1. No category

Washington
Health Alliance Medicare HMO
Formulario 2016
(Lista de medicamentos cubiertos)
LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN
ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN.
Este formulario se actualizó el 1.° de octubre de 2015. Para obtener información más reciente
o si tiene otras preguntas, póngase en contacto con Servicios al miembro de Health Alliance
Medicare, llamando al 1-877-750-3350 o, para los usuarios de TTY, al 711 de 8:00 a. m. a
8:00 p. m., de lunes a viernes, o visite HealthAllianceMedicare.org.
Nota para los miembros actuales: este formulario ha cambiado con respecto al año pasado.
Revise este documento para asegurarse de que aún contiene los medicamentos que usted toma.
Cuando esta Lista de medicamentos (Formulario) menciona “nosotros”, “nos” o “nuestro”,
hace referencia a Health Alliance Medicare. Cuando menciona “plan” o “nuestro plan”,
hace referencia a Health Alliance Medicare HMO.
Este documento incluye una lista de los medicamentos (Formulario) de nuestro plan, la cual
estará en vigencia a partir del 1.° de octubre de 2015. Para ver el formulario actualizado,
comuníquese con nosotros. Nuestra información de contacto, junto con la fecha en que
actualizamos por última vez el formulario, aparece en la portada y la contraportada.
Por lo general, debe utilizar las farmacias de la red para acceder a su beneficio de medicamentos
de venta con receta. Es posible que los beneficios, el formulario, la red de farmacias o los
copagos/coseguros cambien el 1.° de enero de 2017 y, en ocasiones, durante el año.
Health Alliance Medicare es un plan HMO que tiene un contrato con Medicare. La inscripción
en Health Alliance Medicare HMO depende de la renovación del contrato. Esta información
está disponible sin cargo en otros idiomas. Llame a Servicios al miembro al 1-877-750-3350 o,
para usuarios de TTY, al 711, de lunes a viernes de 8:00 a. m. a 8:00 p. m., o visite
HealthAllianceMedicare.org.
med-WACompHMOFormulary-0815
H3471_16_36657_FINAL Accepted
Formulario 00016340 de Health Alliance Medicare Parte D HMO Versión 10
¿Qué es el Formulario de Health Alliance Medicare HMO?
El formulario es una lista de medicamentos cubiertos seleccionados por Health Alliance Medicare con la
colaboración de un equipo de proveedores de atención médica, que representa las terapias con receta que se
consideran como una parte necesaria de un programa de tratamiento de calidad. Normalmente, Health Alliance
Medicare cubre los medicamentos incluidos en el formulario, siempre y cuando el medicamento sea necesario
desde el punto de vista médico, el medicamento de venta con receta se obtenga en una farmacia de la red de
Health Alliance Medicare y se cumpla con otras normas del plan. Para obtener más información sobre cómo
obtener sus medicamentos de venta con receta, consulte la Evidencia de cobertura.
¿Se puede cambiar el Formulario (lista de medicamentos)?
En general, si usted toma un medicamento de nuestro formulario 2016 que estaba cubierto al comienzo del año,
nosotros no interrumpiremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2016,
a menos que esté disponible un nuevo medicamento genérico de menor costo o que se dé a conocer nueva
información negativa acerca de la seguridad o eficacia del medicamento. Otros tipos de cambios en el formulario,
como la eliminación de un medicamento, no afectarán a los miembros que estén actualmente tomando el
medicamento. Este permanecerá disponible al mismo costo compartido durante el resto del año de cobertura para
aquellos miembros que lo toman. Consideramos que es importante que tenga acceso continuo durante el resto del
año de cobertura a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan, salvo en
los casos en que usted podría ahorrar más dinero o que nosotros podríamos garantizarle su seguridad.
Si retiramos medicamentos de nuestro formulario o agregamos autorizaciones previas, límites de cantidad
o restricciones en tratamientos escalonados en relación con un medicamento, o si pasamos un medicamento
a un nivel superior de costo compartido, debemos notificar el cambio a los miembros afectados por este, al
menos 60 días antes de que entre en vigencia dicho cambio o cuando el miembro solicite una renovación del
medicamento, momento en el cual el miembro recibirá un suministro del medicamento para 60 días. Si la
Administración de Medicamentos y Alimentos considera que un medicamento de nuestro formulario es inseguro
o el fabricante del medicamento lo retira del mercado, eliminaremos de inmediato dicho medicamento de nuestro
formulario y notificaremos a los miembros que toman el medicamento en cuestión. El formulario adjunto estará
vigente a partir del 1.° de octubre de 2015. Para recibir información actualizada sobre los medicamentos cubiertos
por Health Alliance Medicare, póngase en contacto con nosotros. Nuestra información de contacto aparece en las
páginas de la portada y la contraportada.
¿Cómo utilizo el Formulario?
Hay dos formas de encontrar su medicamento en el formulario:
Enfermedad
El formulario empieza en la página 1. Los medicamentos de este formulario están agrupados en categorías según
el tipo de afección médica para cuyo tratamiento se los emplea. Por ejemplo, los medicamentos utilizados para
tratar una afección cardíaca se enumeran dentro de la categoría “Agentes cardiovasculares”. Si sabe para qué se
utiliza su medicamento, busque el nombre de la categoría en la lista que empieza en la página 1. Luego, busque
su medicamento debajo del nombre de la categoría.
Listado alfabético
Si no está seguro en qué categoría buscar, debe buscar su medicamento en el Índice que empieza en la página 98.
El Índice brinda una lista alfabética de todos los medicamentos incluidos en este documento. El Índice, incluye
tanto los medicamentos de marca como los genéricos. Busque en el Índice y encuentre su medicamento. Junto a
su medicamento, verá el número de página donde puede encontrar información acerca de la cobertura. Vaya a la
página que figura en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista.
¿Qué son medicamentos genéricos?
Health Alliance Medicare cubre tanto medicamentos de marca como medicamentos genéricos. Un medicamento
genérico está aprobado por la Administración de Medicamentos y Alimentos (Food and Drug Administration,
FDA) dado que se considera que tiene el mismo principio activo que el medicamento de marca. Normalmente,
los medicamentos genéricos cuestan menos que los de marca.
i
¿Hay alguna restricción en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales de cobertura. Estos requisitos y
límites pueden incluir lo siguiente:
•
Autorización previa: Health Alliance Medicare requiere que usted o su médico obtengan una
autorización previa para ciertos medicamentos. Esto significa que necesitará obtener la aprobación de
parte de Health Alliance Medicare antes de que usted obtenga sus medicamentos de venta con receta.
Si no obtiene la aprobación, es posible que Health Alliance Medicare no cubra el medicamento.
•
Límites de cantidad: para ciertos medicamentos, Health Alliance Medicare limita la cantidad del
medicamento que cubriremos. Por ejemplo, Health Alliance Medicare proporciona 20 comprimidos de
trometamina ketorolaco bajo receta. Esto puede ser complementario a un suministro estándar para un mes
o tres meses.
•
Terapia escalonada: en algunos casos, Health Alliance Medicare requiere que usted primero pruebe
ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para esa
afección. Por ejemplo, si tanto el Medicamento A como el Medicamento B tratan su enfermedad, Health
Alliance Medicare podría no cubrir el Medicamento B, a menos que primero pruebe el Medicamento A.
Si el Medicamento A no le sirve, Health Alliance Medicare entonces le cubrirá el Medicamento B.
Para saber si su medicamento tiene requisitos o límites adicionales, busque en el formulario que empieza en la
página 1. También puede obtener más información en nuestro sitio web sobre las restricciones que se aplican a
medicamentos cubiertos específicos. Hemos publicado un documento en línea que explica nuestra restricción de
autorización previa. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto
con la fecha en que actualizamos por última vez el formulario, aparece en la portada y la contraportada.
Puede pedirle a Health Alliance Medicare que haga una excepción a estas restricciones o límites, o bien, puede
solicitarle una lista de otros medicamentos similares que puedan tratar su afección médica. Consulte la sección
“¿Cómo solicito una excepción al Formulario de Health Alliance Medicare HMO?” en la página ii para obtener
información acerca de cómo solicitar una excepción.
¿Qué pasa si mi medicamento no está en el Formulario?
Si el medicamento que toma no está incluido en este formulario (lista de medicamentos cubiertos), primero debe
ponerse en contacto con Servicios al miembro y preguntar si su medicamento está cubierto.
Si resulta que Health Alliance Medicare no cubre el medicamento que toma, usted tiene dos alternativas:
•
Puede solicitar a Servicios al miembro una lista de medicamentos similares que estén cubiertos por Health
Alliance Medicare. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento
similar que esté cubierto por Health Alliance Medicare.
•
Puede pedirle a Health Alliance Medicare que haga una excepción y cubra el medicamento. Consulte más
abajo para obtener información sobre cómo solicitar una excepción.
¿Cómo puedo solicitar que se haga una excepción al formulario de Health Alliance Medicare HMO?
Puede pedirle a Health Alliance Medicare que haga una excepción a nuestras normas de cobertura. Hay varios
tipos de excepciones que puede solicitarnos.
ii
•
Puede pedirnos que cubramos un medicamento, incluso si no está en nuestro formulario. Si se aprueba,
este medicamento estará cubierto a un nivel de costo compartido predeterminado, y usted no podrá
pedirnos que proporcionemos el medicamento a un nivel de costo compartido menor.
•
Puede pedirnos que cubramos un medicamento del formulario a un nivel de costo compartido menor
si este medicamento no está incluido en el nivel de medicamentos de especialidad. Si se aprueba,
esto reduciría el monto que usted debe pagar por su medicamento.
•
Puede pedirnos que no apliquemos restricciones o límites de cobertura para su medicamento. Por ejemplo,
para ciertos medicamentos, Health Alliance Medicare limita la cantidad del medicamento que cubriremos.
Si su medicamento tiene un límite de cantidad, puede pedirnos que hagamos una excepción al límite y
cubramos una cantidad mayor.
Por lo general, Health Alliance Medicare solo aprobará su pedido de excepción si los medicamentos alternativos
incluidos en el formulario del plan, el medicamento de menor costo compartido o las restricciones de uso
adicionales no fueran tan eficaces para tratar su enfermedad o pudieran causarle efectos de salud adversos.
Debe ponerse en contacto con nosotros para solicitarnos una decisión inicial de cobertura respecto de una
excepción al formulario, al nivel o a la restricción de uso. Cuando usted solicita una excepción respecto del
formulario, del nivel del medicamento o de la la restricción de uso, usted debe presentar una declaración
de su médico (o de la persona autorizada para recetar) que respalde su solicitud. Por lo general, debemos
tomar una decisión dentro de las 72 horas a partir de la fecha de haber recibido la declaración que respalda su
solicitud por parte de la persona autorizada para recetar. Puede solicitar una excepción acelerada (rápida) si usted
o su médico consideran que esperar 72 horas para la toma de la decisión podría perjudicar gravemente su salud.
Si se le concede el trámite rápido de la excepción, debemos comunicarle nuestra decisión a más tardar dentro
de las 24 horas después de haber recibido la declaración de respaldo de su médico o de otra persona autorizada
para recetar.
¿Qué debo hacer antes de hablar con mi médico sobre el cambio de los medicamentos que
tomo o la solicitud de una excepción?
Como miembro nuevo o permanente de nuestro plan, es posible que esté tomando medicamentos que no estén
incluidos en el formulario. También es posible que esté tomando un medicamento incluido en el formulario,
pero su capacidad de conseguirlo sea limitada. Por ejemplo, puede necesitar nuestra autorización previa antes de
poder obtener su medicamento de venta con receta. Debe consultar con su médico para decidir si debe cambiar
su medicamento por uno apropiado que nosotros cubramos o solicitar una excepción al formulario para que le
cubramos el medicamento que toma. Mientras evalúa con su médico el procedimiento adecuado por seguir en su
caso, podemos cubrir su medicamento en ciertas situaciones durante los primeros 90 días en que sea miembro de
nuestro plan.
Para cada uno de los medicamentos que no están incluidos en el formulario o si su capacidad para conseguir los
medicamentos es limitada, cubriremos un suministro temporal para 30 días (a menos que tenga una receta para
menos días) cuando acuda a una farmacia de la red. Después del primer suministro para 30 días, no seguiremos
pagando estos medicamentos, incluso si ha sido miembro del plan durante menos de 90 días.
Si reside en un centro de atención a largo plazo, le permitiremos renovar su receta hasta que le hayamos provisto
un suministro de transición de 91 días, de manera coherente con el incremento de dispensación (a menos que
tenga una receta para menos días). Cubriremos más de una renovación de estos medicamentos durante los
primeros 90 días en que usted sea miembro del plan. Si necesita un medicamento que no está en el formulario o
si su capacidad para conseguir los medicamentos es limitada, pero ya pasaron los primeros 90 días de membresía
en nuestro plan, cubriremos un suministro de emergencia del medicamento para 31 días (a menos que tenga una
receta para menos días) mientras solicita la excepción al formulario.
Para más información
Para obtener información más detallada sobre su cobertura de medicamentos de venta con receta de Health
Alliance Medicare, revise su Evidencia de cobertura y los otros materiales del plan.
Si tiene preguntas sobre Health Alliance Medicare, comuníquese con nosotros. Nuestra información de contacto,
junto con la fecha en que actualizamos por última vez el formulario, aparece en la portada y la contraportada.
Si tiene preguntas generales sobre la cobertura de medicamentos de venta con receta de Medicare, llame a
Medicare al 1-800-MEDICARE (1-800-633-4227) las 24 horas del día, los 7 días de la semana. Los usuarios
de TTY deben llamar al 1-877-486-2048. O visite http://www.medicare.gov.
iii
Formulario de Health Alliance Medicare
El formulario que empieza en la página 1 brinda información de cobertura sobre algunos de los medicamentos
cubiertos por Health Alliance Medicare. Si tiene problemas para encontrar su medicamento en la lista, acuda al
Índice que empieza en la página 98.
La primera columna de la tabla enumera el nombre del medicamento. Los medicamentos de marca están en
mayúscula (p. ej., TRADJENTA) y los medicamentos genéricos están en minúscula y cursiva (p. ej., atorvastatina).
La información que se encuentra en la columna Requisitos/Límites le indica si Health Alliance Medicare tiene
requisitos especiales para la cobertura de su medicamento.
Drug Name
Requirements/
Limits
Drug Tier
Antibacterials
Antibacterials, Miscellaneous
ZYVOX tablet
5
PA, QL: 56 in 28 days
B/D
Este medicamento de venta con receta tiene un requisito administrativo de autorización previa de la
Parte B frente a la Parte D. Este medicamento podría estar cubierto por la Parte B o D de Medicare, según
las circunstancias. Es posible que deba presentarse información que describa el uso y las circunstancias de
uso del medicamento para tomar una determinación.
CB
Este medicamento de venta con receta tiene un límite máximo de beneficios.
EA
Cada uno.
HI
Infusión en casa. Este medicamento de venta con receta podría estar cubierto según nuestro beneficio
médico. Para obtener más información, llame a Servicios al miembro al 1-877-750-3350, los siete días
de la semana, de 8:00 a. m. a 8:00 p. m. Los usuarios de TTY/TDD deben llamar al 711.
LA
Disponibilidad limitada. Este medicamento de venta con receta podría estar disponible solamente en
ciertas farmacias. Para obtener más información, consulte su Directorio de farmacias o llame a Servicios
al miembro al 1-877-750-3350, los siete días de la semana, de 8:00 a. m. a 8:00 p. m. Los usuarios de
TTY/TDD deben llamar al 711.
MO
Medicamento con envío por correo. Este medicamento de venta con receta está disponible a través de un
servicio de envíos por correo.
PA
Autorización previa. Health Alliance Medicare requiere que usted o su médico obtengan una autorización
previa para ciertos medicamentos. Esto significa que necesitará obtener la aprobación de parte de Health
Alliance Medicare antes de que usted obtenga sus medicamentos de venta con receta. Si no obtiene la
aprobación, es posible que Health Alliance Medicare no cubra el medicamento.
QL
Límite de cantidad. Para ciertos medicamentos, Health Alliance Medicare limita la cantidad del medicamento
que cubriremos. Por ejemplo, Health Alliance Medicare proporciona 20 comprimidos de trometamina
ketorolaco por receta. Esto puede ser complementario a un suministro estándar para un mes o tres meses.
ST
Terapia escalonada. En algunos casos, Health Alliance Medicare requiere que usted primero pruebe ciertos
medicamentos para tratar su afección médica antes de que cubramos otro medicamento para esa afección.
Por ejemplo, si tanto el Medicamento A como el Medicamento B tratan su enfermedad, Health Alliance
Medicare podría no cubrir el Medicamento B a menos que primero pruebe el Medicamento A. Si el
Medicamento A no le sirve, Health Alliance Medicare entonces le cubrirá el Medicamento B.
Tenga en cuenta lo siguiente: todos los medicamentos, excepto los de especialidad del Nivel 5, están disponibles
para envío por correo.
Los medicamentos de marca figuran entre paréntesis después del genérico. Esto no significa que el nombre de
marca esté cubierto. Consulte el listado real para ese medicamento para determinar la cobertura.
iv
Drug
Drug Name
Tier
ANALGESICS
ANALGESICS, MISCELLANEOUS
acetaminophen/codeine #3 tabs 300mg; 30mg
1
acetaminophen/codeine #4 tabs 300mg; 60mg
1
acetaminophen/codeine #4 tabs 300mg; 60mg
1
acetaminophen/codeine soln 120mg/5ml; 12mg/5ml
1
acetaminophen/codeine tabs 300mg; 15mg
1
aspirin-caffeine-dihydrocodeine caps 356.4mg; 30mg; 16mg
2
buprenorphine hcl inj 0.3mg/ml
2
butalbital/acetaminophen/caffeine/codeine caps 300mg; 50mg;
2
40mg; 30mg
butalbital/acetaminophen/caffeine/codeine caps 325mg; 50mg;
2
40mg; 30mg
butalbital/acetaminophen/caffeine caps 325mg; 50mg; 40mg
2
butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg
2
butalbital/apap/caffeine caps 300mg; 50mg; 40mg
2
butalbital/aspirin/caffeine/codeine caps 325mg; 50mg; 40mg; 30mg 2
butalbital/aspirin/caffeine caps 325mg; 50mg; 40mg
2
butorphanol tartrate inj 1mg/ml
2
butorphanol tartrate inj 2mg/ml
2
butorphanol tartrate soln 10mg/ml
2
BUTRANS PTWK 10MCG/HR
3
BUTRANS PTWK 15MCG/HR
3
BUTRANS PTWK 20MCG/HR
3
BUTRANS PTWK 5MCG/HR
3
BUTRANS PTWK 7.5MCG/HR
3
codeine sulfate tabs 15mg
1
codeine sulfate tabs 30mg
1
codeine sulfate tabs 60mg
1
endocet tabs 325mg; 10mg
2
endocet tabs 325mg; 2.5mg
2
endocet tabs 325mg; 5mg
2
endocet tabs 325mg; 7.5mg
2
endodan tabs 325mg; 4.835mg
2
fentanyl citrate oral transmucosal lpop 1200mcg
5
fentanyl citrate oral transmucosal lpop 1600mcg
5
fentanyl citrate oral transmucosal lpop 200mcg
5
fentanyl citrate oral transmucosal lpop 400mcg
5
fentanyl citrate oral transmucosal lpop 600mcg
5
fentanyl citrate oral transmucosal lpop 800mcg
5
fentanyl pt72 100mcg/hr
2
fentanyl pt72 12mcg/hr
2
fentanyl pt72 25mcg/hr
2
fentanyl pt72 37.5mcg/hr
2
fentanyl pt72 50mcg/hr
2
fentanyl pt72 62.5mcg/hr
2
fentanyl pt72 75mcg/hr
2
1
Requirements/Limits
QL (360 EA per 30 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days)
QL (4500 ML per 30 days)
QL (360 EA per 30 days)
QL (300 EA per 30 days)
QL (5 ML per 28 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (120 EA per 30 days) PA
QL (120 EA per 30 days) PA
QL (120 EA per 30 days) PA
QL (120 EA per 30 days) PA
QL (120 EA per 30 days) PA
QL (120 EA per 30 days) PA
QL (20 EA per 30 days)
QL (10 EA per 30 days)
QL (10 EA per 30 days)
QL (10 EA per 30 days)
QL (10 EA per 30 days)
QL (10 EA per 30 days)
QL (10 EA per 30 days)
Drug Name
fentanyl pt72 87.5mcg/hr
hydrocodone bitartrate/acetaminophen soln 325mg/15ml;
7.5mg/15ml
hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg
hydrocodone bitartrate/acetaminophen tabs 300mg; 5mg
hydrocodone bitartrate/acetaminophen tabs 300mg; 7.5mg
hydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mg
hydrocodone/acetaminophen soln 325mg/15ml; 10mg/15ml
hydrocodone/acetaminophen soln 500mg/15ml; 7.5mg/15ml
hydrocodone/acetaminophen soln 500mg/15ml; 7.5mg/15ml
hydrocodone/acetaminophen tabs 325mg; 10mg
hydrocodone/acetaminophen tabs 325mg; 5mg
hydrocodone/acetaminophen tabs 325mg; 7.5mg
hydrocodone/ibuprofen tabs 10mg; 200mg
hydrocodone/ibuprofen tabs 2.5mg; 200mg
hydrocodone/ibuprofen tabs 5mg; 200mg
hydrocodone/ibuprofen tabs 7.5mg; 200mg
hydromorphone hcl inj 2mg/ml
hydromorphone hcl inj 2mg/ml
hydromorphone hcl inj 4mg/ml
hydromorphone hcl inj 500mg/50ml
hydromorphone hcl inj 50mg/5ml
hydromorphone hcl liqd 1mg/ml
hydromorphone hcl tabs 2mg
hydromorphone hcl tabs 4mg
hydromorphone hcl tabs 8mg
LAZANDA SOLN 100MCG/ACT
LAZANDA SOLN 400MCG/ACT
levorphanol tartrate tabs 2mg
lorcet hd tabs 325mg; 10mg
lorcet plus tabs 325mg; 7.5mg
lorcet tabs 325mg; 5mg
methadone hcl intensol conc 10mg/ml
methadone hcl inj 10mg/ml
methadone hcl soln 10mg/5ml
methadone hcl soln 5mg/5ml
methadone hcl tabs 10mg
methadone hcl tabs 5mg
methadose tbso 40mg
morphine sulfate er cp24 100mg
morphine sulfate er cp24 20mg
morphine sulfate er cp24 30mg
morphine sulfate er cp24 50mg
morphine sulfate er cp24 60mg
morphine sulfate er cp24 80mg
morphine sulfate er tbcr 100mg
morphine sulfate er tbcr 15mg
2
Drug
Tier Requirements/Limits
2
QL (10 EA per 30 days)
2
QL (2700 ML per 30 days)
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
4
4
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (2700 ML per 30 days)
QL (2700 ML per 30 days)
QL (2700 ML per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (150 EA per 30 days)
QL (150 EA per 30 days)
QL (150 EA per 30 days)
QL (150 EA per 30 days)
QL (1200 ML per 30 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days)
QL (120 EA per 30 days)
PA
PA
QL (180 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (1800 ML per 30 days)
QL (1800 ML per 30 days)
QL (1800 ML per 30 days)
QL (360 EA per 30 days)
QL (360 EA per 30 days)
QL (90 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (120 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (120 EA per 30 days)
QL (180 EA per 30 days)
Drug
Tier
2
2
2
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
3
3
3
3
3
2
2
2
2
2
2
2
2
2
2
2
Drug Name
morphine sulfate er tbcr 200mg
morphine sulfate er tbcr 30mg
morphine sulfate er tbcr 60mg
MORPHINE SULFATE INJ 0.5MG/ML
morphine sulfate inj 10mg/0.7ml
morphine sulfate inj 10mg/ml
morphine sulfate inj 10mg/ml
morphine sulfate inj 150mg/30ml
morphine sulfate inj 15mg/ml
morphine sulfate inj 15mg/ml
morphine sulfate inj 1mg/ml
morphine sulfate inj 1mg/ml
morphine sulfate inj 25mg/ml
morphine sulfate inj 2mg/ml
morphine sulfate inj 2mg/ml
morphine sulfate inj 2mg/ml
morphine sulfate inj 4mg/ml
morphine sulfate inj 50mg/ml
morphine sulfate inj 8mg/ml
morphine sulfate inj 8mg/ml
morphine sulfate soln 10mg/5ml
morphine sulfate soln 20mg/5ml
morphine sulfate soln 20mg/ml
morphine sulfate supp 10mg
morphine sulfate supp 20mg
morphine sulfate supp 30mg
morphine sulfate supp 5mg
morphine sulfate tabs 15mg
morphine sulfate tabs 30mg
nalbuphine hcl inj 10mg/ml
nalbuphine hcl inj 20mg/ml
NUCYNTA ER TB12 100MG
NUCYNTA ER TB12 150MG
NUCYNTA ER TB12 200MG
NUCYNTA ER TB12 250MG
NUCYNTA ER TB12 50MG
oxycodone hcl er t12a 10mg
oxycodone hcl er t12a 20mg
oxycodone hcl er t12a 40mg
oxycodone hcl er t12a 80mg
oxycodone hcl caps 5mg
oxycodone hcl conc 100mg/5ml
oxycodone hcl soln 5mg/5ml
oxycodone hcl tabs 10mg
oxycodone hcl tabs 15mg
oxycodone hcl tabs 20mg
oxycodone hcl tabs 30mg
3
Requirements/Limits
QL (180 EA per 30 days)
QL (60 EA per 30 days)
QL (120 EA per 30 days)
QL (700 ML per 30 days)
QL (300 ML per 30 days)
QL (200 ML per 30 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (180 EA per 30 days)
QL (180 ML per 30 days)
QL (1300 ML per 30 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days)
Drug Name
oxycodone hcl tabs 5mg
oxycodone/acetaminophen tabs 325mg; 10mg
oxycodone/acetaminophen tabs 325mg; 2.5mg
oxycodone/acetaminophen tabs 325mg; 5mg
oxycodone/acetaminophen tabs 325mg; 7.5mg
oxycodone/acetaminophen tabs 500mg; 7.5mg
oxycodone/acetaminophen tabs 500mg; 7.5mg
oxycodone/acetaminophen tabs 650mg; 10mg
oxycodone/acetaminophen tabs 650mg; 10mg
oxycodone/aspirin tabs 325mg; 4.835mg
oxycodone/ibuprofen tabs 400mg; 5mg
oxymorphone hydrochloride er tb12 10mg
oxymorphone hydrochloride er tb12 15mg
oxymorphone hydrochloride er tb12 20mg
oxymorphone hydrochloride er tb12 30mg
oxymorphone hydrochloride er tb12 40mg
oxymorphone hydrochloride er tb12 5mg
oxymorphone hydrochloride er tb12 7.5mg
oxymorphone hydrochloride tabs 10mg
oxymorphone hydrochloride tabs 5mg
reprexain tabs 10mg; 200mg
reprexain tabs 2.5mg; 200mg
reprexain tabs 5mg; 200mg
roxicet soln 325mg/5ml; 5mg/5ml
