 MG, 300
MG (Use Lamivudine)
EPZICOM
5
FUZEON
5
INTELENCE 100 MG, 200
MG
5
INTELENCE 25 MG
4
INVIRASE
5
ISENTRESS CHEW 100
MG
4
ISENTRESS CHEW 25 MG
3
ISENTRESS PACK 100
MG
ISENTRESS TABS 400
MG
KALETRA SOLN
400MG/5ML-100MG/5ML
KALETRA TABS 100MG25MG
KALETRA TABS 200MG50MG
lamivudine soln 10 mg/ml
lamivudine tabs 100 mg
NF MO
4
REYATAZ CAPS 100 MG
5
MO
REYATAZ CAPS 150 MG,
200 MG, 300 MG
5
MO
REYATAZ PACK 50 MG
5
PA
5
MO
SELZENTRY
5
MO
4
MO
stavudine caps 15 mg
2
MO; *
5
MO
stavudine caps 20 mg, 30
mg, 40 mg
1
MO; *
stavudine solr 1 mg/ml
2
MO; *
STRIBILD
5
MO
SUSTIVA CAPS 200 MG,
50 MG
4
MO
SUSTIVA TABS 600 MG
5
MO
TIVICAY
5
MO
2
MO; *
2
MO; *
3
lamivudine-zidovudine
5
LEXIVA TABS 700 MG
MO
RETROVIR IV INFUSION
lamivudine tabs 150 mg,
300 mg
LEXIVA SUSP 50 MG/ML
MO
MO
3
5
MO
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
41
Drug Name
TRIUMEQ
Drug Requirements/
Tier Limits
5 MO
TRIZIVIR (Use Abacavir
Sulfate-LamivudineZidovudine)
5
TRUVADA
5
TYBOST
4
VIDEX EC (Use
Didanosine)
MO
MO
NF MO
MO
VIRACEPT
5
MO
4
MO
NF MO
VIRAMUNE XR 100 MG
4
VIRAMUNE XR 400 MG
(Use Nevirapine)
5
MO
VIREAD POWD 40 MG/GM
5
MO
5
MO
ZERIT (Use Stavudine)
ZIAGEN SOLN 20 MG/ML
ZIAGEN TABS 300 MG
(Use Abacavir Sulfate)
5
NF MO
3
MO
NF MO
zidovudine caps 100 mg
1
MO; *
zidovudine syrp 50 mg/5ml
2
MO; *
zidovudine tabs 300 mg
1
MO; *
CMV Agents
cidofovir
CYTOVENE (Use
Ganciclovir Sodium)
ganciclovir sodium
5
NF MO
2
valganciclovir hcl
5
VISTIDE (Use Cidofovir)
5
adefovir dipivoxil
4
VIREAD TABS 150 MG,
300 MG
VIREAD TABS 200 MG,
250 MG
VALCYTE (Use
Valganciclovir HCl)
Drug Requirements/
Tier Limits
5 MO
MO
Hepatitis Agents
VIDEXPEDIATRIC
VIRAMUNE SUSP 50
MG/5ML
VIRAMUNE TABS 200 MG
(Use Nevirapine)
Drug Name
MO; *
BARACLUDE SOLN 0.05
MG/ML
BARACLUDE TABS 0.5
MG, 1 MG (Use Entecavir)
COPEGUS (Use Ribavirin
(Hepatitis C))
5
MO
4
MO
5
MO
NF
entecavir
5
MO
HARVONI
5
PA
HEPSERA (Use Adefovir
Dipivoxil)
5
MO
INCIVEK
5
PA
MODERIBA
5
MODERIBA 1200 DOSE
PACK
5
OLYSIO
5
PEG-INTRON
5
PEG-INTRON REDIPEN
5
PEG-INTRON REDIPEN
PAK 4
5
PEGASYS
5
PEGASYS PROCLICK
5
PEGINTRON
5
REBETOL CAPS 200 MG
(Use Ribavirin (Hepatitis
C))
REBETOL SOLN 40
MG/ML
RIBASPHERE 600 MG
PA
NF
3
5
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
42
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
4 MO
RIBASPHERE RIBAPAK
5
RELENZA DISKHALER
RIBATAB TABS 600 MG
5
rimantadine hydrochloride
1
MO; *
4
TAMIFLU
4
MO
4
Respiratory Syncytial Virus (RSV) Agents
ribavirin (hepatitis c) caps
200 mg
ribavirin (hepatitis c) tabs
200 mg
VIRAZOLE
4
SOVALDI
5
PA
TYZEKA
5
MO
5
PA
2
MO; *
2
*
2
MO; *
2
MO; *
REVLIMID
5
2
MO; *
THALOMID
5
famciclovir 125 mg
2
MO; *
famciclovir 250 mg, 500 mg
3
MO
VICTRELIS
Herpes Agents
acyclovir caps or 200 mg
acyclovir sodium soln 50
mg/ml
acyclovir sodium solr 500
mg
acyclovir susp or 200
mg/5ml
acyclovir tabs or 400 mg,
800 mg
FAMVIR (Use Famciclovir)
valacyclovir hcl tabs or 1
gm, 1000 mg, 500 mg
VALTREX (Use
Valacyclovir HCl)
ZOVIRAX CAPS OR 200
MG (Use Acyclovir)
ZOVIRAX SUSP OR 200
MG/5ML (Use Acyclovir)
ZOVIRAX TABS OR 400
MG, 800 MG (Use
Acyclovir)
Influenza Agents
FLUMADINE (Use
Rimantadine
Hydrochloride)
DEPEN TITRATABS
3
MO
SYPRINE
5
MO
Enzymes
5
Immunomodulators
NF MO
NF MO
MO
NF
MO
LA
Immunosuppressive Agents
ASTAGRAF XL
4
MO; B/D
ATGAM
4
B/D
azasan
2
MO; B/D; *
azathioprine tabs or
2
MO; B/D; *
MO
NF MO
NF
Chelating Agents
XIAFLEX
NF MO
3
ASSORTED CLASSES - Miscellaneous Drugs
CELLCEPT CAPS 250 MG
(Use Mycophenolate
Mofetil)
CELLCEPT
INTRAVENOUS
CELLCEPT SUSR 200
MG/ML (Use
Mycophenolate Mofetil)
CELLCEPT TABS 500 MG
(Use Mycophenolate
Mofetil)
cyclosporine caps or 100
mg, 25 mg
MO; B/D
NF
4
B/D
MO; B/D
5
MO; B/D
NF
3
MO; B/D
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
43
Drug Name
cyclosporine modified
cyclosporine modified (for
microemulsion) caps 100
mg, 25 mg
cyclosporine soln iv 50
mg/ml
IMURAN (Use
Azathioprine)
mycophenolate mofetil
caps 250 mg
mycophenolate mofetil susr
200 mg/ml
mycophenolate mofetil tabs
500 mg
mycophenolate sodium 180
mg
mycophenolate sodium 360
mg
MYFORTIC 180 MG (Use
Mycophenolate Sodium)
MYFORTIC 360 MG (Use
Mycophenolate Sodium)
NEORAL CAPS 100 MG,
25 MG (Use Cyclosporine
Modified (For
Microemulsion))
NULOJIX
PROGRAF CAPS OR 0.5
MG, 1 MG, 5 MG (Use
Tacrolimus)
PROGRAF SOLN IV 5
MG/ML
RAPAMUNE SOLN 1
MG/ML
RAPAMUNE TABS 0.5 MG
(Use Sirolimus)
RAPAMUNE TABS 1 MG,
2 MG (Use Sirolimus)
SANDIMMUNE CAPS OR
100 MG, 25 MG (Use
Cyclosporine)
SANDIMMUNE SOLN IV
50 MG/ML (Use
Cyclosporine)
Drug Requirements/
Tier Limits
2 MO; B/D; *
MO; B/D
3
2
B/D; *
Drug Name
SANDIMMUNE SOLN OR
100 MG/ML
Drug Requirements/
Tier Limits
4 MO; B/D
SIMULECT
5
B/D
sirolimus 0.5 mg, 1 mg
2
MO; B/D; *
sirolimus 2 mg
5
MO; B/D
tacrolimus caps or 0.5 mg,
1 mg, 5 mg
3
MO; B/D
THYMOGLOBULIN
3
B/D
ZORTRESS 0.25 MG
3
MO; B/D
ZORTRESS 0.5 MG, 0.75
MG
5
MO; B/D
2
*
1
MO; *
4
MO; B/D
3
MO; B/D
5
MO; B/D
3
MO; B/D
2
MO; B/D; *
5
MO; B/D
Irrigation Solutions
irrigation solutions,
physiological
4
MO; B/D
water for irrigation, sterile
5
MO; B/D
Potassium Removing Resins
KAYEXALATE (Use
MO
NF
Sodium Polystyrene
Sulfonate)
sodium polystyrene
3 MO
sulfonate powd or
sodium polystyrene
MO; *
2
sulfonate susp or 15
gm/60ml
2 MO; *
sps
MO; B/D
NF
5
B/D
MO; B/D
NF
4
B/D
Systemic Lupus Erythematosus Agents
3
MO; B/D
BENLYSTA
3
MO; B/D
BETA BLOCKERS - Drugs to Treat High Blood
Pressure
5
MO; B/D
Alpha-Beta Blockers
MO; B/D
NF
B/D
4
5
carvedilol 12.5 mg
1
carvedilol 25 mg
1
carvedilol 3.125 mg
1
carvedilol 6.25 mg
1
QL(8 ea daily);
MO; *
QL(4 ea daily);
MO; *
QL(32 ea
daily); MO; *
QL(16 ea
daily); MO; *
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
44
Drug Name
COREG 12.5 MG (Use
Carvedilol)
COREG 25 MG (Use
Carvedilol)
COREG 3.125 MG (Use
Carvedilol)
COREG 6.25 MG (Use
Carvedilol)
COREG CR
Drug Requirements/
Tier Limits
NF QL(8 ea daily);
MO
NF QL(4 ea daily);
MO
NF QL(32 ea
daily); MO
NF QL(16 ea
daily); MO
4 MO
Drug Name
BETAPACE (Use Sotalol
HCl)
BETAPACE AF (Use
Sotalol HCl (AFIB/AFL))
Drug Requirements/
Tier Limits
NF MO
NF MO
CORGARD (Use Nadolol)
NF MO
INDERAL LA (Use
Propranolol HCl)
NF MO
INDERAL XL
4
MO
labetalol hcl tabs or 100
1
mg, 200 mg, 300 mg
TRANDATE (Use
NF
Labetalol HCl)
Beta Blockers Cardio-Selective
acebutolol hcl caps or 200
1
mg, 400 mg
atenolol tabs or 100 mg, 25
1
mg, 50 mg
MO; *
INNOPRAN XL
4
MO
MO
LEVATOL
4
MO
nadolol tabs or 20 mg, 40
mg, 80 mg
1
MO; *
pindolol
1
MO; *
1
MO; *
betaxolol hcl 10 mg
1
MO; *
betaxolol hcl 20 mg
2
MO; *
propranolol hcl cp24 or 120
mg, 160 mg, 60 mg, 80 mg
propranolol hcl tabs or 10
mg, 20 mg, 40 mg, 60 mg,
80 mg
sotalol hcl
1
MO; *
1
MO; *
sotalol hcl (afib/afl)
2
MO; *
4
MO
bisoprolol fumarate
BYSTOLIC
KERLONE (Use Betaxolol
HCl)
LOPRESSOR TABS OR
100 MG, 50 MG (Use
Metoprolol Tartrate)
metoprolol succinate
metoprolol tartrate tabs or
100 mg, 25 mg, 50 mg
SECTRAL (Use Acebutolol
HCl)
MO; *
MO; *
NF MO
MO
NF
BIOLOGICALS MISC - Drugs to Treat Low
Enzymes
Allergenic Extracts
GRASTEK
4
PA; MO
4
PA; MO
5
LA
1
MO; *
RAGWITEK
1
MO; *
Biologicals Misc
NF MO
TENORMIN (Use Atenolol)
NF MO
TOPROL XL (Use
Metoprolol Succinate)
ZEBETA (Use Bisoprolol
Fumarate)
NF MO
NF MO
Beta Blockers Non-Selective
MO; *
1
ADAGEN
CALCIUM CHANNEL BLOCKERS - Drugs to
Treat High Blood Pressure
Calcium Channel Blockers
ADALAT CC (Use
Nifedipine)
amlodipine besylate tabs or
10 mg
amlodipine besylate tabs or
2.5 mg
NF MO
1
1
QL(1 ea daily);
MO; *
QL(4 ea daily);
MO; *
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
45
Drug Requirements/
Tier Limits
amlodipine besylate tabs or 1 QL(2 ea daily);
5 mg
MO; *
CALAN (Use Verapamil
NF MO
HCl)
CALAN SR (Use
NF MO
Verapamil HCl)
CARDIZEM (Use Diltiazem NF MO
HCl)
CARDIZEM CD (Use
MO
NF
Diltiazem HCl Coated
Beads)
4 MO
CARDIZEM LA 120 MG
Drug Name
CARDIZEM LA 180 MG,
240 MG, 300 MG, 360 MG,
420 MG (Use Diltiazem
HCl Coated Beads)
DILACOR XR (Use
Diltiazem HCl)
diltiazem hcl coated beads
diltiazem hcl cp12 or 120
mg, 60 mg, 90 mg
diltiazem hcl cp24 or 120
mg, 180 mg, 240 mg
diltiazem hcl extended
release beads
diltiazem hcl tabs or 120
mg, 30 mg, 60 mg, 90 mg
felodipine
ISOPTIN SR (Use
Verapamil HCl)
nicardipine hcl caps or 20
mg, 30 mg
nifedipine caps or 10 mg,
20 mg
nifedipine tb24 or 30 mg,
60 mg, 90 mg
nimodipine caps or
nisoldipine 17 mg, 34 mg,
8.5 mg
NORVASC 10 MG (Use
Amlodipine Besylate)
NORVASC 2.5 MG (Use
Amlodipine Besylate)
MO
NF
NF MO
Drug Name
NORVASC 5 MG (Use
Amlodipine Besylate)
NYMALIZE
Drug Requirements/
Tier Limits
NF QL(2 ea daily);
MO
5
PROCARDIA (Use
Nifedipine)
PROCARDIA XL (Use
Nifedipine)
NF AL; MO
SULAR (Use Nisoldipine)
NF MO
TIAZAC (Use Diltiazem
HCl Extended Release
Beads)
verapamil hcl cp24 or 100
mg, 120 mg, 180 mg, 200
mg, 240 mg, 300 mg, 360
mg
verapamil hcl tabs or 120
mg, 40 mg, 80 mg
verapamil hcl tbcr or 120
mg, 180 mg, 240 mg
VERELAN (Use Verapamil
HCl)
VERELAN PM (Use
Verapamil HCl)
NF MO
MO
NF
MO; *
1
1
MO; *
1
MO; *
1
MO; *
1
MO; *
1
MO; *
1
MO; *
CARDIOTONICS - Drugs to Treat Heart Failure
and Abnormal Heart Rhythm
1
MO; *
1
MO; *
Cardiac Glycosides
DIGOXIN SOLN OR 0.05
MG/ML
digoxin tabs or 0.125 mg,
0.25 mg, 125 mcg, 250
mcg
NF MO
1
MO; *
2
AL; MO; *
LANOXIN PEDIATRIC
1
MO; *
2
MO; *
1
MO; *
NF QL(1 ea daily);
MO
NF QL(4 ea daily);
MO
LANOXIN TABS OR 125
MCG, 250 MCG (Use
Digoxin)
LANOXIN TABS OR 187.5
MCG, 62.5 MCG
NF MO
NF MO
4
MO
MO; *
2
4
AL
MO
4
4
MO
CARDIOVASCULAR AGENTS - MISC. - Drugs to
Treat Heart and Circulation Conditions
Cardiovascular Agents Misc. - Combinations
amlodipine besylate2 MO; *
atorvastatin calcium
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
46
Drug Name
BIDIL
CADUET (Use Amlodipine
Besylate-Atorvastatin
Calcium)
Drug Requirements/
Tier Limits
4 MO
MO
4
Drug Name
ADEMPAS 2 MG
ADEMPAS 2.5 MG
Drug Requirements/
Tier Limits
5 PA; QL(3.75 ea
daily)
5 PA; QL(3 ea
daily)
CEPHALOSPORINS - Drugs to Treat Bacterial
Infections
Prostaglandin Vasodilators
ORENITRAM 0.125 MG
4
PA
Cephalosporins - 1st Generation
ORENITRAM 0.25 MG, 1
MG, 2.5 MG
5
PA
cefadroxil caps 500 mg
1
MO; *
5
LA; B/D
cefadroxil susr 250 mg/5ml
2
MO; *
REMODULIN
5
LA; B/D
cefadroxil susr 500 mg/5ml
1
MO; *
TYVASO
5
LA; B/D
cefadroxil tabs 1 gm
1
MO; *
TYVASO REFILL
5
LA; B/D
1
MO; *
TYVASO STARTER
VENTAVIS 10 MCG/ML
3
LA; B/D
2
MO; *
VENTAVIS 20 MCG/ML
5
LA; B/D
1
MO; *
2
MO; *
Pulmonary Hypertension - Endothelin Receptor
5 LA
LETAIRIS
OPSUMIT
5
TRACLEER
5
LA
Pulmonary Hypertension - Phosphodiesterase
5 PA
ADCIRCA
REVATIO SOLN IV 10
MG/12.5ML
REVATIO TABS OR 20
MG (Use Sildenafil Citrate
(Pulmonary Hypertension))
sildenafil citrate (pulmonary
hypertension)
5
PA
PA
5
5
PA
Pulmonary Hypertension - Sol Guanylate Cyclase
5 PA; QL(15 ea
ADEMPAS 0.5 MG
daily)
5 PA; QL(7.5 ea
ADEMPAS 1 MG
daily)
5 PA; QL(5 ea
ADEMPAS 1.5 MG
daily)
cefazolin sodium solr ij 1
gm, 10 gm
cefazolin sodium solr ij 500
mg
cephalexin caps 250 mg,
500 mg
cephalexin caps 750 mg
cephalexin susr 125
2
mg/5ml, 250 mg/5ml
KEFLEX 250 MG, 500 MG
NF
(Use Cephalexin)
KEFLEX 750 MG (Use
4
Cephalexin)
Cephalosporins - 2nd Generation
cefaclor caps 250 mg, 500
1
mg
MO; *
cefprozil susr 125 mg/5ml
2
MO; *
cefprozil susr 250 mg/5ml
1
MO; *
1
MO; *
cefprozil tabs 250 mg, 500
mg
CEFTIN SUSR 125
MG/5ML (Use Cefuroxime
Axetil)
CEFTIN TABS 250 MG,
500 MG (Use Cefuroxime
Axetil)
cefuroxime axetil
MO
MO
MO; *
MO
NF
MO
NF
2
MO; *
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
47
Drug Name
Drug Requirements/
Tier Limits
1 *
cefuroxime sodium ij 1.5
gm
cefuroxime sodium ij 7.5
2 *
gm
cefuroxime sodium ij 750
1 MO; *
mg
ZINACEF SOLR IJ 1.5 GM,
NF
7.5 GM (Use Cefuroxime
Sodium)
ZINACEF SOLR IJ 750 MG NF MO
(Use Cefuroxime Sodium)
Cephalosporins - 3rd Generation
4 QL(1 ea daily);
CEDAX CAPS 400 MG
MO
2 MO; *
cefdinir caps 300 mg
Drug Requirements/
Tier Limits
ceftriaxone sodium solr iv 2
2 QL(2 ea daily);
gm
MO; *
CLAFORAN IJ 1 GM, 10
MO
NF
GM, 2 GM (Use
Cefotaxime Sodium)
CLAFORAN IJ 500 MG
NF
(Use Cefotaxime Sodium)
FORTAZ SOLR IJ 1 GM, 2 NF MO
GM (Use Ceftazidime)
FORTAZ SOLR IJ 6 GM
NF
(Use Ceftazidime)
ROCEPHIN 1 GM (Use
NF QL(4 ea daily);
Ceftriaxone Sodium)
MO
ROCEPHIN 500 MG (Use
NF QL(8 ea daily);
Ceftriaxone Sodium)
MO
4 MO
SUPRAX CAPS 400 MG
Drug Name
2
MO; *
3
MO
cefotaxime sodium 1 gm
1
MO; *
cefotaxime sodium 10 gm,
2 gm
2
MO; *
cefotaxime sodium 500 mg
2
*
cefpodoxime proxetil
2
MO; *
ceftazidime solr ij 1 gm, 2
gm
3
MO
TEFLARO
ceftazidime solr ij 6 gm
1
*
CONTRACEPTIVES - Drugs to Prevent
Pregnancy
QL(1 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(16 ea
daily); MO; *
QL(8 ea daily);
MO
QL(4 ea daily);
*
MO
Combination Contraceptives - Oral
cefdinir susr 125 mg/5ml
cefdinir susr 250 mg/5ml
CEFTIBUTEN CAPS 400
MG
ceftriaxone sodium solr ij 1
gm
ceftriaxone sodium solr ij 2
gm
ceftriaxone sodium solr ij
250 mg
ceftriaxone sodium solr ij
500 mg
ceftriaxone sodium solr iv 1
gm
ceftriaxone sodium solr iv
10 gm
4
3
3
1
3
1
3
SUPRAX SUSR 500
MG/5ML
4
Cephalosporins - 4th Generation
cefepime hcl
CEFEPIME SOLN 1
GM/50ML, 2 GM/100ML
MAXIPIME IJ 1 GM, 2 GM
(Use Cefepime HCl)
3
MO
4
NF MO
Cephalosporins - 5th Generation
BEYAZ
BREVICON-28 (Use
Norethindrone & Eth
Estradiol)
DESOGEN (Use
Desogestrel & Ethinyl
Estradiol)
desogestrel & ethinyl
estradiol
desogestrel-ethinyl
estradiol (biphasic)
drospirenone-ethinyl
estradiol
4
4
MO
MO
NF
MO
NF
1
MO; *
1
MO; *
1
MO; *
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
48
Drug Name
ethynodiol diacet & eth
estrad
FEMCON FE (Use
Norethindrone & Ethinyl
Estradiol-Fe)
GENERESS FE
levonorgestrel & eth
estradiol
levonorgestrel-eth estradiol
(triphasic)
levonorgestrel-ethinyl
estradiol (91-day)
LO LOESTRIN FE
LO MINASTRIN FE
LOESTRIN 1.5/30-21 (Use
Norethindrone Acet & Eth
Estra)
LOESTRIN 1/20-21 (Use
Norethindrone Acet & Eth
Estra)
LOESTRIN FE 1.5/30 (Use
Norethin Acet & Estrad-Fe)
LOESTRIN FE 1/20 (Use
Norethin Acet & Estrad-Fe)
LOSEASONIQUE (Use
Levonorgestrel-Ethinyl
Estradiol (91-Day))
MINASTRIN 24 FE
MIRCETTE (Use
Desogestrel-Ethinyl
Estradiol (Biphasic))
MODICON (Use
Norethindrone & Eth
Estradiol)
NORDETTE-28 (Use
Levonorgestrel & Eth
Estradiol)
norethin acet & estrad-fe
75mg-20mcg-1mg, 75mg30mcg-1.5mg
norethindrone & eth
estradiol 0.4mg-35mcg,
1mg-35mcg
Drug Requirements/
Tier Limits
1 MO; *
MO
NF
4
MO
1
MO; *
1
MO; *
1
MO; *
4
MO
4
MO
NF
MO
NF
NF MO
NF MO
MO
NF
4
MO
MO
NF
MO
NF
MO
NF
MO; *
1
MO; *
1
Drug Name
norethindrone & eth
estradiol 0.5mg-35mcg
norethindrone & ethinyl
estradiol-fe
norethindrone acet & eth
estra
norethindrone-eth estradiol
(triphasic)
norgestimate-ethinyl
estradiol
norgestimate-ethinyl
estradiol (triphasic)
norgestrel & ethinyl
estradiol
NORINYL 1+35 (Use
Norethindrone & Eth
Estradiol)
ORTHO TRI-CYCLEN
(Use Norgestimate-Ethinyl
Estradiol (Triphasic))
ORTHO-CEPT (Use
Desogestrel & Ethinyl
Estradiol)
ORTHO-CYCLEN (Use
Norgestimate-Ethinyl
Estradiol)
ORTHO-NOVUM 1/35
(Use Norethindrone & Eth
Estradiol)
ORTHO-NOVUM 7/7/7
(Use Norethindrone-Eth
Estradiol (Triphasic))
OVCON-35 (Use
Norethindrone & Eth
Estradiol)
Drug Requirements/
Tier Limits
2 MO; *
2
MO; *
1
MO; *
2
MO; *
1
MO; *
1
MO; *
1
MO; *
MO
NF
MO
NF
MO
NF
MO
NF
MO
NF
MO
NF
MO
NF
QUARTETTE
4
MO
SAFYRAL
4
MO
SEASONIQUE (Use
Levonorgestrel-Ethinyl
Estradiol (91-Day))
YASMIN 28 (Use
Drospirenone-Ethinyl
Estradiol)
YAZ (Use DrospirenoneEthinyl Estradiol)
MO
NF
MO
NF
NF MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
49
Drug Name
Drug Requirements/
Tier Limits
Combination Contraceptives - Transdermal
norelgestromin-ethinyl
2 MO; *
estradiol
ORTHO EVRA (Use
MO
3
Norelgestromin-Ethinyl
Estradiol)
Combination Contraceptives - Vaginal
3 MO
NUVARING
budesonide cp24 or
CELESTONE
CELESTONE-SOLUSPAN
(Use Betamethasone Sod
Phosphate & Acetate)
CORTEF (Use
Hydrocortisone)
cortisone acetate tabs or
Emergency Contraceptives
ELLA
Drug Name
3
levonorgestrel (emergency
1 *
oc) 0.75 mg
levonorgestrel (emergency
1 RX/OTC; *
oc) 1.5 mg
PLAN B (Use
NF
Levonorgestrel
(Emergency OC))
PLAN B ONE-STEP (Use
RX/OTC
4
Levonorgestrel
(Emergency OC))
Progestin Contraceptives - Injectable
DEPO-PROVERA
MO
CONTRACEPTIVE (Use
NF
Medroxyprogesterone
Acetate (Contraceptive))
DEPO-SUBQ PROVERA
MO
4
104
medroxyprogesterone
MO; *
1
acetate (contraceptive)
Progestin Contraceptives - Oral
NOR-QD (Use
MO
NF
Norethindrone
(Contraceptive))
norethindrone
1 MO; *
(contraceptive)
ORTHO MICRONOR (Use
MO
NF
Norethindrone
(Contraceptive))
CORTICOSTEROIDS - Steroid Hormone Drugs to
Treat Systemic Swelling Conditions
Glucocorticosteroids
betamethasone sod
1 MO; *
phosphate & acetate
DEPO-MEDROL 20
MG/ML
DEPO-MEDROL 40
MG/ML, 80 MG/ML (Use
Methylprednisolone
Acetate)
dexamethasone elix or 0.5
mg/5ml
dexamethasone sodium
phosphate soln ij 10 mg/ml,
120 mg/30ml
dexamethasone sodium
phosphate soln ij 100
mg/10ml, 20 mg/5ml, 4
mg/ml
dexamethasone soln or 0.5
mg/5ml
dexamethasone tabs or 0.5
mg, 0.75 mg, 1 mg, 1.5 mg,
2 mg, 4 mg, 6 mg
Drug Requirements/
Tier Limits
5 MO
4
MO
4
NF MO
1
MO; *
4
MO
MO
NF
2
MO; *
*
1
MO; *
1
2
MO; *
MO; *
1
dexpak 10 day
2
MO; *
dexpak 13 day
2
MO; *
dexpak 6 day
2
MO; *
ENTOCORT EC (Use
Budesonide)
5
MO
FLO-PRED
4
MO
hydrocortisone tabs or 10
mg, 20 mg, 5 mg
2
MO; *
KENALOG-10
4
MO
KENALOG-40
4
MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
50
Drug Requirements/
Tier Limits
MEDROL 16 MG, 32 MG, 4
MO
NF
MG, 8 MG (Use
Methylprednisolone)
3 MO
MEDROL 2 MG
Drug Name
MEDROL DOSEPAK (Use
Methylprednisolone)
methylprednisolone acetate
susp ij 40 mg/ml, 80 mg/ml
methylprednisolone sod
succ
methylprednisolone tabs or
16 mg, 32 mg, 4 mg, 8 mg
MILLIPRED TABS 5 MG
NF MO
1
MO; *
1
MO; *
2
MO; *
4
MO
ORAPRED (Use
MO
NF
Prednisolone Sodium
Phosphate)
ORAPRED ODT 15 MG, 30
MO
4
MG (Use Prednisolone
Sodium Phosphate)
PEDIAPRED (Use
MO
4
Prednisolone Sodium
Phosphate)
1 MO; *
prednisolone
prednisolone sodium
phosphate soln or 15
mg/5ml, 5 mg/5ml, 6.7
mg/5ml
prednisolone sodium
phosphate soln or 25
mg/5ml
prednisolone sodium
phosphate tbdp or 15 mg,
30 mg
prednisone intensol
prednisone soln or 5
mg/5ml
prednisone tabs or 1 mg,
10 mg, 2.5 mg, 20 mg, 5
mg, 50 mg
prednisone tabs or 10 mg,
5 mg
PRELONE (Use
Prednisolone)
MO; *
1
Drug Name
RAYOS 2 MG, 5 MG
SOLU-CORTEF 100 MG,
250 MG
SOLU-MEDROL 1000 MG,
125 MG, 40 MG (Use
Methylprednisolone Sod
Succ)
Drug Requirements/
Tier Limits
4 MO
4
MO
MO
NF
SOLU-MEDROL 2 GM
4
UCERIS
5
MO
2
MO; *
Mineralocorticoids
fludrocortisone acetate tabs
or
COUGH/COLD/ALLERGY - Drugs to Treat
Cough, Cold and Allergy Symptoms
Cough/Cold/Allergy Combinations
CLARINEX-D 12 HOUR
4
MO
CLARINEX-D 24 HOUR
4
MO
promethazine &
phenylephrine
2
AL; MO; *
SEMPREX-D
4
MO
1
MO; B/D; *
Mucolytics
acetylcysteine soln in 10 %,
20 %
MO; *
DERMATOLOGICALS - Drugs to Treat Skin
Conditions
MO; *
Acne Products
2
2
ACANYA
4
MO
2
MO; *
adapalene crea 0.1 %
1
MO; *
2
MO; *
adapalene gel 0.1 %
3
MO
MO; *
adapalene gel 0.3 %
2
MO; *
ATRALIN
4
MO
AZELEX
4
MO
1
Dose Pack;MO;
*
NF MO
2
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
51
Drug Name
BENZACLIN (Use
Clindamycin PhosphateBenzoyl Peroxide)
BENZACLIN WITH PUMP
(Use Clindamycin
Phosphate-Benzoyl
Peroxide)
BENZAMYCIN (Use
Benzoyl PeroxideErythromycin)
benzoyl peroxideerythromycin
CLEOCIN-T (Use
Clindamycin Phosphate
(Topical))
clindamycin phosphate
(topical) foam
clindamycin phosphate
(topical) gel
clindamycin phosphate
(topical) lotn
clindamycin phosphate
(topical) soln
clindamycin phosphate
(topical) swab
clindamycin phosphatebenzoyl peroxide
clindamycin phosphatebenzoyl peroxide
(refrigerate)
DIFFERIN CREA 0.1 %
(Use Adapalene)
DIFFERIN GEL 0.1 % (Use
Adapalene)
DIFFERIN GEL 0.3 % (Use
Adapalene)
DUAC (Use Clindamycin
Phosphate-Benzoyl
Peroxide (Refrigerate))
EPIDUO
ERYGEL (Use
Erythromycin (Acne Aid))
