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2015 Comprehensive Formulary
Aetna Medicare
(List of Covered Drugs)
Saver Formulary 1
PLEASE READ: This document contains information about the
drugs we cover in this plan
This formulary was updated on 2/1/2015.
For more recent information or other questions, please contact
Aetna Medicare Member Services at
1-877-238-6211 or for TTY: 711, 8 a.m. to 8 p.m.,
seven days a week, or visit
http://www.aetnamedicare.com/2015formulary.
Formulary ID Number: 15041 Version 6
Y0001_1085_3476_FINAL_1 Accepted 7/2014
Page 1 of 73
Aetna Medicare is an HMO, PPO and prescription drug plan with a Medicare contract.
Enrollment in Aetna Medicare depends on contract renewal. Plans are offered by Aetna Health
Inc., Aetna Health of California Inc., and/or Aetna Life Insurance Company (Aetna). Not all
health services are covered. See Evidence of Coverage for a complete description of benefits,
exclusions, limitations and conditions of coverage. Plan features and availability may vary by
location. Aetna is the brand name used for products and services provided by one or more
of the Aetna group of subsidiary companies. The Aetna companies that offer, underwrite or
administer benefits coverage include Aetna Health Inc., Aetna Health of California Inc., and or
Aetna Life Insurance Company. Aetna Pharmacy Management refers to an internal business unit
of Aetna Health Management, LLC.
Mail Order Pharmacy
For mail-order, you can get prescription drugs shipped to your home through the network mailorder delivery program, which is called Aetna Rx Home Delivery. Typically, mail-order drugs
arrive within 7 to 10 days. You can call 1-888-792-3862 (TTY: 1-800-823-6373) if you do not
receive your mail-order drugs within this timeframe. Members may have the option to sign-up
for automated mail-order delivery.
This information is available for free in other languages. Please call our customer service
number at 1-877-238-6211 (TTY: 711), 8 a.m. to 8 p.m., seven days a week.
Esta información está disponible en otros idiomas de manera gratuita. Comuníquese con
Servicios al Cliente al 1-877-238-6211 (TTY: 711). Horario de atención: de 8 a.m. a 8 p.m.,
los siete días de la semana.
Note to existing members: This formulary has changed since last year. Please review this
document to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Aetna Medicare. When it
refers to “plan” or “our plan,” it means Aetna.
This document includes a list of the drugs (formulary) for our plan which is current as of
2/1/2015. For a complete, updated formulary, please contact us. Our contact information, along
with the date we last updated the formulary, appears on the front and back cover pages.
The benefit information provided is a brief summary, not a complete description of benefits. For
more information contact the plan. Limitations, copayments, and restrictions may apply.
You must generally use network pharmacies to use your prescription drug benefit. Benefits,
formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2016,
and from time to time during the year.
Page 1 of 73
What is the Aetna Medicare Comprehensive Formulary?
A formulary is a list of covered drugs selected by our plan in consultation with a team of health
care providers, which represents the prescription therapies believed to be a necessary part of a
quality treatment program.
We will generally cover the drugs listed in our formulary as long as the drug is medically
necessary, the prescription is filled at our network pharmacy, and other plan rules are followed.
For more information on how to fill your prescriptions, please review your Evidence of
Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning
of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage
year except when a new, less expensive generic drug becomes available or when new adverse
information about the safety or effectiveness of a drug is released. Other types of formulary
changes, such as removing a drug from our formulary, will not affect members who are
currently taking the drug. It will remain available at the same cost-sharing for those members
taking it for the remainder of the coverage year. We feel it is important that you have continued
access for the remainder of the coverage year to the formulary drugs that were available when
you chose our plan, except for cases in which you can save additional money or we can ensure
your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step
therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify
affected members of the change at least 60 days before the change becomes effective, or at
the time the member requests a refill of the drug, at which time the member will receive a 60day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to
be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately
remove the drug from our formulary and provide notice to members who take the drug. The
enclosed formulary is current as of 2/1/2015. To get updated information about the drugs
covered by our plan, please contact us. Our contact information appears on the front and back
cover pages.
In the event of any CMS-approved, mid-year non-maintenance formulary changes, the
formularies will be updated monthly and posted on our website.
Page 2 of 73
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 8. The drugs in this formulary are grouped into categories
depending on the type of medical conditions that they are used to treat. For example, drugs
used to treat a heart condition are listed under the category, “Cardiovascular Agents”. If you
know what your drug is used for, look for the category name in the list that begins on page 8.
Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index
that begins on page 56. The Index provides an alphabetical list of all of the drugs included in
this document. Both brand name drugs and generic drugs are listed in the Index. Look in the
Index and find your drug. Next to your drug, you will see the page number where you can find
coverage information. Turn to the page listed in the Index and find the name of your drug in the
first column of the list.
What are generic drugs?
Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the
FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost
less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These
requirements and limits may include:
• Prior Authorization: Our plan requires you or your physician to get prior authorization for
certain drugs. This means that you will need to get approval from us before you fill your
prescriptions. If you don’t get approval, we may not cover the drug.
• Quantity Limits: For certain drugs, our plan limits the amount of the drug that we
will cover. For example, our plan provides 30 tablets per 30 days per prescription for
candesartan. This may be in addition to a standard one-month or three-month supply.
• Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your
medical condition before we will cover another drug for that condition. For example, if
Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you
try Drug A first. If Drug A does not work for you, we will then cover Drug B.
Page 3 of 73
You can find out if your drug has any additional requirements or limits by looking in the
formulary that begins on page 8. You can also get more information about the restrictions
applied to specific covered drugs by visiting our Web site. We have posted online documents
that explain our prior authorization and step therapy restrictions. You may also ask us to send
you a copy. Our contact information, along with the date we last updated the formulary,
appears on the front and back cover pages.
You can ask us to make an exception to these restrictions or limits or for a list of other, similar
drugs that may treat your health condition. See the section, “How do I request an exception to
the Aetna Medicare’s formulary?” on page 4 for information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact
Member Services and ask if your drug is covered.
If you learn that our plan does not cover your drug, you have two options:
• You can ask Member Services for a list of similar drugs that are covered by our plan. When
you receive the list, show it to your doctor and ask him or her to prescribe a similar drug
that is covered by our plan.
• You can ask us to make an exception and cover your drug. See below for information about
how to request an exception.
How do I request an exception to the Aetna Medicare’s Formulary?
You can ask us to make an exception to our coverage rules. There are several types of
exceptions that you can ask us to make.
• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will
be covered at a pre-determined cost-sharing level, and you would not be able to ask us to
provide the drug at a lower cost-sharing level.
• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on
the specialty tier. If approved this would lower the amount you must pay for your drug.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, we will only approve your request for an exception if the alternative drugs
included on the plan’s formulary, the lower cost-sharing drug or additional utilization
restrictions would not be as effective in treating your condition and/or would cause you
to have adverse medical effects.
Page 4 of 73
You should contact us to ask us for an initial coverage decision for a formulary, tiering or
utilization restriction exception. When you request a formulary, tiering or utilization restriction
exception you should submit a statement from your prescriber or physician supporting your
request. Generally, we must make our decision within 72 hours of getting your prescriber’s
supporting statement.
You can request an expedited (fast) exception if you or your doctor believe that your health
could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is
granted, we must give you a decision no later than 24 hours after we get a supporting statement
from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting
an exception?
As a new or continuing member in our plan, you may be taking drugs that are not on
our formulary. Or, you may be taking a drug that is on our formulary but your ability
to get it is limited.
For example, you may need a prior authorization from us before you can fill your prescription.
You should talk to your doctor to decide if you should switch to an appropriate drug that we
cover or request a formulary exception so that we will cover the drug you take. While you
talk to your doctor to determine the right course of action for you, we may cover your drug in
certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited,
we will cover a temporary 30-day supply (unless you have a prescription written for fewer days)
when you go to a network pharmacy. After your first 30-day supply, we will not pay for these
drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription
until we have provided you with at least 91 and up to a 98-day transition supply, consistent
with dispensing increment, (unless you have a prescription written for fewer days). We will
cover more than one refill of these drugs for the first 90 days you are a member of our
plan. If you need a drug that is not on our formulary or if your ability to get your drugs is
limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day
emergency supply of that drug (unless you have a prescription for fewer days) while you
pursue a formulary exception.
If you experience a change in your setting of care (such as being discharged or admitted to
a long term care facility), your physician or pharmacy can request a one-time prescription
override. This one-time override will provide you with temporary coverage (up to a 30-day
supply) for the applicable drug(s).
Page 5 of 73
For more information
For more detailed information about our plan’s prescription drug coverage, please review your
Evidence of Coverage and other plan materials.
If you have questions about our plan, please contact us. Our contact information, along with the
date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare
at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call
1-877-486-2048. Or, visit http://www.medicare.gov.
Aetna Medicare’s Formulary
The comprehensive formulary that begins on page 8 provides coverage information about the
drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that
begins on page 56.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g.,
LEVEMIR) and generic drugs are listed in lower-case italics (e.g., candesartan).
The information in the Requirements/Limits column tells you if our plan has any special
requirements for coverage of your drug. The following abbreviations are used:
QL
PA
ST
LA
MO
B/D
Quantity Limits
Prior Authorization
Step Therapy
Limited Access
Mail Order Delivery
Part B vs. D Prior Authorization
QL: Quantity Limits. For certain drugs, our plan limits the amount of the drug that we will cover.
For example, our plan provides 30 tablets per 30 days per prescription for candesartan.
PA: Prior Authorization. Our plan requires you or your provider to get prior authorization
for certain drugs. This means that you will need to get approval from us before you fill your
prescriptions. If you don’t get approval, we may not cover the drug.
ST: Step Therapy. In some cases, our plan requires you to first try certain drugs to treat your
medical condition, before we will cover another drug for that condition. For example, if Drug A
and Drug B both treat your medical condition, we may not cover drug B unless you try Drug A
first. If Drug A does not work for you, we will then cover Drug B.
Page 6 of 73
LA: Limited Access. These prescriptions may be available only at certain pharmacies. For
more information consult your Pharmacy Directory or call Aetna Medicare Member Services at
1-877-238-6211 (TTY: 711) 8 a.m. to 8 p.m., seven days a week.
MO: Mail Order. For certain kinds of drugs, you can use Aetna Rx Home Delivery. Generally,
the drugs available through mail order are drugs that you take on a regular basis, for a chronic
or long-term medical condition. The drugs available through our plan’s mail-order service
are marked as “mail-order” drugs in our Drug List or MO. For more information consult your
Pharmacy Directory or call Aetna Medicare Member Services at 1-877-238-6211 (TTY:711),
8 a.m. to 8 p.m., seven days a week.
B/D: Part B versus Part D. This prescription drug has a Part B versus Part D administrative
priorauthorization requirement. This drug may be covered under Medicare Part B or D
depending upon the circumstances. Information may need to be submitted describing the
use and setting of the drug to make the determination.
Drug tier copay levels
This 2015 comprehensive formulary is a listing of brand name and generic drugs. Aetna
Medicare’s 2015 formulary covers most drugs identified by Medicare as Part D drugs, and your
copay may differ depending upon the tier at which the drug resides.
The copay tiers for covered prescription medications are listed below. Copay amounts and
coinsurance percentages for each tier vary by plan. Consult your plan’s Summary of Benefits or
Evidence of Coverage for your applicable copays and coinsurance amounts.
Copay tier
Tier 1
Tier 2
Tier 3
Tier 4
Tier 5
Type of drug
Preferred Generic drugs
Non-Preferred Generic drugs
Preferred Brand drugs
Non-Preferred Brand drugs
Specialty drugs
Our plan, in some instances, combines higher cost generic drugs on brand tiers. Refer to the
drug list to determine the tier of coverage for each drug you take.
Page 7 of 73
KEY*
Drug Name
UPPERCASE = Brand name
prescription drugs
Drug Tier
1,2,3,4,5 = Copay tier level
Lower case italics = Generic
medications
Requirements/Limits
QL= Quantity Limit
ST = Step Therapy
PA = Prior Authorization
LA = Limited Access
MO = Mail order delivery
B/D = Part B vs. Part D
Drug
Tier
Drug Name
Analgesics
acetaminophen/codeine #3
2
acetaminophen/codeine soln
2
acetaminophen/codeine tabs 300mg; 15mg, 300mg; 60mg
2
ascomp/codeine
4
butalbital compound/codeine
4
butalbital/acetaminophen/caffeine/codeine
4
butalbital/acetaminophen/caffeine caps
4
butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg 4
butalbital/apap/caffeine
4
butalbital/aspirin/caffeine/codeine
4
butalbital/aspirin/caffeine caps
4
capacet
4
codeine sulfate tabs
4
diclofenac potassium
2
diclofenac sodium dr
2
diclofenac sodium er
2
diclofenac sodium/misoprostol
4
diflunisal tabs
4
duramorph
2
endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg
4
endodan
4
esgic caps
4
etodolac er
2
etodolac caps, tabs
2
fenoprofen calcium tabs
3
fentanyl patch
4
fentanyl citrate oral transmucosal
5
flurbiprofen tabs
2
hydrocodone bitartrate/acetaminophen soln
4
hydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mg
4
hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg,
4
300mg; 5mg, 300mg; 7.5mg
hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 4
325mg; 7.5mg
hydrocodone/ibuprofen
4
Requirements/Limits
QL (390 EA per 30 days) MO
QL (4500 ML per 30 days) MO
QL (390 EA per 30 days) MO
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA
QL (180 EA per 30 days) MO
MO
MO
MO
MO
MO
B/D
QL (360 EA per 30 days)
QL (360 EA per 30 days)
QL (180 EA per 30 days) PA MO
MO
MO
MO
QL (15 EA per 30 days) MO
QL (120 EA per 30 days) PA MO
MO
QL (5550 ML per 30 days) MO
QL (360 EA per 30 days)
QL (390 EA per 30 days) MO
QL (360 EA per 30 days) MO
QL (150 EA per 30 days) MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 8 of 73
Drug
Drug Name
Tier
hydromorphone hcl liqd
4
hydromorphone hcl inj 1mg/ml, 2mg/ml, 4mg/ml, 500mg/50ml 4
hydromorphone hcl tabs 4mg, 8mg
4
hydromorphone hcl tabs 2mg
4
ibudone tabs 5mg; 200mg
4
ibuprofen tabs 400mg, 600mg, 800mg
2
ketoprofen er
4
ketoprofen caps
2
lorcet
4
lorcet hd
4
lorcet plus tabs 325mg; 7.5mg
4
lortab tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg
4
margesic
4
meclofenamate sodium caps
4
meloxicam susp, tabs
2
methadone hcl inj
2
methadone hcl tabs
2
methadone hcl oral soln
2
methadone hcl conc
2
methadone hcl tbso
2
methadose sugar-free
2
methadose conc
2
methadose tbso
2
morphine sulfate er cp24 120mg
4
morphine sulfate er cp24 45mg, 75mg, 90mg
4
morphine sulfate er cp24 100mg, 10mg, 20mg, 30mg, 50mg, 4
60mg, 80mg
morphine sulfate er tbcr
4
morphine sulfate tabs
2
morphine sulfate inj 0.5mg/ml, 10mg/ml, 150mg/30ml,
2
15mg/ml, 1mg/ml, 25mg/ml, 2mg/ml, 4mg/ml, 50mg/ml,
5mg/ml, 8mg/ml
morphine sulfate oral soln 20mg/5ml
2
morphine sulfate oral soln 20mg/ml
2
morphine sulfate oral soln 10mg/5ml
2
nabumetone
2
nalbuphine hcl inj
4
naproxen dr
2
naproxen sodium tabs 275mg, 550mg
2
naproxen susp, tabs
2
oxaprozin
4
oxycodone hcl conc
4
oxycodone hcl caps
4
oxycodone hcl soln
4
oxycodone hcl tabs 10mg, 15mg, 20mg, 30mg
4
Requirements/Limits
QL (2400 ML per 30 days) MO
B/D MO
QL (240 EA per 30 days) MO
QL (480 EA per 30 days) MO
QL (150 EA per 30 days)
MO
MO
MO
QL (360 EA per 30 days)
QL (360 EA per 30 days)
QL (360 EA per 30 days)
QL (360 EA per 30 days)
QL (180 EA per 30 days) PA MO
MO
MO
QL (240 EA per 30 days) MO
QL (3000 ML per 30 days) MO
QL (360 ML per 30 days) MO
QL (90 EA per 30 days)
QL (360 ML per 30 days) MO
QL (360 ML per 30 days) MO
QL (90 EA per 30 days)
QL (180 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (180 EA per 30 days) MO
B/D
QL (1020 ML per 30 days) MO
QL (180 ML per 30 days) MO
QL (1800 ML per 30 days) MO
MO
MO
MO
MO
MO
MO
QL (180 ML per 30 days) MO
QL (360 EA per 30 days) MO
QL (5400 ML per 30 days) MO
QL (180 EA per 30 days) MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 9 of 73
Drug
Drug Name
Tier
oxycodone hcl tabs 5mg
4
oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 4
325mg; 5mg, 325mg; 7.5mg
oxycodone/aspirin tabs 325mg; 4.835mg
4
oxycodone/ibuprofen
4
piroxicam caps
3
roxicet tabs 325mg; 5mg
4
sulindac tabs
2
tolmetin sodium
2
tramadol immediate release tabs
2
tramadol hydrochloride/acetaminophen
4
vicodin es tabs 300mg; 7.5mg
4
vicodin hp tabs 300mg; 10mg
4
vicodin tabs 300mg; 5mg
4
VOLTAREN GEL
3
ZAMICET
4
zebutal caps 325mg; 50mg; 40mg
4
Anesthetics
glydo
2
lidocaine hcl jelly
2
lidocaine hcl gel 2%
2
lidocaine hcl inj 0.5%, 1.5%
2
lidocaine hcl inj 1%, 2%, 4%
2
lidocaine hcl external soln 4%
2
lidocaine hcl mouth/throat soln 4%
2
lidocaine viscous
2
lidocaine/prilocaine kit
3
lidocaine/prilocaine crea
3
lidocaine oint
2
lidocaine ptch
2
Anti-Addiction/Substance Abuse Treatment Agents
acamprosate calcium dr
4
buprenorphine hcl/naloxone hcl
3
buprenorphine hcl subl
3
buproban
3
bupropion hcl sr tb12 150mg
3
CHANTIX CONTINUING MONTH PAK
4
CHANTIX STARTING MONTH PAK
4
CHANTIX TABS 0.5MG, 1MG
4
disulfiram tabs
3
EVZIO
4
naloxone hcl inj
2
naltrexone hcl tabs
2
NICOTROL NS
4
SUBOXONE FILM 12MG; 3MG
4
Requirements/Limits
QL (360 EA per 30 days) MO
QL (360 EA per 30 days) MO
QL (360 EA per 30 days) MO
QL (120 EA per 30 days) MO
MO
QL (360 EA per 30 days)
MO
MO
QL (240 EA per 30 days) MO
QL (240 EA per 30 days) MO
QL (390 EA per 30 days)
QL (390 EA per 30 days)
QL (390 EA per 30 days)
QL (1020 GM per 30 days) MO
QL (5550 ML per 30 days) MO
QL (180 EA per 30 days) PA MO
MO
MO
MO
MO
MO
MO
MO
QL (90 EA per 30 days) PA MO
MO
QL (90 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (336 EA per 365 days) MO
QL (106 EA per 365 days) MO
QL (336 EA per 365 days) MO
MO
QL (0.8 ML per 365 days) PA MO
MO
QL (40 ML per 30 days) MO
QL (60 EA per 30 days) PA MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 10 of 73
Drug Name
SUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG, 8MG; 2MG
Antibacterials
amikacin sulfate inj 1gm/4ml, 500mg/2ml
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium er
amoxicillin chew 125mg, 250mg
amoxicillin caps, susr, tabs
ampicillin sodium inj 10gm, 125mg, 1gm for IV, 250mg, 2gm
for IV
ampicillin sodium inj 1gm, 2gm, 500mg
ampicillin-sulbactam
ampicillin caps
ampicillin susr 125mg/5ml
ampicillin susr 250mg/5ml
azithromycin pack, susr, tabs
azithromycin inj 500mg
aztreonam inj 2gm
aztreonam inj 1gm
baciim
bacitracin inj 50000unit
BICILLIN L-A
cefaclor er
cefaclor caps
cefaclor susr 125mg/5ml, 375mg/5ml
cefaclor susr 250mg/5ml
cefadroxil
cefazolin sodium/dextrose
cefazolin sodium inj 100gm, 1gm; 5%, 1gm for IV, 20gm
cefazolin sodium inj 10gm, 1gm, 500mg
cefdinir
cefditoren pivoxil tabs 400mg
cefepime inj 1gm/50ml; 5%, 1gm/50ml, 2gm/100ml,
2gm/50ml; 5%
cefepime inj 1gm, 2gm
cefotaxime sodium inj 10gm, 500mg
cefotaxime sodium inj 1gm, 2gm
cefotetan
cefotetan/dextrose
cefoxitin sodium inj 10gm, 1gm; 4%, 2gm; 2.2%
cefoxitin sodium inj 1gm, 2gm
cefpodoxime proxetil
cefprozil
ceftazidime/dextrose
ceftazidime inj 6gm
ceftazidime inj 1gm, 2gm
Drug
Tier
4
Requirements/Limits
QL (90 EA per 30 days) PA MO
4
2
2
2
2
4
MO
MO
MO
MO
MO
4
4
2
2
2
2
2
4
4
4
4
4
4
4
4
4
2
4
4
4
4
4
4
MO
4
4
4
4
4
4
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 11 of 73
Drug Name
ceftriaxone in iso-osmotic dextrose
ceftriaxone sodium i.v. 1gm
ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg
ceftriaxone/dextrose
cefuroxime axetil susr
cefuroxime axetil tabs
cefuroxime sodium inj 1.5gm, 7.5gm
cefuroxime sodium inj 750mg
cefuroxime/dextrose inj 750mg; 4.1%
cephalexin
chloramphenicol sodium succinate
ciprofloxacin er
ciprofloxacin hcl tabs 100mg, 250mg, 500mg, 750mg
ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5%
ciprofloxacin i.v.-in d5w inj 400mg/200ml; 5%
ciprofloxacin otic soln, susr
ciprofloxacin inj 200mg/20ml, 400mg/40ml
clarithromycin susr, immediate release tabs
clindamycin hcl caps
clindamycin palmitate hcl
clindamycin phosphate add-vantage
clindamycin phosphate in d5w
clindamycin phosphate crea 2%
clindamycin phosphate inj 150mg/ml, 300mg/2ml,
9000mg/60ml
clindamycin phosphate inj 600mg/4ml, 900mg/6ml
colistimethate sodium
CUBICIN
dicloxacillin sodium
doxy 100
doxycycline hyclate dr
doxycycline hyclate caps, inj, tabs
doxycycline monohydrate
doxycycline caps, susr
E.E.S. 400
e.s.p.