tramadol hcl er cp24 100mg
tramadol hcl er cp24 150mg
tramadol hcl er cp24 200mg
tramadol hcl er cp24 300mg
tramadol hcl er tb24 100mg
tramadol hcl er tb24 200mg
tramadol hcl er tb24 300mg
tramadol hcl tabs 50mg
tramadol hydrochloride/acetaminophen tabs 325mg; 37.5mg
vicodin es tabs 300mg; 7.5mg
vicodin hp tabs 300mg; 10mg
vicodin tabs 300mg; 5mg
xylon tabs 10mg; 200mg
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
celecoxib caps 100mg
celecoxib caps 200mg
celecoxib caps 400mg
celecoxib caps 50mg
choline magnesium trisalicylate liqd 500mg/5ml
diclofenac potassium tabs 50mg
diclofenac sodium dr tbec 25mg
diclofenac sodium dr tbec 50mg
diclofenac sodium dr tbec 75mg
4
Drug
Tier
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
1
1
1
1
1
Requirements/Limits
QL (180 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days)
QL (240 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days)
QL (150 EA per 30 days)
QL (150 EA per 30 days)
QL (150 EA per 30 days)
QL (1800 ML per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days) ST
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (90 EA per 30 days) ST
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
QL (240 EA per 30 days)
QL (240 EA per 30 days) ST
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (150 EA per 30 days)
Drug Name
diclofenac sodium er tb24 100mg
diclofenac sodium/misoprostol tbec 50mg; 200mcg
diclofenac sodium/misoprostol tbec 75mg; 200mcg
diclofenac sodium gel 3%
diflunisal tabs 500mg
etodolac er tb24 400mg
etodolac er tb24 500mg
etodolac er tb24 600mg
etodolac caps 200mg
etodolac caps 300mg
etodolac tabs 400mg
etodolac tabs 500mg
fenoprofen calcium tabs 600mg
flurbiprofen tabs 100mg
flurbiprofen tabs 50mg
ibuprofen susp 100mg/5ml
ibuprofen tabs 400mg
ibuprofen tabs 600mg
ibuprofen tabs 800mg
ketoprofen er cp24 200mg
ketoprofen caps 50mg
ketoprofen caps 75mg
ketorolac tromethamine inj 15mg/ml
meclofenamate sodium caps 100mg
meclofenamate sodium caps 50mg
mefenamic acid caps 250mg
meloxicam susp 7.5mg/5ml
meloxicam tabs 15mg
meloxicam tabs 7.5mg
nabumetone tabs 500mg
nabumetone tabs 750mg
naproxen dr tbec 375mg
naproxen ec tbec 500mg
naproxen sodium tabs 275mg
naproxen sodium tabs 550mg
naproxen susp 125mg/5ml
naproxen tabs 250mg
naproxen tabs 375mg
naproxen tabs 500mg
oxaprozin tabs 600mg
piroxicam caps 10mg
piroxicam caps 20mg
salsalate tabs 500mg
salsalate tabs 750mg
sulindac tabs 150mg
sulindac tabs 200mg
tolmetin sodium caps 400mg
5
Drug
Tier Requirements/Limits
1
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
2
2
1
1
1
Drug
Drug Name
Tier
tolmetin sodium tabs 200mg
1
tolmetin sodium tabs 600mg
1
VOLTAREN GEL 1%
4
ANESTHETICS
LOCAL ANESTHETICS
glydo gel 2%
1
lidocaine hcl jelly gel 2%
1
lidocaine hcl jelly gel 2%
1
lidocaine hcl jelly gel 2%
1
lidocaine hcl gel 2%
1
lidocaine hcl gel 2%
1
lidocaine hcl inj 0.5%
1
lidocaine hcl inj 1%
1
lidocaine hcl inj 1.5%
1
lidocaine hcl inj 2%
1
lidocaine hcl inj 4%
1
lidocaine hcl soln 4%
1
lidocaine hcl soln 4%
1
lidocaine viscous soln 2%
1
lidocaine/prilocaine crea 2.5%; 2.5%
1
lidocaine/prilocaine kit 2.5%; 2.5%
2
lidocaine oint 5%
1
lidocaine ptch 5%
2
SYNERA PTCH 70MG; 70MG
4
SYNERA PTCH 70MG; 70MG
4
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT
AGENTS
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
acamprosate calcium dr tbec 333mg
2
BUPRENORPHINE HCL/NALOXONE HCL SUBL 2MG; 0.5MG 4
BUPRENORPHINE HCL/NALOXONE HCL SUBL 8MG; 2MG 4
buprenorphine hcl subl 2mg
2
buprenorphine hcl subl 8mg
2
buproban tb12 150mg
2
bupropion hcl sr tb12 150mg
1
CHANTIX CONTINUING MONTH PAK TABS 1MG
4
CHANTIX STARTING MONTH PAK TABS 0
4
CHANTIX TABS 0.5MG
4
CHANTIX TABS 1MG
4
depade tabs 50mg
1
disulfiram tabs 250mg
2
disulfiram tabs 500mg
2
naloxone hcl inj 0.4mg/ml
1
naloxone hcl inj 0.4mg/ml
1
naloxone hcl inj 1mg/ml
1
naltrexone hcl tabs 50mg
1
NICOTROL INHALER INHA 10MG
4
6
Requirements/Limits
PA
QL (90 EA per 30 days)
QL (90 EA per 30 days)
QL (90 EA per 30 days)
QL (90 EA per 30 days)
PA
PA
PA
PA
QL (480 EA per 30 days)
Drug Name
NICOTROL NS SOLN 10MG/ML
VIVITROL INJ 380MG
ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE)
ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE)
AVC CREA 15%
CLEOCIN SUPP 100MG
clindamycin phosphate crea 2%
metronidazole vaginal gel 0.75%
NUVESSA GEL 1.3%
terconazole crea 0.4%
terconazole crea 0.8%
terconazole supp 80mg
zazole crea 0.4%
zazole crea 0.8%
ANTIANXIETY AGENTS
BENZODIAZEPINES
alprazolam odt tbdp 0.25mg
alprazolam odt tbdp 0.5mg
alprazolam odt tbdp 1mg
alprazolam odt tbdp 2mg
alprazolam xr tb24 0.5mg
alprazolam xr tb24 1mg
alprazolam xr tb24 2mg
alprazolam xr tb24 3mg
alprazolam tabs 0.25mg
alprazolam tabs 0.5mg
alprazolam tabs 1mg
alprazolam tabs 2mg
chlordiazepoxide hcl caps 10mg
chlordiazepoxide hcl caps 25mg
chlordiazepoxide hcl caps 5mg
clonazepam odt tbdp 0.125mg
clonazepam odt tbdp 0.25mg
clonazepam odt tbdp 0.5mg
clonazepam odt tbdp 1mg
clonazepam odt tbdp 2mg
clonazepam tabs 0.5mg
clonazepam tabs 1mg
clonazepam tabs 2mg
clorazepate dipotassium tabs 15mg
clorazepate dipotassium tabs 3.75mg
clorazepate dipotassium tabs 7.5mg
diazepam intensol conc 5mg/ml
diazepam gel 10mg
diazepam gel 2.5mg
diazepam gel 20mg
diazepam inj 5mg/ml
7
Drug
Tier Requirements/Limits
4
QL (720 ML per 365 days)
5
4
4
2
2
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (90 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (150 EA per 30 days)
QL (90 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (90 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (90 EA per 30 days)
QL (90 EA per 30 days)
QL (90 EA per 30 days)
Drug Name
diazepam soln 1mg/ml
diazepam tabs 10mg
diazepam tabs 2mg
diazepam tabs 5mg
estazolam tabs 1mg
estazolam tabs 2mg
flurazepam hcl caps 15mg
flurazepam hcl caps 30mg
lorazepam inj 2mg/ml
lorazepam inj 2mg/ml
lorazepam inj 4mg/ml
lorazepam tabs 0.5mg
lorazepam tabs 1mg
lorazepam tabs 2mg
midazolam hcl inj 2mg/2ml
midazolam hcl inj 5mg/ml
midazolam hcl syrp 2mg/ml
ONFI SUSP 2.5MG/ML
ONFI TABS 10MG
ONFI TABS 20MG
oxazepam caps 10mg
oxazepam caps 15mg
oxazepam caps 30mg
QUAZEPAM TABS 15MG
temazepam caps 15mg
temazepam caps 22.5mg
temazepam caps 30mg
temazepam caps 7.5mg
triazolam tabs 0.125mg
triazolam tabs 0.25mg
ANTIBACTERIALS
AMINOGLYCOSIDES
amikacin sulfate inj 1gm/4ml
amikacin sulfate inj 1gm/4ml
gentamicin sulfate pediatric inj 10mg/ml
gentamicin sulfate/0.9% sodium chloride inj 0.8mg/ml; 0.9%
gentamicin sulfate/0.9% sodium chloride inj 0.9mg/ml; 0.9%
gentamicin sulfate/0.9% sodium chloride inj 1.4mg/ml; 0.9%
gentamicin sulfate inj 40mg/ml
isotonic gentamicin inj 1.2mg/ml; 0.9%
isotonic gentamicin inj 1.6mg/ml; 0.9%
isotonic gentamicin inj 1mg/ml; 0.9%
isotonic gentamicin inj 2mg/ml; 0.9%
neomycin sulfate tabs 500mg
streptomycin sulfate inj 1gm
TOBI PODHALER CAPS 28MG
tobramycin sulfate/sodium chloride inj 0.9%; 0.8mg/ml
8
Drug
Tier
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
2
2
2
4
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
2
1
5
2
Requirements/Limits
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (120 EA per 30 days)
QL (90 EA per 30 days)
QL (60 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
PA
Drug Name
tobramycin sulfate/sodium chloride inj 0.9%; 1.2mg/ml
tobramycin sulfate inj 10mg/ml
tobramycin sulfate inj 80mg/2ml
tobramycin nebu 300mg/5ml
ANTIBACTERIALS, MISCELLANEOUS
baciim inj 50000unit
bacitracin inj 50000unit
chloramphenicol sodium succinate inj 1gm
clindamycin hcl caps 150mg
clindamycin hcl caps 300mg
clindamycin hcl caps 75mg
clindamycin palmitate hcl solr 75mg/5ml
clindamycin phosphate add-vantage inj 150mg/ml
clindamycin phosphate in d5w inj 300mg/50ml; 5%
clindamycin phosphate in d5w inj 600mg/50ml; 5%
clindamycin phosphate in d5w inj 900mg/50ml; 5%
colistimethate sodium inj 150mg
CUBICIN INJ 500MG
DALVANCE INJ 500MG
LINCOCIN INJ 300MG/ML
linezolid inj 2mg/ml
linezolid tabs 600mg
methenamine hippurate tabs 1gm
methenamine mandelate tabs 1gm
MONUROL PACK 5.631GM
nitrofurantoin macrocrystals caps 50mg
ORBACTIV INJ 400MG
ORBACTIV INJ 400MG
polymyxin b sulfate inj 500000unit
PRIMSOL SOLN 50MG/5ML
SIVEXTRO INJ 200MG
SIVEXTRO TABS 200MG
SYNERCID INJ 350MG; 150MG
trimethoprim tabs 100mg
VANCOMYCIN HCL IN DEXTROSE INJ 0; 1GM/200ML
vancomycin hcl caps 125mg
vancomycin hcl caps 250mg
VANCOMYCIN HCL INJ 10GM
VANCOMYCIN HCL INJ 5000MG
VANCOMYCIN HCL INJ 500MG
VANCOMYCIN HCL INJ 750MG
VIBATIV INJ 250MG
XIFAXAN TABS 200MG
XIFAXAN TABS 550MG
ZYVOX SUSR 100MG/5ML
CEPHALASPORINS
AVYCAZ INJ 0.5GM; 2GM
9
Drug
Tier Requirements/Limits
2
2
2
5
PA
1
1
1
1
1
1
1
1
2
2
2
2
5
5
3
5
5
2
2
4
2
5
5
2
3
5
5
3
1
4
5
5
4
4
4
4
4
4
5
5
4
PA
QL (56 EA per 28 days) PA
QL (6 EA per 30 days)
QL (6 EA per 30 days)
PA
Drug
Tier Requirements/Limits
Drug Name
CEPHALOSPORINS
CEDAX SUSR 90MG/5ML
cefaclor er tb12 500mg
cefaclor caps 250mg
cefaclor caps 500mg
cefaclor susr 125mg/5ml
cefaclor susr 250mg/5ml
cefaclor susr 375mg/5ml
cefadroxil caps 500mg
cefadroxil susr 250mg/5ml
cefadroxil susr 500mg/5ml
cefadroxil tabs 1gm
cefazolin sodium/dextrose inj 2gm; 3%
cefazolin sodium inj 100gm
cefazolin sodium inj 10gm
cefazolin sodium inj 1gm
cefazolin sodium inj 1gm
cefazolin sodium inj 300gm
cefazolin sodium inj 500mg
cefdinir caps 300mg
cefdinir susr 125mg/5ml
cefdinir susr 250mg/5ml
cefditoren pivoxil tabs 200mg
cefditoren pivoxil tabs 400mg
CEFEPIME INJ 1GM/50ML
cefepime inj 1gm
CEFEPIME INJ 2GM/50ML; 5%
cefepime inj 2gm
cefixime susr 100mg/5ml
cefixime susr 200mg/5ml
cefotaxime sodium inj 10gm
cefotaxime sodium inj 1gm
cefotaxime sodium inj 2gm
cefotaxime sodium inj 500mg
cefotetan/dextrose inj 1gm; 3.58%
cefotetan/dextrose inj 2gm; 2.08%
cefotetan inj 10gm
cefotetan inj 1gm
cefotetan inj 2gm
cefoxitin sodium inj 10gm
cefoxitin sodium inj 1gm
cefoxitin sodium inj 2gm
cefoxitin sodium inj 2gm; 2.2%
cefpodoxime proxetil susr 100mg/5ml
cefpodoxime proxetil susr 50mg/5ml
cefpodoxime proxetil tabs 100mg
cefpodoxime proxetil tabs 200mg
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
2
3
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
10
Drug Name
cefprozil susr 125mg/5ml
cefprozil susr 250mg/5ml
cefprozil tabs 250mg
cefprozil tabs 500mg
CEFTAZIDIME/DEXTROSE INJ 1GM/50ML; 5%
CEFTAZIDIME/DEXTROSE INJ 2GM/50ML; 5%
ceftazidime inj 1gm
ceftazidime inj 2gm
ceftazidime inj 6gm
ceftibuten caps 400mg
ceftibuten susr 180mg/5ml
CEFTIN SUSR 125MG/5ML
CEFTIN SUSR 250MG/5ML
CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE INJ 20MG/ML;
0
CEFTRIAXONE SODIUM INJ 10GM
CEFTRIAXONE SODIUM INJ 1GM
CEFTRIAXONE SODIUM INJ 250MG
CEFTRIAXONE SODIUM INJ 2GM
cefuroxime axetil tabs 250mg
cefuroxime axetil tabs 500mg
cefuroxime sodium inj 1.5gm
cefuroxime sodium inj 7.5gm
cefuroxime sodium inj 750mg
cefuroxime/dextrose inj 1.5gm; 2.9%
cefuroxime/dextrose inj 750mg; 4.1%
cephalexin caps 250mg
cephalexin caps 500mg
cephalexin caps 750mg
cephalexin susr 125mg/5ml
cephalexin susr 250mg/5ml
cephalexin tabs 250mg
cephalexin tabs 500mg
SUPRAX CAPS 400MG
SUPRAX CHEW 100MG
SUPRAX CHEW 200MG
SUPRAX SUSR 500MG/5ML
SUPRAX TABS 400MG
tazicef inj 1gm
tazicef inj 2gm
tazicef inj 6gm
TEFLARO INJ 400MG
TEFLARO INJ 600MG
ZERBAXA INJ 1GM; 0.5GM
MACROLIDES
azithromycin inj 500mg
azithromycin inj 500mg
11
Drug
Tier Requirements/Limits
2
2
2
2
4
4
1
1
1
2
2
4
4
4
4
4
4
4
2
2
2
2
2
2
2
1
1
1
1
1
1
1
4
4
4
4
4
1
1
1
4
4
4
1
1
Drug Name
azithromycin pack 1gm
azithromycin susr 100mg/5ml
azithromycin susr 200mg/5ml
azithromycin tabs 250mg
azithromycin tabs 500mg
azithromycin tabs 600mg
clarithromycin er tb24 500mg
clarithromycin susr 125mg/5ml
clarithromycin susr 250mg/5ml
clarithromycin tabs 250mg
clarithromycin tabs 500mg
DIFICID TABS 200MG
e.e.s. 400 tabs 400mg
E.E.S. GRANULES SUSR 200MG/5ML
e.s.p. susr 200mg/5ml; 600mg/5ml
ery-tab tbec 250mg
ERY-TAB TBEC 333MG
ery-tab tbec 500mg
ERYTHROCIN LACTOBIONATE INJ 1000MG
ERYTHROCIN LACTOBIONATE INJ 500MG
erythrocin stearate tabs 250mg
erythromycin base tabs 250mg
erythromycin base tabs 500mg
erythromycin ethylsuccinate tabs 400mg
erythromycin cpep 250mg
KETEK TABS 300MG
KETEK TABS 400MG
ZMAX SUSR 2GM
MISCELLANEOUS B-LACTAM ANTIBIOTICS
AZACTAM IN ISO-OSMOTIC DEXTROSE INJ 1GM; 0
aztreonam inj 1gm
aztreonam inj 2gm
CAYSTON SOLR 75MG
DORIBAX INJ 250MG
DORIBAX INJ 500MG
imipenem/cilastatin inj 250mg; 250mg
imipenem/cilastatin inj 500mg; 500mg
INVANZ INJ 1GM
meropenem inj 1gm
meropenem inj 500mg
PENICILLINS
amoxicillin er tb24 775mg
amoxicillin/clavulanate potassium er tb12 1000mg; 62.5mg
amoxicillin/clavulanate potassium chew 200mg; 28.5mg
amoxicillin/clavulanate potassium chew 400mg; 57mg
amoxicillin/clavulanate potassium susr 200mg/5ml; 28.5mg/5ml
amoxicillin/clavulanate potassium susr 250mg/5ml; 62.5mg/5ml
12
Drug
Tier Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
4
ST
2
3
2
2
4
2
3
3
2
2
2
2
2
4
4
4
4
1
1
5
4
4
1
1
3
2
1
2
1
2
2
2
2
PA
Drug Name
amoxicillin/clavulanate potassium susr 400mg/5ml; 57mg/5ml
amoxicillin/clavulanate potassium susr 600mg/5ml; 42.9mg/5ml
amoxicillin/clavulanate potassium tabs 250mg; 125mg
amoxicillin/clavulanate potassium tabs 500mg; 125mg
amoxicillin/clavulanate potassium tabs 875mg; 125mg
amoxicillin caps 250mg
amoxicillin caps 500mg
amoxicillin chew 125mg
amoxicillin chew 250mg
amoxicillin susr 125mg/5ml
amoxicillin susr 200mg/5ml
amoxicillin susr 250mg/5ml
amoxicillin susr 400mg/5ml
amoxicillin tabs 500mg
amoxicillin tabs 875mg
ampicillin sodium inj 10gm
ampicillin sodium inj 125mg
ampicillin sodium inj 2gm
ampicillin sodium inj 2gm
ampicillin-sulbactam inj 10gm; 5gm
ampicillin-sulbactam inj 1gm; 0.5gm
ampicillin-sulbactam inj 2gm; 1gm
ampicillin caps 250mg
ampicillin caps 500mg
ampicillin susr 125mg/5ml
ampicillin susr 250mg/5ml
AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML
bactocill in dextrose inj 0; 1gm/50ml
bactocill in dextrose inj 0; 2gm/50ml
BICILLIN C-R INJ 300000UNIT/ML; 300000UNIT/ML
BICILLIN C-R INJ 900000UNIT/2ML; 300000UNIT/2ML
BICILLIN L-A INJ 1200000UNIT/2ML
BICILLIN L-A INJ 2400000UNIT/4ML
BICILLIN L-A INJ 600000UNIT/ML
dicloxacillin sodium caps 250mg
dicloxacillin sodium caps 500mg
nafcillin sodium inj 10gm
nafcillin sodium inj 2gm
nafcillin sodium inj 2gm
NALLPEN ISO-OSMOTIC IN DEXTROSE INJ 0; 2GM/100ML
oxacillin sodium inj 10gm
oxacillin sodium inj 2gm
penicillin g potassium in iso-osmotic dextrose inj 0; 20000unit/ml
penicillin g potassium in iso-osmotic dextrose inj 0; 40000unit/ml
penicillin g potassium in iso-osmotic dextrose inj 0; 60000unit/ml
penicillin g potassium inj 20000000unit
penicillin g potassium inj 5000000unit
13
Drug
Tier Requirements/Limits
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
4
2
2
3
3
3
3
3
1
1
2
2
2
4
2
2
1
1
1
1
1
Drug Name
penicillin g procaine inj 600000unit/ml
penicillin v potassium solr 125mg/5ml
penicillin v potassium solr 250mg/5ml
penicillin v potassium tabs 250mg
penicillin v potassium tabs 500mg
pfizerpen-g inj 20mu
piperacillin sodium/ tazobactam sodium inj 36gm; 4.5gm
piperacillin sodium/tazobactam sodium inj 4gm; 0.5gm
TIMENTIN INJ 1GM; 30GM
QUINOLONES
AVELOX INJ 400MG/250ML; 0.8%
ciprofloxacin er tb24 1000mg; 0
ciprofloxacin er tb24 500mg; 0
ciprofloxacin hcl tabs 100mg
ciprofloxacin hcl tabs 250mg
ciprofloxacin hcl tabs 500mg
ciprofloxacin hcl tabs 750mg
ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5%
ciprofloxacin inj 200mg/20ml
ciprofloxacin susr 250mg/5ml
ciprofloxacin susr 500mg/5ml
FACTIVE TABS 320MG
levofloxacin in d5w inj 5%; 500mg/100ml
levofloxacin inj 25mg/ml
levofloxacin soln 25mg/ml
levofloxacin tabs 250mg
levofloxacin tabs 500mg
levofloxacin tabs 750mg
NOROXIN TABS 400MG
ofloxacin tabs 200mg
ofloxacin tabs 300mg
ofloxacin tabs 300mg
ofloxacin tabs 400mg
SULFONAMIDES
smz-tmp ds tabs 800mg; 160mg
sulfadiazine tabs 500mg
sulfamethoxazole/trimethoprim inj 400mg/5ml; 80mg/5ml
sulfamethoxazole/trimethoprim susp 200mg/5ml; 40mg/5ml
sulfamethoxazole/trimethoprim tabs 400mg; 80mg
sulfasalazine tabs 500mg
sulfasalazine tbec 500mg
sulfatrim pediatric susp 200mg/5ml; 40mg/5ml
sulfazine tabs 500mg
TETRACYCLINES
demeclocycline hcl tabs 150mg
demeclocycline hcl tabs 300mg
doxy 100 inj 100mg
14
Drug
Tier Requirements/Limits
1
1
1
1
1
1
1
1
3
4
2
2
1
1
1
1
1
1
2
2
4
2
2
2
2
2
2
4
1
1
1
1
1
1
1
1
1
1
1
2
1
2
2
2
Drug
Tier Requirements/Limits
2
2
2
2
2
2
2
2
1
1
1
2
2
2
2
2
2
2
4
1
1
1
1
1
1
1
1
1
2
2
4
4
Drug Name
doxycycline hyclate dr tbec 100mg
doxycycline hyclate dr tbec 150mg
doxycycline hyclate dr tbec 75mg
doxycycline hyclate caps 100mg
doxycycline hyclate caps 50mg
doxycycline hyclate cpep 100mg
doxycycline hyclate tabs 100mg
doxycycline hyclate tabs 20mg
doxycycline monohydrate caps 100mg
doxycycline monohydrate caps 50mg
doxycycline monohydrate tabs 100mg
doxycycline monohydrate tabs 150mg
doxycycline monohydrate tabs 50mg
doxycycline monohydrate tabs 50mg
doxycycline monohydrate tabs 75mg
doxycycline caps 150mg
doxycycline caps 75mg
doxycycline susr 25mg/5ml
MINOCIN INJ 100MG
minocycline hcl er tb24 135mg
minocycline hcl er tb24 45mg
minocycline hcl er tb24 90mg
minocycline hcl caps 100mg
minocycline hcl caps 50mg
minocycline hcl caps 75mg
minocycline hcl tabs 100mg
minocycline hcl tabs 50mg
minocycline hcl tabs 75mg
tetracycline hcl caps 250mg
tetracycline hcl caps 500mg
TYGACIL INJ 50MG
VIBRAMYCIN SYRP 50MG/5ML
ANTICANCER AGENTS
ANTICANCER AGENTS
ABRAXANE INJ 900MG; 100MG
ADCETRIS INJ 50MG
adriamycin inj 10mg
adrucil inj 500mg/10ml
AFINITOR DISPERZ TBSO 2MG
AFINITOR DISPERZ TBSO 3MG
AFINITOR DISPERZ TBSO 5MG
AFINITOR TABS 10MG
AFINITOR TABS 2.5MG
AFINITOR TABS 5MG
AFINITOR TABS 7.5MG
ALIMTA INJ 500MG
anastrozole tabs 1mg
4
5
1
2
5
5
5
5
5
5
5
3
1
15
B/D
B/D
PA
PA
PA
PA
PA
PA
PA
Drug
Tier
3
5
5
5
3
5
1
3
1
5
5
5
3
5
5
1
1
1
3
5
5
5
4
4
1
1
1
5
5
1
1
1
1
1
1
4
2
4
4
4
1
1
1
1
1
4
4
Drug Name
ARRANON INJ 5MG/ML
ARZERRA INJ 1000MG/50ML
AVASTIN INJ 100MG/4ML
AVASTIN INJ 400MG/16ML
AZACITIDINE INJ 100MG
BELEODAQ INJ 500MG
bicalutamide tabs 50mg
BICNU INJ 100MG
bleomycin sulfate inj 30unit
BLINCYTO INJ 35MCG
BOSULIF TABS 100MG
BOSULIF TABS 500MG
BUSULFEX INJ 6MG/ML
CAPRELSA TABS 100MG
CAPRELSA TABS 300MG
carboplatin inj 50mg/5ml
cisplatin inj 50mg/50ml
cladribine inj 1mg/ml
CLOLAR INJ 1MG/ML
COMETRIQ KIT 0
COMETRIQ KIT 0
COMETRIQ KIT 20MG
CYCLOPHOSPHAMIDE CAPS 25MG
CYCLOPHOSPHAMIDE CAPS 50MG
cyclophosphamide inj 2gm
cyclophosphamide tabs 25mg
cyclophosphamide tabs 50mg
CYRAMZA INJ 100MG/10ML
CYRAMZA INJ 500MG/50ML
cytarabine aqueous inj 100mg/ml
cytarabine aqueous inj 20mg/ml
cytarabine inj 500mg
dacarbazine inj 200mg
dactinomycin inj 0.5mg
daunorubicin hcl inj 5mg/ml
DAUNOXOME INJ 2MG/ML
decitabine inj 50mg
DEPOCYT INJ 50MG/5ML
DOCEFREZ INJ 20MG
DOCEFREZ INJ 80MG
docetaxel inj 20mg/0.5ml
docetaxel inj 20mg/2ml
docetaxel inj 80mg/4ml
doxorubicin hcl liposome inj 2mg/ml
doxorubicin hcl inj 10mg
DROXIA CAPS 200MG
DROXIA CAPS 300MG
16
Requirements/Limits
PA
B/D
PA
PA
PA
PA
PA
B/D
PA
PA
PA
B/D
B/D
B/D
B/D
B/D
PA
PA
B/D
B/D
B/D
B/D
B/D
B/D
Drug
Tier
4
4
4
4
4
4
3
4
1
3
5
5
4
1
2
5
5
5
5
3
4
4
1
1
2
2
3
5
1
5
5
5
5
5
5
3
5
1
5
5
5
5
5
1
1
1
5
Drug Name
DROXIA CAPS 400MG
ELIGARD INJ 22.5MG
ELIGARD INJ 30MG
ELIGARD INJ 45MG
ELIGARD INJ 7.5MG
ELOXATIN INJ 50MG/10ML
ELSPAR INJ 10000UNIT
EMCYT CAPS 140MG
epirubicin hcl inj 50mg/25ml
ERBITUX INJ 200MG/100ML
ERIVEDGE CAPS 150MG
ERWINAZE INJ 10000UNIT
ETOPOPHOS INJ 100MG
etoposide inj 500mg/25ml
exemestane tabs 25mg
FARESTON TABS 60MG
FARYDAK CAPS 10MG
FARYDAK CAPS 15MG
FARYDAK CAPS 20MG
FASLODEX INJ 250MG/5ML
FIRMAGON INJ 120MG
FIRMAGON INJ 80MG
floxuridine inj 0.5gm
fludarabine phosphate inj 50mg/2ml
fluorouracil inj 500mg/10ml
flutamide caps 125mg
FOLOTYN INJ 20MG/ML
GAZYVA INJ 1000MG/40ML
gemcitabine inj 1gm/26.3ml
GILOTRIF TABS 20MG
GILOTRIF TABS 30MG
GILOTRIF TABS 40MG
GLEEVEC TABS 100MG
GLEEVEC TABS 400MG
HALAVEN INJ 1MG/2ML
HERCEPTIN INJ 440MG
HEXALEN CAPS 50MG
hydroxyurea caps 500mg
IBRANCE CAPS 100MG
IBRANCE CAPS 125MG
IBRANCE CAPS 75MG
ICLUSIG TABS 15MG
ICLUSIG TABS 45MG
idarubicin hcl inj 5mg/5ml
ifosfamide/mesna inj 1gm; 1gm
ifosfamide inj 1gm/20ml
IMBRUVICA CAPS 140MG
17
Requirements/Limits
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
B/D
B/D
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Drug
Tier
5
5
1
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
2
4
2
2
3
3
3
4
4
4
4
4
4
4
4
5
3
5
5
5
2
1
1
5
5
1
2
1
1
Drug Name
INLYTA TABS 1MG
INLYTA TABS 5MG
irinotecan inj 40mg/2ml
ISTODAX INJ 10MG
IXEMPRA KIT INJ 15MG
JAKAFI TABS 10MG
JAKAFI TABS 15MG
JAKAFI TABS 20MG
JAKAFI TABS 25MG
JAKAFI TABS 5MG
JEVTANA INJ 60MG/1.5ML
KADCYLA INJ 100MG
KEYTRUDA INJ 50MG
KYPROLIS INJ 60MG
LENVIMA 10MG DAILY DOSE CPPK 10MG
LENVIMA 14MG DAILY DOSE CPPK 0
LENVIMA 20MG DAILY DOSE CPPK 10MG
LENVIMA 24MG DAILY DOSE CPPK 0
letrozole tabs 2.5mg
LEUKERAN TABS 2MG
leuprolide acetate inj 1mg/0.2ml
lipodox inj 2mg/ml
LOMUSTINE CAPS 100MG
LOMUSTINE CAPS 10MG
LOMUSTINE CAPS 40MG
LUPRON DEPOT-PED INJ 11.25MG
LUPRON DEPOT-PED INJ 15MG
LUPRON DEPOT-PED INJ 30MG
LUPRON DEPOT INJ 11.25MG
LUPRON DEPOT INJ 22.5MG
LUPRON DEPOT INJ 3.75MG
LUPRON DEPOT INJ 45MG
LUPRON DEPOT INJ 7.5MG
LYNPARZA CAPS 50MG
LYSODREN TABS 500MG
MARQIBO INJ 5MG/31ML
MATULANE CAPS 50MG
MEGACE ES SUSP 625MG/5ML
megestrol acetate susp 40mg/ml
megestrol acetate tabs 20mg
megestrol acetate tabs 40mg
MEKINIST TABS 0.5MG
MEKINIST TABS 2MG
melphalan hydrochloride inj 50mg
mercaptopurine tabs 50mg
methotrexate sodium inj 1gm/40ml
methotrexate sodium inj 1gm
18
Requirements/Limits
PA
PA
QL (60 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (60 EA per 30 days) PA
PA
PA
PA
PA
PA
PA
B/D
PA
PA
PA
PA
PA
PA
PA
PA
PA
Drug
Tier
1
1
1
3
5
4
3
3
5
1
1
1
1
1
5
3
5
5
5
5
3
4
5
5
5
5
5
5
3
4
5
5
5
5
5
5
5
5
5
5
5
5
5
5
4
5
5
Drug Name
methotrexate tabs 2.5mg
mitomycin inj 20mg
mitoxantrone hcl inj 2mg/ml
MUSTARGEN INJ 10MG
NEXAVAR TABS 200MG
NILANDRON TABS 150MG
ONCASPAR INJ 750UNIT/ML
ONTAK INJ 150MCG/ML
OPDIVO INJ 40MG/4ML
oxaliplatin inj 100mg/20ml
oxaliplatin inj 50mg/10ml
paclitaxel inj 300mg/50ml
paclitaxel inj 30mg/5ml
pentostatin inj 10mg
PERJETA INJ 420MG/14ML
PHOTOFRIN INJ 75MG
POMALYST CAPS 1MG
POMALYST CAPS 2MG
POMALYST CAPS 3MG
POMALYST CAPS 4MG
PROLEUKIN INJ 22000000UNIT
PURIXAN SUSP 2000MG/100ML
REVLIMID CAPS 10MG
REVLIMID CAPS 15MG
REVLIMID CAPS 2.5MG
REVLIMID CAPS 20MG
REVLIMID CAPS 25MG
REVLIMID CAPS 5MG
RITUXAN INJ 10MG/ML
SOLTAMOX SOLN 10MG/5ML
SPRYCEL TABS 100MG
SPRYCEL TABS 140MG
SPRYCEL TABS 20MG
SPRYCEL TABS 50MG
SPRYCEL TABS 70MG
SPRYCEL TABS 80MG
STIVARGA TABS 40MG
SUTENT CAPS 12.5MG
SUTENT CAPS 25MG
SUTENT CAPS 37.5MG
SUTENT CAPS 50MG
SYLVANT INJ 100MG
SYLVANT INJ 400MG
SYNRIBO INJ 3.5MG
TABLOID TABS 40MG
TAFINLAR CAPS 50MG
TAFINLAR CAPS 75MG
19
Requirements/Limits
B/D
PA
PA
PA
QL (21 EA per 28 days) PA
QL (21 EA per 28 days) PA
QL (21 EA per 28 days) PA
QL (21 EA per 28 days) PA
PA
PA LA
PA LA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Drug
Tier
1
1
5
5
5
5
4
5
5
5
3
1
1
4
5
5
5
3
3
3
5
3
5
3
4
5
1
1
1
1
5
5
5
5
5
5
3
5
5
4
5
5
5
5
5
Drug Name
tamoxifen citrate tabs 10mg
tamoxifen citrate tabs 20mg
TARCEVA TABS 100MG
TARCEVA TABS 150MG
TARCEVA TABS 25MG
TARGRETIN CAPS 75MG
TARGRETIN GEL 1%
TASIGNA CAPS 150MG
TASIGNA CAPS 200MG
TEMODAR INJ 100MG
TENIPOSIDE INJ 10MG/ML
toposar inj 1gm/50ml
topotecan hcl inj 4mg/4ml
TORISEL INJ 25MG/ML
TREANDA INJ 100MG
TREANDA INJ 180MG/2ML
TREANDA INJ 45MG/0.5ML
TRELSTAR MIXJECT INJ 11.25MG
TRELSTAR MIXJECT INJ 22.5MG
TRELSTAR MIXJECT INJ 3.75MG
tretinoin caps 10mg
TRISENOX INJ 10MG/10ML
TYKERB TABS 250MG
VALSTAR INJ 40MG/ML
VECTIBIX INJ 100MG/5ML
VELCADE INJ 3.5MG
vinblastine sulfate inj 1mg/ml
vincasar pfs inj 1mg/ml
vincristine sulfate inj 1mg/ml
vinorelbine tartrate inj 10mg/ml
VOTRIENT TABS 200MG
XALKORI CAPS 200MG
XALKORI CAPS 250MG
XTANDI CAPS 40MG
YERVOY INJ 50MG/10ML
ZALTRAP INJ 100MG/4ML
ZANOSAR INJ 1GM
ZELBORAF TABS 240MG
ZOLADEX INJ 10.8MG
ZOLADEX INJ 3.6MG
ZOLINZA CAPS 100MG
ZYDELIG TABS 100MG
ZYDELIG TABS 150MG
ZYKADIA CAPS 150MG
ZYTIGA TABS 250MG
ANTICHOLINERGIC AGENTS
ANTIMUSCARINICS/ANTISPASMODICS
20
Requirements/Limits
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
B/D
B/D
B/D
PA
PA
PA
PA
PA
B/D
PA
PA
PA
PA
PA
PA
PA
PA
Drug
Tier Requirements/Limits
1
1
1
1
2
Drug Name
atropine sulfate inj 0.05mg/ml
atropine sulfate inj 0.1mg/ml
atropine sulfate inj 0.4mg/ml
atropine sulfate inj 1mg/ml
propantheline bromide tabs 15mg
ANTICONVULSANTS
ANTICONVULSANTS
APTIOM TABS 200MG
APTIOM TABS 400MG
APTIOM TABS 600MG
APTIOM TABS 800MG
BANZEL SUSP 40MG/ML
BANZEL TABS 200MG
BANZEL TABS 400MG
carbamazepine er cp12 100mg
carbamazepine er cp12 200mg
carbamazepine er cp12 300mg
carbamazepine er tb12 200mg
carbamazepine er tb12 400mg
carbamazepine chew 100mg
carbamazepine susp 100mg/5ml
carbamazepine tabs 200mg
CELONTIN CAPS 300MG
CEREBYX INJ 100MG PE/2ML
DILANTIN INFATABS CHEW 50MG
DILANTIN-125 SUSP 125MG/5ML
DILANTIN CAPS 100MG
DILANTIN CAPS 30MG
divalproex sodium dr tbec 125mg
divalproex sodium dr tbec 250mg
divalproex sodium dr tbec 500mg
divalproex sodium er tb24 250mg
divalproex sodium er tb24 500mg
divalproex sodium cpsp 125mg
epitol tabs 200mg
EQUETRO CP12 100MG
EQUETRO CP12 200MG
EQUETRO CP12 300MG
ethosuximide caps 250mg
ethosuximide soln 250mg/5ml
felbamate susp 600mg/5ml
felbamate tabs 400mg
felbamate tabs 600mg
fosphenytoin sodium inj 100mg pe/2ml
fosphenytoin sodium inj 500mg pe/10ml
FYCOMPA TABS 10MG
FYCOMPA TABS 12MG
4
5
5
5
4
4
4
1
1
1
2
1
1
1
1
3
4
4
4
4
4
1
1
1
2
2
1
1
4
4
4
2
2
2
2
2
1
1
4
4
21
ST
ST
ST
ST
Drug
Tier
4
4
4
4
1
1
1
1
1
1
4
4
4
4
4
4
4
4
1
1
3
1
3
1
1
1
1
1
1
1
1
1
2
2
2
1
1
1
1
1
1
4
4
4
4
4
4
Drug Name
FYCOMPA TABS 2MG
FYCOMPA TABS 4MG
FYCOMPA TABS 6MG
FYCOMPA TABS 8MG
gabapentin caps 100mg
gabapentin caps 300mg
gabapentin caps 400mg
gabapentin soln 250mg/5ml
gabapentin tabs 600mg
