1. No category

Fidelis Care
2015 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
H3328_FC 14102 CMS Accepted
00015369. Version 10
Note to existing members: This formulary has changed since last year. Please review this
document to make sure that it still contains the drugs you take.
This document includes the list of the drugs (formulary) for our plan which is current as of
11/01/2015. For an updated formulary, please contact us. Our contact information, along with the
date we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits,
formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2015, and
from time to time during the year.
Fidelis Care is an HMO plan with a Medicare contract. Enrollment in Fidelis Care depends on
contract renewal.
Fidelis Care is a Coordinated Care plan with a Medicare contract and a contract with the New York
State Department of Health Medicaid program. Enrollment in Fidelis Care depends on contract
renewal.
This information is available for free in other languages. Please contact our Member Services
number at 1-800-247-1447 for additional information. (TTY users should call 1-800-695-8544).
Hours are 8:00 a.m. to 8:00 p.m. seven days a week from October 1 to February 14, and Monday
through Friday, 8:00 a.m. to 8:00 p.m. from February 15 through September 30. Member Services
also has free language interpreter services available for non-English speakers.
Esta información está disponible de forma gratuita en otros idiomas. Por favor comuníquese con
nuestro número de Servicios al Socio al 1-800-247-1447 para obtener información adicional. Los
usuarios con deficiencia auditiva (TTY) deberán llamar al 1-800-695-8544. El horario de atención
es de 8:00 a.m. a 8:00 p.m. los siete días de la semana desde el 1 de octubre hasta el 14 de febrero, y
de lunes a viernes, de 8:a.m. hasta las 8:00 p.m. desde el 15 de febrero hasta el 30 de septiembre.
Servicios al Socio también tiene servicios gratuitos de intérprete disponibles para personas que no
hablan inglés.
1
What is the Fidelis Care Formulary?
A formulary is a list of covered drugs selected by Fidelis Care in consultation with a team of health
care providers, which represents the prescription therapies believed to be a necessary part of a
quality treatment program. Fidelis Care will generally cover the drugs listed in our formulary as
long as the drug is medically necessary, the prescription is filled at a Fidelis Care network pharmacy,
and other plan rules are followed. For more information on how to fill your prescriptions, please
review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the
year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except
when a new, less expensive generic drug becomes available or when new adverse information about
the safety or effectiveness of a drug is released. Other types of formulary changes, such as
removing a drug from our formulary, will not affect members who are currently taking the drug. It
will remain available at the same cost-sharing for those members taking it for the remainder of the
coverage year. We feel it is important that you have continued access for the remainder of the
coverage year to the formulary drugs that were available when you chose our plan, except for cases
in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step
therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected
members of the change at least 60 days before the change becomes effective, or at the time the
member requests a refill of the drug, at which time the member will receive a 60-day supply of the
drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the
drug’s manufacturer removes the drug from the market, we will immediately remove the drug from
our formulary and provide notice to members who take the drug. The enclosed formulary is current
as of 11/01/2015. To get updated information about the drugs covered by Fidelis Care, please
contact us. Our contact information appears on the front and back cover pages. To get updated
information about the drugs covered by Fidelis Care, please visit our Web site at
www.fideliscare.org or call Member Services at 1-800-247-1447. Hours are 8:00 a.m. to 8:00 p.m.
seven days a week from October 1 to February 14, and Monday through Friday, 8:00 a.m. to 8:00
p.m. from February 15 through September 30. TTY/TDD users should call 1-800-695-8544.
We will mail you updated information about our formulary in the event that there are mid-year
non-maintenance formulary changes.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 14. The drugs in this formulary are grouped into categories
depending on the type of medical conditions that they are used to treat. For example, drugs used
to treat a heart condition are listed under the category, “Cardiovascular”. If you know what
your drug is used for, look for the category name in the list that begins on page number 14.
Then look under the category name for your drug.
2
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that
begins on page 75. The Index provides an alphabetical list of all of the drugs included in this
document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index
and find your drug. Next to your drug, you will see the page number where you can find
coverage information. Turn to the page listed in the Index and find the name of your drug in the
first column of the list.
What are generic drugs?
Fidelis Care covers both brand name drugs and generic drugs. A generic drug is approved by the
FDA as having the same active ingredient as the brand name drug. Generally, generic drugs
cost less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements
and limits may include:

Prior Authorization: Fidelis Care requires you or your physician to get prior authorization
for certain drugs. This means that you will need to get approval from Fidelis Care before
you fill your prescriptions. If you don’t get approval, Fidelis Care may not cover the drug.

Quantity Limits: For certain drugs, Fidelis Care limits the amount of the drug that Fidelis
Care will cover. For example, Fidelis Care provides 30 pills per prescription for
LUNESTA. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, Fidelis Care requires you to first try certain drugs to treat your
medical condition before we will cover another drug for that condition. For example, if
Drug A and Drug B both treat your medical condition, Fidelis Care may not cover Drug B
unless you try Drug A first. If Drug A does not work for you, Fidelis Care will then cover
Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary
that begins on page 14. You can also get more information about the restrictions applied to specific
covered drugs by visiting our Web site. We have posted on line a document that explains our prior
authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact
information, along with the date we last updated the formulary, appears on the front and back cover
pages.
You can ask Fidelis Care to make an exception to these restrictions or limits or for a list of other,
similar drugs that may treat your health condition. See the section, “How do I request an exception to
the Fidelis Care’s formulary?” on page 4 for information about how to request an exception.
3
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact
Member Services and ask if your drug is covered.
If you learn that Fidelis Care does not cover your drug, you have two options:

You can ask Member Services for a list of similar drugs that are covered by Fidelis Care.
When you receive the list, show it to your doctor and ask him or her to prescribe a similar
drug that is covered by Fidelis Care.

You can ask Fidelis Care to make an exception and cover your drug. See below for
information about how to request an exception.
How do I request an exception to the Fidelis Care’s Formulary?
You can ask Fidelis Care to make an exception to our coverage rules. There are several types of
exceptions that you can ask us to make.

You can ask us to cover a drug even if it is not on our formulary.

You can ask us to provide a higher level of coverage for your drug. If your drug is contained
in our non-preferred brand or specialty tier you can ask us to cover it at the cost-sharing
amount that applies to drugs in our preferred brand tier. If your drug is in our non-preferred
generic tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in our
preferred generic tier instead. This would lower the amount you must pay for your drug.
Please note, if we grant your request to cover a drug that is not on our formulary, you may
not ask us to provide a higher level of coverage for the drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for
certain drugs, Fidelis Care limits the amount of the drug that we will cover. If your drug has
a quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, Fidelis Care will only approve your request for an exception if the alternative drugs
included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions
would not be as effective in treating your condition and/or would cause you to have adverse medical
effects.
You should contact us to ask us for an initial coverage decision for a formulary exception. When
you request a formulary exception you should submit a statement from your prescriber or
physician supporting your request. Generally, we must make our decision within 72 hours of
getting your prescriber’s supporting statement. You can request an expedited (fast) exception if
you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for
a decision. If your request to expedite is granted, we must give you a decision no later than 24
hours after we get a supporting statement from your doctor or other prescriber.
4
What do I do before I can talk to my doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary.
Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For
example, you may need a prior authorization from us before you can fill your prescription. You
should talk to your doctor to decide if you should switch to an appropriate drug that we cover or
request a formulary exception so that we will cover the drug you take. While you talk to your
doctor to determine the right course of action for you, we may cover your drug in certain cases
during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we
will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when
you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even
if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we
have provided you with a 91-day transition supply, consistent with dispensing increment, (unless
you have a prescription written for fewer days). We will cover more than one refill of these drugs
for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or
if your ability to get your drugs is limited, but you are past the first 90 days of membership in our
plan, we will cover a 34-day emergency supply of that drug (unless you have a prescription for fewer
days) while you pursue a formulary exception.
For more information
For more detailed information about your Fidelis Care prescription drug coverage, please review
your Evidence of Coverage and other plan materials.
If you have questions about Fidelis Care, please contact us. Our contact information, along with the
date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at
1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call
1-877-486-2048. Or, visit http://www.medicare.gov.
5
Fidelis Care’s Formulary
The formulary below provides coverage information about the drugs covered by Fidelis Care. If
you have trouble finding your drug in the list, turn to the Index that begins on page 75.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., BICILLIN)
and generic drugs are listed in lower-case italics (e.g., ampicillin).
The information in the Requirements/Limits column tells you if Fidelis Care has any special
requirements for coverage of your drug. For example, “PA” means prior authorization is required.
(This means that you will need to get approval from Fidelis Care before you fill your prescriptions);
"ST" means that step therapy is required. (This means you may be required to try certain drugs for
your medical condition before we will cover another drug for that condition); “QL” means that
quantity limits apply (Fidelis Care limits the amount of the drug that Fidelis Care will cover); “B/D”
means that the drug is covered under Part B and Part D of Medicare (Fidelis Care will determine
whether a particular prescription is covered under Part B or Part D).
6
Fidelis Care
Formulario 2015
(Lista de medicamentos cubiertos)
POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE
LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
H3328_FC 14102_SP CMS Aceptado
00015369. Version 10
Nota para socios actuales: Hubo cambios en este formulario durante el último año. Lea este
documento para asegurarse de que siga conteniendo los medicamentos que toma.
Este documento incluye la lista de los medicamentos (formulario) para nuestro plan, que está
vigente al 1 de enero del 2015. Para obtener un formulario actualizado, por favor póngase en
contacto con nosotros. Nuestra información de contacto, junto con la fecha de la última
actualización del formulario, aparecen en la portada y contraportada.
Usted generalmente debe utilizar farmacias de la red para utilizar su beneficio de medicamentos con
receta médica. Los beneficios, la lista de medicamentos, la red farmacéutica, y/o los
copagos/coaseguros pueden variar el 1 de enero de 2015, y de vez en cuando durante el año.
Fidelis Care es un plan HMO con un contrato de Medicare. La inscripción en Fidelis Care depende
de la renovación del contrato.
Fidelis Care es un plan de Cuidado Coordinado con un contrato de Medicare y un contrato con el
programa del Departamento de Salud de Medicaid del Estado de Nueva York. La inscripción en
Fidelis Care depende de la renovación del contrato.
Esta información está disponible de forma gratuita en otros idiomas. Por favor comuníquese con
nuestro número de Servicios al Socio al 1-800-247-1447 para obtener información adicional. (Los
usuarios de TTY deben llamar al 1-800-695-8544). El horario de atención es de 8:00 a.m. a 8:00
p.m. los siete días de la semana desde el 1 de octubre hasta el 14 de febrero, y de lunes a viernes, de
8:00 a.m. a 8:00 p.m. desde el 15 de febrero hasta el 30 de septiembre. Servicios al Socio también
tiene servicios gratuitos de intérprete disponibles para personas que no hablan inglés.
This information is available for free in other languages. Please contact our Member Services
number at 1-800-247-1447 for additional information. (TTY users should call 1-800-695-8544).
Hours are 8:00 a.m. to 8:00 p.m. seven days a week from October 1 to February 14, and Monday
through Friday, 8:00 a.m. to 8:00 p.m. from February 15 through September 30. Member Services
also has free language interpreter services available for non-English speakers.
7
¿Qué es el formulario de Fidelis Care?
Un formulario es una lista de medicamentos cubiertos seleccionados por Fidelis Care con el
asesoramiento de un equipo de proveedores de cuidados de la salud, la cual representa las terapias
con medicamentos recetados consideradas una parte necesaria de un programa de tratamiento de
calidad. Fidelis Care cubrirá, generalmente, los medicamentos incluidos en nuestro formulario,
siempre y cuando el medicamento sea médicamente necesario, la receta se surta en una farmacia de
la red de Fidelis Care y se cumplan otras reglas del plan. Para obtener más información sobre cómo
surtir sus recetas, lea su Comprobante de cobertura.
¿Puede cambiar el formulario?
En general, si está tomando un medicamento incluido en nuestro formulario 2015 que estaba
cubierto a principio de año, no discontinuaremos ni reduciremos la cobertura del medicamento
durante el año de cobertura 2015, salvo cuando haya un nuevo medicamento genérico menos
costoso disponible o cuando se haya publicado nueva información adversa sobre la seguridad o
efectividad de un medicamento. Otro tipo de cambios de formulario, tales como quitar un
medicamento de nuestro formulario, no afectará a los socios que actualmente estén tomando el
medicamento. Seguirá disponible con el mismo costo compartido para los socios que estén
tomando tal medicamento durante el resto del año de cobertura. Creemos que es importante
que tenga un acceso continuado durante el resto del año de cobertura a los medicamentos del
formulario que estaban disponibles cuando eligió nuestro plan, salvo en situaciones en las que
pueda ahorrar dinero adicional o en caso de que nosotros podamos afianzar su seguridad.
Si quitamos medicamentos de nuestro formulario, o, con autorización previa, aumentamos los
límites de cantidades y/o hacemos restricciones a terapias escalonadas sobre un medicamento o
pasamos un medicamento a un nivel mayor de costos compartidos, debemos notificar del cambio a
los socios afectados, al menos, 60 días antes de que el cambio entre en vigencia o al momento en que
el socio solicite un nuevo surtido del medicamento, momento en el cual el socio recibirá un
suministro del medicamento para 60 días. Si la Administración de Alimentos y Medicamentos
(Food and Drug Administration, FDA) considera que un medicamento que está en nuestro
formulario es inseguro o si el fabricante del medicamento retira el medicamento del mercado,
inmediatamente retiraremos el medicamento de nuestro formulario y daremos aviso a los socios que
toman dicho medicamento.
El formulario adjunto está vigente desde el 11/01/2015. Para recibir información actualizada sobre
los medicamentos con cobertura de Fidelis Care, visite nuestro sitio web en www.fideliscare.org o
llame a Servicios al Socio al 1-800-247-1447. El horario de atención es de 8:00 a.m. a 8:00 p.m. los
siete días de la semana desde el 1 de octubre hasta el 14 de febrero, y de lunes a viernes, de 8:00 a.m.
a 8:00 p.m. desde el 15 de febrero hasta el 30 de septiembre. Los usuarios de TTY/TDD deben
llamar al 1-800-695-8544.
Le enviaremos por correo información actualizada sobre nuestro formulario en caso de que haya
cambios a mitad de año en el formulario, no vinculados con el mantenimiento.
8
¿Cómo uso el formulario?
Hay dos maneras de encontrar un medicamento en el formulario:
Afección médica
El formulario comienza a partir de la página 14. Los medicamentos del formulario están
agrupados en categorías que dependen del tipo de afección médica para cuyo tratamiento se
utilizan. Por ejemplo, los medicamentos usados para tratar una afección cardiaca se enumeran en
la categoría Cardiovascular. Si sabe para qué se usa su medicamento, busque el nombre de la
categoría en la lista que comienza en la página número 14. Después, busque su medicamento en
el nombre de la categoría.
Listado alfabético
Si no está seguro(a) en qué categoría buscar, debe buscar su medicamento en el índice que
empieza en la página 75. El índice proporciona un listado alfabético de todos los medicamentos
incluidos en este documento. En el Índice, se incluyen los medicamentos de marca y los
medicamentos genéricos. Busque en el índice para encontrar su medicamento. Al lado del
medicamento, verá el número de página donde puede encontrar la información de cobertura.
Vaya a la página indicada en el índice y busque el nombre de su medicamento en la primera
columna de la lista.
¿Qué son los medicamentos genéricos?
Fidelis Care cubre tanto medicamentos de marca como medicamentos genéricos. Un
medicamento genérico está aprobado por la FDA cuando tiene el mismo ingrediente activo que
el medicamento de marca. En general, los medicamentos genéricos cuestan menos que los de
marca.
¿Hay alguna restricción en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites en la cobertura. Entre
los requisitos y límites se pueden incluir:

Autorización previa: Fidelis Care le exige (o su médico) que obtenga autorización previa para
determinados medicamentos. Esto significa que usted deberá tener la autorización previa de
Fidelis Care para surtir sus recetas. Si usted no tiene la aprobación, Fidelis Care no podrá cubrir
el medicamento.

Límites en la cantidad: en el caso de determinados medicamentos, Fidelis Care limita la
cantidad de medicamento que cubrirá. Por ejemplo, Fidelis Care proporciona 30 pastillas por
receta para LUNESTA. Esto puede proporcionarse además de un suministro estándar de uno
o tres meses.

Terapia escalonada: en algunos casos, Fidelis Care exige que usted primero pruebe ciertos
medicamentos para tratar su afección médica antes de que cubramos otro medicamento para
9
esa condición. Por ejemplo, si un Medicamento A y también un Medicamento B tratan su
afección médica, Fidelis Care quizás no cubra el Medicamento B a menos que usted primero
trate el Medicamento A. Si el Medicamento A no funciona en su caso, Fidelis Care cubrirá
entonces el Medicamento B.
Puede averiguar si su medicamento tiene algún requisito adicional o límites consultando el
formulario que comienza en la página 14. También puede obtener más información sobre las
restricciones aplicadas a determinados medicamentos cubiertos a través de nuestro sitio web.
Hemos publicado en línea un documento que explica nuestras restricciones de autorización
previa y terapia escalonada. También puede pedirnos que le enviemos una copia. Nuestra
información de contacto, junto con la fecha en que actualizamos por ultima vez el formulario,
aparecen en la portada y contraportada.
Puede pedirle a Fidelis Care que haga una excepción a estas restricciones o límites. Consulte la
sección “¿Cómo solicito una excepción al formulario de Fidelis Care?” en la página 10 para obtener
más información sobre cómo solicitar una excepción.
¿Qué sucede en caso de que mi medicamento no esté en el formulario?
Si su medicamento no está incluido en este formulario, primero deberá contactarse con Servicios al
Socio y preguntar si su medicamento no tiene cobertura. Si se entera de que Fidelis Care no cubre su
medicamento, tiene dos opciones:

Puede pedirle a Servicios al Socio una lista de medicamentos similares que estén cubiertos
por Fidelis Care. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un
medicamento similar que esté cubierto por Fidelis Care.

Puede pedirle a Fidelis Care que haga una excepción y que cubra el medicamento. Consulte
la información a continuación para saber cómo solicitar una excepción.
¿Cómo solicito una excepción al formulario de Fidelis Care?
Puede pedirle a Fidelis Care que haga una excepción a nuestras reglas de cobertura. Hay varios tipos
de excepciones que puede solicitarnos.

Puede pedirnos que cubramos un medicamento aunque no esté en nuestro formulario.

Puede pedirnos que desestimemos las restricciones o límites de cobertura que aplican a su
medicamento. Por ejemplo, en el caso de determinados medicamentos, Fidelis Care limita la
cantidad de medicamento que cubrirá. Si su medicamento tiene un límite de cantidad, puede
pedirnos que no consideremos el límite y que cubramos una mayor cantidad.