ERYTHROCIN LACTOBIONATE INJ 500MG
erythromycin base tabs
erythromycin ethylsuccinate tabs
erythromycin stearate tabs
erythromycin/sulfisoxazole
erythromycin cpep 250mg
gentamicin sulfate pediatric
Drug
Tier
4
4
4
4
2
2
4
4
4
2
4
2
2
2
2
2
2
3
2
2
4
4
2
4
4
4
5
2
4
4
4
4
4
4
2
4
2
2
2
2
2
2
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 12 of 73
Drug Name
gentamicin sulfate/0.9% sodium chloride inj 0.9mg/ml; 0.9%,
1.2mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/ml;
0.9%
gentamicin sulfate/0.9% sodium chloride inj 0.8mg/ml; 0.9%
gentamicin sulfate inj 10mg/ml
gentamicin sulfate inj 40mg/ml
imipenem/cilastatin
INVANZ IV 1GM
INVANZ INJ 1GM
isotonic gentamicin inj 1.2mg/ml; 0.9%, 2mg/ml; 0.9%
isotonic gentamicin inj 0.8mg/ml; 0.9%
levofloxacin in d5w
levofloxacin inj 25mg/ml
levofloxacin oral soln 25mg/ml
levofloxacin tabs 250mg, 500mg, 750mg
meropenem
methenamine hippurate
METRO IV
metronidazole in nacl 0.79%
metronidazole vaginal
metronidazole caps 375mg
metronidazole tabs 250mg, 500mg
minocycline hcl caps
morgidox 1x100mg caps
morgidox 2x100mg caps
NALLPEN ISO-OSMOTIC IN DEXTROSE
NALLPEN/DEXTROSE INJ 0; 1GM/50ML
neomycin sulfate tabs
nitrofurantoin macrocrystals
nitrofurantoin monohydrate
nitrofurantoin susp
ofloxacin tabs 200mg
ofloxacin tabs 300mg, 400mg
oxacillin sodium inj 10gm, 1gm
oxacillin sodium inj 2gm
paromomycin sulfate
penicillin g potassium inj 20000000unit, 5000000unit
penicillin g procaine
penicillin g sodium
penicillin v potassium
piperacillin sodium/ tazobactam sodium
piperacillin sodium/tazobactam sodium inj 2gm; 0.25gm
piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm,
4gm; 0.5gm
SIVEXTRO INJ
Drug
Tier
2
2
2
2
3
4
4
2
2
4
2
2
2
4
4
4
4
2
2
2
2
4
4
4
4
4
4
4
4
2
2
4
4
4
4
4
4
2
4
4
4
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
5
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 13 of 73
Drug Name
SIVEXTRO TABS
streptomycin sulfate inj
sulfadiazine tabs
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim ds
SUPRAX CHEW, TABS
SUPRAX CAPS
SUPRAX SUSR 500MG/5ML
SUPRAX SUSR 100MG/5ML, 200MG/5ML
SYNERCID
tazicef inj 1gm, 2gm, 6gm
TEFLARO
tetracycline hcl caps
TIMENTIN INJ 0.1GM; 3GM, 1GM; 30GM
tinidazole
tobramycin sulfate/sodium chloride inj 0.9%; 0.8mg/ml
tobramycin sulfate inj 1.2gm, 10mg/ml, 40mg/ml
tobramycin sulfate inj 1.2gm/30ml, 80mg/2ml
trimethoprim tabs
TYGACIL
vancomycin hcl in dextrose
vancomycin hcl caps
vancomycin hcl inj 1000mg, 10gm, 5000mg, 750mg
vancomycin hcl inj 500mg
vandazole
ZYVOX INJ
ZYVOX SUSR
ZYVOX TABS
Anticonvulsants
APTIOM TABS 200MG, 400MG, 800MG
APTIOM TABS 600MG
BANZEL TABS
BANZEL SUSP
carbamazepine er
carbamazepine chew, susp, tabs
CELONTIN
clonazepam odt tbdp 1mg
clonazepam odt tbdp 2mg
clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg
clonazepam tabs 1mg
clonazepam tabs 2mg
clonazepam tabs 0.5mg
diazepam gel 10mg, 2.5mg, 20mg
DILANTIN CAPS 30MG
divalproex sodium
Drug
Tier
5
4
4
2
2
4
4
4
4
5
4
4
2
4
4
2
2
2
2
4
4
5
4
4
2
5
5
5
MO
MO
PA
QL (1800 ML per 28 days) PA MO
QL (56 EA per 28 days) PA MO
4
4
4
5
4
2
4
4
4
4
4
4
4
4
4
4
QL (30 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
PA MO
PA MO
MO
MO
MO
QL (120 EA per 30 days) MO
QL (300 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (120 EA per 30 days) MO
QL (300 EA per 30 days) MO
QL (90 EA per 30 days) MO
MO
MO
MO
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 14 of 73
Drug Name
divalproex sodium dr
divalproex sodium er
epitol
ethosuximide
felbamate
fosphenytoin sodium inj 100mg pe/2ml
fosphenytoin sodium inj 500mg pe/10ml
FYCOMPA TABS 10MG, 12MG, 4MG, 6MG, 8MG
FYCOMPA TABS 2MG
gabapentin caps, soln, tabs
GABITRIL TABS 12MG, 16MG
lamotrigine immediate release tablet, chew
levetiracetam oral soln, immediate release tabs
levetiracetam inj 1000mg/100ml; 750mg/100ml,
1500mg/100ml; 540mg/100ml, 500mg/100ml; 820mg/100ml
levetiracetam inj 500mg/5ml
LYRICA SOLN
LYRICA CAPS 225MG, 300MG
LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG,
75MG
ONFI SUSP
ONFI TABS
oxcarbazepine
PEGANONE
phenobarbital tabs
phenobarbital elix
phenytoin sodium extended
phenytoin sodium inj
phenytoin chew, susp
POTIGA TABS 50MG
POTIGA TABS 200MG, 300MG, 400MG
primidone tabs
SABRIL
TEGRETOL-XR TB12 100MG
tiagabine hydrochloride
topiramate cpsp, tabs
valproate sodium inj
valproic acid caps, syrp
VIMPAT INJ
VIMPAT ORAL SOLN
VIMPAT TABS 50MG
VIMPAT TABS 100MG, 150MG, 200MG
zonisamide
Antidementia Agents
donepezil hcl tbdp
Drug
Tier
4
4
2
4
4
4
4
4
4
2
4
2
2
4
Requirements/Limits
MO
MO
MO
MO
MO
QL (30 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
MO
MO
MO
MO
4
4
4
4
MO
QL (900 ML per 30 days) PA MO
QL (60 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
4
4
4
4
4
4
2
4
2
4
4
2
5
4
4
4
4
2
4
4
4
4
2
PA MO
QL (60 EA per 30 days) PA MO
MO
MO
QL (120 EA per 30 days) PA MO
QL (1500 ML per 30 days) PA MO
MO
MO
QL (180 EA per 30 days) MO
QL (60 EA per 30 days) MO
MO
2
QL (30 EA per 30 days) MO
MO
QL (270 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
MO
PA LA
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 15 of 73
Drug Name
donepezil hcl tabs 23mg, 5mg
donepezil hcl tabs 10mg
ergoloid mesylates tabs
EXELON PT24
EXELON SOLN
galantamine hydrobromide soln
galantamine hydrobromide cp24
galantamine hydrobromide tabs
NAMENDA XR
NAMENDA XR TITRATION PACK
rivastigmine tartrate
Antidepressants
amitriptyline hcl tabs
amoxapine
BRINTELLIX
bupropion hcl er
bupropion hcl sr tb12 100mg, 150mg, 200mg
bupropion hcl xl
bupropion hcl tabs
chlordiazepoxide/amitriptyline
citalopram hydrobromide soln
citalopram hydrobromide tabs 10mg
citalopram hydrobromide tabs 40mg
citalopram hydrobromide tabs 20mg
clomipramine hcl caps
desipramine hcl tabs
doxepin hcl caps, conc
duloxetine hcl cpep 20mg, 60mg
duloxetine hcl cpep 30mg
EMSAM
escitalopram oxalate soln
escitalopram oxalate tabs 20mg
escitalopram oxalate tabs 10mg, 5mg
FETZIMA
FETZIMA TITRATION PACK
fluoxetine dr
fluoxetine hcl caps, soln, tabs
fluvoxamine maleate tabs
imipramine hcl tabs
maprotiline hcl
MARPLAN
mirtazapine odt tbdp 30mg, 45mg
mirtazapine tabs
mirtazapine tbdp
nefazodone hcl
Drug
Tier
2
2
3
3
4
4
4
4
3
3
4
Requirements/Limits
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
PA MO
QL (30 EA per 30 days) MO
QL (180 ML per 30 days) MO
QL (200 ML per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) PA MO
QL (30 EA per 30 days) PA MO
QL (60 EA per 30 days) MO
2
2
4
3
3
3
3
4
2
2
2
2
4
3
2
3
3
5
4
4
4
4
4
4
2
4
2
2
4
4
2
4
4
PA MO
MO
QL (30 EA per 30 days) ST MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (180 EA per 30 days) MO
MO
QL (600 ML per 30 days) MO
QL (120 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
PA MO
MO
PA MO
QL (60 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (30 EA per 30 days) ST MO
QL (600 ML per 30 days) MO
QL (30 EA per 30 days) MO
QL (45 EA per 30 days) MO
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) ST MO
QL (4 EA per 28 days) MO
MO
MO
PA MO
MO
MO
QL (30 EA per 30 days) MO
MO
QL (30 EA per 30 days) MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 16 of 73
Drug Name
nortriptyline hcl caps, soln
olanzapine/fluoxetine
paroxetine immediate release tabs
PAXIL SUSP
perphenazine/amitriptyline
phenelzine sulfate tabs
PRISTIQ
protriptyline hcl
sertraline hcl conc, tabs
SURMONTIL
tranylcypromine sulfate
trazodone hcl tabs
venlafaxine hcl
venlafaxine hcl er cp24 37.5mg, 75mg
venlafaxine hcl er cp24 150mg
venlafaxine hcl er tb24 225mg, 37.5mg, 75mg
venlafaxine hcl er tb24 150mg
VIIBRYD TABS
VIIBRYD KIT
Antiemetics
dronabinol caps 2.5mg, 5mg
dronabinol caps 10mg
EMEND CAPS 40MG
EMEND PAK, 125MG, 80MG
granisetron hcl tabs
meclizine hcl tabs
ondansetron hcl oral soln
ondansetron hcl inj 40mg/20ml, 4mg/2ml
ondansetron hcl tabs 4mg, 8mg
ondansetron hcl tabs 24mg
ondansetron odt
phenadoz supp 25mg
phenadoz supp 12.5mg
phenergan supp
promethazine hcl supp
promethegan supp 12.5mg, 25mg
promethegan supp 50mg
TRANSDERM-SCOP
Antifungals
ABELCET
AMBISOME
amphotericin b
CANCIDAS INJ 50MG
CANCIDAS INJ 70MG
ciclodan
Drug
Tier
2
4
2
4
4
3
4
4
2
4
4
2
2
2
2
4
4
4
4
Requirements/Limits
MO
QL (30 EA per 30 days) MO
MO
MO
MO
MO
QL (30 EA per 30 days) ST MO
MO
MO
PA MO
MO
MO
MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 365 days) MO
4
5
4
4
4
2
3
3
3
3
3
4
4
4
4
4
4
4
QL (60 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
QL (1 EA per 30 days) B/D MO
QL (6 EA per 30 days) B/D MO
QL (60 EA per 30 days) B/D MO
MO
QL (900 ML per 30 days) B/D MO
MO
B/D MO
QL (5 EA per 30 days) B/D
B/D MO
PA
PA MO
PA
PA MO
PA
PA MO
MO
5
5
4
5
5
4
B/D
B/D MO
B/D MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 17 of 73
Drug Name
ciclopirox
ciclopirox nail lacquer
ciclopirox olamine crea
clotrimazole/betamethasone dipropionate
clotrimazole soln, troc
econazole nitrate crea
ERAXIS
fluconazole in dextrose
fluconazole in nacl
fluconazole susr, tabs
flucytosine caps 250mg
flucytosine caps 500mg
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole caps
ketoconazole crea, sham, tabs
NOXAFIL INJ
NOXAFIL SUSP, TBEC
nyamyc
nystatin crea, oint, powd, susp, tabs
nystop
pedi-dri
SPORANOX SOLN
terbinafine hcl tabs
terconazole
voriconazole inj
voriconazole susr, tabs
Antigout Agents
allopurinol tabs
COLCRYS
probenecid/colchicine
probenecid tabs
Antimigraine Agents
dihydroergotamine mesylate inj
MIGERGOT
naratriptan hcl
rizatriptan benzoate
rizatriptan benzoate odt
sumatriptan spray
sumatriptan succinate refill inj 6mg/0.5ml
sumatriptan succinate refill inj 4mg/0.5ml
sumatriptan succinate tabs
sumatriptan succinate inj 6mg/0.5ml
sumatriptan succinate inj 4mg/0.5ml, 6mg/0.5ml
Drug
Tier
4
4
4
3
2
2
5
4
4
2
5
5
4
4
4
2
5
5
2
2
2
2
5
2
4
4
5
Requirements/Limits
MO
MO
MO
MO
MO
MO
PA
MO
MO
MO
MO
PA MO
MO
PA
PA MO
MO
MO
MO
PA MO
MO
MO
MO
2
3
2
2
MO
MO
MO
MO
3
4
4
4
4
3
4
4
3
4
4
MO
QL (20 EA per 28 days) MO
QL (9 EA per 30 days) MO
QL (12 EA per 30 days) MO
QL (12 EA per 30 days) MO
QL (6 EA per 30 days) MO
QL (4 ML per 30 days)
QL (4 ML per 30 days) MO
QL (9 EA per 30 days) MO
QL (4 ML per 30 days)
QL (4 ML per 30 days) MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 18 of 73
Drug Name
Antimyasthenic Agents
guanidine hcl
MESTINON TIMESPAN
MESTINON SYRP
pyridostigmine bromide tabs
Antimycobacterials
CAPASTAT SULFATE
cycloserine
dapsone tabs
ethambutol hcl tabs
isoniazid syrp, tabs
PASER
PRIFTIN
pyrazinamide tabs
rifabutin
rifampin caps, inj
RIFATER
SIRTURO
TRECATOR
Antineoplastics
ABRAXANE
adriamycin inj 10mg, 2mg/ml, 50mg
adrucil
AFINITOR
AFINITOR DISPERZ
ALIMTA
ALKERAN TABS
amifostine
anastrozole tabs
ARRANON
ARZERRA
AVASTIN
azacitidine
BELEODAQ
bicalutamide
BICNU
bleomycin sulfate
BOSULIF
BUSULFEX
CAPRELSA TABS 300MG
CAPRELSA TABS 100MG
carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml,
600mg/60ml
cisplatin
cladribine
Drug
Tier
Requirements/Limits
4
4
4
3
MO
MO
MO
4
4
3
4
2
4
4
4
4
4
4
5
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (188 EA per 365 days) PA LA
MO
5
4
4
5
5
5
4
5
2
5
5
5
5
5
2
4
4
5
5
5
5
4
4
2
B/D
B/D
QL (30 EA per 30 days) PA
QL (60 EA per 30 days) PA
PA
B/D MO
MO
PA
PA
PA
PA
MO
B/D
PA
QL (30 EA per 30 days) PA LA
QL (60 EA per 30 days) PA LA
B/D
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 19 of 73
Drug Name
CLOLAR
COMETRIQ KIT 60MG, 100MG
COMETRIQ KIT 140MG
COSMEGEN
cyclophosphamide caps, tabs
cyclophosphamide inj
CYRAMZA
cytarabine aqueous
cytarabine inj 100mg, 1gm
dacarbazine inj
daunorubicin hcl inj 5mg/ml
DAUNOXOME
decitabine
DEPOCYT
dexrazoxane
DOCEFREZ
docetaxel inj 140mg/7ml, 160mg/16ml, 20mg/2ml, 20mg/ml,
80mg/4ml, 80mg/8ml
doxorubicin hcl
doxorubicin hcl liposome
DROXIA
ELITEK
EMCYT
epirubicin hcl inj 200mg/100ml, 50mg/25ml, 50mg
ERBITUX
ERIVEDGE
ERWINAZE
etoposide inj
exemestane
FARESTON
FASLODEX
floxuridine
fludarabine phosphate
fluorouracil inj 1gm/20ml, 2.5gm/50ml, 500mg/10ml,
5gm/100ml
flutamide
FOLOTYN
FUSILEV
GAZYVA
gemcitabine
gemcitabine hcl
GILOTRIF
GLEEVEC TABS 400MG
GLEEVEC TABS 100MG
HALAVEN
Drug
Tier
5
5
5
5
3
4
5
2
2
2
2
5
4
4
4
5
5
4
4
4
5
4
4
5
5
5
3
4
5
5
2
4
4
4
5
5
5
5
5
5
5
5
5
Requirements/Limits
PA
PA MO
B/D MO
PA
B/D
B/D
B/D
MO
PA
MO
PA
QL (30 EA per 30 days) PA LA
PA
MO
MO
PA
B/D
B/D
MO
PA
QL (30 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (90 EA per 30 days) PA
PA
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 20 of 73
Drug
Tier
5
5
2
5
5
2
4
2
5
5
5
5
5
4
5
5
5
5
5
5
4
4
4
4
3
5
5
5
5
4
4
4
4
2
4
5
4
5
5
5
4
5
5
5
5
Drug Name
HERCEPTIN
HEXALEN
hydroxyurea caps
ICLUSIG TABS 45MG
ICLUSIG TABS 15MG
idarubicin hcl
ifosfamide
ifosfamide/mesna inj 1gm; 1gm
IMBRUVICA
INLYTA TABS 5MG
INLYTA TABS 1MG
INTRON-A
INTRON-A W/DILUENT
irinotecan
ISTODAX
IXEMPRA KIT
JAKAFI
JEVTANA
KADCYLA
KEYTRUDA
letrozole
leucovorin calcium inj
leucovorin calcium tabs
LEUKERAN
lomustine
MATULANE
MEKINIST TABS 0.5MG
MEKINIST TABS 2MG
melphalan hydrochloride
mercaptopurine tabs
mesna
MESNEX TABS
mitomycin
mitoxantrone hcl
MUSTARGEN
NEXAVAR
NILANDRON
NIPENT
ONCASPAR
oxaliplatin
paclitaxel
PANRETIN
PERJETA
POMALYST
PROLEUKIN
Requirements/Limits
PA
MO
QL (30 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (120 EA per 30 days) PA
QL (120 EA per 30 days) PA LA
QL (240 EA per 30 days) PA LA
PA
PA
PA
PA
QL (60 EA per 30 days) PA LA
PA
PA
PA
MO
MO
MO
QL (120 EA per 30 days) PA
QL (30 EA per 30 days) PA
MO
MO
QL (120 EA per 30 days) PA LA
MO
MO
PA
QL (21 EA per 28 days) PA LA
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 21 of 73
Drug Name
PURIXAN
REVLIMID
RITUXAN
SOLTAMOX
SPRYCEL TABS 100MG, 140MG
SPRYCEL TABS 20MG, 50MG, 70MG, 80MG
STIVARGA
SUTENT CAPS 25MG, 37.5MG, 50MG
SUTENT CAPS 12.5MG
SYLATRON
SYLVANT
SYNRIBO
TABLOID
TAFINLAR CAPS 75MG
TAFINLAR CAPS 50MG
tamoxifen citrate tabs
TARCEVA TABS 25MG
