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Formulario Buena Salud de Rocky Mountain Health Plans (RMHP)
La familia de planes médicos de RMHP incluye estas entidades:
Rocky Mountain Health Maintenance Organization
Rocky Mountain HealthCare Options
www.rmhp.org
Revised 10/01/2016
Descarte todas las copias anteriores del formulario
Los beneficiarios deben usar las farmacias en red para tener acceso a sus beneficios de
medicamentos con receta médica.
¿Qué es el formulario
El formulario es una lista de medicamentos cubiertos seleccionados por Rocky Mountain Health Plans
(RMHP), en consulta con un equipo de proveedores de atención médica, que representa las terapias
recetadas que se consideran necesarias como parte de un programa de tratamiento de calidad. RMHP
generalmente cubrirá los medicamentos incluídos en nuestro formulario siempre y cuando el medicamento
sea médicamente necesario, la receta sea surtida en una farmacia en red y se sigan otras reglas del plan.
Para más información acerca de cómo rellenar sus prescripciones, por favor revise su Evidencia de Cobertura.
¿Puede cambiar el formulario?
Sí. El formulario no es una lista estática, pero continúa siendo revisado y modificado. RMHP se reserva
el derecho de cambiar la cobertura de un medicamento en cualquier momento apropiado y necesario
para permanecer al paso de las terapias actuales de drogas y de la medicina basada en evidencias. Si
retiramos medicamentos de nuestro formulario, añadimos requisitos de autorización previa o límites de
cantidad o cambiamos un medicamento a un nivel superior de costo compartido, informaremos de estos
cambios a los Miembros afectados. El estado genérico o de marca de cualquier medicamento está sujeto
a cambios en cualquier momento y no está sujeto a la notificación a los Miembros. Si la Administración
Federal de Alimentos y Medicamentos (FDA, por sus siglas en inglés) de los Estados Unidos considera
que un medicamento que se encuentra en nuestro formulario no es seguro o el fabricante del
medicamento lo retira del mercado, eliminaremos inmediatamente dicho medicamento de nuestro
formulario y le enviaremos un aviso a los Miembros que lo toman. El formulario adjunto está vigente a
partir del 10/01/2016. El formulario se actualiza constantemente. Para obtener información actualizada
sobre los medicamentos que cubre RMHP, por favor llame al Centro de Atención a Clientes.
Miembros Individuales y Miembros de Plan Grupal llamar al 970-243-7050 ó 800-346-4643
Miembros de Medicaid llamar al 970-244-7860 ó 888-282-8801
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FORM-Good Health-Octubre 2016
¿Cómo utilizo el formulario?
Existen dos formas de encontrar su medicamento en el formulario:
Por Condición Médica
Los medicamentos que se encuentran en este formulario se agrupan en categorías dependiendo del tipo de
enfermedad en que se utilizan. Por ejemplo, los medicamentos utilizados para tratar una enfermedad cardiaca
se detallan en la categoría “Agentes cardiovasculares”. Entonces busque su medicamento en esa categoría.
Por orden Alfabético
El índice presenta una lista alfabética de todos los medicamentos incluidos en este documento. En dicho
índice se detallan los medicamentos de marca y los genéricos. Busque su medicamento en el índice. Junto a
su medicamento, verá el número de página donde podrá encontrar información sobre la cobertura. Vaya a la
página que se indica en el índice y encuentre el nombre de su medicamento en la primera columna de la lista.
El formulario contiene información sobre la cobertura de algunos de los medicamentos cubiertos por el plan
médico. Si tiene problemas para encontrar su medicamento en la lista, consulte el índice.
La primera columna del cuadro indica el nombre del medicamento. Los medicamentos de marca aparecen en
mayúsculas (por ejemplo, ALLEGRA) y los medicamentos genéricos se describen en letra minúscula (por
ejemplo, amoxicilina).
La información que se encuentra en la columna Cobertura indica si el plan médico tiene algún requisito
especial para la cobertura de su medicamento. Consulte la siguiente clave de abreviaturas del formulario.
Consulte la sección “¿Existen restricciones sobre mi cobertura?”, donde encontrará información para obtener
autorización previa.
¿Qué son los medicamentos genéricos?
Un medicamento genérico contiene el mismo ingrediente activo que contiene un medicamento de marca. Los
medicamentos genéricos generalmente cuestan menos que los medicamentos de marca y han sido
aprobados por la Administración de Alimentos y Medicamentos de los Estados Unidos (FDA, por sus siglas en
inglés), organismo que asegura que se cumplan las siguientes condiciones:



El medicamento genérico debe contener los mismos principios activos, tener la misma potencia y la
misma forma de dosificación que el medicamento de marca.
La FDA ha otorgado una calificación de “A” en comparación con el medicamento de marca homólogo
y, por lo tanto, ha determinado que el genérico es bioequivalente en términos terapéuticos.
Cuando se cumplen los dos criterios mencionados anteriormente, los medicamentos de marca pueden
sustituirse por genéricos con la plena certeza de que el producto sustituto tendrá el mismo efecto
clínico y perfil de seguridad que el producto recetado.
¿Qué es una sustitución genérica?
Algunos medicamentos se venden en una versión genérica que cuesta menos. Los medicamentos que tienen
una versión genérica disponible por lo general se surten en la farmacia en la versión genérica en lugar de la
de marca, salvo que su médico o usted soliciten el de marca.
Los medicamentos genéricos generalmente están incluidos en el nivel 1. Si un medicamento genérico no
ofrece ahorros financieros sobre la versión de marca, lo puede colocar en un nivel superior. Los
medicamentos que tienen un equivalente genérico se presentan en minúsculas. Cuando sale a la venta una
versión genérica de un medicamento de marca, el medicamento de marca se clasificará en un nivel superior.
Es probable que los Miembros tengan que pagar más por una receta cuando adquieran el producto de marca
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FORM-Good Health-Octubre 2016
que se corresponde a un nivel superior. El pago que deberá efectuar el Miembro queda determinado por el
plan de beneficios de farmacia. Cuando el sustituto genérico entra en conflicto con los reglamentos o
restricciones estatales, el farmacéutico debe obtener primero la aprobación del médico tratante u otro
profesional de la salud para sustituir el medicamento de marca por el genérico equivalente.
¿Qué es intercambio terapéutico?
Rocky Mountain Health Plans admite, pero no requiere necesariamente el uso del intercambio terapéutico
como parte de una estrategia integral de tratamiento del paciente que sea económica y de calidad. El
intercambio terapéutico es la práctica de sustituir, con autorización del médico tratante, un medicamento que
originalmente se prescribió a un paciente por un medicamento con una composición química diferente. Se
espera que los medicamentos utilizados en los programas de intercambio terapéutico produzcan niveles
similares de eficacia clínica y resultados médicos sólidos, con base en los datos científicos disponibles.
La Academy of Managed Care Pharmacy describe el intercambio terapéutico como programas elaborados por
un equipo de médicos, farmacéuticos y otros profesionales médicos que son expertos en el diagnóstico y
tratamiento de las enfermedades. Estos programas se diseñan para funcionar en conjunto con otras
herramientas que los profesionales de la salud usan para promover resultados médicos de calidad.
El uso del intercambio terapéutico ofrece varias ventajas:
Valor para los pacientes: cuando el intercambio terapéutico tiene lugar es porque los médicos y otros expertos
de la salud han determinado que los pacientes experimentarán resultados clínicos similares o mejores con las
medicinas de reemplazo. Puede ser más cómodo para el paciente tomar el medicamento de reemplazo. Por
ejemplo, es más probable que el paciente tome el medicamento recetado si se le proporciona un producto
terapéuticamente equivalente que sólo necesita tomar dos veces al día en lugar de cuatro. Un medicamento
que tiene muchas probabilidades de causar efectos secundarios puede sustituirse por otro que tenga menos
probabilidades de causarlos. Un nuevo medicamento que ofrece mejores resultados terapéuticos puede
sustituir a otro anterior. Por lo general, hay menos probabilidades de que el paciente omita la dosis y, en
consecuencia, puede recibir todo el beneficio clínico del medicamento si le resulta práctico tomarlo, le causa
menos efectos secundarios o le proporciona mayor control o alivio de la enfermedad.
Asequibilidad: un medicamento de reemplazo que es equivalente en términos terapéuticos simplemente
puede costar menos. Una vez que se determina que dos medicamentos producen los mismos resultados
positivos para el paciente, conviene que el hospital, el plan médico o la red de farmacias usen la alternativa
menos cara. Además, esto puede dar por resultado desembolsos personales menores para el paciente debido
a las reducciones de los copagos. En los casos en que dos medicamentos son equivalentes terapéuticos, la
AMCP no admite los programas de intercambio terapéutico que dan por resultado costos más altos para los
pacientes o los patrocinadores del plan.
Sin embargo, el intercambio terapéutico no siempre se relaciona con costos menores de los medicamentos. El
intercambio terapéutico ocurre a menudo cuando es posible ahorrar en la atención médica en general. La
sustitución de un medicamento por otro más caro puede dar origen a menos fallas del tratamiento, mejor
observancia del plan de tratamiento por parte del paciente, menos efectos secundarios y mejores resultados
clínicos. Este uso eficiente de los recursos médico contribuye a reducir los gastos médicos, mejora el acceso
del paciente a atención médica más asequible y mejora la calidad de vida del paciente
¿Existe alguna restricción en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos adicionales o limitaciones en la cobertura. Dichos
requisitos y limitaciones pueden incluir:
 Autorización Previa: RMHP requiere que usted o su médico obtengan autorización previa para ciertos
medicamentos. Esto significa que deberá obtener la aprobación de RMHP antes de surtir sus recetas.
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FORM-Good Health-Octubre 2016
Si no obtiene dicha aprobación, el plan médico puede no cubrir el medicamento. Los 4 medicamentos
que están sujetos a autorización previa tienen un símbolo “PA” al lado del nombre del medicamento.
o
Médicos y farmacias, favor llamar al 970-248-5031 or 800-641-8921
Fax: 858-357-2538
 Límites de Cantidad: En el caso de ciertos medicamentos, el plan de salud limita la cantidad del
medicamento que ser. Por ejemplo, el plan médico proporciona 12 dosis por receta de Imitrex en
tabletas. Esto puede ser adicional a la provisión normal para uno o tres meses. Los medicamentos que
están sujetos a límites de cantidad tienen un símbolo “QL” al lado del nombre del medicamento.
o
Limitaciones de Reposición: las recetas pueden volver a surtirse cuando se ha
consumido 75% o más de la provisión diaria.
 Terapia escalonada: En algunos casos, el Plan de Salud exige que primero pruebe ciertos
medicamentos para tratar su enfermedad antes de que cubramos su su enfermedad antes de que
cubramos otro medicamento para dicha enfermedad. Por ejemplo, si el medicamento A y el medicamento
B sirven para tratar su enfermedad, es posible que no proporcionemos cobertura del medicamento B a
menos que usted pruebe primero el medicamento A. Si el medicamento A no le funciona, entonces
cubriremos el medicamento B. Los medicamentos que están sujetos a tratamiento escalonado tienen un
símbolo “ST” al lado del nombre del medicamento.
 Límite de edad: En algunos casos, los medicamentos sólo están disponibles para un Miembro que
pertenece a una categoría de edad seleccionada. Los medicamentos que están sujetos a límites de
edad tienen un símbolo “AGE” al lado del nombre del medicamento.
 Límite de género: Algunos medicamentos sólo están disponibles para Miembros de cierto género. Los
medicamentos que están disponibles sólo para cierto género tienen un símbolo “GM”/”GF” (Hombre /
Mujer) al lado del nombre del medicamento.
Para averiguar si su medicamento tiene algún requisito o límite adicional, busque dicho medicamento
en el formulario a partir de la página 1.
Medicamentos Especializados
Ciertas condiciones de salud crónica o difícil requieren el uso de medicamentos especializados. Esto es lo que
necesita saber acerca de estos medicamentos:
¿Qué hace que los medicamentos especializados sean diferentes?
Los medicamentos especializados por lo general requieren un manejo especial de administración o de
supervisión. Por lo general son muy caros y a menudo son prescritos por especialistas y podrían requerir la
aprobación previa de RMHP antes de poder surtir su receta. Es posible que tenga que ordenar a través de
una farmacia especializada.
¿Cómo sé si mi medicamento es un medicamento de especialidad?
Los medicamentos especializados se enumeran en los Niveles 4 y 5 en el formulario. El nivel 6 también
incluye algunos medicamentos especializados.
¿Dónde consigo los medicamentos especializados?
Usted puede conseguir algunos medicamentos especializados en una farmacia minorista. No todas las
farmacias despachan recetas para medicamentos de especialidad, así que consulte primero. Algunos
medicamentos especializados son de Distribución Limitada y sólo se pueden obtener de una farmacia
especializada RMHP. Estos incluyen la Modern Health, Diplomat, CVS, Accredo, y otros. Revise la lista de
medicamentos especiales para ver si un medicamento especializado es de Distribución Limitada.
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FORM-Good Health-Octubre 2016
¿Puedo obtener un suministro de 90 días de medicamentos especializados como mi otra medicación?
Debido a que estos medicamentos pueden ser frágiles y pueden requerir un manejo especial o monitoreo,
sólo se puede solicitar un suministro para 30 días de medicamentos especializados. Algunos medicamentos
especializados son las inyecciones que duran 3 meses o 6 meses por inyección. Estos han sido aprobados
para esa duración.
Para preguntas acerca de los medicamentos especializados y nuestras farmacias especializadas, por favor
póngase en contacto con la oficina de asistencia farmacéutica de RMHP al 970-248-5031 (1-800-640-8921).
Exclusiones del formulario
RMHP se reserva el derecho de excluir cualquier medicamento del formulario de RMHP, en cualquier
momento, por motivos de salud y seguridad o por otras razones que RMHP determine a su exclusivo criterio.
Los siguientes medicamentos están excluidos del formulario de RMHP:

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
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Todo medicamento que por disposición de la FDA lleve la leyenda: “Precaución, limitado por la ley
federal al uso en investigación”
Medicamentos que no estén disponibles, no se comercialicen o no se vendan en los Estados Unidos.
Medicamentos obtenidos de una farmacia o proveedor situado fuera de los Estados Unidos, excepto
medicamentos obtenidos en relación con una emergencia médica.
Todo medicamento que no esté aprobado por la FDA.
Todo medicamento que se use en relación con un servicio o suministro que no sea un beneficio (por
ejemplo, los medicamentos empleados para la atención dental no están cubiertos).
Medicamentos perdidos o robados: RMHP no cubrirá reposiciones de recetas por medicamentos
perdidos, robados o dañados
Adicionalmente, todos los medicamentos de las siguientes categorías se excluyen de la cobertura del
formulario de RMHP:
Nombre o categoría genérica del medicamento
Anorexígenos/medicamentos para bajar de peso.
Ejemplo
Medicamentos compuestos que se emplean para indicaciones o
por vías de administración que no han sido autorizadas por la FDA.
Neurontin tópico y
bloqueadores de canales
de calcio de uso tópico.
Medicamentos compuestos para los cuales existe un fármaco
aprobado por la FDA en la potencia y dosis prescritas.
Hormonas compuestas no aprobadas por la FDA.*
Tri-est, Bi-est
Medicamentos compuestos inyectables para la disfunción eréctil.
Trimix, prostaglandins
Medicamentos compuestos que utilizan polvos. [Excepciones:
sulfonato de poliestireno (Kayexalate), ácido salicílico, nistatina,
cafeína]
Fármacos cosméticos.
Propecia, Renova, Vaniqa,
Lustra, Botox Cosmetic
DHEA
Medicamentos dentales.
Monodox, Periostat
Suplementos dietéticos
Deplin, Metanx, Limbrel,
Vayarin, Hypertensa,
Theramine
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FORM-Good Health-Octubre 2016
Nombre o categoría genérica del medicamento
Soluciones nebulizadas compuestas a partir de polvo
Ejemplo
triamcinolone
Medicamentos que requieran receta médica para los cuales exista
un equivalente disponible de Venta Libre. Ciertos medicamentos de
Venta Libre están cubiertos bajo la Ley de protección al paciente y
del Cuidado de Salud a Bajo Precio para Grupos Comerciales y
Miembros Individuales solamente.
Claritin, lac-hydrin
* La progesterona en la inyección de aceite no está dentro de estas exclusiones.
Medicamentos venta libre: Los Medicamentos de Venta Libre, con la excepción de la insulina, no están
cubiertos. Para los pacientes con diálisis renales : antiácidos, todas las multi-vitaminas, reemplazo de calcio,
Proferrin y Proferrin Forte están cubiertos con una autorización previa. Los Medicamentos de Venta Libre para
dejar de fumar están cubiertos por Medicaid con autorización previa, los ejemplos incluyen el parche Nicoderm
y la goma de mascar Nicorette.
Los Medicamentos de Venta Libre cubiertos bajo la Ley de protección al paciente y del Cuidado de
Salud a Bajo Precio (PPACA por sus siglas en Inglés): requiere que los planes de salud cubran el costo de
algunos productos de venta libre para grupos comerciales y miembros de grupos individuales solamente. Se
requiere una receta de su médico para este reembolso. Estos productos incluyen:
Suplementos de Ácido fólico de venta libre: El costo de suplementos de ácido fólico de venta libre
que contenga 0,4 mg a 0,8 mg de ácido fólico será reembolsado para las mujeres de 18 años y mayores
que tengan planes o sean capaces de embarazo. Los miembros serán reembolsados hasta un suministro
de 90 días por encargo.
Aspirina de Venta Libre: El costo de la aspirina de venta libre utilizado en régimen de terapia de aspirina
para la salud cardiovascular será reembolsado a los miembros femeninos de edades 55-79 y miembros
masculinos de edades 45-79. Los miembros serán reembolsados hasta un suministro de 90 días por
encargo.
Suplementos de hierro de Venta Libre: El costo de los suplementos de hierro de venta libre será
reembolsado para los niños de 6-12 meses de edad que están en riesgo incrementado de anemia por
deficiencia de hierro. . Los miembros serán reembolsados hasta un suministro de 90 días por encargo.
Anticonceptivos de Venta libre: El costo de esponjas de venta libre, espermicidas y condones
femeninos se le reembolsará a las mujeres (No aplicable para las mujeres que participen o sean
beneficiarias en planes de salud grupales patrocinado por empleadores religiosos) capaces de quedar
embarazadas pero que quieran prevenir un embarazo. Los miembros serán reembolsados hasta un
suministro de 90 días por encargo. Vitamina D de Venta Libre: El costo de suplementos de vitamina D de venta libre se reembolsará en la
comunidad-residencia para adultos de 65 años de edad o mayores que estén en mayor riesgo de caídas.
Los miembros serán reembolsados hasta un suministro de 90 días por solicitud.
Para solicitar el reembolso de alguno de estos artículos de venta libre, contacte a Servicio al Cliente y
confirme que usted es elegible para el reembolso. Si es elegible, debe completar el formulario de Reembolso
Directo al Miembro.
¿Qué sucede si mi medicamento no se encuentra en el Formulario?
Miembros: Si su medicamento no está incluido en este formulario, debe comunicarse primero con Atención a
clientes y confirmar que su medicamento no está cubierto. Si averigua que RMHP no cubre su medicamento,
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FORM-Good Health-Octubre 2016
puede solicitarnos que hagamos una excepción a nuestras reglas, restricciones o limitaciones de cobertura.
Llame al centro de atención a clientes para solicitar una revisión de excepción 6 al formulario, o encontrará un
formulario de solicitud de excepción al formulario en https://www.rmhp.org/members/rx-info/formularyexceptions-requests-commercial.
Existen distintos tipos de excepciones que usted nos puede solicitar.

Nos puede pedir que cubramos su medicamento aun cuando el mismo no se encuentre en nuestro
formulario.

Puede pedirnos que anulemos las restricciones o limitaciones de cobertura con respecto a su
medicamento. Por ejemplo, para ciertos medicamentos, RMHP limita la cantidad del medicamento que
cubriremos. Si su medicamento tiene un límite de cantidad, puede pedirnos que anulemos dicho límite y
cubramos más.
Generalmente, RMHP sólo aprobará su solicitud de una excepción si los medicamentos alternativos incluidos
en el formulario del plan, el medicamento de nivel más bajo o las restricciones adicionales a la utilización no
fueran tan eficaces para tratar su enfermedad y/o causaran efectos médicos adversos.
Información para proveedores:
SOLICITUDES DE EXCEPCIÓN AL FORMULARIO: Para solicitar cobertura de un medicamento excluido,
comuníquese con la oficina de asistencia farmacéutica de RMHP al 970-248-5031 (1-800-640-8921). Se le
enviará por fax un formulario de solicitud de excepción al formulario, mismo que deberá llenar por completo y
devolverlo por fax a RMHP al 970-248-5034.
AUTORIZACIÓN PREVIA: Algunos medicamentos requieren autorización previa para que RMHP los cubra.
Consulte los criterios específicos de PA para todos los medicamentos que requieren autorización previa en
nuestro sitio web: http://www.rmhp.org/providers/prior-authorization/prior-authorizationpharmacy. También
puede llamar a la oficina de asistencia farmacéutica de RMHP al 970-248-5031 (800-640-8921) y ellos le
enviarán por fax un formulario de solicitud de autorización previa. Llene este formulario, adjunte el historial
médico pertinente y devuélvalo por fax a la oficina de asistencia farmacéutica de RMHP.
Indicadores de la Política del Formulario
T1
Medicamentos de alto costo (copago más bajo). Puede contener medicamentos
genéricos y de marca.
T2
Medicamentos preferidos (bajo copago). Contiene medicamentos genéricos y de
marca.
T3
Medicamentos no preferidos (copago medio). Contiene medicamentos genéricos y
de marca.
T4
Medicamentos especializados (copago más alto). Contiene medicamentos de
marca y medicamentos especializados genéricos de alto costo.
T5
Medicamentos especializados no preferentes (copago más alto). Contiene
medicamentos de marca y medicamentos especializados genéricos de alto costo.
T6
Beneficio Médico
PA
Requiere Autorización Previa.
PA NSO
Requiere Autorización Previa. – Solo Nuevos Comienzos.
QL
Límites de Cantidad
ST
Tratamiento Escalonado
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FORM-Good Health-Octubre 2016
Indicadores de la Política del Formulario
AGE
GM/GF
Límite de Edad
Límite de Género (Hombre / Mujer)
EX
Medicamento Excluido
minúscula cursiva
Medicamento Genérico
MAYÚSCULAS
Medicamentos de marca
POLÍTICA DE REVISIÓN
Los formularios de RMHP se revisan por lo menos cada trimestre. La cobertura de medicamentos puede
cambiar entre revisiones.
EDITOR
Agradecemos sus comentarios y sugerencias, ya que mejoramos y actualizamos el formulario de manera
contínua. No dude en comunicarse con Steve Nolan, Pharm D (970-248-5182, 800-843-0719 ext. 5182) RMHP,
2775 Crossroads Blvd., Grand Junction, CO 81506.
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FORM-Good Health-Octubre 2016
Drug Name
Drug Tier
Requirements/Limits
Analgesics
Analgesics, Miscellaneous
acetaminophen with codeine
butalb/acetaminophen/caffeine capsule, tablet
butalbit/acetamin/caff/codeine
butalbital/acetaminophen
butalbital/aspirin/caffeine
butorphanol tartrate spray
codeine sulfate
codeine/butalbital/asa/caffein
DISKETS
ESGIC capsule
fentanyl citrate
fentanyl patch td72: 12mcg/hr, 25mcg/hr, 50mcg/hr,
75mcg/hr, 100mcg/hr
hydrocodone/acetaminophen solution, tablet: 2.5325mg, 5mg-300mg, 5mg-325mg, 7.5-300mg, 7.5325mg, 10mg-300mg, 10mg-325mg
hydrocodone/ibuprofen tablet: 7.5-200mg
hydromorphone hcl liquid, tablet
ibuprofen/oxycodone hcl
LORTAB tablet
meperidine hcl tablet
methadone hcl oral conc, solution, tablet, tablet sol
morphine sulfate cap er pel, cpmp 24hr, solution:
10mg/5ml, 20mg/5ml; tablet er
oxycodone hcl capsule, oral conc, tablet
oxycodone hcl/acetaminophen solution: 5-325/5ml;
tablet
oxycodone hcl/aspirin
oxymorphone hcl
pentazocine hcl/naloxone hcl
tramadol hcl tab er 24h, tablet
tramadol hcl/acetaminophen
VERDROCET
ZAMICET
aspirin/caffein/dihydrocodeine
butalb/acetaminophen/caffeine solution
BUTRANS
CAPITAL W-CODEINE
CODEINE SULFATE
FENTORA
hydromorphone hcl supp.rect
levorphanol tartrate
meperidine hcl solution
morphine sulfate solution: 100mg/5ml; supp.rect
MORPHINE SULFATE tablet
NUCYNTA
(Tylenol-Codeine No.3)
(Fioricet)
(Fioricet with Codeine)
(Tencon)
(Fiorinal)
(Butorphanol Tartrate)
(Codeine Sulfate)
(Fiorinal with Codeine #3)
(Actiq)
(Duragesic)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
(Norco)
T1
(Ibudone)
(Dilaudid)
(Ibuprofen/Oxycodone HCl)
T1
T1
T1
T1
T1
T1
T1
(Demerol)
(Dolophine HCl)
(Morphine Sulfate ER)
(Roxicodone)
(OxycodoneAcetaminophen)
(Percodan)
(Opana)
(Pentazocine HCl/Naloxone
HCl)
(Ultram)
(Ultracet)
(Synalgos-Dc)
(Butalb/Acetaminophen/
Caffeine)
(Hydromorphone HCl)
(Levorphanol Tartrate)
(Meperidine HCl)
(Morphine Sulfate)
PA
QL: 15 in 30 days
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
PA, QL: 4 in 28 days
PA
QL: 60 in 30 days
1
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
OPANA ER
opium/belladonna alkaloids
oxycodone hcl tab er 12h
oxycodone hcl/acetaminophen solution: 5-325/5ml
OXYCONTIN
SYNALGOS-DC
AVINZA
BUPAP
DEMEROL tablet
DILAUDID liquid, tablet
DOLOPHINE HCL
DURAGESIC
ESGIC tablet
FIORICET WITH CODEINE
FIORICET
FIORINAL WITH CODEINE #3
FIORINAL
HYCET
hydrocodone/acetaminophen tablet: 5mg-300mg,
7.5-300mg, 10mg-300mg
KADIAN
METHADOSE
MS CONTIN
NORCO
NUCYNTA ER tab er 12h: 50mg, 100mg
NUCYNTA ER tab er 12h: 150mg, 200mg, 250mg
OPANA tablet
oxycodone hcl solution
PERCOCET
PERCODAN
ROXICODONE
TYLENOL-CODEINE NO.3
TYLENOL-CODEINE NO.4
ULTRACET
ULTRAM ER
ULTRAM
VICOPROFEN
ZOHYDRO ER
LAZANDA
alfentanil hcl
Drug Tier
(Opium/Belladonna
Alkaloids)
(Oxycontin)
(Oxycodone HCl/
Acetaminophen)
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
(Norco)
(Oxycodone HCl)
(Alfentanil HCl)
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T4
T6
ALFENTANIL HCL
T6
BUPRENEX
T6
buprenorphine hcl
(Buprenorphine HCl)
Requirements/Limits
T6
QL: 15 in 30 days
QL: 120 in 30 days
QL: 60 in 30 days
QL: 60 in 30 days
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
2
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
butorphanol tartrate vial
(Butorphanol Tartrate)
T6
clonidine hcl/pf
(Clonidine HCl/PF)
T6
DEMEROL ampul, syringe
T6
DEPODUR
T6
DILAUDID ampul
T6
DILAUDID-HP
T6
DURACLON
T6
DURAMORPH
T6
FENTANYL CITRATE ampul
T6
fentanyl citrate/pf ampul, vial
(Fentanyl Citrate/PF)
T6
hydromorphone hcl syringe, vial
(Hydromorphone HCl)
T6
hydromorphone hcl/pf
(Hydromorphone HCl/PF)
T6
INFUMORPH
T6
meperidine hcl cartridge
(Meperidine HCl)
T6
meperidine hcl/pf
(Meperidine HCl/PF)
T6
methadone hcl vial
(Methadone HCl)
T6
morphine sulfate in 0.9 % nacl plast. bag
(Morphine Sulfate In 0.9 %
NaCl)
morphine sulfate cartridge, pen injctr, syringe: 5mg/ (Morphine Sulfate)
ml, 10mg/ml; vial
morphine sulfate/d5w/pf
(Morphine Sulfate/D5w/PF)
T6
T6
morphine sulfate/pf pca vial, vial
(Morphine Sulfate/PF)
T6
nalbuphine hcl
(Nalbuphine HCl)
T6
T6
OFIRMEV
T6
OPANA ampul
T6
PRIALT
T6
sufentanil citrate
(Sufentanil Citrate)
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
3
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
TALWIN
T6
ULTIVA
T6
ABSTRAL
acetaminophen/phenyltolx tablet: 325mg-30mg,
500-55mg, 500mg-30mg
ACTIQ
BELBUCA
CONZIP
EMBEDA
EXALGO
fentanyl patch td72: 37.5mcg/hr, 62.5mcg/hr,
87.5mcg/hr
hydrocodone/ibuprofen tablet: 2.5-200mg, 5mg200mg, 10mg-200mg
hydromorphone hcl tab er 24h
HYSINGLA ER
IBUDONE
LORTAB solution
OXECTA
PRIMLEV
RELAGESIC tablet: 650mg-50mg
SUBSYS
tramadol hcl cpbp 17-83, cpbp 25-75
TREZIX
XARTEMIS XR
XODOL 10-300
XODOL 5-300
XODOL 7.5-300
Nonsteroidal Anti-Inflammatory Agents
celecoxib
choline sal/mag salicylate
diclofenac potassium
diclofenac sodium gel (gram): 3%
diclofenac sodium: tab er 24h, tablet dr
diclofenac sodium/misoprostol
diflunisal
etodolac
flurbiprofen
ibuprofen
indomethacin
ketoprofen capsule
ketorolac tromethamine tablet
mefenamic acid
meloxicam tablet
nabumetone
naproxen sodium
naproxen
(Relagesic)
EX
EX
(Duragesic)
EX
EX
EX
EX
EX
EX
(Ibudone)
EX
(Exalgo)
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
(Conzip)
(Celebrex)
(Choline Sal/Mag
Salicylate)
(Cataflam)
(Solaraze)
(Diclofenac Sodium)
(Arthrotec 75)
(Diflunisal)
(Etodolac)
(Flurbiprofen)
(Ibuprofen)
(Indomethacin)
(Ketoprofen)
(Ketorolac Tromethamine)
(Ponstel)
(Mobic)
(Nabumetone)
(Anaprox Ds)
(Naprosyn)
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
4
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
oxaprozin
piroxicam
salsalate
sulindac
tolmetin sodium
diclofenac sodium gel (gram): 1%
fenoprofen calcium
INDOCIN
ketoprofen cap24h pel
LEVACET
meclofenamate sodium
meloxicam oral susp
NALFON
ANAPROX DS
ANAPROX
ARTHROTEC 50
ARTHROTEC 75
CAMBIA
CATAFLAM
DAYPRO
EC-NAPROSYN
FELDENE
MOBIC
NAPRELAN
NAPROSYN
PONSTEL
SOLARAZE
VOLTAREN
Drug Tier
(Daypro)
(Feldene)
(Salsalate)
(Sulindac)
(Tolmetin Sodium)
(Voltaren)
(Fenoprofen Calcium)
(Ketoprofen)
(Meclofenamate Sodium)
(Mobic)
VOLTAREN-XR
CALDOLOR
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T6
ibuprofen lysine/pf
(Ibuprofen Lysine/PF)
T6
indomethacin sodium
(Indomethacin Sodium)
T6
ketorolac tromethamine cartridge, syringe, vial
(Ketorolac Tromethamine)
T6
NEOPROFEN
T6
CELEBREX
COMFORT PAC-IBUPROFEN
COMFORT PAC-MELOXICAM
COMFORT PAC-NAPROXEN
diclofenac sodium drops
DUEXIS
ENOVARX-NAPROXEN
FLECTOR
NAPRODERM
EX
EX
EX
EX
EX
EX
EX
EX
EX
(Pennsaid)
Requirements/Limits
Not covered for Medicaid
QL: 9 in 30 days
(Gel; NOT COVERED FOR
MEDICAID: Covered
Alternatives Available)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
5
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
PENNSAID
SPRIX
VIMOVO
ZIPSOR
ZORVOLEX
Requirements/Limits
EX
EX
EX
EX
EX
Anesthetics
Local Anesthetics
cocaine hcl
lidocaine hcl cream (g), jel (ml), jel/pf app: 2%;
solution
lidocaine
lidocaine/hydrocortisone ac
lidocaine/prilocaine cream (g)
lidocaine/tetracaine
benzocaine
BUCALSEP
PONTOCAINE solution
EMLA
lidocaine/prilocaine kit
LIDODERM
LIDORX
PLIAGLIS
SYNERA
XYLOCAINE solution
bupivacaine hcl
bupivacaine hcl/dex-water/pf
bupivacaine hcl/epinephrine bi
bupivacaine hcl/epinephrine
bupivacaine hcl/epinephrine/pf
bupivacaine hcl/pf
(Cocaine HCl)
(Pre-Attached Lta Kit)
T1
T1
(Lidoderm)
(Lidocaine/Hydrocortisone
Ac)
(EMLA)
(Pliaglis)
(Benzocaine)
T1
T1
(Lidocaine/Prilocaine)
(Marcaine)
(Bupivacaine HCl/DexWater/PF)
(Bupivacaine HCl/
Epinephrine Bi)
(Bupivacaine HCl/
Epinephrine)
(Bupivacaine HCl/
Epinephrine/PF)
(Marcaine)
CARBOCAINE
chloroprocaine hcl/pf vial: 20mg/ml
T1
T1
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T6
T6
T6
T6
T6
T6
T6
(Chloroprocaine HCl/PF)
EXPAREL
T6
T6
lidocaine hcl vial
(Xylocaine)
T6
lidocaine hcl/epinephrine bit
(Lidocaine HCl/Epinephrine
Bit)
(Xylocaine with
Epinephrine)
T6
lidocaine hcl/epinephrine
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
6
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
lidocaine hcl/epinephrine/pf
lidocaine hcl/pf
Drug Tier
(Lidocaine HCl/
Epinephrine/PF)
(Lidocaine HCl/PF)
T6
T6
LIDOCAINE-EPINEPHRINE
T6
MARCAINE SPINAL
T6
MARCAINE vial: 2.5mg/ml
T6
MARCAINE vial: 5mg/ml, 7.5mg/ml
T6
MARCAINE-EPINEPHRINE
T6
mepivacaine hcl/pf
(Mepivacaine HCl/PF)
T6
NAROPIN
T6
NESACAINE
T6
NESACAINE-MPF
T6
PONTOCAINE ampul
T6
ropivacaine hcl/pf vial
(Ropivacaine HCl/PF)
T6
SENSORCAINE-MPF EPINEPHRINE
T6
SENSORCAINE-MPF
T6
tetracaine hcl/pf
(Pontocaine)
T6
XYLOCAINE WITH EPINEPHRINE vial: 0.51:200k, 1%-1:100k
XYLOCAINE WITH EPINEPHRINE vial: 2%1:200k
XYLOCAINE vial
T6
XYLOCAINE-MPF WITH EPINEPHRINE
T6
XYLOCAINE-MPF ampul: 15mg/ml
T6
XYLOCAINE-MPF ampul: 40mg/ml; vial
T6
LETS KIT
PRO DNA MEDICATED COLLECTION
RELADOR PAK
EX
EX
EX
T6
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Anti-Addiction/Substance Abuse Treatment Agents
acamprosate calcium
buprenorphine hcl
(Campral)
(Buprenorphine HCl)
T1
T1
PA NSO, QL: 90 in 30 days
7
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
buprenorphine hcl/naloxone hcl
bupropion hcl
disulfiram
naltrexone hcl
CHANTIX
Drug Tier
(Buprenorphine HCl/
Naloxone HCl)
(Zyban)
(Antabuse)
(Naltrexone HCl)
T1
PA NSO, QL: 90 in 30 days
T1
PPACA $0 COPAY FOR
SMOKING CESSATION
T1
T1
T2
NARCAN
NICOTROL NS
T2
T2
NICOTROL
T2
SUBOXONE film: 12mg-3mg
SUBOXONE film: 2mg-0.5mg, 4mg-1mg, 8mg2mg
ANTABUSE
CAMPRAL
NICODERM CQ
T2
T2
T3
T3
T3
NICORETTE
T3
NICOTINE PATCH
T3
nicotine polacrilex
(Nicorette)
T3
nicotine
(Nicoderm Cq)
T3
(Naloxone HCl)
T3
T3
T6
REVIA
ZYBAN
naloxone hcl
BUNAVAIL
EVZIO
VIVITROL
ZUBSOLV
Requirements/Limits
PPACA $0 COPAY FOR
SMOKING CESSATION
QL: 2 in 365 days
PPACA $0 COPAY FOR
SMOKING CESSATION
PPACA $0 COPAY FOR
SMOKING CESSATION
PA NSO, QL: 60 in 30 days
PA NSO, QL: 90 in 30 days
Medicaid ONLY; PPACA $0
COPAY FOR SMOKING
CESSATION
Medicaid ONLY; PPACA $0
COPAY FOR SMOKING
CESSATION
Medicaid ONLY; PPACA $0
COPAY FOR SMOKING
CESSATION
Medicaid ONLY; PPACA $0
COPAY FOR SMOKING
CESSATION
Medicaid ONLY; PPACA $0
COPAY FOR SMOKING
CESSATION
(Non-self administerable
injectable)
EX
EX
EX
EX
Antianxiety Agents
Benzodiazepines
alprazolam
chlordiazepoxide hcl
clonazepam
clorazepate dipotassium
diazepam tablet
estazolam
flurazepam hcl
(Xanax)
(Chlordiazepoxide HCl)
(Klonopin)
(Tranxene T-Tab)
(Valium)
(Estazolam)
(Flurazepam HCl)
T1
T1
T1
T1
T1
T1
T1
8
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
lorazepam oral conc, tablet
midazolam hcl syrup
oxazepam
temazepam
triazolam
ALPRAZOLAM INTENSOL
DIASTAT ACUDIAL
DIASTAT
diazepam kit, oral conc, solution
DORAL
ONFI
quazepam
ATIVAN tablet
HALCION
KLONOPIN
RESTORIL
TRANXENE T-TAB
VALIUM
XANAX XR
XANAX
ATIVAN vial
Drug Tier
(Ativan)
(Midazolam HCl)
(Oxazepam)
(Restoril)
(Halcion)
(Diastat Acudial)
(Doral)
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T6
diazepam vial
(Diazepam)
T6
lorazepam syringe, vial
(Ativan)
T6
midazolam hcl vial
(Midazolam HCl)
T6
midazolam hcl/pf syringe: 2mg/2ml
(Midazolam HCl/PF)
T6
midazolam hcl in 0.9 % nacl
(Midazolam Hcl In 0.9 %
NaCl)
(Midazolam Hcl In 0.9 %
Nacl/PF)
EX
(Neomycin Sulfate)
T1
T4
T4
T5
T6
midazolam hcl in 0.9 % nacl/pf
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
Antibacterials
Aminoglycosides
neomycin sulfate
TOBI PODHALER
tobramycin in 0.225% nacl
TOBI
amikacin sulfate
gentamicin in nacl, iso-osm
(Tobi)
(Amikacin Sulfate)
gentamicin sulfate
(Gentamicin In Nacl, IsoOsm)
(Gentamicin Sulfate)
T6
T6
gentamicin sulfate/pf
(Gentamicin Sulfate/PF)
T6
streptomycin sulfate
(Streptomycin Sulfate)
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
9
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
tobramycin sulfate
(Tobramycin Sulfate)
T6
tobramycin/sodium chloride
(Tobramycin/Sodium
Chloride)
T6
(Cleocin HCl)
(Cleocin Palmitate)
(Urelle)
T1
T1
T1
(Hiprex)
(Methenamine Mandelate)
(Flagyl)
(Macrodantin)
(Macrobid)
(Furadantin)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
Antibacterials, Miscellaneous
clindamycin hcl
clindamycin palmitate hcl
meth/meblue/sod phos/psal/hyos tablet: 81-0.12mg,
81.6-10.8
methenamine hippurate
methenamine mandelate tablet: 1g
metronidazole
nitrofurantoin macrocrystal
nitrofurantoin monohyd/m-cryst capsule: 100mg
nitrofurantoin
PHOSPHASAL
trimethoprim
URETRON D-S
URIN D.S.
URYL
vancomycin hcl capsule
methen/sod phos/meth blue/hyos tablet: 81.6-.12mg
methenamine mandelate tablet: 500mg
MONUROL
POLYMYXIN B SULFATE powder(ea):
100mmunit
PRIMSOL
UROQID-ACID NO.2
XIFAXAN tablet: 200mg
CLEOCIN HCL
CLEOCIN PALMITATE
FLAGYL ER
FLAGYL
FURADANTIN
HIPREX
MACROBID
MACRODANTIN
methen/m-blue/sal/na phos/hyos
URELLE
UTIRA-C
VANCOCIN HCL
linezolid
XIFAXAN tablet: 550mg
ZYVOX susp recon, tablet
bacitracin
chloramphenicol sod succ
(Trimethoprim)
(Vancocin HCl)
(Methen/Sod Phos/Meth
Blue/Hyos)
(Methenamine Mandelate)
(Methen/M-Blue/Sal/Na
Phos/Hyos)
(Zyvox)
(Bacitracin)
(Chloramphenicol Sod
Succ)
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T4
T4
T5
T6
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
10
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
CLEOCIN PHOSPHATE IN D5W
T6
CLEOCIN PHOSPHATE
T6
clindamycin phosphate
(Cleocin Phosphate)
T6
clindamycin phosphate/d5w
(Cleocin Phosphate In D5w)
T6
colistin (colistimethate na)
(Coly-Mycin M Parenteral)
T6
COLY-MYCIN M PARENTERAL
T6
CUBICIN
T6
LINCOCIN
T6
lincomycin hcl
(Lincocin)
T6
linezolid-0.9% sodium chloride
(Linezolid-0.9% Sodium
Chloride)
(Metro IV)
T6
(Moxifloxacin/Sod.Ace,Sul/
Water)
(Polymyxin B Sulfate)
T6
metronidazole/sodium chloride
moxifloxacin/sod.ace,sul/water
polymyxin b sulfate
SYNERCID
vancomycin hcl vial
T6
T6
T6
(Vancomycin HCl)
T6
ZYVOX iv soln
T6
VIBATIV
Cephalosporins
cefaclor capsule
cefadroxil
cefdinir
cefixime
cefpodoxime proxetil
cefprozil
cefuroxime axetil
CEFUROXIME AXETIL
cephalexin capsule, susp recon
cefaclor tab er 12h
cephalexin tablet
KEFLEX capsule: 750mg
SUPRAX
CEDAX
cefaclor susp recon
ceftibuten
CEFTIN
EX
(Cefaclor)
(Cefadroxil)
(Cefdinir)
(Suprax)
(Cefpodoxime Proxetil)
(Cefprozil)
(Ceftin)
(Keflex)
(Cefaclor)
(Cephalexin)
(Cefaclor)
(Cedax)
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T3
T3
T3
T3
11
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
KEFLEX capsule: 250mg, 500mg
cefazolin sodium
cefazolin sodium/dextrose,iso
cefepime hcl
Drug Tier
(Cefazolin Sodium)
(Cefazolin Sodium/
Dextrose, Iso)
(Maxipime)
T3
T6
T6
T6
CEFEPIME
T6
CEFEPIME-DEXTROSE
T6
CEFOTAN vial: 2g
T6
cefotaxime sodium
(Claforan)
T6
cefotetan disod/dextrose,iso
T6
cefotetan disodium
(Cefotetan Disod/Dextrose,
Iso)
(Cefotetan Disodium)
T6
cefoxitin sodium
(Cefoxitin Sodium)
T6
cefoxitin sodium/dextrose,iso
(Cefoxitin Sodium/
Dextrose, Iso)
(Fortaz)
T6
ceftazidime vial: 1g, 2g, 6g
CEFTAZIDIME
ceftriaxone na/dextrose,iso
T6
T6
ceftriaxone sodium
(Ceftriaxone Na/Dextrose,
Iso)
(Ceftriaxone Sodium)
T6
T6
cefuroxime sodium
(Zinacef)
T6
CLAFORAN vial: 1g, 2g, 10g; vial port
T6
CLAFORAN-DEXTROSE
T6
FORTAZ
T6
MEFOXIN
T6
ROCEPHIN
T6
TEFLARO
T6
ZINACEF
T6
MAXIPIME
SPECTRACEF
Macrolides
azithromycin susp recon, tablet
EX
EX
(Zithromax)
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T1
12
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
clarithromycin
erythromycin base capsule dr
erythromycin ethylsuccinate susp recon: 200mg/
5ml; tablet: 400mg
ERYPED 200
ERYPED 400
ERY-TAB
erythromycin base tablet, tablet dr
erythromycin ethylsuccinate tablet: 400mg
erythromycin stearate
PCE
azithromycin packet
BIAXIN XL
BIAXIN
DIFICID
KETEK
ZITHROMAX TRI-PAK
ZITHROMAX packet, susp recon, tablet
ZMAX
azithromycin vial
Drug Tier
(Biaxin)
(Erythromycin Base)
(Eryped 200)
(Erythromycin Base)
(Erythromycin
Ethylsuccinate)
(Erythromycin Stearate)
(Zithromax)
(Zithromax)
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T6
ERYTHROCIN LACTOBIONATE
T6
ZITHROMAX vial
T6
Miscellaneous B-Lactam Antibiotics
CAYSTON
AZACTAM
T4
T6
AZACTAM-ISO-OSMOTIC DEXTROSE
T6
aztreonam
(Azactam)
T6
DORIBAX
imipenem/cilastatin sodium
T6
(Primaxin)
INVANZ
meropenem
T6
T6
(Merrem)
T6
MERREM
T6
PRIMAXIN
T6
Penicillins
amoxicillin capsule, susp recon, tab chew, tablet
amoxicillin/potassium clav
ampicillin trihydrate
dicloxacillin sodium
(Amoxicillin)
(Augmentin)
(Ampicillin Trihydrate)
(Dicloxacillin Sodium)
Requirements/Limits
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T1
T1
T1
T1
13
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
penicillin v potassium
AUGMENTIN ES-600
AUGMENTIN XR
AUGMENTIN
ampicillin sodium
(Penicillin V Potassium)
(Ampicillin Sodium)
T1
T3
T3
T3
T6
ampicillin sodium/sulbactam na
(Unasyn)
T6
BICILLIN C-R
T6
BICILLIN L-A
T6
nafcillin in dextrose,iso-osm
T6
nafcillin sodium
(Nafcillin In Dextrose,IsoOsm)
(Nafcillin Sodium)
oxacillin sodium
(Oxacillin Sodium)
T6
oxacillin sodium/dextrose,iso
T6
pen g pot/dextrose-water
(Oxacillin Sodium/Dextrose,
Iso)
(Pen G Pot/Dextrose-Water)
T6
penicillin g potassium
(Penicillin G Potassium)
T6
penicillin g procaine
(Penicillin G Procaine)
T6
penicillin g sodium
(Penicillin G Sodium)
T6
piperacillin sodium/tazobactam
(Zosyn)
T6
T6
TIMENTIN
T6
UNASYN
T6
ZOSYN froz.piggy
T6
ZOSYN vial
T6
amoxicillin tbmp 24hr
MOXATAG
Quinolones
ciprofloxacin hcl
ciprofloxacin
ciprofloxacin/ciprofloxa hcl
levofloxacin solution, tablet
moxifloxacin hcl
ofloxacin
CIPRO sus mc rec
AVELOX ABC PACK
AVELOX
CIPRO tablet: 250mg, 500mg
(Moxatag)
EX
EX
(Cipro)
(Cipro)
(Cipro XR)
(Levaquin)
(Avelox)
(Ofloxacin)
T1
T1
T1
T1
T1
T1
T2
T3
T3
T3
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
14
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
FACTIVE
LEVAQUIN solution, tablet
NOROXIN
AVELOX IV
T3
T3
T3
T6
CIPRO I.V.