gabapentin tabs 800mg
GABITRIL TABS 12MG
GABITRIL TABS 16MG
GRALISE STARTER MISC 0
GRALISE TABS 300MG
GRALISE TABS 600MG
HORIZANT TBCR 300MG
HORIZANT TBCR 600MG
LAMICTAL CHEW 2MG
lamotrigine er tb24 100mg
lamotrigine er tb24 200mg
LAMOTRIGINE ER TB24 250MG
lamotrigine er tb24 25mg
LAMOTRIGINE ER TB24 300MG
lamotrigine er tb24 50mg
lamotrigine chew 25mg
lamotrigine chew 5mg
lamotrigine tabs 100mg
lamotrigine tabs 150mg
lamotrigine tabs 200mg
lamotrigine tabs 25mg
levetiracetam er tb24 500mg
levetiracetam er tb24 750mg
levetiracetam inj 1000mg/100ml; 750mg/100ml
levetiracetam inj 1500mg/100ml; 540mg/100ml
levetiracetam inj 500mg/100ml; 820mg/100ml
levetiracetam inj 500mg/5ml
levetiracetam soln 100mg/ml
levetiracetam tabs 1000mg
levetiracetam tabs 250mg
levetiracetam tabs 500mg
levetiracetam tabs 750mg
LYRICA CAPS 100MG
LYRICA CAPS 150MG
LYRICA CAPS 200MG
LYRICA CAPS 225MG
LYRICA CAPS 25MG
LYRICA CAPS 300MG
22
Requirements/Limits
ST
ST
ST
Drug
Tier Requirements/Limits
4
4
4
1
1
1
1
4
4
4
4
1
1
1
1
1
1
1
1
1
1
1
3
3
1
1
1
1
1
1
1
5
5
5
4
1
1
5
PA
5
PA
4
4
4
2
2
2
2
2
Drug Name
LYRICA CAPS 50MG
LYRICA CAPS 75MG
LYRICA SOLN 20MG/ML
oxcarbazepine susp 300mg/5ml
oxcarbazepine tabs 150mg
oxcarbazepine tabs 300mg
oxcarbazepine tabs 600mg
OXTELLAR XR TB24 150MG
OXTELLAR XR TB24 300MG
OXTELLAR XR TB24 600MG
PEGANONE TABS 250MG
phenobarbital sodium inj 130mg/ml
phenobarbital sodium inj 65mg/ml
phenobarbital elix 20mg/5ml
phenobarbital tabs 100mg
phenobarbital tabs 15mg
phenobarbital tabs 16.2mg
phenobarbital tabs 30mg
phenobarbital tabs 32.4mg
phenobarbital tabs 60mg
phenobarbital tabs 64.8mg
phenobarbital tabs 97.2mg
PHENYTEK CAPS 200MG
PHENYTEK CAPS 300MG
phenytoin infatabs chew 50mg
phenytoin sodium extended caps 100mg
phenytoin sodium extended caps 200mg
phenytoin sodium extended caps 300mg
phenytoin sodium inj 50mg/ml
phenytoin chew 50mg
phenytoin susp 125mg/5ml
POTIGA TABS 200MG
POTIGA TABS 300MG
POTIGA TABS 400MG
POTIGA TABS 50MG
primidone tabs 250mg
primidone tabs 50mg
SABRIL PACK 500MG
SABRIL TABS 500MG
STAVZOR CPDR 125MG
STAVZOR CPDR 250MG
STAVZOR CPDR 500MG
tiagabine hydrochloride tabs 2mg
tiagabine hydrochloride tabs 4mg
topiragen tabs 100mg
topiragen tabs 200mg
topiragen tabs 25mg
23
Drug
Tier Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
4
1
1
1
3
3
3
3
3
3
1
1
1
Drug Name
topiragen tabs 50mg
topiramate er cs24 100mg
topiramate er cs24 150mg
topiramate er cs24 200mg
topiramate er cs24 25mg
topiramate er cs24 50mg
topiramate cpsp 15mg
topiramate cpsp 25mg
topiramate tabs 100mg
topiramate tabs 200mg
topiramate tabs 25mg
topiramate tabs 50mg
TROKENDI XR CP24 100MG
TROKENDI XR CP24 200MG
TROKENDI XR CP24 25MG
TROKENDI XR CP24 50MG
valproate sodium inj 500mg/5ml
valproic acid caps 250mg
valproic acid syrp 250mg/5ml
VIMPAT INJ 200MG/20ML
VIMPAT SOLN 10MG/ML
VIMPAT TABS 100MG
VIMPAT TABS 150MG
VIMPAT TABS 200MG
VIMPAT TABS 50MG
zonisamide caps 100mg
zonisamide caps 25mg
zonisamide caps 50mg
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS
donepezil hcl tabs 10mg
donepezil hcl tabs 5mg
donepezil hcl tbdp 10mg
donepezil hcl tbdp 5mg
galantamine hydrobromide cp24 16mg
galantamine hydrobromide cp24 24mg
galantamine hydrobromide cp24 8mg
galantamine hydrobromide soln 4mg/ml
galantamine hydrobromide tabs 12mg
galantamine hydrobromide tabs 4mg
galantamine hydrobromide tabs 8mg
NAMENDA TITRATION PAK TABS 0
NAMENDA XR TITRATION PACK CP24 0
NAMENDA XR CP24 14MG
NAMENDA XR CP24 21MG
NAMENDA XR CP24 28MG
NAMENDA XR CP24 7MG
1
1
1
1
2
2
2
2
2
2
2
3
4
4
4
4
4
24
Drug Name
NAMENDA SOLN 10MG/5ML
NAMENDA TABS 10MG
NAMENDA TABS 5MG
rivastigmine tartrate caps 1.5mg
rivastigmine tartrate caps 3mg
rivastigmine tartrate caps 4.5mg
rivastigmine tartrate caps 6mg
ANTIDEPRESSANTS
ANTIDEPRESSANTS
AMITRIPTYLINE HCL TABS 100MG
AMITRIPTYLINE HCL TABS 10MG
AMITRIPTYLINE HCL TABS 150MG
AMITRIPTYLINE HCL TABS 25MG
AMITRIPTYLINE HCL TABS 50MG
AMITRIPTYLINE HCL TABS 75MG
amoxapine tabs 100mg
amoxapine tabs 150mg
amoxapine tabs 25mg
amoxapine tabs 50mg
APLENZIN TB24 174MG
APLENZIN TB24 348MG
APLENZIN TB24 522MG
BRINTELLIX TABS 10MG
BRINTELLIX TABS 20MG
BRINTELLIX TABS 5MG
BRISDELLE CAPS 7.5MG
bupropion hcl sr tb12 100mg
bupropion hcl sr tb12 150mg
bupropion hcl sr tb12 200mg
bupropion hcl xl tb24 150mg
bupropion hcl xl tb24 300mg
bupropion hcl tabs 100mg
bupropion hcl tabs 75mg
CHLORDIAZEPOXIDE/AMITRIPTYLINE TABS 12.5MG; 5MG
CHLORDIAZEPOXIDE/AMITRIPTYLINE TABS 25MG; 10MG
citalopram hydrobromide soln 10mg/5ml
citalopram hydrobromide tabs 10mg
citalopram hydrobromide tabs 20mg
citalopram hydrobromide tabs 40mg
CLOMIPRAMINE HCL CAPS 25MG
CLOMIPRAMINE HCL CAPS 50MG
CLOMIPRAMINE HCL CAPS 75MG
desipramine hcl tabs 100mg
desipramine hcl tabs 10mg
desipramine hcl tabs 150mg
desipramine hcl tabs 25mg
desipramine hcl tabs 50mg
25
Drug
Tier Requirements/Limits
3
3
3
2
2
2
2
4
4
4
4
4
4
1
1
1
1
4
4
4
4
4
4
4
1
1
1
1
2
1
1
4
4
1
1
1
1
4
4
4
2
2
2
2
2
PA
PA
PA
PA
PA
PA
ST
ST
ST
PA
PA
QL (600 ML per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
PA
PA
PA
Drug Name
desipramine hcl tabs 75mg
DESVENLAFAXINE ER TB24 100MG
desvenlafaxine er tb24 100mg
DESVENLAFAXINE ER TB24 50MG
desvenlafaxine er tb24 50mg
DOXEPIN HCL CAPS 100MG
DOXEPIN HCL CAPS 10MG
DOXEPIN HCL CAPS 150MG
DOXEPIN HCL CAPS 25MG
DOXEPIN HCL CAPS 50MG
DOXEPIN HCL CAPS 75MG
DOXEPIN HCL CONC 10MG/ML
duloxetine hcl cpep 20mg
duloxetine hcl cpep 30mg
duloxetine hcl cpep 40mg
duloxetine hcl cpep 60mg
EMSAM PT24 12MG/24HR
EMSAM PT24 6MG/24HR
EMSAM PT24 9MG/24HR
escitalopram oxalate soln 5mg/5ml
escitalopram oxalate tabs 10mg
escitalopram oxalate tabs 20mg
escitalopram oxalate tabs 5mg
FETZIMA TITRATION PACK C4PK 0
FETZIMA CP24 120MG
FETZIMA CP24 20MG
FETZIMA CP24 40MG
FETZIMA CP24 80MG
fluoxetine dr cpdr 90mg
fluoxetine hcl caps 10mg
fluoxetine hcl caps 20mg
fluoxetine hcl caps 40mg
fluoxetine hcl soln 20mg/5ml
fluoxetine hcl tabs 10mg
fluoxetine hcl tabs 20mg
fluoxetine hcl tabs 60mg
FLUVOXAMINE MALEATE ER CP24 100MG
FLUVOXAMINE MALEATE ER CP24 150MG
fluvoxamine maleate tabs 100mg
fluvoxamine maleate tabs 25mg
fluvoxamine maleate tabs 50mg
FORFIVO XL TB24 450MG
IMIPRAMINE HCL TABS 10MG
IMIPRAMINE HCL TABS 25MG
IMIPRAMINE HCL TABS 50MG
IMIPRAMINE PAMOATE CAPS 100MG
IMIPRAMINE PAMOATE CAPS 125MG
26
Drug
Tier
2
4
2
4
2
4
4
4
4
4
4
4
2
2
2
2
4
4
4
1
1
1
1
4
4
4
4
4
1
1
1
1
1
1
1
1
4
4
1
1
1
4
4
4
4
4
4
Requirements/Limits
PA
PA
PA
PA
PA
PA
PA
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (600 ML per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
ST
ST
ST
ST
ST
ST
ST
PA
PA
PA
PA
PA
Drug Name
IMIPRAMINE PAMOATE CAPS 150MG
IMIPRAMINE PAMOATE CAPS 75MG
IRENKA CPEP 40MG
maprotiline hcl tabs 25mg
maprotiline hcl tabs 50mg
maprotiline hcl tabs 75mg
MARPLAN TABS 10MG
mirtazapine odt tbdp 15mg
mirtazapine odt tbdp 30mg
mirtazapine odt tbdp 45mg
mirtazapine tabs 15mg
mirtazapine tabs 30mg
mirtazapine tabs 45mg
mirtazapine tabs 7.5mg
nefazodone hcl tabs 100mg
nefazodone hcl tabs 150mg
nefazodone hcl tabs 200mg
nefazodone hcl tabs 250mg
nefazodone hcl tabs 50mg
nortriptyline hcl caps 10mg
nortriptyline hcl caps 25mg
nortriptyline hcl caps 50mg
nortriptyline hcl caps 75mg
nortriptyline hcl soln 10mg/5ml
olanzapine/fluoxetine caps 25mg; 12mg
olanzapine/fluoxetine caps 25mg; 3mg
olanzapine/fluoxetine caps 25mg; 6mg
olanzapine/fluoxetine caps 50mg; 12mg
olanzapine/fluoxetine caps 50mg; 6mg
paroxetine hcl er tb24 12.5mg
paroxetine hcl er tb24 25mg
paroxetine hcl er tb24 37.5mg
paroxetine hcl tabs 10mg
paroxetine hcl tabs 20mg
paroxetine hcl tabs 30mg
paroxetine hcl tabs 40mg
PAXIL SUSP 10MG/5ML
PERPHENAZINE/AMITRIPTYLINE TABS 10MG; 2MG
PERPHENAZINE/AMITRIPTYLINE TABS 10MG; 4MG
PERPHENAZINE/AMITRIPTYLINE TABS 25MG; 2MG
PERPHENAZINE/AMITRIPTYLINE TABS 25MG; 4MG
PERPHENAZINE/AMITRIPTYLINE TABS 50MG; 4MG
PEXEVA TABS 10MG
PEXEVA TABS 20MG
PEXEVA TABS 30MG
PEXEVA TABS 40MG
phenelzine sulfate tabs 15mg
27
Drug
Tier
4
4
4
2
2
2
4
1
1
1
1
1
1
1
2
2
2
2
2
1
1
1
1
1
2
2
2
2
2
1
1
1
1
1
1
1
4
4
4
4
4
4
4
4
4
4
2
Requirements/Limits
PA
PA
QL (30 EA per 30 days)
PA
PA
PA
PA
PA
ST
ST
ST
ST
Drug
Tier
4
2
4
2
2
1
1
1
1
4
4
4
4
4
2
1
1
1
1
1
1
1
1
1
1
1
1
4
4
4
4
Drug Name
PRISTIQ TB24 100MG
PRISTIQ TB24 25MG
PRISTIQ TB24 50MG
protriptyline hcl tabs 10mg
protriptyline hcl tabs 5mg
sertraline hcl conc 20mg/ml
sertraline hcl tabs 100mg
sertraline hcl tabs 25mg
sertraline hcl tabs 50mg
SILENOR TABS 3MG
SILENOR TABS 6MG
SURMONTIL CAPS 100MG
SURMONTIL CAPS 25MG
SURMONTIL CAPS 50MG
tranylcypromine sulfate tabs 10mg
trazodone hcl tabs 100mg
trazodone hcl tabs 150mg
trazodone hcl tabs 300mg
trazodone hcl tabs 50mg
venlafaxine hcl er cp24 150mg
venlafaxine hcl er cp24 37.5mg
venlafaxine hcl er cp24 75mg
venlafaxine hcl tabs 100mg
venlafaxine hcl tabs 25mg
venlafaxine hcl tabs 37.5mg
venlafaxine hcl tabs 50mg
venlafaxine hcl tabs 75mg
VIIBRYD KIT 0
VIIBRYD TABS 10MG
VIIBRYD TABS 20MG
VIIBRYD TABS 40MG
ANTIDIABETIC AGENTS
ANTIDIABETIC AGENTS, MISCELLANEOUS
acarbose tabs 100mg
acarbose tabs 25mg
acarbose tabs 50mg
AVANDIA TABS 2MG
AVANDIA TABS 4MG
AVANDIA TABS 8MG
BYDUREON INJ 2MG
BYDUREON INJ 2MG
BYETTA INJ 10MCG/0.04ML
BYETTA INJ 5MCG/0.02ML
CYCLOSET TABS 0.8MG
glipizide/metformin hcl tabs 2.5mg; 250mg
glipizide/metformin hcl tabs 2.5mg; 500mg
glipizide/metformin hcl tabs 5mg; 500mg
1
1
1
4
4
4
4
4
4
4
3
1
1
1
28
Requirements/Limits
QL (31 EA per 31 days) ST
QL (30 EA per 30 days) ST
QL (31 EA per 31 days) ST
ST
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
Drug Name
GLYSET TABS 100MG
GLYSET TABS 25MG
GLYSET TABS 50MG
INVOKANA TABS 100MG
INVOKANA TABS 300MG
JENTADUETO TABS 2.5MG; 1000MG
JENTADUETO TABS 2.5MG; 500MG
JENTADUETO TABS 2.5MG; 850MG
KAZANO TABS 12.5MG; 1000MG
KAZANO TABS 12.5MG; 500MG
KORLYM TABS 300MG
metformin hcl er tb24 1000mg
metformin hcl er tb24 500mg
metformin hcl er tb24 750mg
metformin hcl tabs 1000mg
metformin hcl tabs 500mg
metformin hcl tabs 850mg
nateglinide tabs 120mg
nateglinide tabs 60mg
NESINA TABS 12.5MG
NESINA TABS 25MG
NESINA TABS 6.25MG
OSENI TABS 12.5MG; 15MG
OSENI TABS 12.5MG; 30MG
OSENI TABS 12.5MG; 45MG
OSENI TABS 25MG; 15MG
OSENI TABS 25MG; 30MG
OSENI TABS 25MG; 45MG
pioglitazone hcl-glimepiride tabs 2mg; 30mg
pioglitazone hcl-glimepiride tabs 4mg; 30mg
pioglitazone hcl/metformin hcl tabs 500mg; 15mg
pioglitazone hcl/metformin hcl tabs 850mg; 15mg
pioglitazone hcl tabs 15mg
pioglitazone hcl tabs 30mg
pioglitazone hcl tabs 45mg
repaglinide tabs 0.5mg
repaglinide tabs 1mg
repaglinide tabs 2mg
RIOMET SOLN 500MG/5ML
SYMLINPEN 120 INJ 2700MCG/2.7ML
SYMLINPEN 60 INJ 1500MCG/1.5ML
TANZEUM INJ 30MG
TANZEUM INJ 50MG
TRADJENTA TABS 5MG
VICTOZA INJ 18MG/3ML
INSULINS
HUMALOG KWIKPEN INJ 100UNIT/ML
29
Drug
Tier
4
4
4
3
3
3
3
3
4
4
5
1
1
1
1
1
1
2
2
4
4
4
4
4
4
4
4
4
2
2
2
2
2
2
2
2
2
2
3
4
4
4
4
3
4
3
Requirements/Limits
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
QL (60 EA per 30 days) ST
QL (60 EA per 30 days) ST
QL (60 EA per 30 days) ST
QL (60 EA per 30 days) ST
QL (60 EA per 30 days) ST
PA
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
PA
PA
ST
ST
QL (30 EA per 30 days) ST
ST
QL (60 ML per 30 days)
Drug
Drug Name
Tier
HUMALOG KWIKPEN INJ 200UNIT/ML
3
HUMALOG MIX 50/50 KWIKPEN INJ 50UNIT/ML; 50UNIT/ML 3
HUMALOG MIX 50/50 INJ 50UNIT/ML; 50UNIT/ML
3
HUMALOG MIX 75/25 KWIKPEN INJ 25UNIT/ML; 75UNIT/ML 3
HUMALOG MIX 75/25 INJ 25UNIT/ML; 75UNIT/ML
3
HUMALOG INJ 100UNIT/ML
3
HUMALOG INJ 100UNIT/ML
3
HUMULIN 70/30 KWIKPEN INJ 30UNIT/ML; 70UNIT/ML
3
HUMULIN 70/30 INJ 30UNIT/ML; 70UNIT/ML
3
HUMULIN N KWIKPEN INJ 100UNIT/ML
3
HUMULIN N INJ 100UNIT/ML
3
HUMULIN R U-500 (CONCENTRATED) INJ 500UNIT/ML
3
HUMULIN R INJ 100UNIT/ML
3
LANTUS SOLOSTAR INJ 100UNIT/ML
3
LANTUS INJ 100UNIT/ML
3
LEVEMIR FLEXTOUCH INJ 100UNIT/ML
3
LEVEMIR INJ 100UNIT/ML
3
TOUJEO SOLOSTAR INJ 300UNIT/ML
3
SULFONYLUREAS
glimepiride tabs 1mg
1
glimepiride tabs 2mg
1
glimepiride tabs 4mg
1
glipizide er tb24 10mg
1
glipizide er tb24 2.5mg
1
glipizide er tb24 5mg
1
glipizide tabs 10mg
1
glipizide tabs 5mg
1
tolazamide tabs 250mg
1
tolazamide tabs 500mg
1
tolbutamide tabs 500mg
1
ANTIFUNGALS
ANTIFUNGALS
ABELCET INJ 5MG/ML
3
AMBISOME INJ 50MG
3
amphotericin b inj 50mg
1
CANCIDAS INJ 50MG
3
CANCIDAS INJ 70MG
3
ciclopirox nail lacquer soln 8%
2
ciclopirox olamine crea 0.77%
2
ciclopirox treatment kit 0; 8%; 0
2
ciclopirox gel 0.77%
2
ciclopirox sham 1%
2
ciclopirox susp 0.77%
2
clotrimazole/betamethasone dipropionate crea 0.05%; 1%
2
clotrimazole/betamethasone dipropionate lotn 0.05%; 1%
2
clotrimazole crea 1%
2
clotrimazole soln 1%
2
30
Requirements/Limits
QL (60 ML per 30 days)
QL (60 ML per 30 days)
QL (60 ML per 30 days)
QL (60 ML per 30 days)
QL (60 ML per 30 days)
QL (60 ML per 30 days)
QL (60 ML per 30 days)
QL (60 ML per 30 days)
QL (60 ML per 30 days)
QL (60 ML per 30 days)
QL (60 ML per 30 days)
QL (60 ML per 30 days)
QL (60 ML per 30 days)
QL (60 ML per 30 days)
QL (60 ML per 30 days)
QL (27 ML per 30 days)
PA
PA
B/D
Drug Name
clotrimazole troc 10mg
CRESEMBA CAPS 186MG
CRESEMBA INJ 372MG
econazole nitrate crea 1%
ERAXIS INJ 100MG
fluconazole in dextrose inj 56mg/ml; 400mg/200ml
fluconazole in nacl inj 200mg/100ml; 0.9%
fluconazole susr 10mg/ml
fluconazole susr 40mg/ml
fluconazole tabs 100mg
fluconazole tabs 150mg
fluconazole tabs 200mg
fluconazole tabs 50mg
flucytosine caps 250mg
flucytosine caps 500mg
griseofulvin microsize susp 125mg/5ml
griseofulvin microsize tabs 500mg
griseofulvin ultramicrosize tabs 125mg
griseofulvin ultramicrosize tabs 250mg
itraconazole caps 100mg
ketoconazole crea 2%
ketoconazole sham 2%
ketoconazole tabs 200mg
MENTAX CREA 1%
miconazole 3 supp 200mg
MYCAMINE INJ 100MG
MYCAMINE INJ 50MG
naftifine hcl crea 1%
NAFTIN CREA 2%
NAFTIN GEL 1%
NAFTIN GEL 2%
NOXAFIL INJ 300MG/16.7ML
NOXAFIL SUSP 40MG/ML
NOXAFIL TBEC 100MG
nystatin/triamcinolone crea 100000unit/gm; 0.1%
nystatin/triamcinolone oint 100000unit/gm; 0.1%
nystatin crea 100000unit/gm
nystatin oint 100000unit/gm
nystatin powd 100000unit/gm
nystatin susp 100000unit/ml
nystatin tabs 500000unit
nystop powd 100000unit/gm
pedi-dri powd 100000unit/gm
SPORANOX SOLN 10MG/ML
terbinafine hcl tabs 250mg
voriconazole inj 200mg
VORICONAZOLE SUSR 40MG/ML
31
Drug
Tier
2
5
5
2
4
1
2
2
2
2
2
2
2
1
1
1
2
2
2
2
2
2
2
4
1
3
3
2
4
4
4
4
4
4
2
2
2
2
2
2
2
2
2
4
1
2
4
Requirements/Limits
PA
PA
ST
ST
ST
ST
PA
PA
PA
PA
PA
Drug Name
voriconazole tabs 200mg
voriconazole tabs 50mg
ANTIHISTAMINES
ANTIHISTAMINES
cetirizine hcl syrp 1mg/ml
cyproheptadine hcl syrp 2mg/5ml
cyproheptadine hcl tabs 4mg
diphenhydramine hcl inj 50mg/ml
ANTIMIGRAINE AGENTS
ANTIMIGRAINE AGENTS
CAFERGOT TABS 100MG; 1MG
dihydroergotamine mesylate inj 1mg/ml
DIHYDROERGOTAMINE MESYLATE SOLN 4MG/ML
ERGOMAR SUBL 2MG
migergot supp 100mg; 2mg
naratriptan hcl tabs 1mg
naratriptan hcl tabs 2.5mg
rizatriptan benzoate odt tbdp 10mg
rizatriptan benzoate odt tbdp 5mg
rizatriptan benzoate tabs 10mg
rizatriptan benzoate tabs 5mg
sumatriptan succinate inj 4mg/0.5ml
sumatriptan succinate inj 6mg/0.5ml
sumatriptan succinate inj 6mg/0.5ml
sumatriptan succinate tabs 100mg
sumatriptan succinate tabs 25mg
sumatriptan succinate tabs 50mg
sumatriptan soln 20mg/act
sumatriptan soln 5mg/act
zolmitriptan odt tbdp 2.5mg
zolmitriptan odt tbdp 5mg
zolmitriptan tabs 2.5mg
zolmitriptan tabs 5mg
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS
CAPASTAT SULFATE INJ 1GM
cycloserine caps 250mg
dapsone tabs 100mg
dapsone tabs 25mg
ethambutol hcl tabs 100mg
ethambutol hcl tabs 400mg
isoniazid inj 100mg/ml
isoniazid syrp 50mg/5ml
isoniazid tabs 100mg
isoniazid tabs 300mg
PASER PACK 4GM
PRIFTIN TABS 150MG
32
Drug
Tier Requirements/Limits
5
PA
5
PA
2
2
2
2
4
2
4
4
2
2
2
2
2
2
2
2
2
2
1
1
1
2
2
2
2
2
2
4
2
1
1
2
2
1
1
1
1
4
4
QL (8 ML per 23 days)
QL (18 EA per 30 days)
QL (18 EA per 30 days)
QL (18 EA per 30 days)
QL (18 EA per 30 days)
QL (18 EA per 30 days)
QL (18 EA per 30 days)
QL (2 ML per 30 days)
QL (4 ML per 30 days)
QL (6 ML per 30 days)
QL (9 EA per 30 days)
QL (9 EA per 30 days)
QL (9 EA per 30 days)
QL (12 EA per 30 days)
QL (18 EA per 30 days)
QL (9 EA per 30 days)
QL (9 EA per 30 days)
QL (9 EA per 30 days)
QL (9 EA per 30 days)
Drug
Tier Requirements/Limits
1
2
2
2
2
4
5
PA
4
Drug Name
pyrazinamide tabs 500mg
rifabutin caps 150mg
rifampin caps 150mg
rifampin caps 300mg
rifampin inj 600mg
RIFATER TABS 50MG; 300MG; 120MG
SIRTURO TABS 100MG
TRECATOR TABS 250MG
ANTINAUSEA AGENTS
ANTINAUSEA AGENTS
CESAMET CAPS 1MG
compro supp 25mg
dimenhydrinate inj 50mg/ml
DRONABINOL CAPS 10MG
DRONABINOL CAPS 2.5MG
DRONABINOL CAPS 5MG
EMEND CAPS 0
EMEND CAPS 125MG
EMEND CAPS 40MG
EMEND CAPS 80MG
EMEND INJ 150MG
granisetron hcl inj 0.1mg/ml
granisetron hcl inj 1mg/ml
granisetron hcl tabs 1mg
granisol soln 2mg/10ml
meclizine hcl tabs 12.5mg
ondansetron hcl inj 4mg/2ml
ondansetron hcl inj 4mg/2ml
ondansetron hcl soln 4mg/5ml
ondansetron hcl tabs 24mg
ondansetron hcl tabs 4mg
ondansetron hcl tabs 8mg
ondansetron odt tbdp 4mg
ondansetron odt tbdp 8mg
phenadoz supp 12.5mg
phenadoz supp 25mg
phenergan supp 12.5mg
phenergan supp 25mg
phenergan supp 50mg
prochlorperazine edisylate inj 5mg/ml
prochlorperazine maleate tabs 10mg
prochlorperazine maleate tabs 5mg
prochlorperazine supp 25mg
promethazine hcl supp 12.5mg
promethazine hcl supp 25mg
promethazine hcl supp 50mg
promethegan supp 12.5mg
4
2
1
4
4
4
4
4
4
4
4
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
2
2
2
2
33
QL (60 EA per 30 days)
QL (90 EA per 30 days)
QL (90 EA per 30 days)
PA
PA
PA
PA
PA
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
Drug Name
promethegan supp 25mg
promethegan supp 50mg
SANCUSO PTCH 3.1MG/24HR
scopolamine hydrobromide inj 0.4mg/ml
TRANSDERM-SCOP PT72 1MG/3DAYS
ANTIPARASITE AGENTS
ANTIPARASITE AGENTS
ALBENZA TABS 200MG
ALINIA SUSR 100MG/5ML
ALINIA TABS 500MG
atovaquone/proguanil hcl tabs 250mg; 100mg
atovaquone/proguanil hcl tabs 62.5mg; 25mg
atovaquone susp 750mg/5ml
BILTRICIDE TABS 600MG
chloroquine phosphate tabs 250mg
chloroquine phosphate tabs 500mg
COARTEM TABS 20MG; 120MG
DARAPRIM TABS 25MG
hydroxychloroquine sulfate tabs 200mg
ivermectin tabs 3mg
mefloquine hcl tabs 250mg
metronidazole in nacl 0.79% inj 500mg/100ml; 0.79%
metronidazole caps 375mg
metronidazole tabs 250mg
metronidazole tabs 500mg
NEBUPENT SOLR 300MG
paromomycin sulfate caps 250mg
pentam 300 inj 300mg
PRIMAQUINE PHOSPHATE TABS 26.3MG
quinine sulfate caps 324mg
tinidazole tabs 250mg
tinidazole tabs 500mg
YODOXIN TABS 210MG
YODOXIN TABS 650MG
ANTIPARKINSONIAN AGENTS
ANTIPARKINSONIAN AGENTS
amantadine hcl caps 100mg
amantadine hcl syrp 50mg/5ml
amantadine hcl tabs 100mg
APOKYN INJ 10MG/ML
AZILECT TABS 0.5MG
AZILECT TABS 1MG
benztropine mesylate tabs 0.5mg
benztropine mesylate tabs 1mg
benztropine mesylate tabs 2mg
bromocriptine mesylate caps 5mg
bromocriptine mesylate tabs 2.5mg
34
Drug
Tier Requirements/Limits
2
2
5
2
4
4
4
4
2
2
2
4
1
1
4
3
1
2
1
1
1
1
1
3
1
1
3
2
2
2
4
4
2
2
2
5
3
3
1
1
1
2
1
B/D
PA
PA
Drug Name
cabergoline tabs 0.5mg
carbidopa/levodopa er tbcr 25mg; 100mg
carbidopa/levodopa er tbcr 50mg; 200mg
carbidopa/levodopa odt tbdp 10mg; 100mg
carbidopa/levodopa odt tbdp 25mg; 100mg
carbidopa/levodopa odt tbdp 25mg; 250mg
CARBIDOPA/LEVODOPA/ENTACAPONE TABS 12.5MG;
200MG; 50MG
CARBIDOPA/LEVODOPA/ENTACAPONE TABS 18.75MG;
200MG; 75MG
CARBIDOPA/LEVODOPA/ENTACAPONE TABS 25MG;
200MG; 100MG
CARBIDOPA/LEVODOPA/ENTACAPONE TABS 31.25MG;
200MG; 125MG
CARBIDOPA/LEVODOPA/ENTACAPONE TABS 37.5MG;
200MG; 150MG
CARBIDOPA/LEVODOPA/ENTACAPONE TABS 50MG;
200MG; 200MG
carbidopa/levodopa tabs 10mg; 100mg
carbidopa/levodopa tabs 25mg; 100mg
carbidopa/levodopa tabs 25mg; 250mg
carbidopa tabs 25mg
entacapone tabs 200mg
NEUPRO PT24 1MG/24HR
NEUPRO PT24 2MG/24HR
NEUPRO PT24 3MG/24HR
NEUPRO PT24 4MG/24HR
NEUPRO PT24 6MG/24HR
NEUPRO PT24 8MG/24HR
pramipexole dihydrochloride er tb24 0.75mg
pramipexole dihydrochloride er tb24 1.5mg
pramipexole dihydrochloride tabs 0.125mg
pramipexole dihydrochloride tabs 0.25mg
pramipexole dihydrochloride tabs 0.5mg
pramipexole dihydrochloride tabs 0.75mg
pramipexole dihydrochloride tabs 1.5mg
pramipexole dihydrochloride tabs 1mg
ropinirole er tb24 12mg
ropinirole er tb24 2mg
ropinirole er tb24 4mg
ropinirole er tb24 6mg
ropinirole er tb24 8mg
ropinirole hcl tabs 0.25mg
ropinirole hcl tabs 0.5mg
ropinirole hcl tabs 1mg
ropinirole hcl tabs 2mg
ropinirole hcl tabs 3mg
35
Drug
Tier Requirements/Limits
2
1
1
1
1
1
4
4
4
4
4
4
1
1
1
2
2
3
3
3
3
3
3
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Drug
Tier Requirements/Limits
1
1
1
1
2
4
Drug Name
ropinirole hcl tabs 4mg
ropinirole hcl tabs 5mg
selegiline hcl caps 5mg
selegiline hcl tabs 5mg
tolcapone tabs 100mg
ZELAPAR TBDP 1.25MG
ANTIPSYCHOTIC AGENTS
ANTIPSYCHOTIC AGENTS
ABILIFY DISCMELT TBDP 10MG
ABILIFY MAINTENA INJ 400MG
ABILIFY SOLN 1MG/ML
aripiprazole tabs 10mg
aripiprazole tabs 15mg
aripiprazole tabs 20mg
aripiprazole tabs 2mg
aripiprazole tabs 30mg
aripiprazole tabs 5mg
chlorpromazine hcl inj 25mg/ml
chlorpromazine hcl tabs 100mg
chlorpromazine hcl tabs 10mg
chlorpromazine hcl tabs 200mg
chlorpromazine hcl tabs 25mg
chlorpromazine hcl tabs 50mg
clozapine odt tbdp 100mg
clozapine odt tbdp 12.5mg
clozapine odt tbdp 150mg
clozapine odt tbdp 200mg
clozapine odt tbdp 25mg
clozapine tabs 100mg
clozapine tabs 200mg
clozapine tabs 25mg
clozapine tabs 50mg
FANAPT TITRATION PACK TABS 0
FANAPT TABS 10MG
FANAPT TABS 12MG
FANAPT TABS 1MG
FANAPT TABS 2MG
FANAPT TABS 4MG
FANAPT TABS 6MG
FANAPT TABS 8MG
fluphenazine decanoate inj 25mg/ml
fluphenazine hcl conc 5mg/ml
fluphenazine hcl elix 2.5mg/5ml
fluphenazine hcl inj 2.5mg/ml
fluphenazine hcl tabs 10mg
fluphenazine hcl tabs 1mg
fluphenazine hcl tabs 2.5mg
4
5
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
4
4
4
4
4
1
1
1
1
1
1
1
36
PA
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
Drug
Tier
1
4
2
2
2
2
2
2
2
2
2
2
5
5
5
4
4
4
4
4
5
4
4
4
4
4
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
4
4
2
2
2
2
Drug Name
fluphenazine hcl tabs 5mg
GEODON INJ 20MG
haloperidol decanoate inj 100mg/ml
haloperidol decanoate inj 50mg/ml
haloperidol lactate inj 5mg/ml
haloperidol conc 2mg/ml
haloperidol tabs 0.5mg
haloperidol tabs 10mg
haloperidol tabs 1mg
haloperidol tabs 20mg
haloperidol tabs 2mg
haloperidol tabs 5mg
INVEGA SUSTENNA INJ 117MG/0.75ML
INVEGA SUSTENNA INJ 156MG/ML
INVEGA SUSTENNA INJ 234MG/1.5ML
INVEGA SUSTENNA INJ 39MG/0.25ML
INVEGA SUSTENNA INJ 78MG/0.5ML
INVEGA TB24 1.5MG
INVEGA TB24 3MG
INVEGA TB24 6MG
INVEGA TB24 9MG
LATUDA TABS 120MG
LATUDA TABS 20MG
LATUDA TABS 40MG
LATUDA TABS 60MG
LATUDA TABS 80MG
loxapine succinate caps 25mg
loxapine succinate caps 50mg
loxapine succinate caps 5mg
loxapine caps 10mg
olanzapine odt tbdp 10mg
olanzapine odt tbdp 15mg
olanzapine odt tbdp 20mg
olanzapine odt tbdp 5mg
olanzapine inj 10mg
olanzapine tabs 10mg
olanzapine tabs 15mg
olanzapine tabs 2.5mg
olanzapine tabs 20mg
olanzapine tabs 5mg
olanzapine tabs 7.5mg
ORAP TABS 1MG
ORAP TABS 2MG
perphenazine tabs 16mg
perphenazine tabs 2mg
perphenazine tabs 4mg
perphenazine tabs 8mg
37
Requirements/Limits
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
Drug
Tier
1
1
1
1
1
1
4
4
5
5
1
1
1
1
1
2
1
1
1
1
1
1
1
4
4
4
3
3
3
3
3
2
2
2
2
1
1
1
1
1
1
1
1
4
4
4
4
Drug Name
quetiapine fumarate tabs 100mg
quetiapine fumarate tabs 200mg
quetiapine fumarate tabs 25mg
quetiapine fumarate tabs 300mg
quetiapine fumarate tabs 400mg
quetiapine fumarate tabs 50mg
RISPERDAL CONSTA INJ 12.5MG
RISPERDAL CONSTA INJ 25MG
RISPERDAL CONSTA INJ 37.5MG
RISPERDAL CONSTA INJ 50MG
risperidone m-tab tbdp 0.5mg
risperidone m-tab tbdp 1mg
risperidone m-tab tbdp 2mg
risperidone m-tab tbdp 3mg
risperidone m-tab tbdp 4mg
risperidone odt tbdp 0.25mg
risperidone soln 1mg/ml
risperidone tabs 0.25mg
risperidone tabs 0.5mg
risperidone tabs 1mg
risperidone tabs 2mg
risperidone tabs 3mg
risperidone tabs 4mg
SAPHRIS SUBL 10MG
SAPHRIS SUBL 2.5MG
SAPHRIS SUBL 5MG
SEROQUEL XR TB24 150MG
SEROQUEL XR TB24 200MG
SEROQUEL XR TB24 300MG
SEROQUEL XR TB24 400MG
SEROQUEL XR TB24 50MG
thioridazine hcl tabs 100mg
thioridazine hcl tabs 10mg
thioridazine hcl tabs 25mg
thioridazine hcl tabs 50mg
thiothixene caps 10mg
thiothixene caps 1mg
thiothixene caps 2mg
thiothixene caps 5mg
trifluoperazine hcl tabs 10mg
trifluoperazine hcl tabs 1mg
trifluoperazine hcl tabs 2mg
trifluoperazine hcl tabs 5mg
VERSACLOZ SUSP 50MG/ML
ZIPRASIDONE HCL CAPS 20MG
ZIPRASIDONE HCL CAPS 40MG
ZIPRASIDONE HCL CAPS 60MG
38
Requirements/Limits
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
Drug Name
ZIPRASIDONE HCL CAPS 80MG
ZYPREXA RELPREVV INJ 210MG
ZYPREXA RELPREVV INJ 405MG
ANTIVIRALS (SYSTEMIC)
ANTIRETROVIRALS
ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE TABS
300MG; 150MG; 300MG
abacavir tabs 300mg
APTIVUS CAPS 250MG
APTIVUS SOLN 100MG/ML
ATRIPLA TABS 600MG; 200MG; 300MG
COMPLERA TABS 200MG; 25MG; 300MG
CRIXIVAN CAPS 200MG
CRIXIVAN CAPS 400MG
didanosine cpdr 125mg
didanosine cpdr 200mg
didanosine cpdr 250mg
didanosine cpdr 400mg
EDURANT TABS 25MG
EMTRIVA CAPS 200MG
EMTRIVA SOLN 10MG/ML
EPIVIR HBV SOLN 5MG/ML
EPZICOM TABS 600MG; 300MG
EVOTAZ TABS 300MG; 150MG
FUZEON INJ 90MG
INTELENCE TABS 100MG
INTELENCE TABS 200MG
INTELENCE TABS 25MG
INVIRASE CAPS 200MG
INVIRASE TABS 500MG
ISENTRESS CHEW 100MG
ISENTRESS CHEW 25MG
ISENTRESS PACK 100MG
ISENTRESS TABS 400MG
KALETRA SOLN 400MG/5ML; 100MG/5ML
KALETRA TABS 100MG; 25MG
KALETRA TABS 200MG; 50MG
lamivudine/zidovudine tabs 150mg; 300mg
lamivudine soln 10mg/ml
lamivudine tabs 100mg
lamivudine tabs 150mg
lamivudine tabs 300mg
LEXIVA SUSP 50MG/ML
LEXIVA TABS 700MG
nevirapine er tb24 400mg
nevirapine susp 50mg/5ml
nevirapine tabs 200mg
39
Drug
Tier Requirements/Limits
4
ST
4
4
4
2
4
4
5
5
4
4
2
2
2
2
4
4
4
4
5
5
5
5
5
4
4
4
5
3
3
5
4
4
5
5
2
2
2
2
4
4
2
2
2
Drug Name
NORVIR CAPS 100MG
NORVIR SOLN 80MG/ML