Puede pedirnos que le brindemos un nivel mayor de cobertura en su medicamento. Si su
medicamento está incluido en nuestro nivel de medicamentos de marca no preferida o de
10
especialidades, puede pedirnos que lo cubramos según el monto de costo compartido que
aplica a los medicamentos que están en el nivel de medicamentos de marca preferida. Si su
medicamento está incluido en el nivel de medicamentos de marca no preferida, puede
pedirnos que lo cubramos según el monto de costo compartido que aplica a los
medicamentos que están en el nivel de medicamentos genéricos preferidos. Esto reduciría el
monto que debe pagar por el medicamento. Tenga en cuenta que si aceptamos su solicitud de
cubrir un medicamento que no está en el formulario, no podrá pedirnos un mayor nivel de
cobertura para el medicamento.
En general, Fidelis Care sólo aprobará su solicitud de hacer una excepción si el medicamento
alternativo está incluido en el formulario del plan, si es un medicamento del nivel más bajo o si las
restricciones de utilización adicionales no resultaran tan efectivas para tratar su afección y/o le
provocaran efectos médicos adversos.
Deberá comunicarse con nosotros para solicitar una excepción a una decisión de cobertura inicial
con respecto al formulario. Cuando vaya a solicitar una excepción al formulario, deberá
presentar una declaración de su médico para avalar la solicitud. En general, debemos tomar una
decisión en un plazo de 72 horas después de recibir la declaración de aval del médico o persona que
emitió la receta. Puede solicitar una excepción urgente (rápida) si usted o su médico creen que su
salud podría verse gravemente afectada por esperar 72 horas para recibir una decisión. Si aceptamos
acelerar el trámite tal como lo solicitara usted, debemos tomar una decisión en no más de 24 horas
después de que recibamos la declaración de aval del médico o persona que emitió la receta.
¿Qué hago antes de hablar con mi médico acerca de cambiar el medicamento
que tomo o solicitar una excepción?
Ya sea si usted es un nuevo socio o un socio actual de nuestro plan, puede que esté tomando
medicamentos que no estén en nuestro formulario. O puede que esté tomando un medicamento que
está en nuestro formulario, pero su capacidad de obtenerlo es limitada. Por ejemplo, puede que
necesite una autorización previa nuestra antes de poder surtir su receta. Deberá hablar con su médico
para decidir si debería pasar a tomar otro medicamento adecuado que esté cubierto por nosotros o
solicitar una excepción al formulario para que cubramos el medicamento que toma. Mientras habla
con su médico para determinar la acción adecuada para usted, podemos cubrir su medicamento en
determinados casos durante los primeros 90 días de su membresía en nuestro plan.
Para cada uno de sus medicamentos que no esté en nuestro formulario o si su capacidad de obtener
sus medicamentos es limitada, cubriremos temporalmente un suministro de 30 días (a menos que
tenga una receta escrita por menos días) cuando vaya a una farmacia de la red. Después de su primer
suministro de 30 días, no pagaremos estos medicamentos, aunque sea socio del plan desde hace
menos de 90 días.
Si usted reside en un centro de cuidados a largo plazo, le permitiremos surtir su receta hasta que le
hayamos brindado un suministro de transición para 91 días, consistente con el incremento de la
entrega, (a menos que tenga una receta escrita por menos días). Cubriremos más de un surtido de
estos medicamentos durante los primeros 90 días de su membresía en el plan. Si necesita un
medicamento que no está en nuestro formulario o si su capacidad de obtener sus medicamentos es
limitada, pero hace más de 90 días es socio del plan, cubriremos un suministro de emergencia por 34
11
días para dicho medicamento (a menos que tenga una receta por menos días) mientras intenta
conseguir una excepción al formulario.
Para mayor información
Para obtener información más detallada sobre la cobertura de medicamentos con receta de Fidelis
Care, consulte su Comprobante de cobertura y otros materiales del plan.
Si tiene preguntas sobre Fidelis Care, por favor llame a Servicios al Socio al 1-800-247-1447, el
horario de atención es de 8:00 a.m. a 8:00 p.m. los siete días de la semana desde el 1 de octubre hasta
el 14 de febrero, y de lunes a viernes, de 8:00 a.m. a 8:00 p.m. desde el 15 de febrero hasta el 30 de
septiembre. Los usuarios de TTY/TDD deben llamar al 1-800-695-8544. O visitar
www.fideliscare.org.
Si tiene consultas generales sobre la cobertura de medicamentos con 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/TDD deben llamar al 1-877-486-2048. O visítenos en
http://www.medicare.gov.
Formulario de Fidelis Care
El formulario a continuación proporciona información de la cobertura sobre algunos medicamentos
cubiertos por Fidelis Care. Si le resulta difícil encontrar su medicamento en la lista, pase al Índice
que comienza en la página 75.
La primera columna del cuadro enumera los nombres de los medicamentos. Los medicamentos de
marca están en mayúscula (por ej., BICILLIN) y los medicamentos genéricos están en minúscula y
cursiva (por ej., ampicilina).
La información que se encuentra en la columna Requisitos/Límites indica si Fidelis Care tiene algún
requisito especial de cobertura para el medicamento. Por ejemplo, “PA” significa que se requiere
autorización previa. (Esto significa que deberá obtener la aprobación de Fidelis Care antes de que
pueda surtir las recetas); “ST” significa que se exige terapia escalonada. (Esto significa que le pueden
solicitar que intente con ciertos medicamentos para su afección médica antes de que cubramos otro
medicamento para esa condición); “QL” significa que se aplican límites de cantidad (Fidelis Care
limita la cantidad de medicamento que Fidelis Care cubrirá); “B/D” significa que el medicamento
tiene cobertura de Parte B y Parte D de Medicare (Fidelis Care determinará si una receta en particular
tiene cobertura de Parte B o Parte D).
12
BG_CY15_5T_EXP_PERFORMANCE eff 11/01/2015
Drug Name
Drug Tier Requirements/Limits
ANALGESICS
GOUT
allopurinol tab
colchicine w/ probenecid
COLCRYS
probenecid
ULORIC
1
2
3
2
3
QL (120 tabs / 30 days)
ST
MISCELLANEOUS
diclofenac w/ misoprostol
DUEXIS
VIMOVO
2
4
4
NSAIDS
celecoxib CAPS
diclofenac potassium
diclofenac sodium TB24; TBEC
diflunisal
etodolac
etodolac er
fenoprofen calcium TABS
flurbiprofen TABS
ibuprofen SUSP
ibuprofen TABS 400mg, 600mg, 800mg
ketoprofen CAPS; CP24
mefenamic acid CAPS
MELOXICAM SUSP
meloxicam tabs
nabumetone TABS
NAPRELAN
naproxen SUSP
naproxen TABS; TBEC
NAPROXEN SOD TAB 375MG CR
NAPROXEN SOD TAB 500MG CR
naproxen sodium TABS 275mg, 550mg
oxaprozin
piroxicam CAPS
sulindac TABS
tolmetin sodium
ZIPSOR
ZORVOLEX
2
2
2
2
2
2
2
2
2
1
2
2
2
1
2
4
2
1
2
2
1
2
2
1
2
4
4
OPIOID ANALGESICS
acetaminophen w/ codeine SOLN
acetaminophen w/ codeine TABS
acetaminophen-caff-dihydrocod
2
2
2
QL (5000 mL / 30 days)
QL (400 tabs / 30 days)
QL (360 caps / 30 days)
13
Drug Name
ASPIRIN-CAFFEINE-DIHYDROCODEINE
BITARTRATE
butorphanol nasal spray
butorphanol tartrate SOLN
BUTRANS 5mcg/hr
Drug Tier Requirements/Limits
2
QL (360 caps / 30 days)
2
2
3
BUTRANS 7.5mcg/hr, 10mcg/hr
3
BUTRANS 15mcg/hr, 20mcg/hr
3
capital and codeine
4
CONZIP 100mg
4
CONZIP 200mg
4
CONZIP 300mg
4
hydrocodone-acetaminophen 2.5-325mg 2
hydrocodone-acetaminophen 5-300mg
2
hydrocodone-acetaminophen 5-325mg
2
hydrocodone-acetaminophen 7.5-300mg 2
hydrocodone-acetaminophen 7.5-325
2
mg/15ml
hydrocodone-acetaminophen 7.5-325mg 2
hydrocodone-acetaminophen 10-300mg
2
hydrocodone-acetaminophen tab 10-325mg2
hydrocodone-ibuprofen
2
hydrocodone-ibuprofen tab 7.5-200 mg
2
ibudone tab 10-200mg
2
lorcet hd tab 10-325mg
2
lorcet plus tab 7.5-325
2
lorcet tab 5-325mg
2
lortab elix
4
lortab tab 5-325mg
2
lortab tab 7.5-325
2
lortab tab 10-325mg
2
reprexain 10/200
2
TRAMADOL HCL CP24 100mg
2
TRAMADOL HCL CP24 200mg
2
TRAMADOL HCL CP24 300mg
2
TRAMADOL HCL TB24
2
tramadol hcl er TB24 100mg
2
tramadol hcl er TB24 200mg
2
tramadol hcl er (biphasic) 100mg
2
tramadol hcl er (biphasic) 200mg
2
tramadol hcl er (biphasic) 300mg
2
tramadol hcl tab 50 mg
2
tramadol-acetaminophen
2
trezix
4
vicodin
2
vicodin es
2
vicodin hp
2
QL (10 mL / 30 days)
QL (16 patches / 28
days)
QL (8 patches / 28 days)
QL (4 patches / 28 days)
QL (5000 mL / 30 days)
QL (90 caps / 30 days)
QL (60 caps / 30 days)
QL (30 caps / 30 days)
QL (360 tabs / 30 days)
QL (400 tabs / 30 days)
QL (360 tabs / 30 days)
QL (400 tabs / 30 days)
QL (5400 mL / 30 days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(360 tabs / 30 days)
(400 tabs / 30 days)
(360 tabs / 30 days)
(150 tabs / 30 days)
(150 tabs / 30 days)
(150 tabs / 30 days)
(360 tabs / 30 days)
(360 tabs / 30 days)
(360 tabs / 30 days)
(6000 mL / 30 days)
(360 tabs / 30 days)
(360 tabs / 30 days)
(360 tabs / 30 days)
(150 tabs / 30 days)
(90 caps / 30 days)
(60 caps / 30 days)
(30 caps / 30 days)
(30 tabs / 30 days)
(90 tabs / 30 days)
(30 tabs / 30 days)
(90 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(240 tabs / 30 days)
(240 tabs / 30 days)
(360 caps / 30 days)
(400 tabs / 30 days)
(400 tabs / 30 days)
(400 tabs / 30 days)
14
Drug Name
zamicet
Drug Tier Requirements/Limits
2
QL (5400 mL / 30 days)
OPIOID ANALGESICS, CII
ABSTRAL
5
CODEINE SULFATE 15mg
CODEINE SULFATE 30mg
CODEINE SULFATE 60mg
DILAUDID-HP INJ 250MG
DURAMORPH
EMBEDA CAPS 20-0.8MG
EMBEDA CAPS 30-1.2MG
EMBEDA CAPS 50-2MG
EMBEDA CAPS 60-2.4MG
EMBEDA CAPS 80-3.2MG
EMBEDA CAPS 100-4MG
endocet
ENDODAN TAB
fentanyl citrate LPOP
2
2
2
4
2
4
4
4
4
4
4
2
2
5
fentanyl patch
12mcg/hr, 25mcg/hr
2
fentanyl patch
100mcg/hr
FENTORA
50mcg/hr, 75mcg/hr,
2
5
hydromorphone hcl LIQD
HYDROMORPHONE HCL SOLN 1mg/ml,
2mg/ml, 4mg/ml
hydromorphone hcl SOLN 500mg/50ml
hydromorphone hcl TABS
HYDROMORPHONE HCL 32MG
hydromorphone tab 8mg er
hydromorphone tab 12mg er
hydromorphone tab 16mg er
HYSINGLA ER 20mg, 30mg, 40mg, 60mg
HYSINGLA ER 80mg, 100mg, 120mg
INFUMORPH 200
INFUMORPH 500
LAZANDA
2
2
levorphanol tartrate TABS
methadone hcl CONC
methadone hcl SOLN
methadone hcl TABS
METHADONE INJ 10MG/ML
MORPHINE SUL 20MG/ML ORAL SOL
2
2
2
2
4
2
2
2
5
2
2
2
4
5
4
4
5
QL (120 tabs / 30 days),
PA
QL (720 tabs / 30 days)
QL (360 tabs / 30 days)
QL (180 tabs / 30 days)
B/D
B/D
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (360 tabs / 30 days)
QL (360 tabs / 30 days)
QL (120 lozenges / 30
days), PA
QL (10 patches / 30
days)
QL (10 patches / 30
days), PA
QL (120 tabs / 30 days),
PA
B/D
B/D
QL (270 tabs / 30 days)
QL (60 tabs / 30 days)
QL (60 tabs / 30 days)
QL (60 tabs / 30 days)
QL (60 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
B/D
B/D
QL (30 bottles / 30
days), PA
QL (180 tabs / 30 days)
QL (120 mL / 30 days)
QL (600 mL / 30 days)
QL (240 tabs / 30 days)
15
Drug Name
Drug Tier Requirements/Limits
morphine sulfate CP24 10mg, 20mg,
2
QL (60 caps / 30 days)
30mg, 50mg, 60mg
morphine sulfate CP24 80mg, 100mg
5
QL (60 caps / 30 days)
MORPHINE SULFATE SOLN 1mg/ml,
2
B/D
2mg/ml, 4mg/ml, 8mg/ml, 10mg/ml,
15mg/ml
MORPHINE SULFATE SOLN 10mg/5ml,
2
20mg/5ml
morphine sulfate SOLN .5mg/ml, 1mg/ml 2
B/D
MORPHINE SULFATE TABS
2
QL (180 tabs / 30 days)
morphine sulfate beads
2
QL (60 caps / 30 days)
morphine sulfate ext-rel tab 15mg, 30mg,2
QL (90 tabs / 30 days)
60mg, 100mg
morphine sulfate ext-rel tab 200mg
2
QL (60 tabs / 30 days)
NUCYNTA 50mg
4
QL (360 tabs / 30 days)
NUCYNTA 75mg
4
QL (240 tabs / 30 days)
NUCYNTA 100mg
4
QL (180 tabs / 30 days)
NUCYNTA ER 50mg, 100mg
4
QL (120 tabs / 30 days)
NUCYNTA ER 150mg, 200mg, 250mg
4
QL (60 tabs / 30 days)
OPANA ER (CRUSH RESISTANT 5mg,
4
QL (120 tabs / 30 days)
7.5mg, 10mg, 15mg, 20mg, 30mg
OPANA ER (CRUSH RESISTANT 40mg
5
QL (120 tabs / 30 days)
OXECTA
4
QL (270 tabs / 30 days)
OXYCODONE HCL CAPS
2
QL (180 caps / 30 days)
OXYCODONE HCL CONC
2
oxycodone hcl SOLN
2
oxycodone hcl TABS
2
QL (180 tabs / 30 days)
oxycodone w/ acetaminophen 2.5-325mg 2
QL (360 tabs / 30 days)
oxycodone w/ acetaminophen 5-325mg
2
QL (360 tabs / 30 days)
oxycodone w/ acetaminophen 7.5-325mg 2
QL (360 tabs / 30 days)
oxycodone w/ acetaminophen 10-325mg 2
QL (360 tabs / 30 days)
oxycodone-aspirin
2
QL (360 tabs / 30 days)
oxycodone-ibuprofen
2
QL (28 tabs / 30 days)
OXYCONTIN 10mg, 15mg, 20mg, 30mg, 4
QL (120 tabs / 30 days)
40mg
OXYCONTIN 60mg, 80mg
5
QL (120 tabs / 30 days)
oxymorphone hcl TABS
2
QL (180 tabs / 30 days)
roxicet soln
3
QL (1800 mL / 30 days)
roxicet tabs
2
QL (360 tabs / 30 days)
SUBSYS
5
QL (4 boxes / 30 days),
PA
XARTEMIS XR
4
QL (120 tabs / 30 days)
ZOHYDRO ER (ABUSE DETERRENT) 10mg,4
QL (120 caps / 30 days)
15mg, 20mg
ZOHYDRO ER (ABUSE DETERRENT) 30mg,4
QL (60 caps / 30 days)
40mg, 50mg
ANESTHETICS
16
Drug Name
Drug Tier Requirements/Limits
LOCAL ANESTHETICS
lidocaine
lidocaine
lidocaine
lidocaine
lidocaine
lidocaine
hcl (local anesth.)
hcl (local anesth.)
inj 0.5%
inj 1%
inj 1.5%
inj 2%
4%
.5%, 1%
2
2
2
2
2
2
B/D
B/D
B/D
B/D
B/D
ANTI-INFECTIVES
ANTI-BACTERIALS - MISCELLANEOUS
amikacin sulfate SOLN
BETHKIS
gentamicin in saline
gentamicin sulfate SOLN
neomycin sulfate TABS
paromomycin sulfate CAPS
streptomycin sulfate SOLR
sulfadiazine TABS
TOBI PODHALER
tobramycin NEBU
tobramycin sulfate SOLN; SOLR
tobramycin sulfate in saline
2
5
2
2
2
2
2
4
5
5
2
3
B/D, NM
NM, PA
B/D, NM
ANTI-INFECTIVES - MISCELLANEOUS
ALBENZA
ALINIA
atovaquone SUSP
AZACTAM
AZACTAM/DEX INJ 1GM
AZACTAM/DEX INJ 2GM
aztreonam
BILTRICIDE
CAYSTON
clindamycin hcl CAPS
clindamycin palmitate hydrochloride
clindamycin phosphate SOLN
clindamycin phosphate in d5w
colistimethate sodium SOLR
CUBICIN
DALVANCE
dapsone TABS
DARAPRIM
DORIBAX
imipenem-cilastatin
INVANZ
ivermectin TABS
linezolid SOLN
LINEZOLID TABS
4
4
5
4
4
5
2
3
5
1
2
2
2
2
5
5
2
4
4
2
4
2
5
5
NM, LA, PA
17
Drug Name
MACRODANTIN 25mg
meropenem
methenamine hippurate
METRO IV
metronidazole CAPS
metronidazole TABS
metronidazole inj
NEBUPENT
nitrofurantoin SUSP
nitrofurantoin macrocrystal
nitrofurantoin monohyd macro
PENTAM 300
polymyxin b sulfate SOLR
PRIMSOL SOL 50MG/5ML
SIVEXTRO
sulfamethoxazole-trimethop
sulfamethoxazole-trimethoprim inj
SYNERCID
trimethoprim TABS
TYGACIL
vancomycin hcl CAPS
vancomycin hcl SOLR
XIFAXAN TAB 200MG
ZYVOX SUSR; TABS
Drug Tier Requirements/Limits
4
PA; 90 day limit if >64 yr
2
2
3
2
1
2
4
B/D
2
PA; 90 day limit if >64 yr
4
PA; 90 day limit if >64 yr
4
PA; 90 day limit if >64 yr
4
2
4
5
1
2
5
1
5
5
2
5
5
ANTIFUNGALS
ABELCET
AMBISOME
AMPHOTEC
amphotericin b SOLR
CANCIDAS
CRESEMBA
ERAXIS
fluconazole SUSR; TABS
fluconazole in dextrose
fluconazole in nacl
flucytosine CAPS
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole CAPS
ketoconazole TABS
LAMISIL PACK
MYCAMINE
NOXAFIL
nystatin TABS
ONMEL
SPORANOX SOL 10MG/ML
5
5
4
2
5
5
5
2
2
2
5
2
2
2
2
4
5
5
2
4
5
B/D
B/D
B/D
B/D
PA
PA
PA
18
Drug Name
terbinafine hcl TABS
voriconazole SUSR; TABS
voriconazole inj 200mg
Drug Tier Requirements/Limits
1
QL (90 tabs / 365 days)
5
2
ANTIMALARIALS
ATOVAQUONE-PROGUANIL HCL TAB
2
62.5-25 MG
atovaquone-proguanil hcl tab 250-100 mg 2
chloroquine phosphate TABS
2
COARTEM
3
mefloquine hcl
2
PRIMAQUINE PHOSPHATE
3
quinine sulfate CAPS
2
ANTIRETROVIRAL AGENTS
abacavir sulfate
APTIVUS
CRIXIVAN
didanosine
EDURANT
EMTRIVA
EPIVIR SOL 10MG/ML
FUZEON
INTELENCE 25mg
INTELENCE 100mg, 200mg
INVIRASE CAPS
INVIRASE TABS
ISENTRESS CHEW 25mg
ISENTRESS CHEW 100mg
ISENTRESS PACK
ISENTRESS TABS
lamivudine
LEXIVA SUSP
LEXIVA TABS
NEVIRAPINE SUSP
nevirapine TABS; TB24
NORVIR
PREZISTA SUSP
PREZISTA TABS 75mg, 150mg
PREZISTA TABS 600mg, 800mg
RESCRIPTOR
RETROVIR IV INFUSION
REYATAZ
SELZENTRY
stavudine
SUSTIVA CAPS
SUSTIVA TABS
TIVICAY
2
5
4
2
5
3
3
5
4
5
4
5
3
5
3
5
2
4
5
2
2
3
5
3
5
4
3
5
5
2
3
5
5
NM
19
Drug Name
TYBOST
VIDEX PEDIATRIC
VIRACEPT
VIRAMUNE XR 100mg
VIREAD
VITEKTA
ZIAGEN SOLN
zidovudine
Drug Tier Requirements/Limits
4
4
5
4
5
5
4
2
ANTIRETROVIRAL COMBINATION AGENTS
abacavir sulfate-lamivudine-zidovudine
ATRIPLA
COMPLERA
EPZICOM
EVOTAZ
KALETRA SOL
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
lamivudine-zidovudine
PREZCOBIX
STRIBILD
TRIUMEQ
TRUVADA
5
5
5
5
5
5
3
5
5
5
5
5
5
QL (30 tabs / 30 days)
ANTITUBERCULAR AGENTS
CAPASTAT SULFATE
cycloserine CAPS
ethambutol hcl TABS
isoniazid SOLN; SYRP
isoniazid tabs
paser d/r
PRIFTIN
pyrazinamide
rifabutin
rifamate
rifampin CAPS; SOLR
RIFATER
SIRTURO
TRECATOR
5
2
2
2
1
3
4
2
2
4
2
4
5
4
LA, PA
ANTIVIRALS
acyclovir CAPS; TABS
acyclovir SUSP
acyclovir sodium
adefovir dipivoxil
BARACLUDE SOLN
cidofovir
entecavir
EPIVIR HBV SOLN
1
2
2
5
3
2
5
4
B/D
20
Drug Name
famciclovir TABS
ganciclovir inj 500mg
HARVONI
lamivudine (hbv)
moderiba pak
moderiba tab 200mg
OLYSIO
REBETOL SOLN
RELENZA DISKHALER
ribapak mis 600/day
ribasphere CAPS
ribasphere TABS 200mg, 400mg
ribasphere TABS 600mg
ribasphere ribapak 800
ribasphere ribapak 1000
ribasphere ribapak 1200
ribavirin 200mg
rimantadine hydrochloride
SOVALDI
TAMIFLU
TYZEKA
valacyclovir hcl TABS
VALCYTE SOLR
valganciclovir hcl
VICTRELIS
Drug Tier Requirements/Limits
2
2
B/D
5
NM, PA
2
5
NM, PA
2
NM, PA
5
NM, PA
5
NM, PA
3
5
NM, PA
2
NM, PA
2
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
2
NM, PA
2
5
NM, PA
3
5
2
5
5
5
NM, PA
CEPHALOSPORINS
AVYCAZ
CEDAX SUSR 90mg/5ml
cefaclor
cefaclor er tab 500mg
cefadroxil
cefazolin inj
cefazolin sodium 1gm, 20gm
cefazolin/dextrose
cefdinir
CEFEPIME 1GM SOLN
CEFEPIME 2GM SOLN
cefepime inj 1gm
cefepime inj 2gm
cefixime
cefotaxime sodium 1gm, 2gm, 500mg
cefotetan disodium
cefoxitin sodium
CEFOXITIN SODIUM IN DEXTROSE
cefpodoxime proxetil
cefprozil
5
4
2
3
2
2
2
3
2
4
4
2
2
2
2
4
2
4
2
2
21
Drug Name
Drug Tier Requirements/Limits
ceftazidime
2
CEFTAZIDIME/DEXTROSE
4
ceftibuten
2
CEFTIN SUSR
4
ceftriaxone sodium SOLR 1gm, 2gm,
2
10gm, 250mg, 500mg
cefuroxime axetil SUSR
2
cefuroxime axetil TABS
1
cefuroxime sodium 1.5gm, 7.5gm, 750mg2
cephalexin CAPS 250mg, 500mg
1
cephalexin CAPS 750mg
2
cephalexin SUSR
2
cephalexin TABS
2
claforan 1gm, 2gm
4
FORTAZ SOLN
4
FORTAZ SOLR 500mg
4
MAXIPIME
4
SUPRAX CAPS
3
suprax CHEW
4
suprax SUSR 100mg/5ml, 200mg/5ml
3
SUPRAX SUSR 500mg/5ml
3
tazicef SOLR
2
tazicef vial
2
TEFLARO
4
ZERBAXA
5
ZINACEF SOLR 750mg
4
ERYTHROMYCINS/MACROLIDES
AZITHROMYCIN PACK
azithromycin SOLR 500mg
azithromycin SUSR
azithromycin TABS 250mg
azithromycin TABS 500mg, 600mg
clarithromycin SUSR; TABS; TB24
DIFICID
e.e.s. 400 tab 400mg
E.E.S. GRANULES
ery-tab
ERYPED 200
ERYPED 400
erythrocin lactobionate 500mg
erythrocin stearate
erythromycin base
erythromycin cap 250mg ec
erythromycin ethylsuccinate
PCE
ZMAX
2
2
2
1
2
2
5
2
4
4
4
4
4
2
2
2
2
4
3
22
Drug Name
Drug Tier Requirements/Limits
FLUOROQUINOLONES
ciprofloxacin SOLN 200mg/20ml
ciprofloxacin SUSR
ciprofloxacin er
ciprofloxacin hcl TABS
ciprofloxacin in d5w
ciprofloxacn inj
levofloxacin SOLN; TABS
levofloxacin in d5w
MOXIFLOXACIN HCL SOLN
moxifloxacin hcl TABS
2
2
2
1
2
2
2
2
4
2
PENICILLINS
amoxicillin
amoxicillin & pot clavulanate
ampicillin & sulbactam sodium
ampicillin cap 250mg
ampicillin cap 500 mg
ampicillin inj
ampicillin sodium
ampicillin susp
AUGMENTIN SUSR
BACTOCILL INJ DEX 1GM
BACTOCILL INJ DEX 2GM
BICILLIN C-R
BICILLIN L-A
dicloxacillin sodium
nafcillin sodium 1gm
nafcillin sodium 2gm, 10gm
NALLPEN ISO-OSMOTIC IN DE
NALLPEN/DEXTROSE
oxacillin sodium 1gm, 2gm
oxacillin sodium 10gm
PENICILLIN G POT IN DEXTROSE
penicillin g potassium
PENICILLIN G POTASSIUM IN
penicillin g procaine
penicillin g sodium
penicillin v potassium
pfizerpen
piperacillin sodium-tazobactam sodium
ZOSYN SOLN
1
2
2
1
1
2
2
1
4
4
5
4
4
2
2
5
5
4
2
5
4
2
4
3
2
1
2
2
4
TETRACYCLINES
demeclocycline hcl
DORYX 200mg
doxy inj
doxycycline (monohydrate)
2
4
2
2
23
Drug Name
doxycycline hyclate CAPS; SOLR; TABS;
TBEC
minocycline hcl CAPS; TABS; TB24
SOLODYN
TETRACYCLINE HCL CAPS
VIBRAMYCIN SYRP
Drug Tier Requirements/Limits
2
2
5
2
4
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
BICNU
BUSULFEX
CYCLOPHOSPHAMIDE CAPS
cyclophosphamide SOLR
dacarbazine
EMCYT
GLEOSTINE
HEXALEN
IFEX 3gm
ifosfamide
ifosfamide for inj 1 gm
IFOSFAMIDE FOR INJ 3 GM
LEUKERAN
LOMUSTINE
melphalan hcl
MUSTARGEN
TREANDA
ZANOSAR
4
4
4
2
2
4
4
5
4
2
2
4
4
2
5
4
5
4
B/D
B/D
B/D
B/D
B/D
2
2
5
2
4
2
2
5
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
2
2
B/D
B/D
2
5
4
5
5
4
2
B/D
B/D
B/D
B/D, NM
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D, NM
B/D
ANTHRACYCLINES
daunorubicin hcl
doxorubicin hcl 50mg
doxorubicin hcl liposomal inj 2mg/ml
doxorubicin inj 50mg
EPIRUBICIN INJ 50MG
epirubicin inj 50mg/25ml
epirubicin inj 200mg
idarubicin hcl
ANTIBIOTICS
bleomycin sulfate
mitomycin SOLR
ANTIMETABOLITES
adrucil
ALIMTA
ARRANON
azacitidine
cladribine
CLOLAR
cytarabine inj
24
Drug Name
decitabine
fludarabine phosphate
fluorouracil SOLN
GEMCITABINE
gemcitabine hcl
mercaptopurine TABS
methotrexate sodium inj
NIPENT
PURIXAN
TABLOID
Drug Tier Requirements/Limits
2
B/D, NM
2
B/D
2
B/D
5
B/D
5
B/D
2
2
B/D
5
B/D
5
4
ANTIMITOTIC, TAXOIDS
ABRAXANE
DOCETAXEL INJ 20MG/2ML
DOCETAXEL INJ 20MG/ML
DOCETAXEL INJ 80MG/4ML
DOCETAXEL INJ 80MG/8ML
docetaxel inj 140mg/7ml
DOCETAXEL INJ 160MG/16ML
DOCETAXEL INJ 200MG/20ML
paclitaxel
5
2
5
5
5
5
5
5
2
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
3
2
2
2
B/D
B/D
B/D
B/D
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
B/D, NM
B/D, NM
B/D, NM
NM, LA, PA
NM, LA, PA
B/D, NM
NM, LA, PA
B/D, NM
B/D, NM
NM, PA
B/D, NM
NM, PA
B/D, NM
B/D, NM
B/D, NM
NM, PA
ANTIMITOTIC, VINCA ALKALOIDS
vinblastine sulfate
vincasar
vincristine sulfate
vinorelbine tartrate
BIOLOGIC RESPONSE MODIFIERS
ARZERRA
AVASTIN
ERBITUX
ERIVEDGE
FARYDAK
HERCEPTIN
IBRANCE
ISTODAX
KADCYLA
LYNPARZA
PROLEUKIN
RITUXAN 500mg/50ml
TORISEL
VECTIBIX
VELCADE
ZOLINZA
HORMONAL ANTINEOPLASTIC AGENTS
anastrozole TABS
bicalutamide
DEPO-PROVERA INJ 400/ML
2
2
4
B/D
25
Drug Name
ELIGARD 7.5mg
ELIGARD 45mg
ELIGARD INJ 22.5MG
ELIGARD INJ 30MG
exemestane
FARESTON
FASLODEX
FIRMAGON 80mg
FIRMAGON 120mg
flutamide
letrozole TABS
leuprolide acetate KIT
LUPR DEP-PED INJ 15MG
LUPR DEP-PED INJ 30MG (3-MONTH)
LUPRON DEP INJ 11.25MG
LUPRON DEPOT 3.75mg, 7.5mg
LUPRON DEPOT INJ 22.5MG (3-MONTH)
LUPRON DEPOT INJ 30MG (3-MONTH)
LUPRON DEPOT-PED
LYSODREN
MEGACE ES
megestrol acetate TABS
megestrol acetate sus 40mg/ml
MEGESTROL ACETATE SUS 625MG/5ML
NILANDRON
SOLTAMOX
tamoxifen citrate TABS
TRELSTAR MIXJECT
XTANDI
ZYTIGA
Drug Tier Requirements/Limits
4
B/D, NM
5
B/D, NM
4
B/D, NM
4
B/D, NM
2
5
5
B/D
4
B/D, NM
5
B/D, NM
2
2
2
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
3
5
PA
4
PA
4
PA
5
PA
5
4
1
5
NM, PA
5
NM, LA, PA
5
NM, PA
KINASE INHIBITORS
AFINITOR
AFINITOR DISPERZ
BOSULIF
CAPRELSA
COMETRIQ
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
GLEEVEC
ICLUSIG
IMBRUVICA CAP 140MG
INLYTA
IRESSA
JAKAFI
LENVIMA 10MG DAILY DOSE
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
LA,
PA
LA,
LA,
LA,
PA
LA,
LA,
LA,
LA,
LA,
LA,
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
26
Drug Name
LENVIMA 14MG DAILY DOSE
LENVIMA 20MG DAILY DOSE
LENVIMA 24MG DAILY DOSE
MEKINIST
NEXAVAR
SPRYCEL
STIVARGA
SUTENT
TAFINLAR
TARCEVA
TASIGNA
TYKERB
VOTRIENT
XALKORI
ZELBORAF
ZYDELIG
ZYKADIA
Drug Tier Requirements/Limits
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, PA
5
NM, LA, PA
5
NM, PA
5
NM, LA, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, LA, PA
5
NM, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
MISCELLANEOUS
bexarotene
DROXIA
HALAVEN
hydroxyurea CAPS
IXEMPRA KIT
MATULANE
mitoxantrone hcl
POMALYST
SYLATRON KIT 296MCG
SYLATRON KIT 444MCG
SYLATRON KIT 888MCG
TARGRETIN CAPS
tretinoin CAPS
TRISENOX
UVADEX
5
3
5
2
5
5
2
5
5
5
5
5
5
5
4
NM, PA
2
2
5
5
B/D
B/D
B/D
B/D
5
5
5
5
2
2
2
B/D
B/D
B/D
B/D
B/D
B/D
B/D, NM
B/D, NM
B/D, NM
NM, LA, PA
NM, PA
NM, PA
NM, PA
NM, PA
B/D
B/D
PLATINUM-BASED AGENTS
carboplatin
cisplatin
ELOXATIN
oxaliplatin
PROTECTIVE AGENTS
amifostine crystalline
dexrazoxane 250mg
ELITEK
KEPIVANCE
leucovor ca inj
leucovorin calcium SOLR
leucovorin calcium TABS
27
Drug Name
leucovorin calcium 500 mg
mesna
MESNEX TABS
Drug Tier Requirements/Limits
2
B/D
2
B/D
5
TOPOISOMERASE INHIBITORS
CAMPTOSAR 300mg/15ml
ETOPOPHOS
etoposide SOLN 500mg/25ml
irinotecan
irinotecan hcl
toposar 1gm/50ml
topotecan hcl SOLR
4
4
2
5
5
2
5
B/D
B/D
B/D
B/D
B/D
B/D
B/D
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
amlodipine besylate-benazepril hcl
benazepril & hydrochlorothiazide
captopril & hydrochlorothiazide
enalapril maleate & hydrochlorothiazide
fosinopril sodium & hydrochlorothiazide
lisinopril & hydrochlorothiazide
moexipril-hydrochlorothiazide
quinapril-hydrochlorothiazide
TARKA
trandolapril-verapamil hcl
1
1
1
1
1
1
1
1
4
1
ACE INHIBITORS
benazepril hcl TABS
captopril TABS
enalapril maleate TABS
fosinopril sodium
lisinopril TABS
moexipril hcl
perindopril erbumine
quinapril hcl
ramipril
trandolapril
1
1
1
1
1
1
1
1
1
1
ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone
spironolactone
TABS
2
1
ALPHA BLOCKERS
doxazosin mesylate
prazosin hcl
terazosin hcl
2
1
1
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS
amlodipine besylate-valsartan tab 5-160
mg
amlodipine besylate-valsartan tab 5-320
mg
1
1
28
Drug Name
amlodipine besylate-valsartan tab 10-160
mg
amlodipine besylate-valsartan tab 10-320
mg
amlodipine-valsartan-hydrochlorothiazide
5-160-12.5mg
amlodipine-valsartan-hydrochlorothiazide
5-160-25mg
amlodipine-valsartan-hydrochlorothiazide
10-160-12.5mg
amlodipine-valsartan-hydrochlorothiazide
10-160-25mg
amlodipine-valsartan-hydrochlorothiazide
10-320-25mg
AZOR
BENICAR HCT
candesartan cilexetil-hydrochlorothiazide
EDARBYCLOR
irbesartan-hydrochlorothiazide
losartan potassium & hydrochlorothiazide
telmisartan-amlodipine
telmisartan-hydrochlorothiazide
TEVETEN HCT
TRIBENZOR
valsartan & hctz tab 320-25mg
valsartan-hydrochlorothiazide
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
3
3
1
4
1
1
1
1
4
3
1
1
ANGIOTENSIN II RECEPTOR ANTAGONISTS
BENICAR
candesartan cilexetil
EDARBI
eprosartan mesylate
irbesartan
losartan potassium
TELMISARTAN
valsartan
3
1
4
1
1
1
1
1
ANTIARRHYTHMICS
amiodarone hcl SOLN
amiodarone hcl TABS 100mg, 400mg
amiodarone hcl TABS 200mg
amiodarone inj 50mg/ml
disopyramide phosphate
flecainide acetate
mexiletine hcl
MULTAQ
NORPACE CR
pacerone 100mg, 400mg
pacerone 200mg
2
2
1
2
4
2
2
4
4
2
1
PA
PA
29
Drug Name
propafenone hcl
quinidine gluconate er
quinidine sulfate TABS
sorine
sotalol hcl
sotalol hcl (afib/afl)
TIKOSYN
Drug Tier Requirements/Limits
2
2
1
2
2
2
4
NM
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS
ALTOPREV
atorvastatin calcium TABS
CRESTOR
fluvastatin sodium
LESCOL XL
LIVALO
lovastatin
pravastatin sodium
simvastatin TABS 5mg, 10mg, 20mg,
40mg
simvastatin TABS 80mg
4
1
3
1
4
4
1
1
1
1
QL (30 tabs / 30 days)
ANTILIPEMICS, MISCELLANEOUS
ADVICOR
ANTARA
cholestyramine
cholestyramine light
choline fenofibrate
colestipol hcl
FENOFIBRATE CAPS
fenofibrate TABS 48mg, 54mg, 145mg,
160mg
FENOFIBRATE TABS 120mg
fenofibrate micronized
FENOFIBRIC ACID
FENOGLIDE
gemfibrozil TABS
LIPTRUZET
niacin (antihyperlipidemic)
niacor
omega-3-acid ethyl esters
prevalite
SIMCOR
TRIGLIDE
VASCEPA
VYTORIN
WELCHOL
ZETIA TAB 10MG
4
4
2
2
2
2
2
2
2
2
2
4
2
4
2
2
2
2
4
4
4
4
3
3
BETA-BLOCKER/DIURETIC COMBINATIONS
30
Drug Name
atenolol & chlorthalidone
bisoprolol & hydrochlorothiazide
DUTOPROL
metoprolol & hctz tab 50-25mg
metoprolol & hctz tab 100-25mg
metoprolol & hctz tab 100-50mg
nadolol & bendroflumethiazide
propranolol & hydrochlorothiazide
Drug Tier Requirements/Limits
1
1
4
2
2
2
2
2
BETA-BLOCKERS
acebutolol hcl CAPS
atenolol TABS
betaxolol hcl
bisoprolol fumarate
BYSTOLIC
carvedilol
COREG CR
labetalol hcl SOLN; TABS
metoprolol succinate
metoprolol tartrate SOLN
metoprolol tartrate TABS
nadolol TABS
pindolol
propranolol hcl er
propranolol inj 1mg/ml
propranolol sol
propranolol tab
SOTYLIZE
timolol maleate TABS
1
1
2