T6
ciprofloxacin lactate
(Ciprofloxacin Lactate)
T6
ciprofloxacin lactate/d5w
(Ciprofloxacin Lactate/
D5W)
T6
LEVAQUIN piggyback
T6
levofloxacin vial
(Levofloxacin)
T6
levofloxacin/d5w
(Levofloxacin/D5W)
T6
CIPRO XR
Sulfonamides
sulfamethoxazole/trimethoprim oral susp, tablet
sulfasalazine
sulfadiazine
AZULFIDINE
BACTRIM DS
BACTRIM
sulfamethoxazole/trimethoprim vial
Tetracyclines
demeclocycline hcl
doxycycline hyclate capsule, tablet: 100mg
doxycycline monohydrate capsule: 50mg, 100mg;
susp recon, tablet: 100mg
minocycline hcl capsule
tetracycline hcl
ALODOX
doxycycline monohydrate cap ir dr
VIBRAMYCIN syrup
MINOCIN capsule
MINOCIN combo. pkg
MONODOX capsule: 50mg, 100mg
OCUDOX
ORACEA
VIBRAMYCIN capsule
VIBRAMYCIN susp recon
doxycycline hyclate vial
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
(Bactrim DS)
(Azulfidine)
(Sulfadiazine)
(Sulfamethoxazole/
Trimethoprim)
T1
T1
T2
T3
T3
T3
T6
(Demeclocycline HCl)
(Vibramycin)
(Avidoxy)
T1
T1
T1
(Minocin)
(Tetracycline HCl)
T1
T1
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T6
(Oracea)
(Doxycycline Hyclate)
MINOCIN vial
T6
TYGACIL
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
15
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
ADOXA
AVIDOXY DK
AVIDOXY
DORYX MPC
DORYX
doxycycline hyclate tablet: 20mg; tablet dr
doxycycline monohydrate capsule: 75mg, 150mg;
tablet: 50mg, 75mg, 150mg
minocycline hcl tab er 24h, tablet
MONDOXYNE NL
MONODOX capsule: 75mg
MORGIDOX capsule
MORGIDOX kit
SOLODYN
TARGADOX
Drug Tier
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
(Doryx)
(Avidoxy)
(Minocycline HCl)
EX
EX
EX
EX
EX
EX
EX
(Arimidex)
(Casodex)
(Cyclophosphamide)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
Anticancer Agents
anastrozole
bicalutamide
cyclophosphamide tablet
CYCLOPHOSPHAMIDE
exemestane
flutamide
hydroxyurea
letrozole
megestrol acetate
mercaptopurine
methotrexate sodium tablet
tamoxifen citrate tablet: 10mg
tamoxifen citrate tablet: 20mg
ALKERAN tablet
DROXIA
EMCYT
FARESTON
HEXALEN
LEUKERAN
lomustine
LYSODREN
MATULANE
MYLERAN
nilutamide
RHEUMATREX
TABLOID
TREXALL
AFINITOR DISPERZ
AFINITOR
ARIMIDEX
AROMASIN
bexarotene
(Aromasin)
(Flutamide)
(Hydrea)
(Femara)
(Megestrol Acetate)
(Purinethol)
(Methotrexate Sodium)
(Tamoxifen Citrate)
(Tamoxifen Citrate)
(Lomustine)
(Nilandron)
(Targretin)
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
PA NSO (PA Req'd, Women's
Preventive Healthcare); (Oral
Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
16
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
BOSULIF
capecitabine
CAPRELSA
CASODEX
COMETRIQ
COTELLIC
ERIVEDGE
etoposide capsule
FARYDAK
FEMARA
GILOTRIF
GLEEVEC
HYCAMTIN capsule
HYDREA
IBRANCE
ICLUSIG
imatinib mesylate
IMBRUVICA
INLYTA
IRESSA
LENVIMA
LONSURF
MEKINIST
NEXAVAR
NILANDRON
NINLARO
POMALYST
PURINETHOL
REVLIMID
SPRYCEL
STIVARGA
SUTENT
TAFINLAR
TAGRISSO
TARCEVA
TARGRETIN capsule
TASIGNA
TEMODAR capsule
temozolomide
tretinoin
TYKERB
VOTRIENT
XALKORI
XELODA
XTANDI
ZELBORAF
ZOLINZA
ZYDELIG
ZYKADIA
Drug Tier
(Xeloda)
(Etoposide)
(Gleevec)
(Temodar)
(Tretinoin)
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
Requirements/Limits
PA (Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA, QL: 30 in 30 days (Oral
Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
(Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
17
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
ZYTIGA
JAKAFI
TARGRETIN gel (gram)
ABRAXANE
T3
T4
T4
T6
ADCETRIS
T6
ALIMTA
T6
ALKERAN vial
T6
ARRANON
T6
ARZERRA
T6
AVASTIN
T6
azacitidine
(Vidaza)
T6
BELEODAQ
T6
BEXXAR vial: 14mg/ml
T6
BEXXAR vial: 5.6mci/ml
T6
BICNU
T6
bleomycin sulfate
(Bleomycin Sulfate)
T6
BLINCYTO
T6
BUSULFEX
T6
CAMPTOSAR
T6
carboplatin
(Carboplatin)
CERUBIDINE
T6
T6
cisplatin
(Cisplatin)
T6
cladribine
(Cladribine)
T6
CLOLAR
T6
COSMEGEN
T6
cyclophosphamide vial
(Cyclophosphamide)
CYRAMZA
T6
T6
Requirements/Limits
PA (Oral Cancer Drug)
PA (Oral Cancer Drug)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
18
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
cytarabine/pf
(Cytarabine/PF)
T6
dacarbazine
(Dacarbazine)
T6
DACOGEN
dactinomycin
T6
(Dactinomycin)
DARZALEX
daunorubicin hcl
T6
(Daunorubicin HCl)
DAUNOXOME
decitabine
T6
T6
T6
(Decitabine)
T6
DEPOCYT
T6
DOCEFREZ
T6
docetaxel
(Taxotere)
T6
DOXIL
T6
doxorubicin hcl peg-liposomal
(Doxil)
T6
doxorubicin hcl
(Doxorubicin HCl)
T6
ELIGARD
T6
ELLENCE
T6
ELOXATIN
T6
ELSPAR
T6
EMPLICITI
T6
epirubicin hcl
(Ellence)
T6
ERBITUX
T6
ERWINAZE
T6
ETOPOPHOS
T6
etoposide vial
(Etoposide)
FASLODEX
T6
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
19
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
FIRMAGON
T6
floxuridine
(Floxuridine)
T6
fludarabine phosphate
(Fludarabine Phosphate)
T6
fluorouracil
(Fluorouracil)
T6
FOLOTYN
T6
GAZYVA
T6
gemcitabine hcl
(Gemzar)
T6
GEMZAR
T6
GLIADEL
T6
HALAVEN
T6
HERCEPTIN
T6
HYCAMTIN vial
T6
IDAMYCIN PFS
T6
idarubicin hcl
(Idamycin Pfs)
IFEX
T6
T6
ifosfamide
(Ifex)
T6
ifosfamide/mesna
(Ifosfamide/Mesna)
T6
irinotecan hcl
(Camptosar)
T6
ISTODAX
T6
IXEMPRA
T6
JEVTANA
T6
KADCYLA
T6
KEYTRUDA
T6
KYPROLIS
T6
leuprolide acetate
(Leuprolide Acetate)
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
20
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
LUPRON DEPOT
T6
MARQIBO
T6
melphalan hcl
(Alkeran)
T6
methotrexate sodium vial
(Methotrexate Sodium)
T6
methotrexate sodium/pf
(Methotrexate Sodium/PF)
T6
mitomycin
(Mitomycin)
T6
mitoxantrone hcl
(Mitoxantrone HCl)
T6
MUSTARGEN
T6
NAVELBINE
T6
NIPENT
T6
ONCASPAR
T6
OPDIVO
T6
oxaliplatin
(Eloxatin)
T6
paclitaxel
(Paclitaxel)
T6
pentostatin
(Pentostatin)
T6
PERJETA
T6
PHOTOFRIN
T6
PROLEUKIN
T6
RITUXAN
T6
SYLVANT
T6
SYNRIBO
T6
TAXOTERE
T6
TEMODAR vial
T6
teniposide
(Teniposide)
T6
thiotepa
(Thiotepa)
T6
Requirements/Limits
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
21
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
topotecan hcl
Drug Tier
(Hycamtin)
T6
TORISEL
T6
TREANDA
T6
TRELSTAR
T6
TRISENOX
T6
UNITUXIN
T6
VALSTAR
T6
VECTIBIX
T6
VELCADE
T6
VIDAZA
T6
vinblastine sulfate
(Vinblastine Sulfate)
T6
vincristine sulfate
(Vincristine Sulfate)
T6
vinorelbine tartrate
(Vinorelbine Tartrate)
T6
YERVOY
T6
ZANOSAR
T6
ZEVALIN
T6
ZOLADEX
T6
GLEOSTINE
IMLYGIC
LYNPARZA
ODOMZO
PORTRAZZA
SOLTAMOX
ZALTRAP
EX
EX
EX
EX
EX
EX
EX
Requirements/Limits
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Anticholinergic Agents
Antimuscarinics/Antispasmodics
chlordiazepoxide/clidinium br
phenobarb/hyoscy/atropine/scop
DONNATAL elixir, tablet er
propantheline bromide
STIOLTO RESPIMAT
DONNATAL tablet
LEVBID
(Librax)
(Donnatal)
(Propantheline Bromide)
T1
T1
T2
T2
T2
T3
T3
QL: 4 in 30 days
22
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
LIBRAX
PAMINE FQ
ATROPEN
atropine sulfate syringe: 0.05mg/ml, 0.1mg/ml; vial
T3
T3
T6
(Atropine Sulfate)
ENLON-PLUS
T6
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Anticonvulsants
carbamazepine
divalproex sodium
ethosuximide
felbamate
gabapentin
lamotrigine tab er 24, tablet, tb chw dsp
levetiracetam solution, tab er 24h, tablet
oxcarbazepine
phenobarbital elixir, tablet: 15mg, 16.2mg, 30mg,
32.4mg, 60mg, 100mg
phenytoin sodium extended
phenytoin
primidone
tiagabine hcl
topiramate cap sprink, tablet
valproic acid (as sodium salt) solution
valproic acid
zonisamide
APTIOM
BANZEL
BRIVIACT solution, tablet
CELONTIN
DILANTIN capsule: 30mg
EQUETRO
FYCOMPA
GABITRIL tablet: 12mg, 16mg
LAMICTAL tb chw dsp: 2mg
lamotrigine tab rapdis, tb rd dspk
PEGANONE
phenobarbital tablet: 64.8mg, 97.2mg
POTIGA
VIMPAT solution, tablet
CARBATROL
DEPAKENE capsule
DEPAKENE solution
DEPAKOTE ER
DEPAKOTE SPRINKLE
DEPAKOTE
DILANTIN-125
DILANTIN capsule: 100mg
DILANTIN tab chew
(Tegretol)
(Depakote ER)
(Zarontin)
(Felbatol)
(Neurontin)
(Lamictal)
(Keppra)
(Trileptal)
(Phenobarbital)
T1
T1
T1
T1
T1
T1
T1
T1
T1
(Dilantin)
(Dilantin)
(Mysoline)
(Gabitril)
(Topamax)
(Depakene)
(Depakene)
(Zonegran)
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
(Lamictal Odt)
(Phenobarbital)
QL: 90 in 30 days
23
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
FELBATOL
GABITRIL tablet: 2mg, 4mg
HORIZANT
KEPPRA XR
KEPPRA solution, tablet
LAMICTAL (BLUE)
LAMICTAL (GREEN)
LAMICTAL (ORANGE)
LAMICTAL ODT (BLUE)
LAMICTAL ODT (GREEN)
LAMICTAL ODT (ORANGE)
LAMICTAL ODT
LAMICTAL XR (BLUE)
LAMICTAL XR (GREEN)
LAMICTAL XR (ORANGE)
LAMICTAL XR
LAMICTAL tablet, tb chw dsp: 5mg, 25mg
LYRICA
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
MYSOLINE
NEURONTIN
PHENYTEK
STAVZOR
TEGRETOL XR
TEGRETOL
TOPAMAX
TRILEPTAL
ZARONTIN
ZONEGRAN
SABRIL
BRIVIACT vial
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T4
T6
DEPACON
T6
fosphenytoin sodium
(Fosphenytoin Sodium)
KEPPRA vial
levetiracetam in nacl (iso-os)
levetiracetam vial
T6
T6
(Levetiracetam In Nacl (IsoOs))
(Keppra)
LUMINAL SODIUM
T6
T6
T6
phenobarbital sodium
(Phenobarbital Sodium)
T6
phenytoin sodium
(Phenytoin Sodium)
T6
Requirements/Limits
(Prior Authorization Criteria
Requirements apply to
Medicaid Only)
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
24
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
valproic acid (as sodium salt) vial
Drug Tier
(Depacon)
T6
VIMPAT vial
T6
CEREBYX
GRALISE
OXTELLAR XR
SPRITAM
TROKENDI XR
EX
EX
EX
EX
EX
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Antidementia Agents
donepezil hcl tab rapdis, tablet: 5mg, 10mg
galantamine hbr
memantine hcl
rivastigmine tartrate
NAMENDA tab ds pk, tablet
rivastigmine
ARICEPT ODT
ARICEPT tablet: 5mg, 10mg
EXELON capsule
EXELON patch td24
NAMENDA XR
NAMENDA solution
RAZADYNE ER
RAZADYNE
ARICEPT tablet: 23mg
donepezil hcl tablet: 23mg
NAMZARIC
(Aricept)
(Razadyne)
(Namenda)
(Exelon)
(Exelon)
(Aricept)
T1
T1
T1
T1
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
EX
EX
EX
Antidepressants
amitriptyline hcl
amitriptyline/chlordiazepoxide
bupropion hcl tab er 24h: 150mg, 300mg; tablet,
tablet er
citalopram hydrobromide
clomipramine hcl
desipramine hcl
doxepin hcl
duloxetine hcl
escitalopram oxalate
fluoxetine hcl capsule, solution, tablet
fluvoxamine maleate tablet
imipramine hcl
imipramine pamoate
mirtazapine
nefazodone hcl
nortriptyline hcl
paroxetine hcl tablet
phenelzine sulfate
protriptyline hcl
(Amitriptyline HCl)
(Amitriptyline/
Chlordiazepoxide)
(Wellbutrin XL)
T1
T1
(Celexa)
(Anafranil)
(Norpramin)
(Doxepin HCl)
(Cymbalta)
(Lexapro)
(Prozac)
(Fluvoxamine Maleate)
(Tofranil)
(Tofranil-Pm)
(Remeron)
(Nefazodone HCl)
(Pamelor)
(Paxil)
(Nardil)
(Protriptyline HCl)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
25
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
sertraline hcl
tranylcypromine sulfate
trazodone hcl
venlafaxine hcl cap er 24h, tablet
amoxapine
maprotiline hcl
MARPLAN
PAXIL oral susp
perphenazine/amitriptyline hcl
trimipramine maleate
ANAFRANIL
BRINTELLIX
CELEXA
CYMBALTA
EFFEXOR XR
FETZIMA
LEXAPRO
NARDIL
NORPRAMIN
PAMELOR
PARNATE
PAXIL tablet
PROZAC
REMERON
SURMONTIL
TOFRANIL
TOFRANIL-PM
TRINTELLIX
VIIBRYD
VIVACTIL
WELLBUTRIN SR
WELLBUTRIN XL
WELLBUTRIN
ZOLOFT
APLENZIN
BRISDELLE
DESVENLAFAXINE ER
DESVENLAFAXINE FUMARATE ER
desvenlafaxine
EMSAM
ENOVARX-AMITRIPTYLINE
fluoxetine hcl capsule dr
FLUOXETINE HCL
fluvoxamine maleate cap er 24h
FORFIVO XL
KHEDEZLA
LUVOX CR
Drug Tier
(Zoloft)
(Parnate)
(Trazodone HCl)
(Effexor XR)
(Amoxapine)
(Maprotiline HCl)
(Perphenazine/Amitriptyline
HCl)
(Trimipramine Maleate)
(Desvenlafaxine)
(Prozac Weekly)
(Luvox CR)
Requirements/Limits
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
ST
ST
ST
(NOT COVERED FOR
MEDICAID: Covered
Alternatives Available)
T3
T3
T3
T3
T3
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
26
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
olanzapine/fluoxetine hcl
OLEPTRO ER
paroxetine hcl tab er 24h
PAXIL CR
PEXEVA
PRISTIQ ER
PROZAC WEEKLY
SARAFEM
SILENOR
SYMBYAX
venlafaxine hcl tab er 24
Drug Tier
(Symbyax)
(Venlafaxine Hcl ER)
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
(Precose)
(Glucophage XR)
T1
T1
(Glyset)
(Starlix)
(Actos)
(Actoplus Met)
(Prandin)
(Prandimet)
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
(Paxil CR)
Requirements/Limits
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
acarbose
metformin hcl tab er 24, tab er 24h, tablet
miglitol
nateglinide
pioglitazone hcl
pioglitazone hcl/metformin hcl
repaglinide
repaglinide/metformin hcl
ACTOPLUS MET XR
GLYXAMBI
INVOKAMET
INVOKANA
JANUMET XR
JANUMET
JANUVIA
JARDIANCE
JENTADUETO XR
JENTADUETO
MIFEPREX
RIOMET
SYMLINPEN 120
SYMLINPEN 60
SYNJARDY
TRADJENTA
TRULICITY
VICTOZA 3-PAK
T2
ACTOPLUS MET
ACTOS
AVANDAMET
AVANDARYL
AVANDIA
BYDUREON PEN
T3
T3
T3
T3
T3
T3
Includes generic Glucophage
and Fortamet
QL: 60 in 30 days
ST
ST
QL: 60 in 30 days
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
QL: 4 in 28 days (Self
Administerable (Select)
Injectable)
27
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
Requirements/Limits
BYDUREON
T3
BYETTA
T3
QL: 4 in 28 days (Self
Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
DUETACT
FARXIGA
GLUCOPHAGE XR
GLUCOPHAGE
GLYSET
pioglitazone hcl/glimepiride
PRANDIMET
PRANDIN
PRECOSE
STARLIX
TANZEUM
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
XIGDUO XR tab bp 24h: 5mg-500mg, 10-1000mg,
10mg-500mg
XIGDUO XR tab bp 24h: 5mg-1000mg
KORLYM
alogliptin benz/metformin hcl
alogliptin benz/pioglitazone
alogliptin benzoate
FORTAMET
GLUMETZA
KAZANO
KOMBIGLYZE XR
metformin hcl tabergr24h
NESINA
ONGLYZA
OSENI
Insulins
HUMALOG KWIKPEN U-100
HUMALOG KWIKPEN U-200
HUMALOG MIX 50-50 KWIKPEN
HUMALOG MIX 50-50
HUMALOG MIX 75-25 KWIKPEN
HUMALOG MIX 75-25
HUMALOG
HUMULIN 70/30 KWIKPEN
HUMULIN 70-30
HUMULIN N KWIKPEN
HUMULIN N
HUMULIN R U-500 KWIKPEN
HUMULIN R U-500
HUMULIN R
LANTUS SOLOSTAR
LANTUS
LEVEMIR FLEXTOUCH
(Duetact)
T3
(Kazano)
(Oseni)
(Nesina)
(Glucophage XR)
T3
T5
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
ST
(Self Administerable (Select)
Injectable)
QL: 30 in 30 days
QL: 60 in 30 days
PA
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
28
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
LEVEMIR
NOVOLIN 70-30
NOVOLIN N
NOVOLIN R
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30 FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG
AFREZZA
APIDRA SOLOSTAR
APIDRA
TOUJEO SOLOSTAR
TRESIBA FLEXTOUCH U-100
TRESIBA FLEXTOUCH U-200
Sulfonylureas
glimepiride
glipizide
glipizide/metformin hcl
glyburide
glyburide,micronized
glyburide/metformin hcl
tolazamide tablet: 250mg
chlorpropamide
tolazamide tablet: 500mg
tolbutamide
AMARYL
DIABETA
GLUCOTROL XL
GLUCOTROL
GLUCOVANCE
GLYNASE
Drug Tier
Requirements/Limits
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
(Amaryl)
(Glucotrol)
(Glipizide/Metformin HCl)
(Glyburide)
(Glynase)
(Glucovance)
(Tolazamide)
(Chlorpropamide)
(Tolazamide)
(Tolbutamide)
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T3
T3
T3
T3
T3
T3
Antifungals
CICLODAN cream (g)
CICLODAN solution: 8%
ciclopirox olamine
ciclopirox
clotrimazole
clotrimazole/betamethasone dip
econazole nitrate
fluconazole
flucytosine
griseofulvin ultramicrosize
griseofulvin, microsize
itraconazole
ketoconazole cream (g), shampoo, tablet
naftifine hcl
nystatin
nystatin/triamcin
terbinafine hcl
(Ciclopirox Olamine)
(Penlac)
(Clotrimazole)
(Lotrisone)
(Econazole Nitrate)
(Diflucan)
(Ancobon)
(Gris-Peg)
(Griseofulvin, Microsize)
(Sporanox)
(Ketoconazole)
(Naftin)
(Nystatin)
(Nystatin/Triamcin)
(Lamisil)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
29
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
FIRST-DUKE'S
FIRST-MARY'S
gentian viol/brlnt grn/proflav
miconazole nitrate supp.vag
NOXAFIL oral susp, tablet dr
NYSTATIN
oxiconazole nitrate
SPORANOX solution
ALA-QUIN
ANCOBON
ciclopirox/ure/camph/menth/euc
ciclopirox/vite/nail lacq remo
DERMASORB AF
DIFLUCAN
ERTACZO
EXELDERM
FIRST-BXN
GRIFULVIN V
GRIS-PEG
LAMISIL
LOPROX shampoo
LOTRISONE
MENTAX
NAFTIN
NIZORAL
OXISTAT
PEDIADERM AF
PENLAC
SPORANOX capsule
TERBINEX
VUSION
VFEND
voriconazole susp recon, tablet
ABELCET
Drug Tier
(Gentian Viol/Brlnt Grn/
Proflav)
(Miconazole Nitrate)
(Oxistat)
(Ciclodan)
(Ciclopirox/Vite/Nail Lacq
Remo)
AMBISOME
amphotericin b
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T4
T4
T6
(Vfend)
T6
(Amphotericin B)
T6
CANCIDAS
T6
ERAXIS (WATER DILUENT)
T6
fluconazole in nacl,iso-osm
(Fluconazole In Nacl,IsoOsm)
MYCAMINE
Requirements/Limits
T6
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
30
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
NOXAFIL vial
T6
VFEND IV
T6
voriconazole vial
CICLODAN combo. pkg
CICLODAN solution: 8%
CNL 8
EXTINA
JUBLIA
KERYDIN
ketoconazole foam
KETODAN
LOPROX cream (g)
LUZU
ONMEL
PEDIPIROX-4
XOLEGEL
(Vfend IV)
T6
(Ketoconazole)
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
31
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
Requirements/Limits
Antihistamines
carbinoxamine maleate liquid: 4mg/5ml; tablet
(Carbinoxamine Maleate)
T1
clemastine fumarate syrup, tablet: 2.68mg
(Clemastine Fumarate)
T1
cyproheptadine hcl
desloratadine tablet
diphenhydramine hcl elixir
phenylephrine hcl/prometh hcl
(Cyproheptadine HCl)
(Clarinex)
(Diphenhydramine HCl)
(Phenylephrine HCl/
Prometh HCl)
(Promethazine HCl)
(Carbinoxamine Maleate)
T1
T1
T1
T1
promethazine hcl
carbinoxamine maleate liquid: 4mg/5ml
doxylamine succinate
PALGIC
p-ephed hcl/chlor-mal/bell alk
POLY HIST DHC
SEMPREX-D
diphenhydramine hcl syringe, vial
brompheniramine/phenylephrine
cetirizine hcl
chlorpheniramine/phenylephrine drops: 1mg-2mg/
ml
CLARINEX
CLARINEX-D 12 HOUR
CLARINEX-D 24 HOUR
desloratadine tab rapdis
dexchlorphenir/pseudoephed/dm
fexofenadine hcl
fexofenadine/pseudoephedrine
levocetirizine dihydrochloride
V-HIST
XYZAL
ZYRTEC-D
(Doxylamine Succinate)
(P-Ephed HCl/Chlor-Mal/
Bell Alk)
(Diphenhydramine HCl)
(Brompheniramine/
Phenylephrine)
(Cetirizine HCl)
(Chlorpheniramine/
Phenylephrine)
(Desloratadine)
(Deltuss Dmx)
(Fexofenadine HCl)
(Fexofenadine/
Pseudoephedrine)
(Xyzal)
T1
T3
T3
T3
T3
T3
T3
T6
(Non-self administerable
injectable)
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
32
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
Requirements/Limits
Anti-infectives (Skin and Mucous Membrane)
clindamycin phosphate
metronidazole
terconazole cream/appl: 0.4%, 0.8%; supp.vag
VANDAZOLE
AVC
CLEOCIN supp.vag
CLINDESSE
CLEOCIN cream/appl
FEM PH
GYNAZOLE 1
METROGEL-VAGINAL
RELAGARD
TERAZOL 3
TERAZOL 7
(Cleocin)
(Metrogel-Vaginal)
(Terazol 7)
T1
T1
T1
T1
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T1
isomethepten/caf/acetaminophen tablet: 65-20-325,
130-20-500
naratriptan hcl
(Ergotamine Tartrate/
Caffeine)
(Isomethept/Dichlphn/
Acetaminop)
(Isomethepten/Caf/
Acetaminophen)
(Amerge)
T1
rizatriptan benzoate
(Maxalt)
T1
sumatriptan succinate tablet
(Imitrex)
T1
sumatriptan succinate cartridge: 6mg/0.5ml; pen
injctr, syringe, vial
(Imitrex)
T1
zolmitriptan
(Zomig)
T1
almotriptan malate
CAFERGOT
dihydroergotamine mesylate spray/pump
ERGOMAR
frovatriptan succinate
IMITREX spray
(Axert)
T2
T2
T2
T2
T2
T2
Antimigraine Agents
ergotamine tartrate/caffeine
isomethept/dichlphn/acetaminop
MIGERGOT
MIGRANAL
sumatriptan
(Migranal)
(Frova)
T1
T1
T2
T2
T2
(Imitrex)
QL: 12 in 30 days (QL applies
to all oral Antimigraine agents
combined)
QL: 12 in 30 days (QL applies
to all oral Antimigraine agents
combined)
QL: 12 in 30 days (QL applies
to all oral Antimigraine agents
combined)
QL: 6 in 30 days (Self
Administerable (Select)
Injectable)
QL: 12 in 30 days (QL applies
to all oral Antimigraine agents
combined)
QL: 12 in 30 days
QL: 12 in 30 days
QL: 12 in 30 days (QL applies
to all oral Antimigraine agents
combined)
QL: 12 in 30 days (QL applies
to all oral Antimigraine agents
combined)
33
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
Requirements/Limits
AMERGE
T3
AXERT
T3
FROVA
T3
IMITREX tablet
T3
IMITREX cartridge, pen injctr, vial
T3
QL: 12 in 30 days (QL applies
to all oral Antimigraine agents
combined)
QL: 12 in 30 days (QL applies
to all oral Antimigraine agents
combined)
QL: 12 in 30 days (QL applies
to all oral Antimigraine agents
combined)
QL: 12 in 30 days (QL applies
to all oral Antimigraine agents
combined)
QL: 6 in 30 days (Self
Administerable (Select)
Injectable)
isomethepten/caf/acetaminophen tablet: 65-20-325
(Isomethepten/Caf/
Acetaminophen)
T3
MAXALT MLT
T3
MAXALT
T3
ONZETRA XSAIL
PRODRIN
RELPAX
T3
T3
T3
ZOMIG ZMT
T3
ZOMIG
ZOMIG
T3
T3
D.H.E.45
T6
dihydroergotamine mesylate ampul
(D.H.E.45)
ALSUMA
SUMAVEL DOSEPRO
TREXIMET
T6
QL: 12 in 30 days (QL applies
to all oral Antimigraine agents
combined)
QL: 12 in 30 days (QL applies
to all oral Antimigraine agents
combined)
ST, QL: 16 in 30 days
QL: 12 in 30 days (QL applies
to all oral Antimigraine agents
combined)
QL: 12 in 30 days (QL applies
to all oral Antimigraine agents
combined)
QL: 12 in 30 days
QL: 12 in 30 days (QL applies
to all oral Antimigraine agents
combined)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
EX
EX
Antimycobacterials
ethambutol hcl
isoniazid tablet
pyrazinamide
rifabutin
rifampin capsule
cycloserine
dapsone
isoniazid solution
(Myambutol)
(Isoniazid)
(Pyrazinamide)
(Mycobutin)
(Rifadin)
(Cycloserine)
(Dapsone)
(Isoniazid)
T1
T1
T1
T1
T1
T2
T2
T2
34
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
PASER
PRIFTIN
RIFAMATE
RIFATER
TRECATOR
MYAMBUTOL
MYCOBUTIN
RIFADIN capsule
CAPASTAT SULFATE
isoniazid vial
T2
T2
T2
T2
T2
T3
T3
T3
T6
(Isoniazid)
RIFADIN vial
rifampin vial
T6
T6
(Rifadin)
T6
SIRTURO
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
Antinausea Agents
COMPAZINE supp.rect
dronabinol
granisetron hcl tablet
ondansetron hcl
ondansetron
PHENERGAN supp.rect: 25mg
prochlorperazine maleate
prochlorperazine
promethazine hcl supp.rect, tablet
trimethobenzamide hcl capsule
ANZEMET tablet
CESAMET
EMEND cap ds pk, capsule, susp recon
granisetron hcl solution
TRANSDERM-SCOP
COMPAZINE tablet
MARINOL
PHENERGAN supp.rect: 12.5mg, 50mg
SANCUSO
TIGAN capsule
ZOFRAN ODT
ZOFRAN solution, tablet
ALOXI
(Marinol)
(Granisetron HCl)
(Zofran)
(Zofran Odt)
(Prochlorperazine Maleate)
(Prochlorperazine)
(Promethazine HCl)
(Tigan)
(Granisetron HCl)
ANZEMET vial
dimenhydrinate
T6
(Dimenhydrinate)
EMEND vial
granisetron hcl vial
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T6
T6
T6
(Granisetron HCl)
T6
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
35
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
granisetron hcl/pf
(Granisetron HCl/PF)
T6
ondansetron hcl/pf
(Ondansetron HCl/PF)
T6
PHENERGAN ampul, vial
T6
prochlorperazine edisylate
(Prochlorperazine Edisylate)
T6
promethazine hcl vial
(Phenergan)
T6
scopolamine hydrobromide
(Scopolamine
Hydrobromide)
T6
TIGAN vial
trimethobenzamide hcl vial
T6
(Trimethobenzamide HCl)
ZOFRAN vial
DICLEGIS
meclizine hcl
ZUPLENZ
T6
T6
(Meclizine HCl)
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
EX
EX
Antiparasite Agents
atovaquone/proguanil hcl
chloroquine phosphate
hydroxychloroquine sulfate
ivermectin
mefloquine hcl
paromomycin sulfate
quinine sulfate
tinidazole
ALBENZA
ALINIA
BILTRICIDE
COARTEM
DARAPRIM
NEBUPENT
PRIMAQUINE
YODOXIN
MALARONE
PLAQUENIL
QUALAQUIN
STROMECTOL
TINDAMAX
atovaquone
MEPRON
PENTAM 300
(Malarone)
(Chloroquine Phosphate)
(Plaquenil)
(Stromectol)
(Mefloquine HCl)
(Paromomycin Sulfate)
(Qualaquin)
(Tindamax)
(Mepron)
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T4
T4
T6
(Non-self administerable
injectable)
Antiparkinsonian Agents
amantadine hcl
benztropine mesylate tablet
(Amantadine HCl)
(Benztropine Mesylate)
T1
T1
36
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
bromocriptine mesylate
cabergoline
carbidopa
carbidopa/levodopa
carbidopa/levodopa/entacapone
entacapone
pramipexole di-hcl tablet
ropinirole hcl
selegiline hcl
trihexyphenidyl hcl
AZILECT
LODOSYN
pramipexole di-hcl tab er 24h
tolcapone
ZELAPAR
COMTAN
ELDEPRYL
MIRAPEX ER
MIRAPEX
NEUPRO
PARCOPA
PARLODEL
REQUIP XL
REQUIP
RYTARY
SINEMET 10-100
SINEMET 25-100
SINEMET 25-250
SINEMET CR
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
TASMAR
APOKYN
(Bromocriptine Mesylate)
(Cabergoline)
(Lodosyn)
(Sinemet 25-100)
(Stalevo 200)
(Comtan)
(Mirapex)
(Requip)
(Eldepryl)
(Trihexyphenidyl HCl)
benztropine mesylate ampul
(Cogentin)
(Mirapex ER)
(Tasmar)
COGENTIN
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T5
T6
T6
Requirements/Limits
QL: 30 in 30 days
PA (Self Administerable
(Select) Injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Antipsychotic Agents
aripiprazole
chlorpromazine hcl tablet
clozapine tablet
fluphenazine hcl tablet
haloperidol lactate oral conc
haloperidol
loxapine succinate
(Abilify Discmelt)
(Chlorpromazine HCl)
(Clozaril)
(Fluphenazine HCl)
(Haloperidol Lactate)
(Haloperidol)
(Loxapine Succinate)
T1
T1
T1
T1
T1
T1
T1
37
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
molindone hcl
olanzapine tab rapdis, tablet
perphenazine
quetiapine fumarate
risperidone
thioridazine hcl
thiothixene
trifluoperazine hcl
ziprasidone hcl
fluphenazine hcl elixir, oral conc
pimozide
SEROQUEL XR
ABILIFY DISCMELT
ABILIFY solution, tablet
CLOZARIL
FANAPT
GEODON capsule
LATUDA
LOXITANE
ORAP
RISPERDAL M-TAB
RISPERDAL
SAPHRIS
SEROQUEL
VRAYLAR cap ds pk
VRAYLAR capsule
ZYPREXA ZYDIS
ZYPREXA tablet
NUPLAZID
ABILIFY MAINTENA
Drug Tier
(Molindone HCl)
(Zyprexa)
(Perphenazine)
(Seroquel)
(Risperdal)
(Thioridazine HCl)
(Thiothixene)
(Trifluoperazine HCl)
(Geodon)
(Fluphenazine HCl)
(Orap)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T5
T6
ABILIFY vial
T6
ARISTADA
T6
chlorpromazine hcl ampul
(Chlorpromazine HCl)
T6
fluphenazine decanoate
(Fluphenazine Decanoate)
T6
fluphenazine hcl vial
(Fluphenazine HCl)
T6
GEODON vial
T6
HALDOL DECANOATE 100
T6
HALDOL DECANOATE 50
T6
HALDOL
T6
Requirements/Limits
QL: 30 in 30 days
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
38
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
haloperidol decanoate
(Haloperidol Decanoate)
T6
haloperidol lactate vial
(Haloperidol Lactate)
T6
INVEGA SUSTENNA
T6
INVEGA TRINZA
T6
olanzapine vial
(Zyprexa)
T6
RISPERDAL CONSTA
T6
ZYPREXA RELPREVV
T6
ZYPREXA vial
T6
clozapine tab rapdis
FAZACLO
INVEGA
paliperidone
REXULTI
(Fazaclo)
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
ST (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
EX
EX
EX
EX
(Invega)
Antivirals (Systemic)
Antiretrovirals
abacavir sulfate
didanosine
lamivudine
lamivudine/zidovudine
nevirapine tab er 24h, tablet
stavudine
zidovudine
abacavir/lamivudine/zidovudine
APTIVUS capsule
APTIVUS solution
COMBIVIR
CRIXIVAN
DESCOVY
EDURANT
EMTRIVA
EPIVIR HBV solution
EPZICOM
EVOTAZ
INTELENCE
INVIRASE
ISENTRESS
KALETRA
nevirapine oral susp
NORVIR
PREZCOBIX
RESCRIPTOR
REYATAZ
(Ziagen)
(Videx EC)
(Epivir Hbv)
(Combivir)
(Viramune)
(Zerit)
(Zidovudine)
(Trizivir)
(Viramune)
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
39
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
SELZENTRY
SUSTIVA
TRUVADA
VIDEX
VIRACEPT
VIREAD
ZIAGEN
EPIVIR HBV tablet
EPIVIR
RETROVIR capsule, syrup
TIVICAY
VIDEX EC
VIRAMUNE XR
VIRAMUNE
ZERIT
ATRIPLA
COMPLERA
GENVOYA
LEXIVA
PREZISTA
STRIBILD
TRIUMEQ
TRIZIVIR
FUZEON
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T4
T4
T4
T4
T4
T4
T4
T4
T5
VITEKTA
RETROVIR vial
T5
T6
Antivirals, Miscellaneous
rimantadine hcl
RELENZA
TAMIFLU
FLUMADINE
foscarnet sodium
(Rimantadine HCl)
T1
(Foscarnet Sodium)
T2
T2
T3
T6
FOSCAVIR
T6
SYNAGIS
T6
HCV Antivirals
EPCLUSA
HARVONI
INCIVEK
SOVALDI
OLYSIO
VICTRELIS
VIEKIRA PAK
VIEKIRA XR
Interferons
T5
T5
T5
T5
EX
EX
EX
EX
Requirements/Limits
(Self Administerable (Select)
Injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA
PA
PA
40
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
Requirements/Limits
INTRON A
T5
PEGASYS PROCLICK
T5
PEGASYS
T5
PEGINTRON REDIPEN
T5
PEGINTRON
T5
SYLATRON
T5
ALFERON N
T6
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
(Non-self administerable
injectable)
Nucleosides and Nucleotides
acyclovir
famciclovir
valacyclovir hcl
valganciclovir hcl soln recon
FAMVIR
VALTREX
ZOVIRAX
adefovir dipivoxil
BARACLUDE
COPEGUS
entecavir
HEPSERA
REBETOL
RIBATAB
ribavirin
TYZEKA
VALCYTE
valganciclovir hcl tablet
VIRAZOLE
acyclovir sodium
cidofovir
(Zovirax)
(Famvir)
(Valtrex)
(Valcyte)
(Acyclovir Sodium)
T1
T1
T1
T1
T3
T3
T3
T4
T4
T4
T4
T4
T4
T4
T4
T4
T4
T4
T4
T6
(Vistide)
T6
(Hepsera)
(Baraclude)
(Ribavirin)
(Valcyte)
CYTOVENE
ganciclovir sodium
T6
(Cytovene)
T6
VISTIDE
T6
MODERIBA
EX
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Blood Products/Modifiers/Volume Expanders
Anticoagulants
warfarin sodium
sodium citrate solution
COUMADIN tablet
(Coumadin)
(Sodium Citrate)
T1
T2
T3
(Includes Jantoven)
41
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
ELIQUIS
PRADAXA
XARELTO tab ds pk, tablet: 15mg, 20mg
XARELTO tablet: 10mg
enoxaparin sodium
(Lovenox)
T3
T3
T3
T3
T4
fondaparinux sodium
(Arixtra)
T4
IPRIVASK
T4
ARIXTRA
T5
FRAGMIN
T5
LOVENOX
T5
ANGIOMAX
T6
ARGATROBAN
T6
ARGATROBAN-0.9% NACL
T6
bivalirudin
(Angiomax)
T6
CEPROTIN
T6
COUMADIN vial
T6
heparin sod,porcine/0.9 % nacl iv soln: 1k/1000ml,
6k/1000ml, 2000/500ml; kit
heparin sod,pork in 0.45% nacl
(Heparin Sod,Porcine/0.9 %
NaCl)
(Heparin Sod,Pork In 0.45%
NaCl)
HEPARIN SODIUM IN 0.45% NACL
T6
T6
T6
heparin sodium,porcine
(Heparin Sodium,Porcine)
T6
heparin sodium,porcine/d5w iv soln: 20k/500ml,
25000/250
heparin sodium,porcine/ns/pf
(Heparin Sodium,Porcine/
D5W)
(Heparin Sodium,Porcine/
Ns/PF)
(Monoject Prefill Advanced)
T6
heparin sodium,porcine/pf
T6
T6
MONOJECT PREFILL ADVANCED
T6
THROMBATE III
T6
SAVAYSA
Blood Formation Modifiers
PROMACTA
EX
Requirements/Limits
QL: 94 in 365 days
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
PA (Self Administerable
(Select) Injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T4
42
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
Requirements/Limits
NEUMEGA
T5
ARANESP
T6
BERINERT
T6
CINRYZE
T6
EPOGEN
T6
GRANIX
T6
LEUKINE
T6
MOZOBIL
T6
NEULASTA
T6
NEUPOGEN
T6
OMONTYS
T6
PROCRIT
T6
(Self Administerable (Select)
Injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Hematologic Agents, Miscellaneous
aminocaproic acid solution, tablet: 500mg
anagrelide hcl
AGRYLIN
AMICAR tablet
aminocaproic acid tablet: 1000mg
AVITENE
GELFOAM
OXYCEL
RECOTHROM
TACHOSIL
thrombin (bovine)
tranexamic acid tablet
ULTRAFOAM
ACTIVASE
(Aminocaproic Acid)
(Agrylin)
(Aminocaproic Acid)
(Thrombin (Bovine))
(Lysteda)
T1
T1
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T6
ADVATE
T6
ADYNOVATE
T6
ALPHANATE
T6
ALPHANINE SD
T6
aminocaproic acid vial
(Aminocaproic Acid)
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
43
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
BEBULIN
T6
BENEFIX
T6
CATHFLO ACTIVASE
T6
COAGADEX
T6
CORIFACT
T6
CYKLOKAPRON
T6
ELOCTATE
T6
FEIBA NF
T6
HELIXATE FS
T6
HEMOFIL M
T6
HUMATE-P
T6
IXINITY
T6
KCENTRA
T6
KOATE-DVI
T6
KOGENATE FS
T6
MONOCLATE-P
T6
MONONINE
T6
NOVOEIGHT
T6
NOVOSEVEN RT
T6
NUWIQ
T6
OBIZUR
T6
PRAXBIND
T6
PROFILNINE
T6
protamine sulfate
(Protamine Sulfate)
RECOMBINATE
T6
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
44
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
RETAVASE
T6
RIASTAP
T6
RIXUBIS
T6
TNKASE
T6
tranexamic acid vial
(Tranexamic Acid)
T6
WILATE
T6
XYNTHA SOLOFUSE
T6
XYNTHA
T6
ALPROLIX
ARTISS
LYSTEDA
TISSEEL VHSD
Platelet-Aggregation Inhibitors
aspirin/dipyridamole
cilostazol
clopidogrel bisulfate
dipyridamole
pentoxifylline
ticlopidine hcl
AGGRENOX
BRILINTA
EFFIENT
PERSANTINE
PLAVIX
PLETAL
AGGRASTAT
EX
EX
EX
EX
eptifibatide
(Aggrenox)
(Pletal)
(Plavix)
(Persantine)
(Pentoxifylline)
(Ticlopidine HCl)
(Integrilin)
T1
T1
T1
T1
T1
T1
T3
T3
T3
T3
T3
T3
T6
T6
INTEGRILIN
T6
REOPRO
T6
ZONTIVITY
Volume Expanders
ALBUKED-25
EX
ALBUKED-5
T6
ALBUMIN (HUMAN)
T6
ALBUMINAR-25
T6
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
45
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
ALBUMINAR-5
T6
ALBURX
T6
ALBUTEIN
T6
BUMINATE
T6
FLEXBUMIN
T6
KEDBUMIN
T6
OCTAPLAS plast. bag: 45to70mg
T6
OCTAPLAS plast. bag: 45to70mg
T6
OCTAPLAS plast. bag: 45to70mg
T6
OCTAPLAS plast. bag: 45to70mg
T6
PLASBUMIN-25
T6
PLASBUMIN-5
T6
PLASMANATE
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Caloric Agents
PROTECT PLUS
AMINO ACIDS
T3
T6
AMINOSYN II WITH ELECTROLYTES
T6
AMINOSYN II iv soln: 10%
T6
AMINOSYN II iv soln: 15%
T6
AMINOSYN II iv soln: 7%
T6
AMINOSYN II iv soln: 8.5%
T6
AMINOSYN M
T6
AMINOSYN WITH ELECTROLYTES iv soln:
7%
AMINOSYN WITH ELECTROLYTES iv soln:
8.5%
AMINOSYN iv soln: 10%
T6
T6
AMINOSYN iv soln: 3.5%
T6
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
46
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
AMINOSYN iv soln: 7%
T6
AMINOSYN iv soln: 8.5%
T6
AMINOSYN-HBC
T6
AMINOSYN-PF iv soln: 10%
T6
AMINOSYN-PF iv soln: 7%
T6
AMINOSYN-RF
T6
CLINIMIX E iv soln: 2.75%
T6
CLINIMIX E iv soln: 2.75%
T6
CLINIMIX E iv soln: 4.25%
T6
CLINIMIX E iv soln: 4.25%
T6
CLINIMIX E iv soln: 4.25%
T6
CLINIMIX E iv soln: 5%
T6
CLINIMIX E iv soln: 5%
T6
CLINIMIX E iv soln: 5%
T6
CLINIMIX iv soln: 2.75%
T6
CLINIMIX iv soln: 4.25%
T6
CLINIMIX iv soln: 4.25%
T6
CLINIMIX iv soln: 4.25%
T6
CLINIMIX iv soln: 4.25%
T6
CLINIMIX iv soln: 5%
T6
CLINIMIX iv soln: 5%
T6
CLINIMIX iv soln: 5%
T6
CLINISOL
T6
cysteine hcl
(Cysteine HCl)
T6
dextrose 10 % in water iv soln
(Dextrose 10 % in Water)
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
47
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
dextrose 20 % in water
(Dextrose 20 % in Water)
T6
dextrose 25 % in water
(Dextrose 25 % in Water)
T6
dextrose 30 % in water
(Dextrose 30 % in Water)
T6
dextrose 40 % in water
(Dextrose 40 % in Water)
T6
dextrose 5 % in ringers
(Dextrose 5 % In Ringers)
T6
dextrose 5 % in water
(Dextrose 5 % in Water)
T6
dextrose 50 % in water
(Dextrose 50 % in Water)
T6
dextrose 70 % in water
(Dextrose 70 % in Water)
T6
fat emul/soy/mct/oliv/fish oil
(Fat Emul/Soy/Mct/Oliv/
Fish Oil)
T6
FREAMINE HBC
T6
FREAMINE III
T6
HEPATAMINE
T6
HEPATASOL
T6
INTRALIPID
T6
KABIVEN
T6
NEPHRAMINE
T6
NUTRILIPID
T6
PERIKABIVEN
T6
PREMASOL iv soln: 10%
T6
PREMASOL iv soln: 6%
T6
PROCALAMINE
T6
PROSOL
T6
TRAVASOL
T6
TROPHAMINE iv soln: 10%
T6
TROPHAMINE iv soln: 6%
T6
AXONA
EX
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
48
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
GLYTACTIN 10 PE BETTERMILK
GLYTACTIN 15 PE BETTERMILK
Requirements/Limits
EX
EX
Cardiac Function
thallous chloride tl-201
(Thallous Chloride Tl-201)
THALLOUS CHLORIDE TL-201
T6
(Non-self administerable
injectable)
EX
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl
clonidine
doxazosin mesylate
guanfacine hcl
methyldopa
midodrine hcl
prazosin hcl
clonidine hcl/chlorthalidone
methyldopa/hydrochlorothiazide
phenoxybenzamine hcl
CARDURA
CATAPRES
CATAPRES-TTS 1
CATAPRES-TTS 2
CATAPRES-TTS 3
MINIPRESS
TENEX
NORTHERA
methyldopate hcl
(Catapres)
(Catapres-Tts 3)
(Cardura)
(Tenex)
(Methyldopa)
(Midodrine HCl)
(Minipress)
(Clorpres)
(Methyldopa/
Hydrochlorothiazide)
(Dibenzyline)
(Methyldopate HCl)
NEO-SYNEPHRINE
phenylephrine hcl
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T4
T6
T6
(Phenylephrine HCl)
T6
VAZCULEP
T6
CARDURA XL
DIBENZYLINE
Angiotensin II Receptor Antagonists
candesartan cilexetil
candesartan/hydrochlorothiazid
eprosartan mesylate
irbesartan
irbesartan/hydrochlorothiazide
losartan potassium
losartan/hydrochlorothiazide
telmisartan
telmisartan/hydrochlorothiazid
valsartan
valsartan/hydrochlorothiazide
EX
EX
(Atacand)
(Atacand HCT)
(Teveten)
(Avapro)
(Avalide)
(Cozaar)
(Hyzaar)
(Micardis)
(Micardis HCT)
(Diovan)
(Diovan HCT)
QL: 4 in 28 days
QL: 4 in 28 days
QL: 4 in 28 days
QL: 4 in 28 days
PA, QL: 180 in 30 days
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
49
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
ATACAND HCT
ATACAND
AVALIDE
AVAPRO
BENICAR HCT
BENICAR
COZAAR
DIOVAN HCT
DIOVAN
EDARBI
EDARBYCLOR
ENTRESTO
HYZAAR
MICARDIS HCT
MICARDIS
TEVETEN HCT
TEVETEN
telmisartan/amlodipine
(Twynsta)
TWYNSTA
Angiotensin-Converting Enzyme Inhibitors
benazepril hcl
(Lotensin)
benazepril/hydrochlorothiazide
(Lotensin HCT)
captopril
(Captopril)
captopril/hydrochlorothiazide
(Captopril/
Hydrochlorothiazide)
enalapril maleate
(Vasotec)
enalapril/hydrochlorothiazide
(Vaseretic)
fosinopril sodium
(Fosinopril Sodium)
fosinopril/hydrochlorothiazide
(Fosinopril/
Hydrochlorothiazide)
lisinopril
(Zestril)
lisinopril/hydrochlorothiazide
(Zestoretic)
moexipril hcl
(Univasc)
moexipril/hydrochlorothiazide
(Uniretic)
perindopril erbumine
(Perindopril Erbumine)
quinapril hcl
(Accupril)
quinapril/hydrochlorothiazide
(Accuretic)
ramipril
(Altace)
trandolapril
(Mavik)
trandolapril/verapamil hcl
(Tarka)
ACCUPRIL
ACCURETIC
ACEON
ALTACE
LOTENSIN HCT
LOTENSIN
MAVIK
PRINIVIL
TARKA
UNIRETIC
Requirements/Limits
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
EX
EX
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
50
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
UNIVASC
VASERETIC
VASOTEC
ZESTORETIC
ZESTRIL
enalaprilat dihydrate
EPANED
Antiarrhythmic Agents
amiodarone hcl tablet
disopyramide phosphate
dofetilide
flecainide acetate
mexiletine hcl
propafenone hcl
quinidine gluconate tablet er
quinidine sulfate tablet: 300mg
NORPACE CR
quinidine sulfate tablet: 200mg; tablet er
CORDARONE
MULTAQ
NORPACE
RYTHMOL SR
RYTHMOL
TIKOSYN
ADENOCARD
Drug Tier
(Enalaprilat Dihydrate)
T3
T3
T3
T3
T3
T6
Requirements/Limits
(Non-self administerable
injectable)
EX
(Cordarone)
(Norpace)
(Tikosyn)
(Tambocor)
(Mexiletine HCl)
(Rythmol)
(Quinidine Gluconate)
(Quinidine Sulfate)
(Quinidine Sulfate)
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T3
T3
T3
T3
T3
T3
T6
adenosine
(Adenosine)
T6
amiodarone hcl syringe, vial
(Amiodarone HCl)
T6
CORVERT
T6
ibutilide fumarate
(Corvert)
T6
lidocaine hcl/d5w/pf
(Lidocaine HCl/D5w/PF)
T6
lidocaine hcl/d7.5w/pf
(Lidocaine HCl/D7.5w/PF)
T6
lidocaine hcl/pf
(Lidocaine HCl/PF)
T6
NEXTERONE
T6
procainamide hcl
(Procainamide HCl)
T6
quinidine gluconate vial
(Quinidine Gluconate)
T6
Beta-Adrenergic Blocking Agents
acebutolol hcl
atenolol
(Sectral)
(Tenormin)
T1
T1
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
51
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
atenolol/chlorthalidone
betaxolol hcl
bisoprolol fumarate
bisoprolol fumarate/hctz
carvedilol
labetalol hcl tablet
metoprolol succinate
metoprolol tartrate tablet: 25mg, 50mg, 100mg
metoprolol/hydrochlorothiazide
nadolol
nadolol/bendroflumethiazide
pindolol
propranolol hcl cap sa 24h, tablet
propranolol/hydrochlorothiazid
sotalol hcl
BYSTOLIC
DUTOPROL
LEVATOL
propranolol hcl solution
timolol maleate
BETAPACE AF
BETAPACE
COREG
CORGARD
CORZIDE
INDERAL LA
INNOPRAN XL
LOPRESSOR HCT
LOPRESSOR tablet
SECTRAL
TENORETIC 100
TENORETIC 50
TENORMIN
TOPROL XL
TRANDATE
ZEBETA
ZIAC
BREVIBLOC iv soln
Drug Tier
(Tenoretic 50)
(Betaxolol HCl)
(Zebeta)
(Ziac)
(Coreg)
(Trandate)
(Toprol XL)
(Lopressor)
(Lopressor HCT)
(Corgard)
(Corzide)
(Pindolol)
(Propranolol HCl)
(Propranolol/
Hydrochlorothiazid)
(Betapace AF)
(Propranolol HCl)
(Timolol Maleate)
BREVIBLOC vial
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T6
T6
esmolol hcl
(Esmolol HCl)
T6
labetalol hcl vial
(Labetalol HCl)
T6
LOPRESSOR ampul
metoprolol tartrate vial
T6
(Metoprolol Tartrate)
Requirements/Limits
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
52
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
propranolol hcl vial
Drug Tier
(Propranolol HCl)
SOTALOL HCL
COREG CR
metoprolol tartrate tablet: 37.5mg, 75mg
Calcium-Channel Blocking Agents
diltiazem hcl cap er 12h, cap er 24h, cap er deg,
capsule er, tab er 24h, tablet
verapamil hcl cap24h pct, cap24h pel, tablet, tablet
er: 120mg, 180mg, 240mg
CALAN SR
CALAN
CARDIZEM CD
CARDIZEM LA
CARDIZEM
DILACOR XR
TIAZAC
VERELAN PM
VERELAN
diltiazem hcl vial, vial port
T6
T6
(Lopressor)
EX
EX
(Cardizem CD)
T1
(Calan SR)
T1
(Diltiazem HCl)
T3
T3
T3
T3
T3
T3
T3
T3
T3
T6
verapamil hcl syringe, vial
(Verapamil HCl)
T6
Cardiovascular Agents, Miscellaneous
digoxin tablet
hydralazine hcl tablet
isoxsuprine hcl
papaverine hcl capsule er
ADRENACLICK
(Lanoxin)
(Hydralazine HCl)
(Isoxsuprine HCl)
(Papaverine HCl)
T1
T1
T1
T1
T2
AUVI-Q
T2
DEMSER
DIGOXIN
epinephrine auto injct
T2
T2
T2
(Epinephrine)
EPIPEN 2-PAK
T2
EPIPEN JR 2-PAK
T2
reserpine
LANOXIN tablet
RANEXA
FIRAZYR
(Reserpine)
T2
T3
T3
T5
ADRENALIN
T6
CORLOPAM
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
PA (Self Administerable
(Select) Injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
53
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
DIGIFAB
T6
digoxin syringe
(Digoxin)
T6
dipyridamole
(Dipyridamole)
T6
dobutamine hcl
(Dobutamine HCl)
T6
dobutamine hcl/d5w
(Dobutamine HCl/D5W)
T6
dopamine hcl
(Dopamine HCl)
T6
dopamine hcl/d5w
(Dopamine HCl/D5W)
T6
ephedrine sulfate
(Ephedrine Sulfate)
T6
epinephrine hcl/pf
(Epinephrine HCl/PF)
T6
epinephrine ampul, syringe
(Epinephrine)
T6
ethanolamine oleate
(Ethanolamine Oleate)
T6
hydralazine hcl vial
(Hydralazine HCl)
T6
LANOXIN PEDIATRIC
T6
LANOXIN ampul
T6