NORVIR TABS 100MG
PREZCOBIX TABS 150MG; 800MG
PREZISTA SUSP 100MG/ML
PREZISTA TABS 150MG
PREZISTA TABS 400MG
PREZISTA TABS 600MG
PREZISTA TABS 75MG
PREZISTA TABS 800MG
RESCRIPTOR TABS 100MG
RESCRIPTOR TABS 200MG
RETROVIR IV INFUSION INJ 10MG/ML
REYATAZ CAPS 150MG
REYATAZ CAPS 200MG
REYATAZ CAPS 300MG
REYATAZ PACK 50MG
SELZENTRY TABS 150MG
SELZENTRY TABS 300MG
stavudine caps 15mg
stavudine caps 20mg
stavudine caps 30mg
stavudine caps 40mg
stavudine solr 1mg/ml
STRIBILD TABS 150MG; 150MG; 200MG; 300MG
SUSTIVA CAPS 200MG
SUSTIVA CAPS 50MG
SUSTIVA TABS 600MG
TIVICAY TABS 50MG
TRIUMEQ TABS 600MG; 50MG; 300MG
TRUVADA TABS 200MG; 300MG
VIDEX PEDIATRIC SOLR 2GM
VIDEX PEDIATRIC SOLR 4GM
VIRACEPT TABS 250MG
VIRACEPT TABS 625MG
VIRAMUNE XR TB24 100MG
VIREAD POWD 40MG/GM
VIREAD TABS 150MG
VIREAD TABS 200MG
VIREAD TABS 250MG
VIREAD TABS 300MG
VITEKTA TABS 150MG
VITEKTA TABS 85MG
ZIAGEN SOLN 20MG/ML
zidovudine caps 100mg
zidovudine syrp 50mg/5ml
zidovudine tabs 300mg
40
Drug
Tier Requirements/Limits
3
3
3
5
5
4
5
4
4
5
4
4
4
5
5
5
5
5
5
1
1
1
1
1
5
4
4
4
5
5
5
4
4
4
4
4
4
4
4
4
5
5
5
4
1
1
1
Drug Name
ANTIVIRALS, MISCELLANEOUS
FOSCARNET SODIUM INJ 24MG/ML
RAPIVAB INJ 200MG/20ML
RELENZA DISKHALER AEPB 5MG/BLISTER
rimantadine hcl tabs 100mg
SYNAGIS INJ 100MG/ML
TAMIFLU CAPS 30MG
TAMIFLU CAPS 45MG
TAMIFLU CAPS 75MG
TAMIFLU SUSR 6MG/ML
HCV ANTIVIRALS
HARVONI TABS 90MG; 400MG
SOVALDI TABS 400MG
INTERFERONS
ALFERON N INJ 5MU/ML
INFERGEN INJ 15MCG/0.5ML
INTRON A W/DILUENT INJ 18MU
INTRON A W/DILUENT INJ 50MU
INTRON A INJ 10MU/ML
INTRON A INJ 6000000UNIT/ML
INTRON-A INJ 3MU/0.2ML
PEG-INTRON REDIPEN PAK 4 INJ 80MCG/0.5ML
PEG-INTRON REDIPEN INJ 120MCG/0.5ML
PEG-INTRON REDIPEN INJ 150MCG/0.5ML
PEG-INTRON REDIPEN INJ 50MCG/0.5ML
PEG-INTRON INJ 50MCG/0.5ML
PEGASYS PROCLICK INJ 135MCG/0.5ML
PEGASYS PROCLICK INJ 180MCG/0.5ML
PEGASYS INJ 180MCG/0.5ML
PEGASYS INJ 180MCG/ML
PEGINTRON INJ 120MCG/0.5ML
PEGINTRON INJ 150MCG/0.5ML
PEGINTRON INJ 80MCG/0.5ML
SYLATRON INJ 200MCG
SYLATRON INJ 200MCG
SYLATRON INJ 300MCG
SYLATRON INJ 300MCG
SYLATRON INJ 600MCG
SYLATRON INJ 600MCG
NUCLEOSIDES AND NUCLEOTIDES
acyclovir sodium inj 50mg/ml
acyclovir caps 200mg
acyclovir susp 200mg/5ml
acyclovir tabs 400mg
acyclovir tabs 800mg
adefovir dipivoxil tabs 10mg
BARACLUDE SOLN 0.05MG/ML
41
Drug
Tier Requirements/Limits
4
4
3
1
5
3
3
3
3
PA
5
5
PA
PA
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
1
1
1
1
1
5
4
B/D
QL (56 EA per 180 days)
PA
PA
Drug Name
cidofovir inj 75mg/ml
entecavir tabs 0.5mg
entecavir tabs 1mg
famciclovir tabs 125mg
famciclovir tabs 250mg
famciclovir tabs 500mg
ganciclovir inj 500mg
REBETOL SOLN 40MG/ML
ribasphere ribapak tabs 0
ribasphere ribapak tabs 0
ribasphere ribapak tabs 400mg
ribasphere caps 200mg
ribasphere tabs 200mg
RIBASPHERE TABS 400MG
ribasphere tabs 600mg
ribavirin caps 200mg
ribavirin tabs 200mg
TYZEKA TABS 600MG
valacyclovir hcl tabs 1000mg
valacyclovir hcl tabs 500mg
VALCYTE SOLR 50MG/ML
VALGANCICLOVIR TABS 450MG
virazole solr 6gm
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
COUMADIN INJ 5MG
COUMADIN INJ 5MG
COUMADIN TABS 10MG
COUMADIN TABS 1MG
COUMADIN TABS 2.5MG
COUMADIN TABS 2MG
COUMADIN TABS 3MG
COUMADIN TABS 4MG
COUMADIN TABS 5MG
COUMADIN TABS 6MG
COUMADIN TABS 7.5MG
ELIQUIS TABS 2.5MG
ELIQUIS TABS 5MG
enoxaparin sodium inj 100mg/ml
enoxaparin sodium inj 120mg/0.8ml
enoxaparin sodium inj 150mg/ml
ENOXAPARIN SODIUM INJ 300MG/3ML
ENOXAPARIN SODIUM INJ 30MG/0.3ML
ENOXAPARIN SODIUM INJ 40MG/0.4ML
ENOXAPARIN SODIUM INJ 60MG/0.6ML
ENOXAPARIN SODIUM INJ 80MG/0.8ML
fondaparinux sodium inj 10mg/0.8ml
42
Drug
Tier Requirements/Limits
2
2
2
2
2
2
1
4
5
5
5
2
2
4
5
2
2
4
PA
2
2
4
4
5
PA
3
3
3
3
3
3
3
3
3
3
3
4
4
5
5
5
4
4
4
4
4
5
QL (30 ML per 90 days)
QL (30 ML per 90 days)
QL (30 ML per 90 days)
QL (30 ML per 90 days)
QL (30 ML per 90 days)
QL (30 ML per 90 days)
QL (30 ML per 90 days)
QL (30 ML per 90 days)
Drug Name
FONDAPARINUX SODIUM INJ 2.5MG/0.5ML
fondaparinux sodium inj 5mg/0.4ml
fondaparinux sodium inj 7.5mg/0.6ml
FRAGMIN INJ 10000UNIT/ML
FRAGMIN INJ 12500UNIT/0.5ML
FRAGMIN INJ 15000UNIT/0.6ML
FRAGMIN INJ 18000UNT/0.72ML
FRAGMIN INJ 25000UNIT/ML
FRAGMIN INJ 2500UNIT/0.2ML
FRAGMIN INJ 5000UNIT/0.2ML
FRAGMIN INJ 7500UNIT/0.3ML
FRAGMIN INJ 95000UNIT/3.8ML
heparin sodium dcu inj 20000unit/ml
heparin sodium/d5w inj 5%; 40unit/ml
heparin sodium/nacl 0.45% inj 100unit/ml; 0.45%
heparin sodium/nacl 0.45% inj 50unit/ml; 0.45%
heparin sodium/nacl 0.9% inj 2unit/ml; 0.9%
heparin sodium inj 10000unit/ml
heparin sodium inj 1000unit/ml
heparin sodium inj 5000unit/ml
jantoven tabs 10mg
jantoven tabs 1mg
jantoven tabs 2.5mg
jantoven tabs 2mg
jantoven tabs 3mg
jantoven tabs 4mg
jantoven tabs 5mg
jantoven tabs 6mg
jantoven tabs 7.5mg
PRADAXA CAPS 150MG
PRADAXA CAPS 75MG
warfarin sodium tabs 10mg
warfarin sodium tabs 1mg
warfarin sodium tabs 2.5mg
warfarin sodium tabs 2mg
warfarin sodium tabs 3mg
warfarin sodium tabs 4mg
warfarin sodium tabs 5mg
warfarin sodium tabs 6mg
warfarin sodium tabs 7.5mg
XARELTO STARTER PACK TBPK 0
XARELTO TABS 10MG
XARELTO TABS 15MG
XARELTO TABS 20MG
BLOOD FORMATION MODIFIERS
ARANESP ALBUMIN FREE INJ 100MCG/0.5ML
ARANESP ALBUMIN FREE INJ 100MCG/ML
43
Drug
Tier Requirements/Limits
4
5
5
4
4
4
4
4
4
4
4
4
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
4
4
1
1
1
1
1
1
1
1
1
3
3
QL (35 EA per 180 days)
3
3
4
4
PA
PA
Drug Name
ARANESP ALBUMIN FREE INJ 10MCG/0.4ML
ARANESP ALBUMIN FREE INJ 150MCG/0.3ML
ARANESP ALBUMIN FREE INJ 200MCG/0.4ML
ARANESP ALBUMIN FREE INJ 200MCG/ML
ARANESP ALBUMIN FREE INJ 25MCG/0.42ML
ARANESP ALBUMIN FREE INJ 25MCG/ML
ARANESP ALBUMIN FREE INJ 300MCG/0.6ML
ARANESP ALBUMIN FREE INJ 300MCG/ML
ARANESP ALBUMIN FREE INJ 40MCG/0.4ML
ARANESP ALBUMIN FREE INJ 40MCG/ML
ARANESP ALBUMIN FREE INJ 500MCG/ML
ARANESP ALBUMIN FREE INJ 60MCG/0.3ML
ARANESP ALBUMIN FREE INJ 60MCG/ML
BERINERT INJ 500UNIT
CINRYZE INJ 500UNIT
EPOGEN INJ 10000UNIT/ML
EPOGEN INJ 20000UNIT/ML
EPOGEN INJ 2000UNIT/ML
EPOGEN INJ 3000UNIT/ML
EPOGEN INJ 4000UNIT/ML
granix inj 300mcg/0.5ml
granix inj 480mcg/0.8ml
LEUKINE INJ 250MCG
MIRCERA INJ 100MCG/0.3ML
MIRCERA INJ 200MCG/0.3ML
MIRCERA INJ 50MCG/0.3ML
MIRCERA INJ 75MCG/0.3ML
MOZOBIL INJ 24MG/1.2ML
NEULASTA INJ 6MG/0.6ML
NEUMEGA INJ 5MG
NEUPOGEN INJ 300MCG/0.5ML
NEUPOGEN INJ 300MCG/ML
NEUPOGEN INJ 480MCG/0.8ML
PROCRIT INJ 10000UNIT/ML
PROCRIT INJ 20000UNIT/ML
PROCRIT INJ 2000UNIT/ML
PROCRIT INJ 3000UNIT/ML
PROCRIT INJ 40000UNIT/ML
PROCRIT INJ 4000UNIT/ML
PROMACTA TABS 12.5MG
PROMACTA TABS 25MG
PROMACTA TABS 50MG
PROMACTA TABS 75MG
RUCONEST INJ 2100UNIT
HEMATOLOGIC AGENTS, MISCELLANEOUS
aminocaproic acid inj 250mg/ml
aminocaproic acid syrp 25%
44
Drug
Tier
4
5
5
5
4
4
5
5
4
4
5
4
4
5
5
4
4
4
4
4
5
5
5
3
3
3
3
5
5
5
5
5
5
4
4
4
4
4
4
5
5
5
5
5
1
2
Requirements/Limits
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Drug
Drug Name
Tier
aminocaproic acid tabs 1000mg
2
aminocaproic acid tabs 500mg
2
anagrelide hydrochloride caps 0.5mg
2
anagrelide hydrochloride caps 1mg
2
tranexamic acid inj 100mg/ml
2
tranexamic acid tabs 650mg
2
PLATELET-AGGREGATION INHIBITORS
AGGRENOX CP12 25MG; 200MG
4
BRILINTA TABS 90MG
3
cilostazol tabs 100mg
1
cilostazol tabs 50mg
1
clopidogrel tabs 300mg
1
clopidogrel tabs 75mg
1
pentoxifylline er tbcr 400mg
1
CALORIC AGENTS
CALORIC AGENTS
AMINOSYN 7%/ELECTROLYTES INJ 124MEQ/L;
3
900MG/100ML; 690MG/100ML; 96MEQ/L; 900MG/100ML;
210MG/100ML; 510MG/100ML; 660MG/100ML; 510MG/100ML;
10MEQ/L; 280MG/100ML; 310MG/100ML; 30MMOLE/L;
65MEQ/L; 610MG/100ML; 300MG/100ML; 65MEQ/L;
370MG/100ML; 120MG/100ML; 44MG/100ML; 560MG/100ML
3
AMINOSYN 8.5%/ELECTROLYTES INJ 142MEQ/L;
1100MG/100ML; 850MG/100ML; 98MEQ/L; 1100MG/100ML;
260MG/100ML; 620MG/100ML; 810MG/100ML; 624MG/100ML;
10MEQ/L; 340MG/100ML; 380MG/100ML; 30MEQ/L; 65MEQ/L;
750MG/100ML; 370MG/100ML; 65MEQ/L; 460MG/100ML;
150MG/100ML; 44MG/100ML; 680MG/100ML
AMINOSYN II 8.5%/ELECTROLYTES INJ 61MEQ/L;
3
844MG/100ML; 865MG/100ML; 595MG/100ML; 86MEQ/L;
627MG/100ML; 425MG/100ML; 255MG/100ML; 561MG/100ML;
850MG/100ML; 893MG/100ML; 10MEQ/L; 146MG/100ML;
253MG/100ML; 30MMOLE/L; 66MEQ/L; 614MG/100ML;
450MG/100ML; 80MEQ/L; 340MG/100ML; 170MG/100ML;
230MG/100ML; 425MG/100ML
AMINOSYN II INJ 107.6MEQ/L; 1490MG/100ML;
3
1527MG/100ML; 1050MG/100ML; 1107MG/100ML;
750MG/100ML; 450MG/100ML; 990MG/100ML;
1500MG/100ML; 1575MG/100ML; 258MG/100ML;
447MG/100ML; 1083MG/100ML; 795MG/100ML; 50MEQ/L;
600MG/100ML; 300MG/100ML; 405MG/100ML; 750MG/100ML
AMINOSYN II INJ 50.3MEQ/L; 695MG/100ML; 713MG/100ML; 3
490MG/100ML; 517MG/100ML; 350MG/100ML; 210MG/100ML;
462MG/100ML; 700MG/100ML; 735MG/100ML; 120MG/100ML;
209MG/100ML; 505MG/100ML; 371MG/100ML; 31.3MEQ/L;
280MG/100ML; 140MG/100ML; 189MG/100ML; 350MG/100ML
45
Requirements/Limits
B/D
B/D
B/D
B/D
B/D
Drug
Drug Name
Tier
AMINOSYN II INJ 61.1MEQ/L; 844MG/100ML; 865MG/100ML; 3
595MG/100ML; 627MG/100ML; 425MG/100ML; 255MG/100ML;
561MG/100ML; 850MG/100ML; 893MG/100ML; 146MG/100ML;
253MG/100ML; 614MG/100ML; 450MG/100ML; 33.3MEQ/L;
340MG/100ML; 170MG/100ML; 230MG/100ML; 425MG/100ML
3
AMINOSYN II INJ 71.8MEQ/L; 993MG/100ML;
1018MG/100ML; 700MG/100ML; 738MG/100ML;
500MG/100ML; 300MG/100ML; 660MG/100ML;
1000MG/100ML; 1050MG/100ML; 172MG/100ML;
298MG/100ML; 722MG/100ML; 530MG/100ML; 45.3MEQ/L;
400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML
AMINOSYN M INJ 65MEQ/L; 448MG/100ML; 343MG/100ML; 3
40MEQ/L; 448MG/100ML; 105MG/100ML; 252MG/100ML;
329MG/100ML; 252MG/100ML; 3MEQ/L; 140MG/100ML;
154MG/100ML; 3.5MMOLE/L; 13MEQ/L; 300MG/100ML;
147MG/100ML; 40MEQ/L; 182MG/100ML; 56MG/100ML;
31MG/100ML; 280MG/100ML
AMINOSYN-HBC INJ 7.1MEQ/100ML; 660MG/100ML;
3
507MG/100ML; 4MEQ/100ML; 660MG/100ML; 154MG/100ML;
789MG/100ML; 1576MG/100ML; 265MG/100ML;
206MG/100ML; 1.12GM/100ML; 228MG/100ML;
448MG/100ML; 221MG/100ML; 272MG/100ML; 88MG/100ML;
33MG/100ML; 789MG/100ML
AMINOSYN-HF INJ 62MEQ/L; 770MG/100ML; 600MG/100ML; 3
3MEQ/L; 20MG/100ML; 900MG/100ML; 240MG/100ML;
900MG/100ML; 1100MG/100ML; 610MG/100ML;
100MG/100ML; 100MG/100ML; 115MG/100ML; 800MG/100ML;
500MG/100ML; 100MG/100ML; 450MG/100ML; 66MG/100ML;
840MG/100ML
3
AMINOSYN-PF 7% INJ 32.5MEQ/L; 490MG/100ML;
861MG/100ML; 370MG/100ML; 576MG/100ML; 270MG/100ML;
220MG/100ML; 534MG/100ML; 831MG/100ML; 475MG/100ML;
125MG/100ML; 10.69GM/L; 300MG/100ML; 570MG/100ML;
70GM/L; 347MG/100ML; 50MG/100ML; 360MG/100ML;
125MG/100ML; 44MG/100ML; 452MG/100ML
AMINOSYN-PF INJ 46MEQ/L; 698MG/100ML; 1227MG/100ML; 3
527MG/100ML; 820MG/100ML; 385MG/100ML; 312MG/100ML;
760MG/100ML; 1200MG/100ML; 677MG/100ML;
180MG/100ML; 427MG/100ML; 812MG/100ML; 495MG/100ML;
3.4MEQ/L; 70MG/100ML; 512MG/100ML; 180MG/100ML;
44MG/100ML; 673MG/100ML
AMINOSYN-RF INJ 113MEQ/L; 600MG/100ML;
3
429MG/100ML; 462MG/100ML; 726MG/100ML; 535MG/100ML;
726MG/100ML; 726MG/100ML; 330MG/100ML; 165MG/100ML;
528MG/100ML
46
Requirements/Limits
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
Drug
Drug Name
Tier
AMINOSYN INJ 148MEQ/L; 1280MG/100ML; 980MG/100ML; 3
1280MG/100ML; 300MG/100ML; 720MG/100ML;
940MG/100ML; 720MG/100ML; 400MG/100ML; 440MG/100ML;
5.4MEQ/L; 860MG/100ML; 420MG/100ML; 520MG/100ML;
160MG/100ML; 44MG/100ML; 800MG/100ML
AMINOSYN INJ 50.3MEQ/L; 695MG/100ML; 713MG/100ML; 3
490MG/100ML; 517MG/100ML; 350MG/100ML; 210MG/100ML;
462MG/100ML; 700MG/100ML; 735MG/100ML; 120MG/100ML;
209MG/100ML; 505MG/100ML; 371MG/100ML; 31.3MEQ/L;
280MG/100ML; 140MG/100ML; 189MG/100ML; 350MG/100ML
AMINOSYN INJ 51MEQ/L; 448MG/100ML; 343MG/100ML;
3
448MG/100ML; 105MG/100ML; 252MG/100ML; 329MG/100ML;
252MG/100ML; 140MG/100ML; 154MG/100ML; 300MG/100ML;
147MG/100ML; 182MG/100ML; 56MG/100ML; 31MG/100ML;
280MG/100ML
AMINOSYN INJ 90MEQ/L; 1100MG/100ML; 850MG/100ML;
3
35MEQ/L; 1100MG/100ML; 260MG/100ML; 620MG/100ML;
810MG/100ML; 624MG/100ML; 340MG/100ML; 380MG/100ML;
5.4MEQ/L; 750MG/100ML; 370MG/100ML; 460MG/100ML;
150MG/100ML; 44MG/100ML; 680MG/100ML
CLINIMIX 2.75%/DEXTROSE 5% INJ 24MEQ/1000ML;
3
570MG/100ML; 316MG/100ML; 11MEQ/1000ML; 5GM/100ML;
283MG/100ML; 132MG/100ML; 165MG/100ML; 201MG/100ML;
159MG/100ML; 110MG/100ML; 154MG/100ML; 187MG/100ML;
138MG/100ML; 116MG/100ML; 50MG/100ML; 11MG/100ML;
160MG/100ML
CLINIMIX 4.25%/DEXTROSE 10% INJ 37MEQ/L;
3
880MG/100ML; 489MG/100ML; 17MEQ/L; 10GM/100ML;
438MG/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML;
247MG/100ML; 170MG/100ML; 238MG/100ML; 289MG/100ML;
213MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML;
247MG/100ML
3
CLINIMIX 4.25%/DEXTROSE 20% INJ 37MEQ/L;
880MG/100ML; 489MG/100ML; 17MEQ/L; 20GM/100ML;
438MG/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML;
247MG/100ML; 170MG/100ML; 238MG/100ML; 289MG/100ML;
213MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML;
247MG/100ML
CLINIMIX 4.25%/DEXTROSE 25% INJ 37MEQ/L;
3
880MG/100ML; 489MG/100ML; 17MEQ/L; 25GM/100ML;
438MG/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML;
247MG/100ML; 170MG/100ML; 238MG/100ML; 289MG/100ML;
213MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML;
247MG/100ML
47
Requirements/Limits
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
Drug
Drug Name
Tier
CLINIMIX 4.25%/DEXTROSE 5% INJ 37MEQ/L;
3
880MG/100ML; 489MG/100ML; 17MEQ/L; 5GM/100ML;
438MG/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML;
247MG/100ML; 170MG/100ML; 238MG/100ML; 289MG/100ML;
213MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML;
247MG/100ML
CLINIMIX 5%/DEXTROSE 15% INJ 42MEQ/1000ML;
3
1035MG/100ML; 575MG/100ML; 20MEQ/1000ML;
15GM/100ML; 515MG/100ML; 240MG/100ML; 300MG/100ML;
365MG/100ML; 290MG/100ML; 200MG/100ML; 280MG/100ML;
340MG/100ML; 250MG/100ML; 210MG/100ML; 90MG/100ML;
20MG/100ML; 290MG/100ML
CLINIMIX 5%/DEXTROSE 20% INJ 42MEQ/L; 1035MG/100ML; 3
575MG/100ML; 20MEQ/L; 20GM/100ML; 515MG/100ML;
240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML;
200MG/100ML; 280MG/100ML; 340MG/100ML; 250MG/100ML;
210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML
CLINIMIX 5%/DEXTROSE 25% INJ 42MEQ/L; 1035MG/100ML; 3
575MG/100ML; 20MEQ/L; 25GM/100ML; 515MG/100ML;
240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML;
200MG/100ML; 280MG/100ML; 340MG/100ML; 250MG/100ML;
210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML
3
CLINIMIX E 2.75%/DEXTROSE 10% INJ 570MG/100ML;
316MG/100ML; 33MG/100ML; 10GM/100ML; 132MG/100ML;
165MG/100ML; 201MG/100ML; 159MG/100ML; 51MG/100ML;
110MG/100ML; 454MG/100ML; 154MG/100ML; 261MG/100ML;
187MG/100ML; 138MG/100ML; 217MG/100ML; 112MG/100ML;
116MG/100ML; 50MG/100ML; 11MG/100ML; 160MG/100ML
CLINIMIX E 2.75%/DEXTROSE 5% INJ 570MG/100ML;
3
316MG/100ML; 33MG/100ML; 5GM/100ML; 132MG/100ML;
165MG/100ML; 201MG/100ML; 159MG/100ML; 51MG/100ML;
110MG/100ML; 454MG/100ML; 154MG/100ML; 261MG/100ML;
187MG/100ML; 138MG/100ML; 217MG/100ML; 112MG/100ML;
116MG/100ML; 50MG/100ML; 11MG/100ML; 160MG/100ML
CLINIMIX E 4.25%/DEXTROSE 10% INJ 880MG/100ML;
3
489MG/100ML; 33MG/100ML; 10GM/100ML; 204MG/100ML;
255MG/100ML; 311MG/100ML; 247MG/100ML; 51MG/100ML;
170MG/100ML; 702MG/100ML; 238MG/100ML; 261MG/100ML;
289MG/100ML; 213MG/100ML; 297MG/100ML; 77MG/100ML;
179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML
CLINIMIX E 4.25%/DEXTROSE 25% INJ 880MG/100ML;
3
489MG/100ML; 33MG/100ML; 25GM/100ML; 204MG/100ML;
255MG/100ML; 311MG/100ML; 247MG/100ML; 51MG/100ML;
170MG/100ML; 702MG/100ML; 238MG/100ML; 261MG/100ML;
289MG/100ML; 213MG/100ML; 297MG/100ML; 77MG/100ML;
179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML
48
Requirements/Limits
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
Drug
Drug Name
Tier
CLINIMIX E 4.25%/DEXTROSE 5% INJ 880MG/100ML;
3
489MG/100ML; 33MG/100ML; 5GM/100ML; 204MG/100ML;
255MG/100ML; 311MG/100ML; 247MG/100ML; 51MG/100ML;
170MG/100ML; 702MG/100ML; 238MG/100ML; 261MG/100ML;
289MG/100ML; 213MG/100ML; 297MG/100ML; 77MG/100ML;
179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML
CLINIMIX E 5%/DEXTROSE 15% INJ 1035MG/100ML;
3
575MG/100ML; 33MG/100ML; 15GM/100ML; 240MG/100ML;
300MG/100ML; 365MG/100ML; 290MG/100ML; 51MG/100ML;
200MG/100ML; 826MG/100ML; 280MG/100ML; 261MG/100ML;
340MG/100ML; 250MG/100ML; 340MG/100ML; 59MG/100ML;
210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML
CLINIMIX E 5%/DEXTROSE 20% INJ 1035MG/100ML;
3
575MG/100ML; 33MG/100ML; 20GM/100ML; 240MG/100ML;
300MG/100ML; 365MG/100ML; 290MG/100ML; 51MG/100ML;
200MG/100ML; 826MG/100ML; 280MG/100ML; 261MG/100ML;
340MG/100ML; 250MG/100ML; 340MG/100ML; 59MG/100ML;
210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML
CLINIMIX E 5%/DEXTROSE 25% INJ 1035MG/100ML;
3
575MG/100ML; 33MG/100ML; 25GM/100ML; 240MG/100ML;
300MG/100ML; 365MG/100ML; 290MG/100ML; 51MG/100ML;
200MG/100ML; 826MG/100ML; 280MG/100ML; 261MG/100ML;
340MG/100ML; 250MG/100ML; 340MG/100ML; 59MG/100ML;
210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML
CLINISOL SF 15% INJ 151MEQ/L; 2170MG/100ML;
3
1470MG/100ML; 434MG/100ML; 749MG/100ML;
1040MG/100ML; 894MG/100ML; 749MG/100ML;
1040MG/100ML; 1180MG/100ML; 749MG/100ML;
1040MG/100ML; 894MG/100ML; 592MG/100ML;
749MG/100ML; 250MG/100ML; 39MG/100ML; 960MG/100ML
cysteine hcl inj 50mg/ml
1
dextrose 10%/nacl 0.45% inj 10%; 0.45%
1
dextrose 2.5% inj 2.5%
1
dextrose 10% flex container inj 10%
1
dextrose 10%/nacl 0.2% inj 10%; 0.2%
1
dextrose 10%/nacl 0.225% inj 10%; 0.225%
1
dextrose 10%/nacl 0.225% inj 10%; 0.225%
1
dextrose 10%/sodium chloride 0.9% inj 10%; 0.9%
1
dextrose 2.5%/nacl 0.45% inj 2.5%; 0.45%
2
dextrose 2.5%/sodium chloride 0.45% inj 2.5%; 0.45%
2
dextrose 20% inj 20%
1
dextrose 25% inj 250mg/ml
1
dextrose 40% inj 40%
1
dextrose 5%/lactated ringers inj 2.7meq/l; 109meq/l; 5%; 28meq/l; 1
4meq/l; 130meq/l
dextrose 5%/nacl 0.225% inj 5%; 0.225%
1
dextrose 5%/nacl 0.3% inj 5%; 0.3%
1
49
Requirements/Limits
B/D
B/D
B/D
B/D
B/D
Drug
Drug Name
Tier
dextrose 5%/nacl 0.33% inj 5%; 0.33%
1
dextrose 5%/nacl 0.45% inj 5%; 0.45%
1
dextrose 5%/nacl 0.9% inj 5%; 0.9%
2
dextrose 5%/ringers inj 4.5meq/l; 156meq/l; 5%; 4meq/l; 147meq/l 1
dextrose 5%/sodium chloride 0.2% inj 5%; 0.2%
1
dextrose 5%/sodium chloride 0.45% inj 5%; 0.45%
1
dextrose 5%/sodium chloride 0.9% inj 5%; 0.9%
2
dextrose 5% inj 5%
1
dextrose 50% inj 50%
1
3
FREAMINE HBC 6.9% INJ 59.3MEQ/L; 400MG/100ML;
580MG/100ML; 3MEQ/L; 14MG/100ML; 330MG/100ML;
160MG/100ML; 760MG/100ML; 1370MG/100ML;
410MG/100ML; 250MG/100ML; 320MG/100ML; 630MG/100ML;
330MG/100ML; 10MEQ/L; 200MG/100ML; 90MG/100ML;
880MG/100ML
FREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3
3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML;
690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML;
560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML;
590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML;
660MG/100ML
HEPATAMINE INJ 62MEQ/L; 770MG/100ML; 600MG/100ML; 3
3MEQ/L; 20MG/100ML; 900MG/100ML; 240MG/100ML;
900MG/100ML; 1100MG/100ML; 610MG/100ML;
100MG/100ML; 100MG/100ML; 115MG/100ML; 800MG/100ML;
500MG/100ML; 100MG/100ML; 450MG/100ML; 66MG/100ML;
840MG/100ML
HEPATASOL INJ 0.77GM/100ML; 0.6GM/100ML;
3
0.02GM/100ML; 0.9GM/100ML; 0.24GM/100ML; 0.9GM/100ML;
1.1GM/100ML; 0.61GM/100ML; 0.1GM/100ML; 0.1GM/100ML;
0.115GM/100ML; 0.8GM/100ML; 0.5GM/100ML;
0.45GM/100ML; 0.065GM/100ML; 0.84GM/100ML
INTRALIPID INJ 20GM/100ML
3
INTRALIPID INJ 30GM/100ML
3
kcl 0.15%/d5w/lr inj 3meq/l; 149meq/l; 5%; 28meq/l; 24meq/l;
1
130meq/l
l-cysteine hcl inj 50mg/ml
1
LIPOSYN III INJ 1.2GM/100ML; 2.5GM/100ML; 10GM/100ML 3
LIPOSYN III INJ 1.2GM/100ML; 2.5GM/100ML; 10GM/100ML 3
LIPOSYN III INJ 1.2GM/100ML; 2.5GM/100ML; 20GM/100ML 3
LIPOSYN III INJ 2.5%; 30%
3
LIPOSYN II INJ 2.5%; 10%; 10%
3
NEPHRAMINE INJ 44MEQ/L; 20MG/100ML; 250MG/100ML; 3
560MG/100ML; 880MG/100ML; 640MG/100ML; 880MG/100ML;
880MG/100ML; 6MEQ/L; 400MG/100ML; 200MG/100ML;
640MG/100ML
NUTRILIPID INJ 20GM/100ML
3
50
Requirements/Limits
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
Drug
Drug Name
Tier
PLENAMINE INJ 151MEQ/L; 2170MG/100ML; 1470MG/100ML; 3
434MG/100ML; 749MG/100ML; 1040MG/100ML;
894MG/100ML; 749MG/100ML; 1040MG/100ML;
1180MG/100ML; 749MG/100ML; 1040MG/100ML;
894MG/100ML; 592MG/100ML; 749MG/100ML; 250MG/100ML;
39MG/100ML; 960MG/100ML
PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML;
3
34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML;
526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML;
152MG/100ML
PREMASOL INJ 56MEQ/L; 320MG/100ML; 730MG/100ML;
3
190MG/100ML; 3MEQ/L; 20MG/100ML; 300MG/100ML;
220MG/100ML; 290MG/100ML; 490MG/100ML; 840MG/100ML;
490MG/100ML; 200MG/100ML; 290MG/100ML; 410MG/100ML;
230MG/100ML; 5MEQ/L; 15MG/100ML; 250MG/100ML;
120MG/100ML; 140MG/100ML; 470MG/100ML
PROCALAMINE INJ 47MEQ/L; 210MG/100ML; 290MG/100ML; 3
3MEQ/L; 41MEQ/L; 20MG/100ML; 420MG/100ML;
85MG/100ML; 210MG/100ML; 270MG/100ML; 220MG/100ML;
5MEQ/L; 160MG/100ML; 170MG/100ML; 7MMOLE/L;
24MEQ/L; 340MG/100ML; 180MG/100ML; 35MEQ/L;
120MG/100ML; 46MG/100ML; 200MG/100ML
PROSOL INJ 2.76GM/100ML; 1.96GM/100ML; 600MG/100ML; 3
1.02GM/100ML; 2.06GM/100ML; 1.18GM/100ML;
1.08GM/100ML; 1.08GM/100ML; 1.35GM/100ML;
760MG/100ML; 1GM/100ML; 1.34GM/100ML; 1.02GM/100ML;
980MG/100ML; 320MG/100ML; 50MG/100ML; 1.44GM/100ML
3
TRAVASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML;
34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML;
526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML;
152MG/100ML
3
TROPHAMINE INJ 0; 0.32GM/100ML; 0.73GM/100ML;
0.19GM/100ML; 0.014GM/100ML; 0.22GM/100ML;
0.29GM/100ML; 0.49GM/100ML; 0.3GM/100ML;
0.84GM/100ML; 0.49GM/100ML; 0.2GM/100ML;
0.29GM/100ML; 0.41GM/100ML; 0.23GM/100ML;
0.05GM/100ML; 0.015GM/100ML; 0.25GM/100ML;
0.12GM/100ML; 0.14GM/100ML; 0.47GM/100ML
TROPHAMINE INJ 97MEQ/L; 0.54GM/100ML; 1.2GM/100ML; 3
0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML;
0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML;
0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML;
0.38GM/100ML; 5MEQ/L; 0.025GM/100ML; 0.42GM/100ML;
0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML
CARDIOVASCULAR AGENTS
51
Requirements/Limits
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
Drug Name
ALPHA-ADRENERGIC AGENTS
clonidine hcl ptwk 0.1mg/24hr
clonidine hcl ptwk 0.2mg/24hr
clonidine hcl ptwk 0.3mg/24hr
clonidine hcl tabs 0.1mg
clonidine hcl tabs 0.2mg
clonidine hcl tabs 0.3mg
clorpres tabs 15mg; 0.1mg
clorpres tabs 15mg; 0.2mg
clorpres tabs 15mg; 0.3mg
DIBENZYLINE CAPS 10MG
doxazosin mesylate tabs 1mg
doxazosin mesylate tabs 2mg
doxazosin mesylate tabs 4mg
doxazosin mesylate tabs 8mg
midodrine hcl tabs 10mg
midodrine hcl tabs 2.5mg
midodrine hcl tabs 5mg
NORTHERA CAPS 100MG
NORTHERA CAPS 200MG
NORTHERA CAPS 300MG
prazosin hcl caps 1mg
prazosin hcl caps 2mg
prazosin hcl caps 5mg
ANGIOTENSIN II RECEPTOR ANTAGONISTS
BENICAR HCT TABS 12.5MG; 20MG
BENICAR HCT TABS 12.5MG; 40MG
BENICAR HCT TABS 25MG; 40MG
BENICAR TABS 20MG
BENICAR TABS 40MG
BENICAR TABS 5MG
candesartan cilexetil/hydrochlorothiazide tabs 16mg; 12.5mg
candesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg
candesartan cilexetil/hydrochlorothiazide tabs 32mg; 25mg
candesartan cilexetil tabs 16mg
candesartan cilexetil tabs 32mg
candesartan cilexetil tabs 4mg
candesartan cilexetil tabs 8mg
eprosartan mesylate tabs 600mg
irbesartan/hydrochlorothiazide tabs 12.5mg; 150mg
irbesartan/hydrochlorothiazide tabs 12.5mg; 300mg
irbesartan tabs 150mg
irbesartan tabs 300mg
irbesartan tabs 75mg
losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg
losartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg
losartan potassium/hydrochlorothiazide tabs 25mg; 100mg
52
Drug
Tier Requirements/Limits
2
2
2
1
1
1
2
2
2
4
1
1
1
1
2
2
2
5
5
5
1
1
1
3
3
3
3
3
3
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
Drug Name
losartan potassium tabs 100mg
losartan potassium tabs 25mg
losartan potassium tabs 50mg
telmisartan/hydrochlorothiazide tabs 12.5mg; 40mg
telmisartan/hydrochlorothiazide tabs 12.5mg; 80mg
telmisartan/hydrochloroth tabs 25mg; 80mg
telmisartan tabs 20mg
telmisartan tabs 40mg
telmisartan tabs 80mg
valsartan/hydrochlorothiazide tabs 12.5mg; 160mg
valsartan/hydrochlorothiazide tabs 12.5mg; 320mg
valsartan/hydrochlorothiazide tabs 12.5mg; 80mg
valsartan/hydrochlorothiazide tabs 25mg; 160mg
valsartan/hydrochlorothiazide tabs 25mg; 320mg
valsartan tabs 160mg
valsartan tabs 320mg
valsartan tabs 40mg
valsartan tabs 80mg
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg
benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg
benazepril hcl/hydrochlorothiazide tabs 20mg; 25mg
benazepril hcl/hydrochlorothiazide tabs 5mg; 6.25mg
benazepril hcl tabs 10mg
benazepril hcl tabs 20mg
benazepril hcl tabs 40mg
benazepril hcl tabs 5mg
captopril/hydrochlorothiazide tabs 25mg; 15mg
captopril/hydrochlorothiazide tabs 25mg; 25mg
captopril/hydrochlorothiazide tabs 50mg; 15mg
captopril/hydrochlorothiazide tabs 50mg; 25mg
captopril tabs 100mg
captopril tabs 12.5mg
captopril tabs 25mg
captopril tabs 50mg
enalapril maleate/hydrochlorothiazide tabs 10mg; 25mg
enalapril maleate/hydrochlorothiazide tabs 5mg; 12.5mg
enalapril maleate tabs 10mg
enalapril maleate tabs 2.5mg
enalapril maleate tabs 20mg
enalapril maleate tabs 5mg
enalaprilat inj 1.25mg/ml
fosinopril sodium/hydrochlorothiazide tabs 10mg; 12.5mg
fosinopril sodium/hydrochlorothiazide tabs 20mg; 12.5mg
fosinopril sodium tabs 10mg
fosinopril sodium tabs 20mg
fosinopril sodium tabs 40mg
53
Drug
Tier Requirements/Limits
1
1
1
2
2
2
2
2
2
1
1
1
1
1
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
1
1
1
1
1
1
1
2
2
1
1
1
Drug Name
lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg
lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg
lisinopril/hydrochlorothiazide tabs 25mg; 20mg
lisinopril tabs 10mg
lisinopril tabs 2.5mg
lisinopril tabs 20mg
lisinopril tabs 30mg
lisinopril tabs 40mg
lisinopril tabs 5mg
moexipril hcl tabs 15mg
moexipril hcl tabs 7.5mg
moexipril/hydrochlorothiazide tabs 12.5mg; 15mg
moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg
moexipril/hydrochlorothiazide tabs 25mg; 15mg
perindopril erbumine tabs 2mg
perindopril erbumine tabs 4mg
perindopril erbumine tabs 8mg
quinapril hcl tabs 10mg
quinapril hcl tabs 20mg
quinapril hcl tabs 40mg
quinapril hcl tabs 5mg
quinapril/hydrochlorothiazide tabs 12.5mg; 10mg
quinapril/hydrochlorothiazide tabs 12.5mg; 20mg
quinapril/hydrochlorothiazide tabs 25mg; 20mg
ramipril caps 1.25mg
ramipril caps 10mg
ramipril caps 2.5mg
ramipril caps 5mg
trandolapril/verapamil hcl tbcr 1mg; 240mg
trandolapril/verapamil hcl tbcr 2mg; 180mg
trandolapril/verapamil hcl tbcr 2mg; 240mg
trandolapril/verapamil hcl tbcr 4mg; 240mg
trandolapril tabs 1mg
trandolapril tabs 2mg
trandolapril tabs 4mg
ANTIARRHYTHMIC AGENTS
amiodarone hcl inj 50mg/ml
amiodarone hcl inj 50mg/ml
amiodarone hcl tabs 100mg
amiodarone hcl tabs 200mg
amiodarone hcl tabs 400mg
flecainide acetate tabs 100mg
flecainide acetate tabs 150mg
flecainide acetate tabs 50mg
LIDOCAINE HCL IN D5W INJ 5%; 4MG/ML
lidocaine hcl in d5w inj 5%; 8mg/ml
lidocaine hcl/dextrose inj 7.5%; 5%
54
Drug
Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
3
1
1
Drug Name
lidocaine hcl inj 10mg/ml
lidocaine hcl inj 20mg/ml
mexiletine hcl caps 150mg
mexiletine hcl caps 200mg
mexiletine hcl caps 250mg
MULTAQ TABS 400MG
NEXTERONE INJ 150MG/100ML; 42.1MG/ML
NEXTERONE INJ 360MG/200ML; 41.4MG/ML
pacerone tabs 100mg
pacerone tabs 200mg
pacerone tabs 400mg
procainamide hcl inj 100mg/ml
procainamide hcl inj 500mg/ml
propafenone hcl er cp12 225mg
propafenone hcl er cp12 325mg
propafenone hcl er cp12 425mg
propafenone hcl tabs 150mg
propafenone hcl tabs 225mg
propafenone hcl tabs 300mg
quinidine gluconate cr tbcr 324mg
quinidine gluconate inj 80mg/ml
quinidine sulfate tabs 200mg
quinidine sulfate tabs 300mg
TIKOSYN CAPS 125MCG
TIKOSYN CAPS 250MCG
TIKOSYN CAPS 500MCG
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl caps 200mg
acebutolol hcl caps 400mg
atenolol/chlorthalidone tabs 100mg; 25mg
atenolol/chlorthalidone tabs 50mg; 25mg
atenolol tabs 100mg
atenolol tabs 25mg
atenolol tabs 50mg
betaxolol hcl tabs 10mg
betaxolol hcl tabs 20mg
bisoprolol fumarate/hydrochlorothiazide tabs 10mg; 6.25mg
bisoprolol fumarate/hydrochlorothiazide tabs 2.5mg; 6.25mg
bisoprolol fumarate/hydrochlorothiazide tabs 5mg; 6.25mg
bisoprolol fumarate tabs 10mg
bisoprolol fumarate tabs 5mg
BYSTOLIC TABS 10MG
BYSTOLIC TABS 2.5MG
BYSTOLIC TABS 20MG
BYSTOLIC TABS 5MG
carvedilol tabs 12.5mg
carvedilol tabs 25mg
55
Drug
Tier Requirements/Limits
1
1
2
2
2
4
3
3
2
2
2
1
1
2
2
2
1
1
1
2
2
1
1
4
4
4
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
1
1
Drug Name
carvedilol tabs 3.125mg
carvedilol tabs 6.25mg
esmolol hcl inj 100mg/10ml
HEMANGEOL SOLN 4.28MG/ML
labetalol hcl inj 5mg/ml
labetalol hcl tabs 100mg
labetalol hcl tabs 200mg
labetalol hcl tabs 300mg
metoprolol succinate er tb24 100mg
metoprolol succinate er tb24 200mg
metoprolol succinate er tb24 25mg
metoprolol succinate er tb24 50mg
metoprolol tartrate inj 1mg/ml
metoprolol tartrate tabs 100mg
metoprolol tartrate tabs 25mg
metoprolol tartrate tabs 50mg
metoprolol/hydrochlorothiazide tabs 25mg; 100mg
metoprolol/hydrochlorothiazide tabs 25mg; 50mg
metoprolol/hydrochlorothiazide tabs 50mg; 100mg
nadolol/bendroflumethiazide tabs 5mg; 40mg
nadolol/bendroflumethiazide tabs 5mg; 80mg
nadolol tabs 20mg
nadolol tabs 40mg
nadolol tabs 80mg
pindolol tabs 10mg
pindolol tabs 5mg
propranolol hcl er cp24 120mg
propranolol hcl er cp24 160mg
propranolol hcl er cp24 60mg
propranolol hcl er cp24 80mg
propranolol hcl inj 1mg/ml
propranolol hcl soln 20mg/5ml
propranolol hcl soln 40mg/5ml
propranolol hcl tabs 10mg
propranolol hcl tabs 20mg
propranolol hcl tabs 40mg
propranolol hcl tabs 60mg
propranolol hcl tabs 80mg
propranolol/hydrochlorothiazide tabs 25mg; 40mg
propranolol/hydrochlorothiazide tabs 25mg; 80mg
sorine tabs 120mg
sorine tabs 160mg
sorine tabs 240mg
sorine tabs 80mg
sotalol hcl (af) tabs 120mg
sotalol hcl (af) tabs 160mg
sotalol hcl (af) tabs 80mg
56
Drug
Tier Requirements/Limits
1
1
1
4
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Drug Name
sotalol hcl tabs 240mg
SOTALOL HYDROCHLORIDE INJ 150MG/10ML
SOTYLIZE SOLN 5MG/ML
timolol maleate tabs 10mg
timolol maleate tabs 20mg
timolol maleate tabs 5mg
CALCIUM-CHANNEL BLOCKING AGENTS
cartia xt cp24 120mg
cartia xt cp24 180mg
cartia xt cp24 240mg
cartia xt cp24 300mg
dilt-xr cp24 120mg
dilt-xr cp24 180mg
dilt-xr cp24 240mg
diltiazem cd cp24 120mg
diltiazem cd cp24 240mg
diltiazem hcl cd cp24 360mg
diltiazem hcl er cp12 120mg
diltiazem hcl er cp12 60mg
diltiazem hcl er cp12 90mg
diltiazem hcl er cp24 180mg
diltiazem hcl er cp24 300mg
diltiazem hcl er cp24 420mg
diltiazem hcl er tb24 180mg
diltiazem hcl er tb24 240mg
diltiazem hcl er tb24 300mg
diltiazem hcl er tb24 360mg
diltiazem hcl er tb24 420mg
diltiazem hcl inj 100mg
diltiazem hcl inj 25mg/5ml
diltiazem hcl tabs 120mg
diltiazem hcl tabs 30mg
diltiazem hcl tabs 60mg
diltiazem hcl tabs 90mg
matzim la tb24 180mg
matzim la tb24 240mg
matzim la tb24 300mg
matzim la tb24 360mg
matzim la tb24 420mg
taztia xt cp24 120mg
taztia xt cp24 180mg
taztia xt cp24 240mg
taztia xt cp24 300mg
taztia xt cp24 360mg
verapamil hcl er cp24 100mg
verapamil hcl er cp24 120mg
verapamil hcl er cp24 180mg
57
Drug
Tier Requirements/Limits
1
3
4
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Drug Name
verapamil hcl er cp24 200mg
verapamil hcl er cp24 240mg
verapamil hcl er cp24 300mg
verapamil hcl er tbcr 120mg
verapamil hcl er tbcr 180mg
verapamil hcl er tbcr 240mg
verapamil hcl sr cp24 360mg
verapamil hcl inj 2.5mg/ml
verapamil hcl tabs 120mg
verapamil hcl tabs 40mg
verapamil hcl tabs 80mg
CARDIOVASCULAR AGENTS, MISCELLANEOUS
AUVI-Q INJ 0.15MG/0.15ML
AUVI-Q INJ 0.3MG/0.3ML
DEMSER CAPS 250MG
digitek tabs 0.125mg
DIGOXIN SOLN 0.05MG/ML
digoxin tabs 125mcg
digox tabs 125mcg
dobutamine hcl/d5w inj 5%; 1mg/ml
dobutamine hcl/d5w inj 5%; 2mg/ml
dobutamine hcl/d5w inj 5%; 4mg/ml
dobutamine hcl inj 250mg/20ml
dopamine hcl inj 160mg/ml
dopamine hcl inj 40mg/ml
dopamine hcl inj 80mg/ml
dopamine hcl inj 80mg/ml
dopamine/d5w inj 5%; 0.8mg/ml
dopamine/d5w inj 5%; 1.6mg/ml
dopamine/d5w inj 5%; 3.2mg/ml
epinephrine hcl inj 0.1mg/ml
epinephrine hcl inj 1mg/ml
epinephrine inj 0.15mg/0.15ml
epinephrine inj 0.3mg/0.3ml
EPIPEN 2-PAK INJ 0.3MG/0.3ML
EPIPEN-JR 2-PAK INJ 0.15MG/0.3ML
FIRAZYR INJ 30MG/3ML
hydralazine hcl inj 20mg/ml
hydralazine hcl tabs 100mg
hydralazine hcl tabs 10mg
hydralazine hcl tabs 25mg
hydralazine hcl tabs 50mg
LANOXIN PEDIATRIC INJ 0.1MG/ML
LANOXIN TABS 125MCG
milrinone in dextrose inj 5%; 40mg/200ml
norepinephrine bitartrate inj 1mg/ml
RANEXA TB12 1000MG
58
Drug
Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
4
4
5
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
1
3
3
5
1
1
1
1
1
3
3
1
2
4
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
PA
B/D
Drug Name
RANEXA TB12 500MG
CARDIOVASCULAR AGENTS, OTHER
CORLANOR TABS 5MG
CORLANOR TABS 7.5MG
DIHYDROPYRIDINES
afeditab cr tb24 30mg
afeditab cr tb24 60mg
amlodipine besylate/benazepril hcl caps 10mg; 40mg
amlodipine besylate/benazepril hcl caps 5mg; 40mg
amlodipine besylate/benazepril hydrochloride caps 10mg; 20mg
amlodipine besylate/benazepril hydrochloride caps 2.5mg; 10mg
amlodipine besylate/benazepril hydrochloride caps 5mg; 10mg
amlodipine besylate/benazepril hydrochloride caps 5mg; 20mg
amlodipine besylate/valsartan tabs 10mg; 160mg
amlodipine besylate/valsartan tabs 10mg; 320mg
amlodipine besylate/valsartan tabs 5mg; 160mg
amlodipine besylate/valsartan tabs 5mg; 320mg
amlodipine besylate tabs 10mg
amlodipine besylate tabs 2.5mg
amlodipine besylate tabs 5mg
CARDENE IV INJ 4.8%; 20MG/200ML
CARDENE IV INJ 5%; 40MG/200ML
CARDENE SR CP12 30MG
CARDENE SR CP12 45MG
CARDENE SR CP12 60MG
CLEVIPREX INJ 0.5MG/ML
isradipine caps 2.5mg
isradipine caps 5mg
nicardipine hcl caps 20mg
nicardipine hcl caps 30mg
nicardipine hcl inj 2.5mg/ml
nifedical xl tb24 30mg
nifedical xl tb24 60mg
nifedipine er tb24 30mg
nifedipine er tb24 60mg
nifedipine er tb24 90mg
nimodipine caps 30mg
NYMALIZE SOLN 60MG/20ML
DIURETICS
amiloride hcl tabs 5mg
amiloride/hydrochlorothiazide tabs 5mg; 50mg
bumetanide inj 0.25mg/ml
bumetanide tabs 0.5mg
bumetanide tabs 1mg
bumetanide tabs 2mg
chlorothiazide sodium inj 500mg
chlorothiazide tabs 250mg
59
Drug
Tier Requirements/Limits
4
4
4
1
1
1
1
1
1
1
1
2
2
2
2
1
1
1
3
3
4
4
4
4
2
2
1
1
1
1
1
1
1
1
2
4
1
1
1
1
1
1
1
1
Drug Name
chlorothiazide tabs 500mg
chlorthalidone tabs 25mg
chlorthalidone tabs 50mg
DIURIL SUSP 250MG/5ML
DYRENIUM CAPS 0; 100MG
DYRENIUM CAPS 50MG
EDECRIN TABS 25MG
furosemide inj 10mg/ml
furosemide inj 10mg/ml
furosemide soln 10mg/ml
furosemide soln 8mg/ml
furosemide tabs 20mg
furosemide tabs 40mg
furosemide tabs 80mg
hydrochlorothiazide caps 12.5mg
hydrochlorothiazide tabs 12.5mg
hydrochlorothiazide tabs 25mg
hydrochlorothiazide tabs 50mg
indapamide tabs 1.25mg
indapamide tabs 2.5mg
methyclothiazide tabs 5mg
metolazone tabs 10mg
metolazone tabs 2.5mg
metolazone tabs 5mg
SAMSCA TABS 15MG
SAMSCA TABS 30MG
torsemide inj 20mg/2ml
torsemide tabs 100mg
torsemide tabs 10mg
torsemide tabs 20mg
torsemide tabs 5mg
triamterene/hydrochlorothiazide caps 25mg; 37.5mg
triamterene/hydrochlorothiazide caps 25mg; 50mg
triamterene/hydrochlorothiazide tabs 25mg; 37.5mg
triamterene/hydrochlorothiazide tabs 50mg; 75mg
DYSLIPIDEMICS
amlodipine besylate/atorvastatin calcium tabs 10mg; 10mg
amlodipine besylate/atorvastatin calcium tabs 10mg; 20mg
amlodipine besylate/atorvastatin calcium tabs 10mg; 40mg
amlodipine besylate/atorvastatin calcium tabs 10mg; 80mg
amlodipine besylate/atorvastatin calcium tabs 2.5mg; 10mg
amlodipine besylate/atorvastatin calcium tabs 2.5mg; 20mg
amlodipine besylate/atorvastatin calcium tabs 2.5mg; 40mg
amlodipine besylate/atorvastatin calcium tabs 5mg; 10mg
amlodipine besylate/atorvastatin calcium tabs 5mg; 20mg
amlodipine besylate/atorvastatin calcium tabs 5mg; 40mg
amlodipine besylate/atorvastatin calcium tabs 5mg; 80mg
60
Drug
Tier Requirements/Limits
1
1
1
4
3
3
4
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
5
PA
5
PA
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
Drug Name
atorvastatin calcium tabs 10mg
atorvastatin calcium tabs 20mg
atorvastatin calcium tabs 40mg
atorvastatin calcium tabs 80mg
cholestyramine pack 4gm
colestipol hcl for oral suspension pack 5gm
CRESTOR TABS 10MG
CRESTOR TABS 20MG
CRESTOR TABS 40MG
CRESTOR TABS 5MG
fenofibrate micronized caps 134mg
fenofibrate micronized caps 200mg
fenofibrate micronized caps 67mg
fenofibrate caps 130mg
fenofibrate caps 150mg
fenofibrate caps 43mg
fenofibrate caps 50mg
fenofibrate tabs 145mg
fenofibrate tabs 160mg
fenofibrate tabs 48mg
fenofibrate tabs 54mg
fenofibric acid dr cpdr 135mg
fenofibric acid dr cpdr 45mg
fenofibric acid tabs 105mg
fenofibric acid tabs 35mg
gemfibrozil tabs 600mg
JUXTAPID CAPS 10MG
JUXTAPID CAPS 20MG
JUXTAPID CAPS 30MG
JUXTAPID CAPS 40MG
JUXTAPID CAPS 5MG
JUXTAPID CAPS 60MG
KYNAMRO INJ 200MG/ML
lovastatin tabs 10mg
lovastatin tabs 20mg
lovastatin tabs 40mg
micronized colestipol hcl tabs 1gm
niacin er tbcr 1000mg
niacin er tbcr 500mg
niacin er tbcr 750mg
niacor tabs 500mg
omega-3-acid ethyl esters caps 375mg; 465mg; 1gm
pravastatin sodium tabs 10mg
pravastatin sodium tabs 20mg
pravastatin sodium tabs 40mg
pravastatin sodium tabs 80mg
prevalite powd 4gm/dose
61
Drug
Tier
1
1
1
1
2
1
3
3
3
3
1
1
1
2
2
2
2
2
2
2
2
2
1
1
1
1
5
5
5
5
5
5
5
1
1
1
1
2
2
2
1
2
1
1
1
1
2
Requirements/Limits
PA
PA
PA
PA
PA
PA
PA
Drug Name
simvastatin tabs 10mg
simvastatin tabs 20mg
simvastatin tabs 40mg
simvastatin tabs 5mg
simvastatin tabs 80mg
WELCHOL PACK 3.75GM
WELCHOL TABS 625MG
ZETIA TABS 10MG
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
eplerenone tabs 25mg
eplerenone tabs 50mg
spironolactone/hydrochlorothiazide tabs 25mg; 25mg
spironolactone tabs 100mg
spironolactone tabs 25mg
spironolactone tabs 50mg
VASODILATORS
BIDIL TABS 37.5MG; 20MG
isoditrate er tbcr 40mg
ISORDIL TITRADOSE TABS 40MG
isosorbide dinitrate subl 2.5mg
isosorbide dinitrate tabs 10mg
isosorbide dinitrate tabs 20mg
isosorbide dinitrate tabs 30mg
isosorbide dinitrate tabs 5mg
isosorbide mononitrate er tb24 120mg
isosorbide mononitrate er tb24 30mg
isosorbide mononitrate er tb24 60mg
isosorbide mononitrate tabs 10mg
isosorbide mononitrate tabs 20mg
minitran pt24 0.1mg/hr
minitran pt24 0.2mg/hr
minitran pt24 0.4mg/hr
minitran pt24 0.6mg/hr
minoxidil tabs 10mg
minoxidil tabs 2.5mg
NITRO-BID OINT 2%
NITRO-DUR PT24 0.3MG/HR
NITRO-DUR PT24 0.8MG/HR
nitroglycerin in dextrose 5% inj 5%; 100mcg/ml
nitroglycerin in dextrose 5% inj 5%; 200mcg/ml
nitroglycerin in dextrose 5% inj 5%; 400mcg/ml
nitroglycerin lingual soln 0.4mg/spray
nitroglycerin transdermal pt24 0.1mg/hr
nitroglycerin transdermal pt24 0.2mg/hr
nitroglycerin transdermal pt24 0.4mg/hr
nitroglycerin transdermal pt24 0.6mg/hr
nitroglycerin inj 5mg/ml
62
Drug
Tier Requirements/Limits
1
1
1
1
1
3
3
4
2
2
1
1
1
1
4
1
4
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
4
4
2
2
2
2
1
1
1
1
2
Drug
Drug Name
Tier
NITROSTAT SUBL 0.3MG
3
NITROSTAT SUBL 0.4MG
3
NITROSTAT SUBL 0.6MG
3
PROGLYCEM SUSP 50MG/ML
4
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg; 1.25mg; 2
1.25mg
amphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg;
2
2.5mg
amphetamine/dextroamphetamine cp24 3.75mg; 3.75mg; 3.75mg; 2
3.75mg
amphetamine/dextroamphetamine cp24 5mg; 5mg; 5mg; 5mg
2
amphetamine/dextroamphetamine cp24 6.25mg; 6.25mg; 6.25mg; 2
6.25mg
amphetamine/dextroamphetamine cp24 7.5mg; 7.5mg; 7.5mg;
2
7.5mg
amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 2
1.25mg
amphetamine/dextroamphetamine tabs 1.875mg; 1.875mg;
2
1.875mg; 1.875mg
amphetamine/dextroamphetamine tabs 2.5mg; 2.5mg; 2.5mg; 2.5mg 2
amphetamine/dextroamphetamine tabs 3.125mg; 3.125mg;
2
3.125mg; 3.125mg
amphetamine/dextroamphetamine tabs 3.75mg; 3.75mg; 3.75mg; 2
3.75mg
amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg
2
amphetamine/dextroamphetamine tabs 7.5mg; 7.5mg; 7.5mg; 7.5mg 2
AMPYRA TB12 10MG
5
caffeine citrate inj 60mg/3ml
2
caffeine citrate soln 20mg/ml
1
caffeine citrate soln 20mg/ml
1
caffeine/sodium benzoate inj 125mg/ml; 125mg/ml
2
clonidine hcl er tb12 0.1mg
2
DAYTRANA PTCH 10MG/9HR
4
DAYTRANA PTCH 15MG/9HR
4
DAYTRANA PTCH 20MG/9HR
4
DAYTRANA PTCH 30MG/9HR
4
dexmethylphenidate hcl er cp24 15mg
2
dexmethylphenidate hcl er cp24 20mg
2
dexmethylphenidate hcl er cp24 30mg
2
dexmethylphenidate hcl er cp24 40mg
2
dexmethylphenidate hcl er cp24 5mg
2
dexmethylphenidate hcl tabs 10mg
2
dexmethylphenidate hcl tabs 2.5mg
2
dexmethylphenidate hcl tabs 5mg
2
dextroamphetamine sulfate er cp24 10mg
2
63
Requirements/Limits
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
PA
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (180 EA per 30 days)
Drug Name
dextroamphetamine sulfate er cp24 15mg
dextroamphetamine sulfate er cp24 5mg
DEXTROAMPHETAMINE SULFATE SOLN 5MG/5ML
dextroamphetamine sulfate tabs 10mg
dextroamphetamine sulfate tabs 5mg
lithium carbonate er tbcr 300mg
lithium carbonate er tbcr 450mg
lithium carbonate caps 150mg
lithium carbonate caps 300mg
lithium carbonate caps 600mg
lithium carbonate tabs 300mg
lithium soln 8meq/5ml
methamphetamine hcl tabs 5mg
methylphenidate hcl cd cpcr 10mg
methylphenidate hcl cd cpcr 20mg
methylphenidate hcl cd cpcr 50mg
methylphenidate hcl cd cpcr 60mg
methylphenidate hcl er cp24 30mg
methylphenidate hcl er cp24 40mg
methylphenidate hcl er tbcr 10mg
methylphenidate hcl er tbcr 18mg
methylphenidate hcl er tbcr 27mg
methylphenidate hcl er tbcr 36mg
methylphenidate hcl er tbcr 54mg
methylphenidate hcl sr tbcr 20mg
methylphenidate hcl chew 10mg
methylphenidate hcl chew 2.5mg
methylphenidate hcl chew 5mg
methylphenidate hcl tabs 10mg
methylphenidate hcl tabs 20mg
methylphenidate hcl tabs 5mg
methylphenidate hydrochloride soln 10mg/5ml
methylphenidate hydrochloride soln 5mg/5ml
NUEDEXTA CAPS 20MG; 10MG
PROCENTRA SOLN 5MG/5ML
RILUZOLE TABS 50MG
SAVELLA TITRATION PACK MISC 0
SAVELLA TABS 100MG
SAVELLA TABS 12.5MG
SAVELLA TABS 25MG
SAVELLA TABS 50MG
STRATTERA CAPS 100MG
STRATTERA CAPS 10MG
STRATTERA CAPS 18MG
STRATTERA CAPS 25MG
STRATTERA CAPS 40MG
STRATTERA CAPS 60MG
64
Drug
Tier
2
2
3
2
2
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
4
4
3
3
3
3
3
4
4
4
4
4
4
Requirements/Limits
QL (180 EA per 30 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days)
QL (150 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (180 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (90 EA per 30 days)
QL (180 EA per 30 days)
QL (90 EA per 30 days)
QL (90 EA per 30 days)
QL (90 EA per 30 days)
QL (90 EA per 30 days)
QL (90 EA per 30 days)
QL (900 ML per 30 days)
QL (900 ML per 30 days)
Drug Name
STRATTERA CAPS 80MG
XENAZINE TABS 12.5MG
XENAZINE TABS 25MG
CONTRACEPTIVES
CONTRACEPTIVES
altavera tabs 0.03mg; 0.15mg
alyacen 1/35 tabs 35mcg; 1mg
alyacen 7/7/7 tabs 0; 0
amethia lo tabs 0; 0
amethia tabs 0; 0
apri tabs 0.15mg; 30mcg
aranelle tabs 0; 0
ashlyna tabs 0; 0
aubra tabs 20mcg; 0.1mg
aviane tabs 20mcg; 0.1mg
azurette tabs 0; 0
balziva tabs 35mcg; 0.4mg
briellyn tabs 35mcg; 0.4mg
camila tabs 0.35mg
camrese lo tabs 0; 0
camrese tabs 0; 0
caziant tabs 0; 0
cryselle-28 tabs 30mcg; 0.3mg
cyclafem 1/35 tabs 35mcg; 1mg
cyclafem 7/7/7 tabs 0; 0
dasetta 1/35 tabs 35mcg; 1mg
dasetta 7/7/7 tabs 0; 0
daysee tabs 0; 0
deblitane tabs 0.35mg
delyla tabs 20mcg; 0.1mg
desogestrel/ethinyl estradiol tabs 0.15mg; 30mcg
desogestrel/ethinyl estradiol tabs 0; 0
drospirenone/ethinyl estradiol tabs 3mg; 0.03mg
elinest tabs 30mcg; 0.3mg
ELLA TABS 30MG
ELLA TABS 30MG
emoquette tabs 0.15mg; 30mcg
enpresse-28 tabs 0; 0
enskyce tabs 0.15mg; 30mcg
errin tabs 0.35mg
estarylla tabs 35mcg; 0.25mg
falmina tabs 20mcg; 0.1mg
gianvi tabs 3mg; 0.02mg
gildagia tabs 35mcg; 0.4mg
gildess 1.5/30 tabs 30mcg; 1.5mg
gildess 1/20 tabs 20mcg; 1mg
gildess 24 fe tabs 20mcg; 75mg; 1mg
65
Drug
Tier Requirements/Limits
4
5
PA
5
PA
2
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
3
3
2
2
1
2
2
2
2
2
2
2
2
Drug Name
gildess fe 1.5/30 tabs 30mcg; 75mg; 1.5mg
gildess fe 1/20 tabs 20mcg; 75mg; 1mg
heather tabs 0.35mg
introvale tabs 0.03mg; 0.15mg
jencycla tabs 0.35mg
jolessa tabs 0.03mg; 0.15mg
jolivette tabs 0.35mg
junel 1.5/30 tabs 30mcg; 1.5mg
junel 1/20 tabs 20mcg; 1mg
junel fe 1.5/30 tabs 30mcg; 75mg; 1.5mg
junel fe 1/20 tabs 20mcg; 75mg; 1mg
junel fe 24 tabs 20mcg; 75mg; 1mg
kariva tabs 0; 0
kelnor 1/35 tabs 35mcg; 1mg
kurvelo tabs 0.03mg; 0.15mg
larin 1.5/30 tabs 30mcg; 1.5mg
larin 1/20 tabs 20mcg; 1mg
larin fe 1.5/30 tabs 30mcg; 75mg; 1.5mg
larin fe 1/20 tabs 20mcg; 75mg; 1mg
leena tabs 0; 0
lessina tabs 20mcg; 0.1mg
levonest tabs 0; 0
levonorgestrel and ethinyl estradiol tabs 0; 0
levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg
levonorgestrel/ethinyl estradiol tabs 0; 0
levonorgestrel/ethinyl estradiol tabs 20mcg; 0.1mg
levonorgestrel tabs 0.75mg
levonorgestrel tabs 1.5mg
levora 0.15/30-28 tabs 30mcg; 0.15mg
lomedia 24 fe tabs 20mcg; 75mg; 1mg
loryna tabs 3mg; 0.02mg
low-ogestrel tabs 30mcg; 0.3mg
lutera tabs 20mcg; 0.1mg
lyza tabs 0.35mg
marlissa tabs 0.03mg; 0.15mg
microgestin 1.5/30 tabs 30mcg; 1.5mg
microgestin 1/20 tabs 20mcg; 1mg
microgestin fe 1.5/30 tabs 30mcg; 75mg; 1.5mg
microgestin fe tabs 20mcg; 75mg; 1mg
mono-linyah tabs 35mcg; 0.25mg
mononessa tabs 35mcg; 0.25mg
my way tabs 1.5mg
myzilra tabs 0; 0
necon 0.5/35-28 tabs 35mcg; 0.5mg
necon 1/35 tabs 35mcg; 1mg
necon 1/50-28 tabs 50mcg; 1mg
necon 10/11-28 tabs 35mcg; 0
66
Drug
Tier Requirements/Limits
2
2
2
2
1
1
2
1
1
1
1
2
2
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
1
2
2
2
1
1
1
1
2
1
2
2
2
2
2
2
Drug Name
necon 7/7/7 tabs 0; 0
next choice one dose tabs 1.5mg
nikki tabs 3mg; 0.02mg
nora-be tabs 0.35mg
norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs
20mcg; 75mg; 1mg
norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg
norethindrone tabs 0.35mg
norgestimate/ethinyl estradiol tabs 0; 0
norlyroc tabs 0.35mg
nortrel 0.5/35 (28) tabs 35mcg; 0.5mg
nortrel 1/35 tabs 35mcg; 1mg
nortrel 1/35 tabs 35mcg; 1mg
nortrel 7/7/7 tabs 0; 0
ocella tabs 3mg; 0.03mg
ogestrel tabs 50mcg; 0.5mg
orsythia tabs 20mcg; 0.1mg
philith tabs 35mcg; 0.4mg
pimtrea tabs 0; 0
pirmella 1/35 tabs 35mcg; 1mg
pirmella 7/7/7 tabs 0; 0
portia-28 tabs 0.03mg; 0.15mg
previfem tabs 35mcg; 0.25mg
quartette tabs 0; 0
quasense tabs 0.03mg; 0.15mg
reclipsen tabs 0.15mg; 30mcg
sharobel tabs 0.35mg
sprintec 28 tabs 35mcg; 0.25mg
sronyx tabs 20mcg; 0.1mg
syeda tabs 3mg; 0.03mg
tarina fe 1/20 tabs 20mcg; 75mg; 1mg
tilia fe tabs 0; 75mg; 1mg
tri-estarylla tabs 0; 0
tri-legest fe tabs 0; 75mg; 1mg
tri-linyah tabs 0; 0
tri-previfem tabs 0; 0
tri-sprintec tabs 0; 0
trinessa tabs 0; 0
trivora-28 tabs 0; 0
velivet tabs 0; 0
vestura tabs 3mg; 0.02mg
viorele tabs 0; 0
vyfemla tabs 35mcg; 0.4mg
wera tabs 35mcg; 0.5mg
wymzya fe chew 35mcg; 0; 0.4mg
xulane ptwk 35mcg/24hr; 150mcg/24hr
zarah tabs 3mg; 0.03mg
67
Drug
Tier Requirements/Limits
2
2
2
1
2
2
2
2
2
1
1
1
1
2
2
2
2
2
2
2
1
2
2
2
2
2
1
2
2
2
2
2
2
2
2
1
1
2
2
2
2
2
2
2
2
2
Drug Name
zenchent fe chew 35mcg; 0; 0.4mg
zenchent tabs 35mcg; 0.4mg
zeosa chew 35mcg; 0; 0.4mg
zovia 1/35e tabs 35mcg; 1mg
zovia 1/50e tabs 50mcg; 1mg
DENTAL AND ORAL AGENTS
DENTAL AND ORAL AGENTS
cevimeline hcl caps 30mg
chlorhexidine gluconate soln 0.12%
denta 5000 plus crea 1.1%
dentagel gel 1.1%
fluoridex daily defense enhanced whitening gel 1.1%
fluoridex daily defense gel 1.1%
neutral sodium fluoride soln 0.2%
oralone pste 0.1%
periogard soln 0.12%
pilocarpine hcl tabs 7.5mg
pilocarpine hydrochloride tabs 5mg
sf 5000 plus crea 1.1%
stannous fluoride oral rinse conc 0.63%
triamcinolone in orabase pste 0.1%
DERMATOLOGICAL AGENTS
DERMATOLOGICAL AGENTS, OTHER
8-MOP CAPS 10MG
ACITRETIN CAPS 10MG
ACITRETIN CAPS 17.5MG
ACITRETIN CAPS 25MG
ACYCLOVIR OINT 5%
ALCOH-WIPE 12" X 12" PADS
ALCOHOL PREP PADS PADS 70%
ammonium lactate lotn 12%
AZELEX CREA 20%
CALCIPOTRIENE OINT 0.005%
calcipotriene soln 0.005%
calcitriol oint 3mcg/gm
DENAVIR CREA 1%
DRITHO-CREME HP CREA 1%
FINACEA PLUS KIT 15%
FINACEA GEL 15%
fluorouracil crea 0.5%
fluorouracil crea 5%
fluorouracil soln 2%
fluorouracil soln 5%
GLOBAL ALCOHOL PREP EASE PADS PADS 70%
hypercare soln 20%
imiquimod crea 5%
MAFENIDE ACETATE PACK 5%
68
Drug
Tier Requirements/Limits
2
2
2
2
2
2
1
1
1
1
1
1
2
1
2
2
1
1
2
3
3
3
3
3
3
3
1
4
4
2
2
4
4
4
4
2
2
2
2
3
2
2
4
PA
ST
PA
PA
Drug Name
methoxsalen caps 10mg
OXSORALEN LOTN 1%
PANRETIN GEL 0.1%
podocon 25 in benzoin tincture soln 25%
podofilox soln 0.5%
PRUDOXIN CREA 5%
PYROGALLIC ACID OINT 2%; 25%
REGRANEX GEL 0.01%
RIMSO-50 INJ 50%
SANTYL OINT 250UNIT/GM
SULFAMYLON CREA 85MG/GM
UVADEX INJ 20MCG/ML
VALCHLOR GEL 0.016%
VEREGEN OINT 15%
ZONALON CREA 5%
DERMATOLOGICAL ANTI-INFLAMMATORY AGENTS
alclometasone dipropionate crea 0.05%
alclometasone dipropionate oint 0.05%
amcinonide oint 0.1%
augmented betamethasone dipropionate crea 0.05%
augmented betamethasone dipropionate gel 0.05%
augmented betamethasone dipropionate lotn 0.05%
augmented betamethasone dipropionate oint 0.05%
betamethasone dipropionate crea 0.05%
betamethasone dipropionate lotn 0.05%
betamethasone dipropionate oint 0.05%
betamethasone valerate crea 0.1%
betamethasone valerate lotn 0.1%
betamethasone valerate oint 0.1%
clobetasol propionate crea 0.05%
CLOBETASOL PROPIONATE FOAM 0.05%
clobetasol propionate gel 0.05%
clobetasol propionate oint 0.05%
clobetasol propionate soln 0.05%
CORDRAN TAPE TAPE 4MCG/SQCM
CORDRAN CREA 0.05%
CORDRAN LOTN 0.05%
CORDRAN OINT 0.05%
cormax scalp application soln 0.05%
cortalo gel 0; 2%
desonide crea 0.05%
desonide oint 0.05%
desoximetasone crea 0.25%
ELIDEL CREA 1%
fluocinolone acetonide body oil 0.01%
fluocinolone acetonide crea 0.01%
fluocinolone acetonide crea 0.025%
69
Drug
Tier Requirements/Limits
2
3
3
2
1
3
4
3
PA
4
4
4
3
5
PA
4
3
1
1
1
2
2
2
2
2
2
2
1
1
1
2
4
2
2
2
4
4
4
4
2
1
2
2
2
3
2
2
2
Drug
Tier Requirements/Limits
2
2
2
2
2
2
2
1
1
2
2
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
2
2
1
1
1
2
2
1
1
1
1
1
1
1
1
1
Drug Name
fluocinolone acetonide oint 0.025%
fluocinolone acetonide soln 0.01%
fluocinonide crea 0.05%
fluocinonide crea 0.1%
fluocinonide gel 0.05%
fluocinonide oint 0.05%
fluocinonide soln 0.05%
fluticasone propionate crea 0.05%
fluticasone propionate oint 0.005%
halobetasol propionate crea 0.05%
halobetasol propionate oint 0.05%
hydrocortisone acetate/aloe gel 0; 2%
hydrocortisone butyrate crea 0.1%
hydrocortisone butyrate oint 0.1%
hydrocortisone butyrate soln 0.1%
hydrocortisone valerate crea 0.2%
hydrocortisone crea 1%
hydrocortisone crea 2.5%
hydrocortisone enem 100mg/60ml
hydrocortisone lotn 2.5%
hydrocortisone oint 1%
hydrocortisone oint 2.5%
lokara lotn 0.05%
mometasone furoate crea 0.1%
mometasone furoate oint 0.1%
mometasone furoate soln 0.1%
prednicarbate crea 0.1%
prednicarbate oint 0.1%
procto-pak crea 1%
proctosol hc crea 2.5%
proctozone-hc crea 2.5%
tacrolimus oint 0.03%
tacrolimus oint 0.1%
triamcinolone acetonide crea 0.025%
triamcinolone acetonide crea 0.1%
triamcinolone acetonide crea 0.5%
triamcinolone acetonide lotn 0.025%
triamcinolone acetonide lotn 0.1%
triamcinolone acetonide oint 0.025%
triamcinolone acetonide oint 0.1%
triamcinolone acetonide oint 0.5%
u-cort crea 1%; 10%
DERMATOLOGICAL ANTIBACTERIALS
BACTROBAN NASAL OINT 2%
clindamax gel 1%
clindamycin phosphate foam 1%
clindamycin phosphate gel 1%
4
1
2
2
70
Drug Name
clindamycin phosphate lotn 1%
clindamycin phosphate soln 1%
clindamycin phosphate swab 1%
erythromycin gel 2%
erythromycin pads 2%
erythromycin soln 2%
gentamicin sulfate crea 0.1%
gentamicin sulfate oint 0.1%
metronidazole crea 0.75%
metronidazole gel 0.75%
metronidazole gel 1%