Drug Requirements/
Tier Limits
MO
NF
MO
Drug Name
EVOCLIN (Use
Clindamycin Phosphate
(Topical))
Drug Requirements/
Tier Limits
MO
NF
FABIOR
4
isotretinoin caps or 10 mg
2
QL(1.67 gm
daily); MO
*
isotretinoin caps or 20 mg
1
*
isotretinoin caps or 40 mg
4
NF
MO
NF
1
MO; *
MO
NF
3
MO
2
MO; *
2
MO; *
2
MO; *
2
MO; *
3
MO
MO
3
NF MO
NF MO
4
MO
MO
NF
4
KLARON (Use
Sulfacetamide Sodium
(Acne))
NF
RETIN-A (Use Tretinoin)
NF MO
RETIN-A MICRO (Use
Tretinoin Microsphere)
RETIN-A MICRO PUMP
0.04 %, 0.1 % (Use
Tretinoin Microsphere)
RETIN-A MICRO PUMP
0.08 %
sulfacetamide sodium
(acne)
tretinoin crea ex 0.025 %,
0.05 %, 0.1 %
tretinoin gel ex 0.01 %,
0.025 %
NF MO
MO
MO
NF
4
MO
1
MO; *
2
MO; *
2
MO; *
tretinoin microsphere
4
MO
VELTIN
4
MO
ZIANA
4
MO
Agents for External Genital and Perianal Warts
4 MO
VEREGEN
Anti-inflammatory Agents - Topical
MO
NF MO
erythromycin (acne aid) gel
1
MO; *
erythromycin (acne aid)
soln
1
MO; *
diclofenac sodium (topical)
2
MO; *
FLECTOR
4
PA; MO
PENNSAID (Use
Diclofenac Sodium
(Topical))
4
MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
52
Drug Name
VOLTAREN
Drug Requirements/
Tier Limits
4 MO
Antibiotics - Topical
ALTABAX
BACTROBAN (Use
Mupirocin Calcium
(Topical))
BACTROBAN (Use
Mupirocin)
CORTISPORIN CREA EX
10000UNIT/GM-0.5%-0.5%
CORTISPORIN OINT EX
400UNIT/GM5000UNIT/GM-0.5%-1%
4
MO
MO
NF
NF MO
3
MO
MO
3
Drug Name
LOPROX (Use Ciclopirox)
LOPROX SHAMPOO (Use
Ciclopirox)
LOTRISONE (Use
Clotrimazole w/
Betamethasone)
Drug Requirements/
Tier Limits
NF MO
NF MO
MO
NF
LUZU
4
MO
NAFTIN
4
MO
NIZORAL (Use
Ketoconazole (Topical))
NF MO
nystatin (topical)
2
MO; *
2
MO; *
nystatin-triamcinolone
3
MO
mupirocin calcium (topical)
2
MO; *
OXISTAT
4
MO
mupirocin oint ex
PENLAC NAIL LACQUER
(Use Ciclopirox)
Antifungals - Topical
NF MO
ciclopirox gel 0.77 %
3
MO
ciclopirox olamine crea ex
2
MO; *
ciclopirox olamine susp ex
2
MO; *
ciclopirox sham 1 %
3
MO
ciclopirox soln 8 %
2
MO; *
fluorouracil (topical)
4
MO
clotrimazole (topical)
2
RX/OTC; MO; *
FLUOROURACIL CREA
EX 0.5 %
3
MO
2
MO; *
PANRETIN
5
MO
3
MO
PICATO
5
MO
econazole nitrate
2
MO; *
5
EXELDERM SOLN
4
MO
SOLARAZE (Use
Diclofenac Sodium (Actinic
Keratoses))
TARGRETIN
5
VALCHLOR
5
PA
acitretin
5
MO
calcipotriene crea
4
MO
clotrimazole w/
betamethasone crea
clotrimazole w/
betamethasone lotn
EXTINA (Use
Ketoconazole (Topical))
NF MO
2
MO; *
ketoconazole (topical) foam
3
MO
ketoconazole (topical)
sham
2
MO; *
ketoconazole (topical) crea
Antineoplastic or Premalignant Lesion Agents 3 MO
CARAC
diclofenac sodium (actinic
keratoses)
EFUDEX (Use Fluorouracil
(Topical))
5
MO
NF MO
MO
Antipsoriatics
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
53
Drug Name
calcipotriene oint
calcipotriene soln
CALCITRIOL OINT EX 3
MCG/GM
DOVONEX (Use
Calcipotriene)
Drug Requirements/
Tier Limits
4 MO
3
MO
alclometasone dipropionate
1
MO; *
4
MO
amcinonide crea
3
MO
2
MO; *
NF MO
MO
5
MO
5
MO
4
MO
STELARA
5
PA;
TAZORAC
3
MO
VECTICAL
4
MO
OXSORALEN ULTRA
(Use Methoxsalen Rapid)
SORIATANE (Use
Acitretin)
SORILUX
Antiseborrheic Products
selenium sulfide lotn ex 2.5
%
SELSUN SHAMPOO (Use
Selenium Sulfide)
Antivirals - Topical
acyclovir topical
2
MO; *
NF MO
4
MO
betamethasone
dipropionate (topical)
betamethasone
dipropionate augmented
crea
betamethasone
dipropionate augmented
gel
betamethasone
dipropionate augmented
lotn
betamethasone
dipropionate augmented
oint
betamethasone valerate
crea ex 0.1 %
betamethasone valerate
foam ex 0.12 %
betamethasone valerate
lotn ex 0.1 %
betamethasone valerate
oint ex 0.1 %
calcipotrienebetamethasone
dipropionate
DENAVIR
4
MO
XERESE
4
MO
CAPEX
ZOVIRAX CREA EX 5 %
4
MO
clobetasol propionate crea
ex
clobetasol propionate
emollient base
clobetasol propionate
emulsion
clobetasol propionate foam
ex
clobetasol propionate gel
ex
clobetasol propionate liqd
ex
ZOVIRAX OINT EX 5 %
(Use Acyclovir Topical)
Burn Products
SILVADENE (Use Silver
Sulfadiazine)
Drug Requirements/
Tier Limits
MO
NF
ACLOVATE (Use
Alclometasone
Dipropionate)
5
methoxsalen rapid
Drug Name
NF MO
NF MO
silver sulfadiazine crea ex
2
MO; *
SULFAMYLON CREA 85
MG/GM
4
MO
Corticosteroids - Topical
MO; *
2
MO; *
2
MO
3
MO
3
2
MO; *
3
MO
2
MO; *
2
MO; *
MO; *
2
4
MO
2
MO; *
2
MO; *
4
MO
3
MO
2
MO; *
2
MO; *
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
54
Drug Name
clobetasol propionate lotn
ex
clobetasol propionate oint
ex
clobetasol propionate sham
ex
clobetasol propionate soln
ex
CLOBEX LIQD (Use
Clobetasol Propionate)
CLOBEX LOTN (Use
Clobetasol Propionate)
CLOBEX SHAM (Use
Clobetasol Propionate)
CLOCORTOLONE
PIVALATE
CLOCORTOLONE
PIVALATE PUMP
Drug Requirements/
Tier Limits
4 MO
2
MO; *
3
MO
2
MO; *
4
MO
NF MO
NF MO
4
MO
4
MO
CLODERM
4
MO
CLODERM PUMP
4
MO
CORDRAN TAPE
4
MO
CUTIVATE (Use
Fluticasone Propionate)
DERMA-SMOOTHE/FS
BODY (Use Fluocinolone
Acetonide)
DERMA-SMOOTHE/FS
BODY OIL (Use
Fluocinolone Acetonide)
DERMA-SMOOTHE/FS
SCALP (Use Fluocinolone
Acetonide)
DERMA-SMOOTHE/FS
SCALP OIL (Use
Fluocinolone Acetonide)
DERMATOP CREA (Use
Prednicarbate)
NF MO
MO
NF
MO
NF
MO
NF
MO
NF
NF MO
DESONATE
4
MO
desonide crea ex
3
MO
desonide lotn ex
3
MO
Drug Name
desonide oint ex
DESOWEN (Use
Desonide)
desoximetasone crea ex
0.25 %
desoximetasone gel ex
0.05 %
DESOXIMETASONE OINT
EX 0.05 %
desoximetasone oint ex
0.25 %
diflorasone diacetate oint
ex
DIPROLENE (Use
Betamethasone
Dipropionate Augmented)
DIPROLENE AF (Use
Betamethasone
Dipropionate Augmented)
ELOCON CREA (Use
Mometasone Furoate)
ELOCON OINT (Use
Mometasone Furoate)
fluocinolone acetonide crea
ex 0.01 %, 0.025 %
fluocinolone acetonide oil
ex 0.01 %
fluocinolone acetonide oint
ex 0.025 %
fluocinolone acetonide soln
ex 0.01 %
fluocinonide crea ex 0.05
%, 0.1 %
fluocinonide emulsified
base
Drug Requirements/
Tier Limits
2 MO; *
NF MO
3
MO
3
MO
4
MO
3
MO
1
MO; *
MO
NF
MO
NF
NF MO
NF MO
2
MO; *
2
MO; *
2
MO; *
3
MO
2
MO; *
1
MO; *
fluocinonide gel ex 0.05 %
2
MO; *
fluocinonide oint ex 0.05 %
2
MO; *
fluocinonide soln ex 0.05 %
2
MO; *
1
MO; *
4
MO
fluticasone propionate crea
ex 0.05 %
fluticasone propionate lotn
ex 0.05 %
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
55
Drug Name
fluticasone propionate oint
ex 0.005 %
Drug Requirements/
Tier Limits
1 MO; *
Drug Name
OLUX (Use Clobetasol
Propionate)
OLUX-E (Use Clobetasol
Propionate Emulsion)
halobetasol propionate
3
MO
HALOG CREA
4
MO
1
RX/OTC; MO; *
1
MO; *
2
MO; *
1
RX/OTC; MO; *
1
MO; *
TACLONEX SUSP
1
MO; *
2
MO; *
2
MO; *
3
MO
3
MO
TEMOVATE (Use
Clobetasol Propionate)
TEMOVATE E (Use
Clobetasol Propionate
Emollient Base)
TOPICORT CREA 0.25 %
(Use Desoximetasone)
TOPICORT GEL 0.05 %
(Use Desoximetasone)
hydrocortisone (topical)
crea 1 %
hydrocortisone (topical)
crea 2.5 %
hydrocortisone (topical)
lotn 2.5 %
hydrocortisone (topical)
oint 1 %
hydrocortisone (topical)
oint 2.5 %
hydrocortisone butyrate
hydrocortisone butyrate
hydrophilic lipo base
hydrocortisone valerate
crea
hydrocortisone valerate
oint
KENALOG
LOCOID CREA (Use
Hydrocortisone Butyrate)
LOCOID LIPOCREAM
(Use Hydrocortisone
Butyrate Hydrophilic Lipo
Base)
LOCOID LOTN
LOCOID OINT (Use
Hydrocortisone Butyrate)
LOCOID SOLN (Use
Hydrocortisone Butyrate)
LUXIQ (Use
Betamethasone Valerate)
mometasone furoate crea
ex
mometasone furoate oint
ex
mometasone furoate soln
ex
NF MO
MO
NF
4
MO
NF MO
NF MO
NF MO
2
MO; *
2
MO; *
2
MO; *
Drug Requirements/
Tier Limits
NF MO
NF MO
pramosone crea 1%-1%
1
MO; *
prednicarbate crea
1
MO; *
SYNALAR (Use
Fluocinolone Acetonide)
TACLONEX OINT (Use
CalcipotrieneBetamethasone
Dipropionate)
NF MO
MO
4
5
MO
NF MO
MO
NF
NF MO
NF MO
TOPICORT LIQD 0.25 %
4
MO
TOPICORT OINT 0.05 %
4
MO
TOPICORT OINT 0.25 %
(Use Desoximetasone)
triamcinolone acetonide
(topical)
ULTRAVATE (Use
Halobetasol Propionate)
VANOS (Use
Fluocinonide)
WESTCORT (Use
Hydrocortisone Valerate)
Emollients
LAC-HYDRIN (Use Lactic
Acid (Ammonium Lactate))
lactic acid (ammonium
lactate) crea 12 %
lactic acid (ammonium
lactate) lotn 12 %
NF MO
2
MO; *
NF MO
4
MO
NF MO
NF RX/OTC; MO
2
RX/OTC; MO; *
2
RX/OTC; MO; *
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
56
Drug Name
Drug Requirements/
Tier Limits
Enzymes - Topical
SANTYL
Drug Requirements/
Tier Limits
Rosacea Agents
3
MO
Immunomodulating Agents - Topical
ALDARA (Use Imiquimod) NF MO
imiquimod crea ex
4
MO
ZYCLARA
5
MO
5
MO
ZYCLARA PUMP
Drug Name
Immunosuppressive Agents - Topical
4 MO
ELIDEL
FINACEA
METROCREAM (Use
Metronidazole (Topical))
METROGEL (Use
Metronidazole (Topical))
METROLOTION (Use
Metronidazole (Topical))
4
NF MO
NF MO
NF MO
metronidazole (topical)
3
MO
MIRVASO
4
PA; MO
NORITATE
4
MO
4
MO
PROTOPIC (Use
Tacrolimus (Topical))
4
MO
ORACEA
tacrolimus (topical)
2
MO; *
Scabicides & Pediculicides
ELIMITE (Use Permethrin)
NF MO
Keratolytic/Antimitotic Agents
CONDYLOX GEL
CONDYLOX SOLN (Use
Podofilox)
podofilox soln ex
Local Anesthetics - Topical
EMLA (Use LidocainePrilocaine)
4
MO
NF MO
1
MO; *
EURAX
4
MO
lindane lotn ex
1
MO; *
malathion lotn ex
3
MO
OVIDE (Use Malathion)
NF MO; B/D
MO
permethrin crea ex 5 %
NF MO
2
MO; *
5
MO
Wound Care Products
2
RX/OTC; MO; *
2
MO; *
lidocaine oint ex 5 %
2
MO; *
DIGESTIVE AIDS - Drugs to Treat Low Digestive
Enzymes
lidocaine ptch ex 5 %
3
PA; MO
Digestive Enzymes
3
MO; B/D
lidocaine hcl gel ex 2 %
lidocaine hcl soln ex 4 %
lidocaine-prilocaine
LIDODERM (Use
Lidocaine)
XYLOCAINE EX 4 % (Use
Lidocaine HCl)
NF PA; MO
NF MO
Pigmenting-Depigmenting Agents
OXSORALEN
4
MO
REGRANEX
CREON
3
MO
PANCREAZE
3
MO
PANCRELIPASE
4
MO
PERTZYE
4
MO
VIOKACE
4
MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
57
Drug Name
ZENPEP 10000UNIT3000UNIT-16000UNIT,
17000UNIT-5000UNIT27000UNIT, 34000UNIT10000UNIT-55000UNIT,
51000UNIT-15000UNIT82000UNIT, 68000UNIT20000UNIT-109000UNIT,
85000UNIT-25000UNIT136000UNIT
ZENPEP 136000UNIT40000UNIT-218000UNIT
Drug Requirements/
Tier Limits
MO
4
5
DIURETICS - Drugs to Treat Heart, Circulation
Conditions and Blood Pressure
Carbonic Anhydrase Inhibitors
acetazolamide cp12 or 500
1
mg
acetazolamide tabs or 250
1
mg
DIAMOX (Use
NF
Acetazolamide)
methazolamide tabs or 25
1
mg, 50 mg
neptazane
Diuretic Combinations
ALDACTAZIDE 25MG25MG (Use Spironolactone
& Hydrochlorothiazide)
ALDACTAZIDE 50MG50MG
amiloride &
hydrochlorothiazide
DYAZIDE (Use
Triamterene &
Hydrochlorothiazide)
MAXZIDE (Use
Triamterene &
Hydrochlorothiazide)
MAXZIDE-25 (Use
Triamterene &
Hydrochlorothiazide)
spironolactone &
hydrochlorothiazide
triamterene &
hydrochlorothiazide
1
Drug Name
Loop Diuretics
bumetanide tabs or 0.5 mg,
1 mg, 2 mg
DEMADEX (Use
Torsemide)
1
MO; *
NF MO
EDECRIN
4
MO
furosemide soln ij 10 mg/ml
1
MO; *
1
MO; *
1
MO; *
furosemide soln or 10
mg/ml
furosemide tabs or 20 mg,
40 mg, 80 mg
LASIX (Use Furosemide)
MO; *
Drug Requirements/
Tier Limits
NF MO
MO; *
torsemide tabs or 10 mg,
1 MO; *
100 mg, 20 mg, 5 mg
Potassium Sparing Diuretics
ALDACTONE (Use
NF MO
Spironolactone)
1 MO; *
amiloride hcl
MO; *
DYRENIUM
MO
spironolactone tabs or 100
1 MO; *
mg, 25 mg, 50 mg
Thiazides and Thiazide-Like Diuretics
1 MO; *
chlorothiazide 500 mg
MO; *
MO
NF
3
MO
1
MO; *
MO
NF
hydrochlorothiazide caps or
12.5 mg
hydrochlorothiazide tabs or
12.5 mg, 25 mg, 50 mg
indapamide tabs or 1.25
mg, 2.5 mg
MO
metolazone
MO
MICROZIDE (Use
Hydrochlorothiazide)
ZAROXOLYN (Use
Metolazone)
NF
NF
1
MO; *
1
MO; *
4
MO
1
MO; *
1
MO; *
1
MO; *
1
MO; *
NF MO
NF MO
ENDOCRINE AND METABOLIC AGENTS MISC. - Drugs to Treat Bone Disease and
Regulate Hormones
Bone Density Regulators
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
58
Drug Requirements/
Tier Limits
QL(0.04 ea
ACTONEL 150 MG (Use
3 daily,93 day(s)
Risedronate Sodium)
limit); MO
3 QL(1 ea daily);
ACTONEL 30 MG, 5 MG
MO
3 QL(0.15 ea
ACTONEL 35 MG
daily); MO
alendronate sodium tabs
1 QL(1 ea daily);
10 mg, 5 mg
MO; *
alendronate sodium tabs
1 QL(0.15 ea
35 mg, 70 mg
daily); MO; *
3 QL(0.15 ea
ATELVIA
daily); MO
BONIVA SOLN IV 3
QL(0.04 ml
4 daily,90 day(s)
MG/3ML (Use Ibandronate
Sodium)
limit); MO; B/D
ea
BONIVA TABS OR 150 MG NF QL(0.036
daily,90
day(s)
(Use Ibandronate Sodium)
limit); MO; B/D
2 MO; B/D; *
calcitonin (salmon)
Drug Name
FORTEO
FOSAMAX (Use
Alendronate Sodium)
FOSAMAX PLUS D
ibandronate sodium soln iv
3 mg/3ml
ibandronate sodium tabs or
150 mg
MIACALCIN IJ 200
UNIT/ML
MIACALCIN NA 200
UNIT/ACT (Use Calcitonin
(Salmon))
PROLIA
RECLAST (Use Zoledronic
Acid)
QL(0.09 ml
daily)
NF QL(0.15 ea
daily); MO
4 QL(0.15 ea
daily); MO
QL(0.04 ml
2 daily,90 day(s)
limit); MO; B/D;
*
QL(0.036 ea
2 daily,90 day(s)
limit); MO; B/D;
*
4 MO; B/D
3
MO; B/D
NF
QL(0.01 ml
3 daily,180
day(s) limit)
QL(0.28 ml
NF daily,365
day(s) limit)
Drug Name
risedronate sodium
XGEVA
Drug Requirements/
Tier Limits
QL(0.04 ea
2 daily,93 day(s)
limit); MO; *
5 QL(0.061 ml
daily)
zoledronic acid conc 4
mg/5ml
5
zoledronic acid soln 5
mg/100ml
2
ZOLEDRONIC ACID SOLR
4 MG
ZOMETA CONC 4
MG/5ML (Use Zoledronic
Acid)
QL(0.28 ml
daily,365
day(s) limit); *
5
5
Corticotropin
H.P. ACTHAR
Fertility Regulators
chorionic gonadotropin solr
im
5
PA; LA
4
Growth Hormone Receptor Antagonists
SOMAVERT 10 MG, 15
5 LA
MG, 20 MG
SOMAVERT 25 MG, 30
5
MG
Growth Hormone Releasing Hormones (GHRH)
EGRIFTA
5
Growth Hormones
GENOTROPIN 5 MG
5
PA
GENOTROPIN MINIQUICK
0.4 MG
5
PA
HUMATROPE
5
PA
5
PA
5
PA
5
PA
5
PA
HUMATROPE COMBO
PACK
NORDITROPIN FLEXPRO
10 MG/1.5ML, 5 MG/1.5ML
NUTROPIN AQ NUSPIN
20
NUTROPIN AQ PEN 20
MG/2ML
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
59
Drug Name
OMNITROPE SOLN 10
MG/1.5ML, 5 MG/1.5ML
Drug Requirements/
Tier Limits
5 PA
Drug Name
levocarnitine (metabolic
modifiers) tabs or 330 mg
Drug Requirements/
Tier Limits
1 MO; B/D; *
SEROSTIM 4 MG, 6 MG
5
PA
LUMIZYME
5
LA
TEV-TROPIN
5
PA
MYALEPT
5
LA
Hormone Receptor Modulators
EVISTA (Use Raloxifene
NF QL(1 ea daily);
HCl)
MO
2 QL(1 ea daily);
raloxifene hcl
MO; *
MYOZYME
5
LA
NAGLAZYME
5
LA
ORFADIN
3
LA
Insulin-Like Growth Factors (Somatomedins)
4 LA
INCRELEX
paricalcitol caps or 1 mcg
3
MO; B/D
2
MO; B/D; *
LHRH/GnRH Agonist Analog Pituitary
LUPRON DEPOT-PED
5 3 Month Kit;
11.25 MG
LUPRON DEPOT-PED
5
11.25 MG, 7.5 MG
LUPRON DEPOT-PED 15
4
MG
LUPRON DEPOT-PED 30
5
MG
5 MO
SYNAREL
Metabolic Modifiers
calcitriol caps or 0.25 mcg,
0.5 mcg
calcitriol soln or 1 mcg/ml
CARNITOR TABS OR 330
MG (Use Levocarnitine
(Metabolic Modifiers))
CYSTADANE
doxercalciferol caps or 0.5
mcg, 1 mcg, 2.5 mcg
FABRAZYME 35 MG
HECTOROL CAPS OR 0.5
MCG, 2.5 MCG (Use
Doxercalciferol)
HECTOROL CAPS OR 1
MCG (Use Doxercalciferol)
KUVAN TBSO
2
MO; B/D; *
2
MO; B/D; *
MO; B/D
NF
4
LA
2
MO; B/D; *
5
LA
MO; B/D
4
5
MO; B/D
5
LA
paricalcitol caps or 2 mcg,
4 mcg
ROCALTROL (Use
Calcitriol)
NF MO; B/D
SENSIPAR 30 MG
3
SENSIPAR 60 MG, 90 MG
5
VIMIZIM
5
ZEMPLAR CAPS OR 1
MCG, 2 MCG, 4 MCG (Use
Paricalcitol)
MO; B/D
NF
Posterior Pituitary Hormones
DDAVP (Use
NF
Desmopressin Acetate
Refrigerated)
DDAVP (Use
NF
Desmopressin Acetate
Spray)
DDAVP (Use
NF
Desmopressin Acetate)
desmopressin acetate
1
refrigerated
desmopressin acetate soln
2
ij 4 mcg/ml
desmopressin acetate
3
spray
desmopressin acetate
3
spray refrigerated
desmopressin acetate tabs
2
or 0.1 mg, 0.2 mg
MO
MO
MO
MO; *
MO; *
MO
MO
MO; *
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
60
Drug Name
STIMATE
Drug Requirements/
Tier Limits
ALORA
Somatostatic Agents
octreotide acetate 100
mcg/ml
octreotide acetate 1000
mcg/5ml, 200 mcg/ml, 50
mcg/ml
SANDOSTATIN 100
MCG/ML (Use Octreotide
Acetate)
SANDOSTATIN 200
MCG/ML, 50 MCG/ML
(Use Octreotide Acetate)
SANDOSTATIN LAR
DEPOT 20 MG, 30 MG
3
MO
4
*
1
5
NF
5
SIGNIFOR
5
SOMATULINE DEPOT
5
LA
Vasopressin Receptor Antagonists
SAMSCA
5
ESTROGENS - Hormone Replacement/Modifying
Drugs
Estrogen Combinations
ACTIVELLA (Use Estradiol
& Norethindrone Acetate)
Drug Requirements/
Tier Limits
Estrogens
4
Prolactin Inhibitors
cabergoline
Drug Name
NF AL; MO
CENESTIN 0.3 MG, 0.45
MG, 0.9 MG
CENESTIN 0.625 MG, 1.25
MG
4
AL; MO
4
AL
4
AL; MO
CLIMARA (Use Estradiol)
NF AL; MO
DELESTROGEN (Use
Estradiol Valerate)
DIVIGEL 0.25 MG/0.25GM,
0.5 MG/0.5GM
NF MO
4
MO
DIVIGEL 1 MG/GM
4
AL; MO
ELESTRIN
4
AL; MO
ENJUVIA 0.3 MG, 0.45
MG, 0.9 MG, 1.25 MG
4
AL; MO
ENJUVIA 0.625 MG
4
AL
estradiol pttw td 0.025
mg/24hr, 0.0375 mg/24hr,
0.05 mg/24hr, 0.075
mg/24hr, 0.1 mg/24hr
estradiol ptwk td 0.025
mg/24hr, 0.05 mg/24hr,
0.06 mg/24hr, 0.075
mg/24hr, 0.1 mg/24hr, 37.5
mcg/24hr
estradiol tabs or 0.5 mg, 1
mg, 2 mg
estradiol valerate oil im 10
mg/ml, 20 mg/ml, 40 mg/ml
estropipate tabs or 0.75
mg, 1.5 mg
AL; MO; *
2
AL; MO; *
2
2
AL; MO; *
1
MO; *
2
AL; MO; *
ANGELIQ 0.5MG-1MG
4
AL; MO
CLIMARA PRO
4
AL; MO
COMBIPATCH
4
AL; MO
EVAMIST
4
AL; MO
DUAVEE
4
MO
MENOSTAR
4
AL; MO
estradiol & norethindrone
acetate
2
AL; MO; *
MINIVELLE
4
AL; MO
FEMHRT LOW DOSE
4
AL; MO
PREMPHASE
4
AL; MO
PREMARIN TABS OR 0.3
MG, 0.45 MG, 0.625 MG,
0.9 MG, 1.25 MG
VIVELLE-DOT (Use
Estradiol)
PREMPRO
4
AL; MO
AL; MO
4
4
AL; MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
61
Drug Name
Drug Requirements/
Tier Limits
FLUOROQUINOLONES - Drugs to Treat Bacterial
Infections
Fluoroquinolones
AVELOX ABC PACK (Use
Moxifloxacin HCl)
AVELOX TABS OR 400
MG (Use Moxifloxacin HCl)
CIPRO I.V.-IN D5W
200MG/100ML-5% (Use
Ciprofloxacin in D5W)
CIPRO I.V.-IN D5W
400MG/200ML-5% (Use
Ciprofloxacin in D5W)
CIPRO SUSR 5
GM/100ML, 500 MG/5ML
(Use Ciprofloxacin)
CIPRO TABS 250 MG, 500
MG (Use Ciprofloxacin
HCl)
CIPRO XR (Use
Ciprofloxacin-Ciprofloxacin
HCl)
ciprofloxacin hcl tabs or
100 mg, 250 mg, 500 mg,
750 mg
ciprofloxacin in d5w
200mg/100ml-5%
ciprofloxacin in d5w
400mg/200ml-5%
ciprofloxacin susr or 250
mg/5ml, 500 mg/5ml
ciprofloxacin-ciprofloxacin
hcl
LEVAQUIN SOLN IV
250MG/50ML-5%,
500MG/100ML-5% (Use
Levofloxacin in D5W)
LEVAQUIN SOLN IV
750MG/150ML-5% (Use
Levofloxacin in D5W)
LEVAQUIN SOLN OR 25
MG/ML (Use Levofloxacin)
LEVAQUIN TABS OR 250
MG, 750 MG (Use
Levofloxacin)
4
MO
4
MO
NF
MO
NF
Drug Name
LEVAQUIN TABS OR 500
MG (Use Levofloxacin)
levofloxacin in d5w
250mg/50ml-5%,
500mg/100ml-5%
levofloxacin in d5w
750mg/150ml-5%
levofloxacin soln iv 25
mg/ml
levofloxacin soln or 25
mg/ml
levofloxacin tabs or 250
mg, 500 mg, 750 mg
Drug Requirements/
Tier Limits
4 MO
*
1
1
MO; *
2
*
3
MO
2
MO; *
2
MO; *
MO
moxifloxacin hcl
MO
GASTROINTESTINAL AGENTS - MISC. Miscellaneous Gastrointestinal Drugs
3
NF
Gallstone Solubilizing Agents
MO
NF
ACTIGALL (Use Ursodiol)
CHENODAL
NF MO
5
LA
MO; *
URSO 250 (Use Ursodiol)
NF MO
URSO FORTE (Use
Ursodiol)
NF MO
2
*
1
MO; *
2
MO; *
3
MO
1
NF
MO
NF
NF MO
MO
NF
ursodiol caps or 300 mg
2
MO; *
ursodiol tabs or 250 mg,
3 MO
500 mg
Gastrointestinal Antiallergy Agents
cromolyn sodium
4 MO
(mastocytosis)
GASTROCROM (Use
MO
NF
Cromolyn Sodium
(Mastocytosis))
Gastrointestinal Chloride Channel Activators
3 MO
AMITIZA
Gastrointestinal Stimulants
metoclopramide hcl soln ij
5 mg/ml
metoclopramide hcl soln or
10 mg/10ml, 5 mg/5ml
2
MO; *
2
MO; *
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
62
Drug Requirements/
Tier Limits
metoclopramide hcl tabs or
1 MO; *
10 mg, 5 mg
REGLAN (Use
NF MO
Metoclopramide HCl)
Drug Name
Inflammatory Bowel Agents
APRISO
3
ASACOL
3
ASACOL HD
3
AZULFIDINE (Use
Sulfasalazine)
AZULFIDINE EN-TABS
(Use Sulfasalazine)
balsalazide disodium
Irritable Bowel Syndrome (IBS) Agents
3 MO
LINZESS
LOTRONEX
MO
Peripheral Opioid Receptor Antagonists
RELISTOR KIT 12
4
MG/0.6ML
RELISTOR SOLN 12
5 MO
MG/0.6ML, 8 MG/0.4ML
NF MO
MO
Phosphate Binder Agents
calcium acetate (phosphate
binder)
ELIPHOS (Use Calcium
Acetate (Phosphate
Binder))
CANASA
3
MO
CIMZIA
5
PA
FOSRENOL
CIMZIA STARTER KIT
5
PA
PHOSLO (Use Calcium
Acetate (Phosphate
Binder))
COLAZAL (Use
Balsalazide Disodium)
NF MO
3
MO
DIPENTUM
5
MO
ENTYVIO
5
PA
LIALDA
3
MO
4
MO
mesalamine w/ cleanser
4
MO
PENTASA
4
MO
REMICADE
5
PA
DELZICOL
mesalamine enem re