LEVOPHED BITARTRATE
T6
milrinone lactate
(Milrinone Lactate)
T6
milrinone lactate/d5w
(Milrinone Lactate/D5W)
T6
NATRECOR
T6
NITROPRESS
T6
norepinephrine bitartrate
(Levophed Bitartrate)
T6
papaverine hcl vial
(Papaverine HCl)
T6
VECAMYL
Dihydropyridines
amlodipine besylate
amlodipine besylate/benazepril
amlodipine/valsartan
felodipine
nicardipine hcl capsule
nifedipine
nimodipine
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
(Norvasc)
(Lotrel)
(Exforge)
(Felodipine)
(Nicardipine HCl)
(Adalat CC)
(Nimodipine)
T1
T1
T1
T1
T1
T1
T1
54
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
nisoldipine tab er 24h: 8.5mg, 17mg, 34mg
CARDENE SR
isradipine
nisoldipine tab er 24h: 20mg, 30mg, 40mg
ADALAT CC
LOTREL
nisoldipine tab er 24h: 25.5mg
NORVASC
PROCARDIA XL
PROCARDIA
SULAR
CARDENE I.V. ampul
Drug Tier
(Sular)
(Isradipine)
(Sular)
(Sular)
CARDENE I.V. piggyback
nicardipine hcl in 0.9% nacl
nicardipine hcl vial
amlodipine/valsartan/hcthiazid
AZOR
CLEVIPREX
EXFORGE HCT
EXFORGE
Diuretics
amiloride hcl
amiloride/hydrochlorothiazide
T1
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T6
T6
(Nicardipine Hcl In 0.9%
NaCl)
(Nicardipine HCl)
(Exforge HCT)
(Amiloride HCl)
(Amiloride/
Hydrochlorothiazide)
bumetanide tablet
(Bumetanide)
chlorothiazide
(Chlorothiazide)
chlorthalidone
(Chlorthalidone)
furosemide solution: 10mg/ml; tablet
(Lasix)
hydrochlorothiazide
(Microzide)
indapamide
(Indapamide)
metolazone
(Zaroxolyn)
torsemide tablet
(Demadex)
triamterene/hydrochlorothiazid capsule: 37.5-25mg; (Maxzide-25 Mg)
tablet
DIURIL
DYRENIUM
ethacrynic acid
(Edecrin)
furosemide solution: 40mg/5ml
(Furosemide)
methyclothiazide
(Methyclothiazide)
triamterene/hydrochlorothiazid capsule: 50mg(Dyazide)
25mg
DEMADEX
DYAZIDE
EDECRIN
LASIX
MAXZIDE-25 MG
T6
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
EX
EX
EX
EX
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
55
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
MAXZIDE
MICROZIDE
ZAROXOLYN
SAMSCA
bumetanide vial
(Bumetanide)
T3
T3
T3
T4
T6
chlorothiazide sodium
(Sodium Diuril)
T6
ethacrynate sodium
(Sodium Edecrin)
T6
furosemide syringe, vial
(Furosemide)
T6
mannitol
(Mannitol)
T6
OSMITROL
T6
SODIUM DIURIL
T6
SODIUM EDECRIN
T6
torsemide vial
(Torsemide)
VAPRISOL-5% DEXTROSE
Dyslipidemics
atorvastatin calcium
cholestyramine (with sugar)
cholestyramine/aspartame
colestipol hcl
fenofibrate nanocrystallized
fenofibrate tablet
fenofibrate,micronized
fluvastatin sodium capsule
gemfibrozil
lovastatin
niacin tab er 24h
pravastatin sodium
rosuvastatin calcium
simvastatin
fluvastatin sodium tab er 24h
niacin tablet
SIMCOR
VYTORIN
WELCHOL
ADVICOR
amlodipine/atorvastatin
ANTARA
CADUET
COLESTID
CRESTOR
T6
T6
(Lipitor)
(Questran)
(Questran Light)
(Colestid)
(Tricor)
(Fenoglide)
(Antara)
(Lescol)
(Lopid)
(Mevacor)
(Niaspan)
(Pravachol)
(Crestor)
(Zocor)
(Lescol XL)
(Niacin)
(Caduet)
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
56
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
fenofibrate capsule
fenofibric acid (choline)
(Lipofen)
(Trilipix)
T3
T3
fenofibric acid
FENOGLIDE
FIBRICOR
LESCOL XL
LESCOL
LIPOFEN
LOFIBRA capsule
LOFIBRA tablet
LOPID
MEVACOR
NIASPAN
PRAVACHOL
QUESTRAN LIGHT
QUESTRAN
TRICOR
TRIGLIDE
TRILIPIX
(Fibricor)
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
ZETIA
ZOCOR
PRALUENT PEN
T3
T3
T4
PRALUENT SYRINGE
T4
REPATHA PUSHTRONEX
T4
REPATHA SURECLICK
T4
REPATHA SYRINGE
T4
ALTOPREV
JUXTAPID
KYNAMRO
LIPICHOL 540
LIPITOR
LIPTRUZET
LIVALO
LOVAZA
omega-3 acid ethyl esters
(Lovaza)
VASCAZEN
VASCEPA
Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone
(Inspra)
spironolact/hydrochlorothiazid
(Aldactazide)
spironolactone
(Aldactone)
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
Requirements/Limits
(NOT COVERED FOR
MEDICAID: Covered
Alternatives Available)
(NOT COVERED FOR
MEDICAID: Covered
Alternatives Available)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
T1
T1
T1
57
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
ALDACTAZIDE
ALDACTONE
INSPRA
AMTURNIDE
TEKTURNA HCT
TEKTURNA
Sclerosing Agents
ASCLERA
VARITHENA
Vasodilators
ISOCHRON
isosorbide dinitrate tablet, tablet er
isosorbide mononitrate
minoxidil
nitroglycerin patch td24
nitroglycerin capsule er, tab subl
BIDIL
ISORDIL
isosorbide dinitrate tab subl
NITRO-BID
nitroglycerin spray
NITROLINGUAL
NITROMIST
NITROSTAT
PROGLYCEM
DILATRATE-SR
IMDUR
ISORDIL TITRADOSE
NITRO-DUR
nitroglycerin vial
nitroglycerin/d5w
Drug Tier
Requirements/Limits
T3
T3
T3
EX
EX
EX
EX
EX
(Nitroglycerin)
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T6
(Nitroglycerin/D5W)
T6
(Isordil Titradose)
(Imdur)
(Minoxidil)
(Nitro-Dur)
(Nitroglycerin)
(Isosorbide Dinitrate)
(Nitrolingual)
NITRONAL
T6
QL: 30 in 30 days
QL: 30 in 30 days
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Central Nervous System Agents
caffeine citrated solution
DEXEDRINE tablet
dexmethylphenidate hcl
dextroamphetamine sulfate
dextroamphetamine/amphetamine
guanfacine hcl
lithium carbonate
methamphetamine hcl
methylphenidate hcl
riluzole
lithium citrate
RITALIN LA cpbp 50-50: 10mg
ADDERALL XR
(Cafcit)
(Focalin)
(Dextroamphetamine
Sulfate)
(Adderall)
(Intuniv)
(Lithium Carbonate)
(Desoxyn)
(Concerta)
(Rilutek)
(Lithium Citrate)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T3
PA
58
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
ADDERALL
CAFCIT solution
CONCERTA
DESOXYN
DEXEDRINE capsule er
FOCALIN XR
FOCALIN
INTUNIV
T3
T3
T3
T3
T3
T3
T3
T3
LITHOBID
METADATE CD
METHYLIN
PROCENTRA
RILUTEK
RITALIN LA cpbp 50-50: 20mg, 30mg, 40mg,
60mg
RITALIN
RITALIN-SR
SAVELLA
T3
T3
T3
T3
T3
T3
STRATTERA
VYVANSE
ZENZEDI
tetrabenazine
XENAZINE
BREVITAL SODIUM
T3
T3
T3
T4
T5
T6
T3
T3
T3
(Xenazine)
CAFCIT vial
T6
caffeine citrated vial
(Caffeine Citrated)
T6
caffeine/sodium benzoate
(Caffeine/Sodium Benzoate)
T6
flumazenil
(Romazicon)
T6
ADDYI
ADIPEX-P
ADZENYS XR-ODT
AMPYRA
APTENSIO XR
BELVIQ
benzphetamine hcl
clonidine hcl
DAYTRANA
DIDREX
diethylpropion hcl
EVEKEO
KAPVAY
(Didrex)
(Kapvay)
(Diethylpropion HCl)
Requirements/Limits
PA
(NOT COVERED FOR
MEDICAID: Covered
Alternatives Available)
(NOT COVERED FOR
MEDICAID: Covered
Alternatives Available)
PA
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
59
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
NUEDEXTA
phentermine hcl
QSYMIA
QUILLIVANT XR
REGIMEX
SUPRENZA ODT
Drug Tier
(Adipex-P)
Requirements/Limits
EX
EX
EX
EX
EX
EX
Contraceptives
desog-e.estradiol/e.estradiol
(Mircette)
T1
desogestrel-ethinyl estradiol
(Desogen)
T1
ethinyl estradiol/drospirenone
(Yaz)
T1
ethynodiol d-ethinyl estradiol
(Ethynodiol D-Ethinyl
Estradiol)
T1
levonorgestrel tablet: 0.75mg, 1.5mg
(Plan B One-Step)
T1
levonorgestrel-ethin estradiol
(Amethyst)
T1
l-norgest/e.estradiol-e.estrad
(Seasonique)
T1
norelgestromin/ethin.estradiol
(Ortho Evra)
T1
noreth-ethinyl estradiol/iron tab chew: 0.4-35(21)
(Generess Fe)
T1
norethindrone ac-eth estradiol
(Loestrin)
T1
(Women's Preventive
Healthcare; see Appendix A
for list of covered generic
contraceptives)
(Women's Preventive
Healthcare; see Appendix A
for list of covered generic
contraceptives)
(Women's Preventive
Healthcare; see Appendix A
for list of covered generic
contraceptives)
(Women's Preventive
Healthcare; see Appendix A
for list of covered generic
contraceptives)
(Women's Preventive
Healthcare; see Appendix A
for list of covered generic
contraceptives)
(Women's Preventive
Healthcare; see Appendix A
for list of covered generic
contraceptives)
(Women's Preventive
Healthcare; see Appendix A
for list of covered generic
contraceptives)
QL: 3 in 28 days (Women's
Preventive Healthcare; see
Appendix A for list of
covered generic
contraceptives)
(Women's Preventive
Healthcare; see Appendix A
for list of covered generic
contraceptives)
(Women's Preventive
Healthcare; see Appendix A
for list of covered generic
contraceptives)
60
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
norethindrone
(Ortho Micronor)
T1
norethindrone-e.estradiol-iron
(Loestrin Fe)
T1
norethindrone-ethinyl estrad
(Ortho-Novum)
T1
norethindrone-mestranol
(Norinyl 1+50)
T1
norgestimate-ethinyl estradiol
(Ortho Tri-Cyclen Lo)
T1
norgestrel-ethinyl estradiol
(Norgestrel-Ethinyl
Estradiol)
T1
AMETHYST
ELLA
T2
T2
MINASTRIN 24 FE
NORINYL 1+50
NUVARING
T2
T2
T2
CYCLESSA
DEMULEN 1-50-21
DESOGEN
ESTROSTEP FE
FEMCON FE
LOESTRIN FE
LOESTRIN
LOSEASONIQUE
MIRCETTE
MODICON
NATAZIA
NOR-Q-D
ORTHO EVRA
ORTHO MICRONOR
ORTHO TRI-CYCLEN LO
ORTHO TRI-CYCLEN
ORTHO-CEPT
ORTHO-CYCLEN
ORTHO-NOVUM
OVCON-35
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
Requirements/Limits
(Women's Preventive
Healthcare; see Appendix A
for list of covered generic
contraceptives)
(Women's Preventive
Healthcare; see Appendix A
for list of covered generic
contraceptives)
(Women's Preventive
Healthcare; see Appendix A
for list of covered generic
contraceptives)
(Women's Preventive
Healthcare; see Appendix A
for list of covered generic
contraceptives)
(Women's Preventive
Healthcare; see Appendix A
for list of covered generic
contraceptives)
(Women's Preventive
Healthcare; see Appendix A
for list of covered generic
contraceptives)
(Women's Preventive
Healthcare)
QL: 1 in 28 days (Women's
Preventive Healthcare)
QL: 3 in 28 days
61
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
PLAN B ONE-STEP
SEASONIQUE
TAKE ACTION
TRI-NORINYL
YASMIN 28
YAZ
CAYA CONTOURED
T3
T3
T3
T3
T3
T3
T6
LILETTA
T6
MIRENA
T6
NEXPLANON
T6
ORTHO ALL-FLEX
T6
PARAGARD T 380-A
T6
SKYLA
T6
WIDE SEAL DIAPHRAGM
T6
BEYAZ
GENERESS FE
LO LOESTRIN FE
MICROGESTIN 24 FE
QUARTETTE
SAFYRAL
EX
EX
EX
EX
EX
EX
Requirements/Limits
(Women's Preventive
Healthcare)
QL: 1 in 365 days (Women's
Preventive Healthcare)
QL: 1 in 365 days (Women's
Preventive Healthcare)
(Women's Preventive
Healthcare)
(Women's Preventive
Healthcare)
QL: 1 in 365 days (Women's
Preventive Healthcare)
(Women's Preventive
Healthcare)
QL: 3 in 365 days (Women's
Preventive Healthcare)
Cough And Cold Products
benzonatate capsule: 100mg, 200mg
(Zonatuss)
brompheniramine/pseudoephed/dm syrup: 2-30-10/5 (Brompheniramine/
Pseudoephed/Dm)
chlorpheniramine/codeine phos liquid: 2mg-10mg/5 (Chlorpheniramine/Codeine
Phos)
guaifenesin/codeine phosphate liquid: 100-10mg/5, (M-Clear Wc)
200-8mg/5, 225-7.5/5
hydrocodone bit/homatrop me-br
(Hydrocodone Bit/Homatrop
Me-Br)
hydrocodone/chlorphen p-stirex
(Hydrocodone/Chlorphen PStirex)
hydrocodone/cpm/pseudoephed
(Zutripro)
p-ephed hcl/cod/chlorphenir
(P-Ephed HCl/Cod/
Chlorphenir)
p-ephed hcl/codeine/guaifen
(Tusnel C)
promethazine hcl/codeine
(Promethazine HCl/
Codeine)
promethazine/dextromethorphan
(Promethazine/
Dextromethorphan)
promethazine/phenyleph/codeine
(Promethazine/Phenyleph/
Codeine)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
62
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
TUSSIGON
ALA-HIST AC
ALAHIST DHC
ALLFEN CD
ALLFEN CDX
COTABFLU
DESPEC-PDC
GILPHEX TR
LORTUSS EX
MAXIFED CD
MAXIFLU CD
MAXIFLU CDX
M-END MAX D
PHENFLU CD
PHENFLU CDX
POLY HIST NC
POLY-TUSSIN DHC
POLY-TUSSIN EX
PRO-CLEAR CAPS
REZIRA
TESSALON PERLE
TESSALON
TUSNEL tablet
TUSSICAPS
TUSSIONEX
Z-TUSS AC
Z-TUSS E
ZUTRIPRO
AMBIFED DM
AMBIFED
benzonatate capsule: 150mg
bromphenrm/pseudoeph/dihydrocd
dihydrocodeine/guaifenesin
Drug Tier
(Zonatuss)
(Bromphenrm/Pseudoeph/
Dihydrocd)
(Dihydrocodeine/
Guaifenesin)
TUSNEL PEDIATRIC
ZONATUSS
Requirements/Limits
T1
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
EX
EX
EX
EX
EX
EX
EX
Dental And Oral Agents
cevimeline hcl
chlorhexidine gluconate
pilocarpine hcl
sodium borate
triamcinolone acetonide
CAPHOSOL
DEBACTEROL
FIRST-MOUTHWASH BLM
NEUTRASAL
EVOXAC
GELCLAIR
GELX
(Evoxac)
(Peridex)
(Salagen)
(Sodium Borate)
(Triamcinolone Acetonide)
T1
T1
T1
T1
T1
T2
T2
T2
T2
T3
T3
T3
63
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
PERIDEX
SALAGEN
AQUORAL
ARESTIN
CLINPRO 5000
PREVIDENT 5000 SENSITIVE
PREVIDENT
sodium fluoride
sodium fluoride/potassium nit
stannous fluoride
Drug Tier
(Prevident 5000 Plus)
(Sodium Fluoride/Potassium
Nit)
(Stannous Fluoride)
Requirements/Limits
T3
T3
EX
EX
EX
EX
EX
EX
EX
EX
Dermatological Agents
Dermatological Agents, Other
acyclovir
alcohol antiseptic pads
aluminum chloride
AVAR cleanser
AVAR-E
benzoyl peroxide cleanser: 3%, 4.25%, 6%, 7%, 9%;
gel (gram): 10%; lotion
BP WASH
calcipotriene
CLARIS
fluorouracil
imiquimod
lactic acid
mafenide acetate
podofilox
REA LO 39
REA LO 40
ROSANIL
salicylic acid cream (g), foam: 6%; gel (gram), liqfilm, shampoo
salicylic acid/ceramide cmb #1
sodium thiosulfate/sal acid
sulfacetamide sod/sulfur/urea cleanser
sulfacetamide sodium
sulfacetamide sodium/sulfur various dosage and/or
strengths are available
sulfacetm na/avobenzone/sulfur
trypsin/balsam peru/castor oil oint. (g)
urea cream (g), foam: 40%; gel (ml): 40%; lotion:
40%
urea/lactic ac/zn undecylenate emulsn(g)
(Zovirax)
(Alcohol Antiseptic Pads)
(Aluminum Chloride)
(Benzoyl Peroxide)
(Dovonex)
(Carac)
(Aldara)
(Lactic Acid)
(Mafenide Acetate)
(Condylox)
(Virasal)
(Salex)
(Sodium Thiosulfate/Sal
Acid)
(Claris)
(Sulfacetamide Sodium)
(Sumadan)
(Sulfacetm Na/Avobenzone/
Sulfur)
(Xenaderm)
(Aluvea)
(Urea/Lactic Ac/Zn
Undecylenate)
X-VIATE
ZENCIA
DENAVIR
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
64
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
doxepin hcl
iodine/potassium iodide solution
LUGOL'S
methoxsalen, rapid
PHENOL liquid: 89%
PICATO
ZOVIRAX cream (g)
8-MOP
ACZONE
ALDARA
aluminum acetate
ALUVEA
ANACAINE
APOP
AVAR LS
AVAR med. pad
AVAR-E LS
AZELEX
BENSAL HP
BENZAC AC
benzoyl peroxide microspheres kit cl-crm
benzoyl peroxide gel (gram): 4%, 8%; kit
calcitriol
CARAC
CETACAINE
CLARIFOAM EF
CONDYLOX
DELOS
DESQUAM-X cleanser: 5%
DOVONEX
DRITHOCREME HP
DRYSOL
EFUDEX
ethyl chloride
FINACEA
FLUOROPLEX
GORDOFILM
GORDO-UREA
HYDRO 40
hydrocortisone/lidocaine/aloe
Drug Tier
(Zonalon)
(Iodine/Potassium Iodide)
(Oxsoralen-Ultra)
(Aluminum Acetate)
(Benzoyl Peroxide
Microspheres)
(Benzoyl Peroxide)
(Vectical)
(Ethyl Chloride)
(Hydrocortisone/Lidocaine/
Aloe)
INOVA 4-1
INOVA 8-2
INOVA
KERAFOAM
KERALAC
KERALYT
KEROL
LEVULAN
Requirements/Limits
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
65
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
MIRVASO
NIVATOPIC PLUS
NUOX
OVACE PLUS WASH
OVACE PLUS
OXSORALEN
OXSORALEN-ULTRA
PACNEX MX
PACNEX
PANRETIN
podophyllum resin
protect cmb2/ceramide 1,3,6-11
PRUDOXIN
PYROGALLIC ACID
RADIAPLEXRX
REGENECARE
REGRANEX
SALACYN
SALEX combo. pkg, kit clcmer
SALEX shampoo
salicylic acid foam: 6%; lotion
SALKERA
SANTYL
SILVASORB
SILVRSTAT
SORILUX
sulfacetamide sod/sulfur/urea gel (gram)
sulfacetamide sodium/sulfur foam: 10%-4%
SULFAMYLON
SUMADAN
SUMAXIN TS
SUMAXIN
trichloroacetic acid
trypsin/balsam peru/castor oil spray
UMECTA
URAMAXIN cream (g), gel (ml)
urea gel/pf app
urea/lactic ac/zn undecylenate eml md pmp
Drug Tier
(Podophyllum Resin)
(Protect Cmb2/Ceramide
1,3,6-11)
(Salicylic Acid)
(Sulfacetamide Sod/Sulfur/
Urea)
(Clarifoam Ef)
(Trichloroacetic Acid)
(Trypsin/Balsam Peru/
Castor Oil)
(Uramaxin Gt)
(Urea/Lactic Ac/Zn
Undecylenate)
UTOPIC
VALCHLOR
VECTICAL
VENELEX
VEREGEN
VIRASAL
XENADERM
XERAC AC
Requirements/Limits
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
PA
66
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
ZITHRANOL
ZITHRANOL-RR
ZONALON
ZOVIRAX oint. (g)
acitretin
isotretinoin
Drug Tier
(Soriatane)
(Isotretinoin)
T3
T3
T3
T3
T4
T4
SORIATANE
COSENTYX (2 SYRINGES)
T4
T5
COSENTYX PEN (2 PENS)
T5
TALTZ AUTOINJECTOR
T5
TALTZ SYRINGE
T5
RIMSO-50
T6
UVADEX
T6
ABSORICA
ammonium lactate
BENZEFOAM ULTRA
BENZEFOAM
benzoin/aloe vera/storax/tolu
benzoyl peroxide foam: 5.3%; towelette: 3%, 6%,
9%
calcipotriene/betamethasone
CHLORHEXIDINE GLUCONATE
ENOVARX-BACLOFEN
FINACEA PLUS
HYDRO 35
hydroquinone cream (g): 4%
LAC-HYDRIN
LIDOVIR
LUSTRA
NEOBENZ MICRO
PACNEX HP
PACNEX LP
PLEXION
QUTENZA
RADIGEL
sulfacetamide sodium/sulfur cleanser: 9.8%-4.8%;
cream (g): 9.8%-4.8%; lotion: 9.8%-4.8%
sulfacetamide sodium/urea
(Ammonium Lactate)
(Benzoin/Aloe Vera/Storax/
Tolu)
(Benzefoam Ultra)
(Taclonex)
(Hydroquinone)
(Sumadan)
(Sulfacetamide Sodium/
Urea)
TACLONEX
TRI-LUMA
Requirements/Limits
Includes Amnesteem,
Zenatane, Claravis, and
Myorisan
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
67
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
URAMAXIN foam, lotion
urea foam: 35%; gel (ml): 45%; lotion: 45%
VANIQA
VANOXIDE-HC
vite ac/grape/hyaluronic acid
XERESE
ZYCLARA
Dermatological Antibacterials
CLINDACIN ETZ med. swab
clindamycin phos/benzoyl perox
clindamycin phosphate
erythromycin base/ethanol
erythromycin/benzoyl peroxide
gentamicin sulfate
metronidazole
mupirocin calcium
mupirocin
neomycin su/polymyx b sulf
ROSADAN gel (gram)
selenium sulfide lotion
silver sulfadiazine
sulfacetamide sodium
THERMAZENE
BACTROBAN NASAL
clindamycin/tretinoin
NORITATE
ACANYA
AKNE-MYCIN
BACTROBAN cream (g)
BACTROBAN oint. (g)
BENZACLIN
BENZAMYCIN
CENTANY AT
CENTANY
CLEOCIN T
CLINDACIN ETZ kit
CLINDAGEL
CORTISPORIN cream (g)
CORTISPORIN oint. (g)
DUAC
ERYGEL
EVOCLIN
KLARON
METROCREAM
METROGEL
METROLOTION
NEOSPORIN G.U. IRRIGANT
NEO-SYNALAR
OVACE PLUS
Drug Tier
(Hydro 40)
(Atopiclair)
(Duac)
(Cleocin T)
(Erythromycin Base/
Ethanol)
(Benzamycin)
(Gentamicin Sulfate)
(Metrogel)
(Bactroban)
(Bactroban)
(Neosporin G.U. Irrigant)
(Selenium Sulfide)
(Silvadene)
(Klaron)
(Ziana)
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
68
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
ROSADAN kit cl-crm
selenium sulfide shampoo
(Selenium Sulfide)
SELRX
SILVADENE
silver nitrate
(Silver Nitrate)
VELTIN
ZIANA
ALTABAX
NEUAC
TERSI FOAM
Dermatological Anti-Inflammatory Agents
alclometasone dipropionate
(Aclovate)
amcinonide cream (g)
(Amcinonide)
betamethasone dipropionate
(Betamethasone
Dipropionate)
betamethasone valerate
(Betamethasone Valerate)
betamethasone/propylene glyc
(Diprolene AF)
clobetasol propionate
(Temovate)
CLODAN shampoo
desonide cream (g), lotion: 0.05%; oint. (g)
(Desowen)
desoximetasone cream (g): 0.25%; gel (gram), oint. (Topicort)
(g): 0.25%
diflorasone diacetate oint. (g)
(Diflorasone Diacetate)
fluocinolone acetonide
(Derma-Smoothe-Fs)
fluocinonide
(Vanos)
fluticasone propionate
(Cutivate)
halobetasol propionate
(Ultravate)
HALONATE PAC
hydrocort/pramoxin/emol/pram#1
(Analpram E)
hydrocortisone acetate
(Anusol-HC)
hydrocortisone acetate/aloe v
(Hydrocortisone Acetate/
Aloe V)
hydrocortisone butyrate
(Locoid)
hydrocortisone valerate
(Hydrocortisone Valerate)
hydrocortisone cream (g), cream/appl, enema:
(Anusol-HC)
100mg/60ml; lotion: 2.5%; oint. (g)
hydrocortisone/iodoquinol
(Hydrocortisone/Iodoquinol)
hydrocortisone/lidocaine/aloe kit: 2.5-3%(7g)
(Hydrocortisone/Lidocaine/
Aloe)
hydrocortisone/pramoxine
(Analpram HC)
lidocaine/hydrocortisone ac
(Lidocaine/Hydrocortisone
Ac)
mometasone furoate
(Elocon)
PRAMCORT
prednicarbate
(Dermatop)
RECTACORT-HC
SCALACORT
tacrolimus
(Protopic)
triamcinolone acetonide cream (g), lotion, oint. (g): (Triamcinolone Acetonide)
0.025%, 0.1%
T3
T3
T3
T3
T3
T3
T3
EX
EX
EX
Requirements/Limits
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
69
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
CORTIFOAM
flurandrenolide
ONFI
triamcinolone acetonide aerosol
amcinonide lotion, oint. (g)
ANALPRAM ADVANCED
ANALPRAM HC
ANUSOL-HC cream (g)
ANUSOL-HC supp.rect
APEXICON E
CAPEX SHAMPOO
CLOBEX
clocortolone pivalate
CLODERM
CORDRAN
CORTENEMA
CUTIVATE
DERMA-SMOOTHE-FS
DERMASORB TA
DERMATOP
DESONATE
DESOWEN
desoximetasone cream (g): 0.05%; oint. (g): 0.05%
diflorasone diacetate cream (g)
DIPROLENE AF
DIPROLENE
ELIDEL
ELOCON
EPIFOAM
FIRST-HYDROCORTISONE
HALOG
hydrocort/pramoxn/skn clnsr#16
hydrocortisone acetate/urea
hydrocortisone enema: 100mg/60ml; lotion: 2%
KENALOG
LOCOID
LUXIQ
NOVACORT
NUCORT
OLUX
PANDEL
PEDIADERM TA
PRAMOSONE E
PRAMOSONE
PROCORT
PROCTOCORT cream (g)
PROCTOCORT supp.rect
PROCTOFOAM-HC
Drug Tier
(Flurandrenolide)
(Kenalog)
(Amcinonide)
(Cloderm)
(Topicort)
(Diflorasone Diacetate)
(Hydrocort/Pramoxn/Skn
Clnsr#16)
(Hydrocortisone Acetate/
Urea)
(Cortenema)
Requirements/Limits
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
70
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
PROTOPIC
PSORCON
SYNALAR TS
SYNALAR cmb ont cr, cream (g): 0.025%
SYNALAR cream (g): 0.025%; oint. (g), solution
TEMOVATE
TEXACORT
TOPICORT
triamcinolone acetonide oint. (g): 0.05%, 0.5%
ULTRAVATE PAC
ULTRAVATE X
ULTRAVATE cream (g), oint. (g)
VANOS
VERDESO
XILAPAK
AQUA GLYCOLIC HC
CLODAN kt shm cln
DERMASORB HC
HALONATE
hydrocortisone/lidocaine/aloe kit: 2%-2%
MOMEXIN
NAPRO
PEDIADERM HC
SCALACORT DK
ZYPRAM
Dermatological Retinoids
adapalene
tretinoin microspheres
tretinoin cream (g), gel (gram): 0.01%, 0.025%
DIFFERIN
EPIDUO
FABIOR
RETIN-A MICRO
RETIN-A
TAZORAC
TRETIN-X combo. pkg
TRETIN-X cream (g)
ATRALIN
AVAGE
DERMAPAK PLUS
RENOVA
tretinoin gel (gram): 0.05%
tretinoin/emollient base
Scabicides and Pediculicides
lindane
malathion
permethrin
ELIMITE
EURAX
Drug Tier
(Triamcinolone Acetonide)
(Hydrocortisone/Lidocaine/
Aloe)
Requirements/Limits
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
(Differin)
(Retin-A Micro)
(Retin-A)
(Retin-A)
(Tretinoin/Emollient Base)
(Lindane)
(Ovide)
(Elimite)
T1
T1
T1
T3
T3
T3
T3
T3
T3
T3
T3
EX
EX
EX
EX
EX
EX
T1
T1
T1
T3
T3
71
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
OVIDE
NATROBA
SKLICE
spinosad
Drug Tier
Requirements/Limits
T3
EX
EX
EX
(Natroba)
Devices
NUMOISYN liquid
APLIGRAF
BIAFINE
DERMAGRAFT
ELETONE
emollient combination no.10
emollient combination no.32
emollient combination no.43
emollient combination no.85
ENDOFORM sheet: 2"x2", 4"x5"
ENDOFORM sheet: 2"x2", 4"x5"
EPICERAM
EPISIL
GELFOAM COMPRESSED
GELFOAM
MUGARD
NUMOISYN lozenge
OASIS ULTRA
PROMISEB
TETRIX
WOUND MATRIX
0.9 % sodium chloride
(Biafine)
(Emollient Combination
No.32)
(Emollient Combination
No.43)
(Emollient Combination
No.85)
(0.9 % Sodium Chloride)
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T6
DISCOVISC
T6
DUOVISC
T6
VISCOAT
T6
A.I.R.S. NEBULIZER
ACE AEROSOL CLOUD ENHANCER
ADAPTER
ADULT AEROSOL MASK
AEROCHAMBER MINI
AEROCHAMBER MV
AEROCHAMBER PLUS FLOW-VU
AEROCHAMBER PLUS Z STAT
AEROCHAMBER WITH FLOWSIGNAL
AEROCHAMBER Z-STAT PLUS
AEROECLIPSE II
AEROECLIPSE
AEROGEAR ASTHMA ACTION KIT
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
72
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
AERONEB GO NEBULIZER
AERONEB GO
AEROTRACH PLUS
AEROVENT PLUS
AIR FILTER
AIR TUBE WITH AIR PLUGS
AIRS ADULT AEROSOL MASK
AIRS DISPOSABLE NEBULIZER
AIRZONE PEAK FLOW METER
ALL FLOW 1000
ALL FLOW 2000
ALL FLOW 3000 KIT
ALL FLOW 3000 PFT
ALL FLOW 4000
ALL FLOW 5000
ALL FLOW 6000
ALL FLOW 7000
ALTERA NEBULIZER
ASSESS
ASTHMA CHECK
ASTHMAMENTOR
ASTHMAPACK CHILDREN'S
ASTHMAPACK I
ASTHMAPACK II
BABY CONVERSION KIT
BABY CONVERSION PACK 1
BABY CONVERSION PACK 2
BABY NEBULIZER
BREATHERITE
BREATHRITE
BUBBLES THE FISH II
CLEVER CHOICE HOLDING CHAMBER
CO MONITOR REPLACEMENT T
CO MONITOR
COMPACT COMPRESSOR NEBULIZER
COMPACT SPACE CHAMBER PLUS
COMPACT SPACE CHAMBER
COMPACT ULTRASONIC NEBULIZER
COMP-AIR ELITE COMPRESSOR SYST
COMP-AIR NEBULIZER COMPRESSOR
COMPMIST COMPRESSOR NEBULIZER
DEVILBISS DISPOSABLE NEBULIZER
DEVILBISS PULMO-AIDE
DEVILBISS PULMONEB LT COMP-NEB
DEVILBISS TRAVELER
DEVILBLISS
EASIVENT each
EASIVENT spacer
EBASE CONTROLLER
ERAPID NEBULIZER HANDSET
Requirements/Limits
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
73
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
ERAPID NEBULIZER
EXPIRATORY
E-Z SPACER PEDSPAK
E-Z SPACER
FILTER PAD
FILTER, VALVE SET FOR LL AND LC
FILTERS REPLACEMENT
FLEXICHAMBER
FLUTTER
IN-CHECK DIAL
IN-CHECK NASAL WITH MASK
IN-CHECK ORAL
INNOSPIRE DELUXE
INNOSPIRE ELEGANCE
INNOSPIRE ESSENCE
INNOSPIRE MINI
INNOSPIRE REPLACEMENT FILTER
INSPIRACHAMBER
INSPIRATION ELITE FILTER
INSPIRATION ELITE each: n/a
INSPIRATION ELITE each: n/a
INSPIRATION
LC D NEBULIZER SET
LC PLUS
LC SPRINT NEBULIZER
LC STAR
LITEAIRE
LITETOUCH
MASK SET WITH Y-PIECE
MASK VORTEX
MICRO AIR
MICRO ELITE REPLACEMENT FILTER
MICRO ELITE each: n/a
MICRO ELITE each: n/a
MICRO PLUS
MICROCHAMBER
MICROLIFE PEAK FLOW
MICROSPACER
MINI ELITE FILTER REPLACEMENT
MINI PLUS NEBULIZER
MINICOMP COMPRESSOR NEBULIZER
MINIELITE each: n/a
MINIELITE each: n/a
MINI-WRIGHT PEAK FLOW METER
MISTASSIST
MONAGHAN Z STAT
MOUTHPIECE each: n/a
MOUTHPIECE each: n/a
MY MDI PORTABLE NEBULISER
NESSI SPACER
Requirements/Limits
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
74
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
NOSE CLIP
ONE FLOW FVC each
ONE FLOW FVC kit
ONE WAY MOUTHPIECE
OPTICHAMBER DIAMOND
OPTICHAMBER each
OPTICHAMBER spacer
OPTIONHOME
PANDA MASK
PARI SINUS AEROSOL SYSTEM
PEAK-AIR
PEDIATRIC AEROSOL MASK
PEDIATRIC MASK
PEDIATRIC PANDA MASK
PERSONAL BEST
PFLEX TRAINER
PIKO 1
PILLOW MASK FOR CHILDREN
PILLOW MASK each: n/a
PILLOW MASK each: n/a
POCKET CHAMBER
POCKET PEAK
PRIMEAIRE
PROCHAMBER
PRODIGY MINI-MIST
PRONEB ULTRA II
PRONEB ULTRA
PULMO-AIDE
PULMONEB LT COMPRESSOR NEBUL
QUAKE
REUSABLE NEBULIZER KIT
RITEFLO
RUBBER MOUTHPIECE
SAMI THE SEAL FILTER
SAMI THE SEAL MASK
SAMI THE SEAL
SIDESTREAM MASK
SIDESTREAM NEBULIZER
SIDESTREAM PEDIATRIC
SIDESTREAM PLUS
SIDESTREAM
SILICONE MASK each: n/a
SILICONE MASK each: n/a
SMARTMASK KIDS
SOOTHENEB COMPRESSOR NEBULIZER
SOOTHENEB MESH NEBULIZER
SOOTHENEB NBL100 ADULT MASK
SOOTHENEB NBL100 CHILD MASK
SOOTHENEB NBL100 MED CUP
SPACE CHAMBER PLUS
Requirements/Limits
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
75
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
SUNRISE COMPRESSOR-NEBULIZER
THRESHOLD IMT
THRESHOLD PEP
TREK S COMBO PACK
TREK S COMPACT COMPRESSOR
TREK S PORTABLE PWR KIT
TRUZONE PEAK FLOW METER
VIOS AEROSOL DELIVERY SYSTEM
VORTEX FROG MASK
VORTEX LADYBUG MASK
VORTEX VHC FROG MASK
VORTEX each
VORTEX spacer
WATCHHALER
WINDMILL TRAINER
WING TIP TUBING
1ST CHOICE LANCETS
1ST TIER UNILET COMFORTOUCH
ACCU-CHEK FASTCLIX
ACCU-CHEK SAFE-T-PRO PLUS
ACCU-CHEK SAFE-T-PRO
ACCU-CHEK SOFTCLIX
ACCU-CHEK each
ACTI-LANCE
ADVANCED TRAVEL LANCETS
ADVOCATE LANCET
ADVOCATE LANCETS
ALTERNATE SITE LANCETS
ASSURE HAEMOLANCE PLUS each: 18gauge,
21gauge, 25gauge, 28gauge
ASSURE LANCE PLUS
ASSURE LANCE
BD MICROTAINER LANCETS
BD ULTRA-FINE II
BD ULTRA-FINE
BLOOD LANCETS
BREEZE 2 each: n/a
BREEZE 2 each: n/a
BREEZE 2 each: n/a
BREEZE 2 strip
BREEZE 2 kit
BULLSEYE MINI SAFETY LANCETS
CAREONE
CARESENS
CLEVER CHEK LANCETS
COAGUCHEK
COLOR LANCETS
COMFORT EZ
COMFORT LANCETS
CONTOUR LINK
Requirements/Limits
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
QL: 1 in 365 days
QL: 1 in 365 days
76
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
CONTOUR NEXT CONTROL SOLUTION each:
n/a
CONTOUR NEXT CONTROL SOLUTION each:
n/a
CONTOUR NEXT EZ
CONTOUR NEXT LINK
CONTOUR NEXT USB
CONTOUR NEXT strip
CONTOUR NEXT each
CONTOUR USB
CONTOUR each: n/a
CONTOUR each: n/a
CONTOUR each: n/a
CONTOUR strip
CONTOUR each: n/a
DROPLET LANCETS
EASY COMFORT
EASY TOUCH LANCETS
EASY TOUCH each
EASY TWIST AND CAP LANCETS
EMBRACE each: 30gauge
E-Z JECT LANCETS
EZ SMART LANCETS
E-ZJECT LANCETS
FIFTY50 SAFETY SEAL LANCETS
FINE 30 UNIVERSAL LANCETS
FINGERSTIX
FORA LANCETS
FORACARE LANCETS
FREESTYLE LANCETS
FREESTYLE UNISTIK 2
GLUCOCOM LANCETS
GLUCOCOM
GLUCOLET 2
GLUCOSOURCE
GMATE
HEALTHY ACCENTS UNILET LANCET
INCONTROL SUPER THIN LANCETS
INCONTROL ULTRA THIN LANCETS
INJECT EASE LANCETS
INVACARE LANCETS
KINNEY BRAND LANCETS
LANCETS THIN
LANCETS ULTRA THIN
LANCETS
LITE TOUCH
MAJOR COMFORT
MEDI-LANCE
MEDISENSE THIN LANCETS
MEDLANCE PLUS
Requirements/Limits
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
77
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
MICRO THIN LANCETS
MICROLET 2
MICROLET
MONOLET LANCETS
MONOLET THIN LANCETS
MYGLUCOHEALTH LANCETS
NOVA SAFETY LANCETS
NOVA SUREFLEX
ON CALL LANCET
ON CALL PLUS LANCET
ONE TOUCH DELICA
ONETOUCH DELICA each
ONETOUCH DELICA kit
ONETOUCH FINEPOINT LANCETS
ONETOUCH LANCETS
ONETOUCH SURESOFT
ONETOUCH ULTRA CONTROL SOLN
ONETOUCH ULTRA SMART
ONETOUCH ULTRA SYSTEM
ONETOUCH ULTRA TEST STRIPS
ONETOUCH ULTRA2
ONETOUCH ULTRALINK
ONETOUCH ULTRAMINI
ONETOUCH VERIO FLEX
ONETOUCH VERIO IQ
ONETOUCH VERIO SYNC
ONETOUCH VERIO each: n/a
ONETOUCH VERIO each: n/a
ONETOUCH VERIO strip
ONETOUCH VERIO each: n/a
ON-THE-GO
pen needle, diabetic
PENLET PLUS BLOOD SAMPLER
PRESSURE ACTIVATED LANCETS
PRO COMFORT LANCETS
PRODIGY LANCETS
PRODIGY TWIST TOP LANCET
PUSH BUTTON SAFETY LANCETS
RELIAMED SAFETY SEAL LANCETS
RELIAMED
RELION THIN
RIGHTEST GL300 LANCETS
SAFETY LANCETS
SAFETY SEAL LANCETS
SAFETY-LET
SINGLE-LET
SMART SENSE LANCETS
SMART SENSE
SMARTDIABETES VANTAGE
SMARTEST LANCET
Drug Tier
(Pen Needle, Diabetic)
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
Requirements/Limits
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
QL: 1 in 365 days
78
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
SOFT TOUCH
SOLUS V2 LANCETS
SOLUS V2 each: 28gauge
STERILANCE TL
sub-q insulin device, 40 unit
SUPER THIN LANCETS
SURE COMFORT LANCETS
SURE-LANCE
SURESTEP CONTROL SOLUTION
SURESTEP PRO each: n/a
SURESTEP PRO each: n/a
SURESTEP PRO each: n/a
SURESTEP PRO strip
SURESTEP PRO kit
SURE-TOUCH
syringe and needle,insulin,1ml
syringe-needle,insulin,0.5 ml
syring-needl,disp,insul,0.3 ml
Drug Tier
(Sub-Q Insulin Device, 40
Unit)
(Syringe and
Needle,Insulin,1ml)
(Syringe-Needle,Insulin,0.5
Ml)
(SyringNeedl,Disp,Insul,0.3 Ml)
TECHLITE LANCETS
TELCARE each
THIN LANCETS
TOPCARE UNIVERSAL1 LANCET
TOPCARE UNIVERSAL1 THIN LANCET
TRUEPLUS LANCETS
ULTILET BASIC
ULTILET CLASSIC
ULTILET LANCETS
ULTILET SAFETY
ULTRA THIN LANCETS
ULTRA THIN PLUS LANCETS
ULTRA THIN PLUS
ULTRALANCE
ULTRA-THIN II
ULTRATLC LANCETS
UNILET COMFORTOUCH
UNILET EXCELITE II
UNILET EXCELITE
UNILET GP LANCET
UNILET LANCET
UNILET LANCETS
UNISTIK 3 EXTRA
UNISTIK 3
UNISTIK CZT
UNISTIK SAFETY
UNISTIK TOUCH
UNIVERSAL 1
Requirements/Limits
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
QL: 1 in 365 days
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
79
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
EASY TOUCH HYPODERMIC NEEDLE
EASY TOUCH disp syrin
ECLIPSE LUER-LOK SYRINGE
EXEL HYPODERMIC NEEDLE
EXEL SYRINGE
FLOW-EZE
HYPODERMIC NEEDLE
INTEGRA NEEDLE
INTEGRA SYRINGE
LIFESHIELD BLUNT CANNULA
LUER-LOK SYRINGE-NEEDLE
MEDSAVER
MONOJECT SYRINGE
NEEDLE
NEEDLES
NOKOR ADMIX NEEDLE
PRECISIONGLIDE dis needle
PRECISIONGLIDE disp syrin
REGULAR BEVEL NEEDLES
SAFETYGLIDE SYRINGE
SHORT BEVEL NEEDLES
SPECIALTY USE NEEDLES
SYRINGE
TERUMO SYRINGE
THIN WALL NEEDLES
VANISHPOINT
YALE NEEDLES
ACCU-CHEK ACTIVE
ACCU-CHEK AVIVA PLUS each
ACCU-CHEK AVIVA PLUS strip
ACCU-CHEK AVIVA
ACCU-CHEK COMFORT CURVE
ACCU-CHEK COMPACT PLUS
ACCU-CHEK NANO SMARTVIEW
ACCU-CHEK SMARTVIEW
ACCU-CHEK VOICEMATE
ACCU-CHEK kit
ACCUTREND GLUCOSE
ACURA METER KIT
ACURA PLUS
ACURA STARTER KIT
ACURA TEST STRIPS
ADVOCATE BLOOD GLUCOSE MONITOR
ADVOCATE REDI-CODE+ each
ADVOCATE REDI-CODE+ strip
ADVOCATE REDI-CODE each, kit
ADVOCATE REDI-CODE strip
ADVOCATE TEST STRIP
AGAMATRIX AMP each
AGAMATRIX AMP strip
Requirements/Limits
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
80
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
ASSURE 4 each
ASSURE 4 strip
ASSURE PLATINUM each
ASSURE PLATINUM strip
ASSURE PRO kit
ASSURE PRO strip
AURSTAT
BG-STAR
BLOOD GLUCOSE METER
BLOOD GLUCOSE MONITOR
BLOOD GLUCOSE MONITORING
BLOOD GLUCOSE TEST STRIP
BLOOD GLUCOSE TEST
BLOOD-GLUCOSE METER
CARESENS N VOICE
CARESENS N each
CARESENS N strip
CHOICEDM G20 kit
CHOICEDM G20 strip
CLEVER CHOICE BLOOD GLUC SYS
CLEVER CHOICE HD GLUCOSE SYST
CLEVER CHOICE MICRO TEST STRIP
CLEVER CHOICE MICRO
CLEVER CHOICE PRO each
CLEVER CHOICE PRO strip
CLEVER CHOICE TEST STRIPS
CLEVER CHOICE VOICE+ TST STRIP
CLEVER CHOICE
CONTROL G3
CONTROL kit
CONTROL strip
DEXCOM G4 each: n/a
DEXCOM G4 each: n/a
DEXCOM G4 each: n/a
DEXCOM G5-G4 SENSOR
DIATRUE PLUS each
DIATRUE PLUS strip
EASY GLUCO G2
EASY PLUS II each
EASY PLUS II strip
EASY STEP each, kit
EASY STEP strip
EASY TALK each, kit
EASY TALK strip
EASY TOUCH GLUCOSE MONITOR
EASY TOUCH TEST STRIP
EASY TRAK kit
EASY TRAK strip
EASYGLUCO METER STARTER KIT
EASYGLUCO TEST STRIPS
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
81
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
EASYGLUCO
EASYMAX 15
EASYMAX L
EASYMAX N
EASYMAX NG
EASYMAX V SPEAKING
EASYMAX V2
EASYMAX V
EASYMAX
EASYPLUS R13N
EASYPLUS V
EASYPLUS
ECLIPSE each
ECLIPSE strip
ELEMENT BLOOD GLUCOSE METER
ELEMENT COMPACT each
ELEMENT COMPACT strip
ELEMENT PLUS kit
ELEMENT PLUS strip
ELEMENT TEST STRIPS
em#53/namgf/cyc/phos/nahc/nacl
EMBRACE EVO kit
EMBRACE EVO strip
EMBRACE PRO each
EMBRACE PRO strip
EMBRACE each: n/a; kit
EMBRACE strip
ENVISION kit
ENVISION strip
EPIFIX AMNIOTIC MEMBRANE
EVENCARE G2 each
EVENCARE G2 strip
EVENCARE G3 kit
EVENCARE G3 strip
EVENCARE kit
EVENCARE strip
EVOLUTION BLOOD GLUCOSE METER
EVOLUTION TEST STRIPS
EZ SMART PLUS kit
EZ SMART PLUS strip
EZ SMART kit
EZ SMART strip
FIFTY50 TEST STRIP
FORA D10
FORA D15C
FORA D15G
FORA D15Z
FORA D20
FORA G20 kit
FORA G20 strip
Drug Tier
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
(Aurstat)
82
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
FORA G30A each
FORA G30A strip
FORA G71A kit
FORA G71A strip
FORA G90 each
FORA G90 strip
FORA TEST STRIP
FORA V10 kit
FORA V10 strip
FORA V10-V12-D10-D20
FORA V12 each, kit
FORA V12 strip
FORA V20 kit
FORA V20 strip
FORA V22 each
FORA V22 strip
FORA V30A each, kit
FORA V30A strip
FORACARE GD20 each
FORACARE GD20 strip
FORACARE GD40A
FORACARE GD40B
FORACARE GD40
FREESTYLE FLASH SYSTEM
FREESTYLE FREEDOM LITE
FREESTYLE FREEDOM
FREESTYLE INSULINX TEST STRIPS
FREESTYLE INSULINX each
FREESTYLE INSULINX strip
FREESTYLE LITE TEST STRIPS
FREESTYLE SIDEKICK II
FREESTYLE SYSTEM
FREESTYLE TEST STRIPS
G-4 kit
G-4 strip
GE100 BLOOD GLUCOSE SYSTEM
GE100 BLOOD GLUCOSE TEST STRIP
GENADUR kit
GENADUR liquid
GLUCO NAVII kit
GLUCO NAVII strip
GLUCOCARD 01 SENSOR PLUS
GLUCOCARD 01
GLUCOCARD 01-MINI
GLUCOCARD EXPRESSION each, kit
GLUCOCARD EXPRESSION strip
GLUCOCARD VITAL SENSOR
GLUCOCARD VITAL kit
GLUCOCARD VITAL strip
GLUCOCOM BLOOD GLUCOSE
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
83
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
GLUCOCOM GLUCOSE
GLUCOLAB kit
GLUCOLAB strip
GLUCOSE TEST STRIP
GMATE TEST STRIPS
GMATE VOICE METER
GRAFIX CORE
GRAFIX PRIME
GUARDIAN REAL-TIME
GUARDIAN RT STARTER KIT
HEALTHPRO GLUCOSE MONITOR
HEALTHPRO TEST STRIPS
IBG-STAR
INFINITY TEST STRIPS
INFINITY
JAZZ WIRELESS 2
KEYNOTE PRO
KEYNOTE each
KEYNOTE strip
LIBERTY BLOOD GLUCOSE METER
LIBERTY MONITOR
LIBERTY TEST STRIPS
MAXIMA
MEDIHONEY bandage: 2"x2", 4"x5"
MICRO
MICRODOT each
MICRODOT strip
MYGLUCOHEALTH kit
MYGLUCOHEALTH strip
NASONEB NASAL NEBULIZER each: n/a
NASONEB NASAL NEBULIZER each: n/a
NEUTEK 2TEK TEST STRIPS
NOVA MAX BLOOD GLUCOSE METER
NOVA MAX GLUCOSE TEST STRIPS
NUVAIL
ON CALL EXPRESS METER
ON CALL EXPRESS TEST STRIP
ON CALL PLUS METER
ON CALL PLUS TEST STRIP
ON CALL VIVID METER
ON CALL VIVID PAL
ON CALL VIVID TEST STRIP
OPTIUM EZ
OPTIUM
OPTUMRX each, kit
OPTUMRX strip
PHARMACIST CHOICE each
PHARMACIST CHOICE strip
PRECISION PCX PLUS
PRECISION PCX
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
84
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
PRECISION POINT OF CARE
PRECISION Q-I-D
PRECISION XTRA each
PRECISION XTRA strip
PREMIUM BLOOD GLUCOSE TEST
PREMIUM BLOOD GLUCOSE
PREMIUM V10 each
PREMIUM V10 strip
PRESTO PRO
PRODIGY AUTOCODE PRO
PRODIGY AUTOCODE
PRODIGY NO CODING
PRODIGY POCKET PRO
PRODIGY POCKET
PRODIGY VOICE PRO
PRODIGY VOICE
PRODIGY
QUINTET AC each
QUINTET AC strip
QUINTET each
QUINTET strip
REFUAH PLUS kit
REFUAH PLUS strip
RELION CONFIRM
RELION CONFIRM-MICRO
RELION MICRO
RELION PRIME TEST STRIPS
RELION PRIME
RESTORE
REVEAL BLOOD GLUCOSE METER
REVEAL TEST STRIP
RIGHTEST GM100 SYSTEM
RIGHTEST GM300 SYSTEM
RIGHTEST GM550 SYSTEM
RIGHTEST GS100 TEST STRIPS
RIGHTEST GS300 TEST STRIPS
RIGHTEST GS550 TEST STRIPS
SEVEN PLUS
SINUSTAR each: n/a
SINUSTAR each: n/a
SMART SENSE MONITORING SYSTEM
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
SMART SENSE TEST STRIPS
SMARTDIABETES XPRES kit
SMARTDIABETES XPRES strip
SMARTEST EJECT
SMARTEST PERSONA
SMARTEST PRONTO
SMARTEST PROTEGE
SMARTEST TEST
EX
EX
EX
EX
EX
EX
EX
EX
Requirements/Limits
85
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
SOLUS V2 TEST STRIPS
SOLUS V2 each: n/a; kit
SURE EDGE BLOOD GLUCOSE METER
SURE EDGE TEST STRIPS
SURECHEK TEST STRIPS
SURE-TEST EASYPLUS MINI each
SURE-TEST EASYPLUS MINI strip
TELCARE kit
TELCARE strip
TEST N'GO each
TEST N'GO strip
thrombin/ca/cmc/gel/dress, hem
Drug Tier
(Thrombin/Ca/Cmc/Gel/
Dress, Hem)
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
TRUE2GO BLOOD GLUCOSE SYSTEM
EX
TRUERESULT BLOOD GLUCOSE METER
EX
TRUERESULT BLOOD GLUCOSE SYSTM
EX
TRUETEST TEST STRIPS
EX
TRUETRACK BLOOD GLUCOSE SYSTEM
EX
TRUETRACK SMART SYSTEM kit
EX
TRUETRACK SMART SYSTEM strip
EX
TRUETRACK TEST STRIP
EX
ULTIMA each
EX
ULTIMA strip
EX
ULTRATRAK PRO
EX
ULTRATRAK ULTIMATE each
EX
ULTRATRAK ULTIMATE strip
EX
ULTRATRAK each
EX
ULTRATRAK strip
EX
UNISTRIP1
EX
VICTORY each
EX
VICTORY strip
EX
VOCAL POINT
EX
86
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
WAVESENSE AMP
EX
WAVESENSE JAZZ
EX
WAVESENSE PRESTO each, kit
EX
WAVESENSE PRESTO strip
EX
Requirements/Limits
Diagnostic Agents
INDIUM IN-111 DTPA
T6
(Non-self administerable
injectable)
87
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
Requirements/Limits
Disinfectants (For Non-Dermatologic Use)
GLUTARALDEHYDE
T3
Enzyme Replacement/Modifiers
CREON
CYSTAGON
lipase/protease/amylase
PANCREAZE
PERTZYE
SUCRAID
ULTRESA
VIOKACE
ZENPEP
KUVAN
ORFADIN
PULMOZYME
ZAVESCA
ADAGEN
T2
T2
T2
T2
T2
T2
T2
T2
T2
T4
T4
T4
T4
T6
(Zenpep)
ALDURAZYME
T6
AMPHADASE
T6
CEREZYME
T6
ELAPRASE
T6
ELELYSO
T6
ELITEK
T6
FABRAZYME
T6
HYLENEX
T6
KRYSTEXXA
T6
LUMIZYME
T6
MYOZYME
T6
NAGLAZYME
T6
VITRASE
T6
VPRIV
T6
XIAFLEX
T6
CHENODAL
EX
PA
PA
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
88
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
Requirements/Limits
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents, Miscellaneous
apraclonidine hcl
(Iopidine)
atropine sulfate drops
(Isopto Atropine)
azelastine hcl drops
(Optivar)
carteolol hcl
(Carteolol HCl)
chloroxylenol/pramoxine hcl
(Chloroxylenol/Pramoxine
HCl)
cromolyn sodium
(Cromolyn Sodium)
cyclopentolate hcl
(Cyclogyl)
epinastine hcl
(Elestat)
homatropine hbr
(Isopto Homatropine)
ipratropium bromide
(Atrovent)
olopatadine hcl spray/pump
(Patanase)
olopatadine hcl drops
(Patanol)
phenylephrine hcl
(Mydfrin)
proparacaine hcl drops: 0.5%
(Proparacaine HCl)
tetracaine hcl
(Tetracaine HCl)
TETRAVISC FORTE
tropicamide
(Mydriacyl)
ADRENALIN CHLORIDE
ALOMIDE
atropine sulfate oint. (g)
(Atropine Sulfate)
azelastine hcl spray/pump
(Astepro)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
CYCLOMYDRIL
EMADINE
ISOPTO HYOSCINE
LASTACAFT
naphazoline hcl
PATADAY
TYZINE
AKTEN
ASTELIN
T2
T2
T2
T2
T2
T2
T2
T3
T3
(Naphazoline HCl)
T1
T1
T1
T1
T1
ASTEPRO
T3
ATROVENT
BSS
T3
T3
CYCLOGYL
DYMISTA
ELESTAT
IOPIDINE
ISOPTO ATROPINE
ISOPTO HOMATROPINE
MYDRIACYL
OPTIVAR
PATANASE
PATANOL
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
QL: 5 in 30 days
QL: 5 in 30 days
QL: 60 in 30 days (Quantity
listed is 2 bottles)
QL: 2.5 in 30 days
QL: 60 in 30 days (Quantity
listed is 2 bottles)
QL: 60 in 30 days (Quantity
listed is 2 bottles)
(Self Administerable (Select)
Injectable)
QL: 5 in 30 days
89
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
proparacaine hcl drops: 0.5%
LACRISERT
0.9 % sodium chloride
(Proparacaine HCl)
(0.9 % Sodium Chloride)
T3
T4
T6
balanced salt irrig soln no.2
(Bss)
T6
BSS PLUS
T6
CELLUGEL
T6
EYLEA
T6
JETREA
T6
LUCENTIS
T6
MACUGEN
T6
OCUCOAT
T6
OZURDEX
T6
RETISERT
T6
VISUDYNE
T6
BEPREVE
CYSTARAN
LATISSE
Eye, Ear, Nose, Throat Anti-Infectives Agents
acetic acid/aluminum acetate
(Acetic Acid/Aluminum
Acetate)
acetic acid/hydrocortisone
(Vosol HC)
antipyrine/benzocaine
(Antipyrine/Benzocaine)
bacitracin/polymyxin b sulfate
(Bacitracin/Polymyxin B
Sulfate)
ciprofloxacin hcl drops
(Ciloxan)
erythromycin base oint. (g): 5mg/g
(Erythromycin Base)
GARAMYCIN oint. (g)
gatifloxacin
(Zymaxid)
gentamicin sulfate
(Garamycin)
ILOTYCIN
levofloxacin
(Levofloxacin)
neo/polymyx b sulf/dexameth
(Maxitrol)
neomycin su/baci zn/poly/hc
(Neomycin Su/Baci Zn/
Poly/HC)
neomycin su/bacitra/polymyxin
(Neomycin Su/Bacitra/
Polymyxin)
neomycin/polymyxin b sulf/hc drops susp: 3.5-10k-1; (Cortisporin)
solution
neomycin/polymyxn b/gramicidin
(Neosporin)
EX
EX
EX
Requirements/Limits
QL: 60 in 30 days
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
90
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
ofloxacin
polymyxin b sulf/trimethoprim
sulfacetamide sodium drops: 10%
sulfacetamide/prednisolone sp
tobramycin
tobramycin/dexamethasone
trifluridine
AZASITE
bacitracin
BETADINE
BLEPHAMIDE S.O.P.