2
4
1
4
2
2
2
1
2
2
2
2
2
1
5
2
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS
AMLODIPINE BESYLATE/ATORV
1
CALCIUM CHANNEL BLOCKERS
afeditab cr
amlodipine besylate TABS
CARDIZEM LA 120mg
cartia xt
dilt-cd cap
dilt-xr cap
diltiazem cap 120mg/24hr
diltiazem cap er/12hr
diltiazem hcl TABS
diltiazem hcl coated beads cp24
diltiazem hcl coated beads cp24
diltiazem hcl coated beads cp24
diltiazem hcl coated beads cp24
diltiazem hcl coated beads cp24
diltiazem hcl er
120mg
180mg
240mg
300mg
360mg
2
1
4
2
2
2
2
2
1
2
2
2
2
2
2
31
Drug Name
diltiazem hcl extended release beads
diltiazem inj 25mg/5ml
diltiazem inj 50/10ml
diltiazem inj 100mg
diltiazem inj 125/25ml
diltzac
felodipine
isradipine
matzim la
nicardipine hcl CAPS
nifedical
nifedipine TB24
nifedipine er
nimodipine CAPS
nisoldipine
NYMALIZE
taztia xt
verapamil hcl CP24 100mg, 120mg,
180mg, 200mg, 240mg, 300mg
VERAPAMIL HCL CP24 360mg
verapamil hcl SOLN
verapamil hcl TABS
verapamil hcl TBCR
Drug Tier Requirements/Limits
2
2
2
4
2
2
2
2
2
2
2
2
2
2
2
5
2
2
2
2
1
2
DIGITALIS GLYCOSIDES
digitek .25mg
digitek .125mg
digoxin 125mcg
digoxin 250mcg
digoxin inj
DIGOXIN SOL 50MCG/ML
LANOXIN TABS 62.5mcg
LANOXIN TABS 187.5mcg
LANOXIN PEDIATRIC
LANOXIN TAB 125mcg
LANOXIN TAB 250mcg
2
2
2
2
2
2
3
3
4
3
3
PA
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
PA
PA
QL (60 tabs / 30 days)
PA
QL (30 tabs / 30 days)
PA
DIRECT RENIN INHIBITORS/COMBINATIONS
TEKAMLO TAB 150-5MG
TEKAMLO TAB 150-10MG
TEKTURNA
TEKTURNA HCT
3
3
3
3
DIURETICS
acetazolamide CP12; TABS
acetazolamide sodium
ALDACTAZIDE TAB 50/50
amiloride & hydrochlorothiazide
amiloride hcl
2
2
4
1
2
32
Drug Name
bumetanide SOLN
bumetanide TABS
chlorothiazide
chlorthalidone 25mg, 50mg
DIURIL SUS 250/5ML
DYRENIUM
EDECRIN
furosemide SOLN; TABS
furosemide inj
furosemide oral soln 8 mg/ml
hydrochlorothiazide CAPS; TABS
indapamide
methazolamide TABS
methyclothiazide
metolazone
spironolactone & hydrochlorothiazide
torsemide inj 20mg/2ml
torsemide inj 50mg/5ml
torsemide tabs
triamt/hctz cap 37.5-25
triamt/hctz cap 50-25mg
triamt/hctz tab 37.5-25
triamt/hctz tab 75-50mg
Drug Tier Requirements/Limits
2
1
1
1
3
4
4
1
2
2
1
1
2
2
2
1
2
2
1
1
2
1
1
MISCELLANEOUS
BIDIL
clonidine hcl PTWK
clonidine hcl TABS
clorpres
CORLANOR
DEMSER
DIBENZYLINE
hydralazine hcl SOLN; TABS
midodrine hcl
minoxidil TABS
PHENOXYBENZAMINE HCL CAPS
RANEXA
3
2
1
2
4
5
4
2
2
2
2
3
NITRATES
DILATRATE SR
ISORDIL TITRADOSE 40mg
isosorbide dinitrate
isosorbide mononitrate
minitran
nitro-bid
NITRO-DUR .3mg/hr, .8mg/hr
NITROGLYCERIN .4mg/spray
NITROGLYCERIN LINGUAL
4
4
2
1
2
3
4
2
2
33
Drug Name
nitroglycerin patches
NITROLINGUAL SPR PUMPSPRA
NITROMIST
NITROSTAT
Drug Tier Requirements/Limits
2
3
4
3
PULMONARY ARTERIAL HYPERTENSION
ADCIRCA
5
ADEMPAS
5
LETAIRIS
5
OPSUMIT
5
ORENITRAM TAB 0.25MG
5
ORENITRAM TAB 0.125MG
4
ORENITRAM TAB 1MG
5
ORENITRAM TAB 2.5MG
5
REMODULIN
5
REVATIO SUSR
5
sildenafil citrate (pulmonary hypertension) 5
TABS
TRACLEER
5
TYVASO
5
VENTAVIS
5
NM, PA
NM, PA
NM, LA, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
B/D, NM, LA
NM, PA
NM, PA
NM, LA, PA
B/D, NM
B/D, NM
CENTRAL NERVOUS SYSTEM
ANTIANXIETY
alprazolam CONC
alprazolam TABS 1mg
alprazolam TABS 2mg
alprazolam TABS .5mg
alprazolam TABS .25mg
buspirone hcl TABS
fluvoxamine maleate 25mg, 50mg
fluvoxamine maleate 100mg
fluvoxamine maleate er 100mg
fluvoxamine maleate er 150mg
lorazepam CONC
lorazepam SOLN
lorazepam TABS
2
1
1
1
1
2
2
2
2
2
2
2
1
QL
QL
QL
QL
QL
(300
(120
(150
(240
(480
mL / 30 days)
tabs / 30 days)
tabs / 30 days)
tabs / 30 days)
tabs / 30 days)
QL (45 tabs / 30 days)
QL (90 caps / 30 days)
QL (60 caps / 30 days)
QL (150 mL / 30 days)
QL (150 tabs / 30 days)
ANTICONVULSANTS
APTIOM
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
carbamazepine CHEW; TABS
carbamazepine CP12; SUSP; TB12
CELONTIN
clonazepam TABS 1mg
clonazepam TABS 2mg
clonazepam TABS .5mg
4
5
4
5
1
2
4
1
1
1
PA
PA
PA
QL (600 tabs / 30 days)
QL (300 tabs / 30 days)
QL (1200 tabs / 30 days)
34
Drug Name
clonazepam TBDP 1mg
clonazepam TBDP 2mg
clonazepam TBDP .5mg
clonazepam TBDP .25mg
clonazepam TBDP .125mg
clorazepate dipotassium 3.75mg, 7.5mg
Drug Tier Requirements/Limits
2
QL (600 tabs / 30 days)
2
QL (300 tabs / 30 days)
2
QL (1200 tabs / 30 days)
2
QL (2400 tabs / 30 days)
2
QL (4800 tabs / 30 days)
2
QL (120 tabs / 30 days),
PA
clorazepate dipotassium 15mg
2
QL (180 tabs / 30 days),
PA
diazepam CONC
2
QL (240 mL / 30 days),
PA
diazepam SOLN 1mg/ml
2
QL (1200 mL / 30 days),
PA
diazepam SOLN 5mg/ml
2
diazepam TABS
1
QL (120 tabs / 30 days),
PA
DIAZEPAM GEL (ANTICONVULSANT)
2
dilantin
3
DILANTIN-125
3
divalproex sodium
2
epitol
1
ethosuximide CAPS; SOLN
2
felbamate SUSP
5
felbamate TABS 400mg
2
felbamate TABS 600mg
5
FYCOMPA
4
PA
gabapentin CAPS 100mg
1
QL (1080 caps / 30 days)
gabapentin CAPS 300mg
1
QL (360 caps / 30 days)
gabapentin CAPS 400mg
1
QL (270 caps / 30 days)
gabapentin SOLN
2
QL (2160 mL / 30 days)
gabapentin TABS 600mg
2
QL (180 tabs / 30 days)
gabapentin TABS 800mg
2
QL (120 tabs / 30 days)
GABITRIL 12mg, 16mg
4
LAMICTAL ODT
4
LAMICTAL STARTER
4
LAMICTAL XR KIT
4
lamotrigine CHEW; TB24; TBDP
2
lamotrigine TABS
1
levetiracetam SOLN; TABS; TB24
2
LEVETIRACETAM IN NACL
4
levetiracetam inj 500/5ml
2
LYRICA CAPS 25mg, 50mg, 75mg, 100mg,3
QL (120 caps / 30 days)
150mg
LYRICA CAPS 200mg
3
QL (90 caps / 30 days)
LYRICA CAPS 225mg, 300mg
3
QL (60 caps / 30 days)
LYRICA SOLN
3
QL (946 mL / 30 days)
ONFI SUS 2.5MG/ML
4
PA
35
Drug Name
ONFI TAB 10MG
oxcarbazepine
OXTELLAR XR
PEGANONE
phenobarbital ELIX; TABS
PHENOBARBITAL SODIUM 65mg/ml
phenobarbital sodium 130mg/ml
phenytek
phenytoin CHEW; SUSP
phenytoin inj 50mg/ml
phenytoin sodium extended
POTIGA 50mg
POTIGA 200mg
POTIGA 300mg, 400mg
primidone TABS
QUDEXY XR
SABRIL PACK
SABRIL TABS
TEGRETOL
TEGRETOL-XR
tiagabine hcl
topiramate CPSP; TABS
TOPIRAMATE CS24
TROKENDI XR
valproate sodium SOLN; SYRP
valproic acid CAPS
VIMPAT
zonisamide CAPS
Drug Tier Requirements/Limits
4
PA
2
4
4
4
PA
4
PA
4
PA
3
2
2
2
4
4
QL (180 tabs / 30 days)
4
QL (90 tabs / 30 days)
2
4
5
QL (180 packets / 30
days), NM, LA, PA
5
QL (180 tabs / 30 days),
NM, LA, PA
4
4
2
2
2
4
2
2
4
2
ANTIDEMENTIA
donepezil odt 5mg
donepezil odt 10mg
donepezil tab hcl 23mg
donepezil tabs 5mg
donepezil tabs 10mg
EXELON PATCHES
galantamine hydrobromide
memantine hcl 5mg
MEMANTINE HCL 10mg
NAMENDA SOL 10MG/5ML
NAMENDA TAB
NAMENDA XR
NAMENDA XR TITRATION PACK
NAMZARIC
rivastigmine tartrate
2
2
2
2
2
2
2
2
2
3
4
4
4
4
2
PA;
PA;
PA;
PA;
PA;
PA;
PA
PA
PA
PA
PA
PA
if
if
if
if
if
if
<30
<30
<30
<30
<30
<30
yr
yr
yr
yr
yr
yr
ANTIDEPRESSANTS
36
Drug Name
Drug Tier Requirements/Limits
amitriptyline hcl TABS
4
PA
amoxapine
2
APLENZIN 174mg, 348mg
4
APLENZIN 522mg
5
BRINTELLIX
4
bupropion hcl TABS; TB12; TB24
2
citalopram hydrobromide SOLN
2
citalopram hydrobromide TABS
1
clomipramine hcl CAPS
4
PA
desipramine hcl TABS
2
doxepin hcl CAPS; CONC
4
PA
duloxetine hcl CPEP 20mg, 30mg, 60mg 2
EMSAM
5
PA
escitalopram oxalate
2
FETZIMA
4
FETZIMA TITRATION PACK
4
fluoxetine cap 10mg
1
fluoxetine cap 20mg
1
fluoxetine cap 40mg
1
fluoxetine cap 90mg dr
2
fluoxetine sol 20mg/5ml
2
fluoxetine tab 10mg
1
fluoxetine tab 20mg
1
FLUOXETINE TAB 60MG
4
FORFIVO XL
4
QL (30 tabs / 30 days)
imipramine hcl TABS
4
PA
imipramine pamoate
4
PA
maprotiline hcl
2
MARPLAN
4
mirtazapine TABS 7.5mg
2
mirtazapine TABS 15mg, 30mg, 45mg
1
mirtazapine TBDP
2
nefazodone hcl
2
nortriptyline hcl CAPS
1
nortriptyline hcl SOLN
2
paroxetine er tab
2
paroxetine hcl
1
PAXIL SUSP
4
PEXEVA
4
phenelzine sulfate TABS
2
PRISTIQ
3
protriptyline hcl
2
sertraline hcl CONC
2
sertraline hcl TABS
1
SURMONTIL
4
PA
tranylcypromine sulfate
2
trazodone hcl TABS 50mg, 100mg, 150mg1
37
Drug Name
trazodone hcl TABS 300mg
venlafaxine cap er
venlafaxine hcl
venlafaxine tab
VENLAFAXINE TAB 225MG ER
venlafaxine tab er
VIIBRYD
VIIBRYD STARTER PACK
Drug Tier Requirements/Limits
2
2
2
2
2
2
4
4
ANTIPARKINSONIAN AGENTS
amantadine hcl CAPS; SYRP; TABS
APOKYN
AZILECT
benztropine mesylate SOLN
benztropine mesylate TABS
bromocriptine mesylate CAPS; TABS
carbidopa TABS
carbidopa-levodopa
CARBIDOPA/LEVODOPA/ENTACAPONE
DUOPA
entacapone
MIRAPEX .75mg
MIRAPEX ER
NEUPRO
pramipexole dihydrochloride
pramipexole dihydrochloride er tabs
ropinirole hydrochloride
RYTARY
selegiline hcl CAPS; TABS
ZELAPAR
2
5
3
2
4
2
2
2
2
4
2
4
4
4
2
2
2
4
2
4
NM, LA, PA
PA
B/D, NM
ANTIPSYCHOTICS
ABILIFY DISCMELT
ABILIFY INJ 9.75MG
ABILIFY MAIN INJ 300MG
ABILIFY MAIN INJ 400MG
ABILIFY MAINTENA
ABILIFY SOLN
ABILIFY TABS
aripiprazole SOLN
aripiprazole TABS
chlorpromaz inj 25mg/ml
chlorpromazine hcl TABS
clozapine 25mg, 50mg
clozapine 100mg
clozapine 200mg
CLOZAPINE ODT 12.5mg, 25mg
5
4
5
5
5
5
5
5
5
4
2
2
2
2
2
QL
QL
QL
QL
QL
(60 tabs / 30 days)
(4 mL / 1 day)
(1 vial / 28 days)
(1 vial / 28 days)
(1 syringe / 28 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (270 tabs / 30 days)
QL (135 tabs / 30 days)
PA
38
Drug Name
CLOZAPINE ODT
100mg
CLOZAPINE ODT 150MG
CLOZAPINE ODT 200MG
FANAPT
FANAPT TITRATION PACK
FAZACLO 12.5mg, 25mg
FAZACLO 100mg
FAZACLO 150mg
FAZACLO 200mg
fluphenazine decanoate SOLN
fluphenazine hcl
GEODON INJ
haloperidol TABS
haloperidol decanoate SOLN
haloperidol lactate
INVEGA 1.5mg, 3mg, 9mg
INVEGA 6mg
INVEGA SUST INJ 39 MG/0.25 ML
INVEGA SUST INJ 78 MG/0.5 ML
INVEGA SUST INJ 117 MG/0.75 ML
INVEGA SUST INJ 156MG/ML
INVEGA SUST INJ 234 MG/1.5 ML
INVEGA TRINZA
LATUDA 20mg
LATUDA 40mg, 120mg
LATUDA 60mg, 80mg
loxapine succinate
olanzapine SOLR
olanzapine TABS 2.5mg, 5mg, 7.5mg
olanzapine TABS 10mg, 15mg, 20mg
olanzapine odt 5mg
olanzapine odt 10mg, 15mg
olanzapine odt 20mg
ORAP
perphenazine TABS
quetiapine fumarate
REXULTI 1mg
REXULTI
2mg
Drug Tier Requirements/Limits
2
QL (270 tabs / 30 days),
PA
2
QL (180 tabs / 30 days),
PA
2
QL (135 tabs / 30 days),
PA
4
QL (60 tabs / 30 days),
ST
4
ST
4
PA
4
QL (270 tabs / 30 days),
PA
4
QL (180 tabs / 30 days),
PA
4
QL (135 tabs / 30 days),
PA
2
2
4
QL (6 mL / 3 days)
2
2
2
5
QL (30 tabs / 30 days)
5
QL (60 tabs / 30 days)
4
QL (1 injection / 28 days)
5
QL (1 injection / 28 days)
5
QL (1 injection / 28 days)
5
QL (1 injection / 28 days)
5
QL (1 injection / 28 days)
5
QL (1 syringe / 90 days)
5
QL (240 tabs / 30 days)
5
QL (30 tabs / 30 days)
5
QL (60 tabs / 30 days)
2
2
QL (3 vials / 1 day)
2
QL (30 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (30 tabs / 30 days)
2
QL (60 tabs / 30 days)
5
QL (60 tabs / 30 days)
4
2
2
QL (90 tabs / 30 days)
5
QL (90 tabs / 30 days),
ST
5
QL (60 tabs / 30 days),
ST
39
Drug Name
REXULTI 3mg, 4mg
REXULTI
.5mg
REXULTI
.25mg
RISPERDAL INJ 12.5MG
RISPERDAL INJ 25MG
RISPERDAL INJ 37.5MG
RISPERDAL INJ 50MG
risperidone SOLN
risperidone TABS 1mg, 2mg, 3mg
risperidone TABS 4mg
risperidone TABS .25mg, .5mg
risperidone odt 1mg, 2mg, 3mg
risperidone odt 4mg
risperidone odt .25mg, .5mg
SAPHRIS 2.5mg
SAPHRIS 5mg
SAPHRIS 10mg
SEROQUEL XR 50mg
SEROQUEL XR 150mg, 200mg
SEROQUEL XR 300mg, 400mg
thioridazine hcl TABS
thiothixene
trifluoperazine hcl
VERSACLOZ
ziprasidone hcl 20mg, 40mg
ziprasidone hcl 60mg, 80mg
ZYPREXA RELPREVV
Drug Tier Requirements/Limits
5
QL (30 tabs / 30 days),
ST
5
QL (180 tabs / 30 days),
ST
5
QL (360 tabs / 30 days),
ST
4
QL (2 injections / 28
days)
4
QL (2 injections / 28
days)
5
QL (2 injections / 28
days)
5
QL (2 injections / 28
days)
2
QL (240 mL / 30 days)
2
QL (60 tabs / 30 days)
2
QL (120 tabs / 30 days)
2
QL (90 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (120 tabs / 30 days)
2
QL (90 tabs / 30 days)
4
QL (240 tabs / 30 days)
4
QL (120 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
QL (120 tabs / 30 days)
4
QL (30 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
PA
2
2
5
QL (600 mL / 30 days),
PA
2
QL (60 caps / 30 days)
2
QL (90 caps / 30 days)
5
B/D
ATTENTION DEFICIT HYPERACTIVITY DISORDER
amphetamine cap 10mg er
amphetamine cap 15mg er
amphetamine cap 20mg er
amphetamine cap 25mg er
amphetamine cap 30mg er
amphetamine-dextroamphetamine cap sr
24hr 5 mg
amphetamine-dextroamphetamine tab 5
mg
amphetamine-dextroamphetamine tab 7.5
mg
2
2
2
2
2
2
QL
QL
QL
QL
QL
QL
(90
(30
(30
(30
(30
(90
caps
caps
caps
caps
caps
caps
/
/
/
/
/
/
30
30
30
30
30
30
days)
days)
days)
days)
days)
days)
2
QL (360 tabs / 30 days)
2
QL (240 tabs / 30 days)
40
Drug Name
Drug Tier Requirements/Limits
amphetamine-dextroamphetamine tab 10 2
QL (180 tabs / 30 days)
mg
amphetamine-dextroamphetamine tab 12.52
QL (144 tabs / 30 days)
mg
amphetamine-dextroamphetamine tab 15 2
QL (120 tabs / 30 days)
mg
amphetamine-dextroamphetamine tab 20 2
QL (90 tabs / 30 days)
mg
amphetamine-dextroamphetamine tab 30 2
QL (60 tabs / 30 days)
mg
APTENSIO XR 10mg, 15mg, 20mg, 30mg 4
QL (60 caps / 30 days)
APTENSIO XR 40mg, 50mg, 60mg
4
QL (30 caps / 30 days)
DAYTRANA
4
QL (30 patches / 30
days)
guanfacine hcl (adhd)
4
metadate er 20mg
2
QL (90 tabs / 30 days)
METHYLIN CHEW TAB
4
QL (180 tabs / 30 days)
methylphenidate hcl CHEW
2
QL (180 tabs / 30 days)
methylphenidate hcl CP24 20mg, 30mg 2
QL (60 caps / 30 days)
methylphenidate hcl CP24 40mg
2
QL (30 caps / 30 days)
methylphenidate hcl CPCR 10mg, 20mg, 2
QL (60 caps / 30 days)
30mg
methylphenidate hcl CPCR 40mg, 50mg, 2
QL (30 caps / 30 days)
60mg
methylphenidate hcl SOLN 5mg/5ml
2
QL (1800 mL / 30 days)
methylphenidate hcl SOLN 10mg/5ml
2
QL (900 mL / 30 days)
methylphenidate hcl TABS 5mg, 10mg
2
QL (180 tabs / 30 days)
methylphenidate hcl TABS 20mg
2
QL (90 tabs / 30 days)
methylphenidate hcl er TB24 27mg, 36mg2
QL (60 tabs / 30 days)
methylphenidate hcl er TB24 54mg
2
QL (30 tabs / 30 days)
methylphenidate hcl er tabs 10mg
2
QL (90 tabs / 30 days)
methylphenidate hcl er tabs 18mg
2
QL (60 tabs / 30 days)
methylphenidate hcl er tabs 20mg
2
QL (90 tabs / 30 days)
QUILLIVANT XR
4
QL (360 mL / 30 days)
RITALIN LA 10mg
4
QL (60 caps / 30 days)
RITALIN LA 60mg
4
QL (30 caps / 30 days)
STRATTERA 10mg, 18mg, 25mg
4
QL (120 caps / 30 days)
STRATTERA 40mg
4
QL (60 caps / 30 days)
STRATTERA 60mg, 80mg, 100mg
4
QL (30 caps / 30 days)
VYVANSE 10mg, 20mg, 30mg
4
QL (60 caps / 30 days)
VYVANSE 40mg, 50mg, 60mg, 70mg
4
QL (30 caps / 30 days)
HYPNOTICS
ROZEREM
SILENOR 3mg
SILENOR 6mg
temazepam 7.5mg
4
3
3
2
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 caps / 30 days),
PA; 90 day limit if >64 yr
41
Drug Name
temazepam 15mg
zolpidem tartrate
TABS
Drug Tier Requirements/Limits
2
QL (60 caps / 30 days),
PA; 90 day limit if >64 yr
4
QL (30 tabs / 30 days),
PA; 90 day limit if >64 yr
MIGRAINE
almotriptan malate
2
ALSUMA
4
AXERT
4
cafergot tab 1-100mg
4
dihydroergotamine mesylate 1mg/ml
2
DIHYDROERGOTAMINE MESYLATE
2
4mg/ml
ergomar
4
FROVA TAB 2.5MG
4
migergot
2
naratriptan hcl
2
RELPAX
3
rizatriptan benzoate
2
SUMATRIPTAN SUCCINATE SOAJ
2
4mg/0.5ml
sumatriptan succinate SOAJ 6mg/0.5ml 2
SUMATRIPTAN SUCCINATE SOCT
2
SUMATRIPTAN SUCCINATE SOLN 5mg/act 2
SUMATRIPTAN SUCCINATE SOLN
20mg/act
sumatriptan succinate SOSY
sumatriptan succinate TABS
sumatriptan succinate inj
SUMAVEL DOSEPRO 4mg/0.5ml
SUMAVEL DOSEPRO 6mg/0.5ml
TREXIMET
zolmitriptan TABS
zolmitriptan odt
ZOMIG NASAL SPRAY
2
2
2
2
5
5
4
2
2
4
QL (12 tabs / 30 days)
QL (6 mL / 30 days)
QL (12 tabs / 30 days)
QL (8 mL / 30 days)
QL (18 tabs / 30 days)
QL
QL
QL
QL
(9 tabs / 30 days)
(12 tabs / 30 days)
(18 tabs / 30 days)
(6 mL / 30 days)
QL (6 mL / 30 days)
QL (6 mL / 30 days)
QL (24 inhalers / 30
days)
QL (12 inhalers / 30
days)
QL (6 mL / 30 days)
QL (9 tabs / 30 days)
QL (6 mL / 30 days)
QL (6mL / 30 days)
QL (6 mL / 30 days)
QL (9 tabs / 30 days)
QL (12 tabs / 30 days)
QL (12 tabs / 30 days)
QL (2 boxes / 30 days)
MISCELLANEOUS
BRISDELLE
EQUETRO
GRALISE 300mg
GRALISE 600mg
GRALISE STARTER
HORIZANT
LITHIUM
lithium carbonate CAPS; TABS
lithium carbonate TBCR
MESTINON SYRUP
MESTINON TIMESPAN
4
4
3
3
3
4
3
1
2
4
4
QL (180 tabs / 30 days)
QL (90 tabs / 30 days)
42
Drug Name
NUEDEXTA
pyridostigmine bromide TABS; TBCR
riluzole
SAVELLA 12.5mg
SAVELLA 25mg
SAVELLA 50mg
SAVELLA 100mg
SAVELLA TITRATION PACK
TETRABENAZINE 12.5mg
TETRABENAZINE
25mg
XENAZINE 12.5mg
XENAZINE 25mg
Drug Tier Requirements/Limits
3
PA
2
2
4
QL (480 tabs / 30 days)
4
QL (240 tabs / 30 days)
4
QL (120 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
5
QL (240 tabs / 30 days),
NM, PA
5
QL (120 tabs / 30 days),
NM, PA
5
QL (240 tabs / 30 days),
NM, LA, PA
5
QL (120 tabs / 30 days),
NM, LA, PA
MULTIPLE SCLEROSIS AGENTS
AMPYRA
AUBAGIO
5
5
AVONEX KIT
5
AVONEX PSKT
5
AVONEX PEN
5
BETASERON
5
COPAXONE INJ 40MG/ML
5
COPAXONE KIT 20MG/ML
5
EXTAVIA
5
GILENYA CAP 0.5MG
5
LEMTRADA
PLEGRIDY SOPN
5
5
PLEGRIDY
5
SOSY
PLEGRIDY STARTER PACK
5
REBIF
5
REBIF REBIDOSE
5
REBIF REBIDOSE TITRATION
5
NM, LA, PA
QL (30 tabs / 30 days),
NM, PA
QL (4 boxes / 28 day),
NM, PA
QL (4 boxes / 28 days),
NM, PA
QL (4 boxes / 28 days),
NM, PA
QL (14 syringes / 28
days), NM, PA
QL (12 syringes / 28
days), NM, PA
QL (30 syringes / 30
days), NM, PA
QL (15 syringes / 30
days), NM, PA
QL (28 caps / 28 days),
NM, PA
NM, LA, PA
QL (2 pens / 28 days),
NM, PA
QL (2 syringes / 28
days), NM, PA
QL (1 box / 28 days),
NM, PA
QL (6 mL / 28 days), NM,
PA
QL (6 mL / 28 days), NM,
PA
QL (6 mL / 30 days), NM,
PA
43
Drug Name
REBIF TITRATION PACK
TECFIDERA CAP 120MG
TECFIDERA CAP 240MG
TECFIDERA MIS STARTER
TYSABRI
Drug Tier Requirements/Limits
5
QL (6 mL / 30 days), NM,
PA
5
QL (14 caps / 7 days),
NM, PA
5
QL (60 caps / 30 days),
NM, PA
5
NM, PA
5
NM, LA, PA
MUSCULOSKELETAL THERAPY AGENTS
baclofen TABS
cyclobenzaprine hcl TABS 5mg, 10mg
dantrolene sodium CAPS
tizanidine
1
4
2
2
PA
NARCOLEPSY/CATAPLEXY
modafinil 100mg
2
modafinil 200mg
5
NUVIGIL 50mg
4
NUVIGIL 150mg
4
NUVIGIL 200mg, 250mg
4
XYREM
5
QL (30 tabs / 30 days),
PA
QL (60 tabs / 30 days),
PA
QL (150 tabs / 30 days),
PA
QL (60 tabs / 30 days),
PA
QL (30 tabs / 30 days),
PA
QL (540 mL / 30 days),
LA, PA
PSYCHOTHERAPEUTIC-MISC
acamprosate calcium
BUNAVAIL MIS 2.1-0.3
2
4
BUNAVAIL MIS 4.2-0.7
4
BUNAVAIL MIS 6.3-1MG
4
buprenorphine hcl SUBL
buprenorphine hcl-naloxone hcl sl
2
2
buproban
CHANTIX
CHANTIX CONTINUING MONTH
CHANTIX STARTER PACK
disulfiram TABS
naloxone hcl SOLN
naltrexone hcl TABS
NICOTROL INHALER
NICOTROL NS
SARAFEM
2
4
4
4
2
2
2
4
4
4
QL
PA
QL
PA
QL
PA
PA
QL
PA
(4 boxes / 30 days),
(4 boxes / 30 days),
(2 boxes / 30 days),
(120 tabs / 30 days),
PA
PA
PA
44
Drug Name
SUBOXONE MIS 2-0.5MG
SUBOXONE MIS 4-1MG
SUBOXONE MIS 8-2MG
SUBOXONE MIS 12-3MG
VIVITROL
ZUBSOLV SUB 1.4-0.36
ZUBSOLV SUB 5.7-1.4
ZUBSOLV SUB 8.6-2.1
ZUBSOLV SUB 11.4-2.9
Drug Tier Requirements/Limits
4
QL (4 boxes / 30 days),
PA
4
QL (4 boxes / 30 days),
PA
4
QL (4 boxes / 30 days),
PA
4
QL (2 boxes / 30 days),
PA
5
NM
4
QL (120 tabs / 30 days),
PA
4
QL (120 tabs / 30 days),
PA
4
QL (60 tabs / 30 days),
PA
4
QL (60 tabs / 30 days),
PA
ENDOCRINE AND METABOLIC
ANDROGENS
ANDRODERM
4
ANDROGEL 1%
4
ANDROGEL 1.62%
4
ANDROGEL GEL PUMP 1%
4
AXIRON
4
depo-testosterone
FORTESTA
100mg/ml
4
4
oxandrolone TABS
STRIANT
TESTIM
2
4
3
testosterone cypionate SOLN
testosterone enanthate SOLN
VOGELXO
2
2
4
VOGELXO PUMP
4
QL (30 patches / 30
days), PA
QL (300 grams / 30
days), PA
QL (150 grams / 30
days), PA
QL (300 grams / 30
days), PA
QL (440 mL / 30 days),
PA
QL (120 grams / 30
days), PA
PA
QL (1 kit / 30 days), PA
QL (300 grams / 30
days), PA
QL (300 grams / 30
days), PA
QL (300 grams / 30
days), PA
ANTIDIABETICS, INJECTABLE
ALCOHOL SWABS
APIDRA
APIDRA SOLOSTAR
BYDUREON PEN
BYDUREON SUSR
3
4
4
4
4
QL (4 pens / 28 days), PA
QL (4 vials / 28 days), PA
45
Drug Name
BYETTA
GAUZE PADS 2X2
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50 KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25 KWIKPEN
HUMULIN 70/30
HUMULIN 70/30 KWIKPEN
HUMULIN N
HUMULIN N KWIKPEN
HUMULIN R
HUMULIN R U-500 (CONCENTRATE)
INSULIN PEN NEEDLES
INSULIN SAFETY NEEDLES
INSULIN SYRINGE
INSULIN SYRINGES
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXTOUCH
NOVOLIN 70/30
NOVOLIN 70/30 RELION
NOVOLIN N
NOVOLIN N RELION
NOVOLIN R
NOVOLIN R RELION
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILL
NOVOLOG PENFILL
SYMLINPEN 60
SYMLINPEN 120
TANZEUM
TOUJEO SOLOSTAR
TRULICITY
VICTOZA
Drug Tier Requirements/Limits
4
3
4
4
4
4
4
4
4
4
4
4
4
5
B/D
3
3
3
3
3
3
3
3
3
4
3
4
3
4
3
3
3
3
3
4
PA
4
PA
3
QL (4 pens / 28 days)
3
4
QL (4 pens / 28 days)
3
QL (3 pens / 30 days)
ANTIDIABETICS, ORAL
acarbose
ACTOPLUS MET XR 15-1000MG
ACTOPLUS MET XR 30-1000MG
FARXIGA 5mg
FARXIGA 10mg
glimepiride 1mg
2
4
4
3
3
1
QL
QL
QL
QL
QL
(60 tabs / 30 days)
(30 tabs / 30 days)
(60 tabs / 30 days)
(30 tabs / 30 days)
(240 tabs / 30 days)
46
Drug Name
glimepiride 2mg
glimepiride 4mg
glipizide TABS 5mg
glipizide TABS 10mg
glipizide er 2.5mg
glipizide er 5mg
glipizide er 10mg
glipizide-metformin 2.5-250 mg
glipizide-metformin 2.5-500 mg
glipizide-metformin 5-500mg
GLUMETZA 500mg
GLUMETZA 1000mg
GLYSET
GLYXAMBI
INVOKAMET TAB 50-500MG
INVOKAMET TAB 50-1000
INVOKAMET TAB 150-500
INVOKAMET TAB 150-1000
INVOKANA TAB 100MG
INVOKANA TAB 300MG
JANUMET
JANUMET XR TAB 50-500MG
JANUMET XR TAB 50-1000
JANUMET XR TAB 100-1000
JANUVIA
JARDIANCE 10mg
JARDIANCE 25mg
JENTADUETO
KAZANO
KOMBIGLYZE XR 2.5-1000MG
KOMBIGLYZE XR 5-500MG
KOMBIGLYZE XR 5-1000MG
metformin er 500mg
metformin er 750mg
metformin hcl TABS 500mg
metformin hcl TABS 850mg
metformin hcl TABS 1000mg
metformin hcl TB24 500mg
metformin hcl TB24 1000mg
nateglinide
NESINA 6.25mg
NESINA 12.5mg
NESINA 25mg
ONGLYZA
OSENI TAB 12.5-15MG
OSENI TAB 12.5-30MG
OSENI TAB 12.5-45MG
Drug Tier Requirements/Limits
1
QL (120 tabs / 30 days)
1
QL (60 tabs / 30 days)
1
QL (240 tabs / 30 days)
1
QL (120 tabs / 30 days)
1
QL (240 tabs / 30 days)
1
QL (120 tabs / 30 days)
1
QL (60 tabs / 30 days)
1
QL (240 tabs / 30 days)
1
QL (120 tabs / 30 days)
1
QL (120 tabs / 30 days)
4
QL (120 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
4
QL (30 tabs / 30 days)
3
QL (120 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (90 tabs / 30 days)
3
QL (30 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (30 tabs / 30 days)
3
QL (30 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
QL (30 tabs / 30 days)
3
QL (60 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
QL (30 tabs / 30 days)
4
QL (30 tabs / 30 days)
1
QL (120 tabs / 30 days)
1
QL (60 tabs / 30 days)
1
QL (150 tabs / 30 days)
1
QL (90 tabs / 30 days)
1
QL (75 tabs / 30 days)
1
QL (150 tabs / 30 days)
1
QL (75 tabs / 30 days)
1
QL (90 tabs / 30 days)
4
QL (120 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
QL (30 tabs / 30 days)
4
QL (30 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
QL (30 tabs / 30 days)
4
QL (30 tabs / 30 days)
47
Drug Name
OSENI TAB 25-15MG
OSENI TAB 25-30MG
OSENI TAB 25-45MG
pioglitazone hcl
pioglitazone hcl-glimepiride
pioglitazone hcl-metformin hcl
PRANDIMET
repaglinide 2mg
repaglinide .5mg, 1mg
RIOMET
TRADJENTA
XIGDUO XR TAB 5-500MG
XIGDUO XR TAB 5-1000MG
XIGDUO XR TAB 10-500MG
XIGDUO XR TAB 10-1000MG
Drug Tier Requirements/Limits
4
QL (30 tabs / 30 days)
4
QL (30 tabs / 30 days)
4
QL (30 tabs / 30 days)
1
QL (30 tabs / 30 days)
1
QL (30 tabs / 30 days)
1
QL (90 tabs / 30 days)
4
QL (150 tabs / 30 days)
1
QL (240 tabs / 30 days)
1
QL (120 tabs / 30 days)
4
QL (946 mL / 30 days)
3
QL (30 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (30 tabs / 30 days)
3
QL (30 tabs / 30 days)
BISPHOSPHONATES
alendronate sodium SOLN
alendronate sodium TABS 5mg, 10mg,
35mg, 70mg
alendronate sodium TABS 40mg
ATELVIA
BINOSTO
FOSAMAX PLUS D
ibandronate sodium SOLN 3mg/3ml
2
1
ibandronate sodium SOLN 3mg/3ml
ibandronate sodium TABS
pamidronate disodium SOLN
risedronate sodium
zoledronic inj 4mg/5ml
zoledronic inj 5/100ml
ZOMETA SOLN
2
2
2
2
5
2
5
2
4
4
4
2
QL (300 mL / 28 days)
B/D, QL (1 syringe / 90
days)
B/D, QL (1 vial / 90 days)
B/D
B/D
B/D, NM
B/D, NM
B/D, NM
CALCIUM RECEPTOR AGONISTS
SENSIPAR 30mg
SENSIPAR 60mg, 90mg
3
5
NM
NM
CHELATING AGENTS
CHEMET
DEPEN TITRATABS
EXJADE
FERRIPROX
JADENU
kionex
sodium polystyrene sulfonate
SYPRINE
4
5
5
5
5
2
2
5
NM, LA, PA
NM, PA
NM, PA
ENDOMETRIOSIS
danazol CAPS
2
48
Drug Name
LUPANETA PACK
SYNAREL
Drug Tier Requirements/Limits
5
NM, PA
5
ENZYME REPLACEMENTS
ADAGEN
ALDURAZYME
CARBAGLU
CERDELGA
CEREZYME
CYSTADANE
CYSTAGON
ELAPRASE
ELELYSO
FABRAZYME
KUVAN
levocarnitine (metabolic modifiers)
LUMIZYME
MYOZYME
NAGLAZYME
ORFADIN
PROCYSBI
sodium phenylbutyrate
VIMIZIM
VPRIV
ZAVESCA
5
5
5
5
5
5
4
5
5
5
5
2
5
5
5
5
5
5
5
5
5
NM,
NM,
NM,
NM,
NM,
NM
NM,
NM,
NM,
NM,
NM,
B/D
NM,
NM,
NM,
NM,
NM,
NM
NM,
NM,
NM,
4
4
4
4
4
2
PA
PA
LA, PA
LA, PA
LA, PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
LA, PA
PA
LA, PA
PA
PA
LA, PA
ESTROGENS
ALORA
COMBIPATCH
depo-estradiol
estrace CREA
estradiol PTTW; PTWK; TABS
ESTRADIOL VALERATE OIL 10mg/ml,
40mg/ml
estradiol valerate OIL 20mg/ml
ESTRING
FEMRING
MENOSTAR
MINIVELLE
PREMARIN CREAM
PREMARIN INJ
VAGIFEM
PA
2
4
4
4
4
4
4
4
PA
PA
2
2
4
2
1
B/D
GLUCOCORTICOIDS
a-hydrocort
cortisone acetate TABS
DEPO-MEDROL INJ 20MG/ML
dexamethasone CONC; ELIX; SOLN
dexamethasone TABS
49
Drug Name
dexamethasone sodium phosphate
dexpak taperpak 13 day
FLO-PRED SUS
fludrocortisone acetate TABS
hydrocortisone TABS
MEDROL TAB 2MG
methylpr ace inj 40mg/ml
methylpr ace inj 80mg/ml
methylpr ss inj 1gm
methylpr ss inj 40mg
methylpr ss inj 125mg
methylpred pak 4mg
methylpred tab 4mg
methylpred tab 8mg
methylpred tab 16mg
methylpred tab 32mg
millipred
ORAPRED ODT TAB 10MG
pred sod pho sol 5mg/5ml
prednisolone sodium phosphate
prednisolone sol 15mg/5ml
prednisolone sol 25mg/5ml
prednisolone syrup 15 mg/5ml
prednisone con 5mg/ml
prednisone pak 5mg
prednisone pak 10mg
prednisone sol 5mg/5ml
prednisone tab 1mg
prednisone tab 2.5mg
prednisone tab 5mg
prednisone tab 10mg
prednisone tab 20mg
prednisone tab 50mg
RAYOS TAB 1MG
RAYOS TAB 2MG
RAYOS TAB 5MG
SOLU-CORTEF 100MG
SOLU-CORTEF 250MG
SOLU-CORTEF 500MG
SOLU-CORTEF 1000MG
SOLU-MEDROL INJ 2GM
veripred
Drug Tier Requirements/Limits
2
4
4
B/D
2
2
4
B/D
2
B/D
2
B/D
2
B/D
2
B/D
2
B/D
2
B/D
2
B/D
2
B/D
2
B/D
2
B/D
4
B/D
4
B/D
2
B/D
2
B/D
2
B/D
1
B/D
1
B/D
3
B/D
1
B/D
1
B/D
2
B/D
1
B/D
1
B/D
1
B/D
1
B/D
1
B/D
1
B/D
5
B/D
5
B/D
5
B/D
3
3
3
3
4
B/D
4
B/D
GLUCOSE ELEVATING AGENTS
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
PROGLYCEM SUS 50MG/ML
3
3
4
50
Drug Name
Drug Tier Requirements/Limits
HUMAN GROWTH HORMONES
GENOTROPIN
GENOTROPIN MINIQUICK .2mg
GENOTROPIN MINIQUICK .4mg, .6mg,
.8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg,
2mg
HUMATROPE
HUMATROPE COMBO PACK
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX PEN
NUTROPIN AQ INJ 20MG/2ML
NUTROPIN AQ NUSPIN 5
NUTROPIN AQ PEN
OMNITROPE 5.8MG
OMNITROPE 5MG
OMNITROPE 10MG
SAIZEN
SAIZEN CLICK.EASY
SEROSTIM
TEV-TROPIN
ZOMACTON
ZORBTIVE
5
4
5
NM, PA
NM, PA
NM, PA
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
MISCELLANEOUS
AFREZZA
4
cabergoline
2
calcitonin (salmon) nasal spray
2
CHORIONIC GONADOTROPIN SOLR
2
EGRIFTA
5
FORTICAL SPR 200/ACT
3
H.P. ACTHAR
5
INCRELEX
5
methylergonovine maleate TABS
2
MIACALCIN INJ 200U/ML
4
NOVAREL INJ 10000UNT
2
octreotide acetate 50mcg/ml, 100mcg/ml,2
200mcg/ml
octreotide acetate 500mcg/ml,
5
1000mcg/ml
PREGNYL W/DILUENT BENZYL
2
PROLIA
4
raloxifene hcl
2
SAMSCA
5
SANDOSTATIN LAR DEPOT
5
SIGNIFOR
5
SIGNIFOR LAR
5
SOMATULINE DEPOT
5
SOMAVERT
5
NM, PA
NM, PA
NM, PA
NM, LA, PA
B/D
NM, PA
NM, PA
NM, PA
NM, PA
NM
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
LA, PA
PA
LA, PA
51
Drug Name
XGEVA
Drug Tier Requirements/Limits
5
NM, PA
PARATHYROID HORMONES
FORTEO
NATPARA
5
5
NM, PA
NM, PA
PHOSPHATE BINDER AGENTS
AURYXIA
calcium acetate (phosphate binder)
FOSRENOL
PHOSLYRA
RENAGEL
RENVELA PAK
RENVELA TAB 800MG
VELPHORO
5
2
5
3
4
5
3
5
PROGESTINS
CRINONE
medroxyprogesterone acetate
norethindrone acetate TABS
progesterone micronized CAPS
4
1
2
2
THYROID AGENTS
levothyroxine sodium TABS
LEVOXYL
liothyronine sodium SOLN; TABS
methimazole TABS