ROWASA (Use
Mesalamine w/ Cleanser)
MO
MO
NF MO
3
Drug Requirements/
Tier Limits
2 MO; *
lactulose (encephalopathy)
Drug Name
NF MO
sulfasalazine tabs or
2
MO; *
sulfasalazine tbec or
2
MO; *
5
2
MO; *
MO
NF
3
MO
MO
NF
PHOSLYRA
4
MO
RENAGEL 800 MG
4
MO
RENVELA
3
MO
SEVELAMER
CARBONATE
3
MO
VELPHORO
5
MO
Short Bowel Syndrome (SBS) Agents
5 PA; LA
GATTEX
GENITOURINARY AGENTS - MISCELLANEOUS
- Miscellaneous Drugs to Treat Reproductive
Organs and Urinary System
Alkalinizers
potassium citrate
(alkalinizer) 1080 mg
potassium citrate
(alkalinizer) 540 mg
2
MO; *
1
MO; *
Intestinal Acidifiers
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
63
Drug Name
UROCIT-K 10 (Use
Potassium Citrate
(Alkalinizer))
UROCIT-K 5 (Use
Potassium Citrate
(Alkalinizer))
Drug Requirements/
Tier Limits
MO
NF
Drug Name
Drug Requirements/
Tier Limits
GOUT AGENTS - Drugs to Treat Gout
Gout Agent Combinations
MO
NF
colchicine w/ probenecid
1
MO; *
Gout Agents
Cystinosis Agents
CYSTAGON
4
PROCYSBI
4
LA
Genitourinary Irrigants
allopurinol tabs or 100 mg
1
allopurinol tabs or 300 mg
1
COLCHICINE TABS OR
3
QL(8 ea daily);
MO; *
QL(2 ea daily);
MO; *
MO
acetic acid ir 0.25 %
1
MO; *
COLCRYS
3
MO
neomycin/polymyxin b gu
1
MO; *
ULORIC
3
MO
MO
ZYLOPRIM 100 MG (Use
Allopurinol)
ZYLOPRIM 300 MG (Use
Allopurinol)
NEOSPORIN GU
IRRIGANT (Use
Neomycin/Polymyxin B
GU)
sodium chloride (gu
irrigant)
NF
2
MO; *
NF QL(8 ea daily);
MO
NF QL(2 ea daily);
MO
Uricosurics
probenecid
Interstitial Cystitis Agents
2
MO; *
4
MO
alfuzosin hcl
2
MO; *
AVODART
3
GL; MO
CARDURA XL
4
MO
BERINERT
5
finasteride tabs or
2
GL; MO; *
CINRYZE
5
LA
2
MO; *
ELMIRON
Prostatic Hypertrophy Agents
FLOMAX (Use Tamsulosin
HCl)
JALYN
PROSCAR (Use
Finasteride)
RAPAFLO
tamsulosin hcl
UROXATRAL (Use
Alfuzosin HCl)
Bradykinin B2 Receptor Antagonists
FIRAZYR
NF MO
3
HEMATOLOGICAL AGENTS - MISC. - Drugs to
Treat Blood Disorders
GL; MO
NF GL; MO
4
MO
2
MO; *
NF MO
5
Complement Inhibitors
Hematorheologic Agents
pentoxifylline tbcr or
TRENTAL (Use
Pentoxifylline)
NF MO
Plasma Kallikrein Inhibitors
KALBITOR
5
Platelet Aggregation Inhibitors
AGGRENOX
3
MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
64
Drug Requirements/
Tier Limits
AGRYLIN (Use Anagrelide NF MO
HCl)
1 MO; *
anagrelide hcl
Drug Name
BRILINTA
3
MO
cilostazol
1
MO; *
clopidogrel bisulfate 300
mg
2
*
clopidogrel bisulfate 75 mg
2
MO; *
dipyridamole tabs or 25
mg, 50 mg, 75 mg
2
AL; MO; *
EFFIENT
3
MO
Drug Name
ARANESP ALBUMIN
FREE 100 MCG/0.5ML,
100 MCG/ML, 150
MCG/0.3ML, 150
MCG/0.75ML, 200
MCG/0.4ML, 200 MCG/ML,
300 MCG/0.6ML, 300
MCG/ML, 500 MCG/ML
ARANESP ALBUMIN
FREE 25 MCG/0.42ML, 25
MCG/ML, 40 MCG/0.4ML,
40 MCG/ML, 60
MCG/0.3ML, 60 MCG/ML
Drug Requirements/
Tier Limits
PA; B/D
5
PA; B/D
4
EPOGEN
4
PA; B/D
GRANIX
5
PA
PERSANTINE (Use
Dipyridamole)
PLAVIX 300 MG (Use
Clopidogrel Bisulfate)
PLAVIX 75 MG (Use
Clopidogrel Bisulfate)
NF AL; MO
LEUKINE SOLR IV 250
MCG
5
PA
NF
NEULASTA
5
PA
NF MO
NEULASTA DELIVERY
KIT
5
PA
PLETAL (Use Cilostazol)
NF MO
NEUMEGA
3
PA
NEUPOGEN
5
PA
ticlopidine hcl
2
AL; MO; *
ZONTIVITY
3
MO
HEMATOPOIETIC AGENTS - Drugs to Treat
Blood Disorders
Agents for Gaucher Disease
PROCRIT 10000 UNIT/ML,
2000 UNIT/ML, 3000
UNIT/ML, 4000 UNIT/ML
PROCRIT 20000 UNIT/ML,
40000 UNIT/ML
PA; B/D
3
5
CERDELGA
5
PA
PROMACTA 12.5 MG
5
CEREZYME 400 UNIT
5
LA
PROMACTA 25 MG
5
ELELYSO
5
PROMACTA 50 MG
5
VPRIV
5
PROMACTA 75 MG
5
ZAVESCA
5
LA
4
MO
Agents for Sickle Cell Anemia
DROXIA
QL(8 ea daily);
LA
QL(4 ea daily);
LA
QL(2 ea daily);
LA
QL(1 ea daily);
LA
Stem Cell Mobilizers
MOZOBIL
Hematopoietic Growth Factors
PA; B/D
5
HEMOSTATICS - Drugs to Stop Bleeding/Treat
Blood Disorders
Hemostatics - Systemic
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
65
Drug Name
AMICAR TABS 1000 MG
AMICAR TABS 500 MG
(Use Aminocaproic Acid)
AMINOCAPROIC ACID
TABS OR 1000 MG
aminocaproic acid tabs or
500 mg
CYKLOKAPRON (Use
Tranexamic Acid)
LYSTEDA (Use
Tranexamic Acid)
tranexamic acid soln iv 100
mg/ml
tranexamic acid tabs or
650 mg
Drug Requirements/
Tier Limits
5 MO
NF MO
Drug Name
eszopiclone
flurazepam hcl
5
MO
HALCION (Use Triazolam)
3
MO
INTERMEZZO
NF
NF MO
LUNESTA (Use
Eszopiclone)
RESTORIL (Use
Temazepam)
Drug Requirements/
Tier Limits
2 AL; MO; *
1
NF MO
4
AL; MO
4
AL; MO
NF MO
NF AL; MO
1
*
SONATA (Use Zaleplon)
MO
temazepam
2
MO; *
3
triazolam
2
MO; *
zaleplon
2
AL; MO; *
HYPNOTICS - Drugs to Help Sleep
Barbiturate Hypnotics
butisol sodium elix 30
mg/5ml
BUTISOL SODIUM TABS
30 MG, 50 MG
phenobarbital elix or 20
mg/5ml
phenobarbital soln or 20
mg/5ml
phenobarbital tabs or 100
mg, 15 mg, 16.2 mg, 30
mg, 32.4 mg, 60 mg, 64.8
mg, 97.2 mg
Hypnotics - Tricyclic Agents
SILENOR
Non-Barbiturate Hypnotics
AMBIEN 10 MG (Use
Zolpidem Tartrate)
AMBIEN 5 MG (Use
Zolpidem Tartrate)
AMBIEN CR 12.5 MG (Use
Zolpidem Tartrate)
AMBIEN CR 6.25 MG (Use
Zolpidem Tartrate)
EDLUAR
MO; *
2
AL; *
zolpidem tartrate tabs 10
mg
2
4
AL; MO
zolpidem tartrate tabs 5 mg
2
2
AL; MO; *
2
AL; MO; *
zolpidem tartrate tbcr 12.5
mg
zolpidem tartrate tbcr 6.25
mg
AL; MO; *
2
4
ZOLPIMIST
4
4
4
QL(1 ea daily);
AL; MO; *
QL(2 ea daily);
AL; MO; *
QL(1 ea daily);
AL; MO
QL(2 ea daily);
AL; MO
AL; MO
Selective Melatonin Receptor Agonists
5 PA
HETLIOZ
MO
ROZEREM
4
MO
LAXATIVES - Bowel Treatment Drugs
NF QL(1 ea daily);
AL; MO
NF QL(2 ea daily);
AL; MO
NF QL(1 ea daily);
AL; MO
NF QL(2 ea daily);
AL; MO
4 AL; MO
Laxative Combinations
COLYTE-FLAVOR PACKS
227.1GM-21.5GM-5.53GM2.82GM-6.36GM
COLYTE-FLAVOR PACKS
240GM-22.72GM-5.84GM2.98GM-6.72GM (Use PEG
3350-KCl-Sod Bicarb-Sod
Chloride-Sod Sulfate)
4
MO
NF
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
66
Drug Name
GOLYTELY 227.1GM21.5GM-5.53GM-2.82GM6.36GM
GOLYTELY 236GM22.74GM-5.86GM-2.97GM6.74GM (Use PEG 3350KCl-Sod Bicarb-Sod
Chloride-Sod Sulfate)
HALFLYTELY BOWEL
PREP/FLAVOR PACKS
MOVIPREP
NULYTELY/FLAVOR
PACKS (Use PEG 3350Potassium Chloride-Sod
Bicarbonate-Sod Chloride)
peg 3350-kcl-sod bicarbsod chloride-sod sulfate
peg 3350-potassium
chloride-sod bicarbonatesod chloride
Drug Requirements/
Tier Limits
MO
4
MO
4
MO
MO
NF
2
MO; *
MO; *
2
PREPOPIK
4
MO
SUPREP BOWEL PREP
4
MO
Laxatives - Miscellaneous
lactulose soln or 10
gm/15ml, 20 gm/30ml
polyethylene glycol 3350
pack or
polyethylene glycol 3350
powd or
2
MO; *
2
RX/OTC; MO; *
2
RX/OTC; MO; *
Saline Laxatives
OSMOPREP
4
MO
LOCAL ANESTHETICS-Parenteral - Drugs for
Numbing
Local Anesthetics - Amides
lidocaine hcl (local anesth.)
1 MO; B/D; *
1 %, 2 %
XYLOCAINE IJ 1 %, 2 %
MO; B/D
NF
(Use Lidocaine HCl (Local
Anesth.))
XYLOCAINE-MPF 1 %
MO; B/D
NF
(Use Lidocaine HCl (Local
Anesth.))
Drug Requirements/
Tier Limits
MACROLIDES - Drugs to Treat Bacterial
Infections
Azithromycin
azithromycin solr iv 500 mg
NF
4
Drug Name
azithromycin susr or 100
mg/5ml, 200 mg/5ml
azithromycin tabs or 250
mg, 500 mg, 600 mg
ZITHROMAX SOLR IV 500
MG (Use Azithromycin)
ZITHROMAX SUSR OR
100 MG/5ML, 200 MG/5ML
(Use Azithromycin)
ZITHROMAX TABS OR
250 MG, 500 MG, 600 MG
(Use Azithromycin)
ZITHROMAX TRI-PAK
(Use Azithromycin)
ZITHROMAX Z-PAK (Use
Azithromycin)
ZMAX
Clarithromycin
BIAXIN (Use
Clarithromycin)
BIAXIN XL (Use
Clarithromycin)
BIAXIN XL PAC (Use
Clarithromycin)
clarithromycin susr or 125
mg/5ml
clarithromycin susr or 250
mg/5ml
clarithromycin tabs or 250
mg, 500 mg
clarithromycin tb24 or 500
mg
2
MO; *
2
MO; *
2
MO; *
NF MO
MO
NF
MO
NF
NF MO
NF MO
4
MO
NF MO
NF MO
NF MO
2
MO; *
3
MO
2
MO; *
2
MO; *
Erythromycins
e.e.s. 400
2
E.E.S. GRANULES
4
ERYPED 200
4
QL(10 ea
daily); MO; *
QL(100 ml
daily); MO
QL(100 ml
daily); MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
67
Drug Requirements/
Tier Limits
4 QL(50 ml
ERYPED 400
daily); MO
erythrocin lactobionate 500
2 QL(8 ea daily);
mg
*
erythromycin base cpep or
2 QL(16 ea
250 mg
daily); MO; *
erythromycin base tabs or
2 QL(16 ea
250 mg
daily); MO; *
erythromycin base tabs or
2 QL(8 ea daily);
500 mg
MO; *
erythromycin
2 QL(10 ea
ethylsuccinate tabs or
daily); MO; *
4 QL(12 ea
PCE 333 MG
daily); MO
4 QL(8 ea daily);
PCE 500 MG
MO
Drug Name
Fidaxomicin
DIFICID
5
MO
MEDICAL DEVICES
Bandages-Dressings-Tape
gauze pads 2" x 2"
1
RX/OTC; MO
Misc. Devices
ALCOHOL PADS
3
Parenteral Therapy Supplies
INSULIN SYRINGES AND
3
PEN NEEDLES
RX/OTC; MO
MO
MIGRAINE PRODUCTS - Drugs to Treat Migraine
Headaches
Migraine Combinations
TREXIMET
4
MO
4
MO
Migraine Products - NSAIDs
CAMBIA
Migraine Products
D.H.E. 45 (Use
Dihydroergotamine
Mesylate)
dihydroergotamine
mesylate soln ij 1 mg/ml
MO
NF
1
MO; *
Drug Name
DIHYDROERGOTAMINE
MESYLATE SOLN NA 4
MG/ML
MIGRANAL
Serotonin Agonists
AMERGE (Use Naratriptan
HCl)
AXERT
FROVA
IMITREX SOLN SC 6
MG/0.5ML (Use
Sumatriptan Succinate)
IMITREX STATDOSE
REFILL 4 MG/0.5ML (Use
Sumatriptan Succinate)
IMITREX STATDOSE
REFILL 6 MG/0.5ML (Use
Sumatriptan Succinate)
IMITREX STATDOSE
SYSTEM 4 MG/0.5ML (Use
Sumatriptan Succinate)
IMITREX STATDOSE
SYSTEM 6 MG/0.5ML (Use
Sumatriptan Succinate)
IMITREX TABS OR 100
MG (Use Sumatriptan
Succinate)
IMITREX TABS OR 25 MG
(Use Sumatriptan
Succinate)
IMITREX TABS OR 50 MG
(Use Sumatriptan
Succinate)
MAXALT 10 MG (Use
Rizatriptan Benzoate)
MAXALT 5 MG (Use
Rizatriptan Benzoate)
MAXALT-MLT 10 MG (Use
Rizatriptan Benzoate)
MAXALT-MLT 5 MG (Use
Rizatriptan Benzoate)
naratriptan hcl
Drug Requirements/
Tier Limits
MO
5
5
MO
NF QL(0.3 ea
daily); MO
4 QL(0.4 ea
daily); MO
4 QL(0.6 ea
daily); MO
QL(0.27 ml
NF daily); MO
QL(0.14 ml
NF daily); MO
QL(0.27 ml
NF daily); MO
QL(0.14 ml
NF daily); MO
QL(0.27 ml
NF daily); MO
QL(0.3 ea
NF daily); MO
QL(0.9 ea
NF daily); MO
QL(0.6 ea
NF daily); MO
NF QL(0.4 ea
daily); MO
NF QL(0.8 ea
daily); MO
NF QL(0.4 ea
daily); MO
NF QL(0.8 ea
daily); MO
1 QL(0.3 ea
daily); MO; *
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
68
Drug Requirements/
Tier Limits
4 QL(0.2 ea
RELPAX
daily); MO
rizatriptan benzoate tabs
2 QL(0.4 ea
10 mg
daily); MO; *
rizatriptan benzoate tabs 5
2 QL(0.8 ea
mg
daily); MO; *
rizatriptan benzoate tbdp
3 QL(0.4 ea
10 mg
daily); MO
rizatriptan benzoate tbdp 5
3 QL(0.8 ea
mg
daily); MO
sumatriptan succinate soaj
2 QL(0.14 ml
sc 4 mg/0.5ml
daily); MO; *
sumatriptan succinate soaj
2 QL(0.27 ml
sc 6 mg/0.5ml
daily); MO; *
sumatriptan succinate soct
2 QL(0.14 ml
sc 4 mg/0.5ml
daily); MO; *
sumatriptan succinate soct
2 QL(0.27 ml
sc 6 mg/0.5ml
daily); MO; *
sumatriptan succinate soln
4 QL(0.27 ml
sc 6 mg/0.5ml
daily); MO
sumatriptan succinate sosy
2 *
sc 6 mg/0.5ml
sumatriptan succinate tabs
2 QL(0.3 ea
or 100 mg
daily); MO; *
sumatriptan succinate tabs
2 QL(0.9 ea
or 25 mg
daily); MO; *
sumatriptan succinate tabs
2 QL(0.6 ea
or 50 mg
daily); MO; *
SUMAVEL DOSEPRO 4
4 QL(0.14 ml
MG/0.5ML
daily)
SUMAVEL DOSEPRO 6
4 QL(0.14 ml
MG/0.5ML
daily); MO
2 QL(0.2 ea
zolmitriptan
daily); MO; *
4 QL(2 ea daily);
ZOMIG NASAL SPRAY
MO
4 QL(4 ea daily);
ZOMIG SOLN NA 2.5 MG
MO
ZOMIG TABS OR 2.5 MG, NF QL(0.2 ea
5 MG (Use Zolmitriptan)
daily); MO
ZOMIG ZMT (Use
NF QL(0.2 ea
Zolmitriptan)
daily); MO
Drug Name
MINERALS & ELECTROLYTES
Drug Name
sodium bicarbonate soln iv
8.4 %
Chloride
Drug Requirements/
Tier Limits
1 MO; *
2
MO; *
1
*
2
*
1
*
1
MO; *
lactated ringer's
1
*
parenteral electrolytes
2
B/D; *
ammonium chloride soln iv
Electrolyte Mixtures
dextrose in lactated ringers
dextrose w/ sodium
chloride 0.45%-2.5%
dextrose w/ sodium
chloride 0.45%-5%
dextrose w/ sodium
chloride 0.9%-5%
potassium chloride in
dextrose & sodium chloride
0.45%-20meq/l-5%
Fluoride
sodium fluoride chew or
0.25 mg, 0.5 mg, 1 mg, 1.1
mg, 2.2 mg
sodium fluoride soln or
0.125 mg/drop
sodium fluoride soln or 0.5
mg/ml
sodium fluoride tabs or 1
mg
Magnesium
magnesium sulfate soln ij
50 %
Potassium
K-TAB 10 MEQ (Use
Potassium Chloride)
MICRO-K (Use Potassium
Chloride)
potassium chloride cpcr or
10 meq, 8 meq
potassium chloride liqd or
10 %, 20 %
*
1
MO; *
1
1
*
1
MO; *
1
*
1
MO; *
NF MO
NF MO
2
MO; *
2
MO; *
Bicarbonates
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
69
Drug Requirements/
Tier Limits
potassium chloride
MO; *
2
microencapsulated crystals
cr
potassium chloride soln iv
1 MO; *
2 meq/ml
potassium chloride soln or
2 MO; *
10 %, 20 %
potassium chloride tbcr or
2 MO; *
10 meq, 8 meq
Drug Name
Sodium
sodium chloride soln iv
0.45 %
sodium chloride soln iv 0.9
%
baclofen tabs or 20 mg
2
carisoprodol tabs or 250
mg, 350 mg
2
chlorzoxazone tabs or
2
AL; MO; *
2
*
2
2
cyclobenzaprine hcl tabs or
10 mg, 5 mg, 7.5 mg
AL; MO; *
MO; *
fexmid
2
AL; MO; *
2
MO; *
2
MO; *
clotrimazole troc mt
2
MO; *
nystatin (mouth-throat)
2
MO; *
1
MO; *
EVOXAC (Use Cevimeline
HCl)
pilocarpine hcl (oral)
SALAGEN (Use
Pilocarpine HCl (Oral))
Central Muscle Relaxants
QL(8 ea daily);
MO; *
QL(4 ea daily);
MO; *
AL; MO; *
clotrimazole lozg mt
cevimeline hcl
MUSCULOSKELETAL THERAPY AGENTS Drugs to Treat Spasms
2
Anti-infectives - Throat
Antiseptics - Mouth/Throat
chlorhexidine gluconate
(mouth-throat)
PERIDEX (Use
Chlorhexidine Gluconate
(Mouth-Throat))
Steroids - Mouth/Throat
triamcinolone acetonide
(mouth)
Throat Products - Misc.
Drug Requirements/
Tier Limits
baclofen tabs or 10 mg
MOUTH/THROAT/DENTAL AGENTS
Anesthetics Topical Oral
lidocaine hcl (mouth-throat)
2%
Drug Name
MO
NF
2
3
MO; *
MO
NF MO
2
MO; *
NF MO
FLEXERIL (Use
Cyclobenzaprine HCl)
metaxalone
methocarbamol tabs or 500
mg, 750 mg
orphenadrine citrate soln ij
30 mg/ml
orphenadrine citrate tb12 or
100 mg
PARAFON FORTE DSC
(Use Chlorzoxazone)
ROBAXIN TABS OR 500
MG (Use Methocarbamol)
ROBAXIN-750 (Use
Methocarbamol)
SKELAXIN (Use
Metaxalone)
SOMA 350 MG (Use
Carisoprodol)
NF AL; MO
3
AL; MO
2
AL; MO; *
2
AL; MO; *
2
AL; MO; *
NF AL; MO
NF AL; MO
NF AL; MO
NF AL; MO
NF AL; MO
tizanidine hcl caps or 2 mg
3
tizanidine hcl caps or 4 mg
3
tizanidine hcl caps or 6 mg
3
tizanidine hcl tabs or 2 mg
2
tizanidine hcl tabs or 4 mg
2
QL(18 ea
daily); MO
QL(9 ea daily);
MO
QL(6 ea daily);
MO
QL(18 ea
daily); MO; *
QL(9 ea daily);
MO; *
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
70
Drug Name
ZANAFLEX CAPS 2 MG
(Use Tizanidine HCl)
ZANAFLEX CAPS 4 MG
(Use Tizanidine HCl)
ZANAFLEX CAPS 6 MG
(Use Tizanidine HCl)
ZANAFLEX TABS 4 MG
(Use Tizanidine HCl)
Direct Muscle Relaxants
DANTRIUM (Use
Dantrolene Sodium)
dantrolene sodium caps or
100 mg, 50 mg
dantrolene sodium caps or
25 mg
Drug Requirements/
Tier Limits
NF QL(18 ea
daily); MO
NF QL(9 ea daily);
MO
NF QL(6 ea daily);
MO
NF QL(9 ea daily);
MO
NF MO
1
MO; *
3
MO
Muscle Relaxant Combinations
carisoprodol w/ aspirin
3
AL; MO
carisoprodol w/ aspirin &
2 AL; MO; *
codeine
orphenadrine w/ aspirin &
2 AL; *
caff
NASAL AGENTS - SYSTEMIC AND TOPICAL Drugs to treat the Nose or Sinus
Nasal Agent Combinations
4 MO
DYMISTA
Nasal Anti-infectives
BACTROBAN NASAL
Nasal Antiallergy
ASTELIN (Use Azelastine
HCl)
ASTEPRO (Use
Azelastine HCl)
4
MO
NF MO
3
MO
azelastine hcl
2
MO; *
olopatadine hcl (nasal)
2
MO; *
PATANASE (Use
Olopatadine HCl (Nasal))
4
MO
Nasal Anticholinergics
ATROVENT (Use
Ipratropium Bromide
(Nasal))
Drug Requirements/
Tier Limits
ipratropium bromide (nasal) 2 MO; *
Drug Name
Nasal Steroids
BECONASE AQ
4
MO
budesonide (nasal)
2
MO; *
FLONASE (Use
Fluticasone Propionate
(Nasal))
flunisolide (nasal)
FLUNISOLIDE 0.025 %
(Use Flunisolide (Nasal))
fluticasone propionate
(nasal)
NASACORT AQ (Use
Triamcinolone Acetonide
(Nasal))
RX/OTC; MO
NF
2
NF MO
2
RX/OTC; MO; *
RX/OTC; MO
NF
NASONEX
3
MO
OMNARIS
4
MO
QNASL
4
MO
QNASL CHILDRENS
4
RHINOCORT AQUA (Use
Budesonide (Nasal))
triamcinolone acetonide
(nasal)
4
MO
2
RX/OTC; MO; *
VERAMYST
4
MO
ZETONNA
4
MO
NEUROMUSCULAR AGENTS - Drugs to
Relax/Paralyze Muscles
ALS Agents
RILUTEK (Use Riluzole)
5
MO
riluzole
2
MO; *
Neuromuscular Blocking Agent - Neurotoxins
4 PA
BOTOX
MO
NF
MO; *
XEOMIN 50 UNIT
4
PA
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
71
Drug Name
Drug Requirements/
Tier Limits
NUTRIENTS
Carbohydrates
dextrose soln iv 10 %
2
B/D; *
dextrose soln iv 5 %
1
MO; B/D; *
Lipids
fat emulsion 20 gm/100ml
3
B/D
Proteins
amino acid infusion 15%
AMINOSYN II 15% (Use
amino acid infusion)
CLINIMIX
2.75%/DEXTROSE 5%
1
MO; *
4
MO
4
B/D
Miotics
ISOPTO CARPINE (Use
Pilocarpine HCl)
4
B/D
PHOSPHOLINE IODIDE
4
pilocarpine hcl soln op 1 %,
2 %, 4 %
2
PILOPINE HS
4
MO; *
Ophthalmic - Angiogenesis Inhibitors
5 LA
EYLEA
Ophthalmic Adrenergic Agents
BETIMOL 0.25 %
4
BETIMOL 0.5 %
4
MO
BETOPTIC-S
3
MO
COSOPT (Use
Dorzolamide HCl-Timolol
Maleate)
NF MO
B/D
Beta-blockers - Ophthalmic
BETAGAN (Use
NF MO
Levobunolol HCl)
1 MO; *
betaxolol hcl (ophth)
COMBIGAN
Cycloplegic Mydriatics
CYCLOGYL 1 %, 2 % (Use
Cyclopentolate HCl)
cyclopentolate hcl soln op 1
%, 2 %
4
OPHTHALMIC AGENTS - Drugs to Treat the Eye
carteolol hcl (ophth)
Drug Requirements/
Tier Limits
timolol maleate (ophth) soln 1 MO; *
0.25 %, 0.5 %
TIMOPTIC (Use Timolol
NF MO
Maleate (Ophth))
TIMOPTIC-XE (Use
NF Gel Forming
Timolol Maleate (Ophth))
Soln;MO
Drug Name
1
MO; *
4
MO
MO
NF
ALPHAGAN P 0.1 %
ALPHAGAN P 0.15 % (Use
Brimonidine Tartrate)
3
MO
NF MO
apraclonidine hcl
1
MO; *
brimonidine tartrate
2
MO; *
IOPIDINE 0.5 % (Use
Apraclonidine HCl)
NF MO
IOPIDINE 1 %
4
MO
4
MO
COSOPT PF
4
MO
SIMBRINZA
dorzolamide hcl-timolol
maleate
2
MO; *
Ophthalmic Anti-infectives
3
MO
AZASITE
4
MO
ISTALOL
2
bacitracin-polymyxin b
(ophth)
1
MO; *
levobunolol hcl 0.5 %
MO; *
timolol maleate (ophth)
solg 0.25 %, 0.5 %
Gel Forming
Soln;MO; *
BESIVANCE
4
MO
2
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
72
Drug Name
BLEPH-10 (Use
Sulfacetamide Sodium
(Ophth))
CILOXAN OINT
CILOXAN SOLN (Use
Ciprofloxacin HCl (Ophth))
Drug Requirements/
Tier Limits
MO
NF
4
MO
NF MO
ciprofloxacin hcl (ophth)
2
MO; *
erythromycin (ophth)
2
MO; *
GARAMYCIN (Use
Gentamicin Sulfate
(Ophth))
NF
gatifloxacin (ophth)
2
MO; *
gentamicin sulfate (ophth)
2
MO; *
levofloxacin (ophth)
1
MO; *
MOXEZA
3
MO
NATACYN
3
MO
1
MO; *
1
MO; *
neomycin-bacitracin znpolymyxin
neomycin-polymyxingramicidin
NEOSPORIN (Use
Neomycin-PolymyxinGramicidin)
OCUFLOX (Use Ofloxacin
(Ophth))
ofloxacin (ophth)
polymyxin b-trimethoprim
POLYTRIM (Use
Polymyxin B-Trimethoprim)
sulfacetamide sodium
(ophth)
MO
trifluridine soln op
VIGAMOX
VIROPTIC (Use
Trifluridine)
ZIRGAN
ZYMAXID (Use
Gatifloxacin (Ophth))
Drug Requirements/
Tier Limits
3 MO
3
MO
NF MO
4
MO
NF MO
Ophthalmic Immunomodulators
RESTASIS
3
MO
Ophthalmic Local Anesthetics
ALCAINE (Use
NF MO
Proparacaine HCl)
1 MO; *
proparacaine hcl soln op
Ophthalmic Steroids
ALREX
4
MO
bacitracin-poly-neomycinhc
1
MO; *
BLEPHAMIDE
4
MO
dexamethasone sodium
phosphate (ophth)
1
MO; *
NF
DUREZOL
3
MO
NF MO
FLAREX
3
MO
fluorometholone (ophth)
2
MO; *
FML
3
MO
FML FORTE
3
MO
MO
2
MO; *
2
MO; *
NF MO
2
tobramycin (ophth)
2
TOBREX OINT
4
TOBREX SOLN (Use
Tobramycin (Ophth))
Drug Name
MO; *
MO; *
MO
NF MO
FML LIQUIFILM (Use
Fluorometholone (Ophth))
NF MO
LOTEMAX
4
MO
MAXIDEX
4
MO
MAXITROL (Use
Neomycin-PolymyDexameth)
MO
NF
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Health Net 2015 Value Formulary
73
Drug Name
neomycin-polymydexameth
OMNIPRED (Use
Prednisolone Acetate
(Ophth))
PRED FORTE (Use
Prednisolone Acetate
(Ophth))
Drug Requirements/
Tier Limits
2 MO; *
MO
NF
MO
NF
Drug Name
bromfenac sodium (ophth)
cromolyn sodium (ophth)
Drug Requirements/
Tier Limits
2 Once daily
dosing;MO; *
2 MO; *
CYSTARAN
4
diclofenac sodium (ophth)
3
QL(2.15 ml
daily); LA
MO
2
MO; *
3
MO
dorzolamide hcl
2
MO; *
ELESTAT (Use Epinastine
HCl (Ophth))
1
MO; *
epinastine hcl (ophth)
1
MO; *
TOBRADEX OINT
4
MO
flurbiprofen sodium
1
MO; *
TOBRADEX ST
4
MO
ILEVRO
3
MO
MO
ketorolac tromethamine
(ophth)
2
MO; *
LASTACAFT
4
MO
NEVANAC
3
MO
PRED MILD
prednisolone acetate
(ophth)
sulfacetamide sodprednisolone
TOBRADEX SUSP (Use
TobramycinDexamethasone)
tobramycindexamethasone
NF
2
MO; *
VEXOL
4
MO
ZYLET
3
MO
Ophthalmics - Misc.