BLEPHAMIDE
CILOXAN oint. (g)
CIPRO HC
CIPRODEX
COLY-MYCIN S
CORTISPORIN-TC
cresyl acetate
NATACYN
neomycin/polymyxin b sulf/hc drops susp: 3.5-10k10
PRED-G
sulfacetamide sodium oint. (g)
TOBRADEX oint. (g)
TOBREX oint. (g)
VIGAMOX
ZIRGAN
ZYLET
BESIVANCE
CETRAXAL
CILOXAN drops
ciprofloxacin hcl droperette
CORTISPORIN
GARAMYCIN drops
MAXITROL
MOXEZA
NEOSPORIN
OCUFLOX
OTOZIN
POLYTRIM
sulfacetamide sodium drops: 10%
TOBRADEX drops susp
TOBREX drops
VIROPTIC
VOSOL HC
ZYMAXID
VITRASERT
Drug Tier
(Ocuflox)
(Polytrim)
(Sulfacetamide Sodium)
(Sulfacetamide/Prednisolone
Sp)
(Tobrex)
(Tobradex)
(Viroptic)
(Bacitracin)
(Cresyl Acetate)
(Cortisporin)
(Sulfacetamide Sodium)
(Cetraxal)
(Sulfacetamide Sodium)
FLOXIN
Requirements/Limits
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T6
QL: 20 in 30 days
QL: 5 in 30 days
QL: 20 in 30 days
(Non-self administerable
injectable)
EX
91
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
TOBRADEX ST
Eye, Ear, Nose, Throat Anti-Inflammatory Agents
dexamethasone sod phosphate
(Dexasol)
diclofenac sodium
(Diclofenac Sodium)
flunisolide
(Flunisolide)
EX
fluocinolone acetonide oil
fluorometholone
flurbiprofen sodium
fluticasone propionate
(Dermotic)
(FML)
(Ocufen)
(Flonase)
T1
T1
T1
T1
hc/pramoxine hcl/chloroxylenol drops: 10-10-1/ml
ketorolac tromethamine
prednisolone acetate
triamcinolone acetonide
(Oticin HC)
(Acular LS)
(Pred Forte)
(Nasacort Aq)
T1
T1
T1
T1
(Bromfenac Sodium)
(Rhinocort Aqua)
T2
T2
T2
T2
ALOCRIL
ALREX
bromfenac sodium
budesonide
FLAREX
FML FORTE
FML S.O.P.
ILEVRO
LOTEMAX
MAXIDEX
mometasone furoate
NEVANAC
PRED MILD
prednisolone sod phosphate
(Nasonex)
(Prednisolone Sod
Phosphate)
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
RESTASIS
VEXOL
ZETONNA
T2
T2
T2
ACULAR LS
ACULAR
BECONASE AQ
T3
T3
T3
CORTANE-B
DERMOTIC
DUREZOL
FLONASE
T3
T3
T3
T3
FML
hc/pramoxine hcl/chloroxylenol drops: 10-10-1/ml
NASACORT AQ
(Oticin HC)
T3
T3
T3
Requirements/Limits
QL: 5 in 30 days
QL: 50 in 30 days (Quantity
listed is 2 bottles)
QL: 32 in 30 days (Quantity
listed is 2 bottles)
QL: 33 in 30 days (Quantity
listed is 2 bottles)
QL: 17.2 in 30 days (Quantity
listed is 2 bottles)
QL: 34 in 30 days
QL: 60 in 30 days
(NOT COVERED FOR
MEDICAID: Covered
Alternatives Available)
QL: 50 in 30 days (Quantity
listed is 2 bottles)
QL: 32 in 30 days (Quantity
listed is 2 bottles)
QL: 33 in 30 days (Quantity
listed is 2 bottles)
92
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
NASONEX
T3
OCUFEN
OMNARIS
T3
T3
OMNIPRED
OTICIN HC
PRED FORTE
PROLENSA
QNASL CHILDREN
QNASL
RHINOCORT AQUA
T3
T3
T3
T3
T3
T3
T3
VERAMYST
TRIESENCE
T3
T6
chloroxylenol/benzoc/hydrocort
(Chloroxylenol/Benzoc/
Hydrocort)
TRIOXIN
Requirements/Limits
QL: 34 in 30 days (Quantity
listed is 2 bottles)
(NOT COVERED FOR
MEDICAID: Covered
Alternatives Available)
QL: 17.2 in 30 days (Quantity
listed is 2 bottles)
(Non-self administerable
injectable)
EX
EX
Gastrointestinal Agents
Antiulcer Agents And Acid Suppressants
cimetidine hcl
cimetidine
famotidine
lansoprazole
lansoprazole/amoxiciln/clarith
misoprostol
nizatidine
omeprazole
pantoprazole sodium tablet dr
rabeprazole sodium
ranitidine hcl capsule, syrup, tablet
sucralfate
CARAFATE oral susp
DEXILANT
esomeprazole magnesium
FIRST-LANSOPRAZOLE
FIRST-OMEPRAZOLE
PREVACID tab rap dr
AXID
CARAFATE tablet
CYTOTEC
NEXIUM suspdr pkt
PEPCID
PREVACID capsule dr
PREVPAC
PRILOSEC capsule dr
PROTONIX
ZANTAC tablet
(Cimetidine HCl)
(Cimetidine)
(Pepcid)
(Prevacid)
(Prevpac)
(Cytotec)
(Axid)
(Prilosec)
(Protonix)
(Aciphex)
(Zantac)
(Carafate)
(Nexium)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
93
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
esomeprazole sodium
(Nexium I.V.)
T6
famotidine in nacl,iso-osm/pf
(Famotidine In Nacl,IsoOsm/PF)
(Famotidine/PF)
T6
famotidine/pf
NEXIUM I.V.
pantoprazole sodium vial
T6
(Protonix IV)
PROTONIX IV
ranitidine hcl vial
T6
T6
T6
(Zantac)
T6
ZANTAC vial
T6
ACIPHEX SPRINKLE
ACIPHEX
esomeprazole strontium
NEXIUM capsule dr
omeprazole/sodium bicarbonate
ZEGERID
Gastrointestinal Agents, Other
cromolyn sodium
dicyclomine hcl capsule, tablet
diphenoxylate hcl/atropine tablet
glycopyrrolate tablet
hyoscyamine sulfate
lactulose
loperamide hcl
methscopolamine bromide
metoclopramide hcl solution, tablet
NULEV
opium tincture
sodium phenylbutyrate
sodium polystyrene sulfon/sorb
EX
EX
EX
EX
EX
EX
sodium polystyrene sulfonate
SYMAX DUOTAB
SYMAX
SYMAX-SL
ursodiol
BUPHENYL tablet
CANTIL
CUVPOSA
dicyclomine hcl solution
diphenoxylate hcl/atropine liquid
(Esomeprazole Strontium)
(Zegerid)
(Gastrocrom)
(Bentyl)
(Lomotil)
(Robinul)
(Levsin-Sl)
(Lactulose)
(Loperamide HCl)
(Methscopolamine Bromide)
(Reglan)
(Opium Tincture)
(Buphenyl)
(Sodium Polystyrene
Sulfon/Sorb)
(Sodium Polystyrene
Sulfonate)
(Urso)
(Dicyclomine HCl)
(Diphenoxylate HCl/
Atropine)
KRISTALOSE
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
94
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
MOTOFEN
MOVANTIK
NUTRESTORE
paregoric
PYLERA
ACTIGALL
AMITIZA
ANASPAZ
BENTYL capsule, tablet
BUPHENYL powder
DIGEX NF
GASTRINEX NF
GASTROCROM
KAYEXALATE
l.acidophilus/b.bifidum,longum
Drug Tier
(Paregoric)
(L.Acidophilus/
B.Bifidum,Longum)
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
LEVSIN tablet
LEVSIN-SL
LINZESS
LOMOTIL
PAMINE FORTE
PAMINE
REGLAN
ROBINUL FORTE
ROBINUL tablet
URSO FORTE
URSO
VELPHORO
RELISTOR syringe, vial
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T4
CARBAGLU
LOTRONEX
BENTYL ampul
T5
T5
T6
glycopyrrolate vial
(Glycopyrrolate)
LEVSIN ampul
metoclopramide hcl vial
T6
T6
(Metoclopramide HCl)
T6
ROBINUL vial
T6
CESINEX
ENTEREG
FULYZAQ
GLYCATE
metoclopramide hcl tab rapdis
METOZOLV ODT
RAVICTI
VIBERZI
EX
EX
EX
EX
EX
EX
EX
EX
(Metozolv Odt)
Requirements/Limits
ST
ST (Self Administerable
(Select) Injectable)
PA
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
95
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
VSL#3 DS
XENICAL
Laxatives
peg 3350/na sulf,bicarb,cl/kcl
sodium chloride/nahco3/kcl/peg
COLYTE WITH FLAVOR PACKETS
GOLYTELY powd pack
MOVIPREP
OSMOPREP
PREPOPIK
SUPREP
GOLYTELY soln recon
NULYTELY WITH FLAVOR PACKS
SUCLEAR
polyethylene glycol 3350
Phosphate Binders
calcium acetate capsule, tablet: 667mg
calcium carbonate/mag carb/fa
FOSRENOL
PHOSLYRA
RENAGEL
RENVELA
sevelamer carbonate
calcium acetate tablet: 667mg
PHOSLO
AURYXIA
Drug Tier
Requirements/Limits
EX
EX
(Golytely)
(Nulytely with Flavor
Packs)
(Polyethylene Glycol 3350)
(Phoslo)
(Calcium Carbonate/Mag
Carb/Fa)
(Sevelamer Carbonate)
(Calcium Acetate)
T1
T1
T2
T2
T2
T2
T2
T2
T3
T3
T3
EX
T1
T2
T2
T2
T2
T2
T2
T3
T3
EX
General Anesthetics
General Anesthetics, Miscellaneous
AMIDATE
T6
DIPRIVAN
T6
etomidate
(Etomidate)
KETALAR
T6
T6
ketamine hcl vial
(Ketalar)
T6
propofol vial
(Propofol)
T6
propofol/pf
(Propofol/PF)
T6
ketamine hcl in 0.9 % nacl syringe: 50mg/5ml; vial
(Ketamine Hcl In 0.9 %
NaCl)
(Ketamine Hcl In Sterile
Water)
EX
(Enflurane)
EX
ketamine hcl in sterile water
Inhalation Anesthetics
enflurane
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
96
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
ETHRANE
FORANE
isoflurane
sevoflurane
ULTANE
Drug Tier
(Isoflurane)
(Sevoflurane)
Requirements/Limits
EX
EX
EX
EX
EX
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl
oxybutynin chloride
tolterodine tartrate
trospium chloride
darifenacin hydrobromide
OXYTROL
DETROL LA
DETROL
DITROPAN XL
ENABLEX
GELNIQUE gel md pmp
GELNIQUE gel packet
MYRBETRIQ
SANCTURA XR
SANCTURA
TOVIAZ
VESICARE
Genitourinary Agents, Miscellaneous
alfuzosin hcl
meth/meblue/sod phos/psal/hyos
methen/m-blue/sal/na phos/hyos capsule: 1200.12mg
methenam/me blue/ba/salicy/hyo tablet: 81.6-0.12
phenazopyridine hcl
tamsulosin hcl
terazosin hcl
FLOMAX
PYRIDIUM
RAPAFLO
(Flavoxate HCl)
(Oxybutynin Chloride)
(Detrol)
(Sanctura)
(Enablex)
T1
T1
T1
T1
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
(Uroxatral)
(Uribel)
(Uta)
T1
T1
T1
(Methenam/Me Blue/Ba/
Salicy/Hyo)
(Phenazopyridine HCl)
(Flomax)
(Terazosin HCl)
T1
URIBEL
UROXATRAL
T1
T1
T1
T3
T3
T3
Not covered for Medicaid
QL: 8 in 28 days
Not covered for Medicaid
ST
Not covered for Medicaid
(NOT COVERED FOR
MEDICAID: Covered
Alternatives Available)
T3
T3
Heavy Metal Antagonists
CA-DTPA
CHEMET
CUPRIMINE
DEPEN
GALZIN
SYPRINE
ZN-DTPA
T2
T2
T2
T2
T2
T2
T2
97
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
EXJADE
FERRIPROX tablet
BAL IN OIL
T3
T5
T6
CALCIUM DISODIUM VERSENATE
T6
deferoxamine mesylate
(Deferoxamine Mesylate)
T6
DESFERAL MESYLATE
T6
DESFERAL
T6
sodium thiosulfate
(Sodium Thiosulfate)
T6
Requirements/Limits
PA
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Hormonal Agents, Stimulant/Replacement/Modifying
Androgens
danazol
estrogen,ester/me-testosterone
oxandrolone
ANADROL-50
ANDRODERM
ANDROID
AXIRON
FIRST-TESTOSTERONE MC
FIRST-TESTOSTERONE
fluoxymesterone
FORTESTA
METHITEST
methyltestosterone
STRIANT
testosterone
ANDROGEL
OXANDRIN
TESTIM
TESTRED
VOGELXO
DEPO-TESTOSTERONE
(Danazol)
(Estrogen,Ester/MeTestosterone)
(Oxandrin)
(Fluoxymesterone)
(Android)
(Androgel)
TESTOPEL
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T6
T6
testosterone cypionate
(Depo-Testosterone)
T6
testosterone enanthate
(Testosterone Enanthate)
T6
Estrogens and Antiestrogens
clomiphene citrate
estradiol patch tdwk
estradiol tablet
estradiol patch tdsw
(Clomiphene Citrate)
(Climara)
(Estrace)
(Vivelle-Dot)
T1
T1
T1
T1
QL: 30 in 30 days
QL: 180 in 30 days
QL: 300 in 30 days
QL: 300 in 30 days
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA
QL: 4 in 28 days
QL: 8 in 28 days
98
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
estradiol/norethindrone acet
(Activella)
T1
estradiol/norethindrone acet
estropipate
norethindrone ac-eth estradiol
(Activella)
(Estropipate)
(Femhrt)
T1
T1
T1
norethindrone ac-eth estradiol
raloxifene hcl
(Femhrt)
(Evista)
T1
T1
SEROPHENE
ANGELIQ
CLIMARA PRO
COMBIPATCH
DIVIGEL
DUAVEE
ELESTRIN
ESTRACE cream/appl
ESTRING
EVAMIST
FEMRING
MENEST
MENOSTAR
PREMARIN cream/appl, tablet
PREMPHASE
PREMPRO
VAGIFEM
ACTIVELLA
ALORA
CENESTIN
CLIMARA
ESTRACE tablet
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
ESTRASORB
T3
ESTROGEL
T3
EVISTA
T3
FEMHRT
T3
JEVANTIQUE LO
T3
MINIVELLE
T3
OSPHENA
T3
Requirements/Limits
(Women's Preventive
Healthcare; see Appendix A
for list of covered generic
contraceptives)
(Women's Preventive
Healthcare; see Appendix A
for list of covered generic
contraceptives)
PA NSO (PA Req'd Women's
Preventive Healthcare)
PA
QL: 4 in 28 days
QL: 8 in 28 days
QL: 1 in 90 days
QL: 1 in 90 days
QL: 4 in 28 days
QL: 8 in 28 days
QL: 4 in 28 days
QL: 8 in 28 days
99
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
Requirements/Limits
PREFEST
T3
VIVELLE-DOT
T3
QL: 8 in 28 days
DELESTROGEN
T6
DEPO-ESTRADIOL
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
estradiol valerate
(Delestrogen)
T6
PREMARIN vial
T6
ENJUVIA
EX
100
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Glucocorticoids/Mineralocorticoids
dexamethasone
fludrocortisone acetate
hydrocortisone
methylprednisolone
prednisolone sod phosphate solution: 5mg/5ml,
15mg/5ml; tab rapdis
prednisone solution, tab ds pk, tablet: 1mg, 2.5mg,
5mg, 10mg, 20mg, 50mg
cortisone acetate
DEXAMETHASONE INTENSOL
DEXPAK
MILLIPRED solution
prednisolone sod phosphate solution: 25mg/5ml
PREDNISONE INTENSOL
VERIPRED 20
CORTEF
MEDROL
MILLIPRED DP
MILLIPRED tablet
ORAPRED ODT
ORAPRED
PEDIAPRED
A-METHAPRED
Drug Tier
(Dexamethasone)
(Fludrocortisone Acetate)
(Cortef)
(Medrol)
(Orapred)
T1
T1
T1
T1
T1
(Prednisone)
T1
(Cortisone Acetate)
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T6
(Orapred)
ARISTOSPAN
betamet acet/betamet na ph
T6
(Celestone)
T6
CELESTONE
T6
DEPO-MEDROL
T6
dexamethasone sod phosphate
hydrocortisone sod succinate
(Dexamethasone Sod
Phosphate)
(Solu-Cortef)
T6
T6
KENALOG-10
T6
KENALOG-40
T6
methylprednisolone acetate
(Depo-Medrol)
T6
methylprednisolone sod succ
(Solu-Medrol)
T6
SOLU-CORTEF
T6
SOLU-MEDROL vial: 2g, 500mg
T6
SOLU-MEDROL vial: 40mg/ml, 125mg/2ml,
1000mg/8ml
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
101
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
triamcinolone acetonide
EZ USE JOINT-TUNNEL-TRIGGER
FLO-PRED
RAYOS
Pituitary
desmopressin acetate solution, spray/pump, tablet
DDAVP solution, tablet
DDAVP spray/pump
STIMATE
SAIZEN
Drug Tier
(Triamcinolone Acetonide)
T6
Requirements/Limits
(Non-self administerable
injectable)
EX
EX
EX
(DDAVP)
T1
T3
T3
T3
T4
SEROSTIM
T4
ZORBTIVE
T4
BRAVELLE
T5
CHORIONIC GONADOTROPIN
T5
FOLLISTIM AQ cartridge
T5
GENOTROPIN
T5
HUMATROPE
T5
INCRELEX
T5
MENOPUR
T5
NORDITROPIN FLEXPRO
T5
NOVAREL
T5
NUTROPIN AQ NUSPIN
T5
NUTROPIN AQ
T5
OMNITROPE
T5
PREGNYL
T5
REPRONEX
T5
SOMAVERT
T5
TEV-TROPIN
T5
ZOMACTON
T5
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
102
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
CETROTIDE
T6
DDAVP ampul
T6
desmopressin acetate vial
(Desmopressin Acetate)
T6
FOLLISTIM AQ vial
T6
GONAL-F RFF REDI-JECT
T6
GONAL-F RFF
T6
GONAL-F
T6
LUPRON DEPOT-PED
T6
octreotide acetate
(Octreotide Acetate)
T6
OVIDREL
T6
PITRESSIN
T6
SANDOSTATIN LAR DEPOT
T6
SANDOSTATIN
T6
SUPPRELIN LA
T6
VANTAS
T6
vasopressin
EGRIFTA
SOMATULINE DEPOT
Progestins
medroxyprogesterone acetate tablet
megestrol acetate
norethindrone acetate
progesterone,micronized
CRINONE
ENDOMETRIN
FIRST-PROGESTERONE VGS 100
FIRST-PROGESTERONE VGS 200
FIRST-PROGESTERONE VGS 25
FIRST-PROGESTERONE VGS 400
FIRST-PROGESTERONE VGS 50
AYGESTIN
MEGACE ES
MEGACE
PROMETRIUM
PROVERA
(Pitressin)
T6
Requirements/Limits
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
EX
(Provera)
(Megace Es)
(Aygestin)
(Prometrium)
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
(Oral Cancer Drug)
PA
PA
(Oral Cancer Drug)
(Oral Cancer Drug)
103
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
DEPO-PROVERA
T6
DEPO-SUBQ PROVERA 104
T6
MAKENA
T6
medroxyprogesterone acetate syringe, vial
(Depo-Provera)
T6
progesterone
(Progesterone)
T6
(Synthroid)
(Levothyroxine Sodium)
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T6
(Liothyronine Sodium)
T6
Thyroid and Antithyroid Agents
levothyroxine sodium tablet
LEVOXYL
liothyronine sodium tablet
methimazole
propylthiouracil
thyroid,pork
UNITHROID
ARMOUR THYROID
potassium iodide
potassium iodide/iodine
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-1
THYROLAR-2
THYROLAR-3
CYTOMEL
SYNTHROID
TAPAZOLE
TIROSINT
levothyroxine sodium vial
liothyronine sodium vial
(Cytomel)
(Tapazole)
(Propylthiouracil)
(Thyroid,Pork)
(Potassium Iodide)
(Potassium Iodide/Iodine)
THYROGEN
T6
TRIOSTAT
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Women's Preventive
Healthcare)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Immunological Agents
azathioprine
cyclosporine capsule
cyclosporine, modified capsule: 25mg, 100mg;
solution
HECORIA
leflunomide
mycophenolate mofetil
mycophenolate sodium
sirolimus
tacrolimus
ASTAGRAF XL
(Imuran)
(Sandimmune)
(Neoral)
T1
T1
T1
(Arava)
(Cellcept)
(Myfortic)
(Rapamune)
(Prograf)
T1
T1
T1
T1
T1
T1
T2
104
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
CELLCEPT susp recon
cyclosporine, modified capsule: 50mg
ENVARSUS XR
RAPAMUNE solution
RIDAURA
SANDIMMUNE solution
ARAVA
CELLCEPT capsule, tablet
cyclosporine, modified capsule: 50mg
IMURAN
MYFORTIC
NEORAL
PROGRAF capsule
RAPAMUNE tablet
SANDIMMUNE capsule
ENBREL
Drug Tier
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T4
(Neoral)
(Neoral)
HUMIRA PEDIATRIC CROHN'S
T4
HUMIRA PEN CROHN-UC-HS STARTER
T4
HUMIRA PEN PSORIASIS-UVEITIS
T4
HUMIRA PEN
T4
HUMIRA
T4
ZORTRESS
ARCALYST
T4
T5
CIMZIA syringekit
T5
HIZENTRA
T5
HYQVIA
T5
KINERET
T5
ORENCIA syringe
T5
ANASCORP
T6
ANTIVENIN LATRODECTUS MACTANS
T6
ANTIVENIN MICRURUS FULVIUS
T6
ATGAM
T6
azathioprine sodium
(Azathioprine Sodium)
T6
Requirements/Limits
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
105
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
BIVIGAM
T6
CARIMUNE NF NANOFILTERED
T6
CELLCEPT vial
T6
CIMZIA kit
T6
CROFAB
T6
cyclosporine ampul
(Sandimmune)
T6
CYTOGAM
T6
FLEBOGAMMA DIF vial: 10%
T6
FLEBOGAMMA DIF vial: 5%
T6
GAMASTAN S-D
T6
GAMMAGARD LIQUID
T6
GAMMAKED
T6
GAMMAPLEX
T6
GAMUNEX-C
T6
HEPAGAM B
T6
HYPERHEP B S-D
T6
HYPERRAB S-D
T6
HYPERRHO S-D
T6
HYPERTET S-D
T6
ILARIS
T6
IMOGAM RABIES-HT
T6
MICRHOGAM ULTRA-FILTERED PLUS
T6
NABI-HB
T6
OCTAGAM
T6
ORENCIA vial
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
106
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
PRIVIGEN
T6
PROGRAF ampul
T6
RHOGAM ULTRA-FILTERED PLUS
T6
RHOPHYLAC
T6
SANDIMMUNE ampul
T6
THYMOGLOBULIN
T6
TYSABRI
T6
WINRHO SDF
T6
AUBAGIO
AZASAN
Vaccines
ACTHIB
ADACEL TDAP
AFLURIA 2015-2016 syringe
AFLURIA 2015-2016 vial
AFLURIA 2016-2017 syringe
AFLURIA 2016-2017 vial
AFLURIA QUAD 2016-2017 syringe
AFLURIA QUAD 2016-2017 vial
BCG (TICE STRAIN)
BCG VACCINE (TICE STRAIN)
BEXSERO
BIOTHRAX
BOOSTRIX TDAP
CERVARIX
COMVAX
DAPTACEL DTAP
DIPHTHERIA-TETANUS TOXOIDS-PED
ENGERIX-B ADULT
ENGERIX-B PEDIATRIC-ADOLESCENT
FLUARIX QUAD 2015-2016
FLUARIX QUAD 2016-2017
FLUBLOK 2015-2016
FLUBLOK 2016-2017
FLUCELVAX 2015-2016
FLUCELVAX QUAD 2016-2017
FLULAVAL QUAD 2015-2016
FLULAVAL QUAD 2016-2017 syringe
FLULAVAL QUAD 2016-2017 vial
FLUMIST QUAD 2015-2016
FLUVIRIN 2015-2016 syringe
FLUVIRIN 2015-2016 vial
EX
EX
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
107
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
FLUVIRIN 2016-2017 syringe
FLUVIRIN 2016-2017 vial
FLUZONE 2015-2016
FLUZONE HIGH-DOSE 2015-2016
FLUZONE HIGH-DOSE 2016-2017
FLUZONE INTRADERM QUAD 2015-16
FLUZONE INTRADERM QUAD 2016-17
FLUZONE QUAD 2015-2016 syringe
FLUZONE QUAD 2015-2016 vial
FLUZONE QUAD 2016-2017
GARDASIL 9
GARDASIL
HAVRIX
HIBERIX
IMOVAX RABIES VACCINE
INFANRIX DTAP
IPOL
KINRIX
MENACTRA
MENHIBRIX
MENOMUNE-A-C-Y-W-135
MENVEO A-C-Y-W-135-DIP
MENVEO MENA COMPONENT
MENVEO MENCYW-135 COMPONENT
M-M-R II VACCINE
PEDIARIX
PEDVAXHIB
PENTACEL
PNEUMOVAX 23
PREVNAR 13
PROQUAD
QUADRACEL DTAP-IPV
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
TENIVAC
TETANUS TOXOID ADSORBED
tetanus, diphtheria tox,adult
Drug Tier
(Tetanus, Diphtheria
Tox,Adult)
THERACYS
TRUMENBA
TWINRIX
VAQTA
VARIVAX VACCINE
ZOSTAVAX
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
Requirements/Limits
(Restricted to ages 9-26)
(Restricted to ages 9-26)
T6
T6
T6
T6
T6
T6
Inflammatory Bowel Disease Agents
balsalazide disodium
budesonide
mesalamine enema
(Colazal)
(Entocort EC)
(Sfrowasa)
T1
T1
T1
108
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
APRISO
CANASA
DIPENTUM
mesalamine tablet dr
PENTASA
ASACOL HD
COLAZAL
DELZICOL
ENTOCORT EC
LIALDA
SFROWASA
UCERIS tabdr - er
alosetron hcl
GIAZO
Drug Tier
(Asacol Hd)
(Alosetron HCl)
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T4
EX
Requirements/Limits
PA
PA
Irrigating Solutions
acetic acid
glycine urologic solution
LACTATED RINGERS
PHYSIOLYTE
ringers solution
sodium chloride irrig solution
water for irrigation,sterile
mannitol/sorbitol solution
RESECTISOL
sorbitol solution
VIASPAN BELZER-UW
PHYSIOSOL
DELFLEX WITH 1.5% DEXTROSE ip soln:
2.5meq(ca)
DELFLEX WITH 1.5% DEXTROSE ip soln:
3.5meq(ca)
DELFLEX WITH 2.5% DEXTROSE
(Acetic Acid)
(Glycine Urologic Solution)
(Ringers Solution)
(Sodium Chloride Irrig
Solution)
(Water For
Irrigation,Sterile)
(Mannitol/Sorbitol Solution)
(Sorbitol Solution)
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T3
T6
T6
T6
DELFLEX WITH 4.25% DEXTROSE
T6
DIANEAL PD-2 W-1.5% DEXTROSE
T6
DIANEAL PD-2 W-2.5% DEXTROSE
T6
DIANEAL PD-2 W-4.25% DEXTROSE
T6
DIANEAL WITH 1.5% DEXTROSE
T6
EXTRANEAL ICODEXTRIN DIALYSIS
T6
periton. dialysis #7-dex 2.5 %
(Periton. Dialysis #7-Dex
2.5 %)
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
109
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
periton.dialysis #8-dex 4.25 %
Drug Tier
(Periton.Dialysis #8-Dex
4.25 %)
T6
Requirements/Limits
(Non-self administerable
injectable)
Liver Function
EOVIST
EX
Metabolic Bone Disease Agents
alendronate sodium tablet: 5mg, 10mg
alendronate sodium tablet: 35mg, 70mg
calcitonin,salmon,synthetic
calcitriol capsule, solution
doxercalciferol capsule
ibandronate sodium tablet
paricalcitol
risedronate sodium tablet: 5mg, 30mg
risedronate sodium tablet: 150mg
risedronate sodium tablet: 35mg
alendronate sodium tablet: 40mg
etidronate disodium
FORTICAL
ACTONEL tablet: 5mg, 30mg
ACTONEL tablet: 150mg
ACTONEL tablet: 35mg
alendronate sodium solution
BONIVA tablet
FOSAMAX PLUS D
FOSAMAX
HECTOROL capsule
MIACALCIN spray/pump
ROCALTROL
ZEMPLAR capsule
FORTEO
(Fosamax)
(Fosamax)
(Miacalcin)
(Rocaltrol)
(Hectorol)
(Boniva)
(Zemplar)
(Actonel)
(Actonel)
(Actonel)
(Fosamax)
(Etidronate Disodium)
(Alendronate Sodium)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T5
MIACALCIN vial
T5
BONIVA syringe
T6
calcitriol ampul
(Calcitriol)
T6
doxercalciferol ampul
(Doxercalciferol)
T6
HECTOROL vial
T6
ibandronate sodium syringe
(Boniva)
T6
pamidronate disodium
(Pamidronate Disodium)
T6
PARICALCITOL
T6
PROLIA
T6
QL: 4 in 28 days
QL: 1 in 28 days
QL: 1 in 28 days
QL: 4 in 28 days
QL: 1 in 28 days
QL: 4 in 28 days
QL: 300 in 28 days
QL: 1 in 28 days
QL: 4 in 28 days
QL: 4 in 28 days
PA (Self Administerable
(Select) Injectable)
(Self Administerable (Select)
Injectable)
QL: 3 in 90 days (Non-self
administerable injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
QL: 3 in 90 days (Non-self
administerable injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
110
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
RECLAST
T6
XGEVA
T6
ZEMPLAR vial
T6
zoledronic acid
(Zometa)
T6
zoledronic acid/mannitol and water
(Reclast)
T6
ZOMETA infus. btl
T6
ZOMETA vial
T6
ATELVIA
BINOSTO
risedronate sodium tablet dr
EX
EX
EX
(Atelvia)
Requirements/Limits
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Miscellaneous Therapeutic Agents
acetylcysteine
allopurinol
bethanechol chloride
buspirone hcl
colchicine/probenecid
dutasteride
dutasteride/tamsulosin hcl
ergoloid mesylates
finasteride tablet: 5mg
hydroxyzine hcl solution, tablet
hydroxyzine pamoate capsule: 25mg, 50mg
leucovorin calcium tablet: 5mg, 25mg
levocarnitine (with sugar)
levocarnitine tablet
meprobamate
methylergonovine maleate tablet
probenecid
pyridostigmine bromide
CERVIDIL
ELMIRON
GLUCAGEN
GLUCAGON EMERGENCY KIT
guanidine hcl
hydroxyzine pamoate capsule: 100mg
leucovorin calcium tablet: 10mg, 15mg
LITHOSTAT
MESTINON syrup
mineral oil
MINERAL OIL
POTABA
PREPIDIL
PROSTIN E2 VAGINAL SUPPOSITORY
(Acetylcysteine)
(Zyloprim)
(Urecholine)
(Buspirone HCl)
(Colchicine/Probenecid)
(Avodart)
(Jalyn)
(Ergoloid Mesylates)
(Propecia)
(Hydroxyzine HCl)
(Vistaril)
(Leucovorin Calcium)
(Carnitor)
(Carnitor)
(Meprobamate)
(Methylergonovine Maleate)
(Probenecid)
(Mestinon)
(Guanidine HCl)
(Vistaril)
(Leucovorin Calcium)
(Mineral Oil)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
111
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
SENSIPAR
SYNAREL
THIOLA
TRICHLOROACETIC ACID soln recon: 25%
TRICITRASOL
TYBOST
ULORIC
ASTRINGYN
AVODART
b3/azel ac/zinc/b6/copper/fa
BIONECT
BIOSTEP AG
BIOSTEP
CARNITOR SF
CARNITOR tablet
CARRASYN HYDROGEL WOUND
colchicine tablet
COLCRYS
ENDO-AVITENE
GELFILM
GRASTEK
HYLASE
JALYN
KENDALL
MESTINON tablet, tablet er
MONSEL'S
NICAZEL FORTE
NICAZEL
ORALAIR tab subl: 100ir, 300ir
PROSCAR
RAGWITEK
REZYST
SILVERSEAL HYDROGEL
SPECTRAGEL
SYRINGE AVITENE
THALOMID
ULESFIA
URECHOLINE
VISTARIL
XCLAIR
ZYLOPRIM
BETASERON
Drug Tier
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T4
(Nicazel)
(Colcrys)
COPAXONE syringe: 40mg/ml
glatiramer acetate
T4
(Copaxone)
MESNEX tablet
ACTEMRA syringe
T4
T4
T5
Requirements/Limits
ST
PA
PA
PA
(Oral Cancer Drug)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
PA (Self Administerable
(Select) Injectable)
112
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
Requirements/Limits
ACTIMMUNE
T5
AVONEX PEN
T5
AVONEX kit
T5
AVONEX syringekit
T5
COPAXONE syringe: 20mg/ml
T5
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
CYSTADANE
EXTAVIA
T5
T5
GANIRELIX ACETATE
T5
GILENYA
ORENCIA CLICKJECT
T5
T5
PLEGRIDY PEN
T5
PLEGRIDY
T5
RADIOGARDASE
REBIF REBIDOSE
T5
T5
REBIF
T5
SIMPONI
T5
TECFIDERA
XELJANZ
ACTEMRA vial
T5
T5
T6
ALCOHOL,DEHYDRATED
T6
allopurinol sodium
(Allopurinol Sodium)
ALOPRIM
T6
T6
amifostine crystalline
(Amifostine Crystalline)
T6
ammonium chloride
(Ammonium Chloride)
T6
amobarbital sodium
(Amobarbital Sodium)
T6
AMVISC PLUS
T6
AMVISC
T6
BENLYSTA
T6
(Self Administerable (Select)
Injectable)
PA (Self Administerable
(Select) Injectable)
PA (Self Administerable
(Select) Injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
(Self Administerable (Select)
Injectable)
PA (Self Administerable
(Select) Injectable)
PA
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
113
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
BLOXIVERZ
T6
BOTOX
T6
CARNITOR vial
T6
CARTICEL
T6
dexrazoxane hcl
(Zinecard)
T6
droperidol
(Droperidol)
T6
DUODOTE
T6
DYSPORT
T6
ELLIOTTS B
T6
ENTYVIO
T6
ETHYOL
T6
EUFLEXXA
T6
fomepizole
(Fomepizole)
T6
FUSILEV
T6
HEMABATE
T6
HYALGAN
T6
hydroxyzine hcl vial
(Hydroxyzine HCl)
T6
KALBITOR
T6
KEPIVANCE
T6
leucovorin calcium vial
(Leucovorin Calcium)
T6
levocarnitine vial
(Carnitor)
T6
levoleucovorin calcium
(Fusilev)
T6
mesna
(Mesnex)
T6
MESNEX vial
methylene blue
T6
(Methylene Blue)
T6
Requirements/Limits
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
114
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
methylergonovine maleate vial
Drug Tier
(Methylergonovine Maleate)
T6
MYOBLOC
T6
NEOSTIGMINE METHYLSULFATE
T6
NEXAVIR
T6
NITHIODOTE
T6
NPLATE
T6
OXYTOCIN
T6
PANHEMATIN
T6
PHYSICIANS EZ USE M-PRED
T6
physostigmine salicylate
(Physostigmine Salicylate)
T6
PITOCIN
T6
PRALIDOXIME CHLORIDE
T6
PROSTASCINT
T6
PROTOPAM CHLORIDE
T6
PROVENGE
T6
PROVISC
T6
REGONOL
T6
REMICADE
T6
SCLEROSOL
T6
SIMPONI ARIA
T6
SIMULECT
T6
sodium morrhuate
(Sodium Morrhuate)
T6
sodium nitrite
(Sodium Nitrite)
T6
sodium tetradecyl sulfate
(Sodium Tetradecyl Sulfate)
T6
SOTRADECOL
T6
Requirements/Limits
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
115
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
STELARA
T6
SUPARTZ FX
T6
SUPARTZ
T6
SYNVISC-ONE
T6
SYNVISC
T6
talc
(Talc)
T6
THAM
T6
TOTECT
T6
TRIFERIC
VORAXAZE
T6
T6
XEOMIN
T6
ZINECARD
T6
TEGADERM + PAD
TEGADERM
aa8/a-carnitin/grp/cocoa/hc126
T6
T6
EX
aa9/a-carnitin/dex/cocoa/hc127
AQUAFLO
ATRAPRO DERMAL SPRAY
AURSTAT
borage and fish oil/fruct/soy lec
BOTOX COSMETIC
colchicine capsule
ENTERAGAM
finasteride tablet: 1mg
fish oil/omega-3/e/fa/b6-b12
formaldehyde
FORMALDEHYDE
FORMA-RAY
FOSTEUM
FOVEX
genistein/cit zn bisgly/vit d3
H.P. ACTHAR
HYPERTENSA
LIMBREL250
LIMBREL500
LIMBREL
LISTER-V
(Aa8/A-Carnitin/Grp/Cocoa/
Hc126)
(Aa9/A-Carnitin/Dex/
Cocoa/Hc127)
(Lunglaid)
(Colchicine)
(Propecia)
(Fish Oil/Omega-3/E/Fa/B6B12)
(Formaldehyde)
(Fosteum)
Requirements/Limits
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
116
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
METHERGINE
MITIGARE
MYALEPT
ORAFATE
ORTHOVISC
OTEZLA
OTREXUP
PERCURA
PREFLIN
PROCYSBI
PROPECIA
PROTEOLIN
PROTHELIAL
RASUVO
RECTIV
RESTORE CALCIUM ALGINATE
RESTORE CONTACT LAYER SILVER
RESTORE
SANARE SCAR THERAPY BASE
SENTRA PM
SIGNIFOR
SOLIRIS
THERAMINE
TREPADONE
VAYACOG
VAYARIN
VAYAROL
VERTIGOHEEL
VP-PRECIP
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
Ocular Disorders
MEMBRANEBLUE
T6
VISIONBLUE
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide
betaxolol hcl
brimonidine tartrate
dorzolamide hcl
dorzolamide hcl/timolol maleat
latanoprost
levobunolol hcl drops: 0.5%
methazolamide
pilocarpine hcl
timolol maleate drops: 0.25%
timolol maleate drops: 0.5%; sol-gel
ALPHAGAN P drops: 0.1%
BETOPTIC S
(Acetazolamide)
(Betaxolol HCl)
(Alphagan P)
(Trusopt)
(Cosopt)
(Xalatan)
(Betagan)
(Neptazane)
(Isopto Carpine)
(Timolol Maleate)
(Timolol Maleate)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
QL: 5 in 30 days
QL: 10 in 30 days
QL: 10 in 30 days
QL: 2.5 in 30 days
QL: 5 in 30 days
QL: 15 in 30 days
QL: 5 in 30 days
QL: 10 in 30 days
QL: 10 in 30 days
117
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
COMBIGAN
ISOPTO CARBACHOL
levobunolol hcl drops: 0.25%
LUMIGAN
metipranolol
PHOSPHOLINE IODIDE
SIMBRINZA
TIMOPTIC OCUDOSE
ALPHAGAN P drops: 0.15%
AZOPT
BETAGAN
BETIMOL
COSOPT PF
COSOPT
DIAMOX SEQUELS
ISOPTO CARPINE
ISTALOL
NEPTAZANE
TIMOPTIC-XE
TRAVATAN Z
travoprost (benzalkonium)
TRUSOPT
XALATAN
ZIOPTAN
acetazolamide sodium
Drug Tier
(Betagan)
(Metipranolol)
(Travoprost
(Benzalkonium))
(Acetazolamide Sodium)
T2
T2
T2
T2
T2
T2
T2
T2
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T3
T6
MIOCHOL-E
T6
MIOSTAT
T6
MITOSOL
T6
bimatoprost
RESCULA
(Bimatoprost)
Requirements/Limits
QL: 10 in 30 days
QL: 5 in 30 days
QL: 5 in 60 days
QL: 10 in 30 days
QL: 10 in 30 days
QL: 5 in 30 days
QL: 10 in 30 days
QL: 60 in 30 days
QL: 10 in 30 days
QL: 15 in 30 days
QL: 5 in 30 days
QL: 5 in 30 days
QL: 5 in 60 days
QL: 5 in 60 days
QL: 2.5 in 30 days
QL: 30 in 30 days
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
EX
Radioactive Agents
AMYVID
T6
INDICLOR
T6
METASTRON
T6
QUADRAMET
T6
XOFIGO
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
Replacement Preparations
cardioplegic solution no.1
citric acid/sodium citrate
KLOR-CON 10
(Plegisol)
(Citric Acid/Sodium Citrate)
T1
T1
T1
118
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
KLOR-CON 8
KLOR-CON
phosphorus #1
pot chloride/pot bicarb/cit ac
potassium bicarbonate/cit ac
potassium chloride capsule er, liquid, packet, tab er
prt, tablet er
potassium citrate
potassium citrate/citric acid packet, solution: 1100334/5
zinc sulfate capsule
K-PHOS NO.2
K-PHOS ORIGINAL
ORACIT
sod/pot/k cit/sod cit/cit acid
K-PHOS NEUTRAL
K-TAB ER
PLEGISOL
SHOHL'S MODIFIED
UROCIT-K
0.9 % sodium chloride
Drug Tier
(K-Phos Neutral)
(Pot Chloride/Pot Bicarb/Cit
Ac)
(Klor-Con-Ef)
(Klor-Con)
(Urocit-K)
(Potassium Citrate/Citric
Acid)
(Zinc Sulfate)
(Sod/Pot/K Cit/Sod Cit/Cit
Acid)
(Sodium Chloride)
AMMONUL
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T2
T2
T3
T3
T3
T3
T3
T6
T6
calcium chloride
(Calcium Chloride)
T6
calcium gluconate
(Calcium Gluconate)
T6
chromic chloride
(Chromic Chloride)
T6
cupric chloride
(Cupric Chloride)
T6
cupric sulfate
(Cupric Sulfate)
T6
dextrose 10 % and 0.2 % nacl
(Dextrose 10 % and 0.2 %
NaCl)
(Dextrose 10 % and 0.45 %
NaCl)
(Dextrose 2.5 % and 0.45 %
NaCl)
(Dextrose 5 % and 0.3 %
NaCl)
(Dextrose 5 % and 0.9 %
NaCl)
(Dextrose 5 %-0.2 % NaCl)
T6
dextrose 10 % and 0.45 % nacl
dextrose 2.5 % and 0.45 % nacl
dextrose 5 % and 0.3 % nacl
dextrose 5 % and 0.9 % nacl
dextrose 5 %-0.2 % nacl
dextrose 5 %-0.45 % nacl
(Dextrose 5 %-0.45 %
NaCl)
Requirements/Limits
T6
T6
T6
T6
T6
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
119
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
dextrose 5%-lactated ringers
electrolyte-48 solution/d5w
Drug Tier
(Dextrose 5%-Lactated
Ringers)
(Electrolyte-48 Solution/
D5W)
HESPAN
hetastarch in 0.9 % nacl
T6
T6
T6
(Hespan)
T6
HEXTEND LACTATED ELECTROLYTE
T6
HYPERLYTE CR
T6
IONOSOL B WITH DEXTROSE 5%
T6
IONOSOL MB-DEXTROSE 5%
T6
ISOLYTE H WITH DEXTROSE
T6
ISOLYTE M WITH DEXTROSE
T6
ISOLYTE P WITH DEXTROSE
T6
ISOLYTE S
T6
LACTATED RINGERS
T6
LMD 10% WITH 5% DEXTROSE
T6
magnesium chloride
(Magnesium Chloride)
T6
magnesium sulfate in water
T6
magnesium sulfate
(Magnesium Sulfate in
Water)
(Magnesium Sulfate)
T6
magnesium sulfate/d5w piggyback: 1g/100ml
(Magnesium Sulfate/D5W)
T6
manganese chloride
(Manganese Chloride)
T6
manganese sulfate
(Manganese Sulfate)
T6
molybdenum(ammonium molybdate)
(Molybdenum(Ammonium
Molybdate))
T6
NEUT
T6
NORMOSOL-M AND DEXTROSE
T6
NORMOSOL-R AND DEXTROSE
T6
NORMOSOL-R
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
120
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
NUTRILYTE II
T6
NUTRILYTE
T6
PHOXILLUM solution: 4-1.5-1/l
T6
PHOXILLUM solution: 4-2.5-1/l
T6
PLASMA-LYTE 148
T6
PLASMA-LYTE 56 IN DEXTROSE
T6
PLASMA-LYTE A PH 7.4
T6
potassium acetate
(Potassium Acetate)
T6
potassium chloride in 0.9%nacl
(Potassium Chloride In
0.9%NaCl)
(Potassium Chloride In
D5w)
(Potassium Chloride In LrD5)
(Klor-Con)
T6
potassium chloride in d5w
potassium chloride in lr-d5
potassium chloride piggyback, vial
potassium chloride/d5-0.2%nacl
potassium chloride/d5-0.3%nacl
potassium chloride/d5-0.45nacl
potassium chloride/d5-0.9%nacl
potassium chloride-0.45% nacl
potassium phos,m-basic-d-basic
(Potassium Chloride/D50.2%NaCl)
(Potassium Chloride/D50.3%NaCl)
(Potassium Chloride/D50.45nacl)
(Potassium Chloride/D50.9%NaCl)
(Potassium Chloride-0.45%
NaCl)
(Potassium Phos,M-BasicD-Basic)
T6
T6
T6
T6
T6
T6
T6
T6
T6
PRISMASOL solution: 1.2meq/l
T6
PRISMASOL solution: 2.5-1.5/l
T6
PRISMASOL solution: 2-1.5meq/l
T6
PRISMASOL solution: 2-1meq/l
T6
PRISMASOL solution: 2-3.5meq/l
T6
PRISMASOL solution: 4-1.2meq/l
T6
PRISMASOL solution: 4-1.5meq/l
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
121
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
PRISMASOL solution: 4-2.5-1.5
T6
ringers solution
(Ringers Solution)
T6
selenium
(Selenium)
T6
sodium acetate
(Sodium Acetate)
T6
sodium benzoate/sod phenylacet
(Sodium Benzoate/Sod
Phenylacet)
sodium bicarbonate syringe, vial: 0.5meq/ml, 1meq/ (Sodium Bicarbonate)
ml
sodium chloride 0.45 %
(Sodium Chloride 0.45 %)
T6
sodium chloride 3 %
(Sodium Chloride 3 %)
T6
sodium chloride 5 %
(Sodium Chloride 5 %)
T6
SODIUM CHLORIDE syringe
T6
T6
T6
sodium chloride
(Sodium Chloride)
T6
sodium glycerophosphate
(Sodium Glycerophosphate)
T6
sodium lactate
(Sodium Lactate)
T6
sodium phos,m-basic-d-basic
(Sodium Phos,M-Basic-DBasic)
T6
SWABFLUSH
T6
TPN ELECTROLYTES II
T6
trace elements comb no.1
(Trace Elements Comb
No.1)
VOLUVEN
T6
T6
zinc chloride
(Zinc Chloride)
T6
zinc gluconate
(Zinc Gluconate)
T6
zinc sulf/cuso4 p-hyd/mn/cr/se
(Zinc Sulf/Cuso4 P-Hyd/
Mn/Cr/Se)
(Zinc Sulfate)
T6
zinc sulfate vial
zinc/copper/mangan/chromic chl
zn/cu/mang/selen/fluor/pot iod
(Zinc/Copper/Mangan/
Chromic Chl)
(Zn/Cu/Mang/Selen/Fluor/
Pot Iod)
FOSTEUM PLUS
T6
T6
T6
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
Respiratory Tract Agents
Anti-Inflammatories, Inhaled Corticosteroids
122
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
ASMANEX aer pow ba: 110mcg(30), 110mcg(7),
220mcg(14), 220mcg(30), 220mcg(60)
ASMANEX aer pow ba: 220mcg120
budesonide
ADVAIR DISKUS
ADVAIR HFA
AEROSPAN
ALVESCO
ARNUITY ELLIPTA
ASMANEX HFA
BREO ELLIPTA
DULERA
FLOVENT DISKUS
FLOVENT HFA aer w/adap: 110mcg, 220mcg
FLOVENT HFA aer w/adap: 44mcg
Drug Tier
T1
(Pulmicort)
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
PULMICORT FLEXHALER
T2
PULMICORT ampul-neb: 1mg/2ml
QVAR
SYMBICORT
PULMICORT ampul-neb: 0.25mg/2ml, 0.5mg/2ml
Antileukotrienes
montelukast sodium
zafirlukast
ACCOLATE
SINGULAIR
ZYFLO CR
ZYFLO
Bronchodilators
albuterol sulfate
ipratropium bromide
ipratropium/albuterol sulfate
T2
T2
T2
T3
levalbuterol hcl vial-neb: 1.25mg/0.5, 1.25mg/3ml
metaproterenol sulfate syrup
terbutaline sulfate tablet
theophylline anhydrous solution, tab er 12h, tab er
24h
ANORO ELLIPTA
ARCAPTA NEOHALER
ATROVENT HFA
BROVANA
COMBIVENT RESPIMAT
FORADIL
INCRUSE ELLIPTA
levalbuterol hcl vial-neb: 0.31mg/3ml, 0.63mg/3ml
LUFYLLIN
metaproterenol sulfate tablet
PERFOROMIST
(Singulair)
(Accolate)
T1
T1
T3
T3
T3
T3
(Albuterol Sulfate)
(Ipratropium Bromide)
(Ipratropium/Albuterol
Sulfate)
(Xopenex)
(Metaproterenol Sulfate)
(Terbutaline Sulfate)
(Theophylline Anhydrous)
T1
T1
T1
(Xopenex)
(Metaproterenol Sulfate)
Requirements/Limits
QL: 1 in 30 days (Quantity
listed is # of inhalers)
QL: 1 in 60 days
QL: 60 in 30 days
QL: 12 in 30 days
QL: 12.2 in 30 days
QL: 30 in 30 days
QL: 13 in 30 days
QL: 60 in 30 days
QL: 13 in 30 days
QL: 120 in 30 days
QL: 21.2 in 30 days (Quantity
listed is 2 inhalers)
QL: 2 in 30 days (Quantity
listed is # of inhalers)
QL: 17.4 in 30 days
QL: 10.2 in 30 days
T1
T1
T1
T1
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
QL: 30 in 30 days
QL: 25.8 in 30 days
QL: 8 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
123
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
PROAIR HFA
T2
PROAIR RESPICLICK
SEEBRI NEOHALER
SEREVENT DISKUS
SPIRIVA RESPIMAT
SPIRIVA
STRIVERDI RESPIMAT
THEO-24
theophylline anhydrous elixir
TUDORZA PRESSAIR
UTIBRON NEOHALER
VENTOLIN HFA
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
T2
(Theophylline Anhydrous)
PROVENTIL HFA
T3
VOSPIRE ER
XOPENEX HFA
T3
T3
XOPENEX
aminophylline
(Aminophylline)
ISUPREL
T3
T6
T6
terbutaline sulfate vial
(Terbutaline Sulfate)
T6
theophylline/d5w
(Theophylline/D5W)
T6
(Acetadote)
(Cromolyn Sodium)
(Guaifenesin/Dyphylline)
T1
T1
T1
T1
T1
Respiratory Tract Agents, Other
acetylcysteine vial: 100mg/ml, 200mg/ml
cromolyn sodium
guaifenesin/dyphylline
PULMOSAL
sodium chloride for inhalation
(Sodium Chloride For
Inhalation)
CUROSURF
HYPER-SAL vial-neb: 3.5%
INFASURF
NEBUSAL
SURFAXIN
SURVANTA
HYPER-SAL vial-neb: 7%
ESBRIET
KALYDECO
OFEV
ACETADOTE
acetylcysteine vial: 200mg/ml
T2
T2
T2
T2
T2
T2
T3
T5
T5
T5
T6
(Acetadote)
T6
Requirements/Limits
QL: 17 in 30 days (Quantity
listed is 2 inhalers)
QL: 2 in 30 days
QL: 60 in 30 days
QL: 60 in 30 days
QL: 4 in 30 days
QL: 60 in 30 days
QL: 36 in 30 days (Quantity
listed is 2 inhalers)
QL: 13.4 in 30 days (Quantity
listed is 2 inhalers)
QL: 30 in 30 days (Quantity
listed is 2 inhalers)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA
PA
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
124
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
ARALAST NP
T6
DOPRAM
T6
doxapram hcl
(Doxapram HCl)
T6
GLASSIA
T6
NUCALA
T6
PROLASTIN C
T6
XOLAIR
T6
ZEMAIRA
T6
DALIRESP
EX
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
Roentgenography
OCTREOSCAN
T6
(Non-self administerable
injectable)
Skeletal Muscle Relaxants
baclofen
carisoprodol tablet: 350mg
carisoprodol/aspirin
chlorzoxazone
codeine/carisoprodol/aspirin
cyclobenzaprine hcl tablet: 5mg, 10mg
dantrolene sodium capsule: 25mg, 50mg
metaxalone tablet: 400mg, 800mg
methocarbamol tablet
orphenadrine citrate tablet er
orphenadrine/aspirin/caffeine tablet: 25-385-30
tizanidine hcl tablet
dantrolene sodium capsule: 100mg
orphenadrine/aspirin/caffeine tablet: 50-770-60
(Baclofen)
(Soma)
(Carisoprodol/Aspirin)
(Parafon Forte DSC)
(Codeine/Carisoprodol/
Aspirin)
(Fexmid)
(Dantrium)
(Skelaxin)
(Robaxin)
(Orphenadrine Citrate)
(Orphenadrine/Aspirin/
Caffeine)
(Zanaflex)
(Dantrium)
(Orphenadrine/Aspirin/
Caffeine)
DANTRIUM capsule
PARAFON FORTE DSC
ROBAXIN-750
ROBAXIN tablet
SKELAXIN
SOMA tablet: 350mg
ZANAFLEX
ANECTINE
atracurium besylate
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T2
T2
T3
T3
T3
T3
T3
T3
T3
T6
(Atracurium Besylate)
T6
(Non-self administerable
injectable)
(Non-self administerable
injectable)
125
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
cisatracurium besylate
Drug Tier
(Nimbex)
T6
DANTRIUM vial
dantrolene sodium vial
T6
(Dantrium)
T6
GABLOFEN
T6
LIORESAL INTRATHECAL
T6
methocarbamol vial
(Methocarbamol)
NIMBEX
T6
T6
orphenadrine citrate ampul
(Orphenadrine Citrate)
T6
pancuronium bromide
(Pancuronium Bromide)
T6
QUELICIN
T6
ROBAXIN vial
T6
rocuronium bromide
(Rocuronium Bromide)
T6
vecuronium bromide
(Vecuronium Bromide)
T6
ZEMURON
AMRIX
carisoprodol tablet: 250mg
COMFORT PAC-CYCLOBENZAPRINE
COMFORT PAC-TIZANIDINE
cyclobenzaprine hcl tablet: 7.5mg
FEXMID
LORZONE
SOMA tablet: 250mg
tizanidine hcl capsule
T6
(Soma)
(Fexmid)
(Zanaflex)
Requirements/Limits
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
EX
EX
EX
EX
EX
EX
EX
EX
Sleep Disorder Agents
eszopiclone
modafinil
zaleplon
zolpidem tartrate tablet
BUTISOL SODIUM
SECONAL SODIUM
AMBIEN
LUNESTA
PROVIGIL
ROZEREM
SONATA
(Lunesta)
(Provigil)
(Sonata)
(Ambien)
T1
T1
T1
T1
T2
T2
T3
T3
T3
T3
T3
PA
PA
126
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
zolpidem tartrate tab mphase
(Ambien CR)
T3
XYREM
dexmedetomidine hcl
(Precedex)
T5
T6
NEMBUTAL SODIUM
T6
PRECEDEX infus. btl, vial: 80mcg/20ml
T6
PRECEDEX vial: 200mcg/2ml
T6
AMBIEN CR
armodafinil
BELSOMRA
EDLUAR
HETLIOZ
INTERMEZZO
NUVIGIL
zolpidem tartrate tab subl
ZOLPIMIST
(Nuvigil)
(Intermezzo)
Requirements/Limits
QL: 30 in 30 days (NOT
COVERED FOR
MEDICAID: Covered
Alternatives Available)
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
EX
EX
EX
EX
EX
EX
EX
EX
EX
Sympatholytic Adrenergic Blocking Agents
Alpha-Adrenergic Blocking Agents
phentolamine mesylate
(Phentolamine Mesylate)
T6
(Non-self administerable
injectable)
Urine And Feces Contents
Ketones
CHEMSTRIP K
KETONE CARE
KETONE
KETOSTIX REAGENT
T6
T6
T6
T6
Vasodilating Agents
sildenafil citrate tablet
VIAGRA
CAVERJECT
(Revatio)
T1
T2
T3
CIALIS tablet: 2.5mg, 5mg
CIALIS tablet: 10mg, 20mg
EDEX
T3
T3
T3
LEVITRA
STAXYN
STENDRA
ADCIRCA
ADEMPAS
LETAIRIS
T3
T3
T3
T4
T4
T4
QL: 8 in 30 days
PA, QL: 6 in 30 days (Self
Administerable (Select)
Injectable)
QL: 30 in 30 days
QL: 8 in 30 days
PA, QL: 6 in 30 days (Self
Administerable (Select)
Injectable)
QL: 8 in 30 days
QL: 8 in 30 days
QL: 8 in 30 days
PA
PA
PA
127
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
OPSUMIT
TRACLEER
TYVASO REFILL KIT
TYVASO STARTER KIT
TYVASO
VENTAVIS
ORENITRAM ER
alprostadil
(Alprostadil)
T4
T4
T4
T4
T4
T4
T5
T6
epoprostenol sodium (glycine)
(Flolan)
T6
FLOLAN
T6
PROSTIN VR PEDIATRIC
T6
REMODULIN
T6
REVATIO vial
T6
sildenafil citrate vial
(Revatio)
T6
VELETRI
T6
MUSE
REVATIO tablet
EX
EX
Requirements/Limits
PA
PA
PA
PA
PA
PA
PA
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
(Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
PA (Non-self administerable
injectable)
(Non-self administerable
injectable)
Vitamins and Minerals
b cmplx 4/vit d3/c/fa/zinc ox
b complex and c no.20/folic acid
(B Cmplx 4/Vit D3/C/Fa/
Zinc Ox)
(Nephrocaps)
T1
calcium/mag/d3/b12/fa/b6/boron tablet
(Folgard Os)
T1
CORVITE FREE
T1
T1
cyanocobalamin/fa/pyridoxine
(Folgard Rx)
T1
cyanocobalamin/mecobalamin
(Cyanocobalamin/
Mecobalamin)
(Drisdol)
T1
ergocalciferol (vitamin d2)
fe fumarate/doss/fa/bcomp,c
T1
ferrous fumarate/folic acid
(Fe Fumarate/Doss/Fa/
Bcomp,C)
(Fe Fumarate/Vit C/B12/
Stomc)
(Fe Fumarate/Vit C/B12-If/
Fa)
(Hemocyte-F)
T1
ferrous sulfate/vit c/fa
(Ferrous Sulfate/Vit C/Fa)
T1
fe fumarate/vit c/b12/stomc
fe fumarate/vit c/b12-if/fa
T1
T1
T1
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
128
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
folic acid tablet
(Folic Acid)
T1
folic acid/b complex and c no.17
(Folic Acid/B Complex and
C No.17)
(Folic Acid/B Cplx/C/Selen/
Zinc)
(Folic Acid/Vit Bcomp,C)
T1
folic acid/b cplx/c/selen/zinc
folic acid/vit bcomp,c
folic acid/vit bcomp,c/cu/znox
T1
T1
T1
iron fum and polysac#1/fa/mv no.18
(Folic Acid/Vit Bcomp,C/
Cu/Znox)
(Iron Bg,Ps/Vitc/B12/Fa/
Calcium)
(Tandem Plus)
iron fum and ps cmp/fa/vit c/b3
(Integra F)
T1
iron fum,ps/fa/vit b with c #9
(Integra Plus)
T1
iron fumarate/vit c/vit b12/fa
T1
iron ps cmplx/vit b12/fa
(Iron Fumarate/Vit C/Vit
B12/Fa)
(Iron Ps Cmplx/Vit B12/Fa)
T1
iron, carbonyl/fa/c/b-6/b12/zn
(Corvite 150)
T1
iron,carb/dss/b12if/fa/mv-mn
(Hemax)
T1
iron/fa/vit bcomp,c/minerals
(Iron/Fa/Vit Bcomp,C/
Minerals)
(Iron/Liver Ext/Vit
Bcomp,C/Min)
T1
iron bg,ps/vitc/b12/fa/calcium
iron/liver ext/vit bcomp,c/min
LYSIPLEX PLUS
multivit, min cmb#20/iron/fa
multivitamin-minerals no.7/fa
multivit-min/fa/lycopen/lutein
mv,min #10/fa/d3/alip acid/lut
T1
T1
T1
T1
(Multivit, Min Cmb#20/
Iron/Fa)
(Multivitamin-Minerals
No.7/Fa)
(Biocel)
(Mv,Min #10/Fa/D3/Alip
Acid/Lut)
NEPHROCAPS capsule: 1mg
T1
T1
T1
T1
T1
om-3/dha/epa/b12/fa/b6/phytost
(Animi-3)
T1
pedi m.vit no.17 with fluoride
T1
pnv with ca,no.72/iron/fa
(Pedi M.Vit No.17 with
Fluoride)
(Pnv with Ca,No.72/Iron/Fa)
T1
pnv95/ferrous fumarate/fa
(Prenatal)
T1
Requirements/Limits
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
PREVENTATIVE
FLUORIDE
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
129
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
prenatal vit calc,iron,folic
prenatal vit no.130/iron/fa
prenatal vit no.131/iron/fa
prenatal vit#96/ferrous fum/fa
prenatal vit/iron fumarate/fa
vit b cmplx 3/fa/vit c/biotin
vit b cmplx no3/fa/c/biot/zinc
vit b cplx #11/fa/c/biot/zn ox
Drug Tier
(Prenatal Vit
Calc,Iron,Folic)
(Prenatal Vit No.130/Iron/
Fa)
(Prenatal Vit No.131/Iron/
Fa)
(Prenatal Vit#96/Ferrous
Fum/Fa)
(Prenatal Vit/Iron Fumarate/
Fa)
(Vit B Cmplx 3/Fa/Vit C/
Biotin)
(Vit B Cmplx No3/Fa/C/
Biot/Zinc)
(Vit B Cplx #11/Fa/C/Biot/
Zn Ox)
ACTIVE FE
calcium/mag/d3/b12/fa/b6/boron wafer
T1
T1
T1
T1
T1
T1
T1
T1
T2
(Calcium/Mag/D3/B12/Fa/
B6/Boron)
T2
CENTRATEX
T2
DECARA
FUSION PLUS
T2
T2
FUSION SPRINKLES
T2
iron ag and fum/c/fa/mv cmb11/ca-t
iron ag/c/b12/ca/suc.acid/stom tablet: 70-150-10
iron aspgly and ps/c/b12/fa/ca/suc capsule: 150-251
iron aspgly/c/b12/fa/ca-th/suc
iron fum and ag/c/b12/fa/ca/succ tablet: 151-601mg
iron polysac/iron heme/fa/b12
iron/fa/b12/c/docusate sodium
(Iron Ag and Fum/C/Fa/Mv
Cmb11/Ca-T)
(Iron Ag/C/B12/Ca/
Suc.Acid/Stom)
(Iron Aspgly and Ps/C/B12/
Fa/Ca/Suc)
(Iron Aspgly/C/B12/Fa/CaTh/Suc)
(Iron Fum and Ag/C/B12/
Fa/Ca/Succ)
(Bifera Rx)
(Iron/Fa/B12/C/Docusate
Sodium)
T2
T2
T2
T2
T2
T2
T2
MEPHYTON
T2
NOVAFERRUM
T2
PROFERRIN-FORTE
T2
WHEAT GERM OIL
T2
b complex with vitamin c tablet
(B Complex with Vitamin
C)
T3
Requirements/Limits
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
PA (See Appendix B for list
of covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
130
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
BIFERA RX
T3
BIOCEL
T3
cod liver oil oil
(Cod Liver Oil)
T3
CORVITA
T3
CORVITE 150 tablet: 150-1.25mg
T3
CORVITE 150 tablet: 150mg-1mg
T3
CORVITE FE tablet: 150mg-1mg
T3
CORVITE
T3
DIALYVITE 5000
T3
DIALYVITE SUPREME D
T3
DRISDOL
T3
fe fumarate/cal/e/fa/multivit
(Fe Fumarate/Cal/E/Fa/
Multivit)
T3
FERIVA FA capsule: 110mg-1mg
T3
FERIVA FA capsule: 110mg-1mg
T3
FERRALET 90
T3
FOLGARD OS
T3
FOLGARD RX
T3
FOLTRATE
T3
FORTAVIT
T3
HEMATRON-AF
T3
HEMOCYTE PLUS
T3
HEMOCYTE-F
T3
INTEGRA F
T3
INTEGRA PLUS
T3
iron carb,gl/fa/b12/c/docusate tablet: 90-1-50mg
(Ferralet 90)
T3
Requirements/Limits
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
131
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
iron carb/fa#9/vit c/d3/b6/b12
Drug Tier
(Iron Carb/Fa#9/Vit C/D3/
B6/B12)
T3
IROSPAN
T3
MAXARON FORTE
T3
METHAVER
T3
MULTICHEW
T3
multivit, iron, min #5, fa
(Multivit, Iron, Min #5, Fa)
T3
multivitamin with minerals liquid: n/a
(Multivitamin with
Minerals)
T3
NASCOBAL
T3
NEPHROCAPS QT
T3
NEPHRONEX-SL
T3
NICADAN
T3
NICOMIDE tablet: 0.5-750mg
T3
NICOMIDE tablet: 0.5-750mg
T3
NUTRICAP
T3
NUTRIVIT
T3
pnv no.118/iron fumarate/fa
pnv#71/iron/folic acid/dha
pnv#79/iron/fa/lmfolate ca/dha
prenatal #48/iron cb,glu/fa/b6
(Pnv No.118/Iron Fumarate/
Fa)
(Pnv#71/Iron/Folic Acid/
Dha)
(Neevo Dha)
(Prenatal #48/Iron Cb,Glu/
Fa/B6)
T3
T3
T3
T3
PRENATAL 19
T3
PROTECT IRON
T3
PUREVIT DUALFE PLUS
T3
REQ49+
T3
STROVITE ONE
T3
SUPERVITE EC
T3
Requirements/Limits
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
132
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
Drug Tier
SUPERVITE
T3
TANDEM PLUS
T3
AQUASOL A
ascorbic acid
cyanocobalamin (vitamin b-12)
dexpanthenol
FERAHEME
FERRLECIT
folic acid vial
hydroxocobalamin
INFED
INFUVITE ADULT
INFUVITE
INJECTAFER
iron dextran complex
M.V.I. ADULT
M.V.I. PEDIATRIC
M.V.I.-12
phytonadione ampul, syringe
pyridoxine hcl
sodium ferric gluconat/sucrose
thiamine hcl
VENOFER
vitamins b1,b2,b3,b5, and b6
ANIMI-3 capsule: 500-0.5-1
ANIMI-3 capsule: 500-1000-1
b complex with vitamin c capsule
b12/levomefolate calcium/b-6 tablet: 2-1.13-25
CARDIOTEK-RX
CEREFOLIN NAC tablet: 6-600-2mg
CEREFOLIN
DEPLIN-ALGAL OIL
DEPLIN
DERMANIC
ENLYTE
fa/arginine hcl/b12/b6/pep ex
FERIVA
FOLTX tablet: 2-1.13-25
FOLTX tablet: 2-2.5-25mg
levomefolate calcium
levomefolate/algal oil
levomefolate/b6/b12/algal oil
lmfol ca/acetyl/mb12/algal oil
MAXFE
(Ascorbic Acid)
(Cyanocobalamin (Vitamin
B-12))
(Dexpanthenol)
(Folic Acid)
(Hydroxocobalamin)
(Infed)
(Phytonadione)
(Pyridoxine HCl)
(Sodium Ferric Gluconat/
Sucrose)
(Thiamine HCl)
(Vitamins B1,B2,B3,B5,
and B6)
(B Complex with Vitamin
C)
(Foltx)
(Cardiotek-Rx)
(Levomefolate Calcium)
(Deplin-Algal Oil)
(Metanx)
(Cerefolin Nac)
Requirements/Limits
(See Appendix B for list of
covered multivitamins)
(See Appendix B for list of
covered multivitamins)
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
T6
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
133
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
Drug Name
mecobal/levomefolat ca/b6 phos
METANX capsule
METANX tablet
methyltetrahydrofolate glucosa
mv, min cmb#43/lut/om3/dha/epa
om-3/calcium/d3/fa/mv cmb 13
om-3/dha/epa/d3/b12/fa/b-6/phy
PODIAPN
PROBARIMIN QT
PROTECT CARDIO
RELAMINE
RHEUMATE
SYNAGEX
TOZAL
UDAMIN SP
UROSEX
vit a,c,e/zinc/copper/lut/zeax
vit b12/lmefolate ca/vit b6/b2
VITA-RESPA
Drug Tier
(Mecobal/Levomefolat Ca/
B6 Phos)
(Methyltetrahydrofolate
Glucosa)
(Mv, Min Cmb#43/Lut/
Om3/Dha/Epa)
(Om-3/Calcium/D3/Fa/Mv
Cmb 13)
(Animi-3)
(Vit A,C,E/Zinc/Copper/
Lut/Zeax)
(Cerefolin)
Requirements/Limits
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
EX
134
FORM-Good Health-2016
Formulary ID: 82160.000, Version: 4Q2016
Effective: October 1, 2016
INDEX
0.9 % sodium chloride .. 80, 99, 131
1ST CHOICE LANCETS ............. 84
1ST TIER UNILET
COMFORTOUCH ................... 84
8-MOP ........................................ 72
A.I.R.S. NEBULIZER .................. 80
aa8/a-carnitin/grp/cocoa/hc126 128
aa9/a-carnitin/dex/cocoa/hc127 128