metronidazole lotn 0.75%
mupirocin crea 2%
mupirocin oint 2%
neomycin/polymyxin b sulfates soln 40mg/ml; 200000unit/ml
rosadan crea 0.75%
selenium sulfide lotn 2.5%
selenium sulfide sham 0; 2.25%; 0
silver nitrate soln 0.5%
silver nitrate soln 10%
silver nitrate soln 25%
silver nitrate soln 50%
silver sulfadiazine crea 1%
ssd crea 1%
sulfacetamide sodium susp 10%
DERMATOLOGICAL RETINOIDS
adapalene crea 0.1%
adapalene gel 0.1%
avita crea 0.025%
avita gel 0.025%
TAZORAC CREA 0.05%
TAZORAC CREA 0.1%
TAZORAC GEL 0.05%
TAZORAC GEL 0.1%
TRETINOIN MICROSPHERE GEL 0.04%
TRETINOIN MICROSPHERE GEL 0.1%
tretinoin crea 0.025%
tretinoin crea 0.05%
tretinoin crea 0.1%
tretinoin gel 0.01%
tretinoin gel 0.025%
SCABICIDES AND PEDICULICIDES
EURAX CREA 10%
EURAX LOTN 10%
lindane lotn 1%
lindane sham 1%
malathion lotn 0.5%
71
Drug
Tier Requirements/Limits
2
2
2
1
1
2
1
1
2
2
2
2
1
1
2
2
1
1
2
2
2
2
1
1
2
1
1
2
2
4
4
4
4
4
4
1
2
2
2
2
3
3
1
1
1
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Drug Name
permethrin crea 5%
SKLICE LOTN 0.5%
SOOLANTRA CREA 1%
spinosad susp 0.9%
spinosad susp 0.9%
DEVICES
DEVICES
BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2" MISC
BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" MISC
BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" MISC
BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" MISC
BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM MISC
EQL INSULIN SYRINGE/0.3ML/31G X 5/16" MISC
SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"
MISC
TODAYS HEALTH ORIGINAL PEN NEEDLES 29G X 1/2"
MISC
ENZYME REPLACEMENT/MODIFIERS
ENZYME REPLACEMENT/MODIFIERS
ADAGEN INJ 250UNIT/ML
ALDURAZYME INJ 2.9MG/5ML
alosetron hydrochloride tabs 0.5mg
alosetron hydrochloride tabs 1mg
CEREZYME INJ 400UNIT
CHENODAL TABS 250MG
CIMZIA INJ 200MG/ML
CIMZIA INJ 200MG
CREON CPEP 120000UNIT; 24000UNIT; 76000UNIT
CREON CPEP 15000UNIT; 3000UNIT; 9500UNIT
CREON CPEP 180000UNIT; 36000UNIT; 114000UNIT
CREON CPEP 30000UNIT; 6000UNIT; 19000UNIT
CREON CPEP 60000UNIT; 12000UNIT; 38000UNIT
CYSTAGON CAPS 150MG
CYSTAGON CAPS 50MG
ELAPRASE INJ 6MG/3ML
ELELYSO INJ 200UNIT
ELITEK INJ 1.5MG
FABRAZYME INJ 35MG
GATTEX INJ 5MG
KRYSTEXXA INJ 8MG/ML
KUVAN PACK 500MG
KUVAN TBSO 100MG
LINZESS CAPS 145MCG
LINZESS CAPS 290MCG
LUMIZYME INJ 50MG
MYOZYME INJ 50MG
NAGLAZYME INJ 1MG/ML
72
Drug
Tier Requirements/Limits
2
4
4
2
2
3
3
3
3
3
3
3
3
5
5
2
2
5
5
5
5
3
3
3
3
3
4
4
5
5
5
5
5
5
5
5
3
3
5
5
5
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Drug Name
ORFADIN CAPS 10MG
ORFADIN CAPS 2MG
ORFADIN CAPS 5MG
pancrelipase cpep 27000unit; 5000unit; 17000unit
PULMOZYME SOLN 1MG/ML
SUCRAID SOLN 8500UNIT/ML
VIMIZIM INJ 5MG/5ML
VPRIV INJ 400UNIT
XIAFLEX INJ 0.9MG
ZAVESCA CAPS 100MG
EYE, EAR, NOSE, THROAT AGENTS
EYE, EAR, NOSE, THROAT AGENTS, MISCELLANEOUS
altacaine soln 0.5%
apraclonidine soln 0.5%
atropine sulfate oint 1%
atropine sulfate soln 1%
azelastine hcl soln 0.1%
azelastine hcl soln 0.15%
azelastine hcl soln 0.05%
carteolol hcl soln 1%
cromolyn sodium soln 4%
cyclopentolate hcl soln 1%
cyclopentolate hcl soln 2%
epinastine hcl soln 0.05%
homatropaire soln 5%
homatropine hbr soln 5%
ipratropium bromide soln 0.03%
ipratropium bromide soln 0.06%
naphazoline hcl soln 0.1%
parcaine soln 0.5%
PATADAY SOLN 0.2%
PATANOL SOLN 0.1%
PAZEO SOLN 0.7%
phenylephrine hcl soln 10%
phenylephrine hcl soln 10%
phenylephrine hcl soln 2.5%
phenylephrine hcl soln 2.5%
proparacaine hcl soln 0.5%
tetracaine hcl soln 0.5%
tropicamide soln 0.5%
tropicamide soln 1%
TYZINE PEDIATRIC NASAL DROPS SOLN 0.05%
EYE, EAR, NOSE, THROAT ANTI-INFECTIVES AGENTS
acetasol hc soln 2%; 1%
acetic acid soln 2%
bacitracin/polymyxin b oint 500unit/gm; 10000unit/gm
bacitracin oint 500unit/gm
73
Drug
Tier
5
5
5
2
5
5
5
5
5
5
1
1
1
1
2
2
2
1
1
1
1
1
1
1
1
1
1
1
4
4
4
1
1
1
1
1
1
1
1
3
2
2
2
2
Requirements/Limits
PA
PA
PA
PA
PA
PA
PA
PA
PA
Drug Name
ciprofloxacin hcl soln 0.3%
ciprofloxacin soln 0.2%
erythromycin oint 5mg/gm
gatifloxacin soln 0.5%
gentak oint 0.3%
gentamicin sulfate oint 0.3%
gentamicin sulfate soln 0.3%
hydrocortisone/acetic acid soln 2%; 1%
levofloxacin soln 0.5%
MOXEZA SOLN 0.5%
neo-polycin hc oint 400unit/gm; 1%; 3.5mg/gm; 10000unit/gm
neomycin/bacitracin/polymyxin oint 400unit/gm; 5mg/gm;
10000unit/gm
neomycin/polymyxin/bacitracin/hydrocortisone oint 400unit/gm;
1%; 0.5%; 10000unit/gm
neomycin/polymyxin/dexamethasone oint 0.1%; 3.5mg/gm;
10000unit/gm
neomycin/polymyxin/dexamethasone susp 0.1%; 3.5mg/ml;
10000unit/ml
neomycin/polymyxin/gramicidin soln 0.025mg/ml; 1.75mg/ml;
10000unit/ml
neomycin/polymyxin/hydrocortisone soln 1%; 3.5mg/ml;
10000unit/ml
neomycin/polymyxin/hydrocortisone susp 1%; 3.5mg/ml;
10000unit/ml
neomycin/polymyxin/hydrocortisone susp 1%; 3.5mg/ml;
10000unit/ml
ofloxacin soln 0.3%
ofloxacin soln 0.3%
polymyxin b sulfate/trimethoprim sulfate soln 10000unit/ml; 0.1%
sodium sulfacetamide soln 10%
sulfacetamide sodium/prednisolone sodium phosphate soln 0.23%;
10%
sulfacetamide sodium oint 10%
tobramycin sulfate soln 0.3%
tobramycin/dexamethasone susp 0.1%; 0.3%
trifluridine soln 1%
VIGAMOX SOLN 0.5%
ZIRGAN GEL 0.15%
EYE, EAR, NOSE, THROAT ANTI-INFLAMMATORY AGENTS
ALOCRIL SOLN 2%
bromfenac soln 0.09%
dexamethasone sodium phosphate soln 0.1%
diclofenac sodium soln 0.1%
DUREZOL EMUL 0.05%
flunisolide soln 0.025%
fluocinolone acetonide oil 0.01%
74
Drug
Tier Requirements/Limits
1
2
1
2
1
1
1
2
2
4
1
2
2
1
1
1
2
2
1
1
1
1
2
1
2
1
2
2
4
4
4
2
1
1
4
1
2
Drug Name
fluorometholone susp 0.1%
flurbiprofen sodium soln 0.03%
fluticasone propionate susp 50mcg/act
ILEVRO SUSP 0.3%
ketorolac tromethamine soln 0.4%
ketorolac tromethamine soln 0.5%
prednisolone acetate susp 1%
prednisolone sodium phosphate soln 1%
RESTASIS EMUL 0.05%
triamcinolone acetonide aero 55mcg/act
GASTROINTESTINAL AGENTS
ANTIULCER AGENTS AND ACID SUPPRESSANTS
cimetidine hcl/nacl inj 6mg/ml; 0.9%
cimetidine hcl inj 150mg/ml
cimetidine hcl soln 300mg/5ml
cimetidine tabs 200mg
cimetidine tabs 300mg
cimetidine tabs 400mg
cimetidine tabs 800mg
esomeprazole magnesium cpdr 20mg
esomeprazole sodium inj 20mg
esomeprazole sodium inj 40mg
famotidine premixed inj 0.4mg/ml; 0.9%
famotidine inj 20mg/2ml
famotidine susr 40mg/5ml
famotidine tabs 20mg
famotidine tabs 40mg
lansoprazole cpdr 15mg
lansoprazole cpdr 30mg
misoprostol tabs 100mcg
misoprostol tabs 200mcg
nizatidine caps 150mg
nizatidine caps 300mg
nizatidine soln 15mg/ml
omeprazole/sodium bicarbonate caps 20mg; 1100mg
omeprazole/sodium bicarbonate caps 40mg; 1100mg
omeprazole cpdr 10mg
omeprazole cpdr 20mg
omeprazole cpdr 40mg
pantoprazole sodium inj 40mg
pantoprazole sodium tbec 20mg
pantoprazole sodium tbec 40mg
rabeprazole sodium tbec 20mg
ranitidine hcl caps 150mg
ranitidine hcl caps 300mg
ranitidine hcl inj 50mg/2ml
ranitidine hcl syrp 15mg/ml
75
Drug
Tier Requirements/Limits
2
1
1
4
1
1
1
1
4
2
1
1
1
1
1
1
1
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
Drug Name
ranitidine hcl tabs 150mg
ranitidine hcl tabs 300mg
sucralfate susp 1gm/10ml
sucralfate tabs 1gm
GASTROINTESTINAL AGENTS, OTHER
AMITIZA CAPS 24MCG
AMITIZA CAPS 8MCG
BUPHENYL TABS 500MG
CANTIL TABS 25MG
CARBAGLU TABS 200MG
CHOLBAM CAPS 250MG
CHOLBAM CAPS 50MG
constulose soln 10gm/15ml
cromolyn sodium conc 100mg/5ml
CUVPOSA SOLN 1MG/5ML
dicyclomine hcl caps 10mg
dicyclomine hcl soln 10mg/5ml
dicyclomine hcl tabs 20mg
diphenatol tabs 0.025mg; 2.5mg
diphenoxylate/atropine liqd 0.025mg/5ml; 2.5mg/5ml
enulose soln 10gm/15ml
generlac soln 10gm/15ml
glycopyrrolate inj 4mg/20ml
glycopyrrolate tabs 1mg
glycopyrrolate tabs 2mg
KRISTALOSE PACK 10GM
KRISTALOSE PACK 20GM
lactulose soln 10gm/15ml
loperamide hcl caps 2mg
methscopolamine bromide tabs 2.5mg
methscopolamine bromide tabs 5mg
metoclopramide hcl inj 5mg/ml
metoclopramide hcl soln 5mg/5ml
metoclopramide hcl tabs 10mg
metoclopramide hcl tabs 5mg
metoclopramide odt tbdp 5mg
NUTRESTORE PACK 5GM
opium tincture (paregoric) tinc 2mg/5ml
PYLERA CAPS 140MG; 125MG; 125MG
RAVICTI LIQD 1.1GM/ML
RELISTOR INJ 12MG/0.6ML
RELISTOR INJ 12MG/0.6ML
RELISTOR INJ 8MG/0.4ML
ursodiol caps 300mg
ursodiol tabs 250mg
ursodiol tabs 500mg
LAXATIVES
76
Drug
Tier Requirements/Limits
1
1
1
1
4
4
5
4
5
5
5
2
1
4
2
2
2
1
1
2
2
1
1
1
3
3
2
1
2
2
1
1
1
1
2
4
2
4
5
4
4
5
2
2
2
QL (60 EA per 30 days)
QL (60 EA per 30 days)
PA
PA
PA
PA
PA
PA
PA
Drug Name
gavilyte-c solr 240gm; 2.98gm; 6.72gm; 5.84gm; 22.72gm
gavilyte-g solr 236gm; 2.97gm; 6.74gm; 5.86gm; 22.74gm
gavilyte-n/flavor pack solr 420gm; 1.48gm; 5.72gm; 11.2gm
GOLYTELY SOLR 227.1GM; 2.82GM; 6.36GM; 5.53GM;
21.5GM
MOVIPREP SOLR 4.7GM; 100GM; 1.015GM; 5.9GM; 2.691GM;
7.5GM
OSMOPREP TABS 0.398GM; 1.102GM
peg 3350/electrolytes solr 240gm; 2.98gm; 6.72gm; 5.84gm;
22.72gm
peg-3350/electrolytes solr 236gm; 2.97gm; 6.74gm; 5.86gm;
22.74gm
peg-3350/nacl/na bicarbonate/kcl solr 420gm; 1.48gm; 5.72gm;
11.2gm
polyethylene glycol 3350 powd 0
PREPOPIK PACK 12GM; 3.5GM; 10MG
SUCLEAR KIT 1.6GM/180ML; 210GM; 0.74GM;
3.13GM/180ML; 2.86GM; 5.6GM; 17.5GM/180ML
SUPREP BOWEL PREP SOLN 1.6GM/180ML; 3.13GM/180ML;
17.5GM/180ML
trilyte solr 420gm; 1.48gm; 5.72gm; 11.2gm
PHOSPHATE BINDERS
calcium acetate caps 667mg
calcium acetate tabs 667mg
eliphos tabs 667mg
FOSRENOL CHEW 1000MG
FOSRENOL CHEW 500MG
FOSRENOL CHEW 750MG
FOSRENOL PACK 1000MG
FOSRENOL PACK 750MG
kionex susp 15gm/60ml
magnebind 400 tabs 200mg; 1mg; 400mg
PHOSLYRA SOLN 667MG/5ML
RENAGEL TABS 400MG
RENVELA PACK 0.8GM
RENVELA PACK 2.4GM
sevelamer carbonate tabs 800mg
sodium polystyrene sulfonate susp 15gm/60ml
sodium polystyrene sulfonate susp 30gm/120ml
sps susp 15gm/60ml
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
ENABLEX TB24 15MG
ENABLEX TB24 7.5MG
flavoxate hcl tabs 100mg
oxybutynin chloride er tb24 10mg
oxybutynin chloride er tb24 15mg
77
Drug
Tier Requirements/Limits
2
2
2
4
4
4
2
2
2
1
4
4
4
2
2
2
1
4
4
4
4
4
1
1
4
4
4
4
2
1
2
1
4
4
1
1
1
Drug Name
oxybutynin chloride er tb24 5mg
oxybutynin chloride syrp 5mg/5ml
oxybutynin chloride tabs 5mg
tolterodine tartrate er cp24 2mg
tolterodine tartrate er cp24 4mg
tolterodine tartrate tabs 1mg
tolterodine tartrate tabs 2mg
TOVIAZ TB24 4MG
TOVIAZ TB24 8MG
trospium chloride er cp24 60mg
trospium chloride tabs 20mg
VESICARE TABS 10MG
VESICARE TABS 5MG
GENITOURINARY AGENTS, MISCELLANEOUS
alfuzosin hcl er tb24 10mg
RAPAFLO CAPS 4MG
RAPAFLO CAPS 8MG
tamsulosin hcl caps 0.4mg
terazosin hcl caps 10mg
terazosin hcl caps 1mg
terazosin hcl caps 2mg
terazosin hcl caps 5mg
HEAVY METAL ANTAGONISTS
HEAVY METAL ANTAGONISTS
CHEMET CAPS 100MG
CUPRIMINE CAPS 250MG
deferoxamine mesylate inj 2gm
DEPEN TITRATABS TABS 250MG
EXJADE TBSO 125MG
EXJADE TBSO 250MG
EXJADE TBSO 500MG
FERRIPROX TABS 500MG
PENTETATE CALCIUM TRISODIUM SOLN 200MG/ML
PENTETATE ZINC TRISODIUM SOLN 200MG/ML
sodium thiosulfate inj 10%
sodium thiosulfate inj 25%
SYPRINE CAPS 250MG
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/MODIFYING
ANDROGENS
ANDROGEL PUMP GEL 1%
ANDROGEL PUMP GEL 1.62%
ANDROGEL GEL 20.25MG/1.25GM
ANDROGEL GEL 40.5MG/2.5GM
androxy tabs 10mg
danazol caps 100mg
danazol caps 200mg
78
Drug
Tier Requirements/Limits
1
1
1
2
2
2
2
3
3
2
2
3
3
1
4
4
1
1
1
1
1
4
3
1
3
5
5
5
4
4
4
1
1
3
3
3
3
3
2
2
2
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Drug Name
danazol caps 50mg
OXANDROLONE TABS 2.5MG
testosterone cypionate inj 100mg/ml
testosterone cypionate inj 200mg/ml
testosterone enanthate inj 200mg/ml
ESTROGENS AND ANTIESTROGENS
DEPO-ESTRADIOL INJ 5MG/ML
ESTRACE CREA 0.1MG/GM
estradiol valerate inj 10mg/ml
estradiol valerate inj 20mg/ml
estradiol valerate inj 40mg/ml
estradiol tabs 2mg
ESTRASORB EMUL 4.35MG/1.74GM
ESTRING RING 2MG
ESTROGEL GEL 0.06%
FEMRING RING 0.05MG/24HR
FEMRING RING 0.1MG/24HR
norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg
norethindrone acetate/ethinyl estradiol tabs 5mcg; 1mg
PREMARIN CREA 0.625MG/GM
PREMARIN INJ 25MG
raloxifene hydrochloride tabs 60mg
VAGIFEM TABS 10MCG
GLUCOCORTICOIDS/MINERALOCORTICOIDS
betamethasone sodium phosphate/betamethasone acetate inj
3mg/ml; 3mg/ml
cortisone acetate tabs 25mg
DEXAMETHASONE INTENSOL CONC 1MG/ML
dexamethasone sodium phosphate inj 100mg/10ml
dexamethasone sodium phosphate inj 120mg/30ml
dexamethasone elix 0.5mg/5ml
dexamethasone tabs 0.5mg
dexamethasone tabs 0.75mg
dexamethasone tabs 1.5mg
dexamethasone tabs 1mg
dexamethasone tabs 2mg
dexamethasone tabs 4mg
dexamethasone tabs 6mg
fludrocortisone acetate tabs 0.1mg
hydrocortisone tabs 10mg
hydrocortisone tabs 20mg
hydrocortisone tabs 5mg
methylprednisolone acetate inj 40mg/ml
methylprednisolone acetate inj 80mg/ml
methylprednisolone dose pack tabs 4mg
methylprednisolone sodiumsuccinate inj 1000mg
methylprednisolone sodiumsuccinate inj 125mg
79
Drug
Tier Requirements/Limits
2
PA
3
QL (240 EA per 30 days) PA
1
1
1
4
3
1
1
1
2
3
3
3
4
4
2
2
4
4
2
3
1
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
Drug Name
methylprednisolone sodiumsuccinate inj 40mg
methylprednisolone tabs 16mg
methylprednisolone tabs 32mg
methylprednisolone tabs 4mg
methylprednisolone tabs 8mg
prednisolone sodium phosphate odt tbdp 10mg
prednisolone sodium phosphate odt tbdp 15mg
prednisolone sodium phosphate odt tbdp 30mg
prednisolone sodium phosphate soln 15mg/5ml
prednisolone sodium phosphate soln 25mg/5ml
prednisolone sodium phosphate soln 5mg/5ml
PREDNISONE INTENSOL CONC 5MG/ML
prednisone soln 5mg/5ml
prednisone tabs 10mg
prednisone tabs 10mg
prednisone tabs 10mg
prednisone tabs 1mg
prednisone tabs 2.5mg
prednisone tabs 20mg
prednisone tabs 50mg
prednisone tabs 5mg
prednisone tabs 5mg
prednisone tabs 5mg
PITUITARY
CHORIONIC GONADOTROPIN INJ 10000UNIT
desmopressin acetate inj 4mcg/ml
desmopressin acetate soln 0.01%
desmopressin acetate soln 0.01%
desmopressin acetate tabs 0.1mg
desmopressin acetate tabs 0.2mg
INCRELEX INJ 40MG/4ML
NOVAREL INJ 10000UNIT
octreotide acetate inj 1000mcg/ml
OCTREOTIDE ACETATE INJ 100MCG/ML
OCTREOTIDE ACETATE INJ 200MCG/ML
octreotide acetate inj 500mcg/ml
OCTREOTIDE ACETATE INJ 50MCG/ML
OMNITROPE INJ 10MG/1.5ML
OMNITROPE INJ 5.8MG
OMNITROPE INJ 5MG/1.5ML
PREGNYL W/DILUENT BENZYL ALCOHOL/NACL INJ
10000UNIT
SANDOSTATIN LAR DEPOT INJ 10MG
SANDOSTATIN LAR DEPOT INJ 20MG
SANDOSTATIN LAR DEPOT INJ 30MG
SEROSTIM INJ 4MG
SEROSTIM INJ 5MG
80
Drug
Tier
2
2
2
2
2
2
2
2
2
2
2
3
1
1
1
1
1
1
1
1
1
1
1
Requirements/Limits
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
4
1
2
2
1
1
5
4
5
4
4
5
4
4
5
4
4
PA
5
5
5
5
5
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Drug Name
SEROSTIM INJ 6MG
SIGNIFOR LAR INJ 20MG
SIGNIFOR LAR INJ 40MG
SIGNIFOR LAR INJ 60MG
SIGNIFOR INJ 0.3MG/ML
SIGNIFOR INJ 0.6MG/ML
SIGNIFOR INJ 0.9MG/ML
SOMATULINE DEPOT INJ 120MG/0.5ML
SOMATULINE DEPOT INJ 60MG/0.2ML
SOMATULINE DEPOT INJ 90MG/0.3ML
SOMAVERT INJ 10MG
SOMAVERT INJ 15MG
SOMAVERT INJ 20MG
SOMAVERT INJ 25MG
SOMAVERT INJ 30MG
STIMATE SOLN 1.5MG/ML
VANTAS INJ 50MG
vasopressin inj 20unit/ml
vasostrict inj 20unit/ml
PROGESTINS
CRINONE GEL 4%
DEPO-PROVERA INJ 400MG/ML
DEPO-SUBQ PROVERA 104 INJ 104MG/0.65ML
ENDOMETRIN INST 100MG
medroxyprogesterone acetate inj 150mg/ml
medroxyprogesterone acetate tabs 10mg
medroxyprogesterone acetate tabs 2.5mg
medroxyprogesterone acetate tabs 5mg
norethindrone acetate tabs 5mg
progesterone caps 100mg
progesterone caps 200mg
progesterone inj 50mg/ml
THYROID AND ANTITHYROID AGENTS
levothyroxine sodium inj 100mcg
levothyroxine sodium tabs 100mcg
levothyroxine sodium tabs 112mcg
levothyroxine sodium tabs 125mcg
levothyroxine sodium tabs 137mcg
levothyroxine sodium tabs 150mcg
levothyroxine sodium tabs 175mcg
levothyroxine sodium tabs 200mcg
levothyroxine sodium tabs 25mcg
levothyroxine sodium tabs 300mcg
levothyroxine sodium tabs 50mcg
levothyroxine sodium tabs 75mcg
levothyroxine sodium tabs 88mcg
LEVOXYL TABS 100MCG
81
Drug
Tier
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
3
5
1
2
4
4
3
4
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
Requirements/Limits
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Drug
Tier Requirements/Limits
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
3
3
3
Drug Name
LEVOXYL TABS 112MCG
LEVOXYL TABS 125MCG
LEVOXYL TABS 137MCG
LEVOXYL TABS 150MCG
LEVOXYL TABS 175MCG
LEVOXYL TABS 200MCG
LEVOXYL TABS 25MCG
LEVOXYL TABS 50MCG
LEVOXYL TABS 75MCG
LEVOXYL TABS 88MCG
liothyronine sodium inj 10mcg/ml
liothyronine sodium tabs 25mcg
liothyronine sodium tabs 50mcg
liothyronine sodium tabs 5mcg
methimazole tabs 10mg
methimazole tabs 5mg
propylthiouracil tabs 50mg
SYNTHROID TABS 100MCG
SYNTHROID TABS 112MCG
SYNTHROID TABS 125MCG
SYNTHROID TABS 137MCG
SYNTHROID TABS 150MCG
SYNTHROID TABS 175MCG
SYNTHROID TABS 200MCG
SYNTHROID TABS 25MCG
SYNTHROID TABS 300MCG
SYNTHROID TABS 50MCG
SYNTHROID TABS 75MCG
SYNTHROID TABS 88MCG
THYROLAR-1/2 TABS 30MG
THYROLAR-1/4 TABS 15MG
THYROLAR-1 TABS 60MG
THYROLAR-2 TABS 120MG
THYROLAR-3 TABS 180MG
TIROSINT CAPS 100MCG
TIROSINT CAPS 112MCG
TIROSINT CAPS 125MCG
TIROSINT CAPS 137MCG
TIROSINT CAPS 13MCG
TIROSINT CAPS 150MCG
TIROSINT CAPS 25MCG
TIROSINT CAPS 50MCG
TIROSINT CAPS 75MCG
TIROSINT CAPS 88MCG
UNITHROID TABS 100MCG
UNITHROID TABS 112MCG
UNITHROID TABS 125MCG
82
Drug Name
UNITHROID TABS 137MCG
UNITHROID TABS 137MCG
UNITHROID TABS 150MCG
UNITHROID TABS 175MCG
UNITHROID TABS 200MCG
UNITHROID TABS 25MCG
UNITHROID TABS 300MCG
UNITHROID TABS 50MCG
UNITHROID TABS 75MCG
UNITHROID TABS 88MCG
IMMUNOLOGICAL AGENTS
IMMUNOLOGICAL AGENTS
ARCALYST INJ 220MG
ASTAGRAF XL CP24 0.5MG
ASTAGRAF XL CP24 1MG
ASTAGRAF XL CP24 5MG
ATGAM INJ 50MG/ML
AZASAN TABS 100MG
AZASAN TABS 75MG
azathioprine sodium inj 100mg
azathioprine tabs 50mg
BIVIGAM INJ 10GM/100ML
CARIMUNE NANOFILTERED INJ 3GM
CELLCEPT INTRAVENOUS INJ 500MG
cyclosporine modified caps 100mg
cyclosporine modified caps 25mg
cyclosporine modified caps 50mg
cyclosporine modified soln 100mg/ml
cyclosporine caps 100mg
cyclosporine caps 25mg
cyclosporine inj 50mg/ml
CYTOGAM INJ 50MG/ML
FLEBOGAMMA DIF INJ 0.5GM/10ML
FLEBOGAMMA DIF INJ 10%
FLEBOGAMMA DIF INJ 10%
GAMASTAN S/D INJ 0
GAMMAGARD LIQUID INJ 0
GAMMAKED INJ 1GM/10ML
GAMMAKED INJ 20GM/200ML
GAMMAPLEX INJ 10GM/200ML
GAMUNEX-C INJ 10GM/100ML
gengraf caps 100mg
gengraf caps 25mg
gengraf soln 100mg/ml
HEPAGAM B INJ 0
HIZENTRA INJ 4GM/20ML
HUMIRA PEN-CROHNS DISEASESTARTER INJ 40MG/0.8ML
83
Drug
Tier Requirements/Limits
3
3
3
3
3
3
3
3
3
3
5
4
4
4
3
3
3
1
1
5
5
4
2
2
2
2
2
2
2
5
5
5
5
4
5
5
5
5
4
2
2
2
4
5
5
PA
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
PA
PA
Drug Name
HUMIRA PEN INJ 40MG/0.8ML
HUMIRA INJ 10MG/0.2ML
HUMIRA INJ 20MG/0.4ML
HYPERHEP B S/D INJ 0
HYPERHEP B S/D INJ 0
HYPERHEP B S/D INJ 0
HYPERHEP B S/D INJ 0
HYPERRAB S/D INJ 150UNIT/ML
HYPERRAB S/D INJ 150UNIT/ML
HYPERRHO S/D INJ 1500UNIT
HYPERRHO S/D INJ 250UNIT
HYPERTET S/D INJ 250UNIT/ML
HYQVIA INJ 10GM/100ML; 800UNIT/5ML
HYQVIA INJ 2.5GM/25ML; 200UNT/1.25ML
HYQVIA INJ 20GM/200ML; 1600UNIT/10ML
HYQVIA INJ 30GM/300ML; 2400UNIT/15ML
HYQVIA INJ 5GM/50ML; 400UNIT/2.5ML
ILARIS INJ 180MG
IMOGAM RABIES-HT INJ 150UNIT/ML
KINERET INJ 100MG/0.67ML
leflunomide tabs 10mg
leflunomide tabs 20mg
MICRHOGAM ULTRA-FILTERED PLUS INJ 250UNIT
mycophenolate mofetil caps 250mg
mycophenolate mofetil susr 200mg/ml
mycophenolate mofetil tabs 500mg
mycophenolic acid dr tbec 180mg
mycophenolic acid dr tbec 360mg
NABI-HB INJ 0
NULOJIX INJ 250MG
OCTAGAM INJ 10GM/200ML
OCTAGAM INJ 20GM/200ML
OCTAGAM INJ 25GM/500ML
OCTAGAM INJ 2GM/20ML
ORENCIA INJ 250MG
PRIVIGEN INJ 5GM/50ML
RAPAMUNE SOLN 1MG/ML
RHOGAM ULTRA-FILTERED PLUS INJ 1500UNIT
RHOPHYLAC INJ 1500UNIT/2ML
RIDAURA CAPS 3MG
sirolimus tabs 0.5mg
sirolimus tabs 1mg
sirolimus tabs 2mg
tacrolimus caps 0.5mg
tacrolimus caps 1mg
tacrolimus caps 5mg
THYMOGLOBULIN INJ 25MG
84
Drug
Tier
5
5
5
4
4
4
4
3
3
4
4
3
5
5
5
5
5
5
3
4
2
2
4
2
2
2
2
2
4
5
5
5
5
5
5
5
3
4
4
3
2
2
2
2
2
2
3
Requirements/Limits
PA
PA
PA
B/D
B/D
B/D
B/D
B/D
PA
PA
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
PA
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
Drug Name
TYSABRI INJ 300MG/15ML
WINRHO SDF INJ 15000UNIT/13ML
WINRHO SDF INJ 5000UNIT/4.4ML
ZORTRESS TABS 0.25MG
ZORTRESS TABS 0.5MG
ZORTRESS TABS 0.75MG
VACCINES
ACTHIB INJ 0
ADACEL INJ 15.5MCG/0.5ML; 2LF/0.5ML; 5LF/0.5ML
BCG VACCINE INJ 0
BEXSERO INJ 0
BIOTHRAX INJ 0
BOOSTRIX INJ 18.5MCG/0.5ML; 2.5LF/0.5ML; 5LF/0.5ML
BOOSTRIX INJ 18.5MCG/0.5ML; 2.5LF/0.5ML; 5LF/0.5ML
CERVARIX INJ 0
COMVAX INJ 7.5MCG/0.5ML; 5MCG/0.5ML
DAPTACEL INJ 10MCG/0.5ML; 15LF/0.5ML; 5LF/0.5ML
DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC
INJ 25LFU/0.5ML; 5LFU/0.5ML
ENGERIX-B INJ 10MCG/0.5ML
ENGERIX-B INJ 10MCG/0.5ML
ENGERIX-B INJ 20MCG/ML
GARDASIL 9 INJ 0
GARDASIL 9 INJ 0
GARDASIL INJ 0
GARDASIL INJ 0
HAVRIX INJ 1440ELU/ML
HAVRIX INJ 720ELU/0.5ML
IMOVAX RABIES (H.D.C.V.) INJ 2.5UNIT/ML
INFANRIX INJ 58MCG/0.5ML; 25LFU/0.5ML; 10LFU/0.5ML
IPOL INACTIVATED IPV INJ 0
IPOL INACTIVATED IPV INJ 0
IXIARO INJ 0
M-M-R II INJ 0; 0; 0
MENACTRA INJ 0
MENHIBRIX INJ 2.5MCG; 5MCG; 5MCG
MENOMUNE-A/C/Y/W-135 INJ 0
MENVEO INJ 0
PEDVAX HIB INJ 7.5MCG/0.5ML
PENTACEL INJ 48MCG/0.5ML; 15LFU/0.5ML; 0; 0;
5LFU/0.5ML
PROQUAD INJ 0; 0; 0; 0
QUADRACEL INJ 48MCG/0.5ML; 15LFU/0.5ML; 0;
5LFU/0.5ML
RABAVERT INJ 0
RECOMBIVAX HB INJ 10MCG/ML
RECOMBIVAX HB INJ 10MCG/ML
85
Drug
Tier
5
4
4
4
5
5
Requirements/Limits
PA LA
B/D
B/D
B/D
4
3
4
4
5
3
3
4
4
3
4
4
4
4
4
4
4
4
4
4
4
3
4
4
4
4
4
3
4
4
4
4
B/D
B/D
B/D
4
4
4
4
4
B/D
B/D
Drug Name
RECOMBIVAX HB INJ 40MCG/ML
RECOMBIVAX HB INJ 5MCG/0.5ML
ROTARIX SUSR 0
ROTATEQ SOLN 0
TENIVAC INJ 2LFU; 5LFU
TETANUS TOXOID ADSORBED INJ 5LFU
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT INJ
2LF/0.5ML; 2LF/0.5ML
THERACYS INJ 81MG/VIAL
TRUMENBA INJ 0
TWINRIX INJ 720ELU/ML; 20MCG/ML
TYPHIM VI INJ 25MCG/0.5ML
TYPHIM VI INJ 25MCG/0.5ML
VAQTA INJ 25UNIT/0.5ML
VAQTA INJ 50UNIT/ML
VARIVAX INJ 1350PFU/0.5ML
VIVOTIF BERNA CPDR 0
YF-VAX INJ 0
ZOSTAVAX INJ 19400UNT/0.65ML
INFLAMMATORY BOWEL DISEASE AGENTS
INFLAMMATORY BOWEL DISEASE AGENTS
APRISO CP24 0.375GM
ASACOL HD TBEC 800MG
balsalazide disodium caps 750mg
budesonide cp24 3mg
DELZICOL CPDR 400MG
DIPENTUM CAPS 250MG
MESALAMINE KIT 4GM
UCERIS TB24 9MG
IRRIGATING SOLUTIONS
IRRIGATING SOLUTIONS
acetic acid 0.25% soln 0.25%
LACTATED RINGERS IRRIGATION SOLN 3MEQ/L;
109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L
RENACIDIN SOLN 6.602GM/100ML; 0.198GM/100ML;
3.177GM/100ML
ringers irrigation soln 4.5meq/l; 156meq/l; 4meq/l; 147meq/l
sodium chloride 0.9% soln 0.9%
sterile water irrigation soln 0
METABOLIC BONE DISEASE AGENTS
METABOLIC BONE DISEASE AGENTS
alendronate sodium soln 70mg/75ml
alendronate sodium tabs 10mg
alendronate sodium tabs 35mg
alendronate sodium tabs 40mg
alendronate sodium tabs 5mg
alendronate sodium tabs 70mg
86
Drug
Tier Requirements/Limits
4
B/D
4
B/D
4
4
3
3
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
2
4
4
4
5
2
3
4
1
2
1
1
1
1
1
1
1
Drug
Tier
2
1
1
1
1
2
2
2
2
1
1
5
4
4
2
4
5
5
5
5
1
1
1
3
3
3
4
4
4
2
2
5
4
4
4
4
4
5
Drug Name
calcitonin-salmon soln 200unit/act
calcitriol caps 0.25mcg
calcitriol caps 0.5mcg
calcitriol inj 1mcg/ml
calcitriol soln 1mcg/ml
doxercalciferol caps 0.5mcg
doxercalciferol caps 1mcg
doxercalciferol caps 2.5mcg
doxercalciferol inj 4mcg/2ml
etidronate disodium tabs 200mg
etidronate disodium tabs 400mg
FORTEO INJ 600MCG/2.4ML
FORTICAL SOLN 200UNIT/ACT
HECTOROL INJ 2MCG/ML
ibandronate sodium tabs 150mg
MIACALCIN INJ 200UNIT/ML
NATPARA INJ 100MCG
NATPARA INJ 25MCG
NATPARA INJ 50MCG
NATPARA INJ 75MCG
pamidronate disodium inj 30mg/10ml
pamidronate disodium inj 6mg/ml
pamidronate disodium inj 90mg/10ml
PARICALCITOL CAPS 1MCG
PARICALCITOL CAPS 2MCG
PARICALCITOL CAPS 4MCG
PARICALCITOL INJ 2MCG/ML
PARICALCITOL INJ 5MCG/ML
PROLIA INJ 60MG/ML
risedronate sodium dr tbec 35mg
risedronate sodium tabs 35mg
XGEVA INJ 120MG/1.7ML
ZEMPLAR INJ 2MCG/ML
ZEMPLAR INJ 5MCG/ML
ZOLEDRONIC ACID INJ 4MG/100ML
ZOLEDRONIC ACID INJ 4MG/5ML
ZOLEDRONIC ACID INJ 5MG/100ML
ZOMETA INJ 4MG/100ML
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
ACTIMMUNE INJ 2000000UNIT/0.5ML
allopurinol sodium inj 500mg
allopurinol tabs 100mg
allopurinol tabs 300mg
amifostine inj 500mg
ammonium chloride inj 5meq/ml
amytal sodium inj 500mg
5
1
1
1
1
2
2
87
Requirements/Limits
B/D
B/D
B/D
B/D
B/D
PA
QL (2 EA per 28 days) PA
QL (2 EA per 28 days) PA
QL (2 EA per 28 days) PA
QL (2 EA per 28 days) PA
B/D
B/D
PA
PA
B/D
B/D
Drug Name
BENLYSTA INJ 120MG
bethanechol chloride tabs 10mg
bethanechol chloride tabs 25mg
bethanechol chloride tabs 50mg
bethanechol chloride tabs 5mg
BLOXIVERZ INJ 10MG/10ML
BLOXIVERZ INJ 5MG/10ML
BOTOX INJ 100UNIT
BOTOX INJ 200UNIT
buspirone hcl tabs 10mg
buspirone hcl tabs 15mg
buspirone hcl tabs 30mg
buspirone hcl tabs 5mg
buspirone hcl tabs 7.5mg
CERDELGA CAPS 84MG
colchicine tabs 0.6mg
COLCRYS TABS 0.6MG
COPAXONE INJ 40MG/ML
CURITY ALL PURPOSE SPONGES 2"X2" PADS
CURITY GAUZE PADS 2"X2" PADS
CYSTADANE POWD 0
dexrazoxane inj 250mg
droperidol inj 2.5mg/ml
DUODOTE INJ 2.1MG/0.7ML; 600MG/2ML
DYSPORT INJ 500UNIT
ELMIRON CAPS 100MG
finasteride tabs 5mg
fomepizole inj 1gm/ml
FUSILEV INJ 50MG
GLATOPA INJ 20MG/ML
GLUCAGEN HYPOKIT INJ 1MG
GLUCAGON EMERGENCY KIT INJ 1MG
GRASTEK SUBL 2800BAU
guanidine hcl tabs 125mg
KALBITOR INJ 10MG/ML
KEPIVANCE INJ 6.25MG
leucovorin calcium inj 200mg
leucovorin calcium inj 200mg
leucovorin calcium inj 350mg
leucovorin calcium tabs 10mg
leucovorin calcium tabs 15mg
leucovorin calcium tabs 25mg
leucovorin calcium tabs 5mg
levocarnitine inj 200mg/ml
levocarnitine soln 1gm/10ml
levocarnitine tabs 330mg
LITHOSTAT TABS 250MG
88
Drug
Tier
5
1
1
1
1
4
4
4
4
1
1
1
1
1
5
2
3
5
3
3
4
1
1
4
4
4
1
1
3
5
3
3
4
1
5
5
1
1
1
1
1
1
1
1
1
1
4
Requirements/Limits
B/D
B/D
PA
PA
B/D
PA
PA
Drug Name
mesna inj 100mg/ml
MESNEX TABS 400MG
MESTINON TIMESPAN TBCR 180MG
MESTINON SYRP 60MG/5ML
methylergonovine maleate inj 0.2mg/ml
methylergonovine maleate tabs 0.2mg
MIFEPREX TABS 200MG