TARCEVA TABS 100MG, 150MG
TARGRETIN
TASIGNA
TEMODAR INJ
THALOMID CAPS 100MG, 150MG, 50MG
THALOMID CAPS 200MG
THERACYS
TICE BCG
toposar
topotecan hcl
TORISEL
TREANDA
tretinoin caps 10mg
TRISENOX
TYKERB
UVADEX
VALCHLOR
VALSTAR
VECTIBIX
VELCADE
vinblastine sulfate
vincasar pfs
vincristine sulfate
vinorelbine tartrate
VOTRIENT
XALKORI
XTANDI
YERVOY
Drug
Tier
5
5
5
4
5
5
5
5
5
5
5
5
4
5
5
2
5
5
5
5
5
5
5
4
4
3
5
5
5
5
4
5
4
5
5
5
5
2
4
4
4
5
5
5
5
Requirements/Limits
PA
QL (30 EA per 30 days) PA LA
PA
PA MO
QL (30 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (120 EA per 30 days) PA LA
QL (30 EA per 30 days) PA
QL (90 EA per 30 days) PA
PA
PA
PA
MO
QL (120 EA per 30 days) PA
QL (180 EA per 30 days) PA
MO
QL (60 EA per 30 days) PA
QL (90 EA per 30 days) PA
PA
QL (120 EA per 30 days) PA
B/D
QL (28 EA per 28 days) PA
QL (56 EA per 28 days) PA
MO
PA
QL (180 EA per 30 days) PA LA
PA
PA
PA
B/D
B/D
B/D
QL (120 EA per 30 days) PA
QL (60 EA per 30 days) PA LA
QL (120 EA per 30 days) PA LA
PA
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 22 of 73
Drug Name
ZALTRAP
ZANOSAR
ZELBORAF
ZOLINZA
ZYDELIG
ZYKADIA
ZYTIGA
Antiparasitics
ALBENZA
ALINIA
atovaquone
atovaquone/proguanil hcl
chloroquine phosphate tabs
COARTEM
DARAPRIM
hydroxychloroquine sulfate tabs
ivermectin tabs
lindane lotn, sham
malathion lotn
mefloquine hcl
MEPRON
NEBUPENT
PENTAM 300
permethrin crea
primaquine phosphate tabs
quinine sulfate
STROMECTOL
Antiparkinson Agents
amantadine hcl caps, syrp, tabs
APOKYN
AZILECT
benztropine mesylate tabs
benztropine mesylate inj
bromocriptine mesylate caps, tabs
carbidopa/levodopa
carbidopa/levodopa er
carbidopa/levodopa odt
carbidopa/levodopa/entacapone
carbidopa tabs
entacapone
NEUPRO
pramipexole dihydrochloride
ropinirole hcl immediate release tabs
selegiline hcl caps, tabs
trihexyphenidyl hcl
Drug
Tier
5
4
5
5
5
5
5
Requirements/Limits
PA
QL (240 EA per 30 days) PA LA
QL (120 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (150 EA per 30 days) PA
QL (120 EA per 30 days) PA
4
4
5
4
2
4
4
2
2
4
4
2
5
4
4
3
3
4
3
MO
MO
PA MO
MO
MO
MO
MO
MO
MO
PA MO
B/D MO
MO
MO
MO
PA MO
MO
3
5
4
2
4
3
2
2
2
4
2
4
4
2
2
3
2
MO
PA LA
QL (30 EA per 30 days) MO
PA MO
PA MO
MO
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
MO
MO
MO
PA MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 23 of 73
Drug Name
Antipsychotics
ABILIFY DISCMELT
ABILIFY MAINTENA
ABILIFY INJ
ABILIFY TABS
ABILIFY ORAL SOLN
ADASUVE
chlorpromazine hcl inj, tabs
clozapine
clozapine odt
compazine supp
compro
FANAPT
FANAPT TITRATION PACK
FAZACLO
fluphenazine decanoate inj
fluphenazine hcl conc, elix, inj, tabs
GEODON INJ
haloperidol decanoate
haloperidol lactate
haloperidol conc, tabs
INVEGA SUSTENNA INJ 39MG/0.25ML
INVEGA SUSTENNA INJ 78MG/0.5ML
INVEGA SUSTENNA INJ 117MG/0.75ML
INVEGA SUSTENNA INJ 156MG/ML
INVEGA SUSTENNA INJ 234MG/1.5ML
INVEGA TB24 1.5MG, 3MG, 9MG
INVEGA TB24 6MG
LATUDA
loxapine succinate caps
olanzapine odt
olanzapine inj
olanzapine tabs 10mg, 15mg, 20mg, 5mg, 7.5mg
olanzapine tabs 2.5mg
ORAP
perphenazine tabs
prochlorperazine supp
prochlorperazine edisylate inj
prochlorperazine maleate tabs
quetiapine fumarate tabs 200mg
quetiapine fumarate tabs 25mg
quetiapine fumarate tabs 300mg, 400mg
quetiapine fumarate tabs 100mg, 50mg
RISPERDAL CONSTA
risperidone odt tbdp 4mg
Drug
Tier
4
4
4
4
4
4
4
3
3
4
4
4
4
4
3
2
4
4
4
2
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
2
4
4
4
4
4
4
Requirements/Limits
QL (60 EA per 30 days) MO
MO
MO
QL (30 EA per 30 days) MO
QL (900 ML per 30 days) MO
MO
MO
QL (60 EA per 30 days) ST MO
QL (16 EA per 365 days) ST
ST
MO
MO
MO
MO
MO
MO
QL (0.25 ML per 28 days) MO
QL (0.5 ML per 28 days) MO
QL (0.75 ML per 28 days) MO
QL (1 ML per 28 days) MO
QL (1.5 ML per 28 days) MO
QL (30 EA per 30 days) ST MO
QL (60 EA per 30 days) ST MO
QL (30 EA per 30 days) MO
MO
QL (30 EA per 30 days) MO
MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
MO
MO
MO
MO
MO
QL (120 EA per 30 days) MO
QL (180 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (90 EA per 30 days) MO
MO
QL (120 EA per 30 days) MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 24 of 73
Drug Name
risperidone odt tbdp 1mg, 2mg
risperidone odt tbdp 0.25mg, 0.5mg, 3mg
risperidone soln
risperidone tabs 4mg
risperidone tabs 1mg, 2mg
risperidone tabs 0.25mg, 0.5mg, 3mg
SAPHRIS
thioridazine hcl tabs
thiothixene caps
trifluoperazine hcl tabs
VERSACLOZ
ziprasidone hcl
ZYPREXA RELPREVV INJ 405MG
ZYPREXA RELPREVV INJ 210MG, 300MG
Antispasticity Agents
baclofen tabs
dantrolene sodium caps
tizanidine hcl tabs
Antivirals
abacavir
abacavir sulfate/lamivudine/zidovudine
acyclovir sodium inj 1000mg, 50mg/ml
acyclovir sodium inj 500mg
acyclovir caps, susp, tabs
acyclovir oint
adefovir dipivoxil
APTIVUS SOLN
APTIVUS CAPS
ATRIPLA
BARACLUDE SOLN
BARACLUDE TABS
COMPLERA
CRIXIVAN CAPS 200MG, 400MG
DENAVIR
didanosine
EDURANT
EMTRIVA
entecavir
EPIVIR HBV SOLN
EPIVIR SOLN
EPZICOM
famciclovir tabs 125mg, 250mg
famciclovir tabs 500mg
foscarnet sodium
FUZEON
Drug
Tier
4
4
2
2
2
2
4
4
2
4
5
4
4
4
Requirements/Limits
QL (60 EA per 30 days) MO
QL (90 EA per 30 days) MO
MO
QL (120 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (60 EA per 30 days) MO
PA MO
MO
MO
ST
QL (60 EA per 30 days) MO
QL (1 EA per 28 days)
QL (2 EA per 28 days)
2
4
2
MO
MO
MO
4
5
2
2
2
4
2
5
5
5
4
5
5
3
4
4
5
4
5
4
4
5
4
4
4
5
MO
MO
B/D
B/D MO
MO
MO
QL (30 EA per 30 days) MO
MO
QL (30 EA per 30 days) MO
QL (630 ML per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO
MO
MO
QL (30 EA per 30 days) MO
MO
QL (30 EA per 30 days) MO
MO
MO
MO
QL (60 EA per 30 days) MO
QL (90 EA per 30 days) MO
B/D
QL (60 EA per 30 days)
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 25 of 73
Drug Name
ganciclovir inj
INTELENCE TABS 25MG
INTELENCE TABS 100MG, 200MG
INVIRASE CAPS
INVIRASE TABS
ISENTRESS PACK
ISENTRESS TABS
ISENTRESS CHEW 25MG
ISENTRESS CHEW 100MG
KALETRA SOLN
KALETRA TABS 100MG; 25MG
KALETRA TABS 200MG; 50MG
lamivudine
lamivudine/zidovudine
LEXIVA SUSP
LEXIVA TABS
moderiba tabs
nevirapine
nevirapine er
NORVIR
OLYSIO
PEG-INTRON
PEG-INTRON REDIPEN
PREZISTA SUSP
PREZISTA TABS 75MG
PREZISTA TABS 150MG, 600MG, 800MG
RELENZA DISKHALER
RESCRIPTOR
RETROVIR IV INFUSION
REYATAZ CAPS 150MG, 200MG, 300MG
ribavirin
rimantadine hcl
SELZENTRY TABS 300MG
SELZENTRY TABS 150MG
SOVALDI
stavudine
STRIBILD
SUSTIVA
TAMIFLU CAPS 30MG
TAMIFLU CAPS 45MG, 75MG
TAMIFLU SUSR 6MG/ML
TIVICAY
TRUVADA
TYBOST
TYZEKA
Drug
Tier
2
4
5
4
5
3
5
3
5
5
4
5
3
5
4
5
3
4
4
4
5
5
5
5
4
5
4
3
4
5
3
2
5
5
5
4
5
4
4
4
4
5
5
4
4
Requirements/Limits
B/D
QL (180 EA per 30 days)
QL (60 EA per 30 days) MO
MO
MO
QL (60 EA per 30 days)
QL (120 EA per 30 days) MO
QL (180 EA per 30 days) MO
QL (180 EA per 30 days) MO
QL (390 ML per 30 days) MO
QL (240 EA per 30 days) MO
QL (120 EA per 30 days) MO
MO
MO
MO
MO
PA
MO
MO
MO
QL (30 EA per 30 days) PA
PA
PA
MO
MO
QL (120 EA per 365 days) MO
MO
MO
PA
MO
QL (120 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (28 EA per 28 days) PA
MO
QL (30 EA per 30 days) MO
MO
QL (168 EA per 365 days) MO
QL (84 EA per 365 days) MO
QL (1080 ML per 365 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days)
QL (30 EA per 30 days) MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 26 of 73
Drug Name
valacyclovir hcl
VALCYTE
valganciclovir
VICTRELIS
VIDEX PEDIATRIC
VIRACEPT TABS
VIRAMUNE XR TB24 100MG
VIRAMUNE SUSP
VIRAZOLE
VIREAD POWD
VIREAD TABS 200MG, 250MG
VIREAD TABS 150MG, 300MG
ZIAGEN SOLN
zidovudine
Anxiolytics
alprazolam tabs 0.25mg, 0.5mg
alprazolam tabs 1mg, 2mg
buspirone hcl tabs
clorazepate dipotassium tabs 15mg
clorazepate dipotassium tabs 3.75mg, 7.5mg
diazepam intensol
diazepam inj 5mg/ml
diazepam oral soln 1mg/ml
diazepam tabs 10mg, 2mg, 5mg
lorazepam intensol
lorazepam tabs
lorazepam inj 4mg/ml
lorazepam inj 2mg/ml
Bipolar Agents
EQUETRO
lithium
lithium carbonate er
lithium carbonate caps, tabs
Blood Glucose Regulators
acarbose
glimepiride
glipizide er
glipizide xl
glipizide/metformin hcl
glipizide tabs
GLUCAGEN
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
glyburide micronized
glyburide/metformin hcl
Drug
Tier
4
5
5
5
4
5
4
4
5
4
4
4
4
3
MO
MO
MO
3
3
2
4
4
4
4
4
4
3
3
3
3
QL (120 EA per 30 days) MO
QL (150 EA per 30 days) MO
MO
QL (180 EA per 30 days) MO
QL (90 EA per 30 days) MO
MO
QL (240 ML per 30 days) PA MO
QL (1200 ML per 30 days) PA MO
QL (120 EA per 30 days) PA MO
QL (150 ML per 30 days) MO
QL (90 EA per 30 days) MO
QL (120 ML per 30 days)
QL (120 ML per 30 days) MO
4
2
2
2
MO
MO
MO
MO
2
1
2
2
2
1
3
3
3
4
4
MO
MO
MO
MO
MO
MO
QL (4 EA per 30 days) MO
QL (4 EA per 30 days) MO
QL (4 EA per 30 days) MO
PA MO
PA MO
Requirements/Limits
MO
MO
QL (360 EA per 30 days) PA
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 27 of 73
Drug Name
glyburide tabs
JENTADUETO
LEVEMIR
LEVEMIR FLEXTOUCH
metformin hcl er
metformin hcl tabs
nateglinide
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
NOVOLOG PENFILL
pioglitazone hcl
pioglitazone hcl-glimepiride
pioglitazone hcl/metformin hcl
PROGLYCEM
repaglinide tabs 0.5mg, 1mg
repaglinide tabs 2mg
SYMLINPEN 120
SYMLINPEN 60
tolazamide
tolbutamide
TRADJENTA
VICTOZA
Blood Products/Modifiers/Volume Expanders
AGGRENOX
anagrelide hydrochloride
ARANESP ALBUMIN FREE INJ 60MCG/0.3ML
ARANESP ALBUMIN FREE INJ 40MCG/0.4ML
ARANESP ALBUMIN FREE INJ 25MCG/0.42ML
ARANESP ALBUMIN FREE INJ 100MCG/0.5ML
ARANESP ALBUMIN FREE INJ 100MCG/ML,
25MCG/ML, 40MCG/ML, 60MCG/ML
ARANESP ALBUMIN FREE INJ 500MCG/ML
ARANESP ALBUMIN FREE INJ 150MCG/0.3ML
ARANESP ALBUMIN FREE INJ 200MCG/0.4ML
ARANESP ALBUMIN FREE INJ 300MCG/0.6ML
ARANESP ALBUMIN FREE INJ 150MCG/0.75ML
ARANESP ALBUMIN FREE INJ 200MCG/ML,
300MCG/ML
BRILINTA
cilostazol
Drug
Tier
4
3
3
3
1
1
2
3
3
3
3
3
3
3
3
2
2
2
4
2
2
4
4
2
2
3
3
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (90 EA per 30 days) MO
MO
QL (120 EA per 30 days) MO
QL (240 EA per 30 days) MO
QL (10.8 ML per 30 days) MO
QL (6 ML per 30 days) MO
MO
MO
MO
QL (9 ML per 30 days) MO
3
2
3
3
3
3
3
QL (60 EA per 30 days) MO
MO
QL (1.2 ML per 28 days) PA
QL (1.6 ML per 28 days) PA
QL (1.68 ML per 28 days) PA
QL (2 ML per 28 days) PA
QL (4 ML per 28 days) PA
5
5
5
5
5
5
QL (1 ML per 21 days) PA
QL (1.2 ML per 28 days) PA
QL (1.6 ML per 28 days) PA
QL (2.4 ML per 28 days) PA
QL (3 ML per 28 days) PA
QL (4 ML per 28 days) PA
3
2
QL (60 EA per 30 days) MO
MO
Requirements/Limits
PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 28 of 73
Drug Name
clopidogrel tabs 300mg
clopidogrel tabs 75mg
enoxaparin sodium
fondaparinux sodium
heparin sodium/d5w
heparin sodium/nacl 0.45%
heparin sodium/nacl 0.9%
heparin sodium/sodium chloride 0.9%
heparin sodium/sodium chloride 0.9% premix
heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml,
5000unit/0.5ml, 5000unit/ml
jantoven
LEUKINE INJ 250MCG
NEUMEGA
NEUPOGEN
PRADAXA
PROCRIT INJ 10000UNIT/ML, 20000UNIT/ML,
2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML
PROCRIT INJ 40000UNIT/ML
PROMACTA
ticlopidine hcl
tranexamic acid tabs
tranexamic acid inj
warfarin sodium tabs
XARELTO STARTER PACK
XARELTO TABS 10MG, 20MG
XARELTO TABS 15MG
Cardiovascular Agents
acebutolol hcl caps
acetazolamide er
acetazolamide tabs
amiloride hcl tabs
amiloride/hydrochlorothiazide
amiodarone hcl tabs
amlodipine besylate/atorvastatin calcium
amlodipine besylate/valsartan
amlodipine besylate tabs
amlodipine/valsartan/hctz
atenolol/chlorthalidone
atenolol tabs
atorvastatin calcium
benazepril hcl/hydrochlorothiazide
benazepril hcl tabs
betaxolol hcl tabs 10mg, 20mg
bisoprolol fumarate/hydrochlorothiazide
Drug
Tier
2
2
4
4
4
4
4
4
4
4
2
5
5
5
3
3
Requirements/Limits
QL (2 EA per 365 days)
QL (30 EA per 30 days) MO
MO
MO
MO
PA
PA
PA
QL (60 EA per 30 days) MO
QL (12 ML per 28 days) PA
5
5
4
3
4
2
3
3
3
QL (8 ML per 28 days) PA
QL (30 EA per 30 days) PA LA
PA MO
QL (30 EA per 5 days) PA MO
MO
QL (51 EA per 30 days)
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
2
4
3
2
2
2
4
2
2
2
2
2
2
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
MO
QL (30 EA per 30 days)
MO
MO
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 29 of 73
Drug
Drug Name
Tier
bumetanide inj, tabs
3
candesartan cilexetil
2
candesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg, 2
32mg; 25mg
candesartan cilexetil/hydrochlorothiazide tabs 16mg; 12.5mg 2
captopril/hydrochlorothiazide
1
captopril tabs
1
cartia xt
2
carvedilol
2
chlorothiazide tabs
2
chlorthalidone tabs 25mg, 50mg
2
cholestyramine light
2
cholestyramine pack, powd
2
clonidine hcl tabs
2
clonidine hcl ptwk
4
colestipol hcl
3
colestipol hcl for oral suspension
3
digox
2
digoxin oral soln, tabs
2
digoxin inj
4
dilt-cd
2
dilt-xr
2
diltiazem cd
2
diltiazem hcl cd
2
diltiazem hcl er
2
diltiazem hcl inj
2
diltiazem hcl tabs
2
diltzac
2
disopyramide phosphate caps
2
doxazosin mesylate
2
enalapril maleate/hydrochlorothiazide
1
enalapril maleate tabs
1
eprosartan mesylate
2
fenofibrate
3
fenofibrate micronized
3
fenofibric acid
3
fenofibric acid dr
3
flecainide acetate
2
fluvastatin
4
fosinopril sodium
2
fosinopril sodium/hydrochlorothiazide
2
furosemide inj, oral soln, tabs
2
gemfibrozil tabs
2
hydralazine hcl inj, tabs
2
hydrochlorothiazide caps, tabs
1
Requirements/Limits
MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (8 EA per 28 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
PA MO
MO
MO
MO
QL (30 EA per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 30 of 73
Drug Name
indapamide tabs
irbesartan
irbesartan/hydrochlorothiazide
isosorbide dinitrate er
isosorbide dinitrate tabs
isosorbide mononitrate
isosorbide mononitrate er
isradipine
labetalol hcl inj
labetalol hcl tabs
lidocaine hcl inj 10mg/ml, 20mg/ml
lisinopril
lisinopril/hydrochlorothiazide
losartan potassium/hydrochlorothiazide