ACULAR (Use Ketorolac
Tromethamine (Ophth))
ACULAR LS (Use
Ketorolac Tromethamine
(Ophth))
OCUFEN (Use
Flurbiprofen Sodium)
OPTIVAR (Use Azelastine
HCl (Ophth))
NF MO
NF MO
NF MO
NF MO
PATADAY
3
MO
MO
PATANOL
4
MO
PROLENSA
4
MO
NF
ACUVAIL
4
MO
ALOCRIL
4
MO
ALOMIDE
4
MO
latanoprost
2
MO; *
azelastine hcl (ophth)
2
MO; *
LUMIGAN
3
MO
AZOPT
3
MO
RESCULA
4
MO
BEPREVE
4
MO
TRAVATAN Z
3
MO
bromfenac sodium (ophth)
1
MO; *
XALATAN (Use
Latanoprost)
TRUSOPT (Use
Dorzolamide HCl)
NF MO
Prostaglandins - Ophthalmic
NF MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
74
Drug Name
ZIOPTAN
Drug Requirements/
Tier Limits
4 MO
OTIC AGENTS - Drugs to Treat the Ear
Otic Agents - Miscellaneous
acetic acid (otic)
acetic acid/aluminum
acetate
Otic Anti-infectives
ofloxacin (otic)
CIPRODEX
COLY-MYCIN S
CORTISPORIN SOLN OT
10000UNIT/ML-3.5MG/ML1% (Use NeomycinPolymyxin-HC (Otic))
CORTISPORIN-TC
Drug Requirements/
Tier Limits
Immune Serums
BIVIGAM
5
B/D
FLEBOGAMMA DIF 10 %
5
B/D
1
MO; *
GAMASTAN S/D
4
B/D
1
MO; *
GAMMAGARD LIQUID
5
B/D
GAMMAKED
5
B/D
GAMUNEX-C
5
B/D
HIZENTRA 1 GM/5ML
4
B/D
5
B/D
5
B/D
B/D
2
MO; *
4
MO
3
MO
4
MO
HIZENTRA 10 GM/50ML, 2
GM/10ML, 4 GM/20ML
OCTAGAM 2 GM/20ML, 20
GM/200ML, 5 GM/50ML
MO
PRIVIGEN
5
VARIZIG
5
Otic Combinations
CIPRO HC
Drug Name
NF
4
MO
neomycin-polymyxin-hc
2 MO; *
(otic)
Otic Steroids
DERMOTIC (Use
MO
NF
Fluocinolone Acetonide
(Otic))
fluocinolone acetonide
2 MO; *
(otic)
hydrocortisone w/acetic
3 MO
acid
VOSOL HC (Use
MO
NF
Hydrocortisone w/Acetic
Acid)
OXYTOCICS - Drugs to Prevent/Control Uterine
Bleeding
Oxytocics
methylergonovine maleate
3 MO
tabs or 0.2 mg
PASSIVE IMMUNIZING AGENTS - Antibody
Drugs to Treat Low Immune System
Monoclonal Antibodies
SYNAGIS
5
Passive Immunizing Agents - Combinations
5 B/D
HYQVIA
PENICILLINS - Drugs to Treat Bacterial Infections
Aminopenicillins
amoxicillin caps 250 mg,
500 mg
amoxicillin susr 125
mg/5ml, 200 mg/5ml, 250
mg/5ml, 400 mg/5ml
amoxicillin tabs 500 mg,
875 mg
ampicillin caps 250 mg,
500 mg
1
MO; *
MO; *
2
2
MO; *
2
MO; *
ampicillin sodium ij 1 gm
2
MO; *
ampicillin sodium ij 125 mg
2
*
ampicillin sodium ij 2 gm
1
MO; *
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net 2015 Value Formulary
75
Drug Name
ampicillin sodium iv 10 gm
Natural Penicillins
BICILLIN L-A 1200000
UNIT/2ML, 2400000
UNIT/4ML
penicillin g potassium 20
mu, 20000000 unit
penicillin g potassium
5000000 unit
penicillin v potassium
PFIZERPEN-G 20 MU
(Use Penicillin G
Potassium)
PFIZERPEN-G 5000000
UNIT (Use Penicillin G
Potassium)
Penicillin Combinations
amoxicillin & pot
clavulanate
ampicillin & sulbactam
sodium ij 1gm-2gm
ampicillin & sulbactam
sodium iv 5gm-10gm
AUGMENTIN ES-600 (Use
Amoxicillin & Pot
Clavulanate)
AUGMENTIN SUSR
250MG/5ML-62.5MG/5ML
(Use Amoxicillin & Pot
Clavulanate)
AUGMENTIN TABS
500MG-125MG, 875MG125MG (Use Amoxicillin &
Pot Clavulanate)
AUGMENTIN XR (Use
Amoxicillin & Pot
Clavulanate)
piperacillin sodiumtazobactam sodium
0.25gm-2gm, 4.5gm-36gm
piperacillin sodiumtazobactam sodium
0.375gm-3gm
Drug Requirements/
Tier Limits
2 *
MO
4
1
MO; *
4
MO
2
MO; *
MO
NF
MO
4
2
MO; *
1
MO; *
2
*
MO
NF
MO
NF
MO
NF
MO
NF
3
MO
3
Drug Requirements/
Tier Limits
piperacillin sodiumMO; *
1
tazobactam sodium 0.5gm4gm
UNASYN IJ 1GM-2GM
MO
NF
(Use Ampicillin &
Sulbactam Sodium)
ZOSYN SOLN
0.25GM/50ML-2GM/50ML5%, 0.375GM/50ML4
3GM/50ML-5%,
0.5GM/100ML4GM/100ML-5%
ZOSYN SOLR 0.25GM2GM, 4.5GM-36GM (Use
NF
Piperacillin SodiumTazobactam Sodium)
ZOSYN SOLR 0.375GMMO
3GM, 0.5GM-4GM (Use
NF
Piperacillin SodiumTazobactam Sodium)
Drug Name
Penicillinase-Resistant Penicillins
dicloxacillin sodium
2
MO; *
nafcillin sodium ij 1 gm
2
*
nafcillin sodium ij 10 gm, 2
5
gm
PROGESTINS - Hormone Replacement/Modifying
Drugs
Progestins
AYGESTIN (Use
NF MO
Norethindrone Acetate)
medroxyprogesterone
1 MO; *
acetate
4 AL; MO
MEGACE ES
norethindrone acetate tabs
or
progesterone micronized
caps or 100 mg, 200 mg
PROMETRIUM (Use
Progesterone Micronized)
PROVERA (Use
Medroxyprogesterone
Acetate)
1
MO; *
2
MO; *
NF MO
MO
NF
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net 2015 Value Formulary
76
Drug Name
Drug Requirements/
Tier Limits
PSYCHOTHERAPEUTIC AND NEUROLOGICAL
AGENTS - MISC. - Drugs to Treat Mental and
Emotional Conditions
Agents for Chemical Dependency
acamprosate calcium
ANTABUSE (Use
Disulfiram)
CAMPRAL (Use
Acamprosate Calcium)
disulfiram tabs or 250 mg,
500 mg
3
MO
NF MO
NF MO
3
MO
Anti-Cataplectic Agents
XYREM
Antidementia Agents
ARICEPT (Use Donepezil
Hydrochloride)
ARICEPT ODT (Use
Donepezil Hydrochloride)
donepezil hydrochloride
5
LA
Drug Requirements/
Tier Limits
4 QL(4 ea daily);
NAMENDA XR 7 MG
AL; MO
NAMENDA XR TITRATION 4 AL; MO
PACK
RAZADYNE (Use
MO
NF
Galantamine
Hydrobromide)
RAZADYNE ER (Use
MO
NF
Galantamine
Hydrobromide)
3 MO
rivastigmine tartrate
Drug Name
Combination Psychotherapeutics
chlordiazepoxide/amitriptyli
2 AL; MO; *
ne
4 MO
olanzapine-fluoxetine hcl
NF MO
perphenazine/amitriptyline
NF MO
SYMBYAX (Use
Olanzapine-Fluoxetine HCl)
2
MO; *
EXELON CAPS OR 1.5
MO
NF
MG, 3 MG, 4.5 MG, 6 MG
(Use Rivastigmine Tartrate)
EXELON PT24 TD 13.3
MO
3
MG/24HR, 4.6 MG/24HR,
9.5 MG/24HR
galantamine hydrobromide
3 MO
cp24 16 mg, 24 mg, 8 mg
galantamine hydrobromide
2 MO; *
soln 4 mg/ml
galantamine hydrobromide
3 MO
tabs 12 mg, 4 mg, 8 mg
NAMENDA SOLN 10
4 PA; MO
MG/5ML
NAMENDA TABS 10 MG, 5 4 MO
MG
NAMENDA TITRATION
4 MO
PAK
4 QL(2 ea daily);
NAMENDA XR 14 MG
AL; MO
NAMENDA XR 21 MG, 28
4 QL(1 ea daily);
MG
AL; MO
2
AL; MO; *
NF MO
Fibromyalgia Agents
SAVELLA
4
PA; MO
SAVELLA TITRATION
PACK
4
PA; MO
Movement Disorder Drug Therapy
XENAZINE
5
LA
Multiple Sclerosis Agents
AMPYRA
5
AUBAGIO
5
PA
AVONEX
5
PA
AVONEX PEN
5
PA
BETASERON
5
PA
COPAXONE
5
PA
EXTAVIA
5
PA
GILENYA
5
PA
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net 2015 Value Formulary
77
Drug Name
REBIF
Drug Requirements/
Tier Limits
5 PA
Drug Name
BRISDELLE
Drug Requirements/
Tier Limits
4 MO
REBIF REBIDOSE
5
PA
REBIF REBIDOSE
TITRATIONPACK
5
PA
REBIF TITRATION PACK
5
PA
Alpha-Proteinase Inhibitor (Human)
5 LA
ARALAST NP 1000 MG
TECFIDERA
5
PA
GLASSIA
4
LA
TECFIDERA STARTER
PACK
5
PA
PROLASTIN-C
5
LA
TYSABRI
5
PA
ZEMAIRA
5
LA
KALYDECO
5
PA; LA
PULMOZYME
5
B/D
Postherpetic Neuralgia (PHN) Agents
4 MO
GRALISE
GRALISE STARTER
4
MO
Pseudobulbar Affect (PBA) Agents
NUEDEXTA
3
MO
Psychotherapeutic and Neurological Agents 2 AL; MO; *
ergoloid mesylates tabs or
ORAP
4
MO
Restless Leg Syndrome (RLS) Agents
4 MO
HORIZANT
Smoking Deterrents
bupropion hcl (smoking
deterrent)
CHANTIX
CHANTIX CONTINUING
MONTHPAK
CHANTIX STARTING
MONTH PAK
4
QL(2 ea daily);
MO; *
PA; MO
4
PA; MO
4
PA; MO
1
NICOTROL INHALER
4
NICOTROL NS
4
ZYBAN (Use Bupropion
HCl (Smoking Deterrent))
QL(17 ea
daily); MO
MO
NF QL(2 ea daily);
MO
RESPIRATORY AGENTS - MISC. - Drugs to
Treat Lung Conditions
Cystic Fibrosis Agents
SULFONAMIDES - Drugs to Treat Bacterial
Infections
Sulfonamides
sulfadiazine tabs or
2
MO; *
TETRACYCLINES - Drugs to Treat Bacterial
Infections
Tetracyclines
ADOXA PAK 1/100 (Use
Doxycycline
(Monohydrate))
ADOXA PAK 1/150 (Use
Doxycycline
(Monohydrate))
ADOXA PAK 2/100 (Use
Doxycycline
(Monohydrate))
ADOXA TABS 100 MG, 50
MG, 75 MG (Use
Doxycycline
(Monohydrate))
demeclocycline hcl tabs or
150 mg, 300 mg
DORYX 150 MG (Use
Doxycycline Hyclate)
DORYX 200 MG
MO
NF
MO
NF
MO
NF
MO
NF
1
MO; *
NF MO
4
PA; MO
Vasomotor Symptom Agents
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Health Net 2015 Value Formulary
78
Drug Requirements/
Tier Limits
doxycycline (monohydrate)
MO; *
2
caps 100 mg, 50 mg, 75
mg
doxycycline (monohydrate)
2 MO; *
susr 25 mg/5ml
doxycycline (monohydrate)
MO; *
2
tabs 100 mg, 150 mg, 50
mg, 75 mg
doxycycline hyclate caps or 1 MO; *
100 mg, 50 mg
doxycycline hyclate solr iv
2 MO; *
100 mg
doxycycline hyclate tabs or
1 MO; *
100 mg, 20 mg
doxycycline hyclate tbec or
3 MO
100 mg, 150 mg
doxycycline hyclate tbec or
2 MO; *
75 mg
DYNACIN 100 MG, 50 MG NF MO
(Use Minocycline HCl)
MINOCIN CAPS OR 100
MO
NF
MG, 50 MG, 75 MG (Use
Minocycline HCl)
minocycline hcl caps or
2 MO; *
100 mg, 50 mg, 75 mg
minocycline hcl tabs or 100
3 MO
mg, 50 mg
MONODOX (Use
MO
NF
Doxycycline
(Monohydrate))
tetracycline hcl caps or 250
1 MO; *
mg, 500 mg
VIBRAMYCIN CAPS 100
MO
NF
MG (Use Doxycycline
Hyclate)
VIBRAMYCIN SUSR 25
MO
4
MG/5ML (Use Doxycycline
(Monohydrate))
VIBRAMYCIN SYRP 50
4 MO
MG/5ML
Drug Name
THYROID AGENTS - Drugs to Regulate Thyroid
Hormones
Antithyroid Agents
methimazole tabs or 10
mg, 5 mg
2
MO; *
Drug Name
propylthiouracil tabs or
TAPAZOLE (Use
Methimazole)
Thyroid Hormones
CYTOMEL (Use
Liothyronine Sodium)
levothyroxine sodium tabs
or 100 mcg, 112 mcg, 125
mcg, 137 mcg, 150 mcg,
175 mcg, 200 mcg, 25
mcg, 300 mcg, 50 mcg, 75
mcg, 88 mcg
liothyronine sodium tabs or
25 mcg, 5 mcg, 50 mcg
SYNTHROID (Use
Levothyroxine Sodium)
Drug Requirements/
Tier Limits
2 MO; *
NF MO
NF MO
MO; *
2
2
MO; *
4
MO
TOXOIDS
Toxoid Combinations
ADACEL
4
BOOSTRIX
4
DAPTACEL
4
DIPHTHERIA/TETANUS
TOXOIDS ADSORBED
PEDIATRIC
4
INFANRIX
4
TENIVAC
4
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED
ADULT
4
Toxoids
TETANUS TOXOID
ADSORBED
B/D
B/D
4
B/D
ULCER DRUGS - Drugs to Treat Bowel, Intestine
and Stomach Conditions
Antispasmodics
BENTYL CAPS OR 10 MG
(Use Dicyclomine HCl)
BENTYL TABS OR 20 MG
(Use Dicyclomine HCl)
NF MO
NF MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
79
Drug Name
CANTIL
Drug Requirements/
Tier Limits
4 MO
dicyclomine hcl caps 10 mg
2
MO; *
dicyclomine hcl tabs 20 mg
2
MO; *
glycopyrrolate soln ij 0.2
mg/ml
2
MO; *
glycopyrrolate tabs or 1 mg
1
glycopyrrolate tabs or 2 mg
1
methscopolamine bromide
tabs or 2.5 mg, 5 mg
PAMINE (Use
Methscopolamine Bromide)
PAMINE FORTE (Use
Methscopolamine Bromide)
ROBINUL FORTE (Use
Glycopyrrolate)
ROBINUL SOLN IJ 0.2
MG/ML (Use
Glycopyrrolate)
ROBINUL TABS OR 1 MG
(Use Glycopyrrolate)
H-2 Antagonists
1
QL(8 ea daily);
MO; *
QL(4 ea daily);
MO; *
MO; *
NF MO
NF MO
NF QL(4 ea daily);
MO
MO
NF
NF QL(8 ea daily);
MO
1
RX/OTC; MO; *
1
MO; *
1
MO; *
1
*
3
MO
famotidine tabs or 20 mg
1
RX/OTC; MO; *
famotidine tabs or 40 mg
1
MO; *
cimetidine tabs or 200 mg
cimetidine tabs or 300 mg,
400 mg, 800 mg
famotidine soln iv 20
mg/2ml, 40 mg/4ml
famotidine soln iv 200
mg/20ml
famotidine susr or 40
mg/5ml
nizatidine caps 150 mg,
1 MO; *
300 mg
PEPCID SUSR 40 MG/5ML NF MO
(Use Famotidine)
PEPCID TABS 20 MG (Use NF RX/OTC; MO
Famotidine)
Drug Requirements/
Tier Limits
PEPCID TABS 40 MG (Use NF MO
Famotidine)
ranitidine hcl caps or 150
2 MO; *
mg, 300 mg
ranitidine hcl syrp or 15
MO
3
mg/ml, 150 mg/10ml, 75
mg/5ml
ranitidine hcl tabs or 150
1 RX/OTC; MO; *
mg
ranitidine hcl tabs or 300
1 MO; *
mg
ZANTAC SYRP OR 15
MO
NF
MG/ML (Use Ranitidine
HCl)
ZANTAC TABS OR 150
NF RX/OTC; MO
MG (Use Ranitidine HCl)
ZANTAC TABS OR 300
NF MO
MG (Use Ranitidine HCl)
Drug Name
Misc. Anti-Ulcer
CARAFATE SUSP 1
GM/10ML
CARAFATE TABS 1 GM
(Use Sucralfate)
4
MO
NF MO
2
MO; *
DEXILANT
3
ST; MO
lansoprazole cpdr or 15 mg
4
RX/OTC; MO
lansoprazole cpdr or 30 mg
4
MO
2
MO; *
2
*
1
MO; *
sucralfate tabs or
Proton Pump Inhibitors
omeprazole cpdr or 10 mg,
20 mg, 40 mg
pantoprazole sodium solr iv
40 mg
pantoprazole sodium tbec
or 20 mg, 40 mg
PREVACID 15 MG (Use
Lansoprazole)
PREVACID 30 MG (Use
Lansoprazole)
PRILOSEC CPDR 10 MG,
20 MG, 40 MG (Use
Omeprazole)
NF RX/OTC; MO
NF MO
MO
NF
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
80
Drug Name
PROTONIX PACK OR 40
MG
PROTONIX SOLR IV 40
MG (Use Pantoprazole
Sodium)
PROTONIX TBEC OR 20
MG, 40 MG (Use
Pantoprazole Sodium)
Drug Requirements/
Tier Limits
4 QL(1 ea daily);
MO
NF
MO
NF
Ulcer Drugs - Prostaglandins
CYTOTEC (Use
NF MO
Misoprostol)
misoprostol tabs or 100
2 MO; *
mcg, 200 mcg
Ulcer Therapy Combinations
amoxicillin-clarithromycin
w/ lansoprazole
omeprazole-sodium
bicarbonate 20mg-1100mg
omeprazole-sodium
bicarbonate 40mg-1100mg
PREVPAC (Use
Amoxicillin-Clarithromycin
w/ Lansoprazole)
PYLERA
ZEGERID CAPS 20MG1100MG (Use
Omeprazole-Sodium
Bicarbonate)
ZEGERID CAPS 40MG1100MG (Use
Omeprazole-Sodium
Bicarbonate)
ZEGERID PACK 40MG1680MG
MACRODANTIN 100 MG,
50 MG (Use Nitrofurantoin
Macrocrystal)
Drug Requirements/
Tier Limits
AL; MO
NF
MACRODANTIN 25 MG
4
AL; MO
methenamine hippurate
2
MO; *
MONUROL
4
MO
2
AL; MO; *
2
MO; *
4
AL; MO
nitrofurantoin macrocrystal
caps or 100 mg, 50 mg
nitrofurantoin monohyd
macro
nitrofurantoin susp or
4
MO
UREX (Use Methenamine
Hippurate)
2
RX/OTC; MO; *
URINARY ANTISPASMODICS - Drugs to Treat
Miscellaneous Bladder Spasms
4
MO
Urinary Antispasmodic - Antimuscarinics
DETROL (Use Tolterodine NF MO
Tartrate)
DETROL LA (Use
NF MO
Tolterodine Tartrate)
DITROPAN XL (Use
NF MO
Oxybutynin Chloride)
3 MO
ENABLEX
MO
NF
4
MO
RX/OTC; MO
NF
GELNIQUE
MO
NF
4
MO
URINARY ANTI-INFECTIVES - Drugs to Treat
Bladder/Kidney Infections
Urinary Anti-infectives
FURADANTIN (Use
Nitrofurantoin)
HIPREX (Use
Methenamine Hippurate)
MACROBID (Use
Nitrofurantoin Monohyd
Macro)
Drug Name
NF AL; MO
NF MO
MO
NF
oxybutynin chloride syrp 5
mg/5ml
oxybutynin chloride tabs 5
mg
oxybutynin chloride tb24 10
mg, 15 mg, 5 mg
OXYTROL
SANCTURA (Use
Trospium Chloride)
SANCTURA XR (Use
Trospium Chloride)
tolterodine tartrate cp24 2
mg, 4 mg
tolterodine tartrate tabs 1
mg, 2 mg
NF MO
4
MO
2
MO; *
3
MO
3
MO
4
RX/OTC; MO
4
MO
NF MO
2
MO; *
3
MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
81
Drug Name
TOVIAZ
Drug Requirements/
Tier Limits
3 MO
trospium chloride cp24 60
mg
trospium chloride tabs 20
mg
VESICARE
3
MO
2
3
IMOVAX RABIES
(H.D.C.V.)
Drug Requirements/
Tier Limits
4 B/D
IPOL INACTIVATED IPV
4
MO; *
IXIARO
4
MO
M-M-R II W/DILUENT 10
DOSE
4
PROQUAD
4
RABAVERT
4
B/D
RECOMBIVAX HB
4
B/D
ROTARIX
4
ROTATEQ
3
TWINRIX
4
VAQTA
4
VARIVAX
4
Urinary Antispasmodics - Beta-3 Adrenergic
4 MO
MYRBETRIQ
Urinary Antispasmodics - Cholinergic Agonists
2 MO; *
bethanechol chloride
URECHOLINE (Use
Bethanechol Chloride)
Drug Name
NF MO
Urinary Antispasmodics - Direct Muscle Relaxants
1 MO; *
flavoxate hcl
VACCINES
Bacterial Vaccines
ACTHIB
4
YF-VAX
4
MENACTRA
4
ZOSTAVAX
4
MENOMUNE-A/C/Y/W-135
4
VAGINAL PRODUCTS - Drugs to Treat Vaginal
Infections and Low Hormones
MENVEO
4
PEDVAX HIB
4
TYPHIM VI
4
Vaginal Anti-infectives
CLEOCIN CREA VA 2 %
(Use Clindamycin
Phosphate Vaginal)
CLEOCIN SUPP VA 100
MG
clindamycin phosphate
vaginal
METROGEL-VAGINAL
(Use Metronidazole
Vaginal)
Mixed Vaccine Combinations
COMVAX
4
Viral Vaccines
CERVARIX
4
ENGERIX-B SUSP IJ 10
MCG/0.5ML, 20 MCG/ML
4
B/D
GARDASIL
4
MO
HAVRIX
4
metronidazole vaginal
TERAZOL 3 (Use
Terconazole Vaginal)
TERAZOL 7 (Use
Terconazole Vaginal)
MO
NF
4
MO
1
MO; *
MO
NF
2
MO; *
NF MO
NF MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
82
Drug Name
terconazole vaginal
Drug Requirements/
Tier Limits
2 MO; *
Vaginal Estrogens
ESTRING
4
MO
FEMRING
4
MO
PREMARIN CREA VA
0.625 MG/GM
3
MO
VAGIFEM
4
MO
CRINONE
4
MO
ENDOMETRIN
4
MO
Vaginal Progestins
VASOPRESSORS - Drugs to Treat Heart and
Circulation Conditions
Anaphylaxis Therapy Agents
ADRENACLICK
3
MO
AUVI-Q
3
MO
EPINEPHRINE SOAJ IJ
0.15 MG/0.15ML, 0.3
MG/0.3ML
3
EPIPEN 2-PAK
3
MO
EPIPEN-JR 2-PAK
3
MO
MO
Neurogenic Orthostatic Hypotension (NOH) 5 PA; QL(18 ea
NORTHERA 100 MG
daily)
5 PA; QL(9 ea
NORTHERA 200 MG
daily)
5 PA; QL(6 ea
NORTHERA 300 MG
daily)
Vasopressors
dobutamine hcl
1
*
midodrine hcl
3
MO
You can find information on what the symbols and abbreviations on this table mean by going to
page ix.