MYALEPT INJ 11.3MG
MYOBLOC INJ 2500UNIT/0.5ML
neostigmine methylsulfate inj 0.5mg/ml
NEOSTIGMINE METHYLSULFATE INJ 10MG/10ML
neostigmine methylsulfate inj 1mg/ml
NEOSTIGMINE METHYLSULFATE INJ 5MG/10ML
NITHIODOTE INJ 300MG/10ML; 12.5GM/50ML
NPLATE INJ 250MCG
ORALAIR SUBL 0; 0; 0; 0; 0
OTEZLA TABS 30MG
OTEZLA TBPK 0
OTEZLA TBPK 0
physostigmine salicylate inj 1mg/ml
PRALIDOXIME CHLORIDE INJ 600MG/2ML
probenecid/colchicine tabs 0.5mg; 500mg
probenecid tabs 500mg
PROCYSBI CPDR 25MG
PROCYSBI CPDR 75MG
PROSTIN E2 SUPP 20MG
PROTOPAM CHLORIDE INJ 1GM
pyridostigmine bromide tabs 60mg
RAGWITEK SUBL 12AMB A 1-U
REBIF REBIDOSE TITRATION PACK INJ 0
REBIF REBIDOSE INJ 22MCG/0.5ML
REBIF REBIDOSE INJ 44MCG/0.5ML
REBIF TITRATION PACK INJ 0
REBIF INJ 22MCG/0.5ML
REBIF INJ 44MCG/0.5ML
RECTIV OINT 0.4%
REGONOL INJ 10MG/2ML
REMICADE INJ 100MG
SENSIPAR TABS 30MG
SENSIPAR TABS 60MG
SENSIPAR TABS 90MG
SIMULECT INJ 20MG
SOLIRIS INJ 10MG/ML
SYNAREL SOLN 2MG/ML
TECFIDERA STARTER PACK MISC 0
TECFIDERA CPDR 120MG
TECFIDERA CPDR 240MG
89
Drug
Tier
1
3
3
3
1
1
4
5
5
1
4
1
4
4
5
4
5
5
5
1
4
1
1
4
4
4
4
1
4
5
5
5
5
5
5
4
3
5
3
5
5
4
5
3
5
5
5
Requirements/Limits
PA
B/D
PA
PA
PA
PA
PA
PA
PA
B/D
PA
QL (60 EA per 30 days)
Drug Name
THALOMID CAPS 100MG
THALOMID CAPS 150MG
THALOMID CAPS 200MG
THALOMID CAPS 50MG
THIOLA TABS 100MG
TYBOST TABS 150MG
ULESFIA LOTN 5%
ULORIC TABS 40MG
ULORIC TABS 80MG
VORAXAZE INJ 1000UNIT
XEOMIN INJ 100UNIT
OPHTHALMIC AGENTS
ANTIGLAUCOMA AGENTS
acetazolamide er cp12 500mg
acetazolamide sodium inj 500mg
acetazolamide tabs 125mg
acetazolamide tabs 250mg
betaxolol hcl soln 0.5%
brimonidine tartrate soln 0.15%
brimonidine tartrate soln 0.2%
dorzolamide hcl/timolol maleate soln 22.3mg/ml; 6.8mg/ml
dorzolamide hcl soln 2%
latanoprost soln 0.005%
levobunolol hcl soln 0.25%
levobunolol hcl soln 0.5%
methazolamide tabs 25mg
methazolamide tabs 50mg
metipranolol soln 0.3%
PHOSPHOLINE IODIDE SOLR 0.125%
pilocarpine hcl soln 1%
pilocarpine hcl soln 2%
pilocarpine hcl soln 4%
SIMBRINZA SUSP 0.2%; 1%
timolol maleate ophthalmic gel forming solg 0.25%
timolol maleate ophthalmic gel forming solg 0.5%
timolol maleate soln 0.25%
timolol maleate soln 0.5%
TRAVATAN Z SOLN 0.004%
travoprost soln 0.004%
REPLACEMENT PREPARATIONS
REPLACEMENT PREPARATIONS
AMMONUL INJ 10%; 10%
calcium gluconate inj 10%
citric acid/sodium citrate soln 334mg/5ml; 500mg/5ml
cytra-2 soln 334mg/5ml; 500mg/5ml
cytra-3 syrp 334mg/5ml; 550mg/5ml; 500mg/5ml
cytra-k soln 334mg/5ml; 1100mg/5ml
90
Drug
Tier
5
5
5
5
4
3
4
4
4
5
4
2
1
2
2
1
2
2
1
1
1
1
1
2
2
1
4
2
2
2
4
1
1
1
1
3
2
4
1
1
1
1
1
Requirements/Limits
PA
PA
PA
PA
ST
ST
PA
B/D
Drug Name
dextrose 5% /electrolyte #48 viaflex inj 24meq/l; 5%; 23meq/l;
3meq/l; 3meq/l; 20meq/l; 25meq/l
dextrose 5%/potassium chloride 0.15% inj 5%; 20meq/l
EFFER-K TBEF 0.84GM; 1GM
EFFER-K TBEF 1.68GM; 2GM
effer-k tbef 25meq
effervescent pot chloride tbef 0.55gm; 0.91gm; 0.5gm; 1.5gm
HYPERLYTE-CR INJ 30MEQ/L; 5MEQ/L; 30MEQ/L; 5MEQ/L;
20MEQ/L; 25MEQ/L
IONOSOL-B/DEXTROSE 5% INJ 49MEQ/L; 5%; 25MEQ/L;
5MEQ/L; 13MEQ/L; 25MEQ/L; 57MEQ/L
IONOSOL-MB/DEXTROSE 5% INJ 22MEQ/L; 5%; 23MEQ/L;
3MEQ/L; 3MEQ/L; 20MEQ/L; 25MEQ/L
ISOLYTE-H/DEXTROSE 5% INJ 17MEQ/L; 39MEQ/L; 5%;
3MEQ/L; 13MEQ/L; 42MEQ/L
ISOLYTE-M/DEXTROSE 5% INJ 20MEQ/L; 44MEQ/L; 5%;
15MEQ/L; 35MEQ/L; 38MEQ/L
ISOLYTE-P/DEXTROSE 5% INJ 23MEQ/L; 23MEQ/L; 5%;
3MEQ/L; 3MEQ/L; 20MEQ/L; 25MEQ/L
ISOLYTE-S/DEXTROSE 5% INJ 30MEQ/L; 98MEQ/L; 5%;
23MEQ/L; 3MEQ/L; 5MEQ/L; 142MEQ/L
ISOLYTE-S INJ 27MEQ/L; 98MEQ/L; 23MEQ/L; 3MEQ/L;
5MEQ/L; 140MEQ/L
k-effervescent tbef 25meq
K-LOR HOSPITAL PACK PACK 20MEQ
K-PHOS NO 2 TABS 305MG; 700MG
K-PHOS TABS 500MG
k-vescent tbef 25meq
kcl 0.075%/d5w/nacl 0.2% inj 5%; 10meq/l; 0.2%
kcl 0.075%/d5w/nacl 0.45% inj 5%; 10meq/l; 0.45%
kcl 0.15%/d5w/ nacl 0.3% inj 5%; 20meq/l; 0.33%
kcl 0.15%/d5w/nacl 0.2% inj 5%; 20meq/l; 0.2%
kcl 0.15%/d5w/nacl 0.45% inj 5%; 20meq/l; 0.45%
kcl 0.15%/d5w/nacl 0.9% inj 5%; 20meq/l; 0.9%
kcl 0.224%/d5w/nacl 0.2% inj 5%; 30meq/l; 0.2%
kcl 0.3%/d5w/nacl 0.2% inj 5%; 40meq/l; 0.2%
kcl 0.3%/d5w/nacl 0.45% inj 5%; 40meq/l; 0.45%
kcl 0.3%/d5w/nacl 0.9% inj 5%; 40meq/l; 0.9%
klor-con 10 tbcr 10meq
klor-con 8 tbcr 8meq
klor-con m15 tbcr 15meq
klor-con m20 tbcr 20meq
klor-con/ef tbef 25meq
klor-con pack 20meq
magnesium chloride inj 200mg/ml
magnesium sulfate in d5w inj 5%; 10mg/ml
magnesium sulfate inj 40mg/ml
91
Drug
Tier Requirements/Limits
1
1
4
4
1
1
3
3
3
3
3
3
3
3
1
4
3
3
1
1
1
1
1
2
1
1
1
1
1
2
2
2
2
2
2
1
1
1
Drug
Drug Name
Tier Requirements/Limits
magnesium sulfate inj 50%
1
magnesium sulfate inj 50%
1
magnesium sulfate inj 80mg/ml
1
NEUT INJ 4%
3
NORMOSOL-M IN D5W INJ 16MEQ/L; 40MEQ/L; 5%; 3MEQ/L; 3
13MEQ/L; 40MEQ/L
normosol-r in d5w inj 27meq/l; 98meq/l; 5%; 23meq/l; 3meq/l;
1
5meq/l; 140meq/l
NORMOSOL-R INJ 27MEQ/L; 98MEQ/L; 23MEQ/L; 3MEQ/L; 3
5MEQ/L; 140MEQ/L
NUTRILYTE II INJ 1.475MEQ/ML; 0.225MEQ/ML;
3
1.75MEQ/ML; 0.25MEQ/ML; 1MEQ/ML; 1.75MEQ/ML
NUTRILYTE INJ 2.03MEQ/ML; 0.25MEQ/ML; 1.68MEQ/ML; 3
0.25MEQ/ML; 0.4MEQ/ML; 2.03MEQ/ML; 1.25MEQ/ML
NUTRILYTE INJ 2.03MEQ/ML; 0.25MEQ/ML; 1.68MEQ/ML; 3
0.25MEQ/ML; 0.4MEQ/ML; 2.03MEQ/ML; 1.25MEQ
ORACIT SOLN 640MG/5ML; 490MG/5ML
4
ORACIT SOLN 640MG/5ML; 490MG/5ML
4
phospha 250 neutral tabs 155mg; 852mg; 130mg
1
PLASMA-LYTE A INJ 27MEQ/L; 98MEQ/L; 23MEQ/L;
3
3MEQ/L; 5MEQ/L; 140MEQ/L
PLASMA-LYTE-148 INJ 27MEQ/L; 98MEQ/L; 23MEQ/L;
3
3MEQ/L; 5MEQ/L; 140MEQ/L
PLASMA-LYTE-56/D5W INJ 16MEQ/L; 40MEQ/L; 5%;
3
3MEQ/L; 13MEQ/L; 40MEQ/L
PLASMA-LYTE-M/D5W INJ 12MEQ/L; 5MEQ/L; 40MEQ/L; 5%;3
12MEQ/L; 3MEQ/L; 16MEQ/L; 40MEQ/L
potassium acetate inj 2meq/ml
1
potassium acetate inj 4meq/ml
1
potassium chloride 0.075%/d5w/nacl 0.225% inj 5%; 10meq/l;
1
0.2%
potassium chloride 0.15% /nacl 0.45% viaflex inj 20meq/l; 0.45% 1
potassium chloride 0.15% d5w/nacl 0.33% inj 5%; 20meq/l; 0.33% 1
potassium chloride 0.15% d5w/nacl 0.45% viaflex inj 5%; 20meq/l; 2
0.45%
potassium chloride 0.15% d5w/nacl 0.45% inj 5%; 20meq/l; 0.45% 2
potassium chloride 0.15%/nacl 0.9% inj 20meq/l; 0.9%
1
potassium chloride 0.22% d5w/nacl 0.45% inj 5%; 30meq/l; 0.45% 1
potassium chloride 0.224%/d5w inj 5%; 30meq/l
1
potassium chloride 0.3%/ nacl 0.9% inj 40meq/l; 0.9%
1
potassium chloride 0.3%/d5w inj 5%; 40meq/l
1
potassium chloride er cpcr 10meq
1
potassium chloride er cpcr 8meq
1
potassium chloride er tbcr 10meq
1
potassium chloride er tbcr 20meq
1
potassium chloride sr tbcr 8meq
1
potassium chloride inj 10meq/100ml
1
92
Drug Name
potassium chloride inj 10meq/50ml
potassium chloride inj 20meq/50ml
potassium chloride inj 2meq/ml
potassium chloride inj 30meq/100ml
potassium chloride liqd 10%
potassium chloride liqd 20%
potassium chloride pack 20meq
potassium citrate er tbcr 1080mg
potassium citrate er tbcr 15meq
potassium citrate er tbcr 540mg
potassium citrate-citric acid crystals pack 1002mg; 3300mg
potassium phosphate inj 236mg/ml; 224mg/ml
ringers injection inj 4.5meq/l; 156meq/l; 4meq/l; 147meq/l
shohls solution modified soln 334mg/5ml; 500mg/5ml
sodium acetate inj 2meq/ml
sodium acetate inj 4meq/ml
sodium bicarbonate inj 4.2%
sodium bicarbonate inj 7.5%
sodium bicarbonate inj 8.4%
sodium chloride 0.45% viaflex inj 0.45%
sodium chloride inj 0.9%
sodium chloride inj 2.5meq/ml
sodium chloride inj 3%
sodium chloride inj 4meq/ml
sodium chloride inj 5%
sodium lactate inj 5meq/ml
sodium phosphate inj 3mmole/ml
TPN ELECTROLYTES II INJ 10.5MEQ/20ML; 4.5MEQ/20ML;
35MEQ/20ML; 5MEQ/20ML; 18MEQ/20ML; 18MEQ/20ML
TPN ELECTROLYTES INJ 29.5MEQ/20ML; 4.5MEQ/20ML;
35MEQ/20ML; 5MEQ/20ML; 20MEQ/20ML; 35MEQ/20ML
tricitrates soln 334mg/5ml; 550mg/5ml; 500mg/5ml
RESPIRATORY TRACT AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
AEROSPAN AERS 80MCG/ACT
ASMANEX HFA AERO 100MCG/ACT
ASMANEX HFA AERO 200MCG/ACT
ASMANEX TWISTHALER 120 METERED DOSES AEPB
220MCG/INH
ASMANEX TWISTHALER 14 METERED DOSES AEPB
220MCG/INH
ASMANEX TWISTHALER 30 METERED DOSES AEPB
110MCG/INH
ASMANEX TWISTHALER 30 METERED DOSES AEPB
220MCG/INH
ASMANEX TWISTHALER 60 METERED DOSES AEPB
220MCG/INH
93
Drug
Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
1
1
3
3
2
4
3
3
3
3
3
3
3
Drug Name
ASMANEX TWISTHALER 7 METERED DOSES AEPB
110MCG/INH
budesonide susp 0.25mg/2ml
budesonide susp 0.5mg/2ml
DULERA AERO 5MCG/ACT; 100MCG/ACT
DULERA AERO 5MCG/ACT; 200MCG/ACT
PULMICORT FLEXHALER AEPB 180MCG/ACT
PULMICORT FLEXHALER AEPB 90MCG/ACT
PULMICORT SUSP 1MG/2ML
QVAR AERS 40MCG/ACT
QVAR AERS 80MCG/ACT
SYMBICORT AERO 160MCG/ACT; 4.5MCG/ACT
SYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT
ANTILEUKOTRIENES
montelukast sodium chew 4mg
montelukast sodium chew 5mg
montelukast sodium pack 4mg
montelukast sodium tabs 10mg
zafirlukast tabs 10mg
zafirlukast tabs 20mg
ZYFLO CR TB12 600MG
ZYFLO TABS 600MG
BRONCHODILATORS
albuterol sulfate er tb12 4mg
albuterol sulfate er tb12 8mg
albuterol sulfate nebu 0.083%
albuterol sulfate nebu 0.5%
albuterol sulfate nebu 0.63mg/3ml
albuterol sulfate nebu 1.25mg/3ml
albuterol sulfate syrp 2mg/5ml
albuterol sulfate tabs 2mg
albuterol sulfate tabs 4mg
aminophylline inj 25mg/ml
ANORO ELLIPTA AEPB 62.5MCG/INH; 25MCG/INH
ARCAPTA NEOHALER CAPS 75MCG
ATROVENT HFA AERS 17MCG/ACT
BROVANA NEBU 15MCG/2ML
COMBIVENT RESPIMAT AERS 100MCG/ACT; 20MCG/ACT
elixophyllin elix 80mg/15ml
FORADIL AEROLIZER CAPS 12MCG
ipratropium bromide/albuterol sulfate soln 2.5mg/3ml; 0.5mg/3ml
ipratropium bromide soln 0.02%
ISUPREL INJ 0.2MG/ML
LEVALBUTEROL HCL NEBU 0.31MG/3ML
LEVALBUTEROL HCL NEBU 0.63MG/3ML
LEVALBUTEROL HCL NEBU 1.25MG/3ML
LUFYLLIN TABS 200MG
94
Drug
Tier Requirements/Limits
3
2
2
3
3
3
3
3
3
3
3
3
B/D
B/D
B/D
1
1
1
1
1
1
3
3
2
2
2
2
2
2
1
2
2
1
4
4
3
4
3
1
3
1
1
3
4
4
4
4
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
Drug
Tier Requirements/Limits
4
1
1
1
3
3
3
3
1
1
1
3
3
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
Drug Name
LUFYLLIN TABS 400MG
metaproterenol sulfate syrp 10mg/5ml
metaproterenol sulfate tabs 10mg
metaproterenol sulfate tabs 20mg
SEREVENT DISKUS AEPB 50MCG/DOSE
SPIRIVA HANDIHALER CAPS 18MCG
SPIRIVA RESPIMAT AERS 2.5MCG/ACT
STRIVERDI RESPIMAT AERS 2.5MCG/ACT
terbutaline sulfate inj 1mg/ml
terbutaline sulfate tabs 2.5mg
terbutaline sulfate tabs 5mg
THEO-24 CP24 0; 100MG
THEO-24 CP24 200MG
THEO-24 CP24 300MG
THEO-24 CP24 400MG
theochron tb12 100mg
theochron tb12 200mg
theochron tb12 300mg
theophylline cr tb12 100mg
theophylline cr tb12 200mg
theophylline er tb12 300mg
theophylline er tb12 450mg
theophylline er tb24 400mg
theophylline er tb24 600mg
theophylline/d5w inj 5%; 0.8mg/ml
theophylline/d5w inj 5%; 2mg/ml
theophylline/d5w inj 5%; 3.2mg/ml
theophylline/d5w inj 5%; 4mg/ml
theophylline soln 80mg/15ml
TUDORZA PRESSAIR AEPB 400MCG/ACT
TUDORZA PRESSAIR AEPB 400MCG/ACT
VENTOLIN HFA AERS 108MCG/ACT
RESPIRATORY TRACT AGENTS, OTHER
acetylcysteine inj 200mg/ml
acetylcysteine soln 10%
acetylcysteine soln 20%
ARALAST NP INJ 800MG
cromolyn sodium nebu 20mg/2ml
DALIRESP TABS 500MCG
ESBRIET CAPS 267MG
GLASSIA INJ 1000MG/50ML
KALYDECO PACK 50MG
KALYDECO PACK 75MG
KALYDECO TABS 150MG
NEBUSAL NEBU 6%
OFEV CAPS 100MG
OFEV CAPS 150MG
1
1
1
5
1
4
5
5
5
5
5
3
5
5
95
B/D
B/D
PA
B/D
ST
PA
PA
PA
PA
PA
QL (60 EA per 30 days) PA
QL (60 EA per 30 days) PA
Drug Name
PROLASTIN-C INJ 1000MG
sodium chloride nebu 0.9%
sodium chloride nebu 7%
XOLAIR INJ 150MG
ZEMAIRA INJ 1000MG
SKELETAL MUSCLE RELAXANTS
SKELETAL MUSCLE RELAXANTS
baclofen tabs 10mg
baclofen tabs 20mg
cyclobenzaprine hcl tabs 10mg
cyclobenzaprine hcl tabs 5mg
cyclobenzaprine hcl tabs 7.5mg
dantrolene sodium caps 100mg
dantrolene sodium caps 25mg
dantrolene sodium caps 50mg
GABLOFEN INJ 10000MCG/20ML
GABLOFEN INJ 20000MCG/20ML
GABLOFEN INJ 40000MCG/20ML
GABLOFEN INJ 50MCG/ML
LIORESAL INTRATHECAL INJ 0.05MG/ML
LIORESAL INTRATHECAL INJ 10MG/20ML
LIORESAL INTRATHECAL INJ 40MG/20ML
tizanidine hcl caps 2mg
tizanidine hcl caps 4mg
tizanidine hcl caps 6mg
tizanidine hcl tabs 2mg
tizanidine hcl tabs 4mg
SLEEP DISORDER AGENTS
SLEEP DISORDER AGENTS
HETLIOZ CAPS 20MG
NEMBUTAL INJ 50MG/ML
NUVIGIL TABS 150MG
NUVIGIL TABS 200MG
NUVIGIL TABS 250MG
NUVIGIL TABS 50MG
ROZEREM TABS 8MG
XYREM SOLN 500MG/ML
zolpidem tartrate tabs 10mg
zolpidem tartrate tabs 5mg
SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTS
ALPHA-ADRENERGIC BLOCKING AGENTS
phentolamine mesylate inj 5mg/ml
VASODILATING AGENTS
VASODILATING AGENTS
ADCIRCA TABS 20MG
ADEMPAS TABS 0.5MG
ADEMPAS TABS 1.5MG
96
Drug
Tier
5
2
2
5
5
1
1
2
2
2
1
1
1
4
4
5
4
3
3
3
2
2
2
1
1
5
4
3
3
3
3
4
5
2
2
Requirements/Limits
PA
PA
PA
PA
PA
PA
B/D
B/D
B/D
B/D
B/D
B/D
B/D
PA
PA
PA
PA
PA
QL (30 EA per 30 days)
PA LA
QL (90 EA per 180 days)
QL (90 EA per 180 days)
1
5
5
5
PA
PA
PA
Drug Name
ADEMPAS TABS 1MG
ADEMPAS TABS 2.5MG
ADEMPAS TABS 2MG
CIALIS TABS 2.5MG
CIALIS TABS 5MG
epoprostenol sodium inj 0.5mg
epoprostenol sodium inj 1.5mg
LETAIRIS TABS 10MG
LETAIRIS TABS 5MG
OPSUMIT TABS 10MG
ORENITRAM TBCR 0.125MG
ORENITRAM TBCR 0.25MG
ORENITRAM TBCR 1MG
ORENITRAM TBCR 2.5MG
REMODULIN INJ 10MG/ML
REMODULIN INJ 1MG/ML
REMODULIN INJ 2.5MG/ML
REMODULIN INJ 5MG/ML
REVATIO SUSR 10MG/ML
SILDENAFIL CITRATE TABS 20MG
sildenafil inj 10mg/12.5ml
TRACLEER TABS 125MG
TRACLEER TABS 62.5MG
TYVASO REFILL SOLN 0.6MG/ML
TYVASO STARTER SOLN 0.6MG/ML
TYVASO SOLN 0.6MG/ML
VELETRI INJ 0.5MG
VELETRI INJ 1.5MG
VENTAVIS SOLN 10MCG/ML
VENTAVIS SOLN 20MCG/ML
VITAMINS AND MINERALS
VITAMINS AND MINERALS
prenatal 19 tabs 100mg; 200mg; 400unit; 12mcg; 25mg; 29mg;
1mg; 15mg; 7mg; 20mg; 3mg; 3mg; 1000unit; 30unit; 20mg
prenatal plus tabs 120mg; 0; 200mg; 400unit; 2mg; 12mcg; 27mg;
1mg; 20mg; 10mg; 3mg; 1.84mg; 22mg; 4000unit; 25mg
prenatal vitamins plus tabs 120mg; 0; 0; 200mg; 400unit; 2mg;
12mcg; 27mg; 1mg; 20mg; 10mg; 3mg; 1.84mg; 22mg; 4000unit;
25mg
tri-vit/fluoride soln 35mg/ml; 400unit/ml; 0.25mg/ml; 1500unit/ml
97
Drug
Tier
5
5
5
4
4
5
5
5
5
5
3
5
5
5
5
5
5
5
5
3
5
5
5
5
5
5
5
5
5
5
1
1
1
1
Requirements/Limits
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA LA
PA LA
PA
PA
PA
PA
PA
PA
PA
Index
Drug Name Page #
8-MOP
68
39
abacavir
ABACAVIR
39
SULFATE/LAMIVUDINE/ZIDOVUDINE
ABELCET
30
ABILIFY
36
ABILIFY DISCMELT
36
ABILIFY MAINTENA
36
ABRAXANE
15
acamprosate calcium dr
6
acarbose
28
55
acebutolol hcl
acetaminophen/codeine
1
acetaminophen/codeine #3
1
acetaminophen/codeine #4
1
acetasol hc
73
acetazolamide
90
acetazolamide er
90
90
acetazolamide sodium
acetic acid
73
86
acetic acid 0.25%
acetylcysteine
95
ACITRETIN
68
ACTHIB
85
ACTIMMUNE
87
acyclovir
41
ACYCLOVIR
68
acyclovir sodium
41
ADACEL
85
ADAGEN
72
adapalene
71
ADCETRIS
15
ADCIRCA
96
adefovir dipivoxil
41
ADEMPAS
96
adriamycin
15
adrucil
15
AEROSPAN
93
afeditab cr
59
AFINITOR
15
AFINITOR DISPERZ
15
AGGRENOX
45
ALBENZA
34
albuterol sulfate
94
albuterol sulfate er
94
98
Drug Name Page #
69
alclometasone dipropionate
ALCOHOL PREP PADS
68
ALCOH-WIPE 12" X 12"
68
ALDURAZYME
72
alendronate sodium
86
ALFERON N
41
78
alfuzosin hcl er
ALIMTA
15
ALINIA
34
allopurinol
87
allopurinol sodium
87
ALOCRIL
74
alosetron hydrochloride
72
alprazolam
7
alprazolam odt
7
alprazolam xr
7
altacaine
73
altavera
65
alyacen 1/35
65
alyacen 7/7/7
65
amantadine hcl
34
AMBISOME
30
amcinonide
69
65
amethia
amethia lo
65
amifostine
87
amikacin sulfate
8
59
amiloride hcl
amiloride/hydrochlorothiazide
59
aminocaproic acid
44
aminophylline
94
AMINOSYN
47
AMINOSYN 7%/ELECTROLYTES
45
AMINOSYN 8.5%/ELECTROLYTES
45
AMINOSYN II
45
AMINOSYN II 8.5%/ELECTROLYTES
45
AMINOSYN M
46
AMINOSYN-HBC
46
AMINOSYN-HF
46
AMINOSYN-PF
46
AMINOSYN-PF 7%
46
AMINOSYN-RF
46
54
amiodarone hcl
AMITIZA
76
AMITRIPTYLINE HCL
25
amlodipine besylate
59
amlodipine besylate/atorvastatin calcium
60
amlodipine besylate/benazepril hcl
59
Drug Name Page #
Drug Name Page #
amlodipine besylate/benazepril
59 ASMANEX TWISTHALER 60 METERED
93
hydrochloride
DOSES
amlodipine besylate/valsartan
59
ASMANEX TWISTHALER 7 METERED
94
ammonium chloride
87
DOSES
ammonium lactate
68
aspirin-caffeine-dihydrocodeine
1
AMMONUL
90
ASTAGRAF XL
83
amoxapine
25
atenolol
55
amoxicillin
13
atenolol/chlorthalidone
55
amoxicillin er
12
ATGAM
83
amoxicillin/clavulanate potassium
12
atorvastatin calcium
61
amoxicillin/clavulanate potassium er
12
atovaquone
34
amphetamine/dextroamphetamine
63
atovaquone/proguanil hcl
34
amphotericin b
30
ATRIPLA
39
ampicillin
13
atropine sulfate
21
ampicillin sodium
13
atropine sulfate
73
ampicillin-sulbactam
13
ATROVENT HFA
94
AMPYRA
63
aubra
65
amytal sodium
87
augmented betamethasone dipropionate
69
anagrelide hydrochloride
45
AUGMENTIN
13
anastrozole
15
AUVI-Q
58
ANDROGEL
78
AVANDIA
28
ANDROGEL PUMP
78
AVASTIN
16
androxy
78
AVC
7
ANORO ELLIPTA
94
AVELOX
14
APLENZIN
25
aviane
65
APOKYN
34
avita
71
apraclonidine
73
AVYCAZ
9
apri
65
AZACITIDINE
16
APRISO
86
AZACTAM IN ISO-OSMOTIC
12
APTIOM
21
DEXTROSE
APTIVUS
39
AZASAN
83
ARALAST NP
95
azathioprine
83
aranelle
65
azathioprine sodium
83
ARANESP ALBUMIN FREE
43
azelastine hcl
73
ARCALYST
83
AZELEX
68
ARCAPTA NEOHALER
94
AZILECT
34
aripiprazole
36
azithromycin
11
ARRANON
16
aztreonam
12
ARZERRA
16
azurette
65
ASACOL HD
86
baciim
9
ashlyna
65
bacitracin
9
ASMANEX HFA
93
bacitracin
73
ASMANEX TWISTHALER 120
93
bacitracin/polymyxin b
73
METERED DOSES
baclofen
96
ASMANEX TWISTHALER 14 METERED
93
bactocill in dextrose
13
DOSES
BACTROBAN NASAL
70
ASMANEX TWISTHALER 30 METERED
93
balsalazide disodium
86
DOSES
balziva
65
99
Drug Name Page #
BANZEL
21
BARACLUDE
41
BCG VACCINE
85
BD INSULIN SYRINGE
72
SAFETYGLIDE/1ML/29G X 1/2"
BD INSULIN SYRINGE
72
ULTRAFINE/0.3ML/31G X 5/16"
BD INSULIN SYRINGE
72
ULTRAFINE/0.5ML/30G X 1/2"
BD INSULIN SYRINGE
72
ULTRAFINE/1ML/31G X 5/16"
BD PEN NEEDLE/ULTRAFINE/29G X
72
12.7MM
BELEODAQ
16
benazepril hcl
53
benazepril hcl/hydrochlorothiazide
53
BENICAR
52
BENICAR HCT
52
BENLYSTA
88
benztropine mesylate
34
BERINERT
44
betamethasone dipropionate
69
betamethasone sodium
79
phosphate/betamethasone acetate
betamethasone valerate
69
betaxolol hcl
55
betaxolol hcl
90
bethanechol chloride
88
BEXSERO
85
bicalutamide
16
BICILLIN C-R
13
BICILLIN L-A
13
BICNU
16
BIDIL
62
BILTRICIDE
34
BIOTHRAX
85
bisoprolol fumarate
55
bisoprolol fumarate/hydrochlorothiazide
55
BIVIGAM
83
bleomycin sulfate
16
BLINCYTO
16
BLOXIVERZ
88
BOOSTRIX
85
BOSULIF
16
BOTOX
88
briellyn
65
BRILINTA
45
brimonidine tartrate
90
100
Drug Name Page #
BRINTELLIX
25
BRISDELLE
25
bromfenac
74
bromocriptine mesylate
34
BROVANA
94
budesonide
86
budesonide
94
bumetanide
59
BUPHENYL
76
buprenorphine hcl
1
buprenorphine hcl
6
BUPRENORPHINE HCL/NALOXONE
6
HCL
buproban
6
bupropion hcl
25
bupropion hcl sr
6
bupropion hcl sr
25
bupropion hcl xl
25
buspirone hcl
88
BUSULFEX
16
butalbital/acetaminophen/caffeine
1
butalbital/acetaminophen/caffeine/codeine
1
butalbital/apap/caffeine
1
butalbital/aspirin/caffeine
1
butalbital/aspirin/caffeine/codeine
1
butorphanol tartrate
1
BUTRANS
1
BYDUREON
28
BYETTA
28
BYSTOLIC
55
cabergoline
35
CAFERGOT
32
caffeine citrate
63
caffeine/sodium benzoate
63
CALCIPOTRIENE
68
calcitonin-salmon
87
calcitriol
68
calcitriol
87
calcium acetate
77
calcium gluconate
90
camila
65
camrese
65
camrese lo
65
CANCIDAS
30
candesartan cilexetil
52
candesartan cilexetil/hydrochlorothiazide
52
CANTIL
76
CAPASTAT SULFATE
32
Drug Name Page #
CAPRELSA
16
captopril
53
captopril/hydrochlorothiazide
53
CARBAGLU
76
carbamazepine
21
carbamazepine er
21
carbidopa
35
carbidopa/levodopa
35
carbidopa/levodopa er
35
carbidopa/levodopa odt
35
CARBIDOPA/LEVODOPA/ENTACAPON
35
E
carboplatin
16
CARDENE IV
59
CARDENE SR
59
CARIMUNE NANOFILTERED
83
carteolol hcl
73
cartia xt
57
carvedilol
55
CAYSTON
12
caziant
65
CEDAX
10
cefaclor
10
cefaclor er
10
cefadroxil
10
cefazolin sodium
10
cefazolin sodium/dextrose
10
cefdinir
10
cefditoren pivoxil
10
CEFEPIME
10
cefixime
10
cefotaxime sodium
10
cefotetan
10
cefotetan/dextrose
10
cefoxitin sodium
10
cefpodoxime proxetil
10
cefprozil
11
ceftazidime
11
CEFTAZIDIME/DEXTROSE
11
ceftibuten
11
CEFTIN
11
CEFTRIAXONE IN ISO-OSMOTIC
11
DEXTROSE
CEFTRIAXONE SODIUM
11
cefuroxime axetil
11
cefuroxime sodium
11
cefuroxime/dextrose
11
celecoxib
4
101
Drug Name Page #
CELLCEPT INTRAVENOUS
83
CELONTIN
21
cephalexin
11
CERDELGA
88
CEREBYX
21
CEREZYME
72
CERVARIX
85
CESAMET
33
cetirizine hcl
32
cevimeline hcl
68
CHANTIX
6
CHANTIX CONTINUING MONTH PAK
6
CHANTIX STARTING MONTH PAK
6
CHEMET
78
CHENODAL
72
chloramphenicol sodium succinate
9
chlordiazepoxide hcl
7
CHLORDIAZEPOXIDE/AMITRIPTYLIN
25
E
chlorhexidine gluconate
68
chloroquine phosphate
34
chlorothiazide
59
chlorothiazide sodium
59
chlorpromazine hcl
36
chlorthalidone
60
CHOLBAM
76
cholestyramine
61
choline magnesium trisalicylate
4
CHORIONIC GONADOTROPIN
80
CIALIS
97
ciclopirox
30
ciclopirox nail lacquer
30
ciclopirox olamine
30
ciclopirox treatment
30
cidofovir
42
cilostazol
45
cimetidine
75
cimetidine hcl
75
cimetidine hcl/nacl
75
CIMZIA
72
CINRYZE
44
ciprofloxacin
14
ciprofloxacin
74
ciprofloxacin er
14
ciprofloxacin hcl
14
ciprofloxacin hcl
74
ciprofloxacin i.v.-in d5w
14
cisplatin
16
Drug Name Page #
citalopram hydrobromide
25
citric acid/sodium citrate
90
cladribine
16
clarithromycin
12
clarithromycin er
12
CLEOCIN
7
CLEVIPREX
59
clindamax
70
clindamycin hcl
9
clindamycin palmitate hcl
9
clindamycin phosphate
7
clindamycin phosphate
70
clindamycin phosphate add-vantage
9
clindamycin phosphate in d5w
9
CLINIMIX 2.75%/DEXTROSE 5%
47
CLINIMIX 4.25%/DEXTROSE 10%
47
CLINIMIX 4.25%/DEXTROSE 20%
47
CLINIMIX 4.25%/DEXTROSE 25%
47
CLINIMIX 4.25%/DEXTROSE 5%
48
CLINIMIX 5%/DEXTROSE 15%
48
CLINIMIX 5%/DEXTROSE 20%
48
CLINIMIX 5%/DEXTROSE 25%
48
CLINIMIX E 2.75%/DEXTROSE 10%
48
CLINIMIX E 2.75%/DEXTROSE 5%
48
CLINIMIX E 4.25%/DEXTROSE 10%
48
CLINIMIX E 4.25%/DEXTROSE 25%
48
CLINIMIX E 4.25%/DEXTROSE 5%
49
CLINIMIX E 5%/DEXTROSE 15%
49
CLINIMIX E 5%/DEXTROSE 20%
49
CLINIMIX E 5%/DEXTROSE 25%
49
CLINISOL SF 15%
49
clobetasol propionate
69
CLOLAR
16
CLOMIPRAMINE HCL
25
clonazepam
7
clonazepam odt
7
clonidine hcl
52
clonidine hcl er
63
clopidogrel
45
clorazepate dipotassium
7
clorpres
52
clotrimazole
30
clotrimazole/betamethasone dipropionate
30
clozapine
36
clozapine odt
36
COARTEM
34
codeine sulfate
1
colchicine
88
102
Drug Name Page #
COLCRYS
88
colestipol hcl for oral suspension
61
colistimethate sodium
9
COMBIVENT RESPIMAT
94
COMETRIQ
16
COMPLERA
39
compro
33
COMVAX
85
constulose
76
COPAXONE
88
CORDRAN
69
CORDRAN TAPE
69
CORLANOR
59
cormax scalp application
69
cortalo
69
cortisone acetate
79
COUMADIN
42
CREON
72
CRESEMBA
31
CRESTOR
61
CRINONE
81
CRIXIVAN
39
cromolyn sodium
73
cromolyn sodium
76
cromolyn sodium
95
cryselle-28
65
CUBICIN
9
CUPRIMINE
78
CURITY ALL PURPOSE SPONGES
88
2"X2"
CURITY GAUZE PADS 2"X2"
88
CUVPOSA
76
cyclafem 1/35
65
cyclafem 7/7/7
65
cyclobenzaprine hcl
96
cyclopentolate hcl
73
CYCLOPHOSPHAMIDE
16
cycloserine
32
CYCLOSET
28
cyclosporine
83
cyclosporine modified
83
cyproheptadine hcl
32
CYRAMZA
16
CYSTADANE
88
CYSTAGON
72
cysteine hcl
49
cytarabine
16
cytarabine aqueous
16
Drug Name Page #
CYTOGAM
83
cytra-2
90
cytra-3
90
cytra-k
90
dacarbazine
16
16
dactinomycin
DALIRESP
95
DALVANCE
9
danazol
78
dantrolene sodium
96
dapsone
32
DAPTACEL
85
DARAPRIM
34
dasetta 1/35
65
dasetta 7/7/7
65
daunorubicin hcl
16
DAUNOXOME
16
daysee
65
DAYTRANA
63
deblitane
65
decitabine
16
deferoxamine mesylate
78
delyla
65
DELZICOL
86
14
demeclocycline hcl
DEMSER
58
DENAVIR
68
denta 5000 plus
68
dentagel
68
depade
6
DEPEN TITRATABS
78
DEPOCYT
16
DEPO-ESTRADIOL
79
DEPO-PROVERA
81
DEPO-SUBQ PROVERA 104
81
desipramine hcl
25
desmopressin acetate
80
desogestrel/ethinyl estradiol
65
69
desonide
desoximetasone
69
DESVENLAFAXINE ER
26
dexamethasone
79
DEXAMETHASONE INTENSOL
79
dexamethasone sodium phosphate
74
dexamethasone sodium phosphate
79
dexmethylphenidate hcl
63
dexmethylphenidate hcl er
63
dexrazoxane
88
103
Drug Name Page #
DEXTROAMPHETAMINE SULFATE
64
dextroamphetamine sulfate er
63
dextrose 10%/nacl 0.45%
49
dextrose 2.5%
49
dextrose 5% /electrolyte #48 viaflex
91
49
dextrose 10% flex container
dextrose 10%/nacl 0.2%
49
dextrose 10%/nacl 0.225%
49
dextrose 10%/sodium chloride 0.9%
49
dextrose 2.5%/nacl 0.45%
49
dextrose 2.5%/sodium chloride 0.45%
49
dextrose 20%
49
dextrose 25%
49
dextrose 40%
49
dextrose 5%
50
dextrose 5%/lactated ringers
49
dextrose 5%/nacl 0.225%
49
dextrose 5%/nacl 0.3%
49
dextrose 5%/nacl 0.33%
50
dextrose 5%/nacl 0.45%
50
dextrose 5%/nacl 0.9%
50
dextrose 5%/potassium chloride 0.15%
91
dextrose 5%/ringers
50
50
dextrose 5%/sodium chloride 0.2%
dextrose 5%/sodium chloride 0.45%
50
dextrose 5%/sodium chloride 0.9%
50
dextrose 50%
50
7
diazepam
diazepam intensol
7
DIBENZYLINE
52
diclofenac potassium
4
diclofenac sodium
5
diclofenac sodium
74
4
diclofenac sodium dr
diclofenac sodium er
5
diclofenac sodium/misoprostol
5
dicloxacillin sodium
13
dicyclomine hcl
76
39
didanosine
DIFICID
12
diflunisal
5
digitek
58
digox
58
DIGOXIN
58
dihydroergotamine mesylate
32
DILANTIN
21
DILANTIN INFATABS
21
DILANTIN-125
21
Drug Name Page #
diltiazem cd
57
diltiazem hcl
57
diltiazem hcl cd
57
diltiazem hcl er
57
dilt-xr
57
dimenhydrinate
33
DIPENTUM
86
diphenatol
76
diphenhydramine hcl
32
diphenoxylate/atropine
76
DIPHTHERIA/TETANUS TOXOIDS
85
ADSORBED PEDIATRIC
disulfiram
6
DIURIL
60
divalproex sodium
21
divalproex sodium dr
21
divalproex sodium er
21
dobutamine hcl
58
dobutamine hcl/d5w
58
DOCEFREZ
16
docetaxel
16
donepezil hcl
24
dopamine hcl
58
dopamine/d5w
58
DORIBAX
12
dorzolamide hcl
90
dorzolamide hcl/timolol maleate
90
doxazosin mesylate
52
DOXEPIN HCL
26
doxercalciferol
87
doxorubicin hcl
16
doxorubicin hcl liposome
16
doxy 100
14
doxycycline
15
doxycycline hyclate
15
doxycycline hyclate dr
15
doxycycline monohydrate
15
DRITHO-CREME HP
68
DRONABINOL
33
droperidol
88
drospirenone/ethinyl estradiol
65
DROXIA
16
DULERA
94
duloxetine hcl
26
DUODOTE
88
DUREZOL
74
DYRENIUM
60
DYSPORT
88
104
Drug Name Page #
e.e.s. 400
12
E.E.S. GRANULES
12
e.s.p.