propylthiouracil TABS
SYNTHROID
TIROSINT
UNITHROID
1
1
2
1
2
4
4
1
VASOPRESSINS
DESMOPRESSIN ACETATE SOLN
desmopressin acetate TABS
desmopressin acetate inj
desmopressin acetate spray
desmopressin acetate spray refrigerated
STIMATE
2
2
2
2
2
4
NM
GASTROINTESTINAL
ANTIEMETICS
AKYNZEO
ALOXI
CESAMET
4
5
5
compro supp
dronabinol 2.5mg, 5mg
2
2
dronabinol
10mg
5
EMEND CAP 40MG
4
B/D
B/D, QL (60 caps / 30
days)
B/D, QL (60 caps / 30
days)
B/D, QL (60 caps / 30
days)
B/D
52
Drug Name
EMEND CAP 80MG
EMEND CAP 125MG
EMEND PAK 80 & 125
granisetron hcl SOLN
granisetron hcl TABS
meclizine hcl TABS
metoclopramide hcl SOLN; TABS
metoclopramide hcl TBDP
metoclopramide hcl inj 5 mg/ml
METOZOLV ODT
ondansetron hcl SOLN
ondansetron hcl TABS
ondansetron hcl inj
ondansetron hcl oral soln
ondansetron odt
prochlorperazine inj 5 mg/ml
prochlorperazine maleate TABS
prochlorperazine supp
promethazine hcl SOLN 25mg/ml,
50mg/ml
SANCUSO
TRANSDERM-SCOP
ZUPLENZ
Drug Tier Requirements/Limits
4
B/D
4
B/D
4
B/D
2
2
B/D
2
1
2
2
4
2
2
B/D
2
2
B/D
2
B/D
2
1
2
4
PA
5
4
5
QL (4 patches / 30 days)
QL (10 patches / 30
days), PA
B/D
ANTISPASMODICS
ATROPINE SULFATE SOLN .05mg/ml,
.1mg/ml
BENTYL SOLN
CANTIL
CUVPOSA
dicyclomine hcl CAPS; TABS
dicyclomine hcl SOLN
glycate
glycopyrrolate SOLN; TABS
methscopolamine bromide TABS
2
4
4
4
1
2
4
2
2
H2-RECEPTOR ANTAGONISTS
cimetidine TABS
cimetidine sol 300/5ml
famotidine SOLN 20mg/2ml, 40mg/4ml,
200mg/20ml
famotidine SUSR
famotidine TABS 20mg, 40mg
nizatidine
ranitidine hcl CAPS
ranitidine hcl SOLN
ranitidine hcl SYRP
ranitidine hcl TABS 150mg, 300mg
1
2
2
2
1
2
2
2
2
1
53
Drug Name
Drug Tier Requirements/Limits
INFLAMMATORY BOWEL DISEASE
APRISO
ASACOL HD
balsalazide disodium
budesonide CP24
CANASA
colocort
DELZICOL
DIPENTUM
ENTYVIO
GIAZO
HYDROCORTISONE (INTRARECTAL)
LIALDA
mesalamine enema
PENTASA
SF-ROWASA
sulfasalazine dr
sulfasalazine ir
UCERIS FOAM
UCERIS TB24
3
4
2
5
4
2
4
5
5
4
2
4
2
4
4
2
2
4
5
NM, PA
LAXATIVES
COLYTE-FLAVOR PACKS
constulose
enulose
gaviltye-g
gavilyte-c
gavilyte-h
gavilyte-n
generlac
GOLYTELY
kristalose
lactulose
lactulose (encephalopathy)
MOVIPREP
NULYTELY/FLAVOR PACKS
OSMOPREP
peg 3350-kcl-sod bicarb-sod chloride-sod
sulfate
peg 3350-potassium chloride-sod
bicarbonate-sod chloride
polyethylene glycol 3350 PACK; POWD
PREPOPIK
RELISTOR
SUCLEAR
SUPREP BOWEL PREP
trilyte
4
2
2
1
1
2
2
2
3
3
2
2
4
3
4
1
2
2
4
4
4
4
2
PA
54
Drug Name
Drug Tier Requirements/Limits
MISCELLANEOUS
alosetron hcl
AMITIZA
amoxicillin-clarithromycin w/ lansoprazole
CARAFATE SUSP
cromolyn sodium (mastocytosis)
diphenoxylate w/ atropine LIQD
diphenoxylate w/ atropine TABS
GATTEX
LINZESS
loperamide hcl CAPS
LOTRONEX
misoprostol TABS
MOVANTIK
OMECLAMOX-PAK
PYLERA
SUCRAID
sucralfate TABS
ursodiol CAPS; TABS
XIFAXAN TAB 550MG
5
3
2
4
5
2
1
5
3
1
5
2
3
4
4
5
2
2
5
PA
NM, LA, PA
PA
PA
PANCREATIC ENZYMES
CREON
PANCREAZE
PERTZYE
ULTRESA
VIOKACE 10
VIOKACE 20
ZENPEP
3
4
4
4
4
5
4
10K U
20K U
PROTON PUMP INHIBITORS
ACIPHEX SPR CAP 5MG
ACIPHEX SPR CAP 10MG
DEXILANT
esomeprazole sodium inj
lansoprazole CPDR
NEXIUM CAP 20MG
NEXIUM CAP 40MG
NEXIUM GRA 2.5MG DR
NEXIUM GRA 5MG DR
NEXIUM GRA 10MG DR
4
4
3
2
2
2
2
3
3
3
NEXIUM GRA 20MG DR
3
NEXIUM GRA 40MG DR
3
omeprazole
omeprazole
1
1
CPDR 10mg, 40mg
CPDR 20mg
QL (60 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (30
days)
QL (30
days)
QL (30
days)
QL (30
QL (60
packets / 30
packets / 30
packets / 30
caps / 30 days)
caps / 30 days)
55
Drug Name
OMEPRAZOLE-SODIUM BICARBONATE
pantoprazole sodium tbec
PREVACID SOLUTAB
PRILOSEC PACK
PROTONIX PACK
rabeprazole sodium
ZEGERID PACK
Drug Tier Requirements/Limits
2
QL (30 caps / 30 days)
2
QL (30 tabs / 30 days)
4
QL (30 tabs / 30 days)
3
4
QL (30 packets / 30
days)
2
QL (30 tabs / 30 days)
4
QL (30 packets / 30
days)
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
alfuzosin hcl
AVODART
CARDURA XL
finasteride TABS 5mg
JALYN
RAPAFLO
tamsulosin hcl
2
3
4
2
3
4
2
MISCELLANEOUS
bethanechol chloride TABS
ELMIRON
POTASSIUM CITRATE (ALKALINIZER)
2
4
2
URINARY ANTISPASMODICS
ENABLEX
GELNIQUE
MYRBETRIQ
oxybutynin chloride SYRP
oxybutynin chloride TABS; TB24
OXYTROL
TOLTERODINE TARTRATE ER
tolterodine tartrate tab 1 mg
tolterodine tartrate tab 2 mg
TOVIAZ
trospium chloride
trospium chloride er
VESICARE
4
4
4
1
2
4
2
2
2
3
2
2
4
VAGINAL ANTI-INFECTIVES
CLEOCIN VAG SUPP 100MG
clindamycin cre 2% vag
CLINDESSE
metronidazole vaginal
miconazole nitrate vaginal
NUVESSA
terconazole vaginal
VANDAZOLE
zazole .4%
4
2
4
2
2
4
2
2
2
56
Drug Name
ZAZOLE .8%
Drug Tier Requirements/Limits
2
HEMATOLOGIC
ANTICOAGULANTS
COUMADIN
4
ELIQUIS TAB 2.5MG
3
ELIQUIS TAB 5MG
3
enoxaparin sodium 30mg/0.3ml,
2
40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml,
300mg/3ml
enoxaparin sodium 100mg/ml,
5
120mg/0.8ml, 150mg/ml
fondaparinux sodium 2.5mg/0.5ml
2
fondaparinux sodium 5mg/0.4ml,
5
7.5mg/0.6ml, 10mg/0.8ml
FRAGMIN 2500unit/0.2ml,
4
5000unit/0.2ml
FRAGMIN 7500unit/0.3ml, 10000unit/ml, 5
12500unit/0.5ml, 15000unit/0.6ml,
18000unt/0.72ml, 95000unit/3.8ml
HEP SOD/NACL INJ 25000
3
HEPARIN (PORCINE) IN SODIUM CHLORIDE3
100U/ML
heparin sod inj 1000u/ml
2
HEPARIN SOD INJ 2000U/ML
3
HEPARIN SOD INJ 2500U/ML
3
heparin sod inj 5000u/0.5ml
2
heparin sod inj 5000u/ml
2
heparin sod inj 10000u/ml
2
heparin sod inj 20000u/ml
2
HEPARIN SODIUM/D5W
3
HEPARIN SODIUM/NACL 0.45%
3
jantoven
1
PRADAXA
3
SAVAYSA
4
warfarin sodium
1
XARELTO
3
XARELTO STARTER PACK
3
B/D
B/D
B/D
B/D
B/D
B/D
B/D
HEMATOPOIETIC GROWTH FACTORS
ARANESP ALBUMIN FREE SOLN
3
10mcg/0.4ml, 25mcg/ml, 40mcg/ml,
60mcg/ml
ARANESP ALBUMIN FREE SOLN
5
100mcg/ml, 150mcg/0.75ml, 200mcg/ml,
300mcg/ml
ARANESP ALBUMIN FREE SOSY
3
25mcg/0.42ml, 40mcg/0.4ml,
60mcg/0.3ml
NM, PA
NM, PA
NM, PA
57
Drug Name
Drug Tier Requirements/Limits
ARANESP ALBUMIN FREE SOSY
5
NM, PA
100mcg/0.5ml, 150mcg/0.3ml,
200mcg/0.4ml, 300mcg/0.6ml, 500mcg/ml
EPOGEN
4
NM, PA
GRANIX
5
NM, PA
LEUKINE
5
NM, PA
MIRCERA
4
NM, PA
MOZOBIL
5
NM, PA
NEULASTA
5
NM, PA
NEUMEGA
5
NM
NEUPOGEN
5
NM, PA
PROCRIT 2000unit/ml, 3000unit/ml,
3
NM, PA
4000unit/ml, 10000unit/ml
PROCRIT 20000unit/ml, 40000unit/ml
5
NM, PA
MISCELLANEOUS
anagrelide hcl
cilostazol
CINRYZE
FIRAZYR
pentoxifylline TBCR
PROMACTA 12.5mg
2
2
5
5
2
5
PROMACTA
25mg
5
PROMACTA
50mg
5
PROMACTA
75mg
5
RUCONEST
tranexamic acid SOLN; TABS
5
2
NM, LA, PA
NM, PA
QL (360 tabs / 30 days),
NM, LA, PA
QL (180 tabs / 30 days),
NM, LA, PA
QL (90 tabs / 30 days),
NM, LA, PA
QL (60 tabs / 30 days),
NM, LA, PA
NM, PA
PLATELET AGGREGATION INHIBITORS
AGGRENOX
BRILINTA
clopidogrel bisulfate
EFFIENT
ZONTIVITY
2
3
2
4
4
IMMUNOLOGIC AGENTS
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)
ACTEMRA
CIMZIA
ENBREL
ENBREL SURECLICK
HUMIRA
HUMIRA PEN
HUMIRA PEN-CROHNS STARTER KIT
HUMIRA PEN-PSORIASIS STARTER KIT
hydroxychloroquine sulfate
5
5
5
5
5
5
5
5
1
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
PA
PA
PA
PA
PA
58
Drug Name
KINERET
leflunomide TABS
methotrexate sodium tabs
ORENCIA
OTEZLA
REMICADE
RHEUMATREX
SIMPONI
SIMPONI ARIA
trexall
XELJANZ
Drug Tier Requirements/Limits
5
NM, PA
2
2
5
NM, PA
5
NM, PA
5
NM, PA
4
5
NM, PA
5
NM, PA
4
B/D
5
NM, PA
IMMUNOGLOBULINS
BIVIGAM
CARIMUNE NANOFILTERED
FLEBOGAMMA
FLEBOGAMMA DIF
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAGARD S/D
GAMMAGARD S/D IGA LESS TH
GAMMAKED
GAMMAPLEX 2.5gm/50ml, 5gm/100ml,
10gm/200ml
GAMUNEX-C
GAMUNEX-C 1GM/10ML
OCTAGAM 1gm/20ml, 2gm/20ml,
2.5gm/50ml, 5gm/100ml, 10gm/200ml,
25gm/500ml
PRIVIGEN
5
5
5
5
3
5
5
5
5
5
NM, PA
NM, PA
NM, PA
NM, PA
B/D, NM
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
5
5
5
NM, PA
NM, PA
NM, PA
5
NM, PA
5
5
4
5
5
5
5
5
5
5
5
4
5
5
NM, LA, PA
NM, PA
PA
B/D, NM
B/D, NM
B/D, NM
B/D, NM
NM, PA
NM, PA
NM, PA
NM, PA
PA
NM, LA, PA
NM, PA
5
B/D
IMMUNOMODULATORS
ACTIMMUNE
ARCALYST
GRASTEK
INTRON-A INJ 10MU
INTRON-A INJ 18MU
INTRON-A INJ 25MU
INTRON-A INJ 50MU
PEG-INTRON
PEG-INTRON REDIPEN
PEGASYS
PEGASYS PROCLICK
RAGWITEK
REVLIMID
THALOMID
IMMUNOSUPPRESSANTS
ASTAGRAF XL 5mg
59
Drug Name
ASTAGRAF XL .5mg, 1mg
ATGAM
azasan
azathioprine TABS
CELLCEPT INTRAVENOUS
cyclosporine CAPS; SOLN
cyclosporine modified (for microemulsion)
gengraf
mycophenolate mofetil CAPS; TABS
mycophenolate mofetil SUSR
mycophenolate sodium 180mg
mycophenolate sodium 360mg
NEORAL
NULOJIX
PROGRAF CAPS 5mg
PROGRAF CAPS .5mg, 1mg
PROGRAF SOLN
RAPAMUNE SOLN
SANDIMMUNE CAPS
SANDIMMUNE SOLN
SIMULECT
SIROLIMUS TABS 1mg
SIROLIMUS TABS 2mg
sirolimus TABS .5mg
tacrolimus CAPS 5mg
tacrolimus CAPS .5mg, 1mg
THYMOGLOBULIN
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.75MG
Drug Tier Requirements/Limits
4
B/D
4
B/D
4
B/D
2
B/D
4
B/D
2
B/D
2
B/D
2
B/D
2
B/D
5
B/D
2
B/D
5
B/D
3
B/D
5
B/D
5
B/D
4
B/D
4
B/D
5
B/D
3
B/D
3
B/D
4
B/D
2
B/D
5
B/D
2
B/D
5
B/D
2
B/D
5
B/D
5
B/D
4
B/D
5
B/D
VACCINES
ACTHIB
ADACEL
BCG VACCINE
BEXSERO
BOOSTRIX
CERVARIX
COMVAX
DAPTACEL
DIPHTHERIA/TETANUS TOXOID
ENGERIX-B SUSP
GARDASIL
GARDASIL 9
HAVRIX
HIBERIX
IMOVAX RABIES (H.D.C.V.)
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
B/D
B/D
60
Drug Name
INFANRIX
IPOL INACTIVATED IPV
IXIARO
KINRIX
M-M-R II
MENACTRA
MENOMUNE-A/C/Y/W-135
MENVEO
PEDVAX HIB
PROQUAD
QUADRACEL
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
SYNAGIS
TENIVAC
TETANUS TOXOID ADSORBED
TETANUS/DIPHTHERIA TOXOID
TRUMENBA
TWINRIX INJ
TYPHIM VI
VAQTA
VARIVAX
YF-VAX
ZOSTAVAX
Drug Tier Requirements/Limits
3
3
3
3
3
3
3
3
3
3
3
3
3
B/D
3
3
5
NM
3
B/D
3
B/D
3
B/D
3
3
3
3
3
3
3
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
ammonium chloride SOLN
KLOR-CON 8
KLOR-CON 10
klor-con m15
klor-con m20
klor-con pow 20meq
klor-con spr cap
MAGNESIUM SULFATE SOLN 4gm/50ml,
20gm/500ml
magnesium sulfate SOLN 50%
MAGNESIUM SULFATE SOLN 50%
MAGNESIUM SULFATE IN D5W
potassium chloride SOLN 10%, 20%
potassium chloride TBCR 8meq
POTASSIUM CHLORIDE TBCR 10meq,
20meq
potassium chloride caps er
potassium chloride microencapsulated
crystals cr
4
2
2
2
2
2
2
3
2
2
3
1
2
2
2
2
61
Drug Name
Drug Tier Requirements/Limits
SODIUM CHLORIDE SOLN 2.5meq/ml
2
SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F)2
MG/ML SOLN
TPN ELECTROLYTES
4
B/D
IV NUTRITION
AMINOSYN
AMINOSYN 7%/ELECTROLYTES
AMINOSYN II
AMINOSYN II 8.5%/ELECTROL
AMINOSYN INJ 8.5/LYTE
AMINOSYN M
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-PF 7%
AMINOSYN-RF
CLINIMIX 2.75%/DEXTROSE 5%
CLINIMIX 4.25%/DEXTROSE 5%
CLINIMIX 4.25%/DEXTROSE 10%
CLINIMIX 4.25%/DEXTROSE 20%
CLINIMIX 4.25%/DEXTROSE 25%
CLINIMIX 5%/DEXTROSE 15%
CLINIMIX 5%/DEXTROSE 20%
CLINIMIX 5%/DEXTROSE 25%
CLINIMIX E 2.75%/DEXTROSE 5%
CLINIMIX E 2.75%/DEXTROSE 10%
CLINIMIX E 4.25%/DEXTROSE
CLINIMIX E 4.25%/DEXTROSE 5%
CLINIMIX E 4.25%/DEXTROSE 25%
CLINIMIX E 5%/DEXTROSE 15%
CLINIMIX E 5%/DEXTROSE 20%
CLINIMIX E 5%/DEXTROSE 25%
clinisol 15
FREAMINE HBC 6.9%
FREAMINE III
HEPATAMINE
INTRALIPID INJ 20%
INTRALIPID INJ 30%
LIPOSYN III INJ 10%
NEPHRAMINE
NUTRILIPID EMU 20%
premasol 6%
premasol 10%
PROCALAMINE
PROSOL
travasol 10
TROPHAMINE INJ 10%
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
4
4
4
3
3
4
4
3
2
4
4
4
4
4
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
62
Drug Name
Drug Tier Requirements/Limits
IV REPLACEMENT SOLUTIONS
DEXTROSE SOLN 50%
dextrose SOLN 70%
DEXTROSE 2.5%/NACL 0.45%
DEXTROSE 5%
DEXTROSE 5% /ELECTROLYTE
DEXTROSE 5%/LACTATED RING
DEXTROSE 5%/NACL 0.2%
DEXTROSE 5%/NACL 0.3%
DEXTROSE 5%/NACL 0.9%
DEXTROSE 5%/NACL 0.33%
DEXTROSE 5%/NACL 0.45%
DEXTROSE 5%/NACL 0.225%
DEXTROSE 5%/POTASSIUM CHL
DEXTROSE 10% FLEX CONTAIN
DEXTROSE 10% W/ SODIUM CHLORIDE
0.2%
DEXTROSE 10%/NACL 0.45%
ELECTROLYTE-R IN DEXTROSE
IONOSOL-B/DEXTROSE 5%
IONOSOL-MB/DEXTROSE 5%
ISOLYTE P
isolyte s
KCL0.15%/D5W/NACL0.2%
KCL0.15%/D5W/NACL0.225%
kcl 0.3%/d5w/lr iv lac ri
KCL 0.3%/D5W/NACL 0.9%
KCL 0.3%/D5W/NACL 0.45%
KCL 0.15%/D5W/LR
KCL 0.15%/D5W/NACL 0.9%
KCL 0.075%/D5W/NACL 0.45%
KCL IN NACL INJ .15-0.45
KCL/D5W/NACL INJ .15/.33%
KCL/D5W/NACL INJ .15/.45%
LACTATED RINGERS VIAFLEX
normosol-m
NORMOSOL-R
PLASMA-LYTE A
PLASMA-LYTE-56/D5W
PLASMA-LYTE-148
potassium chloride SOLN .4meq/ml,
2meq/ml, 10meq/100ml, 10meq/50ml,
20meq/100ml, 40meq/100ml
POTASSIUM CHLORIDE 0.3%/D
POTASSIUM CHLORIDE 0.15%
POTASSIUM CHLORIDE 0.22%
potassium chloride in nacl
2
2
2
2
3
2
2
2
2
2
2
2
2
2
3
2
4
4
4
4
4
2
3
4
2
2
4
2
2
2
2
2
1
2
4
4
4
4
2
2
2
2
2
63
Drug Name
POTASSIUM CHLORIDE IN NACL
RINGER'S
SODIUM CHLORIDE SOLN .9%, 3%, 5%
SODIUM CHLORIDE 0.45% VIA
Drug Tier Requirements/Limits
2
2
2
2
VITAMINS
calcitriol CAPS; SOLN
2
doxercalciferol
2
paricalcitol CAPS
2
PARICALCITOL SOLN
2
PRENATAL VITAMIN/FOLIC ACID > 0.8 MG 2
(GENERIC)
ZEMPLAR INJ 2MCG/ML
4
ZEMPLAR INJ 5MCG/ML
4
B/D
B/D
B/D
B/D
B/D
B/D
OPHTHALMIC
ANTI-INFECTIVE/ANTI-INFLAMMATORY
bacitracin-poly-neomycin-hc
blephamide OINT
BLEPHAMIDE SUSP
neomycin-polymy-dexameth
neomycin-polymyxin-hc (ophth)
PRED-G
PRED-G S.O.P.
sulfacetamide sod-prednisolone
TOBRADEX OINT
TOBRADEX ST
tobramycin-dexamethasone
ZYLET
2
4
4
2
2
4
4
2
3
3
2
3
ANTI-INFECTIVES
AZASITE
bacitracin (ophthalmic)
bacitracin-polymyxin b (ophth)
BESIVANCE
CILOXAN OIN 0.3% OP
ciprofloxacin hcl (ophth)
erythromycin (ophth)
gatifloxacin (ophth)
gentak
gentamicin sulfate (ophth) OINT
gentamicin sulfate (ophth) SOLN
ilotycin
levofloxacin (ophth)
MOXEZA
NATACYN
neomycin-bacitracin zn-polymyxin
neomycin-polymyxin-gramicidin
ofloxacin (ophth)
4
2
2
3
3
2
1
2
2
2
1
1
2
3
4
2
2
1
64
Drug Name
polymyxin b-trimethoprim
sulfacetamide sodium (ophth)
sulfacetamide sodium (ophth)
tobramycin (ophth)
TOBREX OINT 0.3%
trifluridine SOLN
VIGAMOX
ZIRGAN
OINT
SOLN
Drug Tier Requirements/Limits
1
2
1
1
4
2
3
4
ANTI-INFLAMMATORIES
ACUVAIL
4
ALREX
3
bromfenac sodium (ophth)
2
BROMFENAC SODIUM
2
(OPHTH)(ONCE-DAILY)
dexamethasone sodium phosphate (ophth) 2
diclofenac sodium (ophth)
2
DUREZOL
3
FLAREX
4
FLUOROMETHOLONE (OPHTH)
2
flurbiprofen sodium
1
FML
4
FML FORTE
4
ILEVRO
3
ketorolac tromethamine (ophth)
2
LOTEMAX
3
MAXIDEX
3
NEVANAC
3
PRED MILD
4
PREDNISOLONE ACETATE (OPHTH)
2
prednisolone sodium phosphate (ophth)
3
VEXOL
4
ANTIALLERGICS
ALOCRIL
ALOMIDE
azelastine drop 0.05%
BEPREVE
cromolyn sodium (ophth)
EMADINE
epinastine hcl (ophth)
LASTACAFT
PATADAY
PATANOL
PAZEO
4
4
2
3
1
4
2
4
3
3
3
ANTIGLAUCOMA
ALPHAGAN P 0.1%
AZOPT
3
3
65
Drug Name
betaxolol hcl (ophth)
BETIMOL
BETOPTIC-S
brimonidine sol 0.2%
BRIMONIDINE SOL 0.15%
carteolol hcl (ophth)
COMBIGAN
COSOPT PF
dorzolamide hcl
dorzolamide hcl-timolol maleate
ISTALOL
latanoprost SOLN
levobunolol hcl .5%
LEVOBUNOLOL HCL .25%
LUMIGAN
metipranolol
PHOSPHOLINE IODIDE
PILOCARPINE HCL SOLN
SIMBRINZA SUS 1-0.2%
timolol maleate (ophth)
TIMOLOL MALEATE GEL
TIMOPTIC .25%
TIMOPTIC OCUDOSE
TRAVATAN Z
ZIOPTAN
Drug Tier Requirements/Limits
2
4
3
1
2
1
3
4
2
2
3
2
2
2
3
2
3
2
3
1
2
4
4
3
4
MISCELLANEOUS
BOTOX INJ 100UNIT
BOTOX INJ 200UNIT
LACRISERT
naphazoline 0.1%
PROLENSA
proparacaine hcl SOLN
RESTASIS
XEOMIN
4
4
4
1
3
1
3
4
NM, PA
NM, PA
NM, PA
RESPIRATORY
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
ANORO ELLIPT AER 62.5-25
COMBIVENT RESPIMAT
ipratropium-albuterol
STIOLTO RESPIMAT
3
4
2
4
QL (1 inhaler / 30 days)
QL (2 inhalers / 30 days)
B/D
QL (1 inhaler / 30 days)
4
4
2
2
3
QL (2 inhalers / 30 days)
QL (1 Inhaler / 30 days)
ANTICHOLINERGICS
ATROVENT HFA
INCRUSE ELLIPTA
ipratropium bromide (nasal)
ipratropium sol inhal
SPIRIVA HANDIHALER
B/D
QL (30 caps / 30 days)
66
Drug Name
SPIRIVA RESPIMAT 2.5mcg/act
TUDORZA PRESSAIR
TUDORZA PRESSAIR (INSTITUTIONAL
PACK) 400MCG/ACT
Drug Tier Requirements/Limits
3
QL (1 inhaler / 30 days)
3
QL (1 inhaler / 30 days)
3
QL (2 inhalers / 30 days)
ANTIHISTAMINE COMBINATIONS
CLARINEX-D TAB 2.5-120
DYMISTA SPR 137-50
SEMPREX-D
4
4
4
QL (1 bottle / 30 days)
ANTIHISTAMINES
ASTEPRO
azelastine hcl SOLN
azelastine spr 0.1%
cetirizine syrup
CLARINEX SYRP
desloratadine
diphenhydram inj 50mg/ml
hydroxyzine hcl inj
levocetirizine soln 2.5mg/5ml
levocetirizine tab 5 mg
olopatadine hcl (nasal)
3
2
2
2
4
2
2
4
2
2
2
PA
BETA AGONISTS
albuterol sulfate NEBU
albuterol sulfate SYRP
albuterol sulfate TABS
albuterol sulfate er
ARCAPTA NEOHALER
BROVANA
FORADIL AEROLIZER
levalbuterol conc 1.25mg/0.5ml
LEVALBUTEROL HCL NEBU 1.25mg/3ml
levalbuterol hcl NEBU .31mg/3ml,
.63mg/3ml
PERFOROMIST
PROAIR HFA
PROAIR RESPICLICK
PROVENTIL HFA
SEREVENT DISKUS
STRIVERDI RESPIMAT
terbutaline sulfate SOLN; TABS
VENTOLIN HFA
XOPENEX HFA
2
1
2
2
4
4
3
2
2
2
B/D
4
3
4
4
3
4
2
4
3
B/D
QL (2
QL (2
QL (2
QL (1
QL (1
QL (30 caps / 30 days)
B/D
QL (60 caps / 30 days)
B/D
B/D
B/D
inhalers / 30 days)
inhalers / 30 days)
inhalers / 30 days)
inhaler / 30 days)
inhaler / 30 days)
QL (2 inhalers / 30 days)
QL (2 inhalers / 30 days)
LEUKOTRIENE RECEPTOR ANTAGONISTS
montelukast sodium CHEW; PACK; TABS 2
zafirlukast
2
ZYFLO CR
5
MAST CELL STABILIZERS
67
Drug Name
cromolyn sodium
NEBU
Drug Tier Requirements/Limits
2
B/D
MISCELLANEOUS
acetylcysteine SOLN 10%, 20%
ARALAST NP
AUVI-Q
DALIRESP
EPINEPHRINE SOAJ
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
ESBRIET
GLASSIA
OFEV
ORKAMBI
PROLASTIN-C
PULMOZYME
tyzine .05%
XOLAIR
ZEMAIRA
2
5
3
4
2
3
3
5
5
5
5
5
5
4
5
5
B/D
NM, LA, PA
4
2
2
2
4
4
4
4
2
4
4
QL (2
QL (2
QL (2
QL (1
QL (2
QL (1
QL (1
QL (1
QL (1
QL (1
QL (1
4
4
4
3
4
4
3
2
3
QL (2 inhalers / 30 days)
QL (2 inhalers / 30 days)
QL (1 Inhaler / 30 days)
QL (2 inhalers / 30 days)
QL (2 Inhalers / 30 days)
QL (1 inhaler / 30 days)
QL (2 inhalers / 30 days)
B/D
QL (2 inhalers / 30 days)
3
3
4
5
3
QL (4
QL (2
QL (2
B/D
QL (1
NM, PA
NM, LA, PA
NM, PA
NM, PA
NM, LA, PA
B/D, NM
NM, LA, PA
NM, LA, PA
NASAL STEROIDS
BECONASE AQ
budesonide (nasal)
flunisolide (nasal)
fluticasone propionate (nasal)
NASONEX
OMNARIS
QNASL
QNASL CHILDRENS
triamcinolone acetonide (nasal)
VERAMYST
ZETONNA
inhalers / 30 days)
bottles / 30 days)
bottles / 30 days)
bottle / 30 days)
bottles / 30 days)
inhaler / 30 days)
inhaler / 30 days)
inhaler / 30 days)
bottle / 30 days)
bottle / 30 days)
inhaler / 30 days)
STEROID INHALANTS
AEROSPAN
ALVESCO
ARNUITY ELLIPTA
ASMANEX
ASMANEX HFA 100mcg/act
ASMANEX HFA 200mcg/act
ASMANEX TWISTHALER 14 MET
budesonide (inhalation)
FLOVENT DISKUS 50mcg/blist,
100mcg/blist
FLOVENT DISKUS 250mcg/blist
FLOVENT HFA
PULMICORT FLEXHALER
PULMICORT INH SUSP 1MG/2ML
QVAR 40mcg/act
inhalers / 30 days)
inhalers / 30 days)
inhalers / 30 days)
inhaler / 30 days)
68
Drug Name
QVAR 80mcg/act
Drug Tier Requirements/Limits
3
QL (2 inhalers / 30 days)
STEROID/BETA-AGONIST COMBINATIONS
ADVAIR DISKUS
ADVAIR HFA
BREO ELLIPTA
DULERA
SYMBICORT
3
3
3
4
3
QL
QL
QL
QL
QL
(1
(1
(1
(1
(1
inhaler
inhaler
inhaler
inhaler
inhaler
/
/
/
/
/
30
30
30
30
30
days)
days)
days)
days)
days)
XANTHINES
aminophylline inj
elixophyllin
lufyllin 200mg
theo-24
theophylline SOLN; TB24
theophylline TB12
2
4
4
4
2
1
TOPICAL
DERMATOLOGY, ACNE
ABSORICA
ACANYA
ACZONE
adapalene CREA
adapalene GEL .1%
ADAPALENE GEL .3%
amnesteem
ATRALIN
AVITA
AZELEX
benzoyl peroxide-erythromycin
claravis
CLINDAGEL
clindamax
clindamycin phosphate (topical)
clindamycin phosphate-benzoyl peroxide
clindamycin phosphate-benzoyl peroxide
(refrigerate)
DIFFERIN LOTN
EPIDUO
EPIDUO FORTE
ery pad 2%
erythromycin (acne aid)
FABIOR
myorisan
neuac gel 1.2-5%
ONEXTON
RETIN-A MICRO PUMP .08%
sulfacetamide sodium (acne)
tretin-x CREA
5
4
4
2
2
2
2
4
2
4
2
2
4
2
2
2
2
4
4
4
2
2
4
2
2
4
4
2
4
69
Drug Name
tretinoin CREA; GEL
TRETINOIN MICROSPHERE
VELTIN
zenatane
ZIANA
Drug Tier Requirements/Limits
2
2
4
2
4
DERMATOLOGY, ANTIBIOTICS
ALTABAX
BACTROBAN NASAL
CENTANY
CORTISPORIN CREA; OINT
gentamicin sulfate (topical)
mupirocin OINT
mupirocin calcium (topical)
SILVER SULFADIAZINE CREA
SSD
SULFAMYLON CREA
4
4
4
4
1
1
2
2
2
4
DERMATOLOGY, ANTIFUNGALS
ciclopirox GEL
ciclopirox cre 0.77%
ciclopirox shampoo 1%
ciclopirox sus 0.77%
clotrimazole (topical) CREA
clotrimazole (topical) SOLN
econazole nitrate CREA
ERTACZO
EXELDERM
ketoconazole (topical)
ketodan aer 2%
LUZU
MENTAX
NAFTIFINE HCL
NAFTIN
nyamyc
nystatin (topical)
nystatin pow 100000
nystop
OXISTAT
2
2
2
2
2
1
2
4
4
2
2
4
4
2
4
2
2
2
2
4
DERMATOLOGY, ANTIPRURITIC
CORTIFOAM
procto-pak
proctosol hc 2.5 %
proctozone hc
PRUDOXIN CRE 5%
4
2
1
1
2
DERMATOLOGY, ANTIPSORIATICS
acitretin
calcipotriene
CREA; OINT; SOLN
5
2
PA
70
Drug Name
calcitrene oin 0.005%
CALCITRIOL OINT
COSENTYX
COSENTYX SENSOREADY PEN
methoxsalen rapid
8-MOP
SORILUX
STELARA
TAZORAC CREA
Drug Tier Requirements/Limits
2
2
5
NM, PA
5
NM, PA
5
4
4
5
NM, PA
4
PA
DERMATOLOGY, ANTISEBORRHEICS
ketoconazole shampoo
selenium sulfide LOTN
1
1
DERMATOLOGY, ANTIVIRALS
acyclovir topical
DENAVIR
XERESE
ZOVIRAX CREA
2
4
4
4
DERMATOLOGY, CORTICOSTEROIDS
ala-cort
alclometasone dipropionate
amcinonide CREA; LOTN
amcinonide OINT
apexicon e cre 0.05%
betamethasone dipropionate (topical)
betamethasone dipropionate augmented
betamethasone valerate CREA; FOAM;
LOTN; OINT
calcipotrien oin betameth
CAPEX
clobetasol e cre 0.05%
clobetasol propionate CREA; FOAM; GEL;
LIQD; LOTN; OINT; SHAM; SOLN
clobetasol propionate emulsion
CLOCORTOLONE PIVALATE
clodan sha 0.05%
CORDRAN TAPE
cormax
DESONATE
DESONIDE CREA
desonide LOTN; OINT
desoximetasone CREA
desoximetasone GEL
DESOXIMETASONE OINT .05%
desoximetasone OINT .25%
diflorasone diacetate
1
2
2
4
4
2
2
2
2
4
2
2
2
2
2
4
2
4
2
2
2
2
2
2
2
71
Drug Name
Drug Tier Requirements/Limits
fluocinolone acetonide CREA; OIL; OINT; 2
SOLN
fluocinolone acetonide body oil
2
fluocinonide CREA; GEL; OINT; SOLN
2
fluocinonide emulsified base
2
fluticasone propionate CREA; LOTN; OINT 2
halobetasol propionate
2
HALOG
4
hydrocortisone (topical) CREA; OINT
1
hydrocortisone (topical) LOTN
2
hydrocortisone butyrate
2
hydrocortisone butyrate hydrophilic lipo
2
base
hydrocortisone valerate
2
KENALOG
4
LOCOID LOTN
4
LOKARA LOTN 0.05%
2
mometasone furoate CREA; OINT; SOLN 2
PANDEL
4
PREDNICARBATE CREA
2
prednicarbate OINT
2
TACLONEX SUSP
5
texacort
4
TOPICORT LIQD
4
triamcinolone acetonide (topical) AERS; 2
LOTN
triamcinolone acetonide (topical) CREA; 1
OINT
trianex
4
triderm
1
DERMATOLOGY, LOCAL ANESTHETICS
lidocaine OINT
lidocaine PTCH
lidocaine hcl GEL
lidocaine hcl SOLN 4%
lidocaine-prilocaine
SYNERA
2
2
2
1
2
4
PA
B/D
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE
ammonium lactate CREA; LOTN
CONDYLOX GEL
diclofenac sodium (actinic keratoses)
diclofenac sodium (topical)
DOXYCYCLINE (ROSACEA)
ELIDEL
FINACEA
fluorouracil (topical) CREA 5%
FLUOROURACIL (TOPICAL) CREA .5%
2
4
5
2
2
4
4
2
2
PA
PA
72
Drug Name
fluorouracil (topical) SOLN
imiquimod CREA
laclotion lot 12%
metronidazole (topical)
NORITATE
ORACEA
OXSORALEN
PANRETIN
PENNSAID SOL 2%
PICATO
podofilox SOLN
RECTIV
rosadan cre 0.75%
SOOLANTRA
tacrolimus (topical)
TARGRETIN GEL
VALCHLOR
VOLTAREN GEL 1%
ZYCLARA
Drug Tier Requirements/Limits
2
2
2
2
4
4
4
5
4
5
2
4
2
4
2
PA
5
NM, PA
5
NM, LA, PA
3
5
DERMATOLOGY, SCABICIDES AND PEDICULIDES
EURAX
malathion
permethrin
SKLICE
4
2
2
4
DERMATOLOGY, WOUND CARE AGENTS
acetic acid .25%
neomycin/polymyxin b gu
REGRANEX
SANTYL
SODIUM CHLORIDE 0.9%
STERILE WATER IRRIGATION
1
2
5
4
1
2
PA
MOUTH/THROAT/DENTAL AGENTS
cevimeline hcl
chlorhexidine gluconate (mouth-throat)
clotrimazole TROC
lidocaine hcl (mouth-throat)
nystatin (mouth-throat)
periogard soln 0.12%
pilocarpine hcl (oral)
triamcinolone acetonide (mouth)
2
1
2
1
2
1
2
2
OTIC
acetasol hc
acetic acid (otic)
acetic acid sol/hc
acetic acid-aluminum acetate
CIPRO HC
2
2
2
2
4
73
Drug Name
CIPRODEX
COLY-MYCIN S
CORTISPORIN-TC
fluocinolone acetonide (otic)
neomycin-polymyxin-hc (otic)
ofloxacin (otic)
Drug Tier Requirements/Limits
3
4
4
2
2
2
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at mail order
B/D - Covered under Medicare B or D LA - Limited Access
74
Index
8
8-MOP .............................................71
A
abacavir sulfate ................................19
abacavir sulfate-lamivudine-zidovudine20
ABELCET ..........................................18
ABILIFY DISCMELT ............................38
ABILIFY INJ 9.75MG ..........................38
ABILIFY MAIN INJ 300MG ..................38
ABILIFY MAIN INJ 400MG ..................38
ABILIFY MAINTENA ...........................38
ABILIFY SOLN ..................................38
ABILIFY TABS ...................................38
ABRAXANE .......................................25
ABSORICA .......................................69
ABSTRAL .........................................15
acamprosate calcium .........................44
ACANYA ...........................................69
acarbose ..........................................46
acebutolol hcl ...................................31
acetaminophen w/ codeine .................13
acetaminophen-caff-dihydrocod ..........13
acetasol hc .......................................73
acetazolamide ..................................32
acetazolamide sodium .......................32
acetic acid........................................73
acetic acid (otic) ...............................73
acetic acid sol/hc ..............................73
acetic acid-aluminum acetate .............73
acetylcysteine ..................................68
ACIPHEX SPR CAP 10MG ....................55
ACIPHEX SPR CAP 5MG......................55
acitretin ...........................................70
ACTEMRA .........................................58
ACTHIB ...........................................60
ACTIMMUNE .....................................59
ACTOPLUS MET XR 15-1000MG ..........46
ACTOPLUS MET XR 30-1000MG ..........46
ACUVAIL ..........................................65
acyclovir ..........................................20
acyclovir sodium ...............................20
acyclovir topical ................................71
ACZONE ..........................................69
ADACEL ...........................................60
ADAGEN ..........................................49
adapalene ........................................69
ADAPALENE......................................69
ADCIRCA......................................... 34
adefovir dipivoxil .............................. 20
ADEMPAS ........................................ 34
adrucil ............................................ 24
ADVAIR DISKUS............................... 69
ADVAIR HFA .................................... 69
ADVICOR ........................................ 30
AEROSPAN ...................................... 68
afeditab cr ....................................... 31
AFINITOR ........................................ 26
AFINITOR DISPERZ .......................... 26
AFREZZA ......................................... 51
AGGRENOX ..................................... 58
a-hydrocort ..................................... 49
AKYNZEO ........................................ 52
ala-cort ........................................... 71
ALBENZA......................................... 17
albuterol sulfate ............................... 67
albuterol sulfate er ........................... 67
alclometasone dipropionate ............... 71
ALCOHOL SWABS ............................. 45
ALDACTAZIDE TAB 50/50 .................. 32
ALDURAZYME .................................. 49
alendronate sodium .......................... 48
alfuzosin hcl .................................... 56
ALIMTA ........................................... 24
ALINIA ............................................ 17
allopurinol tab.................................. 13
almotriptan malate ........................... 42
ALOCRIL ......................................... 65
ALOMIDE ........................................ 65
ALORA ............................................ 49
alosetron hcl .................................... 55
ALOXI ............................................. 52
ALPHAGAN P 0.1% ........................... 65
alprazolam ...................................... 34
ALREX ............................................ 65
ALSUMA .......................................... 42