abacavir sulfate .......................... 43
abacavir/lamivudine/zidovudine .. 43
ABELCET ................................... 34
ABILIFY ...................................... 42
ABILIFY DISCMELT ................... 42
ABILIFY MAINTENA ................... 42
ABRAXANE ................................ 20
ABSORICA ................................. 74
ABSTRAL ..................................... 4
acamprosate calcium .................... 8
ACANYA ..................................... 76
acarbose ..................................... 30
ACCOLATE .............................. 136
ACCU-CHEK ........................ 84, 89
ACCU-CHEK ACTIVE ................ 89
ACCU-CHEK AVIVA ................... 89
ACCU-CHEK AVIVA PLUS ........ 89
ACCU-CHEK COMFORT CURVE
................................................ 89
ACCU-CHEK COMPACT PLUS . 89
ACCU-CHEK FASTCLIX ............ 84
ACCU-CHEK NANO SMARTVIEW
................................................ 89
ACCU-CHEK SAFE-T-PRO ........ 84
ACCU-CHEK SAFE-T-PRO PLUS
................................................ 84
ACCU-CHEK SMARTVIEW ........ 89
ACCU-CHEK SOFTCLIX ............ 84
ACCU-CHEK VOICEMATE ........ 89
ACCUPRIL ................................. 56
ACCURETIC ............................... 56
ACCUTREND GLUCOSE ........... 89
ACE AEROSOL CLOUD
ENHANCER ............................ 80
acebutolol hcl .............................. 57
ACEON ....................................... 56
ACETADOTE ............................137
acetaminophen with codeine ........ 1
acetaminophen/phenyltolx ........... 4
acetazolamide ...........................129
acetazolamide sodium ..............130
acetic acid .................................120
acetic acid/aluminum acetate ......99
acetic acid/hydrocortisone ...........99
acetylcysteine....................122, 137
ACIPHEX ..................................104
ACIPHEX SPRINKLE ................104
acitretin .......................................74
ACTEMRA ........................124, 125
ACTHIB .....................................118
ACTIGALL .................................105
ACTI-LANCE ...............................84
ACTIMMUNE ............................124
ACTIQ .......................................... 4
ACTIVASE ..................................48
ACTIVE FE ...............................143
ACTIVELLA ...............................110
ACTONEL .................................121
ACTOPLUS MET ........................31
ACTOPLUS MET XR ..................30
ACTOS........................................31
ACULAR ...................................102
ACULAR LS ..............................102
ACURA METER KIT ...................89
ACURA PLUS .............................89
ACURA STARTER KIT ...............89
ACURA TEST STRIPS ...............89
acyclovir ................................45, 71
acyclovir sodium..........................46
ACZONE .....................................72
ADACEL TDAP .........................118
ADAGEN .....................................97
ADALAT CC ................................60
adapalene ...................................79
ADAPTER ...................................80
ADCETRIS ..................................20
ADCIRCA ..................................141
ADDERALL .................................65
ADDERALL XR ...........................65
ADDYI .........................................66
adefovir dipivoxil ......................... 45
ADEMPAS ................................ 141
ADENOCARD............................. 56
adenosine ................................... 56
ADIPEX-P ................................... 66
ADOXA ....................................... 17
ADRENACLICK .......................... 59
ADRENALIN ............................... 59
ADRENALIN CHLORIDE............ 98
ADULT AEROSOL MASK .......... 80
ADVAIR DISKUS ...................... 135
ADVAIR HFA ............................ 135
ADVANCED TRAVEL LANCETS 84
ADVATE ..................................... 48
ADVICOR ................................... 62
ADVOCATE BLOOD GLUCOSE
MONITOR ............................... 89
ADVOCATE LANCET ................. 84
ADVOCATE LANCETS .............. 85
ADVOCATE REDI-CODE ........... 89
ADVOCATE REDI-CODE+ ......... 89
ADVOCATE TEST STRIP .......... 89
ADYNOVATE ............................. 48
ADZENYS XR-ODT .................... 66
AEROCHAMBER MINI ............... 80
AEROCHAMBER MV ................. 80
AEROCHAMBER PLUS FLOW-VU
................................................ 80
AEROCHAMBER PLUS Z STAT 80
AEROCHAMBER WITH
FLOWSIGNAL ........................ 80
AEROCHAMBER Z-STAT PLUS 81
AEROECLIPSE .......................... 81
AEROECLIPSE II ....................... 81
AEROGEAR ASTHMA ACTION
KIT .......................................... 81
AERONEB GO ........................... 81
AERONEB GO NEBULIZER ...... 81
AEROSPAN.............................. 135
AEROTRACH PLUS ................... 81
AEROVENT PLUS ..................... 81
AFINITOR ................................... 19
AFINITOR DISPERZ .................. 18
AFLURIA 2015-2016 ................ 118
AFLURIA 2016-2017 ................ 118
AFLURIA QUAD 2016-2017 ..... 118
AFREZZA ................................... 32
AGAMATRIX AMP ...................... 89
AGGRASTAT ............................. 50
AGGRENOX ............................... 50
AGRYLIN .................................... 48
AIR FILTER ................................ 81
AIR TUBE WITH AIR PLUGS ..... 81
AIRS ADULT AEROSOL MASK . 81
AIRS DISPOSABLE NEBULIZER
................................................ 81
AIRZONE PEAK FLOW METER 81
AKNE-MYCIN ............................. 76
AKTEN........................................ 98
ALA-HIST AC ............................. 69
ALAHIST DHC ............................ 69
ALA-QUIN................................... 33
ALBENZA ................................... 40
ALBUKED-25 .............................. 50
ALBUKED-5 ................................ 50
ALBUMIN HUMAN...................... 50
ALBUMINAR-25.......................... 50
ALBUMINAR-5............................ 50
ALBURX ..................................... 50
ALBUTEIN .................................. 50
albuterol sulfate ........................ 136
alclometasone dipropionate ........ 76
alcohol antiseptic pads ............... 71
ALCOHOL,DEHYDRATED ....... 125
ALDACTAZIDE ........................... 64
ALDACTONE .............................. 64
ALDARA ..................................... 72
ALDURAZYME ........................... 97
alendronate sodium .................. 121
alfentanil hcl .................................. 3
ALFENTANIL HCL ........................ 3
ALFERON N ............................... 45
alfuzosin hcl .............................. 107
ALIMTA....................................... 20
ALINIA ........................................ 40
ALKERAN ............................. 18, 20
ALL FLOW 1000 ......................... 81
ALL FLOW 2000 ......................... 81
ALL FLOW 3000 KIT .................. 81
ALL FLOW 3000 PFT ................. 81
ALL FLOW 4000 ......................... 81
ALL FLOW 5000 .........................81
ALL FLOW 6000 .........................81
ALL FLOW 7000 .........................81
ALLFEN CD ................................69
ALLFEN CDX ..............................69
allopurinol ..................................122
allopurinol sodium .....................125
almotriptan malate.......................36
ALOCRIL ...................................101
ALODOX .....................................17
alogliptin benz/metformin hcl .......31
alogliptin benz/pioglitazone .........31
alogliptin benzoate ......................31
ALOMIDE ....................................98
ALOPRIM ..................................125
ALORA ......................................110
alosetron hcl ..............................120
ALOXI .........................................39
ALPHAGAN P ...................129, 130
ALPHANATE ...............................48
ALPHANINE SD ..........................48
alprazolam ................................... 9
ALPRAZOLAM INTENSOL .........10
ALPROLIX ..................................50
alprostadil ..................................141
ALREX ......................................101
ALSUMA .....................................38
ALTABAX ....................................76
ALTACE ......................................56
ALTERA NEBULIZER .................81
ALTERNATE SITE LANCETS.....85
ALTOPREV .................................63
aluminum acetate ........................72
aluminum chloride .......................71
ALUVEA ......................................72
ALVESCO .................................135
amantadine hcl ............................40
AMARYL .....................................32
AMBIEN ....................................139
AMBIEN CR ..............................140
AMBIFED ....................................70
AMBIFED DM..............................70
AMBISOME .................................34
amcinonide ............................76, 77
AMERGE ....................................37
A-METHAPRED ........................111
AMETHYST ................................67
AMICAR ..................................... 48
AMIDATE ................................. 106
amifostine crystalline ................ 125
amikacin sulfate .......................... 10
amiloride hcl ............................... 61
amiloride/hydrochlorothiazide ..... 61
AMINO ACIDS ............................ 51
aminocaproic acid....................... 48
aminophylline............................ 137
AMINOSYN ................................ 51
AMINOSYN II ............................. 51
AMINOSYN II WITH
ELECTROLYTES.................... 51
AMINOSYN M ............................ 51
AMINOSYN WITH
ELECTROLYTES.................... 51
AMINOSYN-HBC........................ 51
AMINOSYN-PF........................... 52
AMINOSYN-RF .......................... 52
amiodarone hcl ........................... 56
AMITIZA ................................... 105
amitriptyline hcl ........................... 28
amitriptyline/chlordiazepoxide..... 28
amlodipine besylate .................... 60
amlodipine besylate/benazepril .. 60
amlodipine/atorvastatin ............... 62
amlodipine/valsartan ................... 60
amlodipine/valsartan/hcthiazid.... 61
ammonium chloride .................. 125
ammonium lactate ...................... 74
AMMONUL ............................... 131
amobarbital sodium .................. 125
amoxapine .................................. 29
amoxicillin ............................. 15, 16
amoxicillin/potassium clav .......... 15
AMPHADASE ............................. 97
amphotericin b ............................ 34
ampicillin sodium ........................ 15
ampicillin sodium/sulbactam na .. 15
ampicillin trihydrate ..................... 15
AMPYRA .................................... 66
AMRIX ...................................... 139
AMTURNIDE .............................. 64
AMVISC .................................... 125
AMVISC PLUS ......................... 125
AMYVID .................................... 130
ANACAINE ................................. 72
ANADROL-50 ........................... 108
ANAFRANIL ............................... 29
anagrelide hcl ............................. 48
ANALPRAM ADVANCED ........... 77
ANALPRAM HC .......................... 77
ANAPROX .................................... 5
ANAPROX DS .............................. 5
ANASCORP ............................. 116
ANASPAZ ................................. 105
anastrozole ................................. 18
ANCOBON ................................. 33
ANDRODERM .......................... 108
ANDROGEL ............................. 109
ANDROID ................................. 108
ANECTINE ............................... 138
ANGELIQ.................................. 109
ANGIOMAX ................................ 46
ANIMI-3 .................................... 147
ANORO ELLIPTA ..................... 136
ANTABUSE .................................. 9
ANTARA ..................................... 62
antipyrine/benzocaine ............... 100
ANTIVENIN LATRODECTUS
MACTANS ............................ 116
ANTIVENIN MICRURUS FULVIUS
.............................................. 116
ANUSOL-HC .............................. 77
ANZEMET .................................. 39
APEXICON E .............................. 77
APIDRA ...................................... 32
APIDRA SOLOSTAR .................. 32
APLENZIN .................................. 29
APLIGRAF .................................. 80
APOKYN..................................... 41
APOP.......................................... 72
apraclonidine hcl ......................... 98
APRISO .................................... 119
APTENSIO XR............................ 66
APTIOM ...................................... 26
APTIVUS .................................... 43
AQUA GLYCOLIC HC ................ 79
AQUAFLO ................................ 128
AQUASOL A ............................. 146
AQUORAL .................................. 70
ARALAST NP ........................... 137
ARANESP .................................. 47
ARAVA ..................................... 115
ARCALYST ...............................116
ARCAPTA NEOHALER ............136
ARESTIN ....................................71
ARGATROBAN ...........................46
ARGATROBAN-0.9% NACL .......46
ARICEPT ....................................28
ARICEPT ODT ............................28
ARIMIDEX ...................................19
aripiprazole .................................41
ARISTADA ..................................42
ARISTOSPAN ...........................111
ARIXTRA ....................................46
armodafinil ................................140
ARMOUR THYROID .................114
ARNUITY ELLIPTA ...................135
AROMASIN .................................19
ARRANON ..................................20
ARTHROTEC 50 .......................... 5
ARTHROTEC 75 .......................... 5
ARTISS .......................................50
ARZERRA ...................................20
ASACOL HD .............................120
ASCLERA ...................................64
ascorbic acid .............................146
ASMANEX ................................135
ASMANEX HFA ........................135
aspirin/caffein/dihydrocodeine ...... 1
aspirin/dipyridamole ....................50
ASSESS ......................................81
ASSURE 4 ............................89, 90
ASSURE HAEMOLANCE PLUS .85
ASSURE LANCE ........................85
ASSURE LANCE PLUS ..............85
ASSURE PLATINUM ..................90
ASSURE PRO.............................90
ASTAGRAF XL .........................115
ASTELIN .....................................98
ASTEPRO ...................................98
ASTHMA CHECK........................81
ASTHMAMENTOR......................81
ASTHMAPACK CHILDREN'S .....81
ASTHMAPACK I .........................81
ASTHMAPACK II ........................81
ASTRINGYN .............................123
ATACAND ...................................55
ATACAND HCT...........................55
ATELVIA ...................................122
atenolol ....................................... 57
atenolol/chlorthalidone ................ 57
ATGAM ..................................... 116
ATIVAN ...................................... 10
atorvastatin calcium .................... 62
atovaquone ................................. 40
atovaquone/proguanil hcl ........... 40
atracurium besylate .................. 138
ATRALIN .................................... 79
ATRAPRO DERMAL SPRAY ... 128
ATRIPLA .................................... 44
ATROPEN .................................. 25
atropine sulfate ..................... 25, 98
ATROVENT ................................ 99
ATROVENT HFA ...................... 136
AUBAGIO ................................. 118
AUGMENTIN .............................. 15
AUGMENTIN ES-600 ................. 15
AUGMENTIN XR ........................ 15
AURSTAT ........................... 90, 128
AURYXIA .................................. 106
AUVI-Q ....................................... 59
AVAGE ....................................... 79
AVALIDE .................................... 55
AVANDAMET ............................. 31
AVANDARYL .............................. 31
AVANDIA .................................... 31
AVAPRO .................................... 55
AVAR .................................... 71, 72
AVAR LS .................................... 72
AVAR-E ...................................... 71
AVAR-E LS ................................. 72
AVASTIN .................................... 20
AVC ............................................ 36
AVELOX ..................................... 16
AVELOX ABC PACK .................. 16
AVELOX IV ................................. 16
AVIDOXY ................................... 18
AVIDOXY DK.............................. 17
AVINZA ........................................ 2
AVITENE .................................... 48
AVODART ................................ 123
AVONEX .................................. 124
AVONEX PEN .......................... 124
AXERT ....................................... 37
AXID ......................................... 103
AXIRON .................................... 108
AXONA ....................................... 54
AYGESTIN ............................... 114
azacitidine ................................... 20
AZACTAM .................................. 15
AZACTAM-ISO-OSMOTIC
DEXTROSE ............................ 15
AZASAN ................................... 118
AZASITE................................... 100
azathioprine .............................. 115
azathioprine sodium.................. 116
azelastine hcl .............................. 98
AZELEX ...................................... 72
AZILECT ..................................... 41
azithromycin ......................... 14, 15
AZOPT...................................... 130
AZOR.......................................... 61
aztreonam................................... 15
AZULFIDINE ............................... 17
b cmplx 4/vit d3/c/fa/zinc ox ...... 141
b complex and c no.20/folic acid
.............................................. 141
b complex with vitamin c ... 144, 147
b12/levomefolate calcium/b-6 ... 147
b3/azel ac/zinc/b6/copper/fa ..... 123
BABY CONVERSION KIT .......... 81
BABY CONVERSION PACK 1 ... 81
BABY CONVERSION PACK 2 ... 81
BABY NEBULIZER ..................... 81
bacitracin ............................ 12, 100
bacitracin/polymyxin b sulfate ... 100
baclofen .................................... 138
BACTRIM ................................... 17
BACTRIM DS ............................. 17
BACTROBAN ............................. 76
BACTROBAN NASAL................. 75
BAL IN OIL ............................... 108
balanced salt irrig soln no.2 ........ 99
balsalazide disodium ................ 119
BANZEL...................................... 26
BARACLUDE .............................. 45
BCG TICE STRAIN................... 118
BCG VACCINE TICE STRAIN .. 118
BD MICROTAINER LANCETS ... 85
BD ULTRA-FINE......................... 85
BD ULTRA-FINE II...................... 85
BEBULIN .................................... 48
BECONASE AQ........................ 102
BELBUCA .................................... 4
BELEODAQ ................................20
BELSOMRA ..............................140
BELVIQ .......................................66
benazepril hcl ..............................55
benazepril/hydrochlorothiazide....55
BENEFIX .....................................48
BENICAR ....................................55
BENICAR HCT ............................55
BENLYSTA ...............................125
BENSAL HP ................................72
BENTYL ....................................105
BENZAC AC................................72
BENZACLIN ................................76
BENZAMYCIN.............................76
BENZEFOAM ..............................74
BENZEFOAM ULTRA .................74
benzocaine ................................... 7
benzoin/aloe vera/storax/tolu ......74
benzonatate ..........................69, 70
benzoyl peroxide .............71, 72, 74
benzoyl peroxide microspheres...72
benzphetamine hcl ......................66
benztropine mesylate ............40, 41
BEPREVE ...................................99
BERINERT ..................................47
BESIVANCE .............................101
BETADINE ................................100
BETAGAN .................................130
betamet acet/betamet na ph......111
betamethasone dipropionate .......76
betamethasone valerate ..............76
betamethasone/propylene glyc ...76
BETAPACE .................................57
BETAPACE AF ...........................57
BETASERON ............................124
betaxolol hcl ........................57, 129
bethanechol chloride .................122
BETIMOL ..................................130
BETOPTIC S .............................129
bexarotene ..................................19
BEXSERO .................................118
BEXXAR .....................................20
BEYAZ ........................................69
BG-STAR ....................................90
BIAFINE ......................................80
BIAXIN ........................................14
BIAXIN XL .................................. 14
bicalutamide ............................... 18
BICILLIN C-R.............................. 15
BICILLIN L-A .............................. 15
BICNU ........................................ 20
BIDIL .......................................... 64
BIFERA RX............................... 144
BILTRICIDE ................................ 40
bimatoprost ............................... 130
BINOSTO ................................. 122
BIOCEL .................................... 144
BIONECT ................................. 123
BIOSTEP .................................. 123
BIOSTEP AG ............................ 123
BIOTHRAX ............................... 118
bisoprolol fumarate ..................... 57
bisoprolol fumarate/hctz ............. 57
bivalirudin ................................... 46
BIVIGAM .................................. 116
bleomycin sulfate ........................ 20
BLEPHAMIDE .......................... 100
BLEPHAMIDE S.O.P. ............... 100
BLINCYTO.................................. 20
BLOOD GLUCOSE METER ....... 90
BLOOD GLUCOSE MONITOR... 90
BLOOD GLUCOSE MONITORING
................................................ 90
BLOOD GLUCOSE TEST .......... 90
BLOOD GLUCOSE TEST STRIP90
BLOOD LANCETS ..................... 85
BLOOD-GLUCOSE METER ....... 90
BLOXIVERZ ............................. 125
BONIVA .................................... 121
BOOSTRIX TDAP .................... 118
borage and fish oil/fruct/soy lec 128
BOSULIF .................................... 19
BOTOX ..................................... 125
BOTOX COSMETIC ................. 128
BP WASH ................................... 71
BRAVELLE ............................... 112
BREATHERITE .......................... 81
BREATHRITE ............................. 81
BREEZE 2 .................................. 85
BREO ELLIPTA ........................ 135
BREVIBLOC ............................... 58
BREVITAL SODIUM ................... 65
BRILINTA ................................... 50
brimonidine tartrate ................... 129
BRINTELLIX ............................... 29
BRISDELLE ................................ 29
BRIVIACT ............................. 26, 27
bromfenac sodium .................... 102
bromocriptine mesylate............... 40
brompheniramine/phenylephrine 35
brompheniramine/pseudoephed/dm
................................................ 69
bromphenrm/pseudoeph/dihydrocd
................................................ 70
BROVANA ................................ 136
BSS ............................................ 99
BSS PLUS .................................. 99
BUBBLES THE FISH II ............... 81
BUCALSEP .................................. 7
budesonide ............... 102, 119, 135
BULLSEYE MINI SAFETY
LANCETS ............................... 85
bumetanide ................................. 61
BUMINATE ................................. 50
BUNAVAIL .................................... 9
BUPAP ......................................... 2
BUPHENYL ...................... 104, 105
bupivacaine hcl ............................. 7
bupivacaine hcl/dex-water/pf ........ 7
bupivacaine hcl/epinephrine ......... 7
bupivacaine hcl/epinephrine bi...... 7
bupivacaine hcl/epinephrine/pf ..... 7
bupivacaine hcl/pf ......................... 7
BUPRENEX .................................. 3
buprenorphine hcl ..................... 3, 8
buprenorphine hcl/naloxone hcl .... 8
bupropion hcl .......................... 8, 28
buspirone hcl ............................ 122
BUSULFEX ................................. 20
butalb/acetaminophen/caffeine ..... 1
butalbit/acetamin/caff/codeine ...... 1
butalbital/acetaminophen .............. 1
butalbital/aspirin/caffeine .............. 1
BUTISOL SODIUM ................... 139
butorphanol tartrate .................. 1, 3
BUTRANS .................................... 1
BYDUREON ............................... 31
BYDUREON PEN ....................... 31
BYETTA...................................... 31
BYSTOLIC .................................. 57
cabergoline .................................40
CA-DTPA ..................................108
CADUET .....................................62
CAFCIT .......................................65
CAFERGOT ................................36
caffeine citrated .....................64, 65
caffeine/sodium benzoate ...........65
CALAN ........................................58
CALAN SR ..................................58
calcipotriene ................................71
calcipotriene/betamethasone ......74
calcitonin,salmon,synthetic .......121
calcitriol ...............................72, 121
calcium acetate .........................106
calcium carbonate/mag carb/fa .106
calcium chloride ........................131
CALCIUM DISODIUM
VERSENATE .........................108
calcium gluconate .....................131
calcium/mag/d3/b12/fa/b6/boron
......................................141, 143
CALDOLOR ................................. 6
CAMBIA ....................................... 5
CAMPRAL .................................... 9
CAMPTOSAR .............................20
CANASA ...................................119
CANCIDAS .................................34
candesartan cilexetil....................54
candesartan/hydrochlorothiazid ..54
CANTIL .....................................104
CAPASTAT SULFATE ................38
capecitabine ................................19
CAPEX SHAMPOO.....................77
CAPHOSOL ................................70
CAPITAL W-CODEINE ................ 2
CAPRELSA .................................19
captopril ......................................55
captopril/hydrochlorothiazide.......55
CARAC .......................................72
CARAFATE ...............................103
CARBAGLU ..............................105
carbamazepine............................25
CARBATROL ..............................26
carbidopa ....................................40
carbidopa/levodopa .....................40
carbidopa/levodopa/entacapone .40
carbinoxamine maleate ...............35
CARBOCAINE .............................. 7
carboplatin .................................. 20
CARDENE I.V............................. 61
CARDENE SR ............................ 60
cardioplegic solution no.1 ......... 130
CARDIOTEK-RX ...................... 147
CARDIZEM ................................. 58
CARDIZEM CD........................... 58
CARDIZEM LA ........................... 58
CARDURA .................................. 54
CARDURA XL ............................ 54
CAREONE .................................. 85
CARESENS ................................ 85
CARESENS N ............................ 90
CARESENS N VOICE ................ 90
CARIMUNE NF NANOFILTERED
.............................................. 116
carisoprodol ...................... 138, 139
carisoprodol/aspirin .................. 138
CARNITOR ....................... 123, 125
CARNITOR SF ......................... 123
CARRASYN HYDROGEL WOUND
.............................................. 123
carteolol hcl ................................ 98
CARTICEL ................................ 125
carvedilol .................................... 57
CASODEX .................................. 19
CATAFLAM .................................. 5
CATAPRES ................................ 54
CATAPRES-TTS 1 ..................... 54
CATAPRES-TTS 2 ..................... 54
CATAPRES-TTS 3 ..................... 54
CATHFLO ACTIVASE ................ 48
CAVERJECT ............................ 140
CAYA CONTOURED .................. 68
CAYSTON .................................. 15
CEDAX ....................................... 13
cefaclor ....................................... 13
cefadroxil .................................... 13
cefazolin sodium ......................... 13
cefazolin sodium/dextrose,iso..... 13
cefdinir ........................................ 13
CEFEPIME ................................. 13
cefepime hcl ............................... 13
CEFEPIME-DEXTROSE ............ 13
cefixime ...................................... 13
CEFOTAN .................................. 13
cefotaxime sodium ...................... 13
cefotetan disod/dextrose,iso ....... 13
cefotetan disodium...................... 13
cefoxitin sodium .......................... 13
cefoxitin sodium/dextrose,iso ...... 13
cefpodoxime proxetil ................... 13
cefprozil ...................................... 13
ceftazidime ................................. 13
CEFTAZIDIME ............................ 14
ceftibuten .................................... 13
CEFTIN....................................... 13
ceftriaxone na/dextrose,iso ......... 14
ceftriaxone sodium...................... 14
cefuroxime axetil ......................... 13
CEFUROXIME AXETIL .............. 13
cefuroxime sodium...................... 14
CELEBREX .................................. 6
celecoxib....................................... 5
CELESTONE ............................ 111
CELEXA ..................................... 29
CELLCEPT ....................... 115, 116
CELLUGEL ................................. 99
CELONTIN ................................. 26
CENESTIN ............................... 110
CENTANY .................................. 76
CENTANY AT ............................. 76
CENTRATEX ............................ 143
cephalexin .................................. 13
CEPROTIN ................................. 46
CEREBYX .................................. 27
CEREFOLIN ............................. 147
CEREFOLIN NAC..................... 147
CEREZYME ................................ 97
CERUBIDINE ............................. 21
CERVARIX ............................... 118
CERVIDIL ................................. 122
CESAMET .................................. 39
CESINEX .................................. 106
CETACAINE ............................... 72
cetirizine hcl ................................ 35
CETRAXAL ............................... 101
CETROTIDE ............................. 113
cevimeline hcl ............................. 70
CHANTIX ...................................... 9
CHEMET .................................. 108
CHEMSTRIP K ......................... 140
CHENODAL ................................ 98
chloramphenicol sod succ ...........12
chlordiazepoxide hcl..................... 9
chlordiazepoxide/clidinium br ......25
chlorhexidine gluconate ..............70
CHLORHEXIDINE GLUCONATE74
chloroprocaine hcl/pf .................... 7
chloroquine phosphate ................40
chlorothiazide ..............................61
chlorothiazide sodium .................62
chloroxylenol/benzoc/hydrocort .103
chloroxylenol/pramoxine hcl ........98
chlorpheniramine/codeine phos ..69
chlorpheniramine/phenylephrine .35
chlorpromazine hcl ................41, 42
chlorpropamide ...........................32
chlorthalidone ..............................61
chlorzoxazone ...........................138
CHOICEDM G20 .........................90
cholestyramine (with sugar) ........62
cholestyramine/aspartame ..........62
choline sal/mag salicylate ............ 5
CHORIONIC GONADOTROPIN
..............................................112
chromic chloride ........................131
CIALIS.......................................140
CICLODAN ...........................33, 34
ciclopirox .....................................33
ciclopirox olamine........................33
ciclopirox/ure/camph/menth/euc..33
ciclopirox/vite/nail lacq remo .......33
cidofovir .......................................46
cilostazol .....................................50
CILOXAN ..........................100, 101
cimetidine ..................................103
cimetidine hcl ............................103
CIMZIA ......................................116
CINRYZE ....................................47
CIPRO.........................................16
CIPRO HC ................................100
CIPRO I.V. ..................................16
CIPRO XR ...................................17
CIPRODEX ...............................100
ciprofloxacin ................................16
ciprofloxacin hcl........... 16, 100, 101
ciprofloxacin lactate.....................17
ciprofloxacin lactate/d5w .............17
ciprofloxacin/ciprofloxa hcl ..........16
cisatracurium besylate .............. 138
cisplatin ...................................... 21
citalopram hydrobromide ............ 28
citric acid/sodium citrate ........... 130
cladribine .................................... 21
CLAFORAN ................................ 14
CLAFORAN-DEXTROSE ........... 14
CLARIFOAM EF ......................... 72
CLARINEX.................................. 35
CLARINEX-D 12 HOUR ............. 35
CLARINEX-D 24 HOUR ............. 35
CLARIS ...................................... 71
clarithromycin ............................. 14
clemastine fumarate ................... 35
CLEOCIN ................................... 36
CLEOCIN HCL ........................... 11
CLEOCIN PALMITATE ............... 11
CLEOCIN PHOSPHATE............. 12
CLEOCIN PHOSPHATE IN D5W12
CLEOCIN T ................................ 76
CLEVER CHEK LANCETS ......... 85
CLEVER CHOICE ...................... 90
CLEVER CHOICE BLOOD GLUC
SYS......................................... 90
CLEVER CHOICE HD GLUCOSE
SYST ...................................... 90
CLEVER CHOICE HOLDING
CHAMBER .............................. 81
CLEVER CHOICE MICRO ......... 90
CLEVER CHOICE MICRO TEST
STRIP ..................................... 90
CLEVER CHOICE PRO.............. 90
CLEVER CHOICE TEST STRIPS
................................................ 90
CLEVER CHOICE VOICE+ TST
STRIP ..................................... 90
CLEVIPREX ............................... 61
CLIMARA ................................. 110
CLIMARA PRO ......................... 109
CLINDACIN ETZ .................. 75, 76
CLINDAGEL ............................... 76
clindamycin hcl ........................... 11
clindamycin palmitate hcl ............ 11
clindamycin phos/benzoyl perox . 75
clindamycin phosphate ... 12, 36, 75
clindamycin phosphate/d5w........ 12
clindamycin/tretinoin ................... 75
CLINDESSE ............................... 36
CLINIMIX .................................... 52
CLINIMIX E ................................. 52
CLINISOL ................................... 52
CLINPRO 5000 ........................... 71
clobetasol propionate.................. 76
CLOBEX ..................................... 77
clocortolone pivalate ................... 77
CLODAN............................... 76, 79
CLODERM .................................. 77
CLOLAR ..................................... 21
clomiphene citrate..................... 109
clomipramine hcl ......................... 28
clonazepam .................................. 9
clonidine ..................................... 54
clonidine hcl .......................... 54, 66
clonidine hcl/chlorthalidone ......... 54
clonidine hcl/pf .............................. 3
clopidogrel bisulfate .................... 50
clorazepate dipotassium ............... 9
clotrimazole ................................ 33
clotrimazole/betamethasone dip . 33
clozapine .............................. 41, 43
CLOZARIL .................................. 42
CNL 8 ......................................... 34
CO MONITOR ............................ 81
CO MONITOR REPLACEMENT T
................................................ 81
COAGADEX ............................... 48
COAGUCHEK............................. 85
COARTEM .................................. 40
cocaine hcl.................................... 6
cod liver oil ................................ 144
codeine sulfate ............................. 1
CODEINE SULFATE .................... 2
codeine/butalbital/asa/caffein ....... 1
codeine/carisoprodol/aspirin ..... 138
COGENTIN ................................. 41
COLAZAL ................................. 120
colchicine .......................... 123, 128
colchicine/probenecid ............... 122
COLCRYS ................................ 123
COLESTID .................................. 62
colestipol hcl ............................... 62
colistin (colistimethate na) .......... 12
COLOR LANCETS ..................... 85
COLY-MYCIN M PARENTERAL 12
COLY-MYCIN S ........................100
COLYTE WITH FLAVOR
PACKETS ..............................106
COMBIGAN ..............................129
COMBIPATCH ..........................109
COMBIVENT RESPIMAT..........136
COMBIVIR ..................................43
COMETRIQ .................................19
COMFORT EZ ............................85
COMFORT LANCETS ................85
COMFORT PACCYCLOBENZAPRINE ...........139
COMFORT PAC-IBUPROFEN..... 6
COMFORT PAC-MELOXICAM .... 6
COMFORT PAC-NAPROXEN ..... 6
COMFORT PAC-TIZANIDINE...139
COMPACT COMPRESSOR
NEBULIZER ............................81
COMPACT SPACE CHAMBER ..81
COMPACT SPACE CHAMBER
PLUS .......................................81
COMPACT ULTRASONIC
NEBULIZER ............................81
COMP-AIR ELITE COMPRESSOR
SYST .......................................81
COMP-AIR NEBULIZER
COMPRESSOR.......................81
COMPAZINE .........................38, 39
COMPLERA ................................44
COMPMIST COMPRESSOR
NEBULIZER ............................81
COMTAN ....................................41
COMVAX ..................................118
CONCERTA ................................65
CONDYLOX ................................72
CONTOUR ..................................85
CONTOUR LINK .........................85
CONTOUR NEXT .......................85
CONTOUR NEXT CONTROL
SOLUTION ..............................85
CONTOUR NEXT EZ ..................85
CONTOUR NEXT LINK ..............85
CONTOUR NEXT USB ...............85
CONTOUR USB..........................85
CONTROL ..................................90
CONTROL G3 .............................90
CONZIP ....................................... 4
COPAXONE ............................. 124
COPEGUS.................................. 45
CORDARONE ............................ 56
CORDRAN ................................. 77
COREG ...................................... 57
COREG CR ................................ 58
CORGARD ................................. 57
CORIFACT ................................. 48
CORLOPAM ............................... 59
CORTANE-B ............................ 102
CORTEF ................................... 111
CORTENEMA............................. 77
CORTIFOAM .............................. 77
cortisone acetate ...................... 111
CORTISPORIN................... 76, 101
CORTISPORIN-TC ................... 100
CORVERT .................................. 56
CORVITA ................................. 144
CORVITE ................................. 144
CORVITE 150........................... 144
CORVITE FE ............................ 144
CORVITE FREE ....................... 141
CORZIDE ................................... 57
COSENTYX 2 SYRINGES ......... 74
COSENTYX PEN 2 PENS .......... 74
COSMEGEN............................... 21
COSOPT .................................. 130
COSOPT PF ............................. 130
COTABFLU ................................ 69
COTELLIC .................................. 19
COUMADIN ................................ 46
COZAAR .................................... 55
CREON ...................................... 97
CRESTOR .................................. 62
cresyl acetate ........................... 100
CRINONE ................................. 114
CRIXIVAN................................... 43
CROFAB .................................. 116
cromolyn sodium ........ 98, 104, 137
CUBICIN ..................................... 12
cupric chloride .......................... 131
cupric sulfate ............................ 131
CUPRIMINE ............................. 108
CUROSURF ............................. 137
CUTIVATE .................................. 78
CUVPOSA ................................ 105
cyanocobalamin (vitamin b-12) . 146
cyanocobalamin/fa/pyridoxine .. 141
cyanocobalamin/mecobalamin.. 141
CYCLESSA ................................ 68
cyclobenzaprine hcl .......... 138, 139
CYCLOGYL ................................ 99
CYCLOMYDRIL .......................... 98
cyclopentolate hcl ....................... 98
cyclophosphamide ................ 18, 21
CYCLOPHOSPHAMIDE ............. 18
cycloserine .................................. 38
cyclosporine ...................... 115, 116
cyclosporine, modified .............. 115
CYKLOKAPRON ........................ 48
CYMBALTA ................................ 29
cyproheptadine hcl...................... 35
CYRAMZA .................................. 21
CYSTADANE ............................ 124
CYSTAGON ............................... 97
CYSTARAN ................................ 99
cysteine hcl ................................. 52
cytarabine/pf ............................... 21
CYTOGAM ............................... 116
CYTOMEL ................................ 114
CYTOTEC ................................ 103
CYTOVENE ................................ 46
D.H.E.45 ..................................... 38
dacarbazine ................................ 21
DACOGEN ................................. 21
dactinomycin ............................... 21
DALIRESP ................................ 138
danazol ..................................... 108
DANTRIUM ............................... 138
dantrolene sodium ............ 138, 139
dapsone ...................................... 38
DAPTACEL DTAP .................... 118
DARAPRIM ................................. 40
darifenacin hydrobromide ......... 107
DARZALEX ................................. 21
daunorubicin hcl ......................... 21
DAUNOXOME ............................ 21
DAYPRO ...................................... 5
DAYTRANA ................................ 66
DDAVP ............................. 112, 113
DEBACTEROL ........................... 70
DECARA................................... 143
decitabine ................................... 21
deferoxamine mesylate............. 108
DELESTROGEN .......................110
DELFLEX WITH 1.5% DEXTROSE
..............................................120
DELFLEX WITH 2.5% DEXTROSE
..............................................120
DELFLEX WITH 4.25%
DEXTROSE ...........................120
DELOS ........................................72
DELZICOL ................................120
DEMADEX ..................................61
demeclocycline hcl ......................17
DEMEROL ................................2, 3
DEMSER .....................................59
DEMULEN 1-50-21 .....................68
DENAVIR ....................................72
DEPACON ..................................27
DEPAKENE ................................26
DEPAKOTE ................................26
DEPAKOTE ER...........................26
DEPAKOTE SPRINKLE ..............26
DEPEN......................................108
DEPLIN .....................................147
DEPLIN-ALGAL OIL..................147
DEPOCYT ...................................21
DEPODUR ................................... 3
DEPO-ESTRADIOL ..................110
DEPO-MEDROL .......................111
DEPO-PROVERA .....................114
DEPO-SUBQ PROVERA 104 ...114
DEPO-TESTOSTERONE..........109
DERMAGRAFT ...........................80
DERMANIC ...............................147
DERMAPAK PLUS......................79
DERMA-SMOOTHE-FS ..............78
DERMASORB AF .......................33
DERMASORB HC .......................79
DERMASORB TA .......................78
DERMATOP ................................78
DERMOTIC ...............................102
DESCOVY ..................................43
DESFERAL ...............................108
DESFERAL MESYLATE ...........108
desipramine hcl ...........................28
desloratadine ..............................35
desmopressin acetate .......112, 113
desog-e.estradiol/e.estradiol .......66
DESOGEN ..................................68
desogestrel-ethinyl estradiol ....... 66
DESONATE ................................ 78
desonide ..................................... 76
DESOWEN ................................. 78
desoximetasone ................... 76, 78
DESOXYN .................................. 65
DESPEC-PDC ............................ 69
DESQUAM-X .............................. 72
desvenlafaxine............................ 29
DESVENLAFAXINE ER.............. 29
DESVENLAFAXINE FUMARATE
ER ........................................... 29
DETROL ................................... 107
DETROL LA.............................. 107
DEVILBISS DISPOSABLE
NEBULIZER ............................ 82
DEVILBISS PULMO-AIDE .......... 82
DEVILBISS PULMONEB LT
COMP-NEB ............................ 82
DEVILBISS TRAVELER ............. 82
DEVILBLISS ............................... 82
dexamethasone ........................ 111
DEXAMETHASONE INTENSOL
.............................................. 111
dexamethasone sod phosphate
...................................... 101, 111
dexchlorphenir/pseudoephed/dm 35
DEXCOM G4 .............................. 90
DEXCOM G5-G4 SENSOR ........ 90
DEXEDRINE......................... 64, 65
DEXILANT ................................ 103
dexmedetomidine hcl ................ 140
dexmethylphenidate hcl .............. 64
DEXPAK ................................... 111
dexpanthenol ............................ 146
dexrazoxane hcl ....................... 125
dextroamphetamine sulfate ........ 64
dextroamphetamine/amphetamine
................................................ 65
dextrose 10 % and 0.2 % nacl .. 131
dextrose 10 % and 0.45 % nacl 131
dextrose 10 % in water ............... 52
dextrose 2.5 % and 0.45 % nacl131
dextrose 20 % in water ............... 52
dextrose 25 % in water ............... 53
dextrose 30 % in water ............... 53
dextrose 40 % in water ............... 53
dextrose 5 % and 0.3 % nacl .... 131
dextrose 5 % and 0.9 % nacl .... 131
dextrose 5 % in ringers ............... 53
dextrose 5 % in water ................. 53
dextrose 5 %-0.2 % nacl ........... 132
dextrose 5 %-0.45 % nacl ......... 132
dextrose 5%-lactated ringers .... 132
dextrose 50 % in water ............... 53
dextrose 70 % in water ............... 53
DIABETA .................................... 32
DIALYVITE 5000 ...................... 144
DIALYVITE SUPREME D ......... 144
DIAMOX SEQUELS.................. 130
DIANEAL PD-2 W-1.5%
DEXTROSE .......................... 120
DIANEAL PD-2 W-2.5%
DEXTROSE .......................... 120
DIANEAL PD-2 W-4.25%
DEXTROSE .......................... 120
DIANEAL WITH 1.5% DEXTROSE
.............................................. 120
DIASTAT .................................... 10
DIASTAT ACUDIAL .................... 10
DIATRUE PLUS.......................... 90
diazepam ................................ 9, 10
DIBENZYLINE ............................ 54
DICLEGIS ................................... 40
diclofenac potassium .................... 5
diclofenac sodium ............. 5, 6, 101
diclofenac sodium/misoprostol ...... 5
dicloxacillin sodium ..................... 15
dicyclomine hcl ................. 104, 105
didanosine .................................. 43
DIDREX ...................................... 66
diethylpropion hcl ........................ 66
DIFFERIN ................................... 79
DIFICID....................................... 14
diflorasone diacetate............. 77, 78
DIFLUCAN .................................. 33
diflunisal........................................ 5
DIGEX NF ................................. 105
DIGIFAB ..................................... 59
digoxin ........................................ 59