losartan potassium tabs 100mg
losartan potassium tabs 25mg, 50mg
lovastatin
LOVAZA
matzim la
methazolamide
methyclothiazide tabs
metolazone
metoprolol succinate er
metoprolol tartrate inj, tabs
metoprolol/hydrochlorothiazide
mexiletine hcl
micronized colestipol hcl
midodrine hcl
minitran
minoxidil tabs
moexipril hcl
moexipril/hydrochlorothiazide
MULTAQ
nadolol/bendroflumethiazide
nadolol tabs 20mg, 40mg, 80mg
niacin er
nicardipine hcl caps
nitroglycerin lingual spray
nitroglycerin transdermal pt24 0.1mg/hr, 0.6mg/hr
nitroglycerin inj
nitroglycerin pt24 0.2mg/hr, 0.4mg/hr, 0.6mg/hr
NITROSTAT
omega-3-acid ethyl esters
pacerone
pentoxifylline cr
Drug
Tier
1
2
2
2
2
2
2
4
2
2
2
1
1
1
1
1
2
4
2
4
4
2
2
2
2
4
3
4
2
2
2
2
4
4
4
2
2
4
2
2
2
4
2
2
2
Requirements/Limits
MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
MO
QL (120 EA per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (60 EA per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (120 EA per 30 days) MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 31 of 73
Drug Name
pentoxifylline er
perindopril erbumine
pindolol
pravastatin sodium
prazosin hcl
prevalite
propafenone hcl
propafenone hcl er
propranolol hcl er
propranolol hcl inj
propranolol hcl oral soln, tabs
propranolol/hydrochlorothiazide
quinapril hcl
quinapril/hydrochlorothiazide
quinidine gluconate cr
quinidine gluconate er
quinidine sulfate
quinidine sulfate er
ramipril
simvastatin tabs 10mg, 20mg, 40mg, 5mg
simvastatin tabs 80mg
sorine
sotalol hcl
sotalol hcl (af)
spironolactone/hydrochlorothiazide
spironolactone tabs
taztia xt cp24 180mg, 300mg
taztia xt cp24 120mg, 240mg, 360mg
terazosin hcl
TIKOSYN
timolol maleate tabs 10mg, 20mg, 5mg
torsemide tabs
trandolapril
triamterene/hydrochlorothiazide
valsartan
valsartan/hydrochlorothiazide
VASCEPA
verapamil hcl er
verapamil hcl sr cp24
verapamil hcl sr tbcr 240mg
verapamil hcl inj, tabs
ZETIA
Central Nervous System Agents
amphetamine/dextroamphetamine tabs 5mg, 7.5mg, 10mg,
12.5mg, 15mg, 30mg
Drug
Tier
2
2
4
2
2
2
4
4
2
2
2
2
2
3
4
4
2
2
2
1
1
2
2
2
2
2
2
2
2
4
2
3
2
2
2
2
3
2
2
2
2
4
MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
3
QL (60 EA per 30 days) PA MO
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
MO
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 32 of 73
Drug Name
amphetamine/dextroamphetamine tabs 20mg
COPAXONE INJ 40MG/ML
COPAXONE INJ 20MG/ML
dextroamphetamine sulfate tabs
dextroamphetamine sulfate soln
EXTAVIA
INTUNIV
metadate er
methylphenidate hcl er tbcr 10mg, 20mg
methylphenidate hcl sr 20mg tab
methylphenidate hcl tabs 5mg, 10mg, 20mg
NUEDEXTA
riluzole
XENAZINE TABS 25MG
XENAZINE TABS 12.5MG
Dental and Oral Agents
chlorhexidine gluconate oral rinse
oralone
paroex
periogard
pilocarpine hcl tabs 7.5mg
pilocarpine hydrochloride
triamcinolone acetonide pste 0.1%
triamcinolone in orabase
Dermatological Agents
8-MOP
acitretin
ALTABAX
ammonium lactate crea, lotn
amnesteem
avita crea
avita gel
calcipotriene
calcitrene
claravis
clindamycin phosphate foam 1%
clindamycin phosphate gel 1%
clindamycin phosphate lotn 1%
clindamycin phosphate external soln 1%
clindamycin phosphate swab 1%
clindamycin/benzoyl peroxide
ELIDEL
ery acne pad
erythromycin/benzoyl peroxide
erythromycin gel 2%
Drug
Tier
3
5
5
4
4
5
4
4
4
4
2
3
5
5
5
Requirements/Limits
QL (90 EA per 30 days) PA MO
QL (12 ML per 28 days) PA
QL (30 ML per 30 days) PA
QL (180 EA per 30 days) PA MO
QL (1800 ML per 30 days) PA MO
QL (15 EA per 30 days) PA
QL (30 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (60 EA per 30 days) MO
MO
QL (120 EA per 30 days) PA LA
QL (90 EA per 30 days) PA LA
2
2
2
2
3
3
2
2
MO
MO
MO
MO
MO
4
5
4
2
4
4
4
4
4
4
2
2
2
2
2
4
4
2
2
2
PA MO
MO
MO
PA
PA
PA MO
MO
MO
PA
MO
MO
MO
MO
MO
MO
QL (60 GM per 30 days) ST MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 33 of 73
Drug Name
erythromycin pads 2%
erythromycin soln 2%
fluorouracil crea 0.5%
fluorouracil crea 5%
fluorouracil external soln 2%, 5%
gentamicin sulfate crea 0.1%
gentamicin sulfate external oint 0.1%
imiquimod crea
methoxsalen caps
metronidazole crea 0.75%
metronidazole gel 0.75%, 1%
metronidazole lotn 0.75%
mupirocin calcium cream
mupirocin oint
mupirocin crea
myorisan
OXSORALEN
podofilox soln
REGRANEX
rosadan
SANTYL
selenium sulfide lotn
silver sulfadiazine
sodium sulfacetamide lotn 10%
ssd
sulfacetamide sodium susp 10%
SULFAMYLON CREAM
TAZORAC
tretinoin crea 0.025%, 0.05%, 0.1%
tretinoin gel 0.01%, 0.025%
zenatane
ZONALON
Enzyme Replacement/Modifiers
ADAGEN
ALDURAZYME
BUPHENYL TABS
CEREZYME INJ 400UNIT
CREON
CYSTADANE
CYSTAGON
FABRAZYME
KUVAN
LUMIZYME
NAGLAZYME
ORFADIN
Drug
Tier
2
2
4
4
4
2
2
4
5
4
4
4
4
2
4
4
4
4
5
4
3
2
2
4
2
4
4
4
4
4
4
4
5
5
5
5
3
5
4
5
5
5
5
5
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA
MO
MO
QL (15 GM per 30 days) PA MO
MO
MO
MO
MO
MO
MO
MO
PA MO
PA MO
PA
MO
PA LA
PA LA
PA
PA
MO
PA
PA
PA
PA LA
PA
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 34 of 73
Drug Name
pancrelipase
sodium phenylbutyrate powd
VPRIV
ZAVESCA
ZENPEP CPEP 109000UNIT; 20000UNIT; 68000UNIT,
136000UNIT; 25000UNIT; 85000UNIT, 16000UNIT;
3000UNIT; 10000UNIT, 27000UNIT; 5000UNIT;
17000UNIT, 55000UNIT; 10000UNIT; 34000UNIT,
82000UNIT; 15000UNIT; 51000UNIT
Gastrointestinal Agents
AMITIZA
cimetidine hcl soln
cimetidine tabs
constulose
cromolyn sodium conc 100mg/5ml
dicyclomine hcl caps, soln, tabs
enulose
esomeprazole sodium inj
famotidine premixed
famotidine susr
famotidine inj 200mg/20ml, 40mg/4ml
famotidine inj 20mg/2ml
famotidine tabs 20mg, 40mg
gavilyte-c
gavilyte-g
gavilyte-n/flavor pack
generlac
glycopyrrolate inj, tabs
lactulose soln
loperamide hcl caps
LOTRONEX
methscopolamine bromide
metoclopramide hcl inj, oral soln, tabs
misoprostol tabs
omeprazole cpdr 20mg
omeprazole cpdr 10mg
omeprazole cpdr 40mg
pantoprazole sodium inj
pantoprazole sodium tbec 20mg
pantoprazole sodium tbec 40mg
peg 3350/electrolytes
peg-3350/nacl/na bicarbonate/kcl
polyethylene glycol 3350 pack, powd
ranitidine hcl caps, syrp
ranitidine hcl inj 150mg/6ml
Drug
Tier
2
5
5
5
3
3
2
2
2
2
4
2
3
4
2
2
2
2
2
2
2
2
4
2
2
5
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Requirements/Limits
MO
PA
PA
PA LA
MO
QL (60 EA per 30 days) MO
MO
MO
MO
PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (60 EA per 30 days) MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 35 of 73
Drug Name
ranitidine hcl inj 50mg/2ml
ranitidine hcl tabs 150mg, 300mg
RELISTOR INJ 12MG/0.6ML
RELISTOR INJ 12MG/0.6ML, 8MG/0.4ML
sucralfate susp, tabs
trilyte
ursodiol caps, tabs
Genitourinary Agents
bethanechol chloride tabs
calcium acetate caps
calcium acetate tabs 667mg
finasteride tabs 5mg
FOSRENOL
methylergonovine maleate tabs
MYRBETRIQ
oxybutynin chloride er tb24 5mg
oxybutynin chloride er tb24 10mg, 15mg
oxybutynin chloride tabs
oxybutynin chloride syrp
RENVELA
sevelamer carbonate
sodium chloride 0.9%
tamsulosin hcl
THIOLA
tolterodine tartrate tabs
VESICARE
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
a-hydrocort
alclometasone dipropionate
amcinonide
augmented betamethasone dipropionate
betamethasone dipropionate crea, lotn, oint
betamethasone valerate crea, foam, lotn, oint
budesonide cp24 3mg
clobetasol propionate e
clobetasol propionate emollient foam
clobetasol propionate crea, foam, gel, lotn, oint, sham, soln
colocort
cormax scalp application
cortisone acetate tabs
desonide crea, lotn, oint
desoximetasone crea, gel, oint
DEXAMETHASONE INTENSOL
dexamethasone sodium phosphate inj 100mg/10ml, 10mg/ml,
120mg/30ml, 20mg/5ml, 4mg/ml
Drug
Tier
2
2
4
4
4
2
4
Requirements/Limits
MO
MO
PA
PA MO
MO
MO
MO
3
3
3
2
4
4
3
2
2
2
2
3
3
2
2
3
2
3
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (120 EA per 30 days) MO
QL (600 ML per 30 days) MO
MO
MO
MO
MO
MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
2
4
4
4
4
4
5
2
2
2
2
2
2
4
4
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 36 of 73
Drug Name
dexamethasone sodium phosphate inj 10mg/ml
dexamethasone elix, soln, tabs
diflorasone diacetate crea, oint
fludrocortisone acetate tabs
fluocinolone acetonide body
fluocinolone acetonide scalp
fluocinolone acetonide crea 0.01%, 0.025%
fluocinolone acetonide oint 0.025%
fluocinolone acetonide soln 0.01%
fluocinonide-e
fluocinonide crea, gel, oint, soln
fluticasone propionate crea 0.05%
fluticasone propionate lotn 0.05%
fluticasone propionate oint 0.005%
halobetasol propionate
hydrocortisone butyrate (lipophilic)
hydrocortisone butyrate crea, oint, soln
hydrocortisone in absorbase
hydrocortisone valerate
hydrocortisone crea 2.5%
hydrocortisone enem, tabs
hydrocortisone lotn 2.5%
hydrocortisone oint 1%, 2.5%
methylprednisolone acetate inj
methylprednisolone dose pack
methylprednisolone sodiumsuccinate inj 1gm
methylprednisolone sodiumsuccinate inj 1000mg, 125mg,
40mg
methylprednisolone tabs
MILLIPRED
MILLIPRED DP
mometasone furoate crea, oint, soln
prednicarbate
prednisolone sodium phosphate oral soln 15mg/5ml,
25mg/5ml, 5mg/5ml
prednisolone soln, syrp
PREDNISONE INTENSOL
prednisone soln, tabs
proctosol hc
proctozone-hc
triamcinolone acetonide crea 0.025%, 0.1%, 0.5%
triamcinolone acetonide lotn 0.025%, 0.1%
triamcinolone acetonide oint 0.025%, 0.1%, 0.5%
triderm crea
Drug
Tier
3
3
4
3
4
4
4
4
4
4
4
2
2
2
4
4
4
2
4
2
2
2
2
4
4
4
4
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
4
4
4
2
4
2
MO
MO
MO
MO
MO
MO
2
4
2
2
2
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 37 of 73
Drug Name
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
desmopressin acetate inj, nasal soln, tabs
EGRIFTA INJ 2MG
INCRELEX
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX PEN INJ 30MG/3ML
VASOSTRICT
Hormonal Agents, Stimulant/Replacement/Modifying (Sex
Hormones/Modifiers)
altavera
alyacen 1/35
alyacen 7/7/7
amethia
amethia lo
AMETHYST
ANADROL-50
ANDROGEL PUMP GEL 1.62%
ANDROGEL PUMP GEL 1%
ANDROGEL GEL 20.25MG/1.25GM, 40.5MG/2.5GM
ANDROGEL GEL 25MG/2.5GM, 50MG/5GM
ANDROXY
apri
aranelle
aubra
aviane
azurette
balziva
briellyn
camila
camrese
camrese lo
caziant
chateal
cryselle-28
cyclafem 1/35
cyclafem 7/7/7
danazol caps
dasetta 1/35
dasetta 7/7/7
daysee
deblitane
DELYLA
DEPO-ESTRADIOL
DEPO-PROVERA 400MG/ML
desogestrel/ethinyl estradiol
Drug
Tier
3
5
5
5
5
4
4
4
4
4
4
4
4
3
3
3
3
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
Requirements/Limits
MO
QL (30 EA per 30 days) PA
PA LA
PA
PA
MO
MO
PA MO
QL (300 GM per 30 days) PA
PA MO
QL (300 GM per 30 days) PA MO
PA MO
MO
MO
MO
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 38 of 73
Drug
Tier
4
4
3
4
4
4
4
4
4
4
2
2
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
4
4
4
4
4
Drug Name
drospirenone/ethinyl estradiol
elinest
ELLA
emoquette
enpresse-28
enskyce
errin
estarylla
ESTRACE CREA
estradiol/norethindrone acetate
estradiol tabs
estradiol ptwk
falmina
gianvi
gildagia
gildess 1.5/30
gildess 1/20
gildess fe 1.5/30
gildess fe 1/20
heather
introvale
jencycla
jinteli
jolessa
jolivette
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
kariva
kelnor 1/35
kurvelo
larin 1.5/30
larin 1/20
larin fe 1.5/30
larin fe 1/20
leena
lessina
levonest
levonorgestrel
levonorgestrel and ethinyl estradiol
levonorgestrel/ethinyl estradiol
levora 0.15/30-28
loryna
low-ogestrel
Requirements/Limits
MO
MO
MO
PA MO PA MO QL (4 EA per 28 days) PA MO MO
MO
MO
PA MO MO
MO
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 39 of 73
Drug Name
lutera
lyza
marlissa
medroxyprogesterone acetate tabs
medroxyprogesterone acetate inj
megestrol acetate susp, tabs
MENEST
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
mimvey
mimvey lo
mono-linyah
mononessa
my way
myzilra
necon 0.5/35-28
necon 1/35
NECON 1/50-28
NECON 10/11-28
necon 7/7/7
next choice one dose
nikki
nora-be
norethindrone acetate/ethinyl estradiol
NORETHINDRONE ACETATE/ETHINYL
ESTRADIOL/FERROUS FUMARATE
norethindrone acetate tabs
norethindrone tabs
norgestimate/ethinyl estradiol
NORINYL 1+50
NORLYROC
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
ocella
OGESTREL
orsythia
oxandrolone tabs 2.5mg
oxandrolone tabs 10mg
philith
pimtrea
pirmella 1/35
pirmella 7/7/7
Drug
Tier
4
4
4
2
4
3
4
4
4
4
4
4
4
4
4
2
4
4
4
4
4
4
2
4
4
4
4
2
4
4
4
4
4
4
4
4
4
4
3
3
4
4
4
4
Requirements/Limits
MO
MO
MO
PA MO
PA MO
PA MO
PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (120 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 40 of 73
Drug Name
portia-28
previfem
progesterone caps, inj
quasense
raloxifene hydrochloride
reclipsen
sharobel
sprintec 28
sronyx
syeda
tarina fe 1/20
TESTIM
testosterone cypionate inj
testosterone enanthate inj
tilia fe
tri-estarylla
tri-legest fe
tri-linyah
tri-previfem
tri-sprintec
trinessa
trivora-28
VAGIFEM
velivet
vestura
viorele
vyfemla
wera
wymzya fe
zarah
zenchent
zenchent fe
zovia 1/35e
zovia 1/50e
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothyroxine sodium tabs
levoxyl
liothyronine sodium tabs
SYNTHROID
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
Drug
Tier
4
4
4
4
2
4
4
4
4
4
4
3
4
4
4
4
4
4
4
4
4
4
3
4
4
4
4
4
4
4
4
4
4
4
MO
2
2
2
3
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
Requirements/Limits
MO
MO
MO
MO
QL (300 GM per 30 days) PA MO
PA MO
PA MO
MO
MO
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 41 of 73
Drug Name
unithroid tabs 100mcg, 112mcg, 125mcg, 150mcg, 175mcg,
200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TABS 30MG
SENSIPAR TABS 90MG
SENSIPAR TABS 60MG
Hormonal Agents, Suppressant (Pituitary)
cabergoline
FIRMAGON INJ 80MG
FIRMAGON INJ 120MG
leuprolide acetate inj
LUPRON DEPOT
LUPRON DEPOT-PED
octreotide acetate
SIGNIFOR
SOMATULINE DEPOT INJ 60MG/0.2ML
SOMATULINE DEPOT INJ 90MG/0.3ML
SOMATULINE DEPOT INJ 120MG/0.5ML
SOMAVERT INJ 25MG, 30MG
SOMAVERT INJ 10MG, 15MG, 20MG
SYNAREL