12
econazole nitrate
31
EDECRIN
60
EDURANT
39
EFFER-K
91
effervescent pot chloride
91
ELAPRASE
72
ELELYSO
72
ELIDEL
69
ELIGARD
17
elinest
65
eliphos
77
ELIQUIS
42
ELITEK
72
elixophyllin
94
ELLA
65
ELMIRON
88
ELOXATIN
17
ELSPAR
17
EMCYT
17
EMEND
33
emoquette
65
EMSAM
26
EMTRIVA
39
ENABLEX
77
enalapril maleate
53
enalapril maleate/hydrochlorothiazide
53
enalaprilat
53
endocet
1
endodan
1
ENDOMETRIN
81
ENGERIX-B
85
enoxaparin sodium
42
enpresse-28
65
enskyce
65
entacapone
35
entecavir
42
enulose
76
epinastine hcl
73
epinephrine
58
epinephrine hcl
58
EPIPEN 2-PAK
58
EPIPEN-JR 2-PAK
58
epirubicin hcl
17
epitol
21
EPIVIR HBV
39
Drug Name Page #
eplerenone
62
EPOGEN
44
epoprostenol sodium
97
eprosartan mesylate
52
EPZICOM
39
EQL INSULIN SYRINGE/0.3ML/31G X
72
5/16"
EQUETRO
21
ERAXIS
31
ERBITUX
17
ERGOMAR
32
ERIVEDGE
17
errin
65
ERWINAZE
17
ery-tab
12
ERYTHROCIN LACTOBIONATE
12
erythrocin stearate
12
erythromycin
12
erythromycin
71
erythromycin
74
erythromycin base
12
erythromycin ethylsuccinate
12
ESBRIET
95
escitalopram oxalate
26
esmolol hcl
56
esomeprazole magnesium
75
esomeprazole sodium
75
estarylla
65
estazolam
8
ESTRACE
79
estradiol
79
estradiol valerate
79
ESTRASORB
79
ESTRING
79
ESTROGEL
79
ethambutol hcl
32
ethosuximide
21
etidronate disodium
87
etodolac
5
etodolac er
5
ETOPOPHOS
17
etoposide
17
EURAX
71
EVOTAZ
39
exemestane
17
EXJADE
78
FABRAZYME
72
FACTIVE
14
105
Drug Name Page #
falmina
65
famciclovir
42
famotidine
75
famotidine premixed
75
FANAPT
36
FANAPT TITRATION PACK
36
FARESTON
17
FARYDAK
17
FASLODEX
17
felbamate
21
FEMRING
79
fenofibrate
61
fenofibrate micronized
61
fenofibric acid
61
fenofibric acid dr
61
fenoprofen calcium
5
fentanyl
1
fentanyl citrate oral transmucosal
1
FERRIPROX
78
FETZIMA
26
FETZIMA TITRATION PACK
26
FINACEA
68
FINACEA PLUS
68
finasteride
88
FIRAZYR
58
FIRMAGON
17
flavoxate hcl
77
FLEBOGAMMA DIF
83
flecainide acetate
54
floxuridine
17
fluconazole
31
fluconazole in dextrose
31
fluconazole in nacl
31
flucytosine
31
fludarabine phosphate
17
fludrocortisone acetate
79
flunisolide
74
fluocinolone acetonide
69
fluocinolone acetonide
74
fluocinolone acetonide body
69
fluocinonide
70
fluoridex daily defense
68
fluoridex daily defense enhanced whitening
68
fluorometholone
75
fluorouracil
17
fluorouracil
68
fluoxetine dr
26
fluoxetine hcl
26
Drug Name Page #
fluphenazine decanoate
36
fluphenazine hcl
36
flurazepam hcl
8
flurbiprofen
5
flurbiprofen sodium
75
flutamide
17
fluticasone propionate
70
fluticasone propionate
75
fluvoxamine maleate
26
FLUVOXAMINE MALEATE ER
26
FOLOTYN
17
fomepizole
88
fondaparinux sodium
42
FORADIL AEROLIZER
94
FORFIVO XL
26
FORTEO
87
FORTICAL
87
FOSCARNET SODIUM
41
fosinopril sodium
53
fosinopril sodium/hydrochlorothiazide
53
fosphenytoin sodium
21
FOSRENOL
77
FRAGMIN
43
FREAMINE HBC 6.9%
50
FREAMINE III
50
furosemide
60
FUSILEV
88
FUZEON
39
FYCOMPA
21
gabapentin
22
GABITRIL
22
GABLOFEN
96
galantamine hydrobromide
24
GAMASTAN S/D
83
GAMMAGARD LIQUID
83
GAMMAKED
83
GAMMAPLEX
83
GAMUNEX-C
83
ganciclovir
42
GARDASIL
85
GARDASIL 9
85
gatifloxacin
74
GATTEX
72
gavilyte-c
77
gavilyte-g
77
gavilyte-n/flavor pack
77
GAZYVA
17
gemcitabine
17
106
Drug Name Page #
61
gemfibrozil
generlac
76
gengraf
83
gentak
74
gentamicin sulfate
8
gentamicin sulfate
71
gentamicin sulfate
74
gentamicin sulfate pediatric
8
gentamicin sulfate/0.9% sodium chloride
8
GEODON
37
gianvi
65
gildagia
65
gildess 1.5/30
65
gildess 1/20
65
gildess 24 fe
65
gildess fe 1.5/30
66
gildess fe 1/20
66
GILOTRIF
17
GLASSIA
95
GLATOPA
88
GLEEVEC
17
glimepiride
30
glipizide
30
glipizide er
30
glipizide/metformin hcl
28
GLOBAL ALCOHOL PREP EASE PADS
68
GLUCAGEN HYPOKIT
88
GLUCAGON EMERGENCY KIT
88
glycopyrrolate
76
glydo
6
GLYSET
29
GOLYTELY
77
GRALISE
22
GRALISE STARTER
22
granisetron hcl
33
granisol
33
granix
44
GRASTEK
88
griseofulvin microsize
31
griseofulvin ultramicrosize
31
guanidine hcl
88
HALAVEN
17
halobetasol propionate
70
haloperidol
37
haloperidol decanoate
37
haloperidol lactate
37
HARVONI
41
HAVRIX
85
Drug Name Page #
heather
66
HECTOROL
87
HEMANGEOL
56
HEPAGAM B
83
heparin sodium
43
heparin sodium dcu
43
heparin sodium/d5w
43
heparin sodium/nacl 0.45%
43
heparin sodium/nacl 0.9%
43
HEPATAMINE
50
HEPATASOL
50
HERCEPTIN
17
HETLIOZ
96
HEXALEN
17
HIZENTRA
83
homatropaire
73
homatropine hbr
73
HORIZANT
22
HUMALOG
30
HUMALOG KWIKPEN
29
HUMALOG MIX 50/50
30
HUMALOG MIX 50/50 KWIKPEN
30
HUMALOG MIX 75/25
30
HUMALOG MIX 75/25 KWIKPEN
30
HUMIRA
84
HUMIRA PEN
84
HUMIRA PEN-CROHNS
83
DISEASESTARTER
HUMULIN 70/30
30
HUMULIN 70/30 KWIKPEN
30
HUMULIN N
30
HUMULIN N KWIKPEN
30
HUMULIN R
30
HUMULIN R U-500 (CONCENTRATED)
30
hydralazine hcl
58
hydrochlorothiazide
60
hydrocodone bitartrate/acetaminophen
2
hydrocodone/acetaminophen
2
hydrocodone/ibuprofen
2
hydrocortisone
70
hydrocortisone
79
hydrocortisone acetate/aloe
70
hydrocortisone butyrate
70
hydrocortisone valerate
70
hydrocortisone/acetic acid
74
hydromorphone hcl
2
hydroxychloroquine sulfate
34
hydroxyurea
17
107
Drug Name Page #
68
hypercare
HYPERHEP B S/D
84
HYPERLYTE-CR
91
HYPERRAB S/D
84
HYPERRHO S/D
84
HYPERTET S/D
84
HYQVIA
84
ibandronate sodium
87
IBRANCE
17
ibuprofen
5
ICLUSIG
17
idarubicin hcl
17
ifosfamide
17
ifosfamide/mesna
17
ILARIS
84
ILEVRO
75
IMBRUVICA
17
imipenem/cilastatin
12
IMIPRAMINE HCL
26
IMIPRAMINE PAMOATE
26
imiquimod
68
IMOGAM RABIES-HT
84
IMOVAX RABIES (H.D.C.V.)
85
INCRELEX
80
indapamide
60
INFANRIX
85
INFERGEN
41
INLYTA
18
INTELENCE
39
INTRALIPID
50
INTRON A
41
INTRON A W/DILUENT
41
INTRON-A
41
introvale
66
INVANZ
12
INVEGA
37
INVEGA SUSTENNA
37
INVIRASE
39
INVOKANA
29
IONOSOL-B/DEXTROSE 5%
91
IONOSOL-MB/DEXTROSE 5%
91
IPOL INACTIVATED IPV
85
ipratropium bromide
73
ipratropium bromide
94
ipratropium bromide/albuterol sulfate
94
irbesartan
52
irbesartan/hydrochlorothiazide
52
IRENKA
27
Drug Name Page #
irinotecan
18
ISENTRESS
39
isoditrate er
62
ISOLYTE-H/DEXTROSE 5%
91
ISOLYTE-M/DEXTROSE 5%
91
ISOLYTE-P/DEXTROSE 5%
91
ISOLYTE-S
91
ISOLYTE-S/DEXTROSE 5%
91
isoniazid
32
ISORDIL TITRADOSE
62
isosorbide dinitrate
62
isosorbide mononitrate
62
isosorbide mononitrate er
62
isotonic gentamicin
8
isradipine
59
ISTODAX
18
ISUPREL
94
itraconazole
31
ivermectin
34
IXEMPRA KIT
18
IXIARO
85
JAKAFI
18
jantoven
43
jencycla
66
JENTADUETO
29
JEVTANA
18
jolessa
66
jolivette
66
junel 1.5/30
66
junel 1/20
66
junel fe 1.5/30
66
junel fe 1/20
66
junel fe 24
66
JUXTAPID
61
KADCYLA
18
KALBITOR
88
KALETRA
39
KALYDECO
95
kariva
66
KAZANO
29
kcl 0.075%/d5w/nacl 0.2%
91
kcl 0.075%/d5w/nacl 0.45%
91
kcl 0.15%/d5w/ nacl 0.3%
91
kcl 0.15%/d5w/lr
50
kcl 0.15%/d5w/nacl 0.2%
91
kcl 0.15%/d5w/nacl 0.45%
91
kcl 0.15%/d5w/nacl 0.9%
91
kcl 0.224%/d5w/nacl 0.2%
91
108
Drug Name Page #
91
kcl 0.3%/d5w/nacl 0.2%
kcl 0.3%/d5w/nacl 0.45%
91
kcl 0.3%/d5w/nacl 0.9%
91
k-effervescent
91
kelnor 1/35
66
KEPIVANCE
88
KETEK
12
ketoconazole
31
ketoprofen
5
ketoprofen er
5
ketorolac tromethamine
5
ketorolac tromethamine
75
KEYTRUDA
18
KINERET
84
kionex
77
K-LOR HOSPITAL PACK
91
klor-con
91
klor-con 10
91
klor-con 8
91
klor-con m15
91
klor-con m20
91
klor-con/ef
91
KORLYM
29
K-PHOS
91
K-PHOS NO 2
91
KRISTALOSE
76
KRYSTEXXA
72
kurvelo
66
KUVAN
72
k-vescent
91
KYNAMRO
61
KYPROLIS
18
labetalol hcl
56
LACTATED RINGERS IRRIGATION
86
lactulose
76
LAMICTAL
22
lamivudine
39
lamivudine/zidovudine
39
lamotrigine
22
lamotrigine er
22
LANOXIN
58
LANOXIN PEDIATRIC
58
lansoprazole
75
LANTUS
30
LANTUS SOLOSTAR
30
larin 1.5/30
66
larin 1/20
66
larin fe 1.5/30
66
Drug Name Page #
larin fe 1/20
66
latanoprost
90
LATUDA
37
LAZANDA
2
l-cysteine hcl
50
leena
66
leflunomide
84
LENVIMA 10MG DAILY DOSE
18
LENVIMA 14MG DAILY DOSE
18
LENVIMA 20MG DAILY DOSE
18
LENVIMA 24MG DAILY DOSE
18
lessina
66
LETAIRIS
97
letrozole
18
leucovorin calcium
88
LEUKERAN
18
LEUKINE
44
leuprolide acetate
18
LEVALBUTEROL HCL
94
LEVEMIR
30
LEVEMIR FLEXTOUCH
30
levetiracetam
22
levetiracetam er
22
levobunolol hcl
90
levocarnitine
88
levofloxacin
14
levofloxacin
74
levofloxacin in d5w
14
levonest
66
levonorgestrel
66
levonorgestrel and ethinyl estradiol
66
levonorgestrel/ethinyl estradiol
66
levora 0.15/30-28
66
levorphanol tartrate
2
levothyroxine sodium
81
LEVOXYL
81
LEXIVA
39
lidocaine
6
lidocaine hcl
6
lidocaine hcl
55
LIDOCAINE HCL IN D5W
54
lidocaine hcl jelly
6
lidocaine hcl/dextrose
54
lidocaine viscous
6
lidocaine/prilocaine
6
LINCOCIN
9
lindane
71
linezolid
9
109
Drug Name Page #
LINZESS
72
LIORESAL INTRATHECAL
96
liothyronine sodium
82
lipodox
18
LIPOSYN II
50
LIPOSYN III
50
lisinopril
54
lisinopril/hydrochlorothiazide
54
lithium
64
lithium carbonate
64
lithium carbonate er
64
LITHOSTAT
88
lokara
70
lomedia 24 fe
66
LOMUSTINE
18
loperamide hcl
76
lorazepam
8
lorcet
2
lorcet hd
2
lorcet plus
2
loryna
66
losartan potassium
53
losartan potassium/hydrochlorothiazide
52
lovastatin
61
low-ogestrel
66
loxapine
37
loxapine succinate
37
LUFYLLIN
94
LUMIZYME
72
LUPRON DEPOT
18
LUPRON DEPOT-PED
18
lutera
66
LYNPARZA
18
LYRICA
22
LYSODREN
18
lyza
66
MAFENIDE ACETATE
68
magnebind 400
77
magnesium chloride
91
magnesium sulfate
91
magnesium sulfate in d5w
91
malathion
71
maprotiline hcl
27
marlissa
66
MARPLAN
27
MARQIBO
18
MATULANE
18
matzim la
57
Drug Name Page #
Drug Name Page #
meclizine hcl
33
90
metipranolol
meclofenamate sodium
metoclopramide hcl
5
76
medroxyprogesterone acetate
81
metoclopramide odt
76
mefenamic acid
metolazone
5
60
mefloquine hcl
34
metoprolol succinate er
56
56
MEGACE ES
18
metoprolol tartrate
metoprolol/hydrochlorothiazide
18
56
megestrol acetate
MEKINIST
18
metronidazole
34
meloxicam
5
metronidazole
71
melphalan hydrochloride
metronidazole in nacl 0.79%
18
34
MENACTRA
85
metronidazole vaginal
7
mexiletine hcl
MENHIBRIX
85
55
MENOMUNE-A/C/Y/W-135
85
MIACALCIN
87
MENTAX
31
miconazole 3
31
MENVEO
85 MICRHOGAM ULTRA-FILTERED PLUS
84
mercaptopurine
18
66
microgestin 1.5/30
meropenem
12
microgestin 1/20
66
MESALAMINE
86
microgestin fe
66
mesna
89
microgestin fe 1.5/30
66
MESNEX
89
micronized colestipol hcl
61
MESTINON
89
midazolam hcl
8
MESTINON TIMESPAN
89
midodrine hcl
52
metaproterenol sulfate
95
MIFEPREX
89
29
32
metformin hcl
migergot
metformin hcl er
29
milrinone in dextrose
58
methadone hcl
2
minitran
62
methadone hcl intensol
2
MINOCIN
15
2
15
methadose
minocycline hcl
methamphetamine hcl
64
minocycline hcl er
15
methazolamide
90
minoxidil
62
methenamine hippurate
9
MIRCERA
44
methenamine mandelate
9
mirtazapine
27
methimazole
82
mirtazapine odt
27
19
75
methotrexate
misoprostol
methotrexate sodium
18
mitomycin
19
methoxsalen
69
mitoxantrone hcl
19
methscopolamine bromide
76
M-M-R II
85
methyclothiazide
60
moexipril hcl
54
89
54
methylergonovine maleate
moexipril/hydrochlorothiazide
methylphenidate hcl
64
mometasone furoate
70
64
66
methylphenidate hcl cd
mono-linyah
methylphenidate hcl er
mononessa
64
66
methylphenidate hcl sr
64
montelukast sodium
94
methylphenidate hydrochloride
64
MONUROL
9
methylprednisolone
80
MORPHINE SULFATE
3
methylprednisolone acetate
79
morphine sulfate er
2
methylprednisolone dose pack
79
MOVIPREP
77
methylprednisolone sodiumsuccinate
79
MOXEZA
74
110
Drug Name Page #
MOZOBIL
44
MULTAQ
55
mupirocin
71
MUSTARGEN
19
my way
66
MYALEPT
89
MYCAMINE
31
mycophenolate mofetil
84
mycophenolic acid dr
84
MYOBLOC
89
MYOZYME
72
myzilra
66
NABI-HB
84
nabumetone
5
nadolol
56
nadolol/bendroflumethiazide
56
nafcillin sodium
13
naftifine hcl
31
NAFTIN
31
NAGLAZYME
72
nalbuphine hcl
3
NALLPEN ISO-OSMOTIC IN
13
DEXTROSE
6
naloxone hcl
naltrexone hcl
6
NAMENDA
25
NAMENDA TITRATION PAK
24
NAMENDA XR
24
NAMENDA XR TITRATION PACK
24
naphazoline hcl
73
naproxen
5
naproxen dr
5
naproxen ec
5
5
naproxen sodium
naratriptan hcl
32
nateglinide
29
NATPARA
87
NEBUPENT
34
NEBUSAL
95
necon 0.5/35-28
66
66
necon 1/35
necon 1/50-28
66
necon 10/11-28
66
necon 7/7/7
67
nefazodone hcl
27
NEMBUTAL
96
neomycin sulfate
8
neomycin/bacitracin/polymyxin
74
111
Drug Name Page #
71
neomycin/polymyxin b sulfates
neomycin/polymyxin/bacitracin/hydrocortis
74
one
neomycin/polymyxin/dexamethasone
74
neomycin/polymyxin/gramicidin
74
74
neomycin/polymyxin/hydrocortisone
neo-polycin hc
74
neostigmine methylsulfate
89
NEPHRAMINE
50
NESINA
29
NEULASTA
44
NEUMEGA
44
NEUPOGEN
44
NEUPRO
35
NEUT
92
neutral sodium fluoride
68
nevirapine
39
nevirapine er
39
NEXAVAR
19
next choice one dose
67
NEXTERONE
55
niacin er
61
niacor
61
59
nicardipine hcl
NICOTROL INHALER
6
NICOTROL NS
7
nifedical xl
59
59
nifedipine er
nikki
67
NILANDRON
19
nimodipine
59
NITHIODOTE
89
NITRO-BID
62
NITRO-DUR
62
nitrofurantoin macrocrystals
9
nitroglycerin
62
nitroglycerin in dextrose 5%
62
nitroglycerin lingual
62
62
nitroglycerin transdermal
NITROSTAT
63
nizatidine
75
nora-be
67
norepinephrine bitartrate
58
norethindrone
67
norethindrone acetate
81
norethindrone acetate/ethinyl estradiol
67
norethindrone acetate/ethinyl estradiol
79
Drug Name Page #
norethindrone acetate/ethinyl
67
estradiol/ferrous fumarate
norgestimate/ethinyl estradiol
67
norlyroc
67
NORMOSOL-M IN D5W
92
NORMOSOL-R
92
92
normosol-r in d5w
NOROXIN
14
NORTHERA
52
nortrel 0.5/35 (28)
67
nortrel 1/35
67
nortrel 7/7/7
67
nortriptyline hcl
27
NORVIR
40
NOVAREL
80
NOXAFIL
31
NPLATE
89
NUCYNTA ER
3
NUEDEXTA
64
NULOJIX
84
NUTRESTORE
76
NUTRILIPID
50
NUTRILYTE
92
NUTRILYTE II
92
NUVESSA
7
NUVIGIL
96
NYMALIZE
59
nystatin
31
nystatin/triamcinolone
31
nystop
31
ocella
67
OCTAGAM
84
octreotide acetate
80
OFEV
95
14
ofloxacin
ofloxacin
74
ogestrel
67
olanzapine
37
37
olanzapine odt
olanzapine/fluoxetine
27
61
omega-3-acid ethyl esters
omeprazole
75
omeprazole/sodium bicarbonate
75
OMNITROPE
80
ONCASPAR
19
ondansetron hcl
33
ondansetron odt
33
ONFI
8
112
Drug Name Page #
ONTAK
19
OPDIVO
19
opium tincture (paregoric)
76
OPSUMIT
97
ORACIT
92
ORALAIR
89
68
oralone
ORAP
37
ORBACTIV
9
ORENCIA
84
ORENITRAM
97
ORFADIN
73
orsythia
67
OSENI
29
OSMOPREP
77
OTEZLA
89
13
oxacillin sodium
oxaliplatin
19
OXANDROLONE
79
oxaprozin
5
oxazepam
8
oxcarbazepine
23
OXSORALEN
69
OXTELLAR XR
23
oxybutynin chloride
78
oxybutynin chloride er
77
oxycodone hcl
3
3
oxycodone hcl er
oxycodone/acetaminophen
4
oxycodone/aspirin
4
oxycodone/ibuprofen
4
oxymorphone hydrochloride
4
oxymorphone hydrochloride er
4
55
pacerone
paclitaxel
19
pamidronate disodium
87
pancrelipase
73
PANRETIN
69
pantoprazole sodium
75
parcaine
73
PARICALCITOL
87
paromomycin sulfate
34
paroxetine hcl
27
paroxetine hcl er
27
PASER
32
PATADAY
73
PATANOL
73
PAXIL
27
Drug Name Page #
PAZEO
73
pedi-dri
31
PEDVAX HIB
85
peg 3350/electrolytes
77
peg-3350/electrolytes
77
77
peg-3350/nacl/na bicarbonate/kcl
PEGANONE
23
PEGASYS
41
PEGASYS PROCLICK
41
PEGINTRON
41
PEG-INTRON
41
PEG-INTRON REDIPEN
41
PEG-INTRON REDIPEN PAK 4
41
penicillin g potassium
13
penicillin g potassium in iso-osmotic
13
dextrose
14
penicillin g procaine
penicillin v potassium
14
PENTACEL
85
pentam 300
34
PENTETATE CALCIUM TRISODIUM
78
PENTETATE ZINC TRISODIUM
78
pentostatin
19
45
pentoxifylline er
perindopril erbumine
54
periogard
68
PERJETA
19
72
permethrin
perphenazine
37
PERPHENAZINE/AMITRIPTYLINE
27
PEXEVA
27
pfizerpen-g
14
phenadoz
33
27
phenelzine sulfate
phenergan
33
phenobarbital
23
phenobarbital sodium
23
phentolamine mesylate
96
73
phenylephrine hcl
PHENYTEK
23
phenytoin
23
phenytoin infatabs
23
phenytoin sodium
23
phenytoin sodium extended
23
philith
67
PHOSLYRA
77
phospha 250 neutral
92
PHOSPHOLINE IODIDE
90
113
Drug Name Page #
PHOTOFRIN
19
physostigmine salicylate
89
pilocarpine hcl
68
pilocarpine hcl
90
pilocarpine hydrochloride
68
67
pimtrea
pindolol
56
pioglitazone hcl
29
pioglitazone hcl/metformin hcl
29
pioglitazone hcl-glimepiride
29
piperacillin sodium/ tazobactam sodium
14
piperacillin sodium/tazobactam sodium
14
pirmella 1/35
67
pirmella 7/7/7
67
piroxicam
5
PLASMA-LYTE A
92
PLASMA-LYTE-148
92
PLASMA-LYTE-56/D5W
92
PLASMA-LYTE-M/D5W
92
PLENAMINE
51
podocon 25 in benzoin tincture
69
podofilox
69
polyethylene glycol 3350
77
9
polymyxin b sulfate
polymyxin b sulfate/trimethoprim sulfate
74
POMALYST
19
portia-28
67
92
potassium acetate
potassium chloride
92
potassium chloride 0.075%/d5w/nacl
92
0.225%
potassium chloride 0.15% /nacl 0.45%
92
viaflex
92
potassium chloride 0.15% d5w/nacl 0.33%
potassium chloride 0.15% d5w/nacl 0.45%
92
potassium chloride 0.15% d5w/nacl 0.45%
92
viaflex
potassium chloride 0.15%/nacl 0.9%
92
92
potassium chloride 0.22% d5w/nacl 0.45%
potassium chloride 0.224%/d5w
92
92
potassium chloride 0.3%/ nacl 0.9%
potassium chloride 0.3%/d5w
92
potassium chloride er
92
potassium chloride sr
92
potassium citrate er
93
potassium citrate-citric acid crystals
93
potassium phosphate
93
POTIGA
23
Drug Name Page #
PRADAXA
43
PRALIDOXIME CHLORIDE
89
pramipexole dihydrochloride
35
pramipexole dihydrochloride er
35
pravastatin sodium
61
prazosin hcl
52
prednicarbate
70
prednisolone acetate
75
prednisolone sodium phosphate
75
prednisolone sodium phosphate
80
prednisolone sodium phosphate odt
80
prednisone
80
PREDNISONE INTENSOL
80
PREGNYL W/DILUENT BENZYL
80
ALCOHOL/NACL
PREMARIN
79
PREMASOL
51
prenatal 19
97
prenatal plus
97
prenatal vitamins plus
97
PREPOPIK
77
prevalite
61
previfem
67
PREZCOBIX
40
PREZISTA
40
PRIFTIN
32
PRIMAQUINE PHOSPHATE
34
primidone
23
PRIMSOL
9
PRISTIQ
28
PRIVIGEN
84
probenecid
89
probenecid/colchicine
89
procainamide hcl
55
PROCALAMINE
51
PROCENTRA
64
prochlorperazine
33
prochlorperazine edisylate
33
prochlorperazine maleate
33
PROCRIT
44
procto-pak
70
proctosol hc
70
proctozone-hc
70
PROCYSBI
89
progesterone
81
PROGLYCEM
63
PROLASTIN-C
96
PROLEUKIN
19
114
Drug Name Page #
PROLIA
87
PROMACTA
44
promethazine hcl
33
promethegan
33
propafenone hcl
55
propafenone hcl er
55
propantheline bromide
21
proparacaine hcl
73
propranolol hcl
56
propranolol hcl er
56
propranolol/hydrochlorothiazide
56
propylthiouracil
82
PROQUAD
85
PROSOL
51
PROSTIN E2
89
PROTOPAM CHLORIDE
89
protriptyline hcl
28
PRUDOXIN
69
PULMICORT
94
PULMICORT FLEXHALER
94
PULMOZYME
73
PURIXAN
19
PYLERA
76
pyrazinamide
33
pyridostigmine bromide
89
PYROGALLIC ACID
69
QUADRACEL
85
quartette
67
quasense
67
QUAZEPAM
8
quetiapine fumarate
38
quinapril hcl
54
quinapril/hydrochlorothiazide
54
quinidine gluconate
55
quinidine gluconate cr
55
quinidine sulfate
55
quinine sulfate
34
QVAR
94
RABAVERT
85
rabeprazole sodium
75
RAGWITEK
89
raloxifene hydrochloride
79
ramipril
54
RANEXA
58
ranitidine hcl
75
RAPAFLO
78
RAPAMUNE
84
RAPIVAB
41
Drug Name Page #
RAVICTI
76
REBETOL
42
REBIF
89
REBIF REBIDOSE
89
REBIF REBIDOSE TITRATION PACK
89
REBIF TITRATION PACK
89
reclipsen
67
RECOMBIVAX HB
85
RECTIV
89
REGONOL
89
REGRANEX
69
RELENZA DISKHALER
41
RELISTOR
76
REMICADE
89
REMODULIN
97
RENACIDIN
86
RENAGEL
77
RENVELA
77
repaglinide
29
reprexain
4
RESCRIPTOR
40
RESTASIS
75
RETROVIR IV INFUSION
40
REVATIO
97
REVLIMID
19
REYATAZ
40
RHOGAM ULTRA-FILTERED PLUS
84
RHOPHYLAC
84
ribasphere
42
ribasphere ribapak
42
ribavirin
42
RIDAURA
84
rifabutin
33
rifampin
33
RIFATER
33
RILUZOLE
64
rimantadine hcl
41
RIMSO-50
69
ringers injection
93
ringers irrigation
86
RIOMET
29
risedronate sodium
87
risedronate sodium dr
87
RISPERDAL CONSTA
38
risperidone
38
risperidone m-tab
38
risperidone odt
38
RITUXAN
19
115
Drug Name Page #
rivastigmine tartrate
25
rizatriptan benzoate
32
rizatriptan benzoate odt
32
ropinirole er
35
ropinirole hcl
35
rosadan
71
ROTARIX
86
ROTATEQ
86
roxicet
4
ROZEREM
96
RUCONEST
44
SABRIL
23
salsalate
5
SAMSCA
60
SANCUSO
34
SANDOSTATIN LAR DEPOT
80
SANTYL
69
SAPHRIS
38
SAVELLA
64
SAVELLA TITRATION PACK
64
scopolamine hydrobromide
34
selegiline hcl
36
selenium sulfide
71
SELZENTRY
40
SENSIPAR
89
SEREVENT DISKUS
95
SEROQUEL XR
38
SEROSTIM
80
sertraline hcl
28
sevelamer carbonate
77
sf 5000 plus
68
sharobel
67
shohls solution modified
93
SIGNIFOR
81
SIGNIFOR LAR
81
sildenafil
97
SILDENAFIL CITRATE
97
SILENOR
28
silver nitrate
71
silver sulfadiazine
71
SIMBRINZA
90
SIMULECT
89
simvastatin
62
sirolimus
84
SIRTURO
33
SIVEXTRO
9
SKLICE
72
smz-tmp ds
14
Drug Name Page #
Drug Name Page #
sodium acetate
93
74
sulfacetamide sodium/prednisolone sodium
sodium bicarbonate
93
phosphate
sulfadiazine
sodium chloride
93
14
sodium chloride
sulfamethoxazole/trimethoprim
96
14
sodium chloride 0.9%
86
SULFAMYLON
69
93
14
sodium chloride 0.45% viaflex
sulfasalazine
sodium lactate
sulfatrim pediatric
93
14
sodium phosphate
sulfazine
93
14
sodium polystyrene sulfonate
77
sulindac
5
sodium sulfacetamide
sumatriptan
74
32
sodium thiosulfate
78
sumatriptan succinate
32
SOLIRIS
89
SUPRAX
11
SOLTAMOX
19
SUPREP BOWEL PREP
77
SOMATULINE DEPOT
81 SURE COMFORT INSULIN SYRINGE/U72
SOMAVERT
81
100/0.5ML/29G X 1/2"
SOOLANTRA
72
SURMONTIL
28
56
sorine
SUSTIVA
40
sotalol hcl
57
SUTENT
19
syeda
sotalol hcl (af)
56
67
SOTALOL HYDROCHLORIDE
57
SYLATRON
41
SOTYLIZE
57
SYLVANT
19
SOVALDI
41
SYMBICORT
94
spinosad
SYMLINPEN 120
29
72
SYMLINPEN 60
29
SPIRIVA HANDIHALER
95
SYNAGIS
41
SPIRIVA RESPIMAT
95
62
SYNAREL
89
spironolactone
spironolactone/hydrochlorothiazide
62
SYNERA
6
SYNERCID
9
SPORANOX
31
67
sprintec 28
SYNRIBO
19
SPRYCEL
19
SYNTHROID
82
sps
77
SYPRINE
78
sronyx
67
TABLOID
19
tacrolimus
ssd
71
70
68
84
stannous fluoride oral rinse
tacrolimus
stavudine
40
TAFINLAR
19
STAVZOR
23
TAMIFLU
41
sterile water irrigation
86
tamoxifen citrate
20
STIMATE
81
tamsulosin hcl
78
STIVARGA
19
TANZEUM
29
STRATTERA
64
TARCEVA
20
8
streptomycin sulfate
TARGRETIN
20
STRIBILD
40
tarina fe 1/20
67
STRIVERDI RESPIMAT
95
TASIGNA
20
SUCLEAR
77
tazicef
11
SUCRAID
73
TAZORAC
71
sucralfate
76
taztia xt
57
sulfacetamide sodium
71
TECFIDERA
89
sulfacetamide sodium
74
TECFIDERA STARTER PACK
89
116
Drug Name Page #
TEFLARO
11
telmisartan
53
telmisartan/hydrochloroth
53
telmisartan/hydrochlorothiazide
53
temazepam
8
TEMODAR
20
TENIPOSIDE
20
TENIVAC
86
terazosin hcl
78
terbinafine hcl
31
terbutaline sulfate
95
terconazole
7
testosterone cypionate
79
testosterone enanthate
79
TETANUS TOXOID ADSORBED
86
TETANUS/DIPHTHERIA TOXOIDS86
ADSORBED ADULT
tetracaine hcl
73
tetracycline hcl
15
THALOMID
90
THEO-24
95
theochron
95
theophylline
95
theophylline cr
95
theophylline er
95
theophylline/d5w
95
THERACYS
86
THIOLA
90
thioridazine hcl
38
thiothixene
38
THYMOGLOBULIN
84
THYROLAR-1
82
THYROLAR-1/2
82
THYROLAR-1/4
82
THYROLAR-2
82
THYROLAR-3
82
tiagabine hydrochloride
23
TIKOSYN
55
tilia fe
67
TIMENTIN
14
timolol maleate
57
timolol maleate
90
timolol maleate ophthalmic gel forming
90
tinidazole
34
TIROSINT
82
TIVICAY
40
tizanidine hcl
96
TOBI PODHALER
8
117
Drug Name Page #
tobramycin
9
tobramycin sulfate
9
tobramycin sulfate
74
tobramycin sulfate/sodium chloride
8
tobramycin/dexamethasone
74
TODAYS HEALTH ORIGINAL PEN
72
NEEDLES 29G X 1/2"
tolazamide
30
tolbutamide
30
tolcapone
36
tolmetin sodium
5
tolterodine tartrate
78
tolterodine tartrate er
78
topiragen
23
topiramate
24
topiramate er
24
toposar
20
topotecan hcl
20
TORISEL
20
torsemide
60
TOUJEO SOLOSTAR
30
TOVIAZ
78
TPN ELECTROLYTES
93
TPN ELECTROLYTES II
93
TRACLEER
97
TRADJENTA
29
tramadol hcl
4
tramadol hcl er
4
tramadol hydrochloride/acetaminophen
4
trandolapril
54
trandolapril/verapamil hcl
54
tranexamic acid
45
TRANSDERM-SCOP
34
tranylcypromine sulfate
28
TRAVASOL
51
TRAVATAN Z
90
travoprost
90
trazodone hcl
28
TREANDA
20
TRECATOR
33
TRELSTAR MIXJECT
20
tretinoin
20
tretinoin
71
TRETINOIN MICROSPHERE
71
triamcinolone acetonide
70
triamcinolone acetonide
75
triamcinolone in orabase
68
triamterene/hydrochlorothiazide
60
Drug Name Page #
triazolam
8
tricitrates
93
tri-estarylla
67
trifluoperazine hcl
38
trifluridine
74
tri-legest fe
67
tri-linyah
67
trilyte
77
trimethoprim
9
trinessa
67
tri-previfem
67
TRISENOX
20
tri-sprintec
67
TRIUMEQ
40
tri-vit/fluoride
97
trivora-28
67
TROKENDI XR
24
TROPHAMINE
51
tropicamide
73
trospium chloride
78
trospium chloride er
78
TRUMENBA
86
TRUVADA
40
TUDORZA PRESSAIR
95
TWINRIX
86
TYBOST
90
TYGACIL
15
TYKERB
20
TYPHIM VI
86
TYSABRI
85
TYVASO
97
TYVASO REFILL
97
TYVASO STARTER
97
TYZEKA
42
TYZINE PEDIATRIC NASAL DROPS
73
UCERIS
86
u-cort
70
ULESFIA
90
ULORIC
90
UNITHROID
82
ursodiol
76
UVADEX
69
VAGIFEM
79
valacyclovir hcl
42
VALCHLOR
69
VALCYTE
42
VALGANCICLOVIR
42
valproate sodium
24
118
Drug Name Page #
valproic acid
24
valsartan
53
valsartan/hydrochlorothiazide
53
VALSTAR
20
vancomycin hcl
9
VANCOMYCIN HCL IN DEXTROSE
9
VANTAS
81
VAQTA
86
VARIVAX
86
vasopressin
81
vasostrict
81
VECTIBIX
20
VELCADE
20
VELETRI
97
velivet
67
venlafaxine hcl
28
venlafaxine hcl er
28
VENTAVIS
97
VENTOLIN HFA
95
verapamil hcl
58
verapamil hcl er
57
verapamil hcl sr
58
VEREGEN
69
VERSACLOZ
38
VESICARE
78
vestura
67
VIBATIV
9
VIBRAMYCIN
15
vicodin
4
vicodin es
4
vicodin hp
4
VICTOZA
29
VIDEX PEDIATRIC
40
VIGAMOX
74
VIIBRYD
28
VIMIZIM
73
VIMPAT
24
vinblastine sulfate
20
vincasar pfs
20
vincristine sulfate
20
vinorelbine tartrate
20
viorele
67
VIRACEPT
40
VIRAMUNE XR
40
virazole
42
VIREAD
40
VITEKTA
40
VIVITROL
7
Drug Name Page #
VIVOTIF BERNA
86
VOLTAREN
6
VORAXAZE
90
voriconazole
31
VOTRIENT
20
VPRIV
73
vyfemla
67
warfarin sodium
43
WELCHOL
62
wera
67
WINRHO SDF
85
wymzya fe
67
XALKORI
20
XARELTO
43
XARELTO STARTER PACK
43
XENAZINE
65
XEOMIN
90
XGEVA
87
XIAFLEX
73
XIFAXAN
9
XOLAIR
96
XTANDI
20
xulane
67
xylon
4
XYREM
96
YERVOY
20
YF-VAX
86
YODOXIN
34
zafirlukast
94
ZALTRAP
20
ZANOSAR
20
zarah
67
ZAVESCA
73
zazole
7
ZELAPAR
36
ZELBORAF
20
ZEMAIRA
96
ZEMPLAR
87
zenchent
68
zenchent fe
68
zeosa
68
ZERBAXA
11
ZETIA
62
ZIAGEN
40
zidovudine
40
ZIPRASIDONE HCL
38
ZIRGAN
74
ZMAX
12
119
Drug Name Page #
ZOLADEX
20
ZOLEDRONIC ACID
87
ZOLINZA
20
zolmitriptan
32
zolmitriptan odt
32
zolpidem tartrate
96
ZOMETA
87
ZONALON
69
zonisamide
24
ZORTRESS
85
ZOSTAVAX
86
zovia 1/35e
68
zovia 1/50e
68
ZYDELIG
20
ZYFLO
94
ZYFLO CR
94
ZYKADIA
20
ZYPREXA RELPREVV
39
ZYTIGA
20
ZYVOX
9
Este formulario se actualizó el 1.° de octubre de 2015. Para obtener información más reciente o si tiene
otras preguntas, póngase en contacto con Servicios al miembro de Health Alliance Medicare, llamando al
1-877-750-3350 o, para los usuarios de TTY, al 711 de 8:00 a. m. a 8:00 p. m., de lunes a viernes, o visite
HealthAllianceMedicare.org.
1-877-750-3350, TTY/TDD 711
HealthAllianceMedicare.org
Última actualización el 10/1/2015