DIGOXIN .................................... 59
dihydrocodeine/guaifenesin ........ 70
dihydroergotamine mesylate . 36, 38
DILACOR XR .............................. 58
DILANTIN ....................................26
DILANTIN-125.............................26
DILATRATE-SR ..........................64
DILAUDID .................................2, 3
DILAUDID-HP .............................. 3
diltiazem hcl ................................58
dimenhydrinate............................39
DIOVAN ......................................55
DIOVAN HCT ..............................55
DIPENTUM ...............................119
diphenhydramine hcl ...................35
diphenoxylate hcl/atropine 104, 105
DIPHTHERIA-TETANUS
TOXOIDS-PED ......................118
DIPRIVAN .................................106
DIPROLENE ...............................78
DIPROLENE AF ..........................78
dipyridamole ..........................50, 59
DISCOVISC ................................80
DISKETS ...................................... 1
disopyramide phosphate .............56
disulfiram ...................................... 8
DITROPAN XL ..........................107
DIURIL ........................................61
divalproex sodium .......................25
DIVIGEL ....................................109
dobutamine hcl ............................59
dobutamine hcl/d5w ....................59
DOCEFREZ ................................21
docetaxel .....................................21
dofetilide ......................................56
DOLOPHINE HCL ........................ 2
donepezil hcl ...............................28
DONNATAL ................................25
dopamine hcl ...............................59
dopamine hcl/d5w .......................59
DOPRAM ..................................137
DORAL........................................10
DORIBAX ....................................15
DORYX .......................................18
DORYX MPC ..............................18
dorzolamide hcl .........................129
dorzolamide hcl/timolol maleat ..129
DOVONEX ..................................72
doxapram hcl ............................137
doxazosin mesylate.....................54
doxepin hcl ............................28, 72
doxercalciferol .......................... 121
DOXIL ......................................... 21
doxorubicin hcl............................ 21
doxorubicin hcl peg-liposomal .... 21
doxycycline hyclate............... 17, 18
doxycycline monohydrate ..... 17, 18
doxylamine succinate ................. 35
DRISDOL ................................. 144
DRITHOCREME HP ................... 72
dronabinol ................................... 38
droperidol ................................. 125
DROPLET LANCETS ................. 85
DROXIA ...................................... 18
DRYSOL ..................................... 72
DUAC ......................................... 76
DUAVEE ................................... 109
DUETACT................................... 31
DUEXIS ........................................ 6
DULERA ................................... 135
duloxetine hcl.............................. 28
DUODOTE................................ 125
DUOVISC ................................... 80
DURACLON ................................. 3
DURAGESIC ................................ 2
DURAMORPH .............................. 3
DUREZOL ................................ 102
dutasteride ................................ 122
dutasteride/tamsulosin hcl ........ 122
DUTOPROL................................ 57
DYAZIDE .................................... 61
DYMISTA ................................... 99
DYRENIUM ................................ 61
DYSPORT ................................ 125
EASIVENT .................................. 82
EASY COMFORT ....................... 85
EASY GLUCO G2 ...................... 90
EASY PLUS II............................. 90
EASY STEP................................ 90
EASY TALK ................................ 90
EASY TOUCH ...................... 85, 88
EASY TOUCH GLUCOSE
MONITOR ............................... 90
EASY TOUCH HYPODERMIC
NEEDLE ................................. 88
EASY TOUCH LANCETS ........... 85
EASY TOUCH TEST STRIP....... 90
EASY TRAK ............................... 91
EASY TWIST AND CAP LANCETS
................................................ 85
EASYGLUCO ............................. 91
EASYGLUCO METER STARTER
KIT .......................................... 91
EASYGLUCO TEST STRIPS ..... 91
EASYMAX .................................. 91
EASYMAX 15 ............................. 91
EASYMAX L ............................... 91
EASYMAX N ............................... 91
EASYMAX NG ............................ 91
EASYMAX V ............................... 91
EASYMAX V SPEAKING ............ 91
EASYMAX V2 ............................. 91
EASYPLUS ................................. 91
EASYPLUS R13N....................... 91
EASYPLUS V ............................. 91
EBASE CONTROLLER .............. 82
ECLIPSE .................................... 91
ECLIPSE LUER-LOK SYRINGE. 88
EC-NAPROSYN ........................... 6
econazole nitrate ........................ 33
EDARBI ...................................... 55
EDARBYCLOR ........................... 55
EDECRIN ................................... 61
EDEX ........................................ 140
EDLUAR ................................... 140
EDURANT .................................. 43
EFFEXOR XR ............................. 29
EFFIENT..................................... 50
EFUDEX ..................................... 72
EGRIFTA .................................. 113
ELAPRASE ................................. 97
ELDEPRYL ................................. 41
electrolyte-48 solution/d5w ....... 132
ELELYSO ................................... 97
ELEMENT BLOOD GLUCOSE
METER ................................... 91
ELEMENT COMPACT ................ 91
ELEMENT PLUS ........................ 91
ELEMENT TEST STRIPS ........... 91
ELESTAT.................................... 99
ELESTRIN ................................ 110
ELETONE ................................... 80
ELIDEL ....................................... 78
ELIGARD .................................... 21
ELIMITE...................................... 79
ELIQUIS ......................................46
ELITEK........................................97
ELLA ...........................................68
ELLENCE ....................................21
ELLIOTTS B ..............................125
ELMIRON ..................................122
ELOCON .....................................78
ELOCTATE .................................48
ELOXATIN ..................................22
ELSPAR ......................................22
em#53/namgf/cyc/phos/nahc/nacl
................................................91
EMADINE ....................................98
EMBEDA ...................................... 4
EMBRACE ............................85, 91
EMBRACE EVO ..........................91
EMBRACE PRO..........................91
EMCYT .......................................18
EMEND .......................................39
EMLA ........................................... 7
emollient combination no.10........80
emollient combination no.32........80
emollient combination no.43........80
emollient combination no.85........80
EMPLICITI ..................................22
EMSAM .......................................29
EMTRIVA ....................................43
ENABLEX .................................107
enalapril maleate .........................55
enalapril/hydrochlorothiazide.......55
enalaprilat dihydrate ....................56
ENBREL ....................................115
ENDO-AVITENE .......................123
ENDOFORM ...............................80
ENDOMETRIN ..........................114
enflurane ...................................107
ENGERIX-B ADULT..................118
ENGERIX-B PEDIATRICADOLESCENT ......................118
ENJUVIA ...................................110
ENLON-PLUS .............................25
ENLYTE ....................................147
ENOVARX-AMITRIPTYLINE ......29
ENOVARX-BACLOFEN ..............74
ENOVARX-NAPROXEN .............. 6
enoxaparin sodium ......................46
entacapone .................................40
entecavir ..................................... 45
ENTERAGAM ........................... 128
ENTEREG ................................ 106
ENTOCORT EC ....................... 120
ENTRESTO ................................ 55
ENTYVIO .................................. 125
ENVARSUS XR ........................ 115
ENVISION .................................. 91
EOVIST .................................... 121
EPANED ..................................... 56
EPCLUSA ................................... 45
ephedrine sulfate ........................ 59
EPICERAM ................................. 80
EPIDUO ...................................... 79
EPIFIX AMNIOTIC MEMBRANE 91
EPIFOAM ................................... 78
epinastine hcl.............................. 98
epinephrine ........................... 59, 60
epinephrine hcl/pf ....................... 59
EPIPEN 2-PAK ........................... 59
EPIPEN JR 2-PAK...................... 59
epirubicin hcl............................... 22
EPISIL ........................................ 80
EPIVIR ........................................ 44
EPIVIR HBV ......................... 43, 44
eplerenone ................................. 64
EPOGEN .................................... 47
epoprostenol sodium (glycine) .. 141
eprosartan mesylate ................... 54
eptifibatide .................................. 50
EPZICOM ................................... 43
EQUETRO .................................. 26
ERAPID NEBULIZER ................. 82
ERAPID NEBULIZER HANDSET82
ERAXIS WATER DILUENT ........ 34
ERBITUX .................................... 22
ergocalciferol (vitamin d2)......... 141
ergoloid mesylates.................... 122
ERGOMAR ................................. 36
ergotamine tartrate/caffeine ........ 36
ERIVEDGE ................................. 19
ERTACZO .................................. 33
ERWINAZE................................. 22
ERYGEL ..................................... 76
ERYPED 200 .............................. 14
ERYPED 400 .............................. 14
ERY-TAB .................................... 14
ERYTHROCIN LACTOBIONATE 15
erythromycin base .............. 14, 100
erythromycin base/ethanol .......... 75
erythromycin ethylsuccinate ....... 14
erythromycin stearate ................. 14
erythromycin/benzoyl peroxide ... 75
ESBRIET .................................. 137
escitalopram oxalate ................... 28
ESGIC ...................................... 1, 2
esmolol hcl .................................. 58
esomeprazole magnesium ........ 103
esomeprazole sodium............... 103
esomeprazole strontium ........... 104
estazolam ..................................... 9
ESTRACE ................................. 110
estradiol .................................... 109
estradiol valerate ...................... 110
estradiol/norethindrone acet ..... 109
ESTRASORB ........................... 110
ESTRING.................................. 110
ESTROGEL .............................. 110
estrogen,ester/me-testosterone 108
estropipate ................................ 109
ESTROSTEP FE ........................ 68
eszopiclone ............................... 139
ethacrynate sodium .................... 62
ethacrynic acid ............................ 61
ethambutol hcl ............................ 38
ethanolamine oleate ................... 60
ethinyl estradiol/drospirenone ..... 66
ethosuximide .............................. 25
ETHRANE ................................ 107
ethyl chloride .............................. 72
ethynodiol d-ethinyl estradiol ...... 66
ETHYOL ................................... 125
etidronate disodium .................. 121
etodolac ........................................ 5
etomidate .................................. 107
ETOPOPHOS ............................. 22
etoposide .............................. 19, 22
EUFLEXXA ............................... 125
EURAX ....................................... 79
EVAMIST .................................. 110
EVEKEO ..................................... 66
EVENCARE ................................ 91
EVENCARE G2 .......................... 91
EVENCARE G3 .......................... 91
EVISTA .....................................110
EVOCLIN ....................................76
EVOLUTION BLOOD GLUCOSE
METER ....................................91
EVOLUTION TEST STRIPS .......91
EVOTAZ ......................................43
EVOXAC .....................................70
EVZIO .......................................... 9
EXALGO ...................................... 4
EXEL HYPODERMIC NEEDLE ..88
EXEL SYRINGE ..........................88
EXELDERM ................................33
EXELON .....................................28
exemestane ................................18
EXFORGE ..................................61
EXFORGE HCT ..........................61
EXJADE ....................................108
EXPAREL .................................... 7
EXPIRATORY .............................82
EXTAVIA ...................................124
EXTINA .......................................34
EXTRANEAL ICODEXTRIN
DIALYSIS ..............................120
EYLEA ........................................99
E-Z JECT LANCETS ...................86
EZ SMART ............................91, 92
EZ SMART LANCETS ................86
EZ SMART PLUS........................91
E-Z SPACER...............................82
E-Z SPACER PEDSPAK .............82
EZ USE JOINT-TUNNELTRIGGER ..............................112
E-ZJECT LANCETS ....................86
fa/arginine hcl/b12/b6/pep ex ....147
FABIOR.......................................79
FABRAZYME ..............................97
FACTIVE .....................................16
famciclovir ...................................45
famotidine .................................103
famotidine in nacl,iso-osm/pf .....104
famotidine/pf .............................104
FAMVIR ......................................45
FANAPT ......................................42
FARESTON ................................18
FARXIGA ....................................31
FARYDAK ...................................19
FASLODEX .................................22
fat emul/soy/mct/oliv/fish oil ........ 53
FAZACLO ................................... 43
fe fumarate/cal/e/fa/multivit ....... 144
fe fumarate/doss/fa/bcomp,c .... 142
fe fumarate/vit c/b12/stomc....... 142
fe fumarate/vit c/b12-if/fa .......... 142
FEIBA NF ................................... 48
felbamate .................................... 25
FELBATOL ................................. 26
FELDENE ..................................... 6
felodipine .................................... 60
FEM PH ...................................... 36
FEMARA .................................... 19
FEMCON FE .............................. 68
FEMHRT .................................. 110
FEMRING ................................. 110
fenofibrate .................................. 62
fenofibrate nanocrystallized ........ 62
fenofibrate,micronized ................ 62
fenofibric acid ............................. 63
fenofibric acid (choline) ............... 63
FENOGLIDE ............................... 63
fenoprofen calcium ....................... 5
fentanyl ..................................... 1, 4
fentanyl citrate .............................. 1
FENTANYL CITRATE .................. 3
fentanyl citrate/pf .......................... 3
FENTORA .................................... 2
FERAHEME.............................. 146
FERIVA .................................... 147
FERIVA FA ............................... 145
FERRALET 90 .......................... 145
FERRIPROX............................. 108
FERRLECIT.............................. 146
ferrous fumarate/folic acid ........ 142
ferrous sulfate/vit c/fa ............... 142
FETZIMA .................................... 29
FEXMID .................................... 139
fexofenadine hcl ......................... 35
fexofenadine/pseudoephedrine .. 35
FIBRICOR .................................. 63
FIFTY50 SAFETY SEAL LANCETS
................................................ 86
FIFTY50 TEST STRIP ................ 92
FILTER PAD ............................... 82
FILTER, VALVE SET FOR LL AND
LC ........................................... 82
FILTERS REPLACEMENT ......... 82
FINACEA .................................... 72
FINACEA PLUS .......................... 74
finasteride ......................... 122, 128
FINE 30 UNIVERSAL LANCETS 86
FINGERSTIX .............................. 86
FIORICET ..................................... 2
FIORICET WITH CODEINE.......... 2
FIORINAL ..................................... 2
FIORINAL WITH CODEINE #3 ..... 2
FIRAZYR .................................... 59
FIRMAGON ................................ 22
FIRST-BXN ................................. 33
FIRST-DUKE'S ........................... 33
FIRST-HYDROCORTISONE ...... 78
FIRST-LANSOPRAZOLE ......... 103
FIRST-MARY'S........................... 33
FIRST-MOUTHWASH BLM ........ 70
FIRST-OMEPRAZOLE ............. 103
FIRST-PROGESTERONE VGS
100 ........................................ 114
FIRST-PROGESTERONE VGS
200 ........................................ 114
FIRST-PROGESTERONE VGS 25
.............................................. 114
FIRST-PROGESTERONE VGS
400 ........................................ 114
FIRST-PROGESTERONE VGS 50
.............................................. 114
FIRST-TESTOSTERONE ......... 109
FIRST-TESTOSTERONE MC .. 108
fish oil/omega-3/e/fa/b6-b12 ..... 128
FLAGYL ...................................... 11
FLAGYL ER ................................ 11
FLAREX.................................... 102
flavoxate hcl .............................. 107
FLEBOGAMMA DIF.................. 116
flecainide acetate ........................ 56
FLECTOR ..................................... 6
FLEXBUMIN ............................... 50
FLEXICHAMBER ........................ 82
FLOLAN.................................... 141
FLOMAX ................................... 108
FLONASE ................................. 102
FLO-PRED ............................... 112
FLOVENT DISKUS ................... 135
FLOVENT HFA ......................... 135
FLOW-EZE .................................88
FLOXIN .....................................101
floxuridine ....................................22
FLUARIX QUAD 2015-2016......118
FLUARIX QUAD 2016-2017......118
FLUBLOK 2015-2016................118
FLUBLOK 2016-2017................118
FLUCELVAX 2015-2016 ...........118
FLUCELVAX QUAD 2016-2017 118
fluconazole ..................................33
fluconazole in nacl,iso-osm .........34
flucytosine ...................................33
fludarabine phosphate .................22
fludrocortisone acetate ..............111
FLULAVAL QUAD 2015-2016 ...118
FLULAVAL QUAD 2016-2017 ...118
FLUMADINE ...............................44
flumazenil ....................................66
FLUMIST QUAD 2015-2016 .....118
flunisolide ..................................101
fluocinolone acetonide ................77
fluocinolone acetonide oil ..........101
fluocinonide .................................77
fluorometholone ........................101
FLUOROPLEX ............................72
fluorouracil ............................22, 71
fluoxetine hcl .........................28, 29
FLUOXETINE HCL .....................29
fluoxymesterone ........................109
fluphenazine decanoate ..............42
fluphenazine hcl ....................41, 42
flurandrenolide ............................77
flurazepam hcl .............................. 9
flurbiprofen ................................... 5
flurbiprofen sodium....................101
flutamide .....................................18
fluticasone propionate .........77, 101
FLUTTER ....................................82
fluvastatin sodium .......................62
FLUVIRIN 2015-2016................118
FLUVIRIN 2016-2017................118
fluvoxamine maleate .............28, 29
FLUZONE 2015-2016 ...............118
FLUZONE HIGH-DOSE 2015-2016
..............................................118
FLUZONE HIGH-DOSE 2016-2017
..............................................118
FLUZONE INTRADERM QUAD
2015-16................................. 118
FLUZONE INTRADERM QUAD
2016-17................................. 118
FLUZONE QUAD 2015-2016 ... 118
FLUZONE QUAD 2016-2017 ... 119
FML .......................................... 102
FML FORTE ............................. 102
FML S.O.P. ............................... 102
FOCALIN .................................... 65
FOCALIN XR .............................. 65
FOLGARD OS .......................... 145
FOLGARD RX .......................... 145
folic acid ........................... 142, 146
folic acid/b complex and c no.17
.............................................. 142
folic acid/b cplx/c/selen/zinc...... 142
folic acid/vit bcomp,c ................ 142
folic acid/vit bcomp,c/cu/znox ... 142
FOLLISTIM AQ ................. 112, 113
FOLOTYN .................................. 22
FOLTRATE ............................... 145
FOLTX ...................................... 147
fomepizole ................................ 126
fondaparinux sodium .................. 46
FORA D10 .................................. 92
FORA D15C ............................... 92
FORA D15G ............................... 92
FORA D15Z ................................ 92
FORA D20 .................................. 92
FORA G20 .................................. 92
FORA G30A ............................... 92
FORA G71A ............................... 92
FORA G90 .................................. 92
FORA LANCETS ........................ 86
FORA TEST STRIP .................... 92
FORA V10 .................................. 92
FORA V10-V12-D10-D20 ........... 92
FORA V12 .................................. 92
FORA V20 .................................. 92
FORA V22 .................................. 92
FORA V30A ................................ 92
FORACARE GD20 ..................... 92
FORACARE GD40 ..................... 92
FORACARE GD40A ................... 92
FORACARE GD40B ................... 92
FORACARE LANCETS .............. 86
FORADIL .................................. 136
FORANE................................... 107
FORFIVO XL .............................. 30
formaldehyde ............................ 128
FORMALDEHYDE .................... 128
FORMA-RAY ............................ 128
FORTAMET ................................ 31
FORTAVIT ................................ 145
FORTAZ ..................................... 14
FORTEO................................... 121
FORTESTA .............................. 109
FORTICAL ................................ 121
FOSAMAX ................................ 121
FOSAMAX PLUS D .................. 121
foscarnet sodium ........................ 44
FOSCAVIR ................................. 44
fosinopril sodium ......................... 55
fosinopril/hydrochlorothiazide ..... 55
fosphenytoin sodium ................... 27
FOSRENOL .............................. 106
FOSTEUM ................................ 128
FOSTEUM PLUS ...................... 135
FOVEX ..................................... 128
FRAGMIN ................................... 46
FREAMINE HBC......................... 53
FREAMINE III ............................. 53
FREESTYLE FLASH SYSTEM... 92
FREESTYLE FREEDOM ............ 92
FREESTYLE FREEDOM LITE ... 92
FREESTYLE INSULINX ............. 92
FREESTYLE INSULINX TEST
STRIPS ................................... 92
FREESTYLE LANCETS ............. 86
FREESTYLE LITE TEST STRIPS
................................................ 92
FREESTYLE SIDEKICK II .......... 92
FREESTYLE SYSTEM ............... 92
FREESTYLE TEST STRIPS ....... 92
FREESTYLE UNISTIK 2 ............. 86
FROVA ....................................... 37
frovatriptan succinate.................. 37
FULYZAQ ................................. 106
FURADANTIN............................. 11
furosemide ............................ 61, 62
FUSILEV................................... 126
FUSION PLUS .......................... 143
FUSION SPRINKLES ............... 143
FUZEON .....................................44
FYCOMPA ..................................26
G-4 ..............................................92
gabapentin ..................................25
GABITRIL ....................................26
GABLOFEN ..............................139
galantamine hbr ..........................28
GALZIN .....................................108
GAMASTAN S-D .......................117
GAMMAGARD LIQUID .............117
GAMMAKED .............................117
GAMMAPLEX ...........................117
GAMUNEX-C ............................117
ganciclovir sodium.......................46
GANIRELIX ACETATE .............124
GARAMYCIN ....................100, 101
GARDASIL ................................119
GARDASIL 9 .............................119
GASTRINEX NF........................105
GASTROCROM ........................105
gatifloxacin ................................100
GAZYVA .....................................22
GE100 BLOOD GLUCOSE
SYSTEM..................................92
GE100 BLOOD GLUCOSE TEST
STRIP ......................................93
GELCLAIR ..................................70
GELFILM ...................................123
GELFOAM ............................48, 80
GELFOAM COMPRESSED ........80
GELNIQUE ...............................107
GELX ..........................................70
gemcitabine hcl ...........................22
gemfibrozil ...................................62
GEMZAR .....................................22
GENADUR ..................................93
GENERESS FE...........................69
genistein/cit zn bisgly/vit d3 .......128
GENOTROPIN ..........................112
gentamicin in nacl, iso-osm .........10
gentamicin sulfate .........11, 75, 100
gentamicin sulfate/pf ...................11
gentian viol/brlnt grn/proflav ........33
GENVOYA ..................................44
GEODON ....................................42
GIAZO .......................................120
GILENYA ..................................124
GILOTRIF ................................... 19
GILPHEX TR .............................. 69
GLASSIA .................................. 137
glatiramer acetate ..................... 124
GLEEVEC .................................. 19
GLEOSTINE ............................... 25
GLIADEL .................................... 22
glimepiride .................................. 32
glipizide ...................................... 32
glipizide/metformin hcl ................ 32
GLUCAGEN ............................. 123
GLUCAGON EMERGENCY KIT
.............................................. 123
GLUCO NAVII ............................ 93
GLUCOCARD 01........................ 93
GLUCOCARD 01 SENSOR PLUS
................................................ 93
GLUCOCARD 01-MINI ............... 93
GLUCOCARD EXPRESSION .... 93
GLUCOCARD VITAL .................. 93
GLUCOCARD VITAL SENSOR.. 93
GLUCOCOM .............................. 86
GLUCOCOM BLOOD GLUCOSE
................................................ 93
GLUCOCOM GLUCOSE ............ 93
GLUCOCOM LANCETS ............. 86
GLUCOLAB ................................ 93
GLUCOLET 2 ............................. 86
GLUCOPHAGE .......................... 31
GLUCOPHAGE XR .................... 31
GLUCOSE TEST STRIP ............ 93
GLUCOSOURCE ....................... 86
GLUCOTROL ............................. 32
GLUCOTROL XL ........................ 32
GLUCOVANCE .......................... 32
GLUMETZA ................................ 31
GLUTARALDEHYDE .................. 97
glyburide ..................................... 32
glyburide,micronized ................... 32
glyburide/metformin hcl .............. 32
GLYCATE ................................. 106
glycine urologic solution ........... 120
glycopyrrolate ................... 104, 105
GLYNASE .................................. 33
GLYSET ..................................... 31
GLYTACTIN 10 PE BETTERMILK
................................................ 54
GLYTACTIN 15 PE BETTERMILK
................................................ 54
GLYXAMBI ................................. 30
GMATE ....................................... 86
GMATE TEST STRIPS ............... 93
GMATE VOICE METER ............. 93
GOLYTELY ............................... 106
GONAL-F.................................. 113
GONAL-F RFF .......................... 113
GONAL-F RFF REDI-JECT ...... 113
GORDOFILM .............................. 72
GORDO-UREA ........................... 72
GRAFIX CORE ........................... 93
GRAFIX PRIME .......................... 93
GRALISE .................................... 27
granisetron hcl ............................ 39
granisetron hcl/pf ........................ 39
GRANIX ...................................... 47
GRASTEK ................................ 123
GRIFULVIN V ............................. 33
griseofulvin ultramicrosize .......... 33
griseofulvin, microsize ................ 33
GRIS-PEG .................................. 33
guaifenesin/codeine phosphate .. 69
guaifenesin/dyphylline .............. 137
guanfacine hcl ...................... 54, 65
guanidine hcl ............................ 123
GUARDIAN REAL-TIME ............. 93
GUARDIAN RT STARTER KIT ... 93
GYNAZOLE 1 ............................. 36
H.P. ACTHAR ........................... 128
HALAVEN ................................... 22
HALCION.................................... 10
HALDOL ..................................... 42
HALDOL DECANOATE 100 ....... 42
HALDOL DECANOATE 50 ......... 42
halobetasol propionate ............... 77
HALOG ....................................... 78
HALONATE ................................ 79
HALONATE PAC ........................ 77
haloperidol .................................. 41
haloperidol decanoate ................ 43
haloperidol lactate................. 41, 43
HARVONI ................................... 45
HAVRIX .................................... 119
hc/pramoxine hcl/chloroxylenol 101,
102
HEALTHPRO GLUCOSE
MONITOR ...............................93
HEALTHPRO TEST STRIPS ......93
HEALTHY ACCENTS UNILET
LANCET ..................................86
HECORIA ..................................115
HECTOROL ..............................121
HELIXATE FS .............................48
HEMABATE ..............................126
HEMATRON-AF ........................145
HEMOCYTE PLUS ...................145
HEMOCYTE-F ..........................145
HEMOFIL M ................................48
HEPAGAM B .............................117
heparin sod,porcine/0.9 % nacl ...47
heparin sod,pork in 0.45% nacl ...47
HEPARIN SODIUM IN 0.45%
NACL .......................................47
heparin sodium,porcine ...............47
heparin sodium,porcine/d5w .......47
heparin sodium,porcine/ns/pf ......47
heparin sodium,porcine/pf ...........47
HEPATAMINE .............................53
HEPATASOL...............................53
HEPSERA ...................................45
HERCEPTIN ...............................22
HESPAN ...................................132
hetastarch in 0.9 % nacl ............132
HETLIOZ ...................................140
HEXALEN ...................................18
HEXTEND LACTATED
ELECTROLYTE.....................132
HIBERIX ....................................119
HIPREX .......................................11
HIZENTRA ................................116
homatropine hbr ..........................98
HORIZANT ..................................26
HUMALOG ..................................32
HUMALOG KWIKPEN U-100 ......31
HUMALOG KWIKPEN U-200 ......31
HUMALOG MIX 50-50 ................31
HUMALOG MIX 50-50 KWIKPEN
................................................31
HUMALOG MIX 75-25 ................32
HUMALOG MIX 75-25 KWIKPEN
................................................32
HUMATE-P .................................49
HUMATROPE........................... 112
HUMIRA ................................... 116
HUMIRA PEDIATRIC CROHN'S
.............................................. 115
HUMIRA PEN ........................... 116
HUMIRA PEN CROHN-UC-HS
STARTER ............................. 115
HUMIRA PEN PSORIASISUVEITIS ................................ 115
HUMULIN 70/30 KWIKPEN ........ 32
HUMULIN 70-30 ......................... 32
HUMULIN N................................ 32
HUMULIN N KWIKPEN .............. 32
HUMULIN R................................ 32
HUMULIN R U-500 ..................... 32
HUMULIN R U-500 KWIKPEN ... 32
HYALGAN ................................ 126
HYCAMTIN ........................... 19, 22
HYCET ......................................... 2
hydralazine hcl...................... 59, 60
HYDREA .................................... 19
HYDRO 35.................................. 75
HYDRO 40.................................. 72
hydrochlorothiazide .................... 61
hydrocodone bit/homatrop me-br 69
hydrocodone/acetaminophen ... 1, 2
hydrocodone/chlorphen p-stirex . 69
hydrocodone/cpm/pseudoephed 69
hydrocodone/ibuprofen ............. 1, 4
hydrocort/pramoxin/emol/pram#177
hydrocort/pramoxn/skn clnsr#16. 78
hydrocortisone .............. 77, 78, 111
hydrocortisone acetate ............... 77
hydrocortisone acetate/aloe v ..... 77
hydrocortisone acetate/urea ....... 78
hydrocortisone butyrate .............. 77
hydrocortisone sod succinate ... 111
hydrocortisone valerate .............. 77
hydrocortisone/iodoquinol ........... 77
hydrocortisone/lidocaine/aloe .... 72,
77, 79
hydrocortisone/pramoxine .......... 77
hydromorphone hcl ........... 1, 2, 3, 4
hydromorphone hcl/pf ................... 3
hydroquinone .............................. 75
hydroxocobalamin .................... 146
hydroxychloroquine sulfate ......... 40
hydroxyurea ................................ 18
hydroxyzine hcl ................. 122, 126
hydroxyzine pamoate........ 122, 123
HYLASE ................................... 123
HYLENEX ................................... 97
hyoscyamine sulfate ................. 104
HYPERHEP B S-D ................... 117
HYPERLYTE CR ...................... 132
HYPERRAB S-D ....................... 117
HYPERRHO S-D ...................... 117
HYPER-SAL ............................. 137
HYPERTENSA ......................... 128
HYPERTET S-D ....................... 117
HYPODERMIC NEEDLE ............ 89
HYQVIA .................................... 116
HYSINGLA ER.............................. 4
HYZAAR ..................................... 55
ibandronate sodium .................. 121
IBG-STAR................................... 93
IBRANCE.................................... 19
IBUDONE ..................................... 4
ibuprofen....................................... 5
ibuprofen lysine/pf......................... 6
ibuprofen/oxycodone hcl ............... 1
ibutilide fumarate ........................ 57
ICLUSIG ..................................... 19
IDAMYCIN PFS .......................... 22
idarubicin hcl ............................... 22
IFEX............................................ 23
ifosfamide ................................... 23
ifosfamide/mesna........................ 23
ILARIS ...................................... 117
ILEVRO .................................... 102
ILOTYCIN ................................. 100
imatinib mesylate ........................ 19
IMBRUVICA ................................ 19
IMDUR ........................................ 64
imipenem/cilastatin sodium ......... 15
imipramine hcl ............................ 28
imipramine pamoate ................... 28
imiquimod ................................... 71
IMITREX ..................................... 37
IMLYGIC ..................................... 25
IMOGAM RABIES-HT............... 117
IMOVAX RABIES VACCINE ..... 119
IMURAN ................................... 115
IN-CHECK DIAL ......................... 82
IN-CHECK NASAL WITH MASK .82
IN-CHECK ORAL ........................82
INCIVEK ......................................45
INCONTROL SUPER THIN
LANCETS ................................86
INCONTROL ULTRA THIN
LANCETS ................................86
INCRELEX ................................112
INCRUSE ELLIPTA...................136
indapamide .................................61
INDERAL LA ...............................57
INDICLOR .................................130
INDIUM IN-111 DTPA .................96
INDOCIN ...................................... 5
indomethacin ................................ 5
indomethacin sodium ................... 6
INFANRIX DTAP .......................119
INFASURF ................................137
INFED .......................................146
INFINITY .....................................93
INFINITY TEST STRIPS .............93
INFUMORPH ............................... 3
INFUVITE ..................................146
INFUVITE ADULT .....................146
INJECT EASE LANCETS ...........86
INJECTAFER ............................147
INLYTA .......................................19
INNOPRAN XL ............................57
INNOSPIRE DELUXE .................82
INNOSPIRE ELEGANCE ............82
INNOSPIRE ESSENCE ..............82
INNOSPIRE MINI ........................82
INNOSPIRE REPLACEMENT
FILTER ....................................82
INOVA .........................................73
INOVA 4-1 ...................................72
INOVA 8-2 ...................................73
INSPIRACHAMBER ....................82
INSPIRATION .............................82
INSPIRATION ELITE ..................82
INSPIRATION ELITE FILTER .....82
INSPRA .......................................64
INTEGRA F ...............................145
INTEGRA NEEDLE .....................89
INTEGRA PLUS ........................145
INTEGRA SYRINGE ...................89
INTEGRILIN ................................50
INTELENCE ............................... 43
INTERMEZZO .......................... 140
INTRALIPID ................................ 53
INTRON A .................................. 45
INTUNIV ..................................... 65
INVACARE LANCETS ................ 86
INVANZ ...................................... 15
INVEGA ...................................... 43
INVEGA SUSTENNA ................. 43
INVEGA TRINZA ........................ 43
INVIRASE ................................... 43
INVOKAMET .............................. 30
INVOKANA ................................. 30
iodine/potassium iodide .............. 72
IONOSOL B WITH DEXTROSE 5%
IONOSOL MB-DEXTROSE 5% 132
IOPIDINE .................................... 99
IPOL ......................................... 119
ipratropium bromide............ 98, 136
ipratropium/albuterol sulfate ..... 136
IPRIVASK ................................... 46
irbesartan ................................... 54
irbesartan/hydrochlorothiazide.... 55
IRESSA ...................................... 19
irinotecan hcl .............................. 23
iron ag and fum/c/fa/mv cmb11/ca-t
.............................................. 143
iron ag/c/b12/ca/suc.acid/stom . 143
iron aspgly and ps/c/b12/fa/ca/suc
.............................................. 144
iron aspgly/c/b12/fa/ca-th/suc ... 144
iron bg,ps/vitc/b12/fa/calcium ... 142
iron carb,gl/fa/b12/c/docusate... 145
iron carb/fa#9/vit c/d3/b6/b12 ... 145
iron dextran complex ................ 147
iron fum and ag/c/b12/fa/ca/succ
.............................................. 144
iron fum and polysac#1/fa/mv no.18
iron fum and ps cmp/fa/vit c/b3 . 142
iron fum,ps/fa/vit b with c #9 ..... 142
iron fumarate/vit c/vit b12/fa...... 142
iron polysac/iron heme/fa/b12... 144
iron ps cmplx/vit b12/fa ............. 142
iron, carbonyl/fa/c/b-6/b12/zn ... 142
iron,carb/dss/b12if/fa/mv-mn .... 142
iron/fa/b12/c/docusate sodium .. 144
iron/fa/vit bcomp,c/minerals ...... 142
iron/liver ext/vit bcomp,c/min .... 142
IROSPAN ................................. 145
ISENTRESS ............................... 43
ISOCHRON ................................ 64
isoflurane .................................. 107
ISOLYTE H WITH DEXTROSE 132
ISOLYTE M WITH DEXTROSE 132
ISOLYTE P WITH DEXTROSE 132
ISOLYTE S ............................... 132
isomethept/dichlphn/acetaminop 36
isomethepten/caf/acetaminophen
.......................................... 36, 37
isoniazid...................................... 38
ISOPTO ATROPINE ................... 99
ISOPTO CARBACHOL ............. 129
ISOPTO CARPINE ................... 130
ISOPTO HOMATROPINE .......... 99
ISOPTO HYOSCINE .................. 98
ISORDIL ..................................... 64
ISORDIL TITRADOSE ................ 64
isosorbide dinitrate...................... 64
isosorbide mononitrate ............... 64
isotretinoin .................................. 74
isoxsuprine hcl ............................ 59
isradipine .................................... 60
ISTALOL ................................... 130
ISTODAX .................................... 23
ISUPREL .................................. 137
itraconazole ................................ 33
ivermectin ................................... 40
IXEMPRA ................................... 23
IXINITY ....................................... 49
JAKAFI ....................................... 20
JALYN ...................................... 123
JANUMET ................................... 30
JANUMET XR ............................. 30
JANUVIA .................................... 30
JARDIANCE ............................... 30
JAZZ WIRELESS 2..................... 93
JENTADUETO ............................ 30
JENTADUETO XR ...................... 30
JETREA ...................................... 99
JEVANTIQUE LO ..................... 110
JEVTANA ................................... 23
JUBLIA ....................................... 34
JUXTAPID .................................. 63
KABIVEN .................................... 53
KADCYLA ...................................23
KADIAN ........................................ 2
KALBITOR ................................126
KALETRA ....................................43
KALYDECO ..............................137
KAPVAY ......................................66
KAYEXALATE ...........................105
KAZANO .....................................31
KCENTRA ...................................49
KEDBUMIN .................................51
KEFLEX ......................................13
KENALOG ...................................78
KENALOG-10............................111
KENALOG-40............................111
KENDALL ..................................123
KEPIVANCE .............................126
KEPPRA ...............................26, 27
KEPPRA XR ...............................26
KERAFOAM ................................73
KERALAC ...................................73
KERALYT ....................................73
KEROL ........................................73
KERYDIN ....................................34
KETALAR ..................................107
ketamine hcl ..............................107
ketamine hcl in 0.9 % nacl ........107
ketamine hcl in sterile water ......107
KETEK ........................................14
ketoconazole .........................33, 34
KETODAN ...................................34
KETONE ...................................140
KETONE CARE ........................140
ketoprofen .................................... 5
ketorolac tromethamine .....5, 6, 101
KETOSTIX REAGENT ..............140
KEYNOTE ...................................93
KEYNOTE PRO ..........................93
KEYTRUDA ................................23
KHEDEZLA .................................30
KINERET ..................................116
KINNEY BRAND LANCETS ........86
KINRIX ......................................119
KLARON .....................................76
KLONOPIN .................................10
KLOR-CON ...............................131
KLOR-CON 10 ..........................130
KLOR-CON 8 ............................131
KOATE-DVI ................................ 49
KOGENATE FS .......................... 49
KOMBIGLYZE XR ...................... 31
KORLYM .................................... 31
K-PHOS NEUTRAL .................. 131
K-PHOS NO.2 .......................... 131
K-PHOS ORIGINAL .................. 131
KRISTALOSE ........................... 105
KRYSTEXXA .............................. 97
K-TAB ER ................................. 131
KUVAN ....................................... 97
KYNAMRO ................................. 63
KYPROLIS.................................. 23
l.acidophilus/b.bifidum,longum.. 105
labetalol hcl........................... 57, 58
LAC-HYDRIN.............................. 75
LACRISERT ............................... 99
LACTATED RINGERS ..... 120, 132
lactic acid .................................... 71
lactulose ................................... 104
LAMICTAL ............................ 26, 27
LAMICTAL BLUE........................ 26
LAMICTAL GREEN .................... 26
LAMICTAL ODT ......................... 27
LAMICTAL ODT BLUE ............... 26
LAMICTAL ODT GREEN ............ 26
LAMICTAL ODT ORANGE ......... 27
LAMICTAL ORANGE ................. 26
LAMICTAL XR ............................ 27
LAMICTAL XR BLUE .................. 27
LAMICTAL XR GREEN .............. 27
LAMICTAL XR ORANGE............ 27
LAMISIL ...................................... 33
lamivudine .................................. 43
lamivudine/zidovudine ................ 43
lamotrigine ............................ 25, 26
LANCETS ................................... 86
LANCETS THIN.......................... 86
LANCETS ULTRA THIN ............. 86
LANOXIN .............................. 59, 60
LANOXIN PEDIATRIC ................ 60
lansoprazole ............................. 103
lansoprazole/amoxiciln/clarith ... 103
LANTUS ..................................... 32
LANTUS SOLOSTAR ................. 32
LASIX ......................................... 61
LASTACAFT ............................... 98
latanoprost ................................ 129
LATISSE ..................................... 99
LATUDA ..................................... 42
LAZANDA ..................................... 3
LC D NEBULIZER SET .............. 82
LC PLUS..................................... 82
LC SPRINT NEBULIZER ............ 82
LC STAR .................................... 82
leflunomide ............................... 115
LENVIMA .................................... 19
LESCOL ..................................... 63
LESCOL XL ................................ 63
LETAIRIS.................................. 141
letrozole ...................................... 18
LETS KIT ...................................... 8
leucovorin calcium .... 122, 123, 126
LEUKERAN ................................ 18
LEUKINE .................................... 47
leuprolide acetate ....................... 23
LEVACET ..................................... 5
levalbuterol hcl .......................... 136
LEVAQUIN ........................... 16, 17
LEVATOL ................................... 57
LEVBID ....................................... 25
LEVEMIR .................................... 32
LEVEMIR FLEXTOUCH ............. 32
levetiracetam ........................ 26, 27
levetiracetam in nacl (iso-os) ...... 27
LEVITRA................................... 140
levobunolol hcl .......................... 129
levocarnitine ..................... 122, 126
levocarnitine (with sugar) .......... 122
levocetirizine dihydrochloride ...... 35
levofloxacin ................... 16, 17, 100
levofloxacin/d5w ......................... 17
levoleucovorin calcium.............. 126
levomefolate calcium ................ 147
levomefolate/algal oil ................ 147
levomefolate/b6/b12/algal oil .... 147
levonorgestrel ............................. 66
levonorgestrel-ethin estradiol ...... 67
LEVOPHED BITARTRATE ......... 60
levorphanol tartrate ....................... 2
levothyroxine sodium ........ 114, 115
LEVOXYL ................................. 114
LEVSIN ..................................... 105
LEVSIN-SL ............................... 105
LEVULAN ....................................73
LEXAPRO ...................................29
LEXIVA .......................................44
LIALDA......................................120
LIBERTY BLOOD GLUCOSE
METER ....................................93
LIBERTY MONITOR ...................93
LIBERTY TEST STRIPS .............93
LIBRAX .......................................25
lidocaine ....................................... 6
lidocaine hcl ..............................6, 7
lidocaine hcl/d5w/pf .....................57
lidocaine hcl/d7.5w/pf ..................57
lidocaine hcl/epinephrine .............. 7
lidocaine hcl/epinephrine bit ......... 7
lidocaine hcl/epinephrine/pf .......... 7
lidocaine hcl/pf ........................7, 57