TRELSTAR DEPOT MIXJECT
TRELSTAR LA MIXJECT
TRELSTAR MIXJECT
VANTAS
ZOLADEX
Hormonal Agents, Suppressant (Thyroid)
methimazole tabs
propylthiouracil tabs
Immunological Agents
ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML
ACTHIB
ACTIMMUNE
ADACEL
ARCALYST
ATGAM
azathioprine tabs
bcg vaccine
BENLYSTA
BOOSTRIX
CELLCEPT INTRAVENOUS
CELLCEPT SUSR
CERVARIX
Drug
Tier
2
Requirements/Limits
3
MO
3
5
5
QL (60 EA per 30 days)
QL (120 EA per 30 days)
QL (60 EA per 30 days)
4
4
5
2
5
5
4
5
5
5
5
5
5
5
5
5
5
4
4
MO
PA
PA
PA
PA
PA
PA
QL (60 ML per 30 days) PA
QL (0.2 ML per 28 days) PA
QL (0.3 ML per 28 days) PA
QL (0.5 ML per 28 days) PA
PA
PA LA
MO
PA
PA
PA
2
2
MO
MO
5
4
5
4
5
5
2
2
5
4
4
5
4
QL (40 ML per 28 days) PA
PA LA
PA
PA
B/D MO
PA
PA
PA MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 42 of 73
Drug Name
CIMZIA
CIMZIA STARTER KIT
CINRYZE
COMVAX
cyclosporine modified
cyclosporine inj
cyclosporine caps
DAPTACEL
diphtheria/tetanus toxoids adsorbed pediatric
ENGERIX-B
FIRAZYR
GAMASTAN S/D
GAMMAPLEX
GAMUNEX-C
GARDASIL
gengraf caps
gengraf soln
HAVRIX
hecoria
HUMIRA PEDIATRIC CROHNS DISEASE STARTER
PACK
HUMIRA PEN
HUMIRA PEN-CROHNS DISEASESTARTER
HUMIRA PEN-PSORIASIS STARTER
HUMIRA INJ 10MG/0.2ML, 20MG/0.4ML
HUMIRA INJ 40MG/0.8ML
ILARIS
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
IXIARO
KINRIX
leflunomide
M-M-R II W/DILUENT 10 DOSE
MENACTRA
MENOMUNE-A/C/Y/W-135
MENVEO
methotrexate sodium inj 1gm/40ml, 1gm
methotrexate sodium inj 25mg/ml
methotrexate tabs
mycophenolate mofetil caps, tabs
NULOJIX
PEDIARIX
PEDVAX HIB
PENTACEL
Drug
Tier
5
5
5
4
4
4
4
4
2
3
5
3
5
5
4
4
4
4
4
5
5
5
5
5
5
5
4
4
3
4
4
2
3
4
3
4
2
2
2
4
5
4
4
4
Requirements/Limits
QL (6 EA per 28 days) PA
QL (6 EA per 28 days) PA
PA
PA MO
PA
PA MO
B/D
QL (270 ML per 30 days) PA
PA
PA
PA
MO
PA
PA MO
PA
QL (6 EA per 28 days) PA
QL (6 EA per 28 days) PA
QL (6 EA per 28 days) PA
QL (6 EA per 28 days) PA
QL (2 EA per 28 days) PA
QL (6 EA per 28 days) PA
QL (2 EA per 28 days) PA
B/D
MO
MO
MO
PA MO
PA MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 43 of 73
Drug Name
PROGRAF INJ
PROQUAD
RABAVERT
RAPAMUNE SOLN
RAPAMUNE TABS 1MG, 2MG
RECOMBIVAX HB
REMICADE
ROTARIX
ROTATEQ
SANDIMMUNE SOLN
SIMULECT
sirolimus tabs
SYNAGIS
tacrolimus caps
TENIVAC
tetanus toxoid adsorbed
tetanus/diphtheria toxoids-adsorbed adult
THYMOGLOBULIN
TWINRIX
TYPHIM VI
VAQTA
VARIVAX
YF-VAX
ZORTRESS TABS 0.25MG
ZORTRESS TABS 0.5MG, 0.75MG
ZOSTAVAX
Inflammatory Bowel Disease Agents
APRISO
balsalazide disodium
mesalamine enem, kit
sulfasalazine tabs, tbec
sulfazine
sulfazine ec
Metabolic Bone Disease Agents
alendronate sodium soln
alendronate sodium tabs 10mg, 40mg, 5mg
alendronate sodium tabs 35mg, 70mg
calcitonin-salmon
calcitriol caps, oral soln
calcitriol inj 1mcg/ml
doxercalciferol caps
etidronate disodium
FORTEO
MIACALCIN INJ
pamidronate disodium inj 30mg, 90mg/10ml, 90mg
Drug
Tier
4
4
4
4
4
4
5
4
3
4
5
4
5
4
4
3
3
5
4
4
4
3
3
4
5
4
3
2
4
2
2
2
2
2
2
3
2
2
4
4
5
4
4
Requirements/Limits
PA
B/D
PA MO
PA MO
B/D
PA
PA MO
B/D
PA MO
PA
PA MO
B/D
PA
PA MO
PA MO
QL (1 EA per 365 days)
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
QL (4 EA per 28 days) MO
MO
MO
MO
MO
QL (2.4 ML per 28 days) PA
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 44 of 73
Drug Name
pamidronate disodium inj 30mg/10ml, 6mg/ml
paricalcitol inj
paricalcitol caps
PROLIA
risedronate sodium
XGEVA
zoledronic acid inj 5mg/100ml
zoledronic acid inj 4mg/5ml, 4mg
Miscellaneous Therapeutic Agents
ALCOHOL PREPS
BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2"
BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16"
BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2"
BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16"
BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM
CURITY GAUZE PADS 2"X2"
V-GO 20
V-GO 30
V-GO 40
Ophthalmic Agents
ACUVAIL
ak-poly-bac
ALPHAGAN P SOLN 0.1%
apraclonidine
AZASITE
azelastine hcl ophthalmic soln 0.05%
bacitracin/neomycin/polymyxin
bacitracin/polymyxin b
bacitracin oint 500unit/gm
BESIVANCE
betaxolol hcl soln 0.5%
brimonidine tartrate
carteolol hcl
ciprofloxacin hcl soln 0.3%
COMBIGAN
cromolyn sodium soln 4%
CYSTARAN
dexamethasone sodium phosphate ophthalmic soln 0.1%
dorzolamide hcl
dorzolamide hcl/timolol maleate
DUREZOL
epinastine hcl
erythromycin oint 5mg/gm
fluorometholone
flurbiprofen sodium
Drug
Tier
4
2
2
4
3
5
4
5
Requirements/Limits
MO
MO
QL (1 ML per 180 days) PA
QL (1 EA per 28 days) MO
PA
3
3
3
3
3
3
3
3
3
3
MO
ST MO
ST MO
ST MO
ST MO
ST MO
4
2
3
3
3
3
2
2
4
4
2
3
2
2
3
2
5
2
2
2
4
3
2
2
2
MO
ST MO
ST MO
ST MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (60 ML per 28 days)
MO
MO
MO
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 45 of 73
Drug Name
garamycin oint
gentak
gentamicin sulfate ophthalmic oint 0.3%
gentamicin sulfate ophthalmic soln 0.3%
ILEVRO
ISOPTO CARPINE
ketorolac tromethamine
latanoprost
levobunolol hcl
levofloxacin ophthalmic soln 0.5%
LUMIGAN SOLN 0.01%
metipranolol
naphazoline hcl
neo-polycin
neomycin/bacitracin/polymyxin
neomycin/polymyxin/bacitracin/hydrocortisone
neomycin/polymyxin/dexamethasone
neomycin/polymyxin/gramicidin
neomycin/polymyxin/hydrocortisone ophthalmic susp 1%;
3.5mg/ml; 10000unit/ml
NEVANAC
ofloxacin ophthalmic soln 0.3%
PATADAY
PATANOL
PHOSPHOLINE IODIDE
pilocarpine hcl soln 1%, 2%, 4%
polycin
polymyxin b sulfate/trimethoprim sulfate
prednisolone acetate
prednisolone sodium phosphate ophthalmic soln 1%
PROLENSA
proparacaine hcl
RESTASIS
SIMBRINZA
sodium sulfacetamide soln 10%
sulfacetamide sodium/prednisolone sodium phosphate
sulfacetamide sodium oint 10%
sulfacetamide sodium soln 10%
timolol maleate ophthalmic gel forming
timolol maleate soln 0.25%, 0.5%
tobramycin sulfate ophthalmic soln 0.3%
tobramycin/dexamethasone
TOBREX OINT
TRAVATAN Z
travoprost
Drug
Tier
2
2
2
2
4
4
2
2
2
2
3
2
2
2
2
2
2
2
2
4
2
4
4
4
2
2
2
2
2
4
2
3
4
2
2
4
2
2
2
2
3
4
4
4
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 46 of 73
Drug Name
trifluridine
trimethoprim sulfate/polymyxin b sulfate
triple antibiotic
ZIRGAN
Otic Agents
acetasol hc
acetic acid
acetic acid/aluminum acetate
antibiotic ear
fluocinolone acetonide oil 0.01%
hydrocortisone/acetic acid
neomycin/polymyxin/hc
neomycin/polymyxin/hydrocortisone otic susp 1%; 3.5mg/ml;
10000unit/ml
ofloxacin otic soln 0.3%
Respiratory Tract/Pulmonary Agents
acetylcysteine soln
ADVAIR DISKUS
ADVAIR HFA
albuterol sulfate er
albuterol sulfate nebu
albuterol sulfate syrp, tabs
aminophylline inj
ARCAPTA NEOHALER
ASMANEX TWISTHALER 120 METERED DOSES
ASMANEX TWISTHALER 14 METERED DOSES
ASMANEX TWISTHALER 30 METERED DOSES
ASMANEX TWISTHALER 60 METERED DOSES
ASMANEX TWISTHALER 7 METERED DOSES
azelastine hcl nasal soln 0.15%
azelastine hcl nasal soln 137mcg/spray
BREO ELLIPTA
budesonide inhalation susp 0.25mg/2ml, 0.5mg/2ml
budesonide nasal susp 32mcg/act
CAYSTON
clemastine fumarate syrp
clemastine fumarate tabs 2.68mg
COMBIVENT RESPIMAT
cromolyn sodium nebu 20mg/2ml
DALIRESP
diphenhydramine hcl elix
diphenhydramine hcl inj
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
epoprostenol sodium
Drug
Tier
4
2
2
4
Requirements/Limits
MO
MO
MO
4
4
4
2
4
4
2
2
MO
MO
MO
MO
2
MO
3
3
3
4
2
2
2
4
3
3
3
3
3
3
3
4
4
4
5
4
4
3
2
4
2
2
3
3
3
B/D MO
QL (60 EA per 30 days) MO
QL (12 GM per 30 days) MO
MO
B/D MO
MO
MO
QL (30 EA per 30 days) MO
QL (1 EA per 30 days) MO
QL (2 EA per 28 days) MO
QL (1 EA per 30 days) MO
QL (1 EA per 30 days) MO
QL (4 EA per 28 days)
MO
QL (30 ML per 25 days) MO
QL (60 EA per 30 days) MO
B/D MO
MO
QL (84 ML per 56 days) LA
PA MO
PA MO
QL (8 GM per 30 days) MO
B/D MO
QL (30 EA per 30 days) MO
PA
PA MO
QL (2 EA per 30 days) MO
QL (2 EA per 30 days) MO
PA
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 47 of 73
Drug Name
flunisolide soln 0.025%
fluticasone propionate susp 50mcg/act
FORADIL AEROLIZER
hydroxyzine hcl inj
ipratropium bromide/albuterol sulfate
ipratropium bromide inhalation soln
ipratropium bromide nasal soln
levalbuterol hcl nebu
levalbuterol nebu
levocetirizine dihydrochloride tabs
levocetirizine dihydrochloride soln
metaproterenol sulfate syrp, tabs
montelukast sodium
olopatadine hcl
OPSUMIT
PROAIR HFA
PROLASTIN-C
PULMOZYME
QVAR
sildenafil
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
terbutaline sulfate tabs
theophylline cr tb12 100mg, 200mg
theophylline er
tobramycin nebu
TRACLEER
triamcinolone acetonide aero 55mcg/act
TUDORZA PRESSAIR
TYZINE PEDIATRIC NASAL DROPS
VENTAVIS
VENTOLIN HFA
XOLAIR
zafirlukast
Skeletal Muscle Relaxants
chlorzoxazone tabs
cyclobenzaprine hcl tabs
Sleep Disorder Agents
modafinil tabs 100mg
modafinil tabs 200mg
ROZEREM
XYREM
zaleplon caps 5mg
zaleplon caps 10mg
zolpidem tartrate
Drug
Tier
2
2
3
4
2
2
2
4
4
4
4
2
2
4
5
3
5
5
3
5
3
3
2
2
2
5
5
4
3
4
5
3
5
4
Requirements/Limits
MO
MO
QL (60 EA per 30 days) MO
PA MO
B/D MO
B/D MO
MO
B/D MO
B/D MO
QL (30 EA per 30 days) MO
QL (300 ML per 30 days) MO
MO
QL (30 EA per 30 days) MO
QL (30.5 GM per 30 days) MO
QL (30 EA per 30 days) PA
QL (17 GM per 30 days) MO
PA LA MO
B/D
QL (17.4 GM per 30 days) MO
QL (90 EA per 30 days) PA
QL (30 EA per 30 days) MO
QL (4 GM per 30 days)
MO
MO
MO
QL (280 ML per 56 days) B/D
QL (60 EA per 30 days) PA LA
MO
QL (1 EA per 30 days) MO
PA
QL (36 GM per 30 days) MO
QL (6 EA per 28 days) PA LA
QL (60 EA per 30 days) MO
4
3
QL (180 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
3
3
4
5
3
3
4
QL (30 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
QL (30 EA per 30 days) MO
QL (540 ML per 30 days) PA LA
QL (30 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
QL (30 EA per 30 days) PA MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 48 of 73
Drug
Drug Name
Tier
Therapeutic Nutrients/Minerals/Electrolytes
AMINOSYN 7%/ELECTROLYTES
4
aminosyn 8.5%/electrolytes
4
AMINOSYN II
4
aminosyn ii 8.5%/electrolytes
4
AMINOSYN-HBC
4
AMINOSYN-PF
4
AMINOSYN-PF 7%
4
AMINOSYN-RF
4
AMINOSYN INJ 148MEQ/L; 1280MG/100ML;
4
980MG/100ML; 1280MG/100ML; 300MG/100ML;
720MG/100ML; 940MG/100ML; 720MG/100ML;
400MG/100ML; 440MG/100ML; 5.4MEQ/L;
860MG/100ML; 420MG/100ML; 520MG/100ML;
160MG/100ML; 44MG/100ML; 800MG/100ML, 90MEQ/L;
1100MG/100ML; 850MG/100ML; 35MEQ/L;
1100MG/100ML; 260MG/100ML; 620MG/100ML;
810MG/100ML; 624MG/100ML; 340MG/100ML;
380MG/100ML; 5.4MEQ/L; 750MG/100ML;
370MG/100ML; 460MG/100ML; 150MG/100ML;
44MG/100ML; 680MG/100ML
BAL-CARE DHA
4
BAL-CARE DHA ESSENTIAL
4
cavan-ec sod dha
4
CITRANATAL 90 DHA MISC 120MG; 160MG; 400UNIT; 4
2MG; 300MG; 50MG; 0.75MG; 1MG; 90MG; 20MG;
150MCG; 20MG; 3.4MG; 3MG; 30UNIT; 25MG
CITRANATAL ASSURE MISC 120MG; 125MG; 400UNIT; 4
2MG; 300MG; 50MG; 0.75MG; 1MG; 35MG; 20MG;
150MCG; 25MG; 3.4MG; 3MG; 30UNIT; 25MG
CITRANATAL B-CALM MISC 120MG; 120MG; 400UNIT; 4
0; 1MG; 20MG; 0; 25MG
CITRANATAL DHA MISC 120MG; 125MG; 400UNIT;
4
2MG; 250MG; 50MG; 0.625MG; 0; 1MG; 27MG; 0; 20MG;
150MCG; 20MG; 3.4MG; 3MG; 30UNIT; 25MG
CITRANATAL HARMONY CAPS 650MG; 104MG;
4
400UNIT; 265MG; 50MG; 1MG; 29MG; 25MG; 30UNIT
CITRANATAL RX TABS 120MG; 125MG; 400UNIT;
4
2MG; 30UNIT; 50MG; 1MG; 27MG; 20MG; 150MCG;
20MG; 3.4MG; 3MG; 25MG
clinisol sf 15%
4
complete natal dha
4
completenate
4
CONCEPT DHA
4
CONCEPT OB
4
Requirements/Limits
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
MO
MO
MO
MO
MO
MO
MO
B/D
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 49 of 73
Drug
Drug Name
Tier
CUPRIMINE
4
DEPEN TITRATABS
4
dextrose 10%/nacl 0.45%
2
dextrose 10% flex container
2
dextrose 10%/nacl 0.2%
2
dextrose 2.5%/sodium chloride 0.45%
2
dextrose 20%
2
dextrose 25%
2
dextrose 30%
2
dextrose 40%
2
dextrose 5%
2
dextrose 5%/lactated ringers
2
dextrose 5%/nacl 0.2%
2
dextrose 5%/nacl 0.225%
2
dextrose 5%/nacl 0.3%
2
dextrose 5%/nacl 0.33%
2
dextrose 5%/nacl 0.45%
2
dextrose 5%/nacl 0.9%
2
dextrose 5%/potassium chloride 0.15%
2
dextrose 50%
2
dextrose 70%
2
DUET DHA BALANCED MISC 120MG; 2840UNIT;
4
215MG; 840UNIT; 2MG; 12MCG; 0; 0; 0; 1MG; 210MCG;
26MG; 0; 25MG; 20MG; 278MG; 0; 50MG; 4MG; 0; 1.5MG;
2MG; 25MG
ESCAVITE D
4
EXJADE
5
EXTRA-VIRT PLUS DHA
4
fluoritab chew 0.5mg, 1mg
4
FLURA-DROPS SOLN 0.25MG/DROP
4
FOCALGIN-B
4
FOLCAL DHA
4
FOLCAPS OMEGA 3
4
FOLET ONE
4
FOLIVANE-OB
4
FOLIVANE-PRX DHA NF
4
fomepizole
5
HEMENATAL OB
4
HEMENATAL OB + DHA
4
hepatamine
4
hepatasol
4
inatal advance
4
inatal ultra
4
INTRALIPID INJ 1.7%; 30%
4
intralipid inj 2.25%; 20%
4
Requirements/Limits
MO
MO
B/D
B/D
B/D
B/D
B/D
MO
MO
B/D
B/D
PA LA
MO
MO
MO
MO
MO
MO
MO
MO
B/D
B/D
B/D
B/D
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 50 of 73
Drug
Drug Name
Tier
kcl 0.075%/d5w/nacl 0.45%
2
kcl 0.15%/d5w/lr
2
kcl 0.15%/d5w/nacl 0.2%
2
kcl 0.15%/d5w/nacl 0.225%
2
kcl 0.15%/d5w/nacl 0.45%
2
kcl 0.15%/d5w/nacl 0.9%
2
kcl 0.3%/d5w/lr iv lac ring
2
kcl 0.3%/d5w/nacl 0.45%
2
kcl 0.3%/d5w/nacl 0.9%
2
kionex powd
4
kionex susp
4
klor-con 10
2
klor-con 8
2
klor-con m10
2
klor-con m20
2
lactated ringers dextrose 5% viaflex
2
lactated ringers viaflex
2
levocarnitine tabs
3
LIPOSYN III
4
mult-vitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.5mg; 4
0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1.05mg; 2500unit; 15unit
multi-vit/fluoride soln 35mg/ml; 400unit/ml; 2mcg/ml;
4
8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml;
1500unit/ml
multi-vit/iron/fluoride soln 35mg/ml; 400unit/ml; 10mg/ml; 4
8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml;
1500unit/ml
multi-vitamin/fluoride/iron soln 35mg/ml; 400unit/ml;
4
5unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml;
0.5mg/ml; 1500unit/ml
multi-vitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.3mg; 4
13.5mg; 1.05mg; 1.2mg; 1mg; 1.05mg; 2500unit; 15unit
multi-vitamin/fluoride soln 35mg/ml; 400unit/ml; 2mcg/ml; 4
5unit/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 0.5mg/ml;