ALTABAX ......................................... 70
ALTOPREV ....................................... 30
ALVESCO ........................................ 68
amantadine hcl ................................ 38
AMBISOME ...................................... 18
amcinonide ...................................... 71
amifostine crystalline ........................ 27
amikacin sulfate ............................... 17
amiloride & hydrochlorothiazide ......... 32
75
amiloride hcl ....................................32
aminophylline inj ..............................69
AMINOSYN .......................................62
AMINOSYN 7%/ELECTROLYTES ..........62
AMINOSYN II....................................62
AMINOSYN II 8.5%/ELECTROL ...........62
AMINOSYN INJ 8.5/LYTE ....................62
AMINOSYN M....................................62
AMINOSYN-HBC ................................62
AMINOSYN-PF ..................................62
AMINOSYN-PF 7%.............................62
AMINOSYN-RF ..................................62
amiodarone hcl .................................29
amiodarone inj 50mg/ml....................29
AMITIZA ..........................................55
amitriptyline hcl ................................37
amlodipine besylate ..........................31
AMLODIPINE BESYLATE/ATORV ..........31
amlodipine besylate-benazepril hcl ......28
amlodipine besylate-valsartan tab 10-160
mg ..................................................29
amlodipine besylate-valsartan tab 10-320
mg ..................................................29
amlodipine besylate-valsartan tab 5-160
mg ..................................................28
amlodipine besylate-valsartan tab 5-320
mg ..................................................28
amlodipine-valsartan-hydrochlorothiazide
10-160-12.5mg ................................29
amlodipine-valsartan-hydrochlorothiazide
10-160-25mg ...................................29
amlodipine-valsartan-hydrochlorothiazide
10-320-25mg ...................................29
amlodipine-valsartan-hydrochlorothiazide
5-160-12.5mg ..................................29
amlodipine-valsartan-hydrochlorothiazide
5-160-25mg .....................................29
ammonium chloride ..........................61
ammonium lactate ............................72
amnesteem ......................................69
amoxapine .......................................37
amoxicillin .......................................23
amoxicillin & pot clavulanate ..............23
amoxicillin-clarithromycin w/ lansoprazole
......................................................55
amphetamine cap 10mg er ................40
amphetamine cap 15mg er ................40
amphetamine cap 20mg er ................40
amphetamine cap 25mg er ................ 40
amphetamine cap 30mg er ................ 40
amphetamine-dextroamphetamine cap sr
24hr 5 mg ....................................... 40
amphetamine-dextroamphetamine tab 10
mg ................................................. 41
amphetamine-dextroamphetamine tab
12.5 mg .......................................... 41
amphetamine-dextroamphetamine tab 15
mg ................................................. 41
amphetamine-dextroamphetamine tab 20
mg ................................................. 41
amphetamine-dextroamphetamine tab 30
mg ................................................. 41
amphetamine-dextroamphetamine tab 5
mg ................................................. 40
amphetamine-dextroamphetamine tab
7.5 mg............................................ 40
AMPHOTEC ...................................... 18
amphotericin b ................................. 18
ampicillin & sulbactam sodium ........... 23
ampicillin cap 250mg ........................ 23
ampicillin cap 500 mg ....................... 23
ampicillin inj .................................... 23
ampicillin sodium ............................. 23
ampicillin susp ................................. 23
AMPYRA .......................................... 43
anagrelide hcl .................................. 58
anastrozole ..................................... 25
ANDRODERM ................................... 45
ANDROGEL 1% ................................ 45
ANDROGEL 1.62%............................ 45
ANDROGEL GEL PUMP 1% ................. 45
ANORO ELLIPT AER 62.5-25 .............. 66
ANTARA .......................................... 30
apexicon e cre 0.05% ....................... 71
APIDRA ........................................... 45
APIDRA SOLOSTAR........................... 45
APLENZIN ....................................... 37
APOKYN .......................................... 38
APRISO ........................................... 54
APTENSIO XR .................................. 41
APTIOM........................................... 34
APTIVUS ......................................... 19
ARALAST NP .................................... 68
ARANESP ALBUMIN FREE ............. 57, 58
ARCALYST ....................................... 59
ARCAPTA NEOHALER ........................ 67
76
aripiprazole ......................................38
ARNUITY ELLIPTA .............................68
ARRANON ........................................24
ARZERRA .........................................25
ASACOL HD ......................................54
ASMANEX ........................................68
ASMANEX HFA ..................................68
ASMANEX TWISTHALER 14 MET ..........68
ASPIRIN-CAFFEINE-DIHYDROCODEINE
BITARTRATE.....................................14
ASTAGRAF XL ............................. 59, 60
ASTEPRO .........................................67
ATELVIA ..........................................48
atenolol ...........................................31
atenolol & chlorthalidone ...................31
ATGAM ............................................60
atorvastatin calcium ..........................30
atovaquone ......................................17
atovaquone-proguanil hcl tab 250-100 mg
......................................................19
ATOVAQUONE-PROGUANIL HCL TAB
62.5-25 MG......................................19
ATRALIN ..........................................69
ATRIPLA ..........................................20
ATROPINE SULFATE ..........................53
ATROVENT HFA ................................66
AUBAGIO .........................................43
AUGMENTIN .....................................23
AURYXIA ..........................................52
AUVI-Q ............................................68
AVASTIN ..........................................25
AVITA ..............................................69
AVODART.........................................56
AVONEX ..........................................43
AVONEX PEN ....................................43
AVYCAZ ...........................................21
AXERT .............................................42
AXIRON ...........................................45
azacitidine .......................................24
AZACTAM .........................................17
AZACTAM/DEX INJ 1GM .....................17
AZACTAM/DEX INJ 2GM .....................17
azasan.............................................60
AZASITE ..........................................64
azathioprine .....................................60
azelastine drop 0.05% .......................65
azelastine hcl ...................................67
azelastine spr 0.1% ..........................67
AZELEX ........................................... 69
AZILECT.......................................... 38
azithromycin .................................... 22
AZITHROMYCIN ............................... 22
AZOPT ............................................ 65
AZOR.............................................. 29
aztreonam ....................................... 17
B
bacitracin (ophthalmic) ..................... 64
bacitracin-polymyxin b (ophth) .......... 64
bacitracin-poly-neomycin-hc .............. 64
baclofen .......................................... 44
BACTOCILL INJ DEX 1GM .................. 23
BACTOCILL INJ DEX 2GM .................. 23
BACTROBAN NASAL .......................... 70
balsalazide disodium ......................... 54
BANZEL SUS 40MG/ML ..................... 34
BANZEL TAB 200MG ......................... 34
BANZEL TAB 400MG ......................... 34
BARACLUDE .................................... 20
BCG VACCINE .................................. 60
BECONASE AQ ................................. 68
benazepril & hydrochlorothiazide ........ 28
benazepril hcl .................................. 28
BENICAR ......................................... 29
BENICAR HCT .................................. 29
BENTYL ........................................... 53
benzoyl peroxide-erythromycin .......... 69
benztropine mesylate ....................... 38
BEPREVE ......................................... 65
BESIVANCE ..................................... 64
betamethasone dipropionate (topical) . 71
betamethasone dipropionate augmented
...................................................... 71
betamethasone valerate .................... 71
BETASERON .................................... 43
betaxolol hcl .................................... 31
betaxolol hcl (ophth) ........................ 66
bethanechol chloride ......................... 56
BETHKIS ......................................... 17
BETIMOL ......................................... 66
BETOPTIC-S .................................... 66
bexarotene ...................................... 27
BEXSERO ........................................ 60
bicalutamide .................................... 25
BICILLIN C-R ................................... 23
BICILLIN L-A ................................... 23
BICNU ............................................ 24
77
BIDIL ..............................................33
BILTRICIDE ......................................17
BINOSTO .........................................48
bisoprolol & hydrochlorothiazide .........31
bisoprolol fumarate ...........................31
BIVIGAM ..........................................59
bleomycin sulfate ..............................24
blephamide ......................................64
BLEPHAMIDE ....................................64
BOOSTRIX .......................................60
BOSULIF ..........................................26
BOTOX INJ 100UNIT..........................66
BOTOX INJ 200UNIT..........................66
BREO ELLIPTA ..................................69
BRILINTA .........................................58
BRIMONIDINE SOL 0.15% .................66
brimonidine sol 0.2% ........................66
BRINTELLIX .....................................37
BRISDELLE.......................................42
bromfenac sodium (ophth) .................65
BROMFENAC SODIUM
(OPHTH)(ONCE-DAILY) ......................65
bromocriptine mesylate .....................38
BROVANA ........................................67
budesonide ......................................54
budesonide (inhalation) .....................68
budesonide (nasal) ...........................68
bumetanide ......................................33
BUNAVAIL MIS 2.1-0.3 ......................44
BUNAVAIL MIS 4.2-0.7 ......................44
BUNAVAIL MIS 6.3-1MG ....................44
buprenorphine hcl .............................44
buprenorphine hcl-naloxone hcl sl .......44
buproban .........................................44
bupropion hcl ...................................37
buspirone hcl....................................34
BUSULFEX........................................24
butorphanol nasal spray ....................14
butorphanol tartrate ..........................14
BUTRANS .........................................14
BYDUREON ......................................45
BYETTA ...........................................46
BYSTOLIC ........................................31
C
cabergoline ......................................51
cafergot tab 1-100mg........................42
calcipotrien oin betameth ...................71
calcipotriene.....................................70
calcitonin (salmon) nasal spray .......... 51
calcitrene oin 0.005% ....................... 71
calcitriol .......................................... 64
CALCITRIOL .................................... 71
calcium acetate (phosphate binder) .... 52
CAMPTOSAR .................................... 28
CANASA .......................................... 54
CANCIDAS....................................... 18
candesartan cilexetil ......................... 29
candesartan cilexetil-hydrochlorothiazide
...................................................... 29
CANTIL ........................................... 53
CAPASTAT SULFATE ......................... 20
CAPEX ............................................ 71
capital
and codeine .................................. 14
CAPRELSA ....................................... 26
captopril ......................................... 28
captopril & hydrochlorothiazide .......... 28
CARAFATE ....................................... 55
CARBAGLU ...................................... 49
carbamazepine ................................ 34
carbidopa ........................................ 38
CARBIDOPA/LEVODOPA/ENTACAPONE 38
carbidopa-levodopa .......................... 38
carboplatin ...................................... 27
CARDIZEM LA .................................. 31
CARDURA XL ................................... 56
CARIMUNE NANOFILTERED................ 59
carteolol hcl (ophth) ......................... 66
cartia xt .......................................... 31
carvedilol ........................................ 31
CAYSTON ........................................ 17
CEDAX ............................................ 21
cefaclor ........................................... 21
cefaclor er tab 500mg ....................... 21
cefadroxil ........................................ 21
cefazolin inj ..................................... 21
cefazolin sodium .............................. 21
cefazolin/dextrose ............................ 21
cefdinir ........................................... 21
CEFEPIME 1GM SOLN ........................ 21
CEFEPIME 2GM SOLN ........................ 21
cefepime inj 1gm ............................. 21
cefepime inj 2gm ............................. 21
cefixime .......................................... 21
cefotaxime sodium ........................... 21
cefotetan disodium ........................... 21
78
cefoxitin sodium ...............................21
CEFOXITIN SODIUM IN DEXTROSE .....21
cefpodoxime proxetil .........................21
cefprozil...........................................21
ceftazidime ......................................22
CEFTAZIDIME/DEXTROSE ..................22
ceftibuten ........................................22
CEFTIN ............................................22
ceftriaxone sodium ............................22
cefuroxime axetil ..............................22
cefuroxime sodium ............................22
celecoxib .........................................13
CELLCEPT INTRAVENOUS ...................60
CELONTIN ........................................34
CENTANY .........................................70
cephalexin .......................................22
CERDELGA .......................................49
CEREZYME .......................................49
CERVARIX ........................................60
CESAMET .........................................52
cetirizine syrup .................................67
cevimeline hcl ..................................73
CHANTIX .........................................44
CHANTIX CONTINUING MONTH ..........44
CHANTIX STARTER PACK ...................44
CHEMET ...........................................48
chlorhexidine gluconate (mouth-throat)
......................................................73
chloroquine phosphate ......................19
chlorothiazide ...................................33
chlorpromaz inj 25mg/ml ...................38
chlorpromazine hcl ............................38
chlorthalidone ..................................33
cholestyramine .................................30
cholestyramine light ..........................30
choline fenofibrate ............................30
CHORIONIC GONADOTROPIN .............51
ciclopirox .........................................70
ciclopirox cre 0.77%..........................70
ciclopirox shampoo 1% ......................70
ciclopirox sus 0.77% .........................70
cidofovir ..........................................20
cilostazol .........................................58
CILOXAN OIN 0.3% OP ......................64
cimetidine ........................................53
cimetidine sol 300/5ml ......................53
CIMZIA ............................................58
CINRYZE ..........................................58
CIPRO HC ........................................ 73
CIPRODEX ....................................... 74
ciprofloxacin .................................... 23
ciprofloxacin er ................................ 23
ciprofloxacin hcl ............................... 23
ciprofloxacin hcl (ophth).................... 64
ciprofloxacin in d5w .......................... 23
ciprofloxacn inj ................................ 23
cisplatin .......................................... 27
citalopram hydrobromide .................. 37
cladribine ........................................ 24
claforan .......................................... 22
claravis ........................................... 69
CLARINEX ....................................... 67
CLARINEX-D TAB 2.5-120 ................. 67
clarithromycin .................................. 22
CLEOCIN VAG SUPP 100MG ............... 56
CLINDAGEL ..................................... 69
clindamax ....................................... 69
clindamycin cre 2% vag .................... 56
clindamycin hcl ................................ 17
clindamycin palmitate hydrochloride ... 17
clindamycin phosphate ...................... 17
clindamycin phosphate (topical) ......... 69
clindamycin phosphate in d5w ........... 17
clindamycin phosphate-benzoyl peroxide
...................................................... 69
clindamycin phosphate-benzoyl peroxide
(refrigerate) .................................... 69
CLINDESSE ..................................... 56
CLINIMIX 2.75%/DEXTROSE 5% ........ 62
CLINIMIX 4.25%/DEXTROSE 10% ...... 62
CLINIMIX 4.25%/DEXTROSE 20% ...... 62
CLINIMIX 4.25%/DEXTROSE 25% ...... 62
CLINIMIX 4.25%/DEXTROSE 5% ........ 62
CLINIMIX 5%/DEXTROSE 15% .......... 62
CLINIMIX 5%/DEXTROSE 20% .......... 62
CLINIMIX 5%/DEXTROSE 25% .......... 62
CLINIMIX E 2.75%/DEXTROSE 10% ... 62
CLINIMIX E 2.75%/DEXTROSE 5% ..... 62
CLINIMIX E 4.25%/DEXTROSE ........... 62
CLINIMIX E 4.25%/DEXTROSE 25% ... 62
CLINIMIX E 4.25%/DEXTROSE 5% ..... 62
CLINIMIX E 5%/DEXTROSE 15% ........ 62
CLINIMIX E 5%/DEXTROSE 20% ........ 62
CLINIMIX E 5%/DEXTROSE 25% ........ 62
clinisol 15 ........................................ 62
clobetasol e cre 0.05% ..................... 71
79
clobetasol propionate ........................71
clobetasol propionate emulsion ...........71
CLOCORTOLONE PIVALATE ................71
clodan sha 0.05% .............................71
CLOLAR ...........................................24
clomipramine hcl ..............................37
clonazepam ................................ 34, 35
clonidine hcl .....................................33
clopidogrel bisulfate ..........................58
clorazepate dipotassium ....................35
clorpres ...........................................33
clotrimazole .....................................73
clotrimazole (topical) .........................70
clozapine .........................................38
CLOZAPINE ODT ......................... 38, 39
CLOZAPINE ODT 150MG ....................39
CLOZAPINE ODT 200MG ....................39
COARTEM ........................................19
codeine
and capital ....................................14
CODEINE SULFATE ............................15
colchicine w/ probenecid ....................13
COLCRYS .........................................13
colestipol hcl ....................................30
colistimethate sodium........................17
colocort ...........................................54
COLY-MYCIN S .................................74
COLYTE-FLAVOR PACKS .....................54
COMBIGAN.......................................66
COMBIPATCH ...................................49
COMBIVENT RESPIMAT ......................66
COMETRIQ .......................................26
COMPLERA .......................................20
compro supp ....................................52
COMVAX ..........................................60
CONDYLOX ......................................72
constulose .......................................54
CONZIP ...........................................14
COPAXONE INJ 40MG/ML ...................43
COPAXONE KIT 20MG/ML ...................43
CORDRAN ........................................71
COREG CR .......................................31
CORLANOR ......................................33
cormax ............................................71
CORTIFOAM .....................................70
cortisone acetate ..............................49
CORTISPORIN ..................................70
CORTISPORIN-TC .............................74
COSENTYX ...................................... 71
COSENTYX SENSOREADY PEN ............ 71
COSOPT PF ...................................... 66
COUMADIN ...................................... 57
CREON ............................................ 55
CRESEMBA ...................................... 18
CRESTOR ........................................ 30
CRINONE ........................................ 52
CRIXIVAN........................................ 19
cromolyn sodium .............................. 68
cromolyn sodium (mastocytosis) ........ 55
cromolyn sodium (ophth) .................. 65
CUBICIN ......................................... 17
CUVPOSA ........................................ 53
cyclobenzaprine hcl .......................... 44
cyclophosphamide ............................ 24
CYCLOPHOSPHAMIDE ....................... 24
cycloserine ...................................... 20
cyclosporine .................................... 60
cyclosporine modified (for microemulsion)
...................................................... 60
CYSTADANE .................................... 49
CYSTAGON ...................................... 49
cytarabine inj .................................. 24
D
dacarbazine ..................................... 24
DALIRESP ....................................... 68
DALVANCE ...................................... 17
danazol ........................................... 48
dantrolene sodium ........................... 44
dapsone .......................................... 17
DAPTACEL ....................................... 60
DARAPRIM....................................... 17
daunorubicin hcl............................... 24
DAYTRANA ...................................... 41
decitabine ....................................... 25
DELZICOL ....................................... 54
demeclocycline hcl ........................... 23
DEMSER .......................................... 33
DENAVIR ......................................... 71
DEPEN TITRATABS ........................... 48
depo-estradiol ................................. 49
DEPO-MEDROL INJ 20MG/ML ............. 49
DEPO-PROVERA INJ 400/ML .............. 25
depo-testosterone ............................ 45
desipramine hcl................................ 37
desloratadine ................................... 67
desmopressin acetate ....................... 52
80
DESMOPRESSIN ACETATE ..................52
desmopressin acetate inj ...................52
desmopressin acetate spray ...............52
desmopressin acetate spray refrigerated
......................................................52
DESONATE .......................................71
desonide ..........................................71
DESONIDE .......................................71
desoximetasone ................................71
DESOXIMETASONE ...........................71
dexamethasone ................................49
dexamethasone sodium phosphate .....50
dexamethasone sodium phosphate
(ophth) ............................................65
DEXILANT ........................................55
dexpak taperpak 13 day ....................50
dexrazoxane ....................................27
dextrose ..........................................63
DEXTROSE .......................................63
DEXTROSE 10% FLEX CONTAIN..........63
DEXTROSE 10% W/ SODIUM CHLORIDE
0.2% ...............................................63
DEXTROSE 10%/NACL 0.45% ............63
DEXTROSE 2.5%/NACL 0.45% ...........63
DEXTROSE 5% .................................63
DEXTROSE 5% /ELECTROLYTE ...........63
DEXTROSE 5%/LACTATED RING .........63
DEXTROSE 5%/NACL 0.2% ................63
DEXTROSE 5%/NACL 0.225% ............63
DEXTROSE 5%/NACL 0.3% ................63
DEXTROSE 5%/NACL 0.33% ..............63
DEXTROSE 5%/NACL 0.45% ..............63
DEXTROSE 5%/NACL 0.9% ................63
DEXTROSE 5%/POTASSIUM CHL.........63
diazepam .........................................35
DIAZEPAM GEL (ANTICONVULSANT) ...35
DIBENZYLINE ...................................33
diclofenac potassium .........................13
diclofenac sodium .............................13
diclofenac sodium (actinic keratoses) ..72
diclofenac sodium (ophth) ..................65
diclofenac sodium (topical) .................72
diclofenac w/ misoprostol ...................13
dicloxacillin sodium ...........................23
dicyclomine hcl .................................53
didanosine .......................................19
DIFFERIN .........................................69
DIFICID ...........................................22
diflorasone diacetate ........................ 71
diflunisal ......................................... 13
digitek ............................................ 32
digoxin ........................................... 32
digoxin inj ....................................... 32
DIGOXIN SOL 50MCG/ML .................. 32
dihydroergotamine mesylate.............. 42
DIHYDROERGOTAMINE MESYLATE ...... 42
dilantin ........................................... 35
DILANTIN-125 ................................. 35
DILATRATE SR ................................. 33
DILAUDID-HP INJ 250MG .................. 15
dilt-cd cap ....................................... 31
diltiazem cap 120mg/24hr ................. 31
diltiazem cap er/12hr........................ 31
diltiazem hcl .................................... 31
diltiazem hcl coated beads cp24 120mg
...................................................... 31
diltiazem hcl coated beads cp24 180mg
...................................................... 31
diltiazem hcl coated beads cp24 240mg
...................................................... 31
diltiazem hcl coated beads cp24 300mg
...................................................... 31
diltiazem hcl coated beads cp24 360mg
...................................................... 31
diltiazem hcl er ................................ 31
diltiazem hcl extended release beads .. 32
diltiazem inj 100mg .......................... 32
diltiazem inj 125/25ml ...................... 32
diltiazem inj 25mg/5ml ..................... 32
diltiazem inj 50/10ml ........................ 32
dilt-xr cap ....................................... 31