Health Net 2015 Value Formulary
83
Index
abacavir sulfate
40
abacavir sulfate-lamivudinezidovudine
40
ABELCET
25
ABILIFY 1 MG/ML
40
ABILIFY 10 MG
40
ABILIFY 15 MG
40
ABILIFY 2 MG
40
ABILIFY 20 MG, 30 MG
40
ABILIFY 5 MG
40
ABILIFY 9.75 MG/1.3ML
40
ABILIFY DISCMELT 10 MG 40
ABILIFY DISCMELT 15 MG 40
ABILIFY MAINTENA
40
ABRAXANE
37
ABSTRAL 100 MCG
4
ABSTRAL 200 MCG
4
ABSTRAL 300 MCG, 400 MCG,
600 MCG, 800 MCG
4
acamprosate calcium
77
ACANYA
51
acarbose
21
ACCOLATE
13
ACCUNEB
14
ACCUPRIL
28
ACCURETIC
30
acebutolol hcl 200 mg, 400
mg
45
ACEON 4 MG
28
ACEON 8 MG
28
acetaminophen w/ codeine
120mg/5ml-12mg/5ml
7
acetaminophen w/ codeine
300mg-15mg, 300mg-30mg,
300mg-60mg
7
acetazolamide 250 mg
58
acetazolamide 500 mg
58
acetic acid (otic)
75
acetic acid 0.25 %
64
acetic acid/aluminum
acetate
75
acetylcysteine 10 %, 20 % 51
acitretin
53
ACLOVATE
54
ACTEMRA
3
ACTHIB
82
ACTIGALL
62
ACTIMMUNE
36
Index 1
ACTIQ 1200 MCG, 1600 MCG,
400 MCG, 600 MCG, 800
MCG
4
ACTIQ 200 MCG
4
ACTIVELLA
61
ACTONEL 150 MG
59
ACTONEL 30 MG, 5 MG 59
ACTONEL 35 MG
59
ACTOPLUS MET
21
ACTOPLUS MET XR 15MG1000MG
21
ACTOPLUS MET XR 30MG1000MG
21
ACTOS
23
ACULAR
74
ACULAR LS
74
ACUVAIL
74
acyclovir 200 mg
43
acyclovir 200 mg/5ml
43
acyclovir 400 mg, 800 mg 43
acyclovir sodium 50 mg/ml 43
acyclovir sodium 500 mg 43
acyclovir topical
54
ADACEL
79
ADAGEN
45
ADALAT CC
45
adapalene 0.1 %
51
adapalene 0.3 %
51
ADASUVE
39
ADCIRCA
47
ADDERALL
1
ADDERALL XR
1
adefovir dipivoxil
42
ADEMPAS 0.5 MG
47
ADEMPAS 1 MG
47
ADEMPAS 1.5 MG
47
ADEMPAS 2 MG
47
ADEMPAS 2.5 MG
47
ADOXA 100 MG, 50 MG, 75
MG
78
ADOXA PAK 1/100
78
ADOXA PAK 1/150
78
ADOXA PAK 2/100
78
ADRENACLICK
83
ADVAIR DISKUS
14
ADVAIR HFA
14
ADVICOR
28
AEROSPAN
13
AFINITOR
35
AFINITOR DISPERZ
35
AGGRENOX
64
AGRYLIN
65
ALBENZA
9
albuterol sulfate 0.083 %, 0.5 %,
0.63 mg/3ml, 1.25 mg/3ml 14
albuterol sulfate 2 mg, 4 mg 14
albuterol sulfate 2 mg/5ml 14
albuterol sulfate 4 mg, 8 mg 14
ALCAINE
73
alclometasone dipropionate 54
ALCOHOL PADS
68
ALDACTAZIDE 25MG25MG
58
ALDACTAZIDE 50MG50MG
58
ALDACTONE
58
ALDARA
57
alendronate sodium 10 mg, 5
mg
59
alendronate sodium 35 mg, 70
mg
59
alfuzosin hcl
64
ALIMTA 100 MG
33
ALIMTA 500 MG
33
ALINIA 500 MG
10
ALKERAN 2 MG
32
ALKERAN 50 MG
32
allopurinol 100 mg
64
allopurinol 300 mg
64
ALOCRIL
74
ALOMIDE
74
ALORA
61
ALPHAGAN P 0.1 %
72
ALPHAGAN P 0.15 %
72
alprazolam 0.25 mg, 0.5 mg, 1
mg, 2 mg
12
alprazolam 0.5 mg, 1 mg, 2 mg, 3
mg
12
ALREX
73
ALTABAX
53
ALTACE
28
ALTOPREV
28
ALVESCO 160 MCG/ACT 13
ALVESCO 80 MCG/ACT
13
amantadine hcl 100 mg
37
amantadine hcl 50 mg/5ml 37
AMARYL
24
AMBIEN 10 MG
66
AMBIEN 5 MG
66
AMBIEN CR 12.5 MG
66
AMBIEN CR 6.25 MG
66
AMBISOME
25
amcinonide
54
AMERGE
68
AMICAR 1000 MG
66
AMICAR 500 MG
66
amifostine crystalline
36
amikacin sulfate 1 gm/4ml, 500
mg/2ml
2
amiloride &
hydrochlorothiazide
58
amiloride hcl
58
amino acid infusion 15%
72
AMINOCAPROIC ACID 1000
MG
66
aminocaproic acid 500 mg 66
aminophylline
15
AMINOSYN II 15% (Use amino
acid infusion)
72
amiodarone hcl 100 mg, 200 mg,
400 mg
13
AMITIZA
62
amitriptyline hcl
21
amlodipine besylate 10 mg 45
amlodipine besylate 2.5 mg 45
amlodipine besylate 5 mg
46
amlodipine besylate-atorvastatin
calcium
46
amlodipine besylate-benazepril
hcl
30
amlodipine besylatevalsartan
30
amlodipine-valsartanhydrochlorothiazide
30
ammonium chloride
69
amoxapine 100 mg, 25 mg, 50
mg
21
amoxapine 150 mg
21
amoxicillin & pot clavulanate 76
amoxicillin 125 mg/5ml, 200
mg/5ml, 250 mg/5ml, 400
mg/5ml
75
amoxicillin 250 mg, 500 mg 75
amoxicillin 500 mg, 875 mg 75
amoxicillin-clarithromycin w/
lansoprazole
81
amphetaminedextroamphetamine 1.25mg1.25mg-1.25mg-1.25mg,
1.875mg-1.875mg-1.875mg1.875mg, 2.5mg-2.5mg-2.5mg2.5mg, 3.125mg-3.125mg3.125mg-3.125mg, 3.75mg3.75mg-3.75mg-3.75mg, 5mg5mg-5mg-5mg, 7.5mg-7.5mg7.5mg-7.5mg
1
amphetaminedextroamphetamine 1.25mg1.25mg-1.25mg-1.25mg,
2.5mg-2.5mg-2.5mg-2.5mg,
3.75mg-3.75mg-3.75mg3.75mg, 5mg-5mg-5mg-5mg,
6.25mg-6.25mg-6.25mg6.25mg, 7.5mg-7.5mg-7.5mg7.5mg
1
amphotericin b 50 mg
25
ampicillin & sulbactam sodium
1gm-2gm
76
ampicillin & sulbactam sodium
5gm-10gm
76
ampicillin 250 mg, 500 mg 75
ampicillin sodium 1 gm
75
ampicillin sodium 10 gm 76
ampicillin sodium 125 mg 75
ampicillin sodium 2 gm
75
AMPYRA
77
AMTURNIDE
30
ANADROL-50
8
ANAFRANIL
21
anagrelide hcl
65
ANAPROX
3
ANAPROX DS
3
anastrozole
34
ANCOBON 250 MG
25
ANCOBON 500 MG
25
ANDRODERM
8
ANDROGEL
9
ANDROGEL PUMP
9
androxy
9
ANGELIQ 0.5MG-1MG
61
ANORO ELLIPTA
14
ANTABUSE
77
ANTARA 130 MG
27
ANTARA 30 MG
27
ANTARA 43 MG
27
ANTARA 90 MG
27
APIDRA
23
APIDRA SOLOSTAR
23
APLENZIN 174 MG
19
APLENZIN 348 MG, 522 MG19
APOKYN
37
apraclonidine hcl
72
APRISO
63
APTIOM 200 MG
16
APTIOM 400 MG
16
APTIOM 600 MG
16
APTIOM 800 MG
16
APTIVUS 100 MG/ML
40
APTIVUS 250 MG
40
ARALAST NP 1000 MG
78
ARALEN
31
ARANESP ALBUMIN FREE 100
MCG/0.5ML, 100 MCG/ML, 150
MCG/0.3ML, 150 MCG/0.75ML,
200 MCG/0.4ML, 200 MCG/ML,
300 MCG/0.6ML, 300 MCG/ML,
500 MCG/ML
65
ARANESP ALBUMIN FREE 25
MCG/0.42ML, 25 MCG/ML, 40
MCG/0.4ML, 40 MCG/ML, 60
MCG/0.3ML, 60 MCG/ML
65
ARAVA
4
ARCALYST
2
ARCAPTA NEOHALER
14
argatroban 100 mg/ml
15
ARICEPT
77
ARICEPT ODT
77
ARIMIDEX
34
ARIXTRA 10 MG/0.8ML, 5
MG/0.4ML, 7.5 MG/0.6ML 15
ARIXTRA 2.5 MG/0.5ML
15
AROMASIN
34
ARRANON
33
ARTHROTEC 50
3
ARTHROTEC 75
3
ARZERRA
34
ASACOL
63
ASACOL HD
63
ASMANEX TWISTHALER 120
METERED DOSES
13
ASMANEX TWISTHALER 14
METERED DOSES
13
ASMANEX TWISTHALER 30
METERED DOSES 110
MCG/INH
14
ASMANEX TWISTHALER 30
METERED DOSES 220
MCG/INH
14
Index 2
ASMANEX TWISTHALER 60
METERED DOSES
14
ASMANEX TWISTHALER 7
METERED DOSES
14
ASTAGRAF XL
43
ASTELIN
71
ASTEPRO
71
ATACAND
29
ATACAND HCT
30
ATELVIA
59
atenolol & chlorthalidone
30
atenolol 100 mg, 25 mg, 50
mg
45
ATGAM
43
ATIVAN 0.5 MG, 1 MG, 2
MG
12
ATIVAN 2 MG/ML
12
ATIVAN 4 MG/ML
12
atorvastatin calcium
28
atovaquone
10
atovaquone-proguanil hcl 250mg100mg
31
atovaquone-proguanil hcl
62.5mg-25mg
31
ATRALIN
51
ATRIPLA
40
ATROVENT
71
ATROVENT HFA
13
AUBAGIO
77
AUGMENTIN 250MG/5ML62.5MG/5ML
76
AUGMENTIN 500MG-125MG,
875MG-125MG
76
AUGMENTIN ES-600
76
AUGMENTIN XR
76
AUVI-Q
83
AVALIDE
30
AVANDAMET 2MG-1000MG,
4MG-500MG
21
AVANDAMET 2MG-500MG 21
AVANDAMET 4MG-1000MG21
AVANDARYL 4MG-1MG, 4MG2MG, 4MG-4MG, 8MG-4MG 21
AVANDARYL 8MG-2MG
21
AVANDIA 2 MG
23
AVANDIA 4 MG, 8 MG
23
AVAPRO
29
AVASTIN
34
AVEED
9
AVELOX 400 MG
62
Index 3
AVELOX ABC PACK
62
AVINZA
4
AVODART
64
AVONEX
77
AVONEX PEN
77
AXERT
68
AXIRON
9
AYGESTIN
76
azacitidine
33
AZACTAM 1 GM
9
AZACTAM 2 GM
9
azasan
43
AZASITE
72
azathioprine
43
azelastine hcl
71
azelastine hcl (ophth)
74
AZELEX
51
AZILECT
38
azithromycin 100 mg/5ml, 200
mg/5ml
67
azithromycin 250 mg, 500 mg,
600 mg
67
azithromycin 500 mg
67
AZOPT
74
AZOR
30
aztreonam 1 gm
9
aztreonam 2 gm
9
AZULFIDINE
63
AZULFIDINE EN-TABS
63
bacitracin-poly-neomycin-hc
73
bacitracin-polymyxin b
(ophth)
72
baclofen 10 mg
70
baclofen 20 mg
70
BACTRIM
10
BACTRIM DS
10
BACTROBAN
53
BACTROBAN NASAL
71
balsalazide disodium
63
BANZEL 200 MG
16
BANZEL 40 MG/ML
16
BANZEL 400 MG
16
BARACLUDE 0.05 MG/ML 42
BARACLUDE 0.5 MG, 1
MG
42
BECONASE AQ
71
BELEODAQ
35
benazepril &
hydrochlorothiazide
30
benazepril hcl 10 mg, 20 mg, 40
mg, 5 mg
29
BENICAR
29
BENICAR HCT
30
BENLYSTA
44
BENTYL 10 MG
79
BENTYL 20 MG
79
BENZACLIN
52
BENZACLIN WITH PUMP 52
BENZAMYCIN
52
benzoyl peroxideerythromycin
52
benztropine mesylate 0.5 mg, 1
mg, 2 mg
37
benztropine mesylate 1
mg/ml
37
BEPREVE
74
BERINERT
64
BESIVANCE
72
BETAGAN
72
betamethasone dipropionate
(topical)
54
betamethasone dipropionate
augmented
54
betamethasone sod phosphate &
acetate
50
betamethasone valerate 0.1
%
54
betamethasone valerate 0.12
%
54
BETAPACE
45
BETAPACE AF
45
BETASERON
77
betaxolol hcl (ophth)
72
betaxolol hcl 10 mg
45
betaxolol hcl 20 mg
45
bethanechol chloride
82
BETHKIS
2
BETIMOL 0.25 %
72
BETIMOL 0.5 %
72
BETOPTIC-S
72
BEYAZ
48
BIAXIN
67
BIAXIN XL
67
BIAXIN XL PAC
67
bicalutamide
34
BICILLIN L-A 1200000
UNIT/2ML, 2400000
UNIT/4ML
76
BICNU
32
BIDIL
47
BILTRICIDE
9
bisoprolol &
hydrochlorothiazide
30
bisoprolol fumarate
45
BIVIGAM
75
bleomycin sulfate 15 unit
35
bleomycin sulfate 30 unit
35
BLEPH-10
73
BLEPHAMIDE
73
BLINCYTO
34
BONIVA 150 MG
59
BONIVA 3 MG/3ML
59
BOOSTRIX
79
BOSULIF
35
BOTOX
71
BREO ELLIPTA
14
BREVICON-28
48
BRILINTA
65
brimonidine tartrate
72
BRINTELLIX 10 MG
20
BRINTELLIX 20 MG
20
BRINTELLIX 5 MG
20
BRISDELLE
78
bromfenac sodium (ophth) 74
bromocriptine mesylate 2.5
mg
38
bromocriptine mesylate 5 mg38
BROVANA
14
budesonide
50
budesonide (inhalation) 0.25
mg/2ml
14
budesonide (inhalation) 0.5
mg/2ml
14
budesonide (nasal)
71
bumetanide 0.5 mg, 1 mg, 2
mg
58
BUNAVAIL
8
buprenorphine hcl 2 mg
8
buprenorphine hcl 8 mg
8
buprenorphine hcl-naloxone hcl
dihydrate 2mg-0.5mg
8
buprenorphine hcl-naloxone hcl
dihydrate 8mg-2mg
8
bupropion hcl (smoking
deterrent)
78
bupropion hcl 100 mg
19
bupropion hcl 150 mg
19
bupropion hcl 150 mg, 200
mg
19
bupropion hcl 300 mg
19
bupropion hcl 75 mg
19
buspirone hcl 10 mg, 15 mg, 30
mg, 5 mg, 7.5 mg
12
BUSULFEX
32
butalbital-acetaminophencaffeine w/ codeine 300mg50mg-40mg-30mg
7
butalbital-acetaminophencaffeine w/ codeine 325mg50mg-40mg-30mg
7
butalbital-aspirin-caffeine
w/cod
7
BUTISOL SODIUM 30 MG, 50
MG
66
butisol sodium 30 mg/5ml 66
butorphanol tartrate 10
mg/ml
8
BUTRANS 10 MCG/HR
8
BUTRANS 15 MCG/HR
8
BUTRANS 20 MCG/HR, 7.5
MCG/HR
8
BUTRANS 5 MCG/HR
8
BYDUREON
23
BYETTA
23
BYSTOLIC
45
cabergoline
61
CADUET
47
CALAN
46
CALAN SR
46
calcipotriene
53
calcipotriene-betamethasone
dipropionate
54
calcitonin (salmon)
59
calcitriol 0.25 mcg, 0.5
mcg
60
calcitriol 1 mcg/ml
60
CALCITRIOL 3 MCG/GM 54
calcium acetate (phosphate
binder)
63
CAMBIA
68
CAMPRAL
77
CAMPTOSAR 100 MG/5ML, 40
MG/2ML
37
CAMPTOSAR 300
MG/15ML
37
CANASA
63
candesartan cilexetil
29
candesartan cilexetilhydrochlorothiazide
30
CANTIL
80
CAPASTAT SULFATE
32
CAPEX
54
CAPRELSA
35
captopril 100 mg, 12.5 mg, 25
mg, 50 mg
29
CAPTOPRIL/HYDROCHLOROT
HIAZIDE
30
CARAC
53
CARAFATE 1 GM
80
CARAFATE 1 GM/10ML
80
carbamazepine 100 mg
16
carbamazepine 100 mg, 200 mg,
300 mg
16
carbamazepine 100 mg/5ml 16
carbamazepine 200 mg
16
carbamazepine 200 mg, 400
mg
16
CARBATROL
16
carbidopa
37
carbidopa-levodopa
38
carbidopa-levodopa-entacapone
38
carbinoxamine maleate 4 mg26
carbinoxamine maleate 4
mg/5ml
26
carboplatin 150 mg/15ml, 600
mg/60ml
32
carboplatin 450 mg/45ml, 50
mg/5ml
32
CARDIZEM
46
CARDIZEM CD
46
CARDIZEM LA 120 MG
46
CARDIZEM LA 180 MG, 240 MG,
300 MG, 360 MG, 420 MG 46
CARDURA
29
CARDURA XL
64
carisoprodol 250 mg, 350
mg
70
carisoprodol w/ aspirin
71
carisoprodol w/ aspirin &
codeine
71
CARNITOR 330 MG
60
carteolol hcl (ophth)
72
carvedilol 12.5 mg
44
carvedilol 25 mg
44
carvedilol 3.125 mg
44
carvedilol 6.25 mg
44
CASODEX
34
CATAFLAM
3
CATAPRES
29
CATAPRES-TTS-1
29
Index 4
CATAPRES-TTS-2
CATAPRES-TTS-3
CAYSTON
CEDAX 400 MG
CEENU
cefaclor 250 mg, 500 mg
cefadroxil 1 gm
cefadroxil 250 mg/5ml
cefadroxil 500 mg
cefadroxil 500 mg/5ml
cefazolin sodium 1 gm, 10
gm
cefazolin sodium 500 mg
cefdinir 125 mg/5ml
cefdinir 250 mg/5ml
cefdinir 300 mg
CEFEPIME 1 GM/50ML, 2
GM/100ML
cefepime hcl
cefotaxime sodium 1 gm
cefotaxime sodium 10 gm, 2
gm
cefotaxime sodium 500 mg
cefpodoxime proxetil
cefprozil 125 mg/5ml
cefprozil 250 mg, 500 mg
cefprozil 250 mg/5ml
ceftazidime 1 gm, 2 gm
ceftazidime 6 gm
CEFTIBUTEN 400 MG
CEFTIN 125 MG/5ML
CEFTIN 250 MG, 500 MG
ceftriaxone sodium 1 gm
ceftriaxone sodium 10 gm
ceftriaxone sodium 2 gm
ceftriaxone sodium 250 mg
ceftriaxone sodium 500 mg
cefuroxime axetil
cefuroxime sodium 1.5 gm
cefuroxime sodium 7.5 gm
cefuroxime sodium 750 mg
CELEBREX
celecoxib
CELESTONE
CELESTONE-SOLUSPAN
CELEXA 10 MG
CELEXA 20 MG
Index 5
30
30
9
48
32
47
47
47
47
47
47
47
48
48
48
48
48
48
48
48
48
47
47
47
48
48
48
47
47
48
48
48
48
48
47
48
48
48
3
3
50
50
19
19
CELEXA 40 MG
19
CELLCEPT 200 MG/ML 43
CELLCEPT 250 MG
43
CELLCEPT 500 MG
43
CELLCEPT
INTRAVENOUS
43
CELONTIN
18
CENESTIN 0.3 MG, 0.45 MG,
0.9 MG
61
CENESTIN 0.625 MG, 1.25
MG
61
cephalexin 125 mg/5ml, 250
mg/5ml
47
cephalexin 250 mg, 500
mg
47
cephalexin 750 mg
47
CERDELGA
65
CEREBYX 100 MG
PE/2ML
18
CEREBYX 500 MG
PE/10ML
18
CEREZYME 400 UNIT
65
CERVARIX
82
CESAMET
25
cetirizine hcl 1 mg/ml
26
cetirizine hcl 1 mg/ml, 5
mg/5ml
26
cevimeline hcl
70
CHANTIX
78
CHANTIX CONTINUING
MONTHPAK
78
CHANTIX STARTING MONTH
PAK
78
CHEMET
24
CHENODAL
62
chloramphenicol sodium
succinate
10
chlordiazepoxide hcl
12
chlordiazepoxide/amitriptyline
77
chlorhexidine gluconate
(mouth-throat)
70
chloroquine phosphate 250 mg,
500 mg
31
chlorothiazide 500 mg
58
chlorpromazine hcl 10 mg, 100
mg, 200 mg, 25 mg, 50 mg 40
chlorpromazine hcl 25
mg/ml
40
chlorpropamide
24
chlorzoxazone
70
cholestyramine 4 gm
27
cholestyramine 4 gm/dose 27
cholestyramine light
27
choline fenofibrate
27
chorionic gonadotropin
59
ciclopirox 0.77 %
53
ciclopirox 1 %
53
ciclopirox 8 %
53
ciclopirox olamine
53
cidofovir
42
cilostazol
65
CILOXAN
73
cimetidine 200 mg
80
cimetidine 300 mg, 400 mg, 800
mg
80
CIMZIA
63
CIMZIA STARTER KIT
63
CINRYZE
64
CIPRO 250 MG, 500 MG
62
CIPRO 5 GM/100ML, 500
MG/5ML
62
CIPRO HC
75
CIPRO I.V.-IN D5W
200MG/100ML-5%
62
CIPRO I.V.-IN D5W
400MG/200ML-5%
62
CIPRO XR
62
CIPRODEX
75
ciprofloxacin 250 mg/5ml, 500
mg/5ml
62
ciprofloxacin hcl (ophth)
73
ciprofloxacin hcl 100 mg, 250 mg,
500 mg, 750 mg
62
ciprofloxacin in d5w
200mg/100ml-5%
62
ciprofloxacin in d5w
400mg/200ml-5%
62
ciprofloxacin-ciprofloxacin
hcl
62
cisplatin 100 mg/100ml, 50
mg/50ml
32
CISPLATIN 200 MG/200ML 32
citalopram hydrobromide 10
mg
19
citalopram hydrobromide 10
mg/5ml
19
citalopram hydrobromide 20
mg
19
citalopram hydrobromide 40
mg
19
cladribine
33
CLAFORAN 1 GM, 10 GM, 2
GM
48
CLAFORAN 500 MG
48
CLARINEX 5 MG
26
CLARINEX REDITABS 5
MG
26
CLARINEX-D 12 HOUR
51
CLARINEX-D 24 HOUR
51
clarithromycin 125 mg/5ml 67
clarithromycin 250 mg, 500
mg
67
clarithromycin 250 mg/5ml 67
clarithromycin 500 mg
67
clemastine fumarate 2.68 mg26
CLEOCIN 100 MG
82
CLEOCIN 150 MG, 300 MG, 75
MG
11
CLEOCIN 2 %
82
CLEOCIN IN D5W
11
CLEOCIN PEDIATRIC
GRANULES
11
CLEOCIN PHOSPHATE
300MG/50ML-5%, 600MG/50ML5%, 900MG/50ML-5%
11
CLEOCIN PHOSPHATE 600
MG/4ML, 900 MG/6ML
11
CLEOCIN-T
52
CLIMARA
61
CLIMARA PRO
61
clindamycin hcl 150 mg, 300 mg,
75 mg
11
clindamycin palmitate
hydrochloride
11
clindamycin phosphate
(topical)
52
clindamycin phosphate 150
mg/ml
11
clindamycin phosphate 150
mg/ml, 9000 mg/60ml
11
clindamycin phosphate 600
mg/4ml, 900 mg/6ml
11
clindamycin phosphate in
d5w
11
clindamycin phosphate
vaginal
82
clindamycin phosphate-benzoyl
peroxide
52
clindamycin phosphate-benzoyl
peroxide (refrigerate)
52
CLINIMIX 2.75%/DEXTROSE
5%
72
clobetasol propionate
54
clobetasol propionate emollient
base
54
clobetasol propionate
emulsion
54
CLOBEX
55
CLOCORTOLONE
PIVALATE
55
CLOCORTOLONE PIVALATE
PUMP
55
CLODERM
55
CLODERM PUMP
55
CLOLAR
33
clomipramine hcl 25 mg, 50
mg
21
clomipramine hcl 75 mg 21
clonazepam 0.125 mg, 0.25
mg, 0.5 mg, 1 mg, 2 mg
16
clonazepam 0.5 mg
16
clonazepam 1 mg
16
clonazepam 2 mg
16
clonidine hcl (adhd)
1
clonidine hcl 0.1 mg, 0.2 mg,
0.3 mg
30
clonidine hcl 0.1 mg/24hr, 0.2
mg/24hr, 0.3 mg/24hr
30
clopidogrel bisulfate 300
mg
65
clopidogrel bisulfate 75 mg 65
clorazepate dipotassium 12
clotrimazole
70
clotrimazole (topical)
53
clotrimazole w/
betamethasone
53
clozapine 100 mg, 25 mg 39
clozapine 200 mg, 50 mg 39
CLOZAPINE ODT
39
CLOZARIL
39
COARTEM
31
CODEINE SULFATE 15 MG4
codeine sulfate 30 mg
4
codeine sulfate 60 mg
4
COGENTIN
37
COLAZAL
63
COLCHICINE
64
colchicine w/ probenecid 64
COLCRYS
64
COLESTID
27
COLESTID FLAVORED 5
GM
27
colestipol hcl 1 gm
27
colestipol hcl 5 gm
27
colistimethate sodium
9
COLY-MYCIN M
9
COLY-MYCIN S
75
COLYTE-FLAVOR PACKS
227.1GM-21.5GM-5.53GM2.82GM-6.36GM
66
COLYTE-FLAVOR PACKS
240GM-22.72GM-5.84GM2.98GM-6.72GM
66
COMBIGAN
72
COMBIPATCH
61
COMBIVENT RESPIMAT
14
COMBIVIR
40
COMETRIQ
35
COMPAZINE
40
COMPLERA
40
COMTAN
37
COMVAX
82
CONCERTA
1
CONDYLOX
57
COPAXONE
77
COPEGUS
42
CORDARONE
13
CORDRAN TAPE
55
COREG 12.5 MG
45
COREG 25 MG
45
COREG 3.125 MG
45
COREG 6.25 MG
45
COREG CR
45
CORGARD
45
CORTEF
50
CORTENEMA
9
CORTIFOAM
9
cortisone acetate
50
CORTISPORIN 10000UNIT/GM0.5%-0.5%
53
CORTISPORIN 10000UNIT/ML3.5MG/ML-1%
75
CORTISPORIN 400UNIT/GM5000UNIT/GM-0.5%-1%
53
CORTISPORIN-TC
75
CORZIDE
30
COSMEGEN
35
COSOPT
72
COSOPT PF
72
COUMADIN 1 MG, 10 MG, 2 MG,
2.5 MG, 3 MG, 4 MG, 5 MG, 6
MG, 7.5 MG
15
COZAAR
29
CREON
57
CRESTOR
28
CRINONE
83
CRIXIVAN
40
cromolyn sodium
13
Index 6
cromolyn sodium
(mastocytosis)
62
cromolyn sodium (ophth)
74
CUBICIN
10
CUTIVATE
55
cyclobenzaprine hcl 10 mg, 5 mg,
7.5 mg
70
CYCLOGYL 1 %, 2 %
72
cyclopentolate hcl 1 %, 2 % 72
cyclophosphamide 1 gm, 500
mg
32
cyclophosphamide 25 mg
32
cyclophosphamide 50 mg
32
CYCLOSET
23
cyclosporine 100 mg, 25 mg 43
cyclosporine 50 mg/ml
44
cyclosporine modified
44
cyclosporine modified (for
microemulsion) 100 mg, 25
mg
44
CYKLOKAPRON
66
CYMBALTA
20
cyproheptadine hcl 2 mg/5ml 27
cyproheptadine hcl 4 mg
27
CYRAMZA
34
CYSTADANE
60
CYSTAGON
64
CYSTARAN
74
cytarabine 100 mg/ml
33
cytarabine 20 mg/ml
33
cytarabine 500 mg
33
CYTOMEL
79
CYTOTEC
81
CYTOVENE
42
D.H.E. 45
68
dacarbazine 100 mg
36
dacarbazine 200 mg
36
DACOGEN
33
DALIRESP
13
danazol 100 mg, 200 mg
9
danazol 50 mg
9
DANTRIUM
71
dantrolene sodium 100 mg, 50
mg
71
dantrolene sodium 25 mg
71
dapsone 100 mg, 25 mg
11
DAPTACEL
79
DARAPRIM
31
Index 7
daunorubicin hcl 5 mg/ml 35
DAUNOXOME
35
DAYPRO
3
DAYTRANA 30 MG/9HR
1
DDAVP
60
decitabine
33
DELESTROGEN
61
DELZICOL
63
DEMADEX
58
demeclocycline hcl 150 mg,
300 mg
78
DEMEROL 100 MG
4
DEMEROL 50 MG
4
DEMSER
29
DENAVIR
54
DEPACON
18
DEPAKENE
18
DEPAKOTE
18
DEPAKOTE ER
18
DEPAKOTE SPRINKLES 18
DEPEN TITRATABS
43
DEPO-MEDROL 20
MG/ML
50
DEPO-MEDROL 40 MG/ML, 80
MG/ML
50
DEPO-PROVERA
34
DEPO-PROVERA
CONTRACEPTIVE
50
DEPO-SUBQ PROVERA
104
50
DEPO-TESTOSTERONE 100
MG/ML
9
depo-testosterone 200
mg/ml
9
DERMA-SMOOTHE/FS
BODY
55
DERMA-SMOOTHE/FS BODY
OIL
55