1500unit/ml
multivitamin with fluoride chew 60mg; 4.5mcg; 0.3mg;
4
13.5mg; 1.05mg; 1.2mg; 0.25mg; 1.05mg; 2500unit; 400unit;
15unit, 60mg; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg;
0.5mg; 1.05mg; 2500unit; 400unit; 15unit
mvc-fluoride
4
NATACHEW CHEW 120MG; 2700UNIT; 400UNIT;
4
12MCG; 0; 0; 1MG; 28MG; 20MG; 10MG; 3MG; 0; 2MG;
20UNIT
NATAFORT TABS 120MG; 400UNIT; 12MCG; 0; 1MG;
4
60MG; 0; 20MG; 10MG; 3MG; 2MG; 11UNIT
Requirements/Limits
MO
MO
MO
MO
MO
MO
B/D
MO
MO
MO
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 51 of 73
Drug Name
NATAL-V RX
NATALVIRT 90 DHA
NATALVIRT CA
NEPHRAMINE
NESTABS
NESTABS DHA
NEXA PLUS CAPS 28MG; 250MCG; 660MG; 160MG;
800UNIT; 350MG; 55MG; 29MG; 1.25MG; 25MG; 30UNIT
O-CAL PRENATAL
OB COMPLETE ONE
OB COMPLETE PETITE
OB COMPLETE PREMIER
OB COMPLETE/DHA
PAIRE OB
PERIKABIVEN
PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID
PNV FOLIC ACID + IRON MULTIVITAMIN
PNV OB+DHA
PNV PRENATAL PLUS MULTIVITAMIN
PNV TABS 29-1
pnv-dha
PNV-FIRST
pnv-select
PNV-VP-U
poly-vitamin/fluoride chew
poly-vitamin/fluoride soln 35mg/ml; 50mcg/ml; 2mcg/ml;
0.25mg/ml; 8mg/ml; 3mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml;
1500unit/ml; 400unit/ml; 5unit/ml
polyvits/fluoride/iron
potassium chloride 0.15% /nacl 0.45% viaflex
potassium chloride 0.15% d5w/nacl 0.33%
potassium chloride 0.15% d5w/nacl 0.45%
potassium chloride 0.15% d5w/nacl 0.45% viaflex
potassium chloride 0.15% nacl 0.9%
potassium chloride 0.22% d5w/nacl 0.45%
potassium chloride 0.224%d5w/nacl 0.45% viaflex
potassium chloride 0.3%/ nacl 0.9%
potassium chloride 0.3%/d5w
potassium chloride cr tbcr 10meq, 20meq
potassium chloride er
potassium chloride sr tbcr 8meq
potassium chloride inj 10meq/50ml, 20meq/100ml,
40meq/100ml
potassium chloride inj 0.4meq/ml, 10meq/100ml, 2meq/ml
potassium citrate er
Drug
Tier
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
Requirements/Limits
MO
MO
MO
B/D
MO
MO
MO
MO
MO
MO
MO
MO
MO
B/D
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 52 of 73
Drug
Drug Name
Tier
pr natal 400
4
pr natal 400 ec
4
pr natal 430
4
pr natal 430 ec
4
PREFERA OB
4
PREFERA OB + DHA MISC 30MCG; 10MG; 400UNIT;
4
0.8MG; 12MCG; 200MG; 2.5MG; 1MG; 6MG; 0.5MG;
17MG; 203MG; 28MG; 250MCG; 50MG; 1.6MG; 65MCG;
1.5MG; 10UNIT; 4.5MG
PREFERAOB ONE
4
PREMASOL INJ 52MEQ/L; 1760MG/100ML;
4
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML; 526MG/100ML;
492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML; 390MG/100ML;
34MG/100ML; 152MG/100ML
premasol inj 56meq/l; 320mg/100ml; 730mg/100ml;
4
190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml;
220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml;
490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml;
230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml;
120mg/100ml; 140mg/100ml; 470mg/100ml
PRENA1 CHEW/QUATREFOLIC
4
PRENA1 PLUS/QUATREFOLIC
4
PRENA1/QUATREFOLIC
4
PRENAISSANCE
4
PRENAISSANCE PLUS
4
PRENATA
4
prenatabs fa
4
PRENATABS OBN
4
PRENATAL 19 CHEW 100MG; 1000UNIT; 200MG; 7MG; 4
400UNIT; 12MCG; 29MG; 1MG; 15MG; 20MG; 3MG;
3MG; 30UNIT; 20MG
PRENATAL 19 TABS 100MG; 1000UNIT; 200MG; 7MG; 4
400UNIT; 12MCG; 25MG; 29MG; 1MG; 15MG; 20MG;
3MG; 3MG; 30UNIT; 20MG
prenatal plus iron tabs 120mg; 0; 200mg; 400unit; 2mg;
4
12mcg; 1mg; 29mg; 20mg; 10mg; 3mg; 1.84mg; 22mg;
4000unit; 25mg
PRENATAL PLUS TABS 120MG; 0; 200MG; 400UNIT;
4
2MG; 12MCG; 27MG; 1MG; 20MG; 10MG; 3MG; 1.84MG;
22MG; 4000UNIT; 25MG
PRENATE AM
4
PRENATE DHA CAPS 90MG; 145MG; 220UNIT; 13MCG; 4
300MG; 28MG; 400MCG; 600MCG; 50MG; 26MG; 10UNIT
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
B/D
B/D
MO
MO
MO
MO
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 53 of 73
Drug
Drug Name
Tier
PRENATE ELITE TABS 75MG; 2600UNIT; 330MCG;
4
100MG; 6MG; 450UNIT; 1.5MG; 13MCG; 26MG; 400MCG;
150MCG; 600MCG; 25MG; 21MG; 21MG; 3.5MG; 3MG;
10UNIT; 15MG
PRENATE ESSENTIAL CAPS 90MG; 280MCG; 145MG; 4
220UNIT; 13MCG; 300MG; 40MG; 29MG; 0; 400MCG;
600MCG; 50MG; 150MCG; 26MG; 10UNIT
PRENATE MINI CAPS 60MG; 280MCG; 100MG;
4
220UNIT; 13MCG; 350MG; 400MCG; 29MG; 600MCG;
25MG; 150MCG; 26MG; 10UNIT; 25MG
PREPLUS
4
PREQUE 10 TABS 30MG; 1250UNIT; 0; 120UNIT; 50MG; 4
1MG; 1MCG; 15UNIT; 50MG; 25MG; 0.5MG; 15MG; 5MG;
10MG; 1.7MG; 0; 7.5MCG; 1MG; 12.5MG
PRETAB
4
PUREFE OB PLUS
4
REAPHIRM
4
RELNATE DHA
4
ringers injection
2
SAMSCA TABS 15MG
5
SAMSCA TABS 30MG
5
se-natal 19
4
se-tan dha
4
SELECT-OB CHEW 60MG; 0; 400UNIT; 5MCG; 0.4MG; 4
0.6MG; 25MG; 15MG; 29MG; 2.5MG; 1.8MG; 0; 1.6MG;
30UNIT; 1700UNIT; 15MG
seton et-ec
4
setonet
4
sodium chloride 0.45% viaflex
2
sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5%
2
sodium fluoride chew 0.5mg, 1.1mg
4
sodium polystyrene sulfonate rectal susp
4
sodium polystyrene sulfonate powd, oral susp
4
SYPRINE
3
TARON-PREX
4
TL-CARE DHA
4
TL-SELECT
4
TL-SELECT DHA
4
tpn electrolytes
4
tri-vit/fluoride
4
tri-vit/fluoride/iron
4
tri-vitamin/fluoride
4
triadvance
4
TRICARE
4
TRICARE PRENATAL COMPLEAT
4
Requirements/Limits
MO
MO
MO
MO
MO
QL (30 EA per 30 days) PA
QL (60 EA per 30 days) PA
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 54 of 73
Drug Name
TRICARE PRENATAL DHA ONE
TRINATAL GT
trinatal rx 1
triple-vitamin/fluoride
TRIVEEN-DUO DHA
TRIVEEN-PRX RNF
ultimatecare one nf
VEMAVITE-PRX 2
VENA-BAL DHA
VIRT-PN
VIRT-PN DHA
VIRT-PN PLUS
VIRT-SELECT
VITAFOL-ONE
VITAFOL-PLUS
VITAMEDMD ONE RX/QUATREFOLIC
VITAMEDMD PLUS RX/QUATRE FOLIC
VITAMEDMD REDICHEW RX/QUATREFOLIC
vitamins a/c/d/fluoride
vitamins a/d/c/fluoride
VOL-NATE
VOL-PLUS
VP CH ULTRA
VP-CH-PNV
VP-HEME OB
VP-PNV-DHA
ZATEAN-CH
ZATEAN-PN
ZATEAN-PN DHA
ZATEAN-PN PLUS
ZINGIBER
Unclassified
ESCAVITE LQ
FLORIVA
FOLET DHA
KABIVEN
PRENATE PIXIE
TRIUMEQ
Drug
Tier
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
5
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
B/D
QL (30 EA per 30 days) MO
*You can find information on what the symbols and abbreviations on this table mean by going to page
numbers 6 and 7.
Page 55 of 73
Index
Drug Name
8-MOP
abacavir
abacavir sulfate/lamivudine/zidovudine
ABELCET
ABILIFY
ABILIFY DISCMELT
ABILIFY MAINTENA
ABRAXANE
acamprosate calcium dr
acarbose
acebutolol hcl
acetaminophen/codeine
acetaminophen/codeine #3
acetasol hc
acetazolamide
acetazolamide er
acetic acid
acetic acid/aluminum acetate
acetylcysteine
acitretin
ACTEMRA
ACTHIB
ACTIMMUNE
ACUVAIL
acyclovir
acyclovir sodium
ADACEL ADAGEN
ADASUVE
adefovir dipivoxil
adriamycin
adrucil
ADVAIR DISKUS
ADVAIR HFA
AFINITOR
AFINITOR DISPERZ
AGGRENOX
a-hydrocort
ak-poly-bac
ALBENZA
albuterol sulfate
albuterol sulfate er
alclometasone dipropionate
ALCOHOL PREPS
ALDURAZYME
alendronate sodium
Page #
33
25
25
17
24
24
24
19
10
27
29
8
8
47
29
29
47
47
47
33
42
42
42
45
25
25
42
34
24
25
19
19
47
47
19
19
28
36
45
23
47
47
36
45
34
44
Page 56 of 73 Drug Name
ALIMTA
ALINIA
ALKERAN
allopurinol
ALPHAGAN P
alprazolam
ALTABAX
altavera
alyacen 1/35
alyacen 7/7/7
amantadine hcl
AMBISOME
amcinonide
amethia
amethia lo
AMETHYST
amifostine
amikacin sulfate
amiloride hcl
amiloride/hydrochlorothiazide
aminophylline
AMINOSYN
AMINOSYN 7%/ELECTROLYTES
aminosyn 8.5%/electrolytes
AMINOSYN II
aminosyn ii 8.5%/electrolytes
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-PF 7%
AMINOSYN-RF
amiodarone hcl
AMITIZA
amitriptyline hcl
amlodipine besylate
amlodipine besylate/atorvastatin calcium
amlodipine besylate/valsartan
amlodipine/valsartan/hctz
ammonium lactate
amnesteem
amoxapine
amoxicillin
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium er
amphetamine/dextroamphetamine
amphotericin b
ampicillin
ampicillin sodium
ampicillin-sulbactam
ANADROL-50
Page #
19
23
19
18
45
27
33
38
38
38
23
17
36
38
38
38
19
11
29
29
47
49
49
49
49
49
49
49
49
49
29
35
16
29
29
29
29
33
33
16
11
11
11
32
17
11
11
11
38
Drug Name
anagrelide hydrochloride
anastrozole
ANDROGEL
ANDROGEL PUMP
ANDROXY
antibiotic ear
APOKYN
apraclonidine
apri
APRISO APTIOM APTIVUS aranelle
ARANESP ALBUMIN FREE
ARCALYST
ARCAPTA NEOHALER
ARRANON
ARZERRA
ascomp/codeine
ASMANEX TWISTHALER 120
METERED DOSES
ASMANEX TWISTHALER 14 METERED
DOSES
ASMANEX TWISTHALER 30 METERED
DOSES
ASMANEX TWISTHALER 60 METERED
DOSES
ASMANEX TWISTHALER 7 METERED
DOSES
atenolol
atenolol/chlorthalidone
ATGAM
atorvastatin calcium
atovaquone
atovaquone/proguanil hcl
ATRIPLA
aubra
augmented betamethasone dipropionate
AVASTIN
aviane
avita
azacitidine
AZASITE
azathioprine
azelastine hcl
azelastine hcl
AZILECT
azithromycin
aztreonam
Page # 28
19
38
38
38
47
23
45
38
44
14
25
38
28
42
47
19
19
8
47
47
47
47
47
29
29
42
29
23
23
25
38
36
19
38
33
19
45
42
45
47
23
11
11
Page 57 of 73 Drug Name
azurette
baciim
bacitracin
bacitracin
bacitracin/neomycin/polymyxin
bacitracin/polymyxin b
baclofen
BAL-CARE DHA
BAL-CARE DHA ESSENTIAL
balsalazide disodium
balziva
BANZEL
BARACLUDE
bcg vaccine
BD INSULIN SYRINGE
SAFETYGLIDE/1ML/29G X 1/2" BD INSULIN SYRINGE
ULTRAFINE/0.3ML/31G X 5/16" BD INSULIN SYRINGE
ULTRAFINE/0.5ML/30G X 1/2" BD INSULIN SYRINGE
ULTRAFINE/1ML/31G X 5/16" BD PEN NEEDLE/ULTRAFINE/29G X
12.7MM BELEODAQ
benazepril hcl
benazepril hcl/hydrochlorothiazide
BENLYSTA
benztropine mesylate
BESIVANCE
betamethasone dipropionate
betamethasone valerate
betaxolol hcl
betaxolol hcl
bethanechol chloride
bicalutamide
BICILLIN L-A
BICNU
bisoprolol fumarate/hydrochlorothiazide
bleomycin sulfate
BOOSTRIX
BOSULIF
BREO ELLIPTA
briellyn
BRILINTA
brimonidine tartrate
BRINTELLIX
bromocriptine mesylate
budesonide
Page #
38
11
11
45
45
45
25
49
49
44
38
14
25
42
45
45
45
45
45
19
29
29
42
23
45
36
36
29
45
36
19
11
19
29
19
42
19
47
38
28
45
16
23
36
Drug Name
budesonide
bumetanide
BUPHENYL
buprenorphine hcl
buprenorphine hcl/naloxone hcl
buproban
bupropion hcl
bupropion hcl er
bupropion hcl sr
bupropion hcl sr
bupropion hcl xl
buspirone hcl
BUSULFEX
butalbital compound/codeine
butalbital/acetaminophen/caffeine
butalbital/acetaminophen/caffeine/codeine
butalbital/apap/caffeine
butalbital/aspirin/caffeine
butalbital/aspirin/caffeine/codeine
cabergoline
calcipotriene
calcitonin-salmon
calcitrene
calcitriol
calcium acetate
camila
camrese
camrese lo
CANCIDAS
candesartan cilexetil
candesartan cilexetil/hydrochlorothiazide
capacet
CAPASTAT SULFATE
CAPRELSA
captopril
captopril/hydrochlorothiazide
carbamazepine
carbamazepine er
carbidopa
carbidopa/levodopa
carbidopa/levodopa er
carbidopa/levodopa odt
carbidopa/levodopa/entacapone
carboplatin
carteolol hcl
cartia xt
carvedilol
cavan-ec sod dha
CAYSTON
Page #
47
30
34
10
10
10
16
16
10
16
16
27
19
8
8
8
8
8
8
42
33
44
33
44
36
38
38
38
17
30
30
8
19
19
30
30
14
14
23
23
23
23
23
19
45
30
30
49
47
Page 58 of 73 Drug Name
caziant
cefaclor
cefaclor er
cefadroxil
cefazolin sodium
cefazolin sodium/dextrose
cefdinir
cefditoren pivoxil
cefepime
cefotaxime sodium
cefotetan
cefotetan/dextrose
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime
ceftazidime/dextrose
ceftriaxone in iso-osmotic dextrose
ceftriaxone sodium
ceftriaxone/dextrose
cefuroxime axetil
cefuroxime sodium
cefuroxime/dextrose
CELLCEPT
CELLCEPT INTRAVENOUS
CELONTIN
cephalexin
CEREZYME
CERVARIX
CHANTIX
CHANTIX CONTINUING MONTH PAK
CHANTIX STARTING MONTH PAK
chateal
chloramphenicol sodium succinate
chlordiazepoxide/amitriptyline
chlorhexidine gluconate oral rinse
chloroquine phosphate
chlorothiazide
chlorpromazine hcl
chlorthalidone
chlorzoxazone
cholestyramine
cholestyramine light
ciclodan
ciclopirox
ciclopirox nail lacquer
ciclopirox olamine
cilostazol
cimetidine
Page #
38
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
12
12
12
12
12
12
42
42
14
12
34
42
10
10
10
38
12
16
33
23
30
24
30
48
30
30
17
18
18
18
28
35
Drug Name
cimetidine hcl
CIMZIA
CIMZIA STARTER KIT
CINRYZE
ciprofloxacin
ciprofloxacin er
ciprofloxacin hcl
ciprofloxacin hcl
ciprofloxacin i.v.-in d5w
cisplatin
citalopram hydrobromide
CITRANATAL 90 DHA
CITRANATAL ASSURE
CITRANATAL B-CALM
CITRANATAL DHA
CITRANATAL HARMONY
CITRANATAL RX
cladribine
claravis
clarithromycin
clemastine fumarate
clindamycin hcl
clindamycin palmitate hcl
clindamycin phosphate
clindamycin phosphate
clindamycin phosphate add-vantage
clindamycin phosphate in d5w
clindamycin/benzoyl peroxide
clinisol sf 15%
clobetasol propionate
clobetasol propionate e
clobetasol propionate emollient
CLOLAR
clomipramine hcl
clonazepam
clonazepam odt
clonidine hcl
clopidogrel
clorazepate dipotassium
clotrimazole
clotrimazole/betamethasone dipropionate
clozapine
clozapine odt
COARTEM
codeine sulfate
COLCRYS
colestipol hcl
colestipol hcl for oral suspension
colistimethate sodium
Page #
35
43
43
43
12
12
12
45
12
19
16
49
49
49
49
49
49
19
33
12
47
12
12
12
33
12
12
33
49
36
36
36
20
16
14
14
30
29
27
18
18
24
24
23
8
18
30
30
12
Page 59 of 73 Drug Name
colocort
COMBIGAN
COMBIVENT RESPIMAT
COMETRIQ
compazine
COMPLERA
complete natal dha
completenate
compro
COMVAX
CONCEPT DHA
CONCEPT OB
constulose
COPAXONE
cormax scalp application
cortisone acetate
COSMEGEN
CREON
CRIXIVAN
cromolyn sodium
cromolyn sodium
cromolyn sodium
cryselle-28
CUBICIN
CUPRIMINE
CURITY GAUZE PADS 2"X2"
cyclafem 1/35
cyclafem 7/7/7
cyclobenzaprine hcl
cyclophosphamide
cycloserine
cyclosporine
cyclosporine modified
CYRAMZA
CYSTADANE
CYSTAGON
CYSTARAN
cytarabine
cytarabine aqueous
dacarbazine
DALIRESP
danazol
dantrolene sodium
dapsone
DAPTACEL
DARAPRIM
dasetta 1/35
dasetta 7/7/7
daunorubicin hcl
Page #
36
45
47
20
24
25
49
49
24
43
49
49
35
33
36
36
20
34
25
35
45
47
38
12
50
45
38
38
48
20
19
43
43
20
34
34
45
20
20
20
47
38
25
19
43
23
38
38
20
Drug Name
DAUNOXOME
daysee
deblitane
decitabine
DELYLA
DENAVIR
DEPEN TITRATABS
DEPOCYT
DEPO-ESTRADIOL
DEPO-PROVERA
desipramine hcl
desmopressin acetate
desogestrel/ethinyl estradiol
desonide
desoximetasone
dexamethasone
DEXAMETHASONE INTENSOL