diltzac............................................. 32
DIPENTUM ....................................... 54
diphenhydram inj 50mg/ml ............... 67
diphenoxylate w/ atropine ................. 55
DIPHTHERIA/TETANUS TOXOID ......... 60
disopyramide phosphate ................... 29
disulfiram ........................................ 44
DIURIL SUS 250/5ML........................ 33
divalproex sodium ............................ 35
docetaxel inj 140mg/7ml................... 25
DOCETAXEL INJ 160MG/16ML ............ 25
DOCETAXEL INJ 200MG/20ML ............ 25
DOCETAXEL INJ 20MG/2ML ............... 25
DOCETAXEL INJ 20MG/ML ................. 25
DOCETAXEL INJ 80MG/4ML ............... 25
81
DOCETAXEL INJ 80MG/8ML ................25
donepezil odt 10mg...........................36
donepezil odt 5mg ............................36
donepezil tab hcl 23mg ......................36
donepezil tabs 10mg .........................36
donepezil tabs 5mg ...........................36
DORIBAX .........................................17
DORYX ............................................23
dorzolamide hcl ................................66
dorzolamide hcl-timolol maleate .........66
doxazosin mesylate ...........................28
doxepin hcl ......................................37
doxercalciferol ..................................64
doxorubicin hcl .................................24
doxorubicin hcl liposomal inj 2mg/ml ...24
doxorubicin inj 50mg .........................24
doxy inj ...........................................23
doxycycline (monohydrate) ................23
DOXYCYCLINE (ROSACEA) .................72
doxycycline hyclate ...........................24
dronabinol .......................................52
DROXIA ...........................................27
DUEXIS ...........................................13
DULERA ...........................................69
duloxetine hcl ...................................37
DUOPA ............................................38
DURAMORPH ....................................15
DUREZOL .........................................65
DUTOPROL .......................................31
DYMISTA SPR 137-50 ........................67
DYRENIUM .......................................33
E
e.e.s. 400 tab 400mg ........................22
E.E.S. GRANULES .............................22
econazole nitrate ..............................70
EDARBI ...........................................29
EDARBYCLOR ...................................29
EDECRIN .........................................33
EDURANT .........................................19
EFFIENT...........................................58
EGRIFTA ..........................................51
ELAPRASE ........................................49
ELECTROLYTE-R IN DEXTROSE ...........63
ELELYSO ..........................................49
ELIDEL ............................................72
ELIGARD..........................................26
ELIGARD INJ 22.5MG ........................26
ELIGARD INJ 30MG ...........................26
ELIQUIS TAB 2.5MG ......................... 57
ELIQUIS TAB 5MG ............................ 57
ELITEK ............................................ 27
elixophyllin ...................................... 69
ELMIRON......................................... 56
ELOXATIN ....................................... 27
EMADINE ........................................ 65
EMBEDA CAPS 100-4MG.................... 15
EMBEDA CAPS 20-0.8MG................... 15
EMBEDA CAPS 30-1.2MG................... 15
EMBEDA CAPS 50-2MG ..................... 15
EMBEDA CAPS 60-2.4MG................... 15
EMBEDA CAPS 80-3.2MG................... 15
EMCYT ............................................ 24
EMEND CAP 125MG .......................... 53
EMEND CAP 40MG ............................ 52
EMEND CAP 80MG ............................ 53
EMEND PAK 80 & 125 ....................... 53
EMSAM ........................................... 37
EMTRIVA ......................................... 19
ENABLEX ......................................... 56
enalapril maleate ............................. 28
enalapril maleate & hydrochlorothiazide
...................................................... 28
ENBREL........................................... 58
ENBREL SURECLICK ......................... 58
endocet .......................................... 15
ENDODAN TAB ................................. 15
ENGERIX-B...................................... 60
enoxaparin sodium ........................... 57
entacapone ..................................... 38
entecavir ......................................... 20
ENTYVIO ......................................... 54
enulose ........................................... 54
EPIDUO........................................... 69
EPIDUO FORTE ................................ 69
epinastine hcl (ophth) ....................... 65
EPINEPHRINE .................................. 68
EPIPEN 2-PAK .................................. 68
EPIPEN-JR 2-PAK ............................. 68
epirubicin inj 200mg ......................... 24
EPIRUBICIN INJ 50MG ...................... 24
epirubicin inj 50mg/25ml .................. 24
epitol .............................................. 35
EPIVIR HBV ..................................... 20
EPIVIR SOL 10MG/ML ....................... 19
eplerenone ...................................... 28
EPOGEN .......................................... 58
82
eprosartan mesylate .........................29
EPZICOM .........................................20
EQUETRO .........................................42
ERAXIS ............................................18
ERBITUX ..........................................25
ergomar ..........................................42
ERIVEDGE ........................................25
ERTACZO .........................................70
ery pad 2% ......................................69
ERYPED 200 .....................................22
ERYPED 400 .....................................22
ery-tab ............................................22
erythrocin lactobionate ......................22
erythrocin stearate............................22
erythromycin (acne aid).....................69
erythromycin (ophth) ........................64
erythromycin base ............................22
erythromycin cap 250mg ec ...............22
erythromycin ethylsuccinate ...............22
ESBRIET ..........................................68
escitalopram oxalate .........................37
esomeprazole sodium inj ...................55
estrace ............................................49
estradiol ..........................................49
estradiol valerate ..............................49
ESTRADIOL VALERATE.......................49
ESTRING .........................................49
ethambutol hcl .................................20
ethosuximide....................................35
etodolac ..........................................13
etodolac er .......................................13
ETOPOPHOS .....................................28
etoposide .........................................28
EURAX .............................................73
EVOTAZ ...........................................20
EXELDERM .......................................70
EXELON PATCHES .............................36
exemestane .....................................26
EXJADE ...........................................48
EXTAVIA ..........................................43
F
FABIOR ...........................................69
FABRAZYME .....................................49
famciclovir .......................................21
famotidine .......................................53
FANAPT ...........................................39
FANAPT TITRATION PACK ..................39
FARESTON .......................................26
FARXIGA ......................................... 46
FARYDAK ........................................ 25
FASLODEX ....................................... 26
FAZACLO......................................... 39
felbamate ........................................ 35
felodipine ........................................ 32
FEMRING ........................................ 49
fenofibrate ...................................... 30
FENOFIBRATE .................................. 30
fenofibrate micronized ...................... 30
FENOFIBRIC ACID ............................ 30
FENOGLIDE ..................................... 30
fenoprofen calcium ........................... 13
fentanyl citrate ................................ 15
fentanyl patch.................................. 15
FENTORA ........................................ 15
FERRIPROX ..................................... 48
FETZIMA ......................................... 37
FETZIMA TITRATION PACK ................ 37
FINACEA ......................................... 72
finasteride ....................................... 56
FIRAZYR ......................................... 58
FIRMAGON ...................................... 26
FLAREX ........................................... 65
FLEBOGAMMA .................................. 59
FLEBOGAMMA DIF ............................ 59
flecainide acetate ............................. 29
FLO-PRED SUS ................................. 50
FLOVENT DISKUS ............................. 68
FLOVENT HFA .................................. 68
fluconazole ...................................... 18
fluconazole in dextrose ..................... 18
fluconazole in nacl ............................ 18
flucytosine....................................... 18
fludarabine phosphate ...................... 25
fludrocortisone acetate ..................... 50
flunisolide (nasal) ............................. 68
fluocinolone acetonide ...................... 72
fluocinolone acetonide (otic) .............. 74
fluocinolone acetonide body oil .......... 72
fluocinonide ..................................... 72
fluocinonide emulsified base .............. 72
FLUOROMETHOLONE (OPHTH) ........... 65
fluorouracil ...................................... 25
fluorouracil (topical) .................... 72, 73
FLUOROURACIL (TOPICAL) ................ 72
fluoxetine cap 10mg ......................... 37
fluoxetine cap 20mg ......................... 37
83
fluoxetine cap 40mg ..........................37
fluoxetine cap 90mg dr ......................37
fluoxetine sol 20mg/5ml ....................37
fluoxetine tab 10mg ..........................37
fluoxetine tab 20mg ..........................37
FLUOXETINE TAB 60MG .....................37
fluphenazine decanoate .....................39
fluphenazine hcl................................39
flurbiprofen ......................................13
flurbiprofen sodium ...........................65
flutamide .........................................26
fluticasone propionate .......................72
fluticasone propionate (nasal) ............68
fluvastatin sodium ............................30
fluvoxamine maleate .........................34
fluvoxamine maleate er .....................34
FML .................................................65
FML FORTE.......................................65
fondaparinux sodium .........................57
FORADIL AEROLIZER .........................67
FORFIVO XL .....................................37
FORTAZ ...........................................22
FORTEO ...........................................52
FORTESTA .......................................45
FORTICAL SPR 200/ACT .....................51
FOSAMAX PLUS D .............................48
fosinopril sodium ..............................28
fosinopril sodium & hydrochlorothiazide
......................................................28
FOSRENOL .......................................52
FRAGMIN .........................................57
FREAMINE HBC 6.9% ........................62
FREAMINE III ...................................62
FROVA TAB 2.5MG ............................42
furosemide .......................................33
furosemide inj ..................................33
furosemide oral soln 8 mg/ml .............33
FUZEON ...........................................19
FYCOMPA .........................................35
G
gabapentin .......................................35
GABITRIL .........................................35
galantamine hydrobromide.................36
GAMASTAN S/D ................................59
GAMMAGARD LIQUID ........................59
GAMMAGARD S/D .............................59
GAMMAGARD S/D IGA LESS TH ..........59
GAMMAKED ......................................59
GAMMAPLEX .................................... 59
GAMUNEX-C .................................... 59
GAMUNEX-C 1GM/10ML .................... 59
ganciclovir inj 500mg........................ 21
GARDASIL ....................................... 60
GARDASIL 9 .................................... 60
gatifloxacin (ophth) .......................... 64
GATTEX .......................................... 55
GAUZE PADS 2X2 ............................. 46
gaviltye-g........................................ 54
gavilyte-c ........................................ 54
gavilyte-h........................................ 54
gavilyte-n........................................ 54
GELNIQUE ....................................... 56
GEMCITABINE .................................. 25
gemcitabine hcl ................................ 25
gemfibrozil ...................................... 30
generlac .......................................... 54
gengraf ........................................... 60
GENOTROPIN................................... 51
GENOTROPIN MINIQUICK .................. 51
gentak ............................................ 64
gentamicin in saline .......................... 17
gentamicin sulfate ............................ 17
gentamicin sulfate (ophth) ................ 64
gentamicin sulfate (topical) ............... 70
GEODON INJ.................................... 39
GIAZO ............................................ 54
GILENYA CAP 0.5MG ......................... 43
GILOTRIF TAB 20MG......................... 26
GILOTRIF TAB 30MG......................... 26
GILOTRIF TAB 40MG......................... 26
GLASSIA ......................................... 68
GLEEVEC ......................................... 26
GLEOSTINE ..................................... 24
glimepiride ................................. 46, 47
glipizide .......................................... 47
glipizide er ...................................... 47
glipizide-metformin 2.5-250 mg ......... 47
glipizide-metformin 2.5-500 mg ......... 47
glipizide-metformin 5-500mg ............. 47
GLUCAGEN HYPOKIT......................... 50
GLUCAGON EMERGENCY KIT ............. 50
GLUMETZA ...................................... 47
glycate............................................ 53
glycopyrrolate .................................. 53
GLYSET ........................................... 47
GLYXAMBI ....................................... 47
84
GOLYTELY ........................................54
GRALISE ..........................................42
GRALISE STARTER ............................42
granisetron hcl .................................53
GRANIX ...........................................58
GRASTEK .........................................59
griseofulvin microsize ........................18
griseofulvin ultramicrosize..................18
guanfacine hcl (adhd) ........................41
H
H.P. ACTHAR ....................................51
HALAVEN .........................................27
halobetasol propionate ......................72
HALOG ............................................72
haloperidol .......................................39
haloperidol decanoate .......................39
haloperidol lactate ............................39
HARVONI .........................................21
HAVRIX ...........................................60
HEP SOD/NACL INJ 25000 .................57
HEPARIN (PORCINE) IN SODIUM
CHLORIDE 100U/ML ..........................57
heparin sod inj 10000u/ml .................57
heparin sod inj 1000u/ml ...................57
heparin sod inj 20000u/ml .................57
HEPARIN SOD INJ 2000U/ML ..............57
HEPARIN SOD INJ 2500U/ML ..............57
heparin sod inj 5000u/0.5ml ..............57
heparin sod inj 5000u/ml ...................57
HEPARIN SODIUM/D5W .....................57
HEPARIN SODIUM/NACL 0.45% ..........57
HEPATAMINE ....................................62
HERCEPTIN ......................................25
HEXALEN .........................................24
HIBERIX ..........................................60
HORIZANT .......................................42
HUMALOG ........................................46
HUMALOG KWIKPEN ..........................46
HUMALOG MIX 50/50 ........................46
HUMALOG MIX 50/50 KWIKPEN ..........46
HUMALOG MIX 75/25 ........................46
HUMALOG MIX 75/25 KWIKPEN ..........46
HUMATROPE.....................................51
HUMATROPE COMBO PACK .................51
HUMIRA ...........................................58
HUMIRA PEN ....................................58
HUMIRA PEN-CROHNS STARTER KIT ...58
HUMIRA PEN-PSORIASIS STARTER KIT 58
HUMULIN 70/30 ............................... 46
HUMULIN 70/30 KWIKPEN ................. 46
HUMULIN N ..................................... 46
HUMULIN N KWIKPEN ....................... 46
HUMULIN R ..................................... 46
HUMULIN R U-500 (CONCENTRATE) ... 46
hydralazine hcl................................. 33
hydrochlorothiazide .......................... 33
hydrocodone-acetaminophen 10-300mg
...................................................... 14
hydrocodone-acetaminophen 2.5-325mg
...................................................... 14
hydrocodone-acetaminophen 5-300mg 14
hydrocodone-acetaminophen 5-325mg 14
hydrocodone-acetaminophen 7.5-300mg
...................................................... 14
hydrocodone-acetaminophen 7.5-325
mg/15ml ......................................... 14
hydrocodone-acetaminophen 7.5-325mg
...................................................... 14
hydrocodone-acetaminophen tab
10-325mg ....................................... 14
hydrocodone-ibuprofen ..................... 14
hydrocodone-ibuprofen tab 7.5-200 mg
...................................................... 14
hydrocortisone ................................. 50
HYDROCORTISONE (INTRARECTAL).... 54
hydrocortisone (topical) .................... 72
hydrocortisone butyrate .................... 72
hydrocortisone butyrate hydrophilic lipo
base ............................................... 72
hydrocortisone valerate .................... 72
hydromorphone hcl .......................... 15
HYDROMORPHONE HCL ..................... 15
HYDROMORPHONE HCL 32MG ............ 15
hydromorphone tab 12mg er ............. 15
hydromorphone tab 16mg er ............. 15
hydromorphone tab 8mg er ............... 15
hydroxychloroquine sulfate ................ 58
hydroxyurea .................................... 27
hydroxyzine hcl inj ........................... 67
HYSINGLA ER .................................. 15
I
ibandronate sodium .......................... 48
IBRANCE ......................................... 25
ibudone tab 10-200mg ..................... 14
ibuprofen ........................................ 13
ICLUSIG .......................................... 26
85
idarubicin hcl ....................................24
IFEX ................................................24
ifosfamide ........................................24
ifosfamide for inj 1 gm ......................24
IFOSFAMIDE FOR INJ 3 GM ................24
ILEVRO ............................................65
ilotycin ............................................64
IMBRUVICA CAP 140MG .....................26
imipenem-cilastatin ...........................17
imipramine hcl..................................37
imipramine pamoate .........................37
imiquimod ........................................73
IMOVAX RABIES (H.D.C.V.) ................60
INCRELEX ........................................51
INCRUSE ELLIPTA .............................66
indapamide ......................................33
INFANRIX ........................................61
INFUMORPH 200 ...............................15
INFUMORPH 500 ...............................15
INLYTA ............................................26
INSULIN PEN NEEDLES ......................46
INSULIN SAFETY NEEDLES .................46
INSULIN SYRINGE.............................46
INSULIN SYRINGES ...........................46
INTELENCE ......................................19
INTRALIPID INJ 20% .........................62
INTRALIPID INJ 30% .........................62
INTRON-A INJ 10MU..........................59
INTRON-A INJ 18MU..........................59
INTRON-A INJ 25MU..........................59
INTRON-A INJ 50MU..........................59
INVANZ ...........................................17
INVEGA ...........................................39
INVEGA SUST INJ 117 MG/0.75 ML .....39
INVEGA SUST INJ 156MG/ML .............39
INVEGA SUST INJ 234 MG/1.5 ML .......39
INVEGA SUST INJ 39 MG/0.25 ML .......39
INVEGA SUST INJ 78 MG/0.5 ML .........39
INVEGA TRINZA................................39
INVIRASE ........................................19
INVOKAMET TAB 150-1000 ................47
INVOKAMET TAB 150-500 ..................47
INVOKAMET TAB 50-1000 ..................47
INVOKAMET TAB 50-500MG ...............47
INVOKANA TAB 100MG ......................47
INVOKANA TAB 300MG ......................47
IONOSOL-B/DEXTROSE 5% ...............63
IONOSOL-MB/DEXTROSE 5% .............63
IPOL INACTIVATED IPV ..................... 61
ipratropium bromide (nasal) .............. 66
ipratropium sol inhal ......................... 66
ipratropium-albuterol ........................ 66
irbesartan ....................................... 29
irbesartan-hydrochlorothiazide ........... 29
IRESSA ........................................... 26
irinotecan ........................................ 28
irinotecan hcl ................................... 28
ISENTRESS ..................................... 19
ISOLYTE P ....................................... 63
isolyte s .......................................... 63
isoniazid ......................................... 20
isoniazid tabs ................................... 20
ISORDIL TITRADOSE ........................ 33
isosorbide dinitrate ........................... 33
isosorbide mononitrate ..................... 33
isradipine ........................................ 32
ISTALOL.......................................... 66
ISTODAX ......................................... 25
itraconazole ..................................... 18
ivermectin ....................................... 17
IXEMPRA KIT ................................... 27
IXIARO ........................................... 61
J
JADENU .......................................... 48
JAKAFI ............................................ 26
JALYN ............................................. 56
jantoven ......................................... 57
JANUMET ........................................ 47
JANUMET XR TAB 100-1000............... 47
JANUMET XR TAB 50-1000 ................ 47
JANUMET XR TAB 50-500MG.............. 47
JANUVIA ......................................... 47
JARDIANCE ..................................... 47
JENTADUETO ................................... 47
K
KADCYLA ........................................ 25
KALETRA SOL .................................. 20
KALETRA TAB 100-25MG ................... 20
KALETRA TAB 200-50MG ................... 20
KAZANO .......................................... 47
KCL 0.075%/D5W/NACL 0.45% ......... 63
KCL 0.15%/D5W/LR ......................... 63
KCL 0.15%/D5W/NACL 0.9% ............. 63
kcl 0.3%/d5w/lr iv lac ri .................... 63
KCL 0.3%/D5W/NACL 0.45% ............. 63
KCL 0.3%/D5W/NACL 0.9% .............. 63
86
KCL IN NACL INJ .15-0.45..................63
KCL/D5W/NACL INJ .15/.33% ............63
KCL/D5W/NACL INJ .15/.45% ............63
KCL0.15%/D5W/NACL0.2% ...............63
KCL0.15%/D5W/NACL0.225% ............63
KENALOG .........................................72
KEPIVANCE ......................................27
ketoconazole ....................................18
ketoconazole (topical) .......................70
ketoconazole shampoo ......................71
ketodan aer 2% ................................70
ketoprofen .......................................13
ketorolac tromethamine (ophth) .........65
KINERET ..........................................59
KINRIX ............................................61
kionex .............................................48
KLOR-CON 10 ...................................61
KLOR-CON 8 ....................................61
klor-con m15....................................61
klor-con m20....................................61
klor-con pow 20meq..........................61
klor-con spr cap ................................61
KOMBIGLYZE XR 2.5-1000MG ............47
KOMBIGLYZE XR 5-1000MG ...............47
KOMBIGLYZE XR 5-500MG .................47
kristalose .........................................54
KUVAN ............................................49
L
labetalol hcl .....................................31
laclotion lot 12%...............................73
LACRISERT ......................................66
LACTATED RINGERS VIAFLEX .............63
lactulose ..........................................54
lactulose (encephalopathy) ................54
LAMICTAL ODT .................................35
LAMICTAL STARTER ..........................35
LAMICTAL XR ...................................35
LAMISIL ...........................................18
lamivudine .......................................19
lamivudine (hbv) ..............................21
lamivudine-zidovudine .......................20
lamotrigine ......................................35
LANOXIN .........................................32
LANOXIN PEDIATRIC .........................32
LANOXIN TAB ...................................32
lansoprazole .....................................55
LANTUS ...........................................46
LANTUS SOLOSTAR ...........................46
LASTACAFT ..................................... 65
latanoprost ...................................... 66
LATUDA .......................................... 39
LAZANDA ........................................ 15
leflunomide ..................................... 59
LEMTRADA ...................................... 43
LENVIMA 10MG DAILY DOSE ............. 26
LENVIMA 14MG DAILY DOSE ............. 27
LENVIMA 20MG DAILY DOSE ............. 27
LENVIMA 24MG DAILY DOSE ............. 27
LESCOL XL ...................................... 30
LETAIRIS ........................................ 34
letrozole.......................................... 26
leucovor ca inj ................................. 27
leucovorin calcium ............................ 27
leucovorin calcium 500 mg ................ 28
LEUKERAN ....................................... 24
LEUKINE ......................................... 58
leuprolide acetate............................. 26
levalbuterol conc 1.25mg/0.5ml ......... 67
levalbuterol hcl ................................ 67
LEVALBUTEROL HCL ......................... 67
LEVEMIR ......................................... 46
LEVEMIR FLEXTOUCH ....................... 46
levetiracetam................................... 35
LEVETIRACETAM IN NACL.................. 35
levetiracetam inj 500/5ml ................. 35
levobunolol hcl ................................. 66