DERMA-SMOOTHE/FS
SCALP
55
DERMA-SMOOTHE/FS SCALP
OIL
55
DERMATOP
55
DERMOTIC
75
desipramine hcl 10 mg, 100
mg, 150 mg, 25 mg, 50 mg, 75
mg
21
desloratadine 5 mg
26
desmopressin acetate 0.1 mg,
0.2 mg
60
desmopressin acetate 4
mcg/ml
60
desmopressin acetate
refrigerated
60
desmopressin acetate spray 60
desmopressin acetate spray
refrigerated
60
DESOGEN
48
desogestrel & ethinyl
estradiol
48
desogestrel-ethinyl estradiol
(biphasic)
48
DESONATE
55
desonide
55
DESOWEN
55
desoximetasone 0.05 %
55
DESOXIMETASONE 0.05 % 55
desoximetasone 0.25 %
55
DESOXYN
1
DESVENLAFAXINE ER 100 MG,
50 MG
20
DETROL
81
DETROL LA
81
dexamethasone 0.5 mg, 0.75 mg,
1 mg, 1.5 mg, 2 mg, 4 mg, 6
mg
50
dexamethasone 0.5 mg/5ml 50
dexamethasone sodium
phosphate (ophth)
73
dexamethasone sodium
phosphate 10 mg/ml, 120
mg/30ml
50
dexamethasone sodium
phosphate 100 mg/10ml, 20
mg/5ml, 4 mg/ml
50
DEXEDRINE
1
DEXILANT
80
dexmethylphenidate hcl 10 mg,
2.5 mg, 5 mg
1
dexmethylphenidate hcl 15
mg
1
dexpak 10 day
50
dexpak 13 day
50
dexpak 6 day
50
dexrazoxane 250 mg
36
dexrazoxane 500 mg
36
dextroamphetamine sulfate 10
mg, 15 mg, 5 mg
1
dextroamphetamine sulfate 10
mg, 5 mg
1
dextrose 10 %
72
dextrose 5 %
72
dextrose in lactated ringers 69
dextrose w/ sodium chloride
0.45%-2.5%
69
dextrose w/ sodium chloride
0.45%-5%
69
dextrose w/ sodium chloride
0.9%-5%
69
DIABETA
24
DIAMOX
58
DIASTAT ACUDIAL
16
DIASTAT PEDIATRIC
16
diazepam 1 mg/ml
12
diazepam 10 mg, 2 mg, 5
mg
12
DIAZEPAM 10 MG, 2.5 MG, 20
MG
16
diazepam 5 mg/ml
12
DIBENZYLINE
29
diclofenac potassium
3
diclofenac sodium (actinic
keratoses)
53
diclofenac sodium (ophth) 74
diclofenac sodium (topical) 52
diclofenac sodium 100 mg
3
diclofenac sodium 25 mg, 50 mg,
75 mg
3
diclofenac w/ misoprostol
3
dicloxacillin sodium
76
dicyclomine hcl 10 mg
80
dicyclomine hcl 20 mg
80
didanosine 125 mg
40
didanosine 200 mg, 250 mg, 400
mg
41
DIFFERIN 0.1 %
52
DIFFERIN 0.3 %
52
DIFICID
68
diflorasone diacetate
55
DIFLUCAN
26
diflunisal
4
DIGOXIN 0.05 MG/ML
46
digoxin 0.125 mg, 0.25 mg, 125
mcg, 250 mcg
46
dihydroergotamine mesylate 1
mg/ml
68
DIHYDROERGOTAMINE
MESYLATE 4 MG/ML
68
DILACOR XR
46
dilantin 100 mg, 30 mg
18
DILANTIN 125 MG/5ML
18
dilantin infatabs
18
DILATRATE SR
11
DILAUDID 1 MG/ML
4
DILAUDID 2 MG
4
DILAUDID 2 MG/ML
4
DILAUDID 4 MG
4
DILAUDID 8 MG
4
DILAUDID-HP 10 MG/ML 4
diltiazem hcl 120 mg, 180 mg,
240 mg
46
diltiazem hcl 120 mg, 30 mg, 60
mg, 90 mg
46
diltiazem hcl 120 mg, 60 mg, 90
mg
46
diltiazem hcl coated beads 46
diltiazem hcl extended release
beads
46
DIOVAN
29
DIOVAN HCT
30
DIPENTUM
63
diphenhydramine hcl 50
mg/ml
26
diphenoxylate w/ atropine 24
DIPHTHERIA/TETANUS
TOXOIDS ADSORBED
PEDIATRIC
79
DIPROLENE
55
DIPROLENE AF
55
dipyridamole 25 mg, 50 mg, 75
mg
65
disopyramide phosphate 100
mg, 150 mg
12
disulfiram 250 mg, 500 mg 77
DITROPAN XL
81
divalproex sodium
18
DIVIGEL 0.25 MG/0.25GM, 0.5
MG/0.5GM
61
DIVIGEL 1 MG/GM
61
dobutamine hcl
83
DOCEFREZ
37
DOCETAXEL 140 MG/7ML, 20
MG/ML, 80 MG/2ML, 80
MG/4ML
37
DOCETAXEL 160 MG/16ML,
20 MG/2ML, 80 MG/8ML 37
DOCETAXEL 20
MG/0.5ML
37
docetaxel 20 mg/ml, 80
mg/4ml
37
DOLOPHINE
4
DOLOPHINE HCL
4
donepezil hydrochloride 77
DORIBAX 500 MG
10
DORYX 150 MG
78
DORYX 200 MG
78
dorzolamide hcl
74
dorzolamide hcl-timolol
maleate
72
DOVONEX
54
doxazosin mesylate
30
doxepin hcl 10 mg, 100 mg, 150
mg, 25 mg, 50 mg, 75 mg
21
doxepin hcl 10 mg/ml
21
doxercalciferol 0.5 mcg, 1 mcg,
2.5 mcg
60
DOXIL
35
doxorubicin hcl 10 mg
35
doxorubicin hcl 2 mg/ml
35
doxorubicin hcl 50 mg
35
doxorubicin hcl liposomal
35
doxycycline (monohydrate) 100
mg, 150 mg, 50 mg, 75 mg 79
doxycycline (monohydrate) 100
mg, 50 mg, 75 mg
79
doxycycline (monohydrate) 25
mg/5ml
79
doxycycline hyclate 100 mg 79
doxycycline hyclate 100 mg, 150
mg
79
doxycycline hyclate 100 mg, 20
mg
79
doxycycline hyclate 100 mg, 50
mg
79
doxycycline hyclate 75 mg 79
dronabinol 10 mg
25
dronabinol 2.5 mg
25
dronabinol 5 mg
25
drospirenone-ethinyl
estradiol
48
DROXIA
65
DUAC
52
DUAVEE
61
DUETACT
22
DUEXIS
3
DULERA
14
duloxetine hcl
20
DUONEB
14
DURAGESIC 100 MCG/HR 4
DURAGESIC 12 MCG/HR
4
DURAGESIC 25 MCG/HR
5
DURAGESIC 50 MCG/HR
5
DURAGESIC 75 MCG/HR
5
DUREZOL
73
DYAZIDE
58
DYMISTA
71
DYNACIN 100 MG, 50 MG 79
Index 8
DYRENIUM
e.e.s. 400
E.E.S. GRANULES
EC-NAPROSYN
econazole nitrate
EDARBI
EDARBYCLOR
EDECRIN
EDLUAR
EDURANT
EFFEXOR XR 150 MG
EFFEXOR XR 37.5 MG
EFFEXOR XR 75 MG
EFFIENT
EFUDEX
EGRIFTA
ELDEPRYL
ELELYSO
ELESTAT
ELESTRIN
ELIDEL
ELIGARD
ELIMITE
ELIPHOS
ELIQUIS
ELITEK
ELLA
ELLENCE
ELMIRON
ELOCON
ELOXATIN 100 MG/20ML
ELOXATIN 50 MG/10ML
EMCYT
EMEND 125 MG, 80 MG
EMEND 40 MG
EMLA
EMSAM
EMTRIVA
ENABLEX
enalapril maleate &
hydrochlorothiazide
enalapril maleate 10 mg
enalapril maleate 2.5 mg
enalapril maleate 20 mg
enalapril maleate 5 mg
enalaprilat
Index 9
58
67
67
3
53
29
30
58
66
41
20
20
20
65
53
59
38
65
74
61
57
34
57
63
15
36
50
35
64
55
32
32
34
25
25
57
19
41
81
30
29
29
29
29
29
ENBREL
4
ENBREL SURECLICK
4
ENDOMETRIN
83
ENGERIX-B 10 MCG/0.5ML,
20 MCG/ML
82
ENJUVIA 0.3 MG, 0.45 MG, 0.9
MG, 1.25 MG
61
ENJUVIA 0.625 MG
61
enoxaparin sodium 100 mg/ml,
60 mg/0.6ml, 80 mg/0.8ml 15
enoxaparin sodium 120
mg/0.8ml, 150 mg/ml
15
enoxaparin sodium 30
mg/0.3ml, 40 mg/0.4ml
15
enoxaparin sodium 300
mg/3ml
15
entacapone
37
entecavir
42
ENTOCORT EC
50
ENTYVIO
63
EPIDUO
52
epinastine hcl (ophth)
74
EPINEPHRINE 0.15
MG/0.15ML, 0.3
MG/0.3ML
83
epinephrine hcl 0.1 mg/ml 14
EPIPEN 2-PAK
83
EPIPEN-JR 2-PAK
83
epirubicin hcl 200
mg/100ml
35
epirubicin hcl 50 mg/25ml 35
EPIVIR 10 MG/ML
41
EPIVIR 150 MG, 300 MG 41
EPIVIR HBV
41
eplerenone 25 mg
31
eplerenone 50 mg
31
EPOGEN
65
eprosartan mesylate
29
EPZICOM
41
EQUETRO
38
ERAXIS 100 MG
25
ERBITUX
34
ergoloid mesylates
78
ERIVEDGE
34
ERWINAZE
36
ERYGEL
52
ERYPED 200
67
ERYPED 400
68
erythrocin lactobionate 500
mg
68
erythromycin (acne aid)
52
erythromycin (ophth)
73
erythromycin base 250 mg 68
erythromycin base 500 mg 68
erythromycin ethylsuccinate 68
escitalopram oxalate
19
estradiol & norethindrone
acetate
61
estradiol 0.025 mg/24hr, 0.0375
mg/24hr, 0.05 mg/24hr, 0.075
mg/24hr, 0.1 mg/24hr
61
estradiol 0.025 mg/24hr, 0.05
mg/24hr, 0.06 mg/24hr, 0.075
mg/24hr, 0.1 mg/24hr, 37.5
mcg/24hr
61
estradiol 0.5 mg, 1 mg, 2 mg 61
estradiol valerate 10 mg/ml, 20
mg/ml, 40 mg/ml
61
ESTRING
83
estropipate 0.75 mg, 1.5 mg 61
eszopiclone
66
ethambutol hcl 100 mg, 400
mg
32
ethosuximide 250 mg
18
ethosuximide 250 mg/5ml 18
ethynodiol diacet & eth
estrad
49
ETHYOL
36
etodolac 200 mg, 300 mg
3
etodolac 400 mg, 500 mg
3
etodolac 400 mg, 500 mg, 600
mg
3
ETOPOPHOS
37
etoposide 1 gm/50ml, 100
mg/5ml
37
etoposide 500 mg/25ml
37
EURAX
57
EVAMIST
61
EVISTA
60
EVOCLIN
52
EVOXAC
70
EXALGO 12 MG
5
EXALGO 16 MG
5
EXALGO 32 MG
5
EXALGO 8 MG
5
EXELDERM
53
EXELON 1.5 MG, 3 MG, 4.5 MG,
6 MG
77
EXELON 13.3 MG/24HR, 4.6
MG/24HR, 9.5 MG/24HR
77
exemestane
34
EXFORGE
30
EXFORGE HCT
30
EXJADE
25
EXTAVIA
77
EXTINA
53
EYLEA
72
FABIOR
52
FABRAZYME 35 MG
60
famciclovir 125 mg
43
famciclovir 250 mg, 500 mg 43
famotidine 20 mg
80
famotidine 20 mg/2ml, 40
mg/4ml
80
famotidine 200 mg/20ml
80
famotidine 40 mg
80
famotidine 40 mg/5ml
80
FAMVIR
43
FANAPT 1 MG, 10 MG, 12 MG, 2
MG, 4 MG
39
FANAPT 6 MG, 8 MG
39
FANAPT TITRATION PACK 39
FARESTON
34
FARXIGA
24
FASLODEX
34
fat emulsion 20 gm/100ml 72
FAZACLO
39
felbamate 400 mg
18
felbamate 600 mg
18
felbamate 600 mg/5ml
18
FELBATOL 400 MG
18
FELBATOL 600 MG
18
FELBATOL 600 MG/5ML
18
FELDENE
3
felodipine
46
FEMARA
34
FEMCON FE
49
FEMHRT LOW DOSE
61
FEMRING
83
fenofibrate 145 mg, 48 mg 27
FENOFIBRATE 150 MG, 50
MG
27
fenofibrate 160 mg, 54 mg 27
fenofibrate micronized 130
mg
27
fenofibrate micronized 134 mg,
200 mg, 67 mg
27
fenofibrate micronized 43
mg
27
FENOGLIDE
27
fentanyl 100 mcg/hr
5
fentanyl 12 mcg/hr
5
fentanyl 25 mcg/hr
5
fentanyl 50 mcg/hr
5
fentanyl 75 mcg/hr
5
fentanyl citrate 1200 mcg, 1600
mcg, 400 mcg, 600 mcg, 800
mcg
5
fentanyl citrate 200 mcg
5
FENTORA 100 MCG, 200
MCG
5
FENTORA 400 MCG, 600
MCG, 800 MCG
5
FETZIMA 120 MG, 40 MG, 80
MG
20
FETZIMA 20 MG
20
FETZIMA TITRATION
PACK
20
fexmid
70
FINACEA
57
finasteride
64
FIORICET/CODEINE 300MG50MG-40MG-30MG
7
FIORICET/CODEINE 325MG50MG-40MG-30MG
7
FIORINAL/CODEINE #3
7
FIRAZYR
64
FIRMAGON 120 MG
34
FIRMAGON 80 MG
34
FLAGYL 250 MG
9
FLAGYL 375 MG
9
FLAGYL 500 MG
9
FLAGYL ER
9
FLAREX
73
flavoxate hcl
82
FLEBOGAMMA DIF 10 % 75
flecainide acetate 100 mg 13
flecainide acetate 150 mg 13
flecainide acetate 50 mg 13
FLECTOR
52
FLEXERIL
70
FLO-PRED
50
FLOMAX
64
FLONASE
71
FLOVENT DISKUS 100
MCG/BLIST
14
FLOVENT DISKUS 250
MCG/BLIST
14
FLOVENT DISKUS 50
MCG/BLIST
14
FLOVENT HFA 110 MCG/ACT,
220 MCG/ACT
14
FLOVENT HFA 44
MCG/ACT
14
fluconazole 10 mg/ml
26
fluconazole 100 mg, 150 mg, 200
mg, 50 mg
26
fluconazole 40 mg/ml
26
fluconazole in dextrose
26
fluconazole in nacl 200mg/100ml0.9%, 400mg/200ml-0.9% 26
flucytosine 250 mg
25
flucytosine 500 mg
25
FLUDARA
33
fludarabine phosphate 50
mg
33
fludrocortisone acetate
51
FLUMADINE
43
flunisolide (nasal)
71
FLUNISOLIDE 0.025 %
71
fluocinolone acetonide (otic) 75
fluocinolone acetonide 0.01
%
55
fluocinolone acetonide 0.01 %,
0.025 %
55
fluocinolone acetonide 0.025
%
55
fluocinonide 0.05 %
55
fluocinonide 0.05 %, 0.1 % 55
fluocinonide emulsified base 55
fluorometholone (ophth)
73
fluorouracil (topical)
53
FLUOROURACIL 0.5 %
53
fluorouracil 1 gm/20ml
33
fluorouracil 2.5 gm/50ml, 500
mg/10ml
33
fluoxetine hcl 10 mg, 20 mg 19
fluoxetine hcl 10 mg, 20 mg, 40
mg
19
fluoxetine hcl 20 mg/5ml
19
FLUOXETINE HCL 60 MG 19
fluoxetine hcl 90 mg
19
fluphenazine decanoate
40
fluphenazine hcl 1 mg, 10 mg, 2.5
mg, 5 mg
40
fluphenazine hcl 2.5 mg/ml 40
fluphenazine hcl 5 mg/ml
40
flurazepam hcl
66
flurbiprofen 100 mg, 50 mg
3
flurbiprofen sodium
74
flutamide
34
Index 10
fluticasone propionate
(nasal)
71
fluticasone propionate 0.005
%
56
fluticasone propionate 0.05
%
55
fluvastatin sodium
28
fluvoxamine maleate 100 mg,
150 mg
19
fluvoxamine maleate 100 mg, 25
mg, 50 mg
20
FML
73
FML FORTE
73
FML LIQUIFILM
73
FOCALIN
1
FOCALIN XR 10 MG, 20 MG 1
FOCALIN XR 15 MG
1
FOLOTYN
33
fondaparinux sodium 10
mg/0.8ml, 5 mg/0.4ml, 7.5
mg/0.6ml
15
fondaparinux sodium 2.5
mg/0.5ml
15
FORADIL AEROLIZER
14
FORFIVO XL
19
FORTAMET 1000 MG
22
FORTAMET 500 MG
22
FORTAZ 1 GM, 2 GM
48
FORTAZ 6 GM
48
FORTEO
59
FORTESTA
9
FOSAMAX
59
FOSAMAX PLUS D
59
fosinopril sodium
29
fosinopril sodium &
hydrochlorothiazide
30
fosphenytoin sodium 100 mg
pe/2ml
18
fosphenytoin sodium 500 mg
pe/10ml
18
FOSRENOL
63
FRAGMIN 10000 UNIT/ML, 2500
UNIT/0.2ML, 5000
UNIT/0.2ML
15
FRAGMIN 12500 UNIT/0.5ML,
15000 UNIT/0.6ML, 18000
UNT/0.72ML, 25000 UNIT/ML,
7500 UNIT/0.3ML
15
FROVA
68
FULYZAQ
24
FURADANTIN
81
furosemide 10 mg/ml
58
Index 11
furosemide 20 mg, 40 mg, 80
mg
58
FUSILEV
36
FUZEON
41
FYCOMPA 10 MG
16
FYCOMPA 12 MG
16
FYCOMPA 2 MG
16
FYCOMPA 4 MG
16
FYCOMPA 6 MG
16
FYCOMPA 8 MG
16
gabapentin 100 mg, 300 mg,
400 mg
16
gabapentin 250 mg/5ml
16
gabapentin 600 mg, 800
mg
16
GABITRIL 12 MG, 16 MG 18
GABITRIL 2 MG, 4 MG
18
galantamine hydrobromide 12
mg, 4 mg, 8 mg
77
galantamine hydrobromide 16
mg, 24 mg, 8 mg
77
galantamine hydrobromide 4
mg/ml
77
GAMASTAN S/D
75
GAMMAGARD LIQUID
75
GAMMAKED
75
GAMUNEX-C
75
ganciclovir sodium
42
GARAMYCIN
73
GARDASIL
82
GASTROCROM
62
gatifloxacin (ophth)
73
GATTEX
63
gauze pads 2" X 2"
68
GAZYVA
34
GELNIQUE
81
GEMCITABINE
33
gemcitabine hcl 1 gm
33
gemcitabine hcl 2 gm
33
gemcitabine hcl 200 mg 33
gemfibrozil
27
GEMZAR 1 GM
33
GEMZAR 200 MG
33
GENERESS FE
49
GENOTROPIN 5 MG
59
GENOTROPIN MINIQUICK 0.4
MG
59
gentamicin in saline 0.9%0.8mg/ml
2
gentamicin in saline 0.9%1.2mg/ml
2
gentamicin in saline 0.9%1.6mg/ml, 0.9%-1mg/ml
2
gentamicin sulfate (ophth) 73
gentamicin sulfate 10 mg/ml 2
gentamicin sulfate 10 mg/ml, 40
mg/ml
2
GEODON 20 MG
38
GEODON 20 MG, 40 MG, 60
MG, 80 MG
38
GILENYA
77
GILOTRIF
35
GLASSIA
78
GLEEVEC
35
glimepiride
24
glipizide 10 mg, 2.5 mg, 5
mg
24
glipizide 10 mg, 5 mg
24
glipizide-metformin hcl 2.5mg250mg
22
glipizide-metformin hcl 2.5mg500mg, 5mg-500mg
22
GLUCAGEN
22
GLUCAGEN HYPOKIT
22
glucagon emergency kit
22
GLUCOPHAGE 1000 MG 22
GLUCOPHAGE 500 MG
22
GLUCOPHAGE 850 MG
22
GLUCOPHAGE XR 500 MG 22
GLUCOPHAGE XR 750 MG 22
GLUCOTROL
24
GLUCOTROL XL
24
GLUCOVANCE 1.25MG250MG
22
GLUCOVANCE 2.5MG-500MG,
5MG-500MG
22
GLUMETZA 1000 MG
22
GLUMETZA 500 MG
22
glyburide 1.25 mg, 2.5 mg, 5
mg
24
glyburide micronized 1.5 mg 24
glyburide micronized 3 mg 24
glyburide micronized 6 mg 24
glyburide-metformin 1.25mg250mg
22
glyburide-metformin 2.5mg500mg, 5mg-500mg
22
glycopyrrolate 0.2 mg/ml
80
glycopyrrolate 1 mg
80
glycopyrrolate 2 mg
80
GLYNASE 1.5 MG
24
GLYNASE 3 MG
24
GLYNASE 6 MG
24
GLYSET
21
GOLYTELY 227.1GM-21.5GM5.53GM-2.82GM-6.36GM
67
GOLYTELY 236GM-22.74GM5.86GM-2.97GM-6.74GM
67
GRALISE
78
GRALISE STARTER
78
granisetron hcl 1 mg
25
GRANIX
65
GRASTEK
45
GRIFULVIN V
25
GRIS-PEG
25
griseofulvin microsize 125
mg/5ml
26
griseofulvin microsize 500
mg
26
griseofulvin ultramicrosize 125
mg
26
griseofulvin ultramicrosize 250
mg
26
guanfacine hcl
30
guanfacine hcl (adhd)
1
guanidine hcl
32
H.P. ACTHAR
59
HALAVEN
37
HALCION
66
HALDOL
39
HALDOL DECANOATE 100 39
HALDOL DECANOATE 50 39
HALFLYTELY BOWEL
PREP/FLAVOR PACKS
67
halobetasol propionate
56
HALOG
56
haloperidol
39
haloperidol decanoate
39
haloperidol lactate
39
HARVONI
42
HAVRIX
82
HECTOROL 0.5 MCG, 2.5
MCG
60
HECTOROL 1 MCG
60
heparin sodium (porcine) 1000
unit/ml
15
heparin sodium (porcine) 10000
unit/ml, 20000 unit/ml, 5000
unit/0.5ml, 5000 unit/ml
15
HEPSERA
42
HERCEPTIN
34
HETLIOZ
66
HEXALEN
32
HIPREX
81
HIZENTRA 1 GM/5ML
75
HIZENTRA 10 GM/50ML, 2
GM/10ML, 4 GM/20ML
75
HORIZANT
78
HUMALOG
23
HUMALOG KWIKPEN
23
HUMALOG MIX 50/50
23
HUMALOG MIX 50/50
KWIKPEN
23
HUMALOG MIX 75/25
23
HUMALOG MIX 75/25
KWIKPEN
23
HUMATROPE
59
HUMATROPE COMBO
PACK
59
HUMIRA
2
HUMIRA PEDIATRIC CROHNS
DISEASE STARTER PACK 2
HUMIRA PEN
2
HUMIRA PEN-CROHNS
DISEASESTARTER
2
HUMIRA PEN-PSORIASIS
STARTER
2
HUMULIN 70/30
23
HUMULIN 70/30
KWIKPEN
23
HUMULIN 70/30 PEN
23
HUMULIN N
23
HUMULIN N KWIKPEN
23
HUMULIN N U-100 PEN 23
HUMULIN R
23
HUMULIN R U-500
(CONCENTRATED)
23
HYCAMTIN 4 MG
37
HYCET
7
hydralazine hcl 10 mg, 100 mg,
25 mg, 50 mg
31
HYDREA
36
hydrochlorothiazide 12.5
mg
58
hydrochlorothiazide 12.5 mg,
25 mg, 50 mg
58
hydrocodone-acetaminophen
10mg-300mg, 5mg-300mg,
7.5mg-300mg
7
hydrocodone-acetaminophen
10mg-325mg, 5mg-325mg,
7.5mg-325mg
7
hydrocodone-acetaminophen
10mg-750mg
7
hydrocodone-acetaminophen
10mg/15ml-325mg/15ml,
2.5mg/5ml-108mg/5ml,
5mg/10ml-217mg/10ml,
7.5mg/15ml-325mg/15ml
7
hydrocodone-acetaminophen
5mg-500mg
7
hydrocodone-ibuprofen 200mg10mg, 200mg-5mg, 200mg7.5mg
7
hydrocortisone (intrarectal)
9
hydrocortisone (rectal)
9
hydrocortisone (topical) 1 % 56
hydrocortisone (topical) 2.5
%
56
hydrocortisone 10 mg, 20 mg, 5
mg
50
hydrocortisone butyrate
56
hydrocortisone butyrate
hydrophilic lipo base
56
hydrocortisone valerate
56
hydrocortisone w/acetic acid 75
hydromorphone hcl 1 mg/ml 5
hydromorphone hcl 10 mg/ml, 2
mg/ml, 50 mg/5ml, 500
mg/50ml
5
hydromorphone hcl 12 mg
5
hydromorphone hcl 16 mg
5
hydromorphone hcl 2 mg
5
hydromorphone hcl 4 mg
5
hydromorphone hcl 8 mg
5
HYDROMORPHONE HCL ER5
hydroxychloroquine sulfate 31
hydroxyurea
36
hydroxyzine hcl 10 mg, 25 mg, 50
mg
12
hydroxyzine hcl 10 mg/5ml 12
hydroxyzine hcl 50 mg/ml
12
hydroxyzine pamoate 25 mg, 50
mg
12
HYQVIA
75
HYZAAR
30
ibandronate sodium 150 mg 59
ibandronate sodium 3
mg/3ml
59
IBUDONE
7
ibuprofen 100 mg/5ml
3
ibuprofen 400 mg
3
ibuprofen 600 mg
3
ibuprofen 800 mg
3
ICLUSIG
35
Index 12
IDAMYCIN PFS
35
idarubicin hcl
35
IFEX
32
ifosfamide 1 gm
32
ifosfamide 1 gm/20ml, 3
gm/60ml
32
IFOSFAMIDE 3 GM
32
ILARIS
3
ILEVRO
74
IMBRUVICA
35
IMDUR
11
imipenem-cilastatin 250mg250mg
10
imipenem-cilastatin 500mg500mg
10
imipramine hcl 10 mg, 25 mg, 50
mg
21
imipramine pamoate 100 mg 21
imipramine pamoate 125 mg, 150
mg, 75 mg
21
imiquimod
57
IMITREX 100 MG
68
IMITREX 25 MG
68
IMITREX 50 MG
68
IMITREX 6 MG/0.5ML
68
IMITREX STATDOSE REFILL 4
MG/0.5ML
68
IMITREX STATDOSE REFILL 6
MG/0.5ML
68
IMITREX STATDOSE SYSTEM 4
MG/0.5ML
68
IMITREX STATDOSE SYSTEM 6
MG/0.5ML
68
IMOVAX RABIES (H.D.C.V.) 82
IMURAN
44
INCIVEK
42
INCRELEX
60
indapamide 1.25 mg, 2.5 mg 58
INDERAL LA
45
INDERAL XL
45
INDOCIN 25 MG/5ML
3
indomethacin 25 mg, 50 mg 3
indomethacin 75 mg
3
INFANRIX
79
INLYTA
35
INNOPRAN XL
45
INSPRA
31
INSULIN SYRINGES AND PEN
NEEDLES
68
INTELENCE 100 MG, 200
MG
41
Index 13
INTELENCE 25 MG
41
INTERMEZZO
66
INTRON A
36
INTRON-A 10 MU/ML
36
INTRON-A 6000000
UNIT/ML
36
INTRON-A W/DILUENT 36
INTUNIV
1
INVANZ
10
INVEGA 1.5 MG
39
INVEGA 3 MG
39
INVEGA 6 MG
39
INVEGA 9 MG
39
INVEGA SUSTENNA 117
MG/0.75ML, 156 MG/ML, 234
MG/1.5ML
39
INVEGA SUSTENNA 39
MG/0.25ML, 78 MG/0.5ML 39
INVIRASE
41
INVOKAMET 150MG-1000MG,
150MG-500MG, 50MG1000MG
22
INVOKAMET 50MG500MG
22
INVOKANA 100 MG
24
INVOKANA 300 MG
24
IOPIDINE 0.5 %
72
IOPIDINE 1 %
72
IPOL INACTIVATED IPV 82
ipratropium bromide
13
ipratropium bromide
(nasal)
71
ipratropium-albuterol
14
irbesartan
29
irbesartan-hydrochlorothiazide
30
irinotecan
37
irinotecan hcl
37
irrigation solutions,
physiological
44
ISENTRESS 100 MG
41
ISENTRESS 25 MG
41
ISENTRESS 400 MG
41
isoniazid 100 mg, 300 mg 32
ISOPTIN SR
46
ISOPTO CARPINE
72
ISORDIL TITRADOSE 40
MG
11
ISORDIL TITRADOSE 5
MG
11
isosorbide dinitrate 10 mg, 20
mg, 30 mg, 5 mg
11
isosorbide dinitrate 2.5 mg 11
isosorbide dinitrate 40 mg 11
isosorbide mononitrate 10
mg
11
isosorbide mononitrate 120 mg,
30 mg, 60 mg
11
isosorbide mononitrate 20
mg
11
isotretinoin 10 mg
52
isotretinoin 20 mg
52
isotretinoin 40 mg
52
ISTALOL
72
ISTODAX
35
itraconazole
26
ivermectin
9
IXEMPRA KIT
37
IXIARO
82
JAKAFI
35
JALYN
64
JANUMET
22
JANUMET XR 100MG1000MG
22
JANUMET XR 50MG-1000MG,
50MG-500MG
22
JANUVIA 100 MG
23
JANUVIA 25 MG
23
JANUVIA 50 MG
23
JENTADUETO
22
JEVTANA
37
JUVISYNC 100MG-20MG 22
JUXTAPID 10 MG
28
JUXTAPID 20 MG
28
JUXTAPID 5 MG
28
K-TAB 10 MEQ
69
KADCYLA