dexamethasone sodium phosphate dexamethasone sodium phosphate dexrazoxane dextroamphetamine sulfate dextrose 10%/nacl 0.45% dextrose 10% flex container
dextrose 10%/nacl 0.2% dextrose 2.5%/sodium chloride 0.45% dextrose 20% dextrose 25% dextrose 30% dextrose 40% dextrose 5% dextrose 5%/lactated ringers dextrose 5%/nacl 0.2% dextrose 5%/nacl 0.225% dextrose 5%/nacl 0.3%
dextrose 5%/nacl 0.33%
dextrose 5%/nacl 0.45%
dextrose 5%/nacl 0.9%
dextrose 5%/potassium chloride 0.15%
dextrose 50%
dextrose 70%
diazepam
diazepam
diazepam intensol
diclofenac potassium
diclofenac sodium dr
diclofenac sodium er
diclofenac sodium/misoprostol
dicloxacillin sodium
dicyclomine hcl
Page #
20
38
38
20
38
25
50
20
38
38
16
38
38
36
36
37
36
36
45
20
33
50
50
50
50
50
50
50
50
50
50
50
50
50
50
50
50
50
50
50
14
27
27
8
8
8
8
12
35
Page 60 of 73 Drug Name
didanosine
diflorasone diacetate
diflunisal
digox
digoxin
dihydroergotamine mesylate
DILANTIN
dilt-cd
diltiazem cd
diltiazem hcl
diltiazem hcl cd
diltiazem hcl er
dilt-xr
diltzac
diphenhydramine hcl
diphtheria/tetanus toxoids adsorbed
pediatric disopyramide phosphate
disulfiram
divalproex sodium
divalproex sodium dr
divalproex sodium er
DOCEFREZ
docetaxel
donepezil hcl
dorzolamide hcl
dorzolamide hcl/timolol maleate
doxazosin mesylate
doxepin hcl
doxercalciferol
doxorubicin hcl
doxorubicin hcl liposome
doxy 100
doxycycline
doxycycline hyclate
doxycycline hyclate dr
doxycycline monohydrate
dronabinol
drospirenone/ethinyl estradiol
DROXIA
DUET DHA BALANCED
duloxetine hcl
duramorph
DUREZOL
E.E.S. 400
e.s.p.
econazole nitrate
EDURANT EGRIFTA
Page #
25
37
8
30
30
18
14
30
30
30
30
30
30
30
47
43
30
10
14
15
15
20
20
15
45
45
30
16
44
20
20
12
12
12
12
12
17
39
20
50
16
8
45
12
12
18
25
38
Drug Name
ELIDEL
elinest
ELITEK
ELLA
EMCYT
EMEND
emoquette
EMSAM
EMTRIVA
enalapril maleate
enalapril maleate/hydrochlorothiazide
endocet
endodan
ENGERIX-B
enoxaparin sodium
enpresse-28
enskyce
entacapone
entecavir
enulose
epinastine hcl
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
epirubicin hcl
epitol
EPIVIR
EPIVIR HBV
epoprostenol sodium
eprosartan mesylate
EPZICOM
EQUETRO
ERAXIS
ERBITUX
ergoloid mesylates
ERIVEDGE
errin
ERWINAZE
ery
ERYTHROCIN LACTOBIONATE
erythromycin
erythromycin
erythromycin
erythromycin base
erythromycin ethylsuccinate
erythromycin stearate
erythromycin/benzoyl peroxide
erythromycin/sulfisoxazole
ESCAVITE D
ESCAVITE LQ
Page #
33
39
20
39
20
17
39
16
25
30
30
8
8
43
29
39
39
23
25
35
45
47
47
20
15
25
25
47
30
25
27
18
20
16
20
39
20
33
12
12
33
45
12
12
12
33
12
50
55
Page 61 of 73 Drug Name
escitalopram oxalate
esgic
esomeprazole sodium
estarylla
ESTRACE
estradiol
estradiol/norethindrone acetate
ethambutol hcl
ethosuximide
etidronate disodium
etodolac
etodolac er
etoposide
EVZIO
EXELON
exemestane
EXJADE
EXTAVIA
EXTRA-VIRT PLUS DHA
FABRAZYME
falmina
famciclovir
famotidine
famotidine premixed
FANAPT
FANAPT TITRATION PACK
FARESTON
FASLODEX
FAZACLO
felbamate
fenofibrate
fenofibrate micronized
fenofibric acid
fenofibric acid dr
fenoprofen calcium
fentanyl
fentanyl citrate oral transmucosal
FETZIMA
FETZIMA TITRATION PACK
finasteride
FIRAZYR
FIRMAGON
flecainide acetate
FLORIVA
floxuridine
fluconazole
fluconazole in dextrose
fluconazole in nacl
flucytosine
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8
35
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39
39
39
19
15
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8
8
20
10
16
20
50
33
50
34
39
25
35
35
24
24
20
20
24
15
30
30
30
30
8
8
8
16
16
36
43
42
30
55
20
18
18
18
18
Drug Name
fludarabine phosphate
fludrocortisone acetate
flunisolide
fluocinolone acetonide
fluocinolone acetonide
fluocinolone acetonide body
fluocinolone acetonide scalp
fluocinonide
fluocinonide-e
fluoritab
fluorometholone
fluorouracil
fluorouracil
fluoxetine dr
fluoxetine hcl
fluphenazine decanoate
fluphenazine hcl
FLURA-DROPS
flurbiprofen
flurbiprofen sodium
flutamide
fluticasone propionate
fluticasone propionate
fluvastatin
fluvoxamine maleate
FOCALGIN-B FOLCAL DHA FOLCAPS OMEGA 3 FOLET DHA FOLET ONE FOLIVANE-OB
FOLIVANE-PRX DHA NF FOLOTYN
fomepizole
fondaparinux sodium
FORADIL AEROLIZER
FORTEO
foscarnet sodium
fosinopril sodium
fosinopril sodium/hydrochlorothiazide
fosphenytoin sodium
FOSRENOL
furosemide
FUSILEV
FUZEON
FYCOMPA
gabapentin
GABITRIL
galantamine hydrobromide
Page #
20
37
48
37
47
37
37
37
37
50
45
20
34
16
16
24
24
50
8
45
20
37
48
30
16
50
50
50
55
50
50
50
20
50
29
48
44
25
30
30
15
36
30
20
25
15
15
15
16
Page 62 of 73 Drug Name
GAMASTAN S/D
GAMMAPLEX
GAMUNEX-C
ganciclovir
garamycin
GARDASIL
gavilyte-c
gavilyte-g
gavilyte-n/flavor pack
GAZYVA
gemcitabine
gemcitabine hcl
gemfibrozil
generlac
gengraf
gentak
gentamicin sulfate
gentamicin sulfate
gentamicin sulfate
gentamicin sulfate pediatric
gentamicin sulfate/0.9% sodium chloride
GEODON
gianvi
gildagia
gildess 1.5/30
gildess 1/20
gildess fe 1.5/30
gildess fe 1/20
GILOTRIF
GLEEVEC
glimepiride
glipizide
glipizide er
glipizide xl
glipizide/metformin hcl
GLUCAGEN
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
glyburide
glyburide micronized
glyburide/metformin hcl
glycopyrrolate
glydo
granisetron hcl
griseofulvin microsize
griseofulvin ultramicrosize
guanidine hcl
HALAVEN
halobetasol propionate
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43
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26
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43
35
35
35
20
20
20
30
35
43
46
13
34
46
12
13
24
39
39
39
39
39
39
20
20
27
27
27
27
27
27
27
27
28
27
27
35
10
17
18
18
19
20
37
Drug Name
haloperidol
haloperidol decanoate
haloperidol lactate
HAVRIX
heather
hecoria
HEMENATAL OB
HEMENATAL OB + DHA
heparin sodium
heparin sodium/d5w
heparin sodium/nacl 0.45%
heparin sodium/nacl 0.9%
heparin sodium/sodium chloride 0.9%
heparin sodium/sodium chloride 0.9%
premix
hepatamine
hepatasol
HERCEPTIN
HEXALEN
HUMIRA
HUMIRA PEDIATRIC CROHNS
DISEASE STARTER PACK
HUMIRA PEN
HUMIRA PEN-CROHNS
DISEASESTARTER
HUMIRA PEN-PSORIASIS STARTER
hydralazine hcl
hydrochlorothiazide
hydrocodone bitartrate/acetaminophen
hydrocodone/acetaminophen
hydrocodone/ibuprofen
hydrocortisone
hydrocortisone butyrate
hydrocortisone butyrate (lipophilic)
hydrocortisone in absorbase
hydrocortisone valerate
hydrocortisone/acetic acid
hydromorphone hcl
hydroxychloroquine sulfate
hydroxyurea
hydroxyzine hcl
ibudone
ibuprofen
ICLUSIG
idarubicin hcl
ifosfamide
ifosfamide/mesna
ILARIS
ILEVRO
Page # 24
24
24
43
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43
50
50
29
29
29
29
29
29
50
50
21
21
43
43
43
43
43
30
30
8
8
8
37
37
37
37
37
47
9
23
21
48
9
9
21
21
21
21
43
46
Page 63 of 73 Drug Name
IMBRUVICA
imipenem/cilastatin
imipramine hcl
imiquimod
IMOVAX RABIES (H.D.C.V.)
inatal advance
inatal ultra
INCRELEX
indapamide
INFANRIX
INLYTA
INTELENCE
INTRALIPID
INTRON-A
INTRON-A W/DILUENT
introvale
INTUNIV
INVANZ
INVEGA
INVEGA SUSTENNA
INVIRASE
IPOL INACTIVATED IPV
ipratropium bromide
ipratropium bromide/albuterol sulfate
irbesartan
irbesartan/hydrochlorothiazide
irinotecan
ISENTRESS
isoniazid
ISOPTO CARPINE
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate
isosorbide mononitrate er
isotonic gentamicin
isradipine
ISTODAX
itraconazole
ivermectin
IXEMPRA KIT
IXIARO
JAKAFI
jantoven
jencycla
JENTADUETO
JEVTANA
jinteli
jolessa
jolivette
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13
16
34
43
50
50
38
31
43
21
26
50
21
21
39
33
13
24
24
26
43
48
48
31
31
21
26
19
46
31
31
31
31
13
31
21
18
23
21
43
21
29
39
28
21
39
39
39
Drug Name
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
KABIVEN
KADCYLA
KALETRA
kariva
kcl 0.075%/d5w/nacl 0.45%
kcl 0.15%/d5w/lr
kcl 0.15%/d5w/nacl 0.2%
kcl 0.15%/d5w/nacl 0.225%
kcl 0.15%/d5w/nacl 0.45%
kcl 0.15%/d5w/nacl 0.9%
kcl 0.3%/d5w/lr iv lac ring
kcl 0.3%/d5w/nacl 0.45%
kcl 0.3%/d5w/nacl 0.9%
kelnor 1/35
ketoconazole
ketoprofen
ketoprofen er
ketorolac tromethamine
KEYTRUDA
KINRIX
kionex klor-con 10 klor-con 8 klor-con m10 klor-con m20 kurvelo KUVAN
labetalol hcl
lactated ringers dextrose 5% viaflex
lactated ringers viaflex
lactulose
lamivudine
lamivudine/zidovudine
lamotrigine
larin 1.5/30
larin 1/20
larin fe 1.5/30
larin fe 1/20
latanoprost
LATUDA
leena
leflunomide
lessina
letrozole
leucovorin calcium
Page #
39
39
39
39
55
21
26
39
51
51
51
51
51
51
51
51
51
39
18
9
9
46
21
43
51
51
51
51
51
39
34
31
51
51
35
26
26
15
39
39
39
39
46
24
39
43
39
21
21
Page 64 of 73 Drug Name
LEUKERAN
LEUKINE
leuprolide acetate
levalbuterol
levalbuterol hcl
LEVEMIR
LEVEMIR FLEXTOUCH
levetiracetam
levobunolol hcl
levocarnitine
levocetirizine dihydrochloride
levofloxacin
levofloxacin
levofloxacin in d5w
levonest
levonorgestrel
levonorgestrel and ethinyl estradiol
levonorgestrel/ethinyl estradiol
levora 0.15/30-28
levothyroxine sodium
levoxyl
LEXIVA
lidocaine
lidocaine hcl
lidocaine hcl
lidocaine hcl jelly
lidocaine viscous
lidocaine/prilocaine
lindane
liothyronine sodium
LIPOSYN III
lisinopril
lisinopril/hydrochlorothiazide
lithium
lithium carbonate
lithium carbonate er
lomustine
loperamide hcl
lorazepam
lorazepam intensol
lorcet
lorcet hd
lorcet plus
lortab
loryna
losartan potassium
losartan potassium/hydrochlorothiazide
LOTRONEX
lovastatin
Page #
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29
42
48
48
28
28
15
46
51
48
13
46
13
39
39
39
39
39
41
41
26
10
10
31
10
10
10
23
41
51
31
31
27
27
27
21
35
27
27
9
9
9
9
39
31
31
35
31
Drug Name
LOVAZA
low-ogestrel
loxapine succinate
LUMIGAN
LUMIZYME
LUPRON DEPOT
LUPRON DEPOT-PED
lutera
LYRICA
LYSODREN
lyza
malathion
maprotiline hcl
margesic
marlissa
MARPLAN
MATULANE
matzim la
meclizine hcl
meclofenamate sodium
medroxyprogesterone acetate
mefloquine hcl
megestrol acetate
MEKINIST
meloxicam
melphalan hydrochloride
MENACTRA
MENEST
MENOMUNE-A/C/Y/W-135
MENVEO
MEPRON
mercaptopurine
meropenem
mesalamine
mesna
MESNEX
MESTINON
MESTINON TIMESPAN
metadate er
metaproterenol sulfate
metformin hcl
metformin hcl er
methadone hcl
methadose
methadose sugar-free
methazolamide
methenamine hippurate
methimazole
methotrexate
Page #
31
39
24
46
34
42
42
40
15
42
40
23
16
9
40
16
21
31
17
9
40
23
40
21
9
21
43
40
43
43
23
21
13
44
21
21
19
19
33
48
28
28
9
9
9
31
13
42
43
Page 65 of 73 Drug Name
methotrexate sodium
methoxsalen
methscopolamine bromide
methyclothiazide
methylergonovine maleate
methylphenidate hcl
methylphenidate hcl er
methylphenidate hcl sr
methylprednisolone
methylprednisolone acetate
methylprednisolone dose pack
methylprednisolone sodiumsuccinate
metipranolol
metoclopramide hcl
metolazone
metoprolol succinate er
metoprolol tartrate
metoprolol/hydrochlorothiazide
METRO IV
metronidazole
metronidazole
metronidazole in nacl 0.79%
metronidazole vaginal
mexiletine hcl
MIACALCIN
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
micronized colestipol hcl
midodrine hcl
MIGERGOT
MILLIPRED
MILLIPRED DP
mimvey
mimvey lo
minitran
minocycline hcl
minoxidil
mirtazapine
mirtazapine odt
misoprostol
mitomycin
mitoxantrone hcl
M-M-R II W/DILUENT 10 DOSE
modafinil
moderiba
moexipril hcl
moexipril/hydrochlorothiazide
Page #
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34
35
31
36
33
33
33
37
37
37
37
46
35
31
31
31
31
13
13
34
13
13
31
44
40
40
40
40
31
31
18
37
37
40
40
31
13
31
16
16
35
21
21
43
48
26
31
31
Drug Name
mometasone furoate
mono-linyah
mononessa
montelukast sodium
morgidox 1x100mg
morgidox 2x100mg
morphine sulfate
morphine sulfate er
MULTAQ
multi-vit/fluoride
multi-vit/iron/fluoride
multivitamin with fluoride
multi-vitamin/fluoride
multi-vitamin/fluoride/iron
mult-vitamin/fluoride
mupirocin
mupirocin calcium
MUSTARGEN
mvc-fluoride
my way
mycophenolate mofetil
myorisan
MYRBETRIQ
myzilra
nabumetone
nadolol
nadolol/bendroflumethiazide
NAGLAZYME
nalbuphine hcl
NALLPEN ISO-OSMOTIC IN
DEXTROSE
NALLPEN/DEXTROSE
naloxone hcl
naltrexone hcl
NAMENDA XR
NAMENDA XR TITRATION PACK
naphazoline hcl
naproxen
naproxen dr
naproxen sodium
naratriptan hcl
NATACHEW
NATAFORT
NATAL-V RX
NATALVIRT 90 DHA
NATALVIRT CA
nateglinide
NEBUPENT
necon 0.5/35-28
Page #
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40
40
48
13
13
9
9
31
51
51
51
51
51
51
34
34
21
51
40
43
34
36
40
9
31
31
34
9
13
13
10
10
16
16
46
9
9
9
18
51
51
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52
28
23
40
Page 66 of 73 Drug Name
necon 1/35
NECON 1/50-28
NECON 10/11-28
necon 7/7/7
nefazodone hcl
neomycin sulfate
neomycin/bacitracin/polymyxin
neomycin/polymyxin/bacitracin/hydrocortis
one neomycin/polymyxin/dexamethasone
neomycin/polymyxin/gramicidin
neomycin/polymyxin/hc
neomycin/polymyxin/hydrocortisone
neomycin/polymyxin/hydrocortisone
neo-polycin
NEPHRAMINE
NESTABS
NESTABS DHA
NEUMEGA
NEUPOGEN
NEUPRO
NEVANAC
nevirapine
nevirapine er
NEXA PLUS
NEXAVAR
next choice one dose
niacin er
nicardipine hcl
NICOTROL NS
nikki
NILANDRON
NIPENT
nitrofurantoin
nitrofurantoin macrocrystals
nitrofurantoin monohydrate
nitroglycerin
nitroglycerin lingual
nitroglycerin transdermal
NITROSTAT
nora-be
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX PEN
norethindrone
norethindrone acetate
norethindrone acetate/ethinyl estradiol
NORETHINDRONE
ACETATE/ETHINYL ESTRADIOL/FERROUS FUMARATE Page #
40
40
40
40
16
13
46
46
46
46
47
46
47
46
52
52
52
29
29
23
46
26
26
52
21
40
31
31
10
40
21
21
13
13
13
31
31
31
31
40
38
38
40
40
40
40
Drug Name
norgestimate/ethinyl estradiol
NORINYL 1+50
NORLYROC
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
nortriptyline hcl
NORVIR
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILLED
FLEXPEN
NOVOLOG PENFILL
NOXAFIL
NUEDEXTA
NULOJIX
nyamyc
nystatin
nystop
OB COMPLETE ONE
OB COMPLETE PETITE
OB COMPLETE PREMIER
OB COMPLETE/DHA
O-CAL PRENATAL
ocella
octreotide acetate
ofloxacin
ofloxacin
ofloxacin
OGESTREL
olanzapine
olanzapine odt
olanzapine/fluoxetine
olopatadine hcl
OLYSIO
omega-3-acid ethyl esters