lidocaine/hydrocortisone ac .....6, 77
lidocaine/prilocaine....................6, 7
lidocaine/tetracaine ...................... 6
LIDOCAINE-EPINEPHRINE ........ 7
LIDODERM .................................. 7
LIDORX........................................ 7
LIDOVIR ......................................75
LIFESHIELD BLUNT CANNULA .89
LILETTA ......................................68
LIMBREL ...................................128
LIMBREL250 .............................128
LIMBREL500 .............................128
LINCOCIN ...................................12
lincomycin hcl ..............................12
lindane ........................................79
linezolid .......................................12
linezolid-0.9% sodium chloride ....12
LINZESS ...................................105
LIORESAL INTRATHECAL .......139
liothyronine sodium ...........114, 115
lipase/protease/amylase .............97
LIPICHOL 540 .............................63
LIPITOR ......................................63
LIPOFEN .....................................63
LIPTRUZET ................................63
lisinopril .......................................55
lisinopril/hydrochlorothiazide .......55
LISTER-V ..................................128
LITE TOUCH ...............................86
LITEAIRE ....................................82
LITETOUCH ............................... 82
lithium carbonate ........................ 65
lithium citrate .............................. 65
LITHOBID ................................... 65
LITHOSTAT .............................. 123
LIVALO ....................................... 63
LMD 10% WITH 5% DEXTROSE
.............................................. 132
lmfol ca/acetyl/mb12/algal oil .... 147
l-norgest/e.estradiol-e.estrad ...... 67
LO LOESTRIN FE ...................... 69
LOCOID ...................................... 78
LODOSYN .................................. 41
LOESTRIN.................................. 68
LOESTRIN FE ............................ 68
LOFIBRA .................................... 63
LOMOTIL .................................. 105
lomustine .................................... 18
LONSURF .................................. 19
loperamide hcl .......................... 104
LOPID ......................................... 63
LOPRESSOR ............................. 58
LOPRESSOR HCT ..................... 58
LOPROX .............................. 33, 34
lorazepam ................................... 10
LORTAB ................................... 1, 4
LORTUSS EX ............................. 69
LORZONE ................................ 139
losartan potassium ..................... 55
losartan/hydrochlorothiazide ....... 55
LOSEASONIQUE ....................... 68
LOTEMAX ................................ 102
LOTENSIN.................................. 56
LOTENSIN HCT ......................... 56
LOTREL ..................................... 60
LOTRISONE ............................... 33
LOTRONEX .............................. 105
lovastatin .................................... 62
LOVAZA ..................................... 63
LOVENOX .................................. 46
loxapine succinate ...................... 41
LOXITANE .................................. 42
LUCENTIS .................................. 99
LUER-LOK SYRINGE-NEEDLE . 89
LUFYLLIN ................................. 136
LUGOL'S .................................... 72
LUMIGAN ................................. 129
LUMINAL SODIUM ..................... 27
LUMIZYME ................................. 97
LUNESTA ................................. 139
LUPRON DEPOT ....................... 23
LUPRON DEPOT-PED ............. 113
LUSTRA ..................................... 75
LUVOX CR ................................. 30
LUXIQ ......................................... 78
LUZU .......................................... 34
LYNPARZA ................................. 25
LYRICA....................................... 27
LYSIPLEX PLUS ...................... 142
LYSODREN ................................ 18
LYSTEDA ................................... 50
M.V.I. ADULT ........................... 147
M.V.I. PEDIATRIC .................... 147
M.V.I.-12 ................................... 147
MACROBID ................................ 12
MACRODANTIN ......................... 12
MACUGEN ................................. 99
mafenide acetate ........................ 71
magnesium chloride.................. 132
magnesium sulfate.................... 132
magnesium sulfate in water ...... 132
magnesium sulfate/d5w ............ 132
MAJOR COMFORT .................... 86
MAKENA .................................. 114
MALARONE ............................... 40
malathion .................................... 79
manganese chloride ................. 132
manganese sulfate ................... 132
mannitol ...................................... 62
mannitol/sorbitol solution .......... 120
maprotiline hcl ............................ 29
MARCAINE ................................... 7
MARCAINE SPINAL ..................... 7
MARCAINE-EPINEPHRINE ......... 8
MARINOL ................................... 39
MARPLAN .................................. 29
MARQIBO................................... 23
MASK SET WITH Y-PIECE ........ 82
MASK VORTEX .......................... 82
MATULANE ................................ 18
MAVIK ........................................ 56
MAXALT ..................................... 37
MAXALT MLT ............................. 37
MAXARON FORTE .................. 145
MAXFE......................................147
MAXIDEX ..................................102
MAXIFED CD ..............................70
MAXIFLU CD ..............................70
MAXIFLU CDX ............................70
MAXIMA ......................................93
MAXIPIME ..................................14
MAXITROL ................................101
MAXZIDE ....................................61
MAXZIDE-25 MG ........................61
meclizine hcl ...............................40
meclofenamate sodium ................ 5
mecobal/levomefolat ca/b6 phos
..............................................147
MEDIHONEY ..............................93
MEDI-LANCE ..............................86
MEDISENSE THIN LANCETS ....86
MEDLANCE PLUS ......................86
MEDROL ...................................111
medroxyprogesterone acetate...114
MEDSAVER ................................89
mefenamic acid ............................ 5
mefloquine hcl .............................40
MEFOXIN ....................................14
MEGACE ..................................114
MEGACE ES .............................114
megestrol acetate................18, 114
MEKINIST ...................................19
meloxicam .................................... 5
melphalan hcl ..............................23
memantine hcl .............................28
MEMBRANEBLUE ....................129
MENACTRA ..............................119
M-END MAX D ............................70
MENEST ...................................110
MENHIBRIX ..............................119
MENOMUNE-A-C-Y-W-135 ......119
MENOPUR ................................112
MENOSTAR ..............................110
MENTAX .....................................33
MENVEO A-C-Y-W-135-DIP .....119
MENVEO MENA COMPONENT
..............................................119
MENVEO MENCYW-135
COMPONENT .......................119
meperidine hcl .......................1, 2, 3
meperidine hcl/pf .......................... 3
MEPHYTON ............................. 144
mepivacaine hcl/pf ........................ 8
meprobamate ........................... 122
MEPRON .................................... 40
mercaptopurine........................... 18
meropenem ................................ 15
MERREM ................................... 15
mesalamine .............................. 119
mesna....................................... 126
MESNEX .......................... 124, 126
MESTINON............................... 123
METADATE CD .......................... 65
METANX .................................. 147
metaproterenol sulfate .............. 136
METASTRON ........................... 130
metaxalone ............................... 138
metformin hcl ........................ 30, 31
meth/meblue/sod phos/psal/hyos
........................................ 11, 107
methadone hcl .......................... 1, 4
METHADOSE ............................... 2
methamphetamine hcl ................ 65
METHAVER.............................. 145
methazolamide ......................... 129
methen/m-blue/sal/na phos/hyos12,
107
methen/sod phos/meth blue/hyos11
methenam/me blue/ba/salicy/hyo
.............................................. 108
methenamine hippurate .............. 11
methenamine mandelate ............ 11
METHERGINE.......................... 128
methimazole ............................. 114
METHITEST ............................. 109
methocarbamol ................. 138, 139
methotrexate sodium ............ 18, 23
methotrexate sodium/pf .............. 23
methoxsalen, rapid ..................... 72
methscopolamine bromide........ 104
methyclothiazide ......................... 61
methyldopa ................................. 54
methyldopa/hydrochlorothiazide . 54
methyldopate hcl ........................ 54
methylene blue ......................... 126
methylergonovine maleate 122, 126
METHYLIN ................................. 65
methylphenidate hcl.................... 65
methylprednisolone................... 111
methylprednisolone acetate ...... 111
methylprednisolone sod succ ... 111
methyltestosterone ................... 109
methyltetrahydrofolate glucosa . 147
metipranolol .............................. 129
metoclopramide hcl... 104, 105, 106
metolazone ................................. 61
metoprolol succinate ................... 57
metoprolol tartrate................. 57, 58
metoprolol/hydrochlorothiazide ... 57
METOZOLV ODT ..................... 106
METROCREAM .......................... 76
METROGEL ............................... 76
METROGEL-VAGINAL ............... 36
METROLOTION ......................... 76
metronidazole ................. 11, 36, 75
metronidazole/sodium chloride ... 12
MEVACOR ................................. 63
mexiletine hcl .............................. 56
MIACALCIN .............................. 121
MICARDIS .................................. 55
MICARDIS HCT .......................... 55
miconazole nitrate....................... 33
MICRHOGAM ULTRA-FILTERED
PLUS..................................... 117
MICRO........................................ 93
MICRO AIR................................. 82
MICRO ELITE ............................. 82
MICRO ELITE REPLACEMENT
FILTER.................................... 82
MICRO PLUS ............................. 82
MICRO THIN LANCETS ............. 86
MICROCHAMBER ...................... 82
MICRODOT ................................ 93
MICROGESTIN 24 FE ................ 69
MICROLET ................................. 86
MICROLET 2 .............................. 86
MICROLIFE PEAK FLOW .......... 83
MICROSPACER ......................... 83
MICROZIDE ............................... 61
midazolam hcl ............................. 10
midazolam hcl in 0.9 % nacl ....... 10
midazolam hcl in 0.9 % nacl/pf ... 10
midazolam hcl/pf ......................... 10
midodrine hcl .............................. 54
MIFEPREX ................................. 30
MIGERGOT ................................37
miglitol .........................................30
MIGRANAL .................................37
MILLIPRED ...............................111
MILLIPRED DP .........................111
milrinone lactate ..........................60
milrinone lactate/d5w ..................60
MINASTRIN 24 FE ......................68
mineral oil ..................................123
MINERAL OIL ...........................123
MINI ELITE FILTER
REPLACEMENT......................83
MINI PLUS NEBULIZER .............83
MINICOMP COMPRESSOR
NEBULIZER ............................83
MINIELITE ..................................83
MINIPRESS ................................54
MINIVELLE ...............................110
MINI-WRIGHT PEAK FLOW
METER ....................................83
MINOCIN ....................................17
minocycline hcl ......................17, 18
minoxidil ......................................64
MIOCHOL-E ..............................130
MIOSTAT ..................................130
MIRAPEX ....................................41
MIRAPEX ER ..............................41
MIRCETTE ..................................68
MIRENA ......................................68
mirtazapine .................................28
MIRVASO ...................................73
misoprostol ................................103
MISTASSIST ...............................83
MITIGARE .................................128
mitomycin ....................................23
MITOSOL ..................................130
mitoxantrone hcl ..........................23
M-M-R II VACCINE ...................119
MOBIC ......................................... 6
modafinil ....................................139
MODERIBA .................................46
MODICON ...................................68
moexipril hcl ................................55
moexipril/hydrochlorothiazide ......55
molindone hcl ..............................41
molybdenum(ammonium
molybdate) .............................132
mometasone furoate........... 77, 102
MOMEXIN .................................. 79
MONAGHAN Z STAT ................. 83
MONDOXYNE NL ...................... 18
MONOCLATE-P ......................... 49
MONODOX........................... 17, 18
MONOJECT PREFILL ADVANCED
................................................ 47
MONOJECT SYRINGE .............. 89
MONOLET LANCETS ................ 86
MONOLET THIN LANCETS ....... 86
MONONINE ................................ 49
MONSEL'S ............................... 123
montelukast sodium .................. 135
MONUROL ................................. 11
MORGIDOX................................ 18
morphine sulfate ................... 1, 2, 4
MORPHINE SULFATE ................. 2
morphine sulfate in 0.9 % nacl...... 4
morphine sulfate/d5w/pf ............... 4
morphine sulfate/pf ....................... 4
MOTOFEN................................ 105
MOUTHPIECE............................ 83
MOVANTIK ............................... 105
MOVIPREP............................... 106
MOXATAG.................................. 16
MOXEZA .................................. 101
moxifloxacin hcl .......................... 16
moxifloxacin/sod.ace,sul/water ... 12
MOZOBIL ................................... 47
MS CONTIN ................................. 2
MUGARD ................................... 80
MULTAQ .................................... 56
MULTICHEW ............................ 145
multivit, iron, min #5, fa ............. 145
multivit, min cmb#20/iron/fa ...... 142
multivitamin with minerals ......... 145
multivitamin-minerals no.7/fa .... 142
multivit-min/fa/lycopen/lutein..... 143
mupirocin .................................... 75
mupirocin calcium ....................... 75
MUSE ....................................... 141
MUSTARGEN............................. 23
mv, min cmb#43/lut/om3/dha/epa
.............................................. 147
mv,min #10/fa/d3/alip acid/lut ... 143
MY MDI PORTABLE NEBULISER
................................................ 83
MYALEPT ................................. 128
MYAMBUTOL ............................. 38
MYCAMINE ................................ 34
MYCOBUTIN .............................. 38
mycophenolate mofetil .............. 115
mycophenolate sodium ............. 115
MYDRIACYL ............................... 99
MYFORTIC ............................... 115
MYGLUCOHEALTH ................... 93
MYGLUCOHEALTH LANCETS .. 86
MYLERAN .................................. 18
MYOBLOC ................................ 126
MYOZYME ................................. 97
MYRBETRIQ ............................ 107
MYSOLINE ................................. 27
NABI-HB ................................... 117
nabumetone .................................. 5
nadolol ........................................ 57
nadolol/bendroflumethiazide ....... 57
nafcillin in dextrose,iso-osm ........ 16
nafcillin sodium ........................... 16
naftifine hcl ................................. 33
NAFTIN....................................... 34
NAGLAZYME ............................. 97
nalbuphine hcl .............................. 4
NALFON ....................................... 5
naloxone hcl ................................. 9
naltrexone hcl ............................... 8
NAMENDA .................................. 28
NAMENDA XR ............................ 28
NAMZARIC ................................. 28
naphazoline hcl ........................... 98
NAPRELAN .................................. 6
NAPRO ....................................... 79
NAPRODERM .............................. 6
NAPROSYN ................................. 6
naproxen....................................... 5
naproxen sodium .......................... 5
naratriptan hcl ............................. 36
NARCAN ...................................... 9
NARDIL ...................................... 29
NAROPIN ..................................... 8
NASACORT AQ........................ 102
NASCOBAL .............................. 145
NASONEB NASAL NEBULIZER 93
NASONEX ................................102
NATACYN .................................100
NATAZIA .....................................68
nateglinide ...................................30
NATRECOR ................................60
NATROBA ...................................80
NAVELBINE ................................23
NEBUPENT ................................40
NEBUSAL .................................137
NEEDLE ......................................89
NEEDLES ...................................89
nefazodone hcl ............................28
NEMBUTAL SODIUM ...............140
neo/polymyx b sulf/dexameth ....100
NEOBENZ MICRO ......................75
neomycin su/baci zn/poly/hc .....100
neomycin su/bacitra/polymyxin .100
neomycin su/polymyx b sulf ........75
neomycin sulfate .........................10
neomycin/polymyxin b sulf/hc....100
neomycin/polymyxn b/gramicidin
..............................................100
NEOPROFEN .............................. 6
NEORAL ...................................115
NEOSPORIN.............................101
NEOSPORIN G.U. IRRIGANT ....76
NEOSTIGMINE METHYLSULFATE
NEO-SYNALAR ..........................76
NEO-SYNEPHRINE ....................54
NEPHRAMINE ............................53
NEPHROCAPS .........................143
NEPHROCAPS QT ...................145
NEPHRONEX-SL ......................145
NEPTAZANE.............................130
NESACAINE ................................ 8
NESACAINE-MPF........................ 8
NESINA .......................................31
NESSI SPACER..........................83
NEUAC .......................................76
NEULASTA .................................47
NEUMEGA ..................................47
NEUPOGEN................................47
NEUPRO .....................................41
NEURONTIN ...............................27
NEUT ........................................133
NEUTEK 2TEK TEST STRIPS....94
NEUTRASAL...............................70
NEVANAC ................................ 102
nevirapine ............................. 43, 44
NEXAVAR .................................. 19
NEXAVIR .................................. 126
NEXIUM ........................... 103, 104
NEXIUM I.V. ............................. 104
NEXPLANON ............................. 68
NEXTERONE ............................. 57
niacin .......................................... 62
NIASPAN .................................... 63
NICADAN ................................. 146
nicardipine hcl....................... 60, 61
nicardipine hcl in 0.9% nacl ........ 61
NICAZEL .................................. 123
NICAZEL FORTE ..................... 123
NICODERM CQ............................ 9
NICOMIDE................................ 146
NICORETTE ................................. 9
nicotine ......................................... 9
NICOTINE PATCH ....................... 9
nicotine polacrilex ......................... 9
NICOTROL ................................... 9
NICOTROL NS ............................. 9
nifedipine .................................... 60
NILANDRON .............................. 19
nilutamide ................................... 18
NIMBEX .................................... 139
126
nimodipine .................................. 60
NINLARO ................................... 19
NIPENT ...................................... 23
nisoldipine .................................. 60
NITHIODOTE ........................... 126
NITRO-BID ................................. 64
NITRO-DUR ............................... 64
nitrofurantoin............................... 11
nitrofurantoin macrocrystal ......... 11
nitrofurantoin monohyd/m-cryst .. 11
nitroglycerin ................................ 64
nitroglycerin/d5w......................... 64
NITROLINGUAL ......................... 64
NITROMIST ................................ 64
NITRONAL ................................. 64
NITROPRESS ............................ 60
NITROSTAT ............................... 64
NIVATOPIC PLUS ...................... 73
nizatidine .................................. 103
NIZORAL .................................... 34
NOKOR ADMIX NEEDLE ........... 89
NORCO ........................................ 2
NORDITROPIN FLEXPRO ....... 112
norelgestromin/ethin.estradiol ..... 67
norepinephrine bitartrate............. 60
noreth-ethinyl estradiol/iron ........ 67
norethindrone ............................. 67
norethindrone acetate ............... 114
norethindrone ac-eth estradiol ... 67,
109
norethindrone-e.estradiol-iron ..... 67
norethindrone-ethinyl estrad ....... 67
norethindrone-mestranol............. 67
norgestimate-ethinyl estradiol ..... 67
norgestrel-ethinyl estradiol.......... 67
NORINYL 1+50........................... 68
NORITATE ................................. 75
NORMOSOL-M AND DEXTROSE
.............................................. 133
NORMOSOL-R ......................... 133
NORMOSOL-R AND DEXTROSE
.............................................. 133
NOROXIN ................................... 16
NORPACE .................................. 56
NORPACE CR ............................ 56
NORPRAMIN .............................. 29
NOR-Q-D .................................... 68
NORTHERA ............................... 54
nortriptyline hcl ........................... 28
NORVASC .................................. 60
NORVIR...................................... 44
NOSE CLIP ................................ 83
NOVA MAX BLOOD GLUCOSE
METER ................................... 94
NOVA MAX GLUCOSE TEST
STRIPS ................................... 94
NOVA SAFETY LANCETS ......... 86
NOVA SUREFLEX...................... 86
NOVACORT ............................... 78
NOVAFERRUM ........................ 144
NOVAREL ................................ 112
NOVOEIGHT .............................. 49
NOVOLIN 70-30 ......................... 32
NOVOLIN N ................................ 32
NOVOLIN R ................................ 32
NOVOLOG ................................. 32
NOVOLOG FLEXPEN ................ 32
NOVOLOG MIX 70-30 ................32
NOVOLOG MIX 70-30 FLEXPEN
................................................32
NOVOSEVEN RT........................49
NOXAFIL ...............................33, 34
NPLATE ....................................126
NUCALA ...................................138
NUCORT .....................................78
NUCYNTA .................................... 2
NUCYNTA ER .............................. 2
NUEDEXTA ................................66
NULEV ......................................104
NULYTELY WITH FLAVOR
PACKS ..................................106
NUMOISYN .................................80
NUOX..........................................73
NUPLAZID ..................................42
NUTRESTORE .........................105
NUTRICAP ................................146
NUTRILIPID ................................53
NUTRILYTE ..............................133
NUTRILYTE II ...........................133
NUTRIVIT .................................146
NUTROPIN AQ .........................112
NUTROPIN AQ NUSPIN ...........112
NUVAIL .......................................94
NUVARING .................................68
NUVIGIL ....................................140
NUWIQ........................................49
nystatin........................................33
NYSTATIN ..................................33
nystatin/triamcin ..........................33
OASIS ULTRA ............................80
OBIZUR ......................................49
OCTAGAM ................................117
OCTAPLAS .................................51
OCTREOSCAN .........................138
octreotide acetate......................113
OCUCOAT ..................................99
OCUDOX ....................................17
OCUFEN ...................................102
OCUFLOX .................................101
ODOMZO ....................................25
OFEV ........................................137
OFIRMEV ..................................... 4
ofloxacin ..............................16, 100
olanzapine .............................41, 43
olanzapine/fluoxetine hcl ............ 30
OLEPTRO ER ............................ 30
olopatadine hcl ........................... 98
OLUX.......................................... 78
OLYSIO ...................................... 45
om-3/calcium/d3/fa/mv cmb 13 . 147
om-3/dha/epa/b12/fa/b6/phytost143
om-3/dha/epa/d3/b12/fa/b-6/phy
.............................................. 147
omega-3 acid ethyl esters........... 63
omeprazole ............................... 103
omeprazole/sodium bicarbonate
.............................................. 104
OMNARIS ................................. 102
OMNIPRED .............................. 102
OMNITROPE ............................ 113
OMONTYS ................................. 47
ON CALL EXPRESS METER ..... 94
ON CALL EXPRESS TEST STRIP
................................................ 94
ON CALL LANCET ..................... 86
ON CALL PLUS LANCET ........... 86
ON CALL PLUS METER ............ 94
ON CALL PLUS TEST STRIP .... 94
ON CALL VIVID METER ............ 94
ON CALL VIVID PAL .................. 94
ON CALL VIVID TEST STRIP .... 94
ONCASPAR ............................... 23
ondansetron................................ 39
ondansetron hcl .......................... 39
ondansetron hcl/pf ...................... 39
ONE FLOW FVC ........................ 83
ONE TOUCH DELICA ................ 86
ONE WAY MOUTHPIECE .......... 83
ONETOUCH DELICA ................. 86
ONETOUCH FINEPOINT
LANCETS ............................... 86
ONETOUCH LANCETS.............. 86
ONETOUCH SURESOFT........... 86
ONETOUCH ULTRA CONTROL
SOLN ...................................... 87
ONETOUCH ULTRA SMART ..... 87
ONETOUCH ULTRA SYSTEM... 87
ONETOUCH ULTRA TEST
STRIPS ................................... 87
ONETOUCH ULTRA2 ................ 87
ONETOUCH ULTRALINK .......... 87
ONETOUCH ULTRAMINI ........... 87
ONETOUCH VERIO ................... 87
ONETOUCH VERIO FLEX ......... 87
ONETOUCH VERIO IQ .............. 87
ONETOUCH VERIO SYNC ........ 87
ONFI ..................................... 10, 77
ONGLYZA .................................. 31
ONMEL ....................................... 34
ON-THE-GO ............................... 87
ONZETRA XSAIL ....................... 37
OPANA ..................................... 2, 4
OPANA ER ................................... 2
OPDIVO...................................... 23
opium tincture ........................... 104
opium/belladonna alkaloids .......... 2
OPSUMIT ................................. 141
OPTICHAMBER ......................... 83
OPTICHAMBER DIAMOND........ 83
OPTIONHOME ........................... 83
OPTIUM...................................... 94
OPTIUM EZ ................................ 94
OPTIVAR .................................... 99
OPTUMRX .................................. 94
ORACEA .................................... 17
ORACIT .................................... 131
ORAFATE ................................. 128
ORALAIR .................................. 123
ORAP ......................................... 42
ORAPRED ................................ 111
ORAPRED ODT ....................... 111
ORENCIA ......................... 116, 117
ORENCIA CLICKJECT ............. 124
ORENITRAM ER ...................... 141
ORFADIN ................................... 97
orphenadrine citrate .......... 138, 139
orphenadrine/aspirin/caffeine ... 138
ORTHO ALL-FLEX ..................... 68
ORTHO EVRA ............................ 68
ORTHO MICRONOR .................. 68
ORTHO TRI-CYCLEN ................ 68
ORTHO TRI-CYCLEN LO .......... 68
ORTHO-CEPT ............................ 68
ORTHO-CYCLEN ....................... 68
ORTHO-NOVUM ........................ 68
ORTHOVISC ............................ 128
OSENI ........................................ 31
OSMITROL ................................. 62
OSMOPREP .............................106
OSPHENA ................................110
OTEZLA ....................................128
OTICIN HC ................................102
OTOZIN ....................................101
OTREXUP .................................128
Outpatient Formulary Guidelines... I
OVACE PLUS .......................73, 76
OVACE PLUS WASH .................73
OVCON-35 ..................................68
OVIDE .........................................79
OVIDREL ..................................113
oxacillin sodium ...........................16
oxacillin sodium/dextrose,iso.......16
oxaliplatin ....................................24
OXANDRIN ...............................109
oxandrolone ..............................108
oxaprozin ..................................... 5
oxazepam ...................................10
oxcarbazepine .............................26
OXECTA ...................................... 4
oxiconazole nitrate ......................33
OXISTAT .....................................34
OXSORALEN ..............................73
OXSORALEN-ULTRA .................73
OXTELLAR XR ...........................28
oxybutynin chloride ...................107
OXYCEL .....................................48
oxycodone hcl ...........................1, 2
oxycodone hcl/acetaminophen ..1, 2
oxycodone hcl/aspirin ................... 1
OXYCONTIN ................................ 2
oxymorphone hcl .......................... 1
OXYTOCIN ...............................126
OXYTROL .................................107
OZURDEX ..................................99
paclitaxel .....................................24
PACNEX .....................................73
PACNEX HP ...............................75
PACNEX LP ................................75
PACNEX MX ...............................73
PALGIC .......................................35
paliperidone ................................43
PAMELOR ..................................29
pamidronate disodium ...............122
PAMINE ....................................105
PAMINE FORTE .......................105
PAMINE FQ ................................ 25
PANCREAZE.............................. 97
pancuronium bromide ............... 139
PANDA MASK ............................ 83
PANDEL ..................................... 78
PANHEMATIN .......................... 126
PANRETIN ................................. 73
pantoprazole sodium ........ 103, 104
papaverine hcl ...................... 59, 60
PARAFON FORTE DSC........... 138
PARAGARD T 380-A .................. 69
PARCOPA .................................. 41
paregoric .................................. 105
PARI SINUS AEROSOL SYSTEM
................................................ 83
paricalcitol ................................ 121
PARICALCITOL........................ 122
PARLODEL ................................ 41
PARNATE................................... 29
paromomycin sulfate .................. 40
paroxetine hcl ....................... 28, 30
PASER ....................................... 38
PATADAY ................................... 98
PATANASE ................................ 99
PATANOL ................................... 99
PAXIL ......................................... 29
PAXIL CR ................................... 30
PCE ............................................ 14
PEAK-AIR ................................... 83
pedi m.vit no.17 with fluoride .... 143
PEDIADERM AF......................... 34
PEDIADERM HC ........................ 79
PEDIADERM TA......................... 78
PEDIAPRED ............................. 111
PEDIARIX ................................. 119
PEDIATRIC AEROSOL MASK ... 83
PEDIATRIC MASK ..................... 83
PEDIATRIC PANDA MASK ........ 83
PEDIPIROX-4 ............................. 34
PEDVAXHIB ............................. 119
peg 3350/na sulf,bicarb,cl/kcl ... 106
PEGANONE ............................... 26
PEGASYS .................................. 45
PEGASYS PROCLICK ............... 45
PEGINTRON .............................. 45
PEGINTRON REDIPEN ............. 45
pen g pot/dextrose-water ............ 16
pen needle, diabetic.................... 87
penicillin g potassium.................. 16
penicillin g procaine .................... 16
penicillin g sodium ...................... 16
penicillin v potassium .................. 15
PENLAC ..................................... 34
PENLET PLUS BLOOD SAMPLER
................................................ 87
PENNSAID ................................... 6
PENTACEL ............................... 119
PENTAM 300 .............................. 40
PENTASA ................................. 120
pentazocine hcl/naloxone hcl ........ 1
pentostatin .................................. 24
pentoxifylline ............................... 50
PEPCID .................................... 103
p-ephed hcl/chlor-mal/bell alk ..... 35
p-ephed hcl/cod/chlorphenir ....... 69
p-ephed hcl/codeine/guaifen ....... 69
PERCOCET .................................. 2
PERCODAN ................................. 2
PERCURA ................................ 128
PERFOROMIST ....................... 136
PERIDEX .................................... 70
PERIKABIVEN ............................ 53
perindopril erbumine ................... 55
periton. dialysis #7-dex 2.5 % ... 121
periton.dialysis #8-dex 4.25 % .. 121
PERJETA ................................... 24
permethrin .................................. 79
perphenazine .............................. 41
perphenazine/amitriptyline hcl .... 29
PERSANTINE ............................. 50
PERSONAL BEST ...................... 83
PERTZYE ................................... 97
PEXEVA ..................................... 30
PFLEX TRAINER........................ 83
PHARMACIST CHOICE ............. 94
phenazopyridine hcl .................. 108
phenelzine sulfate ....................... 28
PHENERGAN ............................. 39
PHENFLU CD ............................. 70
PHENFLU CDX .......................... 70
phenobarb/hyoscy/atropine/scop 25
phenobarbital .............................. 26
phenobarbital sodium ................. 27
PHENOL ..................................... 72
phenoxybenzamine hcl ...............54
phentermine hcl...........................66
phentolamine mesylate .............140
phenylephrine hcl ..................54, 98
phenylephrine hcl/prometh hcl ....35
PHENYTEK .................................27
phenytoin ....................................26
phenytoin sodium ........................27
phenytoin sodium extended ........26
PHOSLO ...................................106
PHOSLYRA ..............................106
PHOSPHASAL ............................11
PHOSPHOLINE IODIDE ...........129
phosphorus #1 ..........................131
PHOTOFRIN ...............................24
PHOXILLUM .............................133
PHYSICIANS EZ USE M-PRED126
PHYSIOLYTE............................120
PHYSIOSOL .............................120
physostigmine salicylate ...........126
phytonadione ............................147
PICATO.......................................72
PIKO 1 ........................................83
PILLOW MASK ...........................83
PILLOW MASK FOR CHILDREN83
pilocarpine hcl .....................70, 129
pimozide ......................................42
pindolol........................................57
pioglitazone hcl ...........................30
pioglitazone hcl/glimepiride .........31
pioglitazone hcl/metformin hcl .....30
piperacillin sodium/tazobactam ...16
piroxicam ...................................... 5
PITOCIN ...................................127
PITRESSIN ...............................113
PLAN B ONE-STEP ....................68
PLAQUENIL ................................40
PLASBUMIN-25 ..........................51
PLASBUMIN-5 ............................51
PLASMA-LYTE 148 ..................133
PLASMA-LYTE 56 IN DEXTROSE
..............................................133
PLASMA-LYTE A PH 7.4 ..........133
PLASMANATE ............................51
PLAVIX .......................................50
PLEGISOL ................................131
PLEGRIDY ................................124
PLEGRIDY PEN ....................... 124
PLETAL ...................................... 50
PLEXION .................................... 75
PLIAGLIS ..................................... 7
PNEUMOVAX 23...................... 119
pnv no.118/iron fumarate/fa ...... 146
pnv with ca,no.72/iron/fa ........... 143
pnv#71/iron/folic acid/dha ......... 146
pnv#79/iron/fa/lmfolate ca/dha.. 146
pnv95/ferrous fumarate/fa......... 143
POCKET CHAMBER .................. 83
POCKET PEAK .......................... 83
PODIAPN ................................. 148
podofilox ..................................... 71
podophyllum resin ...................... 73
POLY HIST DHC ........................ 35
POLY HIST NC........................... 70
polyethylene glycol 3350 .......... 106
polymyxin b sulf/trimethoprim ... 100
polymyxin b sulfate ..................... 12
POLYMYXIN B SULFATE .......... 11
POLYTRIM ............................... 101
POLY-TUSSIN DHC ................... 70
POLY-TUSSIN EX ...................... 70
POMALYST ................................ 19
PONSTEL ..................................... 6
PONTOCAINE .......................... 7, 8
PORTRAZZA .............................. 25
pot chloride/pot bicarb/cit ac ..... 131
POTABA ................................... 123
potassium acetate .................... 133
potassium bicarbonate/cit ac .... 131
potassium chloride............ 131, 133
potassium chloride in 0.9%nacl 133
potassium chloride in d5w ........ 133
potassium chloride in lr-d5 ........ 133
potassium chloride/d5-0.2%nacl133
potassium chloride/d5-0.3%nacl133
potassium chloride/d5-0.45nacl 133
potassium chloride/d5-0.9%nacl133
potassium chloride-0.45% nacl . 133
potassium citrate ...................... 131
potassium citrate/citric acid....... 131
potassium iodide....................... 114
potassium iodide/iodine ............ 114
potassium phos,m-basic-d-basic
.............................................. 133
POTIGA ...................................... 26
PRADAXA .................................. 46
PRALIDOXIME CHLORIDE ...... 127
PRALUENT PEN ........................ 63
PRALUENT SYRINGE ............... 63
PRAMCORT ............................... 77
pramipexole di-hcl................. 40, 41
PRAMOSONE ............................ 78
PRAMOSONE E ......................... 78
PRANDIMET .............................. 31
PRANDIN ................................... 31
PRAVACHOL ............................. 63
pravastatin sodium...................... 62
PRAXBIND ................................. 49
prazosin hcl ................................ 54
PRECEDEX .............................. 140
PRECISION PCX........................ 94
PRECISION PCX PLUS ............. 94
PRECISION POINT OF CARE ... 94
PRECISION Q-I-D ...................... 94
PRECISION XTRA ..................... 94
PRECISIONGLIDE ..................... 89
PRECOSE .................................. 31
PRED FORTE........................... 103
PRED MILD .............................. 102
PRED-G.................................... 100
prednicarbate .............................. 77
prednisolone acetate ................ 101
prednisolone sod phosphate .... 102,
111
prednisone ................................ 111
PREDNISONE INTENSOL ....... 111
PREFEST ................................. 110
PREFLIN .................................. 128
PREGNYL ................................ 113
PREMARIN ............................... 110
PREMASOL ................................ 53
PREMIUM BLOOD GLUCOSE ... 94
PREMIUM BLOOD GLUCOSE
TEST ....................................... 94
PREMIUM V10 ........................... 94
PREMPHASE ........................... 110
PREMPRO ............................... 110
prenatal #48/iron cb,glu/fa/b6 ... 146
PRENATAL 19 .......................... 146
prenatal vit calc,iron,folic .......... 143
prenatal vit no.130/iron/fa ......... 143
prenatal vit no.131/iron/fa..........143
prenatal vit#96/ferrous fum/fa....143
prenatal vit/iron fumarate/fa.......143
PREPIDIL ..................................123
PREPOPIK ................................106
PRESSURE ACTIVATED
LANCETS ................................87
PRESTO PRO.............................94
PREVACID ................................103
PREVIDENT................................71
PREVIDENT 5000 SENSITIVE ...71
PREVNAR 13 ............................119
PREVPAC .................................103
PREZCOBIX ...............................44
PREZISTA ..................................44
PRIALT ........................................ 4
PRIFTIN ......................................38
PRILOSEC ................................103
PRIMAQUINE .............................40
PRIMAXIN ...................................15
PRIMEAIRE ................................83
primidone ....................................26
PRIMLEV ..................................... 4
PRIMSOL ....................................11
PRINIVIL .....................................56
PRISMASOL .....................133, 134
PRISTIQ ER ................................30
PRIVIGEN .................................117
PRO COMFORT LANCETS ........87
PRO DNA MEDICATED
COLLECTION .......................... 8
PROAIR HFA ............................136
PROAIR RESPICLICK ..............136
PROBARIMIN QT .....................148
probenecid ................................122
procainamide hcl .........................57
PROCALAMINE ..........................53
PROCARDIA ...............................60
PROCARDIA XL .........................60
PROCENTRA..............................65
PROCHAMBER ..........................83
prochlorperazine .........................39
prochlorperazine edisylate ..........39
prochlorperazine maleate ............39
PRO-CLEAR CAPS ....................70
PROCORT ..................................78
PROCRIT ....................................47
PROCTOCORT .......................... 78
PROCTOFOAM-HC ................... 78
PROCYSBI ............................... 128
PRODIGY ................................... 94
PRODIGY AUTOCODE .............. 94
PRODIGY AUTOCODE PRO ..... 94
PRODIGY LANCETS ................. 87
PRODIGY MINI-MIST ................. 83
PRODIGY NO CODING ............. 94
PRODIGY POCKET ................... 94
PRODIGY POCKET PRO........... 94
PRODIGY TWIST TOP LANCET 87
PRODIGY VOICE ....................... 94
PRODIGY VOICE PRO .............. 94
PRODRIN ................................... 37
PROFERRIN-FORTE ............... 144
PROFILNINE .............................. 49
progesterone ............................ 114
progesterone,micronized .......... 114
PROGLYCEM............................. 64
PROGRAF ........................ 115, 117
PROLASTIN C.......................... 138
PROLENSA .............................. 103
PROLEUKIN ............................... 24
PROLIA .................................... 122
PROMACTA ............................... 47
promethazine hcl .................. 35, 39
promethazine hcl/codeine ........... 69
promethazine/dextromethorphan 69
promethazine/phenyleph/codeine69
PROMETRIUM ......................... 114
PROMISEB................................. 80
PRONEB ULTRA........................ 83
PRONEB ULTRA II..................... 83
propafenone hcl .......................... 56
propantheline bromide ................ 25
proparacaine hcl ................... 98, 99
PROPECIA ............................... 129
propofol .................................... 107
propofol/pf ................................ 107
propranolol hcl ...................... 57, 58
propranolol/hydrochlorothiazid.... 57
propylthiouracil ......................... 114
PROQUAD ............................... 119
PROSCAR ................................ 123
PROSOL .................................... 53
PROSTASCINT ........................ 127
PROSTIN E2 VAGINAL
SUPPOSITORY .................... 123
PROSTIN VR PEDIATRIC ........ 141
protamine sulfate ........................ 49
PROTECT CARDIO.................. 148
protect cmb2/ceramide 1,3,6-11 . 73
PROTECT IRON....................... 146
PROTECT PLUS ........................ 51
PROTEOLIN ............................. 129
PROTHELIAL ........................... 129
PROTONIX ............................... 103
PROTONIX IV .......................... 104
PROTOPAM CHLORIDE .......... 127
PROTOPIC ................................. 78
protriptyline hcl ........................... 28
PROVENGE ............................. 127
PROVENTIL HFA ..................... 137
PROVERA ................................ 114
PROVIGIL................................. 139
PROVISC ................................. 127
PROZAC..................................... 29
PROZAC WEEKLY ..................... 30
PRUDOXIN ................................. 73
PSORCON ................................. 78
PULMICORT ............................ 135
PULMICORT FLEXHALER ....... 135
PULMO-AIDE ............................. 83
PULMONEB LT COMPRESSOR
NEBUL .................................... 83
PULMOSAL .............................. 137
PULMOZYME ............................. 97
PUREVIT DUALFE PLUS ......... 146
PURINETHOL ............................ 19
PUSH BUTTON SAFETY
LANCETS ............................... 87
PYLERA ................................... 105
pyrazinamide .............................. 38
PYRIDIUM ................................ 108
pyridostigmine bromide............. 122
pyridoxine hcl ............................ 147
PYROGALLIC ACID ................... 73
QNASL ..................................... 103
QNASL CHILDREN .................. 103
QSYMIA...................................... 66
QUADRACEL DTAP-IPV .......... 119
QUADRAMET ........................... 130
QUAKE ....................................... 83
QUALAQUIN ...............................40
QUARTETTE ..............................69
quazepam ...................................10
QUELICIN .................................139
QUESTRAN ................................63
QUESTRAN LIGHT.....................63
quetiapine fumarate ....................41
QUILLIVANT XR .........................66
quinapril hcl .................................55
quinapril/hydrochlorothiazide.......55
quinidine gluconate ...............56, 57
quinidine sulfate ..........................56
quinine sulfate .............................40
QUINTET ....................................94
QUINTET AC ..............................94
QUTENZA ...................................75
QVAR ........................................135
RABAVERT ...............................119
rabeprazole sodium...................103
RADIAPLEXRX ...........................73
RADIGEL ....................................75
RADIOGARDASE .....................124
RAGWITEK ...............................123
raloxifene hcl .............................109
ramipril ........................................55
RANEXA .....................................59
ranitidine hcl ......................103, 104
RAPAFLO .................................108
RAPAMUNE ..............................115
RASUVO ...................................129
RAVICTI ....................................106
RAYOS .....................................112
RAZADYNE ................................28
RAZADYNE ER...........................28
REA LO 39 ..................................71
REA LO 40 ..................................71
REBETOL ...................................45
REBIF .......................................124
REBIF REBIDOSE ....................124
RECLAST .................................122
RECOMBINATE ..........................49