34
KADIAN 10 MG
5
KADIAN 100 MG
5
KADIAN 130 MG, 150 MG
5
KADIAN 20 MG, 30 MG, 50 MG,
60 MG, 80 MG
5
KADIAN 40 MG, 70 MG
5
KALBITOR
64
KALETRA 100MG-25MG
41
KALETRA 200MG-50MG
41
KALETRA 400MG/5ML100MG/5ML
41
KALYDECO
78
KAPVAY
1
KAYEXALATE
44
KAZANO
22
KEFLEX 250 MG, 500 MG 47
KEFLEX 750 MG
47
KENALOG
56
KENALOG-10
50
KENALOG-40
50
KEPIVANCE
36
KEPPRA
16
KEPPRA XR
16
KERLONE
45
KETEK 300 MG
10
KETEK 400 MG
10
ketoconazole
26
ketoconazole (topical)
53
ketoprofen 50 mg, 75 mg
3
ketorolac tromethamine
(ophth)
74
ketorolac tromethamine 10
mg
3
ketorolac tromethamine 15
mg/ml, 30 mg/ml
3
ketorolac tromethamine 30
mg/ml, 60 mg/2ml
3
KEYTRUDA
34
KHEDEZLA
20
KINERET
3
KLARON
52
KLONOPIN 0.5 MG
16
KLONOPIN 1 MG
16
KLONOPIN 2 MG
16
KOMBIGLYZE XR 2.5MG1000MG
22
KOMBIGLYZE XR 5MG1000MG, 5MG-500MG
22
KUVAN
60
KYNAMRO
27
labetalol hcl 100 mg, 200 mg, 300
mg
45
LAC-HYDRIN
56
lactated ringer's
69
lactic acid (ammonium lactate) 12
%
56
lactulose (encephalopathy) 63
lactulose 10 gm/15ml, 20
gm/30ml
67
LAMICTAL 100 MG, 150 MG,
200 MG, 25 MG
17
LAMICTAL CHEWABLE
DISPERSIBLE
16
LAMICTAL ODT 100 MG, 200
MG, 25 MG, 50 MG
16
LAMICTAL STARTER/NOT
TAKING
CARBAMAZEPINE
16
LAMICTAL STARTER/TAKING
CARBAMAZEPINE/NOT
TAKING VALPROATE
16
LAMICTAL STARTER/TAKING
VALPROATE
17
LAMICTAL XR
17
LAMICTAL XR 100 MG, 250
MG
17
LAMICTAL XR 200 MG, 25
MG, 300 MG, 50 MG
17
LAMISIL 125 MG, 187.5
MG
26
LAMISIL 250 MG
26
lamivudine 10 mg/ml
41
lamivudine 100 mg
41
lamivudine 150 mg, 300
mg
41
lamivudine-zidovudine
41
lamotrigine 100 mg, 150 mg,
200 mg, 25 mg
17
lamotrigine 100 mg, 250
mg
17
lamotrigine 200 mg, 25 mg, 300
mg, 50 mg
17
lamotrigine 25 mg, 5 mg 17
LANOXIN 125 MCG, 250
MCG
46
LANOXIN 187.5 MCG, 62.5
MCG
46
LANOXIN PEDIATRIC
46
lansoprazole 15 mg
80
lansoprazole 30 mg
80
LANTUS
23
LANTUS SOLOSTAR
23
LASIX
58
LASTACAFT
74
latanoprost
74
LATUDA 120 MG
38
LATUDA 20 MG
38
LATUDA 40 MG
39
LATUDA 60 MG
39
LATUDA 80 MG
39
LAZANDA 100 MCG/ACT 5
LAZANDA 400 MCG/ACT 5
leflunomide
4
LESCOL
28
LESCOL XL
28
LETAIRIS
47
letrozole
34
leucovorin calcium 10 mg, 15 mg,
25 mg, 5 mg
36
leucovorin calcium 100 mg, 200
mg, 350 mg
36
leucovorin calcium 50 mg, 500
mg
36
LEUKERAN
33
LEUKINE 250 MCG
65
leuprolide acetate
34
levalbuterol hcl 0.31 mg/3ml, 0.63
mg/3ml, 1.25 mg/0.5ml, 1.25
mg/3ml
14
LEVAQUIN 25 MG/ML
62
LEVAQUIN 250 MG, 750
MG
62
LEVAQUIN 250MG/50ML-5%,
500MG/100ML-5%
62
LEVAQUIN 500 MG
62
LEVAQUIN 750MG/150ML5%
62
LEVATOL
45
LEVEMIR
23
LEVEMIR FLEXPEN
23
LEVEMIR FLEXTOUCH
23
levetiracetam 100 mg/ml, 500
mg/5ml
17
levetiracetam 1000 mg, 250 mg,
500 mg, 750 mg
17
LEVETIRACETAM
1000MG/100ML-750MG/100ML,
1500MG/100ML-540MG/100ML,
500MG/100ML-820MG/100ML
17
levetiracetam 500 mg, 750
mg
17
levetiracetam 500 mg/5ml 17
levobunolol hcl 0.5 %
72
levocarnitine (metabolic
modifiers) 330 mg
60
levocetirizine dihydrochloride 2.5
mg/5ml
26
levocetirizine dihydrochloride 5
mg
26
levofloxacin (ophth)
73
levofloxacin 25 mg/ml
62
levofloxacin 250 mg, 500 mg, 750
mg
62
levofloxacin in d5w 250mg/50ml5%, 500mg/100ml-5%
62
levofloxacin in d5w
750mg/150ml-5%
62
levonorgestrel & eth
estradiol
49
Index 14
levonorgestrel (emergency oc)
0.75 mg
50
levonorgestrel (emergency oc)
1.5 mg
50
levonorgestrel-eth estradiol
(triphasic)
49
levonorgestrel-ethinyl estradiol
(91-day)
49
levothyroxine sodium 100 mcg,
112 mcg, 125 mcg, 137 mcg, 150
mcg, 175 mcg, 200 mcg, 25 mcg,
300 mcg, 50 mcg, 75 mcg, 88
mcg
79
LEXAPRO
20
LEXIVA 50 MG/ML
41
LEXIVA 700 MG
41
LIALDA
63
lidocaine 5 %
57
lidocaine hcl (cardiac)
13
lidocaine hcl (local anesth.) 1 %,
2%
67
lidocaine hcl (mouth-throat) 2
%
70
lidocaine hcl 2 %
57
lidocaine hcl 4 %
57
lidocaine-prilocaine
57
LIDODERM
57
LINCOCIN
11
lindane
57
linezolid
11
LINZESS
63
liothyronine sodium 25 mcg, 5
mcg, 50 mcg
79
LIPITOR
28
LIPOFEN
28
LIPTRUZET
27
lisinopril &
hydrochlorothiazide
30
lisinopril 10 mg, 2.5 mg, 20 mg,
30 mg, 40 mg, 5 mg
29
lithium
38
lithium carbonate 150 mg, 300
mg, 600 mg
38
lithium carbonate 300 mg
38
lithium carbonate 300 mg, 450
mg
38
LITHOBID
38
LIVALO
28
LO LOESTRIN FE
49
LO MINASTRIN FE
49
LOCOID
56
LOCOID LIPOCREAM
56
Index 15
LODOSYN
37
LOESTRIN 1.5/30-21
49
LOESTRIN 1/20-21
49
LOESTRIN FE 1.5/30
49
LOESTRIN FE 1/20
49
LOFIBRA
28
LOMOTIL
24
lomustine 10 mg
33
lomustine 100 mg, 40 mg 33
loperamide hcl 2 mg
24
LOPID
28
LOPRESSOR 100 MG, 50
MG
45
LOPRESSOR HCT
30
LOPROX
53
LOPROX SHAMPOO
53
lorazepam 0.5 mg, 1 mg, 2
mg
12
lorazepam 2 mg/ml
12
lorazepam 2 mg/ml, 20
mg/10ml
12
lorazepam 4 mg/ml
12
LORAZEPAM INTENSOL 12
losartan potassium
29
losartan potassium &
hydrochlorothiazide
30
LOSEASONIQUE
49
LOTEMAX
73
LOTENSIN
29
LOTENSIN HCT
30
LOTREL
30
LOTRISONE
53
LOTRONEX
63
lovastatin
28
LOVAZA
27
LOVENOX 100 MG/ML, 30
MG/0.3ML, 40 MG/0.4ML, 60
MG/0.6ML, 80 MG/0.8ML 15
LOVENOX 120 MG/0.8ML, 150
MG/ML
15
LOVENOX 300 MG/3ML 15
loxapine succinate 10 mg, 25
mg, 5 mg, 50 mg
39
loxitane 10 mg, 25 mg
39
LUMIGAN
74
LUMIZYME
60
LUNESTA
66
LUPRON DEPOT
34
LUPRON DEPOT-PED 11.25
MG
60
LUPRON DEPOT-PED 11.25
MG, 7.5 MG
60
LUPRON DEPOT-PED 15
MG
60
LUPRON DEPOT-PED 30
MG
60
LUVOX CR
20
LUXIQ
56
LUZU
53
LYNPARZA
35
LYRICA 100 MG
17
LYRICA 150 MG
17
LYRICA 20 MG/ML
17
LYRICA 200 MG
17
LYRICA 225 MG, 300 MG 17
LYRICA 25 MG
17
LYRICA 50 MG
17
LYRICA 75 MG
17
LYSODREN
34
LYSTEDA
66
M-M-R II W/DILUENT 10
DOSE
82
MACROBID
81
MACRODANTIN 100 MG, 50
MG
81
MACRODANTIN 25 MG
81
magnesium sulfate 50 %
69
MALARONE 250MG-100MG 31
MALARONE 62.5MG-25MG 31
malathion
57
maprotiline hcl 25 mg, 50 mg19
maprotiline hcl 75 mg
19
MARINOL 10 MG, 5 MG
25
MARINOL 2.5 MG
25
MARPLAN
19
MATULANE
36
MAVIK
29
MAXALT 10 MG
68
MAXALT 5 MG
68
MAXALT-MLT 10 MG
68
MAXALT-MLT 5 MG
68
MAXIDEX
73
MAXIDONE
7
MAXIPIME 1 GM, 2 GM
48
MAXITROL
73
MAXZIDE
58
MAXZIDE-25
58
meclizine hcl 12.5 mg, 25
mg
25
MEDROL 16 MG, 32 MG, 4 MG,
8 MG
51
MEDROL 2 MG
51
MEDROL DOSEPAK
51
medroxyprogesterone
acetate
76
medroxyprogesterone acetate
(contraceptive)
50
mefenamic acid
3
mefloquine hcl
31
MEGACE ES
76
MEGACE ORAL
34
megestrol acetate 20 mg, 40
mg
34
megestrol acetate 40 mg/ml, 400
mg/10ml
34
MEKINIST
35
meloxicam 15 mg, 7.5 mg
3
melphalan hcl
33
MENACTRA
82
MENOMUNE-A/C/Y/W-135 82
MENOSTAR
61
MENVEO
82
meperidine hcl 100 mg
5
meperidine hcl 50 mg
5
meprobamate
12
MEPRON
10
mercaptopurine
33
meropenem 1 gm
10
meropenem 500 mg
10
MERREM 1 GM
10
MERREM 500 MG
10
mesalamine
63
mesalamine w/ cleanser
63
mesna
36
MESNEX 100 MG/ML
36
MESNEX 400 MG
36
MESTINON 60 MG
32
MESTINON TIMESPAN
32
METADATE CD
1
metaxalone
70
metformin hcl 1000 mg
22
metformin hcl 500 mg
22
metformin hcl 750 mg
22
metformin hcl 850 mg
22
methadone hcl 10 mg
5
methadone hcl 10 mg/5ml
5
methadone hcl 5 mg
5
methadone hcl 5 mg/5ml
5
methamphetamine hcl
1
methazolamide 25 mg, 50
mg
58
methenamine hippurate
81
methimazole 10 mg, 5 mg 79
methocarbamol 500 mg, 750
mg
70
methotrexate sodium 1 gm 33
methotrexate sodium 1
gm/40ml, 100 mg/4ml, 200
mg/8ml, 25 mg/ml, 250
mg/10ml, 50 mg/2ml
33
methotrexate sodium 2.5
mg
33
methotrexate sodium 25
mg/ml
33
methoxsalen rapid
54
methscopolamine bromide 2.5
mg, 5 mg
80
methyldopa 250 mg, 500
mg
30
methylergonovine maleate 0.2
mg
75
methylphenidate hcl 10 mg, 20
mg, 30 mg, 40 mg, 50 mg, 60
mg
1
methylphenidate hcl 10 mg, 20
mg, 5 mg
2
methylphenidate hcl 18 mg, 20
mg, 27 mg, 36 mg
2
methylphenidate hcl 20 mg, 40
mg
1
methylphenidate hcl 30 mg 1
methylphenidate hcl er 54
mg
2
methylprednisolone 16 mg, 32
mg, 4 mg, 8 mg
51
methylprednisolone acetate 40
mg/ml, 80 mg/ml
51
methylprednisolone sod
succ
51
metoclopramide hcl 10 mg, 5
mg
63
metoclopramide hcl 10
mg/10ml, 5 mg/5ml
62
metoclopramide hcl 5
mg/ml
62
metolazone
58
metoprolol &
hydrochlorothiazide 100mg25mg, 50mg-25mg
30
metoprolol &
hydrochlorothiazide 100mg50mg
31
metoprolol succinate
45
metoprolol tartrate 100 mg, 25
mg, 50 mg
45
METROCREAM
57
METROGEL
57
METROGEL-VAGINAL
82
METROLOTION
57
metronidazole (topical)
57
metronidazole 250 mg
10
metronidazole 375 mg
10
metronidazole 500 mg
10
metronidazole in nacl
10
metronidazole vaginal
82
MEVACOR
28
mexiletine hcl
13
MIACALCIN 200 UNIT/ACT 59
MIACALCIN 200 UNIT/ML 59
MICARDIS
29
MICARDIS HCT
31
MICRO-K
69
MICROZIDE
58
midodrine hcl
83
MIGRANAL
68
MILLIPRED 5 MG
51
MINASTRIN 24 FE
49
MINIPRESS
30
MINIVELLE
61
MINOCIN 100 MG, 50 MG, 75
MG
79
minocycline hcl 100 mg, 50
mg
79
minocycline hcl 100 mg, 50 mg,
75 mg
79
minoxidil 10 mg, 2.5 mg
31
MIRAPEX
38
MIRAPEX ER
38
MIRCETTE
49
mirtazapine
19
MIRVASO
57
misoprostol 100 mcg, 200
mcg
81
mitomycin 20 mg, 40 mg, 5
mg
35
mitoxantrone hcl
35
MOBIC 15 MG, 7.5 MG
3
modafinil 100 mg
2
modafinil 200 mg
2
MODERIBA
42
MODERIBA 1200 DOSE
PACK
42
Index 16
MODICON
49
moexipril hcl
29
moexipril-hydrochlorothiazide
31
mometasone furoate
56
MONODOX
79
montelukast sodium 10 mg 13
montelukast sodium 4 mg, 5
mg
13
MONUROL
81
morphine sulfate 0.5 mg/ml, 1
mg/ml
5
morphine sulfate 10 mg
5
morphine sulfate 10 mg/5ml 6
morphine sulfate 100 mg
5
morphine sulfate 100 mg/5ml, 20
mg/ml
6
morphine sulfate 15 mg
6
morphine sulfate 20 mg, 30 mg,
50 mg, 60 mg, 80 mg
5
morphine sulfate 20 mg/5ml 6
morphine sulfate 200 mg
6
MORPHINE SULFATE 30 MG6
morphine sulfate 30 mg, 60
mg
6
morphine sulfate beads
5
MOTOFEN
24
MOVIPREP
67
MOXEZA
73
moxifloxacin hcl
62
MOZOBIL
65
MS CONTIN 100 MG
6
MS CONTIN 15 MG
6
MS CONTIN 200 MG
6
MS CONTIN 30 MG, 60 MG 6
MULTAQ
13
mupirocin
53
mupirocin calcium (topical) 53
MUSTARGEN
33
MYALEPT
60
MYAMBUTOL
32
MYCAMINE 100 MG
25
MYCOBUTIN
32
mycophenolate mofetil 200
mg/ml
44
mycophenolate mofetil 250
mg
44
mycophenolate mofetil 500
mg
44
Index 17
mycophenolate sodium 180
mg
44
mycophenolate sodium 360
mg
44
MYFORTIC 180 MG
44
MYFORTIC 360 MG
44
MYOZYME
60
MYRBETRIQ
82
MYSOLINE
17
nabumetone
3
nadolol & bendroflumethiazide
40mg-5mg
31
nadolol & bendroflumethiazide
80mg-5mg
31
nadolol 20 mg, 40 mg, 80
mg
45
nafcillin sodium 1 gm
76
nafcillin sodium 10 gm, 2
gm
76
NAFTIN
53
NAGLAZYME
60
naloxone hcl 1 mg/ml
25
naltrexone hcl
25
NAMENDA 10 MG, 5 MG 77
NAMENDA 10 MG/5ML
77
NAMENDA TITRATION
PAK
77
NAMENDA XR 14 MG
77
NAMENDA XR 21 MG, 28
MG
77
NAMENDA XR 7 MG
77
NAMENDA XR TITRATION
PACK
77
NAPRELAN 375 MG, 750
MG
3
NAPROSYN 250 MG, 375 MG,
500 MG
3
naproxen 250 mg, 375 mg, 500
mg
3
naproxen 375 mg, 500 mg 3
naproxen sodium 275 mg, 550
mg
3
naratriptan hcl
68
NARDIL
19
NASACORT AQ
71
NASONEX
71
NATACYN
73
nateglinide
24
NAVELBINE
37
NEBUPENT
10
nefazodone hcl
20
neomycin sulfate
2
neomycin-bacitracin znpolymyxin
73
neomycin-polymy-dexameth 74
neomycin-polymyxin-gramicidin
73
neomycin-polymyxin-hc
(otic)
75
neomycin/polymyxin b gu
64
NEORAL 100 MG, 25 MG 44
NEOSPORIN
73
NEOSPORIN GU IRRIGANT64
neptazane
58
NESINA
23
NEULASTA
65
NEULASTA DELIVERY KIT 65
NEUMEGA
65
NEUPOGEN
65
NEUPRO
38
NEURONTIN
17
NEVANAC
74
nevirapine 200 mg
41
nevirapine 400 mg
41
NEVIRAPINE 50 MG/5ML 41
NEXAVAR
35
niacin (antihyperlipidemic) 28
NIASPAN
28
nicardipine hcl 20 mg, 30 mg 46
NICOTROL INHALER
78
NICOTROL NS
78
nifedipine 10 mg, 20 mg
46
nifedipine 30 mg, 60 mg, 90
mg
46
NILANDRON
34
nimodipine
46
NIPENT
36
NIRAVAM
12
nisoldipine 17 mg, 34 mg, 8.5
mg
46
NITRO-DUR 0.1 MG/HR, 0.2
MG/HR, 0.4 MG/HR, 0.6
MG/HR
11
NITRO-DUR 0.3 MG/HR, 0.8
MG/HR
11
nitrofurantoin
81
nitrofurantoin macrocrystal 100
mg, 50 mg
81
nitrofurantoin monohyd
macro
81
nitroglycerin 0.1 mg/hr, 0.2 mg/hr,
0.4 mg/hr, 0.6 mg/hr
12
nitroglycerin 0.4 mg/spray 12
NITROGLYCERIN LINGUAL 11
NITROLINGUAL
PUMPSPRAY
12
NITROMIST
12
NITROSTAT
12
nizatidine 150 mg, 300 mg 80
NIZORAL
53
NOR-QD
50
NORCO
7
NORDETTE-28
49
NORDITROPIN FLEXPRO 10
MG/1.5ML, 5 MG/1.5ML
59
norelgestromin-ethinyl
estradiol
50
norethin acet & estrad-fe 75mg20mcg-1mg, 75mg-30mcg1.5mg
49
norethindrone & eth estradiol
0.4mg-35mcg, 1mg-35mcg 49
norethindrone & eth estradiol
0.5mg-35mcg
49
norethindrone & ethinyl estradiolfe
49
norethindrone
(contraceptive)
50
norethindrone acet & eth
estra
49
norethindrone acetate
76
norethindrone-eth estradiol
(triphasic)
49
norgestimate-ethinyl
estradiol
49
norgestimate-ethinyl estradiol
(triphasic)
49
norgestrel & ethinyl estradiol 49
NORINYL 1+35
49
NORITATE
57
NORPACE
12
NORPACE CR 100 MG
12
NORPRAMIN
21
NORTHERA 100 MG
83
NORTHERA 200 MG
83
NORTHERA 300 MG
83
nortriptyline hcl 10 mg, 25 mg, 50
mg, 75 mg
21
nortriptyline hcl 10 mg/5ml 21
NORVASC 10 MG
46
NORVASC 2.5 MG
46
NORVASC 5 MG
46
NORVIR
41
NOVOLIN 70/30
23
NOVOLIN 70/30 RELION
23
NOVOLIN N
23
NOVOLIN N RELION
23
NOVOLIN R
23
NOVOLIN R RELION
24
NOVOLOG
24
NOVOLOG FLEXPEN
24
NOVOLOG MIX 70/30
24
NOVOLOG MIX 70/30
PREFILLED FLEXPEN
24
NOVOLOG PENFILL
24
NOXAFIL 100 MG
26
NOXAFIL 300 MG/16.7ML 26
NOXAFIL 40 MG/ML
26
NUCYNTA 100 MG
6
NUCYNTA 50 MG
6
NUCYNTA 75 MG
6
NUCYNTA ER 100 MG
6
NUCYNTA ER 150 MG, 200
MG, 250 MG
6
NUCYNTA ER 50 MG
6
NUEDEXTA
78
NULOJIX
44
NULYTELY/FLAVOR
PACKS
67
NUTROPIN AQ NUSPIN
20
59
NUTROPIN AQ PEN 20
MG/2ML
59
NUVARING
50
NUVIGIL
2
NYMALIZE
46
nystatin
26
nystatin (mouth-throat)
70
nystatin (topical)
53
nystatin-triamcinolone
53
OCTAGAM 2 GM/20ML, 20
GM/200ML, 5 GM/50ML 75
octreotide acetate 100
mcg/ml
61
octreotide acetate 1000
mcg/5ml, 200 mcg/ml, 50
mcg/ml
61
OCUFEN
74
OCUFLOX
73
ofloxacin (ophth)
73
ofloxacin (otic)
75
olanzapine 10 mg
39
olanzapine 10 mg, 15 mg, 2.5
mg, 20 mg, 5 mg, 7.5 mg 39
olanzapine 10 mg, 15 mg, 20
mg, 5 mg
39
olanzapine-fluoxetine hcl
77
OLEPTRO
20
olopatadine hcl (nasal)
71
OLUX
56
OLUX-E
56
OLYSIO
42
omega-3-acid ethyl esters 27
omeprazole 10 mg, 20 mg, 40
mg
80
omeprazole-sodium bicarbonate
20mg-1100mg
81
omeprazole-sodium bicarbonate
40mg-1100mg
81
OMNARIS
71
OMNIPRED
74
OMNITROPE 10 MG/1.5ML, 5
MG/1.5ML
60
ONCASPAR
36
ondansetron
25
ondansetron hcl 24 mg, 4 mg, 8
mg
25
ondansetron hcl 4 mg/2ml 25
ondansetron hcl 4 mg/5ml 25
ondansetron hcl 40 mg/20ml 25
ONFI 10 MG, 5 MG
16
ONFI 2.5 MG/ML
16
ONFI 20 MG
16
ONGLYZA 2.5 MG
23
ONGLYZA 5 MG
23
ONMEL
26
OPANA 10 MG
6
OPANA 5 MG
6
OPDIVO
34
opium tincture
24
OPSUMIT
47
OPTIVAR
74
ORACEA
57
ORAP
78
ORAPRED
51
ORAPRED ODT 15 MG, 30
MG
51
ORENCIA
4
ORENITRAM 0.125 MG
47
ORENITRAM 0.25 MG, 1 MG,
2.5 MG
47
ORFADIN
60
orphenadrine citrate 100 mg 70
orphenadrine citrate 30
mg/ml
70
Index 18
orphenadrine w/ aspirin &
caff
71
ORTHO EVRA
50
ORTHO MICRONOR
50
ORTHO TRI-CYCLEN
49
ORTHO-CEPT
49
ORTHO-CYCLEN
49
ORTHO-NOVUM 1/35
49
ORTHO-NOVUM 7/7/7
49
OSENI 12.5MG-15MG
22
OSENI 12.5MG-30MG, 12.5MG45MG, 25MG-15MG, 25MG30MG, 25MG-45MG
22
OSMOPREP
67
OTEZLA
4
OTREXUP
2
OVCON-35
49
OVIDE
57
oxaliplatin 100 mg, 50 mg
33
oxaliplatin 100 mg/20ml
33
oxaliplatin 50 mg/10ml
33
OXANDRIN 10 MG
8
OXANDRIN 2.5 MG
8
oxandrolone 10 mg
8
oxandrolone 2.5 mg
8
oxaprozin
3
oxazepam
12
oxcarbazepine 150 mg, 300 mg,
600 mg
17
oxcarbazepine 300 mg/5ml, 60
mg/ml
17
OXECTA 5 MG
6
OXECTA 7.5 MG
6
OXISTAT
53
OXSORALEN
57
OXSORALEN ULTRA
54
oxybutynin chloride 10 mg, 15
mg, 5 mg
81
oxybutynin chloride 5 mg
81
oxybutynin chloride 5
mg/5ml
81
oxycodone hcl 10 mg
6
oxycodone hcl 100 mg/5ml
6
oxycodone hcl 15 mg
6
oxycodone hcl 20 mg
6
oxycodone hcl 30 mg
6
oxycodone hcl 5 mg
6
OXYCODONE HCL ER 10 MG,
20 MG, 40 MG
6
Index 19
OXYCODONE HCL ER 80
MG
6
oxycodone w/ acetaminophen
10mg-325mg
8
oxycodone w/ acetaminophen
2.5mg-325mg, 5mg-325mg,
7.5mg-325mg
8
oxycodone-aspirin
8
OXYCONTIN 10 MG, 15 MG,
20 MG, 30 MG, 40 MG, 60
MG
6
OXYCONTIN 80 MG
6
oxymorphone hcl 10 mg
6
oxymorphone hcl 15 mg
6
oxymorphone hcl 20 mg
6
oxymorphone hcl 30 mg, 40
mg
6
oxymorphone hcl 5 mg
6
oxymorphone hcl 7.5 mg
6
OXYTROL
81
paclitaxel 100 mg/16.7ml, 30
mg/5ml, 300 mg/50ml
37
paclitaxel 150 mg/25ml
37
PALGIC
26
PAMELOR
21
PAMINE
80
PAMINE FORTE
80
PANCREAZE
57
PANCRELIPASE
57
PANRETIN
53
pantoprazole sodium 20 mg, 40
mg
80
pantoprazole sodium 40
mg
80
PARAFON FORTE DSC 70
PARCOPA
38
parenteral electrolytes
69
paricalcitol 1 mcg
60
paricalcitol 2 mcg, 4 mcg 60
PARLODEL
38
PARNATE
19
paromomycin sulfate
2
paroxetine hcl
20
paser
32
PATADAY
74
PATANASE
71
PATANOL
74
PAXIL 10 MG, 20 MG, 30 MG,
40 MG
20
PAXIL 10 MG/5ML
20
PAXIL CR
20
PCE 333 MG
68
PCE 500 MG
68
PEDIAPRED
51
PEDVAX HIB
82
peg 3350-kcl-sod bicarb-sod
chloride-sod sulfate
67
peg 3350-potassium chloride-sod
bicarbonate-sod chloride
67
PEG-INTRON
42
PEG-INTRON REDIPEN
42
PEG-INTRON REDIPEN PAK
4
42
PEGANONE
18
PEGASYS
42
PEGASYS PROCLICK
42
PEGINTRON
42
penicillin g potassium 20 mu,
20000000 unit
76
penicillin g potassium 5000000
unit
76
penicillin v potassium
76
PENLAC NAIL LACQUER 53
PENNSAID
52
PENTAM 300
10
PENTASA
63
pentazocine w/ naloxone
8
pentazocine-acetaminophen 8
pentoxifylline
64
PEPCID 20 MG
80
PEPCID 40 MG
80
PEPCID 40 MG/5ML
80
PERCOCET 10MG-325MG,
2.5MG-325MG, 5MG-325MG,
7.5MG-325MG
8
PERCODAN
8
PERFOROMIST
14
PERIDEX
70
perindopril erbumine 2 mg 29
perindopril erbumine 4 mg 29
perindopril erbumine 8 mg 29
PERJETA
34
permethrin 5 %
57
perphenazine 16 mg, 2 mg, 4 mg,
8 mg
40
perphenazine/amitriptyline 77
PERSANTINE
65
PERTZYE
57
PEXEVA
20
PFIZERPEN-G 20 MU
76
PFIZERPEN-G 5000000
UNIT
76
phenelzine sulfate
19
PHENERGAN
26
phenobarbital 100 mg, 15 mg,
16.2 mg, 30 mg, 32.4 mg, 60 mg,
64.8 mg, 97.2 mg
66
phenobarbital 20 mg/5ml
66
phenytek 200 mg, 300 mg 18
phenytoin 125 mg/5ml
18
phenytoin 50 mg
18
phenytoin sodium
18
phenytoin sodium extended 18
PHISOHEX
40
PHOSLO
63
PHOSLYRA
63
PHOSPHOLINE IODIDE
72
PICATO
53
pilocarpine hcl (oral)
70
pilocarpine hcl 1 %, 2 %, 4
%
72
PILOPINE HS
72
pindolol
45
pioglitazone hcl
23
pioglitazone hcl-glimepiride 22
pioglitazone hcl-metformin
hcl
22
piperacillin sodium-tazobactam
sodium 0.25gm-2gm, 4.5gm36gm
76
piperacillin sodium-tazobactam
sodium 0.375gm-3gm
76
piperacillin sodium-tazobactam
sodium 0.5gm-4gm
76
piroxicam 10 mg, 20 mg
4
PLAN B
50
PLAN B ONE-STEP
50
PLAQUENIL
31
PLAVIX 300 MG
65
PLAVIX 75 MG
65
PLETAL
65
podofilox
57
polyethylene glycol 3350
67
polymyxin b sulfate
11
polymyxin b-trimethoprim
73
POLYTRIM
73
POMALYST
35
PONSTEL
4
potassium chloride 10 %, 20
%
69
potassium chloride 10 meq, 8
meq
69
potassium chloride 2
meq/ml
70
potassium chloride in dextrose