omeprazole
ONCASPAR
ondansetron hcl
ondansetron odt
ONFI
OPSUMIT
oralone
ORAP
ORFADIN
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40
40
40
40
40
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26
28
28
28
28
28
28
28
28
18
33
43
18
18
18
52
52
52
52
52
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42
13
46
47
40
24
24
17
48
26
31
35
21
17
17
15
48
33
24
34
Page 67 of 73 Drug Name
orsythia
oxacillin sodium
oxaliplatin
oxandrolone
oxaprozin
oxcarbazepine
OXSORALEN
oxybutynin chloride
oxybutynin chloride er
oxycodone hcl
oxycodone/acetaminophen
oxycodone/aspirin
oxycodone/ibuprofen
pacerone
paclitaxel
PAIRE OB
pamidronate disodium
pancrelipase
PANRETIN
pantoprazole sodium
paricalcitol
paroex
paromomycin sulfate
paroxetine hcl
PASER
PATADAY
PATANOL
PAXIL
PEDIARIX
pedi-dri
PEDVAX HIB
peg 3350/electrolytes
peg-3350/nacl/na bicarbonate/kcl
PEGANONE
PEG-INTRON
PEG-INTRON REDIPEN
penicillin g potassium
penicillin g procaine
penicillin g sodium
penicillin v potassium
PENTACEL
PENTAM 300
pentoxifylline cr
pentoxifylline er
PERIKABIVEN
perindopril erbumine
periogard
PERJETA
permethrin
Page #
40
13
21
40
9
15
34
36
36
9
10
10
10
31
21
52
44
35
21
35
45
33
13
17
19
46
46
17
43
18
43
35
35
15
26
26
13
13
13
13
43
23
31
32
52
32
33
21
23
Drug Name
perphenazine
perphenazine/amitriptyline
phenadoz
phenelzine sulfate
phenergan
phenobarbital
phenytoin
phenytoin sodium
phenytoin sodium extended
philith
PHOSPHOLINE IODIDE
pilocarpine hcl
pilocarpine hcl
pilocarpine hydrochloride
pimtrea
pindolol
pioglitazone hcl
pioglitazone hcl/metformin hcl
pioglitazone hcl-glimepiride
piperacillin sodium/ tazobactam sodium
piperacillin sodium/tazobactam sodium
pirmella 1/35
pirmella 7/7/7
piroxicam
PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID PNV FOLIC ACID + IRON MULTIVITAMIN PNV OB+DHA PNV PRENATAL PLUS MULTIVITAMIN PNV TABS 29-1 pnv-dha
PNV-FIRST
pnv-select
PNV-VP-U
podofilox polycin polyethylene glycol 3350 polymyxin b sulfate/trimethoprim sulfate poly-vitamin/fluoride polyvits/fluoride/iron POMALYST
portia-28 potassium chloride potassium chloride 0.15% /nacl 0.45%
viaflex potassium chloride 0.15% d5w/nacl 0.33% potassium chloride 0.15% d5w/nacl 0.45% Page # 24
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17
17
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15
15
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28
28
13
13
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40
10
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Page 68 of 73 Drug Name
potassium chloride 0.15% d5w/nacl 0.45%
viaflex
potassium chloride 0.15% nacl 0.9%
potassium chloride 0.22% d5w/nacl 0.45%
potassium chloride 0.224%d5w/nacl 0.45%
viaflex
potassium chloride 0.3%/ nacl 0.9%
potassium chloride 0.3%/d5w
potassium chloride cr
potassium chloride er
potassium chloride sr
potassium citrate er
POTIGA
pr natal 400
pr natal 400 ec
pr natal 430
pr natal 430 ec
PRADAXA
pramipexole dihydrochloride
pravastatin sodium
prazosin hcl
prednicarbate
prednisolone
prednisolone acetate
prednisolone sodium phosphate
prednisolone sodium phosphate
prednisone
PREDNISONE INTENSOL
PREFERA OB
PREFERA OB + DHA
PREFERAOB ONE
PREMASOL
PRENA1 CHEW/QUATREFOLIC
PRENA1 PLUS/QUATREFOLIC
PRENA1/QUATREFOLIC
PRENAISSANCE
PRENAISSANCE PLUS
PRENATA
prenatabs fa
PRENATABS OBN
PRENATAL 19
PRENATAL PLUS
prenatal plus iron
PRENATE AM
PRENATE DHA
PRENATE ELITE
PRENATE ESSENTIAL
PRENATE MINI
PRENATE PIXIE
Page #
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52
52
52
52
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53
53
53
53
29
23
32
32
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37
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37
46
37
37
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53
53
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53
53
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53
53
53
53
53
53
53
53
54
54
54
55
Drug Name
PREPLUS PREQUE 10 PRETAB prevalite
previfem
PREZISTA
PRIFTIN
primaquine phosphate
primidone
PRISTIQ
PROAIR HFA
probenecid
probenecid/colchicine
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
PROCRIT
proctosol hc
proctozone-hc
progesterone
PROGLYCEM
PROGRAF
PROLASTIN-C
PROLENSA
PROLEUKIN
PROLIA
PROMACTA
promethazine hcl
promethegan
propafenone hcl
propafenone hcl er
proparacaine hcl
propranolol hcl
propranolol hcl er
propranolol/hydrochlorothiazide
propylthiouracil
PROQUAD
protriptyline hcl
PULMOZYME
PUREFE OB PLUS
PURIXAN
pyrazinamide
pyridostigmine bromide
quasense
quetiapine fumarate
quinapril hcl
quinapril/hydrochlorothiazide
quinidine gluconate cr
quinidine gluconate er
Page # 54
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54
32
41
26
19
23
15
17
48
18
18
24
24
24
29
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37
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28
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46
21
45
29
17
17
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32
46
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19
19
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Page 69 of 73 Drug Name
quinidine sulfate
quinidine sulfate er
quinine sulfate
QVAR
RABAVERT
raloxifene hydrochloride
ramipril
ranitidine hcl
RAPAMUNE
REAPHIRM
reclipsen
RECOMBIVAX HB
REGRANEX
RELENZA DISKHALER
RELISTOR
RELNATE DHA
REMICADE
RENVELA
repaglinide
RESCRIPTOR
RESTASIS
RETROVIR IV INFUSION
REVLIMID
REYATAZ
ribavirin
rifabutin
rifampin
RIFATER
riluzole
rimantadine hcl
ringers injection
risedronate sodium
RISPERDAL CONSTA
risperidone
risperidone odt
RITUXAN
rivastigmine tartrate
rizatriptan benzoate
rizatriptan benzoate odt
ropinirole hcl
rosadan
ROTARIX
ROTATEQ
roxicet
ROZEREM
SABRIL
SAMSCA
SANDIMMUNE
SANTYL
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35
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26
36
54
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36
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26
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26
22
26
26
19
19
19
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26
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25
24
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16
18
18
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48
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Drug Name
SAPHRIS
SELECT-OB
selegiline hcl
selenium sulfide
SELZENTRY
se-natal 19 SENSIPAR
sertraline hcl
se-tan dha
seton et-ec
setonet
sevelamer carbonate
sharobel
SIGNIFOR
sildenafil
silver sulfadiazine
SIMBRINZA
SIMULECT
simvastatin
SIROLIMUS
SIRTURO
SIVEXTRO
sodium chloride
sodium chloride 0.45% viaflex
sodium chloride 0.9%
sodium fluoride
sodium phenylbutyrate
sodium polystyrene sulfonate
sodium sulfacetamide
sodium sulfacetamide
SOLTAMOX
SOMATULINE DEPOT
SOMAVERT
sorine
sotalol hcl
sotalol hcl (af)
SOVALDI
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
spironolactone
spironolactone/hydrochlorothiazide
SPORANOX
sprintec 28 SPRYCEL
sronyx
ssd
stavudine
STIVARGA
streptomycin sulfate
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23
34
26
54
42
17
54
54
54
36
41
42
48
34
46
44
32
44
19
13
54
54
36
54
35
54
34
46
22
42
42
32
32
32
26
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48
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Page 70 of 73 Drug Name
STRIBILD
STROMECTOL
SUBOXONE
sucralfate
sulfacetamide sodium
sulfacetamide sodium
sulfacetamide sodium/prednisolone sodium
phosphate sulfadiazine
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim ds
SULFAMYLON
sulfasalazine
sulfazine
sulfazine ec
sulindac
sumatriptan
sumatriptan succinate
sumatriptan succinate refill
SUPRAX
SURMONTIL
SUSTIVA
SUTENT
syeda
SYLATRON
SYLVANT
SYMLINPEN 120
SYMLINPEN 60
SYNAGIS
SYNAREL
SYNERCID
SYNRIBO
SYNTHROID
SYPRINE
TABLOID
tacrolimus
TAFINLAR
TAMIFLU
tamoxifen citrate
tamsulosin hcl
TARCEVA
TARGRETIN
tarina fe 1/20
TARON-PREX
TASIGNA
tazicef
TAZORAC
taztia xt
TEFLARO
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23
10
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34
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46
14
14
14
34
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44
44
10
18
18
18
14
17
26
22
41
22
22
28
28
44
42
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22
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54
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22
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22
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34
32
14
Drug Name
TEGRETOL-XR
TEMODAR
TENIVAC
terazosin hcl
terbinafine hcl
terbutaline sulfate
terconazole
TESTIM
testosterone cypionate
testosterone enanthate
tetanus toxoid adsorbed
tetanus/diphtheria toxoids-adsorbed adult
tetracycline hcl
THALOMID
theophylline cr
theophylline er
THERACYS
THIOLA
thioridazine hcl
thiothixene
THYMOGLOBULIN THYROLAR-1 THYROLAR-1/2 THYROLAR-1/4 THYROLAR-2 THYROLAR-3 tiagabine hydrochloride
TICE BCG
ticlopidine hcl
TIKOSYN
tilia fe
TIMENTIN
timolol maleate
timolol maleate
timolol maleate ophthalmic gel forming
tinidazole
TIVICAY
tizanidine hcl
TL-CARE DHA
TL-SELECT
TL-SELECT DHA
tobramycin
tobramycin sulfate
tobramycin sulfate
tobramycin sulfate/sodium chloride
tobramycin/dexamethasone
TOBREX
tolazamide
tolbutamide
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22
44
32
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48
18
41
41
41
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44
14
22
48
48
22
36
25
25
44
41
41
41
41
41
15
22
29
32
41
14
32
46
46
14
26
25
54
54
54
48
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46
14
46
46
28
28
Page 71 of 73 Drug Name
tolmetin sodium
tolterodine tartrate
topiramate
toposar
topotecan hcl
TORISEL
torsemide
tpn electrolytes
TRACLEER
TRADJENTA
tramadol hcl
tramadol hydrochloride/acetaminophen
trandolapril
tranexamic acid
TRANSDERM-SCOP
tranylcypromine sulfate
TRAVATAN Z
travoprost
trazodone hcl
TREANDA
TRECATOR
TRELSTAR DEPOT MIXJECT
TRELSTAR LA MIXJECT
TRELSTAR MIXJECT
tretinoin
tretinoin
triadvance
triamcinolone acetonide
triamcinolone acetonide
triamcinolone acetonide
triamcinolone in orabase
triamterene/hydrochlorothiazide
TRICARE
TRICARE PRENATAL COMPLEAT
TRICARE PRENATAL DHA ONE
triderm
tri-estarylla
trifluoperazine hcl
trifluridine
trihexyphenidyl hcl
tri-legest fe
tri-linyah
trilyte
trimethoprim
trimethoprim sulfate/polymyxin b sulfate
TRINATAL GT
trinatal rx 1
trinessa
triple antibiotic
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36
15
22
22
22
32
54
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28
10
10
32
29
17
17
46
46
17
22
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42
42
42
22
34
54
33
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48
33
32
54
54
55
37
41
25
47
23
41
41
36
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47
55
55
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47
Drug Name
triple-vitamin/fluoride
tri-previfem
TRISENOX
tri-sprintec
TRIUMEQ
TRIVEEN-DUO DHA
TRIVEEN-PRX RNF
tri-vit/fluoride
tri-vit/fluoride/iron
tri-vitamin/fluoride
trivora-28
TRUVADA TUDORZA PRESSAIR TWINRIX TYBOST TYGACIL TYKERB TYPHIM VI TYZEKA
TYZINE PEDIATRIC NASAL DROPS ultimatecare one nf
unithroid
ursodiol
UVADEX
VAGIFEM
valacyclovir hcl
VALCHLOR
VALCYTE
valganciclovir
valproate sodium
valproic acid
valsartan
valsartan/hydrochlorothiazide
VALSTAR
vancomycin hcl
vancomycin hcl in dextrose
vandazole
VANTAS
VAQTA
VARIVAX
VASCEPA
VASOSTRICT
VECTIBIX
VELCADE
velivet
VEMAVITE-PRX 2 VENA-BAL DHA venlafaxine hcl
venlafaxine hcl er
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22
41
55
55
55
54
54
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26
48
44
26
14
22
44
26
48
55
42
36
22
41
27
22
27
27
15
15
32
32
22
14
14
14
42
44
44
32
38
22
22
41
55
55
17
17
Page 72 of 73 Drug Name
VENTAVIS
VENTOLIN HFA
verapamil hcl
verapamil hcl er
verapamil hcl sr
VERSACLOZ
VESICARE
vestura
V-GO 20
V-GO 30
V-GO 40
vicodin
vicodin es
vicodin hp
VICTOZA
VICTRELIS
VIDEX PEDIATRIC
VIIBRYD
VIMPAT
vinblastine sulfate
vincasar pfs
vincristine sulfate
vinorelbine tartrate
viorele
VIRACEPT
VIRAMUNE
VIRAMUNE XR
VIRAZOLE
VIREAD
VIRT-PN
VIRT-PN DHA
VIRT-PN PLUS
VIRT-SELECT
VITAFOL-ONE
VITAFOL-PLUS
VITAMEDMD ONE RX/QUATREFOLIC
VITAMEDMD PLUS RX/QUATRE
FOLIC VITAMEDMD REDICHEW
RX/QUATREFOLIC vitamins a/c/d/fluoride
vitamins a/d/c/fluoride
VOL-NATE
VOL-PLUS
VOLTAREN
voriconazole
VOTRIENT
VP CH ULTRA
VP-CH-PNV
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48
32
32
32
25
36
41
45
45
45
10
10
10
28
27
27
17
15
22
22
22
22
41
27
27
27
27
27
55
55
55
55
55
55
55
55
55
55
55
55
55
10
18
22
55
55
Drug Name
VP-HEME OB
VP-PNV-DHA
VPRIV
vyfemla
warfarin sodium
wera
wymzya fe
XALKORI
XARELTO
XARELTO STARTER PACK
XENAZINE
XGEVA
XOLAIR
XTANDI
XYREM
YERVOY
YF-VAX
zafirlukast
zaleplon
ZALTRAP ZAMICET ZANOSAR
zarah
ZATEAN-CH
ZATEAN-PN
ZATEAN-PN DHA
ZATEAN-PN PLUS
ZAVESCA
zebutal
ZELBORAF
zenatane
zenchent
zenchent fe
ZENPEP
ZETIA
ZIAGEN
zidovudine
ZINGIBER
ziprasidone hcl
ZIRGAN
ZOLADEX
zoledronic acid
ZOLINZA
zolpidem tartrate
ZONALON
zonisamide
ZORTRESS
ZOSTAVAX
zovia 1/35e
Page #
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55
35
41
29
41
41
22
29
29
33
45
48
22
48
22
44
48
48
23
10
23
41
55
55
55
55
35
10
23
34
41
41
35
32
27
27
55
25
47
42
45
23
48
34
15
44
44
41
Page 73 of 73
Drug Name
zovia 1/50e
ZYDELIG
ZYKADIA
ZYPREXA RELPREVV
ZYTIGA
ZYVOX
Page #
41
23
23
25
23
14
This formulary was updated on 2/1/2015. For more recent information or other questions, please contact
Aetna Medicare Member Services at 1-877-238-6211 or for TTY: 711, 8 a.m. to 8 p.m., seven days a week,
or visit http://www.aetnamedicare.com/2015formulary.
http://www.aetnamedicare.com
©2015 Aetna Inc.
58.05.319.1 C (2/15)
15041