LEVOBUNOLOL HCL .......................... 66
levocarnitine (metabolic modifiers) ..... 49
levocetirizine soln 2.5mg/5ml ............ 67
levocetirizine tab 5 mg ...................... 67
levofloxacin ..................................... 23
levofloxacin (ophth).......................... 64
levofloxacin in d5w ........................... 23
levorphanol tartrate .......................... 15
levothyroxine sodium........................ 52
LEVOXYL ......................................... 52
LEXIVA ........................................... 19
LIALDA ........................................... 54
lidocaine ......................................... 72
lidocaine hcl .................................... 72
lidocaine hcl (local anesth.) ............... 17
lidocaine hcl (mouth-throat) .............. 73
lidocaine inj 0.5% ............................ 17
lidocaine inj 1% ............................... 17
lidocaine inj 1.5% ............................ 17
lidocaine inj 2% ............................... 17
87
lidocaine-prilocaine ...........................72
linezolid ...........................................17
LINEZOLID .......................................17
LINZESS ..........................................55
liothyronine sodium ...........................52
LIPOSYN III INJ 10% ........................62
LIPTRUZET .......................................30
lisinopril...........................................28
lisinopril & hydrochlorothiazide ...........28
LITHIUM ..........................................42
lithium carbonate ..............................42
LIVALO ............................................30
LOCOID ...........................................72
LOKARA LOTN 0.05% ........................72
LOMUSTINE .....................................24
loperamide hcl ..................................55
lorazepam ........................................34
lorcet hd tab 10-325mg .....................14
lorcet plus tab 7.5-325 ......................14
lorcet tab 5-325mg ...........................14
lortab elix ........................................14
lortab tab 10-325mg .........................14
lortab tab 5-325mg ...........................14
lortab tab 7.5-325.............................14
losartan potassium ............................29
losartan potassium & hydrochlorothiazide
......................................................29
LOTEMAX .........................................65
LOTRONEX .......................................55
lovastatin .........................................30
loxapine succinate ............................39
lufyllin .............................................69
LUMIGAN .........................................66
LUMIZYME .......................................49
LUPANETA PACK ...............................49
LUPR DEP-PED INJ 15MG ...................26
LUPR DEP-PED INJ 30MG (3-MONTH) ..26
LUPRON DEP INJ 11.25MG .................26
LUPRON DEPOT ................................26
LUPRON DEPOT INJ 22.5MG (3-MONTH)
......................................................26
LUPRON DEPOT INJ 30MG (3-MONTH) .26
LUPRON DEPOT-PED .........................26
LUZU ...............................................70
LYNPARZA........................................25
LYRICA ............................................35
LYSODREN .......................................26
M
MACRODANTIN ................................ 18
magnesium sulfate ........................... 61
MAGNESIUM SULFATE ...................... 61
MAGNESIUM SULFATE IN D5W........... 61
malathion ........................................ 73
maprotiline hcl ................................. 37
MARPLAN ........................................ 37
MATULANE ...................................... 27
matzim la ........................................ 32
MAXIDEX ........................................ 65
MAXIPIME ....................................... 22
meclizine hcl .................................... 53
MEDROL TAB 2MG ............................ 50
medroxyprogesterone acetate............ 52
mefenamic acid ................................ 13
mefloquine hcl ................................. 19
MEGACE ES ..................................... 26
megestrol acetate ............................ 26
megestrol acetate sus 40mg/ml ......... 26
MEGESTROL ACETATE SUS 625MG/5ML
...................................................... 26
MEKINIST ....................................... 27
MELOXICAM .................................... 13
meloxicam tabs ................................ 13
melphalan hcl .................................. 24
memantine hcl ................................. 36
MEMANTINE HCL .............................. 36
MENACTRA ...................................... 61
MENOMUNE-A/C/Y/W-135 ................. 61
MENOSTAR ...................................... 49
MENTAX .......................................... 70
MENVEO ......................................... 61
mercaptopurine ............................... 25
meropenem ..................................... 18
mesalamine enema .......................... 54
mesna ............................................ 28
MESNEX .......................................... 28
MESTINON SYRUP ............................ 42
MESTINON TIMESPAN ....................... 42
metadate er 20mg ........................... 41
metformin er ................................... 47
metformin hcl .................................. 47
methadone hcl ................................. 15
METHADONE INJ 10MG/ML ................ 15
methazolamide ................................ 33
methenamine hippurate .................... 18
methimazole .................................... 52
88
methotrexate sodium inj ....................25
methotrexate sodium tabs .................59
methoxsalen rapid ............................71
methscopolamine bromide .................53
methyclothiazide...............................33
methylergonovine maleate .................51
METHYLIN CHEW TAB ........................41
methylphenidate hcl ..........................41
methylphenidate hcl er ......................41
methylphenidate hcl er tabs 10mg ......41
methylphenidate hcl er tabs 18mg ......41
methylphenidate hcl er tabs 20mg ......41
methylpr ace inj 40mg/ml ..................50
methylpr ace inj 80mg/ml ..................50
methylpr ss inj 125mg .......................50
methylpr ss inj 1gm ..........................50
methylpr ss inj 40mg ........................50
methylpred pak 4mg .........................50
methylpred tab 16mg ........................50
methylpred tab 32mg ........................50
methylpred tab 4mg ..........................50
methylpred tab 8mg ..........................50
metipranolol .....................................66
metoclopramide hcl ...........................53
metoclopramide hcl inj 5 mg/ml .........53
metolazone ......................................33
metoprolol & hctz tab 100-25mg.........31
metoprolol & hctz tab 100-50mg.........31
metoprolol & hctz tab 50-25mg ..........31
metoprolol succinate .........................31
metoprolol tartrate ............................31
METOZOLV ODT ................................53
METRO IV ........................................18
metronidazole ..................................18
metronidazole (topical) ......................73
metronidazole inj ..............................18
metronidazole vaginal .......................56
mexiletine hcl ...................................29
MIACALCIN INJ 200U/ML ...................51
miconazole nitrate vaginal .................56
midodrine hcl ...................................33
migergot ..........................................42
millipred ..........................................50
minitran ..........................................33
MINIVELLE .......................................49
minocycline hcl .................................24
minoxidil ..........................................33
MIRAPEX..........................................38
MIRAPEX ER .................................... 38
MIRCERA......................................... 58
mirtazapine ..................................... 37
misoprostol ..................................... 55
mitomycin ....................................... 24
mitoxantrone hcl .............................. 27
M-M-R II ......................................... 61
modafinil ......................................... 44
moderiba pak .................................. 21
moderiba tab 200mg ........................ 21
moexipril hcl .................................... 28
moexipril-hydrochlorothiazide ............ 28
mometasone furoate ........................ 72
montelukast sodium ......................... 67
MORPHINE SUL 20MG/ML ORAL SOL... 15
morphine sulfate .............................. 16
MORPHINE SULFATE ......................... 16
morphine sulfate beads ..................... 16
morphine sulfate ext-rel tab .............. 16
MOVANTIK ...................................... 55
MOVIPREP ....................................... 54
MOXEZA.......................................... 64
moxifloxacin hcl ............................... 23
MOXIFLOXACIN HCL ......................... 23
MOZOBIL ........................................ 58
MULTAQ .......................................... 29
mupirocin ........................................ 70
mupirocin calcium (topical)................ 70
MUSTARGEN .................................... 24
MYCAMINE ...................................... 18
mycophenolate mofetil ...................... 60
mycophenolate sodium ..................... 60
myorisan ......................................... 69
MYOZYME........................................ 49
MYRBETRIQ ..................................... 56
N
nabumetone .................................... 13
nadolol ........................................... 31
nadolol & bendroflumethiazide ........... 31
nafcillin sodium ................................ 23
NAFTIFINE HCL ................................ 70
NAFTIN ........................................... 70
NAGLAZYME .................................... 49
NALLPEN ISO-OSMOTIC IN DE ........... 23
NALLPEN/DEXTROSE ........................ 23
naloxone hcl .................................... 44
naltrexone hcl .................................. 44
NAMENDA SOL 10MG/5ML ................. 36
89
NAMENDA TAB .................................36
NAMENDA XR ...................................36
NAMENDA XR TITRATION PACK ..........36
NAMZARIC .......................................36
naphazoline 0.1% .............................66
NAPRELAN .......................................13
naproxen .........................................13
NAPROXEN SOD TAB 375MG CR .........13
NAPROXEN SOD TAB 500MG CR .........13
naproxen sodium ..............................13
naratriptan hcl ..................................42
NASONEX ........................................68
NATACYN .........................................64
nateglinide .......................................47
NATPARA .........................................52
NEBUPENT .......................................18
nefazodone hcl .................................37
neomycin sulfate ..............................17
neomycin/polymyxin b gu ..................73
neomycin-bacitracin zn-polymyxin ......64
neomycin-polymy-dexameth ..............64
neomycin-polymyxin-gramicidin .........64
neomycin-polymyxin-hc (ophth) .........64
neomycin-polymyxin-hc (otic) ............74
NEORAL ...........................................60
NEPHRAMINE ...................................62
NESINA ...........................................47
neuac gel 1.2-5% .............................69
NEULASTA .......................................58
NEUMEGA ........................................58
NEUPOGEN ......................................58
NEUPRO...........................................38
NEVANAC .........................................65
nevirapine ........................................19
NEVIRAPINE .....................................19
NEXAVAR .........................................27
NEXIUM CAP 20MG ...........................55
NEXIUM CAP 40MG ...........................55
NEXIUM GRA 10MG DR ......................55
NEXIUM GRA 2.5MG DR .....................55
NEXIUM GRA 20MG DR ......................55
NEXIUM GRA 40MG DR ......................55
NEXIUM GRA 5MG DR ........................55
niacin (antihyperlipidemic) .................30
niacor ..............................................30
nicardipine hcl ..................................32
NICOTROL INHALER ..........................44
NICOTROL NS ..................................44
nifedical .......................................... 32
nifedipine ........................................ 32
nifedipine er .................................... 32
NILANDRON .................................... 26
nimodipine ...................................... 32
NIPENT ........................................... 25
nisoldipine ....................................... 32
nitro-bid.......................................... 33
NITRO-DUR ..................................... 33
nitrofurantoin .................................. 18
nitrofurantoin macrocrystal ............... 18
nitrofurantoin monohyd macro ........... 18
NITROGLYCERIN .............................. 33
NITROGLYCERIN LINGUAL ................. 33
nitroglycerin patches ........................ 34
NITROLINGUAL SPR PUMPSPRA ......... 34
NITROMIST ..................................... 34
NITROSTAT ..................................... 34
nizatidine ........................................ 53
NORDITROPIN FLEXPRO .................... 51
NORDITROPIN NORDIFLEX PEN ......... 51
norethindrone acetate ....................... 52
NORITATE ....................................... 73
normosol-m ..................................... 63
NORMOSOL-R .................................. 63
NORPACE CR ................................... 29
nortriptyline hcl ............................... 37
NORVIR .......................................... 19
NOVAREL INJ 10000UNT ................... 51
NOVOLIN 70/30 ............................... 46
NOVOLIN 70/30 RELION ................... 46
NOVOLIN N ..................................... 46
NOVOLIN N RELION .......................... 46
NOVOLIN R ..................................... 46
NOVOLIN R RELION .......................... 46
NOVOLOG ....................................... 46
NOVOLOG FLEXPEN .......................... 46
NOVOLOG MIX 70/30 ........................ 46
NOVOLOG MIX 70/30 PREFILL ........... 46
NOVOLOG PENFILL ........................... 46
NOXAFIL ......................................... 18
NUCYNTA ........................................ 16
NUCYNTA ER ................................... 16
NUEDEXTA ...................................... 43
NULOJIX ......................................... 60
NULYTELY/FLAVOR PACKS ................. 54
NUTRILIPID EMU 20% ...................... 62
NUTROPIN AQ INJ 20MG/2ML ............ 51
90
NUTROPIN AQ NUSPIN 5 ....................51
NUTROPIN AQ PEN ............................51
NUVESSA .........................................56
NUVIGIL ..........................................44
nyamyc ...........................................70
NYMALIZE ........................................32
nystatin ...........................................18
nystatin (mouth-throat) .....................73
nystatin (topical) ..............................70
nystatin pow 100000 .........................70
nystop .............................................70
O
OCTAGAM ........................................59
octreotide acetate .............................51
OFEV ...............................................68
ofloxacin (ophth) ..............................64
ofloxacin (otic) .................................74
olanzapine .......................................39
olanzapine odt ..................................39
olopatadine hcl (nasal) ......................67
OLYSIO ...........................................21
OMECLAMOX-PAK .............................55
omega-3-acid ethyl esters..................30
omeprazole ......................................55
OMEPRAZOLE-SODIUM BICARBONATE .56
OMNARIS .........................................68
OMNITROPE 10MG ............................51
OMNITROPE 5.8MG ...........................51
OMNITROPE 5MG ..............................51
ondansetron hcl ................................53
ondansetron hcl inj ...........................53
ondansetron hcl oral soln ...................53
ondansetron odt ...............................53
ONEXTON ........................................69
ONFI SUS 2.5MG/ML .........................35
ONFI TAB 10MG ................................36
ONGLYZA .........................................47
ONMEL ............................................18
OPANA ER (CRUSH RESISTANT ...........16
OPSUMIT .........................................34
ORACEA...........................................73
ORAP ..............................................39
ORAPRED ODT TAB 10MG ..................50
ORENCIA .........................................59
ORENITRAM TAB 0.125MG .................34
ORENITRAM TAB 0.25MG ...................34
ORENITRAM TAB 1MG .......................34
ORENITRAM TAB 2.5MG .....................34
ORFADIN......................................... 49
ORKAMBI ........................................ 68
OSENI TAB 12.5-15MG ..................... 47
OSENI TAB 12.5-30MG ..................... 47
OSENI TAB 12.5-45MG ..................... 47
OSENI TAB 25-15MG ........................ 48
OSENI TAB 25-30MG ........................ 48
OSENI TAB 25-45MG ........................ 48
OSMOPREP ...................................... 54
OTEZLA........................................... 59
oxacillin sodium ............................... 23
oxaliplatin ....................................... 27
oxandrolone .................................... 45
oxaprozin ........................................ 13
oxcarbazepine ................................. 36
OXECTA .......................................... 16
OXISTAT ......................................... 70
OXSORALEN .................................... 73
OXTELLAR XR .................................. 36
oxybutynin chloride .......................... 56
oxycodone hcl .................................. 16
OXYCODONE HCL ............................. 16
oxycodone w/ acetaminophen 10-325mg
...................................................... 16
oxycodone w/ acetaminophen 2.5-325mg
...................................................... 16
oxycodone w/ acetaminophen 5-325mg
...................................................... 16
oxycodone w/ acetaminophen 7.5-325mg
...................................................... 16
oxycodone-aspirin ............................ 16
oxycodone-ibuprofen ........................ 16
OXYCONTIN..................................... 16
oxymorphone hcl ............................. 16
OXYTROL ........................................ 56
P
pacerone ......................................... 29
paclitaxel ........................................ 25
pamidronate disodium ...................... 48
PANCREAZE ..................................... 55
PANDEL .......................................... 72
PANRETIN ....................................... 73
pantoprazole sodium tbec ................. 56
paricalcitol....................................... 64
PARICALCITOL ................................. 64
paromomycin sulfate ........................ 17
paroxetine er tab ............................. 37
paroxetine hcl .................................. 37
91
paser d/r .........................................20
PATADAY .........................................65
PATANOL .........................................65
PAXIL ..............................................37
PAZEO .............................................65
PCE .................................................22
PEDVAX HIB .....................................61
peg 3350-kcl-sod bicarb-sod chloride-sod
sulfate .............................................54
peg 3350-potassium chloride-sod
bicarbonate-sod chloride ....................54
PEGANONE .......................................36
PEGASYS .........................................59
PEGASYS PROCLICK ..........................59
PEG-INTRON ....................................59
PEG-INTRON REDIPEN .......................59
PENICILLIN G POT IN DEXTROSE ........23
penicillin g potassium ........................23
PENICILLIN G POTASSIUM IN .............23
penicillin g procaine ..........................23
penicillin g sodium ............................23
penicillin v potassium ........................23
PENNSAID SOL 2% ...........................73
PENTAM 300 ....................................18
PENTASA .........................................54
pentoxifylline....................................58
PERFOROMIST ..................................67
perindopril erbumine .........................28
periogard soln 0.12% ........................73
permethrin .......................................73
perphenazine ...................................39
PERTZYE ..........................................55
PEXEVA ...........................................37
pfizerpen .........................................23
phenelzine sulfate .............................37
phenobarbital ...................................36
phenobarbital sodium ........................36
PHENOBARBITAL SODIUM ..................36
PHENOXYBENZAMINE HCL .................33
phenytek .........................................36
phenytoin ........................................36
phenytoin inj 50mg/ml ......................36
phenytoin sodium extended ...............36
PHOSLYRA .......................................52
PHOSPHOLINE IODIDE ......................66
PICATO ............................................73
PILOCARPINE HCL .............................66
pilocarpine hcl (oral) .........................73
pindolol ........................................... 31
pioglitazone hcl ................................ 48
pioglitazone hcl-glimepiride ............... 48
pioglitazone hcl-metformin hcl ........... 48
piperacillin sodium-tazobactam sodium 23
piroxicam ........................................ 13
PLASMA-LYTE A ............................... 63
PLASMA-LYTE-148 ............................ 63
PLASMA-LYTE-56/D5W...................... 63
PLEGRIDY ....................................... 43
PLEGRIDY STARTER PACK ................. 43
podofilox ......................................... 73
polyethylene glycol 3350 ................... 54
polymyxin b sulfate .......................... 18
polymyxin b-trimethoprim ................. 65
POMALYST....................................... 27
potassium chloride ...................... 61, 63
POTASSIUM CHLORIDE ..................... 61
POTASSIUM CHLORIDE 0.15% ........... 63
POTASSIUM CHLORIDE 0.22% ........... 63
POTASSIUM CHLORIDE 0.3%/D ......... 63
potassium chloride caps er ................ 61
potassium chloride in nacl ................. 63
POTASSIUM CHLORIDE IN NACL ........ 64
potassium chloride microencapsulated
crystals cr ....................................... 61
POTASSIUM CITRATE (ALKALINIZER) . 56
POTIGA ........................................... 36
PRADAXA ........................................ 57
pramipexole dihydrochloride .............. 38
pramipexole dihydrochloride er tabs ... 38
PRANDIMET ..................................... 48
pravastatin sodium ........................... 30
prazosin hcl ..................................... 28
PRED MILD ...................................... 65
pred sod pho sol 5mg/5ml ................. 50
PRED-G ........................................... 64
PRED-G S.O.P. ................................. 64
prednicarbate .................................. 72
PREDNICARBATE .............................. 72
PREDNISOLONE ACETATE (OPHTH) .... 65
prednisolone sodium phosphate ......... 50
prednisolone sodium phosphate (ophth)
...................................................... 65
prednisolone sol 15mg/5ml ............... 50
prednisolone sol 25mg/5ml ............... 50
prednisolone syrup 15 mg/5ml........... 50
prednisone con 5mg/ml .................... 50
92
prednisone pak 10mg ........................50
prednisone pak 5mg ..........................50
prednisone sol 5mg/5ml ....................50
prednisone tab 10mg ........................50
prednisone tab 1mg ..........................50
prednisone tab 2.5mg .......................50
prednisone tab 20mg ........................50
prednisone tab 50mg ........................50
prednisone tab 5mg ..........................50
PREGNYL W/DILUENT BENZYL ............51
PREMARIN CREAM.............................49
PREMARIN INJ ..................................49
premasol 10% ..................................62
premasol 6% ....................................62
PRENATAL VITAMIN/FOLIC ACID > 0.8
MG (GENERIC) .................................64
PREPOPIK ........................................54
PREVACID SOLUTAB ..........................56
prevalite ..........................................30
PREZCOBIX ......................................20
PREZISTA ........................................19
PRIFTIN ...........................................20
PRILOSEC ........................................56
PRIMAQUINE PHOSPHATE ..................19
primidone ........................................36
PRIMSOL SOL 50MG/5ML ...................18
PRISTIQ ..........................................37
PRIVIGEN ........................................59
PROAIR HFA .....................................67
PROAIR RESPICLICK .........................67
probenecid .......................................13
PROCALAMINE ..................................62
prochlorperazine inj 5 mg/ml..............53
prochlorperazine maleate ...................53
prochlorperazine supp .......................53
PROCRIT ..........................................58
procto-pak .......................................70
proctosol hc 2.5 % ............................70
proctozone hc ...................................70
PROCYSBI ........................................49
progesterone micronized ....................52
PROGLYCEM SUS 50MG/ML ................50
PROGRAF .........................................60
PROLASTIN-C ...................................68
PROLENSA .......................................66
PROLEUKIN ......................................25
PROLIA ............................................51
PROMACTA.......................................58
promethazine hcl ............................. 53
propafenone hcl ............................... 30
proparacaine hcl .............................. 66
propranolol & hydrochlorothiazide ...... 31
propranolol hcl er ............................. 31
propranolol inj 1mg/ml ..................... 31
propranolol sol ................................. 31
propranolol tab ................................ 31
propylthiouracil ................................ 52
PROQUAD ....................................... 61
PROSOL .......................................... 62
PROTONIX ....................................... 56
protriptyline hcl................................ 37
PROVENTIL HFA ............................... 67
PRUDOXIN CRE 5% .......................... 70
PULMICORT FLEXHALER .................... 68
PULMICORT INH SUSP 1MG/2ML ........ 68
PULMOZYME .................................... 68
PURIXAN ......................................... 25