& sodium chloride 0.45%20meq/l-5%
69
potassium chloride
microencapsulated crystals
cr
70
potassium citrate (alkalinizer)
1080 mg
63
potassium citrate (alkalinizer)
540 mg
63
POTIGA 200 MG
17
POTIGA 300 MG
17
POTIGA 400 MG
17
POTIGA 50 MG
17
PRADAXA
15
pramipexole
dihydrochloride
38
pramosone 1%-1%
56
PRANDIMET
22
PRANDIN 0.5 MG, 1 MG 24
PRANDIN 2 MG
24
PRAVACHOL
28
pravastatin sodium
28
prazosin hcl
30
PRECOSE
21
PRED FORTE
74
PRED MILD
74
prednicarbate
56
prednisolone
51
prednisolone acetate
(ophth)
74
prednisolone sodium
phosphate 15 mg, 30 mg 51
prednisolone sodium
phosphate 15 mg/5ml, 5
mg/5ml, 6.7 mg/5ml
51
prednisolone sodium
phosphate 25 mg/5ml
51
prednisone 1 mg, 10 mg, 2.5
mg, 20 mg, 5 mg, 50 mg 51
prednisone 10 mg, 5 mg 51
prednisone 5 mg/5ml
51
prednisone intensol
51
PRELONE
51
PREMARIN 0.3 MG, 0.45 MG,
0.625 MG, 0.9 MG, 1.25
MG
61
PREMARIN 0.625 MG/GM 83
PREMPHASE
61
PREMPRO
61
PREPOPIK
67
PREVACID 15 MG
80
PREVACID 30 MG
80
PREVPAC
81
PREZISTA 100 MG/ML
41
PREZISTA 150 MG
41
PREZISTA 400 MG
41
PREZISTA 600 MG, 800 MG41
PREZISTA 75 MG
41
PRIFTIN
32
PRILOSEC 10 MG, 20 MG, 40
MG
80
PRIMAQUINE PHOSPHATE 31
PRIMAXIN IV
10
PRIMAXIN IV ADDVANTAGE
10
primidone 250 mg, 50 mg
17
PRIMSOL
10
PRINIVIL
29
PRISTIQ
20
PRIVIGEN
75
PROAIR HFA
14
probenecid
64
PROCARDIA
46
PROCARDIA XL
46
prochlorperazine
40
prochlorperazine edisylate 40
prochlorperazine maleate 10 mg,
5 mg
40
PROCRIT 10000 UNIT/ML, 2000
UNIT/ML, 3000 UNIT/ML, 4000
UNIT/ML
65
PROCRIT 20000 UNIT/ML,
40000 UNIT/ML
65
PROCTOCORT 1 %
9
PROCYSBI
64
progesterone micronized 100 mg,
200 mg
76
PROGLYCEM
23
PROGRAF 0.5 MG, 1 MG, 5
MG
44
PROGRAF 5 MG/ML
44
PROLASTIN-C
78
PROLENSA
74
PROLEUKIN
36
PROLIA
59
Index 20
PROMACTA 12.5 MG
65
PROMACTA 25 MG
65
PROMACTA 50 MG
65
PROMACTA 75 MG
65
promethazine &
phenylephrine
51
promethazine hcl 12.5 mg, 25
mg, 50 mg
27
promethazine hcl 25 mg/ml, 50
mg/ml
27
promethazine hcl 6.25
mg/5ml
27
PROMETRIUM
76
propafenone hcl
13
proparacaine hcl
73
propranolol hcl 10 mg, 20 mg, 40
mg, 60 mg, 80 mg
45
propranolol hcl 120 mg, 160 mg,
60 mg, 80 mg
45
propylthiouracil
79
PROQUAD
82
PROSCAR
64
PROTONIX 20 MG, 40 MG 81
PROTONIX 40 MG
81
PROTOPIC
57
protriptyline hcl
21
PROVENTIL HFA
14
PROVERA
76
PROVIGIL
2
PROZAC
20
PROZAC WEEKLY
20
PULMICORT 0.25 MG/2ML 14
PULMICORT 0.5 MG/2ML 14
PULMICORT 1 MG/2ML
14
PULMICORT FLEXHALER 180
MCG/ACT
14
PULMICORT FLEXHALER 90
MCG/ACT
14
PULMOZYME
78
PURINETHOL
33
PURIXAN
33
PYLERA
81
pyrazinamide
32
pyridostigmine bromide
32
QNASL
71
QNASL CHILDRENS
71
QUALAQUIN
31
QUARTETTE
49
QUESTRAN 4 GM
27
QUESTRAN 4 GM/DOSE
27
Index 21
QUESTRAN LIGHT
27
quetiapine fumarate
39
quinapril hcl
29
quinapril-hydrochlorothiazide
31
quinidine gluconate 324
mg
12
quinidine sulfate
12
quinine sulfate
32
QVAR
14
RABAVERT
82
RAGWITEK
45
raloxifene hcl
60
ramipril
29
RANEXA
11
ranitidine hcl 15 mg/ml, 150
mg/10ml, 75 mg/5ml
80
ranitidine hcl 150 mg
80
ranitidine hcl 150 mg, 300
mg
80
ranitidine hcl 300 mg
80
RAPAFLO
64
RAPAMUNE 0.5 MG
44
RAPAMUNE 1 MG, 2 MG 44
RAPAMUNE 1 MG/ML
44
RAYOS 2 MG, 5 MG
51
RAZADYNE
77
RAZADYNE ER
77
REBETOL 200 MG
42
REBETOL 40 MG/ML
42
REBIF
78
REBIF REBIDOSE
78
REBIF REBIDOSE
TITRATIONPACK
78
REBIF TITRATION PACK 78
RECLAST
59
RECOMBIVAX HB
82
RECTIV
9
REGLAN
63
REGRANEX
57
RELENZA DISKHALER
43
RELISTOR 12 MG/0.6ML 63
RELISTOR 12 MG/0.6ML, 8
MG/0.4ML
63
RELPAX
69
REMERON
19
REMERON SOLTAB
19
REMICADE
63
REMODULIN
47
RENAGEL 800 MG
63
RENVELA
63
repaglinide 0.5 mg, 1 mg
24
repaglinide 2 mg
24
REPREXAIN 200MG-5MG
8
REQUIP
38
REQUIP XL
38
RESCRIPTOR 100 MG
41
RESCRIPTOR 200 MG
41
RESCULA
74
reserpine 0.1 mg, 0.25 mg 30
RESTASIS
73
RESTORIL
66
RETIN-A
52
RETIN-A MICRO
52
RETIN-A MICRO PUMP 0.04 %,
0.1 %
52
RETIN-A MICRO PUMP 0.08
%
52
RETROVIR
41
RETROVIR IV INFUSION 41
REVATIO 10 MG/12.5ML
47
REVATIO 20 MG
47
REVIA
25
REVLIMID
43
REYATAZ 100 MG
41
REYATAZ 150 MG, 200 MG, 300
MG
41
REYATAZ 50 MG
41
RHEUMATREX
2
RHINOCORT AQUA
71
RIBASPHERE 600 MG
42
RIBASPHERE RIBAPAK
43
RIBATAB 600 MG
43
ribavirin (hepatitis c) 200 mg 43
RIDAURA
2
rifabutin
32
RIFADIN
32
rifamate
32
rifampin 150 mg, 300 mg
32
rifampin 600 mg
32
RIFATER
32
RILUTEK
71
riluzole
71
rimantadine hydrochloride 43
RIOMET
22
risedronate sodium
59
RISPERDAL
39
RISPERDAL CONSTA 12.5
MG
39
RISPERDAL CONSTA 25
MG
39
RISPERDAL CONSTA 37.5 MG,
50 MG
39
RISPERDAL M-TAB
39
risperidone 0.25 mg, 0.5 mg, 1
mg, 2 mg, 3 mg, 4 mg
39
risperidone 0.25 mg, 3 mg, 4
mg
39
risperidone 0.5 mg, 1 mg, 2
mg
39
risperidone 1 mg/ml
39
RITALIN
2
RITALIN LA 10 MG
2
RITALIN LA 20 MG, 30 MG, 40
MG
2
RITALIN SR
2
RITUXAN
34
rivastigmine tartrate
77
rizatriptan benzoate 10 mg 69
rizatriptan benzoate 5 mg
69
ROBAXIN 500 MG
70
ROBAXIN-750
70
ROBINUL 0.2 MG/ML
80
ROBINUL 1 MG
80
ROBINUL FORTE
80
ROCALTROL
60
ROCEPHIN 1 GM
48
ROCEPHIN 500 MG
48
ropinirole hydrochloride 0.25 mg,
0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg,
5 mg
38
ropinirole hydrochloride 12 mg, 2
mg, 4 mg, 6 mg, 8 mg
38
ROTARIX
82
ROTATEQ
82
ROWASA
63
ROXICODONE 15 MG
6
ROXICODONE 30 MG
6
ROXICODONE 5 MG
6
ROZEREM
66
RYTHMOL
13
RYTHMOL SR
13
SABRIL
18
SAFYRAL
49
SALAGEN
70
SAMSCA
61
SANCTURA
81
SANCTURA XR
81
SANCUSO
25
SANDIMMUNE 100 MG, 25
MG
44
SANDIMMUNE 100
MG/ML
44
SANDIMMUNE 50 MG/ML 44
SANDOSTATIN 100
MCG/ML
61
SANDOSTATIN 200 MCG/ML,
50 MCG/ML
61
SANDOSTATIN LAR DEPOT
20 MG, 30 MG
61
SANTYL
57
SAPHRIS 10 MG
39
SAPHRIS 5 MG
39
SAVELLA
77
SAVELLA TITRATION
PACK
77
SEASONIQUE
49
SECTRAL
45
selegiline hcl
38
selenium sulfide 2.5 %
54
SELSUN SHAMPOO
54
SELZENTRY
41
SEMPREX-D
51
SENSIPAR 30 MG
60
SENSIPAR 60 MG, 90 MG 60
SEREVENT DISKUS
14
SEROQUEL
40
SEROQUEL XR 150 MG, 200
MG, 300 MG, 50 MG
40
SEROQUEL XR 400 MG 40
SEROSTIM 4 MG, 6 MG 60
sertraline hcl 100 mg, 25 mg,
50 mg
20
sertraline hcl 20 mg/ml
20
SEVELAMER
CARBONATE
63
SIGNIFOR
61
sildenafil citrate (pulmonary
hypertension)
47
SILENOR
66
SILVADENE
54
silver sulfadiazine
54
SIMBRINZA
72
SIMCOR 20MG-1000MG,
20MG-500MG, 20MG750MG
28
SIMCOR 40MG-1000MG,
40MG-500MG
28
SIMPONI
2
SIMPONI ARIA
2
SIMULECT
44
simvastatin 10 mg
28
simvastatin 20 mg
28
simvastatin 40 mg
28
simvastatin 5 mg
28
simvastatin 80 mg
28
SINEMET
38
SINEMET CR
38
SINGULAIR 10 MG
13
SINGULAIR 4 MG, 5 MG
13
sirolimus 0.5 mg, 1 mg
44
sirolimus 2 mg
44
SIRTURO
32
SIVEXTRO
11
SKELAXIN
70
sodium bicarbonate 8.4 % 69
sodium chloride (gu irrigant) 64
sodium chloride 0.45 %
70
sodium chloride 0.9 %
70
sodium fluoride 0.125
mg/drop
69
sodium fluoride 0.25 mg, 0.5 mg,
1 mg, 1.1 mg, 2.2 mg
69
sodium fluoride 0.5 mg/ml 69
sodium fluoride 1 mg
69
sodium polystyrene
sulfonate
44
sodium polystyrene sulfonate 15
gm/60ml
44
SOLARAZE
53
SOLTAMOX
34
SOLU-CORTEF 100 MG, 250
MG
51
SOLU-MEDROL 1000 MG, 125
MG, 40 MG
51
SOLU-MEDROL 2 GM
51
SOMA 350 MG
70
SOMATULINE DEPOT
61
SOMAVERT 10 MG, 15 MG, 20
MG
59
SOMAVERT 25 MG, 30 MG 59
SONATA
66
SORIATANE
54
SORILUX
54
sotalol hcl
45
sotalol hcl (afib/afl)
45
SOVALDI
43
Index 22
SPIRIVA HANDIHALER
13
SPIRIVA RESPIMAT
13
spironolactone &
hydrochlorothiazide
58
spironolactone 100 mg, 25 mg,
50 mg
58
SPORANOX 10 MG/ML
26
SPORANOX 100 MG
26
SPORANOX PULSEPAK
26
SPRIX
4
SPRYCEL
35
sps
44
STALEVO 100
38
STALEVO 125
38
STALEVO 150
38
STALEVO 200
38
STALEVO 50
38
STALEVO 75
38
STARLIX
24
stavudine 1 mg/ml
41
stavudine 15 mg
41
stavudine 20 mg, 30 mg, 40
mg
41
STELARA
54
STIMATE
61
STIVARGA
35
STRATTERA 10 MG
1
STRATTERA 100 MG, 60 MG, 80
MG
1
STRATTERA 18 MG
1
STRATTERA 25 MG
1
STRATTERA 40 MG
1
STRIBILD
41
STRIVERDI RESPIMAT
14
STROMECTOL
9
SUBOXONE 12MG-3MG, 2MG0.5MG, 4MG-1MG, 8MG-2MG8
SUBOXONE 2MG-0.5MG
8
SUBOXONE 8MG-2MG
8
SUBSYS 100 MCG, 200 MCG7
SUBSYS 1200 MCG, 1600
MCG
7
SUBSYS 400 MCG, 600 MCG,
800 MCG
7
sucralfate
80
SULAR
46
sulfacetamide sodprednisolone
74
sulfacetamide sodium (acne) 52
Index 23
sulfacetamide sodium
(ophth)
73
sulfadiazine
78
sulfamethoxazole-trimethoprim
160mg-800mg, 80mg400mg
10
sulfamethoxazole-trimethoprim
160mg/20ml-800mg/20ml,
40mg/5ml-200mg/5ml
10
sulfamethoxazole/trimethoprim
10
SULFAMYLON 85 MG/GM 54
sulfasalazine
63
sulindac 150 mg, 200 mg 4
sumatriptan succinate 100
mg
69
sumatriptan succinate 25
mg
69
sumatriptan succinate 4
mg/0.5ml
69
sumatriptan succinate 50
mg
69
sumatriptan succinate 6
mg/0.5ml
69
SUMAVEL DOSEPRO 4
MG/0.5ML
69
SUMAVEL DOSEPRO 6
MG/0.5ML
69
SUPRAX 400 MG
48
SUPRAX 500 MG/5ML
48
SUPREP BOWEL PREP 67
SURMONTIL
21
SUSTIVA 200 MG, 50 MG 41
SUSTIVA 600 MG
41
SUTENT
35
SYLATRON
36
SYMBICORT
14
SYMBYAX
77
SYMLINPEN 120
21
SYMLINPEN 60
21
SYNAGIS
75
SYNALAR
56
SYNAREL
60
SYNERCID
11
SYNRIBO
36
SYNTHROID
79
SYPRINE
43
TABLOID
33
TACLONEX
56
tacrolimus (topical)
57
tacrolimus 0.5 mg, 1 mg, 5
mg
44
TAFINLAR
35
TALWIN
8
TAMBOCOR 100 MG
13
TAMBOCOR 150 MG
13
TAMBOCOR 50 MG
13
TAMIFLU
43
tamoxifen citrate 10 mg, 20
mg
34
tamsulosin hcl
64
TANZEUM
23
TAPAZOLE
79
TARCEVA
35
TARGRETIN
36
TASIGNA
35
TASMAR
37
TAXOL
37
TAXOTERE
37
TAZORAC
54
TECFIDERA
78
TECFIDERA STARTER
PACK
78
TEFLARO
48
TEGRETOL
17
TEGRETOL-XR
17
TEKAMLO
31
TEKTURNA
31
TEKTURNA HCT
31
telmisartan
29
telmisartan-amlodipine
31
telmisartan-hydrochlorothiazide
31
temazepam
66
TEMODAR 100 MG
33
TEMOVATE
56
TEMOVATE E
56
TENEX
30
TENIVAC
79
TENORETIC 100
31
TENORETIC 50
31
TENORMIN
45
TERAZOL 3
82
TERAZOL 7
82
terazosin hcl
30
terbinafine hcl
26
terbutaline sulfate 2.5 mg, 5
mg
15
terconazole vaginal
83
TESTIM
9
TESTOSTERONE 1 %, 10
MG/ACT
9
TESTOSTERONE 25
MG/2.5GM
9
testosterone cypionate
9
testosterone enanthate
9
TESTOSTERONE PUMP
9
TETANUS TOXOID
ADSORBED
79
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED
ADULT
79
tetracycline hcl 250 mg, 500
mg
79
TEV-TROPIN
60
TEVETEN 400 MG
29
TEVETEN 600 MG
29
THALOMID
43
theophylline 100 mg, 200 mg,
300 mg, 450 mg
15
theophylline 400 mg, 600 mg15
THERACYS
36
thioridazine hcl 10 mg, 100 mg,
25 mg, 50 mg
40
thiothixene 1 mg, 10 mg, 2 mg, 5
mg
40
THYMOGLOBULIN
44
tiagabine hcl
18
TIAZAC
46
TICE BCG
36
ticlopidine hcl
65
TIGAN
25
TIKOSYN
13
timolol maleate (ophth) 0.25 %,
0.5 %
72
TIMOPTIC
72
TIMOPTIC-XE
72
TINDAMAX
10
tinidazole 250 mg, 500 mg 10
TIVICAY
41
tizanidine hcl 2 mg
70
tizanidine hcl 4 mg
70
tizanidine hcl 6 mg
70
TOBI
2
TOBI PODHALER
2
TOBRADEX
74
TOBRADEX ST
74
tobramycin
2
tobramycin (ophth)
73
tobramycin sulfate 1.2 gm
2
tobramycin sulfate 1.2 gm/30ml,
40 mg/ml, 80 mg/2ml
2
tobramycin sulfate 10 mg/ml 2
tobramycindexamethasone
74
TOBREX
73
TOFRANIL
21
TOFRANIL-PM 100 MG 21
TOFRANIL-PM 125 MG, 150
MG, 75 MG
21
tolazamide 250 mg
24
tolazamide 500 mg
24
tolbutamide
24
tolmetin sodium 200 mg
4
tolmetin sodium 400 mg
4
tolterodine tartrate 1 mg, 2
mg
81
tolterodine tartrate 2 mg, 4
mg
81
TOPAMAX
17
TOPAMAX SPRINKLE
17
TOPICORT 0.05 %
56
TOPICORT 0.25 %
56
topiramate 100 mg, 200 mg, 25
mg, 50 mg
17
topiramate 15 mg, 25 mg 17
topotecan hcl 4 mg
37
TOPROL XL
45
TORISEL
36
torsemide 10 mg, 100 mg, 20
mg, 5 mg
58
TOTECT
36
TOVIAZ
82
TRACLEER
47
TRADJENTA
23
tramadol hcl 100 mg
7
tramadol hcl 200 mg
7
tramadol hcl 300 mg
7
tramadol hcl 50 mg
7
tramadol-acetaminophen
8
TRANDATE
45
trandolapril
29
tranexamic acid 100 mg/ml 66
tranexamic acid 650 mg 66
TRANSDERM-SCOP
25
TRANXENE T
12
tranylcypromine sulfate
19
TRAVATAN Z
74
trazodone hcl 100 mg, 150 mg,
300 mg, 50 mg
20
TREANDA
33
TRECATOR
32
TRELSTAR DEPOT
34
TRELSTAR DEPOT
MIXJECT
34
TRELSTAR LA
34
TRELSTAR LA MIXJECT
34
TRELSTAR MIXJECT
34
TRENTAL
64
tretinoin (chemotherapy)
36
tretinoin 0.01 %, 0.025 %
52
tretinoin 0.025 %, 0.05 %, 0.1
%
52
tretinoin microsphere
52
trexall 10 mg, 15 mg
33
trexall 5 mg, 7.5 mg
33
TREXIMET
68
triamcinolone acetonide
(mouth)
70
triamcinolone acetonide
(nasal)
71
triamcinolone acetonide
(topical)
56
triamterene &
hydrochlorothiazide
58
triazolam
66
TRIBENZOR
31
TRICOR
28
trifluoperazine hcl
40
trifluridine
73
TRIGLIDE 50 MG
28
trihexyphenidyl hcl
37
TRILEPTAL 150 MG, 300 MG,
600 MG
17
TRILEPTAL 300 MG/5ML
17
TRILIPIX
28
trimethobenzamide hcl 100
mg/ml
25
trimethobenzamide hcl 300
mg
25
trimethoprim
10
trimipramine maleate 100
mg
21
trimipramine maleate 25 mg, 50
mg
21
TRISENOX
36
TRIUMEQ
42
TRIZIVIR
42
trospium chloride 20 mg
82
trospium chloride 60 mg
82
TRUSOPT
74
Index 24
TRUVADA
42
TUDORZA PRESSAIR
13
TWINRIX
82
TWYNSTA
31
TYBOST
42
TYGACIL
10
TYKERB
36
TYLENOL/CODEINE #3
8
TYLENOL/CODEINE #4
8
TYPHIM VI
82
TYSABRI
78
TYVASO
47
TYVASO REFILL
47
TYVASO STARTER
47
TYZEKA
43
UCERIS
51
ULORIC
64
ULTRACET
8
ULTRAM
7
ULTRAM ER 100 MG
7
ULTRAM ER 200 MG
7
ULTRAM ER 300 MG
7
ULTRAVATE
56
UNASYN 1GM-2GM
76
UNIRETIC
31
UNIVASC
29
URECHOLINE
82
UREX
81
UROCIT-K 10
64
UROCIT-K 5
64
UROXATRAL
64
URSO 250
62
URSO FORTE
62
ursodiol 250 mg, 500 mg
62
ursodiol 300 mg
62
UVADEX
36
VAGIFEM
83
valacyclovir hcl 1 gm, 1000 mg,
500 mg
43
VALCHLOR
53
VALCYTE
42
valganciclovir hcl
42
VALIUM
12
valproate sodium 100 mg/ml, 500
mg/5ml
18
valproate sodium 250
mg/5ml
18
Index 25
valproic acid
19
valsartan
29
valsartan-hydrochlorothiazide
31
VALSTAR
35
VALTREX
43
VANCOCIN HCL
10
vancomycin hcl 10 gm, 1000
mg, 5000 mg
10
vancomycin hcl 125 mg, 250
mg
10
vancomycin hcl 500 mg
10
VANCOMYCIN HCL IN
DEXTROSE
10
VANOS
56
VANTAS
35
VAQTA
82
VARIVAX
82
VARIZIG
75
VASCEPA
27
VASERETIC
31
VASOTEC 10 MG
29
VASOTEC 2.5 MG
29
VASOTEC 20 MG
29
VASOTEC 5 MG
29
VECTIBIX
34
VECTICAL
54
VELCADE
36
VELPHORO
63
VELTIN
52
venlafaxine hcl 100 mg
20
venlafaxine hcl 150 mg
20
venlafaxine hcl 25 mg
20
venlafaxine hcl 37.5 mg
20
venlafaxine hcl 50 mg
20
venlafaxine hcl 75 mg
20
venlafaxine hcl er 150 mg 20
VENLAFAXINE HCL ER 225
MG
20
venlafaxine hcl er 37.5 mg 20
venlafaxine hcl er 75 mg 20
VENTAVIS 10 MCG/ML 47
VENTAVIS 20 MCG/ML 47
VENTOLIN HFA
15
VERAMYST
71
verapamil hcl 100 mg, 120 mg,
180 mg, 200 mg, 240 mg, 300
mg, 360 mg
46
verapamil hcl 120 mg, 180 mg,
240 mg
46
verapamil hcl 120 mg, 40 mg, 80
mg
46
VEREGEN
52
VERELAN
46
VERELAN PM
46
VERSACLOZ
40
VESICARE
82
VEXOL
74
VFEND 200 MG, 50 MG
26
VFEND IV
26
VIBRAMYCIN 100 MG
79
VIBRAMYCIN 25 MG/5ML 79
VIBRAMYCIN 50 MG/5ML 79
VICOPROFEN
8
VICTOZA
23
VICTRELIS
43
VIDAZA
33
VIDEX EC
42
VIDEXPEDIATRIC
42
VIGAMOX
73
VIIBRYD
20
VIMIZIM
60
VIMOVO
4
VIMPAT 10 MG/ML
18
VIMPAT 100 MG, 150 MG, 200
MG, 50 MG
18
VIMPAT 200 MG/20ML
17
vinblastine sulfate 1 mg/ml 37
vinblastine sulfate 10 mg
37
vincristine sulfate
37
vinorelbine tartrate
37
VIOKACE
57
VIRACEPT
42
VIRAMUNE 200 MG
42
VIRAMUNE 50 MG/5ML
42
VIRAMUNE XR 100 MG
42
VIRAMUNE XR 400 MG
42
VIRAZOLE
43
VIREAD 150 MG, 300 MG 42
VIREAD 200 MG, 250 MG 42
VIREAD 40 MG/GM
42
VIROPTIC
73
VISTARIL
12
VISTIDE
42
VIVELLE-DOT
61
VOGELXO
9
VOGELXO PUMP
9
VOLTAREN
53
VOLTAREN-XR
4
voriconazole 200 mg
26
voriconazole 200 mg, 50 mg 26
VOSOL HC
75
VOSPIRE ER
15
VOTRIENT
36
VPRIV
65
VYTORIN 10MG-10MG
27
VYTORIN 10MG-20MG
27
VYTORIN 40MG-10MG
27
VYTORIN 80MG-10MG
27
VYVANSE 20 MG
1
VYVANSE 30 MG
1
VYVANSE 40 MG, 50 MG, 60
MG, 70 MG
1
warfarin sodium
15
water for irrigation, sterile
44
WELCHOL
27
WELLBUTRIN 100 MG
19
WELLBUTRIN 75 MG
19
WELLBUTRIN SR 100 MG 19
WELLBUTRIN SR 150 MG, 200
MG
19
WELLBUTRIN XL 150 MG 19
WELLBUTRIN XL 300 MG 19
WESTCORT
56
XALATAN
74
XALKORI
36
XANAX
12
XANAX XR
12
XARELTO
15
XARELTO STARTER PACK 15
XELJANZ
2
XENAZINE
77
XEOMIN 50 UNIT
71
XERESE
54
XGEVA
59
XIAFLEX
43
XIFAXAN
10
XODOL 5MG-300MG
8
XOLAIR
13
XOPENEX
15
XOPENEX CONCENTRATE 15
XOPENEX HFA
15
XTANDI
35
XYLOCAINE 1 %, 2 %
67
XYLOCAINE 20 MG/ML 13
XYLOCAINE 4 %
57
XYLOCAINE-MPF 1 %
67
XYREM
77
XYZAL
26
YASMIN 28
49
YAZ
49
YERVOY
34
YF-VAX
82
zafirlukast
13
zaleplon
66
ZALTRAP
34
ZANAFLEX 2 MG
71
ZANAFLEX 4 MG
71
ZANAFLEX 6 MG
71
ZANOSAR
33
ZANTAC 15 MG/ML
80
ZANTAC 150 MG
80
ZANTAC 300 MG
80
ZARONTIN 250 MG
18
ZARONTIN 250 MG/5ML 18
ZAROXOLYN
58
ZAVESCA
65
ZEBETA
45
ZEGERID 20MG-1100MG 81
ZEGERID 40MG-1100MG 81
ZEGERID 40MG-1680MG 81
ZELAPAR
38
ZELBORAF
36
ZEMAIRA
78
ZEMPLAR 1 MCG, 2 MCG, 4
MCG
60
ZENPEP 10000UNIT3000UNIT-16000UNIT,
17000UNIT-5000UNIT27000UNIT, 34000UNIT10000UNIT-55000UNIT,
51000UNIT-15000UNIT82000UNIT, 68000UNIT20000UNIT-109000UNIT,
85000UNIT-25000UNIT136000UNIT
58
ZENPEP 136000UNIT40000UNIT-218000UNIT 58
ZERIT
42
ZESTORETIC
31
ZESTRIL
29
ZETIA
28
ZETONNA
71
ZIAC
31
ZIAGEN 20 MG/ML
42
ZIAGEN 300 MG
42
ZIANA
52
zidovudine 100 mg
42
zidovudine 300 mg
42
zidovudine 50 mg/5ml
42
ZINACEF 1.5 GM, 7.5 GM 48
ZINACEF 750 MG
48
ZINECARD
36
ZIOPTAN
75
ziprasidone hcl
39
ZIPSOR
4
ZIRGAN
73
ZITHROMAX 100 MG/5ML, 200
MG/5ML
67
ZITHROMAX 250 MG, 500 MG,
600 MG
67
ZITHROMAX 500 MG
67
ZITHROMAX TRI-PAK
67
ZITHROMAX Z-PAK
67
ZMAX
67
ZOCOR 10 MG
28
ZOCOR 20 MG
28
ZOCOR 40 MG
28
ZOCOR 5 MG
28
ZOCOR 80 MG
28
ZOFRAN 4 MG, 8 MG
25
ZOFRAN 4 MG/5ML
25
ZOFRAN 40 MG/20ML
25
ZOFRAN ODT
25
ZOHYDRO ER
7
ZOLADEX
35
ZOLEDRONIC ACID 4 MG 59
zoledronic acid 4 mg/5ml
59
zoledronic acid 5 mg/100ml 59
ZOLINZA
36
zolmitriptan
69
ZOLOFT
20
zolpidem tartrate 10 mg
66
zolpidem tartrate 12.5 mg
66
zolpidem tartrate 5 mg
66
zolpidem tartrate 6.25 mg
66
ZOLPIMIST
66
ZOMETA 4 MG/5ML
59
Index 26
ZOMIG 2.5 MG
69
ZOMIG 2.5 MG, 5 MG
69
ZOMIG NASAL SPRAY
69
ZOMIG ZMT
69
ZONEGRAN
18
zonisamide
18
ZONTIVITY
65
ZORTRESS 0.25 MG
44
ZORTRESS 0.5 MG, 0.75
MG
44
ZOSTAVAX
82
ZOSYN 0.25GM-2GM, 4.5GM36GM
76
ZOSYN 0.25GM/50ML2GM/50ML-5%, 0.375GM/50ML3GM/50ML-5%, 0.5GM/100ML4GM/100ML-5%
76
ZOSYN 0.375GM-3GM, 0.5GM4GM
76
ZOVIRAX 200 MG
43
ZOVIRAX 200 MG/5ML
43
ZOVIRAX 400 MG, 800 MG 43
ZOVIRAX 5 %
54
ZUBSOLV
8
ZYBAN
78
ZYCLARA
57
ZYCLARA PUMP
57
ZYDELIG
36
ZYFLO CR
13
ZYKADIA
36
ZYLET
74
ZYLOPRIM 100 MG
64
ZYLOPRIM 300 MG
64
ZYMAXID
73
ZYPREXA
40
ZYPREXA ZYDIS
40
ZYTIGA
35
ZYVOX 100 MG/5ML
11
ZYVOX 2 MG/ML
11
ZYVOX 600 MG
11
Index 27
Este formulario se actualizó el 1 de GFCSFSP
de 2015. Si desea obtener información más reciente
o si tiene otras preguntas, comuníquese con
Health Net Medicare Parte D al:
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o para los usuarios de TTY: 711, de 8:00 a.m. a
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Servicios al Aἀliado al número de teléfono que
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