RECOMBIVAX HB ....................119
RECOTHROM.............................48
RECTACORT-HC .......................77
RECTIV .....................................129
REFUAH PLUS ...........................94
REGENECARE ...........................73
REGIMEX ................................... 66
REGLAN ................................... 105
REGONOL................................ 127
REGRANEX ............................... 73
REGULAR BEVEL NEEDLES .... 89
RELADOR PAK ............................ 8
RELAGARD ................................ 36
RELAGESIC ................................. 4
RELAMINE ............................... 148
RELENZA ................................... 44
RELIAMED ................................. 87
RELIAMED SAFETY SEAL
LANCETS ............................... 87
RELION CONFIRM .................... 94
RELION CONFIRM-MICRO ....... 94
RELION MICRO ......................... 94
RELION PRIME .......................... 95
RELION PRIME TEST STRIPS .. 95
RELION THIN ............................. 87
RELISTOR................................ 105
RELPAX ..................................... 37
REMERON ................................. 29
REMICADE............................... 127
REMODULIN ............................ 141
RENAGEL ................................ 106
RENOVA .................................... 79
RENVELA ................................. 106
REOPRO .................................... 50
repaglinide .................................. 30
repaglinide/metformin hcl ........... 30
REPATHA PUSHTRONEX ......... 63
REPATHA SURECLICK ............. 63
REPATHA SYRINGE ................. 63
REPRONEX ............................. 113
REQ49+.................................... 146
REQUIP ...................................... 41
REQUIP XL ................................ 41
RESCRIPTOR ............................ 44
RESCULA................................. 130
RESECTISOL ........................... 120
reserpine .................................... 59
RESTASIS ................................ 102
RESTORE .......................... 95, 129
RESTORE CALCIUM ALGINATE
.............................................. 129
RESTORE CONTACT LAYER
SILVER ................................. 129
RESTORIL .................................. 10
RETAVASE ................................ 49
RETIN-A ..................................... 79
RETIN-A MICRO ........................ 79
RETISERT .................................. 99
RETROVIR ................................. 44
REUSABLE NEBULIZER KIT ..... 83
REVATIO .................................. 141
REVEAL BLOOD GLUCOSE
METER ................................... 95
REVEAL TEST STRIP ................ 95
REVIA ........................................... 9
REVLIMID................................... 19
REXULTI .................................... 43
REYATAZ ................................... 44
REZIRA ...................................... 70
REZYST ................................... 123
RHEUMATE ............................. 148
RHEUMATREX........................... 18
RHINOCORT AQUA ................. 103
RHOGAM ULTRA-FILTERED
PLUS..................................... 117
RHOPHYLAC ........................... 117
RIASTAP .................................... 49
RIBATAB .................................... 45
ribavirin ....................................... 45
RIDAURA ................................. 115
rifabutin ....................................... 38
RIFADIN ..................................... 38
RIFAMATE ................................. 38
rifampin ....................................... 38
RIFATER .................................... 38
RIGHTEST GL300 LANCETS .... 87
RIGHTEST GM100 SYSTEM ..... 95
RIGHTEST GM300 SYSTEM ..... 95
RIGHTEST GM550 SYSTEM ..... 95
RIGHTEST GS100 TEST STRIPS
................................................ 95
RIGHTEST GS300 TEST STRIPS
................................................ 95
RIGHTEST GS550 TEST STRIPS
................................................ 95
RILUTEK .................................... 65
riluzole ........................................ 65
rimantadine hcl ........................... 44
RIMSO-50................................... 74
ringers solution ................. 120, 134
RIOMET ......................................30
risedronate sodium............121, 122
RISPERDAL ................................42
RISPERDAL CONSTA ................43
RISPERDAL M-TAB....................42
risperidone ..................................42
RITALIN ......................................65
RITALIN LA .................................65
RITALIN-SR ................................65
RITEFLO .....................................84
RITUXAN ....................................24
rivastigmine .................................28
rivastigmine tartrate.....................28
RIXUBIS ......................................49
rizatriptan benzoate.....................36
ROBAXIN ..........................138, 139
ROBAXIN-750 ...........................138
ROBINUL ..........................105, 106
ROBINUL FORTE .....................105
ROCALTROL ............................121
ROCEPHIN .................................14
rocuronium bromide ..................139
ropinirole hcl ................................40
ropivacaine hcl/pf ......................... 8
ROSADAN ............................75, 76
ROSANIL ....................................71
rosuvastatin calcium....................62
ROTARIX ..................................119
ROTATEQ .................................119
ROXICODONE............................. 2
ROZEREM ................................139
RUBBER MOUTHPIECE ............84
RYTARY .....................................41
RYTHMOL ..................................56
RYTHMOL SR.............................56
SABRIL .......................................27
SAFETY LANCETS.....................87
SAFETY SEAL LANCETS ..........87
SAFETYGLIDE SYRINGE ..........89
SAFETY-LET ..............................87
SAFYRAL ....................................69
SAIZEN .....................................112
SALACYN ...................................73
SALAGEN ...................................70
SALEX ........................................73
salicylic acid ..........................71, 73
salicylic acid/ceramide cmb #1 ....71
SALKERA ................................... 73
salsalate ....................................... 5
SAMI THE SEAL ........................ 84
SAMI THE SEAL FILTER ........... 84
SAMI THE SEAL MASK ............. 84
SAMSCA .................................... 61
SANARE SCAR THERAPY BASE
.............................................. 129
SANCTURA .............................. 107
SANCTURA XR ........................ 107
SANCUSO .................................. 39
SANDIMMUNE ................. 115, 117
SANDOSTATIN ........................ 113
SANDOSTATIN LAR DEPOT ... 113
SANTYL ..................................... 73
SAPHRIS .................................... 42
SARAFEM .................................. 30
SAVAYSA ................................... 47
SAVELLA ................................... 65
SCALACORT.............................. 77
SCALACORT DK........................ 79
SCLEROSOL............................ 127
scopolamine hydrobromide......... 39
SEASONIQUE ............................ 68
SECONAL SODIUM ................. 139
SECTRAL ................................... 58
SEEBRI NEOHALER ................ 136
selegiline hcl ............................... 40
selenium ................................... 134
selenium sulfide .................... 75, 76
SELRX ........................................ 76
SELZENTRY .............................. 44
SEMPREX-D .............................. 35
SENSIPAR ............................... 123
SENSORCAINE-MPF ................... 8
SENSORCAINE-MPF
EPINEPHRINE.......................... 8
SENTRA PM............................. 129
SEREVENT DISKUS ................ 136
SEROPHENE ........................... 109
SEROQUEL................................ 42
SEROQUEL XR.......................... 42
SEROSTIM ............................... 112
sertraline hcl ............................... 28
sevelamer carbonate ................ 106
SEVEN PLUS ............................. 95
sevoflurane ............................... 107
SFROWASA ............................. 120
SHOHL'S MODIFIED ................ 131
SHORT BEVEL NEEDLES ......... 89
SIDESTREAM ............................ 84
SIDESTREAM MASK ................. 84
SIDESTREAM NEBULIZER ....... 84
SIDESTREAM PEDIATRIC ........ 84
SIDESTREAM PLUS .................. 84
SIGNIFOR ................................ 129
sildenafil citrate ................. 140, 141
SILENOR .................................... 30
SILICONE MASK ........................ 84
SILVADENE ............................... 76
SILVASORB ............................... 73
silver nitrate ................................ 76
silver sulfadiazine ....................... 75
SILVERSEAL HYDROGEL ....... 123
SILVRSTAT ................................ 73
SIMBRINZA .............................. 130
SIMCOR ..................................... 62
SIMPONI .................................. 124
SIMPONI ARIA ......................... 127
SIMULECT ............................... 127
simvastatin.................................. 62
SINEMET 10-100........................ 41
SINEMET 25-100........................ 41
SINEMET 25-250........................ 41
SINEMET CR ............................. 41
SINGLE-LET ............................... 87
SINGULAIR .............................. 136
SINUSTAR ................................. 95
sirolimus ................................... 115
SIRTURO ................................... 38
SKELAXIN ................................ 138
SKLICE ....................................... 80
SKYLA ........................................ 69
SMART SENSE .......................... 87
SMART SENSE LANCETS ........ 87
SMART SENSE MONITORING
SYSTEM ................................. 95
SMART SENSE TEST STRIPS .. 95
SMARTDIABETES VANTAGE ... 87
SMARTDIABETES XPRES ........ 95
SMARTEST EJECT .................... 95
SMARTEST LANCET ................. 87
SMARTEST PERSONA .............. 95
SMARTEST PRONTO ................ 95
SMARTEST PROTEGE ..............95
SMARTEST TEST ......................95
SMARTMASK KIDS ....................84
sod/pot/k cit/sod cit/cit acid .......131
sodium acetate ..........................134
sodium benzoate/sod phenylacet
..............................................134
sodium bicarbonate ...................134
sodium borate .............................70
sodium chloride .........................134
SODIUM CHLORIDE ................134
sodium chloride 0.45 % .............134
sodium chloride 3 % ..................134
sodium chloride 5 % ..................134
sodium chloride for inhalation....137
sodium chloride irrig solution .....120
sodium chloride/nahco3/kcl/peg 106
sodium citrate ..............................46
SODIUM DIURIL .........................62
SODIUM EDECRIN.....................62
sodium ferric gluconat/sucrose..147
sodium fluoride ............................71
sodium fluoride/potassium nit ......71
sodium glycerophosphate .........134
sodium lactate ...........................134
sodium morrhuate .....................127
sodium nitrite .............................127
sodium phenylbutyrate ..............104
sodium phos,m-basic-d-basic....134
sodium polystyrene sulfon/sorb .104
sodium polystyrene sulfonate ....104
sodium tetradecyl sulfate ..........127
sodium thiosulfate .....................108
sodium thiosulfate/sal acid ..........71
SOFT TOUCH .............................87
SOLARAZE .................................. 6
SOLIRIS ....................................129
SOLODYN ..................................18
SOLTAMOX ................................25
SOLU-CORTEF ........................112
SOLU-MEDROL ........................112
SOLUS V2 ............................87, 95
SOLUS V2 LANCETS .................87
SOLUS V2 TEST STRIPS ..........95
SOMA ...............................138, 139
SOMATULINE DEPOT .............113
SOMAVERT ..............................113
SONATA ................................... 139
SOOTHENEB COMPRESSOR
NEBULIZER ............................ 84
SOOTHENEB MESH NEBULIZER
................................................ 84
SOOTHENEB NBL100 ADULT
MASK...................................... 84
SOOTHENEB NBL100 CHILD
MASK...................................... 84
SOOTHENEB NBL100 MED CUP
................................................ 84
sorbitol solution......................... 120
SORIATANE ............................... 74
SORILUX .................................... 73
sotalol hcl ................................... 57
SOTALOL HCL ........................... 58
SOTRADECOL ......................... 127
SOVALDI .................................... 45
SPACE CHAMBER PLUS .......... 84
SPECIALTY USE NEEDLES ...... 89
SPECTRACEF ........................... 14
SPECTRAGEL ......................... 124
spinosad ..................................... 80
SPIRIVA ................................... 136
SPIRIVA RESPIMAT ................ 136
spironolact/hydrochlorothiazid .... 64
spironolactone ............................ 64
SPORANOX ......................... 33, 34
SPRITAM ................................... 28
SPRIX ........................................... 6
SPRYCEL ................................... 19
STALEVO 100 ............................ 41
STALEVO 125 ............................ 41
STALEVO 150 ............................ 41
STALEVO 200 ............................ 41
STALEVO 50 .............................. 41
STALEVO 75 .............................. 41
stannous fluoride ........................ 71
STARLIX .................................... 31
stavudine .................................... 43
STAVZOR................................... 27
STAXYN ................................... 140
STELARA ................................. 127
STENDRA ................................ 141
STERILANCE TL ........................ 87
STIMATE .................................. 112
STIOLTO RESPIMAT ................. 25
STIVARGA ................................. 19
STRATTERA .............................. 65
streptomycin sulfate .................... 11
STRIANT .................................. 109
STRIBILD ................................... 44
STRIVERDI RESPIMAT ........... 136
STROMECTOL ........................... 40
STROVITE ONE ....................... 146
SUBOXONE ................................. 9
sub-q insulin device, 40 unit ....... 87
SUBSYS ....................................... 4
SUCLEAR ................................. 106
SUCRAID ................................... 97
sucralfate .................................. 103
sufentanil citrate............................ 4
SULAR........................................ 60
sulfacetamide sod/sulfur/urea71, 73
sulfacetamide sodium .. 71, 75, 100,
101
sulfacetamide sodium/sulfur 71, 73,
75
sulfacetamide sodium/urea ......... 75
sulfacetamide/prednisolone sp . 100
sulfacetm na/avobenzone/sulfur . 71
sulfadiazine ................................. 17
sulfamethoxazole/trimethoprim ... 17
SULFAMYLON ........................... 73
sulfasalazine ............................... 17
sulindac ........................................ 5
SUMADAN .................................. 73
sumatriptan ................................. 37
sumatriptan succinate ................. 36
SUMAVEL DOSEPRO................ 38
SUMAXIN ................................... 73
SUMAXIN TS .............................. 73
SUNRISE COMPRESSORNEBULIZER ............................ 84
SUPARTZ ................................. 127
SUPARTZ FX ........................... 127
SUPER THIN LANCETS ............ 87
SUPERVITE ............................. 146
SUPERVITE EC ....................... 146
SUPPRELIN LA ........................ 113
SUPRAX ..................................... 13
SUPRENZA ODT........................ 66
SUPREP ................................... 106
SURE COMFORT LANCETS ..... 87
SURE EDGE BLOOD GLUCOSE
METER ....................................95
SURE EDGE TEST STRIPS .......95
SURECHEK TEST STRIPS ........95
SURE-LANCE .............................87
SURESTEP CONTROL
SOLUTION ..............................87
SURESTEP PRO ..................87, 88
SURE-TEST EASYPLUS MINI ...95
SURE-TOUCH ............................88
SURFAXIN ................................137
SURMONTIL ...............................29
SURVANTA ..............................137
SUSTIVA .....................................44
SUTENT ......................................19
SWABFLUSH ............................134
SYLATRON .................................45
SYLVANT ....................................24
SYMAX .....................................104
SYMAX DUOTAB......................104
SYMAX-SL ................................104
SYMBICORT .............................135
SYMBYAX ...................................30
SYMLINPEN 120 ........................30
SYMLINPEN 60 ..........................30
SYNAGEX .................................148
SYNAGIS ....................................44
SYNALAR ...................................78
SYNALAR TS ..............................78
SYNALGOS-DC ........................... 2
SYNAREL .................................123
SYNERA ...................................... 7
SYNERCID .................................12
SYNJARDY .................................30
SYNRIBO ....................................24
SYNTHROID .............................114
SYNVISC ..................................127
SYNVISC-ONE .........................127
SYPRINE ..................................108
SYRINGE ....................................89
syringe and needle,insulin,1ml ....88
SYRINGE AVITENE..................124
syringe-needle,insulin,0.5 ml .......88
syring-needl,disp,insul,0.3 ml ......88
TABLOID .....................................18
TACHOSIL ..................................48
TACLONEX .................................75
tacrolimus ........................... 77, 115
TAFINLAR .................................. 19
TAGRISSO ................................. 19
TAKE ACTION............................ 68
talc ............................................ 127
TALTZ AUTOINJECTOR ............ 74
TALTZ SYRINGE ....................... 74
TALWIN ........................................ 4
TAMIFLU .................................... 44
tamoxifen citrate ......................... 18
tamsulosin hcl ........................... 108
TANDEM PLUS ........................ 146
TANZEUM .................................. 31
TAPAZOLE ............................... 115
TARCEVA................................... 19
TARGADOX ............................... 18
TARGRETIN ......................... 19, 20
TARKA ....................................... 56
TASIGNA .................................... 19
TASMAR .................................... 41
TAXOTERE ................................ 24
TAZORAC .................................. 79
TECFIDERA ............................. 125
TECHLITE LANCETS ................. 88
TEFLARO ................................... 14
TEGADERM ............................. 128
TEGADERM + PAD .................. 128
TEGRETOL ................................ 27
TEGRETOL XR .......................... 27
TEKTURNA ................................ 64
TEKTURNA HCT ........................ 64
TELCARE ............................. 88, 95
telmisartan .................................. 55
telmisartan/amlodipine ................ 55
telmisartan/hydrochlorothiazid .... 55
temazepam ................................. 10
TEMODAR............................ 19, 24
TEMOVATE ................................ 78
temozolomide ............................. 19
TENEX ....................................... 54
teniposide ................................... 24
TENIVAC .................................. 119
TENORETIC 100 ........................ 58
TENORETIC 50 .......................... 58
TENORMIN ................................ 58
TERAZOL 3 ................................ 36
TERAZOL 7 ................................ 36
terazosin hcl ............................. 108
terbinafine hcl ............................. 33
TERBINEX .................................. 34
terbutaline sulfate ............. 136, 137
terconazole ................................. 36
TERSI FOAM .............................. 76
TERUMO SYRINGE ................... 89
TESSALON ................................ 70
TESSALON PERLE .................... 70
TEST N'GO................................. 95
TESTIM .................................... 109
TESTOPEL ............................... 109
testosterone .............................. 109
testosterone cypionate.............. 109
testosterone enanthate ............. 109
TESTRED ................................. 109
TETANUS TOXOID ADSORBED
.............................................. 119
tetanus, diphtheria tox,adult ...... 119
tetrabenazine .............................. 65
tetracaine hcl .............................. 98
tetracaine hcl/pf ............................ 8
tetracycline hcl ............................ 17
TETRAVISC FORTE .................. 98
TETRIX ....................................... 80
TEVETEN ................................... 55
TEVETEN HCT ........................... 55
TEV-TROPIN ............................ 113
TEXACORT ................................ 78
thallous chloride tl-201 ................ 54
THALLOUS CHLORIDE TL-201 . 54
THALOMID ............................... 124
THAM ....................................... 127
THEO-24 .................................. 136
theophylline anhydrous ............. 136
theophylline/d5w ....................... 137
THERACYS .............................. 119
THERAMINE ............................ 129
THERMAZENE ........................... 75
thiamine hcl .............................. 147
THIN LANCETS .......................... 88
THIN WALL NEEDLES ............... 89
THIOLA..................................... 123
thioridazine hcl ............................ 42
thiotepa ....................................... 24
thiothixene .................................. 42
THRESHOLD IMT ...................... 84
THRESHOLD PEP ......................84
THROMBATE III..........................47
thrombin (bovine) ........................48
thrombin/ca/cmc/gel/dress, hem .95
THYMOGLOBULIN ...................117
THYROGEN ..............................115
thyroid,pork ...............................114
THYROLAR-1 ...........................114
THYROLAR-1/2 ........................114
THYROLAR-1/4 ........................114
THYROLAR-2 ...........................114
THYROLAR-3 ...........................114
tiagabine hcl ................................26
TIAZAC .......................................58
ticlopidine hcl ..............................50
TIGAN .........................................39
TIKOSYN ....................................56
TIMENTIN ...................................16
timolol maleate ....................57, 129
TIMOPTIC OCUDOSE ..............130
TIMOPTIC-XE ...........................130
TINDAMAX .................................40
tinidazole .....................................40
TIROSINT .................................115
TISSEEL VHSD ..........................50
TIVICAY ......................................44
tizanidine hcl .....................138, 139
TNKASE ......................................49
TOBI............................................10
TOBI PODHALER .......................10
TOBRADEX ......................100, 101
TOBRADEX ST .........................101
tobramycin ................................100
tobramycin in 0.225% nacl ..........10
tobramycin sulfate .......................11
tobramycin/dexamethasone ......100
tobramycin/sodium chloride.........11
TOBREX ...........................100, 101
TOFRANIL ..................................29
TOFRANIL-PM ............................29
tolazamide ...................................32
tolbutamide .................................32
tolcapone ....................................41
tolmetin sodium ............................ 5
tolterodine tartrate .....................107
TOPAMAX ..................................27
TOPCARE UNIVERSAL1 LANCET
................................................ 88
TOPCARE UNIVERSAL1 THIN
LANCET .................................. 88
TOPICORT ................................. 78
topiramate .................................. 26
topotecan hcl .............................. 24
TOPROL XL ............................... 58
TORISEL .................................... 24
torsemide .............................. 61, 62
TOTECT ................................... 127
TOUJEO SOLOSTAR ................ 32
TOVIAZ .................................... 107
TOZAL ...................................... 148
TPN ELECTROLYTES II .......... 134
trace elements comb no.1 ........ 134
TRACLEER .............................. 141
TRADJENTA .............................. 30
tramadol hcl .............................. 1, 4
tramadol hcl/acetaminophen......... 1
TRANDATE ................................ 58
trandolapril .................................. 56
trandolapril/verapamil hcl ............ 56
tranexamic acid .................... 48, 49
TRANSDERM-SCOP ................. 39
TRANXENE T-TAB ..................... 10
tranylcypromine sulfate ............... 28
TRAVASOL ................................ 53
TRAVATAN Z ........................... 130
travoprost (benzalkonium) ........ 130
trazodone hcl .............................. 29
TREANDA .................................. 24
TRECATOR ................................ 38
TREK S COMBO PACK ............. 84
TREK S COMPACT
COMPRESSOR ...................... 84
TREK S PORTABLE PWR KIT... 84
TRELSTAR ................................. 24
TREPADONE ........................... 129
TRESIBA FLEXTOUCH U-100 ... 32
TRESIBA FLEXTOUCH U-200 ... 32
tretinoin ................................. 19, 79
tretinoin microspheres ................ 79
tretinoin/emollient base ............... 79
TRETIN-X ................................... 79
TREXALL ................................... 18
TREXIMET ................................. 38
TREZIX ......................................... 4
triamcinolone acetonide . 70, 77, 79,
101, 112
triamterene/hydrochlorothiazid.... 61
triazolam ..................................... 10
trichloroacetic acid ...................... 73
TRICHLOROACETIC ACID ...... 123
TRICITRASOL .......................... 123
TRICOR ...................................... 63
TRIESENCE ............................. 103
TRIFERIC ................................. 128
trifluoperazine hcl........................ 42
trifluridine .................................. 100
TRIGLIDE ................................... 63
trihexyphenidyl hcl ...................... 41
TRILEPTAL ................................ 27
TRILIPIX ..................................... 63
TRI-LUMA ................................... 75
trimethobenzamide hcl.......... 39, 40
trimethoprim ................................ 11
trimipramine maleate .................. 29
TRI-NORINYL ............................. 68
TRINTELLIX ............................... 29
TRIOSTAT ................................ 115
TRIOXIN ................................... 103
TRISENOX ................................. 24
TRIUMEQ ................................... 44
TRIZIVIR..................................... 44
TROKENDI XR ........................... 28
TROPHAMINE ...................... 53, 54
tropicamide ................................. 98
trospium chloride ...................... 107
TRUE2GO BLOOD GLUCOSE
SYSTEM ................................. 95
TRUEPLUS LANCETS ............... 88
TRUERESULT BLOOD GLUCOSE
METER ................................... 95
TRUERESULT BLOOD GLUCOSE
SYSTM.................................... 95
TRUETEST TEST STRIPS ......... 95
TRUETRACK BLOOD GLUCOSE
SYSTEM ................................. 96
TRUETRACK SMART SYSTEM. 96
TRUETRACK TEST STRIP ........ 96
TRULICITY ................................. 30
TRUMENBA ............................. 119
TRUSOPT ................................ 130
TRUVADA ...................................44
TRUZONE PEAK FLOW METER84
trypsin/balsam peru/castor oil71, 73
TUDORZA PRESSAIR ..............136
TUSNEL ......................................70
TUSNEL PEDIATRIC ..................70
TUSSICAPS ................................70
TUSSIGON .................................69
TUSSIONEX ...............................70
TWINRIX ...................................119
TWYNSTA ..................................55
TYBOST ....................................123
TYGACIL .....................................17
TYKERB ......................................20
TYLENOL-CODEINE NO.3 .......... 2
TYLENOL-CODEINE NO.4 .......... 3
TYSABRI ...................................117
TYVASO ...................................141
TYVASO REFILL KIT ................141
TYVASO STARTER KIT ...........141
TYZEKA ......................................45
TYZINE .......................................98
UCERIS ....................................120
UDAMIN SP ..............................148
ULESFIA ...................................124
ULORIC ....................................123
ULTANE ....................................107
ULTILET BASIC ..........................88
ULTILET CLASSIC .....................88
ULTILET LANCETS ....................88
ULTILET SAFETY .......................88
ULTIMA .......................................96
ULTIVA ........................................ 4
ULTRA THIN LANCETS .............88
ULTRA THIN PLUS.....................88
ULTRA THIN PLUS LANCETS ...88
ULTRACET .................................. 3
ULTRAFOAM ..............................48
ULTRALANCE ............................88
ULTRAM ...................................... 3
ULTRAM ER ................................ 3
ULTRA-THIN II ............................88
ULTRATLC LANCETS ................88
ULTRATRAK ...............................96
ULTRATRAK PRO ......................96
ULTRATRAK ULTIMATE ............96
ULTRAVATE ...............................79
ULTRAVATE PAC ...................... 79
ULTRAVATE X ........................... 79
ULTRESA ................................... 97
UMECTA .................................... 73
UNASYN .................................... 16
UNILET COMFORTOUCH ......... 88
UNILET EXCELITE .................... 88
UNILET EXCELITE II ................. 88
UNILET GP LANCET ................. 88
UNILET LANCET........................ 88
UNILET LANCETS ..................... 88
UNIRETIC................................... 56
UNISTIK 3 .................................. 88
UNISTIK 3 EXTRA ..................... 88
UNISTIK CZT ............................. 88
UNISTIK SAFETY ...................... 88
UNISTIK TOUCH........................ 88
UNISTRIP1 ................................. 96
UNITHROID.............................. 114
UNITUXIN................................... 24
UNIVASC ................................... 56
UNIVERSAL 1 ............................ 88
URAMAXIN........................... 74, 75
urea ................................ 71, 74, 75
urea/lactic ac/zn undecylenate .. 71,
74
URECHOLINE .......................... 124
URELLE ..................................... 12
URETRON D-S........................... 11
URIBEL .................................... 108
URIN D.S. ................................... 11
UROCIT-K ................................ 131
UROQID-ACID NO.2 .................. 11
UROSEX .................................. 148
UROXATRAL............................ 108
URSO ....................................... 105
URSO FORTE .......................... 105
ursodiol ..................................... 104
URYL .......................................... 11
UTIBRON NEOHALER ............. 136
UTIRA-C ..................................... 12
UTOPIC ...................................... 74
UVADEX ..................................... 74
VAGIFEM ................................. 110
valacyclovir hcl ........................... 45
VALCHLOR ................................ 74
VALCYTE ................................... 45
valganciclovir hcl......................... 45
VALIUM ...................................... 10
valproic acid................................ 26
valproic acid (as sodium salt) 26, 27
valsartan ..................................... 55
valsartan/hydrochlorothiazide ..... 55
VALSTAR ................................... 24
VALTREX ................................... 45
VANCOCIN HCL......................... 12
vancomycin hcl ..................... 11, 12
VANDAZOLE .............................. 36
VANIQA ...................................... 75
VANISHPOINT ........................... 89
VANOS ....................................... 79
VANOXIDE-HC ........................... 75
VANTAS ................................... 113
VAPRISOL-5% DEXTROSE ....... 62
VAQTA ..................................... 119
VARITHENA ............................... 64
VARIVAX VACCINE ................. 119
VASCAZEN ................................ 63
VASCEPA................................... 63
VASERETIC ............................... 56
vasopressin .............................. 113
VASOTEC .................................. 56
VAYACOG ................................ 129
VAYARIN .................................. 129
VAYAROL................................. 129
VAZCULEP ................................. 54
VECAMYL .................................. 60
VECTIBIX ................................... 24
VECTICAL .................................. 74
vecuronium bromide ................. 139
VELCADE ................................... 24
VELETRI................................... 141
VELPHORO .............................. 105
VELTIN ....................................... 76
VENELEX ................................... 74
venlafaxine hcl ...................... 29, 30
VENOFER ................................ 147
VENTAVIS ................................ 141
VENTOLIN HFA........................ 136
VERAMYST .............................. 103
verapamil hcl ........................ 58, 59
VERDESO .................................. 79
VERDROCET ............................... 1
VEREGEN .................................. 74
VERELAN ...................................58
VERELAN PM .............................58
VERIPRED 20 ...........................111
VERTIGOHEEL.........................129
VESICARE ................................107
VEXOL ......................................102
VFEND ........................................34
VFEND IV ...................................34
V-HIST ........................................35
VIAGRA ....................................140
VIASPAN BELZER-UW ............120
VIBATIV ......................................13
VIBERZI ....................................106
VIBRAMYCIN ..............................17
VICOPROFEN ............................. 3
VICTORY ....................................96
VICTOZA 3-PAK .........................30
VICTRELIS .................................45
VIDAZA .......................................24
VIDEX .........................................44
VIDEX EC ...................................44
VIEKIRA PAK ..............................45
VIEKIRA XR ................................45
VIGAMOX .................................100
VIIBRYD ......................................29
VIMOVO....................................... 6
VIMPAT.................................26, 27
vinblastine sulfate........................25
vincristine sulfate.........................25
vinorelbine tartrate ......................25
VIOKACE ....................................97
VIOS AEROSOL DELIVERY
SYSTEM..................................84
VIRACEPT ..................................44
VIRAMUNE .................................44
VIRAMUNE XR ...........................44
VIRASAL .....................................74
VIRAZOLE ..................................45
VIREAD .......................................44
VIROPTIC .................................101
VISCOAT ....................................80
VISIONBLUE.............................129
VISTARIL ..................................124
VISTIDE ......................................46
VISUDYNE ..................................99
vit a,c,e/zinc/copper/lut/zeax .....148
vit b cmplx 3/fa/vit c/biotin .........143
vit b cmplx no3/fa/c/biot/zinc ..... 143
vit b cplx #11/fa/c/biot/zn ox...... 143
vit b12/lmefolate ca/vit b6/b2 .... 148
vitamins b1,b2,b3,b5, and b6.... 147
VITA-RESPA ............................ 148
vite ac/grape/hyaluronic acid ...... 75
VITEKTA .................................... 44
VITRASE .................................... 97
VITRASERT ............................. 101
VIVACTIL ................................... 29
VIVELLE-DOT .......................... 110
VIVITROL ..................................... 9
VOCAL POINT ........................... 96
VOGELXO ................................ 109
VOLTAREN .................................. 6
VOLTAREN-XR ............................ 6
VOLUVEN ................................ 135
VORAXAZE .............................. 128
voriconazole ............................... 34
VORTEX ..................................... 84
VORTEX FROG MASK .............. 84
VORTEX LADYBUG MASK........ 84
VORTEX VHC FROG MASK ...... 84
VOSOL HC ............................... 101
VOSPIRE ER............................ 137
VOTRIENT ................................. 20
VP-PRECIP .............................. 129
VPRIV ......................................... 98
VRAYLAR ................................... 42
VSL#3 DS ................................. 106
VUSION ...................................... 34
VYTORIN ................................... 62
VYVANSE .................................. 65
warfarin sodium .......................... 46
WATCHHALER .......................... 84
water for irrigation,sterile .......... 120
WAVESENSE AMP .................... 96
WAVESENSE JAZZ ................... 96
WAVESENSE PRESTO ............. 96
WELCHOL .................................. 62
WELLBUTRIN ............................ 29
WELLBUTRIN SR ...................... 29
WELLBUTRIN XL ....................... 29
WHEAT GERM OIL .................. 144
WIDE SEAL DIAPHRAGM ......... 69
WILATE ...................................... 49
WINDMILL TRAINER ................. 84
WING TIP TUBING ..................... 84
WINRHO SDF........................... 118
WOUND MATRIX ....................... 80
XALATAN ................................. 130
XALKORI .................................... 20
XANAX ....................................... 10
XANAX XR ................................. 10
XARELTO ................................... 46
XARTEMIS XR ............................. 5
XCLAIR..................................... 124
XELJANZ .................................. 125
XELODA ..................................... 20
XENADERM ............................... 74
XENAZINE .................................. 65
XENICAL .................................. 106
XEOMIN ................................... 128
XERAC AC ................................. 74
XERESE ..................................... 75
XGEVA ..................................... 122
XIAFLEX ..................................... 98
XIFAXAN .............................. 11, 12
XIGDUO XR ............................... 31
XILAPAK..................................... 79
XODOL 10-300 ............................. 5
XODOL 5-300 ............................... 5
XODOL 7.5-300 ............................ 5
XOFIGO.................................... 130
XOLAIR .................................... 138
XOLEGEL ................................... 34
XOPENEX ................................ 137
XOPENEX HFA ........................ 137
XTANDI ...................................... 20
X-VIATE...................................... 71
XYLOCAINE ............................. 7, 8
XYLOCAINE WITH EPINEPHRINE
.................................................. 8
XYLOCAINE-MPF ........................ 8
XYLOCAINE-MPF WITH
EPINEPHRINE .......................... 8
XYNTHA ..................................... 49
XYNTHA SOLOFUSE................. 49
XYREM ..................................... 140
XYZAL ........................................ 35
YALE NEEDLES ......................... 89
YASMIN 28 ................................. 68
YAZ............................................. 68
YERVOY..................................... 25
YODOXIN ...................................40
zafirlukast ..................................135
zaleplon .....................................139
ZALTRAP ....................................25
ZAMICET ..................................... 1
ZANAFLEX ...............................138
ZANOSAR ...................................25
ZANTAC............................103, 104
ZARONTIN ..................................27
ZAROXOLYN ..............................61
ZAVESCA ...................................97
ZEBETA ......................................58
ZEGERID ..................................104
ZELAPAR ....................................41
ZELBORAF .................................20
ZEMAIRA ..................................138
ZEMPLAR .........................121, 122
ZEMURON ................................139
ZENCIA .......................................72
ZENPEP ......................................97
ZENZEDI .....................................65
ZERIT..........................................44
ZESTORETIC .............................56
ZESTRIL .....................................56
ZETIA ..........................................63
ZETONNA .................................102
ZEVALIN .....................................25
ZIAC ............................................58
ZIAGEN.......................................44
ZIANA .........................................76
zidovudine ...................................43
ZINACEF .....................................14
zinc chloride ..............................135
zinc gluconate ...........................135
zinc sulf/cuso4 p-hyd/mn/cr/se ..135
zinc sulfate ........................131, 135
zinc/copper/mangan/chromic chl
..............................................135
ZINECARD ................................128
ZIOPTAN ..................................130
ziprasidone hcl ............................42
ZIPSOR........................................ 6
ZIRGAN ....................................101
ZITHRANOL ................................74
ZITHRANOL-RR .........................74
ZITHROMAX .........................14, 15
ZITHROMAX TRI-PAK ................14
ZMAX ......................................... 15
zn/cu/mang/selen/fluor/pot iod .. 135
ZN-DTPA .................................. 108
ZOCOR ...................................... 63
ZOFRAN ............................... 39, 40
ZOFRAN ODT ............................ 39
ZOHYDRO ER.............................. 3
ZOLADEX ................................... 25
zoledronic acid.......................... 122
zoledronic acid/mannitol and water
.............................................. 122
ZOLINZA .................................... 20
zolmitriptan ................................. 36
ZOLOFT ..................................... 29
zolpidem tartrate ............... 139, 140
ZOLPIMIST............................... 140
ZOMACTON ............................. 113
ZOMETA .................................. 122
ZOMIG........................................ 38
ZOMIG ZMT ............................... 38
ZONALON .................................. 74
ZONATUSS ................................ 70
ZONEGRAN ............................... 27
zonisamide ................................. 26
ZONTIVITY ................................. 50
ZORBTIVE................................ 112
ZORTRESS .............................. 116
ZORVOLEX .................................. 6
ZOSTAVAX .............................. 119
ZOSYN ....................................... 16
ZOVIRAX ........................ 45, 72, 74
Z-TUSS AC................................. 70
Z-TUSS E ................................... 70
ZUBSOLV ..................................... 9
ZUPLENZ ................................... 40
ZUTRIPRO ................................. 70
ZYBAN ......................................... 9
ZYCLARA ................................... 75
ZYDELIG .................................... 20
ZYFLO ...................................... 136
ZYFLO CR ................................ 136
ZYKADIA .................................... 20
ZYLET ...................................... 101
ZYLOPRIM ............................... 124
ZYMAXID ................................. 101
ZYPRAM .................................... 79
ZYPREXA ............................. 42, 43
ZYPREXA RELPREVV ............... 43
ZYPREXA ZYDIS ....................... 42
ZYRTEC-D ..................................35
ZYTIGA .......................................20
ZYVOX ....................................... 12
APPENDIX A
Name
Covered Generic Contraceptives
Tier
Notes
ALTAVERA
ALYACEN
ALYACEN
AMETHIA
AMETHIA LO
APRI
ARANELLE
ASHLYNA
AUBRA
AVIANE
AZURETTE
BALZIVA
BEKYREE
BLISOVI 24 FE
BLISOVI FE
BLISOVI FE
BREVICON
BRIELLYN
CAMILA
CAMRESE
CAMRESE LO
CAZIANT
CHATEAL
CRYSELLE
CYCLAFEM
CYCLAFEM
CYRED
DASETTA
DASETTA
DAYSEE
DEBLITANE
DELYLA
DESOGESTREL-ETHINYL ESTRADIOL
DESOGESTR-ETH ESTRAD ETH ESTRA
DROSPIRENONE-ETHINYL ESTRADIOL
DROSPIRENONE-ETHINYL ESTRADIOL
ECONTRA EZ
ELINEST
EMOQUETTE
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
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
Name
Covered Generic Contraceptives
Tier
Notes
ENPRESSE
ENSKYCE
ERRIN
ESTARYLLA
FALLBACK SOLO
FALMINA
GIANVI
GILDAGIA
GILDESS
GILDESS
GILDESS 24 FE
GILDESS FE
GILDESS FE
HEATHER
INTROVALE
JENCYCLA
JOLESSA
JOLIVETTE
JULEBER
JUNEL
JUNEL
JUNEL FE
JUNEL FE
JUNEL FE 24
KARIVA
KELNOR 1-35
KIMIDESS
KURVELO
LARIN
LARIN
LARIN 24 FE
LARIN FE
LARIN FE
LARISSIA
LEENA
LESSINA
LEVONEST
LEVONORGESTREL
LEVONORGESTREL
LEVONORGESTREL
LEVONORGESTREL-ETH ESTRADIOL
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
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
Name
Covered Generic Contraceptives
Tier
Notes
LEVONORGESTREL-ETH ESTRADIOL
LEVONORGESTREL-ETH ESTRADIOL
LEVONORGESTREL-ETH ESTRADIOL
LEVONORG-ETH ESTRAD ETH ESTRAD
LEVONORG-ETH ESTRAD ETH ESTRAD
LEVORA-28
LOMEDIA 24 FE
LORYNA
LOW-OGESTREL
LUTERA
LYZA
MARLISSA
MICROGESTIN
MICROGESTIN
MICROGESTIN FE
MICROGESTIN FE
MONO-LINYAH
MONONESSA
MY WAY
MYZILRA
NECON
NECON
NECON
NECON
NECON
NEXT CHOICE
NEXT CHOICE ONE DOSE
NEXT CHOICE ONE DOSE
NIKKI
NORA-BE
NORETHINDRONE
NORETHINDRON-ETHINYL ESTRADIOL
NORETHIN-ETH ESTRA-FERROUS FUM
NORGESTIMATE-ETHINYL ESTRADIOL
NORGESTIMATE-ETHINYL ESTRADIOL
NORINYL 1+35
NORLYROC
NORTREL
NORTREL
NORTREL
NORTREL
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
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
Name
OCELLA
OGESTREL
OPCICON ONE-STEP
ORSYTHIA
PHILITH
PIMTREA
PIRMELLA
PIRMELLA
PORTIA
PREVIFEM
QUASENSE
RECLIPSEN
SETLAKIN
SHAROBEL
SPRINTEC
SRONYX
SYEDA
TARINA FE
TILIA FE
TRI-ESTARYLLA
TRI-LEGEST FE
TRI-LINYAH
TRI-LO-ESTARYLLA
TRI-LO-MARZIA
TRI-LO-SPRINTEC
TRINESSA
TRINESSA LO
TRI-PREVIFEM
TRI-SPRINTEC
TRIVORA-28
VELIVET
VESTURA
VIENVA
VIORELE
VYFEMLA
WERA
WYMZYA FE
XULANE
ZARAH
ZENCHENT
ZENCHENT FE
Covered Generic Contraceptives
Tier
Notes
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
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
Name
ZEOSA
ZOVIA 1-35E
ZOVIA 1-50E
Covered Generic Contraceptives
Tier
Notes
1
1
1
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
WOMEN'S PREVENTIVE HEALTHCARE
APPENDIX B
Name
BACMIN
B-PLEX
CHOICE-TABS
CORVITA 150
CORVITE FREE
DIALYVITE
DIALYVITE 3000
DIALYVITE ZINC
FABB
FEROCON
FERREX 150 FORTE
FERROCITE PLUS
FERROGELS FORTE
FOLBEE
FOLBEE PLUS
FOLBEE PLUS CZ
FOLBIC
FOLBIC
FOLCAPS
FOLIC ACID
FOLIC ACID
FOLIC ACID
FOLIC ACID-VIT B6-VIT B12
FOLITAB 500
FOLIVANE-F
FOLIVANE-PLUS
FOLPLEX 2.2
HEMATINIC PLUS
HEMATINIC WITH FOLIC ACID
HEMATOGEN
HEMATOGEN FA
HEMATOGEN FORTE
IFEREX 150 FORTE
LYSIPLEX PLUS
MYFERON-150 FORTE
MYNEPHRON
NEPHPLEX RX
NEPHROCAPS
NEPHROCAPS
Covered Multivitamins
Tier Notes
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
Name
Covered Multivitamins
Tier Notes
NEPHRON FA
NEPHRO-VITE RX
NEURIN-SL
POLY-IRON 150 FORTE
PRENATAL
PRENATAL
PRENATAL
PRENATAL
PRENATAL FORMULA
PRENATAL FORMULA
PRENATAL MULTIVITAMINS
PRENATAL PLUS
PRENATAL VITAMINS
PRENATAL VITAMINS
PRENATAL VITAMINS
PRENATAL VITAMINS
PRENATAL VITAMINS
PRENATAL VITAMINS
PRENATAL VITAMINS
RENAL CAPS
RENA-VITE RX
RENO CAPS
RIGHT STEP PRENATAL VITAMINS
SE-TAN PLUS
SIDEROL
SIDEROL
STUART PRENATAL
TARON FORTE
TL GARD RX
TL G-FOL OS
TL-FOL 500
TL-HEM 150
TRIGELS-F FORTE
V-C FORTE
VIC-FORTE
VIRT-CAPS
VIRT-VITE
VIRT-VITE PLUS
VIT 3
VITACEL
VITAL-D RX
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
Name
VITAMIN D2
VOL-CARE RX
VP-VITE RX
Covered Multivitamins
Tier Notes
1
1
1