PYLERA ........................................... 55
pyrazinamide ................................... 20
pyridostigmine bromide .................... 43
Q
QNASL ............................................ 68
QNASL CHILDRENS .......................... 68
QUADRACEL .................................... 61
QUDEXY XR ..................................... 36
quetiapine fumarate ......................... 39
QUILLIVANT XR ............................... 41
quinapril hcl .................................... 28
quinapril-hydrochlorothiazide ............. 28
quinidine gluconate er ...................... 30
quinidine sulfate .............................. 30
quinine sulfate ................................. 19
QVAR ......................................... 68, 69
R
RABAVERT....................................... 61
rabeprazole sodium .......................... 56
RAGWITEK ...................................... 59
raloxifene hcl ................................... 51
ramipril ........................................... 28
RANEXA .......................................... 33
ranitidine hcl ................................... 53
RAPAFLO ......................................... 56
RAPAMUNE ...................................... 60
RAYOS TAB 1MG .............................. 50
RAYOS TAB 2MG .............................. 50
RAYOS TAB 5MG .............................. 50
93
REBETOL .........................................21
REBIF ..............................................43
REBIF REBIDOSE ..............................43
REBIF REBIDOSE TITRATION..............43
REBIF TITRATION PACK .....................44
RECOMBIVAX HB ..............................61
RECTIV ............................................73
REGRANEX .......................................73
RELENZA DISKHALER ........................21
RELISTOR ........................................54
RELPAX ...........................................42
REMICADE .......................................59
REMODULIN .....................................34
RENAGEL .........................................52
RENVELA PAK ...................................52
RENVELA TAB 800MG ........................52
repaglinide .......................................48
reprexain 10/200 ..............................14
RESCRIPTOR ....................................19
RESTASIS ........................................66
RETIN-A MICRO PUMP .......................69
RETROVIR IV INFUSION ....................19
REVATIO ..........................................34
REVLIMID ........................................59
REXULTI .................................... 39, 40
REYATAZ .........................................19
RHEUMATREX ...................................59
ribapak mis 600/day .........................21
ribasphere .......................................21
ribasphere ribapak 1000 ....................21
ribasphere ribapak 1200 ....................21
ribasphere ribapak 800 ......................21
ribavirin 200mg ................................21
rifabutin ..........................................20
rifamate ..........................................20
rifampin ...........................................20
RIFATER ..........................................20
riluzole ............................................43
rimantadine hydrochloride .................21
RINGER'S.........................................64
RIOMET ...........................................48
risedronate sodium ...........................48
RISPERDAL INJ 12.5MG .....................40
RISPERDAL INJ 25MG ........................40
RISPERDAL INJ 37.5MG .....................40
RISPERDAL INJ 50MG ........................40
risperidone .......................................40
risperidone odt .................................40
RITALIN LA...................................... 41
RITUXAN ......................................... 25
rivastigmine tartrate ......................... 36
rizatriptan benzoate ......................... 42
ropinirole hydrochloride .................... 38
rosadan cre 0.75% ........................... 73
ROTARIX ......................................... 61
ROTATEQ ........................................ 61
roxicet soln ..................................... 16
roxicet tabs ..................................... 16
ROZEREM ........................................ 41
RUCONEST ...................................... 58
RYTARY ........................................... 38
S
SABRIL ........................................... 36
SAIZEN ........................................... 51
SAIZEN CLICK.EASY ......................... 51
SAMSCA .......................................... 51
SANCUSO ........................................ 53
SANDIMMUNE CAPS ......................... 60
SANDIMMUNE SOLN ......................... 60
SANDOSTATIN LAR DEPOT ................ 51
SANTYL ........................................... 73
SAPHRIS ......................................... 40
SARAFEM ........................................ 44
SAVAYSA ........................................ 57
SAVELLA ......................................... 43
SAVELLA TITRATION PACK ................ 43
selegiline hcl .................................... 38
selenium sulfide ............................... 71
SELZENTRY ..................................... 19
SEMPREX-D ..................................... 67
SENSIPAR ....................................... 48
SEREVENT DISKUS ........................... 67
SEROQUEL XR ................................. 40
SEROSTIM ....................................... 51
sertraline hcl ................................... 37
SF-ROWASA .................................... 54
SIGNIFOR ....................................... 51
SIGNIFOR LAR ................................. 51
sildenafil citrate (pulmonary
hypertension) .................................. 34
SILENOR ......................................... 41
SILVER SULFADIAZINE ..................... 70
SIMBRINZA SUS 1-0.2% ................... 66
SIMCOR .......................................... 30
SIMPONI ......................................... 59
SIMPONI ARIA ................................. 59
94
SIMULECT ........................................60
simvastatin ......................................30
sirolimus ..........................................60
SIROLIMUS ......................................60
SIRTURO .........................................20
SIVEXTRO ........................................18
SKLICE ............................................73
SODIUM CHLORIDE ..................... 62, 64
SODIUM CHLORIDE 0.45% VIA ..........64
SODIUM CHLORIDE 0.9% ..................73
SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5
F) MG/ML SOLN ................................62
sodium phenylbutyrate ......................49
sodium polystyrene sulfonate .............48
SOLODYN ........................................24
SOLTAMOX.......................................26
SOLU-CORTEF 1000MG ......................50
SOLU-CORTEF 100MG .......................50
SOLU-CORTEF 250MG .......................50
SOLU-CORTEF 500MG .......................50
SOLU-MEDROL INJ 2GM .....................50
SOMATULINE DEPOT .........................51
SOMAVERT.......................................51
SOOLANTRA .....................................73
SORILUX..........................................71
sorine ..............................................30
sotalol hcl ........................................30
sotalol hcl (afib/afl) ...........................30
SOTYLIZE ........................................31
SOVALDI .........................................21
SPIRIVA HANDIHALER .......................66
SPIRIVA RESPIMAT ...........................67
spironolactone ..................................28
spironolactone & hydrochlorothiazide ..33
SPORANOX SOL 10MG/ML ..................18
SPRYCEL ..........................................27
SSD ................................................70
stavudine .........................................19
STELARA..........................................71
STERILE WATER IRRIGATION .............73
STIMATE ..........................................52
STIOLTO RESPIMAT ..........................66
STIVARGA ........................................27
STRATTERA ......................................41
streptomycin sulfate ..........................17
STRIANT ..........................................45
STRIBILD .........................................20
STRIVERDI RESPIMAT .......................67
SUBOXONE MIS 12-3MG ................... 45
SUBOXONE MIS 2-0.5MG .................. 45
SUBOXONE MIS 4-1MG ..................... 45
SUBOXONE MIS 8-2MG ..................... 45
SUBSYS .......................................... 16
SUCLEAR......................................... 54
SUCRAID......................................... 55
sucralfate ........................................ 55
sulfacetamide sodium (acne) ............. 69
sulfacetamide sodium (ophth) ............ 65
sulfacetamide sod-prednisolone ......... 64
sulfadiazine ..................................... 17
sulfamethoxazole-trimethop .............. 18
sulfamethoxazole-trimethoprim inj ..... 18
SULFAMYLON ................................... 70
sulfasalazine dr ................................ 54
sulfasalazine ir ................................. 54
sulindac .......................................... 13
sumatriptan succinate ....................... 42
SUMATRIPTAN SUCCINATE ................ 42
sumatriptan succinate inj .................. 42
SUMAVEL DOSEPRO ......................... 42
suprax ............................................ 22
SUPRAX .......................................... 22
SUPREP BOWEL PREP ....................... 54
SURMONTIL ..................................... 37
SUSTIVA ......................................... 19
SUTENT .......................................... 27
SYLATRON KIT 296MCG .................... 27
SYLATRON KIT 444MCG .................... 27
SYLATRON KIT 888MCG .................... 27
SYMBICORT ..................................... 69
SYMLINPEN 120 ............................... 46
SYMLINPEN 60 ................................. 46
SYNAGIS ......................................... 61
SYNAREL ......................................... 49
SYNERA .......................................... 72
SYNERCID ....................................... 18
SYNTHROID..................................... 52
SYPRINE ......................................... 48
T
TABLOID ......................................... 25
TACLONEX ...................................... 72
tacrolimus ....................................... 60
tacrolimus (topical) .......................... 73
TAFINLAR ........................................ 27
TAMIFLU ......................................... 21
tamoxifen citrate .............................. 26
95
tamsulosin hcl ..................................56
TANZEUM ........................................46
TARCEVA .........................................27
TARGRETIN CAPS .............................27
TARGRETIN GEL ...............................73
TARKA .............................................28
TASIGNA .........................................27
tazicef .............................................22
tazicef vial .......................................22
TAZORAC .........................................71
taztia xt ...........................................32
TECFIDERA CAP 120MG .....................44
TECFIDERA CAP 240MG .....................44
TECFIDERA MIS STARTER ..................44
TEFLARO..........................................22
TEGRETOL .......................................36
TEGRETOL-XR ..................................36
TEKAMLO TAB 150-10MG ...................32
TEKAMLO TAB 150-5MG.....................32
TEKTURNA .......................................32
TEKTURNA HCT ................................32
TELMISARTAN ..................................29
telmisartan-amlodipine ......................29
telmisartan-hydrochlorothiazide ..........29
temazepam ................................ 41, 42
TENIVAC ..........................................61
terazosin hcl.....................................28
terbinafine hcl ..................................19
terbutaline sulfate .............................67
terconazole vaginal ...........................56
TESTIM ............................................45
testosterone cypionate ......................45
testosterone enanthate ......................45
TETANUS TOXOID ADSORBED ............61
TETANUS/DIPHTHERIA TOXOID ..........61
TETRABENAZINE ...............................43
TETRACYCLINE HCL ..........................24
TEVETEN HCT ...................................29
TEV-TROPIN .....................................51
texacort ...........................................72
THALOMID .......................................59
theo-24 ...........................................69
theophylline .....................................69
thioridazine hcl .................................40
thiothixene.......................................40
THYMOGLOBULIN..............................60
tiagabine hcl ....................................36
TIKOSYN..........................................30
timolol maleate ................................ 31
timolol maleate (ophth) .................... 66
TIMOLOL MALEATE GEL..................... 66
TIMOPTIC ........................................ 66
TIMOPTIC OCUDOSE ........................ 66
TIROSINT ........................................ 52
TIVICAY .......................................... 19
tizanidine ........................................ 44
TOBI PODHALER .............................. 17
TOBRADEX ...................................... 64
TOBRADEX ST ................................. 64
tobramycin ...................................... 17
tobramycin (ophth) .......................... 65
tobramycin sulfate ........................... 17
tobramycin sulfate in saline ............... 17
tobramycin-dexamethasone .............. 64
TOBREX OINT 0.3% ......................... 65
tolmetin sodium ............................... 13
TOLTERODINE TARTRATE ER ............. 56
tolterodine tartrate tab 1 mg ............. 56
tolterodine tartrate tab 2 mg ............. 56
TOPICORT ....................................... 72
topiramate ...................................... 36
TOPIRAMATE ................................... 36
toposar ........................................... 28
topotecan hcl ................................... 28
TORISEL ......................................... 25
torsemide inj 20mg/2ml .................... 33
torsemide inj 50mg/5ml .................... 33
torsemide tabs ................................. 33
TOUJEO SOLOSTAR .......................... 46
TOVIAZ ........................................... 56
TPN ELECTROLYTES .......................... 62
TRACLEER ....................................... 34
TRADJENTA ..................................... 48
TRAMADOL HCL ............................... 14
tramadol hcl er ................................ 14
tramadol hcl er (biphasic) 100mg ....... 14
tramadol hcl er (biphasic) 200mg ....... 14
tramadol hcl er (biphasic) 300mg ....... 14
tramadol hcl tab 50 mg ..................... 14
tramadol-acetaminophen .................. 14
trandolapril...................................... 28
trandolapril-verapamil hcl.................. 28
tranexamic acid ............................... 58
TRANSDERM-SCOP ........................... 53
tranylcypromine sulfate..................... 37
travasol 10 ...................................... 62
96
TRAVATAN Z ....................................66
trazodone hcl ............................. 37, 38
TREANDA .........................................24
TRECATOR .......................................20
TRELSTAR MIXJECT ...........................26
tretinoin .................................... 27, 70
TRETINOIN MICROSPHERE .................70
tretin-x ............................................69
trexall .............................................59
TREXIMET ........................................42
trezix ..............................................14
triamcinolone acetonide (mouth) ........73
triamcinolone acetonide (nasal) ..........68
triamcinolone acetonide (topical) ........72
triamt/hctz cap 37.5-25 .....................33
triamt/hctz cap 50-25mg ...................33
triamt/hctz tab 37.5-25 .....................33
triamt/hctz tab 75-50mg ...................33
trianex ............................................72
TRIBENZOR ......................................29
triderm ............................................72
trifluoperazine hcl .............................40
trifluridine ........................................65
TRIGLIDE .........................................30
trilyte ..............................................54
trimethoprim ....................................18
TRISENOX........................................27
TRIUMEQ .........................................20
TROKENDI XR ..................................36
TROPHAMINE INJ 10% ......................62
trospium chloride ..............................56
trospium chloride er ..........................56
TRULICITY .......................................46
TRUMENBA.......................................61
TRUVADA .........................................20
TUDORZA PRESSAIR .........................67
TUDORZA PRESSAIR (INSTITUTIONAL
PACK) 400MCG/ACT ..........................67
TWINRIX INJ ....................................61
TYBOST ...........................................20
TYGACIL ..........................................18
TYKERB ...........................................27
TYPHIM VI .......................................61
TYSABRI ..........................................44
TYVASO ...........................................34
TYZEKA ...........................................21
tyzine ..............................................68
U
UCERIS ........................................... 54
ULORIC ........................................... 13
ULTRESA ......................................... 55
UNITHROID ..................................... 52
ursodiol .......................................... 55
UVADEX .......................................... 27
V
VAGIFEM ......................................... 49
valacyclovir hcl ................................ 21
VALCHLOR ...................................... 73
VALCYTE ......................................... 21
valganciclovir hcl .............................. 21
valproate sodium ............................. 36
valproic acid .................................... 36
valsartan ......................................... 29
valsartan & hctz tab 320-25mg .......... 29
valsartan-hydrochlorothiazide ............ 29
vancomycin hcl ................................ 18
VANDAZOLE .................................... 56
VAQTA ............................................ 61
VARIVAX ......................................... 61
VASCEPA......................................... 30
VECTIBIX ........................................ 25
VELCADE......................................... 25
VELPHORO ...................................... 52
VELTIN ........................................... 70
venlafaxine cap er ............................ 38
venlafaxine hcl ................................. 38
venlafaxine tab ................................ 38
VENLAFAXINE TAB 225MG ER ............ 38
venlafaxine tab er ............................ 38
VENTAVIS ....................................... 34
VENTOLIN HFA................................. 67
VERAMYST ...................................... 68
verapamil hcl ................................... 32
VERAPAMIL HCL ............................... 32
veripred .......................................... 50
VERSACLOZ..................................... 40
VESICARE ....................................... 56
VEXOL ............................................ 65
VIBRAMYCIN ................................... 24
vicodin ............................................ 14
vicodin es ........................................ 14
vicodin hp ....................................... 14
VICTOZA ......................................... 46
VICTRELIS ...................................... 21
VIDEX PEDIATRIC ............................ 20
97
VIGAMOX .........................................65
VIIBRYD ..........................................38
VIIBRYD STARTER PACK ....................38
VIMIZIM ..........................................49
VIMOVO ..........................................13
VIMPAT ...........................................36
vinblastine sulfate .............................25
vincasar ...........................................25
vincristine sulfate ..............................25
vinorelbine tartrate ...........................25
VIOKACE 10 .....................................55
VIOKACE 20 .....................................55
VIRACEPT ........................................20
VIRAMUNE XR ..................................20
VIREAD ...........................................20
VITEKTA ..........................................20
VIVITROL .........................................45
VOGELXO.........................................45
VOGELXO PUMP ................................45
VOLTAREN GEL 1% ...........................73
voriconazole .....................................19
voriconazole inj 200mg ......................19
VOTRIENT ........................................27
VPRIV ..............................................49
VYTORIN .........................................30
VYVANSE .........................................41
W
warfarin sodium ................................57
WELCHOL ........................................30
X
XALKORI ..........................................27
XARELTO .........................................57
XARELTO STARTER PACK ...................57
XARTEMIS XR ...................................16
XELJANZ ..........................................59
XENAZINE ........................................43
XEOMIN ...........................................66
XERESE ...........................................71
XGEVA.............................................52
XIFAXAN TAB 200MG ........................18
XIFAXAN TAB 550MG ........................55
XIGDUO XR TAB 10-1000MG ..............48
XIGDUO XR TAB 10-500MG ................48
XIGDUO XR TAB 5-1000MG ................48
XIGDUO XR TAB 5-500MG .................48
XOLAIR............................................68
XOPENEX HFA ..................................67
XTANDI ...........................................26
XYREM ............................................ 44
Y
YF-VAX ........................................... 61
Z
zafirlukast ....................................... 67
zamicet ........................................... 15
ZANOSAR ........................................ 24
ZAVESCA ........................................ 49
zazole ............................................. 56
ZAZOLE .......................................... 57
ZEGERID ......................................... 56
ZELAPAR ......................................... 38
ZELBORAF ....................................... 27
ZEMAIRA ......................................... 68
ZEMPLAR INJ 2MCG/ML ..................... 64
ZEMPLAR INJ 5MCG/ML ..................... 64
zenatane ......................................... 70
ZENPEP ........................................... 55
ZERBAXA ........................................ 22
ZETIA TAB 10MG.............................. 30
ZETONNA ........................................ 68
ZIAGEN........................................... 20
ZIANA............................................. 70
zidovudine ....................................... 20
ZINACEF ......................................... 22
ZIOPTAN ......................................... 66
ziprasidone hcl ................................. 40
ZIPSOR ........................................... 13
ZIRGAN .......................................... 65
ZMAX ............................................. 22
ZOHYDRO ER (ABUSE DETERRENT) .... 16
zoledronic inj 4mg/5ml ..................... 48
zoledronic inj 5/100ml ...................... 48
ZOLINZA ......................................... 25
zolmitriptan ..................................... 42
zolmitriptan odt ............................... 42
zolpidem tartrate ............................. 42
ZOMACTON ..................................... 51
ZOMETA .......................................... 48
ZOMIG NASAL SPRAY ....................... 42
zonisamide ...................................... 36
ZONTIVITY ...................................... 58
ZORBTIVE ....................................... 51
ZORTRESS TAB 0.25MG .................... 60
ZORTRESS TAB 0.5MG ...................... 60
ZORTRESS TAB 0.75MG .................... 60
ZORVOLEX ...................................... 13
ZOSTAVAX ...................................... 61
98
ZOSYN ............................................23
ZOVIRAX .........................................71
ZUBSOLV SUB 1.4-0.36 .....................45
ZUBSOLV SUB 11.4-2.9 .....................45
ZUBSOLV SUB 5.7-1.4 .......................45
ZUBSOLV SUB 8.6-2.1 .......................45
ZUPLENZ .........................................53
ZYCLARA .........................................73
ZYDELIG ......................................... 27
ZYFLO CR ........................................ 67
ZYKADIA ......................................... 27
ZYLET ............................................. 64
ZYPREXA RELPREVV ......................... 40
ZYTIGA ........................................... 26
ZYVOX ............................................ 18
99
This formulary was updated on 11/01/2015.
This information is available for free in other languages. Please contact our Member Services number at
1-800-247-1447 for additional information. (TTY users should call 1-800-695-8544). Hours are 8:00 a.m. to 8:00
p.m. seven days a week from October 1 to February 14, and Monday through Friday, 8:00 a.m. to 8:00 p.m. from
February 15 through September 30. Member Services also has free language interpreter services available for
non-English speakers.
Esta información está disponible de forma gratuita en otros idiomas. Por favor comuníquese con nuestro número
de Servicios al Socio al 1-800-247-1447 para obtener información adicional. Los usuarios con deficiencia
auditiva (TTY) deberán llamar al 1-800-695-8544. El horario de atención es de 8:00 a.m. a 8:00 p.m. los siete días
de la semana desde el 1 de octubre hasta el 14 de febrero, y de lunes a viernes, de 8:a.m. hasta las 8:00 p.m. desde
el 15 de febrero hasta el 30 de septiembre. Servicios al Socio también tiene servicios gratuitos de intérprete
disponibles para personas que no hablan inglés.
Fidelis Care is an HMO plan with a Medicare contract. Enrollment in Fidelis Care depends on contract renewal.
Fidelis Care is a Coordinated Care plan with a Medicare contract and a contract with the New York State
Department of Health Medicaid program. Enrollment in Fidelis Care depends on contract renewal.
Fidelis Care es un plan HMO con un contrato de Medicare. La inscripción en Fidelis Care depende de la
renovación del contrato.
Fidelis Care es un plan de Cuidado Coordinado con un contrato de Medicare y un contrato con el programa del
Departamento de Salud de Medicaid del Estado de Nueva York. La inscripción en Fidelis Care depende de la
renovación del contrato.
H3328_FC 14102 CMS Accepted
00015369. Version 10
100